THE PRACTICE OF 
P E D I AT R I C S 
CHARLES GILMORE KERLEY 
BY 
Formerly Professor of Diseases of Children in the New York Polyclinic Medical School 
and Hospital; Attending Physician to the New York Nursery and Child's Hospital; 
Consulting Physician to the Babies’ Hospital, New York City; Consulting 
Pediatrist to the Babies’ Hospital, Newark, N. J; Consulting Pediatrist to 
the Fifth Avenue Hospital, New York; Consulting Pediatrist to the 
Greenwich (Conn.) Hospital, to the Tarrytown (N. Y.) Hospital, to 
the Englewood (N. J.) Hospital, and to the Lawrence (Bronx- 
ville) Hospital; Ex-President American Pediatric Society; 
Ex-President New York County Medical Society 
AND 
GAYLORD WILLIS GRAVES 
Associate in Diseases of Children in the College of Physicians and Surgeons (Columbia 
University); Adjunct Assistant Visiting Physician and Physician to Out-Patients, 
the Children’s Medical Service of Bellevue Hospital; Attending Phys- 
ician to the Seaside Hospital of St. John’s Guild, New York 
THIRD EDITION 
REVISED AND RESET 
W. B. SAUNDERS COMPANY 
PHILADELPHIA AND LONDON Copyright, 1914, by W. B. Saunders Company. Reprinted July, 1914, February, 1915, and October, 1915 
Revised, entirely reset, reprinted, and recopyrighted January, 1918. Reprinted January', 1919, and 
May, 1920. Revised, entirely reset, reprinted, and recopyrighted October, 1924 
Copyright, 1924, by W. B. Saunders Company 
PRESS OP 
W. B. SAUNDERS COMPANY 
PHILADELPHIA 
MADE IN U. S. A, PREFACE TO THE THIRD EDITION 
This edition has been prepared with the assistance of my former asso- 
ciate, Dr. Gaylord Willis Graves, who will hereafter be connected with the 
work as co-author. 
The book has been largely rewritten, with the addition of much new 
material both in the form of text and illustrations. In particular the 
additions comprise consideration of the following subjects: Growth and 
Development, Methods of Infant Feeding, Developmental Gastro-intestinal 
Abnormalities as Shown by z-Ray, Scurvy, Rickets, Asthma, Pneumonia, 
Influenza, Endocrine Disorders, Nephritis, Tetany, Hydrocephalus, Epi- 
demic Meningitis, Encephalitis Lethargica, Smallpox, Measles, Diphtheria, 
Scarlet Fever, Acidosis and Alkalosis, Diabetes Mellitus, Acrodynia, 
Defective Bodily Mechanics, Foreign Bodies, Diagnostic Methods, and 
Special Therapeutic Procedures. 
A number of the older articles and illustrations have been omitted as 
no longer essential. 
With the incorporation of new material the foot-note references have 
been greatly supplemented. 
The authors desire to express their indebtedness to Dr. Howard Reid 
Craig for valued assistance in the preparation of the work, and to acknowl- 
edge helpful courtesies from the staff of the Children’s Medical Division of 
Bellevue Hospital. 
New York City, 
October, 1924. 
Charles Gilmore Kerley. 
11 CONTENTS 
PAGE 
Nutrition—Growth—Development 17 
Nutrition and Growth, 17—Food Properties and Physiologic Requirements, 
19—Aids to Nutrition, 25—Normal Development, 33—Weight, 33—Height, 
35—Height and Weight Ratio, 36—Standards Other Than Weight and 
Height, 36—The Teeth, 37—Special Mental and Physical Development in 
the Infant, 38—Suggestions for Memorizing Facts Pertaining to Growth 
and Development, 41. 
Infant Feeding 43 
Maternal Nursing, 42—The Problem, 42—Human Milk, 44—Breast Feeding, 
45—Weaning, 55—Wet-nurse, 56—Artificial Feeding, 58—The Problem, 
58—Scientific Infant Feeding, 59—Cow’s Milk, 60—The Adaptation of 
Cow’s Milk, 66—The Proprietary Foods, 91—Special Supplementary 
Foods and Their Preparation, 94—Milk for Traveling, 96—Substitutes 
for Stomach Feeding, 96—Common Digestive Disorders of Infancy, 99- 
Disorders of Nutrition in Infancy, 105—Marasmus (Athrepsia; Infantile 
Atrophy), 105—Malnutrition in Infants, 111—Idiosyncrasy to Cow’s Milk, 
113—Scurvy (Scorbutus), 114—Rickets (Rachitis), 118. 
Care and Nutrition in Childhood 131 
The Formative Period, 131—Education, 132—Disease Prevention, 133— 
Diet from the First to the Eleventh Year, 134—Malnutrition in Childhood, 
137—Errors in Feeding, 137—Habitual Loss of Appetite, 137—The Phys- 
ically Subnormal Child, 140—Tardy Malnutrition and Malnutrition in 
Older Children, 146—Essentials in the Care of Acute Illness, 148—Diet 
During Illness, 154—Treatment of the Individual, 155. 
Examination and Diagnosis 157 
Mortality and Morbidity 161 
The Newborn. 164 
Premature and Congenitally Weak Infants, 164—Diseases of the Newborn, 
166—Cephalhematoma, 166—Hematoma of the Sternocleidomastoid, 167— 
Sclerema, 167—Asphyxia Neonatorum, 168—Delayed Asphyxia, 172— 
Atelectasis, 172—Sepsis in the Newborn, 173—The Care of the Stump of 
the Umbilical Cord, 175—Umbilical Granuloma, 175—Umbilical Polyp, 
176—Congenital Umbilical Hernia, 176—Mastitis in the Newborn, 176— 
Mammary Abscess in Infants, 177—Tetanus Neonatorum, 177—Oph- 
thalmia Neonatorum—Gonorrheal Ophthalmia, 187—Icterus Neonatorum, 
179—Congenital Absence of the Bile-ducts, 181—Hemorrhagic Diseases of 
the Newborn, 182. 
Diseases of the Mouth and Esophagus 186 
Stomatitis, 186—Sprue (Thrush; Mycotic Stomatitis), 189—Cancrum Oris 
(Noma), 190—-Fissures of the Lips, 191—Ulcerations and Fissures at the 
Angle of the Mouth, 191—Geographic Tongue, 191—Difficult Dentition, 192 
—Diseased Teeth, 192—Harelip and Cleft-palate, 193—Malformation of 
the Esophagus, 194—Acquired Stricture of the Esophagus, 195. 
Diseases of the Stomach, Intestines, and Peritoneum 196 
The Stomach, 196—The Management of Vomiting Babies, 198—Vomiting of 
Older Children, 199—Acute Gastritis and Acute Gastric Indigestion, 200— 
Chronic Gastric Indigestion (Chronic Gastritis), 202—Gastric Hyper- 
acidity in Children, 202—Hemorrhage from the Stomach; Vomiting Blood, 
205—Ulceration of the Stomach, 205—Rumination, 206—Pyloric Obstruc- 
tion in Young Infants, 207—Pylorospasm in Older Children, 218—Mechan- 
ical Defects in the Gastro-intestinal Tract as Etiologic Factors in Gastro- 
intestinal Disorders of Older Children, 220—Ptosis and Dilatation of the 
Stomach, 221—Colic, 225—Prevention of the Acute Intestinal Diseases, 227 
—Acute Intestinal Indigestion, 230—Persistent Intestinal Indigestion, 231 
—Persistent Intestinal Indigestion in Older Children, 232—Acute Gastro- 
enteric Intoxication, 234—Acute Enteric Intoxication, 241—Acute Ileo- 
colitis (Dysentery), 243—Chronic Ileocolitis, 250—Mucous Colitis, 251— 
Developmental Abnormalities in the Intestinal Tract as a Cause of Diges- 
tive Disturbances, 253—Hirschsprung’s Disease (Idiopathic Dilatation of 
13 14 
CONTENTS 
PAGE 
the Colon), 261—Celiac Disease, 263—The Intestinal Infantilism of Herter, 
266—Incontinence of Feces, 266—Constipation, 267—Intestinal Obstruc- 
tion, 276—Paralytic Ileus, 277—Intussusception, 277—Intestinal Cysts 
or Diverticula (Congenital), 281—Meckel’s Diverticulum, 282—Hernia 
at the Umbilicus, 283—Hernia of the Umbilical Cord, 283—Inguinal Her- 
nia, 285—Duodenal Ulcer, 286—Appendicitis, 287—Chronic Appendicitis, 
290—Acute General Peritonitis, 291—The Intestinal Parasites, 293. 
The Rectum and Anus 299 
The Rectum in Children, 299—Imperforate Anus—Atresia Ani, 299—Per- 
sistent Anal Membrane, 299—Prolapse of the Anus and Rectum, 300— 
Inflammation of the Anus, 300—Fissure of the Anus, 300—Proctitis, 301— 
Ischiorectal Abscess, 302. 
Diseases of the Liver 303 
Abnormalities of Function and Size, 303—Abscess of the Liver, 303—Cir- 
rhosis of the Liver, 304—Biliary Colic, 304—Icterus (Obstructive Jaundice; 
Catarrhal Jaundice), 304. 
Diseases of the Respiratory Tract 306 
The Nose and Throat, 306—Acute Rhinitis (Coryza; Snuffles; Cold in the 
Head), 306—Chronic Rhinitis (Nasal Catarrh), 308—Nasal Hemorrhage, 310 
-—Persistent Cough, 308—Throat Examination, 312—Faucitis, 313—Simple 
Pharyngitis, 313—The Tonsils, 314—Acute Follicular Tonsillitis, 314— 
Peritonsillar Abscess (Quinsy), 318—Vincent’s Angina, 319—Septic Sore 
Throat (Milk Borne), 320—Irrigation of the Throat, 321—Adenoids, 
322—Hypertrophied and Permanently Diseased Tonsils, 325—Retro- 
pharyngeal Adenitis, 327—Acute Retropharyngeal Abscess, 327—Retro- 
pharyngeal Abscess Complicating Tuberculous Caries of the Cervical 
Vertebrae, 330—Acute Catarrhal Laryngitis (Spasmodic Croup), 330—- 
Traumatic Laryngitis, 334—Laryngeal Obstruction, 335—Foreign Bodies 
in the Larynx, 335—The Lungs, 336—Examination of the Lungs, 336— 
Bronchitis, 341—Recurrent Bronchitis, 346—Acute Spasmodic Bronchitis; 
Bronchial Asthma, 347—Pollinosis, Pollen Disease, Hay-fever, 354— 
Pneumonia, 355—Lobar Pneumonia, 355—Bronchopneumonia (Catarrhal 
Pneumonia), 368—Interstitial Pneumonia and Bronchiectasis, 387—In- 
sufflation Pneumonia, 381—Hypostatic Pneumonia, 381—Pneumothorax, 
381—Emphysema, 383—Subcutaneous Emphysema with Emphysema of 
the Mediastinum, 384—Primary Pleurisy 384—Secondary Pleurisy, 385- 
Empyema (Pleurisy with Purulent Effusion), 388—Pulmonary Gangrene, 
393—Pulmonary Abscess, 394—Pulmonary Tuberculosis, 394—Helio- 
therapy, 399. 
Diseases of the Heart 401 
Diagnosis in Diseases of the Heart, 401—Heart Murmurs, 404—-Functional 
Abnormalities in Cardiac Rate and Rhythm, 407—Congenital Heart Dis- 
ease, 409—Pericarditis, 413—Acute Endocarditis, 416—Myocarditis, 422- 
Chronic Valvular Disease of the Heart, 425—Adherent Pericardium, 429. 
The Blood and Blood Diseases 430 
The Blood in the Newborn, 430—The Blood in Infancy and Childhood, 430— 
The Blood in Different Diseases, 433—Blood-pressure in Children, 437— 
Coagulation Time, 438—Simple Anemia, 438—Chlorosis, 440—Pseudo- 
leukemic Anemia of von Jaksch, 441—Leukemia, 443—Pernicious Anemia, 
445—Purpura, 446—Hemophilia (Bleeder’s Disease), 448. 
Diseases of the Glandular System 451 
The Spleen, 451—Splenomegaly, 451—Splenic Anemia (Banti’s Disease), 
451—Gaucher’s Disease, 453—Hemolytic Icterus, 454—The Lymphatic 
Glands, 454—-Acute Cervical Adenitis, 454—Persistent Cervical Adenitis, 
456—Axillary and Inguinal Adenitis, 457—Glandular Fever, 457—Tuber- 
culous Adenitis, 458—Hodgkin’s Disease, 461—The Breast, 462—Mastitis in 
Young Girls, 462—The Thyroid Gland, 463—Simple Enlargement of the 
Thyroid, 463—Congenital Goiter, 463—Simple Goiter in Older Children, 
464—Exophthalmic Goiter, 464—Cretinism (Infantile Myxedema; Cretinoid 
Idiocy), 464—The Thymus Gland, 470—Status Lymphaticus, 471—The 
Pituitary Gland, 475—Dyspituitarism, Dystrophy Adiposogenitalis (Froh- 
lich), 475—Disease of the Pineal Gland, 477-—Diseases of the Suprarenal 
Glands, 477—Addison’s Disease, 477—Tumors of the Adrenal Gland, 477— 
General Developmental Disorders Attributed to Endocrine Dyscrasia, 477 
—Infantilism and Dwarfism, 477—Obesity, 479—The Differentiation of 
Endocrine Disorders, 479. CONTENTS 
15 
PAGE 
The Urogenital System 481 
The Urine, 481—Dysuria (Difficult and Painful Urination), 482—Suppression 
and Retention of Urine, 482—Incontinence of Urine (Enuresis), 484— 
Hematuria (Blood in the Urine), 487—Hemoglobinuria, 488—Pyuria, 488— 
Glycosuria, 489—The Kidneys, 490—Tuberculosis of the Kidney, 490— 
New Growths of the Kidney, 490—Hydronephrosis and Pyonephrosis, 491— 
Cysts of the Kidney, 492—The Various Forms of Nephritis, 493—Acute 
Parenchymatous Nephritis (Acute Diffuse Nephritis), 494—Chronic Diffuse 
Nephritis, 502—Chronic Interstitial Nephritis (Malignant Hypertension), 
505—Pyelocystitis (Pyelitis), 505—The Bladder, 509—-Cystitis, 509—Vesical 
Calculus (Stone in the Bladder), 510—Exstrophy of the Bladder, 510—The 
Male Genitals, 511—Balanitis, 511—Phimosis, 511—Paraphimosis, 512— 
Circumcision, 512—Undescended Testicle, 513—Orchitis, 514—Hydrocele, 
514—Gonorrhea in the Male, 515—Epispadias and Hypospadias, 516— 
The Female Genitals, 516—Precocious Menstruation and Precocious Matur- 
ity, 516—Simple Vulvovaginitis, 517—Gonorrheal Vulvogaginitis (Specific 
Vaginitis), 518—Atresia of the Urethra and Vagina, 521. 
Affections of the Nervous System 522 
Headache, 522—Pavor Diurnus, 522—Night-terrors (Pavor Nocturnus), 523 
—Gyrospasm (Spasmus Nutans), 524—Hysteria, 524—Habits, 529—- 
Masturbation, 531—Hiccup, 533—Infantile Convulsions, 533—Laryngis- 
mus Stridulus, 537—Congenital Stridor, 540—Spasmophilia and Tetany, 
540—Tetany, 542—Insanity in Children, 548—-Malformations of the 
Brain and Cord, 549—Hydrocephalus, 550—Microcephalus, 554—Spina 
Bifida, 555—Type and Incidence of Brain Tumor, 557—Mental Deficiency; 
Imbecility; Idiocy, 558—Mongolian Idiocy, 560—Amaurotic Family Idiocy, 
563—Cerebral Palsies, 565—The Prenatal and Birth Forms, 565—The 
Acquired Form, 568—Chorea (St. Vitus’ Dance), 570—Habit Spasm (Tic), 
575—Stammering, 576—The Progressive Muscular Atrophies, 577—Progres- 
sive Spinal Muscular Atrophy or Progressive Amyotrophy, 577—The Pro- 
gressive Myopathies (Primary Muscular Dystrophies), 579—Amyotonia 
Congenita (Oppenheim’s Disease), 582—Epilepsy, 583—Acute Poliomy- 
elitis (Infantile Paralysis), 587—Multiple Neuritis, 593—Facial Paralysis, 
597—Erb’s Palsy (Obstetric Paralysis), 598—-Friedreich’s Ataxia (Hered- 
itary Ataxia), 600—Acute Infective Meningitis, 603—Tuberculous Menin- 
gitis, 606—Cerebrospinal Meningitis (Meningococcus Meningitis), 610—- 
Meningismus (Serous Meningitis), 619—Epidemic Encephalitis (Enceph- 
alitis Lethargica; Nona), 619—Diagnostic Characteristics of Cerebrospinal 
Fluid, 622. 
Diseases of the Skin 624 
Miliaria (Prickly Heat), 625—Urticaria (Hives; Nettle-rash), 625—Giant 
Hives (Angioneurotic Edema), 626—Rhus Poisoning (Ivy Poisoning), 627— 
Scabies (Itch), 628—Furunculosis (Boils), 629—Pediculi (Head Lice), 630 
—Tinea Circinata (Ringworm), 631—Tinea Tonsurans (Ringworm of the 
Scalp), 632—Impetigo Contagiosa, 634—Pemphigus Neonatorum, 635— 
Erythema Nodosum, 636—Erythema Multiforme, 637—Herpes Simplex 
(Fever Blisters), 637—Herpes Zoster (Shingles; Zona), 638—Erysipelas, 639 
—Dermatitis (Eczema), 642—Intertrigo, 650—Dermatitis in Older Chil- 
dren, 651—Dermatitis Due to Seborrhea, 653—Psoriasis, 655—Bed-sores 
(Decubitus), 656—Nevus (Birth-mark), 657. 
Diseases of the Ear 658 
Earache, 658—Deafness, 658—Acute Otitis, 659—Chronic Suppurative Otitis, 
663—Mastoiditis, 663—Sinus Thrombosis, 664. 
The Transmissible Diseases 665 
Care to be Exercised by the Physician in Visiting Infectious and Contagious 
Diseases, 666—Smallpox (Variola), 666—Chickenpox (Varicella), 670— 
Mumps (Epidemic or Specific Parotitis), 672—Whooping-cough (Pertussis), 
674—Measles, 680—German Measles (Rotheln; Rubella), 685—Diphtheria, 
686—Scarlet Fever (Scarlatina), 701—Typhoid Fever, 714—Malaria, 724— 
Influenza (La Grippe), 728—Rheumatic Fever (Acute Rheumatism), 734 
—The Rheumatic Diathesis, 738—Rheumatoid Arthritis; Arthritis De- 
formans; Still’s Disease, 742—Syphilis, 743—Acute Hereditary or Con- 
genital Syphilis, 744—Acquired Syphilis, 750—-Tardy Hereditary Syphilis, 
751—Tardy Malnutrition of Syphilitic Origin, 755—Tuberculosis, 756— 
Abdominal Tuberculosis (Tuberculosis of the Mesenteric Glands; Tabes 
Mesenterica), 759—Chronic Tuberculous Peritonitis, 760—Tuberculin Skin 
Reactions, 765—Dactylitis, 768. 16 
CONTENTS 
PAGE 
Diseases Due to Disturbances op Metabolism 771 
Acidosis (Ketosis), 771—Alkalosis, 773—Cyclic Vomiting (Recurrent or 
Periodic Vomiting), 773—Cyclic Diarrhea, 777—Acetonuria in Children, 779 
—Periodic Fever, 779—The Suboxidation Syndrome, 780—Diabetes In- 
sipidus, 783—Diabetes Mellitus, 784—Pellagra, 787—Beriberi, 790—Acro- 
dynia, 791. 
Diseases of Muscles, Bones, and Joints 794 
Diagnosis in Bone and Joint Diseases, 794—Osteogenesis Imperfecta (Frag- 
ilitas Ossium; Osteopsathyrosis Infantilis; Lobstein’s Disease, 796—Chon- 
drodystrophia (Achondroplasia), 797—The Influence of Defective Bodily 
Mechanics on Health, 800. 
Miscellaneous Subjects 804 
Heredity and Environment, 804—Consanguinity, 805—Temperature in Chil- 
dren, 805—Obscure Elevation of Temperature, 808—Neurocirculatory 
Asthenia (Effort Syndrome), 811—Anaphylaxis, 814—New Growths, 815— 
Foreign Bodies, 817. 
Special Diagnostic Methods 820 
Therapeutic Measures 831 
The Fundamentals of Therapeutics in Childhood, 831—The Therapeutic 
Value of Climate, 833—Summer Resorts, 834—Instructions for the Summer, 
835—Days to Go Out-of-doors; Indoor Airing, 838—The Exercise Pen, 
839—Cold Sponging in Fever, 840—The Cool Pack, 841—Baths, 842— 
Bathing in Illness, 844—Heat Therapy, 844—Counterirritation, 846—Cold 
as a Therapeutic Agent, 847—Blood Transfusion and Intramuscular Injec- 
tion, 848—Intramuscular Medication, 849—Intraperitoneal Injections, 850 
—Intravenous Medication, 850—Hypodermoclysis, 851—Lavage (Stomach 
Washing), 852—Gavage, 853—Colon Irrigation; Colon Flushing, 855— 
—Vaccination, 857—Vaccine Therapy, 859—Serum Therapy, 864—Non- 
specific Protein Therapy, 864. 
Drugs and Drug Dosage 866 
Unpalatable and Nauseating Drugs, 866—Alcohol, 867—Anesthetics, 869— 
Drugs for Internal Use, 871—Drugs for External Use, 882. 
Index 887 The Practice of Pediatrics 
I. NUTRITION—GROWTH—DEVELOPMENT 
Nutrition and Growth 
The fundamental principles in the life of the young of all animals 
are growth and development. This statement applies to the young 
of the lower animals as well as to man. Nature has fixed and definite 
laws in accordance with which this growth and development proceed. 
The type of animal produced depends in no small degree upon the way 
in which we comply with these laws. 
Heredity.—Inheritance is, of course, an important factor, but environ- 
ment counts for more. The young of the lower animals or of man may 
possess all that can be desired in the way of heredity, but if manage- 
ment during growth is faulty, the adult is almost certain to fall short 
of the normal. On the other hand, an individual without the benefits 
of good heredity, when given the advantages of faithful scientific care 
may develop into an adult decidedly superior in all respects to those 
more fortunate in birth. 
Environment.—One who carefully watches the growth and develop- 
ment of animals will observe that under care as to feeding, housing, 
ventilation, cleanliness, and exercise, those which promise but little at 
birth develop into perfect specimens of their kind. Similarly, prolonged 
intimate association with thousands of infants and growing children in 
private, in hospital, and in out-patient work inevitably impresses upon 
a physician the possibilities of growth under good management even 
when little has been expected, judging from the original condition of the 
patient. 
The child is here through no choice of his own. He is to have a future. 
Because his health, vigor, powers of resistance, happiness, and usefulness 
as a citizen are determined in no small degree by the nature of his care 
during the first fifteen years of life, he has a right to demand that such 
care be given him as will be conducive at least to a sound, well-developed 
body, and this should be our first thought and object regarding him. 
Consider for a moment the number of occupations, other than those 
of the army and the navy, that require physical fitness before a candidate 
is accepted. Competition is keen at the present time and will be keener 
in the future. Employers of men and women, whether in the office, 
the factory, or on the farm, cannot afford to utilize the physically weak. 
Care and Feeding.—The most important physical factor in the making 
of men and women is nutrition. No great power of reasoning is required 
to appreciate the fact that the child who is fed on suitable food will become 
17 18 
THE PRACTICE OF PEDIATRICS 
a more vigorous, better developed adult than one who, beginning at birth 
and continuing throughout the entire period of growth, is given only food 
possessing indifferent qualities for tissue building. Next in importance to 
food, and following in close correlation, are fresh air, cleanliness, cheerful 
surroundings, and healthful amusements, together with an absence of 
school work or service of an arduous nature. That the offspring of man 
suffers more from nutritional errors due to the lack of suitable care than 
do the young of the lower animals is lamentable, but nevertheless a fact. 
The absence of thought and care and of knowledge relating to children 
is due to the fact that the child as such has apparently no intrinsic value 
in dollars and cents, whereas the young of the lower animals represent 
no small part of their owner’s material possessions. Another factor 
having a deterrent influence upon the development of children is their 
unfavorable start during the first year. 
Positive success in the management demands daily attention to 
detail. Feeding the child properly one or two months out of the year 
is of little value. He should be fed properly every day in the year, for 
under normal conditions every day is a day of growth. Unfortunately, 
many mothers cannot supply to the infant the requisite nourishment. 
This brings us to the matter of substitute feeding, fraught with per- 
plexities and uncertainties in the most competent hands, and with dan- 
gers and disasters in the hands of the incompetent and inefficient. In 
the section on Artificial Feeding of infants their nutrition is considered 
in detail. It is sufficient to remark here that nature has provided for 
the baby a food which contains the nutritional elements, fat, sugar, and 
protein, in fairly definite proportions and in peculiar forms. Success 
in substitute feeding depends upon our ability to supply in suitable forms, 
and the child’s ability to assimilate, a food containing the nutritive 
elements in approximately the quantities found in human milk. An 
exact reproduction of mother’s milk by the use of cow’s milk or other 
food is, of course, impossible. We can imitate human milk, however, 
with sufficient accuracy to make acceptable and sufficient food for most 
children who are deprived of the breast. After the nursing or the bottle 
age the feeding must not be left to the family judgment, for at this period 
of rapid growth suitable nutrition is most important. Left to the family, 
the diet during the second year too frequently consists of milk, which 
in large cities is often of uncertain nutritive value, together with insuffi- 
ciently cooked cereals, boxed breakfast foods, bread-stuffs, crackers, 
and cake—often procured at the grocer’s or baker’s. At the Out-patient 
Departments of the New York Babies’ Hospital and the New York Poly- 
clinic Medical School only 20 per cent, of a large group of the children 
treated who were over one year of age were found to be of normal de- 
velopment. In those under one year of age only 35 per cent, were nor- 
mal. While these groups are not to be considered as representing the 
country as a whole, still they do represent a large part of the population 
of our larger cities, the offspring of day-laborers, drivers, waiters, and 
small-wage earners generally. Such children were fed in the manner 
above described, not because of poverty, but because of an absence of 
the slightest knowledge on the part of the parents regarding suitability 
of foods. The children were not hungry, and were fed to satisfy taste FOOD PROPERTIES AND PHYSIOLOGIC REQUIREMENTS 
19 
rather than true appetite; when that was accomplished the parents 
considered their duty done. To feed with a definite purpose—with a 
view solely to the physical development of their children—had never 
entered the minds of the parents, yet most of them could read and write 
and possessed a fair degree of general intelligence. They were conversant 
with affairs and had attended the public schools, but were absolutely 
untaught as to how they should live. 
FOOD PROPERTIES AND PHYSIOLOGIC REQUIREMENTS 
Substances used as foods, regardless of the animal which they may 
nourish, possess the common property of being composed of fat, protein, 
carbohydrate, mineral substances, and water in varying proportions. 
The purposes that these serve in the animal economy are essentially the 
same in all forms of animal life. In order to determine the food value 
of any substance a chemical analysis which shows the quantities of 
these nutritional elements is required. It will be found that foods varying 
widely in appearance and physical properties are still similar in that they 
are composed of the same food elements, although in different proportions. 
Foods used to sustain animal life of any kind must contain the in- 
gredients needed by all animals, and in a form suited to the particular 
kind of animal to be fed, whether it is man or one of the lower animals. 
The Ingredients of Foods.—While all foods are composed of fat, 
carbohydrate, protein, mineral substance, and water, these elements 
exist in widely differing forms. Fat may be supplied in meat, egg, 
milk, butter, oleomargerine or butterine, lard, olive oil, cod-liver oil, 
linseed oil, cottonseed oil, etc. Carbohydrates may be furnished in the 
form of cane-sugar, milk-sugar, maltose and dextrose, soluble products 
derived from starch, cornstarch, wheat or other flour, oatmeal, rice, 
hominy, bread, potatoes, etc. Proteins are secured in the form of lean 
beef, lamb or pork, chicken, fish, the gluten of such cereals as wheat and 
oats, in large quantities from peas, beans, lentils, and other legumes, 
from the curd of milk, and also from eggs. The mineral substances of 
food are found combined with the other ingredients in the form of lime, 
phosphates, magnesium, iron, etc. 
The Function of the Food Elements.—The proteins of the food are 
used to form the bodily structures and to replace tissue consumed by 
the vital processes and excreted as urea. The vital processes, such as 
the circulation of the blood, respiration, and contractions of the muscles, 
call for energy, and this together with bodily heat must be supplied by 
the fats and carbohydrates. The mineral substances are used in the 
formation of bone and teeth, while the water serves to dissolve the food 
elements after they have been digested and to carry off waste products. 
As the demands made are variable and directly dependent upon 
numerous changing conditions both within and without the body, food 
must be varied in amount and character to meet the altering demands. 
Exercise, variations in external temperature, lowered digestive capacity, 
illness accompanied by fever, growth, and repair all have to be considered 
apart from the conditions attendant upon the so-called basal metabolism 
of the resting organism. Thus meat, with its abundance of protein, 
serves as the chief food of the laborer expending muscular energy, fat 20 
THE PRACTICE OF PEDIATRICS 
serves as the reserve store of the Eskimo, and carbohydrate, by reason of 
its easy digestibility and ready availability as fuel to spare tissue waste, 
is of great value in disease states associated with fever. 
When one thus considers food in the light of its component elements 
more detailed knowledge is seen to be essential to any mastery of the 
subject of nutrition of the growing body. 
Proteins.—These are commonly called nitrogenous foods because of 
the characteristic presence of nitrogen in the complex protein molecule. 
The nitrogen component makes the protein element in food invaluable 
for tissue growth and repair, while the carbon available in protein supplies 
heat and energy. Protein is thus the one complete food, but it has the 
disadvantages of being less concentrated in caloric value and less stable 
under the influence of physical and chemical agencies, including bacterial, 
action, than many forms of carbohydrate and fat, while the difficulty of 
absorption and elimination of some forms of protein has also to be reckoned 
with in the problem of diet. Not to be forgotten is the fact that the most 
expensive foods are usually those high in protein, and that protein sus- 
ceptibility or anaphylaxis exceptionally constitutes a contraindication 
to the use of certain foods by certain individuals. 
Of the numerous amino-acids into which the protein foods are event- 
ually broken down in the digestive canal, lysin, cystin, and tryptophan 
are of greatest value for growth. 
Fat.—For purposes of nutrition, fat is of value as a protein sparer of 
very high caloric value. In spite of its relatively slow digestibility it is 
largely absorbed, and besides serving as a fuel of slow combustion is readily 
stored up. The unoxidized intermediate products of fat metabolism may 
lead to acidosis, particularly if there is not enough available carbohydrate 
to “make fire” for their complete oxidation. 
Calcium and other mineral substances are ordinarily stored more 
readily in the body when the fat intake is adequate. This is illustrated 
by the rapid lowering of calcium excretion in rachitic subjects when cod- 
liver oil is added to a previously deficient diet. 
Carbohydrates.—These not only serve as protein sparers, but are im- 
mediately available for combustion. When stored as glycogen, carbohy- 
drates may be transformed into fat. 
Of the two chief forms of carbohydrate, the sugars and starches, 
the former are absorbed most readily, but by reason of their ready fer- 
mentability not infrequently contribute to vomiting and diarrhea. 
To safeguard against this possibility we employ mixtures of starch and 
sugar in order that absorption may take place at more than one level 
in the digestive tract, thus entailing less risk of fermentation than would 
exist if the stomach were required to do all the work. 
Starch after being converted into dextrin and then maltose eventually 
breaks down into two molecules of dextrose; cane-sugar is split into dex- 
trose and levulose, and lactose into dextrose and galactose. 
The argument as to what is the best form of carbohydrate to ad- 
minister in a given case always evokes controversy, but in general one has 
only to remember the following facts: 
Lactose, the natural milk sugar, ferments more readily in the intes- 
tine than in the stomach and is more slowly absorbed than maltose. FOOD PROPERTIES AND PHYSIOLOGIC REQUIREMENTS 
21 
Cane-sugar has the great advantage of cheapness and availability. 
Maltose is readily absorbed, but not infrequently conduces to gastric 
fermentation. 
Dextrin derived from starch has a protective colloid action, and 
undergoing slow change to maltose does not readily contribute to sugar 
excess in the intestine. 
This subject will receive further consideration under the discussion 
of Artificial Feeding of infants, p. 69. 
The Mineral Substances.—A discussion under this heading leads one 
immediately into the chemistry of bodily structure as well as that of 
function, and the problem involved belongs to a special sphere of medi- 
cine. 
We may remind ourselves, however, that in milk we have relatively 
large amounts of the calcium, phosphorus, and magnesium salts necessary 
for bone development, whereas we are confronted with a lack of iron so 
essential to the blood. 
At an early age the requirements of the infant must therefore be 
met by the use of supplementary foods, particularly iron containing 
vegetables, meat juice, and egg. 
Vitamins.-—A definition of these substances may hardly be made 
specific. In general, vitamins are accessory elements in raw foods, of 
little or no caloric value, but of vital importance even in minute quan- 
tities to the maintenance of health and nutrition. 
Vitamin A, or the fat-soluble vitamin, is found in cream, egg yolk, 
and cod-liver oil, but is lacking in vegetable oils. It is not appreciably 
affected by heat. Vitamin A has been called the antirachitic vitamin 
because of the demonstrable value of the substances which contain it, 
particularly cod-liver oil, in the prevention and cure of rickets. Whether 
the term “vitamin” really belongs to the “antirachitic principle” in the 
cod-liver oil remains to be proved. 
Vitamin B, a water-soluble vitamin, occurs in yeast, husks of grains, 
milk sugar, and a large range of vegetable foods. It is affected, but not 
rendered inadequate by heat. By reason of its preventive and curative 
value in polyneuritis and beriberi vitamin B is called antineuritic. 
Vitamin C, water soluble, is found in fruit and vegetable juices, par- 
ticularly oranges, lemons, tomatoes, and potatoes. It is present also in 
small amount in raw milk. This vitamin is destroyed by heat. Its absence 
for a long period from the diet may lead to the development of scurvy. 
For this condition, moreover, it is specifically curative, consequently 
bearing the name antiscorbutic vitamin. 
Water, the remaining food constituent, comprises about 87 per cent, of 
milk and is present in large amounts in a wide variety of natural foods. 
In health its importance is not likely to be forgotten. Nevertheless, 
wrong notions on the part of the laity sometimes preclude adequate fluid 
intake in illness. For the digestion of food, the radiation of heat, the 
dilution of toxins in the circulation, and the proper functioning of the 
bowel and kidneys the administration of water by at least some avenue 
of entrance to the body must always be maintained. 
The Advantage of a Knowledge of the Composition of Foods.— 
Inasmuch as each food element has a special function to perform, and 22 
THE PRACTICE OF PEDIATRICS 
since growth is impossible without a sufficient supply of these nutri- 
tional elements, particularly the protein, it is essential to know within 
reasonable limits the composition of a food, because if the elements are 
not present in proper proportions, disappointing results may be obtained 
from its use. Difficulty which may appear inexplicable will readily be 
accounted for if we know what element of the food is at fault. For these 
reasons it is coming to be the practice, in infant feeding especially, to speak 
of the percentage composition of the milk foods, as, for example, a food 
containing 4 per cent, fat, 7 per cent, carbohydrate, 2 per cent, protein, 
and 0.35 per cent, mineral substances. Knowing from wide experience 
the percentages of these ingredients generally needed in a food if it is 
properly to nourish a child, the physician can determine in an instant 
whether an infant is having a food of suitable nutritive value by com- 
paring its known composition with that established, by experiment, as 
requisite. 
Values of Common Foods.—The following table shows the average 
chemical composition of a few of the more common American foods1: 
Food material. 
Water, 
per cent. 
Protein, 
per cent. 
Fat, 
per cent. 
Carbohy- 
drate, 
per cent. 
Calories 
per 
100 gm. 
Cooked: 
Roast beef 
48.2 
22.3 
28.6 
357 
Round steak (fat removed as pur- 
chased 
63 
27.6 
7.7 
185 
Tenderloin, broiled 
54.8 
23.5 
20.4 
287 
Beef juice 
93 
4.9 
0.6 
25 
Lamb chops, broiled 
47.6 
21.7 
29.9 
367 
Lamb, leg, roast 
67.1 
19.7 
12.7 
198 
Mutton, leg, roast 
50.9 
25.0 
22.6 
313 
Ham, smoked, broiled as purchased.. . 
51.3 
20.2 
22.4 
291 
Bacon, smoked 
20.2 
10.5 
64.8 
646 
Chicken, broiler 
69.7 
20.7 
8.3 
196 
Codfish, fresh, whole 
82.6 
16.5 
6.4 
1.2 
103 
Salmon, whole 
64.6 
22 
12.8 
1.4 
209 
Egg, boiled, 1 egg (50 gm.) 
36.6 
6.5 
6.0 
169 
Butter 
11 
1.0 
(Total, 
85.0 
1 egg 
83) 
795 
Milk, whole 
87 
3.3 
4.0 
5.0 
72 
Oatmeal, boiled 
84.5 
2.8 
0.5 
11.5 
63 
Rice, boiled 
72.5 
2.8 
0.1 
24.4 
112 
Bread, wheat 
36.7 
7.9 
4.8 
49.7 
281 
String beans, cooked 
95.3 
0.8 
1.1 
1.9 
21 
Peas, green, cooked as purchased. . . . 
73.8 
6.7 
3.4 
14.6 
119 
Potatoes, boiled 
75.5 
2.5 
0.1 
20.9 
97 
Spinach, cooked as purchased 
89.8 
2.1 
4.1 
2.6 
57 
Apples, edible portion 
84.6 
0.4 
0.5 
14.2 
64 
Bananas, edible portion 
75.3 
1.3 
0.6 
22 
101 
Oranges, edible portion 
86.9 
0.8 
0.2 
11.6 
53 
Calculation of Caloric Values from Food Composition Percentages.— 
In order to calculate the approximate quantity of heat energy available 
to the body from a given food we assume the physiologic fuel values as 
4.1 calories per gram for carbohydrate, 9.3 calories per gram for fat, 
and 4.1 per gram for protein.2 
1 Nutrition and Clinical Dietetics, Carter, Howe, Mason. 2 Ibid. FOOD PROPERTIES AND PHYSIOLOGIC REQUIREMENTS 
23 
The One Hundred Calorie Portion.—For rough computation one may 
base estimates on the 100 calorie portion into which many articles of 
food naturally fall.1 
Examples of food portions containing about 100 calories are as follows: 
Milk 5 ounces 
Meat 2 ounces (1 chop) 
Fish 3 ounces 
Bread 1 slice (3x3x1 inch) 
Potato 1 medium 
Sugar 2 tablespoonfuls 
Apple, orange 1 of good size 
Egg H 
Caloric Requirements.—The actual requirement in calories per diem 
depends on many factors, not the least important of which is the age of 
the individual whose needs are to be met. During infancy the caloric 
requirement usually accepted is 100 per kilogram or 45 calories per pound 
of body weight. During the first few weeks of life the requirement ranges 
from 25 to 35 calories per pound of body weight. 
The following table gives the calories per day required by children of 
different ages, as estimated by Miss Gillett.2 
FOOD ALLOWANCES FOR CHILDREN (GILLETT) 
Age, years. 
Calories per day: 
Boys. 
Girls. 
Under 2 
900-1200 
900-1200 
2-3 
1000-1300 
980-1280 
3-4 
1100-1400 
1060-1360 
4-5 
1200-1500 
1140-1440 
5-6 
1300-1600 
1220-1520 
6-7 
1400-1700 
1300-1600 
7-8 
1500-1800 
1380-1680 
8-9 
1600-1900 
1460-1760 
9-10 
1700-2000 
1550-1850 
10-11 
1900-2200 
1650-1950 
11-12 
2100-2400 
1750-2050 
12-13 
2300-2700 
1850-2150 
13-14 
2500-2900 
1950-2250 
14-15 
2600-3100 
2050-2350 
15-16 
2700-3300 
2150-2450 
16-17 
2700-3400 
2250-2550 
The basal requirements as determined by Benedict and Talbot are 
highest at about nine months and thereafter steadily diminish. 
Holt and Fales3 found that the average for three of the component 
factors which go to make up the total requirements (i. e., basal metabolism, 
growth, and excretion) is nearly uniform for children of the same weight 
under similar living conditions, but that the requirement for activity 
1 Vide Fisher’s Table of One Hundred Calorie Portions, Jour. Amer. Med. Assoc., 
1907, xlviii, 1320. 
2 Food Allowances for Healthy Children, Pub. 115, New York Assoc, for Improving 
the Conditions of the Poor, 1917. 
s Amer. Jour. Dis. Child., January, 1921. 24 
THE PRACTICE OF PEDIATRICS 
varies markedly. According to these writers the following is the average 
caloric requirement for children: 
At one year, 100 calories per kilo. 
At six years (for children weighing 20 kilos), 80 calories for boys, 76 
calories for girls. 
At ten to fifteen years, 80 calories for both sexes. 
After fifteen years for those weighing at least 50 kilos, about 48 calories. 
These investigations confirmed Benedict’s statement that a most lib- 
eral diet is desirable for children, since evidence indicates that children 
receive too little rather than too much food. 
The Value of Caloric Feeding.—The caloric standard in its application 
to infant feeding is further considered in a later section (p. 67). The 
method has been severely criticized and there is little doubt that its value 
is greater as a check than as a guide for the dietitian. Computations 
based upon weight alone are misleading and are being replaced by those 
which take into account the relation between body surface and basal 
metabolism. Upon this subject the work of DuBois, Benedict, Harris, 
Gephart, and others has been in the front rank. 
The Feeding Method of the Von Pirquet School.—This method was 
a direct outgrowth of needs existing in Vienna as a result of the World 
War. The founder concluded that the square surface of the intestinal 
canal was the best measure of the amount of food one required as a daily 
allowance, and he estimated this surface as equal to the square of the 
individual’s sitting height. He further coined the word “nem” (“nahrungs 
einheit milch,” nutritional unit milk) to express the value in energy of 1 
gram of mother’s milk. 
This was selected as the basic food in terms of which all diets were 
calculated with due allowance for the factors of age, activity, and illness. 
In the feeding of large numbers this ingenious method as applied 
abroad proved of great value. The system, however, has as yet not 
been generally adopted in this country, and whether the “nem” will re- 
place the calorie in our computations remains to be proved. 
The Selection of Food.—In a review of analyses of foods many sub- 
stances will be noticed which, according to their chemical composition, 
have the same food value, but which obviously are not interchangeable. 
For instance, no one would attempt to feed to a human being cracked 
oats unless thoroughly cooked, but he would give them raw to the lower 
animals. Oats will nourish a man or the animal equally well, but for man 
they must be prepared, while the horse, for example, can utilize them in 
their original state. This illustrates the importance of adapting food to 
the consumer. Often the question in feeding is not so much, Is the food 
nutritious? as, Can the patient assimilate it? Thus, success in infant 
feeding lies in the physician’s ability to discover a form of fat, carbohy- 
drate, and protein which the infant can assimilate. In the following pages 
feeding measures for temporary use will be described which may not 
conform to what may seem strictly scientific principle, yet often give 
brilliant results. Looking a little below the surface one will discover that 
the measures suggested are not unscientific, and that the results are due 
to applying the fixed principles of nutrition in perhaps novel or unusual AIDS TO NUTRITION 
25 
ways. It is usually best to follow the most direct route to any place, 
but when this is badly blocked it is better to go another way, if there 
is one, rather than not to arrive at one’s destination. 
General Properties of Milks.—When most young animals are born 
their digestive organs are in a more or less embryonic condition, and it 
is several months before they entirely outgrow this state. During this 
period the nourishment is supplied by the mother through her mammary 
glands, first as colostrum and later as milk. When these secretions are 
analyzed they are found to consist of fat, carbohydrate, protein, mineral 
substances, and water, and in this respect they do not differ from other 
foods. But the elements exist in the secretion in peculiar forms, and 
the natural inference is that in some way this food must be particularly 
suited to animals whose digestive organs are still undeveloped. 
The digestive secretions of the stomachs of all known animals contain 
pepsin and hydrochloric acid. In the very young these secretions are 
feeble, but as development proceeds they are much more abundant. 
To understand milk as a food one must know the effect upon it of pepsin 
and acid. When pepsin is added to tepid cow’s milk it causes the milk 
to solidify, with the formation of curd or junket. If the milk is slightly 
acidified or soured, the curd formed is dense and solid and more difficult 
of digestion. When the milk of the cow, of the ass, and human milk 
are separately treated with pepsin and acid in exactly the same way, 
curds totally different are formed, and as the human digestive organs 
are different from those of the cow or the ass, it is believed that these 
differences in the digestive properties of milks are for the purpose of mak- 
ing the milks suitable for the different kinds of digestive tracts. Milks 
may be regarded as special forms of food which require greater digestive 
effort as the digestive secretions of the stomach become stronger, and 
thus solid food is furnished to the developing stomach. It is that portion 
of the protein of the milk called “casein” that is changed into a solid by 
the pepsin of the stomach. The term “casein,” however, has been loosely 
applied to all the proteins of all milks. The caseins of all milks are not 
alike in their digestive properties and the mistake of so considering them 
should be guarded against. A consideration of such a modification and 
adaptation of cow’s milk as will make not only the protein but the other 
ingredients acceptable to the infant’s digestive capacity will be found 
in the chapters dealing with Substitute Feeding. 
Aids to Nutrition 
Fresh Air.—Doubtless the next most important factor after food and 
the means of giving it is good air. It is a just criticism of the average 
American that he is afraid of fresh air not only by night but by day. 
Ventilation is one of the most difficult features of a child’s management 
with which the physician has to deal. Mothers will feed the children in 
detail according to instruction and will bathe them and follow out to our 
satisfaction every order and direction. The stumbling-block is the open 
window. It is to be hoped that a knowledge of the means and results 
of treating tuberculosis by open-air methods, and the recent agitation 
concerning the treatment of pneumonia and other infectious diseases 26 
THE PRACTICE OF PEDIATRICS 
along similar lines, may so permeate the minds of the masses as to quiet 
their fears regarding dangers of outdoor air. 
While the child is out of the living-room or nursery the room should 
be ventilated by opening all the windows, when family conditions allow, 
the nursery always being aired in this way. The sleeping-room should 
always be aired for one hour before the child is put to bed. Indoor airing 
for which the child is dressed as for going out, placed in his carriage or 
cart, and wheeled up and down the room for an hour or two with the 
windows wide open regardless of the weather, is most satisfactory in 
treating very young and delicate children, and promoting convalescence 
from illness. On.inclement days the well child accustomed to his daily 
outing will be greatly benefited by the indoor airing. It is fully ap- 
preciated that such a course of management is impossible in many house- 
holds. The scheme is the ideal one, however, and should be followed out 
as closely as possible. 
The Window-board.—A convenient and simple means for ventilating 
the living-room, sleeping-room, or sick-room of a child in cold weather 
is what is known as the window-board. A plain inch board is sawed 
the width of the window-frame and placed under the raised window in 
the lateral frame groove, resting upon the sill. This raises the top of the 
lower sash above the bottom of the upper one, leaving a space between 
through which the air enters with the current directed upward. The 
board may be of any width—4, 6, or 8 inches. A width of 6 inches 
is commonly used. There are various ventilating devices in the market. 
Those that are of value are expensive, and their effectiveness over the 
simple means above suggested does not always warrant the expenditure. 
Sunlight.—Long before Rollier, who has been called the High Priest 
of Modern Sun Worshipers, opened his first clinic at Leysin in 1903, the 
value of sunlight had been appreciated. As heliotherapy is developed 
more highly and the relative value of the different component rays of the 
spectrum is being accurately determined, knowledge that had been only 
empirical is being established as scientific truth. “Who would have 
guessed,” wrote Saleeby,1 “that a few minutes’ exposure to sunlight 
will double the quantity of phosphorus in a baby’s blood in a fort- 
night.” 
Dick, writing of the geographic distribution of rickets, has shown a 
direct relationship between its incidence and the amount of sunlight 
available to the inhabitants of a country. Recently the fact that sunlight 
which traverses window glass is deprived of its actinic rays and is no 
longer appreciably curative has been established. 
In detail the effects of sunlight are to promote a rise in body tem- 
perature, surface pigmentation, better nutrition of skin and muscles, and 
increased reaction against disease foci, such as those of tuberculosis. Vari- 
ous skin diseases, tuberculosis, rickets, arthritis, lymphatic gland diseases, 
and even leukemia have all been benefited by the solar rays. 
To the growing child outdoor sunlight is a first essential. 
Suitable Clothing.—If this problem were submitted to the best ex- 
ponents of heliotherapy, the answer would be no clothing; for their 
work has shown conclusively that the body is soon inured to temperature 
1 Rollier, Heliotherapy, 1923, p. 17. AIDS TO NUTRITION 
27 
changes, and even when undergoing the depletion of actual disease, such 
as tuberculosis, may show most rapid recuperation if the surface is com- 
pletely exposed to light and air. Practically, however, the overheated 
modern apartment, on the one hand, and the slush-filled, wind-exposed 
street on the other, make for a situation that must be met by individual 
care. Particularly in the case of the delicate child proper clothing thus 
becomes a chief aid to nutrition. 
A mixture of silk and wool or linen mesh next the skin is uniformly 
desirable. For the infant the circular abdominal band is a physiologic 
asset, and this may well be worn until after the completion of the first 
year even when other clothing is very light, particularly if there is a ten- 
dency to gastro-enteritis, which is readily aggravated by chilling of the 
surface. Outer clothing rather than the underclothing should be varied 
to meet weather changes and should insure at all times warm hands and 
feet. Further than this one needs not to advise, particularly when every 
nursery is flooded with literature concerning the details of the baby’s 
and child’s habiliments. 
For a baby on very hot days a napkin, a muslin slip, and a band com- 
prise complete equipment. 
Bathing.—The necessity for the daily bath is appreciated and acted 
upon by nearly all classes of society. From the time the cord falls and 
the cicatrix forms, the well infant or child should have one tub-bath 
daily. If he is too ill for the tub, he is not too ill to be sponged. 
Relaxation.—The well child is naturally good natured and happy. 
When such is not the condition, we have not a well child to deal with. 
Something is wrong. Perhaps it is the home management. Adults often 
forget that exuberance of spirits and thoughtlessness belong to childhood. 
Persistent child nagging becomes a habit with many parents and teachers; 
in fact, irritable mothers usually have irritable children. Work involving 
strain, whether physical or mental, should form no part of the life of the 
child. In our modern school system the forcing process, the competi- 
tions, and the giving of rewards of merit are all pernicious practices. 
As a result of the competitive system, progress, to be sure, is made along 
intellectual lines, but at the expense of the physical; and what does intel- 
lectual attainment count for in a weakly or diseased body? A child 
cannot do hard mental work, such as is required of many children from 
the tenth to the fifteenth year, and be expected at the same time to develop 
to the best advantage physically. The appetite and digestive power, 
the capacity for taking and assimilating food, is diminished. The result 
is apparent in hundreds of cases. On the streets in New York two pictures 
always fill us with pity. One is that of the pale, slender school-girl strug- 
gling home with a load of books. (Such a child had 11 text-book studies 
besides piano and dancing lessons!) When the question is asked the 
child or the parents as to the necessity for all this work and worry and 
the close confinement which it entails, the reply almost invariably is that 
all the girls of her age do the same and she does not want to be behind. 
The other picture is that of the “little mother”—a pale, wan, tired child 
from seven to twelve years of age who “minds the baby” and the other 
younger members of the household while their mother is away from 
home or at work. Children so abused are happily growing fewer, owing 28 
THE PRACTICE OF PEDIATRICS 
to various factors which need not be discussed. It is needless to say 
that neither type of girl makes the ideal woman or mother in any station 
in life. The condition of boys who work in factories, sweat-shops, or else- 
where is no better. When too much energy is expended in work, food 
cannot go to the building up of a strong, normal body. The State is 
the loser and the child is robbed of his birthright. 
It is the duty of physicians to explain in detail to parents their re- 
sponsibility as regards the physical welfare of their children. Parents, 
as a rule, are ignorant concerning a child’s management; but they are 
anxious and willing to do the best things possible, and will carry out sug- 
gestions if we take the trouble to enlighten them as to their errors. 
Sleep.—The infant who sleeps well is almost always a normal, well- 
fed baby. Irritability and sleeplessness are associated with indigestion 
more frequently than with any other disorder. During the first few days 
of life the sleep, in normal conditions, is almost unbroken, except when 
the infant is fed. During the first month the infant sleeps about twenty- 
two hours out of every twenty-four; during the second and third months, 
from twenty to twenty-two hours. At the sixth month the child should 
sleep from 6 p. m. to 6 a. m. without interruption except for feeding or 
nursing, which need cause very little disturbance. At this age there 
should be a two-hour nap during the morning and a two-hour nap in the 
afternoon, although it is not well to have the baby sleep after 3 o’clock 
in the afternoon. The twelve-hour night rest should be continued until 
the child is six years of age. The day naps will gradually be shortened 
by the child. At one year of age one hour in the morning and two hours 
in the afternoon suffice. From the eighteenth month to the second year 
the morning nap may be given up. Afternoon rest for at least one and 
one-half hours should be continued until the sixth year of age, and longer 
if the child is inclined to be delicate. Regular sleep is largely a matter 
of habit, and if the infant is started right with suitable feedings given 
at definite times, followed by the proper period of sleep, little trouble 
will be experienced. When sleep is disturbed and broken the condition 
means bad habits, unsuitable food, minor forms of indigestion, or positive 
illness of some kind. Sleep is important for purposes of growth, not 
only in early infancy but throughout childhood. Not a few infants form 
habits of sleeping in the daytime and being wakeful at night. This is 
best remedied by keeping the baby awake during the day by entertain- 
ment and by keeping him in a well-lighted room. A proper amount of 
sleep is most essential to nutrition, and we are sure that the satisfactory 
results achieved in the treatment of secondary malnutrition and anemia 
have been due in part to insistence that the child sleep in a quiet, darkened 
room for two hours after the noon-day meal. The energy expended in 
twelve hours by an active child is incalculable, and when a portion of 
this energy is reserved and the body fortified by rest and sleep dui'ing 
the middle of the day, there is a greatly diminished daily expenditure 
of strength units. 
Crying as Exercise.—Notwithstanding the desirability of sufficient 
sleep it is well for the young infant to cry a little every day. Muscular 
movements involving a greater part of the body accompany the act 
of crying and furnish exercise. Peristalsis is increased, as is often evi- AIDS TO NUTRITION 
29 
denced by a movement of the bowels occurring during crying, particu- 
larly when there is diarrhea. In crying, deep breathing is necessary, the 
lungs are expanded, and the blood oxygenated. In this respect crying 
itself is an aid to growth and development. The well baby cries when 
frightened, or uncomfortable from hunger, soiled napkins, or irritated 
buttocks. He cries from pain, from heat, from cold, from unsuitable 
clothing, and during difficult evacuation of the bowels. He also cries 
when displeased or angry. 
Authors are prone to refer to the diagnostic value of an infant’s cry. 
It is probable that characteristic cries are not to be depended upon suffi- 
ciently to give them a differential diagnostic dignity. Children slightly 
but painfully ill may cry incessantly for an hour or two. Thus, with 
intestinal colic, the cry is loud and continuous until the child is relieved 
or falls asleep from exhaustion. Earache is not an infrequent cause. 
The habitual criers, the restless and vigorous, crying, whining infants, 
are uncomfortable. With very few exceptions the trouble will be found 
in the intestinal tract. The well-trained, normal child, whose nourish- 
ment is suitable, is seldom troublesome. When well, all babies are naturally 
good natured and happy in their own way. Badly managed, spoiled 
infants often cry vigorously when left alone. When attention is given 
them, when they are taken up and talked to, the crying ceases. This 
readily tells us that pain or discomfort was not an element in causing 
the cry. By these infants discipline, not medication, is needed. The 
management of the habitual crier calls for the relief of the condition 
which causes the discomfort, or the most rigid discipline, when it is dem- 
onstrated that we are dealing with a “spoiled infant.” 
The Nursery Maid.—In certain stations and conditions of society the 
young child is cared for by the mother with the assistance of the im- 
mediate members of the family. In thousands of homes, however, a helper 
is employed to take charge of the child or assist in the care. The selection 
of a nursery maid is consequently a matter of much importance. Schools 
for training nursery maids exist in New York, Boston, Albany, Newark 
(New Jersey), and doubtless in many other cities. Although such trained 
help is greatly to be desired, the supply is very limited. Some of the 
best children’s attendants have been women who, although they have not 
passed the meridian of life, still have reached the seasoned age when 
the attractive qualities of policemen and grocery boys have faded into 
a dim recollection. Any industrious, sensible young woman of quiet 
tastes who is fond of children can be trained in a few weeks into a most 
useful helper. The association of the nursery maid and child is a close 
one, and it is the physician’s duty to know that the applicant is phys- 
ically fit for the position. 
During a single year the senior writer has known of three nursery 
maids who developed pulmonary tuberculosis while in service. Numerous 
similar instances have been cited by other observers.1 Not only should 
the applicant’s lungs be examined but also the mouth, nose, and throat. 
Carious teeth and .diseased conditions of the throat and nose should 
receive careful attention before the maid is allowed to assume the position. 
1 Healthy Servants Only in a Healthy Home, by Charles Hendee Smith, M. D., 
Bulletin of New York Tuberculosis Association, vol. iii, No. 4. 30 
THE PRACTICE OF PEDIATRICS 
It is also important that something of the applicant’s previous life should 
be known. 
One of the most important things to know about an applicant in a 
large city, and one most difficult for the physician to discover, is the ex- 
istence of leukorrhea, or vaginal discharge.1 This, however, can usually 
be discovered by the tactful young mother. Not only should the ideal 
nursery maid be physically fit, she must be mentally fit as well. For 
proper mental and physical development children must be entertained 
and pleasantly employed. An ill-natured, impatient nurse should be 
forced to seek other employment. It should not be a task for a child’s 
attendant to play with him. A woman should not be condemned, how- 
ever, because she fails with any given child. With a child differently 
situated, with a different temperament, the results may be perfectly 
satisfactory. 
The Nursery.—This should be the largest and best ventilated room 
in the house. In a city home the room may well be located on the 
third or fourth floor, with a southern exposure. In apartments, quiet, 
and the possibility of free ventilation and sunlight must be considered 
in selecting the room. For the sake of quiet the nursery should not 
communicate with the sleeping-rooms of older children. 
In placing children in sleeping-rooms or in a nursery, or in estimating 
the capacity of hospital wards for children, it is to be remembered that 
at least 1000 cubic feet of air space should be allowed to each child. 
The floor of the nursery should not be carpeted. A hardwood floor 
is best. If this is not possible, covering the floor with oil-cloth or lino- 
leum is always possible. This can be cleaned with a damp cloth every 
day. A broom should never be used in a nursery. Paint or hard finish 
on the walls is preferable to paper. There should be at least two win- 
dows and an open fireplace. If possible, the bath-room should be con- 
nected with the nursery, to be used not only for bathing the child but 
as a “changing room.” The child’s napkins should not be changed in 
a living-room if it can be avoided. It is needless to say that napkins 
should never be dried in the nursery. 
Steam heat as ordinarily used today is the least desirable means 
of heating on account of its uncertainty. In many New York apart- 
ments of the better class the fires are banked at 10 p. m.; the tem- 
perature when the child retires is from 70° to 80° F. or more; by 5 or 6 
o’clock in the morning a fall to 50° or 60° F. has taken place. Such a 
change in the temperature, with the tendency of children to kick off the 
bedclothes, explains many cases of tonsillitis and bronchitis. The tem- 
perature of the nursery should be kept as even as possible. When for 
any reason this cannot be controlled, it is best to have two means of 
heating, so that when one fails the other may be used. The open-grate 
fire or a small wood-stove is best. Gas should never be employed as 
a means of heating a child’s sleeping-room on account of the rapid ex- 
haustion of the oxygen which results. 
The furniture of the nursery should be of the plainest. Hardwood 
chairs and tables with enamel or brass cribs or bedsteads should be used. 
There should be no article of furniture or furnishings in a nursery that 
1 A very severe gonorrhea was contracted by one patient from a nursery maid. AIDS TO NUTRITION 
31 
cannot be washed. In the bath-room or in some adjoining room a pail 
should be kept containing some disinfectant solution, such as carbolic 
acid, 1 : 100, or carbonate of soda solution, 1 ounce to 2 gallons of water, 
in which the napkins are placed as soon as soiled. 
There should be two shades at each window, a light and a dark one, 
so that it will be possible to darken the room during the sleeping time, 
as well as to exclude the early morning light, which is the usual cause 
of too early waking. Babies should be taught to sleep until at least 6 
o’clock in the morning. This is far better for the child and also for the 
mother if she occupies the same room. The unnecessary habit of an 
early waking at 4 or 5 o’clock will in most instances readily be broken 
by keeping the room dark. 
The nursery should have suitable means for ventilation. For this 
purpose, aside from the fireplace, the window-board is of no little service 
(p. 26). 
There should be a thermometer in every child’s living-room or nursery. 
It should register from 70° to 72° F. by day and from 65° to 68° F. by 
night. The nursery should be given an hour’s airing twice a day. The 
child should sleep in a crib, alone, not with an adult or an older child. 
The old-fashioned cradle in which generations have been rocked may 
be an interesting heirloom, but under no circumstances should it be re- 
moved from its place in the garret. It is realized that the above sug- 
gestions are not applicable in many homes. Nevertheless, if we aim at 
the ideal, existing conditions, no matter how unpromising, will invariably 
be made better. 
The Nursing-bottle and Nipple.—There are two requirements that 
a nursing-bottle must fulfil: it must have a capacity sufficient for one 
full feeding and it must be so constructed as to be readily cleansed. The 
oval bottle with rounded edges answers best. These may be obtained 
in sizes of from 3 to 9 ounces. As many bottles are needed as there 
are feedings in twenty-four hours. The bottles should be boiled once 
a day, scrubbed with a stiff brush with hot borax water, and remain 
in the borax water until needed. Two teaspoonfuls of borax to a pint 
of water is the strength usually used. Before using, bottles should be 
rinsed in plain boiled water. The straight black nipple is also preferred, 
for the reason that it can be turned inside out and easily cleansed. A 
nipple which cannot be turned should never be used. After use the 
nipple should be turned and scrubbed with a stiff brush and borax water 
—a tablespoonful of borax to a pint of water. When not in use the 
nipple should be kept in borax water, and before being placed on the 
bottle it should be rinsed in boiled water. The nipple should be boiled 
once a day. The blind nipples—those without holes-—are the best. 
Holes of the required size may be made with a red-hot cambric needle. 
For the administration of thick feedings which are not easily intro- 
duced into the ordinary feeding bottle, the “Hygeia” bottle and nipple 
have proved satisfactory. 
The Breck feeder is described on p. 165. 
Baskets for Early Exercises.—It is a mistake made in many families 
to have the baby in the arms a greater part of his waking hours. This 
practice should be discouraged by physicians, for when the child is held 32 
THE PRACTICE OF PEDIATRICS 
there is always a tendency to make him sit upright on the arms or knee 
without proper support. During the early months of life the vertebrae 
and vertebral ligaments are not sufficiently developed to support the heavy 
head and trunk. If this thoughtlessness on the part of parents with its 
attendant dangers were explained, there would be fewer cases of displaced 
scapulae and spinal curvature to be treated later. Many cases of spinal 
curvature are the direct outcome of such early abuse of the spinal col- 
umn. Still, it is not desirable that the infant should constantly occupy 
the crib. A large clothes-basket in which a thick blanket and pillow 
have been placed affords a safe playground for a small baby. For the 
first few months he will lie on his back and amuse himself in his own pecu- 
liar way. After the sixth month, when he may be allowed to sit up for 
a short time each day, a pillow should be placed behind his back for 
support. The basket supplies plenty of room for toys and other means 
Fig. 1.—Scoop and platform scale. 
of entertainment. When the child begins to stand and attempts to walk 
the basket period is at an end and the exercise pen (p. 839) or screened 
“coop” should be brought into use. 
Scales.—A scale for weighing the baby is a very necessary adjunct 
to the nursery furnishings. There are several varieties of scales on the 
market known as “baby scales.” Their usual construction provides for a 
basket for holding the baby, the basket being supported by a steel rod 
which rests upon a spring. A needle indicates on a dial the weight of 
the child. This variety of scale is very unsatisfactory: it gets out of 
order easily, it is expensive, and with a vigorous, kicking child, the rapid 
oscillation of the needle makes an accurate reading of the weight difficult 
if not impossible. Further, the weight capacity of these scales is but 
20 pounds. When the child’s weight reaches this figure it necessitates 
the purchase of another scale. The scoop and platform scales used by 
grocers (Fig. 1) are best. They do not easily get out of order, they WEIGHT 
33 
weigh correctly from \ ounce to 280 pounds, and, being very simple in 
construction, they can readily be understood. The infant rests on his 
back in the scoop during the weighing process; older children stand on 
the platform. 
Normal Development 
weight 
The average weight of the full-term, newborn infant varies from 6 
to 9 pounds. Some are born at term weighing less than 6 pounds, 
and a few weighing over 9 pounds, but in the great majority the birth 
weight will be found between these figures. Holt found from a study of the 
records of three large maternity institutions in New York city as follows: 
The average weight of 568 females was 7.16 pounds. 
The average weight of 590 males was 7.55 pounds. 
Every family which can afford it should have a scale (p. 32) for 
weighing the baby, for only by regular weighing during infancy and 
childhood can we gain an accurate knowledge of growth. During the 
first three days of life there is usually a loss in weight of 9 or 10 ounces, 
according to Holt’s record, 11 per cent, of the birth weight. After this 
initial loss, which may be expected, but which does not always occur, a 
weekly gain in weight is to be looked for, the child regaining the birth 
weight on the eighth or tenth day. At first it is advisable to weigh twice 
a week, or even daily, if the child is not progressing satisfactorily. After 
the second month, when the infant is making satisfactory progress, a 
weekly weighing will answer, and this should be continued until the 
child is one year of age. During the second year bimonthly weighings 
are sufficient. Girls of the same age, after the first year, will average 
from \ to 1 pound lighter than boys. During the third year monthly 
weighings will be sufficient to enable one to keep in touch with the 
child’s condition. During the first six months of life a weekly gain of 
4 to 8 ounces has been made by well children. When a child does not 
make at least an average gain of 4 ounces weekly we do not put him in 
the “doing well” class, but look into his care and nutrition to learn what 
is wrong. Children vary in growing capacity. Some will increase in 
weight rapidly, gaining 4 ounces a day, while others will make a slower 
gain and yet be perfectly well. Through the care of many children we 
have come to regard 4 ounces as the minimum weekly gain for a well 
child. In a well infant the birth weight should be doubled by the fifth 
or the sixth month, and at one year the weight should be a little over 
two and one-half times that at birth. During the second year a gain 
of 5| to 7 pounds will usually result under proper conditions. During 
the third year from 5 to 6 pounds will be added. It is not to be in- 
ferred that these are arbitrary figures or that perfectly well children may 
not be under or above the figures given at the ages mentioned. These 
figures are, however, to be regarded as the average for the different ages. 
Suggestions for the memorizing of weight and height figures are offered 
on p. 41. 
A weight chart with its colored “normal” line will not be found in 
this book, and physicians are advised against its use. Time and again 
one sees well infants, though slow in growth, made ill by overfeeding, 34 
THE PRACTICE OF PEDIATRICS 
in the vain attempts of an ambitious mother or nurse to keep her infant 
up to the “normal” line. It may be said that the weekly weighing might 
have similar effect; not so. Here there is nothing for comparison—no 
normal red line “staring” the mother in the face. 
The weighing alone is not sufficient to inform us absolutely concern- 
ing the development of children. Condensed milk babies may show 
WEIGHT 
—HEIGHT—AGE TABLE 
FOR 
BOYS 
Height 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
Inches 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
38 
34 
34 
39 
35 
35 
40 
36 
36 
41 
38 
38 
38 
42 
39 
39 
39 
39 
Sa 
fcs. 
43 
41 
41 
41 
41 
Pn 
44 
44 
44 
44 
44 
jJ 
L 
X 
45 
46 
46 
46 
46 
46 
X 
40 
47 
48 
48 
48 
48 
Wr 
47 
49 
50 
50 
50 
50 
50 
v 
48 
52 
53 
63 
53 
53 
49 
55 
55 
55 
55 
55 
55 
50 
57 
58 
58 
68 
58 
68 
68 
51 
61 
61 
61 
61 
61 
61 
52 
63 
64 
64 
64 
64 
64 
64 
63 
66 
67 
67 
67 
67 
68 
68 
64 
70 
70 
70 
70 
71 
71 
72 
65 
72 
72 
73 
73 
74 
74 
74 
50 
75 
76 
77 
77 
77 
78 
78 
80 
57 
79 
80 
81 
81 
82 
83 
83 
58 
83 
84 
84 
85 
85 
86 
87 
59 
87 
88 
89 
89 
90 
90 
90 
60 
91 
92 
92 
93 
94 
95 
96 
61 
95 
96 
97 
99 
100 
103 
106 
62 
100 
101 
102 
103 
104 
107 
111 
116 
63 
105 
106 
107 
108 
110 
113 
118 
123 
127 
64 
109 
111 
113 
115 
117 
121 
126 
130 
65 
114 
117 
118 
120 
122 
127 
131 
134 
66 
119 
122 
125 
128 
132 
136 
139 
67 
124 
128 
130 
134 
136 
139 
142 
68 
134 
134 
137 
141 
143 
147 
69 
137 
139 
143 
146 
149 
152 
70 
143 
144 
145 
148 
151 
155 
71 
148 
150 
151 
152 
154 
159 
72 
153 
155 
156 
158 
163 
73 
157 
160 
162 
164 
167 
74 
160 
164 
168 
170 
171 
PREPARED 
BY BIRD 
T. 
BALDWIN, PH.D., AND THOMAS D 
WOOD, M.D. 
These new Weight-Height-Age Tables, 
which are similar to 
the Wood Tables (formerly issued by the Child Health Organiza- 
tion of America), are the most accurate available. * 
These tables should be used as a 
means of interesting the 
child in his growth, and as a factor in determining the child’s 
health and nutrition.** 
* Representing 
a large group of presumably healthy children most of 
whom 
are 
native 
born. Tables for technical workers with detailed inf or- 
motion can be secured from the American CHILD HEALTH Association. 
** Encourage the annual 
Physical examination of 
every child 
by a 
physician. 
a most satisfactory weight curve, yet on examination may be found 
by no means up to the requirements for their age as regards bone and 
muscle development. A nursing or bottle baby should be examined once 
a month in order to determine if the progress is along the desired lines 
as shown by the condition of the teeth, the fontanels, the long bones, 
and the muscles. HEIGHT 
35 
HEIGHT 
From the standpoint of health or development height is of no great 
significance. The length at birth usually varies from to 21 inches. 
Children suffering from tardy malnutrition, particularly if syphilitic, 
may be undersized. Not a few of the non-specific malnutrition and 
WEIGHT- 
-HEIGHT- 
-AGE TABLE FOR 
GIRLS 
Height 
5 
6 
7 
8 
9 
10 
li 
12 
13 
14 
15 
16 
17 
18 
Inches 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
Yrs. 
38 
33 
33 
39 
34 
34 
40 
36 
36 
36 
41 
37 
37 
37 
42 
39 
39 
39 
jA 
43 
41 
41 
41 
41 
/\ 
44 
42 
42 
42 
42 
A 4 
s 
45 
45 
45 
45 
45 
45 
\ 
46 
47 
47 
47 
48 
48 
mr 
47 
49 
50 
50 
50 
50 
50 
w 
48 
52 
52 
52 
52 
53 
53 
49 
54 
54 
55 
55 
56 
56 
50 
56 
56 
57 
58 
59 
61 
62 
51 
59 
60 
61 
61 
63 
65 
62 
63 
64 
64 
64 
65 
67 
53 
66 
67 
67 
68 
68 
69 
71 
54 
69 
70 
70 
71 
71 
73 
55 
72 
74 
74 
74 
75 
77 
78 
56 
76 
78 
78 
79 
81 
83 
57 
80 
82 
82 
82 
84 
88 
92 
68 
84 
86 
86 
88 
93 
96 
101 
59 
87 
90 
90 
92 
96 
100 
103 
104 
60 
91 
95 
95 
97 
101 
105 
108 
109 
Ill 
61 
99 
100 
101 
105 
108 
112 
113 
116 
32 
104 
105 
106 
109 
113 
115 
117 
118 
63 
110 
110 
112 
116 
117 
119 
120 
64 
114 
115 
117 
119 
120 
122 
123 
65 
118 
120 
121 
122 
123 
125 
126 
66 
124 
124 
125 
128 
129 
130 
67 
128 
130 
131 
133 
133 
135 
68 
131 
133 
135 
136 
138 
138 
69 
135 
137 
138 
140 
142 
70 
136 
138 
140 
142 
144 
71 
138 
140 
142 
144 
145 
PREPARED BY BIRD 
f. BALDWIN, 
PH.D. 
AND 
THOMAS D. WOOD, M.D, 
When taking measurements, remove the child’s outdoor cloth- 
ing, shoes and coat. 
Take heights with a square, consisting of 
two flat pieces of wood joined at right angles (a chalk box will 
-serve) 
. The child is placed 
in a good erect position, with heels 
and shoulders against the wall or wide board, upon which has 
been marked or pasted 
an 
accurate measure. 
Age is taken to 
the nearest birthday. 
Published by 
The American CHILD HEALTH Association 
370 Seventh Avenue, New York City 
© BY A C. H. A. 2ND EDITION SOM > 23 
anemic children are tall and thin. It is often a matter of no little distress 
to parents that their children are undersized. Short mothers and fathers 
cannot expect very tall children. If the latter have right care, they will 
probably be larger than the parents, but cannot be expected to grow 
as much as playmates whose fathers and mothers are tall. The height 
bears much less relation to the condition of the child than does the weight. 36 
THE PRACTICE OF PEDIATRICS 
The following table, taken from Holt and Howland,1 gives the figures 
for weight, height, chest, and head circumference from birth to three years 
of age: 
AVERAGE NET WEIGHT, HEIGHT, AND CIRCUMFERENCE OF HEAD 
AND CHEST OF HEALTHY CHILDREN FROM BIRTH TO THREE 
YEARS 
Age. 
Sex. 
Weight. 
Height. 
Chest. 
Head. 
Pounds. 
Kilos. 
Inches. 
Cm. 
Inches. 
Cm. 
Inches. 
Cm. 
Birth 
Boys. 
Girls. 
7.55 
3.43 
20.6 
52.5 
13.4 
34.2 
13.9 
35.2 
7.16 
3.26 
20.5 
52.0 
13.0 
33.0 
13.5 
34.3 
6 months 
Boys. 
Girls. 
16.0 
15.5 
7.26 
7.03 
26.5 
26.0 
67.4 
66.1 
16.5 
16.1 
41.9 
40.8 
17.0 
16.6 
43.2 
42.3 
12 months 
Boys. 
Girls. 
21.0 
20.5 
9.54 
9.31 
29.5 
29.0 
75.0 
73.7 
18.0 
17.5 
45.7 
44.5 
18.0 
17.5 
45.7 
44.5 
18 months 
Boys. 
Girls. 
24.5 
23.7 
11.13 
10.77 
31.5 
31.0 
80.0 
78.8 
18.7 
18.2 
47.8 
46.2 
18.6 
18.0 
47.5 
45.7 
2 years 
Boys. 
Girls. 
27.0 
26.0 
12.27 
11.81 
33.5 
33.0 
85.1 
83.8 
19.3 
18.8 
49.1 
48.0 
19.2 
18.6 
48.7 
47.5 
2§ years 
Boys. 
Girls. 
29.7 
28.7 
13.50 
13.04 
35.5 
35.0 
90.2 
89.0 
19.8 
19.3 
50.4 
49.1 
19.5 
19.0 
49.5 
48.2 
3 years 
Boys. 
Girls. 
32.0 
31.0 
14.54 
14.09 
37.0 
36.5 
94.0 
92.8 
20.3 
19.8 
51.5 
50.4 
19.8 
19.4 
50.4 
49.3 
About what should be the relation existing between the height and 
weight for boys and girls of five years and over is shown by the tables 
on pages 34 and 35, prepared by Dr. Thomas D. Wood and published by 
the Child Health Organization.2 
THE HEIGHT AND WEIGHT RATIO 
The Midpoint of the Body.—At birth the midpoint is above, and at 
one year just below, the umbilicus. At six years the midpoint is midway 
between the symphysis and umbilicus, and in adult life at the symphysis. 
The Head and Chest Circumferences.—The figures for these measure- 
ments are included in the table above. 
The development of the head is a good criterion of the growth of the 
brain which determines the size of the skull. The skull circumference 
increases about | inch per month during the first half of the first year and 
j inch per month during the last half of the first year. 
The chest circumference follows very closely that of the head till the 
third year, then increases much more rapidly than the growth of the 
head, the increase in chest circumference averaging 1 inch per year from 
the first to the fifteenth year. 
STANDARDS OTHER THAN WEIGHT AND HEIGHT 
1 Diseases of Infancy and Childhood, 1923, p. 22. 
2 Copyrighted 1918 by Child Health Organization, 156 Fifth Ave., New York. THE TEETH 
37 
The Abdomen.—The abdominal measurement corresponds closely to 
that of the chest up to the third year, at which time the measurements 
of head, chest, and abdomen are all about equal. 
The Fontanels.—The lateral are closed at birth, the posterior is closed 
at two to four months, and the anterior at about eighteen months. At 
one year the diameter of the anterior fontanel is normally about 1 inch. 
The Blood.—The composition of the blood presents marked differences 
dependent upon age. The characteristics of greatest significance in the 
blood of infancy are mentioned on page 430. 
The Gastric Capacity.—The anatomic capacity is the actual holding 
volume of the stomach as determined by the measurement of water 
poured in postmortem at a pressure of 15 cm. 
The physiologic capacity represents what an infant can take and retain 
at a nursing. By reason of the fact that immediately after its ingestion 
milk begins to leave the stomach and pass into the intestine the rule 
that physiologic capacity is greater than anatomic capacity is readily 
explained. 
Figures representing the anatomic capacity as determined postmor- 
tem by Holt are in part as follows: 
Birth 1.2 ounces 
4 weeks 2.0 “ 
8 weeks 3.37 “ 
12 weeks 4.5 “ 
6 months 5.75 “ 
Mosenthal,1 in a study of 24 cases, found that an amount of 3.6 ounces 
was ingested at a nursing when the anatomic gastric capacity (determined 
postmortem) was only 2.6 ounces. 
THE TEETH 
Twenty teeth comprise the first set. In the well child the first tooth 
usually appears between the sixth and the eighth months; the first teeth 
may, however, in perfectly normal cases, come earlier or much later. 
A perfectly well, vigorous child may not show a tooth until the thirteenth 
month. The first teeth are usually the two lower central incisors. The 
four upper incisors and the two lower lateral incisors appear normally 
between the eighth and the tenth months. The first four molars appear 
between the twelfth and the fifteenth months; the four canines between 
the eighteenth and the twenty-fourth months; the four posterior molars, 
which complete the first set, between the twenty-fourth and the thirtieth 
months. This regularity in the appearance of the teeth is by no means 
constant, even in well children. Repeatedly one sees the upper central 
incisors cut first. Rarely the upper lateral incisors have appeared first. 
In delayed dentition in rachitis and other forms of malnutrition the 
teeth are very apt to appear irregularly. In a markedly rachitic dis- 
pensary patient the bicuspids were the first teeth cut. 
The 'permanent set consists of 32 teeth. The second dentition begins 
about the sixth year, and is usually completed about the twentieth year, 
although it may be delayed several years. The permanent teeth appear 
in somewhat the following order: 
1Arch. Ped., 1909, xxvi, 761. 38 
THE PRACTICE OF PEDIATRICS 
First molars sixth year 
Central incisors sixth to seventh year 
Lateral incisors seventh to eighth year 
First bicuspids ninth to tenth year 
Second bicuspids ninth to tenth year 
Canines eleventh to twelfth year 
Second molars thirteenth to fifteenth year 
Third molars after the eighteenth year 
Care of the Teeth.—As soon as the teeth appear they require at- 
tention. Until the second year is reached the mouth should be cleansed 
at least twice a day with a solution of boric acid—f ounce to a pint 
of water. This can best be done by means of absorbent cotton wound 
around the tip of a clean index-finger and afterward dipped in the solu- 
tion, which should be applied with gentle friction to the gums and teeth. 
When a child is two years old it is well to begin the use of a soft tooth- 
brush and a simple tooth-powder composed of the following ingredients: 
Precipitated chalk 5j 
Bicarbonate of soda 3j 
Oil of wintergreen .. q. s. 
The child should also be instructed as to the proper use of a quill 
toothpick. The teeth of every child over two years of age should be 
examined by a dentist every six months. Cavities discovered in the 
first teeth should be filled with a soft filling. 
The milk teeth are lost between the sixth and the eighth years. They 
should not decay, but fall out or be forced out by the second set. 
The Calcification of the Teeth.—This begins in utero. The normal 
progress of calcification is most important if the permanent teeth are to 
present no hypoplasia or deficiency of enamel. 
In a consideration of the teeth in rickets, Dick1 has clearly shown 
by diagram the steps by which calcification proceeds and the effects of 
hypoplasia of enamel due to rickets, as exhibited in the permanent set. 
Of this set the central and lateral incisors, the canines and the first molars, 
undergo comparatively advanced calcification in the first two years of 
life. Consequently these teeth in late childhood show the extensive 
inroads of a possibly forgotten rickets which has conformed to the fairly 
constant law of incidence and greatest activity between the ages of six 
months and two years. (See page 123.) 
SPECIAL MENTAL AND PHYSICAL DEVELOPMENT IN THE INFANT 
Dr. Frederick Peterson,2 of New York, made an exhaustive study of 
the mental development of the newborn. 
In all, 1060 newborn infants were examined, the observations ex- 
tending for one year. His observations, which are to be looked upon 
as authentic, are as follows: 
“1. Sight.—Sensibility to light is present in most infants at birth, 
and this is the case even in those prematurely born. The optic nerve 
1 J. Lawson Dick, Rickets, 1922. 
2 Bulletin, Lying-in Hospital, December, 1910. SPECIAL MENTAL AND PHYSICAL DEVELOPMENT IN THE INFANT 
39 
is, therefore, already prepared to receive impressions, sometimes even 
before the time of normal birth. 
“2. Hearing.—Sensibility to sound is quite as apparent as sensibility 
to light at birth, for 276 normal white children reacted to sound on the 
first day of life and 146 reacted to light. A similar condition existed 
among the premature infants, many reacting to sound on the first day 
as well as to light. The auditory nerve is already prepared to receive 
impressions of sound sometimes before the period of normal birth. This 
is wholly contrary to the opinions of other authorities. 
“3. Taste.—The gustatory nerve not only reacts differently to salt, 
Sweet, bitter, and sour at birth, but the same mimetic reactions are ob- 
served in premature infants. This nerve is, therefore, ready to receive 
taste impressions some time before the normal period of birth. 
“4. Smell.—T 'wo hundred and seven normal white children reacted 
to odors on the first day of birth, and similar reactions were observed 
in premature infants. The olfactory nerve is ready to receive smell 
impressions some time before the end of the normal period of gestation. 
“5. Cutaneous Sensibility.—Reactions to touch and temperature 
and affective manifestations of discomfort, obtained the first day in 
large numbers of normal infants, were similarly obtained in premature 
infants, showing that such sensibility is already present before the ex- 
piration of the period of normal gestation. There is every reason to 
believe that sensitiveness to painful stimuli is present, but the reactions are 
more vague and uncertain than in later life, which leads many to assume 
that the sense of pain is dull in the newborn. Muscular sense cannot be 
tested in infants, but there is every reason to believe that muscular sense, 
the sense of motion, and sense of position are developed early in utero. 
"6. Thirst-hunger and Organic Sensation.—The newborn child 
frequently reacts to thirst-hunger on the first day, though the actual 
need of food is seldom apparent until after the first or second day. Dis- 
comfort is clearly marked when nourishment is not forthcoming. The 
cries of discomfort and pain are marked in the first day in full-term infants 
and noteworthy in the premature. 
“7. The Beginning of Memory, Feeling, and Consciousness in the 
Newborn Child.—There are good grounds for believing that the new- 
born child comes to the world already with a small store of experiences 
and associated feelings and shadowy consciousness. The fact that even 
in premature infants we find the senses already prepared for the recep- 
tion of impressions on the five senses is some evidence of such impres- 
sions having been already received and stored up in the dim storehouse 
of a memory already begun. It may even be that some sort of vague 
light impressions have been received, for it is possible that in the interior 
of the body the alternation of day and night may in a mild degree be 
manifested. The transillumination of the hands before a candle, of the 
skull and face bones by examination of the frontal sinuses and antrum 
with electric lights, are evidences of a certain amount of translueency 
of the whole organism to sunlight, which is so much more powerful than 
any artificial light. There is greater possibility in the matter of the 
auditory sense, that it may be stimulated by sounds within the body 
of the mother (by bone conduction possibly)—such sounds as the beats 40 
THE PRACTICE OF PEDIATRICS 
of the maternal and fetal hearts, the uterine and funic souffles, and the 
bruit of the maternal aorta. 
“Moderate stimulation of the gustatory nerve is thought to occur 
through the common swallowing of amniotic fluid by the fetus. 
“A marked development of receptivity in the senses of touch and of 
muscular sense during uterine life is undisputed. Movements begin 
considerably before the sixteenth week of pregnancy, and increase in 
character and extent from that time on. Often they are so violent as 
to be painful to the mother. The activity of the muscles and constant 
contact of various parts of the fetal body with the uterine walls for a 
period of months before birth must lay a foundation under the threshold 
of consciousness for a sense of equilibrium and vague spatial relations. 
The material basis of consciousness is prepared long before birth. 
“There is already a feeling tone associated with the earliest reactions, 
though we are altogether in the dark as regards its psychophysiology. 
The process has been thus formulated: Stimulus—reaction—liking— 
reinforcement. Stimulus—reaction—dislike or pain—inhibition. This 
is the early simple associative memory in reactions to stimuli. 
“8. There are no perceptible differences in reactions of colored and 
white children or between pairs of twins. 
“Ability to Hold the Head Erect.—This may be acquired at the third 
month. Few infants, however, are able fully to support the head before 
the fifth month. Not a few perfectly normal infants will not be able 
to support the head before the ninth month. 
“Sitting Erect.—The ability to sit erect unsupported is acquired be- 
tween the sixth and eighth months. 
“Standing.—Many infants will stand with simply hand support at 
the tenth month. Exceptionally well-developed infants will stand with 
the hands resting on some object at the eighth month. A remarkable 
infant under my observation could stand at the fifth month, and walked 
alone at the eighth month. The average infant walks alone from the 
fourteenth to the sixteenth month. A few will be able to walk unsup- 
ported before this period, and other normal children will not walk alone 
before the eighteenth or twentieth month. 
“Laughing.—Many infants may be made to laugh from the third 
to the sixth week. 
“Memory.—The infant’s memory is very short. I have repeatedly 
known infants eighteen months of age who have entirely forgotten the 
mother in a week. 
“Speech.—Intelligible words are formed at about the twelfth month. 
From the eighteenth month to the second year two or three words will 
be intelligently put together.” 
Sleep and Crying.—These are physiologic phenomena exhibiting vari- 
ations dependent on growth of the finer senses and muscular powers and 
belong to the criteria indicating normal development. Their consideration 
has already been taken up (p. 28). MEMORIZING FACTS PERTAINING TO GROWTH AND DEVELOPMENT 
41 
SUGGESTIONS FOR MEMORIZING FACTS PERTAINING TO GROWTH AND 
DEVELOPMENT 
If proper allowance be made for minor inaccuracies which reference to 
the standards given will readily correct, the multiplication table of the 
number 7 may be used as an association link in fixing many of the figures 
of growth and development in the reader’s mind: 
7 equals the approximate weight in pounds at birth, the approximate 
month of life when the infant sits up and when he cuts his first tooth, the 
approximate year of life when he enters upon his second dentition. 
7X2 equals 14, the approximate circumference in inches of the head 
and chest at birth and the number of the month when walking is un- 
assisted. 
7X3 equals 21, the approximate length in inches of the body at 
birth, the approximate weight figure for one year, the number of the 
month when the anterior fontanel is closed, and a little more than the cir- 
cumference of head, chest, and abdomen at three years. 
7X4 equal 28, the approximate weight in pounds at two years and 
the height in inches at one year. 
7X7 equals 49, the figure for both weight and height at seven years. 
In addition, it is easy to remember that the ordinary child doubles 
his weight at five months and trebles it at one year, and that the weight 
increase from two to seven years ranges between 4 and 5 pounds per year. II. INFANT FEEDING 
Maternal Nursing 
THE PROBLEM 
Writers on this subject are very prone to state that the ability of the 
mother, particularly among the well-to-do, to fulfil this most important 
function is surely decreasing. Although this may have been a true state- 
ment twenty years ago, at the present time it is undoubtedly erroneous. 
That the young mother of today is better able to nurse her offspring 
than was her sister fifteen or twenty years ago is, moreover, explained by 
the fact that the youth of the present day are more vigorous, more nearly 
normal individuals than were those of an earlier date. 
The inability adequately to perform the nursing function has always 
been attributed to the mother ipse. This belief, too, is in error. A child 
born with a generally enfeebled vitality keenly feels any slight abnor- 
mality in the milk, or may not be able to digest perfectly normal milk; 
in either event, the milk disagrees and the nursing is discontinued. Breast 
milk during the first two or three weeks of the infant’s life is produced 
under unfavorable conditions which do not indicate the possibilities of 
the breast as a secreting organ, and early nursing, following as it does 
upon the stress of confinement, is not indicative of what may be possible 
later when the customary life and daily habits are resumed. Repeatedly 
a very high fat or a high protein, or both, have been shown to be entirely 
corrected after the first week or two without interference. This condi- 
tion at the time was considered sufficiently serious to warrant the dis- 
continuance of nursing on the part of a weakly infant, while in a vigorous 
infant it would be entirely ignored. 
The change which enables more mothers successfully to nurse their 
infants is due to two causes—more vigorous fathers and mothers and 
more vigorous offspring. The more normal the mother, the better able 
is she to perform this normal function. That this is the case is due with- 
out doubt to the fact that growing girls and young women are leading 
more hygienic lives than formerly. The making of golf, bicycle and 
horseback riding, boating, and automobiling popular and fashionable— 
in short, the taking of girls out-of-doors and keeping them there a con- 
siderable portion of the day—has worked a marvelous change for the 
better, both physically and mentally. Proportionate to the population, 
■there are fewer neurasthenics among the young women today than there 
were twenty years ago, and there will be still fewer twenty years hence, 
because at the present time the timid, retiring young woman of the neu- 
rasthenic type is not popular in her set. It is very fortunate for the future 
of the human race, at least for that portion which resides in the United 
States, that the young woman has thus transferred her allegiance from 
the crochet and embroidery needle to out-of-door sports, for a neurotic 
mother makes the poorest possible milk producer. 
42 THE PROBLEM 
43 
While it may be said that our argument holds only with the wealthy 
or the well-to-do, nevertheless imitation is one of the strongest charac- 
teristics of the human race, and this tendency in America to outdoor 
hygienic living pervades all classes. Saturday half-holidays, and the 
excursions and outings afforded by reduced rates in transportation, are 
much more popular than they were twenty years ago. Finally, food is 
better selected and better prepared, owing to increased knowledge on the 
part of the people as to what constitutes proper nutrition. 
It may be thought that we have wandered from our subject—maternal 
nursing—but such is not the case, for conditions which relate even re- 
motely to this important function demand our respectful consideration. 
The food and care of the growing girl have the most intimate bearing 
upon her future life, and if she is to be called upon to perform the most 
important function of womanhood, she surely has the right to demand 
that she receive during her girlhood proper preparation, which hereto- 
fore has too often been denied her. 
It is not pleasant to criticize physicians, but we venture that the 
family physician does not, in a great majority of instances, fulfil his 
function, or extend his field of usefulness to its full capacity, his con- 
ception of duty too often including only the care of the sick. Unsought 
advice concerning the feeding and daily habits of a child’s life is usually 
welcomed and appreciated, for the reason that in almost every instance 
errors in a child’s management are due to ignorance. Parents, no matter 
what their station in life, are glad to do what is for the best interests of 
their children when the reason for certain procedures is made clear. 
If a thorough and careful physician can have the physical direction 
of 10 average girls in any station in life, provided they have the 
benefit of fresh air and good food from infancy to adolescence, he may 
confidently predict that successful nursing mothers will be made out of 
8 of them. • 
Certain rules of life having a direct bearing on nursing thus lead us 
nearer the ideal and may enable the mother who otherwise could not 
nurse her child to do so successfully. These requirements, it will be seen, 
are laid along common sense lines and cause no hardship or mental dis- 
tress, one of the chief requirements of a nursing woman being that she 
shall be mentally normal. 
Some mothers will be able to carry on the nursing for only two months; 
others, three, five, seven, or nine months. After the ninth month it is 
extremely rare for the breast milk to be sufficient for a child. 
The most successful nursing age is between the twentieth and thirty- 
fifth years. Successful nursing carried on by a girl of fourteen, by a woman 
of fifty-two, and by the much abused society girl has been noted, while 
it has been seen to fail absolutely in peasant women fresh from the fields 
of Hungary and Bohemia. Many whose nursing is at first most unsatis- 
factory develop into perfect nurses. 
Finally, few functions with which we are called to deal are so variable 
and uncertain as the production of breast milk. Breast milk is one of 
the most precious substances. It is invaluable—unless we can put a value 
on human life. 44 
THE PRACTICE OF PEDIATRICS 
HUMAN MILK 
While human milk varies as to the proportion of its nutritional ele- 
ments at different periods of lactation, and even at different times of 
the day, milks upon which infants thrive agree within certain limits, 
so that a standard of limitations may be laid down. Among a great 
many specimens examined the solids have ranged between 12 and 13 
per cent. The range in fat has been from 2.75 to 4.65 per cent., protein 
from 0.9 to 1.8 per cent., sugar from 5.50 to 7.3 per cent. These figures 
represent the analyses of the breast milks given children who were thriving 
and who were of different ages. The variations are not as wide as have 
been reported by others, but it is to be remembered that all these babies 
were thriving. Whoever has examined breast milk even a few times 
is aware of the existence of the widest possible variations. One may see 
breast milks which contain 8 per cent, and others which contain only 
0.5 per cent, of fat; but infants thus fed have not been well. 
Fat exists in mother’s milk as minute globules in emulsion, varying 
somewhat in composition, depending upon the kind of food eaten. 
The proteins of breast milk offer a wide field for further study. There 
are several of these, the most important being casein and lactalbumim 
The proportions are subject to considerable variation, depending upon 
the diet and habits of life of the producer. With a continuation of lacta- 
tion there is a diminution of the protein, so that at the ninth or tenth 
month the total protein is considerably reduced, often being not over 
1 per cent. 
The sugar content varies less than does either the fat or protein, 
its range of limitation, even in milk otherwise poor, being rarely over 
2 per cent. 
Examination of Human Milk.—Milk of the mother is usually ex- 
amined to determine whether it contains a sufficient amount of fat, sugar, 
and protein to nourish the infant; or to determine whether the quantity 
of one or more of the nutritional factors is excessive or deficient. Micro- 
scopic examination shows us little except the presence of colostrum, which 
usually disappears about the ninth day and is to be considered abnormal 
if present after the twelfth day. The presence of blood and pus may 
also be detected by the microscope. For an accurate analysis the milk 
should be sent to a laboratory properly equipped for such work. For 
absolute accuracy it is not safe to judge from the analysis of one specimen 
of milk; at least two, better three, specimens should be analyzed before 
coming to a conclusion. In collecting milk for examination the middle 
of a nursing should be selected. 
Laboratory analysis is expensive, however, and beyond the possi- 
bilities of many. For out-patient work and those cases in which a deter- 
mination of approximate percentages is sufficient the Holt milk set is of 
great service. The set consists of a lactometer and two cream gages. 
The method of its use as explained by Holt is as follows: 
Fat Determination.—“The simplest method is by the cream gage. 
Its results are only approximate, but in most cases sufficiently accurate 
for clinical purposes. The tube, filled to the zero mark with fresh milk, 
stands, corked, at room temperature for twenty-four hours, when the BREAST FEEDING 
45 
percentage of cream is read off. The ratio of this to the fat is approxi- 
mately 5 to 3; thus 5 per cent, cream indicates 3 per cent fat, etc.” 
“For an accurate determination the best method is the Babcock test, 
which requires 20 c.c. of milk, or the modification by Lewi of the Leffman 
and Beam test for cow’s milk. This requires special tubes.” 
Sugar Determination.—There is no accurate clinical method for deter- 
mining the amount of sugar; only a chemical analysis is reliable. How- 
ever, the sugar varies less in different milks than do the fat and protein 
and its variations are of much less importance clinically. 
Protein Estimation.—“Clinical methods for the estimation of the protein 
are not very satisfactory. We may form some idea of the protein from a 
knowledge of the specific gravity and the percentage of fat if we regard 
the sugar and salts as constant, or so nearly so as not to affect the specific 
gravity. We may thus determine whether it is greatly in excess or very 
low, which, after all, is the important fact. The specific gravity will then 
vary directly with the proportion of protein, and inversely with the pro- 
portion of fat, i. e., high protein, high specific gravity; high fat, low specific 
gravity.” 
By subtracting the sum of the percentage of fat and the estimated 
sugar and ash percentages from that of the total solids a fair calculation 
of the percentage of protein in a given sample of milk may be made. 
For accurate estimation the method of Van Slyke and Bosworth1 may 
be used to determine the casein percentage which multiplied by 1.4 gives 
with sufficient accuracy the total protein percentage. 
“A specimen taken for examination should be either the middle portion 
of the milk—i. e., after nursing two or three minutes—or, better, the 
entire quantity from one breast. The first milk is slightly richer in pro- 
tein and much poorer in fat. The last drawn from the breasts is lower 
in protein and much higher in fat. The following analyses from Forster 
illustrate these differences”: 
First portion, 
Second portion, 
Third portion, 
per cent,. 
per cent. 
per cent. 
Fat 
1.71 
2.77 
5.51 
Protein 
1.13 
0.94 
0.71 
Fundamental Rules.—The following may be laid down as nursing 
axioms: 
A diet similar to what the mother was accustomed to before the ad- 
vent of motherhood should be taken. 
There should be one bowel evacuation daily. 
From three to four hours daily should be spent in the open air in 
exercise which does not fatigue. 
At least eight hours out of every twenty-four should be given to sleep. 
There should be absolute regularity in nursing. 
There should be no worry and no excitement. 
The mother should be temperate in all things. 
BREAST FEEDING 
1 New York Med. Jour., 1909, xc, 542. 46 
THE PRACTICE OF PEDIATRICS 
In addition to these fundamental axioms certain rules applicable to 
the details of nursing should be remembered. 
Twenty minutes is the maximum time during which a baby should be 
allowed to remain at the breast. In most instances the twenty minutes 
is too long. (See Rate of Milk Secretion, p. 49.) On no account should 
the infant be allowed to sleep at the breast. 
The three-hour interval between feedings is best in most instances, 
at least until the completion of the third or fourth month. 
One breast at a nursing should be given if the milk is plentiful. If 
the supply is not enough, both breasts may be given at the same feeding 
period. 
After the nursing the baby should be held up against the mother’s 
shoulder and patted gently on the back to allow eructation of air from 
the stomach. 
Finally, after the baby has been put down, and before the cleansing 
of the mother’s nipples, massage of her breasts is desirable as a means of 
expressing any residual milk and of stimulating the productive activity 
of the glands. The value of such breast massage in cases of deficient 
lactation has been repeatedly demonstrated. 
Early Giving of Water.—From \ to 1 ounce of a 5 per cent, solution 
of milk-sugar should be given the infant every two hours until the milk 
appears in the breast. Otherwise there will be unnecessary loss in weight 
and perhaps a high degree of fever due to inanition. 
If the baby is restless and uncomfortable, it is safe to conclude that 
he is thirsty; 1 ounce of the sugar-water will usually satisfy him. With 
the commencement of nursing he should be accustomed to getting his 
food at regular intervals. 
The First Nursing.—Six hours after delivery or confinement the 
nipples should be washed with a saturated solution of boric acid and 
the child put to the breast and nursing attempted. After this the at- 
tempts at nursing should be repeated every four hours, although the 
milk does not appear in the breasts until from forty-eight to seventy-two 
hours after the birth. Colostrum may be present. It is useful as a laxa- 
tive and may satisfy the child. Further advantages of early nursing are 
that it promotes uterine involution and gradually accustoms both the 
infant and the mother to what will be required later. 
Care of the Nipples.—Immediately after the nursing the nipple should 
be carefully washed with a saturated solution of boric acid and thor- 
oughly but gently dried. A baby should never be allowed to nurse from 
a cracked or fissured nipple. For this veiy painful condition a nipple- 
shield (Fig. 2) should always be used. (See p. 53.) 
The Diet.—Many times, when consulted by a nursing mother because 
the nursing was unsuccessful or a partial failure, the physician finds that 
her diet has been restricted to an extreme degree. To put on a greatly 
restricted diet a robust young mother who has always eaten bountifully 
of a generous variety of foods is one of the best means of curtailing the 
quantity and lowering the quality of her milk supply. When asked to 
prescribe a diet one may safely tell such mothers to eat as they were 
accustomed to before the advent of pregnancy and motherhood. That 
this particular vegetable or that particular fruit should be forbidden on BREAST FEEDING 
47 
general principles is a fallacy. Food that the patient can digest without 
inconvenience is a safe food so far as the nursing is concerned, as may 
readily be determined in any given case. For certain individuals, how- 
ever, a plain, more or less restricted diet is desirable. This must be 
remembered in the management of the wet-nurse (p. 56). Many a wet- 
nurse who has been carefully selected, and who to the best of our judg- 
ment should prove satisfactory, utterly fails in a few days to fulfil the 
duties of the office for which she was chosen. In not a few instances 
the failure is due to a very full diet of unusual articles of food, the ex- 
istence of which, in many instances, she never dreamed of. Indigestion 
and constipation follow, both the nurse and the baby are made ill, and 
the woman’s usefulness ceases. A woman who has lived and kept well 
on the diet and food found in the home of the laboring man, whether 
in the city or country, will make a far better wet-nurse on this diet than 
if she indulges in food to which she 
is entirely unaccustomed. In gen- 
eral, the diet of a nursing mother, 
then, should be that to which she 
has been accustomed. 
Nursing is a perfectly normal 
function, and a woman should be 
permitted to carry it out along only 
natural lines. Inasmuch as there 
are two lives to be provided for 
instead of one, more food, par- 
ticularly of a liquid character, 
may be taken than the mother 
may have been accustomed to. 
It is customary to advise that 
milk be given freely. A glass of 
milk may be taken in the middle 
of the afternoon and 8 ounces of 
milk with 8 ounces of oatmeal or cornmeal gruel at bedtime, if it does 
not disagree with the patient. Our only evidence that a food is not 
disagreeing is the condition of the digestion. When any article of food 
disagrees with the mother, or if she is convinced that it disagrees, 
whether or not such is really the case, the food should be discontinued. 
In a general way, milk in quantities not over one quart daily, eggs, meat, 
fish, poultry, cereals, green vegetables, and stewed fruit constitute a 
basis for selection. The method of preparation of the different meals 
is not arbitrary. 
The Bowel Function.—A very important and often neglected matter 
in relation to nursing is the condition of the bowels. There must be 
one free evacuation daily. For the treatment of constipation in nursing 
women different methods have been tried in many cases. The dietetic 
treatment does not promise much. For here, again, manipulation of the 
diet may interfere with the milk production. Three methods are open 
to use—massage, local measures, and drugs. Massage is available in 
comparatively few cases. Local measures consist in the use of enemas 
or suppositories. Every nursing woman should use an enema at bedtime 
Fig. 2.—Nipple-shield. 48 
THE PRACTICE OF PEDIATRICS 
if no evacuation of the bowels has taken place during the previous twenty- 
four hours. Many out-patients, in whom constipation is a frequent 
symptom, indulge in excessive tea drinking, often taking from 1 to 2 
gallons of tea daily. In treating such patients where an absolute dis- 
continuance of the tea drinking is often impossible and not absolutely 
necessary one may allow 2 cups a day. For a laxative in such cases 
and in many others a capsule of the following composition has served 
well: 
1$. Extracti belladonnse gr. \ 
Extracti nucis vomicse gr. f 
Extracti cascara; sagradse gr. v 
M. et ft. capsula No. i. 
Sig.—To be taken at bedtime. 
The amount of the cascara sagrada may be varied as the case may 
require. In not a few instances it will be found necessary to give two 
capsules a day in order to produce the desired result. Neither the bella- 
donna, the nux vomica, nor the cascara appears to have any appreciable 
effect on the child. 
Air and Exercise.—Outdoor life and exercise are not only as desir- 
able here as they are under all other conditions, but to the nursing woman, 
with her added responsibility, they are doubly valuable. In order to get 
the best results exercise or work should so be adjusted as not to reach 
the point of fatigue. The mother whose nights are disturbed should be 
given the benefit of a midday rest of an hour or two. She should have 
at least eight hours’ sleep out of every twenty-four. Certain annoyances, 
anxieties, and worries are inseparable from the life of every child-bearing 
woman. It should be our duty, however, to explain to the mother and 
to other members of the family that an important element in satisfactory 
nursing is a tranquil mind. During the lactation period she should be 
spared all unnecessary care and petty annoyances. 
Regularity in Nursing.—The breast which is emptied at definite in- 
tervals invariably functionates better than does one which is not, not 
only as regards the quantity but also the quality, of the milk; so that 
system in breast feeding is almost as essential to milk production as 
to its digestion and assimilation. 
After it is demonstrated that the nursing is progressing satisfactorily, 
as proved by the satisfied, thriving child, it is well to begin with one bottle 
feeding daily. The advisability of this is obvious: in case of illness of the 
mother, if she is called away from home, or if, for any reason, the child 
cannot have the breast, the feeding is provided for. Another advantage 
of this provision is that it gives the mother needed freedom from re- 
straint. She is thus enabled to have the benefit of a change of scene. 
Amusements and recreations which the invariable nursing period denies 
her can be indulged in. As a result of this greater freedom she is able 
to supply better milk and to continue nursing longer than if tied con- 
tinually to the baby, no matter how fond of the infant she may be. 
Frequency of Nursing.—From birth until the third month seven 
nursings in twenty-four hours are allowed as follows: 6 and 9 a. m., 
12 m., 3 and 6 p. m., and 2 a. m. From the third to the completion of 
the six month, six nursings, as follows: 6 and 9 a. m., 12 m., 3, 6, and 10 BREAST FEEDING 
49 
p. m. After the sixth month, and in large strong children after the fifth 
month, five nursings in twenty-four hours, as follows: 6 and 10 a. m., 2, 6, 
and 10 p. m. 
Determination of the Milk Supply.—Whether or not the child is getting 
a sufficient quantity of milk may be determined by weighing the baby 
before and after nursing. For this purpose the scales used for weighing 
children should weigh accurately in half-ounces. The child, who need 
not be undressed, should be weighed when put to the breast and weighed 
at the completion of the nursing. Repeatedly one will find that an 
infant who should get 3 ounces or more at a feeding during the fifteen- 
minute nursing increases in weight but | to 1 ounce, showing that only 
so much milk has been taken. Occasionally cases have been seen which 
showed no gain whatever after nursing and yet the child was sup- 
posed to have been fed. In the event of difficult breast feeding it is 
well for the physician personally to supervise a nursing or two, for by 
this means much valuable information may be gained. 
The Rate of Milk Secretion.—After a study of the rate of secretion of 
breast milk in a group of cases at Bellevue Hospital, Smith and Merritt1 
stated that nursing infants obtain from 40 to 60 per cent, of their supply 
in the first two minutes and from 60 to 85 per cent, in the first four min- 
utes, only the larger, vigorous infants nursing from an abundant supply 
getting milk up to sixteen minutes. These observers concluded “A baby 
who needs both breasts may nurse from six to eight minutes on the first 
and from five to seven on the second. Very few babies need as long 
as ten minutes on a breast. A good many will empty the breast in four 
or five minutes.” 
Signs of Successful Nursing.—The normal infant shows a gain of 
not less than 4 ounces weekly. This is the minimum weekly gain 
which may safely be allowed. When a nursing baby remains stationary 
in weight or makes a gain of but 2 or 3 ounces a week, something 
is wrong, and the defect will usually, but not invariably, be found in 
the milk supply. When the baby is nursed at proper intervals and the 
supply of milk is ample and of good quality, he is satisfied at the com- 
pletion of the nursing. Under three months of age he falls asleep after 
ten or twenty minutes at the breast. When the nursing period again 
approaches, he becomes restless and unhappy, crying lustily if the nursing 
is delayed. When the breast is offered, he takes it greedily. The stools 
are yellow and number from two to three daily. The weekly gain in 
weight under such conditions is usually from 6 to 8 ounces. 
Signs and Causes of Unsuccessful Nursing.—Theoretically, every 
normal breast infant should be a thriving, well baby. That the standard 
established for a well baby is not upheld is unfortunate. When the supply 
of milk is scanty the child remains long at the breast, cries when he is 
removed, and shows signs of hunger before the nursing hour arrives. 
A cause of failure in breast feeding, and probably the most frequent 
cause, is a scanty milk supply. 
The chief nutritional elements in mother’s milk are: fat, 3 to 4 per 
cent.; sugar, 7 per cent.; protein, 1.5 per cent. Failure may be due to a 
marked disproportion of these elements, which may cause sufficient 
1 The Rate of Secretion of Breast Milk, Amer. Jour. Dis. Child., November, 1922. 50 
THE PRACTICE OF PEDIATRICS 
indigestion and resulting loss in weight to necessitate a discontinuance of 
nursing. Thus there may be a high fat—from 5 to 6 per cent.; or very 
low fat—from 1 to 1.5 per cent. In the high fat cases there is usually 
diarrhea with green, watery stools. The child strains a great deal and 
there are green stains on many of the napkins. In high fat cases there 
is also regurgitation or vomiting of sour material. The fat globules may 
readily be made out if the vomited material is placed under a low-power 
microscope. Low fat means deficient nourishment and may cause con- 
stipation. Sugar is rarely a cause of trouble in nursing babies. It seldom 
varies, ranging from 5 to 7 per cent, in the great majority of breast 
milks. Young children, further, have a marked toleration for sugar. 
The protein of mother’s milk is a most frequent cause of nursing diffi- 
culties. Like the fat, the protein may be so decreased that nutritional 
disorder may be induced in the patient, or it may be very much increased, 
the latter condition being usually the cause of colic or constipation in 
otherwise healthy nursing infants. In such cases curds may be found in 
the stools, the passage of which is always accompanied by a great deal 
of gas. 
The milk may contain the normal percentage of fat, sugar, and 
protein, but be scanty in amount. Instead of the 4 or 5 ounces to 
which the child is entitled, he may get but 1 or 2 ounces. Whether 
or not the quantity is sufficient may be determined by weighing the 
baby before and after each nursing for twenty-four hours. One ounce 
of breast milk weighs practically 1 ounce avoirdupois. The quality or 
strength is determined by an examination of the milk itself (p. 44). 
The quantity is determined by noting the weight of the child, wearing 
the same clothing, before and after nursing. By nursing for fifteen min- 
utes a child under one week old should gain from 1 to 1| ounces; at 
three weeks of age, 1J to 2 ounces; four to eight weeks of age, 2 to 3 ounces; 
eight to sixteen weeks of age, 3 to 4 ounces; sixteen to twenty-four weeks 
of age, 4 to 6 ounces; six to nine months of age, 6 to 8 ounces; nine to 
twelve months of age, 8 to 9 ounces. Of course, arbitrary limits cannot 
be fixed as to the quantity. Stationary weight or loss in weight, with 
a dissatisfied child, usually means a deficiency of milk, which is readily 
proved by the weighing. 
To be fed at the breast may also cause the child to suffer from an excess 
of good milk, in which event there will be vomiting or regurgitation, 
usually associated with colic. When this overfeeding continues, dilata- 
tion of the stomach develops, vomiting becomes habitual, the child loses 
in weight, the breast milk is said not to agree, and often, unfortunately, 
the baby is weaned. This has been the outcome in scores of cases. When 
there is habitual vomiting and colic in a nursing baby, two things are to 
be done—the baby must be weighed before and after nursing, and the 
milk must be examined. 
Repeatedly children treated for indigestion have been entirely relieved 
by shortening the nursing period. Weighing the baby at intervals of 
from three to five minutes and noting the gain has shown that the 3 or 4 
ounces which may represent the child’s stomach capacity were obtained 
in two, three, or five minutes, the excess which the child took over this 
amount being the cause of his trouble. From a free, full breast a vig- BREAST FEEDING 
51 
orous nurser will take one ounce in one minute. When the nursing “gait” 
is established, a child should be kept up to the schedule. There are few 
more pernicious teachings than that a baby should be allowed to nurse 
when he wants to and as long as he wants to. In fact, the idea that a 
nursing infant will take no more than is good for him is the fruit of in- 
experience. 
Illustrative Case.—A mother sought advice regarding giving her one-month-old 
baby the bottle, as he had many green stools, cried a great part of his waking hours, 
and weighed but a few ounces more than at birth. Her milk was supposed to be “too 
strong” for the child. An examination of the breast and a talk with the mother indi- 
cated that the breast milk was not at fault. An examination of the milk proved it to 
be good average milk, containing 3.5 per cent, fat., 6 per cent, sugar, 1.45 per cent, 
protein. A one day’s test by weighing was instituted. The infant was allowed to nurse 
one minute and rest one minute. During the resting period he was weighed. In this 
way it was found that in three minutes he got from 3 to 3| ounces of milk. The nursing 
was then reduced to three minutes on one breast and five minutes on the other, which 
was the “slower” breast. Thereupon every sign of indigestion promptly disappeared, 
the stools became normal, and the infant made a satisfactory gain in weight of 1 ounce 
daily. 
The quantity may be suitable for the age, the child may not vomit 
or show a sign of indigestion, and yet may not thrive. In such a case an 
examination or repeated examinations of the milk at intervals of two 
or three days will usually show that it is poor, below the normal perhaps 
in both fat and protein. 
Illustrative Case.—A Swedish woman was admitted to the New York Infant Asylum 
with an infant two months old in fair condition. The woman had an abundance of 
milk and asked for a foster-child, so great was her discomfort from the excessive flow 
of milk. The weekly weighings of the children soon revealed that there was no growth, 
and after a few weeks both children upon examination showed developing rickets. 
The milk was then examined and was found deficient—fat, 1.2 per cent.; sugar, 5 per 
cent., and protein, 0.73 per cent. 
Signs of Insufficient Nursing—The baby remains long at the breast, 
perhaps one-half to three-quarters of an hour. When removed he is 
restless and uncomfortable. After a short time, in an hour or less, he is 
very hungry and demands frequent nursings day and night. 
Conditions Which May Temporarily Produce an Unfavorable Effect 
Upon the Breast Milk, but Not Necessitate the Discontinuance of Nurs- 
ing.—The advent of the first menstruation period particularly, and in 
some cases the beginning of every menstruation period, is attended with 
an attack of colic or indigestion in the child. Such attacks, however, 
rarely necessitate the discontinuance of the nursing even for a single 
day. 
Factors influencing the mental condition of the mother, such as 
anger, fright, worry, shock, distress, sorrow, or the witnessing of an 
accident, may affect the milk secretion sufficiently to cause no little 
discomfort to the child, and often lessening of the flow for a day or two. 
Illustrative Case.—In the County Branch of the New York Infant Asylum there 
were at one time about 200 nursing mothers, the majority of them from the lower walks 
of life, at least 95 per cent, of the infants being illegitimate. The necessity of placing a 
considerable number of these mothers in wards, in close social contact, gave rise to 
rather frequent disputes, and not infrequently to fistic encounters of a decidedly vigor- 
ous character. After a particularly active disturbance, several nursing infants in the 
ward would become suddenly ill, usually with vomiting, diarrhea, and fever. One 52 
THE PRACTICE OF PEDIATRICS 
soon learned to know the cause when inquiry or hasty inspection showed that the 
mothers of those who were ill had been particularly active in the dispute. A small 
proportion of the mothers were from the better walks of life. Letters of forgiveness or 
reproach or visits of a like nature from fathers, mothers, or sisters have brought many 
a sick baby to attention and caused many anxious moments. 
Conditions Which Call for Temporary Discontinuance of Nursing.— 
During an acute illness with fever, such as indigestion, tonsillitis, and 
minor illnesses of a like nature, nursing should be discontinued for a day 
or two. During this period it should be our effort to maintain the flow 
of the milk. This is best done by emptying the breast with a breast- 
pump (p. 54) at the usual nursing period until the time arrives when the 
nursing may be resumed. In such conditions the advantage of having 
the baby accustomed to one bottle a day will at once be appreciated. 
Management of Abnormal Milk Conditions.—When it is found that 
the breast milk is too strong or too weak, or when the normal ratio of 
fat, sugar, and protein is not maintained, it may be possible to increase 
or diminish the milk strength. When desirable, it may also be possible 
to increase either the fat or the protein. The heavy milk will usually 
be found in mothers who are robust, who eat heartily, and who take 
but little exercise. In such a case the prescribing of a plain diet, allow- 
ing red meat but once a day, discontinuing the malt liquors or wine— 
which it will often be found that the mother is taking—and directing 
that she walk a mile or two a day, will frequently bring the milk to di- 
gestible proportions. In some cases, however, this will not be successful, 
and the colic, constipation, and vomiting may continue, even though 
the quantity obtained at each nursing is within normal limits. In some 
instances it will be impossible to change the mode of the mother’s life, 
except perhaps in the discontinuance of alcohol. When such conditions 
prevail, the milk may be modified by giving from 5 to 1 ounce of 
boiled water or plain barley-water before each nursing. One teaspoon- 
ful of lime-water added to 1 ounce of water before each nursing has made 
the breast milk agree when otherwise breast feeding would have been 
impossible. When the milk is deficient both in fat and protein, a diet 
composed largely of red meat, poultry, fish, rye bread, or whole-wheat 
bread, oatmeal, cornmeal, with 2 or 3 pints of milk daily, will often be 
followed by an increase both in fat and protein. The use of alcohol in 
moderate amounts, in the form of malt liquors or wine, will often in- 
crease the fat 2 per cent, in from two to three days. Disappointments 
in improving the quantity or quality of the breast milk, however, are 
frequent. In general, it may be stated that if a mother has been getting 
adequate nourishment in appropriate form to satisfy her desire, the pos- 
sibility of improving her breast milk by measures such as those just out- 
lined is by no means as good as in the case of a poorly nourished, under- 
fed woman. 
In addition to the one bottle which, for reasons above mentioned, 
is given early in the child’s life, it is necessary at the seventh month 
to add an extra bottle or two. Usually at this time the protein in human 
milk begins to diminish in quantity, and as this is the most important 
nutritional element, an insufficient quantity at this rapidly growing 
period of life is of no little importance. At the twelfth month, with very BREAST FEEDING 
53 
few exceptions, exclusive breast feeding, if one consider the best interests 
of the child, is practically out of the question. Out of many thousands 
of cases we recall but one instance when a mother was able successfully 
to nurse her child after the twelfth month. This remarkable woman, 
a mother of 6 children, had nursed every one of them exclusively up to 
the fifteenth or the eighteenth month. 
Management of Abnormal Breast Conditions.—Cracked and Fissured 
Nipples.—Fissures of the nipples often result from lack of care and 
cleanliness. Nipples that are not washed and dried, but allowed to re- 
main moist after nursing, particularly during the first few days, are also 
very apt to become macerated and cracked. In the cases in which there 
is a tendency for the breasts to “leak,” the milk decomposes on the nipples, 
and the nipple becomes actually excoriated by the acids formed by the 
decomposition in the milk. Leaking nipples should be kept covered 
with pads of sterile absorbent gauze. Cracks and fissures in the nipple 
may be sufficiently painful to prevent a continuance of the nursing. 
In getting the histories of not a few bottle babies one is told that nursing 
has been stopped because of cracked nipples. A strong child tugging 
on a fissured nipple may occasion excruciating pain to the mother, and 
when the fissures are not healed, it can readily be understood that such 
pain and the dread of nursing may produce sufficient mental distress to 
change the character or stop the flow of the milk, either of which con- 
ditions may require that the nursing be discontinued. The prevention 
and successful treatment of the condition, therefore, is a matter of no 
little importance. 
The treatment which gives the best results, and which has been in 
use at the New York Nursery and Children’s Hospital, is to bathe the 
parts with a saturated solution of boric acid after each nursing, dry the 
nipple, and apply a pad of sterile gauze. Once or twice a day the cracks 
or fissures are painted with an 8 per cent, solution of silver nitrate. There 
is no pain attending this application. The pad of sterile gauze is placed 
over the nipple and held in position by a binder sufficiently tight to sup- 
port the breasts. Before the nursing the nipple is bathed with sterile 
water and the infant takes the breast as usual. If there are deep fissures, 
it may be well for a day or two to use a nipple-shield (Fig. 2). The use 
of a light lead nipple-shield between nursings, particularly at night, has 
given good results in some cases, presumably from the formation of 
lactate of lead by contact of the shield with the moist nipple. Cleansing 
is essential after the use of this device. The use of an ointment on the 
nipples is not advised, for the reason that it is of little or no service, and 
in most cases ointments do actual harm because they soften the epithe- 
lium and make the nipple tender. Diminishing the number of nursings 
to three daily has been of use in some severe cases which were slow of 
response to treatment. Removing the child from the breast entirely 
is to be advised only under conditions of much urgency, as the milk may 
be entirely lost as a result of protracted absence of this stimulation to 
the breast. 
Another important reason for securing rapid healing is the danger of 
infection through the open nipple wound, the usual cause of mammary 
abscess. 54 
THE PRACTICE OF PEDIATRICS 
Depressed Nipples.—Not an infrequent source of difficulty in the 
management of the nursing function in a primipara are depressed nipples. 
The child cannot get a sufficient hold to make suction possible. He thus 
fails to get the desired nutriment, and, in consequence, both the child 
and the mother become exhausted. When this is repeated a few times, 
the child is very apt to refuse to make any attempt at nursing. In such 
cases the use of the nipple-shield is often indispensable until the nipple 
is sufficiently drawn out and developed for the child to get hold of. Pre- 
ceding each nursing it is well to manipulate the nipple for a few minutes 
or to elongate it by the use of the breast-pump (Fig. 3), without using 
sufficient force to draw the milk. 
Caking of the Breasts.-— Induration of the breasts is of very frequent 
occurrence during the first few days of nursing. The milk, when it ap- 
pears in the breasts, is often secreted in large amount. A great deal 
more is supplied than the child, with his small stomach and usually in- 
different nursing, is able to digest. The breasts should therefore be watched 
very carefully during this time so as to guard against the possibility of 
the milk remaining undrawn. After the completion of the regular nurs- 
Fig. 3.—English breast-pump. 
ing, if a considerable amount of milk remains in the breasts, it should 
be drawn by the breast-pump and the breast thus relieved. 
Caking is frequently the outcome of fissured nipples. Sucking on 
the part of the child, the use of the breast-pump, and hard pressure in 
milking are all very painful procedures, with the result that the milk 
remains undrawn. 
When nodules form, they may readily be softened by gentle mas- 
sage. Lanolin should be used on the fingers so as to avoid unnecessary 
irritation of the skin. The massage should be repeated as often as the 
nodules appear. The caking is more apt to occur in the dependent por- 
tion of the glands. The so-called pendulous breasts, which may show 
a tendency to cake, should be supported by a binder tightly applied. 
Acute and Suppurative Mastitis.—When inflammation of the breast 
develops with fever, chills, and prostration, it is usually the result of an 
infection through the nipple, generally one with visible cracks and fissures. 
For our purposes the different varieties of mastitis need not be considered. 
Nursing of the involved breast should be discontinued for the sake of 
both the child and the mother; in fact, the pain is often so great that 
nursing is impossible. A supporting bandage should be applied and WEANING 
55 
the milk drawn with the breast-pump at the usual nursing times. It 
must be our aim to induce resolution without the formation of pus. This 
is best accomplished by the use of an ice-bag which is applied to the 
inflamed, indurated area. If there is a tendency to constipation, saline 
laxatives should be used. In fact, the patient will often be benefited 
not a little by two or three watery evacuations daily. With a subsidence 
of the temperature and an abatement of the inflammation, nursing may 
be resumed. As soon as the presence of pus is determined, it should be 
removed regardless of its location in the gland. Many cases of intestinal 
infection in the infant, and of infectious processes in other parts of the 
body, have undoubtedly been due to nursing from suppurating breasts. 
Mixed Feeding.—With a diminution in the amount of milk secreted, 
the breast milk must, of course, be supplemented by modified cow’s 
milk. This method of feeding is usually successful. If the mother of 
a six-month-old baby can satisfactorily nurse him three times in twenty- 
four hours, he may be given, in addition, three bottle feedings, supple- 
menting the mother’s milk. It is best when using mixed feedings to 
alternate the breast and the bottle. The modified milk strength should 
be that which is suitable for the average child of the same age. (See 
General Rules, p. 73.) In beginning the use of cow’s milk, however, 
it must be remembered that at first a weaker strength must be used 
than the child will require for growth, this weaker food being necessary 
in order gradually to accustom the infant to the change. If too strong 
a cow’s milk mixture is given at first, it will be very apt to disagree, 
causing colic and vomiting. Later, when the child has become accus- 
tomed to the new food, a stronger mixture may be given. When a mother 
cannot give her infant at least two satisfactory breast feedings daily, 
it is advisable to wean the child. 
Maternal Conditions Under Which Nursing is Forbidden.—When 
the mother has tuberculosis in any of its various forms or manifesta- 
tions, whether it involves the glands, the joints, or the lungs, breast 
feeding is to be forbidden. In epilepsy and syphilis nursing is likewise 
forbidden. In nephritis and malignant disease of any nature, and in 
chorea, nursing should be discontinued. Women who are rapidly losing- 
weight should not be allowed to continue nursing their infants. In most 
cases of serious illness, such as typhoid fever, pneumonia, or diphtheria, 
and upon the advent of pregnancy, nursing should be terminated. 
It is the consensus of opinion of many authorities that when the 
mother is suffering from a mild attack of one of the infectious diseases, 
including pertussis, diphtheria, and scarlet fever, nursing may still be 
permitted. This rule does not apply in severe cases. Nursing babies 
rarely contract contagious disease from their mothers because the milk 
secretion undoubtedly conveys immunity.1 
WEANING 
When is the nursing baby to be given other food, or how long can the 
breast be relied upon to furnish the sole nourishment? If the mother, 
unassisted, is able to nourish her infant completely for seven months, she 
1 Hartshorn, Maternal Nursings, New York Med. Jour., July 6, 1912. 56 
THE PRACTICE OF PEDIATRICS 
is doing remarkably well. There are very few nursing mothers who can 
pass that period without assistance. Perhaps one or two bottle feedings 
a day may suffice. In many cases the milk will fail about the seventh 
month, and absolute weaning be necessary. Granting, however, that 
the child is thriving on the breast alone, or doing satisfactorily on the 
breast with only two daily feedings, at what age should the weaning 
take place? Just one mother out of several thousand came under our 
observation who could nurse her child to the child’s advantage after 
twelve months had passed. Many pronounced cases of malnutrition, 
rickets, indigestion, and diarrhea have been the outcome of prolonged 
breast feeding. 
The weaning in health should begin not later than the twelfth month, 
and in many instances it would be to the advantage of the child if nursing 
were interrupted earlier. Weaning is best accomplished gradually by 
substituting bottle feeding for nursing, giving only one bottle the first 
day, two the second, three the third, and so on until in a week or ten days 
weaning is complete. , In case the child is ill we may be obliged to wean 
at once by substituting bottle feeding for the breast, but the milk formula 
corresponding to his age should not be given. A baby six months of age 
should receive the three-month formula; an infant nine months of age 
should receive the six-month formula. A gradual increase to the formula 
suggested for a child the age of the patient may be made if all goes well. 
After the ninth month it is often possible to feed from a cup, which is 
then to be preferred to bottle feeding as a substitute for the breast. It 
is best not to attempt weaning during the hot months unless the conditions 
demanding it are urgent. 
Care of the Breasts During Weaning.—When the breast feeding 
is carried on the usual length of time—from nine to twelve months— 
the process of weaning ordinarily causes little or no discomfort. All 
that is usually required is to press out enough of the milk to relieve the 
patient as often as the breast becomes painful, which may not be Aiore 
than two or three times a day. When the weaning is necessarily abrupt, 
no little discomfort may result. If there is a free flow of milk, which 
is apt to be the case when the weaning must take place in the early nurs- 
ing period, tightly bandaging the breasts is required. When localized 
hardened areas occur in the glands, they should be massaged until soft- 
ened, and the bandage reapplied and worn until the secretion ceases. 
When the weaning can be accomplished more gradually, the infant should 
have one less nursing every second or third day until only two are given 
daily. After this has been practised for one week nursing can be dis- 
continued. In cases where sudden weaning is required, a saline laxative, 
such as citrate of magnesia or Rochelle salts, should be given every day 
for five days—sufficient to produce two or three watery evacuations 
daily. In the meantime the mother should abstain from fluids of all 
kinds up to the point of positive discomfort. 
THE WET-NURSE 
We are called upon to select a wet-nurse under various conditions. 
A few families, particularly those who have had disastrous feeding ex- THE WET-NURSE 
57 
periences, ask that no attempts at artificial feeding be made, but that 
a wet-nurse be engaged in advance of the confinement so as to be ready 
when the time for her service arrives. Usually, however, our minds 
and those of the parents turn to the wet-nurse when nutrition by other 
means is a failure. It is well to remember in this connection that it is 
not wise to postpone our resort to the wet-nurse until every chance of 
her being of assistance has passed. It may take a few days’ observation 
or but a single glance at one of these difficult feeding cases to decide 
whether a wet-nurse must be secured. Certain it is that in a few cases 
we cannot do without such aid. 
In the selection of a wet-nurse the age during which nursing is most 
successfully carried on is to be remembered. As a rule a wet-nurse 
should not be under twenty-two or over thirty-five years of age. The 
peasant women of the continent of Europe make the best wet-nurses. 
A woman should not be selected as a wet-nurse without a thorough ex- 
amination both of herself and of her infant. She must be free from skin 
diseases, tuberculosis, and syphilis. Whether she is stout or thin, tall or 
short, amounts to little. Neither can we place much reliance on the 
size of her breasts. Although full, firm breasts and prominent nipples 
are desirable, the best indication as to her nursing ability is the condition 
of her baby. For this reason it is best not to select a woman before her 
baby is four weeks old, for by that time his physical condition will indi- 
cate with considerable accuracy the kind of food he has been getting. 
The wet-nurse’s milk need not correspond with the age of the patient 
for whom she is engaged, as breast-milk from the fourth week to the 
third month of lactation will answer for any infant. 
The results attending the first few days of wet-nursing are often 
most disappointing. The radical change which takes place in the nurse’s 
habits of life, necessitating the leaving of her own child to the care of 
others, sometimes produces nervous conditions which may have a de- 
cidedly unfavorable influence upon her milk. Before arriving at the 
conclusion that she will not answer in a given case she should, there- 
fore, have time to adjust herself to the changed conditions. Many a 
good wet-nurse, accustomed to a very plain diet and some work, which 
necessarily means exercise, has been ruined, so far as her usefulness as 
a milk producer is concerned, by overindulgence at the table. Upon 
assuming her new office she is temporarily the most important member 
of the household next to the baby, and articles of food are supplied to 
which she is entirely unaccustomed and of which she eats plentifully. 
The result is an attack of indigestion with fever, the baby is made ill, 
and the usefulness of the wet-nurse in the family ceases. These women 
usually do best upon a plain diet of meat, poultry, fish, vegetables, cereals, 
and milk. If they are accustomed to taking beer, one bottle daily may 
be permitted. Coffee may be allowed to the extent of one cup daily, 
and of tea not more than two cups should be allowed. Women of this 
class are almost invariably neglectful of the bowel function, so that this 
must be attended to. One free evacuation should take place daily. As 
a rule, the wet-nurse has been accustomed to work and will be more 
contented and happy when her time is occupied. If she possess sufficient 
intelligence to take the baby for outings, she should be allowed to do so. 58 
THE PRACTICE OF PEDIATRICS 
Being out of doors from three to four hours a day is of decided advantage 
to every nursing woman. For the comfort of the family it is wise not to 
let a wet-nurse know her full value. Wrhen she feels that she is indis- 
pensable, trouble is apt to follow. It is particularly necessary, there- 
fore, that babies who are wet-nursed should be given one bottle feeding 
daily as soon as they are able to take care of it. The wet-nurse will then 
realize that she can be dispensed with in case of misconduct, or if she 
leave with an hour’s notice the child can be given the bottle until another 
nurse is secured. In the great majority of cases it has not been necessary 
to continue the wet-nursing after the children are seven months of age, 
for by this time they can usually be fed on the bottle. Of course, unless 
her nursing proves unsatisfactory, a wet-nurse should not be dismissed 
at the commencement of or during the summer. 
Artificial Feeding 
THE PROBLEM 
A considerable number of the young of the human race are deprived 
of the natural means of nutrition, the milk of the mother. For com- 
paratively few is a wet-nurse available. While in proportion to the 
children born more mothers are nursing their infants now than formerly, 
nevertheless every year thousands of infants are brought into the world 
who have to be nourished by other means than human milk. The fact 
that an immense number of deaths occur every year among these infants 
because of defective nutrition speaks for itself. 
Nutritional Errors.—Mortality statistics give a very inadequate idea 
as to the part played by nutritional errors in the young, for the reason 
that in many instances such errors are not the direct or immediate cause 
of death, and for this reason their influence does not appear in mortality 
statistics. As elsewhere pointed out, and dwelt upon at length in this 
work, in disease of any nature a child’s resistance is a factor of para- 
mount importance. With defective nutrition resistance is invariably 
below the normal. Many of the infants who die from the intestinal 
diseases of summer, from grip, from tuberculosis, or from infectious 
diseases, suffer from defective nutrition in different degrees of severity 
before the immediate cause of death exists. 
The Needs of the Patient Paramount.—As nutrition deals directly 
with questions of life and death, it is not surprising that volumes have 
been written on the subject, but it is surprising that the fundamental 
principles of infants’ nutrition are so little understood. This is due in 
part to the fact that writers and teachers of infant feeding, in their efforts 
to be scientific or ultrascientific, have lost sight of the point that there 
is a patient as well as a pupil to be considered, and that not a few teachers 
with their algebraic or otherwise intricate formulas do little but obstruct 
the progress of rational feeding by making a readily comprehended sub- 
ject impossible to many. Another common error is in not distinguishing 
between children—the rich and the poor, the sick and the well. A baby 
with malnutrition, with marasmus, or with temporarily disordered di- 
gestion is by no means well, and when he is given food suitable only 
for the well, his condition very naturally is not improved. SCIENTIFIC INFANT FEEDING 
59 
Environment.—In feeding an infant, several predominant factors 
must be considered: First, the influences of environment. The infant 
in a children’s institution has to be fed differently from one who comes 
to a dispensary for treatment, and both must be fed differently in summer 
than in winter. The child of well-to-do, intelligent parents is fed still 
differently. There are no hard-and-fast rules in infant feeding other than 
that there must be an ample supply of such nourishment as the child 
can digest and thrive upon. Cow’s milk is used as the basis of infant’s 
food, for the reason that it is ordinarily readily adapted to the child’s 
digestion and is the most available substitute for human milk. 
Successful Artificial Feeding.—Successful substitute feeding of in- 
fants consists, then, in giving something upon which the child can live 
and thrive, and when, in addition, this “something” supplies the nutri- 
tion which nature demands, it constitutes scientific infant food, what- 
ever the source of the nutriment. Cow’s milk is just as fully an unnatural 
food for an infant as is barley or rice gruel or the milk of the goat or the 
ass; and cow’s milk only is used, as already mentioned, because in a 
great majority of cases it answers the given purpose better than does any 
other food, in that it furnishes in available form the nearest approach 
to the nutritional elements required.' 
SCIENTIFIC INFANT FEEDING 
The senior author was recently taken to task by a young colleague for 
using evaporated milk, malt soup, dextrimaltose, and various flours, 
such as barley and Imperial Granum, in feeding difficult cases. It was 
unscientific to use these substances, the argument maintained, because 
the human breast did not elaborate evaporated milk, malt soup, barley 
flour, or dextrimaltose. Instead of such substances, fresh cow’s milk, 
lime-water, milk-sugar (Squibb’s), and boiled water should be employed. 
The writer replied that he had used the substances enumerated daily for 
twenty-five years and had fed several thousands of infants on fresh cow’s 
milk, milk-sugar, and lime-water; while in experience with many nursing 
mothers in institutions and in private work he could not recall a single 
instance wherein the human breast had secreted fresh cow’s milk, lime- 
water, or Squibb’s milk-sugar. 
Scientific infant feeding consists in supplying a balanced ration of fat, 
protein, carbohydrate, and mineral salts in an assimilable form upon which 
the infant makes normal development. Neither the fat, protein, nor car- 
bohydrate must be of one invariable form. Nature permits of a wide 
latitude. 
In function, moreover, the fat and carbohydrate are interchangeable 
and may vary widely in nature and in quantity. There must, however, 
be a fairly definite content of protein of a nature that admits of its util- 
ization; or we shall have varying degrees of malnutrition and marasmus; 
for without nitrogen and other protein constituents cell growth is impos- 
sible. By the use of starch and alkalis, the subjection of milk to the 
influence of heat of varying degrees, and by other means, we may change 
the nature of the protein to such an extent that the infant may utilize 
the food in a manner before impossible. 60 
THE PRACTICE OF PEDIATRICS 
An immense amount has been learned concerning infant feeding dur- 
ing the past twenty-five years. Our scientific attainments, however, will 
be much greater after a few more decades, and even then the last word 
will not have been spoken. 
COW'S MILK 
As cow’s milk furnishes the most available basis of nutrition for the 
infant who is deprived of the mother’s milk, it is essential in order to 
secure the best results from its use as an infant food, that it contain 
total solids between 12 and 13 per cent, and that the solids be represented 
in the nutritional elements in somewhat the following proportions: 
Fat 3.5 to 4 per cent. 
Sugar 4 to 4.5 
Total protein 3.5 to 4 
Ash 0.7 to 0.9 “ 
Specific gravity 1.028 to 1.033 
In order that the milk may be of a fairly constant strength, herd 
milk is to be preferred to the product of one or two cows, as the quality 
of the latter may vary considerably from day to day. It has been dem- 
onstrated that the best cows for this purpose are what are known as 
“grade cows,” that is, not pure bred. Such cows thrive better, are more 
easily kept healthy, and are more uniform in the nutritional equivalent 
of their milk supply than are high-class registered herds of the Alderney 
or Jersey strain. 
Milks necessarily differ in composition. The feeding of the cows 
and their care particularly influence the quality of the milk. The per- 
centages given indicate approximately its nutritional value and are 
sufficiently accurate for, purposes of feeding. 
The Fat.—This ingredient of milk is in the form of a fine emulsion and 
separates as cream. Its character is affected by the cow’s food, being soft- 
ened when some articles are fed and hardened when other kinds of food 
are used. The fatty acids exist in a proportion about six times as great 
in cow’s milk as in human milk. Furthermore, the emulsion of fat droplets 
is not so fine in cow’s milk as in breast milk. These are two important 
facts explanatory of the ability of a nursling to digest 4 per cent, fat in 
breast milk when he may be incompetent to digest over 1.5 per cent, fat 
from cow’s milk. 
In the stomach the fat becomes entangled in the casein curds and under- 
goes very little digestion, leaving the stomach last of all the food elements, 
and, if given in too large amount even inhibiting to some degree gastric 
motility. In the intestines emulsification and saponification of the fatty 
acids into which the fats are split takes place in the medium of alkaline 
bile. The soaps on absorption are acted upon by the epithelium of the 
intestine and yield neutral fat which is taken up by the thoracic duct 
and eventually the blood. Rapid fat excretion is the rule in diarrhea. 
If, however, excessive fat in the intestine can be brought into combination 
with alkalies to form calcium soaps, constipation may result. 
These &re only a few of the considerations one must weigh in ap- 
proaching the problem of fat per cent, determination for the given case. 
The Sugar.—Ordinarily lactose is used because it is the sugar present cow’s MILK 
61 
in breast milk. Because of the lower lactose content in cow’s milk, an 
amount ranging from 6 to 4 per cent, must be added to modified milk 
feedings as the infant gradually increases his feeding capacity, in order 
to approximate the 7 per cent, sugar content of breast milk. As the 
whole milk proportion in the formula is raised, less sugar need be added. 
After absorption the sugar element circulates in part in the blood in con- 
centration of 0.1 per cent, and is stored as glycogen not only in the liver 
but also in the muscles. 
Reference to the selection of the individual sugars for different feed- 
ing requirements has already been made (pp. 20, 21). 
The Protein.—In breast milk two-thirds of the protein is available 
in the form of soluble lactalbumin, whereas in cow’s milk six-sevenths 
is in the form of casein, a kind of protein hard to digest and relatively 
poor in the essential amino-acid, cystin. This accounts for the relative 
ease with which the infant thrives on breast milk containing 1.25 per 
cent, protein, whereas, 1.75 to 2.50 per cent, protein is required from 
cow’s milk to provide him with equivalent nitrogenous material neces- 
sary for growth. In terms of cow’s milk 1| to If grams of protein is con- 
sidered a fair allowance per pound of body weight, and since cow’s milk 
contains 1 gram of protein per ounce we derive the simple feeding rule 
that protein requirements are fully met in terms of cow’s milk by about 
If ounces per pound of body weight. 
The problem of modifying the casein to insure easy digestibility has 
been attacked in various ways to be described later. 
Examination of Cow’s Milk.—In the use of cow’s milk, as in that of 
human milk, a chemical analysis is necessary in order to know accurately 
the nutritional elements. The specific gravity varies from 1.029 to 1.035. 
Milk is acid in reaction to phenolphthalein, and may be neutral to lit- 
mus. The Babcock milk-test machine is what is generally employed 
in examining cow’s milk in laboratories and institutions. The test con- 
sists in mixing the milk with strong sulphuric acid, which dissolves the 
proteins and liberates the fat, the quantity of which is read off from 
the graduated neck of the bottle used in mixing the milk and acid. Only 
the fat is determined in this way. Knowing the fat and the specific 
gravity, one may readily determine the solids other than fat by adding 
to one-fourth of the specific gravity, reading to the right of the decimal 
point, one-fourth of the percentage of fat. 
Differences Between Human and Bovine Milks.—The following 
comparison has been made by Morse and Talbot.1 
Human milk. 
Cow’s milk. 
Fat 
4.00 
4.00 
Sugar 
Protein 
7.00 
4.75 
1.50 
3.50 
Salt 
0.20 
0.70 
“Both are amphoteric in reaction when they leave the breast. Cow’s 
milk is usually acid when it reaches the baby. Human milk is practically 
sterile as the baby takes it. Cow’s milk, even under the best conditions, 
is far from sterile when the baby gets it. The emulsion of the fat is much 
finer in human milk than in cow’s milk. The proportion of fatty acids 
1 Diseases of Nutrition and Infant Feeding, 1915, p. 182. 62 
THE PRACTICE OF PEDIATRICS 
is much higher in cow’s milk than in human milk. A large proportion 
of the protein in human milk is in the form of whey protein. A large pro- 
portion of the protein in cow’s milk is in the form of casein. Human 
milk is not coagulated by commercial rennin, cow’s milk is coagulated. 
Both are coagulated by human rennin. The enzymes of the two milks 
are different and each milk has a specific serum reaction. 
“It is evident, therefore, that no matter how cow’s milk is modified, 
it will still be different from human milk. The percentages of the differ- 
ent food elements can be made the same. The difference in the protein 
can be corrected by the use of whey. The emulsion and the composition 
of the fat will, however, always be different. The ferments can never 
be made the same and the specific serum cannot be changed.” 
Bacteriology of Cow’s Milk.—Milk fresh from the udder contains 
very few bacteria, particularly if the first two or three jets from each 
teat are discarded. The time for bacterial contamination is during the 
milking and while the milk remains in the stable. Certain forms of bac- 
teria are harmless, and it is impossible to have a milk absolutely free 
from bacteria. What we need to know is how dangerous bacteria get 
into the milk, and how they cause changes that may convert it into a 
poison of greater or less virulence. 
Harmless Bacteria.—The souring of milk is the result of the presence 
of bacteria, which produce changes in the sugar of milk, with the forma- 
tion of lactic acid. Of these, Bacillus acidi lactici and Streptococcus lac- 
ticus are the common forms. The “turning” of milk during a thunder- 
shower is due to certain changes in the atmosphere that aid in the devel- 
opment of the bacteria which convert lactose into lactic acid. 
Harmful Bacteria.—Bacteria of decomposition, under conditions 
favorable to their growth, attack the protein constituents of the milk, 
producing putrefactive changes with evolution of poisons which may be 
of the greatest virulence. The putrefactive bacteria are always present 
in stables where manure is allowed to collect and where cleanliness is not 
observed. When we remember what a culture-field milk affords to bac- 
teria, and when we see the manure and the surroundings in which milk 
is usually drawn, it is not surprising that the milk should contain many 
millions of bacteria to a cubic centimeter. They may enter the milk 
from the dust in the stable—a very fruitful source—or they may find 
entrance from the milker’s hands or from droppings of fine particles 
of manure from the belly of the cow. Bacteria from these sources are 
among the most dangerous forms found in milk. 
Among diseases readily transmitted through contaminated milk are 
to be mentioned tuberculosis, typhoid fever, scarlet fever, diphtheria, and 
septic sore throat. 
The organisms of dysentery, cowpox, hydrophobia, actinomycosis, 
foot-and-mouth disease, the staphylococcus, gas bacillus, colon bacillus, 
cholera bacillus, and anthrax bacillus are all at times found in milk. 
Market Milk.—The legal standards for pure milk in most instances 
relate only to the chemical composition of the milk. The laws of most 
of the States call for 12 per cent, of total solids, and at least 3 per cent, 
of fat. If the milk contains less than these percentages it is considered 
impure, even if it is just as it was when it left the cow’s udder. Some cow’s MILK 
63 
cows give milk considerably below this standard. The chemical anal- 
ysis of milk does not show whether it is suitable for use as an infant food, 
this point being decided according to its freshness and the care with 
which it has been handled with reference to the exclusion of bacteria 
and the prevention of their growth. The production of clean, safe milk 
is expensive without allowing anything for the labor of caring for the cows. 
The milk must be carried to the consumer, which is also expensive. Yet, 
in New York City milk that satisfies the legal requirements retails in the 
grocery stores, during the summer months, at 10 or 12 cents a quart. 
This milk is known as “grocery milk,” or loose milk, and is a very poor 
food for infants. It is teeming with bacteria, as little care is taken in its 
preservation. 
The next grade of milk is sold in quart bottles which have been filled 
in the country, packed in cracked ice, and shipped to the city. The 
milk contains many bacteria, but is far better than grocery milk. It is 
retailed to the consumer in two grades, at a difference of about 3 cents in 
cost. Grade A milk must contain not over 30,000; and Grade B, not over 
100,000 bacteria per cubic centimeter. 
Certified Milk.—The best grade of milk, and the one which should 
be used in feeding infants whenever possible, is known as “certified milk,” 
and is produced under the direction of what is known as a “milk com- 
mission.” The establishing of “milk commissions” in different cities 
throughout the country has been the means of securing a much better 
milk supply than was formerly possible, and has unquestionably been 
instrumental in saving thousands of lives. To Dr. H. L. Coit, of New- 
ark, N. J., is due the credit of organizing the first milk commission. 
Certified milk must conform to certain standards as to its nutritional 
value and as to the number of bacteria per cubic centimeter. These 
standards are established by a committee of medical men who compose 
the milk commission, and who have complete control of the dairy and 
its entire output. 
The Milk Commission of the New York County Medical Society 
requires a standard of milk not containing over 10,000 bacteria in a cubic 
centimeter. When a dairyman has shown to the satisfaction of the Com- 
mission that he can produce a milk up to the required standard, he is 
allowed to attach to his bottles labels certifying to that fact. Milk thus 
“certified” is taken from the delivery wagon from time to time and sub- 
jected to examination by their bacteriologist in order to determine whether 
it conforms to the requirements of the Commission. Certified milk, 
furthermore, must contain an average of 4 per cent, butter fat and must 
be obtained from tuberculin-tested, tuberculosis-free cows. 
A study of the details that must be observed in the production of 
such milk is most instructive and gives insight into the best methods of 
dairy management. Suffice it, however, to state that certified milk con- 
taining fewer than 5000 bacteria per cubic centimeter is now a common 
commodity and is obtainable by a steadily increasing number of families. 
Sterilization and Pasteurization of Milk.—The sterilization and pas- 
teurization of milk, as the terms imply, are for purposes of preservation. 
The term sterilized milk is applied to milk that is heated to the boiling- 
point and maintained at that temperature—212° F.—for twenty min- 64 
THE PRACTICE OF PEDIATRICS 
utes. The effect of sterilization is the destruction of the pathogenic bac- 
teria, but it will not destroy the spores. Dr. R. G. Freeman’s observations 
show that heating the milk to 140° F. 
and maintaining it at this point for 
one hour is of advantage, in that the 
bactericidal effects are as good as 
when a higher temperature is used. 
At the same time the lower tempera- 
ture produces less chemical change 
in the milk. Pasteurization consists 
in heating the milk to 167° F., main- 
taining it at that temperature for 
thirty minutes, and then quickly cool- 
ing it. The effect of sterilization 
and the rapid cooling is to kill the 
existing bacteria, thus preventing, 
temporarily, further bacterial growth 
in the milk. 
The milk which is boiled in a bot- 
tle which is properly covered is “ster- 
ilized milk,” but if the sterilization is to be carried on day after day an 
Arnold sterilizer (Fig. 4) should be used. For purposes of pasteurization 
the Freeman pasteurizer (Fig. 5) is recommended. Pasteurization makes 
Fig. 4.—Arnold sterilizer. 
Fig. 5.—Freeman pasteurizer. 
less change in the character of the milk content; consequently, there is 
less interference with its nutritive value. The temperature, too, 167° F., 
is sufficiently high to destroy pathogenic bacteria, including Bacterium cow’s MILK 
65 
lactis aerogenes, and hence acts as a valuable preservative, particularly 
during hot weather. 
Pasteurization Safest for Exclusive Use.—The question, whether milk 
should be given sterilized, pasteurized, or raw has given rise to endless 
discussion in the press and in medical societies. Each method has its 
advocates. Among the pediatrists at the present time some contend 
that milk should be sterilized, regardless of the season of the year, the 
character of the milk, or the station in life of the patient; others main- 
tain that invariably it should be given raw, regardless of the above- 
mentioned conditions; while still others are devoted to pasteurization. 
If any of the methods were to be used exclusively, pasteurization, being 
the safest, should be selected. Judging from varied experience in the 
matter of the heating of milk for infant foods, the subject should be 
considered from a broad standpoint. There is no one way of heating 
milk that is invariably the best. There are several factors which determine 
which is the proper procedure in a given case. 
Raw Milk Preferred if Fresh and Pure.—There is no doubt what- 
ever that the less the milk is heated, the better food it is for the average 
well baby, provided it is clean when procured and can be kept clean and 
sweet until it is used. (See Cow’s Milk, p. 60.) This is possible in 
some of our dairies of the better class; it is possible with many who live 
in the country, or who go to the country for the summer and who keep 
their own cows or who get their milk supply from a neighboring source 
which they can control. Under such conditions the milk may be given 
raw during the entire year. 
When, however, the milk has to be shipped a considerable distance 
during the summer, when its safety depends upon the industry and 
carefulness of the employees of a milk farm, pasteurization is advisable 
during the heated term. Sterilized milk is rarely used among our private 
patients except during an ocean journey (see Milk for Traveling, p. 96) 
or a long-distance journey by land. For hospital out-patients the fol- 
lowing scheme is the safest: From May 1st until October 1st the milk is 
boiled (sterilized). These people, most of them, cannot afford a pasteurizer 
or sterilizer or understand the use of either. From October 1st to May 1st 
the milk is given raw. Pasteurization would be preferable, but it is possible 
with but very few dispensary patients. Even the giving of cooked milk, 
which unquestionably often becomes contaminated after cooking, is at- 
tended with no little risk to the child, as is shown by the death records of 
bottle babies during the summer. The giving of the cheap market milk 
raw to infants of the tenements during the heated term in any large city 
can only help to increase the mortality of this season. 
The object of heating the milk should always be explained to the 
mother so that she may appreciate the necessity of keeping it carefully 
covered and properly caring for it afterward. The idea is prevalent 
among uninformed people that after sterilization but little further pro- 
tection is required. When one is satisfied the out-patients have not 
the requisite intelligence nor the means for keeping cow’s milk during 
the summer, such as an ice-box and ice, he may discontinue the 
ordinary milk feeding for the hot months and use evaporated milk 
instead (p. 78). 66 
THE PRACTICE OF PEDIATRICS 
Cream.—Market creams are known as “gravity cream” and “centrif- 
ugal cream.” 
Gravity cream is obtained by allowing the milk to stand for a certain 
length of time and then removing the cream. When milk, as soon as it 
is drawn, is placed in a quart milk bottle or fruit jar and kept at a tem- 
perature of between 40° and 50° F., most of the fat will have risen at the 
end of five hours. When the cream is carefully removed at the end of 
this time, from 0.3 to 0.8 per cent, of fat will remain in the milk. The 
fat content of gravity cream is subject to considerable variation, depend- 
ing, of course, upon the richness of the milk and the manner in which 
it is treated, particularly as relates to rapid cooling. In cream from 
well-kept grade cows the fat will average about 16 per cent. In cream 
from well-fed Alderney or Jersey herds it may be as high as 20 per 
cent, or higher. In cream from cows indifferently fed, or those which 
subsist entirely upon poor pasturage, the fat may be as low as 10 or 12 
per cent. For infant feeding gravity cream from the milk of grade cows 
is preferred. In using cream for infant feeding all the cream to the milk 
line should be removed, as the upper layers are much richer in fat than 
that adjoining the milk. Further, when cream is mixed with milk both 
must be of the same age, as the addition of older, bacteria-laden cream 
to fresh milk will surely result in grave digestive disorders. 
Centrifugal cream is that which is removed by an apparatus known 
as a separator, which consists of a circular bowl for holding the milk, so 
arranged as to make from 3000 to 5000 revolutions a minute. This results 
in a rapid separation of the lighter fat from the milk. The fat collects 
near the center of the bowl and is removed by a device arranged for this 
purpose. The skimmed milk flows outward from another portion of the 
bowl by a similar device. Centrifugal cream is more difficult of digestion 
than gravity cream, in that the natural emulsion in which the fat is held 
in the milk is destroyed by the process of centrifuging. Centrifugal cream 
may vary greatly in its fat content, depending upon the rapidity of opera- 
tion of the separator. According to Babcock and Russell the proteins 
also undergo a change which does not add to their nutritive value. 
The skimmed milk derived in the manner described contains a remnant 
of 0.5 per cent. fat. 
THE ADAPTATION OF COW'S MILK 
At one time it was thought that, by changing the percentage com- 
position of cow’s milk and altering the reaction, it could be made prac- 
tically identical with human milk, and the term “modified milk” was 
applied to cow’s milk so manipulated. A great variety of manipula- 
tions of cow’s milk has been introduced, which often differ greatly in 
the principles involved. Yet to products of all these different manip- 
ulations the term “modified milk” is applied. It may mean any one 
of a dozen or more different products. Cow’s milk diluted with water 
and given as a food to an infant is called “modified milk.” When sugar, 
cereal gruel, lime-water, bicarbonate of sodium, or citrate of sodium 
is added, the mixture is still “modified milk.” When a prescription 
is sent to the laboratory calling for definite amounts of fat, sugar, and 
protein the product furnished is “modified milk.” When a mother is THE ADAPTATION OF COW’S MILK 
67 
told to use a definite amount of cream, milk, sugar, and water, “modi- 
fied milk” is also the outcome. 
As a matter of fact, successful infant feeding consists in what should 
be termed “milk adaptation,” that is, modifying the milk to suit the 
case in hand. The routine prescriber is content to prescribe “modified 
milk” which is a simple imitation of human milk. The best-informed 
prescriber uses “an adapted modified milk.” 
The Percentage Standard.—To Rotch, of Boston, we are indebted 
for the establishment of the practice of thinking in percentages in the 
feeding of infants. The method based on the fact that the proportion 
of fat, sugar, and protein in average breast milk as fairly indicative of 
the needs of the normal infant, is employed as a means of varying formulae 
for individual patients. 
Working with cream and skimmed milk each of known composition one 
may add varying amounts of milk-sugar and construct mixtures of any 
desired composition. Slight increase or diminution in any of the different 
elements may also be made with control over the rearrangement of the 
proportions of the constituents. 
Sufficient variation in the percentages of the protein and fat for prac- 
tical feeding purposes may be similarly obtained by diluting top milk 
from different levels after the natural separation of cream on standing. 
Formulae illustrative of this point are to be found on pp. 70, 71. 
To reduce any given formula to the percentages of its constituents 
one may simply multiply the percentage of the respective elements in 
the original undiluted milk by the proportion of the milk in the total 
formula. For example, a formula containing 10 ounces of milk of the com- 
position fat 5 per cent., protein 3.50, and sugar 4.50, with water up to 
30 ounces, will without the addition of the usual supplementary sugar 
contain 10/30 of each of the percentages given for each ingredient, i. e., 
1.66 per cent, fat, 1.16 per cent, protein, and 1.5 percent, sugar. Adding 
1§ ounces of sugar to the 30-ounce mixture will increase the sugar content 
by 5 per cent., thus making the total sugar percentage 6.5. 
The practice of thinking in percentages is easy to acquire and of un- 
doubted value. 
The Calorimetric Standard.—In brief, the calorimetric standard is 
based upon the amount of energy indicated in calories for each pound 
of body weight. A calorie is the amount of heat required to raise the tem- 
perature of 1 liter of water 1° C. 
Heubner, of Berlin, several years ago began the employment of cal- 
orimetric principles in infant feeding. His original observations, which 
were made on healthy breast-fed infants, weighed before and after each 
feeding, showed that under six months 100 calories were required daily 
for every kilogram of body weight. After the sixth month, the number 
of calories required gradually lessened, so that at the completion of one 
year about 85 calories to each kilogram of body weight appeared to be 
necessary. 
Lamb1 reduced Heubner’s figures to pounds. He gave the calorimetric 
requirements during the first three months of life as 45 calories daily per 
pound of body weight, during the next three months from 40 to 45 calories 
1 Archives of Pediatrics. June, 1908. 68 
THE PRACTICE OF PEDIATRICS 
daily per pound, decreasing gradually during the next six months, so that 
at the twelfth month from 32 to 35 calories daily per pound of body 
weight are necessary. 
Heubner’s observations, upon which the standard is based, were made 
on thriving breast babies. In order to judge of its practical value in arti- 
ficial feeding the histories of 33 bottle-fed infants were selected at ran- 
dom, from office files, for investigation. It was found that every child 
was getting food of greater caloric value than the standard called for. 
All but 2 required food in caloric value exceeding 100, as set by the 
standard. The daily consumption of 31 of these splendidly thriving 
infants, all of whom continued to do well, was from 140 to 360 calories 
in excess of the Heubner standard. Only 33 histories were investigated. 
Hundreds of records are available showing the same result. The 
calorimetric standard is thus a means of little utility in infant feeding. 
It may aid as a check to excessive feeding of very young and delicate 
infants. Infants whom we see—and they differ not at all from the average 
infants in this country—cannot be fed successfully by this method alone. 
As the factors of absorption, body length, surface area, and rate of 
metabolism are studied the limitations of the application of the calori- 
metric standard to infant feeding are being better understood. (See pp. 
22-24.) 
Milk Modification.—The analysis of mixed dairy milk shows it to 
contain approximately: 
4.0 per cent. fat. 
4.0 per cent, sugar. 
3.5 per cent, total protein. 
Human milk contains approximately: 
4.0 per cent. fat. 
7.0 per cent, sugar. 
1.5 per cent, total protein. 
The first aim in the modification is to make the chief nutritional 
elements in the food prepared from cow’s milk correspond grossly to the 
nutritional elements in the human milk. The protein must be reduced, 
the sugar increased, and the fat reduced even slightly below that usually 
found in mother’s milk, as the child’s digestive capacity for cow’s milk 
fat is less by from 15 to 25 per cent, than it is for human milk. 
The 'protein element in an infant’s food is its chief nutritional content. 
This has to be reduced to approximately the proportions that exist in 
human milk, and the change can be accomplished only by dilution. The 
diluent may be plain water or it may be a cereal gruel. 
If 8 ounces of milk is mixed with 8 ounces of water, we get a pint 
mixture with an approximate nutritional equivalent of: 
2.0 per cent. fat. 
2.0 per cent, sugar. 
1.75 per cent, total protein. 
If 4 ounces of milk is mixed with 12 ounces of water, we have a 16- 
ounce mixture with an approximate nutritional equivalent of: 
1.0 per cent. fat. 
1.0 per cent, sugar. 
0.9 per cent, total protein. THE ADAPTATION OF COW*S MILK 
69 
If 6 ounces of milk is mixed with 10 ounces of water, a 16-ounce 
mixture is produced with an approximate nutritional equivalent of: 
1.5 per cent. fat. 
1.5 per cent, sugar. 
1.3 per cent, total protein. 
By this simple dilution with water the desired protein content of the 
food may be arrived at. 
The Sugar.—For nourishment of an infant, however, the mixture 
is weak in fat and very weak in sugar. The sugar content is increased 
by the addition of milk-sugar or cane-sugar. It will be remembered 
that in human milk there is a sugar content of 7 per cent. The com- 
bination of full cow’s milk and water as above gives a sugar content of 
2 per cent, or less, so that sufficient sugar must be added to make the 
increase approximately 7 per cent. What is necessary, then, is to in- 
crease the sugar content 5 per cent. A 1 per cent, sugar and water mix- 
ture would contain approximately 5 grains of sugar to the ounce. A 6 
per cent, sugar mixture would contain 30 grains to the ounce, and as 
our dealings are with a 16-ounce mixture, we require an addition of 16 
times 30 grains of sugar-of-milk, or 480 grains, so that if we direct that 
a pint mixture contain 6 ounces of a 4-4-3.50 milk, 10 ounces water, 
1 ounce milk-sugar, there would be an approximate nutritional equivalent 
of: 
1.5 per cent. fat. 
7.5 per cent, sugar. 
1.3 per cent, total protein. 
Or if the mixture were 4 ounces of milk, 12 ounces of water, 1 ounce of 
milk-sugar, there would be an approximate nutritional equivalent of: 
1.0 per cent. fat. 
7.0 per cent, sugar. 
0.9 per cent, total protein. 
It is convenient to remember that 1 ounce of sugar added to any 20- 
ounce mixture increases the sugar content 5 per cent. 
The Fat.—While a child of from two to four months might thrive 
on the above formulae, the fat is obviously deficient and must be increased. 
This may be accomplished by the use of cream. Cream of the same 
age as the milk should be used. When this method of feeding is carried 
out, in order to secure a suitable cream, a quart bottle of milk from a 
mixed herd of grade cows is allowed to stand at a temperature of 40° 
or 50° F. for five hours, when a cream which has been referred to as gravity 
cream will be produced of the approximate strength of: 
16.0 per cent, butter-fat. 
3.2 per cent, sugar. 
3.2 per cent, total protein. 
With milk, cream, and sugar-of-milk food of every possible strength 
may thus be obtained. 
This method of milk preparation is more accurate than when top 
milk mixtures are used, but it has the disadvantage of requiring 2 quarts 
of milk for the twenty-four-hour feeding period, one to supply the milk 70 
THE PRACTICE OF PEDIATRICS 
and the other the cream, all of which must be removed and mixed before 
any of it is used in the food. It is unnecessary to go into the details of 
the cream and milk mixture method. 
A more satisfactory method of obtaining any desired fat percentage 
consists in the appropriate dilution of various top milk portions with 
water. By this procedure after the gravity cream has formed in the 
manner described a convenient number of ounces supplying the desired 
fat content for dilution is removed from the top of the quart bottle with 
a Chapin dipper and the desired fat percentage is obtained usually by the 
use of a single quart of milk. 
The fat content of various milk portions from one 
ordinary quart bottle (provided the milk is allowed 
to stand at a temperature not over 50° F. for five 
hours after milking) is as follows: 
Portion. Fat, per cent. 
Top 5 ounces 20 
Top 10 ounces 10 
Top 16 ounces 7 
Top 20 ounces 6 
Top 25 ounces 5 
Bottom 28 ounces 2 
Bottom 24 ounces 1 
In all of the samples, for purposes of feeding, the pro- 
tein and sugar content may be considered the same as 
in whole milk. 
By using the appropriate top milk for dilution it 
is thus possible to vary the fat as desired without ap- 
preciable change in the protein and sugar percentages 
selected on the basis of the customary whole milk 
dilution. For example: A top 12-ounce portion 
diluted with twice its volume of water may afford a 
desired 3 per cent. fat. If such dilution reduces the 
protein content below the percentage desired in a 
given case the use of a top 16-ounce portion diluted 
with less water per given volume of milk will supply 
more protein without exceeding the desired 3 per cent, 
fat. 
Top Milk Mixtures.—In adaptation by the use of 
top milk the milk is first allowed to stand in a quart 
bottle at a temperature of 45° to 50° F. for five hours. 
The quantity needed is then removed from the top of 
the bottle with a Chapin dipper (Fig. 6) and diluted 
as desired with water or gruel to which sugar-of-milk 
and lime-water are added. The value of the lime-water will be con- 
sidered under the “Use of Alkalies and Antacids,” p. 75. The milk 
selected should be the cleanest obtainable from grade cows; usually the 
most expensive is the best. 
From a quart bottle of milk on which the cream has risen, dip from 
the top with a Chapin dipper 16 ounces and mix. From average milk 
this should contain: 
Fig. 6.—Self- 
filling and empty- 
ing Chapin dipper, THE ADAPTATION OF COW’S MILK 
71 
7.0 per cent. fat. 
3.2 per cent, sugar. 
3.2 per cent, total protein. 
The following formulas are suggested for the various ages: 
Milk (top 16 oz.) 6 ounces 
Lime-water. f ounce 
Milk-sugar ounces 
Boiled water to make 24 “ 
From the Third to the Tenth Day: 
Approximate Percentage Equivalent. 
Fat 1.75 
Sugar ; 6.6 
Total protein 0.8 
Seven feedings in twenty-four hours; 2 to 3 ounces at each feeding. 
One ounce = 12.5 calories. 
Milk (top 16 oz.) 7\ ounces 
Lime-water 2 “ 
Milk-sugar 2 “ 
Water to make 30 “ 
From the Tenth to the Twenty-first Day: 
Approximate Percentage Equivalent. 
Fat 1.75 
Sugar 6.8 
Total protein 0.8 
Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. 
One ounce = 14.2 calories. 
Milk (top 16 oz.) 10 ounces 
Lime-water 2 “ 
Milk-sugar 2 “ 
Water to make 32 “ 
From the Third to the Sixth Week: 
Approximate Percentage Equivalent. 
Fat 2.2 
Sugar ; 7.0 
Total protein 1.0 
Seven feedings in twenty-four hours; 3 to 4 ounces at each feeding. 
One ounce = 16 calories. 
Milk (top 16 oz.) 12 ounces 
Milk-sugar 2 “ 
Lime-water 2 “ 
Water to make 32 “ 
From the Sixth Week to the Third Month: 
Approximate Percentage Equivalent. 
Fat 2.6 
Sugar 7.2 
Total protein 1.2 
Seven feedings in twenty-four hours; 4 to 5 ounces at each feeding. 
One ounce = 17.5 calories. 
After this age two bottles of milk are required, 16 ounces being taken 
from the top of each bottle and mixed. At this time a cereal jelly is 
usually added to the food. 
From the Third to the Fifth Month: 
Milk (top 16 oz.) 18 ounces 
Milk-sugar 2 “ 
Lime-water 3 “ 
Water to make 40 “ 
Approximate Percentage Equivalent. 
Fat 3.15 
Sugar 6.4 
Total protein. . . 1.4 
Six feedings in twenty-four hours; 5 to 6 ounces at each feeding. 
One ounce = 18.3 calories. 
From the Fifth to the Seventh Month: 
Milk (top 16 oz.) 21 ounces 
Milk-sugar ' 2 
Lime-water 3 “ 
Water to make 42 “ 
Approximate Percentage Equivalent. 
Fat 3.50 
Sugar 6.4 
Total protein 1.6 
Five to six feedings in twenty-four hours; 6 to 7 ounces at each feeding. 
One ounce = 19.6 calories. 
After the fifth month it is desirable to add from 1 to 3 teaspoon- 
fuls of a cereal jelly to each feeding. This may be added to the milk 72 
THE PRACTICE OF PEDIATRICS 
mixture when it is made in the morning. Thus, if 1 teaspoonful is to 
be given at each feeding, where a child is getting six feedings, 6 tea- 
spoonfuls of the jelly may be added to the entire quantity. 
From the Seventh to the Ninth Month: 
Milk (top 16 oz.) 27 ounces 
Milk-sugar 2§ “ 
Lime-water 3 “ 
Water to make 48 “ 
Approximate Percentage Equivalent. 
Fat 3.9 
Sugar 7.0 
Total protein 1.8 
Five feedings in twenty-four hours; 7 to 8 ounces at each feeding. 
One ounce = 21.7 calories. 
Milk (top 16 oz.) 35 ounces 
Milk-sugar 21 “ 
Lime-water 4 “ 
Water to make 56 “ 
From the Ninth to the Twelfth Month: 
Approximate Percentage Equivalent. 
Fat 4.3 
Sugar 6.5 
Total protein 2.0 
Five feedings in twenty-four hours; 8 to 9 ounces at each feeding. 
One ounce = 22.4 calories. 
After the twelfth month plain undiluted cow’s milk may be given 
with the cereal jelly in addition to the other articles of diet suggested for 
a child one year old. (See p. 135.) 
Considerable latitude is allowed as to the amount of food which 
may be given at each feeding, because of the difference in the capacity 
and requirements of individual children. The well child of average size 
and weight will require daily about 30 ounces of a suitably adapted food 
at the third month, 30 to 40 ounces at the sixth month, and 40 to 45 
ounces at the ninth to the twelfth month. 
Night Feedings.—After the third month the midnight feeding should 
be discontinued. Six feedings are sufficient, the first at 6 a. m. and the 
last at 10 p. m. 
Between 10 p. m. and 6 a. m. the child should sleep. Babies are easily 
weaned from the night bottle by substituting a bottle of boiled water 
or a milk mixture greatly diluted with water. The child soon discovers 
that this is not worth waking for. As a result of a full night’s rest the 
digestive organs are better able to do their work, the appetite is increased, 
and a larger amount of food may be given at each feeding. 
The Quality of Milk Variable.—It is not claimed that the nutritional 
value as indicated by the percentage equivalents in the above series is 
absolutely correct. Milks necessarily differ in composition. Only mixed 
dairy milk is referred to, the product of several grade cows. The feeding 
of the cows and their care also influence the quality of the milk. The 
percentages given indicate approximately the nutritional value and 
are sufficiently accurate for purposes of supplying satisfactory nutrition 
to well babies of the various ages. The fat will not be found too low 
for proper nutrition in any of the formulae given. It may be too high 
for proper digestion and require adjustment. The proteins as given are 
sufficient for nutrition if they are assimilated. 
General Rules for Computing Formulae.—Volumes of set formulae 
applicable to well and sick babies have been written in the past and the 
list of top milk feedings above given might easily be supplemented by THE ADAPTATION OF COW’s MILK 
73 
many more lists, were it not that the tradition for multiplicity of com- 
putations has been sufficiently upheld by writers in the past. It is only 
essential for the student to reserve for his guidance certain simple rules. 
Those presented at the New York College of Physicians and Surgeons 
may, in part, be cited. (The method employs whole milk dilutions, but 
is readily extended to the use of top milk of known composition.) 
The daily fluid requirement of the infant is about 2 ounces per pound 
weight for the first two weeks, and 3 ounces during the early months, 
decreasing to 2 ounces again by the end of the first year. 
The amount of the individual feeding based on the figures for anatomic 
and physiologic capacity is about | ounce per pound of body weight. 
The caloric requirement of the average healthy infant during the first 
two weeks is from 25 to 35 calories per pound, from two weeks to six 
months 45, and after six months a little less. 
The protein requirement is fundamental. It ranges from If to If 
grams per pound of body weight. Since 1 ounce of cow’s milk contains 
1 gram, the protein necessary for an infant is supplied by a number of 
ounces of cow’s milk equivalent to the number of grams of protein indi- 
cated in a given case. 
The fat requirement for a normal infant will have been met by an 
amount contained in the whole milk in about the same proportion as 
the protein. 
The sugar requirement ranges from 4 to 7 per cent. To most dilutions 
of milk for feeding 4 or 5 per cent, of carbohydrate should be added. 
In writing a feeding formula in terms of a whole milk mixture for a 
normal infant the rules cited are applicable in detail as follows: 
1. Total volume fluid equals the body wreight in pounds X 3 to 2. 
2. Number of feedings equals 7, 6, or 5 according to age. 
„ XT , . , , Total volume of food in ounces1 
3. Number of ounces per feeding equals ~r j-?—T. 
Number of feedings. 
4. Total calories needed equals body weight in pounds X 45 to 40. 
5. Protein requirement equals body weight X protein of 1| to If ounces of milk. 
6. Caloric value of the milk protein equals number of ounces taken X 21 (for 
convenience, 20). 
7. Balance of caloric allotment to be supplied by added carbohydrate equals in 
Calories required minus calories in milk 
ounces 1 
100 to 120 (depending on caloric value of 1 ounce of the form of carbohydrate used. 
8. Volume of diluent equals total volume minus volume of milk portion. 
Example: 
Child three and a half months—weight 13 pounds. 
1. Total volume = 13 X 2J = 321 oz. 
2. Number of feedings = 6 
321 
3. Ounces per feeding = = (Take 5§.) 
4. Calories needed = 13 X 45 = 585. 
5. Protein requirement = 13 X If = 22f oz. milk. (Take 23.) 
6. Calories in milk = 23 X 21 = 483 (roughly 23 X 20 = 460). 
„ f x U J 585 - 483 „ 585 - 460 , N 
7. Ounces of sugar to be added = - ,)(( = £ oz. (roughly —— — ' oz.) 
8. Diluent to be added = 33 — 23 = 10 oz. 
The formula would therefore read: 23 ounces whole milk. 
1 ounce of sugar. 
10 ounces of water. 
5 5 ounces at each of six feedings. 
1 If there is a small fraction in quotient take nearest half-ounce, 74 
THE PRACTICE OF PEDIATRICS 
For undernourished babies a rough guide as to the proper allowance 
for caloric requirements is the mean between the actual weight of the 
patient and the weight of a normal infant of the same age. 
Example: 
A child at nine months weighs 10 pounds. 
A normal infant at this age weighs about 18 pounds. 
The weight figure on which to base food estimation is 14. 
It has now been shown how by appropriate dilution, and by the ad- 
dition of sugar the chief nutritional elements in cow’s milk may be made 
to correspond roughly with those of human milk; the protein being re- 
duced, the sugar increased, and the fat reduced slightly below that usually 
found in human milk in order to meet the child’s digestive capacity, 
which is 15 to 25 per cent, less for cow’s milk fat than for human milk fat. 
The problem of altering the character of the milk to meet special 
needs remains to be considered, and this brings us to the details of milk 
modification. 
The Effect of Heating Milk Upon Its Assimilation.—Concerning the 
treatment of milk in order to make it easier of utilization we have much 
to learn. The milk proteins lend themselves to influences which entirely 
change their character, and affect their utilization by the infant. The 
heating of milk influences its digestibility and heating with different 
substances produces further changes in this respect. 
As previously stated, evaporated milk is easily and effectively utilized 
by the infant with a very weak digestive system, and this milk has been 
subjected to a heating process. 
When one studies the data available for explanation of the beneficial 
effects clinically observed as a result of the use of boiled and evaporated 
milk he meets with disappointment, because the changes demonstrated 
in milk which has been heated do not all make for its easier digestibility. 
The mineral salts largely undergo precipitation. The casein is rendered 
less easy of coagulation by the digestive fluids, but is softer and lighter 
than in raw milk. The lactalbumin is precipitated and forms a portion 
of the scum on the surface of the heated milk, which entangles a portion 
of the fat. The fatty acids are in part volatilized. Prolonged heating 
may caramelize a portion of the sugar. 
While the bactericidal effects of heating are in the main beneficial, 
certain putrefactive spore-bearing organisms may remain after heating 
and spoil the milk before it turns sour, as it ordinarily does from the action 
of viable lactic acid organisms before the putrefactive protein changes 
occur. 
The antiscorbutic vitamin is destroyed by heating. 
These, in brief, are the principal changes, their completeness depending 
largely on the degree and duration of the heat applied. 
In addition, the boiling of milk with cereal furthers the subdivision 
of the casein and secures a protective colloid action of undoubted benefit 
in the digestive canal. 
Boiled Milk.—A certain child cannot take fresh cow’s milk, modify 
and adapt it as we will. We give him evaporated milk of the same nutri- 
tional value and he thrives. The digestive ferments are unchanged and THE ADAPTATION OF COW’S MILK 
75 
the food capacity remains the same; the change that takes place is in the 
most important of the milk constituents, the protein. The degree of 
heat used and the length of its application also have a controlling influence 
on the digestibility of milk. The most favorable effects are apparently 
produced through heating milk in the presence of starch and then adding 
an alkali or antacid. 
For example, an infant suffering from malnutrition is given a for- 
mula of— 
10 ounces milk (top 15). 
1 ounce milk-sugar. 
| ounce barley flour. 
20 ounces water. 
10 grains bicarbonate of soda. 
The food agrees to the extent that the child is comfortable, but he fails 
to make a substantial gain. He gains and loses an ounce or two weekly. 
We now order that the milk and the barley be cooked together in a double 
boiler for thirty minutes and that water be added at the completion to 
make up for that which passes off in evaporation. The food is given 
in the same amount at the same interval, and at once the child begins to 
take on weight. The feeding schemes have been identical excepting 
that in the latter we have added heat. Such an outcome will not take 
place in all cases, yet this effect has been demonstrated time and again. 
Repeatedly, when an infant has been brought for treatment of mal- 
nutrition and found to be taking a rational cow’s milk formula, the food 
strength has been continued as it was with the simple substitution of 
starch and malt soup for the original milk-sugar or dextrimaltose; the new 
carbohydrate portion being mixed together with the milk and cooked for 
thirty minutes in a double boiler. The same carbohydrate content has 
been maintained, the food has been given in the same amount and at the 
same interval. Following this, the record repeatedly has shown prompt 
and continuous gain in weight. 
Frozen Milk.—During the past thirty years many thousand quarts 
of frozen milk have been fed to infants under the senior author’s care. 
In no instance has it been demonstrated that frozen milk was the cause 
of illness. There is, therefore, little reason for the belief that milk which 
has been frozen disagrees with the average bottle-fed baby. 
Furthermore, little experimental evidence has been elaborated on this 
point indicating any very definite changes in the composition of milk in 
freezing. 
Nevertheless many pediatricians make it a rule to boil all milk that 
has been frozen, ascribing otherwise unexplained diarrheal attacks to 
neglect of this practice. 
The Use of Alkalies and Antacids.—The casein of human milk when 
it enters the infant’s stomach separates into small, flocculent masses. 
Cow’s milk entering the infant’s stomach, without an addition of an 
alkali or other modifying medium, is precipitated by the pepsin in the 
stomach and forms a heavy curd, consisting of paracasein, which fails of 
digestion or assimilation, and at which the child’s stomach often rebels. 
The adaptation of the casein of cow’s milk to the child’s digestive capac- 
ity, so as to maintain suitable nutrition, is a central point around which 76 
THE PRACTICE OF PEDIATRICS 
the whole subject of infant feeding revolves. It will be noted in the 
formulas for cow’s milk feeding that lime-water is used as a diluent. 
This is used not simply to dilute the milk nor to render it alkaline, as has 
frequently been stated, but also to prevent the coagulation of the casein 
and the resulting formation of tough curds of paracasein. Simple dilution 
with water may make a smaller curd, but does not produce the fiocculent 
character peculiar to human milk that follows the addition of alkalies 
and antacids to cow’s milk. In the presence of an alkali the casein does 
not combine with the acid in the stomach; consequently the resulting 
acid coagulation does not take place. For this reason alkalies and ant- 
acids are added to cow’s milk. Usually the additions are too small. 
Poynton, of London, has advocated the use of citrate of soda with a 
view to preventing the solid coagulation of the casein. It is claimed that 
by using citrate of soda, 1 grain to the ounce, sodium paracasein is pro- 
duced, which is a fluid. Citric acid is liberated and unites with the cal- 
cium, forming the citrate of calcium, which is absorbed. 
Signs of indigestion of the casein in the milk are usually pain and 
discomfort. There are usually acute attacks of colic. There may be 
constipation, or diarrhea alternating with constipation, associated with 
the passage of many hard curds in the stools, the patient losing steadily 
in weight. In such instances the best means of adaptation consists in 
reducing the amount of protein to a total of 1 per cent, by dilution with 
water, and the addition of sufficient alkali, such as lime-water, bicar- 
bonate of soda, or citrate of soda, to form a curd more readily attacked 
by the digestive juices. One who feeds many infants will not be fully 
in accord with the belief, which is now fashionable, that the casein of cow’s 
milk is a factor of no importance in its adaptation. 
Whey Feeding.—Whey mixtures may be of temporary use. In whey 
the casein is largely removed—about 0.3 per cent, remaining. Analyses 
of whey show a nutritional equivalent of about: 
0.5 per cent. fat. 
0.9 per cent, lactalbumin. 
0.3 per cent, casein. 
4.5 per cent, sugar. 
As whey is ordinarily made, it is impossible to obtain a lower percentage 
of casein than 0.25. The amount of casein will oftentimes reach 0.5 
per cent, unless it is heated and strained a second time. The deficiency 
in fat may be overcome by adding gravity cream (p. 66) of the same 
age as the milk from which the whey is obtained, in the proportion of 
1 or 2 ounces to a pint of whey. This, of course, carries with it a very 
small amount of casein, which may make a total beyond the child’s 
digestive capacity. Low protein must be given only during acute illness 
or indigestion, and should be a diet for temporary purposes until the 
child is able to care for more suitable nourishment. 
Adaptation Through Peptonization.—When a child has incapacity 
for cow’s milk to such a degree that he is not able to take milk prop- 
erly diluted and given at suitable intervals, peptonization may often aid 
us, although we have frequently been sorely disappointed in its use. 
Theoretically, peptonization—the predigestion of the food—should be a THE ADAPTATION OF COAV’s MILK 
77 
solution of many digestive problems. Its efficiency in actual use may be 
learned from mortality statistics of children under two years of age in 
large cities, an immense proportion of the deaths being due either pri- 
marily or secondarily to nutritional errors. Not every infant, of course, 
is given peptonized milk; but if it possessed the value claimed for it by 
some of its advocates, the demand would be such as to compel its universal 
use, and difficult feeding cases would be no more. 
In using peptonized milk the protein strength should be reduced to 
1 per cent.—the lowest point compatible with safety. The amount and 
intervals of feeding should correspond with those suggested for the age 
of the patient. The following method has served best: Fifteen minutes 
before nursing the bottle is removed from the ice and from one-eighth 
to one-fourth of a tube (Fairchild’s peptonizing tube), depending upon 
the amount of milk in the bottle, is added. The bottle is then placed 
in water sufficiently heated—110° to 120° F.—to make it the right temper- 
ature for a child at the end of ten minutes. The degree of the temperature 
of the water must of necessity vary according to the temperature in the 
bottle and the amount to be heated. So-called complete peptonization 
produces a product with a decidedly bitter taste, which few children will 
take. 
This form of milk in which there is a complete conversion of the casein 
has been most useful in two types of cases: 
For Garage.—During acute or chronic illness when a child cannot 
take food by the natural method, as in diphtheric paralysis, or when he 
will not swallow on account of an acute inflammatory disease of the 
throat, such as peritonsillitis, retropharyngeal abscess, or retropharyn- 
geal adenitis, or v:hen he is in a comatose condition from any cause except 
intestinal infection, the feeding of completely peptonized milk by gav- 
age (p. 853) is of inestimable value. 
For Nutrient Enema.—In conditions when stomach feeding is im- 
possible either by gavage or the natural method—conditions met with 
in persistent vomiting due to acute cerebral diseases, in recurrent vomit- 
ing, in acute gastric indigestion—and as an accessory means of feeding 
when sufficient nourishment cannot be taken by the stomach, the colon 
feeding of completely peptonized, skimmed milk has a decided field of 
usefulness. Feeding children by the bowel, however, is usually possible 
for a few days only, because of the local irritation produced by the nutri- 
ment and by the passage of the tube. Skimmed milk, peptonized, with 
the addition of the white of egg makes the best nutrient enema for 
such cases (p. 98). It should be given at a temperature between 90° 
and 95° F. at from six- to eight-hour intervals. The tube should be 
introduced at least 9 inches. In cases of recurrent vomiting, repeatedly 
both hunger and thirst have been relieved by feeding in this way. 
Adaptation by the Use of Cereal Gruels.—It is claimed by many 
excellent observers that the use of cereal gruels causes a mechanical 
division of the casein, and it is thus more readily acted upon by the di- 
gestive juices. While we use gruels largely as milk diluents, and fre- 
quently as milk substitutes, we have yet to be convinced that in difficult 
feeding cases they possess any great value in the adaptation of milk 
to the child’s digestive capacity, unless given in sufficient concentration 78 
THE PRACTICE OF PEDIATRICS 
to change the consistency of the food. They are valuable adjuncts to the 
diet in cases in which weak milk foods must be given, but we do not recall 
an instance in which we thought the use of a stronger casein possible 
because of the cereal-water diluent. One who has fed gruels as diluents 
in a large number of cases for years will have had abundant opportunity 
to see enormous curds vomited and passed by the rectum by children 
on a milk and gruel diet in spite of test-tube demonstrations representing 
the process of curdling which takes place in the stomach and showing 
a minute division of the curd when the milk is treated with gruels. The 
advantage of a cereal diluent lies in the fact that a greater amount of 
food is thereby given, the starch often being tolerated better than 
sugar. 
Malt-soup Feeding.—The use of malt-soup extract offers a most satis- 
factory method of making cow’s milk assimilable. 
The chief use of this food is in malnutrition cases of slow-growing 
infants who, though not actually ill, fail to show a satisfactory growth. 
In treating bottle-fed infants who suffer from colic and marked constipa- 
tion due to casein incapacity this food has also considerable use. 
The milk strength considered suitable for the condition and age of the 
child may be used. Lime-water is not employed because of the presence 
of carbonate of potash in the malt soup. The maltose and flour, a con- 
siderable portion of the latter having been dextrinized, takfe the place of 
other carbohydrates in the mixture. 
The milk and flour mixture, strained and added to the solution of malt 
soup and water, should be placed over a slow fire and “simmered” for 
thirty minutes with constant stirring. Excess of malt soup may produce 
vomiting, so that any increase should be made with caution. 
Condensed and Evaporated Milk.—In not a few cases the feeding of 
fresh cow’s milk, manipulate it as we may, is impossible. For such cases 
another breast milk substitute is available, a cow’s milk product in which 
a portion of the water content has been removed by evaporation at a 
low temperature. 
Condensed milk is in the market in three forms—fresh condensed 
milk sold in bulk, condensed milk to which cane-sugar is added, sold in 
hermetically sealed cans, and evaporated milk without the addition of 
sugar, sold in hermetically sealed cans. The best known and most readily 
available brands are Borden’s condensed milk, known as the Eagle Brand, 
and Borden’s evaporated milk, known as Unsweetened Evaporated 
Milk. The Eagle Brand contains cane-sugar in considerable amount, 
and is rarely to be used. The unsweetened brand is evaporated milk 
without the addition of sugar. In the condensing process the milk is 
heated to 200° F. It is then transferred to vacuum pans, where it is main- 
tained at a temperature of 125° F. until sufficient water is evaporated 
to bring the product to the required condensation. 
The analysis of the Eagle Brand is as follows: 
Fat 9.5 per cent. 
Sugar 54.67 “ 
Total protein 7.84 “ 
Ash 1.68 “ 
Water 27.31 “ THE ADAPTATION OF COW’S MILK 
79 
The analyses of unsweetened evaporated milk and the unsweetened 
condensed milk sold in bulk are very similar. The standard maintained 
is as follows: 
Fat 8.3 per cent. 
Sugar 10.05 “ 
Protein 7.1 “ 
Ash 1.43 “ 
Water 73.07 “ 
The above products are respectively typical of numerous other con- 
densed and evaporated milks on the market, the percentage figures show- 
ing the composition of the different products being remarkably similar. 
Sweetened condensed milk (e. g. Eagle Brand) by reason of its high 
sugar content is to be fed in dilutions of about 1 to 8, or a dram to the 
ounce of water. In the nutrition of young infants wTith a good sugar toler- 
ance the value of this brand of condensed milk is probably greatest. 
In using milk of this type for feeding that known on the market as 
evaporated milk is to be preferred. A fresh can must be opened daily. 
The fact that the evaporated milk is free from added sugar makes possible 
the feeding of a larger amount. One part of the milk to 3, 5, 6, or more 
parts of diluent may be used. Thus, the formula for a day’s food would 
read like the following: 
7 ounces evaporated milk. 
28 ounces water. 
carbohydrate {S-ao„p extract. 
10 grains bicarbonate of soda. 
Milk of this strength affords a nutritional value of 1.66 per cent, fat, 
1.43 per cent, protein, 2.01 per cent, sugar. To this mixture carbo- 
hydrate in the form of starch, cane-sugar, dextrimaltose, milk-sugar, 
or malt-soup extract may be added to raise the total carbohydrate to 
6 or 7 per cent. If malt soup and starch are used, cooking will be re- 
quired. (See Malt-soup Feeding, p. 78.) More or less of the evaporated 
milk may be used as may be required. Many infants of very weak di- 
gestion will thrive on the evaporated milk thus given when all other 
artificial methods fail. To the very young, and those with poor digestive 
capacity, and to athreptics, a lesser amount of milk may be given at 
first—1 part of milk to 7 or 8 of diluent—the quantity being increased 
as the infant shows improved capacity. 
As the child grows older and increases in weight the amount of evap- 
orated milk may be increased. We have never given a stronger formula 
than 14 ounces of the unsweetened evaporated milk, 26 ounces water, 
carbohydrate to 6 or 7 per cent. The weight chart (Fig. 7) shows 
the progress made by a child on this scheme of feeding. Notes on the 
chart indicate when the evaporated milk feeding was begun and the 
various strengths used. Previously the child had been given various 
fresh cow’s milk formulae. 
In not a few cases the food seems to be better assimilated if the 
entire mixture—milk, starch, and sugar—is kept just under the boiling- 
point in a double boiler for thirty minutes. Occasional stirring is neces- 80 
THE PRACTICE OF PEDIATRICS 
Fig. 7.—Chart showing progress made on evaporated milk. Food value indicated in percentages and calories. 
sary, and at the completion of the heating process water should be added 
to bring the food to the original amount. 
When the child has remained comfortable for six to eight weeks or THE ADAPTATION OF COW’S MILK 
81 
longer on such feeding, almost always with a gain in weight, one feeding 
daily of a plain milk mixture may replace a feeding of condensed milk. 
A raw milk mixture should always be given in weaker strength than 
the child’s age calls for. In spite of the dilution it may occasion indiges- 
tion, colic, and the passage of curds. In such an event the evaporated 
milk and its diluent must again be the sole diet for two or three weeks; 
then the use of ordinary milk may again be attempted. After a few 
days or a week, in case one such feeding is taken without inconvenience, 
a second feeding may replace another evaporated milk feeding. In this 
way the number of plain milk feedings may be gradually increased until 
the child is taking a rational diet of this milk alone. 
Illustrative Case.—A six-month-old baby took daily three feedings of condensed milk 
and three of raw milk. Attempts were made to give him the fourth feeding of raw 
milk, but invariably with disastrous results. He was slightly under weight, but in a 
fair general condition. 
We have successfully managed a great many of these difficult feeding 
infants, as described above, withholding ordinary milk feeding until the 
child is taking the evaporated milk well and gaining, then gradually 
advancing the raw milk feeding until, when the child is five or six months 
old, he is taking daily and assimilating two or three feedings of the fresh 
milk. When six months old, and sometimes earlier, he may be given 
suitable raw milk feedings exclusively. By the above method the desired 
end of complete plain milk feeding is reached sooner than when small 
quantities of cow’s milk are added to the evaporated milk mixture. 
In beginning, it is best to give the raw milk at the first or second 
feeding in the morning, when the digestive powers are stronger than 
they are later in the day. When the second raw milk feeding is given, it 
should never immediately follow the first. The raw milk and the evap- 
orated milk should be alternated until more than one-half of the daily 
feedings are of fresh milk. 
If this method has to be used for a considerable period it is best to 
give 2 or 3 teaspoonfuls of orange juice daily. A convenient time to use 
the orange juice is one hour before the second feeding. 
FORMULAE FOR EVAPORATED MILK FEEDING 
From the Third to the Tenth Day: 
Milk, evaporated 2 ounces 
Lime-water \ ounce 
Milk-sugar 1 
Boiled water 17 J ounces 
One ounce = 10 calories. 
Seven feedings in twenty-four hours; 2 to 3 ounces at three-hour intervals during the 
day and four-hour intervals at night. 
From the Tenth to the Twenty-first Day: 
Milk, evaporated. 3 ounces 
Lime-water 1? “ 
Milk-sugar 1§ “ 
Boiled water 19| “ 
One ounce = 12£ calories. 
Seven feedings in twenty-four hours; 2 to 3 ounces at three-hour intervals during the 
day and four-hour intervals at night. 82 
THE PRACTICE OF PEDIATRICS 
From the Third to the Sixth Week: 
Milk, evaporated 5 ounces 
Lime-water 2 
Milk-sugar 2 
Boiled water 25 
One ounce = 13f calories. 
Seven feedings in twenty-four hours; 3 to 4 ounces at three-hour intervals during the 
day and four-hour intervals at night. 
From the Sixth Week to the Third Month: 
Milk, evaporated 6 ounces 
Lime-water 3 
Milk-sugar 2 
Boiled water 26 
One ounce = 13f calories. 
Seven feedings in twenty-four hours; 4 to 5 ounces at three-hour intervals during the 
day and four-hour intervals at night. 
From the Third to the Fifth Month: 
Milk, evaporated 7| ounces 
Lime-water 3 
Milk-sugar 2 
Boiled water 29 \ “ 
One ounce = 13| calories. 
Six feedings in twenty-four hours; 5 to 6 ounces at three-hour intervals during the 
day and a feeding at 10 p. m. 
From the Fifth to the Seventh Month: 
Milk, evaporated 10 ounces 
Lime-water 3 
Milk-sugar 2 
Boiled water 29 
One ounce = 15 § calories. 
Five feedings in twenty-four hours; 6 to 7 ounces at four-hour intervals, the last feeding 
at 10 p. m. 
From the Seventh to the Ninth Month: 
Milk, evaporated 11 ounces 
Lime-water : 3 
Milk-sugar 2 
Barley water 35 
One ounce = 16 f calories. 
Five feedings in twenty-four hours; 7 to 9 ounces at four-hour intervals, the last feeding 
at 10 p. m. 
From the Ninth to the Twelfth Month: 
Milk, evaporated 12 ounces 
Lime-water 3 
Milk-sugar 2 
Barley water 34 “ 
One ounce = 17y calories. 
Five feedings in twenty-four hours, 8 to 9 ounces at four-hour intervals, the last 
feeding at 10 p. m. Nine ounces is the maximum amount that should be given a baby 
at one time. 
The foregoing formula) may require changing to suit the individual case. If the 
formula seems to produce indigestion, an ounce of the milk may be removed and an 
ounce of the water substituted. If the formula agrees, but the child is not satisfied, 
the formula may be increased by adding an ounce of milk and removing an ounce of 
water. 
In arranging formulae for the different ages, it is assumed that the child is of average 
weight and vitality. Very small, delicate children may at first require reduction in the 
milk strength and a lesser amount at each feeding. THE ADAPTATION OF COW’S MILK 
83 
Dry Milk Preparations.—Preparations of dry milk powder from which 
the moisture has almost completely been removed have during the past 
few years come into general use. In the sense that these preparations 
are as yet in the hands of a few concerns and are dissimilar in composition 
depending on their source, they are to be regarded as proprietary foods. 
The principles of their use are identical, however, and their application 
to infant feeding may be taken up at this point. 
Dry milk is prepared by two chief methods. By one the milk is sprayed 
into a heated chamber in the form of a fine spray which is at once con- 
densed to a powder falling to the floor of the chamber like fine snow. 
By the other process the milk is instantaneously dried by flowing over 
hot revolving cylinders. In most of the preparations the fat content is 
kept low to insure better keeping of the product. The advantages of dry 
milk are its ready transportability, its stability, its cleanliness, its con- 
venience to the consumer in the ready preparation of food. 
Dry milk probably has its greatest value in the feeding of small in- 
fants whose capacity for finely divided casein is good, but whose fat and 
sugar tolerance is low. The protein element in this type of food may 
often be raised above the proportion customary in feeding without symp- 
toms of indigestion resulting, and the gains in weight thus attained are 
often spectacular, particularly when an infant getting an inadequate 
breast-milk supply is given supplementary dry milk feeding. In not a 
few instances, however, after a fortnight or more of favorable progress 
such an infant will begin to show signs of protein intolerance, the first of 
which is often a strongly ammoniacal urine productive of excoriation 
of buttocks. If food is longer continued, even with admixture of alkali, 
gastric indigestion and diarrhea may be induced. In such instances sub- 
stitution of weak evaporated milk feeding for a time is often beneficial. 
Dry milk filled a particular field of usefulness during the war as a food 
for infants in countries where fresh milk was unobtainable. 
The various preparations of malted milk contain in most instances 
maltose and dextrin in addition to dry milk. The tabulation given 
(p. 93) includes a number of these complex foods. In the main they are 
applicable to cases in which the sugar tolerance is not diminished' and have 
no advantage over dry milk to which appropriate carbohydrate is added. 
Cereal Gruels; Starch Feeding.—Much discussion has taken place 
during the past few years concerning the use of cereals in infant feeding. 
The cereals consist of plant embryos surrounded by a mass of highly 
nutritious proteins and carbohydrates in the form of starch, which nour- 
ishes the embryonic plant until it becomes rooted in the ground. As 
the developing plant needs nourishment it converts the starch into dex- 
trin and maltose. Cereals are analogous to eggs in that the germ is 
packed away in a supply of exceedingly nutritious food, which in the 
process of development it converts into tissue. Almost all of the pre- 
pared infant foods are made from cereal flours with or without the ad- 
dition of a little dried milk or sugar, or from cereals in which the starch 
has been transformed into dextrin and maltose. The proprietary meal 
foods, which consist of baked flours of different kinds, are useful aids 
in infant feeding and most useful as milk substitutes when milk must 
temporarily be withheld. The conversion of starch into dextrin by the 84 
THE PRACTICE OF PEDIATRICS 
baking process is so slight that it may be ignored. Robinson’s barley 
flour, Cereo Co.’s barley flour and the other gruel flours, and Imperial 
Granum (baked wheat flour) require boiling before use. They may be 
prepared according to the instructions given in the formulary (p. 95). 
It is customary in bottle feeding to begin with a cereal by at least the 
fifth to the seventh month, by using a cereal water as a diluent of the 
milk mixture. For this purpose barley or granum is usually employed. 
Very often in out-patient work we begin with a cereal diluent very early in 
life in order to make the food mixture more nutritious. This method of 
feeding is useful when accurate modifications are not possible and when 
the child for any reason cannot take a milk formula as strong as age 
and nutritional requirements demand. Such cases are frequently seen 
in the marasmic, the malnutrition, and the difficult feeding class. The 
addition of 2 or 3 tablespoonfuls of flour to the daily food will increase 
its nutritive value not a little. That boiled starch may be digested by 
the youngest and most marasmic infant has been proved. 
The principal use of these flours, however, is in the treatment of 
gastro-enteric diseases, where cereal may with safety replace the milk 
for considerable periods of time. By eliminating milk from the diet 
and giving carbohydrates, a putrefactive culture-field is removed and a 
less favorable soil is furnished for the development of the pathogenic 
types of intestinal bacteria; further, there are no by-products formed 
to produce intestinal toxemia or kidney irritation. Two even table- 
spoonfuls of these flours to 1 pint of water give approximately a food 
strength of 0.07 per cent, fat, 0.3 per cent, protein, 2 per cent, carbohy- 
drate. In order to increase the nutritive value, sugar may be added in 
sufficient quantity to bring the carbohydrate percentage up to 5. The 
addition of the sugar also makes the cereal more palatable, and there- 
fore more acceptable to the patient. 
During an invasion of scarlet fever, pneumonia, or any of the ill- 
nesses of childhood which may be accompanied by great prostration, the 
usual foods, whatever their nature, should be withheld, and the cereal 
gruel, alone or mixed with chicken or mutton broth, used as a very satis- 
factory substitute. Likewise later in the disease it is never well to give 
full milk while fever and prostration are present. Cereal gruels are 
especially serviceable as diluents of the milk in conditions where this 
combination must often furnish the nutrition for a period of days. 
The use of the baked-flour gruels, with sugar or without, as a means 
of nutrition should be continued only during the active symptoms of the 
disease, whether it is scarlet fever or one of the intestinal diseases. In 
no sense are these gruels advocated as exclusive foods for infants or for 
growing children. This error has been made with most disastrous results. 
The Infant's Capacity for Starch Digestion Proved by Experiment.— 
It has been claimed with more or less tenacity by different writers that 
the young infant possesses no capacity for starch digestion. That the 
youngest infants may digest starch is now definitely established. The 
experiments of Moro, Zwiefel, Corwin, Hess1 and Kerley2 have proved 
the earlier beliefs erroneous. 
1 Amer. Jour. Dis. Child., October, 1912. 
2 Kerley, Mason, and Craig, Arch. Ped., July, 1906, THE ADAPTATION OF COw’s MILK 
85 
Concentrated Cereal-milk Mixtures.— History.—In 1911 Hahn1 re- 
ported good results from the administration of 5 to 6 per cent, grits in 
milk in such form that 1 liter represented 1000 calories. McClure2 re- 
ported the case of a neurotic vomiting infant who promptly ceased vom- 
iting when fed thick barley gruel for which thick farina and milk was 
later substituted. Sauer3 applied the method, which he elaborated in- 
dividually, to 12 cases of pyloric obstruction with striking success in 11 
cases, and a year later Porter4 reported similar success with 10 pyloric 
cases. Mixsell5 applied thick cereal feeding successfully to cases of mal- 
nutrition dependent on vomiting, and Current and Durand6 extended 
its use to breast-fed babies with colic. 
Thick cereal feeding is therefore no longer to be regarded as a radical 
experiment, but rests upon an established basis. Representative case 
histories together with a more detailed review of the literature are avail- 
able in a report by Graves.7 
One of the patients in his series who had a complete breast milk in- 
tolerance took a cereal mixture readily from a spoon beginning at one 
week of age. 
The Method.—The feeding of concentrated cereal in milk is based on 
the simple physical behavior in the stomach of a paste as opposed to a 
liquid. The liquid in vomiting cases, particularly those dependent on 
pylorospasm is rejected with a spurt or gush while the cereal paste mass 
containing more food in smaller bulk distends the stomach less, apparently 
has some soothing effect on the irritable gastric mucosa, and eventually 
induces pyloric relaxation which permits of the passage of gastric contents 
provided no true organic closure of the pylorus exists. 
“The cereal of choice is probably farina, because of its property 
of great expansion under cooking, thus permitting thickening of the 
mixture with a minimum amount of added starch. Three or 4 table- 
spoonfuls in a 20-ounce formula will ensure sufficient solidification by 
the time cooking has reduced the quantity one-third, although greater 
concentration may at times be advisable. Obviously the amount of 
water to be used is not arbitrary. Skimmed milk, evaporated milk, 
dry milk powder, or breast milk may be incorporated in preference to 
whole milk. Sugar of any form may be employed, but should be main- 
tained at a low percentage until tolerance is proved, with due regard 
for the possible ill effect of maltose when vomiting is a chief symptom. 
For an infant under six months of age an allowance of 2 or 3 tablespoon- 
fuls at a feeding ordinarily suffices. If more is demanded the indication 
is for a thicker rather than a larger feeding. 
“The calorie guide is more valuable than the percentage method 
in calculating the ration. Empirically it has been found that 60 to 75 
calories per pound of body weight may be required to maintain a satis- 
factory gain, and that a larger allowance may be demanded and tolerated. 
1 Med. Klin., 1911, 7, 1452. 
2 Amer. Jour. Dis. Child., 1914, 7, 48. 
3 Arch. Ped., July, 1918, 385. 4 Ibid. 
5 Arch. Ped., August, 1919, 449; August, 1920, 486. 
6 Northwest Med., October, 1920, 240. 
7 The Role of Concentrated Cereal-milk Mixtures in Early Infancy, Amer. Jour. 
Med. Sci., April, 1922, clxiii, 576. 86 
THE PRACTICE OF PEDIATRICS 
“The importance of starch-free stools is likely to be magnified. Com- 
plete starch digestion is, of course, advantageous, but if incomplete 
digestion of the starch gives rise to no concomitant colic, distention, or 
hiccup the method may be continued with appreciation that the cereal is 
at least serving as a good vehicle. 
“Water between feedings is desirable, but not at all times necessary.”1 
For further discussion of the application of this method to the treat- 
ment of vomiting the reader is referred to p. 218. 
Butter-flour Feeding.—The butter-flour feeding of Czerny and Klein- 
schmidt2 is prepared by gently heating 4 level tablespoonfuls of ordinary 
salt butter in a pan until foaming occurs, and the odor of volatile fatty 
acids has disappeared (three to five minutes). To this is added 5 level 
tablespoonfuls of fine wheat flour. Again the mixture is heated with 
constant stirring until the mass is thin and brown (three to five minutes). 
Then 20 ounces of water in which 3 level tablespoonfuls of sugar have 
been dissolved is added. The mixture is then boiled and rubbed through 
a fine sieve. The percentage constitution of this stock solution is fat 
5.75 per cent., carbohydrate 10 per cent., protein 0.5 per cent., provid- 
ing 26.6 calories per ounce.3 To this stock solution cow’s milk is added 
in quantities dependent on the weight and requirements of the child. 
The following directions constitute a guide: 
For a child under 6| pounds, use 2 parts stock solution and 1 part 
milk; for example: 
Stock solution (prepared as above), 12 ounces Fat, 4.6 per cent. 
Cow’s milk, 6 ounces Carbohydrates, 8.2 per cent. 
Seven feedings in twenty-four hours Protein, 1.5 per cent. 
2§ ounces at each feeding 24.6 calories per ounce 
For an infant over 6| pounds, use 3 parts stock solution and 2 parts 
milk. For example an 8-pound child failing to gain should receive: 
Stock solution (prepared as above), 15 ounces Fat, 4.6 per cent. 
Cow’s milk, 10 ounces Carbohydrates, 7.8 per cent. 
Seven feedings in twenty-four hours Protein, 1.7 per cent. 
ounces at each feeding 24.3 calories per ounce 
For larger children the proportion of milk is increased as, for example, 
for a child of 11 pounds: 
Stock solution (prepared as above), 17 ounces Fat, 4.9 per cent. 
Cow’s milk, 17 ounces Carbohydrates, 7.0 per cent. 
Seven feedings in twenty-four hours Protein, 2 per cent. 
4 to 5 ounces at each feeding 24.4 calories per ounce 
Because of the high caloric value per ounce, it is usually best not to 
feed more than 3 to 4 ounces per pound of body weight in twenty-four 
hours, water being given separately. High caloric feedings, 75 to 90 
calories per pound, are well borne. 
The stools produced by this type of feeding are bright, glistening and 
yellow with a pungent aromatic odor, similar to that of breast-milk stools. 
1 The Role of Concentrated Cereal-milk Mixtures in Early Infancy, Amer. Jour. 
Med. Sci., April, 1922, clxiii, 576. 
2 Czerny and Kleinschmidt: Jahrb. fur Ivinderhcilk., 1918, lxxxvii, 1. 
3 Griffith and Mitchell, New York Medical Journal, August 3, 1921. THE ADAPTATION OF COW’S MILK 
87 
Butter-flour feedings are especially indicated for children who have 
good stools, and do not vomit, but fail to gain properly on other rational 
feedings. 
Czerny and Kleinschmidt consider it most important that the relation 
of butter to flour by weight be 1 : 1. 
Buttermilk and Lactic Acid Milk.—As ordinarily prepared buttermilk 
is a skimmed milk preparation of a composition approximately as follows: 
Fat 0.5 to 2 per cent. 
Lactose 3 to 4 “ 
Protein 3 to 4 “ 
Lactic acid 0.5 to 0.75 “ 
This composition varies, depending on whether the buttermilk is pre- 
pared from skimmed milk, whole milk, or cream. 
The advantages of such food are its low fat percentage, its compar- 
atively low sugar percentage, and its relatively high protein content 
which comprises more than the usual proportion of soluble albumin 
together with casein in a finely divided form which cannot be acted upon 
by rennin. 
As ordinarily prepared buttermilk is soured naturally and contains 
not only the lactic acid organisms largely responsible for the souring, 
but various other bacteria certain of which may be pathogenic. It is 
more rational to use prepared lactic acid milk than ordinary buttermilk, 
not only because of the bacterial factor involved but also because the 
composition of prepared lactic acid milk may be controlled more readily. 
Preparation.—Lactic acid milk is ordinarily prepared artificially by 
adding 1 or 2 of the commercial lactic acid tablets, such as the Lactone 
tablet of Parke, Davis & Co., to fresh milk at room temperature and 
allowing it to stand over night, the principle being the same as that em- 
ployed in the East in making ordinary Bulgarian sour milk with a “starter” 
portion obtained from the milk of a previous day. Sterilization of the milk 
before the artificial souring is not necessary if the milk is known to be 
fresh and clean. Such sterilization delays the action of the lactic acid 
organisms. 
A simple scientific method of preparing lactic acid milk that readily 
commends itself was worked out by Sherman and Lohnes.1 Taking ad- 
vantage of the known facts that the fine clotting desired in the milk 
occurred at an acidity point of 60 as measured by decinormal sodium 
hydroxid, and that when the acidity reached 170 to 190 fermentation 
spontaneously ceased, these authors simply allowed the milk selected 
to ferment for twenty-four hours in a warm place in the usual manner 
and then diluted the product with boiled milk in equal amount, thus 
cutting down the acidity to below 95. This acidity still being above 60 
insured the clotting of the added milk after which the mixture was kept 
on ice. 
These and other investigators have employed corn syrup extensively 
because of its cheapness and the character of its sugar to supplement 
the lactic acid milk in the feeding of infants whose sugar tolerance permit- 
ted. Surprisingly large amounts of sugar in a lactic acid medium have 
1 Jour. Amer. Med. Assoc., October 2, 1920. 88 
THE PRACTICE OF PEDIATRICS 
been taken even by very young and underweight infants with resulting 
improvement in stools that had previously been putrefactive, and rapid 
gains in body weight. 
Undoubtedly the good effects of lactic acid milk are in part due not 
only to the lactic acid itself, but to the contained organisms which tend to 
discourage the growth of a putrefactive intestinal flora. Surprisingly good 
results, however, are obtained by the simple addition of lactic acid to 
whole milk in the proportion of 1 dram to 1 pint.1 
Protein Milk.—This preparation is designated also as albumin milk, 
Eiweissmilch, and Finkelstein’s milk. Its use was developed by Finkel- 
stein and Meyer and has long been a matter of routine in hundreds of 
institutions. Variations in the process of making this food are respon- 
sible for much of the disagreement which still exists respecting its value. 
For this reason we have selected Lowenburg’s description of Finkelstein’s 
method of preparation2 as a reliable guide: “A teaspoonful of any milk 
coagulant, as rennin or pepsin, is added to 1 liter of whole milk. This is 
thoroughly mixed and the vessel containing the material is placed in a 
water-bath the temperature of which is about 110° F. This raises the 
milk to about 100° F. Within a short period coagulation occurs and 
the entire mixture becomes solid. The mass is then incised by a complete 
crucial incision. This facilitates the escape of the whey. The coagulum is 
now placed in a suspension bag (made of either four or five layers of cheese- 
cloth or of a porous material resembling thin, unbleached muslin) for a 
period of four hours. This permits all the whey to escape, carrying with 
it the major portion of the salts and the sugar of milk. The tough curd 
is then pushed through a hair-mesh sieve in order to completely com- 
minute it. This process is accomplished with a wooden spoon, or drug- 
gist’s pestle, or with a wooden instrument resembling a potato masher. 
It is repeated four or five times, adding about £ liter of water to facili- 
tate the passage through the fine sieve; £ liter of good buttermilk is added 
to the finely divided coagulum, and the entire mixture is again passed 
through the sieve. The bulk of the product should equal 1 liter, and, 
should it not, the deficiency is supplied by adding sufficient water. The 
mixture is now brought to the boiling-point, meanwhile stirring thoroughly 
and constantly from the moment that heat is applied. This maneuver is 
crucial in its effect upon the perfection of the finished product. If it is 
not employed, the finely divided curd will become one solid mass. This 
accident seems to occur with great frequency in America, while in Finkel- 
stein’s kitchen it rarely ever happens.” 
The product thus obtained contains: fat 2.5 per cent., protein 3 per 
cent., lactose 1.5 per cent. 
Protein milk is thus poor in fat and sugar and rich in protein, which 
exists in a finely divided state as calcium paracasein. 
Uses.—The chief value of such a milk lies in its applicability to the 
treatment of diarrheal conditions, notably those prevalent in the hot 
summer season. The low sugar content, tending to diminish intestinal 
fermentation, the relatively high fat content contributing to the forma- 
1 Marriott and Davidson, Jour. Amer. Med. Assoc., Dec. 15, 1923, vol. 81, pp. 2007- 
2009. 
2 Lowenburg, Infant Feeding and Allied Topics, 1916, 126. THE ADAPTATION OF COW’S MILK 
89 
tion of soap stools and the high protein in a subdivided easily digestible 
form all combine to make this albumin milk acceptable to infants suffer- 
ing from summer diarrhea or difficulty in the digestion of protein and fat 
together with abnormal susceptibility to the irritant effects of sugar. 
The lactic acid content of protein milk is also beneficial and probably, 
in those cases in which the end-product is not boiled after the addition 
of the buttermilk, lactic acid organisms themselves have some antiputre- 
factive effect. 
Dilution of the food may be made to fit individual cases, and when 
it is poorly taken saccharin may be added, 1 grain to the quart, to improve 
the taste. 
Within four or five days after beginning this feeding, or as soon as the 
stools have appreciably improved, carbohydrate in the form of starch 
or sugar should be added to increase the nutritional value. 
Ultimately the transition from protein milk to boiled milk and cereal 
water, or to an evaporated milk formula with low sugar content may be 
accomplished. Not before this time may the infant be expected to show 
much gain in weight. 
Typical mistakes in protein milk feeding cited by Strauch1 are as 
follows: 
“1. Insufficient dosages of protein milk in the beginning of treatment. 
“2. Too late addition or too small amounts of carbohydrate. 
“3. Withdrawal of carbohydrate or excessive diminution of food dur- 
ing a recurrence of the symptoms of nutritional disturbance after a period 
of improvement.” 
Dry Protein Milk.—To meet the demand for a protein milk which 
could be easily made in any household without special knowledge a number 
of preparations of albumin milk in powder form have been marketed. 
These preparations require only to be added in correct amounts to warm 
water before feeding in order to duplicate with fair accuracy the com- 
position of ordinary protein milk. 
The analyses of several of the more common substitutes of this class 
are given on page 93. 
In general, our experience would incline us to give preference to the 
original form of liquid protein milk whenever this is obtainable. 
Protein Milk Made From the Evaporated Product.—The standard 
protein milk of Finkelstein and Meyer as suggested in the preceding 
article fails us in not a few cases, and for three reasons: (1) The patient 
refuses to take it because of the decidedly sour taste. (2) When taken 
it is not well retained in not a few instances. (3) The curd may pass 
through the intestinal tract unchanged. This is particularly apt to be 
the case in the very young. 
In order to overcome the difficulties it was necessary that a method 
be devised that would obviate the disadvantages of the standard product, 
would supply something that the most delicate infant would take and 
retain, and that would give the results obtained with the standard product 
in cases in which it was impossible. At the senior author’s suggestion the 
Walker-Gordon Laboratory made a series of experiments in preparing a 
protein milk, using the evaporated milk for this purpose. It seemed that 
1 International Clinics, vol. iv, Series 32, 90 
THE PRACTICE OF PEDIATRICS 
if so many marantic infants could be fed on the evaporated milk by the 
prescription, a practice with which we have had marked success for 
several years, that the addition of the .Bulgarian bacillus might make 
this milk useful in treating those of the same type who had diarrhea. 
It was found that the eight-hour period of incubation ordinarily employed 
was unnecessary for satisfactory results, likewise that the addition of 
protein in the form of powdered curd was not essential. It was dem- 
onstrated also that an incubation period of two hours gave a much 
more palatable mixture, one that was taken very readily, was rarely 
vomited and relieved the diarrhea, at the same time producing a gain 
in weight. 
In the preparation of the milk a culture is used which is prepared as 
follows: One quart of skimmed milk is boiled for one hour, it is then 
cooled to 90° F., and divided into two equal parts. One-half tube of 
Bacillus acidi lactici is added to one portion, and one-half tube of B. 
bulgaricus to the other portion. The cultures are incubated eight hours 
at a temperature of 80° F., then shaken well, cooled, and kept on ice. 
The protein milk is prepared as follows: One teaspoonful of each 
culture added to 1 pint of the evaporated milk formula employed is 
incubated two hours. After this time the milk should be packed in ice to 
prevent a further incubation. 
It will be appreciated that this procedure is quite impossible in the 
home. It may be used, however, in any hospital in which there is an 
ordinarily well equipped diet kitchen. 
In using this method the evaporated milk formulae (p. 81) may be 
employed. It is best to use a weak mixture not giving over 1) per cent, 
of fat or over 3 per cent, of lactose until the diarrhea has subsided. The 
carbohydrate content may be increased by the use of barley flour in amount 
that brings the total carbohydrate percentage up to 5 or 6. As the diar- 
rhea improves the fat and sugar content may be increased. Every summer 
we feed a considerable number of cases along these lines, continuing the 
incubation process until well on into autumn. 
Illustrative Case.—A case demonstrating the type in which we employ this feeding 
was a marantic infant five weeks old weighing 6 pounds, 15 ounces. For two weeks he 
had been having from 5 to 7 loose green mucous stools daily. The following was pre- 
scribed: fat 1.25 per cent., protein 1.25 per cent., starch 5 per cent., lactose 4 per cent. 
In three days the child was reported constipated and hungry. The food was then in- 
creased to fat 1.50 per cent., protein 1.50 per cent., starch 2 per cent., lactose 7 per 
cent. In five days more he had entirely recovered, was hungry, and weighed 7 pounds, 
ten ounces, having made a gain of 11 ounces in the eight days. 
Every year, particularly in the autumn, we have a large number of 
infants suffering from chronic indigestion in which diarrhea or a tendency 
to diarrhea is a prominent symptom. These infants who are usually 
brought to us on a barley and skimmed milk diet of varying strengths, 
have always been difficult feeders and have incompletely recovered from 
some acute intestinal disorder. With these patients the establishment 
of thriving has been most difficult and it is in such cases that the method 
presented gives brilliant results. Infants who will thrive on fresh cow’s 
milk during the cooler months in New York City and its environment 
may not be able to digest the same milk during the hot months. In such THE PROPRIETARY FOODS 
91 
cases the evaporated protein milk has aided us greatly as a temporary 
substitute for a fresh cow’s milk formula. 
It is not claimed that the scheme presented is a method of infant 
feeding; it is a means of temporary feeding for sickly, delicate infants 
who are having a hard time. By this means we can give a well-balanced 
ration of increased caloric value which the patient is able to utilize, with 
resulting cessation of the diarrhea and gain in weight. 
THE PROPRIETARY FOODS 
The foods on the market prepared for purposes of infant feeding are 
very numerous. From our knowledge of the composition of mother’s 
milk we learn what nutritional elements are required, and approximately 
in what relative proportions these elements must exist, in order to supply 
the child with the food which nature intended him to have. The ex- 
amination of the milk of thousands of nursing women shows that it con- 
tains from 2.5 to 4 per cent, fat, 6 to 7 per cent, sugar, and 1 to 1.5 per 
cent, protein; and this furnishes the balanced ration with normal caloric 
requirements. These figures may be put down as the normal limits of 
human milk, and they are so simply because the infant will thrive and 
grow best when the nutritional elements in approximately the above 
proportions are supplied to him. It is within these limits with few excep- 
tions that the food must be kept in order that there may be normal growth 
and development. While the child may exist and temporarily do fairly 
well on a percentage of fat lower than 2.5, he will invariably show defective 
growth if the protein remains persistently under 1 per cent. The chief 
disadvantage in the infant foods which are used without the addition 
of cow’s milk lies in the fact that they do not contain the nutritional 
elements as they exist in normal breast milk, and besides, of necessity, 
they are all cooked foods. 
A further objection to the use of proprietary foods in general is their 
excessive cost. This is readily contributed to by advertisements which 
direct the feeding of babies both well and sick. It is not well to put too 
much reliance on the analysis sometimes published by the proprietary 
food manufacturer. This type of food is decidedly weak in animal fat 
for the reason that there is no means of keeping more than a small per- 
centage of it in a food without its becoming rancid. When considerable 
percentages are indicated in the analysis it is certain that the fat does 
not consist of butter fat. The quantity of animal milk protein is like- 
wise deficient, and what is present has been cooked, which detracts ma- 
terially from the value of the food in infant nutrition. Scurvy is not an 
infrequent result of the exclusive use of these foods. 
The Uses of Proprietary Dried-milk Foods.—It is to be remembered 
in spite of what has just been written that this type of food is condemned 
because of its being an unsuitable food when used exclusively and per- 
sistently. Hysteric, general condemnation is unjust. Throughout this 
book the uses of the proprietary foods will be mentioned from time to 
time and dwelt upon. Milk is often an important factor in the production 
of constipation; and the importance of this food in the nutrition of “run- 
about” and older children who are on a general diet is secondary. In 92 
THE PRACTICE OF PEDIATRICS 
such cases cow’s milk may be replaced by one of the proprietary dried- 
milk, malted foods which has a laxative effect. During acute illness and 
in convalescence and in certain forms of malnutrition such foods are 
usually readily digested and may help us over difficult places. 
Proprietary Foods to Which Fresh Cow’s Milk is Added.—These 
are not foods in the usual acceptation of the term, and if they are used 
alone, independent of milk, the patient will soon present a sorry spec- 
tacle. They are largely sugars, composed of maltose and dextrose, which 
are derived from starch. Some contain a considerable quantity of un- 
converted starch. When added to the water and milk mixtures they 
furnish the soluble carbohydrates and free starch, and thus fulfil this 
function of the food with results as good as, but usually no better than, 
those obtained with milk-sugar and a cereal gruel. Maltose is a laxative 
sugar. In some cases of constipation in the bottle fed it may replace the 
milk-sugar in equal quantity, with decided advantage. In other cases 
this change to maltose is without effect. 
According to our observation, the statement that the addition of 
maltose to cow’s milk facilitates its digestion is unfounded. We have 
tried this method in many cases, but have never been able in conse- 
quence to use a stronger cow’s milk mixture. The true test of such a 
measure is in treating the delicate and in feeding difficult cases, rather 
than well babies who thrive regardless of the carbohydrate employed. 
The maltose preparations, then, in the sense that they may contain 
a small amount of protein and a laxative sugar, are useful and to be 
recommended when such a carbohydrate is needed. 
The Proprietary Beef Foods.—Numerous preparations of this nature 
are on the market, and there has been abundant opportunity to test 
their value. Without going into a lengthy discussion as to how and under 
what conditions these preparations have been used, it is sufficient to say 
that as means of nutrition for children they play a very unimportant 
part. Their principal use is in illness, in which they act as a stimulant, 
and to a less degree as a food. They all make weak protein mixtures 
when diluted so that the child can take them. The possibility of supply- 
ing any great amount of nutrition by their use is negligible; occasionally, 
however, they may be used to advantage. When milk is withdrawn, 
they may be added to the cereal gruel substitute. If there is diarrhea, 
great care must be exercised, as the proprietary beef preparations as well 
as beef juice may aggravate this condition. On account of the creatinin 
which they contain these foods should not be given in any of the forms 
of nephritis. Another obstacle which limits their use is that a child soon 
tires of them. They can rarely be given more than two or three times in 
twenty-four hours. Valentine’s is the preparation usually selected. It 
may be given in solution—\ to | teaspoonful to 6 ounces of the diluent. 
The Composition of Infant Foods.—In the table on p. 93 an attempt 
is made to group some of the more common proprietary foods according 
to their leading characteristics and to give fairly dependable figures 
showing the respective analyses. The list of such foods is being constantly 
augmented and there is no guarantee that change in the manufacture 
of any one of the patent foods may not at any time alter the proportions 
of its ingredients. For practical purposes in spite of the fact that the THE PROPRIETARY FOODS 
93 
Percentages. 
Group. 
Name of food. 
Fat. 
Carbohydrate. 
Protein. 
Cane- 
sugar. 
Lactose. 
Maltose. 
Dextrins. 
Starch. 
Condensed and Evaporated Milks 
9.6 
43 
12 
8 
8.3 
10 
7 
8.1 
10 
7.3 
Dry Milks—Plain 
12 
46 
32 
12.1 
55 3 
24.3 
Klim 
28 
38 
26.7 
Malted Dry Milks 
8.5 
13 7 
38.8 
17 
8.7 
8.8 
49 
. 1 
18.8 
16.3 
17 
25 
25 
18 
Allenburv’s Food 
No. 1 
18 6 
42 
14 
10 
10.6 
No. 2 
15.8 
36 
20 
13 
9.9 
No. 3 
1.05 
16.5 
8.5 
60 
10.2 
5.5 
25 
6.6 
27 
.4 
15.4 
14.3 
Starchy Foods 
1.0 
1.38 
73.5 
14 
0.3 
7.8 
74 
12.5 
0.9 
3.3 
77 
12.1 
Starch and Sugar Combinations 
3.5 
54 
1.7 
30 
6.7 
Allenbury’s Food, No. 31 
Nestle’s Food1 
Malt Sugar Foods 
52 
41 
0.16 
58.9 
20.7 
10.35 
Dry Protein Milks 
27 
24 
38 
30 15 
(Free lactic 
acid 3) 
21 5 
38.3 
Larosan, “Roche” (A casein-calcium powder to be added 
0.3 
(Lactic 
acid 3) 
85 
(CaO 2.5 
P205 2.2) 
1 Analyses under Malted Drj 
Milks. 94 
THE PRACTICE OF PEDIATRICS 
figures given are derived from various sources,1 including in some instances 
the manufacturer’s labels, the data is sufficiently accurate. 
SPECIAL SUPPLEMENTARY FOODS AND THEIR PREPARATION 
Numerous adjuvants to milk are of value in infant feeding, particularly 
as a means of fulfiling the demands of the borderline period between 
infancy and childhood. For short intervals certain of these foods may be 
used as substitutes for milk when the latter for any reason is unavailable 
or is poorly tolerated. 
Formulae 
Beef Juice.—Take a round steak, cut into pieces the size of a horse 
chestnut, place in a buttered pan in a hot oven, and bake for fifteen 
minutes; remove from the pan and press out the blood; add salt to the 
taste. 
Beef, Mutton, and Chicken Broth.—Take 1 pound of meat free from 
fat, cook for three hours in 1 quart of water, adding water from time to 
time, so that when the cooking is completed there will be 1 quart of broth. 
When the broth is cool, remove the fat, strain, and add salt to the taste. 
Scraped Beef.—Broil round steak slightly over a brisk fire. Split 
the steak and scrape out the pulp, using a dull knife. 
Egg-water.—The white of 1 egg, thoroughly beaten in 1 pint of cold 
boiled water; strain; add salt to the taste. 
Coddled Egg.—Take a fresh egg, place it in a pan of boiling water, 
put on the back of the stove and stand for three minutes, having pan 
tightly covered. 
Cornstarch Pudding— Dissolve 1 tablespoonful of cornstarch in a 
little milk. Heat 1 pint of milk to nearly boiling-point. Add cornstarch 
slowly, then 1 tablespoonful of sugar and stir until it thickens. When 
cool add 5 drops of flavoring. 
Soft Custard.—Heat 1 cup of milk to boiling-point. Add 1 yolk of egg 
well beaten, one teaspoonful of sugar, and a pinch of salt. Cook in a 
double boiler, stirring until it thickens. Strain and add 5 drops of flavor- 
ing. 
Oatmeal Jelly.—Oatmeal, 4 ounces; water, 1 pint; boil for three hours 
in a double boiler, water being added, so that when the cooking is com- 
pleted a thin paste will be formed. This while hot is forced through a 
colander to remove the coarser particles. When cold a semisolid mass 
will be formed. 
Wheat Jelly and Barley Jelly.—Wheat jelly and barley jelly are made 
in the same way as oatmeal jelly, using cracked wheat or barley grains. 
Barley-water No. 1.—Robinson’s barley flour or Cereo Co.’s barley 
flour, 1 rounded tablespoonful; water, 1 pint. Boil thirty minutes; strain; 
add water to make 1 pint. 
In making barley-water No. 2, 2 tablespoonfuls of the flour are used, 
and for No. 3, 3 tablespoonfuls are used. 
Rice-water No. 1.—Rice, 1 tablespoonful; water, 1 pint; boil three 
1 Morse and Talbot, Diseases of Nutrition and Infant Feeding, 1915, 230, 231; 
Holt and Howland, Diseases of Infancy and Childhood; Mellins Food Co., Proprietary 
Foods, Formulae. SPECIAL SUPPLEMENTARY FOODS AND THEIR PREPARATION 
95 
hours, adding water from time to time, so that there is 1 pint of rice- 
water at the end of the three hours. 
In making rice-water No. 2, 2 tablespoonfuls of rice are used. 
Oatmeal-water No. 1.—Oatmeal, 1 tablespoonful; water, 1 pint; cook 
three hours and add water to make 1 pint. 
In making oatmeal-ivater No. 2, 2 tablespoonfuls of oatmeal are used. 
Percentage Gruel Flours.—There is on the market in tin boxes, the covers 
of which are used as measures, a series of flours, especially made for pre- 
paring cereal gruels and jellies of known percentage composition. On 
the labels are given only the cooking directions for preparing plain or 
dextrinized gruels, and their composition when different quantities of 
flour are used. They are as follows: 
Approximate Composition of Gruels Made From Cereo Co/s Gruel Flours 
Barley. 
Legume.1 
Oat. 
Wheat. 
Proteins. 
Carbo- 
hydrates. 
Proteins. 
Carbo- 
hydrates. 
Proteins. 
Carbo- 
hydrates. 
Proteins. 
Carbo- 
hydrates. 
Per 
Per 
Per 
Per 
Per 
Per 
Per 
Per 
cent. 
cent. 
cent. 
cent. 
cent. 
cent. 
cent. 
cent. 
\4 ounce flour to quart of water 
0.12 
0.60 
0.19 
0.53 
0.12 
0.60 
0.10 
0.62 
Vi ounce flour to quart of water 
0.24 
1.20 
0.39 
1.06 
0.24 
1.20 
0.20 
1.25 
V. ounce flour to quart of water 
0.36 
1 .80 
0.58 
1.59 
0.36 
1.80 
0.30 
1.88 
1 ounce flour to quart of water 
0.48 
2.40 
0.78 
2.12 
0.48 
2.40 
0.40 
2.50 
2 ounces flour to quart of water 
0.96 
4.80 
1 .56 
4.24 
0.96 
4.80 
0.80 
5.00 
3 ounces flour to quart of water 
1.44 
7.20 
2.34 
6.36 
1.44 
7.20 
1 .20 
7.50 
4 ounces flour to quart of water 
1.99 
9.60 
3.12 
8.40 
1.92 
9.60 
1.60 
10.00 
1 Made from equal parts of peas, beans, and lentils. 
Dextrinized Barley-water.—Robinson’s barley flour or Cereo barley 
flour, 3 tablespoonfuls; water, 1 pint; boil thirty minutes; add water to 
make a pint. When lukewarm (100° F.), add 1 teaspoonful of Cereo; 
strain; this changes the starch into dextrinized maltose. 
Oatmeal-water No. 1.—-Oatmeal, 1 tablespoonful; water, 1 pint; cook 
three hours and add water to make 1 pint. 1 
In making oatmeal-water No. 2, 2 tablespoonfuls of oatmeal are used. 
Imperial Granum-water No. 1.—Imperial Granum, 1 tablespoonful; 
water, 1 pint; cook thirty minutes and add hot water to make 1 pint. 
In making Granum-water No. 2, 2 tablespoonfuls of Granum are used. 
Whey.—Put 1 pint of fresh milk into a saucepan and heat it lukewarm, 
not over 100° F.; then add 2 teaspoonfuls of Fairchild’s essence of pepsin 
and stir just enough to mix. Let it stand until firmly jellied, then beat 
with a fork until it is finely divided; strain, and the whey, the liquid part, 
is ready for use. 
Junket.—To 1 pint of fresh milk add 2 teaspoonfuls of sugar and 1 
junket tablet or 2 teaspoonfuls of essence of pepsin. Allow it to stand 
over a fire until the temperature is 100° F.; then add vanilla as a flavoring 
and allow it to stand until the curd is set, when it should be placed on ice. 
Prune Juice.—Take 1 pound of prunes, wash thoroughly, place in a 
pan, cover with cold water, and allow to stand over night. Place on stove 
next morning, bring to a boil, and allow to simmer until very soft. Strain 96 
THE PRACTICE OF PEDIATRICS 
off the juice (which should be 8 ounces) and give the required amount 
for the infant. 
For older children the pulp may be used with the juice after putting 
through a sieve. 
Lactic Acid Milk.—The preparation of lactic acid milk is described 
on page 87. 
MILK FOR TRAVELING 
In making long journeys with infants by land or water the feeding of 
the child is an important matter, and advice is often sought by mothers 
who wish to make the contemplated trip with the least possible risk. It 
is, of course, desirable that no change be made in the milk commonly 
used, and there are means of treating the milk and of keeping it which 
enable us to assure the patient of reasonable safety. It is convenient with 
New York City children to have the milk prepared at the Walker-Gordon 
Laboratory, where at a trifling expense small ice-boxes can be obtained 
which contain sufficient space for a few days’ supply of milk and which 
can be conveniently carried on cars and boats. Larger boxes with a 
capacity of 12 quarts may be used for an ocean voyage. The smaller box 
will need refilling with ice, which is usually readily secured once or twice 
a day. The larger box for ocean voyages is packed in ice and placed 
in a cold-storage room of the vessel and will not need repacking during 
the trip. The milk prepared for a journey should be cooled to 45° F. as 
soon as it is drawn and kept at this temperature until it can be sterilized 
at a temperature of 212° F. for twenty minutes. It should then be cooled 
rapidly to at least 50° F. and kept at this point until used. These directions 
can be carried out by any intelligent family. When this is done, the milk 
will be safe for use for the time required—from seven to eight days. Of 
course, laboratory milk is available for comparatively few. But the sug- 
gestion as to the making of an ice-box can be followed in any town or 
village, so that a milk laboratory is not essential. All that is required 
is the ice-box, the quart fruit-jars or quart milk-bottles, and clean milk. 
Those who for any reason cannot avail themselves of the milk thus pre- 
served will find in canned evaporated or condensed milk or in dry milk 
a fairly good substitute. 
Malted milk or any of the dried milks on the market may be used as 
a temporary substitute for cow’s milk. 
SUBSTITUTES FOR STOMACH FEEDING 
In the management of the diseases of children conditions arise from 
time to time which necessitate the nourishment of the patient by chan- 
nels other than the stomach. In persistent vomiting, when there is an 
acute congestion of the stomach, as in an acute gastro-enteric infection, 
in cyclic vomiting, and in vomiting due to some more remote cause, as 
meningitis or nephritis, the patient must receive water and food in order 
to sustain the system until the exciting factor is removed. 
Nutrition by means other than stomach feeding may be necessary in 
retropharyngeal adenitis or abscess, in stricture of the esophagus, in 
diphtheria, in the exanthemata, and in pneumonia during the course of 
active delirium, A substitute for stomach feeding is also often useful SUBSTITUTES FOR STOMACH FEEDING 
97 
in marasmus, for the generally delicate, and in nourishing those with 
reduced assimilative powers. Various means of substitute feeding have 
been attempted from time to time. Nutritive suppositories have been 
advocated and proved failures, perhaps because of our inability to place 
them sufficiently high in the bowel. Placed in the rectum, they excite 
peristalsis and are expelled. 
Rectal and Colonic Feeding.—Any means of treatment which is 
disagreeable both to patients and attendants, and difficult of execution, is 
very liable to fall into disfavor unless pronounced beneficial results are 
the rule. While absolutely nothing can be promised so far as supplying 
nutrition by this means is concerned, careful observation and experience 
tell us that in a certain number of cases the measure is of much value. 
When the treatment will be of service in nourishing the patient can be 
determined by trial only. In children, particularly in very young chil- 
dren, on account of the ease with which peristalsis is excited, nutrition 
by this means is less frequently successful than in the adult. Never- 
theless, the method has been of material assistance in many a trjdng 
situation. 
Not a few of the failures are due to a lack of appreciation of the details 
of the procedure. Directions to mothers or nurses to inject a certain 
quantity of some particular food, unless specific instructions are given, 
will usually be carried out as follows: A hard glass or rubber tip will 
be passed into the rectum from 1 to 2 inches. Through this the fluid 
will be forced. In a very few minutes, perhaps immediately, the bowel 
will empty itself into the napkin or bed-pan, the enema being of no ser- 
vice. This is what may be expected and what will happen when the 
child is given the nutrient enema in this way. The hard tip, placed within 
the anal ring, and the fluid are very apt to excite vigorous perstalsis. 
In order that the nourishment may be retained, it should be carried 
high up into the descending colon. The advantages of this method are 
that the fluid is much better retained, and, on account of the greater sur- 
face of mucous membrane with which it comes in contact, it will be quickly 
and more completely absorbed. 
How to Give a Nutrient Enema.—The nutrient enema is best given 
as follows: 
A soft-rubber catheter, No. 18 American, or a small adult size rectal 
tube is slipped over the small tip of an ordinary fountain-syringe. The 
tube should not be too flexible nor yet too stiff, and the catheter is to be 
preferred. If too flexible, the instrument folds readily on itself when 
the point meets with any resistance, and the fluid escapes perhaps 1 or 2 
inches within the anal opening. If the tube is too rigid or if force is 
employed, the mucous membrane and the parts may very easily be 
lacerated. 
The position of the child while the enema is being given is important. 
He should rest on his left side, preferably in Sims’ position, with the 
buttocks elevated to a plane at least 4 inches higher than the shoulders. 
A pillow or a folded blanket covered with a rubber sheet should always be 
available for this purpose if a bed-pan is not at hand. The child, if old 
enough to understand, should be assured that no harm will come to him. 
With the patient in position and an assistant to hold him, the anus is 98 
THE PRACTICE OF PEDIATRICS 
covered with vaselin. It is not enough to oil the tube. The tube at- 
tached to a fountain-sj'ringe is warmed and well oiled and passed into 
the rectum. The lower end of the bag should be 3 feet higher than the 
child’s body. There may be some straining at first, but with the child 
in a proper position one may pass a tube of the right degree of flexibility 
high into the intestine in a few seconds. The tube should be introduced 
about 9 inches—far enough at least to be felt in the descending colon; 
then the fluid is allowed to pass rapidly into the bowel. When the bag 
is emptied, the tube is rapidly withdrawn and the child, although allowed 
to change to the dorsal position, is encouraged to rest on his side. In 
any event the buttocks must be kept elevated for at least one-half hour. 
In using small amounts of fluid it is well to allow for the quantity which 
may remain in the tube of the syringe and in the catheter after the enema 
is given. In managing older children, who exert much bearing down or 
straining, it may be necessary to attach the catheter to a Davidson sjWnge 
or to an ordinary rubber or glass piston-syringe of large size, in order 
to provide sufficient force to overcome the pressure exerted by the ab- 
dominal muscles. 
The nutriment should be neither too hot nor too cold. With either 
of these extremes, peristalsis is apt to be excited. A temperature of 
95° F. is the most satisfactory. If bowel action has been fairly free, 
previous washing with a normal salt solution is not necessary. If there 
has been no movement for six hours, it will be well first to use an irri- 
gation of normal salt solution. Glycerin should not be used. The 
irrigation should precede the enema by from fifteen minutes to half an 
hour. 
Nourishment Not to Be Used in the Rectum.—Oils or fats in any form, 
even though pancreatinized, should not be used. Alcohol should be 
used only in very urgent cases, and then it should be well diluted and 
used not oftener than once or twice in twenty-four hours, because it has 
a decidedly irritant action on the intestinal mucous membrane and is 
not well retained. When used alcohol should be diluted with from 12 to 
16 parts of water or an equal quantity of skimmed milk, which has been 
peptonized or pancreatinized. In giving stimulants by the rectum, 
whisky is usually employed in quantities from \ ounce for a child two 
years of age, to 1 ounce for a child from six to ten years of age. 
Nourishment to he Used.—By far the best food for rectal alimen- 
tation is skimmed milk completely pancreatinized. It is better retained 
and more completely assimilated than any other form of nutriment 
which we possess. In cases in which it is desired that a considerable 
amount of fluid be absorbed by the intestine, the pancreatinized milk 
may be diluted with normal salt solution. Where such milk is not avail- 
able, the whites of 3 raw eggs, mixed with a normal salt solution, may 
be given. Not infrequently the whites of 1 or 2 raw eggs are given in 
the pancreatinized skimmed milk, this combination constituting the best 
form of nutrient enema. The predigested proprietary preparations, the 
so-called “peptones,” have not proved satisfactory in our hands. 
The amount of nourishment to be used at one time varies with the 
age and condition of the child. COMMON DIGESTIVE DISORDERS OF INFANCY 
99 
Ordinary Amount to Be Given in Enema 
Under three months 2-4 ounces 
Prom three to six months 4-6 “ 
From six to twenty-four months 6-8 “ 
After the twenty-fourth month 8-16 “ 
Because the first enema is not retained, it does not follow that a sec- 
ond given immediately thereafter will share the same fate. In not a few 
instances, when the second enema has been given ten minutes after all 
or the greater part of the first had been expelled, the entire second amount 
has been retained. It is rarely wise to repeat the enema oftener than 
at six-hour intervals, and when the intestine shows a tendency to intol- 
erance the intervals should be increased to eight or ten hours. 
This means of nutrition in children is of temporary use at best. The 
period of its application in the average case, even when tolerated at 
first, is only two or three days. In a few instances it has been found 
practicable to use the method longer. 
Illustrative Cases.—During the summer season a very delicate three-month-old 
child, weighing 6 pounds and 10 ounces, retained 2 ounces of completely pancreatinized 
skimmed milk, given at six-hour intervals for three days, and 3 ounces at eight-hour 
intervals for eight days longer, making a period of eleven days in which the enemata 
were employed. Such tolerance of the large intestine, however, is very rare. 
In another case the use of enemata following an operation for intestinal obstruction 
with protracted vomiting and prostration unquestionably saved a child’s life. 
In a third severe case of cyclic vomiting, which was seen in considtation, the vom- 
iting had persisted for three days. This child was six years of age. He showed marked 
emaciation, and suffered from intense thirst; his pulse was weak and soft. A nutrient 
enema was given, composed of 8 ounces of pancreatinized skimmed milk, 8 ounces of 
normal salt solution, and the whites of two eggs. Not one drop was expelled. In one- 
half hour the boy claimed to feel better. The intense thirst was relieved and he fell 
into a res.tful sleep. In six hours the enema was repeated, about 4 ounces being expelled. 
This was followed by enemata at eight-hour intervals, 8 ounces of the milk with the 
whites of two eggs being given, all of which was retained. At this point the vomiting 
abruptly ceased and further enemata were not required. 
Common Digestive Disorders of Infancy 
The Recognition of Digestive Disturbance.—In order successfully to 
carry on the feeding of an infant one must be alert to slight departures 
from the normal which singly are often overlooked and many times are 
of no significance, but collectively make up the picture of “disturbed 
balance” which may be followed by persistent indigestion. 
Successful infant nurses and the mothers of large families acquire a 
sort of sixth sense, the possession of which enables one to judge whether 
an infant is doing well or poorly even before a change in the appearance 
or behavior of the baby can be detected by the less experienced. 
The value of such a developed instinct is unquestionable. It may be 
acquired by any one who will make the study of minor manifestations 
on the part of the infant a serious undertaking. 
Hunger.—In the case of a strong, lusty nursling an error in diagnosing 
hunger can hardly be made. The insistent cry, the crowding of the 
baby’s hands into his mouth, the beginning of sucking even before the 
nipple can be grasped, the recurrence of the cry when nursing is inter- 
rupted, the normal sleep following the filling of the stomach all make un- 
mistakable the recognition of the infant’s simple periodic need for food. 
In the bottle-fed infant who has a poor digestive capacity or has been 100 
THE PRACTICE OF PEDIATRICS 
improperly fed the hunger symptoms may pass unrecognized. Hunger 
in such an infant is often associated with colic or may follow directly 
after vomiting, or recur without apparent reason after a feeding in caloric 
value far above the normal requirements. To understand such a case, 
to correctly gage the relative importance of hunger and more serious 
disturbance, in guiding the feeding, and to withhold increase in food 
in the presence of a consistent gain by a baby who “is always hungry,” 
calls for a differentiation between normal and abnormal hunger, possible 
only when all the factors are considered by one who is experienced. 
In general, hunger in the absence of vomiting or symptoms indicative 
of intestinal indigestion may be taken as a favorable symptom and not 
infrequently will justify a temporary increase in food, disproportionate 
to computed caloric needs. In the event of rapid gain following such 
increase in the food, the hunger manifestations will probably diminish 
in intensity so that the food may be maintained without further increase 
till the augmented weight of the infant entitles him to more. 
Hiccup due to spasm of the diaphragm is ordinarily a minor symp- 
tom due to the distention of the stomach with air swallowed at a too 
rapid nursing, or to the presence of gas from carbohydrate or butyric 
acid fermentation. This symptom may be relieved by the administra- 
tion of a little very warm water and by holding the infant upright and 
patting his back. Persistent hiccup may yield to warm abdominal ap- 
plications and an enema. 
The baby with recurrent hiccup should have slower feedings, food 
in smaller volume, and possibly food with lower carbohydrate and fat 
content. If he does not vomit or show by his stools evidence of indiges- 
tion, the hiccup may be interpreted simply as a mild warning that diges- 
tive capacity is being moderately taxed. 
Colic.—This is a more serious condition due to the presence of gas 
in the intestine. The peristalsis thus excited takes the form of definite 
cramps upon the occurrence of which the subject draws up the legs and 
screams. The diagnosis of colic is facilitated by noting the presence of 
tympanites and the occasional passage of gas from the bowel at which 
times the baby may manifest relief. A saline enema affords more lasting 
relief. A discussion of this condition in greater detail will be found in 
the section on Intestinal Diseases, pp. 225-227. 
Vomiting.—The significance of this symptom depends upon its char- 
acter and cause. 
Vomiting with eructation of gas is often due to neglect of the practice 
of patting the infant on the back while he is held upright after feeding. 
Air swallowing from too rapid feeding increases this susceptibility. 
Simple regurgitation or “spilling over” is regarded as a physiologic 
form of relief to an overfilled stomach. The indication to meet this con- 
dition is obvious. In infants of a neuropathic type (of which class there 
are not a few) this habit may become complicated by actual rumination. 
Sour vomiting at intervals indicates fermentation from too much fat 
or sugar in the feeding. High fat feeding tends to induce retention of 
gastric contents beyond the period when emptying is normally accom- 
plished. Vomiting of very acid contents in such cases frequently follows 
the taking of a fresh feeding. COMMON DIGESTIVE DISORDERS OF INFANCY 
101 
Other common forms of vomiting (p. 199) with the important excep- 
tions of those types dependent on spasm and obstruction in the gastro- 
intestinal tract belong less exclusively to infancy. 
Pylorospasm and pyloric stenosis occasion forcible projectile vomiting 
of a type requiring special consideration. (See p. 207.) 
Intussusception and congenital obstruction of the intestine present 
surgical signs and symptoms. 
Vomiting dependent on reflex causes (particularly teething), vomiting 
with pertussis, meningitis, peritonitis, and the onset of acute infective 
diseases with fever, and finally, the vomiting belonging to acidosis, all 
occur in infancy and require treatment considered under discussion of 
the respective underlying conditions, to be presented later. To many 
cases the treatment outlined in the section on Acute Gastric Indigestion 
(p. 200) is applicable. 
Certain particular phases of the subject of vomiting in infancy may be 
considered at once. The vomiting infant should be watched by the phys- 
ician for a considerable time to determine the nature of the vomiting, 
because statements by the family cannot always be relied upon. The 
vomiting may be projectile. This, if habitual, is very apt to mean the 
existence of pylorospasm or hypertrophic pyloric stenosis (p. 207). In 
vomiting due to unsuitable food productive of gastric irritation the ejected 
material usually comes up in large mouthfuls during the interval between 
feedings, and is of a disagreeable sour odor. Regurgitation of small amounts 
of partially digested food may occur in this type of case. In all such 
cases, however, rumination (p. 206) is to be thought of, a condition which, 
although fairly common, is usually overlooked by the attending phys- 
ician. It is very sure to be overlooked if the child is not watched for a 
half-hour or so after the feeding. Spasmophilic infants vomit much 
more readily than those not so constituted, but we have never been 
impressed by the so-called “nervous vomiter” or “habit vomiter.” 
Careful observation of such cases will usually disclose a hyperstalsis 
or pylorospasm. The point of hyperstalsis is frequently overlooked. 
The pyloric opening at best is small, and the overacting stomach in its 
efforts to force food through the pylorus is very apt to take on a reverse 
stalsis, with resulting rejection of the food. 
Every year we see several cases in which the vomiting is apparently 
due indirectly to mucous gastritis. In these infants there is a production 
of thick gelatinous mucus which covers the lining of the stomach and 
unquestionably plugs the pyloric orifice and acts in a mechanical fashion 
to prevent the passage of the food, the results being identical with those 
of pylorospasm. 
In the cases that are occasioned by unsuitable food and resulting 
gastric irritability the treatment is obvious and will be found under 
Acute Gastric Indigestion (p. 200). For all vomiting infants, regardless 
of the nature or cause of the vomiting, the use of a daily stomach wash- 
ing is always of advantage, and in some instances gives most surpris- 
ingly favorable results. The cases of mucous gastritis particularly are 
quickly relieved by daily stomach washing. Because of this tendency 
to varying degrees of mucous gastritis in all deranged stomachs, whether 
the causative factor is mechanical or otherwise, lavage is indicated. A 102 
THE PRACTICE OF PEDIATRICS 
5 per cent, solution of bicarbonate of soda is the fluid used. From 2 to 4 
ounces should pass into the stomach and be siphoned out, this procedure 
being repeated until the water is clear. 
Constipation.—This is perhaps the most common functional digestive 
disorder of infancy. Its consideration in detail is taken up on p. 267. 
When present in a feeding case that presents no other departures from 
the normal, constipation rarely constitutes a serious problem. It is note- 
worthy that constipated babies (perhaps because the slow expulsion 
of the intestinal contents gives more time for complete food absorption) 
characteristically gain weight rapidly. 
Obstipation, in distinction from constipation, serves as a valuable 
symptom in the differentiation of pyloric stenosis from simple pyloro- 
spasm. 
Diarrhea.—Frequent watery stools are common in breast-fed infants 
during the first days of life and have little significance. As the breast 
milk improves the diarrheal tendency usually subsides. In other instances 
the frequent stools may persist and the condition may perhaps be traced 
to errors in the mother’s diet or laxatives which she is taking and ex- 
creting in part through the medium of her breast milk. Diarrhea in the 
bottle fed, as a rule, demands lowering of the sugar content in the infant’s 
food, and frequently the adoption of gruel to replace the sugar removed. 
Intestinal indigestion and the various inflammations of the intestinal 
tract in which diarrhea is the prominent symptom are discussed in a 
later section (pp. 230-253). 
The Ammoniacal Diaper.—Probably every physician has been told 
by the mother or nurse that the baby’s diaper smells of ammonia. South- 
worth found in a study of several cases that the condition was readily 
corrected by eliminating or reducing the fat in the milk or by giving 
alkalies, such as magnesia or citrate of potash. 
This author, quoting Czerny and Keller, accounted for the excessive 
ammonia excretion as “depending upon the chemical property of am- 
monia to combine with acids as an alkaline base. While under normal 
conditions all but a little of the ammonia becomes urea and is excreted 
as such, if under abnormal conditions there is present in the body an 
excess of unoxidized acids for whose neutralization the available supply 
of fixed alkalies does not suffice, the ammonia can then take the place 
of fixed alkalies and form with the acids ammonia salts, which will be 
excreted in the urine.” Zahorsky1 found that the disorder was largely 
limited to artifically fed infants and that high fat milk feeding and the 
giving of orange juice and of egg were among the etiologic factors in caus- 
ing the ammonical diaper. The ammonia was found to be liberated from 
ammonia containing compounds in the urine under the action of an alkali 
present in the diaper—soap, lye, lime, or stool. 
Cooke2 demonstrated the presence of a urea-fermenting, ammonia- 
producing organism, “Bacillus ammoniagenes,” in the stools of artificially 
fed infants with ammoniacal diapers. The ammonia production was found 
to be inhibited by acid intestinal contents, being reduced when the intake 
of fat was low, and in the case of the. breast-fed infant. When the 
1 Amer. Jour. Dis. Child., vol. x, 1915, pp. 436-444. 
2 Ibid., November, 1921, pp. 481-492. COMMON DIGESTIVE DISORDERS OF INFANCY 
103 
diaper was impregnated with antiseptic the ammonia formation was 
readily controlled. 
Treatment.—The management of these cases as suggested above 
consists in reducing the fat to the child’s capacity, or in the use of alkalies. 
In most cases the reduction of the fat content in the food has been all 
that was required. 
Persistent ammonical urine not infrequently follows prolonged feeding 
of dry milk owing to defective utilization of the high protein content 
in this food. If the ordinary measures are not effective in relieving the 
condition in such a case, the substitution of another form of food is indi- 
cated. 
The practice recommended by Cooke of wringing out the dry, clean 
diapers in boric acid solution, 1 : 20, and again drying them before ap- 
plying is a dependable routine preventive measure applicable to all cases. 
Evidence Afforded by the Stools.—Breast Milk Stools.—Infants on the 
breast average two to three large stools daily, although the number may 
range from one to five and still be consistent with perfect health. Their 
color is usually of a bright yellow or orange tint, and their character of a 
smooth and homogeneous consistency, with a slightly acid reaction. The 
odor is not as offensive as that of the cow’s milk stool, as there is less 
putrefaction of the breast milk protein while in the intestinal tract. The 
bulk or residue corresponds to the amount of ingested food. 
Cow’s Milk Stools.—Infants on the bottle usually average only one 
stool a day, which often is smaller than that of the breast-fed baby. 
The color is lighter and the proportion of feces to the amount of food 
taken numerically less when the infant is artificially fed. 
Hard Constipated Stools.—A hard constipated stool, when not pro- 
duced by any mechanical cause, is usually due to a deficiency in the 
food of either carbohydrates or fats, generally the latter. Food too low 
in total solids, leaving an insufficient residue, is also a cause. Irregular 
habits in the time of going to stool and a lack of systematic general train- 
ing also play a part. Sterilization and, to a lesser degree, pasteurization, 
make milk somewhat constipating. 
Loose Watery Stools.—This type of stool is seen in indigestion, with 
fermentative changes in the carbohydrates, and to a lesser extent in the 
fats. The stools vary in color from a yellow or yellowish brown to green. 
They are usually alkaline in reaction and have a foul, musty odor. Curds 
are seldom seen and there is very little mucus. 
Stools in Hard Balls.—This variety of stool is usually due to an excess 
of fat in the food. The feces vary in color from a light yellow to a light 
gray. They are sometimes large and hard, and at other times dry, small, 
and crumbly. 
“Scrambled Egg” Stools.—Stools of this order are seen when the car- 
bohydrate digestion is at fault. Bacterial fermentation of the starch 
or sugar which is not assimilated by the organism gives rise to loose, 
green, frothy movements. These are very acid, frequently causing ex- 
coriations of the buttocks and surrounding parts. 
Mucus in Stools.—Mucus excretion denotes a form of irritation in 
the digestive tract which gives rise to an excessive secretion from the 
mucous glands of the intestine. It is almost invariably present in ab- 104 
THE PKACTICE OF PEDIAT1HCS 
normal stools. Mucus intimately mixed with feces indicates the source 
of the trouble to be in the small intestine; if on the outside of a con- 
stipated stool, in the rectum; or if in combination with a clay-colored 
stool, in the duodenum. 
Blood in Stools.—In older children blood intimately mixed with the 
stools would suggest an ulceration of the stomach or small intestine. 
When on the outside of a constipated stool the blood may indicate a rectal 
lesion, an anal fissure, diverticuli, or incomplete intussusception. A stool 
composed of a jelly-like mass of blood and mucus without fecal material 
is very characteristic of intussusception. Malsena neonatorum or hemor- 
rhage of the newborn is characterized by a profuse discharge of blood 
from the rectum. 
Curds in Stools.—'Curds are one of the most frequent of the abnormal 
constituents. Two kinds are found: one firm and tough and very hard 
to press out, insoluble in ether, varying in size from a small pea to a hick- 
ory nut, with a brown or greenish coating, but white on cross-section, 
known as a protein curd; the other is composed of fat, easily pressed out, 
does not sink in water, varies in color from white or yellow to green, is 
somewhat soluble in ether, and is not hardened by formalin. 
Stool Examination.—Much may be learned from the gross appearance 
of the feces. Variations in color ranging from the clay color character- 
istic of the presence of fat and absence of bile, to the dark green or black 
stool produced by the ingestion of spinach, bismuth, or iron are all readily 
appreciable by the naked eye. The consistency of the stool, its size, and 
many other points regarding it are also readily apparent, and much ad- 
ditional information relating to the presence of such contents as strings 
of mucus and foreign substances may be obtained by pressing a portion 
of the stool between glass plates. 
For the determination of the finer degrees of digestive capacity, and 
the bacterial content of the feces, microscopic and chemical analysis is 
essential. 
A few of the more common tests are the following: 
Fat droplets not ordinarily present in the stool to any marked extent 
are stained black by osmic acid, and orange with 3 per cent, sudan III 
in 50 per cent, alcohol. 
Fatty acid crystals, the presence of which is abnormal, are detected 
on cooling a slide upon which has been heated a drop of feces and 2 drops 
of 30 to 50 per cent, acetic acid. 
Starch grains are stained dark blue or black by Gram’s iodin solution. 
The proportion of Gram-positive to Gram-negative bacteria in the stool 
is less important than the type of organism predominant. In the stool of 
protein putrefaction Bacillus aerogenes capsulatus and B. putrificus or their 
spores are significant. In that of .carbohydrate fermentation B. acidoph- 
ilus and Gram-positive diplococci predominate over the organisms of 
the colon group and B. aerogenes capsulatus. Pathogenic organisms of 
common occurrence are those of dysentery, including Amoeba coli, B. 
typhosus, the tubercle bacillus, and streptococci productive of mem- 
branous colitis. 
The presence of occult blood is best determined by the benzidin test. 
Carbohydrate fermentation and protein putrefaction may be studied MARASMUS (ATHREPSIA; INFANTILE ATROPHY) 
105 
by simple fermentation tests combined with color and reaction observa- 
tions. 
For the actual details of microchemical examination of the feces the 
reader should consult a standard work on clinical pathology. 
Disorders of Nutrition in Infancy 
MARASMUS (ATHREPSIA; INFANTILE ATROPHY) 
Under the title of marasmus will be considered those cases which 
are associated with and dependent upon derangement of function of 
the gastro-enteric tract. Tuberculosis, syphilis, and atelectasis are 
consequently excluded, these affections being considered elsewhere under 
their respective headings. 
Age.—Marasmus is seen most frequently in young infants under 
nine months of age. Cases are frequently seen, however, from the ninth 
to the twelfth month, and comparatively few between the twelfth and 
eighteenth months. 
Etiology.—A great deal of research work has been done among maras- 
mic infants in order to determine the nature of the condition, but as 
yet no satisfactory explanation has been offered. The disease is un- 
questionably due to defective intestinal assimilation. The principal 
fact that disproves the existence of any atrophic condition or neces- 
sarily severe derangement of function is that these patients very often 
make complete recoveries, becoming perfectly normal children after three 
months or more of treatment. 
The Usual History.—The history of these cases is as follows: The 
mother could not or did not nurse the baby. The child was put on cow’s 
milk, which was usually given too strong or in too large quantities— 
often both errors were combined, or the milk may have been too old 
when used, and improperly cared for; in any case the milk disagreed, the 
child was made ill, there was loss in weight, cow’s milk was discontinued, 
and one of the infant foods, alone or combined with milk, was given. 
The child’s digestion was thoroughly disordered, and the foods failed 
to agree. There was vomiting or regurgitation, with undigested, green 
stools, or both combined, while the loss in weight continued. The child 
may have been inherently weak or may have shown a cow’s milk idiosyn- 
crasy to help account for the lack of success in the milk feeding. Usually 
there followed a series of experiments with different kinds of food and 
methods of feeding, the vomiting, diarrhea, or colic continued with wast- 
ing, and when the child reached the hospital or office he was perhaps six 
months of age and weighed from 6 to 9 pounds, presenting a typical 
athreptic picture. Some of these children are born with a digestion that 
is apparently incompatible with cow’s milk mixtures. Others have their 
digestive capacity for cow’s milk hopelessly deranged by improper feeding 
methods. The majority of the cases occur among the overcrowded tene- 
ment poor—the worst possible environment for a delicate infant. There 
is little or no protein assimilation, so that any approximation to normal 
growth is impossible. Marasmic infants may also possess a poor fat ca- 
pacity, and if there is, in addition, a diminished sugar capacity the pro- 
teins of the tissues are drawn upon to supply heat and energy, with re- 106 
THE PRACTICE OF PEDIATRICS 
suiting progressive emaciation. Heredity, environment, and the season 
of the year all influence the prognosis. 
Infection as a Contributing Factor in Marasmus.—In our manage- 
ment of athreptics we have been so occupied with nutrition and the 
gastro-intestinal fault that other possible etiologic agencies may have 
been neglected. Occult infections may and do play a very decided part 
in some of these cases. Thus during a service at the Babies’ Hospital, 
out of 17 cases in which blood-cultures were made, 5 were positive, and 
of these 5 infants, 4 died. Of the remaining 12 patients with negative 
cultures, 8 died, and of the 4 that recovered, 1 had an otitis; and 1 a fu- 
runculosis of mild degree, while the remaining 2 had no demonstrable 
lesions. Of the 8 fatal cases, there were only 2 in which there was no 
evident infection. The infection varied from an otitis to a severe bron- 
chopneumonia. 
The blood-cultures in each case were taken when the infant was losing 
in weight and apparently retrogressing without any digestive disturb- 
ances. In two instances the clinical evidence (if it might be called such) 
consisted simply of a subnormal temperature, well-digested stools, and 
progressive loss in weight. In two others there existed a temperature 
and later signs of a bronchopneumonia, while a third showed Klebs- 
Loffler bacilli in the nose. Blood-counts were of no aid in diagnosis. 
Marasmic infants who fail to thrive on suitable food and good gen- 
eral management, whether there are evident digestive disturbances or 
not, should be thoroughly examined for hidden infections. In not a 
few of those who show progressive loss in weight there has been a sup- 
purative otitis without active symptoms. In others there has been a 
bacteremia, the only symptom being that of progressive loss in weight. 
It is not infrequent to find miliary tuberculosis at autopsy where 
it was not suspected during life owing to absence of any fever. 
Pyloric Obstruction as a Cause of Marasmus.—All malnutrition infants 
with persistent vomiting should be examined and observed to deter- 
mine whether or not there is trouble at the pyloric outlet. 
Utheim1 has made a careful study of a number of cases of athrepsia 
and demonstrated a greatly increased loss of food material as seen in the 
stools during the active stages. The loss may be as great as 26 per cent, 
of the food intake, but utilization of the food is much greater as im- 
provement takes place in the infant’s condition. 
Pathology.—There is no lesion or set of lesions peculiar to infantile 
atrophy. The senior author has personally autopsied a large number of 
cases. There is often a strip of hypostatic pneumonia, perhaps a large 
area of atelectasis. Now and then the liver is fatty or shows fatty areas. 
The spleen, kidneys, and heart are pale. The stomach and intestines 
contain thick, sticky mucus, which when removed shows a pale, washed- 
out-appearing mucous membrane. Blood infections with the pyogenic 
cocci have explained the etiology in several recent cases. 
Treatment.— The Wet-nurse.—An important factor determining the 
prognosis is the possibility of obtaining breast milk. 
That a great majority of cases of simple athrepsia recover, and often 
recover promptly1, making a most satisfactory growth when a wet-nurse 
1 Amer. Jour. Dis. Child., vol. xxii, pp. 329-350. MARASMUS (aTHREPSIA; INFANTILE ATROPHY) 
107 
is secured, is proof, as above stated, that the condition, so far as relates 
to any peculiar systemic state or pathologic condition, depends more 
upon the nature of the nutrition than upon the patient. In securing a 
wet-nurse the physician’s duties are by no means completed. The patient 
may not take kindly to the breast, and will have to be taught breast 
nursing. A great deal of time may be required in teaching older infants, 
those who have been on the bottle for seven or eight months. To this 
end various devices may have to be used. For the first nursing it is well 
to allow the child to go for an hour or two beyond the feeding time in order 
that his appetite may be voracious. It is advisable also to give the first 
few nursings in a darkened room with the person who has been accustomed 
to feeding the patient very near. Sufficient milk should be forced from the 
breast to enable the child to taste it. A little powdered sugar sprinkled 
on the nipple is a good means of increasing his interest. In some instances 
it has been necessary to cover the wet-nurse with a blanket or sheet, 
leaving only the breasts exposed; or it may be necessary to use the nipple- 
shield for a few days in order gradually to accustom the child to the 
change. We have yet to see a case in which success did not follow per- 
sistent effort. Often the nurse’s milk will not agree at first; but this is 
not surprising and need cause no discouragement. Breast milk ordinarily 
is a much stronger food than the child has been accustomed to, and it 
may produce vomiting, colic, or diarrhea. When indigestion follows, 
the nurse’s milk should be modified by giving the baby weak barley- 
water or plain boiled water, before the nursing in case he nurses well, 
or after the nursing in case he nurses poorly. One or two ounces of breast 
milk at a feeding is all that these patients can be expected to take dur- 
ing the first few days. The amount obtained may readily be determined 
by weighing the patient, without the trouble of undressing him, before 
the nursing, and then weighing him at intervals of from three to five 
minutes after the nursing has commenced. One ounce of breast milk 
is practically 1 ounce avoirdupois. These children, if not too weak, will 
take greedily almost anything from the bottle. The addition of 1 or 2 
ounces of barley-water or plain water dilutes the milk and renders it easier 
of digestion, and furnishes at the same time the necessary fluid for the 
child. 
The most unpromising cases of marasmus are not to be despaired of 
nor the treatment relaxed, although the physician should be cautious 
in his prognosis. If the child is too weak or indifferent to swallow, the 
wet-nurse’s milk may be expressed, diluted, and given by gavage. In 
many cases evaporated milk (p. 78) may be used successfully for maran- 
tic infants. It is much easier of digestion than fresh cow’s milk, and is 
a temporary measure of much value. 
Illustrative Case.—The most pronounced and the most hopeless recovery case coming 
under our personal observation was seen in consultation in one of the suburbs of New 
York. The child was four months old and weighed 5 pounds. He was emaciated to a 
skeleton, having weighed 8 pounds at birth. The temperature for several days ranged 
between 92° and 94° F. A trained nurse and an unusually intelligent mother were in 
charge. Because of doubt respecting the accuracy of the thermometer reading, dif- 
ferent thermometers were used. The temperature was taken by the rectum. The 
attending physician had also taken it repeatedly, so that finally there was no doubt. 
The child was too weak to nurse. The breasts were accordingly pumped, and for 
each feeding he was given l ounce of breast-milk with an ounce of barley-water, to 108 
THE PRACTICE OF PEDIATRICS 
which a few drops of sherry wine were added. This was given by gavage at two-hour 
intervals. He was wrapped in flannel and wool and surrounded with hot-water bottles. 
The food was retained and digested. In four days he could nurse, and was allowed to 
take a small amount from the breast and finish the meal with barley-water. The tem- 
perature gradually rose to the normal. More breast milk was allowed as he proved 
able to care for it, and the child made a perfect recovery, weighing 18 pounds when 
he was nine months old. This case demonstrated that a marasmic child is never a 
hopeless case until he ceases to live. 
Unfortunately, very few marantic children can have the benefit of 
a wet-nurse, but without a wet-nurse many of these cases are not hopeless. 
The use of evaporated milk (p. 78) and malt soup (p. 78) will furnish 
a satisfying diet in not a few instances. Marasmus is, of course, a very 
serious condition, but the chances are much better in a reasonably good 
home than in a hospital, where the story is often as follows: The patients 
take the modified milk or whatever is given them without inconvenience. 
The stools may be offensive if cow’s milk is given, or there may be consti- 
pation, or the stools may appear perfectly normal. As a rule, there is no 
serious diarrhea or any other evidence of an acute inflammatory process 
in the intestine. However, in spite of fairly normal stools, the patient 
grows thinner and thinner. After a time all food is refused, gavage is 
used as a last resort, and the child finally dies. The autopsy shows noth- 
ing but pale organs, with perhaps a strip of hypostatic pneumonia. Now 
and then one of these cases in a children’s institution or in a hospital 
recovers without a wet-nurse, but it is the exception proving the rule. 
Put these athreptics on a wet-nurse, as one should do at every oppor- 
tunity, and many of them will thrive in spite of the well-known unfavor- 
able influence exerted by institutional life upon the very young. In 
addition to putting the athreptic baby on the wet-nurse, his stomach 
should be washed once daily and he should live out-of-doors. In the 
cases of extreme dehydration transfusion, hvpodermoclysis or intra- 
peritoneal infusion (p. 850) may be employed. 
Outdoor Life.—Next to the wet-nurse we know of no agent fraught 
with so much good as is outdoor life. The season of the year exerts con- 
siderable influence on the prognosis. The athreptic bears the heat and 
humidity very badly, and the early summer mortality of all large cities 
is materially increased by these children, who wilt and die in institutions 
and tenements with the first two or three days of continuous hot weather. 
Parents residing in a large city who can so afford should send such chil- 
dren to the country not later than June 1st, to return, in this latitude 
(New York City), not earlier than October 1st. During the day the child 
should be on a porch or in the shade continuously. At night the windows 
of his sleeping-room should be wide open. During the cooler months, if 
the child is too ill to be taken out-of-doors, he should have from morning 
until evening a continuous indoor airing (p. 838). The sleeping-room should 
always communicate with the open air. The roof-garden in large cities 
is a most valuable aid in the management of athreptic children. 
Cases in Which a Wet-nurse is Impossible.—One phase of this most 
interesting and important subject has not been touched upon. We 
refer to the athreptic infant of the tenement, and those others in pri- 
vate lile for whom a wet-nurse is impossible. They furnish by far the 
largest number of our marasmic patients. Perhaps the most frequent MARASMUS (ATHREPSIA; INFANTILE ATROPHY) 
109 
error in the management of these cases is an endeavor to select at the 
start a food for the child to thrive upon. In doing this, almost invariably 
a stronger food is selected than the child is capable of digesting, and he 
is made worse by the attempt. Our ultimate object in treating these 
infants will be more readily attained if, at first, we attempt only to supply 
a food upon which they can exist without loss in weight. The number 
of calories necessary for an athreptic child is not great. It must be re- 
membered, furthermore, that we are not dealing with a case of infant 
feeding as the term is commonly understood. True, we are feeding an 
infant, but a sick infant, and the methods of feeding used for the com- 
paratively well do not apply here in all respects. The problem of nourish- 
ing these children is to be considered from two standpoints—that of the 
food and that of the baby, with special reference to the organs of digestion. 
The stomach, in many of these infants, is dilated, with a consequent 
lack of motility. Residual undigested food remains long after feeding. 
There has been a constant fermentative change, with the production 
of lactic and butyric acids, resulting in local changes of an inflamma- 
tory nature in the mucous membrane of the stomach, so that not only 
must the organ be prepared for the food, but the food must be adapted 
to the stomach capacity, and when this is done—when both require- 
ments receive due consideration—we are much more likely to succeed. 
Stomach Washing.—In all of these cases for the first few days of treat- 
ment it is advisable to wash out the stomach with sterile water, regardless 
of the presence of vomiting and regurgitation and regardless as to whether 
the child is bottle fed or breast fed. It is often surprising to note the 
amount of thick mucus and undigested food that will be washed from a 
stomach from which there has never been vomiting. The daily wash- 
ings enable the child to take more and stronger food. It may even be 
necessary to continue the washings for days. They may first be dis- 
continued when the water siphons clear and without mucus. They 
should be repeated if there are indications, such as regurgitation of sour 
water or mucus or loss of appetite. In one case in which there was chronic 
gastritis with athrepsia washings were continued at gradually lengthened 
intervals for six months. 
Temporary Feeding.—If the case is one with pronounced stomach in- 
volvement, a 3 per cent, milk-sugar solution should be given for twenty- 
four hours in quantity suitable for the age and size of the patient. The 
following day barley-water No. 1 (see Formulae, p. 94) is to be given, 
to which sugar is added to make the mixture 5 per cent. 
Cow’s Milk.—While it is doubtful if the child can take cow’s milk, 
after this period of stomach rest and stomach washing it may be at- 
tempted. Two drams of as safe milk as can be obtained are added to 
every second feeding of the barley-ancl-sugar-water. If it agrees, after 
a day or two, 2 drams are added to every feeding, with a gradual in- 
crease of a dram every two or three days. The intervals of feeding, for 
children under one year of age, may range from two to three hours. It 
is rarely advisable to feed even the most delicate athreptic oftener than 
once in two hours. If the milk can be retained and assimilated in the 
strength of one-fourth milk and three-fourths barley with 5 per cent, sugar, 
or if an equal quantity of milk and sugar-water alone is found to agree, 110 
THE PRACTICE OF PEDIATRICS 
the child will begin to grow and general improvement will rapidly fol- 
low. If the cow’s milk is not well borne, skimmed milk or a weak 
cream mixture dram of cream to a feeding—may be tried. It is 
practically impossible to have whey made properly outside of a hospital 
laboratory or an intelligent home. In using whey one may give it in 
quantities suitable to the age of the patient. The prescribing of cream 
among the poor is a hazardous procedure, for the cream may be old, 
improperly cared for, and swarming with bacteria. If there is a tendency 
to looseness of the bowels, the diarrhea is thus made worse. Cream 
mixtures rarely succeed as foods for athreptic children. Cream should 
be prescribed only among those who can properly care for it (p. 66). 
Evaporated and unsweetened milk may, however, often be used with suc- 
cess. 
Sweetened Condensed Milk.—For the out-patient athreptic and for 
some in better circumstances the much abused condensed milk fulfils 
a useful function. It is one of the cleanest foods we can give the dis- 
pensary baby. It is the cheapest, the most easily kept, and the most 
easily digested milk that can be furnished him. Consequently, when 
ordinary milk feeding is impracticable or when it disagrees, one may 
give condensed milk, beginning with \ dram, which is added to the 
barley-water or to the plain water for every second feeding, later to 
every feeding, increasing the quantity gradually as the child shows an 
ability to digest it. The patient must be seen frequently and the stools 
carefully examined in order that an increase in the food strength may be 
made as soon as conditions allow. The mother should be told to bring 
the napkins to the dispensary, and the child should be weighed at each 
visit, every second day. It is most gratifying to see how well some gain 
in weight, not because they are getting an ideal food by any means, but 
because the food used temporarily fits the case. Condensed milk is thus 
used as a stepping-stone to something better. When the child has taken 
condensed milk with benefit for a month or six weeks, ordinary milk is 
attempted if the time of the year is between October and the following 
June. After June 1st one may continue with condensed milk, as the 
possibility of some degree of anemia and rachitis as the cooler months 
approach is to be preferred to the risk of attempting cow’s milk feeding, 
with poor milk, in the hands of an overworked or ignorant mother. 
In beginning the use of ordinary milk, in order to avoid sudden radical 
changes it is well to replace one feeding of the condensed milk mixture 
daily with one feeding of a weak plain milk mixture. In some cases this 
will produce illness and must be stopped; in others it will be well borne. 
When it is found to agree, two feedings should replace two condensed 
milk feedings daily. In this way, by increasing by one the number of 
plain milk feedings every third or fourth day, entire plain milk feeding 
may safely be inaugurated. The strength of the plain milk should not, 
of course, correspond to that suggested for well babies. To a child of six 
months a three-month formula may be given. As the child improves, 
the strength of the milk may correspondingly be increased. In this way 
a great many tenement athreptics have been successfully treated. 
Some children will be able to take and properly care for only two 
plain milk feedings daily; others will take every second feeding of plain MALNUTRITION IN INFANTS 
111 
milk. One patient aged fourteen months would take two plain milk 
feedings daily with comfort, but when the third was given he was inva- 
riably made ill. Some will not be able to take a particle of ordinary milk. 
When this is the case, the condensed milk should be combined with a 
gruel, such as oatmeal, which contains a high percentage of protein. 
These cases may also be given beef juice at a very early age. Pure cod- 
liver oil, from 15 to 30 drops of which may usually be taken three times 
daily without disturbance, may also be given. 
The tenement athreptic is to be given the benefit of as much fresh air 
as possible. He is also to be given the advantage of the daily tub-bath 
and the oil rub. For further suggestions, see Common Digestive Dis- 
orders of Infancy (p. 99). 
MALNUTRITION IN INFANTS 
Malnutrition may profitably be considered as the first stage of ma- 
rasmus. Every child with marasmus must first have undergone a longer 
or shorter period of malnutrition. Victims through inheritance, such 
as those who are constitutionally inferior, the offspring of the tuberculous, 
and the remotely syphilitic, often show signs of malnutrition, are in- 
herently weak, and possess low vital resistance. Frequent child-bearing 
may be a predisposing factor—the fourth or fifth child, when the preg- 
nancies have been close together, may show general lack of vigor. 
Symptoms.—With malnutrition the infant may be 3 or 4 pounds 
underweight, his gain being slow and irregular; often inappreciable, 
or, at best, a few ounces a week. The muscles are soft, and if the con- 
dition persists, bone changes, indicating rachitis, soon appear. The 
child is pale and usually thin. There is a secondary anemia. Dentition 
is delayed. The hands and feet are apt to be cold and the skin is dry. 
Excoriations of the buttocks and intertrigo are of common occurrence. 
The patient shows evidence of .indigestion by a distended abdomen and 
stools that are far from the normal. There may, however, be no intestinal 
derangement whatever, the malnutrition being due to the fact that the 
child’s diet for months has consisted of food that did not contain the 
nutritional elements required, or the fact that he was unable to utilize 
that which had been given him. 
Illustrative Case.—A case due to high fat feeding was that of a male, six months of 
age, weighing 13 pounds, a resident of a New York suburb, where the conditions are 
most healthful. His fontanel was slightly depressed, the muscles were soft and flabby, 
and the ribs were beaded. The child had lost his appetite and suffered from con- 
stipation. A history of the feeding showed that he had been getting a cow’s milk mix- 
ture containing approximately 6 per cent, fat, 4 per cent, sugar, and 2 per cent, protein. 
His indigestion, loss of appetite, and constipation was unquestionably due to the high 
percentage of fat. The energy exerted in digesting the food almost counterbalanced 
the benefit derived from it, the result being a very slow gain in weight. 
Diagnosis.—Upon assuming the care of one of these infants one must 
invariably make a very thorough examination in order to determine 
whether there are other factors than that of imperfect gastro-intestinal 
function. Following the usual physical examination, which should in- 
clude the ears, the urine should be examined; there should be a von Pir- 
quet test for possible tuberculosis; there should be a blood-count to learn 
the degree of anemia and the possibilities of occult pus, and if the case 112 
THE PRACTICE OF PEDIATRICS 
is very persistent, a blood-culture should be made, as it not infrequently 
occurs that a hitherto unsuspected cause of malnutrition may be bac- 
teremia. In hospital cases the pneumococcus, the streptococcus, and 
the staphylococcus have been found in the blood of malnutrition babies. 
Treatment.—The management of malnutrition due to most causes 
consists in correcting the digestive errors, in using castor oil or calomel 
with stomach washing, and in adjusting the food to the child’s require- 
ments and digestive capacity. 
These cases are all difficult to feed satisfactorily. 
The problem which confronts us is often most difficult of solution. 
Chapin is an advocate of the use of cereal gruel as a milk diluent, 
claiming that the milk is rendered more easily digested because of the 
presence of the starch. Others believe that the use of alkalies and ant- 
acids renders the milk easier of digestion. In very few of these difficult 
cases, however, do the ordinary cow’s milk dilutions and adaptations 
produce satisfactory results. The majority of such infants cannot digest 
cow’s milk unless it is materially changed by other than mechanical 
methods. It is also to be remembered that in difficult feeding the food 
helps to solve only a part of our problem. The physical condition of the 
child, his care, and particularly the containing and working capacity of 
the stomach, are matters requiring thought and adjustment. 
A difficult feeding case requires: 
1. Fresh air. Indoor airing in winter or roof treatment—cold air. 
2. Clothing sufficient to insure warmth; particularly must the ex- 
tremities never be cold. 
3. Quiet—absence of handling other than is necessary for clean- 
liness. Quiet is particularly necessary if there is a tendency to regur- 
gitation or vomiting. 
4. Stomach washing—a most useful procedure, even when there is 
no vomiting. A stomach lavage cleans out the mucus and undigested 
material from the stomach, which is very apt to be enlarged and of de- 
fective motility. The lavage may be used daily for a week or less fre- 
quently—perhaps every other day. In some cases one or two wrashings 
suffice. In others lavage is continued at intervals determined by the 
condition—rarely longer than three to four weeks. 
5. Position. In the cases wdth habitual regurgitation the position 
in which the child rests in the crib is important. Smith and Le Wald1— 
as a result of six Roentgen ray studies of infants after feeding—advise 
the erect position after feeding, the child being held against the nurse’s 
shoulder for a few moments. When the child is placed in the prone 
position, the head of the crib should be considerably elevated. Both 
of these proceedings aid in the expulsion of gas, which they proved is 
swallowed during the act of nursing. 
Two methods that have been particularly useful in nourishing these 
infants are malt soup feeding, and the use of appropriate dilutions of 
evaporated milk combined with a cereal diluent containing a low percentage 
of sugar. Both methods have been discussed (p. 78). 
For many infants dry milk has proved easily assimilable when car- 
bohydrate and fat have been poorly tolerated. 
1 Amer. Jour. Dis. Child., vol. ix, pp. 261-282. IDIOSYNCRASY TO COW’S MILK 
113 
For the more advanced cases of malnutrition in infants the treat- 
ment outlined for actual marasmus is indicated (p. 106). 
IDIOSYNCRASY TO COW’S MILK 
Rare cases are encountered in which there exists an intolerance of 
cow’s milk or any form of food which contains cow’s milk, including 
condensed milk and all the malted foods containing desiccated cow’s 
milk. In such cases the use of any of these substances as foods produces 
illness of such an alarming type as to necessitate prompt discontinuance 
of the food. The only hope for infants thus constituted is a wet-nurse. 
This extreme reaction to milk constitutes what is known as milk 
allergy, or milk protein sensitization. 
Instances of breast milk allergy are reported.1 
Illustrative Cases.—Case 1.—An illustration of allergy to milk foods occurred in 
the senior author’s own family. A healthy, full-term female infant whose birth weight 
was 7 pounds, 12 ounces was nursed by her mother with indifferent success for two 
weeks, when the supply failed absolutely. Feeding with a most carefully prepared 
modified cow’s milk was begun. The child refused the food, and 2 drams were forced. 
This was followed in a few moments by vomiting and retching, which continued at 
intervals for twenty-four hours, with collapse and exhaustion to an extreme degree. 
A wet-nurse was secured, the breast was well taken, and the milk agreed perfectly. 
In three days the wet-nurses’ milk began to fail and was entirely lost in twenty-four 
hours. A weak dilution of condensed milk was then given, with results almost as 
disastrous as before. The child at this time weighed 6 pounds, 4 ounces, and showed 
all the symptoms of early marasmus. A second wet-nurse was secured, whose milk 
also failed in a few days. Before her departure, however, a third nurse was engaged, 
on whose milk the child thrived most satisfactorily. When the patient was three 
months of age a weak cow’s milk mixture, prepared by the Walker-Gordon Labora- 
tory, was given. The child refused the food, and \ ounce was forced. As on the 
previous occasion, vomiting with prostration bordering on collapse was the outcome. 
Vomiting continued at frequent intervals for twelve hours, and the breast was refused 
for twelve hours longer. The giving of cow’s milk was not again attempted until the 
child was nine months old, a wet-nurse meanwhile being employed. The child was 
then strong and vigorous, and weighed 18 pounds. Two drams of cow’s milk mixture 
suitable for a baby three months of age were given. This produced nausea and vomiting, 
as though an equal quantity of syrup of ipecac had been given, but no more serious 
disturbance. At this time the wet-nurse’s milk began to fail. The breast milk nutri- 
tion was supplemented by the use of cereal made into a thick gruel. Oatmeal in the 
form of a gruel to which sugar was added was given, largely because of its high protein 
content. Beef juice, scraped beef, and pure cod-liver oil were also given about this 
time. At the completion of the first year a portion of a soft egg was added to the diet. 
Zwieback and bread crusts soaked in sugar-water were also used. These solid sub- 
stances were given two or three times a day, after which the child was nursed. Pure 
cod-liver oil was given almost continuously during the second year. Butter-fat could 
be taken without inconvenience at one year. 
Following out the above lines of treatment, the child was weaned when thirteen 
months of age. She was then fed with an entire absence of cow’s milk from the diet. 
When six years of age her weight was 55 pounds, height 48 inches. She was normal 
in every respect, but 6 ounces of milk given at one time would produce a coated tongue, 
foul breath, constipation, and excessive irritability which was entirely foreign to her 
nature. At the twelfth year the intolerance for milk was entirely overcome. 
Case 2.—The young mother of a vigorous, eight-month-old breast-fed girl deter- 
mined to wean the baby. The family physician prescribed a suitable formula. The child 
refused to take the milk mixture. A small quantity was taken and immediately vomited. 
After further unsuccessful attempts at feeding 2 ounces were forced. This was at 10 
a. m. The child did not vomit, but passed into a condition approaching collapse. 
A few hours later she presented the appearance of a case of severe intestinal intoxica- 
tion. She was very apathetic, but could be aroused with difficulty. The pulse was 
1Weil, Jour, des practiciens, September 20, 1920, and MMecine, August, 1920. 
Starck: Anaphylaxis to Breast Milk, Archives de medecine des enfants, Paris, Septem- 
ber, 1921. 114 
THE PRACTICE OF PEDIATRICS 
small, very soft, and thready. The respiration was superficial, but not rapid. The 
eyes were sunken, the skin blanched. In spite of active stimulation and external heat 
the child grew gradually weaker, making but temporary response to stimulation, and 
died seventeen hours after the milk had been given. The case was one of anaphylactic 
shock from the milk protein. Of many cases of allergy to foods, this case alone proved 
fatal. 
Case 3.—A boy treated for colitis gave a history of allergy to milk. The placing of 
a few drops on his tongue would be followed immediately by intense general urticaria. 
Case 4.—A vigorous, nine-month-old breast baby was given a feeding of cow’s 
milk and vomited it at once. In a few days another feeding was attempted. The 
child took only a swallow or two of the food, but at once developed general urticaria. 
The ears suddenly became several times their normal size, and the eyelids swelled and 
closed the eyes. The respiration became greatly impeded through edema of the glottis 
to the extent that the mother feared the child would suffocate. Six hours later the 
voice was still hoarse and croupy. Three weeks later 5 drops of milk were placed on 
this baby’s tongue. In three minutes he vomited and became decidedly pale; in a few 
minutes more he vomited again. This was followed by hiccup, which lasted until he 
left the office one-half hour later. The child, months afterward, was still so sensitive 
to milk protein that a vaccination with milk would produce at the site of the scarification 
a large urticarial wheal. The wheal was also produced by egg-white. 
Case 5.~An eight-year-old perfectly developed girl had never been able to take 
cow’s milk in any form. The cutaneous test induced a marked reaction, and all 
attempts at immunization failed. 
SCURVY (SCORBUTUS) 
Scurvy in infants was first described by Glisson in 1651. It was 
not well recognized, however, until Moller described it again in 1859, 
viewing the disease as an acutfe type of rachitis. Ingelev, of Sweden, 
recognized a case of apparent infantile scorbutus in 1873, and in the 
period 1879-82 Cheadle reported several cases. In 1883 Sir Thomas 
Barlow was able to give a clear demonstration of the clinical features 
and pathology of this disease, and thenceforth reports of its occurrence 
were frequent. Infantile scurvy, or Moller-Barlow’s disease, is a very 
definite affection, and, although the term “scurvy-rickets” still persists, 
this serves only to emphasize the frequent coexistence in a patient of 
the two essentially distinct conditions. 
Etiology.—The age incidence is significant. In a large number of cases 
we have seen but two over eighteen months of age; the first patient was 
four years cld, the second an idiot slightly older. Occasionally scurvy oc- 
curs in infants under six months of age, but this is unusual. Our youngest 
case was that of a nursing baby three weeks old. In this infant there 
was a separation of the epiphyses at both wrists. 
The immediate physiologic cause of the hemorrhagic condition has 
not been discovered. It seems proved that there is some constitutional 
error, due to nutritional defect, which accounts for the development of 
the actual disease. 
In most instances the nutritional defect may be ascribed to the use 
of cooked foods. The well-known collective investigation of the Ameri- 
can Pediatric Society established the influence of foods that had been 
subjected to the influence of heat. Thus, 10 patients were entirely breast 
fed, 4 were getting raw cow’s milk, 116 were on pasteurized, sterilized, 
or condensed milk feeding, 214 were on proprietary foods. So pronounced 
a factor is cooked food in the production of scurvy that in all cases so 
fed we invariably give orange juice, 2 or 3 teaspoonfuls daily. 
The heating of milk invariably removes something from it which is 
necessary for the prevention of scurvy; nevertheless, such cooking does SCURVY (scorbutus) 
115 
not interfere with its nutritional properties. This has been demonstrated 
in hundreds of cases. The undetermined factor is the antiscorbutic vita- 
min or vitamin C, which is extremely thermolabile in an alkaline medium. 
Vitamin C is present in greatest concentration in the citrous fruits. 
Malnutrition is not necessary for the development of scurvy, neither 
is previous illness a factor of much consequence. 
In scurvy there are probably alterations in the capillary walls which 
permit the diapedesis of the red cells. Wright showed that in this 
disease the alkalinity of the blood may be reduced to a point as 
low as 35/200 of the normal, and he regarded scurvy as a form of acid 
intoxication. 
Pathology.—The two leading features in the morbid anatomy of 
scurvy are multiple hemorrhages and rarefaction of bone. Whether 
the atrophy in the bone is or is not a result of the intra-osseous extrav- 
asations seems uncertain. It is, however, believed that the rarefaction 
may occur primarily, independent of the hemorrhagic lesions. Although 
in some instances hematuria is the only 
prominent symptom, bleeding is usually 
not confined to any particular site, but 
may occur under the periosteum, in the 
bone-marrow, under the skin, under the 
membrane lining the serous cavities, 
or from the mucous surfaces. In the 
bones the most severe lesions are found 
in the neighborhood of the epiphyses. 
The lymphoid marrow cells and the 
osteoblasts are diminished in number, 
and there is increased porosity of the 
cancellous tissue. Fractures of the 
ends of the long bones are exceedingly 
common. In some cases there is separa- 
tion of the epiphyses. In one case 
there were four so-called fractures—two 
at the shoulder-joint in each humerus, 
and two at the hips in each femur. 
Beneath the periosteum are extensive 
extravasations of blood, which frequently become organized into firm 
layers of clot. In rare instances hemorrhages occur within the joints. 
Symptoms.—The first sign noticed is that of evident pain upon manip- 
ulation of different portions of the body, most frequently one of the legs. 
The complaint is that the child cries when the napkin is changed, or 
when he is being bathed or dressed. Further, instead of freely moving 
his arms and legs, he allows one or more of his limbs to rest, while the 
others may be moved freely. 
In advanced cases all the limbs may be involved, and the child makes 
no attempt at even changing the position of a limb, and cries vigorously 
when such a change is made. The position taken is that of outwTard 
rotation of the extremity affected. 
In advanced cases the involved joint or joints will be swollen. The 
swelling may involve the entire limb. In a case occurring at the Babies’ 
Fig. 8.—Bilateral subperiosteal hem- 
orrhagic extravasations in advanced 
scurvy. (New Rochelle Hospital.) 116 
THE PRACTICE OF PEDIATRICS 
Hospital the leg, from above the knee downward, was twice the size of 
the unaffected leg. 
Upon manipulation the parts are excruciatingly tender. Repeatedly 
mothers complain that the child who previously has enjoyed attention 
in the way of handling and holding, prefers to lie quietly in his crib and 
apparently fears to be touched. 
While the long bones are usually involved, the other bony parts may 
be affected. In two children the ribs, spine, and scapula were affected. 
The extremities were normal. Both infants were about nine months of 
age. They cried vigorously when they were lifted by placing the hands 
around the body under the arms. The diagnosis of scurvy was proved 
by the quick and complete response to orange juice and the use of un- 
cooked food. 
A few ecchymotic areas may be found on the skin, but this is un- 
usual. 
Too much emphasis is placed upon this symptom, which is not an 
early manifestation and may not appear for two or three or more weeks 
after the first manifestation of the local lesion in the limbs. If the con- 
dition is not recognized, submucous bleeding almost invariably appears, 
and is characteristic, providing the child has teeth in the upper jaw; 
the gums in the lower jaw are rarely involved. The gums are swollen, 
edematous, and bleed readily. Over teeth about to be erupted blood 
blebs of a dark bluish color may be seen. In the absence of teeth the 
gums are usually normal. In a very few cases a slight bluish discolor- 
ation may be noted. It is only in the very advanced cases that the lower 
gum and teeth will show involvement. 
Hematuria to a slight degree is present in most cases. In a few in- 
stances it has been severe, showing macroscopic blood. Blood in the 
stools is of very rare occurrence. 
An unusual form of hemorrhage is that occurring in the orbit and 
producing protrusion of the eyeball. Exophthalmos of this type cured 
by orange-juice therapy has been reported. 
Prognosis.—The prognosis is very favorable. All cases recover if 
a reasonably early diagnosis is made and proper treatment instituted. 
If there is simply an involvement of a joint, of short duration, the child 
may be apparently well in two to five days. In cases in which extensive 
lesions have formed, two or three weeks or more may be required for 
complete recovery. The longest time under treatment in our cases was 
three months. 
Illustrative Case.—A baby eighteen months of age was taken to Dr. V. P. Gibney, 
who recognized the condition at once and referred the child for treatment. The child 
had been treated for rheumatism for three months. All four extremities were swollen 
to twice or three times their natural size, and were swathed in bandages, each saturated 
with a different lotion or liniment. In this way each liniment was to be tested out and 
the one that served best was to be selected for all the limbs. The odors emanating 
from the child were those of a chemical establishment in active operation. 
After all previous local applications employed and those in use had failed, the child, 
with complete paralysis of all the extremities, was considered a suitable subject for the 
orthopedist. In addition to the symptoms described, the gums were bleeding freely. 
In this case, the most severe we have seen, the progress toward improvement was very 
slow. There was much extravasated blood to be absorbed and infractions—how many 
one could not determine—to be healed. Resolution was, however, eventually complete. SCURVY (scorbutus) 
117 
Studies of the bones in scurvy with the aid of the x-ray show that 
even in mild cases complete restoration of the normal bone condition 
is a matter requiring many weeks, even after the patient is, to all ap- 
pearance, well. 
Differential Diagnosis.—Scurvy in infants was formerly most fre- 
quently confused with rheumatism. The age for scurvy—under eighteen 
months—is not the age for rheumatism. Scurvy is a disease of early 
infancy, and rheumatism, a disease of childhood. In rheumatism fever 
is a usual symptom. In scurvy fever is unusual. From poliomyelitis 
scurvy may be differentiated by the acute pain upon manipulation and 
the presence of the knee-jerk. Specific epiphysitis may be mistaken for 
scurvy if the upper extremity is involved. The absence of other signs 
Fig. 9.—Extensive hemorrhage about 
the right femur due to scurvy in a neg- 
lected six-year-old idiot. 
Fig. 10.—Hematoma about right femur. 
(Same case depicted in Fig. 9.) (Bellevue 
Hospital.)* 
of syphilis, and a negative Wassermann test, will render a differentiation 
possible. Further, in any case which is doubtful, the use of orange 
juice will, in a few days, through relieving the symptoms of scurvy, de- 
termine the diagnosis. This is a perfectly innocent procedure upon any 
evidence of pain in any of the limbs. 
Supposed trauma, such as a sprain or a fall, is the interpretation 
often applied to the symptoms of scurvy. Trauma in infants is most 
unusual, but possible, and the orange juice treatment test may be re- 
quired to differentiate. 
Among the conditions simulated by severe scurvy are to be mentioned 
osteomyelitis and new growths of bone. 
In all doubtful cases the .r-ray is essential. 
Treatment.—Dietetic.—The first step in the treatment is to supply 118 
THE PRACTICE OF PEDIATRICS 
fresh milk for the child, diluted, if necessary, to meet the digestive ca- 
pacity. Cases in which the diagnosis is made early often recover without 
the aid of any other measure upon a change from sterilized milk or in- 
fant foods to raw milk. Inasmuch as the disease is a most painful one, 
every means possible should be employed toward furnishing early relief. 
If orange juice is not well tolerated, beef juice may be given, or the juice 
of any ripe fruit, suitably diluted. The orange juice very exceptionally 
disagrees with the digestion. A scorbutic child who has never tasted 
orange juice will take it greedily and beg for more. One teaspoonful 
may be given at two-hour intervals, 1 ounce at least being given ordina- 
rily in twenty-four hours. 
Among other antiscorbutic foods, lemon, tomato, potato, and even 
turnip are particularly rich in the essential vitamin. Recent investigations 
have shown that canned tomato juice and even dried orange juice may 
still retain their antiscorbutic potency. 
Unless the case is an advanced one, with extensive subperiosteal hem- 
orrhages and separation of the epiphyses, relief will be noticed in twenty- 
four hours and an entire cessation of symptoms in from five to seven 
days. We have seen a few cases entirely relieved at the end of seventy- 
two hours of treatment. These cases have been those in which the diag- 
nosis was made very early, the only symptom being the evidence of pain 
during manipulation of the limbs in bathing or while changing the 
napkin. 
The management of more severe cases is the same as that applied to 
those of milder type. Fresh food, with orange juice or beef juice, must 
be freely given. The patients should be handled very gently, and only 
when necessary, as the pain on manipulation of the involved parts is 
most excruciating. In cases of epiphyseal separation splints should be 
temporarily applied. 
RICKETS (RACHITIS) 
Rickets was described by Whistler in 1645, and again in 1650 by 
Glisson. The disease has been more wide-spread in countries with cool, 
temperate climates than in tropical or semitropical regions, where the 
inhabitants live for the most part out of doors. Similarly, this disease 
shows a slightly greater tendency to develop during the winter than in 
the summer. Attempts to define the exact etiology of the condition 
for centuries uniformly failed. Most of the earlier theories have been 
reviewed by Dr. R. G. Freeman,1 who found the disease most frequent 
in institution babies who were fed on breast milk supplemented by arti- 
ficial feedings of condensed milk. In his opinion both unsuitable food and 
infection or toxemia from the alimentary tract may be influential causes. 
Siegert in 1903 expressed the view that rickets was often hereditary, 
supporting his belief by observations of severe cases in the breast-fed 
children of rachitic parents. By other authorities, however, rickets of 
congenital origin was held to be improbable or in any event exceedingly 
rare. 
Rickets is a chronic disease of nutrition. Its chief manifestations 
are in the bones during the growing period. It is peculiar, however, 
1 R. G. Freeman, The Etiology of Rachitis, Archives of Pediatrics, April, 1904. RICKETS (RACHITIS) 
119 
in that a greater part of the structure which goes to make up the infant 
organism may be involved in the rachitic process, which is in effect a 
metabolic derangement of wide possibilities. 
Age.—Rickets may occur at any age after the first month. It 
usually makes its appearance between the third and the twelfth months. 
Few cases develop earlier, and congenital rickets is questionable. 
Etiology.—Italian and negro infants show a decided predisposition. 
A negro or Italian baby between six and twelve months of age in New 
York City without some evidence of rachitis is a curiosity. 
Environment.—Much has been written regarding the etiology of the 
disease in its relation to climatic and unhygienic surroundings. While 
such surroundings may contribute to the result, we have yet to be con- 
vinced that as etiologic factors they are very important except when 
the conditions preclude outdoor life and sunshine. It is true that we 
often find rachitic children in unhygienic surroundings, but thousands 
of others who live under the same conditions do not have rachitis. 
A child fed on normal breast milk will endure and thrive in an environ- 
ment that typifies “unhygienic conditions” (a popular term with writers). 
Dick1 has pointed out in detail that the countries of the globe most 
free from this disease are those where the inhabitants live most of the 
year in the open air and in communities free from fog and smoke. The 
Chinese are peculiarly free from rickets. 
Diet.—In the treatment of several thousand rachitic children one 
fact is impressed most strongly: A child suffering from rachitis is suffer- 
ing from nutritional errors as a result of improper feeding or inability 
to assimilate a suitable food. We have yet to see a case which will not 
improve when suitable nourishment can be given and assimilated, regard- 
less of the age of the patient, provided, of course, there is no other disease. 
In children under one year of age prolonged feeding of the proprietary 
foods or sweetened condensed milk has long been considered the most 
frequent cause of the disease. The next most frequent cause is the feed- 
ing of a too strong cow’s milk mixture, which produces indigestion and 
faulty assimilation. 
Rachitis in the Breast Fed.—Breast-fed babies among the Italians 
and negroes often have mild rachitis, and an examination of the breast 
milk will invariably show a diminution of one or more of the nutritional 
elements—usually the protein. 
Illustrative Case.—A nursing woman in the New York Infant Asylum had such a 
free flow of milk that a foster-child was given her to nurse. The children failed to 
thrive; each made a gain of but 2 or 3 ounces weekly; both developed rachitis, one in 
a marked degree. Repeated examinations of the breast milk showed it never to con- 
tain more than 1.5 per cent, fat, 4 per cent, sugar, and 0.5 per cent, protein. 
We have time and again seen rachitis in breast-fed infants for whom 
the milk was adequate in amount, but deficient in nutritional elements. 
These cases will most often be seen from the seventh to the tenth month. 
After the First Year.—After the first year fewer cases develop, but 
a late rachitis is by no means uncommon. The development of the disease 
at one year and after, as in the very young, has been distinctly traceable 
to faulty feeding and faulty assimilation. 
1 Lawson Dick, Rickets, 1922. 120 
THE PRACTICE OF PEDIATRICS 
Not a few cases during the second and third years are due to pro- 
longed nursing. The senior author has known just two mothers who 
could nurse their children, and substantially nourish them, by the breast 
later than the twelfth month. Usually when the breast furnishes the only 
means of nourishment after the ninth month, beginning rachitis will 
soon be noticed. The feeding after the first year of an exclusive diet of 
milk or of digestible starches is not infrequently a cause. Among the 
poorer classes children during the second and third years are almost 
always badly fed. The diet often consists of poor milk and poorly cooked 
Fig. 11.—Late rachitic deformities: Bowing of clavicles, thoracic sulci, lordosis, knock- 
knee, saber tibia, flat-foot. (Seaside Hospital.) 
starches. Children thus fed furnish no small proportion of our rachitic 
patients. 
Fat-soluble Vitamin.—-The outstanding factor in the causation of rickets 
is now affirmed to be the lack of the fat-soluble vitamin A, together with 
an abnormal calcium-phosphate ratio in the diet. Shipley, McCollum, 
et al.x have shown that, in the presence of a vitamin A deficiency, there 
are two forms of the disease, depending on the calcium phosphate imbal- 
ance, one of which is characterized by a low blood phosphorus and a 
1 Shipley, P. G., McCollum, E. V., Park, E. A., Simmonds, N., Jour. Biol. Chem., 
August, 1921, p. 507. RICKETS (RACHITIS) 
121 
normal calcium content; the other by a low calcium and a normal phos- 
phorus. They believe that the low calcium type is associated with the 
occurrence of tetany, whereas the skeletal changes are related to an 
abnormal calcium phosphorus ratio. A large amount of research by 
various other observers is being contributed to this subject along the lines 
of metabolism studies and blood chemistry. 
Light.—It has been definitely shown by Hess and his co-workers that, 
although the most important etiologic factor is dietetic, lack of sun- 
light, particularly the short ray ultraviolet portion of the spectrum, 
hastens very markedly the onset of rickets. 
Association with Other Diseases.—The development of rachitis bears 
no relation to other disorders, except in its influence upon the nutrition 
of the patient. The coincidence of scurvy with rickets is not unusual. 
Theories of Pathogenesis.—Deficiency of lime salts in the system, 
either as the result of poor food or faulty assimilation, has been long 
regarded as the cause of the disease, but evidence that rachitic subjects 
present the supposed variations from the normal, either in alkalinity 
of the blood or in lime elimination, is still incomplete. 
Experiments in depriving young animals of fat have failed to render 
them rachitic. Attempts at bacterial inoculation have likewise afforded 
no convincing results. 
Monti, of Vienna, was able to demonstrate a diminution in hydro- 
chloric acid associated with an excess of lactic acid in the stomachs of af- 
fected infants, and he coupled with this discovery the observation that 
the disease was more prevalent among the breast-fed infants of Saxony, 
whose mothers received little salt in their food, than in communities 
where the individual intake of sodium chlorid was normal. 
Hirschfeld demonstrated the existence of a vasoconstrictor substance 
in the serum of rachitic infants. To the presence of this substance he 
ascribed the frequent coexistence of simple rickets with tetany, eczema, 
and such catarrhal conditions of the mucous membranes as are indicative 
of a so-called exudative diathesis. 
Sweet1 has attributed the disease not to a deficiency of fat-soluble 
vitamin, but primarily to a lack of fresh animal food conveying suitable 
protein, and secondarily to endocrine dysfunction. 
In the state of confusion arising from so many diverse theories we 
may summarize the results of clinical evidence in only a few facts: 
Rickets is infrequent in the breast fed unless colored or Italian; rela- 
tively infrequent amid good hygienic surroundings; rare before the age 
of three or four months, and uniformly absent from infants who have 
been taking and assimilating a substantial, well-proportioned food and 
live in the open air and sunlight. 
Pathology.—The most obvious changes are in the bones. Here there 
is indeed a marked deficiency of lime salts. The formation of bone is 
interfered with not only at the epiphyses but also in the region sub- 
jacent to the enveloping periosteum. 
In the epiphyseal ends of the long bones there is an excessive pro- 
liferation of the cartilage cells, and an abnormal vascularization of the 
zones of proliferation and calcification, which intervene between epiphysis 
1 Sweet, Brit. Med. Jour., December 24, 1921. 122 
THE PRACTICE OF PEDIATRICS 
and diaphysis. The deposit of lime salts in the cartilaginous matrix 
is imperfect, and the solid cartilage undergoes a variable amount of 
Fig. 12.—Epiphyseal evidences of active rickets in the bones of the legs, 
(Bellevue Hospital.) 
absorption. As a result of these changes the epiphyses are softened and 
enlarged and the bones are subjected to varying deformities. 
Fig. 13.—Multiple fractures of the bones of the forearm with marked epiphyseal en- 
largement and defects in calcification. (New York Nursery and Child’s Hospital.) 
Associated with the defective development at the epiphysis there 
is likewise incomplete formation of bone beneath the periosteum. This 
membrane is thickened, and the subperiosteal layer of bone, which nor- RICKETS (rachitis) 
123 
mally undergoes calcification, is vascularized, soft, and deficient in cal- 
cium salts. 
“The pathologic changes may be summed up in the statement that 
there is excessive absorption of the bone with impairment of the process 
of calcification.”1 When the disease subsides, the imperfect bone under- 
goes calcification and hardening, but retains the deformities previously 
acquired. The enlargement of the epiphysis characteristic of rickets is 
usually first apparent at the costochondral joints, which acquire the well- 
known beaded appearance suggestive of the title rachitic rosary. In 
the more advanced cases the thorax undergoes actual distortions, de- 
fined by the terms Harrison’s grooves and pigeon breast. Curvatures of 
the spine and pelvic deformities which may be combined with lordosis 
Fig. 14.—The teeth in rickets. (From Dick, “Rickets.”) 
are common. In severe cases the legs become curved, owing to the in- 
ability of the bones to sustain the weight of the body, and portions of 
the cranial vault may undergo a variable amount of absorption. Local- 
ized areas of thinness in the occipital and parietal bones are characteristic 
of the craniotabes of rickets. The affected skull is large and the centers 
of ossification of the frontal and parietal bones are marked by hyper- 
ostoses or bosses. In many instances the anterior fontanel instead of 
becoming closed at the twentieth month remains patent until the third 
or fourth year. The eruption of the teeth is uniformly delayed. Figure 
14 shows the normal calcification of the two sets at various periods, the 
parts normally calcified in the first two years, and the commonest form of 
rachitic hypoplasia. (See p. 38.) 
1 Adami and Nicholls, Principles of Pathology, vol. ii, p. 1009. 124 
THE PRACTICE OF PEDIATRICS 
Although rickets is fundamentally a disease of general nutrition, 
the lesions, apart from those occurring in the osseous system, are of 
relatively slight significance. The spleen is frequently enlarged; less 
often, the liver. The stomach and colon may be dilated. The muscles 
undergo wasting, slight degenerative changes, and a variable amount 
of fatty infiltration. The ligaments are relaxed. The blood shows the 
existence of a secondary anemia and a mononuclear leukocytosis. 
The changes, aside from those of a secondary anemia, relate to the 
content of calcium and phosphorus in the blood. During active rickets 
either the calcium or phosphorus,1 or both may be markedly decreased. 
There is no question of the presence of a negative calcium balance in 
active rickets. In the older cases the calcium balance varies, but during 
convalescence there is a definite retention of calcium. 
Fig. 15.—Thoracic deformity and enlarged abdomen of rickets. (Bellevue Hospital.) 
Symptoms .—In a vast majority of the cases there are no symptoms 
depending upon the presence of the disease. There may be sweating 
of the head, restlessness, constipation; but these symptoms are also 
present in cases which show no rachitic change. There is usually mal- 
nutrition, and yet malnutrition may be present without rachitis. Rachitic 
children are unusually susceptible to catarrhal conditions of the res- 
piratory tract and they have a weak resistance to infection of the in- 
testines; yet, again, we find these conditions in children who do not have 
rachitis. In rachitic children there is pronounced lack of nerve balance, 
and this occurs in children who do not have rachitis. All these con- 
ditions are present in rickets, and as a symptom-complex they point to 
rachitis. Such symptoms, therefore, are not diagnostic without further 
corroboration. 
Most of the conditions enumerated may be considered secondary 
to, rather than characteristic of, the disease. 
1 Howland, J., and Kramer, B., Amer. Jour. Dis. Child., 22, 105, August, 1921. RICKETS (RACHITIS) 
125 
So far as the pathognomonic symptoms are concerned, which means 
the conclusive manifestations of a disease, there are none. 
The signs proving rachitis comprise the physical appearance of the 
child, the findings upon physical examination, and the evidence dem- 
onstrated by the z-ray and by postmortem examinations. 
Diagnosis.—In a well-marked case inspection shows a condition 
that is seen in no other disease. There is the large head, cuboid in shape, 
flat on the top, due somewhat to the exaggeration of the frontal and 
parietal eminences. The beading of the ribs stands out plainly. The 
chest is narrow, retracted at the sides, and increased in the anteroposterior 
diameter, producing the so-called pigeon breast. In pronounced cases 
there often is an axillary groove extending the length of the chest. A 
rare deformity is the funnel chest, in which there is a marked retraction 
of the lower portion of the sternum, greatly decreasing the anteroposterior 
diameter at this point, with a corresponding increase in the lateral di- 
ameter. 
The epiphyses of both the upper and lower extremities are enlarged, 
and there is a decided outward curvature of the tibia. There may 
be anterior bowing of the femur. The radius and ulna may also show 
Fig. 16.—Rachitic head, Harrison’s grooves, and "pot belly.” (Bellevue Hospital.) 
curvature, but this is less usual. Knock-knee is present in a compar- 
atively small number of cases. 
The child has a pot belly, often with umbilical hernia. The liver and 
spleen are enlarged. 
Physical examination reveals a large fontanel, two or three times 
the size normal for the age. Dentition is delayed; repeatedly infants 
of a year and over will not have erupted a tooth. Craniotabes, which 
consists of soft, compressible areas in the skull showing deficient deposit 
of bone-cells, is present in many young rachitic infants. 
A non-angular posterior spinal curvature involving several vertebrae 
will be found in a majority of the patients under fifteen months of age. 
This is due to muscle and ligament weakness, as will be proved by 
suspending the child by the arms, when the curvature will usually dis- 
appear. This straightening may not completely take place, in older 
children, in whom the deformity has existed for several months. Fur- 
ther, in older cases there may be associated lateral and rotatory curva- 
tures. 
The clavicle may show thickening at the ends, and in severe cases 
there is frequently seen an increase in the anterior curve. 126 
THE PRACTICE OF PEDIATRICS 
Rachitic children will be found abnormal in other respects. There 
is usually a secondary anemia. They possess poor resistance to bacterial 
infection, notably pneumonia, and when such infection or, in fact, any dis- 
ease occurs the chances of recovery are less than in a normal individual. 
The vital resources are of a low order. Convulsions may occur upon 
slight irritation. The digestion is rarely up to the normal for the child’s 
age. 
It is to be understood that in this description we have been consider- 
ing a well-marked case. Hundreds of children show varying degrees of 
mild rachitis in which the conditions may in no way compromise the 
individual. Further, it must be appreciated that not every case shows 
the even distribution of the lesions enumerated. There may be cases 
with bowed legs or knock-knees, spinal deformity, or enlarged cranium, 
in which one of the conditions mentioned may be the only sign of conse- 
quence. 
Differential Diagnosis.—That confusion arises in differentiating 
rachitis from cretinism, mongolianism, and hydrocephalus is demon- 
strated in consultation practice. A clear mental picture as to what con- 
stitutes mongolianism, cretinism, and rachitis would eliminate confusion 
without the assistance of a consultant. A differentiation, however, 
between the large, rachitic head and one due to an acquired hydrocephalus 
or to a mild degree of congenital hydrocephalus, is not a simple matter, 
for the reason that when there is hydrocephalus there is usually rachitis. 
An immediate diagnosis is impossible. It is not unheard of for even 
competent neurologists to ask for time for further observation before 
making a diagnosis. The further observation has usually included re- 
peated measurement of the circumference of the child’s head. A child’s 
head increases in circumference from birth onward about as follows: 
During the first year, 4 inches, 3 inches of which is the increase during the 
first six months; during the second year, 1 inch; during the third year, | to 
f inch; during the fourth and fifth years, l\ inches. When the rate of 
growth considerably exceeds these figures it is an indication of hydro- 
cephalus. A prominent fontanel and ununited sutures indicate hydro- 
cephalus. (See p. 550.) 
Other diseases occasionally confused with rickets in making a diag- 
nosis are scurvy, rheumatism, paralysis of central origin, chondrodys- 
trophy, osteomalacia, osteomyelitis, and syphilis. 
Prognosis.—The prognosis is favorable in so far as the immediate 
disease is concerned. In early childhood the negative calcium balance 
becomes reversed. Uncomplicated with intercurrent disease, all cases 
recover if properly treated. Indirectly, because of the susceptibility to 
infection and the lack of resistance, rachitis is a large factor in the mor- 
tality of the young. Cured patients suffer no inconvenience in later 
life. There is doubtless some shortening in stature; it is difficult to de- 
termine the effects in this respect, as there are no means of knowing 
what height the individual might have attained had he not had rachitis. 
In women at childbirth its baneful possibilities are made prominent in 
a narrow and contracted pelvis in which the sacral promontory approaches 
the pubis. 
Coxa vara is characteristic of the rickets of late childhood and adoles- RICKETS (rachitis) 
127 
cence. High arch palate and deviated nasal septum are finally to be 
noted as deformities in many instances—due to past rickets. The prob- 
lem of prognosis is thus carried into adult life and deserves consideration 
in other spheres as well as that of pediatrics. 
Treatment.—It will readily be seen from the foregoing that the 
treatment of rachitis resolves itself into the adjustment of the diet to 
the needs of the patient. As growth and normal development cannot 
take place without protein and salts, and as the history of our cases 
has shown that these elements, together with fat, are most frequently 
lacking in the diet of rachitic children, suitable feeding should be our 
first consideration. 
Diet of Infants.—Artificial foods usually are deficient in both the 
fat and protein; therefore these foods should be discontinued. We have 
seen a vast number of cases that were on cow’s milk feeding of such 
strength that it could not be assimilated. In such cases a properly adapted 
cow’s milk formula is the only treatment required. 
Diet After the First Year.—For those over one year of age not only 
should artificial food be discontinued and cow’s milk given, but the 
cow’s milk should be supplemented by a diet rich in nitrogen, composed 
largely of milk, scraped beef, soft-boiled egg, oatmeal, and wheat gruel. 
After the second year purees of beans and peas may be added to the 
dietary because of the large percentage of protein which they contain. 
The physician must remember that a diet as highly nitrogenous as the child 
can assimilate is to be given. Unfortunately, many rachitic children can- 
not take cow’s milk in quantities sufficient to make it of real nutritive 
value because of inability to digest the fat, the milk being taken without 
inconvenience when a large proportion of the fat is removed. Skimmed 
milk contains at least 3 per cent, of the nutritional element much desired, 
the protein, and makes a valuable addition to the diet. If a dilution of 
the milk is necessary, oatmeal gruel should be used. 
Many children of this class who cannot take a full milk diet will take 
1 or 2 ounces of butter daily without inconvenience. It is advisable 
to give rachitic children a moderate amount of fat, as it aids in the pro- 
duction of heat and thus saves the tissues. Egg yolk is antirachitic. 
Specific Cod-liver Oil Therapy.—Kassowitz, toward the end of the 
last century, advised the use of cod-liver oil. Since that time it has been 
abundantly proved clinically and experimentally, roentgenographically 
and chemically, that cod-liver oil in sufficient dosage cures rickets and 
produces healing in the lesions. This is probably due to the large amount 
of fat-soluble vitamin contained in it. Changes are demonstrable in al- 
most all cases adequately dosed and under competent radiographic study 
within a month.1 
Before the second year of age cod-liver oil is often a valuable addition 
to the dietary. In prescribing cod-liver oil we prefer to use the plain oil. 
In spite of the disgust adults have for cod-liver oil, children usually take 
it readily. The younger the child, the better the oil will be taken. To 
delicate children six months of age from 10 to 30 drops may be given 
three times daily after meals. From the sixth to the eighteenth month 
from 20 drops to 1 dram may be given three times daily after feedings. 
1 Park and Howland, Bull. Johns Hopkins Hosp., November, 1921. 128 
THE PRACTICE OF PEDIATRICS 
After the eighteenth month from 1 to 3 drams may be given at the same 
intervals. 
Hygiene.—Brine baths and oil inunctions aid materially and are of 
great value in improving the child’s condition as a whole. The brine 
bath (p. 843), which is given at bedtime, is to be followed by an inunction 
of goose grease, unsalted lard, or cacao-butter. The goose oil or lard 
is preferred. At least 2 teaspoonfuls should be rubbed into the skin. 
The benefit derived from the inunctions is largely due to the massage. 
The rubbing should be continued for at least ten minutes. The muscles 
of the back and legs should receive special attention. In a few instances 
the animal fats act as irritants to the skin and produce a fine, papular 
eruption. 
The rachitic child should have plenty of fresh air by means either 
of a fireplace or an open window. On stormy and very cold days he 
should be given an indoor airing (p. 838), being placed in his carriage 
or cart and wheeled about the room. To avoid drafts, the window or 
windows on only one side of the room should be opened. 
Rachitic children are very susceptible to head colds and bronchitis; 
therefore, every means must be employed to prevent exposure. As 
creeping and playing on the floor are the most frequent methods of tak- 
ing cold, the exercise pen (p. 839) is particularly useful in these cases. 
Drugs are of little value except as they increase the appetite and the 
capacity for properly selected foods. The administration of phosphorus 
is without avail if the deficient diet is continued. Specific medication 
without proper food and a fair digestive capacity is valueless. With 
proper food and a fair digestive capacity medication is superfluous, and 
a child rapidly recovers without it. 
We have used phosphorus extensively, and have yet to see a single 
case in which the beneficial action of the drug could be proved clinically. 
In giving phosphorus the oleum phosphori is the easiest and most con- 
venient form for administration. One drop of the preparation represents 
grain of phosphorus. To children under one year of age 1 drop 
may be given three times daily. To those between the first and second 
year to 2 drops may be given three times daily after meals. 
Heliotherapy.—A mass of evidence is now available from numerous 
sources proving the curative action of the sun’s rays in various diseases. 
Not only is the cure produced in the bone lesions of rachitic subjects 
much like that obtained under treatment with cod-liver oil but there is 
a similar improvement in the phosporus content of the blood as the result 
of exposure to direct sunlight. Hess and Gutman1 have demonstrated 
in addition that owing to the filtering out of certain of the actinic rays 
of the spectrum the passage of sunlight through clothing or window 
glass inhibits to a marked degree the beneficial action of ordinary sun- 
shine. Finally it has been shown conclusively that satisfactory curative 
effects are to be obtained from the quartz mercury vapor light even in 
the absence of both sunlight and cod-liver oil. 
Treatment of Deformities.—The deformities of the osseous system, 
particularly of the spine and long bones, may be prevented—the first, 
by keeping the child on his back a greater part of the time, and, if the de- 
1 Jour. Amer. Med. Assoc., January 7, 1922. RICKETS (RACHITIS) 
129 
fortuity is well marked, by teaching him to sleep resting on his stomach. 
When a kyphosis is present the child should be allowed to remain in the 
upright position but a few moments at a time. 
Fig. 17.—Saber tibia) of rickets. (Seaside Hospital.) 
Deformities of the femur, tibia, and fibula occur long before the child 
attempts to stand, but too early use of the legs, while not necessarily 
Fig. 18.—x-Ray appearance of bones of legs. Patient shown in Fig. 17. 
a cause of deformity, may greatly aggravate the existing conditions. 
For this reason rachitic children should not be encouraged to walk or 
stand until they have been under treatment for three or four months. 130 
THE PRACTICE OF PEDIATRICS 
Operative measures for the correction of bow-legs are better post- 
poned until after the third year. If corrected at an earlier period the 
deformity is apt to return, and the late deformity may be greater than 
the original one. 
The use of the braces to correct the deformity of the legs has been 
of but little assistance, and the use of braces and jackets of plaster of 
Paris in kyphosis is usually unnecessary. Rest, massage, and exercises 
directed to restoring power to the weakened muscles have been of value. III. CARE AND NUTRITION IN CHILDHOOD 
THE FORMATIVE PERIOD 
Throughout the first year of life nutrition constitutes the main prob- 
lem in the program of human development. Habit formation has its 
inception and the adaptation of the growing organism to its environment 
is in a measure completed during infancy. The expression of individu- 
ality has only begun. During the period after infancy this new problem 
is presented and upon the harmonious combining of good guidance with 
free rein to the rapidly developing faculties that go to make up person- 
ality depends in no small degree the future of the individual. 
In the succeeding pages an attempt is made to emphasize the oppor- 
tunities existing during early childhood not only for the furtherance of 
good nutrition but also for the formation of habits essential to the well- 
being of all children irrespective of individual traits. 
Necessity of Method in the Management of Children.—One whose 
work in pediatrics is among all types and classes of people cannot fail 
to be particularly impressed with the fact that some children are the 
source of an immense amount of trouble, while others of no better health 
or greater strength cause very little anxiety on the part of their parents. 
Children differ greatly as regards individual traits and disposition, but 
these can be fashioned to a great extent by proper management. The 
more spirited the child, the greater need of method in the care. 
Many mothers are worn-out, nervous wrecks for no other reason 
than a lack of system in the management of the daily life of their children. 
Thoroughgoing and conscientious these women may be, but they repre- 
sent that large number who have never been taught that certain functions 
and duties should be performed only at certain definite times every day. 
Beginning at birth, the baby should be fed or nursed at definite times 
and at no others. Sleeping should never interfere with the nursing hours. 
The child should have time for undisturbed repose, and a midday nap 
should be insisted upon until the end of the sixth year. The definite 
time for meals, with properly selected food, should be continued through- 
out adolescence. The child should be bathed at a certain hour and aired 
at a certain hour. “Runabouts” should have their hours for play and 
should retire at a definite time every evening. Such a regime is con- 
ducive to perfect health, consequently to better growth and develop- 
ment and to a stronger manhood. It is idle to say that many parents, 
particularly among the poor, cannot conform to such requirements. 
The poor are just as anxious to do the best for their children as are the 
rich, and will do this to the best of their ability if reasons are explained 
to them. If they cannot reach the ideal, they will attain to a higher 
degree of efficiency by striving. The trouble ordinarily is not with the 
mother, it rests more with the medical adviser, who is largely responsible 
for the ignorance of the mother and the resulting harm to her offspring. 
131 132 
THE PRACTICE OF PEDIATRICS 
The School.—Education only in the narrow sense belongs to school. 
Long before the actual acquiring of book learning is begun habits of 
application, concentration, and simple reasoning processes are acquired. 
The degree of development of these faculties constitutes a better measure 
of mental capacity than knowledge of letters or even ability to read or 
recite. 
Only exceptionally is there any need for school in the accepted sense 
of the term before the sixth year of life. Rearing a “good animal” is the 
first problem of the early years, and this does not preclude the funda- 
mental training which has already been emphasized. 
The kindergarten, of course, has its function in developing good habits, 
promoting association between children, in forming the school habit, and 
in relieving overworked mothers from responsibility at certain hours. 
This agency, nevertheless, is not to be regarded as essential to childhood. 
As a means of dissemination of contagious disease during the danger 
period before the fifth year the kindergarten, when close supervision in 
this respect is lacking, is actually to be regarded with disfavor. 
For all young children school sessions should be short and broken 
by recess periods. Single sessions should not postpone the noon meal for 
which inadequate lunch is too frequently substituted, and school work 
at home should be prohibited whenever it imposes any strain. When 
possible young children should not be required to climb stairs in the 
school building. This rule applies with even greater force to the school 
child who is delicate or has a cardiac defect. 
The ideal school is the open-air school. To what degree the open-air- 
school method may promote well-being may readily be learned from 
the work of Rollier and his associates (p. 26). 
The private tutor is of value in the exceptional case only when special 
attention is demanded because of the existence of peculiarities or defects 
in development which handicap the child with his fellows, or when time 
lost because of illness (from which recovery has been as complete as 
possible) must be made up. If a child is to become a great musician 
or attempt the prodigious in any chosen sphere the demands of child- 
hood must be recognized as even more insistent than in ordinary cases, 
and in some way these demands must be satisfied even at the sacrifice 
of the technical and the artistic. 
The Summer Camp.—This institution is a development of the past 
two decades. As a means of promoting out-door life and helpful associ- 
ation between growing boys and as a preparation for the boarding school 
or college of later years, the summer camp is of great value. On the 
other hand, one cannot deny that the influence of a bad, improperly 
supervised camp may be far reaching in ill effects. 
Certain rules applicable to all camps of any size may be mentioned: 
The general sanitary regulations of a good army camp must be rigidly 
adhered to. The water and milk supply must be beyond suspicion. 
Provision for isolation and care of the sick in separate quarters should be 
made. Sleeping tents should be provided with wooden floors. A resi- 
dent physician or one in the immediate neighborhood should make daily 
EDUCATION DISEASE PREVENTION 
133 
rounds with a view to caring for affections even as minor as bad sun- 
burn. Bathing, particularly, should be supervised. Regular hours for 
sleep at night and an afternoon rest hour should be enforced. 
The wisdom of sending a boy or girl to a summer camp before the age 
of ten or twelve years is questionable. Our advice to parents should 
be that they themselves inspect the camp in person before making an en- 
rolment. 
Physical Training.—Voluntary exercise is a part of the normal life 
of every child. Play in the open air, with all that play signifies—run- 
ning, jumping, bicycle riding, ball playing, tennis, swimming, and skating 
—make for a good physique without the need of gymnasia and classes 
for postural correction. Aside from the normal play activities and the 
simple setting-up exercises employed in the modern school, special phys- 
ical training is not ordinarily required. If indoor exercise must be sub- 
stituted, the specialized forms of children’s dancing probably offer the 
most benefit in developing the body symmetrically. Dancing for girls 
and appropriate modifications of military drill for boys fulfil the demands 
for beneficial exercise without the sacrifice of fun. 
The boy and girl scout activities probably meet the developmental 
requirements of late childhood as well if not better than any other single 
agency. 
DISEASE PREVENTION 
General Safeguards.—The knowledge that because the more common 
infectious diseases are seldom escaped throughout childhood, and that 
certain of these diseases frequently assume a severe form in attacking the 
adult who has no immunity from a previous attack, leads many people 
even in this enlightened day to advocate the exposure of children pro- 
miscuously to whooping-cough, measles, and various other diseases. 
“Unjustifiable” is too mild a term to characterize such a course. It is no 
less than criminal. Statistics indicate clearly the generally increased 
susceptibility and the higher mortality during the first few years of life. 
Statistics likewise show the greatly decreased incidence of such diseases 
in adult life even among those who have never previously been attacked. 
Without this knowledge science and instinct together should still dic- 
tate the fullest measure of postponement of exposure, if not extreme 
protection against exposure, in the safeguarding of the young. 
The young child has no place in a crowd. The crowded theater, the 
crowded department store, the crowded railway train, and even the 
crowded elevator afford a risk at all times of infection by contact. The 
mother who appreciates this fact and acts accordingly, who supervises her 
child’s playmates, and constitutes herself a beneficent detective upon 
their mention of sore throat, or their paroxysmal coughs will, without 
giving offence or instilling panic, go far in the safeguarding of her own 
fold. She must still be on guard against those of her own household. 
(See pp. 29-30.) 
Specific Measures.—That means for the eradication of smallpox, 
diphtheria, and typhoid must be made the subject of publicity campaigns 
is a commentary on the bigotry and laziness of too many people. As 
the list of diseases for which preventive specific therapy becomes longer 134 
THE PRACTICE OF PEDIATRICS 
it is to be hoped that these obstacles encountered in the past will no 
longer block the road. 
There is no valid argument against the immunization of a well baby 
against smallpox in the first year of life or his protection against diph- 
theria at the end of the first year. There is the best of reasons for the 
application of the Schick test to older children and the best of reasons for 
typhoid vaccination for children who bathe in public pools or travel with 
their parents in unsanitary countries. 
The details of application of the different methods will be considered 
under discussion of the respective diseases. 
DIET FROM THE FIRST TO THE ELEVENTH YEAR 
At the completion of the twelfth month the average well-regulated 
baby should be weaned and given other nourishment. If bottle fed, 
he should receive more than the milk and cereals with which most chil- 
dren are fed. The food suitable for the second year of life and the method 
of its preparation and administration are subjects concerning which the 
masses are most profoundly ignorant. A few children at this period of 
life are underfed, but the great majority are overfed and carelessly given, 
at improper intervals, unsuitable food, indifferently prepared. Summer 
diarrhea finds its greatest number of victims among those children over 
twelve months of age who have been carelessly fed. 
The Second Summer.—The dreaded “second summer” robs many 
homes because of ignorant or careless parents. The second summer, 
approached properly, is hardly more dangerous than any other summer 
during the early years of a child’s life. It is almost a universal custom, 
when the child is weaned or given something other than a milk diet, to 
allow him “tastes” from the table. Very often these tastes comprise 
the entire dietary of the adult. Milk is often the only suitable article of 
diet that is given. Eventually not only is the other food selected un- 
suitable, but it is given irregularly, and supplemented by crackers kept 
on hand for use between meals. During the hot months the gastro- 
intestinal tract is least able to bear such abuse and the child becomes ill. 
Feeding After the First Year.—Usually when the twelfth month is 
completed we give the mother a diet schedule, with instructions to begin 
gradually with the articles allowed, in order to test the child’s ability to 
digest them. Every new article of food should be carefully prepared and 
given at first in very small quantities. All meals are to be given regularly, 
with nothing between meals. With many children this expansion of the 
diet list is attended with considerable difficulty. They are thoroughly 
satisfied with milk, and refuse all other forms of nourishment. In such 
cases time and patience are necessary at the feeding time. The more 
solid articles of diet should be given first and the milk kept in the back- 
ground. 
Among the underfed seen at this period of life are those who have 
been nursed too long and those who have been kept too long upon an 
exclusive milk diet. A great majority of the cases of malnutrition of the 
second year are seen in the exclusively milk fed. These children are pale, 
soft, flabby, and badly nourished. DIET FROM THE FIRST TO THE ELEVENTH YEAR 
135 
The following is a diet schedule which has proved of value. The mother 
is instructed to select, from the foods allowed, a suitable meal: 
From the Twelfth to the Fifteenth Month: Four Meals Daily 
7 a. m. : Two or 3 tablespoonfuls of cornmeal, oatmeal, wheatena, hominy, rice 
(all cooked four hours the day before in water) served with butter or milk and a little 
sugar. Eight ounces milk from glass or bottle. Bread stuffs.1 
9 a. m. : Juice of one-half orange or 3 ounces prune juice. 
11 a. m. : One tablespoonful of either scraped steak, minced chicken or minced chop, 
or soft-boiled egg mixed with bread crumbs. Baked or mashed potato (medium size). 
Glass or bottle of milk. Bread stuffs. Sleep after this meal. 
2.30 p. m. : Eight ounces chicken or mutton broth with bread or rice in the broth, 
or 8 ounces milk. One tablespoonful stewed carrots, squash or spinach when broth 
is given. Desserts: Custard, cornstarch, junket. Bread stuffs. 
6 p. m. : Two or 3 tablespoonfuls farina or cream of wheat (cooked two hours in 
water), or one of above cereals served as directed. Eight ounces milk from glass or 
bottle. Bread stuffs. 
From the Fifteenth to the Eighteenth Month: Four Meals Daily 
7.30 a. m. : Two or 3 tablespoonfuls cornmeal, oatmeal, wheatena, hominy, rice 
(all cooked four hours the day before in water), served with butter or milk, with or with- 
out sugar. Glass of milk. Bread stuffs.2 
9 a. m.: Juice of one orange or 3 ounces prune juice. 
11 a. m. : One tablespoonful scraped steak, minced chicken, minced chop, or a soft- 
boiled egg mixed with bread crumbs. Baked or mashed potato. One tablespoonful 
spinach, asparagus, string beans, peas, squash, stewed carrots, or stewed celery. Des- 
serts: Stewed apples, stewed prunes, baked apple. No milk at this meal. Bread stuffs. 
Sleep after this meal. 
2.30 p. m. : Eight ounces of chicken or mutton broth with bread or rice in it or 8 
ounces milk. Small cup of custard, cornstarch, or junket. Bread stuffs. 
0 p. m. : Two or 3 tablespoonfuls farina or cream of wheat (cooked two hours in 
water) or one of above cereals served as directed. Glass of milk. 
From the Eighteenth Month to the Third Year: Three Meals Daily 
7.30 a. m.: Two or 3 tablespoonfuls cornmeal, oatmeal, wheatena, hominy, or 
rice (all cooked four hours the day before in water), served with butter or milk, with or 
without sugar. Glass of milk. Bread stuffs. 
9 a. m. : Juice of one orange or 3 ounces prune juice. 
12.30 p. m.: One or 2 tablespoonfuls scraped steak, chop or minced chicken, or soft- 
boiled egg. Baked or mashed potato. One or two tablespoonfuls spinach, asparagus, 
string beans, peas, squash, white turnip, stewed carrots, stewed celery, or stewed onions. 
Desserts: Stewed apple, stewed prunes, baked apple, rice-, bread-, or tapioca-pudding. 
Gelatin pudding with lemon, vanilla, or orange flavor. No milk at this meal. Bread 
stuffs. 
Rest one and one-half hours after this meal. 
4 p. m. : Drink of milk and piece of toast or plain cracker. 
6 p. m. : Two tablespoonfuls farina or cream of wheat (cooked two hours in water) 
or one of above cereals served as directed. Drink of milk or 8 ounces chicken or mutton 
broth. Spaghetti. Desserts: Custard, cornstarch, or junket. Cream cheese or honey 
on bread or crackers. Bread stuffs. 
From the Third to the Fifth Year: Three Meals Daily 
7.30 a. m. : Three to 4 tablespoonfuls cornmeal, oatmeal, wheatena, hominy, or 
rice (all cooked four hours the day before in water), served with butter or milk, with or 
without sugar. One slice of bacon or soft-boiled or poached egg. Cereal may be 
given with either bacon or egg, or egg may be given alone with milk and slice of bread 
and butter. Glass of milk. Bread stuffs. 
12.30 p. m. : Steak, chop, minced chicken, baked or boiled halibut or codfish. 
Baked or mashed potato. Two tablespoonfuls spinach, asparagus, string beans, peas, 
1 Bread stuffs: Wheatsworth biscuit, zwieback or Holland rusk, toast. 
2 Bread stuffs: Wheatsworth biscuit, zwieback or Holland rusk, dried bread, plain 
white or whole wheat bread, toast. 136 
THE PRACTICE OF PEDIATRICS 
squash, white turnip, stewed carrots, stewed onions, mashed cauliflower. Desserts: 
Stewed apple, stewed prunes, baked apple, rice-, bread-, or tapioca-pudding. Gelatin 
pudding with orange, lemon, or vanilla flavor. Stewed or raw peaches and cherries. 
All stewed fruits in season except strawberries. Bread stuffs. 
Rest one and one-half hours after this meal. 
4 p. m. : Scraped apple, pear, or grapes. 
6 p. m. : Three or 4 tablespoonfuls farina or cream of wheat (cooked two hours in 
water) or one of above cereals, served as directed. Instead of cereal, spaghetti may 
be given. Glass of milk, or 4 ounces milk, 4 ounces water and 1 teaspoonful Phillip’s 
cocoa, with sugar, or 8 ounces chicken or mutton broth. Custard, cornstarch, junket. 
Cream cheese or honey on bread or crackers. (Either milk, cocoa, or soup may be 
given at night for variety.) Bread stuffs. 
Raw fruit may be enjoyed by most children during the midafternoon at this age. 
Apple, pear, grapes, or half medium-sized banana may be given. 
Y 
From the Fifth to the Seventh Year: Three Meals Daily 
7.30 a. m. : Three to 4 tablespoonfuls cornmeal, oatmeal, wheatena, hominy, or 
rice (all cooked four hours the day before in water), served with butter or milk, either 
with or without sugar. Bacon, soft-boiled, scrambled or poached egg or minced chicken. 
Glass of milk. Bread stuffs. (The child will do best at this age if he is given more than 
a cereal and milk breakfast.) 
12.30 p. m.: Steak, chop, roast beef, roast lamb, poultry, baked or boiled halibut 
or codfish. Baked or mashed potato. Two tablespoonfuls spinach, asparagus, string 
beans, peas, squash, white turnip, stewed carrots, stewed celery, stewed onions, mashed 
cauliflower. Desserts: Stewed apple, stewed prunes, baked apple, rice-,jbread-, or tapioca- 
pudding. Gelatin pudding with lemon, orange, or vanilla flavor. Raw and stewed 
peaches and cherries. All stewed berries in season except strawberries. Bread stuffs. 
Rest one and one-half hours after this meal. 
4 p.m.: Raw apple, pear, grapes, or banana. 
6 p. m. : Three tablespoonfuls farina or cream of wheat (cooked two hours in water) 
or one of above cereals served as directed. Glass of milk or 4 ounces of milk, 4 ounces 
of water and 1 teaspoonful of Phillip’s cocoa, or 8 ounces of chicken or mutton broth. 
When broth is given stewed fruit is to be given as dessert. Instead of cereal spaghetti 
may be given. Desserts: Custard, cornstarch, junket. Cream cheese or honey on 
bread or crackers. Bread stuffs. 
From the Seventh to the Eleventh Year: Three Meals Daily 
7.30 a. m. : Cornmeal, oatmeal, wheatena, hominy, rice (all cooked four hours the 
day before in water), served with butter or milk, either with or without sugar. Occa- 
sionally a dried cereal may be given—shredded wheat, cornflakes, puffed rice or puffed 
wheat. Bacon, soft-boiled, scrambled, or poached egg, minced chicken or broiled fish. 
Glass of milk. Bread stuffs. 
12.30 p. m. : Steak, chop, roast beef, roast lamb, poultry, baked or boiled halibut 
or codfish. Baked or mashed potato. Spinach, asparagus, string beans, peas, squash, 
white turnip, stewed carrots, stewed celery, stewed onions, mashed cauliflower. Raw 
celery and lettuce. No milk at this meal. Desserts: Stewed apple, stewed prunes, 
baked apple, rice, bread, or tapioca pudding. Gelatin pudding with orange, lemon, or 
vanilla flavor. Raw and stewed peaches and cherries. All stewed berries in season 
except strawberries. Bread stuffs. 
6 p. m. : Farina or cream of wheat (cooked two hours in water) or one of above 
cereals served as directed. Glass of milk or cocoa. Chicken or mutton broth or dried 
pea or bean soup. When soup is given, stewed fruit is to be given as dessert. Instead 
of cereal spaghetti or baked potato or 2 or 3 tablespoonfuls of green vegetables may be 
given. Desserts: Custard, cornstarch, junket. Cream cheese or honey on bread or 
crackers. Bread stuffs. 
Many children require considerable variety in the preparation of the 
cereals suggested. The flavoring may be changed by the use of maple 
syrup and butter. 
It will be noticed that dried boxed cereals are allowed. This is to secure 
variety for those who do not take kindly to the cooked products. HABITUAL LOSS OP APPETITE 
137 
Malnutrition in Childhood 
ERRORS IN FEEDING 
In the care of the bottle-fed the most frequent error is overfeeding, 
or the use of a stronger mixture than the child is able to digest. Par- 
ticularly is this apt to be the case at the commencement of bottle feed- 
ing. The amount is usually too large and the intervals between the 
feedings are almost invariably too short. Children of the same age cannot 
all be fed alike. Artificially fed babies of equal health and vigor, but of 
considerably varied size and weight, will require food of approximately 
the same strength, and the same intervals between feedings; but the 
larger the child, the greater the quantity of food required. Thus, the 
quantity given at one feeding for a child weighing 13 pounds at the sixth 
month will not be sufficient for a child of the same age weighing 16 pounds. 
Nervous overactive children and those subject to a good deal of atten- 
tion will require a greater amount of nourishment than the less active 
children with quiet surroundings. In other words, the active child burns 
up more food than one less active in order to supply the requisite nervous 
energy. 
Keeping the child on an exclusive milk diet until the twelfth month 
or later is a not infrequent error. As a rule, starch in some form may be 
added to the food at the seventh month, and should always be added as 
early as the ninth month. The giving of food other than well-cooked 
cereals and milk before the eighth month is a mistake made in many 
households, and a common error from the twelfth month to the third 
year is to allow the child’s diet to consist largely of milk and insufficiently 
cooked cereals. Crackers and milk, bread and milk, cake, and fancy 
crackers often constitute the only articles of diet during this very impor- 
tant period of growth. The fact that a high protein food is as necessary 
for proper development now as at bottle age is overlooked. During 
early infancy milk is invaluable, but it is not sufficient for the demands of 
older childhood. Milk, eggs, meat, and cereals, such as oatmeal, rich in 
protein, are absolutely necessary to normal growth. 
Irregularity in feeding is another frequent error. The child should 
have his meals “on the minute,” at the same time every day. The lack 
of observance of this rule will surely result in loss of appetite and indiges- 
tion. Indiscriminate eating between meals of bread and butter, pastry, or 
confectionery, if persistently practised, will surely be followed by indiges- 
tion and malnutrition. 
Forcing or coaxing a child to eat is a practice always to be avoided. 
If suitable food is given at definite well-ordered intervals, a normal child 
will be hungry at those intervals. If he does not eat, something is wrong, 
and it is our duty to discover the cause of his loss of appetite. 
HABITUAL LOSS OF APPETITE 
The child, like the adult, not only requires sufficient nourishment to 
sustain life, but, in addition to this, an extra amount to supply the de- 
mands of growth. Proportionate to their size, all growing animals require 
more food than do those that have reached maturity. The young child 138 
THE PRACTICE OF PEDIATRICS 
is naturally such a very hungry animal that ample feeding is absolutely 
essential. Therefore, when there is habitual loss of appetite so that the 
child’s entire life may be unfavorably influenced, we must realize that the 
condition is abnormal and strive to discover the cause and apply the 
remedjr. 
Physicians are often consulted by parents whose children are suf- 
fering temporarily or persistently from loss of appetite—a condition 
usually associated with secondary anemia and defective growth. The 
child apparently is not ill; he may be active and playful, but he tires easily. 
The sleep ordinarily is sound and refreshing, but the child must be coaxed 
to eat. Often he will take food only when his attention is diverted by a 
story or a toy. He usually eats for the entire family, taking a mouthful 
each for father and mother, and for the cook! Three or four times a 
day, depending upon the number of meals, this coaxing, entertaining 
process has to be gone through. 
Occasionally children with habitually poor appetites for food in gen- 
eral will have a history of excessive milk drinking. From 3 to 5 glasses 
of milk may be taken daily and all other food refused. When milk forms 
the principal or only article of nourishment after the eighteenth month, 
children will invariably show evidences of malnutrition. They are apt 
to be pale and sallow, with flabby muscles. 
The most frequent cause of loss or lack of appetite is too frequent 
feeding. It is not at all uncommon to see children from two to four years 
of age who are being fed six or seven times in twenty-four hours, the 
argument of the parents being that: “The child takes so little food, he 
ought to take it oftener.” With increasing age, more and stronger food 
is required at less frequent intervals. In other cases children may not 
get their regular feedings at such frequent intervals, but are generously 
supplied between meals with candy, cake, crackers, and fruits. Unsuit- 
able food may be the cause of a habitually poor appetite. 
Children of tender age who are regularly fed from the adult table 
with heavy adult food, often improperly cooked, soon suffer from loss of 
appetite. 
Children who are poor eaters usually have the associated ailment— 
constipation. 
Too close confinement indoors is not infrequently associated with, if 
not a direct cause of, lack of appetite. Children who are kept uninter- 
ruptedly in the house for weeks at a time invariably have poor appetites. 
Children with stomachs of slow emptying capacity (Fig. 37) are almost 
invariably those in whom the appetite is habitually poor. An x-ray study 
of the stomachs of a considerable number of these cases shows residue 
after a bismuth meal from five to twelve hours (p. 222). 
Illustrative Case.—A girl five years of age was brought because of habitually poor 
appetite. Coaxing and forcing were, always necessary. There was a moderate appetite 
for breakfast. The other meals had to be forced and vomiting at the table frequently 
resulted. An x-ray study was made, and it was found that there was a food residue 
after ten hours. The retention was corroborated by the use of the stomach-tube after 
an ordinary meal. 
Treatment.—In order to emphasize a point in teaching, when treat- 
ment is under consideration, it has often been found useful to state, first, HABITUAL LOSS OF APPETITE 
139 
what not to do. Do not give these children drugs as a means of inducing 
an appetite until all other means have failed. The only medication that 
should be permitted is some simple laxative. There must be one evacua- 
tion of the bowels daily. The aromatic fluidextract of cascara sagrada, 
from 1 to 2 drams, given daily at bedtime, or from 3 to 5 ounces of the 
citrate of magnesia, given before breakfast, ordinarily answers well. 
Fresh Air.—Every “runabout” child with poor appetite should spend 
at least five hours daily in the open air, regardless of the season of the 
year. During very inclement weather in winter indoor airing (see p. 838) 
is a most satisfactory substitute. 
Diet.—An important step in the treatment is the regulation of the feed- 
ing hours. A child from twelve to fifteen months old should have four 
feedings daily (see Dietary, p. 135). Ordinarily, for “runabout” chil- 
dren from the fifteenth to the twenty-fourth month, four meals daily are 
necessary, but when there is loss of appetite, three meals at five-hour in- 
tervals often answer best. After the second year three meals are in- 
variably the rule unless the child is weak or ill. All feedings should be 
given at a definite time each day, from which there should be no deviation. 
Nothing whatever except water should be allowed between meals in the 
retention cases. The next step, in case these regulations fail, is to place 
the child temporarily on a markedly reduced diet, no solid food, such as 
meat, eggs, bread stuffs, vegetables, or fruits, being allowed. Milk, gruels, 
and broths should comprise the nourishment. When the desire for food 
returns the regular feeding schedule is to be resumed. The mother must 
be given the directions both orally and in writing. 
If the case is one of milk habit, then the milk must be entirely cut off, 
and broth, thin gruel, dry bread, or zwieback substituted. The mother 
is instructed to return with the child in two days. In the great majority 
of instances the report after forty-eight hours is that the child is raven- 
ously hungry. When such is the case freer feeding is allowed, but under 
the same strict observance of feeding intervals, with absolutely no feeding 
between meals. It is extremely rare to meet a case of habitual loss of 
appetite which will not respond to this simple method. In a large number 
of cases of failing appetite we have succeeded in restoring the desire for 
food by removing milk largely from the diet, having it skimmed and given 
in small amounts, morning and evening, and in reducing the sugar intake 
to a minimum. Many children get more milk than is good for them, and 
practically all children get more sugar than they can utilize with benefit. 
Feeding in the Retention Cases.—When food residue is found to be 
habitually in the stomach the interval between the feedings must be pro- 
longed. The breakfast is to be given at 7 a. m., dinner at 1, and supper at 
(> p. m. Immediately after feeding the child should rest in a recumbent 
position for one hour, preferably on the right side. But little fluid should 
be given with the meal. Our schedule in these cases is roughly as follows: 
Breakfast at 7 a. m., with 6 ounces of milk; 10.30 a. m. a drink of water; 
12.30 p. m. usual meal without w7ater, soup, or milk; 4 p. m. milk or water; 
0 p. m. usual supper with milk. To bed immediately, or supper to be given 
in bed. 
Change of Climate.—Occasionally a child fails to show the least evi- 
dence of disease and yet will not respond to proper dietetic and hygienic 140 
THE PRACTICE OF PEDIATRICS 
measures. For such a case a change from the city to the country, or from 
the inland country to the seashore, has been followed by a decided im- 
provement. When such changes are impossible, or when proper dietetic 
regulations are impracticable, as with dispensary patients, medication 
may be of service. 
Tonics.—One of the best medicinal means of improving the appetite 
in cases in which there is no delay in emptying and no hyperacidity is a 
solution of citrate of iron and quinin in sherry wine, 1 to 2 grains of citrate 
of iron and quinin being dissolved in \ dram of sherry wine and given, well 
diluted, before meals. This dosage will answer for children over eighteen 
months of age. For younger children, 1 grain of the citrate of iron and 
quinin in \ dram of sherry wine, well diluted, may be given. If this is not 
successful, 1 minim of dilute hydrochloric acid, minim of the tincture of 
mix vomica, and 2 teaspoonfuls of water may be given at two-hour in- 
tervals to children over fifteen months and under two years of age. After 
the second year 2 minims of the dilute hydrochloric acid and 1 minim of 
nux vomica, in 3 teaspoonfuls of water, may be given at two-hour intervals. 
There remain also to be considered under this head not a few children 
who habitually suffer from poor appetite and are below the average in 
every respect. 
THE PHYSICALLY SUBNORMAL CHILD 
In the treatment of the diseases of children the general practitioner 
as well as the pediatric specialist is frequently consulted regarding chil- 
dren who are deficient in physical development. They lack endurance 
and possess poor resisting powers. They are usually underheight, always 
underweight, and, in short, have so many subnormal physical character- 
istics in common that they constitute a class by themselves. 
Normal Development.—The average child, at the various periods of 
early life, conforms with a certain degree of regularity to the mental and 
physical development which by long association we have come to regard 
as normal. Thus a standard may be said to have been established, and 
it is up to this standard that we expect the growing child to measure. This 
is what we look upon as the average of physical and mental development. 
A few children exceed these requirements and are stronger and larger 
at the sixth month than the average child at the ninth month. Again, 
older children at the fourth or fifth year may be in every way equal to 
their normal playmates a year or two older. 
Abnormal Development.—On the other hand, there are children who 
are bom with reduced vitality, or who, through faulty management, 
usually in relation to feeding, have a reduced vitality. Semi-invalid 
adults almost invariably beget semi-invalid children. If the parents are 
of average health and of good habits and the debilitated condition of the 
child is due to faulty management and nutritional errors, the result of 
proper dietetic and hygienic management is usually prompt and satis- 
factory. With the persistently subnormal, the offspring of physically en- 
feebled parents, the results are less satisfactory. 
Treatment.—By proper regulation of the habits of such a child, as 
regards all the details of his daily life, a far better adult is produced than 
if no such effort has been made. In other words, a diet and general regime THE PHYSICALLY SUBNORMAL CHILD 
141 
of life best adapted to the individual in question will invariably improve 
the physical condition of that individual. This applies to the strong as 
well as to the subnormal, to the growing young of the lower animals as 
well as to the offspring of man. It is the poorly developed, delicate child 
that we are particularly to consider—the undersized, frail, small-boned 
child, whose appetite is persistently poor or capricious, who sleeps poorly, 
tires easily, is usually constipated, who is subject to catarrhal conditions 
of the respiratory tract, and whose powers of resistance generally are 
diminished. 
On assuming the management of one of these children it is absolutely 
necessary to make a thorough examination, followed in some instances 
by a few weeks’ observation, in order to become acquainted with the 
case in its individual aspects, to learn idiosyncrasies, and to eliminate the 
factor of actual disease as a caustive agent. When we demonstrate to 
our satisfaction that the child is free from such diseases as tuberculosis, 
syphilis, and malaria; when we have eliminated by properly directed 
treatment all causes, such as adenoids, phimosis, vaginitis, or parasitic and 
irritant skin lesions, which may have had a deterrent influence upon 
growth; and when we have satisfied ourselves as to the actual condition 
of our patient, we are in a position to lay down definite rules of manage- 
ment. 
Inasmuch as growth and development depend, above all things, upon 
a properly adapted food-supply, it must be our first step to provide such 
nutriment as will be most conducive to growth. As growth takes place 
in all parts of the body through cellular activity, the nutritive elements 
which promote cell nutrition and proliferation must be important con- 
stituents of the diet, and among these the proteins are of prime impor- 
tance; hence in the management of these children a point to be remembered 
in the adaptation of the food is the necessity of feeding as rich a protein 
as the child can assimilate. The younger the child, the greater the neces- 
sity for growth. 
Regular Weighings Necessary.—An infant should be weighed at reg- 
ular intervals, and if under one year of age should not be considered as 
doing even passably well if not gaining at least 4 ounces weekly. When 
a baby remains stationary in weight the development is invariably abnor- 
mal. When the weight is stationary or when only a slight gain of 1 or 2 
ounces weekly is made, we always find after a few weeks that there is 
malnutrition in spite of the apparent gain, as will be evidenced by the 
symptoms of beginning rickets—anemia, the characteristic bone changes, 
flabby muscles, and a tendency to disease of the mucous membranes. 
Subnormal infants should be weighed daily at first; then, as improvement 
takes place, at intervals of two or more days, but never less frequently 
than once a week during the first year, no matter how vigorous they 
may become. The weighing keeps us directly in touch with the child’s 
condition, but since the increase may be in fat alone, an occasional ex- 
amination of the child stripped is necessary to tell us whether there is 
substantial growth in bone and muscle. 
Feeding Infants.—When it is demonstrated that a child will not thrive 
on the breast of the mother, another breast should be substituted, or an 
adapted high protein cow’s milk should supplement or replace the breast 142 
THE PRACTICE OF PEDIATRICS 
milk. If the child is bottle fed and it is demonstrated that proper growth 
and development are impossible on cow’s milk on account of protein 
incapacity, then a wet-nurse should be secured. 
When, after the first year, more liberal feeding is allowed, the neces- 
sity for high protein in the food selected is as urgent as before. This 
applies to those children who show evidences of late malnutrition, as well 
as to those whom we have under our care from early infancy. 
An important element in the diet up to the third year is milk. A 
child from the first to the third year ought to receive 1 quart of milk 
daily. Unfortunately, many debilitated children have a very poor ca- 
pacity for fat assimilation. When given full milk in as small an amount 
as 1 pint daily, they often develop foul breath, coated tongue, and loss 
of appetite, or they suffer from frequent attacks of acute indigestion. The 
milk is necessary, not because of the fat, which can easily be dispensed 
with, but because of the high percentage of protein which it contains— 
from 3 to 4 per cent. When this fat exists, the milk is said to 
“disagree,” although skimmed milk will be taken without inconvenience. 
Enough sugar may be added to bring the percentage up to seven, in 
order that the extra sugar may replace the fat for fuel. Skimmed milk 
with sugar added furnishes a food of no mean order. Too much milk, 
however, must not be given. When more than 1 quart daily is taken, the 
desire for more substantial nourishment, such as eggs, meat, and cereals, 
is removed. 
Diet After the First Year.—At the completion of the first year, keep- 
ing in mind the high protein we may give scraped beef, at first 1 teaspoon- 
ful once a day, in addition to the cereal and milk. If the beef is well borne, 
and it usually is, a teaspoonful may be given twice a day, and later three 
times a day, immediately before the bottle feeding. Eggs should be 
brought into use from the twelfth to the fifteenth month. At first one-half 
an egg, boiled two minutes, is given mixed with bread crumbs. If well 
borne, a whole egg may be allowed. The cereals used should be those 
richest in vegetable protein, such as oatmeal, containing 16 per cent, of 
protein, dried peas, with 20 per cent, of protein, and dried beans, con- 
taining 24 per cent, of protein. The peas, beans, and lentils should be 
given in the form of a puree. 
If the child during the second year has an indifferent appetite, the 
quantity of milk should be reduced, never more than 1 pint of skimmed 
milk being permitted daily for the first week or two. Many subnormal 
children who apply for treatment after the first year of age have been 
subjected to as grave errors in diet as are seen among the bottle fed. 
Starch and milk frequently furnish the only nutrition up to the fourth or 
fifth year, the starch used being generally in the form of bread, crackers, 
and ill-cooked cereals. In one case 4 quarts of milk were taken daily by a 
boy of seven years. 
In dealing with this class of children—the delicate, undersized, slow- 
growing class—it is our aim to give as liberal nitrogenous nourishment as 
is compatible with the digestive capacity of the patient. If, however, 
the child has had rheumatism, or if there is a tendency to lithiasis, the 
use of a large amount of meat is contraindicated. For such children 
the high protein cereals are particularly valuable. THE PHYSICALLY SUBNORMAL CHILD 
143 
In general, from early life the diet of the delicate child should consist 
of milk, suitably adapted, with highly nitrogenous cereals added when 
permissible. Many subnormal children of the "runabout” age who can- 
not digest milk containing 4 per cent, of fat will easily digest butter-fat 
spread on bread or potatoes. Used in this way butter constitutes a pro- 
tein sparer. Oatmeal-water or oatmeal jelly, mixed with the milk, should 
be ordered at the seventh month. When age allows, the addition of rare 
meat, poultry, eggs, and purees of dried peas, beans, and lentils should 
be made. Boxed, "ready to serve” cereals are never to be given; raw 
cereals are essential which are cooked three hours. While a high protein 
diet is desirable, other foods are necessary. Green vegetables, animal 
fats, the ordinary cereals, cooked and raw fruits, are required to furnish 
the necessary acids and salts, as well as the necessary variety. In short, 
the ideal diet for a subnormal child is that combination of foods which, 
while imposing the least burden upon the digestive organs, supplies the 
body with material sufficient for its needs. (See Dietary, p. 135.) 
Baths.—On account of the fear that a delicate child may take cold, 
the bath is often omitted. All children, both the well and the subnormal, 
after the second week should be tubbed daily; the delicate particularly 
require bathing. The salt bath (p. 843) is usually advised. The best time 
for giving the bath is at bedtime, and in order to avoid all chance of ex- 
posure the temperature of the room should be elevated to 80° F. The 
temperature of the water may vary. It should never be above 95° F. 
except for very delicate young children in whom there is a tendency to a 
subnormal temperature. Even in these cases the temperature of the 
bath should never be higher than the temperature of the body. For the 
frail and the very young the bath should not be continued over' five 
minutes. In bathing children of eighteen months or over, if the phys- 
ical conditions allow, a distinct advantage will be gained by a reduction 
of the temperature of the bath while the child is in the water. An im- 
mersion in water at 90° F., followed by a gradual reduction during the 
space of five or six minutes to 70° F., should, upon brisk rubbing, be 
followed by quick reaction. For children after the third year a graduated 
cold spinal douche has served well. (See The Cold Douche, p. 842.) If 
the reaction is not good, if the extremities are slow in becoming warm, the 
reduction in the temperature should be less or none at all. With the very 
poorly nourished a reduction below 80° F. should not be attempted. 
Following the drying process, primarily for the benefit of the massage, 
goose oil, unsalted lard, or olive oil should be rubbed into the skin over the 
entire body for five to ten minutes. The bath and massage inunction, 
besides favorably influencing nutrition, are very effective in inducing 
sleep. 
Fresh Air.—Subnormal children are usually deprived of a proper 
amount of fresh air for the same reason that they are insufficiently bathed 
—the fear of making them ill. All children need an abundance of fresh 
air both in illness and in health. To the delicate fresh air is even more 
essential than to the robust. As many hours daily as practicable should 
be spent out of doors. The time thus spent depends upon the season of 
the year and the residence of the child, whether in the city or the coun- 
try. In the city, during the colder months with pleasant weather, the 144 
THE PRACTICE OF PEDIATRICS 
child should spend at least five hours daily in the open air, dividing the 
day into two outing periods—from 9 to 11.30 in the morning and from 2 
to 4.30 in the afternoon. On very cold days (20° F. or below), on stormy 
days, and on days with very high winds the child should be given his 
airing indoors. He is dressed as for out of doors, placed in his carriage, 
and left in a room, the windows on one side of which are open. Not infre- 
quently during February and March subnormal children will be pre- 
vented from going out of doors for several consecutive days. If some 
means for a daily systematic indoor airing is not provided, these children 
will often go backward, no matter how excellent the other management. 
The first symptoms are loss of appetite and the ability to assimilate food. 
In private work among athreptics, the child has been placed in the baby 
carriage or in a basket and allowed to rest before an open window for ten 
or twelve hours of every twenty-four, with a hot-water bottle at his 
feet. Here he has been fed, being removed only temporarily to warmer 
quarters for a change of napkins. 
Sleep.—'The subnormal child requires no more sleep than does the 
strong, and the rules governing this function at the various periods of life 
are the same both for the strong and for the weak. (See Sleep, p. 28.) 
The sleeping-room should always communicate with the open air by a 
window, either directly or through an adjoining room. A satisfactory 
means of ventilation is the window-board (p. 26). The child should 
occupy the room alone, if possible, sharing it neither with an adult nor 
another child. This ruling applies to all ages, but is particularly neces- 
sary after the second year. 
The Nursery.—The temperature of the nursery, day or night, should 
never be above 70° F. during the colder months. Very young infants, 
and those who are with difficulty kept covered, should not sleep in air 
below 65° F. 
Subnormal children of the “runabout” age are very susceptible to 
colds. In the management of such children it is necessary to use every 
precaution against exposure. The most frequent way of exposing a child 
to cold is by allowing him to sit on the floor. To keep the child of ten 
months to three years of age off the floor during the winter months, and 
thereby to eliminate this means of exposure, is very difficult. In fact, 
with active children learning to walk, or who have just learned to walk, 
it is practically impossible under the usual conditions. During the colder 
months there is always a current of cold air near the floor, and allowing 
the child to creep in winter, even if the floor is protected by rugs and car- 
pets, is one of the surest ways of permitting him to take cold. If he is 
allowed to walk on the floor, he is very sure soon to sit down. If he is not 
allowed to creep and walk about at will, he will not get the proper exercise 
and will show faulty development. For such cases the exercise pen is 
of immense service. (See p. 839.) After being dressed, washed, and fed, 
the child is placed in the pen, on a rug if desired. Toys are given him and 
the door is closed. He can now roam about at will, stand up, sit down, 
creep or walk without the slightest danger from drafts. 
Influence of Climate.—Much has been written regarding the influence 
of climate in the type of case we are considering. According to our ob- 
servation, this matter does not deserve the attention it has received. THE PHYSICALLY SUBNORMAL CHILD 
145 
The city child in a well-to-do family is, as a rule, better off for eight 
months of the year in his own home with its usual conveniences. The 
benefits attributed to change in climate are usually the result of a change 
not of climate, but to more fresh air, which is afforded by the larger 
rooms of the hotel, with its loosely constructed doors and windows; and 
the fact that, since the parent is desirous that the child shall receive 
the full benefit of the change, he is kept in the open air for a much longer 
time than when at home. The air at such a place is more expensive, and 
consequently more appreciated than the air at home. With sufficient 
heat and proper ventilation we may make our own climate. It is not to 
be denied, however, that a change of residence for a few weeks, during 
March and April, from New York to Lakewood or Atlantic City, is some- 
times of advantage. 
From the first of June to the first of October the child should not 
remain in any large city if removal is possible. The humidity and the 
heat which may prevail for protracted periods during this time render the 
city unsafe, particularly during July and August. The seashore for the 
entire summer is not to be advised. The children who have been sent 
inland to the country and to the mountains have, as a rule, returned in 
the autumn in much better physical condition than those who spend the 
summer by the sea. 
Clothing.—Thin, poorly nourished children require more clothing 
than do those physically normal. A fairly good index as to whether 
a child is sufficiently clad is the condition of his lower extremities. The 
forearm and hand cannot be relied upon. The legs and feet of every child 
should always be warm to the touch. 
As clothing, a mixture of silk and wool next to the skin is most de- 
sirable. Although less desirable, a mixture of wool and cotton may be 
used. The linen mesh, often useful for the vigorous “runabout,” is not 
to be advised. 
Exercise is to be encouraged, but should never be allowed to the point 
of fatigue. In large cities all subnormal “runabouts” from three to five 
years of age should be allowed to walk not more than six blocks in going 
to the playgrounds. If the distance is greater, the child should ride part 
of the way, play or walk for a time, and then be placed in the carriage 
or cart and ride home. Younger children, two or three years of age, should 
be wheeled both ways and taken out at the park for a run when the weather 
conditions permit. 
Midday Nap.—Every day after the midday meal the child, regardless 
of age, whether two years or six, should be undressed and put to bed for 
two hours. He should be left alone in the room, and whether he sleeps 
or not he should remain in bed for the two hours. 
Entertainment.—Entertaining play is necessary, but every kind of 
excitement, such as children’s parties, emotional plays at the theater, 
and rough play with older children, should be avoided. 
Education.—The delicate child under eight years of age should be 
taught only to the extent of strict obedience and good habits. In other 
respects he should be a little animal. There should be no teaching in 
the ordinary sense of the term, no mental stimulation, until the child 
is physically able to bear it. When school-work begins, which in this 146 
THE PRACTICE OF PEDIATRICS 
class of children should never be before the eighth year, the studies should 
be made easy and the school hours short. Such children should never 
be forced and usually should attend only the morning session. 
The delicate child should be carefully watched from the time he 
comes into our hands until he reaches the normal, or until the period of 
development is completed. While the management as outlined will 
not always be attended with brilliant results, it will not be in vain. Many 
lives will be saved, and as a result of their increased resistance stronger 
men and women will be added to the race. 
Now and then one meets with a case among the well-to-do in which, 
because of prolonged faulty feeding or vicious heredity, the vital spark 
is so low that, fan it as we may, no impression upon it is made. As a 
rule, these stubborn patients are the offspring of alcoholism and debauch- 
ery. The patients are thin, anemic infants; they develop into thin, 
anemic children, and into thin, anemic adults. The subnormal and de- 
generate are found in all the walks of life, but thejr are especially numerous 
in dispensaries and in children’s institutions. 
Much of the work of the pediatrist is with the weakly of the so-called 
“better class.” His success in the management of these children depends 
largely upon the home co-operation, and a promise of this should be 
obtained before taking the case. The parents must be taught that the 
development of the intellect, the character, and the body go hand in hand, 
and that a vigorous intellect is rarely found without a vigorous body. 
They must be convinced that the body is more than a machine. It has 
delicate organs to keep in repair and supply with energy. It has a nervous 
organization; it has sensibilities. The normal exercise of all these func- 
tions demands the normal nourishment of the body. In our experience 
family co-operation is at times difficult to obtain. The parents have 
begun well, but soon tired of the extra work required. It is difficult to 
make the untrained mind appreciate the necessity of continuous careful 
attention to details in management. 
TARDY MALNUTRITION AND MALNUTRITION IN OLDER CHILDREN 
Malnutrition, associated with tuberculosis and syphilis, is not a part 
of our subject. 
In the sections on Malnutrition in Infants and Children it may be 
thought that there is repetition of what is said under the title of The 
Physically Subnormal Child. While the management necessarily is along 
the same lines, two distinct types of children are represented. The 
marasmic and malnutrition infant or young child may be but temporarily 
delicate. When he recovers he may develop into as normal a specimen 
of robust childhood as could be desired. The physically subnormal child 
as he has been described is inherently delicate, and our efforts are toward 
improving his condition, with the hope, perhaps, but with no great assur- 
ance, that he will some time become a robust adult. 
Tardy malnutrition is usually seen in children of the school age, 
although it may appear any time after the third j'ear. Such children are 
deficient in weight, in resistance to disease, and in capacity for work; 
they are pale, thin, tired children. TARDY MALNUTRITION AND MALNUTRITION IN OLDER CHILDREN 
147 
Etiology.—Cases of tardy malnutrition as well as those of marasmus 
and infantile malnutrition are seen in all the walks of life, among the 
wealthy, the so-called middle class, and among the poor. Strange as it 
may seem, these cases, regardless of the station of life, have two causes 
common to all, waste of energy and defective feeding. The scion of wealth 
who is overfed or badly fed—given food which is unsuitable and allowed 
the promiscuous use of sweets—may develop malnutrition just as effec- 
tively as the child of the tenement who subsists on fried meats, grocery 
milk, boxed breakfast foods, and poorly cooked vegetables. 
Most important factors in these cases are overwork—excessive energy 
output in school, at work, or at play—and inadequate rest. The child 
is active from early morning until bedtime at 7 or 8 o’clock. This entails 
waste of vitality and the organism suffers. Every child until the seventh 
year should have an after-dinner rest, sleep if possible, for one to one and 
one-half hours. There should be twelve hours of uninterrupted sleep at 
night. 
In all cases errors in the daily life of the patient will be most apparent. 
There is a painful lack of knowledge among all classes as regards 
the nourishment required by a growing child. He is fed to satisfy his 
appetite, and when this is accomplished, the parents believe that their 
duty is done. How far they fall short of proper feeding is demonstrated 
daily in out-patient clinics and in private work. 
Treatment.—The first step in the management of a case of tardy mal- 
nutrition is to make a study of the gastro-intestinal tract. A great many 
children develop errors in nutrition because of defective gastro-intestinal 
mechanics (p. 220), associated with ptosed stomach and faulty intestinal 
formation making for poor absorption and slow elimination. 
We have repeatedly seen children from five to ten years of age, with 
marked malnutrition, gain from 3 to 4 pounds the first month under 
treatment which consisted simply in inaugurating the midday rest and in 
giving food that they had a right to demand, properly prepared at definite 
intervals, providing, of course, that structural abnormalities have been 
corrected, in case they were found to exist. 
The school child suffering from malnutrition should be removed from 
school temporarily, and as much outdoor life as possible should be made 
available to him, regardless of his station in life. Everything of a strenu- 
ous nature should be avoided. He should be put to bed early and en- 
couraged to sleep late. A midday rest for one who shows marked emacia- 
tion and diminished resistance is absolutely essential. 
Illustrative Cases.—Case 1.—The following is quite a usual history of an advanced 
case of malnutrition in a girl, seven years of age, and the treatment is that which we 
usually employ: The mother brought the girl to the out-patient service at the New 
York Polyclinic because the child was pale, did not grow, and was always tired—too tired 
to go to school, of which she was very fond; too tired to play with other children, as 
had previously been her custom. Her weight was 41 pounds. No food was being taken 
except on compulsion. There was no evidence of congenital syphilis or tuberculosis. 
There was a secondary anemia. The child slept in a badly ventilated room; she drank 
tea and coffee. Cake, pastry, and sweets were her regular diet, and because she did 
not eat at mealtimes she was allowed to eat between meals whenever and whatever 
she pleased. The following mode of life and diet was prescribed: She was to sleep in 
the front room, known as a sitting room or parlor, with a window open at least 6 inches. 
She was given three meals a day writh nothing whatever between meals. The diet 
consisted of red meat once a day, 2 or 3 soft-boiled eggs daily, 1 quart of good milk 148 
THE PRACTICE OF PEDIATRICS 
daily if it agreed (and it did agree). She was to have only natural cereals, such as oat- 
meal, cracked wheat, and cornmeal—each of which was to be cooked three hours the 
day before it was to be given. Baked or boiled potatoes and one green vegetable were 
to form a part of the dinner at midday. Stewed and raw fruits and plain puddings with 
home-made bread and plenty of butter completed the dietary. She was put to bed at 
7 o’clock and arose at 7 the following morning. An after-dinner rest in a darkened 
room for an hour was insisted upon. Before retiring she was given a brine bath (p. 
843), followed by brisk drying with a rough towel, after which her entire body was 
rubbed for ten minutes with olive oil. In one month a radical change had taken place. 
She had gained 4 pounds in weight. Her color was good. She complained no more of 
languor or fatigue. She was eager for school. The improvement continued, and in 
ten weeks she made a perfect recovery. 
In not every case will results be so prompt and satisfactory. In some a longer 
time will be required before pronounced results are to be seen. Nevertheless, every 
child suffering from malnutrition of this type cannot help being benefited more or less 
by such a regime. 
Case 2.—A most pronounced case of this type was that of a boy, eight years of age, 
who presented a most dilapidated picture. He was tall for his age, very thin, pale, habit- 
ually tired, and had a well-developed habit-spasm. He was restless, active, and played 
hard when he was not too tired to play. His weight was 591 pounds. 
The living regime prescribed was as follows: He breakfasted at 7.30 a. m. He 
was to remain in bed until 10 o’clock in the morning, then be up and about at play as 
he wished. Dinner at 12.30 was followed by a rest, of one and one-half hours. Play 
was permitted without particular restraint until supper at 6.30. Bedtime was 7.30 
p. m. He improved rapidly and in one month was permitted to arise with the family. 
From October 12th to May 27th he gained in weight 191 pounds. 
We have treated a great many of these cases of malnutrition in older 
children in the same manner by limiting the energy output, and right 
feeding. A gain of from 2 to 6 pounds a month for the first month or 
two is the usual result of the treatment. At the same time there is a 
radical change in the child’s mental attitude and general appearance. 
Tonics.—The tincture of nux vomica, 4 drops in water before meals, 
is sometimes given to children whose appetite is defective. One grain 
of the citrate of iron and quinin in 1 dram of equal parts of sherry wine 
and water may be substituted. If there is secondary anemia and defective 
nerve resistance, the following prescription may be given, interrupted by 
five days free from medication. 
For a child five to ten years of age: 
Ib Liq. potassii arsenitis njjlxiv 
Liq. ferri albuminati 3iv 
Syr. hypophosphitum (calcis et soda;) 5iij 
Aquae q. s. ad, 5vj 
M. ft. Sig.—One teaspoonful after meals in water. 
During the five days without the medication cod-liver oil may be given. 
Laxatives.—If constipation is present, olive oil may be given in- 
ternally, 2 or 3 drams after meals. If the oil is not well taken, or if it 
disagrees in any way, its use should be discontinued. Liquid petrolatum 
(aromatic), in to 1-ounce dosage at bedtime, answers well. The dosage 
may be gradually reduced and later discontinued. 
ESSENTIALS IN THE CARE OF ACUTE ILLNESS 
A well child, regardless of the position he may occupy in the social 
scale, subscribes to a certain living regime, which should be so fashioned 
as to supply the requirements of nutrition and healthy growth, which 
means normal development. Thus, he is fed, clothed, and has the benefit 
of fresh air, exercise, and bathing. When he becomes ill his position tem- ESSENTIALS IN THE CARE OF ACUTE ILLNESS 
149 
porarily is changed, and in order for us to act to his best interest radical 
changes must be instituted in order to meet this changed condition as 
regards appetite, the digestive capacity, and rest. The great majority 
of the serious illnesses in children are acute in character. Vitality and 
resistance determine in no small degree the issue of the disease. Every 
child begins the illness with a definite number of strength units. We 
must so act as to conserve every strength unit. 
Our first duty, then, toward the sick child is to place him in the most 
favorable position to withstand the ordeal through which he must pass. 
Regardless of the nature of the disease, certain requirements must be 
fulfilled that apply to all severe illnesses, the general management of which 
in children is very similar. 
Patient to Be Kept in Bed.—The patient is to be kept in bed, not held 
on the lap. The handling of the child, the passing from one person to 
another, the attempt at entertaining, cause active excitement and waste 
energy when quiet is necessary. 
Quiet Attendants.—Attendants who are quiet and agreeable to the 
child should care for him. In serious disease states—pneumonia, endo- 
carditis, and the like—but one person, and that the attendant, should be 
allowed in the room at one time. 
Clothing.—The clothing should be the usual night clothing to which 
the patient has been accustomed in health. There is no illness that 
requires extra clothing for the body when the customary room tem- 
perature (66° to 68° F.) is maintained. Heavy shirts and oiled silk or 
cotton-wool jackets are never to be employed, regardless of the nature 
of the illness. 
In summer the lightest clothing should be used; for younger chil- 
dren a thin linen slip with the addition of a napkin is all that is required. 
Sponging.—The body surface is to be sponged once or twice a day for 
cleansing purposes, regardless of the nature of the illness. During the 
hot days of summer the sponging may be repeated several times with 
advantage. There is no disease of childhood in which the application of 
water to the skin is a dangerous procedure. On the contrary, it is quite 
necessary that the skin be so treated that it function actively. 
Room Temperature.—In winter the thermometer should never go 
above 70° F. Hot, ill-ventilated rooms depress the vital powers. The 
child is poisoned by carbonic dioxid; he is made restless and irritable. 
He uses up nerve force and energy is wasted. A room temperature of 
66° to 68° F. is best under most conditions. There are few households 
which cannot have a thermometer. 
Ventilation.—There must always be a communication between the 
sick room and out of doors. A convenient means of ventilation is the 
window-board (p. 26). 
Cold Air.—We are not inclined to advocate cold air to the extreme 
degree advised by some. A wide open window during illness, such as 
convalescence from acute pulmonary disease, is an excellent measure 
if the child is suitably protected by a hood and an extra outer garment. 
When possible, the patient should have the advantage of two rooms, one 
for use during the day and one for the night. This is of particular ad- 
vantage in grip and in the respiratory diseases in which there is a possi- 150 
THE PRACTICE OF PEDIATRICS 
bility of reinfection. The room which is not occupied should be aired 
continually. 
Drinking of Water.—There is no illness of childhood in which water 
to drink should not be given freely. If there is any question as to its 
purity, it should be boiled. 
Diet.—The digestive capacity of every sick child is lessened; this 
we all appreciate, the degree of incapacity depending largely upon the 
severity and nature of the illness. In every illness the food strength should 
be lessened. This we do not all appreciate. For breast-fed babies this is 
done by giving water, sugar-water, or some cereal decoction, as barley- 
water, before each nursing, in amount ranging usually from 2 to 3 ounces. 
This dilutes the mother’s milk. The nursing baby is satisfied when his 
stomach is full. He needs as much fluid as usual, but is unable to digest 
the usual amount of breast milk. For the bottle fed the food strength 
is reduced by substituting water for a given quantity of the milk mixture. 
A safe rule to follow is to reduce the food strength one-half by the addition 
of water. If the illness is a very severe one of intestinal disorder, whether 
typhoid fever or summer diarrhea, milk is to be discontinued absolutely, 
and usually cereal decoctions should be substituted. During a very severe 
attack of pneumonia or scarlet fever milk is to be also discontinued, and 
cereal gruels given. If the milk must be withheld for several days milk- 
sugar may be added to the cereal water substitute so that it shall con- 
tain 5 per cent, of milk-sugar. This is obviously to supply fuel for the or- 
ganism and spare the protein waste. When the usual feeding is continued 
gastro-intestinal infection is almost sure to add to the burden of the pa- 
tient through toxins absorbed from the putrefaction of undigested milk 
in the gut. The resulting tympanites is a very serious feature in respir- 
atory and cardiac diseases. Tympanites embarrasses the action of the 
overworked or diseased heart and interferes with respiration already suffi- 
ciently obstructed by the processes in the lungs or in the pleural cavity. 
The carbohydrates leave no by-products to be eliminated by the kidneys, 
thus lessening the work of these diseased organs, and perhaps preventing 
their involvement in such diseases as scarlet fever and diphtheria by 
diminishing the amount of irritation to which they may be subjected. 
In short, we must allow just as much food as the patient can care for. 
When we give more we diminish the chances of recovery through added 
toxemia or by interfering with the vital processes. 
Protection from Needless Interference.—Regardless of the nature of 
the severe illness we must conserve vitality by disturbing the patient as 
little as possible. The various attentions to the child should be given at 
distinct, but reasonably long, intervals. It is rare that a child will need 
food or medication oftener than once in two hours during the night— 
three hours answer in most cases. Food and medicine may be given at 
the same time. Not infrequently one sees cases in consultation where 
something is being done to the child every hour in the twenty-four. This 
would exhaust any well child. What can the effect be upon the very ill 
but to diminish chances of recovery? 
Urine Examination.—Nephritis is a complication, and a serious one, 
that may be looked for in all acute diseases of children. An early recog- 
nition of this complication is most important. Albumin in the urine is ESSENTIALS IN THE CARE OF ACUTE ILLNESS 
151 
one of the earliest signs of nephritis, and involvement of the kidneys 
may be discovered by urine examinations before any of the other signs 
of nephritis appear. It is a wise custom in scarlet fever and diphtheria, 
diseases peculiarly liable to nephritic involvement, to examine the urine 
daily—in other acute diseases with fever, at two- or three-day intervals. 
This examination is simplified by writing a prescription for 1 ounce of 
nitric acid (c. p.) and a few test-tubes, which are kept in the sick room. 
The cold test is sufficient to detect the smallest trace of albumin. When 
the physician must carry the urine with him or have it sent to his home, 
the examination is sometimes postponed or otherwise neglected. 
Bowel Function.—Every nurse or mother is given a standing order 
that there is to be one evacuation of the bowels daily, and if this does 
not occur naturally, an enema must be given. 
Bowel Feeding.—In conditions of collapse in any illness, in coma, 
and certain gastric disorders particularly, sufficient nourishment cannot 
be given by the stomach. When such a condition obtains, regardless of 
the illness, we must resort to colonic feeding (p. 97). 
Measures to Prevent Suppression of the Urine.—Suppression of the 
urine is not an unusual occurrence in pediatric practice, and may occur in 
a wide range of diseases. One of our most successful means of combating 
this condition is the use of colonic flushings. 
Prevention of Pyrexia.—High temperature in children, regardless of 
the nature of the illness, is to be managed by the same methods. The 
most satisfactory has been the abstraction of heat through the means of 
hydrotherapy, in the use of sponging and packs (pp. 840-841). It is a pop- 
ular belief among laymen that cold should not be used in scarlet fever or 
measles because of some unfavorable influences on the rash. There 
is no disease of childhood with temperature in which the application of 
water to the skin does harm. One may use spongings and packs in scarlet 
fever exactly the same as in pneumonia or typhoid fever. 
When is elevation of the temperature to be interfered with? What 
are the indications that necessitate interference? When we have a degree 
of temperature that causes restlessness, loss of sleep, rapid heart action, 
with resulting loss of vitality—i. e., wasted energy—then measures to 
effect reduction should be instituted. This will be necessary in some cases 
at 103° F.; in others at 105° F. In other words, we should be governed 
largely by the effects of the temperature upon the individual and not by 
the reading of the thermometer. If sponging is employed, it is advisable 
to use 1 part alcohol with 3 parts of water at about 80° F., the skin being 
repeatedly moistened with the solution, which is allowed to evaporate. 
In some cases such a procedure is soothing. In others it occasions no little 
annoyance, in which event it must not be used. 
Drugs.—Regardless of the nature of the disease, a full dose of castor 
oil is of benefit at the beginning of the illness. 
When drugs are used it is essential that no harm shall result. 
In any illness in a child one requirement is to keep on good terms 
with the child’s digestive tract. In our medication we must seek to 
protect the stomach. This may be done by giving much of the medi- 
cation after meals, using it by preference in capsules, powder, or tablet; 
or when it is administered between meals, by giving it well diluted with 152 
THE PRACTICE OF PEDIATRICS 
water. When liquid medication is necessary, elixir simplex in small amount 
is of value as a flavoring medium. Useless syrups are to be avoided. 
The worst possible custom is the using of heavy syrups for flavoring. The 
practice of giving the ammonia salts and ipecac, usually with syrup of 
tolu, to a child with severe bronchitis or bronchopneumonia is wretched: 
and this is putting it mildly. 
Stimulation.—Two criticisms of general application relate to the 
management of sick children. The first is that heart stimulants are used 
too early and in too large dosage. Second, antipyretic measures are 
resorted to when such management is not called for. We have already 
referred to the latter in stating that a child should not necessarily have 
antipyretic measures used because he has fever with pneumonia, typhoid, 
or scarlet fever. Neither does he require stimulation because he has ty- 
phoid or scarlet fever or pneumonia. Regardless of the nature of the ill- 
ness, our choice of stimulants is very much the same, and our reason for 
using them is exactly the same—to assist a heart that needs help. (The 
employment of heart stimulants will be discussed in detail under proper 
headings in the different chapters.) 
It will be seen from the foregoing that the treatment of different 
diseases of children has many features in common, and these essentials 
must be appreciated by every man in order that he do the best work in 
treating children. 
If there is one thing that has been impressed upon those engaged 
in children’s work, it is the necessity of completeness of detail in manage- 
ment. We little realize how sensitive the sick child is, how all nervous 
effort, all untoward influences, cost something. They cost energy and 
output of vitality which may be sufficient at times to preclude recovery. 
Family co-operation is necessary for success, and will be best obtained 
through the confidence and affection engendered by thorough, painstaking 
work on the part of the physician. 
The Sick Room.—If there is a choice of rooms for the patient, the size 
of the room and the means of ventilation are important points to be con- 
sidered in the selection. During cold weather a room with southern ex- 
posure, to which the sun has free access, should be chosen. During the 
hot months of summer, however, the cooler the room, the better, pro- 
vided the size and ventilation are satisfactory. The furnishings should 
be of the simplest, only those articles being allowed to remain which are 
required for the patient. So many of the ailments of childhood are of 
an infectious nature that only such articles of furniture as can be washed 
should be used. Curtains, hangings, and plush furniture have no place 
in a sick room. A plain wooden floor is much better than one that is 
carpeted. Enameled beds and plain wooden or enameled chairs and 
fables are best. A painted wall is much better than a papered one. A 
fireplace is desirable not only for heating purposes but also for ventila- 
tion. 
A child ill in a dirty, badly ventilated, overfurnished, overheated room 
is from the first at a decided disadvantage. 
The Window-board.—The value of this simple device in the sick room 
may readily be appreciated. For a description the reader is referred to 
p. 26. ESSENTIALS IN THE CARE OF ACUTE ILLNESS 
153 
Written Directions.—If possible, directions for the care of sick children 
should be given outside the sick room, so that the physician may have the 
undivided attention of the mother or nurse. These directions should first 
be given orally and thoroughly explained, and then written out in detail. 
When the child is crying, and two or three onlookers are talking, the mother 
or nurse becomes confused and is almost sure to misunderstand or forget 
important directions. 
If there is not a trained nurse in charge, the doctor should show the 
mother or nursery maid how to perform the various offices for the child. 
One can in a few moments be taught how to read the clinical thermometer, 
how to give a sponge-bath and an enema, and how to do many other 
things which the changed condition of the child requires. The use of a 
croup kettle, which may be needed for croup or bronchitis, should always 
be explained. 
The printed form as given below has proved very useful not only in 
making the directions absolutely plain and unmistakable but also as 
a great time-saving measure. The expense of printing is but a trifle. 
Form A represents the front of the slip. A few minutes only are required 
to fill in the blank spaces. Form B represents the back of the slip; on this 
the observations of the preceding twelve or twenty-four hours are entered. 
One chart may be made to answer for twelve or twenty-four hours, and 
when the case is finished constitutes a complete record secured with the 
expenditure of little time and labor. 
FORM A 
Date Name Age Disease 
ORDERS 
Food. 
Temperature to be taken every hrs. 
1 every hrs. 
2 every hrs. 
3 every hrs. 
Whisky every hrs. 
Brandy every hrs. 
Steam Inhalations every hrs. 
using 
Sponge Bath for. . .min. every. . .hrs. 
at.... ° F. if Temp, reaches . . . . ° F. 
Cool Pack to be given if Temp, reaches 
. . . . ° F., and continued until Temp, 
falls to.... ° F., using water at....0 F. 
Spray Gargle Throat with 
every. . . .hrs. 
Irrigate Throat with 
every.... hrs. 
Irrigate Ear with 
at. . ° F. every.... hrs. 
Irrigate Colon with 
at. . ° F. every.... hrs. 
Counterirritation with 
Mustard. . . .parts 
Flour parts 
to every.... hrs. 
Give Enema of Soapsuds 
Saline at....°F. 
at. . . .o’clock if necessary. 
FORM B 
Date 
CLINICAL NOTES 
... ... ... ... ... . . hour. 
Temperature ° F. ° F. ° F. ° F. ° F. ° F. 
Pulse 
Respiration 
Sleep 
Skin 
Tongue 
Throat 
Lungs 
Heart 
Abdomen 
Nervous Symptoms 
Special Symptoms 
Nourishment 
Vomiting 
Stools, No. in twenty-four hours 
character 
Urine, amount, oz., in twenty-four hours. 
Blood 154 
THE PRACTICE OF PEDIATRICS 
DIET DURING ILLNESS 
The extent to which the digestive capacity of every child is diminished 
during illness depends largely upon the age of the child and the severity 
of the disease. The younger the child, the greater the incapacity. This 
is fairly constant with all the ailments of childhood, including, of course, 
those which directly affect the gastro-enteric tract. 
Reduction in Food Strength. —In a moderately severe bronchitis, 
with a degree or two of fever, the digestive capacity is slightly diminished 
and a 25 per cent, reduction in the strength of the food will answer. 
During the critical stage of a lobar pneumonia the digestive powers 
are held in abeyance and predigested foods and exceptionally alcohol 
must sustain the patient. During an attack of measles, scarlet fever, 
bronchopneumonia or diphtheria in a bottle-fed infant, at the height of 
the disease, it is a good custom to reduce the strength of the food one-half 
by the addition of water, to make up for the quantity removed. For ail- 
ments of lesser severity, such as bronchitis, with a temperature of 100° 
to 101° F., or chickenpox, or mild measles, one may reduce the strength 
of the food from one-fourth to one-third. In the event of any mild ail- 
ment or injury which confines a child to his bed, the food strength should 
be cut down, for inactivity as well as disease lessens the digestive capacity. 
Among nurslings and the bottle fed these precautions are particularly 
necessary. A child with fever is apt to be thirsty and to take more fluid 
than in health. This is frequently the case during summer diarrhea. In 
order to prevent taking too much food, one should not only order that 
the milk be diluted for the bottle fed but also instruct the mothers of 
nurslings to give a drink of water immediately before each nursing and 
between nursings, and then to allow the child to nurse only one-half or 
two-thirds the usual time. For the bottle fed, one-half to one-third the 
contents of each bottle is to be removed and the quantity replaced by 
boiled water, so that the amount of fluid given remains the same. 
If a child is a “runabout” over two years of age he may be given broths 
and thin gruel—one-half milk and one-half gruel. By carefully watching 
the stools, thus fitting the food to the child’s capacity, we may avoid 
grave intestinal complications which, during the summer, often prove to 
be more serious than the original ailment. In the acute gastro-enteric 
infections and in typhoid fever all milk must at times be discontinued. 
The dietetic management of the acute intestinal diseases and typhoid 
fever is referred to in detail under the respective headings. 
The Art of Feeding in Illness.—Not only is food often taken in in- 
sufficient quantity in illness, but in many cases it is absolutely refused. 
In other cases, during coma and asthenic states, swallowing is impossible. 
In delirium and in conditions of collapse nourishment must be given, and 
when this is impossible by the natural method we have, as temporary 
substitutes, gavage, rectal feeding, and such expedients as intravenous 
infusion. 
Forcing the child to take nourishment by the mouth is rarely neces- 
sary. Coaxing and bribing ordinarily succeed far better. For a child 
from three to five years of age a bright new penny possesses much per- 
suasive power. The child will usually take food better from one to whom TREATMENT OF THE INDIVIDUAL 
155 
he is accustomed, like the mother or nursery maid. The trained nurse 
should understand that while she is unacquainted with the patient, the 
simpler needs of the child are to be looked after by others to whom the 
patient is accustomed. 
The nourishment should be as palatable as possible and served in 
bowls, cups, or plates that are attractive to the patient because of color, 
pictures, or peculiarities of shape. Junket flavored with vanilla, served 
cold, is a favorite food for sick children of the “runabout” age. Frozen 
custard and home-made ice-cream, made with one-third cream and two- 
thirds milk, will usually be well taken. Toast, dry bread, and crackers 
made in peculiar shapes are attractive to the child. In not a few cases we 
have succeeded in feeding satisfactorily children two or three years old, 
when several other schemes had failed, by allowing the temporary return 
to the bottle, from which they had been weaned for a year or so. 
In these difficult feeding cases the child’s peculiarities and wishes 
must be studied. Children in illness require water, but frequently take it in 
insufficient quantities. Those who refuse plain water wall often take 
ginger ale, sarsaparilla, or vichy. If these drinks are well taken, they 
may be given freely. In the acute infectious diseases, especially pneu- 
monia, free water drinking is a therapeutic measure of no mean value. 
TREATMENT OF THE INDIVIDUAL 
In these days of specialization one is sometimes impressed with the 
fact that there is a tendency for the patient, the individual, to be lost 
sight of, to be overshadowed by the immediate disease or condition from 
which he may be suffering. With children the success of the treatment in 
practically every chronic ailment depends upon the vitality of the indi- 
vidual patient and his powers of resistance as a whole, to a much greater 
degree than is the case with the adult. 
The object of taking up this subject is not to be unkindly critical, but 
to call attention to one phase of management which is not sufficiently 
appreciated by many who have to deal with children in their professional 
work. 
Not at all infrequently poorly conditioned children, who have been 
treated for months by local measures for a skin affection, recover without 
any local treatment whatever (other than an attempt perhaps to relieve 
the itching) when their lives are ordered according to the requirements 
of the growing child as regards nutrition, bowel evacuation, sleep, suitable 
clothing, fresh air, and rational exercise. Cases of chronic rhinitis and bron- 
chitis which may have persisted for weeks respond promptly when local 
measures, sprays and douches, and the internal use of drugs are suspended 
and the child’s life is directed along rational lines. Those who treat tuber- 
culosis and chronic bone diseases, chronic otitis, chorea, and hysteria, are 
to be reminded -that their work is not half finished when they have directed 
the usual daily or weekly routine treatment. In these chronic ailments 
it is folly to expect what a cure really means (a constructive process) on a 
destructive diet and improper habits of life. 
Children possess marked recuperative powers, and the rapidity of 
progress toward recovery is often most gratifying when right conditions 156 
THE PRACTICE OF PEDIATRICS 
are instituted as relates to these fundamentals in child management, 
viz., food, sleep, clothing, and bathing. It is the height of folly to give 
children iron for anemia and allow them every form of indiscretion in diet. 
It should always be remembered that the best results are obtained in 
the treatment of a child, whatever the nature of his illness, when he has a 
child’s normal existence, and it is only under such conditions that' satis- 
factory results of treatment can be expected. IV. EXAMINATION AND DIAGNOSIS 
Knowledge of the Normal.—Before a student of diseases of children 
is shown a sick child he should be made thoroughly familiar with the 
normal child of approximately the following ages: under three months, 
one year, three years, five years, and ten years. 
The student should learn the normal appearance of the eyes, ears, 
throat, skin, genitals, and the character of the stools of the various ages. 
He should be instructed in the examination of the liver, spleen, abdomen, 
heart, and lungs. 
One who teaches diagnosis in children in postgraduate work is repeat- 
edly impressed with the handicap under which many physicians work 
because of a very indifferent conception of the normal. 
Without sufficient ability to examine the canal and drum of the ear, 
and to know the possibilities for variations within the normal, it is futile 
to attempt the recognition of disease processes. 
Many physicians expert in pulmonary diagnosis in adults are wholly 
unable to make out even approximately diseased conditions in the lungs 
of infants and young children. These are all conditions that cannot 
be taught in a didactic way. Neither can one learn much of the subject 
through reading. What is required is the examination of the normal infant 
or young child—not a few examinations, but a very careful routine ex- 
amination of many infants and young children. Most difficult to deter- 
mine is the borderland between normal and diseased processes, as 
evidenced by physical signs. 
Diagnosis in children requires ability to estimate the condition as a 
whole. The fact that the patient cannot describe his symptoms is of more 
advantage than detriment. The child appears in the perfectly natural 
condition, without attempt to mislead, with no preconceived ideas or the- 
ories. In other words, the child, unless alarmed, is always natural, always 
himself; this is a very definite aid. Further, the young child has no 
imagination. He is never hypochondriac. Instead of giving the im- 
pression that he is more ill, he is liable to be judged less ill than he really 
is because of his activities and disinclination to give up. This tendency 
to remain active may be misleading. When, therefore, a child appears 
very ill, while the condition may not be dangerous, we may always know 
that he feels very badly. 
Physicians who wish to become expert in diagnosis must first learn 
the normal child from birth until he passes into the adult. 
First Examination.—Upon being called upon for the first time to see 
a patient, it is an essential custom in every case to take a history. Below 
is a copy of a blank history record which has proved of value. Form A 
represents the front of the slip. Form B represents the back of the same 
slip. Further records are kept on plain ruled sheets of the same size— 
5 by 8 inches. 
157 158 
THE PRACTICE OF PEDIATRICS 
HISTORY RECORD 
FORM A 
Date Address Name 
Mr- Age 
Family History Children living Ch. dead Cause 
Rheumatism Tuberculosis Syphilis 
Nervous Dis. Alcohol, tea, etc. Miscarriages 
Personal History child, born at Labor Wt. at B. lb. 
Sat up at mo. Talked at mo. Teeth at mo. Walked at mo. 
General Health and Habits 
Appetite Eats between meals? Tea, beer, etc.? 
Bowels Bath Fresh air 
Sleeps from to ; and from to . Snores? Mouth Br.? 
Previous Diseases Meas. Wh. Cg. C-pox Scarlet. Diphth. 
Mumps. Sm-pox. 
Gastro-enteric 
Respiratory 
Ear Throat Colds 
Diet from Birth Nursed 
Present History 
FORM B 
Examination 
Weight lh. Height in. Circ. Head in. Circ. Chest in. 
General Condition Color Muscles Reflexes 
Mentality Sits? Walks? Talks? 
Head Fontanel Sutures Craniotabes 
Eyes Nose Disch. Breathing 
Mouth Tongue Muc. Memb. Teeth 
Throat Tonsil Adenoids 
Lymph-nodes Ears Epitrochlears 
Thorax Shape Rosary Groove 
Heart 
Lungs 
Abdomen Umbilicus liver Spleen 
Genitals Skin 
Extremities Epiphyses Contour Feet 
°P. R. Blood R.B.C. Hb. % W.B.C. 
Urine React. S. G. Alb. S. Ind. Ace. Mic. Exam. 
When the history is completed the leaves are placed in a Moore 
loose-leaf binder. 
The patient’s family history is to be carefully taken. The habit of ob- 
taining a complete and accurate record of family peculiarities in relation 
to disease is often of much service, subsequently, if not at the time. Only 
upon systematic questioning will necessary facts be brought out relating 
to tuberculosis, rheumatism, and syphilis. The child’s personal history 
includes the birth weight, the rate of growth, the nature of previous 
illnesses, present weight, the condition of the skin, eyes, nose, heart, lungs, 
tongue, bowels, bones, and the temperature. All these points are noted 
and recorded. It is only by such an examination, requiring much time 
and patience, that we are able to become thoroughly acquainted with the 
case in hand. 
The child must be stripped for the examination. The conditions found 
are then entered in the proper spaces in the history chart. After the 
family history has been taken and the general physical examination is 
completed, we are in a position to devote ourselves to the present condi- 
tion of the patient. After one has practised for a time, thoroughly ex- EXAMINATION AND DIAGNOSIS 
159 
amining every new case, he is impressed not only with the value of the 
method as bearing upon the management of the condition in question, but 
also with the unexpected pathologic findings in perhaps other organs, 
particularly the heart, throat, and lungs. 
Diagnosis by Inspection.—We must learn the appearance and bodily 
habit of the child under normal conditions. Thus the baby of a few weeks 
cries when hungry, and with inco-ordinate movements of the arms and 
legs expresses his discomfort. With colic or pain of any nature he also 
cries, and with inco-ordinate movements of hands and legs makes known 
his discomfort. But the child’s manner of crying and the movements of 
the body are in no way alike. A baby spoiled and who wants to be taken 
up also makes a great ado, and yet he acts vastly different than when 
he is in hunger or pain. 
All the above manifestations are vastly different from the cry and 
the arhythmic movements of early meningitis. 
The position in which the child rests in bed often supplies us with 
very good evidence as to the nature of the trouble. Thus one position 
is assumed in meningitis, another in paraplegia, and another in scurvy or 
poliomyelitis. The countenance or the facial expression may be indicative 
of the disorder. The anxious, flushed countenance of acute pneumonia, 
with the dilatation of the alee nasi and the rapid breathing and grunt, are 
all strongly suggestive. The sunken eyes, the expressionless countenance, 
the ashy pallor, the superficial breathing, all characterize the appearance 
of the patient with intestinal toxemia. 
The diagnosis of malnutrition and marasmus is always stamped on 
the countenance. In cretinism, in Mongolian idiocy, in microcephaly, 
and other forms of mental deficiency the name of the disorder is written 
on each countenance, and for diagnosis we need go little further. 
The blue-white skin of anemia, the pallor of nephritis, with the fulness 
about the eyes, are often diagnostic in themselves. Among the trans- 
missible diseases, measles, mumps, and chickenpox are readily diagnosed 
by inspection. In scarlet fever, also, inspection is our greatest aid. 
In hemiplegia the quiet arm and leg, with the other arm and leg in 
motion, are strongly suggestive as to the nature of the trouble. 
The only way in which whooping-cough may be positively diagnosed is 
to watch the child during a paroxysm. 
By inspection we can fairly accurately determine the existence of 
acute laryngitis or membranous laryngitis. As mentioned elsewhere, 
the obstruction in acute laryngitis is inspiratory, while in membranous 
laryngitis it is both expiratory and inspiratory. 
The position of the head, the dysphagia, and the peculiar cracked 
voice mark retropharyngeal abscess. The method or peculiarities of 
locomotion supply most valuable evidences of Pott’s, hip, or other bone 
and joint disease. In tetany, the “accoucheur’s” hand, and the feet in 
extreme extension, are all that are necessary for diagnosis. 
The yellow conjunctive and the tinted skin indicate jaundice. In 
the skin diseases or skin manifestations of any nature inspection again is 
an important means of diagnosis. 
The facial expression due to adenoids is so characteristic that every 
text-book contains a photograph demonstrating the “adenoid face” (p. 111). 160 
THE PRACTICE OF PEDIATRICS 
Laryngismus stridulus, convulsions, tonsillitis, rachitis, scurvy, and 
stomatitis are all diagnosed by inspection. 
It will readily be seen what a great aid in diagnosis is possessed by 
the physician who has trained powers of observation. 
Inspection During Sleep.—It is of advantage to observe many chil- 
dren when they are asleep and beyond all the influences of their sur- 
roundings. In not a few cases correct respiratory observations are possible 
only when the child is asleep. V. MORTALITY AND MORBIDITY 
All figures from which statistical studies can be made with reference 
to the etiology of disease and the relative importance of the different 
causative factors are dependent upon accurate tabulation of births and 
deaths. Only in the more highly developed nations is the recording 
of vital statistics carried out with requisite accuracy, and even in 1920 
the death registration area of the United States comprised all of only 
33 States; and the birth registration area (established in 1915) only 23 
States. 
Except in the case of the reportable diseases, and then only when the 
records of a community are kept fairly complete, we still have incomplete 
data for the study of the incidence of diseases which seldom prove fatal. 
Many facts, however, are readily obtainable through the United States 
Census Bureau records and the reports of health departments in large 
communities. The physician should keep informed concerning those 
facts which are fundamental. In the preparation of the following para- 
graphs compilations by Dr. Philip Van Ingen, of New York, have been 
freely employed. 
The death-rate for the first year of life in spite of intensive infant 
welfare work averages 96.6, while the crude death-rate is 14.6, only 
one-seventh as high. If the figures for the United States Army in the 
recent war be taken for comparison, a baby’s risk of life during the first 
year is disclosed to be eight times as great as that of the soldier for a 
corresponding period. 
From 20 to 30 per c ent. of the infant mortality is ascribed to acci- 
dents at birth or defective developmental conditions operative in the 
first month of life. No stronger argument could be cited to emphasize 
the need of responsible obstetric attendants, to say nothing of prenatal 
care. 
The following table includes for purposes of comparison the leading 
disease groups important in determining the mortality of infancy: 
PERCENTAGE OF INFANT DEATHS AT VARIOUS AGES UNDER ONE 
YEAR FROM CERTAIN CAUSES 
Infectious 
diseases. 
Respiratory 
and influenza. 
Diarrheal. 
Develop- 
mental.1 
All others. 
First quarter 
3.06 
11.04 
12.46 
60.99 
12.45 
Second quarter 
9.26 
30.60 
47.41 
11.61 
1.42 
Third quarter 
11.42 
31.39 
38.59 
5.05 
13.57 
Fourth quarter. . . . 
15.66 
32.97 
34.75 
5.18 
13.44 
(Five-year Averages—Death Registration Area) 
Of all the deaths occurring in infancy three-fifths occur in the first 
quarter and nearly half in the first month of life when the youthful or- 
ganism is subjected to conditions previously inexperienced, with the 
added handicap of embryonic defect or birth injury. 
1 Including accidents. 
161 162 
THE PRACTICE OF PEDIATRICS 
PERCENTAGE OF INFANT DEATHS AT VARIOUS AGES UNDER ONE 
YEAR 
Under one day 15.7 
First week 31.3 
Second week 6.2 
Third week 4.4 
Fourth week 3.5 
(Five-year Averages—Death Registration Area) 
First month 45.5 
Second month 8.7 
Third month 6.9 
First quarter of year 61.1 
Second quarter “ 16.2 
Third quarter “ 12.5 
Fourth quarter “ 10.2 
The following table shows the part played by various diseases in the 
mortality of the first year taken as a whole: 
PERCENTAGE OF INFANT DEATHS DUE TO VARIOUS CAUSES 
Typhoid 0.04 
Measles 0.96 
Scarlet fever 0.08 
Pertussis 2.45 
Diphtheria 0.53 
Erysipelas 0.46 
Tetanus 0.20 
(Five-year Averages—Death Registration Area) 
Influenza 2.98 
Tuberculosis: 
All forms 1.35 
Pulmonary 0.47 
General and men- 
ingeal 0.64 
Abdominal 0.11 
Other forms 0.13 
Bronchitis..' 2.19 
Bronchopneumonia. . 8.68 
Pneumonia 4.43 
Gastro-intestinal. . . .20.01 
Congenital malforma- 
tions 6.45 
Prematurity and con- 
genital debility.. . .20.26 
Injury at birth 3.72 
Syphilis 1.03 
In the study of age groups after the age of one year we are handi- 
capped by the lack of census tabulations of the figures for population 
by age groups. Until such tabulations are available mortality statistics 
give only an idea of the relative importance of various diseases as causes 
of death, and in what period of child life they have the maximum influence. 
PERCENTAGE OF TOTAL DEATHS AT STATED AGES DUE TO CERTAIN 
CAUSES 
Under 
one 
month. 
One 
month 
and 
under 
one 
year. 
Second 
year. 
Third 
year. 
Fourth 
year. 
Fifth 
year. 
Sixth 
to tenth 
year. 
Measles 
0.15 
1.67 
5.14 
4.60 
3.85 
2.99 
2.28 
Kcarlet fever 
0.01 
0.13 
0.68 
1 .71 
2.46 
2.94 
2.71 
Diphtheria 
0 13 
0.88 
4.37 
9.15 
12.70 
14.33 
12.29 
Pertussis 
0.38 
4.20 
5.05 
4.17 
3.25 
2.53 
1.32 
Tuberculosis (all forms). . . 
0.18 
2.58 
4.91 
5.92 
6.27 
6.57 
7.41 
(Jastro-intestinal 
5.0 
34.70 
26.55 
14.45 
8.90 
6.15 
3.5 
Bronchitis 
1.10 
3.02 
2.01 
1.50 
0.98 
0.83 
0.35 
Bronchopneumonia 
3.16 
13.36 
13.55 
10.56 
7.70 
6.23 
3.93 
Pneumonia 
1.59 
6.85 
9.03 
9.07 
8.23 
7.92 
7.52 
Influenza 
0.86 
4.78 
8.54 
10.96 
11.68 
11.63 
11.19 
Meningitis 
0.25 
1.39 
1.86 
2.61 
2.51 
2.65 
2.52 
Nephritis 
0.62 
0.71 
1.19 
1.56 
1.70 
2.14 
(Five-year Averages—Death Registration Area) 
As a factor in the mortality of infants and children measles is most im- 
portant in the second year; its greatest influence is during the second, 
third, and fourth years. MORTALITY AND MORBIDITY 
163 
Scarlet fever steadily increases in importance with age, reaching its 
maximum in the fifth year. 
Diphtheria, like measles, becomes important during the second 3rear 
and steadily increases through the fifth year. 
Pertussis becomes important after the first month of life and reaches 
its maximum in the second year. 
Tuberculosis steadily increases with each period. 
Gastro-intestinal disease is of greatest importance after the first 
month throughout the first and second years. 
Bronchitis and bronchopneumonia as causes of death exert the greatest 
influence during the period from one month to two years of age. 
Nephritis shows a steady increase in importance with age. 
The influence of scarlet fever on the incidence of nephritis indirectly 
affects the mortality figures for the latter disease. 
Through the agencies working to promote better understanding of 
infant feeding, better obstetrics, and what may be designated by the 
general term “improved baby hygiene,” a rapid reduction in infant mor- 
tality in many communities is being obtained. New York City has well 
illustrated the effectiveness of work along this line. 
TABLE SHOWING REDUCTION IN INFANT MORTALITY RATE IN NEW 
YORK CITY—PROGRESSIVE AVERAGES1 
1910. 
1911. 
1912. 
1913. 
1914. 
1915. 
1916. 
1917. 
1918. 
1919. 
Percent. 
changes. 
Scarlet fever 
0.36 
0.30 
0.27 
0.19 
0.15 
0.10 
0.07 
0.06 
0.04 
0.04 
-88.8 
Gastrointestinal 
39.40 
35 35 
32.01 
27.02 
24.42 
23.61 
22.28 
21.92 
19.52 
18.45 
-53.2 
Diphtheria 
1.57 
1 .35 
1 13 
0.97 
0.96 
1.03 
1.04 
0.98 
0.84 
0.78 
-50.4 
Measles 
1 .67 
1.50 
1.33 
1.41 
1.32 
1.19 
1.12 
1.15 
1.25 
1.01 
-39.8 
Tuberculosis 
2.31 
2.36 
2.23 
2.15 
1 95 
1.94 
1 .88 
1.87 
1.80 
1.67 
-27.5 
Respiratory 
25.95 
26 06 
24 00 
23.38 
22.06 
21.46 
20.43 
19.88 
20.43 
19.40 
-25.2 
Development 
28.78 
29.63 
30.32 
30.75 
30.43 
29.95 
28.75 
27.41 
26.97 
26.91 
-6.5 
Injuries at birth .... 
3.12 
3.31 
3.48 
3.62 
3.82 
4.01 
4.17 
4.17 
33.4 
Pertussis 
i.14 
1.38 
1.22 
1.31 
1.19 
1.34 
1.31 
1.52 
1.77 
1.53 
34.1 
Infant mortality 
rate 
127 
122 
114.0 
106.0 
101.0 
99.0 
96.0 
92.0 
91.0 
87.0 
31.5 
Neonatal 
39.7 
38.7 
37.7 
36.7 
36.3 
36.3 
36.7 
36.0 
9.3 
1 These figures are progressive averages. A fairer idea of progress is obtained by averages than by 
figures for single years—“Progressive Averages” are averages for three consecutive years, the last figure 
in each group of 3 being consecutive. Thus 1910 is three-year average 1908-10; 1911 is three year aver- 
age 1909-11, etc. 
Throughout this book under the heading “Prognosis” an attempt 
is made to give some idea of the influence of various specific conditions 
to which the patient is subjected upon the chances of recovery from a 
given disease. Only by bedside observation coupled with a knowledge 
of probabilities dependent on statistical studies is the ability to make 
fairly accurate prognosis acquired. VI. THE NEWBORN 
Premature and Congenitally Weak Infants 
Comparatively few infants born before the completion of the twenty- 
eighth week of pregnancy survive the first year. Reported cases of sur- 
vival of those born before that time are usually unreliable, as the reports 
seldom follow the child beyond the third month. The prognosis is in- 
fluenced by the factors causing the premature birth. If syphilis is present, 
the child may survive but a day or two. Children whose births are forced 
because of kidney disease in the mother do not appear to do as well as 
others. In children’s institutions we have treated a large number of 
premature infants and have had anything but brilliant results with 
them. They not infrequently live to be two, three, or four months of 
age or older, but on account of reduced vitality they readily succumb to 
the slightest ailment, a mild bronchitis or fermentative diarrhea being 
sufficient to terminate their existence. 
In the management of the premature and delicate newborn there 
are four points to be considered—the air the child gets to breathe, the 
nourishment, the maintenance of bodily heat, and the danger of infec- 
tion. It is also to be remembered that we are dealing with an unde- 
veloped body which is not ready for the environment in which it is placed. 
The premature baby should be handled only when necessary, and then 
in the gentlest manner. Bathing is often best omitted for the first few 
weeks, oil being used for cleansing purposes. Because of the undeveloped 
parenchyma of the lungs unusually good fresh air is required. Because 
of the undeveloped heat centers the body heat of these infants is quickly 
lost and must be maintained by artificial means. The stomach is small 
and the digestive processes are undeveloped and weak, so that the nour- 
ishment should be of the most easily assimilable character. 
Artificial Heat.—The maintenance of heat is of the utmost impor- 
tance. For this purpose incubators and their various modifications 
have been used from time to time. They may, under careful watching, 
maintain an even temperature, but practically all have been defective 
in supplying fresh air to the child. Incubator babies invariably are prone 
to do badly. 
The padded crib with the child wrapped in cotton and surrounded 
by hot-water bottles is a safe means of maintaining the temperature. 
A thermometer should rest between the cotton and the bed-clothing 
as a guide to the nurses in the use of the hot-water bottles. Ordinarily 
this should register between 85° and 90° F., depending upon the tem- 
perature of the child, whose rectal temperature' should at first be taken 
frequently. If there is a tendency for his temperature to be greatly re- 
duced—below 95° F.—more external heat will be necessary than if his 
temperature is 97° or 98° F. Various beds and devices on the market 
for the premature are rather fanciful affairs, but of no greater service than 
those perhaps more crude. Means and methods complicated in char- 
164 PREMATURE AND CONGENITALLY WEAK INFANTS 
165 
acter are to be avoided in treating children in the home. Thp best means 
of maintaining adequate warmth without sacrifice of ventilation is afforded 
by the premature ward of a hospital. 
Room Temperature.—The temperature of the room should be main- 
tained at about 80° F., and not under 75° F. 
Fresh Air.—Suitable ventilation may be secured by the window- 
board device (p. 26). 
Absence of Infection.—Only the nurse and rarely the physician should 
be allowed in the room. Infection of any nature is a very serious matter. 
The family generally, and visitors always, should be excluded from the 
presence of the premature. * 
Feeding of Premature Infants.—Breast milk for pre- 
mature infants born under twenty-eight weeks is almost 
a necessity, and should always be procured when pos- 
sible for all premature children. The mother, with the 
rarest exception, is unable to supply it, so that a wet- 
nurse should be secured. In selecting a wet-nurse for a 
premature baby it is advisable to take the wet-nurse’s 
baby also, as the premature infant may not be able to 
nurse, or if he nurses will not take all the milk. Pumping 
the breasts of a wet-nurse will almost invariably dry 
them up if her own baby is not with her to furnish the 
necessary stimulation of nursing. Sufficient milk may be 
removed by the breast-pump to supply the premature 
infant if he is unable to nurse, and the wet-nurse’s 
baby will empty the breast. For premature babies who 
refuse the breast or are unable to take a nipple, the 
Breck feeder (Fig. 19) may be used as a means of giving 
nourishment; or gavage (p. 853) may be brought into use. 
To this we are obliged to resort in rare cases. The Breck 
feeder consists of a graduated glass tube, narrowed at 
one end. Over this end is placed a small rubber nipple, 
the other end being closed by a flexible rubber cap. 
Suction on the nipple is aided and encouraged by press- 
ure on the air-filled cap. 
If the breast milk proves too strong, it may be diluted with equal 
parts of a 6 per cent, sugar solution, from \ to 1 ounce of the mixture 
being given at first at intervals of from one to one and one-half hours. 
Fourteen to fifteen feedings may be given in the twenty-four hours, the 
amount depending upon the child’s digestive ability. 
If human milk is not obtainable, whey made from whole milk may 
be given, the nutritional equivalent of which is approximately 1 per 
cent, fat, 1 per cent, protein, 3.5 per cent, sugar; or 1 ounce of gravity 
cream may be given with 1 ounce of milk-sugar and 15 ounces of water, 
which affords a nutritional equivalent of 1 per cent, fat, 5 per cent, sugar, 
and 0.3 per cent, protein. Evaporated milk (p. 78) is a useful means 
of feeding in these cases. The food strength is increased, the intervals 
are made longer, and the feedings larger as the patient proves able to 
assimilate the food. 
The premature child requires unusual advantages, and even when 
Fig. 19.—The 
Breck feeder. 166 
THE PRACTICE OF PEDIATRICS 
but one month premature, rarely “catches up” during the first year, 
sometimes not for two or three years. 
Diseases of the Newborn 
CEPHALHEMATOMA 
These tumors are usually situated at the site of the caput succeda- 
neum, and are composed of blood. Sometimes pressure of the forceps 
is accountable for their presence, but rarely can any injury be found. 
During a long and tedious labor the pressure on the blood-vessels of the 
scalp is increased, and this is thought to be an active cause in the for- 
mation of these tumors. Blood changes are also cited as a possible etiologic 
factor. The cause cannot be ascribed entirely to pressure against the 
presenting part, as we find cephalhematomata in breech as well as in 
vertex presentations. The hematomata are of three varieties, as shown 
by Fig. 20. 
Double cephalhematoma may exist. 
Pathology.—These tumors are generally situated over the parietal 
bones. The scalp may show small hemorrhages and ecchymotic areas. 
The tumor itself is composed of blood. Soon after birth the blood is 
btScalp 
■Periosteum 
S/iu-lL 
-Dura mater 
Fig. 20.—Varieties of cephalhematoma: a, Between scalp and periosteum; b, between 
periosteum and skull; c, between skull and dura mater. 
usually in a fluid state, while in later cases coagulation has taken place. 
The tumor may be infected with pus-forming bacteria and an abscess 
may result. 
Symptoms.—At a time varying from the first to the fifth day of life 
a tumor is seen occupying a position generally over the parietal bones. 
It is soft, gradually increases in size for about a week, and then dimin- 
ishes; infrequently a ridge develops around the outer border of the tumor, 
giving the sensation upon pressure of a depressed fracture. 
During the latter stage of the tumor a crackling sensation will be 
elicited on pressure by the fingers. There is no accompanying fever. 
The child shows no annoyance. The tumor does not pulsate. One must 
be careful not to confound this condition with scalp edema, as seen in 
fracture of the skull after severe traumatism. In uncomplicated cases 
the tumor gradually becomes smaller and smaller, until finally, after some 
five to twelve weeks, it disappears, sometimes leaving a slightly raised, 
uneven, bony base. 
Differential Diagnosis.—Encephalocele occurs along the lines of 
sutures or at the fontanels. Pressure may cause convulsions. With 
movements of respiration, the swelling may vary in prominence. 
Hydrocephalus.—The head enlarges as a whole, showing separated 
sutures and large fontanels. SCLEREMA 
167 
Caput succedaneum is edematous, does not fluctuate, and disappears 
on the second day. 
Depressed Fracture of Skull.—Depression exists and not a tumor. 
Prognosis.—In the uncomplicated cases the prognosis is usually 
good. The prognosis depends upon the amount of injury to the parts 
and the occurrence of any infection. Internal cephalhematoma with 
effusion is invariably fatal. 
Treatment.—These tumors are usually absorbed if let alone. Care 
should be exercised that no injury may happen to them during handling 
the infant. No dressing is necessary. In infected cases, where the forma- 
tion of an abscess has occurred, incision and drainage are indicated. 
HEMATOMA OF THE STERNOCLEIDOMASTOID 
This condition is the result of trauma which takes place during de- 
livery. The muscle is torn as the result of pulling by forceps or manipu- 
lation on the part of the accoucheur in the endeavor to bring down the 
after-coming head in breech cases. 
The injury consists in a rupture of the muscle-fibers and blood-ves- 
sels. A tumor forms within the muscle sheath, which may be small or 
large, involving the muscle structure in its entire width. There is al- 
ways an associated contraction of the muscle, which places the head 
in the wry-neck position, drawn toward the affected side. The tumor 
is usually located in the lower third of the muscle. Occasionally it is lo- 
cated immediately at the attachment to the clavicle. 
The tendency of these cases is toward complete recovery. The tumor 
is absorbed, but a shorter muscle is sometimes left, which holds the head 
in the characteristic position. 
Treatment.—It has seemed from the observation of a large number 
of cases that massage hastened the absorption of the tumor. The mas- 
sage should be practised for fifteen minutes three times a day. At the 
same time a moderate stretching of the muscle should be attempted by 
rotating the head toward the unaffected side and upward. 
All cases eventually make complete recoveries. 
SCLEREMA 
Sclerema neonatorum (Underwood’s disease) is a rare affection of 
early infancy characterized by progressive induration of the skin. 
Etiology.—The condition may be present at birth. The majority 
of the cases develop before the tenth day of life. Nearly all the reported 
cases have occurred in premature infants or those weakened by pre- 
existing diarrhea or pneumonia. Poor hygienic surroundings are in- 
cluded among the possible predisposing causes. 
Pathology.—Parrot described the essential process as a drying up 
and thickening of the skin, associated with a diminution in the fatty 
elements of the underlying connective tissue. Langer ascribed the con- 
dition to a solidification of the fat as a result of low body temperature, 
a phenomenon more readily possible in the newborn infant than in the 
older subject, because of the peculiar chemical composition of infant 
fat and its corresponding property of solidifying at a relatively high 168 
THE PRACTICE OF PEDIATRICS 
temperature (89.6° F.). Other authorities have likened the cutaneous 
changes of sclerema to those occurring in myxedema. Mensi1 distinguished 
three types of sclerema, depending upon the degree of atrophy in the skin. 
In all the forms atrophy of the subcutaneous connective tissue was the 
chief lesion. Northrup reported a case in which microscopic examination 
of the skin revealed nothing abnormal. 
Symptoms.—The chief general symptoms comprise progressive 
emaciation and asthenia, subnormal temperature, and failing pulse and 
respiration. The thickening and hardening of the integument begin, 
as a rule, in the lower extremities, and extend upward to the trunk and 
face. The skin assumes a yellowish, waxy hue, and later becomes livid 
and perhaps mottled. It is extremely tense, does not pit on pressure, 
and imparts stiffness to the motions of the joints and the play of the 
muscles of the face. Sucking and swallowing may be prevented. The 
infant usually dies within a few days, but exceptionally may survive 
the disease. Dr. Lotta Meyers2 reported a mild case in a female infant, 
without the usual subnormal temperature, death occurring on the twenty- 
fifth day. 
Prognosis.—The disease is frequently, but not invariably, fatal. 
Diagnosis.—Scleroderma and scleredema, the only conditions re- 
sembling sclerema, may be distinguished by the fact that the first has 
not been noted before the second year (Stelwagon), while scleredema 
is seldom generalized or accompanied by extreme wasting, and does not 
deprive the skin of its color or elasticity under pressure. 
Treatment.—The only management of possible value consists in 
the maintenance of nutrition and bodily heat. In suitable cases the 
incubator may be used. 
ASPHYXIA NEONATORUM 
Asphyxia neonatorum is a condition of the newborn of grave menace 
requiring the most active and intelligent treatment. 
Etiology.—The asphyxia is due to a subaeration of the blood of the 
fetus or infant. This subaeration may be caused by anything which 
tends to retard the interchange of carbon dioxid and oxygen in the fetal 
circulation, and may take place before or during labor. As a result of 
the interference of the placental interchange of gases, the products of 
metabolism in the fetus stimulate the inactive respiratory center. This 
at first causes respiratory efforts, with the aspiration of more or less 
air, meconium, or amniotic fluid, according to the infant’s position in 
the parturient tract, and later, if the subaeration is not relieved by the 
quick extraction of the child, allowing access of air for the expansion 
of the lungs, depression of the respiratory center is the result. 
The causes operating antepartum include any conditions which inter- 
fere with the oxidation of the mother’s blood, such as cardiac or res- 
piratory disease in the mother, hemorrhage, or eclampsia; anything 
which causes a premature separation of the placenta, such as placenta 
prsevia or accidental hemorrhage; and anything which causes pressure 
upon the cord or the child, as the premature rupture of the membranes, 
1 Jour. Cutaneous Diseases, October, 1912. 2 Ibid., 1909. ASPHYXIA NEONATOKUM 
169 
maternal convulsions, or tetanic contractions of the uterus. During 
labor, likewise, pressure upon the corcl from prolapse or malposition, 
pressure upon the head, with or without meningeal hemorrhage, or sepa- 
ration of the placenta before the delivery of the head, as in “vaginal birth,” 
may cause asphyxia. Prematurity and congenital disability or defects, 
such as atresia of the pulmonary artery, may be causative factors in- 
herent in the child. 
Pathology.—The pathologic changes are due to the venous engorge- 
ment and the aspiration of fluids. The right heart is distended with 
fluid blood or soft clots; the vena cava, the large thoracic veins, the 
sinuses of the dura, and the hepatic vessels are also distended. The 
pulmonary vessels may be distended or not, according to the extent 
and degree of respiratory efforts made. As a result of aspiration the 
trachea and bronchi may be quite filled with mucus, meconium, blood, 
and amniotic fluid. The lungs may show areas of atelectasis, or may 
be partially aerated and intensely engorged. The liver is dark bluish 
in color. There may be punctate hemorrhages in various parts of the 
body. 
Symptomatology.—It has been customary to divide the symptoms 
of asphyxia neonatorum into two groups, according to the color of the 
child and the state of the musculature—asphyxia livida and asphyxia 
pallida. They are essentially the same condition, asphyxia pallida being 
the terminal stage of asphyxia livida, and a case of asphyxia pallida 
(if recovery takes place) passing through the stage of asphyxia livida. 
Asphyxia Livida.—The child who is in the condition of asphyxia 
livida presents a characteristic appearance: the skin is blue or livid, 
the mucous membranes are dusky, the sclerotics are congested. The 
pupils are equal and react, and the position of the eyes is normal. The 
respiratory efforts are infrequent and gasping. The heart action is rapid 
and tumultuous, and the heart sounds are loud. The umbilical vessels 
are engorged and pulsate forcibly. The muscles are everywhere tense; 
the reflexes are active; the cutaneous sensibility is preserved, and the 
skin is warm. The anal sphincter functionates. The condition is a 
sthenic one, and analogous to the convulsive stage of ordinary asphyxia. 
A child in this form of asphyxia may recover by the respirations 
becoming more frequent, the color changing to normal hue, the over- 
acting heart quieting down, and a normal condition appearing; or the 
condition may pass by gradual stages into the other form—asphyxia 
pallida. The degree of asphyxia in the beginning may be midway between 
the two types. 
Asphyxia Pallida.—The child with asphyxia pallida is limp and 
pale. The entire musculature is relaxed, the lower jaw and head hang 
down, and the limbs drop. Respiratory efforts are absent altogether 
or so slight as to escape detection. The cord is flabby, the pulsation 
is inappreciable, or can be hardly felt, and the cord, when cut, bleeds 
very little. The heart sounds are usually faintly heard and may be slow 
or rapid. The sphincter ani is relaxed and allows the passage of meco- 
nium. The subcutaneous sensibility and reflexes are abolished. The tem- 
perature is lowered 1 to 3 degrees. In this form spontaneous recovery 
almost never takes place. 170 
THE PRACTICE OF PEDIATRICS 
Diagnosis.—The diagnosis of asphyxia neonatorum may be made 
intrapartum by detecting the slowing of a previously well-acting fetal 
heart, the passage of meconium in the liquor amnii, the trembling of the 
head in a breech extraction, and the so-called vaginal cry. Postpartum, 
the condition is recognized by the symptoms as detailed. Asphyxia 
neonatorum must occasionally be differentiated from meningeal hemor- 
rhage, which is likewise caused by prolonged labor and which often occurs 
with asphyxia. When the hemorrhage is large, it can be readily recog- 
nized by the bulging, tense fontanel and by the existence of coma and 
possibly paralysis. Hemorrhage may affect the respiratory center, in 
which event the two conditions are really one. 
Prognosis.—The prognosis without treatment is always bad. In 
cases of asphyxia pallida spontaneous recovery is rare, and even with 
the most active treatment many do not survive. After apparent recov- 
ery death may yet occur from weakness or injuries incidental to the 
initial asphyxia. Idiocy and feeble-mindedness may often be due to the 
same cause. 
Prophylaxis.—In the treatment of asphyxia prevention belongs to 
the province of the obstetrician. Everything shoidd be done to avoid 
any of the maternal causative factors, and in the conduct of labor itself 
the aim of the physician should be to deliver the child as quickly as is 
compatible with safety, not hesitating to apply low or medium forceps 
in preference to a long and tedious second stage. 
Treatment.—The active treatment is directed toward maintenance 
of body heat and stimulation of respiration. The child, as soon as born, 
should be wrapped up, and if asphyxia exists, active treatment should 
immediately be instituted. The mouth and throat should be wiped 
free of the mucus, which will almost invariably be found, by means of 
the index-finger well wrapped with absorbent cotton or sterile gauze. 
It may be necessary to suck out the secretions by means of a catheter 
and a glass tube with a bulb on it to prevent the secretions from the 
mouth of the physician or nurse getting into the child’s pharynx. This 
will be especially necessary when, as the result of respiratory efforts 
during the passage of the head through the pelvis, much amniotic fluid, 
mucus, etc., may have been aspirated. It is not advisable, however, 
to attempt much instrumentation of the larynx, but to rely on Schultze’s 
method for bringing out aspirated secretions. The respiratory center 
must be stimulated. This may be attempted, depending upon the severity 
of the asphyxia, by tickling the nares, by administering the fumes of 
ammonia, by spanking (“flagellating the buttocks,” Koplik), by the 
alternate use of hot (110° F.) and cold (60° F.) baths, the child being 
transferred rapidly from one to the other, always ending with the hot 
one, or by combining with these one of flu1 various methods of artificial 
respiration, of which the simplest is perhaps the mouth-to-mouth method. 
Sometimes bleeding of the cord will relieve the intense congestion of the 
right heart and large thoracic veins, and allow the heart to restore the 
circulation and relieve the respiratory center. The most commonly 
used methods of artificial respiration are those of Laborde, Dew, and 
Schultze. 
The Laborde method consists in making rhythmic traction on the ASPHYXIA NEONATORUM 
171 
tongue, from twelve to fourteen times a minute, which it is claimed ex- 
cites respiration. 
The Dew method consists in grasping the infant by the back of the 
neck with one hand and by the knees with the other. The upper and 
lower portions of the child are then approximated by a flexion of the 
thorax on the abdomen, and the reverse movement, extension, is next 
effected. Alternate flexion and extension are thus practised fifteen to 
twenty times a minute. 
Schultze’s method as described by him and quoted by Edgar1 is as fol- 
lows: “The child lying upon its back is grasped by the shoulders, the 
open hand having been slipped beneath the head. The last three fingers 
remain extended in contact with the back, while each index-finger is 
inserted into an axilla, the thumbs lying upon and in front of the shoulders. 
When the child thus held is allowed to hang suspended, its entire weight 
rests upon the two fingers in the armpits. It is now swung forward and 
upward, the operator’s hands going to the height of his own head; the 
pelvic end of the child rises above its head and falls slowly toward the 
operator by its own weight, flexion occurring in the lumbar region. The 
thumbs in front of the shoulders compress the chest, while the hyper- 
flexed lumbar vertebrae and pelvis compress the abdomen, and through 
it the thorax; finally, the last three fingers on each side compress the 
thorax laterally. As a result of this maneuver, when properly done, 
aspirated secretions flow abundantly from the mouth. The distended 
heart also feels the compression which forces the blood into the arteries. 
The child is now swung back into its original position and supported 
entirely by the fingers in the axilla. The compression of the thumbs 
and last three fingers is removed. The downward swing elevates the 
sternum and ribs, while gravitation and the traction of the intestines 
depress the diaphragm. It is often possible to hear the air rush into the 
infant’s glottis as it reaches the original position, although this can occur 
in a cadaver. The amplification of the thorax lowers the intracardiac 
pressure. The child should be swung up and down ten times for the space 
of a minute. The effects of the maneuver should be as follows: the heart 
beat increases in frequency, the cadaveric pallor of the skin becomes re- 
placed by a rosy hue, and the muscular tonus appears. The child is then 
placed in a warm bath and watched. If the inspirations are superficial, 
a momentary dip in cold water is indicated. If the heart action becomes 
poor, the child should be swung again. If prolonged swinging becomes 
necessary, the root of the tongue should be compressed forward in order 
to raise the epiglottis and permit the removal of secretions with the 
fingers. In premature children the thoracic walls are often too soft to 
benefit by the compression of the fingers. In these cases insufflation 
of air should be practised.” 
In the cases of asphyxia livida, where the reflexes and the cutaneous 
sensibility are abolished, all attention should be devoted to the general 
stimulation of the child. The cord should be cut at once; it will often 
not bleed at all. The air passages should be freed from accumulated 
secretions as before. The child should be put into a warm bath and 
artificial respiration attempted by the mouth-to-mouth method or La- 
1 Edgar, Practice of Obstetrics, 5th ed., p. 791. 172 
THE PRACTICE OF PEDIATRICS 
horde’s method. Rectal injection of 1 to 2 ounces of coffee infusion, or 
hypodermic injection of grain of strychnin, may be given and re- 
peated in half an hour. 
Signs of recovery in asphyxia pallida are a return of the cutaneous 
sensibility, a reappearance of the reflexes, an increase of the tonicity 
of the muscles, one or more respirations, or a gradually increasing cyan- 
osis and venous engorgement approximating the condition of asphyxia 
livida. Finally, a gradual change to normal hue, with restored respira- 
tion and relaxation, indicates recovery. 
A strict watch must be kept over the child for several days, for re- 
lapses are common. Oxygen must be at hand, and all apparatus ready 
for a resumption of the active treatment at any moment. 
DELAYED ASPHYXIA 
Asphyxia may occur after birth in a child who has had an unevent- 
ful delivery and who appears quite normal when born. 
Etiology.—This form of asphyxia is due to some cause interfering 
with the proper continuance of the respiratory function. Developmental 
anomalies, such as defects of the nervous system, the heart, the dia- 
phragm, the thoracic wralls, or the lungs, or the general weakness of pre- 
maturity, may be the cause. Compression of the trachea by enlarged 
thyroids, and possibly by thymus glands, has been reported. Syphilitic 
pneumonia or bilateral pleuritic effusions or an enlarged liver may be 
the etiologic factors. 
Symptoms.—The clinical symptoms correspond closely to those of 
ordinary asphyxia. The infant makes very feeble respiratory efforts 
or none at all; the heart beats with considerable strength, becoming 
weak as the asphyxia continues and approaches the stage of flaccidity. 
Prognosis.—The prognosis is dependent upon the severity of the 
asphyxia and the removability of the cause. 
Treatment.—Treatment is that of any form of asphyxia, and con- 
sists in stimulating respiration and circulation upon the removal of the 
cause. Asphyxia due to prematurity should be treated according to the 
methods advised for caring for premature babies (p. 164). 
ATELECTASIS 
Atelectasis may be present in the newborn who come into the 
world asphyxiated, and it is not infrequently seen when there has been 
a prolonged, difficult delivery. Atelectasis may be the result of weak- 
ness, pure and simple, and is not of unusual occurrence in the premature. 
For some reason there is a failure or inability to dilate the air vesicles. 
Sudden collapse may occur in marantic infants, the child dying in a few 
moments with cyanosis and orthopnea, the autopsy proving the diagnosis 
of atelectasis. The condition may be produced also through compression 
of the lung with exudation in pleurisy, or by the obstruction of a bron- 
chus with mucus. The most dangerous types are those which are present 
in the newborn and which occur in the weakly during early life. The 
warning symptoms are usually cyanosis and rapid superficial breathing, 
with or without convulsions. SEPSIS IN THE NEWBORN 
173 
Treatment.—The management of atelectasis, both in the newborn, 
who come into the world asphyxiated because of prolonged difficult 
delivery, and in those in whom the condition is the result of weakness, 
consists in making the child cry lustily. If auscultation over the lower 
lobes posteriorly does not show free vesicular breathing, the child should 
be made to cry every day, either by spanking or by plunging him first 
into water at 110° F. and again into cold water at 60° F., our object 
being to induce vigorous crying and thus dilate the air vesicles. A recent 
patient made satisfactory improvement by receiving oxygen inhalations 
for one minute out of every fifteen, with stimulation of various kinds to 
induce crying. Atelectasis from obstruction of a bronchus or from com- 
pression is usually readily relieved when the source of the trouble is re- 
moved. In out-patient work we occasionally see marantic young infants 
in whom there is an involvement of a considerable area of one of the 
lower lobes posteriorly without any sign whatever of discomfort. The 
process of resolution in these cases progresses from the periphery toward 
the center and is very slow. The condition is probably of much more 
frequent occurrence than is generally supposed, if we are to judge from 
the autopsy findings in cases of young infants, particularly in institutions. 
The newborn infant is peculiarly susceptible to infections, partic- 
ularly with pyogenic bacteria. During this early period of life the 
normal bodily defenses are weakened. Phagocytosis, which is the great 
protector of the adult, is of little service to the newborn, who display 
little resistance against any bacterial invasion. 
Etiology.—The cause of sepsis in the newborn is the entrance of 
some form of pathogenic bacteria into the body. These bacteria are 
usually of the streptococcus or the staphylococcus groups. The pneu- 
mococcus, the colon bacillus, and Bacillus pyocyaneus may also cause 
the condition. These bacteria have been shown to exist even in normal 
breast milk, and they lurk in the air of hospital wards and dwellings. 
The lochia and amniotic fluid of the mother have been shown to contain 
them. The newborn infant is thus surrounded on all sides by bacteria 
ready to gain admission to his body. The severity of a given case of 
sepsis is proportionate to the degree of virulence of the bacteria at the 
time of the infection. 
Sources of Infection.—Infection may occur through the mouth, 
which is probably the most frequent port of entry, through the nose, 
the skin, the rectum, the conjunctivse, the digestive tract, the lungs, 
the ears, the urethra, the umbilicus, and, in girls, the vagina. Almost 
any portion of the body may be the seat of the infection. It is rare 
to find only one organ or structure affected. Usually two or more portions 
of the body are involved in the septic process. 
Parts Most Frequently Involved.—The following parts of the body 
are most frequently involved: 
Umbilicus.—The seat of this infection is usually about, or in the 
substance of, the stump of the umbilical cord. The skin and tissues 
about the umbilicus are red, indurated, and show the usual signs of septic 
SEPSIS IN THE NEWBORN 174 
TIIE PRACTICE OF PEDIATRICS 
infiltration. The blood-vessels of the cord may be the seat of inflam- 
mation. 
Peritoneum.—Peritonitis may follow the extension of the septic process 
from the umbilical cord to the peritoneum, and under such conditions 
often results fatally. The peritonitis may be local or general. 
Joints.—The joint surfaces and membranes may be the seat of sup- 
puration, or osteomyelitis may occur. Sometimes the epiphysis only 
is involved, and in other cases the shaft of the bone is affected. 
Skin.—Single or multiple abscesses of the skin and underlying cellular 
structures are also not infrequent. 
Lungs.—Pneumonia, usually of the bronchial variety, may develop 
as a septic process, with only vague symptoms, such as rapid respira- 
tion and cyanosis, accompanying the fever. 
Intestines.—Diarrhea accompanies nearly all forms of sepsis in the 
newborn. Vomiting may occur. 
Brain.—The meninges are rarely attacked by the septic process, 
and when they are involved, indefinite symptoms of meningitis are the 
result. 
Heart.—Septic pericarditis may occur, but is extremely rare. Septic 
endocarditis is more common. 
Gonorrheal sepsis is discussed separately (pp. 178, 518 and 794). 
Prophylaxis.—This is of the greatest importance in guarding against 
sepsis. The obstetrician’s hands and those of the nurse should be just 
as sterile when handling the newborn infant as they are in caring for 
the mother. Asepsis should be stringently observed in ligating the cord. 
The mother’s breasts and nipples should be cleansed with boric acid 
before and after each nursing. 
Prognosis.—Even in its mildest form, septic infection of the new- 
born is very serious. When structures such as the peritoneum, brain, 
pericardium, or lungs are involved, the disease is invariably fatal. 
The red cells are decreased by disintegration, while the leukocytes 
are increased. 
Treatment.—The management resolves itself into relieving the system 
of the infection, which is possible when its seat is in the skin. When 
there is multiple abscess formation, incision should be made and fol- 
lowed by a wet dressing of a saturated solution of boric acid, or, if the 
area is not too large, a 1 : 5000 solution of bichlorid. If the site of the 
infection is at the umbilicus, the suppurating surface should be thor- 
oughly cleansed and kept covered with a wet dressing of 1 : 5000 bi- 
chlorid, which should be changed at least every two hours. If there is 
erysipelas, an ointment composed of 30 per cent, ichthyol in vaselin 
affords one of the best dressings. This should be freshly applied every 
four hours. 
The septic infant, whether the infection is mild or severe, usually 
nurses very poorly. Often both breast and bottle are refused. When 
a sufficient amount of fluid is not taken, plain boiled water or sugar water, 
5 per cent., or completely peptonized skimmed milk, may be given by 
gavage. If fluids are not given, the child is very apt to develop inanition 
fever, which, added to the infection, makes a serious condition more 
serious. From 2 to 4 ounces of a normal salt solution used lukewarm, UMBILICAL GRANULOMA 
175 
injected into the descending colon through a catheter, will often be re- 
tained, with beneficial residts. It should not be repeated oftener than 
once in six hours. 
Early transfusion in sepsis neonatorum deserves the place of a routine 
procedure. 
Medication other than small doses of alcohol—5 drops of brandy, 
well diluted, every hour, if necessary—has been without avail in our 
cases. The prognosis at best is very grave, although cases in which 
the vital organs are not involved occasionally recover. 
Illustrative Case.—An unusual instance of infection which ended in recovery was 
that of a child who had no fever, but lost rapidly in weight and experienced marked pros- 
tration. The skin took on a greenish hue, and we were at a loss to discover the cause of 
the illness. The infection was suspected, but no portal of entry could be found; neither 
could we find any localized process until the nurse discovered that the umbilicus and the 
surrounding skin were bathed in pus. The umbilicus had apparently healed without 
any indication of local trouble. Investigation showed, however, that the infection had 
entered at this site, and, extending along the vein or artery, had become pocketed and 
formed an abscess II inches deep. Enlarging the opening at the umbilicus and estab- 
lishing free drainage were followed by a gradual closure of the abscess cavity and re- 
covery. 
THE CARE OF THE STUMP OF THE UMBILICAL CORD 
Emphasis must be laid upon all procedures tending to diminish the 
incidence of sepsis. 
The management of granuloma, polypus, and localized eczema about 
the umbilicus will be referred to elsewhere. In order to secure a rapid 
and complete cicatrization after the cord falls it is essential that the 
parts be kept dry. Gratifying success has been obtained with a powder 
composed as follows: 
Pulveris acidi salicylici gr. x 
Pulveris acidi borici gr. xxv 
Pulveris amyli, 
Pulveris zinci oxidi aa 5ss 
UMBILICAL GRANULOMA 
A granuloma at the umbilicus consists of a reddish, secreting mass 
of granulations involving the umbilical stump. It may vary in size 
between that of the head of a pin and a pea. Granulomata usually occur 
in cases in which the care of the cord has been neglected. In out-patient 
work they are very frequently seen, and occur usually in children who 
have been delivered by midwives. The mother brings the child to the 
dispensary with the story that the navel will not heal. 
The granulations are very vascular and bleed readily. 
Treatment.—After thorough cleansing of the parts, one or more ap- 
plications of a 50 per cent, nitrate of silver solution, followed by the 
free use of an absorbent dusting-powder, soon produces a normal cica- 
trix. A powder of the following composition is recommended: 
lb Acidi salicylici gr. xv 
Acidi borici gr. xxv 
Pulveris zinci oxid,i 
Pulveris amyli aa 3j 176 
THE PRACTICE OF PEDIATRICS 
The powder should be applied very freely at two-hour intervals during 
the day, or at least often enough to keep the wound dry. 
UMBILICAL POLYP 
An umbilical polyp is usually the result of an overgrowth or an out- 
growth of a negelected granuloma. The mass, which may vary in size 
from a flaxseed to a pea, is reddened, moist, and usually bathed in a 
viscid, mucopurulent secretion. There is often considerable excoria- 
tion of the skin about the umbilical opening. Sometimes the mass is 
so small that it is hidden by the overlapping folds of skin and its pres- 
ence would not be suspected but for the secretion which keeps the parts 
moist. The polyps are very vascular. 
Treatment.—Cutting the pedicle and applying nitrate of silver or 
carbolic acid is not a safe procedure. Severe hemorrhage has followed 
such treatment. About twenty-five years ago the senior author was 
obliged to sit for three hours by the side of a crying, wriggling child mak- 
ing pressure on the cut stump of an umbilical polyp after a colleague 
had cut the pedicle. In no other way coidd the hemorrhage be controlled. 
The best management in these cases is to ligate the pedicle and allow the 
polyp to wither and drop off. The powder referred to under the head 
of Granuloma should be applied after the ligature is fixed, and reap- 
plied frequently before and after the polyp has dropped off, until the 
wound is cicatrized and dry. 
CONGENITAL UMBILICAL HERNIA 
This subject is discussed under the general topic of Hernia (p. 283). 
MASTITIS IN THE NEWBORN 
Inflammation of the breasts in the newborn, both in the male 
and in the female, is seen with considerable frequency in hospital prac- 
tice. The mammary glands may be acutely tender and swollen to several 
times their normal size. These glands in young infants shoidd not be 
pressed or manipulated in any way more than is required for cleanli- 
ness. Not a few out-patient cases of mastitis have been due to the at- 
tempts of a midwife to express the milk from the breasts. The cases 
are explained by the fact that the opening of the nipple is large and the 
gland readily becomes infected from unwashed hands or unclean wearing 
apparel. 
Treatment.—The cases have usually responded well to the appli- 
cation of ichthyol—25 per cent, in oxid of zinc, U. S. P. The ointment 
is spread generously upon old linen which has been boiled and dried, 
and is then gently bound upon the inflamed gland. Over this is placed 
oiled silk to protect the clothing, and over all a gauze bandage is ap- 
plied with very light pressure. The dressing should be changed and 
fresh ointment applied every six hours. Wet dressings in the manage- 
ment of this condition in infants are not advised. In 5 cases the mas- 
titis was beyond control when first seen, and suppuration of the gland— 
mammary abscess—followed, requiring incision and drainage, with loss 
of the gland substance. TETANUS NEONATORUM 
177 
MAMMARY ABSCESS IN INFANTS 
Mammary abscess is the result of mastitis which has failed to undergo 
resolution. It occurs as frequently in males as in females. All the senior 
author’s cases but 2 were seen in institutions or in out-patient work. 
In 5 the abscess developed under his own observation. In the case of 
a female child at the New York Infant Asylum both glands were en- 
tirely destroyed. 
Treatment.—As soon as pus is discovered the abscess should be in- 
cised and drained, with a view to saving as much of the gland as possible. 
Of course, this advice applies particularly to a female patient. Wet 
dressings are not applicable in cases of young infants when the parts 
covering the thorax or abdomen are involved. It is good custom to pro- 
tect the skin from infection by the use of a 25 per cent, boric acid oint- 
ment in cold cream as a base. This should be applied on old linen about 
the abscess opening. The dressing should be changed three times daily. 
Tetanus is an acute infectious disease caused by the tetanus bacil- 
lus, an organism having its natural habitat in garden soil or dung heaps. 
Its point of entrance into the human body may be a lacerated wound, 
a mere abrasion, or, as is the case in tetanus neonatorum, the umbilicus. 
The local reaction may be very slight or attended by suppuration. 
Tetanus is extremely rare in our hospitals and institutions for children 
because of the care exercised in treating the umbilical wound. Wherever 
gross uncleanliness prevails, tetanus neonatorum will be found. It is 
particularly prevalent among savage and half-civilized races. 
Specific Cause.—The tetanus bacillus is a slender, slightly mobile 
organism, positive to Gram’s stain, growing only anaerobically, and de- 
veloping a round spore characteristically placed at one end of the rod, 
giving it a nail or drumstick form. It was described by Nicolaier in 
1885, and cultivated four years later by Kitasato. 
The bacilli remain localized at the seat of infection, whence their 
toxins are carried along the axis-cylinders of the motor nerves to the 
motor cells of the spinal cord, pons varolii, medulla oblongata, and, to 
a lesser degree, the brain cortex. The localized spasms characteristic 
of the disease are due to the action of the tetanus toxin on the ganglion 
cells. 
Incubation.—From the second to the ninth day is the usual period 
for the development of the disease, although it may appear as late as 
the fifth or sixth week. The period of incubation of the tetanus bacillus 
in man is probably of wide variation. The disease may appear immedi- 
ately after birth or be delayed for five or six weeks. Few cases, how- 
ever, develop after the third week of life. 
Pathology.—The lesions found at autopsy in infants dead of tetanus 
neonatorum are few and non-specific in character. Acute omphalitis 
is usually present. The thoracic and abdominal viscera do not show 
any abnormality. The meninges of the brain and spinal cord are con- 
gested, while small hemorrhages into the nerve substance are frequent. 
These are manifestly the result, and not the cause, of the tetanic spasms. 
TETANUS NEONATORUM 178 
THE PRACTICE OF PEDIATRICS 
On microscopic examination degenerative changes in the nerve-cells 
of the gray matter of the spinal cord are noted, but these changes are in 
no way specific. 
Prognosis.—Few cases recover. Holt reported one recovery. The 
mortality is high. Those writers who have seen much of the disease 
place the mortality at 95 to 98 per cent. 
Symptoms.—The earliest symptom usually observed is difficulty 
in nursing. The child attempts to grasp the nipple and lets go suddenly 
and cries. Perhaps the infant will give a sudden start and cry as though 
in acute pain, which is doubtless the case. Examination of the patient 
will show well-marked trismus; the jaw is set; the jaw muscles are tense. 
Stiffening and relaxation of the muscles successively occur. As the case 
progresses the muscles of deglutition become involved, and swallowing 
is impossible. The lips are said to pucker in the position of whistling. 
The temporary relaxations become shorter; there is a tonic spasm, 
and, at the slightest irritation, such as the dropping of a pencil or a sud- 
den, awkward movement of an attendant, the muscle spasm increases 
until a marked permanent opisthotonos results. The temperature is 
usually high—104° to 106° F.; the pulse very rapid—180 to 200. Death 
is usually due to exhaustion. Spasm of the respiratory muscles is prob- 
ably a factor. 
Treatment.—The treatment consists in the use of antispasmodics— 
among which bromid and chloral are most frequently used. Large doses 
are necessary. 
In Holt’s recovery case 8 grains of sodium bromid were given every 
two hours. 
The patient is to be kept very quiet. Food and drugs are adminis- 
tered through a tube. 
Tetanus Antitoxin.—Tetanus antitoxic serum is made by inoculat- 
ing a horse with tetanus toxin formed by the growth in bouillon of the 
tetanus bacillus. Its prophylactic use has been of far greater value than 
its curative effect, and in every case of possible tetanus infection a dose 
of 1500 units of the antitoxin should be injected subcutaneously near the 
wound. Repetition of the dose after the expiration of a week gives ad- 
ditional security. 
In order to do good, after symptoms of tetanus have appeared, the 
antitoxin must be administered as early as possible. The New York 
City Board of Health advises giving the initial dose of 10,000 units in- 
travenously, and, if possible, also into the spinal canal and into the sheath 
of the nerve of the affected part. These energetic measures should be 
followed by subcutaneous doses of 5000 to 10,000 units every six to twelve 
hours for four days. In more severe cases, or in those in which symptoms 
have been present for several days before the treatment was begun, the 
initial dose should be doubled. It is also recommended that the wound 
be treated with a solution of iodin and that large amounts of water be 
given for its diuretic effect, since tetanus toxin is eliminated by the kidneys. 
OPHTHALMIA NEONATORUM—GONORRHEAL OPHTHALMIA 
One of the commonest forms of sepsis occurring in the newborn is 
acute purulent conjunctivitis. ICTERUS NEONATORUM 
179 
Etiology.—In almost all instances the infection is conveyed at par- 
turition from a pre-existing vaginitis of the mother. Two-thirds of the 
cases of ophthalmia neonatorum are produced from gonorrheal vaginitis; 
one-third from simple catarrhal vaginitis.1 In cases in which the gono- 
coccus is absent from the discharge the pneumococcus, Bacillus coli, and 
other organisms may be found. Infection may be conveyed indirectly 
after birth by dressings or towels or even by the fingers of the obstetric 
nurse. 
Symptoms.—The condition becomes evident between two and four 
days after birth; infection developing later is acquired postpartum. The 
conjunctiva becomes red and swollen and is bathed in a secretion at first 
serosanguineous, then seropurulent, and ultimately purulent. The swelling 
and chemosis diminish during the stage of profuse purulent discharge 
which lasts two to three weeks and then gives way to a chronic inflam- 
mation with thickening of the conjunctiva which ordinarily persists for 
several weeks longer. Exceptionally this final stage is shortened. In 
four-fifths of the cases the disease is bilateral. 
Complications.—Corneal infiltration with ulcer formation is frequent. 
Perforation of an ulcer may be followed by staphyloma and even pan- 
ophthalmitis. 
Prognosis.—Under early and efficient treatment the prognosis is fairly 
good, depending on the virulence of the infection and the degree of corneal 
involyement. 
Treatment.—Prophylaxis by the Crede method has become general 
and in advanced communities is almost universally compulsory. The 
method consists in immediate cleansing of the infant’s eyes at birth, 
followed by the instillation of a drop of 2 per cent, silver nitrate solution. 
“A 1 per cent, solution of silver nitrate may be substituted, but 25 per 
cent, argyrol or 10 per cent, protargol are not so reliable.”2 
Treatment of the developed disease consists in the application of an 
eye shield to the unaffected eye (if one has escaped), and in the use of 
iced compresses and cool boric acid irrigations until tension and redness 
have abated. In the event of corneal involvement hot applications are 
to be substituted. During the later stages daily applications of 1 per 
cent, silver nitrate solution to the everted lids are recommended. 
It is a safe rule to treat all cases of purulent conjunctivitis in in- 
fancy as if they belonged to the gonorrheal type. Too great care cannot 
be taken by physicians and nurses in the handling of these cases to prevent 
spread of the discharge by contaminated articles, and a safe rule is for all 
engaged in caring for such patients to wear glasses as a protection from 
spurting pus droplets and contaminated fingers. 
The theories relating to icterus neonatorum are most ingenious, but 
as all, or most all, are based on speculation, they are, as a result, most 
unsatisfactory. In fact, only very recently has there been much ex- 
perimental work along this line. 
As Stadelmann stated years ago, “Without a liver, no icterus,” so 
ICTERUS NEONATORUM 
1 May, Diseases of the Eye, 10th ed., p. 108. 2 Ibid., p. 109. 180 
THE PRACTICE OF PEDIATRICS 
it is true today that theories excluding the liver as a participant are 
valueless. The forms of icterus in which biliary acids are demonstrated 
in the urine must be attributed to the resorption of bile in the liver. 
In icterus neonatorum the presence of biliary acids has been clearly 
demonstrated not only in the urine (Holberstein), but also in the peri- 
cardial fluid (Hofmeister). In view of these facts it is apparent that the 
liver must play the all-important part in the production of icterus because 
it is certain that the jaundice cannot be explained by hyperemia or cap- 
illary hemorrhage. The so-called hematogenous jaundice deserves more 
consideration in the light of recent experiments. 
Such explanations as that of Franck, assuming a plugging of the 
ductus choledochus by means of mucus and cast-off epithelium, have 
been disproved. Of no further moment is the theory of Birch-Hirschfeld, 
who assumed an edema of Glisson’s capsule; none of these assumptions 
has been verified by other observers. By anatomic examinations of the 
liver Bouchut’s hypothesis of a hepatitis, and Epstein’s theory of a catarrh 
of all ducts of the liver, have been demolished. 
To the hematogenic factor, which has been strongly supported by 
Hofmeier, Stadelmann, and others, one must give more than a passing 
thought. These authors assumed that, as a result of the countless destruc- 
tion of erythrocytes during the first days after birth, a polycholia resulted. 
This supposition of red-cell destruction has been refuted, the cause for the 
apparent destruction being attributed to increase in the blood-plasma. 
Heiman1 supported the blood destruction theory, stating that an actual 
destruction of erythrocytes does occur. Assuming this later observation 
to be correct, one can readily see how with this destruction there is libera- 
tion of hemoglobin, which is taken up by the liver and transformed into 
bile pigments. It is further apparent that when bile is thus produced in 
excess and is taken up rapidly by the liver in large amounts, the bile 
capillaries are overtaxed and the bile cannot be rapidly removed, but is 
reabsorbed into the blood, whereupon choluria develops. If this excessive 
production of hemoglobin increases over certain limits, the “threshold of 
the kidney” is reached and the hemoglobin is excreted through the kid- 
neys, thus producing a hemoglobinuria.2 
The theory today, which, according to Finkelstein3 probably finds 
greatest acceptance, is that of Quincke. This author considers a patency 
of the ductus venosus to be the deciding factor; by a persistency of the 
lumen of this duct the bile passes directly from the meconium in the 
intestine to the portal vein, and, circumventing the liver, enters the infe- 
rior vena cava, thus producing the icterus. In the light of more recent 
research, however, this duct has been found open as late as the fourth 
week of life; thus if this anatomic fact be considered a criterion, we 
would not be led to believe that icterus was produced by the patency of 
the ductus venosus, for if such were the case, icterus would be a phenom- 
enon not of the first week, but of the first month of life. 
According to Hess’s observation with the duodenal catheter, bile 
is excreted into the intestine rarely during the first twelve hours of life, 
1 Zeitschr. f. Geburtsh. u. Gynak., 1912. 
2 Pearce, Austin, and Eisenberg, Jour. Exp. Med., 1912. 
3 Lehrbuch d. Sauglingkrankh., 1905. CONGENITAL ABSENCE OF THE BILE-DUCTS 
181 
and is variable during the subsequent twenty-four hours, but in every 
one of his cases was profuse in icterus neonatorum. In many of his cases 
of marked jaundice the secretion was so profuse as to overflow into the 
stomach—a fact demonstrated by the introduction of the stomach-tube. 
Although Hess stated that the cause of this condition is not at present 
definitely proved, if one follows the principles of the physiology of the 
secretion of bile, one can assume, what seems to be probable, that the 
icterus is due to an increased amount of available hemoglobin; further, 
that some bile salts are taken up from the intestine, resulting in this 
disintegration of blood cells and a consequent increase of bile. Approach- 
ing the matter from another view, one can readily assume that the di- 
minutive excretory mechanism of the liver at this stage is unable to cope 
with this excess of bile which Hess has demonstrated, and that a con- 
gestion of the bile capillaries ensues, as is shown by histologic examina- 
tions, and icterus results. 
Symptoms.—Probably 75 per cent, of all newborn infants show 
more or less icterus a few days after birth. The degree of jaundice varies 
greatly. In comparatively a small proportion of the cases the conjunctiva 
becomes deeply involved. 
Infants showing marked jaundice may lose in weight as a result of 
this condition. The jaundice rarely persists longer than two weeks, 
and such a duration is seen only in the severe cases. In the majority 
of the cases the skin is clear in a week after the onset. The urine is usually 
free from bile pigment. The stools are normal throughout the period. 
Treatment is not required. 
CONGENITAL ABSENCE OF THE BILE-DUCTS 
This malformation is of very rare occurrence. The first symptom, 
a rapidly developing jaundice, appears not later than the third day after 
birth. The jaundice increases rapidly, and in a few days is intense. In 
a case seen at the fifth month the skin was of a deep, greenish-yellow 
color, the conjunctiva was deep yellow, and the mucous membranes of 
the lips and buccal cavity were involved in the discoloration. In all 
cases after the passage of the meconium the stools become clay colored 
and so remain. The urine is of a deep brown color. The liver is always 
enlarged. 
Death usually results from inanition before the third month. In 
one case the child died at the ninth month. In two cases the common 
duct was represented by a fibrous cord; in another there was an entire 
absence of the common duct. An abnormality of the bile-ducts should 
always be thought of in cases of prolonged icterus neonatorum. 
Holmes1 made an extensive review of the literature covering over 
100 cases, with 89 diagrammatic representations of the different de- 
formities. These diagrams show a wide range of deformities. 
Diagnosis.—In icterus neonatorum of the familiar type bile is never 
absent from the stools, even though there is a marked degree of jaun- 
dice, and the skin begins to clear in the second week. A continuation 
of the jaundice without abatement after this time is suggestive of con- 
1 Amer. Jour. Dis. Child., vol. xi, No. 6. 182 
THE PRACTICE OF PEDIATRICS 
genital obstruction of the ducts, and an examination of the stools de- 
termines the condition. 
HEMORRHAGIC DISEASES OF THE NEWBORN 
In 1861 von Hecker and Buhl described a series of cases, under the 
title of “Acute Fett-Degeneration der Neugeborenen,” that presented 
a somewhat similar picture without evidence of either syphilis or navel 
sepsis. Since that time this condition has been commonly called Buhl's 
disease. In the original article it was noted that most of the children 
were born in asphyxia. These cases showed the typical symptoms of 
the disease, and at autopsy all the viscera showed multiple hemorrhages 
as large as pinheads or larger, together with fatty changes that may 
be extensive. The authors did not attempt to explain the etiology, but 
considered that the condition was not due to navel infection and that it 
was not a manifestation of hemophilia because the ratio of males to 
females is not maintained as in hemophilia. In conclusion they said: 
“It is hardly necessary to state that one here has to do with a disturbance 
of metabolism manifested over the whole body, in which the changes 
in single organs are only a partial expression of the whole disease. This 
disturbance is evidently inborn, acquired in the last days before birth.” 
In 1879 Winckel tried to establish an entity distinct from the so- 
called Buhl’s disease by describing a series of cases that manifested a 
slightly different clinical and pathologic picture. He considered this 
condition distinct from Buhl’s disease, chiefly because it seemed to be 
epidemic in character and because the hemorrhages were more and 
the fatty changes less prominent than in the disorder described by Buhl. 
Winckel recognized the similarity of this condition to that of intoxica- 
tion by phosphorus, arsenic, and potassium chlorate, and he ruled out, 
by careful histories and by chemical examination of the viscera, any 
possible participation of these drugs in the etiology of his cases. 
In more recent times the Germans, in particular, have come to re- 
gard as Buhl’s disease any condition affecting the newborn, that pro- 
duces a severe icterus and fatty infiltration without evidence of infec- 
tion; whereas any similar condition, of which the chief features are icterus 
and hemoglobinuria, has been looked upon as Winckel's disease. 
These two classifications, however, have failed to suffice for all the 
hemorrhagic icteric conditions of the newborn infant. 
Various other names have sprung into rather general use, and have 
served to complicate the nomenclature by adding terms based solely 
on clinical and morbid anatomic differences. 
Melcena neonatorum is a term that has been applied to conditions 
in which hemorrhage has occurred from the gastro-intestinal tract, with- 
out necessarily any clinical evidence of hemorrhage elsewhere. Since 
1829, when Cruveilhier found ulcers in the stomach of an infant who 
presented evidence of true melena, many others have recorded the pres- 
ence of such lesions with the result that a gastric or intestinal ulcer is 
usually considered to be the source of the hemorrhage in these conditions. 
Syphilis.—These hemorrhagic conditions have frequently been found 
associated with congenital syphilis. There are hemorrhages, cyanosis, HEMORRHAGIC DISEASES OF THE NEWBORN 
183 
edema, icterus, etc., but in many cases evidence of syphilis is wanting. 
Cases of Buhl’s disease have been recorded by Furstenburg as occurring 
spontaneously even in the offspring of domestic animals, where pre- 
sumably the presence of syphilis may be safely excluded. 
Bacteria.—The role of bacteria has received the greatest considera- 
tion for the following reasons: 
1. The close similarity between these conditions and the picture 
produced by navel sepsis. 
2. The epidemicity of at least one group (Winckel’s). 
3. The finding of organisms at autopsy. 
4. The experimental production in animals of certain of these con- 
ditions by inoculation with bacteria. 
The belief is now almost universally held that many different bacteria 
may produce these diseases, because of the variety of micro-organisms that 
has been found at autopsy (staphylococci, streptococci, Gartner’s bacil- 
lus, Bacillus pyocyaneus, B. coli, and various other types). The inocula- 
tion of animals with many of these organisms has frequently been fol- 
lowed by the production of diseases similar to those in human beings. 
In certain cases, at autopsy, lesions indicative of an infectious process, 
as, for example, hyperplasia of intestinal lymphatic tissue, have been 
found, but, on the other hand, such findings are frequently absent, and 
it is very striking that in many cases there seems to be very insufficient 
evidence that infection has played an important role. 
In general one may conclude that there is strong evidence favoring 
the idea that many cases are caused by infections, and, on the contrary, 
insufficient evidence for assuming that all are due to infections. 
Mechanical Causes.—Mechanical factors, such as trauma, thrombosis, 
embolism (Landau), deserve only mention, as they have been found only 
very occasionally (Thomson). 
Heredity.—The possible importance of hereditary influences was 
considered by von Hecker and Buhl when they stated that the disease 
was evidently inborn, and acquired during the last few days of preg- 
nancy. The relation of heredity to true hemophilia requires no present 
mention. 
There are certain affections of the adult, at present of unknown eti- 
ology, which, if transmitted to the fetus, might cause their various syn- 
dromes in the newborn. Reference is made particularly to the closely 
related conditions of acute yellow atrophy, of eclampsia, and of certain 
septicemic conditions. Numerous observations are on record describing 
the pathologic changes in the offspring of eclamptic mothers, and it is 
particularly interesting that in general the abnormal features correspond 
closely with the icteric and hemorrhagic syndromes of the newborn. 
Each report summarizes the pathologic changes as thrombosis and 
parenchymatous degeneration, fatty degeneration or necrosis, espe- 
cially in the liver and kidneys, hemorrhages in the organs, and subphrenal, 
subpericardial, and subendocardial extravasations of blood. 
Chemical Agents.—Finally, intoxication by known chemical agents 
occasions symptoms and pathologic changes similar to the disease in 
question. Among this long list of agents may be mentioned phosphorus, 
arsenic, potassium chlorate, and chloroform. That there are many 184 
THE PRACTICE OF PEDIATRICS 
features of these conditions that suggest a common general process has 
already been emphasized by Knopfelmacher. 
Metabolic Changes.—The symptoms and gross changes are suggestive 
of poisoning by the above-mentioned agents, but they also occur in con- 
ditions of obscure etiology, such as acute yellow atrophy, eclampsia, 
arid cyclic vomiting of children. All the chief features that characterize 
this latter group, including certain metabolic phenomena, such as ap- 
pearance of lactic acid and sugar in the urine, not to mention others, 
are known to occur also after respiration of rarefied air or after asphyxia 
from any cause, that is to say, from lack of oxygen. In phosphorus- 
poisoning there is a deficiency of available oxygen. Chloroform does 
not belong to this group, producing deficient oxidation of the tissues; 
but it would seem, a priori, that there was some evidence to suggest 
the existence of a causal relationship between chloroform used at labor 
and the occurrence of some of these various conditions of the newborn. 
Evarts Graham (Chicago) concluded, after a careful experimental 
study and review of the literature, of which the preceding paragraphs 
are a resume, that the conditions of the newborn characterized by a 
hemorrhagic tendency, icterus, and fatty changes, are probably all sjm- 
dromes which may occur as the result of a number of toxic agents. He 
produced experimentally the essential features of the disease group by 
the administration of chloroform to the point of asphyxia. 
Duke believed that the bleeding is due to a deficiency in the number 
of platelets in the blood, and thus absence of thrombin formation, which 
is essential in order to produce clotting. In some cases the coagulation 
time is normal, in others, abnormal. 
Gelston1 has reported a case of hemorrhage in a newborn male infant 
treated by whole blood injections in which it was possible to demonstrate 
at the time of the hemorrhage a practical lack of prothrombin, while within 
eight hours after the cessation of the hemorrhage prothrombin was present 
in normal quantities. The loss of prothrombin-antithrombin balance is 
considered to be a direct factor in the etiology of such diseases. Gelston 
concluded: 
“Several possibilities present themselves. There may be simply a 
stimulation to the production of prothrombin; the injection may supply 
enough prothrombin to cause cessation of the bleeding, although not 
fully re-establishing the balance, or it may actually re-establish the bal- 
ance. The latter seems hardly logical, considering the small amounts 
of whole blood necessary. It is more probable that a combination of 
the first two possibilities is involved, with a stimulation to the produc- 
tion of prothrombin and the addition of a sufficient quantity in itself 
to bring the constituents just within the margin compatible with ap- 
proximately normal function.” 
Rodda2 found that the incidence of true hemorrhage neonatorum, 
which is accompanied by delayed coagulation and prolonged bleeding 
time, conformed closely to the prolonged coagulation and bleeding time 
observed for normal infants between the first and fifth days of life. 
1 C. F. Gelston, Etiology of Hemorrhagic Diseases in the Newborn, Amer. Jour. 
Dis. Child., vol. xxii, p. 351. 
2 Jour. Amer. Med. Assoc., August 14, 1920. HEMORRHAGIC DISEASES OF THE NEWBORN 
185 
Cerebral hemorrhage was found in over 50 per cent, of all infants who 
died intrapartum or during the first days of life. 
A considerable number of these cases have come under our observa- 
tion. Repeatedly hemorrhages from the newborn have been observed 
to occur in the internal organs and from various portions of the body. 
A colored infant at the New York Nursery and Child’s Hospital bled 
to death in the pericranial tissues without a sign of hemorrhage else- 
where. At this institution there was at the same time during the senior 
author’s service a small epidemic of fatal hemorrhages in the newborn. 
The colored child referred to was the only one in which the hemorrhages 
were not multiple. Some cases were due to proved sepsis; in others there 
was no demonstrable lesion of the blood or vascular apparatus. In one 
infant the hemorrhages began on the third day subcutaneously on the 
dorsum of the foot and rapidly extended until the child bled to death 
in her own tissue. 
At this time we were not aware of the usefulness of human blood in 
these cases. In just such cases the results from human blood treatment 
referred to below are most promising. 
Treatment.—The use of styptics and astringents for controlling 
the hemorrhage is useless. The only local measure that has assisted 
in any way has been the application of pressure to the bleeding parts, 
and this is not possible in many situations. Adrenalin, locally or by 
internal administration, has not been of any appreciable service. 
Illustrative Case.—One of the most important contributions to the literature of 
hemorrhage in the newborn was presented in the Medical Record of May 30, 1909, 
by Dr. Samuel W. Lambert, of New York City. In his case a direct transfusion of 
blood from the father to the child was successful in stopping the hemorrhage when the 
case was almost hopeless. 
The only general treatment worth considering is the use of human 
blood, administered by transfusion or injected intramuscularly. 
During the past few years many cases of hemorrhage in the new- 
born have been treated by the use of human whole blood injections. The 
blood is readily drawn from the basilic vein of the donor and injected into 
the buttocks of the patient. This is the most rapid method. No tests 
are required for hemolysis and agglutination. One ounce of blood was 
used in each of 3 of the writer’s cases, completely controlling the hem- 
orrhage. 
When subcutaneous injections of blood prove ineffective immediate 
transfusion is indicated. Typing of the blood of both the infant and the 
donor should be done when possible in all transfusion cases. VII. DISEASES OF THE MOUTH AND ESOPHAGUS 
The term stomatitis is applied to an inflammation of the mucous 
membrane of the mouth. Three types are usually described by pediatric 
authors—the catarrhal, the aphthous, and the ulcerative. 
A specific type in which throat symptoms are usually pronounced, 
known as Vincent’s angina, is described on p. 319. 
There are many cases of catarrhal stomatitis which, under treat- 
ment, go no further; other cases, with or without treatment, go on to 
the development of aphthae, or an ulcerative condition. Both conditions 
may be combined. Many cases, when they appear for treatment, have 
the so-called aphthous spots already developed, but the condition des- 
cribed as “catarrhal stomatitis” also is present. Other cases when they 
come to us show marked ulceration, but never without catarrhal symp- 
toms. 
Bacteriology.—Catarrhal, aphthous, and ulcerative stomatitis have 
no established specific bacteriologic etiology. 
Etiology.—The cause of the disease is unquestionably an infection, 
and there is no doubt that it is contagious. As to the nature of the in- 
fection positively nothing is known. The combined action of several 
varieties of micro-organisms is the most plausible explanation. Stomatitis 
has been observed to go through an entire family of several children. 
Authors are prone to attribute the trouble primarily to mechanical irri- 
tation, such as careless manipulation during the mouth toilet; but the 
majority of children when they applied for treatment had never been 
accustomed to mouth toilets of any kind. The giving of overheated food 
is supposed by some to be a causative agent. If this were the case, 75 
per cent, of the infants among the poorer classes would never be free 
from the disease. The food of bottle-fed children unless carefully watched 
is almost invariably given too hot. The disease, however, is not limited 
to dispensary patients. We have seen many cases among the well-to-do. 
Where gross uncleanliness is the family habit, the number of cases of sto- 
matitis will, for obvious reasons, be greater; there are more bacteria to 
carry infection. Children wThose mouths are carefully cleaned after each 
feeding do not develop stomatitis. To teach that a child’s mouth should 
not be washed because an indifferent doctor may fail to instruct the mother 
or nurse as to how it should be done is rank heresy. When errors of 
the mother or nurse occur in performing the various offices for the child, 
it is our observation that, nine times out of ten, the fault is due to lack 
of instruction by the physician. The mouth may be very effectually 
cleansed without injuring the mucous membrane in the slightest degree. 
Symptoms.—The first symptom of a stomatitis is a superficial ca- 
tarrhal inflammation of the mucous membrane of the mouth characterized 
by redness and injection of the gums. If “aphthae” develop, small gray- 
ish plaques appear on the mucous surface of any portion of the buccal 
STOMATITIS 
186 STOMATITIS 
187 
cavity. In mild cases there may be but three or four areas. In a case 
of moderate severity the mucous membrane of the gums, the hard and 
soft palate, and the inner side of the cheek will be studded with ulcerated, 
grayish-white areas, varying in size from a pinhead to a split pea. Oc- 
casionally the areas coalesce, forming larger plaques of a serpiginous 
type. 
Ulceration, which ordinarily does not appear until after the catarrhal 
condition has been present for at least three or four days, will first be 
noticed as a faint yellow line at the margin of the gum where it joins 
the teeth. This is the commencement of what Virchow describes as 
“necrobiosis.” Ulceration never occurs unless teeth are present. We 
have never known a case to go on to ulceration in a baby fed entirely 
at the breast. Whether the case remains simply catarrhal, or whether 
aphthae or ulceration, or both result, certain symptoms are common to 
all. There is a marked increase in the flow of saliva, which in some 
cases may be said to stream from the mouth, running down over the 
chin and soiling the clothes. On account of its acid properties it causes 
irritation of the skin and even eczema. The mouth is hot and painful. 
Fever is present in a slight degree both when the condition is simply 
catarrhal and when aphthse are present. There is but little prostration 
and the child appears but slightly indisposed. In cases which go on to 
ulceration the fever may be very high, frequently 104° F. or over. In 
one case it reached 107° F., although no cause except the ulcerative sto- 
matitis could be found for the fever. Under properly directed treat- 
ment this child recovered in a few days. 
On account of the pain occasioned by drawing on the nipple nutri- 
tion may be considerably interfered with. The child takes the breast 
or bottle greedily, draws a few times, stops, and begins to cry. If he is 
urged to try again, the behavior is repeated. The pain appears to be 
particularly severe when aphthae are present. The advent of ulcera- 
tion will be indicated by a change in the breath, which becomes dis- 
gustingly foul. The gums are thick, spongy, and bleed easily, and in 
some cases overlap the teeth very early in the ulcerative stage. If a 
case has been neglected or improperly treated, which is the history of not 
a few dispensary patients, the ulceration is often so extensive that the 
teeth become loose as a result of the destruction of the gum, and their 
removal is necessary. Strong, vigorous children seem as susceptible to 
the disease as are the rachitic, the badly fed, or the generally delicate. 
Prognosis.—The prognosis is good. All cases recover if seen early 
and if properly treated. Loss of teeth may result in those seen when 
the process is well advanced. 
Treatment.—Mouth Washing.—When the stomatitis is catarrhal or 
aphthous, preventive treatment—the washing of the mouth after each 
feeding with a saturated solution of boric acid in boiled water—is also 
curative. A baby’s mouth should be washed as follows: The child is 
placed on the side or stomach. The index-finger of the mother or nurse 
thoroughly wrapped in absorbent cotton is then dipped into the solu- 
tion, and without expressing the fluid, is placed in the child’s mouth. 
By gentle pressure upon the gums and cheeks a sufficient amount of the 
fluid is then expressed to run out of the mouth and effectively cleanse it. 188 
THE PRACTICE OF PEDIATRICS 
The washing is assisted by the opposition offered by the child to the 
manipulation of the tongue, cheeks, and jaws. 
Drugs.—Internal medication is of no value except indirectly. If there 
is a disordered digestive state, it should receive attention by diet and saline 
laxatives. Calomel should not be given. Whether the condition is catar- 
rhal or aphthous, it is practically never necessary to use other means 
than the free mouth washing. Astringents and caustics have never been 
necessary. 
The cases usually terminate in recovery in from four to seven days 
under strict attention to cleanliness as regards the feeding apparatus or 
the mother’s nipple, together with the free use of the boric acid solution 
as a mouth wash. 
Feeding.—The food problem is difficult to deal with, particularly 
in the case of nurslings, on account of the pain caused by drawing on 
the nipple, the child refusing absolutely to nurse. In some cases it may 
be necessary to draw the milk with a breast-pump, and for a day or two 
feed the baby with a spoon. With the bottle fed spoon feeding may 
also be resorted to. The child will take the nourishment much better 
if it is given cool. Small pieces of ice and teaspoonful doses of cold water 
are taken eagerly. 
Treatment After Ulceration.—With the development of ulceration 
a change in the management is necessary, both as regards a mouth wash 
and the necessity for internal medication. Among the local measures 
hydrogen peroxid as a mouth wash, 1 part of a 3 per cent, solution 
in 2 parts of water, used after each feeding, has given the best results. 
Such means, however, are rarely necessary if the case is seen early. Except 
in cases that show a considerable destruction of tissue no other means to 
secure cleanliness than the boric acid solution is required. 
Chlorate of Potash.—In the internal administration of chlorate of 
potash we have what is practically a specific in this disease. Its ad- 
ministration should be commenced as soon as the condition is recog- 
nized. One may prescribe the drug conveniently in syrup of raspberry, 
using 1 part of syrup to 2 parts of water. For a child under eighteen 
months of age one may order 2 grains at intervals of two or three hours 
—not more than 10 grains in twenty-four hours; for a child from eighteen 
months to three years of age 2 or 3 grains at the same intervals, not 
more than 15 grains in twenty-four hours. With the above dosage it will 
be necessary, in the average case to continue the drug from three to 
five days. Very often, after the improvement is well marked, we reduce 
the dose one-half and continue it for three or four days longer. 
Dangers of Chlorate of Potash.-—Much has been written concerning 
the danger of the internal use of chlorate of potash in children, particu- 
larly in relation to its effects upon the kidneys. If the use of the drug 
in suitable doses were of special danger in this respect, the free use of 
the chlorate of potash and iron mixture, so extensively prescribed in 
diphtheria in the pre-antitoxin period, would have been universally 
condemned. We have never seen any unpleasant effects from chlorate 
of potash given in doses of 10 to 20 grains daily, and we have used it in 
many hundreds of cases of acute inflammatory conditions of the throat 
and mouth. sprue (thrush; mycotic stomatitis) 
189 
SPRUE (THRUSH- MYCOTIC STOMATITIS) 
The disease makes its appearance in the form of small white masses 
of about the size of a pinhead. The tongue and the inner sides of the 
cheeks are favorite sites for the growth, although in severe cases the 
entire buccal cavity may be studded, as though finely curdled milk had 
been scattered over the surface, and the lesions may extend into the 
stomach. The growth is firmly adherent, and its forcible removal pro- 
duces slight bleeding. 
Etiology.—Sprue is invariably associated with uncleanliness, and 
occurs, as a rule, in weakly and marasmic nurslings and in the bottle 
fed—more frequently in the latter. The disease is rarely seen after the 
sixth month. 
Thrush, soor, or mycotic stomatitis is due to Oidium albicans, an 
organism which stands between the yeasts and the fungi. The threads 
of the mycelium end in egg-shaped conidia which bud and form new 
hyphse. Spores are formed only under favorable cultural conditions. 
Preparations made from the white patches on the buccal mucosa show 
both mycelia and yeast-like conidia. 
Symptoms.—An infant with this disease gives evidence of much pain 
and discomfort while nursing or while feeding from the bottle. Active 
gastro-enteric disturbances, such as vomiting and diarrhea, may be as- 
sociated with sprue, but such association is not the rule. Time and again 
one sees cases in which there are absolutely no other signs of the disease 
than the characteristic mouth lesions and the patient’s refusal of food. 
The average case may easily be cured in a week if treatment is carefully 
carried out. Sprue is not contagious, and if the means of prophylaxis, 
which will be suggested, are used as a part of the daily routine the dis- 
ease will never appear. 
Treatment.—If the patient is breast fed, the mother’s nipples must 
be washed with a saturated solution of boric acid and moistened with 
alcohol, diluted one-half, which is allowed to evaporate before each 
nursing. If the infant is bottle fed, both nipple and bottle should be 
boiled after each nursing, and the nipples turned inside out and scrubbed 
with borax water—1 ounce of borax to 1 pint of water. In either case 
the mouth should be washed with a saturated solution of boric acid after 
each feeding. For this purpose a generous amount of absorbent cotton 
loosely wrapped around the clean index-finger of the mother or nurse 
is placed in the cold solution, and then, without expression of the water, 
introduced by the finger into the child’s mouth. In the care of fully 
developed sprue, the application should be brought gently into contact 
with the diseased parts, first on one side and then on the other, and finally 
pressed over the tongue and under the tongue. It is well to have the 
child rest on the side or abdomen so that the fluid which is pressed out 
by the manipulation of the cotton against the cheek and jaws can readily 
escape from the mouth. The washing, which really amounts to an irri- 
gation, can be done in a few seconds, without the slightest danger of 
abrading the epithelium. In obstinate cases this treatment may be 
supplemented by penciling once a day with 1 per cent, solution of formalin. 
Internal medication is of no value except as a means of correcting 190 
THE PRACTICE OF PEDIATRICS 
any intestinal derangement that may exist, with a view to improving 
the general condition. If the bottle or breast is refused, spoon feeding, 
for a few days, may be found necessary, and in any event will hasten 
the cure. If the child is nursed, the mother’s milk may be drawn with 
a breast-pump (see p. 54) or pressed out with the fingers and then fed 
by the spoon. The domestic remedy, honey and borax, should not be 
used in treating any of the inflammatory diseases of the mouth in children. 
Etiology.—No single micro-organism has been proved to be the cause 
of noma. Spirilla and fusiform bacilli have been found (Weaver and Tun- 
nicliff) not only in the necrotic tissue, but in the surrounding healthy 
parts. Whether these organisms represent the primary cause of the lesion 
or only secondary invaders is not known. In other instances Bacillus 
diphtherise has alone been found. The nature of the lesion points to 
the action of a specific infection. Measles and diphtheria are at times 
precursors of noma. 
Symptoms.—The site of the disease is usually the inner side of one 
or both cheeks. The gangrenous process usually begins as a small, in- 
flamed, infiltrated area in the mucous membrane opposite the teeth. 
Localized destruction of tissue follows, and. this process extends with 
great rapidity until the tissue sloughs away in masses. The parts for 
some distance around the ulcer become hard, infiltrated, and discolored, 
presenting an inflamed, edematous look. After two or three days a dis- 
colored, ecchymosis-like area may be noticed on the outer side of the 
cheek, corresponding in location to the gangrenous portion within. At 
this point the ulcer soon perforates. The destruction of tissue continues 
quite symmetrically around the ulcer until the whole cheek is destroyed. 
The process not infrequently involves the bony structure, causing necrosis 
of the jaw, with loosening and falling out of the teeth. A symptom which 
will never fail and can never be forgotten by one who has seen even one 
of these cases is the almost unbearable stench which emanates from the 
patient. When the hands or the fingers of the physician or nurse come 
in contact with the gangrenous slough, it is almost impossible to remove 
or neutralize the disgusting odor. The disease usually occurs in weakly, 
marantic children, who die, ordinarily, from exhaustion and sepsis within 
ten days or two weeks from the onset of the disease. Hemorrhage is 
rarely a complication. The disease is usually fatal, even under the best 
management. 
Treatment.—The treatment pursued has consisted in the use of 
free cauterization with nitric acid, chemically pure, and the application 
of disinfectant wet dressings of biehlorid 1 :2000, saturated solution of 
boric acid, or equal parts of alcohol and water. The dilute alcohol is 
apparently more effective in staying the progress of the disease than is 
either the biehlorid or the boric acid solution. On account of its rapid 
evaporation the alcohol should be applied on two or three layers of 
lint and covered with rubber tissue. Even then frequent renewals are 
required. Hydrogen dioxid may be used to cleanse the ulcer both before 
and after perforation. 
CANCRUM ORIS (NOMA) GEOGRAPHIC TONGUE 
191 
FISSURES OF THE LIPS 
Deep cracks and fissures in the lips are of quite frequent occurrence 
among children. Usually the lower lip is involved, and in many of the 
cases there is but one deep fissure and that at about the middle of the 
lower lip. Marasmic, ill-conditioned children are the most frequent 
sufferers. The fissures bleed easily and occasion considerable pain during 
nursing. As a result less food is taken than the child requires. 
Treatment.—If the fissure is deep, a 50 per cent, solution of nitrate 
of silver should be applied at the commencement of the treatment. This 
is to be followed by frequent applications—three or four times daily 
—of a 25 per cent, solution of ichthyol. Healing is usually prompt, 
requiring but a few days. If the mucous membrane of the lip generally 
is dry and fissured, as in cases of prolonged illness with fever, the frequent 
use of a 5 per cent, boric acid ointment, made with cold cream as a base, 
will be of material assistance in controlling the condition. 
ULCERATIONS AND FISSURES AT THE ANGLE OF THE MOUTH 
Ulcerations and fissures at the angle of the mouth are by no means 
uncommon in delicate and marasmic infants. While ulceration in this 
location is one of the manifestations of congenital syphilis, such ulcers 
are not necessarily syphilitic. The condition, however, is of sufficient 
importance to require treatment, because the affection is so painful 
as to prevent the taking of adequate nourishment. Painting the fissure 
with a 25 per cent, solution of ichthyol every three hours during the 
day will insure prompt healing. 
GEOGRAPHIC TONGUE 
The condition known as a “geographic tongue” consists of distinct, 
smooth, reddish patches on the tongue’s surface, surrounded by a light 
grayish, narrow, raised border. The smooth surfaces comprising the 
involved areas are devoid of epithelium; the borders are composed of 
hypertrophied papillae which take on a grayish color, making a distinct 
framework for the reddish areas, which are almost always crescentic 
in shape. This peculiar marking has given rise to the term “ringwTorm 
of the tongue.” Geographic tongue is seen most frequently in children 
under three years of age, and occurs as often among the strong and vig- 
orous as among the delicate and weakly. The condition is usually dis- 
covered by the mother, who, with much agitation, brings the child to the 
physician. It does not appear to be due to and is usually not associated 
with any disturbance of the gastro-enteric tract. That portion of the 
tongue which is not involved appears perfectly normal. 
Treatment of geographic tongue is unnecessary, as the condition 
causes no symptoms and apparently is independent of any disease. It 
is a good custom to assure mothers that the condition is of no conse- 
quence, for it usually disappears in a few months. One case was ob- 
served to last for a year. 192 
THE PRACTICE OF PEDIATRICS 
DIFFICULT DENTITION 
It is claimed that the eruption of the teeth is a physiologic process, 
and as such is not productive of harm. In normal, well babies this is 
generally the case. There may be a slight fever and restlessness, with 
loss of appetite, associated with the eruption of a tooth, but the disorder 
is usually very temporary in character. In delicate children, particularly 
in those who teethe late, as in the rachitic, when several teeth are cut 
at one time, not a little inconvenience may be caused by dentition. Even 
these patients, however, rarely have grave digestive disorders. In a 
large experience with teething infants we have known barely one in 
whose case convulsions were apparently directly dependent upon denti- 
tion. Such an exceptional patient was a rachitic, institution child who 
cut his first tooth at the ninth month, and with each of the three succeed- 
ing teeth, which were cut during the next three months, developed con- 
vulsions without any other signs of illness. 
Temporary digestive disorders are of very frequent occurrence in this 
type of child during an active dentition. The child may be restless and 
irritable and perhaps have fever of a degree or two. His digestive capac- 
ity is lessened, and if the usual diet is continued, fermentative diarrhea 
results, which may be, and often is, the starting-point of grave intestinal 
disease. When it is apparent that the child’s generally good natured, 
daily habit of life is being unfavorably influenced by dentition, the food 
should temporarily be reduced, particularly if the weather is hot. 
Breast babies may be given water before each nursing so as to re- 
duce the capacity for milk. For the bottle fed 2 or 3 ounces of the food 
mixture may be removed from each bottle, the amount being replaced 
with boiled water. 
That cough and respiratory and skin diseases are immediate results 
of dentition is without foundation. During active dentition, when the 
gums are distended and swollen from pressure, relief will often be fur- 
nished promptly by rubbing through the prominent points of the tooth 
with a clean towel over the index-finger. Lancing alone may be per- 
formed, but unless the tooth is well advanced it is quite possible that 
the gums will reunite over the tooth, forming a cicatrix which will make 
the eruption more difficult than before. If a week or ten days’ discom- 
fort can be obviated by assisting a tooth through the gum, we fail to 
see any contraindication to such a procedure. 
DISEASED TEETH 
The influence of diseased teeth upon the proper mastication of the 
food and indirectly upon digestion and nutrition has long been recognized. 
During the past two decades the role of such teeth as potential foci for 
disseminating general infection has assumed an importance secondary 
only to that of diseased tonsils. 
Many factors combine to promote faulty structure and early decay 
of the teeth. Defective calcium metabolism from whatever cause in the 
early years when enamel formation is active is perhaps a foremost caus- 
ative factor. This is best exemplified in rickets. In syphilis the teeth 
are notoriously diagnostic of the disease. In typhoid and many of the HARELIP AND CLEFT-PALATE 
193 
acute infectious diseases inroads upon the normal tooth structure are 
often marked, conforming closely to the bad effects on the nutrition of 
the body as a whole. When to such direct causes of tooth decay are 
added the factors of improper diet, poor heredity, malformation of the 
jaws and palate, adenoid obstruction, and lack of cleanliness of the mouth 
it is apparent why the demands made upon the dentist for therapy are 
often paramount to those made upon the physician. 
The clinician should make the examination of the teeth a matter of 
routine, and in the absence of other disease foci in the body will do well 
to consider bad teeth as perhaps the salient etiologic factor underlying 
the following conditions: anorexia, bad breath, stomatitis, headache, 
unexplained temperature elevation, rheumatism, cervical adenitis, sec- 
ondary anemia and malnutrition, faulty nervous control, chorea, and 
exceptionally even epilepsy. In all such cases the indications are obvious. 
The argument often advanced that diseased teeth of the first set require 
no dentistry because they will soon be replaced by a good second set is 
analogous to the reasoning of the dirty housekeeper who relaxes her 
energy completely in view of a remote moving day. 
HARELIP AND CLEFT-PALATE 
Harelip is a vertical cleft in the upper lip resulting from arrested 
embryonic development. This defect may or may not be associated 
with cleft-palate, and varies from a slight indentation in the border of 
the lip to a deep fissure, which may be bilateral, extending into the nos- 
tril, complicated by non-union of the palate. In any case the deformity 
will be easily understood if we recall that the normal development of the 
face depends upon the union of the central or frontonasal process with 
the two lateral superior maxillary processes. Posteriorly, this union is 
completed in the median line of the palate, and anteriorly, on either 
side external to the incisors, in the soft parts beneath the nostril. 
Etiology.—The malformation is more frequent in males than in fe- 
males, and in some instances can be ascribed to heredity. Not infre- 
quently with cleft-palate other congenital defects coexist. The true cause 
of the arrest in development is unknown. 
Varieties.—Both harelip and cleft-palate may be complete or in- 
complete, unilateral or bilateral. When the harelip is double, cleft-palate 
also almost always exists. Median harelip is of exceptional occurrence. 
Symptoms.—The character of these deformities is wholly apparent. 
In the simple forms of harelip the disdavantages may be merely cos- 
metic. When there is a cleft in the palate, however, suckling will be 
interfered with, deglutition will be difficult, and if the child goes un- 
treated and survives, articulation will be imperfect. 
Treatment.—The treatment of both harelip and cleft-palate is es- 
sentially surgical. The former defect, if uncomplicated, may usually 
be satisfactorily obliterated by an operation of the Konig or Nelaton 
type. Cleft-palate offers more serious obstacles. Brophy’s operation 
secures an approximation of the edges of the cleft by the gradual tight- 
ening of silver wire sutures traversing two lead plates, each of which is 
fitted to the lateral portions of the alveolar arch. The operation on the 194 
THE PRACTICE OF PEDIATRICS 
hard parts is deferred until the child is fourteen to eighteen months of 
age. When the cleft is small, this procedure may be excluded in favor 
of a mQre direct method. An operation during the first months of life 
involves considerable risk, but offers better possibilities for good de- 
velopment of the nasopharynx than an operation deferred until the 
third or fourth year, after the growth of the teeth. The appropriate 
course to adopt in any case should, therefore, be left to the surgeon. 
In young infants with cleft-palate spoon feeding or gavage is fre- 
quently necessary. Good results in some cases are reported to have 
followed the use of a special nipple with a flange on either side, designed 
to bridge over the fissure in the palate. 
MALFORMATION OF THE ESOPHAGUS 
Malformation of the esophagus is of infrequent occurrence, and 
when present is usually accompanied by other congenital deformities. 
Fig. 21.—Atresia of the esophagus with esophagotracheal fistula. Anterior view. 
A, Tongue; B, larynx; C, blind esophageal pouch; D, lungs; E, stomach; F, trachea; 
G, liver; H, lower end of esophagus, which communicates with the trachea. (From a 
dissection by Losee.) 
In most instances the differentiation of the esophagus from the trachea 
and bronchi, in the metamorphosis of the embryonic foregut, has been 
incomplete. ACQUIRED STRICTURE OF THE ESOPHAGUS 
195 
The list of possible abnormalities includes the following: 
(а) Total absence of the esophagus. 
(б) Diesophagus, involving partial or complete reduplication of the 
esophagus. 
(c) Esophagotracheal fistula, with or without obliteration of the 
lumen of the esophagus in a portion of its extent. 
(d) Division of the esophagus into upper and lower non-communi- 
cating pouches. 
(e) Congenital stenosis. 
(/) Congenital dilatation. 
The symptoms caused by these conditions depend on the obstacles 
opposed to deglutition. Regurgitation of food and accumulated mucus 
is constant, accompanied by suffocative attacks due to the entrance 
of material into the respiratory tract. Congenital dilatation above the 
diaphragm may produce the symptom of rumination. 
In a large majority of the cases congenital malformation of the esoph- 
agus results in death before the tenth day from asphyxia, aspiration 
pneumonia, or starvation. 
Gastrostomy offers the only possible means of prolonging the pa- 
tient’s life till surgery directed at the primary defect can justifiably 
be attempted. 
Illustrative Cases.—An autopsy on an infant a few days old referred to the Babies’ 
Hospital showed that the trachea communicated with the esophagus just above the 
bifurcation. 
The esophagus was normal at its upper portion, dilated lower down, and formed 
a blind diverticulum which ended below the level of the tracheal bifurcation. Above 
the diverticulum the esophagus communicated with the trachea through an opening 
in its anterior wall. Below the diverticulum the esophagus was smaller in caliber 
than normal, but it was pervious and communicated with the stomach. A probe could 
be passed upward through the esophagus into the larynx. 
A baby seven days old took the bottle greedily and, after swallowing about 2 drams, 
regularly returned the milk through the nose. He would nurse vigorously with the milk 
streaming from the nose. 
ACQUIRED STRICTURE OF THE ESOPHAGUS 
Practically all cases of this nature are the result of the swallowing of 
a corrosive poison. In one of our own patients carbolic acid was the cause. 
Chevalier Jackson has reported several cases due to commerical lye 
used for cleansing purposes, and warned strongly against the danger of 
leaving such substances carelessly in places accessible to children.1 
1 Jour. Amer. Med. Assoc., July 2, 1921. VIII. DISEASES OF THE STOMACH, INTESTINES, AND 
PERITONEUM 
THE STOMACH 
Anatomy.—During fetal life the position of the stomach is almost 
vertical, at birth slightly oblique, the obliquity increasing with age. 
At birth the stomach is almost cvlindric, and, according to Pfaundler, 
between the time of birth and the seventh month the fundus of the stomach 
increases to fully twice its original length, so that at about the end of 
infancy the stomach lies in a somewhat oblique position, passing from 
behind forward and downward. The diaphragm is penetrated by the 
esophagus at about the level of the ninth dorsal vertebra, while the cardia 
is about on a level with the tenth. The pylorus, though usually situated 
in the median line, may occasionally be found to the right of it. 
Capacity.—The capacity of the infant’s stomach is, even up to the 
present day, a subject of more or less speculation, due, no doubt, to 
the fact that during life aspirations are unreliable on account of the 
fact that food passes almost immediately into the duodenum, and methods 
of experiment on the cadaver require an amount of pressure (14 to 30 c.c. 
of water) that does not exist in the normal state during life. The stomach 
undergoes a systolic contraction after death, and thus the distention 
with fluids is artificial. 
The absolute capacity, according to Holt, Rotch, Pfaundler, and 
Fleishmann, varies, depending on the method of examination employed. 
According to Holt’s observations, based on postmortem examinations 
of 91 infants, the capacity at birth is ounces; at three months, 
ounces; at six months, 6 ounces; at twelve months, 9 ounces. This subject 
is discussed on page 38. 
Gastric Digestion.—Digestion in the stomach is not so important 
in the infant as in the adult. The function of the infant’s stomach is 
mainly that of a reservoir, the digestive processes being only preliminary. 
The principal change in the milk, so far as the stomach is concerned, 
occurs in connection with the casein curd, and up to the present time 
it is well established that protein digestion in the stomach does not go 
beyond the stage of peptone formation. Pepsin is found in large amounts 
in the infant’s stomach, and, according to some observers, occurs as early 
as the fourth month of fetal life. The reaction of the stomach contents 
is usually acid inside of fifteen minutes after ingestion of food, but free 
hydrochloric acid is not present till thirty or forty-five minutes after, the 
reason being that hydrochloric acid combines with the casein and milk 
salts. 
The coagulation of milk, which is the first change that it undergoes, 
is brought about through the agency of the rennet ferment. The casein 
coagulum of cow’s and of human milk is essentially different, the former 
being a firm mass, containing in its meshes the fat of the milk, the latter 
being in fine flocculi, with little of the fat, and readily acted on by the 
196 THE STOMACH 
197 
stomach juices. Due to the influence of pepsin and hydrochloric acid 
solution of the coagulum begins; this occurs more rapidly in woman’s 
milk on account of the lower casein content and the small size of the 
curds. During the first half-hour the fluid portion or whey begins to 
leave the stomach, and at this time a considerable portion may be found 
in the intestine, and at the end of an hour in a young infant the stomach 
may often be found empty. In a bottle-fed baby the coagula are larger, 
solution is retarded, and consequently the food is retained longer. If 
the milk is boiled, solution is more rapid and gastric retention lessened. 
Fig. 22.—Normal stomach of a newborn infant. Some of the opaque mixture has 
immediately passed through the pylorus and reached the jejunum (J). 
Some observers believe a fat-splitting ferment to be present, but this, 
if present in the stomach, plays but a small role in digestion. 
Motility.—The duration of digestion varies of necessity with the 
age of the infant and the composition of the food. In general terms 
it may be stated that in breast-fed infants digestion is completed in one 
and one-half to two hours; in artificially fed infants taking raw milk, 
in about one to two hours longer; and in those taking boiled milk, in a 
little less time. 
Cannon demonstrated that an acid reaction of the contents of the 
pyloric portion causes the pylorus to open, while an acid reaction in the 
duodenum causes it to remain closed. After the coagulation of the casein 198 
THE PRACTICE OF PEDIATRICS 
of the milk the whey is readily acidified and passes the pylorus first, 
together with the carbohydrates. As the protein requires a longer time 
to combine with the acid of the stomach it is some time before free acid 
is present, and the exit of the protein from the stomach is, therefore, 
delayed. The fatty acids and neutral fats are the last to pass the pylorus, 
because of the longer time required for the fatty acids to be neutralized 
by the duodenal secretions; and the pylorus, therefore, remains closed 
because of duodenal activity. The opening and closing of the pylorus, 
according to these investigations, depends chiefly on the reaction of the 
gastric contents, which is the most vital factor in the motor activity of 
the stomach. 
THE MANAGEMENT OF VOMITING BABIES 
The baby who habitually vomits or regurgitates his food is one of 
the most troublesome patients with whom we have to deal. 
In such cases the possibility of existing pyloric stenosis or of rumina- 
tion must be excluded. Excellent results, in feeding these habitual vom- 
iting children, have been gained by the use of cereal decoction and a fat- 
free milk. One ounce of barley flour to the pint of water is cooked for 
thirty minutes, and water added to make one pint at the completion of 
the boiling. The child is fed one-third skimmed milk to two-thirds barley 
water, or equal parts of skimmed milk and barley water, depending upon 
the patient’s age and condition. Unless the child is very young the 
interval between feedings should be three hours or longer, and absolute 
quiet should be enforced for one and one-half hours after feeding. The 
handling and tossing about of the vomiting child is one of the best ways 
of keeping up the trouble. If constipation results from such a diet, mag- 
nesia in sufficient amount may be added to the daily ration. 
It is not to be expected that a patient will grow on the above diet. 
When the vomiting is controlled, the food strength may be advanced 
by the use of whole milk, and later by the addition of milk-sugar. The 
addition of 20 grains of bicarbonate of soda to the day’s ration is of de- 
cided benefit in very troublesome cases. 
By some infants fresh cow’s milk will not be tolerated, even in very 
weak dilution. In such instances we have been successful in using evap- 
orated milk to which cane-sugar has not been added. From 1 dram to 
| ounce is added to the amount of barley water given at one feeding. 
The more severe and persistent cases call for trial of the thick cereal 
feeding described on page 85. The remarkable effects of this mode of 
treatment in occasional cases can hardly be exaggerated, and the range 
of its application has been greatly widened in the past few years. 
Stomach Washing.—Nearly all habitually vomiting infants will im- 
prove more rapidly if they have a stomach washing every day for a week, 
and every two or three days thereafter, as may be necessary. For vom- 
iting in rumination see p. 206. 
Additional consideration has been given the general subject of vomit- 
ing in infancy in a preceding chapter (p. 100)'. VOMITING OF OLDER CHILDREN 
199 
While vomiting does not constitute a disease in itself, it is a condition 
of such frequency and occurs in such widely varying circumstances that 
any work relating to diseases of children would be incomplete without its 
consideration. Certain facts concerning this subject have already been 
emphasized (p. 100). 
The most frequent causes of vomiting depend solely upon the func- 
tions of the stomach. When the stomach is overfilled, vomiting may re- 
sult. When substances sufficiently irritating come in contact with its 
lining mucous membrane, whether they are swallowed or are produced 
by fermentation in the stomach contents, they are ejected. Wffien there 
is an inflammatory involvement of the mucous membrane of the stom- 
ach, either acute or chronic in character, the organ becomes intoler- 
ant of the blandest of fluids. Another condition involving the structure 
of the stomach, but only occasionally seen in children, is ulceration, 
which is usually multiple. Vomiting is the prominent, in fact, usually 
the only, symptom. 
Dilatation of the Stomach.—In this condition the food does not pass 
readily into the intestine, but remains in the stomach and undergoes 
changes which produce sufficient irritation to cause vomiting. 
Pylorospasm.—In pyloric obstruction or spasm the food is prevented 
by the narrow pyloric opening from passing into the intestine, one feeding 
follows another, the stomach becomes overloaded, and, by reason of fer- 
mentative change in the residue, sufficient irritation is produced in con- 
nection with the spasmodic contractions of the stomach peculiar to the 
condition, to induce vomiting. 
Causes Remote from the Stomach.—Delayed emptying of the stom- 
ach is not infrequently an indirect cause of vomiting. It is not gen- 
erally appreciated that persistent constipation is a cause of prolonged 
retention of the stomach contents, although fecal retention unques- 
tionably has an influence in prolonging stomach retention. This has 
been brought out in our z-ray studies. In order for the stomach to 
function normally it should be empty at least by four hours after a meal. 
When food is added to undigested stomach contents vomiting is sooner 
or later bound to appear; in this way mechanical agencies, such as ptosis, 
angulations, and the greatly elongated sigmoid, may be indirect factors in 
producing vomiting of a habitual nature (p. 220). In intestinal obstruc- 
tion, whether due to intussusception, volvulus, peritonitis, abnormalities 
of structure, or impacted feces, vomiting is an invariable accompaniment, 
continuing at irregular intervals until the obstruction is relieved or until 
the child dies. 
The exanthemata and lobar pneumonia are very commonly ushered 
in by vomiting if the onset is sudden and intense. In appendicitis in 
children vomiting is usually one of the early symptoms; so also, in the 
different forms of meningitis, it is often an early symptom, and may con- 
tinue persistently during the first few days of the illness. In nephritis, 
with uremia, vomiting is usually present. Vomiting may be caused by 
fright, by shock, or by a strain of any nature, as in whooping-cough, or 
may be of purely nervous origin. 
VOMITING OF OLDER CHILDREN 200 
THE PRACTICE OF PEDIATRICS 
Illustrative Case.—A girl patient four years old, pale and thin, had the history of 
vomiting for more than a year, beginning with rather a protracted, badly managed 
attack of indigestion. At first there were but one or two attacks a day. Later they 
became more frequent, and for a few weeks before the child came under personal ob- 
servation the vomiting had occurred at the table with nearly every meal, before the 
meal was completed. The mother was most anxious and apprehensive regarding the 
child’s condition, was always with the patient, always fed her, and always worried 
constantly throughout the meal, fearing an attack of vomiting. The most thorough 
means of examination of the stomach failed to show anything wrong with it. After 
some days’ observation it occurred to the writer that the presence of the apprehensive 
mother, in whose mind the condition of the child and the vomiting were uppermost, 
might be a factor in causing the vomiting. He accordingly directed that the child take 
her meals in the kitchen with the maid, and that the possibility of vomiting should not 
be mentioned. The mother was directed not to come in contact with the child in any 
way during the meal. We were much gratified and not a little surprised when the 
vomiting promptly ceased. After a few months of this regime the maid was taken ill, 
and the mother for one day attended to the feeding. Again the child vomited as before. 
The management of the different types of vomiting will be referred 
to in the consideration of the various diseases with which it is associated. 
ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION 
Not a little confusion exists respecting the differentiation of acute 
gastritis and acute gastric indigestion. Cases of gastric indigestion are 
often diagnosed as gastritis. Actually acute gastritis in children is a very 
rare condition, while acute gastric indigestion is very frequent. Acute 
gastritis in the young is usually due to the ingestion of corrosive or irri- 
tant drugs. Food, unsuitable in character or quantity, or food which 
may have undergone chemical or bacterial change, may produce pro- 
nounced vomiting, usually transient in character. Inflammation of the 
mucous membrane of the stomach may be produced in this way, but 
according to autopsy findings it is most unusual. 
Cases of persistent vomiting which are often diagnosed as gastritis 
are not infrequently due to obstruction at the pyloric outlet dependent 
upon the presence of hypertrophic stenosis (p. 215), or pylorospasm 
(p. 214). Any of the various forms of meningitis or encephalitis may be 
preceded or accompanied by persistent vomiting. Acute intestinal 
obstruction should be kept in mind as a cause of persistent vomiting. 
Acute acid intoxication may occur at any age and should always be taken 
into consideration before making a diagnosis of acute gastritis. 
Autopsies on infants dying from acute gastro-enteric diseases, such 
as cholera infantum, rarely show any actual stomach lesion, although 
there may have been persistent vomiting for two or three days. 
Acute gastric indigestion is manifested in sudden repeated vomiting, 
often with fever, always with prostration, and with apparent disgust for 
food. The temperature may be high—104° to 105° F.—or normal through- 
out the case. After a few hours there will often be evidence of bowel 
involvement. The stools are undigested, greenish in color, and contain a 
moderate amount of mucus. There may be moderate abdominal distention. 
The symptoms other than that of emesis may appear of little significance. 
Treatment.—A high enema should always be given as the initial treat- 
ment in any illness of any nature in which there is acute vomiting with 
an absence of free bowel action. If the vomiting is continued, the man- 
agement of the case, regardless of the exciting cause, is to wash out the ACUTE GASTRITIS AND ACUTE GASTRIC INDIGESTION 
201 
stomach at least once and to give no food by mouth. If the case is of 
more than twelve hours’ duration in an infant or twenty-four hours’ in 
an older child, colon flushings should be carried out to supply fluids to 
the organism (p. 855). A remedy of much value, both for infants and 
older children, is a solution of bicarbonate of soda, 5 grains in 6 ounces 
of water, given hot in teaspoonful doses at intervals of a very few min- 
utes. 
Diet.—After twelve or twenty-four hours’ abstinence from food, 
small quantities of water or some very weak food may be given ten- 
tatively if the child craves it. Whey, skimmed or diluted milk, barley 
water, weak tea, chicken or mutton broth may be tried in teaspoonful 
doses every half-hour. Usually cold foods will be retained better than 
those that are heated. If the food or water is rejected, a further stomach 
rest of from eight to twelve hours may be ordered before the feeding 
is resumed. 
Treatment of Protracted Cases.—In the protracted cases the stom- 
ach should be washed, at least once daily, with a 5 per cent, solution 
of bicarbonate of soda. It is never wise, in the event of vomiting, to 
attempt forced feeding, as nothing will be gained; in fact, the vomiting 
may be continued indefinitely, and chronic gastric indigestion estab- 
lished, as a result of injudicious attempts at feeding. For the persistent 
vomiting of infants, gavage (p. 853) may also be used. A food which 
is rejected when swallowed will often be retained when put into the stom- 
ach through a tube. It is from the lack of fluid that the child suffers 
most in the case of protracted vomiting. In such cases colon flushing is 
particularly valuable, as they are rarely sufficiently severe to require 
hypodermoclysis. 
Applications of heat or counterirritation over the stomach area are 
of no real service, but at times are grateful to the patient. One who has 
treated many of these cases of acute indigestion with different forms of 
medication, including calomel, small doses of ipecac, oxalate of cerium, 
opium, etc., cannot fail to have been far more impressed with their use- 
lessness than with their beneficial influence. 
An enema, the recumbent position, and the withholding of food, 
with nourishment, or fluids such as normal salt solution, by the bowel, 
have given the best results. When the child craves food and asks for 
water after an abstinence of several hours, feeding may be tried, but 
the fact that he asks for it is by no means a guarantee that what is given 
will be retained. In exceptional cases rectal feeding may be required. 
Treatment of Persistent Vomiting by Drugs.—In pronounced, urgent, 
frequent vomiting of undoubted gastric origin, morphin hypodermically 
may be required. The morphin should be guarded by atropin and given 
in doses of 1/50 to 1/40 grain for a child one year old, to 1/10 grain for 
a child from eight to twelve years old. The relation of the dose of mor- 
phin to that of the atropin should be as 1 is to 1/20. Thus, a child who 
is given 1/30 grain morphin should have combined with it 1/600 grain 
atropin; with 1/10 grain morphin there should be given 1/200 grain 
atropin. 
It will rarely be necessary to repeat the morphin more than once, 
two injections being given at an interval of from four to six hours. In all 202 
THE PRACTICE OF PEDIATRICS 
cases the usual feedings must be resumed gradually. A trial of differ- 
ent foods will soon show which will best be retained. 
CHRONIC GASTRIC INDIGESTION (CHRONIC GASTRITIS) 
Chronic gastric indigestion develops most frequently in comparatively 
young infants, and is often associated with, or is a cause of, marasmus 
and malnutrition. 
Symptoms.—Vomiting and regurgitation of food are the predomi- 
nant acute manifestations of the disorder, which, untreated, interferes 
seriously with the nutrition of the patient. The condition is almost 
invariably a result of slight but persistent errors in feeding—errors too 
small to make the child violently ill, but sufficient to keep the stomach 
in a constant state of unrest. 
Pathology.—The lesions in these cases are insignificant. There may 
be some superficial, localized congestion at the pyloric end of the stom- 
ach; there may be destruction of the superficial epithelium and infiltra- 
tion of the mucosa with round cells. 
Treatment.—The management consists in daily stomach washings, 
sometimes for a long period, and an adaptation of the food to the child’s 
digestive capacity (p. 198). While there is no one way of feeding these 
cases, a food of greatly reduced strength must always be given, par- 
ticularly when cow’s milk is used. As a rule, these children have a low 
fat and sugar tolerance. Usually the proteins are fairly well taken care 
of if the function of the stomach is not disordered by too much fat and 
sugar. 
GASTRIC HYPERACIDITY IN CHILDREN 
A vast amount of literature has appeared relating to hyperacidity and 
associated conditions of the gastric contents in adults. That a similar 
condition may exist in young children has not been appreciated. A clin- 
ical study of the cases demonstrating high stomach acidity was forced upon 
us by a symptom complex which was shown by many patients and which 
corresponded to the symptomatology of gastric hyperacidity in adults. 
Etiology.—Dietetic errors will usually but not invariably be found 
responsible for the disorder. In addition to the usual bad feeding habits, 
taking unsuitable food at irregular hours, eating between meals and the 
liberal patronage of confectionery stores and soda fountains, the habitual 
use of orange juice in liberal amounts on an empty stomach before the 
first meal is significant. In fact, the hyperacidity condition may be due 
to the taking of orange juice cold and undiluted on an empty stomach 
before breakfast. 
Hypomotility and pvlorospasm, both conditions not uncommon in 
children, cause delayed emptying of the stomach beyond the four hours 
that is the normal evacuation time for the runabout child. This gives 
rise to gastric retention, which causes hyperacidity. We have studied 
109 children in regard to this point by means of the Roentgen ray, using 
the stomach-tube as a control in several of the cases. We find causative 
also the short period allowed between the first and second meal of the 
day. On account of family habits or because the child is a late sleeper GASTRIC HYPERACIDITY IN CHILDREN 
203 
the first meal is delayed and not completed before 8.30 or 9 o’clock. 
The second meal is given promptly at 12 or 12.30, which means that the 
second meal is given before the first meal has entirely passed through the 
pylorus, and again there are retention and hyperacidity. In order that 
the appetite and digestion may be normal there must be no food residue 
in the stomach when a meal is given. Further, we have found that a 
rest period or interdigestive period of from one-half to one hour is required 
in order that the stomach functions may be carried on normally. It is to 
be understood that the rest period implies an empty stomach. 
Symptomatology.—The symptoms in their order of frequency are: 
abdominal pain that has not been relieved by previous treatment, nausea 
without vomiting, vomiting at irregular intervals, and loss of appetite. 
The pain occurs most often before meals when the stomach is sup- 
posedly empty. In many cases pain is complained of before the morning 
meal. At times the child is awakened early because of the abdominal 
discomfort. When asked to locate the pain, the child usually places 
the hand over the abdomen above the umbilicus. In some the pain is 
of a colicky character sufficiently severe to cause crying. 
Vomiting.—With the pain there may be daily morning vomiting, or 
the vomiting may occur independently of pain, or the child may be nau- 
seated and vomit before the meal or immediately after. Breakfast is 
usually the meal vomited. 
Nausea.—In some there is neither vomiting nor pain, the condition 
manifesting itself by nausea, most prominent before mealtime, and 
perhaps relieved by taking food. 
Appetite.—The appetite is variable. In most instances it is much 
impaired. In others the child will be eager for food, but is satisfied by 
a few mouthfuls, complaining of a feeling of fulness, so that further feed- 
ing must be urged. 
Many children with an habitually poor appetite are victims of hyper- 
acidity. 
Nausea and Eructation of Gas.—This combination is not infrequently 
seen, and is almost always associated with an indifferent and capricious 
appetite. Eructations of gas and belching may be the only symptoms 
complained of. Mothers have stated that the eructation was so pronounced 
as to be embarrassing. 
Constipation.—This is usually present; probably the small food intake 
has much to do with this. In cases in which the condition has existed 
for a considerable time malnutrition and anemia due to the defective food 
intake are marked. In mild cases the appetite alone is affected. 
In 67 recent cases of chronic stomach disorders we have insisted on 
the test meal and gastric analysis, and have been surprised at the co- 
operation of the parents. This is to be accounted for probably by the fact 
that the child is brought for a condition which is believed to be serious. 
Examination of Gastric Contents.1—Test Meal.—-The test meal con- 
sists of 2 ounces (60 gm.) of dried bread and 6 ounces (178 c.c.) of weak 
tea. In one hour the stomach contents are removed by the stomach- 
tube. 
The Preparation of the Patient.—The child is wrapped snugly in a 
1 By Dr. E. J. Lorenze, Jr. 204 
THE PRACTICE OF PEDIATRICS 
rubber sheet, primarily to prevent struggling and secondarily to prevent 
soiling of the clothing by material vomited along the sides of the tube 
and by the profuse secretion of saliva. The child is held firmly by the 
assistant. After the tube has been moistened in warm water, it is passed 
to the posterior part of the pharynx. Older children are asked to swallow, 
but in dealing with the younger it is necessary to pass the tube without 
co-operation. A certain definite resistance is encountered when the tube 
strikes the greater curvature of the stomach. Usually the evacuation of 
the stomach contents begins immediately. The flow is accelerated by 
coughing, crying, and vomiting. It is frequently necessary to begin the 
evacuation by aspiration. We find the Hess bulb satisfactory for this 
procedure (p. 211). 
Technic of Gastric Analysis.—Three separate portions of 10 c.c. of 
unfiltered gastric juice are placed in three small beakers. To the first 
portion 3 or 4 drops of phenolphthalein are added, and this is titrated 
with tenth-normal sodium hydroxid until a deep permanent purple is 
obtained. The number of cubic centimeters of tenth-normal sodium 
hydroxid used in titrating is then multiplied by 10, giving the total acidity 
of 100 c.c. of gastric contents. Three or 4 drops of alizarin is added to 
the second beaker, and this is titrated until a permanent violet is ob- 
tained, when the reading on the buret is made. This result is subtracted 
from the number of cubic centimeters used with phenolphthalein as the 
indicator. This is multiplied by 10 to obtain the amount of combined 
hydrochloric acid in 100 c.c. of gastric juice. To the third beaker 3 or 4 
drops of Toepfer’s reagent is added, and this is titrated until the red 
disappears and yellow makes its appearance. The buret is read and the 
result multiplied by 10. This gives the amount of free hydrochloric 
acid in 100 c.c. 
Results of Examination of Gastric Contents— Among 67 cases, 44 
showed a total acidity over 60; 36 over 70; 24 over 80; 3 over 90, and 
2 over 100. The 2 cases showing a total acidity over 100 were those 
in which there was a food residue remaining from the meal prior to the 
test meal. Of the 23 that were under 60, the findings were: 14 between 
50 and 60; 4 between 40 and 50; 4 between 30 and 40, and 1 between 20 
and 30. We have come to look upon the normal acidity in children as 
ranging between 30 and 40. 
In the same series we determined the amount of free hydrochloric 
acid in the gastric contents of 59 patients. Fifteen showed the amount 
of free hydrochloric acid to be between 1 and 10; 17, 10 and 20; 8, between 
30 and 40; 4, between 40 and 50; 2, between 50 and 60; 3, between 60 
and 70, and 1, between 70 and 80. There were but 3 cases in which we 
found an absence of free hydrochloric acid in those investigated. 
Management.—Three full meals are allowed: breakfast at 7.30 a. m., 
dinner at 12.30, a cracker at 3.30, and supper at 6 p. m. Kaw fruits, fruit 
juices, and condiments are forbidden. Solids and liquids are to be given 
neither very hot nor very cold. Ice-cream and all iced drinks are ex- 
cluded. Sugar is used scantily. Medication consisting of a powder com- 
posed of sodium bicarbonate and bismuth subcarbonate, each 2 grains 
(0.13 gm.), and magnesium carbonate, 1 grain (0.065 gm.) is given with a 
half glass of warm water fifteen minutes before each meal. If constipa- ULCERATION OF THE STOMACH 
205 
tion is a factor, from 15 to 30 drops of aromatic fluidextract of cascara 
sagrada is given after each meal, and not in one dose at bedtime. 
Results of Treatment.—The outcome of the treatment has been most 
satisfactory. Children rarely have gastric, pyloric, or duodenal ulcers. 
Malignant disease of the stomach is so rare an occurrence that it can 
be excluded. Relief with few exceptions is prompt, but the diet and the 
medication should be continued for several weeks. We have known 
relapses to occur a year or more after the cessation of treatment. When 
there has once been a definite hyperacidity, there is a strong tendency for 
it to return, and some of these patients are unquestionably in line for 
surgical procedure later in life. 
HEMORRHAGE FROM THE STOMACH* VOMITING BLOOD 
With the exception of hemorrhagic disease in the newborn, the vom- 
iting of blood by infants is due to ulceration of the stomach (p. 205), to 
purpura fulminans (Henoch’s), or to accidental causes. A boy six years 
of age died on the third day with purpura fulminans. There were profuse 
hemorrhages from the stomach, from the mucous surfaces, and under the 
skin. In two proved cases extensive ulceration of the stomach was found 
at autopsy. Accidental sources of hematemesis include the swallowing of 
blood, which may take place as the result of a nasal hemorrhage, or from 
a blow or fall causing injury to the nose or mouth, or from the presence 
of a foreign body in one of the nostrils. Injury to the pharynx also may 
be followed by hemorrhage sufficient to cause vomiting if the blood is 
swallowed. 
Illustrative Case.—A case of hematemesis in a well-nourished breast-fed infant five 
months of age was productive of a great deal of anxiety. The vomiting of blood con- 
tinued for several days without the slightest evidence as to its source. This occurred 
two or three times a day, usually shortly after nursing, the quantity of blood being 
especially large after the early morning nursing. There were no cracks or fissures in 
the mother’s nipples, nor could blood be made to exude from any portion of the nipples 
on reasonably strong pressure. Convinced, nevertheless, that the source must be the 
breast, the writer applied a breast-pump, making use of as strong suction as possible, 
and obtained milk with a large mixture of blood. Evidently there had been a rupture 
of some of the smaller blood-vessels in the gland behind the nipple. At the first nursing 
the child was very hungry and tugged vigorously at the breast, which doubtless explains 
why the early morning vomiting showed the most blood. 
In hematemesis of the newborn the patient should have the advan- 
tage of the human blood injections (p. 185). 
ULCERATION OF THE STOMACH 
Ulceration of the stomach is usually associated with marked gastric 
disturbance, such as occurs in gastritis and in the different forms of mal- 
nutrition. 
Notwithstanding a large autopsy experience among infants and 
young children, the writer has yet to see a perforating ulcer, tuberculous 
or of other type. In fact, aside from those in the newborn he has seen 
at autopsy only 2 cases of gastric ulceration. In 3 other cases the diag- 
nosis of ulceration was made because of hematemesis. 
Illustrative Cases.—A child one month old repeatedly vomited blood, and eventually 
bled to death. At autopsy about 2 ounces of coagulated blood were found in the stom- 206 
THE PRACTICE OF PEDIATRICS 
ach. The gastric mucous membrane was the seat of many ulcers, varying in size, none 
exceeding inch in diameter. 
Another patient, three months old, had chronic gastro-enteritis with occasional vom- 
iting of blood and died from exhaustion, the autopsy showing multiple small ulcers in 
the mucous membrane of the stomach. 
That gastric ulcerations, even of a mild degree, play any great part 
in the digestive disorders of infants and young children is disproved by 
the infrequency of the lesion at autopsy. 
In treating cases of gastric disorder by stomach washing it is com- 
paratively rare to find blood in the water siphoned off. At rare inter- 
vals the water may be tinged with blood, but the washings invariably 
should be continued in spite of this, as we have never known any severe 
hemorrhage to follow. The blood which appears under these conditions 
is doubtless from the capillaries of the congested mucous structure. 
Treatment.—In the event of persistent vomiting of blood of small 
or large amount, which cannot otherwise be accounted for, the walls of 
the stomach are to be regarded as the source of the hemorrhage. Under 
these conditions oral feeding should be discontinued and the nutrient 
enema (p. 98) should be brought into use. Bromid and chloral, or 
stimulants, if necessary, may thus be given with the food. Adrenalin 
1 : 1000 solution in small doses may be given hourly and continued for 
twelve hours after the vomiting ceases. After thirty-six hours water 
may be given in small amounts; and the usual milk mixture diluted one- 
half, in small quantities of 2 or 3 ounces, may also be allowed. The normal 
diet should not be resumed in less than a week, even in the event of entire 
absence of vomiting during this period. 
Rumination is a rather infrequent condition, and one which is likely 
to be overlooked unless one is very careful to watch the vomiting child 
after feedings. It is characterized by the regurgitation of food after almost 
every feeding, part of which is actually vomited and the rest is reswallowed. 
Etiology.—This condition occurs most frequently in children a few 
months of age and is often not diagnosed until the vomiting has been going 
on for several weeks. Rumination may also be present in older children. 
When practised at this age it has become a habit and occurs especially in 
the neurotic. In infants there may be an associated pylorospasm. 
Symptoms.—The clinical picture is fairly characteristic, closely re- 
sembling that afforded by the ruminating animals, such as the cow chew- 
ing the cud. A few minutes after the baby gets the bottle, he will start 
peculiar suction movements, and presently some of the milk can be seen 
in the mouth, a part may spill out and part will be chewed and reswallowed. 
This proceeding will be repeated until the child has emptied the stomach 
or fallen asleep. 
Such children are often much emaciated from the prolonged loss of 
food. 
Treatment.—A popular method of treatment is to give food so thick 
that it cannot readily be regurgitated. A mixture containing 1| ounces 
of barley flour to 1 pint of skimmed milk is cooked in a double boiler for 
one hour. On cooling, this forms a thick gelatinous mass. It is fed with 
RUMINATION PYLORIC OBSTRUCTION IN YOUNG INFANTS 
207 
a spoon to the child in quantities to which he is accustomed at intervals 
of three to four hours. (See p. 85.) 
Strauch, of Chicago, observed that the nostrils had to be open to aid 
the child in regurgitating the food. He therefore improvised a clamp 
to keep them closed for a certain time after feedings. In this way he con- 
trolled the vomiting to a great extent. 
In a private patient the habit was broken by substituting another 
habit, less harmful. The ruminating infant was taught to use the pacifier. 
Sucking the pacifier proved more entertaining than ruminating. 
Sedgwick advised strapping the lower jaw firmly to the upper by means 
of adhesive plaster, thereby preventing the rhythmic jaw action neces- 
sary for regurgitation. 
A device which has served well is shown in Fig. 23. 
Fig. 23.—Device to prevent rumination, showing manner of applying it under chin. 
Note the two buckles on top and the strap which runs posteriorly and is fastened 
at the distal end by a buckle. 
The patient was five months old, weighed 7 pounds, 11 ounces, and showed extreme 
emaciation. The thick gruel feeding (p. 206) was of use only after the appliance 
effectually prevented the manipulation of the lower jaw and the tongue. The patient 
gained 18 ounces in two weeks and in four weeks had gained 2 pounds and 7 ounces.1 
PYLORIC OBSTRUCTION IN YOUNG INFANTS 
Cases of pyloric obstruction may be grouped under three main di- 
visions : 
1. Simple pylorospasm in which there is no hypertrophy (Figs. 29-31). 
2. Hypertrophic stenosis, in which there is tumor with marked increase 
in the circular fibers (Figs. 32-35). 
3. Combined hypertrophy and spasm. 
Age and Sex Incidence.—In this disease the age is of great impor- 
tance as a diagnostic point. Of 38 patients reported by Still, one be- 
gan to vomit within twenty-four hours after birth and six others within 
the first week. Pfaundler found that the first vomiting indicating the 
onset of the disease was between the fourth and fourteenth days in 50 
per cent, of the cases; from the second to third week in 25 per cent.; 
and from the third to sixth week in 25 per cent. In over 60 of our own 
cases the vomiting never developed later than the sixth week. In one 
1 Kerley and Lorenze, Arch, of Pediatrics, May, 1921. 208 
THE PRACTICE OF PEDIATRICS 
case a tumor was palpable when the infant was six days old. The symp- 
toms may begin a few hours or days after birth, or they may not appear 
until the third or fourth week; occasionally not until the second month, 
and very rarely not until a later date. Instances of hypertrophy and 
stenosis of the pylorus coming on in adult life have been frequently re- 
corded, and these may not infrequently be due to a persistence of the 
condition from early life. According to Ibrahim’s investigations of 266 
cases, the total number of cases shows a rapidly ascending curve in the 
first month and a reduced frequency with advancing age. 
In the case of a baby five or six months of age, with a history of vom- 
iting over a period of three or four weeks, the age alone is evidence against 
pyloric stenosis. In exceedingly rare cases seen in older children vomiting 
due to stenosis might be confounded with cyclic vomiting. Holt saw 
one such case. 
'Total nutnbeh 
of cases 
Weeks ofLIfe 
Fig. 24.—Drawn in accordance with Ibrahim’s 266 cases (Pfaundler and Schlossmann’s 
System, 1912). 
Sex.—No great stress is to be laid on sex in the diagnosis of this dis- 
ease. The large number of male patients, however, contrasts remark- 
ably with the corresponding small number of females. Out of a collec- 
tion of 42 cases in which this point was noted, 35 were males (Still). 
According to Ibrahim, males are affected about four times as often as 
females. Cases have been met in the same family (Freund). This oc- 
curred once under our observation. In another instance a brother of 
the patient’s mother had died in infancy with symptoms typical of pyloric 
obstruction. Some authorities state that when the disease occurs in girl 
babies, it is usually of a mild form. One of our cases in which the patient 
was a girl was exceptionally severe despite the fact that recovery occurred 
without operation. 
Etiology.—Pyloric stenosis is one of the diseases concerning which a 
great amount of theorizing has been done, especially in the early days, PYLORIC OBSTRUCTION IN YOUNG INFANTS 
209 
when few autopsy specimens were at hand. Most of the various sur- 
mises have been discarded, such as the probability of the stomach under- 
going an agonal contraction, thus producing the thickening (Pfaundler). 
Many new views, however, have been offered, as the various names 
of the disease might suggest. Prominent, and among the most universally 
recognized, theories up to 1897 were those of Hirschsprung and John 
Thomson. According to the former, the disease was due to a congenital 
organic defect, resulting from a primary pathologic hypertrophy of the 
pyloric wall, which constricted the lumen. Thomson contended that the 
essential lesion was not muscular, but primarily nervous: “A functional 
disorder of the nerves of the stomach and pylorus leading to ill co-or- 
dinated and therefore antagonistic action of their muscular arrange- 
ments.” This latter view corresponded very closely to Still’s theory of 
“stomach stuttering.” 
There is, to date, no convincing evidence that the spasm is set up 
by erroneous feeding or by hyperacidity. In 7 of 11 cases Feer found 
the total acidity varying from 50 to 105, and free hydrochloric acid from 
0 to 50. Similar results have been obtained by other observers (Ram- 
sey, Bernheim, Karo, Engel, Freund, Miller, Clark). Miller and Will- 
cox (1901), in a series of carefully conducted investigations, attempted 
to show that pylorospasm may be due to hyperacidity, and that in hy- 
pertrophic stenosis, spasm, if present, is produced by some other cause. 
In hypertrophic stenosis hyperacidity is very common. 
Of recent years most authorities have regarded the condition as 
primarily spasmodic, and probably due to gastric or duodenal irritation 
or nervous disturbances. According to this theory the hypertrophy 
is secondary and depends to a large extent upon the degree of spasm. 
The possible existence of a certain amount of antenatal hypertrophy 
may be appreciated when one considers that the pylorus begins to form 
as early as the third month of fetal life. Such hyperplasia has actually 
been found by C. T. Dent in a seven months’ fetus. P3rlorospasm has 
its analogue in certain other spasmodic conditions of the circular fibers, 
such as constipation due to a spastic condition of the sphincter ani, and 
various allied conditions of the larynx and bronchi. By some observers, 
however, the essential condition in pyloric stenosis is regarded as a pri- 
mary hypertrophy with secondary spasm. 
Pathology.—The postmortem findings are remarkably uniform. The 
alimentary canal below the pylorus is perfectly normal. The esophagus 
is sometimes noticeably dilated, sometimes of normal caliber. 
The stomach is usually much dilated, the lower border being fre- 
quently below the umbilicus; the wall at the cardiac end is as thin as 
normal, but elsewhere much thicker, especially toward the pylorus. 
Occasionally the cardia may assist in the general hypertrophy. The 
pyloric part of the stomach consists of a rigid, resistant, cartilaginous 
mass of a bulging or nearly cylindric shape. The swelling appears like 
a separately interpolated insertion between the stomach and duodenum. 
When looked at from the duodenum, the pylorus seems almost closed, 
the mucous membrane being puckered by the contraction of the hy- 
pertrophied muscular wall, not unlike that of the os uteri. No fibrous 
stricture is present, and the whole narrowing seems to be due to com- 210 
THE PRACTICE OF PEDIATRICS 
pression by hypertrophied muscle. The tumor enlargement varies from 
2 to 3 cm. in length, and from lb to 2 cm. in thickness. On section, the 
thickening appears to be due to the hypertrophy of the circular fibers, 
which may be two or three times their normal thickness. Finkelstein 
reported a case in which the thickening was due to an increase in the 
Fig. 25.—A, Drawing to indicate normal pylorus. B, Hypertrophic pyloric stenosis. 
A 
B 
longitudinal fibers. The lumen varies in size. In some instances it barely 
admits a fine probe. Walbach, in one case, found the lumen 2 cm. in 
diameter. Occasionally a slight connective tissue increase is found in 
addition to a slight thickening of the mucosa and submucosa. Catarrhal 
Fig. 26.—Congenital hypertrophic pyloric stenosis: Section through pylorus to show 
thickened muscular ring. P, Hypertrophied pyloric muscle. 
or inflammatory changes are usually absent. The test of functional 
potency by hydrostatic pressure is fallacious, for the redundant folds 
of mucous membrane may act as valves. 
An observation of the illustration (Fig. 26) showing the cartilaginous 
ring makes it obvious that spasm here would be impossible. Figure 26 PYLORIC OBSTRUCTION IN YOUNG INFANTS 
211 
further emphasizes the uselessness of drugs or any means other than 
operative procedures for the relief of extreme obstruction. 
Symptoms.—Vomiting is the only active symptom of the stenosis, 
whether it is spasmodic or due to stricture. The history is usually that 
of an infant, apparently normal at birth, who remains well for two or 
three weeks or more. The child regains the early loss in weight, the 
stools are normal, and there is no suggestion of gastric disturbance. 
Then, without apparent cause, the child, whether breast or bottle fed, 
begins to reject the food. 
Vomiting.—The vomiting may occur after each feeding. More fre- 
quently two or three nursings are retained and then a large amount is 
Fig. 27.—The Hess bulb. 
ejected, so that the nurse or mother is impressed with the large amount 
of vomiting, and volunteers the information that two or three feedings 
would be necessary to replace the large amount of food lost. In most 
cases the vomiting is forcible and decidedly explosive in character. 
Retention.—The stomach of an infant who takes from 3 to 4 ounces 
at a feeding should be empty at the end of three hours. When food is 
retained longer than three hours it means, in a vast majority of the cases, 
an obstruction at the pyloric outlet and is a very valuable sign in pyloric 
stenosis. A retention of 1 or 2 ounces is not at all unusual and when 
there is an associated dilatation of the stomach—two or more feedings 
being retained—the retention has been 4 to 5 ounces. A convenient 
device for testing the retention is the Hess bulb (Fig. 27). By this device 212 
THE PRACTICE OF PEDIATRICS 
all the contained fluid in the stomach may be aspirated into the glass bulb 
and measured. 
Constipation.—With the vomiting is associated constipation. The 
passages, previously full and normal, become very scanty, and are passed 
only upon rectal stimulation. Mucus is usually mixed with the feces. 
The degree of constipation depends upon the degree of permanency 
of the stricture. In the purely spasmodic cases considerable fecal material 
will be passed. A lesser amount will be passed in cases of the combined 
type. 
Fig. 28.—Visible peristaltic waves. Pyloric obstruction. (John Thomson, Clinical Study 
and Treatment of Sick Children, 3d ed.) 
Loss in Weight.—There is rapid loss in weight, as would be expected. 
We have repeatedly seen such infants reduced to mere skeletons. 
Appetite.—These patients are voraciously hungry, and will take 
everything in the form of liquid food that is offered. Water will fre- 
quently be taken as eagerly as milk mixtures or the breast. 
Absence of Other Signs of Illness.—There is no elevation of the tem- 
perature and there are no nervous phenomena. The urine is scanty 
and of high specific gravity, but shows no evidence of diseased kidneys. 
The child appears ill only on account of the wasting and moderate pros- 
tration. PYLORIC OBSTRUCTION IN YOUNG INFANTS 
213 
Diagnosis.—In all young infants who develop persistent vomiting 
with constipation, or even persistent vomiting without constipation, 
the possibility of stenosis of the pylorus should be considered. 
The Peristaltic Wave.—-'This sign consists of a rounded, circumscribed 
elevation of the abdominal wall, a lump from 1 to 2 inches in diameter, 
which forms q,t the left of the median line, sometimes appearing to rise 
from the margin of the ribs, and passes across the epigastrium (main- 
taining its original size in transit) to the right hypochondrium, where 
it disappears. In a few seconds the phenomenon is repeated. Not in- 
frequently, before the first wave disappears a second will form. The 
elevation and depression may be sufficient to involve the entire abdom- 
inal wall (see Fig. 28). The peristaltic wave described occurs in no other 
condition. 
Method of Obtaining the Wave.—The wave may best be demonstrated 
after feeding. The stomach should not be overfull. If the usual feed- 
ting time is near, 2 ounces of food or water are given. If the child has 
been recently fed, before giving the food the stomach is washed out. 
The abdomen is then exposed, and usually before the child has finished 
the bottle the peristalsis will appear. Occasionally a case is seen in which 
no peristalsis will be elicited at the first examination. 
The Tumor.—Palpation of the tumor through the abdominal wall 
is possible in nearly all cases. Considerable practice is required in order 
to be able to locate the tumor. We have not been as successful as other 
writers in demonstrating this conclusive sign. Still was able to palpate 
the pyloric tumor in 41 out of 42 cases. 
Palpation is aided by a partially filled stomach that is in active per- 
istalsis. 
Differential Diagnosis Between Hypertrophic Steyiosis and Pyloric 
Spasm and Obstruction of the Combined Type.—The palpable pylorus 
may be looked upon as a hypertrophic pylorus. In a pylorus, moreover, 
that has undergone sufficient thickening to be palpable the connective 
tissue changes are in all probability sufficient to necessitate operation. 
Constipation is always present in stenosis of the hypertrophic form. 
There is dilatation of the stomach, and the vomiting is persistent. In 
the spasmodic type the vomiting appears to occur periodically—per- 
haps not oftener than once or twice a day. In some cases of simple spasm 
there may be no vomiting for a day or two, and during this time the 
stools will be fairly large. The short cessation will then be followed by 
a return of the repeated emesis. Cases of this type present the best 
chances for cure without operation. 
In the combined tijpe, in which there is moderate hypertrophy and 
spasm, the stenosis, when the stomach is at rest, is moderate in degree. 
It is possible for a considerable portion of the stomach contents to pass 
into the intestine if but small quantities of food are given at one time. 
Illustrative Cases.—A case expected to undergo recovery without operation was 
of this type. Vomiting occurred sometimes once a day—never more than twice. 
The active peristaltic wave was present. The stools were fairly large and well digested, 
from 10 to 15 ounces of food being retained daily. Without apparent cause the child 
went into collapse and died. The autopsy showed a pyloric canal about 1/16 inch in 
diameter, and revealed moderate thickening and hypertrophy of the circular fibers. 
That there may be pyloric spasm without hypertrophy, producing typical signs of 214 
THE PRACTICE OF PEDIATRICS 
Fig. 29. 
Fig. 30. 
Fig. 31. 
Figs. 29-31.—Pylorospasm: Male, aged eleven weeks. Weight at birth, 9 pounds, 
5 ounces. When ten days old began to exhibit attacks of vomiting accompanied by 
fluctuation in weight. 
Roentgen Examination: Directly after feeding. Dilated stomach with no evidences 
of opaque substance having passed through the pylorus (Fig. 29). Twenty minutes 
later evidence of active peristalsis and a slight amount of opaque meal in the jejunum 
(Fig. 30). One hour after the meal, stomach apparently resting, as no more of opaque 
meal had passed through the pylorus. Roentgenogram made about four hours later, 
stomach practically empty (Fig. 31). 
Comment: The irregular emptying of the stomach was undoubtedly due to spasm 
of the pylorus which relaxed from time to time. Pyloric stenosis would probably have 
been demonstrated by a uniformly slow emptying; hence the diagnosis of pylorospasm. 
This case recovered completely without operation. PYLORIC OBSTRUCTION IN YOUNG INFANTS 
215 
Fig. 32. 
Fig. 33. 
Fig. 34. 
Fig. 35. 
Figs. 32-35.—Congenital hypertrophic pyloric stenosis: Male, aged eight weeks. 
Apparently normal up to five weeks of age. Projectile vomiting for seventeen days; 
stools very small and green; peristaltic waves visible; an epigastric tumor palpable 
somewhat to the right of the midline. 
Roentgen Examination: A most extreme case of pyloric stenosis. Twenty-four 
hours, some of the opaque substance still in the stomach, although the stomach had 
been washed out. Atropin administered without causing observable 'pyloric relaxation. 
Figure 32 shows the stomach four minutes after the first meal, previous to the ad- 
ministration of atropin. Figures 33-35: After the use of atropin—four minutes, twenty- 
two minutes, and twenty-two hours respectively after the second meal. 
Operation: Pylorus showed marked thickening of muscular ring. The pyloric 
muscle incised according to Downes’ method.1 
Roentgen examination sixteen days after the operation showed that the stomach 
emptied at a normal rate. 
Comment: The use of atropin was of no avail. Although some claim that atropin 
is useful in simple pylorospasm, we do not believe it can be depended upon in cases of 
true hypertrophic stenosis as determined by Roentgen examination. 
1 Dovnes, W. A., Congenital Hypertrophic Stenosis, Trans. Sec. on Surgery, Amer 
Med. Assoc., 1920. 216 
THE PRACTICE OF PEDIATRICS 
the disease was demonstrated by a private patient who began vomiting at three weeks. 
There was the peristaltic wave, the vomiting several times a day, emaciation, and con- 
stipation. Operation was partially arranged for. The child had been bottle fed, 
however, and preparatory to the operation a wet-nurse was solicited in order that the 
postoperative management might be the more secure. The wet-nurse was supplied 
and the baby’s stomach was washed daily. In four weeks the vomiting had subsided 
and the child gained 2 pounds, 2 ounces in weight. There was no further trouble with 
the case. Here surely was not a case of organic stenosis. 
Prognosis.—The prognosis is dependent upon many factors. The 
age of the patient and the nature of the surgical treatment are such that 
operative procedure will always show a considerable mortality. 
The severity of the operation and the tender age of the subject are 
not the only reasons for the high mortality. Many of the patients when 
they come to the surgeon are so emaciated and reduced in vitality that 
operation simply hastens the end. 
In surgical cases of children the surgeon should receive the opinion 
of counsel as to when and how long a condition may continue and still 
afford a good surgical risk. 
Cases With Palpable Tumor.—These infants should be given the ad- 
vantage of immediate operation. 
In 1920 Downes1 reviewed 100 cases in which the Fredet-Itammstedt 
operation was performed for pyloric obstruction. He recommended 
that medical treatment in doubtful cases be limited to a period not longer 
than ten days, provided the weight loss during this period did not exceed 
20 per cent. The mortality among patients coming to operation within 
four weeks of onset of symptoms he found to be less than 8 per cent. 
We are indebted to Downes and Bolling for additional information 
concerning cases coming under their care during a period of three years 
and nine months beginning January 1, 1920. Of 181 operations, all 
except 3 were performed at the Babies’ Hsopital. One hundred forty- 
five patients were males and only 36 females. The average age was 
six weeks and five days; and the average duration of symptoms three weeks 
and five days. A pyloric tumor was felt in every case. 
In a group of 82 infants under 7 pounds on admission the mortality 
was slightly less than 27 per cent. In a group of 99 weighing 7 pounds 
and over, the mortality was slightly less than 6 per cent. The mortality 
for the whole group was slightly less than 15.5 per cent. 
In a number of the fatal cases death proved to be due to causes in- 
dependent of the pyloric condition and the operation. 
This record reinforces Downes’ contention that operative interference 
in cases of pyloric obstruction in which medical care is unproductive of 
prompt improvement is a conservative procedure. His results have been 
permanent. 
The Spasmodic Cases.—There are probably comparatively few pyloric 
cases without involvement of the muscle structure. In such cases the 
prognosis is good, and all should survive without operation. 
In the combined cases of spasm and hypertrophy, which represent the 
largest number of cases, the prognosis is dependent largely upon the 
degree of hypertrophy and the management. Exclusive of operation, 
the management of the spasmodic and combined type is the same. 
1 Jour. Amer. Med. Assoc., June 24, 1920, vol. 75, pp. 228-232. PYLORIC OBSTRUCTION IN YOUNG INFANTS 
217 
Surgical Treatment.—The great majority of cases come to operation. 
In view of the fact that the presence of the tumor is difficult to demon- 
strate, it is not wise for the physician to depend on this sign. Frank 
clinical signs and symptoms in 95 per cent, of the cases mean that an 
organic obstruction exists and that an operation will eventually be re- 
quired. When the vomiting continues in spite of treatment, and the 
child shows progressive loss in weight and strength, it is safe to assume 
that a considerable degree of Irypertrophic stenosis exists and operation 
should not be delayed. Temporizing is safe only when there is no pro- 
nounced loss in weight. It is best to operate while the child possesses 
a good resistance. The Rammstedt operation offers the best results. 
This operation consists in making a longitudinal incision from 2 to 3 
cm. in length through the serosa and the hypertrophied circular mus- 
cle-fibers of the pylorus down to the thickened mucosa. The duration 
of the operation, as performed by Downes, is ten to twenty minutes. 
Postoperative Treatment.—Vomiting after operation rarely causes 
trouble. Regurgitation, which is troublesome, will occur in some patients. 
This may be obviated by bringing the force of gravity into use by elevat- 
ing the head and shoulders of the patient on a high pillow. These children 
need fluid badly, and this may be supplied, during the first hours after 
the operation, by the “Murphy drip” or better by hypodermoclysis. 
If breast milk is not obtainable, fresh cow’s milk or condensed milk, 
suitably diluted, may be used. 
The following directions cover the procedure developed at the Rabies’ 
Hospital, New York City, in conjunction with the Fredet-Rammstedt 
operation: 
On admission a lavage is to be given and a two-hour retention test done, using 60 
cc. of breast milk. Two hours after operation give 15 cc. of water. 
Three hours after operation begin feedings on a three-hour schedule giving each of 
the following mixtures for two successive feedings before advancing to the next on the 
list: 
1. Breast milk 4 cc. 
Barley water 4 “ 
2. Breast milk 8 “ 
Barley water 4 “ 
3. Breast milk 12 “ 
Barley water 4 “ 
4. Breast milk 16 “ 
Barley water 4 “ 
5. Breast milk 20 “ 
Barley water 4 “ 
6. Breast milk 24 “ 
Barley water 4 “ 
Then give 30 cc. every three hours for eight feedings in twenty-four hours. In- 
crease 5 cc. each day until 50 cc. is reached on an eight-feeding day. Then give 60 cc. 
every three hours for seven feedings in twenty-four hours. Thereafter increase 5 cc. 
each day until the reauired amount is reached. Give 15 cc. water between feedings. 
Stomach-tube is to be passed before the feedings for the first seven or eight days 
after operation. Feed with medicine-dropper for first four or five days, then with the 
nipple. If patient is a nursing baby, put to breast on the seventh day, once for five 
minutes, twice on the eighth day, three times on the ninth day, and so on. 
Management in the Non-operative Type.—Breast milk should always 
be given a trial, although this usually means the securing of a wet-nurse. 
In large centers breast milk may sometimes be purchased, but this means 218 
THE PRACTICE OF PEDIATRICS 
of supply is usually quite unsatisfactory. Further, breast milk is often 
disappointing and is often vomited as readily as other foods. We have 
had both failures and successes in its use. When it fails, thick gruel feed- 
ing (see p. 85) should at once be resorted to. In preparing the gruel 
mixture we find the evaporated milk gives us the best results. For an 
infant weighing 8 pounds with uncomplicated pylorospasm or spasm 
and moderate hypertrophy whose vomiting, although persistent, admits 
of pallative measures, we would give the following feeding directions: 
7 ounces of evaporated milk. 
23 ounces of water. 
5 tablespoonfuls of farina. 
1 tablespoonful of granulated sugar. 
Add the 5 tablespoonfuls of farina to the 23 ounces of water, bring to a boil, simmer 
for one and a half hours, then add the milk and simmer for another thirty minutes. 
When mixture is cool add the granulated sugar. The final mixture should not exceed 
20 ounces (two-thirds the original volume), and when cold should be of the consistency 
of soft butter. 
Give 2 to 3 ounces at four-hour intervals. 
A Hygeia bottle and nipple may be used if an extra large opening 
is made in the nipple, or the food may be given with a spoon. For the 
first few days water should not be given between feedings. 
Smaller amounts of 1| to 2 ounces are given to children weighing 5 
or 6 pounds. For the first day or two perhaps not more than 2 ounces 
are best given at a feeding. In all cases the stomach should be lavaged 
with a 5 per cent, sodium bicarbonate solution daily. The thick gruel 
feeding may be continued for several months, the milk strength, of course, 
being increased from time to time. 
Having used this thick gruel feeding in a considerable number of cases 
of persistent pylorospasm, we consider it by far the best means available 
in the management of the vomiting of infancy. Failures have occurred 
in cases with distinct hypertrophic stenosis, and without mechanical aid 
the method has been of very little value in combating rumination (p. 206). 
The Use of Atropin.—A solution of atropin sulphate of which 1 drop is 
equivalent to 1/1000 grain is commonly administered for the relief of 
pylorospasm in infants. The dosage should be given coincident with the 
four-hourly feedings and must be governed by the effects observed; 
1/500 grain exceptionally produces pupillary dilatation and flushing. If 
no such effect is observed and the vomiting persists the dose may be 
increased to 4 or 5 drops of a 1 : 1000 solution, or 1/400 to 1/300 grain 
at four-hour intervals. Larger doses, although recommended, have sel- 
dom been used by us. 
In cases of spasm uncomplicated by true stenosis atropin is at times 
of value. More frequently its usual physiologic effects have been ob- 
served in our own cases without decisive relief of the vomiting, so that the 
results thus obtained have been at best indifferent. 
PYLOROSPASM IN OLDER CHILDREN 
The fact that pylorospasm in greater or less degree is of fairly frequent 
occurrence in children is readily demonstrable from the following case 
records: PYLOROSPASM IN OLDER CHILDREN 
219 
Figure 36 shows the stomach of a boy seven years of age in a state of 
active peristalsis as evidenced by the circular muscular contraction with 
pronounced pylorospasm three hours after injection of a bismuth meal. 
The boy had been ill for a week following a dissipation in ice-cream and 
raw fruit. There had been extreme paroxysmal pain in his stomach 
to such a degree that morphin hypodermically had been repeatedly 
necessary. It will be observed that but little bismuth had passed the 
pylorus three hours after the food had been taken. 
Figure 37 represents the stomach of a girl five years of age showing 
a lesser degree of pylorospasm. The radiogram was made six hours after 
the injection of the bismuth meal and shows very pronounced gastric 
retention which was repeatedly corroborated by stomach-tube examina- 
Fig. 36.—Pylorospasm in a boy of seven years: S, stomach; D, duodenum 
tion after a bismuth meal and a usual home meal. The girl was absolutely 
devoid of all desire for food, showed moderate malnutrition, and was 
habitually constipated. Enemas or laxatives were required daily. This 
patient was under the care of a trained nurse and did not in the least 
object to stomach-tube manipulation. At various times the tube was 
used during the night to learn the emptying time of an ordinary evening 
meal given at 6 o’clock. The stomach was rarely found empty before 
5 a. m. the following morning. The patient had a greatly elongated 
and sacculated sigmoid, at least four times the normal length. 
Etiology.—We have proved with the aid of the x-ray two causes for 
pylorospasm—gastric hyperacidity and intestinal stasis. 
Figure 36 is taken from a case of the former, and the writer has had 220 
THE PRACTICE OF PEDIATRICS 
other similar cases. Figure 37, taken from a case of intestinal stasis, 
shows evidence of sufficient spasm to produce retention. 
Symptoms.—Gastric irritability will cause stomach hyperstalsis and 
spasm, so that in the cases of those patients with elongated and sacculated 
sigmoids and resulting stasis the emptying time of the stomach is always 
delayed. There apparently is direct* association between the emptying 
time of the stomach and that of the large intestine. A peculiar feature 
of these cases of retention is loss of appetite. The patient will perhaps 
have a fair appetite for breakfast when the stomach is empty, but for 
the other meals must be forced or coaxed. 
The most prominent symptom of the retention cases is loss of appe- 
tite, and the next in order is recurrent vomiting. 
Fig. 37.—Female, five years. Pylorospasm, wandering stomach: Retention at four 
hours, showing large residue, corroborated by stomach-tube examination. Habitually 
poor appetite; malnutrition. D, Duodenum. 
Treatment.—Relief of the constipation through treatment and a long 
interfeeding period goes far to restore a normal desire for food as the result 
of more rapid emptying of the stomach. 
MECHANICAL DEFECTS IN THE GASTRO-INTESTINAL TRACT AS ETIO- 
LOGIC FACTORS IN GASTRO-INTESTINAL DISORDERS OF OLDER 
CHILDREN 
Until a fow years ago children had been given the credit of having a 
structurally normal gastro-intestinal tract, except in those instances 
in which there were gross abnormalities which involved the immediate 
well-being or life of the infant. Appreciation of the fact that there could PTOSIS AND DILATATION OF THE STOMACH 
221 
be structural defects, congenital and acquired, of a bearing of more re- 
mote nature was partly the outcome of the extensive studies that have 
been made on congenital hypertrophic pyloric stenosis. 
In clinical work among children suffering from persistent gastro- 
intestinal disorders it was found that in not a few cases the usual diagnostic 
methods (insp*ection, manipulation, and urine and stool examination) 
were not sufficient to establish a diagnosis upon which satisfactory therapy 
could be fashioned. Many conditions, such as the various forms of ptosis 
which were supposed to exist only in adult life, unquestionably have 
their origin in childhood, and produce as prominent symptoms in the 
child as in the adult. In such cases in childhood erroneous interpreta- 
tions or none at all have been the custom. As a result of the abnormal- 
ities in structure, whether congenital or acquired, producing disturbed re- 
lations of various portions of the gastro-intestinal tract, derangement of 
function due to imperfectly carried out physiologic and chemical processes 
within the body becomes established, the result being in many instances1 
faulty nutrition, defective growth, and inferior general development of the 
child both physical and mental. 
In x-ray studies of the stomach we find dilatation and ptosis, singly 
or combined, hyperstalsis and hypostalsis, pylorospasm anti cardiospasm. 
In the intestines an elongation of the sigmoid to three or four times 
its normal length is the most usual deformity. With this there are the 
invariable angulations, sacculations, and torsions. The colon is frequently 
elongated, dilated in part and entire, and ptosed. Typical V-shaped 
ptosis (page 223) is the usual form in which this abnormality is found. 
Several cases of dilatation of the sigmoid have been observed which 
give a train of symptoms all their own. Anal sphincter spasm causing 
rectal constipation is a particular factor of importance in delayed stomach 
emptying and recurrent vomiting. The diagnosis of several cases of chronic 
appendicitis (page 291) has been confirmed by the x-ray. A continuation 
of pronounced gastro-intestinal disorders, particularly recurrent vomiting 
and persistent constipation with the patient under a proper living regime 
and right dietetic regulations, calls invariably for an x-ray study of the 
gastro-intestinal tract. In the pages that follow the abnormal x-ray 
findings will be discussed in connection with the symptomatology of the 
various gastro-intestinal disorders. 
Ptosis and Dilatation of the Stomach 
This combination we are finding in a considerable number of children 
who appearfor treatment of persistent stomach derangements. A dilated 
stomach, however, may not be ptosed. Roentgen ray studies of a great 
many stomachs lead us to believe that Fig. 38 represents the average 
stomach of a child four years of age, normal in size and position. 
Etiology.—The abnormal condition in some children is probably 
carried over from infancy, being the outcome of a defective pylorus, 
and may result from a habitual overfilling of the stomach. Children who 
have the milk habit, who drink large quantities of milk or water with 
their regular meals, are very apt to have dilated and ptosed stomachs. 
The carrying capacity of this organ is not unlimited and the full meal 
1 Our x-ray studies now cover over 150 cases. 222 
THE PRACTICE OF PEDIATRICS 
of solid food with a considerable amount of milk or water, produces an 
increase in the weight of the stomach contents, with gradually result- 
ing enlargement and ptosis. 
The fact that children who have had pylorospasm or actual stenosis 
in infancy and recover without operation are actually among those who 
have dilated and ptosed stomachs in later life has been proved by z-ray 
examinations of a great many personal cases, and one feature common 
to all is delayed emptying which has become a fixed habit. 
Fig. 38.—Male four years of age. Normal stomach. 
After the third year the stomach should normally be empty in four 
hours. In one patient the stomach contained residue after ten hours 
and did not begin to empty for two hours. This stomach required about 
twelve hours to empty a bismuth meal. In 6 cases the stomach contained 
residue after six hours. 
The Opaque Meal.—The opaque substance added to the food in 
order to give a contrast in the roentgenogram is bismuth subcarbonate, 
bismuth oxychlorid, or barium sulphate, especially prepared for rr-ray 
work. The opaque substances are usually used in the preparation of 
1 part to 8 of food for a child four years of age. 
Symptoms.—The appetite is variable and appears to depend upon PTOSIS AND DILATATION OF THE STOMACH 
223 
the emptying time of the stomach. If the organ empties readily and there 
is an interdigestive period of one-half to one hour, the appetite is usually 
abnormally developed. In the event of retention of the stomach contents 
until the next mealtime the appetite is poor, the child has to be coaxed 
to eat, a vicious circle is established, and the delayed emptying helps to 
cause the ptosis and dilatation which, in turn, delays the emptying. It 
is not at all unusual for patients to show considerable stomach residue 
from six to ten hours after the meal. There is usually a good deal of belch- 
ing and sometimes regurgitation of food, and practically all children 
thus affected suffer from periodic vomiting seizures which are commonly 
Fig. 39.—Ptosis of stomach: This represents a dilated and ptosed stomach in a 
boy eleven years of age who exhibited a high grade of malnutrition, weighing only 52 
pounds, and suffered from habitual constipation and periodic vomiting. His blood 
showed Hb. 72 per cent., red blood-cells 4,440,000. This boy rarely passed six weeks 
without a seizure, which lasted two or three days. Being a very wealthy boy he had 
passed through many hands and was treated uniformly for “acidosis.” In this case 
there was also coloptosis, the colon presenting the typical V-shaped abnormality 
depicted in Fig. 48. He was put under appropriate treatment and during subse- 
quent observation extending over a long period never had an attack of vomiting. 
diagnosed as “acidosis” attacks. In all the cases there is distention of 
the upper abdomen. Stomach pain paroxysmal in character, usually 
after eating, is not infrequent. Studies of the gastric contents show that 
there is usually a well-marked hyperacidity, and in cases in which hyper- 
acidity has been proved the pain or discomfort complained of occurs 
more often before the meal, particularly before breakfast. Practically 
all such children, furthermore, suffer from malnutrition; they are thin, 
underweight, and irritable, and in most instances show secondary anemia 
and have a diminished capacity for school work and play. 
In one significant case with emptying of the stomach delayed after 224 
THE PRACTICE OF PEDIATRICS 
six hours there was a persistent urticaria for which condition previously 
the child was brought for treatment. She was nine years old and the urti- 
caria first appeared at the age of two years. It was largely relieved 
by correcting the gastroptosis. 
Treatment.—An important feature in the treatment of the dilated 
stomach whether ptosed or not is to avoid overloading the organ at any 
time. In order to overcome this tendency the following procedure is 
followed: The child is given meals with a minimum allowance of fluid 
Fig. 40.—This shows extreme dilatation of the stomach of a girl six years old who 
weighed but 29 pounds, showed a high-grade secondary anemia, and had recurrent 
vomiting seizures lasting from twenty-four to seventy-two hours at intervals ranging 
from six weeks to two months. She had been treated for “acidosis” and had always 
been a difficult “feeder.” The vomiting seizures began at about the eighteenth month. 
After the commencement of treatment there were no subsequent seizures and the child 
gained 13 pounds in weight in thirty months. 
and is made to rest on the back or preferably on the right side for an 
hour after the morning and midday meal of solid food. Three meals are 
given daily at not less than five-hour intervals. Three hours after the 
breakfast and midday meal 6 to 8 ounces of milk or water is given. The 
evening meal is given in bed with 8 ounces of fluid. The child is made 
to lie down immediately after. Upon awakening the following morning 
as much water is given as the child cares to drink, and in one-half to one 
hour the breakfast is served. COLIC 
225 
Such a regime carried out for a few months will reduce the size of 
the stomach if there is no pyloric obstruction. 
To insure further the attainment of good results children with ptosis 
are supplied with an Aaron band with a transverse shelf so arranged as 
to fit under the ptosed stomach and furnish support. To those who 
suffer from accumulation and eructation of gas 2-grain doses of salicin are 
given at mealtime or the following prescription is ordered: 
W Magnesise carbonatis gr. xxx 
Sodii bicarbonatis gr. xl 
Bismuthi subcarbonatis gr. lx 
M. div. in chart, no. xxx. 
Sig.—One fifteen minutes before meals, with water. 
In cases of dilatation due to pyloric obstruction pyloroplasty or 
gastro-enterostomy may be required. 
COLIC 
A brief reference to this subject has been made on p. 100. Few chil- 
dren complete their first year without having severe attacks of intestinal 
colic. In some cases the child thrives in spite of the attacks, in others 
such a grave degree of indigestion exists that the condition may prove 
most serious. The character of both human and cow’s milk, its ready 
decomposition in the intestine, with the formation of gas, together with 
the lack of development of the infant’s digestive apparatus, explain in no 
small degree the frequency of colic in the young. When cow’s milk is 
used, as in bottle feeding, we are dealing with a substance foreign to the 
infant’s digestive apparatus, and often colic is the outcome. Any condi- 
tion that will give rise to indigestion may, of course, be a cause of colic. 
Children who take too much milk, too strong milk, or who take milk too 
frequently are the usual subjects. Probably the most frequent cause of 
colic is indigestion of the protein of the milk. The protein may be given 
in excess or the child may have poor protein capacity. Not a few cases of 
colic are due secondarily to defective bowel action. A passage occurs each 
day, but in too small amount. There is a continual fecal residue in the 
intestine which undergoes decomposition with gas formation. Cold feet 
are often associated with colic. Fright, anger, fatigue, excitement—any 
condition, in short, which may make a sufficiently unfavorable impression 
upon the child’s nervous organism—may produce indigestion and colic. 
Likewise any adverse nervous mental state in the mother may produce 
colic in the breast baby. Constipation in the mother is not an infrequent 
cause. 
Infants who have colic habitually more often suffer late in the day than 
at any other time. 
Colic may be caused by an elongated sigmoid which forms angula- 
tions and prevents the natural passage of gas. 
Since making our x-ray studies of the intestinal tract we have been 
impressed by the frequency of stomach colic at different ages. Most of 
us have been under the impression that the seat of the colic was usually in 
the intestines. In the case now cited accumulation of gas in the stomach 
evidently was the cause of violent muscular contractions. This capability 226 
THE PRACTICE OF PEDIATRICS 
of the stomach muscle-fiber under such stimulation has been emphasized 
by Alvery.1 
Illustrative Case.—Figure 41 represents the x-ray findings in a case of most obstinate 
and severe colic. The patient, a girl, aged three and a half months, weighing 10 pounds, 
was suffering from malnutrition, extreme colic night and day, and constipation. An 
enema was required daily. The Roentgen ray revealed hyperperistalsis of the stomach. 
The sigmoid was elongated, passing 1 inch above the umbilicus, and the stomach was 
distended with gas. In this case the elongated sigmoid and the obstinate constipation 
were the cause of the stomach colic. The fluoroscope showed the stomach in active 
peristalsis. The colic was entirely relieved by the use of olive oil as a laxative and by 
the regular feeding. 
Fig. 41.—Female aged three and one-half months. Entire stomach outline can be 
made out owing to the presence of air. No bismuth present. (Roentgenogram bv Dr. 
L. T. LeWald.) 
Diagnosis.—While the diagnosis is usually a simple matter, it must 
be remembered that intussusception (p. 277) and appendicitis (p. 287) may 
cause symptoms identical with colic. 
Treatment.—Nursing babies who suffer from habitual colic often re- 
cover after the regulation of the mother’s bowels by exercise, diet, and 
1 The Mechanics of the Digestive Tract, Hoeber, 1922. PREVENTION OF THE ACUTE INTESTINAL DISEASES 
227 
medication. In cases in which the mother’s milk upon repeated ex- 
amination proves too strong and the child suffers from daily colic, a dilu- 
tion of the milk may be made by the use of plain water or barley-water, 
from ounce to ounces of the diluent being given before each nursing. 
In addition, the bowels of the colicky infant should be made to move at 
least twice daily, morning and evening. When this does not take place 
readily a simple laxative, such as milk of magnesia, § to 1 teaspoonful, 
or 10 to 30 drops of aromatic cascara sagrada, may be given daily. Under 
no condition should a child subject to colic be allowed to go without a 
bowel evacuation for more than twenty-four hours. 
Diet.—The dietetic management of colic in the bottle fed consists 
in adapting the food to the child’s digestive capacity. The bottle baby 
may have habitual colic moderately and thrive, but is receiving an im- 
perfectly adapted food. Here, as in the breast fed, the condition is usually 
dependent upon an excessive casein supply or a diminished casein capacity. 
The matter of the adjustment of cow’s-milk protein in indigestion is dis- 
cussed in detail under Milk Adaptation (p. 66). It is sufficient to say 
that the colicky bottle baby should have long intervals between feedings 
—usually one-half hour longer than ordinarily allowed. Digestion is 
slow in many of these infants, although in other respects they may be 
healthy children. In some the indigestion and pain are so severe that a 
perfect adaptation of cow’s milk is impossible, and some other food than 
cow’s milk will be required. The prevention of colic, then, rests upon a 
proper adjustment of the food. 
Enemas.—The immediate attack is usually best relieved by the use 
of an enema at 110° F. of a normal salt solution, or of soapsuds, which, 
by inducing a movement of the bowels, allows the gas to escape. 
Medication.—A soda-mint tablet dissolved in 1 ounce of hot water 
given in 1-teaspoonful dose repeated at five-minute intervals is some- 
times efficacious. For a child under one year of age 3 drops of spiritus 
setheris compositus (Hoffmann’s anodyne) may be given in 2 teaspoonfuls 
of hot water and repeated at ten-minute intervals. 
Hot applications to the abdomen are often gratefid to the patient. 
For this purpose 10 drops of turpentine in 1 quart of water at 120° F. may 
be Used with benefit. A flannel is wrung out of this turpentine solution 
and applied over the abdomen and covered with a dry piece of flannel. 
The dressing may be changed every ten or fifteen minutes. 
Opium and its derivatives should not be used in the treatment of 
colic. This drug may relieve the pain temporarily, but it aggravates the 
condition to which the colic is due. 
PREVENTION OF THE ACUTE INTESTINAL DISEASES 
The general topic of disease prevention has been touched upon in an 
earlier chapter (p. 133). The acute intestinal diseases of summer, with 
their large infant mortality, offer a better field for life-saving measures 
than does any other group. 
Potent etiologic factors contributing to summer diarrhea are unfavor- 
able climate and unfavorable environment. In dealing with the class which 
furnishes the largest mortality, climate cannot be changed for a sufficient 
number to exert any great influence on the general mortality. Through 228 
THE PRACTICE OF PEDIATRICS 
education the environment may be radically improved, but it cannot 
be changed. The hot months come and the tenement child must remain 
at home. Excursions and outings of various kinds are valuable in a small 
way to comparatively few, as the child must return to the tenement home 
at night or after a few days’ absence, so that in our consideration of this 
class of patients in large cities we must accept unfavorable environment 
and hot weather—in other words, we must treat these cases in their 
homes. Those more fortunately situated, who can have the advantage 
of the country and intelligent care, are proportionately less liable to diar- 
rheal diseases. Other than climate and environment, the determining 
etiologic factors among all classes are: first, a disordered gastro-enteric 
tract; second, infected food; third, faulty feeding methods; fourth, an 
absence of appreciation on the part of the parents and physicians of 
the fact that an attack of diarrhea or vomiting, or even a single green, 
undigested stool, occurring in an infant under eighteen months of age 
during hot weather, is to be looked upon as a serious matter requiring 
prompt attention. 
Children as well as adults are frequently exposed to disease from 
sources of which they are ignorant, because their power of resistance 
is insufficient for their protection. With milk, the most readily infected 
of all nutritional substances, as the chief article of diet, it may safely be 
assumed that few infants will pass through the heated term without being 
subjected repeatedly to infection from bacteria, sufficient to produce grave 
illness. An infant’s best safeguard against intestinal infection is a strongly 
resistant gut. Feeding and intelligent management generally throughout 
the year has, consequently, a decided bearing upon summer mortality 
from intestinal diseases. 
We have abundant opportunity to observe that the children who 
have frequent attacks of intestinal indigestion during the colder months 
furnish our severe cases during the summer. A most important feature, 
then, in prophylaxis is to teach the mother how to feed and care for the 
child all the year round, in order that, by keeping well, the child may 
maintain a high grade of intestinal resistance. 
Dispensary Rules of Universal Application.—At the Out-patient De- 
partments of the Babies’ Hospital and the New York Polyclinic the 
senior author had abundant opportunity to come into close contact with a 
great many tenement mothers and tenement children. At these institu- 
tions the clientele is fairly regular in attendance, year after year; for as 
one baby after another appears in the family, each is brought for treat- 
ment. At these dispensaries there is a surprisingly low summer diarrhea 
mortality, because the mothers are taught how to feed and care for their 
children all the year round. They are taught the value of fresh air, the 
use of boiled water as a beverage, and the benefits of frequent spongings 
on hot days. Both private patients and dispensary mothers have been 
given pamphlets of instruction and also oral teaching bearing on these 
points, and particularly those relating to the care of the feeding bottle 
and the milk. In case special articles of diet are to be given, the mothers 
are taught how to prepare them. Written directions are always given 
covering the point; nothing is left to the memory. Each mother and 
nurse has it impressed upon her that she must wash her hands in soap PREVENTION OF THE ACUTE INTESTINAL DISEASES 
229 
and water before touching the baby’s food or feeding apparatus for any 
purpose, and that there must be a covered vessel in which the soiled 
napkins are to be kept until washed. At the first sign of intestinal de- 
rangement, regardless of the season of the year, they are taught to stop 
the milk at once, to give instead a cereal water, such as barley-water or 
rice-water, and a dose of castor oil. It is impressed upon them that, in 
winter as well as summer, a green, watery stool means that the baby is 
ill and needs treatment. When the mother learns the above lesson for 
December, January, and March, she will not forget it in July. Further- 
more, as a result of the immediate correction of a child’s digestive disorder 
during the winter months, the digestive tract affords a much less fertile 
field for pathogenic bacteria during the summer. 
Prompt Treatment Essential.—Comparatively few cases of intestinal 
diseases have pronounced toxic symptoms at the outset. At first there 
are evidences of a milk infection only. There may be vomiting, several 
green, watery stools, and a slight elevation of temperature, or the signs 
may comprise only one or two loose green defecations. Prompt treat- 
ment at this time, even in a crowded tenement, usually means prompt 
recovery. When treatment is delayed and the administration of milk is 
continued, severe toxic symptoms and intestinal lesions are almost in- 
variably the result. 
New York City Experiments.—An interesting demonstration of 
what may be accomplished by proper care was made under the direc- 
tion of Dr. William H. Park, of the New York Health Department, 
during the summer season. Fifty tenement children, ranging from three 
to nine months of age, were selected for the experiment. These children 
were all fed on the Straus pasteurized milk and were visited two or three 
times a week by physicians especially assigned to them. The mothers 
were carefully instructed as to the care of the milk and the feeding appa- 
ratus, and in other necessary details. With the first signs of illness the 
milk was to be stopped, the physician notified, and suitable treatment 
instituted. Among these 50 tenement children, all under one year of 
age, all bottle fed, selected at random, there was not one death during 
the summer. This valuable observation bears out the contention that the 
deaths from summer diarrhea among tenement children may be greatly 
reduced by the use of good milk given under proper supervision, supple- 
mented by prompt and competent medical care at the first sign of illness. 
Perhaps in 1 per cent, of the cases of summer diarrhea a very severe direct 
infection is evident, and the condition of the patient is very grave from 
the onset. In the remainder the invasion is gradual; and, if the warnings 
are heeded, the illness will usually terminate quickly in recovery. 
How to Secure Good Milk.—To patients of the better class who go to the 
country for the summer, and who have cows of their own in order to con- 
trol their milk-supply, the following directions have been given: 
Before milking, the udders and belly of the cow should be wiped with a damp cloth 
to remove clinging particles of dirt. It is in these droppings containing manure that 
the most dangerous forms of bacteria of decomposition enter the milk. The milker 
should wash his hands before milking. The first few jets of milk, coming from the ducts 
near the openings, are apt to be swarming with bacteria, and are, therefore, to be dis- 
carded. Immediately after the milking the milk should be strained through several 
thicknesses of cheese-cloth, or through absorbent cotton, into an ordinary milk bottle, 
which is at once placed in a pail of cracked ice. 230 
THE PRACTICE OF PEDIATRICS 
Such simple care as this, even on an ordinary farm, gives a very low 
bacteria count. As may readily be seen, it is attended with very little 
trouble and expense. 
The Necessity for Education.—The suggestions we have offered are 
all included under the one general heading of Education. The mother 
must be educated how to live, how to care for the baby, how to clothe 
and bathe him during the summer. It must be impressed upon her that 
he needs all the fresh air available. She must be educated to the point 
of knowing what to do at the first sign of threatened disease. Municipal- 
ities must be educated to appreciate their responsibility as factors, nega- 
tive or positive, in the summer mortality. The farmer must be educated 
to produce safe milk, and the consumer must be educated to appreciate 
its value and pay for it. Above all others, the physician must be educated 
along these lines so as to be able to teach the mothers how to do right in 
the care of their children the year round. 
ACUTE INTESTINAL INDIGESTION 
This disorder is referred to first because, according to our observa- 
tion, of all the intestinal disorders, it is the most frequently seen. Be- 
cause its importance is not recognized the prophylaxis and treatment 
receive but little consideration. The proper appreciation and manage- 
ment of a disordered intestinal function are essential to the solution 
of that most important problem—summer mortality from diarrheal 
diseases. As pointed out elsewhere, the most fertile field for later dis- 
ease is furnished by the intestine which is persistently deranged. 
In June the mortality from acute intestinal disease in Greater New 
York in children under two years of age has repeatedly been but 300 to 
500 less than in August. The high June mortality has been explained 
by the fact that the list included many cases of malnutrition and maras- 
mus, but it must be remembered that the list includes also cases of infants 
with diminished intestinal resistance, who are ready victims to the al- 
most invariable exposure, through infected food, to which every bottle- 
fed infant is subjected at some time during the summer, when heat and 
humidity aid in lowering the general vitality. A close investigation of 
hundreds of cases of severe acute intestinal disorders of infants has shown 
that a great majority are not so acute as a superficial history would indi- 
cate. A complete history in a case of acute gastro-enteric intoxication 
(cholera infantum), or in one of apparently severe intestinal infection 
with resulting colitis, or one of acute colitis (dysentery), will show that 
the child had defective intestinal digestion during the previous cold months, 
and that the grave condition which he presented when brought for treat- 
ment had been preceded for two or three or more days by simple diar- 
rhea, probably without vomiting and with little fever. The fact that 
the patient did have green passages and did have diarrhea indicates the 
existence of intestinal indigestion before the urgent symptoms of fever 
and prostration developed. In only about 1 per cent, of the cases of 
severe gastro-enteric diseases of children in summer the onset is sudden 
without warning, and with urgent symptoms. 
Symptoms.—Fever is usually present in varying degree. It may be PERSISTENT INTESTINAL INDIGESTION 
231 
as high as 104° or 105° F. Restlessness, abdominal pain, and moderate 
prostration are usual symptoms. The stools are frequent, undigested, 
green, and may contain mucus. 
Duration.—Properly managed, the case has but a few days’ dura- 
tion. The temperature readily subsides, and the child soon shows evi- 
dence of displeasure at the reduced diet. 
Prognosis.—The condition is serious only in the sense that it may 
be the starting-point of severe intestinal intoxication. Properly treated 
cases present few dangers. 
Treatment.—The time to treat these cases of intestinal indigestion, 
in order to secure most effective prevention of severe toxemia and grave 
lesions, is before the physician sees the patient. The reduction in the 
mortality rests in the education of the mother to the point of realizing 
that a loose green stool is a danger signal. When it occurs, she is to give 
a dose of castor oil (2 teaspoonfuls), stop the bottle or stop the nursing, 
and give the baby boiled water or barley-water until the physician can 
see the patient. Every mother should at the beginning of warm weather 
be instructed in proper summer care of the infant. 
The Breast Fed.—Intestinal disease of severity in infants fed entirely 
on breast milk is exceedingly rare. With a breast-fed baby it may be 
necessary to discontinue nursing for from twelve to thirty-six hours, 
to give 1 or 2 drams of castor oil, and to substitute for breast milk 
barley-water or rice-water No. 1 (see p. 94), to each pint of which or J 
ounce of cane-sugar is added. While nursing is discontinued the breasts 
should be pumped at the regular nursing hour so as to keep up the flow 
of milk and relieve tension. Rarely will other treatment be required. 
The Bottle Fed.—With the bottle fed greater caution will be necessary. 
The management consists in continuing the carbohydrate diet, which 
the properly informed mother has instituted, until the stools approximate 
the normal. This may necessitate an abstinence from milk for three 
or four days, by which time it may usually be resumed. The milk should 
always be given in reduced quantities for the succeeding day. One- 
half ounce of skimmed milk may be added to every second feeding or to 
every feeding of the gruel. If it is well digested and causes no return 
of the diarrhea, the amount of milk may be increased tentatively every 
day or two by the addition of \ ounce to each feeding. 
In some of these cases the diarrhea without fever will continue. In 
such instances the administration of 10 grains of bismuth subnitrate 
with \ to \ grain of Dover’s powder at two- to three-hour intervals, aids 
materially in establishing the normal intestinal function. 
PERSISTENT INTESTINAL INDIGESTION 
The special part of this subject, which has been covered in the con- 
sideration of the management of malnutrition and marasmus, is again 
referred to here in order to call attention to those conditions which, 
though mild in character, constitute so important an etiologic factor 
in the acute intestinal diseases of summer. We have learned that a 
considerable part of the summer mortality of acute intestinal diseases 
occurs in children who have a reduced intestinal resistance as a result of 232 
THE PRACTICE OF PEDIATRICS 
peristent intestinal indigestion, although this may not have been suffi- 
cient to have interfered appreciably with nutrition. 
A considerable number of infants do not have a normal bowel evac- 
uation even for two days out of ten. There is constipation, which is 
neglected, or there is passage of undigested or loose stools. In some 
cases constipation alternates with diarrhea. Occasionally there is a 
sharp attack of diarrhea with fever. In getting the history of our cases, 
regardless of the nature of the illness, we often learn that the infants 
have undigested stools. There is a tendency to an unstable intestinal 
equilibrium. This condition of intestinal indigestion is ordinarily due to 
errors in diet involving the habitual giving of unsuitable articles of food, 
or of food too strong, or feeding at too short intervals. 
Treatment.—The management of each case is determined by the 
age of the patient and the conditions of the family, and is discussed in 
the sections relating to Nutrition, Substitute Feeding, and Modification 
and Adaptation of Foods. 
In some instances the intestinal indigestion is the result of anatomic 
defects or malformations in the gastro-intestinal canal. 
In this condition there is disturbance of function and there may be 
sufficient absorption of toxins from the intestinal canal to produce a wide 
range of symptoms. Whether this causes pathologic conditions in other 
organs it is often not possible to state. One may assume, however, that 
such is the result. Comparatively little attention appears to have been 
given the subject. There is no doubt whatever concerning its etiologic 
importance in the nutritional and so-called functional nervous disorders 
of childhood. One reason why little attention has been called to the 
intestinal tract as an etiologic factor is perhaps because the child is not 
necessarily constipated. Intestinal toxemia may exist with one or two 
apparently normal passages daily, and even without the presence of 
indican in the urine. 
Pain is not a necessary symptom. It is occasionally present, how- 
ever, as is also abdominal discomfort involving a sensation of constriction 
and pressure. 
The conditions in wThich intestinal toxemia has seemed to play a 
part sufficient to form a symptom complex have been habitual headache, 
disorders of speech, choreic in character, secondary anemia, habitual 
sleep talking, sleep walking, teeth grinding, and general irritability 
without apparent cause. Well children are naturally bright and happy. 
When a child is persistently cross and irritable he is not a well child. 
Chronic papular eczema has proved to be of intestinal origin in a con- 
siderable number of cases, particularly among the out-patient class. The 
condition often regarded and treated as malaria is not infrequently due 
to intestinal toxemia, as fever of a degree or two may be present for 
protracted periods, leading the physician to give at some time or other 
a course of quinin. Such a patient is very apt to be habitually tired and 
languid, and although he may be fairly bright early in the day, in the 
afternoon he yawns and complains of being tired and sleepy. The blood 
examination fails to reveal signs of malarial infection, and quinin in full 
Persistent Intestinal Indigestion in Older Children PERSISTENT INTESTINAL INDIGESTION 
233 
doses furnishes no relief. The appetite may be fairly normal, the tongue 
may show no signs of digestive disorder, although such is rarely the case. 
The tongue is usually coated and the appetite capricious. The symp- 
tom complex which suggests to the mother the thought of worms is usually 
the manifestation of intestinal toxemia. 
An important feature of these cases is the continuous elevation of 
the temperature a degree or more daily. In not a few instances the case 
is proved to be one of a low type of toxemia due to milk incapacity. 
Illustrative Cases.—A boy, aged three years, highly nervous and irritable, was 
afflicted with day terrors—pavor diurnus. The attention of the nurse was attracted 
to the condition when he asked that the “bugs” be removed from his lap-robe when 
he was in his go-cart. The time was midwinter, and there were no bugs present. 
On one of these occasions when asked to pick up a bug, he tried to do this with his 
fingers and could not understand why he could not catch them. His tongue was heavily 
coated and he had required a laxative every third day. There was an excess of indican 
in the urine. He was taking a large amount of rich cow’s milk daily. After stopping 
this, a full dose of rhubarb and soda was given daily and he was well in a week. 
A boy five years old was brought for examination because of disturbance of speech. 
He had been normal until three and a half years of age, when he had difficulty in the 
formation of entire words. This had increased with the development of other nervous 
phenomena. There was marked inco-ordination in speech—dysarthria—due to choreic 
movements evidently of the tongue and laryngeal muscles. The boy was exceptionally 
well nourished and there was an absence of choreic movements in other parts of the 
body. The knee reflexes wTere considerably increased. He was easily excited. Hard 
play was followed by restless nights, and he talked in his sleep every night, regardless 
of the habits of the day. Inquiry into the diet failed to reveal any grave errors. He 
drank 1 quart of milk daily, although milk had never agreed with him as an infant. 
The bowels moved once daily. The movements were often of foul odor, and the mother 
stated that she was satisfied they were too small. The patient after three weeks showed 
striking improvement on a diet without milk, with a daily laxative, and made a com- 
plete recovery in three months. 
A third patient was a girl six years of age who lived in the best surroundings, in 
a country district. She was pale, rather thin, and below weight for her age. She had 
been chronically tired and irritable for two years. The blood showred the existence of 
a secondary anemia, and the urine contained a marked excess of indican. She had 
been taking quantities of quinin. Her appetite was indifferent, but she had no con- 
stipation. She favored milk and was paid for drinking extra quantities to the amount 
of about 2 quarts daily. Marked improvement followed the withdrawal of milk from 
the diet and the use of laxatives. 
Treatment.—In our experience the management of these cases which 
has been most successful has consisted in the discontinuance of cow’s 
milk, with the further dietetic restriction to but one egg every second 
day, and flesh food but once daily. Cereals, fruit, and vegetables may 
be taken as suggested in the dietary (p. 135). The use of green vegetables 
is particularly to be encouraged. In place of cow’s milk malted milk 
may be given, and to facilitate the bowel action a raw apple may be 
given in the middle of the afternoon. The patient should take an after 
dinner rest for an hour or two. If constipation is obstinate, rhubarb and 
soda of the following strength are recommended: 
1$. Pulveris rhei gr. iv 
Sodii bicarbonatis gr. viij 
Syrupi rhei aromatici 3ss 
Aquae q. s. ad. 3j 
M. Sig.—One teaspoonful once or twice daily. 
If the patient can take a capsule the following is preferable for a 
child from five to eight years of age: 234 
THE PRACTICE OF PEDIATRICS 
lb Tincturse belladonna} gtt. ij 
Tinctura} nucis vomicae gtt. iv 
Extracti cascarae sagradae gr. i-iij 
Sodii bicarbonatis gr. iij 
M. ft. capsula No. i. 
Sig.—To be taken at bedtime. 
The medication may be continued for three or four weeks, after which 
time 1 dram of the syrup of the hypophosphites (Gardner’s) may be 
given three times a day. This may be alternated with: 
3. Ferri et ammonii citratis gr. xxiv 
Elix. simplicis 3j 
Aqua? q. s. ad. 3iv 
M. Sig.—One teaspoonful three times daily after meals. 
In the event of constipation persisting after the use of the laxative, 
the oil treatment (p. 273) may be brought into use and continued until 
the condition is relieved. 
The gastrointestinal tract is exposed, of necessity, to influences from 
without which may exert decided effects upon the physiologic processes 
of its different parts. It is obvious that there may be lesions in any part 
of its structure, and that such lesions may cause a derangement of function, 
if not actual disease, by transfer of infection to other parts of the tract. 
Thus there may be lesions, single or multiple, in various portions of the 
gastro-intestinal tract. There may be a simple gastritis, or an ileitis 
or colitis singly or in combination, entirely independent of pathologic 
conditions of the other portions of the tract. 
The function of the gastro-intestinal tract is the final preparation of 
food substances for the use of the organism. These food substances are 
perishable in character and susceptible to bacterial influences and chem- 
ical change. Obviously, this long tube, adapted for absorption and of an 
anatomic and physiologic construction of most intricate and sensitive 
nature, offers ready fields for bacterial invasion and chemical change, 
and consequently is subjected to constant insult by toxic agents result- 
ing from bacterial and chemical processes. 
For the past two hundred years investigators have attempted a classi- 
fication of the acute gastro-intestinal disorders, and while much progress 
has been made in framing a classification sufficient for bedside and teach- 
ing purposes, let no one imagine that the last word has been said. With 
an increase in knowledge of the subject, old theories and concepts will 
be disproved and new theories evolved which may share the fate of their 
predecessors. It is not wise to be carried away by the theories of our time 
concerning a subject the etiology of which is based upon so many factors, 
not the least important of which is that of physiologic chemistry, a 
subject of which we can boast too little absolute knowledge. 
Until we possess demonstrable facts it is best in teaching not to go 
into vague chemical and metabolic theories. 
Symptoms.—This form of intoxication, while acute in character, is 
rarely of primary origin. It is usually preceded by disordered gastro- 
enteric digestion. 
The onset is sudden, with pronounced prostration, persistent vomit- 
ACUTE GASTRO-ENTERIC INTOXICATION ACUTE GASTROENTERIC INTOXICATION 
235 
ing, retching, and the passage of large, watery stools of greenish color. 
The pulse is soft and rapid. 
In a few hours the prostration becomes extreme, the respiration 
quick and shallow, the eyes sunken, and the skin dry and ashen in color. 
The extremities are cold; thirst is intense. The fontanel is depressed. 
The anus becomes relaxed, and often there is a constant slight discharge 
of the intestinal contents. 
The temperature is variable and inconstant—it may be high, 105° 
to 106° F., or it may never arise above the normal. The lower tem- 
perature cases with repeated vomiting and profuse diarrhea are the 
most hopeless. The system is so overwhelmed by the poisoning that 
a reaction is impossible. 
As the disease progresses toward a fatal termination the patient 
develops stupor and occasionally convulsions. Coma rapidly ensues, 
and death from a virulent poisoning process is the outcome. 
An infant may die in twelve hours from the onset of the symptoms. 
The loss of weight is most rapid. In twenty hours a nine-month- 
old baby lost 2 pounds. The loss of a pound or more in twenty-four hours 
is not at all unusual. 
Illustrative Cases.—At the Nursery and Child’s Hospital a child fifteen months of 
age was taken acutely ill with vomiting and diarrhea at 11 o’clock in the morning. 
The child was seen by the house physician, and suitable management was instituted. 
On rounds at 4 o’clock the child was found moribund in spite of active treatment, and 
death took place six hours later. 
Thirty-one children in this institution were poisoned by a can of stale milk left by 
a dealer who was short of a sufficient fresh supply. Thirteen deaths in children under 
eighteen months were traceable to this can of milk. 
Not all cases are as severe as the foregoing descriptions represent. 
There are cases in which there is a sharp rise in temperature to 105° or 
106° F., with active vomiting and profuse watery stools. The fever 
soon subsides. The stomach is washed, milk is withheld, boiled water, 
weak barley-water, or rice-water No. 1 (see formula, p. 94) is given, 
and the child is well in a few days. In the more severe cases that re- 
cover several weeks elapse before the patient regains normal vigor. 
The urine contains albumin, and usually a few hyaline and epithelial 
casts—findings that are common in all severe acute toxic processes, and 
have no significant bearing upon the illness. 
Infants ill with intestinal intoxication not infrequently develop severe 
acidosis. In such cases the prostration is extreme. There is rapid breath- 
ing—evidence of air hunger without cyanosis or respiratory obstruction, 
and with the chest signs negative. Coma early supervenes and the out- 
come is usually fatal. 
Pathology.—The postmortem findings are negligible. The stom- 
ach and intestines present a very pale, washed-out appearance. The 
intestine usually contains a mucoid, yellowish substance entirely free 
from fecal odor. The brain may show a cerebral anemia; more often 
there is moderate edema of the meninges—the so-called wet brain. 
Treatment.—The management of the case depends entirely upon 
the nature and urgency of the symptoms. In the acute choleraic or so- 
called cholera infantum cases, with repeated vomiting, severe toxemia, 
retching, and profuse watery stools, stomach washing and bowel irri- 236 
THE PRACTICE OF PEDIATRICS 
nations are useless procedures. We must support the patient and aid 
him to bear the infection with which he has to contend. 
If the temperature is high and the skin dry and hot, a cool pack to 
the trunk, at 85° to 90° F., subsequently moistened with water at this 
temperature every half-hour, will often control the pyrexia. If the feet 
are cold, hot-water bottles should be brought into use. If the temper- 
ature is below normal and the peripheral circulation poor, as indicated 
by a leaden hue of the skin, a hot-water bath at 108° F. for five minutes 
will always be of service. The bath may be repeated at half-hour 
intervals. 
In addition, the immediate treatment calls for hypodermic stimulation 
and sedatives. The administration by mouth of food or stimulants should 
not be attempted. Tincture of strophanthus and brandy, hypoder- 
mically, have served well in these cases. Twenty drops of brandy with 
2 drops of the tincture of strophanthus may be given at intervals of one, 
two, three, or four hours, depending upon the urgency of the case. A 
combination of morphin and atropin may be used in cases with persistent 
vomiting, with a view to controlling the attempts at vomiting which 
exhaust the patient, and also to diminish the continuous loss of the fluids 
of the body from the repeated large, watery stools. Obviously, morphin 
should not be given unless this condition exists. For a child one year 
of age 1/50 grain of morphin may be given with 1/500 grain atropin, and 
repeated as required, not oftener than once in two hours. After the 
first year 1/30 grain of morphin may be given as an initial dose. Bene- 
ficial effects from the morphin will be noted in a diminution in the number 
of stools and the frequency of the vomiting. 
In milder cases of infection in which the vomiting and defecation are 
less frequent, a different course is to be pursued. In these cases abstin- 
ence from food must be enforced, boiled water being given if the child 
can retain it. If vomiting persists, the water should be discontinued. 
The stomach should be washed at least once daily and the colon ir- 
rigated. If the irrigation brings away mucus and fecal matter, it should 
be repeated at intervals of from eight to twelve hours. The child should 
never be disturbed for this purpose if the intestine continues to empty 
itself at frequent intervals. 
A reduction in the temperature, cessation of the vomiting, and a dim- 
inution in the number and improvement in the character of the stools, 
tell us whether or not the case is doing well and determine the further 
treatment, after the initial dose of castor oil or calomel has been given. 
As a rule, the milder type of case does better when calomel is used. If 
there is a tendency to vomit, the oil will rarely be retained, regardless of 
how it is given. From 1/15 to 1/10 grain of calomel may be given at 
fifteen-minute intervals until 1 grain is given. While slower in its 
action, it is ultimately of more benefit than the oil, which is apt to be re- 
jected. 
Feeding During the Attack.—When the vomiting has subsided, tea- 
spoonful doses of plain water, bicarbonate of soda solution, barley-water, 
Granum-water, or rice-water, should be given at fifteen-minute or half- 
hour intervals, and the amount should be increased in quantity and 
be given less frequently as the case improves. It is well, in using milk ACUTE GASTROENTERIC INTOXICATION 
237 
substitutes, such as cereal waters, to use alternately, for the sake of 
variety, three or four different preparations. The child will not then so 
soon tire of the milk substitute as when but one is given, and will thus 
take more food. It is extremely rare that the substitutes barley, rice, or 
Granum will not be taken if used in this way, particularly if they are 
made more palatable by the addition of salt and sugar or saccharin. 
In cases showing signs of acidosis, which is indicated particularly by 
deep and labored breathing, bicarbonate of soda should be given at once, 
10 grains every hour if possible, until the patient receives at least 120 
grains in twenty-four hours. It is to these urgent cases that not only 
bicarbonate of soda but glucose should be given intravenously (p. 772). 
Intraperitoneal saline injections and even transfusion should be employed 
in extreme cases. 
Drugs.—Unusual care must be exercised in the use of astringent 
drugs in the cases we are discussing, particularly in cases that are mild 
or moderately severe. It is to be remembered that it is in the intestinal 
contents that the trouble exists, and not in the intestinal structure, and 
that the diarrhea is a conservative attempt on the part of nature to pro- 
tect the intestinal structure. Our first efforts, therefore, should not be 
directed toward stopping the diarrhea, but toward assisting in the elim- 
ination of the intestinal contents productive of the illness. The indis- 
criminate use of opium and astringents may do irreparable damage in 
a very short time through a locking up of the intestine, which may be 
followed by a sudden rise in temperature, convulsions, coma, and death. 
When there is tenesmus, with frequent large, watery stools, opium may be 
given with caution in small doses sufficient to control the number and 
character of the stools, with a view to prevention of an excessive loss of 
fluids from the body. This drug should never be given when there are 
only four or five free evacuations in twenty-four hours, associated with 
more or less fever, as in such cases this number is required to maintain 
proper drainage. The opium should further be given independently 
of other medication, so that its use may be stopped when the excessive 
number of stools ceases, or in the event of a rise in temperature after it 
has been given. It would not be desirable, perhaps, to discontinue the 
bismuth or other drugs which may have formed a part of the prescription. 
Dover’s powder, \ to § grain, given at intervals of two or three hours 
is suitable for a child from six to eighteen months of age. Bismuth sub- 
nitrate in not less than 10-grain doses at two-hour intervals has given 
most satisfactory results. In order to be of service it must produce black 
stools. In other words, if the bismuth is not converted into the sulphid 
in the intestine, it apparently is of no service, i. e., if it passes through 
the bowel unchanged, no favorable influence will be exerted on the in- 
testine. This lack of effect is observed in a small percentage of cases. 
In such an event the necessary amount of sulphur may be supplied by the 
use of sublimated sulphur, 1 grain being added to each dose of the 
bismuth. A convenient and agreeable way of giving the bismuth is 
the following: 
W Bismuthi subnitratis 3v 
Syrupi rhei aromatici 3i>j 
Aquse ' q. s. ad. 5 iv 
M. Sig.—One teaspoonful every two hours. 238 
THE PRACTICE OF PEDIATRICS 
If sulphur is necessary, a 1-grain powder may be added to each dose of 
the bismuth mixture at the time of its administration. In the same 
way Dover’s powder, if opium is indicated, may be dropped into the 
bismuth mixture. The bismuth is to be continued in the large doses 
until the child is ready for milk, when the dose should be diminished one- 
half and continued until full milk feeding is permissible, or until consti- 
pation contraindicates this drug. In using the bismuth in the large 
doses advised it is necessary that the chemically pure drug be obtained. 
If free nitric acid or arsenic is present, as is the case in some of the com- 
merical bismuth on the market, vomiting may result, or symptoms of 
arsenical poisoning may develop. Irrigation of the colon (p. 854) may 
be used when there is a tendency to bowel inactivity with high tem- 
perature. If there are loose watery passages, irrigation is not called for. 
Hypodermoclysis, Intraperitoneal and Intravenous Infusions.—The 
injection of warm normal salt solution into the subcutaneous cellular 
structure of the body is frequently advocated by pediatric writers for the 
very urgent cases in which there is extreme prostration and rapid loss in 
weight due to the persistent watery discharges. We have employed this 
treatment in a great many cases, but rarely have found it of great utility. 
In the cases where such addition of the fluid is most needed, it may not be 
absorbed because of the lowered vitality of the patient, while those whose 
tissues are able to take up the salt solution frequently do well without it. 
The more direct methods of intravenous glucose administration and 
intraperitoneal injection of saline (p. 850) are now supplanting the older 
procedure of hypodermoclysis, although their indorsement has been by 
no means universal. 
Diet.—A difficult problem of no little importance is the nutrition of 
the patient after the acute symptoms have subsided. When the tem- 
perature has been normal for two or three days, and the character of the 
stools improves to such a degree that freer feeding than carbohydrate 
decoctions is to be thought of, unusual care is necessary in order to avoid 
a reinfection. 
Skimmed Milk.—It must, of course, be our effort to resume milk 
feeding as early as possible, but in resuming milk the amount given 
must be increased very gradually—at first only \ to \ ounce of skimmed 
milk being given in every second feeding of the cereal gruel. In not a 
few cases even these small amounts will result in a rise of temperature 
and a return of the diarrhea. There are always pathogenic bacteria 
remaining in the intestinal tract after an illness of this nature, which, 
under the influence of such a favorable culture-medium as milk, take 
on renewed activity. The whole illness may, therefore, be repeated 
perhaps with greater severity than the original one if the milk feeding 
is persisted in. One repeatedly sees infants who are having what is called 
a relapse. What they have is a reinfection, with all the symptoms as 
severe as, or more severe than, those of the first infection, because of a 
lack of appreciation of the necessity of great care in resuming milk. To 
avoid mistakes in feeding at this time, as well as early in the disease, 
all directions should be carefully written. Nurses and mothers who think 
the physician is overcautious and pity the hungry child are very apt 
to forget oral instructions and give more milk than is ordered. If the ACUTE GASTROENTERIC INTOXICATION 
239 
small amount of milk agrees, it may gradually be increased by the addition 
of \ ounce to each feeding every two or three days. Rarely, however, 
will it be possible or wise to attempt to give, for the remainder of the 
summer, as strong a food as was taken before the illness. In milk feeding 
at this time a high fat content must not be used. Either full milk or 
skimmed milk, properly diluted, should be given. If there is a tendency 
to relaxation of the bowels, with frequent passages, the use of skimmed 
milk is indicated. Whether the milk shall be pasteurized, sterilized, 
or raw depends upon the conditions referred to under Sterilization and 
Pasteurization (p. 63). 
The Wet-nurse.—Not a few marasmic out-patients belong to the class 
who, after an attack of diarrhea, cannot take even as small an amount 
of cow’s milk as | ounce in each feeding. After a sharp intestinal in- 
fection, if the baby shows inability to take a nutritious diet, a wet-nurse 
may be secured for the well-to-do, but the wet-nurse’s milk will not always 
agree. Children who have been very ill with any of the severe forms of 
acute intestinal disease of summer have, as a result, a very weak fat 
capacity, and the wet-nurse’s milk, which perhaps contains 3 or 4 per 
cent, of fat, may produce diarrhea sufficient to require its discontinuance. 
When employing the wet-nurse in such cases it is accordingly best never 
to permit the child to have the full allowance of breast milk at first. 
To an infant from three to six months of age, for example, it is well to give 
2 or 3 ounces of barley-water or a 5 per cent, milk-sugar-water before 
each nursing, so that the patient will be satisfied with 2 or 3 ounces of 
the breast milk. When cow’s milk cannot be given and the nurse’s milk 
does not agree, or where for any reason a wet-nurse is not possible, we 
are called upon to furnish other means of nutrition, and this, with our 
available resources, will not be of a very high order for infants under 
one year of age. 
Animal Broths.—The animal broths are of very little service. They 
contain but little nourishment even if given in considerable quantity 
and may produce a decided laxative effect during convalescence from 
diarrhea. They are of value only in small quantities of an ounce or two 
added to the gruel to make it more palatable. 
Cereal Decoctions.—Strong starch foods cannot be digested in suffi- 
cient amount to maintain the nutrition. Dextrinizing processes are 
therefore of considerable service. The starch is thus converted into 
maltose, which is readily assimilable. With this, as with the broth, the 
relaxing effect of the food on the intestine may be felt, frequent bowel 
evacuations being a possible result. The dextrinized gruels, however, 
are always worthy of trial, and they have been of considerable service 
as a substitute for cow’s milk. 
Condensed and Evaporated Milk.—When breast milk is not available, 
condensed milk usually answers better than any other food, being much 
more easy of digestion than fresh cow’s milk. The condensed milk at 
first is to be added in small quantities to the cereal water made from 
barley, rice, or Granum, No. 1 strength being employed. (See Formulary 
p. 94.) One-half dram may be added to every second feeding for the 
first day, and on the following day this amount may be added to every 
feeding. The condensed milk usually will be well taken and well di- 240 
TIIE PRACTICE OF PEDIATRICS 
gested. It should be gradually increased until 2, 3, or 4 drams are added 
to each feeding. When it seems desirable to use more than 2 drams at 
each feeding, unsweetened evaporated milk, if obtainable, furnishes an 
increased amount of protein and fat without the excessive percentage of 
sugar. In not a few cases the combination of evaporated milk and cereal 
diluent must furnish the nourishment for the remainder of the heated 
term. With the advent of cooler weather, 1 ounce of weak raw milk 
with the cereal diluent may be substituted for one of the regular feed- 
ings, and later this may gradually be increased \ or 1 ounce at a time 
until the raw milk comprises one-third of the food mixture. When this 
point is reached, an attempt may be made to replace with raw milk another 
feeding of the evaporated milk. In this way, by carefully watching the 
case, a gradual replacing of the evaporated milk by fresh raw milk feeding 
may successfully be brought about until raw milk only is given. 
Feedings After the First Year.—After the first year similar methods 
may be followed if necessary, although at this age plain milk will usually 
be tolerated earlier, and other means of feeding than the milk may be 
brought into use. Zwieback, bread crusts, and scraped beef—2 or 3 
teaspoonfuls a day—will often be taken without inconvenience when 
milk in sufficient amount for proper nutrition disagrees. At this age 
the gruels also may be made stronger. No. 2 or No. 3 (see Formulary, 
p. 94) will often be well borne. An important point to be remembered 
in feeding convalescents from an acute gastro-enteric disorder is that 
the food must not be forced, and that the child must be fed only in ac- 
cordance with his digestive capacity. This can best be determined by 
watching the temperature and the stools. The gruels as substitute foods, 
whether alone or combined with condensed milk, may be given in quan- 
tities equal to those which the child was accustomed to take in health, 
and they may be given at more frequent intervals, never, however, oftener 
than every two hours. A child who has been fed at four-hour intervals may 
take the substitute at three-hour intervals. If fed at three-hour intervals, 
he may receive the substitute at two- or two-and-one-half-hour intervals. 
When constipation follows a sharp attack of diarrhea, an enema may 
be used not oftener than once in twenty-four hours. The patient should 
not be given a laxative for several days after the acute symptoms have 
subsided unless there is fever. 
Protein Milk.—For young infants—under nine months or thereabouts 
—protein milk (p. 88) may sometimes be used with good effect. The 
taste, however, is not agreeable to older children, many of whom refuse 
it. In such instances saccharin may be used for sweetening purposes. 
At first, after the acilte symptoms have subsided, the protein milk is to 
be given with barley-water, 1 part of the milk to 3 parts of barley- 
water. This may be rapidly increased to equal parts of protein milk 
and barley-water. It is not wise in most instances to give the milk stronger 
than this dilution. The protein milk is often retained and digested 
more readily than cow’s milk, may be given in larger daily amounts, 
and is a valuable means of sustaining the child for a few days or a week 
until cow’s milk or condensed milk (p. 78) may be tolerated. 
Termination.—The termination of acute gastro-intestinal intoxica- 
tion is in death, prompt recovery, or in the development of ileocolitis. ACUTE ENTERIC INTOXICATION 
241 
The transition to an ileocolitis in some cases is so sudden that its exist- 
ence from the onset is often assumed. That such is not the case is proved 
by autopsy experience in hospital and institution work, with cases dying 
in a day or two from toxemia, in which no intestinal lesions of conse- 
quence are found. The continuation of fever and diarrhea, with loose 
green mucous stools, means that an ileocolitis has developed as a result 
of the toxic agents in the intestine. 
Acute Enteric Intoxication 
This type of intoxication differs clinically from the foregoing in that 
there is no vomiting and rarely fever. Any elevation of temperature 
occurring is usually no more than a sharp rise to 105° or 106° F., and 
is of very temporary duration. In the great majority of the cases there 
is no such elevation, and more often during the entire course the tem- 
perature is subnormal. 
The presence of moderate fever is a favorable sign, and indicates 
a more favorable prognosis. The clinical picture is similar to that of a 
case of gastro-enteric intoxication in that the prostration is extreme, 
the extremities are cold, the eyes sunken, the fontanel depressed, and 
the features drawn and pinched. Convulsions and muscular twitch- 
ings are often present. The mental condition is dulled, and the child 
lies in a semistupor, offering little or no resistance when disturbed. Diar- 
rhea may be severe, or there may be constipation, with or without tym- 
panites. In some cases there is an intestinal paralysis sufficient to resist 
all attempts at an evacuation. In such instances death may occur in 
twenty-lour hours from the onset without a degree of temperature and 
without a sign of diarrhea. If an evacuation occurs, it usually consists 
of green, mucous stool, which may be very offensive, although this is 
not always the case. 
The milder cases are characterized by an elevation of the tempera- 
ture and varying degrees of prostration. 
Pathology.—The intestinal lesions in these cases are of slight signifi- 
cance. There is perhaps an area of congestion here and there in the 
lower ileum or colon, with enlargement of the solitary follicles and epi- 
thelial desquamation. 
Treatment.—As mentioned above, there may be moderate diarrhea 
or marked bowel inactivity. In both conditions castor oil in doses of 
never less than 2 drams is to be given. Milk should be discontinued 
whether the patient is bottle fed or nursed. As a substitute, barley- 
water, rice-water, or Granum-water No. 1 (p. 94) may be given, with 
salt and cane-sugar or saccharin added for flavoring purposes. The 
treatment of these cases is facilitated by the fact that, owing to the ab- 
sence of vomiting, the food is usually well taken throughout the entire 
illness, the patient ordinarily being very thirsty. In the event of excessive 
diarrhea—a rare condition—the indications for medication are the same 
as those given under Acute Gastro-enteric Intoxication (p. 237). Castor 
oil or bicarbonate of soda is to be preferred to calomel at the beginning 
of the illness. 
Intestinal infection with defective bowel action (;paralytic ileus) often 
occasions the most difficult cases and requires special treatment. In 242 
THE PRACTICE OF PEDIATRICS 
this type poisons generated apparently in the intestine seem to be of 
such a nature as to cause a partial paralysis of the small intestine, so 
that often, only with the greatest difficulty, can an evacuation be 
induced. So difficult is this, in fact, that the possibility of an acute 
peritonitis or an intussusception may occur to the physician. It is 
then very necessary to maintain bowel action and to prevent the 
accumulation of gas, which, by distending the intestine, increases the 
tendency to constipation and toxemia. 
Illustrative Cases.—A case in point is that of a female infant nine months of age 
who had been most difficult to feed. In July she developed a sudden fever of 105° F. 
and convulsions, which were followed by muscle twitchings, head-rolling, and marked 
prostration. The temperature was uninfluenced by local means, although there was 
no diarrhea or vomiting. The attending physician, anticipating intestinal infection, 
gave calomel in divided doses with frequent bowel irrigation. Foul-smelling fecal 
material came away with the irrigation, but the temperature and the nervous symp- 
toms persisted; in fact, the condition became worse. After the child had been ill ten 
or twelve hours | ounce of castor oil and a high irrigation of normal salt solution 
at 80° F. were given. As a result there was one small green movement in addition 
to what came away with the irrigation, which was considerable. The patient was 
somewhat relieved and the nervous symptoms measurably subsided, though the tem- 
perature still ranged between 104° and 105° F. As a result of the calomel, 1| grains of 
which had been given, and the J ounce of oil, a free diarrhea had been expected. It 
did not, however, occur. Directions were then given that 5 ounce of castor oil be 
given daily in addition to the irrigations every eight hours. This was followed by 
slight improvement in the symptoms, but five days of the treatment wTere required, 
5 ounce of oil and 1 grain of calomel being given daily, with abdominal massage, before 
the resulting peristalsis was sufficient to relieve the intestine of its contents. After the 
establishment of free bowel action the child recovered. 
A similar case which resulted fatally was seen in consultation. In this patient, a 
girl eight years old, the toxemia was intense. There appeared to be almost complete 
paralysis of the small intestine, and only small, very foul evacuations could be induced 
in spite of the most active measures. This child died from toxemia before free bowel 
action could be established. 
The management of these cases of the inactive type is partially il- 
lustrated in the histories above given. Our efforts are to be directed 
toward supporting the patient by the use of stimulation, given hypoder- 
mically or by the stomach, and by the use of a milk-free diet, powerful 
laxatives, and frequent colon flushings. Castor oil may be required 
repeatedly, and should be given freely in doses of at least | ounce every 
twelve hours, until four or five passages in twenty-four hours result. Bi- 
carbonate of soda (p. 237) is given with beneficial results in cases of 
this type. While the fever, prostration, and bowel inactivity persist 
it is necessary to continue the irrigations. In a few cases apparently 
better results have been secured by using for the irrigations cold 
water (70° to 80° F.), with the addition of Epsom salts, 1 ounce to the 
pint. 
Stimulants.—Because of the tendency to convulsions and nervous 
irritability strychnin should not be given. The tincture of digitalis or 
strophanthus answers better than any other heart stimulant. Alcohol 
should be used only under the most urgent conditions of prostration. 
Atropin sulphate, from 1/1000 to 1/400 grain given hypodermically, 
is probably our most valuable drug for immediate stimulation. It may 
be repeated at four- to six-hour intervals. A combination of tincture of 
strophanthus and brandy, or digitalin and brandy, given hypodermically 
is of value. For a child six months of age 20 minims of brandy with 1 ACUTE ILEOCOLITIS (DYSENTERY) 
243 
drop of tincture of strophanthus, or 20 minims of brandy with 1/300 
grain digitalin, may be given and repeated every two hours if necessary, 
according to the requirements of the case. After the first year children 
may be given as much as 1 /100 grain of digitalin or 2 drops of the tincture 
of strophanthus. 
Irrigation of the colon (p. 855) is a measure of inestimable value, both 
for its immediate local effect and also for increasing general peristalsis 
and thus emptying the small intestine. An increase of the peristalsis 
is sometimes well secured by the following procedure: After the colon 
is washed with a normal salt solution at a temperature of 95° F. the 
tube is introduced as far as possible and 8 ounces of saline at 60° F. is 
allowed to escape. The tube is immediately withdrawn and an attempt 
is made, by elevating the buttocks and pressing them together, to have 
the child retain the solution for a few moments. 
In using nutrient enemata and in colon flushing for purposes of supply- 
ing fluids to the circulation we have found that the solution is best re- 
tained when introduced warm—at a temperature of about 100° F. The 
cooler the solution, the more quickly is it expelled through exciting peris- 
talsis. This fact may be taken advantage of in these cases of bowel 
inactivity. After an enema of cool water peristalsis of the small intestine 
will often result in the passage of a considerable quantity of its contents 
into the colon, to be expelled later with the water. The action of the 
cool water will be further assisted by light abdominal massage main- 
tained after the tube is removed. Recovery may follow the clearing out 
of the intestine, or an ileocolitis may result, as in gastro-enteric intoxica- 
tion. The process of transition from enteric intoxication to actual ileo- 
colitis may require but a surprisingly short time, and if recovery is not 
prompt, ileocolitis will almost certainly be the outcome. 
Upon resuming the milk diet the precautions relating to the use of 
cow’s milk, referred to under Acute Gastro-enteric Intoxication (p. 238), 
must be observed. 
In dysentery there is a well-defined infection of the intestine. In 
common with other intestinal disorders it occurs most frequently dur- 
ing the hot months, the later summer and early autumn supplying the 
most cases. In like manner this disease often follows the milder gastro- 
intestinal derangements that are productive of reduced vitality and di- 
minished intestinal resistance. 
Bacteriology.—In a large percentage of cases of infantile diarrhea 
associated with blood and mucus in the stools the dysentery bacillus is 
present. It may be found in large numbers, sometimes in almost pure 
cultures. Duval and Bassett, in 1902, were the first to find Bacillus dys- 
enterise in the stools of cases of infantile summer diarrhea. The type of 
the bacillus which does not ferment mannite (the Shiga type) is not found 
so often in these cases as are the two mannite-fermenting types: the 
Flexner-Manilla and the Hiss-Russel, of which the former ferments mal- 
tose, saccharose, and dextrin, and the latter does not. 
The presence of agglutinins in the blood of the patient is evidence 
of the causal relationship of Bacillus dysenteriae to the existing disease. 
ACUTE ILEOCOLITIS (DYSENTERY) 244 
THE PRACTICE OF PEDIATRICS 
The agglutinins are not present, as a rule, until the second week of the 
disease. 
Pathology.—The lower portion of the ileum-—rarely more than 3 feet 
•—and the colon are the locations of the lesion which may show a wide 
variation in intensity, depending on the character of the infecting organ- 
ism and the resistance of the patient. While the major lesions are usually 
in the colon, the small intestine shows pathologic changes in at least 35 
per cent, of the cases. There may be localized areas of congestion through 
the intestine, enlargement of the solitary follicles, and swelling of Peyer’s 
patches. In nearly all cases, whether the lesions are mild or severe, mod- 
erate swelling and congestion of the mesenteric glands may be noted. 
The inflammation may be acute or chronic, and catarrhal, ulcera- 
tive, or pseudomembranous in type. Although the term “dysentery” 
is properly used to denote only infections by the bacilli of Shiga and 
Flexner and the special protozoon, Amoeba coli, the lesions produced may 
be conveniently considered under the term “ileocolitis.” 
In a series of 82 autopsies upon cases of ileocolitis Holt found fol- 
licular ulceration predominant in 36, catarrhal inflammation in 26, mem- 
branous inflammation in 14, and catarrhal inflammation with superficial 
ulceration in 6. Of 412 cases studied by Holt and Flexner in 1903, 270 
showed the presence of Bacillus dvsenterise, the Flexner acid-forming 
type of organism appearing most frequently. Strains intermediate be- 
tween the Shiga and Flexner bacilli are occasionally found, and in the 
causation of a certain proportion of cases of epidemic dysentery Bacillus 
pvocyaneus has been shown to be active. Amebic dysentery is common 
only in tropical or subtropical regions. 
In simple ileocolitis of the mild catarrhal form the submucosa is but 
slightly involved. The mucosa, however, is swollen, congested, covered 
with secretion, and dotted with occasional points of hemorrhage and 
spots of epithelial exfoliation. The lymph-follicles are swollen and hyper- 
trophied, and the adjacent connective tissue is infiltrated with round 
cells. Microscopically, this infiltration is also apparent about the vessels 
in the submucosa. The stools are ordinarily green and thin in con- 
sistence, and contain mucus, desquamated epithelium, and traces of blood. 
In severe cases the inflammation acquires the ulcerative or membranous 
character, the lymphoid follicles are elevated and superficially necrotic, 
and the submucosa is infiltrated with pus. In such instances the ulcera- 
tions extend deeply, and exceptionally involve the entire intestinal wall. 
The Ulcerative Form.—In ulcerative ileocolitis the ulcers may origi- 
nate in the solitary follicles, and are then small, superficial, round, yellow, 
sharply defined, and surrounded by an inflammatory zone. Later the 
ulcers may grow larger, coalesce, and become deeper, exposing the sub- 
mucosa or even the muscularis. Ulcers may also originate in the mucosa 
itself and not in the follicles; this may occur in dysentery or in cases of 
severe catarrhal inflammation. As a consequence of the coalescence 
of these ulcers the mucosa has a ragged appearance, with islands of gray 
or congested mucous membrane visible between the irregularly shaped 
ulcers of all sizes. Small ulcers heal completely, but large ulcers rarely 
undergo such healing. Stenoses as the result of cicatrization of these ulcers 
do not occur in children. In cases of long standing all the intestinal coats ACUTE ILEOCOLITIS (DYSENTERY) 
245 
are thickened due to inflammatory infiltration, and the mucosa becomes 
pigmented. 
In pseudomembranous ileocolitis the intestinal mucosa is covered with 
a fibrinous exudate, which, can be rubbed off at first, but later is very 
adherent. The mucosa becomes necrotic, and larger or smaller areas 
are lost, leaving a congested, edematous base, surrounded by necrotic 
tissue. The pseudomembrane becomes colored yellow or greenish by the 
feces. The wall as a whole is thickened. The lesion is usually most 
marked in the colon, but the lower ileum is often involved. Healing may 
occur, but is rare; death is the rule. 
Associated Lesions.—In severe cases of ileocolitis the mesenteric 
lymph-glands are involved and the spleen may be enlarged. Perforation 
of the bowel, abscess of the liver, nephritis, and bronchopneumonia are 
occasional complications. 
Symptoms.—A great deal of confusion has been occasioned by at- 
tempts at a nomenclature of the acute inflammatory diseases of the 
intestine which shall make the clinical aspect of the cases fit the patho- 
logic findings. Differentiation, antemortem, into catarrhal, follicular, 
and ulcerative types is impossible, as has been proved by the care and 
daily observation in institution and hospital work of cases that have 
later come to autopsy. 
Consider briefly, for illustration, the gravest cases—cases which at 
autopsy show most extensive ulceration of the intestine. In many of 
these there has been a low temperature—from 100°. to 102° F.—and 
the stools have never contained a particle of blood. In others in which 
perhaps considerable blood has been passed for several days, there is but 
a mild congestion of the mucous membrane of the large intestine. In 
still other cases which continue for a considerable time—from two to 
three weeks—with moderate temperature, death results from exhaustion, 
and autopsy.shows nothing but an enlargement of the solitary follicles, 
with areas of congestion in the lower portion of the small intestine. 
Acute ileocolitis may be the primary intestinal disease. In this con- 
dition the temperature is usually considerably elevated at the commence- 
ment of the illness—103° to 104° F. After an evacuation of two or three 
undigested stools the passages consist of light-colored mucus, often streaked 
with blood, or they are of green mucus and streaked with blood. In some 
cases there is a considerable hemorrhage. Relaxation of the sphincter 
and prolapse of the rectum are not at all unusual. The passages are 
small, frequent, and attended with considerable pain and tenesmus. 
Repeatedly from twenty to thirty such passages will be observed from 
one patient in twenty-four hours. 
Far more frequently, however, this condition follows acute gastro- 
enteric indigestion or an intestinal infection, the dangers of which have 
not been appreciated, and which, in consequence, has been improperly 
treated. The lesions produced are due to the bacteria and their toxins, 
which have abundant opportunity to produce pathologic changes in the 
intestinal mucous membrane, the extent of which can only be conjectured 
during life. 
An important feature of some of these cases is that an extreme degree 
of toxemia, with resulting prostration, may be present, with little fever 246 
THE PRACTICE OF PEDIATRICS 
and insignificant bowel symptoms. In other cases the bowel manifesta- 
tions are very active and the toxemia is slight. The active cases offer the 
better prognosis. Vomiting may be present at the onset of the attack, 
but is not usually a symptom of consequence. There is always emacia- 
tion. The degree of prostration is dependent upon the amount of toxemia, 
the extent of the lesion, and the management of the case, particularly as 
relates to supportive measures and nutrition. 
Duration.—The duration of ileocolitis is longer than that of any of the 
intestinal disorders previously mentioned. With the disease established 
it is rare for a case to recover under ten days. Oftener the duration of 
the illness is two or three weeks and we have repeatedly known cases to 
continue over four weeks. In fact, the duration in many instances is 
similar to that of typhoid fever. The temperature range is variable—from 
normal to 104° F. For three or four weeks in a given case there may be 
a low temperature range—99.5° to 101.5° or 102° F. 
Treatment.—Recent work in the bacteriology of the acute intestinal 
diseases has added little to our practical knowledge as to the treatment 
of the condition, and consequently does not call for discussion here. 
Milk is to be stopped at once, whether the patient is breast fed or bottle 
fed. Barley-water, Granum-water, or rice-water No. 1 (see Formulary, p. 
94) constitutes the basis of diet for children under one year of age. 
Older children may be given the No. 2 mixture. To these carbohydrate 
foods may be added an ounce of chicken or mutton broth, with salt or 
sugar to make them more palatable. It is well, for variety, to make up 
two or three cereal preparations and alternate their use. In this way the 
foods will be better taken and for longer periods than if but one is pre- 
pared. In this form of substitute feeding an amount similar to what the 
child was accustomed to in health may be given, but the intervals may be 
shorter by one-half hour or one hour. 
To patients of any age two or three feedings of protein milk (p. 88) 
mg,y be given daily. It supplies additional nutrition, and if the disease is 
prolonged, there is correspondingly less emaciation. In using the protein 
milk it should at first be diluted with barley-water—\ milk to f water 
at first, to be increased to \ milk and \ barley-water. In cases in which 
the standard protein milk is not well taken or is vomited, the improved 
product made from evaporated milk (p. 78), with a shortened incubation 
period, has been often employed with much advantage. 
Drugs.—One has abundant opportunity to test the value of the dif- 
ferent drugs advocated from time to time for the treatment of this disease. 
Drugs which have proved of unquestioned value are castor oil, subnitrate 
of bismuth, and opium. Drugs which have an occasional application are 
sulphur and the preparations of tannin. Constitutional measures, sup- 
portive in character, such as heat and stimulation, are, of course, used 
when indicated, as in any severe exhaustive illness. 
At the commencement of the attack 2 drams of castor oil should be 
given. If this is not retained, from 1 to 2 grains of calomel should be 
given in divided doses—\ grain every hour. In cases with considerable 
fever and infrequent stools it is well to repeat the oil or give some other 
laxative, such as magnesia, every two or three days. 
Bismuth subnitrate is best given in 10-grain doses, according to the ACUTE ILEOCOLITIS (DYSENTERY) 
247 
suggestions on p. 237. If black stools do not follow its administration, 
1 grain of precipitated sulphur may be added to each dose. To be effec- 
tive the bismuth must be given in large doses; 2 or 3 grains at inter- 
vals of two or three hours are of no value. To patients over one year 
of age 15 to 20 grains are frequently given at two-hour intervals. The 
writer has used bismuth extensively for children during the past twenty- 
five years, and has yet to see harm resulting from its use. Of course, 
the physician must use a pure article. Not a few cases do admirably 
under the cereal-water diet, castor oil, bismuth, and sulphur. Tannalbin, 
in doses of 2 grains for infants, and from 5 to 8 grains for older children, 
is sometimes of service when there is a tendency to large watery stools 
or stools containing large quantities of mucus. This drug also may be 
given at the same time as the bismuth. 
When there is much pain and tenesmus, with frequent, scanty, mucous 
stools, opium may be used with advantage, with a view to controlling the 
tenesmus and diminishing the frequency of the stools. Paregoric or 
Dover’s powder is usually selected for this purpose. Dover’s powder 
is preferred, because of the absence of a disagreeable taste and the con- 
venience of its administration. It may be added to the bismuth at each 
dose, not combined with it in a prescription, for uncombined it may be at 
once discontinued or given in smaller doses upon a diminution in the 
number of the stools. 
Careful instructions should be given when prescribing opium. It 
is to be given for a definite purpose—to prevent straining and the fre- 
quent passages due to excessive peristalsis. As in the treatment of acute 
intestinal infection, particularly if there is temperature, it is not well to 
attempt to reduce the number of the stools below four or five in twenty- 
four hours, and, of course, opium is not to be given at all unless the stools 
are very frequent. The amount of opium that will be required in a given 
case may readily be determined by carefully watching the character 
and frequency of the stools. For children under one year of age the 
dosage of Dover’s powder is from | to \ grain at two-hour intervals, not 
more than seven doses being given in twenty-four hours. From the first 
to the tenth year the dose ranges from \ grain to 2 grains. Mothers and 
nurses should be instructed that when there is a rise in the temperature, 
or when the child becomes drowsy after its use, the opium is to be dis- 
continued or the dose reduced one-half—another advantage of giving it 
independently. The younger the child, the greater caution to be observed. 
When heart stimulants are necessary the tincture of strophanthus 
may be used in case digitalis is not well borne by the stomach. Because 
of its unfavorable effect upon both the stomach and the kidneys, alcohol 
should be given with caution, and when used should be well diluted and 
given only temporarily—during the urgent period of acute toxemia. 
Prolonged use of alcohol invariably interferes with the stomach function. 
Caffein sodio-salicylate, in to 1-grain doses at two-hour intervals, 
and atropin, to grain at four-hour intervals, are particularly 
useful in the asthenic cases. For threatened collapse camphor, 1 to 2 
grains hypodermically in oil, answers well, but requires frequent repeti- 
tion at one- to two-hour intervals. Adrenalin 1 : 1000 solution in 2- to 
3-drop doses, hypodermically, is also of much service in collapse. 248 
THE PRACTICE OF PEDIATRICS 
Hot Applications.—Hot stupes or hot compresses to the abdomen are 
often most grateful to the patient when there is abdominal pain and 
tenesmus. The hot applications should be changed every fifteen or twenty 
minutes, never being allowed to become cold. 
Colon irrigation should be used at least once in every case of colitis, 
normal salt solution being employed at 100° to 105° F. The solution should 
always be used warm, as it at times has a pronounced sedative effect 
when used in this way, and thus may fulfil two purposes. Whether the 
irrigation is repeated or not must depend upon its effect upon the patient. 
When he strains against it and there is no apparent diminution in the num- 
ber of the stools, it should not be repeated. Frequently, however, the 
intestine remains quiet and the number of passages is diminished after a 
warm irrigation—105° to 110° F. In such cases it may be repeated twice 
daily. In cases in which there is not an active bowel action, and decom- 
posing blood and mucus are removed by the washing, it may be used once 
or twice daily. 
Only in the rarest instances, when there is high fever and bowel action 
is delayed, should intestinal irrigation be practised oftener than once in 
twelve hours. This treatment is often overdone. Irrigation should 
always be used for a definite purpose, and discontinued when that pur- 
pose is accomplished. Every year, at the close of the heated term, one 
sees cases of chronic colitis without fever which are being treated by 
irrigations two or three times daily without any indication for the irriga- 
tion other than the mucous stools. Irrigations, without question, help 
to keep up the secretion of mucus, for repeatedly it has disappeared en- 
tirely in a few days without other treatment after the discontinuance of 
the irrigation. When irrigation is practised frequently in cases with 
inactive peristalsis it is possible to produce a general edema due to the 
absorption of the fluid. This has been done experimentally in well children. 
Starch and Opium.—The time-honored remedy—the injection of 
starch and opium—may be of service in the cases in which there is much 
tenesmus, with the passage of small amounts of blood-streaked mucus 
or the discharge of bloody mucus from the rectum. In these cases the 
principal lesions are usually located in the sigmoid and rectum. A straight- 
pipe, hard-rubber syringe answers best for this purpose. A starch solu- 
tion of the strength of 1 dram of starch to 1 ounce of boiled water is used. 
For infants under one year of age 5 drops of laudanum may be added to 
2 ounces of the starch solution, and repeated at intervals of six to eight 
hours. Older children may be given from 8 to 12 drops of laudanum with 
4 ounces of the starch solution, and this may be repeated in four to six 
hours. 
Improvement in the colitis is indicated by a subsidence of the tem- 
perature, a change in the character of the stools from green or clear mucus, 
with blood and scarcely any odor, to passages which gradually take on a 
fecal odor and show the presence of feces mixed with mucus. 
Infusion and Transfusion.—In cases that are doing badly, in which 
exhaustion and dehydration are marked, transfusion is of great service. 
If this is not possible, hypodermoclysis or intraperitoneal injection of 
normal salt solution may be employed (pp. 850-851). 
Serum Therapy.—The use of antidysenteric serum and solutions of ACUTE ILEOCOLITIS (DYSENTERY) 
249 
bacteriophage or bacteriolysin is theoretically rational and is advocated 
by many workers, but thus far the results in general have not been par- 
ticularly striking. Further advance in the treatment of dysentery will 
probably be along the lines of serum therapy, or from further knowledge 
of the mechanism of the D’Herelle phenomenon. Practical results thus 
far do not warrant further discussion here. 
The Influence of Climate.—When the case is under control, a change 
of climate is most beneficial. A child who has had colitis at the sea- 
shore or in town will invariably have recovery hastened by a removal 
inland to the mountains, where an open-air life is to be insisted upon. 
Diet in Convalescence.—With a subsidence of the fever and an improve- 
ment in the number and character of the stools the patient’s troubles 
are not over. The problem of nutrition is often difficult. The child has 
necessarily been on a reduced diet for several days—often for two to three 
weeks. If better nourishment than cereal gruels and protein milk is not 
soon forthcoming, the patient faces the danger of malnutrition and maras- 
mus, which is the outcome in not a few of the badly treated cases in which 
the disease is not quickly fatal. The use of fresh milk must sooner or 
later be attempted. 
In nearly all these cases the child has not been getting sufficient caloric 
units for maintenance of weight. This applies particularly to children, 
who, on account of age or refusal to take it or intolerance, have not had 
the benefits of protein milk. 
Children who have had colitis bear fat badly. The younger the child, 
the more certainly is this the case. This has been so forcibly impressed 
upon the writer that he has discontinued attempts at feeding these con- 
valescents, even with small quantities of whole milk. They do best on a 
carbohydrate gruel as a basis of diet, to which sugar-of-milk is added in 
the proportion of from § to 1 ounce to the pint, thereby furnishing material 
for heat and energy. To this sugar-cereal combination boiled skimmed 
milk in small quantities is added; not over | ounce, and that to only one 
of the feedings, the first day that milk is given. If this causes no in- 
convenience, an increase of § ounce is made at every second feeding the 
following day, and an increase of ounce at every feeding the third day. 
The total quantity of food given at each feeding is to remain the same, 
an equal quantity of the cereal diluent being removed to make way for 
the milk increase. Thereafter, if all goes well, an increase of \ ounce is 
made in each feeding every day until the child is taking his daily feedings 
of skimmed milk one-half strength. In some cases it may be found that 
the child’s capacity will be only 2 ounces of skimmed milk at a feeding 
with the cereal-water diluent. Here he must be held, perhaps, for a week 
or two before milk can safely be advanced. Usually the younger the 
child, the more difficult will be the resumption of the milk diet. After 
the first year the nutrition may be assisted by thick gruels of vary- 
ing types and compositions, zwieback, bread crusts, or rare scraped 
beef—two or three teaspoonfuls daily, with a couple of feedings of protein 
milk or buttermilk. By infants under one year of age who cannot take 
even a weak dilution of skimmed milk, Granum No. 1 (p. 95) will usually 
be well taken. If there is abdominal distention from starch indigestion 
the Granum may be dextrinized. Cereal-water also answers well as a 250 
THE PRACTICE OF PEDIATRICS 
diluent for evaporated milk. In adding evaporated milk to the cereal- 
water sugar is to be omitted. The evaporated milk may be increased 
slowly until from 1 to 4 drams are given at a feeding. Under no ordinary 
considerations, however, should this diet be permanent. After from two 
to four weeks the use of plain milk should be attempted, replacing one 
feeding of the evaporated by a small amount of diluted plain milk. 
Obstinate constipation sometimes follows recovery from severe ileo- 
colitis. This is to be managed along the lines laid down for the manage- 
ment of constipation (p. 267). Following an attack of ileocolitis the 
patient must never be allowed to pass twenty-four hours without an 
evacuation of the bowels. A standing order should be given that an 
enema should be used when no movement occurs. 
CHRONIC ILEOCOLITIS 
Cases of chronic ileocolitis coming under our observation have in- 
variably been preceded by acute attacks that were unusually severe or 
that were badly managed. These cases represent one of the forms of mal- 
nutrition, but are of such a nature as to require special consideration. 
Pathology.—The walls of the intestines are thickened with connective- 
tissue formation, and the solitary follicles have undergone pigmentation 
as a result of hemorrhages or extreme congestion. 
Symptoms.—The patient is emaciated, and often 3 or 4 pounds under 
weight; the skin is dry and rough; the circulation is poor; the extremities 
are cold, and the temperature is often subnormal, showing an occasional 
sharp rise. The abdomen is always distended with gas. The stools usually 
are loose, number three or four daily, and contain mucus in considerable 
amount. The mucus may be absent for two or three days; then there will 
be a rise in temperature of from 102° to 105° F., and large quantities 
with a very foul odor will be passed. The nervous symptoms are usually 
marked. The child is irritable and sleeps poorly. He cries a great deal, 
is very unhappy, and looks as wretched as he apparently feels. 
In assuming the care of one of these cases it is well to inform the 
parents that a rapid improvement is not to be looked for. 
Illustrative Case.—A patient aged three and one-half years, who eventually recov- 
ered, weighed but 23 pounds—2 pounds less than when she was eighteen months old. 
During the first six months of treatment there was very slow improvement in spite of 
every advantage that care and change of climate could afford. 
Treatment.—The management consists in a proper diet, change of 
climate when possible, and supportive measures. It is for the physician 
to find out in a given case what means of nutrition are best. These cases 
vary considerably in their digestive possibilities, with the exception that 
they all bear fat foods badly. 
Diet.—Chronic colitis is very fatal in young infants, and but few 
survive. By far the best food for infants under one year of age is breast 
milk, which at first must be given in small quantities. Sugar-water 
should be given before the nursing. These young infants do not do well 
on starchy foods unless they have been dextrinized (p. 95); and when 
predigested they may have too laxative an effect, and should be given in MUCOUS COLITIS 
251 
small quantities. The use of starch, therefore, in these cases, for a con- 
siderable time at least, is limited. 
Standard protein milk and buttermilk have failed the writer repeatedly 
in feeding these young children. It is the improved protein milk (p. 89) 
that has given the best results in such cases. The patient may be able to 
digest the unsweetened condensed milk in the proportion of 1 : 6 to 12 of 
water or weak gruel diluents. Two or three feedings a day may be given 
in alternation with a dextrinized gruel. The addition of | ounce of gelatin 
to the pint of food makes a desirable addition to the feeding of mal- 
nutrition cases in which food of low caloric value is necessary. 
The beaten white of egg may be given in diluted skimmed milk or 
in dextrinized gruel No. 3 (p. 95) if it agrees, or in plain water with salt 
added. The whites of two or three eggs may thus be given daily with 
benefit. For older children, after the first year, skimmed milk, protein 
milk, rare scraped meat, junket, and coddled white of egg are usually 
best. Zwieback or bread crusts may be given in small quantities. 
Alcohol, if given at all, should not be long continued. It is well to feed 
these patients five times a day at four-hour intervals. 
There should be a standing order for an enema after an interval of 
twenty-four hours if no bowel movement takes place during that time. 
Absence of bowel movement in these cases almost invariably is followed 
by fever, prostration, and perhaps convulsions. If there is a tendency to 
constipation, some laxative, such as magnesia, mineral oil, or the aromatic 
fluidextract of cascara, should be given daily in sufficient amount to insure 
at least one free evacuation. 
Irrigation of the colon is not to be used as a routine measure. It is 
indicated whenever there is a rise in temperature, even though the bowels 
have moved but a few hours previously. A laxative, preferably castor 
oil or calomel, should also be given. 
The further treatment calls for salt baths, oil inunctions, and the 
open-air life referred to in the section on Malnutrition, p. 146. 
MUCOUS COLITIS 
Mucous colitis is a chronic catarrhal condition of the colon, char- 
acterized by the production of very large quantities of mucus. The 
mucus forms a pseudomembrane over the mucosa, and is passed in the 
form of casts or large worm-like masses. 
Attention has elsewhere been called to the necessity, in dealing with 
some of the diseases of children, of ignoring what appears to be a local 
manifestation of disease, and treating the patient along dietetic and 
hygienic lines. This necessity is in no instance better illustrated than 
in the case of mucous colitis, a disease fortunately rare in children, yet of 
sufficient frequency to warrant our attention. 
Etiology.—The patients treated have invariably been of a pronounced 
neurotic type, usually of neurotic ancestry, and invariably from a neuro- 
pathic environment. It is quite usual to find that a considerable quantity 
of milk has been taken daily. Ptosis of the transverse colon and the elon- 
gated or ptosed sigmoid (p. 255) may be in part responsible for some of 
these cases. 252 
THE PRACTICE OF PEDIATRICS 
Symptoms.—The disease rarely follows an acute inflammatory proc- 
ess in the intestine. In the majority of instances there is a history of 
obstinate constipation in a markedly neurotic, underfed child. Con- 
stipation may have existed during the patient’s entire life. Almost 
without exception the treatment which has been followed has consisted 
in the use of colon irrigations and various kinds of astringents, such 
as solutions of tannic acid, nitrate of silver, etc. In children with mucous 
colitis the appetite is capricious, the bowels are usually constipated, and 
the disposition is chronically irritable. These children are apt to com- 
plain of ill-defined pains in the abdomen, which are never very severe and 
are not necessarily associated with the taking of food. There is usually 
slight generalized abdominal tenderness. A child four years of age, 
however, whose case was the most pronounced ever under our care— 
never had the slightest evidence of pain of any character. With the de- 
jections there is usually mucus in considerable amount, which is occasion- 
ally passed in large masses, at other times in long, tenacious strings, 
sometimes referred to as “ropy.” During a period of several consecutive 
days little or no mucus may be passed; then large amounts will suddenly 
appear. 
Treatment.—These cases respond most quickly when local measures 
which often are irritant to the intestinal mucous membrane are dis- 
carded. Usually, as a result of previous treatment and because of the 
nature of the disease, the constipation is most obstinate. To prevent 
this an injection of 2 to 3 ounces of olive oil is employed at bedtime, the 
tube being introduced 8 inches into the bowel. After breakfast on the 
following morning the child is placed at stool, and if no passage occurs 
within fifteen minutes, a glycerin suppository is inserted. By this means 
one passage daily is insured, and this, ordinarily, is all that is required. 
The use of the suppository is to be discontinued after a very few days, 
as soon as the habit of evacuation at a certain time is established. Should 
this method fail, from 1 to 2 drams of the aromatic fluidextract of cascara 
may be given in addition, at bedtime, this medication being gradually 
diminished and discontinued as soon as it is demonstrated that an evacua- 
tion will occur without medication. A remedy of considerable value is 
the liquid petrolatum given in dosage of | ounce to 2 ounces at bed- 
time, and continued in gradually diminishing doses until the stools are 
free. Local measures other than those suggested for constipation are not 
to be employed. 
Diet.—Not infrequently these patients have been taking a consider- 
able amount of milk. This is to be immediately discontinued. In its 
place malted milk or whey may be given. The further diet consists of 
whole-wheat bread, animal broths, cereals cooked three hours, eggs, poul- 
try, red meat, stewed fruit, and fruit juices. Spinach, stewed carrots, 
and asparagus-tips are the only vegetables allowed at the beginning of 
the treatment, and these by no means should always be given. Puree 
of peas, beans, and lentils may be given freely. The use of butter is 
to be encouraged in amounts up to 3 ounces daily. It may be given on 
bread or on the cereal. 
Drugs.—Strychnin and mix vomica appear to exert a very beneficial 
influence on these cases. The combination of nux vomica and quinin has DEVELOPMENTAL ABNORMALITIES IN THE INTESTINAL TRACT 
253 
been very satisfactory. For a child from five to ten years of age the 
following may be ordered: 
R. Tincturso nucis vomicse gtt. xc 
Quininse bisulphatis gr. lx 
M. div. in capsulas No. xxx. 
Sig.—One capsule after each meal. 
A child suffering from mucous colitis invariably shows a considerable 
degree of malnutrition. For details respecting sleep, rest, exercise, and 
baths, all of which are more important than medication, the reader is 
referred to the section on Tardy Malnutrition (p. 146). 
DEVELOPMENTAL ABNORMALITIES IN THE INTESTINAL TRACT AS A 
CAUSE OF DIGESTIVE DISTURBANCES 
As stated on page 221 observation with the Roentgen ray in associ- 
ation with constant clinical supervision has opened up an entirely new 
field in the etiology of persistent intestinal disorders in children. 
Fig. 42.—Normal sigmoid in a child of three years. 
Due to abnormalities in structure and in the relations of various 
portions of the intestine there results a derangement of function with 
disturbed physiologic and chemical processes which makes for faulty 
nutrition, defective growth, and inferior general development of the child, 
both physical and mental. 
Mechanical defects of the intestine, such as ptosis of the colon, dilata- 
tion of the colon, dilated cecum, and the long sigmoid are the abnormal- 
ities most frequently encountered. The ptosed colon is usually associ- 
ated with dilatation and ptosis of the stomach (p. 221) and is probably 
secondary to that condition. Conversely, one of the most interesting 254 
THE PRACTICE OF PEDIATRICS 
facts brought out in our £-ray studies is the dependence of stomach re- 
tention upon irritation somewhere in the lower bowel. 
The ‘‘gradient idea” of Alvery1 fits these cases admirably. Children 
with stomach retention of this particular type have almost every form 
Fig. 43.—Female aged nine years. Elongated sigmoid passing above level of trans- 
verse colon (LeWald). 
of gastric manifestation, and their histories of loss of appetite, belching, 
vomiting, and pain, either paroxysmal or constant, mild or severe, and at 
1 Mechanics of the Digestive Tract, Hoeber, 1922, DEVELOPMENTAL ABNORMALITIES IN THE INTESTINAL TRACT 
255 
times gnawing, in character, have so impressed us that our first thought 
in treating a disorder of the stomach is to attend to proper intestinal 
elimination. In several cases later to be mentioned periodic vomiting 
Fig. 44.—Female aged two and one-half years. “Double-barreled” transverse colon. 
Appearance due to enlongated sigmoid flexure passing across to right side of abdomen 
and above crest of right iliac bone (LeWald). 
was entirely relieved by curing rectal constipation, a result obtained 
in one instance by stretching the sphincter ani. Many children have 
been relieved by the correction of other abnormalities. 256 
THE PRACTICE OF PEDIATRICS 
We shall have much to say upon the abnormalities of the large in- 
testine. Figure 42 shows what may be looked upon as an anatomically 
normal large intestine. It is appreciated that there are always variations 
in the normal; only those showing gross abnormalities will be discussed. 
The Elongated Sigmoid.—The most frequent abnormality consists 
in an elongation of the sigmoid (Figs. 45-46), which may be from two to 
four times the length given as normal in works on anatomy. This anomaly 
is of congenital origin. It is stated that such elongation always causes 
symptoms. Much depends upon the size of the pelvis and whether there 
are associated dilatations and sacculations. That there are children 
with markedly elongated sigmoids who are in no way inconvenienced 
is fully appreciated, but whether they will go through life without trouble 
Fig. 45.—Three minutes after injection—redundancy of sigmoid amounting to about 
three times average length. Appendix partly filled. 
is another question. The fact remains that when attention is directed 
toward relieving whatever fault may be occasioned by the deformity, 
the patient with rare exceptions makes a very ready response. 
The following illustrations together with the accompanying case 
notes are intended to present this subject more concretely. 
The history of the case represented in Fig. 43 is as follows: A girl 
aged nine years and weighing 54 pounds showed hemoglobin 40 per cent, 
and red blood cells 4,000,000. She was of delicate appearance, and made 
very slow gain in weight. About every two months she had so-called 
bilious attacks simulating recurrent vomiting and accompanied by high 
fever so that she was in bed for several days with each attack. The 
bowels were habitually constipated and daily laxative medication was 
required. The breath was offensive. The Roentgen ray revealed ptosis DEVELOPMENTAL ABNORMALITIES IN THE INTESTINAL TRACT 
257 
of the stomach and showed that the organ failed to empty itself in seven 
hours. There was also marked ptosis of the transverse colon and marked 
elongation of the sigmoid. 
Fig. 46.—Male aged three and a half years. Elongated sigmoid. One of the most 
extreme types encountered. (LeWald.) 
Figure 44. A girl, aged two and one-half years, weighing 25 pounds 
and giving evidence of moderate malnutrition, showed hemoglobin 55 
per cent, and red blood cells 4,600,000. She had had three convulsions 
of gastro-intestinal origin in the previous year. For her habitual consti- 258 
THE PRACTICE OF PEDIATRICS 
pation medication or an enema was required daily. The urine showed 
a moderate amount of acetone. The Roentgen ray revealed an elongated 
sigmoid passing 2 inches above the umbilicus. When the child was in 
the prone position the sigmoid passed to the right as far as the lateral 
abdominal wall. 
Figure 45. A girl five years of age was subject to repeated attacks 
of vomiting and obstinate constipation, the vomiting seizures occurring 
about every two months, continuing two or three days, and leaving her 
Fig- 47.—An elongated colon which had assumed a spiral form to adjust itself to 
the pelvic capacity. The sigmoid is also greatly elongated and there is marked length- 
ening of the colon to about four times its normal length. The patient, a girl three 
years of age, but recently came under observation because of repeated vomiting 
seizures, occurring about once a month, lasting from twenty-four to thirty-six hours, 
and accompanied by convulsions and high temperature. 
much reduced and weak. It will be observed that the sigmoid in this 
case is about three times its normal length. 
Figure 46. A boy, three and one-half years of age, weighing 32 pounds 
showed a markedly elongated and prolapsed sigmoid. 
The history given by the mother was substantially as follows: “The 
boy has had acute gastro-intestinal attacks since birth, with vomiting, 
diarrhea, and fever, acute seizures lasting three to four days during which 
he loses a pound or two of weight. During the past year two months 
have not elapsed without such an illness. Between attacks he is consti- 
pated and requires medication. He has frequent pains in the abdomen. DEVELOPMENTAL ABNORMALITIES IN THE INTESTINAL TRACT 
259 
Appendicitis has been diagnosed. Some of these seizures have been 
diagnosed as colitis attacks because of the passage of considerable quan- 
tities of mucus. He is irritable and very unhappy in disposition. His 
breath is habitually offensive; his tongue habitually coated, and his 
abdomen is distended a greater part of the time.” 
The Dilated Cecum.—The dilated colon and cecum appear to be 
dependent upon the accumulation of feces and gases brought about by 
the obstruction occasioned by the long sigmoid, with its angulation and 
defective peristalsis. 
Figure 48 represents the case of a boy thirteen years old who for six 
years had had severe attacks of pain definitely localized in the right 
lower quadrant. At first the seizures occurred only at intervals of three 
Fig. 48.—Dilated cecum and V-shaped colon in a boy of thirteen years. 
or four months, but later every few weeks. He had no vomiting; or con- 
stipation and only a moderate amount of nausea and anorexia, and this 
only at the time of the pain attack. The case had repeatedly been ciiag- 
nosed as one of appendicitis. No point of tenderness could be discovered, 
and between the attacks no tenderness demonstrable by manipulation 
or otherwise. Blood examinations had been made repeatedly and were 
always negative. There was moderate abdominal distention at the time 
of the attacks. This boy was large for his age and well nourished. 
The illustration shows the cecum so large that its shadow overlaps 
that of the sigmoid flexure and passes quite to the median line. The 
dilatation was probably secondary to retention produced by the V-shaped 
colon also shown in Fig. 48, the distention being the result of the back-up 260 
THE PRACTICE OF PEDIATRICS 
or reverse peristalsis. The boy was given a simple diet of three meals 
daily, and liquid petrolatum in 2-ounce doses for several months. 
There had been no subsequent attacks of colic in the succeeding two 
years. The senior writer has had 5 cases of this nature with symptoms 
almost identical. It would seem beyond doubt that we have a definite 
clinical entity to deal with. 
Symptoms.—The symptoms referable to the above abnormalities 
are repeated attacks of acute indigestion with cyclic or recurrent vomit- 
ing, abdominal distention, habitual or intermittent, intestinal colic, 
constipation which may be extreme, diarrhea alternating with consti- 
pation, or habitually loose mucous evacuations, and periodic fever with 
intestinal manifestations. 
In addition to these active manifestations the patients are usually 
anemic showing secondary malnutrition. Their mental equilibrium 
is easily disturbed, they are apt to be unhappy irritable children, they 
sleep poorly and their appetite is capricious. A few show defects in 
stature. That arrested growth and anemia may be the result of abnormal 
intestinal function is readily understood when one realizes what a vital 
part the intestine plays in growth and development. 
Constipation alone, or with abdominal distention, is present in nearlv 
all cases. In those with diarrhea or habitually loose mucous evacuations 
there is always a history of previous constipation, and the relief of the 
constipation is the keynote of the management. 
Treatment for Constipation.—The selection of suitable food for a 
given case plays a large part in the management. For the constipation 
the following dietetic regulations are advised: White bread, toast, and 
crackers are omitted. Oatmeal, cornmeal, hominy, cracked wheat, and 
the coarse cereals are allowed. Potatoes, rice, milk, and eggs are given 
sparingly. Milk is often replaced by malted milk. Green vegetables 
are given twice a day. Stewed or raw fruits are given the preference as 
desserts. Fresh meats and fish are allowed. Whole wheat bread and 
oatmeal crackers are recommended. Raw fruits are given wifh the 
stomach supposedly empty, an hour to an hour and a half before meals. 
We have found such giving of raw fruits with the stomach empty one of 
the most valuable dietetic aids in managing constipation. We are speak- 
ing now of those cases without stomach involvement. 
Enemata for Temporary Purposes.—An enema may be employed, 
but it should never be given habitually. Marked dilatation of the rectum 
exists as a result of frequent enemata. 
Massage.—Properly applied, daily massage is almost indispensable 
in obstinate cases. Massage and suitable diet may have to be continued 
for several months. 
The Abdominal Belt.—Abdominal support of some sort is always of 
assistance in these cases. The writer has used the Aaron belt with an ad- 
justable shelf, the Bassler belt, and in those cases with lordosis and a pro- 
tuberant abdomen, a Universal Supporter (Lentz & Company, Philadelphia)} 
Medication.—Olive oil and liquid petrolatum are useful in connection 
with other laxatives, but rarely sufficient when used alone. What is 
1 The latter device promises well. We have employed it in about 30 cases, but are 
not ready to pass upon its utility. Hirschsprung’s disease (idiopathic dilatation of colon) 
261 
required is an active peristalsis. In using laxatives, however, care is to 
be exercised to avoid purgation. Our best results have been obtained by 
the use of aromatic fluidextract of cascara given three times daily after 
meals in doses sufficient to produce one or two free evacuations daily. 
With the aid of massage and the oil the cascara may be gradually reduced. 
It should always be given after each meal no matter how small the daily 
dosage. 
Treatment for Diarrhea.—The child with diarrhea or with habitually 
loose evacuations, perhaps but one or two daily, is best treated by omitting 
stewed fruits and green vegetables entirely from the diet. Milk given 
these patients should be skimmed and boiled. 
The writer’s earlier results with this type of 
case were very satisfactory. Two cases under 
treatment at the time of this report, in both 
of which the sigmoid is greatly elongated, 
are, however, proving intractable and not 
much progress is being made with diet and 
medication. Surgical procedures may be re- 
quired in these cases. 
Although there may be a displaced colon 
or an elongated sigmoid, and a history of 
previous constipation, the stool should al- 
ways be examined in case of diarrhea for 
other possible causative factors. 
HIRSCHSPRUNG’S DISEASE (IDIOPATHIC 
DILATATION OF THE COLON) 
Two varieties of Hirschsprung’s disease 
are recognized—the congenital and the ac- 
quired. 
The condition is rarely encountered in its 
typical and extreme form. Only two well- 
marked cases have come under our observa- 
tion. There is an enormous dilatation and 
hypertrophy of the colon without constric- 
tion. The greatest dilatation is found in the 
transverse and descending colon. In the 
cases described by Hirschsprung there were 
ulcerative processes in the mucous mem- 
brane and submucous abscesses. 
Etiology.—In all cases the condition is probably based upon con- 
genital structural defects. 
Symptoms.—The prominent symptoms are obstinate constipation, 
symmetric enlargement of the abdomen (Fig. 49), and malnutrition. 
The bowels may act only once in three to six weeks. Complete ob- 
stipation of two or three months’ duration has been reported (Cautley). 
Respiration is often impeded because of pressure on the diaphragm. 
For a like reason the heart action may be interfered with. The hepatic 
and splenic dulness is obliterated. 
Fig. 49.—Hirschsprung’s dis- 
ease. 262 
THE PRACTICE OF PEDIATRICS 
Prognosis.—The prognosis for a complete cure is unfavorable. The 
patient usually succumbs to intercurrent disease. 
Treatment.—Little is to be expected from treatment, whether medical 
or surgical. Various operative procedures have been attempted. The 
radical operation involving complete removal of the colon has been per- 
Fig. 50. 
Fig. 51. 
Fig. 52. 
Fig. 53. 
Figs. 50-53.—Megalacolon, dilated sigmoid, and markedly distended abdomen. 
formed. As long as it is possible to produce an evacuation of the colon 
the patient may remain in a fairly comfortable condition. Laxative 
drugs, massage, electricity, and colonic irrigations may all prove useful 
as temporary aids. 
The followipg case notes together with Figs. 50-53 illustrate the 
problem presented by a case of this type: CELIAC DISEASE 
263 
Male, aged seven years. Since birth extreme constipation. At eight months 
sigmoidopexy for prolapse of rectum, at which time dilatation of the colon with ad- 
hesions was noted. 
Roentgen Examination.—Enormously dilated hepatic, splenic, and sigmoid flexures 
(I’ig. 50), the sigmoid having a pouch-like appearance. Bilateral eventration of the 
diaphragm. 
Operation.—Many adhesions about the sigmoid divided. 
Roentgen Examination. Iwenty-two months later sigmoid greatly reduced in size. 
A tube instead of another injection was used to demonstrate this reduction, for the 
previous injection required two weeks for elimination (Fig. 51). 
Comment. Six years later physical condition excellent. Treatment had consisted 
or an injection of 8 ounces of warm water upon rising, followed by ten minutes of exer- 
cises. An abdominal belt had been worn. Roentgen examination showed that the 
splemc flexure, descending colon, and sigmoid had been converted into a uniformly 
dilated tube as a result of the operation (Fig. 52). The entire injection was evacuated 
in forty minutes (Fig. 53). 
CELIAC DISEASE 
In 1888 Gee described a disease of unknown etiology which has since 
been established as a clinical entity. Children with this disease closely 
resemble each other in almost as many points as those who are Mongolian 
idiots. Diagnosis can always be made by inspection. The face is thin 
and usually pale, but not drawn and weazened, as in the usual form of 
malnutrition of gastro-intestinal origin. The abdomen is distended with 
gas and has a doughy feel, the distention varying in different cases and 
at different times of day. In those in which there is marked distention 
the abdomen may be quite flat in the early morning and yet the size 
may progress with the day so that when the child retires the abdominal 
circumference will perhaps measure 3 or 4 inches in excess of the morning 
measurement. 
Taylor1 has called attention to the fact that this disease has never 
been recognized in a breast-fed infant, and from a review of 7 cases has 
deduced that ‘The best way to produce celiac disease is to feed a sus- 
ceptible child throughout the second year on a diet rich in milk, fat, and 
potato, and then to subject him to some parenteral infection.” In all 
of the cases of Taylor’s group the liver was smaller than normal, and in 
all of 5 cases examined gastric achlorhydria was present. 
Etiology.—The age at onset is variable. The writer’s youngest patient 
was nine months, and the oldest two years and eight months of age. Some 
of the patients gave a history of difficult feeding which, as a rule, meant 
cow’s milk incapacity, and in many instances the case only gradually took 
on the characteristics of celiac disease. Other cases are typified by the 
child represented in Fig. 141, p. 802. He was a strong vigorous boy 
until thirty-twro months of age, and then had a sharp attack of diarrhea 
followed by the chronic intestinal disturbance. 
Symptomatology.—In this disease the muscles of the entire body 
undergo atrophy. This is particularly noticeable in the arms and legs, in 
which the muscles are very small, flabby, and weak. The knees and feet 
are prominent and appear abnormally large. Muscular atrophy and 
muscular weakness is a comparatively early and very prominent sign and 
a condition slow to be recovered from when the child begins to improve. 
All evidence of normal nutrition is lacking and growth in height ceases. 
The patient may not increase an inch in height while the disease is active. 
1 Celiac Disease, Amer. Jour. Dis. Child., vol. 25, January, 1923, p. 46. 264 
THE PRACTICE OF PEDIATRICS 
In one case height was absolutely stationary for two and a half years, and 
at the end of this time the weight was 6 pounds less than at the outset. 
If the child has walked he soon loses the ability because of muscle weak- 
ness, and he is habitually irritable, sleeps poorly, demands entertainment 
and is not satisfied when it is supplied. 
The enlarged abdomen often gives rise to the diagnosis of abdominal 
tuberculosis and the stunted growth causes confusion in differentiation of 
celiac disease from the infantilism of Herter (p. 266). Hirschsprung’s 
disease also presents a similar train of symptoms. In both these condi- 
tions, however, there is a definite pathology. In the true cases of infan- 
tilism the child remains a dwarf (see descriptive case, p. 266). 
Our patients with true celiac disease have recovered with the exception 
of a small proportion. Those recovering have in* every way taken their 
place in the world with others of their age. That such individuals are 
permanently shorter in stature than would have been the case had the 
celiac disease not handicapped them, has not been proved by the few that 
have been followed to adolescence. 
These patients have another feature in common, persistent bowel 
derangement. The character of the stools is the same in all cases and is 
in itself diagnostic. The stools are loose, watery, sour, glistening, and 
usually foul, and of a greenish color, often presenting a spongy appearance 
as though undergoing fermentation. Occasionally there are periods of 
constipation, but this is not usual. Chemical examination shows the 
presence of fatty acids, unchanged fat, starch and mucus, the findings 
depending, of course, upon the nature of the food ingested. During the 
same year two patients under observation have developed a very obstinate 
tetany, and one of these had two attacks of scurvy on account of incapacity 
for food containing the antiscorbutic vitamin. Both patients were be- 
tween four and five years of age. One died from exhaustion and starva- 
tion while the tetany was active. The other when well on the road to 
recovery required treatment for postural defects caused by the prolonged 
illness and associated muscle weakness. Death in the writer’s cases has 
been due to acute exacerbations of the chronic diarrhea or to inanition. 
Management.—Internal medication has been of no service. We have 
given these children ductless glands, yeast, calomel in minute doses, 
pancreatic extract, and all sorts of so-called intestinal antiseptics, all with- 
out avail. The first step of value is to omit cow’s milk absolutely from 
the diet, the writer’s experience having convinced him that milk is in- 
admissible in every case whether in the form of skimmed, evaporated, 
fat-free, protein, or dried milk. During the past year he has used in 10 
cases a synthetic milk which promises well. It is prepared by the Walker 
Gordon Laboratory according to the following formula: 
Casein 4 per cent. 
Sugar 4 “ 
Starch 6 “ 
One quart is usually ordered, and to this 20 grains of calcium chlorid is 
added. In addition to this the child is given the usual diet for the age 
inclusive of starches, but with perhaps a lessened amount of green vege- 
tables and with the omission of raw fruit temporarily with the exception of CELIAC DISEASE 
265 
ripe banana.1 The giving of orange juice should always be attempted 
even though the amounts are small. Occasionally a child will not take the 
synthetic milk. In such instances it is necessary to establish the child on 
a milk-free diet. Those who take the casein milk thrive much better 
than others. In providing this we give nitrogen, calcium, and soluble 
and insoluble carbohydrates, and thus establish a nutritional foundation, 
which is most valuable. No trouble has been experienced in giving starch 
if fresh milk is omitted. 
Another measure which we believe has a future is the use of the ab- 
dominal support. For the past three or four years the writer has used for 
this purpose some form of belt, chiefly those types advocated by Aaron 
and Bassler. During the past year the universal supporter (Figs. 142- 
144) of Nicholson has been used for patients over two years of age. The 
results with this were so satisfactory in one case (p. 802) that the appli- 
ance seems highly worthy of a wider use. This support, however, is not 
applicable for very young children. 
In every case of celiac disease with enlarged abdomen some form of 
support is of undoubted assistance. 
When the patient has recovered, several months will be required before 
he learns or relearns to walk. Still has reported a case in which a child did 
not walk until he was six years old. The usual muscle stimulants, among 
which massage is of foremost value, will help to restore the muscles in 
these cases. 
Johnson2 has suggested that celiac disease represents a true milk 
allergy. 
We agree with him that the clinical observations would indicate an 
allergy to a marked degree. It is generally accepted that although the 
positive skin test usually is lacking in these cases, this test is not the last 
criterion of protein sensitization. A vast amount remains to be learned 
on this subject regarding degrees of sensitization. It has appeared that 
imperfect metabolism of fat with the formation of fatty acids may be pro- 
ductive of toxic agents inducing temporary dysfunction. That such may 
be the case and that whatever injury is produced simply relates to function 
is shown by the health and vigor of the children who recover. 
Illustrative Cases.—Case 1.—A child who had been through the hands of a half- 
dozen or more of the best pediatrists in the country showed not a particle of improve- 
ment until the synthetic milk was instituted and the fresh cow’s milk in every form 
eliminated. 
Case 2.—A typical case of celiac disease with a satisfactory outcome is the following: 
S. McG., a boy three years and nine months old, had been ill from the twelfth month 
with persistent gastro-intestinal indigestion. About six months previous to coming 
under observation he had undergone operation for Pott’s disease by Dr. Russell Hibbs, 
of New York City. 
At that time the boy’s weight was 21 pounds, 11 ounces, and he showed every 
characteristic of celiac disease; small flabby muscles, a greatly enlarged abdomen, 
inability to walk, and characteristic stools. Cow’s milk including protein milk had been 
given in some form by the various pediatrists who had attended him, the dietetic 
methods varying in other respects. A new diet was given consisting of 1 quart of the 
synthetic milk daily and an ordinary allowance of starches, meat, and vegetables. 
As soon as the cow’s milk was discontinued the stools became dark and formed and 
1 A few years ago Dr. Sidney Haas, of New York, called the writer’s attention to 
the use of banana in celiac cases, and a free use of this fruit has since verified the state- 
ments made as to its desirability. 
2 New York State Journal of Medicine, Chronic Intestinal Indigestion in Children. 266 
THE PRACTICE OF PEDIATRICS 
lost the characteristic sour fetid odor and greasy appearance. At the end of the year 
the boy weighed 30 pounds, 5 ounces, and although 3 inches under height, he was 
well in all respects, walking, running, and playing with his brothers and sisters. The 
abdomen, however, still remained large. 
THE INTESTINAL INFANTILISM OF HERTER 
Notwithstanding the great amount of scientific work accomplished 
by Christian A. Herter, it seems likely that his name will be perpetuated 
in connection with the condition of intestinal infantilism more than by 
any other work that he did, for he described a condition that was never 
before carefully studied and thus established it as a distinct disease with 
characteristic symptoms, intestinal flora, and changes in the urine (Free- 
man1). 
In this disease there is an arrested physical development, the child 
is usually well formed, but does not grow and does not gain in weight. 
A female patient at seven and one-half years of age weighed 20 pounds 
and was 34| inches tall. No growth had taken place since she was two 
years old. 
A description of this child covers the symptomatology in all. The 
mental development was normal, the patient could read and write. In 
contrast to the small stature there was a marked enlargement of the abdo- 
men. The patient was of low resistance—she tired readily and was peevish 
and unhappy. She had an enormous appetite and demanded food about 
five times a day. The stools were large and fatty in appearance and 
contained a large amount of fat and fatty acids. 
In Herter’s infantilism frequent attacks of diarrhea are the rule. 
The urine shows an excess of putrefactive products of intestinal origin; 
the indican and phenol compounds are present. The bacterial flora of the 
intestinal tract, according to Herter,2 comprise Gram-positive organisms 
of the Bacillus bifidus type, B. infantilis type, and cocco-bacillary forms. 
There is a marked absence of Gram-negative bacilli in the stools. 
Infants of this type are very discouraging patients. No pronounced 
improvement is to be expected from any line of treatment. Milk, rare 
meat and poultry, and cereals, such as oatmeal and the wheat derivatives, 
constitute the basis of the diet. 
Freeman feels that he has observed benefit from the use of extract of 
pancreas, 3 grains three times daily in the form of an enteric pill. The 
attempt to implant a Gram-negative flora in the alimentary tract should 
be made. Cultures of Bacillus acidophilus, B. coli, and of B. bulgaricus 
may be given. 
INCONTINENCE OF FECES 
Incontinence of feces is a normal condition during infancy, control 
being established without training during the second year or earlier. In 
well-trained infants we have seen the bowel function under perfect con- 
trol at the third month. This is, however, unusual. With a very little 
teaching it may be accomplished at the sixth month. Incontinence of 
feces in older children occurs during acute inflammatory conditions, par- 
1 Jour. Amer. Med. Assoc., vol. ii, pp. 329-332. 
2 Herter’s Infantilism, Macmillan Co., 1908. CONSTIPATION 
267 
ticularly when the colon is the seat of the lesion. Incontinence may also 
occur in asthenic states, as in grave pneumonia, in typhoid fever, and in 
the more severe types of the exanthemata; and it may occur accidentally 
as the result of fright, shock, or severe straining. It may result from 
spinal cord disease or injury, and is sometimes due to spina bifida, in 
which event the fecal incontinence may be compared to incontinence of 
the urine. We have seen 6 such cases. In 2 the condition had existed for 
months. 
Incontinence of feces, as a condition independent of early infancy 
and illness, is of exceedingly unusual occurrence. Of 5 patients, 2 were 
boys, one four and the other seven years of age. In these 2 the condition 
had persisted for months. The desire for an evacuation came with great 
urgency and was uncontrollable. In 2 other cases there was occasional 
incontinence due to a relaxed sphincter, probably produced by frequent 
irrigations. These responded to the treatment outlined below. In the 
fifth case there was no response to any treatment instituted. The patient 
was a boy six and three-quarter years of age, and had suffered from the 
incontinence for a year and two months. He was under treatment for 
two weeks; no improvement resulted, and he passed from observation. 
Treatment.—The treatment consisted in the removal of green vege- 
tables and fruit from the diet, allowing only a small amount of starches, 
such as bread, potato, and cereals. Eggs, meat, skimmed milk, junket, 
custard, etc., were given freely. The medicine comprised 15 drops of 
the tincture of the muriate of iron in glycerin and water, given every 
four hours, with 1 grain of Dover’s powder and 20 grains of subnitrate 
of bismuth given three times daily. Cases which do not respond promptly 
to diet and medication should have the advantage of surgical procedures. 
CONSTIPATION 
Deficient fat content in the milk of young infants, ancl insufficient 
solid food in the diet of children over one year of age, probably are re- 
sponsible for a majority of the cases of constipation. The digestive organs 
demand not only elements for assimilation, but a certain amount of food 
residue to act as a stimulus to perfectly normal musculature. The results 
of the absence of a fair amount of this food residue in the diet are most 
apparent in children between the first and third years, who receive over 
a quart of milk daily, administered in frequent instalments, and from 
force of parental habit or perverted desire on their own part are deprived 
of such important dietetic ingredients as cereals, vegetables, and fruit. 
Such children are almost invariably sufferers from chronic constipation. 
The cases commonly ascribed to deficient secretion on the part of 
the intestinal glands and liver are also frequently of dietetic origin. 
Mechanical defects and abnormalities may be entirely responsible 
for the most obstinate constipation. Localized proctitis, fissures and 
hemorrhoids, and sphincter spasm may be important causative factors. 
Congenital narrowing of the gut, elongated sigmoid (Fig. 45), prolapse 
of the colon (Fig. 55), hernia, and congenital dilatation of the colon 
(Hirschsprung’s disease) deserve to be borne in mind in this connection. 
As our experience with this disorder increases we are more and more 268 
THE PRACTICE OF PEDIATRICS 
impressed with the importance of disturbed intestinal mechanics as a 
direct or accessory cause of constipation in children of all ages. 
Before instituting treatment of any nature it is necessary to know that 
no mechanical cause exists. 
Fig. 54.—Dilatation and stenosis of the rectum. (The appendix is outlined.) 
Figure 54 represents a female child five years of age showing extreme retention in 
the rectum twenty-seven hours after a bismuth meal. The child came for malnutrition 
and with the diagnosis of acidosis. In very early life she was supposed to have had 
pylorospasm. There had been much trouble in feeding her up to time she was three 
years of age; and she had had frequent vomiting seizures with high fever—103° to 
105° F. During her fourth year she had but two seizures of the fever and vomiting. 
This patient has but recently come under observation. Stretching the anal sphincter, 
abdominal massage, and a diet directed to relieve her constipation (p. 273) will be fol- 
lowed out in this case. 
Bowel Evacuation Necessary.—In order to keep the infant or young 
child in good physical condition one free evacuation of the bowels is 
required once in twenty-four hours. While two or three evacuations daily 
may be desirable, this number is not absolutely necessary. When there 
are more than four passages in twenty-four hours the inference is that 
something is wrong with the intestinal tract. This, however, may not be 
of such a nature as to require radical means for its correction. Thus, CONSTIPATION 
269 
many nursing babies who are supplied with a high-fat breast milk, may 
have several thin greenish stools in twenty-four hours, and in spite of the 
condition thrive satisfactorily. It is well in these cases to attempt to 
reduce the fat in the breast milk by measures suggested elsewhere, but by 
no means should the nursing be interdicted if the baby is making a reason- 
able gain in weight. The proof of successful nursing is a thriving child, 
not the character of the stool. The habit of an evacuation at a certain 
time each day is one of the most important preventives of constipation 
in an infant. There should be a standing order in every household to 
the effect that the child is never to be put to bed for the night unless the 
Fig. 55.—Prolapsed colon and anal sphincter spasm. The patient was a girl six 
years of age with a typical V-shaped ptosed colon and dilated rectum. The story was 
that of recurrent attacks of vomiting every six weeks. Enemata for the chronic con- 
stipation had been given daily since birth. Retention of the opaque meal was observed 
forty-eight hours after injection of the material. This child had also a moderate stom- 
ach ptosis. The anal sphincter was stretched under anesthesia. An Aaron belt with 
shelf was applied and the diet regulated. No attacks of vomiting occurred subsequently 
during observation extending over two and a half years. 
bowels have moved during the preceding twenty-four hours. Either a 
simple soap and water enema or a small glycerin suppository may be 
employed. The enema is preferred, from 4 to 8 ounces of the soap-water 
being used. The suppository is to be used only when, for any good reason, 
the enema is not available. Placing the child at stool immediately after 
the morning bottle is one of the means of establishing the habit of an 
evacuation at a definite time each day. The child soon appreciates the 
reason for this practice and acts accordingly. This procedure may be 
begun when the child is five or six months of age. 
Defective bowel evacuation in infants and young children is a form of 270 
THE PRACTICE OF PEDIATRICS 
constipation very apt to be overlooked, and for this reason it is put under 
an independent heading. As long as an evacuation takes place daily it is 
supposed to be sufficient. Even though a passage takes place daily and 
voluntarily, if it is dry and comes away in pieces or in hard balls, or is 
firmly formed without the moist surfaces caused by the presence of mucus 
and water, it is practically certain that the evacuation is not complete and 
that fecal matter is retained in the intestine. This type of constipation is 
often associated with ptosis of the stomach (p. 221) and anal sphincter 
spasm. (See Fig. 55.) The ptosed stomach always empties very slowly 
and the absorption of the water from the intestinal contents is then more 
than normally complete. This may occur at any age, and when the con- 
dition persists, an intestinal toxemia may result with the manifestations 
referred to under Indigestion (p. 232). The same methods of treat- 
ment are to be followed as suggested for constipation at the various ages 
of infancy and childhood. 
Constipation in Nurslings.-—There are many nursing infants who are 
thriving and well in every respect, except that they are constipated. 
Bowel evacuation is greatly delayed or does not occur without aid. Our 
first step in the management of these cases is to examine into the daily 
life and habits of the mother. A factor in the etiology of constipation in 
the infant is constipation in the mother. Treatment of the mother will 
often relieve the child. If, however, the constipation in the mother is 
not relieved, the subsequent treatment directed toward the child will be 
much less effective. Nursing women who drink a great deal of tea are apt 
to be constipated, and their infants are similarly affected. The nurslings 
of mothers who lead indolent lives, taking but little exercise, are likewise 
sufferers from constipation. 
Treatment of the Mother.—Errors in the mother’s diet and habits of 
life must be corrected and the scheme carried out which is recommended 
under Maternal Nursing (p. 42). 
When a proper regime for the mother has been established, the breast 
milk should be examined. While high protein may contribute to con- 
stipation, this factor is rarely a cause. Low fat, from 1.5 to 2.5 per cent., 
with normal protein is much oftener found to be present. 
Often in such cases the fat in the mother’s milk may be increased, 
if only temporarily, by the use of some form of alcohol, given with the 
meals. Wine, beer, ale, porter, or the liquid malt preparations may be 
given, the mother being allowed to make her own selection according to 
her taste. The free eating of red meats also increases the fat in the milk. 
Several years ago a series of observations were made in the New York 
Infant Asylum relating to the effects of diet on breast milk. It was found 
that in some cases the fat could be increased from 1 to 2 per cent, by the 
addition of alcohol to the mother’s diet. The value of many of the various 
galactagogues on the market depends, in all probability, upon the alcohol 
which they contain. 
Treatment of the Child.—A very tight sphincter is the cause of con- 
stipation in a small proportion of nurslings; and before beginning other 
treatment in such cases the sphincter should be stretched by passing a 
protected index-finger into the rectum. As an aid to nutrition and as a 
laxative a valuable addition to the diet of the constipated breast-fed CONSTIPATION 
271 
infant, when the mother’s milk is found weak in fat, is cow’s milk cream, 
i to 1 teaspoonful of which may be given before every second nursing or 
before every nursing, according to the age of the child and the capacity 
for fat digestion. Children during the early months of life take pure cod- 
liver oil readily, and oil, like cream, may serve the double function of a 
food and a laxative. Establishing by careful instruction the habit of an 
evacuation of the bowels at a certain time every day is a valuable measure. 
Drugs.—Drug giving is rarely necessary in treating very young chil- 
dren and should be resorted to only when other measures fail. In case 
drugs are necessary, those most useful ordinarily are the preparations of 
cascara sagrada. The aromatic fluidextract is palatable and may be 
given in sufficient doses to be effective once or twdce daily. The milk of 
magnesia with equal parts of the aromatic syrup of rhubarb, given in doses 
of from 1 to 3 teaspoonfuls daily, is an agreeable and usually an effective 
combination. The liquid petrolatum, in 1- to 4-dram doses, acting as a 
lubricant, often gives surprisingly good results. 
Enemata and Suppositories.—The use of water enemata and sup- 
positories is not to be advised as a routine measure. The habit of de- 
pending upon them is readily established, the bowel, by their frequent 
use, becomes insensitive to stimulation, and in a few weeks they fail to 
act. Many mothers are thrown into a state of great distress when this 
stage is reached. When the stool is dry and hard and is passed with 
difficulty, the injection of 2 ounces of warm sweet oil at bedtime is of 
advantage. This is not intended to produce an immediate evacuation, 
but rather to act as a lubricant for the evacuation expected the following 
morning. 
Malted Foods.—It is elsewhere advised that the nursing baby be 
given one bottle feeding daily. The malted proprietary foods are dis- 
tinctly laxative to many children. When, in a nursing infant, a condition 
of constipation exists which is not relieved by careful regulation of the 
mother’s diet, one feeding of malted milk daily, in the strength of 1 tea- 
spoonful to an ounce of water, may be prescribed. Some children will not 
take malted milk of this strength, as the sweet taste is objectionable. In 
such cases it may be given weaker at the beginning, or it may be given 
in a milk mixture suitable to the age of the child. When it is used in this 
way there should be no addition of sugar. Malted milk or Mellin’s food 
may be used in a quantity equal to that of the sugar previously employed 
in the formula. 
Massage is a most valuable means of treatment of the constipation 
of older children, but for nurslings and the bottle fed of tender age, on 
account of the restlessness and crying, it is not always practicable, and 
to be effective should be given only by those skilled in its use. There- 
fore, unless the case is an extreme one, and all other measures have failed, 
massage is not to be employed in treating the very young. 
Constipation in the Bottle Fed.—Before undertaking the treatment of 
constipation in any infant the rectum should be examined to determine 
the presence or absence of sphincter spasm (p. 276). In the bottle fed 
inactivity of the bowel is more easily managed than in the nursling, 
because, in dealing with the former, we are in a better position to adapt the 
food to the child’s digestive peculiarities. As a rule, constipated bottle 272 
THE PRACTICE OF PEDIATRICS 
babies should have a reasonably high fat—3.5 to 4 per cent.—and sugar 
up to at least 7 per cent. This rule, however, is open to exceptions; a 
few of the most obstinate cases of constipation that have come under 
our care have been fed on a very high fat, the constipation being due to 
fat indigestion. It is extremely rare to find a child who can digest day 
after day a milk mixture containing more than 4 per cent, of cow’s milk 
fat. 
The Protein.—Cow’s milk casein, although probably the most fruit- 
ful factor in causing constipation in bottle-fed babies, nevertheless is 
necessary for the child’s nutrition. A considerable reduction, such as 
may be obtained by giving a mixture of cream, sugar, and water, may 
relieve the constipation, but the child thus fed will suffer from a nutri- 
tional standpoint, and instead of being constipated may become athreptic, 
which is much worse. In not a few instances malnutrition has been 
observed as the result from cutting down the protein in the effort to relieve 
constipation. 
The child’s growth and development must never be held subservient 
to anything else. A child under six months of age will not thrive satis- 
factorily on less than 1 per cent, of protein as found in cow’s milk. He is 
entitled to at least 1.5 per cent., and thrives best when this amount is 
given. The relief of the constipation can in almost every instance be 
accomplished by other means than a too great reduction in the protein— 
the most essential nutritive element in the infant’s food. 
Milk given constipated infants should always be raw, as cooking 
increases its constipating tendency. 
Laxative Agents in the Food.—The simplest means of treating con- 
stipation in the bottle fed is by the employment of a laxative agent in 
the food, and when such an agent adds to its nutritive value, it serves a 
double purpose. Instead of water as a diluent, oatmeal-water No. 1 
(p. 94) may be employed. The malted proprietary foods, such as Mellin’s 
food and malted milk, are laxative to most children. Mellin’s food is 
composed largely of dextrose and maltose, which are laxative sugars, and 
therefore may be used in place of sugar-of-milk or cane-sugar in the food 
mixture, for the purpose of relieving constipation. The presence of 
potassium carbonate in dextrose and maltose combinations also probably 
increases their laxative property. In some instances we substitute a feeding 
of malted milk with from 4 to 8 ounces of water once daily for the regular 
milk food, the quantity and strength depending, of course, upon the age 
of the child. 
Drugs and Local Measures.—Dietetic measures should always be 
tried before drugs are resorted to. One or 2 teaspoonfuls of milk of mag- 
nesia in one bottle daily may be recommended as a temporary expedient 
in some cases. The magnesia may be of service until the condition is 
controlled by the diet. The aromatic fluidextract of cascara, in doses of 
from 15 drops to 1 dram, may be tried if success does not follow the use 
of the magnesia. 
Water enemata and suppositories should be used only as temporary 
measures. Orange juice, 2 teaspoonfuls twice daily before feedings, is 
worthy of trial, and is of antiscorbutic value for children artifically fed. 
Sweet oil and the pure cod-liver oil may be also used in doses from 30 CONSTIPATION 
273 
drops to 2 drams, three times daily, after feedings. Oils produce bene- 
ficial effects not only as laxatives but also as aids to nutrition. Acting 
purely as a lubricant, liquid petrolatum in dosage of 2 drams to \ ounce, 
once daily after the evening meal, is of much service in many cases. 
Oil Injections.—In case the stool remains hard and dry in spite of a 
trial of the above suggestions, an injection of 2 ounces of warm sweet oil 
may be given at bedtime every night, not with a view to inducing a passage 
at the time, but as a lubricant to the parts and as a solvent of the hard 
fecal masses. 
Constipation in Older Children.—Etiology.—Probably the most potent 
dietetic factor in causing constipation in children of the “runabout” 
age is the use of abundant milk, crackers, and dry bread-stuffs. Par- 
ticularly is this apt to be the case if the milk is boiled. Constipation at 
this age may also be occasioned by too great concentration of the food, 
insufficient volume being furnished to produce copious evacuations. 
Local Causes.—In a great majority of children the freer feeding fol- 
lowing weaning from the breast and bottle relieves the tendency to con- 
stipation from which many suffer during the earlier months of life. In a 
small percentage of cases, however, such relief is not furnished, and the 
child will require the attention of a physician. In making the physical 
examination of a case of this nature, special care should be directed toward 
the examination of the rectum, in order that local causes, such as fissures, 
hemorrhoids, or sphincter spasm may be eliminated. If fissures are pres- 
ent, the child will use every effort to prevent a bowel movement. 
Mechanical Obstruction.—Elongation of the sigmoid (p. 256), ptosis 
of the colon and cecum (p. 259) play a part hitherto unsuspected as the 
causation of constipation. Recently much light has been thrown on many 
difficult and obstinate cases by the use of the Roentgen ray. Mechanics 
play an immediate role in constipation, as will be appreciated by referring 
to Fig. 48. The long sigmoid loop is an important factor in causing 
constipation, and even after infancy anal sphincter spasm may be an im- 
portant etiologic factor. 
Regular Habits.—As a rule, children who are presented for treat- 
ment after the second year have not had the benefit of carefully regu- 
lated habits of life, so that our first step is to correct bad habits that 
may have a bearing on the condition, and to teach good habits. The 
desirability of establishing in the child the habit of a bowel evacuation 
at a certain definite time every day should be impressed upon the mother 
or nurse. In order to bring this about an attempt should be made to 
induce a movement of the bowels by voluntary effort every morning after 
breakfast. Not a few children are too busy, too active in their play, to 
respond to the call of nature when it comes, and if it can be repressed, they 
say nothing about it. If a certain time of the day is selected for the 
evacuation, and if the child is required to remain at stool until it occurs 
naturally, or by means of a suppository after fifteen minutes have elapsed, 
much is accomplished by this means alone toward establishing the normal 
habit. 
Diet.—Ultimately, much may be accomplished in these cases by diet. 
Foods other than milk may after infancy be given, so that a high-protein 
milk, rich in casein, is not necessary. As it is desirable to continue the 274 
THE PRACTICE OF PEDIATRICS 
use of milk at this age, the following combination of top milk and water 
may be used instead of plain milk: A quart bottle of milk may be allowed 
to stand at a temperature between 40° and 50° F. for five hours, after 
which the top 10 ounces are to be removed with a Chapin dipper. (See 
Fig. 6, p. 70.) The 10 ounces of top milk may then be mixed with 20 
ounces of oatmeal gruel or plain boiled water and given as a drink. 
The giving of high-fat mixtures in constipation is sometimes overdone 
even in feeding older children. We seldom find a child five years of age 
who can digest day after day a milk or cream mixture containong over 
4 per cent, of fat. Attacks of acute indigestion and faulty nutrition are 
very apt to result when too high a fat is persistently given. In not a few 
instances grave malnutrition results from an attempt to relieve the con- 
stipation by high-fat feeding. It must also be remembered that high-fat 
mixtures, if given to children of any age, may produce constipation, with 
hard, very light colored, and foul-smelling stools. By using the top milk, 
diluted, we give a sufficient amount of fat and relieve the constipation by 
removing a considerable percentage of the casein, the usual constipating 
element, the percentage of which in the 30 ounces of food, above referred 
to, is but one-third that in whole milk. Of course, the nutritive value of the 
dilution is less than that of full milk, but the child is now at an age when 
protein can be given in other forms than in the milk. 
Diet After the Second Year.—White wheaten bread, wheaten flour 
crackers, with full raw milk should form no part of the dietary of these 
patients. It is best to give to parents of children we are treating for con- 
stipation a list of permissible articles of food from which suitable meals 
may be prepared. The following articles of diet may be allowed: 
Animal broths, purges of peas, 
beans, and lentils. 
Rare roast beef. 
Rare steak. 
Hashed chicken. 
Lamb chops. 
Soft-boiled eggs. 
Green vegetables, such as: 
Peas. 
String beans. 
Spinach. 
Asparagus. 
Strained stewed tomatoes. 
Cauliflower, mashed. 
Cereals, as follows (each cooked for three hours): 
Cracked wheat. 
Oatmeal. 
Hominy. 
Cornmeal. 
The cereals may be served with a small amount of milk and sugar 
or, better, with butter and sugar. 
Bran biscuits. 
Oatmeal crackers. 
Graham wafers. 
Zwieback. 
Whole wheaten bread. 
Desserts: 
Stewed rhubarb. 
Stewed or baked apple. 
Stewed prunes. 
Custard. 
Cornstarch. 
Plain vanilla ice-cream. 
Junket. CONSTIPATION 
275 
Malted milk may be given as a drink, 6 teaspoonfuls of malted milk in 
8 ounces of hot water being given once or twice daily. An agreeable 
change in the taste of the malted milk may be made by the addition of a 
teaspoonful of cocoa. If milk is given as a drink, the top 10 ounces from 
a quart bottle should be used as described above, mixed with 20 ounces 
of boiled water or oatmeal water. 
A child in fair health after the second year usually thrives best on 
three meals daily. If he is delicate, or if a fourth meal does not interfere 
with the appetite for the other meals, it may be allowed. The extra meal, 
however, should be light, and is best given between 2 and 3 o’clock in the 
afternoon. For a child suffering from constipation this meal may consist 
of a cup of broth with a Graham or oatmeal cracker. Orange juice or a 
scraped raw apple may also be given at this time. When only three meals 
are allowed, the orange juice or scraped apple should be given in the after- 
noon about two hours before the evening meal. Six ounces of prune 
juice will be found very useful. The giving of the fruit juice or the apple 
on an empty stomach is a valuable aid in relieving chronic constipation. 
These patients should also be encouraged to eat plenty of butter. The 
use of olive oil internally is of as much service here as in treating bottle or 
nursing babies. From 2 to 3 teaspoonfuls are to be given after each meal. 
Oil is usually well borne by the stomach; in fact, many children become 
very fond of it. Inasmuch as it is more of a food than a medicine, its use 
may be continued for months if necessary. 
Diet After the Fifth Year.—Permissible articles for a constipated 
child of from five to ten years of age include those mentioned above, with 
the addition of dates, figs, raw and cooked fruits, baked and stewed pota- 
toes, meats, baked and broiled poultry, and fish. The latter should be 
served plain, without sauce. Plain puddings may also be allowed. One 
or two raw apples, an orange, or a large peach or pear should be given 
every afternoon. It is not promised that in a case of chronic constipation 
the above diet will at once produce normal bowel movement. The diet 
must be continued for weeks in some cases before marked benefit will be 
observed; in others the results are very prompt and satisfactory. 
Local Measures.—Enemata and suppositories will be necessary at 
first until the habit of an evacuation of the bowels at a certain time 
every day is established. Such measures, however, should be continued 
but a very short time. 
Drugs may be of temporary service. The cascara preparations are 
the best for this condition. If the child can swallow a pill or a tablet, the 
drug may be given in this form. The 1-grain tablets of cascara may be 
ordered, and the nurse instructed to give from one to three or four at 
bedtime. If the drug has been properly prepared from the well-seasoned 
bark, a reasonable dose will occasion no griping, and the amount given 
on succeeding nights may be diminished instead of increased, as is often 
necessary with many other laxatives. A most satisfactory form of medi- 
cation has been the following combination: 
1$. Sodii bicarbonatis 3ij 
Syr. rhei aromatici, 
Fluidext. cascarae sagradae aromatic* aa 5'j 
M. Sig.—\ to 1 teaspoonful after each meal. 276 
THE PRACTICE OF PEDIATRICS 
After the diet and habits of life have been arranged the mother or 
nurse should be instructed to give the prescription three times daily after 
meals in sufficient amount to produce at least one free evacuation daily. 
The mixture is very pleasant to the taste and is well taken. Ac its ad- 
ministration is continued, less will be required, but it is to be insisted upon 
that the laxative be given three times daily, even though the dosage be 
reduced to 3 drops at a time. There is always a temptation on the part 
of those in charge of the patient to give one large dose at bedtime. The 
results are not as satisfactory when this is done. In a very large number 
of cases we have been able, with intelligent home co-operation, to dis- 
continue the medication entirely after a month or two. 
Another laxative of value is a combination of 1 to 1| grains of phenol- 
phthalein in a tablet with chocolate. One to three such tablets may be 
given daily. 
Castor oil, calomel, or podophyllin should never be given without 
other indications than simple constipation. In the cases in which the 
stools are soft, but difficult of passage because of deficient peristalsis, the 
tinctures of nux vomica and belladonna may be given with benefit if con- 
tinued for a considerable time. A child three years of age may be given 
3 drops of the tincture of nux vomica and 2 drops of the tincture of bella- 
donna three times daily in tablet, capsule, or liquid form. The constipa- 
tion which accompanies mucous colitis is referred to under that heading. 
Liquid petrolatum may also be used for these patients. A large dose 
may be required at first—perhaps 1 or 2 ounces at bedtime. 
Treatment of Obstinate Constipation.—Children who resist the above 
method of treatment after several months’ trial may be classed with those 
who have some considerable intestinal anomaly—usually an elongated and 
often a displaced sigmoid (p. 256). For these, daily abdominal massage 
by a skilled person, together with the diet suggested, and the internal use 
of liquid petrolatum will prove effective. 
Conditions impeding or preventing normal evacuation of the bowels 
may be either congenital—due to a malformation of some portion of the 
intestinal tract—or they may be acquired. 
Congenital malformation may be found in any portion of the tract, 
but exists most frequently at or near the outlet, or in the region of the duo- 
denum. According to Silverman 42 per cent, of the cases of congenital 
malformation involve the duodenum. Obstruction at the outlet of the 
bowel may be due to an imperforate anus, or the absence of, or atresia of, 
the lower portion of the rectum. The treatment of this deformity is 
surgical. 
The most common cause of acquired obstruction is intussusception 
(p. 277). Peritonitis, both acute and chronic, may cause a cessation of 
bowel action. Tuberculous peritonitis, through the formation of fibrinous 
bands and adhesions, may cause sufficient constriction of the gut to pre- 
vent the passage of the intestinal contents. In such cases, also, relief is 
best furnished by surgical measures. 
Acute infective peritonitis (p. 291), producing a complete cessation 
INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION 
277 
of peristalsis, due to paralytic ileus, acts indirectly as a means of preventing 
the normal passage of the bowel contents. The infection is usually sec- 
ondary. Operative procedures may be attempted, but all our cases have 
been fatal. Two underwent operation, as it was feared there might be an 
intussusception or a volvulus. In one case peritonitis followed pneu- 
monia, the infection being due to the pneumococcus. 
Strangulated hernia is a condition by no means difficult of diagnosis 
and demands prompt surgical relief. 
Intra-abdominal tumors, such as sarcoma of the kidney and hydro- 
nephrosis, may cause obstruction through pressure on the intestine. 
Illustrative Cases.—Fecal impaction was found in 2 cases of intestinal obstruc- 
tion seen in consultation. There had been prolonged constipation with insufficient 
evacuations, owing to neglect on the part of the attendants. The duration of this 
condition it is impossible to state, as the children were permitted to go to the toilet 
alone, and as both were under five years of age, but little dependence could be placed 
upon their testimony. In both cases enemata and cathartics had been tried in vain. 
There was vomiting and slight abdominal distention. There was no fever and no 
marked tenderness on pressure. In the writer’s opinion the vomiting was due chiefly 
to the medication, for it ceased when drugs were discontinued. Both children responded 
to massage and injections of molasses and water. Eight ounces of molasses and 8 
ounces of water were introduced by means of a rectal tube at intervals of four hours. 
One case was relieved after the second injection, the other after the fourth. Massage 
was early brought into use. This was given for thirty minutes and repeated after an 
interval of ninety minutes. The interrupted massage was continued until an evacuation 
occurred. 
An unusual case of intestinal obstruction was seen in a wretched, premature infant, 
five months of age, weighing about 7 pounds. The child had a congenital heart lesion 
and deformities of the ears. He was suddenly taken ill with vomiting, and the passage 
from the bowel of pale mucus streaked with blood. No tumor could be felt, but a 
diagnosis of intussusception was made and the abdomen opened. At the site of the 
obstruction was a Meckel’s diverticulum which had twisted the gut so as to prevent 
the passage of gas or intestinal contents. 
Paralytic Ileus 
Two infants under one year of age, ill with severe intestinal toxemia, developed 
intestinal obstruction with marked abdominal distention. Exploratory abdominal 
incision in one and autopsy on the other failed to show any structural abnormality. 
Intussusception of the bowel consists of a prolapse—an invagination 
—of a portion of the intestine into an immediately adjoining portion. 
Types.—While certain portions of the intestine are particularly liable 
to be involved, the invagination may take place in any portion of the gut. 
Thus the small intestine may be the part involved—the enteric form. The 
colon alone may be involved—the colic type. By far the most common 
form is the prolapse of the cecum, and more or less of the ileum into the 
colon, the valve forming the apex of the tumor. This is known as the 
ileocecal type. 
Invagination Found at Autopsy.—At autopsy it is of most common 
occurrence to find invagination of the small intestine. The writer has 
repeatedly seen 6 to 8 invaginations in one subject. They occur at death, 
and are of no significance. It is unusual to find more than 4 or 5 inches of 
the gut involved. 
Etiology.—The cause of the intussusception in the great majority of 
cases is unknown. Various theories have been advanced from time to 
time, none of which deserves mentioning. Occasionally local causes will 
Intussusception 278 
THE PRACTICE OF PEDIATRICS 
explain the condition. In one case Meckel’s diverticulum caused the 
intussusception. In another there was a persistent incomplete reducible 
invagination of the transverse and descending colon into the sigmoid. 
It was impossible to keep the parts in the normal position, and laparotomy 
was resorted to in order to learn the cause of the prolapse. The entire 
colon was found displaced, the hepatic flexure being bound to the ab- 
dominal wall by a firm adhesion \ inch above the umbilicus. This 
caused a displacement downward of the transverse and descending colon, 
which underwent invagination. A case at the Babies’ Hospital showed 
that the invagination had taken place at the site of a large and thickened 
Peyer’s patch in the lower ileum. Here, evidently, the gut was more 
resistant, and the portion above, during active peristalsis, slipped into the 
less motile section. 
It is peculiar that nearly all the cases occur in well-nourished, vigor- 
ous, breast-fed babies. 
Age.—The age incidence is striking. The majority of the cases occur 
between the third and ninth months of life. Our youngest patient was 
ten days old. Holt’s statistics of 358 collected cases are as follows: 
28 cases under 4 months \ 
113 “ “ 4 to 6 months 
71 “ “ 7 to 9 “ 
18 cases from 10 to 12 months 
32 “ “ 1 to 2 years 
96 “ “ 2 to 10 “ 
Symptoms.—The onset is usually sudden, with evidence of pain and 
vomiting. A further early and very important sign is the marked pros- 
tration, which is much more pronounced than in an ordinary gastro- 
enteric disease. The child in a few hours may look very ill. There is 
cyanosis, and the pulse is rapid and small. This symptom-complex was 
noted in several cases. The vomiting, which is very active, is repeated at 
fairly short intervals, and after the stomach is emptied bile-stained mucus 
is ejected with much straining. Medication, food, and water are ejected 
as soon as they reach the stomach. There is evident tenesmus; the child 
strains, and at first passes normal bowel contents, followed by bile-stained 
mucus, and later clear mucus streaked with blood—a most reliable diag- 
nostic sign. Blood is not always present. In some instances only white, 
tenacious mucus is passed or removed on the examining finger. On the 
other hand, the blood may be present in large amount, constituting a very 
definite hemorrhage. The prostration, urgent at the beginning, increases, 
and the patient may die of shock before operation is attempted. 
The Presence of Tumor.—If the case is seen early, a sausage-shaped 
tumor may be felt, or the rounded apex of the tumor may be felt by rectal 
examination if the descending colon is involved. If the patient is not seen 
until several hours or days have elapsed, the accumulation of gas in the 
intestines renders the palpation of a tumor impossible. 
Occasionally a case is seen in which the onset is more gradual, in 
which gas and bile-stained mucus will be passed for a day or two. This 
indicates that the invagination is not sufficient to close the lumen of the 
gut. Finally, only blood and mucus are passed and the obstruction is 
complete. Three or four days may be required to bring this about. Vom- 
iting is a less pronounced symptom in these cases of gradual development. 
Stercoraceous vomiting does not occur in young infants. INTESTINAL OBSTRUCTION 
279 
The Temperature.—The temperature range is of no significance. In 
many cases the temperature is never above 100° F. 
Diagnosis.—There is no satisfactory excuse for so many failures in 
diagnosing intussusception in infants. The reason for the failure to 
appreciate the condition is because physicians too readily interpret active 
vomiting, with green, mucous, and bloody stools, as significant of gastro- 
enteric intoxication. 
Distinguishing features of intussusception are: Vomiting, sudden 
and urgent by a previously well infant, who may be breast fed; shock and 
collapse out of proportion in severity to the other symptoms; the passage 
of clear, mucous stools streaked with blood, together with the presence of 
pain of a paroxysmal nature, the absence of the passage of flatus, and the 
sudden distention of the abdomen. 
The presence of a tumor which can be felt either by abdominal pal- 
pation or in the rectum occurs in perhaps 80 per cent, of the cases. In 
cases of ileocecal intussusception the tumor may be difficult to map 
out, particularly if there is much distention of the abdomen. Under 
these circumstances anesthesia should be used in suspicious cases. Rectal 
examination is always a valuable aid and should never be neglected. 
Illustrative Case.—A breast-fed infant three weeks old suddenly terminated a 
diarrhea of two days’ duration and in the next thirty-six hours vomited bile-stained 
fluid, developed extreme abdominal distention and rigidity, and failed to respond to 
enemata. The diagnosis of intussusception was made by several observers. Opera- 
tion, however, disclosed a fatal spreading peritonitis with much exudate containing 
Streptococcus hemolyticus, but revealed no obstruction or initial focus of inflammation 
in the bowel. Extreme enteroparesis had simulated obstruction of the intestine and 
the absence of a visibly infected umbilicus left the source of the infection (which may 
have been pulmonary) in doubt. In this instance it is noteworthy that a localized 
abdominal tumor was not felt. Vomiting was not persistent and bloody mucus 
appeared only after rectal examination and was perhaps due to slight trauma of the 
mucosa. 
The prognosis in the immediate, complete type of obstruction depends 
largely upon the time of making the diagnosis and the promptness of 
operative procedures. The chance for recovery from operation decreases 
rapidly with each succeeding day. 
It is impossible to give statistics of value. It is safe to say that over 
50 per cent, of these cases are curable by some means if they are diagnosed 
early. The high mortality—50 to 80 per cent.—is due to two conditions: 
the tender age of the patients and the fact that the cases seen in con- 
sultation and those seen in children’s hospitals usually have been treated 
for something other than intussusception. Sometimes such treatment 
has been continued for several days. By the time those cases reach the 
hands of the surgeon there may be extensive adhesions, gangrene of the 
involved portion of the intestine, and an exhausted child to deal with. 
Treatment.—Reduction by Water-pressure.—This means is only of use 
when the intussusception has involved only the large intestine. In the 
ileocecal type operation at the earliest moment is the only resource. 
A well-oiled catheter, No. 18 American, or a small rectal tube, is attached 
to the small hard-rubber tip of a fountain-syringe. Two quarts of a 
normal salt solution are placed in the bag, which is hung at an elevation 
of 4 feet above the child’s body. The colon, or that part of it below the 280 
THE PRACTICE OF PEDIATRICS 
intussusception, is slowly filled with the warm salt solution. A small wet 
towel is tightly wrapped around the catheter, and fairly strong pressure 
is made at the anus by an assistant, in order to prevent the escape of the 
fluid. With the child on his back, with both hands free, the buttocks are 
elevated on a pillow or bed-pan at a plane 10 inches above the shoulders. 
In the cases in which the tumor is palpable, an attempt is made, by gentle 
abdominal manipulation, to reduce the intussusception. This in 2 cases 
the writer has succeeded in doing. Prolonged and repeated attempts at 
reduction should not be practised. 
Fig. 56.—Ileocecal intussusception (Kerley and LeWald). 
Illustrative Cases.—Case 1.—A child, two and one-half years of age, was brought 
at midnight with a history of a severe attack of colic about 9 o’clock, which was fol- 
lowed by severe attacks of vomiting and two stools of mucus and blood. Gentle 
manipulation of the abdomen showed a large, sausage-shaped tumor, about 5 inches 
long, in the left hypochondrium, which indicated an intussusception. The tumor could 
not be felt by rectal examination. Water-pressure, as described above, with abdominal 
manipulation, reduced the intussusception in a few minutes. 
Case 2.■—The other patient was a baby nine months of age. The senior author 
saw the child in consultation after the intussusception had existed for six days. The 
child was comatose and in profound collapse. He was pulseless, but the heart sounds 
could be faintly distinguished by the aid of stethoscope. The rectal temperature was 
96° F. The abdomen was greatly distended. The child had been treated for cholera 
infantum, although for five days nothing but white mucus tinged with blood had been 
passed. Palpation revealed a sausage-shaped tumor extending along the entire left 
side of the abdomen, which, in spite of the abdominal distention, could easily be made INTESTINAL OBSTRUCTION 
281 
out by firm pressure. As the child was unconscious, there was no resistance to the ex- 
amination. By rectal examination the projection of the involuted gut, which resembled 
the cervix uteri, could readily be distinguished. The condition of the child precluded 
all chance of surgical relief, and the writer hesitated to use water-pressure, fearing that 
the gut might be gangrenous and a rupture result, or that there might be adhesions 
sufficient to prevent reduction, and that the child might die during the manipulations. 
This situation was explained to the parents, who, after considerable urging, consented 
to a trial being made. The patient was accordingly given 1/100 grain of strychnin 1 
drop of tincture of strophanthus, and 30 drops of brandy hypodermically. The water- 
pressure was applied in the usual way, and it was with the greatest surprise and with 
supreme satisfaction that the writer felt the tumor slowly give way, to be followed by 
an expulsion of gas and a quantity of very fetid fecal matter. A hot colon flushing 
at 110° F. with a normal salt solution was given a few minutes later. This was all 
retained, and six hours later 12 ounces more were given. Hot-water bottles and bags 
were'placed about the child. He had sufficiently revived in an hour after the first 
colon flushing to be able to swallow diluted brandy and egg-water, both of which were 
freely given. A rapid recovery followed. 
This case, to the writer, was interesting in many ways, particularly as it emphasized 
what we sometimes see in work among children when victory is snatched from the 
jaws of evident defeat—that we should never cease our efforts so long as life lasts. 
Case 3.—-The following notes in conjunction with Fig. 56 give briefly the record of 
a case terminated favorably by operation: 
“Male, aged sixteen months. On day of illness awrnke apparently normal, but 
later refused regular feeding. Castor oil and an enema administered; results unsatis- 
factory. Vomited during the following night. No rise in temperature; no palpable 
mass; no point of tenderness. Clinical diagnosis: Suspected intussusception. 
“Roentgen Examination.—An opaque enema disclosed site of obstruction and its 
cause: intussusception of the terminal ileum into the cecum. The injected column 
of opaque material, w hen it met the intussuscepted portion of the ileum, spread out over 
it in a thin layer, leaving the central filling defect in the cecum which could hardly be 
simulated by any other known condition (Fig. 56). 
“Operation.—Abdomen palpated under anesthesia; no mass felt. Due to the 
Roentgen diagnosis a small incision wTas made directly over the cecum. Intussusception 
reduced in a very short time. Recovery. 
“Comment.—Only a very few cases of Roentgen diagnosis of intussusception have 
been reported. As the Roentgen findings are so conclusive in a case of this sort, they 
should not be omitted with a questionable diagnosis.” 
Intestinal Cysts or Diverticula (Congenital) 
A most unusual case of intestinal obstruction was presented by a well-nourished, 
breast-fed child, five weeks of age, who became ill with what appeared to be intestinal 
indigestion. There was a slight elevation of the temperature, and the stools were green, 
undigested, and watery. The family physician, Dr. Walter Fleming treated the case 
by the usual methods. An improvement in the stool followed, but a marked degree 
of tympanites remained. Feces and gas were, however, passed in small amounts, and 
at times the abdomen was sufficiently soft to allow of free palpation. The tympanites 
gradually increased, and instead of being intermittent, persisted. About one week 
after the writer first saw the case it came under his immediate supervision in New York 
City. 
Feces and gas were passed with difficulty—occasionally there was a fairly large 
stool. The child was in no way apparently ill, and suffered only from the abdominal 
distention; when this was relieved, the baby took food well and was content. In spite 
of our every effort directed to relief through diet, medication, local measures to the 
abdomen, and colonic treatment, the tympanites gradually increased and became per- 
manent and extreme. 
The patient was sent, at about the sixth day of the writer’s observation, to the 
Babies’ Hospital, where all attempts at reduction of the gaseous distention were like- 
wise futile. 
An exploratory incision was then made into the abdominal wall by Dr. William A. 
Downes, who discovered a tumor of the cecum. An artificial anus was made in the 
ileum above the valve, and the tympanites was relieved; but the child died shortly 
from exhaustion. 
Postmortem examination showed just above the ileocecal valve, and within 5 cm. 
of it, a round, sessile cyst, 3 cm. long and 2.5 wide by 0.75 cm. high, the mucosa over 
it thin, stretched, congested at either side, pale on top, with dilated vessels from the 
base radiating over the sides and top. Immediately beyond was a second cyst, 2.5 x 
2.5 cm. and only 0.25 high; close to it, almost bilocular, was a third, 2.5 x 2 and 0.75 
cm. high. Contents showed mucolymph within a smooth lining. Between the mucosa 282 
THE PRACTICE OF PEDIATRICS 
and submucosa the muscle was normal. Next to the last cyst was a part of a Peyer’s 
patch, mucosa congested, walls thickened and edematous. The colon was congested. 
The cysts or diverticula had encroached upon the lumen of the gut, and because 
of their proximity, formed a sufficient obstruction to preclude the passage of gas and 
the intestinal contents. Evidently the later growth of the cysts was quite rapid, as 
the obstruction caused symptoms increasing only gradually in severity, and permitted 
of the passage of feces until a day or two before the operation. 
Blackader, of Montreal, reported a case of congenital intestinal cysts, 
similar to the foregoing, before the American Pediatric Society in 1913. 
He was able to find records of but 3 other cases of congenital intes- 
tinal cysts in the literature. The condition, according to Gant, is not 
uncommon in adults; and in them the cysts are usually found in the sig- 
moid and colon and are looked upon as acquired. 
Meckel’S Diverticulum 
Meckel’s diverticulum, the remains of the omphalomesenteric duct, 
is present in 1 or 2 per cent, of all individuals and is slightly more common 
in the male sex. It is usually situated about a foot above the ileocecal 
valve and may occur as a fibrous cord or retain a patent lumen. The 
tip may be attached to the umbilicus or may be free. In the latter case 
there are usually no symptoms associated with its presence. 
The pathologic conditions which may be associated with Meckel’s 
diverticulum are: 
1. Obstruction or strangulation of intestine giving the usual symptom 
of obstruction. 
2. A patent lumen which may extrude feces, mucus, worms, or even 
intestine, the bowel in some cases protruding and strangulating at the 
umbilicus. 
3. A cystic tumor containing meconium formed in the duct, obliterating 
it at both ends. 
4. Calculi or foreign bodies resting in the lumen. 
5. Malformations or excessive involution causing contraction or 
kinking of the gut by traction. 
6. A free diverticulum which may invaginate with a subsequent ileo- 
cecal intussusception. 
7. Volvulus. 
8. Hernia. 
9. Diverticulitis, of which the pathology and the signs and symptoms 
are analogous to those of appendicitis. 
The differential diagnosis from appendicitis is practically impossible. 
Whereas in appendicitis inflammation per se is more common than ob- 
struction, obstruction is more commonly associated with Meckel’s di- 
verticulum than a primary diverticulitis. The point of tenderness is 
usually a little higher and closer to the umbilicus than McBurney’s point. 
There may be puffiness and resistance of the abdominal wall in the same 
region. There is usually in the early stages very little tympanites and 
there may be blood in the stools or vomitus. The knowledge of the earlier 
existence of an umbilical fistula or other congenital malformation may 
help in diagnosis. Otherwise the sjmiptoms are closely identical with 
those of intestinal obstruction or appendicitis. 
The treatment is surgical. HERNIA AT THE UMBILICUS 
283 
Illustrative Case.—In a patient nine months of age there was an evident incom- 
plete intestinal obstruction intermittent in character evidenced by marked constipation 
and periodic distention which was very pronounced. The peculiarity of this distention 
was that it could be relieved entirely by an enema combined with abdominal manipu- 
lation. The effects of such procedures could only be explained by some obstruction of 
a mechanical nature that was removed by this method of treatment. Abdominal 
section showed a thick fibrous cord, the remnants of the omphalomesenteric vessels 
extending from the umbilicus to the hepatic flexure of the colon and not to the ileum as 
would be expected. There evidently had been an infection of these vessels immediately 
after birth which had not been recognized. 
HERNIA AT THE UMBILICUS 
Protrusion of the abdominal wall at the umbilicus may be due to an 
improper development of the blastodermic layers, with non-union (ex- 
omphalos, hernia into the umbilical cord); or may result from a true fetal 
hernia after the umbilicus is lined with peritoneum, or a hernia occurring 
after birth through a weak umbilical scar. 
Hernia of the Umbilical Cord 
Morbid Anatomy.—This condition is a true fetal defect, due to a 
failure of union of the blastodermic layers, leaving as the anterior wall 
of the abdominal cavity a membrane covered with amnion externally 
and with peritoneum internally. Through this weakened parietal wall may 
occur a protrusion usually the size of a pear or an apple, but which may 
range from the size of a small finger-tip to that of a child’s head. The 
tumor is glistening and transparent, and shows through its walls the con- 
tents of the sac. These may include any or all of the abdominal con- 
tents, stomach, liver, Meckel’s diverticulum, omentum, intestines. Occa- 
sionally the child will be born eviscerated from the bursting of such a 
hernia in labor; and often its occurrence is associated with that of a spina 
bifida. 
The covering of this variety of hernia falls off with the drying up 
and dropping off of the umbilical cord. The contents are thus exposed. 
If the defect is small enough, it may granulate and epithelialize; but if 
this does not happen and operation is not resorted to, peritonitis and 
death will probably ensue. 
Treatment.—Operation offers a means of cure in these cases. Kindt 
reported 50 cures in a series of 65 operations. 
The management, therefore, should not be expectant. In view of 
the good results of operation, an attempt should be made as soon as 
possible after birth to close the opening in the abdominal wall either 
by cutting away the sac' in its entirety and suturing the abdominal walls 
together, or by separating the amnion from the peritoneum, replacing 
this and its contents into the abdominal cavity, and then suturing the 
walls. 
CONGENITAL UMBILICAL HERNIA 
Etiology.—This type of hernia occurs after the closure of the vis- 
ceral layers, and is due to pressure within the abdominal cavity and 
to the comparative weakness of the upper part of the umbilical ring, 
and to the extension of peritoneum surrounding the umbilical vessels, 
which, forming a sac, directs the force of the increased intra-abdom- 284 
THE PRACTICE OF PEDIATRICS 
inal pressure. It may occur through the linea alba, just above the um- 
bilical ring, either alone or in conjunction with hernia at the umbilicus. 
Prognosis.—The tumor is usually from j to 1 inch in diameter, and 
may protrude as much as 1| inches. There is seldom any discomfort, 
although when the contents are extruded and reduced there may be some 
pain. Danger of strangulation is slight, and the prognosis as regards 
cure is good. The time required ranges from six months to two years. 
The younger the child, the quicker the cure. 
Treatment consists in retaining the hernia and allowing the opening 
to close, and is, therefore, entirely mechanical. Operation is rarely neces- 
sary. Of 2000 operations for hernia in children under fourteen years of 
age at the Hospital for Ruptured and Crippled, but 1.3 per cent, were 
for umbilical hernia. By far the most effective method of treatment is to 
bring together over the umbilicus (Fig. 57) two folds of skin, so that they 
meet in the median line and invert the umbilicus. These folds of skin 
thus form a splint which is retained by a strip of moleskin adhesive plaster 
1 or 2 inches wide and sufficiently long to hold fast to the skin—usually 
Fig. 57.—Umbilical hernia reduced and adhesive plaster applied, 
about 4 to 6 inches. This method in our hands has proved the most 
satisfactory and has been followed by the most rapid cures. 
The objection to the use of a covered button or any form of pad, 
many of which have been recommended, is that unless it is very large 
the pad is apt to make strong pressure upon the abdominal opening, and 
while keeping the hernia reduced, prevent rapid closure of the ring itself. 
A pad or button may also interfere with the circulation and thus hinder 
the nutrition of the muscles and cause the weakness to persist. Umbilical 
trusses and bandages have been used repeatedly, and all have proved 
hopeless failures, and for one reason chiefly—the difficulty of keeping them 
in position. Any intelligent mother or nurse can be taught to apply the 
plaster as suggested above. The child may be bathed with the plaster in 
position. Ordinarily, it is best to apply a fresh piece every fifth day. 
Irritation of the subjacent skin sometimes occurs, and if this tendency 
exists, folds can be made at right angles to those previously made and 
the plaster applied again at right angles to the folds. By this means the 
excoriated skin remains uncovered. INGUINAL HERNIA 
285 
VENTRAL HERNIA AND DIAPHRAGMATIC HERNIA 
This form of hernia is of congenital origin, and is only occasionally 
seen in infants. It may be associated with umbilical hernia or may occur 
independently. It may be due to a failure of the recti to unite in the 
median line, or to weakness or imperfect development of the fibers of 
either muscle. Muscular atrophy following poliomyelitis was the cause 
noted in two cases. 
There is rarely any great protrusion of the abdominal contents, as 
in the other forms of hernia. Usually a ventral hernia manifests itself in a 
fulness or distinctly localized elevation of the skin over the site of the 
absent or weakened muscle tissue in the abdominal walls. The usual 
location is in the hypochondrium. Two or three hernias were observed 
in one subject in this locality. In one case the hernia was in the right 
lumbar region. Not all cases require treatment. 
Treatment.—The application of a 4-inch strip of zinc oxid adhesive 
plaster 2 or 3 inches wide, placed flat on the skin over the hernia is all 
that will usually be required. The support thus furnished must be con- 
tinued for several months. Operation may sometimes be necessary, but 
in our experience has not been required. 
Diaphragmatic Hernia.—These cases are very unusual. Only two 
have come under our observation. In both cases, as in others reported, 
the defect was located at the left anterior border of the diaphragm. This 
allowed the intestines to pass into the pulmonary cavity, displacing the 
heart and the lungs. As may be imagined, the physical signs thus 
produced are most unusual and puzzling. (See p. 383.) 
INGUINAL HERNIA 
Inguinal hernia is of rare occurrence in female infants, but is com- 
paratively frequent in males. It may be present at birth, or develop at 
a later period. The right side is more frequently involved. Double 
hernia, however, is not at all infrequent. 
Etiology.—Anatomic Conditions.—The special anatomic condition pre- 
disposing to inguinal hernia in infancy is the short and direct course of 
the inguinal canal. In the infant the internal abdominal ring is almost 
directly behind the external ring, and on practically the same level. In- 
complete closure of the inner opening, combined with weakness of the 
peritoneum in the neighborhood of the ring, thus affords easy egress to 
the hernia. At the femoral canal, on the contrary, the possible hernial 
opening is quite adequately protected, owing to the close relationship 
existing in the child between the anterior superior iliac spine, Poupart’s 
ligament, and the spine of the pubis. Consequently femoral hernia in 
childhood is rare. 
A more direct and exciting cause of hernia is the pressure exerted 
by the abdominal muscles in particularly from colic, and during 
paroxysms of whooping-cough. 
Diagnosis and Differential Diagnosis.—Inguinal hernia in infants 
is usually readily reducible, and this fact permits of making the diag- 
nosis positive. 286 
THE PRACTICE OF PEDIATRICS 
Strangulated inguinal hernia may be confused with hydrocele of 
the cord, enlarged inguinal glands, and undescended testicle. 
In hydrocele the tumor is translucent, which may be readily proved 
by means of the following light test: A piece of dark, stiff paper is rolled 
in tube form, so that the orifice is | inch in diameter. One end of the paper 
tube is placed over the tumor, which is supported while a flash-light is 
placed underneath. The observer’s eye is now applied to the other end 
of the tube. If the light is not transmitted through the mass, hernia in 
all probability is present. 
Further, if strangulated hernia has persisted for even a few hours, 
there will be vomiting and pronounced abdominal distention. 
In the condition known as undescended testicle the testicle is absent 
from the scrotum and may be demonstrated in the canal as a small, 
ovoid, movable mass. The wearing of a truss over an undescended tes- 
ticle has been witnessed. 
When due to enlarged inguinal glands, the tumor is placed to the 
left or right of the canal. It is firm, hard, and fixed, and usually more 
than one gland is involved. It would seem that there should be no neces- 
sity for confusion in the differentiation of a gland mass. 
Prognosis.—The prognosis for cure of uncomplicated hernia without 
operative procedure is good. Many cases are cured in from six months 
to one year through the use of suitable appliances. 
Treatment.—The treatment of inguinal hernia in infants and young 
children is by mechanical appliances or by operation. In infants under 
one year of age operation is rarely required. A most satisfactory means 
for treating inguinal hernia has been the Hood frame truss, made of hard 
rubber. Measurement for the truss is taken around the hips on a plane 
with the hernia. The truss, if placed in hot water for a few seconds, or 
warmed slightly before a fire, can readily be bent, so as to fit the patient 
comfortably. When the truss is removed for the purpose of cleansing, 
which should be done twice a day, a helper should be at hand to maintain 
support at the ring, so that there shall be no descent of the hernia. One 
descent may mean that several weeks’ care has been brought to naught. 
The child should wear the truss day and night. The skin, where subject 
to pressure, should be kept well powdered when the truss is first applied, 
and the child is often made more comfortable by placing absorbent cotton 
beneath the hard-rubber pad. 
As the child grows the truss will have to be changed frequently. Its 
use should be continued for at least six months after the last descent 
of the hernia. Operation is required when the hernia becomes strangu- 
lated, and this procedure is always to be advised for older children if a 
cure is not effected after two years’ treatment by a truss. Many cases 
entirely recover in less than six months. The use of the truss in such 
instances, however, is to be continued with a view to protecting the 
parts and preventing a recurrence of the hernia under stress. 
DUODENAL ULCER 
Duodenal ulcer is a very unusual disease in infants. In all, only a 
few score cases have been reported. Holt found 99 cases reported in the APPENDICITIS 
287 
literature. To this he added 4 cases of his own which were observed at 
the Babies’ Hospital. Among 1800 autopsies, largely in children under 
one year, the postmortem records showed but 4 cases of duodenal ulcer. 
More recently Veeder1 reported 5 cases. Gerdine and Helmholz" re- 
ported 11 cases including necropsy findings, from which series of cases 
they deduced that the condition was of an epidemic infectious form in 
which diplococci and streptococci played an etiologic role. 
Age.—The great majority of the cases reported have occurred in in- 
fants under six months of age. The lesion has been found postmortem, in 
most of the cases not being recognized during life. In Veeder’s cases 
proved by autopsy the diagnosis of duodenal ulcer was made antemor- 
tem in one only. 
Two cases of duodenal ulcer in children have recently come under 
the writer’s observation. 
Illustrative Cases.—Case 1.—A boy three years old passed free blood in his stools 
in large amount and vomited blood repeatedly. Abdominal incision disclosed exten- 
sive peritonitis, with a mass of adhesions about the pylorus, nature’s attempt at 
closing the perforations. The patient died a few hours after operation. 
Case 2.—A boy two years of age became ill with abdominal pain and vomiting, fol- 
lowed by marked abdominal distention. On the fifth day he was seen in consultation 
and a diagnosis of a perforated appendix was made and concurred in by the operating 
surgeon who, however, found the appendix normal and a perforating duodenal ulcer. 
The abdomen contained about 1 pint of bile and blood-stained fluid. The child made 
a rapid recovery. 
Pathology.—The lesions as described by Veeder are as follows: The 
ulcers may be single or multiple, and vary from small areas of super- 
ficial necrosis to cleanly punched-out ulcers which involve all the layers 
of the intestinal wall, and which in a few cases have perforated, with 
a resulting peritonitis. They are found between the pylorus and the 
ampulla and are most commonly situated just beyond the pyloric ring. 
The ulcers are usually located on the posterior wall. 
Symptoms.—The only symptom of value is the presence of blood 
mixed with the stools. When this occurs in a marantic infant, ulcer 
should always be suspected. We would then have to differentiate duodenal 
ulcer from peptic ulcer, polypus of the lower intestine, fissure of the rec- 
tum, intussusception, ulcerative colitis, melena neonatorum, and diver- 
ticula. It will be observed that the diagnosis of duodenal ulcer is not 
a simple matter, and it is altogether probable that in the future diagnosis 
of the disease will continue to be made postmortem, particularly as in 
some of the cases no hemorrhage occured at any time. 
APPENDICITIS 
The Appendix.3—This organ, normally, is located in the right iliac 
fossa, subjacent to McBurney’s point, which marks the junction of the 
two lower thirds of a line connecting the right anterior superior iliac spine 
with the umbilicus. This position is attained as the result of intra-uterine 
changes in the intestinal canal, involving a gradual migration of the ileo- 
1 Amer. Jour. Dis. Child., vol. vi, pp. 382-393. 
2 Ibid., vol. x, No. 6, December, 1915. 
3 Vide: Anatomy and Physiology of the Appendix, by Dr. Andrew McCosh, in 
American Practice of Surgery, Bryant and Buck vol. vii, p. 618 et seq. 288 
THE PRACTICE OF PEDIATRICS 
colic junction from a primary position in the left iliac fossa upward to 
the right, beneath the liver, and finally downward into the right iliac 
fossa. When these changes are not completed, the organ will not be 
found in its normal adult location, but frequently higher up. Because of 
variations in development the appendix may or may not have its origin 
from the extreme lower portion of the cecum. The lumen of the appendix 
at its base is often very minute. Both of these facts partially explain the 
liability to inflammation. The total diameter of the organ is about \ inch, 
and the length, which is extremely variable, is usually between 2 and 3 
inches. Various abnormalities in shape and direction occur, chiefly as a 
result of peritoneal adhesions. 
The appendix contains serous, muscular, submucous, and mucous 
layers. It is, however, essentially a lymphoid structure, well deserving 
the name “abdominal tonsil.” Like the tonsil, it attains its maximum 
development early in life, and, with the occurrence of the atrophic changes 
common in later years, shows a diminished susceptibility to infection. 
Appendicitis is not so rare a disease of early childhood as is usually 
taught. It occurs with sufficient frequency for the practitioner not to 
forget the possibilities of its unexpected development. 
Both acute and chronic cases are often overlooked because of the 
difficulty in diagnosis. In describing appendicitis, writers are inclined to 
divide the disease into types such as catarrhal, suppurative, gangrenous, 
and perforative. Such division for our purposes is hardly practicable. 
Because of the excess of lymphoid tissue in the child’s appendix, the patho- 
genic process may be extremely active, and a case that is catarrhal today 
may be gangrenous tomorrow. Not all catarrhal cases go on to the later 
stages. Nevertheless, it must always be remembered that appendicitis 
in the child is usually a much more active disease than in the adult. 
Bacteriology.—In order of frequency of attack according to Bower,1 
the micro-organisms directly causing appendicitis are Bacillus coli, 
staphylococcus, streptococcus, B. pyocyaneus, and the tubercle bacillus. 
Age.—No age appears to be exempt. Our youngest patient was nine 
months of age. Shaw reported the case of a patient seven weeks of age. 
Symptoms.—That many errors are made in the diagnosis of appendi- 
citis in infants and young children is in no small measure explained by the 
fact that the cardinal symptoms, as laid down by writers, viz., vomiting, 
colic, and sensitiveness to pressure, do not complete the symptomatology. 
Pain is a relative term, and the complaint of pain, while it must be re- 
spected, is never to be relied upon. Some children will exaggerate the 
sensitiveness of the abdomen to pressure, and others will deny the existence 
of pain actually present. Vomiting and colic are very unreliable signs. 
Fortunately in children one sign is almost invariably present unless there 
is a malformed or misplaced appendix, which is most unusual. This 
sign of real value indicating an involved appendix in a child is localized 
muscle rigidity—a spastic right rectus. This symptom is entirely beyond 
the child’s control, and while young children may be difficult to approach, 
patience in gaining the child’s confidence, combined with attempts at 
diversion, will make a satisfactory examination possible. 
Deep pressure is not necessary. If both recti are persistently rigid, as 
1 Appendicitis in Children, New York Medical Journal, cviii, No. 12, p. 502. APPENDICITIS 
289 
in a few cases, the fact in no way disproves the presence of a diseased 
appendix. Vomiting, pain, and colic are corroborative when there is a 
spostic right rectus. Alone they are suggestive of appendicular disease in 
children, but not diagnostic. 
With the rigidity and unusual sensitiveness to deep pressure, there is 
a tendency to flexion of the thigh on the abdomen, to relieve the tension 
of the abdominal muscles. 
Atypical cases may be seen, and in our experience have most often 
been due to an abnormally long appendix. Thus, in the case of a boy of 
twelve years, the appendix was 6 inches long and the abscess was located 
in the tip, which was in the right hypochondrium. In this case there was 
general muscle rigidity. 
Illustrative Cases.—In an eight-year-old child the diseased appendix was situated 
deeply in the pelvis. There was no pain or rigidity. Appendicitis was not diagnosed 
until rupture occurred and an acute localized peritonitis developed. 
In another child, with a very long appendix, the local symptoms were all referred 
to the left side. Operation was delayed, through no fault of the writer, until abscess 
and peritonitis, developed. The tip of the gangrenous appendix was located 2 inches 
to the left of the median line. 
Leukocytosis.—A leukocytosis is present in practically all cases, the 
differential count showing 70 per cent, or over of polymorphonuclear cells. 
Prognosis.—The prognosis depends upon the ability of the physician 
to diagnose the disease, his courage to act promptly, and the good sense 
of the family. In the young, appendicitis is usually of the fulminating 
type, and while temporizing may answer in the adult case it may be fatal 
to the child. Statistics of high mortality mean defective management. 
In the treatment of children over two years of age the results should be 
as favorable as in that of adults. If one uses ice-bags, stupes, and salines 
for three or four days and then operates, a high mortality is inevitable. 
Diagnosis.—The chief diagnostic symptom is rigidity of the abdomi- 
nal muscles, usually localized in the right side, sometimes general. Marked 
general abdominal rigidity was noted in a girl eleven years of age, whose 
appendix had not perforated. This symptom, with localized tenderness 
and the presence of a tumor, is to be looked upon as an independent 
diagnostic sign. All other symptoms to which much importance is at- 
tached are only of corroborative value. 
Differential Diagnosis.—In cases of intussusception and periodic 
vomiting there is no definite muscle rigidity, and in periodic vomiting no 
localized tenderness. 
Acute peritonitis may simulate a later stage of atypical appendicitis 
so closely that a differential diagnosis is impossible without an explora- 
tory incision. This should always be done in either event, whether 
peritonitis is of the more common origin or is due to intussusception. 
Acute pneumonia at the right base, with pleurisy, may produce signs 
closely simulating appendicitis, and is one of the conditions that may 
produce a spasm of the right rectus. 
In a very typical case operation for removal of the appendix might have been per- 
formed had not the patient presented the scar of a previous appendectomy wound. 
With pneumonia and pleurisy there are the unmistakable physical 
signs, the respiratory grunt, high temperature, and usually cough, to- 290 
THE PRACTICE OF PEDIATRICS 
gether with the objective sign of rapid breathing—signs ordinarily suffi- 
cient to eliminate an error in diagnosis. In cases in which the physician 
feels that a differentiation is impossible the a>ray may be brought into use 
to clear up the situation. 
Treatment.—After a considerable experience with obscure acute and 
chronic abdominal conditions in children we have learned that an ex- 
ploratory incision should be made as soon as we realize we are not positive 
regarding the character of the trouble at hand. This has been learned 
through experiences which we regret. Proved acute appendicitis in chil- 
dren demands operation as early as possible. 
For the borderland case, with mild symptoms in which a positive 
diagnosis is not possible, rest in bed, a fluid diet without milk, and the 
ice-bag comprise the essentials in a scheme of treatment which may 
suffice. The recumbent position and quiet should be maintained until 
every sign of the trouble has disappeared. 
Interval Operation.—In the event of the child’s recovering from a 
well-defined attack without operation a suitable time should be selected 
for an interval operation. A second attack is very likely to follow in 
less than a year, with a strong probability of abscess formation. Further- 
more, we cannot time the subsequent attacks, and these may occur with 
great severity when the child is otherwise ill or away from home where 
necessary surgical skill may not be obtainable. 
CHRONIC APPENDICITIS 
Chronic appendicitis has a very decided entity. It occurs in older 
children. We have never seen a case before the fourth year. In pediatric 
consultation practice it is not unusual to find the condition after this 
period. 
Symptoms.—-The cases usually show one of two groups of symptoms. 
A child in apparent health has complained of frequent abdominal 
pain over a period of several months. If asked to place his hand over 
the painful area, he will almost always point to the umbilicus. There is 
no apparent sensitiveness over the appendix, no pain on deep pressure, 
and no rigidity of the recti. The pain is rarely severe and may occur 
at considerable intervals. In some cases the abdomen will never feel 
quite comfortable. There may be diarrhea alternating with constipation, 
or the stool may be perfectly normal and regular. In other instances 
unwarranted attacks of acute intestinal indigestion may occur, the occa- 
sion of which will not be explained by the habits of the patient. 
Another type of case shows periodic, acute manifestations. These 
include vomiting, fever, and colicky pains, with diarrhea. Two or more 
attacks during the year are usual. As in the cases of the first type there 
may be no localization of signs in the abdomen. 
Illustrative Case.—A badly diseased appendix, as large as an adult index-finger, 
was removed from such a patient who had complained of no localized symptoms other 
than a feeling of pressure or weight in the right side, but who always had, as he expressed 
it, an uncomfortable abdomen. 
Periodic or recurrent intestinal disturbances—so-called indigestion 
—that is not relieved by a rational life and careful feeding will usually ACUTE GENERAL PERITONITIS 
291 
be found due to either an elongated sigmoid (p. 256) or to chronic appen- 
dicitis. 
According to Comby many cases of cyclic vomiting have their origin 
in chronic appendicitis, and a considerable number of such cases have 
been cured by removal of the appendix. 
Illustrative Case.—Figure 58 is taken from a case of this sort. The patient, a boy 
eight years of age, had suffered for a long period from persistent stomach disturbance 
associated with hiccup, belching, and foul breath. He was on a very rigid diet of 
skimmed milk, simple vegetables, and flesh food. Raw fruit and sweets produced what 
were called “stomach upsets.” The x-ray revealed a large appendix that still contained 
the bismuth mixture six days after its injection. Operation disclosed a very long 
chronically inflamed appendix. 
Fig. 58.—Chronic appendicitis. (Retention in the appendix three days after injection, 
with segmentations which probably represent concretions.) 
Treatment.—Suspected subjects should be given an anesthetic after 
fasting for twelve hours, and then examined by deep palpation and through 
the rectum. If tumefaction is found in the right iliac fossa, operation for 
the removal of the appendix should be performed at the convenience of 
the patient. 
Acute general suppurative peritonitis is an infection of the peritoneum 
by pathogenic organisms. It is always a secondary disease, and its bac- 
terial cause is that of the primary lesion. Thus, peritonitis may follow um- 
bilical infection in the newborn, usually due to the streptococcus or to the 
Staphylococcus aureus, or may result from a general blood infection with 
the pneumococcus, the typhoid bacillus, the influenza bacillus, or strep- 
tococcus, whether the point of entrance be the upper respiratory tract or 
a surgical lesion. Peritonitis is a common complication of appendicitis, 
enterocolitis, or intestinal obstruction, and is then most often due to 
Bacillus coli communis, with or without the streptococcus. Peritonitis 
ACUTE GENERAL PERITONITIS 292 
THE PRACTICE OF PEDIATRICS 
also may be due to the gonococcus, as the result of the progressive spread 
of vulvovaginitis, endometritis, and salpingitis in little girls. Finally, 
peritonitis may result from the extension of a pleural inflammation by 
means of the lymphatics, but the inflammation is then more often localized 
about the spleen or liver than generalized. 
The pneumococcus probably is the pathogenic agent in more than half 
the cases. 
An unusual illustrative case of acute peritonitis is recorded under the differential 
diagnosis of intussusception, p. 279. 
Pathology.—The exact character of the inflammation depends upon 
the infecting organism. The process, however, uniformly involves con- 
gestion, exudation of serum and lymph, and the formation of adhesions. 
Depending on the source and degree of infection, peritonitis may be 
localized, “spreading” or general, and serous, seropurulent, purulent, or 
fibrinous. The most frequent infecting agents are the colon and the 
typhoid bacillus and the streptococcus, staphylococcus, pneumococcus, 
and gonococcus. In cases of streptococcus peritonitis the fluid is thin and 
widely diffused, and in pneumococcus infections, thick, greenish-yellow, 
purulent, and associated with fibrinous deposits and many adhesions. 
Gonococcal peritonitis is seldom diffuse. Pus with a characteristic fecal 
odor is suggestive of appendical or intestinal perforation. When the 
peritonitis is of limited extent, the most common sites for the localization 
of the inflammation are the iliac fossa, pelvis, and subdiaphragmatic 
regions. Abscesses occasionally perforate spontaneously at the umbilicus. 
When recovery ensues, the peritoneum frequently becomes the seat of 
permanent adhesions which may or may not occasion symptoms. 
Symptoms.—There are but three diagnostic symptoms of value: 
persistent vomiting, marked tympanites, and obstinate (and often abso- 
lute) constipation. These manifestations comprise a symptom-complex 
that is practically always present in acute peritonitis. Vomiting may be 
absent in very acute and fatal cases. 
The temperature is usually persistently high—103° to 105° F. The 
pulse is small, soft, and quick, and the child appears and is very ill. The 
respiration is short and rapid; there is incomplete expansion. There are 
no evidences of pain except upon manipulation. The onset of all symp- 
toms is usually, but not invariably, abrupt. It may be two or three days 
before the symptom-complex as described is present. 
Illustrative Case.—A fine healthy boy four years of age seen in consultation with 
Dr. Harriet Hyde developed a severe staphylococcus infection of the tonsils. On the 
fourth day of the illness symptoms of acute peritonitis developed with paralytic ileus 
and death in a few hours. 
Duration and Prognosis.—Death rarely occurs before the third day, 
and the cases that pass ten days are rare. We have never known a case 
to recover. Our cases have all been those of children under two years of 
age, with a few exceptions. 
Illustrative Cases.—A child of three developed a streptococcus infection in conjunc- 
tion with endocarditis. 
Another patient, a strong, vigorous girl, three years of age, developed a moderately 
severe enterocolitis. Response to treatment was fairly prompt, and in ten days the THE INTESTINAL PARASITES 
293 
child was convalescent. Suddenly she developed marked distention of the abdomen, 
persistent vomiting, and obstinate constipation. These symptoms, with gradually in- 
creasing prostration, continued for three days, when the child died. The autopsy showed 
an acute general streptococcic peritonitis. Streptococcus was found in the enlarged 
mesenteric glands, indicating that the intestinal tract was the source of the infection. 
Othe*- cases have been those of appendicitis seen too late to forestall the occurrence 
of perforation. 
The prognosis in older children after the fifth year is said to be more 
favorable. 
Differential Diagnosis.—The only condition which acute peritonitis 
may simulate in infants and runabouts is intestinal obstruction, par- 
ticularly that due to intussusception. Intussusception in a large majority 
of the cases occurs in infants under a year of age. Further, in intussuscep- 
tion there is no associated illness, and fever, if present, is insignificant; 
while the stools almost always contain blood-stained mucus or clear white 
mucus. 
Treatment.—Every case of acute peritonitis in a young subject should 
have the benefit of an exploratory incision. There is always a possibility 
in obscure cases (and many cases are obscure) that the trouble is of ap- 
pendicular origin or that there may be some other localized process which 
drainage might relieve. Acute general peritonitis is a very fatal disease, 
and the outlook cannot be made worse by incision and drainage. 
THE INTESTINAL PARASITES 
The most common of the intestinal parasites found in children are 
Ascaris lumbricoides, or round-worm, Oxyuris vermicularis, or thread- 
worm, Tenia, or tapeworm, and Uncinaria, or hook-worm. 
The Blood in Infections by Intestinal Parasites.—Patients with 
teniasis or uncinariasis frequently present a pronounced degree of ane- 
mia of the chlorotic type. In occasional cases of tape-worm infection the 
blood-picture resembles that of actual pernicious anemia. Where un- 
cinariasis is prevalent and the inhabitants are subject to constant infec- 
tion from the soil, such terms as “Egyptian chlorosis,” “miner’s anemia,” 
and “brickmaker’s anemia” are current synonyms for the disease. 
Leukocytosis in the parasitic infections is not characteristic, but 
may occur during the acute stage of trichiniasis. Eosinophilia, however, 
is a very characteristic manifestation of reaction to the parasitic toxins, 
and in trichiniasis often attains a degree of 20 to 50 per cent. Stiles re- 
ported that in uncinariasis the chronic cases with poor resistance show 
little eosinophilia, while those undergoing improvement under treatment 
afford counts averaging as high as 13.2 per cent.1 
Ascaris Lumbricoides (Round-worm).—This parasite is a very fre- 
quent inhabitant of the small intestine. The worm is 5 to 10 inches 
long, cylindric in form, and closely resembles an ordinary earth-worm. 
Large numbers may exist in the same patient, and have been known to 
cause serious secondary symptoms, such as obstruction of the bile-duct 
or a severe attack of choking, induced by the migration of the worms from 
the esophagus into the larynx. They have been known to invade the 
eustachian tube. The ova are taken into the digestive tract in uncooked 
1 Osier’s Modern Medicine, vol. i. 294 
THE PRACTICE OF PEDIATRICS 
food and occasionally in drinking-water. The eggs are of oval form, and 
when present in the feces may be distinguished by their thick shells and 
“mammillated” borders and by the absence of segmentation. 
Symptoms.—The round-worms, if in considerable number, may pro- 
duce colic or constipation, the latter oftentimes alternating with diarrhea. 
Nervous disturbances of an urgent character are not uncommon. In the 
great majority of our cases, however, no single symptom has been 
prominent, and the fact that the child had parasites in the intestine has 
been first learned when a worm has been passed by the rectum. 
Illustrative Case.—A patient, three years of age, had repeated convulsions. The 
mother stated that the child had passed a couple of round-worms the day before. Fol- 
lowing the giving of 1 ounce of castor oil, and after an hour, 2 grains of santonin, 43 
large round-worms were passed during the next twenty-four hours. This is the largest 
number we have known to come from one child. 
The round-worm is relatively rare in New York City children. In 
children who live in the country it is of fairly common occurrence. 
Treatment.—At bedtime it is well to order from 2 to 4 teaspoonfuls of 
castor oil. Early the following morning, about two hours before breakfast, 
santonin is to be given. For children under two years of age a suitable 
dose is 1 grain; for those from two to four years of age, 1| grains; and 
after the fourth year, 2 grains. The santonin is prescribed in a powder or 
capsule, with an equal quantity of sugar-of-milk. If the passage of worms 
follows its use, the treatment should be repeated in three days; and again 
in a week, if worms are passed after the second treatment. 
Oxyuris Vermicularis (Thread-worm or Pin-worm).—Thread-worms 
are of more frequent occurrence in city children than are either round- 
worms or tapeworms. The thread-worms have their habitat in the lower 
portion of the colon, where they become attached to the mucosa, and 
occasionally produce considerable catarrhal inflammation. Exceptionally 
they may invade the appendix and excite inflammation requiring surgery. 
The oxyuris is an insignificant looking object, light in color, from \ to \ 
inch in length, and of the diameter of a pin. The ova are not so large as 
those of the ascaris. Raw fruit and uncooked vegetables may convey the 
infection. 
Symptoms.—The worms produce an irritation and itching about, and 
a pricking sensation within, the anus. The discomfort is bitterly com- 
plained of after the child is in bed at night, the parasites being particularly 
active at this time. If there is any doubt as to their presence, the patient 
should receive a full dose of castor-oil—at least 2 teaspoonfuls. The 
discharges should be kept for inspection. If the parasites are present, 
they will usually be found embedded in a considerable quantity of mucus, 
in the form of pieces resembling white thread from \ to f inch in length. 
Treatment.—Santonin, recommended by some writers as of service in 
these cases, has been without the slightest value in our hands. In fact, 
the use of drugs of any kind by mouth seems to be of very little value. 
After the third year turpentine in 1-drop doses after meals is probably 
the most valuable form of internal medication. It may be given in emul- 
sion or dropped upon sugar. 
Rectal Injections.—Local treatment with the infusions of garlic or 
quassia is our principal reliance in the management of the obstinate cases. THE INTESTINAL PARASITES 
295 
When the worms have existed in the bowel for a considerable time the 
resulting irritation causes a profuse secretion of mucus in the descending- 
colon and sigmoid. This mucus must be washed out before any direct 
treatment can be effective. The colon should first be irrigated with a 
solution of 1 tablespoonful of borax to a pint of water. For this purpose 
a No. 18 American catheter introduced, if possible, 10 inches, should be 
used, as in colon flushings. The child should be encouraged to bear down 
and expel the water alongside the tube, no attempt being made to have 
the solution retained. After the preliminary washing is complete, 8 ounces 
of the infusion of quassia may be passed into the colon. To facilitate re- 
tention of the fluid the tube must be quickly withdrawn. The child may 
then be placed on the left side, with the buttocks elevated on a pillow. 
This position, or at least the recumbent position, should be maintained 
for one half-hour after the injection is given. A solution of bichlorid of 
mercury 1 : 10,000 may be used in the same way. For ordinary family 
use, however, the garlic or the quassia is much safer and equally effective. 
Garlic used in infusion identical with quassia is particularly effective, but 
its very disagreeable odor makes its use objectionable in many house- 
holds, and therefore we advise it only when other means fail. After the 
worms and all evidences of their presence disappear, the treatment should 
be continued for some time on alternate days, and then twice a week, 
gradually reducing the frequency of the irrigations until they are no longer 
required. Few cases recover in less than four weeks, and in many instances 
it will be found necessary to continue the treatment for months. We have 
never seen a case, however, which did not eventually respond to per- 
sistent treatment. 
Tenia (Tapeworm).—The tapeworm is a long, flattened organism, 
consisting of a head or scolex and hundreds of individual proglottides 
or offshoots derived from the head. Each segment in the series contains 
a large number of eggs. After the discharge of the segments from the 
body these ova are ingested and undergo a period of development in 
the tissues of an intermediate host, eventually forming the cysticerci 
or encapsulated bladder-worms which give the “measle” appearance 
to infected meat. This meat, when insufficiently cooked, conveys the 
cysticercus to the stomach of the patient, where the digestive juices 
liberate from the cyst wall a head which is capable of becoming attached 
to the mucosa of the child’s alimentary tract and producing a mature 
parasite. 
The chief varieties of tapeworm are Taenia saginata, or beef-worm, 
Taenia solium, or pork-worm, Bothriocephalus latus, an inhabitant of 
fish, and Taenia elliptica, which passes an intermediate stage in the vermin 
of household pets. 
Taenia saginata attains a length of from 12 to 20 feet. The head is 
from 1 to 2 mm. in diameter, and contains four suckers, but no hooklets. 
Taenia solium is rarely over 12 feet long. The offshoots from the 
median canal forming the uterus of a segment show less branching than 
in the case of Taenia saginata, and the developed segments in Taenia 
solium are more nearly square. The head has a short rostellum with a 
circle of hooklets. 
Bothriocephalus latus is far more common in northern Europe than 296 
THE PRACTICE OF PEDIATRICS 
in America. When mature, this worm is over 25 feet long. The seg- 
ments are unusually broad, and the head is oval in outline and contains 
two lateral grooves. 
Taenia elliptica occurs occasionally in very young infants. It is only 
6 to 12 inches in length, and its segments are long and narrow. 
Symptoms.—The tapeworm may produce symptoms of disturbed in- 
testinal digestion, such as colicky pain and diarrhea. Usually, however, 
the first warning that the child is affected is afforded by the passage of 
segments of the worm. 
Illustrative Cases.—A worm 14 feet in length was expelled, after treatment, by a 
little girl four years old. There had never been a symptom of its presence other than 
the passage of several of the segments. 
A child eighteen months of age passed 18 feet of a tapeworm without dislodging 
the head. 
Treatment.—At bedtime to 1 ounce of castor oil is to be given, 
and early next morning, two hours before breakfast, | dram of the oleo- 
resin of male-fern (aspidium), in emulsion or in capsule. During the day 
a light fluid diet only should be allowed, such as broth, gruel, and fruit 
juices. One treatment with a good preparation of the male-fern will 
usually bring away the worm entire. The head should be carefully 
searched for with the magnifying-glass. If the head is not found, the 
treatment should be repeated after an interval of twenty-four hours. 
Uncinaria (Hook-worm).—The two forms of this parasite, Ankylos- 
toma duodenale and Uncinaria americana, exhibit certain morphologic 
differences, the most marked of which is the existence, in ankylostoma, of 
two pairs of ventral, hook-like teeth, which are not present in the American 
species. The hook-worm measures from | to f inch in length. The ova, 
in large numbers, are present in the feces, and may be recognized as 
small oval bodies, usually clear in appearance, about 50 x 30g in size, 
showing various stages of segmentation. After the administration of 
thymol, followed by a saline cathartic, the worms themselves may appear 
in the stools as small objects, a little thicker than a pin, about \ inch long, 
and with the characteristic, retroverted hooked end. 
The hook-worm has been known for many generations, but only during 
the past twenty years has uncinariasis received due attention. In certain 
localities—notably the West Indies and the Southern States—the soil is 
very generally infected, and a considerable proportion of the population 
harbor the parasites. These not only remove blood from the circulation 
of the victim, but elaborate a toxin which is thought to assist in the 
causation of the significant anemia of this disease. Infection usually takes 
place from the soil, through the skin of bare feet. Infection may also take 
place through the skin of the hands, or by means of the gastro-intestinal 
tract, through the eating of raw fruit or vegetables. 
Symptoms.—The symptoms are those of digestive disturbance com- 
bined with progressive anemia. The anemia is often of an extreme degree. 
Abdominal discomfort of considerable degree may exist and this possibly 
gives rise to the curious habit of earth-eating, which these patients may 
acquire in their desire for the relief which the ingestion of food usually 
affords. Stiles reported a case in which a boy ate three coats, thread by THE INTESTINAL PARASITES 
297 
thread, in twelve months. As the disease progresses, the face and ankles 
may become edematous. The stools contain occult blood. Lassitude and 
incapacity for sustained effort are prominent symptoms, and unless the 
cause of the disease is eliminated, the child falls behind in both physical 
and mental development. 
Treatment.—Thymol is specific for the hook-worm. A purgative 
should precede the administration of the drug. Twelve hours before 
administering the thymol a full dose of cascara sagrada or Epsom salts 
should be given. The thymol should be given in solid form, 5 to 10 grains 
every three hours, until four doses have been given. The drug is best given 
in capsules or pills. Twelve hours after the last dose a saline cathartic 
should be administered. Ten days after the administration of the thymol 
the stools should again be examined for the ova of the parasite, and if ova 
are found, the treatment should be repeated. Thymol poisoning is indi- 
cated by dizziness and discoloration of the urine. When these symptoms 
appear, the treatment should be discontinued and further purgation 
brought into use. During the active treatment the diet should consist 
of milk, broths, and gruels. 
The anemia and malnutrition should be managed along the lines 
suggested under the respective headings. 
Trichiniasis is a disease which children may occasionally acquire 
from the eating of uncooked ham, sausage, or pork. In localities where 
meat inspection is rigid cases of this infection are relatively rare. Trichina 
spiralis (Trichenella spiralis) is not infrequently found in hogs. The fe- 
male parasite deposits larvae in the submucosa, whence they are carried 
by the lymphatics to the blood-stream, and on reaching the voluntary 
muscles become encapsulated. When the uncooked, infected meat is 
eaten the capsules undergo dissolution, and the contained trichinae are 
liberated in the digestive tract of the patient. The forms attain full 
development in the small intestine, and about a week after the ingestion 
of the meat set free a new brood of embryos. 
Van Cott and Lind1 found the Trichina spiralis in the cerebrospinal 
fluid. These findings have since been confirmed by Young, Cummins, 
and others. In doubtful cases an examination of the cerebrospinal fluid 
serves as a means for the possible confirmation of a diagnosis. 
Symptoms.—'The severe symptoms of trichiniasis develop about ten 
days after the eating of the infected meat, frequently following a period of 
preliminary gastro-intestinal disturbance. When well advanced, the 
disease may be mistaken for typhoid, malaria, influenza, nephritis, or 
acute rheumatism. Fever of a remittent type, great muscular pain and 
soreness, and edema of the face and eyelids suggestive of nephritis are the 
more pronounced effects. The blood shows not only leukocytosis, but a 
marked grade of eosinophilia. The symptoms usually subside after a 
week or ten days. Romanowitch demonstrated that in traversing the 
intestinal mucosa the trichina deposits bacteria which may distribute 
secondary infections. Flow important this fact may be in the explanation 
of symptoms occurring in this disease remains to be determined. In 
doubtful cases trichiniasis may be diagnosed by the microscopic demon- 
stration of the encapsulated parasites in a bit of muscle tissue removed 
1 Jour. Amer. Med. Assoc., vol. lxvi, No. xxiv. 298 
THE PRACTICE OF PEDIATRICS 
under local anesthesia from the deltoid, biceps, or gastrocnemius of the 
patient. 
Illustrative Case.—A girl eight years of age developed muscle soreness, edema of 
the skin, and especially marked swelling and stiffness of the muscles of the left leg. 
Trichiniasis was suspected, and a small portion of the deltoid was removed, which 
showed the encapsulated parasite. 
Treatment.—At the outset of the disease thorough catharsis is of 
unquestionable value, for it has been estimated that “each female parasite 
removed from the intestine means a reduction of the muscular infection 
by from 1500 to several thousand worms.”1 Calomel is undoubtedly 
indicated for this purpose, and this drug should be given in doses aggre- 
gating 1 to 2 grains, accompanied by 10 to 20 grains of bicarbonate of 
soda, and followed after six hours by a saline cathartic. Thymol may be 
given in the manner suggested under treatment of uncinariasis, but the 
position of the parasites deep in the intestinal mucosa renders most of 
them secure from the action of an anthelmintic. After the disease has 
become established the treatment is solely symptomatic, consisting in 
the use of means to relieve pain, control temperature, and support the 
pulse, which in severe infections may become weak. 
1 C. W. Stiles, Osier’s Modern Medicine, vol. i. IX. THE RECTUM AND ANUS 
THE RECTUM IN CHILDREN 
In the child the division between the pelvis and abdominal cavities 
is less marked than in the adult, and the rectum is less distinctly a pelvic 
organ. The infantile pelvis, moreover, is peculiarly narrow, so that the 
course of the terminal portion of the intestine is nearly perpendicular. 
This peculiarity, combined with the greater mobility of the child’s rectum, 
renders digital examination per rectum of great value in palpating diseased 
organs within the abdomen. The same anatomic conditions, associated 
with weakness of the levatores ani, are influential in the causation of 
prolapsus recti in children. 
IMPERFORATE ANUS—ATRESIA ANI 
The greater portion of the alimentary tract is derived embryologically 
from entoderm, but the caudal part is formed from the elevation of a fold 
of ectoderm which surrounds a crater-like hollow called the proctodeum. 
This latter ectodermal invagination is separated from the entodermal gut 
till about the fourth week of fetal life by the anal membrane, a portion of 
the eloacal membrane. Cases of imperforate anus or atresia ani may 
be due to a complete or partial persistence of this membrane so that the 
proctodeum or external invagination does not communicate with the 
caudal portion of the hind-gut or is connected with it only through an 
abnormally small opening. Other causes of imperforate anus may be: 
(1) Deficient development of the hind-gut so that there is an interval 
between the gut and the proctodeum. 
(2) The rectum may open into the vagina, uterus, bladder, or ureters. 
(3) Persistent cloaca. 
PERSISTENT ANAL MEMBRANE 
Slight or moderate constriction of the anal ring due to partial per- 
sistence of the anal membrane is a fairly common cause of constipation, 
colic, and difficulty in defecation in small infants. On careful digital 
examination a tight membranous ring may be felt at the level of the 
external sphincter. Frequently the gut above is empty and ballooned 
up with gas which is violently expelled upon withdrawal of the examining 
finger. The ring should be gently dilated. One such dilatation may 
suffice; more often it has to be repeated once or twice till the distention, 
colic, constipation, and difficulty at stool is relieved. Complete persistence 
of the anal membrane necessitates its being broken down to permit the 
free passage of feces. The other forms of imperforate anus require more 
extensive and more difficult surgery. 
The rectum of every newborn infant who suffers from the symptoms 
described should be digitally examined with the purpose of determining 
the presence of this small membrane. This may at times account for 
very urgent symptoms. 
299 300 
THE PRACTICE OF PEDIATRICS 
PROLAPSE OF THE ANUS AND RECTUM 
In anal prolapse there is an eversion of the mucous membrane, a 
condition often presented in constipation and sometimes seen in diarrheal 
conditions of the dysenteric type, in which there is a tendency to con- 
siderable tenesmus and straining. If the case is neglected, the prolapse 
occurring repeatedly for many days in succession in cases of constipation, 
or several times a day in the acute diarrheal cases, the sphincter gradually 
becomes weakened, the prolapse more pronounced, and soon a consider- 
able portion of the involuted rectum appears with each defecation. Chil- 
dren thus affected usually show evidence of illness apart from the local 
condition and the constipation. They are usually underfed and poorly 
nourished. Many are rachitic, or show the evidences of a previous 
rachitic state. 
Treatment.—Cases of simple eversion are usually relieved by con- 
trolling the diarrhea; or, when due to constipation, by supporting the 
perineum during defecation. This support is best furnished by wrap- 
ping a considerable quantity of absorbent cotton around the index- 
finger, which rests against and supports the perineum. The child should 
lie on the back during defecation. The troublesome cases are those due to 
constipation in “runabout” children, in whom the prolapse has been re- 
peated every day for several months. In such cases a wide adhesive strip 
placed across the buttocks, high enough to permit of bowel evacuation, 
will prevent the prolapse. 
INFLAMMATION OF THE ANUS 
An acute painful inflammation of the anus and of the skin surround- 
ing it is frequently seen in children after a diarrhea of some days’ dura- 
tion. It is also seen in weakly, delicate children without any marked 
intestinal disturbance. The inflammation produces considerable dis- 
tress during the passage of a stool, and is conducive to constipation, 
because the child soon dreads to have a bowel movement and tries to 
avoid it. 
Treatment.—The child’s nutrition and management in general must 
be first carefully looked after, as elsewhere suggested (p. 140). For the 
local trouble the free use of warm water after each defecation is neces- 
sary. This is to be followed by a generous application of an ointment 
made as follows: 
Ib Ichthyolis 5j 
Unguenti aqua; rosae §j.—M. 
Instructions are given that the parts are to be kept covered with the 
ointment, applied on a piece of old linen, which should be changed every 
three hours. This treatment is usually followed by prompt relief. 
FISSURE OF THE ANUS 
Anal fissure is a condition that usually occurs in quite young chil- 
Comparatively few cases have been personally seen in children 
over two years of age. Rough manipulation may be a cause, as in the case 
of unskilled use of the syringe or rectal tube. With very few exceptions, 
however, the fissure is due to the stretching of the parts by the passage PROCTITIS 
301 
of large fecal masses, which cause minute lacerations of the mucous mem- 
brane within the anal ring. Under a good light gentle separation of the 
buttocks will usually bring the laceration into view. 
Symptoms .—There are few more painful affections. The vigorous 
crying preceding and during the defecations aids the mother in locating 
the source of the child’s trouble. Occasionally the fecal mass will be 
streaked with blood. The constipation which causes the trouble is aggra- 
vated by the painful nature of the condition, as the child soon learns to 
dread an evacuation, and postpones the act until medication or some 
manipulation is employed to induce a movement. 
Illustrative Case.—A little girl, twenty months old, was brought for treatment 
because she cried and objected to being placed in position for a bowel evacuation, 
and cried even more during the evacuation. On the day preceding the office visit the 
mother feared the child would have a convulsion so great was her distress. Examina- 
tion of the rectum showed two rather small fissures extending through the anal mucous 
membrane. 
Treatment.—Diet.—For a prompt repair of the fissures it is necessary 
to render the stools soft. This, in the bottle fed, is often easily accom- 
plished by the addition to each feeding of 1 or 2 teaspoonfuls of one of 
the malted foods, such as Mellin’s food or malted milk. In other instances 
one feeding of malted milk each day may be substituted for one of the 
regular feedings, in the strength of 4 to 6 teaspoonfuls in 8 ounces of water. 
Drugs.—If drugs are necessary or are preferred, the addition of 2 
teaspoonfuls daily of the milk of magnesia to the milk food will prove 
of value. A teaspoonful of sweet oil after two or more feedings will like- 
wise usually have the desired softening effect upon the stool. 
Local Measures.—Proper regulation of the bowel function, while 
absolutely necessary for a cure of the laceration, is not of itself sufficient 
to effect permanent relief. The parts must be thoroughly washed with 
warm water and Castile soap after each defecation. After the washings, 
and at three-hour intervals during the day, 25 per cent, of ichthyol- 
ammonium-sulphate in zinc ointment should be applied with a clean 
index-finger, which is introduced well up into the anal aperture. If the 
fissure is deep, the treatment should be begun by applying to the parts 
a solution of novocain. The fissure may then be cauterized with 50 per 
cent, solution of nitrate of silver, applied on a cotton-tipped probe. Twelve 
hours later the ichthyol ointment may be used as in the milder cases. 
PROCTITIS 
Inflammations of the rectum are of three different forms—catarrhal, 
croupous or membranous, and ulcerative. 
Catarrhal 'proctitis is usually associated with colitis higher in the 
bowel. When confined to the rectum, the process may be due to the 
careless use of irrigations or irritating suppositories, or the activity of 
thread-worms. 
The mucous membrane is red and swollen, and exudes not only mu- 
cus, but a small amount of blood. In gonorrheal proctitis, which occa- 
sionally complicates a vulvovaginal infection by the same organism, the 
discharge from the inflamed parts is characteristically purulent. 
Membranous proctitis may result from diphtheria of the genitals or 302 
THE PRACTICE OF PEDIATRICS 
from a local streptococcus infection. The morbid lesions closely resemble 
those of membranous colitis, and are not essentially different from those 
which occur in membranous inflammations of the throat. The grayish, 
organized exudate may be visible on the mucosa of the prolapsed bowel, 
or appear in fragments in the stools. 
Ulcerative 'proctitis is usually secondary to a severe catarrhal proc- 
titis, in which case the lesions tend to remain superficial. Follicular 
ulcers of greater depth may occur in connection with follicular colitis. 
Syphilitic and tuberculous ulcerations of the rectum are rare. Holt 
reported one case of the tuberculous type, and recorded Steffen’s observa- 
tions of three others. 
Symptoms.—In all forms of proctitis the movements of the bowels 
are frequent, and associated with tenesmus and the discharge of mucus 
and small amounts of blood. Prolapsus recti is not uncommon, and 
after reduction shows a strong tendency to recur so long as the severe 
peristaltic activity of the bowel persists. The character of the discharge 
is of value in differentiating the existing type of inflammation. 
Treatment.—In mild cases of the catarrhal form injections of warm 
starch solution, alkaline liquid antiseptics, or sweet oil will effect a cure, 
provided the primary cause of the irritation has been removed. When 
the process is diphtheric, antitoxin should be promptly administered, as 
in cases of laryngeal diphtheria. 
Ulcerative proctitis requires especial care involving the use of cleansing 
irrigations and suppositories of tannigen, belladonna, opium, or cocain, 
combined with local application, at intervals, of a solution of silver nitrate 
of from 2 to 5 per cent, strength. For the gonorrheal cases Koplik has 
advised rectal injections of 2 per cent, protargol solution, at a temperature 
of 105° to 108° F., twice daily. 
An abscess of this nature is the result of preceding adenitis of the 
lymph-glands in the neighborhood of the rectum. 
Symptoms.—The first sign will be that of pain on defecation or upon 
manipulation. Upon examination an oval, indurated mass will be found 
under the skin, usually not deeply placed. Much pain is evidenced 
during the examination. In most instances there is redness of the skin 
over the involved gland. Rarely can fluctuation be made out by palpa- 
tion. Suppuration, however, follows the primary infection very rapidly, 
and a distinct area of reddened and inflamed skin indicates the presence 
of pus beneath. Children’s hospitals, children’s asylums, and dispensary 
services supply the majority of these patients. Occasionally a case is 
seen in private work. 
Treatment.—All that is required is a free incision, daily washing 
out of the abscess cavity with a 3 per cent, solution of hydrogen peroxid, 
and packing with sterilized gauze moistened with a saturated solution 
of boric acid. A layer of gauze, covered with oiled silk, should cover 
the dressing, to protect the wound from further infection by the fecal 
discharges. In case the granulations are sluggish, as they may be in 
marasmic infants, the gauze used for the packing may be saturated with 
balsam of Peru. 
ISCHIORECTAL ABSCESS X. DISEASES OF THE LIVER 
ABNORMALITIES OF FUNCTION AND SIZE 
The liver in infants and children is very rarely the seat of primary 
disease, and in the mortality of childhood as an immediate cause plays 
a very unimportant role. 
Derangement of function of the organ, on the other hand, is unques- 
tionably at the bottom of many disorders not at all understood at the 
present time. In conditions of toxemia, particularly in so-called acidosis, 
the failure of normal oxidative processes on the part of the liver constitutes 
a most serious phase in the altered metabolism of the body. The organ 
may be enlarged temporarily or permanently from various causes. One of 
the most common is congestion induced by cardiac insufficiency. Active 
hyperemia may be induced by indigestion. In rickets and syphilis and 
in various diseases of the spleen and lymph-glands the liver is persistently 
enlarged. 
Fatty change in the liver in early life is often found at autopsy. It 
is found in greater or less degree in practically all infants and young 
children who die from prolonged and exhausting diseases. 
Presumably the infiltration is of a temporary nature, and, so far 
as is known, has no symptomatology of its own. In many cases that 
recover the liver must have undergone not only fatty infiltration, but a 
considerable degree of fatty degeneration. It is rare not to find more or 
less fatty change at a postmortem examination of a child under one year 
of age. In some cases the involvement is so extensive that the entire 
organ is firm, smooth, and of a yellowish color. In other cases there 
are only localized evidences of the fatty process. Usually the organ is 
not enlarged. The condition is not to be diagnosed during life. If there 
is a derangement of function, this is not of such a nature as to make 
the actual hepatic conditions manifest. 
Acute Yellow Atrophy.—Fatal cases of this disease in children are 
reported at rare intervals. 
ABSCESS OF THE LIVER 
In the newborn abscess is the result of an infection usually acquired 
from the umbilical veins. Several cases in older children have been 
reported, in which the abscess was caused by the migration of round-worms 
into the hepatic duct. 
Abscess of the liver may result from any pyemic condition. Its rare 
occurrence demonstrates the hepatic powers of resistance against microbic 
invasion. 
Amoeba coli has been the cause of abscess in a considerable number 
of cases. 
Symptoms.—Enlargement of the organ, associated with the presence 
of marked tenderness, is usual. Pain is a very constant symptom, and 
may be referred to different points in the abdomen, not infrequently 
303 304 
THE PRACTICE OF PEDIATRICS 
being felt at the umbilicus, or localized between the right scapula and 
spine. Among the most prominent active manifestations are repeated 
chills, a widely ranging septic temperature, and vomiting. Occasionally 
there is diarrhea. 
Exploration should be performed, and if pus is located, aspiration 
and drainage should follow. Abscesses not operated upon are apt to 
perforate into the peritoneal or pleural cavity. Cases of perforation 
into the intestine have been followed by recovery. 
Cirrhosis of the liver belongs to the curiosities of pediatric practice- 
All the cases reported represent, roughly speaking, the observations of 
as many men. 
In the reported cases in which there has been a supposed etiologic 
factor, syphilis, alcohol, and the infectious diseases have been looked 
upon as the agencies causing the disease. 
Toxic substances of widely different character are apparently capa- 
ble of causing cirrhosis of the liver in the young. The possibility of 
cirrhotic changes occurring as the result of prolonged absorption of toxins 
from fermentative processes in the intestine must be considered as in 
certain instances of adult cirrhosis. 
Symptoms.—At first there is enlargement of the liver and the spleen. 
Persistent but not severe icterus and ascites supervene. The patient 
shows early evidences of malnutrition, and a cachexia that is strongly 
suggestive of the underlying condition. As the case progresses the liver 
becomes very much reduced in size, diarrhea becomes fairly constant, 
vomiting frequent, and dilatation of the superficial abdominal veins 
occurs. Bronchopneumonia is the usual terminal complication. 
Treatment.—The management is entirely symptomatic. Abdominal 
paracentesis may temporarily relieve the embarrassed respiration and the 
general discomfort occasioned by the large amount of fluid in the abdom- 
inal cavity. 
CIRRHOSIS OF THE LIVER 
BILIARY COLIC 
Older children have paroxysmal pain and exhibit persistent jaundice. 
Illustrative Case.—A girl eight years old, the child of a physician, had suffered from 
Kermanent jaundice of three years’ duration, with intermittent attacks of colic followed 
y an increase in the intensity of the jaundice. Operation revealed a large calculus in 
the common duct. 
ICTERUS (OBSTRUCTIVE JAUNDICE; CATARRHAL JAUNDICE) 
Jaundice of this type in children is usually associated with duodeni- 
tis, and is caused by a swelling of the lymphoid bodies in the mucous 
membrane of the common bile-duct at its terminal opening into the 
intestine. The jaundice is due probably to the same form of infection 
that caused the duodenitis. Cases often occur in groups of two or three 
in the same family. 
Illustrative Cases.—In November, 3 children and 2 adults—the mother and nurse— 
had pronounced jaundice with the usual manifestations. Six weeks before all these 
people had suffered from malaria. 
We have seen but one case in which jaundice was due to cholelithiasis. This ICTERUS (OBSTRUCTIVE JAUNDICE; CATARRHAL JAUNDICE) 
305 
patient, a girl six years of age, had distinct attacks of biliary colic, accompanied by 
passage of gall-stones and followed by intense jaundice. She was eventually operated 
upon and many stones were removed from the gall-bladder. 
Symptoms.—The onset is almost never marked by high temperature 
or evidence of severe gastric disturbance. Usually the first signs are loss 
of appetite, coated tongue, rise of a degree or two in temperature, and 
listlessness. The yellow discoloration of the conjunctiva and skin soon 
appears, and this, with the high-colored urine and slightly colored or 
grayish stools, makes the case complete. 
The liver is usually enlarged an inch or two below the ribs, and often 
is slightly tender. The spleen is also slightly enlarged. 
We have never known a fatal case, although such have been reported. 
Vomiting.—In a most severe case the vomiting continued for five 
days, neither food nor water being retained. Vomiting is present in most 
cases. The child vomits two to three times, or at intervals for a day or 
two. 
Treatment.—Diet.—The reason why gastric disorder is considered 
so prominent a symptom by many writers is possibly because of the 
gastric disturbance produced by the treatment. We are advised to 
place the patient on a milk diet and give calomel. We know of no treat- 
ment better calculated to produce vomiting and increase both the intes- 
tinal infection and the jaundice. The treatment which has been found 
most satisfactory is simply the use of very little food for twenty-four 
hours. Water is given as a drink, and later, well-salted chicken or mutton 
broth may be given with toast if the child asks for food. He should not 
be urged to eat. The following day broths, gruels, and orange juice, 
with stewed fruits or lemonade, may be given if wanted. 
Drugs.—The only medication used consists of rhubarb and soda. 
To a child five years of age 4 grains of pulverized rhubarb and 8 grains 
of bicarbonate of soda may be given from two to three times daily, together 
with considerable water. For a day or two sufficient medicine should be 
given to produce a free laxative effect, but not necessarily enough to 
purge the patient. Usually on the third day it is advisable to begin with 
tincture of nux vomica and dilute hydrochloric acid—from 2 to 4 drops 
of each, well diluted. When the stools are again normal, the usual diet 
may be resumed, milk not being used for a week afterward. Rhubarb 
and soda are best given as follows: 
1$. Pulveris rhei gr. xlviij 
Sodii bicarbonatis gr. xcvj 
Syrupi rhei aromatici §j 
Aquae q. s. ad. gij 
M. Sig.—Shake well. One teaspoonful two or three times daily after meals. 
Other measures to hasten the disappearance of the jaundice are daily 
irrigations of the bowel and the administration by mouth of phosphate 
of soda in water before meals, the dose being determined by the effect 
obtained. To most children the effervescent preparation is the more 
palatable. 
For a fortnight after the acute symptoms have abated a diet should 
be maintained that is relatively fat free. Eggs and top milk particularly 
should be excluded. XI. DISEASES OF THE RESPIRATORY TRACT 
The Nose and Throat 
ACUTE RHINITIS (CORYZA; SNUFFLES; COLD IN THE HEAD) 
Acute rhinitis is a very common ailment throughout childhood. 
Newborn babies, ‘‘runabouts,” and school children alike are sufferers. 
The so-called cold in the head is unquestionably an infection and may be 
transmitted from the diseased to the well. That a specific causative 
micro-organism has not been demonstrated in no way invalidates this 
statement. One repeatedly sees an acute rhinitis develop in one member 
of a family and pass through the entire household of perhaps six or eight 
persons, adults and children. Infants and young children should not 
come in contact with other persons suffering from such conditions. 
Symptoms.—The onset is usually sudden, and characterized by 
sneezing and difficulty in breathing through the nose. This may continue 
for a few hours or, in some cases, for a day or two. At the expiration of 
this time a mucous, watery nasal discharge appears. Infants are the 
greatest sufferers, owing to the fact that breathing, which has to be carried 
on largely through the mouth, is rendered difficult, and nursing, in conse- 
quence, is frequently interrupted. A degree or two of fever may exist 
at the commencement of the attack, but any elevation of temperature, 
as a rule, lasts only a few hours. Neglected cases frequently become 
infected with pyogenic bacteria (staphylococcus, pneumococcus, and 
streptococcus), in which event a troublesome purulent rhinitis results. 
In the majority of the neglected cases, and in some of those that are 
well treated, the rhinitis is the beginning of an infection of the mucous 
membrane, which involves successively the fauces, tonsils, larynx, and 
bronchi. Repeated attacks doubtless contribute to the production of 
adenoid growths in the nasopharyngeal vault. Otitis media is not an 
infrequent outcome, particularly if the child has adenoids. 
Differential Diagnosis.—Acute simple rhinitis is to be differentiated 
from specific rhinitis, which is one of the first manifestations of congenital 
syphilis. When due to syphilitic infection the condition is uninfluenced 
by the usual treatment. There is no tendency for it to descend and 
involve the mucous membrane of the bronchi. The hoarseness of con- 
genital syphilis is persistent and of gradual development. Furthermore, 
if the rhinitis is due to syphilis, other diagnostic signs are present or will 
soon appear. 
Measles almost invariably begins as an acute rhinitis. The accom- 
panying conjunctivitis, the hard, dry, hacking cough, and the character- 
istic rash soon make the diagnosis possible. In nasal diphtheria there is 
invariably a discharge from the nose which may be differentiated from 
that of simple rhinitis by the fact that the discharge in diphtheria is 
excoriating in character and is often tinged with blood. A diphtheric 
discharge may be limited entirely to one nostril or may be greater from 
one nostril than the other; while in acute simple rhinitis the amount 
306 ACUTE RHINITIS (CORYZA; SNUFFLES; COLD IN THE HEAD) 
307 
of the discharge is usually the same from both sides. Influenza begins 
with sneezing and nasal discharge, serous in character. In influenza, 
however, there is associated cough, fever, and more or less prostration. 
Duration.—The tendency of acute simple rhinitis in a strong child 
is toward recovery in five or six days. When the surroundings are un- 
favorable, or the child is delicate or rachitic, active treatment will be 
required to bring about a prompt recovery. 
Complications.—Simple rhinitis is very often the beginning of an 
infection which may reach the middle ear and produce purulent otitis 
or mastoid disease. Cervical adenitis is not an infrequent outcome. 
Retropharyngeal adenitis and retropharyngeal abscess, acute laryngi- 
tis, bronchitis, and bronchopneumonia may all result from acute rhinitis. 
Early treatment and care of the primary condition are, therefore, exceed- 
ingly important. 
Treatment.—The first step is the administration of 2 teaspoon- 
fuls of castor oil. During the initial stage of engorgement much may 
be accomplished for the very young by local medicaments. One of the 
best is menthol, \ grain, dissolved in 1 ounce of liquid petrolatum. Of this 
solution 3 drops should be instilled into each nostril every hour by means 
of a medicine-dropper. This treatment alone will relieve the patient 
of distressing obstruction and facilitate freer breathing. Older children 
may use a spray containing 1 grain of menthol to 1 ounce of liquid petro- 
latum at intervals of two or three hours. 
In case menthol and petrolatum are not at hand, melted white vaselin 
may be similarly employed. 
For internal use the following medication has served well. 
At least six doses should be given in the twenty-four hours. 
For a child three months of age: 
1$. Tincturse belladonnse gtt. vij 
Pulveris camphorse gr. iv 
Sacchari lactis, q. s. 
M. div. et ft. tabellse No. xxx. 
Sig.—One tablet every two hours. 
Six months of age: 
1$. Tincturse belladonnse gtt. x 
Pulveris camphorse gr. v 
Pulveris ipecacuanhse et opii gr. iv 
Sacchari lactis, q. s. 
M. div. et ft. tabellse No. xxx. 
Sig.—One every two hours in water. 
From one to two years of age: 
R. Tincturse belladonnse gtt. xv 
Pulveris camphorse gr. vj 
Pulveris ipecacuanhse et opii gr. x 
M. div. et ft. tabellse No. xxx. 
Sig.—One every two hours. 
From two to four years of age: 
Tincturse belladonnse gtt. xv 
Pulveris camphorse gr. vj 
Pulveris ipecacuanhse et opii gr. xv 
Sacchari lactis, q. s. 
M. div. et ft. tabellse No. xxx. 
Sig.—One every two hours. 308 
THE PRACTICE OF PEDIATRICS 
If for any reason the tablets cannot be prepared, powders will answer 
the purpose equally well. 
The above prescriptions are indicated for the second or catarrhal 
stage, in which we usually find the patient on beginning treatment. We 
must guard against the constipating effects of the camphor and the Dover’s 
powder. 
In the treatment of nasal disorders the forcible use of the syringe, 
or any form of nasal irrigation which requires force, should be condemned. 
Infection is easily carried into the eustachian tubes, and may give rise 
to very grave complications. A suppurative otitis is thus very easily 
produced. 
An enema of warm sweet oil or soapsuds should be administered 
if the bowels do not move once in twenty-four hours. In treating chil- 
dren of a markedly constipated habit the Dover’s powder may be omitted. 
Internal medication, if begun early and properly carried out, will not 
be needed for more than two or three days. 
During an attack of acute rhinitis the child should not be unneces- 
sarily exposed to cold, owing to the strong tendency of the inflammation 
to descend and involve the deeper portion of the respiratory tract. Not- 
withstanding the undoubted good effects of open-air treatment in certain 
forms of pneumonia much harm is often done to children with incipient 
colds affecting the upper air passages by injudicious exposure to open 
window drafts in inclement weather. Caution in this respect will insure 
the proper procedure in a given case. 
CHRONIC RHINITIS (NASAL CATARRH) 
Nasal discharge, more or less constant, is present in not a few in- 
dividuals throughout childhood. In the majority of those affected this 
discharge begins with the onset of cold weather and lasts until spring. 
The secretion may be composed of thin, watery mucus, or it may be 
mucopurulent in character. 
Etiology.—In order to treat this condition successfully the source 
of the discharge must be discovered. It may be due to several causes, 
which are here given in the order of their frequency: 
1. Adenoids in the nasopharyngeal vault. 
2. Hypertrophy of the turbinate bones, with septal deviations and 
hypertrophy of the mucous membranes. 
3. Infection due to pyogenic bacteria. When present, this may 
follow acute rhinitis, but is more often the sequel of one of the infectious 
diseases. The discharge may be distinctly purulent and is often very 
profuse. 
4. Infection due to the Klebs-Loffler bacillus. A great many cases 
of this type in children under eight years of age have been observed, 
in which a serous discharge from one or both nostrils has persisted for a 
considerable period of time—in one instance for an entire year. Ex- 
amination of the discharge shows the presence of the Klebs-Loffler bacillus. 
Such children are not ill, and are brought to a physician solely for treat- 
ment of the nasal discharge. The cases do not clear up under ordinary 
methods of treatment, but promptly respond when from 1500 to 2000 
units of diphtheria antitoxin is given. CHRONIC RHINITIS (NASAL CATARRH) 
309 
5. Hay-fever is characterized by a periodic discharge which may be 
said to be chronic in character, persisting over several weeks. 
6. Malnutrition. A thin, watery discharge, apparently due to relaxed 
mucous membranes, occurs in weak and poorly nourished children with 
no other abnormal condition to explain the trouble than the general weak- 
ness. 
7. Disease of the sinuses. Sinus infection of a mild type may cause 
persistent rhinitis without other symptoms, and these cavities should be 
examined in obscure cases. 
8. Foreign bodies. A foreign body in either nostril will produce 
a persistent discharge. When a child is brought to us with a history 
of a persistent serous or purulent discharge from one nostril, we invariably 
examine for a foreign body, and repeatedly have found this discharge 
explained by the presence of a pea, a bean, a piece of coal, or a button. 
Illustrative Case.—At the Out-patient Department of the Babies’ Hospital a child 
three years of age was brought for treatment of a persistent right-sided nasal discharge 
which had existed for seven months. Examination showed a foreign body well up in 
the nostril. This object was removed with considerable difficulty and proved to be a 
piece of cork. 
In these cases of chronic rhinitis the possibility of adenoids (see p. 322) 
should never be forgotten; for their existence cannot be excluded because 
a child is not a mouth-breather and does not snore. A chronic “cold in 
the head” almost invariably indicates the presence of adenoid vegetations 
in the nasopharyngeal vault. Examination may reveal that the naso- 
pharyngeal space is blocked by the growth, so that entrance with the 
finger is almost impossible. In other instances only a small, pulpy mass 
will be found, or a ridge of soft, friable growth at the upper portion of the 
vault, not large enough to produce signs of obstruction, but actively se- 
creting and manifestly the source of the discharge. Children who have 
anterior nasal defects, such as hypertrophies of bone or thickening of the 
membranes, usually have adenoids as well. In fact, adenoids play no small 
part in most of the catarrhal affections of the upper respiratory tract 
in children, and an examination of a child with a nasal discharge or a 
cough which is difficult to explain is never complete without an explora- 
tion of the nasopharyngeal vault. 
Treatment.—The treatment consists in correcting the condition 
which causes the discharge. If adenoids are present in a sufficient amount 
to cause trouble, they should be removed (p. 325). No other treatment 
is of any avail. For deformities and hypertrophies of the anterior nasal 
structure operative measures are also essential, but should be carried 
out by one skilled in rhinoplastic work. Purulent rhinitis, primary or 
following the infectious diseases, is advantageously treated by a spray 
composed of liquid petrolatum, 1 ounce, ichthyol ammonium sulphate, 2 
grains, the mixture being thoroughly shaken before using. This spray 
should be used every twro hours while the child is awake. Once or twice 
a day it may be well, if the secretion is profuse and purulent, to instil 
into the nostril about 20 minims of a 1 : 6 aqueous solution of hydrogen 
peroxid. If the Klebs-Loffler bacillus is present, antitoxin alone will con- 
trol the disease, and that very promptly. 
The anemic and poorly nourished patients, who show almost no ab- 310 
THE PRACTICE OF PEDIATRICS 
normality, but suffer more or less from a constant serous discharge, 
are benefited by constitutional measures only—a dry climate, plain, 
nourishing food, iron, cod-liver oil, massage, and salt baths. Suitable 
management is referred to in detail under The Treatment of the Sub- 
normal Child (p. 140). Applied to such children, local treatment, apart 
from cleanliness, is a loss of time and energy. 
Non-traumatic nasal hemorrhage in a child usually occurs from one 
of two sources—adenoid vegetations in the nasopharyngeal vault or 
an erosion or ulceration of the mucous membrane covering the free vas- 
cular area of the anterior portion of the nasal septum. 
Treatment.—Hemorrhage due to adenoid growth is usually readily 
controlled by keeping the child in an upright position, or by the application 
of cold to the back of the neck—preferably by a piece of ice wrapped in 
a table napkin or by an ice-bag. When the hemorrhage is due to an erosion 
of the septum and pressure of the finger on the outer side of the bleeding 
nostril is found ineffective, the nostril may be packed with cotton saturated 
with a 5 per cent, solution of antipyrin or a 1 : 2000 solution of adrenalin. 
For permanent relief, and to prevent a recurrence of the hemorrhage, 
adenoids should be removed and an excoriated or ulcerated septum 
cauterized with a 50 per cent, solution of silver nitrate. If the ulcer is 
first cleaned with plain water, ordinarily but one or two applications of 
the silver solution will be required. Spraying the affected side with a 1 
per cent, solution of ichthyol in liquid petrolatum will hasten the healing 
process. As the ichthyol is not soluble in the oil, the mixture should be 
well shaken before using. 
NASAL HEMORRHAGE 
PERSISTENT COUGH 
We have had occasion to examine and treat many children who were 
brought to us because of a “ cough ” which had not been controlled by 
the measures employed. The history is usually only that of a persistent 
cough. This may be irritating in character, keeping the child awake at 
night, or it may be paroxysmal, the attacks being more severe when 
the child is lying down. Many times the paroxysms are so severe, par- 
ticularly at night, that in the absence of chest signs, whooping cough is 
suspected. 
Types of Cough.—While we hear much of the cough of teething, 
the “stomach cough,” the “nervous cough,” and the “habit cough,” 
it has never been our lot to see a case in which the cough was not con- 
nected in some way with the respiratory tract. Thorough examination 
of these cases, perhaps repeated examinations, will be required before 
the site of the trouble is definitely located. Then it will invariably be 
found somewhere between the anterior nares and the diaphragm. The 
“stomach cough,” the “nervous cough,” or the “teething cough” fre- 
quently referred to by the older writers stood for the persistent cough 
which could not be accounted for by physical examination of the chest 
or by mere inspection of the throat. 
An adherent pleura and enlarged tonsils without adenoids are ac- PERSISTENT COUGH 
311 
countable for a very small number of these cases. An elongated uvula, 
to which these obscure coughs have also been attributed, is very rarely 
a cause. 
Adenoid Vegetations.—An immense majority of these obscure coughs 
in children are due to adenoid vegetations, with or without enlarged 
tonsils. A child with such a cough may have the typical adenoid face, 
mouth-breathing, and other signs referred to (see Adenoids, page 323), 
or these symptoms may be entirely absent. It is the latter type of case 
that is particularly puzzling and apt to be overlooked. On account 
of the absence of mouth-breathing and other symptoms of nasal obstruc- 
tion, the possibility of adenoid vegetations is often ignored. In these 
cases careful inquiry will usually elicit the history of frequent colds, or 
what is styled “catarrh” (as there is more or less serous discharge from 
the nose), or the statement that the child “takes cold in the head easily.” 
Digital examination of the nasopharyngeal vault will reveal a fringe of 
soft adenoid growth at the upper portion of the posterior pharyngeal wall, 
not large enough to produce obstruction, but actively secreting. This 
secretion, if not profuse, is partially evaporated in the nostrils, or if pro- 
fuse, is discharged from the nostrils or passes backward over the posterior 
pharyngeal wall, thus provoking cough, when the child is up and about. 
When the child rests on his back, the secretion naturally flows over the 
posterior pharyngeal wall, and induces cough. Time and again one may 
relieve the most obstinate cough by cureting and removing this sponge- 
like tissue. 
Illustrative Case.—In the case of one patient, a boy two years of age, who had 
been coughing hard for ten days with paroxysms and vomiting, a diagnosis of pertussis 
had been made both by a member of the family who had seen many cases of whooping- 
cough, and also by the writer. Adenoids were found to be present in a slight degree. 
Their removal was accomplished, with the idea of making the coughing attacks less 
severe, when, greatly to our surprise, the coughing ceased at once, not a paroxysm 
occurring after the growth was removed. The cough was due to the adenoid vege- 
tations and not to pertussis. 
Adherent 'pleura, non-tuberculous, as previously mentioned, is occa- 
sionally a cause of persistent cough. Autopsies upon children who have 
died with non-respiratory diseases often show these pleuritic adhesions, 
which are not suspected during life. 
Illustrative Case.—A girl twelve years of age was brought because of a persist- 
ent cough. The child was otherwise well and gaining in weight. She had been 
treated with expectorants, cod-liver oil, and the usual other medication, without avail. 
The cough remained unchanged and was influenced only by opiates. A very careful 
physical examination revealed friction rales, covering an area the size of a half-dollar, 
at the base of the right lung, adjacent to the spine. They were heard only on forced 
inspiration and had been overlooked in the previous examination. The case had been 
diagnosed as one of “nervous cough.” 
Tracheal Cough.—Tracheitis will produce a severe and intractable 
cough, with no signs in the chest. These cases frequently follow attacks 
of true influenza, or the cough may be present during the active period 
of the disease. If the child is old enough, he will aid us by referring to 
the sense of discomfort and tightness which exists over the upper portion 
of the chest. Sometimes the sensation will be described as a burning 
which is located directly over the trachea. 312 
THE PRACTICE OF PEDIATRICS 
Enlarged Mediastinal Glands.—Children with enlarged tracheobronchial 
lymph-glands are particularly subject to persistent cough which frequently 
assumes a spasmodic, even sneezing type strongly suggestive of pertussis. 
At times the adenitis is tuberculous, but not infrequently it is the result 
of prolonged bronchitis or bronchopneumonia of the influenzal or strep- 
tococcic type, one of the characteristic late results of such infection being 
considerable peribronchial thickening. 
In identifying enlargement of glands in the midchest region prolonged 
slight elevation in temperature, percussion dulness, and a positive D’Espine 
sign are of significance, but the most reliable aid is afforded by the x-ray 
combined with the intradermal tuberculin test. 
Irrespective of the exact nature of the infection the treatment most 
effective is the placing of the patient in a climate where sunshine pre- 
dominates and colds are infrequent. 
Tuberculosis.-— Incipient tuberculous infiltration in any portion of 
the lungs or pleura may produce persistent cough. Thorough physical 
examinations and careful observation of all the cases, with the intradermal 
test, will make a diagnosis possible. 
Pertussis without the whoop or vomiting may cause a persistent 
cough, spasmodic in character. It runs its course and subsides in from 
four to eight weeks. A diagnosis is possible only when there is a history 
of exposure to the disease, or when another member of the family has an 
unquestionable attack. 
Foreign Body Cough.—This type of cough has been given the importance 
which is its due by the notable work of Chevalier Jackson and his followers, 
which has demonstrated beyond argument that in all cases of unexplained 
cough the presence of a foreign body in the air passages must be considered 
until the existing facts are shown by x-ray examination. The facts are 
not always apparent to the untrained interpreter even with the aid of the 
x-ray, but the whereabouts not only of opaque but of transparent objects, 
such as peanut kernels and seeds, may be detected by the expert. 
Upon the removal of the foreign body by the aid of the bronchoscope 
the focus of inflammation in the lung (often in spite of previous long dura- 
tion) usually undergoes spontaneous resolution and the cough ceases. 
Many children have been wrongly called tuberculous for lack of dis- 
cernment by their physicians in cases of respiratory obstruction from 
foreign bodies. (See Foreign Bodies in the Air-passages, p. 818.) 
The treatment of the various conditions producing cough is referred 
to under the respective headings. 
In order to examine the throat of a young child quickly and thor- 
oughly it is necessary that he be held in a proper position in front of 
and at the right side of the attendant, supported by her left arm beneath 
the buttocks. Her right arm, which is thus left free, is passed around 
the child, binding his arms to his sides. The child’s head rests against the 
shoulder of the attendant. The physician places his left hand on the child’s 
head to steady it, and with the tongue-depressor or teaspoon in his right 
hand, with the child in perfect control, presses the tongue downward 
so that it will not obscure the field of vision. In handling an older and 
Throat Examination SIMPLE PHARYNGITIS 
313 
stronger child, it is best to bind the arms to the sides with a large towel 
or small sheet. The most satisfactory view can be obtained by daylight 
before a window. If the examination is made in the evening, a lamp 
or taper held by a third person, a little above and behind the attendant’s 
right shoulder, will furnish satisfactory illumination. The head-mirror 
should be used for children who are too ill to be taken out of bed, the 
reflection from a lighted lamp or candle being sufficient. The various 
electric devices which may be carried in the pocket are very useful. 
FAUCITIS 
By the term “faucitis” we understand an inflammation of that por- 
tion of the mucous membrane of the buccal cavity situated posteriorly 
to the soft palate and the anterior pillars of the fauces, including both 
the anterior and posterior pillars, the tonsils, and the pharyngeal vault. 
The inflammatory process is superficial, involving the mucous membrane 
only, so that the tonsils are involved only to the extent of the mucosa. 
Faucitis is always present in scarlet fever, usually to a marked degree. 
In measles it is also present, but less intense in its manifestations. Its 
most frequent appearance is in connection with a summer cold. Every 
year, in late May and June, we are called upon to treat many such cases. 
The symptoms always comprise cough, which is dry and ineffective, and 
a slight fever—from 100° to 101° F. The child complains of sore throat, 
and has some discomfort on swallowing. Upon inspection an intense 
inflammation will be noticed, involving the entire visible mucous mem- 
brane. In many cases the inflammation extends downward and involves 
the larynx, which fact will be indicated by the hoarse, croupy character 
of the cough. The condition is usually the result of a mixed infection, 
with the streptococcus predominant. The entire illness is ordinarily 
of three or four days’ duration. 
Treatment.—The condition is best relieved by a purgative of rhu- 
barb and soda—3 grains of powdered rhubarb and 3 grains of soda for 
a child from two to five years of age. To a child under two years of age 
1 to 3 grains of rhubarb and 1 to 2 grains of bicarbonate of soda may be 
given. This, in the case of a child from one to three years of age, is fol- 
lowed by a tablet or powder of tartar emetic, 1/90 grain, powdered ipecac, 
1/60 grain, and chlorate of potash, 1 grain, at two-hour intervals. Older 
children, three years and over, receive 2 to 3 grains of chlorate of potash, 
1/90 grain of tartar emetic, and 1/40 grain of ipecac at two-hour intervals 
—six doses in twenty-four hours. 
SIMPLE PHARYNGITIS 
Inflammation limited to the posterior pharyngeal wall is of rather 
infrequent occurrence in young children. When thus affected, the parts 
present a reddened, granular appearance. In the cases which have come 
under our observation such a condition has always been associated with 
digestive disturbances. The tongue is usually coated and the breath 
foul. A dry cough and frequent attempts at clearing the throat are the 
usual symptoms. The temperature is rarely above 101° F. The condi- 
tion is to be distinguished from the pharyngitis which occurs as a result 314 
THE PRACTICE OF PEDIATRICS 
of microbic infection, in that only the posterior wall is involved. The 
tonsils and pillars of the fauces and the soft palate present a normal ap- 
pearance. 
Treatment.—The treatment is to reduce the diet for a few days to 
cereal gruels—barley, rice, or wheat—and chicken or mutton broth. 
Calomel, 1/10 grain, with 1 grain of rhubarb, given after feedings, three 
times a day for three days, will often promptly relieve the condition. 
THE TONSILS 
Anatomically, the lymphoid structures in the pharynx, termed “ton- 
sils,” consist of several groups. Of these, the faucial and pharyngeal 
structures are clinically of most importance. 
The faucial tonsils are situated one on each side of the oropharynx, 
between the anterior and posterior pillars of the fauces. The tonsil is 
roughly ovoid, and in early life about 2 cm. thick, the longest measure- 
ment being the vertical diameter. The inner surface presents many 
depressions or crypts. These are most numerous in the upper portion. 
Above the organ there is a larger depression called the supratonsillar 
fossa. This frequently serves as a pocket for the development of sup- 
purative inflammation. On its outer surface the tonsil is covered by 
a fibrous capsule, from which the reticulum of connective tissue sup- 
porting the lymphoid structure is derived. In close relation to this sur- 
face is the ascending palatine artery. The internal and external carotid 
arteries are normally about 2 cm. distant, but as a result of inflammation 
and hypertrophy in the tonsils, these vessels may be less remote. Branches 
to the organs are derived chiefly from the ascending pharyngeal and facial 
arteries, but also from the lingual and descending palatine. Hemorrhage 
following operations arises principally from the ascending palatine, the 
ascending pharyngeal, and tonsillar branches of the facial. Operative 
wounds of the carotids are very rare. 
The pharyngeal tonsil is a single structure, occupying the posterior- 
pharyngeal wall. According to Piersol, without being markedly hyper- 
trophied, it may encroach upon the nasopharyngeal space. 
The tubal tonsils and the lingual tonsils are developed respectively 
at the eustachian orifices and over the posterior third of the tongue. 
Scattered collections of the same tissue unite with the larger masses 
described, and form an irregular guardian-ring encircling the upper part 
of the pharynx. 
ACUTE FOLLICULAR TONSILLITIS 
Tonsillitis consists in an inflammation of the mucous membrane 
and glandular structure of the tonsil. 
Age.—No age appears to be exempt, the condition at times develop- 
ing in infants three or four weeks old. The great majority of the cases, 
however, occur between the second and twelfth years. 
Etiology.—Tonsillitis is due to a mixed infection, usually with the 
streptococcus predominating. The disease is infectious, 
and frequently occurs in epidemics. ACUTE FOLLICULAR TONSILLITIS 
315 
Predisposition.—One attack prediposes to another by preparing a 
suitable culture-field in the crypts. Children in whom lymphatism is 
prominent, and whose glandular structure possesses a poor resistance, are 
the most susceptible. 
Pathology.—The tonsils undergo considerable enlargement, and the 
crypts become filled with exudate consisting of epithelial detritus, mucus, 
pus, and bacteria. Occasionally the exudate covers the surface of the 
organ in the form of a pseudomembrane similar in appearance to that 
occurring in diphtheria. The pathogenic bacteria most frequently present 
are the streptococcus, staphylococcus, and pneumococcus. Of these, the 
streptococcus is so frequently a cause of the inflammation that in many 
epidemics the term “tonsillitis” has been superseded by the convenient 
designation, “streptococcus sore throat.” When the cellular infiltration 
in the depths of the tonsil becomes extreme, suppuration and abscess- 
formation, combined with severe edema of the peritonsillar tissue, is not 
uncommon. If the discharge of such a collection of pus is not spontaneous 
or else obtained by early incision, complete destruction of the parenchyma 
and the formation of a retropharyngeal abscess may result. 
Symptoms.—The onset of tonsillitis is usually sudden and may be 
attended by a chill. In a few of our cases an attack has been ushered 
in by convulsions. However, the usual mode of onset is with fever— 
101° to 103° F.—headache, loss of appetite, and muscular soreness. Young 
children may show difficulty in swallowung, and older children may com- 
plain of pain in the throat. Not every case of tonsillitis, however, is char- 
acterized by the existence of such pain. Inspection shows that the tonsils 
are swollen and reddened and perhaps covered with scattered, light- 
colored, cheesy deposits. In some instances the local signs consist only 
of the swelling and redness; in other cases the cheesy deposit exists as an 
early manifestation. The spots of exudate may remain distinct and single, 
or they may coalesce, forming a pseudomembrane. During the attack 
the patient feels decidedly ill, and often gives evidence of considerable 
prostration. The temperature ranges from 103° to 105° F. Slight swelling 
may occur in the lymphatic glands at the angle of the jaw, but this is 
usually absent. In a comparatively small percentage of cases the asso- 
ciated adenitis is very pronounced. A great deal of tenderness of the glands, 
with a sore throat, is a suspicious sign, and should lead one to examine 
very carefully for diphtheria. 
Duration.—An uncomplicated attack of tonsillitis lasts from three 
to five days. If the temperature continues for a longer period than six 
days, the possibility of complications should be considered. 
Prognosis.—The prognosis is favorable. When uncomplicated, the 
disease is never fatal. 
Complications.—Cervical adenitis, otitis, peritonsillar abscess (quinsy), 
and retropharyngeal abscess are the most frequent secondary conditions. 
Infrequent complications are arthritis, endocarditis, pericarditis, and pye- 
mia. Acute nephritis is occasionally a sequel of tonsillitis and is apt 
to assume a hemorrhagic character. 
Differential Diagnosis.—Tonsillitis must be differentiated from tonsil- 
lar diphtheria. There are few harder problems, and, in fact, in many 
cases, early in the attack, the solution is impossible without a bacterio- 316 
THE PRACTICE OF PEDIATRICS 
logic examination. The following characteristics of the average case of 
each of the two diseases may aid us in differentiating: 
Tonsillitis.—Onset sudden; fever high at onset—102° to 105° F. 
Glands at the angle of the jaw swollen slightly, if at all. Exudation, 
follicular, appearing as small dots; may form membrane through coales- 
cence. 
Tonsillar Diphtheria.—Onset gradual; fever usually low at onset, 
100° to 102° F. Lymphatic glands at the angle of the jaw considerably 
swollen. Membrane present on the tonsil appearing in thin, grayish 
layers which gradually become thicker and more extensive. 
Mixed Infection.—A case of mixed infection may at first present the 
picture of typical tonsillitis. The temperature may vary from 103° 
to 105° F. Pain upon swallowing, prostration, and loss of appetite may 
exist together with a follicular exudation. Such a case may remain 
stationary for twenty-four to forty-eight hours. The dots then coalesce, 
forming a firm membranous deposit, the lymph-nodes at the angle of 
the jaw enlarge; and, in short, both the clinical manifestations and the 
bacteriologic examination show that we have to deal with a case of diph- 
theria. 
These cases of diphtheria which are preceded by a clinical tonsillitis 
are probably the most dangerous. The primal condition is diagnosed 
as tonsillitis, and for several days is considered to be only a tonsillitis 
in spite of the membranous deposit which later forms. This delay in 
making the diagnosis gives abundant opportunity for the exposure of 
other children, and postpones the use of antitoxin, rendering the remedy, 
when finally given, of little or no avail. The only safe rule is to consider 
as diphtheric every case in which there is a pseudomembrane on the 
tonsils, and to treat such a case with antitoxin without waiting for a 
bacteriologic examination. Furthermore, when there are other children 
in the family, one should invariably isolate every case of simple tonsillitis. 
Treatment.—Local treatment of the diseased parts in tonsillitis by 
spraying, swabbing, and painting has been of very little service in our 
hands, particularly in dealing with children under four years of age. 
When the patient is held by force for such treatment, thoroughness is 
impossible, and little or nothing is accomplished. For tractable children 
and those old enough to understand what is being done, gargles, sprays, 
and irrigations are useful in so far as they relieve pain and cleanse the 
diseased parts. A useful gargle is the following: 
I). Sodii salicylatis, 
Sodii biboratis, 
Sodii bicarbonatis aa gr. xlv 
Essentise menthse piperitse 5j 
Aquae q. s. ad. 3ij 
M. Sig.—One teaspoonful in one-half glass of water at 115° F. Gargle entire 
quantity every hour. 
A useful spray is the following: 
1$. Acidi borici gr. lx 
Aquae menthae piperitae 3 viij 
M. Sig.—Spray throat every two hours. 
In severe tonsillitis associated with much swelling and consequent 
tension, the pain upon swallowing is often excruciating. Irrigation of ACUTE FOLLICULAR TONSILLITIS 
317 
the throat is indicated not only for purposes of cleanliness, but because 
of the relief from pain which it affords. 
The technic recommended is described on page 321. The child with 
simple tonsillitis may receive the irrigation sitting erect. If found accept- 
able this may be repeated in four to six hours. 
It is advisable to begin the general treatment with a laxative. One 
grain of calomel, in divided doses of grain every fifteen minutes, answers 
well. The food should be reduced. For a bottle-fed patient one-half the 
quantity of the usual milk mixture should be given, diluted with an 
equal quantity of water. The fever, if high, may be readily controlled 
by cool sponging. 
The only drug which has appeared to possess any signal value for 
internal use in tonsillitis is chlorate of potash given in the dosage of 1 
Fig. 59.—Cold compress in position. 
grain at two-hour intervals for a child one year of age; 2 grains at two- 
hour intervals for a child two years of age—16 grains in twenty-four 
hours; 3 grains at the same interval for a child three years of age—24 
grains in twenty-four hours. We rarely give more than 3 grains at two- 
hour intervals at any age, although we have never been able to associate 
the action of the drug with kidney complications in any of hundreds of 
cases. This drug is usually given in solution with simple elixir and water 
or syrup of raspberry and water. 
Children who have repeated attacks of tonsillitis should have the 
tonsils enucleated regardless of their size, as diseased tonsils are portals 
of infection and a source of ever-present danger. 
Cold compresses (Fig. 59) applied to the throat are of aid to older 
children, who can appreciate the necessity of this measure. This form 318 
THE PRACTICE OF PEDIATRICS 
of treatment is described in detail under the management of acute catarrhal 
laryngitis. (See p. 333.) 
PERITONSILLAR ABSCESS (QUINSY) 
The seat of a peritonsillar abscess is in the cellular tissue about the 
tonsil, and the condition is due to an invasion of the parts by patho- 
genic bacteria, among which the streptococcus is most frequently present. 
The source of the infecting agent is almost invariably a tonsil more or less 
diseased. The abscess may form above, in front of, or behind the tonsil. 
Quinsy is usually preceded by recognizable tonsillitis. In none of our 
cases has the abscess followed diphtheria, scarlet fever, or measles. 
Symptoms.—The child has tonsillitis with the usual symptoms, and, in 
addition, greatly increased swelling of the throat and pain upon swallow- 
ing. He complains of pain in the muscles of the neck on the affected side, 
and holds the head toward that side. A fairly early symptom is inability 
to open the mouth to the usual extent. In the average case inspection 
reveals a reddened, edematous swelling, slightly above and in front of 
the tonsil, causing a forward displacement of the uvula. Exceptionally, 
when the swelling develops posteriorly, the tonsil is displaced forward 
and appears unduly prominent. A case of this type is very apt to be over- 
looked unless a digital examination is carefully made, when a soft, fluctu- 
ating swelling will readily be felt behind the tonsil. Speech is interfered 
with, and the act of swallowing is carried out with great discomfort. 
Young patients will go for several days with little or no nourishment 
because of the pain occasioned by the taking of food. 
Treatment.—The treatment is incision. This step, however, should 
not, as a rule, be taken until the abscess is fully developed. If the in- 
cision is made too early, it not infrequently becomes closed and requires 
reopening. This closure sometimes occurs even after a timely opera- 
tion, because when too small an incision is made, the contraction of the 
abscess wall necessarily following the free discharge of pus and blood 
effectually closes the opening. 
In exceptional cases the development of dyspnea may be rapid, and 
in such instances prompt incision over the most prominent part of the 
presenting swelling must be made even though the actual location of 
pus is not demonstrated. If the scalpel penetrates to sufficient depth 
and the incision is enlarged with an artery clamp relief afforded will justify 
this more radical course, whereas delay might necessitate tracheotomy. 
For operation the patient should be wrapped in a large towel or sheet 
with the arms securely bound to the sides. He should sit in an upright 
position on the lap of the attendant, against whose right shoulder his 
head rests. The left arm of the attendant is passed around the patient, 
holding him firmly, while the right hand grasps his forehead. A Denhard 
gag of the O’Dwyer set may be used to hold the mouth open. Either 
by the use of reflected light from a head-mirror, or with the patient facing 
a window, the operator, using a guarded bistoury, makes a free incision 
in the abscess from above downward. The escape of a considerable amount 
of blood usually follows the withdrawal of the knife. Frequently more 
blood than pus is discharged. This is particularly apt to be the case if Vincent’s angina 
319 
the abscess is opened early. The use of light ether anesthesia is at times 
desirable, in which case the child’s head must be kept low and turned 
to one side to prevent aspiration of the liberated pus, and consequent 
asphyxia. 
It is interesting to note that the cases which open spontaneously 
rarely heal spontaneously. After a free incision it is advisable during 
daily visits immediately after the operation to prevent a closure of the 
wound by passing into it a director, moving this up and down to break 
up any beginning granulations. With free, uninterrupted drainage the 
patient is usually well in from three to five days. 
With the exception of a saline laxative, which should be given early 
in the attack, internal medication is valueless. Two drams of Rochelle 
salts or 6 ounces of a solution of citrate of magnesia may be ordered. 
Other treatment is directed to the comfort of the patient. An ice-bag 
applied externally before operation may be acceptable. Our greatest 
means of relief, however, is afforded by the use of the hot saline irriga- 
tion, and the hot gargle where practicable. But few children can gargle 
well, however, so that ordinarily this measure is best dispensed with. 
With the few cases where it is practicable, the following prescription and 
method has been of service: 
1$. Sodii bicarbonatis gr. xlv 
Essen tise menthse piperitae 3j 
Aquae q. s. ad. §ij 
M. Sig.—Add 1 teaspoonful to 6 ounces of water at 120° F. and gargle entire 
quantity every half-hour. 
The pain occasioned by gargling is another objection to its practice 
by children. The more effectual means of relieving pain, which causes 
no effort nor distress whatever, and gives astonishing relief, is a saline 
irrigation prepared and given as described on page 321. 
The irrigation may be repeated every hour and may be used as well 
after as before operation. When once the child experiences the relief 
afforded, there will be no trouble in repeating the irrigation. 
In Vincent’s angina there is an ulceration of the tonsil of varying 
size which may involve the whole tonsil or a very small portion. The 
shape of the ulcer is irregular with overhanging edges in advanced cases, 
in appearance not unlike a syphilitic lesion. The ulcer is of varying 
depth, usually not more than \ inch at the deepest part. The sloughing 
base gives the appearance of a membranous deposit. 
In mild cases in which the ulcerative process is slight the lesions may 
present only the appearance of grayish cobweb-like patches. 
Etiology.—Vincent’s angina is an infection in which two forms of 
parasites may be isolated, one a fusiform bacillus and the other a spiril- 
lum. They are always associated. These are also found in many cases of 
ulcerative stomatitis. 
The bacillus is a slender rod measuring from 6 to 12 n long, pointed 
at each end, Gram negative, and is not motile. The spirillum generally 
has from three to ten convolutions, is actively motile, and Gram negative. 
VINCENT'S ANGINA 320 
THE PRACTICE OF PEDIATRICS 
The organisms sometimes appear in a mixed infection with diphtheria. 
They may be cultivated anaerobically on ascitic agar at 37.5° C.1 
Symptoms.—The symptoms are not at all severe, usually a slight 
rise in temperature, 100° to 102° F., with perhaps moderate swelling of 
the lymph-nodes on the affected side. There is often an accompanying 
stomatitis which may be the trouble for which the physician is consulted. 
That there is an involvement of the tonsil is first discovered during the 
examination of the patient. Very severe and fatal cases have been re- 
ported, but these are surely very unusual. 
Diagnosis.—The case may resemble diphtheria sufficiently to require 
that a culture be made. A differential diagnosis is usually readily made 
by a microscopic examination of a smear from the ulcer. 
Treatment.—The medical treatment is the same as for tonsillitis. 
If there is adenitis, a cold compress (p. 333) should be applied. Locally, 
tincture of iodin, peroxid of hydrogen, or a weak watery solution of sal- 
varsan applied twice daily to the ulcer appears to shorten the duration 
of the disease. 
SEPTIC SORE THROAT (MILK BORNE)2 
Epidemic sore throat due to an infection conveyed by milk has been 
of frequent occurrence in England for a number of years. 
Since the Boston epidemic in 1911, visitations of the disease have 
been reported from various sections of this country. Doubtless out- 
breaks had previously occurred, but had not been recognized. In a recent 
epidemic of 40 cases there was a mortality of 15 per cent. 
Age.—All ages are susceptible, the greatest number of cases occur 
among the young. 
Etiology.—In the Boston epidemic of 1911 it was first conclusively 
demonstrated in this country that septic sore throat is a distinct clinical 
entity due to the streptococcus conveyed in a polluted milk supply. 
During this time, and at subsequent outbreaks, an examination of the 
milk source led to the discovery of an epidemic of mastitis existing among 
the cows supplying the infected community, pus-cells being found on 
several occasions in the milk. That the dairyman acting as a human 
carrier is also a factor in infecting the milk has been proved bj" the exist- 
ence of a number of cases of sore throat among dairy employees, one of 
whom (in an epidemic) supplied an abundant growth of almost pure 
streptococci. 
Pathology.—A general redness may be diffused over the pharynx, 
tonsils and soft palate, simulating the aspect of a scarlet fever throat. 
Small isolated patches of exudation in the tonsillar crypts may make the 
condition resemble an acute follicular tonsillitis. Later an extensive pseu- 
domembranous exudate may strongly suggest diphtheria. Both tonsils 
may be involved simultaneously, but more frequently one is infected 
before the other. The cervical lymph-nodes are always involved to some 
extent and occasionally very much swollen, undergoing suppuration in 
the severe cases. The extension of the inflammation to the deeper tissues 
about the neck often leads to diffuse cellulitis of that region. 
1 Tunnicliff, Jour, of Infec. Dis., 3, 1906. 
2 Herman Biggs, New York Medical Record, 1915. SEPTIC SORE THROAT (MILK BORNE) 
321 
Symptoms .—The onset of the septic sore throat is fairly uniform in 
its manifestations, being usually sudden and attended by a chill. Nausea 
is also a frequent accompaniment of the early stages. The temperature 
rises rapidly to 103° or 105° F., and in the more toxic cases there is general 
muscular pain and soreness and severe headache. A marked degree of 
prostration is present in the severe cases. The first period of the disease 
lasts from three to five days. Rapid recovery may follow or complica- 
tions which may be numerous and dangerous may ensue and prolong 
the duration indefinitely. 
Complications.—Cervical adenitis with possible suppuration, and 
otitis media are the most frequent secondary conditions in the young. 
Peritonsillar abscess, nephritis, polyarthritis, pneumonia, and peritonitis 
are occasionally seen, especially in those more advanced in years. 
Prognosis.—The prognosis is better in children and young adults 
than in those who are older, due to the fact that the young enjoy a com- 
parative freedom from the complications. The mortality in recent epi- 
demics according to the literature has varied from 2 to 5 per cent. 
Prophylaxis.—Pasteurization of all milk used for drinking purposes 
will prevent the disease. Dairy employees should be under careful medical 
supervision. 
Treatment.—The treatment suggested for tonsillitis should be car- 
ried out, together with throat irrigation and supportive measures. 
Irrigation of the Throat 
Indications.—In cases of peritonsillar abscess, retropharyngeal abscess 
after operation, or sloughing ulcerative processes in the throat, such 
as we see in diphtheria rarely, but with comparative frequency in scarlet 
fever, irrigation of the throat with hot normal salt solution is of distinct 
therapeutic value. The relief to the pain, particularly in quinsy before 
operation, is sufficient to warrant this treatment. Those who have thus 
treated the fetid, sloughing throat of scarlet fever, for example, need no 
argument as to the possible advantages. Gargling is a measure of very 
limited usefulness even for those children who do it well, for the reason 
that the solution employed scarcely comes in contact with the post- 
pharyngeal wall and the lateral faucial structures. For a great majority 
of older children, and all young children, such a method is practically 
useless so far as the cleansing of the deeper faucial structures is concerned. 
Cervical adenitis, acute, suppurative, or chronic, is usually the direct 
result of throat infection. Acute suppurative otitis is almost always 
due to throat infection. An important means of preventing these 
conditions, with their distressing consequences, is an effective throat 
toilet. Often in scarlet fever not a small part of the systemic infection 
after the third or fourth day is through the throat. The irrigation should 
be done two or three times a day as follows: 
Procedure.—The child is wrapped in a sheet, which is securely pinned, 
binding his arms to his sides. He rests on his right side, without a pillow. 
Directly under his mouth is a pus-basin to catch the outflow. A new 
fountain syringe, containing a hot salt solution, 120° F., is suspended 
about 3 feet above the child’s body. The largest size of the hard-rub- 
ber rectal tip is fastened to the pipe and the tip is placed between the 322 
THE PRACTICE OF PEDIATRICS 
child’s teeth. The current, interrupted every few seconds, should be 
forcible enough to increase its efficacy as a cleansing agent, the volume 
of fluid being so small that no inspiration of the water occurs. 
The first irrigations will arouse more or less rebellion on the part 
of the patient, and but \ pint of the solution need be used. With 
older children no trouble will be experienced after the relief afforded by 
the first irrigation is appreciated. In treating refractory young children, 
from two to four years of age, the assurance that there will be no pain 
and a promise of reward, will reduce the struggling to a minimum. It 
is not to be expected that the child will not cough; in fact, a moderate 
amount of coughing is desirable, as it dislodges the pus and sloughing 
tissue, allowing the solution to cleanse the parts more effectually. 
ADENOIDS 
The importance of adenoid growths as a cause of nasal obstruction 
has been appreciated only during the past thirty years. The vegeta- 
tions were first described by Dr. Wilhelm Meyer, of Copenhagen, in 18G8. 
Etiology.—In proportion to the population, the growths are as fre- 
quent among the wealthy and well-to-do as among the poorer classes. 
In fact, if the throats of all children were carefully examined with the 
finger, adenoid vegetations in the nasopharyngeal vault would be found 
in 95 per cent, of the cases. This, however, does not mean that 95 per 
cent, of children should have the adenoids removed, as in some instances 
the growth is very small and fairly innocent. 
We find adenoids not only in the delicate and ailing but also in the 
strong and well. Among hundreds of cases few are seen in which a part 
in the production of the growths can be attributed to lymphatism. 
The fact that adenoids are so generally prevalent among all classes 
and conditions of children points to common causative agencies: 
First: There is a tendency to overgrowth of lymphoid tissue in all 
children. 
Second: The location of the normal lymphoid tissue in the pharyn- 
geal vault subjects this tissue to the irritation of dust and sudden currents 
of cold air, resulting in the pathologic changes described. 
Third: The first and second conditions prepare the parts for the action 
of the third factor—infection. 
A curved probe tipped with sterilized cotton when passed into the 
adenoid tissue of any child, whether the amount of tissue is small or 
large, will afford a culture of the secretion, in which may be found the 
streptococcus, staphylococcus, pneumococcus, influenza bacillus, and 
many other pathogenic organisms. The local congestion caused by 
the presence of hordes of bacteria further increases the hypertrophy 
of the adenoid mass. 
Heredity is of no immediate consequence. If a new race of children 
could be born free from adenoid antecedents, they would just as surely 
develop the growths. 
Age.-—If a child passes the fourth year without adenoids, he will 
probably not acquire them later. Children are born with adenoids. 
At what period in utero they develop is not known. They may be seen 323 
ADENOIDS 
at birth in infants with cleft-palate. Adenoids were present, in quite con- 
siderable amount, in one infant wrho was one month premature. Signs 
of the growths do not ordinarily develop before the end of the first year. 
The great majority of cases come under observation between the eigh- 
teenth month and the fifth year. At times, however, it is necessary to 
operate upon infants in order to give relief from growths which almost 
completely block the nasopharyngeal vault. 
Pathology.—Hypertrophied adenoids exist as overgrowths of the lym- 
phoid tissue normally present in the nasopharynx. When the lymphoid 
elements alone are increased, the growths are soft and spongy, but when, 
as is frequently the case, there is marked development of fibrous tissue, 
they are firm and resistant. Increase in the connective tissue is primarily 
a perivascular process. Ultimately atrophy of the lymphoid tissue occurs, 
resulting in contracture of the adenoid mass. This change has been 
commonly attributed only to late childhood and early adult life. Such 
changes, however, are not uncommon in the very young. The spontaneous 
abatement of symptoms which is so frequently observed in young adults 
is more probably due to increase in the capacity of the epipharynx than 
to actual diminution in the size of the obstructing mass. 
Symptoms.—Some children have large, roomy nasopharyngeal vaults, 
while in others, on account of the high palatal arch and the prominence 
of the bodies of the vertebrse, this space is very small. In the latter cases 
a very small amount of adenoid tissue causes marked obstruction. The 
character and amount of the growth likewise determine the degree of 
inspiratory impairment and the severity of the related symptoms. 
Mouth-breathing.— In all cases showing a considerable growth, and 
in others in which a moderate growth exists in a srhall vault, mouth- 
breathing occurs because the natural respiratory tract is partially 
blocked. 
Rhinitis.—A more or less persistent rhinitis is also present, and this 
is inteimittent—now better, now worse. It is usually worse during 
the winter. During the summer in some cases it may disappear, only 
to return with the first cold weather. In other cases, with considerable 
adenoid growth, the nasal discharge never ceases, but is apt to be worse 
during the winter and spring months. The child cannot blow the nose, 
the voice and speech are defective, and the voice has a nasal quality. 
Certain letter sounds, such as “n” and “m” in the words “spring” and 
“climb,” are pronounced with difficulty. Because of the presence of the 
mechanical obstruction in the natural respiratory passage, the child 
breathes through the mouth not only when awake, but when asleep, 
consequently snores, and is noisy and restless, tossing about and as- 
suming all sorts of awkward positions during sleep. 
Adenoid Face.—These children all have the characteristic adenoid 
face. The term “mouth-breathing” does not describe the condition ap- 
parent in a pronounced case in an older child. The masseters become 
so relaxed that a habitual drop jaw results. The nostrils are usually 
small; the nasolabial folds are deepened. 
Adenoids Without Facial Deformity.—In a child with a roomy vault, 
adenoids in small or medium-sized masses may be present without pro- 
ducing facial deformity or obstructive symptoms. 324 
THE PRACTICE OF PEDIATRICS 
Apart from the characteristic appearance of the patients two symp- 
toms in particular suggest adenoids: 
First: Persistent rhinitis, indicated by habitual nasal discharge, which 
is ascribed to a chronic cold. 
Second: Cough, habitual, mild, or severe. It may be paroxysmal, 
often being confused with whooping-cough. (See p. 311.) The cough 
is always worse when the patient is lying down. Many of these cases 
pass unrecognized, adenoids being unsuspected because of the absence 
of obstructive signs, while the cough is attributed to the stomach, denti- 
tion, worms, nervousness, etc. 
Diagnosis.—The open mouth (see Fig. 60), the snoring at night, 
the stupid expression, the disturbed articulation, the persistent nasal 
Fig. 60.—Adenoid face. 
discharge, the deafness, the inability to blow the nose, the cough, and 
the chronicity of the symptoms all combine to make a picture afforded 
by no other condition. 
Method of Examination.—In children, after the fifth or sixth year, 
satisfactory examination by means of mirrors and illumination is oc- 
casionally possible. Occasionally a rhinologist will state that he is able 
to make all necessary examinations in much younger children by means 
of posterior rhinoscopy. We have never seen this actually demonstrated. 
Although such procedure is disagreeable to the patient, we prefer the 
finger examination in all cases. The child is securely held by an attend- 
ant, with the arms pinned to the sides. A mouth-gag or tongue depressor 
is then placed between the teeth, at right angles to the jaw, and held in HYPERTROPHIED AND PERMANENTLY DISEASED TONSILS 
325 
position by the left hand of the examiner, thus allowing the right finger 
to be free for the examination. 
Association with Enlarged Tonsils.—In the very young, adenoids 
usually exist independent of enlargement of the tonsils. The older the 
child, the more frequent is the involvement of the tonsils. Enlarged or 
diseased tonsils without adenoids are found only with the greatest rarity. 
Treatment other than by operation is highly ridiculous. 
HYPERTROPHIED AND PERMANENTLY DISEASED TONSILS 
Chronic enlargement of the tonsils is usually the result of repeated 
attacks of tonsillitis. Notwithstanding this fact, we have repeatedly 
seen enlarged tonsils which had never been clinically recognized as in- 
flamed. A tonsil is considered abnormally large when it extends beyond 
the pillars of the fauces. Enlarged tonsils not only produce mouth 
breathing, faulty articulation, and catarrh of the eustachian tube, but 
are doubtless a factor in the etiology of adenoids. 
Without being enlarged a tonsil may still exist as a menace to the 
owner. The very small tonsil which is badly diseased, and the small, 
deeply buried tonsil, largely covered by the pillars, are sources of great 
danger. In the crypts—whether the organ is large or small—are har- 
bored myriads of bacteria capable of producing repeated attacks of acute 
inflammation. The streptococcus, staphylococcus, colon bacillus, pneu- 
mococcus, the tubercle bacillus, and the Klebs-Loffler bacillus all abound. 
The crypts of diseased tonsils unquestionably may supply the infective 
agent in pericarditis, endocarditis, nephritis, anemia, and the various tox- 
emias classified under the broad term of “rheumatism.’’ Adenitis, both 
tuberculous and simple, is very rare in children who do not have foci of 
disease in their throats or teeth. 
The Necessity for Operative Interference in Cases of Diseased Ton- 
sils and Adenoids.—The simple indication to relieve mechanical ob- 
struction is by no means the sole criterion in advising operative measures. 
Diseased tonsils are responsible in no small degree for many of the com- 
plications attending other diseases. In influenza, diphtheria, scarlet 
fever, and measles the throat always shows active participation. A 
child free from adenoids and diseased tonsils presents greatly increased 
resistance to all these diseases; and complications in such children, par- 
ticularly as relates to the lymphatic glands and ears, are most unusual. 
During even a common cold, however, a mass of adenoids in the vault 
serves as a very efficient means of conveying infection to the middle ear. 
A small percentage of middle-ear cases develop mastoid disease; and 
a still smaller percentage, sinus thrombosis, with or without jugular 
involvement. In advising parents the physician should clearly portray 
the culture field which the child may be maintaining in the upper 
respiratory tract. 
Operation for Permanent Relief.—Various methods have been devised, 
all of which have their enthusiastic adherents, for the removal of enlarged 
tonsils and adenoids. For a discussion of these methods and their relative 
merits the reader is referred to works dealing with the surgery of the nose 
and throat. 326 
THE PRACTICE OF PEDIATRICS 
Certain facts relating to the conduct of this operation are worthy 
of emphasis from the standpoint of the pediatrist, of which the following 
may be mentioned: 
Operation is contraindicated, except in urgent cases, during the preva- 
lence of an epidemic of a respiratory disease and whenever the patient 
shows evidence of bronchitis or extreme throat congestion. 
The preparation for the operation should include abstinence from 
food for a period of at least six hours. 
The anesthesia should be as short and as light as possible to satisfy 
the requirements of the operator. The dangers of chloroform should 
always be kept in mind, and if it is used extra care on the part of the 
anesthetist should be exercised. The operation should be as rapid as 
is consistent with care and thoroughness and should in every instance 
secure complete enucleation of the tonsil irrespective of the method 
employed. All hemorrhage should be positively checked before the patient 
is removed from the table. 
Attendance of a nurse for at least six hours following the operation is 
essential. 
Convalescence in bed should be enforced for a period of three to 
four days. This insures, a minimum loss in weight and a more rapid 
recovery. f 
x-Ray Treatment of Tonsils and Adenoids.—Considerable literature 
has accumulated relating to the treatment of diseased tonsils and adenoids 
by means of x-ray. Witherbee, Remer, and others have made careful 
and painstaking observations of a large series of cases. It would appear 
that they have established a field of usefulness for this procedure. In 
cases in which there is gland hyperplasia with infected foci the x-ray has 
given satisfactory results in sterilizing the infected areas and shrinking 
the glandular tissue. 
In cases with marked connective tissue increase enucleation by sur- 
gical procedures will always remain the operative treatment. For cases 
of diseased infected tonsils in subjects with status lymphaticus, the 
bleeding diathesis, and in grave cardiac disease it is wise to give x-ray 
therapy a trial at the hands of those skilled in its use. 
Benefits of the Removal of the Tonsils and Adenoids.—The usual 
advantages claimed, those relating to mouth breathing, facial deformities, 
etc., are sufficiently well known to require no mention. Certain other 
benefits are perhaps not generally appreciated. 
Effect Upon Delicate Children.—In office work one has occasion to 
treat a large number of children who come because of defective growth, 
who are suffering from secondary anemia, or who are otherwise delicate. 
Remarkable improvement in these children follows the removal of diseased 
tonsils and adenoids. 
Influence Upon Acute Infections.—In grippe, scarlet fever, measles, 
diphtheria, and other acute infections a considerable source of danger 
lies in the associated pyogenic infections of the throat and nasopharynx, 
involving secondarily the ears and the adjacent structures, the glands, 
and through the blood-stream the kidneys and the heart. The presence 
of diseased tonsils and adenoids supplies an ideal culture field for pyo- 
genic bacteria and greatly enhances the child’s chances for dangerous ACUTE RETROPHARYNGEAL ABSCESS 
327 
complications. For example, it is comparatively rare to find otitis media 
in the absence of adenoids. 
Adenitis in any common form is a relatively unusual occurrence in a 
child who has had the adenoids and tonsils properly removed. 
Notwithstanding the large number of cases operated upon, one never 
hears regret expressed by the parents because of an operation properly 
performed. 
RETROPHARYNGEAL ADENITIS 
Retropharyngeal adenitis, as the name implies, is an inflammation 
of one or more of the glands situated posterior to the pharynx, between 
the pharyngeal and prevertebral muscles. 
Symptoms.—Pain and difficulty in swallowing are alwrays present. 
Other symptoms are fever—100° to 103° F.—and loss of appetite. The 
patient often holds the head toward the affected side, so as to relax the 
muscle tension caused by the tumor. If the adenitis is situated low 
down, disturbance of the voice (cracked voice) and respiratory obstruc- 
tion may result. 
Diagnosis.—In an acute case inspection of the throat will usually 
show a swelling at the right of the median line. If situated low down 
on the posterior pharyngeal wall, the adenitis may escape detection. 
Upon digital examination, instead of a smooth, flat surface, the finger 
encounters an elevated, rounded mass, which should not be mistaken 
for an unduly prominent cervical vertebra. 
Prognosis.—The glands, as a rule, suppurate, forming a retropharyn- 
geal abscess. This, however, does not invariably follow. 
Treatment.—The treatment must be both local and constitutional. 
Local treatment consists in cleanliness. The mouth should be washed 
with a saturated solution of boric acid after each feeding. Iodids, in 
treating adenitis in children, have been found of questionable service. 
More is accomplished by suitable diet and plenty of fresh air. 
ACUTE RETROPHARYNGEAL ABSCESS 
Acute retropharyngeal abscess is the result of an infection of one 
or more of the retropharyngeal lymph-nodes which form a chain on either 
side of the median line, posterior to the pharynx, and between the pharyn- 
geal and the prevertebral muscles. 
Location.—The abscess is most frequently situated to the right of 
the median line. It may be located high in the pharynx, so as to be 
plainly visible when the mouth is well opened, or it may be placed low, 
posterior to the larynx and upper trachea. Usually the abscess points 
anteriorly into the throat. It may point both externally and internally. 
In a large number of cases not one was seen that pointed externally only. 
Age of Patients.—Retropharyngeal abscess is pre-eminently a disease 
of infancy. The retropharyngeal lymph-nodes are said to disappear 
at the third year. We have not seen a case in a child over three years 
of age. 
Etiology.—Any active infection of the throat may cause the dis- 
ease. It may occur without our knowledge of any infectious process 
having been present. All throats continually harbor pathogenic bacteria, 328 
THE PRACTICE OF PEDIATRICS 
which may infect the retropharyngeal lymph-nodes. The disease is 
usually secondary to retropharyngeal adenitis due to infection from ad- 
jacent diseased structures. 
It has not been our observation that retropharyngeal abscess is a 
common sequel of diphtheria and the exanthemata. 
Symptoms.—Morse and others have emphasized the fact that these 
cases are usually overlooked—erroneously diagnosed. They are fre- 
quently diagnosed as cases of adenoids, and the removal operation is 
advised. 
It is a mistake to lay down too definite a symptomatology of a condi- 
tion that lends itself to widely varying symptoms. In describing the 
disease writers tell us that the patient holds the head in a characteristic 
position—backward and toward the affected side—that the breathing 
is noisy and stertorous in character, that there is difficulty in swallowing, 
that there are enlarged lymph-glands at the angle of the jaw, that there 
is usually a high fever, and that a bulging of one side of the posterior 
pharyngeal wall is usually visible. It is exceedingly rare to find this 
combination of symptoms. There are two diagnostic symptoms that are 
present in all cases—difficulty in swallowing and a persistently changed 
voice—a so-called cracked, high-pitched voice. These symptoms should 
lead one to suspect retropharyngeal adenitis or abscess, and the finger 
examination determines which condition is present. If adenitis exists, 
a rounded, hard tumor will be felt; if an abscess has formed, a soft, fluc- 
tuating tumor will be detected. This may be placed so high in the pharyn- 
geal vault as to be plainly seen through a wide-open mouth, or it may 
be low and out of sight in ordinary examination. There is a variation of 
at least 2 inches in the possible location of the abscess, and this fact 
accounts for the varying symptomatology. The difficulty in swallowing 
interferes greatly with nursing, and should always lead the physician not 
only to inspection but also to digital examination of the throat. 
Illustrative Cases.—Case 1.—A baby nine months of age had been under treatment 
in one of the outdoor clinics of New York City. A diagnosis of adenoids had been 
made and a day appointed for the operation. The mother, wishing to have the diag- 
nosis of adenoids confirmed, brought the child to the Babies’ Hospital. The symptoms 
of mouth-breathing, nasal voice, and slight difficulty in swallowing had been present 
for a couple of weeks. There was no characteristic position of the head, no rigidity of 
the neck, no superficial enlargement of the lymphatic glands. Inspection of the throat 
disclosed a bulging forward of the soft palate on the right side. A digital examination 
revealed a round, fluctuating mass, the size of a hickory-nut. It was found high on 
the posterior pharyngeal wall and almost entirely covered by the soft palate. No 
adenoids were present. 
Case 2.—A baby two years of age had been ill for a week with tonsillar diphtheria 
and was thought to be recovering, when suddenly the voice became hoarse and croupy, 
with gradually increasing dyspnea. Both expiratory and inspiratory obstruction 
were present, such as we expect in laryngeal diphtheria, and the attending physician, 
an excellent practitioner, naturally concluded that the diphtheric process had extended 
to the larynx. There was stiffness of the neck, but no nasal obstruction. (See above.) 
There was slight difficulty in swallowing. Inspection of the throat with a dim light 
revealed nothing but the enlarged tonsils. The writer was called to intubate, and 
finding the respiratory obstruction sufficient to require intubation, proceeded to make 
a digital examination, as is his custom before intubating. He was not a little sur- 
prised to find a soft, fluctuating mass low down in the pharyngeal wall, extending 
below and pressing against the glottis. The abscess was opened, with immediate relief 
of the obstruction. 
Case 3.—A baby, seven and a half months of age, was an inmate of the country 
branch of the New York Infant Asylum during the senior author’s service in that ACUTE RETROPHARYNGEAL ABSCESS 
329 
institution.1 His attention was first called to the child because of the difficulty in 
swallowing. There was very little obstruction, but the voice was harsh, hoarse, and 
croupy. About a month previous there had been a suppurating submaxillary adenitis. 
On examining the throat, a large abscess was visible on the right pharyngeal wall, 
extending downward as far as could be seen. This case afforded the author’s first 
experience with retropharyngeal abscess, and a Denhard gag of the O’Dwyer set, which 
should never be used in these cases, was introduced while the child was held in an 
upright position by the assistant. While the writer was feeling for the thinnest point 
of the sac for a suitable place for the incision, the child suddenly stopped breathing, and 
became limp and apparently lifeless. An intubation tube, the smallest of the O’Dwyer 
set, was quickly introduced without the gag. After several minutes of artificial respira- 
tion, the use of oxygen, and free hypodermic stimulation with brandy, respiration 
was again established. The first inspiration was so long delayed that we had almost 
given up the case as hopeless, when the first short gasp occurred. In half an hour 
the child had sufficiently recovered to allow the opening of the abscess. This was 
done without a gag, with the tube in position. After a copious discharge of pus the 
tube was removed and the child recovered. In. this case the suffocation was doubtless 
due to the introduction of the gag and the pressure of the finger, which forced the pus 
into the lower portion of the sac which extended below the glottis, where the pus exerted 
sufficient pressure to prevent the entrance of air. 
Case %.—A private patient one year old had diphtheria—laryngeal, faucial, and 
tonsillar. Under 9000 units of antitoxin and intubation satisfactory progress was 
made, and on the eighth day of the illness the tube was removed. It had to be replaced 
in a few minutes because of returning dyspnea. Upon replacing the tube an abscess 
was found in the right posterior pharyngeal wall, pressing upon and extending below 
the larynx. The presence of the tube had prevented the recognition of the abscess. 
Upon determination of the cause of the obstruction the abscess was evacuated, but the 
marked edema of the glottis still caused considerable respiratory obstruction, and the 
tube was required for two weeks longer. The child made a perfect recovery. 
Case 5.—Two weeks after the apparent termination of a fever of several days’ 
duration ascribed to otitis a sixteen-month-old girl developed persistent vomiting 
attacks associated with more fever. Vomiting occurred immediately after the taking 
of food, whether solid or liquid, was not projectile, and was unaccompanied by signs of 
digestive incompetency. The vomiting was promptly terminated by the discovery 
and incision of a retropharyngeal abscess. In this instance dyspnea, hoarseness, 
the peculiar attitude of the head and neck, and pronounced cervical adenitis were all 
lacking. 
The above cases are cited in detail in order that the reader may the 
more fully realize that retropharyngeal abscess may exist without the so- 
called “characteristic symptoms,” and also to emphasize the fact that 
many cases have been, and will continue to be, overlooked until physicians 
use the finger as an aid to diagnosis of the diseases of the upper respiratory 
tract. It is to be remembered that there is no “characteristic breathing” 
and no “characteristic position” of the head with retropharyngeal abscess. 
Fever.—There is no characteristic temperature: it may vary a degree 
or two from the normal or it may range high—from 103° to 105° F. 
Treatment.—There is but one means of treatment—incision and 
evacuation of the pus. In order that this may be done it is necessary 
that the child be under perfect control. The arms should be bound to 
the sides with a large towel, or a small sheet, securely pinned. The patient 
is held in an upright position on the lap of the attendant, who passes his 
left arm around the child, while his right hand grasps the forehead, draw- 
ing the head for further support backward against his right shoulder. 
The operation should be performed in a good light—either reflected 
light from a head-mirror or direct light from a window. With a tongue 
depressor in the operator’s left hand holding the tongue out of the way, 
the mouth is kept open, and the right hand is free to make the incision, 
1 The case was reported at the time by Dr. Henry E. Tuley, assistant resident 
physician. 330 
THE PRACTICE OF PEDIATRICS 
for which an ordinary scalpel is used. The proximal portion of the cutting 
surface should be guarded with adhesive plaster wrapped around the 
blade. The incision should be made from above downward, at least 
\ inch in length. A basin should be in readiness and the attendant 
should be instructed to invert the child at a word from the operator as 
soon as the incision is made. This allows the pus and blood, which, if 
aspirated into the trachea, may produce fatal results, to stream out of 
the mouth. While the abscess is discharging and the head is dependent, 
the clean index-finger of the operator should explore the cavity, enlarge 
the opening, if necessary, and remove any necrotic tissue that may be 
present. The case should be carefully watched for several days, as the 
opening may close before resolution is complete, particularly if it has not 
been enlarged with the finger. Recovery is usually complete in from 
five to seven days. 
Occasionally the abscess points outward and requires external incision. 
RETROPHARYNGEAL ABSCESS COMPLICATING TUBERCULOUS CARIES 
OF THE CERVICAL VERTEBRAE 
This is usually wrongly described as identical with idiopathic retro- 
pharyngeal abscess, but actually is a part of, and results from, tuberculous 
disease of the spine, which will be referred to later (page 795). 
ACUTE CATARRHAL LARYNGITIS (SPASMODIC CROUP) 
In acute catarrhal laryngitis two factors are operative: the local 
infection, causing a swelling and infiltration of the mucous membrane, 
and the laryngeal spasm which is apparently excited by the local process. 
Etiology.—The disease may be primary or secondary to inflamma- 
tory conditions in the nasopharynx. Exposure to cold is a predisposing 
cause. Rachitic children, if they develop the disease, are liable to have 
it in a severe form. They are no more predisposed, however, than normal 
children. Adenoids and enlarged tonsils are predisposing causes. 
Illustrative Case.—A case which demonstrates the possible effects of sudden cold 
occurred at the New York Infant Asylum. A delicate baby, six months of age, was 
exposed for a few minutes on a very cold, windy, December day, with no head covering 
and simple ward clothing. Within an hour a croupy cough had developed, and in 
three hours intubation was necessary. 
Pathology.—Early in the attack the mucous membrane is swollen 
and free from secretion. In older children when a larvngoscopic exam- 
ination is possible, the mucous membrane is seen to be intensely con- 
gested and dry. When resolution begins, the parts appear glistening and 
edematous. The lesion itself, however, is never sufficient to produce 
the obstruction to inspiration peculiar to these cases, as the mucosa is 
probably alone involved. 
Symptoms.—The onset may be sudden or gradual. Cases of gradual 
onset usually follow an acute inflammatory condition of the nasopharynx, 
the fauces and larynx becoming successively involved over a period 
of perhaps two or three days before the laryngitis is well marked. The 
temperature at the onset is usually not high. One of the early symptoms 
indicating laryngeal involvement is a hard, dry cough, croupy and “bark- ACUTE CATARRHAL LARYNGITIS (SPASMODIC CROUP) 
331 
ing” in character. The croupy cough increases in severity toward even- 
ing, and is often associated with urgent respiratory obstruction. 
In a typical case with sudden onset the following are the more fre- 
quent symptoms: The child retires at the usual hour in apparently good 
health; a few hours later he wakes with the characteristic cough, active 
laryngeal spasm, cyanosis and labored efforts at inspiration involving 
dilatation of the alse nasi, suprasternal and infrasternal recession, pro- 
fuse perspiration, and rapid pulse. The expression is anxious and The 
child cries in fear. The temperature is variable, but usually elevated. 
Expiration is usually unimpeded. Under right treatment the symptoms 
of spasm subside and do not recur on the following night. The cough, 
which persists for a few days, subsides under proper treatment. In 
some of the cases, however, the course is not so favorable; the cough 
continues, becoming stridulous, every inspiration being accompanied by 
a loud crowing sound, and in extreme instances the laryngeal obstruction 
due to the swelling and laryngeal spasm is so seVere as to require intuba- 
tion. In our experience, however, this is very rare. Only one child with 
catarrhal, non-membranous croup—the infant already referred to—re- 
quired intubation. 
Differential Diagnosis.—Acute laryngitis may be confused with 
diphtheric or membranous laryngitis. (For differentiation, see p. 697.) 
Laryngismus stridulus may be mistaken for catarrhal laryngitis. 
Differentiation is easy when one remembers that in laryngismus stridulus 
there is no cough, and that the laryngeal spasm is often associated with 
excitement or fright in conjunction with Furthermore, 
laryngismus stridulus does not occur as a definite acute illness, but as a 
reaction to an underlying constitutional defect. The continuous obstruc- 
tion, always associated with inflammatory conditions of acute catarrhal 
laryngitis, is, moreover, absent in laryngismus. 
Retropharyngeal adenitis or abscess may be confused with catarrhal 
laryngitis. Respiratory obstruction in acute laryngitis is apparent only 
during inspiration, and the cough and dyspnea are usually of sudden 
onset. Retropharyngeal adenitis and abscess are characterized by a 
persistence of the symptoms while the disease is active. Digital explora- 
tion of the pharynx makes the differentiation final. In congenital stridor 
the stridor is relieved by stress or excitement, the noisy breathing and 
other evidences of obstruction being worst when the child is quiet or 
asleep. 
Treatment.—In the treatment of catarrhal laryngitis in children 
two conditions must be kept in mind: first, the inflammatory infiltra- 
tion and dryness of the parts, producing the metallic cough and the 
stridulous breathing; second, the laryngeal spasm, which is purely a 
nervous manifestation, doubtless due to irritation of the terminal fila- 
ments of the recurrent laryngeal nerves. 
By no means every case of laryngitis in a child develops into croup. 
When croup is present, however, we know that its existence is due to 
the association of laryngeal spasm with congestion and inflammation. 
If we are to promote quick recoveries we must not lose sight of the im- 
portant nervous element. 
Expectorants.—For the simple coughs, without accompanying in- 332 
THE PRACTICE OF PEDIATRICS 
terference with respiration, treatment with expectorants and steam 
is of great service, regardless of the age of the child. This treatment 
should be preceded by the administration of a full dose—from 1 to 3 
teaspoonfuls—of castor oil. To a child under one year of age a tablet 
composed of tartar emetic, 1/100 grain, with powdered ipecac 1/60 
grain, should be given every two hours—eight doses in the twenty-four 
hours. If the tablets or powders are not available, 2 drops of syrup 
of ipecac may be given instead. To a child from one to two years of 
age a tablet or powder composed of 1/100 grain of tartar emetic, 1/40 
Fig. 61.—Crib prepared for steam inhalation. 
grain of powdered ipecac, and \ grain of Dover’s powder may be given 
at two-hour intervals—eight doses in twenty-four hours. After the first 
day the treatment should be resumed early in the morning, so that by 
evening, when the cough and spasm are most severe, the full influence 
of the drugs may be secured. From the third to the sixth year a powder 
or tablet composed of tartar emetic, 1/90 grain, powdered ipecac, 1/30 
grain, and Dover’s powder, | grain, should be given at two-hour inter- 
vals—eight doses in twenty-four hours. At least eight doses of one of the 
above prescriptions should be given daily in order to get the full benefit ACUTE CATARRHAL LARYNGITIS (SPASMODIC CROUP) 
333 
of the drugs employed. If the Dover’s powder produces constipation, this 
ingredient may be omitted or counteracted by a laxative. Ordinarily 
treatment need not be continued more than two or three days. In case 
the attack is mild the Dover’s powder should be omitted. 
Cold Compresses.—In the treatment of older children the application 
of a cold compress to the throat is a valuable local measure. A napkin 
or piece of old linen so folded that there are at least six layers of the 
material, should be moistened with cold water at 60° F., wrung thor- 
oughly, and placed against the neck, under the jaw, so as to extend from 
ear to ear. Over this should be placed a piece of oiled silk or rubber tis- 
sue held in position by a strip of thin muslin or cheese-cloth, which should 
be brought together at the ends and fastened at the top of the head. 
The compress should be changed every thirty minutes. In the manage- 
ment of very young children this measure is rarely satisfactory, for the 
reason that it is difficult to force the child to allow the bandage to remain 
in place. The practice of placing the compress around the neck, as is 
often done, is of no value, as the dressing does not even overlie the 
affected parts. 
Steam inhalations are effective only when the patient is kept in 
an inclosed space. Steam diffused throughout the room is of little or 
no service. The most comfortable and practical place for the child is 
in his crib, which should be covered with a sheet. An open umbrella 
may be employed when a crib is not available. Under the umbrella, 
which rests upon the bed, lies the child, and covering all is a sheet 
pinned to the umbrella. If preferred, the open umbrella, draped as 
before, may be placed over the baby carriage. Any apparatus is ade- 
quate which will furnish steam and conduct it to the inclosed space. 
The Holt croup kettle when obtainable is always to be used. The steam- 
ing may be continued for hours. The sheet should be removed occasionally 
for a few moments in order to allow a change of air. Usually a child 
may be kept under the tent from twenty minutes to one-half hour with- 
out such a change. The tent is seldom so close as to prevent all ventila- 
tion. 
Calomel Fumigations.—A quicker and more effectual means than 
the treatment with steam is the use of calomel fumigations. The patient 
is placed under a tent prepared as above. Ten grains of calomel are 
placed in any tin receptacle, which rests or is held over the flame. The 
Ermold lamp, made especially for this purpose, is recommended, al- 
though the ordinary alcohol lamp used for warming milk answers every 
requirement. An ordinary kerosene lamp has served well in a few instances, 
the calomel being placed in the cover of a tin can which was held by a 
pair of pincers over the top of the lamp chimney. Regardless of the method 
the fumigation must be constantly watched by some competent person, 
so as to avoid the possibility of igniting the bedclothes. When the fumes 
begin to fill the tent, the child will cough considerably. If the cough 
continues for more than a few minutes, a portion of the vapor should 
be permitted to escape. The calomel will be consumed in from five to ten 
minutes, depending upon the degree of heat used. After the tent is filled 
with the vapor, the child may inhale it for about one-half hour. The 
vapor produces free secretion from the mucous membrane of the parts, 334 
THE PRACTICE OF PEDIATRICS 
and local depletion, resulting in enlargement of the lumen of the larynx 
and consequent relief of the symptom. The fumigations may be re- 
peated after an interval of two or three hours. In a non-diphtheric case 
it is rarely necessary to repeat the inhalations more than two or three 
times. 
Antispcfemodics.—In the cases of sudden onset, in which the spas- 
modic element is prominent at the commencement of the attack, as 
indicated by the high-pitched, crowing inspiration, and in some extreme 
cases by the struggle for breath, the cyanosis, the stridor, and the infra- 
sternal recession, the above treatment will not avail. We must combine 
an emetic with antispasmodic drugs. A full dose of syrup of ipecac—1 
to 2 teaspoonfuls—or sufficient to produce emesis—should be given at 
once. If vomiting does not result in twenty minutes, the ipecac should 
be repeated. After emesis has taken place, the antispasmodic remedies 
should be brought into use. Antipyrin and sodium bromid are especially 
effective at this stage. Antipyrin appears to have a direct sedative action 
on the nervous mechanism of the larynx. To a child two years of age 
the following prescription may be given: 
Antipyrini gr. j 
Sodii bromidi gr. ij 
Syrupi ipecacuanha} gtt. ii-iij 
Aqua} q. s. ad. 3j 
M. Sig.—One such dose every two hours—eight doses in twenty-four hours. 
To a child from three to six years of age may be given: 
1$. Antipyrini gr. ij 
Sodii bromidi gr. iv 
Syrupi ipecacuanha gtt. iij 
Syrupi rhei gtt. xv 
A qua q. s. ad. 3j 
M. Sig.—One such dose every two hours—eight doses in twenty-four hours. 
TRAUMATIC LARYNGITIS 
Traumatic laryngitis, although a very rare condition in children, is 
occasionally observed. It may be caused by the inhalation of steam or 
irritating gases or the aspiration of carbolic or other strong acids. 
Illustrative Case.—Death resulted from the aspiration of pure carbolic acid by a 
child three years of age who was given a teaspoonful of the acid by a five-year-old sister. 
As soon as it passed the lips the patient cried and coughed. None of the acid was 
swallowed, apparently, but sufficient was aspirated into the larynx to produce intense 
congestion and sufficient edema to require immediate operative measures. The parts 
sloughed extensively and the child died in two weeks from pneumonia resulting: from 
sepsis. 
Treatment.—No case of corrosive injury to the mucous membrane, 
sufficient to produce congestion and edema with a resulting inspiratory 
obstruction which requires operative relief, should ever be intubated 
except as a temporary expedient, since the presence of a tube will in- 
variably cause extensive sloughing. If the case is urgent, tracheotomy 
is the only justifiable operation. In two cases due to irritating gases 
(sulphur dioxid in one case and steam inhalation in another) the treat- 
ment consisted in the use of cold applications to the neck by means of 
wet compresses at a temperature of 60° F. Both patients recovered. FOREIGN BODIES IN THE LARYNX 
335 
LARYNGEAL OBSTRUCTION 
Laryngeal obstruction may be either complete or partial, causing 
entire cessation of, or greatly impeded, respiration. As the calls upon 
the physician for aid in these cases are attended with great urgency, 
it is well to bear in mind the conditions which may give rise to, or di- 
rectly cause, laryngeal obstruction. These are referred to in detail under 
their respective headings. In order of frequency they occur as follows: 
1. Acute Catarrhal Laryngitis (Catarrhal Croup), p. 330. 
2. Laryngismus Stridulus, p. 537. 
3. Membranous Laryngitis (Laryngeal Diphtheria), p. 696. 
4. Retropharyngeal Abscess, p. 327. 
5. Foreign Bodies in the Larynx (see below). 
6. Traumatic Laryngitis, p. 334. 
7. New Growths. 
Acute catarrhal laryngitis, membranous laryngitis, laryngismus 
stridulus, and retropharyngeal abscess are by far the most frequent 
causes of laryngeal obstruction in children. In children, edema is a 
very infrequent cause of laryngeal obstruction. When present, it is 
a complication or sequel of other pathologic states; for example, it may 
result from an inflammation accompanying a low-placed retropharyn- 
geal abscess, a traumatic laryngitis after the inhalation of irritating 
gases, or from the aspiration of corrosive fluids or powders. (See In- 
sufflation Pneumonia, page 381.) 
Illustrative Case.—A patient eighteen months of age, during convalescence from a 
mastoid operation, developed a cellulitis in the tissue about the wound. The inflam- 
mation involved the entire side of the face, the lips, and mucous membrane of the 
mouth, and eventually extended to the larynx, producing edema, with most urgent 
symptoms of laryngeal obstruction. 
The part played by the thymus gland in causing laryngismus is not 
at all clear; the subject is discussed on page 473. 
FOREIGN BODIES IN THE LARYNX 
Foreign bodies are usually lodged in the larynx by an act of sudden 
inspiration attended by a quick forward movement of the head, as in 
coughing or laughing with a foreign body in the mouth or between the 
teeth. The patient is immediately seized with a violent paroxysm of 
coughing and suffocation, the severity of which depends upon the size 
and shape of the foreign body. 
Treatment.—Inversion of the patient has repeatedly been of no service 
whatever. The first procedure is to introduce into the mouth the index- 
finger, with the hope that a portion of the mass may protrude sufficiently 
to make possible its removal. Should the attempt fail, a laryngeal forceps 
should be brought into use, its introduction being guided and guarded 
by the index-finger. When this is not successful tracheotomy should be 
performed to relieve the child from immediate danger of suffocation, after 
which further surgical procedures may be considered. 336 
THE PRACTICE OF PEDIATRICS 
The Lungs 
EXAMINATION OF THE LUNGS 
Four methods are commonly employed in lung examination: (1) 
Inspection. (2) Palpation. (3) Percussion. (4) Auscultation. 
Inspection.—Inspection of infants and young children is of value 
in determining the existence and nature of any deformity, as well as the 
rapidity and character of the respiration. The frequency of respiration 
varies considerably in children. The younger the child, the more rapid 
the respiration. The variations in number of respirations per minute 
are about as follows: 
Under one year of age 30 to 40 
One to three years of age 24 to 30 
Three to ten years of age 20 to 24 
The most common deformity is the rachitic chest, or so-called pigeon- 
breast. In association with the rachitic chest, as one of the results of 
the rachitis, is found the funnel chest, which is characterized by marked 
depression of the sternum. 
The Depressed or Contracted Chest.—This condition is a result of pneu- 
monia with pleuritic exudation and subsequent adhesions between the 
lung and the chest wall. Dilatation of the lung is interfered with; the 
balance between the intrathoracic and extrathoracic air-pressure is not 
maintained, and deformity is the outcome. Inspiration is marked by a 
lack of motion on the part of the diseased side as compared with the 
normal side. 
The Distended Chest.-—When there is effusion into the pleural cavity, 
and, rarely, when there is pneumothorax, one side of the chest may be 
much larger than the other. In thin subjects the marking of the ribs 
is much less pronounced than normal, the sunken interspace being ob- 
literated by the pressure from within. In the distended chest also there 
will be observed a marked absence of respiratory movement. A great 
many cases, however, of pleuritic effusion are seen in which such bulging 
is not present. 
Asthmatic or Fixed Chest.—Chests of this type are quite common in 
children, and are so characteristic that by watching the respiration one 
may readily make a correct diagnosis of the existing condition. In chil- 
dren normal breathing is of the costal type; that is, there is an outward 
movement of the ribs in inspiration and a downward and inward move- 
ment during expiration. In the emphysematous and those undergoing 
asthmatic seizures both sides of the chest become inactive and the res- 
piration is largely diaphragmatic. 
Defective Expansion.—In pneumonia and in pleurisy there is de- 
layed and incomplete expansion of the diseased side. In pneumonia, 
also, there is unusual rapidity of respiration; and in acute pleurisy, char- 
acteristic, guarded, interrupted inspiration. In atelectasis the inspira- 
tion is very feeble with little or no expansion. In empyema and pneu- 
mothorax there is little or no expansion over the affected area. 
Palpation in the lung examination of infants and young children is 
of little value. Fremitus serves only to corroborate what may be EXAMINATION OF THE LUNGS 
337 
learned by percussion and auscultation, and is not to be relied upon. 
The absence of fremitus in the case of a thin or average built child usu- 
ally means the presence of fluid in the pleural cavity, but, in the pres- 
ence of a thick layer of adipose tissue the sign is of little or no value. 
The presence of marked fremitus may mean consolidation of the lung. 
The absence of fremitus is no guarantee that there is no consolidation. 
Percussion.—The value of percussion depends upon the normal 
resonance of the chest when tapped with the finger or instrument. What 
is known as normal resonance ;s the sound produced by percussion over 
an air-filled lung. The usefulness of percussion in physical diagnosis 
depends upon the nature or quality of the note and the sense of resistance 
imparted by the chest to the percussed finger. When possible, percussion 
should be practised with the patient in a standing or sitting posture. 
The child should be quiet, if possible, as crying not only disturbs the 
listener, but changes the quality of the note as a result of the air taken 
into the chest and the tension on the chest muscles. Light percussion 
with the finger is preferred to that obtained by pleximeter. The chief 
value of percussion in pulmonary diagnosis is in determining the presence 
of fluid in the chest. 
The terms employed for expressing the findings in a given case are 
normal resonance, hyperresonance, dulness, tympanitic dulness, and flat- 
ness. The possibilities of variations in the resonance within the normal 
are considerable. The position of the patient, the age, the condition 
of the patient, whether thin or fat, whether quiet or crying, are all factors 
which may cause the percussion note to vary. The student should famil- 
iarize himself with the normal by percussing the chests of many normal 
children of different ages. 
Hyperresonance of tympanitic quality is obtained over a hollow body, 
as over the stomach, over a distended colon, or a pneumothorax. 
Dulness is characterized by short, high-pitched sounds, caused by a 
solid body or fluid within the chest cavity, which interferes with the 
production of the normal resonant note. 
Flatness is the extreme degree of dulness, and is best demonstrated 
by percussing a chest filled with fluid. An important feature in deter- 
mining dulness and flatness is the sense of resistance offered the percussed 
finger by the chest wall. In the presence of contained fluid the elas- 
ticity and vibration of the chest wall are greatly diminished, a fact read- 
ily appreciated by the finger percussed. 
Auscultation consists in examination of the lung by the ear placed 
directly against the chest, or assisted indirectly by a stethoscope. 
Use of the stethoscope in examining infants and young children is 
almost a necessity. On account of the smallness of the chest and the 
comparatively large area covered by the ear during direct auscultation 
a larger field of sound conduction is covered than is desirable for pur- 
poses of accurate diagnosis. The small stethoscope bell is best, for the 
reason that when applied to the chests of emaciated infants it will fit 
the surface better than a large bell. If the bell does not accurately fit the 
chest extraneous sounds render examination impossible. For accurate 
work with infants the unaided ear—so-called immediate auscultation—is 
out of the question. With older children, after the third or fourth year, 338 
THE PRACTICE OF PEDIATRICS 
the ear alone may be employed if the physician is unable to accustom 
himself to a stethoscope. The physician must accustom himself to correct 
auscultation with the child crying. This, of course, means forced breath- 
ing and a great deal of extraneous noise. To one who is accustomed 
to lung examination of young infants it matters little whether or not 
the child cries; in fact, in many instances crying is of distinct advantage, 
because it brings out the respiratory quality of all portions of the lung. 
In the examination of older children forced breathing is necessary to trans- 
mit the sounds we require for diagnosis. 
In auscultation all the diagnostician’s attention is required for the 
work in hand. Concentration of the mind is most necessary. Students 
are best taught to close their eyes during auscultation for the purpose 
of excluding all visual objects. All sounds appear louder in the darkness 
or when the eyes are closed. The position of the examiner is important. 
He should sit erect or lean slightly forward, but never incline his body 
more than 45 degrees. When the examiner leans too far, the circulatory 
changes in his ears make his work unsatisfactory and uncertain. It is 
essential for the student to familiarize himself with the sound produced 
in the lung and transmitted to the chest wall in the act of normal and 
forced breathing. The sounds thus produced are known as those of 
vesicular breathing. 
Fig. 62.—Vesicular breath- 
ing. 
Fig. 63.—Distant vesicular 
breathing. 
Fig. 64.—Exaggerated ves- 
icular breathing. 
Vesicular breathing has a range of variations within the normal. As 
in the matter of the study of percussion sounds, repeated examinations 
of the chest of normal children of various ages and conditions are ab- 
solutely required before the nature of normal breathing and its possible 
variations will be appreciated. Various terms have been used in a com- 
parative sense to describe vesicular breathing, such as “rustling,” “blow- 
ing,” “swishing,” “purring,” etc.; these are all misleading and useless 
because there is no other sound resembling the sound of vesicular breath- 
ing which deserves mention in comparison. Different investigators have 
attempted, by means of various devices, to produce the sounds resembling 
the respiratory murmur in health and its changes in disease, without 
success. 
The respiratory cycle includes the taking of air into the chest—in- 
spiration; and the forcing of the air out of the chest—expiration. The 
duration of inspiration in comparison to expiration is in the ratio of five 
to three. The inspiratory sound is not only longer, but harsher in quality 
than that of expiration. The respiratory characteristics have been dia- 
grammatically described by Cabot in his excellent work on physical 
diagnosis. Cabot’s diagrams are here used, but modified to correspond to 
the respiratory peculiarities of children. EXAMINATION OF THE LUNGS 
339 
Inspiration is represented by the upward stroke and expiration by 
the downward stroke. The length of the upstroke, as compared with 
that of the downstroke, corresponds to the length of inspiration as com- 
pared with that of expiration. The thickness of the upstroke as com- 
pared with that of the downstroke represents the intensity of inspira- 
tion as compared with that of expiration. The pitch of inspiration as 
compared with that of expiration is represented by the sharpness of the 
angle which the upstroke makes with the perpendicular. 
In the foregoing, an attempt has been made to describe the various 
phases of normal respiration. That the two sides of the chest may show 
considerable variation within the normal, due to changes in the posi- 
tion of the body, the age of the patient, and whether he is at rest or active, 
as in crying, must be appreciated and learned only by repeated studies 
of the normal. Only when the student has so practised upon and studied 
the normal chest is he ready to take up the study of the signs of disease. 
Exaggerated breathing occurs when a sound lung or portion of a sound 
lung is called upon to do an extra amount of work. This type of breath- 
ing is simply compensatory, and occurs when a considerable portion of 
lung structure is incapacitated by consolidation, as in pneumonia, or by 
pressure, as in the event of effusion into the pleural sac. 
Fig. 65.—Bronchial breath- 
ing of moderate intensity. 
Fig. 66.—Distant bronchial 
breathing. 
Fig. 67.—Very loud bron- 
chial breathing. 
Diminished or weakened breathing exists when both inspiration and 
expiration are feebler than the normal. 
Diminished breathing may be due to fluid in the pleural cavity, to 
pleuritic plastic exudation covering the lung like a blanket, to partial 
infiltration of the air-cells, to pneumothorax, to bronchitis because the 
air is impeded in its passage to the air-cells, and to acute pleurisy which 
gives rise to much pain and causes a much shorter excursion of the chest 
walls than normal. In all these conditions inspiration is less deep than 
normal, and diminished respiratory sounds are the result. In laryngeal 
spasm and in diphtheric laryngitis the respiratory murmur may like- 
wise be greatly weakened because of the failure of sufficient air to pass 
the obstruction. 
Bronchial breathing has been symbolically represented and described 
by Cabot as follows: 
The increased length of the downstroke corresponds to the increased 
duration of expiration, the greater thickness of both lines corresponds 
to the greater intensity of both sounds, expiratory and inspiratory, while 
the sharp pitch of the gable on both sides of the perpendicular corresponds 
to the high pitch of both sounds. Expiration, it will be noticed, slightly 
exceeds inspiration, both in intensity and in pitch, but considerably 340 
THE PRACTICE OF PEDIATRICS 
exceeds it in duration. As compared with those of vesicular breathing, 
almost all the relations are reversed. 
Bronchial breathing is found in conditions in which there is com- 
plete infiltration of the pulmonary air-cells, leaving only the bronchi open 
to the inspired air. The vesicular element in the breathing is, therefore, 
wanting, and the sound produced by the passage of air through the tubes 
is alone conveyed to the ear; and the more readily because of the solidity 
which the consolidated lung presents. Any condition, by causing con- 
solidation of the lung, obliterating the air-spaces, may produce bronchial 
breathing. Thus bronchial breathing of the most pronounced type may 
be found over a pleural sac filled with fluid. The lungs solidified by 
the pneumonia or compressed by fluid (carnified) give rise to bronchial 
breathing which is readily transmitted by the fluid under compression 
to the exterior of the chest wall. Bronchial breathing heard all over 
the chest (front, back, axilla, and apex) almost without exception means 
that the pleural cavity is filled with fluid. Failure to recognize fluid 
under marked signs of general bronchial breathing is one of the most fre- 
quent errors made in chest diagnosis in children. 
Bronchovesicular Breathing.—We do not recognize bronchovesicular 
breathing as a distinct type, but one of the forms of weakened or defect- 
ive breathing. 
Fig. 68.—Emphysematous breathing. 
Fig. 69.—Asthmatic breathing: s, s, s, 
Squeaking (musical) rales. 
In emphysematous breathing the inspiration is short and somewhat 
feeble, but not otherwise remarkable. The expiration is long, feeble, 
and low pitched. 
Asthmatic breathing differs from emphysematous breathing, the latter 
being characterized by greater intensity of inspiration. In asthmatic 
breathing, however, both sounds are usually obscured to a great extent 
by the presence of piping and squeaking rales. 
Cavernous Breathing.—Cavernous or amphoric breathing will be 
found over a cavity in the lung tissue or a large bronchiectasis. The 
respiratory sound has a peculiar hollow quality both upon inspiration 
and upon expiration. A low note is produced which has been com- 
pared to the sound produced by blowing gently into a wide-mouthed 
bottle. 
Rales.—Upon auscultation of the lungs rales of different kinds will 
be heard. A rale is the sound produced by impeded air in its passage 
through a bronchus to the lung. This may be brought about through 
a spasm of the tube, through thickening of its mucous membrane, or 
the presence of pus, mucus, or water in the bronchial tube. Rales of 
various types will be produced, depending upon the nature of the lesion BRONCHITIS 
341 
and the size of the tube affected. Thus when there is congestion with 
infiltration there will be sonorous rales in the large tubes and sibilant 
rales in the smaller tubes. 
Sonorous rales are low-pitched snoring sounds, roughened and grat- 
ing in character. Stridor in laryngitis is akin to the sonorous rales. 
Sibilant rales are squeaking, hissing, and crackling in character. In 
the smaller tubes they indicate the same condition as is productive of the 
sonorous rales in the large tubes, with this difference, that the advent of 
bronchial spasm is a considerable factor in the production of sibilant 
rales. Sibilant rales are almost always present in asthma and in asth- 
matic bronchitis, and may indicate an early stage of bronchitis. 
Mucous or moist rales are large, medium, and small; and vary in 
size and number, depending upon the nature of the lesion. They are 
produced by the passage of air through diseased bronchi containing exu- 
date, and are present in all catarrhal conditions of the lung from what- 
ever cause. In bronchitis and bronchopneumonia, if the examiner is suf- 
ficiently industrious, every variety of rale may at some time be heard. 
Crepitant and subcrepitant rales belong to the subvarieties of moist rales. 
BRONCHITIS 
Acute bronchitis, an inflammation of the bronchial mucous membrane, 
occurs with great frequency in infants and young children. 
Etiology.—The majority of cases occur during the colder months of 
the year, when houses are overheated, and when sudden changes in the 
weather are frequent. The sudden advent of exposure lowers the child’s 
resistance, and the infecting agents which are always present are then 
given a favorable field for activity. 
Predisposing Causes.—The chief predisposing cause is absence of 
resistance to bacterial invasion—a condition peculiar to child life. 
Infants and children who are rachitic or who suffer from other forms 
of malnutrition are particularly susceptible. Chronic rhinitis, enlarged 
tonsils, and adenoids are predisposing factors of no small consequence. 
Bacteriology.—The usual bacteriologic agents are the pneumococcus, 
the influenza bacillus, the staphylococcus, and various types of the strep- 
tococcus. 
Types.—Bronchitis may be divided clinically into three types: pri- 
mary and secondary acute forms and chronic bronchits. 
Primary.—In simple primary bronchitis there may have been an ex- 
posure to cold or wet, although this is not at all necessary. The disease 
is more apt to follow exposure to another individual who has a so-called 
“cold,” and who is, temporarily, at least, a germ carrier. 
Secondary.—This type is most often found associated with measles, 
whooping-cough, and grip, or following an acute catarrhal infection of 
the upper respiratory tract. Secondary bronchtis differs from the acute 
primary form only in the mode of onset. In the secondary type the 
onset is gradual—three or more days usually being required before the 
disease is well advanced. 
Chronic.—Chronic bronchitis is somewhat rare in the young. It 
occurs most frequently in conjunction with asthma, or in slow conva- 342 
THE PRACTICE OF PEDIATRICS 
lescence after bronchopneumonia, and is an accompanying process in 
chronic pulmonary tuberculosis. Peribronchial thickening occurs in pro- 
longed cases. 
Pathology.—In simple bronchitis the lesion is very slight. The mucous 
membrane may show congestion and slight round-cell infiltration, and 
there may be elevation or loss of superficial epithelium in small areas 
where the infection is most severe. 
Symptoms.—The onset of acute bronchitis is usually sudden. The 
cough, which may be extremely troublesome, interferes with sleep, and, 
in the case of young infants renders the nursing and bottle feeding diffi- 
cult. The respirations are rarely accelerated above 30 per minute unless 
there is an associated bronchial spasm. (See p. 347.) There may be 
moderate prostration; in mild cases there is none. In severe cases the 
appetite is interfered with. The child is rather peevish and shows general 
discomfort. 
The usual range of the temperature in uncomplicated bronchitis 
is from 100° to 102° F. When the temperature remains above 102° F., 
or makes frequent excursions above this point, a complication of some 
kind will almost always be discoverable to account for the high fever. 
Frequent causes are intestinal disorder, a developing otitis, or a beginning 
bronchopneumonia. If the temperature ranges above 102° F. and the 
respiration is 40 or more, we may be almost certain of a developing pneu- 
monia. 
In chronic bronchitis the physical signs consist of various types of 
mucous rales in the bronchi. The medium-sized bronchi are, as a rule, 
the chief seat of this catarrhal process. 
Cough is the most active symptom, and is worse at night. Fever, 
if present, is due to the associated disease, as chronic bronchitis in a 
child is rarely an independent illness. 
Physical Signs.—Auscultation of the chest early in an attack will 
reveal a harsh, roughened respiratory murmur, fairly evenly distributed 
all over the lungs. Sonorous, sibilant, and mucous rales become audible 
in from twelve to thirty-six hours. 
Percussion.—There is no change in the percussion note except in 
the cases of asthmatic bronchitis (p. 347), which are characterized by 
hyperresonance or tympanitic dulness. 
Palpation is here of no aid. 
Duration.—The duration of an attack of bronchitis depends to some 
extent upon the child’s recuperative powers, but to a much greater degree 
upon the method of treatment. A primary case properly managed 
should terminate favorably in a few days. Many cases are not treated 
at all by a physician. It is these cases of neglected bronchitis which 
furnish a great majority of our cases of bronchopneumonia, a disease 
which contributes largely to the mortality of children under five years 
of age. 
Diagnosis.—Catarrh of the bronchial tubes, manifested by many rales 
of different types, is the chief diagnostic feature of simple bronchitis. 
Cases very often reported as those of capillary bronchitis, in which there 
is rapid breathing—40 to 60 a minute—high temperature—103° to 105° F. 
—and marked prostration, show at autopsy the pneumonic elements 343 
BRONCHITIS 
which gave during life no other signs in the chest than a diminished 
respiratory murmur and many fine mucous rales. 
Differential Diagnosis.—Chronic bronchitis may be differentiated 
from pulmonary tuberculosis by the temperature range, elevation of 
the temperature being unusual in chronic bronchitis. The examination of 
the sputum, the tuberculin skin test, and the x-ray are essential aids to 
a sure diagnosis. 
Treatment.—The management of the primary and secondary cases 
is, in the main, the same, varying, of course, to meet individual condi- 
tions or symptoms. 
Before indicating what should be done in a case of bronchitis it may 
be as important, by way of emphasis, to advise what not to do. Do 
not seal the room up tight by keeping all the windows closed. Do not 
use an oil-silk jacket lined with wadding or any other material. Do 
not allow the child to be wrapped in blankets and shawls and held against 
a warm adult body. Do not give the child large doses of so-called “ex- 
pectorants” in a teaspoonful of a heavy syrup. The temperature of the 
room should be kept as near 68° F. as possible. There should always be 
direct communication with the open air. A window lowered an inch 
or two from the top, or the window-board described on p. 26, is a safe 
means of assisting in ventilation. The child should be kept in his crib 
and wear the night clothing to which he was accustomed in health. Many 
children with bronchitis do not feel particularly ill and rebel against 
the enforced inactivity. A patient who cannot be kept under the covers 
may wear a pinning-blanket or a bath-robe while sitting up in bed, but 
should not be allowed to sleep thus clad. 
The Diet.—If there is little or no fever the diet need be reduced 
but little. If there is fever, 100° to 101.5° F., with restlessness and ir- 
ritability, the food should be reduced in strength, the same amount of 
fluid being allowed as in health. The diet of a nursing baby can best 
be reduced by giving a drink of water before each nursing, and shortening 
the time allowed for nursing from one-third to one-half. We will thus 
avoid digestive disturbances, which often act as a very serious complica- 
tion of the existing disorder. Older children, receiving a mixed diet, 
may be given toast, cocoa, milk, broths, gruels, and fruit juices. 
Steam Inhalations.—Properly administered medicated steam inhala- 
tions are of greater service in bronchitis, particularly in treating young 
infants, than any other form of treatment which we possess. The steam- 
ing is best administered with the child placed in the crib, which is covered 
and draped with sheets. A croup kettle with alcohol lamp attachment 
is the most convenient means for generating steam. The nozzle of the 
croup kettle, which rests on a chair or stand, is carried under the tent 
at a safe distance from the child’s hands and face. For inhalation, creosote 
has given better results than has any other drug. Ten drops are added 
to one quart of boiling water and the steaming is continued for thirty 
minutes. 
Ordinarily, in an urgent case, steaming for thirty minutes is given at 
two-and-a-half-hour intervals day and night until the child recovers. 
Older children, and those whose condition is not grave, need not receive 
the steam after the bedtime of mother or nurse. It is well to allow a change 344 
THE PRACTICE OF PEDIATRICS 
of air in the inclosed space at least three times during the steaming. 
This is done by raising the sheet for a moment or two and then replac- 
ing it. The side of the crib, if preferred, need not be draped. 
Counterirritation of the skin over the thorax is another very useful 
method of treatment in bronchitis. Full instructions must be given 
the mother and nurse as to how the counterirritant is to be applied, or 
the application will be very indifferently made. In most cases the mustard 
plaster has been the most convenient means of counterirritation, and 
has given the best results. It is well to begin with a strength of 1 part 
of mustard and 2 parts of flour. Two or three applications of this 
strength may be made. Later, when the skin becomes sensitive, the plaster 
is to be made weaker by the addition of more flour, 1 part of mustard 
to 5 or 6 of flour. In order to be effective the plaster should remain in 
contact with the skin from five to fifteen minutes, until a diffuse blush 
appears. 
The plaster is prepared as follows: Mix the mustard and the flour, 
using lukewarm water until a paste of medium thickness is formed. This 
is to be spread on cheese-cloth, old linen, or thin white muslin to a thickness 
of about | inch. Over this one thickness of cheese-cloth should be placed. 
The size of the plaster depends upon the age of the child and the area 
of lung involved. In a case of general bronchitis the entire thorax, front 
and back, should be covered. It is easier to make two plasters which 
meet under the arms than to make one to encircle the thorax, as is some- 
times done. A circle is cut out for the arms at the upper corners. If the 
plasters are sufficiently large to meet at the side, as mentioned above, 
they may be pinned together. When all is completed, the application 
really amounts to a mustard jacket. 
The plaster may be applied from two to four times daily, depending 
upon the urgency of the case. 
Counterirritation thus made is of great service early in the attack— 
during the stage of acute congestion. We question whether plasters are 
of much use after two or three days have elapsed. After removal of the 
plaster an application of vaselin is grateful to the patient. 
Mustard Baths.—A mustard bath, | ounce of mustard to 6 gallons 
of water, at a temperature of 110° F., is of considerable service in the 
very acute cases in young children, with extensive involvement of the 
fine tubes, usually known as “capillary bronchitis,” in which there is 
a great deal of bronchial spasm and considerable shock. The hands and 
feet are often cold, the respiration is rapid, and the child is considerably 
prostrated. Under such conditions the bath may be repeated with ad- 
vantage at intervals of from six to eight hours. The child is to remain 
in the bath from one to three minutes, during which time the trunk and 
extremities should be briskly rubbed with the bare hand. 
Drugs.—The value of drugs in the management of this disease has 
been considerably overestimated, and they are mentioned last because 
they are the least important of the remedial agents available. 
During the first stage of bronchitis, that of engorgement, indicated 
by a short, dry cough, and rough, sonorous breathing, small doses of 
castor oil and syrup of ipecac constitute perhaps our best medication. 
From the first to the third year 2 to 3 drops of castor oil and 2 to BRONCHITIS 
345 
3 drops of syrup of ipecac may be given every two hours; after the 
third year, 3 drops of syrup of ipecac and 5 drops of castor oil every 
two hours. At least eight doses should be given in twenty-four 
hours. Ordinarily, after twenty-four hours, auscultation will detect 
more secretion in the bronchi, the fever will diminish, and the child’s 
cough will become loose and less severe. The benefits from the oil and 
ipecac will be obtained in from forty-two to seventy-two hours, after 
which this medication should be discontinued. 
If the cough and the chest sounds tell us that the bronchi are not 
yet clear, a combination of tartar emetic, powdered ipecac, and am- 
monium chlorid may be used. To a child under six months of age a 
powder or tablet containing 1/150 grain of tartar emetic, 1/80 grain of 
powdered ipecac, and \ grain of ammonium chlorid should be given 
at two-hour intervals, eight doses in twenty-four hours; from six months 
to one year, tartar emetic, 1/100 grain; powdered ipecac, 1/60 grain; 
ammonium chlorid, \ grain, at two-hour intervals, eight doses in twenty- 
four hours. If the cough is very annoying and severe, requiring a seda- 
tive, l grain of Dover’s powder may be added to each dose for infants 
under six months, and \ grain for children over six months of age. From 
one to three years of age, tartar emetic, 1/100 grain; powdered ipecac, 
1/40 grain; ammonium chlorid, | grain, may be given at two-hour inter- 
vals, eight doses in twenty-four hours, | grain of Dover’s powder to be 
added to each dose if the character of the cough demands a sedative. 
The tablet or powder, whichever is employed, should be given in 2 
teaspoonfuls of thin gruel or plain water. After the third year 1/80 
grain of tartar emetic, 1/20 grain of pulverized ipecac, and 1 grain of 
ammonium chlorid may be given every two hours, eight doses in the 
twenty-four hours. The use of tablets or powders should be insisted upon, 
particularly in treating very young children. The large doses of ammo- 
nium salts and ipecac in heavy syrups are to be avoided because of their 
liability to produce stomach disturbance. 
The treatment of secondary bronchitis depends to a certain extent 
upon the disease with which it is associated, and the procedure should 
be modified accordingly. Counterirritation and medicated steam in- 
halations ordinarily can be used, as they interfere but little with other 
necessary treatment. 
Treatment of Chronic Cases.—In chronic bronchitis the removal of 
enlarged tonsils and adenoids, fresh air, and change to a dry climate, 
if possible, are our best means of treatment. In addition, general sup- 
portive treatment is to be advised as in the management of subnormal 
children (p. 140). Creasote in small doses, 1 to 3 minims after meals, 
for a child from two to five years of age, has seemed to be of service to 
some of these children. The greatest success, however, with these cases 
has been achieved by ignoring the bronchitis temporarily and putting 
the child in the best hygienic surroundings. Outdoor life inland and a 
nutritious diet are far better than drugs. In many of these cases, under 
such a regime, the disease for which the child was brought for treatment 
has entirely disappeared without any specific medication whatever, show- 
ing that the bronchial catarrh was nothing more nor less than a manifes- 
tation of greatly reduced vitality. 346 
THE PRACTICE OF PEDIATRICS 
RECURRENT BRONCHITIS 
Recurrent bronchitis without the association of asthma and without 
fever or prostration is occasionally encountered. A typical case of this 
kind is the following: 
Illustrative Case.—A. plump, well-nourished, four-year-old girl had a history of 
attacks of bronchitis lasting from five to seven days at intervals of not longer than 
three weeks. The physical examination was negative. The attacks commenced when 
she was two years of age and had continued for two years. The temperature was 
never over 100° F. with the attacks, and the child was not physically ill. She had 
never had cyclic vomiting, tonsillitis, or rheumatism. (The father was a sufferer from 
chronic rheumatism.) The patient was given a diet suitable for her age (p. 135), 
meat being allowed every second day. The considerable quantity of sugar which she 
had been taking was greatly reduced, only enough being allowed to make the food 
palatable. She was also given the following prescription: 
1$. Sodii salicylatis gr. xxxvj 
Sodii bicarbonatis gr. lxxij 
Elix. simplicis 5v 
Aqua) q. s. ad. gij 
M. Sig.—One teaspoonful twice daily after meals. 
The above prescription was given for five days, followed by an interval of five 
days without medicine. This procedure was continued for five months, during which 
time there was no bronchitis. Later this medication was given ten days each month 
for one year, with entire relief of the trouble. Withholding sugar and fat from the diet 
was continued indefinitely. The patient has had no further inconvenience. 
When a child develops joint or bone disease, the family can usually 
recall an injury or fall of some sort to account for the trouble. So, also, 
in the event of bronchitis, an exposure, a change of clothing, or a change 
in the weather will usually be regarded as a cause of the attack. 
In the case above cited and in many others such factors evidently 
have had very little, if anything, to do with the bronchitis, for under 
the same climatic conditions the attacks cease when attention is given 
to the constitutional condition, and proper diet and medication are 
prescribed. The patients are usually of gouty or rheumatic ancestry. 
Treatment.—Sugar and fat cannot be tolerated by patients of this 
type. 
They should lead an active outdoor life when climatic conditions 
allow. There should always be communication between the sleeping 
room and the outer air. All possible influencing factors, such as en- 
larged tonsils and adenoids, are to be removed. (This operation, how- 
ever, is never sufficient in itself to prevent recurrences.) 
Diet.—Red meats, including beef, mutton, and lamb, should be given 
only every second or third day. Sugar is permissible only in sufficient 
amount to make the food palatable. If the case resists treatment, sugar 
is to be discontinued and saccharin substituted. Skimmed milk may be 
given as a drink, 8 ounces being allowed both for breakfast and for 
supper. Green vegetables and cereals well cooked and suitable for the 
age may be given freely. 
There must be a free evacuation of the bowels daily. If there is a 
tendency to constipation the management suggested on page 273 is 
to be applied. 
As in a certain group of asthma cases protein sensitization, particularly ACUTE SPASMODIC BRONCHITIS; BRONCHIAL AS1HMA 
347 
to egg, must receive consideration. Occasionally brilliant results follow 
the elimination from the diet of supposedly harmless food found bjr cuta- 
neous test to be toxic to the patient. The application of the protein theory 
has, however, been rather disappointing. 
Medication.—These patients are not influenced by the usual treat- 
ment for bronchitis, so that expectorant drugs may be omitted. Large 
doses of bicarbonate of soda do more toward shortening the attacks 
than does any other form of medication. To a child five years of age 
10 grains should be given at two-hour intervals. 
The interval treatment, with diet, must be relied upon to prevent 
a recurrence of the attacks. Salicylate of soda is given for five days, in 
doses of from 3 to 5 grains, well diluted, after meals. The salicylate is 
then discontinued and the bicarbonate is given for ten days in the same 
dosage. Next the salicylate is resumed. In this way, by alternating the 
two drugs or by giving aspirin when the salicylate disagrees, the treat- 
ment is continued for two or three months. As the case improves an 
interval of rest from all medication is instituted. If it is more convenient 
the salicylate and the bicarbonate of soda may be given at the same time. 
Bathing.—The skin in these cases should be kept active, and once 
daily the child should be given a tub-bath in lukewarm water. After 
the bath a cool spray or spinal douche is to be used, the temperature of 
the water ranging from 50° to 70° F. An excessive degree of cold is not 
advisable; it should be sufficient, however, to insure a good reaction 
after brisk rubbing with a rough towel. 
ACUTE SPASMODIC BRONCHITIS; BRONCHIAL ASTHMA 
Infants and young children may suffer from spasmodic attacks of 
dyspnea—the manifestation of the disease in the adult. With asthma 
in the child, regardless of age, there is almost invariably an association 
of bronchitis. In some the nervous phenomenon of spasm predomi- 
nates with little bronchial involvement. In others there is consider- 
able bronchitis, with slight, moderate, or intense spasm. 
In the case of the infant and very young child the term capillary 
bronchitis has been given to two distinct conditions. In one there is an 
acute spasmodic bronchitis, and in the other an acute infection of the lungs 
(pneumonia) without localization. In acute asthmatic bronchitis the 
mode of onset, the lesions, and the fever are all as found in acute simple 
bronchitis. The bronchial spasm, however, differentiates the two forms 
from two standpoints: First, the respiration in the asthmatic type appears 
very rapid. A rate of 60 is not unusual. The excursions of the chest 
muscles are, however, incomplete and the rate in many instances is less 
rapid than it appears. Second, the chest signs are most dissimilar. In 
the spasmodic cases there may be an entire absence of, or very feeble, 
respiratory murmur, with inspiration short and squeaking in character, 
while the expiration is prolonged and accompanied by fine sibilant rales. 
These signs may exceptionally be localized in one lung or a portion of a 
lung, more often at the end of the attack, but, as a rule, occur equally in 
both lungs, the same auscultatory signs occurring over the entire chest. 
There is but little action of the respiratory muscles, the chest appears 348 
THE PRACTICE OF PEDIATRICS 
held in fixed position of deep inspiration with little movement of the chest 
wall, the diaphragm being held contracted and undergoing only short ex- 
cursions. Both the entrance and exit of air are impeded, but the expira- 
tory act appears the more difficult. Cyanosis, profuse perspiration, and 
marked prostration are apparent if the attack is prolonged. Percussion 
elicits hyperresonance or tympanitic dulness. 
This type of bronchitis may occur in the youngest infant. Many 
older children always have the spasmodic condition with bronchitis. 
Etiology.—Among the many agencies that have been credited with 
the capacity for causing asthma, but one has been proved positively 
operative-—sensitization to foreign protein. This sensitization may be 
present at any age. 
The asthmatic reaction may be due to sensitization to foods or to 
inhalation of protein-bearing substances from plants and animals. In- 
fants with eczema frequently have an asthmatic type of bronchitis, and 
eczema in many infants is due to food anaphylaxis, most frequently to 
egg, and occasionally to milk. The list of such foods includes also a large 
variety of vegetables and cereals. 
Clinically we may divide asthma into two classes, the sensitive type 
and the non-sensitive type, according to the following tabulation made 
by Bell and Larsen.1 
SENSITIVE TYPE 
NON-SENSITIVE TYPE 
Periodic attacks with complete or 
nearly complete cessation of pathologic 
signs between the attacks. 
1. Course of the Disease 
Either chronic cough without dysp- 
nea or periodic remissions with mod- 
erate dyspnea, but the pathologic signs 
tended to remain constant between the 
remissions. 
2. Type of the Attack 
Onset in which dyspnea was the most 
prominent symptom. This was usually 
characterized by slow, labored breathing 
with prolongation of the expiratory phase 
up to the beginning of the inspiratory 
Ehase, so that there was no period of rest 
etween. Cough was not prominent at 
first, but later, after the dyspnea had begun 
to subside, it became more prominent and 
lasted after the dyspnea had entirely dis- 
appeared. On auscultation in the early 
stages the rales were similar in all parts of 
the chest and occurred about equally dur- 
ing all parts of both inspiration and ex- 
piration. Toward the end they became 
looser and were patchy in their distribu- 
tion, resembling those of simple bronchitis. 
There was usually acceleration of the pulse- 
rate, but no rise in temperature. 
In those with periodic remissions 
cough at the onset was the most prom- 
inent symptom. Dyspnea, if it appeared, 
came on from twenty-four to forty-eight 
hours later and was not as severe as in the 
sensitive type. It also had a tendency to 
be more inspiratory in type. On auscul- 
tation during the attack the rales were 
often very similar to those found in the 
sensitive type, and later also showed a 
loose quality, but between the attacks 
these showed a tendency to remain con- 
stant, though fewer in number. There 
was nearly always acceleration of the 
pulse-rate accompanied by a rise in tem- 
perature. 
3. Duration op the Attack 
This varied from a few minutes to a This varied from a few days to a 
few days and was followed by a relatively week or more and convalescence was 
rapid convalescence. relatively slower. 
1 Classification and Management of Asthma in Childhood, Amer. Jour. Dis. Child., 
November, 1922, vol. 24, pp. 441-449. ACUTE SPASMODIC BRONCHITIS; BRONCHIAL ASTHMA 
349 
W hen obtained this showed a fairly 
clear gelatmous material with small 
opaque bodies, Laennec’s pearls. 
4. Quality of the Sputum 
This was slightly more profuse was 
thick, yellow or greenish, and purulent 
5. Behavior Toward Epinephrin 
Intramuscular injections of a solution 
of epinephrin chlorid 1:1000 gave marked 
immediate temporary relief. 
The relief obtained was not as marked. 
In the group of cases classified as non-sensitive are perhaps many in 
which the activating protein has not been discovered. Some children 
cough, wheeze, and have restricted asthmatic breathing with every attack 
of bronchitis; and yet we find that if we prevent them from contracting 
bronchial infections the asthma does not occur. It is possible, but not 
established, that in such cases the infecting bacterial organism causing 
the bronchitis is operative through its protein in causing asthma. 
In a group of 44 cases in which sensitivity was determined Bell and 
Larsen found the reacting proteins gave tests as follows: 
Rabbit hair, 32 positive reactions; horse dander, 8; cat hair, 6; dog 
hair, 1; guinea-pig, 1; feathers, 1; foods, 8; pollens, 3; total, 60 positive 
reactions. 
The importance of rabbit hair in causing asthma was first emphasized 
by Ratner.1 This hair is commonly used in the manufacture of felt and 
may be found in the hats of susceptible children. 
In many asthmatic infants and children there is an undoubted gouty 
(lithemic) diathesis. Not only are such children subject to bronchitis 
of the spasmodic type, but they also may have attacks of croup, eczema, 
cyclic vomiting, periodic fever, and periodic intestinal crises, with or 
without fever, and with or without gastric crises. 
Most important dietetic factors in these cases are fat and sugar, par- 
ticularly cow’s milk fat and cane-sugar. These patients during the 
asthmatic attack develop the acetone breath, but not to the degree that 
is noted in cyclic vomiting. 
Illustrative Cases.—Case 1.-—A girl eight years of age had the history of an attack 
of asthmatic bronchitis every month for several years. The asthma, although not 
severe, was present at the onset of the attack, and lasted for perhaps twenty-four 
hours. The bronchitis usually cleared up in about five days. She had spent but little 
time in New York because of her so-called frequent “colds,” and was brought by her 
mother for examination in contemplation of a change of residence. In Florida and 
lower California, where the patient had passed the winter, the attacks had occurred, 
but were mild in character. As soon as she returned home the attacks returned, keeping 
her from school for one week out of every four or five. When the matter of adenoids 
and tonsils was mentioned the mother hastened to state that the adenoids and tonsils 
had been removed twice, thus demonstrating that they were not a factor in the case. 
The family history disclosed that all the child’s antecedents on both sides, for three 
generations, had suffered either from rheumatism or gout. The mother had been a 
life-long sufferer from rheumatism. The child had never suffered from rheumatism or 
cyclic vomiting. Aside from revealing a mild secondary anemia and slight emphysema, 
the physical examination proved negative. Upon close questioning, it was found that 
the patient’s diet consisted of red meat twice daily; she disliked vegetables, took cereals 
only when covered with sugar, and drank milk only when 2 teaspoonfuls of sugar were 
added to each glass. She had candy and cake ad libitum. She was recovering from 
an attack of bronchitis when examined, and was taking an expectorant cough-syrup. 
1 Ratner, B., Rabbit Hair Asthma in Children, Medical Clinics N. America, o, 
1129, January, 1922. 350 
THE PRACTICE OF PEDIATRICS 
This was discontinued, red meat was permitted but twice a week, the sugar was largely 
reduced, saccharin being used in the milk to satisfy the abnormal craving for sweets. 
She was bribed by the mother to eat green vegetables and cereals. The desserts con- 
sisted largely of stewed fruits flavored with saccharin. Candy, cake, and pastry were 
forbidden. Four grains of the salicylate of soda given three times daily for five days 
was followed by 10 grains of the bicarbonate three times daily for five days; then for 
five clays there was no medication. This treatment was continued for six months. 
During the following six months the salicylate and the bicarbonate of soda were given 
but five days each out of each month. During the entire year but one mild attack of 
bronchial asthma occurred. 
Case 2.—A most striking case of periodic asthmatic bronchitis occurred in a boy 
nine years of age. The father had had inflammatory rheumatism. Of the mother’s 
family, the grandmother was an invalid with rheumatism and the grandfather was 
slightly rheumatic. 
The boy was pale, but well nourished, weighing 68 pounds. He was very active 
mentally. He had had chickenpox and one attack of tonsillitis. The blood examina- 
tion showed 78 per cent, of hemoglobin, 5,500,000 red cells, and 8000 leukocytes. The 
urine was negative. During the previous year he had had a great many attacks of 
asthmatic bronchitis. The mother stated that they occurred once very three or four 
weeks. Previous to this time there had been very frequent colds—so many that the 
boy’s attendance at school had been practically nil. The mother had discovered that 
sugar did not agree with the child, and very little had been given. He was very fond 
of red meat, however, and wanted it three times a day. It was given twice a day. 
A liberal diet of green vegetables, fruits, milk, and cereals was ordered. In addi- 
tion, egg or bacon was to be given for breakfast, red meat three times a week, poultry 
three times a week, and fish once a week. Sugar was excluded absolutely, saccharin 
being used. Aspirin in 3-grain doses was given after each meal, with 5 grains of bi- 
carbonate of soda. 
This was the treatment for three months, during which time there was one attack 
of the asthmatic bronchitis. This responded to ipecac, antipyrin, and sodium bromid. 
Except for one or two slight colds, the boy experienced no trouble during the ensuing 
winter and lost but little time at school. At the end of seven months he had gained 
7 pounds. 
The bicarbonate and aspirin were given continuously for three months. Then 
for a long period they were given alternately, each for five days, i. e., 3 grains of aspirin 
three times daily for five days, then 5 grains of bicarbonate of soda twice daily for five 
days. 
In the so-called sensitive type of cases the paroxysm typically occurs 
preceding the bronchitis as a result of the irritation from plant pollen or 
the emanations of animals or flowers and often takes the form of hay- 
fever as well as asthma. Hay-fever and asthma due to pollen allergy are 
rarely seen in children under five years of age. 
For a description of an exceptional case of this type seen by the senior 
author in consultation we are indebted to the child’s physician, Dr. 
Murray Bass. 
Baby W., female, third child, was the daughter of a mother who had suffered from 
hay-fever for which she had received prophylactic treatment, having exhibited sen- 
sitivity to June grass and ragweed. 
At the age of six and a half weeks the baby began to show signs of wheezing and 
mild cough. This grew progressively worse until the child had many attacks of cyanosis 
and extreme dyspnea. At no time did she run any temperature. Physical examination 
showed marked asthmatic breathing and sibilant rales over the entire chest. x-Ray 
of chest failed to show any abnormality. Differential blood count showed an eosino- 
philia of 23 per cent. Skin tests on the baby showed her to be sensitive to orchard 
grass, timothy, June grass, redtop and mildly to horse dander. 
Treatment consisted in stopping breast feeding, the use of large doses of adrenalin 
and atropin, and oxygen inhalations. Two treatments of exposure of chest to x-ray 
were also given with the idea that there was possibly an enlarged thymus, in spite of 
negative x-ray. After four weeks of severe illness, in several paroxysms of which the 
child seemed to be moribund, she gradually recovered. “At the present time she is 
gaining in weight, taking food well, though the chest still shows many rales and the 
eosinophilia persists.” ACUTE SPASMODIC BRONCHITIS; BRONCHIA*L ASTHMA 
351 
After several attacks of asthma associated with bronchitis what is 
sometimes called a true asthma results. Through the direct irritation, 
dependent on peculiar susceptibility to emanations such as those from 
cats or horses, or otherwise reflexly because of the presence of abnormalities 
in the upper respiratory tract, the habit becomes once established and there- 
after but very little irritation appears necessary to precipitate an attack. 
While these seizures may occur without clinical bronchitis, in not one of 
them will the bronchi be found normal, and the intolerance for carbohy- 
drates is to be considered as in the cases in which clinical bronchitis is in 
evidence. 
As the study of asthma progresses the number of cases classed as 
sensitive is steadily becoming larger. 
Pathogenesis.—In the motor nerve supply of the bronchial musculature 
are constrictor and dilator sets of fibers, and the bronchospasm typical 
of asthma is induced by irritation of constrictor fibers derived from the 
vagus. This effect may be induced whenever the mucosa of the upper air 
passages is irritated by a protein to which the subject is sensitized. In 
susceptible children the irritant effect may be manifested also by vomiting. 
In many instances this occurrence is a protective phenomenon to be desired.1 
It may readily be understood that if the nasal passages are obstructed 
by adenoids, hypertrophied turbinates, or septal deformity the local 
susceptibility to irritant substances is correspondingly augmented. Dur- 
ing the actual attack the accumulation of tenacious secretion in the 
bronchi increases the degree of obstruction and only when expectoration 
is possible is prompt relief obtained. The sputum, when obtainable, is 
found to be transparent, usually showing “tapioca-like masses” known as 
Laennec’s pearls, together with a high content of eosinophils. Charcot- 
Leyden crystals, casts, and Curshman’s spirals are found more rarely. 
While the dyspnea is pronounced at the height of the paroxysm and 
vital capacity is lessened, systemic effects due to the extreme cyanosis 
are observable, but, characteristically, as soon as the attack has sub- 
sided (provided the asthma is uncomplicated), the lung capacity and al- 
veolar carbon dioxid content are found to be normal. 
It is conceivable that endocrinology may in the future contribute to 
a better understanding of asthmatic phenomena. 
Pathology.—Peribronchial thickening associated with chronic bron- 
chitis and various grades of tracheobronchial adenopathy comprise the 
effects induced in subjects of prolonged asthma. Secondary infection with 
bacteria, particularly various strains of streptococcus adds to the chron- 
icity of many cases. Tuberculosis complicating asthma in childhood, 
while not rare, is less frequent than one would expect from the contributing 
factor of bronchitis present in so many asthma cases. 
Treatment.—The management of a case of asthma in an infant or 
young child depends upon the nature and severity of the seizures. In a 
very urgent case 3 to 5 minims of a 1 : 1000 solution of adrenalin may be 
given hypodermically to a child from two to six years of age. Morphin 
with atropin may also be necessary in severe cases for the purpose of 
relieving the patient during the height of a paroxysm. In the cases in 
which bronchitis is prominent medication by mouth is of much service. 
1 J. C. Walker: Oxford Medicine, II, Chapter VII. 352 
THE PRACTICE OF PEDIATRICS 
For a child six months of age the following prescription has been found 
useful: 
Syrupi ipecacuanha gtt. xviij 
Antipyrina; gr. vj 
Sodii bromidi gr. xviij 
Syrupi rubi idsei 3v 
Aqua? q. s. ad. 36 
M. Sig.—One teaspoonful every two hours—six doses in twenty-four hours. 
For a child one year of age: 
1$. Syrupi ipecacuanha; gtt. xxiv 
Antipyrinse gr. xij 
Sodii bromidi gr. xxiv 
Syrupi rubi idsei 3v 
Aqua;.. q. s. ad. 56 
M. Sig.—One teaspoonful at two-hour intervals—six doses in twenty-four 
hours. 
For a child from two to three years of age: 
1$. Syrupi ipecacuanhse gtt. xxxvj 
Antipyrina; gr. xviij 
Sodii bromidi gr. xxxvj 
Syrupi rubi ida;i 3v 
Aqua; q. s. ad. 56 
M. Sig.—One teaspoonful in water at two-hour intervals—six doses in twenty- 
four hours. 
Added relief will be afforded by steam inhalations, as described under 
Spasmodic Croup (p. 333). If the condition is urgent, the inhalations may 
be given for thirty-minute periods with thirty-minute rest intervals. 
Mustard, in the proportion of 1 part of mustard to 2 parts of 
flour (p. 846), so applied as to envelop the entire thorax, will often re- 
lieve the spasm sufficiently to reduce the respirations from 10 to 20 a 
minute. The mustard should remain on long enough to redden the skin, 
and should not be repeated oftener than once in four hours. 
The cold-air treatment in bronchial asthma is contraindicated re- 
gardless of the age of the patient. Warm, moist air at from 68° to 70° F. 
is best. A sudden blast of cold air may be sufficient to increase the se- 
verity of the paroxysms to a marked degree. Ventilation, however, is a 
necessity in these cases. The best means of obtaining it is by the use of 
two rooms, one of which may be aired while the other is occupied. Before 
the child is changed to the aired room its temperature should be raised 
to that of the other. 
In older children after the fifth year the bronchial spasm may be 
considerable, and more active measures may be required to furnish tem- 
porary relief. Here the methods usually employed for the same purpose 
in adults may be brought into use. A few whiffs of chloroform will often 
be effective. Fumes of nitrate of potash paper will sometimes be of 
service. At this age, also, a combination of antipyrin and bromid of 
soda may be brought into use. For a child from five to ten years of age 
3 grains of antipyrin with 6 to 10 grains of bromid of soda, repeated in 
two hours, will often obtain a cessation of the paroxysm. As soon as the 
spasm subsides the sedatives should be discontinued. We have almost ACUTE SPASMODIC BRONCHITIS; BRONCHIAL ASTHMA 
353 
never found it necessary to give morphin hypodermically or otherwise 
in these cases. 
Illustrative Case.—In a very severe case, in a girl eight years of age, a combination 
of antipyrin and codein in full dosage was required to control the paroxysms. She was 
given \ grain of codein and 4 grains of antipyrin at two-hour intervals until three doses 
had been given. 
Before instituting interval treatment all growths and deformities in 
the rhinopharynx should be removed or corrected and the child given a 
suitable living regime. 
Inasmuch as it is often impossible to differentiate the two types of 
asthma clinically, it would seem advisable to do the protein skin reactions 
on all cases in which there is a possibility of existing sensitivity. The 
great majority of cases will be found to react to one or more of a relatively 
small number of substances. The following list includes all except the more 
unusual causes: 
Inhaled Materials. 
Ingested Materials. 
Horse dander. 
Rabbit hair. 
Cat hair. 
Dog hair. 
Sheep wool. 
Chicken, duck, and goose feathers. 
Cotton seed. 
Orris root (talcum powder). 
Pyre thrum (insect powder). 
Wind-borne pollens which vary in different 
localities. 
Egg-white (ovomucoid). 
Egg-yolk. 
Milk (lactalbumin, casein). 
Wheat (gliadin). 
Barley. 
Cocoanut. 
Veal. 
Pea. 
Crab. 
Rhubarb. 
Rice. 
Chicken. 
Carrot. 
Spinach. 
Banana. 
Corn. 
Cocoa. 
Bean. 
Peanut. 
Lobster. 
Strawberry. 
Rye. 
Lamb. 
Celery. 
Tomato. 
Orange. 
Oat. 
Beef. 
Beet. 
Potato. 
Oyster. 
Mustard. 
Almond. 
Pork. 
Lettuce. 
Clam. 
Prune. 
Cooke1 has found a large number of patients reacting to the dust 
found in their home environment. 
Technic of Skin Test.—In making the cutaneous tests the scratch 
method devised by Schloss and Walker is to be pieferred. An area on 
the back or chest in a baby, or the flexor surface of the forearm in an older 
child is cleansed with alcohol, and a scratch § inch long is made with a 
large Hagedorn needle. On this scratch is placed a drop of hundredth- 
normal sodium hvdroxid and a small amount of the dried extract is 
dissolved in this drop. In fifteen to twenty minutes the site is gently 
cleaned with separate twists of cotton and the reading made. A positive 
reaction varies with the material used. The pollens usually give the larg- 
est reaction, the inhalants the next largest, and the ingested substances 
the smallest. A small reaction may have as much clinical significance 
as a large one. 
In interpreting the results a simple erythema alone or accompanying 
a small round wheal less than 0.5 cm. in diameter is noted as “ =*=Wheals 
with irregular outline from 0.5 to 1 cm. in diameter as and for each 
half centimeter more of diameter a plus mark is added. Doubtful tests 
must be repeated several times before a definite conclusion is reached. 
1 Studies in Specific Hypersensitiveness, III, Jour. Immunology, March, 1922. 354 
THE PRACTICE OF PEDIATRICS 
Interval Treatment.—For the bottle fed this consists in reduction of 
the sugar to one-half the amount suitable for the age, and the use of 1 
grain of bicarbonate of soda for each ounce of the milk food given. The 
bowels must be kept properly open, although constipation or intestinal 
toxemia has seldom appeared to us to be a paramount factor in the asthma 
of children. 
The interval treatment for older children is most important, for by 
it one may postpone the attacks. Since these cases, as has been indicated, 
are usual in lithemic subjects, the scheme of management followed out 
is to some degree the same as for rheumatism, chorea, recurrent bronchi- 
tis, and cyclic vomiting. Sugar is reduced to a minimum, and red meat 
is given not oftener than every second day, and then only in moderate 
amounts. The child’s protein nutrition is maintained by the use of a 
high protein cereal, such as oatmeal, and purees of dried peas, beans, 
and lentils. The eating of green vegetables is encouraged. Food between 
meals is forbidden. Fruits are used in moderation and an active outdoor 
life is encouraged. At bedtime the child is given a brine bath (p. 843), 
followed by a vigorous dry rub. The mother or attendant is instructed 
that one bowel evacuation daily must be insured. 
The best method is so to regulate the life of the patient as to avoid 
contacts with the particular protein or proteins to which the child is 
proved sensitive. In those cases in which the reaction to one or more 
proteins is definitely proved, immunization may be attempted by those 
skilled in this work. 
It is good practice in all cases of true asthma or those in which there is 
a manifest tendency to a bronchitis with associated spasm to advise the 
removal of all feather pillows, hair mattresses, and sachet and dusting- 
powders from the environment of the patient, for the reason that such 
children may be sensitized in a minor degree sufficient to produce a 
bronchial reaction and show no response to the usual skin tests. 
There is no doubt that certain subjects who are “poor oxidizers,” 
with a defective metabolism, the so-called lithemic class, are benefited 
in a prophylactic way when given a diet containing a meager allowance 
of fat and sugar. A child overfed on a diet rich in these substances reacts 
by developing a weakened resistance of the respiratory tract which, in 
turn, allows a bacterial invasion which we believe to be responsible for 
much unexplained asthma. Additional help will be supplied these children 
by the periodic use of bicarbonate of soda in dosage of 10 grains three 
times daily on alternate weeks. 
Hay-fever in older children is by no means a rare disease. Our youngest 
patient was three years of age. The disease is due to the influence of plant 
pollen on the mucous membrane of the nose and throat and represents 
a pollen protein anaphylaxis. A hay-fever subject may be sensitized 
to one or half a dozen pollens. 
The pollens of ragweed and the grasses are perhaps the pollens most 
frequently causing hay-fever. Heredity appears to play an important 
part in the etiology. Oppenheimer and Gottlieb1 reported that in 90 
POLLINOSIS, POLLEN DISEASE, HAY-FEVER 
1 Medical Record, March 18, 1916, PNEUMONIA 
355 
per cent, of their cases members of the family of the patient suffered 
with ailments showing manifestations of anaphylaxis. 
Diagnosis.—The disease may manifest itself any time during the 
period of the flowering of plants. The first sign is usually that of profuse 
lacrimation with itching and burning of the eyes. Sneezing and a profuse 
watery nasal discharge are rarely absent. In many cases later asthmatic 
seizures develop. 
The seizures continue in a given case while the individual is sub- 
jected to the action of the pollen to which he is sensitized. The disease 
may continue during the entire period from May until October. 
The Skin Test.—Individuals who are sensitized to a pollen will usually 
show a cutaneous reaction to the pollen protein. 
The technic of the test has been described on page 353. 
Cooke and Yanderveer have mentioned 25 plants which they personally 
proved had caused hay-fever. 
Treatment.—Those who desire to treat hay-fever by the use of pollen 
preparations are advised to consult the publications of Cooke and Vander- 
veer, Walker, and MacKenzie. 
Pneumonia is an infective process, due to bacterial invasion, seen 
with the greatest frequency in the young. The influence of cold, which 
is that of shock, producing a lowered resistance, temporarily makes the 
individual unusually susceptible to the infecting organisms, which are 
ever present. On account of the different ways in which these infecting 
agents manifest themselves in the lungs, two types grossly are produced— 
lobar or fibrinous -pneumonia and broncho- or catarrhal pneumonia. 
PNEUMONIA 
Lobar Pneumonia 
Lobar pneumonia is an acute infection of the lungs, primary in char- 
acter, and may occur at any age. Until the second year it occurs less 
frequently than bronchopneumonia. 
Etiology.—The influence of cold is to produce a lowered resistance. 
Exposure may therefore play a part. The disease occurs with greatest 
frequency during the winter and spring months. 
Bacterial Etiology.—The specific etiologic cause of lobar pneumonia 
in a large majority of cases is the pneumococcus (Diplococcus pneumoniae, 
Micrococcus lanceolatus) of Frankel1 and Weichselbaum.2 This has been 
definitely established by a large number of independent workers. In 
the Rockefeller Institute series of 529 cases the Diplococcus pneumoniae 
was isolated in 454 instances. From the remaining cases were cultured 
out the Friedlander pneumobacillus, Bacillus influenzae, Streptococcus 
pyogenes, Streptococcus mucosus, Staphylococcus aureus, and mixed 
growths. 
The pneumococcus is an encapsulated, Gram-positive, lancet-shaped 
diplococcus, which grows fairly easily in artificial media, especially defib- 
rinated blood media, and is characterized by solubility in bile.3 For 
1 Frankel, A., Zeit. f. klin. Med., x, 1886. 
2 Weichselbaum, Med. Jahrbucher, Wien, 1886. 
3 Neufeld, F., Zeit. f. Hyg., xxxiv, p. 454, 1900. 356 
THE PRACTICE OF PEDIATRICS 
further morphologic, cultural, and staining characteristics the student 
is referred to standard text-books on bacteriology. 
In 1910 Neufeld, who had previously demonstrated the production 
of precipitins and agglutinins by the pneumococcus,1 found that the 
immune reactions within the pneumococcus group varied.2 Following 
out this line, Dochez and Gillespie3 divided pneumococci into four groups 
according to their immunologic reactions with homologous sera. Types 
I, II, and III are the fixed strains showing homologous immune reactions, 
although Type II shows atypical strains. Type III is the pneumococcus 
mucosus. Type IV is a heterogeneous group with no definite constant 
immune reactions. The incidence and mortality of the four groups as 
reported in the Rockefeller Institute series are as follows: 
Incidence, 
Mortality, 
Type. 
per cent. 
per cent. 
I 
33 
25 
11 
31 
32 
Ill 
12 
45 
IV 
24 
16 
An efficient therapeutic antipneumococcic serum for Type I is avail- 
able.4 Antisera for the other types have not proved effective. 
Pneumococci are found in great numbers in the sputum. Pneumo- 
coccemia, as reported in various series, can be demonstrated in 10 to over 
50 per cent, of the cases. The presence of a pneumococcemia makes the 
prognosis more grave. Specific immune substances are present in the 
urine in a large percentage of cases.5 
Predisposition.—Lobar pneumonia in the young is not a disease of 
the weak. This type of child is the subject of bronchopneumonia. It 
is just as often the strong, vigorous child who develops lobar pneumonia. 
Pathology.—The most apparent effects of the disease are those pro- 
duced in the pulmonary tissue, where there is an exudative inflamma- 
tion which progresses through four well-recognized stages, to which are 
applied the terms: (1) Congestion; (2) red hepatization; (3) gray hepatiza- 
tion, and (4) resolution. These stages are not always clearly defined; 
and not infrequently, at postmortem, neighboring portions of a lung 
simultaneously present the appearances characteristic of two or more 
stages of the same inflammation. Congestion, consolidation, and reso- 
lution have, however, a very constant order of occurrence, and this is 
well understood when one considers the exudative nature of the inflam- 
matory process. 
In the primary stage of congestion the involved portion of the lung 
is the seat of active hyperemia and edema, and becomes darker in color 
and acquires increased consistence. The alveolar capillaries are tur- 
gid, and the epithelial cells lining the air-spaces are swollen. In the 
stage of red hepatization a well-marked exudation into the alveolar spaces 
ensues. The exudate consists chiefly of fibrin, red blood-cells, leukocytes, 
1 Neufeld, F., Zeit. f. Hyg., xi, 1902. 
2 Ibid., u. Handel, Arb. k. Gsndhtsamte, xxxiv, p. 166, 1910. 
3 Dochez and Gillespie, Jour. Amer. Med. Assoc., lxi, p. 72, 1915. 
4 Avery, Chickering, Cole, and Dochez, Rock. Inst. Monograph No. 7, 1917. 
5 Ibid. PNEUMONIA 
357 
and desquamated epithelial cells. The involved lung structure thus 
becomes practically solid and roughly resembles liver. The pleurisy, 
the swelling and heaviness, and the packing of the alveoli are all most 
marked during the red stage. During the stage of gray hepatization the 
alveoli become choked with additional exudate, which consists chiefly 
of leukocytes, the blood-vessels undergo compression, and the lung mass 
becomes swollen and heavy, and assumes a gray appearance. The pleura 
shares in the inflammation and at this period is coated with more or less 
fibrinous exudate. The stage of resolution marks the change by which 
the air-cells are relieved of their burden and the normal circulation is 
restored. This process is essentially one of autolysis, involving disinte- 
Fig. 70.—Lobar pneumonia of right middle lobe. (Dr. C. H. Perkins.) 
"ration of the fibrin meshes in the exudate and degeneration of the masses 
of leukocytes and desquamated epithelial cells. Much of the liquefied 
exudate is coughed up directly, but more is absorbed and eliminated 
through the agency of the lymphatics. 
Eventually the normal lung structure is restored except in those 
instances in which the occurrence of interstitial exudate has facilitated 
the development of abscess or gangrene, or the usual dry pleurisy has 
been superseded by inflammation of the purulent type—empyema. 
In cases of typical lobar pneumonia the pneumococcus present in 
the circulating blood may give rise to localized abscesses or such fatal 
complications as peritonitis and meningitis. 358 
THE PRACTICE OF PEDIATRICS 
Localization of the Lesions.—Orth’s figures for the localization of 
lobar pneumonia are: 
52 per cent, for the right side. 
33 per cent, for the left side. 
15 per cent, for both sides. 
In 217 cases (Koplik) the right lung was involved in 124 and the 
left in 93; the upper right lobe in 74, the upper left in 35, and the upper 
lobe of either lung in 109 cases, as against 100 cases for the lower lobes. 
Occasionally the central portion of a lobe alone may be involved. The 
existence of small foci of consolidation is, however, far more characteristic 
of bronchopneumonia. In lobar pneumonia the lesion is peculiarly distinct 
and circumscribed, the surrounding lung portions remaining uninvolved. 
In double pneumonia a portion or the whole of one or more lobes in each 
lung is involved. 
Fig. 71.—Temperature chart, lobar pneumonia. 
Symptoms.—The onset of the disease is sudden, with fever and rapid 
respiration, which may range from 40 to GO and is usually accompanied 
by cough. The temperature is variable—over 102° and under 105° F. 
The pulse is rapid—130 to 160—and there is considerable. prostration. 
The ratio of respiration rate to pulse rate is high. These are the only 
symptoms distinctly indicative of lobar pneumonia. 
Vomiting, convulsions, stupor, and chill, to which much attention 
is given by writers, occur with many other diseases, and in some cases of 
pneumonia; thus, in the writer’s cases convulsions have ushered in the 
disease in 2 per cent.; vomiting in less than 10 per cent.; chill in about 
5 per cent. Loss of appetite, coated tongue, and drowsiness are, of course, 
noted, and these are all present in dozens of ailments. 
The prostration is most marked for the first forty-eight hours. After 
this time the organism appears to adjust itself to the changes induced PNEUMONIA 
359 
by the infection. During the first or the second day of illness the tem- 
perature becomes established at a high point—103° to 105° F.—where 
it remains, usually with slight variation in a recovery case, until the crisis. 
This steady high range of temperature (see Fig. 71) is not always fol- 
lowed out, the fever in many cases fluctuating considerably. 
Illustrative Case.—In an eight months’ old child the temperature was that of a typ- 
ical malaria, 99° F. in the morning, 104° to 105° F. in the late afternoon. The crisis 
occurred on the eighth day, and the child was promptly well. Thorough examination 
from every standpoint failed to show other than a lobar pneumonia. 
The respiration per minute depends upon the amount of lung in- 
volved, the virulence of the infection, and the age of the patient. In 
children under two years of age, from 60 to 80 respirations per minute 
are not at all unusual. In older children the respiration is less rapid, 
often not exceeding 60 per minute. The pulse in young children is in 
like manner more accelerated—a range from 150 to 180 is not unusual, 
while in children after the third year the rate may not be above 160. 
Duration of the Attack.—The duration is variable. In the event of 
mild infection, probably associated with good resistance, many patients 
make the crisis on the third day, even before the physical signs are posi- 
tive. Such cases are by some authors said to represent the abortive type. 
In the average recovery case the crisis occurs from the fifth to the 
ninth day. A crisis delayed beyond the ninth day means a very serious 
infection and a very grave prognosis. Recovery cases in which the crisis 
does not occur until the eleventh day are not extremely rare. In one 
instance the crisis transpired on the thirteenth; and in another on the 
fifteenth day. 
Unfavorable Symptoms.—The most unfavorable symptom in lobar 
pneumonia is a low temperature in the presence of the other character- 
istic signs—rapidity of respiration, rapid pulse, and prostration. 
Illustrative Case.—The senior author was called by a practitioner in a New York 
suburb to see a case of pneumonia that disturbed him greatly, although it was im- 
possible to make the parents understand that the child was severely ill. There was no 
elevation of the temperature—in fact, it was slightly subnormal. The patient, who 
was ten months old and had been previously healthy, showed marked pallor and pros- 
tration not unlike that presented by an acute gastro-intestinal intoxication case, such 
as is frequently seen in summer. The respiration was about 40 and the pulse was 
rapid and weak. There was nothing to account for the illness other than a frank 
consolidation of the right lower lobe. The writer made a fatal prognosis, recognizing 
the probability of death in a few hours. The child died twelve hours after the visit. 
In this case the child was overwhelmed by the pneumococcus infection, so that 
any reaction indicated by fever was impossible. 
Cases of this kind in vigorous children are rare. In athreptics and 
those older children who suffer from malnutrition or who develop pneu- 
monia after a previous exhausting disease the low temperature range— 
100° to 102° F.—is not at all unusual. With it will often be associated 
petechial skin eruptions. In such instances the prognosis is most un- 
favorable. 
Tympanites.—The development of marked abdominal distention 
is a symptom of grave import, indicating a high grade of toxemia. Further, 
the distention interferes not a little, mechanically, with the already 
embarrassed respiration. 360 
THE PRACTICE OF PEDIATRICS 
Vomiting and diarrhea are usually occasioned by improper feeding. 
Uncorrected, they add to the dangers of the disease. 
Stupor and delirium are cerebral evidences of the systemic toxemia, 
and! while they indicate a severe infection, their presence is more con- 
fusing in a diagnostic sense than an indication of danger to the patient. 
The symptoms are traditionally more active, particularly the temperature 
manifestation, when the right apex is involved. Such a localization, 
however, has no influence on the prognosis. 
Delayed Crisis.—Every day after the ninth, without the critical 
drop, adds to the danger to the patient. 
Lobar pneumonia is rarely fatal before the ninth day. Deaths, of 
course, occur earlier, due to the severity of the infection, but this is very 
exceptional. 
Among 6 fatal cases at the New York Infant Asylum in a six 
months’ service, 2 terminated on the eighth day, 2 on the ninth, 2 
on the twelfth, and 1 on the twenty-first day of the disease. In 
the cases of long duration we have to deal with a condition in which 
the individual is not able to manufacture sufficient antitoxin to destroy 
the infecting agent or agents, and the question naturally arises, will he 
be able to do so. 
Complications.—The advent of a complication adds a more serious 
aspect to the disease. A complication may appear at any time during 
an attack, and change what appears to be a favorable case into one of 
the greatest gravity. 
The complications that have occurred under our observation are 
as follows: myocarditis, pericarditis, pneumococcus meningitis, pneu- 
mococcus peritonitis, empyema, peri-arthritis, otitis, pulmonary ab- 
scess, and pulmonary gangrene. 
Myocarditis.—In very severe infections in which the temperature 
has been high a decided irregularity of the heart action develops. Al- 
though no cyanosis or other indication of general heart failure may be 
apparent, the first sound will be weak and incomplete. 
Pericarditis.—Fluid, serous or purulent, is more often discovered at 
the autopsy than recognized during the illness, and is more common in 
left-sided empyema. Cases have been observed postmortem which 
showed the pericardial sac filled with pus and fibrin, and the heart sur- 
rounded with the exudate so as to be scarcely recognized, although no 
cardiac sign had been present during life, other than that both sounds 
were defective. 
Meningitis of pneumococcus origin (p. 603) is not at all unusual among 
hospital and asylum patients. An invasion of the meninges by the pneu- 
mococcus produces characteristic symptoms (p. 604) quite apart from 
the usual manifestations of pneumonia, so that, recognition of this com- 
plication is readily made (Plate I). Further, when the meninges are 
attacked, the resulting symptoms are very active. At once there may be 
noted slow, irregular respiration, slow, irregular pulse, stupor from which 
the child may not be aroused, and change in the pupils. 
Peritonitis.—Persistent distention of the abdomen, with evident 
pain on pressure, and obstinate constipation are indications of acute 
peritonitis. In our experience these cases have all been fatal. PNEUMONIA 
361 
Empyema (p. 388) may develop during the pneumonia, in which 
case the chief manifestation will be a change in the physical signs—the 
bronchial breathing and bronchial voice changing suddenly to weak, 
distant bronchial sounds, associated with flatness on percussion. 
Empyema, however, is more apt to follow a day or two after the 
crisis than to occur during the active stage of the disease. It is a com- 
plication seen in a large number of cases in different stages of the disease, 
and the possibility of its development should never be forgotten. 
Peri-arthritis will be made evident by pain and swelling of a joint, 
most frequently the shoulder or elbow. 
Otitis is often overlooked because of the absence of pain to locate the 
trouble. It often passes unrecognized until a rupture of the drum occurs, 
the fever being accounted for by the lung disease. Mastoiditis may 
develop unsuspected. 
In every disease of infectious origin the ears should be subjected to 
a daily otoscopic examination. 
Acidosis in Lobar Pneumonia: 
Illustrative Case.—A child eighteen months of age developed fever, prostration, and 
rapid respirations, the typical hyperpnea of acidosis, active deep urgent breathing, in 
marked contrast to the usual quiet superficial sighing, though rapid, respirations of 
lobar pneumonia. A heavy trace of acetone was found in the urine and the acetone 
breath was very noticeable. The chest signs were sufficient for a diganosis of pneu- 
monia, but the child died from unmistakable acidosis. 
Prognosis.—This in private cases depends considerably upon whether 
the patient is under care in a sensible family, or subject to ignorant manage- 
ment. If the physician has the right support the mortality is very low— 
from 2 to 3 per cent. Among the ignorant and careless it will be higher— 
from 5 to 10 per cent.—approaching the mortality in hospitals and chil- 
dren’s institutions. The high mortality in hospitals is due more to the 
wretched condition in which the patient arrives than to peculiarly severe 
features of the disease. In infant asylums and children’s institutional 
homes a lack of resistance to disease is the rule, and pneumonia affords 
no exception. 
Diagnosis.—Recognition of the disease in infants and young children 
is surrounded with few difficulties. The sudden onset of illness, with high 
fever, rapid respiration, dilatation of the alse nasi, expiratory grunt, and 
rapid heart action, are objective signs of real significance. 
Consolidation of the lungs makes the diagnosis positive. The time 
of appearance of this sign is, however, subject to considerable variation. 
It may be present during the first twenty-four hours, but is repeatedly 
delayed to the fourth day. Rarely consolidation may appear as late 
as the fifth day. In one case showing very active symptoms otherwise 
the typical physical signs referable to the lung were not apparent until 
the seventh day. On the day the consolidation appeared crisis occurred. 
Cases of this type may go through the entire course of the disease and 
never show definite consolidation. Such pneumonia was formerly referred 
to as “central.” Mason, of New York, has demonstrated by Roentgen-ray 
studies that these cases are really those of marginal pneumonia. There 
is no doubt but that a pneumococcous infection of the lung may exist 
for several days and run its entire course without the process ever going 362 
THE PRACTICE OF PEDIATRICS 
on to consolidation demonstrable by our usual means of examination. 
We know that this is possible in the two- or three-day cases representing 
clinically the so-called abortive type. 
The Physical Signs.—As already indicated, auscultation may never 
reveal a sign of the disease other than harsh or sonorous breathing. As 
a rule, the infiltration of the air-cells will develop sufficiently from the 
second to the fourth day to produce bronchial breathing and bronchophony. 
Over the consolidated area fine pleuritic friction rales will usually be 
heard at the height of inspiration when the consolidation makes its ap- 
pearance. In practically every early case of lobar pneumonia the pleura 
over the consolidated surface is dry and injected, often showing post- 
mortem a very fine exudation. 
Percussion will show dulness, depending in degree and extent upon 
the nature and distribution of the lesion. Absolute dulness will be present 
only over the consolidated area. 
The chief value of percussion is in differentiating the presence of 
fluid from extensive fibrinous exudation, a condition sometimes desig- 
nated as pleuropneumonia. 
Palpation is of little value in examining children, and reveals nothing 
that may not be learned through auscultation and percussion. 
In diagnosing considerable exudations of fluid in the pleural cavity 
and pneumothorax, the absence of vocal fremitus may furnish corrob- 
orative evidence. 
The agent to-day of greatest value in detecting and diagnosing pul- 
monary consolidation is the x-my. This should be employed when pos- 
sible, particularly in all obscure cases. 
Differential Diagnosis.—Lobar pneumonia is to be differentiated 
from bronchopneumonia, from acute pleurisy with massive output of 
fluid, and from similar cases in which the fluid is less in amount. The 
differentiation between lobar pneumonia and bronchopneumonia is dis- 
cused on p. 373. 
Pleuritic Effusion.—When there is a fluid, pleuritic exudate suffi- 
cient to fill the entire cavity, with the fluid under pressure over a com- 
pressed and consolidated lung, signs will be transmitted to the chest 
wall closely resembling those of frank consolidation. Thus, there may 
be bronchial breathing and bronchophony of a very intense character 
over the entire involved side anteriorly and posteriorly, at both the apex 
and the base. Repeatedly these signs are interpreted by the attending 
physician as evidence of a complete consolidation of the lung. It is to 
be remembered that a lung is almost never entirely consolidated in acute 
pneumonia. Furthermore, in the presence of a massive fluid exudate 
percussion will elicit flatness over the entire region. When the process 
is located on the left side, the heart displacement to the right indicates 
the presence of fluid in the left pleural cavity. 
In cases of effusion, finally, there is an absence of friction-sounds and 
likewise of rales. When doubt exists, as is sometimes the case even after 
the use of the £-ray, which does not invariably differentiate fluid from 
consolidation, exploratory puncture should always be made. Fluid in 
lesser amounts is indicated by diminished respiratory sounds, localized 
flatness, the absence of mucous or pleuritic rales, and displacement of PNEUMONIA 
363 
the heart if the exudation is in sufficient amount. Only in cases in 
which the pleural cavity is absolutely filled with fluid do we find the 
voice and respiratory signs of frank lobar pneumonia. 
Blood-findmgs in lobar pneumonia are of special diagnostic signifi- 
cance (see p. 433.) 
Treatment.—Our efforts in restoring the patient to health are sup- 
portive only. 
When a child is stricken with lobar pneumonia, our first effort should 
be to place him in such a position that he may to the best advantage 
cope with the enemy. In order to do this every detail of his daily life 
should so be arranged as to assist all the organs of the body most favor- 
ably to combat the changed conditions produced by disease. Telling 
the mother what to do for the fever and writing a prescription for a cough 
mixture is a most careless method, worthy of the prescribing apothe- 
cary rather than a physician. A proper regime must be established as 
soon as the child becomes ill. The bowel function, the room temperature, 
ventilation, and sleep, as well as special medication, are all to be con- 
sidered. The child’s comfort demands the avoidance of everything 
causing restlessness or irritability. 
Open Air.—For strong robust children the cold-air treatment is to 
be advised. These patients unquestionably do better with the win- 
dows wide open day and night. In such an atmosphere the respiration 
is slower, the heart action is stronger, and the patients are much more 
comfortable, sleep better, and make a more satisfactory convalescence. 
A woolen hood and suitable woolen clothing should be worn. 
The Sick-room.—When the open-air treatment is not practicable, the 
temperature of the room should be kept at 61° to 65° F. both day and 
night, wide fluctuations in the temperature being prevented. A large 
room, if at hand, should always be selected, and there must always be 
direct communication with the open air by an open window. The child 
should be kept in the crib, and not held on the lap of the mother or nurse. 
Quiet should be maintained in the sick-room, only those in attendance 
upon the patient being admitted. The presence of curious visitors 
annoys the child and takes away a certain number of strength units, 
which may determine the outcome of the case. The advantages of the 
cold-room or roof treatment in this respect are obvious. 
The Clothing.—This should be the usual night-clothing. We have 
long since discarded the oiled-silk jacket or any special form of covering. 
Such applications are very easy to put on, but very difficult to take off 
with safety; further, they tend to elevate the temperature of the patient, 
make him uncomfortable, particularly during convalescence, and pre- 
vent the free action of the skin. 
The Bowels.—There should be a standing order for an enema to be 
given if the bowels do not move once in twenty-four hours; \ to 1 
grain of calomel in doses of £ grain every hour is usually of consider- 
able service. In a case in which there is very high fever this dosage 
may be repeated every three or four days. 
Counterirritation.—Early in the attack, when there is pain, a mustard 
plaster—one-third mustard and two-thirds flour—mixed to a paste, 
spread on cheese-cloth, and placed over the involved area for a few mo- 364 
THE PRACTICE OF PEDIATRICS 
ments, will give signal relief and may be repeated at intervals of from 
four to five hours. This form of counterirritation is also useful in the 
convalescence of delicate children when the lung clears slowly, and exam- 
ination reveals feeble breathing and many mucous rales. In such cases 
two or three applications daily until the lung clears will suffice. Each 
application should be maintained until the skin is well reddened, and 
if this does not occur within ten minutes, the mixture of mustard and 
flour should be made stronger, one part mustard to one part flour. In 
a few cases of delayed resolution dry cups daily, applied directly over 
the involved areas, have been of much service. 
The Diet.—(See Diet in Illness, p. 154.) 
Management of Pyrexia.—Whether or not antipyretic measures are 
to be used, and the nature of the antipyretic to be advised, depends 
upon the case and the family possibilities relating to care and nursing. 
One child will bear a temperature without inconvenience which would 
seriously compromise the chances of recovery of another, so that the 
thermometer is not a sufficient guide unless the effect of the fever upon 
the patient be considered. Some children will be delirious and restless 
and will need antipyretic treatment when the fever is at 103° F., yet a 
temperature of 104° F. rarely calls for interference. A rise of 1° F. usually 
means an increase of 20 to 30 heart-beats per minute. We prefer, there- 
fore, that the temperature should not go above 105° F., even if at the 
time the child shows but little inconvenience. 
Cold water, intelligently applied, is the best means of reducing fever. 
The water may be used either in the form of a sponge-bath or a cool 
pack. The sponge-bath (p. 840), repeated at intervals of from two to 
four hours, suffices in a few cases in which the temperature is readily 
influenced. As a rule the cool pack (p. 841) will be required, especially 
if the fever is particularly high. The sponge-bath, while not controlling 
the fever as well as does the pack, possesses the advantage of safety even 
when administered by the most ignorant. The procedure really amounts 
to nothing more than sponging the entire body with cool water or alcohol 
and water. The cool pack requires a trained nurse or an intelligent 
mother, either of whom should be instructed by the physician as to its 
use. When cool water is properly applied, and the packs or baths agree, 
the child, previously restless and perhaps delirious, falls into a quiet sleep; 
the temperature falls two or three degrees, the pulse becomes slower and 
fuller, and the respiration less frequent. We have never seen a carefully 
given pack or bath do harm. In fact, the water is so grateful to the 
patients that, when old enough, they often ask to have the towel made 
cooler when it becomes warm and dry from the heat of the body. 
Management of Tympa?iites.—Persistent abdominal distention even 
without peritonitis is one of the danger signs in pneumonia and signifies 
an extreme degree of toxemia. Measures to combat the condition should 
be adopted early in the case and procedure found effective should not be 
relaxed. The less serious degrees of distention are relieved by the use of 
stupes applied to the abdomen while a rectal tube is kept in the bowel to 
allow escape of flatus. The coincident administration of spiritus setheris 
compositus in doses of 5 to 10 minims given hourly by mouth may also 
be of service. Daily hot saline colon irrigations or continuous enteroclysis PNEUMONIA 
365 
by the Murphy method should be employed not only for the beneficial 
effect on distention, but to promote absorption of fluid if little is being 
taken by mouth. 
For extreme degrees of distention with almost complete enteroparesis, 
physostigmin or pituitrin hypodermically are indicated. The latter is 
probably safer and in our experience has proved more effective. The dose 
of pituitrin for a child at least three years old ranges from 3 to 5 minims. 
This dose may be repeated after an hour if necessary. 
Heart Stimulants.—A child must never be given a heart stimulant 
simply because he has pneumonia. Only when the pulse shows signs of 
weakness, great rapidity, irregularity, or reduced volume has the time 
arrived for stimulation. For a very rapid pulse, over 150, digitalis is 
the best stimulant. For a child from six months to one year old, 1 
drop of the tincture may be given every two hours—at least six doses 
in twenty-four hours; for a child from one to three years old, 1 or 2 
drops at intervals of two hours—at least six doses in twenty-four hours; 
for a child of three years or over, 2 or 3 drops at intervals of two 
hours—at least six doses in twenty-four hours. If the case is a very 
serious one, the digitalis may be given every two hours during the en- 
tire twenty-four, although if the conditions permit it is better to disturb 
the patient as infrequently as possible during the night. If digitalis 
disturbs the stomach, strophanthus may be employed. 
When the pulse is irregular and intermittent, with reduced volume, 
strychnin is justifiable. To a child from six months to a year old 1/300 
grain is to be given every three hours—six doses in twenty-four hours; 
from the first to the second year, 1/200 grain at three-hour intervals— 
six doses in twenty-four hours; after the second year, 1/150 grain may 
be given at intervals of three or four hours—six doses in twenty-four 
hours. Children who are under strychnin medication should be carefully 
watched for signs of the physiologic effects of the drug, the first symptoms 
being an unusual susceptibility to sudden noise and a slight fibrillary 
twitching of the muscles of the face and the backs of the hands. Instruc- 
tions should be given, when these symptoms appear, to discontinue the 
drug until the next visit of the physician. We have repeatedly noticed 
these signs of the physiologic effects of the administration of strychnin, 
and they need cause no anxiety. They are actually necessary in order to 
get the full benefit of the drug. However, it is only in the most severe 
cases that this drug should be pushed to such an extent. 
When the circulation of the skin is deficient, involving coldness of 
the extremities and cyanosis, indicated by blueness of the finger-nails 
and lips, nitroglycerin is indicated. To a child under one year of age, 
1/300 grain may be given at intervals of two or three hours—six doses 
in twenty-four hours; to a child from one to three years of age, 1/200 
grain at three-hour intervals—six doses in twenty-four hours; after the 
third year, 1/150 grain at intervals of two or three hours—six doses in 
twenty-four hours. Nitroglycerin, if given in large doses, produces head- 
ache, of which older children will complain, while nurslings will show 
their discomfort by restlessness and crying. 
Caffein sodiosalicylate is also very useful in cases of this nature, 
and may with advantage be employed with the strychnin. The dos- 366 
THE PRACTICE OF PEDIATRICS 
age for a child from six months to one year is \ grain. Camphor in the 
foim of the oil of camphor is useful hypodermically in the condition 
just described. It may be given in 1- to 2-grain doses and repeated in 
one to two hours. In collapse, 1 : 1000 solution of adrenalin hypoder- 
mically, administered in dosage of from 3 to 5 drops, is of much use. 
The ammonium preparations are not employed, because their admin- 
istration even for a short period invariably interferes with nutrition by 
diminishing the digestive capacity. 
Alcohol is often prescribed too early. Most cases of pneumonia pass 
through an entire attack without one drop of alcohol. This drug in any 
form should be avoided early in the disease. Later, when the case is 
doing badly, when the strychnin and digitalis, alone or in combina- 
tion, fail, the alcohol may be given, and then it may be a life-saving 
means. It is indicated at this time because it sustains the patient, and 
at the same time stimulates the heart when regular food assimilation is 
impossible. To a child under one year of age one may give from 8 to 30 
drops of brandy at two-hour intervals; from one to two years of age, 
15 drops to 1 dram at two-hour intervals; over two years, 1 to 2 drams 
at two-hour intervals. Patients who show profound sepsis will require 
and consume an enormous quantity of alcohol without showing the slight- 
est intoxicating effect. 
Illustrative Case.—During the senior author’s term as resident physician of the New 
York Infant Asylum a child fourteen months of age, ill with diphtheria, was given 4 
ounces of brandy in twenty-four hours without showing signs of stupor or intoxication. 
Hypodermic Stimulation.—The use of the hypodermic stimulation sug- 
gested is to be advised in an emergency, or when the stomach becomes 
intolerant, or when it becomes evident that drugs administered by mouth 
are not absorbed. If the dietetic suggestions are carried out, and if dis- 
turbing drugs, such as the ammonium salts, heavy syrups, etc., are omit- 
ted, there will rarely be any occasion to resort to hypodermic stimula- 
tion. When indicated, the doses suggested for the stomach may be given 
hypodermically, with the exception that alcohol should not thus be given 
in quantities greater than | dram of brandy or whisky at one time. 
Atropin sulphate in dosage ranging from 1/500 to 1/200 grain may 
be given with good effect when the breathing indicates the beginning of 
pulmonary edema. This dose may be repeated after three hours. 
Oxygen exceptionally is of value (see p. 378). 
Gavage.—Cases are encountered in which, for a time, on account of 
the profound toxemia, no food or medicine will be taken. In such in- 
stances the giving of stimulants and predigested food by means of gavage 
(p. 853) will be of material assistance. The milk used should be com- 
pletely peptonized, and to it whisky, brandy, and stimulating drugs 
may be added. The forced feeding should not be used oftener than once 
in four hours, and preferably only once in six hours. When thus given 
the individual doses of the stimulants should be increased. 
The Murphy drip method of using normal salt solution is of service 
in cases in which feeding difficulties are insurmountable. 
Specific Medication.—There is no drug known which will cut short 
or abort an attack of lobar pneumonia. Mercury in the form of large PNEUMONIA 
367 
doses of calomel, quinin, salicylate of soda, and other drugs have no 
specific action. 
Conservation of the strength of the patient, combined with careful 
medication to meet special requirements as they arise, constitutes our 
treatment of lobar pneumonia, and has given a death-rate of only 2 per 
cent, in children under two years of age. During convalescence great 
care is needed in permitting the child to resume his usual habits of life, 
for in the matters of both food and exercise we must make haste slowly. 
Transfusion.—In long-standing cases of pneumonia in which the vitality 
of the patient is at an extremely low ebb and assimilative capacity is weak 
an opportune transfusion may determine recovery. The value of the pro- 
cedure is probably greater than is generally appreciated. The new blood 
no doubt has both a nutritive and an immunizing value. 
Illustrative Case.—A boy six years of age was gravely ill with lobar pneumonia of 
very severe type. When seen in consultation on the ninth day of the disease, he had 
been comatose for three days to such a degree that the giving of nourishment was 
difficult. The temperature continued to range from 105° to 106° F. without sign of 
impending crisis. Prostration was extreme. Under very free stimulation the heart 
was showing failure of response. Transfusion was suggested and carried out, 6 ounces 
of blood being given. In the few hours following the boy showed a better general 
reaction and on the next day crisis occurred, the temperature dropping to normal. 
Recovery was uninterrupted. It is, of course, impossible to say that the temperature 
would not have fallen without the transfusion. Similar experiences, however, in extreme 
conditions make us feel that this measure was of distinct service and that in transfusion 
we have a remedy that may carry the patient over the critical period when nature is 
doing her best without the outcome desired. 
Serum Treatment.—The serum treatment in small children is relatively 
unimportant because of the low incidence of fixed types of pneumococcus 
and the fact that most children withstand a Type 1 infection perfectly 
well. The serum heretofore employed is effective only in Type I pneu- 
monia and, inasmuch as the prognosis in lobar pneumonia in small chil- 
dren is usually good anyway, there are usually no indications for em- 
ployment of serum. In the occasional severe Type I infection its use is 
justified. 
The possibility of successfully treating pneumonia in childhood with 
pneumococcus antibody solution, which was first prepared by Huntoon 
in 1919, is of great significance. The method has already given encour- 
aging results in a considerable series of adult cases under the supervision 
of Cecil and Larsen,1 and Cecil and Baldwin. 
An aqueous extract of active immune substance from antipneumococcus 
serum is employed. This extract is apparently as potent as the ordinary 
antipneumococcus serum and possesses the distinct advantage of being 
practically free from the proteins of horse-serum. By reason of its poly- 
valent character antibody solution contains protective substances against 
Types I, II, and III of pneumococcus. Moreover, apparently good effects 
have attended its use in many of the Type IV cases which constitute 
the predominant group in childhood. 
The Felton serum represents a still more highly adapted protective 
antibody preparation and gives promise of greatest efficacy both in pre- 
vention and cure of pneumonia. 
1 Jour. Amer. Med. Assoc., July 29, 1922, vol. lxxix, pp. 343-348. 368 
THE PRACTICE OF PEDIATRICS 
Bronchopneumonia (Catarrhal Pneumonia) 
Bronchopneumonia is preeminently a disease of infancy. On ac- 
count of its large mortality, and because of its frequent occurrence as 
a complication of almost every other disease of infancy, it is one of the 
most formidable ailments which we are called upon to treat. The dis- 
ease is usually described as primary or secondary. The condition, when 
described as primary, usually follows a bronchitis—often a neglected 
bronchitis—and theiefore is properly to be termed a secondary condition. 
The severity of the disease varies considerably, depending on the age 
and condition of the child, the nature of the infection, and the amount 
of lung involved. It is most fatal when associated with diphtheria, 
measles, and pertussis. 
Catarrhal pneumonia demands our most careful attention not only 
on account of the delicate organs attacked, but because, unlike lobar 
pneumonia, scarlet fever, typhoid fever, and many other diseases of 
early life, this disease has no self-limitation, no cycle. While in treating 
the other diseases mentioned we are required only to assist a patient 
through the various stages, in case of catarrhal pneumonia we must do 
more, for here a cure is demanded and we are not aided by a tendency 
to spontaneous limitation. 
Etiology.—A great majority of the cases occur in children under two 
years of age. Over one-half of these patients are under one year of age. 
After the third year bronchopneumonia is unusual except as a complica- 
tion of measles or pertussis. A chief cause predisposing to broncho- 
pneumonia is, thus, the tender age of the patient, who, on this account, 
offers little resistance to the infection. Children debilitated from any 
cause are predisposed for a like reason. 
Whooping-cough and measles more than any other diseases predis- 
pose to bronchopneumonia. In a large number of fatal cases of marasmus 
and malnutrition, bronchopneumonia is the terminating illness. 
Bacteriologic Etiology.—The bacteriologic cause of bronchopneumonia 
is not a specific entity. There are a number of micro-organisms which 
may cause the disease, and in over 60 per cent, of the cases there is a mixed 
infection. This is true even in the primary cases. The Diplococcus pneu- 
moniae (Frankel) is the organism most frequently present, but it is found 
in pure culture only about one-fourth as often as in combination with 
other organisms. In children less than three years of age Wollstein1 
found the incidence of fixed types of pneumococcus much less than in 
adults, whereas Type IV occurred far more frequently. Fortunately, 
Type III is very rare. The mortality figures for the types approximate 
the figures for adults. The streptococcus comes next in order of fre- 
quency—three times more often in combination than in pure culture. 
Staphylococcus aureus may be present alone, but is far oftener found 
with the pneumococcus or the streptococcus. The bacillus of Friedlander, 
either in pure culture or in mixed infection, is a rare cause of broncho- 
pneumonia in children. 
Since bronchopneumonia may be secondary to a variety of diseases, 
the causative organism of the primary condition in a given case may be 
1 New York State Journal of Medicine, vol. 23, No. 4, 1923. 369 
PNEUMONIA 
found in the pulmonary lesion. Thus Bacillus diphtherise, B. influenzae, 
the Bordet-Gengou bacillus of pertussis, B. typhosus, B. pestis, B. an- 
thracis, B. pyoeyaneus, or the meningococcus may be found associated 
with one or more of the pyogenic cocci. Bacillus coli communis is a pos- 
sible though very rare factor in this disease. 
Pathology.—Ordinarily the process begins as an inflammation of the 
terminal bronchioles, “capillary bronchitis,” and by extension involves 
the air-vesicles and takes on the character of a true pneumonia. Broncho- 
pneumonia is, as a rule, bilateral, and only exceptionally involves a single 
lobe of one lung. The disease usually produces inflammation of the pleura. 
The affected lung acquires increased weight and the regions most involved 
acquire a firmer consistence and a deeper red or a grayer color than normal, 
depending on the stage of the inflammation, which at the outset occasions 
intense congestion without much leukocytic exudation. On section, 
the affected portions typically appear mottled, owing to the contrast 
apparent between the masses of solid and aerated lobules. 
Microscopic examination reveals an inflammation of the bronchioles 
and of the walls of the air-vesicles immediately surrounding. There 
is not only an exudate in the air-vesicles but also an interstitial exu- 
date. In the bronchopneumonic exudate the cells are more predomi- 
nantly mononuclear, and the amount of fibrin is less than in the exu- 
date of lobar pneumonia. The lesions are distributed throughout the 
lungs in patches, but show a tendency to become conglomerate as the 
disease advances. When the inflammation subsides the exudate is re- 
moved, as at the termination of lobar pneumonia by mechanical proc- 
esses and by the agency of autolysis. The interstitial infiltration char- 
acteristic of bronchopneumonia is responsible for the occurence of its 
more important sequel®, none of which commonly follow lobar pneu- 
monia. These are chronic bronchitis, spasmodic asthma, emphysema, 
and chronic interstitial pneumonia. Pleurisy, when it occurs in children, 
irrespective of the character of complicating pneumonia, is of a pro- 
ductive type. 
Physical Signs.—Auscultation.—The signs elicited by auscultation 
depend upon the stage of the disease and the degree of lung involvement. 
The respiratory murmur may be weakened over certain areas, or it 
may be scarcely discernible. Usually an involved area will be found 
to shade off gradually to the normal. There may be several of these areas. 
Areas of localized fine mucous rales are very suggestive of broncho- 
pneumonia. The fine crepitant rale is often heard over the consolidated 
area. In cases in which there is a considerable distribution of the 
pneumonic process there will be a wide distribution of rales, with sibilant 
and fine, moist, mucous rales predominating. The rales are only evenly 
distributed in cases of the acute congestive type. In these cases they 
are heard both on inspiration and on expiration, and are of a very fine, 
crepitant quality. 
Percussion.—In the very acute cases in which the engorgement inter- 
feres with the entrance of air into the lungs extra resonance or tympanitic 
dulness may be found. In other cases the percussion-note serves as an 
indication of the degree and extent of lung involvement. The signs vary 
from normal to those of complete dulness. 370 
THE PRACTICE OF PEDIATRICS 
Palpation.—Whatever may be elicted by palpation is better dem- 
onstrated by auscultation and percussion. 
Symptoms.—The symptoms are most variable, depending upon the 
age of the patient, the severity of the infection, the extent of lung in- 
volved, and the associated illness and complications. 
In nearly all cases in which the process in the lungs is active there 
are three symptoms which rarely fail to be present: accelerated respira- 
tion, fever, and cough. The symptoms are only exceptionally urgent 
at the onset. Usually there is bronchitis for a few days, without high 
fever or rapidity of the respiration. Then, apparently on the eve of 
improvement, the temperature ranges higher, the respirations per min- 
ute increase, and the child shows prostration. 
Fi g. 72.—Bilateral bronchopneumonia involving chiefly the lower right lung. (Children’s 
Medical Division, Bellevue Hospital.) 
Examination of the lungs at this time may reveal localized fine rales, 
usually posteriorly in one or both lungs. As the urgency of the symp- 
toms increases the temperature ranges from 101° to 104° F., subject to 
considerable variations, and in the event of recovery reaches the normal 
by lysis. 
The respiration rate is from 40 to 60. The pulse-rate is rarely under 
140. The usual range is from 140 to 160. Upon the appearance of acute 
symptoms the chest signs become more marked. Localized areas of 
fine rales appear in different portions. There are also areas in which the 
respiratory murmur is very weak. Consolidation usually develops suffi- 
ciently to produce bronchophony and bronchial breathing. 
Duration.—The duration of a case of this type terminating in recovery 
is rarely less than three weeks. Often a much longer time elapses before 
the chest will be free. In the fatal cases there is an increase in the volume PNEUMONIA 
371 
of lung involved, shown by the physical signs. The heart action be- 
comes feeble, and death takes place from exhaustion or supervening com- 
plication. 
Special Types of Bronchopneumonia.—In the description of a dis- 
ease with as wide possibilities as bronchopneumonia a large number of 
types could be enumerated which would add confusion to the subject. 
As in most diseases due to infections, death may take place very early 
or the infection may be so mild as to pass unrecognized. When we take 
into consideration the age of the patient, the varieties of micro-organisms 
that may be operative, and the amount of lung tissue that may be in- 
volved, we can readily appreciate the occurrence of many and varied 
manifestations. Among these possibilities there is one feature that should 
be emphasized. Consolidation of the lung is not necessary for a correct 
diagnosis of pneumonia. Elevation of the temperature, respiration over 
Fig. 73.—Temperature chart. Bronchopneumonia. 
40, dilatation of the ahe nasi, and cough, together with mucous rales, 
usually definitely localized, are sufficient for a positive diagnosis. 
Cases of the More Active Type.—Bronchopneumonia may be so severe 
as to be fatal in a few hours. 
At the New York Infant Asylum several such cases were observed, which later 
came to autopsy. 
The condition is usually diagnosed as acute capillary bronchitis. In 
such patients the onset is sudden, with high fever, 103° to 106° F., rapid, 
labored respiration, 60 to 80, rapid pulse, 160 to 180, and cyanosis. There 
is immediately marked prostration. The child is toxic and rapidly be- 
comes unconscious. Auscultation detects a very marked increase in 
respiratory murmur, and a few fine rales. The evidence indicates a sudden 
invasion of pneumococci of a virulent type. 372 
THE PRACTICE OF PEDIATRICS 
Doubtless cases of this type are never correctly diagnosed. In two 
notable instances a positive diagnosis could not have been made but 
for the autopsy. On account of the urgency of the symptoms and the 
cerebral manifestations of stupor and sometimes convulsions, the cases 
are looked upon as those of cerebrospinal meningitis, malignant scarlet 
fever, suppressed measles, or acute toxemia of intestinal origin. 
Postmortem examination shows an intense pulmonary congestion. 
A free incision in the lung removed immediately after death will be fol- 
lowed by a profuse outflow of dark blood. Excepting the congestion and 
the presence of the pneumococcus, there are few findings to indicate the 
nature of the disease, the process having been too active and too rapidly 
fatal for the development of the lesions. 
Illustrative Case.—Several years ago the writer was called to perform an autopsy 
on a six-year-old boy who had died after a two days’ illness, the nature of which could 
not be agreed upon by the medical attendants, none of whom had suspected pneu- 
monia. The autopsy findings were those of an acute pneumonia with intense pul- 
monary engorgement and with right heart dilatation, which corresponded to the clinical 
history. 
Cases of this nature represent the extreme possibilities of pneumococcus 
infection. 
There are other cases in which the symptoms are urgent, but less 
pronounced. The onset is sudden, with high fever, 103° to 105° F. The 
respiration is rapid, 40 to 60. Rarely there is a convulsion. Vomiting 
is usually present as an early symptom and occurs but once. Except 
in the nature of the onset, the course in these cases does not vary materially 
from the usual type first described. The temperature range, physical 
signs, duration, and prognosis are much the same as in the cases of gradual 
onset. 
Bronchopneumonia Following Other Diseases.—When bronchopneu- 
monia follows pertussis, influenza, measles, or diphtheria it shows no 
variations from its usual course, but finds a lessened resistance because 
of what has gone before. The prognosis is therefore correspondingly less 
favorable, the disease being particularly fatal with or after pertussis, 
measles, and diphtheria. 
Complications.—Among the complications, otitis is probably the 
most frequent. Empyema occurs in a small proportion of the cases. 
The same is true of pericarditis, meningitis, arthritis, and nephritis. 
Emphysema is always present to a slight degree, and except in rare 
instances is demonstrable at autopsy in fatal cases in young subjects. 
If the illness has been long, with considerable lung involvement, the 
emphysema may be very extensive. 
Differential Diagnosis.—Bronchopneumonia is to be differentiated 
from acute bronchitis and lobar pneumonia. When the respiration is 
persistently above 40 per minute and the temperature persistently above 
102° F., uncomplicated bronchitis does not exist, and pneumonic involve- 
ment of the lung is highly probable. 
If there is an associated bronchial spasm increasing the respiration, 
a differential diagnosis is more difficult and sometimes impossible, as 
pneumonia may exist with a low temperature range. PNEUMONIA 
373 
In lobar pneumonia the well-defined consolidated area in the lung, 
the absence of bronchial catarrh, and the usually persistent high tem- 
perature (Fig. 71) are sufficient to establish the type of the infection. 
The x-ray is invaluable in arriving at accurate diagnosis. 
The age of the patient may be of assistance. Lobar pneumonia is 
least common under two years of age, and the great majority of the 
cases of bronchopneumonia occur before this period. 
Prognosis.—Bronchopneumonia is a disease of high mortality. In 
children’s hospitals and institutions a considerable portion of the total 
mortality is due to bronchopneumonia. It is safe to say that from 25 
to 50 per cent, of such hospital cases are fatal. This, of course, includes 
all cases of bronchopneumonia, those complicating whooping-cough, 
measles, scarlet fever, and diphtheria, as well as the terminal cases that 
occur late with many other ailments. The age and previous condition 
of the patient have a decided influence upon the mortality. The younger 
and feebler the patient, the less is the chance for recovery. 
Rachitis, malnutrition, and marasmus are indirectly accountable 
for many deaths. 
Treatment.—In treating bronchopneumonia it must be our effort to 
preserve every strength unit which the child possesses. An immense 
amount of vitality is wasted because of irritability, restlessness, and loss 
of sleep. One of the first duties in a given case is not to give this or that 
drug or use this or that local application, but to make the child comfort- 
able. 
The Sick-room.—The value of a constant supply of fresh air is too 
little appreciated. In every case there should be a direct communica- 
tion between the sick-room and the open air throughout the attack. 
Various means of ventilation have been devised, of which the window- 
board (p. 26) is the most effective, as it separates the sash and allows 
the free entrance of a current of air which is directed upward. If plenty 
of fresh air at a proper temperature were available during the early part 
of the illness there would be much less use for tanks of oxygen later. 
An absolute necessity in a sick-room is a thermometer. In pneu- 
monia cases it should never register above 70° F. There is a marked 
tendency to coddle, to wrap, and to overclothe the patient. Even during 
the winter, absolutely nothing more is required than a medium-weight 
flannel shirt, a band, if one is ordinarily worn, and the usual night-dress. 
The oiled-silk jacket is cumbersome, cannot be kept clean, and over- 
heats the patient. An infant with catarrhal pneumonia, heavily clad, 
in an unventilated, overheated room, and in close contact with an adult 
body, is tremendously handicapped. There is but one place for a sick 
infant, and that is in his own roomy crib. 
Diet.—In every illness with fever the digestive capacity is consider- 
ably reduced. If the usual milk diet is continued a gastro-enteric infec- 
tion may be added as a serious complication to the existing disease. For 
the breast-fed child a drink of water should be ordered just before the 
nursings and in the intervals between them. The nursing hours should 
be the same as in health, but the time allowed for each nursing should 
be reduced from one-third to one-half. For the bottle fed the milk strength 
should be reduced from one-third to one-half by dilution with water, 374 
THE PRACTICE OF PEDIATRICS 
the quantity remaining the same. Children from two to four years of 
age should be restricted to a diet of diluted milk, gruels, and broths. 
Bowels.—Normal bowel function is more necessary for the sick than 
for the well. There should be at least one stool in twenty-four hours. 
General Treatment.—Having placed the child under the best dietetic 
and hygienic conditions, we are in a position to use medication to a much 
better advantage. But in its use, and in performing the various offices 
for the patient, it must be our effort to disturb him as little as possible. 
In our anxiety to do, we are very liable to overdo, with disastrous results. 
If a well child were given syrup expectorants, stimulants, baths, and local 
applications, something being done for him every hour or two in the 
twenty-four, he would have to be strong to withstand the treatment. 
We should treat our ill with still greater consideration. The intervals 
between which the child is to be disturbed at night should be made as 
long as possible by giving food, medicine, and local treatment at one 
time. When possible, we always endeavor to make the interval at least 
three hours. 
Steam Inhalations.—Among the distinctly remedial measures steam in- 
halations with creosote deserve an important place. The patient is placed « 
in the crib, which is covered and draped with sheets so as to make a fairly 
tight inclosed space. The apparatus necessary is an ordinary croup ket- 
tle. Ten drops of creosote added to 1 quart of water are poured into 
the kettle. The nozzle of the kettle is introduced between the sheets 
at a safe distance from the child’s face and hands, the steaming being 
carried on for thirty minutes every three hours. The sheets should be 
parted slightly about every ten minutes to allow a renewal of the air. 
The inhalations are to be given whether the patient is asleep or awake. 
As he improves, they may be given less frequently until normal respira- 
tions and the chest signs tell us this treatment is no longer required. 
Counterirritants.—The application of counterritants to the skin over 
the thorax is of great service in cases in which there is much bronchial 
catarrh. This includes, of course, most cases. In order that a counter- 
irritant may be of service a distinct red blush must be produced on the 
skin. Turpentine diluted with oil—one-third turpentine and two-thirds 
oil—when briskly rubbed on the parts for a few minutes produces a fairly 
satisfactory counterirritation. An objection to its use is the rare occurrence 
of albuminuria in a patient abnormally susceptible to this drug. The old- 
fashioned home-made mustard plaster has also served well. Written 
directions should always be given for the preparation of the plaster, and 
the boundaries of the area of the skin to be covered should be outlined 
with a pencil on the skin surface. If the nurse or mother is told merely 
to put a mustard plaster on the chest, a plaster the size of a man’s hand 
will usually be placed somewhere between the umbilicus and the chin. 
For the first two or three applications 1 part of mustard to 2 parts 
of flour is used. This is moistened with warm water and made of the 
consistence of a rather thin paste, which is then spread upon cheese-cloth, 
old muslin, or linen, cut to the desired size. The plaster is readily held 
in position by a bandage or any thin material extending around the 
chest. When the skin is well reddened—usually within from five to fifteen 
minutes—the plaster is removed and vaselin or sweet oil is applied. PNEUMONIA 
375 
One should never use a plaster oftener than once in six hours, and then 
only in the severest cases. Ordinarily, two or three applications in twenty- 
four hours are sufficient. If the plasters are continued for several days, 
in order to avoid blistering it will be necessary to make them much weaker 
after a day or two—1 part of mustard to 5 or 10 of flour. Counterirrita- 
tion is particularly effective when used at the commencement of an attack. 
Mustard Baths.—In cases of sudden onset with high fever, rapid 
breathing, and cold extremities, a mustard bath—1 tablespoonful of 
mustard to 6 gallons of water at 110° F.—will often furnish marked 
relief from the immediate symptoms. The duration of the bath should 
be from one to three minutes, in which time the skin should be subjected 
to active manipulation by hand rubbing. The bath may be repeated at 
six-hour intervals. 
This type of bronchopneumonia is usually very rapid in its develop- 
ment, the child being relieved or dead within thirty-six to forty-eight 
hours. By “relieved” we do not mean that recovery has occurred, but 
that the acute, urgent symptoms have subsided. In our opinion only 
these rapid cases should be considered primary. Autopsies on such 
subjects show a general congestion of the internal organs, with intense 
congestion of the lungs. 
Drugs.—The internal medication is, to a large extent, symptomatic. 
It is particularly necessary that, in our endeavors to assist the patient, 
we do nothing to cause harm, for we are treating a disease in which resist- 
ance counts for everything. In illness with fever, with the accompanying 
nervous exhaustion, the stomach is most easily disturbed, the child is 
then not properly nourished, and his powers of resistance are markedly 
diminished. 
Expectorants must be given with care, and are better prescribed 
in the form of tablets or powders. The use of heavy syrups of wild cherry, 
tolu, etc., with large doses of the ammonium salts, only adds to the burden 
of the patient. For a child one year of age with bronchopneumonia 
1/100 grain of tartar emetic and 1/40 grain of ipecac answer well as an 
expectorant. If the cough is very severe and persistent, \ grain of Dover’s 
powder in tablet form with sugar-of-milk, dissolved in at least 2 tea- 
spoonfuls of water, may be given, preferably after feeding, not oftener 
than once in two hours. The ammonium salts so generally used in catar- 
rhal pneumonia for routine treatment are badly borne by the stomach. 
Ammonium muriate is of some value during resolution, but to a child 
two years old it should not be given in larger doses than \ grain well 
diluted at two-hour intervals because of its irritant effect on the stomach. 
In the event of high fever and great restlessness, which are not 
affected by sponging, and where, for any reason, rational bathing is 
impossible, a combination of caffein, Dover’s powder, and phenacetin 
may be used. To a child one year of age may be given \ grain of caffein, 
grain of Dover’s powder, and 1| grains of phenacetin at four-hour 
intervals. In giving Dover’s powder it is well to watch the bowels, as 
constipation often follows its use. 
A heart stimulant should never be given simply because a child has 
pneumonia or diphtheria or scarlet fever, but it should be given in pneu- 
monia or diphtheria or scarlet fever as soon as the heart needs assistance. 376 
THE PRACTICE OF PEDIATRICS 
Briefly, there are two conditions to guide us—a very rapid pulse and a 
soft, not rapid, pulse, with a tendency to irregularity. As a general 
rule one may say that a heart which is beating at the rate of 150 a minute 
during quiet or sleep, and which is not strengthened by sponging or 
packs, needs assistance. The drug which is here indicated is digitalis, 
which acts as a direct stimulant to the heart muscle. The pulse, by its 
use, is made stronger, fuller, and less rapid. When the heart’s action 
shows a tendency to irregularity, with a soft, easily compressible pulse, 
then strychnin is the remedy. Caffein sodiosalicylate in §-grain doses 
every two hours is also of much use in such a condition. To a child one 
year of age 2 drops of tincture of digitalis in water may be given every 
three hours, or 1/300 grain of strychnin every three hours, to be increased 
to 1 /200 or even to 1/100 grain every three hours for a few doses, if the case 
is carefully watched for symptoms of strychnin-poisoning. Digitalis and 
strychnin possess advantages over all other stimulants in that they do their 
work and have no unpleasant effect on the stomach, as is the case with 
alcohol, digitalis, and the ammonium preparations. If the condition is 
very urgent, digitalis and strychnin may be used in combination. Alcohol 
in the form of whisky or brandy is very rarely of great service in catarrhal 
pneumonia. It may stimulate the heart, but its prolonged use greatly 
upsets the stomach. It should be withheld until late in the disease, when 
other means of stimulation fail. Then, given in large amounts, it may 
be the means of saving the patient; \ dram of whisky or brandy, well 
diluted, may be given every hour or every two hours to a child one 
year of age. However, the cases of catarrhal pneumonia actually saved 
by the use of alcohol are few indeed. Nitroglycerin, 1/300 grain every 
three hours for a child one year of age, is of service in cases where there 
is marked cyanosis with cold extremities. Its use should be discontinued 
as soon as improvement in this respect is noticed. The one unpleasant 
feature observed from its administration is its tendency to produce head- 
ache and marked restlessness. 
Hypodermic Medication.—In all urgent cases in which collapse is 
threatened, or when oral medication does not give results desired, one 
may employ the hypodermic, using the same dosage given by the mouth. 
Camphor may be given in 2-grain doses and repeated hourly if neces- 
sary. Digitalin, in dosage of 1/200 grain, may be given and repeated 
in three or [four hours. For urgent collapse, camphor, and 1:1000 solu- 
tion of adrenalin in dosage of 3 to 5 minims, are our best stimulants. 
Baths.—A sponge-bath at 95° F. for cleansing purposes may be given 
daily. 
Pyrexia.—What is to be our guide in dealing with the pyrexia? At 
what degree of temperature are we to interfere? This depends to a great 
extent upon what is behind the fever and the effect of the fever upon 
the individual patient. If a child has a high fever and is more comfortable 
when it is reduced, if he will digest his food better and sleep better, our 
duty is to reduce temperature. Further, by reducing it we lessen the work 
of the heart, saving many beats per minute. Usually, when the rectal 
temperature has a tendency to run above 104° F., interference is of ad- 
vantage, and the best means at our command is the use of local applica- 
tions of water in the form of sponge-baths or packs. If the temperature PNEUMONIA 
377 
is easily controlled, a sponge-bath will answer our purpose. Either salt 
or alcohol may be added to the water. Ordinarily, 2 teaspoonfuls of 
salt to 1 quart of water, or 1 part of alcohol to 3 parts of water, is ample. 
Cold water thus used serves two purposes—it acts as a sedative and it 
reduces the fever. 
Cold sponging, while not as effectual as a bath or a pack, possesses 
the advantage of being applicable even in the hands of the most unskilled. 
For sponging, the child should be stripped and covered with a flannel 
blanket, the sponging being done under the blanket. In order not to 
antagonize or frighten him, it is best to begin with the water at 95° F. 
and gradually to reduce the temperature to 70° or 75° F. by the addition 
of ice or cold water. The sponging may be continued from ten to twenty 
minutes, and should not be repeated at shorter intervals than ninety 
minutes. After the sponging is completed the skin should be rubbed 
briskly for a few minutes with a dry towel. If the temperature is not 
readily controlled in this way, it is best to use other means, as too fre- 
quent sponging exhausts the patient. As a means of controlling the 
temperature in children the tub-bath has not proved successful in our 
hands. The exposure, the fright, and the * necessary shortness of the 
bath render it very unsatisfactory. 
By far the best means at our command for controlling a continued 
high fever is the cool pack (p. 841). Properly applied, it is without the 
slightest danger. A large bath-towel or any thick absorbent material 
may be used, slits being cut in one end of the towel through which the 
arms may pass. The towel should be folded over the body, and should 
extend from the neck to the middle of the thighs, the arms and the legs 
from the knees down remaining free. A hot-water bag, carefully guarded, 
should be placed at the feet. The towel is moistened with water at 95° F. 
It is well to make the pack warm at first, so that the child will not be 
frightened, as shock will thus be avoided. In two or three minutes the 
towel is moistened with water at 85° F., then at 80° F. When 80° F. is 
reached it is best not to make the water any colder for half an hour, at 
the expiration of which time the temperature of the patient should be 
taken. If, in the beginning, it is 105° F. and at the expiration of the half- 
hour shows slight or no reduction, the temperature of the pack may be 
reduced to 70° or even to 60° F. by the addition of cold water or ice, with- 
out removing the child, who is turned from side to side so that all parts of 
the enveloping towel may be moistened with cool water. During the first 
hours in the pack the temperature should be taken every half-hour, and 
when it is reduced to 102° F. the child should be removed and wrapped 
in a warm blanket. In cases of sudden and persistent high fever the child 
may be kept in the pack continuously. We aim to keep the tempera- 
ture between 102.5° and 103.5° F. A fresh towel should be applied every 
three hours. An ice-bag should be kept at the head, a hot-water bag 
at the feet, and the patient should be covered with a flannel blanket of 
medium weight. The degree of cold necessary to control the fever in a 
given case will soon be learned. 
The writer kept in a pack for seventy-two hours a four-year-old boy ill with lobar 
pneumonia. In this case a pack at 70° F. was necessary to keep the temperature at 
104° F. or slightly lower. 378 
THE PRACTICE OF PEDIATRICS 
Oxygen is of immense service in very severe cases with much lung 
involvement. It may be given for one or two minutes out of every seven 
or ten, or continuously with the funnel kept a few inches from the child’s 
face. As often given, for one or two minutes every half-hour, it is of 
little or no service. 
Transfusion is of value under the exceptional conditions which may 
call for its employment in lobar pneumonia (p. 367). 
INTERSTITIAL PNEUMONIA AND BRONCHIECTASIS 
Interstitial pneumonia occurs in two types of cases. After bron- 
chopneumonia the interstitial variety represents an unresolved pneu- 
monia, and usually means that the individual has had more than one 
attack. The great majority of such cases are seen in ill-conditioned 
infants in hospitals and institutional homes. Rarely is this type seen 
in older children. 
The second type represents the cases of unresolved pneumonia, usually 
lobar pneumonia, which have been complicated by empyema, and in 
which the empyema has not been recognized or has been improperly 
treated. 
Pathology.—Chronic interstitial pneumonia is a productive inflam- 
mation characterized by thickening of the connective-tissue framework 
of the lung. This disease follows one or more attacks of bronchopneu- 
monia or may accompany a chronic empyema. The process may involve 
one or more lobes of the lung or only a portion of one lobe. The involved 
lung is usually adherent to the chest wall by very dense fibrous adhesions, 
and is smaller than normal, firm, and grayish in color. On section, the 
pleura and connective-tissue septa are found to be greatly thickened. 
The bronchi are often dilated, and may be the seat of purulent bronchitis. 
Microscopic examination shows that the interlobular septa, the walls 
of the bronchi and blood-vessels, and the alveolar walls are thickened 
with connective tissue. As a consequence some alveoli may be obliterated. 
Compensatory emphysema is often present in a portion of the un- 
affected lung. 
Symptoms .—Not half the symptoms described by writers exist. 
The principal manifestation is afforded by the condition of the patient, 
who is anemic, emaciated, and fails to thrive, or improves but slowly 
even under the best surroundings. 
There may be cough and, rarely, fever. The respiration is acceler- 
ated upon exertion, but otherwise shows no change. If there is an as- 
sociated bronchiectasis, in older patients there will be mucopurulent or 
purulent expectoration. 
Illustrative Case.—A boy for several years expelled free expectoration about once 
a day. There was an interstitial pneumonia involving the lower half of the right 
lung, which was the seat of one or more bronchiectatic cavities. The pus evidently 
collected periodically and filled the cavity, then producing cough and emptying of the 
cavity. 
Diagnosis.—Inspection.—There may be extensive retraction of the 
chest wall or none at all, depending on the age of the patient. In infants 
under eighteen months there is rarely such retraction. INTERSTITIAL PNEUMONIA AND BRONCHIECTASIS 
379 
Upon forced inspiration, as in crying, it will be noticed that the chest 
wall over the involved lung area fails to take part in the normal respiratory 
excursion. Older children exhibit varying degrees of retraction, usually 
associated with spinal curvature. 
Auscultation.—The respiratory signs are subject to wide variations. 
Thus in one case there may be bronchial breathing over one diseased 
area and entire absence of the respiratory murmur over another area. 
Between these extremes in the same case there may be a variety of 
abnormal respiratory sounds. Over the uninvolved lung the respiratory 
murmur undergoes pronounced exaggeration. If there is a consid- 
erable bronchiectasis, signs of a cavity will be indicated by amphoric 
breathing. 
Percussion invariably shows localized dulness over the diseased por- 
tion of the lung. One may find all shades of dulness to flatness. Over the 
free portion of the lung hyperresonance will be found because of the 
emphysema, which is always present in slight or moderate degree. 
x-Ray examinations are of great value, if repeated over a considerable 
period of time, in showing recession or extension of the process. 
Differential Diagnosis.—The question that always arises in these 
cases relates to the possibility of tuberculosis. A considerable number, 
particularly under two years, do develop tuberculosis. An examination 
of the sputum and the intradermal tuberculin test should invariably be 
made. In cases in young infants a positive tuberculin reaction supplies 
reliable corroborative evidence. Repeated examination of the bronchial 
secretions (p. 396) will reveal the tubercle bacillus if it is present. When 
the lesions are tuberculous in older children examination of the sputum 
quickly determines the diagnosis. 
Prognosis.—The prognosis in an infant is very unfavorable. If tuber- 
culosis does not develop, intercurrent disease, such as the intestinal disease 
of summer, whooping-cough, measles, or acute pneumonia, will very likely 
terminate the case. Recovery is not impossible, however, and infants have 
been observed to make almost complete recoveries after the process had 
existed for months. In one case the child’s chest did not begin to “clear” 
until after the third month. In recovery cases the interstitial change 
cannot have been at all extensive. 
In an older child after the sixth year a favorable prognosis as regards 
life is the rule. Whether the case follows bronchopneumonia or pneu- 
monia with empyema, even with the best results, there will be left a more 
or less crippled lung, which does not necessarily compromise the later 
well-being of the patient. Such patients, however, are more liable to 
tuberculous infection, and this possibility is always to be taken into con- 
sideration in their management. 
Bronchiectasis is present in a considerable number of cases of intersti- 
tial pneumonia, both in the young and older children, consisting of dilata- 
tion of the bronchi, usually sacculated or cylindric in form. 
Illustrative Case.—The lungs of a child eighteen months of age who died from 
bronchopneumonia of three months’ duration, with terminal sepsis, presented several 
small cylindric dilatations. One of these, with a capacity of 6 drams, was found in 
the right lung. This case is similar to many seen at autopsy. 380 
THE PRACTICE OF PEDIATRICS 
In young infants bronchiectasis may be very difficult of demonstra- 
tion. In the cases of older patients the expectoration of pus in a chronic 
pneumonia is very suggestive, and in such instances physical examination 
may reveal amphoric breathing and other signs of cavity. 
Dilatation of a bronchus may be cylindric, sacculated, or spindle 
shaped. It is accompanied either by atrophy or by hypertrophy of the 
mucosa and of the entire bronchial wall. Dilated bronchi contain thick 
mucous or purulent secretion, often in very large amount. The secretion 
may be blood-stained, due to rupture of some of the very numerous 
blood-vessels in the hypertrophied mucosa. Pressure of the dilated 
bronchi often causes collapse of the pulmonary alveoli surrounding them. 
The walls of neighboring bronchi may fuse, forming larger cavities. 
Treatment.—The treatment of interstitial pneumonia is not par- 
ticularly brilliant in results. There is always the hope that the inter- 
stitial process dependent on cicatricial change is not extensive, for this 
feature determines in no little degree the outcome of the case. When 
resolution takes place, it occurs always from the periphery toward the 
center of the diseased part. The involved area becomes smaller and 
smaller and disappears, or, more frequently, as the ultimate outcome, 
an area of weakly vesicular breathing remains to mark the site where 
the disease was most active. 
Little can be accomplished by the use of drugs except to improve 
the nutrition of the patient. Children with this unfortunate pulmo- 
nary disease should take up their permanent residence in a dry climate, 
like that of Colorado or New Mexico. A visit of a few months or a year 
is of but little service. The writer used the iodids and the bichlorid of 
mercury for months without any appreciable improvement in two of 
these patients who could not be removed from town. The citrate of iron 
and quinin, 1 grain in a dram of sherry wine, makes a good appetizer, 
and may be given in \ glass of water after meals. Its use can with ad- 
vantage be alternated with that of the syrup of the hvpophosphites 
(Gardner), 1 to 3 drams being given daily in | glass of water after 
meals. Cod-liver oil may be used with advantage for ten days out of 
the month, but its continued use is contraindicated, as it is apt to inter- 
fere with digestion. 
Illustrative Case.—In one of the cases above referred to the iron was given for ten 
days and the oil for ten days, after which the procedure was steadily repeated. The 
patient continued to look well, gained in weight, and remained under treatment until 
he took up an occupation and passed from observation. The condition of the lung 
had remained unchanged, the only active manifestation of the disease being the ex- 
pectoration of a considerable amount of non-tuberculous pus every morning on rising. 
Whenever periodic accumulations of pus are demonstrated the child 
should practice leaning over a chair at least twice daily with head and 
trunk inverted to facilitate evacuation of the cavity. Frequently after 
such a maneuver with its attendant coughing up of expectoration there 
will be localized hyperresonance and amphoric breathing where a few 
minutes previously had been dulness and diminished breath sounds. It 
is desirable that the cavity should be distended by accumulation of secre- 
tion as little of the time as possible. 
Infants and children with bronchiectasis who cannot be removed PNEUMOTHORAX 
381 
to a favorable climate should have the advantages of outdoor life, and 
older children should have as much active exercise as is possible with- 
out fatigue. The diet and general management are the same as for pul- 
monary tuberculosis (p. 397). In a considerable number of cases under 
observation at Bellevue Hospital creosote has been continuously adminis- 
tered, with apparently good effect. 
Gymnastic Therapeutics.—For the purpose of expansion of the lung 
with the hope of curing the chest deformity gymnastic exercises are of 
the greatest value. 
Following the aspiration of foreign material into the lower air-passages 
pneumonia may rapidly develop. In the case of aspiration of a single for- 
eign body such as a seed or kernel the process may be definitely localized. 
When the insufflation takes the form of aspiration of vomitus under an- 
esthesia or is produced by direct mechanical action, such as may occur 
when blood or secretions are forced downward under anesthesia ad- 
ministered intranasally or intratracheally by a tube, the pneumonia 
may be disseminated. This form of pneumonia is the type probably 
most frequently developing in infants or in children with low vitality 
who undergo cleft-palate repair, retropharyngeal abscess incision, and 
tonsillectomy under deep anesthesia. 
The possibility of the occurrence of pneumonia of this type should 
never be overlooked by operators or anesthetists. 
The accidental aspiration of stearate of zinc by infants is a well- 
established cause of asphyxia and lung irritation with lesions which may 
give rise to areas of consolidation and give the physical signs and 
symptoms of bronchopneumonia even though cultures from lung tissue 
taken postmortem may be found sterile.1 The loosely capped talcum 
powder box should, therefore, be regarded as a dangerous toy. 
INSUFFLATION PNEUMONIA 
Hypostatic pneumonia is a form of lobular pneumonia which de- 
velops in fatal cases in the most dependent portions of the lungs, these 
portions having become very hyperemic as the result of weakness of the 
heart and respiration in patients who are severely ill. 
The affected pulmonary tissue is dark red in color, very firm, and 
airless. On section, the cut surface is red and very moist, exuding blood 
freely. Microscopically, the capillaries and veins are distended with 
blood, and the alveoli are filled with red blood-cells, leukocytes, and 
desquamated epithelium. The bronchi are usually in good condition. 
The extent of the consolidation varies. While it usually occupies only 
a superficial strip along the posterior border and base of the lungs, fully 
half of the lower lobes may be involved. 
HYPOSTATIC PNEUMONIA 
Air in the pleural cavity may be due to tuberculosis or to trauma 
(usually through exploratory puncture) causing perforation of the lung. 
We have seen only one or two undoubted cases of this nature. Pneu- 
PNEUMOTHORAX 
1Heiman and Aschner, Amer. Jour. Dis. Child., June, 1922. 382 
THE PRACTICE OF PEDIATRICS 
mothorax also may occur in empyema. By far the most frequent cause 
in children is the formation, by a tuberculous cavity, of a communication 
between a bronchus and the pleural cavity. 
Artificial pneumothorax is employed as a means of treatment in 
selected cases of tuberculosis. 
Symptoms .—In the tuberculous cases of pneumothorax the symp- 
toms comprise very sudden onset of urgent collapse, urgent dyspnea, 
cyanosis, and rapid, feeble pulse. In cases due to trauma the symptoms 
may be urgent or scarcely noticeable, depending upon the extent of the 
lesion. In a case which developed after exploratory puncture, only a 
moderate amount of air entered the pleural cavity and no inconvenience 
was occasioned. 
Physical Signs.—The physical signs are determined largely by the 
amount of air entering the pleural cavity. They may include simply 
Fig. 74.—Pneumothorax resulting from traumatic rupture of the right lung which 
appears as a solid mass close to the midline. (Children’s Medical Division, Bellevue 
Hospital.) 
hyperresonance and absence of respiratory sounds. In cases of tuber- 
culous origin there is usually a sudden inrush of air, with resulting im- 
mobility of the affected side and enlargement of that side of the thorax. 
There is marked hyperresonance, and an absence of fremitus. In cases 
in which the amount of air is not excessive there will be tympanitic dul- 
ness. Displacement of the heart by the accumulated air under pressure 
may be demonstrated in extreme cases. 
Auscultation reveals very weak breath sounds or entire absence of 
the same. The coin test is very diagnostic. A coin is placed on the chest, 
either anteriorly or posteriorly, and tapped with another coin by an 
assistant, while the ear of the examiner is placed on the opposite aspect EMPHYSEMA 
383 
of the same half of the chest. The sharp metallic sound conveyed, in 
comparison with the absence of sound over the opposite lung, furnishes 
a demonstration to students that will never be forgotten. If there is 
fluid in the pleural cavity, splashing, metallic, tinkling sounds may be 
heard. 
Diagnosis.—A rare condition in which the diagnosis of pneumothorax 
has wrongly been made is congenital diaphragmatic hernia. Tympanitic 
coils of intestine in the thoracic cavity of a child ill with bronchitis or 
pneumonia strongly suggests pneumothorax. Radiographs not only of 
the lungs but also the gastro-intestinal tract are essential to give a satis- 
factory demonstration in such an instance. 
Prognosis.—The prognosis depends upon the cause of the air in the 
pleural cavity. The tuberculous cases are rapidly fatal. After trauma 
the recovery depends upon the nature of the injury. In the cases fol- 
lowing exploratory puncture recovery without treatment is common. 
Treatment.—In complicating empyema the fluid should be removed 
by surgical procedures. If there is marked displacement of the heart and 
considerable intrathoracic pressure, tapping the chest with a needle, 
and allowing an escape of the air, may be of value, particularly if a valve- 
like action at the aperture in the lung has induced extreme compression 
of air in the pleural cavity. 
EMPHYSEMA 
Emphysema is a secondary disease. There are few autopsies on 
children dying from pulmonary disorders in which it is not found pres- 
ent in greater or less degree. It is always present in considerable amount 
in cases of interstitial pneumonia, and in this association the emphysema 
is compensatory in character. It is found with whooping-cough, broncho- 
pneumonia, habitual spasmodic bronchitis, and true asthma. 
Pathology.—Emphysema is most frequently found in a pronounced 
degree in the upper lobes, especially at the anterior borders and the 
apices. The air-vesicles are persistently dilated, and on inspection, to 
the unaided eye, present a picture of innumerable pin-point air-bubbles. 
When the septa give way the vesicles enlarge so that blebs of various 
size occur. The condition rarely becomes interlobular. 
Symptoms.—In many cases there is no special manifestation, and 
the fact that emphysema exists is discovered only at the autopsy. This 
is particularly common in compensating cases in which there is a good 
deal of lung involvement, as in interstitial pneumonia or in prolonged 
bronchopneumonia. 
When there has been repeated spasmodic bronchitis or true asthma, 
there is shortness of the breath, with rapid breathing, and the thoracic 
wall presents a fixed appearance owing to the diminished or impercep- 
tible respiratory excursion. 
The so-called barrel-shaped chest is seen in children, but is of com- 
paratively infrequent occurrence. 
The child usually has a dry cough, is incapable of the usual exer- 
tions of early life, and readily becomes cyanosed through air-hunger. 
Physical Signs.—Percussion.—There is increased resonance on per- 
cussion, general in distribution, but most marked over the upper lobes 384 
THE PRACTICE OF PEDIATRICS 
in front. When the emphysema is not excessive tympanitic dulness may 
be elicited. The area of cardiac dulness may be much smaller than normal 
or entirely obliterated. 
Auscultation.—Upon auscultation the respiratory murmur is found 
to be feeble, and expiration is noticeably prolonged and longer than 
inspiration. Squeaking, small, dry rales are usually heard in children 
because of the almost invariable association of bronchitis. The rales 
are heard both on inspiration and on expiration. The respiratory sounds 
have been aptly described as wheezing in character. 
Prognosis.—The prognosis in general emphysema is unfavorable. 
The attacks of recurrent asthma or recurrent spasmodic bronchitis, which 
induce the process, continue, and the condition becomes most pitiable. 
Dilatation of the right heart ultimately occurs. Cardiac failure and 
acute pulmonary disease are the usual terminal affections. 
Treatment.—The management is that of the associated condition. 
SUBCUTANEOUS EMPHYSEMA WITH EMPHYSEMA OF THE MEDIASTINUM 
This is a rare condition in children. Before the use of intubation, when 
tracheotomy was in vogue, many more cases were seen than now. Other 
causes may be pertussis, tuberculosis, or trauma to the lung. The first 
site affected is typically the mediastinum, whence the emphysema extends 
to the subcutaneous tissues and is particularly apt to appear above the 
clavicles, where it produces a cushion-like effect. In one case the emphy- 
sema extended from this point downward over the thorax, and upward, 
involving the entire neck. 
Prognosis.—Cases following operative procedures and trauma may 
undergo recovery. When the condition is a complication of pulmonary 
disease the outlook is very unfavorable. 
PRIMARY PLEURISY 
Acute, primary pleurisy is a very rare condition in children. Of 5 
patients with this condition, under nine years of age, 1 was eight; 1, 
seven; 1, four years of age; 1, two and a half years, and 1, only fifteen 
months old. 
Pathology.—In these cases there is inflammation of the pleura with 
exudate, but usually not sufficient inflammation to produce an appre- 
ciable exudate. 
Symptoms.—The onset of the disease is practically the same as in 
adults. There is localized pain—the so-called “stitch in the side”; the 
respiration is rapid—40 to 60 to the minute—and shallow; the skin is 
dry and hot; the cough is teasing, and, on account of the pain which it 
causes, is partially suppressed by the patient. Fever is present, usually 
ranging from 102° to 105° F. The pulse is rapid—120 to 150 to the 
minute. In two cases the pleuritic inflammation was followed by effusion. 
The fluid in both cases was sterile. So far as we could learn there was no 
associated rheumatism in any of the cases. 
Treatment.—The treatment which proved successful in the 5 cases 
cited was rest in bed. The patients were given a reduced diet of milk, SECONDARY PLEURISY 
385 
broths, and gruel. The fever was not of a very persistent character and 
was readily controlled by sponge-baths. A flaxseed and mustard poultice— 
1 part of mustard to 9 parts of flaxseed—applied as hot as could be borne 
by the back of the nurse’s hand, and changed every half-hour, gave much 
relief from the pain during the acute stage. After the first twenty-four 
hours, however, poultices are of little value. Strapping the affected side 
with strips of Z. O. plaster will give much comfort when the pain con- 
tinues after the second day. Tincture of aconite in doses of 1 drop 
every hour may be given to older children until 10 drops have been given. 
This has produced a fairly free diaphoresis and made the patients more 
comfortable. A grain of calomel in divided doses may be given early in 
the attack, 1/10 grain being given every ten or fifteen minutes. To relieve 
the cough, small doses of codein, 1/10 grain every two hours, may be 
given the older children. 
The duration of the acute symptoms is ordinarily from twelve to 
twenty-four hours, the entire duration of the illness ranging from five 
days to one week. 
In the case of effusion in our youngest patient absorption appeared 
to be stimulated by the introduction of the needle and the withdrawal 
of a small amount of fluid, the remainder quickly disappearing afterward. 
Ultimate Results.—That the cases observed were not of tuberculous 
origin was strongly indicated not only by the absence of the tubercle 
bacilli, but by the complete recovery and continued good health of each 
patient during the next few years. 
SECONDARY PLEURISY 
Etiology.—Tins form of pleurisy is of very frequent occurrence in the 
young, and in by far the larger number of cases occurs as a complication 
of pneumonia. 
Tuberculosis is probably the next most frequent cause. 
Secondary pleurisy may occur with pericarditis; such an association, 
however, is rare. 
Bacteriology.—Acute fibrinous (dry) pleurisy accompanying pneu- 
monia in children is caused by the identical micro-organism found in the 
consolidated areas of lung tissue. This type of pleurisy is more com- 
mon with lobar pneumonia than with bronchopneumonia. 
In acute serous pleurisy accompanying pneumonia small numbers 
of pneumococci may be found in the fluid. Clear, serous, pleural fluid 
containing streptococci has been described. 
In the tuberculous cases the fluid contains the tubercle bacillus, 
demonstrable by staining methods or by intraperitoneal injection into 
guinea-pigs. On ordinary culture-media tuberculous serous fluids give 
no growth. 
Pleurisy with serous effusion may occur with acute rheumatism. 
Pathology.—Following or coincident with pneumonia there may 
occur what is known as dry pleurisy, or pleurisy with effusion. When 
dry pleurisy exists, the pleura loses its usual luster, and, early in the 
attack, is covered with a slight fibrinous exudate. Exudation may go 
no further than this, or it may become most extensive, resulting in a TIIE PRACTICE OF PEDIATRICS 
network of fibrinous bands, in the meshes of which there is a thick, 
gelatinous mass composed largely of fibrin and pus-cells. 
Repeatedly at autopsy the lung will be found so thoroughly bound 
to the chest wall that its removal without the aid of force is impossible. 
In pleurisy with effusion a fluid composed either of pus or of serum 
will be found in the pleural cavity. We have never seen such a case of 
pleurisy secondary to pneumonia in which the effusion did not contain 
bacteria. The fluid upon withdrawal may appear clear, yet bacterio- 
logic examination will show that it is not sterile. The evidence of bac- 
teria in the fluid may be, and often is, the first manifestation of a purulent 
pleurisy or empyema. 
Pleurisy of tuberculous origin may or may not be of the dry type. 
Tubercles may be found on the pleura, and there is more or less exudation 
of fibrin. If the process is an old one, there is considerable thickening 
of the pleura, with very firm adhesions. Effusion, when present in this 
type, often exists in small amount—1 to 4 ounces—sacculated, and 
may be serous or purulent. 
Symptoms.—Secondary pleurisy rarely exhibits distinct symptoms 
of its own. The manifestations are a part of the disease which the pleurisy 
complicates. There may be localized pain, but this is rarely of an active 
type. A sensation of tightness or constriction is more common, and it 
is surprising how little discomfort is present in a vast majority of the 
cases. When fluid is formed, whether serum or pus, there are, again, 
no active symptoms unless the fluid is excessive, in which event there 
will be interference with respiration, and, if the process is on the left side, 
the heart will show the effects of the pressure by rapidity and perhaps 
irregularity. 
The influence that the pleurisy exerts upon the temperature is difficult 
to determine, as the process is secondary to diseases in which temperature 
is a prominent feature. If the exudation is purulent, the temperature 
may take on the characteristic morning drop and evening rise. This 
will be very apt to occur in case of purulent exudation following pneu- 
monia (p. 388). 
Diagnosis.—The diagnosis is dependent more upon the physical 
signs than upon the symptoms. 
Auscultation.-—In the cases without fluid exudate auscultation will 
often detect either fine friction rales, which may be heard only at the 
end of inspiration, or the dry rubbing friction crepitus heard with both 
inspiration and expiration. In the presence of fluid there may be weak- 
ness of, or absence of, respiratory murmur over the area covered by the 
exuded fluid, and the characteristic egophony at the level of the fluid. 
Rales will be absent. Over the uninvolved lung area there will be an exag- 
geration of the normal respiratory sounds. 
Percussion.—In dry pleurisy there is no perceptible dulness. The 
child may complain that the percussion is painful. With fluid there 
will be dulness or flatness, depending upon the amount of fluid present. 
A small amount usually gives circumscribed dulness; a large amount, 
extreme dulness or flatness. Over the uninvolved portion of the lung 
there will be hyperresonance. With a large accumulation the heart may 
be displaced. SECONDARY PLEURISY 
387 
x-Ray.—Radiographic findings are usually definite, but do not always 
give the differentiation clearly between fluid and consolidation. 
Exploratory puncture if successful not only definitely determines the 
presence of fluid but also its nature. 
Treatment.—The treatment of dry secondary pleurisy is usually 
that of the disease which the pleurisy complicates. We have never known 
special medication to be of any practical value. Tonics and supportive 
measures generally are of service. Anything that will improve the con- 
dition of the patient should be brought into use. A change of residence 
from the city to the country for those who can afford it, or an outdoor 
life in the city for those who cannot avail themselves of such a change, 
is always beneficial. 
Counterirritation to the chest with mustard or iodin will often give 
relief to the patient if there is pain, but otherwise this measure pos- 
sesses no value. When there is a sense of “tightness” and constriction 
of the chest which amounts to pain counterirritation will relieve the 
discomfort. The application of a mustard plaster (p. 846) — one-third 
mustard and two-thirds flour—to the bare skin over the diseased area 
for ten or fifteen minutes, at intervals of six or eight hours, will add to 
the comfort of the patient. Painting the affected area with tincture of 
iodin every second or third night has, in a few cases, afforded some relief. 
The administration of iodids as an aid to absorption is of questionable 
value, and is very apt to disturb the digestion. 
When, after recovery from the pneumonia or the empyema, adhesions 
persist compelling restricted lung action, active exercise in the open air 
is to be encouraged. For younger patients horseback-riding, the bicycle, 
and breathing exercises, with physical games which call for active inter- 
est and require deep breathing give the best results. 
Presence of Fluid.—If the exploratory puncture shows the presence 
of serum, the fluid is best left, with the hope that it will be absorbed, 
unless it is in sufficient amount to compromise the respiratory function 
and the action of the heart. In such an event as much as possible without 
undue inconvenience to the patient should be removed by aspiration. 
In many cases the fluid rapidly disappears after one aspiration. If this 
outcome is not attained, aspiration is to be repeated. 
During this operation care should be exercised to observe absolute 
asepsis. We have known clear exudate to become rapidly purulent after 
the insertion of a needle. There is always a question in such instances, 
how much infection has been carried in on the needle. The skin should 
be thoroughly scrubbed with green soap. This is to be followed by wash- 
ing with alcohol, and then with equal parts of alcohol and tincture of 
iodin. The hands should be cleaned, and the instrument used should 
be sterilized, as for a surgical operation. 
If the pleurisy is of tuberculous origin no particular management 
is demanded other than that of the primary disease, except in the event 
of symptoms of pain. This is to be relieved, as already described, by 
the use of local applications of mustard and iodin, with perhaps the 
administration of a sedative, such as small doses of codein. 
Dry pleurisy associated with pericarditis does not call for treatment 
other than that of the pericarditis. 388 
THE PRACTICE OF PEDIATRICS 
EMPYEMA (PLEURISY WITH PURULENT EFFUSION) 
In empyema there is a collection of pus in the pleural cavity, result- 
ing from inflammation of the pleura which has become infected with 
pathogenic organisms. 
Age.—A vast majority of the cases occur in infants and children 
under four years of age. The senior author’s youngest patient was three 
weeks old, and this child recovered. Comparatively few cases develop 
after the tenth year. 
Etiology.—In 95 per cent, of our cases the disease has occurred with 
evident pneumonia. Empyema may follow suppurative processes in 
any part of the body, but such cases are extremely rare. 
Bacteriology.—The pneumococcus is found in pure culture in the 
pus in about 75 per cent, of all cases in children. The streptococcus 
is less commonly present, and the Staphylococcus aureus is very rarely 
found. Bacillus influenza has been found in pure culture in purulent 
pleural fluid after influenzal pneumonia, and B. typhosus may cause 
empyema during an attack of typhoid fever. From empyema following 
inflammatory conditions in the abdomen (appendicitis or peritonitis) 
B. coli communis has been isolated. 
Purulent effusion accompanying pulmonary tuberculosis may con- 
tain the tubercle bacillus, but pyogenic cocci also are almost always present. 
Pathology.—A purulent pleural exudation may follow serous in- 
flammation of the pleura, or the process may be purulent from the outset. 
The pus may be thin or thick, yellowish or greenish in color, and may con- 
tain large masses of fibrin. The quantity of purulent fluid may vary 
from a few ounces to 30 to 40 ounces or more in neglected cases. While 
the inflammation may involve the entire pleural surface of one lung, 
and even involve both pleural cavities it is more often limited to the 
lower lobe and to the posterior portion. The pulmonary and costal sur- 
faces of the pleura are usually covered with a fibrinopurulent exudate, 
and adhesions between the pleural surfaces and between the pleura and 
pericardium are readily separated at this stage. The lung substance 
beneath the exudate is more or less compressed, according to the amount 
of pus present. In extreme cases the affected lung portion may be com- 
pletely airless, bloodless, gray in color, smaller than normal, and flattened 
against the vertebral column. The heart may be pressed toward the healthy 
side. In less severe cases the lung may be congested and still contain 
some air. 
Empyema may heal completely in the early stage. Very often, 
however, it tends toward a chronic course. The pus frequently becomes 
very thick, and the formation of granulation tissue, and later of fibrous 
connectiye tissue, causes irregular thickening of the pleura. Adhesions 
between the pleural surfaces may thus be so dense as to make separation 
impossible, and an encapsulated empyema may be formed by the shutting 
off of a smaller or larger amount of pus by adhesions. The connective- 
tissue formation may finally extend into the lung substance, resulting 
in interstitial pneumonia. 
In cases of empyema which come to autopsy early in the disease the 
pneumonia preceding the empyema may still be present. In later stages, EMPYEMA (PLEURISY WITH PURULENT EFFUSION) 
389 
however, only a complicating bronchopneumonia, acute or chronic, 
may be found in one or more of the lobes not involved by the empyema, 
or an interstitial pneumonia in that portion of the lung substance beneath 
the thickened pleura. 
In untreated cases the pus may be evacuated through a bronchus, 
externally through the chest wall, or into the peritoneal cavity. When 
absorption and spontaneous “cure” occurs without rupture fibrosis of the 
lung is frequently produced. 
Symptoms.—Empyema after Bronchopneumonia.—'The child has bron- 
chopneumonia, running the usual course as to fever, respiration, pulse, 
and prostration. After a time varying from six to twelve days an im- 
provement in the symptoms is noticed; the pulse and respiration become 
slower, and the child appears brighter. During the height of the pneu- 
monia the temperature has been perhaps 104° to 105° F. Now it ranges 
Fig. 75.—Temperature chart. Empyema following lobar pneumonia. 
from 100° to 102° F., at times dropping to 99° F. For twenty-four to 
forty-eight hours the temperature range is quite low. Soon it becomes 
noticeable that the fever is higher in the evening than in the morning, 
although the evening temperature may not be above 102° F., or at most 
103° F. The child coughs, the pulse is rapid—120 to 140—and the 
respiration is accelerated to 40 or more. The appetite is poor. These or 
similar symptoms may continue for weeks if the condition is not recog- 
nized. 
Empyema After Lobar Pneumonia.—Empyema more frequently fol- 
lows lobar pneumonia than bronchopneumonia. The following sympto- 
matology covers a majority of the cases: The crisis occurs, and the tem- 
perature falls to normal (see Fig. 76) and remains normal for a few days; 
or perhaps there is the temporary postcritical rise the day following the 
crisis. In other respects conditions continue favorable for perhaps two, 
three, or rarely five days, when a slight evening rise in temperature oc- 390 
THE PRACTICE OF PEDIATRICS 
curs. The temperature is lower the next morning, but perhaps not quite 
normal; the following evening it is higher than the preceding, and the 
next evening it is still higher. Such a temperature range following pneu- 
monia is almost pathognomonic of empyema (Fig. 76). 
In some few cases the exudation of pus into the pleural cavity is not 
delayed until the temperature falls, but develops during the first few 
days of the pneumonia. With the formation of pus the respiration and 
pulse increase in frequency, the respiration ranging above 40, and the 
pulse from 140 to 180. It is a mistake, however, invariably to expect 
characteristic signs. The lungs and heart soon accommodate them- 
selves to the changed conditions. Repeatedly we have seen cases in 
which there was but slight acceleration of the pulse and respiration. 
The evening temperature, however, is rarely less than 102° F. In addi- 
tion to the symptoms enumerated, these cases (particularly those that 
Fig. 76.—Empyema following lobar pneumonia. Operation. Recovery case. 
have continued for two weeks or longer) show a symptom-complex that 
may almost be said to be characteristic. The child is emaciated and 
his face wears an anxious expression. The skin is pale, of a yellowish 
tinge, and perspires readily. The mucous membrane and conjunctivse 
are pale. Slight exertion causes embarrassment of the respiration. The 
nostrils are distended; the respiration during rest is short, and increased 
from 10 to 20 per minute above the normal. The fingers may show signs 
of clubbing. The blood, which has perhaps shown during the pneumonia 
a leukocytosis ranging from 15,000 to 25,000, with the development of 
empyema may afford leukocyte counts of 35,000 or higher. 
Diagnosis is based upon physical examination of the chest, rr-ray 
examination, and exploratory puncture. Weakness or absence of respira- 
tory murmur and absence of r&les, combined with the presence of dulness 
or flatness, are indications justifying an exploratory puncture. EMPYEMA (PLEURISY WITH PURULENT EFFUSION) 
391 
When the disease is located on the left side, the displacement of the 
heart to the right, as indicated by the changed position of the apex-beat, 
is a very suggestive sign. Over the uninvolved portion of the chest 
auscultation will show exaggerated respiratory murmur; and percus- 
sion, hyperresonance. 
Differential Diagnosis.—Empyema is to be differentiated from serous 
pleurisy, pleurisy with massive exudation of fibrin, unresolved pneu- 
monia, pulmonary tuberculosis, malaria, pyelitis, otitis, and typhoid fever. 
The value of routine blood and urine analysis in such differentiation is 
at all times to be kept in mind. 
Serous pleurisy and pleurisy with a thick, fibrinous exudate give 
signs identical with those of empyema. In many cases of fibrinous pleurisy 
with a considerable exudate not a rale or friction sound will be heard. 
Our only means of differentiating empyema from these processes is ex- 
ploratory puncture with a large needle. 
In unresolved pneumonia the respiratory sounds are heard with 
greater distinctness. Rales, and often friction sounds, are present. The 
dulness is distinctly localized, and there is rarely flatness unless there is 
associated with the pneumonia a thick pleuritic exudate. 
In tuberculosis of the lung of sufficient gravity to allow of confusion 
the presence of tubercle bacilli in smears from the expectoration or tracheal 
secretion (see p. 396) may determine the diagnosis. The intradermal 
tuberculin test (p. 825) and x-ray examinations may be brought into use. 
Here also, however, the exploratory puncture is the best means of estab- 
lishing the diagnosis. 
The difficulties in differentiating typhoid fever and malaria from 
empyema should be slight in view of the marked dissimilarity in the 
disease conditions. Nevertheless, cases of pleurisy are not infrequently 
treated for typhoid and malaria when pus is present in the pleural 
cavity. Whenever the lungs are proved normal by competent physical 
examination, the tests for malaria and typhoid in daily use should be 
instituted. 
Treatment.—When pus is located, operation and drainage are the 
only methods of treatment. Aspiration is never to be looked upon as 
a substitute for incision. 
In a recent case in a young child under two years of age an incision 
with local anesthesia—ethyl chlorid answers the purpose—is at times 
permissible. In the case of an older child, or in a prolonged case in a young 
child, partial resection of a rib under general anesthesia is to be advised 
as furnishing much freer drainage. Occasionally cases are seen among 
older children in which, on account of a very severe, persisting pneu- 
monia, it will not be safe to use a general anesthetic. In such cases an 
incision may be made under novocain—a 1 to 2 per cent, solution being 
injected into the skin at the site of the proposed incision. Such an opera- 
tion will relieve the immediate symptoms—the displacement of the heart 
and the difficult breathing. The resection of a rib may safely be under- 
taken after a week or two, when considerable improvement will have 
taken place in the general condition. As soon as the cavity is opened, 
two drainage-tubes, from 2 to 4 inches in length, joined with a 
large safety-pin, are inserted. Gauze is packed around the tubes and 392 
THE PRACTICE OF PEDIATRICS 
against the skin, and upon this the pin rests. Sterile gauze is placed 
over the end of the tubes as soon as possible after their introduction 
in order to prevent too free escape of pus. When the pus is allowed 
gradually to escape, much less shock will be experienced. Over the gauze 
two or three layers of absorbent cotton are placed, and over this the 
bandage. The dressing should be changed every day and the tubes short- 
ened as the lung expands. This expansion will be indicated by the resulting 
outward displacement of the tubes. After the evacuation of the pus the 
pulse usually falls to normal or nearly normal, where it remains. Oc- 
casionally, however, this expected result does not follow the operation. 
Illustrative Case.—In one case the operation was followed by a free discharge of 
pus, but with no relief whatever to the symptoms. An examination of the chest re- 
vealed at the apex of the lung a pocket of pus which had become walled off by adhe- 
sions. The case was one of three months’ duration when it came under the writer’s 
care. A second operation removed about 6 ounces of pus, but the child died from 
exhaustion about twenty-four hours afterward. Autopsy showed that the pleural 
cavity was divided into two distinct pus-sacs by a firm band of adhesions. 
Failure of the temperature to subside in our cases in which complica- 
tions could be excluded has been due to defective drainage. The tube 
may be too small or plugged, or the pus may become sacculated. Large 
fibrinous masses which the tube will not admit may undergo slow de- 
generation and absorption and continue the temperature. 
Illustrative Case.—In a case of empyema following pneumonia of great severity in 
a girl of five years, on account of the reduced condition of the child, an incision was 
made instead of a resection of the rib. The temperature fell to normal, and all the 
symptoms improved for a few days, when an evening rise to 101° F. was noted, which 
in two or three days reached 103° F. There was a discharge which saturated the 
dressings, although they were changed every three or four hours. Our inability to 
locate an independent pus-pocket, the continued fever, and a strong odor to the dis- 
charge suggested the probability of insufficient drainage. In spite of the fever, the 
child having gained considerably in strength, a second operation was decided upon to 
enlarge the wound. She was anesthetized, and 2 inches of rib were removed, where- 
upon quantities of necrotic fibrinous material were found in the pleural cavity. These 
were removed with the finger and dressing forceps; the temperature immediately fell to 
normal, and the child made a perfect recovery. Irrigation of the cavity had been of 
no avail. 
Ordinarily the tubes should not be removed until from two to six 
weeks after the operation. At least one tube should be kept in posi- 
tion until a free respiratory murmur is heard all over the affected side, 
up to the site of operation in the chest wall. When the lung is fully 
expanded the tubes will be forced out and found in the dressings. Irri- 
gation of the pleural cavity with Carrel-Dakin solution is at times of 
value, but with sufficient drainage is rarely found necessary. The 
cases which require irrigation on account of continued fever and insuffi- 
cient discharge require the resection of a rib. Should a second opera- 
tion be refused, on account of the tender age or the general weakness 
of the patient, or be inadvisable on account of some complication, such 
as a pericarditis, a daily irrigation with the Carrel-Dakin solution may be 
undertaken. 
Deformity Following Untreated Cases.—In hospital and out-patient 
work cases neglected for weeks, showing marked chest deformity and 
retraction, usually associated with spinal curvature, are among those PULMONARY GANGRENE 
393 
treated. The pus has been partially absorbed and partially organized, 
leaving extensive adhesions which have bound the lung tightly to the 
chest wall, preventing expansion, so that the bony wall has become dis- 
placed inward to meet the lung. For these unfortunate children surgi- 
cal measures furnish some relief, but the results have not been brilliant. 
Suction Drainage.—Various methods have been devised to favor the 
escape of pus without the admission of air to the pleural cavity. Such 
methods are undoubtedly of value in selected cases, particularly when 
the pus content is not thick or marked by the presence of large amounts 
of pyogenic membrane. The old-time practice of rib resection and 
drainage is, however, still favored by many conservative surgeons. 
Double Empyema.—But 2 cases coming under our observation have 
had both pleural sacs involved. In such cases both sides should not 
be opened at the same time, on account of the danger of collapse of 
the lungs. There are usually adhesions present sufficiently strong to 
prevent this, but we have no means of knowing beforehand. In both 
of the cases the left pleural cavity was opened first in order to relieve the 
pressure upon the heart and the great vessels. 
Illustrative Cases.—In one case a considerable quantity of pus was removed from 
the right side by aspiration at the time of the operation on the left side. The right 
side was operated upon four days later, by which time sufficient adhesions had formed 
to prevent collapse of the lungs. The patient, a boy of two years, made an excellent 
recovery. 
The second patient was one year of age. Pus had been present in both sides for 
a considerable time. The left thoracic cavity was opened first. The sac on the right 
side was smaller than that on the left, and was operated on by incision three days 
later. The child was very much reduced by the protracted illness. In spite of the free 
daily irrigation of both cavities the typical temperature persisted, probably on account 
of the very extensive suppurating surfaces. The child died from exhaustion twelve 
days after the second operation. 
Empyema Necessitatis.—Spontaneous rupture of the pleural sac 
may occur in cases of empyema of considerable duration which are not 
promptly diagnosed or not operated upon if diagnosed. Cases of this 
nature have been reported in which the pus ruptured into the esopha- 
gus, into the bronchi, or through the diaphragm into the peritoneal cavity. 
Illustrative Cases.—Case 1.—In the case of a well-nourished boy three years of age 
the pus had been sacculated over the anterior portion of the left lung. The parents, 
not particularly intelligent people, objected to operation, and while it was under 
consideration by them, two or three days after the diagnosis was made, the pus rup- 
tured into the bronchi and was discharged from the mouth in large quantities during a 
coughing paroxysm. The child made an uninterrupted recovery. 
Case 2.—Another patient, a boy of two years, came under observation for a soft 
fluctuating swelling, the size of a small orange, on the right side, immediately below 
the nipple. Exploration with a hypodermic needle showed pus. An incision was 
made and about 3 ounces of pus were evacuated. When the sac was emptied it was 
found to communicate with the right pleural cavity by an opening between the seventh 
and eighth ribs. The wound was dressed and the child recovered without further 
complications. 
PULMONARY GANGRENE 
Pulmonary gangrene is a very rare complication of pneumonia. Three 
cases observed by the writer all developed during the course of a broncho- 
pneumonia. The gangrene is supposed to be due to an embolism of some 
branch of the pulmonary artery or to a septic thrombosis. The odor 394 
THE PRACTICE OF PEDIATRICS 
of the breath is most characteristically offensive and actually beggars 
description. As a complication of pneumonia pulmonary gangrene is 
invariably fatal. 
Except for the odor of the breath there are no significant symptoms 
which may not exist with the usual attack of bronchopneumonia. 
PULMONARY ABSCESS 
Pulmonary abscess, except in the form represented by small foci which 
may exist in bronchopneumonia and are not recognizable clinically, is 
a very unusual complication of pneumonia. Comparatively few cases 
are diagnosed, because of the occurrence of the abscess with empyema 
or because symptoms resembling empyema are present. The abscess is 
usually discovered during exploration for pus in the pleural cavity or at 
the time of operation for empyema. a>Ray may reveal the condition. 
Lung abscess may occur as a sequel to tonsillectomy. Whether this 
occurrence is to be ascribed to aspiration of septic material during opera- 
tion or to metastasis of bacterial emboli through open blood channels 
is a moot question. As a rule, any form of insufflation anesthesia is con- 
traindicated in tonsil operations. (See p. 381). 
Illustrative Case.—A child had pneumonia of the right upper lobe, which failed to 
resolve after abatement of the urgent symptoms. The temperature continued at 
101° to 102° F., and there was a distressing cough. For this a mixture was given con- 
taining full doses of syrup of ipecac and ammonium chlorid. This was given repeat- 
edly without dilution, against instructions, and produced violent emesis. During a 
vomiting seizure the child brought up a considerable amount of pus, after which the 
recovery was prompt. Evidently the straining had produced a rupture of a pulmonary 
abscess into one of the larger bronchi. 
PULMONARY TUBERCULOSIS 
Infection of the lungs with the tubercle bacillus constitutes the chief 
type of tuberculosis in the human. The lungs are the most active seat 
of the process in at least 90 per cent, of the cases. 
Pathology.—In the most acute form of pulmonary tuberculosis the 
lungs contain gray, translucent tubercles in varying numbers. These 
may be only few in number, or may be very closely studded throughout 
both lungs. The lesions may also be present on both surfaces of the 
pleura. Acute bronchopneumonia, with or without fibrinous pleurisy, is 
a frequent complication. In a late stage the tubercles undergo cheesy 
degeneration and are yellow in color. The coalescence of neighboring 
tubercles may give rise to cheesy masses, which eventually undergo 
softening. The tubercles are more often peribronchial than perivas- 
cular in distribution. Owing to the more direct course of the right main 
bronchus, the right lung is often involved before the left. 
Caseous degeneration of an area of pneumonic exudate may occur, 
and the resulting cheesy pneumonia frequently leads to softening and 
cavity formation. These cavities may occur in any part of the lung, 
but are most common in the right middle and upper lobes, and usually 
communicate with a bronchus. Their walls are irregular and grayish in 
color, are often crossed by blood-vessels, and contain caseous necrotic 
material. PULMONARY TUBERCULOSIS 
395 
The connective tissue of the lung is increased in cases of pulmonary 
tuberculosis which have undergone repeated attacks of pneumonia, 
or which follow empyema of long standing. In such cases the pleura 
also is thickened and may be covered with an organized exudate. 
Phthisis as it is seen in the lungs of adult subjects is seldom met with 
in children under eight or ten years of age. 
The bronchial lymph-nodes in cases of pulmonary tuberculosis are 
involved in the tuberculous inflammation in about 97 per cent, of the 
cases. The nodes are enlarged, and on section show all stages of tuber- 
culosis, from discrete tubercles with small cheesy centers to cheesy de- 
generation of the entire node. Softening or suppuration is very common, 
while calcareous degeneration of a tuberculous focus in a lymph-node 
is infrequently seen in infants, but is less rare in children over two years 
of age. The bronchial and mediastinal lymph-nodes may be so much 
enlarged as to afford dulness on percussion and occasion respiratory 
difficulty from pressure. 
Symptoms.—In infants and very young children there is no char- 
acteristic symptomatology. This seems strange in a disease of such 
gravity. Even in the miliary type, where we have been taught to ex- 
pect high temperature, rapid respiration, and other severe toxic symp- 
toms, such symptoms do not always exist. The signs correspond to 
those of bronchopneumonia—fever, 101° to 104° F., rapidity of respira- 
tion, cough, and the chest signs peculiar to catarrhal pneumonia. There 
may be only cough and the evidence of a generalized bronchitis. The 
temperature range is not characteristic, and may not differ from that of 
bronchopneumonia. 
A suspicious symptom in an infant is steady emaciation out of pro- 
portion to the other positive evidences of disease. The child takes food 
well, sleeps well, and is comfortable. There may be a slight elevation 
of the temperature or no elevation throughout the illness—in fact, the 
temperature may run a subnormal course. The picture is that of 
marasmus. 
In older children after the third year the disease manifests itself 
by more distinct signs, such as emaciation, loss of appetite, fatigue on 
slight exertion, and perhaps night-sweats. There is, moreover, a trou- 
blesome dry cough with little expectoration. Elevation of tempera- 
ture in older children is almost an invariable symptom. It may not be 
high, however, perhaps not above 101° F. in the evening. The child 
complains of chilliness and soon shows signs of anemia. Pain is unusual 
and hemoptysis rarely occurs. 
In the miliary type in older children the symptoms are also active, 
particularly the temperature, which will range very high—103° to 105° F. 
—or it may be low in the morning and high at night. The respiration 
and the pulse are rapid. Cough is not a prominent symptom. There is 
rapid loss in weight. 
It will be observed that the symptoms may aid us but little. The 
z-ray is of great value, but leaves opportunity for misinterpretation in 
differentiating such conditions as fibrosis and non-tuberculous broncho- 
pneumonia from actual tuberculosis of the lung. 
Diagnosis.—For the positive diagnosis of tuberculosis in children 396 
THE PRACTICE OF PEDIATRICS 
the presence of the tubercle bacilli must be proved. The examination 
of the lungs, except by showing the existence of a cavity, aids us but 
little, for, in the miliary type, there may be tuberculosis without chest 
signs. The various lung changes evident on examination may differ 
in no way from those which may be found in acute or chronic broncho- 
pneumonia. Accompanying tuberculosis, moreover, there may be a 
bronchial catarrh, which in no way differs in its manifestations from 
that of simple generalized bronchitis. 
A positive intradermal tuberculin test (p. 825) is strong corroborative 
evidence of tuberculosis in young infants. The presence of fine crepitant 
rales localized over the right middle lobe (front) often means a localized 
tuberculous process, the bacilli being conveyed by the lymphatic channels 
extending from the bronchial glands to the spaces between the middle 
and upper lobes. The value of this sign has been proved in a large 
number of cases. In the case of older children the tuberculin test, while 
positive, may be misleading, as the tuberculosis may be latent or entirely 
healed, and have no bearing on the immediate illness. 
x-Ray diagnosis of tuberculosis in children is invaluable, but calls for 
interpretation based on large experience. Mediastinal adenopathy and 
peribronchial infiltration indicated by fan-shaped shadows radiating from 
the root of the lung may be easily detected, but do not always spell 
'‘tuberculosis.” Repeated examinations are essential. 
The D’Espine sign, while of value, is only an aid (see p. 810). 
After the fourth or fifth year the diagnosis is seldom beset with the 
difficulties encountered in infancy. At the later period of life localized 
signs of bronchitis, or partial or complete consolidation with dulness, 
may be manifest. Further, children at this age expectorate, so that 
collection of the sputum is easily accomplished. 
Methods of Obtaining Sputum.—In dealing with infants who do not 
expectorate a satisfactory method of obtaining the bronchial secretion 
is to pass a sterile catheter into the child’s larynx. This excites coughing 
so that the secretion is brought up through the larynx and adheres to the 
tube. 
Another method which may be used consists in irritating the pharynx 
with a small piece of sterile gauze grasped in an artery clamp. As a result 
of the coughing thus induced the secretion from the trachea will be de- 
posited on the gauze. Several tests may be necessary before the bacilli 
are discovered. 
Bacilli in the Stool.—To search for bacilli in the stool is not a very 
satisfactory procedure, and is not necessary, in view of the success at- 
tending the above methods of securing material for examination. In 
suspicious cases in which the sputum examination fails to reveal sthe 
bacillus the stools should be examined. 
Prognosis.—The prognosis for infants is very unfavorable. Never- 
theless in infants healed tubercular foci are occasionally found at autopsy. 
A child eighteen months of age who died of diphtheria had a large encysted 
calcareous tubercular nodule in the left lung, 1 inch by H inches in size. 
Likewise the bronchial glands may show evidences of previous disease. 
In view of the large percentage of positive reactions to the von Pirquet 
skin test in children past ten years of age it would seem that there are PULMONARY TUBERCULOSIS 
397 
many more cured cases in children than has heretofore been appreciated. 
After the fifth year, if the case is seen reasonably early, if the child has 
a fair resistance, and if the management can be suitably carried out, the 
prognosis is very good indeed. The prognosis is further favorable if the 
infection is primary. If there is a lighting up of an old tubercular lesion 
in the bronchial glands or elsewhere the prognosis is much less favor- 
able. Recoveries in New York City have been frequent in primary cases 
of children who could not be sent away. 
Associated Lesions.—The invasion of the tubercle bacillus usually 
means the involvement of more than one organ or portion of the body. 
The Liver.—An autopsy in a case of pulmonary tuberculosis will 
very frequently show, in addition to the evidences of the disease in the 
lung and pleura, that the liver is involved to the extent of showing a 
generous distribution of tubercles in its surface and in the liver sub- 
stance. 
The Spleen.—It is rare, in making a postmortem examination in 
pulmonary tuberculosis, not to find the spleen the seat of the disease. 
Both the surface and the splenic tissue may be filled with tubercular 
deposits. 
The Heart.—Tuberculosis of the heart muscle is very unusual. A 
few cases have been reported. The pericardium is occasionally the seat 
of a few tubercles. They are usually found when there is an extensive 
general tuberculosis. 
Stomach.—Tuberculosis of the stomach is of very rare occurrence. 
Hale reported having seen but 5 cases in his large autopsy experience. 
Intestines.—Infection of the intestinal mucosa without further ab- 
dominal involvement is occasionally seen at autopsy. 
The kidney is very frequently the seat of tuberculosis. About 25 per 
cent, of the writer’s cases have shown such lesions. They are usually 
of the miliary type, scattered over the surface, with a few in the kidney 
substance. 
Tuberculosis of the larynx in children is of very unusual occurrence. 
Demme reported a case in a child four and one-half years old (Koplik). 
The pancreas, thymus gland, and peritoneum are rarely at autopsy 
found to be the seat of a few miliary tubercles. 
Tuberculosis of the cervical lymph-glands, brain, mesenteric glands, 
peritoneum, and abdomen will be discussed in separate chapters. 
Treatment.— Climate.—For those who are so situated financially as 
to have the advantages of an equable climate, a change of residence 
or sanitarium treatment should be provided. A dry climate of equable 
temperature that will allow the tuberculous child to spend the greatest 
number of hours in the open air is best. The climate of southern New 
Mexico and Arizona is exceptional for these cases. Children do well 
in the Adirondacks and in Sullivan County, New York, but the severity 
of the winter makes these localities less desirable. 
Diet.—Equally important, if not more so than climate, is the nutri- 
tion of the patient. This must be raised to the highest possible stand- 
ard, but there should be no overfeeding, such procedure being of no 
value in any disease in the young. A liberal protein diet of milk, meat 
and eggs, oatmeal, and the legumes—dried peas, beans, and lentils, 398 
THE PRACTICE OF PEDIATRICS 
which are given in the form of a puree, is to be recommended. It is not 
wise to insist that a definite amount of food be given in twenty-four 
hours. The mother or nurse is to be told, however, that these foods, 
prepared in different ways so that the child will not tire of them, are to 
form a considerable part of the diet. Green vegetables and fruits should 
be given because of their salt and vitamin content. When three meals 
a day are given, with, perhaps, a glass of milk in the middle of the 
afternoon, better nutrition may be maintained than with more frequent 
feedings which often defeat their own purpose by producing disgust for, 
or intolerance of, food. The child should be fed on nutritious food, for 
which an appetite must be developed; for, inasmuch as recovery is 
dependent largely upon nutrition, the question of appetite and food 
capacity is of paramount importance. Candy, sweet crackers, and other 
harmful articles should not be allowed. In order to satisfy the candy 
craving a small quantity of sweet chocolate may be given after the noon- 
day meal. The best appetizers are reasonable exercise, entertainment 
and play that do not fatigue, and fresh air in abundance. Upon our 
ability to meet these requirments depends, to a large degree, the outcome 
of the case. 
The majority of the children with pulmonary tuberculosis cannot 
be sent to sanitariums or to health resorts, but must be treated in their 
homes. This is accomplished successfully in New York City even among 
the tenement population. The basic principles of management comprise 
a properly directed life, good food, and fresh air. These are the weapons 
for fighting the enemy, regardless of whether the residence is among the 
rich or poor, in town or in country. It is, however, among the tenement 
population that we experience the greatest difficulty. To tell these people 
how the child is to be fed is not enough. The feeding as directed entails 
considerable expense, which the parents may not be able to meet. If 
after personal investigation (which should be made in every case) it is 
demonstrated that proper nutrition or suitable clothing is impossible, 
the writer has often explained the situation to some charitably inclined 
person of means, and has yet to know of an instance in which clothing 
and a small but sufficient weekly food allowance were not forthcoming. 
An allowance of 25 cents a day for fresh meat and milk has often fur- 
nished what was required to bring the case to a favorable termination. 
The uselessness of much of our medical advice to the poor would, on slight 
reflection or a little investigation, be apparent. Directions are too often 
given for the care of the sick which are absolutely impossible of fulfilment. 
Hygiene.—In addition to the diet above outlined, the advantages 
of an outdoor life, and the means by which fresh air may be obtained 
all the year round, should be fully explained. Any simple direction as 
to what may appear to be a radical procedure is rarely carried out with- 
out a rational explanation of its necessity. During the daytime the 
child should be kept outdoors. Close, tightly sealed sleeping apart- 
ments at night, however, will undo the good of the outdoor life during 
the day. The mother should be told to have the child sleep alone in 
the largest room of the apartment, and always in a room in which the 
windows are opened. This is usually possible. A sponge-bath or tub- 
bath should be given at bedtime, followed by brisk rubbing with a towel. 399 
HELIOTHERAPY 
If there is much emaciation, an olive-oil or goose-oil inunction should 
follow the salt bath. 
Sometimes these directions are followed implicitly; at other times 
they are forgotten. It is astonishing, however, what rapid improve- 
ment will follow when a tuberculous child of the tenements is given the 
benefit of fresh air, day and night, with suitable food and cleanliness, 
even though the conditions are those of a great city. Among the more 
fortunate classes the same method of treatment, of course, with a more 
satisfactory application, is to be carried out. Among the well-to-do, 
however, we see fewer cases. 
Tonics.—The usefulness of drugs depends to a large degree upon 
an increase of food capacity which their use may cause. Any of the 
prescriptions written below may be used alternately with cod-liver oil 
and malt, each being given for five days. For a child from seven to 
twrelve years of age the following are useful restoratives and appetizers: 
1$. Tincturae nucis vomicae gtt. xlviij 
Saccharini gr. iss 
Aquae q. s. ad. 3iv 
M. Sig.—One teaspoonful every two hours. (Six doses daily.) 
1$. Ferri et quininae citratis gr. xlviij 
Vini xerici 5iv 
M. Sig.—One teaspoonful in water three times a day after meals. 
R. Tincturae nucis vomicae gtt. lxxv 
Extracti ferri pomati gr. vj 
Quininae bisulphatis 3j 
M. ft. capsulae no. xxx. 
Sig.—One after each meal. 
If night-sweats occur, from 1/200 to 1/160 grain of atropin at bed- 
time will often furnish relief. 
Care of the Sputum.—Various devices for collecting the sputum may 
be obtained in the shops. A cheap and effective method is the use of 
a Japanese handkerchief or paper cup which, when used, is at once placed 
in a paper bag, the bag and its contents being burned at the close of the 
day. The dangers of infecting others should be fully explained to those 
in charge of the patient, kissing and fondling being forbidden. 
Heliotherapy 
Heliotherapy, or the treatment of bodily ills by exposure to the sun’s 
rays, has been utilized for curative purposes many centuries. In the 
Swiss Alps Rollier and Bernhard were the first to take up heliotherapy 
in a scientific manner for the definite end of curing tuberculosis. The 
method is very simple and consists in exposing the body to the direct 
rays of the sun for a given time. Most satisfactory results are reported 
by the above authors, particularly in cases of surgical or bone tuberculosis. 
This method of treatment of tuberculosis as carried on by Dr. Gerald 
Webb of Colorado Springs is described as follows: "Children can be ex- 
posed naked at an altitude of 4000 to 5000 feet when snow is on the ground 
because the temperature in the sun may be as high as 90° or even 120° F. 
Patients arriving at this altitude are first allowed to become acclimated 400 
THE PRACTICE OF PEDIATRICS 
by rest indoors for a few days. Then they are placed on verandas with 
a white garment covering the body.” 
“Exposures to the sunlight are made very cautiously and gradually, 
fixed rules being followed no matter what part of the body may be affected 
with tuberculosis. On the first day the feet are exposed three or four 
times at hourly intervals for five minutes each time.” 
“On the second day the bare legs to the knees are exposed in a similar 
manner, and the feet are exposed three times for ten minutes each. On 
the third day these exposures are increased by five minutes, three times 
daily, and on the fourth day the thighs are included. On the fifth day 
the abdomen and chest respectively are exposed. The pulse and tem- 
perature variations are used in guiding the treatment, and for certain 
individuals variations in the sun treatment are made. By this method 
in summer or winter patients can remain from four to six hours bathing 
in the sun.” 
“Naturally, other surgical methods are not neglected. Splints, braces, 
and the like are employed when necessary to limit motion in diseased 
joints. The appliances are made as light and as open as possible. Open 
wounds when not being sunned are dressed with gauze soaked in al- 
cohol. Such “open” cases are found more refractory to the treatment 
than “closed” cases.” 
“Certain blood changes have been noted, such as an increase in the 
phosphorus content and the number of the red blood-corpuscles. Some 
observers, too, have claimed that the lymphocyte blood-cells—known 
to be antagonistic to the tubercle bacillus—are increased by helio- 
therapy.” 
“We feel it wise to warn patients against the careless employment 
of sun baths without proper medical control, as harm can be done by 
them. The head should be protected, especially at first, by a light hat, 
and in the case of adults R oilier sometimes advises the covering of the 
heart with a wet compress.”1 
The range of application of heliotherapy is being rapidly extended as 
its influence on phosphorus and calcium metabolism in rickets is being 
better appreciated, and the value of the method in the treatment of 
tuberculosis is now indubitably established. (See p. 764.) 
1 Jour, of Outdoor Life, September, 1915. XII. DISEASES OF THE HEART 
DIAGNOSIS IN DISEASES OF THE HEART 
Auscultation.—In the diagnosis of the different cardiac lesions in 
children auscultation is by far the most useful means at our command, 
and for this reason may receive foremost consideration. For adults 
the physician employs auscultation, either with the unaided ear or with the 
stethoscope, at the following chest areas: 
The aortic area. 
The pulmonary area. 
The tricuspid area. 
The mitral area. 
In children tricuspid disease is of most infrequent occurrence. The 
pulmonary valves are involved only in congenital heart disease. In 
the routine examination for heart lesions in children the findings are 
simplified by the fact that aortic and mitral valve lesions are those en- 
countered in an immense majority of the cases. 
Owing to the difference in the position of the heart of the child as 
compared with that of the adult, the various sound areas also differ, 
and they vary at the different periods of childhood in accordance with 
the changing position of the heart. 
Before the sixth year the mitral area corresponds with the apex- 
beat at a point in the nipple-line, or not more than \ inch without the 
nipple-line, in the fourth interspace. 
The aortic area is slightly to the right of the sternum in older chil- 
dren ; in the very young, over the sternum or at its immediate right border 
at the level of the second or third interspace, varying with the age of 
the child. 
The pulmonic area is on the same plane at the left border of the ster- 
num. 
At the end of the sternum, slightly to the left, is the tricuspid area. 
It is by no means claimed that sound areas indicate the position 
of the valves, but we know, from combined clinical and autopsy find- 
ings in children, that murmurs indicating lesions of the respective valves 
are best heard at these areas. 
The Normal Sounds.—The normal heart sounds are not easily des- 
cribed. The normal cardiac cycle is made up of the first and second heart 
sounds. Listening at the apex or slightly above, one hears at the time 
of the impulse the low-pitched, dull first sound, followed by the so-called 
second sound, which is short and higher pitched, and is supposed to be 
due to closure of the semilunar valves. 
There is much divergence of opinion as to the cause of the first sound. 
Most diagnosticians believe that it is due to the contraction of the heart 
muscle associated with the sudden closure of the mitral valves. 
The heart sounds vary considerably, depending upon the age of the 
patient; thus, in the infant both sounds are short and high pitched, and 
401 402 
THE PRACTICE OF PEDIATRICS 
the muscle sounds which appear later in life, while present, are not prom- 
inent. 
There is rarely difficulty in differentiating the two sounds in the 
young. The second sound is heard loudest over the base of the heart 
at points corresponding more or less closely to the pulmonic and aortic 
areas. In the event of difficulty in differentiation, the first sound should 
be sought at the apex. On gradually moving the stethoscope upward, 
the first sound will gradually become fainter, and as the base of the heart 
is approached the second sound will be heard much more distinctly and 
loudest in the areas referred to. 
The points of maximum intensity and areas of transmission of heart 
sounds in children cannot be arbitrarily laid down. In a general way the 
landmarks can be indicated, and in most instances will stand. 
In diagnosing cardiac disease in children we have to consider the 
age of the patient with particular reference to the size and position of 
the heart, whether the chest wall is thin and muscular, or fat, and whether 
the child is crying or quiet. All cardiac sounds in the young are pro- 
portionately much louder than in adults. In delicate children the sounds 
vary greatly from those heard in the strong and robust. A first sound, 
characterized by a muffling or absence of clearness, is very frequently 
heard in delicate children. After an illness in a strong child this peculiar 
quality is very apparent, and is without doubt due to muscular insuffi- 
ciency induced by degenerative changes which in most cases are tem- 
porary in character. 
The changed first sound is often interpreted and treated as an evi- 
dence of endocarditis. In heart failure in serious diseases the muscle 
element of the first sound gradually disappears so that this sound be- 
comes short and snappy in quality, due to a degeneration of the heart 
muscle. The weak muscle sound tends to exaggerate the sound pro- 
duced by the valve closure. 
The second sound is caused by the closure of the semilunar valves, 
and as there are two sets of these valves, the aortic and pulmonary, 
the aortic second sound in older children is heard in the aortic area, 
and the pulmonic second sound in the pulmonary area. 
In babies and very young children a differentiation of the aortic 
and pulmonic second sounds is unquestionably difficult. The second 
sound is always accentuated in conditions in which the cardiac vigor 
is temporarily or permanently impaired, as in myocarditis with hyper- 
trophy and dilatation of the left ventricle. 
Inspection alone is of little value in cardiac examination. One learns 
nothing by inspection that may not be discovered through palpation, 
percussion, and auscultation. In acute cardiac disease in which there 
is often a decided overaction of the heart, a decided undulating move- 
ment of the entire left chest anteriorly will be observed. This usually 
occurs when there is much dilatation or hypertrophy of the left ven- 
tricle. 
Inspection may reveal a retraction of the chest wall at the apex be- 
tween the fourth and fifth interspaces. This closing in is due to adhesions 
(the result of a former pericarditis) between the heart, the pericardium, 
and the chest wall. 403 
DIAGNOSIS IN DISEASES OF THE HEART 
Palpation is useful in determining the position of the apex-beat, in 
judging of the force of the cardiac impulse, and in the detection of a thrill. 
The pericardial friction-rub and the heart rhythm may likewise be de- 
termined in this way. 
Percussion.—For this examination the upright position is desirable. 
Percussion is chiefly of value in determining the size of the heart. Hy- 
pertrophy or dilatation of both the right and left heart may be fairly 
accurately determined. This method is also of value in determining the 
amount of fluid in the pericardial sac. 
Fig. 77.—Diagram, over a normal heart, child nine years, taken at 6 feet distance* 
R.A., Right auricle; R.V., right ventricle; L.V., left ventricle; L.A., left auricle; P.A.» 
pulmonary artery; D.A., descending aorta; G.Y., great vessels; M.R., middle right 
diameter; M.L., middle left diameter of the heart; M.R., 3.5 cm. + M.L., 7 cm. = 
10.5 cm. which is one-half the diameter of the chest. (Courtesy of Dr. Charles Winfield 
Perkins.) 
The normal right limit of absolute dulness for the heart may be taken 
as the right sternal border. The midsternal line supplies the boundary 
for relative dulness. The left limit of dulness corresponds to a perpen- 
dicular line drawn slightly without the apex-beat. 
The area of dulness will vary considerably in health. The younger 
the child, the further to the left will be located the border of cardiac 
dulness. This limit is best determined by percussing from a point 
in the anterior axillary line toward the right, in the fourth inter- 
space. 
The maximum transverse diameter of the heart normally in a radio- 
graph does not exceed half the transverse diameter of the chest at the same 
level. The heart may be said to be abnormally large when this proportion 404 
THE PRACTICE OF PEDIATRICS 
is not maintained. The normal relationship of the heart to the chest 
is depicted in detail in Fig. 77.1 
HEART MURMURS 
There are two gross divisions of heart murmurs: Organic or valvular, 
inorganic or f unctional. 
Organic murmurs are the result of a change in the heart structure 
due to a congenital malformation or to deformities resulting from dis- 
eased processes which produce a thickening, contraction, shortening, 
or narrowing of the valves involved. 
An enlargement of the orifice (e. g., the mitral or aortic orifice) may 
also cause a murmur due to the resulting incomplete closure of the valves. 
Regurgitant Murmur.—When the valves fail to close, a murmur is 
caused by the regurgitation of the blood back through the opening. If 
the valves are roughened, the intensity of the murmur is the greater. 
Stenotic Murmur.—When the blood is impeded in its passage through 
the heart as a result of a narrowing of the opening or roughening of the 
valves, a murmur of stenosis is the outcome. 
Organic heart murmurs are classified as follows, depending upon the 
time of their occurrence in the cardiac cycle: 
Systolic. 
Diastolic. 
Presystolic. 
From the association of the murmur with one or another of the different 
phases of the cardiac cycle we determine the location and nature of the 
lesion at hand. 
Location of Lesions.—In examination of the heart in order to locate 
a lesion by the murmur we must determine when it occurs in the cardiac 
cycle, its point of maximum intensity, and its area of diffusion. 
In children acquired valvular lesions will almost invariably be found 
to involve the left heart, the mitral valves being by far the most liable to 
disease. 
Mitral insufficiency takes first place in the order of frequency of 
valvular lesions. Mitral stenosis is evidently present in about 10 per 
cent, of the cases of insufficiency. Lesions of the aortic valves are, for- 
tunately, much rarer. The ratio of mitral to aortic disease is about 15 to 1. 
Table Demonstrating Location and Character of Lesions Based Upon the 
Adventitious Heart Sounds or Murmurs 
Systolic. 
Mitral regurgitation. 
Tricuspid regurgitation. 
Pulmonary stenosis. 
Aortic stenosis. 
Diastolic. 
Aortic regurgitation. 
Pulmonary regurgitation. 
Presystolic. 
Mitral stenosis. 
Pulmonary stenosis. 
Pulmonary stenosis occurs only as the result of congenital lesions, 
and tricuspid lesions in children are only observed very late in severe 
cardiac disease, as a result or accompaniment of right heart failure. In 
the absence of these etiologic conditions a systolic murmur in a child 
hartshorn and Perkins: x-Ray Studies of Cardiac Diseases in Children, New 
York Med. Jour, and Med. Record, March 7, 1923. HEART MURMURS 
405 
must, therefore, be attributed to mitral regurgitation or aortic stenosis. 
Moreover, for the reasons explained, a diastolic murmur means aortic 
regurgitation, and a presystolic murmur, mitral stenosis. 
Acquired lesions in children will, therefore, permit of the following 
grouping: 
Systolic. 
Mitral regurgitation. 
Aortic stenosis. 
Diastolic. 
Aortic regurgitation, 
Presystolic. 
Mitral stenosis. 
Keeping the time of the murmur in mind, we thus have a means 
of readily locating the lesions. 
Mitral regurgitation is due to shortening or adhesions of the mitral 
valves sufficient to prevent proper closure of the leaflets. The valvu- 
lar defects are the result of a previous acute or chronic endocarditis. 
The murmur of mitral regurgitation is heard loudest in the apex region, 
over the so-called mitral area. In children, because of the thin chest 
wall, this murmur has a wide transmission. The particular line of trans- 
mission is upward and to the left toward the axilla, and to the back, 
the sound here being loudest at the angle of the scapula and between the 
scapula and the vertebrae. 
Mitral stenosis (producing a presystolic murmur) is due to a narrow- 
ing of the mitral orifice as the result of adhesions which bind the valves 
together, and produce, in some instances, the so-called funnel or button- 
hole opening. The murmur is heard loudest slightly above and to the 
right of the apex-beat, in point of time preceding the systolic or first 
sound of the heart. Not infrequently this murmur merges into that 
produced by the mitral regurgitation, completely replacing the first 
sound of the heart. The area of diffusion is quite circumscribed. 
Mitral lesions which have existed for some time always give rise to 
compensatory hypertrophy, with corresponding displacement of the 
apex-beat to the left. This may readily be determined by palpation 
and percussion, showing the degree of cardiac enlargement. 
As a result of the contracted orifice or the roughened valve surfaces, 
vibrations are produced in the blood-stream which, when transmitted to 
the chest surface, produce a corresponding peculiar effect upon the pal- 
pating finger or hand of the examiner. This sign is known as a thrill. 
It must be carefully differentiated from the sensation communicated 
in some subjects by the thrust of a normal heart against a thin chest wall. 
Aortic stenosis produces a systolic murmur which is heard loudest 
over the sternum and the second left costal interspace; not over the 
second right interspace or to the right of the sternum, as in the case of 
adults. The murmur, which is usually harsh and grating in character, 
is widely transmitted in a lateral direction and also into the carotids of 
the neck. Autopsy usually shows the existence of adhesions between 
the semilunar valves. 
In comparatively few cases a thrill may be felt over the upper portion 
of the chest and the carotids. 
Illustrative Case.—In a girl patient eight years of age in whose heart stenosis and 
regurgitation were combined there was a most exceptional thrill over the dilated arch 
of the aorta and the carotids. 406 
THE PRACTICE OF PEDIATRICS 
In aortic regurgitation the murmur is diastolic in time, and is heard 
not to the right of the sternum, but sharply against the left border, or 
over the extreme left of the sternum, on a level with the fourth costal 
cartilage. This murmur is usually associated with the obstructive mur- 
mur, and is due to a failure of the deformed valves to close. The area 
of diffusion is wide. There is always displacement of the apex-beat to 
the left. It is the condition of aortic regurgitation, pre-eminently, that 
causes visible pulsation of the carotids. 
In the child already referred to the throbbing was so pronounced that not only was 
the head and body shaken, but the mother, who slept with the patient, was kept awake 
by the vibration of the bed. 
In typical cases auscultation may detect a pistol shot sound if the 
stethoscope is placed over the bifurcation of the brachial artery or over 
the deep palmar arch, and inspection may reveal capillary pulsation be- 
neath the nails. 
Functional murmurs are most frequently encountered between the third 
and twelfth years and are not at all unusual in rapidly growing children 
of both sexes. The functional murmur in infants or very young children 
is not infrequently associated with anemia. This is not invariably the case, 
however, for a non-organic murmur at this age may be the result of a 
very severe illness or whooping-cough, causing a temporary dilatation. 
The functional murmur is systolic in time, and is heard loudest at or 
slightly above the apex, with a uniform, circumscribed area of diffusion 
which extends for only a few inches in any direction. In character the 
murmur is soft and blowing. It is not heard at the back. There is no 
associated hypertrophy or dilatation of the heart nor evidence of any 
stasis or dropsy. There is no accentuation of the second sound. The 
presence of a functional diastolic murmur in a child is practically unknown. 
Special Types of Functional Murmurs.—Venous Murmurs: In anemia 
the normal venous murmur heard over the great vessels above the clav- 
icle and posterior to the sternocleidomastoid muscle is intensified and 
exceeds its normal physiologic limits. The murmur is constant, although 
it may be accentuated when the patient stands with head inclined to 
the opposite side. The venous murmur is to be distinguished from the 
arterial murmur by the fact that the former is continuous and not syn- 
chronous with the heart-beat. 
Cardiorespiratory Murmur: This murmur deserves particular men- 
tion for the reason that it has a distinct entity. It may be heard in 
those cases in which the margin of the lung covers the heart. The mur- 
mur is usually systolic. It is heard best when the patient is standing 
and leaning forward, and at the end of inspiration is usually loudest. 
This murmur has no clinical significance, and is of interest only because 
it may be confused with other murmurs, functional or organic. 
Murmur During Development: As already noted, a functional mur- 
mur is not at all unusual in rapidly growing children. 
After Acute Illness: Inasmuch as the functional murmur which oc- 
casionally occurs with, and disappears after, an acute illness is in all 
respects similar to those that exist for several years and are later out- 
grown, it may be fair to assume that, in both instances, the same cause 407 
FUNCTIONAL ABNORMALITIES IN CARDIAC RATE AND RHYTHM 
is operative, and that this factor, in all probability, is a moderate re- 
gurgitation, due perhaps to a dilatation of the mitral orifice preventing 
proper closure of the valves, a condition temporary in both types of 
cases, but in the one of longer duration than in the other. 
Etiology.—Although anemia probably constitutes the most frequent 
cause, yet functional murmurs are heard in apparently normal children, 
existing for a period of years and then disappearing. A temporary mur- 
mur will often be heard in boys after violent exercises or games of com- 
petition in which a great deal of physical work is involved. In girls the 
murmur may also result from excessive bicycle riding or prolonged rope 
jumping. In the spring of the year, after hard work at school, many 
girls, under careful examination, will show a slight systolic murmur. 
In our opinion many of these cases are due to a dilatation of the left heart, 
producing a wider auriculoventricular orifice than the valves can com- 
pletely close, with the result that there is a moderate amount of leak- 
age. This, in time, is corrected as the heart muscle regains its normal 
condition. 
Differential Diagnosis.—The chief point of aid in differentiating all 
murmurs, whether functional, acquired, or congenital, is the fact that in 
congenital and acquired heart disease there is a distinct lesion, and the 
murmur, as can be readily understood, is, therefore, constant. When, 
however, the murmur is due to causes related to muscular action or blood 
conditions, variations in posture or changes in the heart action dependent 
upon work will produce either a modification of the murmur or its com- 
plete disappearance. Even during a single examination a murmur of 
this nature may not always be the same. 
Illustrative Case.—A boy patient, aged six years, had a soft, blowing systolic mur- 
mur, which presented varying degrees of intensity, depending upon whether he 
lying down or sitting up or whether he w as quiet or exercising. The murmur appeared 
when he was two years old. He was always the picture of health. The murmur grad- 
ually became less each year, giving promise that when he was ten years old it would 
probably cease to exist. An older sister gave evidence of exactly the same condition, 
the murmur in her case disappearing at about the ninth or tenth year. The murmurs 
in these children were not anemic nor cardiorespiratory. 
Treatment.—The functional murmur requires no treatment. But the 
condition causing the murmur may require attention and determine 
treatment. 
FUNCTIONAL ABNORMALITIES IN CARDIAC RATE AND RHYTHM 
In addition to functional murmurs there are functional departures 
from the normal in cardiac dynamics. An outstanding example of the 
disorders of this type is afforded by the condition known as tachycardia, 
in which the heart action independently of the usual causes of increased 
rate is persistently very rapid. Bradycardia, or excessive slowness of 
the heart action, is less commonly encountered. 
The ordinary child, more or less highly emotional, rapidly growing, 
and subject to stress of varying nature, finds a ready reaction in the 
heart muscle and its nerve supply. 
The advent of puberty in both sexes is often suggested by the presence 408 
THE PRACTICE OF PEDIATRICS 
of cardiac arhythmia. The existence of this condition is ordinarily dis- 
covered incidental to the examination of the chest for other possible 
disorders, as the patient is usually unaware of irregularity in the heart 
action. 
Tachycardia may be a manifestation of thyroid dysfunction. Such 
cases are typically those of overworked, overanxious school girls whose 
heart rate ranges from 120 to 140 during ordinary rest and is but slightly 
lessened during sleep. The heart in such instances impresses one as an organ 
that is driven. Under appropriate rest treatment and change the action 
returns to normal. The slight enlargement of the thyroid so common in 
girls at puberty gives rise in many of the cases of the type cited to the 
diagnosis of goiter. Such cases are by no means to be confused with 
those of Graves’ disease, although the functional cardiac cases may be 
potentially those of hyperthyroidism. Proof on this point is lacking. 
The fact remains that in experience with a vast amount of clinical material 
in private practice and hospital and consultation work the senior author 
has seen but 2 cases of actual Graves’ disease in children under fifteen 
years of age. 
Illustrative Cases.—Case 1.—A girl who came under observation for rapid heart 
action when four years old has had simple tachycardia for twelve years. Except for 
this symptom she has been perfectly well, and in spite of her usual pulse-rate of about 
140, suffers no inconvenience. At first rest-treatment was attempted, without benefit. 
At the age of five years the patient was under the care of a physician expert in ductless 
gland treatment for several months, but without response. She was then referred to 
a heart specialist, who made an electrocardiographic examination and reported sinus 
arythmia, but stated that the heart in other respects was normal. He offered no sug- 
gestions other than those that had already failed. Different physicians, later consulted, 
were unable to achieve results, and the parents of the child, at length tired of the re- 
striction of her activity, discontinued all treatment. For the past seven or eight years 
the girl has led the life of the average well school child, riding bicycle, horseback riding, 
going bathing, and playing the usual children’s games, with a pulse-rate ranging about 
140. She is not aware of the rapidity of the heart action and the family have given up 
thinking about it except perhaps when reminded that we would like to see the patient 
for our own information. 
Case 2.—Paroxysmal tachycardia in a boy eight years of age was marked by seizures 
decidedly distressing, at frequent intervals, requiring the use of codein for their control. 
The history suggested gastric hyperacidity and the gastric contents upon examination 
showed a total acidity of 90. Treatment given for this condition was followed by 
cessation of the tachycardia. 
Bradycardia in our experience has almost always been associated with 
a congenital lesion. 
Illustrative Case.—A boy patient never revealed a heart action over 40 during ob- 
servations covering the period from birth till the fourth year, at which time he passed 
from observation. At this time an electrocardiographic examination was suggested 
and refused. 
Heart-block occurs occasionally in childhood as a result of conditions 
interfering with the normal conductivity of the fibers of the bundle of 
His, notably in the cases of myocardial weakness of sudden development 
after diphtheria. Heart-block is also observed as one of the signs of ex- 
treme digitalization and may result from toxic* action of other drugs than 
digitalis. The digitalis effect may be temporarily beneficial and is transient 
if the administration of drug is promptly stopped. 409 
CONGENITAL HEART DISEASE 
Fainting attacks are of frequent occurrence as a result of nervous dis- 
order and may occur independently of cardiac weakness. 
Auricular fibrillation is rarely noted in children. 
The study of cardiac disease has been greatly enhanced during the 
past two decades by the development of electrocardiography. To this 
science Lewis, Mackenzie, Einthoven, and Williams have contributed 
most extensively. 
Under conditions that suggest cardiac disease or derangement it is 
our duty to exclude the existence of organic cardiac disease, and when this 
has been done it is equally our duty to find defects apart from the heart 
that may account for the altered function, and then leave the organ to 
take care of itself. This in the great majority of cases it will do. 
CONGENITAL HEART DISEASE 
In congenital heart disease there is a fundamental structural fault. 
The heart in one or more respects is anatomically imperfect. 
Etiology.—Many cases are directly traceable to defective develop- 
ment in the embryonic cardiovascular system, and to understand well 
the anomalies found at autopsy one must review the subject of the fetal 
circulation. Septal defects in the heart and persistence of the patent 
ductus arterioshs and various forms of hypoplasia of the great vessels 
illustrate the lack of normal completion in cardiovascular development. 
Other abnormalities are ascribed to a fetal endocarditis. Constitutional 
disease in one or both parents may be a causative factor producing the 
endocarditis. The frequent association of congenital heart defects with 
other defects in development is noteworthy, and particularly so is the 
frequent existence of cardiac abnormality in Mongolian idiots. 
Varieties of Congenital Cardiac Disease.—The following tabulations 
based in part on the statistics of Abbott1 are quoted from Griffith’s work.2 
Classification of Forms of Congenital Cardiac Disease 
1. Anomalies of the septa 
Patulous foramen ovale 
Perforate septum ventriculorum 
Pulmonary stenosis 
Pulmonary insufficiency 
Aortic stenosis 
Aortic insufficiency 
Mitral stenosis 
Mitral insufficiency 
(a) Valves 
2. Anomalies of the valves and vessels 
Patulous ductus arteriosus 
Stenosis of pulmonary artery 
Dilatation of pulmonary artery 
Narrowing of aorta 
Dilatation of aorta 
Hypoplasia of aorta and vessels 
Transposition of great vessels 
(6) Vessels 
3. Anomalies in the size and position 
of the heart 
Transposition of heart chambers 
Dextrocardia 
Congenital hypertrophy 
Ectocardia 
1 Osier and McCrae, Modern Med., 1915, 342. 
2 Diseases of Infants and Children, 1919, vol. ii, p. 122. 410 
THE PRACTICE OF PEDIATRICS 
Frequency of Different Forms of Congenital Cardiac Disease 
Variety. 
Number of 
cases. 
Displacement of the heart 
30 
Partial defect of the interauricular septum 
237 
Partial defect of the interventricular septum 
196 
Complete defect of one or more septa, or of both 
34 
Anomalies in the origin of the arteries 
184 
Pulmonary stenosis or atresia 
150 
Aortic stenosis or atresia 
21 
Tricuspid stenosis or atresia 
20 
Mitral stenosis or atresia 
9 
Patulous ductus arteriosus 
193 
Stenosis (coarctation) of the aorta 
102 
Hypoplasia of the aorta 
46 
Pathology.—The initial and chief lesion in the majority of cases is 
at the pulmonary orifice, and is supposedly due to a fetal endocarditis 
which causes a stenosis. This, through interference with the blood-current, 
prevents a closure of the auricular or ventricular septum. 
Fig. 78.—Clubbed fingers in congenital heart disease, 
Cases are occasionally seen, however, in which the defect in one or 
other of the septa exists without atresia or stenosis at the pulmonary orifice. 
Enlargement of the heart is the rule. Usually the right heart will be 
found particularly involved. 
The above conditions represent some of the more common abnor- 
malities. One who observes many autopsies upon children will have 
abundant opportunity to verify the above statements and to see other 
abnormalities which are of academic interest only. 
Symptomatology.—Congenital heart disease is sometimes suggested 
by the appearance of the patient. There may be cyanosis, which is ob- 
served only when the child cries or strains, or the patient may be a “blue 
baby,” in which case the cyanosis is permanent and of such a degree as 
to make the diagnosis positive without further aid than inspection. CONGENITAL HEART DISEASE 
411 
In far the greater number of cases the defect is discovered upon 
routine examination with no external sign whatsoever indicating that 
a lesion exists. 
Classification of Lesions on Clinical Examination.—-It is a hopeless 
task to attempt to classify a congenital lesion according to the nature, 
maximum intensity, or transmission of the murmur. Even after the signs 
have evoked a common diagnosis from several observers autopsy may 
show conditions not flattering to the diagnostic acumen of the examiner. 
In general, the following points may be borne in mind, in an attempt 
to diagnose the existing lesion in a given case: 
Patent interventricular septum gives rise to a systolic murmur maxi- 
mum at about the fourth left interspace near the sternum, not transmitted 
to the neck, and unaccompanied by thrill and cyanosis. 
Pulmonic stenosis typically produces a systolic murmur heard over 
the second left interspace near the sternum and accompanied by a definite 
thrill. Cyanosis, enlargement of the right heart, and clubbing of the 
finger-tips are noteworthy. 
Patent ductus arteriosus gives rise to a loud prolonged “humming- 
top” or “coffee mill” murmur heard in both phases of the cardiac cycle 
over the entire precordium and transmitted upward in the carotids. 
This condition often occasions little physiologic difficulty and might go 
on unrecognized were the heart not examined by the ear. 
Patent foramen ovale, patent interventricular septum, and patent 
ductus arteriosus are compensatory in the presence of pulmonic stenosis. 
Cyanosis and cardiac enlargement without audible murmur may be 
due to complete atresia or hypoplasia of the pulmonary artery. 
Diagnosis in Infants and Very Young Children.—The most valuable 
diagnostic sign is a pronounced cardiac murmur in a child under eighteen 
months of age. Children before this period of life rarely have rheu- 
matism, which is the cause of endocardial lesions in over 95 per cent, of 
the cases. The absence of cyanosis is no evidence against the diagnosis 
of a congenital lesion, as a great majority of the cases have not shown this 
symptom. On the other hand, there may be a marked degree of cyanosis 
and not the slightest trace of a murmur. 
At autopsy such a case showed an entire absence of the ventricular septum. 
First, then, the age of the child is strongly suggestive as to whether 
the condition is due to a congenital abnormality or acquired disease. If 
the patient is under eighteen months of age or even under twTo years, the 
lesion is, in all probability, congenital. 
Second in importance is to be noted the character of the murmur, 
which is usually systolic and of a very loud, rasping character, heard 
loudest in the third or fourth left intercostal space with a very wide area 
of diffusion. Many of these murmurs may be heard over the entire thorax, 
both anteriorly and posteriorly. 
Differential Diagnosis in Infants.—At this period of life the murmur 
of congenital heart disease has to be differentiated from the murmur 
found in anemia. Not all congenital murmurs are as characteristic as 
above described. They may lack the element of loudness and harshness 
and be soft and blowing in character. This, however, is of very infrequent 412 
THE PRACTICE OF PEDIATRICS 
occurrence. In such an event a differential diagnosis between a con- 
genital cardiac lesion and a murmur due to anemia is most difficult, for 
the anemic murmur is systolic in time, is heard loudest over the base, and 
has a fairly evenly distributed area of diffusion in all directions. 
In such cases the blood examination is of decided service. In con- 
genital heart disease there is almost constantly a very extreme poly- 
cythemia with high hemoglobin percentage and specific gravity, and a 
moderate increase in the white cells (Wood). 
Murmurs Due to a Definite Lesion.—These are constant and vary little 
under different states. Whether the patient is at exercise, at rest, sitting, 
standing, or lying down, the murmurs are invariably present and vary only 
in intensity. This fact is a valuable aid in differentiation. 
The Functional Murmur.—The chief characteristic of the functional 
murmur is the inconstancy of the sound, now loud, now weak. Not in- 
frequently these murmurs disappear under stress and reappear when the 
stress is removed. They may disappear or become very faint with the 
patient recumbent, and reappear upon the return to the erect position. 
A relaxed heart muscle might be a cause of some of these cases. 
The anemic murmur typically changes upon change in position of the 
patient, and during exercise it is inconstant. 
Diagnosis and Differential Diagnosis in Older Children.—In children 
after the second year the differential diagnosis may be more difficult. 
It is to be remembered that in cases in which a congenital murmur is 
well marked at this period of life there will usually be other signs that 
may aid us in our judgment. is present in a larger proportion 
of the older patients than of the very young. This is to be explained by 
the fact that the child when very young calls upon the heart to a com- 
paratively small extent. With the assumption of active play and with 
running, stair-climbing, and stress of any nature, the defective heart 
fails to meet the extra demands, and cyanosis, clubbed fingers (Fig. 78), 
and shortness of breath develop. At this age also the question of anemia 
and developmental conditions arises. Repeatedly patients are seen who 
show no inconvenience whatever until this more active period of life is 
reached. 
Murmur After Illness.—The murmur of congenital disease is also to 
be differentiated from other functional murmurs than those of anemia 
(p. 406), which are practically all systolic in time and have a wide area 
of diffusion. These functional murmurs often occur during, or particularly 
after, severe illnesses, such as pneumonia or typhoid fever, when the 
heart has been severely taxed. With such a murmur there is no accentua- 
tion of the second sound, no accompanying dropsy or cardiac enlarge- 
ment, and the murmur is inconstant and variable, being influenced by the 
activity of the heart and the position of the patient. 
Prognosis.—The future of the child with the congenitally defective 
heart is very uncertain. A very few of these patients go on to the adult 
period of life and suffer no inconvenience. In by far the larger number 
of cases, however, the approach of the runabout and active period (if the 
child survives to this time), with the extra demand upon the organ that 
this age necessitates, results in failure of compensation, and dilatation, 
followed by the usual train of symptoms peculiar to right heart failure. PERICARDITIS 
413 
Illustrative Case.—A girl with congenital heart disease developed several attacks 
of angina and cyanosis at the thirtieth month. This continued at rather infrequent 
intervals for a year, when she died in an attack. 
PERICARDITIS 
Etiology.—Inflammation of the pericardium is usually associated with 
endocarditis of rheumatic origin. No period of life appears to be exempt. 
Our youngest patient was six months of age. The disease occurs most 
frequently between the third and the twelfth years. Cases have been 
reported by different authors as occurring in fetal life. As the result of 
an infection the disease occurs not only in association with rheumatism 
but also as a result of the invasion of pathogenic bacteria carried through 
the blood-stream or by the lymph from other portions of the body. Before 
the third year pericarditis is associated with pneumonia and empyema 
with greater frequency than with any other disease. 
Bacteriology.—The organism most often found in the serofibrinous or 
purulent exudate is the pneumococcus, a fact which is explained by the 
frequency of pulmonary lesions as the primary source of the infection in 
70 to 90 per cent, of these cases. The streptococcus or the Staphylococcus 
aureus may be present; and very rarely Bacillus influenzae or the gonococcus 
has been found in the course of septicemia due to these bacteria. The 
tubercle bacillus, as the cause of fibrinous or purulent pericarditis in chil- 
dren, is almost unknown. Tuberculosis is more apt to involve the ex- 
ternal surface of the sac owing to possible extension of tuberculosis of 
the lung. 
Poynton has found the so-called “diplococcus of rheumatism” in the 
plastic exudate of pericarditis complicating rheumatism. 
Pathology.—Pericarditis possesses as wide possibilities as pleuritis, 
and the pathologic processes are quite similar. Thus, there may be only 
simple dryness of the lining of the pericardial sac, or a complete filling of 
the sac with serous or purulent fluid. Over the heart and the enveloping 
membrane only thin layers of fibrin may form; or the heart and peri- 
cardium may become firmly bound together by layers and bands of 
fibrinous exudate. Autopsies in purulent cases often show the heart 
wrapped in the meshy fibrinous exudate to such a degree that the muscle 
surface cannot be seen, while the inner surface of the pericardium is lined 
with a granular exudate and the intervening space is filled with fluid 
serum or pus. On showing postgraduate students such specimens the 
senior author has witnessed complete failure of the entire class to recognize 
the organ before them, so great has been the change from the normal 
appearance. 
Symptoms.—Pericarditis is a disease which stands out peculiarly 
because of the wide range of the possible symptoms. Thus a case of 
purulent pericarditis may run its course under the observation of excel- 
lent clinicians and not be recognized until the autopsy, or may produce 
symptoms of the greatest urgency and occasion intense distress to the 
patient. It is, therefore, impossible to lay down a symptomatology for 
the disease that will apply to all cases. Pericarditis is quite possibly 
more frequently overlooked by clinicians than any other disease. 
Cyanosis is present. The expression is anxious. In urgent cases a 414 
THE PRACTICE OF PEDIATRICS 
prominent symptom is extreme restlessness. Discomfort, pain, and a 
feeling of tension over the precordium are at times complained of. In 
other cases with apparently quite pronounced lesions there is little or no 
discomfort. 
An important symptom indicating pericarditis is rapid respiration. 
Not only is the breathing rapid, as in pneumonia, but it is fairly charac- 
teristic in that the respirations are guarded. The patient appears to 
have his mind centered on breathing. Carefully guarded inspiration is 
taken and careful expiration is carried out. At the same time the respira- 
tion is hurried and short, although not precipitate. This cautious breath- 
ing is due to the feeling of decided discomfort, constriction, and even 
pain which accompanies the chest expansion. The respiration is some- 
what similar to that of acute pleurisy. The individual is not sure that he 
will be able to complete respiration, and perhaps feels obliged to cut 
it short. 
The very rapid heart, action is the most reliable symptom of the dis- 
ease, often exceeding in apparent severity all the other symptoms. We 
have repeatedly seen patients from eight to ten years of age with a 
temperature rise to only 100° F., with a pulse-rate from 130 to 150 
or higher. 
Physical Signs.—The first proof of pericardial inflammation is a rub- 
bing, grating sound, known as the pericardial friction sound, heard over or 
slightly above the apex of the heart. The sound has a double quality 
and is heard both at systole and diastole, or perhaps only with systole, 
and in well-marked cases will be transmitted to the finger on palpation. 
Wherever heard the sound is distinctly localized. In cases of effusion in 
older children there may be bulging of the interspaces. With the appear- 
ance of considerable fluid the friction sounds cease, but return when the 
fluid is absorbed. In cases in which the friction is questionable or indis- 
tinct, it will be accentuated by having the child lean forward in a sitting 
position. 
Percussion.—When fluid in considerable amount is present, the area 
of cardiac dulness will be increased, the apex-beat will be difficult to 
determine, and the normal heart sounds will become weakened. Oblitera- 
tion of the cardiohepatic angle may be noted, although the findings of 
Morris and Little1 indicated that in pericardial effusion this angle 
typically is acute. 
In a fatal case in a six-year-old boy the apex-beat was not demonstrable, and 
the heart sounds could scarcely be heard. 
It has not been our observation that the apex-beat is displaced up- 
ward, as is claimed is the case in adults. With the presence of consider- 
able fluid—over 2 ounces in a child from three to five years of age—the 
dulness will be increased to the left and upward. Shifting dulness, if 
found on change from the recumbent to the erect sitting position, is most 
diagnostic. 
With the larger effusion occurring in the boy above mentioned, the dulness extended 
to the right nipple and 1 inch outside of the left nipple. 
1 Amer. Jour. Med. Sciences, November, 1923. 415 
PERICARDITIS 
The amount of fluid is difficult to determine in any case, and particu- 
larly so when endocarditis and myocarditis coexist, with accompanying 
hypertrophy and dilatation. 
Diagnosis.—The x-ray is essential in doubtful cases. Differentiation 
between cardiac dilatation without effusion, pericarditis with effusion, and 
left pleural effusion is not at all times easy. 
In every case of acute heart disease in a child the physician should 
be particularly careful to investigate the cause of exceptional rapidity of 
breathing and pulse-rate. 
Prognosis.—The prognosis in rheumatic cases is good if proper treat- 
ment can be followed. We are dealing with a disease in which the man- 
agement of the case determines to a large degree the outcome. Just how 
complete a recovery is made in the so-called recovery cases is difficult to 
determine, as there must be, in every case, adhesions between the heart 
and the pericardial sac. A condition known as adherent pericardium 
(p. 429) may be the outcome. The purulent cases, with so-called malig- 
nant endocarditis, have, with rare exceptions, been fatal. 
The duration of the acute cases of rheumatic origin varies from a few 
to a considerable number of weeks. 
Treatment.—In considering the treatment we may divide cases of 
the disease into two groups—those of rheumatic origin and those due to 
the invasion of well-known pathogenic organisms. In the rheumatic 
cases the sick-room management and the diet are the same as in the 
treatment of endocarditis (p. 419). In addition to the management pur- 
sued in endocarditis, additional symptomatic treatment is required. 
For controlling excessive rapidity of the heart the tinctures of digitalis 
and aconite may be of much service. To a child eight months to three 
years of age \ drop of tincture of aconite and 1 drop of tincture of digitalis 
may be given at two-hour intervals, but not to exceed six doses in the 
twenty-four hours. After the third year 1 drop of the tincture of aconite 
and 3 drops of the tincture of digitalis may be given at two-hour intervals— 
six doses in the twenty-four hours. 
For the extreme restlessness which often exists codein or paregoric 
may be given. For a child under two years of age paregoric is safer. 
It may be given in doses of from 10 to 20 drops and repeated when indi- 
cated at intervals of two or three hours. Older chlidren—between the 
second and sixth years—should be given codein in doses of from 1/10 
to 1/6 grain. After the sixth year 1/4 grain may be given, to be repeated 
at three-hour intervals or less frequently, not more than three doses being 
given in twenty-four hours. 
As soon as the diagnosis is made, if the case is of rheumatic origin, 
it is advisable to begin giving salicylate of soda with a view to prevention 
of effusion into the pericardial sac. The belief of various clinicians that 
rheumatic carditis is unaffected by salicylates does not justify neglect in 
the use of the agent acknowledged to be specific for rheumatism in gen- 
eral. To children under three years 14 to 20 grains of salicylate of soda 
should be given daily, with twice the amount of bicarbonate of soda. 
As the salicylate may cause some gastric disturbance, it should never be 
given when the stomach is empty except in milk or with some other 
food; 4 grains is as much as should be given at one time. After the third 416 
THE PRACTICE OF PEDIATRICS 
year from 20 to 30 grains may be given. At the tenth year 40 grains 
may be given daily in divided doses, always in solution, under the same 
precautions as to giving the drug after meals. It is impossible and entirely 
unnecessary in this country to give the large doses of the salicylate which 
are given abroad. 
For delicate children and those by whom the salicylate is not well 
tolerated, aspirin may be substituted; or the salicylate may be given 
by the bowel in doses of 15 grains at a time. The medicine should be 
diluted with at least 4 ounces of water and introduced through a rectal 
tube which has been inserted at least 9 inches. This procedure should 
be carried out not oftener than twice daily, and should be immediately 
preceded by irrigation of the large intestine. 
In the comparatively infrequent cases in which 'pericarditis complicates 
one of the infectious diseases, the salicylate treatment is not to be advised 
unless there is some suspicion of rheumatism. The other methods sug- 
gested are to be carried out with the hope that the disease may be 
controlled. In this type of case the ice-bag is particularly serviceable 
(p. 420). In the event of effusion so excessive as to interfere with the 
heart action, producing orthopnea and cyanosis, with feeble, irregular 
pulse, operation on the pericardium, such as aspiration or incision and 
drainage, is to be considered, although in the few operative cases which 
we have seen we have not been impressed with the great usefulness of this 
treatment. On the other hand, we have seen cases, in which there was 
an excessive accumulation of fluid, recover under less radical measures. 
The Purulent Type.—When it becomes evident that pus is present 
in the sac, incision and drainage may be attempted, as the case will surely 
be fatal if the usual methods are pursued. In this type the blood shows 
a very high white cell count with very high polynucleosis. 
ACUTE ENDOCARDITIS 
Acute endocarditis is an inflammation of the endocardium or lining 
membrane of the heart. Probably in all cases showing even a moderate 
degree of severity there is involvement of the adjacent heart muscle, so 
that when there is an endocarditis there is a myocarditis as well, although 
the latter may be of little moment. Pericarditis has been a complication 
in about 5 per cent, of our cases. In the great majority of instances endo- 
carditis is to be looked upon as a manifestation and not a complication of 
rheumatism. 
Etiology.—Endocarditis is present in a considerable proportion of 
cases of chorea, the statistics of various authors varying from 6 to 55 
per cent. Both the chorea and the endocarditis are active manifesta- 
tions of rheumatism. In our own experience endocarditis has been pres- 
ent in not over 20 per cent, of the cases of chorea. Endocarditis occurs as 
a complication of scarlet fever, diphtheria, measles, and tonsillitis. In 
fact, there are few diseases of bacterial origin with which it has not at 
some time been associated. In 2 cases it was a complication of grip. 
Age.—It is unusual to find endocarditis in children under three years 
of age. Few cases are seen between the third and fifth years. The period 
of greatest susceptibility is between the fifth and the twelfth years. ACUTE ENDOCARDITIS 
417 
Family susceptibility to rheumatism, chorea, and endocarditis is note- 
worthy and has been emphasized in a study of 100 families by St. Law- 
rence.1 
Bacteriology.—The vegetative forms of endocarditis are more fre- 
quently due to rheumatism than to any other infectious disease. Poynton 
and Payne demonstrated a “diploeoccus rheumaticus” in the vegetations 
on the heart valves. The bacteria are said to be found readily only in 
the early stage of the endocarditis, tending to disappear in the later course 
of the disease. 
The identity of the causative organism in rheumatic endocarditis is, 
however, still not universally granted. “The disease would appear to be 
a modified septicopyemia.”2 
Acute ulcerative or septic endocarditis is more often a secondary 
than a primary condition, and is caused by the localization on the heart 
valves of bacteria from the blood-stream. The bacteria causing the 
primary infection are present in the valvular ulcers. Streptococci, staph- 
ylococci, pneumococci, gonococci, typhoid bacilli, colon bacilli, influenza 
bacilli, and diphtheria bacilli have been found. 
In cases of malignant endocarditis the causative organism (not infre- 
quently the Streptococcus viridans, as in adult cases) may be found by 
blood-culture. 
In chronic endocarditis no bacteria are demonstrable in the endo- 
cardial lesions. 
Pathology.—Inflammation of the membrane lining the heart affects 
chiefly the valves; and most frequently those guarding the mitral and 
aortic orifices. The latter fact has been explained by a theory that bac- 
terial development is better favored by the fresh arterial blood of the left 
ventricle than by the venous blood (of low oxygen content) present in 
the right heart. 
The margins of the affected cusps are thickened and covered with 
small masses of necrotic tissue, fibrin, red corpuscles, leukocytes, pro- 
liferating endothelial cells, and bacteria. The chordae tendineae are 
frequently involved and undergo shortening, thickening, and a certain 
amount of fusion. In the myocardium perivascular groups of cells are 
to be found in concentric layers. These foci, known as Aschoff’s bodies, 
may ultimately be incorporated in a process of fibrosis. 
In cases of mild infection the seat of the inflammation is at the base 
of the valves in the heart muscle and there is left no permanent lesion. 
More frequently, however, when the acute inflammation subsides the 
valves undergo considerable cicatrization and contraction, and exist 
thenceforth as deformed and more or less inefficient structures. 
In the severe forms of the disease, commonly termed “malignant en- 
docarditis,” destructive effects are much more marked, and ulceration of 
the mural endocardium may occur. In such cases emboli frequently 
become detached from the friable vegetations on the valves, and produce 
infarcts and abscesses in such remote organs as the brain, spleen, and 
kidney. 
The usual sources of infection are wounds of the skin and mucous 
1 Jour. Amer. Med. Assoc., December 16, 1922. 
2 Reid, The Heart in Modern Practice, 1923, p. 97. 418 
THE PRACTICE OF PEDIATRICS 
membrane, and inflammation of the alimentary, pulmonary, and genito- 
urinary tracts. Prominent in this category are diseased tonsils and teeth. 
Attacks of “simple” acute endocarditis may easily render the heart more 
susceptible to an infection of the malignant type. 
Symptomatology.—By far the majority of cases of endocarditis present 
no symptoms whatever. Hundreds of these cases are overlooked because 
of this peculiarity of the disease, and because writers lay great stress 
upon a symptomatology of prostration, high temperature, and severity 
in general, that may occur in one out of 10 cases, the result being that 
9 are overlooked. A large majority of the cases of endocarditis coming 
under our observation (mild acute endocarditis, not chronic valvular 
disease) have been discovered in the routine examination of the patient, 
and not because anything in the case had suggested the heart as a factor 
in the illness. Every physician who does considerable clinical work 
sees patients with valvular defects of long standing, who have no knowl- 
edge whatever that a heart lesion has existed. Clinicians who examine 
for life insurance will particularly appreciate the force of the above state- 
ment. We have repeatedly seen cases develop during or after tonsillitis 
in children with a rheumatic tendency, the endocarditis being the active 
manifestation of the rheumatism. 
Illustrative Case.—A boy six years of age had a slight pain in his knee, which caused 
a limp. He had just recovered from a mild tonsillitis. In the routine examination 
acute endocarditis was found, involving both the mitral and aortic valves. The boy 
made a complete recovery. 
There are doubtless many cases of endocarditis which pass unrecog- 
nized and terminate in recovery. 
When acute symptoms are present, we find fever which presents wide 
variations—100° to 105° F.—depending upon the severity of the in- 
fection. The height of the temperature is usually a reliable indication 
of the gravity of the illness. With the high temperature there is increased 
heart action ranging from 110 to 140. If the action is irregular, myocar- 
ditis also may be suspected. Pain over the precordium and shortness 
of breath are usually present. 
Diagnosis.—The symptoms alone may be sufficiently pronounced 
to suggest the existence of endocarditis. It is by the physical signs, 
however, that suspicion is verified and the diagnosis made possible. 
Inspection, if it reveals anything abnormal, will show an excessive 
action of the heart, producing an undulating motion of the cardiac area, 
with visible apex-beat. 
Palpation confirms the existence of this overaction of the heart and 
may detect a thrill corresponding to the murmur found on auscultation. 
Percussion may reveal cardiac enlargement. The left ventricle be- 
comes dilated early in the severe cases. 
Auscultation will reveal either a murmur (p. 404) or a combination 
of murmurs. In character the murmur may be soft and blowing, or harsh, 
rough, and grating. It may be systolic, diastolic, or presystolic; or it 
may be double, presystolic and systolic, or diastolic and systolic. The 
fact that the left side of the heart is always involved simplifies materially 
the localization of the lesion. ACUTE ENDOCARDITIS 
419 
If due to mitral regurgitation, the murmur is usually soft and blow- 
ing in character, heard loudest at the apex, transmitted to the left axilla, 
and plainly heard between the scapula and the spine. 
In mitral stenosis the murmur is presystolic in time, and is heard 
loudest just above the site of the apex-beat. This murmur is not trans- 
mitted elsewhere, and is accompanied by a thrill (p. 405). 
When there is combined mitral stenosis and regurgitation the sys- 
tolic murmur folloAvs immediately upon, the presystolic, making a pro- 
longed murmur which completely obliterates the first heart sound. 
Aortic stenosis produces a systolic murmur, heard loudest at the 
second interspace, over the middle of the sternum, or at its immediate 
right border, and transmitted upward to the carotids. 
In aortic regurgitation the murmur is diastolic in time and is usually 
heard loudest over the second and third left interspaces. 
Differential Diagnosis.—Endocarditis may be confused with tem- 
porary functional disturbances of the heart, giving rise to functional 
murmurs (p. 406). This statement, of course, applies only to mitral 
disease. After many disorders in children in which the heart has been 
severely taxed, a soft, blowing, systolic murmur develops. This mur- 
mur, however, is inconstant, changes more or less, or disappears upon 
change in the position of the patient, and, most important of all, has 
no line of transmission and is not heard at the back. After a few days 
or weeks, providing proper management is carried out, such murmurs 
disappear. 
Prognosis.—The outlook, in a great majority of cases of endocardi- 
tis, is favorable for a complete recovery. In other cases, even under 
the best of management, the patient, after recovery from the acute disease, 
is left with crippled valves. When there is a very severe infection of the 
so-called malignant type the outlook is most unfavorable. 
Illustrative Case.—A boy seven years of age died within forty-eight hours from 
the onset of the heart involvement. 
A considerable number of similar fatal cases have been encountered in consultation 
work. 
The inflammation in such cases usually develops rapidly into a pan- 
carditis, the heart muscle, the pericardium, and the endocardium all 
becoming rapidly involved, with resulting dilatation of the heart, which 
is often extreme. 
In such cases there is usually a general septicemia. 
Treatment.—Rest in Bed.—Whatever the nature of the infection, 
and whether the disease is mild or severe, one rule—that regarding quiet 
and rest—must be consistently followed. The child must remain in a 
recumbent position in bed, the bed-pan being used to receive the excreta. 
The use of the arms and the hands should be discouraged, particularly 
early in the attack, as it is at this time that the greatest damage is done 
to the heart. Reaching from the bed to the floor or to the table or chairs 
should be forbidden. The heart must be given as little work to do as 
possible. 
Prolonged Inactivity.—In both pericarditis and endocarditis absence 
of stress of any nature should be secured until every evidence of the 420 
THE PRACTICE OF PEDIATRICS 
disease has disappeared, or at least until the heart becomes regular, and 
its rate, under a test of moderate exercise, approximates the normal. 
Ilustrative Case.—The longest period we have kept a patient recumbent was six 
months. This patient is now a young man, and all that remains of his very extensive 
endocarditis and pericarditis, comprising three distinct attacks, is a slight mitral re- 
gurgitant murmur with full compensation. 
Every patient is kept off the feet for at least six weeks, and several 
have not been allowed to take a step within three to six months. 
Diet.—The diet should consist largely of fluids, administered in com- 
paratively small amounts, at shorter intervals than in health. The 
bowels should move once daily. If a laxative is necessary, a saline should 
be given. A Seidlitz powder or magnesium citrate is usually effective. 
Distention of the stomach, whether by gas or by food, causes pressure 
on the heart and increases its labor. It is a good custom, in these cases, 
to give five feedings in twenty-four hours, and not more than 8 ounces 
at a feeding. Four ounces of milk and 4 ounces of gruel, with zwieback 
or toast, constitute the usual feeding. In order to vary the diet a weaker 
gruel, No. 1 (p. 94), flavored with an ounce or two of chicken or mutton 
broth, may be given; or a gruel of the same strength may be given plain, 
with sufficient salt to make it palatable. If the milk is well borne, it may 
be increased until 1 quart is taken daily. The enforcement of a strict 
milk diet is a mistake. The child very soon tires of it, digestion is im- 
paired, and nutrition is correspondingly faulty. As improvement becomes 
apparent eggs, bread and butter, stewed fruit, poultry, fish, and plain 
puddings may be added to the diet. In order to facilitate freer feeding 
the number of meals should be reduced. 
The Ice-bag.—A screw-top ice-bag half-filled with chopped ice should 
be placed over the heart, and, if possible, kept on continuously. Children 
frequently become restless and irritable under too constant application 
of the ice, and in such instances it may be left off occasionally for half 
an hour or an hour. Gilman and White1 have shown that “the greatest 
effectiveness might be achieved by alternating half-hour periods.” 
A most reprehensible practice is the overfilling of the ice-bag to such a 
degree that its weight is a direct physical burden upon the heart. 
Drugs.—In endocarditis following diphtheria or the exanthemata 
drugs are of little benefit. Salicylate of soda seems to have no bene- 
ficial effect upon these patients. For excessive rapidity of the heart 
action digitalis is more effective than any other drug. To children from 
five to ten years of age 3 to 6 drops may be given at intervals of from 
three to six hours. When a more rapid effect is desired the Eggleston 
method and dosage may be followed (p. 428). 
If there is much excitability and restlessness, i grain of codein or 8 
grains of sodium bromid may be given at sufficiently frequent intervals 
to control the condition. While every case of non-rheumatic endo- 
carditis presents possibilities of serious and permanent damage to the 
heart, not every case, by any means, is of sufficient severity to demand 
other treatment than the ice-bag, rest, and an easily digested diet. 
It is often the milder cases that occasion the gravest sequelae, on account 
1 Jour. Amer. Med. Assoc., September 1, 1923, p. 748. ACUTE ENDOCAEDITIS 
421 
of the lack of objective symptoms, and the liberties given the child by 
parents, who are with difficulty convinced of the gravity of the disease. 
Antirheumatic Treatment.—Every case of endocarditis under our 
care, which is not directly associated with one of the specific infectious 
diseases, is considered and treated as though it were a case of rheumatism, 
owing to the exceeding frequency of this form of infection. Sodium 
salicylate and sodium bicarbonate are early brought into use. To a child 
between five and ten years of age from 3 to 5 grains of sodium salicylate 
with an equal quantity of sodium bicarbonate are given after each feed- 
ing five times daily. The medicine may be given in capsules or in solu- 
tion. If the sodium salicylate is not well borne by the stomach, the equiv- 
alent dosage of aspirin or oil of wintergreen may be given. The salicylate 
should be continued with occasional intermissions of a day or two until 
such urgent symptoms as fever, rapid heart-rate, and dyspnea have sub- 
sided. The dosage should then be varied, 10 grains being given daily 
for five days out of fifteen. 
A child who has recovered from rheumatic endocarcitis should be kept 
under close observation, and the parents should be warned as to the 
possibilities of a second attack. 
Illustrative Cases.—Case 1.—In a private case, in spite of antirheumatic treatment, 
during the intervals four distinct attacks occurred during five years. 
Case 2.—A dispensary patient at the New York Polyclinic had his first attack 
when four years of age. So prominent was his rheumatic tendency that during the 
next four years, in spite of active antirheumatic treatment and a careful diet in the 
intervals, he had eight distinct attacks of endocarditis, and died from the heart in- 
volvement in his eighth year. There were other manifestations of rheumatism in his 
case, and his family on both sides for several generations had been markedly rheumatic. 
Convalescence.—When the pulse-beat is reduced to 100, which is 
not to be expected earlier than the fourth week, the patient may be 
allowed to sit in a reclining chair. Previous to this, while still in bed, 
he may be gradually accustomed to elevation of the head by the addi- 
tion of an extra pillow for an hour or more daily. Greater freedom is 
permitted when it is found that the patient can be indulged and the heart- 
rate still be kept below 100. 
Recurrence.—Inasmuch as a recurrence is very probable, the patient, 
even while in apparent health, should have the benefit of a restricted 
diet, being allowed red meat but twice a week and a minimum amount 
of cane-sugar. During five days out of each month he should receive 
10 grains of sodium salicylate and 10 grains of sodium bicarbonate daily. 
This scheme of medication should be continued for at least two years, 
and much longer if the patient shows any further rheumatic manifesta- 
tion, such as pains in the legs, or repeated attacks of tonsillitis. The length 
of time during which absolute rest in bed is to be enjoined depends on the 
severity of the case. This time in most primary cases is from six weeks 
to three months. 
Illustrative Case.—In the case of a boy who had had a very severe second attack, 
walking was not allowed for six months, the patient using a wheel-chair instead. 
In a case of moderate severity in which the fever may have continued 
for only a week or ten days, the heart action, which has ranged from 140 422 
THE PRACTICE OF PEDIATRICS 
to 160, gradually becomes less frequent. The rapidity of the heart rate 
is the best guide in deciding when walking shall be permitted, and a safe 
rule is to permit increase in activity only when the pulse is consistently 
below 110. 
Every child who has had acute endocarditis should have the tonsils 
enucleated. Dental foci of infection must likewise be eradicated. 
Conclusion.—The above scheme of management may seem unneces- 
sarily severe, but we must remember the importance of the heart in 
the economy, and see to it that if the patient cannot have a perfectly 
sound heart, it shall be damaged as little as possible. The treatment thus 
comprises the observance of every precaution that will tend toward the 
best possible outcome, no matter how drastic may be the requirements. 
MYOCARDITIS 
Myocarditis of mild degree is a frequent accompaniment of inflam- 
matory disease of the pericardium and endocardium. The most severe 
cases, however, may not be of this type. 
Etiology.—Acute parenchymatous myocarditis may follow various 
processes, but is most often due to the activity of the toxin of the pneu- 
mococcus, the typhoid bacillus, or the diphtheria bacillus. Inflammation 
of the endocardium or the pericardium may extend to the myocardium. 
Further references to the causation of this disease are included in the 
discussion of the pathology. 
Pathology.—Classifications of myocarditis are more or less artificial. 
Acute and chronic forms and parenchymatous and interstitial types of 
inflammation are recognized. 
Acute parenchymatous myocarditis usually results from an acute in- 
fection or toxemia, such as diphtheria, typhoid, or scarlet fever. The 
heart muscle is pale in color, soft, and somewhat friable. The heart 
itself may be dilated. Microscopically, the muscle-cells show granular, 
hyaline, and fatty degenerative changes, and frequently contain vacuoles; 
the nuclei stain imperfectly. In the interstitial tissue polynuclear and 
lymphocytic infiltration and even some extravasation of blood may occur, 
these conditions being most marked in the neighborhood of blood-vessels. 
The reparative process is largely that of replacement fibrosis, a pro- 
ductive inflammation terminating in the substitution of fibrous con- 
nective tissue for the degenerated cells. Development of new muscle 
tissue also occurs. This, however, is probably brought about by simple 
hypertrophy of undegenerated muscle-fibers, rather than by true hyper- 
plasia of these elements. 
Acute suppurative myocarditis may result directly from an abscess 
in the mediastinum or a purulent pericarditis, but is more frequently 
due to a general pyemia caused by the pneumococcus, streptococcus, 
staphylococcus, or gonococcus. The wall of the heart contains miliary 
pus foci and small extravasations of blood. Microscopic examination 
shows the vessels to be filled with embolic products, and surrounded 
by the small hemorrhagic areas and collections of pus-cells already des- 
cribed. The process, although essentially one of interstitial inflamma- 
tion, is regularly accompanied by considerable degeneration of the muscle- MYOCARDITIS 
423 
fibers. In the rare cases when recovery from suppurative myocarditis 
occurs, the defects in the heart are remedied by fibrous tissue. 
Chronic interstitial myocarditis in childhood is a productive repara- 
tive process, usually secondary to inflammation of the acute type. The 
development of this condition to compensate for atrophy of the heart 
musculature caused by defective blood-supply through partially occluded 
coronary arteries is essentially a change of later life. When due to syphilis, 
chronic myocarditis in children is usually accompanied by endarteritis. 
Gummata are rare, although Treponema pallidum may be demonstrated 
in the myocardium. 
Symptoms.—The most characteristic early sign of myocarditis in a 
child is a persistently irregular pulse, with or without a tendency to in- 
creased rapidity. It is not at all essential that the pulse be rapid—in 
fact, it is not at all unusual for it to be slower than normal. When such 
irregularity occurs after an acute disease, and particularly when there 
are occasional periods of cyanosis, myocarditis may be expected. It is 
often difficult to judge accurately of the heart’s action when the child 
is awake, because of the excitement and possible resistance which the 
presence of the physician may occasion. For this reason, in suspected 
cases, the child should be examined, if possible, when asleep. 
When the child develops the above symptoms he should be watched 
with the greatest solicitude, as the more urgent symptoms of pallor, 
marked cyanosis, and syncope may occur at any moment. The pulse 
becomes very irregular and thready, or it may be lost entirely at the 
wrist, the patient presenting a picture of impending dissolution. In 
pneumonia, in virulent cases of diphtheria, and in the exanthemata the 
symptoms of acute myocarditis are those of early heart failure and are 
of grave significance. The pulse becomes rapid and irregular, cyanosis 
is constant, and the respiration is increasingly difficult because of the 
sense of pressure and constriction in the cardiac region. 
In diphtheria a sudden extreme drop in the rate of a previously rapid 
heart is of serious import and may be due to heart-block (p. 408). 
Diagnosis.—The diagnosis of myocarditis is based upon the irregularity 
of the pulse following an acute infectious disease, and upon the sudden 
attacks of cyanosis and collapse. Auscultation is of value only in dem- 
onstrating the weakness and indefiniteness of the first sound. 
Treatment.—Rest in Bed.—When the condition follows even a mild 
attack of one of the infectious diseases, the invariable rule of absolute 
heart rest, which is by far the most important feature of the treatment, 
must be insisted upon. The patient, whether in hospital or in a private 
home, should not be allowed to sit up or even to raise his head from the 
pillow; a trained nurse should remain constantly in attendance, so that 
the child may be read to or otherwise entertained while physical exertion 
is prevented. He may be permitted to use his arms, to play with simple 
light toys, but all other exertion must be prohibited. Aside from provis- 
ions for the recumbent position, quiet, a daily bowel evacuation, and easily 
digested food given in small quantities, little treatment is required. It 
is important to keep the stomach free from distention with either gas or 
food. Small quantities of nourishment administered at frequent intervals 
are preferable to large quantities given at the usual mealtime. 424 
THE PRACTICE OF PEDIATRICS 
Drugs.—In the more severe cases with cyanosis and dyspnea a hy- 
podermic containing strychnin, 1/50 grain, and digitalin, 1/100 grain, 
should be kept constantly at the bedside. 
In one case following scarlet fever so urgent were the symptoms that three phys- 
icians were engaged for several days, each being for eight hours daily at the bedside, 
in addition to the two trained nurses, each of whom was doing twelve hours’ duty. 
Strychnin has been routinely given with the thought of possible as- 
sociated involvement of the cardiac ganglion. Moreover, certain portions 
of the heart muscle obviously remain free from the degenerative process 
and may be favorably influenced by the strychnin. To a child one year 
of age 1/200 grain may be given three times daily. From the first to the 
third year 1/200 to 1/100 grain may be given four times daily. After 
the third year the dose is subject to considerable variation, the amount 
depending upon the urgency of the case. Ordinarily, from 1/100 to 1/75 
grain may be given four times a day. If the case is very urgent and the 
strychnin appears to improve the heart action, it may be given to the 
point of producing its physiologic effects, such as fibrillary twitching of 
the muscles of the face and the backs of the hands. Nitroglycerin should 
not be used. Digitalis should be given with care to young children, as 
it is very apt to disturb the digestion if long continued; temporarily, 
in treating older children, it may be used with advantage. A child from 
five to ten years old may be given thrice daily (preferably after meals) 
from 3 to 4 drops of the tincture well diluted with water. The tinc- 
ture of strophanthus may be of more service than the digitalis. Dig- 
italis or strophanthus will be found particularly useful in those cases in 
which there is a tendency to rapidity of the heart action. A child one 
year of age may be given 1 drop of tincture of strophanthus every two 
hours in the twenty-four; from the first to the third year from 1 to 2 
drops at two-hour intervals; and from the third to the tenth year from 
2 to 4 drops at intervals of from two to three hours. 
Convalescence.—The tendency of myocarditis in children is toward 
recovery. How long each patient will require strict observation, and 
how long the treatment will ultimately need to be continued, must be 
determined by each individual case. One fact to be remembered, ac- 
cording to our experience, is that the child either dies suddenly or makes 
a complete recovery, so that in treatment it is well to err on the side 
of caution. It has been found safe, in a very few instances, to allow the 
child to sit up after six weeks. 
In the very severe case above referred to it was not safe for the patient to sit up 
in bed until the end of the third month, and he was not allowed to walk until the end 
of the fourth month. After being kept under observation for one year he was discharged, 
and has remained well during the ensuing years. At the present time there is no evi- 
dence whatever of his former illness. 
A safe rule to follow is to keep the patient in bed as long as the rapid- 
ity or irregularity of the heart exists. When the heart action in the re- 
cumbent position is apparently normal, the patient may be allowed to 
have his head raised by an additional pillow. In this way the head 
anti shoulders may be gradually raised higher day by day, so long as the CHRONIC VALVULAR DISEASE OF THE HEART 
425 
effect upon the heart muscle is not unfavorable. In the same way 
standing and walking may be gradually resumed. Following out this 
careful method of heart rest, and being governed solely by the heart action, 
which indicates the heart power, one will see apparently hopeless cases 
completely recover. Whether fibrous changes in the myocardium are 
present which may have a later influence there is, of course, no means of 
knowing. 
CHRONIC VALVULAR DISEASE OF THE HEART 
Chronic valvular disease of the heart (acquired) is the end-result of 
an endocarditis which has resulted in certain changes in the valves and 
cardiac orifices, producing a permanent lesion. The acquired lesion in 
children will practically always be found on the left side of the heart, 
involving the mitral or aortic valve. With such lesions, compensatory 
hypertrophy, a conservative process, is usually associated. 
Etiology.—A most important feature to keep in mind in connection 
with valvular disease of the heart in children is the source of the disease. 
A large proportion of the cases (95 per cent, in our own experience) are 
due to rheumatic endocarditis. In the absence, then, of a history of 
endocarditis in association with pneumonia, diphtheria, or scarlet fever, 
which association in our experience has been rare, it may be assumed 
that the valvular lesion is of rheumatic origin, even though there may not 
be elsewhere, at the time, positive evidence of rheumatism. Not a few 
children showing cardiac disease without a history of actual acute rheu- 
matism have a history of tonsillitis, angina, coryza, asthmatic bronchitis, 
or chorea, all showing recurrent tendencies. Such patients will often be 
found to have a rheumatic or gouty ancestry, and not infrequently they 
themselves are hearty eaters of red meat and sugars. 
The great majority of cases of valvular defects recognized in early 
adult life are the result of unrecognized endocarditis of childhood. 
Janeway1 found that proved bacterial endocarditis is one of the rare 
causes of chronic valvular disease. 
Symptomatology.—Chronic valvular disease in children may exist 
unchanged for years if the lesion is not severe and if compensation is 
maintained. 
The first symptoms of failure of compensation are shortness of breath 
and rapidity of heart action, both of which the child may mention in 
describing the condition. If the heart is not relieved, the patient will 
soon present evidence of right heart failure, such as persistent general 
bronchitis, inability to assume the recumbent position, dropsy, and en- 
largement of the liver and spleen. Later the breathing becomes more 
difficult, the expression anxious, and the face drawn and cyanosed upon 
the slightest exertion. The superficial veins become dilated, and the 
pulse finally becomes very irregular and soft. Death in children with 
this disease is usually due to terminal bronchopneumonia. 
Diagnosis.—Valvular lesions are indicated by adventitious heart 
sounds, known as murmurs (p. 404), which are heard either with, or 
in place of, the normal sounds (p. 401). 
The character, time, point of maximum intensity, and area of trans- 
1 Boston Med. and Surg. Jour., vol. clxxiv, No. xxvi. 426 
THE PRACTICE OF PEDIATRICS 
mission indicate the location, and to a fairly accurate degree the nature, 
of the lesion. 
Prognosis.—The prognosis depends to a large degree upon both the 
location and the nature of the lesion. In mitral regurgitation with good 
compensation the possibilities for long life are favorable, depending some- 
what, of course, upon the age and condition of the patient. If the case is 
of long standing, the possibility of a complete cure is not to be considered. 
An unknown factor in these cases which has important bearing upon the 
future is the possibility of reinfection. When rheumatic endocarditis has 
once existed in a child, it is likely to return; and in the event of recovery 
from a second or third attack, the heart is left in a more serious condition 
than ever before. 
Mitral regurgitation with good compensation may not seriously in- 
convenience the individual for years if careful habits of life are followed. 
Neither need a mild degree of uncomplicated aortic stenosis cause great 
anxietj'-. Nevertheless, we always look upon stenosis at either the mitral 
or aortic orifice with apprehension, and our own results with the stenosis 
cases during years of observation have been far from satisfactory. Aortic 
regurgitation is often associated with aortic stenosis, and the outlook for 
such patients as well as those with mitral stenosis is not favorable as 
regards the duties of active adult life. 
If there is one word more than another that typifies the life of a child, 
it is the word “stress.” Activity and excitement are so inherently a part 
of child life that the heart crippled by aortic disease is often called upon 
to do work which is impossible. Even if the patient attains the fifteenth 
year without loss of compensation, the heart is in a condition that entails 
semi-invalidism. 
Treatment.—Realizing that rheumatic endocarditis is very likely to 
return, we should make it our first duty, after acquainting ourselves with 
the probable origin of a given case of valvular disease, to explain to the 
parents that other attacks are very likely to occur unless means are used 
for prevention. Enucleation of the tonsils and removal of bad teeth 
should be practised here as after acute endocarditis. 
In the absence of a history of endocarditis in association with pneu- 
monia, diphtheria, scarlet fever, or other infections, it may be assumed 
that the lesion is of rheumatic origin, even though a history or actual 
evidences of rheumatism may be lacking. 
Our next step in the management must be to regulate the life 
so as to prevent a recurrence of the heart involvement. With this end in 
view, it should be directed that red meat be given the child but once every 
second day, and that cane-sugar be given in great moderation. 
A diet of plain, nutritious food, with nothing between meals, is a 
very important feature in the treatment of heart disease in children. 
Poultry, fish, eggs, milk, and cereals with high protein content may be 
given in increased amount in order to maintain nutrition. A tub-bath 
followed by a dry rub should be given daily. The bowels must not be 
allowed to become constipated, and moderate exercise should be encour- 
aged. 
The importance of woolen underclothing if only of light weight should 
be emphasized in dealing with the rheumatic child, and protection from CHRONIC VALVULAR DISEASE OF THE HEART 
427 
sudden temperature changes should be insisted upon even if a complete 
change of climate seems necessary to secure such protection. 
Drugs Advised.—For five successive days out of each month a patient 
from five to ten years old should be given, after meals, 5 grains of sal- 
icylate of soda and 10 grains of bicarbonate of soda. This, with the low 
meat and low sugar diet, is usually, but not invariably, sufficient to pre- 
vent a recurrence. Occasionally it becomes necessary to give the above 
treatment for five days with intervals of only ten days. An interesting 
outcome apparently to be attributed to treatment has repeatedly been 
an entire disappearance of the growing pains, recurrent bronchitis, or low- 
grade eczema, with which the child may have been afflicted. 
Drugs Used With Caution.—The further management of valvular 
disease depends to a certain extent upon the location and nature of the 
lesion. Because a child has a cardiac lesion he does not necessarily require 
digitalis. Not a little harm is done, in the treatment of diseases in chil- 
dren, by giving powerful drugs when they are not indicated. Too often 
in heart disease the physician feels his duty done when he gives digitalis. 
Many times children will be found taking digitalis and strychnin because 
of some cardiac lesion, while, at the same time, they are suffering from 
constipation, recurrent respiratory disorders, and persistent indigestion 
due to dietetic errors, all of which have escaped the attention of the 
physician. 
Mitral Regurgitation.—In mitral regurgitation, well compensated, the 
activities need be but little curtailed; in fact, the patient may be en- 
couraged to indulge in outdoor exercise, although competition in all games 
requiring unusual exertion, tests of speed or endurance of any nature, 
such as running and racing, should be forbidden. When the child is old 
enough, swimming, bicycling, horseback-riding, and golf may be advised. 
Boys, on arriving at the tobacco and alcohol age, must be told the dangers 
attending the use of either drug, and both must be forbidden. Girls with 
mitral insufficiency must be warned against excessive dancing, rope 
jumping, tight lacing, and indiscriminate eating. For patients of both 
sexes rational exercise is beneficial. 
Mitral Stenosis and Aortic Disease.—When the aortic valves are 
involved either in insufficiency or stenosis, or when there is a consider- 
able degree of mitral stenosis, the child’s activities should be considerably 
limited. Under these conditions, with a view to the future, regardless of 
satisfactory existing compensation, it is essential to forbid the bicycle, 
swimming, dancing, baseball, or any sport or game which may call for 
much physical effort. Plenty of entertainment may be provided which 
does not call for great effort. The nature of the disease should be fully 
explained not only to the parents but also to the patient when the latter 
is old enough to understand, so as to secure hearty co-operation in govern- 
ing the child’s activities. Moreover, parents should be told particulaily 
that tonsillitis or angina is a danger-signal, and that, on the occurrence of 
either condition, the salicylates are to be brought into use at once, even 
before the physician is summoned. 
Ordinarily, it is not well to talk over a child’s ailments with him or 
in his presence. To older children with cardiac disease, however, it is 
advisable to explain as clearly as possible the nature of the illness, and 428 
THE PRACTICE OF PEDIATRICS 
insist that certain measures, particularly such as relate to restriction of 
activity, shall be carried out indefinitely. In this way better co-operation 
on the part of the patients is secured than if they are simply given a list 
of dogmatic “dont’s.” It is, furthermore, most important, in cases showing 
aortic involvement or mitral stenosis, to advise what is known as “heart 
rest.” Every day after the midday meal, with clothing off or loosened, the 
child should be made to rest in a recumbent position for at least one hour. 
During this time he may sleep or read as suits his individual taste. 
Constructive Medication.—As most of the cases of valvular disease in 
children are of rheumatic origin, it will be found that the majority of the 
patients are suffering from a mild degree of anemia. All the benefits of 
good nutrition, fresh air, and regularity in living referred to under Tardy 
Malnutrition (p. 146) should be secured to these children. Iron alone 
or with arsenic is here of some value when given with a suitable diet. A 
method often followed is to give, for five days, the salicylate and bicar- 
bonate of soda already referred to; for fifteen days iron and arsenic; and 
during the remaining ten days of each month no medication, unless cod- 
liver oil is well borne, in which case this may well be given in combination 
with the extract of malt. If the patient can swallow a capsule, the follow- 
ing is recommended: 
1$. Liquoris potassii arsenitis gtt. xc 
Extracti ferri pomati gr. x 
Quininae bisulphatis 3 j 
M. ft. capsulae no. xxx. 
Sig.—One after each meal. 
If the iron produces constipation, to \ grain of the extract of cascara 
may be added to each capsule. 
Heart Stimulants.—Aside from such tonic medication, drugs affecting 
the heart itself should not be given unless compensation fails. This may 
take place temporarily, regardless of the nature of the lesion, after some 
forbidden exercise, or during an acute illness sufficient to produce pros- 
tration. Such failure may occur permanently in cases which, for any 
reason, do badly. In the event of defective compensation and dilatation, 
the child should be kept in bed until the normal heart action is restored 
by rest, or until it is demonstrated that the aid of heart stimulants is 
required. In these cases (particularly in those of the latter type, when 
there is a rapid, irregular pulse, difficult breathing or excitement, and 
dropsy) the time-honored remedy, digitalis, is to be brought into use. For 
children we prefer ordinarily to use the tincture. To a child from five to 
ten years old from 3 to 5 drops may be given after meals three or four 
times daily. This drug, because of its well-known irritant effects upon 
the stomach, should be given considerably diluted. 
In the administration of digitalis, when it is desired to obtain the 
therapeutic effect as rapidly as possible, the dosage may be regulated ac- 
cording to the Eggleston method.1 
This method employs as the average therapeutic dose of a first-class 
tincture 0.145 c.c. for each pound of the patient’s weight. ‘‘In this way 
it is possible to give a third to half of the total calculated therapeutic dose 
at a single administration, to follow this in from four to six hours with a 
1 Cary Eggleston, Archives Int. Medicine, vol. xvi, pp. 1-32. ADHERENT PERICARDIUM 
429 
quarter to a third of the total dose, and to give the remainder in a few 
doses of smaller size at intervals of from four to six hours. By this plan 
of administration the full effects can be secured in from twelve to thirty- 
six hours in the majority of cases.” 
Beneficial effects will be apparent first in the relief of the dyspnea, the 
pulse becoming regular and of increasing volume; and later in the in- 
creased excretion of the kidneys and the disappearance of the edema. 
The amount of digitalis given should be reduced as soon as the condition 
will allow, but the medicine may be continued for a considerable time 
after the patient is up and about. The only contraindications to the use 
of digitalis in children are its effect upon the stomach and the occurrence 
of heart-block (p. 408). When loss of appetite results, the preparation 
should be discontinued. In this event the tincture of strophanthus, which 
is referred to repeatedly in this work as a heart stimulant, may be sub- 
stituted in the same doses. In cases requiring a cardiac stimulant for a 
considerable time or permanently, satisfactory results have followed the 
practice of alternating the digitalis with the strophanthus, giving each 
for five days. 
The child, however, who requires constant cardiac stimulation promises 
but little for the future, and, in our experience, few patients of this type 
have survived the eighteenth year. 
ADHERENT PERICARDIUM 
As a result of an unresolved pericarditis with which a myocarditis 
may or may not have been associated, adhesions often exist which bind 
the pericardium to the heart muscle, in most instances completely obliter- 
ating the pericardial sac. The condition is found in cases in which there 
is extensive cardiac disease, with hypertrophy, dilatation, and valvular 
involvement. 
Diagnosis, if made at all, is usully made at the autopsy. The diag- 
nostic sign of real differential value is a retraction of the chest wall in 
the interspace corresponding to the apex-beat. Sometimes permanent 
cardiac friction-sounds may be heard, and there usually is an increase in 
the cardiac dulness to the right of the sternum. XIII. THE BLOOD AND BLOOD DISEASES 
THE BLOOD IN THE NEWBORN 
According to Schiff, Perlin, Carstanjen, Scipiades, and Takasu the 
blood of a newborn baby exhibits numerous characteristic changes. 
1. The specific gravity averages between 1.060 and 1.080, but during 
the first two weeks rapidly sinks to its lowest point, at which it usually re- 
mains until the end of the second year of life, after which it rises until 
puberty, the average thus being between 1.050 and 1.055. 
2. The percentage of hemoglobin is very high—usually between 100 
and 140 per cent, of that found in the healthy adult. 
3. The red cells, which are greatly increased, may number as high as 
7,550,000, and usually above 5,000,000. 
4. The white cells are also increased, in one case numbering 36,000. 
5. According to Carstanjen, the polymorphonuclears number 73.4 per 
cent.., as compared with 16.05 per cent, lymphocytes. 
6. A large number of nucleated red cells are present up to the sixth 
day, after which scarcely any are to be found. 
The variations noted become less marked after the fourth day. The 
number of polynuclear leukocytes diminishes, and after the fourth day 
the percentage of the various kinds of leukocytes is fairly constant during 
the first few months. 
It is suggested that many blood changes observed in the newborn 
are due to the lack of water, a considerable amount of which is lost through 
the intestine and in the form of perspiration. 
THE BLOOD IN INFANCY AND CHILDHOOD 
Hemoglobin.—Throughout the period of infancy and childhood the 
hemoglobin is lower than in the adult, its minimum being usually reached 
between the third month and the second year. From this point it grad- 
ually increases until puberty. The average hemoglobin of childhood 
is between 65 and 85 per cent., the former being considered a low limit 
for a healthy child. 
Red Cells.—The average number in infancy is from 4,000,000 to 
5,500,000, and in later childhood from 4,000,000 to 4,500,000 (Hayem). 
In the blood of the fetus and in premature infants nucleated cells are 
seen, but in later infancy their presence must always be considered path- 
ologic. Formerly their occurrence even in healthy children was con- 
sidered the rule. 
Blood-platelets.—These are normally present to the number of about 
350,000 per centimeter. 
They are now regarded as “pinched off” processes of giant-cells of 
bone-marrow varying from 2 to 5 microns in diameter. For their study 
the Wright and Kinnicutt. method of dilution with a cresyl blue and 
potassium cyanid mixture is considered standard. THE BLOOD IN INFANCY AND CHILDHOOD 
431 
The blood-platelets are diminished in aplastic conditions of bone- 
marrow, as in pernicious or aplastic types of anemia, in severe infectious 
diseases, and in purpura hsemorrhagica. In leukemia, trichinosis, and 
following hemorrhage the platelets are abundant.1 
Normal White Corpuscles.—In health the following varieties are found: 
1. Lymphocytes.—These cells vary from 5 to 10 microns in diameter. 
The nuclei are relatively large, round, deeply stained, centrally placed, and 
contain one or two nucleoli. The cells may be deeply notched, especially 
the smaller ones, and even suggest polymorphonuclear cells, but are never 
identical in appearance. The protoplasm forms a narrow rim around the 
nucleus and is sometimes reticulated. The nucleus stains with basic dyes 
more faintly than the protoplasm. The larger cells of this group have 
an irregularly staining nucleus with a chromatin network and a margin 
of faintly granular protoplasm. The lymphocytes constitute from 40 
to 60 per cent, of the leukocytes in the normal infant’s blood. 
2. Large Mononuclears.—These are not polymorphous cells, but 
contain a single round or large oval nucleus, and are usually two or three 
times as large as red blood-cells. The protoplasm is homogeneous and 
relatively large in amount. These cells constitute about 4 to 6 per cent, 
of the leukocytes. 
3. Transitional Cells.—These are usually larger than the large mono- 
nuclears, which they closely resemble; in fact, they are the largest cells 
of the blood. They possess a “wallet” or “saddle-bag” nucleus. During 
the first few months they comprise 8 to 10 per cent, of the white cells 
(Carstanjen, Karnizki). 
4. Polymorphonuclear Neutrophils. — These cells, which constitute 
from 18 to 40 per cent. (Emerson) of the child’s blood, are somewhat 
smaller than the transitional cells. The nucleus is characterized by its 
polymorphous nature and its deep stain, while the protoplasm is well 
filled with neutrophil granules, which may cover the nucleus. 
5. Eosinophils.—These are usually of the same size as the preceding, 
and occasionally a little larger. The nuclei are fairly well stained, while 
the protoplasm is filled with large eosinophilic granules. These cells 
constitute 2 to 4 per cent, of the normal white cells. 
6. Mast Cells.—These are about the same size as the preceding, but 
frequently smaller; they have a trilobed nucleus and a protoplasm con- 
taining many large basophilic granules; often they are metachromatic. 
Their proportion is about 0.5 per cent, of the white cells. 
Leukocytes Found in Pathologic Conditions: 
1. Myelocytes.—While any cell of bone-marrow is, strictly speaking, 
a myelocyte, by this term is generally meant one with a round nucleus 
and a granular protoplasm. Neutrophilic and eosinophilic myelocytes 
occur. Their size varies from that of the large mononuclears to that of 
red corpuscles. The nucleus is round, oval, and sometimes kidney 
shaped, but never polymorphous; it is usually centrally placed, and is 
not stained diffusely by any good nuclear dye. The protoplasm may 
contain many or few granules of the neutrophilic type. 
2. Eosinophilic Myelocytes.—These resemble the polynuclear eosino- 
phils, except for the rounded, undivided nucleus. 
1 Stitt, Practical Bacteriology. Blood Work, Parasitology, 7th ed., pp. 328, 329. 432 
THE PRACTICE OF PEDIATRICS 
In pathologic conditiohs the leukocytes undergo various degrees of 
degeneration, both acute and chronic. There may be swelling, frag- 
mentation, and hydropic and fatty degeneration, with nuclear changes. 
According to Rieder, the leukocytes average from 8700 to 12,400 
between the second and fourth days; after the fourth day, from 12,400 
to 14,800. In infancy the variations are from 9000 to 14,000; in later 
childhood, from 6000 to 12,000. When the second year is reached, the 
blood gradually begins to assume the adult type. This, however, is 
not attained until the fifteenth or sometimes the twentieth year. Up 
to the sixth year there is a preponderance of lymphocytes. Sex makes 
no material difference until the fifteenth year. The blood-making organs 
of the infant are severely affected by disease. The infantile blood readily 
takes up myelocytes and nucleated cells (Zelenski-Cybulski). 
Leukocytosis.—By this is meant an increase in the number of white 
corpuscles in the blood. It may be of two varieties—relative and abso- 
lute. A relative leukocytosis is more frequent in children than in adults. 
By the leukocytosis one may judge the nature of the reaction of the 
organism to bacteria or to the toxins in the blood elaborated by the bac- 
teria concerned in the inflammation or infection. It may thus be seen 
that the reaction of the individual will depend upon two factors: (a) 
the severity of the infection and (6) the resistance of the individual. Of 
the two, the latter is more important. It is a fact that the most marked 
degree of leukocytosis is observed in a healthy, well-nourished child 
suffering from a severe infection; while, on the other hand, a feeble child 
suffering from the same infection will have a slight leukocytosis or prob- 
ably none at all. The nature of the reaction depends upon the character 
of the inflammatory process. Leukocytosis is less marked in serous and 
more pronounced in suppurative processes, while in both instances it is 
highest during the stage of active exudation. In well-localized suppurative 
inflammations there may be no leukocytosis at all. 
Leukocytosis is present in a great many pathologic conditions, and 
in some cases the explanation is wanting. A satisfactory division of 
leukocytosis is into the two groups: (a) physiologic and (h) pathologic. 
By the former is meant that which follows a meal or exercise or that 
which occurs in the newborn; by the latter is meant that which may 
occur after serious hemorrhage, malignant disease, and various inflam- 
matory and toxic conditions. Japha has not been able to demonstrate 
a genuine leukocytosis of digestion in the bottle-fed infant, and Greger 
did not even find it regularly present in the breast-fed infant. If, how- 
ever, a breast-fed infant was given cow’s milk, there was an immediate 
occurrence of leukocytosis, and hence the opinion (Moro) that it is a re- 
action against foreign protein. Children show a more pronounced di- 
gestive leukocytosis than adults, occasionally the increase amounting 
to one-third of the total number of leukocytes. 
The chief form of leukocytosis in children is the inflammatory type. 
This is especially noticeable in acute pneumonia, diphtheria, acute rheu- 
matism, erysipelas, scarlet fever, tuberculous meningitis, and in sup- 
purative conditions of the subcutaneous tissues, serous cavities, bones, 
joints, and viscera. In these conditions the increase is chiefly in the 
polymorphonuclear neutrophils. THE BLOOD IN DIFFERENT DISEASES 
433 
In pertussis, hereditary syphilis, and certain diseases of the spleen 
there is a relative increase in the lymphocytes, while in leukemia, asthma, 
helminthiasis, and some forms of chronic skin disease there is an increase 
in the eosinophils. 
There is usually no leukocytosis in typhoid fever, measles, rotheln, 
mumps, malaria, and uncomplicated tuberculosis not invading the me- 
ninges or serous surfaces. In the usual forms of gastio-enteritis leukocyto- 
sis is absent, while in “Finkelstein’s alimentary food intoxication” it is 
pronounced. 
THE BLOOD IN DIFFERENT DISEASES 
Pneumonia.—In this disease there is regularly a leukocytosis, and 
it is in this illness that the inflammatory leukocytosis has best been 
studied. The leukocytosis here is an expression of the resistance of the 
organism to the infection, and depends but little on the fever and the 
extent of consolidation (Ewing). In an average case the count may 
vary between 15,000 and 40,000 or 50,000, and but rarely reaches 100,000; 
although there are a number of cases on record with a count as high as 
this. A high count gives no idea of prognosis; it means that the pro- 
tective forces are making a vigorous fight, but gives no hint as to which 
will win, they or the infection. Absence of leukocytosis is usually of bad 
import, and shows that the patient has low resistance; and a rapid fall 
with either a low or a high temperature is usually indicative of a loss 
of resistance on the part of the patient. The fall in the count begins 
just before, just after, or with, that of the temperature; this diminution 
usually corresponds to the change in temperature. If the count remains 
elevated, delayed resolution, empyema, or abscess should be suspected. 
The increase is mainly in the polymorphonuclear cells, which may vary 
from 60 to 90 per cent, of the total leukocytes. In pneumonia following 
pertussis the increase is chiefly in the lymphocytes. The absence of a 
leukocytosis in a strong, well-nourished child who is very ill is always 
strong presumptive evidence against pneumonia. The changes in the 
red cells and hemoglobin are those of a secondary anemia, depending 
on the duration of the disease and the resistance of the patient. 
Leukocytosis is present in both forms of pneumonia in infancy and 
childhood, but is more marked in the lobar form, the number of leu- 
kocytes to the cubic millimeter being about twice as many as in the 
catarrhal types. There is marked leukocytosis in the fatal cases of both 
forms of pneumonia (Koplik). 
Empyema.—Marked leukocytosis is almost invariably present with 
a high polymorphonuclear count-—usually from 75 to 90 per cent. In 
cases of long standing there is often no leukocytosis, but the polymor- 
phonuclear count remains elevated. In tuberculous effusions the count 
is usually low, with no increase in the polymorphonuclear count. 
Influenza.—Uncomplicated influenza has no leukocytosis and fre- 
quently induces a leukopenia. Influenzal pneumonia ordinarily has a 
leukocytosis of from 15,000 to 20,000. To date no uniform conclusions 
have been arrived at concerning any characteristic differential count 
other than that of an ordinary pneumonia. 
Tuberculosis.—In tuberculosis, in general, there exists a mild grade 434 
THE PRACTICE OF PEDIATRICS 
of chlorotic anemia with little or no leukocytosis. The count is nearly 
normal, while the hemoglobin is somewhat reduced. In other cases 
there is a lymphocytosis, absolute or relative. If a secondary infection 
occurs, which is not infrequent in infants and young children, leukocy- 
tosis is the rule, and, in fact, Limbeck considers the presence of a leu- 
kocytosis sufficient guarantee of a secondary infection. In case of pneu- 
monia the leukocytosis is as high as in the ordinary croupous pneumonia. 
Various observers are of the opinion that in incipient tuberculosis there 
is a slight increase in the eosinophils, and that, as the infection progresses, 
they diminish. From a series of 182 blood examinations of tuberculous 
patients Solis-Cohen concluded that an increase in the polynuclear count 
points toward an advance of the disease and vice versa. In tuberculous 
bronchial adenopathy and peritonitis, leukocytosis is absent, although 
in the latter Cabot reported an increase in the cell count in 14 out of 60 
cases. Tuberculous meningitis regularly causes a leukocytosis, reaching 
at times as high as 50,000, while there is usually a polymorphonucleosis, 
in some instances as high as 90 per cent, of the total white cells. In bone 
and joint disease the leukocytes are normal or very slightly increased, 
and only during abscess formation or following operation is there an ap- 
preciable increase in the cell count. 
Typhoid.—As in adults, there is a low white cell count, generally 
under 10,000. The lymphocytes are slightly increased, and there is 
usually a mild grade of anemia. 
Rheumatism.—There is regularly a leukocytosis and a severe grade 
of secondary anemia. 
Peritonitis and Appendicitis.—In the former there is a polymorpho- 
nuclear leukocytosis. This, however, is wanting in some cases of the 
severest type. In a series of 70 cases of appendicitis in children reported 
by Fowler in 1912, the average leukocyte count was 19,106, the average 
polynuclear, 79.7 per cent.; the highest leukocyte count was 48,200; 
the lowest, 8200; the highest polynuclear count, 92 per cent.; the lowest, 
63 per cent. 
Meningitis.—In cerebrospinal meningitis and in meningitis caused 
by the other pyogenic organisms there is regularly a leukocytosis with 
an increase in the polymorphonuclears. The leukocyte count is of no 
value in distinguishing the various forms of meningitis, since it is also 
present in the tuberculous form (Emerson). 
Poliomyelitis.—Until a monograph on poliomyelitis by Draper, 
Peabody, and Dochez, of the Rockefeller Institute, was issued, a num- 
ber of conflicting statements had been made concerning the blood findings 
in this disease. Previous to this clinical study by the above authors, 
Muller, in Germany, and La Fetra, in New York, had made the most 
extensive observations. The latter reported a leukocytosis between 
13,400 and 20,600, while Muller found a leukopenia in the acute stage. 
Draper, Peabody, and Dochez tabulated their findings in 59 hospital 
cases, and came to the conclusion that in the preparalytic stage the counts 
varied within the normal, but that there was a tendency toward a leu- 
kocytosis. In the acute stage, in every case except one in which leu- 
kopenia existed, there was a marked leukocytosis, in several instances 
reaching as high as 30,000. In addition to this increase in the white cell THE BLOOD IN DIFFERENT DISEASES 
435 
count they found a constant increase in the polymorphonuclears of 10 
to 15 per cent, and a diminution of lymphocytes of 15 to 20 per cent. 
The other white cells showed no abnormalities. In view of these findings 
a definite leukocytosis with an increase in the polymorphonuclears and a 
corresponding diminution of the lymphocytes is additional evidence, 
when considered with other available signs, in favor of the disease in 
question. 
Diseases with Eosinophilia.—Asthma.—In true bronchial asthma the 
eosinophils may be from 10 to 20 per cent. Cases have been reported 
with eosinophilia as high as 50 per cent. Holt gave 10.7 per cent, as the 
average in a series of cases examined in his clinics by Wile; the highest 
was 26 per cent. The presence of an eosinophilia serves to distinguish 
the attack from one of acute bronchitis or tuberculosis. The occurrence 
of an increase in the eosinophils apparently determines the asthmatic 
character in certain spasmodic attacks of the respiratory system in in- 
fancy. 
Eczema.—There is no difference between the number of eosinophils 
in infancy and childhood and that in adult life. Occasionally an eosino- 
philia is noted in pemphigus. 
Parasites.—Any parasite, from the harmless pinworm to the most 
malignant uncinaria, may cause eosinophilia. It is not always present, 
nor does its degree bear any relation to the severity of the infection or 
the danger of the parasite. The presence of eosinophilia in a child should 
always make one suspicious of intestinal worms. Amberg, in studying 
amebic dysentery of children, found a slight increase in the eosinophil 
count. The average number of these cells in parasitic diseases is from 
4 to 10 per cent, of the total white cell count, but these figures may be 
exceeded. In not a few cases symptoms of pernicious anemia have been 
present, and a severe grade of secondary anemia may exist. 
In one of our cases of trichinosis the eosinophil count was 72 per cent. 
Syphilis (Congenital).—There is usually a relative increase in the 
mononuclear cells and a severe secondary anemia, while a case with a 
severe rash, especially involving the face, may develop an eosinophilia 
as high as 23 per cent., diminishing as the condition improves. 
Gastro-enteritis.—In this disease there is usually no leukocytosis, 
although in some cases a slight increase may be noted. It is remark- 
able that even in long-standing cases of gastro-enteritis and enterocolitis 
there is not a great reduction in hemoglobin. 
In Finkelstein’s food intoxication one of the cardinal signs is a leu- 
kocytosis of from 20,000 to 40,000, the largest cell percentage being of 
the polymorphonuclear variety. 
Acute Contagious Diseases.—Whooping-cough.—In this disease the 
leukocytes are increased to three or four times the normal amount, averag- 
ing 40,000 (Emerson). The change is more pronounced the younger 
the child. The early appearance of a leukocytosis is important in diag- 
nosis. The increase is chiefly in the lymphocytes, which may constitute 
from 60 to 80 per cent, of the total white count. A moderate eosinophilia 
may be noted. 
According to Frohlich and Muenier, the leukocytosis of pertussis 
far exceeds that of any other afebrile disease of the respiratory tract. 436 
THE PRACTICE OF PEDIATRICS 
The leukocytosis occurs in the early part of the convulsive stage, dis- 
appears with improvement, and does not seem to be influenced by com- 
plications. 
Measles.—Hecker recorded the results of his blood examination of 
14 children. In the incubation period his observations were uniform, 
and he concluded that during the incubation period, and occasionally 
extending into the eruptive period, there existed—(1) a leukopenia; (2) 
a relative lymphocytosis; (3) reduction in the number of eosinophils. 
In 13 cases in the prodromal period Platinger found a neutrophil hyper- 
leukocytosis of even 20,000, which rapidly gave place to a hypoleukocytosis 
during the eruptive stage. According to Holt there is a leukocytosis of 
15,000 to 30,000, beginning soon after infection and increasing for four 
or five days. A marked increase in the leukocytes during the illness usually 
points to a complication. Hektoen, in his animal experimentation and 
observation on human beings, found that there was a preliminary leu- 
kocytosis, followed by a leukopenia, chiefly of the polymorphonuclear 
neutrophils, the lymphocytes being relatively increased. 
Diphtheria.—In this disease there is a moderate anemia, a loss of 
about 2,(X)0,000 red cells at the time of defervescence (Emerson, Ewing). 
The reduction in the hemoglobin is usually proportionate to the reduc- 
tion in the red cells. There is usually a slight leukocytosis, ranging, as 
a rule, from 10,000 to 15,000, but in severe cases the white cells may 
number 17,000 and, with complications, 30,000 (Emerson). The rise is 
in the polymorphonuclear cells. According to Engel, the myelocytes 
are increased, especially in the fatal cases, from 3 to 16 per cent. Morse 
has said, “The examination of the blood in diphtheria is of no practical 
clinical importance in diagnosis, prognosis, or treatment.” 
Scarlet fever produces little change in the red blood-cells, but does 
cause a slight anemia (Reckzan), the average drop being 1,000,000. 
There is uniformly a leukocytosis, beginning in the incubation period and 
continuing into convalescence (Emerson). The leukocytes vary from 
10,000 to 40,000; in mild cases from 10,000 to 20,000; in moderate cases 
from 20,000 to 30,000; in severe cases from 30,000 to 40,000, while, ac- 
cording to Holt, the number may be as high as 75,000. The variation is 
according to the severity of the case. The increase is chiefly in the poly- 
morphonuclear cells, which may constitute 85 to 98 per cent, of the total 
count, especially in severe and fatal cases. At first there is a complete 
disappearance of the eosinophil cells, and later a rapid increase (20 per 
cent.). The disappearance of the eosinophil cells during the course of the 
disease is a bad prognostic sign, and absence of leukocytosis is also 
ominous. 
In the Centralblatt fur Bakteriologie of November, 1911, Dohle 
reported, in 30 cases of scarlet fever, certain inclusion bodies found chiefly 
in the leukocytes. More recent work by Nicoll, of New York, and Kolmer, 
of Philadelphia, showed that these bodies were present in streptococcus 
infections, and the latter observer reported their presence in 42 per cent, 
of diphtheria cases. The inclusion bodies are present in 94 per cent. 
(Kolmer) of scarlet fever cases during the first three days; after this they 
diminish in number, and are generally absent after the ninth day. Thus, 
while their diagnostic value is necessarily limited, their presence has BLOOD-PRESSURE IN CHILDREN 
437 
been considered useful in the differential diagnosis of scarlet fever, rotheln, 
measles, and gastro-intestinal rashes. 
Congenital Heart Disease.—Of congenital affections, this disease 
presents the largest number of cases of polycythemia, although, as Osier 
stated, “polycythemia is not a constant feature in congenital cyanosis. 
It is characteristic rather of the latter stages of the disease, and its ap- 
pearance is said to be of unfavorable prognosis.” Vaquez and Quiserne 
stated their belief that when the polycythemia reaches 6,000,000 it seems 
to be fatally progressive, evidencing a more and more insufficient aera- 
tion, the prognosis becoming correspondingly graver. The red cells 
frequently reach 6,000,000 to 7,000,000, and the percentage of hemo- 
globin may be as high as 160, and the specific gravity 1070; naturally 
the blood-clot is greatly increased, owing to the excess of red blood-cells. 
Cautley reported a case of polycythemia of 10,000,000, and Still, one of 
9,280,000. The white blood-cells are not increased. 
BLOOD-PRESSURE IN CHILDREN 
During the past few years numerous observations of the blood-press- 
ure in different diseases have been made by Rolleston, Sergeant, and 
Hutinel, abroad, and by Howland and Hoobler in America. 
A simple and easily handled machine of the Riva Rocci type is the 
Faught, with a cuff made from an ordinary Voorhees uterine dilating bag. 
With this combination the smallest arm can be readily accommodated. 
An exact estimation of the pressure is not always possible on account 
of the small size of the radial artery and the overlying thick pad of fat, 
which makes palpation rather difficult, and especially so when an infant 
struggles, as is not infrequently the case. 
According to Kolossowa, Oppenheimer, and Bauchwitz, the follow- 
ing figures may be considered normal for systolic pressure: 
Age, Mm. of 
years. mercury. 
1-2 75-85 
3-4 85 
5- 7 90- 95 
8-10 95-100 
11-13 100-110 
The diastolic pressure during infancy is about 45 to 50 mm. of mer- 
cury and rises slowly and gradually until puberty, when it maintains a 
fairly constant level at about 60 mm. 
The pulse pressure in infancy is 18 to 20 mm. of mercury, gradually 
increasing to about 30 mm. at three years of age. After ten years the 
pulse pressure is that of the normal adult, viz., about 40 mm. of mercury.1 
Faber and James2 have shown that there is no significant difference 
between the mean systolic pressures of the two sexes between the ages 
of three and seventeen years. However, the mean diastolic and pulse 
pressures show much greater standard deviations or normal variability 
in adolescent girls. 
All febrile diseases tend to lower the blood-pressure. Comby, Hutinel, 
1 Wiggers, Carl J., Circulation in Health and Disease, 1923, 2d ed., pp. 361, 362. 
2 Amer. Jour. Dis. Child., vol. 22, p. 7, 1921. 438 
THE PRACTICE OF PEDIATRICS 
and Rolleston have found a constant hypotension in scarlet fever and 
diphtheria, more pronounced in the former. These authors considered 
a severe degree of hypotension to be of bad omen, especially in scarlet 
fever, and they believed that this condition should be met by the ex- 
hibition of adrenalin hypodermically. 
Among other causes of hypotension Janeway enumerated hemorrhage, 
collapse, and the action of poisonous drugs, especially chloroform. Hypo- 
tension is also met with in the diarrheas and in bronchial asthma. 
The value of blood-pressure estimation in epidemic meningitis during 
intraspinal injections of serum will be referred to later. 
Increased blood-pressure is observed in conditions of acute cerebral 
compression and anemia and in acute nephritis complicated by uremia. 
COAGULATION TIME 
The great diversity of opinion on the normal coagulation time and 
that in various diseases has no doubt been due to the variety of instru- 
ments employed. Dependable results obtained are those of Rudolf (8.1 
minutes) and Carpenter (9.5 minutes) working with different instruments. 
It has been definitely shown that ordinary surface puncture gives 
variable results, depending on the depth of puncture, temperature, air- 
currents, dust, etc.1,2 
Owing to these wide variations, despite careful technic and regula- 
tion of apparatus, no constant results have been obtained. From a 
rather exhaustive study Carpenter and Gittings concluded that it is 
improbable that any important variation exists in the coagulation of 
the blood in diseases other than of the so-called hemorrhagic type. 
Rodda3 has shown that there is normally an increase in the coagulation 
time of newborn infants (about seven minutes), which reaches its max- 
imum on the fourth or fifth day. This is the period of greatest incidence 
of hemorrhagic disease of the newborn. From the fifth day on there is 
a gradual decrease in coagulation time, till by the tenth day it lies within 
ordinary normal limits. 
In general, the bleeding time, three and a half to four minutes, follows 
the curve of the coagulation time. 
As a general rule, average differences of one, two, or three minutes can 
hardly be construed as of any practical importance, inasmuch as a differ- 
ence of from five to twelve minutes has been found in typhoid fever by 
authoritative observers. 
SIMPLE ANEMIA 
Simple anemia is usually a secondary condition, and is not at all in- 
frequent in children. A vast majority of the cases coming under our 
observation are those of children of the runabout age, and older chil- 
dren who are suffering from tardy malnutrition, having been badly fed 
and having wasted their energy in different ways. Simple anemia may 
be the result of hemorrhage, as in hemorrhagic disease in the newborn 
1 Lee and White, Amer. Jour. Med. Sci., 145, 495. 
2 Lee and Vincent, Arch. Int. Med., 13, 398, April, 1914. 
3 Amer. Jour. Dis. Child., vol. 19, p. 269. SIMPLE ANEMIA 
439 
and in purpura, particularly purpura fulminans (Henoch’s). In the 
average case of anemia the hemoglobin ranges from 40 to 50 per cent., 
and the red cells from 3,500,000 to 4,000,000. Children suffering from 
tuberculosis and syphilis usually show a secondary anemia. It is also 
temporarily present after pneumonia, scarlet fever, diphtheria, and 
typhoid fever, and similar diseases which have severely taxed the or- 
ganism. 
A great many cases develop in runabout children under three years 
of age, for whom the milk diet has been continued as the almost exclusive 
means of nourishment. Children of the poor, because of the defective 
feeding and housing, are frequent sufferers. 
Symptoms.—The chief symptom is that of lack of endurance. The ap- 
petite is usually indifferent and the bowels are constipated. Such chil- 
dren tire readily, and are unable to keep up with their fellows at play 
or in school. They sleep poorly and, as a rule, are irritable and unhappy. 
In appearance they are apt to be pale and thin, although this is not 
invariably the case, as severe anemia is repeatedly observed in plump 
children. 
Illustrative Case.—A very pronounced case was that of a boy of six years who 
weighed 46f pounds. The blood examination showed: hemoglobin, 18 per cent.; red 
cells, 660,000. In two weeks the hemoglobin was 20 per cent.; the red cells, 640,000. 
Five weeks after first examination the hemoglobin was 30 per cent.; red cells, 1,172,000. 
The blood examination was checked up by a second person. No further improvement 
had taken place after one year of treatment. It seemed impossible without transfusion 
to raise the blood above 30 per cent, hemoglobin and 1,500,000 red cells. 
Anemic murmurs may be heard over the heart, but this has been 
unusual in our cases. In the case referred to the heart sounds were 
normal. The spleen is not often found enlarged. 
Examination of the blood in this condition of anemia enables one 
to estimate with accuracy the severity of the process. In mild cases 
there may be only a reduction in hemoglobin, and the blood may assume 
the chlorotic type. There is, in addition, a reduction in the specific 
gravity, depending on the degree of anemia, and if the primary affection, 
like pneumonia, causes an increase in the leukocytes, there will be a 
leukocytosis. In the cases of moderate severity the red cells may range 
between 3,500,000 and 4,000,000, and the hemoglobin from 40 to 60 
per cent. In severe cases the red cells vary from 2,000,000, or a little 
less, to 3,000,000. There is a corresponding reduction in the hemoglobin. 
The more marked the reduction in red cells and hemoglobin, the more 
marked will be the poikilocytosis and polychromatophilia, and the greater 
the number of normoblasts and megaloblasts. In the severe cases myelo- 
cytes may be present. There is no increase in the eosinophil cells. In 
the severe secondary anemias the physical characteristics of the blood 
are very striking. It may be so thin as to separate on puncture into a 
reddish and a colorless portion resembling beef-water (Koplik). 
The prognosis is good in the cases in which syphilis and tuberculosis 
are absent. In fact, the majority of cases respond most satisfactorily 
to properly directed treatment. 
Treatment.—The management consists in placing the child in a 
normal child’s environment, which includes the giving of suitable food. 440 
THE PRACTICE OF PEDIATRICS 
The treatment described under Tardy Malnutrition (p. 147) covers 
these cases. 
In pronounced cases transfusion offers the most prompt results. 
Management of Secondary Anemia Through Blood Transfusion by the 
Lindemann Method.—Signally satisfactory results have been obtained by 
this method of treatment. Infants with hemoglobin under 25 per cent. 
(Dare) and red cells under 2,500,000 have been permanently cured by 
one transfusion. So satisfactory have been the results that we now 
employ transfusion in all cases that fail to make a reasonably satisfactory 
response to other measures. 
The following table gives in a concise manner the results of trans- 
fusion in 8 cases: 
Blood Before Transfusion Blood After Transfusion 
<D 
m 
Age, months. 
A 
M 
% 
£ 
Hgl, per cent. 
d 
m 
« 
Amount trans- 
fused, c.c. 
Hours after. 
Hgl, per cent. 
d 
« 
£ 
Months after. 
Hgl, per cent. 
d 
P$ 
A 
.W) 
£ 
F. 
12 
12.5 
Sahli 
14 
2,400,000 
175 
24 
Sahli 
45 
5,120,000 
17 
Fleischl 
70 
4,600,000 
26.8 
F. 
18 
24.0 
Sahli 
37 
3,900,000 
200 
24 
Sahli 
35 
5,760,000 
14 
Fleischl 
90 
5,000,000 
32.0 
M. 
12 
16.4 
Sahli 
32 
4,480,000 
300 
24 
Sahli 
78 
5,150,000 
3 
6 
12 
18 
Dare 
60 
52 
63 
65 
3,840,000 
4,400,000 
5,000,000 
5,000,000 
19.5 
22.2 
25.5 
28.0 
F. 
23 
24 
15.10 
16.7 
Sahli 
20 
30 
2,800,000 
140 
200 
24 
24 
Sahli 
55 
90 
3,100,000 
4,320,000 
1 
7 
Dare 
37 
2,700,000 
16.7 
19.8 
F. 
6 
11.0 
Sahli 
37 
1,600,000 
150 
24 
Sahli 
85 
4,000,000 
7 
Dare 
65 
4,800,000 
19.5 
M. 
10 
12.5 
Dare 
33 
4,300,000 
200 
24 
Dare 
58 
4,900,000 
1 
Dare 
58 
Died of 
later, 
mal, 
good. 
5,000,000 
meningitis 
Blood cou 
general c 
12.8 
3 mo. 
nt nor- 
ondition 
F. 
12 
12.4 
Sahli 
35 
3,120,000 
170 
24 
Sahli 
62 
4,040,000 
1 
3 
6 
Dare 
50 
50 
56 
5,320,000 
4,100,000 
4,400,000 
14.0 
17.4 
19.8 
M. 
16 
21.0 
Sahli 
35 
3,300,000 
200 
24 
Sahli 
55 
3.400,000 
1 
Dare 
60 
4,500,000 
24.8 
6 
Fleischl 
55 
4,100,000 
25.12 
Chlorosis is a form of anemia most frequently seen in young girls at 
the time of puberty or later. Exceptionally cases showing the typical 
blood-picture of chlorosis are found in very young children.1 The cause of 
the condition is not known. Various theories have been advanced, none 
of which can be proved. The most plausible theory assumes the existence 
CHLOROSIS 
] J. P. C. Griffith, Types of Anemia as Seen in Early Life, Medical Clinics of North 
America 4, 1125, January, 1921. PSEUDOLEUKEMIC ANEMIA OF VON JAKSCH 
441 
of a persistent intestinal intoxication. That such is a probable cause has 
been suggested in numerous cases. The more pronounced changes occur 
in the specific gravity of the blood, and correspondingly in the hemo- 
globin, both of which are reduced out of proportion to the reduction in 
red cells, although in severe cases the red-cell count may fall to 1,000,000. 
In ordinary cases the corpuscles vary between 3,000,000 and 4,500,000, 
while the hemoglobin may be as low as 30 per cent. There is no leuko- 
cytosis, but microcytosis, poikilocytosis, and polychromatophilia are usu- 
ally present. Occasionally a few normoblasts are found. 
Symptoms.—The symptoms are quite characteristic. The patient is 
habitually tired and incapable of unusual or prolonged exertion. The 
skin is of a peculiar sallow, greenish color. The hands and the feet are 
cold. Amenorrhea is almost always noted in girls who have passed the 
period of puberty. The menses may be discontinued for a year. The 
appetite is capricious, and the patient craves most unsuitable articles of 
food and substances not in the food class. The history usually includes 
the story of habitual constipation which was never treated. 
Anemic heart murmurs and the venous hum over the vessels of the 
neck are usually present. The patient is nervous, irritable, and not in- 
frequently hysteric. A pronounced case of hysterocatalepsy was estab- 
lished in one young girl with chlorosis. 
Prognosis.—While this condition is usually obstinate, the outcome in 
our cases has always been favorable. 
Treatment.—The management consists in the correction of the con- 
stipation and in the provision of suitable food at definite intervals. Eating 
between meals must not be allowed. Stress, both physical and mental, is 
to be avoided. Iron and arsenic are of value. The following combination 
of drugs has served well: 
R. Strychninae sulphatis gr. 1/4 
Acidi arsenosi gr. 1/5 
Extracti ferri pomati <• gr. vj 
Extracti cascarae sagradae gr. xxx 
Quininae bisulphatis gr. lx 
M. ft. capsulae No. xxx. 
Sig.—One after meals. 
The amount of cascara prescribed depends upon the degree of con- 
stipation. 
After the diet and the bowel habit have been satisfactorily adjusted, 
the patient should be given a change of environment. Nothing is so 
conducive to a reasonably prompt cure as an absolute change in the daily 
life of the patient. 
Entertainment and amusements which do not excite or overtax are 
to be encouraged. The cure will be aided by removal of the patient 
from association with persons who are not congenial. 
PSEUDOLEUKEMIC ANEMIA OF VON JAKSCH 
In this affection there is marked anemia with enlargement of the 
spleen. The condition was first described by von Jaksch, who believed 
it to be a clinical entity. The disease represents an unusually severe 442 
THE PRACTICE OF PEDIATRICS 
type of secondary anemia, and is of toxic origin, although the nature of 
the toxemia is not understood. 
There are no valid grounds for believing so rare a disease to be de- 
pendent upon rachitis or syphilis. Syphilis and rachitis occur with the 
greatest frequency. If these diseases were causative factors, it is reason- 
able to suppose that there would be many more cases. The great majority 
of the cases occur in children under three years of age and follow prolonged 
intestinal disturbance and malnutrition. 
Pathology.—The pathologic changes comprise enlargement of the 
spleen and moderate swelling of the lymph-nodes, with a diminution in 
the specific gravity, the hemoglobin, and the number of red cells in the 
blood, and an increase in the leukocytes. The liver is at times slightly 
enlarged and the lymph-glands may show moderate hyperplasia. 
The Blood.—The number of red cells is frequently as low as 2,000,000. 
It may fall to 800,000. The color index is low. The hemoglobin reduction 
is very great, and may reach 30 per cent. (Emerson, Comby, Cautley). 
There is always a leukocytosis of from 20,000 to 50,000. In one case 
reported by Emerson the leukocytes numbered 114,000, and in another, 
at the Babies’ Hospital, 96,000. They may show an increase in the 
mononuclear or polynuclear forms. The eosinophils are usually increased, 
but may be normal or diminished. The white cells exhibit great variety 
in size, shape, and staining properties. Mast cells and myelocytes in 
small numbers may be found. Karyokinesis is common, and is regarded 
by some observers as of diagnostic importance (Comby). The red cells 
include many microcytes, myelocytes, normoblasts, and megaloblasts, and 
show, in addition, poikilocytosis and polychromatophilia. 
The blood-picture is indicative but not diagnostic of the disease. 
Symptoms.—The symptoms are those of progressive, pronounced 
anemia in a child fairly well nourished. Emaciation may develop later 
in the disease. The patient becomes very weak and his activities cease. 
The appetite is often greatly impaired, and food, if urged, is apt to 
be vomited. In the later stages hemorrhages from the mucous surfaces 
may occur. Petechise are common. The lymph-nodes show moderate 
enlargement. 
Fever is occasionally present, usually due to abnormal intestinal 
conditions. 
Cabot emphasized the point that the many very different cases thus 
diagnosed cannot be grouped together. 
Diagnosis.—In von Jaksch’s anemia the splenic enlargement exceeds 
that ordinarily found in rickets and in syphilis. In pernicious anemia 
the leukocytes are not increased and the spleen is not enlarged as in pseu- 
doleukemic anemia. Other forms of leukemia are distinguished by the 
blood findings. Banti’s disease occurs in later childhood. 
Prognosis.—The prognosis is very unfavorable. Death in the fatal 
cases takes place from intercurrent disease. Patients who exhibit improve- 
ment for a time usually succumb later. 
Treatment.—The management is entirely supportive. Iron and arsenic 
may be given in the hope that they will be of some benefit. LEUKEMIA 
443 
LEUKEMIA 
Leukemia is a disease marked by the constant presence in the blood 
of granular mononuclears, or an increase in the blood of the non-granular 
cells with round nuclei—the miniature cells of the blood-building organs, 
which are not normally present in the peripheral circulation. There is 
also a decided change in the blood formula. Generally there is a marked 
increase in the leukocytes, and yet there are instances when the count is 
normal and the diagnosis is made from the increase of abnormal cells. 
Splenomyelogenous Leukemia.—In this disease there is a great increase 
in the granular cells, more especially the myelocytes, eosinophils, and 
basophils, and also in the cells with spheric or slightly indented nuclei 
(Emerson). The total blood is increased in the majority of instances and 
diminished in few. In a great many cases the blood may appear to the 
eye normal; in extreme cases it is pale, opaque, and flows sluggishly. 
The red cells are greatly reduced in number—occasionally as low as 
2,000,000. Poikilocytosis is present in all cases; microcytosis and macro- 
cytosis are rare, while polychromatophilia is usually present. 
This is the condition par excellence in which normoblasts are present 
in abundance. In many cases megaloblasts are found. The hemoglobin 
is much reduced. 
The white cells vary from 100,000 to 500,000 (Holt), or, as men- 
tioned before, may be normal in number. Neutrophils are absolutely 
diminished, but relatively increased. The lymphocytes are increased, 
but vary according to the stage of the disease. Eosinophil myelocytes 
are found, and there is an absolute increase in the eosinophils. Ehrlich 
stated that in this disease there is always an increase in the basophils. 
Cornil’s myelocytes are also present. 
Lymphatic Leukemia.—In the lymphatic type there is a marked 
increase in the mononuclears. Despite the name, the increase is not 
always in the lymphocytes, although this increase is most usually in the 
small mononuclears, which in some cases have been known to form 97 
per cent, of the total white cells. Polymorphonuclears are rare. Eosino- 
phil cells are noticeably absent, and in a pure case myelocytes are not 
present. It is important to note that in children the total white cell count 
may be normal or slightly above normal in this disease. The abnormal 
preponderance of the mononuclear cells is the criterion for diagnosis from 
the stained smear. There is a greater anemia in this form than in spleno- 
myelogenous leukemia. In the acute type of lymphatic leukemia coagu- 
lability of the blood is greatly diminished. 
In a review by Churchill (1904) the lowest red-cell count reported 
was 750,000 after a severe hemorrhage, and the leukocytes varied from 
6000 to 810,000 (in a twenty-month-old child). In a case reported by 
Wollstein from personal observation there were 99 per cent, of small 
mononuclears, many of which were degenerated. 
Etiology of Leukemia.—Leukemia is rare in childhood, although it 
may occur in infancy, and according to Ewing1 is “a disease of early years 
when the blood-forming organs are relatively active.” The cause is un- 
known. 
1 Neoplastic Diseases, p. 366. 444 
THE PRACTICE OF PEDIATRICS 
Morbid Anatomy.—The bone-marrow is always changed; in acute 
lymphatic leukemia it is red or gray, with an increase mostly in the 
lymphocytes. In myelogenous leukemia the marrow is red, grayish white, 
or greenish, with an increase in the myelocytes. 
The spleen is enlarged in all forms of leukemia, and may be enormous 
in size. Typically the greatest enlargement occurs in cases of the spleno- 
myelogenous type. 
Adenoid tissue throughout the body is hyperplastic. 
The liver is enlarged, and contains many small grayish or yellowish 
areas which are collections of leukocytes. 
The lymph-nodes are always enlarged in lymphatic leukemia, and 
may be enlarged also in the myelogenous form. The cervical, axillary, 
and inguinal nodes may form masses as large as an egg or even larger. 
These masses are soft, painless, and not adherent to the skin. 
Leukemic infiltrates or lymphomata, circumscribed or diffuse, con- 
sisting of masses of lymphocytes, may be present in the kidneys, lungs, 
skin, peritoneum, dura, myocardium, pancreas, etc. 
Hemorrhages from the gums and the nose and into the subcutaneous 
tissues may occur. In acute lymphatic leukemia this feature is not unlike 
that characteristic of purpura. 
Symptoms.—To a considerable degree the symptomatology may be 
inferred from the description of the blood characteristics and morbid 
anatomy of the disease. 
In the rare myelogenous leukemia the onset is insidious. Glandular 
enlargement may not be evident at any stage or at most be very slight. 
Weakness, anemia, splenomegaly, or sudden hemorrhage from any of the 
mucosae may constitute the initial symptoms. With the progress of the 
disease, petechiae or ecchymoses in the skin appear, gastro-intestinal 
disturbances occur, and irregular and intermittent fever is noted. There is 
marked weakness and prostration. Leukemic plaques may be found on 
retinal examination. The enlargement of the spleen may attain tre- 
mendous proportions. The urine may show albumin and casts. Edema 
of the lower extremities or generalized dropsy is frequently a terminal 
event. The course, although comparatively rapid as compared with that 
observed in adults, does not usually bring about a fatal issue as quickly 
as the true lymphatic type. 
Illustrative Case.—A boy, four years of age, weighing 33 pounds, was referred 
by Dr. Brooke, of Bayonne, N. J. For nine months there had been a gradual abdominal 
enlargement, with pallor and gradually increasing weakness. The spleen was enor- 
mously enlarged, extending to 1 inch above the pubes and I3 inches to the right of the 
umbilicus. Examination of the blood showed: Hemoglobin, 35 per cent.; red blood- 
cells, 2,000,000; white blood-cells, 760,000; myelocytes, 61 per cent.; polynuclears, 41 
per cent,.; lymphocytes, 10 per cent. Benzol, in 2-minim doses (in emulsion), three 
times daily, was given for six weeks, at which time the boy showed marked improvement. 
The appetite was much better. He was more active. The general appearance was 
decidedly better. The spleen had appreciably decreased in size. The blood examina- 
tion showed that, the general betterment was consistent: Hemoglobin, 48 per cent.; 
red blood-cells, 3,728,000; white blood-cells, 272,000; myelocytes, 27 per cent. After 
three months the child failed rapidly, however, and died in another city without later 
blood examination. 
Acute lymphatic leukemia is rapidly fatal. The onset may be sudden, 
with weakness, pallor, prostration, fever, muscular pains, and sore throat, PERNICIOUS ANEMIA 
445 
or the disease may come on gradually with temporary remissions and 
relapses. The glandular enlargement is usually the first objective sign. 
With the adenitis there occurs enlargement of the liver and spleen and 
multiple hemorrhages into the skin and mucous membranes, varying in 
size from small pin-point petechise to extensive ecchymoses. These are 
especially common in the buccal mucosa where ulcerations may develop. 
There is ultimately a high fever which may maintain a fastigium or majr 
fluctuate. The weakness and prostration become progressive. 
A fatal termination within ten days of the onset is not exceptional and 
a course of two months’ duration is rare. The blood-picture in severe cases 
may remain constant, or in milder cases may show irregular remissions. 
Atypical forms of leukemia are observed in which there may be no 
leukocytosis or even a leukopenia; other cases in which enlargement of 
the spleen is extreme with a preponderance of lymphocytes in the blood; 
and still others in which mvelocytosis accompanies leukopenia. By some 
observers von Jaksch’s disease has been regarded as a leukemia peculiar 
to infancy. 
Prognosis.—The prognosis is most unfavorable. Few patients sur- 
vive one year of the disease. Reported recoveries probably mean errors 
in diagnosis. Death usually takes place from intercurrent disease. 
Treatment.—Nutritional measures should be brought into use. Iron, 
arsenic, and cod-liver oil are usually employed. Dr. Frank Billings, of 
Chicago, reported benefit in 5 adult cases treated with benzol. Our own 
observation with benzol has been as unfavorable as with other methods 
of treatment. True, it does temporarily reduce the number of white 
blood-cells, but in children the total white count may not be high. 
The use of x-ray over the spleen and the long bones appears to be 
of temporary benefit, reducing the blood-count and causing remissions, 
but the outcome remains the same. The intravenous use of active deposit 
of radium has not yet reached the stage where it will bear discussion. 
Radium does reduce the white count markedly, and simultaneously to a 
a moderate degree the number of red cells, but the method is at present 
fraught with danger. 
Transfusion, although of very little benefit, possibly tends to counter- 
act multiple hemorrhages. 
PERNICIOUS ANEMIA 
Pernicious anemia in infants and young children is very rarely seen. 
In fact, its existence in children has been questioned, for blood states 
described as peculiar to pernicious anemia have been found in other 
diseases, as in rachitis and syphilis, in which there is extreme anemia. 
On the other hand, cases of primary pernicious anemia have been re- 
ported by observers of repute sufficiently often to establish the disease 
as an entity. 
Lesions.—In pernicious anemia there is extreme general pallor, and 
fatty degeneration of the heart muscle, the liver, the pancreas, the gastro- 
intestinal epithelium, and the kidneys. In addition, hemosiderosis is 
present in the liver, spleen, bone-marrow, and kidneys due to the destruc- 
tion of red blood-cells. Capillary hemorrhages into the viscera are rarely 
lacking, and are especially frequent in the nervous structures and in the 446 
THE PRACTICE OF PEDIATRICS 
serous membranes. The color of the bone-marrow may be changed from 
yellow to red, and microscopically shows many megaloblasts. 
The Blood.—The specific gravity and coagulability are much reduced, 
and the hemoglobin may be as low as 20 per cent. The red corpuscles show 
a proportionately greater reduction in number, so that the color index of 
the blood is high. In the fresh specimen rouleaux formation is absent, 
and the cells vary much in size and shape, extreme poikilocytosis being 
the rule. A large increase in the megalocytes, with absence of microcytes, 
is very suggestive of the disease in question. Owing to the relatively high 
content of hemoglobin the red cells stain fairly well and uniformly, but in 
many cases there is a degeneration with accumulation of hemoglobin in the 
center of the cell. The megaloblasts usually outnumber the normoblasts. 
In severe and uncomplicated cases there is always a leukopenia, and 
the polymorphonuclear count is roughly parallel to the leukocyte count. 
Myelocytes are usually present. 
Symptoms.—The symptoms are those of rapidly progressive, high- 
grade anemia. The chief symptoms are pallor and marked exhaustion. 
The patient is intensely prostrated, and a gastro-intestinal crisis typically 
develops. Emaciation is not of constant occurrence. Petechise and sub- 
mucous hemorrhages occur. The duration of the disease is but a few 
months, and the true cases are fatal. 
Treatment.—Foci of infection possibly contributing to blood im- 
poverishment should be diligently searched for and eradicated, and all the 
general measures employed to improve nutrition and vitality should be 
instituted. 
Transfusion is often of great temporary benefit and should not be post- 
poned for long in order to have the maximum good effect. Unfortunately, 
even repeated transfusions in true pernicious anemia ultimately fail in 
effect. 
PURPURA 
By purpura is understood a condition in which the blood, with no 
constant change in its character or demonstrable lesion in the vascular 
walls, either escapes spontaneously from its natural channels and con- 
stitutes a free hemorrhage, or becomes localized in different portions of the 
skin and subcutaneous tissue. 
Simple purpura occurs in the form of petechise, often as a terminal 
symptom in exhausting diseases. It may result from severe vascular 
strain, as in pertussis. Several such cases are recalled. Purpura is a prom- 
inent symptom in scorbutus and peliosis rheumatica. It may occur as 
a direct effect of poisonous drugs. Thus in the writer’s own cases it has 
resulted from accidental large dosage of phosphorus and antipyrin. In 
a vast majority, if not all, of the cases the condition is due to toxic sub- 
stances originating within the body or introduced from without. 
The Hemorrhagic Type.—The distinction between simple and hem- 
morrhagic purpura is largely one of degree. In the hemorrhagic type 
there are free hemorrhages from different portions of the body, usually 
associated with extensive subcutaneous hemorrhage or hemorrhages 
into different organs. Massive hemorrhages have been designated as 
purpura fulminans, or Henoch's purpura, and here again the differentiation 
is based upon the severity of the condition. PURPURA 
447 
In that form of hemorrhagic disease termed pseudohemophilia, throm- 
bocytopenic purpura, or Werlhofs disease there is consistently found a 
diminution of blood-platelets, prolonged bleeding time, and lack of normal 
clot retractility without diminution in actual clotting time. A diseased 
state of the capillaries combined with an abnormal and excessive blood- 
platelet destruction by the spleen are given as factors in the pathogenesis 
of these persistent cases. 
Illustrative Cases.—One patient two years of age developed a mild purpura while 
taking large doses of antipyrin, which was being administered as the result of a mis- 
understanding. 
In pyemia purpura is not unusual. In a patient nineteen months of age, who died 
from a septic sinus thrombosis with extension to the jugulars, there was extensive 
purpura for forty-eight hours before death. Blood examinations made from this patient 
during life showed pure cultures of streptococci. 
Another patient, a boy eight years of age, previously healthy, died in three days 
from purpura fulminans (Henoch). Death resulted from extensive hemorrhages under 
the skin, combined with hemorrhages from the nose, mouth and intestines, and 
presumably the viscera. An autopsy was not allowed. In this case also blood-cul- 
ture made postmortem from subcutaneous hemorrhagic areas showed pure growth of 
streptococci. 
A notable case was that of a boy seen in consultation with Dr. Corwin, of Rye, 
N. Y. The family history was negative. The tonsils and adenoids were removed six 
months before the illness, without more than the usual bleeding. Two months before 
the illness the boy fell and broke off an incisor tooth. No bleeding followed the accident. 
On June 15, 1910 the patient was taken ill with tonsillitis. The temperature ranged 
from 100° to 102° F., and continued for one week. During this time numerous sub- 
cutaneous hemorrhages appeared at various sites over the body, particularly on the 
leg. A large hematoma developed in the abdominal wall. There was some bleeding 
from the gums, and the subcutaneous hemorrhages continued to appear on the chest, 
abdomen, and legs. There was moderate bleeding from a bicuspid tooth. The child 
was given calcium lactate in small doses, 3 grains every three hours. The hemorrhage 
from the gum stopped, and the subcutaneous hemorrhages began to show signs of 
absorption. 
On July 7th, a little over two weeks after the first sign of the purpura, there was 
a hemorrhage from the nose which lasted about an hour. On the following day there 
was another hemorrhage from the nose which lasted five hours, resisting all ordinary 
methods of control. The patient, who was at this time seen by the senior author, 
evidently had suffered much from loss of blood. The eyes were sunken and the skin 
was pale and sallow and show'ed in many areas the evidences of the previous subcu- 
taneous hemorrhage. The child was markedly prostrated. Calcium lactate was 
resumed in 10-grain doses every two hours. On account of the greatly reduced condi- 
tion of the patient normal salt solution was given by the drop method through the 
tube introduced into the colon. The stools at this time consisted largely of coagulated 
blood. 
July 9th the hemorrhage appeared to be controlled. Twenty grains of calcium 
lactate were given every two hours. 
July 10th nasal hemorrhage began at 5 a. m. and continued for five hours. Saline 
irrigation returned blood-stained. The child was now in an extreme condition, and 
30 c.c. of human serum were injected subcutaneously by Dr. J. E. Welch. During 
the remainder of the day from 45 to 60 c.c. of the human blood-serum were injected at 
two-hour intervals until midnight. The amount injected in twelve hours was 290 c.c. 
In the evening there was an evacuation of the bowels, composed entirely of coagulated 
blood. 
July 11th the stools contained blood, and the expectoration contained some bright 
red blood. There was a moderate nasal hemorrhage. At 8 a. m., 3 p. m., and 9 p. m. 
a total of 167 c.c. of human blood-serum was given in three doses. 
July 12th there was no visible hemorrhage from any portion of the body. Four 
injections of the blood-serum were used, the total amount being 191 c.c. 
July 13th, 14th, and 15th three injections of the blood-serum were given at about 
six-hour intervals, in quantities ranging from 20 to 30 c.c. 
July 16th two injections of the serum were given at twelve-hour intervals—44 c.c. 
in all—and on July 17th one injection of 35 c.c. was given. The total amount of serum 
given during the one week of treatment was 1034 c.c. 
From this time the child manifested a slow but steady improvement, and even- 
tually made a perfect recovery. It was of interest to note that the hemorrhage, which 448 
THE PRACTICE OF PEDIATRICS 
had continued intermittently for nearly three weeks, ceased within fifteen hours after 
the first injection of human serum. While the treatment with the serum was being 
carried on the child was kept alive by predigested foods and free stimulation. 
For obvious reasons a blood-culture was not made, although quite possibly, there was 
a bacteremia with resulting blood changes which the human serum was able to control. 
Diagnosis.—Little difficulty is ordinarily encountered in the recognition 
of this disease, although a differentiation of the particular type occurring 
in a given case may be difficult. A particular point to be kept in mind 
is the possibility of confounding Henoch’s purpura with intussusception. 
In the former abdominal pain is severe and intraperitoneal extravasations 
of blood may give rise to surgical signs. Such cases have undergone 
operation, repeatedly, and it is questionable whether in the event of in- 
ability to make a positive diagnosis exploratory laporatomy is not the 
only procedure to be followed. 
Prognosis.—The prognosis in the simple cases is good. The phos- 
phorus-poisoning case was fatal, but not alone owing to the hemorrhage. 
In hemorrhagic cases of severe type the outcome appears to depend 
upon the promptness with which human serum is introduced into the 
circulation. The appearance of purpura in serious or prolonged diseases 
is a very unfavorable sign. 
Treatment.—The treatment of the milder cases is that of the dis- 
ease with which the purpura is associated. An effort should be made 
to establish the vitality and resistance of the patient by removal, when 
possible, of the cause of the condition, and by the administration of 
acids and fruit juices. The use of ergot and suprarenal extract has not 
been of appreciable service. Calcium lactate has appeared to be of some 
value in cases not severe. Twenty grains should be given every two 
hours. 
Specific Treatment.—As a means of prompt relief human blood far 
exceeds in value all other agents. It may be used in the form of serum, 
as in the case referred to. From 2 to 4 ounces should be given daily 
until the hemorrhage is controlled. (See Hemorrhagic Diseases of the 
Newborn, p. 182.) Injections of whole blood have repeatedly proved of 
similar benefit.1 
Transfusion possesses the greatest immediate restorative power, but 
apparently has no more curative value than the repeated intramuscular 
injections of whole blood. 
Splenectomy has been performed in a few cases unrelieved by other 
measures, with brilliant results.2,3’4 
HEMOPHILIA (BLEEDER'S DISEASE) 
By “hemophilia” is meant a constitutional tendency to uncontrol- 
lable bleeding, spontaneous or arising from wounds which in the normal 
individual occasion little or no bleeding at all. 
Etiology.—Isolated cases of hemophilia are not unknown, but there 
is no doubt that the family histories of these patients are defective. It 
is more usually the case that the bleeding tendency is known in the family, 
1 Dixon, Brit. Med. Jour., 1, 16, 1923. 
2Kaznelson, Wien. klin. Wchnschr., 1916, 29, 1451. 
3 Brill and Rosenthal, Amer. Jour. Med. Sci., October, 1923, 503. 
4Bowen, Bull. Buffalo General Hospital, 1, 1, 1923. HEMOPHILIA (BLEEDER’S DISEASE) 
449 
and that one or more of the child’s ancestors has suffered from the com- 
plaint, or, where a ‘‘bleeder” has been born of healthy parents that one 
or more of the succeeding generations is affected. 
The peculiarity of this condition lies in the mode of inheritance; 
the males of the family chiefly are affected, while the tendency is trans- 
mitted through the females. This law has occasional exceptions, the 
proportion of female to male bleeders being about 1 : 12 (Rachford). 
The mode of inheritance is not unique, for there is evidence that cases 
of partial, albinism follow the same law (Nettleship), and it has also 
been observed in certain cases of color-blindness and night-blindness. 
These and other instances are examples which can be best explained 
by the Menclelian theory. 
In a family of bleeders the female members transmit the disease 
and the males manifest it. Thus, a girl whose mother is a bleeder will 
not show signs of the disease, but will transmit the condition to her chil- 
dren, while her brother will be a bleeder himself and yet his children by 
a healthy wife will not be bleeders, although his grandsons, through 
his daughters, may suffer from the disease. The tendency to transmit 
hemophilia is no stronger in a woman from a family of bleeders, who 
herself is a bleeder, than in her sister, who may not be a bleeder. Marriage 
to individuals who are not affected is no means of preventing the con- 
dition. It is a curious fact that the disease has been found in large fam- 
ilies. 
The condition is rarely noticed at birth, but in most instances is recog- 
nized before the end of the second year has been reached. Before the tenth 
year it is almost always fatal and after the twentieth year the condition 
is very rare. Most of the cases observed have been among Germans 
and Jews, while the disease is practically unknown in the tropics. 
Pathology.—In subjects who succumb the chief alterations are due to 
the draining of the blood from the organs. With this exception there is 
no constant anatomic change. There may be an endarteritis, fatty de- 
generation of the intima, and thinning of the vessel walls, making the 
arteries resemble the veins. 
Blood Changes.—There is usually a slight decrease in the number 
of leukocytes, especially of the polymorphonuclear variety, and beyond 
this the changes are but transitory. Following a severe hemorrhage 
the red cells are promptly restored to their normal number, and the hemo- 
globin much more slowly, so that a simple anemia may be present for 
weeks following a severe hemorrhage. 
The various observations recorded regarding the coagulation time 
are most conflicting and are probably due to the lack of uniformity of 
technic. Wright has shown that the coagulation time is much prolonged, 
while Sahli has considered it diminished in the interval and normal or in- 
creased during the height of an attack. 
In spite of the general law that clot formation is defective, when coag- 
ulation has actually occurred the normal clot retraction takes place, in 
contradistinction to the condition seen in extreme and typical cases of 
purpura (p 447.) 
Various hypotheses have been propounded to explain this abnor- 
mal tendency to hemorrhage, such as abnormal fragility of the vessel 450 
THE PRACTICE OF PEDIATRICS 
walls (Virchow), increased blood-pressure (Immerraan), a definite in- 
fectious process (Koch), while Sahli considered the essential feature an 
abnormal chemical alteration in the walls of the blood-vessels, which 
results in the failure of a substance (thrombokinase) which is essential 
to the formation of a clot. 
Symptoms.—The first manifestations of hemophilia are not often seen 
before the second year. The hemorrhages of the newborn and of purpura 
have no relation to this condition. The most significant symptom is 
bleeding of a serious nature from slight injury or no apparent cause. 
There may be a severe sudden hemoirhage, or a constant oozing of blood 
which resists all attempts to check it. Such trivial injuries as the ex- 
traction of a tooth, or even dentition, may give rise to prolonged bleed- 
ing of a serious aspect. These hemorrhages, usually from mucous 
membranes, take place in the gums, nose, throat, or bowel. Effusion 
of blood into the joints may be chronic, with some limitation of motion 
and even ankylosis resulting. Following these hemorrhages ensue the 
symptoms common to hemorrhage from any cause, and if the case be 
fatal the patient dies from exhaustion. Sometimes death is preceded by 
or occurs during a convulsion. 
Prognosis.—The prognosis is, on the whole, bad in childhood. Fully 
half of the hemophilic patients die before reaching their eighth year, 
and less than 12 per cent, survive to puberty (Littar ,v. Etlinger). The 
first hemorrhagic attack is rarely fatal. 
Diagnosis.—The diagnosis of hemophilia must rest to a large extent 
upon a knowledge of the family history. Where there is no known “bleeder” 
in the pedigree, the diagnosis of hemophilia is always open to criticism. 
It must be remembered that there are other causes of repeated and ob- 
stinate hemorrhage than hemophilia, that, for instance, in recurrent 
idiopathic purpura, such hemorrhages are met with, and that effusion 
into the joint cavities occurs in both diseases. In hemophilia the effusion 
is bloody; in purpura it is invariably serous. In hemophilia, according 
to Pratt, there are about 450,000 platelets per cubic centimeter, whereas 
in purpura there are 50,000 or less. Blood examination rules out anemias 
and leukemias. 
Treatment.—Prophylaxis is the most effective treatment. Marriage 
should be discountenanced. That such advice, however, is rarely followed 
out the records of the various “bleeder” families show. The patient 
should be guarded from birth against all operations unless they be of a 
life-saving nature, and then previous treatment with calcium lactate 
should be used, while at the time of operation blood-serum may be in- 
jected subcutaneously. 
In the event of hemorrhage styptics should be employed, the most 
effective being tannic acid or the perchlorid of iron. No positive results 
are obtained from the administration of calcium lactate in cases of per- 
sistent epistaxis. Gelatin is of little service. In cases of severe hemorrhage 
blood transfusion should be resorted to, and if practicable the father’s 
blood should be employed. Numerous cases are on record where this 
procedure has tided patients over critical periods. If transfusion is impos- 
sible, repeated injections of human serum or even horse-serum may be 
employed. XIV. DISEASES OF THE GLANDULAR SYSTEM 
The Spleen 
In children the spleen is very rarely the seat of primary disease. Sar- 
coma, carcinoma, abscess, and cysts, with primary involvement of the 
spleen, have been reported. This organ, however, frequently shows 
secondary involvement and furnishes an important diagnostic sign in 
a large number of diseases. Thus the spleen is enlarged in syphilis, in 
rachitis, typhoid fever, in persistent intestinal infections, in malaria, 
in cirrhosis of the liver, in portal obstruction due to a neoplasm, in right 
heart failure, and in practically all the blood diseases of early life. 
Usually the organ shows a simple enlargement, which subsides when 
the disease causing the condition is removed. As the result of repeated 
or persistent enlargement for a considerable time, as in malaria and 
some of the blood disorders, the gland undergoes hyperplasia and per- 
manent enlargement. 
Primary splenomegaly of the Gaucher type is of unknown origin. 
The probable cause is a chronic toxic agent, to which a family predis- 
position exists. (See page 453.) 
Splenomegaly in infantile splenic anemia has been found to be as- 
sociated with a parasite, Leishmania infantum, similar to the Leishman- 
Donovan parasite, which is the cause of kala-azar. The parasite was 
discovered in the infantile cases by Pianese and Nicolle. 
Splenomegaly occurs in cases of septicemia, malaria, tuberculosis, 
syphilis, rachitis, leukemia, Hodgkin’s disease, Banti’s disease, and an- 
aemia infantum pseudoleuksemica. In pernicious anemia the spleen is 
rarely very large. 
Neoplasms (sarcoma, angioma, fibroma, cysts) of the spleen are 
very rare. 
SPLENOMEGALY 
SPLENIC ANEMIA (BANTI’S DISEASE) 
Under the heading splenic anemia have been described by various 
writers Yon Jaksch’s anemia, Gaucher’s disease, hemolytic icterus, cer- 
tain forms of leukemia, and the combined splenomegaly and cirrhosis 
of the liver called Banti’s disease. Gradually the various conditions 
have been differentiated until the term ‘‘splenic anemia,” is now usually 
accepted as specific, including properly only Banti’s disease. That this 
last affection as recognized actually represents a late stage of splenic 
anemia is considered probable.1 
Definition.—Splenic anemia is a chronic disease of unknown etiology, 
characterized by splenic enlargement, anemia, hemorrhages, and ulti- 
mately hepatic cirrhosis and ascites. 
Etiology.—The cause is unknown. Few cases are seen in the first 
decade of life. That syphilis is productive of the condition called Banti’s 
1 Pool and Stillman, Surgery of the Spleen, 1923, D. Appleton & Co., p. 174, 
451 452 
THE PRACTICE OF PEDIATRICS 
disease is the view advanced by Norris, Symmers, and Shapiro.1 This 
belief has not as yet received general support, probably due to the exist- 
ence of negative Wassermann reactions in most cases of so-called Banti’s 
disease. 
Pathology.—The changes observed in the spleen consist chiefly in 
fibrosis with thickening of the capsule and trabeculae, reduction in the 
number and size of the Malpigian bodies as a result of the productive 
changes, and associated hyaline degeneration in the walls of arterioles. 
The bone-marrow shows the usual lesions characteristic of severe secondary 
anemia, with reduction in both the hemoglobin and the number of red 
cells. The leukocytes are often reduced in number, but show normal pro- 
portions of the various types of cells. The platelet count and coagulation 
time are not abnormal. The Wassermann reaction is seldom positive. 
Fig. 79.—Banti’s disease. The patient, a girl of ten years, presented icterus, ascites, 
and hematemesis. (Children’s Medical Division of Bellevue Hospital.) 
The liver in advanced cases undergoes atrophic cirrhosis of the Laennee 
type and the splenic portal veins may undergo some degree of thickening. 
Symptoms.—The first sign is, typically, gradual abdominal enlarge- 
ment; and associated with this condition are evident pallor and weak- 
ness. Later the enlargement of the liver may be noted, and finally hem- 
orrhages from the stomach and bowel, epistaxis, hematuria, and ecchy- 
moses may appear. Jaundice is not particularly common. In the last 
stages ascites may occur. 
Dyspnea and heart murmurs not due to organic valvular defects are 
common. 
Course and Prognosis.—In children a tendency to recovery has been 
noted, and it is not unusual for the disease to progress slowly over a 
1 Amer. Jour. Med. Sci., 1917, 154, 893. gaucher’s disease 
453 
period of years, with only moderate splenic enlargement and diminution 
in the size of the liver following earlier enlargement. 
Death may result from hemorrhage and exhaustion, but is more fre- 
quently due to a complication or intercurrent disease. 
Differential Diagnosis.—Cirrhosis of the liver is rare in childhood, usu- 
ally produces ascites early, runs a rapid course, and seldom is associated 
with more than slight enlargement of the spleen. 
Hemolytic jaundice is characterized by excessive fragility of the red 
corpuscles. 
Syphilis ordinarily gives a positive Wassermann reaction and produces 
constitutional or local effects apart from those found in splenic anemia. 
Gaucher’s disease usually begins at an earlier age than splenic anemia, 
shows familial incidence, causes a peculiar brownish pigmentation of 
the skin, and produces an extreme degree of splenic enlargement. 
Although the splenic enlargement and anemia may be extreme in 
malaria, the diagnosis is ordinarily easy in this affection if the temperature 
observations and blood examinations are conducted with care. 
Treatment.—Benefit from splenectomy has been observed in a limited 
number of cases, the best results being obtained from operation early 
in the disease. Other measures of temporary value at times employed 
are z-ray applications to the splenic region and transfusion. 
GAUCHER’S DISEASE 
A rare systemic disease involving the spleen, liver, blood, and lymphatic 
glands, and frequently attacking more than one member of the same 
family, independently of the direct line of inheritance, was described 
by Gaucher as “primary epithelioma of the spleen.” Only a limited 
number of cases have been reported. The first manifestations usually 
occur in early childhood. 
Pathology.—The splenic enlargement is slowly progressive and ex- 
treme. The liver is involved to a lesser degree. Microscopically both 
organs show deposits of large distinctive multinuclear endothelial cells, 
and these cells are found also to some extent in the bone-marrow and 
lymph-glands. 
Symptoms.—Associated with the slowly progressing increase in size 
of the spleen there is a secondary anemia and leukopenia, a variable 
degree of adenopathy, and a brownish-yellow discoloration of the skin 
of the face without actual icterus. Yellowish wedge-shaped thickening 
of the conjunctiva at the corneal margin is at times observed. 
Hemorrhages from the mucous membrane and under the skin may 
occur, but hematemesis is not observed. Ascites, as noted in Banti’s dis- 
ease, is likewise absent. 
Course and Prognosis.—The duration of Gaucher’s disease is measured 
by years. Death is usually due to an intercurrent illness. 
Diagnosis.—The age of the patient, the family history, and the symp- 
toms outlined are sufficient for a diagnosis. In confirming the existence 
of the disease in a given case examination of a section of splenic pulp 
for the typical lesions may be a necessary procedure. 
Treatment.—The disease is probably too generalized to be influenced 454 
THE PRACTICE OF PEDIATRICS 
by splenectomy, although improvement has been reported in a few cases 
following this operation. 
HEMOLYTIC ICTERUS 
This form of jaundice, like Gaucher’s disease, exhibits a familial ten- 
dency, but, unlike Gaucher’s disease, is usually hereditary through both 
male and female antecedents. 
The jaundice is usually manifest soon after birth and may be only 
moderate, the stools remaining dark, but the urine showing an excess 
of urobilin without bile-pigment. The spleen is enlarged, at times to a 
marked degree. Anemia is the rule. A distinctive feature is abnormal 
fragility of the red corpuscles as measured by the action of hypotonic salt 
solution. 
The duration of this affection may be that of normal life, affected sub- 
jects often showing little general ill effects from the condition. 
An acquired type of hemolytic icterus without the familial characteristic 
is recognized. 
The Lymphatic Glands 
Lymphatic gland enlargement is of most frequent occurrence in 
children. It is quite usual, in making a physical examination in children, 
to find the postcervical and the inguinal glands slightly enlarged. Such 
enlargement is frequently of no significance. 
Infants and young children possess a ready susceptibility to gland 
infection. General glandular involvement in a child who is in a depleted 
condition may be of no consequence. In such cases the glands will 
show but very slight or moderate enlargement. In pseudoleukemia, 
leukemia, and lymphatism the glands will show a vastly greater degree 
of hyperplasia, and the blood examination will determine this condition. 
In syphilis the only glandular involvement of diagnostic significance will 
be found in the epitrochlears. 
In tuberculosis the process is often localized, usually at the angle 
of the jaw. The inguinal glands are often found enlarged in eczema, 
intertrigo, and in balanitis. 
ACUTE CERVICAL ADENITIS 
Etiology.—In cervical adenitis the inflammation results from the 
draining of an infected source, which may be a decayed tooth, a diseased 
tonsil, purulent rhinitis, otitis media, or any focus from which bacteria 
may be transferred. In grip, tonsillitis, scarlet fever, diphtheria, measles, 
and in any throat infection adenitis may be, and frequently is, a com- 
plication. Pediculi of the scalp are very apt to produce involvement of 
the posterior cervical glands. 
Pathology.—The process in the gland may be a simple hyperplastic 
change, or it may reach the stage of suppuration. The micro-organisms 
most commonly associated with suppurative adenitis are the strepto- 
coccus and the staphylococcus, but the pneumococcus, the gonococcus, 
and the typhoid bacillus have been cultivated from diseased lymph- 
glands in various regions. ACUTE CERVICAL ADENITIS 
455 
Symptoms.—The first symptom noticed will be that of a swelling, typ- 
ically at the angle of the jaw (Fig. 80), hard, rounded, and quite painful 
to the touch. Preceding the enlargement there may be a period of fever 
for a day or two, during which time the child moves the head awkwardly. 
Rarely one gland alone will be involved. Usually there are several, 
although the external examinations will make it appear that one, or at 
the most, two, are enlarged. The tumor may reach a very large size, 
so that the entire space between the jaw and the clavicle is filled in and 
almost replaced by these glands. 
Fig. 80.—Cervical adenitis. 
The temperature is usually high, in simple adenitis with suppura- 
tion frequently ranging from 102° to 105° F. 
Duration.—The course varies widely. If there is a streptococcus 
infection, suppuration may occur in a few days. In scarlet fever this 
micro-organism is usually the infecting agent, a fact which accounts for 
the many suppurating glands that occur with this disease. 
Termination.—The infection always terminates in one of three ways: 
First, resolution; second, suppuration; third, persistent enlargement 
(chronic adenitis). 456 
THE PRACTICE OF PEDIATRICS 
Differential Diagnosis.—Acute adenitis and mumps are very fre- 
quently confused. By a comparison of Figs. 80 and 117 it will be readily 
seen that the two conditions have but little in common. In mumps 
the parotid gland is involved and the swelling is situated close to the 
ear, with the space posterior to the lobe filled in by that portion of the 
parotid gland. 
Prophylaxis.—A normal, resistant oral cavity is the best safeguard 
against cervical adenitis. Removal of bad teeth and adenoids and enuclea- 
tion of diseased tonsils are better insurance against cervical gland infection 
than all other measures combined. 
Treatment.—After treating many hundreds of cases of adenitis, we 
have been impressed with the great value of cold applications in the form 
of a cold-water compress changed every fifteen minutes to half-hour, 
day and night. Such treatment is arduous, and, of course, in many 
instances impossible, particularly in dealing with young infants. With 
older children the dressing ma}'' be changed without awakening the patient. 
For infants the treatment may be continued with good effect from fourteen 
to sixteen times a day. The last dressing for the night is to be kept bound 
on the parts. The use of ointments and local applications other than 
cold is disappointing. The ice-bag is not so satisfactory as the wet com- 
press. 
Suppurative Cases.—Even when the cold compress or ice-bag is ap- 
plied at the first suggestion of swelling and used faithfully, the cases 
of streptococcus infection usually go on to suppuration. When the swell- 
ing softens we know that suppuration has taken place, and our only treat- 
ment is to incise freely, allowing the pus to escape, and place in the wound 
a strip of sterilized gauze to assist in drainage and to prevent too early 
closure of the incision. The wound should be dressed once daily. Ex- 
tirpation of the diseased gland is not to be advised until later, if at all. 
In fact, a greater part of all the gland tissue may have undergone sup- 
puration, producing complete destruction. 
Repeatedly we have seen the adenitis, which is often an early complica- 
tion of diphtheria, disappear quickly after full doses of diphtheria anti- 
toxin. 
PERSISTENT CERVICAL ADENITIS 
After an acute adenitis, in a small percentage of cases, the gland or 
glands will remain persistently enlarged, so as to constitute a deformity. 
The deformity may likewise be the result of a series of acute attacks, 
each leaving the gland a little larger than before. Whether these glands 
are tuberculous from the outset, or become so later, it is impossible to 
state. We know, however, from observation of many patients that some 
cases which do not show the distinctive characteristics of tuberculous 
adenitis which we have been taught to expect, do showT that they are 
tuberculous upon examination of the glands which have been removed 
at operation because of the unsightly deformity. We have, therefore, 
come to look upon pronounced persistent adenitis as probably of tuber- 
culous origin, even though but two or three glands appear to be involved. 
Because these chronically enlarged glands sometimes undergo resolution 
without suppuration does not prove the absence of tubercle bacilli. GLANDULAR FEVER 
457 
AXILLARY AND INGUINAL ADENITIS 
In axillary and inguinal adenitis the infected area from which the proc- 
ess has its origin must be eradicated. In the inguinal cases balanitis in 
boys and vulvovaginitis in girls are frequent sources of infection. Axillary 
Fig. 81.—Axillary adenitis. 
adenitis (Fig. 81) is very unusual. When it occurs, the infection has 
usually been carried from a lesion somewhere in the upper extremity. 
GLANDULAR FEVER 
Glandular fever is a disease of early childhood. It is characterized by 
swelling of the lymph-nodes at the angle of the jaw forming an elongated 
tumor between the angle of the jaw and the sternomastoid muscle. The 
tumor may reach a considerable size. We have seen cases in which the 
tumors were as large as hen’s eggs. Both sides are usually involved; the 
swelling is first noticed on one side and is usually followed by an infection 
of the glands on the opposite side. Barely are the axillary and inguinal 
glands affected. Fever is present, usually from 101° to 104° F., and 
there is prostration and loss of appetite. 
The disease occurs most frequently in epidemic form, although spo- 
radic cases are not unusual. Park West described an epidemic of 96 
cases in 43 families during a period of three years. A large epidemic was 
described by Schaffer in 1909. A similar outbreak reported by Haas1 
occurred in New York City in the spring of 1911. Dining this epidemic 
the senior author treated 30 cases in his own private practice. 
Pathology and Bacteriology.—The pathology of this affection is 
obscure. Thus far the evidence at hand tends to point to a streptococcus 
1 Amer. Jour. Dis. Child., April, 1912, 241. 458 
THE PRACTICE OF PEDIATRICS 
infection, and with the improved technic of blood-cultures in infants 
an answer to this question should be forthcoming in the near future. 
Cultures from the throat have shown no uniform results, but in many 
instances streptococci have been found in glands either at autopsy or 
operation. Korsakoff found streptococci in pure culture in the cervical 
and axillary glands, liver, spleen, kidneys, and heart’s blood, while in 
the same case the glands showed an acute hyperplastic change with 
dilated blood-vessels. In reports of cases blood-cultures during life are 
usually not mentioned. 
Differential Diagnosis.—This disease is to be differentiated from 
mumps in that the parotid glands are not involved, and from acute simple 
adenitis by the absence of throat involvement, and by the fact that nearly 
all cases terminate in recovery without suppuration or resulting per- 
sistent adenitis. In several of the cases seen during a recent epidemic 
the rhinopharynx was normal. Two or more children in a family may 
have the disease at the same time. 
In the case of a boy fourteen years old with extreme bilateral cervical adenitis 
accompanied by temperature of 104° F., but no throat manifestations, a cobweb-like 
film noted along the gum margins at the site of the molars yielded an unusually good 
smear of Vincent’s sjnrillum and bacillus. Previously the case had been regarded as 
one of typical glandular fever. 
Treatment.—The treatment consists in enforced rest in bed, a re- 
duced diet of broth and gruel, the continuous use of the ice-bag or the cold 
compress (p. 317), and the employment of laxatives, such as milk of mag- 
nesia, sufficient to produce one or two evacuations daily. The swelling 
may last from five days to two weeks, and in all our cases has subsided 
without suppuration. 
TUBERCULOUS ADENITIS 
Tuberculous adenitis is a term applied by common consent to tuber- 
culosis of the cervical lvmph-nodes. In cases of early and localized tuber- 
culous involvement these glands, more often than any other structures, 
harbor the bacilli. Furthermore, because of the possibility of ready 
access to the source of the disease, these cases afford a better prognosis 
as regards its eradication than do cases of tuberculosis in any other part 
of the body. 
Age .—The age incidence is interesting. Cases are rarely seen before 
the third year and do not often develop after the eighth year. Excep- 
tionally cases develop much later. One patient was a girl sixteen years 
of age who was otherwise healthy. 
Conditions Favoring the Development of Lymph-node Tuberculosis.— 
Diseased tonsils and adenoids are the most fruitful cause of tuberculous 
cervical lymph-glands. 
Whether previous inflammatory condition of the glands makes them 
a more favorable focus is not known; neither do we know when the glands 
become tuberculous. Is the tubercle bacillus the first offender? Holt 
believed that in most cases tuberculosis is the primary infection. Heredity 
probably plays no part in causation. That lymphatism may predispose 
an individual to the infection is extremely doubtful. It has not been 
our observation that children predisposed to glandular enlargement TUBERCULOUS ADENITIS 
459 
from some systemic cause are especially susceptible to bacterial infection. 
It is apparent that tuberculous glands are dependent for the infection 
upon the presence of tubercle bacilli in the food and air, and upon a 
means of communication to the gland which is supplied by those 
lymphatics the function of which is to drain bacteria-laden tonsils and 
adenoids and diseased teeth. 
Contributory to this belief is the fact that the age from the third 
to the eighth year is the period during which diseased tonsils and ade- 
noids are of the most frequent occurrence. 
Types of Infection.—In the majority of cases of primary cervical 
adenitis in children the tubercle bacilli, which have been isolated by 
observers in this country, England, and Germany, have conformed to the 
human type. From bronchial and mesenteric lymph-nodes affected 
with tuberculosis in young children Gofflsev isolated the human type 
in 55 out of 57 cases. In 2 the bovine strains were present in the bron- 
chial nodes. 
Stiles of Edinburgh has made a searching study of the surgical tuber- 
culosis of childhood, with paiticular attention to the mode of origin and 
character of the infection. He found that the greater part of lymph- 
gland tuberculosis to which Scotch children were subject was derived 
from milk obtained from tuberculous cows, the bovine organism greatly 
predominating in the infections with which he had to cope. He has 
emphasized the importance of the tonsil as a frequent portal of entrance 
for the bovine organism thus ingested in milk. 
Tuberculous glands which have undergone suppuration are frequently 
the seat of a secondary infection with the streptococcus. 
Symptoms.—A symptomatology of value in tuberculous adenitis is 
most difficult, as we do not know positively when a gland becomes in- 
fected and knowledge of very early symptoms is therefore out of the 
question. Cervical glands are prone to enlargement. One or more may 
enlarge and disappear or diminish in size, and enlarge again and dis- 
appear, and never trouble the child thereafter. In another case perhaps 
the same involvement occurs, but the glands do not diminish in size or 
disappear as formerly, but, on the contrary, remain enlarged. In well- 
developed adenitis the glands cease to be movable. A periadenitis binds 
them to the skin and the adjacent tissue and probably to the adjacent 
glands. Usually one side of the neck is involved. The involved glands 
may be small or large. Repeatedly tuberculous glands as small as a pea 
may be seen undergoing typical cheesy degeneration. Secondary infection 
is productive of abscess; the skin over thfe superficially seated gland be- 
comes acutely reddened and breaks down if not opened, permitting the 
discharge of thin, light yellow pus. Other glands undergo the same 
process of infection, followed by cheesy degeneration and suppuration, 
with the formation of a sinus and destruction of skin. Attempts at reso- 
lution produce cicatricial changes which add to the unsightliness of the 
wound. The entire process is chronic. 
Diagnosis.—The most common form of long-standing cervical adenitis 
is the tuberculous type. Failure of swollen gland masses in. this location 
to diminish in size after the removal of diseased teeth and tonsils and 
the cure of otitis media and scalp infection, such as that secondary to 460 
THE PRACTICE OF PEDIATRICS 
pediculosis, is presumptive evidence that the glands involved are actually 
tuberculous. The positive intradermal tuberculin test, while not diag- 
nostic of the particular local condition, is significant. 
The value of the Roentgen ray in revealing calcified tuberculous 
cervical nodes has been emphasized in a special report by Hanford.1 When 
further evidence is necessary pending extensive operative procedure, 
the removal of a small gland or section of tissue from the affected region 
will render possible accurate microscopic diagnosis. 
Prognosis.—The prognosis is the same as in so many diseases in 
which the treatment is surgical. The outlook is most satisfactory if 
the surgeon is given an opportunity to operate early. 
The girl of sixteen years previously referred to was undergoing treatment for tuber- 
culous nodes by means other than operation. After three months of treatment she 
developed tuberculous meningitis. 
Treatment.—If the gland may be diagnosed as tuberculous, radical 
procedures should be brought into the case. If the diagnosis is not posi- 
tive, but the swelling persists to a degree sufficient to produce a defor- 
mity, the case should be placed in the suspected class and treated as if 
tuberculous. 
Surgical Treatment.—The operation is usually attended with most 
satisfactory results, but should be attempted only by a competent sur- 
geon. We have known results that were not satisfactory. The possibilities 
of an unsightly scar deter many parents from assenting to an operation. 
If the operation is performed by the Dowd method before ulceration of 
the skin develops, the scar is negligible and long before adult life is reached 
will be inconspicuous. 
After the operation the child should, if possible, be given the ad- 
vantage of an outdoor life in the country, inland. These cases appear 
to improve most rapidly at an elevation of 800 feet or more. The diet 
should consist of meat, eggs, milk, and of high-protein cereals, such as 
oatmeal and the dried legumes, given in the form of purees. It is a good 
custom to order cod-liver oil and malt to be given in doses of from 1 
teaspoonful to 1 tablespoonful after meals for one week, followed for 
one week by the syrup of the hypophosphites. The oil and maltine 
may then be resumed for the same time, thus alternating indefinitely 
with the hypophosphites. If an examination of the blood shows that 
the patient is anemic, iron may be used in connection with the other 
remedies. The citrate of iron and extractum ferri pomatum are well 
borne by the stomach, and have appeared to be of considerable service 
in some cases. To children from five to ten years of age 1 grain of the 
citrate of iron and quinin in sherry wine, or 1 grain of citrate of iron 
and ammonia in water, may be given after meals. The dose of extractum 
ferri pomatum at this age is \ grain after each meal. 
Heliotherapy.—The value of the a’-ray and various forms of light 
therapy in the treatment of certain cases of tuberculous adenitis has 
been demonstrated. This method is often of particular value when 
combined with operative treatment. The details of such procedure rest 
1 Roentgen-ray Diagnosis of Tuberculous Cervical Glands, Amer. Jour. Med. Sci., 
No. 4, vol. clxiv, p. 539. hodgkin’s disease 
461 
with those skilled in this work, who should advise at all times concerning 
the applicability of the method in a given case. In our experience the 
method has been disappointing. 
Definition.—Hodgkin’s disease is a granulomatous disease of lymphoid 
organs marked by enlargement of chains of lymph-nodes which show a 
characteristic pathology, by progressive anemia, and a fatal termination. 
Etiology.—The specific cause is unknown.1 Hodgkin’s disease is rare 
in children and very exceptionally occurs under three years. Its relation 
to tuberculous infection has not been proved, although there is a large 
amount of data in favor of such a hypothesis.2 Attention has been 
called by Bunting, Yates, and Torrey to the presence of diphtheroid or- 
ganisms, aerobic and anaerobic, in the diseased nodes. 
Pathology.—The disease is characterized by multiple enlargement of 
lymph-nodes in many regions. The nodes are usually discrete, non- 
infiltrating, and in over 50 per cent, of the cases first affected in the cer- 
vical region.3 The axillary and inguinal nodes may become involved, 
as may the mediastinal and retroperitoneal groups. In 60 to 70 per cent, 
of the cases there is splenomegaly and enlargement of the liver. On 
section, all these tissues present the same cellular picture. There is 
marked hyperplasia of the reticulum with proliferation of the endothe- 
lium, endothelial giant-cells, plasma cells, eosinophil cells, and lymphocytes, 
small and large.4 Areas of necrosis are uncommon except in very acute 
cases or long-standing cases of great bulk. The node capsules remain 
intact and there is no infiltration except that blood-vessels may be oc- 
cluded by invasion of the walls. 
Clinical Course.—The onset may be gradual, with rather indefinite 
skin manifestations of an eczematous nature. However, progressive 
enlargement of cervical lymph-nocles is usually the first clinical evidence 
of Hodgkin’s disease. The swellings are hard, painless, show no signs of 
acute inflammation or suppuration, and remain discrete, manifesting 
little tendency for the glands to coalesce. With the progress of the disease 
more general symptoms are observed. Enlargement of the cervical and 
mediastinal glands may give symptoms associated with pressure on con- 
tiguous structures, such as cough, dyspnea, pain, and even pressure ulcera- 
tion. Symmers has reported a case of ulceration of the trachea from 
pressure of mediastinal nodes. 
In a recent case of a child two years of age the cervical, axillary, and inguinal 
glands were all greatly enlarged. There was no appreciable increase in size of the spleen. 
Gastro-intestinal disturbances occur, with further involvement of ab- 
dominal nodes. 
The spleen is usually but not invariably enlarged. Fever may or 
may not be a prominent feature of the picture. With generalization 
HODGKIN’S DISEASE 
1Zeigler: General Pathology, 5th Amer. ed., 1921. 
2 Ewing, Neoplastic Diseases, 2d ed., 1922. 
3 Ibid. 
4 Reed, On the Pathological Changes in Hodgkin’s Disease with Special Reference 
to its Relation to Tuberculosis, Johns Hopkins Hospital Reports, vol. x, Nos. 3, 4, and 5. 462 
THE PRACTICE OF PEDIATRICS 
of the disease, the temperature may present wide fluctuations. There is 
an accompanying cachexia at this stage. 
The blood shows a marked secondary anemia with little or no decrease 
in the red cells, but a marked fall in the hemoglobin. There is little 
if any leukocytosis, except in the presence of secondary infection. The 
white blood-counts average about 10,000, but may be high during both 
the early and late stages of the disease. There may be slight polynu- 
cleosis. Eosinophilia is common. 
The duration of the disease varies in children from a few months to 
about three years. Rarely do cases run longer. In our cases the duration 
has been from one to two years. 
Diagnosis.—Tuberculosis.—In Hodgkin’s disease the nodes are more 
slowly progressive, are harder, show no signs of acute inflammation or 
suppuration, and remain discrete, whereas tuberculous nodes tend to coa- 
lesce. The coincident wide distribution of Hodgkin’s nodes is not typical 
of tuberculous involvement. The tuberculin test may be of help in 
afebrile Hodgkin’s disease. 
Lymphatic leukemia may be differentiated by repeated examinations 
of the blood and the more rapid clinical progress with nodes which do 
not usually reach the size of Hodgkin’s nodes. 
Lymphosarcoma usually presents coalesced nodes, causes no fever, 
seldom produces splenomegaly, and is more rapid in its course, soon in- 
vading surrounding tissue. 
From the pseudoleukemia of Cohnheim Hodgkin’s is clinically indis- 
tinguishable. Only by microscopic section of an excised gland can dif- 
ferentiation be made. 
The best single diagnostic clinical sign in Hodgkin’s disease is the char- 
acteristic glandular involvement. Mediastinal x-ray is important. 
Prognosis.—The termination is always fatal. 
Treatment.—When Hodgkin’s disease is suspected clinically, a biopsy 
should be performed and the diagnosis be decided by the pathologist. 
Arsenic in full doses is advised, but at present radiation over the affected 
areas with x-rays and radium-packs offers the best palliative treatment. 
Apparently there is some prolongation of life by these means, but the 
ultimate outcome is the same. 
The Breast 
MASTITIS IN YOUNG GIRLS 
Inflammation of the mammary gland in young girls is a compara- 
tively rare condition, but one of sufficiently frequent occurrence to re- 
quire mention. Swelling and tenderness of the breasts, although often 
complained of by young girls about the time of puberty, subside with- 
out treatment if let alone. In such cases there is no rise in temperature 
and the tenderness and enlargement may remain for several weeks. One 
breast only may be involved, and the swelling may anticipate the first 
menstruation by several months. 
The patients with true mastitis have varied in age from seven to twelve 
years. The condition is usually due to the entrance of bacteria through 
the nipple, and in its clinical manifestations the condition resembles mas- CONGENITAL goiter 
463 
titis in the adult, except that the entire gland is usually involved, becom- 
ing swollen, tender, and excruciatingly painful. There is slight fever— 
not above 101° F.—headache, and lassitude. 
Treatment.—Satisfactory treatment during the acute stage has con- 
sisted in the use of an ice-bag, which is kept intermittently applied dur- 
ing the waking hours. At night a wet dressing of bichlorid of mercury, 
1 : 5000, may be kept on the infected glands. A saline laxative in the 
form of citrate of magnesia should be given at the onset, and a diet of 
broth, gruel, toast, and stewed fruit is to be continued during the period 
of fever. Recovery is usual under two weeks. The ice-bag has not been 
required for more than three or four days. After this period the wet 
dressing answers the same purpose. 
The Thyroid Gland 
SIMPLE ENLARGEMENT OF THE THYROID 
Physiologic congestion1 of the thyroid is one of the most common 
conditions affecting the gland in young female subjects, a “premenstrual 
congestion” of the thyroid being common just prior to the first menstrua- 
tion. The enlargement of the gland may subside as the menstruation 
becomes established, but not infrequently recurs with each menstrual 
period. 
Aside from the swelling referred to the symptoms and signs are in- 
significant and no treatment is indicated. 
This type of goiter, chiefly in the vascular and parenchymatous forms* 
occurs occasionally in infants, exhibiting the influence of heredity, partic- 
ularly on the maternal side.2 By the imposed resistance to head flexion 
which it may occasion this form of goiter tends to cause face presenta- 
tion at birth. The thyroid is subject to additional congestion from oc- 
casional constriction of the neck by the umbilical cord. 
In mild cases in infancy no inconvenience may be entailed, but as a 
result of a so-called fulminating type of the disease the child may be 
dead at birth, or if living, show cyanosis, dyspnea, stridor, and exoph- 
thalmos preliminary to an early death. 
Treatment consists in the inunction of potassium iodid ointment 
(Crotti): 
CONGENITAL GOITER 
Kal. iodat 10 grams 
Aq. dest 10 “ 
Lanolin 30 “ 
Vaselin 70 “ 
For the urgent cases cold compresses locally may be of service. 
When the dyspnea persists, isthmectomy or partial thyroidectomy 
is to be considered, tracheotomy being more frequently productive of 
pneumonia. 
Proper treatment of goitrous mothers during pregnancy with thyroid 
1 Crotti, Thyroid and Thymus, Lea & Febiger, 1922, pp. 129-131. 
2 Ibid., pp. 182-185. 464 
THE PRACTICE OF PEDIATRICS 
extract or iodin is said to prevent the development of congenital goiter 
in the offspring. 
With children the various forms of goiter found in adults are at times 
presented, the frequency of the disease being greater in girls at puberty. 
The simpler types of goiter are amenable to potassium iodid in doses of 
5 to 10 grains daily. 
SIMPLE GOITER IN OLDER CHILDREN 
EXOPHTHALMIC GOITER 
Occasional cases of true hyperthyroidism with the symptoms of typical 
exophthalmic goiter are observed in children who may or may not have 
shown abnormality of the thyroid. The incidence of this disease is greater 
in late childhood and the management is the same as that indicated 
for disease in the adult. 
The physician will do well to remember the comparative rarity of the 
condition in comparison with the exceeding frequency of simple swelling 
of the thyroid so frequently observed at puberty. 
Kimball and Marine1 showed by extensive experiment at Akron, Ohio, 
that 0.2 gm. of sodium iodid given daily for ten consecutive days, twice 
yearly, would effectually prevent goiter in children. 
Hunziker and Wyss2 made observations upon several hundred school 
children in Switzerland at an interval of several months during which 
about half of the children received regularly 0.04 gram of potassium 
iodid, while a similar group were untreated. In the untreated boys and 
girls the gland increased 2.1 to 2.8 cm., while in those under treatment 
it decreased 7.2 to 7.6 cm. These observations indicate strongly the value 
of iodin even in small doses as a prophylactic against goiter.3 
CRETINISM (INFANTILE MYXEDEMA; CRETINOID IDIOCY) 
Cretinism was described by Paracelsus early in the seventeenth cen- 
tury. Until the middle of the nineteenth century, however, the disease 
was only imperfectly differentiated. Fagge described the sporadic form 
in 1871, and in 1873 Gull emphasized the similarity of this disease to 
adult myxedema. Some years later,- following the experiments con- 
ducted by Victor Horsley, a commission appointed by the Clinical So- 
ciety of London reported that myxedema and cachexia strumipriva 
were identical, that sporadic cretinism was myxedema occurring in child- 
hood, and that endemic cretinism was closely allied to myxedema. The 
successful work of Schiff, von Eiselsberg, and Horsley in the artificial 
grafting of thyroid gland induced George R. Murray in 1891 to employ 
hypodermic injections of an extract of the gland in the treatment of myx- 
edema. Howitz, Fox, and MacKenzie obtained equally good results 
from thyroid medication by mouth. The wonderful success of this form 
of organotherapy during the five 3rears following its initial use led Osier 
to write: “Not the magic wand of Prospero, or the brave kiss of the daugh- 
ter of Hippocrates, ever effected such a change.” 
1 Arch. Int. Med., 1918. 
2 Schweiz, med. Wchnschr., January 19, 1922. 
3 Practical Medicine Series, Pediatrics, 1922, vol. iv, pp. 137, 138. CRETINISM (INFANTILE MYXEDEMA; CRETINOID IDIOCY) 
465 
Cretins usually do not come under observation before the sixth month. 
Not much is expected of a baby a few months old, and if he is very 
quiet and slow at noticing his surroundings, the fact is attributed to his 
tender age or to his being a good baby. When, however, at the fifth, 
sixth, or seventh month, he fails to show the usual response for his age, 
medical attention is called to the condition. When first seen the patients 
have usually been from six to eighteen months old. A cretin girl three 
years old weighed 15 pounds, 3 ounces. 
Etiology. It is undoubtedly established that the condition termed 
“cretinism” depends upon the absence of the thyroid secretion, and that 
the various degrees of cretinoid idiocy hinge upon the partial or complete 
absence of the thyroid gland. Cretinism 
varies in degree and in the time of its de- 
velopment. In typical cases (Fig. 83) 
there is complete absence of the thyroid 
gland; in others, showing the disease in 
less severe form, an impaired thyroid is 
found. 
Pathology.—In 14 of 16 autopsies col- 
lected by Fletcher Beach the thyroid was 
absent. In 100 cases of Curling, Fagge, 
and Iphophon the gland was wholly absent 
in 25; in the other 75 various connective- 
tissue and colloidal changes were observed. 
In endemic cretinism (“not found in this 
country,” Osier) alterations are found in 
the thyroid consisting of partial or com- 
plete degeneration, which may be either 
atrophic or goitrous in its inception; or, 
as Getzowa has described, cases are found 
in which atrophic areas and goitrous de- 
generated nodules alternate in the same 
gland. In sporadic cretinism there is usu- 
ally congenital absence of the gland, while 
in infantile myxedema due to acquired loss 
or perversion of thyroid function in the 
early years of life the symptoms vary ac- 
cording to the amount of functional distur- 
bance. According to Kocher, in myxedema there is always abolition of 
the function of the gland, which at autopsy is never normal. In the 
majority of cases it is replaced by a band of tissue (Virchow); at other 
times, by adipose tissue without a trace of the thyroid artery (Stilling). 
Ord was the first man to examine microscopically the thyroid in a case 
of myxedema. In the majority of instances neither Virchow nor Horsley, 
in their extensive observations, was able to find vestiges of acini or thy- 
roid cells—masses of connective tissue occupying the region of the gland. 
Stilling made similar investigations, and found the thyroid artery missing, 
while Langhans characterized the changes as those of an interstitial 
inflammation, with embryonal cell infiltration; in fact, an inflammation 
comparable to cirrhosis of the liver. By degrees the tissues become 
Fig. 82.—Cretin four years 
old never having received thyroid 
treatment. 466 
THE PRACTICE OF PEDIATRICS 
sclerosed and the vessels undergo endarteritis obliterans, while the acini 
become atrophied and disappear. As these changes progress the function 
of the gland diminishes. 
The parathyroids are normal. The hypophysis cerebri is atrophied 
in some cases and hypertrophied in others. The brain shows no gross 
abnormality. The genitals are infantile in character. The skin is thick, 
with a scanty development of hair and sweat-glands. The adipose tissue 
is very abundant, both beneath the skin and in the omentum; often there 
are pads of fat above the clavicles. The entire osseous system shows 
a lack of development and ossification. 
Symptoms.—When very young—under one year of age—the chil- 
dren are dull and mentally backward; they are passive, and show little 
or no interest in their surroundings; they resist manipulations, such as 
dressing, bathing, and physical examination, but little if at all. The 
extremities usually are cool, oftentimes slightly moist. 
The general appearance is characteristic (see Fig. 84) regardless 
of the child’s age. The hair is dry and coarse; the face is broad; the 
nose wide and flat, and the lips are broad and thick. The tongue pro- 
trudes between the lips. The tissues have a doughy, edematous ap- 
pearance and feel boggy to the touch, but do not pit. The forehead is 
low. The abdomen is usually large, and there is almost invariably an 
umbilical hernia. The neck is short and thick. The hands and feet 
are large; the fingers and toes are short and thick. The patients are 
very short in stature. 
A typical cretin girl was but 26 inches tall when three years of age. 
The fontanel is widely open. Dentition is greatly delayed. The tem- 
perature is usually subnormal. 
The cretin walks late, rarely, if untreated, before the third year. 
Figure 82 represents a cretin four years old who could not stand without assistance. 
He was when photographed 315 inches tall. 
Mentally and physically such individuals are slow and inactive. The 
mental impairment is considerable, idiocy being the outcome in most 
of the untreated cases. 
Acquired Cretinism.—In some early development is fairly normal, 
and the unmistakable signs do not appear until the child is several months 
of age. 
Illustrative Case.—A girl, three and one-half years of age, with delayed or acquired 
cretinism, was perfectly normal until the third year of age. She then became inactive 
and took no interest in her surroundings. The hair became coarse and dry, the ex- 
tremities cool. The expression was dull and listless. The child presented a general 
edematous appearance. The diagnosis of cretinism was proved by a prompt response 
to thyroid medication. 
Diagnosis.—The diagnosis in typical cases is made without difficulty. 
The nature of the trouble is stamped on every feature. The slow mental 
responses and the dwarfed, edematous extremities furnish a picture 
that is simulated by but one other condition, and this is Mongolian idiocy. 
In the Mongolian the round face, the elliptic eye, and the absence of 
shortening in the long bones are sufficient to establish a differentiation. CRETINISM (INFANTILE MYXEDEMA; CRETINOID IDIOCY) 
467 
Prognosis.—The prognosis for a complete recovery is good if the 
case is discovered before the eighth month. Several patients under 
treatment have become apparently normal children as judged by school 
and family standards. No one knows that these children are cretins. 
In cases in which treatment is not begun until after the first year— 
surely after the eighteenth month—the chances of normal mentality are 
lessened. The earlier the case comes under treatment, the better the 
possibilities for the patient, both physically and mentally. 
Treatment.—The Thyroid Treatment.—The specific treatment is 
the thyroid treatment. The most pronouncedly beneficial results of 
this treatment are noticed when it is brought into use early in life. The 
diagnosis of cretinism is, however, rarely made before the fifth or sixth 
month, often much later, for the reason that the case does not happen 
to come under the observation of those competent to make the diagnosis. 
Illustrative Cases.—In 2 cases the patients were first seen by the writer at the 
fifth and the seventh month respectively. Other cases have been treated in institution 
and in private work. The two referred to, however, were seen earlier and almost 
Fig. 83.—Cretin, aged six months, before beginning thyroid treatment. 
daily for months, consequently there was an excellent opportunity for observing the 
effects of the thyroid administration. The desiccated thyroid extract of Parke, Davis 
& Co. was used. 
A fairly complete history of the progress of one of the cases is as follows: The 
beneficial effects were noticed in three days. The first change for the better was 
observed by the mother, who stated that the child seemed warmer and that less bed- 
clothing was necessary. The next positive change occurred, according to the records, 
on the fifth day of treatment. The child’s general condition was very much improved. 
Her extremities were warmer, her color better, and she commenced to use her arms; but 
what particularly impressed the mother was that less bed-clothing was needed to 
keep the child warm. At about the seventh day of treatment the patient cried vigor- 
ously when disturbed for the purpose of changing the napkin—something which she 
had never done before. She had previously been stupid and apathetic. The next 
changes for the better rapidly followed; the patient noticed and appeared interested in 
her mother, and followed the latter about the room with her eyes, and while previously 
the child had rarely used her legs and arms except when disturbed, she now began to 
move them about voluntarily; as the mother expressed it, “the child had acted as 
though she were under the influence of some powerful depressing drug whose effects 
were gradually wearing off.” When the child was five and one-half months old, after 
she had been under treatment for sixteen days, receiving £ grain of thyroid twice daily, 
she smiled for the first time. She cut the first tooth at the ninth month, and walked 
alone at the fourteenth month. She ultimately took 5 grains daily, and seemed appar- 468 
THE PRACTICE OF PEDIATRICS 
ently normal in every respect. She attends school, and is but one grade below the 
average school child of her age, which means that she is in the same grade with other 
children who are normal. 
When the child in whom treatment was commenced at the seventh month was 
nine months of age it was found necessary to give \ grain three times daily. One 
month later | grain was given four times daily. At this time the child could sit up 
and hold the head erect. The increase in the thyroid extract produced vomiting, 
and the dosage of grain three times daily was resumed. One year after the com- 
mencement of the treatment, when the patient was nineteen months old, 2 grains 
daily were required. 
In both of these infants the protrusion of the tongue was one of the latest symptoms 
to disappear. 
Dosage.—The increase in the thyroid administration must be deter- 
mined by the condition of the patient. As long; as progress is shown in 
more active and normal mentality, with an increase in the growth of the 
long bones and a gradual loss of the typical facial and bodily character- 
istics, it is unwise to increase the dosage of the thyroid. When, how- 
ever, a period arrives when no progress appears to be made, the daily 
dosage should gradually be increased by \ grain. Evidences of over- 
dosage are pallor, prostration, perspiration, and indigestion. When 
any of the above signs present themselves, the medication should be 
discontinued for twenty-four hours and then resumed with smaller doses. 
Our cases have varied considerably as to the amount of thyroid re- 
quired. The dosage used was that taken by those in whom the disease 
was discovered very early in life. The older the patient when the thyroid 
medication is begun, the less marked are the beneficial results. 
Case 3.—A girl patient, nine years old, and normal in every respect except that her 
hair remained rather coarse, with a tendency to dryness of the scalp, was found to 
require the following amounts of desiccated thyroid at the various ages: 
Six months *1§ grains daily 
One year 3 \ “ “ 
Two years 5 “ “ 
Three years 9 “ “ 
Four years 8 “ “ 
This patient both walked and talked at fifteen months. In her case, in order 
to determine what the effects of the withdrawal of the treatment might be, the thyroid 
was discontinued. This was first attempted when she was two and one-half years of 
age. The mother was asked to keep close watch in order to detect the slightest differ- 
ence in the child’s behavior. After three days without thyroid it was noticed that the 
child became less active and disinclined to play. She was not irritable or cross, but 
woidd sit in her little chair the entire day. She had previously been very bright, 
active, and talkative. A few days later she ceased to talk voluntarily and answered 
only when spoken to. After an interval of twelve days the thyroid was resumed, and 
her activity again returned. About one year later a similar trial was attempted, with 
similar results, although the duration of the test was shorter, as the mother, who was a 
dispensary patient and had had the thyroid furnished her, purchased a bottle of tablets 
and gave them on her own responsibility. The child, when nine years old, was taking 
12 grains daily. She was a normal, healthy school girl, alive to all interests of girlhood, 
and no one outside the family circle in the village where she resided knew that she was 
a cretin. 
Case 4-—The patient shown in Fig. 84, A was eight and a half years of age, with 
weight 40\ pounds and height 374 inches, the figures representing about the nor- 
mal for a girl three and a half to four years of age. The first tooth was cut at the 
fifteenth month. The child walked first at the third year. She was dull, inactive, 
and took no interest in her surroundings. The heart, lungs, kidneys, and blood were 
negative. The abdomen was very large and protuberant and there was a large um- 
bilical hernia. The hair was dry and coarse, the skin dry and harsh and cool to the 
touch, the nose flat, and the lips thick. The teeth were poorly formed and decayed, 
six in the lower, and five in the upper jaw. None of the second set had appeared. The CRETINISM (INFANTILE MYXEDEMA; CRETINOID IDIOCY) 
469 
child’s vocabulary consisted of a very few words. She did not care for play and had no 
interest whatever in other children. In fact, as the illustration shows, she had all the 
signs of cretinism. 
She was given a suitable diet and the desiccated thyroid. After a little experi- 
menting it was found that 2 grains of thyroid a day met the requirements. 
Figure 84, B, from a photograph taken one year and two weeks later, shows an 
entirely different child. Her weight was then 49| pounds and her height 43| inches. 
She had gained 6f inches in height and 9 pounds in weight. The character of the 
hair was most noticeable, for it came in soft and silky. Particularly remarkable 
was the fact that the large umbilical hernia was replaced by a fairly normal umbilicus 
without the employment of any local corrective measures. 
A B 
Fig. 84.—Effect of one year’s thyroid administration upon an eight-year-old cretin 
girl. (Case 4.) 
The opinion has been expressed by many observers that not a great deal is to be 
expected from thyroid administration when its use is begun after the period of infancy. 
This child’s mental improvement, however, was surprisingly great and kept pace with 
the change for the better in the physical appearance. It is difficult to realize that the 
figures represent photographs of the same child taken only one year apart. 
s 
The thyroid must be continued during the lifetime of the patient; 
when it is discontinued the mental processes soon begin to lag. In- 
difference to surroundings and aversion to physical effort soon appear, 
all to disappear again when the thyroid is resumed. 470 
THE PRACTICE OF PEDIATRICS 
The Thymus Gland 
The thymus consists of two lobes, faintly red in color. They are 
more or less pointed toward the upper part, rounded off toward the lower, 
and bound together with loose connective tissue. The organ is situated 
in the anterior mediastinum, and the greater portion of the gland lies 
behind the manubrium and body of the sternum. Sappey demonstrated 
that the thymus in the newborn infant reaches from the upper edge of 
the manubrium 5 cm. downward, while the upper border at times may 
reach the isthmus of the thyroid, or be 2 to 3 cm. below it. The sides and 
lower portion are covered by the folds of the mediastinum, while the 
anterior borders of the lungs and loose connective tissue separate the 
gland from the chest wall. Posteriorly in its upper two-thirds the gland 
covers the pericardium and the beginning of the great vessels, the elon- 
gated upper edges covering the trachea. The vagi and phrenic nerves 
and common carotid arteries bound the thymus on either side, while 
posteriorly, again in close relation, are the phrenic nerves. The average 
width of the gland is 2 to 3 cm., and at times the longitudinal diameter 
may reach 11| cm. 
Weight and Size.—As found postmortem the size and weight of 
this organ vary considerably, and, at the present time, there is a wide 
variation of opinion respecting the normal. Exhaustive work on this 
point was done by Bovaird and Nicoll, who weighed the thymus in 495 
consecutive autopsies, the results of which were published in 1906. They 
found the greatest weight at birth, the average being 7.7 gm. Following 
this there was little change until the period of five years was reached, 
from which time a gradual reduction took place. Judging from these 
observations, one may conclude that the average weight at birth is 6 
to 7 gm.; from birth to five years, 3 to 4 gm.; and that any weight over 
10 gm. may be considered abnormal. 
Olivier, in an extensive monograph, gave the following figures: 
Birth 4 gm. 
1 year 6 “ 
2 years 8 “ 
3 years 10 “ 
He considered all thymi over 15 gm. to be hypertrophied. Sappev, 
Murkel, and Testut have all quoted figures higher than Olivier. Friedleben 
and other observers pointed out that these variations in the weight and 
size of the thymus may be accounted for by the body nutrition. It ap- 
pears that the thymus shows the results of excessive loss much more 
than the body as a whole, for in exhausting diseases the weight of the 
thymus sinks much more rapidly than that of the body. In exceptional 
cases the reverse is true. Formerly the thymus was supposed to reach 
its maximum size at birth, and subsequently to atrophy, but more recent 
observations have shown that remnants persist until puberty, and that 
true thymus tissue may persist throughout life. 
In status lymphaticus the thymus often weighs five to ten times more 
than normal. In well-marked cases its weight may be as high as 55 gm., 
and in less pronounced cases range between 10 and 20 gm. As a whole, 
the hypertrophied thymus is a little more vascular than normal, but STATUS LYMPHATICUS 
471 
aside from hyperplasia shows no other consistent changes macroscop- 
ically or microscopically. 
Inasmuch as the size and weight of the gland is supposed to determine 
the existence of status lymphaticus enlargement of the thymus in associ- 
ation with enlargement in other lymphatic structures, has been the sub- 
ject of a great deal of investigation. We are forced to agree that an en- 
larged thymus implies the existence of status lymphaticus and this is 
in accord with the opinion of Friedlander. Liss1 has reported a thymus 
gland study covering a series of cases in which the results of the x-ray 
examinations before postmortem were compared with the findings at 
autopsy. He has made a classification of shadows comprising three types: 
the columnar, the bulbous, and the pedicle, all of which are illustrated 
by roentgenograms. Recognition of the pedicle type was found impos- 
sible in the living subject, as the thymus shadow is included entirely in 
the heart shadow. Liss found the thymus shadow absent in 35 of 119 
cases, a small shadow less than 3 cm. in 34 cases, and in 50 a large shadow 
more than 3 cm. transversely. The observations were made within forty- 
eight hours after birth. These findings are startling in the sense that 
about 52 per cent, of the cases showed a transverse measurement of 
more than 3 cm., a condition that the investigator regarded as pathologic. 
Later observations showed that there was a spontaneous retrogression 
of the gland during the first year. 
One frequently sees cases in very young infants who after an initial 
attack of cyanosis followed by treatment remain as well as other children. 
Physiology.—The physiology of the thymus is indeed very obscure, 
little being known about its functions. Its closeness to the thyroid and 
parathyroid glands and its similarity of origin would almost suggest that 
it played some specific part in metabolism, but physiologic experiments 
of late have failed to discover exactly the character of this influence. 
During the past few years there has been considerable experimenta- 
tion which, so far, has apparently cleared up the matter in two directions, 
namely, the relation of the organ to bone growth and to the condition 
of the bones, on one hand, and to the electric excitability of the nerves 
on the other. Basch showed that following complete extirpation of the 
thymus in a young dog there occurred a softening of the bones and a 
check to their growth; in fact, a condition very much resembling rickets 
and chondrodystrophy. At the same time the peripheral nervous system 
shows an increased electric excitability. Numerous other observers have 
confirmed these observations, and, in addition, have noted that in thy- 
mectomized animals there exists a stage of increased fat absorption and 
later malnutrition and cachexia. 
STATUS LYMPHATICUS 
It is well proved by a long series of cases, carefully studied by com- 
petent observers, that the condition known as status lymphaticus is an 
entity and is characterized clinically by a lowered vitality or an un- 
stable equilibrium of the vital forces, so that accidents or disturbances, 
otherwise unimportant, such as some slight injury or a light anesthesia, 
may precipitate failure of the heart and respiration. 
1 Amer. Jour. Dis. of Child., September, 1922. 472 
THE PRACTICE OF PEDIATRICS 
In status lymphaticus there is hyperplasia of the thymus and general 
lymphatic gland involvement. 
Etiology.—A satisfactory explanation of the disease has never been 
offered. Friedlander found a familial tendency exhibited in 4 families, 
in that more than one child was affected in each. In two pairs of 
twins he found the thymus enlarged in each individual. We have never 
been able to associate the disease with any particular type of child. Like- 
wise the age of the patient is subject to wide variation. Our youngest 
patient was twelve hours old and another was twenty-four hours old. 
Fig. 85.—Enlarged thymus. “The lungs, heart, and thymus are shown in the pic- 
ture. The lungs have been turned back, showing the two lateral lobes of the thymus 
overlapping the heart; the central lobe, above, covers the trachea. History: Breast- 
fed, male child, nine months old, well developed; ill less than twenty-four hours; dysp- 
nea, slight cyanosis, with death from asphyxia. T. 103° F. Autopsy: Besides the 
large thymus there were present the general lesions of the status lymphaticus to a 
marked degree; lungs deeply congested.’’ (From Holt’s Diseases of Children, 1916, D. 
Appleton Company, Publishers.) 
Pathology.—The thymus often weighs five to ten times more than nor- 
mal. In well-marked cases its weight may be as high as 55 gm., and in less 
pronounced cases range between 10 and 20 gm. As a whole, the hyper- 
trophied thymus is a little more vascular than normal, but, aside from 
hyperplasia, shows no other consistent changes macroscopically or mi- 
croscopically. 
Autopsy findings in these subjects usually show a general lymphatic 
enlargement of tonsils and follicles at the base of the tongue and in the STATUS LYMPHATICUS 
473 
intestine, and swelling and enlargement of the thymus, especially at an 
age when it has generally disappeared. 
Symptoms.—These may be almost identical with those of laryn- 
gismus stridulus. There are sudden repeated attacks of croupy voice, 
inspiratory obstruction, cyanosis, apnea, and loss of consciousness which 
may last from a few seconds to a minute or two. In not every instance 
is the above sequence of events carried out. The attacks may cease at 
any stage, or the child may never recover consciousness. 
The above clinical picture, with later proved thymic death, has oc- 
curred under the writer’s own observation several times. On the other 
hand, the first sign of trouble in two perfectly well-nourished infants was 
a convulsion and both children died in the seizure. There had never been 
a previous convulsion or laryngeal stridor. Autopsy in both showed 
an enlarged thymus. 
We have had proved cases in which the manifestations were of a 
much milder nature. There may be simple stridulous breathing and a 
persistent croup cough. We have had infants who showed nothing more 
than so-called sinking spells, characterized by extreme pallor without 
cyanosis, whose attacks were proven by x-ray and subsequent treatment 
to be due to enlarged thymus. 
It is now our custom in any case of respiratory disturbance in a young 
infant when there is no elevation of the temperature, provided the symp- 
toms are persistent, to subject the child to an x-ray study. 
Cause of the Sudden Death.—The explanation of the deaths occur- 
ring in these infants—most frequently during the first eighteen months 
—is very difficult, and in many cases a careful autopsy does not clear up 
the situation. Many extraordinary hypotheses have been advanced. 
Some believe that pressure exerted by the hyperplastic thymus on the 
vital organs in this region is sufficient to account for the deaths. Others 
are convinced that the pressure exerted by this gland is sufficient to 
produce tracheal stenosis, although such a belief seems far fetched when 
one considers the weight of the thymus and contrasts it with the fibrous 
tracheal rings. 
The occurrence of a sudden swelling has not yet been proved, nor has 
the theory of a narrowed thoracic outlet, which might be still more nar- 
rowed by a forceful extension of the head, received much support. It 
does not seem possible that such a powerful vessel as the aorta, which 
is capable of eroding bones, could be pressed upon, with fatal results, 
as is suggested by some authors. 
Many of the sudden deaths occurring during chloroform and ether 
anesthesia have proved to be due to status lymphaticus. 
According to Paltauf’s many extensive observations the cause, ap- 
parently impossible to explain, lies in a peculiar constitutional anomaly, 
which makes its possessor weak, and less able to stand attacks of illness, 
death being easily produced from trifling causes. 
Symmers1 has held that the sudden death may be explained by an- 
aphylaxis due to a process of disintegration of the nuclei of lymphatic 
tissues with the formation of “nuclear dust” and the release of nucleo- 
proteins. This author also believes that the sudden death may be due to 
1 Amer. Jour. Dis. of Child., December, 1917. 474 
THE PRACTICE OF PEDIATRICS 
a spontaneous rupture of a hypoplastic cerebral vessel or to rupture 
following some trivial injury. 
Normal medias- 
tinum 
■jHeart 
Fig. 86.—Normal thymus. 
Diagnosis.—In addition to the clinical signs we have the Roentgen 
ray and percussion to aid us in diagnosis. 
Enlarged 
thymus 
Heart 
Fig. 87.—Enlarged thymus. 
Percussion of the thymus has been carefully studied by Blumenreich, 
and is of much greater value than palpation, although neither of these DYSPITUITARISM. DYSTROPHY ADIPOSOGENITALIS (FROHLICH) 
475 
methods have received much support in this country. Many instruments 
have been devised for percussion, but no two men agree on the results 
obtained. 
Blumenrich found the dulness of the thymus to cover a space some- 
what triangular in outline, the base being represented by a line drawn 
across the top of the manubrium between the sternoclavicular joints, 
while the rounded-off point or apex was found to lie about on a line with 
the second rib. Between this thymus dulness and the normal cardiac 
dulness on the left side is a zone normally filled in by lung tissue; if this 
area be dulled and if all other causes of impairment can be excluded, 
then a diagnosis of enlarged thymus is justifiable. Among other workers 
the names of Basch and Rohn may be mentioned. In their outlining 
of the thymus they found it to be more rhomboid in contour, but, on 
the whole, tended to confirm the older work of Blumenreich. 
Roentgen Ray.—A considerable observation of thymus disease with the 
improved technic of the roentgenologist has led us to believe that in this 
measure we have an invaluable means of diagnosis. Figures 86 and 87 
represent a radiograph by Cole, of New York, in which a normal and an 
enlarged thymus are shown. 
The child was premature and, although nursed by the mother and making satis- 
factory progress in nutrition, had shown since birth a tendency to attacks of mild 
cyanosis. Without any illness or the occurrence of anything of a nature to explain the 
seizure this child suddenly became markedly cyanosed. Respirations ceased and 
life was despaired of. Under active stimulation and artificial respiration by the trained 
nurse in charge respiration was with much difficulty re-established. During the next 
few weeks there were attacks of cyanosis of a less serious nature. Roentgen-ray treat- 
ment was then carried out. There were no further attacks of cyanosis and the child 
made a complete recovery. 
A number of the senior author’s cases have been similarly treated by Dr. Lewis 
Gregory Cole, of New York, with most gratifying results. 
None of the cases in which x-ray therapy was employed proved fatal, 
although in some the symptoms were most severe. After five treatments, 
usually, the child will remain well. 
Surgical Treatment— Removal of the thymus has been practised on 
a limited scale with unsatisfactory results. The mortality is high and 
with the thymus removed there is the probability of defective growth 
and development as has been observed in thymectomized animals. 
The Pituitary Gland 
The physiology of the pituitary gland is most complex. According 
to prevailing belief the anterior lobe exerts a specific influence upon body 
growth while the posterior lobe is concerned in the metabolism of fats and 
carbohydrates and the secretion of urine. Alterations in the amount of 
the internal secretion of a part or the whole of this gland are explan- 
atory of surprising departures from the normal in both chemistry and 
development. 
This disease represents the manifestation in the organism of dimin- 
ished function of the anterior lobe of the pituitary gland. The loss of 
DYSPITUITARISM. DYSTROPHY ADIPOSOGENITALIS (FROHLICH) 476 
THE PRACTICE OF PEDIATRICS 
function, according to Cushing1 may be due to tumor pressure or disease. 
This portion of the gland is associated with the metabolism of fat, and 
with sexual activities, and is closely related with the functions of all the 
other ductless glands in the body. Sexual infantilism is ascribed to 
diminished secretions of the pituitary body, inadequate to activate 
testicular and ovarian functions. 
Symptoms.—In this disease the patient is short in stature, very fat 
and with a marked lack of sexual development, the penis and testicles 
in boys remaining almost infantile in size. There is an absence of pubic 
hair in both sexes. Boys show decidedly feminine characteristics. 
Polyuria and excessive tolerance for carbo- 
hydrates are observed. Badiographs of the head 
may disclose a small sella turcica, indicating a 
smaller than normal pituitary gland. 
Of 6 cases of dyspituitarism coming under 
personal observation, 5 were those of boys, rang- 
ing from eight to sixteen 3rears. 
Treatment.—The administration of the an- 
terior lobe extract is advised in hypopituitarism. 
Cushing found that many of these cases have 
been benefited in the past by thyroid adminis- 
tration, due to an indirect reawakening of the 
functions of the hypophysis and possible second- 
ary endocrine activities. 
Fig. 88.—Nine-year-old 
boy weighing 94 pounds, 
with manifestations of 
dyspituitarism. (Seaside 
Hospital.) 
Fig. 89.—Sella turcica of boy shown in Fig. 88. 
The administration of thyroid in small doses, £ grain three times 
daily with 3 grains of anterior lobe extract, has shown no appreciable 
results in the writer’s cases. 
ACROMEGALY AND GIGANTISM 
The first of these conditions is very rare in childhood, but appears 
closely related to the second in which delay in ossification of the young 
1 Jour. Amer. Med. Assoc., July 24, 1909, p. 249. INFANTILISM and dwarfism 
477 
skeleton permits of great increase above the normal in the skeletal measure- 
ments. Acromegaly occurs after the completion of ossification and is 
therefore not productive of increase in height characteristic of gigantism. 
Both abnormal conditions are ascribed to pathological changes affecting 
the pituitary gland and productive of excessive secretion. Tumor forma- 
tion of various types may be causative of the abnormality. 
One case of undoubted acromegaly involving the bones of the face and particularly 
the lower jaw has been observed by the senior author in a boy of twelve years. 
Disease of the Pineal Gland 
Pineal gland involvement is rarely recognized but has been found due 
to the presence of cysts, gummata, and tumors. The diagnosis in child- 
hood rests on the association of brain tumor manifestations with those 
of abnormal and early sexual development of the body, indicated by early 
growth of hair on the face and genitalia, enlargement of the testicles or 
breasts, obesity and at times mental precocity. These symptoms contrast 
markedly with those typical of the pituitary infantilism known as “Froh- 
lich’s syndrome” (p. 475). 
Diseases of the Suprarenal Glands 
ADDISON’S DISEASE 
This rare condition is only occasionally observed in childhood and 
conforms closely to that found in adult life. 
Pathology.—The typical lesion is some form of tubercle of the adrenal, 
although other lesions have at times been found. The association of tuber- 
culosis elsewhere in the body is common. 
Symptoms.—Briefly, these comprise anemia, asthenia, headache, 
vomiting and other digestive disturbances, and low temperature with 
the significant added sign of bronze pigmentation of the skin usually 
involving first the face and hands. 
Course and Prognosis.—The disease is almost invariably fatal within 
a few months after the diagnosis is made. 
Treatment.—The administration of suprarenal gland extract may be 
tried but is usually ineffective. 
TUMORS OF THE ADRENAL GLAND 
Various new growths have been reported of both epithelial and con- 
nective-tissue origin. A rare form, known as cortical hypernephroma 
and exhibiting the cellular characteristics of the tissue of the suprarenal 
cortex, is productive of marked changes in sexual characteristics, female 
subjects exhibiting the masculine type of development and males show- 
ing precocious development of the male sex character. 
General Developmental Disorders Attributed to Endocrine 
Dyscrasia 
INFANTILISM AND DWARFISM 
The type of infantilism described by Herter has Teen referred to in 
the chapter on Intestinal Diseases (page 266). 478 
THE PRACTICE OF PEDIATRICS 
In dwarfism there is an undervelopment of all parts of the body, 
both of the skeleton and of the soft parts. It cannot be doubted that 
this condition is purely dependent upon a congenital tendency, but the 
same effects can be produced, at least in so far as the inhibition of growth 
is concerned, by harmful influences exerted during the period of devel- 
opment and growth. Thus one cannot always tell with certainty whether 
an abnormal bodily growth is dependent upon a congenital tendency 
or upon pathologic influences during the period of growth. 
A true dwarf is a person of small stature, not deformed, whose de- 
velopment has proceeded symmetrically and at a normal rate (except 
as regards extent) in comparison with other races, families of the same 
race, or members of the same family. According to Sainton, a dwarf 
should not exceed 59 inches (1.5 meters). His best illustration is the 
race of pigmies in Central Africa, whose height is about four feet. In 
them the dwarfing is not due to any pathologic process. Sexual devel- 
opment, epiphyseal union, and ossification take place at the usual time. 
Symptomatic infantilism or dwarfism is a term used for dwarfism 
associated with delayed ossification, dentition, and sexual development. 
It is usually the result of some illness or disturbance of nutrition which 
interferes with growth. In these cases the body is undeveloped, weak, 
and slender. Usually there is both mental and physical delay. The 
common causes are general dystrophies, congenital heart disease, tuber- 
culosis, and syphilis. This condition may also be due to a deficiency of 
the internal secretions, rickets, spinal caries, and lateral curvature. An- 
other type which is described by Loraine is due to a congenital non- 
development of the arteries (an angioplasia). 
According to Hastings Gilford, true dwarfism (ateliosis) is divided 
into two groups—asexual and sexual. The subjects are well propor- 
tioned, with childish faces and intelligence, irregular and backward 
teeth, small bones and muscles, and an imperfect sexual system. In the 
first type the whole body is affected, but the sexual organs are the most 
backward. The arrest in development may occur at any time of life. 
There is usually but one subject in a family. The body proportions, con- 
tour, and intelligence are those of a child, and the testes are commonly 
undescended. In sexual ateliosis the development is always delayed 
until puberty. The epiphyses then unite and the sexual organs mature 
normally. The child resembles a miniature adult, but retains the phy- 
siognomy, proportions, and stature of a child. These patients differ from 
physiologic dwarfs (pigmies) in the retention of many childish char- 
acteristics. Sexual ateliosis is frequently hereditary, and some of the 
affected individuals may have children with dwarfism of the asexual 
type, thus suggesting a relationship between the two. 
In progeria the changes characteristic of senility occur in subjects 
who are in the adolescent or young adult period of life. 
Cretinism and chondrodystrophy are treated under separate headings. 
The cases are often classed with those of dwarfs, but do not represent 
true dwarfism, as the subjects are dwarfed in stature only, and in the 
cretin growth takes place under thyroid therapy if the case is seen early 
in life. THE DIFFERENTIATION OF ENDOCRINE DISORDERS 
479 
OBESITY 
Exceedingly fat children will usually be found to be hearty eaters, 
of inactive habits. The influence of dysfunction of the pituitary and 
thyroid in the causation of certain forms of obesity is not to be forgotten. 
Obesity is rarely a serious condition, and ordinarily requires little 
more than certain restrictions in diet, and regularity in exercise. Gen- 
erally, this is not difficult to obtain, as the patients are usually very 
anxious to reduce the weight because of the attention they attract and the 
remarks the condition occasions in public places and among school- 
fellows. 
Treatment.—Diet.—All fatty foods, including butter and whole 
milk are to be excluded from the diet. Skimmed milk may be given in 
moderation—not over one pint daily. A portion of this may be used on 
the cereal, and the remainder as a drink. The use of sugar, including 
candy and sweets of all kinds, is to be forbidden. Saccharin may be 
used dissolved in the milk on the cereal and in making stewed fruits and 
plain puddings palatable. Green vegetables may be given freely. The 
evening meal should be very light, consisting usually of broth, a small 
amount of stale bread, and stewed fruit. 
Exercise.—During the warmer months golf, swimming, tennis, horse- 
back exercise, and the bicycle are to be advised, a definite time, in hours, 
being prescribed each day for some active physical exercise. During 
the cold months roller-skating, ice-skating, horseback-riding, out-of- 
doors when possible and indoors on inclement days, when the means 
are at hand, together with long walks, should occupy part of the daily 
life. A schedule should be prescribed and written out for each day, 
depending somewhat upon the station in life of the patient, not only 
specifying the food, but also the outdoor exercise. In this way, under 
an established system of living covering the entire day, there will result, 
if the family co-operate, a reduction of the obesity with marked improve- 
ment in the patient’s general condition. 
During the treatment the child should be weighed regularly, as too 
pronounced results are not desired. 
Drugs.—The use of thyroid extract and other drugs for the reduc- 
tion of weight in children is not to be advised. 
The Differentiation of Endocrine Disorders 
The subject of endocrinology is still in its infancy and requires con- 
sideration in a sphere apart from that belonging to the ordinary pedi- 
atric text-book. The facts already presented suggest the extent to which 
the physician must occasionally go in his consideration of the atypical 
child before arriving at a correct case classification. For the purpose 
of facilitating differentiation, the following table is quoted from an ex- 
haustive review by Mark S. Reuben.1 
1 Dvsendocrinism in Children, Amer. Jour, Dis. Child.. August, 1915, vol. x, No. 
2, pp. 141, 142. , 480 
THE PRACTICE OF PEDIATRICS 
oidism 
Hypergonadism — Tumors 
Precocious maturity — 
Functional 
Thymus: 
Hypothymism — Status 
thymolymphaticus 
Pineal: 
Hyposecretion 
Pancreas: 
Hypopancreatism — Dia- 
betes mellitus 
Pluriglandular Disease: 
Hyposecretion, gonads, 
para and thyroid hypo- 
adrenals 
Hypersecretion 
Hyposecretion — Addison’s 
disease 
Gonads: 
Hypogonadism — Eunuch- 
Parathyroids: 
Chronic hyposecretion, lat- 
ent tetany 
Adrenals: 
T. 
3 
Pituitary: 
Hypersecretion of anterior 
lobe types, Marie and 
Launois 
Hyposecretion of posterior 
lobe, type Frohlich 
Hyposecretion of anterior 
and posterior lobes type, 
Burnier 
Hyper of posterior and 
hypo of anterior lobe, 
diabetes insipidus 
Thyroid: 
Hypersecretion — Base- 
dow’s disease 
Hyposecretion — Cretin- 
+ 
+ • + • • 
+ 
: : + 
Dwarfism. 
+ • + ++ 
+ 
+ : : 
: + 
Skeletal overgrowth. 
£ 
<D 
+ 
+ + + + : : 
+ 
+ + 
: + 
+ : 
Skeletal under- 
growth. 
b“ 
• o 
p 
0 
: + : + +: 
+ 
+ : : 
Premature union of 
epiphyses and os- 
sification. 
V 
<5 
p 
a 
c 
+ 
• • + • • + 
+ + 
+ + 
+ + 
Delayed union of 
epiphyses and os- 
sification. 
2. 
P. 
: + : + +: 
+ 
Genital hyperplasia. 
3 
5' 
O 
cr 
£ 
+ 
+ : + : : + 
+ 
: + 
+ + + 
+ + 
Genital hypoplasia. 
: + : + + : : : : : : : : : 
Sexual precocious- 
ness. 
o 
p 
+ 
+ • • • • + 
+ 
: + 
: + + 
+ + 
Impotence. 
3 
O 
+ 
• : + + + ++ 
+ 
: + 
: : + 
+ ’• 
Adiopsity. 
0 
p 
•-< 
+ 
: + : : : : 
+ 
: + 
: : + 
+ : 
Increased carbohy- 
drate tolerance. 
0 
+ : : : : : 
+ 
+ : 
+ + : 
: + 
Glycosuria. 
O 
gr 
: + : + +: 
+ 
: + 
Hypertrichosis. 
► 
+ 
+ : + : + 
+ + 
: : + 
+ : 
Hypotrichosis. 
!N 
C 
cc 
: + : : : : : : : : : : : : 
Mental precocity. 
CC 
: : + : : 
+ 
+ 
+ 
Mental dulness. 
<5 
0^ 
+ 
• • • + 
+ 
: + 
: : + 
+ : 
Hypothermia. 
X 
*0 
+ : : 
+ 
+ : 
+ + : 
: + 
Hyperthermia. 
+ : : : 
+ 
High blood-pressure. 
? 
4- 
-1 
•+ 
• : : : + 
+ 
+ + 
+ : + 
+ + 
Low blood-pressure. 
+ 
+ + 
+ 
4* 
+ 
+ : + 
+ + 
Pigmentation. 
-f 
+ : : 
+ 
+ : 
+ 
Asthenia. 
: + : 
+ + 
+ + 
Cerebral symptoms. 
. -0 
: + + 
+ + 
Sellar deformation. 
: : : + : 
Tachycardia. 
+ 
+ : 
Tremor. 
+ 
+ 
Spasmophilia. 
-f 
+ 
+ + 
Polyuria. 
Table of Various Conditions Due to Disturbance of Ductless Glands1 XV. THE UROGENITAL SYSTEM 
The Urine 
Tables dealing with the frequency of urination and the specific 
gravity of the urine for the different ages of childhood are necessarily 
inaccurate, particularly when they refer to children under one year of 
age. 
Urinary Observations.—At the New York Infant Asylum several 
years ago Dr. George T. Myers, at that time resident physician, made 
a series of investigations relating to the various phases and functions 
of the newborn infant, with results which differed from some of the ob- 
servations previously recorded. The series comprised 45 cases. Among 
other observations was one as to the time of the first micturition after 
birth. It was found that the time varied greatly. In 15 cases mic- 
turition occurred simultaneously with birth; in 10, in less than four 
hours; in 8, in from four to eight hours; and in the remainder, ranged 
between eight and eighteen hours after birth. In but 2 cases was 
the interval longer than fourteen hours. It was also found that the 
specific gravity, the frequency of urination, and the amount of urine 
passed were subject to wide variations within normal limits depending 
upon whether the infant was breast fed or bottle fed, whether a girl 
or a boy, and whether, if the baby was breast fed, the mother had a 
scanty or a free flow of- milk. The bottle fed always passed more urine 
than the breast fed. The quantity of urine is also influenced by the 
clothing worn and by the season of the year. 
Normal variations occur, therefore, within very wide limits. One 
child will urinate every thirty minutes when awake; others, of equal 
health and age, will retain the urine for three hours. Before the child 
takes much fluid, particularly in the first days of life, from 2 to 5 
ounces is probably passed in twenty-four hours, with a specific gravity 
of 1.005 to 1.010. Infants urinating very frequently are apt to develop 
into bed-wetters in later life, probably owing to the undeveloped condi- 
tion of the bladder, the size of that viscus remaining small. In other 
respects, very frequent urination, in the absence of signs of illness, is 
of no significance in the young. After the feeding is established the specific 
gravity will range from 1.003 to 1.012 from the second week to the second 
year. A baby nine months old will pass an average of about 12 ounces 
of urine in twenty-four hours. At the sixth year, from 16 to 25 ounces 
with a specific gravity under 1.015 will be passed. From this age until 
puberty both the quantity and specific gravity gradually increase, the 
usual range in specific gravity being from 1.010 to 1.020. 
Method of Collecting Urine.—The collection of the amount voided 
in twenty-four hours by children of the “runabout” age is difficult, and 
in young infants well-nigh impossible, except in a metabolism bed. For 
accurate work the specimen should be obtained by the catheter. When 
481 482 
THE PRACTICE OF PEDIATRICS 
for any reason this is not possible, there are various devices for collecting 
the urine, any one of which may be tried. The Chapin urinal and the 
Spicer1 urinal are satisfactory forms. The tying on of a wide-mouthed 
bottle or a condom in boys, fastening it with adhesive strips to the body, 
is often successful. Absorbent cotton into which the child urinates, 
the urine being expressed from this into a bottle, may be used for either 
boys or girls, as may also the Chapin collector. The chief disadvantage 
of any of these measures is the certainty of contamination. The urine 
so collected may answer for an examination for albumin, sugar, or the 
renal elements, but is useless for a bacteriologic study. 
Continence Established.—From the second to the third year conti- 
nence at night is usually established. If incontinence continues after 
the third year, the case should be looked upon as abnormal and receive 
treatment accordingly. (See Incontinence of Urine, p. 484.) 
DYSURIA (DIFFICULT AND PAINFUL URINATION) 
Difficult urination is of frequent occurrence in infants and “runabout” 
children as a result of scalding at the urethral meatus from irritating 
urine. The irritation may be due to lack of cleanliness, and in boys with 
long foreskins which remain moistened, permitting the urine to decompose 
in contact with the skin, a considerable degree of inflammation may result. 
On the other hand, properly circumcised boys may develop a minute 
ulceration of the meatus urethrae, which shows a tendency to encrustation 
and may be most annoying. In girls dysuria is often due to hardly 
discernible inflammation about the orifice of the urethra, occurring in 
association with vulvitis or vaginitis. 
In 2 cases calculi were found in the urethra. Both patients were boys about five 
years of age. 
Treatment.—Relief of phimosis and adhesions whenever they exist is 
strongly indicated, and in most instances circumcision will be found bene- 
ficial as a preventive measure. Cleanliness is very essential in all cases, 
and the saturation of the diapers with boric acid solution before final 
drying, as recommended by Cooke (p. 102), must be insisted upon for 
relief of the local irritation accompanying the dysuria of infants. Locally 
the application of boric ointment or castor oil and balsam of Peru may 
fulfil all the requirements of a case, but occasionally, where there is actual 
ulceration, the use of one or more applications of 20 per cent, silver nitrate 
solution may be necessary. 
In all cases of dysuria alkalinization of the urine by the administration 
of sufficient sodium bicarbonate or citrate is advisable, and at times 
small doses of sweet spirits of niter and tincture of belladonna, frequently 
repeated, may prove of value. 
SUPPRESSION AND RETENTION OF URINE 
In using the above terms with reference to diseases of the urinary- 
organs it is well to appreciate their significance. By suppression is meant 
1 Jour. Amer. Med. Assoc., June 5, 1915. SUPPRESSION AND RETENTION OF URINE 
483 
a condition of anuria in which no urine is passed into the bladder, that 
viscus being found empty on catheterization. In retention the urine 
is secreted by the kidneys and passed into the bladder, but is not voided. 
When the urine is not voided, we must always ascertain whether there 
is suppression or retention. If there is retention, this fact may usually 
be discovered by palpation and percussion. In dealing with fat children 
a positive diagnosis may be impossible by this means. In the event 
of doubt a catheter should be employed. For infants under one year 
of age a soft-rubber, No. 4 or 5 American catheter should be used. The 
bladder of the infant and young child is very readily infected and care 
should be exercised to have the catheter sterile. If suppression is diag- 
nosed and treatment by diuretics is instituted, when actually there is 
simple retention, no little trouble will result. 
Suppression of the urine may persist for hours without any grave 
pathologic condition of the kidneys. Chilling of the skin surface may 
be a cause. In acute gastro-intestinal disorders with frequent vomiting 
and watery stools suppression may exist for twenty-four hours. The 
secretion is re-established when there is again available fluid to be 
added to the circulation from the digestive tract. If the suppression 
is due to causes of a grave nature, such as acute nephritis, there will 
usually be signs of other trouble, such as vomiting, fever, and edema. 
Retention may result from an injury to the urethra, or from vagi- 
nitis, or from phimosis. Impacted stone in the urethra was a cause in 
two boys already mentioned. Fortunately, in each case the stone was 
located near the meatus and readily removed. 
Treatment.—Suppression.—Colon flushing is one of the most effective 
measures of relieving suppression of the urine. The apparatus required 
and the methods employed are described on page 857. If the temperature 
of the patient is not above 102° F., normal salt solution, at a temperature 
of 110° F., is advised. We have always found flushing more effective 
when this degree of heat was used. One pint is introduced for a child 
three years of age. In children of one year or under, from 4 to 8 ounces 
is all that will be retained. The enema must not be repeated, however, 
oftener than once in six or eight hours, as the colon of a child soon be- 
comes intolerant of the injections and but little will be retained. Re- 
peatedly, after the first injection, the kidneys have resumed activity 
when other means had failed. 
This method has been particularly useful in cases following or ac- 
companying the exanthemata, when there was an acute nephritis with 
greatly diminished secretion of urine. A large hot poultice of flax-seed 
meal about 2 inches thick and sufficiently large to cover the lumbar and 
lower dorsal regions will often act surprisingly well in re-establishing 
the kidney function. The treatment should be continued for at least 
one hour, using three poultices during this time. 
Retention.—The immediate relief of retention is by catheterization. 
Further treatment consists in the correction of the exciting cause. If a 
catheter is not at hand, the application of a hot stupe over the lower 
portion of the abdomen and the genitals or the administration of a warm 
saline enema may be sufficient to stimulate urination. 484 
THE PRACTICE OF PEDIATRICS 
INCONTINENCE OF URINE (ENURESIS) 
In enuresis there is an involuntary emptying of the bladder. 
Enuresis diurna is the involuntary emptying of the bladder during 
the waking hours. 
Enuresis nocturna is involuntary urination during sleep. 
Involuntary discharge of the urine is normal in the young infant. 
Urination becomes a voluntary function at an age depending largely 
upon the child’s training. In most children, with the right kind of man- 
agement, the function may be controlled during waking hours by the 
tenth month. 
During sleep, involuntary urination continues to a later period, and, 
while in many perfect control may be established at the completion of 
the second year, one need not regard the lack of control as abnormal until 
the third year is completed. If, during the second year, the child shows 
a tendency to frequent urination and involuntary passage of urine dur- 
ing the waking hours, with habitual incontinence at night, it is important 
to advise preventive measures. 
When the incontinence persists during the waking hours at the com- 
pletion of the second year, or during sleep at the completion of the third 
year, the condition is to be regarded as abnormal and the child placed 
under treatment. 
Etiology.—Deformities and Abnormalities.—The condition may be 
due to a congenitally small bladder, with very little holding capacity. 
A girl who came under treatment for incontinence by day and night had a bladder 
the holding capacity of which was but one ounce. 
With such lack of development of the bladder, obviously there must 
be incontinence. In spina bifida it may occur as a result of paralysis of 
the pudic nerve supply to the neck of the bladder. z-Ray in some in- 
stances of incontinence will reveal an unsuspected incomplete spina bifida 
without external evidences. A congenitally large urethra may also be 
a cause. 
Peripheral causes acting through reflex irritation are not infrequently 
encountered. Thus, incontinence may be due to a vaginitis, to an adherent 
clitoris, or to phimosis. Other possible causes are thread-worms in the 
rectum, constipation, stone in the bladder, cystitis, and hyperacidity 
of the urine. 
The diet may also play a part. The use of highly nitrogenous food 
in large amounts or a diet rich in sugar may lead to changes in the urine 
sufficient to cause the trouble. 
Excessive bed-clothing and the habit of sleeping on the back have a 
bearing in the causation. 
Adenoid vegetations in considerable amount in the nasopharyngeal 
vault are looked upon by some authors as an etiologic factor. 
Children afflicted with diabetes insipidus (polyuria) or diabetes mellitus, 
because of the large amount of urine passed, are very apt to suffer from 
incontinence. 
Weakness of the sphincter is supposed to play a part in causing in- 
continence, particularly loss of control when awake. INCONTINENCE OF URINE (ENURESIS) 
485 
Cases of Nervous Origin.—The nervous control of the bladder is de- 
pendent upon a cerebral center and a sacral center, each receiving and 
sending out impulses. 
It is not difficult to understand how a lack of co-ordination from 
faulty development of the sympathetic mechanism might occasion in- 
continence. After all possible dietetic errors and irritations acting re- 
flexly through the above nerve mechanism are excluded, about 90 per 
cent, of our cases remain unexplained. This group represents the cases 
usually chronicled as due to a neurosis or absence of co-ordination due 
to failure of sufficient development of the nerve centers. 
Diagnosis.—The patient always has a ready-made diagnosis. 
Prognosis.—The prognosis depends largely upon the physician and 
the child’s parents or attendant. Great patience and persistence are 
necessary. All cases are curable except when an anatomic abnormality 
exists. In many instances the response to treatment is very prompt. 
In others it is tedious, several months being required before we are sure 
that the cure is complete. 
A fact to be taken into consideration in making a prognosis as to 
the probable duration of the treatment in a given case is the size of the 
bladder, since a child who has suffered from incontinence both by day 
and night may have a small and contracted bladder, because of lack of 
development from disuse. The most reliable means of determining 
the size of a bladder is by measuring the amount of sterile water which 
can be introduced through a catheter. 
Treatment.—In assuming the care of a child with enuresis, obviously 
it is most necessary to learn the cause of the trouble. Two or three ex- 
aminations of the urine should be made, and if it is found persistently 
acid and of a specific gravity over 1020, a reduction in the nitrogenous 
food-stuffs is necessary before beginning medication. If the enuresis 
is due to peripheral causes, they must be corrected and the general phys- 
ical condition of the child improved, although in our experience the 
delicate and chronically ailing are not the children who are the greatest 
sufferers, by far the larger number of such patients having been well- 
nourished children who were otherwise normal. Long-continued incon- 
tinence does not appear to affect the general health. The condition, if 
untreated, uually continues until the child is eight or ten years of age. 
We have known of a few cases which persisted until puberty, or later. 
If no improvement follows the removal of all possible dietetic and 
extrinsic causes — as acidity, phimosis, worms, constipation, etc.—we 
must assume that we have an idiopathic incontinence to deal with. If 
the case is one of nightly incontinence of several months’ or years’ stand- 
ing, we must positively acquaint the mother with the fact that prolonged 
treatment will in all probability be required, and that unless her active 
and continued co-operation is assured the treatment of the case will not 
be undertaken. 
With the very definite understanding that no brilliant results are 
immediately expected, the following scheme of management is inaugu- 
rated: The child receives three meals daily. The breakfast and dinner 
correspond to the age of the child, but with the important exception 
that red meat is to be given but once during the twenty-four hours, and 486 
THE PRACTICE OF PEDIATRICS 
only at midday. The supper, which should not be later than six o’clock, 
we designate as a “dry supper.” It may consist of any cereal, such as 
rice, hominy, farina, or wheatena, served with butter and sugar. If 
this is not well taken, a small quantity of both sugar and milk may be 
added. Permissible articles for the evening meal in addition to the above 
are ice-cream, milk toast, blanc-mange, raw fruit, jelly, stewed fruit, 
bread and butter, junket, and cornstarch. Meat, eggs, or heavy foods 
of any kind should not be given at night. 
Abstinence from Fluids.—At 4 o’clock in the afternoon the child may 
be given a half-glass of water or milk, but after this time no fluids are to 
be allowed other than a scant ounce of milk on the cereal. The with- 
drawal of all fluids after 4 p. m. will at first be a hardship for some chil- 
dren, and they may be allowed 3 or 4 ounces of milk or water with the 
evening meal; but this quantity should gradually be diminished until 
at the end of a week it will not be missed. 
Night Management.—The patient should be as lightly covered at 
night as comfort will permit. There is less tendency to incontinence 
if the child rests on the side or stomach, and sleep in this position should 
be encouraged. In dealing with inveterates, for whom every possible 
aid is brought into use, one may use the knotted towel as a means of 
keeping the child off his back. The towel, knotted in the middle, is 
passed around the child so that the knot will rest on the back. The ends 
of the towel should then be pinned together over the abdomen like those 
of an abdominal binder. When the patient attempts to rest on the back 
the knot causes discomfort and the position is changed. At 10 or 11 
o’clock, when the person in charge retires, the child should be taken up 
to urinate. 
Drugs.—Without a strict observance of these regulations, particularly 
those relating to diet and abstinence from water after 4 p. m., drugs 
are of no value, whatever their method of administration. With the 
above suggestions carried out, we have one remedy which is of real 
value, and that is belladonna. For convenience of administration we 
prefer the alkaloid, atropin. To insure full benefit in severe cases the 
drug must be pushed until the physiologic effect is obtained, as shown 
by slight dilatation of the pupils. Before beginning the treatment it is 
well to advise mothers that redness of the face need cause no alarm, 
but calls for the discontinuance of the drug until further instructions 
are given. The atropin is administered in a solution of one grain to an 
ounce of water; 1 ounce of water contains approximately 500 drops, 
so that 1 drop of the atropin solution will contain approximately 1/500 
grain of the drug. The mother is given a chart containing the directions 
for administration, which for a child five years of age are as follows: 
Day. 
4 P. M. 
7 r. m. 
1st 
1 drop 
2d . : 
1 “ 
1 “ 
3d 
1 “ 
2 drops 
4th 
2 drops 
2 “ 
5th . 
2 “ 
3 “ 
6th 
3 “ 
3 “ 
7th 
3 “ 
4 “ 
8th 
4 “ 
4 “ 
9th 
4 “ 
5 “ 
10th 
5 “ 
5 “ HEMATURIA (BLOOD IN THE URINE) 
487 
The maximum dose given is 1 drop daily at 4 and 7 p. m. for every 
year of age. Thus, for a child three years old the dosage should not 
be greater than 3 drops, twice daily; for a child six years old not over 
6 drops, twice daily. It may be well, if the case is not under close obser- 
vation, to make a more gradual increase in the dosage, so as to avoid 
the possibility of unpleasant physiologic effects. 
It is never necessary to exceed these doses even with older children, for 
the reason that the amounts given are ordinarily sufficient to control the 
enuresis; and the dilated pupils and belladonna blush which follow an 
increased dosage show that such increases are imprudent. 
The tolerance of atropin varies considerably, although children usually 
bear it very well. Now and then a child is treated who cannot take more 
than 2 drops (1/250 grain) daily. To one boy eight years of age but 
1/200 grain could be given twice daily. 
Pronounced benefit, ordinarily, will not be observed during the first 
week or two of treatment. If the child suffers from incontinence while 
awake, this, ordinarily, will first be cured. The improvement in nocturnal 
incontinence is more gradual and may be considerably delayed. Thus, 
no improvement whatever may be seen for two or three weeks. In the 
average case the improvement is gradual. At first there will be nights at 
short intervals when there will be very slight incontinence, or none at all. 
Usually, after a few weeks’ treatment the incontinence entirely ceases. 
The mistake frequently made is to stop the atropin at this point. 
When this is done there is usually an immediate return of the trouble. 
The full treatment should be continued until the child has not wet the 
bed for at least two weeks. The daily amount of atropin should then 
be reduced one-half and kept at this point for six weeks. If at the end 
of two months from beginning treatment there is no incontinence, the 
drug may be discontinued, but the dietetic restrictions, particularly 
the “dry supper,” should be maintained three months longer. It must 
be remembered that the habit which has become established is hard to 
overcome, even after the neurosis and the weakness of the sphincter 
have been corrected. 
Strychnin and tincture of cantharides have been advocated by pedi- 
atric writers. For weak, poorly nourished children strychnin added 
to iron or cod-liver oil may be of service in improving the general condi- 
tion of the patient, and indirectly aid in the treatment of the enuresis. 
When incontinence occurs only during the day, the dietetic regula- 
tions are the same as those given, with the exception that the fluids al- 
lowed need not be curtailed unless the quantity is excessive. The dosage 
of atropin is the same, but the time of administration should be changed 
to after breakfast and after luncheon, instead of at 4 and 7 p. m. In 
addition to the atropin, strychnin should always be given in cases of in- 
continence by day, for in such cases a lack of development or a relaxation 
of the sphincter is more of a factor than is failure of nerve co-ordination. 
HEMATURIA (BLOOD IN THE URINE) 
The presence of blood in the urine may be due to readily discernible 
causes; or when small (microscopic) amounts are present, the cause may 
be most difficult to determine. 488 
THE PRACTICE OF PEDIATRICS 
Highly concentrated urine may be sufficiently irritating to produce 
the passage of microscopic amounts of blood. Blood and albumin are 
not of infrequent occurrence in the urine of the newborn and during the 
first weeks of life, because of the presence of uric acid in large amounts 
peculiar to this period of life. 
Among the possible causes of blood in the urine are: 
Acute nephritis. 
Hemorrhage neonatorum. 
Hemophilia. 
Purpura hsemorrhagica. 
Scurvy. 
Trauma. 
Calculi. 
Malignant growth of the kidney. 
Tuberculosis of the kidney or bladder. 
Certain drugs taken into the stomach. 
In this condition the urine contains the coloring-matter of the blood, 
with few, if any, corpuscles. There may be a small amount of albumin. 
The urine may be light red, brown, or even black. 
In a child one year old who died from creosote poisoning the urine was almost black, 
the color being only in part due to the salts derived from the drug. 
In another case of a child three years of age with malaria the urine was of a deep 
brown color. 
Paroxysmal hemoglobinuria is of very rare occurrence in this country. 
In tropical countries, where severe forms of malaria are common, the 
condition is not unusual. It is due to some toxic agent which dissolves 
the coloring-matter out of the blood. Syphilis is one cause. 
HEMOGLOBINURIA 
PYURIA 
Pus in the urine in the young is usually the result of a pyelocystitis 
or pyonephrosis. (See pp. 505 and 491.) 
Illustrative Case.—A hospital patient, about eighteen months of age, showed 
periodically large amounts of pus in the urine. Pus would be present in the urine 
for a few hours, and then, for two, three, or more days, the urine would be perfectly 
clear and free from pus. 
Autopsy showed that although one kidney wras normal, the other had undergone 
cystic degeneration, the pelvis being greatly dilated and filled with pus. The ureter 
was thickened and partially occluded. When the sac had become filled with pus, and 
the child was in a favorable position, the pus promptly discharged into the bladder. 
Pyelonephritis may be the result of a pyelocystitis. 
Illustrative Case.—A child eleven months of age had pyelitis, evidently primarily, 
which had not been recognized. The temperature ranged very high—105° to 107° 
F.—and the child died from exhaustion and anemia. Autopsy revealed an extensive 
pyelitis with multiple abscesses scattered throughout the kidney structure, varying 
in size from a pin-point to a pea. 
Such cases as the foregoing, it is understood, are of very unusual 
occurrence. In still rarer instances the pus may be due to an abscess GLYCOSURIA 
489 
(phrenic or of another type), which may open into the urinary tract. 
When pus is present in the urine, the source is usually the bladder (cystitis) 
or the pelvis of the kidney (pyelitis). 
Specific urethritis (gonorrhea) will give rise to pus in the urine. Gon- 
orrhea, however, is of very unusual occurrence in boys, and when present, 
is sufficiently active to leave no doubt as to the nature of the trouble. 
GLYCOSURIA 
Temporary glycosuria or dietetic glycosuria is of frequent occurrence 
and little significance. This condition usually means that more carbo- 
hydrate is being taken than can be cared for by the economy, and with 
a discontinuance of the excessive intake the sugar disappears from the 
urine. 
Illustrative Cases.—In a series of observations made several years ngo at the Country 
Branch of the New York Infant Asylum, 10 children were selected for high-sugar feed- 
ing, and 10 per cent, sugar mixtures were given to those under one year of age. Every 
case showed glycosuria after twenty-four hours of this feeding. 
Two most interesting cases of persistent glycosuria without any other manifesta- 
tion of illness have been under observation for over twenty years. That sugar existed 
in the urine of both patients was discovered by accident. How long the sugar may 
have been present we have no means of knowing. The mother, an unusually careful 
woman, conceived the idea that it would be wise to have the urine of all her 4 chil- 
dren examined, and greatly to the writer’s surprise it was found that two specimens, one 
from a boy of four years, the other from his brother of six, contained a large amount of 
sugar, 3 and 3.5 per cent, respectively. A careful examination was at once made of 
both patients, but revealed nothing abnormal. The children were strong; there was 
no unusual thirst and no polyuria, and, further, the examination of the urine failed to 
reveal the presence of either acetone or diacetic acid. They were placed on a rigid 
antidiabetic diet (p. 787), which reduced the sugar to 1.5 and 2 per cent, respectively. 
During the fifteen years thereafter the boys made satisfactory physical and mental 
progress, attending school regularly, except when prevented by the usual ailments of 
childhood. Both underwent operation for adenoids and enlarged tonsils, under ether 
anesthesia, with no more than the usual discomfort. They made normal increase in 
stature, weight, and strength, and are perfectly normal in appearance. During these 
years monthly examinations were made of the urine. There was never less than 1.5 
per cent, of sugar in any specimen, the sugar rarely being below 3 per cent, or above 6 
per cent. 
The condition persisted in spite of the most carefid diet, always without the asso- 
ciation of polyuria or extreme thirst. The children were seen by several consultants 
in New York City, and were at one time under the treatment of three well-known 
specialists in Germany. Acetone has been found in the urine of one. 
Probably every variety of treatment which might be expected to exert an influence 
on the sugar production was tried for protracted periods without exerting a particle 
of influence in reducing it. Indiscretions in diet increase the sugar; otherwise it varies 
as stated above. None of the physicians here or abroad who treated the boys has 
seen similar cases. 
The cases here cited in detail are of much interest as showing the in- 
efficacy of medication and the effects of diet in glycosuria, and, fur- 
thermore, as presenting a clinical picture which is most unusual. It has 
been suggested that the glycosuria in these cases may be due to some 
persistent and unusual toxemia from intestinal sources or to abnormal 
metabolism from disordered pituitary function. Blood chemistry at the 
present is of immense value as applied to cases presenting such problems. 
Case studies today are particularly influenced by fuller understanding 
of the biochemic role of the pancreas, and growing appreciation of the 
remarkable potency of insulin. (See page 786.) 490 
THE PRACTICE OF PEDIATRICS 
The Kidneys 
TUBERCULOSIS OF THE KIDNEY 
Tuberculosis of the kidney is usually secondary to tuberculosis exist- 
ing elsewhere in the body. Primary cases, however, have been reported. 
Lesions.—In general tuberculosis miliary tubercles are scattered 
throughout the kidney. In other forms there are nodular lesions, or 
foci of caseation which may break down, resulting in the formation of 
cavities. 
Symptoms.—The symptoms of the disease are progressive weakness 
and emaciation, attended' by a low grade of fever. In many instances 
the affected kidney is enlarged and palpable. Frequency of urination 
is a characteristic symptom, and the urine may contain albumin, blood, 
or pus. The presence of blood for a considerable period in urine of normal 
specific gravity containing no casts is strongly suggestive of tuberculosis 
of the kidney. The finding of the tubercle bacillus in the centrifuged 
urine substantiates the diagnosis. Catheterization of the ureter is of 
value in demonstrating whether one or both kidneys are involved. 
Prognosis.—The prognosis is unfavorable. 
Treatment.—Tuberculin therapy, in careful hands, may be of value. 
In all cases heliotherapy and the routine supportive treatment followed 
in other forms of tuberculosis should be employed. When one kidney 
remains normal, the best results are gained by surgery involving extir- 
pation of the diseased organ. 
NEW GROWTHS OF THE KIDNEY 
Non-malignant new growths of the kidney are uncommon. Adeno- 
mata and fibromata are occasionally encountered. The adenomata are 
either papillary or cystic, and are encapsulated by connective tissue. 
These growths appear as small, light colored nodules, and, microscopically, 
present an alveolar or tubular structure. Fibromata exist as white, 
nodular masses, usually not over \ inch in diameter. They are imperfectly 
differentiated from the interstitial connective tissue of the kidney. 
Malignant.—Adenosarcomata and adenocarcinomata are two forms 
described in the literature. Herringham1 has emphasized the fact that 
the degree of malignancy of such growths cannot be accurately deter- 
mined from their histologic structure. 
Maligant neoplasms of the kidney are more common before the fifth 
year of life than in any succeeding decade.2 These tumors have been 
classified as carcinomata and sarcomata. Most of the growths, how- 
ever, are atypical mixed tumors of embryonic origin, and may contain 
striped muscle, cartilage, and lipomatous or fibrous connective tissue. 
To such forms the term rhabdomyosarcoma has been applied. 
The hypernephroma is derived from suprarenal tissue, which may be 
included in the developing kidney. This tumor is subject to great vari- 
ations in size and structure, and may resemble sarcoma, adenoma, car- 
cinoma, or perithelioma. The growth characteristically contains pig- 
1 Kidney Diseases, 1912, p. 309. 
2 Herringham on Statistics of Morris, Kidney Diseases, p. 311. HYDRONEPHROSIS AND PYONEPHROSIS 
491 
ment, which is identical with that found in the adrenal. Not infrequently 
the hypernephroma becomes cystic. 
Symptoms of Renal Neoplasms.—Malignant growths of the kidney 
often attain an enormous size, half filling the abdominal cavity and dis- 
placing certain of the contained organs. The abnormal mass is usually 
movable and occasionally communicates pulsations from the subjacent 
aorta. The edges of the tumor are more rounded than those of an en- 
larged spleen or liver, and the anterior surface is less closely related to 
the ribs. Apart from the local physical signs, the patient may exhibit 
no significant symptoms. Nutrition, however, is generally impaired, 
and in many instances the tumor occasions dragging pain and hematuria. 
Prognosis.—In untreated cases the course of the disease is progres- 
sive and its outcome fatal. Metastases, however, are of relatively slow 
development, and are preceded by involvement of the veins closely re- 
lated to the growth. 
Treatment.—Nephrectomy is the only treatment of value, and even 
this is useless when multiple metastases have occurred. 
The majority of the cases which undergo operation develop malig- 
nancy in the remaining kidney within a year or so after the operation. 
A very exceptional case was that of a two-year-old girl, a patient at the Babies’ 
Hospital in New York City. From this child Dr. Robert Abbe removed a large kidney 
sarcoma. The recovery was complete, and the patient became a perfectly well young 
woman. 
Hydronephrosis is a condition characterized by distention of the 
pelvis of the kidney with an accumulation of urine. With an invasion 
of the contained urine by the colon bacillus or other pathogenic Organ- 
isms, pyonephrosis may develop. 
Etiology.—A few cases of traumatic hydronephrosis have been re- 
ported. Ordinarily, however, the disease develops as the result of some 
obstruction in the urinary tract, either congenital or acquired. 
Congenital hydronephrosis may be due to an angular junction of 
the ureter with the pelvis of the kidney, septa'or valves in the ureter, 
an abnormally small ureterovesical orifice, twisting of the ureter by a 
floating kidney, or an imperforate urethra. 
Acquired hydronephrosis may be occasioned by inflammatory stricture 
of the ureter, an obstructing calculus, or external pressure on the ureter 
by a neighboring tumor. 
Pathology.—The ureter is dilated and perhaps sacculated above the 
site of the obstruction. The kidney is usually, but not invariably, en- 
larged, and on section will be found to be structurally deficient and more 
or less cirrhotic. The contained fluid resembles normal urine, but con- 
tains a relatively small amount of urea. In long-standing cases the 
kidney may become infected and undergo suppurative inflammation. 
In such instances the fluid contents become purulent and the condition 
resolves itself into pyonephrosis. In fact, in all the writer’s cases which 
came to autopsy—3 in number—a pyonephrosis was present. Usually 
one kidney only is involved. 
HYDRONEPHROSIS AND PYONEPHROSIS 
In two of these cases both organs were affected, the pelvis being so dilated as to be 
almost unrecognizable. In a newborn babe who died in five days both kidneys were 
enlarged, soft, and easily palpable. 492 
THE PRACTICE OF PEDIATRICS 
Chronic diffuse nephritis is frequently associated with hydroneph- 
rosis. 
Symptoms.—The significant manifestations of “dropsy of the kid- 
ney” are localized pain and tenderness, a fluid tumor in the kidney region, 
and scanty urination, which may be interrupted at intervals by the 
discharge of urine of low gravity in more than normal amount. In doubt- 
ful cases aspiration of the fluid from the tumor may facilitate the diag- 
nosis. Pus is usually present in the urine, and through cultures the nature 
of the infection may be learned. 
Prognosis.—Children suffering from bilateral hydronephrosis die 
in early infancy. When the condition is unilateral, the patient may 
survive, provided the unaffected kidney is normal. 
Treatment.—Prophylactic doses of urotropin have been administered 
to forestall possible suppuration. Surgery, however, offers the best possi- 
bilities, and the only operation of permanent value is nephrectomy. 
Illustrative Case.—An infant presented very puzzling symptoms. There was a 
periodic discharge of large amounts of urine, containing free pus, casts, and epithelial 
cells. The phenomenon occurred about every second or third day. Between times 
specimens of the urine obtained by catheter were normal. The child died from mal- 
nutrition and marasmus. At autopsy one kidney was found normal. The other 
showed a typical dilated hydropyonephrosis, with the upper two-thirds of the ureter 
dilated, sacculated, and thickened. In the lower portion there -was a congenital con- 
striction with angulation which gave way when the pressure from above became pro- 
nounced and the kidney contents were evacuated. 
CYSTS OF THE KIDNEY 
Cysts of the kidney are usually congenital, due to defective embry- 
onic development. These cysts occur in that portion of the organ which 
is developed from the metanephros. They are almost always bilateral, 
and are usually associated with a process of fibrosis which replaces a 
variable amount of the parenchyma of the affected organ. In many of 
the patients other congenital malformations coexist. 
Retention cysts occasionally arise from obstruction along the courses 
of the uriniferous tubules, and secondary cystic degeneration may be 
induced in a kidney which is the seat of a destructive primary disease. 
Hydatid cysts develop occasionally as the result of echinococcus invasion. 
Many infants with congenital cysts of the kidney die in the first 
year of life. 
Symptoms of the diseased condition are unapparent, or else are con- 
fined to the local signs of tumor, and such manifestations of urinary 
retention as edema and uremic convulsions. Wyeth held that it was a 
safe rule to aspirate the contents of a renal tumor which was large enough 
to be appreciated by palpation and inspection. If this be done, the 
fluid from congenital cysts will be found to resemble that from a hydro- 
nephrosis, that from a hydatid cyst will show the presence of hooklets, 
and that from an organ undergoing cystic degeneration will be found 
to be highly albuminous. 
When treatment of cyst of the kidney is justifiable, the procedure 
must be surgical. THE VARIOUS FORMS OF NEPHRITIS 
493 
THE VARIOUS FORMS OF NEPHRITIS 
For many years it has been customary to classify the various diseases 
of the kidney associated with albuminuria and dropsy and commonly 
designated “Brights’ disease” under separate headings to meet the dis- 
similar views of clinicians and pathologists. The problem existing in this 
situation has recently been to a large extent solved by the growing tend- 
ency on the part of various observers to adopt the classification of Vol- 
hard and Fahr.1 
In this classification the degenerative kidney conditions are designated 
as nephroses; the inflammatory, by the term “nephritis”; and the arte- 
riosclerotic processes, which are more frequent in adult life, as scleroses. 
The following tabulation includes the ordinary nephropathies be- 
longing to childhood and conforms closely to the classification of Vol- 
hard.2 
A. Nephroses: Degeneration diseases without definite inflammatory lesions: 
1. Acute nephrosis (“parenchymatous nephritis”). 
2. Chronic nephrosis. 
B. Nephritides: Inflammatory diseases: 
1. Diffuse glomerulonephritis: 
(a) Acute. 
(b) Chronic. 
2. Focal nephritis: 
(a) Focal glomerulonephritis. 
(b) Septic interstitial nephritis. 
(c) Embolic focal nephritis. 
C. Scleroses: Arteriosclerotic diseases: 
1. Benign hypertension. Pure arteriosclerosis of the kidney vessels. 
2. Malignant hypertension. Sclerosis plus nephritis (“interstitial nephritis”). 
The conditions commonly termed “acute parenchymatous nephritis,” 
“chronic parenchymatous nephritis,” “glomerulonephritis,” and “inter- 
stitial nephritis” are to be readily identified in this scheme. The present- 
day narrowing application of the terms “nephritis” and “Bright’s disease” 
should be better appreciated by the clinician. 
Four groups of nephritis in children have been described by Schwartz 
and Kohn.3 
In Group 1 were included the cases in which edema was the out- 
standing feature, developing without apparent cause and accompanied 
by little if any fever. This condition represents a nephrosis or “parenchy- 
matous nephritis.” 
In the cases of Group 2 the onset was acute with or without accom- 
panying acute disease and the course was frequently febrile with hematuria. 
These cases exemplify the various forms of nephritis grouped under 
heading B in the above tabulation. 
In Group 3 were included cases of long duration without outward 
signs of kidney disease, but subject to occasional acute manifestations. 
Heubner4 has used the term “paedonephritis” to describe the condition 
to which the prolonged cases of Group 3 apparently belong. 
To Group 4 were assigned cases presenting the symptoms of vomiting, 
1 Tice, Practice of Medicine, vi, p. 587, 1921. 
2 Die Doppelseitige Haematogischen Nierenkrankheiten, Berlin, 1918. 
3 Studies of Nephritis in Children, Amer. Jour. Dis, of Child., 24, p. 125, August, 1922. 
4 Kinderkrankh. Ed., 3, 2, p. 502. 494 
THE PRACTICE OF PEDIATRICS 
polyuria, hypertension, retinitis, and convulsions, conforming to the 
adult picture of malignant hypertension or “interstitial nephritis.” 
Chronic diffuse nephritis of the type found in adults and conforming 
to the conditions designated by the term sclerosis plus nephritis has been 
considered by Carl H. Greene1 to depend on a congenital origin. 
In Chapter XXIII (p. 828) are considered tests for renal function too 
often not employed by the practitioner in making a diagnosis of “neph- 
ritis.” These procedures together with those of a purely therapeutic 
character, discussed in Chapter XXIV, are essential to the proper hand- 
ling of individual cases. 
ACUTE PARENCHYMATOUS NEPHRITIS (ACUTE DIFFUSE NEPHRITIS) 
Nephritis, in common with many other ailments of children, may be 
either mild or severe. It may be so severe as to cause death in a few 
hours, or so mild as to pass unrecognized. In cases often classed as pri- 
mary, nephritis probably is the sequel of unrecognized scarlet fever, ton- 
sillitis, or acute mastoiditis. In recent years we have seen more cases 
in association with tonsillitis and mastoiditis than with scarlet fever, 
perhaps for the reason that in late years scarlet fever has been of a milder 
type than formerly. 
Three apparently primary cases were those of young infants three and four months 
of age in whom no previous disease had existed. All were institution children, and all 
the cases came to autopsy. 
Etiology.—In an immense majority of cases acute nephritis occurs 
as a complication of the acute infectious diseases. Nephritis is more 
frequently associated with scarlet fever than with any other ailment of 
childhood. We have observed acute nephritis complicating or following 
scarlet fever, diphtheria, tonsillitis, parotiditis, adenitis, measles, malaria, 
influenza, varicella, general sepsis, and acute intestinal infection. 
Effects of Different Toxic Agents.—Acute inflammation of the kidneys 
is caused by chemical or bacterial irritants. In the course of any local 
or general infection toxins or bacteria, or both, are excreted by the kid- 
neys, and may cause degeneration or inflammation of these organs. 
Thus pneumococci may be isolated from the urine in the course of a 
nephritis complicating pneumonia, typhoid bacilli during typhoid fever, 
and streptococci during any streptococcal infection. The bacteria are 
also found in the kidney at autopsy. The diphtheria toxin, and not 
the bacillus itself, is the cause of postdiphtheric nephritis. 
Suppurative inflammation of the kidney may be of hematogenous 
origin due to any one form of the pyogenic cocci, or it may be caused 
by an ascending inflammation from the bladder, ureter, and pelvis of 
the kidney. The latter condition is a pyelonephritis, and its almost 
invariable cause is Bacillus coli communis. 
Nephritis may develop at any time during the active stage of scarlet 
fever. It is rare before the third week, and it may be delayed for several 
weeks after. Cases not infrequently develop after the sixth week. Neph- 
ritis has been known to appear as late as three months after the acute 
1 Chronic Diffuse Nephritis in Childhood. Amer. Jour. Dis. Child., March, 1922, 
vol. 23, No. 3, p. 209. ACUTE PARENCHYMATOUS NEPHRITIS 
495 
symptoms of the primary disease have subsided. The severity of scarlet 
fever bears but little relation to the development of nephritis or the time 
of such development. In consultation practice a previously undiagnosed 
illness, with rash or stomach disturbance, has repeatedly been discovered 
to have been scarlet fever by the sequela of nephritis. 
Pathology.—The changes which occur in the kidney may be pre- 
dominantly exudative or productive in character, and may affect the 
parenchyma most severely, or be fairly well limited to the interstitial 
tissue. Digression for comparison is accordingly here made. 
In ordinary acute nephritis of the parenchymatous type the organ is 
enlarged, of decreased consistence, and on section presents a dull gray 
cortex, the capsule of which strips easily. There is a more deeply con- 
gested medulla. Structural markings are obscured, although occasionally 
the glomeruli stand out on the cut surface as scattered reddish spots. 
Microscopically the parenchyma is found to be the seat of granular 
degeneration and exfoliation, so that the tubules have become dilated 
with necrotic cell products, casts, and free blood-corpuscles, the amount 
of blood depending on the degree of congestion in the vessels of the glom- 
eruli. The kidney stroma is edematous and may show considerable 
cellular infiltration and proliferation. Proliferation of the cells lining 
the capsule of Bowman is also common. 
Shennan has stated that the degenerative changes in the kidney 
depend on the nature of the causative toxin and its concentration, some 
toxins producing chiefly catarrhal changes, while others cause cell necrosis. 
The urine under the conditions described, although decreased in amount 
and containing albumin and casts, may, nevertheless, be of low specific 
gravity due to diminished excretion of urea. 
In acute nephritis of the interstitial type, which is much less frequent, 
the urine may be free from pus, casts, and albumin. More often, how- 
ever, this condition does not obtain, as the nephritis is secondary to a 
general pyemia or part of an ascending pyelonephritis, in which case the 
tubules microscopically show evidences of marked degeneration in ad- 
dition to the more apparent process, an infiltration of the connective 
tissue with polynuclear cells. 
In a late nephritis of the interstitial the development of fibrous 
tissue with atrophic changes in the glomeruli may possibly render the 
diseased organ smaller and firmer instead of larger and softer than normal. 
In the typical diseased kidney of scarlet fever there is a very char- 
acteristic glomerulonephritis, marked by a proliferation of the epithelial 
and endothelial cells lining the capsules and on the tufts, and by an ex- 
tensive round-cell infiltration of the tissue about the glomeruli. A severe 
attack of renal congestion during the febrile period of scarlet fever does 
not ordinarily become chronic; but a glomerulonephritis, slow in onset 
and of the productive type, may cause death from acute suppression 
of urine during convalescence, or perhaps terminate in chronic nephritis. 
Symptoms.—Acute nephritis may exist, run a mild course, and termi- 
nate favorably without symptoms. That this occurs in many instances is 
beyond doubt. 
Usually the first symptom noticed is a slight puffiness (not edema) 
about the eyes. A similar puffiness of the fingers and the ankles occurs, THE PRACTICE OF PEDIATRICS 
and the backs of the hands, as well as the ankles, soon become edematous. 
The skin becomes pale and of peculiar waxy whiteness. The patient 
exhibits loss of appetite and nausea, and sometimes vomits. Mild frontal 
headache is a frequent symptom. As the case progresses the peculiar 
pallor increases, the face becomes very much swollen, the eyes almost 
closed, and the legs and the feet increase very much in size and develop 
a cushion-like appearance and consistence. The subcutaneous tissue 
over the back and abdomen becomes infiltrated, and the whole aspect 
of the body is changed. There is a smoothing out of the folds and angles, 
giving a decidedly rotund appearance. As the result of such a general 
edema the child increases very much in weight. A child weighing 40 
pounds may increase in weight one-third. We have seen an increase 
of 15 to 20 pounds in not a few cases. 
In children one would invariably look for the more active symptoms, 
headache, vomiting, and prostration, but in many instances these symp- 
toms are not prominent. 
Fever.—An elevation of temperature usually exists in all cases, but 
is not necessarily high. Although a fever of 103° to 105° F. is of occa- 
sional occurrence, the usual temperature range is from 100° to 103° F. 
The temperature, as a rule, is not of long duration unless the case is to 
have a fatal termination. A continuous high temperature is an unfavorable 
sign. 
The Urine.—In every case of scarlet fever—in fact, in all infectious 
diseases—the urine should be examined daily, as recommended under 
the subject of management. Time and again we have known cases show- 
ing a moderate amount of albumin and casts, with a few blood-cells, to 
clear up entirely under treatment. If these cases are not recognized 
and properly treated, a large proportion go on to develop the more serious 
characteristic signs of the disease. 
The first objective sign will be scantiness of the excretion of urine. 
The urine voided will be reduced from a total daily quantity of 30 to 40 
ounces to only 10 or 15 ounces. Later a very few ounces only may be 
excreted, or the urine may be completely suppressed (anuria). 
The color becomes very dark, and if blood is present the urine will 
show a decidedly smoky appearance. Blood may be present in such 
large amounts as to give the appearance of pure blood. 
Uremia.—In very severe cases uremic convulsions may occur. Severe 
headache and repeated vomiting, with scanty urine and deficient excre- 
tion of urea, are indications that uremia exists. 
Convulsions.—The convulsion comes on suddenly and is typically 
bilateral. It may last but a few minutes, or it may last for several hours. 
The child may die in convulsions. 
Fulminating Cases.-—A form of acute nephritis which deserves par- 
ticular attention occurs early in malignant scarlet fever. The onset is 
very abrupt. But little urine is passed, and this is filled with albumin, 
casts, and blood. 
Illustrative Case.-—In a severe case complete suppression occurred without previous 
warning, and the child died in thirty-six hours, the duration of the entire illness being 
but seventy-two hours. There was no edema. The patient became comatose, and 
died from the uremia and the intense scarlatinal poisoning. ACUTE PARENCHYMATOUS NEPHRITIS 
497 
Duration.—The duration of an attack depends largely upon the se- 
verity. Exceptionally patients have become well in one week, while in 
other cases the urine was not free from albumin and casts for six weeks 
and sometimes longer. In case of apparent recovery one should not look 
upon the patient as fully recovered until twelve months have elapsed, 
and should not allow a child who has had well-marked nephritis to pass 
from observation within less than one year. A peculiarity of nephritis 
is its tendency to return. The chronic cases which we see almost inva- 
riably give a history of two or more acute attacks at intervals perhaps 
of several months. The second and subsequent attacks might have 
been prevented by proper protection and care. 
It may, therefore, be put down as a fact that chronic nephritis in a 
child often means neglect as much on the part of the family as on the 
part of the physician. 
Prognosis.—The prognosis of severe acute nephritis is good if proper 
management is carried out from the beginning of the illness until at 
least one year has elapsed. The prognosis is bad in even a mild case if 
it is neglected. Nephritis is one of the diseases in which right manage- 
ment is most essential, even in very mild cases. 
Diagnosis.—That nephritis is present is indicated by the appearance 
of swelling about the eyes and ankles, or by a more active onset of vom- 
iting, fever, and headache. 
Suspicion in any given case may be easily verified by a urine examina- 
tion. 
Examination of Urine.—If, during scarlet fever or any of the infec- 
tious diseases, the physician takes the precaution of having nitric acid 
and a few test-tubes at the home of the patient so that the urine may be 
tested for albumin at each visit, in addition to a reasonably frequent 
microscopic examination at the office, nephritis may be detected before 
the more active clinical signs appear; and thus, by placing the patient 
promptly under suitable management, usually but little trouble will be 
experienced. 
Treatment.—The treatment, reflecting as it does the previous methods 
of schools in their advocacy of forced, indiscriminate water-drinking, 
the exclusive milk diet, and the more or less indiscriminate use of diuretic 
drugs, is often open to the most emphatic criticism. Every one of these 
measures is capable of, and has been productive of, no little harm. Too 
great emphasis has been placed upon forcing the kidneys to act, and too 
little upon the necessity of relieving them of the work for which they 
are temporarily incapacitated. The advocacy of drinking large amounts 
of water when the renal blood-vessels are distended, the tubules are ob- 
structed, and the parenchyma is secreting but very little, does nothing 
but harm. Under such conditions heart stimulants, such as digitalis, 
which forces more blood into the kidneys, necessarily make a bad matter 
worse. 
General Management.—In treating nephritis there are several factors 
to be kept in mind. Because a case is mild it should never be given scant 
attention. Nephritis in a child may be most insidious in its course. The 
mildest case, while not treated in all respects like a more severe one, 
should be given every possible attention relating to rest in bed and diet; 498 
THE PRACTICE OF PEDIATRICS 
for through neglect, even for a very few hours, a mild case may become 
most severe. 
A child with nephritis must be kept in bed with the temperature of 
the room at about 70° F. He should be protected from drafts of cold 
air. A mixture of silk and wool or flannel should be worn next to the 
skin. 
Diet.—The nutrition of the patient is to be maintained by food which 
will not add to the existing trouble. We are told that nitrogenous food, 
such as meat and eggs, is to be avoided in order to relieve the kidneys 
from the work of excretion of urea and creatinin; and yet often we are 
advised in the very next line to give a full milk diet, which, in the case of 
a child from five to ten years of age means from 2| to 3 quarts daily. 
Milk, it will be remembered, contains 4 per cent, of nitrogenous food, 
necessitating that large amounts of nitrogenous waste by-products be 
excreted by the kidneys. 
In order to maintain the nutrition of the patient protein is necessary, 
and may be supplied by the use of a moderate amount of milk. To a 
child from five to ten years of age from 16 to 20 ounces of whole milk 
should be given daily—never more than 20 ounces. This should be 
diluted with equal parts of cereal gruel, No. 1 or 2, with the addition of 
1 teaspoonful of sugar (see formulary, p. 94), and given in amounts of 
from 6 to 10 ounces at four-hour intervals. The taste of the food may 
be changed by the use of cereal gruels of different kinds. Zwieback and 
butter, stale bread and butter, prune-juice, simple fruit jelly, thin apple- 
sauce, and orange-juice may be given in order to improve the digestion 
and add variety to the diet. Inasmuch as milk and fruit cannot be taken 
simultaneously by many patients, the fruit may be given between meals 
or with plain gruel, and thus increase the nutritive value of the daily 
ration. Broths and beef extracts are not to be given because of their 
creatinin content. 
The Salt-free Diet.—The value of a salt-free diet in nephritis is very 
generally recognized. The rationale underlying this treatment has been 
concisely set forth by L. Miller, who, after reviewing the work of Widal, 
Javal, and other observers, stated the following conclusions: 
“In patients with moderately severe nephritis associated with edema 
the ingestion of large amounts of sodium chlorid is followed by chlorid 
retention. The patient gains in weight, the edema becomes more 
marked, the albuminuria increases, and symptoms may develop re- 
sembling uremia. 
“In patients with very severe nephritis, and especially those with 
uremia, chlorid retention is very marked, as scarcely any of the extra 
chlorid administered is eliminated. 
“In individuals with apparently healthy kidneys, following the in- 
gestion of sodium chlorid there is a chlorid retention equal to that of a 
mild nephritis. The individual gains in weight, but there is no visible 
edema, no albuminuria, and no uremic symptoms.” 
The degree to which defective kidney excretion is responsible for the 
edema of nephritis is still in doubt, but it is certain that exclusion of 
common salt from the food, including even such substances as bread, ACUTE PARENCHYMATOUS NEPHRITIS 
499 
is frequently followed by marked improvement, which ceases on a return 
to the salt-containing diet. 
Bowel Evacuation.—A patient with nephritis, no matter how mild, 
should have two bowel evacuations daily. These should be rather loose. 
The use of the fruit juices may be sufficient to keep the bowels relaxed. 
If a laxative is necessary, citrate of magnesia, or, for very young children 
and infants, milk of magnesia, may be given in such doses and at such 
intervals as may be necessary to produce the desired results. The child 
should always have an enema at bedtime if no bowel evacuation has taken 
place during the preceding twenty-four hours. 
Bath.—A warm sponge-bath should be administered daily, the body 
of the patient being sponged and dried part by part under a flannel 
blanket. 
Treatment of Severe Cases.—When there is fever with partial sup- 
pression of the urine, only one-half the usual quantity being passed, 
and that loaded with albumin, blood, and casts, with perhaps beginning 
edema, colon flushings (p. 855) with a normal salt solution at a temper- 
ature of 110° F. are to be used. The flushings have the effect of increas- 
ing the functional activity of the kidneys. In the treatment of a child 
from five to ten years of age 1 pint of the warm saline solution may be 
thrown into the colon. An effort should be made to have the child retain 
the fluid by resting on the left side with the buttocks elevated on a pillow. 
For young children from 8 to 12 ounces may be used. Infants under 
nine months may retain only 4 to 6 ounces. The flushings should not 
be repeated oftener than at twelve-hour intervals, unless the condition 
is urgent, as intolerance of the parts is readily brought about by too 
frequent manipulations. 
If the skin is hot and dry and the temperature tends to remain 
above 102° F., tincture of aconite may be given in small doses. To a 
child three years of age \ drop may be given at two-hour intervals. 
Older children may be given 1 drop at a dose. It is rarely wise to in- 
crease the amount above 2 drops at two-hour intervals even for children 
above ten years of age. Only sufficient aconite should be given to pro- 
duce a slight diaphoresis, for when the skin is kept constantly moist 
the blood-vessels of the kidneys are relieved of the tension to which 
they have been subjected. 
In the extremely severe cases, with edema or anasarca, in which but 
2 or 3 ounces of urine are passed daily, more active measures will be re- 
quired. In these urgent cases the diet should consist temporarily of thin 
gruels of barley, Granum, or rice (No. 1), with sugar added to make them 
more palatable, and diluted fruit juices given between the feedings. In a 
carbohydrate diet there are no by-products irritating to the kidney. 
Water should be given scantily, sufficient fluids being given in the food. 
Active measures to increase diaphoresis and thus relieve the kidneys 
must be instituted. The best method of doing this is by the use of hot 
colon flushings, hot packs, hot baths, and hot flaxseed poultices. In 
these severe cases the use of digitalis and alkaline diuretics does an im- 
mense amount of harm. Digitalis drives more blood into the kidneys 
and thus increases the congestion. The alkaline diuretics disturb the 
stomach, which is already showing signs of food intolerance. Colon 500 
THE PRACTICE OF PEDIATRICS 
flushings (p. 857) at 110° F. are to be used every six hours. This is prob- 
ably one of the most valuable means we possess for relieving the con- 
gestion of the kidney and inducing a flow of urine. 
Local Application of Heat.—Heat, either dry or moist, should be 
immediately employed in order to stimulate the skin to vigorous action. 
Dry heat and moist heat each has its advocates. Keeping the child 
in a warm bath at 105° F. for a few minutes, drying rapidly, and immedi- 
ately putting him into bed, surrounded by hot-water bottles, will usually 
produce diaphoresis. A thermometer should be placed under the bed- 
clothing so that excessive heat may readily be detected, for pronounced 
weakness is sometimes produced by the use of excessive heat. The child 
should not be allowed to rest in a temperature higher than 120° F., and 
heat of this degree should not be maintained over ten minutes. A tem- 
perature of 105° or 110° F. may be maintained for an hour if necessary. 
If the pack is used, it may be repeated once in six hours. The disadvan- 
tages of a hot bath are due to the fact that it necessitates considerable 
handling, which with some patients is a cause of no little excitement. 
In such cases dry heat may be substituted, the patient being warmly 
clad in flannels, while hot-water bottles are placed near his body. This 
may be sufficient to induce perspiration. A device which is readily used 
consists of a funnel attached to a 1-inch brass pipe, which is bent in 
the middle to a right angle and which conducts the warm air under the 
bed-clothing. The heat is generated by a kerosene lamp, over the top 
of which the inverted funnel is placed at a sufficient distance to allow 
combustion to take place. The Kilmer croup kettle has an appliance 
which may be used for this purpose. 
In some cases we have had satisfactory results from the use of hot 
flaxseed poultices made very large, 8 or 10 inches wide and 2 inches thick, 
and sufficiently long entirely to envelop the abdomen. These are to be 
applied as hot as can be borne at about twenty-minute intervals for 
one hour, and repeated again in three hours. This interrupted use of 
the poultices has been continued as long as nine days, with most marked 
benefit. 
The Murphy drip may also be used, but has not proved very suc- 
cessful. The pressure of the tube in the bowel for the long time required 
is not borne well by children, and occasions a great deal of restlessness 
and irritability. We apply this means only in extreme conditions, in 
which the child’s state is such that he is not annoyed. 
While a free secretion of urine is desired in these cases, we must not 
be content with that alone. Uremia may occur even while the normal 
amount of urine is being passed. A quantitative test for urea should 
be made in all severe cases in order to determine the amount excreted. 
Normal urine, in children, contains approximately 2 per cent, of urea, 
which in health occasionally rises to 3 per cent. Approximately 0.5 
gram of urea is excreted per kilogram of body weight. The proportion 
in children is relatively higher.1 
1 R. Bradford, in Allbutt’s System of Medicine 
(See continuation of note on opposite page.) ACUTE PARENCHYMATOUS NEPHRITIS 
501 
Treatment of Uremic Convulsions.—Vomiting is one of the first 
symptoms of uremia. When it occurs, all food should be temporarily 
withheld from the stomach and nutrient enemata given. Completely 
peptonized skimmed milk is our best means of nutrition, from 4 to 12 
ounces being given every four to six hours. It is best to give the larger 
quantity at the longer interval—every six hours is best—as the manipula- 
tions with the tube have a tendency to produce intolerance on the part 
of the gut. The tube should be introduced at least 8 inches into the 
bowel and the solution used should be lukewarm. Fluid at a tempera- 
ature of 95° or 100° F. will best be retained. In addition to using colon 
flushings and external heat in the form of the flaxseed poultices referred 
to for control of uremic convulsions, one may employ chloroform or 
the rectal administration of the bromids or chloral. To a child under 
three years of age 2 grains of chloral may be given with 8 grains of bro- 
mid of soda. After the third year 3 grains of chloral may be used with 
8 to 15 grains of bromid of soda. This medicine is best retained when 
given in at least 4 ounces of mucilage of acacia or skimmed milk, the 
enema being repeated in four to six hours. 
When heart stimulants are required, tincture of strophanthus may be 
given—1 or 2 drops at two-hour intervals to a child under three 
years of age. After this age 2 or 3 drops may be given. Digitalis 
is sometimes used as a heart stimulant during convalescence, after the 
secretion of the urine has been established. 
Convalescence is often tedious in these cases. The child should not 
be allowed to be out of bed until albumin has disappeared from the urine. 
For at least six months after an attack the urine should be examined 
weekly. Light-weight w7oolens should be worn next to the skin during 
the entire year, and every effort made to protect the patient from sudden 
exposure to the influence of cold air. Upon the advent of any subsequent 
illness with fever, even though it should not occur for a year or two after- 
ward, unusual precautions should be taken to protect the child, in view 
of the danger of a reinvolvement of the kidneys, with, possibly, a result- 
ing chronic nephritis. Meat and eggs should be given scantily for a year 
after an attack. Exercise calling for more than ordinary muscular effort 
should not be allowed for at least a year after all trace of the nephritis 
Amount of Urea Excreted on the Basis of 0.5 Gram per Kilogram 
1 year < 
f Boys 9.29 
Grams in 
twenty-four 
hours. 
4.645 
{ Girls 8.24* 
4.12 
3 years < 
f Boys 14.14 
7.07 
{ Girls 13.60* 
6.80 
7 years < 
f Boys 22.44 
11.22 
L Girls 21.78* 
10.89 
10 years < 
f Boys 30.22 
15.11 
( Girls 29.07* 
14.535 
13 years < 
' Boys 40.04 
20.02 
i Girls 41.36* 
20.68 
i a „ f Boys 56.09 
!b years ( Gi/ls 51 24* 
28.045 
25.62 
* Figures of Boas, quoted from Holt. 502 
THE PRACTICE OF PEDIATRICS 
has disappeared. It is well to advise, when possible, that the winter 
after an acute attack be spent in a warm climate, such as that of Florida 
or Lower California. 
CHRONIC DIFFUSE NEPHRITIS 
This disease is rarely seen in children under three years of age, although 
a considerable number of cases develop every year in children from the 
fifth to the twelfth year of age. 
Nephritis of this type is almost invariably the result of an acute proc- 
ess which has run its course unrecognized, or of faulty management fol- 
lowing acute nephritis. 
Illustrative Case.—A patient who came under observation with chronic nephritis 
gave a history of having had three distinct acute attacks during the previous four 
years, with intervals of apparent health. The urine had not been examined during 
these intervals nor had she had the advantages of proper treatment. Such a history is 
quite common. 
Pathology.—In chronic parenchymatous nephritis (chronic diffuse 
nephritis without marked interstitial changes) the kidney is enlarged, 
pale, and of decreased consistence. The capsule strips easily, and the 
cortex, on section, is found to be wider than normal, and frequently of a 
light yellowish hue. The most pronounced microscopic changes are 
found in the tubules, the epithelium of which undergoes a variable amount 
of granular and fatty degeneration and exfoliation. The glomeruli also 
may show hyaline changes, swelling, and celluar proliferation and des- 
quamation. In some cases the disease is predominantly a chronic glome- 
rular nephritis (see Kidney of Scarlet Fever, p. 495). Interstitial changes 
are not, as a rule, important. The urine may be cloudy, is usually of in- 
creased specific gravity, and contains albumin in variable amount, leuko- 
cytes, epithelial cells of renal origin, hyaline and granular casts, and oc- 
casionally red corpuscles. 
Symptoms.—Chronic nephritis rarely develops insidiously as in the 
adult. Usually it is a continuation of the second, third, or fourth acute 
exacerbation. Instead of subsiding, the edema and the pallor remain 
pronounced, and the abnormal urinary findings persist. 
Anemia is always present, and, as the condition progresses, digestive 
disturbances become manifest. The appetite is usually indifferent, and 
commonly there is vomiting. Other symptoms are marked edema and 
drowsiness. The progress of the disease is variable. There are periods 
when recovery seems at hand, and then all the symptoms return in an 
aggravated form. Ascites is usually present in the advanced cases. Trans- 
udation into the pleural cavity and into the pericardium may be looked 
for. Pulmonary edema is a constant complication a few days or hours 
before a fatal termination if uremic convulsions are delayed. 
Prognosis.—The patients are always the subjects of much solicitude. 
The results have not been brilliant. In some cases the illness began 
after an infectious disease, usually scarlet fever, and ran a slowly pro- 
gressive course, which under the best of management defied every effort, 
terminating fatally in three months to a year. In other cases improve- 
ment occurred, casts and albumin disappeared from the urine, and the CHRONIC DIFFUSE NEPHRITIS 
503 
child became apparently well. In such cases the ultimate kidney con- 
dition can best be determined by the special tests for renal function. 
(See pp. 828, 829.) 
In cases of nephrosis1 the cholesterol content of the blood shows a 
marked increase. 
Exacerbation.—Even in the most favorable cases—as the result of 
exposure, some intercurrent disease, or some unknown cause—an exacer- 
bation often occurs, and the attack is repeated, usually in graver form than 
the previous one. The urine becomes scanty and loaded with albumin 
and casts; the child becomes edematous and pale. Treatment may per- 
haps relieve the condition, but this attack is followed by another in three 
to six months, after an interval of apparent health. 
Illustrative Cases.—In one girl four years old five distinct recurrences took place 
before death, which occurred in the fifth attack. 
A girl nine years old gave a history of chronic nephritis lasting two years. She 
made a complete recovery—at least there was no recurrence in fourteen succeeding years. 
A boy aged four remained well for two years after an illness covering six months. 
After this period he passed from observation. 
Diagnosis.—The diagnosis is confirmed by repeated urine examina- 
tions. Albumin and casts may be present for a considerable period with- 
out other signs than anemia. The anemia, with puffiness about the eyes 
and swelling of the feet and ankles, is a most suggestive sign. 
Treatment.—The management of chronic diffuse nephritis of only 
moderately severe type is to be considered with respect to four factors: 
diet, baths, exercise, and climate. 
If the patient is confined to bed, the diet should be the same as sug- 
gested under Acute Nephritis. The food should be largely salt-free. 
Twenty ounces of milk may be given daily. If the. child is up and about, 
meat may be given once every second day. Eggs should be excluded. 
In other respects the diet should be simple, as outlined for well children 
(p. 134), this being ample for nutrition. 
The child should receive one warm bath—95° to 100° F.—daily, fol- 
lowed by brisk friction with a dry towel. 
An outdoor life is of decided advantage. Exertion, however, should 
not be allowed to the point of fatigue. Contests or stress of any kind, 
mental or physical, should not be permitted. 
If possible, the child should spend the colder months in a locality 
which is not subject to sudden or wide variations in temperature. The 
climate of Florida or Lower California is to be advocated when the pa- 
rents are financially able to give the patient this benefit. If, however, 
the patient must be kept in his home, which does not offer the advan- 
tages of an equable climate, great care should be exercised in preventing 
sudden chilling of the skin surface. Woolens should be worn next to 
the skin at all seasons of the year. 
Frequent examinations of the urine should be made for albumin and 
casts, and such examinations should be supplemented by special tests for 
renal function (p. 828). Sudden attacks of uremia may occur even while 
the patient is passing an excessive amount of urine. 
1 Schwartz and Kohn, Amer. Jour. Dis. Child., 24, 2, August, 1922, pp. 125-159. 504 
THE PRACTICE OF PEDIATRICS 
The management of suppression and anasarca is very much the same 
as described for these conditions occurring in acute nephritis (p. 497). 
Diuretics with which the physician is familiar and in which he has 
faith, may be given well diluted, so as not to disturb the stomach. In 
the severe forms of chronic diffuse nephritis we have yet to see a diuretic 
of the slightest value. 
Edebohls’ Operation.—This relatively rare operation consisting of 
the removal of the capsule from the kidney for the relief of nephritis has 
recently been the subject of a review by Morse.1 This writer arrived 
at the following conclusions: “Edebohls’ operation is of much value in 
properly selected cases of nephritis in childhood. It may save life and 
Fig. 90.—Chronic nephritis before 
bohls’ operation. 
Fig. 91.—Same case as Fig. 90 after Ede 
bohls’ operation. 
result in permanent cure in acute nephritis. No child ill with acute 
nephritis should be allowed to die, therefore, without giving it the ad- 
vantage of the chance afforded by this operation. It may prolong life 
for considerable periods in a not inconsiderable number of cases of chronic 
nephritis, and may possibly, in rare instances, result in cure. It should 
therefore always be considered in all cases of chronic nephritis in childhood 
which are not responding reasonably well under medical treatment.” 
Illustrative Case.—A three-year-old girl patient in the Babies’ Hospital in the 
senior author’s service presented the typical picture of advanced chronic nephritis 
(see Fig. 90). The usual treatment with calomel, salines, colonic flushings, and hot 
packs and diuretics failed to make any impression. The urine presented the usual 
changes and was very scanty. After two weeks of unavailing treatment, during which 
period the child became constantly worse, the Edebohls operation of decapsulation of 
1 Jour. Amer. Med. Assoc., lxx, pp. 528-530, August 18, 1917. PYELOCYSTITIS (PYELITIS) 
505 
the kidney was performed by Dr. William A. Downes, of New York City. The kidney 
secretion gradually increased—the urine showing but a trace of albumin two weeks after 
the operation. The thirteenth day following the operation the child had lost 16? 
pounds in weight and presented the appearance seen in Fig. 91. There was an interval 
of two weeks between the time of taking the two photographs. 
During convalescence, however, the child developed a very severe colitis, from 
which she died six weeks after the operation. We look upon this case as a remarkable 
demonstration of the temporary value, at least, of decapsulation of the kidney. Un- 
fortunately, the intercurrent colitis terminated life before the permanent effects could 
be determined. 
CHRONIC INTERSTITIAL NEPHRITIS (MALIGNANT HYPERTENSION) 
Chronic interstitial nephritis is a very rare condition in children. 
A typical case was that of a boy ten years of age. 
Etiology.—The etiology is obscure. In the case referred to no caus- 
ative factor could be discovered. A persistent toxemia from intestinal 
sources is the most logical explanation. 
Syphilis, alcoholism, and the infectious diseases have all been looked 
upon by different authors as possible etiologic agencies. 
Symptoms.—A wide range of symptoms is put down. As our personal 
experience has been so meager, we can do no better than recite the symp- 
tomatology of the only complete case coming under our observation. 
Illustrative Case.—This boy evidently had suffered from the disease for three or 
four years. There was a history of chronic polyuria, thirst, and enuresis. He was 
very small, very thin, and anemic. He was habitually tired and listless. The skin 
was dry and rough and appeared to be pigmented in spots. There was no suggestion 
of dropsy, and the child had never been known to perspire. He passed from 60 to 
90 ounces of urine daily. The specific gravity was low. The one specimen examined 
by the writer showed a specific gravity of 1002, no albumin, and no casts. Death re- 
sulted from exhaustion and uremia. 
High blood-pressure is a prominent feature in such cases. 
Treatment.—The management of these cases is symptomatic. 
PYELOCYSTITIS (PYELITIS) 
Pyelocystitis is an infection of the bladder and pelvis of the kidney. 
The bladder is probably always invaded, and may be infected before or 
secondarily to the kidney. Partial ureteral stasis may exist. 
Etiology.—Sex.—The disease occurs with more frequency in girls 
than in boys. Thompson, of Edinburgh, however, has reported among 
his cases more males than females. Our own observation is that girls 
are much more apt to develop the disease, probably in the ratio of at 
least 5 to 1. 
In a report of 3 unusual cases in boys Graves1 has reviewed facts 
touching on this selective incidence. 
Age.—The majority of the patients are under three years of age. 
Pyelitis may, however, occur at any age. Our youngest patient was three 
months of age. Pyelitis is comparatively rare after the fifth year. Its 
occurrence in female adults does not concern us except by reason of the 
belief of not a few internists that the disease of childhood is carried over 
to adult life. 
Bacterial and Associated Factors.—The infection, in the great majority 
1 Amer. Jour. Med. Sci., November, 1917, No. 5, vol. cliv, p. 707. 506 
THE PRACTICE OF PEDIATRICS 
of cases, is due to the colon bacillus. Any of the pyogenic bacteria, how- 
ever, which gain entrance to the pelvis of the kidney may cause the 
disease. Thus the staphylococcus, the streptococcus, the gonococcus, 
or the typhoid bacillus may be the cause. In one case infection was due 
to the typhoid bacillus; in another to the staphylococcus. The para- 
typhoid bacillus was isolated in a recent case at Bellevue Hospital. With 
the exception of one or two cases the attacks were all either preceded 
by an acute intestinal disturbance or occurred independently of any ill- 
ness. Occasionally, as in certain cases of grippe and otitis media, the 
intestinal disturbance was present, but had been overlooked. The facility 
with which the infection may take place through the female urethra has 
been cited as the explanation of the frequency of pyelitis in girls, but the 
role of the lymphatics in conveying bacteria from rectum to bladder, 
a factor particularly emphasized by Eisendrath and Kahn,1 must also be 
considered owing to the closer anatomic relationship of rectum and 
urethra in the female. 
In 2 cases observed by the writer there was a colon bacilluria without demonstrable 
pus, but with the usual clinical signs of pyogenic infection. 
The occurrence of the colon bacillus in the urine of healthy subjects 
at intervals for shorter or longer periods has been repeatedly demon- 
strated, the urine in other respects being normal. Probably in many 
cases of pyelitis developing in association with grip or other febrile 
infections congestion of the kidney and oliguria contribute to the inflam- 
mation of tissue upon which a mild pre-existing bacteriuria has produced 
no previous lesion. 
Pathology.—Because of the fact that autopsies performed upon sub- 
jects at an early stage of pyelitis have been comparatively rare, the actual 
nature of the typical lesion produced is not definitely known. Probably, 
in most instances, the process affecting the kidney is confined to the pelvis 
in colon bacillus infections. In cases of the same type of long duration, 
however, the infection may involve the kidney structure causing mul- 
tiple foci of suppuration, as in the instance below cited. In infections 
of the kidney due to staphylococcus and streptococcous organisms the 
lesions are typically cortical from the onset and tend less to involve select- 
ively the pelvis of the organ. 
Illustrative Case— In one instance late in the illness pyelonephritis developed 
which caused the death of the child. The process had extended from the pelvis of 
the kidney to the parenchyma, which showed dozens of large and small suppurating 
foci at necropsy. 
Symptoms.—Pyelocystitis is a disease the chief symptom of which 
is sudden elevation of temperature. On the other hand, children may 
have the disease without fever. 
With or without some slight intestinal disturbance there is usually 
a sudden rise in temperature from 102° to 105° F. The rise is usually 
to the higher point, and is rarely accompanied by a chill. Thomson, of 
Edinburgh, has expressed the belief that a chill in an infant is always 
due to a pyelitis. The temperature following the onset ranges between 
1 Amer. Jour. Med. Assoc., lxvi, 561. PYELOCYSTITIS (PYELITIS) 
507 
101° and 105° F. for three or more days, with remissions to normal. Dur- 
ing the temperature period the child is fretful and uncomfortable, but 
not particularly prostrated. After the fever has passed the patient may 
appear slightly weak, but is usually bright and manifests no great phys- 
ical prostration; in fact, may exhibit no sign whatever of illness during 
the non-febrile period. The disease is often diagnosed as indigestion 
or some trivial ailment, and is forgotten until there is again a rise in 
temperature, which runs a high, irregular, or indifferent course for two 
or more days, and then again subsides. The accompanying chart (Fig. 
92) represents an acute case of short duration. In a few instances the 
duration of an individual attack has been not more than ten or twelve 
hours. 
There is usually no pain in these cases, and no unusual frequency 
in urination. Very infrequently a case is encountered in which there 
is bearing down and straining during and after urination. Absence of 
Fig. 92.—Temperature charts—pyelitis. 
both discomfort and frequency of urination leads one to believe that 
cystitis in these cases is probably of a trivial nature. 
The symptom above all others of value in this disease is tempera- 
ture, and when we have unexplained temperature periods in girls, such as 
are shown in the chart (Fig. 92), pyelitis, upon completing the exam- 
ination, will almost surely be found as the cause. 
Diagnosis.—The diagnosis suggested by the fever is verified by the 
finding of pus in the urine. Pus is not found in every specimen of urine 
voided. Before deciding that pus is not present in a given case at least 
three specimens should be secured on different days. 
For absolutely accurate work a catheterized specimen of urine should 
be secured, particularly if the urine is to be cultured. This is not ab- 
solutely necessary, however, in routine diagnosis. If the child is carefully 
washed before urinating and the urine is caught in a sterile vessel, there 
will not be sufficient contamination to prevent a right conclusion. 508 
THE PRACTICE OF PEDIATRICS 
Differential Diagnosis.—The diseases most frequently confused 
with pyelocystitis are malaria, typhoid fever, and acute intestinal in- 
fection. The distinct temperature periods and remissions, with days 
of normal temperature, effectually exclude both typhoid and malaria. 
The continuation of the temperature periods, after the intestinal in- 
toxication is relieved, excludes the intestine as the source of the fever. 
Repeated urine examinations confirm or disprove the presence of pyelitis. 
In doubtful cases the catheterized specimen of the urine should be cultured, 
for the possibility of febrile bacilluria without pyuria must be kept in 
mind. Malformations and calculi call for cystoscopy and £-ray. 
Duration.—The duration is variable, and appears to depend more 
upon the time the disease has existed unrecognized than upon the nature 
of the infection. 
A patient in whom the condition is discovered early usually responds 
promptly, and perhaps does not have a second fever period. Others 
in whom the disease has existed for several weeks undiagnosed may 
require several months of treatment. It is not at all unusual for a case 
to continue over two or three months. In one case the disease reappeared 
after an absence of fever and pyuria for three months. In another case 
the disease reappeared after six months and in another after eleven 
months. The continued excretion of pus and colon bacilli over a period 
of years is not unusual even after the febrile exacerbations have ceased 
to occur. Whether some of these cases represent a continuation of the 
old process, or reinfection from the intestine, it is impossible to say. A 
case should not be pronounced cured under six months, even though 
there is no return of the fever. The urine, during this time, should be 
frequently examined for pus. Repeated examinations showing the absence 
of both pus and bacteria may be taken to indicate a complete cure. 
Treatment.—The readiness with which pyelitis responds to treat- 
ment depends considerably upon the duration of the infection. The 
method of treatment which has proved most satisfactory is as follows: 
As soon as the diagnosis is positive, from 60 to 90 grains of citrate of 
sodium are given daily in 10-grain doses at two-hour intervals. Sufficient 
is given to produce an alkaline reaction in the urine. To maintain the 
alkalinity the dosage in many instances must be continued through the 
night, and good results, as Still has emphasized, may be dependent upon 
careful attention to this point. At the end of ten days the sodium 
citrate is discontinued and hexamethylenamin given, usually from 16 to 
24 grains daily; again at the end of ten days the citrate is resumed. 
This procedure is repeated, alternating the two drugs until the urine is 
free from pus. Hexamethylenamin is effective through its liberation of 
formaldehyd only when the urine is acid. Salol is of doubtful value. 
The difficulty that we have experienced has been to obtain sterile 
urine. The fever is usually readily controlled, but pus and bacteria 
remain in the urine over long periods. 
Immunization.—The use of vaccines has not been followed by brilliant 
results. 
The application of this method of treatment to urinary infections 
in children should, therefore, at present be limited to rare cases of gono- 
coccus or staphylococcus origin, and to the very small group remaining, CYSTITIS 
509 
which do not respond to medicinal measures. In persistent chronic 
colon cases vaccine may be given a trial. 
Davis1 has reported cures in resistant cases following the reaction in- 
duced by the injection subcutaneously of 20 c.c. or more of whole blood. 
The Bladder 
CYSTITIS 
Cystitis in boys is very unusual. In girls it occurs frequently. It 
is not of infrequent occurrence in hospital work. 
Etiology.—The most common bacteriologic agent in the causation 
of cystitis is Bacillus coli communis; next in order of frequency is B. 
proteus. The presence of these intestinal bacteria is explained by the 
fact that intestinal disease usually precedes cystitis in children. 
Streptococci and staphylococci have been found in the urine in cystitis. 
Gonorrheal cystitis in children is extremely rare, and tuberculous inflam- 
mation of the bladder is uncommon, even in older children. 
Symptoms.—Frequent calls for urination constitute the most usual 
symptom; so urgent is the desire to void the urine that the child may 
be unable to reach in time a suitable place. Incontinence by day and 
night is usual in children with only a mild degree of bladder involvement. 
There is, ordinarily, but little pain attending urination. Sometimes there 
is evidence of distress at the completion of the act, but this is unusual. 
Inability voluntarily to control the urine during the day, extending over 
a considerable period of time, points to bladder involvement due either 
to the presence of stone, which is most unusual, to cystitis, or to a con- 
genitally small bladder. 
Diagnosis.—Frequent urination due to transient congestion at the 
neck of the bladder may be confused with cystitis. Such cases, how- 
ever, are of very temporary duration, and respond readily to treatment, 
while the urine examination fails to show evidence of bladder infection. 
Pyelocystitis or pyelitis may be confused with simple cystitis. In cystitis 
without involvement of the kidneys the fever, which may signalize an 
infection of the pelvis of the kidney, is lacking. It is almost impossible 
to say positively when the pelvis becomes involved and when a cystitis 
becomes a cystopyelitis, for a cystopyelitis may exist for weeks without 
an elevation of the temperature. In many cases of involvement of the 
pelvis, however, there probably has been a preceding cystitis. Tem- 
perature, when present, is a determining factor in establishing the diag- 
nosis of pyelitis; further, when there is cystitis epithelium from the bladder 
is often in evidence in the urine. 
Treatment.—The treatment consists largely in the use of internal 
medication. Most cases respond promptly. Now and then a chronic 
case is seen which proves most obstinate. 
Illustrative Case.—A case of this nature was observed at the Out-patient Service at 
the Babies’ Hospital. The patient, a girl, came with a cystitis well established. Large 
quantities of pus were present in every specimen of the urine examined. In this case 
six months’ treatment with bladder washings and medication was required before the 
patient could be considered improved. She then developed poliomyelitis and passed 
from observation. 
1 Archives of Pediatrics, xl, 10, October, 1923, p. 698. 510 
THE PRACTICE OF PEDIATRICS 
Irrigation of the bladder may be attempted. It has been of very 
little service in our hands. Bladder washing is carried on with no little 
difficulty and annoyance, and usually with unsatisfactory results. The 
best results have been gained by the use of urotropin and sodium ben- 
zoate, 4 to 6 grains of each, three times daily. The frequent urination is 
thus relieved, and the successive examinations of the urine show a gradual 
disappearance of the pus. 
VESICAL CALCULUS (STONE IN THE BLADDER) 
Stone in the bladder is rarely seen in children under ten years of age. 
The occurrence of suggestive symptoms demands radiography to con- 
firm the clinical diagnosis. Four patients personally observed were 
boys aged respectively three, four and one-half, five, and seven years. 
In each case there was cystitis, with frequent and sometimes impeded 
and painful urination. 
The management is entirely surgical. 
EXSTROPHY OF THE BLADDER 
Exstrophy or eversion of the bladder is a rare deformity, affecting, 
in most instances, the male sex. This condition is due to a defect in 
the anterior wall of the bladder and to failure of development in the 
abdominal wall. Through the existing hiatus the posterior portion of 
the bladder protrudes as a mass covered by reddish mucous membrane, 
on the surface of which the urine from the ureteral orifices is discharged. 
Other malformations usually exist, of which the most important are 
non-union of the pubic bones, absence of the penis or epispadias, ab- 
sence or non-descent of the testis, and hernia. In the female the em- 
bryonic cloaca representing bladder, vagina, and rectum may persist. 
A determination of the sex of the patient is occasionally difficult. 
The condition is most pitiable. The constantly discharging urine 
makes cleanliness impossible, and the odor of decomposing urine is al- 
ways present. No means have been devised for a satisfactory collec- 
tion of the urine. Our own cases have all been seen in hospitals. In 
these instances abundant cotton in a large pad was bound on the parts 
and frequently changed. The skin surface round the exstrophy should 
be protected with zinc oxid ointment, to which 10 per cent, of white 
wax is added. This applied on linen makes a fairly satisfactory water- 
proof dressing and prevents the distressing excoriation of the skin. 
Operation.—The operation for deflecting the ureters to the sigmoid 
or rectum, while rarely successful, should be attempted. 
After the ureters are successfully placed, there is always the danger 
of pyelitis. Cases are recorded, however, in which the results of the 
operation have been most satisfactory. In one such instance the read- 
iness with which the rectum assumed the bladder function was as sur- 
prising as it was gratifjung to the patient. The rectum holds the urine 
from three to six hours without inconvenience. 
Various plastic operations have been devised, the object being to 
secure a bladder orifice to which some portable urinal may be applied. PHIMOSIS 
511 
The Male Genitals 
Practically every male child is born with an adherent prepuce and 
with more or less constriction at the preputial outlet. The penis is to 
be considered normal only when the foreskin can easily be retracted, 
laying bare the glans. 
The adhesions and constrictions may be relieved by moderately 
stretching the foreskin and breaking up the adhesions with a fine blunt 
probe, after which the glans should be cleansed, oiled, and the foreskin 
drawn forward over it. The cleansing of the parts with Castile soap 
and warm water, which necessitates a retraction of the foreskin, should 
be practised on the uncircumcised at least every second day. This not 
only keeps the parts clean, but prevents the later formation of adhe- 
sions and a possible phimosis. 
Circumcision should be performed upon every male child. The opera- 
tion does away for all time with the necessity of manipulation of the 
parts. (See p. 512.) 
BALANITIS 
Balanitis is a swelling and inflammation of the foreskin due to a local 
infection. Unskilled manipulation in stretching the prepuce readily 
produces a laceration, opening up a means of entrance for bacteria. In 
severe cases the parts first show congestion and then edema. We have 
seen patients with long foreskins which were twisted and swollen to 
a size three or four times that of the penis. In advanced cases there 
will be suppuration beneath the foreskin, with a purulent discharge 
from the orifice. Examination of the smear from the discharge will show 
whether or not the case is one of gonorrheal balanitis. 
Treatment.—If the case is seen early, wrapping the parts in gauze 
or old linen, which is saturated with an ice-cold solution of bichlorid of 
mercury 1 :10,000 and changed every half-hour, will usually be effec- 
tive. If there is much edema, puncturing in several places, after dis- 
infection, should precede the wet dressing. If there is a purulent dis- 
charge, the sac should be gently syringed at least twice daily with a 3 
per cent, solution of hydrogen peroxid, diluted one-half with water. 
When the suppuration has ceased, with a return to normal of the 
parts involved, circumcision should be done. Operation during the 
acute stage, particularly with suppuration present, should be avoided 
unless the condition is very urgent. 
PHIMOSIS 
Phimosis consists of a constriction or narrowing of the preputial 
orifice, sometimes to a pin-point. In cases where the foreskin is tightly 
bound to the glans by adhesions the urine may be emitted in drops; 
in other cases the prepuce “balloons out” during urination and the urine 
dribbles away. The opening may be sufficiently large to show under 
pressure the margin of the urethral opening, in which instance urination 
will be but little interfered with. 
Phimosis in addition to causing retention of the urine may be pro- 
ductive of various nervous manifestations, such as restlessness and irri- 512 
THE PRACTICE OF PEDIATRICS 
tability. In 2 of the writer’s cases convulsions were apparently caused 
by phimosis. Both children had repeated convulsions until they were 
circumcised. Both suffered from marked phimosis, with retention of 
smegma and irritation of the prepuce. 
Treatment.—The cases in which urination is impeded require prompt 
relief. This can be furnished temporarily by introducing a small probe 
or a director and carefully slitting the skin with sharp-pointed scissors 
until the glans is reached. The child should be carefully held by an 
attendant during the operation and great care should be exercised in 
introducing the director. After the operation a wet dressing of bichlorid 
of mercury 1 : 10,000 or a saturated solution of boric acid should be 
applied to the wound until it is healed. 
Circumcision should never be long delayed in cases of phimosis, as 
it furnishes the only satisfactory means of relief. Stretching is very 
apt to be followed by recontraction, which only intensifies the original 
condition, while the unavoidable laceration of the mucous membrane 
may open a favorable field for infection. Examples are numerous of 
the harm resulting from force and lack of cleanliness in the manage- 
ment of this simple and easily remedied condition. 
PARAPHIMOSIS 
Paraphimosis is produced by the retraction of a tight foreskin, which 
later becomes so contracted behind the corona as to prevent the return 
venous flow. As a result, the glans becomes greatly swollen, deeply 
congested, and edematous. Urination is impossible. The cases which 
we have seen have all been produced by the mother or nurse in an attempt 
to retract a tight foreskin according to the doctor’s directions, after 
he had stretched the prepuce for phimosis. 
Treatment.—If the retracted skin is edematous, it may be punc- 
tured in various places to let out the fluid. Reduction may then be 
attempted by taking the glans between the thumb and the first and 
second fingers of the right hand and making gradual pressure backward 
against the thumb and first finger of the left hand, which grasps the 
penis behind the prepuce. If the reduction cannot be effected in this 
way, as occasionally happens if the case is of long standing or the con- 
traction very tight, a longitudinal dorsal incision may be made in the 
skin at the site of the constriction. After the reduction a wet dressing 
of a saturated solution of boric acid or of bichlorid of mercury 1 : 10,000 
should be kept constantly applied to the parts until the swelling has 
subsided. Then circumcision should be done. 
CIRCUMCISION 
Should circumcision be practised as a routine measure? There is 
not the slightest doubt that it would be for the best interest of every 
male infant if he were circumcised. The operation during the second 
week of life is a trivial matter. In one out of every five male infants 
circumcision is a necessity both for comfort and health. In marked 
degrees of phimosis and balanitis circumcision is the only means of relief. 
An important reason for the operation as a routine measure is that UNDESCENDED TESTICLE 
513 
it settles at once and for all time the toilet of the parts. The penis after 
a proper circumcision requires no further manipulation on the part of 
the nurse. The daily retraction of the foreskin and bathing of the parts 
is one of the best means of teaching the child self-abuse. When the parts 
are not attended to every day or at least every second day, trouble is 
sure to follow sooner or later, in the form of adhesions and inflammation 
of the prepuce. The sensations produced by the retraction and the 
washing are not unpleasant and the child soon learns to produce them 
himself, through leg rubbing, hand pressure, or other means. (See Mas- 
turbation, p. 531.) Time and again, after having stretched the foreskin 
and broken up the adhesions because operations were refused, the writer 
has had the patient return in a few weeks with the adhesions and the 
contractions as bad as before because the nurse or mother, timid or ne- 
glectful, had failed to follow directions. In case of phimosis it may require 
considerable skill to draw the foreskin forward after a retraction. It 
is not always safe to permit the attendants to attempt it. Not a few 
times we have seen a paraphimosis (p. 512) which resulted from an in- 
ability to bring forward a retracted tight foreskin. 
The dorsal slit, so often practised as a substitute for circumcision, 
is to be used only as a temporary expedient, and as such may be em- 
ployed whenever circumcision is refused. Never, by any means, does 
it take the place of circumcision, but invariably leaves a long, redun- 
dant flap of skin, which easily becomes irritated, causing no little dis- 
comfort and affording the child a great temptation to manipulation. 
UNDESCENDED TESTICLE 
During the latter part of fetal life the testicle rests in the scrotum. 
In a considerable number of infants, moreover, the testicle on one or both 
sides remains in the canal for a varying period, the descent usually taking 
place during the first year. When such descent does not occur the con- 
dition may be considered abnormal. 
In small children usually no inconvenience is caused by the malpo- 
sition of the organ. We have repeatedly found one or both testicles in the 
canal up to the sixth year. The testicles may usually be brought down, 
but disappear as soon as traction is removed. In older boys, after the 
sixth year, the condition may cause trouble because of the exposed sit- 
uation, which subjects the organs to possible injury in play. Further, 
if they are left in the abnormal position, the question of possible faulty 
development is to be considered. 
Permanently undescended testicles in adult life frequently become 
sarcomatous. 
It is important not to confuse undescended testicle with inguinal 
hernia, hydrocele, or enlarged inguinal glands. On several occasions 
a truss has been applied to an undescended testicle. 
Illustrative Cases.—Three unusually fine healthy brothers aged six, eight, and 
eleven years, respectively, all had retained testicles. In the oldest boy there was an 
entire absence of one testicle, the other being in the scrotum. In the eight-year-old 
boy both testicles were firmly fixed in the canal. The younger boy had one testicle 
in its normal location, while the other testicle could be brought down into the scrotum 
only by considerable pressure. 514 
THE PRACTICE OF PEDIATRICS 
Treatment.—While boys may arrive at the age of ten years before 
the permanent descent occurs, waiting is not a wise routine procedure. 
If the testicle is freely movable and can be brought into the scrotum, 
nature will cure the condition. When the testicle is fixed and cannot 
be brought into the scrotum, early operation, at least not later than 
the sixth year, is advisable. In these cases there is a shortening of the 
cord, with adhesions, which prevents the descent. 
ORCHITIS 
Orchitis is a most unusual disease in the young. It is occasionally 
seen as a complication of mumps and may also be due to gonorrhea and 
to trauma. Tuberculous orchitis and syphilitic orchitis occasionally 
occur, but are exceedingly rare. The disease may be accompanied by 
hydrocele. When epididymitis is present, it may usually be traced to 
an injury or to an existing specific urethritis. 
Pathology.—The inflammation in the epididymis is essentially catar- 
rhal, but may involve the interstitial tissue and extend to the testis. 
In the latter organ interstitial changes ordinarily predominate. 
Symptoms.—The process is seldom attended by suppuration, though 
the inflammation may be so severe as to cause fever and other mild con- 
stitutional symptoms. Local manifestations are pain, swelling, increased 
heat, slight redness, and occasionally some edema of the scrotum. 
Treatment.—The management entails rest in bed, the use of saline 
laxatives, if necessary, and support of the inflamed testicles by a wide 
strip of adhesive plaster extending from thigh to thigh. The application 
of warm sedative lotions gives much relief from the pain and discomfort, 
and appears to shorten the duration of the attack. Lead and opium 
solution, U. S. P., applied on several layers of gauze and covered with 
cotton-wool, should be renewed every three hours. After the acute symp- 
toms have subsided a suspensory bandage should be worn for several 
months. 
HYDROCELE 
Hydrocele is an excessive accumulation of serum in the peritoneal 
process enveloping the testicle and epididymis. In children the con- 
dition is usually congenital, although it may be unapparent at the time 
of birth. Hydrocele is also sometimes caused by direct injury. 
The affection is commonly described under a classification of the 
following forms: 
(a) Congenital Hydrocele.—'This exists when the funicular process 
remains patent, and is frequently accompanied by hernia. The tumor 
is translucent, elongated, oval, and fluctuating, and is reducible under 
pressure without special manipulation. When uncomplicated, this 
swelling, in distinction from one produced by hernia, affords only a dull 
percussion note and fails to emit a gurgling sound on reduction. 
(b) Infantile Hydrocele .—This type is distinguished from the fore- 
going by the fact that the funicular process in the upper portion of the 
canal is closed. The fluid mass is elongated and irreducible. 
(c) Hydrocele of the Cord (Funicular Hydrocele).—Simple hydrocele 
of the cord is occasioned by the closure of the canal in its lower portion, GONORRHEA IN THE MALE 
515 
while the funicular process above remains open. Such a condition is 
not usual. The hydrocele is separate from the scrotum and may be 
associated with a hernia. 
More frequently the canal is closed at both its upper and lower por- 
tions, while the intervening part remains open and is distended by an 
accumulation of fluid—encysted hydrocele. 
(d) Encysted hydrocele of the cord is small, translucent, elastic, and 
irreducible, and may resemble an enlarged lymph-gland or an unde- 
scended testicle. 
(e) Hydrocele of the Tunica Vaginalis, with Normal Obliteration of 
the Funicular Process.—“Common vaginal hydrocele” is firm, tense, 
fluctuating, and irreducible. Above the upper limit of the swelling the 
cord may be distinctly felt. 
Treatment.—The cure of hydrocele in infants is usually spontane- 
ous. When the hydrocele is exceedingly large aspiration of the fluid 
under rigid aseptic precautions may produce a permanent good result. 
In cases of the congenital variety, especially those associated with hernia, 
the wearing of a truss is important as a means of assisting in the oblit- 
eration of the funicular process. Injections of irritants have not been 
Fig. 93.—Varieties of hydrocele: a, Congenital; b, infantile; c, funicular; d, encysted; 
e, vaginal. (DaCosta’s Modern Surgery.) 
necessary in our cases. Such a procedure is rarely to be advised. Much 
harm may be done by punctures and injections into the sac. Severe 
cases of infection of the parts have resulted from such procedures. 
If the condition persists a radical operation for the cure of hydrocele 
may eventually be performed. 
GONORRHEA IN THE MALE 
Specific urethritis in male infants and male runabout children is of 
rare occurrence. Eight patients under five years of age have come under 
the writer’s observation. 
The oldest of the group, aged four years, developed a stricture. The boy’s home 
was in a tenement and he had been repeatedly exposed through another member of 
the family, who hoped to rid herself of the trouble by giving it to the boy. 
The other cases occurred in a children’s institution in which there was an epidemic 
of specific vaginitis. 
Treatment.—The younger boys appear to respond unusually well 
to an irrigation of 8 ounces of a 1 : 10,000 permanganate of potash solu- 
tion used twice daily. This may be supplemented by argyrol or protargol 
injections, carefully instilled into the urethra by the physician. 516 
THE PRACTICE OF PEDIATRICS 
EPISPADIAS AND HYPOSPADIAS 
Both of these abnormalities are congenital defects in the develop- 
ment of the penis, characterized by imperfect closure of the urethral 
groove. 
In most cases of hypospadias the urethra terminates before reach- 
ing the base of the glans. In epispadias, which is much less common 
and frequently accompanies exstrophy of the bladder, the urethra opens 
upon the dorsum of the penis. 
The simpler forms of hypospadias may not require treatment, par- 
ticularly if the urethral opening is within an inch of the normal posi- 
tion of the meatus (Wyeth). When, however, the malformations cause 
imperative demands, plastic surgery should be attempted. 
The Female Genitals 
PRECOCIOUS MENSTRUATION AND PRECOCIOUS MATURITY 
Precocious menstruation is a physiologic anomaly of development 
(Morse). The usual time for menstruation to begin is between the ages 
of twelve and fifteen years. In some races catemenia begins normally 
as early as nine or ten years. 
There are two distinct types of cases. In one group the precocious 
menstruation is the only symptom, while in the other there is preco- 
cious maturity, the early menstruation being accompanied by the ana- 
tomic changes of puberty. 
The menstruation in children of the former type usually begins earlier 
than in those with precocious development. The average age is five 
years, but there have been instances reported in which hemorrhages 
begin at birth. The periods last from one to three days and may be 
regular throughout childhood. This is not usual, however, for at times 
for a year or more there may be no signs of menstrual flow. The physical 
and mental development of these children is perfectly normal. 
Illustrative Case.—A private patient, strong and robust, began to menstruate at 
the twenty-first month; the intervals were very irregular at first, ranging from a few 
weeks to two or three months, but with a fair degree of regularity during the period from 
three to nine years. Pubic hair developed at the sixth year and the breasts began to 
develop at the same time. To all outward appearance at nine years she was a per- 
fectly normal child, with no other signs of early sexual development. 
In the second group we are dealing with a profound disturbance of 
development probably due to some derangement of the ductless glands. 
Lenz, in a most exhaustive review in 1912, was able to collect only 150 
such cases from the literature. Menstruation in these children usually 
beings early, that is, during the first two years and frequently at birth. 
In 51 cases collected by Morse, 36 began during the first two years. These 
patients are usually large at birth. They have large breasts, axillary and 
pubic hair, and a prominent mons veneris. They develop very rapidly 
and at eight or ten years may present the full maturity of the adult. 
The menstruation is regular and preceded early in life by various feelings 
of discomfort, analogous to those which announce the periods in women. 
There is also an early development of bone as shown by z-ray. 
That the menstruation in these children is accompanied by ovula- SIMPLE VULVOVAGINITIS 
517 
tion has been proved by autopsy, and there are cases in the literature 
in which pregnancy has developed in childhood. One patient began 
to menstruate at two years, became pregnant at eight years, ceased to 
flow at twenty-five years, and lived to be seventy-five without a recur- 
rence. 
The etiology of this condition is obscure but there are facts which 
seem to indicate that it is due to a disturbance of the endocrine glands. 
There have been instances in which the abnormal development is reported 
to have ceased and even retrogressed after the removal of cystic tumors 
of the ovary. (Cf. p. 480.) 
These children should be kept apart from other children. Their 
early modesty sense should be respected. 
In simple vulvovaginitis there is an inflammation of the mucous 
membrane of the external genitals, with a slight involvement of the 
vagina in its lower portion. Further extension of a non-gonorrheal in- 
fection to the uterus and tubes probably never occurs. 
The orifice of the urethra is usually reddened and inflamed. 
Etiology.—Ill-conditioned children, and those improperly cared for, 
furnish the majority of the cases. Now and then an apparently healthy 
girl will develop the disease. 
Irritation from hand manipulation in masturbation, scratching in 
eczema, thread-worms, and constipation may all bring about the dis- 
charge. The ailment is particularly common in anemic girls whose vitality 
is habitually below normal. 
Symptoms.—There is moderate itching and burning of the parts 
and a secretion of rather viscid mucus. In some cases there is a yellow, 
purulent discharge, resembling that of gonorrheal infection. The at- 
tention may be first called to the condition because of a staining of the 
clothing. 
Diagnosis.—The condition in which there is a purulent discharge 
requires to be differentiated from gonorrheal vaginitis. This is very 
readily done through bacteriologic examination. Without the aid of 
the microscope differentiation is impossible. 
Prognosis.—The prognosis is favorable. Most cases recover in a 
few weeks. Resistance to treatment and chronicity point to the presence 
of the gonococcus. 
Treatment.—The management comprises both constitutional and 
local measures. The patient should be given a daily living regime with 
directions as to when she shall rise in the morning, when she must retire, 
and the amount of rest she must take in the middle of the day. In this 
way the output of energy is curtailed and waste is prevented. The diet 
should be so arranged as to give the patient the most nutrition with the 
least amount of digestive activity. Bitter tonics, cod-liver oil, and iron 
are to be given when indicated. As much out-of-door life as is possible 
should be encouraged. In short, the measures advocated in the section 
on the Subnormal Child (p. 140) are applicable here. 
Local Measures.—Bathing the genitals twice a day with warm water 
SIMPLE VULVOVAGINITIS 518 
THE PRACTICE OF PEDIATRICS 
and Castile soap, followed by drying with absorbent cotton, prepares 
the parts for an absorbent dusting-powder, which has proved useful 
in these cases. The powder is of the following composition: 
Acidi borici gr. xxv 
Pulveris amyli, 
Pulveris zinci oxidi aa 3ss 
The more nearly dry the inflamed surfaces are kept, the more prompt 
will be the relief. If there is a tendency to a free secretion of mucus, the 
powder may be applied at intervals of two hours. 
A convenient means of applying the powder is with an insufflator, 
which may be obtained from any apothecary. After the parts are packed 
with the powder, a dressing of old linen should be applied and held in 
position by a napkin binder. The powder should be reapplied often 
enough to keep the parts dry. 
Many cases of long standing respond promptly to the above manage- 
ment. 
Vaginitis of this type is very prevalent among the congested tene- 
ment population in all large cities. Institutions for children, if they 
would admit the patients, could always supply a considerable number of 
cases. 
Etiology.—It is almost impossible to keep the infection out of in- 
stitutions, and when it once enters, it is most difficult to remove. The 
disease is quite distinct from venereal disease in the adult, in that it is 
contracted through indirect means. The hands of the mother or nurse, 
towels, napkins, the thermometer, may all furnish a means for trans- 
mission from the infected to the healthy.. Day nurseries, most neces- 
sary institutions, are often unwittingly distributing agents of the gono- 
coccus. 
In private work we have known of several cases in which the mother 
had a vaginal discharge of a suspicious character. In 2 cases only the 
disease was evidently contracted from a nursery maid. 
Age.—No age is exempt. Very young females—under three years 
of age—-furnish most of the cases. The infection is not infrequent in new- 
born infants. In older girls, after the tenth year, the possibility of infec- 
tion through sexual contact may be considered, but at this age the disease 
is most unusual; in fact, very few cases are seen in children after the eighth 
year. 
A resistance to the indirect transmission of the infection appears to 
be acquired with advancing years. The nursery maids in training will 
live for months in an infected ward, working with the patients, and not 
become infected, whereas if a healthy female infant is placed at any 
point in the room, she may become infected in twelve to thirty-six hours. 
A female child six months of age, admitted into a ward maintained 
with care and cleanliness, containing 12 healthy females of about the 
same age, may transmit the disease to one-half of the number in two or 
three days. 
Symptoms.—Redness of the vulva may be apparent without dis- 
charge, or there may be a mucous, mucopurulent, or purulent discharge. 
GONORRHEAL VULVOVAGINITIS (SPECIFIC VAGINITIS) GONORRHEAL VULVOVAGINITIS (SPECIFIC VAGINITIS) 
519 
The typical discharge is thick, viscid, and of a greenish-yellow color. 
If the case is of considerable duration, there will be redness and excori- 
ation of both mucous and skin surfaces. There is a good deal of itching 
and discomfort. In older children micturition may be painful. In in- 
fants no discomfort whatsoever appears to be occasioned by the disease. 
Extension of the infection through the uterus to the tubes and pelvic 
cavity is of most unusual occurrence. Hundreds of these cases may be 
observed without exemplifying a complication of this nature. The in- 
flammation very rarely extends beyond the cervix. An endocervicitis, 
however, is usually present. 
Diagnosis.—The presence of a vulvovaginal inflammation with or 
without discharge suggests the possibility of a specific vaginitis. It is 
a mistake to suppose that there must be a visible discharge in each case. 
Time and again smears taken from a vagina that is simply moist will 
show the gonococcus. 
Microscopic examination of the secretion must decide whether or 
not the case is of gonorrheal origin. 
Prognosis.—A guarded prognosis must always be given. Under 
the care of a trained nurse and intelligent mother we have seen cases 
recover in three weeks, but usually from four to eight weeks are required, 
and then management such as is suggested below must be followed out 
most thoroughly. Moreover, apparent recoveries are frequently incom- 
plete and are succeeded by relapses. Vaginitis among female patients 
in an institution is much more difficult to cure. 
Complications.—The most frequent complications are conjunctivitis 
and arthritis. Conjunctivitis is the one most commonly encountered. 
Arthritis (p. 794) is not at all unusual. 
Prophylaxis.—This disease is one of the most infectious of all in- 
fectious diseases. In order to prevent its spread in a family in which there 
are two or more girls, or in an institution, it is necessary not only to 
prevent personal contact, but also to prevent any association of any 
nature whatever, and this includes attendants, clothing, feeding and cook- 
ing utensils, and thermometers. 
It seems almost impossible for nurses in attendance in vaginitis cases 
not to convey the disease to well female infants. At the New York Nur- 
sery and Child’s Hospital it was found necessary to put the infected 
children in a separate building, with nurses who cared for them only. 
Cheese-cloth napkins were used, then burned. All other clothing and 
bed-linen was boiled before being taken to the general laundry. 
Treatment.—The course of the disease is most protracted, and there 
is no specific medication which we may use either locally or internally. 
The writer has treated hundreds of these cases in many different ways, 
including the use of solutions of bichlorid of mercury and of perman- 
ganate of potash of different strengths. Various silver salts in different 
strengths as applications to the parts have likewise been employed. Such 
experience has demonstrated that keeping the parts clean through douch- 
ing does more toward terminating the disease than does the use of any 
particular disinfectant wash or application. Douching of the parts is 
to be practised four times daily, if possible, with the use of 2 quarts 
of water. It is useless to attempt the treatment of a case without pro- 520 
THE PRACTICE OF PEDIATRICS 
vision for douching at least twice a day. It may be remarked that this 
is a very trying treatment for both patient and nurse. Such is certainly 
the case, but we are dealing with a disease in which only strenuous meas- 
ures give hope of cure. 
Details of Procedure.—In order to receive the douche most effectively 
the child should be placed on the back on a douche-pan. A glass female 
catheter attached to a fountain-syringe is all the apparatus required. 
The catheter is passed about \ inch within the vaginal orifice, and 
the water allowed to run. The lower end of the bag should not hang 
higher than 2 feet above the child’s body. Boric acid is a safe drug in 
any household, and for this reason is usually selected instead of bichlorid 
of mercury, permanganate of potash, or any other antiseptic. We are 
not at all sure that plain boiled water would not answer just as well. 
It would be difficult, however, to persuade many families to use the 
repeated douching without the addition of some antiseptic to the water. 
Accordingly, the mother or nurse is instructed how to prepare 2 quarts 
of a saturated solution of boric acid. This is used as a cleansing agent. 
After the parts are dried with sterile absorbent cotton a dusting-powder 
of the formula given on page 518 is freely dusted into the vagina and 
over the diseased surface not only after the douche but also at two-hour 
intervals, during the time the child is awake, from early morning until 
late at night. It is best to tell the attendants to pack the parts with the 
powder. Over this is placed absorbent cotton or gauze, which is covered 
with the napkin. The attendants should be warned of the danger of in- 
fecting themselves and other children in the household with towels, 
sponges, etc.; in fact, sponges should never be used in these cases. The 
danger of infecting the eyes, not only of the patient, but of the attendants 
and others who may come in contact with the case, should be carefully 
explained. When washing or drying is necessary, absorbent cotton or 
old linen should be used and immediately burned. Cheese-cloth napkins 
should be used and burned as soon as soiled. A child suffering from gon- 
orrheal vaginitis should sleep alone. 
A patient treated as above may recover in three weeks, though usually 
from four to eight weeks are required, and in some cases the treatment 
must be continued for months. In many obstinate cases the direct ap- 
plication of antiseptic solutions to the cervical canal by the aid of the 
endoscope will complete the cure. For this purpose 10 per cent, silver 
nitrate or Lugol’s solution of iodin may be used. After we have arrived 
at a point where we consider the case cured, there will sometimes be a 
renewal of the discharge. The treatment must then be resumed. 
Before the case is finally discharged at least two bacteriologic ex- 
aminations of the vaginal secretion should be made in order to deter- 
mine positively the absence of the gonococcus. 
What becomes of the many cases in which the treatment is not con- 
tinued or the cases that are never treated? We are confident, from the 
large number of infant females who have the disease and its absence in 
older children after the fourth year, that cure often takes place spontane- 
ously, without after-results. The gonococci become fewer in number 
and eventually disappear. 
Vaccine Treatment.—Treatment of the disease with vaccines offers ATRESIA OF THE URETHRA AND VAGINA 
521 
no better results—probably not as good results as are obtained by local 
cleanliness and the above treatment. 
ATRESIA OF THE URETHRA AND VAGINA 
Atresia of the Urethra.—This is a congenital occlusion or stricture 
of the urethra, due to agglutination of the walls or closure of the meatus 
urethra) by membrane. The obstruction is often incomplete. 
Treatment.—In some instances simple incision at the meatus may 
relieve the condition. Extreme cases will require urethrotomy, com- 
bined, perhaps, with forcible catheterization. 
Atresia of the vagina may be due to imperforate hymen (atresia hy- 
menalis) or to the presence of a transverse septum obstructing the passage 
at a higher level. A rectovaginal fistula may coexist with the atresia. 
Atresia of the vagina has been recognized as a cause of hematocolpos, 
hematometra, and hematosalpinx. The possible existence of this mal- 
formation should be considered in all cases of delayed menstruation. 
The treatment is surgical. XVI. AFFECTIONS OF THE NERVOUS SYSTEM 
HEADACHE 
A complaint of headache, particularly repeated headache, on the 
part of a child should always be respected. Its occurrence is of greater 
import than in the adult. 
In children of any age headache may be an early symptom of men- 
ingitis, particularly of the tuberculous form, in which the headache may 
exist for days without other signs of illness. In eye-strain headache is 
a very prominent symptom, and may be the only evidence that an ocular 
defect exists. In cases of persistent headache that cannot otherwise 
be satisfactorily explained the physician should invariably have the eyes 
examined. Headache is often the earliest sign of acute infectious disease: 
it is a premonitory symptom of scarlet fever, measles, or pneumonia, 
and is frequently the only discomfort complained of by a child who has 
acute tonsillitis. Persistent toxemia from any source may be a cause 
of headache. Such toxemia may occur in nephritis and in malaria. The 
most usual source, however, is the intestinal tract. With persistent tox- 
emia of intestinal origin anemia is generally associated. This condition 
may exist without constipation. Fatigue, as a result of overwork at 
school, or hard play and unusual excitement, may be a cause of head- 
ache in neurotic children. Late in the school year it is frequently encoun- 
tered in girls. Examination of the urine may show marked indicanuria. 
Children are imitators of adults, and in a family with the headache habit 
the child may complain when the condition does not exist. Such simula- 
tion may readily be interpreted. 
Treatment.—The management of headache consists in the discov- 
ery and removal of the cause. An ice-bag or an ice-cloth applied to the 
head affords much relief in the acute febrile cases. Ocular defects should 
have the benefit of rest and suitable glasses prescribed by an oculist. 
Fatigue headaches are best controlled by limiting the amount of work 
and providing long periods of rest. Headaches due to intestinal toxemia 
with the usual accompaniment of anemia are often most difficult to 
relieve. In spite of our best efforts, the intestinal digestion may remain 
faulty for a considerable time. A change of residence and a radical change 
in the habits of life are usually the best means of effecting a cure. The 
management of these cases is considered in detail under Persistent In- 
testinal Indigestion (pp. 231, 232). 
PAVOR DIURNUS 
Day-terrors are of occasional occurrence. The writer’s cases have 
all been due to intestinal toxemia in children who showed very poor 
milk capacity. The fright has never been as severe as that occurring at 
night. 
522 NIGHT-TERRORS (PAVOR NOCTURNUS) 
523 
Illustrative Cases.—A boy, two and one-half years of age, asked his nurse to brush 
the bugs off his lap-robe and clothes. When the nurse failed to discover the bugs, 
the boy attempted to brush them off himself. When asked what kind of bugs they 
were, he repeated “all kinds.” 
A case almost identical with the foregoing was that of another boy three years 
of age. 
A girl four years of age would suddenly stop her play and hold conversation with 
imaginary people or objects and maintain that the people were present, and describe 
their appearance and dress. As suddenly she would return to play. At these times 
it was with difficulty that the child could be brought to her normal condition of mind. 
In all these cases there was chronic intestinal indigestion manifested 
by heavily coated tongue and foul breath. The children recovered en- 
tirely upon relief of the intestinal condition. 
Uncontrollable attacks of screaming in young children have been at- 
tributed to pavor. 
NIGHT-TERRORS (PAYOR NOCTURNUS) 
The child with night terrors is aroused from his sleep, thoroughly- 
frightened, imagining that animals or persons are trying to injure him. 
He begs to be protected. The following morning he has no recollection 
of the occurrence, and is rather amused than annoyed at the episode. 
Etiology.—In a great majority of the cases the trouble is due to a 
deranged digestion in a neurotic child. This, however, is not neces- 
sarily the case. We have repeatedly known apparently healthy children 
to have the attacks. In a recent case the terrors were due to excessive 
fatigue. 
Illustrative Case.—The boy, four years old, had been treated elsewhere and had 
received careful medication and diet. The attacks continued nearly every night for 
a year. The mother stated that her own health and the boy’s were badly affected 
because of the broken night’s rest, and she looked upon the condition as very serious. 
Upon learning every detail of the boy’s life the writer discovered that there was an older 
and very active brother of six years with whom the patient played daily, and who acted 
as a pacemaker for the patient. The older boy was sent from home, and a quiet, 
uneventful life was prescribed for the younger boy. There was no change in diet, 
as this was not necessary. For one week 8 grains of bromid of soda was given at bed- 
time to break the habit. During the next ten days there were two mild attacks. After 
this the boy slept throughout the night, with no relapse for eighteen months. 
Such cases as the foregoing are unusual. Indulgences in unusual 
articles of diet cause many attacks which may be compared to night- 
mare in the adult. When repeated attacks occur, it will usually be found 
that the child is suffering from persistent intestinal indigestion, or that 
the evening meal is, as a rule, beyond the patient’s digestive capacity. 
Illustrative Case.—A boy patient who was four years of age when he came under 
observation had, during the next five years, two attacks of night-terrors each year. 
One attack occurred on the night of his birthday and the other on Christmas night. 
At those times, in spite of repeated warnings and the repeated attacks, he was indulged 
in unsuitable articles of food. 
Overwork at school and anxiety regarding school duties and lessons 
have been factors contributing to night-terrors. Contributing factors 
also are adenoids, enlarged tonsils, and worms. 
Treatment.—If the patient is a school child and the case is aggra- 524 
THE PRACTICE OF PEDIATRICS 
vated, school should be temporarily discontinued and all exciting play 
and books of an exciting nature forbidden. The heaviest meal should 
be taken at midday. The evening meal should consist of cereals, milk, 
stale bread and butter, and stewed fruits. The child should never be 
allowed to go to bed unless an evacuation of the bowels has taken place 
during the previous twenty-four hours. 
In the very nervous and irritable cases from 5 to 10 grains of sodium 
bromid may be given at bedtime. This should not be continued longer 
than a week. If the child is delicate, anemic, or suffering from ade- 
noids, enlarged tonsils, or thread-worms, these conditions, any one of 
which may contribute to night-terrors, should receive proper treatment. 
GYROSPASM (SPASMUS NUTANS) 
Gyrospasm is a functional nervous affection usually seen in children 
under one year of age who lack sufficient sunlight. 
Etiology.—A considerable number of these patients have come under 
our observation, and all have been children suffering from malnutrition. 
Rachitis is usually present. Two of the patients were mentally defective. 
Symptoms.—The disorder consists of a rhythmic rotatory move- 
ment of the head, at times from 20 to 40 oscillations being made in a 
minute. The movement may be not only lateral, but vertical, which 
constitutes what is known as head-nodding. In one of our patients both 
the lateral and vertical movements took place. 
The oscillations are usually, but not invariably, associated with 
nystagmus. The movements of the head occur only when the child is 
erect, and the oscillations with the nystagmus are increased when the 
child’s attention is focused on some object. 
Prognosis.—The prognosis is good if the child is mentally normal. 
None of these children die of this disease, and practically no cases are 
seen after the eighteenth month. With improvement in the physical 
condition and development of the nervous system, the motions cease 
and occur only under excitement. The disorder is essentially chronic, 
and the improvement is slow. The mother becomes dissatisfied with 
the treatment, and wanders from clinic to clinic. This explains in part 
the large number of cases seen by. pediatrists. 
Treatment.—The only treatment of value is along nutritional lines. 
We have had the opportunity to give a few cases a fair trial with sodium 
bromid in doses from 12 to 18 grains daily, a treatment which is generally 
advocated for this condition, but have failed to note any special benefit 
from the method. With an increase in age and improvement in nutrition 
the patients whom we have been able to follow have slowly improved 
and recovered. Sunlight and cod-liver oil treatment are particularly 
indicated. 
HYSTERIA 
Hysteria is a functional disorder, rare in young children, and char- 
acterized by nervous crises. 
Our youngest patient was three and a half years old when first seen, but the hys- 
teric manifestation had been present for several months. HYSTERIA 
525 
Mental, motor, or sensory manifestations may predominate in an 
individual case, although in all cases the condition is associated more 
or less directly with an absence of mental control. Girls are more fre- 
quently affected than boys, but some of the most typical cases coming 
under our observation have been among the latter. 
Etiology.—We are taught by neurologists that hysteria is almost 
invariably of hereditary origin because of its apparent direct transmission 
from parent to child. It must be remembered that the child, in addition 
to being born of a hysteric mother, is in constant association with her. 
Actually, in hysteria we have exemplified in the most perfect degree 
the effect of environment. A neurotic, hysteric mother puts the whole 
family in a state of high nervous tension. We know of several such 
instances. A neurotic, irritable father will make the whole family neurotic. 
We know of such instances also. Fortunately for the offspring, both 
conditions are seldom combined in one family. When they are, the 
future of the children is discouraging. When one of the parents is suffi- 
ciently normal to offset a reasonable degree of neurosis on the part of the 
other, a stable equilibrium may be maintained. 
Imitation is one of the strongest characteristics of the growing child. 
How often, when arranging with the mother a diet-list for one of these 
nervous, ill-conditioned children, have we heard the child say that he 
“hated” cereals, or “hated” vegetables, or “hated” eggs or fowl; or that 
he “adored” some other articles of food; this adoration and hatred, par- 
ticularly the latter, often influencing the entire future of the child; for 
without a properly regulated diet for every day in the year only an in- 
ferior type of adult can be the outcome. In such cases it will usually be 
found that the likes and dislikes of the child are identical with those of 
the parents, whose preference has often been expressed in the presence of 
the child. “Heredity” here furnishes to the parents a satisfactory expla- 
nation of the child’s limitations in diet. It will usually be found that 
parents who live normally have children who eat normally. 
Illnesses and ailments of different kinds should not be discussed 
before nervous and impressionable children. Time and again an in- 
vestigation of a peculiar pain in a child’s head, side, or back which cannot 
be accounted for by the physical examination will be explained by a 
similar pain in some older member of the family. 
Illustrative Cases.—In one family the senior author has seen three generations of 
genuine hysteria. In the first generation the father, chronically irritable and neurotic, 
was a business man with large interests, rarely ceasing, when at home, to talk about 
his ailments and their remedies; and the mother had marked hysteria, indulging in 
frequent attacks, with apparent unconsciousness lasting for hours. The daughter, 
brought up in this atmosphere, through heredity and environment soon became mark- 
edly hysteric. When some dispute arose in the family (which was not an infrequent 
occurrence) both she and the mother would have simultaneous attacks of hysteria. 
In due time the daughter married and gave birth to a daughter, who promised to main- 
tain the family traditions, with certain additions of her own. 
A girl seven years of age lived in deadly fear of appendicitis and developed an 
attack of hysteria every time she had a pain. She could locate “McBurney’s point,” 
and knew the various stages in the development of the disease and the steps in the opera- 
tion for appendicitis. The mother’s appendix, suitably preserved, is among the family 
relics, whence it cannot be removed. The influence of heredity perhaps had the effect 
of making the child alert; precocious, and impressionable. Such favorable soil and 
the constant association with the hysteric will almost surely develop hysteria in a child. 526 
THE PRACTICE OF PEDIATRICS 
Symptoms.—Three forms of hysteria may be seen—the mental, 
motor, and sensory types. An individual may show one, two, or all 
of the types. 
Hysteric patients will be found who have indulged in “tantrums” 
from very early life. They enjoy their seizures, which are usually mani- 
fested by laughing and crying violently in alternation; and not only 
do they enjoy the indulgence in an attack, but the attention they receive. 
They are usually obstinate, and do not attempt to exert what mental 
control they may possess. They may become most violent. Upon at- 
tempting to quiet a strong girl of ten years in a violent seizure of hysteric 
mania the writer came out a victor, but required the use of plaster band- 
ages as well as the service of a tailor before he could continue the work 
of the day. 
Illustrative Case.—The Motor Type.—A girl thirteen years of age had not been 
able to walk for three weeks; she was most calm and collected. Examination showed 
her muscle and nerve condition to be normal. There was no hyperesthesia nor anes- 
thesia, and the muscles of the legs and back were entirely under her control when 
she was in bed. As soon as she attempted to walk the legs gave way and she sank to 
the floor. About one year earlier she had passed through a period when the left arm 
could not be used for three weeks. She was very fond of looking out of the window. 
She soon could walk in the direction of the window, but would fail utterly when walking 
in any other direction. Likewise she could stand by the window and in front of the 
mirror—she was decidedly handsome—but in other situations the legs would not 
support the body. 
The convulsive cases exhibit every variety of contortion. The patients 
throw themselves about in apparent unconsciousness, without regard, 
yet it will be remarked that they always manage to fall in a soft place. 
Hysteric patients never injure themselves to any extent. If they pull 
their hair, they do not pull very hard. They pull another person’s hair 
much harder than their own. 
Illustrative Case.—A girl of eleven upon little or no provocation would pass into 
a trance-like state and remain in this condition for five or six hours until she became 
very hungry or thirsty. During the attack it was impossible to arouse her by any 
ordinary means. On one occasion “Fire! Fire!” was cried in an adjoining room. This 
promptly brought her to her feet. Later attempts along this line were without effect. 
When, however, instructions were given that no attention be paid to her when in the 
attack the hysteria ceased to be interesting to her and terminated. 
Globus hystericus, hiccup, and inability to speak have all been en- 
countered from time to time. 
Illustrative Case.—A girl of eight developed an incessant cough, which drove the 
members of the family to distraction, but was easily controlled through suggestion. 
That imitation is a factor of much importance is shown the dancing 
mania of former days, and more recently by the school epidemics, neces- 
sitating the closing of the school. 
Illustrative Case.—In a country school a new girl had habit chorea. Two of the 
larger boys amused themselves imitating her. Other small boys and girls imitated 
the boys, and soon the whole group of 30 children were grimacing to such an extent 
that a temporary closure of the school was necessary. 
Hyperesthesia and anesthesia are not common. 
The Sensory Type.—This manifestation in children is also quite 
unusual. Hysteric anorexia or hysteric vomiting has occurred in a few HYSTERIA 
527 
instances. In hysteric anorexia the patient may be unable to eat in 
the presence of a certain person, or exhibit inability to eat in a certain 
room or locality, or be able to eat only with certain utensils or in a favorite 
room or locality, or with the body in a special position. 
Illustrative Case.—A girl three years of age was brought for treatment because 
she vomited at the table, over the table, and over any one who was sufficiently near. 
Not every meal was lost, and food given between meals was retained. There was 
sufficient disturbance of nutrition to warrant anxiety on the part of the mother. The 
child was pale, thin, and undersized, showing a moderate secondary anemia. From 
infancy there had been some gastrointestinal disturbance, and the child had been the 
source of much anxiety to the mother in this regard. For about a year the vomiting 
at the table had been very distressing. The child had been treated in various ways for 
stomach disorder or disease, without any improvement whatsoever. After a thorough 
examination and review of the case the diagnosis of hysteria was made and it was 
directed that the mother, who had neurotic tendencies, should keep apart from the 
child as much as possible. The child was now not allowed to dine with the mother, 
but was permitted to dine in the kitchen with the maid of all work. The vomiting 
stopped at once. After about ten days of dining in the kitchen, during which the 
patient showed marked physical improvement, the maid was called away on account 
of illness; the child returned to the family table, and again promptly vomited once or 
twice a dav at about the completion of the meal. In three days the maid returned 
and the child took up dining in the kitchen, with the former satisfactory results. This 
continued for a few weeks; then there was a disagreement between mistress and maid, 
and the maid left, never to return. Again the child was placed at the family table, and 
again the vomiting recurred. Whether the child ate with the family or dined alone, the 
presence of the mother was sufficient to produce the vomiting. Accordingly, after 
many terrible trials and many failures, the mother, thoroughly distracted, placed the 
child in the family of nearby relations, where there were no other children. Here she 
retained her food and throve. 
We have treated other vomiting cases of similar nature, but none so obstinate. 
Diagnosis.—The diagnosis of hysteria is made. chiefly by exclusion 
of symptoms referable to organic disease of any nature. Electric tests 
and other forms of examination will establish the non-pathologic char- 
acter of the illness. 
Duration.—There is a marked tendency to relapse. Patients who 
continue to live under the original neuropathic environment usually 
continue to enjoy their hysteria. Duration and prognosis depend upon 
the opportunity for right management and co-operation on the part 
of the family and friends. 
Treatment.—General.—Our results with hysteric children have usually 
been very good or very poor, depending to a great extent upon ability 
to separate the child from the family. By this statement the proper 
management of hysteric children is indicated. 
The child should, if possible, be removed from the unfavorable family 
influence. The boarding-school has effectually cured several of the 
writer’s cases. Here the child is placed under the care of trained teachers, 
who bring out the good apd correct the bad by reason, precept, and ex- 
ample, and thus exert a continuous beneficial influence. In the boarding- 
school, plain diet, pleasant occupation, agreeable association, and a scien- 
tifically regulated life replace the spoiling and coddling, and often the 
unsuitable food, together with the endless nagging which the neurotic 
mother is very apt to indulge in, with the best intentions, of course, but 
nevertheless with a most unfortunate effect upon the child. If the child 
is too young for a boarding-school, or if admission is denied him, he should 
be placed under the care of some kindly, well-balanced woman as com- 528 
THE PRACTICE OF PEDIATRICS 
panion and instructor, and see as little of his family as possible; other- 
wise but little can be expected from the treatment. Of course, the con- 
ditions must be explained fully to the parents, in order that they may 
make an effort to regulate their bearing toward the child in the right 
direction. If the former intimate associations with the child continue, 
the good intentions may prove effective only a very few days. It is 
impossible to reform the habits of life of a neurotic adult. Once hysteric 
always hysteric does not come far from the truth. The only hope for 
the child is in his complete removal from such unfavorable influences. 
Physical and Mental Activity.—The further treatment of hysteric 
children consists in curtailing the mental and physical activities, which 
almost invariably have been excessive. A rational scheme of living 
should be formulated. “Showing off” the child to visitors and others 
should be forbidden. If the patient is under ten years of age, he should 
retire at 7 o’clock every night, and rise at 7 every morning. It is to be 
understood by the attendant that this does not mean 6.45 or 7.15. Every 
day after the midday feeding the child should rest quietly in a darkened 
room for an hour or two. Whether he sleeps or not, he should rest in 
a recumbent position with clothing removed. For such children excit- 
ing games of stress and competition of every nature are forbidden. An 
outdoor life is to encouraged. A bicycle, a pony, an individual play-room 
in winter, and a tent on the lawn in summer, should be provided when 
possible. School instruction may be given, but the child is not to be 
crowded. The amount of study and school work depends, of course, 
upon the child’s condition. Until the tenth year, however, there should 
be but one session (and that in the morning) of one and one-half to three 
hours. The child should be given a tub-bath or brine bath daily at 
90° F. (p. 843). At the completion of the bath he should stand with his 
feet in warm water and be given a cool douche at 70° to 60° F., the spray 
tube being attached to a faucet. Cold water may be poured down the 
spine. This application of cold water should be for a few seconds only 
and should be followed by brisk rubbing with a rough towel, which should 
result in a decided skin reaction. 
Treatment During Hysteric Seizure.—During a hysteric seizure the 
child should be treated with kindness, but with firmness. No sympa- 
thy should be shown. The application of ice-water to the face and chest 
is usually sufficient to break up an attack. In some cases a certain amount 
of time appears to be required for a return to the normal. 
Drugs.—Sedative drugs, such as the bromids, should not be used. 
Cases have come under our observation showing the bromid rash. Such 
treatment, as also the use of the opium derivatives, cannot be too strongly 
condemned. Drugs that increase the appetite and improve nutrition 
should be given. Iron and arsenic, particularly, answer well in these 
cases, as most of the patients show a secondary anemia. For a child 
from five to ten years of age the following prescription has been useful: 
1$. Liquoris potassii arsenitis gtt. xlv 
Extract! ferri pomati gr. x 
Quininae bisulphatis gr. lx 
M. div. et ft. capsulse no. xxx. 
Sig.—One after each meal. HABITS 
529 
If constipation results from the use of the small doses of iron, § to 
| grain of the extract of cascara may be added to each capsule. If the 
child cannot swallow a capsule, the following may be used: 
1$. Liquoris potassii arsenitis gtt. xlv 
Ferri et ammonite citratis gr. xlviii 
Elix. simplicis gss 
Aquae q. s. ad. 5iv 
M. Sig.—One teaspoonful after each meal in a glass of water. 
The iron and arsenic may advantageously be alternated with pure 
cod-liver oil—1 to 2 drams after meals—each medicine in turn being 
given for seven successive days. Alcohol should form no part of the 
medication of these children. In using the so-called liquid proprietary 
foods, it is to be remembered that some contain a considerable per- 
centage of alcohol. 
HABITS 
Children readily acquire habits, good or bad. Under the manage- 
ment of an intelligent attendant, directed by the physician, natural 
tendencies toward the repetition of an act may be turned to the child’s 
inestimable advantage. In earliest infancy the habit of taking the nour- 
ishment at definite periods should be established, and as the child in- 
creases in age proper habits of sleep and rest must also be acquired. 
The child should be bathed at a stated time and aired at a stated time 
each day, and, in general, in order to fulfil the requirements of vigorous 
animal life, his life should conform to a routine in which there is but 
little variation. As our sole object is the production of a normal adult, 
only those habits tending toward proper growth and development should 
be encouraged. The habit of self-entertainment is important. An infant 
who requires to be constantly in arms when awake will have a tired 
attendant, and usually will develop into a tired and irritable child. 
Bad Habits and Their Correction.—Among the bad habits early 
acquired and difficult to break are those of thumb-sucking or finger-sucking 
and the use of the “pacifier.” A penalty paid by these children for such 
indulgence is thickened, boggy lips, due to hypertrophy of the orbicularis 
oris muscle and adjacent structures. Persistent sucking also produces 
a forward projection of the upper incisor teeth and an angular deformity 
of the upper jaw. The correction of the rubber-nipple and pacifier habit 
is readily accomplished by the immediate withdrawal of these articles. 
The child will experience several fretful days and make association tem- 
porarily unpleasant for those about him. The thumb-sucking habit 
may be corrected by having the child wear a mitten or glove made of 
muslin or old linen which is shirred and tied at the wrists. The Hand-I- 
Hold Mit (Fig. 95) answers the purpose of preventing thumb- and finger- 
sucking better than any other means. The child has full use of his arms, 
yet the hands contained in the aluminum mit are free from manipulation. 
If the child shows a tendency to bang the hard mits against objects 
about him a band of muslin containing parallel pockets in which wooden 
tongue blades are inserted may be wrapped about each arm at the elbow, 
thus preventing flexion of the forearms without interfering with shoulder 
or hand movements, and doing away with the necessity for the mits. 530 
THE PRACTICE OF PEDIATRICS 
Applying bitter drugs to the fingers or thumb may be effective in 
controlling the habit. The tincture of aloes or a solution of bisulphate 
of quinin, 1 dram to 2 ounces of water, is generally used. The fingers 
should be repeatedly moistened with the solution. Mothers will some- 
times tell us with considerable amusement that the application of the 
bitter drug to the finger makes no difference to the child; he appears to 
like the taste of quinin or aloes. The child, however, soon tires of the 
bitter taste, and continued use of the remedy will stop the habit. Biting 
the finger-nails may likewise be remedied by the use of bitter solutions. 
Picking or rubbing the finger-tips with the fingers of the opposite 
hand is rather an unusual habit. It may cause considerable hypertrophy 
of the ends of the fingers, so that they will acquire an appearance not 
unlike that occasioned in cardiac disease. Mechanical restraint is our 
best preventive. The constant use of gloves or the application of strips 
of adhesive plaster will break the habit. 
Head-banging is, fortunately, an unusual habit. It consists in re- 
peatedly elevating and bringing the head forcibly down on the mattress 
when asleep. This we have seen done with sufficient force to produce 
vibrations in the other rooms of the house and interfere with the repose 
of the occupants. In one instance every means and device for preventing 
the banging was tried without effect. Finally the patient became such 
a nuisance to his family that he was made to sleep in a hammock. This 
was the means of curing the condition. 
Head-rolling is practised with the child resting on the back, the head 
being rolled rapidly from side to side. 
Illustrative Cases.—A two-year-old child at the Nursery and Child’s Hospital im- 
mediately began this rolling whenever resting on the back. As many as 50 oscillations 
would be made in a minute. In this position the child continued until overcome by 
fatigue or sleep. We were unable to control this habit and the child passed out of 
the hospital with the rolling in full force. 
One of our most troublesome cases was that of a child one year old who had an ear 
stretched to twice its normal size. During the greater part of the waking hours the 
child grasped and pulled at the top of the left ear. 
Another patient was brought because of the habit of burrowing the right thumb 
into the right nostril. The nostril had become stretched to at least three times its 
normal size, causing a most peculiar deformity. 
An eight-year-old girl developed the habit of striking her left leg at the calf with 
the heel of her right shoe when walking. Her stockings soon became worn and soiled, 
and the child presented a ridiculous appearance in public. In running or in going up 
and down stairs the habit was not practised. This peculiar habit had been kept up 
for several months. She had received the usual punishments and rewards without 
effect. Upon discovering that she practised the leg-banging only when walking, the 
writer advised a treatment which proved effective. This consisted in not allowing the 
child to walk for six months. She was made to run or walk rapidly whenever walking 
was necessary. 
A girl six years old, without eczema or any evidence of irritation, had the habit of 
rubbing the right thigh. While walking a city block she would raise the clothing with 
the right hand and rub the outer lower third of the thigh for a second. This act, ac- 
cording to the mother, would be repeated a hundred times a day if there was no inter- 
ference. The treatment suggested in this case was simple and effective. Several 
thicknesses of a roller bandage were used in covering up the favorite skin area. What- 
ever gratification was experienced by the manipulation was thus done away with, and 
the habit was promptly broken. The parts were kept bandaged for three months. 
The most pernicious habit, that of masturbation, is referred to below. 
It is impossible to make more than general suggestions for the cor- 
rection of bad habits in children. When there is manipulation of the MASTURBATION 
531 
mouth, the sense of taste can usually be made to aid us. In other instances 
restrictions of a mechanical nature may be necessary. In the ear-pulling 
case, a tight-fitting muslin cap was wrorn constantly and the right hand 
kept pinned to the clothing. Punishment, rewards, and ridicule all may 
be employed in the treatment of these cases. As a rule, however, such 
measures are not as effective as mechanical restraint. Bad habits as to 
hours for feeding and sleeping, as well as the habit of carrying a child 
in arms—all may be corrected by doing the right thing at the right time 
and having a sufficient amount of courage to persist. It is to be remem- 
bered that, regardless of age, a child is never harmed by rigid discipline 
properly applied. 
MASTURBATION 
Before the fifth year a great many more cases of masturbation are 
seen among girls than among boys. After that age it is more frequent in 
boys. The most common method of practising masturbation in either 
sex in infancy is by leg-rubbing. Contact by means of the edge of a chair 
or the corner of a sofa or any object against which pressure may be exerted 
is not infrequently the means used by older girls. Manipulation of the 
parts, while only occasionally seen in girls, is the usual method of boys 
after the third year. 
Our youngest patient was a female child six months of age who was a “leg-rubber,” 
and who evidently passed through a complete orgasm. 
By many the habit will be indulged in several times a day. 
In boys the primary causes of the practice are an elongated foreskin, 
adherent prepuce, and phimosis. The handling of the parts necessary 
to keep the uncircumcised clean is an exciting factor. In girls, vulvitis 
and vaginitis, and adhesions of the clitoris, with the retained smegma 
and resulting irritation, are frequent causes. It is a popular notion that 
thread-worms may be an exciting factor, but among many cases of mas- 
turbation and many cases of thread-worms we do not recall seeing both 
conditions in the same child. 
Prophylaxis.—Masturbation is much easier to prevent than cure. 
In boys, prevention lies in keeping a clean, free glans, which in the great 
majority of male infants can be obtained only after proper surgical pro- 
cedures. The elongated, thickened, uncut portion of the foreskin often 
seen below the glans after a ritual circumcision is but little better than a 
free, elongated prepuce. Slitting of the foreskin on the dorsum gives a 
condition very similar in character to that of a long, redundant foreskin. 
In girls, prevention to a certain degree consists in keeping the parts clean 
through washing them once a day with great gentleness, and the free use 
of non-irritating absorbent powders. A powder composed of equal parts 
of powdered starch and oxicl of zinc gives very satisfactory results. 
Treatment.—When the habit of masturbation has been once estab- 
lished, the first step is to eliminate the cause, if it can be discovered, 
and put the parts in a normal condition. Circumcision in boys, and 
releasing the adhesions of the clitoris in girls, with the maintenance of 
cleanliness and as little manipulation as possible, are absolutely essential. 
The urine should be examined, and if found highly acid, should be 532 
THE PRACTICE OF PEDIATRICS 
corrected by diet and by the use of bicarbonate of soda, CO to 120 grains 
being given daily, according to the age of the patient. If red meat has 
formed a considerable part of the diet, the quantity should be reduced 
and given not oftener than three times a week. 
Having removed all possible sources of local irritation, we are in a 
position to use restrictive measures, as it is through such treatment only 
that a cure will finally be effected. If the practice is prevented the habit 
will soon be forgotten. The older the child, the more difficult will be the 
cure. The restrictive measures employed depend to a considerable extent 
upon the age, sex, and method of practice. In the case of young children 
of both sexes who practise leg-rubbing a large napkin of some coarse 
material, or a towel, should be placed over the napkin usually worn, and 
applied in the same way, so as to keep the legs widely separated. After 
the napkin age a large towel may be used, if necessary, for the same pur- 
Fig. 94.—Knee-crutch.1 
pose, or the knee-crutch (Fig. 94) may be employed. Some children will 
indulge only when in a certain chair or in a certain position. 
Illustrative Cases.—A very troublesome case in a girl seventeen months old had 
been treated without success for several weeks, when it was discovered that the child 
practised the act only when in her high chair, as by leaning forward and grasping the 
projecting arms she managed to bring the necessary pressure to bear upon the genitals. 
The use of the chair was discontinued, and there was no further trouble. 
Another girl six years of age was an inveterate masturbator who had been treated 
unsuccessfully by several physicians. The act was repeated daily, sometimes two or 
three times a day, usually by contact, such as by pressure against the corner of a table, 
sofa, or chair. When in bed she indulged in the practice by manipulation. She had 
become pale, thin, and hysterical, and as she was a member of a prominent family, 
great concern was felt for her. The external genitals were congested and swollen as a 
result of the direct irritation, otherwise they were normal. It seemed that here was a 
case where eternal vigilance was the price of safety. The gravity of the condition was 
apparent, and the parents readily agreed to the suggestion that the child should never 
be left alone. The mother and the nursery maid took turns in being with the child 
in the daytime. A trusty middle-aged woman was selected for the night watch. Direc- 
tions were given that no reference be made to the habit, but that the child should be 
severely punished if the practice was attempted. This, however, was not needed. 
This child, as is the case with all older children, masturbated in secret, and as she 
was never left alone, stopped the practice. She was given suitable food, teaching by 
a visiting governess was begun, and hard play was soon advised, as her physical im- 
provement was rapid. As there was no further tendency to masturbate, the night watch 
was withheld after six months. The child was kept under the closest observation, how- 
ever, for a much longer time. Co-operation to such a degree as in this family may, 
however, rarely be secured. 
1 Made for the author by George Ermold Co., 201 East 23d St., New York City. INFANTILE CONVULSIONS 
533 
Older children who practise manipulation of the parts can usually be 
watched during the daytime, but the habit is frequently indulged in on 
going to bed, after the lights are out, and in 
the early morning, particularly when pre- 
vented during the day. In such instances 
it has been necessary to advise mechanical 
restraint. An inexpensive and effective 
means is a piece of tape, which is tied in 
the center around the child’s neck in a fiat 
knot, leaving the two ends long enough to 
be securely tied around the wrists, so as 
to allow a free movement of the hands 
above the umbilicus. The child can use 
the handkerchief, and adjust the bed- 
clothing, but cannot touch the genitals. If 
the patient is a girl and a masturbator by 
contact with any object, or a leg-rubber, a 
large bath towel, if worn like an infant’s 
diaper, will aid materially in discouraging 
the practise. A brace constructed of steel, 
with a hinge-joint to allow the arm to be 
extended to an angle of about 45 degrees, 
has been used with success in a few cases. 
This brace is worn only at night.1 
The “ Hand-I-Hold Mit.”2—As a means 
for the prevention of scratching, thumb- 
and finger-sucking, nose-boring, ear- and 
lip-pulling, and masturbation the “Hand- 
I-Hold Mit” renders good service. The 
child has free use of the arms and the fingers are movable inside 
the mit. In eczema, however, the hard mit may serve as a very at- 
tractive means of rubbing the diseased surfaces. 
Fig. 95.—The Hand-I-Hold 
Babe Mit and method of apply- 
ing: a, First, roll sleeve over 
ball to expose opening, then in- 
sert the child’s hand; b, second, 
tie tape at wrist and pin with 
safety-pin to dress at elbow. If 
mit is not held in place firmly 
enough, use a broad piece of 
cheese-cloth in place of tape. 
Bind this firmly around the 
wrist and tie; c, x-ray view 
showing freedom of hand. 
Hiccup is a spasm of the diaphragm, usually due to gastric irritation 
from the distention of the stomach or intestine "with gas, or overloading 
of the stomach with food. Under such conditions the spasm is usually 
of little consequence, and may readily be relieved, if the attack is pro- 
longed, by an enema of soap-water and a laxative dose of rhubarb and 
soda. (See p. 100.) With any grave illness, however, persistent hiccup 
is a symptom of serious import. Hysteric girls often have hiccup to quite 
an alarming degree. The attack usually follows a period of unusual ex- 
citement. In these cases from 20 to 30 grains of bromid of soda repeated 
in from twenty to thirty minutes will usually control the spasm. 
HICCUP 
INFANTILE CONVULSIONS 
A convulsion consists of a temporary loss of consciousness, associated 
with clonic contractions of various muscles of the body. 
1 This device had its origin with Dr. Gerald Webb of Colorado Springs. 
2 Manufactured by R. M. Clark & Co., Newton Centre, Mass. 534 
THE PRACTICE OF PEDIATRICS 
During the early days of life a convulsion is always of serious import, 
as it frequently is the result of a birth trauma and suggests a serious 
brain lesion which may terminate in early death or result in spastic paral- 
ysis or idiocy, or both. 
Etiology.—Infants and young children are peculiarly susceptible to 
convulsions because of lack of inhibitory control, due to insufficient 
development of the motor centers in the cortex, which, in consequence, 
discharge the more readily. A convulsion may be looked upon as a motor 
discharge affecting either the entire muscle structure or only a portion 
thereof. Convulsions, therefore, indicate cortical irritation. The irrita- 
tion may be due to injury of the brain structure, as previously mentioned, 
birth trauma being the usual cause of convulsions in the very young, or 
may be the result of meningitis, tumors, hydrocephalus, or trauma in 
later life, such as a fall or blow on the head. 
Illustrative Case.—An infant of eleven months fell from his baby carriage to the 
stone pavement. Convulsions, repeated and severe, continued until the bleeding 
area in the cortex was located, the skull was opened, and the bleeding vessel was tied. 
Heredity as a predisposing cause of convulsions apparently plays but 
little part, except in epilepsy. 
Convulsions may be due to indirect causes. 
Rachitis is a most fertile contributing cause. The reason for this is 
not clearly understood. Various theories have been advanced. Probably 
the nerve-centers share with other portions of the body in malnutrition 
and lack of development. In a rachitic individual the inhibitory control 
is of a very low order. In many rachitic children it is surprising how little 
irritation may bring on a seizure. 
The subject of tetany is discussed on p. 542. 
Gastro-intestinal Cases.—An immense majority of the cases of convul- 
sions coming under our notice have been due to gastro-intestinal disorder, 
most frequently in the form of acute indigestion due to unsuitable articles 
of diet. Rachitic children have supplied many of these cases. 
If the irritation is sufficiently severe convulsions may occur in the most 
robust. 
Thus, a boy of three years had repeated convulsions until he was relieved of 43 
large round-worms (lumbricoids). 
Convulsions of intestinal origin may be due either to the effects of 
toxins elaborated by abnormal digestive processes or to direct intestinal 
irritation. 
A case of the latter type was seen in the New York Infant Asylum, where a child 
had repeated convulsions and died in a seizure. At the autopsy a fourth of a small 
orange was found in the intestine. 
Thymus Gland.—Enlargement of this gland has been present in a 
number of personally observed cases of fatal convulsions. The majority 
of the cases have been seen in hospital work, where the enlargement of the 
thymus could be proved at autopsy. 
Convulsions of toxic origin may usher in pneumonia, scarlet fever, or 
any of the acute infectious diseases. INFANTILE CONVULSIONS 
535 
Uremic convulsions are to be classed under this heading. 
Convulsions are frequently the termination of a prolonged broncho- 
pneumonia or enterocolitis. 
Convulsions in the Newborn.—Particularly disturbing cases are those 
of the newborn, who do not develop convulsions, but grimaces and slight 
twitchings of the face, with a tendency to stupor and irregular respira- 
tions, all very bad signs indeed in a newborn baby. These cases may go 
on to the development of true convulsions, but many never show more 
active symptoms than those mentioned. Particularly unfavorable is the 
outlook if these various manifestations are combined even to a mild 
degree. Sooner or later the child appears for treatment because of re- 
tarded mental development. 
Dr. W. Sharpe, of New York, has performed the decompression opera- 
tion on several of these infants; those with active nervous symptoms, and 
those in which there wTas nothing but defective mentality with a suggestive 
early traumatic history. The extent and degree of the lesions, hemor- 
rhage, cysts, etc., which are to be found with comparatively slight attend- 
ing manifestations have been surprising. 
Dentition may indirectly be a cause in producing indigestion, with 
resulting irritation and toxemia. 
The writer has had 3 patients who had convulsions with every tooth cut and 
without demonstrable associated digestive disorder. 
Phimosis: 
Two boys had repeated convulsions which subsided when they were circumcised 
and relieved of much smegma and local irritation. 
Asphyxia: 
A strong boy nine months of age was taken in bathing by his mother. A large 
wave enveloped and separated them. The baby was unconscious when found. With 
returning consciousness he passed into a convulsive state which lasted several hours. 
Evidently there was a cerebral hemorrhage, as the child is now an imbecile and had been 
perfectly normal before. 
Tetany (p. 542).—Severe convulsions, although exceptional, may be 
present in severe tetany. In tetany the manifestations are usually those 
of continuous tonic contractions. The association between rickets and 
tetany is elsewhere discussed (pp. 540-543). 
Repetition.—With each convulsion, of whatever origin, the inhibitory 
control is lessened, and each succeeding seizure requires less cortical irrita- 
tion than its predecessor. Gowers has stated that 30 per cent, of the cases 
of epilepsy have their origin in so-called simple infantile convulsions. 
Manifestations.—Convulsions vary greatly in their manifestations. 
The seizure may be so slight as to be scarcely recognized. These are the 
so-called “inward” convulsions. There may be a momentary spasm of the 
body, with slight twitching of the face and extremities, after which the 
child appears normal or sleepy and dull for a few moments. The convul- 
sion, on the other hand, may be most intense and prolonged. The onset 
is sudden. There are usually twitchings of the muscles of the face and 536 
THE PRACTICE OF PEDIATRICS 
inco-ordinate movements of the extremities. There are alternate con- 
tractions and relaxations of all the muscles. The eyes become set and the 
child is unconscious. There is frothing at the mouth and the breathing is 
stertorous and labored. The child may rapidly pass out of the convulsive 
state or become quiet, with infrequent twitchings, and thus remain for 
hours. 
In a fatal case the temperature was 111° F.—as high as the thermometer would 
register. The temperature was reduced, and the child lived eight hours, but never 
regained consciousness. 
In many instances the child passes from one convulsion into another. 
During active treatment, such as the hot bath and chloroform administra- 
tion, the seizure will apparently cease, and the child will show signs of 
returning consciousness. As soon as the treatment is discontinued the 
convulsion is again repeated. 
Prognosis.—We have seen a considerable number of cases of fatal 
convulsions, and do not look upon any attack with unconcern. The 
prognosis depends entirely upon the general condition of the patient and 
the direct cause of the convulsions. In the convulsions of scarlet fever, 
pneumonia, and gastro-enteric disease there is usually but little danger to 
life. If the attack is due to an enlarged thymus, the ultimate prognosis 
is unfavorable unless the case can receive the benefit of x-ray therapy 
between seizures. 
A convulsion may be serious in its immediate, as well as in its remote, 
effects. One convulsion may produce cerebral hemorrhage, which may 
change the entire future of the patient, producing spastic paralysis or 
idiocy, or both. About 10 per cent, of the cases of epilepsy originate in 
indigestion—the so-called “dentition convulsions.” In these rachitis plays 
an important etiologic part. 
Under the senior author’s observation several children under one year 
of age, in apparently good health, have died as the result of convulsions. 
In 1 case was found, upon autopsy, as above noted, one-fourth of an 
orange in the small intestine. In 6 the convulsions were due to enlarged 
thymus glands. In 3 of these cases there had been no previous symp- 
toms indicating the existence of this condition. The patients were strong, 
robust infants. Two were breast fed. The diagnosis was confirmed by 
autopsy in 4 cases, which included the breast fed. 
Treatment.—Immediate Treatment.—When a convulsion occurs the 
patient should at once be undressed and placed in a mustard bath (p. 843) 
at a temperature of 105° F. While in the bath he should receive brisk 
friction of the trunk, and particularly of the extremities. At the same 
time an attendant may give an enema of soap-water. In a great majority 
of the cases in less than five minutes the child will show evidence of a 
return to consciousness. As soon as he can swallow, 2 teaspoonfuls of 
castor oil should be given. 
After a seizure the patient should be kept very quiet for twenty- 
four to forty-eight hours. An ice-bag or cold cloths should be applied 
to the head, and a guarded hot-water bottle kept at the feet. 
Diet.—The diet should be the lightest. Chicken broth, weak beef- 
tea, and thin gruels should constitute the nourishment for a day or two. LARYNGISMUS STRIDULUS 
537 
A second seizure is more easily produced than the first, and a third easier 
than the second. 
The Use of Chloroform and Sedatives.—In case the attack is a very severe 
one, when the child is slow to respond or when he passes rapidly from 
one convulsion to another, chloroform inhalations, regardless of the age, 
should be given in sufficient quantity to prevent the seizures until the 
intestinal canal can be emptied, and sufficient sodium bromid and chloral 
can be given by mouth or rectum to prevent a recurrence. 
Rectal Medication.—To a child under one year of age 8 grains of 
sodium bromid and 3 grains of chloral may be given by rectum in 2 ounces 
of mucilage of acacia. After the first year from 3 to 5 grains of chloral 
may be given with 10 to 20 grains of sodium bromid. It is best to attach 
to the syringe a soft-rubber catheter (No. 18 American) or a small rectal 
tube. The catheter should be introduced for at least 9 inches if possible, 
so that the solution may be carried to the descending colon, where it will 
be retained better than if introduced with the small hard-rubber tip just 
within the anus. The bromid and chloral may be repeated at intervals 
of two to six hours, as required to control the convulsions, and continued 
in diminished doses as long as there are noticeable signs of nervous irri- 
tability, such as twitching and involuntary muscular contractions. 
Sedatives Internally Administered.—If the child can swallow, 5 grains 
of sodium bromid in | ounce of water may be given, and repeated at inter- 
vals of one to four hours until the convulsions are controlled. 
Hypodermic Medication.—Morphin hypodermically is rarely required. 
It should be used only when other means fail. A child one year of age 
may be given 1/30 grain, and this may be repeated in two hours, though 
usually it will not be required. Under one year, 1/50 to 1/40 grain may 
be given; under six months, morphin should be omitted. 
LARYNGISMUS STRIDULUS 
In laryngismus there is a spasm of the larynx involving the muscles 
of both inspiration and expiration. This rarely occurs after the eigh- 
teenth month. 
Etiology.—The part played by the thymus in laryngismus stridulus 
may be very important. The writer has seen 2 typical cases of laryn- 
gismus end fatally, with enlarged thymus as the cause of death. An 
x-ray examination of every case of laryngismus is essential. 
Laryngismus is very frequent in rachitic and poorly nourished chil- 
dren. The seizures are induced by fright or anger, and the attacks cease 
in many instances with spoiling the child, allowing him to have his own 
way, by improving his nutrition, and following the use of belladonna 
and bromids. If the thymus were the all-important factor in all cases 
we would not expect a response to the treatment outlined. Further, 
autopsies on infants who have had laryngismus do not always show 
involvement of the thymus. We must continue to look for the expla- 
nation of many of our cases in their belonging to the family of spasmo- 
philics. 
Morbid Anatomy.—No definite lesion has been found to account 
for the spasm, which occurs in association with a wide variety of morbid 
states, as well as without any apparent pathologic condition. 538 
THE PRACTICE OF PEDIATRICS 
Symptomatology.—The attacks are usually excited by some disturb- 
ance of the child’s mental state. Thus, crying ushers in most of the 
paroxysms. The child attempts to draw in the breath preparatory to 
the cry, and the laryngeal spasm begins. There may be several short, 
whistling inspirations, each attempt being less successful than the first. 
The whole procedure requires but a few seconds. The face is first red, 
then blue and cyanosed. The absence of respiration continues for an 
indefinite time—usually but a few seconds. Then the spasm subsides, 
and the child “catches” his breath, which is signaled by a short inspiratory 
crow, followed by a series of longer and more successful inspirations. 
The child cries, the blood becomes oxygenated, the normal color returns, 
and all is well until the next attack. 
The attacks may be milder or more severe than the foregoing. In 
the mild cases complete apnea does not take place. In others the laryn- 
geal spasm is complete from the onset. The child attempts to cry, and 
falls into what the mother calls “a faint,” becoming thoroughly relaxed 
and unconscious. Such attacks as these are always cause for much anxiety, 
as they suggest strongly the possibility of enlarged thymus and sudden 
death. The period of unconsciousness may persist for a variable time, 
ranging from a few seconds to a minute or two. 
A patient three months of age had from twenty to thirty seizures a day, and the 
attacks ceased only with an improvement in the child’s general condition. 
Diagnosis.—The diagnosis is made by the sudden onset of difficult 
breathing, the rapid return to normal breathing, and the continuation 
of normal, unimpeded breathing between the attacks. In susceptible 
subjects the laryngismus may occur with whooping-cough and with 
acute catarrhal laryngitis. These diseases have a distinct symptoma- 
tology of their own, and need cause no confusion. 
Congenital Laryngeal Stridor.—The obstruction is of a mild degree 
and present a greater part of the time. It is relieved during crying and 
at its worst when the child is asleep (p. 540). 
Prognosis.—The prognosis, in the main, is good, but when one has 
seen sudden death in infants in private families and others in hospital 
work, all with the laryngeal spasm association, he does not have the 
confidence in the outcome of a convulsion that is claimed by many writers. 
Prompt results under treatment, except in mild cases, are the excep- 
tion. The attacks may continue, varying widely in number, for several 
weeks. The intervals between attacks in favorable cases lengthen and 
the attacks become less severe. 
Treatment.—The management is divided into two parts: the immediate 
relief of the spasm, and the treatment of the patient’s debilitated physical 
condition, if such condition exists. From our observation, the most 
satisfactory method of relieving spasm in the mild cases—those in which 
the unconsciousness is of but a few seconds’ duration—is by inverting 
the patient and at the same time slapping him on the back. Splashing 
cold water in the child’s face may be of advantage in some cases, but we 
have found it of but little service. In cases which are sufficiently pro- 
longed to resist inversion and slapping on the back, a quick resort to 
alternate hot and cold tub baths, at 60° and 120° F. respectively, has LARYNGISMUS STRIDULUS 
539 
been useful. If recovery is not prompt, intubation or tracheotomy should 
be performed, followed by attempts at artificial respiration. 
Drugs.—Between the attacks the patient should receive small doses 
of antipyrin and sodium bromid. Under six months of age § grain of 
antipyrin and 2 grains of sodium bromid may be administered in 1 dram 
of cinnamon-water, six doses being given in twenty-four hours. From 
the age of twelve months to the third year 1 to 2 grains of antipyrin 
with 2 to 4 grains of sodium bromid may be similarly administered, six 
doses being given in twenty-four hours. The only disadvantage in the 
use of the drugs lies in the fact that these children may have faulty diges- 
tion, which condition may be aggravated by the sodium bromid. When 
this effect is observed, the bromid should be omitted and the antipyrin 
given alone. Antipyrin apparently never produces any unfavorable effects 
upon gastric digestion. 
Rectal Medication.—Colon medication may be of considerable ser- 
vice in these cases, and, when indicated, bromid and chloral are our most 
reliable sedatives. To a child of six months or under, 1 grain of chloral 
with 5 grains of sodium bromid may be given in 2 ounces of mucilage 
of acacia by the bowel; to a child of six to twelve months, 2 grains of 
chloral and 8 grains of sodium bromid in 3 ounces of mucilage of acacia; 
to a child of twelve to twenty-four months, 2 grains of chloral and 10 
grains of sodium bromid may be given in 2 ounces of mucilage of acacia. 
The bromid and chloral should not be administered oftener than once 
in six hours. 
The method of administration is as follows: A large soft-rubber 
catheter or a small rectal tube, attached to a Davidson syringe, should 
be introduced at least 9 inches into the rectum, so as to reach the de- 
scending colon. The child should rest on the left side, with the but- 
tocks elevated on a pillow so that they are higher than the shoulders. 
After the withdrawal of the tube the position of the child should be main- 
tained for several minutes in order to aid in the retention of the fluid. 
After the Attack.—All sources of reflex irritation should be removed. 
If difficult dentition is a factor, the troublesome tooth should be brought 
through the gum. Adenoids, thread-worms, adherent prepuce, and con- 
stipation all should receive proper attention. Particularly must these 
children be kept free from all sources of mental excitement, such as loud 
talking, the overattention of adults, and the rough, active play of older 
children. 
Diet.—'The dietetic management of debilitated, rachitic children 
suffering from laryngismus is the same as that of other debilitated chil- 
dren. (See Malnutrition, p. 137.) In general, they should be given as 
high a protein diet as is compatible with their digestive powers. Thus, 
if there is intolerance of cow’s milk given in suitable dilution, there should 
be no hesitation in advising the employment of a wet-nurse. If the 
proprietary foods are given, they should be used with cow’s milk. For 
children over one year of age cow’s milk, cereals containing a large amount 
of nitrogen, such as oatmeal and soy-bean gruel, soft-boiled eggs, beef 
juice, and scraped beef should form a large part of the diet. 
Antirachitic Treatment.—To meet the rachitic element common in 
cases of this type cod-liver oil should be administered, if the digestion 540 
THE PRACTICE OF PEDIATRICS 
permits, as a routine procedure. In addition, calcium chlorid or bromid is 
indicated as in the treatment of tetany (p. 546). 
CONGENITAL STRIDOR 
Attention was first called to this disease by Rilliet and Barthez in 
1853. 
Etiology.—Various explanations have been offered as to the cause 
of the stridor. It is probably due to a bilateral abductor insufficiency, 
a general relaxation of the larynx, with the result that during inspiration 
there is a partial collapse of the muscular equipment and the lumen of 
the larynx is narrowed in consequence. As the child grows older the parts 
enlarge, the tissues become firmer, a better nerve control is established, 
and the inspiratory obstruction is gradually relieved. 
Symptoms.—The condition is characterized by an inspiratory crow, 
slight in character but fairly constant when the child is quiet and asleep. 
It usually disappears under stress, such as crying. The sound produced 
has been variously described as a crow, a cluck, a croak, etc. It appears 
at birth or within a few days, and continues for months. 
In a very pronounced case the stridor continued until the child was eighteen months 
of age. So noisy was the breathing during sleep that it could be heard in an adjoining 
room with the doors closed. 
As a rule the stridor gradually lessens and ceases before the child 
is one year of age. 
Diagnosis.—So characteristic is congenital stridor that it can hardly 
become confused with anything else. Beginning at birth and continuing 
with but little intermission in pronounced cases, it is most pronounced 
when the child is quiet and when asleep. It disappears under stress. 
There is no hoarseness; no air-hunger. The obstruction involves inspira- 
tion only and is not sufficient to produce discomfort. 
rc-Ray is of value in the differentiation of thymic enlargement. 
Treatment.—No treatment is required. 
Definition.—The term “spasmophilia” was originated by Finkelstein 
and is applied to a state of abnormal nervous irritability in infants, the 
expression of which is in one or more forms of spasm, principally holding 
the breath, convulsions, carpopedal spasm, and laryngospasm. By some 
authors “spasmophilia” is used to designate only the latent form of this 
disease to which, as a whole, is applied the name “tetany.” 
Etiology.—Spasmophilia in all its forms is most common in bottle-fed 
infants after the third month. Heredity exerts some influence in the 
causation and cases are not uncommon among several children of the 
same parents. Spasmophilia and rickets are very closely associated, 
and spasmophilia, like rickets, has been ascribed to a deficiency of lime 
salts in the system. Quest has demonstrated the existence of such a 
deficiency in the brains of children dying from tetany. Marriot and 
Howland have shown a marked reduction of calcium in the blood of 
infants with marked cases, and MeCallum and Voegtlin have shown 
the same condition in the blood of animals with experimental tetany 
SPASMOPHILIA AND TETANY SPASMOPHILIA AND TETANY 
541 
induced by extirpation of the parathyroids, thus confirming Escherich’s 
view that the disease might be due to hemorrhages or other lesions in 
these glands. 
Toxemia from infectious diseases or digestive disorders conduces to 
outbreaks of spasmophilia, and most of the active manifestations are 
observed in the late winter and early spring. 
The pathologic findings, apart from the presence occasionally of hem- 
orrhages in the parathyroids, are the lesions of associated rickets. 
Symptoms.—Lowenburg conveniently divides spasmophilia into two 
types: latent spasmophilia and manifest spasmophilia. Latent spas- 
mophilia is recognized by the presence of abnormal electric reactions 
together with reflex phenomena of nervous origin which may be elicited 
by mechanical stimulation. The amount of electric current required 
to produce a kathodal opening contraction in the muscles of a spas- 
mophilic infant is always less than the amount necessary to produce 
the same reaction in a normal infant. Such response to a current of less 
than 5 milliamperes indicates positive spasmophilia. Chvostek’s sign is 
an evanescent facial contraction elicited in spasmophilics after the second 
month of age, upon tapping the cheek just below the zygomatic process 
of the superior maxilla. Trousseau’s sign is the occurrence of a char- 
acteristic carpal contraction in an extremity following ligation of the wrist 
or ankle in such manner as completely to occlude the blood-supply. The 
peroneus phenomenon obtained by tapping the peronei muscles consists 
in a drawing up of the foot with the toes raised and slightly elevated. 
Theimich’s lip sign consists in a protrusion or pouting of the lips, elicited 
by tapping the orbicularis oris. So-called manifest spasmophilia is char- 
acterized in addition by laryngospasm, carpopedal spasm, eclampsia or 
convulsions of a general character, and by a peculiar induration (hard 
edema) of the hands and feet. The laryngospasm occurs upon slight 
disturbance of the child’s nervous balance and may occur even during 
sleep. Laryngospasm is common during fits of crying and differs from 
congenital stridor particularly in the peculiar crow which in spasmophilic 
laryngospasm follows a state of apnea and cyanosis of possibly a full 
minute’s duration. Many attacks in one day are not uncommon. 
The carpopedal spasm consists in tonic contractions of the hands 
and feet. The larger joints are held flexed, the thumb adducted, and 
the foot typically in a position of equinovarus. 
Eclampsia in spasmophilics is marked by the occurrence of clonic 
convulsions independent of brain lesions, nephritis, and epilepsy. 
The hard edema of the hands and feet is supposedly a vasomotor 
phenomenon. 
Diagnosis.—Among the conditions frequently confounded with spas- 
mophilia are epilepsy, tetanus, pertussis, enlarged thymus, congenital 
stridor, laryngeal stridor, and retropharyngeal abscess. Of these, epilepsy 
is most difficult to exclude. The typical reflexes and electric reactions 
of spasmophilia are of the greatest value for differentiation in doubtful 
cases. 
Prognosis.—Under intelligent care and feeding the outlook is good. 
Progress may be confirmed by the observance of a steadily closer and 
closer approximation to the normal in reflexes and electric response. 542 
THE PRACTICE OF PEDIATRICS 
Treatment.—Maternal nursing and wet-nursing are of greatest value 
not only in preventing tetany, but in limiting its progress. Holt has in- 
sisted that to infants under eight months of age who give of 
tetany woman’s milk should be supplied if possible. Aside from this 
the fundamental management of spasmophilia is essentially that of 
rickets. Most cases do well on cod-liver oil provided the oil can be borne 
by the digestion, which is probably most tolerant if the oil is given about 
half an hour after the feeding. Calcium bromid in simple solution is 
generally recommended as the sedative of choice. The dose of the salt 
should be sufficient to control the spasm and may vary from 20 to 40 
grains daily. Where this is unobtainable or ineffective, chloral, chloro- 
form, or even morphin hypodermically in dosage up to 1/100 grain, 
may be given. Gastric and intestinal lavage are of value when there 
has been overloading of the digestive tract or toxic absorption there- 
from; and when there are general convulsions or pronounced spasms of 
the extremities warm baths are to be employed. 
Tetany 
Frank, active tetany is characterized by persistent tonic contractions 
of the muscles, usually of the upper and lower extremities. In rare in- 
stances cases will be seen in which the peculiar tonic contraction involves 
all the muscles of the body and may assume the character of a general 
convulsion. 
Etiology.—This affection is rarely seen after the second year, though 
cases are occasionally reported as occurring in older children. 
Tetany is most commonly seen in marasmic infants suffering from 
intestinal derangements of a not very active type. Occasionally it occurs 
in well-nourished children. Rachitis is present in the majority of cases. 
In nearly all cases seen by us malnutrition or pronounced digestive dis- 
turbance has been present. 
Illustrative Case.—A baby three months of age was given a high fat mixture (7 
per cent.) in order to supplement the mother’s milk. After a few feedings the child 
developed convulsions, with the typical tonic contractions. Under treatment the 
mental condition cleared, but general muscle contractions continued, which evidently 
caused great pain. The child was absolutely rigid, with both the lower and the upper 
extremities in the characteristic position, which continued for several days. 
The actual cause of this disease is still obscure, but from time to 
time new light is thrown upon the subject. The majority of the cases 
are seen during the winter and early spring months, and, owing to this 
fact, Kassowitz’s theory of a respiratory infection received strong con- 
firmation. Escherich, Ganghofner, and others found that manifest tetany 
and laryngospasm in children increase during the beginning of winter, 
and gradually reach their highest point in February and March, after 
which they diminish in frequency until midsummer, when the incidence 
is practically zero. Escherich’s statistical table of 240 cases shows: 
Month I II III IV V VI VII VIII IX X XI XII 
Number of cases.. 29 51 59 45 10 7 0 1 4 2 21 16 
In extensive work Wilcox, of New York, found that during the months 
of December, January, and February he obtained the greatest number TETANY 
543 
of middle-grade reactions, while 3 of his cases of frank tetany occurred 
in February and 2 each in December and January. The incidence of 
hyperirritability was greatest in December. 
It appears, from the literature on the subject, that the frequency 
of tetany varies considerably in different countries and cities; in some 
localities the cases are almost frequent enough at least to suggest an 
epidemic. In infancy males seem to be more frequently affected than 
females. 
According to Fischl fully 63 per cent, of subjects are rachitic; this, of 
course, will vary in different countries. Kassowitz demonstrated the sim- 
ilar relation to the time of year existing between the incidence of tetany 
and that of the rachitic affections. He came to the conclusion that there 
must be an intimate relation between the two. Wilcox concluded that 
the child’s irritability varies directly with the general condition of nutri- 
tion, and that the well-developed and nourished respond much less readily 
to galvanism than those underfed and below the normal weight. 
Seligmiiller, Pott, Thiemich, and others became convinced that spas- 
mophilia (tetany, laryngospasm, and eclampsia infantum) possesses in 
a well-marked degree the characteristics of heredity. Thiemich’s decis- 
ion has come from a dozen observations at the Breslau Kinderklinik 
relating to families in which the mother had laryngospasm or eclampsia 
in her childhood, and exhibited a pronounced facial phenomenon as a 
residuary latent symptom. 
Cold, intestinal parasites, bowel infections, chronic intestinal dis- 
turbances (of which there were fully 73 per cent, in Fischl’s cases), and 
an enlarged thymus have all, in turn, been regarded as causative fac- 
tors. Concerning the latter theory, which was advanced by Paltauf, 
one must consider the contrast existing between the pasty “lymphatic” 
type and the lean and imperfectly developed child, in which the evi- 
dences of the spasmophilic diathesis are almost solely found. 
It seems improbable that the disturbance has anything to do with 
the sugar, fat, or protein, since no harm results by adding any of these 
substances to a diet consisting of carbohydrates, which tend to diminish 
irritability. On the other hand, whey acts precisely as does cow’s milk 
in increasing both mechanical and electric irritability, and it might be 
supposed that it contains in solution a substance which is concerned in 
the production of the symptoms. 
Considerable evidence has been accumulated of late concerning cal- 
cium metabolism and its relation to tetany. So far the conclusions ar- 
rived at by different observers vary, but, nevertheless, there are a few 
points on which a unanimous opinion exists. Experiments in physiology 
have shown that the peripheral nerve irritability can be influenced by 
salt solutions, and the researches of Holb showed that it is not one salt 
alone, but the interaction with other salts, which influences nerve irri- 
tability; either a diminution of the sodium or an increase of the calcium 
diminishes irritability. This fact suggested that the etiology existed 
in salt metabolism. 
Due to these observations Czerny commenced some experiments 
on the chemical examination of brains, which were carried out by West, 
who showed that there was a diminution of the calcium content of the 544 
THE PRACTICE OF PEDIATRICS 
brains of children with tetany, and further pointed out that, by feeding 
calcium-poor food to dogs, the irritability of the peripheral nerves was 
diminished, while Sabbatini demonstrated that the application of cal- 
cium to the cortex diminished the electric excitability. Stoeltzner, at- 
tempting to repeat these observations, obtained somewhat contradictory 
results. Rosenstern, along with other observers, approached the subject 
from the clinical aspect and fed calcium salts in cases of the spasmophilic 
diathesis, producing a remarkable diminution in the nerve irritability, 
the effect of which disappeared in twenty-four hours, the same results 
being obtainable, only more rapidly, by the intravenous injection of the 
calcium salts. 
An examination of the blood in this condition has shown a consider- 
able diminution of calcium, while, on the other hand, there is known to 
exist an increased output of calcium in the urine and feces. Similar 
results have been obtained in this country by McCallum and Voegtlin 
in experiments on parathyroidectomized dogs. Further explanation 
is offered in postoperative tetany in adults. When the parathyroids 
have been wholly or partially removed the symptoms ensuing are re- 
lieved by the administration of calcium by mouth, the effect passing 
off in a few hours. In infantile tetany less apparent result has been ob- 
tained by the administration of calcium by mouth. 
Howland and Marriott1 have shown that reduction of calcium content 
in the blood causes tetany, frank evidences of tetany occurring when the 
reduction reaches 6 to 7 mg. of calcium per 100 c.c. (The normal calcium 
content ranges approximately from 9 to 11 mg. per 100 c.c.) 
Pathology.—No constant lesions have been located that may be 
associated with tetany. Thus far no uniform anatomic changes in the 
parathyroids have been reported. The most usual findings are hemor- 
rhage, recent or old, cysts, and staining. Fischl in fatal cases found 
tuberculous meningitis, bronchopneumonia, hemorrhagic infiltration of 
the brain, edema, and chronic intestinal inflammation. In one case seen 
by the writer there was a pachymeningitis. Autopsies on many infants 
in whom tetany has been present fail to reveal any diseased condition 
of the nervous system. 
Symptoms.—The appearance of a child with tetany is characteristic. 
The symptoms vary only in their intensity. 
In mild cases there may be simply an adduction of the thumb on the 
palm of the hand, giving rise to the term “the accoucheur hand.” With 
this phenomenon there will usually be an extension of the feet, caused 
by marked contraction of the tendo achillis. 
In the more pronounced cases the hands are flexed on the arms, and 
the fingers are lightly contracted over the adducted thumb (Fig. 96). 
The feet are held in a marked extended position, with the toes flexed 
toward the plantar surface of the foot. With the second and third row 
of phalanges extended, a similar phenomenon is also sometimes seen 
in the fingers. Usually the joints at the elbow, shoulder, hip, and knee 
may be moved without discomfort. Attempts at forcing the other joints 
to the normal position are met with resistance and evidence of pain. 
The knee-jerk is markedly exaggerated. There is an increased response 
1 Quart. Jour. Med., xi, 1918, p. 289. TETANY 
545 
to both the galvanic and faradic current. Muscle irritation may or may 
not cause various phenomena. Trismus has never been present in our 
cases. 
Muscle Irritability.—Evidence of muscle and mechanical irritability 
may be demonstrated by the following tests. (See also p. 541.) 
The Chvostek sign depends on the heightened irritability of the facial 
plexus which, on being tapped with the finger or a percussion-hammer 
midway between the zygoma and the angle of the mouth, produces a 
contraction at the ala of the nostril, the angle of the mouth, and, in marked 
cases, the inner canthus of the eye and eyebrow. This reaction is given 
various grades of importance by authors. Thiemich’s conclusions are 
that “the facial should be stricken from the list of nervous stigmas, and 
must be regarded even in late childhood as a pathognomonic sign of 
latent tetany, even if this disease remains continuously a symptomless 
anomaly of the nervous system.” This sign was found in but one of 
Wilcox’s cases. It will be found in perhaps half of all cases. 
Schultz’s sign is produced 
by stroking the skin over the 
zygoma, which in extreme 
cases of tetany produces a 
contraction similar to the 
Chvostek. In comparatively 
few cases can this sign be 
demonstrated. 
Trousseau’s Sign.— Shut- 
ting off the blood-supply in 
the elbow or groin through 
pressure is followed, after a 
varying interval, by the typ- 
ical carpal or pedal spasm. 
Duration.—Marked tetany, 
under our observation, has 
lasted from a day or two to 
two to six weeks. A return 
to the normal is usually slow. Cases that are entirely relieved in less 
than a week are extremely rare. When the disease disappears rapidly, 
we are not sure that it may not return, possibly in a more severe form. 
Diagnosis.—The diagnosis is not at all difficult, and is made by the 
characteristic contraction of the hands and feet, which occurs in no other 
condition. While perhaps the nervous phenomena might suggest cerebral 
disease, the absence of mental symptoms excludes it. 
Electric Irritability.—In tetany the electric reactions may be said 
to be of distinct diagnostic value. It seems very difficult to establish 
exactly normal reactions for children, as many will react low one day 
and high another, and then again the reactions vary with changes in 
the digestive and metabolic processes. It must be kept in mind that 
the electric reactions are not always diagnostic of tetany, but, on the 
other hand, there is now no doubt that, by this method of diagnosis, 
cases hitherto not suspected of tetany may be brought to correct diag- 
nosis. Just what exact electric findings are essential to a diagnosis is 
Fig. 96.—Hand in tetany. 546 
THE PRACTICE OF PEDIATRICS 
still a matter of dispute. Escherich believed that in normal children 
only KCC appears under 5, and that only occasionally may anodal 
closure be present with this current strength. 
Wilcox has cited the grades of electric irritability as follows: 
1. Normal, in which KCC occurs under 5. Sometimes ACC is found 
at 5 or just below it. 
2. The middle grade, or anodal hyperirritability, in which KCC is 
less than 5, and AOC is less than ACC and less than 5. 
3. Tetany, in which all four reactions are less than 5. A suggestive 
tetany is the occurrence of AOC less than ACC and the appearance of 
KCC tetanus. 
The incidence of tetany varies, due presumably to the varying at- 
titudes of the observers as to what constitutes a true diagnosis. Nu- 
merous authors give figures varying from 6 per cent, down to 0.7 per cent, 
in artificially fed children under three years of age. 
Technic.—A simple and most efficient instrument is one supplied 
by Wappler & Co., of New York. It consists of dry cells which supply 
a galvanic current and contain a switch for reversing the polarity, a rheo- 
stat for controlling the current, and a balanced milliamperemeter meas- 
uring from 0.2 to 10 milliamperes. 
The patient is laid in bed with the feet directed toward the observer, 
who grasps the right foot with the left hand, in such a manner as to be 
able to detect the slightest response occurring in the flexor tendons or 
the ankle or toes. The negative electrode is placed upon the abdomen 
of the patient, while the positive one is controlled by the right hand 
of the operator, who at the same time regulates the rheostat with his 
elbow. The test should always be begun with a current strength sufficient 
to produce muscle response and then gradually reduced. If the opposite 
is attempted, the lowest point will invariably be passed. One should 
always consider the individual skin resistance, which varies directly with 
the amount of fat and is rapidly reduced as the test progresses. 
Prognosis.—The prognosis depends entirely upon the condition 
which accounts for the tetany, which is to be looked upon as a symp- 
tom and not a disease. 
The eclampsia case to which reference has been made came near a fatal termination. 
Fatal cases have been recorded as occurring with thymus gland in- 
volvement, and here again we have enlarged thymus as a cause of death. 
Treatment.—Inasmuch as intestinal toxemia and malnutrition are 
apparently important agencies in causing the phenomena, attention 
directed to the intestinal canal and nutrition is indicated. The child 
should be given 2 drams of castor oil, and milk should be excluded from 
the diet for a day or two until the stools become normal. This treat- 
ment alone has cleared up some cases. Hess has recommended the ad- 
ministration of 3 per cent, calcium ehlorid following a starvation period 
of thirty-six to forty-eight hours, then the giving of the ehlorid or bromid 
over a long period. When the spasm persists, calcium bromid appears 
to be of some service in controlling the symptoms in 5- or 10-grain doses 
four times daily. Ten-grain doses of the ehlorid may be substituted. TETANY 
547 
Experiments show that when calcium is administered through the 
alimentary tract the calcium content of the serum is definitely increased, 
although it may not return to normal. No unpleasant effect has been 
observed from the use of the drug. 
In one case there was decided retention of sodium chlorid. This was relieved by 
free catharsis and the use of urea, 15 grains daily in the food. The child recovered in 
two weeks. 
The patient should be kept very quiet during an attack, as undue 
excitement may precipitate an attack of laryngismus stridulus or con- 
vulsions, which may be of a very serious nature. A warm bath at 105° to 
110° F. for a few moments, repeated at six-hour intervals, will often have 
the desired relaxing effect. 
The later treatment consists in regulating the child’s nutrition. If 
the malnutrition is extreme, or if the infant is under six months of age, 
a wet-nurse affords the safest means of nutrition. A wet-nurse, how- 
ever, is not practicable for children over one year of age. There is, more- 
over, considerable uncertainty as to how older infants approaching the 
twelfth month will take the breast. When employment of the wet-nurse 
is impossible or impracticable, an adjustment of the food to the child’s 
digestive capacity is demanded along the lines laid down in the section 
on Malnutrition (p. 112). 
Diet.—Not a few of the infants who develop tetany have had food 
poor in protein, such as is furnished by the proprietary foods and con- 
densed milk, or they may have had a low protein capacity, which, as 
far as the nutrition is concerned, amounts to practically the same thing. 
The protein elements in the diet, therefore, should be kept well in mind 
in feeding these cases. It is in such cases that peptonized milk and malt 
soup (pp. 76 and 78) are indicated. The milk should always be given 
raw unless the patient’s station in life or the season of the year forbids. 
If the milk is heated, as is necessary in malt-soup feeding, orange- or 
beef-juice should be given at the same time. 
Climate.—When possible, children who have had tetany should in 
every instance be given the advantages furnished by climate. An out- 
door life in the country abounding in sunshine, with open windows at 
night, is necessary for rapid repair of the weakened physical condition 
which underlies the disorder. 
Bath and Oil Inunctions.—The patient should be given a brine bath 
(p. 843) at bedtime. This is to be followed by inunction with an ani- 
mal fat during the cooler months, goose-oil or fresh lard being preferred. 
Tonics.—As these patients are usually suffering from a secondary 
anemia, 1 to 2 grains of citrate of iron and ammonium may be given two 
or three times daily after feeding. The hygienic and dietetic manage- 
ment of tetany is practically the same as that suggested for marasmus 
and malnutrition. 
Because of its established effect in promoting calcium retention and 
its specificity in the prevention and cure of the closely allied disorder, 
rickets, cod-liver oil should be administered routinely in the treatment 
of tetany. 548 
THE PRACTICE OF PEDIATRICS 
INSANITY IN CHILDREN 
Insanity in children, implying a completely developed functional 
mental disorder, is very infrequent. When it occurs, its existence may 
most frequently be traced to hereditary influence. This need not im- 
ply the existence of actual insanity in the patient’s ancestors, but, in 
many instances, only pronounced neuropathic diathesis, the effects of 
which are apparent under conditions of excitement and stress. In cer- 
tain families there may be a gradual deterioration of the character des- 
cribed by Kirchoff: “In the first generation we find, apart from nervous 
symptoms, the disappearance of ethical feelings; then follows a genera- 
tion in which the tendency to excesses appears, and the danger is then 
greatly increased by alcoholism. In the third generation there is per- 
haps suicide, or an affective form of insanity, and finally more profound 
mental disorders appear, such as congenital idiocy.” 
Probably no less important than heredity are the environment and 
the early associations of the patient. A child’s mental processes are 
closely dependent on sensory impressions and the affections of pleasure 
and pain. Desires are inherent, but active volition and self-control 
are faculties of slow development. Imagination, as pointed out by Dr. 
Olga Bridgman,1 is such an important faculty that percepts and images 
at times become confused, this fact accounting for much misunderstood 
lying on the part of young children. 
Under these conditions phenomena, such as fright, illness, injury, 
or neglect, exert a greatly augmented influence. The period of puberty, 
moreover, is responsible for perversions, emotional outbreaks, and other 
manifestations of instability, which explain the origin of a large group 
of cases of mental aberration. 
Thus, in any individual of neurotic temperament subjected to bodily 
suffering, overwork, or mental strain during the period of growth, in- 
sanity may occur, and its relative infrequency can be explained only 
by the remarkable recuperative possibilities of this period. 
Imperative Concepts; Morbid Fears.—These constitute the simplest 
psychic disorders of childhood, and are extremely common and of great 
diversity, ranging from simple incapacity to resist the fascination of 
deep water and high places, to uncontrollable fears of darkness or open 
places and crowds (agoraphobia) or lightning and storms (astraphobia). 
Occasionally the child may become overwhelmed by some impulse too 
great for him to resist, and develop a definite “craze.” The most com- 
mon forms of this are kleptomania, pyromania, and dromomania. Of 
these, the “running away” impulse is perhaps oftenest recognized as 
something for which the subject is not fully responsible. 
Neurasthenia is much less common in children than in adults, but 
may develop in children of neurotic ancestry amid any conditions which 
produce mental or bodily fatigue. Too long school periods, excessive 
social demands at home, and late hours are among the most common 
causes especially affecting poorly developed children. The usual symp- 
toms of chronic irritability, sleeplessness, and “moods” may give way 
at last to a state of true hypochondriasis. 
1 Psychology of the Normal Child, Jour. Amer. Med. Assoc., vol. 81, No. 15, 1923, 
p. 1260. MALFORMATIONS OF THE BRAIN AND CORD 
549 
Hysteria in its more pronounced forms should be distinguished from 
mere laughing and crying spells, which children frequently exhibit with- 
out complete loss of control. Nevertheless, “in all hysteric subjects,” 
according to Sachs, there is “not so much a direct lack of power to exert 
the will as a tendency to exert it in perverse fashion.” Occasionally, 
after a period of severe stress, a child may develop hysteric mania. This 
occurs occasionally in girls on the establishment of menstruation. In 
cases of true hysteria, sensory and motor disturbances are common, 
and occasionally hystero-epileptic attacks may occur. 
This subject is considered more specifically under a separate caption, 
p. 524. 
Melancholia is frequent in children, and may assume a serious form, 
characterized by the development of suicidal tendencies. In most in- 
stances, however, the prognosis for recovery is good. 
Mania unrelated to hysteria may be induced by great excitement, 
fright, or febrile diseases. The influence of puberty upon the develop- 
ment of the condition in girls has been noted. Under symptomatic 
measures involving enforced rest and quiet, maniacal cases in the young 
usually terminate in recovery after a few months. 
Dementia praecox, though not a disease of childhood, is common 
after the twelfth year. Hebephrenic, katatonic, and paranoid types 
are described. The frequency of a prodromal period marked only by 
neurasthenia and hypochondriasis should be remembered. 
Treatment.—The treatment of the psychic disorders of childhood 
is comparatively simple. Under a firm but quiet home regime, with 
proper attention to existing physical defects, the milder cases of de- 
rangement ordinarily respond favorably. Punishment for the persist- 
ence of ideas and fears for which the patient is not directly account- 
able may do great harm. Hysteric symptoms of considerable duration 
may, however, yield readily to the right sort of sensory or psychic “sur- 
prise.” Suggestion has a very wide field in the treatment of children. 
In the more severe forms of mania, isolation, close supervision, rest, 
and hydrotherapy afford good results. 
A properly functionating digestive tract and a good supply of hemo- 
globin and red corpuscles are essential to the preservation of a normal 
mentality in any child, regardless of heredity or environment. 
MALFORMATIONS OF THE BRAIN AND CORD 
The various types of cerebral malformation are of developmental 
rather than of clinical interest. 
Meningocele, encephalocele, and hydrencephalocele are protrusions 
of cranial contents through congenital gaps which persist between the 
bones of the skull. Such defects are most common in the occipital and 
frontonasal regions. 
When the protruding sac consists only of the membranes surrounding 
the brain, it is called a meningocele; when a portion of the brain itself is 
included, the tumor is called an encephalocele; and when the encephalocele 
contains ventricular fluid, a hydrencephalocele. 
Porencephalus is a condition characterized by the existence of a 550 
THE PRACTICE OF PEDIATRICS 
hole in the brain substance. This abnormality may be congenital or 
acquired. The congenital form may develop from a traumatic enceph- 
alitis during intra-uterine life. The acquired form is usually due to 
meningeal hemorrhage. The cavity in porencephalus commonly involves 
the motor areas of the cerebrum and extends into the lateral ventricle. 
According to Dana, true porencephalus due to a congenital defect in 
nutrition occurs in about one-fourth the cases of cerebral palsies in chil- 
dren. 
Cyclops, hemicephalus, anencephalus, and malformations of in- 
dividual lobes of the brain belong to the domain of embryology and 
Fig. 97.—Meningocele. 
neurology, rather than to general pediatrics. The terms themselves 
roughly define the respective conditions. 
HYDROCEPHALUS 
By hydrocephalus is understood an excessive amount of fluid within 
the skull. This fluid may be either within the brain, in the ventricles 
(internal hydrocephalus), or it may be external, existing as an effusion 
into the subarachnoid space (external hydrocephalus). Further differ- 
entiation is made into the acute and chronic, congenital and acquired, 
types. A fault in our nomenclature is that there is too much of it. It 
is a question whether a differentiation into the acute and acquired types 
is possible, for no one can state that in the cases which develop late— 
the so-called acquired cases—there was not an excessive fluid content 
at birth. In fact, acquired internal hydrocephalus is an exceedingly 
rare condition. When it occurs it is usually the result of some mechan- 
ical venous obstruction. It is most common in cases of meningitis, due 
to inflammatory material closing the foramen of Magendie. The aque- 
duct of Sylvius may also be occluded. 
According to Sachs1 the most common form of obstruction is that due 
1 Nervous Diseases of Children. HYDROCEPHALUS 
551 
to tumor in the posterior fossa. Through such obstruction the foramen 
of Magendie may become occluded, and dilatation of the third ventricle 
result. Inflammatory processes may cause a closure of the communi- 
cating channels between the ventricles and cause a hydrocephalus. The 
amount of fluid in the acquired cases is usually small. 
Congenital Hydrocephalus.—An excessive accumulation of fluid develops 
in the cranial cavities during intra-uterine life, which has been attributed 
to many causes, among which syphilis and alcoholism are frequently men- 
tioned. Our own experience is in accord with that of many other ob- 
servers, in that no satisfactory explanation for the condition has been 
obtained. 
Congenital hydrocephalus is essentially chronic. It is an internal 
hydrocephalus, that form of the disease which is usually seen, and the 
condition referred to when the term ‘‘hydrocephalus” is used without 
qualification. The head may reach an enormous size. Holt reported 
a case in which 5 pints of fluid were found at the autopsy. In one of 
our cases there were 3 pints. The usual amount is from \ to 2 pints. 
The fluid is clear, and contains the chlorid of potassium and sodium, 
cholesterin, a trace of albumin, and sometimes urea. As a result of the 
pressure exerted, the brain substance becomes thinned to a mere shell. 
The convolutions are entirely obliterated. Removal intact of what is 
left of the brain may be impossible after the withdrawal of the fluid, 
owing to the fact that what remains of the brain tissue falls together 
in a broken mass. 
The ependyma may be normal or thickened and infiltrated. 
Chronic external hydrocephalus is of rare occurrence. When present 
it will be found associated in nearly all cases with a pachymeningitis. 
The congenital form of external hydrocephalus is exceedingly rare. Very 
few authentic cases have been reported. 
Internal hydrocephalus {acute) is of infectious origin. Any of the 
pathogenic bacteria may be operative, and the symptoms that are pre- 
sented are those of pressure, seen in the various forms of meningitis. 
The subject of hydrocephalus has received much investigation in recent 
years, notably through the studies of Dandy and Blackfan.1 
Two groups of cases were differentiated by the terms obstructive hydro- 
cephalus and communicating hydrocephalus. In the obstructive type 
neutral phenolphthalein solution introduced into the ventricles failed 
to appear in the spinal fluid; in the communicating type the dye ap- 
peared promptly in the spinal fluid. The obstruction when demonstrated 
at autopsy was found to consist of a malformation, inflammatory process 
or tumor, usually at the Sylvian aqueduct or the foramina of Luschka and 
Magendie. In such cases the hydrocephalus is due to failure of the fluid 
formed in the ventricles to pass into the subarachnoid space where alone 
its absorption occurs. 
In the communicating type adhesions at the base of the brain prevent 
the cerebrospinal fluid from reaching the cerebral subarachnoid space 
where a large part of the normal absorption occurs. This type of hydro- 
cephalus is probably always due to meningitis which may have been 
unrecognized. 
1 Amer. Jour. Dis. of Child., 1914, 8406; 1917, 14,424. 552 
THE PRACTICE OF PEDIATRICS 
The occurrence of hydrocephalus following operation upon menin- 
gocele is ascribed to the removal of a considerable portion of absorbing 
area. 
Symptoms.—In a case of the usual type—the congenital—which de- 
velops into chronic hydrocephalus, it is noticed at birth that the child’s 
head is large. During the following week it is apparent that the head 
is increasing out of proportion to the remainder of the body. The skull 
enlarges symmetrically out of proportion to the face (Fig. 98), with 
bulging of the fontanel and separation of the sutures. The blue veins 
of the scalp become enlarged and prominently outlined in the pale skin. 
The head may reach an enormous size. In one of our cases the eircum- 
Fig. 98.—Chronic internal hydrocephalus. 
ference was 27| inches at the time of death—the nineteenth month. The 
infant in advanced cases is not able to hold up the head, is dull and 
stupid, cries when disturbed, and takes food with indifference. The facial 
aspect is characteristic—triangular, pinched, and pale. The eyes take 
on a peculiar stare and are directed downward, showing considerable 
paling of the sclera above, and never below. There is usually convergent 
strabismus, and there may be nystagmus, the latter occurring in quite 
a number of cases. 
Malnutrition is always present. Dentition is delayed. The hair 
is scanty and coarse. Resistance is of a very low order. 
Nervous manifestations, exhibited in the extremities, are not neces- 
sarily present. Some patients will show a moderate degree of spastic HYDROCEPHALUS 
553 
muscular contraction. The hands may be clinched and the feet extended. 
In others no nervous manifestations whatever will be referable to the 
extremities. 
Duration.—The child rarely lives to the twelfth month. Intercur- 
rent disease, usually bronchopneumonia or an intestinal infection, ter- 
minates the case. 
The above is a description of hydrocephalus as usually encountered. 
The course and outcome, however, are not always the same. The proc- 
ess may be arrested at any time. We have seen a few such cases. The 
enlargement of the cranium in these patients is slower, and noticeable 
enlargement may not occur until the fifth or sixth month is reached. 
Illustrative Cases.—A female private patient had suffered from digestive disturbance 
and moderate malnutrition in the early months. She improved satisfactorily, so that 
an interval of six weeks elapsed without medical observation. When she was five months 
old the writer had occasion to readjust her food, and was astounded to note the change 
in the size of the child’s head. It showed the characteristic globular form, the high 
forehead, and large fontanel, but there was no separation of the sutures. The cir- 
cumference was 17 inches. Squint or nystagmus was not present, and the child sup- 
ported the head well. During the next two months the head increased in size 3 inches. 
It remained at 20 inches for four months. The child at six years of age was normal in 
all respects. 
Another female patient first came when she was one year old. The mother thought 
that the head had been growing out of proportion to the body for a few months. The 
growth continued until the child was two years old, at which time the circumference 
of the head was 22 inches. The patient was last seen when six years of age. The mother 
considered the child mentally normal, although we were not convinced that such was 
the case. 
Cases such as the foregoing are those which are reported from time 
to time as cured by various methods of treatment. Further, they might 
be looked upon as belonging to the so-called acquired type. Such cases 
demonstrate that there may be a hydrocephalic process quite active in 
character which subsides of its own accord, as no treatment was given 
these patients except proper food and suitable general care. 
Many authors maintain that cured hydrocephalus is not at all un- 
usual. According to Sachs, the protruding occipital bone, clearly visible 
on so many bald heads, points to a moderate amount of internal hy- 
drocephalus in the early years of life. 
Prognosis.—The prognosis is decidedly unfavorable in those cases 
in which the hydrocephalus is present at birth. Practically all such 
patients die before the tenth month. Occasionally one will live to be 
over one year old. In the cases of slower or possibly later development 
there is a possibility of spontaneous cure. 
Diagnosis.—The diagnosis is not difficult. There is an enlargement 
of the cranium, which is fairly evenly distended in all directions. The 
fontanel is enlarged and pulsating, and the sutures are widened. 
The rachitic and the hydrocephalic head are frequently confused. 
In hydrocephalus the veins of the scalp are distended, and nystagmus 
and squint are present. Earfy in the case, if doubt is felt as to the nature 
of the trouble, weekly measurements of the skull (see p. 36) will deter- 
mine whethei or not there is an excessive growth. 
Treatment.—Until very recently no medical treatment has proved of 
any curative value in hydrocephalus. Favorable results, however, have 554 
THE PRACTICE OF PEDIATRICS 
been attained by Marriott, of St. Louis, to whom we are indebted for the 
following report: 
“In the medical treatment of hydrocephalus the object to be attained 
is an increased absorption or a diminished secretion of cerebrospinal fluid. 
It has been observed that when the surface tension of the blood is raised 
there is a tendency for fluids to pass from intercellular spaces and serous 
cavities into the blood-vessels. One of the most effective means of raising 
the surface tension of the blood is the administration of theobromin 
sodium salicylate (diuretin) by mouth. In a series of patients we have 
been able to definitely influence the course of hydrocephalus by oral 
administration of diuretin. 
“Favorable results are to be expected only in those cases in which 
there is free communication between the ventricles and the subarachnoid 
space. The dosage of diuretin for an infant is from 0.1 to 0.3 gm. three 
or four times a day. The dosage depends upon the rate at which the head 
is increasing. When sufficient diuretin is given to a patient with the com- 
municating type of hydrocephalus, there is usually complete cessation of 
the growth of the head. When the diuretin is stopped the head again 
begins to increase in circumference. The treatment has to be continued 
for a long period, but in some cases, as the child gets older, the amount 
of diuretin can be diminished or even completely stopped. . . . We have 
observed no ill effects from the long-continued use of diuretin. Infants 
under the treatment have gained weight and have developed in a normal 
manner.” 
Radiography of the skull after the injection of air into the ventricles 
has recently been employed to aid in the more accurate diagnosis of the 
existing anatomic conditions in various cases, and in a few instances bril- 
liant operative results have been achieved. 
In this condition (see Fig. 99) the capacity of the skull is less than 
normal, and the brain itself is abnormally small. This defective develop- 
ment has been explained by Virchow’s theory of premature ossification 
in the cranial bones, but according to Sachs, is probably due to atrophic 
changes, which are the result of hemorrhage or inflammation affecting 
the brain and its membranes. If the latter be the true explanation of the 
deformity, any treatment of an operative character to allow brain ex- 
pansion by increasing the dimensions of the skull must promise little. 
Neither explanation is satisfactory. There is more than a prema- 
ture ossification. The skull formation along the line of sutures is exces- 
sive. In many cases may be found at the line of the suture a distinct 
ridge, as though nature had taxed herself to the utmost to unite the 
cranial bones. The ductless glands possibly are a factor in the over- 
development. With the excessive ossification at the sutures the bones of 
the skull generally are much thicker than normal. 
Symptomatology.—The symptomatology is similar to that described 
under Cerebral Palsy. The patients are almost always low-grade de- 
fectives. 
In subjects with microcephalus—microcephalic idiots—who survive 
MICROCEPHALUS SPINA BIFIDA 
555 
infancy, symptoms of paralysis, lack of development of the special senses, 
and low intelligence are the rule. 
Craniectomy.—The operation of craniectomy, based upon the theory 
that the condition is due to a premature ossification of the skull, was 
much in vogue several years ago. It was usually unproductive of bene- 
ficial results, and has been discarded. 
Fig. 99.—Microcephalic idiot. 
Illustrative Case.—Craniectomy was performed on an imbecile boy of four years of 
age at the New York Infant Asylum. After the operation he received more care and 
attention than before, and seemed to develop somewhat along mental lines, but when 
the attention was later withheld he relapsed into the former condition. 
SPINA BIFIDA 
Spina bifida is the term applied to a congenital cleft in the vertebral 
column which permits of a hernia of part of the contents of the canal. 
The defect is found most frequently in the cervical or lower lumbar verte- 
brae. 
In meningocele of the cord the membranes alone constitute the hernial 
sac. 
Myelomeningocele is a protrusion of a portion of the spinal cord and 
its attached nerve-roots, together with an accumulation of fluid, which 
usually has its origin in the anterior subarchnoid space. 
In syringomyelocele, hydromyelocele, or myelocystocele the central ca- 
nal of the cord is dilated with fluid, and the cord substance itself forms 
the lining of the sac. 
The malformations just described are frequently accompanied by 
other abnormalities in the same subject, such as hydrocephalus, club- 
foot, sensory and trophic disturbances, and exstrophy of the bladder. 
With myelomeningocele and paralysis of the extrem- 
ities, bladder, and rectum may exist. 556 
THE PRACTICE OF PEDIATRICS 
Diagnosis of the type of spina bifida present in a given case is not 
always easy. 
Simple spinal meningocele is frequently found in the sacral region. 
This tumor is often translucent. It protrudes through a small cleft in 
the canal and is pedunculated. It is seldom associated with symptoms 
of paralysis. 
Fig. 100.—Spina bifida. 
In myelomeningocele and syringomyelocele the swelling is ordinarily 
less transparent and has a broader base. Pressure on the tumor may 
cause distention of the fontanel. These forms commonly occur in the 
lumbosacral region, but may exist in any region of the spine. Paralytic 
symptoms are much more common than in cases of meningocele. 
Fig. 101.—Spina bifida with complicating hydrocepnalus. (Bellevue Hospital.) 
Of the three forms, syringomyelocele is far the most frequently as- 
sociated with hydrocephalus. 
Prognosis.—Simple meningocele offers a fair prognosis under treat- 
ment. Some cases even terminate favorably by spontaneous rupture 
of the sac and closure of the cleft in the spine. 
In other instances operation may be followed by complete recovery, TYPE AND INCIDENCE OF BRAIN TUMOR 
557 
although in about one-third of the cases the operation is followed by 
an acute hydrocephalus, and in other cases the control of the bladder 
and rectum may be permanently deficient. 
In a child two months of ape the beginning of hydrocephalus was apparent ten 
days after the removal of the meningocele. 
The two other forms of spina bifida are very unpromising, and under 
the best therapeutic measures usually result fatally. 
Treatment.—The results of treatment of spina bifida, regardless of 
its type or the method employed, will scarcely warrant us in promising 
parents much in the way of improvement. In our experience the injection 
of iodin has not been of any value. The pressure treatment is unsatis- 
factory. Surgery promises better results than does any other treat- 
ment. Operative measures are fully described in works on surgery, 
and the results are sometimes brilliant. So-called cured cases, how- 
ever, often develop internal hydrocephalus, so that the latter condi- 
tion is worse than the original. Operations, further, are not without 
immediate danger, for in a great majority of cases portions of the cord 
are within the sac, the excision of which may result in permanent paral- 
ysis and deformity. It is the duty of the physician to see that the tumor 
is carefully protected and kept clean, and that the child is properly nour- 
ished until such time as a suitable operation is thought advisable. 
TYPE AND INCIDENCE OF BRAIN TUMOR 
Tuberculous tumors are by far the most frequent form-of intracranial 
neoplasms occurring in childhood. More than 50 per cent, of all brain 
growths belong to this type. Next in order of frequency are gliomata, 
gliosarcomata, and sarcomata, while adenomata, fibromata, angiosar- 
comata, cholesteomata, and gummata are all rare in children, carcino- 
mata being exceedingly rare. 
Cysts of the brain resulting from an old hemorrhage or from embolic 
softening may simulate the symptoms of a growing neoplasm if the cyst 
contents become suddenly increased. Parasitic cysts of the brain (echi- 
nococcus or cysticercus) are not unknown in children. 
Brain tumors may be congenital, or they may develop at any time 
after birth. Gowers observed 18.5 per cent, in the first ten years and 
14 per cent, in the second decade of life. 
In general the symptoms are those referable to increased intracranial 
pressure combined with signs of irritation or paralysis, showing a focal 
distribution depending upon the site of the neoplasm. 
The sole treatment of lasting value for brain tumor is operative re- 
moval. This presupposes exact diagnosis and correct localization of 
the growth. In an exhaustive review of treatment of brain tumors Dandy1 
has made the following statement with reference to operative procedure 
of a less thorough character: 
“Decompressions, routinely performed, are among the most harmful 
and indefensible operations in surgery. They should never be performed 
for unrealizable tumors. They are the exact equivalent of giving mor- 
phin for abdominal pain; the symptoms are masked until it is too late. 
1 Jour. Amer. Med. Assoc., 77, 24, December 10, 1921. 558 
THE PRACTICE OF PEDIATRICS 
“Decompressions should be performed only as a last resort—when the 
tumor cannot be removed; and then only after the location of the tumor 
is known, for in half the cases of brain tumor no good can possibly be 
derived from a decompression.” 
MENTAL DEFICIENCY; IMBECILITY; IDIOCY 
It is not practicable, even were it possible, to make a differentiation 
of the various types of mentally defective children. Mongolian idiocy, 
cretinism, and amaurotic family idiocy are distinctive types, each type 
having characteristics of its own sufficient to demand a distinct classifi- 
cation. All other forms are so variable in their etiology and the degree 
of impairment which they produce that any separate grouping is im- 
possible. Thus we see idiocy due to microcephalus (p. 554), to hydro- 
cephalus, to antenatal defects, to birth trauma, and to meningitis, par- 
ticularly of the cerebrospinal form. 
Besides microcephalic, hydrocephalic, Mongolian, amaurotic family, 
and cretinoid idiocy, there is a form of idiocy in which the brain shows 
sclerotic areas in the cortex. These may be due to hemorrhage at birth. 
Cerebrospinal meningitis complicated by encephalitis may also be re- 
sponsible for the sclerosis. Finally, there may be porencephalus, a smaller 
or larger defect in a cerebral hemisphere, either of congenital origin or 
due to hemorrhage at birth or later. 
Unclassified Cases.—The brain, although a most important organ, is 
very ineffectively protected until the child is well on in the third year. If 
the facts in each case were known, it would probably be discovered that 
brain trauma at birth was the cause of idiocy in a large majority of the un- 
classified cases. Syphilis, consanguineous marriages, and alcoholism are 
looked upon as etiologic factors by many authors. The mental impairment 
varies within wide limits, and the cases range from those of complete 
idiocy to those in which it is impossible to determine whether the patient 
is within or without the group which is looked upon as normal. Mental 
impairment is often associated with spastic paralysis; the majority of 
the unclassified cases show such association. Nevertheless, in the ex- 
amination of hundreds of cases in institutions, many defectives will 
be found in whom there is no evidence of muscle involvement. Occa- 
sionally the mental impairment is linked with progressive optic atrophy 
independent of amaurotic idiocy. 
Epilepsy in early life tends to mental impairment, and may eventually 
result in idiocy. Cases are frequent in which no cause whatsoever can 
be demonstrated to explain the condition. 
Mentally defective children are described as backward, feeble-minded, 
children of retarded development, imbeciles, and idiots. In a legal sense 
all are imbeciles who cannot appreciate right and wrong. Idiots show 
complete absence of responsibility. 
Defective sight and hearing may place a child, naturally not men- 
tally keen, in the defective class. 
Among the children often classified as defective are unquestionably 
those who are simply retarded in their mental development, and for these 
much may be accomplished. Not every normal child’s mental develop- 
ment corresponds to his physical growth. We see precocious children of MENTAL DEFICIENCY; IMBECILITY; IDIOCY 
559 
eighteen months who are equal in mind to the average child of three 
years, and others three years of age who have a mental development 
of the normal child of eighteen months. This difference in relation between 
the mental and physical age may continue well into adolescence. It is 
therefore a mistake to draw the defining lines of intelligence too hard 
and fast. 
Unquestionably, on the other hand, there are fundamentally stupid, 
mentally slow children who are to be regarded as perhaps having poor 
endocrine capacity, particularly inherent in the thyroid. Such deficiency, 
beyond the slightest doubt, will in the future be shown to play a much 
larger part than is demonstrable at the present time. Only a proportion 
of all children with thyroid dysfunction are cretins. There are lesser de- 
grees of dysfunction, and in some children the endocrine system as a 
whole appears to be slower in manifesting its powers than in others. The 
writer has repeatedly known children who were far behind their fellows 
in mental capacity grow into capable young men and women far more 
clever in their chosen fields of work than others who showed a very early 
development. It has accordingly long been his custom to give the benefit 
of the doubt to such slow children and advise a course of endocrine 
therapy. In such instances a very small dosage of thyroid has been 
employed, perhaps only 1/10 to 1/20 grain a day. 
There is not much difficulty in differentiating the actually defective 
from the slow. The former show traits that are fairly characteristic and 
reactions to their surroundings which are out of tune and out of time as 
regards the age. 
Capacity for purely physical activity in such children is greatly 
retarded.1 They are very slow in holding the head erect. They walk 
late, fail to observe normally, and wear a blank expression. As they grow 
older the mentally defective further prove their deficiency by behavior 
that is perverse and foreign to the instincts of a normal child. They are 
often personally unclean and have no sense of pride; they fail to ap- 
preciate discipline, and may be wantonly cruel and destroy with ap- 
parent pleasure. Speech is usually defective and drooling is common. 
The vacancy of the facial expression is carried on from babyhood. The 
facial expression alone, however, is not to be relied upon in diagnosis, as 
many badly defective children look bright. 
Much may be learned of the child’s mentality by the nature of the 
amusement selected. A child of four whose chief entertainment is to tear 
up paper is mentally defective. Likewise is the one who delights to sit 
and rock his body and stare into space. Pyromaniacs, several of whom the 
writer has had to treat, belong to this class. Finally, an invariable char- 
acteristic of the mentally defective child is inability to concentrate. He 
rushes from one amusement to another and handles one object after an- 
other. If he is interested in anything for a considerable period of time 
it is the thing to which the normal child would not be attracted. 
Treatment.—(See p. 562.) 
1 Refer to Mental and Physical Development in the Infant, p. 38. 560 
THE PRACTICE OF PEDIATRICS 
MONGOLIAN IDIOCY 
The Mongolian type (Figs. 102-104) is found with very few exceptions 
only in the Caucasian race, and received its designation because of the 
facial resemblance of the subjects to the Mongolian. 
Etiology.—Mongolism is of congeni- 
tal origin. There is no known cause. 
Debility in parents seems to play an 
important part. Children of this type 
are often found among the last born of 
old parents, representing the fifth, sixth, 
or seventh pregnancy. This, however, 
is unusual. In this condition, as in 
cretinism, it will possibly be discovered 
in the future that we are dealing with 
a ductless gland defection. Whatever 
may be the cause, it is identical in all, 
for all Mongols are alike in form, fea- 
ture, intelligence, and the many char- 
acteristics that go to form the symp- 
tom complex of Mongolism; this re- 
gardless of race, social position, age, or 
physical condition of the parents. Whatever may be the basic error, 
it is the same in all and it is not due to syphilis. 
Pathology.—Besides the Mongolian type of face, the microcephalic 
skull and the retarded bone growth are characteristic of the disease. 
Fig. 102.—Mongolian idiocy. 
Fig. 103.—Mongolian defective. (Bellevue Hospital.) 
Mongolian idiots at autopsy show the evidence of faulty development 
of the brain cortex. The entire brain is smaller and lighter in weight 
than is normal, and fissuration is defective. Congenital cardiac mal- 
formation is not infrequent in these cases, patent ductus arteriosus and MONGOLIAN IDIOCY 
561 
an incomplete ventricular septum being the commonest lesions found. 
Other visceral malformations occur less frequently, but stigmata of de- 
generation are very numerous, especially of the palate, ears, and fingers. 
Symptomatology.—The face is usually defective in expression, broad 
and flat, the nose small and broad at the base, the eyes wider apart than 
in the normal child. In rare cases the face, which is usually round and 
full, will give the impression of a considerable degree of intelligence (Fig. 
102). The eyes are prominent and placed obliquely, with the palpebral 
fissures extending in an upward direction, elevating the outer canthus. 
The skull shows anteroposterior narrowing, which, together with the 
prominence of the upper cervical vertebra, causes a marked narrowing 
of the nasopharyngeal vault. This is readily appreciated on examining 
the subject for adenoids, which are often suspected because of the habit 
of the open mouth and mouth breathing. The tongue is usually large, 
and protrudes during a greater part of the time. The muscles of the 
arms and legs are soft, the skin is usually rather dry and bluish, and 
Fig. 104.—Mongolian idiot (five months) showing advanced malnutrition 
there is a tendency to coldness of the extremities. The joints are re- 
laxed and the ears are crumpled. There is a distinct inward curve of 
the little fingers, particularly of the third phalanx. The occiput is flat. 
The children have a vacant, stupid expression, and are unusually good- 
natured. They cry much less than normal children. They are feeble, 
and particularly subject to respiratory and intestinal infections. A 
great majority die before they are three years of age. A few grow to 
adult life. In an institution for the feeble-minded there were but two 
Mongols among 300 inmates, all over eight years of age. We recall several 
distinct Mongols who possessed a fair degree of intelligence. Such 
instances, however, are very exceptional. Development is generally de- 
layed, the teeth appear late, and wrhat speech ability is attained is 
acquired only after the child is four or five years of age. 
Diagnosis.—It is difficult to understand why so many of these cases 
fail of diagnosis. The patients are not at all like normal children and 
may only be confused with cretins. (For differential diagnosis see Cre- 
tinism, p. 466.) 562 
THE PRACTICE OF PEDIATRICS 
Treatment of the Mentally Defective.—The mental defectives, with 
the exception of the cretin, the amaurotic family idiot, and the spastic 
paralytic, lend themselves to one scheme or method of treatment, which 
is to be considered from two standpoints: first, that of attention to the 
physical condition; second, that -of attention to the mental condition. 
Under the first heading are included the correction of deformities and 
the management as relates to hygiene and nutrition. The second consid- 
eration, relating to the mental aspect of the case, concerns not only the 
patient but the immediate interests of the family. 
Institutions.—Almost without exception the place for a mentally 
defective child is in an institution which is devoted to the care and teach- 
ing of such children. The defective should be placed where much will 
not be expected, where he will be associated with others of his kind, 
where his work and his play will be adjusted and presided over by edu- 
cated men and women who have made such conditions the study of their 
lives. The defective has his rights. He has a right to live out his un- 
fortunate life in as pleasant a manner as possible, and this is better ac- 
complished in an institution than in any individual home. In an insti- 
tution, among other things, such patients are taught, according to their 
capacity, useful occupations. Not a few thus taught become self-support- 
ing. At rare intervals one is found who possesses remarkable mental 
traits along certain lines, traits which the average normal individual is 
incapable of understanding. Patients showing a moderate degree of 
infirmity often become skilled in handicraft. They execute mechanically 
with surprising accuracy. There have been great geniuses of the past 
who in some respects were not considered mentally normal by their 
contemporaries. It is impossible to form even a fair estimate as to how 
the mentally defective child will develop, with age, and suitable instruc- 
tion from those who are best able to discover his possibilities. 
Placing these children in public institutions is often strenuously 
objected to on sentimental grounds by the poorer members of society 
because of their fears and prejudices a,gainst such institutions. In con- 
sequence, many a child is kept at home, greatly to his detriment and 
to the decided injury of other children in the family. Time and again 
we have pleaded with the mothers and fathers of such children without 
avail. Few villages throughout the country do not have an idiot or an 
idiotic epileptic for school-boys to taunt and for school-girls to fear. 
Most pitiable objects are these human derelicts, with whom the state 
does not interfere because they are “harmless.” Sooner or later, if he 
lives, the idiot of poor parentage will become a public charge, and the 
better his condition at the time, the happier he will be. 
Parents of means and intelligence will usually place such a child in 
one of the many private institutions that are conducted for the care of 
defectives; yet the objection will often be raised, even by these parents, 
that such children have so little mentality that teaching is useless. This 
may be true, but on this very account, if for no other reason, the child 
should be removed from the home because of his invariably pernicious 
influence on other members of the family. 
The vicious, the unclean, and those showing marked moral degen- 
eracy should be placed in institutions as soon after the fourth year as AMAUROTIC FAMILY IDIOCY 
563 
possible. If they are to be a public charge, they should be removed 
from the home as soon as they arrive at the age limit which the rules 
of the institution require for admission. A patient who is tractable 
may remain at home until the sixth or seventh year, particularly if there 
are no other children in the family. If there are in the family younger 
children, whose natural tendencies and powers of imitation are always 
strong, the defective child should be removed as early as possible. 
AMAUROTIC FAMILY IDIOCY 
Amaurotic family idiocy is the name given by Sachs,1 of New York, 
to a very peculiar disease of infancy, first described by Warren Tay 
in 1881. It is characterized by an impairment of the muscle functions 
Fig. 105.—Amaurotic idiocy. (Early stage.) 
volitional movements being at first difficult and later impossible, the 
changes being of a progressive type. Defective vision and mental dul- 
ness appearing in a normal child are among the early signs. The disease 
progresses to complete idiocy and blindness. (See Figs. 105 and 106.) 
Fig. 106.—Amaurotic idiocy. Same case. (Late stage.) 
Etiology.—The etiology of this form of idiocy is unknown. It occurs 
almost exclusively in Hebrews. Different children in the same family 
may be affected. The disease, together with many others the origin of 
1 Nervous Disorders of Children. 564 
THE PRACTICE OF PEDIATRICS 
which is not understood, has been attributed to syphilis and alcohol. 
The pathologic findings prove the disease to be due to a toxemia which 
slowly but persistently attacks and entirely destroys, through degen- 
erative processes, whatever is vital in the entire nervous system. 
Pathology.—Consistency is again shown in the lesions of the disease, 
which, wherever present, are invariably the same. 
Hirsch’s early findings have been corroborated by many others, 
showing that there is a degeneration of the ganglion cells throughout 
the entire nervous system. If we are to believe these investigations, 
there is not a normal cell left either in the cortex or the gray matter of 
the cord. 
The cell protoplasm undergoes degeneration, the nucleus is demon- 
strable with difficulty and becomes a part of the degenerated cell. Later 
changes cause an entire loss of cell structure and render it difficult to 
determine the cell contour. 
The gangion-cells of the retina and the fibers of the optic nerves 
and tracts are degenerated, this fact accounting for the blindness. De- 
generation of the white fibers of the anterior and lateral pyramidal tract 
has been described by Shaffer. Sachs is of the opinion that these are 
secondary changes. 
The thoracic and abdominal viscera show no specific lesions. 
Symptoms.—The history is usually that of a child born well and 
who remained in a normal condition until he was five or six, or perhaps 
nine, months old. He then became inactive, listless, and failed to follow 
objects or persons with the eyes. In all probability the sight is impaired 
much earlier than is supposed, as in the cases which we have had the 
opportunity to examine blindness was present early in the disease, and 
a marked degree of visual impairment as well as mental apathy will pass 
unobserved in many of the homes of the class who supply the amaurotic 
idiot. The eyes assume a peculiar fixed stare fairly early in the disease 
not unlike that of the later stage of meningitis. The child not only shows 
apathy and indifference, but is soon unable to sit up or support the head, 
which falls in any direction in response to the force of gravity. As the case 
progresses the patient loses all power—even the power of changing the 
position of a limb. With the mental, visual, and muscle impairment 
there is invariably progressive emaciation. Convulsions and nystagmus 
may be present, but are not characteristic symptoms. 
Fairly early in the disease there is an unusual susceptibility to sound; 
clapping the hands or any inconsiderable noise causes the child to start 
violently. The reflexes alter at different periods and are variable and 
unreliable. Toward the end the respiration becomes very superficial, 
swallowing is impossible, and the child must be fed by gavage. When 
death occurs, the subject presents the picture of marked inanition. 
Course and Prognosis.—The onset of the disease is very gradual. 
Its course is slow, with the evidence of progressive degeneration. The 
outcome is invariably fatal. A not uninteresting feature of the cases 
is their similarity. They occur in the same race of people. The onset, 
course, and termination are alike, even to the time required for the dis- 
ease to run its course. There is almost a mathematical succession of 
events. THE PRENATAL AND BIRTH FORMS OF CEREBRAL PALSY 
565 
Diagnosis.—The disease is sometimes mistaken for meningitis. Other 
cases have been mistaken for those of birth-palsy. Even if there should 
be occasion for confusion because of the similarity of symptoms, which 
is very slight, the examination of the eye-grounds, which should be under- 
taken in every case in which there is a suspicion of cerebral involvement, 
renders the differentiation possible through the presence or absence of 
“symmetric changes in the region of the yellow spot in each eye of an 
infant” (Tay). This lesion Tay and Kingclon have designated as the 
cherry red spot. The presence of this sign makes the diagnosis in a sus- 
pected case positive, proving the presence of optic nerve atrophy. 
Treatment is of no avail. Our best efforts for these patients are to 
be exerted in maintaining nutrition and in ministering to their comfort. 
Three forms of this affection are recognized—the prenatal, the birth, 
and the postnatal or acquired palsies. 
CEREBRAL PALSIES 
The Prenatal and Birth Forms 
Etiology.—Concerning the etiology of the prenatal cases consider- 
able confusion and varying opinions exist. Degeneracy of the parents, 
alcoholism, syphilis, and trauma are supposed to be contributory causes. 
We have seen a large number of undoubted prenatal cases, and are un- 
able to add anything from the etiologic standpoint. In several instances 
the patients have belonged to families in which there were several other 
children, all normal, with nothing worthy of note in the family history, 
and a record of a normal, uneventful pregnancy preceding the birth 
of the patient. 
Trauma at birth, due to the use of forceps, compression of the head 
in a prolonged or abnormal delivery, or perhaps excessive uterine con- 
tractions induced prematurely in some cases by the use of pituitrin, 
may result in meningeal hemorrhages, causing cerebral palsy. An im- 
mense number of cases are thus caused. The obstetrician should always 
keep in mind that with him rests the possibility of making a hopeless 
invalid or an idiot of the child he is about to deliver. It is fully appre- 
ciated that under unusual conditions in obstetric practice certain risks 
of head injury must be taken for the sake of the immediate demands of 
the mother or the child, but the large number of cases of cerebral palsy 
and idiocy which we have seen have impressed upon us the necessity 
of treating the child’s head during delivery with the utmost care. 
Lesions.—The prenatal and birth palsies are often paraplegias or 
diplegias, and as such show a great variety of lesions. 
In the prenatal cases there is often failure of development of an entire 
hemisphere or a portion thereof. Cysts are sometimes found at autopsy. 
In other cases there is no change visible to the naked eye. Microscopic 
examination of the brain tissue shows a lack of development of the cells 
in the motor areas. In the cases due to trauma at birth the results of the 
early hemorrhage will be found. The most usual changes are sclerosis 
and atrophy. 
In general, the lesions of cerebral palsy include meningeal and cere- 566 
THE PRACTICE OF PEDIATRICS 
bral hemorrhages, thrombosis and embolism, meningitis and encephalitis, 
direct injury, tumors, atrophy, sclerosis, and cyst formation. 
Atrophy, sclerosis, and cysts are the conditions most frequently 
observed at autopsies. Such changes are apparently secondary and 
may generally be ascribed to previous embolism, thrombosis, hemor- 
rhage, or encephalitis. 
Meningeal hemorrhage is much more common than hemorrhage 
from a cerebral vessel. Endarteritis and pachvmengitis are predis- 
posing causes, and direct trauma and the local congestion incident to 
convulsions or spasms of cough- 
ing are exciting causes of such 
hemorrhage. 
Thrombosis and emoblism 
are rare in children, but may 
occur. Thrombosis is some- 
times found in cases of maras- 
mus, and in other instances 
may be ascribed to syphilitic 
endarteritis. Emboli are, as a 
rule, of cardiac origin, and lodge 
in a branch of the middle cere- 
bral artery. Embolism may oc- 
cur in the course of acute infec- 
tious fevers. 
Encephalitis may result from 
an acute infection or from 
trauma. Acute polio-encep- 
halitis as a cause of palsy is 
well recognized. 
According to Cautley, three- 
fourths of the cases of acquired 
cerebral paralysis in children 
develop before the fourth year. 
Sachs has stated that, prior 
to autopsy in a case of acute 
11 cerebral palsy of several years’ 
duration, it is impossible to predict what type of secondary brain lesion 
will be found. When the symptoms have been well defined and focal, 
and associated with little idiocy, he had in several instances correctly 
diagnosed the presence of cysts. Idiocy and epilepsy associated with 
cerebral palsy are symptoms which he has attributed chiefly to sclerosis. 
Symptoms.—In the first days of life stupor and failure of the infant 
to nurse are especially significant. 
Hemiplegia is rare except in the acquired cases. In the prenatal 
cases, and those of hemorrhage at birth, which latter constitute by far the 
majority, there is frequently a diplegia or paraplegia, “Little’s disease.” 
The first symptom of trouble in these cases is usually that of spasticity 
or rigidity of the extremities, with a decided restriction in motion. There 
may be rigidity of the neck muscles. The children are often “head- 
Fig. 107.—Congenital spastic paralysis. Little’s 
disease. (Bellevue Hospital.) THE PRENATAL AND BIRTH FORMS OF CEREBRAL PALSY 
567 
One extremity may show much more involvement than the other. 
Spasticity and lead-pipe rigidity characterize the condition of the muscles. 
The reflexes are usually exaggerated. Owing to the persistent spasticity, 
the patient may be unable to walk or use the hands. If walking is ac- 
complished, it is learned much later than is normal. Often walking is 
interfered with because of spasm of the adductors, which produces a 
cross-legged attitude. In those cases in which walking is finally ac- 
complished the patient is very awkward and falls frequently. In a 
state instutiton for defectives 70 out of 300 inmates, ranging from eight 
years to over forty, had never walked. 
The 'physical development is always of an inferior order in cases 
even moderately severe. The ability to hold the head erect is accom- 
plished very late. We have repeatedly observed patients who could 
never support the head or sit erect. Deafness and blindness are not at 
all unusual. Nystagmus and strabismus are frequently seen. Speech is 
apt to be acquired late and may be very defective. The ability to 
swallow solid food is often much delayed. Even the swallowing of fluid 
can be accomplished only in a certain position. 
Illustrative Case.—A child who was observed for several years could swallow fluids 
onty when resting on his back. The impairment continued during the six years of life 
of the child. 
The physical impairment varies widely in degree from what appears 
as simple awkwardness to complete inability to perform a single volitional 
act. The legs usually show much greater involvement than the arms. 
A child who has little or no use of the legs may be able to use the arms 
to good effect. 
Many of these unfortunates die during the earlier years. Their resist- 
ance to infection is of a low order. Convulsions may occur, but have not 
been of frequent occurrence in our cases. 
Mentality.—The mental capacity is also of w’ide variation. We have 
had under care several patients with normal mentality. Two, through 
gymnastic exercises and training, became able to perform all volitional 
acts and have been looked upon as normal children. There is still a 
slight impairment in gait, and they are known among their fellows as 
“clumsy” boys. The other two, girls, possess unusually bright minds, 
but are pronounced diplegics. One at fourteen years of age had never 
walked without support, the other at six years could walk alone, but 
with much difficulty. The gait remained decidedly spastic. She had had 
daily treatment since two years of age. On the other hand, we see several 
patients every year whose mentality is of a very low order. 
Between these two extremes there are all degrees of mental impair- 
ment. Not infrequently these defective children possess decided bril- 
liancy along a certain line, while the mind is a complete blank in other 
respects. Defectives often learn to accomplish purely mechanical acts 
very well indeed. They may become intense specialists. A defective 
boy developed into an expert carver of wood. Two very clever musicians 
were defective in every other respect. 
Epilepsy.—Authors claim that epilepsy is present in a considerable 
proportion of defectives. Such has not been our experience. In fact, 
in children of this type epilepsy has seemed exceptional. 568 
THE PRACTICE OF PEDIATRICS 
Hemiplegia may be said to characterize the acquired cases, and while 
diplegia and paraplegia may occur, this is the exception. 
Etiology.—Our cases have all been the result of infection, stress, 
or direct trauma; or have been due to spontaneous hemorrhage neona- 
torum. (Cf. Rhodda’s findings, p. 184.) 
A comparatively trifling injury is sometimes sufficient to produce a 
hemorrhage. 
Illustrative Cases.—A boy twelve years of age, a pronounced hemiplegic with 
normal mentality, owes his present condition to a fall from his baby carriage to the 
ground when nine months of age. The fall was followed by repeated convulsions 
and hemiplegia. He came under treatment a few days after the fall. The lesion was 
located, the skull trephined; the blood-clot removed, and the bleeding vessel ligated. 
The boy today walks well with a brace; the arm will probably never be of much service. 
Another child, fourteen months of age, was perfectly normal previous to an acute 
attack of indigestion with high fever and convulsions. The seizures were repeated 
several times during the day. After the third convulsion it was noticed that there wras 
complete paralysis of the left side of the face and of the right arm and leg. The child 
died thirteen months afterward. His mentality was never clear. 
A mother and her seven-month-old babe went in bathing at the seashore, the 
babe in the mother’s arms. A ground swell engulfed them. When the child was 
resuscitated it was found that there was complete hemiplegia. 
Another case occurred during pertussis. Hemiplegia developed after a severe 
paroxysm. The child lost consciousness, which was not regained; and death followed 
in seventy hours as a result of cerebral hemorrhage. 
A child eleven months of age fell to the floor from his crib, striking on the head. 
Hemiplegia developed at once, followed by death in a few hours. Autopsy showed 
extensive cerebral hemorrhage. 
Hemiplegia may be the result of congenital syphilis. The Wasser- 
mann test should always be taken in every instance in which hemiplegia 
develops. In hemiplegia with congenital syphilis there is usually no pro- 
dromal symptom. The paralysis is either noticed when the child wakes 
in the morning, or develops spontaneously during the day. 
Any of the diseases of bacterial origin may cause cerebral palsy of 
the hemiplegic type. Infection as a cause, however, is very infrequent. 
(This opinion is based entirely on our own experience.) More cases 
probably result from cerebrospinal meningitis than from any other form 
of infection. The lesions in the cases reported as occurring with various 
infectious diseases and gastro-enteric disturbances are probably the 
result of the convulsions which may have ushered in the illness. A con- 
vulsion is never without danger in a child. 
Age.—It is unusual for a case to develop after the seventh year. The 
majority of the cases occur before the fourth year. 
Symptoms.—The first symptom is usually that of paralysis follow- 
ing a convulsion or recognized trauma. In some cases there is paralysis 
(hemiplegia) only; in others, profound mental disturbance. The duration 
of the paralysis depends upon the nature and extent of the injury. The 
paralysis, which is spastic in character, may completely disappear, or 
permanent disability with contractures may remain. Usually there 
is some impairment of power. The arm functions may be completely 
restored. The leg improves less rapidly, and is more apt to show per- 
manent disability. (This is the reverse of the experience of most authors.) 
Not infrequently the patient develops one of the various forms of club- 
The Acquired Form THE ACQUIRED FORM OF CEREBRAL PALSY 
569 
foot with resulting permanent contractures and deformity, which means 
that certain muscle groups have been particularly involved. 
The facial muscles are involved in a small proportion of the cases— 
perhaps 15 per cent. Complete restoration to the normal is the rule. 
The patellar reflex is usually exaggerated on both sides, but most markedly 
in the leg of the affected side. The gait may be interfered with or the 
function of the limb may be entirely lost. In other cases in which the 
focal lesion is less pronounced, walking may be accomplished after ortho- 
pedic attention. 
Electric Reaction.—The reaction of degeneration is usually present. 
Sensation is not permanently disturbed. Early in some cases there 
appears to be some impairment which, owing to the mental state of the 
patient, may be difficult to determine accurately. 
Disturbance of Speech.—Aphasia is present when there is a left third 
frontal lobe involvement. Impairment of speech may also occur when 
the right hemisphere is affected, although to a lesser degree. When 
the speech center in the left hemisphere is involved, the right may take 
on the function. 
Inco-ordinate Movements.—Inco-ordination of the paralyzed parts, 
particularly of the arm, has been repeatedly observed. These non-voli- 
tional movements have been erroneously termed “choreic.” 
Illustrative Case.—A patient two years of age had, at the age of one year, repeated 
and prolonged convulsions covering a period of three days. Pronounced hemiplegia 
resulted, with mental impairment. After one year the hemiplegia entirely disappeared, 
but phenomena of muscle gymnastics remained that were difficult to describe. The 
child rocked and swayed the body. The muscles of the right side of the face underwent 
frequent rapid contractions and relaxations. Voluntary muscular acts were, however, 
readily accomplished. Athetosis was present in a marked degree. There were rhythmic 
motions of the flexors and extensors of the fingers and forearm. The child’s mentality 
was much impaired. 
Athetosis is of more usual occurrence in cases in which the lesion 
has apparently been severe. 
Epilepsy may be expected in any case of hemiplegia. Gowers found 
it occurred in over 60 per cent, of his cases. Sachs reported epilepsy in 
50 per cent. Epilepsy may not occur until several years have elapsed. 
Thus, in one of our cases, the child had the injury and hemiplegia when 
nine months of age, and did not develop epilepsy until the tenth year. 
Epilepsy, when it develops, is usually of the jacksonian type, and 
is often very mild in character. 
Mental Impairment.—While mental impairment may be said to be 
the rule, it by no means follows that a child with hemiplegia may not 
be perfectly normal mentally. It would naturally be supposed that 
involvement early in life would be particularly likely to affect the men- 
tality, and such is the case. Nevertheless, patients with conditions of 
this nature may make complete recovery and become mentally com- 
petent individuals. The intelligence may be normal, or there may be 
complete idiocy, or any degree of impairment between these extremes. 
Diagnosis.—The diagnosis is not difficult. In the prenatal and birth 
cases there are early diplegia and paraplegia, with unmistakable evi- 
dence of mental impairment. The child does not smile or hold up the 
head or attempt to play with toys at the usual age, and is slow to recog- 570 
THE PRACTICE OF PEDIATRICS 
nize people or surroundings, frequently also exhibiting difficulty in swal- 
lowing and inability to perform volitional acts. All these patients have 
a characteristic vacant expression—a meaningless stare. 
In the acquired cases the paralysis is unilateral, with exaggerated 
reflexes on the involved side. Further, there is usually the history of 
trauma and sudden onset. 
Treatment.—The medical treatment of the paralysis consists in 
maintaining a high degree of nutrition. The management, in general, 
in the different types of cases varies, depending upon the intelligence 
of the patient, the location and extent of the paralysis, and the resulting 
deformity. Braces are necessary in many instances to prevent con- 
tractures and deformities, as well as to aid in correcting those already 
present. In some cases of normal or fair mentality marked improve- 
ment has followed daily systematic manipulations and exercises under 
the management of an expert in this line of work. 
A number of selected cases have been benefited by cerebral decom- 
pression operations recommended by Sharpe1 and other advocates of the 
method as a procedure applicable particularly to cases showing increased 
spinal fluid pressure, and indicated at an early age. Our experience with 
cases submitted to this operation, although limited, has not been en- 
couraging. 
Chorea, in the form originally described by Paracelsus, is extinct. 
In the Middle Ages, however, a form of dancing mania was widely epi- 
demic throughout Europe, and sketches still testify to enormous four- 
teenth century pilgrimages to the shrine of St. Vitus. The term chorea 
ordinarily applies to the condition described by Sydenham in 1686; 
and the names chorea minor, chorea vulgaris, and chorea anglorum are 
synonymous. 
Under the general title, furthermore, are grouped such cases as those 
described by Huntington in 1872 as hereditary in type, and a large heter- 
ogenous collection designated by such self-explanatory terms as chronic 
progressive chorea, chronic adult chorea, congenital chorea, senile chorea, 
chorea gravidarum, posthemiplegic chorea, choreic insanity, and electric 
chorea or Dubinvs disease (which is marked by the sudden character 
of the spasms). 
Inco-ordination characterizes chorea in children. The child’s control 
over the muscle movement is partially or entirely lost. In addition, 
there are involuntary muscle movements and twitchings, and there is 
loss of muscle power. 
Etiology.—The disease occurs more frequently in girls than in boys. 
The proportion in a group of our own cases has been two to one. 
The susceptible age is from the sixth to the tenth year, the range 
in our cases having been from four to sixteen years. These observations 
are in accord with those of other writers. 
Fright as a factor in causing chorea has been greatly overestimated. 
In a susceptible child the occurrence of stress of any nature may in- 
duce an attack. Regardless of the nervous shock, there is no chorea 
without the underlying constitutional cause. Overwork at school is to 
CHOREA (ST. VITUS' DANCE) 
1 New York State Med. Jour., October, 1916. CHOREA (ST. VITUS* DANCE) 
571 
be looked upon as a predisposing cause, as also is anemia or any influence 
affecting the well-being of the child. But such factors are operative 
only in favorable subjects. 
Basing our judgment on a large number of cases both in private and 
hospital work, we agree with the accepted opinion of most writers that 
rheumatism takes a first place in the etiology. Strlimpell several years 
ago wrote that the association of chorea and rheumatism is so close that 
it is impossible to separate them. Hirt, in discussing nervous diseases, 
expressed the view that there is a common toxic etiologic factor which, 
affecting the cortex, produces chorea, but affecting the joints gives rise 
to acute articular rheumatism. The association of rheumatism and 
chorea is certainly most intimate. At least 50 per cent, of our cases either 
have given a history of rheumatic manifestations, or shown evidence of 
rheumatism when first seen, or developed the signs later. If to the 
above are added the cases of chorea in which there is a family history 
of some form of rheumatism, the percentage is increased to over 80 per 
cent. The association so generally observed clinically is further dem- 
onstrated by the results of treatment. 
In the etiology of chorea as well as rheumatism the influence of diseased 
teeth and tonsils is unquestionable. 
Exceptionally eye strain appears to be an important contributing 
factor. 
Lyttle and Sutton1 have demonstrated an accelerated Kottman reac- 
tion indicating defective thyroid activity in a small group of chorea cases 
and have employed thyroxin as of possible aid in such cases. 
Pathology.—Much has been written concerning the pathology of 
chorea and widely diverse opinions are held. The fact that the child 
makes a complete recovery in a few weeks, and that no permanent lesion 
is demonstrable after several acute attacks, proves that there is no grave 
lesion. 
Poynton and Paine claimed to have found the “diplococcus of rheu- 
matism” in films made from the pia mater in a fatal case of chorea. The 
cocci were seen in the vicinity of a blood-vessel. Poynton2 gave a cut 
showing this ’condition. Morse and Floyd found cocci in the blood in 
4 out of 31 chorea cases studied, but their work proved nothing definite. 
Richards3 reported 2 cases in which Streptococcus viridans culturally 
identical with the streptococcus of Shottmueller and that of Poynton and 
Paine was found in the blood. Notwithstanding these suggestive findings, 
however, the specific etiology and pathology of chorea is still by no means 
conclusively established. 
The spinal fluid is clear. In about 30 per cent, of cases Morse and 
Floyd found a very slight increase in the number of cells, all of which 
were mononuclear in type. No micro-organisms are present. 
Symptoms.—The onset of symptoms is most variable. Usually the 
child will show apparent awkwardness in using one of the hands, or will 
stumble in walking, or will exhibit a hesitancy in speech which is un- 
usual. Such symptoms will be present for a week or more and the child 
JAmer. Jour. Dis. Child,, August, 1923, pp. 179-185. 
2 The British Journal of Children’s Diseases, 1912, vol. ix, p. 49. 
3 Jour. Amer. Med. Assoc., lxii, 1914, pp. 110, 111. 572 
THE PRACTICE OF PEDIATRICS 
will usually be reproved for his awkwardness in handling his drinking 
glass, knife, or fork. The condition may go no further than this, or, as 
is usually the case, the nervous manifestations continue. The arms, hands, 
and fingers may twitch and show short clonic contractions of certain 
muscles. At the commencement one arm is usually involved more than 
the other. This tendency to unilateral involvement may continue 
through the attack. The order of involvement is usually the right arm, 
left arm, right leg, and left leg. The limb involved is much weaker than 
its fellow. This, in the examinations of the upper extremities, may be 
readily appreciated by asking the patient to squeeze the examiner’s hand, 
the patient using first one hand and then the other. 
The muscles of the face or of the shoulders may be prominently in- 
volved, but this is unusual. 
In association with the involuntary muscular contractions there is 
lack of co-ordination, a further development of the awkwardness seen 
early in the attack. The movement of the hand, for example, is slow 
or absolutely refuses to obey the will, and is only accomplished after 
pronounced effort or not at all. Thus when a choreic patient is told to 
place the tip of one index-finger on the tip of the nose or the tip of each 
index-finger alternately on the tip of the nose in rapid succession, return- 
ing the arms in an extended position to his sides, the child experiences 
much confusion, and the fingers rarely reach the tip of the nose. Another 
test is to extend the arms in an outward direction and then bring the 
tips of the index-fingers together quickly. The choreic patient will ex- 
perience much difficulty in its accomplishment. We have had a number 
of patients under ten years of age who were confined to their beds and 
who could perform no voluntary act of such complex nature as self- 
feeding and walking. 
Muscle instability may be further demonstrated by the inability 
of the patient to maintain muscle tension. Thus, wrinkling the brows 
or holding the eyes tightly shut can be continued but a few seconds. 
When the child is asked to protrude the tongue and keep it protruded, 
the organ may undergo various contractions until it is under control, 
and even when at rest will show fine fibrillary twitchings. The facial 
muscles offer a large field for muscle gymnastics with grotesque effects. 
All or any of the voluntary muscles may be involved. There is generalized 
inco-ordination, and lack of power and muscle control. 
Diagnosis.—The diagnosis is made on the presence of muscle con- 
tractions beyond the control of the will, resulting in awkwardness, grim- 
aces, and inability to effect voluntary effort. Chorea is to be differen- 
tiated from habit spasm—so-called “habit chorea”—by the fact that, 
in the latter, while there are contractions of various sets of muscles in 
the body, such contractions may be controlled by mental concentration, 
whereas in true chorea the attempt at control exaggerates the inco-or- 
dination. Chorea, furthermore, is a form of inco-ordination of the so- 
called cerebellar type, and, like alcoholic intoxication, does not lend itself 
to voluntary mimicry by one unaffected. 
The choreiform type of encephalitis may be distinguished by the 
history of the case, by associated manifestations such as ocular paralysis, 
and, if the case be early, by the spinal fluid findings. (See p. 023.) CHOREA (ST. VITUS’ DANCE) 
573 
Prognosis.—The prognosis is good. Of a large number of cases we 
have never known one that did not undergo recovery if the patient was 
free from cardiac involvement. We have seen fatal cases of pancarditis 
(endocarditis, myocarditis, and pericarditis) in which chorea was one of 
the symptoms of the rheumatic infection, but in every case it was the 
heart involvement that killed the patient. Among 250 cases of chorea 
Still noted the presence of cardiac bruits in 155. 
Recurrence.—As with other rheumatic manifestations in children, 
there is with chorea a marked tendency toward a recurrence. In its 
causation there is, moreover, a seasonal element. The majority of the 
cases occur in the spring months. It has not been our observation that 
the fall of the year is a predisposing factor. Repeatedly in out-patient 
work where continuous supervision is impossible one may see these choreic 
children return year after year for treatment. 
Duration.—The duration of these cases depends upon the nervous 
organization of the child, the severity of the attack, and the co-operation 
to be gained from the patient’s family. Fairly severe cases have termi- 
nated in recovery in six weeks, and others have required six months of 
treatment. 
Treatment.—Rest Treatment.—The management of chorea depends 
entirely upon the severity of the attack. It may be necessary in extreme 
cases to keep the child in bed from three to four weeks. In other cases, 
in which the attack is milder in character, the enforced rest may do harm. 
When the involuntary movements are so marked as to interfere with 
locomotion and prevent the child’s feeding himself, rest in bed for a week 
or two is strongly advised. In our opinion it is mental repose that the 
patients particularly require, and if this can best be obtained in bed, then 
the bed is the best place for the patient. If an absence of mental excite- 
ment and stimulation can be secured with a reasonable amount of outdoor 
life and exercise, so much the better. An important fact to be remembered 
in the management of choreic children is that they must not be allowed 
to become fatigued either physically or mentally. 
For the patient who has been confined to bed for several days or 
weeks a gradual return to the usual habits is best. The child should 
be taken up for one-half hour the first day, increasing the time out of 
bed one-half hour daily, until he returns to his usual habits of life. 
School and Entertainments.—Specific instructions as to the amount 
of physical and mental rest required cannot be given so as to apply gen- 
erally in the management of chorea. School and entertainments for 
the choreic patient are, however, out of the question, no matter how 
mild the case. In the great majority of cases play with other children 
must be prohibited. Books and play of an exciting nature are to be avoided 
and there must be no mental stimulation whatever, and no bodily fatigue. 
How best to bring this about depends upon the child and his environ- 
ment. 
Illustrative Cases —In two instances it was found necessary to remove the patient 
from his home to a place with outside relatives, as the influence of the mother in each 
instance was such as hopelessly to prevent the child’s recovery. 
In a severe case of a boy of twelve years, a college student was selected to turn 
the patient’s attention to boyish things, games, target practice, horseback riding, etc. 574 
THE PRACTICE OF PEDIATRICS 
The boy was kept in bed until 9 a. m., rested two hours after the midday meal, and 
retired at 7 p. m. He was practically well in four weeks. 
Antirheumatic Treatment.—By treating every case of chorea as though 
the disease were rheumatism, results are strikingly good. The tonsils 
should receive careful attention, and in the event of repeated attacks 
enucleation should be practised. 
Drugs.—The salicylate of soda may be given in smaller doses than 
are used in acute articular rheumatism—about 10 grains three times daily, 
with double the amount of bicarbonate of soda, being suitable for a 
child from six to ten years of age. The soda should be given between 
meals. To children of this age the salicylate may be given either in 
capsule or in solution. To young children drugs in solution are more 
easily administered. In using salicylate of soda for a considerable time 
it is well to remember that it may interfere with the appetite and 
digestion, no matter how great the care exercised in its use. For this 
reason it is well to give it intermittently—five days of medication being 
followed by five days without medicine. 
In spite of the value of the antirheumatic treatment, this alone will 
not always answer. The administration of arsenic and the salicylate 
and the dietetic regime may best be begun at the same time. The salicyl- 
ate of soda should be given at once at the co*mmencement of the treat- 
ment in as full doses as we expect to give. Arsenic should be commenced 
in a small dose, which is to be gradually increased in order to establish 
a tolerance of the drug. Fowler’s solution of arsenic is usually employed. 
In order that no error be made in its administration, a table similar to 
the following is given to the mother or attendant. To a child six years 
of age on the first day 2 drops should be given after each meal, as 
indicated below. Thereafter the dosage should be increased by 1 drop 
every twenty-four hours, according to the following schedule: 
Dosage of Fowler’s Solution for a Child Six Years Old 
1st day: Morning, 2 drops. Noon, 2 drops. Night, 2 drops. 
2d “ “ 2 “ “2 “ “ 3 “ 
3d “ “ 2 “ “ 3 “ “ 3 “ 
4th “ “ 3 “ “3 “ “ 3 “ 
This rate of daily increase may be continued up to the third week, 
after which time the dosage should range from 5 to 10 drops three times 
a day. For a child of eight to ten years of age the amount may be in- 
creased to 12 or 15 drops three times a day. By putting the patient on 
the antirheumatic treatment it has seemed that much less arsenic is 
required, and that the patient usually makes an earlier recovery. We 
have never been obliged to resort to the large dosage of 25 to 30 drops 
of Fowler’s solution three times a day as suggested by Seguin. It is 
exceedingly rare that more than 10 drops three times daily will be re- 
quired in order to procure satisfactory results. We have never found 
it necessary to give more than 12-drop doses to girls of thirteen to six- 
teen years old. 
Illustrative Case.—A very aggravated case in a girl fifteen years of age terminated 
in complete recovery in three weeks under the antirheumatic diet, the use of aspirin, 
10 grains three times daily after meals, and Fowler’s solution up to 12 drops after each 
meal. HABIT SPASM (Tic) 
575 
Children vary greatly as to their tolerance of arsenic. 
A boy seven years old could not take more than 4 drops of Fowler’s solution three 
times a day. 
In giving arsenic mothers should therefore be advised that in the 
event of abdominal pain, diarrhea, coated tongue, foul breath, vomit- 
ing, or puffiness under the eyes the drug is to be discontinued for at 
least two days. The minimum dose may then be resumed with the same 
gradual increase. 
With the improvement of the case the diet should be continued. 
The medication may gradually be reduced after all the symptoms have 
disappeared. It should be continued, however, in from one-third to 
one-half the quantity for three weeks after the disappearance of all nervous 
symptoms. 
Supplementary Treatment.—It should be remembered that children 
who have once had chorea are very susceptible to recurrent attacks 
just as are children who have had rheumatism. After one attack of 
chorea the danger of a recurrence should be explained to the mother, 
who should be asked to bring the child for examination at the first sug- 
gestion of involuntary muscular twitching. In addition to this, children 
who have had chorea, as well as those who have had only rheumatism, 
should be allowed meat in small portions only, and in no case should an 
excessive use of sugar be permitted. Candy is usually to be forbidden. 
Because of the frequent coexistence of rheumatism when the attack 
is over the writer has ordered that the child shall receive 10 grains of 
bicarbonate of soda three times daily for five days out of every fifteen. 
In this way, under a reasonably quiet home life, with no school contests 
for prizes, a recurrence will almost invariably be prevented. 
Goodman reported good results from autoserum therapy consisting 
of injections into the spinal canal of blood-serum taken from the patient. 
This practice, however, has received little support. A trial of the method 
carefully conducted by the Children’s Medical Division at Bellevue 
Hospital yielded no favorable results. 
By habit spasm is understood a semi-inco-ordinate movement of 
some portion of the body. The term “semi-inco-ordinate’’ is used ad- 
visedly, because the spasm may be controlled when the child’s atten- 
tion is directed to ifc, this being one of the distinguishing features which 
differentiates it from chorea, in which efforts at control make the spasm 
worse. The muscles involved in the spasm are usually those of the head, 
face, or arm. The nose may be drawn up, the chin down, or the head 
to either side. The muscular spasm is worse when the patient is tired, 
and occurs more frequently under excitement. While children thus 
affected cannot be said to have chorea, there is nevertheless a close as- 
sociation between habit spasm and true chorea. 
Several of our patients developed habit spasm from association with 
children who had some special grimace or habit of muscle contraction 
of their own. 
HABIT SPASM (TIC) 576 
THE PRACTICE OF PEDIATRICS 
The cases are readily curable when taken early. In a neglected child 
the spasm may become fixed and continue during the life of the indi- 
vidual. Instances of this sort are often seen in adults. Bad subjects 
will transfer the spasm from one set of muscles to another. 
Illustrative Case.—A boy, twelve years old, came for assistance because of a peculiar 
explosive sound similar to that, made by eructations of gas. The sound was produced 
through some process of laryngeal gymnastics and was almost continuous when awake. 
Treatment.—The management is dietetic, hygienic, and medicinal. 
Diet.— A small portion of red meat may be allowed once a day. Sugar 
may be given in sufficient amount to make the food palatable. The 
vegetable and legume constituents in the diet are to be made prominent. 
The patient will usually be found to be poorly nourished and often suffer- 
ing from a secondary anemia, so that a diet best calculated to improve 
his general condition should be insisted upon. This should contain milk, 
eggs, poultry, fish, red meat in small portion, high-protein cereals, and 
the legumes. 
Bath.—A salt bath should be given at bedtime, and immediately 
after the bath goose oil, unsalted lard, or olive oil should be rubbed into 
the skin. 
School Duties.—Temporary absence from school, or a lightening of 
school duties, and an outdoor life are essential in the successful man- 
agement of a case. The child should not be allowed to do anything of 
a strenuous nature. Hard play and any amusement of an exciting char- 
acter should be forbidden. Fatigue must be avoided. Rest after the 
noon-day meal for an hour or two is strongly recommended. 
Medication.—The medicinal treatment suggested for chorea is also 
applicable here. If there is anemia, iron may be given, conveniently in 
the form of extraction ferri pomatum, l grain three times a day. For 
those children who cannot take cream or butter, cod-liver oil in teaspoon- 
ful doses is a valuable addition to the treatment. The iron may be al- 
ternated with the cod-liver oil, each being given for five days. If there 
is a rheumatic history or inheritance, salicylate of soda is to be given in 
capsule with the iron. The following is useful for a child five years of age: 
1$. Liquoris potassii arsenitis gtt. iij 
Ext. ferri pomati gr. ss 
Sodii salicylatis gr. v 
M. Sig.—One dose; to be given in capsule after each meal. 
The use of arsenic, while of advantage, does not appear to be as val- 
uable as in the treatment of chorea. 
Moral Treatment.—Habit spasm, for the reason that it is practically 
under the control of the will, should be discouraged, rewards being given 
and punishments imposed, as seem to answer best. 
STAMMERING 
Stammering is an affection for the most part limited to self-con- 
scious and precocious children with indifferent nervous control. The 
defect is seldom of importance before the fifth year, and then usually 
may be found to be due to imitation of other stammerers. About 35 
per cent, of the patients are said to have relatives similarly affected. THE PROGRESSIVE MUSCULAR ATROPHIES 
577 
Boys are more frequent victims than girls. Fright gives rise tc the con- 
dition in many instances, and in many the history will show that the 
child has been subjected at an early age to repression and nagging con- 
ducive to psychic instability. Of the concrete causes the most im- 
portant are adenoid and tonsillar hypertrophy, high palatal arch, im- 
perfect epiglottis, and short frenum linguae. The respiratory muscles 
commonly do not co-ordinate properly with the speech muscles and 
thus the subject even when in the act of articulating may lack the neces- 
sary voice. In the most pronounced cases not only the lips and tongue 
but also the face and limbs participate in the loss of control, so that the 
child’s self-reliance becomes greatly weakened. 
Treatment.—All measures that conduce to stability of the nervous 
system are of value in the cure of stammering. According to Hollander, 
the best results are gained from suggestion treatment intended to increase 
the patient’s self-confidence and emphasize the importance of his ideas, 
rather than his manner of utterance. In dealing with older children 
psychotherapy directed to the eradication of the complex of which the 
stammering is perhaps only a phase may be of greatest value. Ana- 
tomic abnormalities should be corrected and breathing exercises should 
be instituted to encourage better poise and co-ordination. Syllabication 
is a practice of special value. 
In the large centers there are clinics for the treatment of speech defects, 
and the results gained by specialists in this department amply justify 
the formation of more such classes under trained supervision. 
The progressive muscular atrophies fall easily into two main groups, 
called the amyotrophies and the myopathies. In cases of the first class 
there are lesions in the spinal cord. In cases of the second group such 
changes are not found. 
THE PROGRESSIVE MUSCULAR ATROPHIES 
Progressive Spinal Muscular Atrophy or Progressive Amyotrophy 
This disease has received many designations, including the follow- 
ing: Chronic anterior 'poliomyelitis, wasting palsy, Charcot’s disease, Du- 
chenne-Aran’s disease, and amyotrophic lateral sclerosis. 
Some justification for the existence of so many terms is found both 
in the variable pathologic conditions and also in the length of the period 
of painstaking research which has made possible our present knowledge 
of the disease. The conditions observed are, however, fundamentally 
similar and admit of a common classification. 
Etiology.—Progressive amyotrophy is uncommon in early child- 
hood, although Werdnig and Hoffmann have recognized a hereditary 
form occurring in the very young. Older children and young adults 
are more frequently affected, and in such instances there is usually no 
family history of this paralysis, and the disease can be ascribed only 
to such uncertain causes as exposure, overwork, injury, or previous in- 
fectious fevers, including poliomyelitis of the acute type. An exception 
to this rule occurs in the case of progressive muscular atrophy of the 
Charcot-Marie or leg type. This form is quite definitely a family disease. 
Pathology.—The essential change common to all types is atrophy 578 
THE PRACTICE OF PEDIATRICS 
and degeneration of the anterior cornua of the spinal cord. This process 
involves the cord vertically and is followed by degeneration of the per- 
ipheral nerves and the muscles which these nerves supply. Secondary 
changes in the cord substance consist chiefly of sclerosis and pigmenta- 
tion which invade the pyramidal tracts and also, in most cases, the an- 
terolateral ground bundles. Although the cervical and upper dorsal 
regions are principally affected, the disease may also attack the lumbar 
region or the motor nerve-cells of the medulla, which supply fibers to the 
lips, tongue, pharynx, and larynx. Muscular atrophy of the leg type 
has been regarded as a disease of neural rather than of spinal origin. 
This form, however, cannot be classed with the myopathies, and quite 
probably develops from primary degeneration in the anterior cornua. 
In a certain proportion of spinal muscular atrophies a marked sclerosis 
of the lateral columns supplements the usual changes secondary to atrophy 
of the cells in the anterior horns. “The degenerative process attacks 
first the terminal fibers and collaterals of the cortical motor neurons. It 
seems to destroy the tips of the nerve processes, so to speak, without 
involving the nerve-cell body itself. The next part attacked is the an- 
terior cornual cell” (Dana). Under these conditions the progressive 
amyotrophy assumes a spastic form and is called amyotrophic lateral 
sclerosis. 
Until the complex pathology which has just been briefly traced is 
further elucidated, the following neurologic conditions may be classi- 
fied under the general heading “progressive spinal muscular atrophy”: 
1. Progressive amyotrophy of the hand type (or Duchenne-Aran type). 
2. Progressive bulbar paralysis. 
3. Progressive muscular atrophy of the leg type (peroneal type or Char- 
cot-Marie-Tooth type). 
4. Progressive spinal muscular atrophy of the spastic type (or amyo- 
trophic lateral sclerosis). 
Symptomatology.—1. Progressive amyotrophy of the hand type typic- 
ally begins as a wasting of the muscles of one thumb. The adductor 
pollicis, deep thenar, hypothenar, and the interossei muscles are pro- 
gressively involved; and as the paralysis extends, it may affect the flexors 
and extensors of the forearm, and eventually the triceps and deltoid 
and other shoulder muscles. The “claw-hand” deformity is common. 
After several months the paralysis may become bilateral, involving 
the trunk and rarely the leg muscles, or it may even develop into a bulbar 
palsy. The paralysis in the hand type of atrophy is usually atonic and 
flaccid, but may assume a spastic character, with exaggerated reflexes, 
thus simulating amyotrophic lateral sclerosis. The varying degrees of 
atony and spasticity are many. In most cases fibrillary contractions 
occur. Electric responses are diminished and partial or complete re- 
actions of degeneration may be elicited. Complete reactions of degen- 
eration belong, as a rule, to cases of rapid course. Occasionally rheu- 
matoid pains and local paresthesias occur, but sensory disturbances are 
for the most part lacking. 
2. Progressive bulbar paralysis is unusual in children. Occasionally 
it marks the termination of an advancing amyotrophic lateral sclerosis 
or ophthalmoplegia. Dysphonia and dysphagia are the cardinal symp- THE PROGRESSIVE MYOPATHIES 
579 
toms. Localized fibrillary twitchings may occur. Electric irritability 
is gradually diminished. 
3. Progressive muscidar atrophy of the leg type attacks first the pero- 
nei, then the anterior tibial muscles and the calf muscles, and, at a late 
stage, the adductors of the thigh and gluteal muscles. 
In cases of the so-called ascending type the arms and trunk may 
become affected. At the outset the paralysis and atrophy are unilateral. 
Fibrillary twitchings and diminished electric responses are observed, 
but there are no significant sensory symptoms. 
4. Progressive spinal muscular atrophy of the spastic type combines 
the symptoms of tonic paralysis with those of progressive wasting. The 
affected extremities are stiff and weak, reflexes are exaggerated, and 
in certain instances the lips, tongue, and larynx may be involved. 
Course and Prognosis.—In all these conditions the course of the 
disease is very chronic and extends over a period of years. The pro- 
gressive amyotrophies are apparently incurable, though remissions in 
the symptoms are frequent. Atrophy of the leg type is said to offer 
the best prognosis. 
Diagnosis.—Cases of progressive muscular atrophy in children are 
to be distinguished from those of primary myopathy, peripheral neu- 
ritis, acute poliomyelitis, and hereditary ataxia. The individual forms 
of amyotrophy should also be distinguished. Without attempting to 
enumerate all the factors valuable in these differentiations we may 
group together the following points: 
In the amyopathies: Family history and absence of fibrillary tremor 
and reaction of degeneration. 
In neuritis: Symmetric distribution of paralysis, possible toxic origin, 
frequent existence of sensory symptoms, and absence of family history. 
In epidemic poliomyelitis: History of acute onset and rapid course. 
In hereditary ataxia: Characteristic tottering gait, normal electric 
reactions, and hereditary influence. 
Treatment.—This is only symptomatic and palliative. Electricity 
may be applied to the wasted muscles and to the spine. The drugs used 
are calculated to exert a tonic action on the nervous system, and include 
iron, arsenic, quinin, and strychnin. Mercury and potassium iodid may 
be tried in cases of possible syphilitic origin. 
The Progressive Myopathies (Primary Muscular Dystrophies) 
These include three types: 
1. Pseudomuscular hypertrophy (Figs. 108-110). 
2. Progressive muscular atrophy of ErVs juvenile type, or the scapulo- 
humeral type. 
3. Infantile myopathy of the facioscapulohumeral type, or Landouzy- 
Dejerine type. 
Etiology.—In these cases there is very frequently definite evidence 
of heredity. With the exception of the juvenile dystrophy of Erb, which 
occurs most frequently in early youth, these conditions begin to develop 
before puberty, usually between the third and tenth years. Pseudo- 
muscular hypertrophy is more common in boys than in girls, yet is ap- 
parently transmitted through the maternal parent. While in many 580 
THE PRACTICE OF PEDIATRICS 
instances the first symptoms of weakness follow an acute illness, it is 
doubtful whether trauma and acute diseases are truly causative factors. 
Fig. 108.—Pseudomuscular hypertrophy. (Early case.) 
Pathology.—According to Erb, the muscular changes are essentially 
due to trophic disturbances. In spite of this there are no demonstrable 
primary lesions in the nerves or spinal cord. In the muscles themselves 
Fig. 109.—Patient shown in Fig. 108, continuing the attempt to rise. 
there is a complex degenerative atrophy which is characterized by a 
preliminary increase in the size of the muscle-fibers and the number of 
nuclei, followed by disintegration of these fibers, increase of connective THE PROGRESSIVE MYOPATHIES 
581 
tissue, and lipomatosis. Although the degeneration is attended by hyper- 
trophy, the end-result is, therefore, atrophy. 
Fig. 110.—Characteristic completion of the act begun as shown in Fig. 108. 
Symptoms.—These have been conveniently outlined by Sachs1 as 
follows: 
TYPES OF PRIMARY DYSTROPHIES 
Muscular pseudohy- 
pertrophy. 
Juvenile form of pro- 
gressive muscular 
atrophy (Erb’s type). 
Landouzy-D6j 6rine 
type. 
Part first affected: 
Legs (calves). 
Shoulder-girdle. 
Face and shoulder- 
girdle. 
Distribution of hy- 
pertrophy: 
Calves, rarely 
thighs. 
Muscles around 
shoulder-girdle and 
pelvic girdle. 
None. 
Distribution of 
Thighs, deep mus- 
Thighs, deep mus- 
Face muscles, includ- 
atrophy: 
cles of back, shoul- 
der and scapular 
muscles. Calves 
during later period; 
at that time also 
general atrophy. 
cles of back, upper 
arm. Hypertro- 
phied parts may 
become atrophic in 
later stage. 
ing lips and orbicu- 
laris palpebrarum; 
shoulder and scap- 
ular muscles. 
Parts remaining: 
Face, forearm, and 
Face, forearm, hand 
Forearm, hand, and 
legs, and deep mus- 
cles of back. 
normal: 
hand, except in 
last stages. 
and leg muscles, 
except in last 
stages. 
1 Nervous Diseases of Children. 582 
THE PRACTICE OF PEDIATRICS 
The “waddling gait,” difficulty in rising from the floor (Fig. 108), 
and large, hard calf muscles constitute the most prominent features 
of the pseudohypertrophic form. The “myopathic face” distinguishes 
the Landouzy-Dejerine type. 
In all the forms there are no fibrillary twitchings and no complete 
reactions of degeneration. The reflexes may be normal. As the pa- 
ralysis progresses they are diminished. 
Diagnosis.—The primary muscular dystrophies are not often con- 
founded with other diseases. A consideration of the history, together 
with a study of the electric and mechanical behavior of the affected 
muscles, will usually render easy the distinction between a case of myop- 
athy and one of amyotrophy. 
Course and Prognosis.—These cases extend over a period of many 
years, usually terminating in death from some secondary disease. 
Treatment.—Orthopedic measures designed to correct existing de- 
formities and complement the action of partially degenerated muscles 
afford the best results. Moderate massage and judicious use of elec- 
tricity and exercise are of value. Further treatment consists only in 
the maintenance of nutrition and the administration of drugs to relieve 
temporary symptoms as these may arise. 
Amyotonia congenita was described by Oppenheim1 in 1900 as “a 
condition of extreme fiaccidity of the muscles, associated with an entire 
loss of deep reflexes, most marked at. the time of birth, and always show- 
ing a tendency to slow and progressing amelioration. There is great 
weakness, but no absolute paralysis of any muscle. The limbs are most 
affected, the face is almost always exempt. The muscles are small and 
soft, but there is no local muscular wasting. Contractures are prone to 
occur in the course of time. The faradic excitability in the muscles is 
lowered, and strong faradic stimuli are borne without complaint. No 
other symptoms indicative of lesions of the nervous system occur.” 
By many authorities amyotonia congenita is grouped with the pseudo- 
muscular dystrophies with which it has points in common. 
Etiology.—The cause is not known. 
Pathology.—In some cases there is degeneration in the anterior horns 
of the spinal cord, but this is not constant. The chief lesions are in the 
muscles which show atrophy and degeneration. 
Symptoms.—The cases show all degrees of severity, from a slight 
weakness which passes entirely unnoticed to a well-marked disability 
which represents a flaccid paralysis, in which the child is perfectly help- 
less. In the latter cases the knee-jerks are absent and the electrical 
reactions are very weak. 
The change in an electrical response is quantitative only and without 
reaction of degeneration. There is no obvious atrophy of tissues and the 
child may be well nourished. Paralysis of the lower extremities is often 
nearly complete, but in the upper some movement can, as a rule, be ob- 
tained. The diaphragm and facial muscles, as a rule, escape, although 
the face may be slightly involved. The intercostal and neck muscles are 
AMYOTONIA CONGENITA (OPPENHEIM’S DISEASE) 
1 Monatschr. f. Psychiat. u. Neurol., 1900, viii, 232. EPILEPSY 
583 
often affected. The feet characteristically show pad-like development. 
Contractures may develop later in the disease. If the intercostals are 
involved the respirations may be labored and diaphragmatic in character. 
Choking attacks occur from accumulation of secretion in the pharynx. 
There is no sensory involvement or sphincter disturbance. Mentality 
is normal. 
Diagnosis.—Amyotonia congenita may be confused with exceptional 
types of poliomyelitis of long duration. The history, distribution of the 
flaccidity, and the electric reactions are of importance in making the 
differentiation. The negative family history and the muscular weakness 
without the atrophy which one would ordinarily look for are typical of 
amyotonia congenita in distinction from muscular atrophy. 
Prognosis.—The severe forms often end in death from some inter- 
current infection, such as broncho-pneumonia. The mild forms may 
continue for years and even show some improvement. 
Treatment.—Massage and electric treatment may be given, but they 
do not offer much hope. 
EPILEPSY 
“Epilepsy,” according to Spratling, “is the strangest disease in human 
history. It respects no race, no class, no age, no occupation. It may 
be in the infant at birth or delayed till extreme old age, even ninety 
years or more.” Some of the most notable characters in history, in- 
cluding Ca3sar and Napoleon, are reported to have been its victims, 
and the existence of the affection in very remote times is proved by the 
ancient descriptions of morbus sacer and morbus comitialis. The term 
“falling sickness” best corresponds to Lucretius’ portrayal of how the 
patient, “struck as with lightning,” drops; while morbus Herculeus might 
well characterize the second stage of a severe seizure. 
Today, in spite of a growing knowledge of contributory causes, most 
potent of which is heredity, we are still ignorant of the essential nature 
of the disease. 
Statistics serve to show that alcoholism in the parents is an under- 
lying factor in many cases of epilepsy. Woods has reported 7 cases of 
epilepsy in children which he traced to single alcoholic intoxication on 
the part of one or both parents, otherwise teetotalers. He quoted De- 
jerine, who stated that 51.5 per cent, of all cases in children are due to 
parental alcoholism and but 21 per cent, to parental epilepsy; also Bins- 
wanger of Germany, who declared of epileptics “made in Germany” 
22 per cent, had their origin in chronic parental inebriations while but 
11 per cent, were due to parental epilepsy. Woods advanced the belief 
that it is not so much chronic drunkenness as drunkenness at the time of 
conception that causes the transmittal of an often overwhelming neurosis 
to offspring. 
Statistics further show that from one to three persons in every thou- 
sand throughout Europe and America are epileptics, the proportion of 
males being slightly in excess. 
Lengthy discussions will be found in works on neurology relating 
to various features of the disease. To these works the reader is referred, 
although in them he will find but little that is conclusive. 584 
THE PRACTICE OF PEDIATRICS 
Epilepsy is not a disease of infancy, and while cases occur in children 
under one year of age, such occurrences are relatively rare. We have 
treated a large number of children who have had infantile convulsions 
and who never developed epilepsy. Neurologists are inclined to attribute 
a varying percentage of the cases of epilepsy to infantile convulsions, 
dentition convulsions, etc. The neurologist does not always comprehend 
the hundreds of such cases seen by pediatrists and practitioners in which 
there is never further trouble. While a certain percentage of epileptics 
may have had convulsions in infancy, a much larger percentage of infants 
have convulsions without subsequent epilepsy. The petit mal type has 
appeared to be the more characteristic infantile form. 
Koplik states, “Epilepsy bears no demonstrable relation to infantile 
convulsions. The fact that the patients developed the disease at an early 
age helps in no way to explain the condition, and the underlying factors 
in epilepsy are the same regardless of the age of the patient. Thus what 
constitutes epilepsy is yet to be determined. Various brain lesions have 
been found in association with epilepsy, and to them the seizures have 
been attributed, and yet these lesions and more pronounced involved 
areas are found at postmortem without the occurrence of epilepsy.” 
Types.—Clinically, epilepsy may be divided roughly into two types, 
petit mal and grand mal. 
Petit Mal.—This form may occur independently, or in association 
with grand mal. One person may be subject to both kinds of attacks. 
In petit mal there is a temporary or partial loss of consciousness with- 
out convulsion. The child may simply hesitate in his play and grow 
pale. There is a dull look in the eyes, then the attack is over, and the 
play is resumed. The attack may manifest itself in what corresponds 
to a fainting attack, in which the child loses color and sinks to the floor, 
but is normal in a few moments. 
Illustrative Cases.—A girl two years old with a good family history had two “fainting 
attacks” on two successive days. The attacks apparently consisted of a temporary 
clouding of the mentality, with a tendency to fall. During the next two years the 
child had six of these attacks. 
In another child the only signs of the disease were manifested by a sudden cessa- 
tion of play, when the patient would gaze into space for a few seconds only, with dilated, 
fixed pupils and a vacant stare. 
Grand Mal.—The epileptic attack is in most cases preceded by pro- 
dromal symptoms, known as “the aurawhich consists of a warning 
by which the patient knows the attack is coming on. The aura is des- 
cribed as a peculiar sensation felt in some portion of the body before 
the attack and at no other time. 
Illustrative Cases.—A boy patient had what he described as a pain in the side. 
It was always in the same side and the area of the pain was not larger than a silver 
dollar. 
Another boy patient of eight years could always anticipate an attack through a 
feeling which he could not describe in the right leg, and which traveled up to the 
abdomen. 
Numbness, tingling, and a feeling of soreness in the stomach have all 
been described as constituting the aura. 
In grand mal there are loss of consciousness, dilatation of the pupils, EPILEPSY 
585 
foaming at the mouth, stertorous breathing, and biting of the tongue 
due to spasm of the jaw muscles. The muscle spasm gradually lessens, 
consciousness slowly returns, and the patient passes into a deep sleep. 
Every variation of the above symptoms may be encountered. 
The character of the convulsive movement may help to determine the 
nature of the disease. Localization of spasm in one portion of the body 
or one set of muscles indicates some distinct focal lesion in the brain. 
Diagnosis.—The diagnosis of epilepsy is not difficult. Repeated 
convulsions after the age of infancy are always epileptic. An infant 
may have repeated convulsions and yet not have epilepsy. We have 
seen this time and again. However, if a child two or more years of age 
has repeated convulsions, even at intervals of several months, the con- 
dition must be looked upon as epilepsy, because children do not have 
repeated innocent fainting spells. Neither are hysteric seizures at all 
common, and when they do occur they simulate epilepsy to such a slight 
degree that a differentiation is superfluous. 
Illustrative Case.—A girl of fifteen had a nocturnal attack. During the ensuing 
twelve years up to the age of twenty-seven there were but five seizures, all at night. 
Cases of this nature constitute epilepsy just as truly as though the attacks had 
occurred in as many months. 
Prognosis.—The prognosis of epilepsy as to a cure is bad. The out- 
look for many patients is hopeless; nevertheless, under a regime involving 
right living, proper diet, and avoidance of excitement, many epileptics 
undergo but little inconvenience. 
There are plenty of examples in history of men who were epileptics 
and yet gained marked distinction. 
Treatment.—In the management of epilepsy practically all we can 
hope to do is to diminish the frequency of the attacks which character- 
ize the disease, whether the case be one of grand mal or petit mal. Proper 
nutrition, rational habits of living, and pleasant outdoor occupations are 
of inestimable service in the management of the epileptic. The manage- 
ment which has proved best has been directed, first, along general and 
hygienic lines; second, it has involved the use of drugs. Our aim should 
be to make the patient physically as normal, as vigorous, and as resistant 
to attacks as lies in our power. 
General Considerations.—Visual defects, enlarged tonsils, adenoids, 
phimosis, and irritant skin lesions must all be corrected before bene- 
ficial results are to be expected from any line of treatment. The pa- 
tient should then be placed under the best environment permitted by 
his station in life. Outdoor life, sports, and games are to be encour- 
aged, always within the bounds of moderation. The child should sleep 
in a cool room with the freest possible ventilation at all seasons of the 
year. If he is a school child, he should, if possible, be instructed at home 
and given short sessions with easy studies. In work or play he should 
never be allowed to reach the point of mental or physical fatigue. This 
is most important. Emotional plays at the theater and exciting amuse- 
ments elsewhere should be forbidden. 
Diet and Bowel Function.—The diet is to be adjusted to the child’s 
digestive capacity. A diet suitable for the age is to be given, just as for 586 
THE PRACTICE OF PEDIATRICS 
the normal child (p. 135), meat being allowed only once a day. As intes- 
tinal indigestion and toxemia from intestinal sources are unquestion- 
ably important etiologic factors in causing a recurrence of the seizures, 
careful attention to the bowel function and diet are most important 
features of the treatment. The epileptic patient should never be al- 
lowed to pass over twenty-four hours without an evacuation of the bowels, 
and if, in the opinion of those in charge, the evacuation is not as copious 
as usual, an enema should be given. If there is a suggestion of consti- 
pation, the treatment with the oil enemata, or other means as recom- 
mended for chronic constipation (p. 267), is to be instituted. In cases 
in which heredity and toxic influences prevail, the importance of at- 
tention to the diet and habits of life cannot be overestimated. When 
there is a focal lesion, attention to the details of living will have less 
influence, but always, surely, some influence, in diminishing the fre- 
quency and severity of the seizures by establishing a more vigorous 
physical resistance. 
Colony Management.—During the past half-century the colony treat- 
ment, which began in Germany with a successful private attempt to 
house 4 patients has become wide-spread, and at present 
this method promises the most practical and far-reaching results. When 
parents are unable to give the patient suitable attention at home, he 
should be placed in one of the excellent institutions devoted to the care 
of epileptics, where the whole manner of life is adjusted and regulated 
with one object in view. 
Drugs.—There are few drugs in the pharmacopeia, particularly those 
of a sedative nature, that have not been used at one time or another 
in the treatment of epilepsy. The bromids unquestionably have long 
served our purpose in controlling the seizures better than has any other 
form of medication. The size of the dose is variable. Because of their 
peculiarly depressing effects upon the child’s mental condition the bro- 
mids should be given in as small quantities as are compatible with the 
beneficial result desired—a diminution in the number of the convulsions. 
To a child ten years old, 10 grains of sodium bromid ordinarily may 
be given, well diluted, in | glass of water after meals. The amount 
may be increased or diminished as the progress of the case indicates. 
If the convulsions are nocturnal, in a child of ten years, large doses—from 
20 to 30 grains—should be given at bedtime. In the event of the dis- 
continuance of the drug to the point where it is given but once a day, the 
time selected should be bedtime. If there is continued improvement 
under the bromid, it may be given on alternate nights, and finally every 
fourth night. 
Luminal in dosage of from 1 to 2 grains daily is a remedy of considerable 
value in cases in which the bromids are not suitable. 
As ocular defects may be important factors in causing epilepsy, every 
child with epilepsy should have the eyes examined by a competent oculist. 
Illustrative Case.—In a young woman already referred to (p. 585) the first convulsion 
occurred at the fifteenth year as a typical nocturnal seizure. Fifteen grains of bromid 
with 5 drops of the tincture of belladonna were given three times daily for three months, 
then the bromid was reduced to 30 grains daily. This was continued for one month, 
when a death occurred in the family which doubtless helped to incite a second attack. 
At this time, as the patellar reflex was scarcely perceptible and the bromid rash was ACUTE POLIOMYELITIS (INFANTILE PARALYSIS) 
587 
considerable, the drug was discontinued. At the end of two months the daily dosage 
was placed at 20 grains, with 10 drops of tincture of belladonna. This was continued 
for four weeks, when there was a third attack, without any apparent cause of an exciting 
nature beyond the fact that the patient had allowed herself to become obstinately con- 
stipated. This was her last attack. 
ACUTE POLIOMYELITIS (INFANTILE PARALYSIS) 
Anterior poliomyelitis is an infectious and widely transmissible disease 
affecting most intensively the anterior cornua of the spinal cord. 
Etiology.—From the brain and spinal cord of human cases of polio- 
myelitis, as well as from experimental cases of the disease in monkeys, 
Flexner and Noguchi1 cultivated, by anaerobic methods, a globular or 
globoid body smaller than any known coccus, 0.15 to 0.3ju in size, and 
staining pale reddish violet by Giemsa’s solution. Noguchi also dem- 
onstrated identical bodies in films prepared directly from the nervous 
tissues. The organism belongs to the filtrable viruses. 
These cultures, when inoculated into monkeys, have caused typical 
experimental poliomyelitis. 
Seasonal Influences.—While the disease may appear at any season 
of the year, a vast majority of the cases develop between July and Oc- 
tober. 
Age Incidence.—Although poliomyelitis is a disease of childhood, 
cases occurring in adults are not at all uncommon. In some recent epi- 
demics adults have numbered as high as 20 per cent, of the cases. In 
the 1907 New York epidemic the youngest patient reported was two 
weeks old. The most susceptible age is from the eighteenth month to 
the sixth year. Males are affected more frequently than females. 
Transmission.—Recent advances in our knowledge of the etiology 
and pathology of anterior poliomyelitis date from the work of Land- 
steiner and Papper in 1909. They succeeded in inoculating monkeys 
intraperitoneally with material obtained from a fatal case of the dis- 
ease in a child. Knoepfelmacher also succeeded in producing polio- 
myelitis in a monkey by the inoculation of human material, but these 
workers were not able to transmit the disease from monkey to monkey. 
Flexner and Lewis succeeded in doing this without difficulty, using the 
intracerebral method of inoculation and carrying their strains of virus 
through many generations. Flexner and Lewis were also able to trans- 
mit poliomyelitis to monkeys by means of subcutaneous and intrave- 
nous inoculation, though not in all cases were such experiments suc- 
cessful. On the other hand, intranasal inoculation in monkeys gives 
results that are always positive, while intraneural inoculation, as prac- 
tised by Leiner and v. Weisner, is less uniformly successful. 
The virus of poliomyelitis is regularly present in the central nervous 
system, and less frequently in the tonsils, nasopharyngeal mucous mem- 
brane, and mesenteric lymph-nodes. It has not been found in the large 
viscera or in the blood. The spinal fluid from a human case of polio- 
myelitis is capable of producing the disease when inoculated into a monkey. 
The virus resists freezing for a period of forty days, and drying for 
seven days, but becomes inert after exposure to 45° to 50° C. for half an 
hour. 
1 Jour. Amer. Med. Assoc., 1913, lx, p. 362. 588 
THE PRACTICE OF PEDIATRICS 
It has been pointed out that epidemics of develop along 
the route of human travel. Flexner and Clark showed that stable flies 
may harbor the virus on their bodies for a period of at least forty-eight 
hours, and that it may remain in their viscera for the same length of time. 
Immunity.—Flexner and Lewis proved that monkeys which have 
recovered from poliomyelitis are immune to further attacks of the dis- 
ease. They further showed that the blood of these immune animals 
contains neutralizing principles. Netter and Levaditi demonstrated 
the presence of such neutralizing principles in the blood of an abortive 
case occurring in a child. 
Pathology.—The lesions produced by the virus of poliomyelitis are 
naturally most marked in the nervous system, but they are present 
in other viscera as well. In the nervous system the gross lesions are not 
always very pronounced. They may appear in the spinal cord, pons, 
medulla, and cerebrum, and consist of congestion and minute hemor- 
rhages, chiefly into the gray matter. The- lesions of the spinal cord are 
not confined to the anterior horn. On microscopic examination the most 
marked lesions are found in the cord at the level corresponding to the 
most completely paralyzed muscle groups. In the gray and white matter 
of the spinal cord there are focal lesions consisting of edema, perivascular 
cellular infiltration, numerous hemorrhages, and degeneration of the 
nerve-cells and fibers. The anterior horns of the gray matter show more 
marked lesions than do the posterior horns, the nerve-cells being some- 
times replaced by leukocytes. The cells in a segment are always unequally 
involved. Similar focal lesions may be present in the medulla, pons, 
and cerebrum. 
The primary lesion seems to be in the meninges, which show peri- 
vascular infiltration with round cells, chiefly lymphocytes. The cellular 
exudate about the vessels, with their resulting partial destruction, leads 
to secondary lesions in the nervous tissue itself. 
The intervertebral ganglia show infiltration with lymphocytes between 
the nerve-cells and fibers, and some ganglion-cells show degeneration 
and necrosis. 
In other viscera the lesions consist of hypertrophy of the lymphoid 
tissue, including that of the tonsils, the thymus gland, the superficial 
and deep lymphatic glands, the small intestine, and the spleen. There 
are also minute focal necroses in the liver.1 
Cerebrospinal Fluid.—The cerebrospinal fluid shows changes varying 
with the stage of the disease. The cell count is almost always increased, 
being highest during the early days of the attack, and falling off progres- 
sively as the attack goes on, reaching the normal in two weeks, or less. 
In the majority of cases the fluid shows lymphocytes and large mon- 
onuclear cells only, but the polymorphonuclear cells may amount to 
90 per cent, of the total.2 The globulin content is increased, more so dur- 
ing the second week than the first. It may remain above the normal 
for seven weeks or more but during the chronic stage of the disease 
it tends to fall to normal. The sugar content is not far from normal, 
ranging from 40 to 80 mgm. per 100 c.c. 
1 Flexner, Peabody, and Draper, Jour. Amer. Med. Assoc., 1912, p. 109. 
2 Draper and Peabody, Amer. Jour. Dis. of Child., vol. iii, 1912. ACUTE POLIOMYELITIS (INFANTILE PARALYSIS) 
589 
Blood.—The blood was studied by Peabody, Draper, and Dochez in 
71 cases of poliomyelitis. In only one case did they find a leukopenia. 
In 70 cases there was a constant and marked leukocytosis, sometimes 
ranging as high as 30,000. 
During the preparalytic stage the total leukocyte count may be normal, 
though there is a tendency toward an increase with more polymorphonu- 
clears and less lymphocytes than during health. 
During the first and second weeks of the disease the leukocytes vary 
from 12,000 to 24,000 with an average of 18,000. The polymorphonu- 
clears are increased 15 to 20 per cent, and the lymphocytes diminished 
15 to 20 per cent. Transitional and large mononuclear cells show no 
change. 
The leukocytosis continues for weeks, the average of 9 cases in the 
seventh week having been 17,250 leukocytes. 
The youngest children showed the highest leukocytosis and the largest 
number of polymorphonuclear cells. 
Nasal Mucous Membrane.—Flexner aud Lewis showed that the 
nasopharyngeal mucosa is a regular site of elimination for the virus of 
poliomyelitis in monkeys experimentally inoculated with the disease, 
and Landsteiner, Levaditi, and Pastia demonstrated the same method 
of excretion of the virus in a human patient dying during the acute stage 
of poliomyelitis. Flexner and Clark also found the virus in the tonsils 
or nasal mucosa of human cases, and Flexner has suggested that “the 
nasopharynx acts in human beings as the portal of entry of the virus 
into the central nervous system, as well as its source of dissemination 
to other human beings.” In monkeys, and also probably in human 
beings, the virus may disappear from the nervous system and from the 
tonsils and nasopharjmgeal mucosa in from eight to ten days after the 
onset of the paralysis, or it may persist there for three or four weeks. 
The observation of Osgood and Lucas, who found that the nasopharyngeal 
mucosa of monkeys was still infectious five months after the acute stage 
of an attack of poliomyelitis, would seem to be exceptional and to indi- 
cate that chronic carriers of poliomyelitis may develop. 
Types of Cases.—For clinical purpose poliomyelitis may be divided 
into three types: the abortive, in which no paralysis occurs; the cerebral, 
representing the rare cases with resulting spastic paralysis; and the bulbar 
spinal group, which comprises all cases with lesions in the lower motor 
neuron, and flaccid paralysis.1 
Period of Incubation.—From five to fourteen days is generally ac- 
cepted as the period of incubation. This observation is based upon 
the results of clinical and laboratory investigations. 
Symptoms.—As in all infectious diseases, the symptoms vary widely. 
In a great majority of the cases there are decided prodromal symptoms. 
The most constant early symptom is fever. Usually there is a sharp 
rise of temperature, in some instances to 105° or 106° F. The duration 
of the fever is variable—from one day to a week. In some cases there 
will be a sharp, sudden rise and rapid fall. In a few there is slight tem- 
perature, and in others none at all. In two recent New York epidemics 
of 1907 and 1916 gastro-intestinal symptoms were very prominent in 
1 Draper, Peabody, and Dochez, Rockefeller Institute Reports, No. iv. 590 
THE PRACTICE OF PEDIATRICS 
a large number of cases, consisting in vomiting and diarrhea or a sharp 
attack of vomiting. A peculiar feature observed has been that the severity 
of the gastro-intestinal symptoms has borne no relation to the degree 
of the resulting paralysis. Ordinarily the paralysis is not noticed until 
the third or fourth day of the prodromal stage. Pain and hyperesthesia 
are very prominent symptoms in many cases. 
The nervous manifestations may be very urgent; thus convulsions, 
apathy and stupor are not uncommon and the cases may closely resemble 
those of acute cerebrospinal meningitis. In fact, such an error in diagnosis 
is frequently made. When bulbar involvement predominates there will 
be facial or ocular paralysis, disturbance of speech and deglutition, and 
paralysis of the respiratory muscles. 
Eleven fatal cases in private work which came under the senior author’s observa- 
tion in the 1916 epidemic were of this type. In 3 cases the paralysis was limited 
to the bladder. One case was of the very unusual ascending Landry type. The feet 
were first involved and then the trunk, arms, and neck. The child recovered after a 
long illness. 
Early in the disease, before the paralytic stage, the reflexes may be 
exaggerated. The paralysis appears from two to four days after the 
acute onset. It may involve an entire limb, or be limited to muscle 
groups irregularly distributed. The extent, degree, and permanency of 
the paralysis depend upon the severity of the lesion in the cord. Lesions 
in the lumbar enlargement are the most frequent and cause the greatest 
number of cases of paralysis. Involvement of the cervical enlargement 
causes the next largest number of cases. Wickman reported the dis- 
tribution of the lesions in 868 cases as follows: 
1. One or both legs 353 
2. One or both arms 75 
3. Combination of arms and legs 152 
4. Combination of legs and trunk muscles 85 
5. Combination of arms and trunk muscles 10 
6. Trunk muscles alone 9 
7. Paralysis of “the whole body” 23 
8. Ascending paralysis 32 
9. Descending paralysis 13 
10. Combination of spinal and cranial nerves 34 
11. Cranial nerves alone 22 
12. Localization of paralyses not given 60 
In about one-half of the cases the paralysis is limited to the legs. 
The cerebral type, in which a differentiation is difficult, presents clinically 
a symptom-complex which distinguishes it from the foregoing. This 
condition has been designated polioencephalitis by Striimpell. The onset 
in these cases is with fever, convulsions, vomiting, strabismus, and coma. 
The reflexes are usually exaggerated. 
Imbecility, epilepsy, and spastic paralysis may be the outcome. Cases 
are often designated as cerebral which strictly do not belong to this type. 
In view of the fact that the infection is general, cerebral symptoms are 
necessarily present in many cases. The fact that these manifestations 
promptly disappear means that no permanent lesions were present, and 
that the brain shared in the toxic systemic effects. 
That there are many cases of poliomyelitis which do not pass to the ACUTE POLIOMYELITIS (INFANTILE PARALYSIS) 
591 
paralytic stage is the opinion of all observers who have seen many cases 
of the disease. In the epidemics of 1907 and 1916 several such cases 
came under our observation. 
Prodromal symptoms were very urgent in 2 patients who developed slight leg 
weakness and absence of patellar reflex. Both recovered in three weeks. In two others, 
a boy and girl in the family of a physician, the prodromal symptoms were rather mild 
and both developed a slight paralysis of short duration. 
Wickman believed that over 25 per cent, of the cases belong to this, 
the so-called abortive type. There is no apparent distinction to be made 
between the symptomatology of the abortive cases and those that go on to 
the development of paralysis. Muller1 believed that the abortive cases 
outnumbered those of paralysis. This view receives striking support from 
the recent demonstration of typical visceral lesions, indicating that there 
is a general systemic infection. With such pathologic findings, sjunp- 
toms such as fever and malaise are reasonably to be expected. It may 
be that the abortive cases are those in which this general process is pres- 
ent, but in which the nervous system has been spared. Netter and Le- 
vaditi2 demonstrated that the serum of abortive cases neutralizes the 
virus in vitro, just as does the serum of the patients that develop paralysis. 
It is quite probable that in the past many of the abortive cases have not 
been recognized, and in certain cases at least, the apparent immunity 
of adults may be dependent upon such a previous, unrecognized attack. 
That the neutralizing substance in the blood may persist for a long period fol- 
lowing an attack of the disease, and probably immunity be present as well, is shown by 
the case of a man who had been paralyzed thirty years before, and whose serum still 
protected a monkey from the virus. 
Course.—Following the prodromal symptoms, flaccid paralysis, 
loss of knee-jerk, and atrophy appear. The paralyzed part becomes 
smaller than the corresponding limb or muscle group. The limb be- 
comes cooler than the normal. Subluxation of a joint, due to relaxation 
of the ligaments, is not an uncommon occurrence in cases in which there 
is extensive paralysis. 
Electric Reactions.—During the onset of the disease the electric 
irritability of the affected muscles and nerves is increased. After two or 
three days, however, these nerves fail to respond to stimulation, and 
the paralyzed muscles contract only under the galvanic current, show- 
ing the typical reaction of degeneration (an anodal opening contraction 
greater than the cathodal closure contraction). Galvanic irritability 
in the paralyzed muscles may be increased for several months, but there- 
after diminishes, and after a year or more disappears. 
Prognosis.—The prognosis in this disease must cover not only the 
mortality, but the resulting permanent paralysis as well. The mor- 
tality varies with epidemics; roughly, it may be said to range from 5 
to 20 per cent. The younger the child, the less the danger to life is a 
rule borne out by experiences in many epidemics. The disease is more 
fatal after the fifteenth year. In a Springfield, Mass., epidemic, 7 patients 
were over fifteen years of age. Of these, 3 died. In the fatal cases death 
usually takes place by the fifth day. 
1 Draper, Peabody, and Dochez: Rockefeller Institute Monograph, No. iv. 
2 Compt. rend. Soc. de biol., 1910, lxviii, 617. 592 
THE PRACTICE OF PEDIATRICS 
Prognosis as regards permanent paralysis is most difficult. Cases 
with very severe prodromal symptoms may have no permanent effects. 
The degree of damage depends upon the severity of the lesion in the 
cord, and this is impossible of demonstration. Patients whose paralysis 
was complete have made perfect recoveries, and other cases of similar 
nature have been followed by permanent residual paralysis. 
Illustrative Case.—A child of eighteen months had complete paralysis of the neck 
muscles and all four extremities. In this case the outlook apparently was hopeless, 
and yet the child made a perfect recovery. 
Permanent paralysis may follow very mild prodromal symptoms. 
The prognosis is further influenced by the possibilities of continued 
treatment. Many cases admit of much improvement through properly 
directed management continued over long periods. Among 530 cases 
collected by Wickman, 56 per cent, were paralyzed, 44 per cent, cured 
after eighteen months. In Massachusetts there were 16.7 per cent, of 
complete recoveries. 
That the disease is communicable by personal contact was definitely 
apparent during the epidemic in this section. 
Illustrative Cases.—There had not been a case in a certain New England village for 
twenty-five years. Two children, aged three and six years, came to the village from an 
infected section. Both became ill with digestive disorders and fever on the day of 
their arrival. The three-year-old girl was kept in her room and later developed para- 
lytic symptoms. The older child was ill about twenty-four hours, presenting a typical 
abortive case. Among the children who associated with her, one, a native, after six 
days developed a fatal poliomyelitis. 
Treatment.—During the acute stage of the involvement of the cord 
our efforts count for little. We order that the child be kept quiet in 
bed, that a laxative be given, and that he receive light, easily digested 
nourishment; and then, so far as the immediate conditions are concerned, 
we have done our little, but our all. The writer has used the bromids 
and ergot and urotropin and the iodids internally, and ice-bags and 
blisters over the spine at the site of the lesion, and is yet to be convinced 
that they are worth the indigestion and discomfort they are apt to oc- 
casion. That the disease is due to an infection is now proved, and in 
a given case our hope must be that the infection will be mild in char- 
acter. The outcome is determined largely by the severity of the infec- 
tion and by the resistance of the child. 
Human Serum.—The intraspinal use of human serum from those 
who have recovered from poliomyelitis has its advocates. Our own 
observations do not warrant an endorsement of this form of treatment. 
Later Treatment.—From ten days to two weeks after the acute stage 
has passed our efforts should be directed toward maintaining the nutri- 
tion of the affected muscle or groups of muscles. This is to be done by 
mechanical means, warm baths, electricity, and gymnastic exercises. 
The beneficial action of electricity consists largely in exercising the 
muscles no longer under voluntary control, and thus increasing their 
circulation and nutrition. The immediate object of the electricity is 
to induce contraction of the muscles. Either the faradic or the galvanic 
current may be used. The faradic should first be tried, and if to this MULTIPLE NEURITIS 
593 
there is no response, the galvanic should be used. Sittings of five to 
fifteen minutes may be desirable, depending upon the age of the child 
and the duration and extent of the lesion. The longer the duration of the 
disease, the longer should be the sittings. Once daily the parts should 
be massaged by one skilled in the work. When such a person is not 
available, the mother or nurse may undertake the systematic manipula- 
tion of the affected muscles by kneading and rubbing. Gymnastic exer- 
cises are unquestionably of very much value, but must be carried out over 
a long period of time. Children showing marked atrophy and paralysis 
and who promise little, often show surprising improvement, and restora- 
tion of function under properly directed exercises and manipulative 
treatment. 
The further management is orthopedic, and consists in the prevention 
of deformities by the use of splints and braces, and their correction by 
tenotomies and tendon transplantation. 
Quarantine.—That the disease is spread largely through undiagnosed 
abortive cases is unquestionable. Quarantine of all suspected or exposed 
cases should therefore be absolute. Furthermore, every child who de- 
velops an active illness with fever and gastro-intestinal disturbance dur- 
ing an epidemic should be quarantined, together with those children with 
whom he has previously associated. 
MULTIPLE NEURITIS 
Multiple neuritis or polyneuritis is an acute inflammatory disease 
of the peripheral nerves, degenerative in character, and usually sym- 
metric in distribution. 
Etiology.—While the great majority of cases observed in children 
follow diphtheria this disease is by no means the only cause. The neuritis 
may be due to various toxic agents, bacterial and of other derivation, 
producing inflammation and degeneration of the peripheral nerves. 
Among possible causes, other than diphtheria, are malaria, the exanthe- 
mata, grip, pneumonia, erysipelas, and typhoid fever. The toxins of the 
micro-organism causing the infectious disease are responsible for the 
nerve lesions far more often than is the organism itself. 
Pronounced cases in two brothers followed very severe scarlet fever. 
Lead, phosphorus, arsenic, and alcohol as possible causes are to be 
kept in mind. Lead in children is a very unusual cause. Arsenic, phos- 
phorus, and alcohol, however, are drugs used extensively during child life 
and should always be considered as possible etiologic factors. Citations 
will be found in pediatric literature calling attention to cases in which 
all these substances have been the means of causing multiple neuritis. 
Many mild cases of neuritis in children, following exhaustive diseases 
with prolonged toxemia, are doubtless overlooked, the prolonged time 
required for the return of muscle power in the arms and legs after disease 
being attributed solely to muscle weakness. 
Diphtheria.—Every child with diphtheria should be watched and 
treated as if diphtheric paralysis were expected. It has occurred to 
some extent in 9 per cent, of the senior author’s cases. 594 
THE PRACTICE OF PEDIATRICS 
Pathology.—The nerves affected may show both interstitial and 
parenchymatous changes. Early in the disease there is a congestion 
of the nerve-sheaths, and multiple hemorrhages have been found in 
them. Later in the disease the changes are those peculiar to degeneration 
in nerve structures. 
Distribution of the Lesion.—A peculiarity of the lesion is that the 
further away the peripheral nerve structure is from the parent cell, the 
greater is the susceptibility of the nerve to the influence of the toxic 
agent. The anterior tibial group, the soft palate, and the muscles of 
deglutition are most frequently involved. 
Sensory Effects.—Sensory disturbances in children are not so prom- 
inent as the neurologist would have us believe, for the reason, possibly, 
that he usually sees only the more severe cases. 
Quite a number of mild cases have been observed in which there were sensory 
disturbances and a diminished patellar reflex following lobar pneumonia with high 
temperature, and also after severe scarlet fever. 
Symptoms.—The symptoms are variable, depending upon the parts 
particularly involved. If the extremities or the neck muscles are affected, 
a careful observer will notice a gradual loss of power. The head is held 
erect with difficulty. The child is timid and refuses to walk. Usually 
there are a few falls which occasion the timidity. The child, if old enough, 
complains of weakness in the legs. In some cases there is nothing more 
than a limp to indicate the disease. Pain may be present, but has been 
of unusual occurrence in our cases. The reflexes may be diminished 
or absent. The characteristic foot-drop and wrist-drop are present in 
severe cases. 
Cases following diphtheria are particularly prone to paralysis of the 
muscles of deglutition. The child attempts to swallow, and the food 
returns through the nose. Deglutition may be interfered with to the 
point of impossibility of swallowing. There may be paralysis of the 
pharynx and larynx. Infrequently the muscles of the extremities are 
affected. The child may not be able to walk or sit upright, or even to 
support the head. It is the rule that if the heart is to be attacked, signs 
indicating heart weakness will appear early—soon after the paralysis of 
other parts is apparent, or even as an earlier symptom. The first warning 
is the heart’s irregularity, and this may be the only evidence of its in- 
volvement. Cases in which the heart has been very rapid or slow have 
been reported by other observers. In personally observed cases the heart 
has not been particularly rapid, neither has it been slow. It is irregular 
in that for ten seconds there may be 10 beats and during the next ten 
seconds perhaps twice this number. Pronounced irregularity may con- 
tinue for two or three weeks. 
Illustrative Cases.—A boy six years of age had a very mild attack of diphtheria, 
not of sufficient severity (in the opinion of his physician) to necessitate his remaining 
in bed. Two weeks after the onset of the attack, at which period he came under the 
writer’s care, there was marked paralysis of the soft palate and pharynx which rendered 
swallowing most difficult. In spite of energetic treatment with strychnin hypoder- 
mically, the paralysis soon involved the larynx, the masseters, and the muscles of 
all the extremities. Fortunately neither the heart nor the diaphragm was involved. 
There was a constant flow of saliva, which at times entered the trachea unimpeded, 
causing severe paroxysms of coughing. In order to prevent this the legs and trunk MULTIPLE NEURITIS 
595 
were elevated, the head being made the most dependent portion of the body. Swallow- 
ing was impossible, and the patient was given by gavage, every six hours, completely 
peptonized milk, whisky, beaten egg, and strychnin. The boy made a complete re- 
covery, but required three months to accomplish this. 
In the case of another patient, fifteen months of age, gavage was practised at 
six-hour intervals for five days before food could be swallowed. 
Electric Reactions.—The responses induced are exceedingly variable, 
depending on the degree of degeneration in the nerves and on the varia- 
tions in this process during the progress of a case. Early in the disease 
both galvanic and faradic irritability may be increased. Faradic re- 
sponses then diminish, and though galvanic excitability is usually in- 
creased temporarily, there is ultimately a more or less complete reaction 
of degeneration. Only in the most severe cases, however, is the gal- 
vanic response completely lost. 
Prognosis.—Complete recovery is the rule if there is no cardiac or 
respiratory involvement, although several weeks or months may be 
required to bring about perfect recovery. 
Few cases of diphtheric origin recover completely under eight weeks. 
Cases showing only a slight degree of heart involvement are never 
free from danger. 
Illustrative Case.—A girl, four years, apparently well, was admitted to the hospital 
with postdiphtheric paralysis of both legs, sufficient to prevent walking. The child, 
while resting on her back, dropped a top to the floor. She turned over and attempted 
to reach to the floor for the top and expired. The heart had previously shown some 
irregularity, and the child had been placed under close observation, which was momen- 
tarily withdrawn. 
Diagnosis.—The diagnosis is readily made through the multiple 
symmetric distribution of the paralysis, the impairment of or complete 
loss of function without impairment of sensation, and finally the dis- 
turbed respiration and cardiac irregularity. 
Treatment.—General Measures.—The treatment of postdiphtheric 
paralysis will be considered separately. In other forms of multiple neu- 
ritis the management is largely palliative, as there is a strong tendency 
to spontaneous recovery in four to eight weeks from the onset. In cases 
due to the use of alcohol or some other drug, the elimination of the excit- 
ing cause will usually be followed by recovery. In those cases due to the 
toxemia of preceding disease, time and good care are usually all that will 
be required to effect a cure. If pain is present, the most relief is afforded 
by heat. The affected limb may be bound in thick layers of cotton-wool. 
Drugs.—Salicylate of soda and iodid of potash are not to be given 
to young children. They produce no appreciable effect, except possi- 
bly a disturbance of digestion and a lessening of the appetite. Should 
the pain be sufficient to interfere with sleep, bromid of soda may be 
given in doses of 8 to 12 grains for a child of five to ten years of age. This 
is best given at bedtime and should be repeated but once. In using 
hypnotics for children, one drug should not be continued longer than 
three days. 
Codein is a satisfactory sedative for a child in case the bromid does 
not suffice. Between the fifth and tenth years from 1/10 to 1/6 grain of 
codein may be given at bedtime and repeated once after an interval of 
three hours. 596 
THE PRACTICE OF PEDIATRICS 
As a tonic for a patient from five to ten years of age a valuable com- 
bination of drugs is the following: 
1$. Strychnin* sulphatis gr. f 
Extracti ferri poinati gr. x 
Quininee bisulphatis 3 j 
M. div. et ft. capsulae no. xxx. 
Sig.—One after each meal. 
If constipation is present or should result from the administration of 
iron, from 4 to | grain of extract of cascara may be added to each capsule. 
The capsules are to be given for ten days, followed by cod-liver oil for 
five days. The oil should be given after meals. At the end of the five 
days the tonic capsules are to be repeated, and in due time followed 
again by the oil. This method may be followed as long as is thought 
necessary. 
Convalescence.—The patient should have the benefit of an outdoor 
life as early as possible. Electricity has not been necessary in our cases, 
nor has the use of orthopedic appliances been required. Massage may be 
used with advantage after subsidence of the acute symptoms. It should 
be given by one skilled in the work. 
Treatment of Multiple Neuritis After Diphtheria.—Cases following 
diphtheria require particular mention because of the danger of involve- 
ment of the heart, muscles of deglutition, and of respiration. If, after 
ten days from the onset of paralysis, there is no evidence of cardiac in- 
volvement, it will probably not develop later, although this is by no 
means certain. 
Mixsell and Cuddings1 reported 8 fatal cases of diaphragmatic paralysis 
out of 4259 cases of diphtheria. In the cases of phrenic paralysis with 
one exception the diphtheric exudate had been extensive and the antitoxin 
with one exception not given until after the third day of the diphtheria. 
The average time of onset of the paralysis was thirty-nine and a half 
days after the beginning of diphtheria. The cases developing paralysis 
of this type terminated fatally within an average period of thirty-six 
hours. Prolonged absolute rest for a period of several weeks is always indi- 
cated for patients receiving antitoxin late in diphtheria. 
Rest.—Should the heart become involved, as shown by irregularity 
or attacks of fainting or nausea, absolute rest in the recumbent position 
is important. The patient should be constantly under the eye of an 
attendant and should not be allowed to turn over in bed or raise his 
head without assistance. 
Medication.—A hypodermic syringe containing 1/100 grain of strychnin 
should be in readiness throughout the entire illness and well on into 
convalescence. Camphor in the dose of 14 grains in capsule may also 
be kept at the bedside, ready for hypodermic use. 
In these cases we rarely have to deal with children under eighteen 
months of age, so that in the consideration of doses only children over 
one year of age will be referred to. To a child from one to two years 
old 1/300 grain of strychnin may be given at three-hour intervals; from 
two to four years of age from 1/200 to 1/150 grain at three-hour intervals. 
After the fourth year 1/150 to 1/100 grain may be given similarly. When 
1 Jour. Amer. Med. Assoc., vol. 77, No. 8, 590, August 20, 1921. FACIAL PARALYSIS 
597 
there is marked rapidity of the heart’s action with irregularity, and 
restlessness, in those under three years of age, from 1 to 2 drops of 
tincture of strophanthus may be given with 1/15 to 1/10 grain of codein, 
and repeated at two-hour intervals. After this age 1| to 3 drops may 
be given with 1/10 to 1/6 grain of codein at two-hour intervals. The 
codein is to be discontinued as soon as the restlessness ceases. For 
those in whom there is simply paralysis of the muscles of deglutition 
or of the extremities, small doses of strychnin will be all the medication 
required, from 1/300 to 1/200 grain three times daily being sufficient. 
Gavage.—Troublesome obstacles in the management of cases in which 
there is marked involvement of the muscles of deglutition, and the palate, 
pharynx, and larynx, are the difficulty in feeding the patient and the 
danger of his aspirating food and mucus as a result of paralysis. For 
such patients gavage (p. 853) may be used with much benefit, 6 to 10 
ounces of food being introduced into the stomach at four- to six-hour 
intervals. In using the so-called forced feedings it is well to give as large 
feedings at one time as possible, as the gavage is always resisted by the 
patient. In the cases in which the aspiration of fluids and mucus into the 
larynx is a troublesome or dangerous factor, the trunk should be elevated 
and the head lowered. 
FACIAL PARALYSIS 
Paralysis of the facial nerve is not of infrequent occurrence in the 
very young and may result from forceps pressure at birth or from pressure 
exerted by the bony parts of the pelvic outlet. In later infancy or child- 
hood facial paralysis may be the result of trauma caused by operative 
manipulations, or may be of rheumatic origin, or due to cerebellar disease, 
or to exposure to cold. In one patient the paralysis was attributed to 
sitting by an open window in a railroad car on a cold day. The nerve, 
in its outward passage through the fallopian canal, may become diseased 
from the presence of a purulent otitis media. This is probably the most 
frequent cause of facial paralysis. It may also be caused by poliomyelitis. 
During the 1916 epidemic a vast number of cases showed facial paralysis— 
many without other signs of paralysis. In other cases the facial paralysis 
was associated with that of other parts. 
Prognosis.—The prognosis depends largely upon the cause of the 
paralysis. Cases due to exposure to cold, and rheumatism, and those 
in the newborn that are due to birth trauma usually terminate in 
recovery. Cases resulting from section of, or other injury of the nerve, 
through accident at operation, likewise almost always have a satisfactory 
outcome. 
The unfavorable cases are those due to brain disease such as menin- 
gitis or tumor, or to severe injury, such as fracture or caries of the tem- 
poral bone. 
In facial paralysis resulting from ear inflammation the prognosis is 
less favorable than in ordinary cases because of the fact that the involve- 
ment of the nerve is apt to be of a destructive type. Cases showing a 
complete reaction of degeneration require months for recovery. If this 
reaction, however, is not complete, recovery may occur in a period of 
weeks. 598 
THE PRACTICE OF PEDIATRICS 
Treatment.—The management depends entirely upon the cause of 
the paralysis. If the condition is due to cerebral disease, but little is 
to be expected from treatment. If the paralysis is due to an otitis media, 
surgical procedures, such as establishing a free drainage from the cavity 
of the middle ear, followed by frequent hot irrigations, should be em- 
ployed. If these are ineffective, the mastoid should be opened and the 
cavity drained posteriorly. When the functional activity of the nerve 
is delayed, electricity may be brought into use in the manner indicated 
below. Cases in which rheumatism is supposed to be a factor should 
be given the benefit of antirheumatic treatment by the use of the salicyl- 
ates (p. 737). In the cases due to cold or trauma there is a strong ten- 
dency toward recovery without treatment. 
It is difficult to judge of the value of such a therapeutic measure as 
electricity; but the effect of exercising the paralyzed muscles and stim- 
ulating nerve conduction by its use must be of some service. If the 
electricity is used, five-minute daily sittings are all that are necessary. 
The faradic current should be employed if it produces sufficient muscle 
response; if not, the interrupted galvanic current. 
ERB’S PALSY (OBSTETRIC PARALYSIS) 
This disease is due to a traumatic neuritis caused by an injury of the 
brachial plexus during labor. 
Lesion.—The injury may be very slight, causing but a temporary 
paralysis, or very extensive, causing subsequent degeneration of the 
nerve structure. The essential lesion in Erb’s palsy is an injury of the 
fifth and sixth cervical nerve-roots near their junction on emergence 
from the spinal cord. This injury may involve rupture, laceration, or 
bruising of the nerves, and occasionally hemorrhage between the fibers. 
In typical cases the seventh and eighth cervical nerves are not injured, 
but occasionally these also may be damaged. The muscles principally 
affected by the paralysis are the deltoid, biceps, brachialis anticus, supi- 
nator longus and supinator brevis, the spinati, and eoracobrachialis. The 
pectorals, latissimus dorsi and triceps may be partially affected. In 
400 of 4G0 cases reported by Sever1 the paralysis was of the upper arm 
type. 
Under the influence of the action of unparalyzed muscles the head of 
the humerus in many cases becomes secondarily displaced backward 
from its socket, so that the arm is abducted on the scapula, flexed for- 
ward, and rotated inward. This condition may be confused with true 
congenital dislocation. 
Diagnosis.-—The chief point in the diagnosis is that one arm alone is 
involved. Cases of bilateral involvement are extremely rare. In dif- 
ferentiating this form of paralysis from cerebral palsies it will be noted 
that in Erb’s palsy there is a flaccid paralysis with some degree of atrophy, 
there is never spasticity, and the mentality is normal. After a few months 
the affected limb becomes smaller and much softer than the unaffected 
arm. Owing to the location of the muscles involved and because of the 
paralysis of the supinator group, the arm is often rotated inward, throwing 
1 Amer. Jour. Orthop. Surg., August, 1916. erb’s palsy (obstetric paralysis) 
599 
the palm of the hand outward and backward. Owing to paralysis of the 
extensors, due to involvement of the musculospiral nerve, the fingers 
and thumb are in a more or less permanent condition of flexion-fixation. 
Exceptionally the deformity caused by a birth fracture may simulate 
that of Erb’s palsy. 
Prognosis.—In the main the prognosis is favorable, but not as favor- 
able, from our observation, as the literature would lead us to believe. 
In fact, a guarded prognosis should always be given. A case involving 
fracture of the humerus with complete paralysis underwent complete 
recovery in three months. Only partial recoveries have occurred in 
other instances, and in still others the lesion has been of such a nature 
as to make recovery impossible. We may safely say that all the subjects 
improve and that they may recover entirely, but we are not in a position 
to promise any outcome in a given case. Improvement should not be 
despaired of even after several months have elapsed. Exceptionally 
the improvement has continued to the eighth and tenth year. In a few 
cases the paralysis and deformity are permanent. If there is complete 
paralysis after one year one may safely assume that the paralysis will 
be permanent. 
Sachs has stated that even in the event of complete paralysis, recovery 
may be looked for in the cases showing a slight response to faradism, 
in two or three months. When there is no faradic response, but reaction 
to the galvanic current, the restoration of power may be expected in 
six months. In those cases in which there is no galvanic or faradic re- 
sponse, a year or two may be required before the arm is normal. 
Treatment.—The atrophy and contractions which develop are de- 
termined largely by the extent of the injury, and to a lesser degree by 
the treatment. During the first three weeks in lifting and handling 
the infant the arm should be protected from other injuries, such as may 
take place in bathing and the usual manipulation necessary in the care 
of the baby. After this time massage of the entire arm and shoulder 
with lanolin should be practised at least twice a day, from ten to fifteen 
minutes at a time. After two weeks electricity may be used for a few 
minutes each day. If the child can bear it, the faradic current answers 
best. In cases in which there is no response to faradism, the galvanic 
current should be used. Under massage and electricity the improve- 
ment in the arm is often most satisfactory. 
To correct deformity the arm should be held in abduction and out- 
ward rotation with the forearm held in supination by a suitable splint. 
If the humerus is dislocated the condition must be corrected, if necessary 
under anesthesia; and the correct position must be maintained long 
enough to prevent recurrence of the dislocation. 
The degree of improvement is dependent upon several factors, the chief 
one of which (the extent of the nerve injury) is in every case uncertain. 
In the more severe forms of obstetric paralysis in which the lower 
arm or the whole arm is affected, provided a reasonably long period has 
elapsed under proper care without improvement in the muscles, an opera- 
tion upon the brachial plexus with excision of indurated tissue and ap- 
proximation of the nerve ends by sutures is to be undertaken. Sharpe1 
1 Jour. Amer. Med. Assoc., March 18, 1916. 600 
THE PRACTICE OF PEDIATRICS 
has recommended this procedure in cases with complete paralysis at 
the end of one month. 
Such a degree of paralysis means that there has been an extensive 
injury and tear in the plexus. In such an instance there is bound to 
be an impaired arm. The early operation is advised in order to forestall 
the formation of large masses of fibrous tissue. The earlier the anastomosis 
of the nerve roots, the more perfect the union of the torn nerve structures 
and consequently the better the ultimate result. 
An important feature in the management of these cases is the pre- 
vention of deformity through contractures. This may be accomplished 
by the use of suitable orthopedic appliances. 
FRIEDREICH’S ATAXIA (HEREDITARY ATAXIA)1 
Friedreich was the first to describe this affection and establish it as 
a clinical entity. The designation, “hereditary ataxia,” is faulty for the 
reason that heredity does not necessarily enter into consideration. This 
disease, however, shows a tendency to family selection. 
Definition.—“A slowly progressive disease of the spinal cord occur- 
ring in late childhood, characterized clinically by loss of equilibratory 
control, ataxia affecting progression, nystagmus, and peculiar defoimi- 
ties, particularly a form of talipes equinovarus or pes cavus. The disease 
is dependent anatomically upon primary degeneration of the dorsal col- 
umns and spinocerebellar and pyramidal tracts. 
History.—“Following Friedreich’s description, Brousse, a Frenchman, 
gave the name of the former to the disease, and later Marie differentiated 
the cerebellar form, typically combining onset after the twentieth year, 
increased knee-jerks, ocular paralyses, and optic atrophy. Schultze, in 
1877, showed that the form described by Friedreich was unrelated to loco- 
motor ataxia and was due to inherent defective cord development. 
“Typical hereditary spinal ataxia of the type first described is com- 
paratively rare. Schoenborn2 in 1901 could collect only about 200 posi- 
tive cases, and later made the estimate of another possible 200 cases in 
the next fifteen years. Griffith3 reported 143 cases in 1889, but believes 
that some of these cases might properly fall into a different category. 
He cites the record of the family reported by Carre,4 in which the grand- 
mother, 9 of her children, and 7 children of one affected daughter were 
all victims of the disease. 
Etiology.—“Fundamentally there is in the spinal cord a lack of devel- 
opment, which is inherited indirectly, oftener than immediately, from 
either parent. The degeneration which occurs is superimposed upon the 
primary abiotrophic defect. Schoenborn found the disease to be familial 
in 114 of 200 cases. Approximately 60 per cent, of cases observed have 
occurred in males.” 
Gowers refers to 65 cases occurring in 19 families. The number of 
1 Quoted portions from Friedreich’s Ataxia, Graves, Arch, of Pediatrics, No- 
vember, 1921. 
2 Burr, Text-book on Nervous Diseases. 
3 Transactions, College of Physicians, Phila., 1888, x, 196, and Diseases of Infants 
and Children. 
4 De 1’ataxie locomotrice progressive, 1865, 65, 248. Friedreich’s ataxia (hereditary ataxia) 
601 
cases in one family was as high as 10. Gowers finds the sexes about 
equally divided as regards liability. Sachs, in a wide experience, has 
never seen a case in a girl. 
Kerley observed the disease in 2 boys aged four and six years whose 
family history had been perfect. 
“The incidence is most commonly between the ages of five and fifteen, 
but cases have been reported between the ages of two and four, and oc- 
casionally after maturity. Consanguinity, alcoholism, syphilis, and in- 
sanity have been noted in ancestors of the patients, but neuropathic 
ancestry is by no means always a discoverable factor. The first symp- 
toms of ataxia often follow an acute illness or one of the infectious 
fevers.” 
Pathology.—Neurologists agree that the pathology of Friedreich’s 
disease is not well understood. Sachs states that “one fact is indisputable, 
in microscopic examinations a sclerosis of the spinal cord is found involv- 
ing at different levels or at one and the same levels various systems 
of the cord. The sclerosis affects most frequently the posterior columns 
or the lateral columns, or both together, and hence the symptoms vary 
between those of a pure posterior spinal sclerosis and those due to a 
posterior lateral sclerosis, resembling the symptoms of the ataxic para- 
plegia of the adult.” 
“A striking feature remarked by many observers is the small caliber 
of the spinal cord. There is sclerosis of the dorsal columns of Goll and 
Burdach, typically also of the crossed pyramidal and spinocerebellar 
tracts and usually involvement of the columns of Clarke and Gower. 
In cases of the Marie type there is likewise atrophy of the cerebellum, 
while even in Friederich’s ataxia atrophic changes in the cerebellum have 
been reported. In most instances, however, the cerebellar changes have 
been limited to hypoplasia. Secondary changes in the dorsal roots are 
common. The variability of the symptoms noted has been easily ex- 
plained by the fact that even in extreme sclerosis normal fibers persist 
and degenerations in different portions of the cord may or may not be 
simultaneous. The cerebrum is apparently unaffected.” 
Symptoms.—“Walking is early interfered with and the child stands 
with difficulty. The first awkwardness in gait frequently makes its ap- 
pearance after an acute illness or a period of physical depression. Grad- 
ually the steps become unsteady, the feet are placed wide apart, and there 
is an increasing tendency to stumble. Checking a quick run and wheeling 
about in the reverse direction calls for excessive movements of the arms 
to maintain balance or gain direct support from some stationary object 
at hand. In standing the trunk is held forward, the legs and arms and 
even the hands are held slightly flexed, and there may be oscillatory 
movements of the head and trunk. As the disease advances the gait 
becomes more staggering, but does not include the throwing out move- 
ments of the feet characteristic of true tabes. The knee-jerks may be 
present early in the disease and are occasionally exaggerated, but usually 
become lost within a year. There is contracture of the posterior tibia 1 
muscles and hyperextension of the large toes, resulting in talipes equino- 
varus, one of the most reliable signs of the development of the condition. 
In cerebellar ataxia also this sign may exist. In the later stages, ataxia 602 
THE PRACTICE OF PEDIATRICS 
of the upper limbs, paraplegia, claw hand, scoliosis, and kyphoscoliosis 
supervene; and nystagmus and scanning speech are added.’’ 
Inco-ordination in the use of the arms is at first not unlike that in 
chorea. Attempts at a concise volitional act with the upper extremities— 
such as writing, bringing the ends of the index-fingers together, or placing 
the tips of the fingers on the tip of the nose—result in hesitancy, tremor, 
and imperfection in the act attempted. In fact, the act can be accom- 
plished only with much effort and after several attempts if at all. 
There is usually a positive Babinski sign. Romberg’s symptom is 
variable. It was present in the 2 boys observed by Kerley. Char- 
acteristically control of bladder and rectum are unimpaired. Sensation 
is not greatly interfered with. The eye changes are not important. Nerve 
atrophy does not occur and the Argyll Robertson pupil is absent. 
The patient is mentally slow and diffident. There is an entire loss 
of confidence, and this is stamped on the countenance and is manifested 
in every voluntary act. The child hesitates and speaks slowly, as though 
ideas were hard to formulate into words. 
“The course is extremely slow and attended by periods when no added 
symptoms are noted and good general health may veil the gradual retro- 
gression in the nervous system, thus giving the impression of improve- 
ment. Five to ten years may elapse before the patient is bedridden, and 
as many more before death ensues from pneumonia or some intercurrent 
disease. From a review of the description it is difficult to foretell with 
any accuracy the sequence of the symptoms in a given case.” 
“The 'pathogenesis of the individual symptoms calls for considerable 
explanation which is not adequate even in some of the best neurologic 
text-books. ‘The ataxia in its spinal components is to be traced back to 
the process in the posterior columns; in its cerebral components, to the 
degeneration in the lateral cerebellar tracts.’1 When the cerebellum is not 
properly informed as to the status of muscles dealing with co-ordinated 
action, owing to improper or defective transmission of impulse sthrough 
the degenerated spinocerebellar tracts, ataxia is the result. The lack of 
marked impairment of sensation is explained by the facts that pain, 
temperature, and pressure are not dependent on the posterior columns 
for their transmission, whereas sensations giving an idea of position and 
degree of contraction of muscles are thus conveyed, the result being ataxia 
without paralysis. The Babinski reflex is explainer! by involvement of 
the pyramidal tracts; and the loss of deep reflexes, by degeneration of 
the lower sensory neurons. The nystagmus, likened to intention tremor, 
and the dysarthria have been ascribed to degeneration in the brain 
stem.” 
Prognosis.—“The outlook in a given case for many years of life is 
good. The outlook for health permitting efficiency is, of course, practically 
hopeless.” 
Diagnosis.—“This is possible even without a family history if one 
reviews the following tabulation in connection with thorough observation 
of the suspected case: 
1Burr, Text-book on Nervous Diseases. ACUTE INFECTIVE MENINGITIS 
603 
Friedreich’s ataxia. 
Heredity. 
Onset at five to fifteen years. 
Ataxia of lower limbs first. 
Loss of knee- jerks within one year. 
Babinski. 
Nystagmus. 
Pes cavus, claw-hand, scoliosis. 
Juvenile tabes dorsalis. 
Early adult life. 
Lightning pains and girdle sensations. 
Early loss or diminution of reflexes. 
Ptosis. 
Pupillary signs. 
Bladder and rectal symptoms. 
Stigmata of syphilis. 
Positive Wassermann. 
Hereditary cerebellar ataxia. 
Onset later. 
Ataxia of all limbs. 
Reflexes increased. 
Optic atrophy. 
Rarely deformity of foot or spine. 
Multiple sclerosis. 
Early adult life. 
Ataxia spastic. 
Intention tremor. 
Increased reflexes. 
Nystagmus, scanning speech. 
Optic atrophy. Pallor of optic disks. 
Multiple neuritis. 
History. Ataxia. Sensory and motor symp- 
toms.” 
Treatment.—“Aside from measures to maintain good general health 
there is no treatment. Education in muscular movements to compensate 
for the ataxia, as in the treatment of tabes by the Fraenkel method, may 
be of some avail.” 
ACUTE INFECTIVE MENINGITIS 
Acute meningitis, as its name implies, is an acute inflammation of 
the meninges covering the brain and cord. 
Etiology.—Acute meningitis may be either a primary or a secondary 
disease. The more common sources are suppuration in the ears, nose, 
and eyes, head injuries, and systemic infections with a bacteremia, such 
as typhoid, influenza, pneumonia, and infective endocarditis. 
When primary, meningitis is usualfy due to the meningoccus or the 
pneumococcus. Meningococcus meningitis is considered under a separate 
caption (p. 610). 
Cases of secondary origin are usually the result of the invasion of 
the staphylococcus. The streptococcus, colon bacillus, typhoid bacillus, 
and influenza bacillus may also be included in the latter group, the men- 
ingeal involvement being a complication or sequel of pneumonia, an 
intestinal infection or typhoid fever. Streptococcus or staphylococcus 
meningitis is often a complication of middle-ear, mastoid, or sinus disease. 
Pathology.—The changes occurring locally in and about the brain 
depend on the character and source of the infection. In ear infections 
the lesions are often unilateral and accompanied by sinus thrombosis. 
In the majority of the other cases the vessels of the pia are congested and 
give origin to small hemorrhages, and the surface of the brain is covered 
with seropurulent or fibrinopurulent exudate. The convolutions are 
flattened to a degree depending on the amount of associated hydro- 
cephalus. Accompanying cord involvement is the rule. The presence 
of a large amount of greenish-yellow exudate over the anterior portion 
of the cerebral cortex, with many fibrinous adhesions, is very character- 
istic of pneumococcus meningitis. In certain infective fevers, such as 
measles and scarlet fever, acute serous meningitis (p. 619) may occur. 604 
THE PRACTICE OF PEDIATRICS 
In a private case due to the pneumococcus the anterior half of the 
brain cortex (see Plate I) was incased in pus. 
Symptoms.—If the case is primary the onset may be sudden, with 
vomiting and convulsions, both of which may be repeated many times. 
Supervening upon the active manifestations there will be at first drowsi- 
ness, followed by stupor, from which the child can with difficulty be 
aroused. 
The first indication of cerebral involvement is the drowsiness, stupor 
combined with irregular respiration, and irregular pulse. A disturbance 
of the heart action is a very significant and early sign. It may be irregular, 
intermittent, or it may be very rapid and regular. Repeatedly the hea? t 
rate has been observed as 140 to 180 a minute, with practically a normal 
temperature. Vasomotor disturbance indicated by the taehe c£rebrale 
may be an early symptom. In the infant a tense fontanel is one of our 
most valuable signs. The pupils are usually dilated symmetrically or 
unevenly, and show little or no response to light. Hyperesthesia and 
rigidity of the neck may be present. Swallowing is earlyr interfered with. 
Purposeless movements of the leg or arm are often seen when the 
symptoms of the disease are well marked. The leg or arm is raised and 
allowed to fall, this being repeated for hours at a time. An elevation of 
temperature is usually present. It may be high, low, or variable. 
In the seven-month-old infant above referred to, whose brain is shown in Plate I, 
the first signs were a temperature of 102° F., a greatly distended fontanel, and stupor. 
The child died in three days. 
Diagnosis.—The only positive information as to the nature ol the in- 
fection is obtained by lumbar puncture; only in this way can a positive 
differential diagnosis between acute simple, tuberculous, and cerebrospi- 
nal meningitis be made. 
In many severe diseases in which there is marked toxemia, symp- 
toms closely resembling meningitis will be in evidence. In pneumonia, 
otitis media, the severe intestinal infections, and in heat prostration the 
cerebral symptoms so closely simulate those of meningitis that a posi- 
tive diagnosis without lumbar puncture may be impossible. Before 
the advent of lumbar puncture most excellent clinicians diagnosed men- 
ingitis in cases which at autopsy showed no pathologic condition in the 
brain. We have known cases so diagnosed to recover too promptly to be a 
comfort to the attending physician. 
Differential Diagnosis.—Acute simple meningitis, tuberculous men- 
ingitis, cerebrospinal meningitis, anterior poliomyelitis, acute epidemic 
encephalitis, and meningismus all show certain symptoms in common, 
sufficient to require a lumbar puncture with examination of the spinal 
fluid, in order that a positive diagnosis be made. In acute simple men- 
ingitis the fluid is usually turbid, and when allowed to stand, a consid- 
erable deposit of pus forms in the tube, bacteriologic examination 
of which determines the nature of the infection. The cells present in the 
fluid are almost exclusively polymorphonuclear leukocytes. In men- 
ingismus there are the signs of drowsiness, stupor, and perhaps hyper- 
esthesia and immobility of the pupils, but no irregularity of the pupils, 
and rarely irregular respiration and distention of the fontanel. Partic- PLATE 1 
Pneumococcus meningitis. (Dr T. W. Kilmer.) ACUTE INFECTIVE MENINGITIS 
605 
ularly significant in such cases is the absence of signs of irregularity or 
slowness in the heart action. The characteristics exhibited by the spinal 
fluid in the diseases mentioned are detailed in a separate section (p. 623). 
Prognosis.—The prognosis is most unfavorable. We have yet to see 
recovery in a case in which the diagnosis was proved by lumbar punc- 
ture. Occasionally such recoveries are reported. 
Treatment.—The most one can do in acute simple meningitis is to 
nourish the patient and lessen his discomfort. We have no means of 
treatment that may be considered in any sense curative. By the use 
of repeated lumbar puncture we can in some cases make the patient 
more comfortable, and perhaps aid him to resist the infection. The 
pulse and the respiration improve, as well as the control of the nervous 
phenomena; the opisthotonos and the excessive hyperesthesia may be 
temporarily relieved. There is no rational ground, however, for ex- 
pecting the withdrawal of the cerebrospinal fluid to be curative; nor 
may the injection of antiseptic solutions into the canal be expected to aid 
in controlling the disease. 
Lumbar puncture (p. 821) may be practised as frequently as once in 
twenty-four hours, the frequency of such procedure depending, of course, 
upon the condition of the patient and the relief afforded. The use of lum- 
bar puncture more frequently than once in twenty-four hours, as has 
been suggested by some writers, is not, however, to be advised. The 
amount of fluid to be withdrawn depends upon the pressure in the canal 
as indicated by the passage of fluid through the cannula, from 1 to 3 
ounces being the usual amount withdrawm. Strict surgical precautions 
as regards asepsis should be observed in performing the operation. One 
dram of aristol in 1 ounce of collodion, applied with a camel’s-hair brush, 
makes a suitable protective dressing after the withdrawal of the cannula. 
Warm Packs:—The warm pack or warm bath at 105° F., by lessen- 
ing the cerebral blood-pressure, may also assist in relieving the more 
active nervous manifestations. If the bath is used, the child should 
not be kept in it longer than three minutes. The hot pack is usually pref- 
erable. A large bath-towel or medium-weight flannel sheet is wrrung out 
of water at 110° F., and wrapped around the child’s body from the waist 
down. This is repeated at half-hour intervals for three hours, when, 
after a period of rest for an hour or two, the packs may be resumed. 
Diet.—The proper nutrition of the patient with meningitis is often 
a matter of no little difficulty. The child may either refuse the food, or 
be unable to swallow. Nutrition by means of the rectum or colon may 
be of assistance for a few days, but cannot be relied upon for long periods 
for the reason that the parts become intolerant and the nutrient enemata 
are expelled. Feeding by means of gavage is always to be employed 
when other means fail. The younger the child, the more applicable 
this method. The feeding should not be attempted oftener than at four- 
hour intervals; usually, feeding every six hours suffices. Completely 
peptonized wrhole milk (p. 76) is usually given in quantities suitable 
for the age. After a few trials of gavage the patient may take the nourish- 
ment by the usual method, or the gavage may be continued. 
Sedatives may be employed with a view to saving the strength of the 
patient. Morphin, codein, bromid of soda, or chloral may be given. 606 
THE PRACTICE OF PEDIATRICS 
As morphin and codein increase the usual existing constipation, their 
use should be very temporary. The bromid of soda for the cases which 
may require the protracted administration of a sedative answers better 
than any other form of medication. To an infant under eighteen months 
of age from 2 to 4 grains may be given at intervals of two to three hours, 
according to the results. In case the nervous symptoms are very urgent, 
\ to 1 grain of chloral may be added. Should administration by mouth 
be impracticable, the sedative may be given by rectum, by means of a 
rectal tube inserted at least 9 inches. In using the bromid and chloral 
in this way twice the amount of chloral and thrice the amount of bromid 
employed in stomach administration should be given. After the eigh- 
teenth month, from 1 to 2 grains of chloral and from 4 to 8 grains of the 
bromid well diluted may be given by the stomach, and repeated as often 
as may be necessary. In case the medication is to be given by rectum, 
it should be diluted with at least 4 ounces of water, and proportionately 
more given. 
Tuberculous meningitis is one of the most fatal diseases of childhood. 
As its name implies, it is a tuberculous inflammation of the meninges. 
The frequency of the disease is due to the favorable field offered by the 
covering of the brain for bacterial growth and the wide dissemination of 
the tubercle bacillus. The rapid development of the brain, the birth 
weight of which is increased about four times during the first four years 
of life, necessitates rapid development and active work on the part of 
the blood-vessels and lymphatics. These, therefore, supply a favorable 
culture field for the invading organism. 
Age.—No age is exempt. Our youngest patient was three months 
old. Between the first and third year the greatest number of cases occur. 
The disease is rare after the eighth year. We have seen a few cases 
between the twelfth and the eighteenth year. 
Pathology.-—This form of meningitis is usually secondary to tuber- 
culosis elsewhere in the body, and is usually part of a general miliary 
infection. Among 413 fatal cases of tuberculosis in children, Shennan 
reported tuberculous meningitis in 184, or 44.5 per cent In 77 of these 
cases the disease had spread from mediastinal glands; in 26, from ab- 
dominal glands; and in a small number, from an active pulmonary in- 
flammation. Transmission is practically always through the blood. 
Miliary tubercles may be numerous on the walls of the blood-vessels of 
the pia mater, and over all surfaces of the cerebrum, cerebellum, and 
cord, but are usually most numerous at the base, between the peduncles. 
There may be more or less exudate of fibrin and leukocytes at the base. 
The spinal fluid is increased in amount and, owing to the closure of the 
foramen of Magendie by inflammatory exudate, the lateral ventricles 
become dilated. The ependyma may contain many miliary tubercles. 
Flattening of the cerebral convolutions may result from accumulation of 
fluid in the ventricles. 
Symptomatology.—Tuberculous meningitis is variable in its early 
manifestations. Probably one of the earliest indications of the disease 
is a change in the disposition of the patient. A happy, easily pleased 
TUBERCULOUS MENINGITIS TUBERCULOUS MENINGITIS 
607 
child becomes cross and disagreeable, and may remain for days in this 
condition. In getting the history of a case we have repeatedly heard 
these symptoms mentioned. 
Illustrative Cases.—A girl patient, three years of age, was in the habit of going 
to the park daily. On her return home, regardless of the street selected by the nurse, 
the child insisted on turning back and passing through another street. She was also 
very irritable and refused to play with other children. The mother had been in the 
habit of singing several songs to the child. The child selected one and would have no 
other. She was not content out of the mother’s arms, and insisted that the song con- 
stantly be sung to her while awake. The mother became nearly distracted at the 
constant performances, and at this time, after three weeks of decided mental aberration 
on the part of the child, brought her for treatment. She died five weeks later from 
tuberculous meningitis. 
In 2 cases the first symptom and the only symptom for two weeks was intense 
headache. 
A boy fourteen years old who had occasioned suspicion of the existence of miliary 
tuberculosis because of unexplained fever of several weeks’ duration suddenly com- 
plained of diplopia. Frank tuberculous meningitis of fatal issue rapidly supervened. 
There may be vomiting without apparent cause, and if the vomit- 
ing is repeated one or more times on successive days and associated with 
other suggestive signs, it constitutes a symptom of no little value. 
Fig. 111.—Facies of tuberculous meningitis, showing facial paralysis and strabismus. 
(Children’s Medical Division, Bellevue Hospital, N. Y.) 
Convulsions may usher in the disease. The convulsions are apt to 
be repeated several times. 
Mental disturbance, diplopia, vomiting without apparent cause, con- 
vulsions, loss of appetite, constipation, restlessness at night, and night- 
cries belong to the earlier manifestations. After a week or perhaps two 
weeks of pronounced though indefinite signs the child becomes dull and 
apathetic, sleeps a great deal, and rapidly passes into a condition of 
semistupor from which he is aroused with difficulty. If roused he mani- 
fests extreme irritability. Hyperesthesia and exaggerated reflexes may 
be present early in the disease. With the progress of the case they often 
disappear. The fontanel in a young child early becomes tense and bulg- 
ing—a very valuable sign. 
Decided evidences of cerebral pressure soon make their appearance. 
The respiration becomes irregular. The pulse-rate is 60 to 80 instead 
of 100 to 120. At times the pulse will change very markedly and be- 608 
THE PRACTICE OF PEDIATRICS 
come rapid for a few hours; as a rule, it is characterized by slowness 
and irregularity. Rigidity of the neck, slight opisthotonos, and spas- 
ticity of the extremities appear. During this time the child will usu- 
ally swallow if food is given. In many cases there is an inco-ordinate, 
almost perpetual motion of the arm and leg on one side of the body. 
The pupils become sluggish, responding slowly to light stimulation, 
or fail to show any response. The pupils may be unequal. One pupil 
may respond to light, while the other remains stationary. 
There is no characteristic temperature in tuberculous meningitis. 
The usual range is between 99° and 102° F. It may be higheV or lower. 
The blood usually shows a considerable leukocytosis ranging between 
12,000 and 20,000, with a corresponding increase in the polynuclear cell 
percentage. 
Very few cases of uncomplicated tuberculous meningitis occur, as 
mentioned before. The meningitis is usually associated with tuber- 
culous processes elsewhere, which exert a controlling influence on the 
temperature. 
Later Symptoms.—The coma increases. It is impossible to arouse 
the child. Liquid food placed in the mouth remains there or runs out 
at the sides. The breathing is labored. Cheyne-Stokes’ respiration 
develops. The pulse becomes slower, intermittent, and irregular; and 
the child dies. 
Regardless of the age, the signs and symptoms are very similar. 
Occasionally one meets with fulminating cases with sudden onset 
and urgent symptoms of vomiting, high fever, rapidly developing stu- 
por, and irregular pulse and respiration. Such cases are rare, and when 
they occur, are easily confused with those of meningococcus meningitis. 
Diagnosis.—Early positive diagnosis is impossible unless the case 
is a very active one. With the development of pressure signs, certain 
phenomena appear which point very strongly to the nature of the disease. 
Rigidity of the neck is usually present in some degree. When the 
child’s head is raised from the pillow, the entire body may be elevated 
accordingly. 
Fulness of the fontanel (in case the fontanel has not become closed) 
is always present in greater or less degree, and is a sign of much value. 
Slow, irregular pulse, and slow, uneven respiration are symptoms of 
great diagnostic value. Rarely does a case pass through its various 
phases without showing these phenomena. 
Drowsiness, gradually increasing, followed by stupor and coma, is a 
constant manifestation. 
Unequal, inactive, usually dilated pupils will be found in cases well 
advanced. Strabismus, deviation of the eyes, and diplopia may develop 
earlier. 
Repeated vomiting without apparent cause, in the presence of sug- 
gestive signs, supplies valuable corroborative evidence. 
The abdomen is characteristically scaphoid. 
The Kernig sign consists of an inability to extend the leg on the thigh 
when the thigh is flexed on the abdomen. This symptom is present in 
nearly all cases late in the disease. 
The Babinski reflex and Oppenheim’s reflex are of very little value; TUBERCULOUS MENINGITIS 
609 
if present, they corroborate other findings. Their absence means nothing. 
True, they may be present in a certain proportion of cases of tuberculous 
meningitis, but they are present in tetany and so-called tetanoid states 
from whatever cause, and they may also be present in brain injury and 
in spastic paraplegia due to birth trauma. 
The temperature range is of no value in diagnosis for reasons already 
given. Optic neuritis is present in a majority of the cases late in the 
disease. Tubercles in the choroid will be found in many cases. 
Lumbar Puncture.—A positive diagnosis can be made only by lumbar 
puncture (p. 821). Tubercle bacilli may be found in the spinal fluid 
in practically all cases of tuberculous meningitis, although it may be 
necessary to make more than one examination. In withdrawing the 
fluid, that which is drawn last should be collected for the examination. 
The test-tube, in which 10 to 15 c.c. of fluid has been collected, should 
then be allowed to rest at room temperature for twelve to eighteen hours 
when a delicate clot of fibrin will have formed in the fluid. The fluid 
is not to be agitated. The fibrin may then be removed and examined 
by the usual methods for the detection of tubercle bacilli. The spinal 
fluid shows lymphocytosis and the globulin test is positive. The spinal 
fluid sugar content is almost invariably below normal and in suspicious 
cases a low sugar content may be taken as strongly indicating tuberculous 
meningitis. 
The appearance of the fluid withdrawn is suggestive, being clear or 
slightly opalescent in tuberculous meningitis, while in other forms of 
meningitis the fluid is usually turbid and cloudy. 
In one case the tubercle bacilli were not found until the tenth spinal puncture was 
made. The child had all the usual symptoms of meningitis, and there were tubercle 
bacilli in the bronchial secretion; the examinations were, therefore, persisted in. 
Differential Diagnosis.—The first problem in a given case is to de- 
cide whether there is a meningitis and whether the signs are such as 
to warrant further investigation. Such being the case, a differentiation 
as to the type we are dealing with is necessary, and here again lumbar 
puncture must be brought into use. 
We may have a very active condition due to the tubercle bacillus 
which may be readily confused clinically with meningitis of the epidemic 
cerebrospinal type. On the other hand, we have seen several proved cases 
of mild cerebrospinal meningitis which surely would have been diagnosed 
as tuberculous without the proof supplied by the lumbar puncture. In 
tuberculous meningitis the Von Pirquet test is regularly positive. Ex- 
ceptionally due to the failure of reactive power in the organism against 
the overwhelming infection, this test may be negative. 
The most frequent error made is in the cases of grave systemic poi- 
soning with active cerebral manifestations. In pneumonia, scarlet fever, 
heat prostration, and in the acute intestinal infections, the stupor, the 
convulsions, and vomiting often are interpreted as due to meningeal 
involvement. In toxic cases of such a nature the evidence supplied by 
the absence of the distended fontanel, the absence of eye symptoms, 
and the absence of the respiratory and pulse phenomena point strongly 
to a meningismus and not to a meningitis. It must be remembered 610 
THE PRACTICE OF PEDIATRICS 
that any cardinal symptom of meningitis may be present in one of these 
acute toxic processes. In meningitis, however, we have a grouping of 
symptoms—a symptom-complex which renders a diagnosis practically 
positive. 
Points of value in differentiating tuberculous meningitis, the cerebral 
type of poliomyelitis, and epidemic encephalitis are presented on pages 
621 and 623. 
Prognosis.—The prognosis is most unfavorable. We have seen a 
large number of cases, both in hospital and private work, and have never 
known a recovery of a positively proved case. Recoveries have been 
reported, however, by competent observers. 
Archanzelsky, of Moscow, reported the recovery of a girl eight years 
of age who showed the characteristic symptoms of the disease, and in 
whose cerebrospinal fluid a large number of tubercle bacilli were found. 
This writer found in the literature instances of recovery in 50 cases of 
tuberculous meningitis, the existence of which he considered proved. 
Duration.—The duration of the disease varies. Few cases pass the 
third week and many terminate fatally within one week from the onset. 
An exceptional case was that of a girl three years old, who lived six weeks from 
the onset of the symptoms. 
Treatment.—No treatment is of curative value. For the com- 
fort of the family and the relief of symptoms the measures suggested 
under the treatment of simple meningitis (p. 605) may be followed out. 
Withdrawal of the cerebrospinal fluid, removing the pressure within 
the cranium, may furnish temporary relief from the very active symp- 
toms of convulsions, restlessness, and muscle contractions. The fluid 
returns, however, and the fontanel, which was sunken after the tapping, 
is soon bulging as much as before. The curative value of the lumbar 
puncture, according to our observation, is nil. 
CEREBROSPINAL MENINGITIS (MENINGOCOCCUS MENINGITIS) 
In 1866 Samuel Webber recorded over a score of epidemics occur- 
ring between the fourteenth and nineteenth centuries, which presented 
the features of this form of meningitis, giving rise to such designations 
as “typhus syncopalis,” “petechial fever,” “fievre cerebrale,” and “ceph- 
alogie epidemique.” 
Danielson and Mann described an epidemic which attacked Massa- 
chusetts in 1806, and in 1811 Elisha Hirth published a very full account 
of “a malignant epidemic called ‘spotted fever.’” Since this period, 
according to Dr. A. Jacobi, outbreaks of the disease have been more 
extensive in America than in any other country. In the years 1904 and 
1905 New York City underwent a very severe epidemic, which caused 
about 3400 deaths, and in the winter of 1904 attained a mortality of 91 
per cent. At this time a commission appointed to investigate the disease 
reported the presence of the meningococcus, as shown by cultures from 
the nasal mucosa, in 50 per cent, of the patients and in 10 per cent, of 
their attendants. This organism, also known as the Diplococcus intra- 
cellularis of Weichselbaum, was discovered in 1887. Heubner first showed 
the existence of the same agent in the spinal fluid of a living patient. CEREBROSPINAL MENINGITIS (MENINGOCOCCUS MENINGITIS) 
611 
Etiology.—Cerebrospinal meningitis occurs sporadically and in epi- 
demic form. 
The disease is one of childhood. It may occur in earliest infancy, 
however, or in extreme old age. From two to ten years appears to be 
the most susceptible age. Rotch had a patient six days old. Koplik’s 
youngest patient was four months of age. 
Bacteriology.—The organism is a Gram-negative diplococcus, and when 
found in the pus cells of the infected spinal fluid in a typical smear presents 
an appearance much like that of the gonococcus in a gonorrheal smear. 
The meningococcus is very sensitive to light, cold, and drying, and its 
cultures die out rapidly, so that its transmission by the air seems im- 
probable. 
Meningococci are not all identical in their serologic reactions; but 
fall into two main groups which have been termed “normal” and “para- 
meningococcus” strains. Many strains should be employed in making 
a polyvalent serum for therapeutic use, in order that immune bodies in 
both groups of meningococci may be produced. The parameningococci 
were first described by Dopter, who isolated them from the nasal se- 
cretion and later they were found in the spinal fluid of cases of cerebro- 
spinal meningitis. There are no morphologic or biologic differences 
between the two types of meningococci. 
Mode of Invasion.—The presence of the meningococcus in the blood- 
stream has been the subject of particular study by Herrick and other ob- 
servers who have held that there was a general meningococcemia of a 
transient nature derived from a local focus in the nasopharynx, and that 
the infection of the meninges occurred subsequent to that of the blood- 
stream, particularly through the medium of the choroid plexus. Herrick 
was able to recognize the premeningitic stage in 45 per cent, of 265 cases 
and stated that positive blood-cultures could be obtained in 50 to 80 per 
cent, of the cases. By other observers who found the organism in the blood 
in a smaller proportion of cases it has been assumed that even when 
cultures from the blood are not obtained the blood nevertheless acts as 
the means of carrying the infection to the meninges. 
Furthermore, the petechial eruption seen in connection with other 
septicemic manifestations in this disease has been found to contain men- 
ingococci. 
If at times direct extension of infection through the cribriform plate 
of the ethmoid may initiate the meningeal infection, the fact seems indis- 
putable that hemic infection constitutes the usual means of localization 
of the organism in the nervous system. 
The organism has been found in the lungs and joints. 
Pathology.—Notwithstanding the general nature of this disease, 
as shown by its fulminant course and the existence of such symptoms as 
petechise, purpura, and herpes, the lesions produced are quite closely 
limited to the central nervous system. Here the conditions found in 
cases of simple meningitis are roughly simulated. Enlargement of the 
spleen, multiple abscesses, acute nephritis, hepatic degeneration, and 
pneumonia may also be found. 
The exudate covering the brain is usually lighter in color and thinner 
than in pneumococcus meningitis and in sporadic cases of the menin- 612 
THE PRACTICE OF PEDIATRICS 
gococcus type. The cord and base of the brain only, or even the cord 
alone, may show the presence of the lesions. The affected portions of 
the brain are covered with the seropurulent or purulent fluid and patches 
of fibrinous exudate, and the cerebral convolutions are more or less flat- 
tened, depending on the degree of accompanying hydrocephalus. This 
last condition is most marked in the posterior basic inflammations, in 
which the foramina of the ventricles are occluded. In very malignant 
cases there may be no postmortem evidences but those of an acute toxe- 
mia. (Sporadic cases, correctly identified neurologically and anatomic- 
ally, have been unnecessarily classified clinically under the term “posterior 
basic meningitis.”) 
The cerebrospinal fluid is turbid. Whether it is greatly increased 
in amount or not depends upon the severity of the infection. The tur- 
bidity is explained by the high content of pus cells within which may 
be found the meningococcus. A high cell content with abrupt variations 
may be noted for some time after improvement has begun following 
the administration of serum. In some instances meningococci have been 
found on postmortem examination in the lateral ventricles, although 
during life the cerebrospinal fluid obtained on lumbar puncture has been 
free from organisms. Such cases have been of the fulminating type. 
Symptoms.—In common with all disease in which the infecting agent 
is microbic in character, cerebrospinal meningitis may exist in so mild 
a form that it is not suspected, or it may be sufficiently severe to take the 
life of the child in a few hours. This very severe form is usually found 
among the earlier cases in an epidemic. 
Illustrative Cases.—During the epidemic of 1904 and 1905 in New York City 
2 patients—one a child of nine months and one a child of four years of age—were 
presented before students at the New York Polyclinic Medical School and Hospital. 
In neither child could the men on the benches discover anything wrong. 
In the younger child the only symptom was a rather full fontanel and a tendency 
to drowsiness when left alone. At that time his cerebrospinal fluid contained the 
meningococcus. 
The four-year-old child had headache and some photophobia and was extremely 
irritable. There had been vomiting, and there was an irregularity in the heart action. 
This boy sat up, answered questions, and did not appear at all ill. 
The day previous meningococcus had been found in the cerebrospinal fluid. 
Both children recovered without treatment. 
On the other hand, during the same epidemic a girl of eight years was taken ill 
with the disease in the early morning and died about 10 o’clock at night on the same day. 
Fulminating Cases.—The symptoms of these cases are from the onset 
most severe. The child is literally “struck down.” The earliest symptom 
may be a violent chill, followed by fever, or the initial symptom may 
be a convulsion. If at this period there is a convulsion, the child rarely 
comes completely out of it. Active vomiting may be present. Extreme 
irritability usually precedes the comatose state, which rapidly super- 
venes. Whatever may be the early manifestations in any fulminating 
case, two symptoms are usually present—intense headache and high 
fever. The heart action becomes very rapid, breathing is superficial 
and irregular, the pupils show no response to light, and the child can- 
not be roused. Rigidity of the neck muscles and general muscle con- 
tractions may be present. There is intense hyperesthesia, the slightest 
sound or touch being acutely felt and resisted, the child perhaps throw- CEREBROSPINAL MENINGITIS (MENINGOCOCCUS MENINGITIS) 
613 
ing himself about during the first hours so that he is with difficulty kept 
in bed. 
Petechise appear, and ecchymotic areas soon are scattered over the 
surface. This symptom, however, does not occur in all cases. Exten- 
sive hemorrhagic purpura is of occasional occurrence in cerebrospinal 
meningitis. 
In 2 such cases large areas of the body surface were involved in subcutaneous 
hemorrhage. It is peculiar that in these cases the nervous manifestations were much 
less pronounced than in the average case. Diagnosis was proved by the typical findings 
in the cerebrospinal fluid. 
Between the mild and fulminating types of the disease symptoms of 
any degree may exist, indicating the varying degrees of virulency of the 
infection. 
As a rule, the onset is more abrupt than in other forms of meningitis. 
Headache is a fairly constant symptom in all cases. This will be 
evidenced by complaint on the part of the child, or in younger children 
by head-rolling, head-boring, or striking the head with the hands. 
Vomiting, severe, repeated, and projectile in character, without relation 
to the taking of food, frequently marks the onset, and may persist during 
the irritative stage. 
Position of Patient.—The posture when the case is fully developed 
is characteristic. The patient rests on his side; the head is retracted, 
the knees are drawn up, and the legs are flexed on the thighs; the arms 
are flexed and the hands clinched. 
The Fontanel.—Distention of the fontanel in the younger patients 
is a constant and very reliable sign. 
The Temperature.—There is no characteristic temperature range in 
the disease. The temperature is variable and irregular—now high, now 
low. 
Convulsions occur in a majority of the cases. There is always hy- 
peresthesia, and evidence of much discomfort when the child is handled. 
Muscle rigidity is usually present, even in the milder cases. The 
entire body may be involved and become stiff and rigid, or a single muscle 
group only may be involved. Rigidity of the neck and some degree 
of opisthotonos are rarely absent except in the milder cases. The feet 
are held in a position of extension. Swallowing is difficult or impossible, 
and toward the end, in fatal cases, gavage has to be employed. In the 
recovery cases, also, during the active stages of the disease, this measure 
may be necessary to sustain the patient. 
Heart and Respiration.—The heart action is much disturbed. It 
may be very rapid or slow. The usual condition after the development 
of coma is that of slowness and irregularity. 
The respiration likewise is slow and irregular, and may assume the 
Cheyne-Stokes type. 
The Blood.—A leukocytosis ranging from 25,000 to 40,000 with a 
polynucleosis as high as 80 per cent, is the rule. Blood-cultures may 
be positive during the premeningitic stage. 
Mental Apathy.—The child becomes extremely dull, and is aroused 
with difficulty. From this condition he may recover, or, what is more 614 
THE PRACTICE OF PEDIATRICS 
frequently the case, he passes into a condition of complete stupor and 
coma. 
Abdominal Condition.—The bowels are usually constipated and the 
abdomen is retracted. These symptoms, made much of by writers, are 
very variable and may or may not be present in severe cases. 
The eyes frequently show strabismus. The pupils are usually dilated, 
often unequal in size, and show no response to light, or react but 
slowly. 
The Ears.—Deafness may occur early and continue throughout. 
In the absence of local ear changes it is due to an inflammatory involve- 
ment of the auditory nerve. 
The Skin.—In but a few cases personally seen by us have there been 
skin lesions. Petechise and ecchymoses have been seen in the very malig- 
nant forms. The skin in the mild and moderately severe cases has re- 
mained negative. 
References to other manifestations typically attending the disease are 
included below under Diagnosis. 
Symptoms in Recovery Cases.—In a case in which there has been 
a moderately severe infection and which goes on to recovery, there is 
a train of symptoms indicative of the favorable outcome. 
As might be expected, a general clearing of the dulled mentality is 
one of the earliest and most favorable signs. The temperature, which, 
though variable as to degree, is almost always present, subsides. The 
child manifests a desire for food, and makes attempts at using his stiff- 
ened muscles. Muscle rigidity is the last symptom to disappear. The 
writer has repeatedly known children to talk, to play, and be interested 
in their surroundings; in fact, apparently well, with the exception of the 
muscle contraction which held them in the characteristic position of 
opisthotonos. 
Illustrative Case.—A boy seen at various times in consultation with a colleague 
was blind for six weeks, absolutely deaf for three months, and on his back for five months, 
yet made a perfect recovery. Toward the end he was emaciated to a skeleton. The 
child was seen on three occasions, and each time given a fatal prognosis. Four months 
after the last fatal prognosis he was seen on the street playing with other boys. 
Diagnosis.—Abrupt onset is the rule. Convulsions, vomiting with- 
out apparent cause, chill, headache, more or less intense photophobia, 
hyperesthesia, rigidity of the neck muscles, and fever constitute the 
earliest diagnostic signs. Such a symptom-complex, followed by drow- 
siness and stupor, warrants the use of lumbar puncture (p. 821) to de- 
termine positively the presence of meningitis. This should be done in 
all suspected cases so as to give the patient the benefit of the serum at 
the earliest possible moment. The later manifestations of the disease 
are unmistakable. The rigid neck, opisthotonos, the dilated, unequal 
and immobile pupils, the slow, irregular respiration, and slow, irregular 
pulse, comprise a group of diagnostic signs found only in meningitis. 
Hyperesthesia is always present. The child almost invariably cries 
when disturbed or handled in any way, so long as his mentality is still 
able to appreciate the disturbance. 
Kernig’s Sign.—This consists in an inability to extend the leg on CEREBROSPINAL MENINGITIS (MENINGOCOCCUS MENINGITIS) 
615 
the thigh when the latter is flexed on the abdomen. The sign is present 
and is fairly reliable in children over two and one-half years of age. In 
younger children, particularly those under eighteen months, because of 
the normal tendency to contraction of the flexor muscles at this period 
of life, the sign is of less value. 
Kernig’s sign is also present with other cerebral lesions and in other 
forms of meningitis. 
Babinski’s phenomenon consists in an extension of the great toe and 
a flexion and separation of the remaining toes when the plantar surface 
of the foot is stroked with the finger. This sign is often absent, and is 
of corroborative value only in the event of other symptoms. Its pres- 
ence may be an indication of meningitis, yet its absence is of no signifi- 
cance. This reflex may be elicited in normal children under eighteen 
months of age. 
The tache cerebrate may be demonstrated in practically every case. 
The patellar reflex is variable and uncertain. It may be increased, 
diminished, or absent, and is of little diagnostic value. 
The Eye Changes.—The pupils are usually dilated, often unequal, 
and may show no response to light or react slowly. 
Strabismus is always present at some stage. The eye-grounds may 
show retinitis, choroiditis, or neuritis of the optic disk. In the prolonged 
cases conjunctivitis and keratitis are often present. 
The pulse, respiration, and temperature are all variable, but, studied 
together, may afford evidence of great value in confirming a diagnosis 
of meningeal irritation. 
Emaciation.—There is such a marked loss in weight that the emacia- 
tion may be looked upon as one of the significant symptoms of the disease. 
In all cases there is wasting, and the longer the case, the greater is the 
emaciation. 
A ward filled with these emaciated children, with their dulled, star- 
ing eyes and bent, rigid trunks and limbs, furnishes a most pitiful and 
gruesome picture. 
Differential Diagnosis.—In spite of the foregoing signs and symp- 
toms numerous cases of cerebrospinal meningitis may only be differ- 
entiated from other types by an examination of the spinal fluid, the 
characteristics of which in this disease have been described on page 612. 
Complications.—Considering the nature and severity of its symp- 
toms, cerebrospinal meningitis is a disease with few complications. Pneu- 
monia is an unusual occurrence. Eye involvement is to be looked upon 
more as a feature of the disease than as a complication. Nephritis is 
exceedingly rare. Bed-sores are frequently developed, and become very 
troublesome, but again decubitus cannot properly be considered a com- 
plication. 
Among the sequela) are idiocy, blindness, deafness, epilepsy, acute 
and chronic hydrocephalus, and spastic paralysis of different sets of 
muscles. 
Several of the writer’s patients who survived meningitis and were 
considered to have had complete recoveries, were nevertheless backward 
in school, had severe headaches, or showed lack of mental control. 
Duration.—The duration of the disease depends largely upon the 616 
THE PRACTICE OF PEDIATRICS 
nature of the infection. Death may take place in a few hours, or the 
patient may linger for weeks. 
A boy twelve years of age died from exhaustion in the twentieth week of the disease. 
Children not infrequently make partial recoveries, linger for several 
weeks in a wretched, emaciated condition, and eventually die from as- 
thenia. Others make incomplete recoveries which place them in the 
dependent class for the remainder of their lives. 
General Treatment.—The medication and general management in 
cerebrospinal meningitis are the same as suggested for acute infective 
meningitis (p. 605). Little or nothing is to be expected from drugs, except 
such as may be used for palliative purposes. 
Serum Treatment.—The Flexner serum is the only agent which prom- 
ises any curative effects in the disease. In 1904 Flexner produced an 
antimeningitic serum for the treatment of cerebrospinal meningitis. 
Horses were immunized by graded injections of cultures of the Diplococcus 
intracellularis and its toxin. He distributed this serum to many observers 
throughout the world, and in 1913 made a final report of 1294 cases which 
had been treated with this serum, which is injected intraspinally. The 
effect of the serum is partly bactericidal, partly by bringing about phagocy- 
tosis, and probably partly by an antitoxic reaction. Previous to the use 
of the serum the mortality ranged from 50 to 90 per cent.; since its use 
the mortality has been reduced to from 20 to 30 per cent. The follow- 
ing are statistics of results as compiled by Flexner1: 
MORTALITY ACCORDING TO 
AGE 
Age. 
Cases. 
Recoveries. 
Deaths. 
Mortality. 
Under 1 year 
129 
65 
64 
49.6 
Between 1 and 2 years 
87 
60 
27 
31.0 
Between 2 and 5 years 
194 
139 
55 
28.4 
Between 5 and 10 years 
218 
185 
33 
15.1 
Between 10 and 20 years 
300 
254 
106 
29.4 
Over 20 years 
288 
180 
108 
37.5 
Age not given 
18 
11 
7 
38.9 
Total 
1294 
894 
400 
30.9 
MORTALITY ACCORDING TO PERIOD OF FIRST INJECTION 
Period of injection. 
Cases. 
Recoveries, 
Deaths. 
Mortality. 
First to third day 
199 
163 
36 
18.1 
Fourth to seventh day 
346 
252 
94 
27.2 
Later than seventh day 
666 
423 
243 
36.5 
Total 
1211 
838 
373 
30.8 
The average mortality rate of the patients of 19 observers who pub- 
lished their results in the literature was 29 per cent. This compilation 
totals 4664 cases, with 1338 deaths. 
1 Jour. Exp. Med., May, 1913. CEREBROSPINAL MENINGITIS (MENINGOCOCCUS MENINGITIS) 
617 
The use of serum gives the best results when injected early and in 
children between the ages of five and ten years. The serum is useful, 
however, even if injected late in the disease. Infants under one year 
do not respond readily to the serum. With the use of the serum 30 per 
cent, of the favorable cases terminate abruptly, while without serum 
crises are unusual. When the first injection is made within the first three 
days, 50 per cent, terminate by crisis. There has also been a remark- 
able reduction in the severity and number of complications by the use 
of serum. Out of 894 children in Flexner’s series who recovered, 68, or 
7\ per cent., had complications as follows: 
39 cases Total deafness 4.4 per cent. 
6 “ Partial deafness 0.7 “ 
3 “ Total blindness 0.3 “ 
6 “ Partial blindness 0.7 “ 
3 “ Impaired mentality 0.3 “ 
11 “ Paralysis 1 
There have been some noteworthy improvements in the serum 
since it was first introduced. Many children were found who did not 
react favorably. Investigations prdved that there are various strains of 
the meningococcus; notable among these is the parameningococcus. 
Horses used to supply the serum are now injected with the cultures of 
these different strains. 
Because of the prevalence of the disease among the soldiers at the 
front on the continent it was found necessary to hasten the production. 
Wollstein and Amoss1 accordingly perfected a method by which the serum 
could be produced in eight to twelve weeks instead of six to twelve months 
as previously. 
Method of Use—The first injection of serum is given in a suspected 
case as soon as turbid fluid is withdrawn, without waiting for baeterio- 
logic examination. It is best to withdraw all the fluid possible at each 
puncture and then inject 25 to 35 c.c. of serum by the gravity method. 
Four injections given daily is the average, but some patients require as 
many as twelve. In the very severe cases the second injection should 
follow in twelve hours. Even though an injection does not seem neces- 
sary, a puncture should be done every day or two during the course of 
the disease for bacteriologic examination. The most important indication 
for an injection is the clinical aspect of the patient. Even though the fluid 
becomes clear and no diplococci are found, if there is persistent Kernig’s 
sign, irregularity of temperature or mental disturbance, a repetition of 
the injections is necessary. 
Soon after one or two injections of the serum in favorable cases the 
diplococci in smears are greatly reduced in number and finally disappear. 
The organisms should also present changes in appearance, as swelling and 
fragmentation, stain diffusely and indistinctly, and lose their mobility in 
cultures. The purulent spinal fluid becomes more translucent and finally 
clears. A reduction of the leukocytes in the blood follows if the serum 
is successfully combating the disease. 
Technic of Spinal Injection.—The child is placed in the recumbent 
1 Jour. Exp. Med., May, 1916. 618 
THE PRACTICE OF PEDIATRICS 
position recommended for spinal puncture. If the patient is an infant and 
can be properly held by an assistant, no anesthetic is necessary. Chloroform 
had best be administered to the older children who resist holding. The grav- 
ity method is preferable to the syringe. Sophian, of New York, has per- 
fected a blood pressure control for the withdrawal of fluid and the injection 
of serum. When the spinal fluid is being withdrawn there should be a drop 
of not more than 5 to 10 mm. of mercury. In case of a further drop no 
more fluid is removed. The funnel of the apparatus is filled with serum 
which has been heated to body temperature. All air should be carefully 
eliminated from the connecting tube. The funnel is gradually raised to 
permit the serum to flow in gradually by gravity. It is seldom possible 
to inject as much serum as fluid withdrawn without disconcerting symp- 
toms. If the blood-pressure drops 10 mm. of mercury the process should 
be temporarily discontinued until the normal blood-pressure is restored, 
at least in part. When the pressure continues to fall, the injection should 
be discontinued. It is always a wise precaution to keep the tube connected 
for three minutes after the injection, so that the serum may be with- 
drawn by lowering the tube if the child shows a falling pressure, dilata- 
tion of the pupils, or shallow irregular respirations. If these symptoms 
supervene, the head should be raised and injections of atropin and ad- 
renalin administered intramuscularly. 
The spinal fluid in some cases will become clear and showr very few 
meningococci and yet the fever and prostration continue. This may be 
due to adhesions or thick exudate at the base of the brain which does 
not allow the seriun to reach the meninges or the lateral ventricles. When 
this occurs it is necessary to puncture the ventricle through the anterior 
fontanel, withdraw the fluid and inject the serum. In older children 
trephining may be necessary. Another not unusual obstacle to the treat- 
ment with serum is a very thick gelatinous fluid which is withdrawn 
writh difficulty. In such cases Sophian has recommended careful irrigation 
with normal saline to aid the withdrawal of the fluid. 
Serum Administration Through the Bloodstream.—Following the 
demonstration of meningococcus septicemia as a most highly important 
feature of the disease the rationale of administering serum not only intra- 
spinally but intravenously and intramuscularly has been generally ap- 
preciated. Particularly because of the difficulty often encountered in 
administering a sufficiently large dose by the spinal route is it advisable 
as a routine procedure to give full doses of the serum intravenously and 
intramuscularly, thus attacking the infection generally as well as at its 
region of localization. The value of the intravenous administration is 
undoubtedly greatest at the onset of the disease. 
Severe anaphylactic reactions following the administration of anti- 
meningococcus serum at times occur. The experience of Blackfan1 has 
led him to advise that the patient be first desensitized by a subcutaneous 
injection of 1 c.c. of the serum. One hour later the intravenous dose 
may be given. This may range in amount from 15 to 30 c.c. and should 
be injected slowly at first at the rate of about 1 c.c. per minute. In the 
event of shock the injection is to be immediately discontinued and the 
untoward symptoms combated by epinephrin and atropin given hypo- 
1 Biologic Therapy, 1921, Amer. Med. Assoc., pp. 16-24. EPIDEMIC ENCEPHALITIS (ENCEPHALITIS LETHARGICA; NONA) 
619 
dermieally. True anaphylaxis may require desensitization of the 
patient to horse-serum if the antimeningitic treatment must be continued. 
Duration of Serum Treatment.—The intraspinal injections must be 
continued at frequent intervals in some instances for a considerable 
number of days. When the clinical picture presented by the patient is 
one of established improvement, indicated both by lessened temperature 
and falling leukocytosis, and when the organisms in the spinal fluid are 
greatly diminished in number or have disappeared the injections may be 
omitted even though the spinal fluid may still show turbidity from the 
presence of leukocytes, a condition that may in some instances be kept 
up by the occurrence of a considerable degree of local reaction to the 
serum. If after a few days without specific treatment the signs again 
become unfavorable further intraspinal injections may again be justi- 
fiable. 
Vaccine.—The first cultures obtained are sometimes used for the 
preparation of an autogenous vaccine. This may be employed if the case 
takes a chronic course. 
“Meningismus” is a term first employed by Dupre to describe cere- 
bral intoxication, a condition clinically closely resembling meningitis, 
in w’hich the spinal fluid is sterile. This condition may occur in typhoid, 
acidosis, acute gastro-enteric intoxication, influenza, pneumonia, or any 
of the exanthemata. Very severe scarlet fever is apt to be accompanied 
by meningismus. 
Symptoms.—There may be stupor, coma or convulsions, retraction 
of the head, vomiting, and twitchings of the face or various parts of the 
body. In fact, the symptoms so closely resemble true meningitis and 
acute polio-encephalitis that a differentiation is only possible in some 
instances by means of lumbar puncture. 
Diagnosis and Differential Diagnosis.—In true meningitis, whether 
simple, acute cerebrospinal, or tubercular, micro-organisms are present 
in the cerebrospinal fluid, the cell count is increased, and globulin is usually 
present. The pupils may be dilated or contracted and show slow response 
to light, but in meningismus they act together and evenly. We have never 
seen the symptom of absence of co-ordination of the pupils in simple 
meningismus. The eye-ground changes in meningismus are, moreover, 
negligible. 
Finally, it is to be remembered that wdth meningismus there is usually 
the association of other diseases, and the cerebral signs are secondary. 
Lumbar Puncture.—In any case showing active cerebral symptoms, 
a lumbar puncture should always be made. (See p. 821.) 
Treatment.—The treatment is covered in the management of the 
disease with which the meningismus is associated. 
MENINGISMUS (SEROUS MENINGITIS) 
EPIDEMIC ENCEPHALITIS (ENCEPHALITIS LETHARGICA; NONA) 
Definition.—Epidemic encephalitis is an acute infectious epidemic 
disease of the nervous system characterized by fever, lethargy, and various 
abnormal motor phenomena. 
History.—The disease has been noted by several writers following 620 
THE PRACTICE OF PEDIATRICS 
epidemics of grip during the past two hundred years. Encephalitis was 
recognized after the wide-spread epidemic of 1890, and since the pandemic 
of influenza in 1917-18 and 1920 has been the subject of much concen- 
trated study. 
Etiology.—The tendency for this disease to appear following influenza 
epidemics has been uniformly noted. Several organisms have been isolated, 
mainly from the nasopharyngeal secretions, but no one has been widely 
accepted as the causative agent. That the disease is caused by a globoid 
filtrable organism similar to that assigned as the cause of poliomyelitis 
and may be transmitted similarly from individual to individual is prob- 
ably true, but little is known of its communicability. Encephalitis occurs 
without regard to age, but is rare under four years. Males are apparently 
slightly more prone to the infection. The first three months of the year 
show the highest incidence. 
Pathology.—The lesions occur regularly in the brain and consist of 
edema, congestion, and minute hemorrhages in the gray matter about the 
base, the third ventricle, the aqueduct of Sylvius, the lateral ventricles, 
the optic thalamus, and the pons and medulla. The cord may be involved. 
The lesions may be nodular or diffuse and consist of intense perivascular 
infiltration with lymphocytes, plasma cells, and a few polynuclear cells. 
There is pathologic proliferation; and degeneration of nerve-cells, fibers, 
and vessel walls may occur. There is little meningeal reaction. The 
paralyses which occur usually are due to invasion of motor nuclei by 
cellular elements. 
Symptoms.—The onset is usually abrupt, with fever, malaise, head- 
ache, vomiting, constipation, and prostration. The variety of symptoms 
referable to the central nervous system is endless. Drowsiness, especially 
during the day, with insomnia at night, is common. In infants convul- 
sions may usher in the disease. Delirium may be an accompaniment. 
Ocular symptoms are very common. Diplopia, strabismus, ptosis either 
unilateral or bilateral, blurred vision, blindness, nystagmus, and irregular 
convulsive or rotary movements of the eyes are frequently seen. A 
viscid conjunctival exudate without redness has occasionally been noted. 
Choked disks have been reported. 
Paralyses, especially of the cranial nerves, may be transient or persist 
over a long period. Myoclonic manifestations run the gamut from fib- 
rillary twitchings to coarse tremors. The reflexes are variable and irreg- 
ular throughout, but the typical signs of meningitis, such as stiff neck and 
Kernig’s sign, are uncommon. The face in a typical lethargic case is ex- 
pressionless and mask-like. Some patients refuse to talk, others may 
be so persuaded, and their speech is slow, measured, and monotonous. 
The fever is of low grade, entirely irregular in its curve, falling to normal 
even for days, and then rising to 101° to 102° F. without apparent reason. 
It is typical of epidemic encephalitis that the patient shows periods of 
marked improvement, with subsidence of symptoms, only to relapse later 
with new manifestations. 
The duration of the disease varies from two weeks to several months, 
averaging in children, according to Neal, about six weeks. 
Laboratory Findings.—The leukocyte count may be normal or slightly 
increased. The spinal fluid is clear, or occasionally slightly blood-tinged, EPIDEMIC ENCEPHALITIS (ENCEPHALITIS LETHARGICA; NONA) 
621 
and is very slightly increased in amount. No film forms on standing. 
The cell count is normal or increased up to 150 cells, all lymphocytes. 
Albumin and globulin are slightly increased. Sugar is present and is, as 
a rule, increased in amount. This may only be detected by the finer 
methods of quantitative analysis. The Wassermann and colloidal gold 
reactions are negative. The urine is ordinarily negative. 
Sequelae.—Probably the most common sequelae of epidemic encepha- 
litis in children are psychiatric. There is complete change in personality 
and disposition, with oddities of behavior, unstable emotions, incorrigi- 
bility, sexual precocity, depressions, hysteria, fears, and retarded mental 
development. These phenomena are much more common than the 
parkinsonian syndromata seen as sequelae of this disease in adults. 
However, true neurologic sequelae do occur frequently in the form of 
choreiform movements, headaches, dizziness, drowsiness, diplopia and 
other visual disturbances, muscular weaknesses, and even endocrine 
changes. 
Diagnosis.—Epidemic encephalitis is diagnosed mainly by elimina- 
tion, especially from tuberculous meningitis and encephalitic poliomyelitis. 
This differentiation is often a problem of the utmost difficulty. 
The mode of onset in encephalitis is usually more abrupt than in 
tuberculous meningitis, its course is usually longer, and its neurologic 
manifestations are more bizarre. The spinal puncture is a valuable aid 
in diagnosis, as the tuberculous fluid early shows a diminished or absent 
sugar reaction, forms a film, and the organisms can be demonstrated. 
Encephalitic poliomyelitis has a more abrupt onset and runs a stormier 
and shorter course. The spinal fluid sugar content in poliomyelitis is 
little, if at all, increased. 
Brain tumor and brain abscess are to be considered. 
The Wassermann and colloidal gold tests will almost surely detect 
syphilis of the central nervous system. 
Encephalitis is only occasionally confused with other conditions than 
those mentioned, but exceptionally may be wrongly diagnosed in the 
presence of typhoid fever, postdiphtheric paralysis, uremia, hysteria, 
or even botulism. 
Prognosis.—During the acute phase the prognosis is uncertain, as 
death may occur at any stage. Inter current infections are to be dreaded. 
In general, the mortality figures are about 28 per cent. The prognosis 
as to sequelae should be most guarded as improvement is slow and un- 
certain. 
Treatment.—The treatment is entirely supportive and symptomatic. 
Hyoscin, gelsemium, and belladonna have been reported to be of value 
in the treatment of sequelae of the parkinsonian type. Serum treatment 
has been employed by a number of investigators without convincing 
success. 
Transfusion has apparently been followed by striking improvement 
in a few instances.1 
1 The rapid change in a recent early typical lethargic case thus treated by Stetson 
in the Children’s Medical Division at Bellevue Hospital was sufficiently convincing and 
unprecedented in the experience of independent observers to suggest a more general 
trial of transfusion in this baffling disease. 622 
THE PRACTICE OF PEDIATRICS 
DIAGNOSTIC CHARACTERISTICS OF CEREBROSPINAL FLUID 
In the differentiation of the various forms of meningitis, poliomyelitis 
and encephalitis, and various other intracranial disease conditions the 
examination of the cerebrospinal fluid is absolutely essential. The char- 
acteristics noted in the respective conditions are approximately as given 
in the table on page 623. DIAGNOSTIC CHARACTERISTICS OF CEREBROSPINAL FLUID 
623 
Fluid. 
Pressure. 
Appearance. 
Cell count. 
Predominant 
cell. 
Bacteria. 
Albumin. 
Globulin. 
Benedict’s 
solution 
reduced. 
Quantity 
of 
sugar. 
Quantity 
of 
protein. 
Normal 
Normal. 
Clear. 
1 to 10 
Mononuclear. 
0 
d= 
dt 
+ 
50 to 60 
30 to 60 
Meningismus 
Normal or 
creased. 
in- 
Clear. 
5 to 10 or in- 
creased 10 to 60 
Mononuclear. 
0 
=b 
=±= 
+ 
50 to 60 
30 to 60 
Hemorrhage 
Normal or 
creased. 
in- 
Red or yellow. 
Normal. 
Mononuclear. 
0 
4“ + 
+ + 
+ 
50 to 70 
50 to 100 
Poliomyelitis 
Normal or slightly 
increased. 
Clear. 
16 to 90 
Mononuclear. 
0 
± to + 
=fc to + 
+ to + + 
40 to 80 
50 to 120 
Encephalitis 
Normal or 
creased. 
in- 
Clear. 
10 to 100 
Mononuclear. 
0 
=t to + + 
± to + + 
+ + to 
++++ 
70 to 120 
70 to 250 
Tuberculous meningitis. . 
Normal to greatly 
increased. 
Clear or slightly 
cloudy. 
40 to 400 
Mononuclear. 
Tubercle 
bacillus. 
+ to 
++++ 
+ to 
+++ 
0 to + 
0 to 
20-30 
100 to 800 
Purulent meningitis 
Normal or 
creased. 
in- 
Cloudy. 
To 1000 
Polynuclear. 
Present. 
+ + to 
++++ 
+ + to 
+++ + 
0 
0 to 10 
300 to 2000 
Brain tumor 
Normal or 
creased. 
in- 
Clear. 
5 to 10 
Mononuclear. 
0 
d= 
=4= 
+ to + + 
50-90 
50 XVII. DISEASES OF THE SKIN 
The skin of an infant is to be looked upon as an organ with impor- 
tant functions to perform. On account of its location it is the most ex- 
posed organ of the body, while among its most important functions is 
protection of the underlying structures. 
In the skin, moreover, are located the most important organs of 
excretion, the sweat glands, as well as those very delicate nerve struc- 
tures, the tactile organs. Through the skin heat radiation is carried 
on by means of the circulating blood in the capillaries. When we con- 
sider the active metabolic processes that are taking place in the infant’s 
body, it is not hard to appreciate the amount of work the skin is called 
upon to do in performing its functions of excretion and heat radiation. 
Care of Skin in Health.—The skin in early life is particularly deli- 
cate, and responds very readily to external irritation of any nature. 
Excessive clothing at any time of the year, but more particularly in 
summer, produces the well-known prickly heat, or miliaria. Dermatitis 
may result from the irritant effects of improper clothing. 
The different forms of intertrigo are the result of irritation produced 
by the contact of unclean napkins containing urine or feces, or both. 
In order to avoid intertrigo the napkin must be changed during the wak- 
ing hours whenever the urine is voided. In some instances it is not well 
to wake a child for a change of napkin because of urination; and at other 
times during the day, such as the outing period, the clothing cannot 
always be changed in the park or street. Under such circumstances a 
prophylatic measure should be employed. Over the groin and folds of 
the buttocks should be spread pieces of old linen which have been well 
smeared with the following ointment: 
1$. Cerse albac 5iv 
Ungt. zinci oxidi q. s. ad. 5 iv 
The addition of white wax to zinc oxid ointment affords a water- 
proof dressing to the skin, and protects it from the irritating products 
of decomposing urine. (See also The Ammoniaeal Diaper, p. 102.) 
Clothing that is applied too tightly will often act as an irritant to 
the skin. To many wool acts as a decided irritant, and frequently it must 
be avoided. In some instances it is necessary to line the child’s under- 
garments with thin old linen, such as a handkerchief. Linen mesh under- 
clothing may be used. 
In order further to keep the skin healthy, the child should be bathed 
in a tub once a day with Castile soap, then carefully dried, and pow- 
dered with a simple powder. 
The following powder is of value: 
1$. Acidi borici gr. xxv 
Pulv, amyli, 
Pulv. zinci oxidi aa 5ss 
M. Sig.—Apply freely. 
624 URTICARIA (HIVES; NETTLE-RASH) 
625 
We prefer the evening bath. In the morning the child should be sponged 
with warm water and soap and carefully dried, after which the powder 
may be applied. During the cold weather the bathing and sponging should 
be done in a warm room with a temperature over 75° F. 
The above simple means are all that are necessary to keep the skin 
in a normal condition. The skin of some children is, of course, much more 
sensitive than that of others, and will require more careful attention. 
MILIARIA (PRICKLY HEAT) 
The rash in prickly heat consists of multiple, minute, transparent 
vesicles, due to an engorgement of the vessels of the sweat-glands and 
obstruction of their outlets. There is a definite inflammatory reaction 
distinguishing this condition from sudamina. 
Symptoms .—The child is very uncomfortable and restless, due to the 
itching which is very distressing. The rash described is characteristic, 
and usually appears quite suddenly. The mild cases are without inflam- 
mation. The inflammation, when present, produces a general erythema 
with many reddened papules. 
Etiology.—Nearly every infant in our climate suffers from prickly 
heat during the summer. The condition in summer is caused by pro- 
fuse sweating incident to the hot weather and independent of possible 
overclothing; in winter too hot living rooms and overclothing may cause 
the condition. 
Treatment.—Heavy clothing and flannels are to be avoided. In order 
to lessen the local irritation the garment worn next to the skin, unless of 
linen mesh or cotton, should be lined with silk or linen. The further man- 
agement directed both to the relief of the patient and the cure of the 
condition consists in the frequent application of cool water either by means 
of a tub-bath or sponging. The soda bath, the bran bath, and the starch 
bath (pp. 843, 844) are all useful. For purposes of sponging a solution 
of bicarbonate of soda should be used containing 1 tablespoonful to a 
gallon of water. The relief afforded the patient depends not so much 
upon what is used in the water, as upon the fact that plenty of cool water 
comes in contact with the itching, burning skin. Ointments and salves 
are of little service, as they tend to produce further maceration of the 
skin. As local applications powders are to be preferred to lotions. A 
powder used with satisfaction for this condition is of the following com- 
position : 
Ip Acidi salicylici gr. v 
Acidi boriei gr. lx 
Pulv. amyli, 
Pulv. zinci oxidi aa 5j 
This is to be dusted freely over the involved surface several times daily 
—every hour if necessary. In case irritation is produced by the sali- 
cylic acid, it may be omitted or its strength may be decreased by the 
addition of powdered starch. 
URTICARIA (HIVES; NETTLE-RASH) 
A discussion of all the aspects of urticaria is unnecessary. Only those 
forms will be considered which are peculiar to children. 626 
THE PRACTICE OF PEDIATRICS 
Acute urticaria is characterized by the sudden appearance and dis- 
appearance upon the skin surface of wheals and lumps of vasomotor 
origin. The wheals, which are of varying size, produce intense itching 
and burning, and then subside without desquamation as rapidly as they 
have appeared. The variation in size and shape has given rise to a dif- 
ferentiation into types for purposes of diagnosis. 
Distribution.—The possibilities of skin involvement in hives are 
most variable. There may be but one wheal, or the lesions may cover 
a large portion of the skin surface. The involved area may be very small, 
of the size of a pin head, or extremely large (Cf. Giant Hives, below), 
occasionally producing marked facial deformity. 
Thus in the case of a child of eleven months who had been given an egg for the 
first time the face was so distorted and grotesque that recognition was impossible. 
Etiology.—Urticaria may be due to agencies operating either from 
without or within the body. Those operating from without include 
irritants of almost any nature, especially the bites of insects, and too 
tight clothing or clothing which may directly irritate the skin. Contact 
with certain plants may also produce the wheal hives, termed “nettle- 
rash.” Such causes as these, however, are operative in comparatively 
few cases. 
Irritation arising from internal sources is the cause of the condition 
in at least 95 per cent, of the cases. The use of certain drugs may oc- 
casion sufficient irritation to cause an outbreak. In not a few instances 
hives have been due to quinin, arsenic, and antipyrin. The adminis- 
tration of antitoxin produces hives in a small percentage of the cases. 
Certain articles of food, such as strawberries, tomatoes, oatmeal, and 
buckwheat, invariably cause urticaria in certain children. An attack 
may occur without apparent digestive disturbance, or may appear coin- 
cident with vomiting, diarrhea, fever, and other acute gastro-intestinal 
symptoms. The condition represents an anaphylactic reaction with vaso- 
motor disturbances of the skin blood-supply, resulting in localized vascu- 
lar paralysis and transudation. The itching may be due to irritation of 
the nerve end-organs. 
This condition is of comparatively rare occurrence in children. It is 
simply a variety of urticaria occasioned by causes similar to those oper- 
ative in other forms. When it occurs in children, it most frequently 
involves the tongue and lip. When involving the soft parts, the lesion 
may produce an immense amount of swelling. This is particularly marked 
when the tongue and lips are affected. The lips may be swollen to several 
times their normal thickness. Such cases usually develop suddenly and 
occasion no little alarm. 
Illustrative Case.—In a boy four years of age the tongue and lower lip were so greatly 
swollen that speaking was impossible and swallowing difficult, and it was supposed 
that he had been given carbolic acid or some corrosive poison. This case necessitated 
a trip of 30 miles into the country to see the child in consultation. 
Cases have been reported in which the swelling of the tongue was 
sufficient to produce suffocation requiring incision to reduce the swelling. 
Giant Hives (Angioneurotic Edema) RHUS POISONING (iVY POISONING) 
627 
Practically all such cases in our experience have been associated with 
gastro-intestinal disturbances. The swellings ordinarily disappear rapidly 
after a few hours, but not with the rapidity that marks their initial ap- 
pearance. 
Treatment.—Digestive disturbances of any nature, whether acute 
or chronic, may cause urticaria. In the event of an attack, therefore, 
even though there be no active manifestations of indigestion, since the 
origin of the trouble may be found in the intestine, a safe procedure 
is to give 2 to 4 teaspoonfuls of castor oil, or grains of calomel 
in divided doses, followed the next morning by the citrate or milk of 
magnesia. At the same time the diet, regardless of the age, should be 
reduced to broths and gruels, to which toast or dried bread may be added, 
depending on the patient’s custom. Milk should not be given. The 
application of a menthol ointment (menthol, 10 grains; rose-water oint- 
ment, 1 ounce) is a valuable supplementary measure. 
In cases caused by antitoxin and food allergy, adrenalin in 3- to 5- 
minim doses given hypodermically will effect a termination of the symp- 
toms sooner than will any other agent. Unfortunately the relief thus 
afforded is often only temporary and the urticaria again manifests itself 
after an interval of a few hours. Sodium salicylate has proved of special 
value in this condition. To a child, three years of age 2 grains of the salic- 
ylate of soda may be given every two hours, with 4 grains of the bicar- 
bonate of soda—five doses being given in twenty-four hours. To older 
patients from 3 to 4 grains of the salicylate may be given at a dose—from 
12 to 24 grains being administered in twenty-four hours. 
Certain children appear to be predisposed to urticaria, and give a his- 
tory of having had several attacks. Unless treated for persistent intes- 
tinal indigestion they are very liable to recurrent attacks, which are 
sometimes very obstinate in character. Urticaria due to the ingestion 
of a drug will disappear when the drug is withdrawn. 
The management of the cases due to local causes demands the re- 
moval of the source of the irritation and the application of the menthol 
ointment, or bathing of the affected part with a 1 per cent, carbolic acid 
solution. 
Contact with Rhus toxicodendron produces in many individuals most 
active dermatitis, characterized by marked burning and considerable 
itching of the involved surface. There may be a simple erythema, 
but usually there are small vesicles and bullse filled with serum, which, 
if they become infected, form pustules, with the possibility of multiple 
abscesses. The exposed portions of the body—the hands, arms, face, 
and neck—are the most frequently affected sites. When the face is 
involved great disfigurement may result. 
Treatment.—In the acute stage—the period of itching, burning, and 
edema—a remedy of considerable value is a wet dressing of the fluid- 
extract of Grindelia rohusta, 1 to 1| drams to 1 pint of water, applied on 
lint or soft old linen. The solution should be used cold and renewed every 
fifteen to thirty minutes. During the stage of resolution a saturated 
solution of boric acid may be used in the same way, or, more con- 
RHUS POISONING (IVY POISONING) 628 
THE PRACTICE OF PEDIATRICS 
veniently, an ointment composed of 5 per cent, boric acid in rose-water 
ointment. This is applied to the parts on linen, after which resolution 
usually promptly takes place. When pustules develop, they must be opened 
and the parts treated with a wet dressing of a saturated solution of boric 
acid. 
A solution of permanganate of potash, 1 : 2000, is a most satisfactory 
means of treatment. The involved parts are freely moistened with the 
solution at intervals of about two hours, the solution meantime being 
allowed to dry on the parts. This often readily controls the acute symp- 
toms. After a few days a 10 per cent, boric-acid ointment may be used 
to soften the skin and remove the crusts and products of the exudation. 
Another simple and readily obtainable topical application of un- 
doubted value is a solution of plain photographic hyposulphite of soda 
crystals in the strength of 1 to 2 tablespoonfuls to a pint of cool water. 
SCABIES (ITCH) 
Scabies is a contagious disease of the skin, caused by the burrowing 
of the female itch-mite, Acarus scabiei. 
Location.—The parts selected for invasion are those portions of the 
skin which are least protected and least resistant, the favored sites being 
between the fingers and toes, the axilla, the groin, and the area imme- 
diately surrounding the umbilicus. The skin over the trunk is usually 
invaded secondarily. 
Lesion.—The impregnated female burrows a tunnel into the layers 
of the skin, which serves as a habitat for the mite during her life. 
In the burrow or canal are deposited the eggs, larvae, and excretions 
of the acarus, and these act as an irritant, producing papules, vesicles, 
and skin infiltration. The presence of the parasite and its products 
causes intense itching which, through scratching, indirectly adds to 
the existing skin irritation. If the skin is clean, the burrows may be 
seen with the aid of a magnifying glass. Upon removal of the epidermis 
at the end of the canal the parasite may be removed with a needle. 
Diagnosis.—Itching is intense and may be confined to the skin areas 
described, or involve all portions of the skin surface. A point of diag- 
nostic value is that the itching is much worse at night due to the fact 
that the mite evidently becomes more active as a result of the increased 
warmth and quiet supplied by the unwilling host. 
In a well-marked case as a result of the action of the acarus together 
with the trauma produced by scratching there is a complex skin picture 
very difficult to describe. An eczema with all its possibilities of skin 
inflammation and infection usually supervenes. The burrows have 
the appearance of dark colored lines extending in a tortuous, zigzag 
course rarely exceeding | inch in length, and these are usually visible 
in sufficient number to make the diagnosis positive. 
Treatment.—The cases differ in severity, but in all the treatment 
is practically the same, varying only in respect to the necessity of its 
repetition or continuation. At bedtime a hot bath is ordered, from 105° 
to 110° F. While in the bath the patient is vigorously scrubbed with 
a towel and yellow laundry soap. After the scrubbing he is dried vig- FURUNCULOSIS (BOILS) 
629 
orously, and sulphur ointment, U. S. P., rubbed as vigorously into the 
skin. This process is repeated twice at intervals of forty-eight hours. 
The repetition at twenty-four-hour intervals is usually too irritating to 
the skin. The third treatment usually terminates the case. For quite 
young children, to whom the sulphur ointment may be too irritating, 
and for older children also, if the first application produces considerable 
dermatitis, the ointment may be diluted one-fourth or one-half by the 
addition of vaselin. Care must be exercised to destroy, boil, or otherwise 
disinfect all clothing previously worn by the patient. 
Boils are frequent in delicate, poorly nourished infants and children, 
and are due to an inoculation of the deep layers of the skin with the 
staphylococcus. Boils may develop in well babies, even under proper 
management, for many delicate skins possess a very poor resistance. 
Often there will be a crop or two comprising perhaps not over five or 
six lesions in all. In marantic infants and poorly nourished young chil- 
dren, however, the lesions may occur in great number. 
Over one hundred furuncles were opened in one patient in caring for the successive 
crops as they appeared. 
The scalp is apparently the most fertile field for their development. 
Repeatedly the boils coalesce, forming a large, sloughing suppurating mass. 
In aggravated cases, in delicate infants with low resistance, fatal results 
are not unusual in institutional work. What might be looked upon as 
a chronic condition of furunculosis sometimes exists in older children. 
The boils will continue to appear at indefinite intervals for a year or 
more in spite of active vaccine treatment. 
Treatment.—Local.—WThen pus is evident in the boil, a free incision 
should be made and the pus expressed. The skin about the wound should 
be washed vigorously with tincture of green soap or ordinary soap and 
water. Applying a few drops of a solution of bichlorid of mercury is 
of little or no value, and will not be sufficient to prevent a reinfection, 
as some pus invariably escapes upon the surrounding healthy skin when 
many boils are opened. A wet disinfectant dressing or a disinfectant 
ointment should follow incision and cleansing. Bichlorid dressings are 
to be used only temporarily for children. The dressing which has ap- 
peared best to prevent the spread of the infection when the involved 
area is not too large is a saturated solution of boric acid, applied by means 
of gauze or lint. In a marantic child, when a considerable portion of the 
surface over the trunk or thorax needs to be covered, the repeated renewal 
of the solution causes a reduction in temperature which is not desirable. 
In treating such infants, and in out-patient work where a wet dressing can- 
not be used, an ointment of 15 per cent, boric acid in vaselin may be 
thickly spread on lint and applied to the wound and a considerable por- 
tion of the surrounding area. The dressing should be changed every six 
hours. Ichthyol is of little service when used in a strength of less than 20 
per cent. The odor is disagreeable; the application stains the skin and 
the clothing and controls the condition no better than does the boric 
acid ointment. Moreover, the latter is comparatively inexpensive. 
FURUNCULOSIS (BOILS) 630 
THE PRACTICE OF PEDIATRICS 
Topical applications of solution containing 6 parts of picric acid and 
60 parts of alcohol to 1000 parts of water have been found of value. 
Caution is essential in applying this to large surfaces. 
In treating fat children who sometimes develop boils on the abraded 
surfaces at the folds of the neck or the nates, and children who perspire 
freely, a dusting-powder has been employed composed as follows: 
Ih Pulv. acidi borici 5j 
Pulv. amyli, 
Pulv. zinci oxidi aa Siss 
M. Sig.—Dusting-powder. 
This is applied as soon as the wound is closed, and the parts are thus 
kept dry. 
A method of great value in treating furunculosis in young patients 
consists in subjecting the affected surfaces to dry heat supplied by bright 
sun or an appropriately devised electric-light bath. 
Constitutional.—The constitutional treatment is important. If the 
child is marantic or suffers from malnutrition, the general treatment 
suggested for these conditions should be brought into use. If delicate 
or anemic, the patient should have the advantage of extra care (pp. 
140-146). In the many cases treated internal medication, other than that 
directed toward the improvement of the general constitutional con- 
dition, has been without value. The sulphid of calcium and other drugs 
which are supposed to have a direct influence upon the condition have 
proved of no service. Observation on a series of cases of this t}Tpe, for 
which opportunity was afforded by institution work, has shown that 
those treated with the sulphid of calcium, for example, made no greater 
progress than did those to whom it was not given. (The existence of this 
line of treatment is an example of “heredity in medicine.” A remedy 
advocated by some one of consequence in the past is handed down from 
generation to generation by writers, many of whom, not having had 
opportunity to support their advocacy of the measure with observations 
of value, simply repeat what has been said by their predecessors). 
Autogenous vaccines, and in numerous instances, even stock staphy- 
lococcus vaccines have been most serviceable in treating furunculosis 
in infants and young children (p. 862). 
Bathing.—No matter how extensive the process, children with furun- 
culosis may be bathed as in health. To the water for the bath, which 
should first be boiled, bicarbonate of soda, 1 tablespoonful to the gallon, 
should be added. There should be little or no friction of the skin. 
PEDICULI (HEAD LICE) 
Head lice, (pediculi capitis), constitute a very frequent source of an- 
noyance in out-patient and hospital work among children. Occasionally 
children better situated may become infected in school or in public con- 
veyances and carry the vermin to other members of the family. Re- 
peatedly all the female members of a household have been found infected. 
Symptoms.—As a result of the irritation produced by the insect 
and the enforced scratching, an eczema of the scalp is of frequent oc- 
currence. The eczema may be slight or give rise to a most extensive TINEA CIRCINATA (RINGWORM) 
631 
and disgusting condition. The suppurating scalp, matted with pus, 
crusts, nits, and vermin, supplies a picture disagreeable even to consider. 
In not a few instances the brows and eyelashes are involved. A slight 
degree of postcervical adenitis is the rule in cases of some weeks’ dura- 
tion. 
Diagnosis.—The diagnosis does not depend upon finding the live 
vermin. The louse cements its eggs to the hair, and the presence of 
the “nit” is in itself diagnostic. 
Treatment.—The most successful and cleanly treatment consists in 
cutting the hair short. The head should then be washed with soap and 
water twice a day; and once daily after the drying the scalp should be 
thoroughly moistened with the following solution: 
jfy. Acidi acetici 3ij 
iEtheris sulphurici 5 iij 
Tineturse delphinii, 
Spiriti vini rectificati aa 5 iv 
Improvement will follow a few treatments. The pediculi will be 
killed and the nits may be removed with a fine-tooth comb. If the patient 
is a girl, it is not absolutely necessary to sacrifice the hair. It may be 
parted at various sites on the scalp and the solution applied, without 
the previous washing. However, if the hair is not cut, a much longer time 
will be required to effect a cure. 
TINEA CIRCINATA (RINGWORM) 
Tinea circinata, ringworm of the body, is a highly contagious para- 
sitic skin infection. 
Etiology.—The disease is due to the trichophyton fungus, which is 
identical with that causing tinea tonsurans. The exposed skin surface, 
the neck, and hands are the sites most frequently involved. 
Domestic animals are subject to the disease. It is rare in cows and 
horses, but quite common in dogs and cats. Children are often infected 
from cats and dogs. 
Symptoms.—The disease usually makes its appearance in the form 
of a small, reddened, irregular-shaped area, which soon becomes circu- 
lar and is covered with a fine, scaly desquamation. The area is sharply 
defined and spreads through the development of fine papules around 
the border of the patch. As the process extends there is a paling and 
smoothing out of the surface in the middle of the patches, while the 
exterior border remains somewhat elevated and reddened. This pro- 
duces in the lesion a ring-form appearance which has given rise to the 
term by which it is known. There may be but one lesion or there may 
be dozens of varying sizes, § inch to 2 or more inches in diameter. Oc- 
casionally the smaller patches run together, forming large areas of ir- 
regular shape. 
Diagnosis.—The diagnosis is usually not difficult. The character- 
istic well-defined ring, circumscribed and usually multiple, is not simu- 
lated by other skin diseases. In some cases in which the margin is not 
so well defined, and in those which show one or more circumscribed scaly 
areas, the lesion may be confused with a patch of seborrheic eczema. 632 
THE PRACTICE OF PEDIATRICS 
Psoriasis may resemble ringworm. Psoriasis is, however, very rare in 
children. Furthermore, the lesions of psoriasis are usually located and 
grouped on the extensor surfaces and at the margin of the hair, and the 
scales are thicker and more abundant than those of ringworm. In patches 
of acute eczema the characteristic abrupt margin is absent, itching is 
more marked than in ringworm, and the inflammatory manifestations 
are changeable from day to day, while in ringworm the appearance of 
the lesion is without change. If doubt exists and the latter condition is 
present, a microscopic examination of the scales to which a few drops of 
liquor potassii have been added will reveal the presence of the long, deli- 
cate threads of mycelium and thus settle the diagnosis. 
Treatment.—The treatment consists in the use of some irritant that 
will produce a desquamation of the superficial layers of the skin in which 
the fungus is located. The tincture of iodin has proved a satisfactory 
remedy whenever the lesion is located where its use is possible. Two or 
three applications of the U. S. P. tincture at twenty-four-hour intervals 
constitute all the treatment ordinarily required. If the case proves ob- 
stinate, 2 grains of the bichlorid of mercury may be added to each ounce 
of tincture of iodin. If the lesion is situated on the face or elsewhere on 
the exposed surface of the body, 5 grains of bichlorid of mercury may be 
dissolved in equal parts of alcohol and glycerin, 1 ounce each, and applied 
locally three or four times daily until a slight dermatitis results. A rapid 
cure follows this treatment. 
TINEA TONSURANS (RINGWORM OF THE SCALP) 
Ringworm of the scalp is of frequent occurrence in institutions for 
children, and is greatly dreaded because, when once it gets a foothold, 
it is most difficult to eradicate. In one personally observed epidemic 
there were over 100 cases. These cases were all cared for by nurses and 
orderlies who lived in the wards with the children, and not one case oc- 
curred in an adult. The susceptible age appears to be from the third to 
the tenth year. 
Etiology.—Ringworm is due to the action of the trichophyton fun- 
gus. The disease, which is most contagious, is transmitted by exchange 
of caps, or by means of towels, brushes, combs, etc. The diseased hair, 
according to Crocker, when placed under the microscope, after being 
soaked in B. P. liquor potass® for half an hour and gently pressed out 
under the cover-glass, presents the following appearance: 
The hair may be seen bent like a green stick, while the free end is frayed out like 
a brush, and (with a power of at least 200 or 300 diameters) abundant conidia or spores, 
with scanty mycelium, may be seen to permeate the shaft, both downward to the root- 
end and upward above the surface for some distance, this appearance differentiating 
the condition from favus. Between the inner root-sheath and the shaft the conidia 
are also apparent in great numbers, but the mycelium is less abundant in the hairs 
than in the scales. The conidia measure from 4 to 5 micra, and are round and sharply 
contoured, with a central nucleus like a black dot. The mycelium consists of well- 
defined, transparent, branched and pointed threads, terminating in conidia. They 
may be seen best in the shaft near the bulb or between and on the scales. 
Diagnosis.—The diagnosis is not difficult. The circular circum- 
scribed patch with the short “stubbles” of hairs on the otherwise normal TINEA TONSURANS (RINGWORM OF THE SCALP) 
633 
scalp is simulated by no other condition. The diameter of the involved 
area varies from § inch to 2 or 3 inches. A large denuded area is usually 
the result of the coalescing of smaller areas. There may be but one in- 
volved area on a scalp or there may be a dozen. 
Prophylaxis.—To prevent an epidemic when the disease breaks out 
in an institution which is the permanent home of children is most nec- 
essary and yet most difficult. The only means of stopping the spread 
of the disease, in the writer’s experience, has been in having the heads 
of all the unaffected children closely clipped and giving them a shampoo 
of equal parts of kerosene and olive oil twice weekly. 
Treatment.—Cures are difficult, and the treatment must be along 
radical lines. In an epidemic several years ago at the Country Branch 
of the New York Infant Asylum, abundant opportunity was offered 
to test the various forms of treatment advocated by different observers. 
Among the applications used were chrysarobin in various combinations, 
carbolic acid, iodin, bichlorid of mercury, sulphur, and white precipitate. 
The location of the fungus in the hair-follicle renders it very diffi- 
cult to apply any drug so that it will be effective as a parasiticide. In 
order to accomplish this it is absolutely necessary to cut the hair of the 
entire scalp as short as possible. Upon beginning the treatment the 
scalp is thoroughly scrubbed with water and strongly alkaline yellow 
laundry soap, so as to remove all the dead hair and desquamated epithe- 
lium. The parasiticide to be used is then rubbed into the diseased area 
and for a considerable distance over the surrounding healthy scalp. The 
parasiticide which proved most valuable in the epidemic cited was com- 
posed of bichlorid of mercury, 2 grains in | ounce each of olive oil and 
kerosene. The bichlorid must be dissolved in a small quantity of alcohol 
before it is added to the oil mixture. This is rubbed into the diseased 
area every day until the scalp becomes sore and tender. In order to 
prevent the spread of the infection to other parts, the kerosene and olive 
cil without the bichlorid may be applied every fourth day, without fric- 
tion, to the entire scalp. To effect a prompt cure it is necessary to pro- 
duce a dermatitis at the site of the lesion. When this occurs, the treat- 
ment should be temporarily discontinued. As soon, however, as the 
dermatitis subsides another inflammation should be produced in like 
manner. After three or four weeks this treatment may be discontinued 
while the patient is still kept under observation, in order that the phys- 
ician may confirm the results. A daily application of sterile oil aids 
in bringing the skin to a normal condition. 
In treating one-third of the children in the epidemic referred to, 
2 grains of the bichlorid of mercury were added to 1 ounce of the tinc- 
ture of iodin. Twenty-six cases were treated by this method, with an 
average duration of treatment of eight and one-half weeks. Several 
recovered in four weeks, while for others twelve weeks of treatment 
were necessary. So long as the treatment is in progress the child should 
wear a cap, day and night. This may be made of any cheap, light-weight 
material, which, after a day or two of use, may be burned. In our cases 
cheese-cloth caps were used. Rubber gloves were necessary to protect 
the hands of the nurse who made the applications, especially if there were 
many heads to be treated. 634 
THE PRACTICE OF PEDIATRICS 
In this epidemic, which was controlled by the above means, pro- 
phylaxis was obtained by the use of the kerosene and olive oil without 
the bichlorid. It was found impossible to maintain a quarantine per- 
manently or effectually even for a short time, particularly during the 
warmer months. Therefore every inmate of the asylum of the “run- 
about” age who did not have the disease was treated as an incipient 
case. Every head was “clipped” and the hair kept short. Twice a week 
the children were given a kerosene and olive oil shampoo. 
In private work the continued use of kerosene and olive oil is not 
popular, for reasons readily understood. In such cases the hair should 
be clipped as soon as the case is diagnosed, and a kerosene shampoo 
given. The bichlorid of mercury, 2 grains to 1 ounce of tincture of iodin, 
U. S. P., should be applied to the parts with sufficient vigor to produce 
a dermatitis. If the disease shows a tendency to spread beyond the 
original site, it is best prevented by the use of the kerosene and olive 
oil, in the manner above described. Bulkley1 has contended that all 
cases are cured spontaneously at puberty, as practically no cases are 
seen in the scalp of the adult. 
Strickler2 reported favorably on the results in 20 cases of ringworm 
of the scalp treated by vaccines. 
Roentgen-ray Treatment of Ringworm of the Scalp.—With many im- 
provements in technic and apparatus x-ray treatment is now compar- 
atively without danger and offers a very speedy cure. The treatment 
must be in the hands of experts. 
The efficacy of the treatment is due to the falling out of the infected 
hairs carrying with them the organisms. There is no direct action on 
the parasite so that precautions must be observed after treatment to 
prevent the infection of others by the falling hair. This is easily ac- 
complished by keeping the head covered. About seven days after x-ray 
treatment a local erythema develops, lasting three to four days. The 
hair falls out about the end of three weeks and begins to regrow in three 
months. No local treatment is used two weeks prior to treatment and for 
one month afterward, when a 5 per cent, ointment of sulphur or of am- 
moniated mercury U. S. P. is applied.3 
IMPETIGO CONTAGIOSA 
Impetigo contagiosa, as the name implies, is a contagious disease 
of the skin. Several children in the same family or school often have 
the infection at the same time. One school child has been known to infect 
an entire class of 20. Cases of impetigo are seen almost daily in large 
out-patient clinics for children. The exposed parts comprising the face, 
head, and hands are those most frequently involved. 
Etiology.—Bacteriologic examination shows a mixed infection with 
staphylococcus predominating. 
Symptoms.—At first the lesion consists of a few closely grouped 
vesicles, which rapidly develop into pustules. These shortly form a 
1 Jour. Amer. Med. Assoc., July 17, 1915. 
2 Ibid., August 17, 1912. 
3 For complete details of technic consult Mackie and Remer, Medical Record, 
New York, vol. lxxviii, p. 217. PEMPHIGUS NEONATORUM 
635 
dry crust of variable size and thickness. One area or a dozen or more 
may be involved. Several small lesions may coalesce, forming one large 
lesion, the crusts of which may be 2 inches in diameter. They rest upon 
an inflamed base, which bleeds slightly when they are removed. There 
are no constitutional symptoms, and rarely is there itching. The only 
evidence of the disease is the disfigurement occasioned by the dry, ad- 
herent crusts. 
Impetigo may occur in the form of ecthyma in which the lesions are 
red and nodular involving the deeper layers of the skin and developing 
into pustules with a tendency to resultant scars. The lesions in ecthyma 
are always discrete and tend to affect the extensor surfaces of the legs 
and the buttocks. The tendency of this condition to follow scabies is 
noteworthy. 
Treatment.—A most satisfactory procedure has been to soften the 
crusts by the application of gauze saturated with sterilized olive oil, 
the gauze being bound to the parts. Usually in twenty-four hours the 
crusts may readily be removed. Afterward an ointment of 2 to 5 per cent, 
ammoniated mercury or 10 per cent, boric acid in ointment of rose-water, 
or one composed of 10 per cent, ichthyol in vaselin, should be spread on 
sterile gauze and bound to the suppurating surface. The dressing should 
be changed at least night and morning. Recovery is usually complete 
in from two to three days. When the crusts are on the lip or other por- 
tions of the face where the dressing described cannot readily be applied, 
the lesions should be kept moist with either the boric acid or ichthyol 
ointment. If the gauze is not used, fresh ointment should be applied 
at least every three hours, both before and after the crusts are removed. 
In the ecthymatous type of impetigo the cure is more difficult and the 
ointment applications must be preceded by wet dressings. For this pur- 
pose aluminium acetate is recommended. 
Pemphigus in the newborn is an infection of the skin manifesting 
itself in a bullous eruption, which may appear on any portion of the 
surface. Two epidemics of pemphigus at the New York Infant Asylum 
involved in all about 30 cases. The patients were mostly well-nourished 
infants. The origin of the disease in each epidemic was unknown. From 
a few hours to a day after birth bullae of the seropus appeared, and in 
several cases the process was so extensive through their coalescence that 
large portions of the skin surface were denuded when the bullae ruptured. 
The disease is very contagious, and these epidemics were only stayed 
by rigid quarantine of all the newborn and by closing the operating- 
room. Examination of the serum from the bullae of several cases showed 
Staphylococcus albus. 
The mortality was about 20 per cent. 
Treatment.—The management of the first epidemic consisted in 
opening the blebs and in the application of various antiseptic solutions 
and ointments. Not much improvement followed until creolin baths 
were used. This treatment not only relieved those cases which had de- 
veloped, but the systematic bathing in a 1 per cent, creolin solution 
PEMPHIGUS NEONATORUM 636 
THE PRACTICE OF PEDIATRICS 
of all the newborn in the institution apparently prevented the spread 
of the infection. 
During the second epidemic the house physician, Dr. Carswell, as- 
cribed favorable results to a 30 per cent, solution of ichthyol kept applied 
to the parts and changed three times a day. 
Erythema nodosum is characterized by the formation, in the skin 
and connective tissue, of multiple brownish nodules of varying size. 
Location of the Lesion.—The nodules are most frequently seen over 
the anterior surface of the leg. 
Etiology.—The disease is to be regarded as an infection, most probably 
one of the many protean manifestations of rheumatism. In our cases 
endocarditis has not been a complication, although all the patients have 
been rheumatic subjects, and in some cases exhibited peliosis rheumatica. 
Symptoms.—Previous to the appearance of the nodules there may 
be fever and loss of appetite and general indisposition on the part of 
the child. According to our observation these prodromal symptoms 
have, however, been unusual, the local manifestations constituting in 
some cases the only evidence of the disease. The nodes are very painful 
to the touch, and show a black and blue discoloration. The entire anterior 
surface of the tibia may have a bronzed appearance. 
Pigmentation follows the disappearance of the nodules. 
In mild cases the pain is confined to the lesions. In severe attacks 
there is not only fever but also a great deal of joint pain and muscle 
soreness. 
Treatment.—If there is fever, the patient should be kept in bed until 
the acute febrile period is passed and the nodules begin to disappear. 
The treatment is begun with the administration of 1 or 2 grains of cal- 
omel, followed by a saline laxative. 
Milk and a vegetable diet are prescribed. A very small amount 
only of sugar is permissible. As a rule, apparently the best results from 
drug therapy have been gained by the use of 5 grains of the salicylate of 
soda in combination with 10 grains of sodium bicarbonate in 6 ounces of 
water after meals. 
Illustrative Case.—A delicate girl had three crops of nodules, the different crops 
having appeared at intervals of about three months. The first attack was associated 
with peliosis and urticaria. This patient who was markedly rheumatic, had taken large 
quantities of the salicylate, and its readministration contrary to experience with other 
cases, had no effect; but in all three attacks the nodules began to diminish and dis- 
appeared completely under the administration of 30 grains of iodid of potash daily. 
The duration of the cases has been from ten days to three weeks, 
with the exception of the one referred to, which persisted for six weeks, 
until the iodid was brought into use, when the improvement was prompt. 
Local Measures.—A most satisfactory local application for the relief 
of pain is the lead and opium solution, U. S. P., applied warm to the 
parts by means of soft old linen or gauze, over which oiled silk or rubber 
tissue is placed to prevent too rapid evaporation, the entire dressing 
being held in position by bandages. 
ERYTHEMA NODOSUM HERPES SIMPLEX (FEVER BLISTERS) 
637 
ERYTHEMA MULTIFORME 
As its name indicates, this is a disease of the skin manifesting itself 
in many different forms. 
Etiology.—It is most frequently encountered in ill-conditioned chil- 
dren of rheumatic diathesis, and is frequently associated with disorders 
of digestion and the toxic action of various drugs, particularly those 
derived from coal-tar. 
Exceptionally a rash of this type is observed in prolonged subacute 
infections such as colon bacillus pyelitis. 
Symptomatology.—The disease usually manifests itself in reddened 
papules, macules, and erythematous, infiltrated skin areas, all of which 
are most frequently found over the dorsal surfaces. There is no pain 
and but little if any itching. 
Diagnosis.—The condition is to be differentiated from acute urti- 
caria by the fact that in urticaria the lesions are very transient, appear- 
ing and disappearing rapidly, while in erythema multiforme several days 
are required for resolution to take place. 
Treatment.—The management consists in relieving whatever diges- 
tive derangement may exist by the use of calomel, rhubarb and soda, 
and the enforcement of a suitable diet (pp. 134-136). 
For a child five years of age 3 grains of salicylate of soda with 6 grains 
of bicarbonate of soda in 4 ounces of water should be given after meals 
three times daily. In the event of itching, which is unusual, an oint- 
ment composed of 10 grains of menthol in 1 ounce of rose-water oint- 
ment will usually furnish relief. The eruption seldom lasts longer than 
a week. A pigmented area may remain at the site of the lesion. 
HERPES SIMPLEX (FEVER BLISTERS) 
An eruption of small vesicles on a reddish edematous base is not 
infrequent about the lips following some constitutional disturbance as- 
sociated with fever. The cheeks as well as the perioral region are at 
times affected. Herpes genitalis is a similar affection not often observed 
in children. 
Etiology.—The lesions are probably due to the activity of bacterial 
toxins. Pneumonia, meningococcus meningitis, and malaria may be 
accompanied by herpes of this type. The exact cause of the condition is 
unknown. 
Pathology.—The vesicles are deeply situated and may be entirely 
beneath the epithelium. They become filled with clear fluid and their 
development is associated with localized hyperemia. Degeneration and 
necrosis of prickle cells in the affected region is an accompaniment. Sup- 
puration may occur, but ordinarily the vesicles undergo desiccation with- 
out rupture and without scarring. 
Symptoms.—Itching and a sensation of tension and soreness locally 
comprise the chief subjective symptoms. The nature of the lesions is 
readily apparent to the eye. Temperature elevation and more serious 
symptoms are dependent on the underlying constitutional disturbance 
with which the herpes is associated. 
Differential Diagnosis.—The distribution of the lesions and their self- 638 
THE PRACTICE OF PEDIATRICS 
limited duration—about a week—serve to distinguish herpes from vesicular 
eczema and impetigo even when the character of the herpes is atypical. 
The vesicles of eczema are characteristically thinner walled and rupture 
more readily than those of herpes. 
Prognosis.—One attack seldom lasts more than a few days. Recur- 
rences, however, are not uncommon. 
Treatment.—Astringents, such as spirits of camphor, alum in 2 per 
cent, solution, and alcohol may be applied locally. When there are fissures 
silver nitrate in 10 to 20 per cent, solution is invaluable. 
An acute inflammatory disease productive of vesicles in large numbers 
similar to those of herpes simplex not infrequently attacks the skin along 
the course of one or more sensory nerves. 
HERPES ZOSTER (SHINGLES? ZONA) 
Fig. 112.—Thoracic herpes zoster (Bellevue Hospital). 
Etiology.—This disease is looked upon as an acute specific disease of 
the nervous system with secondary effects in the skin. The posterior 
ganglia of the spinal cord typically exhibit lesions microscopically in the 
abdominal and thoracic types, while in herpes affecting the head the 
gasserian ganglion may be involved. Chickenpox virus, syphilitic virus, 
and diplococci and streptococci have all been considered causative, and 
in some instances diseased tonsils and teeth probably are foci of origin 
for the infection to which the herpes is indirectly due. Exposure to cold, 
productive of diminished resistance, and the long-continued use of arsenic 
are further causes. 
Pathology.—The vesicles are deeply seated and contain serum, degen- 
erated prickle cells and leukocytes, and rarely blood. The degenerative 
changes occurring in the posterior ganglia cells have already been men- 
tioned. There is apparently a close analogy between the effects of this 
disease, dependent on sensory nerve root lesions and those of poliomye- ERYSIPELAS 
639 
litis due to motor cell degeneration in the anterior cornua. Neuralgic 
pains in herpes, rather than sensory paralyses, are, however, the rule. 
Symptoms.—In children pain of a severe character is less frequent than 
in adults. In fact, very little if any discomfort may be manifested. This 
is usually limited to itching and local soreness. Infrequently adjacent 
lymph-nodes may present slight involvement. The most common sites 
for the lesions -are along the course of the thoracic, lumbar, brachial, and 
supra-orbital cutaneous nerves. (See Fig. 112.) At times the gluteal 
region may be affected. 
Recurrent attacks of herpes in this region were observed in association with gastro- 
intestinal overloading and asthma in a little girl. 
The lesions may be few or numerous and develop in successive patches 
for days. The acute condition usually subsides with the characteristic 
desiccation stage within a fortnight of the onset. 
Exceptionally, bilateral shingles may occur. 
Diagnosis.—The distribution and character of the eruption is diag- 
nostic, particularly when neuralgic pain is an accompaniment. 
Prognosis.—Recurrences in the same patient are unusual. The worst 
effects of the disease have been apparent in eye involvement and men- 
ingitis following zoster of the supra-orbital region.1 
Treatment.—Repeated doses of phenacetin or aspirin are of value 
during the height of the attack. 
Locally the wax treatment as applied to burns has been endorsed by 
Fox. Dusting powders such as dermatol, aristol, and nosophen may be 
employed to hasten desiccation. In the event of suppuration the vesicles 
may require puncture and drainage. 
Erysipelas is a serofibrinous inflammation of the skin, and may go 
on to the stage of gangrene. It is caused by the streptococcus, which 
enters through a wound or abrasion and spreads along the lymph- 
channels. 
In newborn infants the umbilicus may be the point of entrance for 
the streptococcus, and erysipelas of the surrounding portions of the 
body wall may result. 
Etiology.—Infants with low resistance are predisposed. Nevertheless, 
babies ideally cared for are sometimes victims of the infection. The 
absence of resistance of the young to bacterial invasion is unquestionably 
a factor in determining the age incidence. 
Mode of Entrance.—In the newborn the streptococcus may enter 
the skin by the nasal route, or the navel may be the seat of the initial 
infection. Later in development the process may begin in any portion 
of the skin surface. The scalp and the female genitalia are favorite sites. 
Illustrative Cases.—In a fatal case the infection developed at the site of an in- 
completely healed chickenpox lesion on the upper anterior chest. 
In another case which proved to be mild in spite of severe temperature mani- 
festations the rash extended over the cheek from a suppurating mastoid wound. 
ERYSIPELAS 
1 Sutton, Diseases of the Skin, 5th ed., 1924, p. 274. 640 
THE PIIACTICE OF PEDIATRICS 
Symptoms.—The onset may be marked by a convulsion. The first 
sign may be high fever, the cause of which is not known until a reddened, 
indurated area with sharply defined border is found at some point in the 
body. The infection, when not very severe, may invade the scalp and 
continue to spread unrecognized because of the protection of the hair. 
Usually a considerable area, at least 2 or 3 inches in diameter, will be 
present when the disease is discovered. From this primary area there 
is a slow progressive spreading of the process, the margins of the affected 
zone remaining sharply defined. The inflammation may be arrested 
at any point or may involve the entire body. The slowly creeping red 
line of demarcation sharply defines the normal from the reddened infected 
skin. The skin over the feet and hands may be swollen almost to the 
point of rupture. Severe infections are never followed by recovery. If 
the case is mild, the general process will be less intense, the creeping 
extension less rapid, and the response to treatment more prompt, 
permitting recovery. 
The temperature is very high—usually 104° to 106° F.—with but 
little variation. The height of the temperature is indicative of the severity 
of the infection. In mild infections only, the fever may be slight. 
With erysipelas the child is very uncomfortable and restless and cries 
much, giving evidence of considerable pain, particularly upon manipu- 
lation. 
Complications.—Erysipelas does not predispose to any particular 
form of illness. Patients who resist the infection may develop broncho- 
pneumonia as a terminal complication. 
More often the digestive system becomes involved, the child loses 
weight rapidly, and dies from exhaustion. 
A complicating meningitis is not an infrequent cause of death. 
Prognosis.—Erysipelas is a particularly fatal disease in infants. In 
the newborn 95 per cent, of the cases are fatal. Fifty per cent, of the 
senior author’s cases occurring in children under one year of age have been 
fatal. At Bellevue Plospital, where a considerable number of these cases 
are treated, the disease has appeared to be less fatal in the infants who 
were breast fed. When the streptococcus of erysipelas gains entrance into 
the skin of an infant, it is not unusual for the entire skin surface to become 
involved before the process subsides. The long-continued high tem- 
perature, the toxemia, the discomfort from the inflammation, and the 
interference with nutrition so greatly reduce the patient that even if the 
disease is resisted during the acute stage the subject is very apt to die 
later from exhaustion. 
This was the outcome in 4 cases observed at the New York Infant Asylum, 
where each child went through the active period of the disease, but died a week or 
two afterward from exhaustion and marasmus. 
Treatment.—The treatment is unsatisfactory, particularly so in young 
children. The younger the child, the graver the prognosis. Absolutely 
nothing is to be promised. Scarifications in advance of the line of the 
slowly creeping inflammation have been employed and whether solutions 
of the bichlorid of mercury, carbolic acid, or ichthyol were used as a 
dressing, the red line has been observed to pass the scarified, disinfected ERYSIPELAS 
641 
surface regardless of the nature of the antiseptic and regardless of the 
vigor and vitality of the child. 
The termination of the case, whether in recovery or death, depends 
to a great extent upon the resistance of the patient and the severity of 
the infection, so that our first step should be to place the child in the 
best position to resist the disease. 
General Measures.—Particular caution should be exercised by attend- 
ants in caring for this disease both to avoid infecting themselves and 
to avoid conveying the infection. The care of obstetric and surgical 
patients should always be conducted by those who are not attending 
erysipelas cases. Perhaps the most important factor in the treatment 
is abundance of fresh air. In the winter the child does best in a room 
with windows wide open, not for a few moments at intervals, but contin- 
uously. Protection with hot-water bags and sufficient clothing eliminates 
danger as long as the temperature of the room does not fall below 55° F. 
At other seasons of the year the patient should, if possible, be kept out- 
of-doors. 
Infants with erysipelas are particularly liable to develop gastro- 
enteric disorders. In case the child is bottle fed, the milk mixture should 
at once be reduced from 50 to 75 per cent, below the normal by the ad- 
dition of barley-water or Granum-water No. 1, so that the amount of 
fluid given at a feeding remains unchanged. 
Internal medication, such as we have used, has been of no value unless 
stimulating or sustaining in nature. The tincture of the muriate of 
iron is not to be given young infants with erysipelas, for it almost invari- 
ably disturbs the appetite and interferes with the digestion. 
In the event of high temperature—above 104° F.—the cool pack 
(p. 841) may be found effective. 
Local Applications.—The local agent which is unquestionably of 
some value is ichthyol. We prefer a 30 per cent, solution if the involved 
area is on one or more of the extremities or a small portion of the trunk. 
Strongly antiseptic solutions as dressings should not be used for infants 
when the erysipelatous process involves the face or much of the trunk. 
When these parts are involved, a dressing of 30 per cent, ichthyol oint- 
ment in vaselin should be applied on strips of lint or linen and renewed 
every three hours. The frequent renewal is important, and the oint- 
ment-dressing should be used only on the acutely involved areas. When, 
in a given case, the inflammation begins to subside, the dressings should 
be removed and the parts bathed freely. In this connection it must be 
remembered that the skin is an important organ of excretion, particularly 
of carbon dioxid. The constant covering of comparatively large sur- 
faces on a small body, by interfering with the function of the skin, may 
become a serious matter. The local treatment with ichthyol should 
follow up the extension of the inflammatory process and be continued 
until it subsides. Of later years we have been using with a fair degree of 
success a cool wet dressing of a saturated solution of boric acid. The 
lotion is applied on old linen or several thicknesses of gauze. The parts 
are kept continually wet with the solution day and night. 
Stimulants.—Nearly every infant with erysipelas will require stimu- 
lation. For this purpose small doses of whisky well diluted appear best. 642 
THE PRACTICE OF PEDIATRICS 
From 5 to 15 drops at two-hour intervals for children under two years 
of age has aided, the writer is sure, in carrying patients through to a 
successful convalescence. Erysipelas is the only disease in which it is 
wise to use alcohol early, and in many instances as the only Stimulant. 
Convalescence.—When the inflammation subsides the child is by no 
means to be regarded as well; for even in the absence of sequelae, such 
as a phlegmon, endocarditis, or nephritis, vitality may have become so 
reduced that sudden death may take place when it is thought the pa- 
tient is well on the road to recovery, such a result being due, perhaps, 
to unrecognized myocarditis. During the entire attack and through- 
out convalescence the child should be fed to the limit of digestive ca- 
pacity, but never beyond this limit. Correct feeding is possible only by 
careful observation of the case and frequent inspection of the stools. 
Specific Therapy.—The value of vaccine and serum therapy in this 
disease remains to be proved. (See p. 862.) 
DERMATITIS (ECZEMA) 
The term “eczema” should be removed from the nomenclature of skin 
diseases and “dermatitis” substituted. A lengthy discussion of this sub- 
ject is left to the dermatologist.1 We have seen enough of the so-called 
eczema in thousands of cases to warrant our belief that the lesion as we 
find it in the skin of infants and children is the expression of an abnor- 
mality in the bodily function, on the one hand and, a reaction to local ex- 
trinsic irritation on the other. Dermatitis (as we prefer to call it) can be 
successfully treated by local measures only in those cases due to extrinsic 
local causes. It is the problem of the physician to find out the deranged 
processes (usually chemical, physiologic, or allergic) to which the der- 
matitis is a reaction. If we group together all the skin diseases of infancy 
and childhood, it will be found that this affection considerably exceeds 
in prevalence all the others combined. This is not surprising when we 
remember the exposed situation of the skin, its delicate structure, and 
its manifold functions of absorption, secretion, excretion, and heat radi- 
ation. 
Etiology.—Grossly as it occurs in infants dermatitis may be divided 
into two types: the first, due to causes operating from without the body, 
including local infection of various kinds or local irritation of whatever 
nature: the second, due to abnormal systemic conditions affecting the 
skin through the nervous system or by means of the blood-current. Cases 
of this latter class are looked upon as of toxic origin. The irritation of 
the skin or the skin lesion is actually the secondary manifestation of a 
disordered constitutional state. Upon the non-resistant skin lesion in- 
fection is implanted through exposure to the air or through scratching, 
and the result is a form of dermatitis in which both causes are operative. 
This is the etiologic explanation of the majority of the cases in patients 
under two years of age. 
1 “The present tendency is to exclude, as rapidly as possible, all forms of derma- 
titis which have a definite cause, and which upon removal of this cause disappear. 
Eczema is a dermatitis and it is not possible to say in every case which title is the more 
appropriate. A convenient division classes under dermatitis those forms of involve- 
ment of the skin which result from recognized external causes and which subside upon 
removal of the cause,” Ormsby, Diseases of the Skin, 2d ed., 1921, DERMATITIS (ECZEMA) 
643 
In view of the foregoing it is plainly not possible, even were it de- 
sirable, to make the attempts at differentiation, such as is found in text- 
books dealing with dermatology in the adult. Repeatedly one will find 
a weeping or catarrhal skin reaction in one portion of an infant’s body and 
on other portions every variety of inflammatory lesion, including papules, 
vesicles, pustules, and fissures. Moreover, a weeping surface may be 
replaced by perfectly normal skin within a day or two and then sud- 
denly return within a few hours following some dietetic indiscretion. 
Infection of the involved areas by pyogenic bacteria, resulting in 
pustules and furuncles, is more common in infants than in adults, be- 
cause of the child’s tendency to inoculation through manipulation and 
scratching, and because of the diminished resistance offered by a child 
to pathogenic organisms. 
Toxic Origin.—The cases that are due to disordered metabolism, 
digestive derangements, or protein allergy are the most frequently en- 
countered and by far the most resistant to treatment. 
Age.—The susceptible age is from one to twelve months. While 
cases which have developed during the earlier months of life may per- 
sist into the second and third years, so long a duration is comparatively 
rare, and it is equally rare for cases to develop after the first year, the 
latter fact implying that many are cured spontaneously. 
Physical Condition.—The physical condition and vigor of the child 
exert apparently little influence upon the development of the disease. 
In many instances, however, it has been aggravated during active denti- 
tion. Some of our healthiest nursing babies who have made most satis- 
factory progress and have been well in every other respect have been sufferers 
from dermatitis until the nursing period was over or until nursing was 
discontinued and other food given. In fact, the majority of our cases 
have occurred in children whose condition was otherwise satisfactory. 
There have been other patients, to be sure, who have suffered from mal- 
nutrition or been difficult feeding subjects. In some of these dermatitis 
was possibly a factor in causing the malnutrition, for on account of the 
excessive itching and consequent restlessness and sleeplessness, strength 
had become so markedly reduced that malnutrition was just as probably 
a result as a cause of the skin condition. Nevertheless, a consideration 
of all the cases encountered indicates that athreptic and poorly nour- 
ished children are surprisingly free from manifestations of an acute in- 
flammatory type. Whatever process is at fault is usually of such a nature 
as not to interfere with nutrition. 
In a considerable proportion of the cases there is apparent an asso- 
ciated dermatitis of the scalp. 
Several of our patients who have been sufferers from “eczema” in baby- 
hood have in later life developed some tendency to cyclic illness, such as 
recurrent bronchitis, recurrent asthma, or recurrent (cyclic) vomiting. 
Not a few patients have been the offspring of parents who gave a history 
of gout or rheumatism. 
Suboxidation.—Incapacity for the oxidation of cow’s milk fat and sugars 
has been the cause of persistent dermatitis in many of our cases. This 
has been proved clinically bjr the simple procedure of withdrawing these 
substances and using a sugar-free diet and fat-free cow’s milk. The milk- THE PRACTICE OF PEDIATRICS 
sugar in the cow’s milk can be taken care of by the patient. In many 
cases this simple treatment has been followed by recovery. In such 
infants there is an apparent low type of so-called acid intoxication. These 
patients further do best when the alkaline reserve balance is supported 
by the administration of bicarbonate of soda or magnesia. The carbo- 
hydrate as it exists in cereals, vegetables, and fruit appears to exert no 
influence on these cases. Cod-liver oil in moderate doses is usually well 
tolerated. It is a peculiar fact that in dermatitis of the metabolic type 
orange juice and beef juice will start a conflagration of weeping and itch- 
ing. 
The ingestion of fats and cane-sugar may be an important etiologic 
factor in causing dermatitis in the young. Carbohydrate in the form of 
baked flours appears to exert but little influence. Orange juice and beef 
juice, however, when given in association with a high sugar diet will pre- 
cipitate an attack in some children or produce recurrence in a recovered 
case. 
Protein Sensitization.—Allergy to human milk, or more frequently to 
cow’s milk, is responsible for many cases. Infants belonging to this 
group are those who at some time in infant life or in the runabout period 
or even later, give evidence of the existing sensitivity through the res- 
piratory tract by a tendency to bronchial spasm during bronchitis, or the 
development of true asthma. 
Children who are neglected and generally badly fed often have a per- 
sistent dermatitis with no apparent relation to any specific cause. When the 
hygiene and diet of these children are corrected the dermatitis disappears. 
Not all cases admit of a cure and yet quite possibly nearly all cases might 
be cured if we dared draw our dietetic lines sufficiently rigid. This might 
mean a clear skin, but it also might mean faulty growth and malnutri- 
tion. Now and then an infant cannot be maintained free from the der- 
matitis because of loss of weight occasioned by the necessarily restricted 
diet. In such cases proper growth and right development are more im- 
portant than personal appearance. 
Local Irritation as a Factor.—Traumatic dermatitis may be produced 
by any form of irritation, such as woolen worn next to the skin, counter- 
irritants applied for therapeutic purposes, overclothing in hot weather, 
or scratching to relieve the itching caused by the bites of insects. In 
fat babies, portions of whose skin surfaces are in constant contact, suffi- 
cient irritation is produced by friction and perspiration to produce an 
active localized dermatitis. 
Symptoms.—The symptoms cover so wide a field that a description 
is most difficult. A red, inflamed area on the cheek and an extensive acute 
general dermatitis constitute the two extreme possibilities of the acute 
lesions. Between these extremes there is every degree of involvement. 
When an infection with the staphylococcus supervenes we may ex- 
pect all possible varieties of pustules and furuncles, and the case may 
show, throughout, the characteristics of chronic dermatitis in the adult: 
dry, scaly, desquamating epithelium on extensive reddened surfaces, or 
infiltrated skin areas with diffuse macules and papules and abundance 
of scratch-marks. The extensor surfaces of the arms and legs are the 
most frequent sites of election by this form. DERMATITIS (ECZEMA) 
645 
Prognosis.—This is one of the diseases that requires patient and 
persistent treatment. The prognosis is then good, and the results fairly 
prompt, but always commensurate with our ability to discover the mor- 
bid factor which is the occasion of the skin reaction in constitutional 
cases. The disease in its severe form does not tend toward recovery, 
particularly during the first year, although many cases developing 
during the first month terminate in cure spontaneously during the 
second year. In a few subjects the tendency persists during the lifetime 
of the individual. 
Our most difficult patients are often overfat babies, for the dermatitis 
is a reaction due to abundance and not a feature common to starvation. 
In fact, it is exceedingly rare to find an active constitutional dermatitis 
in a marantic or undernourished infant. 
Treatment.—The management is variable, depending upon several 
factors. 
The protein-sensitive cases may be controlled not so readily through 
immunization, which has accomplished little as a rule in this disease, as 
by keeping the patient apart from the offending substance. The cases 
due to fat and sugar incapacity are the most difficult to control, for re- 
duction in these food elements may mean failure to gain or loss in weight, 
a state more serious .than the dermatitis. It is fortunate that, as has 
been stated, many infants adapt themselves to the causative factor and 
get well spontaneously after the first year. 
Management of the Breast Fed.—If the child is a well-nourished, breast- 
fed baby and presents the familiar picture of the red, weeping cheeks, 
with dry crustations extending to the forehead and ears, seborrhea of 
the scalp, and roughened skin over the outer aspect of the arms, the first 
step is to look into the life and habits of both child and mother. Her 
own life and the nursing hours are to be regulated along the lines laid 
down under Maternal Nursing (p. 45). A most important requirement 
of these cases is that the mother’s bowels shall be evacuated at least 
once daily and that the same function shall take place in the baby. In 
a case of the character described the child has usually been getting too 
much food, and probably food high in fat. The mother’s milk should be 
examined and the baby weighed before and after nursings for twenty- 
four hours in order to determine the amount of milk taken at a feeding. 
As a general observation it will be found that these infants do best on 
four-hour nursings, at 6 and 10 a. m.; 2, 6, and 10 p. m. If the mother’s 
milk is found to contain an excess of fat, 1 ounce or 2 of water or 
barley-water should be given before each nursing to diminish the amount 
of fat ingested. 
For the correction of constipation in the mother we may prescribe 
the following laxative: 
1$. Ext. belladonnas gr. iv 
Ext. nucis vomicae gr. viij 
Ext. cascarae sagradae 3ij 
M. Div. in capsnlas no. xxx. 
Sig.—One at bedtime. 
By applying this form of management to the mother and child we 
have repeatedly known the dermatitis to subside very promptly. In 646 
THE PRACTICE OF PEDIATRICS 
other cases we have seen it improve; and in still others persist without 
the slightest benefit. 
The problem which confronts us may be rendered difficult in differ- 
ent ways. If the child is her first offspring, the mother feels keenly the 
disfiguring condition and demands a prompt cure. If this is not forth- 
coming within a few weeks she seeks new medical advice. An excellent 
rule for the persistent breast-fed cases is for the mother to continue to 
nurse the thriving child and tolerate the dermatitis. Local treatment 
should be prescribed to relieve as much as possible the child’s distress. 
The mother may be told that at the time of weaning the unsightly skin 
condition will probably disappear. If weaning is insisted upon, the patient 
forthwith becomes a bottle-fed infant and is treated accordingly. The 
dermatitis often, but not invariably, clears up promptly when nursing is 
stopped. 
Management of the Bottle Fed.—Every year we see many aggravated 
cases of dermatitis in bottle-fed babies who have been treated elsewhere, 
often by dermatologists, without benefit. Failure usually has been due 
to the fact that while a great deal of attention has been paid to local 
measures, little if any has been directed to the feeding and other details 
of the constitutional care. 
The value of local applications in the form of lotions, ointments, and 
powders in the treatment of so-called eczema in childhood depends solely 
on their protective function and their sedative effect. Local treatment, 
furthermore, is attended with disappointment. The external condition 
may be temporarily relieved in a marked degree, but if the underlying 
systemic toxic condition exists, the disease returns with renewed vigor. 
The skin tests have helped us but little for the reason that most of the 
susceptible infants are so sensitized to fresh cow’s milk as to exhibit 9 der- 
matitis without reacting positively to the laboratory skin tests. How- 
ever, there should be a skin test for allergy to whatever milk foods are 
used, and to the cereal flour which is added. Such infants should also 
be tested for the usual cereal starches and simple vegetables which are 
to be added early to the diet to make up in a measure for the deficiencies 
occasioned by the special manipulation of the milk mixture. Such in- 
fants may be generally well and thriving, yet with a distressing dermatitis. 
When they discontinue cow’s milk or are given a milk that has been 
partially or entirely inactivated through heating or drying the dermatitis 
disappears. In most cases we are consequently unable to learn positively 
the nature of the irritant, and inasmuch as it is either due to a fat or car- 
bohydrate incapacity or is derived from protein sources we prescribe a 
food of low sugar and fat content, and so treat the protein as to completely 
or partially eliminate sensitizing possibilities. For this purpose we employ 
dried milk or evaporated milk. The latter is to be cooked for an hour 
or more, as a prolonged heating period appears to render the protein irri- 
tant less active. Some children will do better on a fat-free milk which is 
cooked in a double boiler at least two hours, water being added to re- 
place that lost by evaporation. 
Certain of the commerical dried milk foods appear to have been thus 
inactivated. For example, in chronic dermatitis one of the dry milks may 
be given with advantage as a milk substitute. DERMATITIS (ECZEMA) 
647 
For practical purposes in routine feeding we may assume that the baby 
with persistent active dermatitis has a low fat and low sugar capacity and 
exhibits a reaction to fresh cow’s milk protein. Our feeding plan for a hy- 
pothetic patient six months old and weighing 14 pounds then calls for a 
formula as follows: 
8 ounces of evaporated milk, 
27 ounces of water, 
2 ounces of barley flour, 
1 ounce of granulated sugar. 
Give 7 ounces every four hours. 
Instructions are given that the entire mixture is to be cooked together 
in a double boiler for one to two hours with water added at the com- 
pletion of the cooking to make up for that lost in evaporation. A rather 
thick mixture is produced which may necessitate a large opening in the 
nipple. If constipation results, milk of magnesia may be added to the 
entire mixture when not hot, in sufficient amount to produce an evacua- 
tion daily. There will probably be no gain in weight and little if any loss. 
The milk proportion should then be increased an ounce or two if the child 
is not satisfied. 
Illustrative Cases.—A babv otherwise normal had a most pronounced general der- 
matitis, the entire skin surface being involved. For seven months—until he was past 
one year of age—it was found impossible to give this patient more than 1 per cent, of fat. 
An increase to 1.5 per cent, of fat would be followed in half an hour by intense inflam- 
mation and redness of the skin. 
In another case almost as severe, at the ninth month, it was impossible to give 
plain milk in any form. The condition was so aggravated that the writer discontinued 
entirely the fresh cow’s milk and gave the child only evaporated milk, whereupon the 
skin cleared up promptly without any other treatment whatever. After about six. 
weeks a further trial of whole milk in small quantities was at once followed by a prompt 
return of the dermatitis. At different intervals the plain milk was given for one or 
two feedings daily, but this we were always obliged to discontinue, because of the signs 
of the old trouble which immediately reappeared after two or three of such feedings. 
In treating these obstinate cases, as the urine is usually very acid 
and a deposit of urates will be found on the napkin, it is advisable to give 
bicarbonate of soda, 1 grain to 1 ounce of food, or 10 grains of citrate of 
potash five or six times daily. Citrate of potash in fairly large doses, 
5 to 10 grains every two hours, appears to be a valuable aid during the 
acute stage, yet may be discontinued after the erythema and weeping 
has subsided. 
If a high fat feeding has been practised, cure may at times be effected 
simply by the use of full cow’s milk, with the gruel diluent. 
The successful management of non-traumatic dermatitis depends 
upon our ability to discover the disturbing food factors, to eliminate 
them if we dare, or if possible immunize the patient to such food or foods. 
Local Treatment.—In view of what has been said, little is to be ex- 
pected from local measures. As a rule, too strong lotions and ointments 
are employed and help to keep up the irritation, producing harm rather 
than benefit. Yaselin is often used as a base, and this in itself is irri- 
tating to many skins. In facial eczema of an active type in young infants, 
however, the parts should be protected from scratching and pillow- 
rubbing. This is best accomplished by the use of a mask (p. 649) under 648 
THE PRACTICE OF PEDIATRICS 
which are placed strips of old linen on which the following paste ointment 
is applied: 
1$. Pulv. zinci oxid, 
Pulv. amyli aa 3}j 
Ungt. aq. rosaj q. s. ad. 3ij 
This ointment should be freshly applied three times daily. The child’s 
skin is not to be bathed with water, but cleansed with sterilized sweet 
oil. When the weeping lias subsided, some preparation of tar may be 
employed. An ointment composed of unguentum picis, U. S. P., 1 part, 
with unguentum aquie rosse, from 4 to 6 parts (the strength used de- 
pending upon the irritability of the skin), may be applied with much 
benefit morning and evening. The ointment should be thickly spread 
over old linen and held firmly, yet without great pressure, over the parts. 
If the existing irritation is at all increased, the amount of tar used must 
be diminished. If the itching is not 
considerably relieved by the appli- 
cation, 5 grains of menthol or 5 
grains of salicylic acid may be added 
to each ounce of the ointment. 
For localized areas of persistent 
chronic dermatitis axray therapy is 
particularly indicated. The results 
following only one or two treat- 
ments are often gratifying. 
For the weeping or intensely in- 
flamed surface euresol (Meick) has 
afforded great benefit. In this stage 
this remedy is best used in a solu- 
tion of 1 to 3 per cent. The solu- 
tion is to be applied very gently 
and allowed to dry. It may be 
applied at intervals of three to 
four hours. When the weeping 
ceases and the skin becomes dry and desquamating an ointment of 
euresol 1 to 2 per cent., in unguentum aquae rosae, applied three times 
daily often contributes very substantia! relief. 
The application to obstinate dermatitis areas of undiluted refined 
coal-tar, over which talcum is freely dredged, often produces marked im- 
provement in the skin condition in addition to relieving the itching. 
This application is, however, unsightly and finds greatest favor in the 
treatment of lesions in unexposed portions of the body. 
Bathing.—No infants or young children suffering from generalized 
eczema should be bathed. Water is a decided irritant to the skin. 
For cleansing purposes during the acute stage sterilized olive oil or liquid 
petrolatum may be used. When the skin permits of bathing, the patient 
should have the advantage of the soda or bran bath (p. 844). Unneces- 
sary friction is to be avoided at all times. 
Clothing.—It is an excellent custom to have the clothing which comes 
in contact with the skin lined with thin linen. Wool worn next to the 
skin will frequently retard recovery. 
Fig. 113.—The Herty mask in position. DERMATITIS (ECZEMA) 
649 
The Mask.—The itching produced by facial dermatitis is often most 
intense. In order to effect a cure, scratching and rubbing the parts must 
be prevented. The Herty mask (Fig. 113) fulfils this purpose admirably. 
The ointment or lotion is placed on clean linen, which rests on the in- 
volved parts, and over this is placed the mask, a pattern of which is 
shown in Fig. 114. Opening A is sufficiently large to furnish space for the 
eyes, nose, and mouth. An elastic band, passing over the upper lip, 
draws the sides of the opening together, insuring protection to the cheeks, 
which are usually most severely affected. B and C pass over the ears 
to the back of the head, where they are united. The mask, which should 
be made cf muslin or thin old linen, is to be renewed daily. 
Fig. 114.—Pattern for the Herty mask. 
The mask has been of much assistance in protecting acutely inflamed 
areas. It is useless to attempt the treatment of severe facial dermatitis 
without a protection of this nature. 
Traumatic Dermatitis 
The successful management of eczema due to external causes consists 
in the removal of the source of the irritation. In some cases lining the 
underclothing with old linen or the use of linen mesh underwear will solve 
the entire problem. Local treatment, when necessary, is afforded by the 
soothing or stimulant applications previously described. 
Various remedies have been prescribed for the itching. The following 
lotion is often of service: 
TJ. Phenolis gr. v 
Calamin® prsep 3jj 
Pulv. zinic oxidi 3 jj 
Glycerini f3ij 
Liq. calsic f3ss 
Aqua: rosa: q. s. ad. fjiv 
M. Sig.—Apply locally. 650 
THE PRACTICE OF PEDIATRICS 
An ointment in common use is composed as follows: 
II. Mentholis gr. v 
Acidi salicylici gr. x 
Ung. aquae rosae 5fl 
M. Sig.—Apply locally. 
This form of dermatitis is an affection resulting from persistent ir- 
ritation due to moisture or friction. The primary condition of macera- 
tion soon develops into a chronic inflammation. This occurs with greatest 
frequency in fat children, but may develop in any child through neglect. 
In fact, intertrigo is often a mark of ignorance and neglect. 
Location.—The parts most affected are the lower abdomen, the inner 
aspects of the thighs, and the buttocks. In neglected cases the process 
may involve the entire skin surface from the umbilicus to the lower third 
of the thigh. Other parts usually found affected are the skin folds of 
the neck, the groin and axillae, and the flexor surfaces at the elbow-joint 
where contiguous portions of skin are subjected to chafing. 
Neglected, athreptic, and poorly nourished babies afford many of 
these cases. Among out-patients have been seen infants who presented 
a series of linear ulcers in the groin, productive of entire destruction of 
the skin. In a few such instances resulting infection of the glands in 
the groin has produced an inguinal adenitis. 
Prognosis.—All cases end in prompt recovery if proper care is exercised 
in carrying out the suggestions offered. 
Treatment.—The management consists in separating the opposed 
diseased surfaces by pledgets of cotton, gauze, or old linen, freely dusted 
with equal parts of starch and oxid of zinc. As soon as the material 
becomes moist a fresh dressing should be substituted. 
When there is much associated involvement of the skin over the 
genitals, lower abdomen, thighs, and buttocks care must be exercised 
that the parts be kept free from decomposing urine. 
Except in cases of the seborrheic type (p. 653) the management con- 
sists in neutralizing the urine by the use of bicarbonate of soda and in 
protecting the skin surface from irritating discharges by attention to the 
napkin, (p. 102). Dusting-powders are of very little use. 
A most satisfactory procedure which has been followed with success 
even in the most unpromising cases is as follows: The mother or nurse 
is instructed to keep close watch of the napkin and change it as soon 
as it is soiled. She is further instructed to prepare pieces of gauze or old 
linen of such shape and size as to cover the denuded surfaces. On these 
slips of linen she is directed to spread a thick layer of zinc ointment (U. 
S. P.) to which 10 per cent, white wax has been added. This dressing is 
kept applied to the parts and is to be changed several times daily. If 
the ointment is simply spread over the skin, it will soon be absorbed by 
the napkin and be of no service. 
Over the dressing the napkin is placed. The irritating urine is thus 
prevented by the ointment dressings from coming in contact with the 
skin. An additional quantity of absorbent cotton placed next to the 
genitals serves to absorb the urine as it is passed and thus prevents its 
general distribution over the parts. When the case is well advanced 
Intertrigo DERMATITIS (ECZEMA) 
651 
toward recovery the maintenance of scrupulous cleanliness and the 
application of a dusting-powder composed of equal parts of powdered 
starch and oxid of zinc will be sufficient. 
Dermatitis in Older Children 
We have been considering dermatitis in children under two years of 
age. From the eighteenth month to the second year certain develop- 
mental changes take place in the child which render him much less sus- 
ceptible to the toxic agents capable of producing the eczema. The ratio 
of cases seen after the second year to those under one year of age is about 
one to ten. 
Etiology.—Gouty antecedents have been the rule. In older children 
as well as in the young dermatitis is of metabolic and gastro-intestinal 
origin as well as the result of protein sensitization. We find that in the 
causation of the skin condition certain substances play an important 
part, particularly milk-fats and sugars. Certain fruit acids and meat 
extractives have also proved operative in an etiologic way. Thus grape- 
fruit, orange juice, strawberries, tomatoes and beef juice have all been 
proved the immediate cause in a sufficient number of cases to establish 
the mode of origin beyond the slightest doubt. 
Protein sensitization as a factor must be considered, although less 
prominently a cause than in the cases of young infants. An immunity 
to the offending protein is established with age. The cases of dermatitis 
that persist through infancy into childhood are usually of the so-called 
"lithemic class,” with a defective fat and carbohydrate capacity or a ten- 
dency to seborrheic dermatitis. 
Symptoms.—The cases of acute facial dermatitis are comparatively 
rare except in younger children. The tendency to development of pustules 
and furuncles is also much less in children over two years of age. Weeping 
and desquamating surfaces, however, are common, and squamous patches 
and fairly extensive infiltrated areas are frequently found on different por- 
tions of the body. Perhaps the most frequent manifestation at this age 
is what is referred to by various writers as "neurotic” or "reflex” "ec- 
zema.” The predominating lesions in this form are papules which may 
exist in great number, especially over the extensor surfaces of the arms 
and legs. Often the individual papule is tipped by a black speck which 
represents dried blood and dirt resulting from scratching. In cases 
that have existed for some months there is a general thickening and 
hardening (infiltration) of the affected skin, with surrounding spots 
of inflammation, which are due to secondary infection, usually with 
staphylococus. Dermatologists are now treating such cases with vaccines 
and local applications containing sulphur or salicylic acid. 
By reason of the wide variety of its forms the inflammation may involve 
any portion of the skin. The skin about the umbilicus is one of the sites 
occasionally selected by the disease in older children. In some the only 
manifestation may be a superficial, slightly desquamating dermatitis at 
the angle of the mouth. 
In the cases of seborrheic dermatitis the scalp will often show much 
dandruff and the entire skin surface in extreme instances will be dry and 
“branny,” or dry and glistening. 652 
THE PRACTICE OF PEDIATRICS 
Illustrative Cases.—A most troublesome case was that of a girl four years of age 
who presented a round, red, desquamating area on the right cheek, l inch in diameter. 
In the case of a boy four years old an acute weeping dermatitis had covered both 
buttocks. 
A girl of five had suffered at intervals for eighteen months with an eczema between 
the fingers of the right hand. 
A most interesting girl patient of eight years, after partaking of sugar in any form 
and in the smallest amount, beef juice, or any acid fruit juice, would develop an acute 
dermatitis of the face requiring two weeks for recovery. The mother, who is very 
intelligent, had discontinued milk before the case came under the writer’s observation 
because of attacks of cyclic vomiting from which the child suffered, and which the 
mother stated were worse when milk was taken. Milk also produced hives and “poi- 
soned” the child, so that the mother begged him not to give the patient milk. We 
found that the child could take fat-free milk. In this case there was a marked history 
of gout on both sides of the family. The maternal grandmother required crutches, the 
mother had cyclic vomiting as a child and sick headaches as an adult, and “had been 
treated for uric acid all her life,” and the father stated that he was scarcely ever free 
from pain in his joints or muscles. 
Another girl four years old, of decidedly gouty ancestry, suffered intensely during 
infancy from dermatitis, which was with difficulty kept under control. When two 
years old she developed recurrent bronchitis with asthma of a most severe type, and she 
has had several attacks of spasmodic croup. Milk-fat, sugar, fruit juice, or beef 
juice in the case of this child produced an intense inflammatory skin reaction. 
These patients all recovered under dietetic measures alone. 
Prognosis.—The prognosis is good, and the results are usually quite 
prompt following the right line of management. Relapses are not un- 
common, however, because the treatment is so largely dietetic, and the 
best of people, when well, forget dietetic regulations more readily than 
anything else. 
Treatment.—The successful management of dermatitis not due to 
local irritants depends upon the ability to discover the disturbing food 
factors and to eliminate these, or to render them inoperative through 
the application of heat. Little actual success has followed attempts to 
immunize against such proteins. A full physical examination should 
always be made and the condition of the blood and urine ascertained. 
The child is then given a regime of living suited to his condition. A 
diet schedule is furnished, the hours for rest and sleep and play are indi- 
cated, and if there is defective appetite or anemia, suitable added treat- 
ment is prescribed. One full bowel movement a day is required. It 
has been a matter of no little surprise for observers to find the eczema 
gradually disappearing as a result of improvement in the child’s general 
condition. Through the correction of digestive disorders and the estab- 
lishment of right living we have repeatedly seen cases of persistent 
dermatitis clear up entirely without other treatment. 
In a general way the suggestions laid down for the management of 
subnormal children (p. 140) may apply. In the diet we allow little or no 
sugar. Milk, if used, is always skimmed and boiled for an hour or more. 
Butter, strawberries, tomatoes, and acid fruits are not to be allowed. 
The use of green vegetables is to be encouraged for the reason that they 
possess distinct therapeutic value. An absolute salt-free diet is not in- 
sisted upon, but only sufficient salt is used to make the food barely pal- 
atable. 
Contrary to the established belief, we find arsenic of very little direct 
value, although in improving the general physical state of the patient 
it may be of service. Rhubarb, soda, and cascara appear to be of much 
greater value. DERMATITIS (ECZEMA) 
653 
Local Treatment.—For the acute cases, in which there are much in- 
flammation and itching, a combination of zinc oxid ointment, U. S. P., 
and menthol may be employed: 
lb Mentholis gr. x 
Ungt. zinci oxidi 5j 
After the acute dermatitis has somewhat subsided the following oint- 
ment may be used with advantage: 
Acidi salicylici gr. x 
Ungt. picis, U. S. P gss 
Ungt. aquae rosae q. s. ad. 5ij 
This ointment should be used twice daily, the strength of the tar 
and the salicylic acid being increased if necessary as the case progresses. 
It is always well to begin with an application of a reduced strength and 
to increase the strength later as the case may require. 
The ointment should be bound to the parts so as to completely cover 
the surfaces, thereby insuring the full benefit of the treatment and at 
the same time protecting the skin from further irritation by scratching. 
The case may respond very promptly, or it may be most obstinate and 
require several weeks of both dietetic and local treatment. 
A most important feature of the management consists in protecting 
the involved parts, wherever located, from irritation by scratching and 
rubbing. This end is best accomplished by bandaging on the ointment 
applications. Such procedure not only prevents the scratching, but 
insures contact of the ointment with the affected areas. 
Bathing.—When the skin is acutely involved water should not be 
allowed to come in contact with it. Sterilized olive oil should be used 
for cleansing purposes. On uninvolved portions of the body, and in 
chronic, inactive cases, the soda or bran bath (p. 844) may be used. 
Dermatitis Due to Seborrhea 
Seborrhea is usually classified as an eczema. It is due to excessive 
secretion and activity of the sebaceous glands, and is regarded by some 
observers simply as a derangement of function. By others it is believed 
to be due to a specific infection. 
This form of dermatitis may involve every part of the skin except 
the palms of the hands and soles of the feet. The flexures of the arms 
and legs and the contact skin surfaces in the groin and folds of the neck 
in fat children are particularly apt to be involved. How often one sees 
the picture of seborrhea capitis, scaling wet cheeks, and moist inflamed 
skin surfaces together with an intertrigo of the buttocks! Intertrigo is 
most common in those infants who have evident seborrhea elsewhere. 
The appearance of the involved area is fairly characteristic. It may 
be weeping, or dry and glistening, presenting the characteristics of a so- 
called erythema; or it may exhibit tendency to dryness and desquamation 
of very fine scales. Older children show what appears to be a diffuse 
evenly distributed dry exudate. In such cases there is almost invariably 
an associated extensive seborrhea of the scalp. This dry form, so-called 
seborrhea sicca, will usually be found after.the first year. The picture of 654 
THE PRACTICE OF PEDIATRICS 
the local lesion may be changed by local treatment, irritation through 
scratching or by the formation of cracks and fissures in the skin. Long- 
standing cases are very apt to be associated with gross lesions due to 
trauma. When we fully understand seborrheic dermatitis the problem of 
etiology and treatment of a considerable proportion of the cases of der- 
matitis in infants will have been solved. There is no doubt that this type 
of dermatitis is associated with that occasioned by faulty metabolism 
and protein sensitivity. 
Seborrhea Capitis (Milk Crust).—The form in which the condition 
is most frequently seen in children develops on the head, producing 
thick, dirty, yellow crusts, commonly known as “milk crust.” The 
exudation consists of sebum, dirt, and desquamated epithelium. In 
mild cases the crusts may be isolated or combined in one large patch 
with several surrounding smaller masses. In other cases the exudation 
is thick and uniform, and covers the vertex of the head like a mask. 
Treatment.—The first step is to remove the crusts. The hair should 
be cut very short. If only a few areas are involved, anointing the parts 
with vaselin several times daily will soften the exudate, so that it may 
be removed. If the crust is thick and extensive, it should be softened 
with sterilized olive oil, applied on gauze or old linen which is well saturated 
with the oil, and held in place by a cap of cheese-cloth. If the dressing 
is applied at bedtime the crusts may often be removed the following 
morning. In cases in which the exudation has existed for a long time 
and is very hard, frequent fresh applications of the oil for two or three 
days may be required to soften the crusts sufficiently for their removal 
without injury to the skin. When thoroughly softened, they should 
be washed off with Castile soap and warm water. The underlying skin 
will then usually be found to be reddish and slightly inflamed. To this 
should be applied an ointment of resorcin and vaselin, 5 to 10 grains to 
the ounce. The ointment should be spread on linen or lint and applied 
to the parts with the aid of the gauze cap. In all except the most ag- 
gravated cases this treatment, used only at night, will be sufficient. In 
the severe cases a few additional applications of the ointment during 
the day will usually be effective. 
A few days’ treatment will often relieve the worst cases of seborrhcea 
capitis after the scalp has been freed from crusts. We have yet to see 
a case which will not respond when this treatment is properly carried 
out. It is to be remembered, however, that there is a tendency for the 
exudation to return. Mothers and nurses should be instructed to keep 
the ointment in the nursery for use upon the first appearance of the 
exudation. In children seborrheic dermatitis, according to our obser- 
vation, is comparatively unusual in other portions of the body, although 
by extension of the seborrhea of the scalp, the forehead and face may 
be involved. In these situations, also, resorcin is useful, but must be 
used in much weaker strength, ranging from 0.5 to 1 per cent. If the 
trunk and limbs are involved the inflammation usually is very acute. 
In such cases it is best to use a very simple application, such as sterile 
olive oil or cold cream. 
Seborrhea Intertrigo.—At rare intervals cases of intertrigo are en- 
countered upon which no impression whatever is made by the methods PSORIASIS 
655 
of treatment suggested on p. 650. Several years ago Dr. George T. El- 
liott, of New York, called attention to the fact that these cases were of 
seborrheic origin, and that a change from the ordinary treatment to that 
ordinarily used for seborrheic dermatitis would prove his contention. 
In the cases in question, and in those that we have since seen, the point 
made by him has been confirmed by the treatment. Cases of seborrhoea 
intertrigo are generally associated with seborrhea elsewhere, usually 
upon the head, and show erythema, a tendency to dryness of the skin, 
and desquamation. 
The treatment in this form of intertrigo consists in enforcing cleanli- 
ness and a proper diet, as mentioned under Intertrigo, p. 650. In ad- 
dition to the usual ingredients, from 0.5 to 1 per cent, of resorcin should 
be added to the zinc-oxid ointment which is used as a dressing. Euresol 
is here used with benefit in strength of 1 to 2 per cent, in unguentum 
aquae rosae. Involvement of the buttocks by this form of dermatitis 
results in most pronounced and obstinate cases. Here also applications, 
such as powders and ointments, should be of a soothing and protective 
nature. Instead of heavy, thick napkins cheese-cloth which has been 
boiled should be used, and after one using should be destroyed. Ung. 
zinci oxidi, U. S. P., to which 10 per cent, white wax has been added, may 
be spread on strips of old linen and placed over the parts, after cleansing 
with olive oil every time the napkin is changed. Of course soiled nap- 
kins should be changed at once. (See the Ammoniacal Diaper, p. 102.) 
Removal of the napkins and exposing the parts to the air for a consider- 
able length of time is of much service in severe cases. Obviously little 
is to be expected from local application of drugs. 
Seborrheic dermatitis, although not as difficult of management as the 
other forms of dermatitis in children, nevertheless shows a great ten- 
dency to recur, particularly in subjects of low vitality. 
PSORIASIS 
Psoriasis is an unusual disease in children, that is, unusual to pedi- 
atrists and practitioners. Bulkley has seen the disease in a baby four 
months old. Dermatologists are agreed that from 10 to 15 per cent, 
of the cases that come under observation are under ten years of age. 
The disease is essentially chronic, occurring every winter, and often dis- 
appearing with the advent of warm weather. 
The lesions of psoriasis possess features which render the diagnosis 
of little difficulty. The eruption first appears as brown flat papules with 
a tendency to desquamation. When the disease comes under observation 
there is usually a series of areas of the papules which have coalesced and 
formed plaques which are covered with white or grayish scales. When 
the scales are forcibly removed small bleeding points may be seen. The 
lesions are very variable in number, size, and location. In several patients 
they were situated on the forehead at the margin of the hair. Here 
thick infiltrated, desquamating crusts may form. 
The site of the eruption is usually on the extensor surfaces, often 
about the knees and elbows. There may be but two or three small areas, 
or large portions of the skin surface may be involved. The nails par- 656 
THE PRACTICE OF PEDIATRICS 
ticularly, and other portions of the hands and the plantar aspect of the 
skin of the feet are rarely affected. Staining of the skin at the site of the 
eruption remains more or less persistent. Symptoms not directly re- 
ferable to the lesion are of little moment. There is usually some itching, 
but rarely is it severe. 
Etiology.—The cause of psoriasis is not known. It is generally be- 
lieved to be due to some constitutional error—a break in metabolism. 
Treatment has been very unsatisfactory. The case may be relieved 
by an exclusive vegetable diet, which means an absence of meat, fish, 
poultry, and eggs. Bulkley has affirmed that cases may be cured and 
remain well when managed in this way. 
Arsenic in the form of Fowler’s solution is generally administered in 
the treatment of this disease. Autoserum therapy and foreign protein 
injections have both been advocated. 
Of the various local applications those containing chrysarobin, salicylic 
acid, tar, and ammoniated mercury have been of greatest value. To be 
effective the chrysarobin ointment must be rubbed into the patches 
sufficiently to excite some inflammatory reaction. This treatment is to 
be suspended at intervals, during which a milder application, such as 
rose-water ointment, may be substituted. 
BED-SORES (DECUBITUS) 
During; any illness productive of greatly disturbed nutrition or emaci- 
ation, such as cerebrospinal meningitis, typhoid fever, and empyema, 
constant pressure on the prominent bony parts interferes sufficiently 
with the circulation to cause 
destruction of the integument. 
The most frequent sites for 
decubitus in children are the 
sacrum, the heels, and the 
back of the head. 
The condition is best pre- 
vented by special care in main- 
taining cleanliness, by keeping 
the bed-linen smooth, fre- 
quently changing the position 
of the patient, and by the 
free application of any simple 
powder, such as equal parts of 
powdered zinc oxid and starch. 
Treatment.—The parts as 
they become sensitive and 
show redness should be bathed 
several times a day with al- 
cohol. If this does not relieve 
the condition, the areas should be covered with diachylon plaster so as 
to insure complete protection. The air-cushion or the water-bed may 
be necessary in any prolonged illness. 
When the back of the head is involved the scalp should be shaved 
Fig. 115.—Head-rest to prevent bed-sores. NEVUS (BIRTH-MARK) 
657 
and the head allowed to lie in a home-made head-rest (Fig. 115) which is 
constructed as follows: 
A piece of fairly stiff wrapping paper 4 inches wide is twisted into a rope, of which 
a circle 4 to 5 inches in diameter is made by bringing the ends together. The paper 
is then wrapped thickly with absorbent cotton, which is, in turn, wrapped with a 2-incli 
roller bandage. 
NEVUS (BIRTH-MARK) 
A nevus is a congenital new formation in the skin. The growth may 
be pigmentary or vascular. 
Etiology.—No one of the various theories which have been advanced 
to account for the existence of nevi is well established. The frequent 
occurrence of vascular nevi in such regions as the back of the head and 
nape of the neck has given rise to the belief that these marks may be 
produced by intra-uterine pressure. Virchow emphasized the predilection 
of the growths for the embryonic fissures of the skin, where slight irrita- 
tion would be capable of exciting anomalous vascular development. 
Females are more frequently affected than males. 
Characteristics.—The pigmentary moles comprise ncevus pilus, a 
smooth, pigmented spot; ncevus pilosus, the hairy mole; ncevus verru- 
cosus, a raised warty growth; ncevus lipomatodes, which contains hy- 
pertrophied fat tissue; and ncevus linearis, which is usually unilateral, 
and frequently follows the distribution of cutaneous nerves. The moles 
may be brown or black, single or multiple, and are most common on the 
face, neck, and back. 
Vascular nevi range in character from small capillary angiomata to 
large, raised, pulsating tumors. One of the most disfiguring marks is 
the ncevus flammeus, or “port-wine stain.” This is a bright red or purple 
spot, of irregular outline and more or less uneven surface, commonly 
found on the face, and covering an area which may be as large as the 
palm. The true vascular nevi all become pale under pressure, and, con- 
versely, show the deepest color when the local blood-pressure is increased 
by such acts as crying or coughing. 
Prognosis.—-Pigmentary moles rarely disappear spontaneously. The 
simpler forms of angioma may, however, occasionally undergo atrophy, 
or, on the contrary, increase in size over a limited period. 
Treatment.—Satisfactory results in treatment call for the exercise 
of considerable patience and skill. Many of the smaller capillary nevi 
may be made to disappear under the pressure produced by repeated 
applications of collodion. In more pronounced cases “stippling” with ni- 
tric acid, electrolysis by multiple punctures, and exposure to the z-ray 
or radium are methods of value. Jackson has emphasized particularly 
the value of freezing by liquid air or carbon dioxid snow. In suitable cases 
excision may be performed. 
Special mention should be made of the tragic results which have 
occasionally followed mechanical interference with certain forms of mole. 
Although it is possible that metastasis with general sarcomatosis is a phe- 
nomenon confined to adults, no one who has witnessed such an occurrence 
will advocate conservative surgery in the removal of pigmental growths. 
Unless excision can be thorough and complete, it should not be attempted. XVIII. DISEASES OF THE EAR 
EARACHE 
In every case of earache in an infant or young child the ear-drum 
should be examined. It may show intense congestion and bulging, re- 
quiring immediate incision, or only slight congestion about the periphery 
qf the drum and at the tip of the malleus. When the latter condition 
exists there are various means of relieving the pain, the most effectual 
probably being instillation into the ear of equal parts of a warm 4 per 
cent, solution of cocain and camphor-water, 5 drops of which are dropped 
into the ear, and repeated every half-hour if necessary, after which dry 
heat may be applied by the use of a hot-water bottle or a salt bag. Severe 
attacks of earache are frequently relieved by means of a hot-water douche 
with 1 pint of water at 110° F. When the pain is not promptly relieved, 
the ear should be carefully watched, particularly if there is recurrent shoot- 
ing pain, a throbbing sensation, or a feeling of fulness in the ear. 
In young children a rise in temperature associated with earache is 
often indicative of an acute infectious process in the middle ear, and, 
in addition to the treatment suggested, the ear should be frequently 
examined, in order, if necessary, to insure early incision of the drum 
membrane. 
DEAFNESS 
Hearing is probably established in the newborn during the first two 
or three days of life. During the early months of life the hearing is very 
acute. Acquired deafness is not at all unusual, however, even in com- 
paratively young children. Among its most frequent causes is an ex- 
tension of an inflammation from the throat to the tubal mucous mem- 
brane. In diphtheria, in the exanthemata, in grip, in tonsillitis, and in 
many other ailments of early life there is an associated inflammation 
of the nasopharyngeal structures. Unless infection of the middle ear 
occurs, deafness is usually of a very temporary nature. Persistent deaf- 
ness may be the result of enlarged tonsils, adenoids, or organized changes 
in the canal or in the middle ear. Among the most frequent causes of 
persistent deafness in children are adenoids, scarlet fever, and cerebro- 
spinal meningitis. Congenital syphilis is an infrequent cause of deafness. 
Response to treatment in this type is very satisfactory. Deafness at 
rare intervals follows an attack of mumps and is due to an involvement 
of the labyrinth. This condition calls for expert otologic treatment. 
Deaf children whose condition is not recognized are often accused 
of inattention and punished when they are slow in responding when 
spoken to. They make slow progress in school and are considered stupid. 
Many such children suffer from defective hearing of a pronounced type 
due often to enlarged tonsils and adenoids. 
Every child who presents indications of defective hearing should at 
once be examined by a competent aurist. 
658 ACUTE OTITIS 
659 
ACUTE OTITIS 
Among the ailments of children few diseases are more frequently 
encountered than catarrhal or purulent otitis media. It occurs with 
great frequency in the hospital athreptic and in the institution infant. 
No age is exempt. Otitis is not infrequent in infants a few weeks of age. 
In well-nourished, vigorous older children it is, with but few exceptions, 
a secondary infection. In poorly nourished athreptic infants it may 
occur without other evidence of illness. Repeatedly otitis of a low grade 
has been discovered in athreptics who lacked the usual signs of fever, 
discharge, and bulging of the drum. In fact, in a considerable number 
of cases the otitis was first discovered at autopsy. 
Types.—It is customary to divide the cases into two primary types: 
simple catarrhal and purulent. Such a grouping is hardly necessary, as 
most cases of the purulent type if seen sufficiently early present what 
are described as catarrhal symptoms. If the infection is not severe it 
subsides or responds to treatment. On the other hand, cases are seen 
in which the ears have been frequently examined and in which the in- 
flammation has been unquestionably purulent from the onset. 
Etiology.—Otitis is caused by the invasion of bacteria into the middle 
ear. 
In the atrophic young infant the low systemic resistance and the 
patulous eustachian tube account for the ease with which the infec- 
tion reaches the middle ear and becomes operative. In older children 
adenoids and enlarged tonsils comprise the chief predisposing etiologie 
factors. Influenza, scarlet fever, measles, and diphtheria are the dis- 
eases most frequently accountable for otitis. It may follow any infec- 
tion of the nose or throat, often complicating rhinitis and tonsillitis. 
If a considerable growth of adenoids exists in the vault of a throat affected 
by any one of the above diseases, the chances are more than even that 
suppurative otitis will develop. 
Among a series of 72 private cases which were reported several years 
ago, 3 were apparently primary, in that the condition did not follow and 
was not connected with any previous abnormal state. One case fol- 
lowed German measles; 4, scarlet fever; 7, measles; and 58, influenza 
or catarrhal colds. 
Bacteriology.—In a series of 47 cases in which bacteriologic exam- 
ations were made the results were as follows: 
Streptococci in pure culture 13 
Staphylococci 11 
Streptococci, staphylococci, and pneumococci 12 
Streptococci, staphylococci, and pneumococci 6 
Staphylococci, pneumococci, and colon bacilli 1 
Streptococci and staphylococci 2 
Pneumococci 2 
Streptococcus hemolyticus and Streptococcus mucosus capsulatus 
supply the most dangerous forms of infection, and in these types not 
only are all the symptoms more severe, but there is much greater danger 
of mastoid involvement and secondary sinus thrombosis. 
Symptoms.—Among all the diseases of children none is probably 
so frequently overlooked as otitis. This is due to the fact that the prac- 660 
> THE PRACTICE OF PEDIATRICS 1 
titioner invariably looks for pain as a symptom of the disease, and this 
has been the teaching of the books. In a search of many works on otology 
it was ascertained that the symptoms as laid down comprise almost ex- 
clusively the evidences of pain—earache—the pain being complained 
of by older children, or manifested in the very young by vigorous cry- 
ing, by tossing the head from side to side, by head-rolling, ear-tugging, 
crying out in sleep, disinclination to rest the head on the affected side, 
or pain upon manipulation of the ear. In short, we have been taught 
that there is invariably some manifestation of pain referable to the ear 
or the adjacent structures in all cases of acute otitis in infants and young 
children. Such symptoms exist in a moderate number of cases. 
The most interesting feature, however, in this series of 72 cases was 
the absence of pain or localized tenderness on manipulation in 50 of 
the cases, or 69 per cent. Among those included in the pain group, 22 
in number, there were some cases which perhaps should not be so in- 
cluded, inasmuch as there were no signs of pain, as we generally expect 
to find it. The group included those who were very restless, who slept 
poorly, and who showed evidence of the relief which followed incision 
of the drum membrane, so that it was fair to assume that the source 
of the previous discomfort was the ear. Had we depended upon the 
signs of pain or local tenderness, in 50 of the cases a diagnosis of otitis 
at the time would have been impossible. Six were seen in consultation 
because of the unexplained continued fever. Nine had been treated 
by other physicians who had failed to discover the cause of the con- 
tinued fever. In none of these had ear involvement been suspected, 
because of the absence of pain and localized signs. 
Fever.—Among the 72 private cases already mentioned in well-nour- 
ished children one symptom was present in all—fever. There was noth- 
ing particularly characteristic in the temperature range. In some there 
were the morning drop and the evening rise. In others the temperature 
variations were inconstant. With but few exceptions the otitis developed 
during convalescence from an acute process localized elsewhere, the 
ear involvement being suspected because of a persistent elevation of the 
temperature for which no other cause could be discovered. 
The fact that 58 of the cases, or 81.5 per cent., occurred with or fol- 
lowed non-specific inflammatory conditions of the upper respiratory 
tract, such as tonsillitis, grip, and catarrhal colds, emphasizes the neces- 
sity for frequent aural examinations during or following such disorders, 
particularly when there is an elevation of the temperature, which, in 
the absence of definite clinical signs, we are apt possibly to attribute to 
chronic grip, malaria, typhoid fever, or dentition. 
Course.—In a small number of cases spontaneous perforation of the 
drum occurs. We have known the membrane to rupture in one hour 
from the onset of the ear symptoms, and have known it to remain intact 
with pus in the middle ear, to the best of our judgment, for ten weeks. 
In the average case, after a free opening of the drum, the discharge per- 
sists from ten to twenty days. In cases due to streptococcus infection 
the discharge is usually more prolonged. 
Prognosis.—The prognosis is good if the drum is freely incised and 
kept open. A certain small percentage of cases which is difficult to de- ACUTE OTITIS 
661 
termine develop mastoid disease, and a still smaller number become 
complicated by sinus thrombosis and jugular bulb involvement. Much 
depends upon the nature of the infection. If the streptococcus is found 
in the discharge mastoiditis as a complication is not improbable. 
The drum heals most readily. In numerous cases treated by free 
incision the drum has been found absolutely normal in appearance within 
three or four weeks after the discharge ceased. 
Diagnosis.—Fever without apparent cause should always call for an 
examination of the ears. Earache is a symptom demanding like attention. 
Otoscopic examination settles the diagnosis and is the means of con- 
firming or refuting symptoms of unsolved fever or indefinite pain. 
A culture should be made of the discharge from every ear opened. 
Complications.—The most frequently encountered complication is 
mastoiditis caused by extension of the infective process to the mastoid 
cells. The mastoid antrum is separated from the middle ear by a very 
delicate membrane. In many cases of acute otitis, probably in all cases 
showing prolonged discharge, the antrum is involved. If immediately 
after mopping out the canal there is a free discharge into the canal, this 
affords proof that the antrum is involved, as the small middle ear could 
not form pus with such rapidity. 
Prolapse of the posterior superior wall is another sign of mastoid 
involvement. 
The continuation of fever in spite of free aural discharge is indicative 
of mastoid abscess. 
If the mastoiditis exists, there may be swelling behind the ear or 
tenderness on firm pressure over the mastoid, particularly at the tip. 
Both of these symptoms—pain upon pressure and swelling—may fail 
us, and their absence is not to be considered in any way conclusive evi- 
dence against the presence of mastoid disease. There is no doubt that 
in many cases of prolonged aural discharge the antrum is diseased and 
supplies a large part of the pus, while the deeper cells in the bone 
escape infection. 
There are cases in which the mastoid is primarily involved; others 
in which there is a primary infection which takes in both the mastoid 
and the middle ear at the same time. To have mastoid disease does not 
mean that the middle ear must be primarily involved. 
Treatment.—A small percentage of the catarrhal cases in which 
there is congestion of the drum without bulging, will subside under irri- 
gation at two-hour intervals with normal salt solution at 110° F. One 
pint should be used. A fountain-syringe placed at an elevation of 3 feet 
above the child’s head affords the best means of irrigation. 
Regardless of the age or condition, a bulging drum in the presence of 
fever calls for incision. No harm is done to the ear by the free incision 
properly made, while much harm as the result of chronic otitis media 
and mastoid disease may occur when the incision is delayed. 
Operative.—Every practitioner who has children as his patients should 
be sufficiently familiar with the landmarks of the normal drum mem- 
brane at the various ages of early life to differentiate the normal from 
the abnormal. In the routine examination of the child, in all conditions 
associated with angina or fever, the ear should be included. In quite 662 
THE PRACTICE OF PEDIATRICS 
young babies an otoscopic examination may show a dull, whitish appear- 
ing drum membrane which, on a superficial examination of the case, 
might be ignored. In all cases, particularly at this age, when the drum 
landmarks are indistinct, a cotton-pointed probe should be brushed 
over the surface, thus removing the epithelial scales which may have 
lodged there, with the result that perhaps a congested, bulging mem- 
brane may be revealed. 
Conditions or appearances of the drum membrane which require 
incision are often difficult of recognition by those not skilled in otoscopy. 
When the drum is bulging, deeply congested in appearance, with land- 
marks indistinct, an incision is necessary, and should be made in the 
posterior quadrant, beginning low down and extending upward through 
Shrapnell’s membrane. When also there is congestion of the drum mem- 
brane over the tubal entrance, and when the congestion extends toward 
the periphery, producing indistinct landmarks without bulging, incision 
is indicated. 
Postoperative.—The after-treatment following incision ordinarily 
consists in syringing the ear at three-hour intervals with 8 ounces of a 
saturated solution of boric acid for three or four days, after which the 
syringing may usually be practised at intervals of from four to five hours 
until the drum closes. In very young infants if the boric acid causes a 
deposit in the canal, it is well to change to a sterile normal salt solution, 
using the same quantity of fluid. 
In those cases in which only serum is present at the time of operation, 
closure within ten days may be expected; if, however, pus is present, 
from two to three weeks will be required. A sudden stopping of the dis- 
charge usually means that the opening in the drum is closed, either through 
plugging with thick pus or because of too early healing. In either event 
a re-establishment of the discharge by removing the obstruction or by 
reincision is essential. The chief factors in prolonging the discharge are 
adenoids and a lowered state of physical resistance. 
After the syringing the ear should be carefully dried with absorbent 
cotton. 
For purposes of syringing a l-ounce hard-rubber ear syringe with soft-rubber tip 
answers best. If this is not obtainable, a douche-bag, at an elevation of not more than 
3 feet above the patient’s head, may be used. The douche-bag sometimes is desirable 
for those who are unskilled, or a soft-rubber bulb syringe of a capacity of 1 or 2 ounces 
may be used. The small double-current ear-irrigator may be used with advantage for 
the reason that it largely prevents wetting the patient. During treatment by any of 
these methods the child rests on his back with his hands pinned to his side by means 
of a large bath towel, while a pus basin is held under the ear to catch the flow. If 
the nurse can have an assistant, the upright position may be used. 
Delayed, Resolution.—In a certain number of cases resolution is de- 
layed and the discharge continues. In such cases a decided aid is fur- 
nished by the use of stimulating and disinfectant instillations. After 
the last syringing for the day the canal should be dried by the use of 
a wick of absorbent cotton. Five drops of the following solution are 
then to be instilled into the ear: 
P$. Pulv. acidi borici gr. xxv 
Spts. vini rect., 
Aquae aa 5ss 
A 15 per cent, solution of argyrol may be used in a similar manner. 663 
MASTOIDITIS 
CHRONIC SUPPURATIVE OTITIS 
Not infrequently cases come under our care in which there is a purulent 
discharge from the ears, often most offensive, with a history that the 
discharge has followed measles, scarlet fever, or grip, and has continued 
for weeks or months. Examination may show a perforation of the upper 
portion of the drum, through which there is a free discharge, which, 
however, on account of the site of the perforation, is not sufficient to drain 
completely the middle-ear cavity. In other instances the examination 
may disclose an opening too small for effective drainage. 
Treatment.—In either case incision should be made and free drain- 
age established. The ear should then be syringed at least three times 
a day with a 1 : 10,000 bichlorid solution. The instillation of a solution 
of alcohol and boric acid (see p. 662) may also be used with decided ad- 
vantage. In cases of chronic suppurative otitis it is well to examine for 
adenoids, as these growths in the nasopharyngeal vault help to keep 
up ear discharge indefinitely. The presence of dead bone and granu- 
lations is also to be considered in the chronic suppurative cases. When 
the presence of dead bone or granulations is established, the condition 
calls for radical procedure by a skilled otologist in order to avoid mas- 
toid and intracranial complications. In fact, cases of this nature should 
be treated only by an otologist . 
Because of the ease with which pus may enter the mastoid antrum 
the complication of mastoiditis is of frequent occurrence in acute aural 
diseases. Streptococcal infection of the middle ear predisposes to mas- 
toid involvement. Delay in incising the drum and establishing free 
drainage in acute otitis is also a factor in not a few cases. Finally, as 
an underlying cause of mastoiditis should be mentioned the child’s lack 
of general resistance to bacterial infections. 
It is not to be forgotten that mastoid disease may be primary or occur 
synchronously with the development of otitis media. 
Symptoms.—Mastoid disease may be looked for in all cases in which 
an elevation of the temperature continues in spite of free discharge through 
a wTell-opened drum. Tenderness on pressure is a valuable sign, but its 
absence does not preclude mastoiditis. 
Prolapse of the posterior superior wall and the rapid appearance of 
pus in the canal after thorough cleaning are to be looked upon as most 
important signs. 
When there is tumefaction and swelling of the soft parts behind the 
ear (perimastoiditis), the mastoid cells and antrum will almost invariably 
be found involved. In about 10 per cent, of the cases both mastoids 
will be involved. 
Complications.—The complications are sinus thrombosis, jugular 
involvement, facial paralysis, septic meningitis, and pyemia. We have 
seen all these most serious complications in not a few cases, and have 
cause to regard the presence of pus in the mastoid cells or even in the 
middle ear in children as a matter of serious import. 
Treatment.—Operation, and that early, is the only treatment for the 
MASTOIDITIS 664 
THE PRACTICE OF PEDIATRICS 
condition. Children have unquestionably recovered from mastoid disease 
without operation, but expectant procedures are fraught with great dan- 
ger and should not be countenanced if the child is in condition to admit 
of operation. 
SINUS THROMBOSIS 
In a small percentage of cases of mastoiditis there is extension of the 
infection to the lateral sinus. 
Symptoms.—Sinus involvement will usually be indicated by rapid 
and wide variations in the temperature. The rise is very sudden, and 
may reach 106° F. The fall may be correspondingly rapid, and a pecu- 
liarity of the temperature phenomena in sinus disease is the extent of the 
fall. 
The writer lias seen a rise of 10 degrees in two hours, and has repeatedly known the 
fever to drop to 96° F. 
A confusing and misleading circumstance in these cases may be the 
absence of signs of great prostration. When the temperature is high 
the child appears very ill; when the fever subsides the patient brightens, 
perhaps plays, and is interested in his surroundings. It is difficult to 
reconcile the patient’s demeanor with so grave a disease. The mislead- 
ing behavior, in our observation, has been the occasion of delaying oper- 
ative measures until such means proved of no avail. 
Leukocytosis and a high polynuclear count are usually present. In 
one case, however, the polynucleosis was not above 60 per cent. 
Bacteremia is usually present. Its absence, however, does not pre- 
clude sinus disease. Metastases of bacterial emboli, with the develop- 
ment of septic arthritis, endocarditis, pneumonia, and meningitis, are to 
be expected when the infection is overwhelming. 
Treatment.—The treatment is the radical operation, with resection, 
if necessary, of the jugular vein. Transfusion is a supplementary procedure 
of great value. XIX. THE TRANSMISSIBLE DISEASES 
In this group of diseases for purposes of convenience are not included 
a number of affections elsewhere discussed, the characteristic tendency 
of each of which is to single out one organ or structural group in the body 
for attack. 
The present discussion relates to a less selective group to which the 
term “tranmissible” is probably more patently applicable. Year by year, 
however, such designations become less definite and such terms as “in- 
fectious” and “contagious” have a wider connotation. 
Diseases Which May Be Transmitted Through Contact.—Syphilis, 
diphtheria, gonorrhea, stomatitis, tuberculosis, pneumonia, scarlet fever, 
measles, German measles, mumps, smallpox, chickenpox, pertussis, 
poliomyelitis, meningitis, acute cerebrospinal meningitis, plague, typhus, 
influenza, encephalitis. 
Diseases Which May Be Transmitted Through an Intermediary.— 
Gonorrhea, typhoid fever, malaria, yellow fever, tuberculosis, cholera, 
plague, stomatitis, scarlet fever, diphtheria, measles, chickenpox, pertussis, 
syphilis, typhus, and poliomyelitis. 
It will be observed that some of the foregoing diseases are trans- 
missible in more than one way. 
Syphilis, in addition to being transmissible through association, 
is transmissible by inheritance. 
Gonorrhea is transmissible through association and through inter- 
mediary objects. That the latter mode of conveyance is common is 
absolutely proved by the spread of the disease in institutions and hos- 
pitals, through the use of the thermometer or at the hands of attendants. 
Among the diseases grouped as transmissible through association, 
in which such transmission is eminently a feature of the disease, are 
those that usually have been designated as contagious, e. g., scarlet fever, 
diphtheria, measles, German measles, mumps, smallpox, chickenpox, 
pertussis and poliomyelitis. 
Among the diseases transmissible by intermediary means, gonor- 
rhea has been referred to. 
Typhoid fever is usually water borne or food borne by flies. Ma- 
laria and yellow fever are transmitted by the mosquito. 
Cholera is usually a water-borne disease. 
Plague may be transmitted through any intermediary which has 
been in contact with the infected subject. 
Stomatitis, a comparatively insignificant disease, may be trans- 
mitted through nipples, pacifiers, or toys that have been in the mouth 
of the patient. 
There is quite an unanimity of opinion that scarlet fever, diphthe- 
ria, measles, chickenpox, mumps, and smallpox may be transmitted 
from the diseased to the unprotected individual through the agency of 
an intermediary person or object. Our own observation corroborates 
this view. At the same time we are sure that such transmission is less 
frequent than is generally supposed. 
665 666 
THE PRACTICE OF PEDIATRICS 
The usual means is through association with an individual who has 
the disease, perhaps in so mild a manner that it has not been recognized. 
This is particularly the case with diphtheria, scarlet fever, and polio- 
myelitis. 
These diseases, viz., scarlet fever, diphtheria, measles, chicken-pox, 
pertussis, German measles, poliomyelitis, and mumps, have another fea- 
ture in common. They may be extremely severe, or so mild that the 
case is not recognized, and the patient associates as usual with his fel- 
lows. It is to these mild cases that the spread of the disease is ordinarily 
due rather than to a transference of the contagium through unusual 
channels. 
It has been estimated that 1 per cent, of children in cities have viable 
diphtheria bacilli in their throats. 
Scarlet fever, because of the possible variation of its course and the 
indefinte rash, is overlooked more frequently than any other of the dis- 
eases of this class. It is not at all unusual for school inspectors to find 
children with active scarlet fever desquamation in attendance at schools. 
Abortive non-paralytic cases of poliomyelitis are unquestionably a 
chief agency in the transmission of this disease. 
The writer has seen a case of chickenpox in which there were but five vesicles 
without other sign of illness, and patients with unquestionable pertussis who never 
whooped. 
CARE TO BE EXERCISED BY THE PHYSICIAN IN VISITING INFECTIOUS 
AND CONTAGIOUS DISEASES 
Physicians in attendance upon contagious diseases, particularly 
diphtheria and scarlet fever, should exercise reasonable care in their 
association with other patients. The coat should be removed and shirt- 
sleeves turned up to the elbows. A gown, or a sheet suitably adjusted 
with safety-pins, should protect the clothing. 
History.—Numerous descriptions left by ancient authorities afford 
evidence that smallpox has existed from the earliest times, in fact long 
before the Christian era. France and Italy were ravaged by this form 
of pestilence in the sixth century and England is supposed to have been 
invaded by the disease as long as one thousand years ago. Prior to the 
discovery by Jenner of vaccination in 1798 smallpox annually caused 
thousands of deaths in England, while in less advanced countries the 
mortality was even greater. 
For over one hundred years before Jenner’s discovery inoculations 
had been practised, first in Turkey and later in England and America. 
The disease, when “engrafted,” was uniformly observed to be much 
milder than when contracted in the ordinary manner. When thus in- 
oculated from patient to patient, however, the affection maintained 
its contagious character, and for obvious reasons the practice had much 
to condemn its employment. To Sydenham in the seventeenth century 
was due much of the better understanding of the disease. 
Not until the proof by Jenner that those individuals previously vac- 
cinated with cowpox virus were immune to smallpox was the way opened 
SMALLPOX (VARIOLA) SMALLPOX (VARIOLA) 
667 
for general and safe immunization. As an example of effective artificial 
immunization against disease this form of vaccination, even since the 
time of Pasteur, has remained pre-eminent. 
Etiology.—Smallpox respects no race, no age, and no sex; even infants 
seem to possess no natural immunity. The disease is most prevalent 
in winter. 
The exact nature of the specific cause remains in doubt, although the 
work of numerous investigators, including Guarnieri, Councilman, and 
Prowazek, indicates that the causative organism belongs to the protozoa. 
Contagion is transmitted by direct contact with skin lesions and body 
excretions and also through clothing, the virus being extremely viable 
and persistent. Immunity after one attack is the rule. 
Pathology.—The most significant changes induced are exhibited by the 
skin lesions. Councilman has demonstrated that even at the outset these 
lesions, in spite of their macroscopic papular appearance, are actually 
vesicular, while the organisms causing the disease are apparently brought 
to the skin lesions by the blood. 
In general, the progressive changes exhibited by the cutaneous lesions 
are indicated by the symptomatology presently to be discussed. On 
mucous surfaces, ulcerations and erosions take the place of the lesions 
produced in the skin. 
Fatty degeneration and focal necrotic areas are found in the viscera. 
Necrotic changes in the bone-marrow have also been described. Both 
bone-marrow and blood show a noteworthy diminution in polynuclear 
cells. 
Glomerulonephritis, otitis, pneumonia, and corneal ulcerations are 
among the pathologic conditions which may complicate ordinary small- 
pox. 
Incubation Period.—This ranges typically from ten to twelve days, 
rarely being prolonged to sixteen to twenty days, particularly in the 
mild forms of the disease. 
Symptomatology.—In the child the course of the disease, which is 
practically the same as in the adult, progresses through fairly definite 
stages. 
Invasion.—Prodromal symptoms are usually not significant, although 
chilliness, headache, sore throat, or lassitude may be noted. The onset 
is as a rule sudden and accompanied by a chill with headache, backache, 
and a rapidly rising temperature of 103° F. or higher. Not infrequently 
the fever in children ranges as high as 106° F. The pulse is full and is 
increased in rapidity, proportionally to the temperature elevation. The 
tongue becomes heavily coated and the breath foul. Vomiting may be 
the first symptom and at times is persistent. Convulsions, delirium, and 
in children coma are not infrequent. Vertigo is occasionally a feature. 
Before the completion of the initial stage a prodromal rash may appear. 
This may be scarlatinaform or more often morbilliform and at times is 
definitely petechial or hemorrhagic. 
The Eruptive Stage.—The initial stage is superseded with regularity 
on the third day by a period in which the characteristic phenomenon is 
the development of red macules in rapidly increasing numbers, which 
quickly become elevated and papular, “shotty” on palpation. By the 668 
THE PRACTICE OF PEDIATRICS 
fifth day of the disease the lesions become vesicular and even before this 
they may coalesce. The typical vesicle shows a central umbilication 
and is multilocular. 
The eruption is most profuse on the portions of the body showing the 
greatest skin congestion, particularly the face. 
By the sixth day the vesicles undergo suppuration and show a deeper 
areola so that the parts most affected become actually edematous, the eye- 
lids at times becoming closed. The maturation of the eruption on the face, 
in keeping with the first appearance of the rash at this site, advances be- 
fore the development of pustulation on other portions of the body. Re- 
trogression of the pustules becomes apparent about the eighth day. 
In the mouth, because of the delicate character of the epithelium, the 
lesions take the form of erosions or ulcerations. The tongue may be very 
sore, and the throat so sore as to make swallowing very difficult. 
During the interval between the onset of the eruptive stage and the 
development of suppuration abatement in the fever and accompanying 
constitutional symptoms is the rule, but the fever recurs with the pustular 
stage at about the fifth or sixth day of the illness, usually, however, in 
less degree than during the stage of invasion of disease. 
The blood shows leukocytosis with a relatively high percentage of lym- 
phocytes. 
Involution.—Subsidence of tumefaction marks the beginning of retro- 
gression of the eruption at the end of the pustular stage, the face first 
showing the improvement. Desiccation and crust formation usually 
begins about the tenth to the twelfth day of the eruption. Three or four 
weeks may elapse before desquamation is complete. During the drying 
stage, itching is a most annoying symptom. 
Varieties of Smallpox.—Confluent smallpox, as its name implies, in- 
volves almost the entire body surface. The mortality is high. 
Petechial and purpuric smallpox are malignant hemorrhagic forms of 
the disease, variola purpurica being most fatal. The pustular hemorrhagic 
form is an extreme type. 
Mild smallpox is today the form most prevalent in the United States. 
Individuals affected by this type of the infection may not be confined 
to bed at any period throughout the entire course of the disease. Such 
cases are marked by a moderate intensity and show a rash which is easily 
mistaken for a chicken pox eruption. 
Differential Diagnosis.—The initial symptoms of headache, generalized 
pain, chill, and fever, with perhaps vomiting, are at times mistaken as 
indicative of the onset of grip, pneumonia or meningitis, while the pro- 
dromal eruption may give rise to a wrong diagnosis of scarlet fever or 
measles. 
The disease most frequently confused with variola is chickenpox. 
This is due to the prevalence of smallpox in a mild atypical form because 
of existing partial immunity in the patient, conferred by vaccination. 
This, although performed years before the time of the disease attack, 
may nevertheless afford considerable immunity. 
In making the differentiation between variola and varicella the follow- 
ing points are to be kept in mind: 
In smallpox the rash is particularly abundant on the face, back, and SMALLPOX (VARIOLA) 
669 
limbs, whereas in chickenpox lesions are distributed variably with a 
tendency to avoid the limbs and appear on covered areas of the body. 
Furthermore, the vesicles in varicella are more superficial than in smallpox 
and are generally unilocular, are never umbilicated, and, unlike those of 
smallpox, tend to appear in successive crops. Owing to the prevalence 
of early vaccination variola is relatively rare in early childhood. 
In doubtful cases the vaccination may be used as a test of great value, 
successful recent vaccination or successful vaccination after the third day 
of the eruption being almost positive evidence that the disease under 
observation is not smallpox. 
Complications and Sequelae.—Among the most important and fre- 
quent secondary affections are bronchitis and pneumonia. Edema of 
the glottis with ulcerative lesions in the throat has been observed. Otitis 
media, conjunctivitis, and even corneal ulceration are also seen as the 
outcome of smallpox, while adenitis, nephritis, and pericarditis may de- 
velop. Cellulitis, boils, abscesses, erysipelas, and even tetanus may 
result from secondary infection of the skin lesions. 
Prognosis.—Among children smallpox unmodified by vaccination is 
particularly fatal. Woody1 has emphasized this fact by recalling that in 
an epidemic in Montreal during 1884-86 over 85 per cent, of all fatalities 
were among children under ten years. 
The hemorrhagic and confluent forms are extremely fatal and in gen- 
eral the prognosis is considered to be bad proportionately to the char- 
acter and number of the skin lesions. 
Treatment.—Prophylaxis.—Vaccination, preferably during early in- 
fancy, constitutes the only reliable form of prevention. Vaccination should 
be repeated every five to seven years, although following vaccination in 
infancy revaccination at puberty and again in the fourth decade has 
been proved effective in affording lasting protection in all but exceptional 
individuals. 
Isolation.—This should be practised most conscientiously with regard 
to the prolonged segregation, not only of the patient, but of all recently 
unvaccinated contacts until two weeks at least have elapsed. Quarantine 
of the patient himself should be strictly maintained much longer until all 
crusts have been desquamated. 
General Therapy.—After the stage of onset during which antipyretics 
and sedatives may be administered with advantage, as in the treatment 
of grip, hydrotherapy in the form of sponging, packs, and cool baths 
is of most value. After suppuration is established warm baths may be 
substituted. 
Topical applications to the lesions comprise a long list in which tinc- 
ture of iodin, as an agent of value in shortening suppuration and thus 
preventing scarring, holds a foremost place. Alcohol, 25 per cent., in 
boric acid solution, and bichlorid of mercury, 1 : 10,000 solution, have 
also proved of value. During the late stages various antiseptic ointments 
are of aid in facilitating desquamation and relieving itching. 
Mouth-washes are indicated and their use should be supplemented by 
particular attention to local ulcerative conditions of the gums or tongue. 
The diet during the acute stage should consist of fluids only. Later 
1 Tice, Practice of Medicine, 670 
THE PRACTICE OF PEDIATRICS 
milk toast, ice-cream, stewed fruit, vegetable purees, and simple desserts 
may be added. 
In general, the treatment is solely supportive and symptomatic. Nurs- 
ing in smallpox, as in the conduct of typhoid fever, holds a place of peculiar 
pre-eminence. 
During convalescence an out-of-door life and liberal feeding may be 
supplemented by the administration of appropriate tonics, as in the after- 
management of severe measles. 
CHICKENPOX (VARICELLA) 
Chickenpox belongs to the transmissible diseases, and is usually 
transmitted by association contact, rarely through an intermediary. 
The contagium of varicella is present in the fluid contents of the eruptive 
vesicles, and also in the crusts resulting from the drying of the vesicular 
contents. Consequently the period of transmissible infection persists 
as long as any crusts remain on the skin. The specific etiologic factor in 
this disease is still unknown. 
Fig. 116.—Deep ulceration in case of dermatitis gangrenosa infantum following 
chickenpox. 
Incubation.—The period of incubation is rarely less than eighteen 
days nor longer than twenty-five days. In the majority of cases it has 
ranged between twenty and twenty-five days. 
Symptoms .—Prodromal symptoms are rarely of sufficient severity 
to warrant complaint or give evidence of illness on the part of the child. 
In severe cases there may be slight temperature and muscle soreness. 
The temperature rarely goes above 102° F., usually not over 100° F. 
The Rash.—The eruption is usually the first important sign of the 
disease. The back and abdomen are the sites ordinarily involved early. 
The rash may appear on any portion of the body. It occurs abundantly 
on the scalp. Usually there are a few spots in the mouth. 
Not infrequently from the onset the lesions are distinctly vesicular, 
without any associated skin inflammation, resembling drops of water 
that may have been sprinkled carelessly over the skin surface. More 
frequently the rash consists of macules, then papules, and later vesicles 
resting on well-defined red areolae. At first the vesicles contain clear 
fluid and vary in size from mere points, scarcely discernible to the naked 
eye, to lesions § inch in diameter. In a few hours the serum becomes 
cloudy and purulent. In from twenty-four to seventy-two hours the CHICKENPOX (varicella) 
671 
fluid is absorbed, leaving the erupted area slightly umbilicated, so that 
on further drying this forms a crust or scab. These crusts fall off in 
from one to three weeks, each leaving a distinctly reddish skin area, 
at the site of which there is sometimes a temporary scar. The rash varies 
greatly in its intensity. Most of the lesions do not go through the char- 
acteristic stage just mentioned, and many do not go beyond the papular 
stage. All stages of the eruption may be seen at one time in any well- 
marked case, for the reason that the rash appears in successive crops, 
of which there are usually three, although there may be more. The 
first crop may be in the scabbing stage when the third or a later crop 
appears. The amount of rash is extremely variable. 
Illustrative Cases.—In 1 case there were but three vesicles. 
In 3 others, all institution cases, so severe and extensive was the rash that it 
resulted in a gangrenous dermatitis consisting of clearly punched-out ulcers. The 
gangrenous area coalesced, with destruction of large areas of the skin surface. These 
3 cases were all fatal. 
Duration.—The duration of an attack, from the beginning of the 
period of eruption until the skin clears, is about three weeks. In mild 
cases the skin may become clear in two weeks. 
Quarantine.—The child should be kept in quarantine and not al- 
lowed to come in contact with unprotected children until three weeks 
have elapsed, or until the skin is free from crusts. 
Complications.—Erysipelas was a complication in 2 cases; gangrenous 
dermatitis in 3. Nephritis, although rare, may develop. One of the most 
severe cases of acute glomerular nephritis treated in a long period occurred 
as a sequel of chickenpox. Furunculosis, due to infection by scratching, 
is a quite frequent complication in children’s asylums. 
Prognosis.—The prognosis is good. It is very unusual for the most 
delicate child to succumb to the disease. 
The institution infants who developed gangrenous dermatitis (Fig. 116) and a phys- 
ician’s child who developed erysipelas at the site of a chickenpox lesion presented the 
only fatal cases that have come under our observation. 
Treatment.—Chickenpox is a disease for which very little treat- 
ment is required. During the eruptive period, and until the period of 
vesiculation is passed and the crusts have formed, the child should be 
kept in bed. 
During the stage of active eruption the tub-bath should be omitted. 
Instead, gentle sponging with a tepid solution of boric acid—2 heaping 
tablespoonfuls of boric acid to | gallon of boiled water—will answer the 
requirement of cleanliness for a few days. After the daily sponging, and 
several times during the day, the areas affected should be anointed with 
boric acid ointment made with cold cream as follows: 
I£. Mentholis gr. x 
Pulveris acidi borici gr. c 
Unguenti aquae rosse 5ij-—M. 
The ointment effectually relieves the itching, and doubtless is of 
value in preventing local skin infection through scratching. An equally 
effective remedy, but one less agreeable for domestic use, is a lotion of 672 
THE PRACTICE OF PEDIATRICS 
5 per cent, ichthyol and sterilized olive oil. This is to be applied to the 
entire body twice daily after the bath. Objections to its use are the 
odor and the staining of the clothing and bed-linen. Permanent scars 
at the site of the vesicles are so rarely seen that no special precautions 
are required on this account. 
MUMPS (EPIDEMIC OR SPECIFIC PAROTITIS) 
Mumps is a specific infection of the parotid glands. 
Cocci have been isolated from the inflamed parotid gland in cases 
of mumps, but their specificity has never been proved. More recent 
studies point to a filtrate virus as the probable cause of the disease (Woll- 
stein). The exact nature of the virus has not yet been determined. 
Mumps affects chiefly the runabout and school children. Infants 
and very young children are rarely affected. 
Transmission.—The disease may be conveyed by direct contact 
or through intermediary individuals, books, toys, or clothing. 
Incubation.—The period of incubation is long—from two to three 
weeks. 
Duration.—The duration of the disease from the commencement 
of the swelling until it has completely subsided is from ten days to two 
weeks. 
Quarantine should be maintained until the swelling has entirely sub- 
sided. 
Pathology.—As the great majority of cases are not fatal, it has been 
difficult to study the pathology of the disease. The pathologic changes 
that are known to occur are ordinarily limited to the salivary glands. 
There is edema and cellular infiltration of the connective tissue around 
the ducts and between the acini, while the glandular epithelium is often 
swollen and cloudy. The infiltration is most marked around the ducts. 
When mumps affects the testis, the inflammation assumes a paren- 
chymatous form, and when the epithelial degeneration in the tubules 
is severe, atrophic changes in this gland may follow. Occasionally the 
orchitis is accompanied by urethritis, edema of the scrotum, and in- 
guinal adenitis. 
Ovaritis, mastitis, and acute pancreatitis complicating mumps have 
been observed. 
Symptoms.—Usually one gland is affected at first, and the gland 
first affected is usually the one most prominently involved, the second 
gland rarely reaching the size of the first and subsiding much earlier. 
In some cases, three or four days intervene before the second gland shows 
the characteristic swelling. The submaxillary glands may be involved 
in the process, but usually escape. 
In one patient the submaxillary glands alone were involved. In another child 
three years of age both parotids and submaxillary glands and the sublingual gland 
showed massive involvement. 
Involvement of other salivary glands than the parotid is more fre- 
quent during cold weather. 
There may be prodromal symptoms of fever and languor. Diffi- 
culty is experienced by the patient in working the jaws. Not infrequently MUMPS (EPIDEMIC OR SPECIFIC PAROTITIS) 
673 
there are sharp neuralgic pains and pains referred to the ear. An eleva- 
tion of the temperature is usual during the acute stage, although this 
may not exceed 100° F. In most instances it does not exceed 102° F. 
If the glands are involved separately at two or three days’ interval, there 
may be two distinct rises in temperature. The temperature is rarely 
sufficiently high to demand special treatment. 
Diagnosis and Differential Diagnosis.—The patient presents a char- 
acteristic picture, the face taking on a rotund, rather ludicrous appear- 
ance, produced by no other malady. Acute adenitis of the lymphatic 
glands at the angle of the jaw is most frequently mistaken for mumps. 
Mumps, on the other hand, is not often mistaken for adenitis. 
In history taking not infrequently one is told that the child has had two 
or three attacks of mumps, which means that the child has had perhaps 
Fig. 117.—Mumps. 
one attack of mumps, the others having been acute adenitis. In mumps 
the swelling, by involving the parotid, which it will be remembered is 
in front of and below the ear (Fig. 117), displaces the lobe upward and 
outward and completely fills the depression posterior to the lobe. In 
adenitis (Fig. 80) there is usually a well-marked depression between the 
swelling and the adjoining parotid. 
Abdominal pain and vomiting in mumps should suggest pancreatitis 
rather than appendicitis. 
Complications in mumps are exceedingly rare before puberty. Or- 
chitis may occur in boys and ovaritis in girls, but only very exceptionally 
if the patient is kept in bed. Infection of the parotid other than that 
produced by the specific poison of mumps is extremely rare. Abscess 
as a complication due to a mixed infection has been reported. Nephritis 
is an occasional complication. One such case occurred in a boy two years 674 
THE PRACTICE OF PEDIATRICS 
of age. Complicating pericarditis, endocarditis, and pancreatitis have 
been reported. 
Prognosis.—The prognosis is good. We have never known a second 
attack, a relapse, or a death from the disease. 
Treatment.—During an attack the child should be kept in bed until 
the temperature is normal, and should remain in the house until the 
swelling has entirely subsided. He should receive a reduced diet of broths, 
gruels, and milk, as in any illness with fever. Fruits and acids should 
not be given because of the discomfort they occasion. Unless the bowels 
move daily without assistance, citrate of magnesia or a Seidlitz powder 
should be given. 
Warm applications at times relieve the pressure and discomfort. 
Flannel moistened with warm camphorated oil and bound to the parts 
has been acceptable to many patients. 
WHOOPING-COUGH (PERTUSSIS) 
As an infectious disease of importance, pertussis may be classed 
with diphtheria and scarlet fever. It is probably the cause of more deaths 
today than is any other infectious disease. It does not kill directly through 
a specific poison, as do diphtheria and scarlatina, but on account of its 
prolonged course and its many complications is equally effective as a life 
destroyer. 
History.—Whooping-cough has existed from early times, under such 
names as “tussis perennis,” “tussis infantum,” “chink cough,” “chine- 
cough,” and “king’s cough.” In a treatise published in 1773 William 
Butter, of Edinburgh, aptly described “kinkcough” as “a quick and nu- 
merous succession of violent, short coughs followed by a long, strait, and 
generally shrill inspiration, which coughs and inspiration are repeated 
without intermission for many seconds or often some minutes and often 
terminate in the vomiting of phlegm.” Robert Watt, writing in 1813, 
stated that “next- to the smallpox formerly, and the measles now, chin- 
cough is the most fatal disease to which children are liable.” 
The seat of the affection was variously placed by the early writers 
in the nervous system, in the digestive organs, and in different portions 
of the respiratory tract. Butter believed that “miasms generated in 
the guts, act on the nerves” and “increase irritability.” Further in- 
formation is proffered in statements that “measles render the kinkcough 
very dangerous”; “smallpox either cures or palliates”; and that “hemlock 
cures the kinkcough in a week.” A critic of the hemlock therapy ironically 
recalled that “the flesh of fried mice . . . has been in vogue as a 
specific.” Certain it is that even in very recent years no disease has 
been treated by remedies of wider diversity. Partial explanation of this 
fact undoubtedly rests upon the frequent association of whooping-cough 
with other diseases, as well as upon the varying therapeutic requirements 
of its more common complications. 
Bacteriology.—The bacillus described by Bordet and Gengou in 
1906 is at present generally accepted as the cause of pertussis. The 
bacillus is a short, ovoid, polex, regular, non-motile rod, which does 
not stain by Gram’s method. It is best isolated upon plates of potato- WHOOPING-COUGH (PERTUSSIS) 
675 
agar mixed with rabbit’s blood, as described by Bordet and Gengou, 
but later generations grow readily upon plain agar. The bacillus is present 
in the sputum in enormous numbers, and almost in pure cultures on the 
first two or three days after the onset of the whoop, and it may be found 
several days before the spasmodic stage begins (Wollstein). At the 
end of the first week of this stage, however, other bacteria, such as pneu- 
mococci and staphylococci, have usually become so numerous that isola- 
tion of the bacillus is impossible. Agglutination reactions with the pa- 
tient’s serum are irregular and unsatisfactory. Complement-fixation 
tests have been reported positive, but they are not regularly so. 
Jochmann and Krause found the influenza bacillus in the sputum of 
pertussis patients in 100 per cent, of the cases they studied. 
In children who have died during the spasmodic stage of an attack 
of pertussis the Bordet-Gengou bacillus has been found in the heart’s 
blood and also in the lungs, where Bacillus influenzae is usually present 
as well. 
Transmission, as with most of the communicable diseases, is by 
means of direct contact. That pertussis may be conveyed through the 
medium of clothing, a book, a toy, or a second person is exceedingly 
doubtful. 
Extreme youth offers no protection as in the case of scarlet fever 
or diphtheria. 
Infective Period.—The disease may be transmitted from the begin- 
ning of the catarrhal stage. The duration of the period of infection is 
not known. It probably continues in the average case until the child 
ceases to whoop. 
When pertussis breaks out in a school or in an institution for chil- 
dren, prevention of an epidemic is practically impossible, because the 
disease is infectious during the early catarrhal stage, which lasts from 
one to two weeks. During this time the only symptom is a cough and 
perhaps a slight degree of bronchitis, such as exists with a common cold. 
Susceptibility.—The previous state of health appears to exert no 
influence upon the patient’s susceptibility. The strong and the deli- 
cate are alike predisposed to infection. The very young and the adult 
are less liable to take the disease than are children between the fourth 
month and the third year. This is the most susceptible period of life. 
Cases have been reported in children one week old. Any other concur- 
rent infectious disease exerts no influence upon the duration of the per- 
tussis. The theory has been advanced that the advent of diphtheria or 
scarlet fever during an attack of pertussis shortened and modified the 
course of the disease, but experience does not corroborate this belief. 
Other affections which occur during an attack simply increase the burden 
to be borne by the patient. The largest number of cases develop during 
the warmer months—from May to November. This circumstance may 
be accounted for in part by the fact that during the warm period of the 
year the infected child comes more frequently in contact with unpro- 
tected neighbors. The same circumstance, however, tends to disprove 
that catarrhal affections of the respiratory tract predispose to the disease, 
since respiratory affections in the young during the warmer months are 
notably rare. The normal healthy mucous membrane offers no greater 676 
THE PRACTICE OF PEDIATRICS 
resistance to pertussis than does that which is affected by disease. In 
the early stages of pertussis there is not simply a bronchitis, but a catarrhal 
process due to a specific infection. 
Interesting observations relative to susceptibility to measles and 
pertussis were made by Biedert. After a lapse of sixteen years both 
these diseases broke out in a German village at about the same time. 
There were 401 children in the village under fourteen years of age. These 
children had never been far from home, and not one of them had had 
either measles or pertussis. Of this number, 344 became ill with measles 
and 366 with pertussis, 340 having both diseases at once. The suscep- 
tibility of these unprotected children to pertussis was, therefore, 95.5 
per cent.; to measles, 85.8 per cent. Of those who escaped pertussis, 7 
were under five years of age, 4 between five and ten years, and 9 between 
ten and fourteen years. 
Pathology.—There is very little characteristic pathologic change in 
uncomplicated pertussis. There is an inflammation and infiltration of 
the mucous membrane of the larynx and upper trachea, which is doubt- 
less the seat of the specific infection. Mallory has affirmed that the 
specific lesion is the presence of Bacillus pertussis between the cilia of the 
epithelial cells of the trachea and bronchi. 
Incubation.—The period of incubation is difficult to determine. It 
seems to range from seven to fourteen days. 
Symptoms.—At the outset the cough may be short, hard, and of a 
paroxysmal nature. Usually, however, the cough is in no way char- 
acteristic and does not differ from that which accompanies bronchitis 
or tracheitis. Instead of improving under treatment, this symptom 
becomes more severe and more frequent. The child coughs more at 
night, usually, than during the day. In a week or ten days, rarely less 
than a week, the characteristic whoop occurs. 
Fever depends on the degree of associated bronchitis. 
A leukocytosis is common throughout the disease. The large mon- 
onuclear cells are characteristically increased in number and a moderate 
degree of eosinophilia is common. 
Vomiting is a frequent associated symptom. It is mechanical in 
origin, not dependent primarily on gastric disturbance. For this reason 
the child may eagerly take and retain food almost immediately after 
vomiting. As the disease progresses the paroxysms increase in frequency 
and may occur even to the number of 50 or more daily. 
Duration.—The paroxysmal stage remains at its height for a period 
ranging from one to four weeks. Beginning improvement is always 
marked by a diminution in the frequency and severity of the seizures. 
Complications.—The complications of pertussis are many, and account 
for the fact that the disease is so destructive to life. The most fatal com- 
plication in winter is bronchopneumonia; in summer, gastro-enteric disease. 
Convulsions are not an infrequent complication, and may be fatal. Mal- 
nutrition often follows a severe attack in a delicate, bottle-fed child, thus 
paving the way for intercurrent disease. Tuberculosis not infrequently 
follows a prolonged attack of pertussis. Blindness, deafness, and motor 
disturbances have all been observed during attacks of pertussis, and have 
been followed by complete recovery. These cases may be explained as WHOOPING-COUGH (PERTUSSIS) 
677 
follows: During a severe paroxysm the cerebral circulation is greatly 
disturbed, and as a result of an extreme congestion or venous hyperemia 
there is a disturbance of nutrition in certain portions of the brain. Epis- 
taxis is frequent and in rare instances cerebral hemorrhage with resulting 
permanent paralysis has occurred. On the cessation of the paroxysm 
these symptoms all disappear. 
Diagnosis.—The diagnosis of pertussis is most difficult in the early 
stages, before the whoop or convulsive paroxysm develops. Even a 
spasmodic cough does not always mean a developing pertussis. 
In rachitic children, and in those in whom the nervous element is 
prominent, the cough of an ordinary cold is often of a decidedly par- 
oxysmal character, especially when there is an acute or subacute laryn- 
gitis. 
The cough, however, if more troublesome at night, favors a diagno- 
sis of pertussis. If the diagnosis is correct, the cough grows steadily 
worse and resists the usual treatment of colds. 
The mild cases are also difficult of diagnosis. 
Illustrative Cases.—Two patients, aged eight and ten years respectively, went 
through an attack of pertussis with but two or three severe paroxysmal coughing attacks. 
Two other cases seen in private practice also show how mild may be the course. 
The patients, brother and sister, aged six and eight years respectively, commenced 
coughing about ten days after exposure. The cough was paroxysmal, with from three 
to five seizures in twenty-four hours. The boy whooped only three times during the 
entire course of the disease; the girl did not whoop at all. Vomiting never occurred 
with a paroxysm. Both patients coughed for six weeks. They had neither adenoids 
nor bronchitis. 
Often the very young and the very delicate do not whoop, even dur- 
ing a severe attack. Among the severe cases convulsions and hemor- 
rhage from the nose, ears, and eyes are seen from time to time. 
A very severe seizure in a girl nine months old was followed by small extravasations 
of blood into the skin of the entire body. 
Differential Diagnosis.—In all cases of severe cough of uncertain 
origin the nasopharyngeal vault must be examined for adenoid growths. 
In young children this can be properly done only by the use of the index- 
finger. 
The presence of enlarged bronchial glands, whether of tuberculous 
origin or the result of prolonged respiratory infection of the streptococcus 
or influenzal type, may also readily account for persistent cough of the 
pertussis character. x-Ray is of great value in the differentiation of such 
cases. 
As a general rule, the presence of a persistent cough with a paroxysmal 
tendency, in the absence of local respiratory irritation of any nature, and 
accompanied by eosinophilia, is very suggestive in a suspected case. 
Prognosis.—Pertussis in children under eighteen months of age must 
ever be regarded in a serious light. Delicate and rachitic children should 
be carefully guarded against the disease. Bronchopneumonia and gastro- 
enteric troubles are the most frequent complications among this class 
of children. The majority of healthy children over eighteen months 
of age bear whooping-cough without great inconvenience. 678 
THE PRACTICE OF PEDIATRICS 
Breast-fed babies tolerate the disease in the early months of life far 
better than do those artificially fed. 
Treatment.—The use of drugs in whooping-cough has always been 
more or less of a disappointment. By their use, however, the par- 
oxysms may be lessened in number and severity and the illness may be 
made easier for the patient to bear, which of course is important. Good 
results have been obtained by the use of antipyrin and bromid of soda 
in combination as follows: 
For a child eight months of age, \ grain of antipvrin with 2 grains 
of bromid of soda are given at two-hour intervals—six doses in twenty- 
four hours; for a child of fifteen months, 1 grain of antipyrin and 2f 
grains of bromid of soda at two-hour intervals—six doses in twenty-four 
hours; from the fourth to the eighth year, 2 grains of antipyrin and 5 
grains of bromid of soda at two-hour intervals—six doses in twenty-four 
hours. 
Quinin has been used in a large number of cases in both private and 
outpatient work. Great benefit may be derived from its use if a large 
amount can be given. Its administration, however, is attended with 
difficulties. Twelve to 20 grains in twenty-four hours are required for 
pronounced results in children from two to six years of age, and the ad- 
ministration of such a large amount is not favorably received by many 
parents. Again, our inability to make the drug palatable is a serious 
drawback for any age, and almost excludes its use in the very young; 
furthermore, in the very young and delicate quinin may derange the 
stomach and produce vomiting. A good form of solution to use is 
that of bisulphate in Yerbazin, or a similar preparation “Coca-quinin” 
(Lilly). In older children, when quinin can be given in sufficient quan- 
tities in capsules, the decrease in the number and severity of the parox- 
ysms is sometimes surprising. 
Codein is to be used in the most severe forms of pertussis when other 
means fail to relieve the patient. One of the most troublesome features 
of the disease in infants and young children is the wakefulness at night 
caused by repeated attacks of coughing and vomiting. When the child 
cannot sleep, codein is advisable independent of the other treatment, 
whatever it may be. For a patient five years of age | grain is to be given 
at bedtime and repeated during the night whenever the paroxysms require. 
For a child from eight to twelve years of age, l grain may be given at bed- 
time and repeated twice if necessary. For a child from two to three 
years of age, iV grain may be given and repeated not oftener than twice 
during the night. The drug should not be continued longer than a week 
or ten days. We have never seen unpleasant effects follow its use. 
Interrupted Medication.—It will be observed that the drugs of value 
in whooping-cough are the sedatives. For the reason that by the pro- 
longed use of sedatives their effect is lost, it has been found wise to use 
what may be called “interrupted medication.” For five days the antipyrin 
and bromid of soda are given. Full doses of quinin only are then given 
for five additional days, at the end of which time the antipyrin and bro- 
mid are resumed. In this way, giving the drugs five days each, one may 
continue with advantage for a month or six weeks. It is rarely necessary 
to continue the treatment longer than six weeks—usually from three to WHOOPING-COUGH (PERTUSSIS) 
679 
four weeks is sufficient. Of course, the child will whoop after that time, 
but the active stage of vomiting and severe paroxysms will be over. 
If the vomiting can be controlled in an attack of pertussis, and if the 
patient can obtain sufficient sleep, much has been accomplished. 
What has already been suggested should be emphasized: Do not 
begin the drug treatment of whooping-cough, whether by the administration 
of quinin, antipyrin, or other remedies, until the spasmodic stage is at its 
height. If a sedative is given as soon as a diagnosis is made, by the time 
the disease reaches its height tolerance will have become so established 
that the drug will have lost not a little of its sedative action. If medicines 
must be given during the earliest stage, a placebo may be used. 
Fresh air is of immense value as a means of relief in whooping-cough, 
regardless of the method of treatment followed. We are told that the 
child rarely coughs when out-of-doors, but commences as soon as he is 
brought into the house, which is usually overheated and badly ven- 
tilated. In nearly all cases the cough is worse at night. This may be ex- 
plained in part by the absence of proper ventilation in the sleeping apart- 
ment. A child who for any reason must remain indoors should not be 
allowed to remain constantly in one room. There should be two rooms 
and every window in the one not in use should be freely open. The liv- 
ing room and sleeping room should be kept at a fairly even temperature— 
from 68° to 70° F. 
Vaccine.—Our opinion as to the value of vaccine in pertussis has under- 
gone a series of changes. We confess to periods of enthusiasm and again 
to those of doubt, which implies that as a remedy vaccine is variable in 
its apparent effects. It is most difficult to judge whether a remedy is 
adequate when the improvement noted may be explained in several 
different ways. We have seen what appeared to be brilliant results di- 
rectly due to vaccine, although repeatedly following its use no response 
whatever has been apparent. It is to be remembered that whooping- 
cough varies greatly in its severity and response to ordinary treatment. 
For prophylactic purposes two doses are usually given, the first injection 
consisting of 1,000,000,000 organisms and the second of 2,000,000,000 given 
forty-eight hours after the first. 
Injections for curative purposes are ordinarily given at two-day 
intervals to the number of four or five in all, the dosage ranging from 
500,000,000 at the first injection to four to six times this amount at the 
last treatment. 
Freeman has laid emphasis on the importance of employing only 
freshly prepared vaccine. 
By numerous experienced observers preference is given to a glycerol 
vaccine. 
Quarantine in whooping-cough is particularly difficult, but in some 
adequate degree should be maintained, even if the precaution taken con- 
sists only in making the patients wear an arm band labeled “whooping- 
cough.” A fair rule is to isolate the child during the spasmodic stage and 
at least two weeks after the whooping begins. 
Practical success in limiting the transmission of the disease has been 
attained by attempts to keep well children away from those with sus- 
picious coughs, rather than by actual isolation of the latter. 680 
THE PRACTICE OF PEDIATRICS 
MEASLES 
By some writers measles is credited with an antiquity as great as 
that of smallpox, but the fact that measles was long confused with other 
exanthemata renders it doubtful whether descriptions over two cen- 
turies old should be accepted. Measles has always been one of the most 
rapidly advancing of epidemic diseases. In communities long unaffected, 
such as Iceland and the Fiji Islands, it has attacked the greatest numbers 
and developed the highest virulence. In the years 1834 to 1836, and 
1842 to 1843, nearly the whole of Europe was invaded. 
Buxton, whose elaborate little monograph, published a century and 
a quarter ago, still affords much of value, said: “Those who die of measles 
generally receive their death by a great flux of serum to the lungs.” Cer- 
tain it is that bronchopneumonia has always given to measles an im- 
portance out of all proportion to its immediate severity. 
Transmission.—Measles is the most readily transmitted of all the 
communicable diseases. A very few seconds’ exposure is all that is neces- 
sary. Very few of the human race escape. The disease is transmitted 
by , direct infection. Transmission through an intermediary is not of 
frequent occurrence. We have never known a proved case. 
The disease may be transmitted from the beginning of the earliest 
catarrhal symptoms, which become manifest two or three days before 
the appearance of the rash. The most infective period is during the 
first four or five days; how much longer it may continue is unknown. 
Etiology.—Goldberger and Anderson were able to produce measles in 
rhesus monkeys by inoculating them with the blood of human patients 
with the disease. These investigators proved that the blood in measles 
is infected before the appearance of the rash and during efflorescence of 
the eruption, while the infectivity decreases twenty-four hours after the 
eruption has appeared. The buccal and nasal secretions are also infective 
at the time of the appearance of the eruption and for forty-eight hours 
afterward. The desquamating scales, on the other hand, were not found 
infective. The nature of the virus has not been proved, but it is fil- 
trable through a Berkefeld filter, resists drying for twenty-four hours, and 
becomes inert after fifteen minutes’ exposure to 55° C. 
Lucas and Prizner confirmed the work of Anderson and Goldberger, 
and showed further that the inoculated monkeys develop Koplik spots 
just as do human subjects. 
Blake1 has successfully transmitted measles experimentally in monkeys 
through a considerable series of animals by nasopharyngeal washings, 
tissue emulsion and blood, with the resulting lesion histologically similar 
to measles in man. 
Age.—No age is exempt. In scarlet fever and diphtheria, nature 
surrounds the very young with a certain degree of immunity. Numerous 
young infants are, however, susceptible to measles, although this disease 
almost never occurs in those under three months of age. According to 
Herman2 infants under two months of age whose mothers have had 
measles are absolutely immune, although practically all after the ninth 
month contract the disease on exposure. 
1 Francis G. Blake, Measles Experimentally Produced, Arch. Ped., 38, 1921, pp. 
90-102 2 New York State Jour, of Med., 23, No. 10, October, 1923, pp. 404-407. MEASLES 
681 
Incubation.—The period of incubation ranges from seven to four- 
teen days. It is rare for the disease to develop after the tenth day fol- 
lowing exposure. A few cases develop, however, as late as the fourteenth 
day. 
Symptoms.—In marked contrast to scarlet fever, measles is fairly 
constant in its manifestations. Very severe cases and very mild cases 
are encountered. Institutional children have measles much more sever- 
erely than do private patients, and the former cases are much the more 
fertile in complications. This is because of the natural disadvantages 
which an institution necessitates, no matter how well it is conducted. 
The complications are more frequent because of the more frequent pres- 
ence of secondary infection to produce the complications. 
The Eyes.—The first manifestation of the illness is a coryza with 
mild conjunctivitis. The eyelids become swollen and reddened at the 
margins. There is photophobia. 
Cough.—A cough is present from the beginning or develops in a short 
time. The cough is hard, teasing, and, early in the attack, without 
bronchial secretion. Occasionally the cough is hoarse and croupy, but 
this is of rare occurrence. 
Nervous Manifestations.—Headache is not uncommon. Convulsions 
occur very rarely, and when present are usually due to indigestion. The 
child is very restless and unhappy until the eruption is well developed. 
Buccal spots, described by Filatow and by Koplik (see Plate II), 
preceding the exanthem by three to five days are pathognomonic. 
The Rash.—The characteristic rash usually makes its appearance 
about the ears and over the face, neck, and upper portion of the chest. 
Thence it spreads to the entire body, the last portions involved being 
the feet and hands. In its disappearance, the rash follows the same 
order. It consists of red papules and macules of irregular shape and of 
variable size. Early in all cases, and throughout most mild cases, there 
are areas of uninvolved skin between the erupted areas. In severe cases 
the areas of eruption coalesce so that the face, trunk, and limbs or the 
entire skin surface may present a livid, deeply congested appearance. 
The face, covered with the diffuse rash, swollen and edematous, with 
the swollen eyelids closed and secreting, and the thin, watery nasal 
discharge presents a picture seen in no other disease. 
The rash is sometimes quite irregular in the time of its appearance 
after the onset of symptoms. It may occur very early, coincident with 
the onset of the catarrhal symptoms, or it may be delayed for a week. 
The eruption requires from three to six days to complete development. 
Temperature.—Pronounced fever does not ordinarily develop until the 
appearance of the rash. Both the temperature and the rash reach their 
greatest intensity at the same time. Rarely there is a prodromal fever 
for a few hours which may reach 103° to 104° F. This fever subsides 
quickly and the indications are that the exposed child will not develop 
the disease. Within forty-eight hours, however, or less, the temperature 
again begins to rise with the appearance of the rash. In cases of this 
nature difficulty has been experienced at the outset in persuading par- 
ents of the necessity of keeping the child in bed, or even in the house, 
as the illness is looked upon by the family as a cause of false alarm. 682 
THE PRACTICE OF PEDIATRICS 
Diagnosis and Differential Diagnosis.—The diagnosis in most cases 
of measles is not difficult. A mild case may closely simulate one of se- 
vere German measles. The presence of Koplik spots (see Plate II) on 
the buccal mucous membrane, the conjunctivitis, and cough are usually 
sufficient to mark the case as one of true measles. 
There are no other skin manifestations that simulate those of measles 
sufficiently to occasion confusion. 
Complications.—Children with measles almost always have some 
bronchitis. In fact, a mild degree of bronchitis occurs so regularly that 
it may be looked upon as part of the disease. 
Bronchopneumonia is the most frequent complication, because the 
diseased mucous membrane of the respiratory tract becomes a fertile 
field for infection with pneumococcus and other pathogenic bacteria. 
The mortality in institutions for children with measles is always large, 
because of the complication of bronchopneumonia. In an epidemic 
of measles thus complicated, in a New York institution for children, 
there was a mortality of 40 per cent. 
In a series of 3080 cases of measles reported by Mixsell and Giddings1 
from the service of the Willard Parker Hospital there were 826 cases of 
pneumonia, 26.8 per cent., with a mortality of 424, 51.33 per cent. Both 
lobar and bronchopneumonia were included. 
Otitis.—Acute, simple, and suppurative otitis is a fairly frequent 
complication. Its presence should be suspected when the temperature 
is continued and does not subside with the disappearance of the rash. 
The absence of pain does not mean that the ears are normal. In a large 
percentage of our cases of suppurative otitis in young children pain has 
been absent. 
Nephritis is a very rare complication. We have seen but one case. 
Adenitis is a rare complication. 
Recurrence or Second Attack: 
One recurrence after a two-year interval was observed in a girl seventeen years of 
age. The second attack was very severe, and followed by a moderately severe neph- 
ritis. The family, most intelligent and reliable people, insisted, moreover, that the 
girl had had measles in childhood, together with other members of the household. If 
such was the case, she had three attacks of measles. 
A brother of the patient also had two attacks of the disease. 
Prognosis.—The prognosis is good in the cases in which pneumonia 
does not enter. We have never known a fatal uncomplicated case of 
measles. 
Treatment.—Serotherapy .—A review of this form of treatment in its 
application to measles has been made by Ratnoff.2 The method has 
been developed since 1915 by a number of investigators working inde- 
pendently, and since 1919 has been standardized by Degkwitz. Serum 
obtained from the blood of children seven to fourteen days after the 
establishment of convalescence from measles is administered subcutane- 
ously to exposed children, if possible four days after the known exposure, 
in dosage of 2 to 5 c.c. 
The immunity thus conferred is undoubted. In a few cases symp- 
1 Southern Med. Jour., February, 1923, pp. 90-94. 
2 Serotherapy in Measles, Arch. Ped., xl, 10, October, 1923, pp. 683-691 (Biblio- 
graphy). PLATE II 
Fig. 1 
Fig. 2, 
Fig. 3. 
Fig. 4. 
The Pathognomonic Sign of Measles (Koplik’s Spots). 
Fig. 1.—The discrete measles spots on the buccal mucous membrane, showing the 
isolated rose-red spot, with the minute bluish-white center, on the normally colored 
mucous membrane. 
Fig. 2.—Shows the increased eruption of spots on the mucous membrane of the 
cheeks; patches of pale pink interspersed among rose-red areas, the latter showing 
numerous pale bluish-white spots. 
Fig. 3.—The appearance of the buccal mucous membrane when the measles spots 
coalesce and give a diffuse redness, with myriads of bluish-white specks. The ex- 
anthema is at this time fully developed. 
Fig. 4.—Aphthous stomatitis sometimes mistaken for measles spots. Mucous 
membrane normal in color. Minute yellow points are surrounded by a red area. 
Always discrete. 
/mi t i • i t o 1 non \ 
(The Medical News, June 3, 1899.) MEASLES 
683 
toms of mild abortive measles develop in the exposed subjects treated with 
the serum, but in most instances no signs of the disease are to be noted. 
In Ratnoff’s series of more than 100 cases no “single typical fully developed 
case of measles” occurred. Degkwitz obtained the most potent protective 
serum from adult convalescents. 
There is ample evidence also from the consistent success now obtained 
by the New York Health Department to warrant the wride-spread adop- 
tion of this method of prophylaxis, provided precaution be observed that 
the serum be taken from subjects free from all constitutional disease 
other than measles. The Wassermann and tuberculin tests should be 
employed in fulfilling this precaution. 
The duration of the immunity conferred is variable and apparently 
greater in the cases in which the injections are given six days after ex- 
posure than in those receiving the treatment earlier. The evidence 
indicates that lasting immunity is not conferred, although the possibility 
of reinforcing temporary immunity by later injections has already been 
the subject of study. 
General Management.—The popular conception of the management 
of measles is that the patient should be warmly wrapped, given hot drinks, 
and kept in a warm room with little or no ventilation. An attack of 
measles renders the child temporarily very susceptible to bronchopneu- 
monia. The younger and more delicate the child, the greater the danger. 
The darkened room, with its closed windows and dust, the extra wrap- 
pings, with the resulting failure of heat radiation, the reduced vitality, 
and the resulting loss of appetite do much to prepare the way for an 
infection of the respiratory tract, which so often occasions broncho- 
pneumonia. If to a case of this nature whooping-cough be added, we 
have, with few exceptions, a hopeless condition. 
A child ill with measles should be comfortably clad in the usual night- 
clothes and kept in bed. No extra wraps are required, nor is it desirable 
to keep the room warmer than is customary—68° to 70° F. being a suit- 
able temperature. There are many gradations of light between glaring 
sunlight and utter darkness. Both are extreme and one almost as un- 
desirable as the other. It is desirable that a window-shade of dark green 
be lowered within one foot of the window-sill. A light brown or drab 
shade should be lowered completely. If the shade is white, or of a very 
light color, and not supplemented by a curtain of dark material, it will 
be necessary to exclude the bright light by some other means. The 
child, if old enough, may dictate the degree of light, inasmuch as any 
intelligent child will know when the light is painful. 
Feeding.—For the bottle fed, the milk mixture should be diluted at 
least one-half by adding boiled water, and the same quantity given as 
in health. The appetite in the early stage of measles is practically ab- 
sent, so that little or no food is taken. Patients may be given water to 
drink freely at a temperature not lower than 50° F. For “runabout” 
children, eighteen months of age and over, the diet as suggested for the 
sick (see p. 154) should be given. 
Bowel Function.—There should be one evacuation of the bowels 
daily. An enema should be given when defecation does not otherwise 
take place. The urine should be examined every second day. 684 
THE PRACTICE OF PEDIATRICS 
The Eyes.—During the waking hours the eyes should be generously 
bathed every hour or two with a 3 per cent, solution of boric acid applied 
with old linen or cotton, which is afterward destroyed. 
The Ears.—Otoscopic examination should be made every second 
day until the case is discharged. In the event of a sudden rise in tem- 
perature during convalescence, which cannot be explained by the con- 
dition of the intestine, lungs, or throat, such an examination should 
be made by an expert. 
Baths.—The temperature of uncomplicated measles is rarely high 
enough to call for special measures. If it should have a tendency to 
continue about 104° F. after the rash is well developed, and the child be 
uncomfortable and restless, a tepid sponge-bath of ten or twenty minutes’ 
duration may be given. Whether the fever demands bathing or not, the 
patient should be sponged once a day with tepid water at 100° F. After 
the drying an application of cold cream, liquid petrolatum, or olive oil 
should be made to the entire body. This is to be given for the sole 
reason that it relieves the itching, induces sleep, and thus enables the 
child to pass through the disease with less discomfort. 
Delayed Rash.—Now and then a case is encountered in which the 
rash is slow in appearing. The temperature is high—104° to 105° F. 
—the skin hot and dry, and the child very uncomfortable, perhaps de- 
lirious. In such an event a hot bath—105° to 110° F.—of from three 
to five minutes’ duration, often brings out the rash and greatly relieves 
the symptoms, which may have been of an urgent character. On re- 
moving these children from the bath care must be exercised to keep 
them wrapped for fifteen to twenty minutes in a blanket which has pre- 
viously been warmed. 
The cough during the active period of the attack is one of the annoy- 
ing features of the disease, for which some relief must be attempted, par- 
ticularly if the child is kept awake at night. The ordinary expectorants 
alone are of no service in treating the cough of measles. Only a sedative 
will give relief. To a child six months of age from 5 to 8 drops of paregoric 
may be given, and repeated if necessary after an interval of twro hours. 
The following combination of paregoric and sweet spirits of nitre is often 
of service: 
1$. Tincturse opii camphoratae gtt. x 
Spirit us aetheris nitrosi gtt. iij 
M. Sig.—One dose; to be repeated every two or three hours (for a child of 
eighteen months or older). 
From the first to the second year, 10 to 15 drops of paregoric or \ 
grain of Dover’s powder may be given at two-hour intervals, if required. 
Usually but two or three doses of the sedative will be necessary during the 
night. Should the paregoric or Dover’s powder be objectionable because 
one may dislike to give opium to young children, from 3 to 4 grains of 
sodium bromid in 2 drams of water, repeated as required every hour 
or two, will be of service for a child under two years of age. From the 
second to the fifth year 1 grain of Dover’s powder, or from 15 to 25 drops 
of paregoric, or 1/10 to 1/6 grain of codein, may be given at intervals 
of from two to four hours. GERMAN MEASLES (ROTHELN; RUBELLA) 
685 
If bronchitis develops sufficiently to require treatment, as it does 
in at least one-half the cases, the means for the management of bron- 
chitis suggested on p. 343 will be found useful. The temperature of a 
child ill with measles should be taken three times daily, and the lungs 
and heart should be examined every day. 
Vapor.—It is excellent practice to keep the air of the sick-room moist- 
ened with vapor during the entire illness. The benefits are twofold: 
Vapor relieves the cough, being more agreeable than dry air to the con- 
gested mucous surface during the early stage; and it prevents the free 
circulation of dust, the danger of which has already been referred to. 
If the room is carpeted, it should be well sprinkled with water before 
sweeping. If, fortunately, the floor is bare, the broom can be dispensed 
with, and a damp cloth used instead. 
Fresh Air.—Not only should the air of the sick-room be vapor-charged, 
but it should be frequently changed through proper ventilation. 
Quarantine.—The length of quarantine is usually seven days from 
the onset. In some communities an isolation period of twenty-one days 
is enforced upon exposed children. 
GERMAN MEASLES (ROTHELN; RUBELLA) 
German measles is a disease of the runabout and school-child, rarely- 
occurring in infants. It is one of the mildest diseases of the transmissible 
class. 
Etiology.—The specific etiologic agent of German measles is quite 
unknown, but that it is not identical with that of either measles or scarlet 
fever is evidenced by the fact that an attack of rubella does not pro- 
tect against either of these diseases. 
Transmission is by direct contact. We have never had proof of the 
transfer through an intermediary and have never known of a second 
attack in the same patient. 
Incubation.—The period of incubation is from two to three weeks. 
Symptoms.—The first symptom is usually the rash. The temper- 
ature rarely goes above 101° F. In a very few cases it rises to 103° F., 
usually at the onset of the illness. The catarrhal symptoms are negligible. 
There is rarely more than a slight injection of the conjunctiva. 
The rash is not only the first manifestation of the disease, but it re- 
mains the principal evidence of the infection. The eruption closely 
resembles that of measles, and differentiation between the two diseases 
from the standpoint of the rash may be difficult. It usually appears 
first about the ears and neck and spreads rapidly. The eruption at first 
is distinctly smaller and less crescentic than that of measles; it is papular 
and varies from a faint red to a deep red color; rarely it is distinctly 
punctate. When this is the case, the erupted areas may coalesce, pro- 
ducing a diffuse blush not unlike that of scarlet fever. The eruption is 
usually very temporary, lasting from one to three days and disappearing 
after the order of its appearance, leaving the face and the neck first. 
There is no resulting pigmentation or discoloration of the skin, such as 
may occur in true measles. 
There is no involvement of the buccal surfaces except for a slight 686 
THE PRACTICE OF PEDIATRICS 
punctate red rash which may be seen on the soft palate early in the dis- 
ease. 
Lymphatic Gland Enlargement.—Enlargement of the glands at the 
angle of the jaw and the post-cervical glands, particularly the latter, 
occurs so consistently that this condition may be put down as one of 
the prominent symptoms of the disease. The glandular involvement, 
however, is very slight, and disappears in from two to four days. The 
glands in the axilla and groin very rarely show involvement. 
Desquamation.—Only the severe cases are followed by a slightly 
branny desquamation. 
Diagnosis and Differential Diagnosis.—The disease may be confused 
with measles, scarlet fever, and the indigestion and drug erythemata. 
The mildness of the symptoms is a strong point in favor of German measles. 
Exceptionally, a severe case may be difficult to differentiate from true 
measles. In such an instance the absence of eruption on the buccal 
mucous membrane (Koplik spots) is a valuable aid. Further, the typical 
postcervical lymph-gland enlargement does not occur in measles. 
Scarlet Fever.—The characteristic angina, which is a fairly constant 
symptom in scarlet fever, is never present in German measles. There is 
no post-cervical gland enlargement early in scarlet fever; and while the 
rash of German measles may resemble that of scarlet fever, the former 
exanthem is coarser in appearance, the punctate dots are larger, and the 
rash presents a blotched appearance, in contradistinction to the general 
diffuse intense blush of scarlet fever. In scarlet fever, furthermore, the 
desquamation is characteristic. 
In erythema due to drugs there is no manifestation of illness of any 
nature. 
A rash due to indigestion is very transient and is apt to be urticarial 
in type. 
Complications.—We have never known a complication to develop 
with this disease. 
Prognosis.—We have never known a fatal case. 
Treatment.—Rest in bed for about two days, confinement to the 
house for a slightly longer period, reduced diet, and the promotion of 
free bowel action are usually all that are needed. Recovery is ordinarily 
complete in six to eight days from the beginning of the attack. 
Isolation is not a necessity unless there are very young or delicate 
children in the family. 
Diphtheria has been known by its present name for less than a cen- 
tury, although the terms “ulcus Syracum” and “ulcus Egyptacum,” 
together with references to certain anginas with very peculiar expec- 
toration, indicate that the disease was prevalent as far back as the time 
of Hippocrates. As early as 100 B. C. Asclepiades, of Bithvnia, quoted 
by Galen and Aretseus, is said to have known diphtheria and practised 
laryngotomy. Aretseus gave the first important description of “angina 
gangrenosa,” and Galen, in the second century, described the mem- 
branous expectoration. 
Not, however, until the early part of the eighteenth century did 
DIPHTHERIA DIPHTHERIA 
687 
study of the disease become productive. In 1719 Wolfgang Wedel, of 
Jena, issued a document on the value of isolation. A little later an epi- 
demic near Boston, and in 1745 another in Paris, resulted in the des- 
cription of cutaneous diphtheria and of paralysis of the palate and eye 
muscles. Home accurately described the membranes in 1765 and in- 
vented the term “croup,” to differentiate the condition under discussion 
from the “angina maligna” or “gangrenosa” of ancient writers. Not 
until the publication in 1826 of Bretonneau’s famous treatise on the 
epidemics at Tours was the pathology of the disease accurately defined. 
Bretonneau combined all the inflammations previously called angina 
gangrenosa, ulcers, and croup under the term “diphtheria” {AiyO-rpm, 
a membrane) and asserted his belief that direct inoculation and contact 
were the only modes of transmission. 
The later history of diphtheria contains its two most important epochs: 
the discovery by Klebs of the bacillus, in 1883, with its isolation and 
cultivation by Loffler in 1884; and the introduction of antitoxin into 
general use as a result of long experimentation (by Behring, Roux, Martin, 
Chaillon, and Yersin) with the serum of actively immunized animals. 
Since the report of Roux in 1894 that in certain hospitals antitoxin had 
reduced the mortality from 58 per cent, to 20 per cent., the wider and 
more intelligent use of this specific has revolutionized the disease. 
Age.—Diphtheria is of rare occurrence before the first year, although 
no age is exempt. Our youngest patient was five months of age. A case 
in the practice of a colleague occurred at the sixth week. The most 
susceptible age is between the second and tenth year. 
Predisposition.—Vigor of constitution appears to exert no influence 
on susceptibility to the disease. The strong and the delicate are alike 
subject to the infection. Zingher’s investigations with the Schick test, 
however, have demonstrated a larger proportion of susceptible children 
among those living in the less populous, better communities than in dense 
tenement districts where the children have had mild undiagnosed attacks. 
Diseased Throats.—The presence of diseased tonsils and adenoids 
appears to be a decided predisposing factor. Throats so involved possess 
a poor resistance to the infection. It is apparent that a normal throat is 
a valuable prophylactic agent, which means that children whose diseased 
tonsils and adenoids have been removed have the best chance to escape 
after an exposure. 
Transmission.—Diphtheria is both transmissible directly through 
contact, and indirectly through an intermediary. Transmission from 
the diseased to the well is usually through personal association. That 
the disease may also be transmitted through an intermediary person, 
book, or article of clothing, is not to be questioned. Nevertheless, sec- 
ondary sources of exposure are undoubtedly much less a factor than is 
generally accepted. Diphtheria may be so mild in an individual that its 
presence is not suspected, and to such mild ambulatory cases is due in 
many instances the spread of the disease. 
Diphtheria Carriers.—In many instances the presence of the diph- 
theria bacillus is demonstrable in the nasal secretions of healthy children. 
In a series of observations upon public school children in Baltimore 
Styles found diphtheria bacillus in 5 per cent, of cases. 688 
THE PRACTICE OF PEDIATRICS 
Bacteriology.—The morphology of the Klebs-Loffler bacillus varies 
greatly, but it has a characteristic irregularity of staining and regularity 
of grouping which are aids to diagnosis. Its demonstration in smears 
or cultures from the site of the lesion is a necessity for the diagnosis of 
diphtheria. With the weakly alkaline methylene-blue stain recom- 
mended by Loftier the bacilli appear striped, unevenly beaded, granular, 
or clubbed. They are arranged in groups of four or six elements, lying 
parallel or at sharp angles. 
The most frequent localization of Bacillus diphtherise in the human 
body is on the mucosa of the throat, larynx, and nose. The infection 
may travel down into the lung, causing bronchopneumonia, or into the 
stomach, causing pseudomembranous gastritis. The bacilli have been 
found in pus from the middle ear, and the pseudomembranous lesions 
on the skin and vulva. Exceptionally the conjunctiva is infected. As 
a rule, Bacillus diphtherise remains localized at the site of the lesion it 
has produced, and only in very rare instances does it invade the blood— 
probably as a terminal condition. The toxin formed by the bacillus is 
responsible for the general symptoms. 
The bacillus may persist in the throat for weeks after an attack of 
diphtheria, however mild such an attack may have been. These bacil- 
lus carriers become a menace to other persons, since a mild attack of 
diphtheria in one individual may yet produce a severe case in another 
person. 
The Schick Test and Toxin-antitoxin Immunization.—In the Schick 
test a minute quantity of diphtheria toxin is introduced intradermally. 
The effects indicated by a local reaction determine the susceptibility of 
the individual to diphtheria. Toxin-antitoxin injections are employed 
to confer active immunity upon those who are susceptible. 
Susceptibility to Diphtheria.—As mentioned elsewhere very young 
infants have been looked upon as possessing a natural immunity to diph- 
theria. Among several hundred cases but two were seen under six months 
of age. 
Interesting observations as to the susceptibility of children at vari- 
ous ages have been published by Schick, as follows: 
Age. 
Total. 
Schick’s. 
Positive 
Schick’s. 
Per cent, 
positive. 
Newborn 
291 
275 
16 
7 
First year 
42 
24 
18 
43 
2 to 5 years 
150 
55 
95 
63 
5 to 15 years 
264 
133 
131 
50 
Totals 
747 
487 
260 
34.9 
It will be observed that in the newborn but 7 per cent, were susceptibh 
to diphtheria. Among 747 children under fifteen years but 34.9 pei 
cent, were susceptible to the disease. 
It has been proved that an attack of diphtheria not only causes nc 
immunity, but renders the individual more readily susceptible to future 
attacks. PLATE 111 
a 
b 
d 
c 
Shows four typical positive Schick reactions of varying degrees of intensity 
forty-eight hours after test; (a) is a strongly positive reaction, with vesiculation 
of the surface layers of the epithelium, which is seen occasionally in individuals 
who have practically no antitoxin; (b) and (c) are positive reactions; (d) a mod- 
erately positiye reaction. 
a 
b 
c 
d 
Shows a fading positive Schick reaction one to four weeks after test in various 
stages of scaling and pigmentation; (a) shows redness, scaling and beginning 
pigmentation after one week; (b) and (c) pigmentation after two and three 
weeks; (d) faint pigmentation after four weeks. 
(Zingher, American Journal of Diseases of Children, April, 1916.) PLATE IV 
a 
b 
c 
Shows two pseudoreactions forty-eight hours after test, and a combined 
reaction; (a) mild; (b) marked; (c) a combined positive and pseudoreaction. 
(Zingher, American Journal of Diseases of Children, April, 1916.) DIPHTHERIA 
689 
It has also been demonstrated that susceptibility runs in families. 
When one child in a family is Schick-positive others are apt to be positive, 
and the same holds with negative reactions. 
Technic.—Schick published an elaborate technic which was not prac- 
ticable for ordinary purposes. Park and Zingher have simplified the 
technic and this, with slight modification, has been employed on a large 
scale in the testing of many thousands of children in the New York schools. 
The toxin is supplied in capillary tubes. The contents of a tube is 
mixed with 10 c.c. of sterile salt solution and 0.2 c.c. of the solution is 
injected intradermally with a fine hypodermic needle. 
There may be three results following intracutaneous injection of 
diphtheria toxin: 
Negative.—Where no local reaction at all occurs about the injection 
point. 
Pseudopositive (Plate IV) (meaning not positive at all).—Where a 
red area, probably anaphylactic in character, appears within the first 
twelve to twenty-four hours, but disappears in thirty-six to seventy- 
two, with little or no pigmentation. 
Positive (Plate III).—Where in thirty-six to forty-eight hours a red, 
generally clearly outlined area about \ to 2 cm. appears about the in- 
jection point, which lasts, becoming a brick red in two, three, or four days, 
the skin then wrinkling and scaling, after which the discoloration grad- 
ually disappears, taking three to six weeks to entirely disappear. 
Negative signifies immunity. There is sufficient antitoxin in the sys- 
tem to neutralize the poison introduced. 
Pseudopositive also signifies immunity. 
Positive signifies no immunity. There is not enough antitoxin in the 
system to neutralize the poison introduced. The individual reacting pos- 
itive is susceptible to diphtheria. A combined reaction (Plate IV), rep- 
resenting the positive and pseudo-reaction in the same individual and 
showing evidences of a true reaction after the pseudo-element has dis- 
appeared, indicates absence of immunity. 
According to Zingher1 three prerequisites are necessary for the test: (a) a reliable 
toxin, (b) a proper technic, and (c) a correct interpretation of the reaction. Care in 
getting and keeping the toxin will answer the first. A good syringe (preferably a 1 
cc.), and a fine, sharp but short-beveled platinum-iridium needle are needed for the 
second. The ability to carry out the test properly is easily acquired. One point that 
may serve in guiding one in the injection of the diluted toxin might be emphasized. 
If the needle has been inserted in the proper layer of the epidermis, then the oval open- 
ing of the needle will be visible through the superficial layers of cells. A definite wheal- 
like elevation, with the distinct markings of the openings of sweat-glands, shows that 
the injection has been made properly, and that the fluid is confined to a small area, of 
the epidermis. Here it will exert its irritant action if the individual tested is not im- 
mune to diphtheria. 
' Summary and Conclusions.—The following statements quoted from 
Park2 present concisely the results of twenty-five years’ investigation 
of the immunizing effect of toxin-antitoxin injections and the value of 
the Schick test: 
“Three injections, 1 c.c. each, of a suitable toxin-antitoxin mixture spaced one or 
two weeks apart, will cause about 85 per cent, of susceptible children or older persons 
1 Amer. Jour. Dis. of Child., 11, 269, April, 1916. 
2 Jour. Amer. Med. Assoc., vol. 79, No. 19, pp. 1589, 1590. 690 
THE PRACTICE OF PEDIATRICS 
to develop sufficient antitoxin to give the negative Schick reaction and produce marked, 
if not absolute, protection against diphtheria. 
“The development of the immunity is slow. An amount of antitoxin sufficient to 
prevent the positive Schick reaction develops in the different children in from one to 
six months after the receiving of the injections. Antitoxin, as heretofore, must continue 
to be used to produce immediate immunity. 
“The duration of the immunity in at least 90 per cent, of the children is for more 
than six years and probably for the remainder of life. There seems to be no difference 
in this respect between these and those who develop antitoxin naturally. 
“Toxin-antitoxin injections should not be given within two weeks after an injec- 
tion of antitoxin; otherwise the toxin is slightly overneutralized and the resulting 
development of antitoxin is lessened. 
“Mixtures made from old toxin and antitoxin are fairly stable and may be used for 
a period of one year. Even such preparations are at their best when first sent out, 
as the mixtures slowly tend to become at first neutralized and then slightly antitoxic. 
This change gradually lessens the immunizing power of the toxin. The toxin-antitoxin 
should be kept cool and in a dark place; it is best to use the mixtures within three months 
after their final preparation. 
“A toxin-antitoxin mixture of stabilized materials which is safe when it leaves 
the laboratory cannot become more toxic on being kept. No serious effects have 
ever resulted from the injections given to the tens of thousands of the New York chil- 
dren since we began our work, seven years ago. 
“The Schick test is an extremely reliable means of separating those individuals 
who have antitoxic immunity from those that have none. Although a simple test, it 
must be carried out with extreme care. The toxin must be retained intracutaneously, 
and the toxin must be neither 25 per cent, more nor less than the desired amount. 
It is extremely important to choose glass of suitable chemical composition for the con- 
tainers in which the toxin is to be placed, as otherwise rapid deterioration may take 
place. 
“The preliminary Schick test is usually omitted in children under three years of 
age. This is for two reasons: 1, Two-thirds of these children require the toxin-anti- 
toxin injections anyway. 2, We are not certain whether those that do give the negative 
reaction are immune because of an unusual persistence of the antitoxin given them 
by their mothers, or because of the active development of antitoxin in their own bodies. 
After this age the test is desirable, but it is often omitted. 
“Thus, in practical school work, the first Schick test is frequently omitted in chil- 
dren up to the age of six because it is easier to inject the children at once rather than 
to delay for the test. At this age the percentage of children requiring immunization 
is still high, and the annoyance from the injections is slight. The omission of the 
preliminary Schick test facilitates the introduction of the immunizing injections in the 
schools. Above the age of six years the preliminary Schick test should be made when- 
ever practicable. 
“No child should be pronounced immune from diphtheria because of having re- 
ceived three immunizing injections of toxin-antitoxin. A negative Schick test is abso- 
lutely necessary before one can properly make such a statement or issue a certificate. 
“The use of the control protein test made with the heated toxin is advisable at 
all ages when a careful separation of the pseudonegative reaction from the combined 
positive reaction is important. As with the Schick test, it is frequently omitted be- 
cause of local conditions. The older the child, the more likely it is to be immune and 
to give a confusing protein reaction. In children under five years of age the protein 
reaction seldom confuses the picture if the Schick tests are read as late as on the fourth 
day; between five and seven years the control does not help greatly in more than 5 
per cent. In older children and adults not only does the control protein test help us 
to decide more correctly in about 10 per cent, of doubtful reactions; but when it is 
marked it also indicates with some probability those persons who are likely to have 
the marked local and constitutional reactions from the toxin-antitixin injections. 
“The toxin-antitoxin injections are inadvisable before the age of six months. During 
this time most of the infants retain the antitoxin received from their mothers. Up to 
the age of three months immunizing injections are usually ineffective, as the infant 
tissues do not respond sufficiently during this period to the toxin-antitoxin to produce 
antitoxin. Under usual conditions it is probably safe to wait until the infant is nine 
months old and then to give the injections at the first suitable occasion. During the 
first three years there is almost no annoyance from the injections. As the child grows 
older the danger from diphtheria gradually lessens, and the percentage of those de- 
veloping annoying local and constitutional reactions slowly increases. 
“The immunization of school children in acting to prevent their contracting diph- 
theria also lessens the exposure to infection of the younger children of preschool age 
in their families. 
“There appears to be no difference in the degree of immunity between those indi- DIPHTHERIA 
691 
viduals who have developed antitoxin from natural causes and those who did so because 
of the stimulus of the toxin-antitoxin injections. 
“Institutions in which the children have been given the immunizing injections 
have been remarkably free from diphtheria. 
“The school children who have been injected have had one-fourth as many cases as 
the untreated children, and these cases have been of less severity.” 
\ 
Pathology.—Following an invasion of the mucous membrane by the 
specific bacillus, a pseudomembrane is thrown out which is firmly ad- 
herent to the underlying mucosa. The false membrane may be thin 
and grayish in color, or thick and yellow. It is the result of exudation 
into the mucosa, ulceration, and necrosis. The mass thus formed is 
composed chiefly of fibrin, in the meshes of which are entangled poly- 
nuclear leukocytes, desquamated epithelium, and bacteria. The fibrin 
may be deposited in fairly definite layers. Ulceration and small hem- 
orrhages occur in the subjacent tissue, which is very edematous, and 
detachment of the membrane may leave a raw, bleeding surface. When 
the separation occurs naturally, the loosening process is one of autolysis, 
and large defects in the tissue are healed by granulation. New epithelium 
is generally flat, and cicatricial contractures are common. The Klebs- 
Loffler bacilli present in the exudate during the acute stage are usually 
associated with other organisms, such as streptococci and staphylococci, 
which determine to some degree the appearance of the membrane. 
Any of the mucous surfaces may be involved. The process may involve 
the nasal cavities, the lips, the mouth, the conjunctiva, tonsils, pharynx, 
trachea and bronchi, and rarely the esophagus. The involvement of 
the trachea, bronchi, and esophagus in a case observed by the writer 
was proved at autopsy. The rectum and vagina have also been the 
seat of the disease. 
Incubation.—The period of incubation is variable. It may be but a 
day or two, or it may be a week. According to estimate, 1 per cent, of 
school children carry the bacilli in their throats in a viable form, and yet 
by no means 1 per cent, of the children develop the disease. 
Symptoms.—One of the most important features of diphtheria, in 
the great majority of cases, is the slow and gradual onset. At first the 
child may complain of being tired or sleepy and of loss of appetite. Symp- 
toms referable to the throat may appear, but pain is not necessarily 
present. The breath becomes offensive. The physician is sent for on the 
first, second, third, or some later day, depending upon the intelligence 
of the parents or nurse or upon their confidence in themselves to care 
for what, at the time, appears to be a simple condition. The child, not 
willing to go to bed, is looked upon by the uneducated eye as being not 
at all sick. By the time the case is seen by a physician much valuable 
time may have been lost. 
The earlier antitoxin is used, the more certain the recovery. A delay 
of forty-eight or even twenty-four hours may mean a fatal issue. 
Not every case has so gradual an onset. 
Illustrative Cases.—In the pre-antitoxin period, late in the eighties, an asylum 
patient died eighteen hours after the appearance of the first symptom. 
In March, 1910, a father came leading by the hand two children, aged three and 
six years. Both had been ill about three days with fever and some difficulty in swallow- 
ing. They were supposed to have tonsillitis and had not seemed at all ill to the father. 692 
THE PRACTICE OF PEDIATRICS 
A glance showed that they were very ill. On further examination the throats of both 
were found filled with membrane. They were at once sent to the Willard Parker Hos- 
pital and given large doses of antitoxin. One child died in twelve hours and the other 
in twenty-eight hours. 
Localization of the Membrane.—The usual site of the membrane is 
on the tonsils and the pillars. The pharynx is more rarely involved, 
and when involved, has usually become affected through extension of 
the primary lesion. 
Temperature.—The temperature, unfortunately, is rarely high early 
in the case. It seldom rises above 102° F. The lower temperature and 
gradual onset are accountable for many deaths, the physician being 
called late in the disease. 
The Lymph-glands.—Swelling of the lymphatic glands at the angle of 
the jaw is an early symptom in about 30 per cent, of the cases. 
Diagnosis.—Visible membrane should always be looked upon as 
diphtheric, and treated accordingly with antitoxin. Any physician 
who has looked into thousands of throats, will feel sure that the man 
is yet to be born who can safely affirm after inspection alone, that a given 
membrane is not due to the Klebs-Loffler bacillus. There is no invariable 
manifestation, no reliable characteristic of pseudomembrane due to the 
Klebs-Loffler bacillus. 
Antitoxin should be given in any suspected case, and then a culture 
should be taken. Following out this practice we often give antitoxin 
to children who are later found not to have diphtheria, as proved by 
repeated cultures. Never have we regretted this practice. 
Differential Diagnosis.—Both the streptococcus and staphylococcus 
may produce a membrane identical in appearance with that produced 
by the Klebs-Loffler bacillus, and the disease may be differentiated only 
through cultural examination. 
Tonsillitis.—In tonsillitis the temperature is high—103° to 105° F. 
The child is usually much prostrated, and appears very ill. The phys- 
ician accordingly is called much earlier to the patient ill with tonsillitis 
than to the one ill with diphtheria. 
In tonsillitis the tonsils are more apt to be swollen and enlarged, the 
exudation appearing in the form of white dots which stud the surface. 
Care must be exercised, however, in cases which appear to be those of 
frank tonsillitis. The points of exudation may coalesce and in a day or 
two may produce a distinct membrane firmly organized. The only safe 
practice is to make a culture in every case showing visible exudation, 
whether this is on the tonsils or elsewhere. 
Illustrative Case.—A mother developed fever and sore throat. The left tonsil 
was clear. On the right tonsil there were three or four yellowish-white points of exuda- 
tion. The condition was pronounced tonsillitis by the physician in attendance, and 
she was not visited further. In four days the doctor was again sent for, and found she 
had diphtheria with extensive membrane on both tonsils. The mother passed through 
a desperate illness and recovered completely in six months. In addition to a myo- 
carditis she developed diphtheric paralysis of both lower extremities. Two of her three 
boys developed the disease and recovered without inconvenience following the early 
and free use of antitoxin. 
Many other instances of the atypical onset of diphtheria might be re- 
cited reinforcing the view that one should never look lightly upon a throat 
showing exudation on its mucous membrane. DIPHTHERIA 
693 
Prognosis—A favorable prognosis in a given case depends largely 
upon two factors: An early diagnosis and a knowledge of the use of 
antitoxin. The natural resistance of the patient is most important, 
and particularly important is the condition of the throat—whether 
normal and resistant, or filled with diseased tissue, supplying a favorable 
culture field for the invading bacilli. 
Complications. The complications, are bronchopneumonia, nephritis, 
endocarditis, otitis, adenitis, and diphtheric paralysis. 
Treatment.—Owing to our knowledge of the etiology of diphtheria, 
and as a result of the advent of the specific remedy, antitoxin, the dis- 
ease has lost much of its former terror. Diphtheria is still, however, 
an important contributor to the death-rate of all large cities. This is 
due, fust, to parents who fail to appreciate the possible dangers that 
may aiise from a sore throat and who neglect to call a physician early 
in the illness, and, second, to physicians who do not believe in diph- 
theria antitoxin, who timidly use it in small doses late in the disease, or 
who wait for positive clinical signs or a report of a culture before using 
the remedy. Equally as necessary as the realization of the value of 
antitoxin is the knowledge of how and when to use it and when to re- 
peat its use. In many cases, at the beginning of the disease, when the 
tonsils alone are involved, it is impossible, without the aid of the labora- 
tory* to differentiate diphtheria from tonsillitis. C'ase after case was 
witnessed in the pre-antitoxin period, in which two or three days were 
required to make a positive clinical diagnosis. In towns in which a bac- 
teriologic examination is possible it is in some instances safe to wait 
for a report from such an examination. When one is in doubt, a safer 
rule to follow in those cases in which there is pseudomembrane on the 
tonsils is to give antitoxin at once. If the case proves to be one of simple 
tonsillitis, no harm will follow greater than the inconvenience ordinarily 
attendant upon the administration of horse-serum. 
Illustrative Case. During the winter of 1906-07 a girl six years old developed a 
gray, membranous patch on the left tonsil, of the size of the thumb-nail. There was 
a temperature of 101 1. 1 he child complained of feeling tired, seemed generally 
wretched, and had considerable difficulty in swallowing. Three thousand units of 
antitoxin were immediately given and a culture from the throat was sent to a private 
laboratory. Next morning the report arrived stating that the Klebs-Loffler bacillus 
was absent. At this time the membrane had extended and now covered the right 
tonsil. The 3000 units of antitoxin were repeated, and a second culture was sent to 
another private laboratory. Again the report was negative for the Klebs-Loffler 
bacillus, but the culture showed a pure growth of the streptococcus. The following 
morning the throat began to clear, and in two days was normal. Clinically this case 
was one of diphtheria. There was no scarlatina, but there was some swelling of the 
glands at the angle of the jaw. Aside from the improvement, the child showed no 
symptoms whatever to indicate that antitoxin had been given. 
At the present time a much larger initial dose of antitoxin would be given. 
Antitoxin Dosage.—W hen there is membrane on the uvula, the pillars 
of the fauces, the posterior pharyngeal wall, or in the nose, we should 
never await the report of a culture, but give a full dose of antitoxin at 
once. Ten thousand units should be given at the first injection. This 
should be repeated eight to twelve hours later if there is an extension 
of the membrane or if there is no change in its appearance. If the throat 
shows a tendency toward improvement, if there is a curling up and loosen- 694 
THE PRACTICE OF PEDIATRICS 
ing of the edges of the membrane, or if it has taken on the granular ap- 
pearance peculiar to diphtheric membrane after the use of antitoxin, 
we may safely wait twelve hours longer—twenty-four hours in all— 
before deciding whether a repetition of the original dose or the admin- 
istration of a smaller one is required. If the case is seen on the third 
day or after, 10,000 units should be the initial dose and may be repeated 
as suggested above. In the nasal cases a diminution in discharge, a 
lessening of the breath fetor, a reduction in the glandular swelling, and 
a fall in the temperature—all are indications of improvement, but the 
physician should not rest unless the constitutional improvement and the 
clearing-up process are rapid and complete. W hen the case shows no 
sign of improvement, more antitoxin should be given. 
Intravenous, or at least intramuscular, injections are advisable for 
urgent cases because of the more direct absorption thus secured. 
A child ill with diphtheria must be looked upon as poisoned. Anti- 
toxin is the antidote, and every case must receive enough of the antidote 
to neutralize the poison. 
Means of Injection.—There are several antitoxin syringes on the 
market, any one of which may be used if it will admit of repeated boil- 
ing, for in every instance the syringe should be boiled before using. The 
“Record” antitoxin syringe satisfactorily fulfils these requirements. 
Some of the regular producers of antitoxin furnish it in a container with 
an appliance for subcutaneous injection. The advantages possessed by 
this combination are its convenience and its safety, for as the instru- 
ment has to be used but once, the danger of infection by means of a syringe 
which is used repeatedly is thus avoided. 
Site of Injection.—The skin over the abdomen between the umbilicus 
and the anterior spine of the ilium is doubtless the most convenient 
site for the injection. The skin is very loosely attached at this point 
and the serum passes freely under it, requiring very little force and pro- 
ducing no laceration of the tissues or soreness of the parts sufficient to 
interfere with the child’s customary position in bed. If the buttocks, 
favorite sites for the injection, are selected, the needle should be inserted 
well upon one side, so as not to interfere with the resting posture of the 
child. 
Before injection, the skin should be thoroughly scrubbed with green 
soap and washed with alcohol. Upon the withdrawal of the needle the 
skin should again be washed with alcohol, and a piece of zinc oxid plaster, 
1 inch square, applied over the site of the injection. Under these pre- 
cautions regarding cleanliness there has never been, in our experience, 
a suggestion of a local infection. 
Late Injection.—Antitoxin should always be given in diphtheria, no 
matter how late in the disease the case may first be seen. In one case 
first seen by the senior author on the sixth day, 11,000 units were given. 
The child recovered. In a similar case one would now give 20,000 units. 
In another case of laryngeal diphtheria in a boy five years of age who was 
first seen on the fifth day 10,000 units were given, with prompt recovery. 
In a similar case 20,000 units as the initial dose would now be given and 
repeated if necessary. Even when the antitoxin has been given as late 
as the eighth day, recovery apparently due entirely to the serum has DIPHTHEKIA 
695 
been witnessed. In order to be signally effective, however, the serum 
should be given not later than the third day. The later it is given, the 
greater the amount required, and the greater the need of repeating the 
injection. 
Immunization and Quarantine.—When a member of a family becomes 
ill with diphtheria, the suggestions for quarantine (p. 707) should be 
carefully followed. In every case of diphtheria other children of the 
family should be immunized directly with antitoxin. Less than 1000 
units should never be given for this purpose, regardless of the age of the 
child. Cultures should be taken from the throats of children and adults 
alike. If the Klebs-Loffler bacillus is found, the carrier must be isolated 
and treated as diphtheric so far as quarantine is concerned. 
Two children were observed who developed the disease after immunizing doses of 
antitoxin. A child nine months of age was given 3000 units and developed diphtheria 
four days afterward. This patient recovered after a second injection of 3000 units. A 
boy four years of age was given 1000 units for immunization. He developed diphtheria 
in thirty-six hours, which was controlled by the injection of 3000 units. The throat was 
clear in forty-eight hours after the second injection. 
Antitoxin Idiosyncrasy.—In 20 per cent, of the writer’s cases urticaria 
followed the use of antitoxin. The earliest appearance of the eruption 
was on the fifth day following the injection; its latest appearance, on the 
twenty-first day. The urticaria apparently differs in no respect from that 
due to other causes, and the treatment should be the same. Among 
local applications, a 1 per cent, solution of carbolic acid or a lead and 
opium wash relieves the itching better than do other measures. For 
internal administration salicylate of soda answers better than any other 
form of medication. To a child five years old 3 grains well diluted 
may be given every two hours until five doses have been taken, and 
this treatment may be repeated every day until the rash disappears. 
The hypodermic administration of 3 minims of 1:1000 adrenalin solu- 
tion will produce immediate subsidence of the urticaria and afford 
temporary relief. 
Exceptionally in horse-serum-sensitive subjects severe serum sickness 
with joint manifestations follows the use of antitoxin. In view of the oc- 
casional occurrence of sudden severe anaphylaxis following antitoxin 
injection an initial dose of a minute amount subcutaneously should 
regularly precede the therapeutic dose of antitoxin whenever the patient 
is not known to be free from horse-serum sensitivity. 
Remedial Measures Other Than Antitoxin.—Of the many remedies 
which have been advocated and used from time to time in the treat- 
ment of diphtheria, practically none remains in use at the present time. 
During the pre-antitoxin period the writer had abundant opportunity 
in 103 cases at the New York Infant Asylum, to test the value of drugs, 
inhalations, vaporizing treatment, local applications, gargles, and sprays. 
In an article relating to this epidemic of diphtheria which he wrote sev- 
eral years ago is the following statement: “The death-rate in the insti- 
tution from diphtheria was large-—about 60 per cent, mortality. In 
so far as the methods of treatment were concerned, all were equally 
valueless. The mild and some moderately severe cases recovered under 
good general management. The severe cases died regardless of treat- 696 
THE PRACTICE OF PEDIATRICS 
ment.” In other words, there, was no method or scheme of treatment 
used at that time that was of any signal value. Happily, at the present 
time, all the old methods are forgotten. They are not needed. Anti- 
toxin is a specific. The use of sprays and gargles and applications is of 
value as a means of cleanliness only. For this purpose the throat irri- 
gation (p. 321) answers better than any other means. Forcible irrigation 
of the nose should not be employed. In such cases the danger of forcing 
infected material into the eustachian tube, with resulting secondary 
otitis, is real. To small children, if the breathing is interfered with be- 
cause of membrane or tenacious secretions in the nose, a few drops of 
liquid petrolatum instilled every hour will give as much relief as can be 
furnished by any other local measure. 
Sick-room Regime.—In the management of diphtheria the same sick- 
room regime should be enforced as in other serious diseases. The tem- 
perature of the room should never be above 70° F., and at all seasons 
of the year there should always be a free communication with the outer 
air by means of an open window. The child should wear the customary 
night-clothes, and the bed-clothes should be of the same weight as those 
used in health. 
Nourishment.—The nutrition of the patient is most important. As 
a rule, food is poorly taken because of the pain caused by swallowing. 
Inasmuch as but a few ounces may be taken at one time, the nourish- 
ment may well be given in as concentrated a form as possible. Milk 
should be given as the chief article of diet, with the addition of lime- 
water or bicarbonate of soda. If the taste of milk is disagreeable it may 
be mixed with equal parts of a thick gruel and well salted. Animal broths 
contain so little nutriment that their use is ill advised. The milk, plain 
or diluted, will often best be taken if given cold or cool, even to children 
under one year of age. Fluid will usually also be taken from a spoon 
or cup better than from a bottle, because of the discomfort produced 
by drawing on the nipple. When sufficient nourishment is not swal- 
lowed, gavage (p. 853) or rectal alimentation assists temporarily in main- 
taining nutrition. 
The Temperature.—This is rarely high enough to require the use of any 
means for its reduction. In case of high fever the sponge-bath or cool 
pack (p. 841) will answer the requirements. 
Heart Stimulants.—When the heart action becomes weak, irregular, 
or intermittent, stimulation will be necessary. For this purpose three 
drugs are of signal value—strychnin, digitalis, and alcohol. 
Laryngeal diphtheria may develop coincidently with a tonsillar 
or faucial diphtheria. The laryngeal inflammation may develop sec- 
ondarily after a day or two of illness, or it may be the first manifestation 
of the infection. When a child ill with faucial or tonsillar diphtheria de- 
velops a hoarse or croupy voice, with or without impeded respiration, 
almost invariably the larynx has become involved. 
Differential Diagnosis.—When, in the event of a hoarse, croupy voice 
with obstruction as the manifestation of illness, no membrane is visible, 
it is by no means easy to determine whether the case is one of membran- 
ous laryngitis or acute catarrhal laryngitis. The following suggestions 
have aided not a little in arriving at a right conclusion: DIPHTHERIA 
697 
Diphtheric membranous croup. 
Gradual onset. 
Obstruction persistent, with gradually in- 
creasing severity. 
Obstruction both to inspiration and ex- 
piration. 
Little or no response to emetics or in 
halations. 
No response to sedatives. 
Catarrhal croujp. 
Obstruction intermittent. 
Sudden onset. 
Obstruction to inspiration, but little to 
expiration. 
Response to emetics and inhalations and 
to sedatives. 
Contrary to the usual rule, the onset of catarrhal laryngitis may be 
gradual, while that of diphtheria may be sudden. In the consideration 
of a great many cases, however, the points of differentiation are of suffi- 
cient value to warrant the attention which has been given them. A 
particularly valuable sign of diphtheric involvement is the obstruction 
to expiration as well as inspiration. In catarrhal croup there is obstruc- 
tion to inspiration only. 
Treatment.—A safe rule to follow, in view of the urgent demand for 
early injections of antitoxin, is the same as in other forms of diphtheria, 
i. e., when in doubt, inject 20,000 units. From the gradual cessation 
of the laryngeal symptoms it is fairly safe to assume that the child is 
doing well, although the breathing may not be entirely free for forty- 
eight or seventy-two hours after the first injection. In cases which re- 
quire intubation 20,000 units should be given for the first injection and 
repeated the following day. According to our observation, severe laryn- 
geal cases require from 20,000 to 40,000 units, even when antitoxin is used 
early, by which we understand on the second or third day of the disease. 
The earlier the injection, as has been stated, the less frequent will be 
the necessity for its repetition. 
Nasal Diphtheria.—There are two distinct types of nasal diphtheria 
—the acute and the chronic. 
The acute cases resemble in all respects those of diphtheria as it occurs 
in the throat or larynx with the accompanying clinical manifestations 
of illness and prostration. There may be membrane elsewhere, and in 
many of the cases involving the throat and larynx the nares are also 
involved. At autopsies, before the advent of antitoxin, the nasal passages 
were often found plugged throughout their entire extent, the membrane 
being continuous from the anterior nares to beyond the first bronchial 
bifurcation. 
In what may be looked upon as the strictly nasal cases the mucous 
membrane of one or both nasal passages only is involved. 
Symptomatology.—A symptom pointing strongly to a Klebs-Lofffer 
infection of the mucous membrane of the nasal passages is a persistent 
excoriating mucous discharge, with or without a tinge of blood. The 
fever, prostration, and other evidence of the infection may be as severe 
as when the membrane is elsewhere located. 
Diagnosis.—The diagnosis is made by the appearance of the per- 
sistent excoriating discharge, by the discovery of false membrane in 
the nasal cavities, and by the finding of the Klebs-Lofffer bacillus in 
the nasal discharge. 
Exceptionally a foreign body in the nares may give rise to a similar 
persistent discharge without the presence of the diphtheria organism. 698 
THE PRACTICE OF PEDIATRICS 
Treatment.—The treatment is with antitoxin, as suggested for the 
tonsillar and faucial cases. 
Persistent Nasal Infection with the Klebs-Loffier Bacillus.—Per- 
sistent nasal infection of a mild type is of much more frequent occur- 
rence than is generally known. These cases are sometimes alluded to 
by writers under the term “chronic nasal diphtheria.” 
Symptoms.—The child has a persistent sanious discharge from one or 
both nostrils, but shows no sign of illness other than that occasioned by 
the persistent rhinitis. Since there are no systemic effects, these are 
not cases of diphtheria in the accepted sense of the term. Ulcerations 
are occasionally produced, and there may be destruction of membrane, 
cartilage, and bone. 
Illustrative Cases.—Case 1.—A girl of eight years of age had a nasal discharge 
associated with considerable obstruction. The child had been ill for about one week, 
and had been treated for grip by home remedies. There had been slight fever and 
little or no prostration, but a serous nasal discharge which was at times bloody. There 
had been one or two severe nasal hemorrhages. An examination of the nasal cavities 
disclosed that both were filled with membrane, pus, and blood. Nasal diphtheria was 
at once suspected, and a culture was made wrhich was negative. During the following 
three days six cultures in all were made and examined by three different bacteriologists 
in three laboratories, and all reports were negative for the Klebs-Loffier bacillus. The 
membrane was removed on two occasions, and there were three fairly severe nasal 
hemorrhages while we were trying to determine the nature of the infection. Various 
local measures were employed without in any way influencing the process. After the 
case had been observed one week, during which time the child remained free from con- 
stitutional disturbance of any nature, 5000 units of antitoxin were given. In twenty- 
four hours the nose was clear and only a considerable erosion on the septum remained, 
which promised to give trouble because of its depth and tendency to bleed. This area 
was cauterized and healed promptly, and the child was then well. 
Interesting is this case in view of the cultural absence of the Ivlebs-Loffler bacillus, 
and the prompt response to antitoxin, which indicated beyond doubt that the case was 
one of diphtheria. 
Case 2.—A strong, robust boy, twelve years old, from a New York suburb, came 
for examination solely on account of inability to breathe through his nose and a night 
cough which was quite severe. Examination showed the nose to be filled with crusts, 
pus, and dried blood. Upon removing the obstruction a bleeding surface was left on 
both sides, and a perforation of the septum, the size of a dime, was found posteriorly. 
A culture was taken and showed a pure growth of the Klebs-Loffier bacillus. Five 
thousand units of antitoxin were given. The condition immediately improved. Within 
four days the nose was free from the Klebs-Loffier bacillus. This condition had existed 
for at least a year. 
Case 3.—A girl four years of age became ill with fever, which persisted for thirty- 
six hours, when the attending physician noticed a swelling and edematous condition of 
the soft palate. On seeing the case forty-eight hours after the onset the writer found 
the swelling and edema still present, with considerable post-nasal discharge. At no 
time was membrane visible. A culture was taken which proved negative. Five thou- 
sand units of antitoxin were given, and the child made a prompt recovery in about 
forty-eight hours. While there is no direct proof that the child had diphtheria, the 
prompt recovery after antitoxin suggests this condition. The absence of cultural proof, 
in view of experience in the first case recounted, does not signify that the infection 
did not exist. 
Case 4.—A mother presented for treatment 2 children aged two and four years, 
both of whom had had a chronic cold in the head for six weeks. There wras a persistent 
nasal discharge from both nostrils in each patient, serous in character, requiring several 
handkerchiefs daily. The children were generally well and happy. A culture showed 
Klebs-Loffier bacilli in both. Five thousand units of antitoxin given to each child 
cured the condition. 
Much remains to be learned regarding the Klebs-Loffier bacillus 
and its action upon the individual. The effects of this organism may 
be entirely local. Every year in hospital work we see many of these DIPHTHERIA 
699 
cases. In private they are less frequently encountered. On the other 
hand, what is apparently the same organism, with the same morphologic 
characteristics, may produce not only local effects but the most pro- 
found systemic toxemia and death. 
In the cases with local manifestations, are we dealing with the Klebs- 
Loffler bacillus in an attenuated form, or is the infection of a different 
nature and due to another organism of the same family? Although it 
would seem readily possible for the patients showing only local manifes- 
tations to transmit the disease to others with resulting systemic effects, 
the writer has never known of such an occurrence. 
Treatment.—In these cases usually one dose of 5000 units of anti- 
toxin is sufficient. If the process is not controlled, this dose should be 
repeated. 
Intubation.—To the genius of the late Dr. Joseph O’Dwyer, of New 
York, is due the perfecting of this operation. It will forever stand as a 
monument to the inestimable service which he rendered to mankind. 
The O’Dwyer intubation set furnishes us with the necessary instruments 
for the operation. Various modifications of the tubes, the introductor 
and the retractor have been attempted from time to time by others, but 
the original perfected design of O’Dwyer has yet to be improved upon. 
Intubation of the larynx may be required in case of a retropharyn- 
geal abscess situated low on the posterior pharyngeal wall, edema of the 
larynx, or acute laryngitis. The greatest usefulness of the operation, 
however—that for which it was designed—is to relieve the stenosis of 
laryngeal diphtheria. Before attempting to introduce a tube into the 
larynx of the living subject the physician should familiarize himself 
with the operation on the cadaver. In no other way can the procedure 
safely be learned. Attempts at intubations by the unskilled on the liv- 
ing subject can result only in laceration and other gross injuries to the 
parts. 
Indications for Intubation in Diphtheria.—When to intubate is a ques- 
tion puzzling alike to students and to many physicians. It has been 
variously answered, and many attempts have been made to formulate a 
series of clinical manifestations the presence of which would render the 
operation necessary. Thus, it has been said to be indicated when there is 
a pronounced recession of the suprasternal and infrasternal regions, and 
when, as a result the stenosis, air enters the bases of the lungs but feebly 
or not at all. It may safely be said that intubation is rarely done too 
early, but it is very apt to be done too late—not too late in a great major- 
ity of instances to be of some service to the patient, but too late to be 
of the greatest possible service. The best rule regarding intubation in 
laryngeal diphtheria is to intubate when one sees that the child is wasting 
vitality in his efforts to carry on respiration. Intubation should not be 
postponed until he becomes exhausted in the struggle for air. Diph- 
theria is a disease in which every possible strength-unit must be pre- 
served. Energy wasted in supplying air is an unnecessary waste. 
Operation.—For the operation of intubation the patient should be 
wrapped from his shoulders to his feet in a sheet securely pinned from 
top to bottom. The older and stronger the child, the more this is neces- 
sary. The patient is held on the lap of the nurse, who passes her right 700 
THE PRACTICE OF PEDIATRICS 
hand around the child’s body. The child’s body rests on the nurse’s right 
shoulder, firmly held in position by her left hand. Tf the child be large 
and strong, a third person may be required to hold the head, with the 
patient recumbent. After the gag is in position, the operator, holding 
the introductor in his right hand, locates the glottis with the fore- 
finger of the left and using it as a guide directs the tip of the tube 
into the larynx. He must be certain that the tip is properly placed before 
exerting pressure to put the tube into position. This can readily be ap- 
preciated by one who has practised on the cadaver. When the tip of 
the tube positively is engaged in the glottis, gentle pressure will put it 
into final position. Force should never be used, even when the tube is 
started right, for the child may require a smaller tube than his age indi- 
cates. This is rather unusual, however, as are the cases which require 
larger tubes than the age calls for. When the tube is easily coughed up, 
it is essential to introduce the next larger size. With the tube in position, 
the obturator is quickly removed. One should never trust to pressure on 
the shank of the introductor to disengage the obturator, but keep the 
guiding index-finger of the left hand on the expanded head of the tube 
in order to insure its remaining in position during the extraction of the 
obturator. 
Results of Intubation.—After the operation the child who has pre- 
viously been struggling will take a deep inspiration and cough. One of 
the most welcome sounds to the operator is the sharp rattle produced 
by the passage of air through the mucus which has been forced into the 
tube. This tells him that the tube is in position and that speedy relief 
of the stenosis may be expected. The intubated child will usually cough 
vigorously for several minutes, and in so doing may bring up a quantity 
of mucus and shreds of membrane. One is often astonished at the 
large pieces of membrane and the quantity of thick mucus that can pass 
through the comparatively small lumen of the tube. 
In a few cases the presence of the tube in the larynx has caused such 
a persistent cough that a sedative was required to control it. Small 
doses of bromid of soda—4 grains every half-hour for two or three hours, 
for a child four years of age—usually answer the purpose. 
The thread, looped and knotted, attached to the tube, should be 
long enough to extend 4 or 5 inches beyond the lips. In case relief to the 
stenosis is not immediately perceptible after the operation, or if the breath- 
ing is made more difficult, one may be sure either that the tube is not in 
position or, if in position, that it is plugged with membrane, or that 
membrane may have become disengaged and is pushed downward ahead 
of the tube. A tube in the esophagus, where, in hospital service, it is 
often placed by interns, may exert sufficient pressure upon the posterior 
portion of the larynx effectually to impede respiration. 
Illustrative Case.—It became necessary to intubate a boy two years of age who 
was suffering from moderate stenosis due to diphtheria. The tube was easily intro- 
duced, but its introduction was followed by entire cessation of respiration. The tube 
was immediately extracted by means of the attached thread and was found to be 
plugged with membrane requiring considerable pressure with a wooden toothpick to 
dislodge it. The stenosis evidently was somewhat relieved as the result of dilating 
the parts and a removal of a portion of the membrane, but not sufficiently to insure 
permanent relief to the patient. The tube was again introduced, followed by a com- 
plete relief of the stenosis. SCARLET FEVER (SCARLATINA) 
701 
Displacement of the Membrane.—When membrane is dislodged and 
pushed ahead of the tube, it will usually be expelled by coughing after 
the extraction of the tube. 
Illustrative Case.—A case of this nature, following the withdrawal of the obturator, 
occurred in a child six years of age, whose breathing, before difficult, became impossible. 
The child struggled violently, became much excited, and with one hand free, knocked 
the gag from the mouth. Upon efforts to extract the tube the string broke, and while 
the gag was being introduced in order to use the extractor, the child’s struggles and 
attempts at coughing dislodged both the tube and a large amount of membrane, one 
piece of which, inclosing the tube, came out as a perfect cast of the larynx and upper 
trachea. The relief was immediate. Reintubation was not attempted, nor was it 
later necessary. The child had been given 5000 units of antitoxin twenty-four hours 
before, which helps to explain the dislodgment of the membrane. 
Removal of the Tube.—When the patient is progressing satisfactorily, 
the question arises: How soon may the tube be removed? Rarely should 
this be done before the fourth day after intubation. When the tube 
is taken out on the second or third day, for cleansing or other purposes, 
it must usually be replaced. 
Necessity for Intubation.—With the introduction of antitoxin, the 
necessity for intubation has become less frequent. The free use of anti- 
toxin—10,000 to 30,000 units as an initial dose—given with the first sign 
of obstruction, and repeated at eight-hour intervals until two, three, or more 
doses have been given, will render intubation a still rarer necessity. One 
does not feel safe in these cases until 15,000 or 20,000 units have been 
given. Fortunately, in laryngeal obstruction due to diphtheria the 
stenosis is usually of gradually increasing severity, so that by the early 
use of antitoxin many cases are relieved before the necessity for opera- 
tion arises. 
Suction in Laryngeal Diphtheria.—In view of the high mortality 
ranging from 25 to 40 per cent, in intubated hospital cases suction aided 
by direct laryngoscopy has recently been used at the Willard Parker 
Hospital by Gover and Hardman1 with signal success. This method 
promises to lessen the number of cases requiring intubation and trache- 
otomy, but should not be attempted by one unfamiliar with laryngoscopy, 
intubation, and tracheotomy. 
SCARLET FEVER (SCARLATINA) 
Scarlet fever has been clearly recognized for many centuries, although 
its early history is exceedingly obscure. The disease has always been 
most prevalent in civilized portions of the world, has shown remarkable 
differences in the severity of its separate outbreaks, and in almost all 
instances notably refrained from attacking a certain proportion of ex- 
posed individuals, in this respect contrasting sharply with measles, which 
exhibits no such selectiveness. 
Jurgensen reported an epidemic which in the years 1873 to 1875 
ravaged the Faroe Islands, where for at least half a century the inhabi- 
tants had not been exposed to the disease and where the geographic 
conditions rendered observations on its course unusually easy. Here 
the discovery was made that, from a population comprising all ages and 
certainly not protected against scarlatina by a previous attack, only 
1Arch. of Pediat., March, 1923, 702 
THE PRACTICE OF PEDIATRICS 
38.3 per cent, suffered from the epidemic, whereas a similar study of 
measles in the same locality showed that 99 per cent, of the population 
unprotected by previous infection were attacked. It was furthermore 
observed that the susceptibility to scarlet fever was about seven times 
greater in persons under twenty than in those over forty. 
The records of certain European epidemics exhibit a mortality as 
high as 30 per cent., contrasting with a rate as low as 3 per cent, for the 
same place at another period. In New York State scarlet fever easily 
ranks among the dozen most prominent causes of death, usually causing 
a comparative mortality of five, to four of measles and six of typhoid. 
Recent studies of the disease have been devoted extensively to a 
search for the specific cause, our ignorance regarding which has been in 
the past the most serious obstacle in the management of cases. 
A resume of the more important recent contributions dealing with the 
specific aspects of the disease has been presented by Ruth Crabtree1 
and to this we have resorted for numerous facts here cited. 
Etiology.—The specific etiologic factor in scarlet fever was early recog- 
nized as present in the throat and in discharges from complicating otitis 
and other suppurative inflammations, and the constant association of 
the streptococcus with this disease led to the belief that this organism 
was the cause. Moser,2 as early as 1902, contended that the streptococcus 
found in patients was of a specific type. This belief, however, gave way 
to the view quite generally held that the streptococcus found in scarlet 
fever cases was merely a secondary invader. It was not until after the 
introduction of methods devised by Dochez and Avery3 based on biologic 
immunity reactions that it was established that the strains from throats 
of scarlet fever patients were specific. Attempts to produce the disease 
experimentally culminated late in 1923, with the inoculation of volunteers 
by the Dicks,4 and the production of a disease practically identical with 
scarlet fever in guinea-pigs by Dochez and Sherman.5 
Transmission.—The infection is usually transmitted through asso- 
ciation of the diseased with the unprotected. Conveyance of the infection 
by an intermediary probably is of rare occurrence. Milk may be a means 
of conveyance. 
It has long been appreciated that scarlet fever is among the less 
contagious of the contagious diseases. Repeatedly when a case has been 
seen to develop in a hospital ward, there has been no occurrence of the 
disease in other children confined to bed and so kept from immediate 
contact with the scarlet fever patient. 
The most contagious period is probably during the first three or four 
days of the illness. The danger of transmission during the period of 
desquamation is much less than is generally believed. Although, until 
more concerning the nature of the infecting agent is known it is not wise 
to make definite statements respecting the period of communicability, 
observation of a great many cases in institutions and in private work 
leads to the belief that the desquamation seldom, if ever, transmits the 
1 Archives of Pediatrics, xli, 6, June, 1924. 
2 Jahrbuch f. Kinderh., 57, 1903. 
3 Jour. Exp. Med., 30, 179, September, 1919. 
4 Jour. Amer. Med. Assoc., 81, 1166, October 6, 1923. 
5 Proc. Soc. Exp. Biol, and Med., 21, 184, 1923. SCARLET FEVER (SCARLATINA) 
703 
disease. Even before the specific etiology of the infection was established 
many authors were inclined to place less emphasis upon the possible 
contagion from cutaneous scales and more upon the infective character 
of the nasal and aural discharges. 
Evidence is at hand showing that books, clothing, flowers, and food- 
stuffs are means of conveyance from the diseased to the unprotected. 
From personal observation, we have never known of a case having been 
contracted in any of these ways. A great many cases of scarlet fever 
are seen, however, which, ordinarily, would have passed undiagnosed 
if the patient had not been suspected because of known exposure. Cases 
are frequent in which a positive immediate diagnosis is quite impossible. 
Illustrative Case.—During the visitation of scarlet fever to a family, four children 
were attacked. Dr. S. Finley Bell had treated the two other members of the family 
at Englewood, a suburb of New York. A trained nurse caring for the children con- 
tracted the disease and died. Later, a girl six years old died with the disease. On 
a visit to one of the children who had been sent to New York Citv and later developed 
the disease, a member of the family called attention to the arms of the laundress, which 
were slightly reddened. It was Monday morning and she was washing. She had no 
temperature, a normal throat, no rash except upon the arms, and felt well and was 
annoyed that she should be disturbed in her work. The redness of the arms disappeared 
after the completion of the washing, and nothing further was discovered until two 
weeks later, when she was found to be desquamating profusely on the hands and feet 
and slightly over the body generally. She was sent to the Willard Parker Hospital, 
where she reouired two weeks to complete the desquamation. Here was a case in which 
a most careful search failed to reveal any conclusive evidence of scarlet fever, and yet 
the woman was proved to have had the disease at the time of examination. 
There is strong probability that many of the cases of obscure origin 
are contracted by exposure to such atypical cases, rather than through 
infected milk, books, articles of clothing, or intermediary human carriers. 
Susceptibility.—The most susceptible age is from the second to the 
twelfth year. Cases occurring in children under one year old are rare. 
The very young appear to possess a distinct immunity. 
Illustrative Case.—During an epidemic at the New York Infant Asylum at Mt. 
Vernon, N. Y., a colored boy was found to have the disease in a very active form. 
The institution was built on the cottage plan and this boy, 28 runabout children, and 
4 nursing women orderlies with their 4 nurslings occupied the ward on a second floor 
in one of the two-story cottages. The institution, comprising 400 children and about 
200 women, was crowded. 
To break up the ward would have meant that the exposed children, some of whom 
would probably develop scarlet fever, would be placed with unprotected and unexposed 
children. It was, therefore, decided to quarantine the ward with its inmates. Every 
child in this ward developed scarlet fever except the four nurslings, who at the time 
of the outbreak were under three months of age. Three of the women also escaped. 
The fourth woman developed the disease and had a moderately severe attack, during 
which time she nursed her infant, which remained well. It is of interest that so effective 
was the quarantine that the disease did not spread beyond the ward in which it developed. 
Zingher has noted a similarity between the incidence of positive Dick 
reactions and positive Schick reactions, in that there is a greater apparent 
susceptibility to scarlet fever in the poorer and more populous districts. 
With the wider application of the Dick test this knowledge will be greatly 
supplemented. 
It has not been observed that the presence of wounds in any portion 
of the body renders a person more liable to scarlet fever. 
Second Attacks.—One attack almost always protects from subse- 
quent attacks. 704 
THE PRACTICE OF PEDIATRICS 
Only two undoubted instances of a second attack have been personally observed, 
one of which occurred after an interval of four months in a boy of six years, the child 
dying on the fifth day of the illness; the other in a girl twelve years of age, whose pre- 
vious attack was four years earlier. In the girl the second attack ran a typical but 
uneventful course. 
It is interesting to note that an unprotected individual may be re- 
peatedly exposed and only at a late period develop the disease. 
Thus, during an intern service in the institution referred to, where the writer cared 
for 108 cases ot scarlet fever, and the epidemic was severe, requiring that many children 
be seen several times a day, three months of daily and sometimes hourly exposure 
transpired before he developed unmistakable signs of the disease. 
Specific Skin Reactions.—In 1918 Schultz and Charlton1 described 
their so-called extinction test. They found that the injection of normal 
or convalescent serum intracutaneously at the height of the rash produced 
blanching of the reddened skin about the site of the injection. It remained 
for Mair2 to point out that the blanching power, which was not exhibited 
by all normal serum, was actually peculiar to serum possessing immune 
properties. 
The Dick Test.—By using the filtrate of the cultures used in produc- 
ing scarlet fever experimentally in man the Dicks3 were able to develop 
a specific skin test for immunity, similar to the Schick test for susceptibility 
to diphtheria. The specificity of the Dick test is now well established by 
numerous observers, including Williams, Hussey, Banzaf,4 and Zingher.5 
As might be expected, sera of individuals giving a negative Dick test is 
found to cause blanching when employed for the Schultz and Charlton 
extinction test, and to neutralize the toxin of the filtrates of the specific 
streptococcus cultures; while sera of persons giving positive Dick reactions 
is impotent for the production of both these results. 
Incubation.—The period of incubation is variable. It is rarely less 
than five days. If an exposed child passes the ninth day in safety, the 
disease will probably not develop later. One case developed after twelve 
days’ exposure, and one on the fourteenth day following exposure. These 
observations were made in an institution with adequate quarantine facil- 
ities which removed all doubt as to any other source of exposure than 
the original one. So long a period of incubation, however, is exceed- 
ingly rare. Cases reported as developing after a very long incubation— 
three to four weeks—result from more recent exposure which was not 
known. 
Symptomatology.—Nearly all the characteristics of the disease are 
subject to wide variations. Even the rash, the most constant symp- 
tom, may be simulated by sepsis or produced by drugs. Among the 
diseases of children which we are called upon to treat there is, further- 
more, no other which may present itself in such unusual and peculiar 
ways. 
The three symptoms upon which some reliance may be placed are 
fever, angina, and the rash. Any one of these, however, may be absent 
lZtschr. f. Kinderh., 17, 328, 1918. 
2 Lancet, 2, 1390, December 29, 1923. 
3 Jour. Amer. Med. Assoc.. 82, 301, January 26, 1924. 
4Proc. Soc. Exp. Biol, and Med., 21, February 11, 1924. 
5 Ibid. SCARLET FEVER (SCARLATINA) 
705 
in the mild cases. In the moderately severe cases the onset is usually 
abrupt, with fever, angina, prostration, and vomiting, and after twenty- 
four to forty-eight hours the developing rash, which is usually fairly 
characteristic. The angina causes a diffuse redness of the mucous mem- 
brane of the fauces and tonsils, and on the soft palate above the uvula 
minute red points become visible which may coalesce, forming diffuse, 
small, injected areas, and producing a blotched appearance. 
There is loss of appetite and always thirst. The child is irritable, 
and if old enough, complains of headache and muscle soreness. The 
temperature furnishes a fairly accurate index of the severity of the dis- 
ease. The mild cases show little fever, while the severe cases almost 
always exhibit a high temperature. Tlius a temperature range from 103° 
to 105° F. will usually be accompanied by a well-marked rash and pros- 
tration, which tell us that the poisoning is severe. When the tempera- 
ture remains above 103° F., the child is very uncomfortable and com- 
plains much of itching. 
The eruption remains at its height from two to six days, which may 
be looked upon as the period of the rash. With a subsidence of the rash 
the temperature falls gradually to normal. 
Desquamation.—Coincident with the fading of the rash the desqua- 
mation usually begins. It may be delayed, however, from this time until 
the third or fourth week and may show great irregularity in its duration. 
In a very few cases the rash has lasted later than the tenth day. 
Illustrative Case.—During the epidemic mentioned every child in the institution 
was carefully inspected three times daily. At 5 p. m., the time of the last inspection 
for the day, a boy of two years had a temperature of 102° F., an unmistakable rash over 
the left buttock and thigh, and some redness of the throat. There was but little pros- 
tration. He was quarantined, and six hours after his isolation the rash faded abso- 
lutely, the fever promptly subsiding on the same day. In spite of the suspicion of a 
mistake in diagnosis, inasmuch as he had been placed in a scarlet fever ward and ex- 
posed, we had to keep him there. Greatly to our surprise, on the tenth day free des- 
quamation began. 
When uncomplicated, the average case goes on to recovery, with 
completed desquamation in from two to four weeks. 
The shedding of dead epidermis may be most variable in its mani- 
festations. The skin of the hands and feet has been seen to be shed like 
a glove “en masse/’ and yet in a case in which the rash was equally well 
marked no desquamation of any nature was to be observed at any time. 
There has been desquamation, however, although occasionally very slight, 
in nearly all scarlet fever cases coming under our observation. The heel 
and the anterior aspect of the fingers and toes are the sites usually selected 
when the desquamation is scanty. 
Second Desquamation.—Only 2 cases of second desquamation were 
seen. 
The first patient was a girl of five years, who completed the first desquamation and 
was free for six weeks, when the desquamation again occurred on the hands and feet 
and required three weeks for its completion. In the other case, that of a girl twelve 
years of age, the second desquamation appeared three weeks after the completion of 
the first. It involved only the feet and was of two weeks’ duration. 
The amount of desquamation bears a fairly definite relation to the 
severity of the rash, except in the anomalous cases. 706 
THE PRACTICE OF PEDIATRICS 
Severity.—The illness may be of the mildest type, and impossible of 
positive diagnosis, or it may be so severe that the child will live only a 
few hours. 
A fatal case lasted thirty-six hours from the onset of the symptoms. The child 
was never conscious after the first invasion, and the temperature never below 106° F., 
nor could it be reduced below this point. The rash was hemorrhagic. 
Such cases as these, in which the system is absolutely overpowered 
by the scarlet fever posion, are extremely rare. The disease, when fatal, 
is usually so through its complications. 
Diagnosis.—The diagnosis in many cases is very easy. In some it is 
difficult, and in others impossible. Not only are the mild cases difficult 
of diagnosis but also the very severe cases. In malignant cases the patient 
may die before the development of characteristic signs, or the signs may 
be so masked by the severity of the infection as to render diagnosis 
impossible. 
The diagnostic features are the angina, which occasions a diffuse, 
intense general redness of the throat, the fever, and the diffuse blush of 
the skin, which in twelve to twenty-four hours develops into a diffuse 
punctate rash usually appearing first and most characteristically over 
the lower abdomen, in the groin, on the inner aspect of the thighs, and 
over the buttocks, and thence extending to, and involving, the entire 
skin surface. 
It has not been the rule that the rash first appears on the neck and 
chest, as has been claimed by different writers. 
The so-called strawberry tongue is of little differential value, for it 
may occur in many other forms of illness. 
Complications.—Probably no other disease of infancy or childhood 
is so fertile in serious complications as scarlet fever. In fact, compara- 
tively few die from the direct effects of the scarlet fever poison. A strep- 
tococcus infection of the throat is present in all cases and the throat as 
a culture field for the streptococcus is the great source of danger in the 
disease. 
Membranous non-diphtheric angina complicating scarlet fever has 
always been of streptococcal origin in our cases. On inspection, the exu- 
dation resembles that of true diphtheria and our only means of differen- 
tiation is the making of a culture. Such a membrane may involve the 
nasal passages, but rarely extends to the larynx. 
The local infection may be sufficiently severe to cause extreme necrosis. 
Illustrative Cases.—In one case shortly before the time set for operative removal of 
a pair of very large tonsils, a boy developed very severe scarlet fever. On his recovery 
the throat was as free of tonsil tissue as if they had been carefully enucleated. 
In a fatal case necrosis of the soft palate occurred, resulting in a perforating ulcer 
larger than a dime. 
True diphtheria occurs as a complication in a very small percentage 
of the cases. Before our knowledge of the Klebs-Loffler bacillus much 
was heard of diphtheria as complicating scarlet fever, because of the 
presence on the tonsils of membrane, which we now know to be of strep- 
tococcal origin. 
Adenitis.—From the throat the glands may be infected. The lym- SCARLET FEVER (SCARLATINA) 
707 
phatic glands at the angle of the jaw and the retropharyngeal glands are, 
by reason of their location, the most frequently involved. Suppuration 
of the glands and abscess are very frequent, and diffuse edematous cellu- 
litis of the neck is an occasional result of such infection. 
Cases have been reported in which the pus burrowed into the medi- 
astinum, causing septic endocarditis and empyema. 
Pericarditis and endocarditis have been very rare complications and, 
in the cases personally observed, have always been fatal, for the reason 
that such cases of streptococcal origin are always purulent. 
Myocarditis of a mild degree is often disclosed at autopsy. 
Lobar pneumonia is a very unusual complication. 
Bronchopneumonia is found at autopsy in nearly all the fatal cases. 
The development of the disease during an attack of scarlet fever is of 
very grave import. 
Otitis is a frequent and dangerous complication. If all cases of scarlet 
fever, the mild, the moderately severe, and severe, are included, otitis 
will be found in over 10 per cent. 
Albuminuria.—Early in the average case albumin will be found in 
the urine if this is repeatedly examined with sufficient care. This con- 
dition does not constitute nephritis, however, for albumin in small amounts 
is found in most diseases of toxic origin in childhood. 
Nephritis.—Scarlatinal nephritis rarely appears before the third 
week of the disease. Cases have been personally observed to develop as 
late as the twelfth week after the onset. The nephritis is of the glomerular 
type, and more likely to occur after mild infections. The first sign will 
usually be that of a puffiness under the eyes and about the ankles. The 
urine becomes scanty and high colored. This complication is referred 
to again on p. 713. 
Arthritis.—Joint complication has been present in but 5 per cent, of 
our cases. The arthritis is the manifestation of a local infection. There 
may be swelling and redness of two or more of the joints. We have never 
observed one joint alone to be involved. In some cases pain alone will 
be present, without either of the above symptoms. 
Illustrative Case.—A fatal case of pyemic arthritis was seen in consultation with the 
late Dr. Mclnerny, of New York. The joints at the knees, ankles, elbows, and wrists 
suppurated. 
Mortality.—The mortality varies greatly. Different epidemics give 
a different mortality. In institution epidemics the mortality is higher 
than among children in private life. In the New York Infant Asylum, 
during the service referred to, the mortality in children under six years 
of age was 20 per cent. In private work the average mortality ranges 
under 10 per cent. In greater New York the mortality rate within the 
past ten years has been slightly over 4 per 100,000 of population. 
Quarantine.—The isolation of those ill with contagious diseases is 
an absolute necessity for the protection of others. While it is advis- 
able in cases of scarlet fever to remove from the house children who 
have not had the disease, such removal is often impossible. It then 
becomes our duty to establish such a quarantine as will be effective in 
preventing the transmission of the infection. In order to do this, the 708 
THE PRACTICE OF PEDIATRICS 
child and the attendant must be kept from contact with other members 
of the family, whether children or adults. If the residence is a complete 
house, one or two rooms on the top floor should be selected for the patient, 
the room from which he is removed being carefully cleaned and disin- 
fected. If the family occupy an apartment, an effective isolation is 
more difficult, but is by no means impossible. In such circumstances the 
room must be as remote as possible from the other living rooms. It 
should be prepared for the patient according to the instructions laid down 
on p. 152. Not only should the attendant not come in direct contact with 
other members of the family, but there must be no indirect contact through 
dishes, feeding utensils, clothing, or bed-linen. The dishes, knives, forks, 
and spoons should be placed in boiling water and in this sent to the 
kitchen. The clothing, towels, and bed-linen should be placed either in 
boiling water or in a carbolic solution—1 ounce to 2 gallons of water— 
before sending them to the laundry. Upon their arrival at the laundry 
they should be boiled at once. A chair outside the door of the sick-room 
may be used as a receptacle for the various articles for the patient. 
These are to be removed only when the person who brought them is at 
a safe distance. 
Two isolating rooms are better than one, and if there is a connecting 
bath-room, it is much more agreeable to the occupants. If two rooms 
are devoted to the patient, one is to be used for day and the other for 
night occupancy, the unoccupied room being freely ventilated after 
the removal of the child. Observing the above precautions until the 
child is well, we have in many instances carried through to successful 
convalescence cases of scarlet fever while other susceptible children 
have remained in the household during the entire illness without taking 
the disease. 
Illustrative Case.—An incident, previously referred to, which well demonstrates 
the value of proper quarantine, occurred at the New York Infant Asylum, Mt. Vernon, 
New York, during the senior author’s service as intern in that institution. The institu- 
tion was built on the cottage plan, two wards in a cottage. A colored child, an occu- 
pant of one of the upper wards, was discovered to be ill with scarlet fever. There was 
an extensive rash, considerable swelling of the cervical glands, and the whole aspect 
of the case was that of this disease at its height. Through the negligence of an orderly 
the child had probably been ill two or three days before attention was called to him; 
as a consequence 30 other children of the ward had been exposed. In order to prevent 
the spread of the disease to the other 400 children, it was decided to quarantine the 
ward with its children and the 4 attendants. This was done. Twenty-six children 
and one woman attendant developed the disease. The quarantine, on the plan above 
suggested, was continued for ten weeks. The 30 or more children on the ground 
floor of the cottage remained there as before, but no other case developed in the in- 
stitution. In order to prevent the spread of the contagion there was no personal con- 
tact with those outside of the ward, except on the part of the physician who visited 
them daily, but who always went properly protected. All clothing and bed-linen were 
boiled before being removed from the ward. The dishes and feeding utensils were 
likewise boiled before being sent to the general kitchen. 
If such isolation is possible in an institution among the careless and more or less 
ignorant, it certainly should be equally effective among the intelligent, who are most 
interested in preventing the spread of disease. 
When the quarantine is raised, the child should receive a bath of 
hot water and thorough scrubbing with plenty of soap. A few hours 
later a bath of bichlorid 1 : 3000 should be given. If the hair is cut short 
and shampooed with green soap, followed by the bichlorid, the disin- 
fection is more complete. SCARLET FEVER (SCARLATINA) 
709 
Prophylaxis.—Although convalescent serum has afforded apparently 
favorable results in preventing the disease in exposed persons, it may be 
predicted that this method offers little. 
The Dicks have succeeded in developing an active immunity by inject- 
ing their toxic filtrate into susceptible subjects, and the attempt is being 
made to develop this method on a considerable scale in procedure analogous 
to that employed for toxin-antitoxin administration in diphtheria. 
A most efficient safeguard is a normal throat. The presence of en- 
larged tonsils and adenoids doubtless increases susceptibility to the 
disease, and their presence adds greatly to the dangers. 
Treatment.—The patient must be kept in bed throughout the en- 
tire illness, from four to six weeks from the onset first manifested by sore 
throat and fever, until the desquamation is completed.. We must realize 
at the outset the possibilities latent in the virulence of the infection and 
the complications. 
The sick-room should be as large as it is possible for the family to 
supply. It is desirable that it be well lighted by two windows which 
will make free ventilation possible. For the latter purpose, the window- 
board (p. 26) answers well. There should always be a direct commun- 
ication with the open air, except when the child is being bathed or the 
clothing changed. Light and the free circulation of fresh air are abso- 
lutely necessary for proper management of a severe case. If possible, 
two rooms should be used—one for the day, the other for the night. The 
room which is not occupied should have the windows wide open. When 
nephritis, endocarditis, or otitis develop, they are the result of the scarlet 
fever poison or associated infection, and not due to the fact that a win- 
dow was left open. 
Clothing.—The child requires no extra jacket or wraps. The cus- 
tomary night-gown, with the light gauze undershirt, and the usual bed- 
covering, is all that is required. 
Urine Examinations.—The urine should be examined for albumin 
every day. It is excellent practice to have in the house a few test-tubes 
and a bottle of chemically pure nitric acid. When the busy physician 
has the daily specimen sent to his office or carries it home himself it is 
sometimes forgotten, misplaced, or lost. During convalescence, when 
the daily visit is not made, the nurse or some intelligent member of the 
family may be instructed to make the test and report if trouble is dis- 
covered. Because of a lack of these precautions, nephritis may easily 
be overlooked until puffiness about the eyes and edema of the lower 
extremities are discovered by the attendant after albumin has been 
present in the urine for several days. 
Diet.—For the bottle fed during the acute febrile stage the food 
strength should be reduced one-half by the use of boiled water. If the 
child is getting 8 ounces of a milk mixture, 4 ounces of this mixture should 
be given with 4 ounces of water. For older children the diet should be 
considerably restricted, not only during the acute stage, but during the 
entire course of the disease. During the acute febrile stage diluted milk, 
gruels, and orange-juice should constitute the diet. To a child from two 
to four years of age, 5 ounces of milk with 5 ounces of barley gruel No. 2 
(see Formulary, page 94) may be given at four-hour intervals, four or 710 
THE PRACTICE OF PEDIATRICS 
five feedings in twenty-four hours constituting an acceptable diet. Vari- 
ations may be made in the gruels used. Wheat, rice, and Granum may 
all be brought into use, made as suggested in the formulary and given 
with equal parts of milk. It is always well to provide for some variety 
in the food, in order that the child may not tire of it. The juice of one- 
half an orange may be given twice daily, three hours after the milk and the 
gruel feeding. For the sake of variety a glass of whey or kumyss, or a 
glass of skimmed milk containing | ounce of lime-water may occasionally 
be allowed. Toasted bread, zwieback, or plain crackers, dry or in diluted 
milk, may also be given occasionally. 
Milk Diet.—The extensive milk diet in the management of scarlet 
fever, about which we have all heard and still hear a great deal, has not 
been so successful as has the foregoing. The exclusive milk diet is apt to 
produce constipation, intestinal indigestion, coated tongue and loss of 
appetite; in fact, the child “grows stale” on milk, which should properly 
be our dietetic mainstay during the weeks that are to follow. During 
the post-febrile period slight additions should be made to the diet by the 
use of farina, hominy, wheatena, and the lighter cereals, prepared as 
porridge with a sprinkling of sugar and a little milk. The child’s cus- 
tomary diet should not be resumed until four weeks have elapsed from the 
commencement of the attack. If the case has been severe, showing 
marked systemic infection, six weeks should elapse before the full diet 
is resumed. 
Bowel Evacuation.—If at least one evacuation of the bowels daily 
does not take place, a soap-water enema should be given. If, on account 
of the diet and the recumbent position, there is a tendency to consti- 
pation, a glass of malted milk—6 teaspoonfuls of the malted milk to 8 
ounces of water—as a part of the evening meal will be of service in reliev- 
ing the condition. The addition of 1 teaspoonful of cocoa will be accept- 
able when the taste of malted milk is objectionable. 
Laxatives.—As a laxative during the acute febrile stage citrate of 
magnesia is very satisfactory. As a rule, children like it, and to those 
from two to five years of age it may be given in doses of from 2 to 4 ounces. 
In case it is not well taken, from 1 to 2 teaspoonfuls of aromatic fluid 
extract of cascara may be given. 
Specific Medication.—There is no specific medical treatment for 
scarlet fever. Many cases have passed through the entire illness with- 
out the use of any other measures than those suggested above. 
Nursing.—As the course of scarlet fever is distinctly self-limited, 
much can be done in the most severe cases to prevent complications 
and to relieve the patient of his temporary burden and preserve his 
natural resistance. This we have done in no small degree when we have 
so arranged for clothing, diet, fresh air, bowel evacuation, sleep, and quiet 
as to insure the child’s comfort and well-being. The amount of vitality 
wasted by an uncomfortable, restless child in twenty-four hours may 
turn the case from a successful to a fatal issue. 
We fully believe in “spoiling” a sick child. If a child is more at ease 
with the mother, the mother’s place is with the child. If the mother’s 
presence disturbs the child, as it does in some instances, she should be 
kept in the background. If it is apparent that the muse selected is not SCARLET FEVER (SCARLATINA) 
711 
to the child’s liking, or not adapted to the case, another nurse should be 
secured. A physician may be obliged repeatedly to take his best nurses 
from children gravely ill, because the patients are irritable and unhappy 
under the supervision imposed. 
Quiet is most necessary. One person only should be allowed in the 
sick-room with a child very ill. 
Control of Fever.—It is a safe rule not to allow the temperature to 
go much above 104° F. A higher temperature than this necessitates 
an overworked heart. For the purpose of controlling the temperature, 
a fifteen-minute sponging every hour with water at 90° F. may be tried. 
Packs.—If sponging does not answer, the pack (p. 841) should be 
brought into use. The mere existence of a rash is no contraindication 
to the application of moderate cold to the skin. The pack may be used 
in scarlet fever, just as in pneumonia or typhoid fever. The fear that 
the disease may “strike in” and kill the patient is one of the many in- 
explicable ideas of the laity with no foundation in fact. The child is 
placed in the pack at 95° F. It will rarely be necessary to reduce the 
temperature of the pack below 80° F. If the case is of the fulminating 
type, with persistent high temperature, the pack may gradually be re- 
duced to a temperature of 70° F. In thus reducing the temperature 
the towel is not to be removed from the patient. He is turned from side 
to side and the towel moistened with water at the desired temperature. 
Time and again the observation has been made that a child who was 
tossing about the bed, delirious and sleepless, falls into a quiet sleep 
when placed in a pack. With a reduction of the temperature there is 
a corresponding diminution in the pulse-beats of from 20 to 30 a minute. 
Tub-baths.—The full tub-bath at a temperature of 95° F. for ten 
minutes at the commencement of a case in which there is a great deal 
of restlessness and irritability will often act most satisfactorily in quiet- 
ing the patient. Tub-bathing, however, requires a great deal of hand- 
ling of the patient, and in the cases in which there is persistent high tem- 
perature, and in those in which it mounts up suddenly after the bath, 
the pack is far the more satisfactory. In some cases with intense pros- 
tration, high fever and cold extremities, the warm bath—105° to 110° F. 
—for ten minutes will have a most satisfactory effect, the fever being 
thereby reduced, the child quieted, the heart action improved. 
Oil Inunction.—The itching and burning of the skin in scarlet fever 
is most distressing. This is relieved to a considerable degree by the 
pack. The child’s comfort will be augmented by an inunction twice daily 
of cold cream or liquid petrolatum. Vaselin or olive oil may be used, 
but they are much less satisfactory. Vaselin acts as an irritant to some 
sensitive skins. 
During the period of desquamation the oily applications largely 
prevent a free distribution of the scales. 
Stimulants.—If during sleep the pulse is over 150 a minute, and the 
cardiac first sound is weakened, a heart stimulant is necessary. To a 
child one year of age 1 drop of tincture of strophanthus at two-hour 
intervals, or an equal amount of the tincture of digitalis, should be 
given. On account of its being well borne by the stomach, the tincture 
of strophanthus is at times to be preferred. Strychnin is a remedy of 712 
THE PRACTICE OF PEDIATRICS 
considerable value as a stimulant. When the pulse is soft and the heart 
action shows a tendency to irregularity, 1/200 grain may be given every 
four hours to a child from one to three years of age, and 1/150 grain to 
a child from three to six years of age, at intervals of four hours. Alcohol 
should be used only in the septic, asthenic cases when other forms of 
stimulation have failed. In such instances it should be used freely. In a 
few cases very large quantities have been used with striking benefit. 
One-half dram of whisky, at first given every two hours, may be increased 
gradually until its beneficial effects are noticed on the heart action. It 
is astonishing how much alcohol may be given, in a profoundly septic 
case, without the slightest effect except an improvement in the heart 
action, and a corresponding improvement in the child’s general condition. 
Care of the Throat and Nose.—The throat and nose demand our atten- 
tion during the acute stage. For the nose toilet of older children a solution 
of menthol and liquid petrolatum, 1 grain to 1 ounce, may be used by means 
of an atomizer, and for the very young by instillation with a medicine- 
dropper. Forcible syringing of the nose of a young child is not a safe 
procedure even in the most skilled hands. Local treatment of the throat 
depends entirely upon its condition. If the mucous membrane is swollen, 
edematous, and covered with a glairy, mucopurulent secretion, if there 
is a pseudomembrane, or if there is much pain or discomfort upon swallow- 
ing, the child may be made to gargle, if old enough; or, far better, the 
throat may be irrigated with hot saline solution at 120° F. This is done 
in the manner described on p. 321. Force will be required with the very 
young. In older children the relief from pain that is experienced from 
free irrigation is so great that usually the child takes the tube in his mouth 
gladly for the future irrigations. The use of antiseptic gargles and washes 
has not seemed to possess any value other than that of cleanliness, and 
free douching accomplishes this in a far more satisfactory manner. Suc- 
tion in competent hands is here a valuable aid (see p. 701). 
Specific Serotherapy.—Even before the discovery of the specificity of 
the streptococcus of scarlet fever the use of convalescent serum was carried 
out by various investigators in the belief that it favorably influenced the 
course of the disease; and in 1914 Zingher reported favorable results from 
administration of whole convalescent blood intramuscularly. The most 
promising results thus far achieved have been obtained by Dochez,1 who 
has been able to produce a relatively high degree of immunity in the horse 
to the organism which he had employed in producing the disease experi- 
mentally in guinea-pigs. 
The results already obtained by the practical use of immune serum thus 
obtained from the horse have been highly encouraging, and justify confident 
belief in the success of the method when it is more widely available. 
Treatment of Complications.—Cervical adenitis is a very frequent 
complication, and when suppuration occurs, it is most troublesome. 
On the first appearance of a swollen gland a cold compress should be 
applied and then kept on constantly day and night, until the swelling 
has materially subsided. 
The temperature of the water should be from 50° to 60° F. The 
compresses should be changed every thirty minutes during the day and 
1 Jour. Amer. Med. Assoc., 82, 542, February 16, 1924. SCARLET FEVER (SCARLATINA) 
713 
at least every two hours during the night. Several thicknesses of old 
linen, such as are furnished by a table napkin, answer well as a medium 
for applying the cold. The material used should be cut of sufficient 
length to extend from ear to ear under the jaw. In order that the mois- 
ture may be retained oiled silk or rubber tissue may be placed over the 
dressing, and over all a thin gauze bandage pinned together on top of 
the head. 
Otitis is a complication to be looked for in cases of scarlet fever. In 
view of the grave possibilities of mastoid involvement, sinus thrombosis, 
and jugular bulb infection, the presence of pus in the middle ear should 
be promptly detected, and the pus evacuated by a free incision of the 
drum membrane. The presence of middle-ear infection may be suggested 
by a pain or a sensation of fulness in those old enough to locate it. In 
infants, restlessness, sleeplessness, or tenderness on manipulation in cleans- 
ing the ears may be the only objective sign of the trouble. In the ma- 
jority of cases of otitis none of the above signs of pain and discomfort 
are present. The ear involvement is suggested because of a continued 
elevation of temperature which is not otherwise to be accounted for. A 
persistent elevation of the temperature of unknown origin following 
scarlet fever is sufficient occasion for examination of the ears by an expert 
in otoscopy. As a routine precaution during the disease the condition of 
the drum membrane should be noted every day. 
The incidence of otitis depends somewhat upon the character of the 
epidemic, but more upon the age of the patient. The younger the child, 
the greater the danger of ear involvement. Many cases of deafness have 
had their origin in an attack of scarlet fever, and are due to somebody’s 
ignorance or neglect. Among 185 cases of scarlatinal otitis reported by 
Bezold and quoted by Holt, in 30 there was entire destruction of the 
membrana tympani; in 59 the perforation comprised two-thirds or more 
of the membrane; in 13 there were small perforations; in 44 there were 
granulations or polypi; in 15 there was total loss of hearing on one side, 
and in 6 of the cases upon both sides; in 77 the hearing distance for 
low voice was less than 20 feet. May, of New York, collected statistics 
of 5613 deaf-mutes, of whom 572 owed their condition to otitis following 
scarlet fever. 
The bacteriology of scarlatinal otitis is the same as in suppurative otitis 
developing with or following any other infectious disease, except that there 
is a greater tendency to severity because of the liability to streptococcus 
infection. Prompt relief demands prompt recognition of the condition of 
the drum membrane, with evacuation of the pus and suitable after-treat- 
ment. (See Acute Otitis, p. 662.) 
Cardiac Involvement.—Heart complications are not particularly fre- 
quent in scarlet fever. Nevertheless the heart should be examined daily. 
Such complications have been present in about 2 per cent, of our cases. 
Nephritis.—Early in severe infection there will often be discovered 
a transient albuminuria with a few hyaline casts. There may be slight 
suppression of the urine. 
Illustrative Case.—In one ease there was complete anuria at this stage of the disease. 
Within thirty-six hours, moreover, after the first sign of the disease in this case, the 
kidneys ceased to act, and on the third day the child died from the acute diffuse 
nephritis. 714 
THE PRACTICE OF PEDIATRICS 
The condition of the kidney giving rise to albuminuria is best relieved 
through attention to the skin function by the use of a bath at a tem- 
perature of 105° F. every six or eight hours. The child may remain in 
the bath for ten minutes, during which time the skin should be vigorously 
rubbed with the bare hand. The tincture of aconite in doses of 1 drop, 
with 5 drops of sweet spirits of niter for a child eighteen months of age, 
will usually produce a satisfactory diaphoresis. 
What is known as scarlatinal nephritis rarely appears before the 
third week of the disease and cases occur as late as the sixth week. The 
management of this complication is discussed on page 497. 
Arthritis as a complication of scarlet fever is seen in only a few of the 
cases. There may be swelling or redness of the parts, or both these signs 
may be absent. Whether or not the swelling is present, the joints are very 
painful on manipulation. Affected joints should be wrapped in old linen, 
saturated with lead and opium solution, and the dressing renewed every 
six hours. The following lotion has answered well in a few cases: 
1$. Mentholis 5ij 
Tincturse opii 3 tv 
Spiritus vini recti q. s. ad. 5vj 
Soft linen is moistened with the lotion, wrapped about the parts, and 
covered with oiled silk or rubber tissue. The part affected is then wrapped 
in flannel or cotton-wool. The lotion may be freshly applied at intervals 
of from four to six hours. The only objection to its use is the odor of the 
menthol. 
Internally, to a child four years of age, aspirin may be given in doses 
of 5 grains, with 10 grains of the bicarbonate of soda at four-hour in- 
tervals, four doses being given in the twenty-four hours. Salicylate of soda 
may be used in small doses; but, as this may be badly borne by the stom- 
ach, aspirin at times is preferable. 
Septic Rash Resembling Scarlet Fever.—This type of rash is some- 
times described in text-books as that of scarlet fever. An inoculation 
of the disease is supposed to take place through an abrasion or wound. 
We have never seen a case of true scarlet fever acquired in such a manner. 
One does see surgical cases, however, develop a septic rash which cannot 
be differentiated from the scarlet fever rash. In such cases the skin will 
desquamate on the body generally, but not on the hands and feet. There 
is no angina. Further, a case of this nature does not transmit the disease 
to others. 
TYPHOID FEVER 
Typhoid fever is not a disease common to infants or very young 
children, although persons of any age may acquire the disease. It has 
been established that the fetus may be infected by the mother, different 
observers having proved that bacilli in the fetal organs and blood have 
reacted to the Widal test. Numerous cases are reported as occurring 
during the first months of life, but the fact that these cases are reported 
singly, and that such reports are commented upon and quoted by other 
writers, emphasizes the truth that typhoid in the very young is extremely 
rare. TYPHOID FEVER 
715 
In a large hospital and private experience, covering many thousands of cases of 
acute illness in children, during a period of over thirty years, the senior author has seen 
but 4 cases of proved typhoid in children under two years of age. The youngest was 
eight months old and another ten months old. 
Bacteriology.—Bacillus typhosus was described by Eberth in 1880 
and cultivated by Gaffky in 1884. It is short, it does not retain Gram’s 
stain, and grows readily upon all ordinary laboratory media. Important 
characteristics of the organism are its viability and its inability to pro- 
duce gas in any sugar medium. The Bacillus typhosus enters the human 
body through the gastro-intestinal tract, usually by means of polluted 
water, which, in turn, may contaminate milk, vegetables, and oysters. 
During the course of an attack of typhoid fever Bacillus typhosus may 
be cultured from the blood, rose-spots, feces, the urine, and exceptionally 
from the sputum. The bacilli are found in the blood in practically all 
cases of typhoid fever, most frequently during the first week, less fre- 
quently in each succeeding week. In the feces the organisms do not, 
as a rule, appear until the second week, when ulceration has begun; they 
thereafter remain present until convalescence is established. The urine 
rarely contains typhoid bacilli before the end of the second week of the 
disease, when they are present in about 25 per cent, of all cases. The 
urine may continue to show the bacilli for weeks or months after con- 
valescence. In the gall-bladder the bacilli have been found years after 
an attack of typhoid fever. 
Bacillus typhosus is found in pus from complicating suppurating lesions 
in typhoid fever, such as periostitis, osteomyelitis, synovitis, meningitis, 
peritonitis, and abscesses. 
Typhoid carriers have been estimated by Bussell to develop from 
about 3 per cent, of all typhoid fever patients. These persons may excrete 
the bacilli with the urine or feces for many years after an attack of the 
disease, and are, therefore, a menace to those about them. 
Immune bodies develop and circulate in the blood of the patient with 
typhoid fever. One kind of immune body is the agglutinin, the presence 
of which is demonstrable by the Gruber-Widal reaction. This agglu- 
tination of typhoid bacilli by the diluted serum of a typhoid fever patient 
is not usually apparent until the second week of the disease, and may 
be delayed until the seventh week. The reaction is present, however, 
some time during the attack in 95 per cent, of all cases of typhoid fever, 
and is, therefore, a diagnostic aid of great value. (See p. 823.) 
Pathology.—The lesions produced by typhoid are usually much 
less severe in children than in adults. Autopsies upon youthful sub- 
jects have at times revealed no intestinal lesions sufficiently severe to 
warrant the diagnosis. In nearly all cases, however, the small intes- 
tine is the seat of a catarrhal process, and although there may be no 
actual ulceration, the solitary follicles and Peyer’s patches are reddened 
and swollen. The spleen is almost always enlarged. Doubtful find- 
ings may be substantiated by cultures from the blood and intestinal 
contents. 
The origin of the typical lesion has been well explained in the fol- 
lowing paragraph:1 “According to Mallory, the essential feature of ty- 
1 Adami and Nicholls: Principles of Pathology, 1909, vol. ii, p. 439 716 
THE PRACTICE OF PEDIATRICS 
phoid is a proliferation of the endothelial cells through the body, a change 
which he thinks is due to a diffusible toxin derived from the bacilli. The 
lesion in question is found in Peyer’s patches, mesenteric glands, liver, 
and bone-marrow, as well as in the lymphatics and blood capillaries, 
but is proportionately more intense the nearer to the point at which 
the infecting agent gained entrance. The endothelial plates attached 
to the fibrous meshwork of capillaries proliferate, become fused into 
plasmodial masses or giant-cells, and act as phagocytes. They ingest 
the bacteria and slowly eat up the lymphoid cells, which thus gradually 
disappear. A few leukocytes are to be seen in the follicles, and within 
the crypts of Lieberkiihn, but are not an important feature. Owing 
to the massing of these endothelial cells within the capillaries and the 
consequent obstruction to the blood-supply, the parts deprived of their 
nutrition undergo necrosis. The focal necroses in the liver and spleen 
are to be explained in the same way.” 
Symptoms.—We cannot agree with those writers who describe urgent 
symptoms early in typhoid. 
The early manifestations in a great majority of cases consist in mod- 
erate fever, becoming a little higher each day, apathy, and drowsiness. 
The tongue is coated and there is loss of appetite. Epistaxis is a not 
uncommon symptom. 
In children systemic poisoning from intestinal sources appears to 
have some selective action on the nervous system; thus, disturbed di- 
gestion, whether acute or chronic, is productive of dreams and night 
terrors. Gastro-intestinal disturbances, more than any other indirect 
factor, are productive of convulsions. In typhoid fever the central ner- 
vous system, similarly, is affected, but the effect is one of depression. 
The child is dull and apathetic. So indefinite are the signs that a diagnosis 
is impossible for days, and often it is just this feature of absence of diag- 
nostic signs that arouses a suspicion of typhoid fever. Now and then 
a case is seen with stormy onset, high fever, delirium, and rapid pulse. 
In such cases there is usually an associated infection, such as an acute 
intestinal infection or one due to the pneumococcus. 
Nervous Symptoms.—-In mild cases the nervous manifestations may 
be slight or altogether lacking; or there may be apathy, drowsiness, 
stupor, and delirium. The temperature range and the nervous mani- 
festations appear to bear little relation to each other; thus, with a low 
temperature range there may be pronounced stupor and delirium, sug- 
gesting the possibility of meningitis. 
The Pulse.—The pulse-rate is a most characteristic sign. It is com- 
paratively slow, decidedly out of relation to the temperature range— 
slower than in any other illness excepting meningitis. The pulse shows 
no irregularity in force or rhythm. One may find the pulse at 110 with 
a temperature of 104° F. This in itself is a most suggestive sign. The 
typical typhoid pulse is dicrotic. 
The spleen is usually enlarged, the enlargement corresponding with 
the severity of the attack. The organ is usually palpable some time 
during the second week, but in mild cases may never appear below the 
free border of the rib. 
Gastro-intestinal Symptoms.—Tympanites is the rule; this condition TYPHOID FEVER 
717 
may be extreme or of mild degree, or it may not exist. With suitable 
feeding tympanites may be largely eliminated. 
Either diarrhea or constipation may be present. Here also the feed- 
ing of the patient plays an important part. Patients who are fed with 
large quantities of milk often have diarrhea or constipation, or the two 
conditions alternating, along with abdominal distention, high fever, 
and greater toxicity. 
Rose spots may be absent, few in number, or scattered over the skin 
surface. They appear most often on the abdomen, but frequently also 
on the chest and back. 
The Blood.—A fall in red corpuscles and hemoglobin is to be expected 
after the first two weeks. Leukopenia is constant and there is a relative 
mononuclear increase. The Widal reaction appears usually only after 
the first week and may be delayed until late in the course. This reaction, 
however, may persist for years after the attack. Positive blood-cultures 
may be obtained before the development of the positive Widal reaction 
even when the latter is obtained early in the disease. 
Temperature.—The temperature range is variable. The usual range 
is 101° to 103° F., perhaps occasionally reaching 104° F. It is extremely 
rare for the temperature to continue after the eighteenth day. In typhoid 
a very high temperature is not always a bad prognostic sign. 
Illustrative Cases.—In the case of a girl seen in consultation with Dr. Staub, of Stam- 
ford, Conn., there was a temperature range for eleven days of 104° to 106° F., and from 
101° to 104° F. for ten days longer, the entire duration of temperature being thirty-six 
days. During the illness the child did not appear to be very ill. 
In the case of a boy of ten years, who showed a positive reaction, the temperature 
lasted two weeks, but was never above 100.5° F. by mouth. 
In the exceptional case of a ten-year-old girl the duration of the fever was only 
ten days. 
Complications.—The complications of typhoid in children have been 
exceedingly rare in our experience with the disease, and fatalities have 
been of most unusual occurrence. 
Intestinal hemorrhage of any severity is an exception, and perforation, 
in the case of a child, we have not known. 
The fact that typhoid fever bacilli may be cultivated from the blood 
and urine implies that infection of various organs in the body may and 
does occur; thus the disease may cause pyelitis, peritonitis, meningitis, 
osteomyelitis, synovitis, otitis, neuritis, parotitis, phlebitis, adenitis, 
furunculosis, and abscesses. When bronchopneumonia occurs with 
typhoid fever, it is usually a terminal infection. 
Suspicious Diagnostic Signs.—Apathy, drowsiness, a gradually ris- 
ing temperature curve, with diarrhea, and perhaps tympanites. 
Diagnostic Signs.—Positive Widal reaction; elevation of tempera- 
ture, and pulse slow in comparison to the temperature; involvement of 
the central nervous system, drowsiness, stupor, delirium, enlarged spleen, 
and rose spots. 
The Widal test may be corroborated by culturing the blood and 
urine and by examination of the feces. 
Differential Diagnosis.—Any continued fever of unknown origin, 
until very recent years, would have been called typhoid or malaria. It 718 
THE PRACTICE OF PEDIATRICS 
was only a few years ago that some of our best clinicians in this country 
and in other lands diagnosed as typhoid every continued fever which 
did not respond to quinin, and for which no adequate cause could be 
discovered. 
With the exact means of diagnosis which are at our disposal at the 
present time there is no occasion for failure to differentiate malaria, 
typhoid, and the conditions with temperatures due to occult pus. 
The nervous phenomena of typhoid, when particularly pronounced, 
may, upon inspection alone, closely simulate those of meningitis. In 
typhoid the respirations, if slow, are regular and of even depth; the pulse 
is slow and regular. In meningitis irregularity or some atypical con- 
dition characterizes the pulse; it may be very rapid—180 to 200— 
with a temperature of 101° or 102° F. The spleen is not typically en- 
larged in meningitis, nor are rose spots present. 
Acute miliary tuberculosis may simulate typhoid. In tuberculosis 
of this form there is absence of all typhoid signs except the fever, 
which is usually very high in children of the typhoid age. The eruption 
and the mental dulness of typhoid are not seen in acute miliary tubercu- 
losis. Enlargement of the spleen may be present in both diseases. 
Mortality.—Many of the mortality tables are valueless. Statistics 
of cases and diagnoses antedating the Gruber-Widal reaction and the 
discovery of the bacillus in the blood, urine, and feces are inaccurate. 
Thus, in one series, in infants under one year of age, we find the mor- 
tality given as 50 per cent. 
The mortality in private cases treated in homes or private institu- 
tions ranges from 2 to 3 per cent. In cases treated in hospital wards 
or in institutional homes it ranges from 8 to 10 per cent. 
In 95 hospital cases Koplik lost 9 patients—a mortality of 9.4 per 
cent. Henoch, in 375 cases, had a mortality of 14 per cent. 
Antityphoid Vaccination.—The prophylactic value of antityphoid vac- 
cine has been abundantly established in both civilian and army practice. 
For an average child ten years of age one-half the adult dose should 
be given. Thus if 500,000,000 is given for the first dose, 1,000,000,000 
for two subsequent doses at intervals of ten days, a total dosage for a 
child of ten years would be 1,250,1)00,000. 
Reaction.—A reaction manifested by slight fever and muscle sore- 
ness and fatigue occurs in a small percentage of cases. The local re- 
action is slight, although there may be pain, tenderness, and a localized 
infiltrated area. The neighboring lymph-glands may show temporary 
enlargement and be sensitive to touch. This condition need cause no 
anxiety. 
Duration of Immunity Conveyed.—According to the best observers 
immunity continues from two to two and one-half years, at the end of 
which time a reinoculation should be done. 
Advisability of Inoculating Children.—Children who remain at home 
under careful supervision will not require inoculation, as the incidence 
of typhoid under such conditions is very small. Those who travel about, 
particularly in summer, going by train or boat, living in hotels and board- 
ing houses, are constantly exposed to the possibilities of typhoid infection. 
Such children should have the advantage of antityphoid vaccination. TYPHOID FEVER 
719 
Treatment.—While usually the disease runs a shorter course in the 
child than in the adult, an attack means, at the least, several days of 
illness, and it may mean from three to six weeks. For this reason it 
is best to establish a sick-room regime, under which must be particularly 
considered the feeding, the bathing, the airing of the room, and the main- 
tenance of absolute quiet. If the patient becomes very ill, but one at- 
tendant at a time should be in the sick-room. 
Bathing.—The patient should be sponged twice a day, an ordinary 
cleansing bath being given. During the bath it is not necessary to un- 
cover the body. Parts may be bathed and dried, after which other parts 
may be given attention. 
Mouth Toilet.—Careful mouth toilet should be observed. Gingivi- 
tis and ulcerative stomatitis, with secondary involvement of the cervi- 
cal lymph-nodes, are not infrequent complications in these cases. 
Disposal of the Excreta.—The excreta from both bladder and intes- 
tine should be received in vessels containing a 1 : 1000 solution of 
bichlorid of mercury. Carbolic acid should not be used. The necessity 
for the attendants to wash their hands with soap and water after at- 
tending to the patient should be made very plain. Attendants should 
also be advised as to the proper disposal of the excreta. For children 
of tender age who still require the napkin it is best to dispense with the 
usual article and use cheese-cloth instead, several thicknesses of which 
may be made of the required shape and burned when soiled. The bed- 
linen should be changed every day. 
The Feeding of Typhoid Fever Cases.—Contrary to the general prac- 
tice, little or no milk should be given in many typhoid cases. A trial 
in practice of the early teaching that milk afforded the only diet suitable 
for this disease soon led to the discovery, on the contrary, that the less 
the milk given, the less was the tympanites, that without milk the tem- 
perature course wras lowrer, that there was less tendency to delirium, 
and that the duration of the case was shorter and, as a whole, less severe. 
In fact, these observations bear out the teaching of Seibert, of New York, 
who was the first to advocate the non-milk diet in typhoid fever. 
The diet preferred consists largely of gruels, made from cracked wheat, 
barley, rice, oatmeal, or any of the uncooked cereals. One ounce of 
the cereal is boiled for three hours in 1 pint of wrater. At the completion 
of the boiling, boiled w7ater is added to make the quantity of the gruel 
1 pint. If the gruel is too thick for drinking, more boiled water may be 
added. The gruel thus prepared is used as a “stock.” It may be given 
plain, with salt or wdth sugar, or both. As flavoring, 2 or 3 ounces of chicken 
or mutton broth may be added. From 6 to 8 ounces of the gruel are given 
every three hours—five or six feedings in the twenty-four hours. The pa- 
tient is encouraged to drink water, which is given between feedings. Lemon- 
ade, tea, and weak coffee may also be given between the feedings. Rice 
or other light cereal, wThich has been boiled for at least four hours, is 
given once or twice daily. It is best served with plenty of butter and sugar, 
with the aim of increasing the caloric content of the food. 
The diet schedule for a typhoid patient, aged five years, would thus 
be practically as follows: 720 
THE PRACTICE OF PEDIATRICS 
6 a. m. : Eight ounces of gruel with sugar or a small amount of broth added. Zwieback 
or dried bread and butter. 
8 a. m. : A drink of weak tea with sugar, or the whites of one or two eggs with sugar 
in orange juice. 
10 a. m.: Farina, cream of wheat, rice, served with butter and sugar, or maple-syrup 
and butter. Drink of weak tea or kumyss or matzoon, or perhaps a dried 
milk food, such as malted milk or Nestll’s food. 
2 p. m.: Eight ounces of kumyss, matzoon, or skimmed milk diluted with gruel. 
Zwieback or dried bread and butter if wanted. 
4 p. m. : Orange-egg sherbet, or a drink of lemonade or tea and sugar. 
6 p. m.: Cereal (or gruel) with sugar and butter or with broth. If skimmed milk 
has not been given at 2 p. m., it may be given with cereal at this time. 
10 p. m. : Gruel with sugar or broth, or with wine. 
Later, when the tongue becomes clear and the breath loses its char- 
acteristic odor, scraped rare beef and soft-boiled eggs may be allowed. 
With the use of the more substantial foods, the number of feedings in 
the twenty-four hours is to be reduced to four. 
It will be seen that the caloric requirements, 60 to 70 per kilo, for 
the five-year-old child, may easily be supplied by the above arrange- 
ments of the feeding, although the diet as arranged may not be ideally 
balanced. (It would be high in carbohydrates, rather low in fat, and 
perhaps deficient in protein, particularly during the earlier period of the 
treatment.) 
Fat in considerable quantity is poorly digested by young typhoid 
fever patients. It may be given, however, in small amounts when mixed 
with other foods. Foods containing protein should not be given in con- 
siderable amount until we can predict the course of the disease. Milk, 
scraped beef, and soft-boiled eggs are often not well borne by young 
typhoid patients, and a temporary reduction of protein is not felt by 
them. 
Carbohydrates, such as the cereals and the different sugars, are readily 
cared for when properly prepared and administered. They supply fuel, 
but no toxic by-products, and do not require immediate elimination from 
the body. Excessive emaciation is prevented through their action as 
protein sparers. Mendel and Rose found that the excretion of creatin 
induced by starvation is inhibited in rabbits by feeding a diet of carbohy- 
drates, absolutely free from proteins and fats. When the carbohydrates 
are given in liberal amounts, the creatin entirely disappears from the 
urine. The creatin eliminated is not reduced by feeding a diet of fat alone 
or by a diet of fat and protein. Experimental interference with carbo- 
hydrate metabolism leads to the elimination of creatin, the presence of 
the creatin being due to true tissue or endogenous metabolism. 
Milk should not be given in any considerable amount before the 
temperature has been normal for one week. Even then, in a case in 
which no milk has been given and in which there have been pronounced 
elevation of temperature and intestinal disturbance, the giving of milk 
may cause a rise in the temperature. In not a few cases in which the 
temperature was running a low course—from 100° to 102° F.—without 
the presence of tympanites or delirium, the fever has been seen to shoot 
up to 105.5° F. and the tongue become furred and the abdomen distended, 
following the administration of milk. 
Illustrative Case.—A few years ago a girl twelve years of age had typhoid fever. 
The temperature was not high, the range being from 101° to 103° F. In fact, fever and TYPHOID FEVER 
721 
an enlarged spleen were the only signs of the disease, until the diagnosis was confirmed 
by a positive Widal reaction. The tongue was moist throughout the illness, as is not 
unusual when milk is not given. The family were fearful that the patient was not being 
sufficiently nourished. The mother had been told by a physician, a family friend, 
that such was the case. She begged that the girl be allowed one glass, 8 ounces, of 
whole milk daily. Accordingly the nurse was instructed to give the patient one glass 
of milk once in twenty-four hours. She did so, and in three hours after the first glass 
there was a rise in temperature to 106° F., with abdominal pain and distention. One 
bottle of the citrate of magnesia and a high enema were given, after which the disease 
resumed its usual course under the previous diet, without milk, the temperature not 
going above 99° F. after the seventeenth day. 
Mortality statistics do not teach us all that may be learned regard- 
ing the disease or a method of treatment. The time element, as related 
to the duration of the illness and the duration of the convalescence, is 
important. Observation in the milk-fed cases indicates that the illness 
may be more severe, increasing the danger to life, and that the duration 
of the illness is longer. Emaciation may be much greater, and the con- 
valescence consequently much more protracted than under the feeding 
indicated. The case in which the temperature period is cut down to 
fourteen to twenty days, and in which there is little emaciation and a 
prompt convalescence, should not be put in the same class with the case 
in which the fever lasts from thirty to fifty days or longer, with a con- 
valescence of three or four months, although both patients have had 
typhoid fever and both have recovered. 
It is argued that milk constitutes the ideal diet, for the reason that 
it contains all the nutritional elements required by the organism—fat, 
protein, carbohydrate, and mineral salts—which is the truth. It is 
further claimed that milk may be taken in large quantities and be readily 
digested, which is not true in the case of sick children. The addition 
of pepsin, hydrochloric acid, etc., has been of no value. In order to have 
a short case and a mild case the abdomen must be kept flat. Tympanites 
is an indication of danger, regardless of how it is produced. On the milk 
diet tympanites is the rule. On the mixed diet suggested it is the excep- 
tion. So long as one can keep the belly flat he may feel that he has the case 
reasonably in hand. 
The High Caloric Diet.—The applicability of high caloric feeding 
in typhoid fever, of which practice Coleman has been a pioneer advocate, 
seems to be unquestioned by those who have given this method a trial. 
The precaution, however, has been generally observed by those who have 
reported success, of giving the large allotment of food requisite to com- 
plete the assigned calories in the form of such articles as sugar, cereals, 
egg, and a moderate amount of cream, all of which are fairly well tol- 
erated by most patients. We have had but little experience with this 
method. It would seem that in spite of its very apparent advantages 
such feeding necessarily imposes upon the physician extra watchfulness 
for the occurrence of untoward symptoms such as tympanites, consti- 
pation, and high fever. 
Drugs.—With the so-called intestinal antiseptics in typhoid fever 
experience has been most unsatisfactory so far as concerns their in- 
fluence upon the disease. If there is constipation, the citrate of mag- 
nesia, from 4 to 6 ounces, given cold, is grateful to the patient and usually 
proves effective. If the bowels do not move once in twenty-four hours, 722 
THE PRACTICE OF PEDIATRICS 
a high enema should be given. The digestive capacity is indicated by 
the condition of the tongue and may be improved by the use of dilute 
hydrochloric acid and the tincture of nux vomica. The following will 
be suitable for a child from five to ten years of age: 
1$. Tincturae nucis vomicae. gH- xlvnj 
Acidi hydrochlorici diluti gtb exx 
Glycerini • 3jss 
Aquae destillatae Q- s- a(b 51V 
M. Sig.—One teaspoonful in water after each meal. 
As many as four bowel passages in twenty-four hours may occur 
without harm to the patient. In fact, from two to four may be con- 
sidered necessary to maintain free drainage. When there are more than 
six in twenty-four hours, loose and watery in character, the loss of fluids 
sustained may be a serious factor in the case, in causing a concentration 
of the blood, with corresponding concentration of the poison, as shown 
in the marked general toxemia. 
Diarrhea in typhoid is best controlled by the use of opium combined 
with bismuth. To a child from three to five years of age the following 
may be given: 
1$. Pulv. ipecacuanhae et opii gr. x 
Bismuthi subnitratis gr. c 
M. Div. et ft. chart. No. x. 
Sig.—One every three hours until the stools diminish in frequency, 
then at intervals of six to twelve hours if necessary. 
For children from one to three years old the dose of Dover’s powder 
should be reduced one-half, the full amount of the bismuth being given. 
The amount required to keep the diarrhea under control will soon be 
learned. Of course, constipation must not be produced, for if a free bowel 
action is interfered with, there will be increased prostration and higher 
temperature. 
Control of the Fever.—A temperature at or below 104° F. need not be 
interfered with in the great majority of cases. Of course, a very deli- 
cate child with a weakened heart action may require the use of anti- 
pyretic measures before this temperature is reached. This necessity, 
however, is unusual. When the temperature is above 104° F. the patient 
does better if proper means are used for its control. 
Antipyretic drugs are rarely given. Quinin has never proved of the 
slightest value, even when given in large doses—15 or 20 grains in twenty- 
four hours to a child five years of age. The coal-tar products, such as 
phenacetin, may be used in small doses without harm if hydrotherapy 
is not applicable, as in a case recently seen in a remote country district. 
Illustrative Case.—The patient was a boy six years of age. He was delirious at 
times, tossing almost constantly about the bed, and sleeping but little, with a tem- 
perature ranging from 105° to 106° F. The disease period was the latter part of the 
second week, and the patient was becoming rapidly exhausted. The parents, densely 
ignorant, refused to allow the bath or pack. Sponging, which was carried out indif- 
ferently, had not the slightest effect on the temperature and appeared to excite the 
patient. It was suggested to the attending physician that he give 2 grains of phen- 
acetin and | grain of the citrate of caffein at intervals of three to six hours. From four 
to six powders daily were required to keep the fever within the desired bounds and the 
skin moist. This medicine had a decidedly quieting effect upon the patient, his TYPHOID FEVER 
723 
heart action was in no way unfavorably influenced and he made a complete recovery. 
Had the great restlessness, the loss of sleep, and the delirium continued undoubtedly 
there would have been a fatal termination. 
While there is much truth in what has been written concerning the 
depressing effects of the coal-tar products, and while the dangers from 
their excessive use are realized, on certain occasions they are a neces- 
sity. One cannot help feeling that the dangers have been exaggerated. 
Probably the diseases in which the use of such drugs is most dangerous 
are pneumonia and the inflammatory conditions of the heart. 
Heart Stimulants.—If the heart, by the rapidity of its action, shows 
signs of failure, the tincture of digitalis is our best remedy. When there 
is irregularity in force and rhythm, strychnin should be used. A child 
from five to ten years of age may be given 2 drops of the tincture of dig- 
italis or strophanthus at intervals of twTo to four hours. Strychnin, 1/50 
grain, at intervals of three to four hours, may be given for the same age. 
Alcohol should not be given as a heart stimulant until other means have 
failed. It is a drug to be used only in conditions of great stress. Its 
function is to carry us over and out of difficult places, and it may be 
given in the form of whisky or brandy, 1 to 3 drams at intervals of two 
to four hours for children from three to ten years of age. Its continued 
administration for a considerable period is not to be advised. 
In any disease it is difficult to lay down definite rules for the admin- 
istration of heart stimulants. They are used with the hope of producing 
a definite effect, and when such effects are produced, a larger quantity 
should not be given. It is best always to begin with small doses and 
gradually increase until the desired results are apparent. 
Hydrotherapy.—Pyrexia is best controlled by hydrotherapy. 
Sponging with lukewarm or cool water may be tried, and if the case 
is not severe, this may answer. The child may be sponged with water 
at from 80° to 70° F. for one-half hour out of every four to six hours. 
Sponging, however, even if it controls the temperature, may not be the 
best means of using water for this purpose, for the reason that many 
children object to it, and in consequence the sponging disturbs them, 
increasing their irritability and reducing their vitality. 
The use of the bath for the reduction of fever in children has proved 
disappointing. They invariably object to it, the bath excites or frightens 
them, and, as a rule, particularly in the very young and delicate, the re- 
action following is poor. Moreover, the bath necessitates a great deal 
of handling, undressing and dressing, and therefore tires the patient. 
Reduction of the temperature by means of a rectal irrigation with 
cool water has its advocates. If the temperature is running high and 
intestinal lavage is indicated for reasons other than the temperature, 
lavage may be used, the water being of a lower temperature than 
that of the body, though never lower than 80° F. Without a high 
body temperature, however, and other indications as well, irrigation is 
never advisable. It causes straining, excites the child, and thus in- 
creases the danger of hemorrhage and perforation. Furthermore, such 
irrigation is a very indifferent antipyretic, even when used as cold as 
75° F. 
By far the best means of reducing the temperature in children is 724 
THE PRACTICE OF PEDIATRICS 
the cool pack (p. 841). Its advantages are that it causes no fright or 
shock to the child. He may be placed in a towel, which has been wet 
with water at 95° F. The only manipulation necessary is to turn him 
from side to side, so that the towel may be kept constantly wet with 
cool water at the desired temperature. The pack more effectually controls 
the temperature than does either sponging or the tub-bath. As sug- 
gested elsewhere (p. 841), the child should be removed from the pack 
when his temperature falls to 102° F. 
Hemorrhage and Perforation.—Hemorrhage has not occurred in 
any children’s cases personally observed in which the non-milk diet 
was given. In the event of hemorrhage the cold coil or the ice-bag should 
be applied and Dover’s powder given in full doses to control peristalsis. 
In case of perforation, operative procedure is to be resorted to, but this 
holds out little hope. Children bear abdominal operations badly, and, 
considering the exhausted condition of a young child in the third or fourth 
week of a severe typhoid, the outlook is most unfavorable. 
Malaria is caused by Plasmodium malariae, a protozoon discovered 
by Laveran in 1881. 
Species.—Three species of plasmodium are recognized, one caus- 
ing tertian malarial fever; another, quartan malarial fever, and another, 
malaria of the estivo-autumnal type. 
The tertian malarial parasite, which is the most common form, com- 
pletes its development in the blood in forty-eight hours, and produces 
a malarial paroxysm every second day. When fully grown the tertian 
parasite is much larger than the quartan variety, which sporulates in 
seventy-two hours. The estivo-autumnal parasite produces the remit- 
tent form of malarial fever, with varying intervals between the par- 
oxysms. The characteristic form of this plasmodium is the pigmented 
crescent. 
The plasmodia of malaria enter the red blood-cells and live at their 
expense. The resulting anemia is due to the destruction of the large 
number of erythrocytes, the parasites deriving their pigment from the 
hemoglobin of the red corpuscles upon which they have fed. 
For details concerning the morphology and biology of the organisms 
the reader is referred to standard works on clinical pathology. 
Transmission.-—Malaria is transmitted from one human subject to 
another by the bite of the Anopheles, a species of mosquito. 
The fully developed parasites are most readily found in the blood 
an hour or two before the onset of the paroxysm. 
Craig has stated that in malarial localities children suffer much more 
severely from the disease than do adults, and that malaria is often latent 
in young subjects. The disease may occur in very young infants, but 
is always of postnatal orign. Thayer and others have shown conclu- 
sively that malarial parasites are not transmitted through the placental 
circulation. 
Malarial fever contracted in New York City is of very unusual oc- 
currence. Patients coming under observation have, with few exceptions, 
resided elsewhere, or contracted the disease while in the country during 
MALARIA MALARIA 
725 
the summer. Every autumn a few cases of such origin are treated. They 
are usually of the tertian type. 
Pathology.—The most marked pathologic changes in malaria are 
found in the blood, since the plasmodia feed upon the red blood-cor- 
puscles. As a result, there is a marked reduction in the number of ery- 
throcytes and in the amount of hemoglobin; there is, further, the pro- 
duction of a large amount of black and brownish-yellow pigment. The 
leukocytes are also decreased in number, while there is a relative increase 
of large mononuclear cells. 
At autopsy upon patients dying of pernicious malaria characteristic 
lesions are found in the brain, spleen, and liver. The brain usually shows 
congestion and capillary hemorrhages due to blocking and rupture of 
the capillaries by plasmodia and pigment. There may be pigmentation 
of the gray matter. The capillaries contain infected blood-corpuscles, 
free plasmodia, free pigment, macrophages often large enough to block 
the vessel, and pigmented leukocytes. The nerve-cells show marked 
degenerative changes. 
The liver is enlarged, fatty, pigmented, and congested. In the capil- 
laries malarial plasmodia and pigment are seen within macrophages, 
but only very few plasmodia are found within red blood-cells. The liver- 
cells are degenerated, and sometimes pressed out of existence by the 
distended capillaries. Areas of focal necrosis occur with an increase in 
the connective tissue around them. 
The spleen is enlarged and pigmented, and the pulp is soft and dark 
colored. The venous sinuses are congested, and there are many plas- 
modia free in red blood-cells, in macrophages, and in smaller cells; there 
is also free pigment. The splenic connective tissue is increased only 
in those cases in which repeated attacks of malaria have occurred. 
The other viscera do not show specific lesions of any kind. All the 
capillaries contain malarial plasmodia, and there is present more or 
less pigmentation. The epithelial cells of the kidneys and adrenals are 
usually degenerated as the result of the toxemia. The heart may be 
flabby and anemic. The lungs may show congestion, edema, or broncho- 
pneumonia. 
Symptoms.—The symptoms vary somewhat with the age of the pa- 
tient; thus, an infant, instead of giving evidence of a chill, which signals 
the onset in older children, becomes cold, blue, and pinched in appear- 
ance. Vomiting or convulsions may take the place of a chill. What- 
ever the nature of the immediate onset, fever follows, which rarely con- 
tinues longer than five or six hours. This stage may not be followed 
by sweating. About the same time, on the following day or the day 
after, the same phenomenon is repeated. The patient is very comfort- 
able between the seizures. 
Physical examination of the patient will reveal enlargement of the 
spleen. The blood findings have been mentioned under Pathology. In 
neglected cases signs of malnutrition rapidly develop regardless of the 
age. They differ in no way, however, from those dependent upon febrile 
conditions due to other causes. 
The extreme variability in size of the spleen as a result of malaria is 
not popularly appreciated. 726 
THE PRACTICE OF PEDIATRICS 
Illustrative Case.—A fifteen-month-old Armenian boy, who had contracted malaria 
at eight months of age and had been given no regular treatment, came under the care 
of the junior author with malarial organisms in the blood, an erythrocyte count of 
3,080,000, and a hemoglobin percentage of 35. The spleen was found upon careful pal- 
pation to extend to the anterior superior spine of the ileum in the nipple line, and to 
about 1 inch below the umbilicus in the midline, the arc of the lower border extending 
to about 1 inch below the midpoint of a line joining the anterior superior spine and 
the umbilicus. Response to treatment was immediate, and after the expiration of a 
little over a year the spleen was palpable only slightly below the ribs. 
The possibility of at first confusing the picture in such a case with that of primary 
splenic disease is readily apparent. 
Relapse.—When relapse occurs, it means one of two conditions— 
reinfection, or a case not cured. A relapse after weeks or months is not 
uncommon. Very frequently in cases which have been treated with 
quinin for only a week or two until the active symptoms subside, after 
a long period, another sharp attack results. The manifestations are 
occasionally milder. There is, perhaps, a low periodic temperature with- 
out chill, the temperature not reaching a point above 101° or 102° F. 
Time and again this feature of the disease has been evident. These cases 
represent what is sometimes designated as chronic malarial poisoning or 
persistent malarial infection. In non-malarial sections reinfection is an 
improbability. 
Diagnosis.—The positive diagnosis of malaria depends upon finding 
the malarial organism in the blood. This is, as a rule, possible only when 
quinin has not been recently given. 
The next best means of diagnosis consists in the use, in suspicious 
cases, of adequate doses of an assimilable preparation of quinin. An 
immediate control of the temperature is then strong presumptive evi- 
dence that malaria has existed. When full doses of quinin do not control 
the temperature, this fact usually means that malaria does not exist 
and that there is other cause for the illness. 
Differential Diagnosis.—There are probably very few diseases with 
fever which have not many times been confused with malaria. In fact, 
the erroneous diagnosis of malaria has probably been made more often 
than all other diagnostic errors combined. 
There are many conditions in which there may be a remittent temper- 
ature period, and which may be looked upon as malaria. An enumeration 
is unnecessary. Probably elevation of temperature due to occult pus is 
responsible for more diagnoses of malaria than is any other form of fever. 
Influenza, typhoid fever, pyelitis, tuberculosis, and periodic fever due to 
fatigue often evoke the mistaken diagnosis of malaria. With blood 
examinations and the various newer diagnostic methods there is no 
occasion for errors in differentiation. 
Prophylaxis.—This consists in keeping the child free from the Anopheles 
mosquito. The administration of quinin in malaria-infected communi- 
ties for purposes of prevention of the disease is a common and justifiable 
practice. 
Treatment.—When it is demonstrated that malaria exists, quinin 
should be given in what may be considered large doses, if we are to use 
The adult for comparison. Children tolerate quinin well. In fact, a 
much larger amount comparatively is required than for adults. In giv- 
ing quinin to young children, however, care must be used lest it excite MALARIA 
727 
vomiting, and for this reason it should be given after meals in solution 
or in capsule. An excellent menstruum is a preparation of yerba santa, 
known as Yerbazin.1 A child under eighteen months of age will re- 
quire from 8 to 12 grains of quinin daily. Two to 3 grains of the bisul- 
phate should be given at a dose, not more than four doses being given in 
twenty-four-hours. 
When the writer was resident physician at the New York Infant 
Asylum, then located in southern Westchester County, New York, there 
was a great deal of malaria among the women and children inmates. 
In that institution he repeatedly gave infants under four months of age 
8 grains in twenty-four hours. In some cases at this age a larger quan- 
tity—10 to 12 grains—will be required. Quinin chocolate tablets are 
sometimes used for children. In using these tablets it must be remembered 
that the contained quinin is in the form of the tannate, and that 1 grain 
of the tannate represents about | grain of the sulphate. If sufficient 
quinin to be of value is given in this form, the large amount of chocolate 
in the tablet will almost surely upset the digestion. Lilly’s “coca quinin” 
is a liquid, chocolate-flavored preparation apparently less likely to disagrees 
To children under one year of age with whom Yerbazin may disagree 
because of the sugar which it contains, the bisulphate may be given 
in solution in distilled water, followed by a teaspoonful of orange juice. 
For older children—from two to six years of age—from 15 to 30 grains 
daily will be necessary to control the disease. To these, as to the younger 
children, this drug should be given in one of the palatable liquid forms 
unless the child can be taught to take a capsule, when the quinin may be 
given in 3-grain doses at two-hour intervals until the prescribed daily 
amount has been taken. 
The giving of a large dose of quinin a few hours preceding the ex- 
pected chill does not answer well in treating children, as a large amount 
given at one time may frequently cause vomiting. 
Special Methods of Administration.—The use of quinin by inunction 
or by the rectum has not been satisfactory. Its use by these methods 
was attempted at the Infant Asylum in a great many cases when diffi- 
culty was experienced in the gastric administration. 
Illustrative Case.—With but one patient, aged two years, was it necessary to resort 
to hypodermic medication. The blood in this case showed the tertian parasite, and the 
disease resisted the internal use of quinin in large doses, but responded promptly to the 
muriate of quinin given hypodermically, 7 grains being used at one injection. There 
was no abscess at the site of the injection, and the child was permanently cured. To be 
sure, the administration of quinin was continued by the mouth, but the dosage of 16 
grains daily was now apparently effective, where previously it had failed. 
Recurrence.—The use of quinin in malaria should not be stopped 
abruptly upon a cessation of the fever. It is advisable to give the drug 
in full doses for one week after the temperature fails to rise unless there 
is a subnormal temperature, in which event the drug should be reduced 
one-half or temporarily discontinued. It is a difficult matter to deter- 
mine when a case of malaria is cured. Time and again, weeks after it 
was supposed that a patient was well, a recurrence of the paroxysm took 
place. How often this was due to reinfection, and how often to the old 
1 Made by Lilly & Co. 728 
THE PRACTICE OF PEDIATRICS 
infection which had not been entirely eradicated, it is difficult to say. 
We are inclined to the belief, however, that in many instances the plas- 
modium had remained inactive in the spleen in spite of the return of that 
organ to nearly its normal size, for the reason that the recurrence of 
symptoms sometimes took place coincident with some other illness with 
fever, such as tonsillitis or acute indigestion. Experience with recurrences 
of the disease has been such that, after an attack of malaria it is customary 
to direct that the child be given quinin for one week out of each month 
for an indefinite time—at least for a year following the original attack. 
Illustrative Case.—A girl five years of age had repeated attacks for two years before 
coming under observation. The mother was instructed to give the child 12 grains of 
the bisulphate daily for seven days out of each month. This, without a change of 
residence, was sufficient to prevent a recurrence during the fifteen months which followed. 
INFLUENZA (LA GRIPPE) 
Influenza is an acute infectious disease commonly ascribed to Bacillus 
influenzse, first described by Pfeiffer as a result of his studies during the 
great pandemic of 1889-90. 
Bacteriologic Etiology.—It is a slender, non-motile rod, which stains 
deeply at the poles, does not retain the Gram stain, and is very pleo- 
morphic. Its one unvarying characteristic is its utter inability to grow 
in media which do not contain hemoglobin. On agar mixed with human, 
pigeon’s, or rabbit’s blood, its cultivation is an easy matter. The col- 
onies are small and dewdrop-like, they do not coalesce, and they do 
not cause hemolysis in the surrounding medium. 
Mode of Entrance.—It is the rule for the influenza bacillus to enter 
the human body through the upper respiratory tract, whence it may 
travel down into the lung, causing bronchitis or bronchopneumonia. 
In comparatively few cases it is the cause of otitis media. General blood 
invasion with Bacillus influenzse is a rare condition, which is usually, 
but not invariably, accompanied by purulent inflammation of one or 
more serous membranes—meningitis, pleuritis, pericarditis, peritonitis, 
arthritis. 
Since the pandemic of 1918 views concerning the etiology of influenza 
have been greatly modified and by many observers Pfeiffer’s bacillus is 
no longer credited with being the specific cause. Undoubtedly an organ- 
ism productive of a disease of such definite epidemiologic features and 
symptoms as those of the great pandemics of "flu,” differs from that 
causing ordinary “grip.” Whether the role of Pfeiffer’s bacillus like 
that of the pneumococcus and streptococcus may not be that of a sec- 
ondary invader is thus open to question. In any event, until our know- 
ledge is more accurate, distinction between pandemic influenza and the 
other forms of grip is a difficult problem. 
Source of Infection.—The source of infection is contact with an acute 
case of influenza or with a carrier. In either instance the secretions 
from the nose or bronchi contain the bacilli in a moist state. The organ- 
isms do not resist drying long enough to make clothes or linen a prob- 
able source of contagion, but they do remain viable for months in the 
bronchial secretion of cases of influenzal bronchitis, with or without INFLUENZA (LA GRIPPE) 
729 
bronchiectasis, and they have been found there six months after an at- 
tack of pertussis (Davis). 
The work at the New York Babies’ Hospital (Wollstein) has shown 
that the influenza bacillus is present in the bronchial secretion of young 
children far more often than is usually known, and that it is not pres- 
Fig. 118.—Temperature chart. Prolonged influenzal infection. 
ent as a saprophyte. Patients suffering from tuberculosis are very prone 
to infection with influenza. It may, in such cases, by causing a terminal 
bronchopneumonia be the actual cause of death. 
Age.—All ages are susceptible, particularly infants under one year. 
Pathology.—Influenza produces no distinct lesion of its own. In 
the respiratory tract, where the bacillus is most active, there may be 
Fig. 119.—Prolonged influenzal infection.—(Continued.) 
only the changes characteristic of bronchitis or there may be a broncho- 
pneumonia due to Bacillus influenzae in pure culture. The bacillus is most 
fertile in its power of producing lesions in various organs, but these lesions 
in no sense differ from those produced by certain other forms of infection. 
Incubation.—The period of incubation may be very short. It is 
rarely longer than seven days, and may be but one or two. 730 
THE PRACTICE OF PEDIATRICS 
Symptoms.—The onset of influenza is usually with sneezing, slight 
conjunctivitis, and cough. There may be a moderate fever—from 100° 
to 103° F. or higher. The throat is reddened, and there may be a few 
coarse rales in the chest. The symptoms subside, and the child is well 
in five or six days. After the second year children complain of head- 
Fig. 120.—Prolonged influenzal infection.—(Continued.) 
ache and muscle soreness; there is also a failure of appetite. This rep- 
resents a mild attack of the type seen in a great majority of the cases. 
Severe cases show the above signs, with the exception that there are 
higher fever and much greater prostration. Convulsions are unusual, 
but headache and extreme restlessness are often present. 
Fig. 121.—Prolonged influenzal infection.—(Continued.) 
Cough.—The cough in the severe type is often most troublesome. 
The most severe coughs do not occur, necessarily, when bronchitis is 
a complication. The hard, persistent cough, without expectoration, 
without rales, or with but a few rales in the chest, may be said to typify INFLUENZA (LA GRIPPE) 
731 
the cough of influenza. Every year we see patient after patient who 
has the nagging tracheal cough not only during the attack, but some- 
times for weeks afterward, without a sign in the throat other than per- 
haps unusual redness, and without a chest sign. The influenza bacillus 
seems to have a special tendency for localization in the trachea. 
Gastro-intestinal Manifestations.—Occasionally grip is ushered in 
with pronounced gastric disturbance indicated by nausea and vomit- 
Fig. 122.—Prolonged influenzal infection.—(Continued.) 
ing, no food being retained for twenty-four to forty-eight hours. Pro- 
nounced intestinal disturbance is by no means an unusual evidence of 
infection with the influenza bacillus; there may be diarrhea without 
any evidence of involvement of the intestinal structure, or there may 
be colitis with tenesmus, and mucus and blood in the stools. In not a 
few cases the so-called complications are the only manifestations of the 
Fig. 123.—Prolonged influenzal infection.—(Concluded.) 
infection. This has led writers to describe a “grip colitis,” a “grip gas- 
tritis,” a “grip pyelitis,” etc. 
The temperature characteristics of influenza are peculiar. There is 
a tendency to wide, irregular variations from normal to 105° or 106° F. 
and back again. One repeatedly observes temperature ranging from 
100° to 103° or 104° F. for six or eight weeks (Figs. 118-123), without other 
lesion than that of a catarrhal bronchitis. A peculiar feature of these 
uncomplicated grip cases is the height to which the temperature will rise 732 
THE PRACTICE OF PEDIATRICS 
daily and its long continuation for many days with insignificant signs of 
illness and absence of effects on the patient. 
Fatal Cases.—Fatalities from uncomplicated influenza are unusual. 
Illustrative Cases.—Two cases of grip in infants, in which the diagnosis was made 
by exclusion and verified by autopsy, occurred at the County Branch of the New York 
Infant Asylum during the winter of 1888 and 1889. which, it will be remembered, was 
the time when grip first visited this country in epidemic form. These healthy, breast- 
fed babies were taken with the disease, together with about 40 other inmates, mothers 
and children, in one of the large wards. The infants in question, aged three and four 
months respectively, were stricken suddenly with high fever and marked prostration. 
They quickly went into a condition of collapse, and both died in less than thirty-six 
hours from the onset. The autopsy failed to show any pathologic change other than 
a slight hypostatic congestion of the lungs. 
Complications.—The influenza bacillus alone may produce otitis, 
meningitis, pericarditis, periarthritis, peritonitis, and nephritis of the 
hemorrhagic type. The chief danger attending its invasion of the body 
is its ability to prepare a field for the development of other pathogenic 
organisms. 
The most frequent complication of grip is bronchitis, and that causing 
the most deaths is bronchopneumonia. 
Suppurative otitis is not an infrequent complication; perhaps it would 
be .better to class it as a grip sequela. Among 72 cases of acute sup- 
purative otitis referred to elsewhere, 59, or 81.9 per cent., occurred with 
or followed immediately upon an attack of grip. Patients who, after an 
attack of grip, run a temperature without any apparent cause, should 
be examined by a skilled otologist. 
Adenitis is a complication in many cases. 
Endocarditis associated with grip is not infrequent. 
The Kidneys.—In nearly all cases of severe infection a slight amount 
of albumin is present in the urine during the entire period, and occa- 
sionally, in a few cases, hyaline and granular casts are found. The 
irritation is only of temporary duration, and subsides after a few days. 
In a very large experience with all types of influenza we have never 
known the association with grip of acute nephritis such as occurs with 
scarlet fever or the other exanthemata. 
Every year we see cases of acute hemorrhagic nephritis complicating 
influenza. These cases are peculiar in that there is a large amount of 
blood with a few hyaline and epithelial casts. There is little or no sup- 
pression of the urine and no edema or sign of nephritis except the urinary 
findings. We have never lost such a case, although microscopic blood 
and casts have been present in the urine for several weeks. 
Duration.—The duration of influenza may be two or three days or it 
may be two or three months. One attack of the disease confers no im- 
munity. The long-continued cases are those of reinfection and recrudes- 
cence. 
Prognosis.—The prognosis of influenza is favorable in the absence 
of complications. With complications the outcome depends upon the 
nature of the associated disease. Further, it is to be remembered that, 
as a complication of bronchitis and pneumonia, influenza supplies a 
decided additional danger. 
Diagnosis.—From simple internal colds a differentiation may be INFLUENZA (LA GRIPPE) 
733 
impossible even by a bacteriologic examination. In influenza there is 
a tendency to chronicity and reinfection, with widely fluctuating tem- 
perature, irregular as to rise and fall. It seems most difficult for the 
patient completely to recover. Meningitis, malaria, and typhoid fever 
may be confused with grip, but may be readily differentiated by the 
well-known diagnostic methods. In any case of influenza the ears should 
be subjected to daily examination, as otitis may cause an elevation of 
temperature identical with that of a protracted case of uncomplicated 
influenza. Pyelitis should always be excluded. 
Sequelae.—After even a moderately severe attack of grip the patient 
is left in a condition that is peculiar to this disease and none other. He 
is habitually tired, easily fatigued upon slight exertion, shows but little 
tendency to take up active play, and, if older, finds school work 
difficult. In a large proportion of cases there is a slight elevation of 
temperature nearly every day—rarely higher than 101° F. A feature of 
these temperature cases is that the attack may not have been at all severe. 
Every winter and spring the writer is repeatedly consulted about the ten- 
dency to elevation of temperature after grip. In some cases the tem- 
perature will continue for months. It will be normal—98.5° to 99° F.— 
in the morning, perhaps 100° F. or thereabouts at noon, and 101° F. or 
a fraction higher at night. It rarely reaches 102° F. The peristent tem- 
perature cases are not due to disease processes or to the presence of the 
influenza bacillus in the bronchial tract, as has been claimed, but to 
constitutional weakness and fatigue. In some wray, through the action 
of the toxins of the disease, the heat-regulating center becomes involved, 
and through activities which ordinarily would not produce any effect 
an influence is exerted causing an elevation of the temperature. That 
a portion of this deduction is correct may be readily proved by keeping 
these patients quiet in bed for three days, and taking their temperature 
at the usual intervals, morning, noon, and night (6 p. m.). It will be 
found, if they are kept quiet and the bowels active, that the temperature 
will remain within the normal limits—not above 99° F. This has been 
demonstrated in a great many cases. If fever continues uninfluenced, 
there is a discernible cause wdiich should be discovered. After grip, 
because of the child’s low physical state, he is often urged to take more 
food than he can assimilate, and there may be a mild degree of intestinal 
indigestion, producing sufficient toxic effects to cause the temperature, 
yet unobserved because of the absence of active symptoms. We have 
known the free use of milk and cream to produce a slight persistent ele- 
vation of the temperature after grip. Tuberculosis of the bronchial glands 
may produce a similar but less persistent temperature range. 
Quarantine.—Individuals with influenza should be quarantined 
(p. 707) from other members of the household. Older members of the 
household are often the bacillus carriers and infect the younger members. 
One attack of grip confers no immunity upon the patient; in fact, 
patients apparently reinfect themselves. For this reason we always advise 
that two rooms be used, when possible, one for the day and one for the 
night, the room not occupied during the day being aired for several hours 
with all the windows open. After recovery the sick-rooms should be 
thoroughly aired and cleaned. 734 
THE PRACTICE OF PEDIATRICS 
Treatment.—The individual treatment is symptomatic. The rhinitis 
and bronchitis are treated as if the condition were not grip. 
The management of an otitis, pneumonia, bronchitis, or colitis as- 
sociated with or following an attack of influenza, differs in no way, so 
far as the immediate treatment of the complication is concerned, from 
that which would be advised if the case were independent of the influ- 
enza bacillus. The case, as a whole, however, will require closer watch- 
ing, and on account of the greater prostration, better feeding and freer 
stimulation. 
The hard, dry, teasing, tracheal cough associated with and following 
many cases of influenza, is sufficiently troublesome to require special men- 
tion. In this condition codein should be used in sufficient dosage partially 
to control the cough. The cough is difficult to relieve for the reason 
that the mucous membrane of the trachea is deeply congested. The 
infection, aided by the persistent cough, keeps up and adds to the conges- 
tion; and the irritation thus produced again tends to a persistence of 
the cough. This is a condition where opium is not only justifiable, but 
absolutely necessary, in order that sufficient rest of the parts may be se- 
cured to allow resolution and control of the infection. 
Vapor.—Charging the air with vapor, producing an artificial hu- 
midity, greatly lessens the irritating effects on the mucous membrane 
of the ordinarily dry air of the living room, and relieves the cough. 
External Treatment.—A preparation of mustard—1 part flour to 2 
parts mustard—suitably mixed and applied to the chest for five to 
fifteen minutes at bed-time, will often insure a better night than would 
result were the application not made. 
Change of Climate.—When possible, patients who show pronounced 
systemic depression and who fail to regain their usual physical vigor 
should have the benefit of a change of climate. A change of a few weeks 
will ordinarily completely restore the patient to his normal health. When 
at home, or elsewhere, convalescent grip patients who show slow response 
to treatment should have their activities carefully advised; they should 
not be allowed to arise before 10 in the morning, should have a midday 
rest of two hours, and should retire between 6 and 7 o’clock. 
Drugs.—Small doses of quinin, 1 to 2 grains at two- or three-hour 
intervals, have given better results in hastening a return to health than 
any other form of medication. If there are malnutrition and anemia, 
the measures laid down under the respective headings may be applicable 
to these patients. 
RHEUMATIC FEVER (ACUTE RHEUMATISM) 
Acute rheumatism is a rare disease in young children. Although 
it is properly not to be regarded as a transmissible disease, its infectious 
origin, which seems unquestionable, justifies discussion of the condition 
in this chapter. Disorders described as rheumatism in infants and chil- 
dren under two years are usually scurvy or infectious peri-arthritis. The 
latter is not at all unusual, and the possibilities of scurvy are always 
with us. Among 1027 cases of rheumatism, Still saw none under two 
years of age. Our own cases have all been in children after the third 
year. The majority of the cases occur between the fifth and ninth years. RHEUMATIC FEVER (ACUTE RHEUMATISM) 
735 
It is a mistake to designate rheumatic fever or acute rheumatism as 
“acute articular rheumatism,” as we see many cases in which the joint 
symptoms play a slight part, or no part at all, the heart bearing the 
brunt of the attack. Repeatedly, endocarditis or pericarditis has been 
the main manifestation of the disease. 
Illustrative Cases.—Case 1.—A boy came to the Out-patient Service at the Babies’ 
Hospital because of sore throat and a temperature of 101° F. There was a very mild 
tonsillitis, and for one night there had been pain in the left knee. An examination 
of the heart showed an extensive endocarditis involving both the aortic and mitral 
valves. 
Case 2.—A girl, four years old, subject to periodic colds and asthmatic bronchitis, 
had a mild seizure of this nature, requiring that she remain in bed for a few days. Dur- 
ing examination of the lungs a soft systolic cardiac murmur was detected. Three days 
later pain and swelling appeared in a knee-joint. A polyarthritis followed, involving 
in all nine joints. In this child the heart involvement preceded the joint symptoms 
several days. 
It is not at all unusual to see endocarditis in the offspring of the rheu- 
matic, without the previous existence of a painful joint. These cases, 
however, will afford the history of chorea or recurrent spasmodic bron- 
chitis, frequent anginas, periodic gastric or intestinal crises, or growing 
pains. In fact, endocarditis is far more often the manifestation of acute 
rheumatism than is inflammation of the joints. 
On the other hand, many cases are seen in which the heart remains 
free, with the joint involvement of a most urgent nature. 
Etiology.—That acute rheumatism is a manifestation of some form of 
infecting agent, the majority of the profession are agreed. It will prob- 
ably be demonstrated that more than one infecting agent may cause 
acute rheumatism in a child predisposed in the manner that we shall 
attempt to describe presently (p. 738). Perhaps it will be proved that 
both bacterial and other toxic agents may cause the disease. 
The discovery of the specific infecting agent in acute rheumatism is, 
however, still a problem. That the tonsils often constitute the atrium 
of the infection is well established. Similarly, a diseased sinus or antrum 
or adenoid growth may be a site for establishment of a focus from which 
rheumatism is derived. Numerous writers affirm that diseased teeth and 
infected adjacent structures are often sources of infection. 
Symptoms.—(For Endocarditis, see p. 418.) Like all diseases of an 
infectious origin, acute rheumatism may be so mild as to escape notice, 
or it may be most severe. In the joint type the first symptom is pain 
in the joint; this may be very slight, or it may be most intense—so in- 
tense that the bed-clothing may not touch the parts without increas- 
ing the pain. Between these two extremes there are all degrees of in- 
volvement. There may be neither swelling nor redness, or the swelling 
may be extreme, with marked redness, the part’being twice as large as 
its uninvolved fellow. One joint or several may be affected. The pain 
and swelling usually begin in one, and subsequently affect others. The 
first joint to become inflamed is usually the first in which the inflam- 
mation subsides. In no other joint affection does the pain compare in 
severity with that of acute rheumatic arthritis. The rapid onset and 
corresponding occasional rapid subsidence of the inflammation suggest 
that it may be the reaction to a toxemia and not to a bacteremia. 736 
THE PRACTICE OF PEDIATRICS 
The duration of the attack is subject to much variation, it may last 
but a few days or for six weeks or longer. A case of average severity 
rarely lasts longer than two or three weeks. There may be no fever, or 
the temperature may range from 103° to 105° F., depending entirely 
upon the severity of the infection. 
Special Manifestations.—Peliosis rheumatica and pleurisy, givmg 
evidence of an etiology similar to that of acute rheumatism, are con- 
sidered on p. 742. 
Erythema nodosum, another manifestation probably of the rheumatic 
class, is discussed on p. 636. 
Rheumatic Nodides.—The presence of definite nodules in cases of 
rheumatism in children is only occasionally noted in this country. 
In England they are often encountered and were first described by 
Barlow. John Thomson1 looks upon them as extremely important mani- 
festations of rheumatism from a diagnostic standpoint and interprets their 
presence to indicate that the disease is in a serious and progressive form. 
He has found them present in a considerable proportion of rheumatic 
subjects, varying from the size of a pinhead to that of a pea or larger. 
Generally only a few are found at a time, usually over the bony prom- 
inences of the elbows, knees, and ankles, but occasionally they are present 
in large numbers, growing not only about all the bony prominences of 
the limbs, over the vertebral spines and under the scalp, but also on 
the ribs, clavicles, scapulae, and iliac crest, and over the prominent tendons 
of the extremities, the fasciae of the erector spinae and abdominal muscles, 
and even rarely on the rims of the ears. The nodules are never reddish 
and are not tender. They appear in crops lasting usually a few weeks, 
sometimes several months, and rarely more than a year. 
Brenneman,2 in a review of the literature on rheumatic nodules, has 
affirmed his ability to tell by a glance at the knuckles on which the nodules 
are apparent: “This child has rheumatism; it is probably active; it is 
severe; he has an endocarditis.” In our own cases the disease has as- 
sumed a prolonged course without the acute symptoms of 1 igh fever and 
extreme pain characteristic of many cases of acute rheumatism, and the 
existence of endocarditis as a complication has been practically constant. 
The subcutaneous rheumatic nodule is said to be homologous with 
those that form on the valves and mural endocardium in acute rheum- 
atism, and is evidently the product of local rheumatic inflammation. 
Prognosis.—The prognosis for the immediate attack in articular 
rheumatism is good. All cases terminate in recovery if there is no heart 
involvement. When there has been one attack, however, there is great 
probability of another, and parents should be made to understand this 
feature of the disease. 
Precaution.—In every case of joint rheumatism the heart should 
be examined daily for evidence of endocarditis and pericarditis. 
Treatment.—General Management.—Rest in bed is an absolute neces- 
sity even in the milder cases. The diet of the patient may consist of 
milk, junket, gruel, toast, stale bread, weak tea, stewed fruit, and orange 
juice. Vichy and lemonade may also be given. There should be one 
evacuation of the bowels daily. 
1 Clinical Study of Sick Children, 1921. 2 Amer. Jour. Dis. Child., September, 1919. RHEUMATIC FEVER (ACUTE RHEUMATISM) 
737 
Local Measures.—Considerable comfort may be furnished by local 
measures, which will permit the child to sleep, resulting in a much im- 
proved food capacity. The affected joint or joints should be comfort- 
ably supported on a cushion or pillow, and the parts kept well protected 
by cotton-wool or flannel dressings. The U. S. P. lead-and-opium solu- 
tion, if used to moisten the gauze dressings, will aid in relieving the pain. 
The joint should be loosely wrapped in strips of linen which have been 
wet with the warm solution. Over this should be placed oiled silk to 
prevent rapid evaporation, and over all a flannel bandage. In the acute 
cases the dressing should be changed every hour until the pain is relieved. 
This can readily be done without disturbing the patient. A liniment 
composed of menthol, 2 drams, tincture of opium, ounces, and enough 
alcohol to make 6 ounces, applied on strips of linen and covered with 
oiled silk, is another local application which has been of considerable 
service in relieving pain. This dressing should be renewed every two or 
three hours as the case requires. 
Drugs.—Various drugs, such as oil of wintergreen, aspirin, and com- 
binations of the alkalies with the salicylates, have been used in a consid- 
erable number of cases. The most effective internal medication has 
been the bicarbonate in association with the salicylate of soda. The 
salicylate must be given in large doses. Two points, however, are to 
be kept in mind in the administration of large doses of salicylate to chil- 
dren: its depressing effect upon the heart, and the tendency to produce 
derangement of digestion, as evidenced by nausea and vomiting. The 
salicylate should never be given with the stomach empty. It is given to 
the best advantage after meals, and always in solution. For a child five 
years of age the following may be prescribed: 
1$. Sodii salicylatis 5ij 
Elix. simplicis giss 
Aquae q. s. ad. 5iv 
Sig.—One teaspoonful in plain water or in Vichy four times daily after meals. 
There are about 24 teaspocnfuls in a 4-ounce bottle. The average tea- 
spoonful, as is well known, holds more than 1 dram. Computing 24 
doses to a 4-ounce mixture, we give this five-year-old patient 20 grains 
of salicylate of soda in twenty-four hours. The amount may be increased 
to 60 grains if the condition is serious. larger doses than 60 grains for 
children of this age we consider not always safe, as such doses have 
been followed by irregularity of the heart action and cyanosis. The 
average child from eight to ten years of age will take 60 grains daily 
without inconvenience. At the third year 20 to 30 grains daily have been 
given repeatedly, with most satisfactory results. The bicarbonate of 
soda may be given in combination with the salicylate, but it is best given 
alone in Vichy or carbonic water between meals. To a child five years 
old or under, 60 grains should be given in twenty-four hours. For chil- 
dren from seven to ten years of age 60 to 100 grains daily is the amount 
required. 
The dosage, both of the salicylate and of the bicarbonate of soda, 
should gradually be reduced as the condition of the child improves. 
The Rectal Administration of Sodium Salicylate.—In not a few chil- 738 
THE PRACTICE OF PEDIATRICS 
dren the stomach develops an intolerance of sodium salicylate, give it 
as we may. In such cases in order to secure respite for the stomach the 
drug may be given satisfactorily by the rectum. Twenty grains of the 
salicylate of soda is added to 3 ounces of mucilage of acacia and intro- 
duced by means of a No. 14 American catheter and a large bulb syringe, 
the catheter being inserted at least 8 inches into the bowel. The solution 
should be warm. It will be better retained if the child maintains a position 
on the left side for an hour after the injection. This dose should be 
repeated daily. 
Later Treatment.—It is incumbent upon the physician never, willingly, 
to let a child who has had an attack of acute articular rheumatism dis- 
appear from observation. As the outcome of repeated attacks, endocar- 
ditis is likely to develop sooner or later. After one attack the parents 
should be advised as to the probability of a recurrence and its dangers. 
Five days out of every fifteen 10 grains of the salicylate of soda, sepa- 
rately or combined with 20 grains of bicarbonate, should be given daily. 
This should be continued for six months, when treatment for five days 
out of each month will suffice. In some cases this method has been 
continued for several months. 
In all cases of acute articular rheumatism in children the tonsils 
and adenoids should be thoroughly investigated and their removal ad- 
vised if they are even suspected to be diseased. Foci of infection have 
also been found at the roots of the teeth. Therefore an x-ray examination 
of the teeth should always be made with a view to the removal of such foci. 
THE RHEUMATIC DIATHESIS 
In a considerable proportion of the population there exist certain 
physical characteristics which set these individuals apart in a class by 
themselves. The constitutional condition referred to is well recognized, 
and various designating terms have been applied to it, such as the rheu- 
matic diathesis, the rheumatic complex (Still), lithemia (Osier), and 
lithemic diathesis. The condition is, to be sure, but little understood. 
Nevertheless, if we admit that rheumatic fever (acute articular rheu- 
matism) is due to a specific infecting agent, we must also admit that 
there is a favorable field for activity of this agent in certain members 
of the human race. Children who have the rheumatic symptom-com- 
plex as described below are those who most frequently develop acute 
articular rheumatism and endocarditis. 
The more prominent features of the rheumatic symptom-complex 
comprise lack of resistance to infection of the respiratory mucous mem- 
branes and the tonsils; pronounced lack of nervous balance, manifested 
by habit spasm; and a tendency to a spasmodic condition of the res- 
piratory tract, as seen in bronchial spasm and catarrhal laryngitis. An- 
other peculiarity, as relates to the nervous system, is absence of control 
during play; the patients become much excited, and waste much energy 
over trifles. In the consulting-room one sees such children in ceaseless 
activity, which they apparently cannot control. They are very apt 
to lack concentration. They have frequent “growing pains” and suffer 
from periodic stomach and intestinal crises. They are, furthermore, THE RHEUMATIC DIATHESIS 
739 
subject to eczema and urticaria. Children of this type are the offspring 
of those who have been similarly affected, or who have what they have 
learned to designate as rheumatism, lithemia, gout, or the uric-acid 
diathesis. 
Often in the offspring of these individuals will be found a combina- 
tion of the above tendencies; the association of eczema, spasmodic bron- 
chitis, catarrhal laryngitis, and frequent rhinitis; of growing pains, chorea, 
and endocardial rheumatism; or of cyclic vomiting and acute bronchitis. 
Illustrative Case.—In two brothers, who had cyclic vomiting, there was invariably 
an attack of tonsillitis first and then the vomiting, which was in turn followed by asth- 
matic bronchitis. None of the attacks were very severe, but each time the same 
sequence was carried out. 
The above associations have been remarked in too many cases to 
ascribe them to a coincidence. Further, it is the child of this type who 
develops articular rheumatism and endocarditis. 
Etiology.—The chemicophysiologic defect appears to be in the nature 
of defective oxidation. At any rate, the more apparent bodily functions 
are not appreciably involved. 
The age incidence is of interest. Infants who suffer from eczema, 
who are susceptible to bronchitis, and in whom it is of the spasmodic 
type, often show the rheumatic tendencies later in life. The more active 
manifestations, however, do not appear until the child has passed the 
period of infancy.1 
Treatment.—It is obvious that children of the type described show 
not only a particular predisposition to certain affections but also decided 
lack of resistance to the particular form of infection which occasions acute 
rheumatism. The prevention of cyclic vomiting, recurrent spasmodic 
bronchitis, chorea, and the other conditions referred to depends upon a 
proper management of the so-called vice of constitution. Growing pains, 
habit spasm, tendency to recurrence of eczema, and the various nervous 
manifestations enumerated may be controlled largely through proper 
treatment of the “rheumatic complex.” 
The first and most important step in the treatment relates to diet.. 
Diet.—Children conforming to this class have a poor fat and sugar 
capacity, particularly for cane-sugar and cow’s milk fat. The nearer 
the approach to a vegetable and cereal diet, the better for the patient. 
The nitrogenous foods allowed are poultry, fish, and egg-whites. 
Sugar is not to be permitted. Vegetables, stewed fruits, and skimmed 
milk puddings may be freely used. Skimmed milk or buttermilk may be 
given with the morning and evening meal. All cereals are permissible. 
There is no trouble in establishing a well-balanced ration. Children 
will readily learn to do without sugar. There is little or no trouble in feed- 
ing cereals without sugar. With stewed fruits and puddings, saccharin 
may be used in small amounts. Many children take stewed fruits, cereals, 
1 These observations and conclusions have been made in private practice. The 
hospital does not furnish an opportunity for observations on a child, carried through 
several years, as is necessary in order to know the patient from every standpoint. 
Those who have not had a large private work with children for a considerable period, 
or who have not carefully watched their patients, will not appreciate the conclusions 
expressed. 740 
THE PRACTICE OF PEDIATRICS 
and puddings without a particle of a sweetening agent. Puddings and 
junket are to be made with skimmed milk. The fat in the egg yolk is 
particularly toxic to some of these children, particularly those who have 
cyclic vomiting. Egg yolks are accordingly not to be used in puddings. 
When one whole egg would ordinarily be used, the whites of two eggs 
may be used instead. A custard may thus be made as follows: 
White of one egg. 
Saccharin. 
I cup scalded skimmed milk. 
10 drops of vanilla. 
10 grains salt. 
Stir white of egg with silver fork. Add milk gradually, salt, and flavoring. Strain 
and bake somewhat longer than for ordinary custard. 
In many instances rheumatic children suffering from some one or 
more of the above-mentioned conditions, together with anemia and a 
stationary weight, coated tongue, and loss of appetite, have made aston- 
ishing gain without other treatment when the sugar and cow’s milk fat 
were removed from the diet. Three meals a day should be given. A 
free daily bowel evacuation is to be insured (pp. 273-276). 
If there is malnutrition, the scheme of living, as suggested in tardy 
malnutrition, is indicated (p. 147). 
The Bath.—The child should be given a bath at bedtime, followed 
by a cold splash or douche. After the bath, while the feet remain in 
the warm water, a quart or two of cold water should be thrown over the 
body. The degree of cold may vary— 80° to 70° F. at first; after a week 
or two water as it runs from the faucet may be used if the child enjoys 
it, regardless of tTe season. After the cool douche the patient should 
be vigorously rubbed with a bath towel and put to bed. 
Drug Treatment.—The only drug necessary, other than perhaps an 
appetizer or a laxative, is bicarbonate of soda, which should be given 
in interrupted dosage—from 15 to 30 grains, three times daily, depend- 
ing upon the age and requirement. The soda is best given after meals 
for ten days, with a free interval for five or ten days, when it may be re- 
sumed. After a period of a few weeks the soda may be discontinued, 
but the diet must be kept up indefinitely. 
Lithemic children cannot bear alcohol, and it should not be included 
in their tonic or restorative medication. When there is a high degree 
of systemic poisoning which resists the above measures, sodium salicyl- 
ate in dosage of rarely more than 5 grains should be given three times 
a day, after the interval method, in conjunction with the bicarbonate 
of soda. 
All the measures suggested, without the withdrawal of sugar and 
fat largely from the diet, are of little avail. 
Illustrative Cases.—Case 1.—A case which is characteristic of many was that of 
a two-and-a-half-year-old scion of one of America’s most noted families. When the 
boy came under treatment he was having periodic attacks of catarrhal colds, associated 
with cyclic vomiting. The attacks would last for two or three days and were not 
very severe, rarely being accompanied by fever. He had been treated for these repeated 
colds by different physicians with expectorant drugs and local chest applications, all 
of which, as might be expected, were without effect. He was given the dietetic and 
drug management, as indicated above; and notwithstanding the fact that there had 
been attacks every fourteen days, there was but one attack in the two years under 
treatment. First cousins of this child had habitual colds with spasmodic bronchitis. THE RHEUMATIC DIATHESIS 
741 
Case 2.—A most remarkable case was that of a girl who came under treatment in 
early infancy for an intense and obstinate eczema. From this she recovered, and 
when one year of age developed cyclic vomiting. During the next two years there 
were frequent attacks of cyclic vomiting, spasmodic laryngitis, and bronchial asthma. 
The association of these conditions has been previously referred to. 
Recurrent Bronchitis.—Asthmatic bronchitis is often dependent 
upon the rheumatic state, and repeated attacks suggest the degree of 
the vice of constitution. 
Illustrative Cases.—Case 1.—A girl eight years old had suffered from repeated 
attacks of bronchitis. The mother, a woman of unusual education and refinement, 
stated that the child had had an average of two attacks monthly during the previous 
year, and at least one attack every month since she was five years of age. On meeting 
the expression of some doubt as to the frequency, the mother stoutly maintained that 
her statement was correct. The family lived in Brooklyn, and had been told that 
the child could not remain there during any portion of the year. She had spent the 
colder months at different winter resorts, with very little, if any, resultant effect upon 
the severity or frequency of the attacks. There had been no other illness of conse- 
quence. The attacks were peculiar in that they were of short duration, but very severe. 
There was usually a temperature range from 100° to 101° F., associated with cough, 
difficulty in breathing, and occasional attacks of marked air-hunger. The attacks were 
always accompanied by severe coryza. The patient was seen at the end of an attack. 
She was pale and inclined to be overstout. An examination of the chest showed through- 
out a fairly even distribution of mucous rales involving the smaller tubes. Aside 
from the bronchitis and secondary anemia the examination was negative. The child 
had attended school at irregular intervals, but only for a few weeks of her life. In 
getting the history inquiry was made, as a matter of routine, if the child snored or if 
she were a mouth-breather. This caused the mother to remark that the child had been 
under the care of throat specialists at different times, and each physician had removed 
a set of tonsils and a set of adenoids! The mother did not think that there was very 
much left. There was no sign of a tonsil and the nasopharynx was free. In spite of a 
normal rhinopharynx, the colds had continued. The family was rheumatic on both 
sides for at least three generations. The mother claimed to have suffered a great deal 
from rheumatism. The child was fond of red meat and, according to the mother, 
lived on it, and cared for little else, with the exception of sugar. Here was a girl, eight 
years of age, who would not drink milk until sugar had been added to it. Cereals, 
stewed and raw fruits were loaded down with sugar before she would touch them. 
In the instructions as to the treatment, red meat was allowed once every second 
day and sugar was reduced to a minimum—probably not more than one-fifth the usual 
amount being given. The child was to be bribed, if necessary, to eat green vegetables, 
cereals, and fruits. Expectorant and cough mixtures were discontinued. She was given 
20 grains of the bicarbonate of soda and 20 grains of the salicylate of soda daily for 
three weeks. Later the drug treatment was continued at intervals during the remainder 
of the winter. She passed through the following winter without a sign of rhinitis, 
bronchitis, or asthma, although she continued to live in Brooklyn. 
Case 2.—Another case somewhat similar was referred by a well-known rhinologist. 
The patient, a girl seven years old, had suffered from repeated attacks of bronchitis 
and asthma and had been confined to her home a greater part of each winter. Her 
general condition was thoroughly wretched. Her family physician had attributed the 
condition to enlarged tonsils and adenoids, and the child had been sent to New York 
for operation. The operation was performed, and the child returned to her home. 
As a result the patient could breathe easier and sleep better, and suffered much less 
during her attacks of asthmatic bronchitis; but the frequency of the attacks was in 
no way affected. Early the following summer the patient was again taken to the rhin- 
ologist, who, finding the condition of the upper respiratory tract satisfactory, referred 
the patient for medical supervision, remarking that he had “cut everything in sight and 
out of sight!” The treatment outlined was instituted, and while the results were not 
so flattering as in Case 1, the condition was much improved; only three attacks occurred 
during the next twelve months, and the child gained 15 pounds in weight. 
Repeated inflammatory involvement of the mucous membrane of the 
upper respiratory tract in children, particularly in the absence of enlarged 
tonsils and adenoids, strongly suggests a rheumatic element as a prom- 
inent causative factor. 742 
THE PRACTICE OF PEDIATRICS 
There are other conditions, apparently of rheumatic origin, which 
are not infrequently associated with the common manifestations. 
Rheumatic Pleurisy.—In four cases thus diagnosed there was no pneu- 
monia and no lung involvement of any nature. The fluid was sterile, 
and the patients never, in the years under observation, had further lung 
signs. The amount of fluid in each case was large. All the patients 
came for treatment because of interference with respiration. If there 
had been fever, it had in each instance subsided before the case came 
under observation. There was no pain and no evidence of discomfort 
other than the cyanosis caused by pressure. 
In two of the cases there was a distinct history of rheumatism. These 
children were between two and six years of age. 
Treatment.—The diet was given as outlined, with salicylate and bi- 
carbonate of soda in dosage suitable for the age. In all the cases there 
was a complete absorption of the fluid in less than a week. 
Peliosis Rheumatica.—In this unusual affection, which appears to be 
of rheumatic origin, purpura is a prominent symptom. In our patients 
the purpuric area has always involved the anterior portion of the lower 
extremities, and in every instance the disease has occurred in a patient 
who had had previous attacks of rheumatism or chorea, or in whom 
the rheumatic element was prominent, as shown by recurrent tonsillitis 
or recurrent bronchitis. A further proof of the rheumatic origin of the 
disease is the fact that the cases may yield readily to treatment for rheu- 
matism. 
Treatment.—In one patient there were two distinct attacks, both of 
which yielded fairly well to the salicylate of soda and the iodid of potas- 
sium. The medication and diet are the same as those suggested for 
rheumatism. In case erythema nodosum accompanies the condition, 
local measures for the relief of pain (p. 636) may be necessary. 
RHEUMATOID ARTHRITIS; ARTHRITIS DEFORMANS; STILL’S DISEASE 
Under the above headings may be noted those forms of chronic ar- 
thritis which occur independently of ordinary pyogenic infection, gonor- 
rhea, syphilis, tuberculosis, rheumatism, and rachitis. Attempts at 
exact differentiation of the arthritides of this class rest in the main upon 
varying clinical manifestations which may or may not represent separate 
and distinct disease processes. 
Rachford1 has emphasized three types of “rheumatoid arthritis”— 
(1) Chronic arthritis with hypertrophic changes predominant; (2) chronic 
arthritis with atrophy predominant; (3) Still’s disease. 
The condition last named is sufficiently striking to require special 
attention, and the points emphasized by Still are here mentioned. 
Still’s Disease.—The specific etiology is unknown. The disease is 
probably of bacterial origin. Females are apparently slightly predis- 
posed. Children are rarely susceptible after the sixth year. 
The morbid anatomic changes comprise thickening and vasculariza- 
tion of synovial membranes, capsules, and ligaments of the affected 
joints, and, in advanced cases, moderate atrophic changes in the carti- 
1 Diseases of Children. SYPHILIS 
743 
lage, with perhaps the formation of adhesions. Effusion is not an es- 
sential part of the process. Considerable enlargement of the lymphatic 
glands and spleen is a constant feature. 
Symptoms.—The onset is usually gradual, but may be acute, with 
fever and chills. Primary stiffness in one or more joints is succeeded 
by progressive joint enlargement without bony involvement, ankylosis, 
or suppuration. The knees, wrists, cervical spine, fingers, ankles, and 
toes may be affected. Active and passive movements are restricted, 
and eventually atrophy and contracture of muscles may occur, without, 
however, impairment of electric reactions. The lymphatic glands are 
enlarged, particularly those related to the affected joints. The edge 
of the spleen may usually be found below the costal margin. The blood 
shows a moderate anemia and occasionally a leukocytosis. 
Still’s disease is to be distinguished from rheumatism, rickets, syphilis, 
the various forms of muscular atrophy, and caries of the cervical verte- 
brae. 
The prognosis is not favorable. The disease is not directly fatal, but 
its effects are crippling. Koplik has reported a recovery. 
The treatment of rheumatoid arthritis is largely symptomatic. An 
even climate, free from excess of moisture, is desirable. Anemia and 
malnutrition are to be combated in the usual manner. Massage and 
suitable applications may influence the local conditions favorably. In 
view of the possible influence of latent foci of infection upon the develop- 
ment of the disease, oral sepsis and intestinal putrefaction, especially, 
must be prevented. 
Vaccine treatment is of possible value in cases in which the patient’s 
serum shows reaction against specific organisms, e. g., one or more strains 
of streptococcus. To this end joint fluid should be cultured. 
SYPHILIS 
Syphilis is an infectious, communicable disease seen with great fre- 
quency in early life in all large centers of population. 
Bacteriology.—In 1905 Schaudinn and Hoffmann discovered a spiro- 
chete in syphilitic lesions. From its faint staining reaction they named 
the organism Spirochaeta pallida, and later Treponema pallidum. It is 
present in syphilitic lesions on the skin and mucous membrane, and 
has been found in the blood, in the internal organs, in the lymph-nodes, 
in spermatozoa, in ova, and in cerebrospinal fluid of syphilitic patients. 
The tissues and organs of still-born syphilitic infants contain the spiro- 
chete, and in congenitally syphilitic children the organism is readily 
demonstrable in the mucous patches in the mouth, in the fissures about 
the mouth and anus, and in the skin lesions. The older the lesion, the 
less numerous are the spirochetes. 
Noguchi was the first investigator who succeeded in obtaining pure 
cultures of Treponema pallidum, and by inoculating such pure strains 
into rabbits he produced syphilis in these animals. 
The spirochete is mobile, varying in length and thickness, its average 
transverse diameter being 0.2 to 0.3 micron. It is best seen in the fresh 
state, with the dark field illumination. A rough but fairly reliable method 
of demonstrating the spirochete is to mix the material to be examined 744 
THE PRACTICE OF PEDIATRICS 
on a slide with a drop of India ink. By means of a piece of cigarette 
paper the mixture is easily spread evenly along the slide. Examination 
with the immersion lens shows the unstained spirochetes on a black back- 
ground. 
Types.—The disease in children is usually due to direct inheritance, 
although acquired cases are occasionally encountered. We have, accord- 
ingly, to consider both the hereditary and the acquired types. 
For convenience of description hereditary cases are discussed under 
two headings: Acute hereditary or congenital and late or tardy syphilis. 
Acute Hereditary or Congenital Syphilis 
The severity of the infection in the offspring bears a distinct rela- 
tionship to the severity and duration of the infection in the parent or 
parents. As in all infections, the disease may be most severe, or mild 
to such a degree that its existence is not recognized. A recent infec- 
tion in either parent, or in both, produces the most active manifesta- 
tions, many times sufficient to destroy the life of the fetus or even to 
preclude pregnancy. Death of the fetus, showing marked syphilis, any 
time before the ninth month indicates a comparatively recent infection 
in the parents. It is the parents in whom the disease is of long duration 
or who have undergone active treatment who are responsible for the 
tardy hereditary form. 
Symptoms.—The symptoms, which are most variable, depend upon 
the age of the patient and the severity of the infection. 
Thus the child may be born dead at term, perhaps almost denuded 
of skin and showing bone and extensive visceral lesions. 
In other instances the child is born at term, alive, but shows syph- 
ilitic pemphigus and other lesions, and lives but a few hours. Other 
infants are born apparently normal and show signs of the disease be- 
fore the sixth week. Symptoms are very apt to appear between the 
second and fourth weeks. Seventy-five per cent, of the senior author’s 
cases have shown diagnostic signs before the fourth month. Some cases 
do not show signs until a later period—the sixth, seventh, or eighth month. 
Such cases, however, are unusual. The great majority show some active 
evidence of the disease before the sixth month. The first manifestation 
in congenital syphilis may, nevertheless, appear at any time up to the 
thirtieth year (Fournier). 
In infants apparently normal at birth and developing the signs early 
the symptoms are as follows: 
(1) Restlessness. 
(2) Rhinitis; hoarse voice. 
(3) Enlarged liver and spleen. 
(4) Rash; condylomata; mucous patches. 
(5) Enlargement of epitroclilear glands. 
(6) Deformities of the nails. 
(7) Defective growth and malnutrition. 
Restlessness is the earliest symptom of syphilis. The child sleeps 
poorly and is uncomfortable. This symptom is many times not appre- 
ciated by the physician and usually passes unrecognized by the parents. 
The restlessness is usually attributed to causes other than syphilis. ACUTE HEREDITARY OR CONGENITAL SYPHILIS 
745 
Rhinitis is a very early symptom that is seldom absent. It is char- 
acterized particularly by its persistence and the profuseness of the dis- 
charge; in other respects it may not vary from an ordinary rhinitis. 
Fig. 124.—Rash in congenital syphilis. 
In a considerable proportion of these cases there is a moderate de- 
gree of laryngitis with hoarseness. This may be the earliest and most 
prominent symptom. 
Liver and Spleen.—An enlargement of the liver and spleen is an early 
sign in most cases. The spleen is ordinarily palpable below the ribs for 
Fig. 125.—Condylomata. 
\ inch to 2 inches. The liver also shows enlargement, often extending 
2 to 3 inches below the free border of the rib. 
The rash may appear very early or may be delayed for a week or longer 
after the rhinitis. The rash is fairly characteristic. It appears in dis- 
crete, brownish-colored macules (Fig. 124), rounded and with a tendency 746 
THE PRACTICE OF PEDIATRICS 
to a very fine desquamation in the center. The skin between the macules 
may remain normal. The macules may occur in groups and become so 
extensive as to coalesce and 
involve a large part of the 
skin surface of the patient 
(Fig. 126). . 
The moist parts about the 
buttocks, legs, and over the 
abdomen are usually involved 
first and most extensively. 
There is no order, however, 
as to the appearance of the 
rash. The face and arms may 
be first affected, or the rash 
may be generally distributed 
over the entire skin surface. 
When the rash fades, the skin 
becomes smooth, but there is 
left a copper-colored stain 
which is as characteristic of 
the disease as the rash. 
When the eruption occurs 
about the anus or the moist 
parts, as in flexures and skin folds, the eruption sloughs and condylo- 
mata are formed (Fig. 125). 
In many cases, particularly in very young infants, a diffuse thicken- 
ing of the skin of the soles of the feet and palms of the hands occurs with 
profuse desquamation (Fig. 128), leaving the skin of a glossy, shining 
Fig. 126.—Extensive syphilitic rash. 
Fig. 127.—Fissures and mucous patches. 
appearance. How long the skin eruption would continue, untreated, 
if the patient survived is difficult to determine. Under suitable medi- 
cation the eruption largely disappears in two to four weeks, leaving the 
copper-colored disfigurations, which in turn fade, but require a much 
longer time (Fig. 126). ACUTE HEREDITARY OR CONGENITAL SYPHILIS 
747 
Fissures at the angles of the mouth and on the lip, and mucous patches 
(Fig. 127) are really a part of the skin manifestations—they are character- 
Fig. 128.—Desquamation. Soles of feet. Congenital syphilis. 
istic in the sense that they occur only in syphilis. A mucous patch rep- 
resents the site of papule or macule on a moist surface. Such lesions 
A 
B 
Fig. 129.—Syphilitic lesions in tibia* of a young infant. 
are usually found on the mucous membrane of the mouth. Other possible 
sites are the anus and the female genitals. 748 
THE PRACTICE OF PEDIATRICS 
Acute epiphysitis occurs in young infants, but in this country it is 
an unusual manifestation of syphilis. There is swelling of the epiph- 
yseal cartilages and there may be separation of the epiphysis. The parts 
are very painful, giving rise to the term “syphilitic pseudoparalysis.” 
The nails are dwarfed, dry, and break readily. There may be ex- 
foliation of the nail, but this is unusual in infants. A characteristic defor- 
mity is the bird-claw nail, in which the nail is much contracted, showing 
an arching of the dorsum of the nail with a thickening, and a down- 
ward curve at the free end, over the tip of the finger or toe, producing 
a typical claw appearance. This is a sign of much diagnostic value. 
Hemorrhages in congenital syphilis are rare. 
They may occur from any mucous surface. In 
a large number of cases of congenital syphilis 
seen in this country and on the continent there 
were but 2 in which hemorrhage was a symptom. 
In both these cases, strange to say, there was 
quite severe hemorrhage from the vagina. 
The Wassermann Test.—This is positive in 
a very large percentage of cases, but is subject 
to variation dependent on such factors as age 
of the patient, previous treatment, and dura- 
tion and severity of the infection. (See pp. 826- 
827.) A negative Wassermann test in the first 
months of life does not exclude the possibility of 
congenital syphilis. 
Treatment.—Mercurial Inunction.—Formerly 
the only means of treating congenital syphilis 
in infants was by the use of mercury, either 
locally, as by inunctions, or by internal admin- 
istration. The use of mercurial ointment by 
inunction is a satisfactory method in hospitals 
and in children’s institutions, where a nurse 
can make the necessary applications; in private 
practice, however, it is objectionable because of 
the inunction itself, which may cause comment, 
and because of the staining of the skin. In fact, 
this treatment cannot well be carried on with- 
out other members of the family becoming ac- 
quainted with the nature of the illness. Definite 
rules for management, as regards kissing and the 
care of feeding utensils, should be given, so that 
the other members of the family may be protected 
and the real condition remain unknown. Among the poorer class and in 
out-patient work the inunction method is usually unsatisfactory, for the 
additional reason that its use is not continued sufficiently, and it is 
very apt to be indifferently applied or else postponed and forgotten. 
If the inunction is employed the mercurial ointment, U. S. P., should 
be used, 10 grains being rubbed into the skin daily. The rubbing should 
be continued about ten minutes, as this time will be required for the 
ointment to be thoroughly absorbed. 
Fig. 130.—Bones shown 
in Fig. 129, B. The im- 
provement took place in a 
period of five and a half 
weeks, following daily 
mercurial inunctions com- 
bined with four doses of 
0.075 to 0.1 gm. of neosal- 
varsan, and the adminis- 
tration of cod-liver oil. 
(From the New York Nur- 
sery and Child’s Hospital.) ACUTE HEREDITARY OR CONGENITAL SYPHILIS 
749 
As the disease permits of no temporizing, it is for the interest of the 
patient that more effective means possible for its control be brought 
into use at the earliest possible moment; this is by the internal adminis- 
tration of mercury. 
The Internal Use of Mercury.—The use of mercury internally gives 
good results among all classes. It is the writer’s observation, after the 
treatment of several hundred of these cases, that the bichlorid of mer- 
cury in small, frequently repeated doses is the best form of oral medica- 
tion. It is given in tablet form. Its use may have to be continued for a 
long time, and, as people are fond of giving drugs, we cater to the weak 
side of human nature, and thus do the greatest good to our patient. 
For all infants under one year of age the scheme of medication is the 
same, and this covers the great majority of our cases. Usually the patient 
is seen before the third month. In this event the tablet triturate of bi- 
chlorid of mercury, 1/200 grain, is prescribed. The mother is instructed to 
give 2 tablets daily, morning and night, after feeding. She is told to 
give on alternate days an additional tablet after feeding, until 5 are given 
daily, or until the mercury produces loose green stools. It is compar- 
atively rare that an infant of the ten derest age cannot take 1/40 grain 
daily without inconvenience. If green stools of a watery character result, 
the increase is temporarily withheld. It is very rare that the above amount 
will not ultimately be taken without inconvenience. Further, the dosage 
of 1/40 to 1/30 grain in twenty-four hours, in the great majority of the 
cases, is all that is necessary to control the disease. If an improvement 
does not take place after a week’s administration, in the absence of intes- 
tinal symptoms, the amount may be increased to 1/20 grain in twenty- 
four hours. 
If, after the administration four or five times daily of the bichlorid 
in the small doses of 1/200 grain has been continued for several days, im- 
provement does not take place because of failure on the part of the child 
to absorb the drug, inunctions may be used in addition to the internal 
treatment. 
Arsenicals in the Treatment.—The greatest value of the arsenicals is 
in the very severe congenital case. Repeatedly such infants die before 
the effects of mercury are manifested. The arsenicals act much more rap- 
idly than mercury. In fact, the results of salvarsan treatment on the 
very severe congenital syphilitic border on the miraculous. 
The chief value of salvarsan in pediatric work is, however, in cases of 
this type. For permanent, beneficial effects we are still dependent upon 
mercury and the iodids. 
For babies under six months the average dose of neosalvarsan is 
0.075 to 0.2 gm., and for older children 0.2 to 0.4 gm. Salvarsan is 
used in doses one-half as large. The consensus of opinion now seems 
to be that the arsenical should be given at weekly intervals until the 
gross lesions have cleared up. This treatment is always followed by the 
use of mercury. The arsenicals alone do not effect a cure. 
The Combined Treatment With Mercury and Neosalvarsan.—A practical 
method of treatment for young children, devised by Fordyce and Rosen, 
is the intramuscular injection of mercuric chlorid put up in palmitin in 
individual collapsible ampules. The dosage is 1/10 to 1/8 grain or larger 750 
THE PRACTICE OF PEDIATRICS 
for older children, and the injections are given at intervals of a week for 
about eight doses. Then weekly intramuscular injections of neosalvarsan 
in doses of from 0.075 to 0.2 gm., depending upon the size of the child, 
are begun and continued for about eight doses. The patient is then 
allowed a month’s rest and the cycle again begun. The Wassermann is 
taken at this time. This course is repeated indefinitely regardless of the 
change in the serum reaction or clinical signs. In injecting both the mer- 
cury and the arsenical the Rosen needle is used. This is an ordinary 19 or 
20 gage needle, from \ to 1 inch long, with a curved phlange at the shank 
of the needle which fits snugly over the curve of the buttocks and prevents 
movement of the needle even when the child is squirming. The injection 
is made into the gluteus about 1 inch lateral to the intergluteal fold near 
its upper angle. Infiltration or abscess at the site of puncture may be 
avoided by injection deep into the muscles and rapid withdrawal of the 
needle upon completion, thus preventing the seepage of the drug into the 
subcutaneous tissues. Treatment should extend over a period of at least 
a year regardless of results. The question of the permanent cure of 
congenital syphilis is still debatable. 
Convalescence.—In a typical case the first sign that the child is im- 
proving will be the fading of the rash. It disappears gradually, leaving 
the characteristic staining of the skin, which also clears up in a few weeks. 
Coincident with the fading of the rash the coryza becomes less pronounced 
and the hoarse voice becomes clearer. If there has been an enlargement 
of the liver and spleen, after a few weeks of treatment they will have 
diminished in size. The child gains in weight, and if the case progresses 
satisfactorily, soon looks like a normal baby. This, however, is not al- 
ways the happy outcome. Occasionally we have patients with the vital 
powers greatly depressed or with so intense an infection that treatment 
is of no avail, and they die in a few weeks from marasmus. 
The enlargement of the epitrochlear glands is a late sign to disappear, 
and in many cases these glands, though reduced in size, always remain 
enlarged without any other persistent evidence of the disease. A patient 
is considered cured who fails to give a positive reaction to repeated Wasser- 
mann tests of the blood. 
Later Treatment.—What should be the further management of such 
a so-called “cured” case? Are we justified in discharging the patient 
and allowing him to pass from our observation? Experience proves 
the contrary, nor can we positively state that congenital syphilis is ever 
cured. We have seen many patients, however, who were apparently cured, 
and who showed no signs whatsoever of the disease. Against advice they 
have passed from observation for two, three, or four years, and then 
have reappeared for treatment because of the presentation of some 
manifestation of a tertiary character—a so-called “tardy hereditary 
syphilis.” For this reason we believe every so-called cured congenital 
case should be subjected to the Wassermann test every two years or 
oftener. 
Acquired Syphilis 
Acquired syphilis in children is a comparatively rare occurrence. 
The mouth is the most frequent site for the primary lesion, the genitals 
being rarely involved. Infection may be conveyed by direct contact, TARDY HEREDITARY SYPHILIS 
751 
as in kissing or by sexual contact. The virus may be conveyed by inter- 
mediaries, such as toys, nipples, and feeding utensils. 
The recital of statistics and special modes of infection adds nothing 
to our knowledge of the subject. It is necessary to remember that a 
localized lesion, slightly sloughing over its surface, indurated and sharply 
defined, may be in a child the initial lesion of syphilis. 
The treatment is the same as that of the hereditary form. 
Tardy Hereditary Syphilis 
In this form of syphilis the chief or only manifestation of the disease 
occurs at a later period of life. Fournier has stated that the first signs of 
the disease may appear as late as the thirtieth year. Whether the case 
in which positive signs are not observed until after the thirtieth year did 
not show unrecognized signs early in life is an open question. Most 
observers are convinced that an individual may show signs of syphilis 
at varying periods after infancy without early signs of the disease. 
Several years ago the senior author reported 6 cases of tardy malnutrition of 
syphilitic origin in which there had been no early signs of the disease. Since that time 
he has seen several other cases of a similar nature. 
The great majority of patients with tardy hereditary syphilis, however, 
are those who were treated in infancy in out-patient clinics or elsewhere 
and whose treatment was discontinued when the active symptoms were 
relieved. Many mothers cannot be made to bring their children for treat- 
ment and observation when they are apparently well. 
Pathology.—Eye.—The eye changes are those of an interstitial kera- 
titis, gummatous involvement of the iris, and the so-called deep inflam- 
mations of the eye, chorioretinitis and optic neuritis. 
Ear.—Progressive deafness due to neuritis acustica (Meniere’s disease) 
is typical. 
Skin.—According to Hochsinger, the changes in the skin do not differ 
from the tertiary skin lesions of acquired syphilis. He described two 
forms, small nodules, and laige nodular late syphilids. The small nodules 
are due to a definite infiltration of the true skin, which presents a brownish 
appearance and may desquamate or become covered with a heavy crust. 
Beneath the crusts there is usually broken-down granidar tissue. The 
large nodular syphilid occurs in the form of large skin gummata and 
gummatous ulcers arising from the subcutaneous tissues. 
Mucous Membrane of the Respiratory Tract— This structure may 
become invaded in a specific manner. It may be the seat of gumma- 
tous infiltrations or a rapidly progressive ulceration. Ulcerations of the 
pharynx and larynx are not rare. Such lesions are usually character- 
ized by definitely defined borders and thick indurated walls. In the 
nose there may be a diffuse osseous and periosteal affection of the entire 
nasal skeleton, or a gummatous change may represent the primary path- 
ologic process, followed by ulceration with much pus and crust formation. 
On the contrary, there may occur an atrophic condition of the mucous 
membrane. Levin and Heller have described a smooth atrophy of the base 
of the tongue characterized by absence of glandular tissue and thinness 
of the mucous membrane. Gummatous formation, as described above, 752 
THE PRACTICE OF PEDIATRICS 
may occur on the velum palati, palatine arches, and uvula, with per- 
foration. All the ulcerations show a great tendency to scar formation, 
with corresponding contractions and adhesions to adjacent parts. 
Lymph-nodes.—A general hyperplasia of the lymphatic tissue of 
the pharynx and nasopharynx, including the tonsils, may take place, 
while in the lymph-nodes throughout the body, aside from general hy- 
perplasia, gummatous formation is not uncommon. Occasionally the 
glands may undergo ulceration. 
Vessels.—There may exist, according to Hochsinger, a gummatous 
aortitis, arteriosclerosis, and phlebosclerosis, while myocardial and endo- 
cardial changes have been observed. 
Viscera.—Liver affections deserve the first rank. There may exist 
large nodular gummata; the diffuse hypertrophic cirrhosis is most com- 
mon. These changes are almost always associated with more or less 
Fig. 131.—Showing saber deformity of legs in tertiary congenital syphilis in a child 
nine years of age (Dr. Sill). 
splenic hypertrophy. The kidneys may be small and contracted; amy- 
loid degeneration is rare. Gummatous formation in the lungs may occur, 
but is very uncommon. 
Bones.—Late syphilitic changes occur in the osseous system either 
as a diffuse hyperplastic osteitis and periostitis, or as a gummatous process. 
Lesions of both varieties, however, may occur at the same time in the 
same individual. According to Lannelongue, a hyperplastic osteitis and 
periostitis may involve the whole skeleton. The long bones are chiefly 
affected. The same author has considered that the so-called Paget’s 
bone disease, which is a diffuse progressive periostitis leading to hyper- 
ostosis, is nothing more nor less than hereditary syphilis. 
The tibia is the bone most frequently involved. The disease here 
produces what is known as the "saber deformity.” (See Fig. 131.) Fol- 
lowing the hyperplastic stage is the real stage of hyperostosis, the de- TARDY HEREDITARY SYPHILIS 
753 
formity being due to the continuous formation of new periosteal bone 
layers about the primary one. 
Among the less frequent bone changes in late hereditary syphilis is 
a rarefying periostitis leading to bone absorption. This condition is seen 
on the surface of the cranial bones and causes the formation of rough 
areas (caries sicca). 
Joint affection in late hereditary syphilis may take the form of a 
simple hydrops without capsular thickening or a hyperplastic synovitis. 
Again, there may be a combination of hydrarthrosis, with swelling of 
the joint-ends of the hollow bones, and in rare instances a condition 
resembling white swelling. 
Symptoms.—This form of syphilis in the young may manifest itself 
in widely different ways. 
Errors in Nutrition (see p. 755).—A not infrequent manifestation 
is that of moderate malnutrition and stunted growth. The patient is 
habitually pale, undersized, and shows lack of resistance, such evidences 
perhaps constituting the only signs of the disease. 
Fig. 132.—Hutchinson teeth. 
The Bones.—Characteristic signs are to be found in the bones and 
teeth. The shafts of the long bones are involved in a periostitis. (See 
Fig. 131.) The tibia when affected may show the saber deformity. The 
tibia is most frequently involved; next in frequency, the radius. Gum- 
mata may involve the flat bones of the cranium, although such an occur- 
rence is comparatively rare. The “saddle nose” caused by a destruction 
of the septum is a condition not infrequently seen in congenital syphilis. 
The Teeth.—Fairly characteristic signs, first described by Hutchin- 
son, are often shown by the second set of teeth. The first set in no way 
give evidence of the disease. Hutchinson’s teeth represent faulty de- 
velopment. They are variously described, according to the deformity 
presented, as “notched,” “screw-driver,” and “peg-shaped.” (See Fig. 
132.) 
Lymph-nodes.—The only lymph-node involvement of significance 
is that of the epitrochlears. General lymph-node involvement is to 
be looked upon as corroborative of other signs of consequence. 754 
THE PRACTICE OF PEDIATRICS 
The Eye.—A diffuse interstitial keratitis is one of the most frequent 
manifestations of tardy hereditary syphilis. 
Involvement of Other Structures and Organs.—The spleen is usually 
enlarged, the liver not infrequently. Cases of brain tumor of syphilitic 
origin are occasionally seen. Juvenile tabes and paresis are sufficiently 
frequent to call for consideration in connection with suggestive neuro- 
logic signs. In fact, any portion of the body may be involved in a syphil- 
itic process, and a detailed description of the various possibilities is out 
of place at this time. 
Treatment.—Experience with the new arsenical preparations in tardy 
hereditary syphilis has been thoroughly unsatisfactory. As in the treat- 
ment of tertiary syphilis in the adult, likewise in the treatment of the 
late hereditary form in children, the iodids play an important part. Much 
better results, however, are obtained with the so-called “mixed treat- 
ment.” The iodids alone are not sufficient to give us our best results, 
and the results with mercury alone are not so prompt and satisfactory 
as when the two drugs are combined. For an average case of periostitis 
involving the anterior portion of the tibia in a child four years of age, 
from 1/30 to 1/20 grain of bichlorid of mercury should be given daily, 
combined with sufficient iodid of potash to produce the characteristic 
coryza. This may necessitate the giving of from 12 to 20 grains of iodid 
daily, as children vary greatly in their susceptibility to the drug. The 
mercury and the iodid of potash should not be given in one mixture, as 
the combination is most disagreeable to the taste. It is far better to give 
the bichlorid in the form of tablet triturates. The iodid of potash is 
best given in a saturated solution, 1 drop of which represents 1 grain of 
the drug. This is best taken when dropped into milk after meals. Ben- 
eficial results from the treatment will usually be apparent in a few days. 
If there is a periostitis, the pain will be the first symptom to disappear. 
The administration of the iodid of potash should always be inter- 
rupted, chiefly because of the possibilities of deranging the child’s di- 
gestion. A good rule is to give the drug for ten days, followed by a rest 
of five days, when it is again resumed. Proper nutrition in these cases 
is a most important factor in their management. If the iodid is given to 
the point of tolerance, its omission for a few days will not be noticed. 
The mercury should be given for weeks continuously in doses of from 1 /60 
to 1/20 grain three times a day, graduated according to the age. Later, 
when the progress of the case shows that the disease is under control, 
the two drugs should be given alternately, for ten days each. How long 
this treatment should be continued must be determined by each indi- 
vidual case. The Wassermann test in these cases is of much service. 
Patients who are apparently cured should be instructed to report to the 
physician every three months. A course of treatment for three or four 
weeks two or three times a year is to be advised. A sufficient excuse 
for such action may be the condition of the child, who may show a tend- 
ency toward slow growth and improper nutrition. The patients should 
be kept under observation for years and should be seen at stated inter- 
vals until the adult period is reached, when the nature of the trouble 
should be explained to them. The disease from which such a child is 
suffering should always be made plain to parents, or at least to one of TARDY MALNUTRITION OF SYPHILITIC ORIGIN 
755 
them, in order that the patient may not be allowed to pass from under 
medical observation in ignorance of his true condition. 
Tardy Malnutrition of Syphilitic Origin 
The possible manifestations of syphilis in the young, as in the adult, 
are many. The infection may be so severe as to destroy the fetus, or so 
mild in its effects as to make recognition difficult. Not the least inter- 
esting and important of the cases showing remote manifestations are 
those in which late malnutrition is the only evidence of the syphilitic in- 
fection. The patients are usually thin, sometimes sallow, sometimes pale, 
with little or no adipose tissue. They are almost always under normal 
height, and always underweight; with poor appetite and little endur- 
ance and correspondingly little resistance. Those seen by the writer 
have been between three and ten years of age. None were mentally 
defective. When 2 such children are seen in a family in which both 
parents are robust, this circumstance is a strong indication that the 
children are suffering from the results of a remote syphilitic infection 
in one of the parents. The physical examination may show nothing 
definite, and yet the Wassermann reaction prove positive. 
Cases of late malnutrition, non-syphilitic in character, due to poor 
hygiene and faulty feeding, may present symptoms identical with the 
above, so that while the two conditions cannot be differentiated by the 
clinical signs, there may be sufficient grounds for suspicion to warrant 
us in questioning the father, whereupon the history of a primary sore 
with perhaps secondary lesions may be elicited. There may have been 
prolonged treatment, with a subsidence of all the symptoms, and the 
patient may have been pronounced cured and told that he might safely 
marry. Many times this story is heard when the evidence of transmis- 
sion is before the physician in the form of a typical case of congenital 
syphilis. 
Treatment of tardy malnutrition of syphilitic origin by the supportive 
and restorative methods used in the cases of non-syphilitic malnutrition 
is without avail. (See Tardy Malnutrition, p. 146.) These patients 
require mercury, either alone or combined with the iodids. To the usual 
methods of treatment with iron, cod-liver oil, baths, and massage, there 
will be but little response, but if bichlorid of mercury or the iodid of 
potash be added, the case will improve. The improvement is slow, to be 
sure, but it is invariable. The child should be given the advantage of an 
outdoor life, with free ventilation of the sleeping-room at night. The 
food should be highly nutritious, containing a large amount of protein. 
Eggs, meat, milk, and the high-protein cereals, such as oatmeal, are the 
most valuable. The dried legumes—peas, beans, and lentils—given in 
the form of purees, are a valuable addition to the diet. Brine baths (p. 
843) at bed-time during the entire year, followed by oil inunctions dur- 
ing the cooler months, are valuable in restoring a vigorous condition. 
As these children are almost always anemic, it may be well to combine 
the bichlorid of mercury with nux vomica, iron, and quinin. For a child 
from five to ten years of age the following prescription has been used 
with marked benefit: 756 
THE PRACTICE OF PEDIATRICS 
1$. Hydrargyri bichloridi gr. ss 
Tinctura; nucis vomicae gtt. xc 
Extract! ferri pomati gr. x 
Quininse bisulphatis 5j 
M. Div. et, ft. capsulae No. xxx. 
Sig.—One capsule after each meal. 
This is given for ten days, when the bichlorid of mercury in tablet 
form, 1/60 grain three times daily after meals, is substituted for ten days. 
During the ten days when the bichlorid is given alone maltine and cod- 
liver oil may be given—1 dessertspoonful three times a day after meals. 
In these cases iodid of potash is not to be given early in the treatment, 
for the reason that the appetite is usually poor or indifferent, and the 
administration of the drug at this time might further decrease the desire 
for food. Syrup of the iodid of iron may be used in doses of 10 to 15 
drops, three times daily, if the physician desires to change the form in 
which the iron is administered. 
Duration of Treatment.—Prolonged treatment will usually be re- 
quired. These patients should be kept under close observation for at 
least two years, or until they arrive at adolescence, when, as has been 
stated, they should be made acquainted with the nature of the disease. 
During the entire growing period the administration of mercury during 
one month out of every three, or possibly every six, depending upon the 
child’s condition, will insure better growth and a more vigorous develop- 
ment both physically and mentally. 
TUBERCULOSIS 
Tuberculosis is the condition resulting from an invasion of the body 
by the tubercle bacillus. 
The subjects of pulmonary tuberculosis and tuberculous cervical adenitis 
have been discussed in previous sections (pp. 394 and 458). 
Types of the Infection.—There are two types of the bacillus—the 
human and the bovine. In 132 cases of children between the ages of five 
and sixteen years Park and Krumweide1 found the bovine type in 33 
cases. In 20 of these there was a tuberculous cervical adenitis, in 7 ab- 
dominal tuberculosis, and in 3 generalized tuberculosis. Alimentary 
origin of generalized tuberculosis was apparent in 1, tuberculosis of the 
bones and joints in 1, and tuberculosis of the tonsil in 1. 
The percentages of bovine infections were as follows: 
Pulmonary tuberculosis 
Children five to 
sixteen years, 
per cent. 
0 
Children under 
five years, 
per cent. 
0 
Tuberculous adenitis (cervical) 
37 
57 
Abdominal tuberculosis 
.50 
68 
Generalized tuberculosis 
40 
26 
Tuberculous meningitis, with or without localized lesion 0 
0 
Tuberculosis of bones and joints 
3 
0 
Of 220 children infected under five years of age, 59 showed the bovine 
type. Of these, 20 showed tuberculous cervical adenitis; 13, abdominal 
1 Park and Krumweide: The Relative Importance of the Bovine and Human 
Types of Tubercle Bacilli in the Different Forms of Tuberculosis, Research Lab. Dept. 
Health, New York City, Jour. Med. Research, 1912. TUBERCULOSIS 
757 
tuberculosis; 10, generalized tuberculosis—alimentary origin; 5, gen- 
eralized tuberculosis; 8, generalized tuberculosis including meningitis— 
alimentary origin; 1, generalized tuberculosis including meningitis; 2, 
tuberculous meningitis. 
Park and Krumweide concluded as follows: “In children, the bovine 
type of tubercle bacillus causes a marked percentage of the cases of cer- 
vical adenitis leading to operation, temporary disablement, discom- 
fort, and disfigurement. It causes a large percentage of the rarer types 
of alimentary tuberculosis, requiring operative interference or causing 
the death of the child directly or as a contributing cause in other diseases. 
“In young children it becomes a menace to life and causes from 
to 10 per cent, of the total fatalities from this disease.” 
The bovine infection is largely limited to children, and the fatal cases 
are further limited to infants and very young children. 
A review of the very extensive literature that now exists on this sub- 
ject leads one to the conclusion that about 20 per cent, of the cases of 
tuberculosis in children are of bovine origin. (See p. 459.) 
Avenues of Entrance.—Tubercle bacilli may enter the body by means 
of the respiratory and alimentary tracts, by means of the genito-urinary 
system, and through the skin. The two latter are very unusual modes 
of entrance. The avenue of entrance of the bovine bacillus is the ali- 
mentary tract—that of the human type, the respiratory tract. In a large 
majority of our cases the patient had been in association with a tuberculous 
individual. 
Illustrative Cases.—Two children, aged six and eight, developed pulmonary tuber- 
culosis. They were dispensary patients, and lived in a small three-story tenement 
house. The fact that the 2 cases developed at the same time seemed conclusive evi- 
dence of a common source of infection. Both the father and the mother were well, 
and they, with their 2 children, composed the family. Upon further investigation it 
was found that the janitor of the tenement had advanced pulmonary tuberculosis, and 
that he was not at all careful where he deposited tuberculous sputum. 
Aged people with chronic bronchitis are often carriers of the tubercle 
bacillus, and such persons are the most dangerous. They remain indoors 
and infect the rooms. Not suspected of being tuberculous, they are care- 
less, they kiss and fondle, and often assume considerable care of the 
younger members of the family. Several cases of tuberculous meningitis 
have been personally traced to such origin. 
Illustrative Cases.—In a recent case the infection was traced to the grandfather 
whom the child visited for four weeks. 
A baby of nine months, an only child, died from tuberculous meningitis. No 
source of the infection could be discovered until, six months later, the mother de- 
veloped acute pulmonary tuberculosis of a very active type. She undoubtedly was 
suffering from latent tuberculosis at the time of the child’s death. The father contracted 
the disease apparently from his wife, and died in two years. In all these cases there was 
a decidedly virulent infection. 
Predisposing Causes.—Among the predisposing causes age is im- 
portant. The more tender the age, the greater the susceptibility. Any 
illness which decreases the general resistance or lessens the resistance 
of the upper air-passages or lungs, predisposes to the disease. Thus 
we see many cases following measles, whooping-cough, scarlet fever, 
influenza, and bronchopneumonia. Adenoids and diseased tonsils are 758 
THE PRACTICE OF PEDIATRICS 
eminently predisposing causes, particularly favoring tuberculous cervical 
adenitis. Heredity is less a factor than is generally supposed. Often what 
passes for heredity is a direct infection from a tuberculous parent, in 
whom the disease has remained dormant in the bronchial glands or else- 
where, and does not develop until a late period. 
The close housing of children during the colder months is of no little 
importance as a means of diminishing resistance to tuberculosis. The 
habit of frequent change of residence is also a source of infection. A 
family moves into an apartment or tenement with little thought or knowl- 
edge of the previous occupant, and the owner makes no effort at paint- 
ing or cleaning for the new tenants, carrying out only such changes as 
are absolutely necessary. Tuberculosis has been known to develop in 
children occupying an apartment in which a tuberculous adult had pre- 
viously been domiciled. Infection may rarely take place through the 
blood of the mother by way of the placental circulation. Cases have 
been reported in our country by Jacobi and Wollstein, in which a tuber- 
culous fetus has been born to a tuberculous mother. 
Prophylaxis.—The best insurance against tuberculosis is a vigor- 
ous bodily resistance. At least 85 per cent, of the human race are in- 
fected some time before the thirtieth year, but, fortunately, the great 
majority of those infected are able to withstand the invasion. Obser- 
vation with the von Pirquet test in different countries, covering a large 
number of children of varying ages, shows that from 40 to 70 per 
cent, react positively. The results demonstrate that a vast majority 
of the human race are infected before the fifteenth year. Adenoids and 
diseased tonsils should be removed from every child who possesses them. 
Children should be allowed to make complete recoveries from bronchitis, 
bronchopneumonia, influenza, whooping-cough, measles, etc. A week 
or longer from school is a matter of no moment in the child’s future from 
the standpoint of knowledge. Kissing of children on the mouth should 
be forbidden. This act is a grossly unfair advantage to take of an in- 
nocent child. Overwork at school, in mines, and in factories predisposes 
by fostering close associations and diminishing resistance. 
The reporting of tuberculous cases, and the rigid enforcement of 
hygienic measures relating to the disposal of tuberculous sputum, would 
materially lessen the number of cases. 
Infants and young children up to the fourth year are very suscepti- 
ble to tuberculosis. During this period the child should have absolutely 
no association with an active case in an adult or older child. If there 
is such an association the infant will in all probability develop tuber- 
culosis. 
Milk Infection.—The infection of the bovine type is preventable 
by pasteurizing all milk and butter which is not taken from tested cows 
proved free from tuberculosis. The nutritive qualities of milk are not 
harmed by heating, but all children fed on pasteurized milk should be 
given orange juice. 
Relative Frequency in Different Sites.—Although the tonsil is looked 
upon as a portal for the frequent entrance of the disease, this organ has 
been found tuberculous in comparatively few instances. 
In 90 per cent, of all cases of tuberculosis lymphadenitis the cervical ABDOMINAL TUBERCULOSIS 
759 
glands are involved, and chronic inflammation in these glands, when 
well advanced, is usually aggravated by the presence of infecting or- 
ganisms of the staphylococcus or streptococcus groups. 
Still has reported important findings in 216 postmortem examina- 
tions following fatalities from tuberculosis in children. In 63.8 per cent 
he traced the incidence of the disease to the lung; in 29.1 per cent, to the 
intestine; and in 15 of the 216 cases, to the ear. By other authorities the 
frequency of primary respiratory infection has been estimated at 65 
to 70 per cent., and that of an initial intestinal infection at 15 to 30 per 
cent. 
Both Still and Carr have reported finding caseation of the mediastinal 
glands in 81 per cent, of autopsies on tuberculous subjects, while in a 
proportion ranging approximately from 55 to 60 per cent, the same ob- 
servers found a similar condition in the mesenteric glands. The medias- 
tinal glands on the right side are more frequently diseased than those 
on the left. 
Nearly 60 per cent, of tuberculous cases have shown invasion of the 
mesenteric glands; and in 12 of 100 autopsies upon children under two 
years of age Still found tuberculous peritonitis. 
Abdominal Tuberculosis (Tuberculosis of the Mesenteric Glands , 
Tabes Mesenterica) 
Tuberculosis of the mesenteric glands is not uncommon in the find- 
ings at autopsy upon young tuberculous subjects. Rarely is the condi- 
tion sufficiently developed, in this country, to be recognized clinically 
independent of peritonitis. 
The senior author’s first postmortem examination upon a child, however, was in 
a case of this character. The patient was three months old, colored. In 2 other cases 
autopsy showed uncomplicated tabes mesenterica with no peritonitis. The condition 
in 3 other cases was diagnosed as true tabes mesenterica. 
Symptoms.—The symptoms include slow progressive emaciation, 
slight inconstant elevation of the temperature, distended abdomen, 
persistent intestinal indigestion, diarrhea, flatulence, and abdominal 
pain. The pain is colicky in character, and may be very severe and 
continue over a considerable period. 
Diagnosis.—A positive diagnosis is to be made upon one’s ability 
to palpate the enlarged glands. For critical abdominal examination 
one must often employ light anesthesia, as this renders the examination 
far more satisfactory. The glands are often best felt in the right or left 
iliac fossa. 
The symptoms somewhat resemble those of chronic appendicitis, 
and a rectal examination may be necessary to determine if there is an 
enlargement of the appendix or adhesions or infiltration about it. 
Celiac disease upon superficial examination is readily confused with 
abdominal tuberculosis. 
Prognosis.—The prognosis is unfavorable in cases that have devel- 
oped sufficient signs for a diagnosis. Still, who has had a large experi- 
ence in abdominal tuberculosis, has stated that we are never sure of the 
recovery cases. The diseased glands may at any time be the starting- 760 
THE PRACTICE OF PEDIATRICS 
point of a general or localized inflammation, with the output of exten- 
sive adhesions resulting in a general tuberculous peritonitis or produc- 
ing local effects interfering seriously with the functions of the intestine. 
Illustrative Case.—Some years ago the writer performed an autopsy for a colleague 
on a two-year-old child who had died suddenly with symptoms of acute intestinal 
obstruction. The child had had abdominal trouble during the second year, and had 
been seen by different physicians, one of whom made a diagnosis of tabes mesenterica. 
The patient improved and three months previous to the fatal termination was well, 
except for obstinate constipation. The postmortem showed a most remarkable picture 
of enlarged glands matted together by fibrinous exudate, which had been poured into 
the abdominal cavity and had undergone connective-tissue formation. The descending 
colon resembled a hollow tube held in position by the surrounding exudate. How the 
child had lived and had bowel evacuations is difficult of explanation. The obstruction 
was caused by an angle forming at the point where the free intestine, filled with gas, 
joined the fixed portion. 
Treatment.—All measures that will increase the patient’s resistance 
should be employed. An out-of-door life and the general management 
advised in treating other forms of tuberculosis (p. 397) should be followed. 
Still believes that operative measures are of value. He has found 
that removal of the enlarged glands is to be advised, as thereby eliminating 
a definite focus of infection. At the same time fibrinous bands causing 
pain and other symptoms may be broken up. 
Acute tuberculous invasion of the peritoneum may be found in a few 
cases of general tuberculosis. It is of no clinical significance, and is 
briefly referred to below under Pathology. 
Chronic tuberculous peritonitis is a comparatively infrequent dis- 
ease in this country. In England and on the Continent many more 
cases are seen. Still reported 266 fatal cases of tuberculosis in children 
under twelve years of age, 45 of whom died with tuberculous peritonitis 
—a percentage of 16.8. Under two years of age this author found 12 
cases of tuberculous peritonitis in 100 tuberculous infants. 
Age.—The great majority of cases occur between the first and third 
years. Cases developing before the end of the first year are rare. 
Etiology.—A considerable proportion of the cases are probably due 
to an extension from infected mesenteric glands. Through the lymph 
and blood-channels the bacilli may be carried to the peritoneum from 
any focus. 
Types of Bacilli.—Park and Krumweide found the bovine form in 
20 of 53 cases of tuberculosis between the fifth and sixteenth years. In 
35 children under five years the bovine bacillus was present in 20 cases. 
Pathology.—The course of the inflammation may be acute or chronic, 
and the changes produced have given rise to a classification of several 
types of the disease. 
1. The simplest lesions consist of scattered grayish miliary tubercles 
unassociated with the presence of exudate or other evidences of an ad- 
vanced process. This picture is seen in connection with a general miliary 
tuberculosis which may have presented no local clinical signs. 
2. In a second form of the disease, coexisting with miliary tubercles 
which are scattered over the peritoneum in great number, there is a 
marked ascites depending on the predominance of the element of exu- 
Chronic Tuberculous Peritonitis CHRONIC TUBERCULOUS PERITONITIS 
761 
dation. The exudate is serous and contains only a moderate amount of 
fibrin. When the fluid accumulation is large the intestines are floated 
up and the abdominal cavity is characteristically distended. 
3. A third variety of tuberculous peritonitis is predominantly ad- 
hesive and unaccompanied by the exudation of much fluid. The loops 
of intestines become closely matted together and the omentum is rolled 
up in a firm elongated mass. The typical tubercles are present, but 
have, at many sites, become confluent and been transformed into larger 
foci, or given way to the development of reparative fibrous tissue. The 
amount of fluid exudate is small and may be clear or clouded by the 
admixture of fibrin and flakes of pus. 
4. Finally, the lesions may be of a destructive character, consisting 
of actual ulcerations caused by the disintegration of large caseous foci. 
In such an event adhesions between intestines, mesentery, and omen- 
tum are produced which serve to confine collections of pus. These may 
eventually break forth and discharge externally. Fecal fistulse or ab- 
scesses between adjacent portions of intestine are not uncommon. 
Types of Lesions.—The disease is usually divided pathologically 
into two leading forms—the ascitic and the plastic or fibrous. 
There are few cases of the fibrous type, however, without fluid in 
the abdomen, and few ascitic cases in which there is not some fibrous 
formation. Still found the proportion of the fibrous to the ascitic type 
10 to 1. 
Symptoms.—Suggestive symptoms in all cases are abdominal dis- 
comfort, pain, and distention from gas or fluid, digestive disturbances, 
emaciation, and persistence of all symptoms in spite of medication and 
careful dieting. 
The Ascitic Type.—In the ascitic form, when the patient first comes 
under observation, the abdomen usually contains considerable fluid. 
This increases rapidly and the abdominal wall becomes distended and 
tense. 
There may be a temperature of 100° to 102° F. An elevation of the 
temperature is, however, not invariably present; it is as often absent. 
There is a secondary anemia, and the child becomes emaciated and tires 
readily. A differentiation, however, between tuberculous ascites and 
that due to other causes may not be possible without corroborative evi- 
dence of tuberculosis elsewhere. Examination of the ascitic fluid even 
in positive cases does not always show the presence of the tubercle bacilli. 
Through absorption of the fluid, cases that belong to the ascitic type 
at first, change to the fibrous. This phenomenon is not at all unusual. 
The Plastic Type.—In these cases the onset is gradual, the tempera- 
ture usually is not high—100° to 101° F. There is loss of appetite with 
emaciation. Intestinal indigestion, evidenced by tympanites and oc- 
casional diarrhea, is common. There may be constipation alternating 
with diarrhea, and there is almost always pain. It is the pain that usually 
attracts the attention of the parents to the child’s condition. The course 
of this form of the disease is slow and its progress may be interrupted 
by periods of improvement. 
Figures 133 and 134 are reproductions of the z-ray plates made from 
a case in which tuberculous peritonitis was associated with pylorospasm. 762 
THE PRACTICE OF PEDIATRICS 
The case well illustrates how the inflammatory process may lead to symp- 
toms of mechanical origin. 
Fig. 134. 
Figs. 133, 134.—Tuberculous peritonitis associated with pylorospasm (Kerley and Le 
Wald, Digestive Disturbances in Infants and Young Children). 
Male, aged four and a half months. Family history negative for tuberculosis. 
When patient was four days old a right inguinal hernia was noticed. At seven weeks, 
30 c.c. of fluid removed from a left hydrocele; three weeks later, 30 c.c. again withdrawn. 
Suffered from convulsions, regurgitation of food, and constipation. CHRONIC TUBERCULOUS PERITONITIS 
763 
Roentgen Examination.—One hour after an opaque meal only a trace had gone 
through the pylorus, suggesting either a pyloric stenosis or a spasm (Fig. 133). The 
fact that the stomach had almost completely emptied itself in four hours and twenty-five 
minutes led to diagnosis of spasm which had evidently relaxed after the one-hour plate. 
Distinct delay in the small intestine which appeared dilated. Five hours after the 
meal distended loops of ileum were prominently outlined (Fig. 134). Roentgen diagnosis: 
Tuberculous peritonitis. 
Delay of the bismuth in the small intestine is very suggestive of tuberculous perit- 
onitis. This delay is evidently due to adhesions which are almost invariably present. 
In addition, there is very apt to be pouching of the small intestine for the same reason. 
Operation.—Free fluid in the peritoneal cavity and numerous tubercles on the perit- 
oneum. Small intestine adherent to the abdominal wall in a number of places; hence 
the impossibility of freeing the loops without danger of perforation. Operative diag- 
nosis: Tuberculous peritonitis. 
Diagnosis.—It is rare in cases of the fibrous type or in those due to 
mesenteric lymphadenitis not to find nodules in either of the iliac fossae 
or the evidence of fibrous bands in the abdomen. The retracted, thick- 
ened omentum, forming a distinct ridge across the abdomen, is present 
in many cases. This may be confused with the lower edge of the liver. 
Careful palpation, however, will demonstrate the band as thick and 
roughened, and extending well across the abdomen in a downward di- 
rection toward the left side. A space between the band and the lower 
edge of the liver can usually be made out. 
With the palpable mesenteric nodes or the fibrous bands there will 
be fluid in some amount. An unfolding of the umbilicus, with redness 
about it, producing a condition known as “ pouting,” is a suggestive 
symptom. Perforation at this point is not an uncommon occurrence 
in the experience of those who see many cases of this disease. 
Prognosis.—About one-half of the patients recover. Pronounced 
cases may go on to complete recoveries. It is a difficult matter, however, 
as in the instance cited, to decide when a patient is wrell. The cases 
with ascites promise better than do those of the fibrous type; and yet 
many of the latter form which promise little make complete recoveries. 
Illustrative Case.—A boy three years old developed tuberculous peritonitis of a 
pronounced fibrous type. The omental band could be seen elevating the skin across 
the abdomen in a distinct ridge. After several months of treatment improvement 
began, and there was steady progress toward a betterment until the bodies of the two 
upper lumbar vertebrae became involved. The child made a complete recovery event- 
ually from both conditions. 
Treatment.—The hygienic and medical management is similar to 
the treatment outlined for other cases of tuberculosis (p. 397). Ade- 
quate rest, high-protein diet, open air, and change of climate, when this 
may be supplied, should be provided. Drugs are of value only as a means 
of improving nutritional conditions. A combination which seems to 
possess real value in these cases is the following: 
For a child three years of age: 
1$. Liq. potassii arsenitis njxlviij 
Liq. ferri albuminati . 3vj 
Syr. hypophosphitum (calcis et sodse) q. s. ad. 5vj 
M. Sig.—One teaspoonful in water after meals. 
The medication is given for ten days, then omitted for five days, and 
then resumed. Interrupted medication may be continued in this way 
indefinitely. 764 
THE PRACTICE OF PEDIATRICS 
Moderate exercise may be allowed if the temperature is normal. 
Operation.—There appears to be but little unanimity of opinion as 
regards the advisability of operative procedure in tuberculous perit- 
onitis. Some authors are ardent advocates and give statistics to prove 
their contentions; on the other hand, other physicians, with equally large 
experience, disapprove of the operation. A logical course is as follows: 
If there is marked ascites with much discomfort, interfering with res- 
piration and heart action through pressure on the diaphragm, opera- 
tion is to be advised at once. It would seem that early operation fur- 
nishes the best chance for relief in the acutely active cases. Evidence of 
interference with normal peristalsis, as indicated by persistent consti- 
pation and visible peristalsis, means that intestinal obstruction is im- 
minent, and under such conditions immediate laparotomy is advised. 
When the above conditions do not obtain it is advisable to postpone 
operation, and treat the patient along the lines already defined. 
Some of the cases seen are absolutely hopeless at the time, showing 
marked tuberculous processes elsewhere, and therefore are not consid- 
ered fit for operation. 
The patient should be weighed once a week. In case of a continu- 
ous loss in weight and strength extending over five or six weeks, with or 
without fever, in spite of the advantage of diet, climate, and medica- 
tion, operation is to be advised, regardless of the stage of the process, 
providing always that there is no active tuberculous process elsewhere. 
When the weight remains stationary or nearly so, and there is no evi- 
dence of advance in the abdominal lesions, it is safe to wait for a con- 
siderable time before undertaking operative measures. 
Heliotherapy in Surgical Tuberculosis.—In the summer of 1912 Dr. 
Rollier, of Lysin, Switzerland, published his results in the treatment of 
surgical tuberculosis at the tuberculosis congress in Rome. In the town 
of Lysin are situated, on the snow-covered mountain, the pavilions where 
his method of heliotherapy is practised. It consists in exposing the 
body of the patient to the sun’s rays in open galleries communicating 
with the wards and facing due south. The actual seat of disease is un- 
covered for five minutes only, to begin with, as there must be no blistering 
or burning of the skin; the next day the region is treated for two periods 
of five minutes each, separated by an interval of half an hour; and on 
the third day these exposures are lengthened to fifteen or twenty min- 
utes. At each seance a larger area of skin is exposed, so that at the end 
of two weeks the entire body, except the head, is being exposed to the 
rays of the sun. The head usually requires protection for a little longer 
time so as to prevent congestion. Plaster jackets are rarely- used, while 
abscesses are aspirated and exposed in the usual manner. In the jackets 
windows are cut so that portions, at least, of the body are exposed. 
Improvement is evinced almost immediately. Fever disappears, 
hemoglobin and red cells approach and attain their normal standards, 
while increase in weight is most noticeable. Out of 369 cases of surgical 
tuberculosis treated thus, in 284 (78 per cent.) recovery was obtained; 
in 48, improvement; in 21 the condition remained stationary, while 16 
(4 per cent.) terminated fatally. In visceral tuberculosis the results were 
excellent. In 27 cases of peritonitis and enteritis there were 17 recoveries, TUBERCULIN SKIN REACTIONS 
765 
3 improvements, and 3 deaths. Certainly no other treatment has given 
such results. 
The different rays (blue, indigo, violet) each play a part in the cura- 
tive process as well as the more recently discovered infra-red and ultra- 
violet rays. Some are analgesic, some have a tonic action, and others 
penetrate deeply into the tissues. There is no attempt to utilize any 
particular ray as Finsen did. Experiment has shown that fully 25 or 
30 per cent, of sun’s rays are absorbed by atmosphere and"dust and that 
to make the treatment efficient altitude is of prime importance.1 
In a study of 650 hospital cases Dr. Alan Brown2 found that 70 
per cent, of the cases under two years of age giving a positive reaction 
proved fatal. The lesions were, with but rare exceptions, general in 
distribution. 
That infants show a high degree of susceptibility to tuberculosis 
was shown by the fact that of 61 infants in whom a definite history of 
exposure could be obtained, 41 responded to the test, and of these, 37 
died of tuberculosis. 
In infancy a negative cutaneous reaction, except in moribund cases 
or in children suffering from any very acute infection, is almost conclusive 
evidence against the existence of a tuberculous focus. 
Among 100 consecutive cases of tuberculosis, 95 gave a positive re- 
action, the remaining 5 patients being moribund on admission to the 
hospital. 
In a child in whom tuberculosis is suspected the test should be re- 
peated if at first it proves negative. 
Tuberculin Skin Reactions 
Chart Showing the High Degree of Mortality in Infants Responding to the 
Cutaneous Test. All Fatal Cases Proved Tuberculous Either by Autopsy 
or the Finding of Bacilli in Sputum or Cerebrospinal Fluid 
Age. 
N umber of 
cases. 
Number 
with posi- 
tive re- 
action. 
Number of 
positive 
cases with 
autopsy or 
bacterio- 
logic ex- 
amination. 
Number of 
positive cases 
proved to be 
tuberculous by 
autopsy or 
bacteriologic 
findings. 
Number of 
negative 
cases that 
came to 
autopsy. 
Number of 
negative 
cases which 
showed no 
tuberculosis 
at autopsy. 
1 to 3 months 
62 
3 
3 
3 
or 100 per cent, 
of + reac- 
tions. 
10 
10 
3 to 6 months 
102 
7 
6 
6 
or 85 per cent. 
13 
13 
6 to 12 months 
218 
43 
35 
35 
or 81 per cent. 
19 
18 
Test not re- 
ported in 
one case. 
12 to 18 months 
156 
37 
20 
20 
or 54 per cent. 
15 
15 
18 months to 2 years . . . 
112 
24 
15 
15 
or 62 per cent. 
4 
4 
Total, 0 to 2 years 
650 
114 
79 
79 
or 70 per cent, 
of + reac- 
tions. 
61 
60 
1 Cf. Rollier, Heliotherapy, 1923. 
2 Archives of Pediatrics, July, 1913. 766 
THE PRACTICE OF PEDIATRICS 
Chart Showing the Bearing of Exposure to Tuberculosis on the Mortality 
in the Infant 
Age. 
Number of 
cases. 
Number of cases 
with a definite 
family history. 
Number of cases 
with definite 
family history 
that reacted. 
Mortality of cases 
with definite 
family history 
that reacted. 
1 to 3 months 
62 
4 
3 
3 
3 to 6 months 
102 
8 
4 
4 
6 to 12 months 
218 
30 
20 
20 
12 to 18 months 
156 
10 
10 
• 6 
18 months to 2 years 
112 
9 
4 
4 
Total, 0 to 2 years 
650 
61 
41 
37 
or 60 per cent, of 
those giving a 
history of con- 
tact. 
In a statistical study of tuberculin tests Wahl and Gerstenberger1 
were able to establish the following: 
“A study of the tuberculin tests performed upon exposed, suspicious, 
or actively tuberculous individuals of the clientele of the Babies’ Dispen- 
sary and Hospital of Cleveland from the year 1907 to September, 1921, 
showed the following findings: 
“1. A slight increase of positive tests in the females over the males, 
the former giving a positive percentage of 61 per cent, and the latter a 
positive percentage of 54. 
“2. An increase in the percentage of positive reactions corresponding 
with the increase in age, being 35 per cent, in infants under six months 
of age, and 87 per cent, in young children between thirty-six and forty- 
eight months of age. 
“3. Of the different races and nationalities, the colored race gave the 
highest percentage of positive reactions. 
“4. Patients exposed to two or more sources of tuberculous infection 
showed a higher percentage of positive reactions than those exposed to 
only one. 
“5. When only one source of contact existed for a patient, the mother 
was found responsible for the highest percentage of positive reactions, 
a brother or sister for the next highest, and the father for the lowest of 
the group. 
“6. Children giving a negative history of exposure showed only 15 
per cent, positive reactions as against 44 per cent, for those having a 
positive contact history. In other words, 44 per cent, of the children 
giving positive tuberculin tests gave a definite history of tuberculous 
contact, whereas, of those giving a negative history of exposure only 
15 per cent, reacted positively. 
“7. Scrofula gave the highest percentage of positive reactions and 
was followed by pulmonary tuberculosis, tuberculous adenitis, tuber- 
culous osteomyelitis, tuberculous meningitis, and pulmonary miliary 
tuberculosis. 
“8. By using the intracutaneous test, controlled by checking with 
a known case of tuberculosis, a higher percentage of positive reactions 
can be obtained, especially in cases of tuberculous meningitis and pul- 
monary miliary tuberculous, than has been usually reported. 
1 Arch. Pediatrics, xl, 3, March, 1923, pp. 143-150. TUBERCULIN SKIN REACTIONS 
767 
“9. The intracutaneous tuberculin test, 0.1 c.c. of a 1 : 100 solution, 
is in practically 100 per cent, of the cases more sensitive in its reaction 
than the tuberculin tests performed either with the ‘tattoo’ or the ‘burr’ 
methods. Likewise, the test performed by the ‘tattoo’ method is more 
sensitive than the ‘burr,’ although the former is more difficult from a 
technical standpoint. 
“10. The intracutaneous test with a 1 : 1000 solution has always been 
found positive even when stronger dilutions of 1 : 10 and 1 : 100 were 
used. The reactions with the stronger solutions have been in general 
more marked, but the reaction with the 1 : 1000 dilution has been sufficient 
to convince us to choose it as our standard in performing the intracuta- 
neous test routinely.” 
Fig. 135. 
A fairly accurate idea of the incidence of tuberculosis in different 
cities may be gained from a study of the above chart (Fig. 135), which is 
taken from a report by Smith.1 
“Incidence in cities of infection with tuberculosis, as shown by per- 
centage of positive skin reactions. Upper curves represent series reported 
from European cities and all show a higher percentage of positive re- 
actions than in American cities. The New York series represents about 
1500 consecutive cases in the wards of Bellevue Hospital, Children’s 
Medical Division. In this series the Pirquet and intradermal reactions 
were done on all cases, and nearly all the negative cases were retested with 
1 Tuberculosis in Childhood by Charles Hendee Smith, Bulletin of New York 
Tuberculosis Association, March to April, 1923. 768 
THE PRACTICE OF PEDIATRICS 
increased doses of tuberculin. The children were all under continuous 
observation and the reactions were read daily for five to ten days so that 
the possible error due to reading was practically eliminated.” 
The tuberculin reaction is discussed in further detail with mention 
of results obtained in the use of the intradermal method on pp. 824-826. 
Dactylitis is characterized by a fusiform swelling of one or more of 
the phalanges. (See Fig. 136.) There are two forms—dactylitis syphilitica 
and dactylitis tuberculosa. 
DACTYLITIS 
Fig. 136.—Dactylitis. 
Pathology.—The lesion is the same in both types, consisting of rare- 
fying osteomyelitis. The process begins in the center of the bone, caus- 
Fig. 137. Tuberculous dactylitis of the first metatarsal. (Bellevue Hospital.) 
ing an enlargement of the medullary canal. At the same time, particularly 
in syphilitic types, there is a periostitis with deposit of bone cells, so that DACTYLITIS 
769 
eventually the bone is of much greater circumference than other similar 
bony parts. 
A, Necrosis in first phalanx, middle B, Ten weeks later. Bone structure C, Eventual complete restoration to 
and little fingers. partially re-established. normal. 
Fig. 138.—Radiograph of hands in tuberculous dactylitis. 
Suppuration and necrosis occur. A mere shell of bone may remain 
which, on undergoing further necrosis, may result in the loss of the finger 
or toe. The disease does not limit itself to one bone. 770 
THE PRACTICE OF PEDIATRICS 
Illustrative Case.—In a syphilitic case all the fingers of both hands were involved 
and also the metatarsals of both great toes. The index- and middle fingers of the 
right hand suffered most. On the whole, both hands were alike and appeared almost 
webbed, due to the swelling of the proximal phalanges, while the distal phalanges tapered 
in a definite penciled fashion. There was apparently no pain, and the infant used the 
hands with perfect freedom, The x-ray plates showed a destructive osteitis involving 
the bones of both hands. 
The radiograph reproduced in Fig. 138 shows very graphically the 
hone change taking place in tuberculous dactylitis. The patient, a child 
of eight months, had the advantage of heliotherapy. 
Differentiation between the two types from the clinical appearance 
is impossible. When the lesion is multiple, it is more apt to be of syphilitic 
origin, although this is by no means certain. The tuberculin test and 
the Wassermann reaction, in the absence of disease elsewhere, will be re- 
quired to establish the diagnosis, as the symptoms and appearance are 
identical in both forms. 
Treatment.—Aside from the antisyphilitic treatment, the manage- 
ment of the two types is the same. Absolute rest of the parts appears 
to be essential for success. This is best secured by the use of splints, 
which must be kept bound on the fingers for months in such a way as 
effectually to immobilize them. In a case of the tuberculous form, suc- 
cessfully treated in this way, the finger was kept in splints for six months. 
When abscess and necrosis occur, the case must be treated along surgical 
lines, the immobility of the parts being maintained as completely as the 
conditions allow. XX. DISEASES DUE TO DISTURBANCES OF METABOLISM 
ACIDOSIS (KETOSIS) 
Acidosis is a condition in which there is diminution of the alkali 
reserve of the body fluids, especially of the blood, usually attended by 
an excessive formation of acids with its resulting clinical symptoms. 
Etiology.—An alteration of the equilibrium and normal relationship 
of the alkalies and acids in the body is the direct exciting cause. The 
blood, in order for life to exist, must be maintained at a very constant 
reaction which is slightly alkaline, and there must be, within narrow 
limits, a certain excess of bases over acids. Any change from the normal 
toward the side of acidity tends to inhibit numerous sensitive metabolic 
processes in the organism, and acidosis results. 
(For the specific etiologic factors tending to induce acidosis see p. 774. 
Pathogenesis.—Metabolic products, especially carbonic acid, are con- 
stantly being formed in the tissues and poured into the blood to be trans- 
ferred to the lungs for elimination. This would tend to alter its normal 
slightly alkaline reaction to one strongly acid were it not for the alkali 
reserve formed by bicarbonates both in the blood and tissues, by the 
alkaline phosphates of sodium and potassium, and by the alkali-yielding 
proteins, in conjunction with efforts of elimination by the body. The 
slightest change in the direction of acidity is sufficient to stimulate the 
respiratory center through the agency of the carbon dioxid contained 
in the blood. The increased pulmonary ventilation removes the excess 
of carbon dioxid and the blood returns to its original state, as the res- 
piration lowers the concentration of carbon dioxid in the lungs and thus 
allows it to pass from the tissues where it is in greatest tension to the 
blood and thus to the lungs where the tension is lowest. Certain non- 
volatile acids, as sulphuric and phosphoric, also cause, when formed, 
increased pulmonary ventilation and hyperpnea, as they remove some 
of the alkali reserve of the blood, thus leaving more of the carbonic acid, 
normally produced by the tissues, to be eliminated through the lungs. 
These acids are for the most part eliminated through the kidneys which 
have the power to excrete an acid urine from a practically neutral fluid, 
leaving behind an alkali reserve for further neutralization purposes. 
An interference with the elimination of acids as well as their overpro- 
duction may therefore cause acidosis. A final and very efficient means 
of preserving the alkaline balance lies in the ability of the body to form 
the alkali, ammonia, from urea, a neutral substance, which thus adds 
greatly to the alkali reserve. 
Symptoms.—Acute acidosis in children usually manifests itself in two 
forms: as a peculiar symptom complex seen in infants, and in recurrent 
or cylic vomiting of older children. In the former, hyperpnea is one of 
the earliest and most constant symptoms. The majority of cases occur 
in infants who are of the marasmic type, or suffer from malnutrition 
771 772 
THE PRACTICE OF PEDIATRICS 
and who have finally a severe attack of diarrhea, following a digestive 
disturbance. The hyperpnea is associated with an ashen gray color 
of the skin and a peculiar pallor, but no cyanosis. The lips are cherry 
red. At first there is great irritability and restlessness which is succeeded 
by a condition of stupor and eventually coma. The eyes become deeply 
sunken and staring, and the mouth and lips dry and parched, the fon- 
tanels are depressed, and the respirations are of a deep and sighing 
character, without pause and usually labored. On being aroused from 
the stuporous state the child shows marked irritability, crying as though 
in pain. The temperature curve shows marked fluctuations, not usually 
going above 101.5° F. A polymorphonuclear leukocytosis ranging from 
10,000 to 20,000 is found. A very scanty excretion of urine often amount- 
ing to anuria often obtains. The stools are usually abundant and of a 
watery consistency. Determinations upon the expired or alveolar air 
show a marked reduction in the carbon clioxid tension which may fall 
as low as 15 to 12 mm. of mercury from the normal of 35 to 45 mm. There 
is a great tolerance for alkalies, as much as five to ten times the usual 
amount being needed to bring about an alkaline reaction of the urine 
to litmus, and keep it alkaline for twelve or more hours. Acetone may 
not be found in the urine even in the most severe cases. 
Treatment.—Alkalies must be given promptly, and in sufficient 
quantities to bring the blood back to the normal reaction. A 4 per cent, 
solution of sodium bicarbonate for intravenous use best answers the pur- 
pose, especially where rapidity of action is desired, and should be given 
in amounts of 15 to 20 c.c. per kg. of body weight. This may be repeated 
in three to four hours if the hyperpnea has not disappeared or if the alveolar 
carbon dioxid tension is as low as 25 mm. (See p. 829.) The superior 
longitudinal sinus or the external jugular vein in infants offers a very 
convenient avenue of administration. In older children the median basilic 
may be used. Sodium bicarbonate in doses of 20 to 60 grains should 
also be given by the mouth every two hours until the urine is alkaline 
to litmus. 
Glucose in 10 per cent, solution administered by the bowel, or in ex- 
treme cases intravenously, in amounts up to 20 c.c. per kg. of body weight 
is the recognized easily available fuel with which deficient oxidation must 
be combated. To guard against excretion of this sugar in the urine the 
injections should be gradual. Such administration of glucose, even without 
alkali, tends to restore the normal alkali reserve of the blood. 
In intestinal intoxication there is with the usual acidosis a marked 
increase in the non-protein nitrogenous constituents of the blood, and the 
symptoms resemble those of uremia. Schloss1 has explained that the failure 
of the kidney in intestinal toxemia to preserve the acid-base equilibrium 
results from restricted formation of urine due to the dehydration so char- 
acteristic of the diarrheal disease. 
As the activity of the kidneys is at a low ebb when acidosis develops, 
they should be stimulated by water or salt solution given freely by mouth, 
rectum, subcutaneously, intraperitoneally, or intravenously. “As much 
as 200 to 350 c.c. may be given at a single injection to a small infant.”2 
1 Amer. Jour. Dis. Child., 15, 3, March, 1918, pp. 165-189. 
2 Howland and Marriott, Abt’s Pediatrics, Vol. II, chap, xxviii, p. 841. CYCLIC VOMITING (RECURRENT OR PERIODIC VOMITING) 
773 
Schloss1 has recommended the intraperitoneal injection of normal saline 
as the method of choice in the administration of fluid in severe intestinal 
intoxication cases. Fluid should be administered until the blood concen- 
tration is found to be normal by hemoglobin determination. Following 
this, as an adjunct of great value not so much for nutrition as to promote 
diuresis, he has given glucose in 10 per cent, solution, 20 c.c. per kg. of body 
weight. The administration of the saline before giving the glucose is par- 
ticularly important, as a large amount of tissue fluid is necessary to insure 
the requisite withdrawal of fluid into the blood-stream. This treatment 
may be repeated in five or six hours. 
(For transfusion of citrated human blood in acidosis see p. 777.) 
Following the prolonged administration of bicarbonate of soda in exces- 
sive amounts typical tetany seizures culminating in convulsions have been 
observed in young infants and nephritics. According to Howland and 
Marriott2 these manifestations ordinarily cease promptly on cessation of 
of the dosage, but “when massive doses of sodium bicarbonate are to be 
administered there are theoretic as well as practical reasons for adminis- 
tering magnesium sulphate subcutaneously as a prophylactic against tetany. 
This may be given in 8 per cent, solution in doses up to 0.2 gm. per kg. 
of body weight.” When it is not practicable to determine the bicarbonate 
reserve of the blood-plasma, these observers have recommended that the 
fresh urine be tested with a drop of cresol purple. “If the color remains 
green more alkali is necessary; if it changes to any shade of red or purple 
a sufficient amount of alkali has been given.” 
Greenwald,3 in experiments with dogs, found that only in the tetany of 
hyperpnea is there indication of change in the reaction of the blood follow- 
ing prolonged slow administration of bicarbonate of soda; and “even in 
this condition the tissue anoxemia resulting from increased stability of oxy- 
hemoglobin rather than alkalosis per se, is the exciting factor.” 
From the rather meager evidence at hand it would thus spem that 
whereas excessive alkalinization, particularly in cases of nephritis and pye- 
litis, may constitute a danger, nevertheless this danger is not great and may 
be readily avoided by careful clinical and laboratory observations in carry- 
ing out the treatment of acidosis cases. 
ALKALOSIS 
CYCLIC VOMITING (RECURRENT OR PERIODIC VOMITING) 
By recurrent vomiting is understood the disorder which for a period 
of several months or longer is manifested by vomiting seizures at fairly 
definite intervals. 
True cyclic vomiting or recurrent vomiting may be one of the mani- 
festations of acidosis, p. 770. Children who suffer from dilatation and 
ptosis of the stomach (p. 221) often suffer from periodic vomiting, likewise 
those who have mechanical intestinal defects (p. 253) and chronic ap- 
pendicitis. In these cases, however, the seizure is not prolonged and 
there is no air-hunger, no great prostration, and there are no fatalities. 
‘Boston Med. and Surg. Jour., September 21, 1922; New York State Jour. Med.» 
August, 1918. 2 Abt’s Pediatrics, Vol. II, chap, xxviii, p. 840. 
3 Jour. Biol. Chem., liv, 2, October, 1922. 774 
THE PRACTICE OF PEDIATRICS 
There may be acetonuria as there is in any other acute disorder in 
children, without diminished alveolar air tension. The nature of the 
seizure is quite apart from the vomiting of acidosis. 
Etiology.—Children who have cyclic vomiting often show varying 
nervous phenomena, such as habit spasm, chorea, recurrent spasmodic 
croup, and spasmodic bronchitis. Rachford was the first to designate 
the underlying condition as a gastro-intestinal lithemia. 
Secondary Etiologic Factors.—There are certain associated conditions 
which may precipitate an attack in a susceptible subject. Habitual 
constipation with defective elimination is present in some cases. In other 
cases there is an associated intestinal crisis, with vomiting, high fever, 
and a sharp diarrhea. In others the onset may be with grip, pneumonia, 
or one of the exanthemata. Fright, fatigue, and unusual excitement may 
play a part in inducing an immediate attack. Each of these factors, 
however, represents the spark that ignites the powder. If the condition 
of systemic intoxication did not exist, any of the influences mentioned 
would not produce the vomiting. Runyon reported 6 cases of recurrent 
vomiting cured by the removal of a chronically diseased appendix. 
There are also seasonal influences. When the child can exercise and 
perspire, when he runs much and plays hard, elimination is better, and 
in many cases fewer attacks occur. Repeatedly, in getting the history 
of these cases one hears that there are no attacks between May and 
October. 
Symptoms.—The vomiting periods occur periodically. In some cases 
observed the attacks occurred every nine days, in others but once in three 
or four weeks, or as many months. Each patient involuntarily arranges 
his own distinct periods, and usually fulfils the contract. 
Prodromal symptoms have been unusual. Now and then a mother 
will state that she can anticipate an attack by some peculiar behavior 
on the part of the child—that he will lose his appetite or that the skin 
over the face will have a greenish or yellowish tint, or that the breath 
will be offensive. 
The symptoms are very characteristic, and occur in no other condi- 
tion. The child, without prodromal signs, has a sharp attack of nausea 
and vomiting. The nausea is extreme and the retching and straining 
occur at frequent intervals. There is often no elevation of the tempera- 
ture. There may be, however, decided pyrexia early in the attack. In 
Rachford’s experience an elevation of temperature is the rule in young 
children. There is marked prostration. The child becomes very pale. 
The eyes are sunken and the loss in weight is rapid. Acetone bodies 
are present in the urine. Neither food nor water is retained. The thirst 
is extreme. Eventually there is exaggerated sighing respiration, a true 
air-hunger. The patients beg for water, only to vomit as soon as it is 
given. The vomited material usually contains hydrochloric acid, wrhile 
in true gastritis free hydrochloric acid is absent (Rachford). 
The illness may last but a fewr hours, with one or two vomiting seiz- 
ures. In the average case the duration is from three to five days. The 
longest case witnessed w-as that of a boy of three years who vomited 
persistently for thirteen days. In some cases the vomiting is sufficiently 
severe to produce hematemesis. CYCLIC VOMITING (RECURRENT OR PERIODIC VOMITING) 
775 
I Uustrative Case.—A girl of eight years during an attack vomited such large amounts 
of blood that it was necessary to keep her under the influence of morphin given hypo- 
dermically. 
The Breath.—During the attack the breath usually has the charac- 
teristic odor of acetone. This is a sweetish odor, not unlike that of chloro- 
form. Observant mothers, in describing the child’s symptoms, have 
referred to this sign without suggestion from the physician. Examination 
fails to show anything abnormal except the presence of acetone, diacetic 
acid, and oxybutyric acid in the urine, as described by Edsall. 
In a mild or moderately severe case the vomiting stops abruptly and 
the child asks for food and retains it, providing reasonably simple food 
is given. In a few da vs he has made up the loss in nutrition and is as 
well as ever. 
In more severe attacks the child may require several days to regain 
his usual health and vigor. The resumption of the feeding will neces- 
sitate considerable care. 
Differential Diagnosis.—A first attack of cyclic vomiting may be 
confused with meningitis, acute indigestion, or the vomiting in acute 
nephritis, appendicitis, or intestinal obstruction. In the event of an 
abrupt onset in a first attack a diagnosis may not be made for a day 
or two. The differentiation laid down in some of the books is not de- 
pendable. 
Thus the vomiting which occurs as the earliest symptom of tuber- 
culous meningitis may be clinically identical with that of cylic vomit- 
ing, and only by the appearance of other signs of meningitis or through 
lumbar puncture is the differentiation possible. 
In acute indigestion there is a brief period of fever and one or two 
vomiting seizures, after which the patient is well. In acute nephritis an 
examination of the urine readily settles the diagnosis. In appendicitis 
there is pain and spasticity and the vomiting is not continuous; in cyclic 
vomiting the abdomen is relaxed, soft, and not tender. Intestinal ob- 
struction is an affection of infancy; cyclic vomiting rarely occurs before 
the second year, and usually not until after the third year. In intestinal 
obstruction, moreover, there is abdominal distention and perhaps the 
passage of bloody mucus, due to intussusception. 
Every child presented because of recurrent vomiting should be given the 
benefit of serial x-ray study of the gastro-intestinal tract. 
Illustrative Case.—A boy six years of age had had repeated attacks of severe recur- 
rent vomiting at intervals ranging from six weeks to three months. In the last seizure 
he had lost 9 pounds in weight. 
It was found upon x-ray study that the sigmoid was greatly elongated and that 
there was rectal stasis due to an overacting anal sphincter. In fact, the rectum was 
never empty. The mother, an unusually intelligent woman, was directed to insert, 
her finger into the rectum after a fairly free evacuation had been induced by a mild 
laxative. Invariably there was found fecal material in considerable quantity behind 
the sphincter. Dietetic measures and stretching of the sphincter were sufficient to 
relieve the vomiting. In the ensuing two years there were no attacks. 
Prognosis.—The prognosis is usually good not only as regards life, 
but as regards the continuation of the attacks. We have, nevertheless, 
seen a number of fatal cases. 
Treatment in the Intervals.—In describing the management of children 776 
THE PRACTICE OF PEDIATRICS 
who show the rheumatic complex, the influence of the sugar and fat was 
referred to. In the cyclic vomiting cases the precaution of withholding 
these substances from the diet is one of the most necessary features of the 
interval management. Different authors refer to the fact that the use of 
milk in some children is productive of attacks. It is the fat content of 
the milk that produces the attack. These patients may take fat-free 
milk and buttermilk without inconvenience. The diet prescribed for the 
cyclic vomiting case is that laid down on p. 739. 
Milk-fat, sugar, and egg-yolks are forbidden. 
Medication.—For a child from three to ten years of age from 9 to 12 
grains of salicylate of soda, or aspirin may be given after meals daily 
in divided doses, for five days out of fifteen. During the ten days of rest 
from the salicylates 10 grains of bicarbonate of soda should be given 
twice daily after meals. This method of treatment must be continued 
for months. If the salicylate of soda interferes with digestion or with 
the appetite, aspirin in equal dosage may be substituted. Under this 
method of treatment in cases in which attacks had been occurring every 
month or six weeks the intervals have been increased to six months or 
a year, and in many cases the attacks have entirely ceased. Spasmodic 
treatment is of little value; only persistent treatment is effective, and 
there must be confidence and co-operation on the part of the family 
or any treatment will fail. 
An important requirement in the management is that the patient 
live a normal child’s life. There should be a suitable rest period after 
the midday meal. Three meals are to be given daily, and there must 
be one free bowel evacuation daily without the habitual use of enemata. 
A liberal green vegetable diet with stewed fruit will do much to accom- 
plish this. (See Constipation, p. 274.) 
Treatment of the Acute Attack.—All food should be withheld. Hot 
bicarbonate of soda water, 10 grains in 3 to 4 ounces of water, should be 
given every hour if possible. If it is vomited, 1 teaspoonful of the solu- 
tion is to be given at a time. If this or plain water is ejected, the stomach 
must be allowed to rest. Medication other than the bicarbonate of 
soda should not be attempted. After twenty-four hours, with a con- 
tinuation of the vomiting, a colon flushing (p. 857) with 16 ounces of 
warm water containing 2 drams of bicarbonate of soda may be employed. 
This should be repeated at six- to eight-hour intervals. ‘It is astonishing 
to note how much of this solution will be taken up if the tube is intro- 
duced well into the colon. Repeatedly patients have been observed to 
retain 2 pints a day. The procedure supplies fluid, relieves thirst, and 
prevents prostration and loss in weight. At the same time the bicarbonate 
of soda furnishes the best antidote to the acid intoxication that exists. 
If the colonic medication is not well retained, it should be used but twice 
daily, so as not to establish an intolerance. 
Discretion must be used in giving food. Some children will have a 
disgust for all foods, and others will be as hungry as they are thirsty. 
This, however, is unusual. Twice-baked bread and unsweetened zwieback 
have been retained when nothing else could be kept down. Further, when 
the vomiting ceases and the child is on the borderland of convalescence, 
some one of the dried bread-stuffs often answers better than does fluid. CYCLIC DIARRHEA 
777 
In a general way, however, a diet of broth, gruel (particularly oatmeal), 
skimmed milk, and dried bread is best for the first few days following an 
attack. 
If the case proves resistant and but little of the bicarbonate is re- 
tained, the procedure detailed under Treatment of Acidosis (p. 772) should 
be instituted. 
Transfusion: 
Illustrative Case.—In a case of severe acidosis seen with Dr. Mosher, of Brooklyn, 
a fatal outcome seemed imminent. Bicarbonate of soda freely administered and two 
infusions of bicarbonate of soda with 4 per cent, dextrose, given intravenously, failed 
to produce the slightest improvement. Transfusion of human blood was decided upon, 
and 6 ounces of citrated blood was given. The improvement following the use df 
human blood was most remarkable. The hyperpnea ceased, the pulse improved, and 
the entire expression of the child changed in a very few hours. He made a complete 
recovery, all traces of acidosis disappearing within five days after the transfusion. 
CYCLIC DIARRHEA 
Excess of sugars and fat in the diet of children of the so-called lithemic 
type may produce characteristic gastro-enteric effects entirely independent 
of intestinal and stomach digestive conditions. Patients of this type 
represent those who possess a poor capacity for the metabolism of these 
substances. 
Cases of this kind are not at all unusual, and are usually attributed 
to errors in diet, to fatigue, to overexcitement, or nervousness. 
Symptoms.—There may be a prodromal period of a few days, with 
foul breath, coated tongue, languor, and loss of appetite. More often 
the onset is sudden and without warning. There is sudden high fever, 
headache, vomiting, diarrhea, muscle soreness, and, rarely, delirium. 
Abdominal pain may be present, colicky in character. The fever rarely 
lasts longer than two or three days—often not longer than one day. The 
gastro-intestinal manifestation of the toxemia may persist for a shorter or 
longer time. Some children will have one or two vomiting seizures; others 
none. The intestines, however, are much disturbed. Loose watery stools 
are frequent, and defecation is attended with considerable pain and tenes- 
mus. 
After an indefinite period of time—usually one to three days—the 
symptoms abruptly subside, and the child becomes hungry and begs for 
more food than is good for him. Usually after such an attack the child 
feels unusually well, and no evidence of the seizure remains. 
In the course of a few weeks the identical process is repeated, although 
the mother volunteers the information that the child has been carefully 
fed and that the attacks cannot be attributed to indiscretion in diet. 
Occasionally such cases are associated with cyclic vomiting. 
Illustrative Case.—A boy six years of age almost always—such was the history— 
began the cyclic vomiting attack with the symptoms as described. Vomiting ordinarily 
did not begin until the fever and the urgent intestinal symptoms had subsided. 
The attacks are quite apt to be followed by constipation. These 
gastro-intestinal crises become as distinctly periodic as those of cyclic 
vomiting and spasmodic bronchitis. A large number of these patients 
have been brought for treatment solely because of the periodic attacks 778 
THE PRACTICE OF PEDIATRICS 
which are referred to by the mother or nurse as “indigestion,” “gastritis,” 
or “biliousness.” 
If the attacks are frequent, signs of malnutrition may be noted. Us- 
ually the patient has resistance of a low order and is apt to be nervous 
and pale. The muscles are flabby. The tongue may be habitually coated. 
The child is chronically tired, “or never quite well.” This description 
obtains in the most severe cases. Children, hcwever, who undergo the 
periodic attacks at intervals of several weeks suffer but temporary in- 
convenience. The acetone breath has been present during the attack 
in a few of the cases, although its occurrence has been the exception. 
Illustrative Cases.—Case 1.—A girl, three years of age, of decidedly gouty ante- 
cedents in both parents, had, for the eighteen months previous to examination, attacks 
of “indigestion” every six weeks. There was no vomiting. The temperature rarely 
rose above 103° F. There was pronounced diarrhea with little mucus. At each attack 
she had been given castor oil and a reduced diet, and was well in four or five days. 
Between the attacks she was fairly well, except that the tongue was never clean and 
there was a persistent low-grade dermatitis on the neck and upper portion of the chest, 
which had resisted the treatment of different dermatologists. The child had been 
fed with reasonable care under medical direction. There had been no gain in weight 
during the year. 
She was given a mixed diet of meat, poultry, fish, green vegetables, and cereals. 
One pint of skimmed milk or fat-free buttermilk was allowed daily. Sugar of every 
kind was prohibited. Raw fruit was not permitted. Ten grains of bicarbonate of 
soda was given daily for several weeks. During the twenty-one months of treatment 
there was no suggestion of the former trouble. 
Case 2.—A boy six years of age had repeated attacks of diarrhea lasting from two 
to ten days. The majority of the attacks occurred during the warmer weather, but 
there were also three or four during the winter. There was fever, rarely higher than 
102° F., and rarely vomiting. Dietetic restrictions of the intake of sugar and fat were 
carried out, and skimmed milk in small amount was allowed during the next three 
months—July, August, and September—a period during which he had never before 
been well. He now remained perfectly well, and during this time gained If pounds 
in weight. There ensued no repetition of the attacks. 
Many histories of cases might be cited in which the periodic intestinal 
crises were relieved by the withdrawal of fat and sugar from the diet, 
and by the free use of bicarbonate of soda for protracted periods. Starches 
appear to exert no unfavorable influence on the condition and, similarly, 
sugar that is manufactured by the organism exerts no unfavorable in- 
fluence. 
What appears to be dietetic idiosyncrasy and incapacity in not a 
few instances has been explained by defective gastro-intestinal mechanics, 
sometimes in association with faulty posture. Children with recurrent 
diarrhea should be given the benefit of a serial rr-ray study of the gastro- 
intestinal tract. 
Treatment.—As indicated, the treatment consists in withdrawing 
fat and sugar largely from the diet, and in the use of bicarbonate of soda. 
If constipation is present, 30 grains daily of the soda may be given with 
sufficient aromatic cascara to keep the bowels active. Stewed fruits 
and cereals are usually readily taken without sugar. If necessary, small 
amounts of saccharin may be used for sweetening. Eating between 
meals is forbidden, and the child is made to take an after-dinner rest 
of one and one-half hours. Stress of all kinds must be avoided. PERIODIC FEVER 
779 
ACETONURIA IN CHILDREN 
Ketone bodies occur in the urine in a wide variety of disorders, and 
are due to defective fat metabolism. They are present in diabetes, acid- 
osis, inanition, and malignant diseases. They may be present in practically 
every other disease of childhood, particularly in the exanthemata. 
The presence of acetone in the urine is not necessarily due to star- 
vation or fever as we find it repeatedly when these conditions do not 
exist. We have found it repeatedly in children who were on a liberal 
carbohydrate diet. 
Illustrative Cases.—In two typical cases the patients showed a persistent acetonuria 
when on ordinary foods. The odor of the acetone breath had been noticed by the mother 
in each case. When the fats were entirely eliminated from the diet the acetone dis- 
appeared. 
A boy six years of age had repeated seizures of periodic fever, the temperature 
ranging from 103° to 105° F. for four or five days, without other signs than excessive 
acetone in the urine. There had been several of these attacks during the previous two 
years, one about every two or three months. Treatment during the second year had 
not been attempted because the child recovered just as well without treatment. “The 
fever had to run its course.” With elimination of fat, eggs, and cane-sugar from the 
diet the attacks ceased and did not recur during the ensuing five years. 
Children who readily develop acetonuria do not necessarily have 
attacks of true acidosis. Children, however, who are subject to attacks 
of true acidosis, will frequently have acetone in the urine with minor 
ailments with fever. 
Treatment.—Fats must be given sparingly. Cane-sugar should be 
given in small quantities if at all. The usual diet contains sufficient 
carbohydrate to supply the needs of children, without cane-sugar. If 
sugar is given it is best to use honey or maple sugar. 
PERIODIC FEVER 
Febrile cases somewhat resembling the above are not of unusual oc- 
currence. The clinical condition is that of periodic fever without another 
symptom. 
Illustrative Cases.—Case /.-—The temperature of one patient, aged four years, 
ranged from 102° to 103.5° F. and lasted four to six days. This child came for treat- 
ment because of the periodic elevation of temperature which could not be accounted 
for. During his third year there were six of these temperature periods. In the fourth 
year there were four, all during January, February, and March. There was no gastro- 
intestinal association and no clinical evidence of disease to account for the temperature 
periods. The mother stated that “the breath smelled like chloroform” during the 
attacks. An exhaustive examination failed to detect anything wrong with the child 
other than a persistent erythema at the angle of the mouth on the right side. The 
patient was given a diet free from fat and sugar. Thirty grains of bicarbonate of soda 
were given daily. Two years elapsed without a return of the temperature period. 
Case 2.—In the case of another boy, aged six years, the temperature period per- 
sisted two to five days, and the range was 100° to 104° F. During the attack the tongue 
was coated and the patient complained of being very tired. The attacks appeared 
without warning and disappeared without other evidences of illness than the fever. 
There was no objective gastro-intestinal disturbance. In one year there were five 
temperature periods; during the next year, three. 
In neither of these cases was there another sign of trouble than the recurring tem- 
perature; the children had been treated and examined repeatedly with an aim to deter- 
mine the cause. 
In all, six examples of this fever phenomenon were observed. All the 
patients were relieved promptly by removing sugar and cow’s milk fat 
from the diet, and by the interval use of bicarbonate of soda. 780 
THE PRACTICE OF PEDIATRICS 
THE SUBOXIDATION SYNDROME1 
Another group of children entirely apart from the foregoing are those 
who fall into our classification of the suboxidation syndrome. 
Children coming under this heading are usually but by no means al- 
ways found among the offspring of the well-to-do. The forebears of the 
children presenting this syndrome are usually those who have lived an 
indoor occupational existence for two or more generations, devoting their 
efforts to intellectual persuits and not to manual labor. 
A child with the suboxidation syndrome is one whose metabolic functions 
are habitually below the normal. He may be overweight or of average 
weight; usually he is underweight. Such children have a lowered capacity 
in endurance, because of physical weakness, although as a rule they are 
precocious and mentally overactive and possess much nervous energy. 
One of the striking features is the dryness of the skin with a tendency to 
erythema and mild eczema. Patchy areas of inflammation are par- 
ticularly found about the mouth. Perspiration is scanty and the child 
rarely perspires except on very hot days. The hands and feet readily 
become cold in cold weather and low temperature is keenly felt. This 
symptom is often remarked by the parents. In fact, extra heavy outdoor 
garments are required during the winter months. In most cases a moderate 
anemia is present. The appetite is capricious and constipation is the 
rule. The body temperature is usually below normal in the early morning 
and often rises above normal under activities and stress. 
One of the outstanding features of this syndrome is a marked tendency 
to afebrile rhinitis and bronchitis. The child is scarcely free from one 
attack when another supervenes. There is a chain of these respiratory 
affections throughout the winter. The colds are sufficiently severe and 
frequent in occurrence to interfere seriously with the activity of the 
patient, and much time is lost in school and outdoors. 
As might be expected, it is rare to find a patient of this type who has 
not had the tonsils and adenoids removed, with little or no benefit. 
As a class such children are rather immune to actual infection of the 
respiratory tract, although pneumonia and infectious bronchitis may, 
of course, occur. While they show a certain resistance to bacterial infec- 
tions of the respiratory mucous membrane, these patients quite frequently 
are subjects of protein sensitization; and bronchitis, when it occurs, is 
likely to be of the spasmodic type. 
Another feature of the syndrome is the tendency to attacks of recur- 
rent vomiting, in which the vomiting may occur only once or repeatedly 
for a few hours or a day or two. These seizures may have occurred at 
fairly definite intervals for several months or years. 
In some of these patients transient skin rashes or “eczema” may be 
the predominating manifestation. 
In other cases because of anemia or malnutrition or lack of increase 
in height for a period of several months, the physician is consulted. 
Other cases will afford the history of an elevation of the temperature, 
lasting one or more days, occurring at fairly regular intervals, without 
other manifestations than those of heavy breath and a coated tongue. 
1 Iverley and Berman, Airier. Jour. Med. Assoc., May 1, 1920, vol. 74, pp. 1226, 1227. THE SUBOXIDATION SYNDROME 
781 
Not all cases show an identical train of acute manifestations. In 
one respect, however, these children are very similar: They have a de- 
fective metabolism for the soluble carbohydrates and for fats, particularly 
for cow’s milk fat in the amount that we have accustomed ourselves dur- 
ing the last few decades to give to children. 
Illustrative Cases.—Case 1.—A boy, aged three years, weighing 29 pounds and 
without physical abnormality, had been subject to recurrent attacks of elevation of 
the temperature since the age of one year. They occurred about every two months, 
being characterized by loss of appetite, coated tongue, and listlessness, with a tem- 
perature of from 101° to 103° F., the fever periods lasting from three to five days. There 
was rarely vomiting. The skin showed scattered areas of erythema. Pie was restricted 
to a diet free from cow’s milk fat and sugar. During the next eight months there were 
no further attacks of illness, and he gained 3§ pounds in weight and 2\ inches in height. 
Case 2.—A girl, aged six years, who weighed 471 pounds and who was without 
physical abnormality, had habitually a coated tongue and poor appetite. Meal times 
were a trial to the other members of the family. In disposition she was irritable. 
Her complexion was sallow and the skin was dry over the back of the neck, where 
there was persistent erythema. There were patchy areas of dermatitis about the 
mouth, causing considerable disfigurement. She was subject to frequent catarrhal 
colds. One followed the other so rapidly that it was difficult to say when one was 
finished and another began. Tonsils and adenoids had been removed without benefit. 
It was with concern that the parents looked forward to the approaching winter. 
She was given a diet from which sugar was largely excluded, enough being allowed 
to make the food palatable. Butter was forbidden. One pint of skimmed milk was 
allowed daily. Aside from these restrictions the food given was that of any well 
child of her age. After two months under this management she weighed 53 pounds 
(a gain of 6f pounds). There had not been a day’s illness. The tongue was clean and 
there was no trace of eczema. She was happy and good natured. 
During the final six months of observation there were only two slight colds, and 
the skin remained clear. 
Case 3.—A girl, aged eight years, weighing 51§ pounds, gave the history of early 
eczema and difficult feeding, and “had always been on a diet for her skin.” The im- 
mediate occasion for the consultation was the occurrence of vomiting attacks at inter- 
vals of from four to five weeks. The attacks usually lasted from one to two days, 
during which time the vomiting occurred frequently. The tongue was much coated 
at this time, and there was a moderate elevation of the temperature—from 100° to 
102° F. After a seizure she was left very weak, and required several days for recupera- 
tion. The heart and lungs were normal. The blood showed 50 per cent, hemoglobin, 
and 4,700,000 red cells. The urine was entirely negative. She had been taking 1 
quart of milk daily in addition to that used on cereals and in puddings. Sugar had 
been allowed with the customary freedom. She was put on the usual mixed feeding 
suitable for a child of her age, with restriction to skimmed milk and no sugar. After 
ten weeks and four days she weighed 56 pounds, a gain of \\ pounds. The mother 
reported that during the interval there had been no vomiting and no fever; the tongue 
remained clean and the bowels regular. This case was followed for five months without 
a return of the vomiting seizures. 
Case 4-—A boy, aged seven years, with a height of 471 inches and a weight of 
42 pounds, came for treatment January 2, 1920, because of “frequent colds, persistent 
wheezing in his chest, and a cough which was relieved only by warm weather.” The 
condition had existed for three years, with a particularly severe cough since the pre- 
ceding November. The patient was thin, pale, and weak. The appetite was poor. 
Food had to be forced. The blood showed 70 per cent, hemoglobin and 4,200,000 red 
cells. The urine was negative. The heart action was rapid, but the heart sounds were 
normal. Examination of the lungs revealed mucous and sibilant rales fairly evenly 
distributed with evidence of slight bronchial spasm. The tonsils and adenoids had 
been removed. There was no elevation of the temperature. Acting under medical 
orders the child had been generously supplied with sugar, cream, milk, and butter with 
the idea of improving his physical condition. 
Our treatment was to order a general mixed diet largely sugar-free, 1 pint of milk 
daily, and very little butter. One pint of a Vichy water was to be drunk daily. The 
further instructions were that the boy should remain in bed until 10 a. m. each day, 
rest one and one-half hours after the midday meal, and retire at 7 p. m. 
He was allowed to go outdoors. No cough mixtures were given. 
There was a betterment of the cough in three days, with a gradual cessation com- 
plete in eighteen days. Fourteen days after the first examination the bronchitis had 
entirely disappeared. After six weeks under treatment the weight was 47 pounds, 782 
THE PRACTICE OF PEDIATRICS 
a gain of 5 pounds, with a marked improvement in the general appearance of the pa- 
tient, and an entire absence of cough. The appetite was most satisfactory, and foods 
such as vegetables and cereals, which the patient previously had to be coaxed and 
forced to eat, were taken eagerly. The child remained free from the cough during 
observation throughout ten weeks. 
Comment.—A noteworthy feature in nearly every case treated has 
been the improvement in appetite and the marked gain in weight as soon 
as the fat and sugars which had been given above the capacity of the 
patient had been removed from the diet. Foods such as vegetables and 
cereals which have been taken with reluctance and in only small quan- 
tities are often taken eagerly. 
An examination of the urine in a certain percentage of these cases 
shows a slight but constant acetonuria on an ordinary diet, even when 
the patients are apparently well. Those subject to attacks of vomiting 
show a marked acetonuria during the attack. A great majority exhibit 
a marked acetonuria with acute febrile illness. 
A study by Dr. L. A. Berman of the blood of the patients we have 
come to classify by the designation “suboxidation syndrome” has shown, 
during the intervals of apparent health, a variable hyperglycemia vary- 
ing from 130 mg. of glucose per 100 c.c. of blood to 280 mg. per 100 
c.c., the average being 163. The series comprised 67 cases. Of these, 
27 were cases of recurrent vomiting, sometimes alternating with bron- 
chitis or eczema as the predominating symptom, and showed an aver- 
age blood-sugar of 175 mg. per 100 c.c.; 3 came for recurrent pruritus, 
averaging 170 mg. per 100 c.c.; 11 exhibited eczema as the predomi- 
nating symptom, averaging 148 mg. per 100 c.c.; 2 came for recurrent 
attacks of fever, with coated tongue and acetone breath, averaging 162 
mg. per 100 c.c.; and 23 who had frequent colds and bronchitis as their 
chief complaint averaged 160 mg. per 100 c.c. 
The blood-sugar of 92 children not belonging to this group was also 
examined. The sugar content was found to range between 80 and 125, 
averaging 105. These subjects included those who came for examination 
and feeding, for malnutrition, adenoids, intertrigo, enuresis, simple an- 
emia, constipation, proteinogenous asthma, obesity, chronic nephritis, 
essential headache, chronic cervical adenitis, anorexia, acute bronchitis, 
tics, non-epileptic convulsions, recurrent vomiting with dilated stomach 
and redundant sigmoid, recurrent vomiting unrelated to mechanical de- 
fects, frequent colds, astluna due to enlarged tonsils and adenoids relieved 
by operation, migraine, urticaria, mucous colitis, flat-foot, chorea, sebor- 
rheic dermatitis of the scalp, cardiac disease, tetany, pylorospasm, gon- 
ococcus vaginitis, epilepsy, habit spasm, chronic otitis media, and enlarged 
tonsils. 
Four cases belonging to the suboxidation syndrome group were char- 
acterized by attacks of vomiting at the height of the attack. They showed 
a hypoglycemia, the figures being 80, 85, 85 and 70 mg. per 100 c.c. One 
case of bronchitis with bronchospasm examined in the attack had 75 
mg. sugar per 100 c.c. of blood. 
Ten cases classifiable clinically as belonging to the suboxidation 
syndrome group did not show any definite hyperglycemia at the time 
of examination. Of these there were 4 cases of frequent colds, with an DIABETES INSIPIDUS 
783 
average blood-sugar of 105 mg. per 100 c.c.; 2 cases of “eczema” aver- 
aging 97; 3 cases characterized by recurrent vomiting averaging 106, and 
one of recurrent diarrhea showing 105. 
The method used to determine the blood-sugar was an adaptation of 
Benedict’s1 modified picric and picrate method to finger blood along 
the lines followed by Epstein in applying the original picric acid method: 
Of the blood, 0.2 c.c. was obtained from a finger and was immediately mixed with 
0.8 c.c. of distilled water, the blood laking after a little shaking. To this, 1.5 c.c. of 
Benedict’s picric acid picrate reagent was added drop by drop and thoroughly mixed. 
The precipitated proteins were then thrown down by centrifuging. Of the supernatant 
fluid, 1 c.c. was taken, 0.5 c.c. of 20 per cent, anhydrous sodium carbonate added, and 
the mixture, corked with absoibent cotton, was placed in a water-bath for ten minutes. 
This was compared in the Kuttner colorimeter with a standard solution of potassium 
dichromate, made up by matching against a solution of glucose containing 0.2 mg. to 
the cubic centimeter, treated as the blood was treated, described above. 
Persistent polyuria—diabetes insipidus—is rare in children. The 
disease is characterized by extreme thirst and the passage of large quan- 
tities of pale urine, the condition continuing for months and years. 
Temporary or transient polyuria is of occasional occurrence. There 
is unusual thirst and the passage of abnormally large amounts of urine, 
a condition continuing for a few days or a week or two. 
Etiology.—The cause of persistent polyuria is but little understood. 
Cases are on record in which the condition has seemed to be closely as- 
sociated with brain tumors, hydrocephalus, and trauma. But 3 cases 
have come under our observation. In these 3 no cause could be dis- 
covered. Temporary or transient polyuria has been personally observed 
only in nervous girls of hysteric tendencies. It is most apt to develop 
near the close of the school year, when the child is considerably reduced 
or somewhat excited in anticipation of undergoing examinations. The 
disease is probably of congenital origin. 
Symptoms.—Both the mild and severe cases are characterized by 
thirst and the passage of large amounts of urine, ranging from 50 to 100 
ounces daily. The specific gravity is low—1002 to 1010. The amount 
of urea and uric acid excreted varies but little from the normal. A diet 
low in salt and protein reduces the urinary volume. 
Due to the rapid excretion of fluid the skin is dry and the hair and 
nails may show trophic disturbances. 
In 2 of the cases of true diabetes insipidus there was a secondary 
anemia and a moderate degree of malnutrition. One patient was much 
undersized, and at the age of five and one-half years weighed 30\ pounds 
and was 37| inches high. That the lack of development was due to the 
polyuria, however, is extremely doubtful. 
Diagnosis.—Polyuria is to be differentiated from diabetes mellitus 
by examination of the urine. The absence of sugar determines the diag- 
nosis. Of further significance is the characteristic increase in the amount 
of urine excreted in diabetes insipidus when the ingestion of sodium 
chlorid and protein is increased. 
DIABETES INSIPIDUS 
1 Benedict, S. R., A Modification of the Lewis-Benedict Method for the Deter- 
mination of Sugar in Blood, Jour. Biol. Chem., 34, 203, April, 1918. 784 
THE PRACTICE OF PEDIATRICS 
Treatment.—In the cases of functional nervous origin the cure takes 
place by a change of environment. When the nervous stress is removed, 
the symptoms subside. 
In the true cases no means of treatment have been of avail in our 
hands. 
In the case of the boy referred to various methods of management were attempted, 
without success. With a diminution of the fluids taken there was a corresponding 
reduction in the output. As soon as the patient was allowed freedom in drinking the 
frequency in urination and the polyuria returned. 
Drugs have been of no value with the possible exception of pituitary 
extract, which is said to have a specific action in this condition. 
DIABETES MELLITUS 
True diabetes in children is, fortunately, a comparatively rare disease. 
Etiology.—Much concerning the ultimate causation of diabetes mel- 
litus is not known. Heredity is supposed to play an important part, 
but this association in our experience has been infrequent. In 11 cases 
in children under nine years of age no etiologic factor could be discovered. 
Our youngest patient was nine months of age at death. The disease 
in this instance was known to have existed but three weeks. Among 
adults, Hebrews are more liable to the disease than others. Jewish chil- 
dren, however, have shown no special susceptibility. 
Previous severe infection is now looked upon as an important etiologic 
factor. 
Pathogenesis and Morbid Anatomy.—In “A Study of the Patho- 
logical Anatomy of the Pancreas in 90 cases of Diabetes Mellitus” pub- 
lished in 1909, R. L. Cecil reviewed the work of Opie, von Mering, Min- 
kowski, Sauerbeck, and others, and reported that anatomic lesions of 
the pancreas occur in more than seven-eighths of all cases. In the cases 
associated with lesions of this organ the islands of Langerhans were 
constantly involved in changes ranging from sclerosis and hyaline degen- 
eration to infiltration with leukocytes and hypertrophy, while in some 
cases these islands were the only portions of the gland involved. In 12 
per cent, of the cases investigated no pathologic changes were found, 
although in half of the 12 per cent, the gland was smaller, or the number 
of islands less than normal. Three-fourths of the cases presenting no 
lesions occurred in patients under the age of thirty. 
Abt and Strouse reported 2 cases of traumatic diabetes in children. 
In one the diabetic symptoms followed a fall on the head. In the other 
the injuries were associated with only a brief period of unconsciousness, 
and the chief lesion was a compound fracture of the tibia.. Both patients 
developed persistent glycosuria and other diabetic symptoms, and re- 
sponded typically to treatment. Other cases might be cited of injuries 
varying from simple concussion to fracture of the skull, with a subse- 
quent glycosuria or even permanent diabetes. Langstein recorded per- 
sistent glycosuria in 2 young infants affected respectively by hydroceph- 
alus and malformation of the brain. 
The subject of experimental diabetes was investigated by MacLeod. 
He stated that dextrose may appear in the urine as a result of deficient DIABETES MELLITUS 
785 
utilization of this carbohydrate by the tissues, because of deficient renal 
function permitting the escape of sugar normally present in the blood,1 
or because of an increased production of dextrose in the liver. To the 
last of these sources of a hyperglycemia he attached the greatest im- 
portance. The hepatic conversion of the glycogen into dextrose was shown 
to be influenced by a reflex mechanism operating through the fourth 
ventricle and the splanchnic nerves. That certain drugs and the carbon 
dioxid present in the blood in asphyxia may produce hyperglycemia by 
their effects on these nerve centers controlling glycogen conversion was 
considered probable. 
The influence of an internal secretion from the pancreas, while long 
regarded as probably important, is only now beginning to be fully under- 
stood. (See p. 786.) 
The urine is ordinarily increased in amount, clear, acid, and of high 
specific gravity—1025 to 1050. The amount of glucose present varies 
widely, depending on the character of the diet, time of day, and time 
of meals. During certain periods the sugar may be absent. Acetone, 
diacetic acid, and beta-oxybutyric acid may be found, depending on 
the severity of the disease. The first two of these substances are oxidation 
products of the third, which appears only in severe cases. 
The Blood.—The normal blood-sugar in children closely approximates 
the adult normal (80-110 mg. per 100 c.c. blood), except possibly in breast- 
fed newborn infants, when the blood-sugar is probably slightly lower.2 
In diabetes mellitus, however, the sugar may constitute 0.5 per cent, of 
the blood or even more. This varies with the diet, the time of day, and 
the ability of the patient to metabolize carbohydrates. There may be 
a moderate hyperglycemia without glycosuria, providing the sugar thresh- 
old has not been passed. 
In severe cases with marked emaciation, in addition to the clinical 
signs of ketosis, impending coma, and the presence of the products of 
intermediary fat metabolism in the urine, there may be and usually is 
a marked decrease in the carbon dioxid combining power of the blood. 
“This then is the worst picture of perverted metabolism in diabetes. 
Sugar cannot burn, fat burns only as far as beta-oxybutyric acid, and 
as for protein, a part of its amino-acids are converted into sugar and 
another part into beta-oxybutyric acid, neither of which can be burned.”3 
Symptoms.—Diabetes mellitus is very constant in its symptoma- 
tology in children. An early and never-failing sign is loss of weight with- 
out apparent cause. The loss of weight is so pronounced that it is often 
the first symptom to which the attention is called. Thirst is also an 
early symptom. It is of a very urgent nature. The child never seems 
to be satisfied. The thirst is so great that the patient is awakened by 
it in the night and demands water. Milk or any fluids will be taken, 
but. if a choice is given, water will be selected. Repeatedly patients 
have been known, if allowed, to drink 5 or 6 pints of water a day. 
Frequent urination is always present, large amounts being voided; 
100 ounces in twenty-four hours is not uncommonly excreted by a young 
1 Under normal conditions the blood contains about 0.1 to 0.15 per cent, of glucose. 
2 Lucas, W. P., et ah, Amer. Jour. Dis. Child., December, 1921, vol. 22, No. 6. 
3 Lusk, Graham, The Elements of the Science of Nutrition, 3d ed., 1917. 786 
THE PRACTICE OF PEDIATRICS 
child. Enuresis occurs in over half the cases. The skin is dry; per- 
spiration rarely occurs even on the hottest days or when the body is cov- 
ered with warm clothing. A light brawny desquamation is not infre- 
quently seen. 
The child becomes listless. There is disinclination to play, and the 
interest in childish things flags. 
The appetite is usually voracious, the child being not at all particular 
as to the kind of food taken. No matter how carefully the food is selected 
and prepared, the emaciation continues. 
As the case makes its inevitable progress toward dissolution the 
emaciation progresses and the weakness increases until the patient is 
confined to bed. If an intercurrent disease, such as bronchopneumonia, 
does not terminate the illness, the untreated child dies from exhaustion 
or acetonemia. 
Diagnosis.—The presence of diabetes is suggested by loss in weight 
and strength, in association with a voracious appetite and inordinate 
thirst and dryness of the skin. An examination of the urine and blood 
determines the diagnosis. The disease may be confused with persistent 
polyuria and with chronic interstitial nephritis. Here again the differ- 
entiation is made by the urine examination. Diabetic coma may be con- 
fused with meningitis, uremia, and other states of coma if urine examina- 
tion is neglected. 
Duration of the Disease.—Few child patients without insulin live 
longer than a year. The majority of cases in the past have terminated 
fatally in from three to six months. 
Prognosis.—All our child patients, except those treated with insulin, 
have died within less than a year after the diagnosis was made. True 
diabetes is a fatal disease in both childhood and youth. 
Treatment.—None of our patients treated by limiting the amount 
of fluid taken, by restricting the diet, and by using the opium derivatives 
and arsenic to the point of physiologic effect received the slightest lasting 
benefit. Bicarbonate of soda, furthermore, was given in large dosage. 
The sugar output was reduced, but the patients showed not even tem- 
porary improvement in general condition. 
Insulin.—The introduction of insulin by Banting and Best, working 
in MacLeod’s laboratory at Toronto University, has marked a tremendous 
advance in the treatment of diabetes. It had been pretty well established 
that the islands of Langerhans in the pancreas elaborate an internal 
secretion which is essential in controlling carbohydrate metabolism, the 
secretion of the acinar portion having no effect on this function. At- 
tempts at preparing extracts of whole pancreas had failed because of the 
action of the acinar digestive ferments on the islet tissue. Ligation of the 
pancreatic ducts, however, caused degeneration of the acinar portion of 
the gland, permitting the extraction of the island tissue. This extract was 
found to lower the blood-sugar markedly in both normal and depancreatized 
animals. 
Clinical experience has shown the efficacy of this extract in treating 
diabetics, especially the severe cases which occur in children. Careful 
dietetic measures must be maintained, but insulin raises the patient’s food 
tolerance temporarily. The patient’s caloric needs must be estimated, his PELLAGRA 
787 
protein requirements fulfilled, a limited amount of fat provided, and 
sufficient carbohydrate added to make up the rest of the calories and in- 
sure complete combustion of the fat. Then sufficient insulin should be 
injected hypodermically to keep the blood-sugar close to normal limits. 
Rather than render the urine sugar free, it is better to bring the blood- 
sugar close to normal and permit a slight glycosuria. This acts more 
or less as a buffer against the occurrence of a hypoglycemia which is a very 
real danger. Clinically an overdose of insulin causing hypoglycemia mani- 
fests itself by marked hunger, weakness, vasomotor instability, accelerated 
pulse, sweating, vertigo, delirium, convulsions, low temperature, low 
blood-pressure, and death. The rapid administration of glucose by mouth 
or intravenously, as the case may require, will raise the blood-sugar and 
cause the symptoms to subside. 
Whether the continued use of insulin permanently increases carbo- 
hydrate tolerance remains to be seen. At present the dose must be given 
hypodermically from one to four times daily, depending upon the severity 
of the case, in order to maintain the increased food tolerance which this 
extract provides. In each case the balance between diet and the amount 
of insulin must be'carefully studied. 
Diet.—The following are the ordinarily permissible articles of diet for 
a child ill with diabetes: Soup and broths made from meat, fresh and 
salt fish, shell-fish, occasionally egg, fowl, and game, smoked meats, 
sweetbread, cheese, spinach, celery, lettuce, cucumbers, cranberries, rad- 
ishes, stringbeans, asparagus, squash, cabbage, egg-plant, tomatoes, 
onions, turnips, mushrooms, gelatin jellies sweetened with saccharin, 
butter, cream, olive oil, cod-liver oil, lemon, grape-fruit, sour apples, 
blackberries, raspberries, watermelon. Nuts of all kinds may be eaten. 
Only bread and biscuits made from gluten flour should be used. It is 
impossible to procure a starch-free gluten flour; the flour, however, should 
not contain more than 20 per cent, of starch. 
PELLAGRA 
Pellagra is a systemic disease with a course typically marked by 
intermissions, affecting chiefly the skin, gastro-intestinal tract, and ner- 
vous system. This disease has undoubtedly been endemic in Southern 
Europe for centuries and has long been known under such names as 
“Alpine Scurvy,” “Corn-bread Disease,” and “Italian Leprosy.” In 
the past two decades it has assumed special prominence in the Southern 
United States. The first recorded descriptions are those of Cazal and 
of Frapoli, made about the middle of the eighteenth century. Today it 
is estimated that there are 100,000 cases in Italy and at least 25,000 
in the United States. 
Etiology.—Pellagra has been generally regarded as a metabolic dis- 
ease of food origin rather than an infectious disease. Dermatitis of the 
characteristic type has been produced experimentally by Goldberg, 
in individuals who were fed on a diet rich in maize and rice to the ex- 
clusion of animal and legume proteins, but whether the condition is due 
to deficiency of vitamins in maize, toxins derived from maize, posions 
germinated in diseased corn, or should be viewed as an example of anaphyl- 
axis affecting particularly tissues sensitized by exposure to the sun has 788 
THE PRACTICE OF PEDIATRICS 
not been elucidated. One of the most interesting theories as to the origin 
of pellagra is that of Alessandrini and Scala, who stated positively that it 
is a form of chronic acid intoxication caused by colloidal silica in drinking- 
water and that the disease is localized and contracted only in those regions 
where the water-supply is derived from clay soils. The explanation of 
the production of the disease is thus purely biochemic: The silica in 
colloidal solution attaches to protein substances, and in this manner 
it fixes salts in the tissue cells of the body with the liberation of water 
and an acid—most frequently hydrochloric acid. The abstraction of 
the water and the diminution in alkalinity of the tissue fluids thus in- 
duced are productive of the drying of the tissues and the acid intoxication 
which are so characteristic. 
Objections to the vitamin deficiency theory and to the colloidal silica 
theory have been met more or less convincingly by the respective advo- 
cates of each belief, but the predominant view today is that pellagra is 
a vitamin-deficiency disease, or a low-grade infection of intestinal origin. 
Spring and fall are the seasons of greatest incidence of pellagra and, 
similarly, these are the times for recurrences of the disease in aggra- 
vated form, once it has gained a foothold in a given subject. Most 
of the patients are between the ages of twenty and forty years and only 
about 9 per cent, are under the age of fifteen years. Cases observed 
in infants have never been proved in any degree hereditary. 
Pathology.—The skin lesions exemplify changes varying from an 
early erythema-like sunburn to thickening, pigmentation, and atrophy. 
Except for atrophic changes in the gastro-intestinal tract and fatty de- 
generation of the viscera, the most pronounced additional effects of 
the disease are confined to the spinal cord and brain. There is an en- 
dothelial proliferation in the capillaries of the pia with some connect- 
ive tissue increase, together with diminution in the nerve-cells of the 
cortex and a considerable degree of gliosis. In the cervical cord the 
posterior columns show degeneration, and in the dorsal region the lateral 
columns are similarly affected. 
Symptomatology.—Following a prolonged “incubation” period marked 
by malaise the average pellagrin gives evidence first of digestive disorder. 
This is indicated by redness and coating of the tongue frequently com- 
bined with actual stomatitis, flatulence and abdominal cramps, and 
diarrhea. At some period the last-named symptom occurs in fully 85 
per cent, of cases. Almost as soon, if not equally early, the skin on the 
exposed parts of the body becomes the seat of an erythema which de- 
velops into actual dermatitis. After a few weeks this inflammation sub- 
sides, leaving the integument bronzed and indurated over a period of 
possibly many months. Mental derangement is common, but this symptom 
in children calls for only passing mention. Vertigo and headache are 
not infrequent and many patients show a positive Romberg test, and 
upon ocular examination, changes in the retina and anomalies in the fun- 
dus reflex. The lower tendon reflexes are usually exaggerated, but are 
at times diminished. The disease ordinarily runs a subacute or chronic 
course with a tendency to subsidence during summer and winter, with 
recurrences, as has been noted, during spring and fall. At these periods 
renewed severity in the cutaneous and gastro-intestinal symptoms is the PELLAGRA 
789 
rule. Rises of temperature are not common. Malnutrition and anemia 
are invariably present, but the changes in the blood are in no way pathog- 
nomonic. As a rule there is with the anemia a slight leukocytosis and a 
moderate mononucleosis of from 10 to 20 per cent. The urine contains 
an excess of indican. 
Prognosis.—In children pellagra is ordinarily less severe than in 
adults. The adult mortality in the white race has been estimated at 27 
per cent. Complicating diseases including principally tuberculosis, 
malaria, and hookworm disease doubtless contribute to this high mor- 
tality. Notwithstanding the tendency of pellagra to run a chronic course 
over months and years, occasional acute cases are observed which prove 
fatal in as short a time as a fortnight. 
Diagnosis.—Pellagra may at times be confounded with eczema, 
scurvy, dysentery, tuberculosis, and leprosy. The character and dis- 
tribution of the cutaneous lesions, the significant digestive disturbances, 
the peculiar course of the disease, and the history of other cases in the 
locality where the patient has resided are the points of greatest value 
in reaching conclusions in a given case. 
Treatment.—Preventive measures under Health Department super- 
vision are essential in all communities where pellagra is endemic. Rules 
to govern the care and sale of corn in such communities are justifiable, 
even though spoiled maize shall be proved to have no part in the causa- 
tion of the disease. In view of the findings of Alessandrini and Scala, 
drinking-water should be provided which is free from excessive quantities 
of colloidal silica. All cases of the disease should be reported and given 
opportunity at least to have the advantage of institutional care. Gold- 
berger recommended a diet rich in legumes and animal proteins, com- 
prising milk, eggs, and meat. Baths, salt rubs, and massage are of special 
value in the management of cases in children. Most authorities admin- 
ister arsenic up to the physiologic limit, with intermissions of a few days 
at stated periods. Fowler’s solution, atoxyl, and sodium cacodylate 
are the preparations of choice. The last of these has been administered 
intramuscularly with good results by Deaderick and Thompson in dosage 
of 3 grains daily for an adult. Quinin hydrobromate has received par- 
ticular advocacy from Dyer. Serotherapy, consisting in injections of serum 
from cured patients in healthy individuals, horse-serum specially pre- 
pared according to the method of Nicolaier, or serum from the patient 
himself (autoserotherapy) has given favorable results in a number of 
instances. 
Alessandrini and Scala believed the specific treatment is the admin- 
istration of alkali to combat the acid intoxication produced by silica. 
The preparation of choice is sodium citrate, and this they administered 
hypodermically in a 10 per cent, solution. Oral administration was also 
found by them to be effective. Sodium bicarbonate may also be given 
freely. 
With any form of specific therapy symptomatic treatment must 
be employed and this demands the use of local applications for the skin 
lesions, intestinal astringents and antiseptics, and mouth-washes, pref- 
erably containing chlorate of potash. Concurrent diseases, such as 
hookworm disease and malaria, should not be neglected. 790 
THE PRACTICE OF PEDIATRICS 
BERIBERI 
Beriberi is a disease the leading characteristics of which are mul- 
tiple neuritis and general edema. The disease occurs in individuals 
whose food is deficient in a certain vitamin. 
Etiology.—Beriberi is most common among rice-eating Oriental 
peoples, but is endemic also in Brazil. The prevailing view held for a 
considerable time was that the specific cause was a micro-organism which 
elaborates a toxin productive of neuritis. This view has now given place 
to the theory of food deficiency. Thus in the last two decades it has 
been established that the disease is prevalent only among peoples sub- 
sisting largely on a diet of rice which is “polished” or highly milled. The 
removal of the husk of the rice with the subjacent layer containing pro- 
tein and fat leaves little but the starch, and such rice has been shown 
to be deficient in antineuritic vitamin and phosphorus. The phosphorus 
pentoxid content is more or less directly proportionate to the amount 
of vitamin present and rice containing less than 0.4 per cent, of P205 
will cause beriberi, whereas rice containing more than 0.4 per cent, will 
prevent beriberi.1 Lack of vitamin in other starch food may similarly 
be responsible for the disease in people who do not eat rice, but subsist 
on a similar unbalanced ration. Overheating of food destroys the vit- 
amin. 
Symptoms.—The leading manifestations are multiple neuritis and 
edema. When paralysis predominates the term dry or atrophic beriberi 
is applied to the disease; if the edema is pronounced, the term wet beri- 
beri is employed. Fever is seldom noted. Progressive asthenia, weakness 
in the legs, cardiac palpitation, and shortness of breath constitute the 
early manifestations. With the progress of the affection symptoms of 
multiple neuritis become apparent, such as localized sensory and motor 
disturbances. Coincidently localized edema develops in the extremities. 
Edema in the serous cavities of the body may follow. Nausea, vomiting, 
and epigastric discomfort are common. Eventually foot-drop, wrist- 
drop, and atrophy of the muscles affected by the neuritis develop. Blood 
examination reveals only the existence of a simple anemia. The urine 
may contain albumin, but seldom shows the presence of elements indic- 
ative of nephritis. Special forms of beriberi are the rudimentary type, the 
fulminating or pernicious form, and infantile beriberi. The last type devel- 
ops in infants of mothers who have the disease and is characterized by 
vomiting, edema, and symptoms of cardiac failure. 
Diagnosis.—Sporadic cases may be difficult of diagnosis. In children 
beriberi may be confused with nephritis, alcoholic neuritis, and the neu- 
ritis of diphtheria. The habits of life of the patient, the distribution of 
the paralysis, and the urinary signs aid principally in confirming a doubt- 
ful diagnosis. Leprosy accompanied by neuritic manifestations is at times 
mistaken for beriberi. 
Prognosis.—The death-rate varies markedly in different epidemics, 
ranging from 2 per cent, among Japanese soliders who were treated in 
military hospitals to as high as 50 or 60 per cent, among untreated and 
ignorant peoples. In individual cases the prognosis should be guarded 
1 Barker, Monographic Medicine, vol. iv, p. 777. ACRODYNIA 
791 
as in cases of post diphtheric paralysis because of the constant danger 
of sudden cardiac failure. 
Treatment.—Prophylaxis is most important. A well-balanced diet 
is sufficient to prevent the disease in an individual who will observe the 
ordinary laws of hygiene. Nursing mothers who have the disease should 
promptly be made to cease nursing. Treatment of the developed disease 
is largely symptomatic. The diet should be light but nutritious, and 
contain the elements lacking in polished rice. Brewer’s yeast, powdered 
rice husks and adzucki, and mango beans are among the articles recom- 
mended as favorable to a cure. Rice itself should be removed from the 
diet. Saline laxatives are of great value and the use of these should be 
supplemented with the administration of diuretics, such as potassium 
citrate or even diuretin. Cardiac stimulants which do not upset the 
stomach are of value at times,-but the routine use of digitalis has few 
advocates. For the vomiting small doses of morphin are permissible if 
bromid proves ineffectual. As soon as edema disappears affected extrem- 
ities should be treated by passive movements, massage, and electricity. 
Complete change of climate and environment does most to promote con- 
valescence. 
ACRODYNIA 
For a careful sifting of the literature relating to this disease we are 
indebted to William Weston, who gives to J. B. Bilderback the credit of 
being the first to recognize and describe this disease in the United States. 
Weston claims to have found authentic account of its existence in Europe 
as late as the sixteenth century. A recent contribution by this author1 
aroused a great deal of interest in the disease, and a considerable number 
of additional contributions from different sections of this country have 
appeared. That this condition constitutes an entity appears to be estab- 
lished and that it will eventually be classed among the deficiency diseases 
is probable. 
Symptoms.—In a personal communication Weston has described the 
symptomatology as follows: 
“The onset of the disease may be either abrupt or so gradual that its 
true nature may not become manifest for several weeks. Usually the first 
symptoms to attract attention are: the child becomes peevish and fret- 
ful, loses his appetite, and sleeps poorly. Soon the feet and hands become 
red and swollen accompanied by intense itching or burning of the palms 
and soles. A rash may also appear on the tips of the nose, the ears, and 
cheeks or it may cover the entire body except the back of the neck. Soon 
after the rash appears desquamation begins. The desquamation some- 
times involves all the layers of the skin and deep necrotic ulcers form. 
Usually, however, the desquamation only involves the superficial layers, 
leaving a bluish-red, glistening surface, feeling cold and clammy to the 
touch. These areas may be either hyperesthetic or anesthetic. Coinci- 
dent with the symptoms just enumerated occur profuse irritating sweats 
that add to the child’s discomfort. It becomes pale and emaciated. The 
eyes become irritated and very sensitive to light. The hair becomes 
dry and thin and areas of alopecia appear. The muscles become flabby 
1 Arch, of Ped., September, 1920. 792 
THE PRACTICE OF PEDIATRICS 
and if the child has walked it can no longer do so. It lies with its face 
buried in the pillow or against its mother’s shoulder, its hands in constant 
motion, its feet rubbing against each other, and constantly moaning or 
begging that its feet be rubbed. Such a picture of abject misery once 
seen can never be forgotten. 
“Skin.—The skin manifestations are uniformly present and invariably 
involve the palms and dorsal surface of the hands and soles, less often the 
dorsal surface of the feet. They are cold, clammy, and cyanotic. There 
occurs an erythematous rash most marked at the tips of the fingers and 
gradually diminishing until at the wrists or forearms it entirely disap- 
pears. There is no line of demarcation as in pellagra. 
“Less often there occurs a rash on the tip of the nose, the ears, and 
cheeks. Occasionally the entire body except the neck is covered with an 
erythematous rash. The rash may be constant or it may disappear and 
recur. When it disappears pigmented spots appear. As the rash fades there 
will occur a desquamation which may involve only the superficial layers 
of the skin or may involve all layers. The surface is bathed in a pro- 
fuse, irritating sweat. The extremities are invariably edematous, but there 
is no pitting upon pressure. Less often this edema may be observed about 
the face or other parts of the body. The rash usually appears as an 
erythema, but may appear as macules, papules, or pustules, and in a given 
case all these may be observed. 
“The trophic changes in the skin may at times be very severe and re- 
sult in gangrene of the fingers or deep ulcers on the toes or soles. 
“ Hair.—The hair is dry and tends to fall out. It not infrequently hap- 
pens that the child pulls out ‘handfuls’ of hair. In other cases it will 
pull out hair by hair, leaving bald spots. 
“Eyes.—Photophobia with conjunctivitis and lacrimation are the rule. 
Sometimes injections of the cornea and keratitis are present. 
“Teeth.—Loss of teeth with or without pathologic changes in the 
gums is a manifestation often observed. 
“Nails.—Change in the color of the nails is of frequent occurrence. 
Shedding of the finger and toe nails occurs in many cases. 
“Genito-urinary.—Pyelitis accompanied by frequent and painful mic- 
turition and irregular fever is met with in many cases. Both albumin 
and acetone are found occasionally. 
“Gastro-intestinal.—Loss of appetite is common. Anorexia is often 
present. Diarrhea and vomiting are met with in a small proportion of 
cases. 
“ Nervous System.—Irritability, restlessness, insomnia, and trichotillo- 
mania occur in nearly all cases. Paresthesia of the fingers, hands, toes 
and feet, especially the palms and soles is invariably present. Convul- 
sions occur in a few cases. 
“Glandular.—Cervical glands are often enlarged. 
“Reflexes.—The reflexes may be unaltered, increased, diminished, or 
abolished. 
“Muscular.—There occurs a distinct loss of tone in all the muscles. 
They become flabby and atrophy. Sometimes marked contraction takes 
place. 
“Respiratory.—A nasopharyngitis is usually present. This occasionally ACRODYNIA 
793 
develops into a bronchitis or a bronchopneumonia. Very occasionally 
a pulmonary edema occurs. 
“Circulatory and Blood.—The heart rarely shows any change. A sec- 
ondary anemia is present in a fairly large proportion of cases. 
“ Temperature.—A slight rise in temperature often occurs. High tem- 
perature is seldom met with unless due to some complication. 
“Laboratory Findings.—There usually exists a fairly regular relative 
polymorphonucleosis and an increase in the total number of leukocytes. 
“The red cell count is not materially altered. The Wassermann is uni- 
formly negative. 
“Spinal fluid negative. 
“Tuberculin skin tests and Schick tests negative. 
“Blood-cultures uniformly negative. 
“Feces negative for parasites. 
“In cases studied from a metabolic standpoint it was observed that 
there was a lowered or negative nitrogen balance in some and in others 
a negative balance of bases. The excessive loss of nitrogen and bases 
occurred through the urine.” 
Diagnosis.—The disease most commonly mistaken for acrodynia is 
pellagra. 
This error is not likely to be made if one recalls the following points: 
Acrodynia occurs at any season; pellagra usually commences in the spring 
or fall. Acrodynia shows no tendency to recur, produces a less persistent 
rash than pellagra, typically involves the body in an erythematous rash, 
seldom affecting the dorsal surface of the feet and ankles, seldom produces 
a severe diarrhea, does not occasion insanity but produces most acute 
wretchedness associated with the marked itching and burning not present 
in pellagra. Finally, acrodynia ultimately terminates in recovery, whereas 
in pellagra there is a comparatively high mortality. 
Prognosis.—Spontaneous recovery is the rule. In fatal cases death has 
been due to complications. 
Treatment.—The management consists in attention to the various 
symptoms as they appear. None of those observers who have described 
cases appear to have any definite line of treatment. This disease seems to 
be intractable. 
Weston feels that lack of Vitamin B may be an important factor in 
the etiology. XXL DISEASES OF MUSCLES, BONES, AND JOINTS 
DIAGNOSIS IN BONE AND JOINT DISEASES 
It is not within the province of this book to enter the domain of ortho- 
pedic surgery. The practitioner, however, is the first to see cases of ill- 
ness regardless of their nature, and bone and joint diseases are no excep- 
tion to the rule. For this reason these diseases will be considered largely 
from the standpoint of diagnosis. In the examination for bone and 
joint diseases in runabout and older children the patient should invariably 
be stripped. He should then be encouraged to move about, to run and 
play, to sit down, to lie down, to roll over on his stomach and back again. 
He may be asked to pick up toys, to walk up and down stairs, to climb 
into a chair. By these means limitation of motion, a most valuable 
symptom in joint disease, is made apparent. 
Acute Peri-arthritis.—In infants and young children observed in 
hospital work an infection of the peri-articular structures is not at all 
uncommon. The symptoms presented are those of superficial swelling, 
and at times redness and pain upon manipulation. Fluctuation will be 
present if the case is at all advanced. The shoulder- and elbow-joints 
in our cases have been the more frequently involved. The disease may 
be due to any of the pathogenic organisms. In one case an examination 
of the pus showed pure influenza bacillus infection. The gonococcus 
may produce either a peri-arthritis or an arthritis. Elevation of tem- 
perature is an inconstant symptom. 
Arthritis.—In arthritis the symptoms are usually more urgent. The 
temperature usually is higher, 102° to 104° F., and there is complete loss 
of power in the limb involved, associated with pain, swelling, and red- 
ness. As in peri-arthritis, any one of the pyogenic organisms may be the 
infecting agent. Arthritis of one or more of the larger joints is not in- 
frequent following sinus thrombosis with septicemia. In such cases the 
Streptococcus hemolyticus has often been the infecting organism, and its 
portal of entry to the body, the middle ear. 
Gonorrheal Arthritis.—In gonorrheal arthritis the lesion is apt to 
be multiple. As many as five joints have been observed to be involved 
in one patient. The small joints of the hands are particularly apt to 
be involved in infants with gonorrheal arthritis. Arthritis and peri- 
arthritis are often confused with rheumatism. In the non-gonorrheal cases 
the urgency of the constitutional symptoms and the severe local lesion, 
with the rapid development of pus, render a diagnosis fairly simple. 
In gonorrheal arthritis one may have to look to the age as a point in 
differentiation. Children under eighteen months rarely have rheumatism, 
and in the very young, successive, severe, inflammatory joint infections 
should always arouse the suspicion of an infectious arthritis. 
Joint Tuberculosis.—While tuberculosis may develop in any bony 
structure, that form with which we are particularly concerned in diag- 
nosis affects the hip and spine. 
794 DIAGNOSIS IN BONE AND JOINT DISEASES 
795 
Tuberculosis of the spine may occur in quite young infants. Our 
youngest patient was nine months of age. While the symptoms vary 
somewhat, depending upon the location of the inflammation, one symp- 
tom is almost always present early in the illness—stiffness, a tendency 
to hold the body rigid. The child moves awkwardly. If the cervical 
vertebra are involved, the head will be held fixed on the shoulders, 
often with a bearing slightly either to the right or the left, resembling 
the attitude of torticollis. If the dorsal or lumbar vertebra are in- 
volved, the child holds the body erect and all movements are made 
with care and caution. The shoulders are thrown backward, the child 
assuming a military attitude. Bending the body is difficult. When 
the child attempts to pick an object from the floor, the spine is held 
rigid, while extreme flexion takes place in the knees in order to bring 
the hand to the floor. In every motion the child attempts to protect the 
sensitive spine, making all voluntary motions with precision and apparent 
forethought. Pain referred anteriorly may be present, not always early 
in the case. 
Early in the disease there is no deformity. The first objective sign 
to appear is a projection or undue prominence of one or more of the spinal 
processes. After the development of the angular bony deformity the 
disease is unmistakable. 
Tuberculous Disease of the Hip.—This is very rare in infancy. The 
first symptom is a slight limp, due to spasticity of the hip muscles, which 
causes the child to step short. The onset of the disease is very gradual, 
and the limping may disappear for weeks at a time and return again, 
and again disappear. Pain is an inconstant early symptom, but may be 
indicated by night cries. Pain in the anterior portion of the thigh just 
above the knee may occur early. 
Illustrative Case.—A boy twelve years old had a periodic limp or short step for six 
years; he had been treated for various conditions, particularly for rheumatism. An 
orthopedist, after several weeks of observation assisted by an x-ray, pronounced the 
condition tuberculous. 
A shortening of the gluteal fold and a general flattening of the hip 
with an increased prominence of the trochanter are characteristic of 
hip disease. 
The tendency to spasticity of the hip muscles furnishes a most val- 
uable diagnostic aid. There is a general limitation of motion as com- 
pared with that of the sound side: abduction, adduction, flexion, exten- 
sion, and rotation are all retarded. The joint appears fixed. Tilting 
of the pelvis, due to the muscular spasticity, consists in an elevation 
of the patient’s back from the table when the extended leg of the affected 
side rests fully upon the table. In more advanced cases there is the 
eversion of the foot. 
Outward rotation of the entire limb and apparent lengthening, pain, 
inability to walk, and abscess are the outcome in cases unsuccessfully 
treated. 
Knee-joint Tuberculosis. — This form of tuberculous joint disease 
follows in order of frequency the two just discussed. The condition 
develops gradually, perhaps following an injury, and soon gives rise to 796 
THE PRACTICE OP PEDIATRICS 
slight flexion and rigidity of the knee with an early morning limp which 
may wear off during the day. Eventually the child maintains the knee 
in fixed flexion, walking on the toes. The joint gradually develops swelling 
as the case progresses, and this enlargement is typically spindle shaped, 
covered with tense, shiny skin. To this appearance the term “white 
swelling” is applied. The x-ray is invaluable in showing the underlying 
joint condition. Atrophy of the muscles of the thigh and calf accentuate 
the swelling. 
The prognosis in this condition depends upon its early recognition 
and effective treatment both locally and constitutionally. The tend- 
ency to ascribe the existence of a lame knee in a child to insignificant 
trauma or “growing pains” is indirectly productive of the crippling of 
many, who might otherwise have timely help. 
Dactylitis.—This condition has been considered on pp. 768-770. 
“Quiet hip disease” (Legg’s disease; Perthes’ disease) is an affection 
easily diagnosed incorrectly as tuberculosis of the hip-joint, and for this 
reason deserves mention. 
Flattening of the head of the femur with thinning of the epiphysis 
and hypertrophy of the neck of the bone comprise the characteristic 
features. 
Trauma, rickets, and infectious epiphysitis have been suggested as 
causes. The affection is one of the middle years of childhood. 
The symptoms are slight lameness and moderate limitation of motion, 
particularly in rotation and abduction. 
The diagnosis is confirmed by x-ray, which shows evidence of atrophic 
changes at the epiphysis with possibly thickening of the neck of the femur. 
In most of the cases reported the symptoms have subsided under 
conservative treatment directed toward protection against weight bear- 
ing and overuse of the hip. Joint fixation is only exceptionally indicated.1 
Infective Osteomyelitis.—The infecting organism in most cases of 
acute osteomyelitis is Staphylococcus pyogenes aureus which may gain 
access to the bone through the blood-stream from a remote focus or 
through direct extension from a nearby compound fracture wound. 
The localization of this infection in the bone is attended by sudden 
onset of fever and pain. The pain is most intense and may involve the 
whole affected bone. Leukocytosis and general manifestations of sepsis 
supervene, and metastases of the organisms to other bones may occur. 
The picture of profound sepsis which is not readily explained, even in 
the absence of pain, should always lead to examination for osteomyelitic 
foci. Rheumatism and typhoid fever may be readily excluded, even with- 
out the aid of positive x-ray findings. 
Radical surgery combined with supportive measures of every available 
type, including transfusion, offers the only hope in these cases. 
OSTEOGENESIS IMPERFECTA (FRAGILITAS OSSIUM; OSTEOPSATHYROSIS 
INFANTILIS? LOBSTEIN’S DISEASE) 
This disease is characterized by multiple and repeated fractures of bones, 
particularly long bones. 
Practically nothing is known of its etiology. The association of this 
1 Jones and Lovett, Orthopedic Surgery, 1923. CHRONDRODYSTROPHIA (ACHONDROPLASIA) 
797 
tendency to fractures in families whose members have blue sclerotics has 
been noted. 
The bones show markedly defective calcification together with a paucity 
and inactivity of the osteoblasts so that the bony trabeculae are small and 
few. Multiple intra-uterine fractures are common, but most of these chil- 
dren are still-born or die shortly after delivery. Shortening because of frac- 
tures and bending of extremities in these newborn infants simulate chon- 
drodystrophy. Roentgenograms of the bones show diminished density. 
The skull is parchment-like in consistency but, if the patient survives, 
later assumes a rather characteristic shape, broad and flat, sometimes 
with a projecting ridge of bone around the posterior and lateral aspects 
just above the level of the ears. The features are small in proportion to 
the head, with a rather sharp nose and a long pointed mandible. In 
the surviving cases fracture may occur from very ordinary handling and 
is difficult to prevent. Later, as the stumbling stage is passed and cal- 
cification becomes more complete, the tendency to fracture becomes less. 
The bones, however, often remain brittle and fragile throughout life. 
There is no treatment beyond protection from trauma. Union of the 
fractures usually occurs quite normally. 
Illustrative Cases.—A child, B. S., male, one year of age, was brought with a history 
of disability of the left leg dating back four weeks. There was no known trauma. The 
child had been born by cesarean section at which time the mother died. The history 
of development for the first eleven months was uneventful. 
Roentgenograms of the affected leg showed a fracture of the middle third of the 
left tibia and later plates showed good repair with periosteal bone formation along the 
shaft. The epiphyseal lines were prominent and calcification of the shaft appeared 
less dense than normal. Typical blue sclerotics were present. Hemoglobin was 
58 per cent. (Dare). Otherwise physical and laboratory examinations were in every 
way negative. 
The mother of the patient had the following history of repeated fractures from 
trivial causes: At two years, complete fracture of tibia and fibula from falling one 
step; at four years, compound fracture of right ulna from stumbling to ground; at four 
and a half years, fracture of right malar and nasal bones from a blow; at eight, fractured 
rib from a blow of bicycle handle bars; at ten, fractured metacarpal and phalanx from 
a fall to the ground; at seventeen, a double fracture of the pelvis when falling from a 
horse. The mother did not have the blue sclera nor did another child, a sister of the 
first patient described. 
This other child, P. S., female, also born by cesarean section, was a difficult feeding 
patient with secondary anemia. At one year, at two years, and at four and a half 
years she suffered fractures of long bones. 
All the fractures in the three members of this family made normal repairs as regards 
duration and restored function. Other ascertainable family history was negative. 
CHONDRODYSTROPHIA (ACHONDROPLASIA) 
Achondroplasia is a disease of fetal life characterized chiefly by de- 
fective development of the long bones. 
The terms applied to this disease constitute a long list. Some of 
these are “fetal rickets,” “micromelia,” “chondromalacia,” “fetal chon- 
dritis,” and “chondrodystrophia fcetalis.” 
Emerson1 has cited many examples from Egyptian, Grecian, and medi- 
eval art, which go to prove the antiquity of this disease. He further 
states that of all dwarfs, those with this affection have been most popular 
in the positions of court clowns and jesters. The condition has long been 
1 Osier, Modern Medicine. 798 
THE PRACTICE OF PEDIATRICS 
confused with rickets, cretinism, and certain types of syphilis. Parrot 
first made clear the pathologic distinctions in 1878, and Porak gave a 
very full account of the subject in 1890. 
Etiology.—Heredity is an influential but not, apparently, an unfailing 
factor.1 In many instances there is no family history of a significant char- 
acter. Emerson has suggested that achondroplasia and rickets may be 
related, in spite of the usual variance in their manifestations and the 
evidence against the occurrence of so-called intra-uterine rickets. By 
many achondroplasia is thought to be due to defective function in one 
or more of the glands of internal secretion. Syphilis is sometimes as- 
sociated with this affection, but cannot be said to be a cause. 
Pathology.—The lesions are localized in the bones, more particu- 
larly the long bones and those of the base of the skull. The epiphyses 
are primarily affected. Here there is always defective formation of 
cartilage, whence the descriptive name, chondrodystrophy. Periosteal 
growth goes on, and, by invading the region which is normally supplied 
with bone by the cartilage cells, impairs still more the cartilaginous 
formation of bone, interferes with the union of epiphysis and diaphysis, 
and checks the growth of the bone in length. The irregular co-operation 
of the chondral and periosteal tissues in the development and growth 
of the bones similarly explains the actual deformities in their shape. 
Most of the cases belong to the type known as hypoplastic. The epiphyses 
are normal in size, and there is impaired growth of the cartilage cells. 
In the hyperplastic form, however, which is rare, the growth of cartilage 
exceeds the normal, and the epiphyses are enlarged. In chondrodystrophia 
fcetalis malacia the epiphyses are soft, due to decrease in the consistence 
of the intercellular matrix. 
Symptoms.—The dwarf presents a peculiar appearance. To such a 
degree is this true that he is often a source of revenue. These individuals 
have normal intelligence, and being quick to turn their physical defects 
into pecuniary gain, they may often be seen on the vaudeville or comic 
opera stage doing minor roles as foils to men of large stature. 
The trunk is of normal size, while the extremities are very short. 
The head may be involved. It may be very large, showing a dome- 
shaped contour, not unlike that of hydrocephalus. The features may 
be large, with broad nose and prominent cheek bones. The forehead 
is usually wide, with the eyes set widely apart, due to the broad root 
of the nose. The facial appearance, as described, while usually pres- 
ent, is not necessarily a part of the picture. Cases are occasional in which 
the facial configuration differs in no wise from that of the general average 
of humanity. The muscles of the extremities, while short, are very large 
and strong, often affording these little people prodigious strength in lift- 
ing or carding heavy objects. 
The appearance of the child is characteristic, further, in that the hips 
are very heavy and broad, this appearance being produced in part by 
the peculiar articulation of the thigh with the trunk. The articulation 
takes place at almost a right angle, due to the change in the contour of 
the neck of the femur. There is marked lordosis, the lumbar curve being 
markedly exaggerated. (See Fig. 139.) This causes a tilting and narrow- 
1 See Prognosis, p. 800. CHRONDRODYSTROPHIA (ACHONDROPLASIA) 
799 
ing of the anteroposterior diameter of the pelvis, which in females may 
be a factor influencing childbirth in later life. 
The hands are usually square, and the fingers very short. The feet 
take on the same appearance, being short and thick. 
Diagnosis.—Chondrodystrophia may be confused with rachitis or 
cretinism in the first few months of life. Rachitis and chondrodystrophia 
have been confused, usually for the reason that chondrodystrophia is 
such a rare condition that it was not so generally known to exist. 
The very short, thick extremities, together with the facial charac- 
teristics and normal mentality, are sufficient for a differentiation. Fur- 
Fig. 139.—Chondrodystrophia. 
Lateral view. 
Fig. 140.—Chondrodystrophia. 
ther, the changes due to rachitis are of gradual development, and are 
never present at birth, while in chondrodystrophia the child, when very 
young, shows an appearance as characteristic as when he is two years 
of age or older. 
Cretins are very degenerate mentally. They are slow and stupid, 
exhibit no mental responsiveness, and show but little irritation upon 
manipulation. In chondrodystrophia the mental condition is normal; 
at least those with chondrodystrophia cannot be placed in the class with 
the mentally defective. 800 
THE PRACTICE CF PEDIATRICS 
Prognosis.—Our observation does not bear out the claim of a high 
infant mortality in chondrodystrophia. 
Physical Health.—Of 5 supervised infants, all are well and thriving 
in their own way. One is the offspring of a mother who is a chondrodys- 
trophiac. The father of another is a chondrodystrophiac. 
Both men and women dwarfs have normal reproductive functions. 
Giving birth to children, however, is often a dangerous procedure for 
such women because of the anteroposterior narrowing at the pelvic 
brim and a tilting of the pelvis. 
Treatment is of no avail, no means having been discovered to induce 
growth. 
It has long been our practice to try to improve the physical condition 
of our patients through the development of correct posture in the very 
young, and to correct abnormal posture in those that come to us for other 
causes. A great mistake is for the physician to feel that his duty to a child 
under his care is finished when he treats him for an illness. 
It was through the writer’s efforts for better body building in his 
earlier years that he came to appreciate that defective mechanics played 
a not inconsiderable role in the development of the child and often bore 
a direct relationship to persistent functional ailments of the gastroin- 
testinal tract in particular, sufficient to interfere gravely with the child’s 
future health and bodily prosperity. The conditions of flat-feet, bowed 
legs, knock-knee, spinal curvature, and actual disease of bony structure 
have been admirably cared for by the orthopedist. The influence of 
posture upon physical function in children has, however, received scant 
attention. 
The necessity for proper supervision of growing children has been 
emphasized by Robert J. Cook, who calls attention to the fact that among 
1393 first year students at Yale University he found that but 25 per cent, 
of the men had a normal spinal curvature, that over 50 per cent, had some 
scoliosis, and that over 55 per cent, had an increased anteroposterior curv- 
ature. The chest was flat in 56 per cent, of cases and the abdomen was 
prominent beyond the normal in 42 per cent. 
“Without an analysis of a large group of men it would be difficult 
to realize that poor posture is so common. 
“When it is considered that those defects are found in men who have 
just completed their high school or preparatory school we become impressed 
with the seriousness. Living in a period when the cry is for preventive 
medicine one wonders why we wait until the individual is developed 
before an attempt is made to correct defects of posture which yield to 
corrective therapy so much more readily in the child than in the adult.” 1 
In what constitutes a correct posture for a child there should be an 
equalized muscle balance. This is described by F. D. Dickson2: 
“He should hold the head erect and directly over the chest, and hold 
the chest up in a forward position. The scapulae should lie fairly flat 
THE INFLUENCE OF DEFECTIVE BODILY MECHANICS ON HEALTH 
1 New York Medical Journal, February 7, 1923. 
2 Jour. Amer. Med. Assoc., vol. 77, No. 10, p. 760. THE INFLUENCE OF DEFECTIVE BODILY MECHANICS ON HEALTH 
801 
against the chest and the shoulders be held back, without muscular 
strain. The spinal curves should be slightly convex backward in the dorsal 
region and convex forward in the lumbar region. The abdomen should 
be flattened and held up and in by the muscles. All the muscles of the 
neck, chest, back, shoulders, and abdomen should be in slight contraction 
without strain or effort.” 
The above quotation cited by Nicholson1 presents a picture contrasting 
markedly with Nicholson’s own description of the cases of abnormal 
posture as showing in varying degree the following: 
“The chest flattened, with diminished anteroposterior diameters; 
the ribs approximated; the shoulders rounded and the scapulse alar. 
The back has an exaggeration of the normal curves, and the abdomen is 
relaxed, owing to weak muscles, protruding markedly, especially below 
the umbilicus. The pelvis is tilted down and forward, and in many cases 
the knees are slightly flexed, as a compensatory measure.” 
Figure 141, A shows a boy who well fits the above description. In our 
attempts at improving posture and body mechanics we found that children 
so affected presented a very similar group of symptoms. As a rule they 
came to us not on account of the abnormal posture but because of some 
pronounced gastro-intestinal disorder of a chronic nature, such as recur- 
rent vomiting, habitually poor appetite, or chronic and often obstinate 
constipation. Such patients usually suffer from secondary anemia. They 
lack ambition and initiative, they tire readily and constitute a consider- 
able number of those whom we classify as subjects of tardy malnutrition. 
For the past eight years we have been making a considerable x-ray 
study of the gastro-intestinal tract in children who have shown persistent 
gastro-intestinal disorders, as described at different times in medical lit- 
erature. 
The association of the ptosis position (Fig. 141, A) with gastroptosis as 
proved by the x-ray was striking. Not every child with gastroptosis or 
other defective gastro-intestinal mechanics has a faulty position, but al- 
most every child with a pronounced faulty posture will reveal under x-ray 
either gastric or intestinal ptosis, or both. Unquestionably, there are 
children who have ptosed stomachs, V-shaped colons, and elongated 
sigmoids who do not have faulty posture or relaxed abdominal walls. 
It is these who are the least likely to show symptoms, as strong abdominal 
muscles supply the necessary support to compensate for the abnormality. 
The writer has previously called attention to the use of abdominal 
support in treating ptosis in children, and can only reiterate with added 
emphasis that the most useful individual measure that applies to all types 
of ptosis, both of the stomach and intestines, is the use of proper ab- 
dominal support. For the average case of ptosis the Aaron belt, with or 
without shelf, as the case may require, answers our purposes satisfactorily. 
For the posture cases we were unable to find a suitable support until our 
attention was called to the Universal supporter as described by Nichol- 
son (Figs. 142-144). In this device we have support for the relaxed 
abdominal muscles, a splint for the lordotic spine, and a brace for the 
sagging shoulders, all of which are due in a measure to weak muscles. 
The digestive organs are thus held in better position and the stomach 
1 Penna. Med. Jour. 802 
THE PRACTICE OF PEDIATRICS 
empties better and “on time.” Sharp angulations are removed from 
the intestine and constipation is consequently made easier to manage. 
Mechanical assistance with a suitable dietetic regime, adequate rest, 
and right exercise not only produce a rapid and marked change in the 
physical well-being of a patient but also rapid gain in weight. 
Illustrative Case.—Our most pronounced example of a case of this type is sig- 
nificant. The patient (Fig. 141) presented one of our worst cases of celiac disease. 
A 
B 
Fig. 141.—The Nicholson supporter: Effect on posture apparent on comparing A and B. 
At the age of three and a half years his weight was 22 pounds and he was emaciated 
to a skeleton, with an enormous belly and marked muscular atrophy. Tetany develoi>ed 
and was very troublesome. Calcium chlorid appeared to control this, but was found 
necessary for months. During the next year there was a very irregular gain in weight 
with never a cessation of the characteristic loose, excessively large, rancid stools to 
the number of perhaps two or three daily. Varying diets and schemes of manage- 
ment were tried, with little or no improvement. There were two attacks of scurvy dur- 
ing this time. For two years the boy was unable to walk. An abdominal belt had 
been worn intermittently without any pronounced effect. THE INFLUENCE OF DEFECTIVE BODILY MECHANICS ON HEALTH 
803 
On November 11, 1922 his age was five years and one month, his weight was 26§ 
pounds, and his height, 36 inches. The weight was 7 pounds less than at the onset of 
the illness when he was two years and seven months old. On the above date we de- 
cided to supply a Nicholson supporter, but this was not brought into use for six weeks. 
On February 21, 1923 his weight was 28 pounds, 9 ounces, a gain of 2 pounds, 5 ounces 
having been made after the brace had been brought into use. Then, for the first time 
in his illness, the mother admitted improvement. His disposition was much better, 
he wanted to play and was trying to walk in spite of the fact that he made a very poor 
showing. His position was, nevertheless, better, although the abdomen was still very 
much distended. The stools now showed an improvement in that there were days 
when they were fairly normal; then there would be characteristic celiac stools for a day 
or two. On May 19, 1923 his weight was 33 f pounds and his height was 37 5 inches. 
Walking had improved but he could not go upstairs unassisted or pick up objects from 
the floor. As there was still a tendency to tetany, calcium chlorid was continued. 
A mixed diet was now taken suitable for a child of his age. 
On August 25th the mother reported the height 39 inches and the weight 38 pounds. 
During the three weeks preceding her report he had gained 3f pounds in spite of an 
attack of whooping-cough. At this writing he is on a general mixed diet. He still 
Fig. 142. 
Fig. 143. 
Fig. 144. 
has some difficulty in walking and cannot run, but can pick things from the floor and 
go upstairs. The posture is better and he is very comfortable in the supporter and asks 
to have it replaced when it is taken off. 
The cuts show the posture and general position tremendously improved. The 
lordosis and the large abdomen still persist, and the supporter will have to be worn 
for a couple of years. 
The mother is insistent in stating that no food agreed until he began to wear the 
abdominal support with which he is represented after a gain of about 10 pounds. 
Our results with the Nicholson supporter have been, on the whole, 
satisfactory. From our observation we believe that Nicholson’s claims 
are not exaggerated that the supporter aids in producing an improved 
posture, with a resulting correction of gastro-intestinal mechanics, and 
that its use is followed by greater improvement in persistent gastro- 
intestinal disorders than the measure would at first estimate seem to 
warrant. XXII* MISCELLANEOUS SUBJECTS 
HEREDITY AND ENVIRONMENT 
Many of the diseases, crimes, and failures of life are attributed to 
heredity, as are also vigor of body, attainments, and successes. Hered- 
ity and environment are two important determining factors in the life 
of the child. Both exert their influence over the individual. Most of 
us have been taught, or in some way conceived the idea, that the influence 
of heredity was predominant; but as a result of the closest association 
with developing children involving intimate relations with hundreds 
of them essential to watching carefully their physical and mental develop- 
ment, the great influence exerted by environment, which often means 
only opportunity, is forced upon one. This relegates heredity to the 
background. That certain diseases, such as syphilis and hemophilia 
may be transmitted from parent to child is undisputed; that certain 
physical states—the so-called constitutional vices—may also be trans- 
mitted is indisputable; but that much of natural physical weakness 
and hereditary tendencies may be overcome by the beneficial influence 
of environment is now universally acknowledged. Place a child or one 
of the lower animals, with an ideal heredity, under unfavorable conditions 
of environment and the favorable heritage counts for little. Feeding, 
and general good management shape physical future much more than care, 
does inheritance. In proof of the supposed inheritance of mental traits, 
offspring of criminals or drunkards are pointed out as showing how 
children follow in the footsteps of their fathers and mothers. It must 
be admitted that here the hereditary influence is bad, but one should 
remember that the environment has also been very unfavorable. 
Mental traits much more than physical conditions are apt to have 
an influence on the progeny, although here, again, brilliant fathers rarely 
transmit their higher mental powers to their offspring, as is proved again 
and again in the professional and business world. Many of the ills laid 
at the door of heredity are due to errors in early management. In the 
breeding of animals great stress is laid upon pedigree, and credit is given 
accordingly. It should be remembered, however, that the stock-raiser 
appreciates the value of the young of his herds, and they invariably 
get the care that is best calculated to develop the perfect animal, which 
is exactly what the majority of the children of the human family do not 
get. A well-bred animal, treated from birth to maturity as are many 
children, would cut a sorry figure in the animal world. 
Hereditary influences in animals are much more apt to obtain be- 
cause of the comparatively short period of growth from infancy to ma- 
turity. The age of puberty in the lower animals is reached in most in- 
tances before the first year. In the human the development is much 
slower, supplying a much longer time for the influences of environment 
to make their impress upon the individual. 
804 TEMPERATURE IN CHILDREN 
805 
CONSANGUINITY 
Much has been made of the supposed unfavorable influences exerted 
upon the offspring by parents closely related by blood. Consanguineous 
marriages, however, exert very little influence on the progeny if both 
parents are in good health and there is no latent familial defect in either. 
If, on the other hand, there is a decided family taint or weakness the 
tendency toward this weakness is inevitably exaggerated in the offspring 
of two persons in whom the trait is dominant. The outworking of this 
law may be observed in a study of the transmission of such defects as 
color-blindness and hemophilia. 
The writer has known first cousins to marry and have children in all 
respects normal, and in two instances under his observation fathers had 
impregnated their own daughters, with normal children the outcome. 
Similarly, in the animal world the close breeding of brothers and sisters 
and parents and offspring has resulted in normal vigorous young. 
Doubtless if this in-breeding were continued through successive gen- 
erations the outcome would be disastrous because of the establishment of 
a hereditary uniformity of type with certain unbalanced potentialities. 
It is practically important that, whereas the laws of heredity impose 
fixed general principles, these principles are of broad scope. 
TEMPERATURE IN CHILDREN 
Normal Temperature.—The question is often asked: What is the 
normal temperature of a baby or young child of a given age? In order 
to answer this question from direct observation, a study of the matter 
was carried out by Dr. H. G. Myers, resident physician at The New 
York Infant Asylum. This study comprised 59 cases, the ages varying 
from birth to one year. Only well children were selected for the observation, 
the majority being breast fed. The temperature in each instance was 
taken by the rectum for four minutes. 
It was found that the birth temperature in these infants ranged from 
96° to 98° F., exceeding 98° F. in but 5 cases, when it was between 
98° and 99° F. In one it was 94° F. During the twenty-four hours fol- 
lowing birth there was a rise in the temperature usually of about one 
degree. From this time on there was little variation in the temperature, 
when the child was well, regardless of the age. There would be a vari- 
ation at different times of the day of a fraction of a degree, the tem- 
perature being higher in the evening. Upon looking over the charts upon 
which the results were chronicled, one is impressed by the uniformity of 
the temperature, which ranges, within fairly narrow limits, from 98° 
to 99.2° F. 
Instances when the temperature arose to 99.5° F. were occasionally 
seen, but 100° F. was very unusual. It is not claimed that the tempera- 
ture of a well child may not reach 100° F., in fact, there were occasions 
when it rose to 101° F. and illness could not be proved, and had not the 
temperature been taken for the purpose above mentioned, no elevation 
would have been suspected, for the next reading was normal. In those 
cases in which a rise was proved to be an early sign of illness, the special 
temperature record was discontinued and the first reading was not in- 806 
THE PRACTICE OF PEDIATRICS 
eluded in the observations. In one child a temperature of 103° F. was 
found. It remained at this point for three hours, when it fell to normal 
without any other manifestation of trouble. When, however, the ther- 
mometer registered over 99.5° F., some cause for the elevation could usually 
be discovered, though it may have been nothing more than excitement 
or slight indigestion. 
Several years ago a similar series of observations was made at the 
Country Branch of the New York Infant Asylum upon 25 healthy children 
under eighteen months of age. The temperatures were taken four times 
a day, the observations extending over an entire week. It was found 
that in these well children the temperature varied from 98° to 99° F.; 
and that when it rose daily above 99.5° F., some abnormal condition was 
always found. 
From these observations upon 74 well children, ranging in age from 
birth to eighteen months, whose temperatures were taken several hun- 
dred times, it would seem that a daily rise above 99.5° F. may be con- 
sidered abnormal. An occasional rise, however, considerably higher 
than this, as above mentioned, may occur and does occur in perfectly 
healthy children, without any special significance. 
Fever.—By fever we understand an increase above that which is con- 
sidered the normal body temperature. 
In children, for clinical purposes, the rectal temperature should al- 
ways be taken. With those under five years of age the mouth observa- 
tion is unsafe, because the child is apt to bite off the thermometer bulb, 
and unreliable, because the lips will not remain closed the requisite three 
or four minutes. The axillary temperature is thoroughly misleading and 
should never be depended upon. One-minute thermometers are often 
unreliable. 
Hyperpyrexia.—The highest temperature personally known to the 
writer, and not due to sunstroke or insolation, was 111° F. This was as 
high as the thermometer could register. 
This extreme fever occurred in a child of ten months who was in a convulsion 
which was one of the first symptoms of tuberculous meningitis. The child had been 
placed by the parents in water at a temperature of 115° F., and had been in the water 
about ten minutes before the rectal temperature was taken. How much the tem- 
perature was due to the illness and how much to the hot water will never be known. 
The temperature responded promptly to a cold bath. The child never regained con- 
sciousness and died of meningitis ten days after the initial convulsion. 
Fever as an Indication.—Fever may or may not be an index of the 
gravity of a disease. Thus we frequently see a temperature ranging 
from 103° to 105° F. in tonsillitis, acute indigestion, and stomatitis— 
ailments which respond very quickly to treatment and which present 
no serious aspects. In typhoid fever, pneumonia, scarlet fever, and 
diphtheria, however, when the temperature range is above 104° F., it 
is a symptom of considerable value, as indicating the severity of the 
infection. It is, therefore, not the fever itself, but the condition back 
of and associated with it, which makes it a sign of clinical value. In 
pneumonia children bear a comparatively high temperature, 104° F., 
for example, without much discomfort or danger; while in the acute 
intestinal disorders of summer an equal degree of fever is borne very TEMPERATURE IN CHILDREN 
807 
badly, and if continued is of grave significance. These considerations 
must be kept in mind in our dealings with fever. 
Importance of Fever.—When is a given temperature to be interfered 
with? This question concerns all practitioners. The answer depends to a 
great extent upon the cause of the fever and its effects upon the patient. 
If the fever produces diminished assimilation, loss of sleep, irritability, 
and restlessness, it will do the child harm by diminishing the normal 
resistance to disease, and should be relieved whether it is 102° or 105° F. 
Interference is thus dependent not so much upon the height of the tem- 
perature as upon its effects upon the patient. 
Methods of Relieving Fever.—Elimination.—This applies particularly 
to the gastro-enteric tract and the skin. In a majority of the cases of high 
fever due to acute indigestion with resulting toxemia, purgation, bowel 
washing, and a carefully adjusted diet for a day or two secure recovery. 
We remove the cause of fever, and the fever subsides. Unfortunately, 
this means of controlling fever is limited to disorders of the gastro-enteric 
tract. 
Hydrotherapy.—By far the most satisfactory means of controlling 
fever is the local abstraction of heat by means of sponging (p 840), tub- 
baths (p 843), and cool packs (p 841). 
Antipyretic Drugs.—Much which borders on the sensational has been 
written about the harmfulness of antipyretic drugs, particularly the coal- 
tar products. Used in large and frequent doses, they certainly may do 
a great deal of harm. Under certain conditions, if used in small doses 
and repeated at intervals of from three to six hours, these drugs may be, 
and often are, of benefit. Aconite and liquor ammonii acetatis are of some 
value, as above stated, but they are of little value in controlling a very 
persistent high temperature. The coal-tar products furnish the best anti- 
pyretic drugs, and these may be used with safety, but should be used only 
when, for any reason, the abstraction of heat by the application of cold 
is impossible. In many families there is too little intelligence to make 
a cold pack either possible or safe, while in severe cases of pneumonia, 
scarlet fever, and the intestinal diseases, sponging often will not answer. 
Sponging and tub-bathing, if repeated too frequently, particularly during 
the night, exhaust the child. Moreover, these procedures are often 
strenuously objected to by parents as well as by the patient, and if 
the nurse is one of the family, her sympathy will counterbalance her 
judgment, and the result be far from satisfactory. Under such con- 
ditions, when the application of cold to the skin is impossible, a combi- 
nation of phenacetin and caffein, alone or with Dover’s powder, has 
proved effective. The antipyretic treatment of scarlet fever is the same 
as that of pneumonia or typhoid fever. 
To a child of one year, 1 grain of phenacetin with | grain of citrate 
of caffein may be given and repeated at three-hour intervals if the 
temperature requires it; to a child two years of age 1| grains of phen- 
acetin and | grain of citrate of caffein at three-hour intervals; three 
years and over, 1| to 2 grains of phenacetin with \ to 1 grain of citrate 
of caffein, at intervals of from three to six hours. If there is much rest- 
lessness and irritability, which is not thus controlled, Dover’s powder 
may be added—\ grain to each dose, for a child of from three to six months 808 
THE PRACTICE OF PEDIATRICS 
of age; grain between six and twelve months; 1 grain after the age of 
two years is reached. It is always wise to caution parents as to the use 
of Dover’s powder. They should be told that if the child becomes “heavy” 
or unusually sleepy, the powders must be discontinued. That phenacetin 
and citrate of caffein cannot be given in solution is unfortunate. Like 
all insoluble powders, they are best given in some mucilaginous mixture, 
such as barley-water or one of the cereal jellies. Fruit juice or apple- 
sauce usually answers well. Antipyrin, for the reason that it forms a 
tasteless mixture with water, succeeds well with some intractable children, 
and may be used in the same doses as phenacetin, although as an anti- 
pyretic the antipyrin is less efficient. 
OBSCURE ELEVATION OF TEMPERATURE 
Perhaps the most annoying cases in pediatric work are those with an 
elevation of the temperature for which no adequate cause can be dis- 
covered. In the section on Normal Temperature (p. 805) certain possible 
variations are given which are regarded as within the limits of health. 
When these boundaries are passed, when there is a temperature range 
between 99° and 101° or 102° F., or a temperature persistently at 100° 
or 101° F., without any apparent cause, and continuing for days and 
weeks, the medical adviser is not in an enviable situation. Such cases 
are sometimes easy of solution. At other times, however, the cause of the 
fever may never be discovered, and the patient eventually gets well, leav- 
ing us still in ignorance of the cause. 
Active Exercise in Nervous Children.—This is not infrequently the 
cause of an elevation of the temperature. 
Illustrative Cases.—Case 1.—A country child three years of age, whose temperature 
every afternoon at 1 o’clock was 102° F., while not vigorous, showed no signs of ill- 
ness. He ate well, slept well, and played hard. There was a slow gain in weight. 
The fever was discovered by the mother, who thought that the child, who was a blonde, 
looked flushed every day at about the same time. The temperature by rectum was 
normal in the morning and normal at night. This condition, to the attending phys- 
ician’s knowledge, had persisted for six weeks before the writer saw the patient. How 
long there had been a daily elevation of the temperature above the normal before the 
mother discovered it we have no means of knowing. The family doctor, an excellent 
practitioner, had suspected, examined the child for, and treated him for, various dis- 
eases; at first for malaria, with no response to quinin; then typhoid fever, as by sug- 
gestion and constant inquiry the child came to imagine that he must be sick, and com- 
plained of languor. The fever continued, however, beyond the usual time allowance 
for typhoid fever and there were no other symptoms. There was no enlargement of 
the spleen and the blood had been repeatedly found negative to the Widal reaction. 
Other possible causes of the fever were also given attention. One day the doctor 
suggested tuberculosis. This aroused the family and friends and a consultation at 
the child’s home was the immediate result. 
A rather thin boy three years old was presented. The family history was excellent. 
There was one other child, six years of age, who was a good specimen of robust boyhood. 
The patient had never had a pulmonary disorder and no disease of the respiratory tract 
other than slight bronchitis. There was no apparent association of the condition with 
any intestinal or infectious disease. An exhaustive physical examination failed to 
reveal any abnormality other than a small umbilical hernia and a slight enlargement 
of the inguinal and submaxillary glands. The blood was not examined. The child 
was pale, and doubtless a blood examination would have revealed a mild secondary 
anemia. The appetite was fairly good; the bowels were reported regular and the stools 
normal. The child had not been kept in bed, as the family did not consider him very ill. 
After the negative physical examination the mother was questioned very closely as to 
the child’s habits of life. OBSCURE ELEVATION OF TEMPERATURE 
809 
He rose at 7 a. m., had breakfast at 7.30, and played with his big brother and two 
older boys until 1 o’clock, when he had dinner. A glass of milk and a piece of bread 
and butter were given as a luncheon at 11a. m. He played very actively, kept up with 
the older boys, and was unhappy when he was not with them. Attempts had been 
made without success to entertain him with less strenuous play. It was at midday, 
sometimes before, sometimes after dinner, that the temperature reached the highest 
point. It seemed, therefore, that here, probably, was a case of fatigue temperature. 
Accordingly, it was suggested that the boy be undressed and put to bed at 11.15 a. m. 
after the light luncheon and be made to rest and sleep if possible. At 1.15 p. m. he was 
to be taken up for dinner, his temperature first being taken. These instructions were 
faithfully carried out, and this ended the daily rise in temperature. The case was one 
of an active, nervous child becoming overtired in his attempts to hold his own with 
older and stronger boys. The patient improved rapidly in his physical condition and 
after an interval of several years was still perfectly well. 
Case 2.—Another child, four years of age, was seen in consultation because of a 
daily elevation of the temperature ranging from 100° to 102.5° F., which had con- 
tinued for six weeks. The child was thriving and otherwise perfectly well. No cause 
for the fever could be discovered in his physical condition. He had a noisy, excitable 
nurse, who was inclined to exciting games and rough play. With dismissal of the 
nurse the fever ceased. 
Otitis.—Persistent fever, following the acute catarrhal affections 
of the upper respiratory tract and the exanthemata, is somteimes ex- 
plained by a suppurative process in the middle ear, without other symp- 
toms than the fever. 
Encysted Empyema.—A small focus of encysted empyema may ex- 
plain a persistent fever following pneumonia. Holt described a most 
interesting case of this nature in which there was for over four weeks a 
temperature range from 100° to 105° F. Autopsy showed a small col- 
lection of pus between the diaphragm and the lung. 
Periodic Fever.—Not infrequently we see cases which show clinical 
signs of malaria as regards periodicity in the temperature, but without 
splenic enlargement or the presence of the malarial organism in the blood. 
Yet, often, these cases quickly respond to full doses of the bisulphate of 
quinin. 
Typhoid Fever.—Occasionally a low persistent temperature eleva- 
tion, obscure for a week or two, proves to be due to a mild typhoid. 
Tuberculosis.—An elevation of the temperature is sometimes the 
first premonitory symptom of tuberculosis. Tuberculosis in a child 
is usually an active process when it involves the lungs, and can readily 
be made out. When other parts are involved, such as the bones, glands, 
skin, or peritoneum, the manifestations are usually also sufficiently plain 
to indicate the condition. 
More obscure cases of persistent slight elevation of the temperature 
have been explained by an infection of the mediastinal glands. The tem- 
perature is usually not high (99|° to 101° F.) and is most pronounced after 
activity. 
Illustrative Case.—Recently 2 children came under observation, aged two and 
four years. The temperature in one case had continued for three months. In the 
other there had been an unexplained indefinite temperature for longer or shorter periods 
for over a year. Both patients showed by x-ray evident tuberculous infection of the 
mediastinal glands. 
In confirming the diagnosis of concealed lymph-node tuberculosis the 
x-ray is invaluable. 810 
THE PRACTICE OF PEDIATRICS 
D’Espine’s Sign.—In 1907 D’Espine described a sign which he con- 
sidered diagnostic of enlargement of the bronchial lymph-glands, irrespec- 
tive of the cause of the enlargement. This sign consists simply in whispered 
bronchophony in the interscapular space and may be present in cases of 
leukemia, Hodgkin’s disease, syphilis, and other infectious diseases than 
tuberculosis. According to D’Espine the transmission of the whispered 
voice normally ceases at the level of the seventh cervical spine posteriorly. 
Transmission of bronchophony below this level is very strongly sug- 
gestive of tuberculous involvement of the mediastinal lymph-glands. 
In making the actual test the examiner applies his stethescope firmly 
in the interscapular space at varying levels as the patient says, “three- 
thirty-three.” When the sign is definitely positive the final “e” persists 
like an echo after the actual whisper is terminated.1 
Morse, from a study of “D’Espine’s sign in childhood,”2 concluded 
that the change in voice normally occurs at a level between the seventh 
cervical and first dorsal spines. 
This study was based on 666 patients of the better class seen in private 
work, and in this group the sign was found positive in only 6 per cent. 
Analysis indicated that in half of the 6 per cent., the glandular enlarge- 
ment was not tuberculous. 
It is the consensus of opinion of many observers that in the diagnosis 
of tuberculosis D’Espine’s sign is of undoubted value but should be con- 
sidered not alone, but in conjunction with other physical signs and symp- 
toms. 
Intestinal infection due to chronic constipation may be the cause 
of persistent fever. In a suspected case, in the absence of bowel symp- 
toms, it is well to give a laxative and put the child temporarily on a re- 
duced diet consisting largely of carbohydrates. 
Pyelitis of mild degree may produce a slight elevation of the tem- 
perature, which may be difficult of solution. Several specimens of the 
urine may fail to reveal pus. In doubtful cases the urine should be drawn 
by a catheter and examined by culture methods. 
Unexplained Elevations of Temperature.—Children exhibit an un- 
explained temperature of from 100° to 101.5° F. for weeks, without any 
other signs of illness. One may employ all the newer diagnostic labor- 
atory methods, and still see such patients recover without a diagnosis. 
Of one thing, however, we may rest assured: If a competent, thorough 
examination does not reveal the cause of the slight fever we are safe 
in concluding that there is nothing of very serious nature back of it. 
The fact that milk does not agree with a child may mean that the 
child is mildly sensitized to cow’s milk protein and reacts accordingly 
with a moderate fever. 
Periodic attacks of elevation of the temperature from 101° to 104° F., 
explicable only on the grounds of a disturbed metabolism, are occasionally 
encountered. Except for the finding of acetone in the urine these cases 
are negative throughout. The pyrexia lasts four or five days and then 
subsides by crisis. The acetone is not the result of starvation, and the 
case is not one of true acidosis. 
1 Stoll, IT. F., Amer. Jour. Dis. of Child., 10, 1915, pp. 183-193. 
2 Amer. Jour. Dis. of Child., 11, 1916, pp. 276-280. NEUROCIRCULATORY ASTHENIA (EFFORT SYNDROME) 
811 
Illustrative Case.—The history of a case of this kind, which gave no end of trouble 
and annoyance, may not be without interest. 
The patient, an eight-year-old boy, was the only son of a habitually anxious mother, 
who had unfortunately learned to use the clinical thermometer. She' took her boy’s 
temperature after school one day early in December and found that the thermometer 
registered 100.5° F. The writer was consulted, saw the boy in the evening, took his 
temperature by mouth, with his own thermometer, and found it 100.8°, F., with no 
other evidence of disease. The boy was perfectly normal in every other respect. He 
maintained that he felt well, did not need a doctor, and wished to be let alone to study 
his lessons. The following morning the temperature was 100° F.; in the evening it was 
nearly 101° F. For six weeks this temperature range continued, never below 100° F., 
never higher than 101.2° F. Finally the mother became reconciled to “doing nothing” 
for her son, and he was taken to a nearby winter resort. The boy had an excellent 
time at the winter resort, played with his sled in the snow, skated on the lake, and fell 
through the ice once and received a thorough wetting, without harm. In three weeks 
he returned, improved as much as any city child improves from a country outing. 
His temperature was not taken.during these three weeks at the winter resort and has 
not been taken since, except when there have been evidences of illness. 
NEUROCIRCULATORY ASTHENIA (EFFORT SYNDROME) 
There is but one classification of normal children and such are sup- 
posed to be of the same physical and mental capacity. Two ten-year old 
boys may be equal in general intelligence as shown by the Binet-Simon 
test, yet one will be able to accomplish much more than the other in a 
given time. There is no mental test for initiative, incentive, or mental 
endurance. Because of the lack and the difficulties of an adequate classi- 
fication not a few children are placed at a decided disadvantage. The 
capacity for continued effort, which means the ability to work, counts for 
just as much as does the spontaneous intelligence that the child may 
possess. 
It has long been our observation that children divide themselves into 
groups as relates to individual ability for effort. This tendency to group- 
ing is not discernible to any extent among infants. After the second 
year, however, individual traits and a distinct personality manifest them- 
selves. At about this period it may be said that the child begins to in- 
dividuate. 
During the late international war, English Army surgeons learned 
that, when certain recruits were put to prolonged hard work, at drill, 
hikes, and other exertion, they failed to measure up to the endurance 
standard required of a soldier in the field. Although these recruits had 
passed the various physical tests and had been put to training, after 
a time it was found necessary to disqualify the men because of their 
inability to perform the duties and bear the hardships demanded, which 
others were able to meet. To this condition Dr. Thomas Lewis applied 
the term “effort syndrome.” As the most prominent symptoms involve 
the circulatory and nervous system, later writers have used the term 
“neurocirculatory asthenia” or “neurocirculatory myasthenia” (Mac- 
Farlane). This condition in healthy individuals, Lewis qualified by the 
term “constitutional.” 
Friedlander and Freyhof1 reported on 50 cases of so-called “consti- 
tutional neurocirculatory asthenia.” 
Robey and Boas,2 after an intensive study of a large number of soldiers 
1 Arch. Int. Med., December, 1918. 
2 Jour. Amer. Med. Assoc., August 17, 1918. 812 
THE PRACTICE OF PEDIATRICS 
suffering from neurocirculatory disorders, were obliged to recommend 
for permanent discharge 87 per cent. These cases all belonged to the 
so-called “constitutional” class. 
The boy or girl who may qualify for the diagnosis of neurocirculatory 
asthenia comes to us with a typical story, which, condensed, is that the 
child is bright and responsive but lacks capacity for sustained effort, both 
mental and physical. It is stated that the child is intelligent but cannot 
apply himself sufficiently to become an average student and is behind 
in his classes. In like manner he is physically unfit for the usual activities 
of boyhood. He tires readily and prefers to be a spectator rather than an 
active participant in games and other amusements. Wherever endurance 
is required he fails. If he attempts in later life to make the football or 
baseball team, he is “turned down” by the coach or trainer. Neverthe- 
less he is not ill, and even upon a thorough physical examination will 
fail to show disease. One of the distinguishing characteristics is a lack of 
nervous control. The weight and height apparently have little to do with 
the condition. In the writer’s case records the child of this type has been 
heretofore classified as a “poor individual.” 
The individual boys and girls of this type are subjected to a good 
deal of unjust criticism. They are accused of being lazy, indifferent, care- 
less, and dull. The fact is they are poor types of human machines of from 
50 to 75 per cent, working capacity. It is important not to confuse these 
young people with those who suffer from bad habits, as regards their sleep, 
rest, and general hygiene, or with those who are bodily ill, or with those 
who, because of rapid growth and arduous duties, are temporarily but not 
permanently below normal. It may readily be understood that in girls 
such constitutional peculiarities may attract less attention and be more 
readily excused when present. 
With suitable management in all such cases there will always be a 
sustained response. 
Illustrative Cases.—Case 1.—A young man now twenty-three years of age came 
under the senior author’s care at the age of six months. He was the oldest of 3 
children and the only boy. The father was in fair physical condition. The mother 
was delicate in the sense that she had very little resistance or stamina. Frequent rest 
cures were necessary. She had backaches and headaches habitually, was nervous, thin 
and pale, and always had been a care to her parents. 
The boy had the usual illnesses of childhood and suffered considerably from diges- 
tive disturbances in the early years. He was irritable at home and rather unhappy in 
school. His school life proved very strenuous and was interspersed with frequent 
intermissions for one cause or another. Mental control was defective. Tantrums 
were not unusual. As he grew to older boyhood, various boarding schools were at- 
tempted, but he never remained longer than the Christmas vacation. It was uni- 
formly found by the head master that the school was not suited to the boy. 
When the United States entered the war he volunteered in a certain department 
and was accepted, passed the physical examination, remained a few weeks, and then 
was assigned to another division of the service. Thither he went, and was examined 
and again accepted, but in a short time was advised to apply to another department. 
Again he was accepted and again he failed. The boy was anxious to enter the service 
as all his friends had volunteered and 2 younger sisters made his life miserable by 
their anxiety to have a big brother hero. 
It was absolutely impossible for this boy to do the work required of him in any of 
the positions he attempted, although he was most anxious to serve. 
(These individuals finally drift into the right occupational sphere, one that requires 
very little expenditure of effort.) 
Case 2.—A boy who was a fine physical specimen was frequently ill in early boy- 
hood but never seriously ill. He had a tendency to be introspective and moody. He NEUROCIRCULATORY ASTHENIA (EFFORT SYNDROME) 
813 
did not like school and could not get along very well with other boys. His school 
attendance was interrupted by headaches, attacks of indigestion, and various nervous 
disorders, particularly hysteria and “brain storms,” all of which were produced by 
mental concentration. When he was twelve years of age he was ashamed to go 
to school, because he was so far behind others of his age. With private tutoring he 
was able to enter the primary department of a large boy’s school at the beginning 
of the autumn term, but just before the Christmas holiday, the mother had a letter from 
the head master telling her that in his opinion their particular school was not suited 
to the requirements of her son. 
Work in the garden produced dizziness. 
As a young lad he would ride his bicycle down hill two miles to the village and 
pay some public conveyance to take him and his bicycle home. 
He is now a well-meaning, well-spoken, kindly disposed young man, without a 
trace of initiative. He has tried very hard to be a real boy, but confides that he cannot 
and the attempt has caused him a great deal of worry. Endocrine treatment was of 
no avail. Thousands of dollars have been wasted on him to date. 
The mother was forty-eight years old when the boy was born, and the father, fifty. 
Case 3.—A young man of twenty years is still in school preparing for college. The 
writer has known this boy since he was an infant, and has exerted all possible influence 
to have the boy give up the college idea and go into business. His friends are all in 
college and there only will he be happy. He enjoys fairly good health, but has never 
been known to take part in any sport. He prefers to be a spectator. Exertion makes 
him nervous and any unusual event causes him to remain in bed the next day. He 
is totally devoid of initiative. He is very intelligent and most ambitious until he starts 
to do some thing that requires effort and then he falls “flat.” The mother of the 
boy is a habitual invalid, but is never very ill. The father is an unusually able busi- 
ness man. 
Case 4-—A girl, eighteen years of age, large, well-formed and mentally alert, is in 
school about half the time. She has frequent headaches and backaches and tires 
easily. Other girls make her nervous. Parties tire her. An evening of dancing could 
not be considered. The girl is normal physically and has been examined and treated 
by a goodly number of physicians, with gland therapy and otherwise. The writer 
has known her since she was two years old. She always has been, and always will be, 
useless at any undertaking that requires effort. 
These few cases are given simply as illustrative of the type. Similar 
cases and others less pronounced exist in all communities, and all have 
one feature in common—a lessened capacity. Rest cures, change of clim- 
ate, and various supporting measures are of little avail. As these indi- 
viduals are fashioned, so they remain; a most discouraging group. 
The poor individual exists throughout the entire animal world. Among 
the lower animals, those of defective capacity, for economic reasons, 
usually have a short career. The defectively functionating human, if 
well-born, is urged and forced and stimulated to accomplish that which 
is not in him. It is impossible to get out of any piece of machinery, work 
which the machine was not intended to accomplish. Millions of dollars are 
wasted on youths who are physically and mentally unable to meet the 
standard set up by ambitious parents and friends, in an effort toward 
their so-called higher education. The highly trained teaching talent of 
our preparatory schools and universities is wasted in part on poor student 
material, 25 to 50 per cent, of which should be scrapped and put to pro- 
ductive occupation. Before a boy is permitted to avail himself of unusual 
educational advantages it should be determined that he is worth it. The 
high school and the preparatory school should serve as a clearing house. 
In addition to the examination attainments required for a college entrance 
it should be required that a candidate submit testimonials as to physical 
fitness and mental capabilities from the head master or high school prin- 
cipal. What is needed, for economic reasons, is expert occupational diag- 
nosis by men who will aid in placing the boys at work to which they are 
fitted. 814 
THE PRACTICE OF PEDIATRICS 
The writer has had the opportunity to keep in touch with a great 
many boy patients through manifesting an interest in them, and has 
been able to advise and assist them along occupational lines. A boy 
who belongs in the class we are discussing should discontinue school 
in the fifteenth or sixteenth year and take up business. 
In order to permit of a reasonable success, the occupation must be 
one that is not strenuous. Such boys often make fairly good salesmen, 
clerks, and bookkeepers. They never get very far, however, as they belong 
to that considerable class who watch the clock. Advancement in salary, 
partnership and other promotions go elsewhere. 
It is exceptional to find children of this type the offspring of strong, 
vigorous young persons. In a great majority of the cases they are the 
offspring of weakly mothers, the women of little resistance and of lessened 
endurance capacity. A strong vigorous mother will do much to offset 
the unfavorable influence on the progeny of a weakly male. The progeny 
of vigorous males is, on the other hand, greatly handicapped by inferior 
mothers—all of which applies to the lower animals as well as the human 
individual. 
Frequent child-bearing has apparently been a factor in some instances. 
By far the chief cause, however, for the “50 to 75 per cent, individual” 
is a mother of lowered resistance, of inherent weakened constitution, and 
inability for sustained effort—which defects she transmits to her off- 
spring. 
The need for a great deal of attention to the physical development 
of those who will some day be mothers is very urgent. 
Comment.—There are constitutionally inferior “substandard” (Mac- 
Farlane) children. Thus constituted, they enter the world and thus they 
continue throughout perhaps a long life regardless of attempts at improve- 
ment. A trait common to all is inability for sustained effort. Physicians, 
educators, and all others interested in the development of the young 
should appreciate that what often passes for indifference, indolence, and 
inattention may be of constitutional origin and impossible of correction. 
When such is found to be the case, the child’s curriculum should be made 
to fit the child ; and not the child to fit any “cut-and-dried” curriculum. 
All attempts of the latter class mean wasted energy. 
ANAPHYLAXIS 
The second introduction of a soluble foreign protein at an appro- 
priate interval after the first introduction of that same protein causes a 
train of symptoms designated by the term “anaphylaxis.” The first dose 
sensitizes the organism, while the second dose intoxicates. The time 
required for sensitization may be ten days or longer, and its duration has 
been found to be as long as seven years. 
The therapeutic use of immune sera, the majority of which are de- 
rived from horses, gave rise to anaphylactic phenomena which von Pir- 
quet and Schick recognized and called serum disease. Some patients 
react after a first dose of serum, the symptoms appearing eight or ten 
days after its injection, and consisting of fever, skin eruptions, muscle 
and joint pains, and glandular swellings. Such patients, after the ad- NEW GROWTHS 
815 
ministration of a second dose, develop symptoms after a few hours or only 
after several days. The immediate reaction is characterized by a local 
edema at the site of the injection, increasing slowly for twenty-four hours, 
and then disappearing in two to five days. Fever and skin eruptions 
are also present, and in a small percentage of cases nausea, vomiting, 
and even collapse may occur. When the symptoms are delayed for several 
days, they usually occur suddenly and disappear within a day. They 
are similar to those following the injection of the first dose of serum. 
In individuals who are asthmatic or afflicted with an idiosyncrasy 
to the odor of horses, a first dose of horse-serum may cause an attack 
of respiratory distress with cyanosis, or else cardiac weakness with a 
fatal ending. In such cases we must assume that the sensitization was 
either inherited or acquired through the lungs or through the stomach. 
Experimental data support all three assumptions. 
The tuberculin reaction is a local anaphylaxis in individuals sensi- 
tized to the proteins of the tubercle bacillus. 
Hay-fever is a local anaphylaxis to the protein constituent of cer- 
tain pollens. 
Drug and food idiosyncrasies are anaphylactic in character. 
Allergy to Cow’s Milk.—It is probable that the future will disclose that 
our trouble in cow’s milk feeding is dependent in greater or less degree 
upon a sensitization to cow’s milk protein. Several years ago the senior 
author nearly killed a baby in his office by placing on his tongue 5 drops 
of cow’s milk. When reactions of such severity occur and wrhen the skin 
of an infant reacts to an infinitesimal amount of cow’s milk protein by the 
formation of a large wheal it is fair to assume that there are numerous 
other cases of susceptibility to the foreign protein in which the allergy, 
although less pronounced and perhaps not easily demonstrable, is still an 
important factor. 
We are still on the threshold of knowledge of a vast number of cell 
reactions to foreign substances. When fresh cow’s milk disagrees we 
substitute usually a cow’s milk product which has been subjected to heat 
or drying. Thus, evaporated milk and dried milk have been used for years 
in feeding infants for whom fresh milk proved intolerable. The explana- 
tion of the success achieved in such cases lies in the fact that through 
the use of heat, drying, and other processes the particular toxic element 
in the protein in question has been changed or destroyed so as to remove 
its power for harm. 
NEW GROWTHS 
Carcinoma in children is of very unusual occurrence. We have seen 
but one case of carcinoma in a child. The lung was the site of the growth. 
Phillipp collected 390 cases of carcinoma reported in children under 
fifteen years. Among these he found but 87 which were undoubtedly true 
cancers. To these he added 6 cases, making 93 cases of cancer in child- 
hood. This report was published in 1907. In 1911 Ribbert stated that 
no other cases had come under his notice, so that about 93 cases of cancer 
(real) had then been reported in children. Three-fourths of these occurred 
in older children, between eight and fifteen years of age; only one-fourth 
prior to eight years. 816 
THE PRACTICE OF PEDIATRICS 
The incidence of sarcoma for comparison is not given. 
Chondroma.—Cartilaginous tumors are occasionally observed at the 
adolescent period, with an origin apparently dependent in some instances 
on heredity, and in others, on early rachitic changes. The epiphyses af- 
ford favorite sites. 
Osteoma.—Bony growths are not infrequent in the cranial bones, at 
times arising from the orbit. A congenital origin is to be considered. 
Angioma.—This neoplasm is exemplified by the various forms of vas- 
cular nevi. (See p. 657.) These tumors may arise in embryonal fissures 
or in proximity to nerve trunks. Traumatic origin has been occasionally 
remarked. 
Sarcoma.—Various forms of sarcomata occur in childhood, those of 
bone being probably the more frequent. In some instances trauma is 
undoubtedly the exciting cause. Metastases which may involve the lung 
are to be expected, depending on the exact morphology of the primary 
growth. This, when possible, should be determined by microscopic 
examination of an excised section of tissue. 
Illustrative Case.—A fatal outcome in a case of a rapidly growing bone sarcoma of 
the scapula in a boy of nine years was postponed, with an apparent period of tem- 
porary improvement, through the persistent and intensive use of radium. The disease 
terminated fatally in a period of approximately two years. 
Lymphoma and Lymphosarcoma.—Various tumors of lymphoid tissue 
are well recognized in childhood and are to be differentiated from certain 
types of Hodgkin’s disease exhibiting sarcomatous characteristics (e. g., 
lymphosarcoma of the thymus), syphilitic and tuberculous adenitis, and 
the leukemias. Ewing1 has noted that lymphosarcoma cases may show 
only a moderate degree of illness until shortly before death, while the 
cachexia of Hodgkin’s disease is apparent over a long period. The struc- 
ture of an affected gland determined by its excision and examination 
microscopically affords accurate diagnosis. 
Tumors of the Brain.—Of these the cerebellar growths appear to be 
relatively the more frequent in children. Glioma, endothelioma, and 
sarcoma are the more common types. Glioma of the retina, which may 
be bilateral, occurs in two-thirds of the cases before the fourth year 
(Ewing). 
Embryonal Sarcoma of the Kidney.—This well-recognized malignant 
growth is rare except in the first few years of life, the majority of cases 
terminating fatally before the age of three years. The growth is typically 
of a complex structure described by the term “adenomyosarcoma,” and 
may attain such a size as to fill the entire abdomen. 
Hypernephroma.—The occasional presence of embryonic adrenal 
rests in the kidney explains the origin of this growth in which there is a 
resemblance of structure to that of the adrenal in distinction from that 
of the kidney. 
Tumors of the Adrenal, Pituitary, and Pineal Glands.—Reference to 
this subject has been made in the section on Diseases of. the Glandular 
System (pp. 475-477). 
1 Neoplastic Diseases, 1922, p. 381. FOREIGN BODIES 
817 
FOREIGN BODIES 
From the fifteenth month to the sixth year is the period of life of 
humans when their desire for a close association with all sorts of objects 
is most prominent. This period covers the superinquisitive age. The 
child must handle things and manipulate every object he can get his hands 
on in every possible way. After he has satisfied himself in this respect 
he does not always know how to dispose of the articles. If these 
are small enough a few prominent and readily accessible openings in his 
anatomy appeal to him and become the resting places for a vast variety 
of objects. These selected repositories for foreign bodies are the nose, 
ears, and mouth. 
Foreign Bodies in the Nose.—The favored article here is a shoe button, 
next in order are beads, and then follow kernels of corn, peas, beans, pieces 
of cork, and of coal, wads of absorbent cotton, and live bugs. We have 
repeatedly removed articles belonging to the above group from the nostrils 
and ears of young children. 
Country children waddling through the potato patch are particularly attracted by 
the green potato bug. Two such were recently removed from the nostrils of respective 
children. 
The remains of a dead cockroach were not long since removed from a child’s ear. 
In some cases the discomfort occasioned by a foreign body will be com- 
plained of and the child then comes with the ready-made diagnosis. 
In other instances, and perhaps more often, the presence of a foreign body 
in the nose will be suggested by unilateral nasal discharge, more or less 
profuse, usually purulent, and perhaps blood stained. This usually means 
one of two conditions, an infection with the Klebs-Loffler bacillus or the 
presence of a foreign body. 
A probe slightly curved readily determines whether a foreign body is 
present. A culture in cases of doubt settles the question of diphtheria. 
If a foreign body is located it is best removed by wrapping the child 
in a sheet, binding the arms closely to the sides. Held by an attendant, 
the child then rests on his back with his head between the knees of the 
physician, with face upward. This procedure permits the best position 
for removal of the object, either with a small forceps or a probe slightly 
curved at the distal end. This is passed after the manner of the obstetrician 
in introducing the first blade of the forceps, along the side of, and then 
around, the object. 
In cases in which the foreign body is firmly wedged an anesthetic will 
be required. Foreign bodies in the oral cavity are usually readily removed 
with small thumb forceps. A solution of 5 per cent, bicarbonate of soda 
is useful for purposes of cleanliness after the removal of a foreign body. 
The Mouth as a Repository.—When a small object is placed in the 
mouth it is sometimes coughed out and at other times is swallowed and 
passes into the stomach. Instead it may be aspirated into the larynx, 
where it becomes lodged or whence it passes through into the trachea 
or bronchi. 
The accompanying cut (Fig. 145) demonstrates the possible dangers of swallowing 
foreign objects. A small watch disappeared from the neck of a girl four years of age. 
Because of the belief that it was swallowed, the stools were examined daily. The 818 
THE PRACTICE OF PEDIATRICS 
child took the usual diet without inconvenience, and it was assumed that the watch 
had passed into the stomach. After five days it was decided to locate the watch or 
at least determine if it was in the child’s digestive tract. An x-ray examination lo- 
cated the object as shown. A surprising feature in this case was the passage of the food 
alongside the watch. Without the x-ray the case would probably have been fatal, 
through the formation of a perforating ulcer of the esophagus. The patient was placed 
on her back with the head over the side of a table, to put the mouth and esophagus on 
Fig. 145.—Small watch in the esophagus. 
a plane. By means of a “penny-catcher” Dr. Robert Abbe, with some difficulty, 
succeeded in removing the watch. 
Foreign Bodies in the Stomach.—Here again the variety is legion. 
Illustrative Cases.—Within the past year two children have swallowed and passed 
open safety-pins. 
A baby six months old swallowed an open safety-pin. The mother was not aware 
of this fact until she found the pin obstructing the anal outlet. 
A fifteen-months-old boy swallowed an open safety-pin of medium size during 
the last week of July. An x-ray of the chest and abdomen failed to reveal the pin. 
In October the mother brought the pin to the junior author’s office with the explanation 
that it had only then been passed from the bowel. Investigation disclosed that the 
x-ray had been taken so as to reveal nothing above the suprasternal fossa and that 
on the occasion of the examination, the pin was probably lodged at the level of the 
cricoid cartilage, a favorite site for such obstruction. 
At the time of this writing a child is under observation who has had in his stomach 
an open pin, revealed by the x-ray, for the period of four weeks. 
We have had children who fed on their own hair and such articles as woolen blankets. 
In such instances the foreign material is usually passed in balls. 
It is surprising what large and apparently dangerous objects will 
pass through the entire gastro-intestinal tract without harm. The danger 
lies in the object becoming fastened in some portion of the intestine 
and thereby producing ulceration and perforation. 
Active laxatives should not be employed in treating children who 
have swallowed foreign bodies. Milk, bread-stuffs, and cereal foods that 
will make a large fecal mass should be given with the hope of carrying 
along the object. 
The z-ray should be used, repeatedly if necessary, in all cases in which 
there is a delay in the expulsion. 
Foreign Bodies in the Air-passages.—Foreign bodies are usually lodged FOREIGN BODIES 
819 
in the larynx by an act of sudden inspiration attended by a quick, forward 
movement of the head, as in coughing or laughing with the object in the 
mouth or between the teeth. 
It is customary to describe the invasion of a foreign body into the larynx 
as accompanied by strangulation, coughing, and choking of a severe char- 
acter. This has been disputed by Chevalier Jackson who emphasizes 
the point that while such symptoms may be present there are a very 
considerable number of cases in which no laryngeal symptoms are noticed 
at any time, the foreign bodies passing through the larynx so quickly 
as to cause no irritation. 
Jackson has recited the case of a girl eleven years old in whom a piece of rabbit bone 
14 x 21 mm. was lodged in the larynx for eighteen months without producing sufficient 
reaction to completely cut off the air-supply. 
Inversion of the patient has been of no service whatever in our expe- 
rience. The first procedure is to introduce into the mouth the index- 
finger, with the hope that a portion of the mass may protrude sufficiently 
to make possible its removal. Should the attempt fail, a laryngeal forceps 
should be brought into use, its introduction being guided and guarded 
by the index-finger. When this is not successful, tracheotomy may be 
required to relieve the child from immediate danger of suffocation, after 
which further surgical procedures may be considered. 
Sudden and paroxysmal cough, dyspnea, cyanosis, and hemoptysis 
have all been explained by the presence of foreign bodies in the bronchi. 
Bronchopneumonia and pulmonary tuberculosis have been the conditions 
early diagnosed in repeated cases of lung involvement later proved to be 
due to the presence in the bronchi of foreign bodies, many of which had 
been retained for months and years. 
The x-ray should be employed upon all manifestations of abnormal con- 
ditions within the respiratory tract. 
For a detailed and authentic study of this subject the reader is referred 
to Jackson’s contribution.1 
1 Amer. Jour. Med. Sci., May, 1921. XXIII. SPECIAL DIAGNOSTIC METHODS 
So manifold are the special tests now available for completing and 
confirming ordinary physical diagnosis that more than a cursory survey 
of the special methods is here impracticable. Among the materials com- 
monly sent to the laboratory for examination are blood, urine, stools, 
breast milk, gastric contents, sputum, cerebrospinal fluid, various exu- 
dates and transudates, conjunctival and vaginal discharges, and cultures 
from the throat. 
Blood must be obtained in many cases not only for the routine cell 
count, but for culture, Widal test, the Wassermann test, and detailed 
blood chemistry study. It is essential that the physician be at all times 
prepared to obtain promptly any specimen indicated in a given case. 
For example, Streptococcus viridans growth may be apparent in a blood- 
culture only after the lapse of several days or even a week, so that the time 
element is readily seen to be of great importance in prompt diagnosis. 
Urine may be obtained from young infants by means of the Spicer 
urinal, the Chapin urinal, or one of the many test-tube devices kept applied 
to the urethral orifice. Catheterization is seldom essential in obtaining 
urine for ordinary culture, provided aseptic precautions are observed 
in collecting the specimen. Catheterization of the female ureters may be 
satisfactorily done at an early age by one who is skilled in the technic. 
Sputum, even in the presence of a productive cough, is not readily ob- 
tained from young children because of their failure and apparent inca- 
pacity to expectorate. The insertion of a catheter into the throat will often 
induce coughing of sufficient degree to lodge upon the catheter material 
suitable for microscopic study. 
The ophthalmoscope is available not only for routine eye tests but for 
detection of nephritis, amaurotic idiocy, and intracranial lesions includ- 
ing tuberculous meningitis and brain tumor. 
The laryngoscope and bronchoscope are invaluable in the recognition 
of various forms of respiratory obstruction and in revealing localized 
ulcerations. These instruments have been employed with most gratify- 
ing success in the removal of foreign bodies from the air-passages. The 
esophagoscope has a similar range of application. 
Fluoroscopy is of signal value in the study of the chest and abdomen. 
This means of confirming the findings of ordinary physical examination 
is extremely satisfactory, and its range of applicability includes the ob- 
servation of the gastric and intestinal activity and the recognition of 
abnormalities, among which should not be forgotten diaphragmatic hernia. 
The x-ray is available for countless purposes, ranging from the study 
of pathologic changes within the thorax to the study of rachitic bones 
and the localization of foreign bodies in the respiratorv tract or the ali- 
mentary tract. 
Study of the electric reactions is of value, not only in estimating 
the significance and degree of various paralyses but also in the recognition 
820 SPECIAL DIAGNOSTIC METHODS 
821 
of latent tetany and in the diagnosis of obscure and unusual neurologic 
disorders, e. g., amyotonia congenita. 
Gastric analysis, although less relied upon than formerly, is of value 
to the pediatrist, provided minor variations in chemistry are disregarded. 
Incidentally the permeability of the esophagus is readily ascertained on 
passing the stomach-tube. 
Duodenal catheterization employed for aspiration of duodenal contents 
is similarly of definite aid in determining the permeability of the pylorus. 
Pleural Puncture (Thoracentesis).—The point of election for this pro- 
cedure which is often demanded by the diagnosis of a fluid effusion in 
the pleural cavity is the seventh or eighth intercostal space in the mid- 
axillary line. 
The patient lies on the unaffected side with the shoulders elevated 
by pillows, and the arm on the affected side drawn forward and upward. 
The aspirating needle, which should be of good strength and caliber, should 
be introduced in the interspace just above the costal border, with a sharp 
thrust, to a depth of an inch or more, when it may be detected that the 
point of the needle is in a free cavity. Aspiration should be performed very 
gradually and stopped on the occurrence of coughing. 
Pericardial Puncture.—This may be urgently required in the presence 
of traumatic hemopericardium and pericarditis with effusion, not only 
to corroborate diagnosis but as a life-saving measure. 
The puncture should be made at the site of a small preliminary incision, 
with a needle or fine cannula and trocar fitted to an aspirating apparatus. 
The point of election is in the fifth intercostal space close to the left sternal 
border. From this point the needle should be directed obliquely down- 
ward and inward. By Dieulafoy’s method the puncture is made in the 
fifth space 4 fingerbreadths from the sternum through a short vertical 
preliminary incision. The needle is cautiously pushed obliquely inward 
from this point almost parallel to the plane of the chest wall. 
Peritoneal Puncture.—This procedure is of comparatively recent de- 
velopment and should never be employed indiscriminately. The needle 
may be inserted as in making an intraperitoneal injection at a point 
about 2 inches below the umbilicus. (See p. 850.) The needle should be 
directed carefully inward and upward until it enters the peritoneal cavity. 
The indications for exploratory puncture of the pleural, pericardial, 
peritoneal, and joint cavities are generally appreciated. As a fixed prin- 
ciple, one should refrain from any purely diagnostic step involving the intro- 
duction of a needle into a cavity normally sterile, until all ordinary means 
of arriving at accurate recognition of the existing diseased condition have 
been exhausted. 
Lumbar Puncture.—The site selected for lumbar puncture is on a line 
between the crests of the ilia and between the spinous processes of the 
third and fourth lumbar vertebrae. 
Position of the Patient.—The child should rest on one side (Fig. 147), 
sufficient pressure being exerted on the buttocks to make the spinous 
processes prominent. The Quincke needle (Fig. 146) should always be 
used in making the puncture. The stylet which fits the beveled edge 
of the point of the needle effectually prevents its being plugged. 
Method.—The skin for several inches about the site of the puncture 822 
THE PRACTICE OF PEDIATRICS 
should be scrubbed with tincture of green soap and alcohol. The phys- 
ician’s hands should be thoroughly disinfected. Considerable force 
may be necessary in order to enter the canal. When there is a sudden 
giving way of the obstruction to the progress of the needle, one may 
know that the canal has been entered. The puncture may be made 
in a line with the spinous processes or from the side, the needle being 
passed between the laminae and inward about 1 inch. When the point 
of the needle has been introduced into the spinal canal, the stylet is with- 
Fig. 146.—Quincke’s needle. 
drawn. The cerebrospinal fluid may escape with force in a stream as a 
result of the pressure or it may exude drop by drop. A sterile tube should 
be in readiness in order to collect the fluid for examination. In dealing 
with older children after the third year it is often easier to introduce 
the needle slightly to the right or left of the line of the spinous processes. 
When the canal is entered and the cerebrospinal fluid does not pass 
readily through the needle, the flow may be increased by elevating the 
child almost into a sitting position with the head forward. A dry tap 
Fig. 147.—Position for and site of lumbar puncture. 
usually means that the canal has not been entered. For some children 
it will be necessary to employ a slight degree of anesthesia. Gas or chloro- 
form may be employed for this purpose. 
Uses.—The uses of lumbar puncture are threefold: for diagnostic 
purposes, as a means of conveyance of sera to the spinal canal, and for 
the relief of acute pressure symptoms by the withdrawal of the fluid. 
Ventricular puncture should be performed only in the event of apparent 
blocking of the cerebrospinal fluid channel at the base of the brain (as 
determined by examination including previous lumbar puncture), and is SPECIAL DIAGNOSTIC METHODS 
823 
applicable only exceptionally after the age when closure of the anterior 
fontanel is completed. The head should be shaved and aseptically cleansed. 
With the patient in the recumbent position the needle is inserted through 
the anterior fontanel a little less than 1 cm. to one side of the midline 
and is directed forward and slightly downward to a depth of not over 
1| inches. 
The introduction of air or phenolphthalein into the ventricle is oc- 
casionally resorted to in the differentiation of the exact character of a 
hydrocephalus. 
Cisterna puncture is occasionally employed, when the spinal and ven- 
tricular taps are found impracticable, for the withdrawal of fluid or the 
injection of serum. The needle is introduced for about 4 cm. in the mid- 
line just above the spine of the axis on a plane traversing the glabella and 
the upper margin of the external auditory meatus. 
The Widal Reaction for Typhoid Fever.—To make Widal tests it is 
necessary to keep in stock a well-agglutinating strain of typhoid bacillus. 
A bouillon or agar culture which has grown not longer than eighteen to 
twenty hours should be used for the reaction. The blood to be tested 
should be obtained in a small glass tube of the Wright pattern, 0.5 to 1 
c.c. in amount, sealed at both ends, and the serum allowed to separate. 
Sterile physiologic salt solution is used as the diluent. A porcelain palet 
with six or more cup-like depressions is a convenient receptacle for holding 
the dilutions, if the microscopic method is used. 
By means of a capillary tube marked by a wax pencil 1 drop of serum 
and 9 drops of salt solution are mixed in one of the palet cups, making 
a dilution of 1 : 10. From this stock other dilutions are made; 1 drop 
to 4 of salt solution equals a dilution of 1 : 50, etc. The addition of 1 
drop of culture to 1 drop of a 1 : 10 dilution of serum makes a dilution 
of 1 : 20. This is examined on a hollow slide with a No. 7 lens. Con- 
trols of the culture alone, and of culture plus normal serum should be 
made at the same time. Cessation of motion and clumping of the bacilli 
within one-half to one hour, in a dilution of 1 : 40, constitutes definite 
proof of typhoid infection. 
The microscopic method should be employed by preference. 
By the macroscopic method dilutions are made in small test-tubes. 
The tubes are placed in the incubator at 37.5° C. for one hour and then 
in the ice-chest overnight. The reaction can be read at a glance. The 
clumped bacilli fall to the bottom of the tube and leave the serum quite 
clear, while the control remains turbid and smooth. The quantity of 
serum required is very small, 0.2 cm. being sufficient to make all neces- 
sary dilutions. Each tube may contain 0.8 cm. of diluted serum and 0.2 
cm. of bacillary suspension, making a total of 1 cm. Agglutination 
in a dilution of 1 : 40 may be looked upon as a positive reaction. 
With blood dried on a slide the test cannot be accurately made. Cul- 
tures of typhoid bacilli killed with formalin have been used for making 
the Widal test, but the method has nothing to recommend it. 
The Widal reaction does not given positive results before the end of 
the first week or the beginning of the second week of typhoid. It may 
continue to be positive throughout convalescence and for an indefinite 
period thereafter. Occasionally its appearance is deferred until conva- 824 
THE PRACTICE OF PEDIATRICS 
lescence or until a relapse comes on, but it is present at some time during 
an attack of typhoid fever in over 95 per cent, of all cases. 
Tests for Tuberculosis.—Tuberculin is used as a diagnostic agent to 
detect early, latent, or doubtful cases of tuberculosis. Different methods 
have been employed in the application of tuberculin. 
Subcutaneous Inoculation.—The dose used for diagnosis is larger 
than that allowable for immunization purposes, from 1/10 to 5 or 10 
milligrams being used, according to the age of the child. If the patient 
is tuberculous, the injection is followed in eight to twenty-four hours 
by a rise of temperature, a certain amount of malaise, tenderness at 
the site of injection, and rales over the suspected lung area. The re- 
action is general as well as local. The temperature falls within twenty- 
four hours. No reaction occurs in non-tuberculous cases, while in 95 
per cent, of those of tuberculosis the test is followed by a positive re- 
action. Absolute exclusion of tuberculosis, however, because of a neg- 
ative result, is not possible. The test is applicable only to cases which 
do not run a temperature over 37.7° C. (100° F.), and is useful in doubt- 
ful and obscure cases. It may be necessary to repeat the inoculations 
two or three times before a positive reaction occurs; the initial small dose 
of 1/10 milligram being followed in three days by another of 1 milligram, 
and again, if necessary, in three days by another of 3 or 5 milligrams in 
older children. 
A second subcutaneous test is the puncture or stick reaction of Ham- 
burger. In older children 1/1000 to 1/100 milligram of tuberculin is 
injected just beneath the skin. Within twenty-four hours the local re- 
action begins and lasts for five or six days. The redness and induration 
are visible at the point entered by the needle, and also at the place where 
the injected fluid is deposited. 
Cutaneous Inoculation.—This method of vaccination with tubercu- 
lin was introduced by von Pirquet. A small superficial scarification 
is made on the forearm, and a drop of undiluted tuberculin is applied. 
An untreated scarified area of equal size is made at the same time for 
control purposes. In cases of active tuberculosis the reaction begins 
within twenty-four hours. A small red papule forms, surrounded by a 
limited area of redness and induration. In four to eight days the nodule 
has disappeared. The control scarification heals without any inflam- 
matory sign. Yon Pirquet himself uses a fine boring instrument instead 
of scarifying. The method is most valuable in infants and children under 
two years of age. A positive reaction is accepted by von Pirquet as 
proof positive of tuberculosis. A negative reaction, on the whole, means 
absence of any tuberculous focus. 
In the last days of a miliary tuberculosis the reaction fails to appear 
in about half the cases. Furthermore, in cachectic conditions from 
any cause the reaction does not appear. During the eruptive stage of 
measles it is absent in 100 per cent, of tuberculous cases, while in scarlet 
fever the negative result is less constant, the reaction failing to appear 
in 85 per cent, of the cases. After the eruption has disappeared a von 
Pirquet reaction may be obtained. Tuberculous patients suffering from 
diphtheria or typhoid fever also fail in some instances to react to the 
cutaneous tuberculin test. SPECIAL DIAGNOSTIC METHODS 
825 
Differential Cutaneous Reaction.—Detre devised this method of diag- 
nosing human from bovine tuberculous infection. He used the filtrates 
of bouillon cultures of human and bovine tubercle bacilli, applying them 
by the von Pirquet cutaneous method, making the scarifications and the 
applied drop of fluid as nearly alike as possible. The diagnosis is de- 
termined by the relative size of the resulting reaction papules, which 
Detre carefully measures. Thus far, most observers find that in the major- 
ity of cases the two reactions are equally marked, and it has not yet 
been established that the differential diagnosis between human and bovine 
tubercle bacillus infection is possible by this means. 
The Moro Inunction Test.—Equal parts of old tuberculin and anhy- 
drous lanolin are used in the form of a salve. The dose is about 1 gram 
of the ointment, rubbed into an area of healthy skin about 5 cm. in diam- 
eter. The application is made in the epigastric or submammary region, 
a rubber finger-cot or glove being used to rub the ointment into the skin 
for three-fourths of a minute or more. The inoculated area is exposed 
to the air for ten to twenty minutes, and no dressing is applied. It is 
well to clean the site of the inunction with alcohol before applying the 
salve, and also to ring the inoculated area. A control with plain lanolin 
is to be made on another part of the skin. The reaction manifests itself 
in ten to seventy-two hours, but in the majority of cases it does not appear 
later than the second day. The eruption which appears is papulovesicular 
in character, with an erythematous areola around the individual papules. 
In a severe reaction the areolae may coalesce. The papules vary in number 
from very few (1 to 4) to very many (50 to 100). Itching sometimes occurs. 
The eruption persists for several days; in severe cases it may be appar- 
ent for seven to ten days, and may be followed by pigmentation and 
desquamation. The test is simple and harmless. As a rule, the von 
Pirquet reaction is fully developed several hours before the inunction 
(Moro) reaction. 
Ophthalmo-reaction.—This was first described by Wolff-Eisner and 
shortly afterward by Calmette. It consists in the instillation of 1 drop 
of 0.5 per cent, solution of tuberculin into the conjunctival sac of the 
healthy eye of the patient. Within twelve hours swelling and redness 
are at their height, and gradually subside in twelve hours more. 
The advantage of the cutaneous method over the subcutaneous is 
that the former obviates the possibility of spreading the tuberculosis, 
since no general reaction follows the application. Both methods are 
based upon the principle that in the course of a tuberculous infection 
all the cells of the body are sensitized to the products of the tubercle 
bacillus. When, therefore, a minute quantity of such products (tuber- 
culin) is brought into direct contact with a sensitized and vascular tissue, 
like the skin.or conjunctiva, a rapid inflammatory response occurs. 
The Mantoux or Intradermal Test.—For routine use this test is the 
most reliable of all. The reasons for choosing this method, with a descrip- 
tion of the technic have been given in a review by Smith.1 
“The subcutaneous general febrile reaction is not in general use, and 
is somewhat dangerous in childhood; the Calmette and Moro have been 
1 Charles Hendee Smith, Tuberculosis in Childhood, Bulletin of New York Tuber- 
culosis Association, 1923. 826 
THE PRACTICE OF PEDIATRICS 
practically abandoned. Those in common use are the Pirquet or epider- 
mal, and the Mantoux or intradermal reactions. 
“We have found at Bellevue Hospital that the intradermal is at least 
twice as accurate as the Pirquet, and has the single disadvantage that the 
dilute solution must be prepared. It is very simple, however, to prepare. 
“For a 1 : 1000 dilution, put 1/10 c.c. of old tuberculin in 100 c.c. of 
salt solution. (This can be rapidly done by any one with boiled water 
and a salt tablet.) Dose: 1/20 c.c. or 1/20 mg. for infants (0.00005 
gm.) and 1/10 c.c. or 1/10 mg. for older children (0.0001 gm.). 
“These amounts are injected into the skin not under it (just as in the 
Schick test). If negative, in suspicious cases a larger dose may be used, 
up to 4/10 or 6/10 mg., taking care not to increase too rapidly in order 
to avoid a general reaction. The reaction is easy to read, safe and ac- 
curate, and if positive gives a much larger erythema than the Pirquet. 
It should be read daily for five days, or if only once, on the second or 
third day. 
“The Pirquet is slightly easier to do, but gives us only about half as 
many positive reactions, due to unavoidable sources of error intrinsic 
to the reaction, even when done with the greatest care.” 
The study of a large series of cases with the aid of the intradermal 
test at Bellevue has shown that not over 40 per cent, of children there 
examined are infected at puberty. This percentage is lower than that 
for any previous series reported in this country. (See Fig. 135, p. 767.) 
The Schick Test for Susceptibility to Diphtheria.—This reaction and 
its range of application have been previously discussed (pp. 688-690). 
The Dick test for susceptibility to scarlet fever has also received men- 
tion (p. 704). 
The Wassermann Test for Syphilis.—The Wassermann reaction is the 
application of the complement fixation or deviation test to the diagnosis 
of syphilis. As introduced by Wassermann, Neisser, and Brack it re- 
quired the use of guinea-pig complement, the serum to be tested, antigen 
consisting of extract of syphilitic liver, and a sheep’s hemolytic system. 
By sheep hemolytic system is meant an immune rabbit serum prepared 
by inoculating rabbits with washed sheep’s erythrocytes, and a sus- 
pension of washed red blood-cells of the sheep. In the presence of fresh 
guinea-pig serum (complement) such an immune serum has the power 
of hemolyzing the red blood-cells. In the same way human hemolytic 
system means the combination of washed human erythrocytes and an 
immune serum prepared by inoculating rabbits with washed red blood- 
cells of the human type. 
If the serum to be tested contains immune bodies specific to the anti- 
gen used, these will, in the presence of complement, unite with each 
other and bind the complement. The addition of the hemolytic sys- 
tem will then cause no change in the tubes, i. e., hemolysis will not occur. 
If the antigen and the immune serum are not specific, then the com- 
plement is left free to unite with the hemolytic system and hemolysis 
occurs. This is called the complement fixation or deviation test. 
As simplified by Noguchi, the test requires much smaller quantities 
of guinea-pig complement, the serum to be tested, antigen consisting 
of human or animal tissue extract, and human hemolytic system. For SPECIAL DIAGNOSTIC METHODS 
827 
practical purposes 1 c.c. of the patient’s blood will give an ample amount 
of serum for the test. 
The Wassermann seroreaction is positive in 98 per cent, of cases of 
congenital syphilis, but only in 66 per cent, of latent syphilis. During 
the primary stage of acquired syphilis 90 per cent, of the cases give a 
positive Wassermann test, during the secondary stage, 96 per cent.; 
and during the tertiary stage, 83 per cent, react positively. 
Craig has found that the reaction may disappear from two to four 
weeks after the institution of mercurial treatment, but it may return 
when the treatment is stopped; therefore it is not established that the 
disappearance of the reaction justifies the conclusion that the disease 
has been cured, and that treatment may be discontinued. 
Noguchi found that after treatment with salvarsan the reaction 
may disappear within two weeks in promptly cured cases, although it 
may not do so for four or five weeks. 
The spinal fluid Wassermann reaction is employed in the diagnosis 
of neurosyphilis. This test may be positive in the presence of juvenile 
tabes or paresis even when the blood Wassermann reaction in the patient 
is negative. 
The Noguchi Butyric Acid Test.—This test is based upon the fact 
that the globulin reaction in the blood-serum and in the cerebrospinal 
fluid is increased in syphilis. In the case of the blood-serum the test is 
too complicated to be used anywhere except in a highly equipped laboratory 
and, moreover, it is not needed in children, since Wassermann’s serum re- 
action answers all practical purposes. Applied to the cerebrospinal fluid, 
the Noguchi test is very simple and is carried out as follows: 1/10 or 2/10 
c.c. of cerebrospinal fluid, which must be absolutely free from blood, is 
mixed with 1/2 c.c. of a 10 per cent, solution of butyric acid in normal 
saline and boiled. Then 1/10 c.c. of normal sodium hydroxid solution is 
quickly added, and the whole is boiled for a few seconds. A granular or 
fioccular precipitate indicates a positive reaction. The appearance of the 
precipitate within a few minutes indicates a considerable increase in 
globulin, while weaker reactions may not appear for an hour. Two hours 
should be the time limit. 
Normal cerebrospinal fluid with this test gives a slight opalescence 
and occasionally turbidity, but the granular precipitate does not occur 
at all or only after the time limit has been reached. 
A positive reaction occurs with the cerebrospinal fluid from any case 
of syphilitic or parasyphilitic affection, and also in all acute inflamma- 
tions of the meninges, whether due to the meningococcus, the tubercle 
bacillus, the pneumococcus, the streptococcus, or the influenza bacillus. 
The reaction is also positive in the early stage of poliomyelitis. Such 
conditions can, of course, be readily differentiated from syphilis. In 
acute luetic meningitis the presence of Treponema pallidum in the cere- 
brospinal fluid will serve to exclude the other forms of meningitis. Such 
a case has been reported by Rach1 in a child four months old. In hydro- 
cephalus the cerebrospinal fluid gives a positive butyric acid test in 
cases which are of syphilitic origin. When the amount of cerebrospinal 
fluid is increased without inflammation of the meninges, as sometimes 
1 Jahrb. f. Kinderh., 1912. 828 
THE PRACTICE OF PEDIATRICS 
happens in pneumonia, the fluid does not give a positive butyric acid 
test. 
In children Noguchi’s test is most valuable in differentiating be- 
tween inflammatory and non-inflammatory conditions of the meninges. 
The Colloidal Gold Reaction of Lange.—This depends on the fact that 
normal cerebrospinal fluid when diluted with a 0.4 per cent, sodium 
chlorid solution does not produce color change in colloidal gold, while 
pathologic cerebrospinal fluid similarly treated produces distinctive 
changes for various diseases. This reaction is specific for syphilis ofvthe 
nervous system and is applicable to the diagnosis of meningitis. By 
means of observations on the quality of the color change produced under 
different dilutions of the spinal fluid typical curves are plotted significant 
in diagnosis of the various diseases. 
Tests for Renal Function—In addition to the routine urinary exam- 
inations customary in the general practitioner’s office various tests are 
invaluable for the purpose of more accurate differentiation and prognosis 
in cases of disease of the kidney. In an estimate of the value of kidney 
function Longcope1 has designated the phthalein excretion and 
blood chemistry findings as of value in making the prognosis in acute neph- 
ritis. In chronic nephritis the chlorid and nitrogen concentration partic- 
ularly, together with the phthalein excretion, afford information of value. 
Blood chemistry offers a means of differentiating uremia from other kinds 
of coma. 
The phenolsulphonephthalein test devised by Rowntree and Geraghty2 
consists in the determination of the rate of excretion by the kidney of 1 
c.c. of a solution containing 0.6 gram of phenolsulphonephthalein injected 
in the upper arm. By the normal kidney 40 to 60 per cent, of the drug is 
excreted in the first hour and 20 to 25 per cent, in the second hour, this 
excretion occuring without conformity to the rate of excretion of water. 
The phthalein test is most reliable in acute conditions. Two factors 
markedly influencing this test are the rate of absorption of the dye, de- 
pending on the size of the injection and the existence or non-existence of 
edema; and the amount of urine in the bladder, which should, of course, 
be empty at the time of the injection. 
The Mosenthal test,3 based on a modification of a test for estimating 
renal function, proposed by Hedinger and Schlayer4 has been simplified 
so that it is at present readily available in ordinary practice. With a 
normal diet in health the maximum specific gravity of the urine is to be 
regarded as 1018 or 1020 or higher, and a variation of 9 degrees between 
high and low specific gravity should obtain. The volume of the night 
urine representing the total voiding from 8 p. m. to 8 A. m., in children 
(depending on the age) should be 200 to 500 c.c., the total twenty-four-hour 
excretion being about 1 liter. The nitrogen and sodium chlorid normally 
constitute about 1 per cent. 
When renal function is impaired the quantity of night urine becomes 
increased and the specific gravity of the urine shows fixation which may 
1 Boston Med. Surg. Jour., 189, 269, 302, August 23, 1923. 
2 Jour. Phar. Exper. Therap., 1910, i, 579; Arch. Int. Med., 1912, ix, 284. 
3 Arch. Int. Med., 1918, xxii, 770. 
4Deutsch. Arch. f. klin. Med., 1914, cxiv, 120. SPECIAL DIAGNOSTIC METHODS 
829 
be at a high or low level, while the salt and nitrogen elimination is dimin- 
ished. Variations in degree of edema elimination are to be considered in 
interpreting the test, but the interpretation is not dependent, as was at 
first thought, upon special diet. 
In applying this method the urine is collected at two-hour intervals 
in separate containers from 8 a. m. to 8 p. m. That voided from 8 p. m. 
to 8 a. m., constituting the total night urine, is collected in one container. 
Estimations of urea and urinary nitrogenous constituents of the urine, 
formerly much in vogue, are of little value unless combined with a study 
of the food intake and the chemical content of the blood. Such tests are 
therefore impracticable. 
Blood chemistry determinations are not needed for the recognition 
of the existing kidney disease, but within limits are more reliable than 
urinary and functional tests and afford information on the following- 
points: (1) Whether nitrogen or salt and water elimination is defective, 
(2) degree of retention, (3) prognosis, and (4) trend of the disease, partic- 
ularly in response to treatment. In various acute infections, postoper- 
ative states, diarrhea, vesical calculus, and pyelitis a determination of the 
non-protein nitrogen and its constituents will show the degree of impair- 
ment of kidney function and afford warning of impending nephritis. 
The following figures may be taken as normal for the more important 
substances routinely determined in blood chemistry study: 
Non-protein nitrogen 
Milligrams per 100 c.c. 
20-30 
Urea nitrogen 
8-15 
Uric acid ‘ 
1- 3 
Creatinin 
1- 2 
Glucose 
60-120 
Chlorids 
Calcium 
9-12 
Phosphorus 
5- 6 
Cholesterol 
150 
Corpuscular volume 
35- 45 per cent. 
Carbon dioxid combining power 
Of the non-protein nitrogen constituents creatinin, because it is or- 
dinarily eliminated most readily by the kidney, serves as a valuable prog- 
nostic indicator of the kidney capacity, creatinin retention occurring prac- 
tically only in nephritis. A creatinin content of over 3 mgm. is con- 
sidered serious and one of over 5 mgm., of fatal prognostic import.1 
Uric acid is most difficult to eliminate and in acute conditions is the 
first constituent to show an increase. In chronic conditions there is no 
greater difficulty in its elimination than in that of creatinin and non-pro- 
tein nitrogen. 
Estimation of the carbon dioxid combining power of the blood, for which 
the Van Slyke method is replacing the alveolar air determination method, 
affords valuable information respecting the degree of acidosis in diabetes, 
intestinal intoxication, and postoperative disturbances of metabolism. 
The administration of insulin in diabetes should be checked by repeated 
blood chemistry observations of this type as well as by frequent esti- 
mations of blood-sugar and urinary sugar. 
1 It should be noted that what is determined as creatinin may actually not be crea- 
tinin, but the significance of the color-producing substance remains the same. 830 
THE PRACTICE OF PEDIATRICS 
The determination of the calcium and phosphorus content of the blood 
is particularly valuable in rickets and spasmophilia, although careful 
clinical examination will reveal rickets before it is disclosed by x-ray or 
blood analysis. When the x-ray shows the disease there is regularly a 
diminution in the phosphorus content of the blood. In active tetany the 
blood calcium is always low, without significant increase in the phosphorus 
content. In rickets complicated by tetany, however, the phosphorus is 
relatively high as compared with that in uncomplicated rickets. Latent 
tetany may be shown by low blood calcium as well as by the altered elec- 
tric reactions. 
Other tests to be kept in mind as of particular importance practically 
are the hemolysis and agglutination tests to determine compatibility of donor’s 
and recipient's blood for transfusion, the blood fragility test, invaluable in 
the diagnosis of hemolytic icterus, and the estimation of coagulation time 
and bleeding time. XXIV. THERAPEUTIC MEASURES 
THE FUNDAMENTALS OF THERAPEUTICS IN CHILDHOOD 
It has been our object, in this work, to present as clear and detailed 
a description of the management of the illnesses of infancy and childhood 
as space would permit, with a view to a better understanding of pediatric 
therapeutics. 
If asked what should be considered an important requisite for the 
successful practice of pediatrics, we would answer: The education of the 
mother. It is impossible to do even fairly good work in treating dis- 
eases of children without proper home co-operation. A direction is never 
followed out as well as when the reason for it is properly understood. 
Many of our beneficial results are due to the therapeutic influences 
of remedies outside of the realm of drugs. Thus, diet, fresh air, sunshine, 
cold, heat, massage, electricity, climate—all are important therapeutic 
agents in the diseases of children. Successful therapy applied to chil- 
dren requires an understanding and a knowledge of detail greater, per- 
haps, than for any other line of medical work. It not infrequently is an 
absence of such knowledge on the part of medical men, which explains 
a great deal of the therapeutic doubt existing at the present time. Thera- 
peutic nihilism, so far as pediatrics is concerned, means ignorance and 
incompetency. The time when the physician can make a diagnosis and 
cease from interest in the treatment of the case is past. The faith of 
humanity in curative agents is remarkable, and when the desired end is 
not reached by the first physician, some other physician is called; and when 
he fails, the next resort usually is the charlatan or the proprietary med- 
icine. 
The prosperity of the irregular schools of various cults and “sciences” 
supposedly healing in character, and the consumption by the people of 
millions of dollars’ worth of useless patent drugs, are to be attributed in 
a large degree to an indifferent application of therapeutic measures 
on the part of otherwise well-qualified medical men. A few great teachers 
of medicine, by precept and example, have done an incalculable amount 
of harm in their attitude toward therapeutics. Because they were, or 
are, unable successfully to treat disease, they assume that it cannot be 
done. Thus, therapeutic doubt has been in the past boasted of by men 
considered clever. Text-books on pediatrics are not without fault in 
encouraging careless practice, with necessarily an absence of favorable 
results, especially when they state that “treatment is along supportive 
lines.” What constitute “supportive lines” in a given case? How is 
the practitioner to know the author’s mind? Or, again, perhaps it is 
stated that “free stimulation” is necessary. Stimulation how, when, 
why, and by what means is what must be known, in order to achieve 
satisfactory results. “Treatment according to the indications of the case” 
does not help a puzzled physician to any great extent. “Treatment along 
the same lines as in adults” adds no illumination when a desperately sick 
child is the patient, and moreover is faulty teaching, for the reason that 
831 832 
THE PRACTICE OF PEDIATRICS 
an infant or young child should never be treated the same as an adult, 
either by drugs, or other means, unless we wish more thoroughly to 
convince ourselves of the uselessness of therapeutic measures. 
In order to practice therapeutics successfully with children the methods 
of the physician must be flexible and adaptable. Children vary in their 
physical and mental equipment much more than do adults. The practice 
of pediatrics is necessarily difficult, for every case has to be studied from 
its own standpoint. The physician who invariably treats all his cases 
alike will never do the highest class of work with children. The man, 
for example, who feeds all his difficult feeding cases after one rule or pat- 
tern will be sure to have some other practitioner get his failures, which 
will not be few. A source of disappointment to the physician, particularly 
in the treatment of young infants and children, exists in the disorders of 
nutrition. A tremendous amount of patience is required in dealing with 
such cases, and the absence of prompt results is one of the difficult features 
he has to contend with in his relations with the family. There is, further, 
a distinction to be made as to what constitute good results. If the infant 
develops into a strong child, we may chronicle our results as satisfactory 
even though a year elapses before the condition of the patient becomes 
satisfactory. To cause a malnutrition baby weighing only 8 pounds at 
six months, with marked milk incapacity, to show rapid growth by any 
method of artificial feeding is unusual, and results are good if he gains 
but little during the first few weeks. Chronic colitis, tardy malnutrition, 
or nephritis may require months and years for correcting and yet permit 
of satisfactory results. 
In the treatment of infants and children, particularly as regards the 
use of drugs, two points are to be kept in mind—the benefit hoped for 
and the possible harm that may result. A great deal of judgment must 
be used in the selection of remedies and the means of using them, lest 
our best intentions result to the patient. Thus, in 
bronchitis and in bronchopneumonia, the ammonium salts are often 
given in combination with heavy syrups, such as tolu and wild cherry, 
both possessing little or no value as expectorants, but having the prop- 
erty of interfering seriously with the patient’s digestion. Doubtless, 
alcohol used indiscriminately is, on the whole, productive of more harm 
than benefit, largely through disturbing the digestion. Digitalis, the 
salicylates, and the potassium and sodium salts are all to be used with 
judgment as to method and time of administration or they will do more 
harm than good. A point never to be lost sight of in the treatment of 
diseases of children is the desirability of keeping the gastro-enteric tract 
in the best possible condition. 
In the care of children there are other factors also that bear upon the 
case that tend toward good or evil. The most careful diet, and the best 
selected medication are of little value if the patient is overclad, or kept 
in a superheated room with anxious, distracted, nervously exhausted 
persons in constant attendance, with the disturbance to the patient which 
such attendance entails. It must be remembered that absence of proper 
detail and good judgment, with resulting failures, is no argument against 
the value of therapeutic measures. 
Much may be accomplished by means of prophylaxis in lowering the THE THERAPEUTIC VALUE OF CLIMATE 
833 
mortality" in children under five years of age. In this the educated mother’s 
aid is invaluable. She will lay aside prejudices and unfavorable family 
influences when a physician’s direction appeals to her reason. Maras- 
mus, malnutrition, and the intestinal diseases of summer, which directly 
or indirectly are the cause of thousands of deaths yearly, are to a large 
degree preventable if the right step is taken at the right time, through 
the early appreciation of danger signals, on the part of both the physician 
and the mother. 
THE THERAPEUTIC VALUE OF CLIMATE 
That climate is a valuable therapeutic agency in the treatment of 
diseases of children is a well-recognized fact. An important advantage 
of a change of climate is that it means more air and probably bet- 
ter air. When patients go to a resort for climatic benefit it is usually 
at no inconsiderable expense, and they are therefore pretty likely to 
avail themselves of advantages. The same amount of air could be fur- 
nished at home if the family co-operation always could be secured. By 
the use of the window-board, the roof-garden, and the indoor airing 
we can to a considerable degree make a climate of our own. Neverthe- 
less, in the majority of families the open-air treatment cannot be carried 
out successfully; therefore, the best interests of the patients are secured 
when they are sent away from home. There are conditions also in which 
such means as those just mentioned do not apply even if they are ap- 
preciated. We can give children warm air, and regulate the tempera- 
ture of the air in the winter; but if they live in any of our coast towns or 
villages, we cannot give them cool, dry air in summer. Children who 
can be removed from a large city to the country, inland, for the summer, 
are invariably benefited, not only as regards their food capacity and 
the ordinary apparent effects of open-air life, but they acquire also greater 
powers of resistance, and are thus less liable to acute intestinal diseases. 
(See Summer Resorts, p. 834.) 
Pneumonia, Pertussis, and Grip.—During the colder months New 
York City children who are convalescing from pneumonia, pertussis, or 
any prolonged illness which has greatly reduced them, will make a much 
more rapid recovery when removed to Lakewood or Atlantic City, where 
open-air life is more easily secured than at home. 
Malnutrition and Digestion Disorders.—Infants and children suf- 
fering from chronic digestive disorders, marasmus, and malnutrition, 
who are given the advantages of climate or open-air methods, either in 
the home (p. 838) or by a change of residence, invariably make a more 
rapid recovery than do those deprived of good air because of a lack of 
appreciation of its value, or through fear of the child’s taking cold. 
Nephritis.—There are diseases in children in which sudden change 
of temperature, affecting the peripheral circulation, may be decidedly 
harmful. Such variations are a menace in slow convalescence from 
acute nephritis, and also in chronic nephritis. Cases of this type require 
an equable climate, with a permissible outdoor life, such as is furnished 
during our colder months by Florida and Lower California. 
Asthma.—Experiences as to the effects of climate in asthma have 
been contradictory. 834 
THE PRACTICE OF PEDIATRICS 
With our knowledge of the dependency of asthma upon protein sen- 
sitization, the effect of climate on this condition has been relegated to 
a very unimportant position. Site more than climate is a determining 
factor in those cases due to pollen sensitization. Centers long reputed 
of value in hay-fever and asthma we now know achieved their fame due 
to the absence of plants to which individuals were sensitized. 
For the so-called non-sensitized cases which follow or are dependent 
upon bronchitis a dry atmosphere with relatively slight humidity is of 
advantage. 
Tuberculosis.—The best winter climate for a child with pulmonary 
tuberculosis is a dry climate with a mild temperature, neither high nor 
low, but with sunshine in such abundance as to permit a daily outdoor 
life. Such a climate is found in southern New Mexico and Arizona. 
These places furnish conditions as near to the ideal as it is possible to 
approach. The Adirondacks, while furnishing a climate in winter which 
may be too severe for young children, serve well for those from eight 
to nine years of age in whom the disease is not far advanced. 
The sanitarium treatment is always to be advised if the patient can 
afford it, or if it is otherwise available through charity. The advantages 
consist in the discipline, the diet, the amount of exercise, the sleeping 
quarters, the clothing—in short, in all the details of the life, every one 
of which is important. In a sanitarium all these matters are in the hands 
of those who are skilled in the management of the disease, and who direct 
each case according to individual needs. Ordinary resorts for tuberculous 
cases are dangerous because of the possibilities of reinfection through the 
carelessness of others. In a well-managed sanitarium, however, regulations, 
regarding expectoration and the care of the sputum reduce this danger to 
a minimum. Sanitariums, however, are available to but few patients. 
Many have not the means necessary for change of residence, and many 
others refuse to allow their children to be separated from them, both of 
which facts necessitate the home treatment of a great majority of the cases 
of pulmonary tuberculosis in young children in our larger cities. (See 
p. 398.) 
SUMMER RESORTS 
Where to take a baby for the hot months of the year is a vexed ques- 
tion which is raised in many city households every year, inducing a 
situation in which the physician may be called upon for advice. 
Several years’ observation of a great many New York City children 
who have spent the summer out of town has led to the following con- 
clusions: 
The most desirable summer outing consists in spending the first half 
of the season at the seashore, the remainder inland, preferably in the 
mountains. 
The next sojourn in order of desirability is inland, preferably at the 
mountains, for the entire summer. 
The least desirable is at the seashore for the entire summer. 
It is not to be understood that many children will not do well if kept 
at the seashore throughout the hot months. Some, indeed, improve 
most satisfactorily, but from observing our own patients we have repeat- INSTRUCTIONS FOR THE SUMMER 
835 
edly been impressed with the disadvantages of a too prolonged stay at 
the seashore. If kept there during August, infants are apt to show signs 
of lassitude, and while not ill, they do not return to the city in the autumn 
with the vigor, appetite, and general robustness which characterize those 
from the hills and mountains. It must be remembered that only New 
York City children are referred to. Children whose home is a seaport 
thrive best when given the benefit of a complete change to the dry, in- 
vigorating air inland. Children with catarrhal tendencies, bronchitis, 
or adenoids (before or following operation), and children who have had 
attacks of rheumatism or who show rheumatic tendencies, should not 
go to the seashore, wherever their residence. For an inland resort, the 
mountains, by which we understand an elevation of 1500 to 2000 feet, 
are not always essential. The place selected, however, should be at an 
elevation at of least 600 feet. For cases of chronic bronchitis and rheu- 
matism a soil of sand or gravel is best, and the sleeping-room of the child 
should always be above the ground floor. 
Other points to be considered in connection with the summer outing 
are the kitchen facilities, which must be ample. Often the larger hotels 
refuse the right of way to the kitchen. In this respect much more liberty 
is given in the smaller hotels and boarding-houses. The proper prepara- 
tion of the child’s food in the cramped quarters of sleeping-rooms is not 
impossible, but is often difficult and always objectionable; therefore, 
if a cottage is available, it will be greatly to the child’s advantage. 
Before final selection of a home for the summer the drainage, and the 
source and quality of the milk supply should receive the most careful 
attention. Country well-water or spring-water should ordinarily be 
boiled before using. 
INSTRUCTIONS FOR THE SUMMER 
In addition to advising parents as to a selection of a summer resort 
for the family the physician must advise the mother as to the particular 
care of the child during the summer, whether he is to remain in town or 
go to the country. During the months preceding the heated term every 
mother whose infant is under supervision should be made aware of the 
dangers of the next few months, and receive written directions as to how 
to pass through the summer with the greatest security. 
Selection of Milk.—The mother is told what market milks are the 
best. She is told that the milk must be kept on ice, with ice surround- 
ing the bottle, from the time of its delivery until it is given to the child, 
except, of course, during the time spent in its special preparation. 
Reduction of Food Strength.—During the hot months in the city 
the child’s digestive capacity is not equal to that of the colder months. 
Children who remain in the city are given weaker milk mixtures, in which 
the fat and protein are reduced from 15 to 25 per cent, by diluting with 
water, the sugar remaining the same. The infant may not gain very much 
in weight, but on a reduced diet he is much more capable of passing through 
the summer without intestinal disorders, and has abundant opportunity 
to gain later. 
Clothing.—Mothers are instructed as to the amount of clothing re- 836 
THE PRACTICE OF PEDIATRICS 
quired. They are told that a napkin, a muslin slip, a loose-mesh knitted 
band, are all that are required on a very hot day. 
Water to Drink; Bathing.—They are instructed to give the infant 
frequent drinks of boiled water between feedings, and if he suffers much 
from the heat, as shown by prickly heat and restlessness, to give him 
two or three spongings daily with a cool solution of bicarbonate of soda, 
1 teaspoonful to a pint of water. 
Both nursing and bottle babies as a rule do not need much water 
between feedings. On very hot days, however, when the child perspires 
a great deal an ounce or two of water may be given occasionally between 
the usual feedings. 
Withdrawal of Milk.—It is made very plain that either vomiting or a 
green, undigested stool is a danger-signal which always means that the 
milk must be withheld for twenty-four hours or longer whether the child 
is nursed or bottle fed, and that either barley-water or one of the other 
carbohydrate gruels (p. 94) must be substituted until such time as the 
stools improve or the vomiting ceases. This is one of the most impor- 
tant life-saving measures the physician can teach the mother. 
An immense majority of the intestinal diseases of summer, which des- 
troy thousands of lives yearly, have their origin in neglected acute indi- 
gestion and diarrhea, which if properly managed would mean a slight 
illness of but a day or two. 
It is further impressed upon the mothers that upon resuming the milk 
it must be given at first greatly reduced in strength, and then gradually 
increased until food of the usual strength is given. Beginning with | 
ounce of skimmed milk in each feeding, by watching effects upon the 
temperature and the stools, one may make an increase of perhaps 1 ounce 
each day. 
How to Obtain Safe Milk.—Not a little trouble in the past has been 
experienced in securing safe milk for infants who were removed at a con- 
siderable distance from the depots of the better class of dairies that supply 
certified milk. In remote country districts, where the milk is furnished 
by the farmer, a special arrangement may be made, by which he agrees 
that the cow’s belly, udders, and teats shall be wiped off with a damp 
cloth before milking; that the milker’s hands shall be washed before 
milking; that the few jets of the foremilk shall be thrown away; and 
that as soon as the milk is drawn it shall be strained through absorbent 
cotton into a quart milk bottle, suitably corked, and placed in a pail of 
cracked ice. The cracked ice and the absorbent cotton are, of course, to 
be furnished by the consumer. For the extra trouble the farmer should 
receive a special price for the milk. At one resort three babies were sup- 
plied in this way, by one small producer, with a comparatively safe milk. 
The improved covered milk pail insures a much cleaner milk, as it offers 
much less opportunity for droppings to fall into it during the milking 
than does the old-style pail. 
For those who have country homes and who can control their milk- 
supply the above precautions may be carried out to the letter. By such 
careful control of the home product, and by the use of milk from those 
dairies only which observe the above precautions, the acute digestive 
disorders of summer among patients have been rendered very unusual. 837 
INSTRUCTIONS FOR THE SUMMER 
These precautions, with the knowledge of the mother or nurse as to what 
to do at the first sign of a digestive disorder, will reduce the number 
of the so-called summer diarrhea cases to a very insignificant figure. 
Among out-patients in large cities who have to use other milk and 
milk less clean, summer diarrhea must prevail. Among these, however, 
the death-rate has been remarkably reduced through the education of 
the mothers. 
The mothers are told that a diarrhea is never without dangers; that 
an infant who has frequent attacks of indigestion during the cooler months 
is very sure to develop diarrhea during the hot months, and that the 
safest means of keeping a baby well in the summer is to keep him well 
all the year round. 
Rules for the Care of Dispensary Infants and Young Children During the 
Summer 
1. Clothing.—During the very hot days the baby should wear a napkin, a thin 
gauze shirt, and a thin muslin slip. An abdominal binder made of thin material, and 
loosely applied, may be worn until the child is six months of age.1 
2. Bathing.—Every child should have one tub-bath daily. On very warm days 
from two to four ten-minute spongings with cool soda water (1 teaspoonful of bicar- 
bonate of soda to a pint of water) wTill greatly add to the child’s comfort. 
3. Fresh air is of vital importance. Leave the windows open. Keep the child 
in the open air when possible. Avoid the sun. Select the shady side of the street and 
the shade in the parks. 
4. Sleep is very necessary for growing children. A noon-day nap of at least two 
hours should be insisted upon until the child is four years of age. 
5. Soiled napkins should be placed in some covered receptacle containing water, 
and washed at the earliest opportunity. 
6. Drinking-water.—Boil 1 quart of water every morning. Put it into a clean 
bottle. Keep the bottle in a cool place. Give the water between the feedings—as 
much as the child will take. 
7. Breast Feeding.—The mother should wash the nipple with plain cold water 
before each nursing. She should be very careful as to her diet and habits of life. Her 
bowels should move once a day. Constipation in the mother produces illness in tlie 
child. The mother should have three plain, well-cooked meals daily, consisting largely 
of milk, meat, vegetables, and cereals. 
From birth to the third month: The baby should be nursed at three-hour intervals 
during the day. Seven nursings in twenty-four hours, with only one nursing between 
10.30 p. m. and 6 a. m. 
Third to sixth month: The nursings should be at three-hour intervals during the day; 
six nursings in twenty-four hours, with no night nursing. 
Sixth to ninth month: The child now takes a larger quantity at each feeding and 
should be nursed at four-hour intervals; five nursings in twenty-four hours. 
Ninth to twelfth month: The nursings should be at four-hour intervals; five nursings 
in twenty-four hours. 
8. Bottle Feeding.—The bottle should be thoroughly cleansed with borax and hot 
water (1 teaspoonful of borax to a pint of water) and boiled before using. The nipple 
should be turned inside out, and scrubbed with a brush, using hot borax water. The 
brush should be used for no other purpose. There should be three or four sets of bottles 
and nipples. The bottles and nipples should rest in plain boiled water until wanted. 
Never use grocery milk. Use only bottled milk which is delivered every morning. 
The milk should be boiled for five minutes immediately after receiving. The feeding 
hours are the same as in breast feeding. Children of the same age vary greatly as to 
the strength and amount of food required. Food, when prepared, should be poured 
into a covered glass fruit-jar and kept on the ice. For the average baby the following 
mixtures will be found useful: 
For a child under three months of age: Nine ounces of milk, 27 ounces of boiled 
water, 4 teaspoonfuls of granulated sugar. Feed from 3 to 4 ounces at three-hour in- 
tervals—seven feedings in twenty-four hours. 
Third to sixth month: Eighteen ounces of milk, 30 ounces of barley-water, 6 teaspoon- 
1 After this age the binder, although not necessary, is still desirable. Even in trop- 
ical countries the “belly band” is held in great repute as a prophylactic in forestalling 
intestinal disorders. 838 
THE PRACTICE OF PEDIATRICS 
fuls of sugar. Feed 5 to 6 ounces at three-hour intervals—six feedings in twenty-four 
hours. No night feeding. 
Barley-water is prepared by boiling a tablespoonful of prepared barley flour in 1 
pint of water for twenty minutes; strain and add water to make 1 pint. 
Sixth to ninth month: Twenty-four ounces of milk, 24 ounces of barley-water, 6 
teaspoonfids of granulated sugar. Feed 7 to 8 ounces at four-hour intervals—five feed- 
ings in twenty-four hours. 
Ninth to twelfth month: Thirty-eight ounces of milk, 12 ounces of barley-water, 6 
teaspoonfuls of granulated sugar. Feed 7 to 9 ounces at four-hour intervals—five 
feedings in twenty-four hours. 
9. Condensed Milk.1—When the mother cannot afford to buy bottled milk, when 
she has no ice-chest or cannot afford to buy ice, she should not attempt cow’s milk 
feeding. Canned condensed milk should be used as a substitute during the hot months 
only. The can, when opened, should be kept in the coolest place in the apartment, 
carefully wrapped in clean white paper. The feeding hours are the same as for fresh 
cow’s milk. 
Under three months of age: One-half to 2 teaspoonfuls condensed milk; barley-water 
No. 1 (see Formulary, p. 94), 2 to 4 ounces. 
Third to sixth month: Condensed milk, 2 to 3 teaspoonfuls; barley-water, 4 to 6 
ounces. 
Sixth to ninth month: Condensed milk, 3 to 4 teaspoonfuls; barley-water, 6 to 8 
ounces. 
Ninth to twelfth month: Condensed milk, 4 to 5 teaspoonfuls; barley-water, 8 to 9 
ounces. 
10. Feeding After One Year of Age.—All babies should be weaned at the age of 
twelve months unless other orders are given by a physician. The bottle fed, also, at 
this age require more than milk and cereal water. During the second year children 
are almost invariably badly fed. 
Four meals a day should be given at the same hours every day. The mother will 
select suitable meals from the following articles: soft-boiled egg; scraped rare beef; 
strained broth of beef, mutton or chicken, with stale bread broken into it; toast and 
butter; stale bread and butter; toast and milk; stale bread and milk; oatmeal (cooked 
three hours) and milk; hominy (cooked three hours) and milk; cornmeal (cooked two 
hours) and milk; farina (cooked one hour) and milk. The milk used must be boiled 
during the hot weather. 
Physicians are frequently consulted as to the age when, and the con- 
ditions under which, it is permissible to take the baby out-of-doors. 
To answer this, the place in which the child lives, the season of the year, 
and the age and condition of the patient must be taken into consider- 
ation. 
A child, regardless of the age, should never be taken out in inclem- 
ent weather. If under one year he should not go out if the temperature 
is below 20° F. During the midday heat of summer the baby is better 
off in the largest and coolest room in the house or on a shady veranda. 
On very windy days the young infant should not go out; neither should 
he go out when the snow is melting in large quantities. 
When going out, on account of unfavorable conditions of the weather 
is prevented, there should, however, be no lack of fresh air, and this may 
be insured if the child be given an indoor airing, dressed as for the daily 
outing. All the windows of the nursery or some other large, sunny room 
should be opened on one side of the room only. The doors should be closed, 
so that currents of air are avoided. The child should then be placed in 
his carriage, suitably covered, and left in the open room all day, except 
when he is fed and “changed.” Here he receives most that is good from 
outdoors and avoids much dust and moisture that is objectionable outside. 
This method will be found very useful in caring for “winter babies” 
DAYS TO GO OUT-OF-DOORS; INDOOR AIRING 
1 Evaporated milk is a suitable substitute. (See p. 79.) THE EXERCISE PEN 
839 
—those born during the late fall or winter months. The indoor airing 
may be given for a week or more before the infant is taken out. By 
this means the child may be gradually accustomed to a change of tem- 
perature from that of the average living-room to that out-of-doors, and 
will not be harmed when finally taken out. After an illness, further- 
more, indoor airing will afford a means of returning earlier to the daily 
outing. This indoor method of giving a child fresh air will be found 
useful with very delicate children also, who, by reason of their condition, 
may be unable to go out during the winter months for several weeks at 
a time. Few days during the winter are too cold or too stormy for the 
indoor airing. 
THE EXERCISE PEN 
In another chapter, in speaking of “colds,” and how children are 
exposed to the influences which may bring about what is known as a 
Fig. 148.—The exercise pen. 
“cold,” the custom of allowing a child to sit on the floor and play at 
all seasons of the year has been referred to as a most frequent means of 
exposure. There is always a current of air near the floor, as one readily 
discovers by resting his hand on the floor on a cold winter day; further, the 
floor of the average house is naturally the most unclean part of the dwell- 
ing. Here dust gathers and dirt from the street collects as it is brought 
in on the feet of older members of the family. On this necessarily un- 
clean floor the young child is often permitted to spend a considerable 
portion of his waking hours. It may readily be seen that countless numbers 
of bacteria may be transferred through the medium of the hands from 
the floor to the child’s mouth. Hugs and pillows, which are sometimes 
used, while cleaner than the floor, are of little assistance in preventing 
drafts. 840 
THE PRACTICE OF PEDIATRICS 
Exercise is very necessary for the child’s proper growth and develop- 
ment. He must have an opportunity and place in which to creep, walk, 
and run. In order that he may have these advantages and not be 
subjected to unfavorable influences the exercise pen (Fig. 148) has been 
devised. After being bathed, dressed, and fed the child is placed in 
the pen on a rug or quilt. Toys are given him and the door is closed. 
He cannot come in contact with the stove, he cannot roll downstairs, 
and he is in no danger from the rough play of older children. He is given 
an opportunity for active exercise without a possible chance of injury. 
Specifications: 
The pen can be made of any size, but the usual size is 4 feet square. It can be 
made of any light-weight wood, pine generally being used. The legs should be at least 
12 inches long, bringing the enclosure well off the floor. The pen should be so con- 
structed that it may readily be taken apart and put together again, iron tenon hooks 
and iron mortices being used to hold the parts together. The floor may be made of 
any thin material. One-half inch pine boards nailed together, or papier-mache sup- 
ported by narrow strips of board, may be used. The floor may be supported by strips 
of board about % by 2 inches, which are fastened to the inner sides of the end-pieces. 
Hie pen is best placed in the corner of the nursery or the living-room. Its size may be 
determined entirely by the size of the room. During warm weather in the country the 
pen may often be used out-of-doors. 
COLD SPONGING IN FEVER 
Sponging with plain water, with salt water (a teaspoonlul of salt to a 
pint of water), or with alcohol and water (1 part alcohol to 3 parts water) 
is a means of reducing high temperature, with which every physician 
should be familiar. Cool sponging at 75° to 80° F., with plain or medi- 
cated water is useful for two purposes: as a sedative and for the 
reduction of fever. In measles or scarlet fever, although the temperature 
may not be high, the itching and burning of the skin prevent sleep, and 
the patient is very uncomfortable, but often, under such conditions, 
he will fall asleep during a careful sponging. In pneumonia, in typhoid 
fever, and in the intestinal disorders of summer, nurses may well have a 
standing order to give a cool sponging for fifteen minutes at any time 
when, in their judgment, it may be indicated, not on account of the fever, 
but because of the sedative effect upon the patient. A sponging of ten 
to fifteen minutes three or four times a day with cool water (65° to 75° F.) 
will greatly help a baby, whether sick or well, to pass successfully through 
the hot period of summer. 
Sponging for fever, while possessing less antipyretic value than do 
other measures, such as a cold pack, for example, has the advantage 
that it is safe and easy of application in the hands of the most unskilled, 
and is of assistance in influencing high temperature when other means 
are not available. In order not to antagonize or frighten timid children 
it is often wise to begin with the water at 95° F., and reduce the tem- 
perature gradually by the addition of cold water or small pieces of ice. 
It is rarely necessary to go below 60° F., and usually the sponging should 
not be continued longer than thirty minutes. It is well to have an interval 
of rest—from thirty to ninety minutes—between the spongings, as too 
frequent sponging, if resisted, may exhaust the patient. Every part of 
the body should be sponged in turn, but it is not necessary to expose the 
patient, who should be covered with a flannel blanket. When the pro- the cool pack 
841 
cedure is completed, the skin should be briskly rubbed for a few minutes 
with a dry, rough towel. 
THE COOL PACK 
The cool pack, properly applied, is free from the slightest danger to 
the patient, and is the best means we possess with which to combat a 
continued high fever. The pack may be used as freely and with as much 
success in treating the exanthemata as in dealing with typhoid fever or 
pneumonia. That cool water may not safely be applied to the skin of 
a child with scarlet fever or measles is a fallacy which it is our duty to 
expose to mothers. 
The pack is prepared as follows, a rubber sheet being used to protect 
the bed-sheet: A large bath-towel, or some thick, soft, absorbent mate- 
rial, should be used. Muslin, linen, or any thin material does not answer 
so well. Slits are cut in the towel large enough for the arms to pass through, 
and the towel is folded around the body, enveloping only the trunk and 
buttocks (Fig. 149). The pack should not extend below the middle of 
the thighs. This leaves the arms and the greater part of the lower ex- 
tremities free. A hot-water bag, carefully guarded, should be placed at 
the feet and the patient covered with a blanket of medium weight. The 
towel is moistened with water at 95° F. This higher temperature is neces- 
sary at first in order not to frighten the patient, as sudden cold is apt to 
do, and also to avoid shock. In two or three minutes the towel, without 
being removed, is again moistneed with water at 90° F., later with water 
at 85° F., and still later, at 80° F. When the temperature of the water 
reaches 80° F., it should be maintained at this point for half an hour; 
then the patient’s temperature should again be taken. If at the begin- 
ning his temperature was 105° F. and now shows little or no reduction, 
the temperature of the water with which the towel is moistened should be 
reduced to 70° F., or, if necessary, even to 60° F. The child, throughout 
the treatment need not be disturbed, except to be turned from side to 
side in order that the towel may be wet with water of the desired tem- 
perature, this being one of the advantages of the pack over a tub-bath 
or sponging. The towel, or other application employed, should not be 
used for more than six hours without being replaced by a fresh one. 
For the first hour or two in a pack the temperature of the patient 
should be taken every half-hour. When the fever is reduced to 102° F. 
the pack should be removed, for, if it is continued longer, too great a re- 
duction may take place. If the fever rises again rapidly to 105° F. or 
higher it is well to keep the patient in the pack continuously. The degree 
of cold necessary, in the individual case, to keep the temperature within 
safe limits will soon be learned. 
A boy four years old with lobar pneumonia was kept in packs for seventy-two hours. 
In this case a continuous pack at 70° F. was required to keep the body temperature at 
104° F. or slightly lower. 
Another reason for frequently taking the temperature is that, early 
in the attack, we do not know how the fever will be affected by the con- 
tinued cool applications. In some children it is very readily influenced, 
and in such a case collapse might follow a very sudden reduction of the 842 
THE PRACTICE OF PEDIATRICS 
temperature. In cases readily controlled, the pack may be necessary 
for only one-half hour or an hour, at intervals of three or four hours. An 
ice-bag may with advantage be kept at the head when the child is in the 
pack. Suddenly enveloping the entire skin surface in a cold sheet at 70° F., 
as advocated by some writers, may increase the temperature and occasion 
grave symptoms of impending death, because of the sudden contraction 
Fig. 149.—The cool pack. 
of the superficial blood-vessels, which sends the blood to the viscera, 
producing congestion of the internal organs. 
BATHS 
The newborn child should be given, daily, a basin-bath with luke- 
warm, boiled water and Castile soap until the cord falls and the navel 
heals. When this has taken place, the tub-bath may be given. The 
temperature of the bath for the very young infant should not be below 
95° F. nor above 100° F. Very young infants should not be kept in 
the water more than three minutes. After the third or fourth month 
a temperature of 90° to 95° F. is best, the child being kept in the water 
about five minutes. At this age the tub-bath is best given at night, just 
before the baby is put to bed. A basin-bath may be given in the morn- 
ing. When the child is a year old and fairly vigorous, the temperature 
of the water at the beginning of the bath should be 90° F. This should 
gradually be reduced to 80° F. by the addition of cold water, the child 
being vigorously rubbed with the hand while in the water. The tem- 
perature of the room should be from 76° to 80° F. during the bath, and 
windows and doors should be closed. When removed from the tub the 
child should be dried quickly and thoroughly, the folds of the skin being 
well powdered. A sponge should never be used at any stage of the 
bathing process and should never be included in the nursery outfit. Sponges 
are never clean after they have once been used. 
Some children have a dread of the bath, and cry frantically when placed 
in the water. This is due to fear, and may usually be overcome by placing 
a sheet over the tub and lowering the child on the sheet into the water. 
The Cold Douche.—For “runabouts” from two to three years old it 
may not be wise to use water below 70° F., but during the entire twelve 
months many children over three years have a cold douche after the 843 
BATHS 
cleansing bath at the temperature at which the water runs from the 
faucet. In winter, in New York houses, this ranges from 50° to 60° F. 
In giving the cool douche the child should stand in warm water covering 
the ankles. The douche may be used in the form of a spray or shower, 
or the water may be applied by means of a sponge at the desired tem- 
perature. The head, if the shower or spray is used, should be suitably 
protected by an oilskin or rubber bathing cap. 
After the cold douche there should be a vigorous friction of the skin 
with a rough towel. If there is not a quick reaction, if the skin does not 
become warm and glowing, warmer water should be used. So also if 
there is blueness of the extremities and “goose flesh/’ water less cold should 
be used, but the douche should not be discontinued. 
In the great majority of homes the bathing of the child can be carried 
on with greater convenience immediately before bedtime. He should 
receive the warm bath and the cool douche, and then, in night-clothes, 
a warm wrapper, and suitable foot covering, should eat his supper. How- 
ever, if this time is not convenient, he may be given the evening meal at 
5.30 or 6.30, and one hour later have the bath and go to bed. 
Tub-baths for Fever.—Place the child in water at a temparature of 
95° F. and reduce to 80° or 75° F. by the addition of ice or cold water. 
The duration of the bath should not be more than ten minutes. Constant 
friction should be maintained during the entire process. 
Basin Bathing for Fever.—Add 8 ounces of alcohol to a quart of 
water at a temperature of 70° F. The child is stripped, covered with 
a flannel blanket, and the entire body sponged with this solution for 
ten or fifteen minutes. Drying the skin should not be practised. Allow 
the alcohol and water to evaporate from the body surface, as by this 
means a greater reduction in the temperature will be effected. 
Either the tub-bath or the basin-bath may be used by the mother 
in case of sudden .high fever-—104° to 105° F.—before the physician 
arrives. She should be so instructed. 
Bathing for Comfort m Hot Weather.—The basin-bath and tub- 
bath may also be used as a means of relief during very hot weather. One 
or two basin-baths a day, with a tub-bath at bedtime during this trying 
season, will give the child much relief, and help him to pass safely through 
the heat period. The very young feel the extreme heat most acutely, 
and endure it with difficulty. Nothing else will give a restless, uncom- 
fortable, heat-tormented child such a refreshing sleep as a cool tub- or 
basin-bath. 
Mustard Bath.—A mustard bath is prepared by adding a heaping 
tablespoonful of mustard to 6 gallons of warm water. A time allowance 
of five to ten minutes for the bath is all that is advisable. The special 
use of the mustard bath is in the treatment of convulsions. This measure 
will be found useful also for nervous children who sleep badly. Two or 
three minutes in the mustard water, followed by a quick rubbing immedi- 
ately before going to bed may prove all that is required to induce refresh- 
ing sleep. 
Brine Bath.—A brine bath — 4 even tablespoonfuls of salt to 1 gallon 
of water at a temperature of 95° F.—is of great service with very delicate, 
poorly nourished children. Its action is that of a tonic. If the body is 844 
THE PRACTICE OF PEDIATRICS 
thoroughly soaped and washed with plain water and then immersed in 
the brine bath, no further rubbing is necessary. Ordinarily, the child 
should be kept in the bath for five or ten minutes, constant friction being 
continued during the entire time. The brine bath is not applicable to 
children with intertrigo or eczema. 
Soda Bath.—The soda bath is of some service in cases of prickly 
heat, from which many children suffer during the summer. A table- 
spoonful of bicarbonate of soda should be added to each half gallon of 
water used. The temperature of the water should be that to which the 
child is accustomed. From two to four minutes in the water suffices. 
There should be little or no friction of the skin. It should be dried with soft 
towels. 
Bran Bath.—The bran bath also is of service in treating prickly heat. 
One cup of bran is mixed with the water in the bath-tub and the same 
method employed as for the soda bath. 
Starch Bath.—The starch bath is also useful for soothing an irritated 
skin. One-half cupful of powdered laundry starch is mixed with the water 
in the bath-tub, and the same method employed as for the soda bath. 
Hot Bath.—The child is placed from three to five minutes in water 
which has been raised to* a temperature of 105° to 110° F. Constant 
friction of the extremities is maintained during the bath. 
BATHING IN ILLNESS 
There is a pronounced objection among many to bathing children 
when ill, particularly when they are suffering from respiratory diseases 
or from the exanthemata. The functions of the skin as an organ of ex- 
cretion and elimination are most important, and it is absolutely neces- 
sary that, during illness, when the metabolic processes of the body are 
being carried on to an excessive degree, all the eliminating organs be 
kept in the best possible condition in order that they may the better do 
their work. There is no better means of stimulating the skin to a sharp 
reaction than bathing with weak salt water—a teaspoonful of salt to a 
gallon of water—at a temperature of 85° to 90° F., followed by a brisk 
rubbing. Every sick child should recive a sponge-bath at least once daily. 
It is the sudden contact of cold air with the moist skin, which occurs some- 
times in undressing a child, without the attendant reaction, that causes 
the shock, the “cold,” which is usually attributed to the bath. It is the 
temperature of the room in which the child is undressed, the careless method 
of bathing, and not the application of water, which cause the trouble. 
Even the danger of this exposure is greatly overestimated. In order to 
avoid every possible danger, however, the temperature of the room in 
which the sick or delicate child is bathed should be raised to 80° F. AVe 
have yet to know of a patient who has suffered from effects of a bath 
properly given and we know of hundreds who have suffered because of 
its omission. 
HEAT THERAPY 
Heat has long been used as a therapeutic agent. For infants and 
children it has a wide range of usefulness, both as dry heat and when 
conveyed by the use of water as a vehicle. HEAT THERAPY 
845 
Moist Heat.—Heat, conveyed by water, is used as follows: 
In colic and indigestion and as a diuretic, internally. 
In acute gastritis, as a sedative, taken by sipping. 
In conmdsions, idiopathic and uremic, by means of baths. 
In conmdsions, idiopathic and uremic, in colon flushings at 105° to 
110° F. 
In colic, in the form of a hot stupe applied to the abdomen. 
In torticollis, as a hot compress to the neck. 
In sprains, as a hot compress to the joint or muscle. 
In acute articular rheumatism, as a hot compress to the joint. 
In retention of the urine, as a hot compress applied to the lower ab- 
domen and bladder. 
In suppression of the urine (acute nephritis), in the form of a poultice 
or hot compress over the kidneys and in colon flushings, 105° to 
110° F. 
In cerebrospinal meningitis, as a hot bath or hot compress to the trunk 
and lower extremities. 
In pleurisy, as a hot compress to the painful area. 
In acute angina, as a gargle. 
In conjunctivitis, as a hot compress. 
To hasten suppuration in an abscess, as a poultice or compress. 
In retropharyngeal abscess and in peritonsillitis (quinsy), as a throat 
douche. 
In earache, as a douche or by means of a hot-water bag. 
In toothache, by means of a hot-water bag, or as hot water held in 
the mouth. 
In facial neuralgia, by means of a hot-water bag. 
In prematurity and in lowered vitality or reduced temperature after 
disease, by hot-water bags or bottles. 
Dry heat is used in the following conditions: 
In prematurity, lowered vitality, or reduced temperature after disease, 
by means of the electrotherm. 
In suppression of the urine (acute nephritis), by the electrotherm or 
by hot air. 
In myalgia, arthritis, and incomplete restoration of function after fracture, 
by the electric oven. 
In various forms of dermatitis and for the healing of gramdating burns, 
by the electric-light bath. 
Precautions.—In using heat with children caution should be exercised 
as to the degree employed. Serious burning accidents have occurred 
by the use of hot-water bottles and hot compresses. When used very 
hot the hot-water bottle should be guarded by wrapping it in flannel. 
Moist heat in the form of compresses, poultices, and stupes should always 
be tested by placing them against the face of the attendant. The 
adult hand will often bear a greater degree of heat than is safe to apply 
to the skin of an infant or young child. In using hot packs, hot-water 
bags, the electrotherm, or dry heat generated by a lamp or other device, 
a thermometer should be placed between the child’s clothing and the bed- 
clothing. A temperature of 110° F. is the highest safe to use with chil- 
dren. When water is the vehicle, the patient must be most carefully 846 
THE PRACTICE OF PEDIATRICS 
watched and the application frequently renewed because of the rapid 
evaporation. A compress or poultice must not be allowed to get cool. 
A piece of flannel or oiled silk or rubber tissue over a hot compress will 
obviate the necessity for frequent changes. 
COUNTERIRRITATION 
The counter-irritants found especially useful in pediatrics are mustard, 
capsicum, turpentine, camphor, chloroform, and iodin. 
Counterirritants are useful for two purposes—for the relief of pain 
and for effect upon internal inflammation and congestion. Without 
doubt the disease conditions in which counterirritation is of most value 
are the acute affections of the respiratory tract, such as bronchitis, bron- 
chopneumonia, and pleurisy. In acute bronchitis, when the terminal 
bronchi are involved, when there is cyanosis and rapid respiration—■ 
from 60 to 80 per minute—keeping the thorax enveloped in a mustard 
plaster, 1 part mustard to 2 of flour, until the skin is well reddened, 
will often reduce the respirations from 20 to 30 per minute, so that the 
child, previously tossing and restless, will fall asleep. Repeatedly nurses 
and mothers have asked if the counterirritation in such cases could not 
be applied more frequently because of the apparent relief experienced 
by the patient. The applications may often be made with advantage 
at intervals of from four to six hours. The counterirritant should be suffi- 
ciently strong to produce the desired redness of the skin in from five 
to ten minutes. This will usually be produced by using at first 1 part 
of mustard to 2 of flour. When the skin becomes tender from the 
repeated applications, but 1 part of mustard to 5 or 6 of the flour may 
be required. If the plaster is made too weak, it must remain long in 
contact with the skin, which thereby becomes macerated. 
Indications.—In Acute Inflammations of the Respiratory Tract.— 
When the bronchitis is of the asthmatic type, characterized by decided 
bronchial spasm associated with bronchial catarrh, the counterirritation 
furnishes not a little relief. In this condition the whole thorax should 
be enveloped. In bronchopneumonia with considerable bronchitis local 
applications of mustard over the involved areas are to be advised. The 
pain from pleuritic inflammation occurring independently of, or at the 
onset of, lobar pneumonia, or developing during bronchopneumonia, 
may be considerably relieved by counterirritation. Here also the mus- 
tard should be used only over the painful area. When the pain is severe, 
equal parts of mustard and flour may be used for the first application, 
if carefully watched, for the reason that a quick, sharp skin reaction 
should be produced. 
The mother or nurse should always be cautioned to watch the skin 
under a counterirritant so that a blister shall not be produced. In no 
condition is it necessary to blister a child’s skin. 
We have no evidence that there is any curative action beyond that of 
a sedative retarding the inflammatory process within. That a respiratory 
disease is ever aborted by these methods, as claimed by some, is, however, 
exceedingly doubtful. 
During the stage of engorgement and congestion of the bronchi, 
indicated by roughened or sonorous breathing with occasional sibilant COLD AS A THERAPEUTIC AGENT 
847 
rales, brisk counterirritation with mustard, or with camphorated oil 
and turpentine, appears frequently to hasten the progress of the case to- 
ward recovery. If the turpentine is used with the camphorated oil, the 
proportion should be 1 part of turpentine to 2 parts of the camphorated 
oil. The mixture should be well shaken before use and applied vigorously 
with the hand for ten minutes or until a distinct redness of the skin is 
produced. The mustard or the turpentine should be used in these cases 
at least three times a day. Rarely in susceptible individuals turpentine 
applications may cause albuminuria. Capsicum vaselin may be used in 
the same way and for the same purpose as the camphorated oil and 
turpentine. 
In Colic.—In severe colic a turpentine stupe will often furnish prompt 
relief, 20 drops of turpentine being mixed with 1 pint of water at 106° F. 
Into this a piece of flannel is dipped, then wrung sufficiently dry not 
to moisten the bed-clothing, and placed over the abdomen. Over the 
moist flannel is placed a dry flannel and oiled silk so as to retain the heat 
and moisture. The application may be renewed, if necessary, every 
fifteen or twenty minutes. 
In Pleurisy and Empyema.—When adhesions exist after empyema or 
pleurisy, while the pain is not acute, there is an uncomfortable drawing, 
dragging sensation in the chest, which may persist for months. This 
has been relieved in a few cases by the tincture of iodin, U. S. P., painted 
over the painful parts every third or fourth night. 
In intercostal neuralgia, not infrequently found in overworked school- 
girls, the repeated application, at intervals of three or four days, of tincture 
of iodin over the point of exit of the involved nerve will often be followed 
by complete cessation of the pain. 
Acute Articular Rheumatism.—For the pain in acute articular rheu- 
matism, chloroform liniment, U. S. P., may be applied to the joint, or, 
better, the solution of lead and opium, U. S. P., may be applied warm 
by means of old linen covered with oiled silk. 
COLD AS A THERAPEUTIC AGENT 
In the treatment of children cold is generally used in the form of 
compresses, baths, or packs, and is indicated in the following conditions: 
In tonsillitis, acute 'pharyngitis, and headache, in the form of a cold 
compress. 
In meningitis and pyrexia, by means of the ice-bag or the cool coil. 
In appendicitis, by means of the ice-bag. 
In endocarditis and pericarditis, by means of the ice-bag. 
In fever, by means of baths, cold packs, sponging, and for older chil- 
dren, by colon flushings. (Not lower than 70° F.) 
In adenitis and in threatened superficial abscess, by means of an ice- 
bag. 
In hysteria and neurotic states, as a spinal douche. 
In malnutrition of older children, as a tonic, by means of a moderate 
cool spinal douche following a warm bath. 
For further details as to the application of cold in special diseases 
the reader is referred to the discussion of the diseases in question. 848 
THE PRACTICE OF PEDIATRICS 
BLOOD TRANSFUSION AND INTRAMUSCULAR INJECTION 
Blood transfusion1 has been practised in some form since the dis- 
covery by Harvey of the circulation; and devices to accomplish the trans- 
fer of blood were employed by Folli, and des Gabets, a Benedictine monk, 
as early as the middle of the seventeenth century. Authentic accounts 
exist recording successful operations in transfusion by Richard Lower 
and by Jean Denys in the years 1666-1667. In 1667 Denys and King 
successfully transfused blood from a sheep to a man by means of two 
cannulas united by a section of carotid artery taken from a horse or ox. 
As a means of injecting blood the syringe was employed by James Blun- 
dell in 1818. Later forms of apparatus were all modifications of a direct 
connecting mechanism of some sort, such as that of Lower, or of a “con- 
ducting system” supplemented by an “impellor” or syringe. 
During the past quarter of a century the practice of transfusion which 
for many years was held in disrepute because of fatalities (many of which 
were due to antagonistic action between the blood of donor and that 
of recipient), has been revived with remarkably good results, and the 
technic has been simplified sufficiently to render the operation relatively 
free from risk in ordinary hands. 
The successful but difficult methods of Carrel and Crile have now given 
place to three methods which are in general use: (1) the Lindemann 
syringe and cannula method, together with the Unger2 modification 
which consists in the employment of a stop-cock controlling a syringe 
which transfers the blood from donor to recipient, at the same time per- 
mitting the systematic flushing of the connected cannulse with saline solu- 
tion from a second syringe which forms part of the apparatus; (2) the 
Klimpton paraffin cylinder method3 in which the total amount of blood 
to be transfused is collected in a paraffin-lined cylinder and then intro- 
duced into the vein of the recipient; (3) the citrate method, in which the 
drawn blood is mixed with a sterile 2.5 per cent, sodium citrate solution 
to prevent coagulation, and then injected by gravity into the recipient’s 
vein. The choice of method is a matter of familiarity with and perfection 
of technic, but it has been maintained that there are more post trans- 
fusion reactions with the citrate method than with the unmodified blood 
methods. 
Most of the bad results ascribed to transfusion in the past have been 
due either to incompatibility of blood, i. e., “hemolysis or agglutination 
of the red blood-cells of either donor or patient by the serum of the other,” 
or to failure to select donors free from infectious disease capable of trans- 
mission in the blood. Preliminary tests are, therefore, always essential 
to exclude the possible occurrence of hemolysis and to insure the absence 
of such types of blood infection as syphilis and malaria. 
In testing donors for the transfusion of children the simple and rapid 
method of Rous and Turner4 has proved entirely satisfactory. It con- 
sists of direct matching of drops from the two bloods, in different pro- 
1 Hooker and Satterlee in Johnson’s Operative Therapeusis, vol. i, p. 337. 
2 Jour. Amer. Med. Assoc., lxiv, p. 582. 
3 Klimpton, Jour. Amer. Med. Assoc., July 12, 1913. 
4 Rous, Peyton, and Turner, J. R., Jour. Amer. Med. Assoc., June 12, 1915, vol. 
lxiv, pp. 1980-1982. INTRAMUSCULAR MEDICATION 
849 
portions, under the microscope, without incubation in the ordinary sense 
of the term. 
The indications for transfusion in children include severe secondary 
hemorrhages from whatever cause (whether typhoid fever or tonsil- 
lectomy), severe secondary anemia, the cause of which can be controlled, 
hemorrhagic disease of the newborn, purpura, and occasional cases of 
malnutrition or infectious disease. 
In the actual application of transfusion in a child’s case the external 
jugular vein or the median basilic is selected to receive the blood and 
the amount introduced is seldom over 7 ounces. 
Repeated small transfusions seem to be more effective than a single 
large transfusion. In secondary anemias 8 to 10 c.c. of blood per pound 
of body weight has brought about marked improvement. 
The advantages of direct blood injection over transfusion are con- 
siderable; the technic, which consists only in extracting the blood from 
the vein of the donor and injecting it intramuscularly, can be carried 
out by any physician. Tests for agglutination and hemolysis are not 
required. 
The intramuscular injection of whole, freshly drawn blood in hemor- 
rhage neonatorum has an almost specific curative effect, even in doses 
of 10 to 20 c.c. The blood is best injected into the glutei and need not 
be typed for compatibility. 
Illustrative Cases.—This method has been repeatedly successful in absolutely con- 
trolling the hemorrhage in the writer’s cases. In each, 1 ounce of blood was injected— 
ounce into each buttock. 
Transfusion was used in treating a child who developed a severe purpura after 
diphtheria. There were extensive hemorrhages under the skin and uncontrollable 
bleeding from the nose and gums. Six ounces of blood was transfused by Lindemann, 
using his own method. The bleeding promptly ceased and the child recovered. There 
is no doubt that the issue would have been fatal had transfusion not been promptly 
employed. 
A boy eight years of age developed severe influenza, double otitis media, double 
mastoiditis, and sinus thrombosis of the right side, for which operations were performed 
as the occasions arose. Recovery was proceeding slowly, and after three weeks of a most 
exhausting illness lobar pneumonia developed. It seemed that recovery was now im- 
possible. The parents were advised that transfusion held out the only hope. Two 
transfusions were given by Lindemann, using his own method, with an interval of two 
days. At the first transfusion 8 ounces of blood was given; at the second, 6 ounces. 
The boy then recovered and was perfectly well two years after the illness. Beyond 
all doubt, recovery would have been impossible without the transfusions. 
Transfusion in several cases of extreme secondary anemia in infants was followed by 
complete cure (p. 440). One case showed no improvement. 
(For Transfusion in Acidosis see p. 777.) 
INTRAMUSCULAR MEDICATION 
Intramuscular injection of drugs and other substances is a common 
procedure. The sites most commonly used are in the glutei, the triceps, 
the deltoid, the rectus femoris, and the pectoralis major. The skin over 
the area is cleansed in the usual manner and the needle is inserted through 
the skin deeply into the muscle. Beside the usual medicaments thus ad- 
ministered, special reference should be made to the intramuscular injection 
of neosalvarsan by the Rosen needle which has a curved phlange at the 
hilt. This method is discussed under the treatment of syphilis (p. 749). 850 
THE PRACTICE OF PEDIATRICS 
INTRAPERITONEAL INJECTIONS 
Another route for the injection of fluids in extreme cases of dehydration 
is the intraperitoneal. By this method normal saline, 2 per cent, glucose, 
and 2 per cent, sodium bicarbonate solutions may be rapidly and safely 
injected. 
The ordinary gravity set is used, the container being placed about 
18 inches above the infant’s body. The site of injection (about 2 inches 
below the level of the umbilicus) is thoroughly cleaned with soap and 
alcohol and painted with 2 per cent, tincture of iodin. Under strict 
asepsis the needle (No. 16 or 17 intravenous) is inserted in an upward 
direction through the abdominal wall into the peritoneal cavity, and 
the flow started. 
It is essential that strict asepsis be observed and that the injected 
solution enter the peritoneal cavity at a temperature equal to that of the 
body, not less than 100° F. 
This method has distinct advantages in the facility and rapidity 
with which it may be employed. Absorption from the peritoneum is 
rapid and complete. 
The intravenous method may be employed for the injection of normal 
saline, sodium bicarbonate solution, glucose solution, sera of various 
kinds, whole or citrated blood, or drugs. The commonest sites for such 
injections are: (1) the superior longitudinal sinus, (2) the external jugular 
vein, and (3) the median basilic or cephalic veins in the cubital fossa. 
1. The Superior Longitudinal Sinus. — The 
Goldbloom1 needle (Fig. 150) has proved most 
satisfactory for use at this site. It consists of a 
beveled metal block 3 cm. in thickness, through 
which a needle 4 cm. long passes, leaving 1 cm. 
of the needle projecting. The length of the pro- 
jecting portion of the needle may be varied and 
fixed by a set-screw. The scalp over the an- 
terior fontanel is shaved, washed with green 
soap and alcohol, and painted with iodin. Under 
rigid asepsis the sterile needle is inserted in the 
midline at the apex of the posterior angle of the 
fontanel. The needle is pointed downward and 
backward at an angle of about 50 degrees until 
the sinus is entered. The obturator is removed 
from the needle and blood withdrawn or injec- 
tion made. Injected solutions should be of body 
temperature and should be made slowly, with 
careful watching of the infant’s color, pulse, and 
respiration. Upon completion, the needle should be quickly withdrawn 
and moderate pressure exerted on the site of puncture. A collodion 
dressing is applied. 
This method is of great value in dealing with small infants whose 
superficial veins may be difficult to find and to handle. It should not be 
INTRAVENOUS MEDICATION 
Fig. 150.—The Goldbloom 
needle. 
1 Amer. Jour. Dis. Child., 1918, vol. xvi, pp. 388-390. HYPODERMOCLYSIS 
851 
employed when other veins can be readily entered, or without extreme 
caution in technic. 
2. External Jugular Vein.—The skin over the sternomastoid muscle 
is cleansed and rendered aseptic in the usual manner. With muscular 
effort or crying the vein will be seen to stand out in the region of the 
sternomastoid. The needle is then inserted with one stroke through the 
skin and into the vein, keeping the line of the needle parallel with that 
of the body. 
3. Median Basilic or Cephalic Veins.—The skin over the bend of 
the elbow is cleansed in the usual fashion, a tourniquet lightly applied 
above the elbow until the veins stand out, and the needle inserted at one 
stroke through the skin and into the vein. 
When necessary the skin over the vein may be infiltrated with 1 per 
cent, novocain and a small incision 1 to 1.5 cm. in length made exposing 
the vein in the subcutaneous tissues. 
Fluids or medication injected intravenously should be given by syringe 
or by gravity from a container a short distance above the level of the 
vein. 
HYPODERMOCLYSIS 
Hypodermoclysis is one of the means employed to introduce drugs 
and fluids into the body by other than the gastro-intestinal route. This 
procedure is used chiefly after hemorrhage, in acidosis, in marasmus, and 
in active diarrhea in cases in which there has been excessive loss of bodily 
fluids. 
In acidosis a 4 per cent, chemically pure bicarbonate of soda solu- 
tion is employed, alone or with 4 per cent, of dextrose. From 4 to 6 
ounces may be used at one time, and the injection repeated in four to 
six hours. In marasmus and diarrhea a sterile normal salt solution is 
used. Netter has claimed to have had signally good results in marasmus 
in the use of sterile sea-water. The amount of solution used varies with 
the age of the child or the object in view. From 2 to 4 ounces are usually 
employed. 
In using the bicarbonate of soda after this fashion there is some danger 
of producing necrosis of the tissue at the site of the injection. This, ac- 
cording to Howland, may be obviated by sterilizing the solution by heat. 
The bicarbonate is then changed to the carbonate, and as the carbonate 
is very irritating, it must be changed back to the bicarbonate. This 
can be accomplished by passing carbon dioxid through the cold solution, 
to which a few drops of phenolphthalein have been added, until it be- 
comes colorless. 
That the danger of necrosis in using the chemically pure bicarbonate of soda in 
sterile water has been somewhat exaggerated would be suggested by the observations 
of a former associate, Dr. Mercer Blanchard, who used the 4 per cent, solution in treating 
50 infants at the New York Nursery and Child’s Hospital with but slight local irritation 
of very temporary duration. 
The solution is introduced very slowly by gravity, the container 
being placed about 2 feet above the child’s body. 852 
THE PRACTICE OF PEDIATRICS 
LAVAGE (STOMACH WASHING) 
To Seibert is due the credit of first calling attention in this country 
to the value of stomach washing. Its use was soon appreciated by ped- 
iatricians generally, and at the present time it is an indispensable therapeu- 
tic measure. In the vomiting of children, whether due to pylorospasm, 
acute gastro-enteric infection, chronic indigestion, or a subacute attack of 
chronic gastritis, it is equally valuable. The dangers of stomach washing 
may be said to be practically nil. 
A colleague a few years ago, while washing the stomach of a child two years of age, 
turned away for a moment, when suddenly the struggling child disconnected the tube 
from the glass connecting rod and swallowed the tube. Attempts at its removal through 
the bowel were unsuccessful; gastrotomy was performed, the tube removed, and the 
child recovered. This is the only accident of any kind we have ever known during 
stomach washing. 
The Operation.—For lavage the child is easiest handled when the arms 
are pinned to the sides by a towel passing around the body. He may 
rest on his back in a crib, or sit upright on the lap of the nurse or 
mother. The clean left index-finger of the physician is placed upon 
the base of the patient’s tongue. The tube, moistened with the fluid 
to be used in the washing, not with oil, is passed down over the 
base of the tongue into the esophagus. Passage of the tube into the 
larynx is practically impossible. We have washed the stomachs of many 
hundred children, and the introduction of the tube has never been at- 
tended with difficulty. When it has entered the esophagus, it should 
be passed rapidly into the stomach. At least 9 inches of the tube will 
be required to reach the lower portion of the stomach. At first the child 
will cough, retch, and become red in the face, but this need cause no 
alarm. He will soon cry and begin to breathe regularly. When the tube 
is in position the funnel should be held the length of the tube, 2| to 3 
feet, above the patient’s body; the water, which should first be boiled, 
may then be poured into the funnel. At first the water may remain 
stationary in the funnel, owing to the pressure of air in the stomach 
and the straining of the child. When the child relaxes or the air escapes, 
being forced upward through the water, the water will pass rapidly into 
the stomach. 
The apparatus described under Gavage (p. 853) is used. It should 
always be boiled before using. If much mucus is present, a 1 per 
cent, solution of boric acid or borax may be used. The amount intro- 
duced into the stomach at one time varies with the age of the child. 
For a baby of one week 1 ounce may be used; at six weeks, 2 ounces; 
at six months, from 4 to 6 ounces. It is rarely advisable to introduce 
more than 6 ounces at one time. The fluid is allowed to run into the 
stomach and is then siphoned out by lowering the funnel, the process 
being repeated until the fluid returns perfectly clear. From 1 to 2 pints 
of water may be necessary to complete the washing. 
Indications.—It is rarely necessary to wash the stomach oftener 
than twice in twenty-four hours. Ordinarily, in the acute vomiting 
cases, one washing daily for four or five days will answer. In cases of 
chronic indigestion with regurgitation the washing will be needed less 
frequently—once a day or once every second or third day. GAVAGE 
853 
The following is frequently the history of a case of chronic indiges- 
tion with vomiting: There has been for several weeks vomiting of food 
and mucus two or three times daily. The stomach has been washed, 
the child carefully dieted with a plain barley-water or a weak milk mix- 
ture, and no vomiting has occurred for perhaps twelve to forty-eight 
hours, when the regurgitation or vomiting again commences as before. 
In such a case it will soon be learned how frequently the washings should 
be repeated in order to control the vomiting. 
Illustrative Case.—A child six months old suffering from malnutrition had a history 
of persistent vomiting after each feeding. A greater part of the food taken was lost. 
What was not vomited was digested imperfectly, as was shown by the stools. The 
stomach was washed and a large quantity of thick mucus and curds removed. The 
child was given a barley-water diet. There was no vomiting for three feedings, and 
then only a small quantity of barley-water was ejected. After three days, following 
daily washings, the vomiting entirely subsided. The child was given a weak milk 
mixture, one-fifth milk and four-fifths barley-water, and no significant vomiting resulted. 
The food was carefully strengthened, and although in two weeks the vomiting had en- 
tirely ceased, the washings were continued at intervals of two or three days for a month 
until the water siphoned out was free from mucus. 
In severe cases of chronic indigestion the washings at intervals of 
two or three days may be continued with advantage for several months. 
It must be remembered that in these chronic cases of indigestion the 
patient is ill through abuse of the stomach—usually because too strong 
food has been given, or too much of a suitable food has been given at 
too frequent intervals. As important, then, as the stomach washing 
is the giving of food suited to the child’s digestive capacity. 
The field of usefulness of lavage is not entirely confined to vomiting 
cases. Children with indifferent appetite and limited food capacity, 
but without vomiting, are often greatly benefited by the treatment. 
A not infrequent story is that food is taken without relish and that coax- 
ing is necessary in order that the child shall eat. The loss of appetite is 
usually the result of improper food or faulty feeding methods. Some 
patients are absolutely indifferent to food; many refuse it altogether. 
In cases of this class a stomach washing once a day will often be followed 
by a surprising improvement in the appetite. There is no better appetizer 
for many of these pitiful looking babies. 
In not a few instances we have been surprised at the large amount 
of mucus removed from the stomach of one of these children who had shown 
no vomiting whatever. The fact teaches us that there may be, in infants, 
stomach disorders of considerable importance without vomiting or, in 
fact, without any other symptom than loss of appetite and malnutrition. 
GAVAGE 
Gavage, or forced feeding, is the introduction of nourishment into 
the stomach by means of a tube. The tubes are to be obtained at the 
instrument makers and are known as “stomach-tubes for children,” or 
the physician can make one himself at a small cost. All that is re- 
quired is a soft-rubber catheter, American No. 12, a |-inch glass tube 2 
inches long, 2 feet of {-inch plain rubber tubing, and a small glass funnel. 
An extra opening should be cut in the catheter about \ inch from the 854 
THE PRACTICE OF PEDIATRICS 
outlet. This allows a more rapid introduction of the nourishment. The 
opening can very easily be made with a small pair of curved scissors. 
The position of the child for gavage may be the same as for stomach 
washing, or the child may rest on his back. It is well to clear out 
the stomach with warm water before each feeding. In giving gavage 
to children without teeth the bare index-finger is all that is necessary 
to keep the mouth open. In handling children with teeth a dependable 
gag should be used. 
Indications.—Gavage will be found useful in three types of cases: 
In Obstinate Vomiting.—Several years ago, when the senior writer was 
resident physician at the New York Infant Asylum, a series of observa- 
tions were made on cases of persistent vomiting which could not be con- 
trolled by stomach washing or ordinary methods of treatment. It 
was found that patients who could not retain a teaspoonful of water 
administered by a spoon or a bottle would retain from | to 1 ounce 
of water given through a tube. The same child who vomited 1 teaspoon- 
ful of milk or other food would retain this amount and a great deal more 
when the food was given by the tube. This discovery led to more ex- 
tended observations. Twenty cases of persistent vomiting in all were 
treated in this way, of which 18 were relieved. (This series of observa- 
tions was the first made relating to the use of gavage or forced feeding 
in persistent vomiting.1) 
For the obstinate vomiting cases it is well to use gavage only once 
every four or six hours, with from one-third to one-half the quantity of 
food given in health. 
The tube which is to be passed into the stomach should never be oiled, 
but merely dipped into the solution that is to be used. It is then passed 
in rapidly with the funnel empty, and the nourishment is immediately 
poured into the funnel. When the food has passed into the stomach, 
the tube should be compressed and quickly withdrawn, as some of the 
liquid will be retained in the tube if it is withdrawn slowly. If this is done 
without compressing the tube, an escape of food into the larynx may 
take place during the withdrawal of the tube and cause choking, cough- 
ing, and perhaps vomiting. The food selected should consist of thin 
dextrinized gruels, or broths and gruels combined, which have proved of 
great value in some cases. 
In severe illness, such as diphtheria, pneumonia, and the grave intes- 
tinal diseases, gavage may save the life of the patient. Not infrequently 
in such cases insufficient nourishment is taken to support life. Rectal 
feeding is usually of value only for a day or two, as children soon become 
intolerant. In such circumstances gavage may be employed advantage- 
ously for several days at a time. In fact it is, in such an instance, the only 
way by which the child can be properly nourished. 
Predigested cereal foods, completely peptonized milk, and stimu- 
lants well diluted may be given. Usually these patients badly need 
water. If there is no tendency to vomiting, a large quantity of water 
may be given with the nourishment selected, so that they may receive 
as much liquid as in health. 
1 Kerley, Gavage in Persistent Vomiting in Infants, Archives of Pediatrics, Feb- 
ruary, 1891. COLON irrigation; colon flushing 
855 
In Malnutrition, Exhaustion, and Narcosis.—Gavage is also most 
useful in cases of extreme malnutrition and exhaustion, or in alcoholic 
or opium narcosis. Infants suffering from an extreme degree of malnutri- 
tion and exhaustion are often so reduced in strength that not enough 
energy remains for the taking of nourishment. In these cases gavage 
is distinctly a life-saving measure. To a child four months of age from 
4 to 6 ounces of a suitable mixture may be given every two hours. 
Before the next feeding it is well to introduce a few ounces of water 
and withdraw it to see if the food has been properly digested. By 
this means of feeding there will be noticed, if the vitality is not at too 
low an ebb at the commencement, a daily increase in strength and vigor, 
which proves that the powers of assimilation persist after the desire 
for food or the child’s ability to swallow it has been lost. This proves 
that we must never regard such a case as hopeless so long as the child 
is breathing. Time and again, after a few days’ feeding in this way, 
the child will take the food from the bottle or spoon. Breast milk, if it 
can be obtained, may be given by gavage as successfully as can predigested 
cow’s milk. The malted foods on the market have also been used tem- 
porarily with advantage, for, while deficient in nutritive value for the 
well, they afford sufficient nourishment for temporary use by the very 
ill, and are easy of digestion. 
Illustrative Case.—A patient three months old was almost moribund as the result 
of extreme malnutrition. The temperature ranged from 94° to 96° F. for several 
days. No food could be taken. A wet-nurse was secured, but the child would not 
nurse. He was pale, apathetic, and too weak to cry. The wet-nurse’s milk was drawn 
from the breast and spoon feeding attempted, but swallowing was impossible; If ounces 
of breast milk were fed by gavage, but this proved too strong, and the child promptly 
vomited. The milk was then diluted one-haff with weak barley water. At first 1 ounce 
was given at a feeding; then this was gradually increased to 2 ounces, all the feedings 
being retained and digested. In a week the child was able to nurse, and made a com- 
plete recovery, weighing, when seven months of age, 14 pounds. At the time gavage 
was commenced the weight was but 5 pounds. 
COLON IRRIGATION; COLON FLUSHING 
Colon irrigation was brought prominently into use several years ago 
as a remedy in the summer intestinal disorders of young children. While 
unquestionably its usefulness in this respect has been overestimated 
and the irrigation overdone, in selected cases it is of great service. Be- 
cause a child has summer diarrhea, colitis, or any disorder of the intes- 
tine, it does not follow that irrigation is indicated or that he will be bene- 
fited thereby. A child who is having a passage from the bowels every 
half-hour or hour is not a fit subject for irrigation. The colon is kept 
empty by the active peristalsis, and the washing will remove nothing 
more than a few shreds of mucus. The cases benefited by irrigation are 
those in which peristalsis is not particularly active. When a child is 
running a temperature of 102° F. and over, with five or six green mucous 
passages daily, one or two colon irrigations a day will unquestionably be 
of service in removing the offending material from the intestine. 
Every year we see cases of intestinal infection, particularly those 
of a very acute type, in which there are high fever, intense prostration, 
and infrequent bowel action. Occasionally we see a case of this sort in 
which there is no movement whatever without assistance. In such cases 856 
THE PRACTICE OF PEDIATRICS 
colon irrigation is of inestimable value, and may be used with advantage 
as often as once in six or eight hours. The washing, even if properly con- 
ducted, is apt to be strongly objected to by the patient and should be 
completed as soon as possible. Too frequent irrigation, with strong med- 
icated solutions, may keep up the mucous discharge indefinitely. In a 
few cases the resistance with straining is so marked and so continuous 
that irrigation is impossible. These cases are usually those of children 
who, on account of the excessive peristalsis, do not require irrigation. 
In conducting the irrigation normal salt solution at 95° F. is ordinarily 
used, and a quart usually suffices. If there is a great deal of mucus and 
blood, a 1 per cent, tannic acid solution is better. The irrigation should 
be continued until the solution returns clear. The temperature of the 
solution may be varied with advantage, depending upon the nature of 
the case; thus, in cases with subnormal temperature and intense pros- 
tration, cases of the so-called “algid” type, the solution at 110° F. will 
act as a decided stimulant. It raises the body temperature and improves 
the pulse and the general condition of the patient. In cases with high 
fever—105° to 106° F.—a cold solution answers better. A temperature 
as low as 70° F. has been repeatedly employed, and it has often been 
found that an irrigation with 4 pints of water at 70° F. will reduce the 
body temperature 3 degrees. 
For irrigation a soft-rubber catheter, No. 18 American, is best, for 
the reason that its walls are stiff and the tube does not easily bend upon 
itself in the manner of an ordinary catheter. Should this occur, the 
water may escape an inch or two within the rectum, and obviously be of 
no service. When the tube, well lubricated, has been introduced for 9 
inches, the tip will have passed into the descending colon, and further 
introduction will be of no advantage. When the end of the tube is in the 
colon gentle palpation over the left side of the abdomen will enable one 
readily to locate the tip. The tube is attached to an ordinary fountain- 
syringe by passing the distal end over the smallest rectal tip, which is 
a part of the outfit of every fountain-syringe. The bag should be held 
not over 3 feet above the child’s body. When the water is allowed to 
run, the buttocks should be pressed together to encourage retention 
sufficient to insure flushing of the entire large intestine. If this can be 
done, the irrigation will be most efficient. 
In this connection should be mentioned a particularly beneficial effect 
of irrigation, the absorption of a portion of the salt solution by the intes- 
tines. Not a few of the intestinal cases show a very limited food capacity. 
As a result of the vomiting and very frequent liquid stools the body is 
thoroughly drained of fluids. In such cases, after the washing is completed, 
we endeavor to have the child retain as much as possible of the normal salt 
solution. As an aid to this the child should be placed on his left side 
with the buttocks elevated and the tube introduced well up into the de- 
scending colon. The buttocks should be pressed together so as to assist 
in retaining the water after it has passed into the bowel. When a half 
pint or a pint has passed in, the tube should quickly be withdrawn and 
the child kept for half an hour in a recumbent position with the buttocks 
elevated. The salt solution will be best retained when it is used warm, 
at a temperature of from 100° to 105° F. VACCINATION 
857 
Colon flushing consists in passing into the descending colon a con- 
siderable quantity of fluid, such as normal salt solution or bicarbonate of 
soda solution, ounce to 1 pint. 
The measure is used with much benefit in selected cases in which 
but little fluid is taken by the natural channel. The possibilities of the 
large intestine for absorbing fluids when they are urgently needed by the 
organism are surprising. 
Illustrative Cases.—A boy with cyclic vomiting who had retained absolutely nothing 
given by mouth for three days retained 1 pint at the first colon flushing, \ pint more 
after six hours, and another -j pint six hours later. The flushings were begun on the 
third day of the attack. Although the prostration was extreme, the prompt improve- 
ment in the general condition of this patient was most gratifying. After the first 
injection the pulse improved, the apathy disappeared, and the child began to ask ques- 
tions and showed interest in his surroundings. 
A boy nine years of age, ill with scarlet fever, who could take very little fluid, was 
able to retain 8 ounces of a salt solution given at eight-hour intervals for three days. 
A child six months of age had retained absolutely nothing in the stomach for six 
days because of an intussusception. On the sixth day the respiration was superficial 
and slow. He was cold and practically pulseless. The second heart sound could be 
heard but faintly with the stethoscope. The intussusception very unexpectedly was 
reduced by water pressure (p. 280). Hot salt-water flushings were at once begun; 
the patient retained 12 ounces, given at a temperature of 110° F., and in a few minutes 
exhibited very perceptible improvement. With repeated flushings at six-hour inter- 
vals the child continued to improve and made a perfect recovery. 
Severe toxic cases of diphtheria and scarlet fever, in which but little 
fluid is taken and in which the toxicity of the blood is extreme, as shown 
by the stupor and delirium, are often much improved by the free use of 
colon flushing, which supplies the water which the child needs, but which 
cannot be given by mouth, or, if given, may not be retained. 
Method.—We usually order the salt solution given in quantities of 
from | to 1 pint, depending upon the age of the child, at intervals of 
from six to eight hours, never at a lower temperature than 100° F. 
The apparatus required is a small rectal tube attached to a fountain- 
syringe. 
The flushing is best given with the patient resting on the left side, 
with the buttocks elevated on a pillow, the tube, well oiled, being intro- 
duced at least 9 inches into the bowel. The solution at 105° to 110° F. 
is allowed to pass into the bowel, and the tube is then quickly withdrawn. 
To facilitate the retention of the fluid the patient should remain on his 
side for one-half hour. 
VACCINATION 
Every infant in fair health should be vaccinated. The vaccination 
should be done as soon as the child is thriving on a rational diet. The 
younger the child at the time of vaccination, the less the constitutional 
disturbance. In well infants vaccination should never be delayed beyond 
the fifth month. 
The site selected for the vaccination in boys is usually on the left 
arm, at about the point of insertion of the deltoid, and in girls on the 
outer aspect of the calf of the leg. It has been found, however, that 
it is a matter of much more convenience to the mother in dressing and 
handling the child if the leg is selected in both sexes. The dressing is 858 
THE PRACTICE OF PEDIATRICS 
more easily applied to the wound and can more readily be kept in place 
on the leg. Further, in the manipulation necessary in dressing and un- 
dressing, much less discomfort is occasioned when the sore is on the leg. 
The Method.—Before scarification of the skin the site selected should 
be well scrubbed with common soap and water, dried, and then washed 
with alcohol. The area of scarification should not be over \ inch in 
diameter, and should be sufficient to produce only a light flow of serum. 
A deep scarification, producing a free flow of blood, is very apt to be un- 
successful. The best scarifier is an ordinary sewing needle, which should 
be sterilized by placing the point for a few seconds in an alcohol flame. 
The virus which is furnished in hermetically sealed capillary glass tubes 
is the safest to use. The drop of virus is to be deposited on the abraded 
surface and rubbed well into the wound, using the side of the needle for 
this purpose. When the wound is thoroughly dried, a protective dressing 
should be applied. The safest and most convenient is a sterile gauze 
bandage, which is wrapped several times around the arm or leg and secured 
with a safety-pin. On account of the shape and position of the parts the 
bandage is very apt to become displaced downward. In order to prevent 
this a strip of adhesive plaster 1 inch wide and 5 or 6 inches long may 
be placed over the bandage at right angles to it; the middle portion of 
the plaster readily adheres to the bandage, and the two ends, at least 2 
inches long, are anchored to the skin. 
The After-treatment.—The mother should be instructed to report 
seven days after the vaccination. On the seventh day the dressing may 
be removed, and if the vaccination is successful, the characteristic pearl- 
like vesicle will be present. If, on account of accident or rubbing of the 
parts by the patient, the vesicle is broken, the non-adhering gauze should 
be carefully cut away around the sore, allowing that which adheres to 
remain. Under no conditions should the wound be opened. Again, 
a gauze dressing should be applied and kept in position by adhesive 
strips. At the end of the exudative stage, usually about five or six days, 
the dressing should again be changed, either by the mother or the phys- 
ician, and renewed until the crust falls, the third to the fourth week 
after the vaccination. 
If there is no sign of the vesicle in ten or twelve days, the vaccina- 
tion, if primary, should be repeated. Revaccination should be prac- 
tised at least once in five years and at more frequent intervals during 
epidemics of smallpox. 
Constitutional Disturbance.—A certain degree of constitutional 
disturbance is present in every case in which the vaccination is success- 
ful. After the first month, however, the younger the child, the less the 
constitutional disturbance. Children vaccinated during the second 
or third month suffer practically no inconvenience. There is a rise in 
temperature—from 100° to 101° F.—for a day or two, and when the 
process is at its height, perhaps a slight degree of restlessness. Repeatedly 
it is observed that children, vaccinated at this age, pass through the 
various stages without manifesting the slightest discomfort. In older 
children the severity of the constitutional symptoms appears to increase 
with the age. Thus, a child in the second or third year may have fever, 
102° to 104° F., loss of appetite, coated tongue, and moderate prostra- VACCINE THERAPY 
859 
tion. Very active symptoms rarely last longer than three days unless 
there is considerable accompanying cellulitis. 
Complications.—If vaccination is properly performed the dangers 
attending it are practically nil. That death and serious results have 
followed vaccination is no argument against its use, but a grave reflec- 
tion on the manner in which, as a rule, it is performed. The scarifica- 
tion of bacteria-laden skin, producing at the outset an open wound which 
is indifferently or not at all protected from further infection, is very apt 
to produce complications of a troublesome and often serious nature. 
Erysipelas, extensive cellulitis, and sloughing of the parts as the result 
of careless vaccination are not infrequently seen. In 2 cases we have 
seen reinoculation as the result of scratching the sore, the virus being 
transferred in one case to the upper lip and in the other to the upper 
eyelid. 
Vaccination Shield.—There is not a vaccination shield on the market, 
with which we are familiar, that is safe for use. Some cause a maceration 
of the wound, others allow a free entrance of bacteria, while still others 
prevent a free superficial circulation of the blood and increase the chance 
of ulceration. Moreover, the shields are very apt to become displaced, 
causing a rupture of the vesicle, with resulting infection. 
Local Applications.—Active treatment, except for relief of the im- 
mediate constitutional symptoms, is rarely required. Even when there 
is an active cellulitis we have found it advisable not to attempt local 
applications, such as lotions or compresses. All ointments have a ten- 
dency to dissolve and loosen the crust, producing an open wound. When, 
on account of suppuration, the crust falls, leaving a deep ulcer formed 
by granulation tissue, active local treatment will be required. Such 
ulcers are often seen in out-patient work. A wet dressing of a saturated 
solution of boric acid has answered well in these cases. If the wet dress- 
ing cannot be kept properly applied, a 10 per cent, ointment of boric 
acid, applied twice a day, will be found of considerable service in hasten- 
ing the closure of the wound. The ointment should be smeared freely 
on gauze or clean linen and held in position by a properly applied ban- 
dage. In young children the ulcers are often most obstinate. In a few 
instances we have known them to continue from eight to ten weeks. 
In cases in which the healing has been particularly slow, the familiar 
dressing of balsam of Peru (5 per cent.) in castor oil, applied twice daily 
on a pad of several thicknesses of gauze and covered with oiled silk, has 
appeared to hasten the granulation. Unhealthy granulations may have 
to be cureted or treated with silver nitrate before the dressing is applied. 
VACCINE THERAPY 
Fundamental Principles.—Vaccine therapy for prevention or cure 
of infection has for its object the production of an active immunity to 
the specific bacteria concerned, while serum therapy produces a passive 
immunity only. 
Immunity, which is resistance or lack of susceptibility to a given 
disease or micro-organism, may be natural or acquired. Artificial or 
acquired immunity may be the result of an attack of the disease itself 860 
THE PRACTICE OF PEDIATRICS 
or may follow inoculation with living cultures of micro-organisms in 
sublethal doses or in an attenuated state, with dead cultures, or with 
those products of the growth and metabolism of bacteria known as toxins. 
Immunity so acquired is active or direct, comparatively slow in ap- 
pearance, and of comparatively long, though variable, duration. It is 
brought about by the development in the blood-serum of substances 
antagonistic to the vital activity of the bacteria or to the toxins. Such 
substances are known as antibodies. The serum of an animal which 
has been actively immunized and which is rich in antibodies may be 
inoculated into another animal for the purpose of combating infection. 
The immunity thus produced in the second animal is indirect or passive 
and of comparatively short duration. 
The antibodies are of several kinds: agglutinins, opsonins, bacteri- 
cidins, and lysins. They are formed by the tissue cells under the stimu- 
lus of the infecting bacteria, at first locally, then generally, and are pres- 
ent in the serum and to a lesser extent in the other body fluids. They 
manifest themselves in certain definite ways, demonstrable and measur- 
able by laboratory methods: agglutination reaction, opsonic index, bac- 
tericidal tests, and the complement deviation test. Clinically, their 
increase is accompanied by amelioration of the symptoms of infection. 
The aim of both vaccine and serum therapy, then, is to aid the production 
of antibodies in order to effect a destruction of the invading bacteria and 
the neutralization of their toxins. Metchnikoff claimed that the destruc- 
tion of micro-organisms is brought about by their ingestion by phagocytes, 
especially polymorphonuclear leukocytes. Denys and Leclef proved 
that there is a substance in the blood-serum which prepares the bacteria 
for phagocytosis. This sensitizing substance was named “opsonin” by 
Wright and Douglas, who elaborated methods for its study in the lab- 
oratory and for its practical application to the treatment of infections by 
means of vaccines made of suspensions of dead bacteria. 
It has been found in general that the opsonins are below normal at 
the onset of an infection and during the height of the acute stage, and 
that, as improvement occurs, the amount of opsonin in the blood-serum 
increases. The administration of dead cultures of the bacteria causing 
the infection stimulates the production of opsonins. 
Determination of Opsonic Index.—In order to estimate the opsonic 
index it is necessary to prepare serum from the patient, serum from a 
normal person, leukocytes from a normal person, and a culture of the 
bacteria from the patient’s lesion. 
Serum is readily obtained by pricking the finger and catching the 
blood in a small curved glass tube, as recommended by Wright. The 
blood is allowed to clot in the tube, and the resulting clear serum is re- 
moved by means of a capillary pipet, which is then sealed at its narrow 
end. 
Leukocytes are obtained from a small quantity (about 10 drops) of 
normal blood caught in a tube containing 10 c.c. of 1.5 per cent, sodium 
citrate in normal salt solution. The mixture is centrifuged and the fluid 
carefully drawn off and replaced by normal salt solution, in order to 
wash the blood-cells free from serum. After centrifuging again the super- 
natant fluid is removed, and the upper layer of white blood-cells taken 861 
VACCINE THERAPY 
up into a capillary pipet, the lower end of which is then sealed in the 
flame. This is known as the “leukocytic cream.” 
The suspension of bacteria is made in normal salt solution from an 
agar-culture not over twenty-four hours old. It should not be too thick, 
and should be free from clumps, which may be recovered by shaking or 
by manipulating with a capillary pipet. 
Capillary pipets of the same caliber having been selected, equal quan- 
tities of the patient’s serum, leukocytes, and bacteria are drawn up and 
thoroughly mixed in one, while normal serum, leukocytes, and bacteria 
are drawn into another. A control, using normal salt solution instead 
of serum, should also be made. The pipets are sealed below and incu- 
bated for fifteen minutes at 37° C. The mixture is then expelled on a 
glass slide, thoroughly mixed again, and spread on clean slides. After 
fixing in methyl-alcohol and staining in methylene-blue (Manson stain 
is excellent for the purpose), the slides are placed under the microscope 
and the number of bacteria contained within 50 leukocytes is counted. 
This gives the phagocytic index. The quotient of the patient’s and the 
normal phagocytic indices equals the opsonic index of the patient. More 
satisfactory results have been obtained by making the tests with diluted 
serum, according to Neufeld. The opsonins in the normal blood-serum 
used for control are found to disappear in a lower dilution than do the 
immune opsonins in the blood of the patient who has been immunized 
by the disease or by the administration of vaccines. Detections from 
1 :10,000 may be made. 
As a matter of fact, the test for the opsonic index has been found to 
be too uncertain to make it practical and worth while to follow system- 
atically, the clinical symptoms being sufficient indication of the value of 
the vaccines. 
Preparation of Vaccine.—A vaccine is made by suspending agar- 
cultures less than twenty-four hours old in normal salt solution. In 
order to estimate the dose even approximately the bacterial suspen- 
sion is standardized by counting the bacteria in relation to red blood- 
cells. The method is as follows: Equal quantities of bacterial suspen- 
sion and of blood from a normal person are drawn into a capillary pipet, 
mixed, and thinly spread on a slide. The red cells and the bacteria are 
then counted in a number of fields. Since the normal blood contains 
5,000,000 red cells to the cubic millimeter, the number of bacteria in pro- 
portion to the red cells can be estimated per cubic millimeter, and the 
actual count per cubic centimeter readily calculated. The tube contain- 
ing the bacterial suspension is sealed and heated for one hour at 58° C. 
Control cultures are then made to test the sterility of the undiluted sus- 
pension. This having been properly accomplished, the vaccine is diluted 
in bottles or ampules with sterile normal salt solution, according to the 
dose desired per cubic centimeter, and properly sealed. Thus, if the actual 
count showed that 5,000,000,000 bacteria were present in a cubic centi- 
meter, diluting the vaccine fifty times by adding 1 c.c. of undiluted vaccine 
to 49 c.c. of sterile salt solution would make a vaccine containing 100,000,- 
000 bacteria in 1 c.c. Injections of 1 c.c. or less are made into the shoulder, 
back, or thigh under strictest aseptic precautions. 
Staphylococcus.—In staphylococcus infections vaccine treatment 862 
THE PRACTICE OF PEDIATRICS 
has given good results. While it is always wise to use a vaccine prepared 
from the patient’s own strain of staphylococcus, it is not absolutely 
essential that this be done. Any stock vaccine which has given good 
results in a similar case may be used, provided that it has been proved 
by a culture made from the pus of the patient’s lesion that staphylococci 
are the infecting agents. It is essential also to know whether the Staphy- 
lococcus aureus or albus be present in order that the appropriate vaccine 
may be employed. The dose in infants under two years should vary from 
50,000,000 to 100,000,000 of dead cocci. The inoculations are repeated 
on the second to the seventh day if necessary. Too rapid or too large 
dosage must be avoided, because there is danger of exhausting the re- 
sponding power of the human organism by overstimulation. The tem- 
perature should be taken before the vaccine is injected, and every three 
hours during the following twenty-four. 
Furunculosis in young infants has proved readily amenable to treat- 
ment by staphylococcus vaccines. Improvement is shown by a much 
more rapid healing than usual of the furuncles already incised, and by 
the non-appearance of new ones. After the second inoculation improve- 
ment is the rule. The amount of pus is lessened and fewer dressings 
are required than in cases otherwise treated. No bad effects from the 
injections have been noted. 
In treating otitis media of staphylococcus origin vaccines are reported, 
evidently by enthusiasts, as having proved of value, also in treating sup- 
puration in the antrum, styes, and osteomyelitis. After operation the vaccine 
has been thought of real service in aiding the more rapid disappearance 
of pus from the pleural cavity and in hastening the healing of the wound. 
Obstinate cases of asthma unbenefited by protein therapy have also 
been reported as favorably affected by staphylococcus vaccine. 
Any local suppuration due to staphylococci is occasionally benefited 
by vaccine administration. In general septicemia the results have been 
encouraging (Wright). Fifty million dead bacilli are to be given at the 
first injection; this is followed in five days by 100,000,000 and again 
in five days by 100,000,000. The subsequent administration is depen- 
dent upon the requirements of the case. 
Streptococcus.—-In all cases of streptococcus inflammations the results 
of vaccine therapy have been far less brilliant than in staphylococcus 
cases, but still encouraging enough to warrant their further use. It seems 
to be essential, also, far more than in the staphylococcus cases, that the 
vaccine be prepared from the strain of streptococcus infecting the patient. 
The dose is about 2,000,000 to 3,500,000 in babies under one year of age, 
5,000,000 to 7,000,000 between one and two years, 10,000,000 to 30,000,- 
000 in older children. 
In acute infections streptococcus vaccines are generally contraindi- 
cated because the antibody production of the body is already stimulated 
to the maximum and the addition of bacterial toxin may result in harm. 
Erysipelas.—According to our observation the results of vaccine 
therapy in this disease have been insignificant. 
Scarlet Fever.—In scarlet fever the opsonic index to streptococci 
has been studied by Tunnicliff, who found that it is below the normal 
at the onset of the disease, but rises when the acute symptoms subside. VACCINE THERAPY 
863 
As local streptococcus complications appear the index falls once more. 
Favorable results following the injections of dead streptococci in cases 
of scarlet fever have not been reported. 
On the other hand, this treatment of streptococcus inflammations— 
like subacute or chronic joint affections—has given encouraging results. 
Typhoid Bacillus.—Inoculations of dead typhoid bacilli as a pro- 
phylactic measure against typhoid fever have been extensively em- 
ployed in armies. Relatively early Russell was able to show that the 
incidence of disease was 6 to 15 times as high among the non-inoculated 
as among the inoculated soldiers. Not only are the numbers of cases far 
less numerous among those who have been vaccinated, but the clinical 
course is much less severe and much shorter, while complications are fewer. 
In view of these results prophylactic inoculation of children as well 
as of adults is to be recommended during epidemics of typhoid fever 
or before entering a typhoid district. Immunization is accomplished in 
three vaccinations, the dose of which, in children, may be 100,000,000 
to 500,000,000 dead bacilli. 
By lowering the incidence of typhoid fever cases antityphoid vac- 
cination prevents the development of carriers of typhoid bacilli, and 
thus is fully justified. 
Gonococcus.—In vulvovaginitis due to the gonococcus in infants 
under one year of age, the injections of dead gonococci have had no effect 
in shortening the course of the disease, in lessening the amount of dis- 
charge, nor in causing the cocci to disappear from the vagina. In older 
children Hamilton and Cooke found that the effect of the dead gono- 
coccus injections is more marked in chronic than in acute cases, the 
disease being very decidedly shortened in its course. The later stages 
of the acute cases were also shortened, while no result was noted in the 
first weeks of the attack. Hamilton and Cooke observed no advantage 
from the use of a vaccine made from the patient’s own organism. The 
initial dose of 5,000,000 was gradually increased to 40,000,000 or 50,000,000, 
according to the needs of the case. Injections at eight- or nine-day inter- 
vals proved best. (For personal observations see p. 520.) 
Meningococcus.—In cerebrospinal meningitis due to the meningo- 
coccus of Weichselbaum vaccine therapy has been tried, but it has be- 
come superfluous in view of the brilliant results obtained by means of 
the antimeningococcus serum of Flexner and Jobling. 
Bacillus Coli Communis.—Inoculations of dead colon bacilli in doses 
of 10,000,000 to 50,000,000 are reported to have given excellent results 
in cases of cystitis and pyelitis- due to that micro-organism. The symp- 
toms are said to subside rapidly, and the bacilli to disappear from the 
urine in a comparatively short time. 
In a considerable trial of this method we have had no definite success. 
Tubercle Bacillus.—Local tuberculous lesions have been treated by 
injections of tuberculin in very small doses, with good effect. This is 
true of chronic local tuberculosis without constitutional symptoms, 
especially in bone, joint, gland, skin, and eye affections. In pulmonary 
phthisis of a chronic type, running a nearly apyretic course, tuberculin 
is also of value. In all acute tuberculous lesions with marked fever and 
general symptoms tuberculin therapy has proved useless, and may be 864 
THE PRACTICE OF PEDIATRICS 
attended by grave danger. The dose of crude tuberculin,1 administered 
for purposes of immunization in a chronic tuberculous lesion, should 
be very small, 1/5000 milligram, gradually increased to 1/2000, 1/1000, 
or more. The inoculations should be repeated not oftener than once in 
ten days, at first, and the temperature carefully measured every two 
hours. If a rise occurs, the dose has been too large, and must be reduced 
at the next injection. In selected cases of bone and joint disease and 
also in adenitis good results have followed six or eight months of con- 
tinued treatment, the dose being gradually increased in amount and 
the intervals shortened to three days. 
Bacillus Pertussis.—The evidence as to the value of injections of vaccine 
prepared from the Bordet-Gengou bacillus of whooping-cough is still con- 
flicting. This subject has been discussed on p. 679. 
Pneumococcus.—There is considerable evidence to warrant the use 
of injections of pneumococcus vaccine for increasing resistance prophyl- 
actically against pneumonia. For curative action the serum or antibody 
solution is to be selected. (See p. 367.) 
Cold Vaccines.—“Shot-gun” vaccines prepared from mixed strains of 
various organisms, including Streptococcus hemolyticus, Streptococcus 
viridans, staphylococci, Microccus catarrhalis, Bacillus influenzae, and the 
different types of pneumococcus are gaining popularity in the preventive 
treatment for colds. At present, however, there is little to warrant the 
employment of this measure. We have given such treatment in a few 
instances upon request, and have had favorable reports from the patients, 
but have obtained no evidence of the actual effectiveness of cold vaccines 
and cannot recommend their promiscuous use. 
SERUM THERAPY 
In most forms of serum therapy an attempt is made to confer passive 
immunity by the introduction into the body of an infected individual 
of serum from the blood of another who has a natural or acquired immunity 
to the existing infection. 
Serum therapy is of particular value in the treatment of diphtheria, 
meningococcus meningitis, tetanus, and pneumonia caused by Pneumo- 
coccus Type I. In scarlet fever, poliomyelitis, and measles good results 
have been obtained either in efforts at prevention or cure, by the use 
of the serum of convalescent individuals with recently acquired immunity. 
The details of application of the method are considered in the respective 
chapters dealing with the diseases in which it is employed. 
NON-SPECIFIC PROTEIN THERAPY 
This form of treatment, under other names, has been employed in 
one form or another for many years, but only recently has received the 
consideration which is its due. An ancient example of its efficacy prob- 
ably exists in the traditional cure of obstinate rheumatism by bee stings. 
The non-specific reaction may be induced by numerous substances the 
action of each of which, when injected into the body, is to alter its resist- 
ance against inflammation or toxemia. In many instances this response 
1 Koch’s old tuberculin, as prepared by the New York City Board of Health. NON-SPECIFIC PROTEIN THERAPY 
865 
is at first made manifest by untoward symptoms such as increased tem- 
perature (with perhaps chill), a sudden change in the leukocyte count, 
and increasing malaise, the reaction being anaphylactic. In a second 
phase, however, leukocytosis, antibody release, and increased resistance 
on the part of the organism are brought into play and an abortive cure 
may be attained. 
The non-specific reaction accounts for much of the benefit ascribed to 
the use of various non-specific vaccines and to the cures attributed to 
autoserum injections, horse-serum injections, and injections of whole 
blood. 
Treatment of this form undoubtedly has a limited field of usefulness, 
but is variable in its results and at times may do much harm. The ulti- 
mate range of applicability of this method is problematic. XXV* DRUGS AND DRUG DOSAGE 
UNPALATABLE AND NAUSEATING DRUGS 
It is impossible to mention in detail all the drugs which might be 
included under this heading. Only those will be referred to which we are 
obliged to use almost daily in our work—drugs which are either unpleasant 
to the taste or which may be badly borne by the stomach, or drugs com- 
bining both these disadvantages. How to administer certain drugs so 
that their use may be continued and yet not interfere with the digestive 
function is a question which deeply concerns those who may have children 
for their patients. The element of taste is most important to a child; 
therefore, when possible, drugs disagreeable to the taste should be given 
to children in tablet or pill form or in capsule. The continued use of a 
drug often depends upon its being made palatable. As a general rule, 
when pills, tablets, or capsules are given, one-half glass of water should 
be taken at the same time in order to diminish any possible irritant 
effects upon the mucous membrane of the stomach. 
Salicylate of soda is a drug disagreeable in taste and very liable to 
destroy the appetite and interfere with digestion. In acute rheumatism 
its use is invaluable, and we are obliged frequently to give it in large 
doses. It is best given after meals with one-half glass of milk. Fairly 
large doses at this time, well diluted, are better than more frequent 
smaller doses. This drug usually is better borne if given in solution 
with peppermint-water or with simple elixir diluted 50 per cent, with 
water; but the taste when thus given is only partially disguised, and 
being still very objectionable to many, may be prevented by the use of 
a capsule if the patient is old enough, care being taken to give a considerable 
amount of water or milk with each capsule. 
Iodid of Potash.—This drug is indispensable and for it no other can 
be substituted. It is best given in solution. It is most disagreeable 
in taste and directly irritant to the mucous membrane of the stomach. 
Like salicylate of soda, it should be given after meals with one-half to 
one glass of water or milk. It is best given plain, as the saturated solution, 
which may be dropped into the milk. 
Bichlorid of mercury is usually given in such small doses that its irri- 
tant properties are but little felt. It is best prescribed in tablet form, 
dissolved in two teaspoonfuls of water and followed by a swallow of 
water. When possible, it should be given after feeding. 
Alcohol is another drug which should be given well diluted, regard- 
less of the form in which it is administered. It is best given with or 
after food, but should always be given diluted with at least 6 parts of 
water, if whisky or brandy is used. 
Ipecac and Tartar Emetic, when employed as expectorants, are best 
given with sugar of milk in powder or tablet form. They should never 
be given on an empty stomach. Two or three teaspoonfuls of water 
should precede their administration when they are not given within a 
866 ALCOHOL 
867 
reasonable time after feeding. In many children, when given without 
this precaution even in the usual doses, these drugs often decrease the 
appetite and the digestive capacity. 
The Ammonium Salts.—Carbonate of ammonia must always be given 
in solution and should always be well diluted with water. Muriate of 
ammonia may be used in tablet or powder form. Water or milk should 
precede the administration of either. One part of simple elixir with 2 
parts of water makes an agreeable combination. 
Oils used for nutritive purposes should invariably be given after 
meals. Plain cod-liver oil or any of the preparations containing it should 
never be given on an empty stomach. 
Castor oil is best given when the stomach is empty. A much more 
prompt and satisfactory cathartic effect is thus produced. The oil 
may be given in soda-water or coffee, with orange juice, or in pepper- 
mint-water. Older children sometimes take oil better plain, sandwiched 
between the two halves of a peppermint cream, first the candy, then 
the oil, followed by the remainder of the candy. If castor oil is vom- 
ited, it may be repeated in a few minutes, and often will then be 
retained. 
Creosote is most difficult of administration to many children. It 
is customary to prescribe the carbonate, which is ordered to be dropped 
into 1 or 2 teaspoonfuls of wine after meals. Creosote may also be given 
in soft capsules or in an emulsion. 
Quinin should be given in solution or in capsule. Quinin pills as 
they are sometimes made, with an insoluble coating, pass unchanged 
through the entire intestinal canal. For purposes of solution a most 
satisfactory menstruum is a preparation of yerba santa, known to the 
trade as Yerbazin (Lilly). Coca-quinin (Lilly) is another palatable 
preparation. Of the salts the bisulphate should always be prescribed for 
children, for the reason that it may be given in complete solution without 
the addition of acid. 
Strychnin, on account of its taste, is often strenuously objected to, 
and is therefore better given in tablet triturate form. If the tablet 
cannot be swallowed, it may be broken into small pieces (not pow- 
dered) and mixed with a teaspoonful of orange pulp or in a thick cereal 
jelly. 
Digitalis, in the form of the tincture or the infusion, should never be 
given when the stomach is empty, but should be administered after 
meals or the drinking of water or milk. There are few drugs that will so 
completely destroy a child’s desire for food as the digitalis preparations 
when put into an empty stomach. 
Tincture of Muriate of Iron.—This should be given after meals, well 
diluted, in at least one-half glass of water. The child should take the 
medicine through a glass tube so as not to injure the teeth. Iron prep- 
arations generally should be given after meals, and in case the liquid 
preparations are used, they should be well diluted with water. 
ALCOHOL 
In its relation to children, alcohol, regardless of the form in which it 
is used, must always be considered as a drug and not as a beverage. It 868 
THE PRACTICE OF PEDIATRICS 
is occasionally of great service in diseases of children and under certain 
conditions may answer better than any other means of stimulation we 
possess. The fact that it is grossly misused does not in any way detract 
from its value in illness. It is too often given; chiefly for the reason that 
its use, in the form of whisky and brandy and wine, is advocated in medical 
works in many of the ordinary ailments of childhood where really it is 
absolutely contraindicated. Its use, in our hands, has been that of a 
food and stimulant in very grave conditions, the duration of its usefulness 
being often completed in a day or two. When given to children for a 
prolonged period, even in moderate quantities, it invariably interferes with 
digestion and assimilation, and therefore does harm. It is very liable also 
to act as an additional irritant to the kidneys, which are prone to show 
inflammatory changes as a result of the systemic toxemia due to the disease. 
We have heart stimulants which are ordinarily as effective as alcohol and 
without its danger either to the stomach or the kidneys. 
It is good practice never to give alcohol early in an illness unless the 
onset is accompanied by profound prostration, but rather to hold this 
drug in reserve until it is absolutely necessary. Used in this way, it has 
been of much service in two conditions in which nothing has been found 
that can replace it. We refer, first, to that time which may arise in any 
grave disease when the heart fails to respond to the usual stimulation, as 
in the crisis of lobar pneumonia and in the profound toxemia of scarlet 
fever or diphtheria. At such a time the powers of assimilation for most 
drugs as well as for food are reduced to a minimum. When food is rejected 
or taken badly, when the usefulness of strychnin, strophanthus, musk, 
camphor, digitalis, and caffein has been exhausted, alcohol should be given 
and given in as large doses as may be required to produce the desired 
results. It is astonishing what large quantities of alcohol may be given 
in many such conditions without the slighest intoxicating effects. When 
given well diluted it is usually well borne and assimilated; it supports the 
heart, improves the respiration, and often will carry the patient through 
to a successful convalescence even when the outlook is very unpromising. 
As the system readily becomes accustomed to alcohol, it must be given 
in increasing doses. If it is given early in the illness, it will have lost its 
stimulating effects by the time it is most needed. Brandy and whisky, 
well diluted, are the forms in which it is generally used. 
The second condition in which alcohol is useful is in cases with greatly 
lowered vitality resulting from some severe illness, such as typhoid fever, 
enterocolitis, or pneumonia. If a child is suffering from shock bordering 
on collapse, or collapse with a subnormal temperature with all the vital 
powers at a low ebb, alcohol will do much to sustain him until he is able to 
assimilate easily digested or predigested foods. In such cases whisky, 
well diluted—1 part whisky to 6 parts of water—given at intervals of 
two or three hours, will hasten recovery. If the child cannot swallow, 
the whisky may be given by gavage; if it is vomited, a double quantity, 
well diluted, may be given by the rectum. The hypodermic use of alcohol 
is infrequently resorted to chiefly for the reason that other remedies, such 
as strychnin and digitalis, are more effective than alcohol when so given. 
The doses vary from 5 drops to \ dram every one or two hours, twelve 
to twenty-four doses in twenty-four hours, for a child one year of age. A ANESTHETICS 
869 
child two years of age may be given 1 dram at intervals of one or two 
hours. The use of alcohol is attended with the least disturbance when it 
is given after the feedings. 
ANESTHETICS 
That the administration of anesthetics to children is attended with 
considerable danger is proved by statistics relating to the subject, and that 
the greatest care and judgment should be exercised in the selection of 
an anesthetic for a child is readily understood. 
Ether and Chloroform.—As a routine anesthetic for the young, ether is 
preferable because of its safety. The popular belief that chlorofrom is 
without danger is in error and not sustained by statistics. There are 
conditions, however, .when ether is contraindicated. In cases in which 
there is bronchial involvement, ether increases the bronchial secretions 
and produces a free flow of saliva, which is liable to be aspirated into the 
lungs. In case of any obstruction to respiration, from laryngeal diphtheria, 
retropharyngeal abscess, or enlarged glands which may encroach upon 
the air-passages, chloroform, and not ether, should be employed. Ether is 
further contraindicated in scarlet fever or in nephritis. In such cases 
chloroform is to be selected. Chloroform is to be used also for the sake 
of convenience, if other conditions allow, in minor operations about the 
mouth and the nose. Chlorofrom is contraindicated in general weakness, 
exhaustion, collapse, and in anemia. Ether given by the drop method should 
be used in these cases. Statistics of chloroform anesthesia show a consider- 
able mortality in operations for adenoids and enlarged tonsils. The 
interference with respiration and the sudden hemorrhage make chloroform 
dangerous in these operations. In heart disease with imperfect compen- 
sation any anesthetic is dangerous, but ether, by the drop method is the 
least dangerous. 
Nitrous oxid gas, which of late has become very popular, should be 
given with caution to children under two years of age. Young children 
are very easily asphyxiated by gas; the younger the child, the greater the 
danger. Gas should be used, therefore, very sparingly and the patient 
watched most carefully for signs of cyanosis. The use of gas for children 
frequently precedes the administration of ether, as this practice renders 
the latter much less disagreeable to the patient. Such procedure is con- 
traindicated, however, in any condition where dyspnea is present; in fact, 
in any illness in which respiration is impeded, gas is dangerous. The 
combination of gas and ether in such cases is not as safe as chloroform, 
which is to be given in a minimum amount with oxygen as a safeguard. 
Nitrous Oxid Gas with Oxygen.—The admixture of oxygen renders pos- 
sible prolonged administration of nitrous oxid without (he risk attendant 
upon its use alone. This form of anesthesia has become very popular in 
recent years because of freedom from unpleasant after-effects. The 
method, however, calls for special apparatus of some complexity and im- 
poses upon the anesthetist close watchfulness of the variations in degree 
of unconsciousness of the patient. To secure adequate general relaxation 
ether as a supplement must often be employed. The method is not with- 
out the dangers attendant upon ordinary gas administration, but in 
expert hands may be employed with safety and obvious advantage. 870 
THE PRACTICE OF PEDIATRICS 
Danger-signals with Ether: 
Marked cyanosis; stertorous breathing; rapid pulse; dilated pupils; 
short, quick, gasping respiration. 
Danger-signals with Chloroform: 
Pallor; ashen color; feeble, shallow respirations, gasping in character; 
dilated pupils and separation of the eyelids; slow feeble heart 
action. 
Danger-signals during Gas Administration: 
Cyanosis; jerking respirations; dilated pupils; convulsive movements 
of any portion of the body. 
Ethyl Chlorid.—The use of ethyl chlorid is in the experimental stage. 
Statistics show quite a mortality from its use. It should not be contin- 
uously administered after unconsciousness has set in. In case any of the 
danger-signals are observed the ethyl chlorid should temporarily or per- 
manently be discontinued and some other form of anesthetic substituted. DRUGS FOR INTERNAL USE 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Acetanilid. 
Not advised in the treatment of chil- 
dren. 
Acid, Arseniotjs. See Arsenic. 
Acid, Benzoic. Benzoic acid; flowers of 
benzoin. 
Used in cystitis of alkaline type 
Acid, Gallic. 
Bismuth subgallate. (Dermatol.) 
Used internally as an intestinal astrin- 
1 gr. 
1-2 gr. 
2 gr. 
3-5 gr. 
gent, also externally 
Acid,Hydrochloric,Dilute. (Correspond- 
ing to 31.9 per cent, of absolute HC1.) 
Used in chronic gastritis with atony of 
3-5 gr. 
5 gr. 
10 gr. 
10 gr. 
the stomach 
Acid, Lactic. 
Used in fermentative diarrheas. Given 
best well diluted with syrup and water 
drop 
1 drop 
2 drops 
3-5 drops 
or in milk. (See p. 88.) 
Acid, Phosphoric, Dilute. (Containing 10 
per cent, orthophosphoric acid.) 
1 drop 
2 drops 
3-5 drops 
Used as a stomachic 
Acid, Salicylic. 
Seldom used uncombined. 
Bismuth subsalicylate. 
1-2 drops 
2-3 drops 
5 drops 
10 drops 
Intestinal astringent and sedative 
Methyl salicylate. (Synthetic oil of winter- 
green.) 
1 gr. 
1-2 gr. 
2 gr. 
3-5 gr. 
Antirheumatic 
Oil of Wintergreen. (Natural.) 
1 drop 
2-3 drops 
3 drops 
3-5 drops 
Antirheumatic 
Salol. (Phenyl salicylate.) 
1 drop 
2-3 drops 
3 drops 
3-5 drops 
Intestinal antiseptic and antirheumatic 
Sodium salicylate. 
\ gr. 
1-2 gr. 
2 gr. 
3 gr. 
Antirheumatic 
Aspirin. (Non-official.) (Acetyl-salicylic 
acid.) 
Antirheumatic—a substitute for sodium 
salicylate, at times better tolerated by the 
stomach. Best given in capsules, for it 
is decomposed by alkalis and by moist- 
1 gr. 
1-2 gr. 
2-3 gr. 
3-5 gr. 
ure 
Acid, Tannic. 
Used in the form of: 
Tannalbin. (Dried albuminate of tannin.) 
1 gr. 
1-2 gr. 
2-3 gr. 
3-5 gr. 
Used as an intestinal astringent 
Tannigen. (Acetyl-tannin.) 
1-2 gr. 
1-2 gr. 
2-3 gr. 
3-5 gr. 
Used as an intestinal astringent 
Also by rectum: 1 per cent, solution of 
tannic acid in an enema, for dysentery or 
colitis. 
1-2 gr. 
1-2 gr. 
2-3 gr. 
3-5 gr. 
871 872 
THE PRACTICE OF PEDIATRICS 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Acid, Tartaric. 
Seldom used except as one of its salts. 
Potassium bitartrate. (Cream of tartar.) 
Diuretic, refrigerant, and aperient. 
Used as an ingredient of diuretic drinks. 
To one pint of water to be drunk in 
twenty-four hours is added 
Potassium and antimony tartrate. (Tartar 
emetic.) 
Used as an expectorant. Its action is 
too violent for use as an emetic. Best 
given alone or with ipecac in a tablet or in 
a mixture with a simple elixir. 
May cause severe gastro-enteritis in too 
large doses 
ish gr. 
2 dr. 
xio gr- 
riff gr. 
4 dr. 
ioo gr. 
Potassium and sodium tartrate. (Rochelle 
salt.) 
Laxative 
15 gr. 
30 gr. 
1-2 dr. 
3-4 dr. 
Aconite. (Aconitum napellus.) (Root 
contains 0.5 per cent, aconitin.) 
Tincture of aconite root (10 per cent.) 
Used in a beginning fever as a circula- 
tory sedative and an analgesic 
\ drop 
1 drop 
1 drop 
1-2 drops 
Adrenalin. (1:1000 solution.) See p. 882. 
Ineffective by mouth. Intramuscularly 
and intravenously a vasoconstrictor and 
bronchodilator. Circulatory stimulant 
and antiasthmatic 
1 drop 
2 drops 
3 drops 
3 drops 
Alcohol. (Ethyl alcohol, spirits of wine.) 
General stimulant toward the end of 
an illness or as a last resort. (See p. 867.) 
Brandy. (Spiritus vini gallici, containing 
39-47 per cent, alcohol by weight.).. 
5-10 
10-20 
20-30 
30-40 
Whisky. Spiritus frumenti, containing 
44-50 per cent, alcohol by weight.).. 
drops 
drops 
drops 
drops 
5-10 
10-20 
20-30 
30-40 
Sherry wine. (Vinum xerici, containing 
alcohol, 15-20 per cent, by weight.). 
drops 
drops 
drops 
drops 
30 drops 
45 drops- 
1-2 dr. 
Aloes. Not advised for children. 
Alum. Not advised for children. 
Ammonium. 
Ammonium bromid. See Bromin. 
Ammonium chlorid. (Sal ammoniac.) 
Stimulating expectorant; best given 
dissolved in half an ounce of water 
i gr- 
1 2 gr. 
1 dr. 
1 gr. 
1-2 gr. 
Ammonium carbonate. (Sal volatile.) 
Stimulating expectorant; best given 
dissolved in half an ounce of water 
\~h gr. 
M gr. 
1 gr. 
1-2 gr. 
Solution of ammonium acetate. (Liquor 
ammonii acetatis or spirits of Minde- 
rerus.) 
Stimulating expectorant; best given 
well diluted in carbonic water. 
Used also as a diuretic, antipyretic, and 
diaphoretic 
H dr. 
1 dr. 
2 dr. 
Aromatic spirits of ammonia. (Spiritus 
ammonii aromaticus.) 
Used as a stimulating expectorant, 
volatile stimulant, carminative, and anti- 
spasmodic. Best given well diluted with 
water 
3 drops 
3-5 drops 
5 drops 
5-10 
- 
drops DRUGS FOR INTERNAL USE 
873 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Antimony. 
Antimony and potassium tartrate. (Tartar 
emetic.) See under Acid, Tartaric. 
Antipyrin. 
Analgesic and sedative in pertussis and 
laryngitis. 
Best given alone in powder form, or 
with sodium bromid in solution 
§ gr. 
1-H gr- 
2 gr. 
3 gr. 
Antitoxin. See Serum, Antidiphtheric. 
Apomorphin. 
Not advised in the treatment of chil- 
dren. 
Arsenic. 
Arsenious add. (Arsenic trioxid or white 
arsenic.) 
Used in anemia, malaria, and chorea. 
Administere either in solution (see 
Fowler’s solution) or in tablets with other 
ingredients. 
In large doses it is an irritant poison, 
causing puffiness of the eyes and gastro- 
enteritis, both of which are signs of an 
overdose. 
Cannot be given with astringents, tinc- 
tures, or decoctions or with solutions of 
iron. 
Antidotes are hydrated iron with mag- 
nesia, egg-albumen, and emetics. 
Given three times a day 
sis gr- 
ris gr- 
xis gr- 
Fowler's solution. (Liquor potassii ar- 
senitis.) 
Uses, action, and antidotes are the 
same as those of arsenious acid. 
Best given in water into which it is 
freshly dropped 
§ drop 
1 drop 
2 drops 
2-5 drops 
Asafetida. 
Emulsion of asaf etida. (M ilk of asafetida.) 
Used chiefly as an ingredient of ene- 
mata, especially in excessive tympanites. 
To 8 ounces of diluent 
1 dr. 
1 dr. 
1 dr. 
Aspidium. (Male-fern.) 
Oleoresin of male-fern. 
Teniafuge. 
Best given in emulsion or in capsules. 
10-15 gr. 
20-30 gr. 
Aspirin. See under Acid, Salicylic. 
Atropin. See under Belladonna. 
Basham’s Mixture. See under Iron. 
Belladonna. (From the leaves of the 
Atropa belladonna, containing 0.35 
per cent, of alkaloid.) 
Atropin. (Alkaloid of belladonna.) 
Respiratory stimulant, anidrotic. 
Used as a stimulant, a mydriatic, and 
for the cure of enuresis 
r,ss gr. 
sis gr- 
sis gr- 
sis gr- 
Tincture of bellandonna (10 per cent, 
leaves). 
Uses similar to those of atropin 
\~h drop 
1 drop 
1-2 drops 
3-5 drops 
Belladonna leaves. (Asthma powder.) 
Used occasionally with the leaves of 
conium and stramonium, and potassium 
nitrate (saltpeter) to relieve attacks of 
asthma. To be burned in a metallic 
receptacle. 874 
THE PRACTICE OF PEDIATRICS 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Benzoic Acid. See Acid, Benzoic. 
Benzyl Benzoate. 
Antispasmodic in croup, asthma, per- 
tussis, and colic administered in form of 
a 20 per cent, alcoholic solution 
Bichlorid of Mercury. See under Mercury 
Bismuth. 
Bismuth subcarbonate. 
10 drops 
15 drops 
20 drops 
25-30 
drops 
Intestinal astringent and sedative 
Bismuth subgallate. (Dermatol.) 
Intestinal astringent and sedative. 
10 gr. 
10 gr. 
10 gr. 
20 gr. 
Used also externally 
Bismuth subnitrate. 
3-5 gr. 
5 gr. 
5-10 gr. 
10 gr. 
Intestinal astringent and sedative 
Bismuth subsalicylate. See under Acid, 
Salicylic. 
Blaud’s Pill. See under Iron. 
Borax. (Sodium borate.) See under So- 
dium. 
Brandy. See under Alcohol. 
Bromin. 
Used only in the form of its salts. 
Ammonium bromid. 
Sedative. Used in laryngismus, per- 
tussis, asthmatic bronchitis, and sleep- 
lessness. 
5-10 gr. 
10 gr. 
10-15 gr. 
20 gr. 
Best given well diluted with water.... 
Potassium bromid. 
Used same as the ammonium salt, but 
1-3 gr. 
2-4 gr. 
3-5 gr. 
5-8 gr. 
is more depressing 
Sodium bromid. 
Used same as the above. It is midway 
between the ammonium and the potas- 
1-3 gr. 
2-4 gr. 
3-5 gr. 
5-8 gr. 
sium salts in its depressant action 
Strontium bromid. 
1-3 gr. 
2-4 gr. 
3-5 gr. 
5-8 gr. 
Used same as the above 
Brown Mixture. See under Licorice. 
Caffein. 
1-3 gr. 
2-4 gr. 
3-5 gr. 
5-8 gr. 
Caffein sodiosalicylas (60 per cent, caffein) 
1 PX. 
5-1 gr. 
1-15 gr. 
lf-2gr. 
Caffein sodiobenzoas (50 per cent, caffein) 
Citrate of caffein (50 per cent, caffein). 
\ gr. 
5-1 gr- 
1-15 gr. 
lf-2 gr. 
General stimulant and diuretic 
Calcium. 
Calcium bromid. 
Indicated in convulsive disorders, in- 
5 gr- 
5-1 gr. 
1 gr. 
1-2 gr. 
eluding tetanus neonatorum 
Particularly indicated in tetany in 
which the 3 per cent, solution may be em- 
ployed hypodermically 
Of possible benefit in hemophilia and 
2 gr. 
3 gr. 
5 gr. 
5 gr. 
milder forms of purpura 
5 gr- 
1 gr. 
1-2 gr. 
2 gr. 
Calcium lactate 
Calcium sulphid. 
5 gr. 
10 gr. 
20 gr. 
20 gr. 
Antipustulant 
Prepared chalk. 
A gr- 
A gr- 
A gr. 
i*5 gr- 
Antacid 
Compound chalk mixture. (Mistura cretin 
composita.) 
20 per cent, chalk powder, 40 per cent, 
cinnamon-water. 
2 gr. 
3 gr. 
5 gr. 
5-8 gr. 
Antacid. Every two hours 
Calomel. See under Mercury. 
1 dr. 
1 dr. 
1| dr. 
2 dr. DRUGS FOR INTERNAL USE 
875 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Camphor. 
Powdered camphor. 
Used in coryza. Every two hours.. . . 
A gr. 
i gr- 
4 gr- 
I gr- 
Spirits of camphor (10 per cent, in alcohol). 
Stimulant, anodyne, carminative 
3 drops 
5 drops 
5-10 
10 drops 
Water of camphor. (Aqua camphora?.) 
(Contains 0.8* per cent, of camphor.) 
Used as a vehicle. 
Cantharides. 
Used best in: 
Tincture of cantharides (10 per cent.) 
Useful in cystitis and functional al- 
buminuria 
drops 
\-\ drop 
\ drop 
Capsicum. 
Used best in: 
Tincture of capsicum (10 per cent.). 
Used as a carminative and stomachic. 
Best given well diluted in water 
1 drop 
2-3 drops 
3-5 drops 
Cardamom. 
Used best as: 
Tincture of cardamom. 
Used as a carminative 
5 drops 
10 drops 
15 drops 
20 drops 
Cascara Sagrada. (Bark of Rhamnus pur- 
shiana.) 
Extract of cascara sagrada. 
(Four times the strength of the bark.) 
Tonic laxative 
l gr- 
1-2 gr. 
3-5 gr. 
Fluidextract of cascara sagrada. (Aro- 
matic.) (1 c.c. = 1 gm. bark.) 
The active principles are retained, but 
the bitter principles are eliminated. 
Tonic laxative 
15 drops 
30-45 
1 dr. 
1-2 dr. 
Castor Oil. (Oleum ricini.) 
(Expressed from the seeds of Ricinus 
communis.) 
Bland oil and cathartic. 
Given usually for one dose 
1 dr. 
drops 
2 dr. 
3 dr. 
4 dr. 
Cerium Oxalate. 
Sedative in vomiting 
2 gr. 
2-3 gr. 
3 gr. 
3-5 gr. 
Chalk. See Calcium. 
Chloral Hydrate. 
Sedative, hypnotic, and antispasmodic. 
Best given in some bland fluid by rec- 
tum 
1 gr. 
1§ gr. 
2 gr. 
Chloroform. 
Given internally as: 
Spirits of chloroform. (Chloric ether.) 
(6 per cent, chloroform.) 
Carminative, antispasmodic, and sed- 
ative 
2-3 drops 
3-5 drops 
5-15 
15-20 
Water of chloroform. (Aqua ehloro- 
formi.) (0.5 per cent chloroform.) 
Vehicle and carminative 
h dr. 
2-2 dr. 
drops 
2-3 dr. 
drops 
4 dr. 
Cinchona. See under Quinin. 
Cocain, or: 
Cocain Hydrochlorid. 
Local anesthetic by hypodermic in- 
jection. Not as safe as Novocain q. v. 
Used in 0.2 per cent, to 2 per cent, 
strength. But seldom used for local an- 
esthesia in children. Used by the mouth 
in obstinate vomiting 
tcso gr- 
fa gr- 
-h gr. 876 
THE PRACTICE OF PEDIATRICS 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Codein. See Opium. 
Cod-liver Oil. (Oleum morrhuae.) 
Fixed oil from fresh cod’s livers. 
Alterative and tonic particularly valu- 
able in promoting calcium retention. In- 
dicated in rickets and spasmophilia and to 
be given prophylactically to well infants. 
Given three times a day 
10^15 
15-20 
20-30 
1-1 dr. 
Corrosive Sublimate. See Corrosive Chlo- 
rid of Mercury. 
Cream of Tartar. See under Add, Tar- 
taric. 
Creosote. (Beechwood creosote.) 
Tonic, alterative, and antitubercular. 
Best given in an emulsion with cin- 
namon-water, three times a day after 
meals 
drops 
I drop 
drops 
2 drops 
drops 
2-3 drops 
3-5 drops 
Cresotal. (Carbonate of creosote—92 
per cent, creosote.) 
Is preferable to creosote because it has 
little odor, a more agreeable taste, and 
is better borne by the stomach 
5 drop 
2 drops 
2-3 drops 
3-5 drops 
Dermatol. (Bismuth subgallate.) See 
under Bismuth. 
Digitalis. (From the leaves of Digitalis 
purpurea.) 
Heart stimulant and tonic; also diuretic. 
Best given by mouth in the form of the 
tincture and hypodermically either as the 
tincture or as digitalin. 
Tincture of digitalis (10 per cent, leaves). . 
h drop 
1 drop 
1-2 drops 
2-3 drops 
Infusion of digitalis (66 gm. = l gm. 
leaves) 
1-1 dr. 
1-3 dr. 
Digatalin (10 times strength of leaves).. . . 
gr- 
viv gr ■ 
Tin gr. 
jiv gr- 
Diphtheria Antitoxin. See Serum, An- 
tidiphtheric. 
Diuretin. (Theobromin sodiosalicylate.) 
Diuretic in cardiac dropsy and hydro- 
cephalus 
1 gr. 
H gr. 
2 gr. 
3 gr. 
Dover’s Powder. See under Opium. 
Epsom Salt. See under Magnesium.. 
Ergot. Hemostatic, circulatory stimulant. 
Fluidextract of ergot (1 c.c. = 1 gm. ergot) 
2-3 drops 
5 drops 
5-8 drops 
10-15 
Eriodictyon. See Yerba Santa. 
Ether. 
Used internally as: 
Compound spirits of ether. (Hoffmann’s 
anodyne, 32.5 per cent, ether.) 
Anodyne, carminative, antispasmodic, 
and stimulant. 
Best given well diluted with water. . . 
2 drops 
3-5 drops 
5 drops 
drops 
5-10 
Spirits of nitrous ether. (Sweet spirit of 
niter, 4 per cent, ethyl nitrite.) 
Used as a diaphoretic, diuretic, and car- 
minative. 
It is volatile and explosive and in- 
compatible with many drugs. Best given 
alone or in a simple elixir. . . 
2-3 drops 
3-5 drops 
5 drops 
drops 
5-10 
Fel Bovis. See Ox-gall. 
Ferrum. See Iron. 
Fowler’s Solution. See Arsenic. 
drops. Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Gallic Acid. See Acid, Gallic. 
Gentian. 
Extract of gentian. 
Stomachic and bitter tonic. 
Given three times a day 
Glauber’s Salt. (Sodium suphate.) See 
under Sodium. 
Glonoin. See Nitroglycerin. 
Glycerin. 
Used chiefly as a demulcent base and a 
vehicle for other drugs. 
Glycyrrhiza. See Licorice. 
Hexamethylenamin. Official name for the 
proprietary urotropin, q. v. 
Hoffmann’s Anodyne. See under Ether. 
Hydrargyrum. See Mercury. 
Hyoscyamus. (Of belladonna group.) Sed- 
ative and antispasmodic. 
Not advised for children. 
M gr- 
1-1 gr. 
Ipecac 
jh RT. 
A gr. 
A gr- 
A gr- 
Syrup of ipecac 
Iron. Given every two hours. 
Liquor ferri et ammonii acetatis. 
(Basham’s mixture—solution of iron 
and ammonium acetate—10 per cent. 
§-l drop 
1-2 drops 
3 drops 
3-5 drops 
metallic iron) 
I dr. 
1 dr. 
Ovoferrin. (Proprietary organic iron.). . . 
Pyrophosphate of iron (10 per cent, of 
5 drops 
10 drops 
15-20 
drops 
20-30 
drops 
metallic iron) 
Syrup of the iodid of iron (5 per cent, fer- 
1-2 gr. 
2-3 gr. 
rous iodid) 
Tincture of the chlorid of iron. 
(35 per cent, of ferric chlorid and must 
3 drops 
6 drops 
10 drops 
20-30 
drops 
be at least one year old.) 
Jalap. 
Powdered jalap. (Contains 8 per cent, 
resin.) 
1 drop 
3 drops 
5 drops 
10-15 
drops 
Hydragogue cathartic and diuretic 
Lactic Acid. See Acid, Lactic. 
Licorice. 
Compound licorice mixture. (Brown mix- 
ture—12 per cent, paregoric.) 
Sedative expectorant mixture. 
2 gr. 
3 gr. 
Given at two-hour intervals 
Compound licorice powder. 
15 drops 
20 drops 
30-40 
drops 
40 drops 
-1 dr. 
Laxative 
Magnesium. 
Magnesium carbonate. 
10 gr. 
10-20 gr. 
30 gr. 
40 gr.- 
1 dr. 
Antacid and laxative 
Magnesium citrate, solution of. (Liquor 
magnesii citratis.) 
5-10 gr. 
20 gr. 
30-40 
gr. 
40 gr.- 
1 dr. 
Laxative. For one dose 
Magnesium oxid. (Calcined magnesia.) 
2 oz. 
2-4 oz. 
Antacid and laxative 
Magnesium sulphate. (Epsom salt.) 
Laxative. To be given every two hours 
and discontinued when the desired effect 
5-10 gr. 
10-20 gr. 
20-30 gr. 
30-40 gr. 
has been produced 
Male-fern. See Aspidium. 
Mentha Piperita. See Peppermint. 
Mentha Viridis. See Spearmint. 
10-15 gr. 
20 gr. 
20-30 gr. 
|-1 dr. 
DRUGS FOR INTERNAL USE 
877 878 
THE PRACTICE OF PEDIATRICS 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Mercury. 
Mass of mercury. (Blue mass—35 per 
cent, mercury.) 
Cathartic and antisyphilitic. 
Used once a day 
1 gr. 
1-2 gr. 
Corrosive chlorid of mercury. (Bichlorid 
of mercury or corrosive sublimate.) 
Antisyphilitic. 
Given three times a day 
sk gr. 
xk gr- 
rk gr- 
A gr. 
Mild chlorid, of mercury. (Calomel.) 
Cathartic, cholagogue, antisyphilitic. 
At ten-minute intervals 
A gr. 
1 gr. 
At half-hour intervals 
i gr- 
4 gr. 
Rarely necessary to give more than one 
grain for laxative effect. 
Red iodid of mercury. (Biniodid.) 
Antisyphilitic. 
Given three times a day 
xk gr- 
xk gr- 
A gr- 
A“A gr. 
Mercury with chalk. (Gray powder.) (38 
per cent, mercury.) 
Intestinal antiseptic, cholagogue, and 
antisyphilitic. 
At one-hour intervals—total 1 gr 
i gr. 
4 gr. 
At one-hour intervals—total 2 gr 
\ gr. 
1 gr. 
Methyl Salicylate. See under Add, Sal- 
icylic. 
Mindererus, Spirits of. See under Am- 
monium. 
Morphin. See under Opium. 
Myrrh. 
Tincture of myrrh (20 per cent.). 
Used as a mouth-wash diluted with 
water. 
Niter. See under Ether, Sweet Spirits of 
Niter. 
Nitroglycerin. (Glonoin, glyceryl tri- 
nitrate.) 
Vasodilator 
xk gr. 
TFT) gr. 
sou gr. 
xk gr- 
Spirits of glyceryl trinitrate, or spirits of 
glonoin, old U. S. P. (1 per cent, al- 
coholic solution) 
5 drop 
x drop 
3 drop 
1 drop 
Novocain. Action and uses similar to those 
of cocain, but toxicity much less than 
that of cocain. Novocain is not 
readily absorbed by mucous mem- 
branes or the eye, for which reason it 
must be used hypodermically. Usual 
strength employed is 1 per cent. 
Nux Vomica. (From Strychnos nux-vom- 
ica.) 
Tincture of nux vomica (1 per cent, strych- 
nin.) 
Stomachic and stimulant 
| drop 
1 drop 
1-2 drops 
2-4 drops 
Strychnin. (Alkaloid of nux vomica.) 
General stimulant, well borne by chil- 
dren. 
Every two or three hours 
xk'sk 
xk gr. 
rk gr. 
xk gr- 
Oleum Gaultherium. (Oil of winter- 
green.) See under Acid, Salicylic. 
Oleum Morrhu.*. See Cod-liver Oil. 
Oleum Oliwe. See Olive Oil. 
Oleum Ricini. See Castor Oil. DRUGS FOR INTERNAL USE 
879 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Olive Oil. 
Laxative and nutrient 
Used at night by rectum for the cure of 
15 drops 
15-30 
drops 
30 drops 
-1 dr. 
1 dr. 
constipation 
Opium. 
Sedative, anodyne, hypnotic. 
Tincture of deodorized opium (10 per cent.) 
Used in 3 to 10 drop doses in enemata 
as a sedative for children under five years 
of age. 
Camphorated tincture of opium. (Paregoric 
—0.4 per cent, opium.) 
1 oz. 
If oz. 
2 oz. 
3 oz. 
Sedative and analgesic 
Powder of ipecac and opium. (Dover’s 
powder—10 per cent, each of ipecac 
and opium.) 
3-5 drops 
10 drops 
15-20 
drops 
20-30 
drops 
Sedative 
Morphin. (Alkaloid of opium.) 
Not well borne by children and best 
M gr. 
f-f gr. 
1-1 f gr. 
2-3 gr. 
given hypodermically 
Codein. (Menthylmorphin.) 
rhs gr. 
too gr. 
to gr- 
A gr. 
As sulphate or phosphate 
Heroin. (Diacetylmorphin.) 
As hydrochlorid. 
A gr- 
A gr- 
1 gr. 
Depressant. Codein is preferable 
Orange-juice. (Citrus aurantium.) 
xU gr- 
A gr- 
A gr. 
Antiscorbutic 
Ox-gall. (Fel bovis—fresh ox-bile.) 
Used as a laxative in enemata—f-1 dr. 
to a pint of water. 
Paregoric. Camphorated tincture of opium. 
See under Opium. 
Pepo. See Pumpkin Seed. 
Peppermint. 
Aqua menthce piperitce-Peppermint water. 
(0.2 per cent, oil of peppermint.) 
Carminative, sedative, corrective, and 
f oz. 
1 oz. 
vehicle 
Pepsin. 
1 dr. 
1-2 dr. 
3 dr. 
4 dr. 
Powdered pepsin 
1 gr. 
1-2 gr. 
2-3 gr. 
3 gr. 
Essence of pepsin 
Phenacetin. (Acetphenetidin.) 
20 drops 
30-40 
drops 
40 drops 
-1 dr. 
1 dr. 
Antipyretic and analgesic 
Phenolphthalein 
f gr. 
1 gr. 
If gr. 
2 gr. 
Mild, non-griping, laxative 
Phosphoric Acid. See Acid, Phosphoric. 
Phosphorus. 
Oleum phosphoratum (1 per cent, in al- 
mond oil). 
1 gr. 
If gr. 
2 gr. 
Alterative 
Syrup of hypophosphites. 
(Calcium, 4.5 per cent.; sodium and po- 
f drop 
1 drop 
If drops 
2-4 drops 
tassium, each, 1.5 per cent.) 
Pilocarpin. 
Not advised for children. 
Potassium. 
Potassium acetate. 
f dr. 
f dr. 
1 dr. 
1-2 dr. 
Diuretic, refrigerant, and alterative.. . . 
Potassium bicarbonate. 
Should not be given to children on ac- 
count of its disagreeable taste. 
1-2 gr. 
2-3 gr. 
3 gr. 
5 gr. 880 
THE PRACTICE OF PEDIATRICS 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Potassium (Continued). 
Potassium bitartrate. (Cream of tartar.) 
See under Acid, Tartaric 
Potassium bromid. See under Bromin. 
Potassium citrate. 
Diaphoretic and alkaline diuretic. 
Used in pyelitis 
Potassium chlorate. 
Astringent and antisialogogue. 
Used in stomatitis of every type, in 
1-2 gr. 
2-5 gr. 
5-10 gr. 
10 gr. 
tonsillitis, and angina 
Potassium iodid. 
5 gr. 
1 gr. 
2-3 gr. 
3 gr. 
Antispasmodic and antisyphilitic 
Potassium and sodium tartrate. (Rochelle 
salt.) See under Acid, Tartaric. 
Prunus Virginiana. See Wild Cherry. 
Pumpkin Seed. Pepo. 
Teniafuge. Best given in an emulsion; 
average dose, 1 dr. 
Quassia. 
Infusion of quassia. 
Vermifuge. 
An extemporaneous infusion is made by 
adding 1 or 2 ounces of quassia chips to a 
pint of water. This is injected high up 
into the bowel. 
Used particularly to destroy Oxyuris 
vermicularis. 
Quinin. (Alkaloid of cinchona.) 
1 gr. 
1-2 gr. 
2-3 gr. 
3 gr. 
Bisulphate of quinin 
1 gr. 
1-2 gr. 
2-3 gr. 
3-4 gr. 
Sulphate of quinin 
1 gr. 
1-2 gr. 
2-3 gr. 
3-4 gr. 
Tincture of cinchona 
All these are bitter tonics and anti- 
periodics. 
Rhamnus Purshiana. See Cascara Sa- 
grada. 
Rhubarb. 
Powdered rhubarb. 
5-10 
drops 
15 drops 
20-30 
drops 
Laxative 
Aromatic syrup of rhubarb. 
1-2 gr. 
2-3 gr. 
3-4 gr. 
5 gr. 
Laxative and flavoring medium 
Mixture of rhubarb and soda. 
Corrective and laxative. 
Pidveris rhei, 
Sodii bicarbonatis aa gr. xlviij 
Syrupi rhei aromatici 5 j 
Aquae q. s. ad Sij 
1 dr. 
2 dr. 
3 dr. 
4 dr. 
M. Sig.—One to three doses daily 
Rochelle Salt. See under Acid, Tartaric. 
Saccharin. (Benzosulphinidum.) 
Substitute for sugar, but 200 times 
sweeter. 
For 8 ounces of food, §-l gr. is sufficient. 
Saccharose. See Sxigar. 
Salicylic Acid. See Acid, Salicylic. 
Salol. See under Acid, Salicylic. 
Santonin. (Anhydrid of santoninic acid.) 
hdr. 
2 dr. 
3 dr. 
4 dr. 
Vermifuge,for round-worms particularly 
Senna. 
Cathartic, Best given as compound 
licorice powder, of which it is an ingre- 
dient (q. v.). 
§gr. 
1 gr. 
1-2 gr. 
2 gr. DRUGS FOR INTERNAL USE 
881 
Dbug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Serum Antidiphtheriticum. (Diphtheria 
antitoxin.) 
For immunization: 
2000 to 5000 units. 
In faucial diphtheria: 
5000 to 10,000 units and repeat in eight 
hours if required. 
In laryngeal diphtheria: 
10,000 units and repeat in eight hours if 
required. 
The repetition of the doses of antitoxin 
is discontinued only when the case ceases 
to require the serum. 
The dosage is independent of the age of 
the patient. 
Sodium. 
Sodium benzoate. 
Antiseptic, antipyretic, and antirheu- 
matic. 
Used in cystitis with alkaline fermenta- 
tion to acidify the urine, which it does by 
the liberation of hippuric acid 
Sodium bicarbonate. 
1 gr. 
1-2 gr. 
2 gr. 
3 gr. 
Antacid, antirheumatic 
Sodium borate. (Borax.) 
Antiseptic and astringent. 
Used as a gargle and mouth-wash in 
stomatitis—1 dr. to 8 oz. of water. 
Sodium bromid. See under Bromin. 
Sodium citrate. See Potassium citrate. An- 
ticoagulant in blood transfusion and 
1-2 gr. 
2 gr. 
3 gr. 
5 gr. 
infant feeding. Alkaline diuretic 
Sodium iodid. (See Potassium iodid.) 
Sodium -phosphate. 
1-2 gr. 
2-5 gr. 
5-10 gr. 
10 gr. 
Laxative and cholagogue 
Sodium sulphate. (Glauber’s salt.) 
Cathartic. 
Used in intestinal infection of inactive 
•5-10 gr. 
10-15 gr. 
15-20 gr. 
20-30 gr. 
type 
Sodium salicylate. See under Acid, Sali- 
cylic. 
Spearmint. (Mentha viridis.) 
Water of spearmint. (Aqua menthse viri- 
dis—0.2 per cent, oil of spearmint.) 
15-30 gr. 
30-45 gr. 
40 gr.- 
1 dr. 
1 dr. 
Carminative, sedative, and vehicle.... 
Strontium. 
Strontium bromid. See under Bromin. 
Strophanthus. 
Tincture of strophanthus (11 per cent, in 
New Pharmacopeia, or twice former 
strength). 
Cardiac tonic and diuretic. Occasion- 
ally preferred to digitalis in the treatment 
of children because it is possibly better 
1 dr. 
2 dr. 
3 dr. 
4 dr. 
borne 
Strychnin. See under Nux Vomica. 
Sugar. (Cane-sugar or saccharose.) 
Sweetening agent. May be substituted 
for lactose in the adaptation of cow’s milk 
for infant feeding. 
1 level tablespoonful equals £ oz. Un- 
dergoes alcoholic fermentation. 
1 drop 
1-2 drops 
2 drops 
2-3 drops 882 
THE PRACTICE OF PEDIATRICS 
Drug. 
Dose. 
6 Months. 
18 Months. 
3 Years. 
5 Years. 
Sugar of Milk. (Lactose.) 
Used as an excipient and in the adapta- 
tion of cow’s milk for infant feeding. 
1 level tablespoonful equals § oz. 
SULPHONAL. 
Not advised in the treatment of chil- 
dren. 
Sulphur. 
Precipitated sulphur, or milk of sulphur. 
Laxative and alterative. Given usually 
in syrups or other heavy vehicles 
5 gr. 
5-10 gr. 
15-30 gr. 
1 dr. 
Used also as a reducing agent in bis- 
muth mixtures when the stools do not 
become dark colored 
1 gr. 
1 gr. 
1 gr. 
1 gr. 
Tannalbin. See under Acid, Tannic. 
Tannigen. See under Acid, Tannic. 
Tartar Emetic. See under Acid, Tartaric. 
Tartaric Acid. See Acid, Tartaric. 
Terbene. 
Stimulating expectorant and antiseptic 
1 drop 
1-2 drops 
2 drops 
Terpin Hydrate. 
Expectorant and antiseptic. 
Used in subacute and chronic bron- 
chitis 
i gr- 
1 gr- 
Trional. 
Not advised in the treatment of chil- 
dren. 
Urotropin. (Trade name for hexamethyl- 
enamin.) 
Urinary antiseptic in acid medium . . . . 
\ gr. 
1 gr. 
1-2 gr. 
2-5 gr. 
Whisky. See under Alcohol. 
Wild Cherry. 
Syrup of mid cherry. (Syrupus pruni vir- 
giniani.) 
Bronchial sedative and vehicle. 
Contains hydrocyanic acid 
i dr. 
1 dr. 
Acid, Boric. 
Antiseptic of mild grade. 4% is a saturated solution. 
Used both in solution and in ointments. 
In the form of scales it is most soluble and most convenient. 
Acid, Carbolic. See Phenol. 
Acid, Chromic. (Chromic Trioxid.) 
A very strong caustic and astringent, used as a substitute for Nitrate of Silver. 
Acid, Nitric (68% pure acid). 
Used as a caustic. 
Acid, Salicylic. 
Used in lotions or in ointments, 1 to 3% for skin affections. 
Acid, Tannic. 
Astringent. 
Used in 1% solution in dysentery; as an ingredient of suppositories for hem- 
orrhoids. See also Glycerite of Tannin under Glycerin. 
adrenalin. (Trade name for Epinephrin, the active principle of the Adrenal Gland.) 
Used in a solution in the strength of 1 part to 1000 of normal saline solution or 
sterilized oil. 
Local hemostatic and astringent. It will render bloodless the field of operation 
of the eye, nose, and throat, but its use is often followed by hemorrhage. 
DRUGS FOR EXTERNAL USE DRUGS FOR EXTERNAL USE 
883 
Aluminium Acetate, Solution of. 
Antiseptic dressing for cellulitis, abscesses, etc. 
1. Aluminii sulphatis 5 iiiss 
Acidi acetici 3ivss 
Aquae 5* 
2. Calcii carbonatis 5iss 
Aquae 5 iiss 
Add 1 to 2, stirring. 
Amylum. See Starch. 
Argentum. See Silver. 
Argyrol. See Silver. 
Aristol. (Thymol Di-iodid.) 
Mild antiseptic, used as a dusting-powder or in ointments. 
Balsam of Peru. 
A stimulating dressing for wounds and ulcers. 
In Castor Oil, one part of the Balsam to six of the oil. It makes a useful applica- 
tion for burns and wounds. 
Benzoin. 
Compound Tincture of Benzoin. 
Used as a bronchial sedative in steam inhalations, 1 teaspoonful to one pint of 
water. 
Bichlorid of Mercury. See under Mercury. 
Bismuth Subgallate. (Dermatol.) 
Used externally as a drying antiseptic powder, either pure or in combination. 
Also as an ingredient of ointments of 10 to 20% strength. 
Boracic Acid. See Acid, Boric. 
Cacao-butter. (Oleum Theobromatis.) 
A fixed oil expressed from the seeds of the Theobroma Cacao. Melts at 30°- 
35° C. (86°-95° F.). 
Used as an emollient and as a base for suppositories. It may be used for nutrient 
inunction, but it is less effective than Goose Oil. 
Calamine. (Zinc Carbonate.) 
Used as an ingredient of soothing lotions in itching affections of the skin—ec- 
zema, urticaria, dermatitis venenata, etc. 
Calomel. See under Mercury. 
Cantharides. 
Vesicant. Used best in the form of Collodion of Cantharides, q. v. 
Carron Oil. (Linimentum Calcis.) 
Consists of equal parts of Lime-water and Linseed Oil. 
Used as a soothing application for burns and scalds. 
Chloroform. 
Locally a rubefacient and, when confined, a vesicant as well. A useful ingredient 
of liniments. 
By inhalation, a general anesthetic (p. 869). 
Chrysarobin. 
Used in 5% ointment for psoriasis and tinea tonsurans. 
Cocain. See Eucain (below) and Novocain (p. 878). 
Alkaloid obtained from several varieties of Coca. 
A local anesthetic when applied to wounds or mucous surfaces or when injected 
hypodermically. 
For local application, 3 to 10% solutions. 
For hypodermic use, 0.2 to 2% solutions. 
Cod-liver Oil. 
May be used locally as a nutrient inunction, but its odor is objectionable. 
Collodion. 
Solution of Pyroxylin in Alcohol and Ether. 
Collodion of Cantharides (60% Cantharides). An excellent blistering agent. 
Collodion of Ichthyol (10-20%). Used to cover the wpund after aspirations or 
lumbar punctures and in checking the spread of erysipelas. 
Collodion of Iodoform (5%). Used in erysipelas. 
Collodion of Oil of Cade (1-5%). Used in eczema. 
Collodion of Salicylic Acid (10%). Used in removing corns and calluses. 
Creosote. 
Used in inhalations as a pulmonary antiseptic. 
Dermatol. See Bismuth Subgallate. 
Eucain. 
Beta-eucain. Local anesthetic with action and uses similar to those of Cocain, 
but without its toxicity. Solutions can be sterilized without injury by boiling. 884 
THE PRACTICE OF PEDIATRICS 
Formaldehyd. 
Antiseptic and deodorant. 
Used in solutions of from 0.5 to 2% strength, as an antiseptic. 
Used in the form of the gas for disinfecting, the gas being generated by heat, 
from solutions, or from the solid, Paraform. 
Glycerin. 
Used chiefly as a solvent or excipient. Very hygroscopic. It is the base of the 
Glycerites. 
Glycerite of Carbolic Acid—20% phenol in glycerin. An external antiseptic and 
antipruritic. 
Glycerite of Starch—10%. A vehicle for skin preparations and for pills. 
Goose Oil. 
The oil tried from the goose. An excellent oil for cutaneous inunction. It is 
better than Olive Oil or Cacao-butter, for, being an animal oil, it is more readily 
absorbed by the skin. It is semifluid, has a low melting-point, and does not become 
hard after having been rubbed in. 
Grindelia Robusta. 
The fluidextract, in the strength of one dram to a pint of water, is used as a wet 
dressing in dermatitis venenata. 
Guaiacol. 
Combined with equal parts of Glycerin, it is used in acute joint affections, for 
its analgesic effect. 
Hamamelis. See Witch-hazel. 
Hydrargyrum. See Mercury. 
Hydrogen Peroxid. 
Antiseptic and deodorizer. Used in 10-volume, 3% solution to clean wounds, 
and to dissolve and destroy pus. 
ICHTHYOL. 
Used in 1% solution in intertrigo. 
Used in 10 to 50% ointments to lessen glandular or joint swellings. 
Used in 5 to 50% ointments in skin diseases or in erysipelas. 
Used suspended in oil in strength of 5 to 25% as a nasal spray. 
IODIN. 
Tincture of Iodin (7%). 
Antiseptic and counterirritant. 
Used particularly in tinea tonsurans and tinea circinata. 
Iodoform. Formyl Tri-iodid. 
Antiseptic and alterative. 
Used in the form of a powder, an ointment, or in gauze in the strength of 5 
to 10%. 
Kaolin. 
Cataplasma Kaolini. 
A smooth, homogeneous mass, consisting of Kaolin, Boric Acid, Thymol, Methyl 
Salicylate, Oil of Peppermint, and Glycerin. 
Lanolin. 
Used as an ointment base. 
Lead and Opium Wash. 
Anodyne lotion. 
1$. Liquoris plumbi subacetatis. 5iv 
Tincturae opii §j 
Aquae gxvj 
Fiat mistura. 
Sig.—Use externally. 
Menthol. (Peppermint Camphor.) 
Sedative, analgesic, refrigerant, and antipruritic. 
Used in ointments, 1 to 5%. 
Used in oily solutions, 1 to 5%. 
Used triturated with equal parts of Camphor as an anodyne. 
Mercury. 
Bichlorid of Mercury. 
Antiseptic. Used in 1 : 1000 to 1 : 20,000 solutions. 
Calomel. 
A milder antiseptic than the foregoing. Used as a dusting-powder in eye„ ai- 
feetions and on the lesions of secondary syphilis. 
Mercury and ammonium chlorid. (White precipitate.) 
Used in ointments of l to 10% strength as an antiparasitic and antisyphilitic. 
Of particular value in impetigo contagiosa, ringworm, etc, DRUGS FOR EXTERNAL USE 
885 
Yellow oxid of mercury. 
Antiseptic. Used in ointments of 0.5 to 1% strength in ophthalmia. Of value 
also in ringworm and syphilitic eruptions. 
Mustard. 
Counterirritant. 
In the form of papers (chartce) for local pain or vomiting. 
In the form of powder: 
In pastes of a strength of 1 part of mustard to from 2 to 6 parts of flour. 
In baths—1 tablespoonful to 6 gallons of water. 
In packs, in the same proportion. 
Oil of Cade. (Oil of Juniper Tar.) 
Used as an antiparasitic in skin diseases. 
In powders, 1 to 5% in a base of stearate of zinc. 
In ointments, 1 to 5%. 
In collodion, 1 to 5%. 
Oil of Turpentine. (Spirits of turpentine.) 
Rubefacient and counterirritant. 
Used as an ingredient of liniments. 
Used in the form of turpentine stupes for the relief of abdominal distention. 
Flannel cloths are wrung out in hot water to each pint of which 10 to 20 drops of oil 
of turpentine have been added, and are then applied to the abdomen. 
Olive Oil. 
Used externally as a nutrient inunction. 
Petrolatum (Petroleum Jelly or “Vaselin”). 
Used as a base for ointments. 
Phenol. (Pharmacopceial name of Carbolic Acid.) 
Local anesthetic and antiseptic. 
Used as an antiseptic in solutions of the strength of 5% or less. 
Used as a caustic and local anesthetic in strength of 95%. 
Children are very susceptible to phenol poisoning. 
Pix Liquida. See Tar. 
Potassium Permanganate. 
Antiseptic and disinfectant. 
Used in solutions in the strength of 1 : 4000 to 1 :2000 on mucous surfaces and 
in the strength of 1 : 1000 on ulcers and superficial wounds. 
Resorcin. 
Antiseptic in skin diseases, particulary in seborrheic eczema. 
Lotions, 1 to 5%. 
Ointments, 1 to 5%. 
Silver. 
Silver Nitrate. Antiseptic and astringent. Used in solutions of 1 to 50% strength. 
As a caustic it is used in the solid form. 
Argyrol. (Silver Vitellin—Proprietary.) 
A mild antiseptic, not approaching the nitrate in efficacy. Used in solutions of 
5 to 50% strength or in ointments of 5 to 50% strength. 
Sodium Bicarbonate. 
Used in saturated solution as an antipruritic and as an analgesic in skin diseases 
and burns. 
Starch. 
Used as the base of drying powders. 
Sulphur. 
In 5 to 25% ointments as a parasiticide, particularly in scabies. 
Tar. (Pix Liquida.) 
Antiseptic. Used in skin diseases as the official ointment (50%) or in ointments 
with other ingredients. 
Zinc Oxid. 
Used as a 20% ointment in benzoinated lard in skin diseases, such as eczema, 
needing a mild astringent. 
Used in dusting-powders in the strength of 5 to 10%. 
Official zinc ointment makes a good base for stronger antiseptics, such as tar 
and oil of cade. INDEX 
Abdomen at birth, 37 
Abdominal belt in celiac disease, 265 
in constipation due to developmental 
abnormalities of digestive tract, 260 
tonsil, 288 
tuberculosis, 759 
Ability to hold head erect, 40 
Abscess, ischiorectal, 302 
mammary, in newborn, 177 
of liver, 303 
peritonsillar, 318 
pulmonary, 394 
retropharyngeal, acute, 327-330 
complicating tuberculous caries of 
cervical vertebrse, 330 
spasmodic croup and, differentiation, 
331 
Absence, congenital, of bile-ducts, 181 
of esophagus, 195 
Acarus scabiei, 628 
Acetonuria, 779 
Achondroplasia, 797 
Acid, uric, blood chemistry, 829 
Acidosis, 771 
etiology, 771 
in lobar pneumonia, 361 
pathogenesis, 771 
sodium bicarbonate in, 851 
symptoms, 771 
treatment, 772 
Acrodynia, 791-793 
pellagra and, differentiation, 793 
Acromegaly, 476 
Acute yellow atrophy of liver, 303 
Addison’s disease, 477 
Adenitis, axillary, 457 
cervical, acute, 454--456 
mumps and, differentiation, 456 
persistent, 456 
in influenza, 732 
in measles, 682 
in scarlet fever, 706 
treatment, 712 
inguinal, 457 
retropharyngeal, 327 
spasmodic croup and, differentiation, 
331 
tuberculous, 458-461 
Adenocarcinoma of kidney, 490 
Adenoids, 322 
absence of facial deformity in, 323 
age incidence, 322 
as cause of cough, 311 
association with enlarged tonsils, 325 
diagnosis, 324 
diseased, permanently, necessity for 
operative interference, 325 
drop jaw in. 323 
etiology, 322 
Adenoids, facial expression, 323 
heredity and, 322 
method of examination in, 324 
mouth-breathing in, 323 
necessity for operative interference, 325 
operation for permanent relief, 325 
pathology, 323 
removal of, benefits, 326 
effect upon acute infections, 326 
delicate children, 326 
rhinitis in, 323 
symptoms, 323 
treatment, 325 
without facial deformity, 323 
x-ray treatment, 326 
Adenoma of kidney, 490 
Adenomyosarcoma of kidney, 816 
Adenosarcoma of kidney, 490 
Adherent pericardium, 429 
pleura as cause of cough, 311 
Adrenal gland, tumors of, 477 
Agglutinins, 860 
Agoraphobia, 548 
Air and exercise in breast feeding, 48 
cold, in acute illness, 149 
in lobar pneumonia, 363 
fresh, for delicate children, 143 
for newborn infant, 25 
for premature infant, 165 
in measles, 685 
in whooping-cough, 679 
Airing, indoor, 838 
of nursery, 20 
Air-passages, foreign bodies in, 818 
Albumin milk, 88 
Albuminuria in scarlet fever, 707 
Alcohol, 866, 867 
in bronchopneumonia, 376 
in lobar pneumonia, 366 
Alkalies in milk adaptation, 75 
Alkalosis, 773 
Allergy, milk, 113 
to cow’s milk, 815 
Alpine scurvy, 787 
Alvery, gradient idea of, 254 
Amaurotic family idiocy, 563-565 
Ammoniacal diaper, 102 
treatment of, 103 
Ammonium salts, 867 
Amyotonia congenita, 582 
congenital, poliomyelitis and, differenti- 
ation, 583 
Amyotrophic lateral sclerosis, 577, 578 
Amyotrophy, progressive, 577. See also 
Muscular atrophy, progressive spinal. 
Anal membrane, pereistent, 299 
Anaphylactic reactions following serum 
treatment of cerebrospinal meningitis, 
618 
887 888 
INDEX 
Anaphylaxis, 814 
Anemia, brickmaker’s, 293 
miner’s, 293 
pernicious, 445 
blood in, 446 
lesions, 445 
symptoms, 446 
treatment, 446 
pseudoleukemic, of von Jaksch, 441 
secondary, blood transfusion in, 440 
simple, 438 
splenic, 451 
cirrhosis of liver and, differentiation, 
453 
course, 452 
diagnosis, differential, 453 
etiology, 451 
Gaucher’s disease and, differentiation, 
453 
hemolytic jaundice and, differentia- 
tion, 453 
malaria and, differentiation, 453 
pathology, 452 
prognosis, 452 
symptoms, 452 
syphilis and, differentiation, 453 
treatment, 453 
Anencephalus, 550 
Anesthetics, 869 
Angina gangrenosa, 687 
maligna, 687 
Vincent’s, 319 
Angioma, 816 
Angioneurotic edema, 626 
Angle of mouth, ulcerations and fissures 
at, 191 
Animal broths in acute gastro-enteric in- 
toxication, 239 
Ankylostoma duodenale, 296 
Antacids in milk adaptation, 75 
Antibodies, 860 
Antipyretic drugs as means of relieving 
fever, 807 
Antispasmodics in spasmodic croup, 334 
Antitoxin, tetanus, in tetanus neonatorum, 
178 
treatment of diphtheria, 693 
dosage, 693 
idiosyncrasy to, 695 
late injection, 694 
means of injection, 694 
site of injection, 694 
urticaria after, 695 
Antrum disease, staphylococcus vaccine 
in, 862 
Anus and rectum, 299 
prolapse of, 300 
atresia of, 299 
fissure of, 300 
imperforate, 299 
inflammation of, 300 
Aortic disease, treatment, 427 
regurgitation, heart murmur in, 406 
stenosis, heart murmur in, 405 
Aphthous stomatitis, 186 
Appendicitis, 287 
acute peritonitis and, differentiation, 
289 
pneumonia and, differentiation, 289 
Appendicitis, bacteriology, 288 
chronic, 290 
diagnosis, 289 
differential, 289 
exploratory incision in, 290 
interval operation, 290 
intussusception and, differentiation, 289 
leukocytosis in, 289, 434 
localized muscle rigidity in, 288 
periodic vomiting and, differentiation, 
289 
pleurisy and, differentiation, 289 
prognosis, 289 
symptoms, 288 
treatment, 290 
Appetite, habitual loss, 137-140 
treatment, 138 
in gastric hyperacidity, 203 
in pyloric obstruction, 212 
Arhythmia, cardiac, 408 
Arnold sterilizer, 64 
Arsenicals in acute hereditary syphilis, 
749 
Arthritis deformans, 742 
diagnosis, 794 
gonorrheal, diagnosis, 794 
in scarlet fever, 707 
treatment, 714 
rheumatoid, 742 
Articular rheumatism, acute, 735 
Artificial feeding, 58 
environment in, 59 
needs of patient in, 58 
nutritional errors in, 58 
scientific, 59 
successful, 59 
heat for premature infant, 164 
respiration in asphyxia neonatorum, 170, 
171 
Ascaris lumbricoides, 293 
Asexual dwarfism, 478 
Asphyxia as cause of convulsions, 535 
delayed, of newborn, 172 
livida, 169 
treatment, 171 
neonatorum, 168 
delayed, 172 
Dew method of artificial respiration 
in, 171 
diagnosis, 170 
etiology, 168 
Laborde method of artificial respira- 
tion in, 170 
pathology, 169 
prognosis, 170 
prophylaxis, 170 
Schultze’s method of artificial respira- 
tion in, 171 
symptoms, 169 
treatment, 170 
pallida, 169 
signs of recovery, 172 
Asthenia, neurocirculatory, 811 
Asthma, bronchial, 347 
climate in, 833 
eosinophilia in, 435 
staphylococcus vaccine in, 862 
Asthmatic breathing, 340 
chest, 336 INDEX 
889 
Astraphobia, 548 
Ataxia, Friedreich’s, 600-603 
hereditary, 600-603 
cerebellar, Friedreich’s ataxia and, 
differentiation, 603 
Atelectasis, 172 
Ateliosis, 478 
Athetosis in cerebral paralysis, 569 
Athrepsia, 105. See also Marasmus. 
Atresia ani, 299 
hymenalis, 521 
of urethra, 521 
of vagina, 521 
Atrophies, progressive muscular, 577 
Atrophy, acute yellow, of liver, 303 
infantile, 105. See also Marasmus. 
progressive spinal muscular, 577. See 
also Muscular atrophy, progressive 
spinal. 
Atropin in pyloric obstruction, 218 
Aura of epilepsy, 584 
Auricular fibrillation, 409 
Auscultation, 337 
in acute endocarditis, 418 
in bronchitis, 342 
in bronchopneumonia, 369 
in diseases of heart, 401 
in emphysema, 384 
in interstitial pneumonia, 379 
in pneumothorax, 382 
in secondary pleurisy, 386 
Autoserum treatment of chorea, 575 
Axillary adenitis, 457 
Babinski’s phenomenon in cerebrospinal 
meningitis, 615 
Baby scales, 32 
Bacillus ammoniagenes, 102 
Bordet-Gengou, 674 
vaccine prepared from, in whooping- 
cough, 864 
coli communis in cystitis, 862 
in pyelitis, 863 
Klebs-Loffler, 688 
persistent nasal infection with, 698 
of influenza, 728 
of tuberculosis, 756 
in stool, in pulmonary tuberculosis, 
396 
typhoid fever, 715 
dead, inoculation of, 863 
Bacteria as etiologic factor in hemorrhagic 
diseases of newborn, 183 
in cow’s milk, 62 
suspension of, 861 
Bactericidins, 860 
Balanitis, 511 
Banti’s disease, 451 
Barley jelly, preparation of, 94 
Barley-water, dextrinized, preparation of, 
95 
No. 1, preparation of, 94 
No. 2, preparation of, 94 
Basin bathing for fever, 843 
Baskets for early exercises, 31 
Bath, 842 
basin, for fever, 843 
bran, 844 
Bath, brine, 843 
for comfort in hot weather, 843 
for delicate child, 143 
for newborn infant, 27 
hot, 844 
in illness, 844 
in summer, 836 
mustard, 843 
soda, 844 
starch, 844 
tub-, for fever, 843 
Bed-sores, 656 
Beef broth, preparation of, 94 
foods, proprietary, 92 
juice, preparation of, 94 
scraped, preparation of, 94 
Beef-worm, 295 
Belly, pot, in rickets, 125 
Belt, abdominal, in celiac disease, 265 
in constipation due to developmental 
abnormalities of digestive tract, 260 
Beriberi, 790 
atrophic, 790 
dry, 790 
fulminating type, 790 
infantile, 790 
pernicious type, 790 
rudimentary type, 790 
wet, 790 
Bichlorid of mercury, 866 
Bile-ducts, congenital absence, 181 
Biliary colic, 304 
Birth form of cerebral paralysis, 565 
Birth-mark, 657. See also Ncevus. 
Bladder, diseases of, 509 
exstrophy of, 510 
stone in, 510 
Bleeder’s disease, 448 
Blisters, fever, 637 
Block, heart-, 408 
Blood, 430 
as diagnostic aid, 820 
calcium content, determination of, 830 
carbon dioxid combining power, es- 
timation, 829 
changes in hemophilia, 449 
chemistry determinations, 829 
coagulation time, 438 
diseases of, 430 
in actue poliomyelitis, 589 
in cerebrospinal meningitis, 613 
in diabetes mellitus, 785 
in diseases, 433 
in infections by intestinal parasities, 293 
in newborn, 430 
specific gravity, 430 
in pernicious anemia, 446 
in stools, 104 
in typhoid fever, 717 
in urine, 487 
phosphorus content, determination of, 
830 
transfusion, 848 . 
in bronchopneumonia, 378 
in cyclic vomiting, 777 
in epidemic encephalitis, 621 
in hemorrhagic diseases of newborn, 
185 
in lobar pneumonia, 367 890 
INDEX 
Blood transfusion in secondary anemia, 440 
in sepsis neonatorum, 175 
indications, 849 
vomiting, 205 
Blood-cells, red, 430 
enucleated, 430 
white, 430 
Blood-platelets, 430 
Blood-pressure, 437 
Blood-vessels in tardy hereditary syphilis, 
752 
Bodily mechanics, defective, influence of, 
on health, 800 
Boiled milk, 74 
Boils, 629 
Bones, changes in, in rickets, 121-123 
diseases of, 794 
diagnosis in, 794 
in tardy hereditary syphilis, 752, 753 
Bordet and Gengou’s bacillus, 674 
vaccine prepared from, in whooping- 
cough, 864 
Bothriocephalus latus, 295 
Bovine tuberculosis, 756 
Bowel feeding in acute illness, 151 
function in acute illness, 151 
in breast feeding, 47 
Bowels, evacuation, deficient, 269 
necessary, 268 
in bronchopneumonia, 374 
in lobar pneumonia, 363 
Bradycardia, 407, 408 
Brain, cysts of, 557 
malformations of, 549 
sepsis of, in newborn, 174 
tumors, 557, 816 
tuberculous, 557 
wet, in acute gastro-enteric intoxication, 
235 
Bran'bath, 844 
Breast, abscess of, in newborn, 177 
caking of, 54 
conditions, abnormal, management of, in 
breast feeding, 53 
diseases of, 462 
feeding, 45 
air and exercise and, 48 
bowel function in, 47 
care of nipples, 46 
conditions temporarily producing un- 
favorable effect upon, 51 
determination of milk supply, 49 
diet in, 46 
early giving of water, 46 
exercise $nd air in, 48 
first nursing, 46 
food of mother, 46 
frequency, 48 
fundamental rules, 45 
insufficient, signs of, 51 
management of abnormal breast con- 
ditions in, 53 
milk conditions, 52 
massage of breast after, 46 
maternal conditions under which for- 
bidden, 55 
mixed, 55 
rate of milk secretion, 49 
regularity in, 48 
Breast feeding, signs and causes of unsuc- 
cessful nursing, 49 
of successful nursing, 49 
temporary discontinuance, conditions 
calling for, 52 
massage of, after nursing, 46 
milk, 44 
cow’s milk and, differences between, 
61 
examination, 44 
fat determination, 44 
idiosyncrasy to, 113 
protein estimation, 45 
stools, 103 
sugar determination, 45 
pigeon, in rickets, 123 
Breast-pump, 54 
Breasts, care of, during weaning, 56 
Breath in cyclic vomiting, 775 
Breathing, asthmatic, 340 
bronchial, 339 
bronchovesicular, 340 
cavernous, 340 
diminished, 339 
emphysematous, 340 
vesicular, 338 
distant, 338 
exaggerated, 338, 339 
weakened, 339 
Breck feeder, 165 
Brickmaker’s anemia, 293 
Bright’s disease, 493 
Brine bath, 843 
Bromids in epilepsy, 586 
Bronchial asthma, 347 
breathing, 339 
Bronchiectasis, 378, 379 
Bronchitis, 341 
acute, bronchopneumonia and, differen- 
tiation, 372 
spasmodic, 347-354 
etiology, 348 
interval treatment, 354 
pathogenesis, 351 
pathology, 351 
technic of skin test in, 353 
treatment, 351 
auscultation in, 342 
bacteriology, 341 
capillary, 344, 347 
chronic, 341 
symptoms, 342 
treatment, 345 
counterirritation in, 344, 846 
diagnosis, 342 
differential, 343 
diet in, 343 
drugs in, 344 
duration, 342 
etiology, 341 
in influenza, 732 
mustard baths in, 344 
plaster in, 344 
palpation in, 342 
pathology, 342 
percussion in, 342 
physical signs, 342 
predisposing causes, 341 
primary, 341 INDEX 
891 
Bronchitis, pulmonary tuberculosis and, 
differentiation, 343 
recurrent, 346 
bathing in, 347 
depending on rheumatic state, 741 
diet in, 346 
medication in, 347 
treatment, 346 
secondary, 341 
treatment, 345 
steam inhalations in, 343 
symptoms, 342 
treatment, 343 
types, 341 
Bronchopneumonia, 368 
active type, 371 
acute bronchitis and, differentiation, 
372 
alcohol in, 376 
auscultation in, 369 
bacteriologic etiology, 368 
bath in, 376 
blood transfusion in, 378 
bowels in, 374 
cold sponging in, 377 
complications, 372 
counterirritants in, 374 
diet in, 373 
differential diagnosis, 372 
drugs in, 375 
duration, 370 
empyema after, 389 
etiology, 368 
fever in, treatment, 376 
following other diseases, 372 
heart stimulants in, 375 
hypodermic medication in, 376 
in influenza, 732 
in measles, 682 
in scarlet fever, 707 
lobar pneumonia and, differentiation, 372 
mustard baths in, 375 
oxygen in, 378 
palpation in, 370 
pathology, 369 
percussion in, 369 
physical signs, 369 
prognosis, 373 
sick-room in, 373 
special types, 371 
steam inhalations in, 374 
symptoms, 370 
treatment, 373 
general, 374 
Bronchoscope, 820 
Bronchovesicular breathing, 340 
Broth, beef, preparation of, 94 
chicken, preparation of, 94 
mutton, preparation of, 94 
Broths, animal, in acute gastro-enteric in- 
toxication, 239 
Buccal spots in measles, 681 
Buhl’s disease, 182 
Bulb, Hess, 211 
Bulbar paralysis, progressive, 578 
Butter-flour feeding, 86 
Buttermilk, 87 
Butyric acid test, Noguchi’s, for syphilis, 
827 
Cabot on bronchial breathing, 339 
on characteristics of respiration, 338 
Caking of breast, 54 
Calcification of teeth, 38 
Calcium content of blood, determination, 
830 
Calculus, vesical, 510 
Calmette’s tuberculin test, 825 
Calomel fumigations in spasmodic croup, 
333 
Caloric diet, high, in typhoid fever, 721 
feeding, value of, 24 
requirements of children of different 
ages, 23 
of infant, 73 
values from food composition percent- 
ages, calculation of, 22 
Calorimetric standard of milk adaptation, 
67 
Camp, summer, 132 
Cancrum oris, 190 
Cane-sugar, 21 
Capacity of stomach, 196 
Capillary bronchitis, 344, 347 
Carbohydrates, function of, 20 
Carbon dioxid combining power of blood, 
estimation, 829 
Carcinoma, 815 
Cardiac. See Heart. 
Cardiorespiratory heart murmur, 406 
Care and feeding as factors in nutrition 
and growth of newborn infant, 17 
Carriers, diphtheria, 687 
Castor oil, 867 
Catarrh, nasal, 308 
Catarrhal ileocolitis, 244 
jaundice, 304 
laryngitis, acute, 330. See also Spas- 
modic croup. 
pneumonia, 368. See also Broncho- 
pneumonia. 
proctitis, 301 
stomatitis, 186 
Catheterization, duodenal, 821 
Cavernous breathing, 340 
Cecum, dilated, 259 
Celiac disease, 263 
abdominal belt in, 265 
etiology, 263 
management, 264 
symptoms, 263 
Cells, mast, 431 
transitional, 431 
Central pneumonia, 361 
Centrifugal cream, 66 
Cephalhematoma, 166 
Cephalogie 6pid6mique, 610 
Cereal decoctions in acute gastro-enteric 
intoxication, 239 
feeding, thick, 85 
gruels, 83 
for milk adaptation, 77 
in gastro-enteric diseases, 84 
in infectious diseases, 84 
Cereal-milk mixtures, concentrated, 85 
Cerebellar ataxia, hereditary, Friedreich’s 
ataxia and, differentiation, 603 
Cerebral palsies, 565 
acquired form, 568 892 
INDEX 
Cerebral palsies, birth form, 565 
prenatal form, 565 
Cerebrospinal fluid, diagnostic character- 
istics, 622, 623 
in acute poliomyelitis, 588 
in cerebrospinal meningitis, 612 
meningitis, 610 
abdominal condition in, 614 
Babinski’s phenomenon in, 615 
bacteriology, 611 
blood in, 613 
cerebrospinal fluid in, 612 
complications, 615 
convulsions in, 613 
diagnosis, 614 
differential, 615 
duration, 615 
ears in, 614 
emaciation in, 615 
etiology, 611 
eyes in, 614, 615 
Flexner’s serum in, 616 
fontanel in, 613 
fulminating, 612 
headache in, 613 
heart in, 613 
hyperesthesia in, 614 
Kernig’s sign in, 614 
mental apathy in, 613 
mode of invasion, 611 
muscle rigidity in, 613 
patellar reflex in, 615 
pathology, 611 
position of patient in, 613 
pulse in, 615 
respiration in, 613, 615 
serum treatment, 616-619 
anaphylactic reactions following, 
618 
skin in, 614 
symptoms, 612 
in recovery cases, 614 
tache c6rebrale in, 615 
temperature in, 613, 615 
treatment, 616 
vaccine treatment, 619 
vomiting in, 613 
Certified milk, 63 
requirements of Milk Commission of 
New York County Medical Society 
for production, 63 
Cervical adenitis, acute, 454-456 
mumps and, differentiation, 456 
in scarlet fever, 706 
treatment, 712 
persistent, 456 
lymph-nodes, tuberculosis of, 458 
Chapin dipper, 70 
Charcot-Marie-Tooth type of progressive 
spinal muscular atrophy, 578 
Charcot’s disease, 577 
Charlton and Schultz extinction test in 
scarlet fever, 704 
Chemical agents as etiologic factor in 
hemorrhagic diseases of newborn, 183 
Cherry red spot in amaurotic family 
idiocy, 565 
Chest and head circumferences at birth, 
Chest, asthmatic, 336 
auscultation of, 337 
contracted, 336 
defective expansion, 336 
depressed, 336 
distended, 336 
dulness of, 337 
tympanitic, 337 
fixed, 336 
flatness of, 337 
funnel, in rickets, 125 
hyperresonance of, 337 
palpation of, 336 
percussion of, 337 
resonance of, 337 
tympanitic, 337 
Chicken broth, preparation of, 94 
Chickenpox, 670-672 
smallpox and, differentiation, 668 
Child, management of, necessity of method 
in, 131 
normal development, 140 
subnormal, physically, 140-146. See also 
Subnormal child, ■physically. 
Childhood, care and nutrition in, 131 
Chine-cough, 674 
Chink cough, 674 
Chlorate of potash in stomatitis, 188 
dangers, 188 
Chloroform as anesthetic, 869 
in convulsions, 537 
Chlorosis, 440 
Egyptian, 293 
Cholera infantum, 234. See also Gastro- 
enteric intoxication. 
Chondritis, fetal, 797 
Chondrodystrophia, 797-800 
fcetalis, 797 
malacia, 798 
hyperplastic form, 798 
hypoplastic form, 798 
Chondrodystrophy, 478 
Chondroma, 816 
Chondromalacia, 797 
Chorea, 570 
anglorum 570 
antirheumatic treatment, 574 
autoserum treatment, 575 
chronic adult, 570 
progressive, 570 
congenital, 570 
diagnosis, 572 
drugs in, 574 
duration, 573 
electric, 570 
entertainments in, 573 
etiology, 570 
Fowler’s solution in, 574 
gravidarum, 570 
habit spasm and, differentiation, 572 
minor, 570 
pathology, 571 
posthemiplegic, 570 
prognosis, 573 
recurrence, 573 
rest treatment, 573 
rheumatism and, relation, 571 
salicylate of soda in, 574 
school in, 573 INDEX 
893 
Chorea, senile, 570 
supplementary treatment, 575 
symptoms, 571 
treatment, 573 
vulgaris, 570 
Choreic insanity, 570 
Chvostek’s sign in spasmophilia, 541 
in tetany, 545 
Circumcision, 512 
Cirrhosis of liver, 304 
splenic anemia and, differentiation, 
453 
Cisterna puncture, 823 
Claw-hand in progressive spinal muscular 
atrophy, 578 
Cleft-palate, 193 
Climate, change of, in habitual loss of 
appetite, 139 
for subnormal children, 144 
in asthma, 833 
in digestive disorders, 833 
in influenza, 734, 833 
in malnutrition, 833 
in nephritis, 833 
in pneumonia, 833 
in pulmonary tuberculosis, 397 
in tetany, 547 
in tuberculosis, 834 
in whooping-cough, 833 
influence of, in acute ileocolitis, 249 
therapeutic value, 833 
Clothing for subnormal children, 145 
in acute illness, 149 
in dermatitis, 648 
in heliotherapy, 26 
in lobar pneumonia, 363 
in scarlet fever, 709 
in summer, 835 
Clubbed fingers in congenital heart disease, 
410, 412 
Coagulation time of blood, 438 
Coal-tar products for relieving fever, 807 
Coca-quinin, 867 
Coddled egg, preparation of, 94 
Cod-liver oil in rickets, 127 
in tetany, 547 
Coffee mill heart murmur, 411 
Cold air in acute illness, 149 
in lobar pneumonia, 363 
as therapeutic agent, 847 
compresses in spasmodic, croup, 333 
douche, 842 
in head, 306 
sponging in bronchopneumonia, 377 
in fever, 840 
vaccines, 864 
Colic, 100, 225 
biliary, 304 
counterirritation in, 847 
diagnosis, 226 
diet in, 227 
enemas in, 227 
hot applications in, 227 
medication in, 227 
treatment, 226 
Colitis, acute, 243. See also Ileocolitis, 
acute. 
chronic, 250. See also Ileocolitis, chronic. 
mucous, 251 
Colloidal gold test, Lange’s, for syphilis, 828 
Colon flushing, 857 
iodiopathic dilatation, 261 
irrigation, 855 
in acute enteric intoxication, 243 
ileocolitis, 248 
Colonic feeding, 97 
Colony management of epilepsy, 586 
Communicating hydrocephalus, 551 
Complement fixation test for syphilis, 826 
Compresses, cold, in spasmodic croup, 333 
Concentrated cereal-milk mixtures, 85 
Concepts, imperative, 548 
Condensed milk, 78 
in acute gastro-enteric intoxication, 239 
sweetened, in marasmus, 110 
Confluent smallpox, 668 
Congenital syphilis, 744. See also Syphilis, 
acute hereditary. 
Congenitally weak infant, 164 
Congestion, physiologic, of thyroid gland, 
463 
premenstrual, of thyroid gland, 463 
stage in lobar pneumonia, 356 
Consanguinity, 805 
Consciousness in newborn infant, 39 
Constipation, 102, 267 
bowel evacuation necessary, 268 
defective bowel evacuation, 269 
etiology, 267 
in bottle fed, 271 
drugs in, 272 
laxative agents in food, 272 
local measures in, 272 
oil injections in, 273 
reduction of protein, 272 
in developmental abnormalities of intes- 
tinal tract, treatment, 260 
in gastric hyperacidity, 203 
in nurslings, 270 
drugs in, 271 
enema in, 271 
malted foods in, 271 
massage in, 271 
suppositories in, 271 
treatment of child, 270 
of mother, 270 
in older children, 273 
diet in, 273 
after fifth year, 275 
after second year, 274 
drugs in, 275 
etiology, 273 
from mechanical obstruction, 273 
local causes, 273 
measures in, 275 
regular habits in, 273 
in pyloric obstruction, 212 
obstinate, treatment, 276 
Constitutional neurocirculatory asthenia, 
811 
Contagious diseases, 665 
care of physician in visiting, 666 
Contracted chest, 336 
Convulsions, 533 
asphyxia as cause, 535 
chloroform in, 537 
dentition, 535 
diet in, 536 894 
INDEX 
Convulsions, enlargement of thymus gland 
as cause, 534 
etiology, 534 
gastro-intestinal causes, 534 
hypodermic medication in, 537 
in acute diffuse nephritis, 496 
in cerebrospinal meningitis, 613 
in newborn, 535 
manifestations, 535 
of toxic origin, 534 
phimosis as cause, 535 
prognosis, 536 
rachitis as cause, 534 
rectal medication in, 537 
repetition, 535 
sedatives in, 537 
tetany as cause, 535 
treatment, 536 
uremic, treatment, 501 
Cool pack, 841 
Cord, umbilical, care of stump, 175 
hernia of, 283 
Corn-bread disease, 787 
Cornstarch pudding, preparation of, 94 
Corpuscles, white, normal, 431 
Correct posture, 800 
Coryza, 306 
Cough, 310 
adenoids as cause, 311 
adherent pleura as cause, 311 
chink, 674 
enlarged mediastinal glands as cause, 312 
foreign body, 312 
habit, 310 
in influenza, 730 
in measles, 681 
treatment, 684 
king’s, 674 
nervous, 310 
persistent, 310 
stomach, 310 
teething, 310 
tracheal, 311 
tuberculosis as cause, 312 
types, 310 
whooping-cough as cause, 312 
Counterirritants, 846 
Counterirritation, 846 
in bronchitis, 344 
in bronchopneumonia, 374 
indications, 846 
in lobar pneumonia, 363 
in secondary pleurisy, 387 
Cow’s milk. See Milk, cow’s. 
Cracked nipples, 53 
Craniectomy in microcephalus, 555 
Craniotabes in rickets, 123 
Cream, 66 
centrifugal, 66 
gravity, 66 
Creatinin, blood chemistry, 829 
Cred6’s method of prophylaxis of ophthal- 
mia neonatorum, 179 
Creosote, 867 
Crepitant r&les, 341 
Cretinism, 464, 478 
acquired, 466 
diagnosis, 466 
etiology, 465 
Cretinism, pathology, 465 
prognosis, 467 
rickets and, differentiation, 126 
symptoms, 466 
thyroid treatment, 467-469 
treatment, 467 
Cretinoid idiocy, 464. See also Cretinism. 
Croup, 687 
spasmodic, 330. See also Spasmodic 
croup. 
Crust, milk, 654 
Crying, 40 
as exercise, 28 
Curds in stools, 104 
Custard, soft, preparation of, 92 
Cutaneous inoculation with tuberculin in 
diagnosis of tuberculosis, 824 
sensation in newborn infant, 39 
Cyclic diarrhea, 777 
vomiting, 773 
blood transfusion in, 777 
breath in, 775 
diagnosis, differential, 775 
etiology, 774 
prognosis, 775 
secondary etiologic factors, 774 
symptoms, 774 
treatment in intervals, 775 
of acute attack, 776 
Cyclops, 550 
Cystitis, 509 
Bacillus coli communis in, 863 
Cysts, intestinal, 281 
of brain, 557 
of kidney, 492 
Dactylitis, 768-770 
syphilitic, 768 
tuberculous, 768 
Day-terrors, 522 
Days to go out-of-doors, 838 
Deafness, 658 
Deaths, infant due to various causes, 162 
percentage of, 161-163 
Decubitus, 656 
Defective bodily mechanics, influence of, 
on health, 800 
expansion of chest, 336 
Deficiency, mental, 558. See also Mental 
deficiency. 
Deformities in rickets, treatment, 128 
Deformity following untreated cases of 
empyema, 392 
Delicate child, 140. See also Subnormal 
child, physically. 
Delirium in lobar pneumonia, 360 
Dementia praecox, 549 
Dentition as cause of convulsions, 535 
difficult, 192 
Depressed chest, 336 
nipples, 54 
Dermatitis, 642 
age incidence, 643 
bathing in, 648 
clothing in, 648 
due to seborrhea, 653 
etiology, 642 
Herty mask in, 649 895 
INDEX 
Dermatitis in bottle fed, treatment, 646’ 
in breast fed, treatment, 645 
in older children, 651 
bathing in, 653 
etiology, 651 
prognosis, 652 
symptoms, 651 
treatment, 652 
local irritation as factor, 644 
neurotic, 651 
physical condition in, 643 
prognosis, 645 
protein sensitization in, 644 
reflex, 651 
seborrheic, 653 
suboxidation in, 643 
symptoms, 644 
toxic origin, 643 
traumatic, 649 
treatment, 645 
local, 647 
D’Espine’s sign, 810 
in pulmonary tuberculosis, 396 
Desquamation in German measles, 686 
in scarlet fever, 705 
Detre’s tuberculin test, 825 
Development, abnormal, 140 
normal, of child, 140 
Developmental abnormalities in intestinal 
tract as cause of digestive disturb- 
ances, 253 
disorders attributed to endocrine dys- 
crasia, 477 
Deviation test for syphilis, 826 
Dew method of artificial respiration in as- 
phyxia neonatorum, 171 
Dextrin, 21 
Dextrinized barley-water, preparation of, 95 
Diabetes insipidus, 783 
mellitus, 784 
blood in, 785 
diagnosis, 786 
diet in, 787 «j 
duration, 786 
etiology, 784 
insulin in, 786 
morbid anatomy, 784 
pathogenesis, 784 
prognosis, 786 
symptoms, 785 
treatment, 786 
urine in, 785 
Diagnosis, 157 
by inspection, 159 
during sleep, 160 
knowledge of normal, 157 
Diagnostic methods, 820-830 
Diaper, ammoniacal, 102 
Diaphragm, spasm of, 533 
Diaphragmatic hernia, 285 
congenital, pneumothorax and, dif- 
ferentiation, 383 
Diarrhea, 102 
cyclic, 777 
in developmental abnormalities of in- 
testinal tract, treatment, 261 
in lobar pneumonia, 360 
in typhoid fever, treatment, 722 
protein milk in, 88 
Diathesis, lithemic, 738 
rheumatic, 738. See also Rheumatit 
diathesis. 
Dick test in scarlet fever, 704 
Diesophagus, 195 
Diet after first year in physically sub- 
normal child, 142 
from eighteenth month to third year, 
135 
from fifteenth to eighteenth month, 135 
from fifth to seventh year, 136 
from first to eleventh year, 134 
from seventh to eleventh year, 136 
from third to fifth year, 135 
from twelfth to fifteenth month, 135 
high caloric, in typhoid fever, 719 
in acute diffuse nephritis, 498 
endocarditis, 420 
gastric indigestion, 201 
gastro-enteric intoxication, 238 
illness, 150 
meningitis, 605 
in breast feeding, 46 
in bronchitis, 343 
in bronchopneumonia, 373 
in chronic ileocolitis, 250 
in colic, 227 
in constipation in older children, 273 
after fifth year, 275 
after second year, 274 
in convalescence of acute ileocolitis, 249 
in convulsions, 536 
in diabetes mellitus, 787 
in epilepsy, 585 
in etiology of rickets, 119 
in habit spasm, 576 
in habitual loss of appetite, 139 
in icterus, 305 
in illness, 154 
art of, 154 
reduction of food strength, 154 
in laryngismus stridulus, 539 
in lobar pneumonia, 364 
in mucous colitis, 252 
in obesity, 479 
in pulmonary tuberculosis, 397 
in recurrent bronchitis, 346 
in rheumatic diathesis, 739 
in rickets, 127 
in scarlet fever, 709 
in scurvy, 117 
in smallpox, 669 
in tetany, 547 
in typhoid fever, 719 
milk, in scarlet fever, 710 
salt-free, in acute diffuse nephritis, 498 
Dietetic glycosuria, 489 
Digestion, gastric, 196 
starch, infant’s capacity for, 84 
Digestive disorders, climate in, 833 
common, of infancy, 99 
recognition of, 99 
developmental abnormalities in intes- 
timal tract as cause, 253 
Digitalis, 867 
Dilatation, idiopathic, of colon, 261 
of esophagus, 195 
of stomach in older children, 221-225 
vomiting in, 199 896 
INDEX 
Dilated cecum, 259 
Diminished breathing, 339 
Diphtheria, 686 
age incidence, 687 
antitoxin treatment, 693. See also 
Antitoxin treatment of diphtheria. 
bacillus of, 688 
bacteriology, 688 
carriers, 687 
complications, 693 
diagnosis, 692 
differential, 692 
heart stimulants in, 696 
history, 686 
immunization in, 695 
in scarlet fever, 706 
incubation period, 691 
intubation in, 699-701 
laryngeal, 696 
suction in, 701 
leukocytosis in, 436 
localization of membrane, 692 
lymph-glands in, 692 
multiple neuritis after, 593 
gavage in, 597 
treatment, 596 
nasal, 697 
acute rhinitis and, differentiation, 306 
chronic, 698 
nourishment in, 696 
pathology, 691 
predisposition, 687 
prognosis, 693 
quarantine in, 695 
Schick test in, 688-691 
sick-room regime in, 696 
susceptibility to, 688 
symptoms, 691 
temperature in, 692, 696 
throat irrigation in, 696 
tonsillar, acute follicular tonsillitis and, 
differentiation, 315, 316 
tonsillitis and, differentiation, 692 
toxin-antitoxin immunization in, 688- 
691 
transmission, 687 
treatment, 693 
Diplococcus of rheumatism, 413 
Directions, written, in acute illness, 153 
Disease prevention, 133 
general safeguards, 133 
specific measures, 133 
Dispensary infants and children, rules for 
summer care, 837, 838 
Distended chest, 336 
Diuretin in hydrocephalus, 554 
Diverticulum, intestinal, congenital, 281 
Meckel’s, 282 
appendicitis and, differentiation, 282 
Double empyema, 393 
Douche, cold, 842 
Drainage, suction, in empyema, 393 
Drinking of water in acute illness, 150 
Dromomania, 548 
Drop jaw in adenoids, 323 
Drugs, 866 
dosage, 866 
for external use, 882-885 
for internal use, 871-882 
Drugs in acute illness, 151 
nauseating, 866 
unpalatable, 866 
Dry heat, 845 
protein milk, 89 
Dubini’s disease, 570 
Duchenne-Aran’s disease, 577, 578 
Dulness of chest, 337 
tympanitic, 337 
Duodenal catheterization, 821 
ulcer, 286 
Dwarfism, 477 
asexual, 478 
sexual, 478 
symptomatic, 478 
true, 478 
Dyscrasia, endocrine, developmental dis- 
orders attributed to, 477 
Dysentery, 243. See also Ileocolitis, acute. 
Dyspituitarism, 475 
Dystrophy adiposogenitalis, 475 
muscular, primary, 579 
Dysuria, 482 
Ear, diseases of, 658 
Earache, 658 
Ears in cerebrospinal meningitis, 614 
in measles, treatment, 684 
in tardy hereditary syphilis, 751 
Ecthyma, 635 
Eczema, 642. See also Dermatitis. 
eosinophilia in, 435 
Edebohls’ operation in chronic diffuse 
nephritis, 504 
Edema, angioneurotic, 626 
Education, 132 
for subnormal children, 145 
Effort syndrome, 811 
Effusion, pleurisy with, 386 
pleuritic, lobar pneumonia and, differ- 
entiation, 362 
purulent, pleurisy with, 388. See also 
Empyema. 
Egg, coddled, preparation of, 94 
Egg-water, preparation of, 94 
Egyptian chlorosis, 293 
Eighteenth month to third year, diet from, 
135 
Eiweissmilch, 88 
Electric chorea, 570 
irritability in tetany, 545 
reaction in cerebral paralysis, 569 
reactions as diagnostic aids, 820 
in acute poliomyelitis, 591 
in multiple neuritis, 595 
Electricity in acute poliomyelitis, 592 
Elimination as means of relieving fever, 807 
Elongated sigmoid, 256 
Emaciation in cerebrospinal meningitis, 
615 
Embryonal sarcoma of kidney, 816 
Emphysema, 383 
auscultation in, 384 
of mediastinum, subcutaneous emphy- 
sema with, 384 
pathology, 383 
percussion in, 383 
physical signs, 383 INDEX 
897 
Emphysema, prognosis, 384 
subcutaneous, with emphysema of me- 
diastinum, 384 
symptoms, 383 
treatment, 384 
Emphysematous breathing, 340 
Empyema, 388 
after bronchopneumonia, 389 
lobar pneumonia, 389 
age incidence, 388 
bacteriology, 388 
counterirritation in, 847 
deformity following untreated cases, 392 
diagnosis, 390 
differential, 391 
double, 393 
encysted, as cause of elevation of tem- 
perature, 809 
etiology, 388 
in lobar pneumonia, 361 
leukocytosis in, 433 
malaria and, differentiation, 391 
necessitatis, 393 
pathology, 388 
pleurisy and, differentiation, 391 
pulmonary tuberculosis and, differentia- 
tion, 391 
suction drainage in, 393 
symptoms, 389 ' 
treatment, 391 
typhoid fever and, differentiation, 391 
unresolved pneumonia and, differentia- 
tion, 391 
Encephalitis, epidemic, 619 
lethargica, 619 
Encephalocele, 549 
Endocarditis, acute, 416 
age incidence, 416 
antirheumatic treatment, 421 
auscultation in, 418 
bacteriology, 417 
convalescence in, 421 
diagnosis, 418 
differential, 419 
diet in. 420 
drugs in, 420 
etiology, 416 
family susceptibility, 417 
ice-bag in, 420 
inspection in, 418 
palpation in, 418 
pathology, 417 
percussion in, 418 
prognosis, 419 
prolonged inactivity in, 419 
recurrence, 421 
rest in bed in, 419 
symptoms, 418 
treatment, 419 
in influenza, 732 
in scarlet fever, 707 
malignant, 417 
Endocrine disorders, differentiation, 479 
dyscrasia, developmental disorders at- 
tributed to, 477 
Enema in colic, 227 
in constipation in nurslings, 271 
nutrient, method of giving, 97 
peptonized milk for, 77 
Enteric intoxication, acute, 241-243 
Entertainment for subnormal children, 145 
Enuresis, 484-487 
diurna, 484 
nocturna, 484 
of nervous origin, 485 
Environment, 804 
as factor in nutrition and growth of 
newborn infant, 17 
in artificial feedling, 59 
in etiology of rickets, 119 
Eosinophilia, diseases with, 435 
from parasitic infection, 435 
in asthma, 435 
in congenital syphilis, 435 
in eczema, 435 
in pemphigus, 435 
Eosinophilic myelocytes, 431 
Eosinophils, 431 
Epidemic encephalitis, 619 
parotitis, 672-674 
Epilepsy, 583 
aura of, 584 
bromids in, 586 
care of bowels in, 585 
colony management, 586 
diagnosis, 585 
diet in, 585 
drugs in, 586 
etiology, 583 
grand mal, 584 
in cerebral paralysis, 567, 569 
luminal in, 586 
petit mal, 584 
prognosis, 585 
treatment, 585 
types, 584 
Epiphysitis, acute, in acute hereditary 
syphilis, 748 
Epispadias, 516 
Erb’s juvenile type of progressive mus- 
cular atrophy, 579 
paralysis, 598 
Eructation of gas in gastric hyperacidity, 
203 
Erysipelas, 639 
complications, 640 
convalescence in, 642 
etiology, 639 
ichthyol in, 641 
mode of entrance of streptococcus in, 
639 
prognosis, 640 
serum treatment, 642 
specific therapy, 642 
stimulants in, 641 
streptocccus vaccine in, 862 
symptoms, 640 
treatment, 640 
vaccine therapy, 642 
Erythema multiforme, 637 
nodosum, 636 
Erythrocytes, 430 
Esophagoscope, 820 
Esophagotracheal fistula, 195 
Esophagus, absence of, 195 
dilatation of, 195 
diseases of, 186 
malformation of, 194 898 
INDEX 
Esophagus, stenosis of, 195 
stricture of, 195 
Ether as anesthetic, 869 
Ethyl chlorid as anesthetic, 870 
Evaporated milk, 78 
feeding, formulas for, 81, 82 
in acute gastro-enteric intoxication, 
239 
Exaggerated breathing, 338, 339 
Examination, 157 
first, 157 
knowledge of normal, 157 
of lungs, 336 
of throat, 312 
Excreta, disposal of, in typhoid fever, 719 
Exercise, active, elevation of temperature 
from, 808 
and air in breast feeding, 48 
crying as, 28 
early, baskets for, 31 
for subnormal children, 145 
in obesity, 479 
pen, 839 
Exhaustion, gavage in, 855 
Exophthalmic goiter, 464 
Expansion, defective, of chest, 336 
Expectorants in spasmodic croup, 331 
Exploratory puncture in secondary pleu- 
risy, 387 
Exstrophy of bladder, 510 
Extinction test in scarlet fever, 704 
Eyes in cerebrospinal meningitis, 614, 615 
in measles, 681 
treatment, 684 
in tardy hereditary syphilis, 751, 754 
Face, myopathic, 582 
Facial expression in adenoids, 323 
paralysis, 597 
Fainting attacks, 409 
Falling sickness, 583 
Family idiocy, amaurotic, 563-565 
Fat determination of breast milk, 44 
function of, 20 
in cow’s milk, 60 
in modified milk, 69 
Fat-soluble vitamin, lack of, in etiology 
of rickets, 120 
Fatty changes in liver, 303 
Faucial tonsils, 314 
Faucitis, 313 
Fears, morbid, 548 
Feces. See Stools. 
Feeder, Breck, 165 
Feeding after first year, 134 
and care as factors in nutrition and 
growth of newborn infant, 17 
artificial, 58. See also Artificial feeding. 
bowel, in acute illness, 151 
breast, 45. See also Breast feeding. 
butter-flour, 86 
caloric, value of, 24 
cereal, thick, 85 
colonic, 97 
condensed milk, 78 
errors in, 137 
evaporated milk, 78 
forced, 853 
Feeding, infant, 42 
method of von Pirquet School, 24 
mixed, 55 
nem system of, 24 
night, 72 
of premature infants, 165 
physically subnormal child, 141 
rectal, 97 
method of giving, 97 
nourishment not to be used, 98 
to be used, 98 
starch, 83 
stomach, substitutes for, 96 
temporary, in marasmus, 109 
top milk, 72 
whey, 76 
Feeling, beginning of, in newborn infant, 39 
Female genitals, diseases of, 516 
Fetal chondritis, 797 
rickets, 797 
Fever, 806 
as an indication, 806 
basin bathing for, 843 
blisters, 637 
cold sponging in, 840 
importance of, 807 
in bronchopneumonia, treatment, 376 
in lobar pneumonia, treatment, 364 
methods of relieving, 807 
tub-baths for, 843 
Fibrillation, auricular, 409 
Fibrinous pneumonia, 355 
Fibroma of kidney, 490 
Fievre ceicbrale, 610 
Fifteenth to eighteenth month, diet from, 
135 
Fifth to seventh year, diet from, 136 
Filatow’s spots in measles, 681 
Finger-sucking, 529 
Finger-tips, picking and rubbing, 530 
Fingers, clubbed, in congenital heart dis- 
ease, 410, 412 
Finkelstein’s milk, 88 
First examination, 157 
to eleventh year, diet from, 134 
year, feeding after, 134 
Fissure of anus, 300 
Fissured nipples, 53 
Fissures at angle of mouth, 191 
in acute hereditary syphilis, 747 
of lips, 191 
Fistula, esophagotracheal, 195 
Fixed chest, 336 
Flatness of chest, 337 
Flexner’s serum in cerebrospinal menin- 
gitis, 616 
Flours, percentage gruel, preparation of, 95 
Fluid requirement of infant, 73 
Fluoroscopy, 820 
Flushing, colon, 857 
Follicular tonsillitis, acute, 314 
Fontanel in cerebrospinal meningitis, 613 
Fontanels at birth, 37 
Food, advantage of knowledge of composi- 
tion, 21 
chemical composition of, 22 
common, values of, 22 
composition percentages, calculation of 
caloric values from, 22 899 
INDEX 
Food, dried-milk, proprietary, 91 
elements, function of, 19 
in breast feeding, 46 
ingredients, 19 
one hundred calorie portion, 23 
properties and physiologic requirements, 
19 
proprietary, 91 
addition of fresh cow’s milk, 92 
beef, 92 
composition of, 92 
dried-milk, 91 
retention in pyloric obstruction, 211 
selection of, 24 
strength, reduction in, in illness, 154 
in summer, 835 
supplementary, preparation of, 94 
Forced feeding, 853 
Foreign bodies, 817 
in air-passages, 818 
in larynx, 335, 818 
in nose, 817 
in stomach, 818 
body cough, 312 
Formative period, 131 
Fowler’s solution in chorea, 574 
Fragilitas ossium, 796 
Freeman pasteurizer, 64 
Fresh air for delicate children, 143 
for newborn infant, 25 
for premature infant, 165 
in measles, 685 
in whooping-cough, 679 
Friedreich’s ataxia, 600-603 
hereditary cerebellar ataxia and, dif- 
ferentiation, 603 
juvenile tabes dorsalis and, differentia- 
tion, 603 
multiple neuritis and, differentiation, 
603 
sclerosis and, differentiation, 603 
Frohlich’s dystrophy adiposogenitalis, 475 
Frozen milk, 75 
Fumigations, calomel, in spasmodic croup, 
333 
Functional heart murmurs, 406 
Funicular hydrocele, 514 
Funnel chest in rickets, 125 
Furunculosis, 629 
staphylococcus vaccine in, 862 
Gait, waddling, in pseudomuscular hyper- 
trophy, 582 
Gangrene, pulmonary, 393 
Gas, eructation of, in gastric hyper- 
acidity, 203 
Gastric analysis as diagnostic aid, 821 
capacity in newborn infant, 38 
contents, examination of, in gastric 
hyperacidity, 203, 204 
digestion, 196 
hyperacidity, 202-205 
indigestion, acute, 200 
chronic, 202 
Gastritis, acute, 200 
chronic, 202 
Gastro-enteric diseases, cereal gruels in, 
84 
Gastroenteric intoxication, acute, 234 
animal broths in, 239 
condensed milk in, 239 
diet in, 238 
drugs in, 237 
evaporated milk in, 239 
feeding during attack, 236 
feedings after first year in, 240 
hypodermoclysis in, 238 
intraperitoneal infusions in, 238 
intravenous infusions in, 238 
pathology, 235 
protein milk in, 240 
skimmed milk in, 238 
symptoms, 234 
termination of, 240 
treatment, 235 
wet brain in, 235 
wet-nurse in, 239 
cereal decoctions in, 239 
Gastro-enteritis, leukocytosis in, 435 
Gastro-intestinal causes of convulsions, 534 
tract, mechanical defects in, as etiologic 
factors in gastro-intestinal disorders, 
220 
Gaucher’s disease, 453 
splenic anemia and,"differentiation, 453 
Gavage, 853 
in exhaustion, 855 
in lobar pneumonia, 366 
in malnutrition, 855 
in multiple neuritis after diphtheria, 597 
in narcosis, 855 
in obstinate vomiting, 854 
in severe illness, 854 
indications, 854 
peptonized milk for, 77 
Genitals, female, diseases of, 516 
male, diseases of, 511 
Geographic tongue, 191 
German measles, 685 
scarlet fever and, differentiation, 686 
Giant hives, 626 
Gigantism, 476 
Glands, pituitary, 475 
thymus, 470 
thyroid, 463 
Glandular fever, 457 
system, diseases of, 451 
Globus hystericus, 526 
Glucose in acidosis, 772 
Glycosuria, 489 
dietetic, 489 
temporary, 489 
Goiter, congenital, 463 
exophthalmic, 464 
simple, in older children, 464 
Goldbloom needle, 850 
Gonococcus vaccine, 863 
Gonorrhea in male, 515 
Gonorrheal arthritis, diagnosis, 794 
ophthalmia in newborn, 178 
vulvovaginitis, 518 
Grade cows, 60 
Gradient idea of Alvery, 254 
Grand mal type of epilepsy, 584 
Granuloma, umbilical, 175 
Granum-water No. 1, preparation of, 95 
No. 2, preparation of, 95 900 
INDEX 
Gravity cream, 66 
Gray hepatization in lobar pneumonia, 357 
Gruber-Widal reaction in typhoid fever, 
715, 823 
Gruel flours, percentage, preparation of, 95 
Gruels, cereal, 83 
for milk adaptation, 77 
in gastro-enteric diseases, 84 
Gymnastic therapeutics in interstitial 
pneumonia, 381 
Gyrospasm, 524 
Habit cough, 310 
spasm, 575 
chorea and, differentiation, 572 
vomiter, 101 
Habits, 529 
bad, correction of, 529 
Habitual loss of appetite, 137-140 
treatment, 138 
Hamburger’s tuberculin test, 824 
Hand in tetany, 545 
Hand-I-Hold mit to prevent masturba- 
tion, 533 
Harelip, 193 
Harrison’s grooves in rickets, 123 
Hay-fever, 354 
skin test in, 355 
Head and chest circumferences at birth, 
36 
cold in, 306 
lice, 630 
rachitic, 125 
Headache, 522 
in cerebrospinal meningitis, 613 
Head-banging, 530 
Head-rest to prevent bed-sores, 656 
Head-rolling, 530 
Health, influence of defective bodily 
mechanics on, 800 
Hearing in newborn infant, 39 
Heart, arhythmia, 408 
disease, chronic valvular, 425. Flee also 
Valvular disease, chronic, of heart. 
congenital, 409 
classification of lesions, 411 
clubbed fingers in, 410, 412 
diagnosis, 411, 412 
differential, 411, 412 
etiology, 409 
murmur in, 412 
pathology, 410 
polycythemia in, 437 
prognosis, 412 
symptoms, 410 
varieties, 409 
diseases of, 401 
auscultation in, 401 
diagnosis in, 401 
inspection in, 402 
palpation in, 403 
percussion in, 403 
thrill in, 405 
in cerebrospinal meningitis, 613 
involvement in scarlet fever, treatment, 
713 
murmurs, 404 
acquired, 405 
Heart murmurs, cardiorespiratory, 406 
coffee mill, 411 
functional, 406 
after acute illness, 406 
diagnosis, differential, 407, 412 
during development, 406 
etiology, 407 
treatment, 407 
humming-top, 411 
in aortic regurgitation, 406 
stenosis, 405 
in congenital heart disease, 412 
in mitral regurgitation, 405 
stenosis, 405 
inorganic, 406 
location of lesions by, 404 
organic, 404 
presystolic, 405 
regurgitant, 404 
stenotic, 404 
valvular, 404 
venous, 406 
rate and rhythm, functional abnormal- 
ities in, 407 
sepsis of, in newborn, 174 
sounds, first, 401, 402 
normal, 401 
second, 401, 402 
stimulants in bronchopneumonia, 375 
in chronic valvular disease, 428 
in diphtheria, 696 
in lobar pneumonia, 365 
in typhoid fever, 723 
tuberculosis of, 397 
Heart-block, 408 
Heat, artificial, for premature infant, 164 
as therapeutic agent, 844 
dry, 845 
local application of, in acute diffuse 
nephritis, 500 
moist, 845 
precautions in using, 845 
prickly, 625 
Heating milk, effect of, on its assimilation, 
74 
Height, 35 
Heliotherapy, 26 
clothing in, 26 
in chronic tuberculous peritonitis, 764 
in pulmonary tuberculosis, 399 
in rickets, 128 
in tuberculous adenitis, 460 
Hematoma of sternocleidomastoid in new- 
born, 167 
Hematuria, 487 
Hemicephalus, 550 
Hemiplegia, 566, 568 
Hemoglobin, 430 
percentage of, in newborn, 430 
Hemoglobinuria, 488 
paroxysmal, 488 
Hemolytic jaundice, 454 
splenic anemia and, differentiation, 453 
Hemophilia, 448-450 
Hemorrhage from stomach, 205 
in acute hereditary syphilis, 748 
in leukemia, 444 
in typhoid fever, treatment, 724 
nasal, 310 901 
INDEX 
Hemorrhagic diseases of newborn, 182 
bacteria as etiologic factor, 183 
chemical agents as etiologic factor, 
183 
heredity as etiologic factor, 183 
mechanical causes, 183 
metabolic changes as etiologic fac- 
tor in, 184 
syphilis as etiologic factor in, 182 
treatment, 185 
purpura, 446 
Henoch’s purpura, 446 
Hepatization, grav, in lobar pneumonia, 
357 
red, in lobar pneumonia, 356 
Hereditary ataxia, 600-603 
syphilis, acute, 744. See also Syphilis, 
acute hereditary. 
tardy, 751. See also Syphilis, tardy 
hereditary. 
Heredity, 804 
adenoids and, 322 
as factor in hemorrhagic diseases of 
newborn, 183 
in nutrition and growth of newborn 
infant, 17 
Hernia at umbilicus, 283 
diaphragmatic, 285 
congenital, pneumothorax and, differ- 
entiation, 383 
inguinal, 285 
enlarged inguinal glands and, differ- 
entiation, 286 
hydrocele and, differentiation, 286 
of umbilical cord, 283 
umbilical, congenital, 283 
ventral, 285 
Herpes simplex, 637 
zoster, 638 
Herter, intestinal infantilism of, 266 
Herty mask in dermatitis, 649 
Hess bulb, 211 
Heubner’s calorimetric method of infant 
feeding, 67 
Hiccup, 100, 533 
Hip disease, quiet, 796 
tuberculosis of, diagnosis, 795 
Hirschsprung’s disease, 261 
History record, 158 
Hives, 625 
giant, 626 
Hodgkin’s disease, 461 
lymphatic leukemia and, differentia- 
tion, 462 
lymphosarcoma and, differentiation, 
462 
pseudoleukemia and, differentiation, 
462 
tuberculosis and, differentiation, 463 
Holt’s method of fat determination of 
human milk, 44 
Hook-worm, 296 
Hot applications in acute ileocolitis, 248 
in colic, 227 
bath, 844 
weather, bathing for comfort in, 843 
Human milk, 44. See also Breast milk. 
serum in acute poliomyelitis, 592 
Humming-top heart murmur, 411 
Hunger, 99 
Hutchinson’s teeth in tardy hereditary 
syphilis, 753 
Hydrencephalocele, 549 
Hydrocele, 514 
congenital, 514 
funicular, 514 
infantile, 514 
inguinal hernia and, differentiation, 
286 
of cord, 514 
encysted, 515 
of tunica vaginalis, 515 
treatment, 515 
vaginal, 515 
Hydrocephalus, 550 
communicating, 551 
congenital, 551 
diagnosis, 553 
diuretin in, 554 
duration, 553 
external, 550 
chronic, 551 
internal, 550 
acute, 551 
obstructive, 551 
prognosis, 553 
rickets and, differentiation, 126 
symptoms, 552 
treatment, 553 
Hydromyelocele, 555 
Hydronephrosis, 491 
Hydrotherapy as means of relieving fever, 
807 
Hygiene in pulmonary tuberculosis, 398 
in rickets, 128 
Hyperacidity, gastric, 202-205 
Hypernephroma of kidney, 490 
Hyperpyrexia, 806 
Hyperresonance of chest, 337 
Hypertension, malignant, 505 
Hypertrophy of tonsils, chronic, 325 
operation for, 325 
x-ray treatment, 326 
pseudomuscular, 579 
Hypodermic medication in bronchopneu- 
monia, 376 
in convulsions, 537 
stimulation in lobar pneumonia, 366 
Hypodermoclysis, 851 
in acute gastro-enteric intoxication, 
238 
Hypospadias, 516 
Hypostatic pneumonia, 381 
Hysteria, 524, 549 
convulsive cases, 526 
diagnosis, 527 
drugs in, 528 
duration, 527 
etiology, 525 
globus hystericus in, 526 
imitation in, 525 
mental activity in, 528 
motor type, 526 
physical activity in, 528 
sensory type, 526 
symptoms, 526 
treatment, 527 
during seizure, 528 902 
INDEX 
Ice-bag in acute endocarditis, 420 
Ichthyol in erysipelas, 641 
Icterus, 304 
neonatorum, 179-181 
obstructive, 304 
Idiocy, 558 
amaurotic family, 563-565 
cretinoid, 464. See also Cretinism. 
Mongolian, 560-563 
Idiopathic dilatation of colon, 261 
Idiosyncrasy to breast milk, 113 
to cow’s milk, 113 
Ileocolitis, acute, 243 
associated lesions, 245 
bacteriology, 243 
catarrhal, 244 
climate in, 249 
colon irrigation in, 248 
diet in convalescence, 249 
drugs in, 246 
duration, 246 
hot applications in, . 248 
infusion and transfusion in, 248 
pathology, 244 
pseudomembranous, 245 
serum therapy in, 248 
starch and opium in, 248 
symptoms, 245 
treatment, 246 
ulcerative, 244 
chronic, 250 
diet in, 250 
pathology, 250 
symptoms, 250 
treatment, 250 
Ileus, paralytic, 277 
treatment, 241 
Illness, acute, care of, essentials in, 148 
essentials in care, 148 
bowel feeding, 151 
function, 151 
clothing, 149 
cold air, 149 
diet, 150 
drinking of water, 150 
drugs, 151 
keeping in bed, 149 
measures to prevent suppression 
of urine, 151 
prevention of pyrexia, 151 
protection from needless inter- 
ference, 150 
quiet attendants, 149 
room temperature, 149 
sick room, 152 
sponging, 149 
stimulation, 152 
urine examination, 150 
ventilation, 149 
window-board, 152 
written directions, 153 
diet during, 154 
reduction in food strength, 154 
Imbecility, 558 
Imitation in hysteria, 525 
Immunity, 859 
in acute poliomyelitis, 588 
Immunization in diphtheria, 695 
toxin-antitoxin, in diphtheria, 688-691 
Imperative concepts, 548 
Imperforate anus, 299 
Imperial granum-water No. 1, preparation 
of, 95 
No. 2, preparation of, 95 
Impetigo contagiosa, 634 
Improved baby hygiene, 163 
Incontinence of feces, 266 
treatment, 267 
of urine, 484—487 
Inco-ordinate movements in cerebral 
paralysis, 569 
Index, opsonic, determination of, 860 
phagocytic, 861 
Indigestion, gastric, acute, 200 
chronic, 202 
intestinal, acute, 230 
persistent, 231 
in older children, 232 
Individual, treatment of, 155 
Indoor airing, 838 
Infant feeding, 42 
newborn, 17. See also Newborn infant. 
Infantile atrophy, 105. See also Maras- 
mus. 
convulsions, 533. See also Convulsions. 
hydrocele, 514 
myopathy of facioscapulohumeral type, 
579 
myxedema, 464. See also Cretinism. 
paralysis, 587. See also Poliomyelitis, 
acute. 
Infantilism, 477 
intestinal, of Herter, 266 
symptomatic, 478 
Infectious diseases, 665 
care of physician in visiting, 666 
cereal gruels in, 84 
Inflammation of anus, 300 
of rectum, 301 
Influenza, 728 
acute rhinitis and, differentiation, 307 
adenitis in, 732 
age incidence, 729 
bacillus of, 728 
bacteriologic etiology, 728 
bronchitis in, 732 
brochopneumonia in, 732 
climate in, 734, 833 
complications, 732 
cough in, 730 
treatment, 734 
diagnosis, 732 
drugs in, 734 
duration, 732 
endocarditis in, 732 
external treatment, 734 
gastro-intestinal manifestations, 731 
incubation period, 729 
kidneys in, 732 
leukocytosis in, 433 
mode of entrance, 728 
nephritis in, 732 
otitis in, 732 
pathology, 729 
prognosis, 732 
quarantine in, 733 
sequels, 733 
source of infection, 728 INDEX 
903 
Influenza, symptoms, 730 
temperature in, 731 
treatment, 734 
vapor treatment, 734 
Inguinal adenitis, 457 
glands, enlarged, inguinal hernia and, 
differentiation, 286 
hernia, 285 
enlarged inguinal glands and, dif- 
ferentiation, 286 
hydrocele and, differentiation, 286 
Inhalations, steam, in bronchitis, 343 
in bronchopneumonia, 374 
in spasmodic croup, 333 
Inorganic heart murmurs, 406 
Insanity, 548 
choreic, 570 
Inspection, diagnosis by, 159 
during sleep, 160 
in acute endocarditis, 418 
in diseases of heart, 402 
in interstitial pneumonia, 378 
of lungs, 336 
Insufflation pneumonia, 381 
Insulin in diabetes mellitus, 786 
Intercostal neuralgia, counterirritation in, 
847 
Interstitial pneumonia, 378. See also 
Pneumonia, interstitial. 
Intertrigo, 650 
Intestinal cysts, 281 
diseases, acute, prevention of, 227 
dispensary rules of universal ap- 
plication, 228 
how to secure good milk, 229 
necessity for education, 230 
New York City experiments, 229 
prompt treatment essential, 229 
diverticula, congenital, 281 
indigestion, acute, 230 
persistent, 231 
in older children, 232 
infantilism of Herter, 266 
infection, acute, pyelocystitis and, dif- 
ferentiation, 508 
as cause of elevation of temperature, 
810 
with defective bowel action, treat- 
ment, 241 
invagination, 277 
obstruction, 276 
parasites, 293 
blood in infections by, 293 
tract, developmental abnormalities in, 
as cause of digestive disturbances, 253 
Intestines, diseases of, 196 
sepsis of, in newborn, 174 
tuberculosis of, 397 
Intoxication, enteric, acute, 241-243 
gastro-enteric, acute, 234. See also 
Gastro-enteric intoxication, acute. 
Intradermal test with tuberculin in tuber- 
culosis, 825 
Intramuscular medication, 849 
Intraperitoneal infusion in acute gastro- 
enteric intoxication, 238 
injections, 850 
Intravenous infusions in acute gastro- 
enteric intoxication, 238 
Intravenous medication, 850 
external jugular vein, 851 
median basilic or cephalic veins, 851 
superior longitudinal sinus, 850 
Intubation in diphtheria, 699-701 
Intussusception, 277-281 
acute, general peritonitis and, differentia- 
tion, 293 
age incidence, 278 
appendicitis and, differentiation, 299 
diagnosis, 279 
etiology, 277 
presence of tumor, 278 
prognosis, 279 
reduction by water-pressure, 279 
symptoms, 278 
treatment, 279 
types, 277 
Invagination, intestinal, 277 
Iodid of potash, 866 
Ipecac, 866 
Iron, muriate of, tincture, 867 
Irrigation, colon, 855 
in acute enteric infection, 241 
ileocolitis, 248 
of throat, 321 
indications, 321 
procedure, 321 
Ischiorectal abscess, 302 
Italian leprosy, 787 
Itch, 628 
Ivy poisoning, 627 
Jaundice, catarrhal, 304 
hemolytic, 454 
splenic anemia and, differentiation, 
453 
in newborn, 179-181 
obstructive, 304 
Jaw, drop, in adenoids, 323 
Jelly, barley, preparation of, 94 
oatmeal, preparation of, 94 
wheat, preparation of, 94 
Joint diseases, streptococcus vaccine in, 
863 
Joints, diseases of, 794 
diagnosis in, 794 
sepsis of, in newborn, 174 
tuberculosis of, diagnosis, 794 
Junket, preparation of, 95 
Juvenile type of progressive muscular 
atrophy, Erb’s, 579 
Kernig’s sign in cerebrospinal menin- 
gitis, 614 
in tuberculous meningitis, 608 
Ketone bodies in urine, 779 
Ketosis, 771. See also Acidosis. 
Kidney, adenocarcinoma of, 490 
adenoma of, 490 
adenomyosarcoma of, 816 
adenosarcoma of, 490 
cysts of, 492 
diseases of, 490 
embryonal sarcoma of, 816 
fibroma of, 490 
hypernephroma of, 490 904 
INDEX 
Kidney in influenza, 732 
new growths of, 490 
of scarlet fever, 495 
rhabdomyosarcoma of, 490 
tuberculosis of, 397, 490 
tumors of, 490 
Kindergarten, 132 
King’s cough, 674 
Kinkcough, 674 
Klebs-Loffler bacillus, 688 
persistent nasal infection with, 698 
Kleptomania, 548 
Knee-crutch to prevent masturbation, 
532 
Knee-joint, tuberculosis of, diagnosis, 795 
Koplik’s spots in measles, 681 
Laborde method of artificial respiration 
in asphyxia neonatorum, 170 
Lactic acid milk, 87 
Lactose, 20 
La grippe, 728. See also Influenza. 
Landouzy- Dejeri ne type of progressive 
myopathy, 579 
Lange’s colloidal gold test for syphilis, 828 
Laryngeal diphtheria, suction in, 701 
obstruction, 335 
stridor, congenital, 540 
in laryngismus stridulus, 538 
Laryngismus stridulus, 537-540 
laryngeal stridor in, 538 
spasmodic croup and, differentiation, 
331 
Laryngitis, acute catarrhal, 330. See also 
Spasmodic croup. 
traumatic, 334 
Laryngoscope, 820 
Larynx, foreign bodies in, 335, 818 
tuberculosis of, 397 
Laughing, 40 
Lavage, 852 
indications, 852 
in malnutrition, 112 
in marasmus, 109 
in vomiting, 852, 853 
of infants, 198 
technic, 852 
Laxative agents in food in constipation 
of bottle fed, 272 
Laxatives in scarlet fever, 710 
Leaking nipples, 53 
Legg’s disease, 796 
Leprosy, Italian, 787 
Lethargic encephalitis, 619 
Leukemia, 443 
atypical forms, 445 
etiology, 443 
lymphatic, 443 
acute, 444 
Hodgkin’s disease and, differentiation, 
462 
morbid anatomy, 444 
myelogenous, 444 
prognosis, 445 
splenomyelogenous, 443 
symptoms, 444 
treatment, 445 
Leukemic infiltrates, 444 
Leukocytes, 430 
found in pathologic conditions, 431 
Leukocytic cream, 861 
Leukocytosis, 432 
in appendicitis, 289 
pathologic, 432 
physiologic, 432 
Lice, head, 630 
Light, lack of, in etiology of rickets, 121 
Lingual tonsils, 314 
Lips, fissures of, 191 
Lithemia, 738 
Lithemic diathesis, 738 
Little’s disease, 566 
Liver, abnormalities of function and size, 
303 
abscess of, 303 
acute yellow atrophy of, 303 
cirrhosis of, 304 
splenic anemia and, differentiation, 
453 
derangement of function, 303 
diseases of, 303 
fatty changes in, 303 
in acute hereditary syphilis, 745 
in tardy hereditary syphilis, 754 
tuberculosis of, 397 
Lobar pneumonia, 355. See also Pneu- 
monia, lobar. 
Lobstein’s disease, 796 
Loss of appetite, habitual, 137-140 
Lumbar puncture, 821 
in acute meningitis, 605 
in meningismus, 619 
in tuberculous meningitis, 609 
Luminal in epilepsy, 586 
Lungs, 336 
auscultation of, 337 
dulness of, 337 
tympanitic, 337 
examination of, 336 
hyperresonance of, 337 
inspection of, 336 
percussion of, 337 
resonance of, 337 
tympanitic, 337 
sepsis of, in newborn, 174 
Lymphatic glands, diseases of, 454 
enlargement of, 454 
in diphtheria, 692 
in German measles, 686 
leukemia, 443 
acute, 444 
Hodgkin’s disease and, differentiation, 
462 
Lymph-nodes, cervical, tuberculosis of, 458 
in leukemia, 444 
in tardy hereditary syphilis, 752, 753 
Lymphocytes, 431 
Lymphomata, 444, 816 
Lymphosarcoma, 816 
Hodgkin’s disease and, differentiation, 
462 
Lysins, 860 
Malaria, 724 
diagnosis, 726 
differential, 726 INDEX 
905 
Malaria, empyema and, differentiation, 391 
mosquito transmission, 724 
pathology, 725 
physical examination, 725 
plasmodia of, species, 724 
prophylaxis, 726 
pyelocystitis and, differentiation, 508 
quinin in, 726, 727 
recurrence, 727 
relapse in, 726 
splenic anemia and, differentiation, 453 
symptoms, 725 
transmission, 724 
treatment, 726 
Yerbazin in, 727 
Male genitals, diseases of, 511 
gonorrhea in, 515 
Malformation of brain, 549 
of esophagus, 194 
of spinal cord, 549 
Malignant endocarditis, 417 
hypertension, 505 
Malnutrition, 111 
climate in, 833 
diagnosis, 111 
gavage in, 855 
in childhood, 137 
in older children, 146 
lavage in, 112 
symptoms, 111 
tardy, 146 
etiology, 147 
of syphilitic origin, 755 
treatment, 147 
treatment, 112 
Malted foods in constipation in nurslings, 
271 
Maltose, 21 
Malt-soup feeding for milk adaptation, 78 
Mammary abscess in newborn, 177 
Management of children, necessity of 
method in, 131 
Mania, 549 
Mantoux’s tuberculin test, 825 
Marasmus, 105 
age incidence, 105 
cow’s milk in, 109 
etiology, 105 
history, 105 
infection as cause, 106 
lavage in, 109 
pathology, 106 
pyloric obstruction as cause, 106 
sweetened condensed milk in, 110 
temporary feeding in, 109 
treatment, 106 
outdoor, 108 
where wet-nurse is impossible, 108 
wet-nursing in, 106 
Market milk, 62 
Mask, Herty, in dermatitis, 649 
Massage in acute poliomyelitis, 593 
in constipation due to developmental 
abnormalities of digestive tract, 260 
in nurslings, 271 
of breasts after nursing, 46 
Mast cells, 431 
Mastitis, acute, 54 
in newborn, 176 
Mastitis in young girls, 462 
suppurative, 54 
Mastoiditis, 663 
Masturbation, 531 
Hand-I-hold mit to prevent, 533 
knee-crutch to prevent. 532 
prophylaxis, 531 
treatment, 531 
Maternal nursing, 42 
neurasthenia and, 42 
Maturity, precocious, 516 
Meal, opaque, in ptosis and dilatation of 
stomach, 222 
test, in gastric hyperacidity, 203 
Measles, 680 
acute rhinitis and, differentiation, 306 
adenitis in, 682 
age incidence, 680 
baths in, 684 
bowel function in, 683 
bronchopneumonia in, 682 
buccal spots in, 681 
complications, 682 
cough in, 681 
treatment, 684 
diagnosis, 682 
differential, 682 
ears in, treatment, 684 
etiology, 680 
eyes in, 681 
treatment, 684 
feeding in, 683 
Filtow’s spots in, 681 
fresh air in, 685 
German, 685 
scarlet fever and, differentiation, 686 
incubation period, 681 
Koplik’s spots in, 681 
leukocytosis in, 436 
nephritis in, 682 
nervous manifestations, 681 
otitis in, 682 
prognosis, 682 
quarantine in, 685 
rash in, 681 
delayed, 684 
recurrence, 682 
second attack, 682 
serum treatment, 682 
symptoms, 681 
temperature in, 681 
transmission, 680 
treatment, 682 
vapor, 685 
urine in, 683 
Meckel’s diverticulum, 282 
appendicitis and, differentiation, 282 
Mediastinal glands, enlarged, as cause of 
cough, 312 
infection of, as cause of temperature 
elevation, 809 
Mediastinum, emphysema of, subcutaneous 
emphysema with, 384 
Melsena neonatorum, 182 
Melancholia, 549 
Membranous proctitis, 301 
Memory, 40 
beginning of, in newborn infant, 39 
Meningismus, 619 906 
INDEX 
Meningitis, acute infective, 603-606 
cerebrospinal, 610. See also Cerebrospinal 
meningitis. 
in lobar pneumonia, 360 
leukocytosis in, 434 
meningococcus, 610 
serous, 619 
tuberculous, 606 
age incidence, 606 
diagnosis, 608 
differential, 609 
duration, 610 
Kernig’s sign in, 608 
lumbar puncture in 609 
pathology, 606 
prognosis, 610 
symptoms, 606-608 
treatment, 610 
typhoid fever and, differentiation, 718 
Meningocele, 549 
of spinal cord, 555 
Meningococcus meningitis, 610 
vaccine, 863 
Menstruation, precocious, 516 
Mental apathy in cerebrospinal men- 
ingitis, 613 
deficiency, 558 
institutional treatment, 562 
treatment, 559, 562 
unclassified cases, 558 
impairment in cerebral paralysis, 569 
Mentality in cerebral paralysis, 567 
Mercury, bichlorid of, 866 
in acute hereditary syphilis, 748, 749 
Mesenteric glands, tuberculosis of, 759 
Metabolic changes as etiologic factor in 
hemorrhagic diseases of newborn, 184 
Metabolism, disturbances of, diseases due 
to, 771 
Microcephalus, 554 
Micromelia, 797 
Midday nap for subnormal children, 145 
Miliaria, 625 
Miliary tuberculosis, acute, typhoid fever 
and, differentiation, 718 
Milk, adaptation of, by alkalies and ant- 
acids, 75 
by peptonization, 76 
by whey feeding, 76 
albumin, 88 
allergy, 113 
boiled, 74 
borne septic sore throat, 320 
breast, 44 
examination of, 44 
fat determination, 44 
protein estimation, 35 
sugar determination, 45 
certified, 63 
requirements of Milk Commission of 
New York County Medical Society 
for production, 63 
condensed, 78 
in acute gastro-enteric intoxication, 
239 
sweetened, in marasmus, 110 
cow’s, 60 
adaptation of, 66 
by cereal gruels, 77 
Milk, cow’s, adaptation of, by malt-soup 
feeding, 78 
calorimetric standard, 67 
percentage standard, 67 
allergy to, 81.5 
bacteria in, 62 
bacteriology of, 62 
examination of, 61 
fat in, 60 
human milk and, differences between, 
61 
idiosyncrasy to, 113 
in marasmus, 109 
market, 62 
modified, 68 
by top-milk mixtures, 70 
fat of, 69 
formulas for, 70-72 
protein of, 68 
sugar of, 69 
protein in, 61 
quality variable, 72 
stools of, 103 
sugar in, 60 
crust, 654 
diet in scarlet fever, 710 
evaporated, 78 
inacute gastro-enteric intoxication, 239 
Finkelstein’s, 88 
for traveling, 96 
frozen, 75 
general properties of, 25 
heating, effect of, on its assimilation, 74 
human, 44. See also Breast milk. 
in typhoid fever, 719, 720 
infection in tuberculosis, 758 
lactic acid, 87 
pasteurization of, 63, 64 
advantage and value, 65 
peptonized, 76 
for gavage, 77 
for nutrient enema, 77 
protein, 88 
dry, 89 
in acute gastro-enteric intoxication, 
240 
in diarrhea, 88 
made from evaporated product, 89 
sensitization, 113 
uses of, 88 
raw, advantage and value, 65 
safe, how to obtain, in summer, 836 
selection of, in summer, 835 
skimmed, in gastro-enteric intoxication, 
238 
sterilization of, 63 
sterilized, 63 
withdrawal of, in summer, 836 
Mineral substances, functions of, 21 
Miner’s anemia, 293 
Mitral regurgitation, heart mumurs in, 405 
treatment, 427 
stenosis, heart murmur in, 405 
treatment, 427 
Mixed feeding, 55 
Modified milk, 68. See also Milk, cow’s, 
modified. 
Moist heat, 845 
rales, 341 INDEX 
907 
Mole, pigmentary, 657 
Moler-Barlow’s disease, 114. See also 
Scurvy. 
Mongolian idiocy, 560-563 
Mongolianism, rickets and, differentiation, 
126 
Mononuclears, large, 431 
Moral treatment of habit spasm, 576 
Morbid fears, 548 
Morbidity, 161 
Morbus comitalis, 583 
Herculeus, 583 
sacer, 583 
Moro’s tuberculin test, 825 
Mortality, 161 
Mosenthal’s test of renal function, 828 
Mosquito transmission of malaria, 724 
Motility of stomach, 196 
Mouth, angle of, ulcerations and fissures at, 
191 
as repository, 817 
diseases of, 186 
mucous membrane, inflammation of, 186 
toilet in typhoid fever, 719 
washing in stomatitis, 187 
Mouth-breathing in adenoids, 323 
Mucous colitis, 251 
membrane of mouth, inflammation, 186 
patches in acute hereditary syphilis, 747 
rales, 341 
Mucus in stools, 103 
Multiple neuritis, 593. See also Neuritis, 
multiple. 
sclerosis, Friedreich’s ataxia and, dif- 
ferentiation, 603 
Mumps, 672-674 
acute cervical adenitis and, differentia- 
tion, 456 
Muriate of iron, tincture, 867 
Murmurs, heart, 404. See also Heart 
murmurs. 
Murphy drip in lobar pneumonia, 366 
Muscles, diseases of, 794 
Muscular atrophies, progressive, 577 
atrophy, progressive spinal, 577 
Charcot-Marie-tooth type, 578 
claw-hand in, 578 
course, 579 
diagnosis, 579 
Duchenne-Aran type, 578 
etiology, 577 
hand type, 578 
leg type, 579 
pathology, 577 
peroneal type, 578 
prognosis, 579 
spastic type, 579 
symptoms, 578 
primary dystrophy, 579 
Mustard bath, 843 
in bronchitis, 344 
in bronchopneumonia, 375 
plaster in bronchitis, 344 
Mutton broth, preparation of, 94 
Myasthenia, neurocirculatory, 811 
Mycotic stomatitis, 189 
Myelocystocele, 555 
Myelocytes, 431 
eosinophilic, 431 
Myelogenous leukemia, 444 
Myelomeningocele, 555 
Myocarditis, 422 
acute parenchymatous, 422 
suppurative, 422 
chronic interstitial, 423 
diagnosis, 423 
etiology, 422 
in lobar pneumonia, 360 
in scarlet fever, 707 
pathology, 422 
symptoms, 423 
treatment, 423 
Myopathic face, 582 
Myopathies, progressive, 579 
course, 582 
diagnosis, 582 
etiology, 579 
facioscapulohumeral type, 579 
Landouzy-Dej6rine type, 579 
of Erb’s juvenile type, 579 
pathology, 580 
prognosis, 582 
scapulohumeral type, 579 
symptoms, 581 
treatment, 582 
Myopathy, infantile, of facioscapulohume- 
ral type, 579 
Myxedema, infantile, 464. See also 
Cretinism. 
hhEVTTS, 657 
flammeus, 657 
linearis, 657 
lipomatodes, 657 
pilosus, 657 
pilus, 657 
vascular, 657 
verrucosus, 657 
Nails in acute hereditary syphilis, 748 
Nap, midday, for subnormal children, 145 
Narcosis, gavage in, 855 
Nasal catarrh, 308 
diphtheria, 697 
acute rhinitis and, differentiation, 306 
chronic, 698 
hemorrhage, 310 
infection, persistent, with Klebs-Loffler 
bacillus, 698 
mucous membrane in acute poliomye- 
litis, 589 
Nausea in gastric hyperacidity, 203 
Nauseating drugs, 866 
Necrobiosis in stomatitis, 187 
Needle, Goldbloom, 850 
Quincke’s, 822 
Nem system of feeding, 24 
Neosalvarsan in acute hereditary syphilis, 
749 
Nephritis, acute diffuse, 494 
bath in, 499 
bowels in, 499 
convalescence in, 501 
convulsions in, 496 
treatment, 501 
diagnosis, 497 
diet in, 498 
duration, 497 908 
INDEX 
Nephritis, acute diffuse, etiology, 494 
examination of urine, 497 
fever in, 496 
fulminating cases, 496 
local application of heat in, 500 
pathology, 495 
prognosis, 497 
salt-free diet in, 498 
symptoms, 495 
toxic agents in etiology, 494 
treatment, 497 
of severe cases, 499 
urea excretion in, 501 
uremia in, 496 
uremic convulsions in, treatment, 
501 
urine in, 496 
interstitial, 495 
chronic diffuse, 502 
Edebohls’ operation in, 504 
interstitial, 505 
climate in, 833 
in influenza, 732 
in measles, 682 
in scarlet fever, 707 
treatment, 713 
various forms, 493 
Nervous cough, 310 
system, diseases of, 522 
vomiter, 101 
Nettle-rash, 625 
Neuralgia, intercostal, counterirritation in, 
847 
Neurasthenia, 548 
maternal nursing and, 42 
Neuritis, multiple, 593 
after diphtheria, 593 
gavage in, 597 
treatment, 596 
convalescence in, 596 
diagnosis, 595 
distribution of lesions, 594 
drugs in, 595 
electric reactions in, 595 
etiology, 593 
Friedreich’s ataxia and, differentia- 
tion, 603 
pathology, 594 
prognosis, 595 
sensory effects, 594 
symptoms, 594 
treatment, 595 
Neurocirculatory asthenia, 811 
Neurotic dermatitis, 651 
Neutrophils, polymorphonuclear, 431 
Nevus, 657. See also Ncevus. 
New growths, 815 
of kidney, 490 
Newborn infant, 164 
abdomen of, 37 
asphyxia of, 168 
atelectasis of, 172 
baskets for early exercises, 31 
bathing, 27 
beginning of feeling in, 39 
of memory in, 39 
blood in, 430 
cephalhematoma of, 166 
clothing for, 26 
Newborn infant, congenitally weak, 164 
consciousness in, 39 
convulsions in, 535 
crying of, 28 
cutaneous sensation in, 39 
delayed asphyxia of, 172 
diseases of, 166 
fontanels of, 37 
fresh air for, 25 
gastric capacity, 38 
gonorrheal ophthalmia in, 178 
head and chest circumferences, 36 
hearing in, 39 
hematoma of sternocleidomastoid in, 
167 
hemorrhagic diseases, 182. See also 
Hemorrhagic diseases of newborn. 
jaundice in, 179-181 
length of, 35 
mammary abscess in, 177 
mastitis in, 176 
mental development of, 38 
midpoint of body, 36 
normal development of, 33 
nutrition and growth, 17 
care and feeding as factors, 17 
environment as factor, 17 
heredity as factor, 17 
relaxation as factor, 27 
organic sensation in, 39 
physical development of, 38 
premature, 164. See also Premature 
infant. 
sclerema of, 167 
sense of smell in, 39 
sepsis in, 173. See also Sepsis in new- 
born. 
sight in, 38 
sleep required, 28 
sunlight for, 26 
taste in, 39 
tetanus in, 177 
thirst-hunger in, 39 
umbilical granuloma in, 175 
polyp in, 176 
weight, 33 
Nicholson’s supporter for ptosis, 801 
Night feedings, 72 
Night-terrors, 523 
Nipples, care of, after nursing, 46 
cracked, 53 
depressed, 54 
fissured, 53 
leaking, 53 
Nipple-shield, 47 
Nitrous oxid gas as anesthetic, 869 
with oxygen as anesthetic, 869 
Nodules, rheumatic, 736 
Noguchi’s butyric acid test for syphilis, 827 
Noma, 190, 6i9 
Nose, diseases of, 306 
foreign bodies in, 817 
saddle, in tardy hereditary syphilis, 753 
Nuclear dust, 473 
Nursery, 30 
airing of, 26 
floor of, 30 
for subnormal child, 144 
furniture of, 30 INDEX 
909 
Nursery, heating of, 30 
maid, 29 
ventilation of, 26, 30, 31 
Nursing, breast, 45. See also Breast feed- 
ing. 
first, 46 
in scarlet fever, 710 
maternal, 42 
neurasthenia and, 42 
Nursing-bottle, 31 
Nutrient enema, method of giving, 97 
peptonized milk for, 77 
Nutrition and growth of newborn infant, 
17. See also Newborn infant, nutri- 
tion and growth. 
disorders of, 105 
in childhood, 131 
Nutritional errors in artificial feeding, 58 
in tardy hereditary syphilis, 753 
Oatmeal jelly, preparation of, 94 
Oatmeal-water No. 1, preparation of, 95 
No. 2, preparation of, 95 
Obesity, 479 
Obstetric paralysis, 598 
Obstinate constipation, treatment, 276 
Obstipation, 102 
Obstruction, intestinal, 276 
laryngeal, 335 
Obstructive hydrocephalus, 551 
jaundice, 304 
O’Dwyer on intubation, 699 
Oil, castor, 867 
injections in constipation in bottle fed, 
273 
inunctions in scarlet fever, 711 
in tetany, 547 
Oils, 867 
One hundred calorie portion of foods, 23 
Opaque meal in ptosis and dilatation of 
stomach, 222 
Ophthalmia, gonorrheal, in newborn, 178 
neonatorum, 178 
Ophthalmo-reaction with tuberculin in 
tuberculosis, 825 
Ophthalmoscope, 820 
Oppenheim’s disease, 582 
Opsonic index, determination of, 860 
Opsonins, 860 
Orchitis, 514 
Organic heart murmurs, 404 
sensation in newborn infant, 39 
Orthopedic treatment of acute poliomye- 
litis, 593 
Osteogenesis imperfecta, 796 
Osteoma, 816 
Osteomyelitis, infective, 796 
staphylococcus vaccine in, 862 
Osteopsathyrosis infantilis, 796 
Otitis, acute, 659 
bacteriology, 659 
complications, 661 
course, 660 
diagnosis, 661 
etiology, 659 
fever in, 660 
prognosis, 660 
symptoms, 659 
Otitis, acute, treatment, 661 
operative, 661 
postoperative, 662 
types, 659 
as cause of elevation of temperature, 809 
chronic suppurative, 663 
in influenza, 732 
in lobar pneumonia, 361 
in measles, 682 
in scarlet fever, 707 
treatment, 713 
media, staphylococcus vaccine in, 862 
Out-of-doors, days for, 838 
Overfeeding, 137 
Oxygen in bronchopneumonia, 378 
in lobar pneumonia, 366 
Oxyuris vermicularis, 294 
Pacifier, use of, 529 
Pack, cool, 841 
warm, in acute meningitis, 605 
Packs in scarlet fever, 711 
Pain in gastric hyperacidity, 203 
Palate, cleft-, 193 
Palpation in acute endocarditis, 418 
in bronchitis, 342 
in bronchopneumonia, 370 
in diseases of heart, 403 
of lungs, 336 
Palsies, cerebral, 565 
acquired form, 568 
birth form, 565 
prenatal form, 565 
Palsy. See Paralysis. 
Pancreas, tuberculosis of, 397 
Paralysis, cerebral, 565 
acquired form, 568 
birth form, 565 
prenatal form, 565 
Erb’s, 598 
facial, 597 
infantile, 587. See also Poliomyelitis, 
acute. 
obstetric, 598 
progressive bulbar, 578 
wasting, 577 
Paralytic ileus, 277 
treatment, 241 
Paraphimosis, 512 
Parasites, eosinophilia from, 435 
intestinal, 293 
blood in infections by, 293 
Parotitis, epidemic, 672-674 
specific, 672-674 
Paroxysmal hemoglobinuria, 488 
Pasteurization of milk, 63, 64 
advantage and value, 65 
Pasteurizer, Freeman, 64 
Patellar reflex in cerebrospinal meningitis, 
615 
Pavor diurnus, 522 
nocturnus, 523 
Pediculi capitis, 630 
Peliosis rheumatica, 742 
Pellagra, 787 
acrodynia and, differentiation, 793 
diagnosis, 789 
etiology, 787 910 
INDEX 
Pellagra, pathology, 788 
prognosis, 789 
symptoms, 788 
treatment, 789 
Pemphigus, eosinophilia in, 435 
neonatorum, 635 
Pen, exercise, 839 
Peptonized milk, 76 
for gavage, 77 
for nutrient enema, 77 
Percentage gruel flours, preparation of, 95 
standard of milk adaptation, 67 
Percussion in acute endocarditis, 418 
in bronchitis, 342 
in bronchopneumonia, 369 
in diseases of heart, 403 
in emphysema, 383 
in pericarditis, 414 
in secondary pleurisy, 386 
of lungs, 337 
of thymus gland, 474 
Perforation in typhoid fever, treatment, 
724 
Peri-arthritis, acute, diagnosis, 794 
in lobar pneumonia, 361 
Pericardial puncture, 821 
Pericarditis, 413 
bacteriology, 413 
complicating infectious diseases, treat- 
ment, 416 
diagnosis, 415 
etiology, 413 
in lobar pneumonia, 360 
in scarlet fever, 707 
pathology, 413 
percussion in, 414 
physical signs, 414 
prognosis, 415 
purulent type, treatment, 416 
rheumatic cases, treatment, 415 
symptoms, 413 
treatment, 415 
Pericardium, adherent, 429 
Periodic fever, 779 
as cause of elevation of temperature, 
809 
vomiting, 773 
appendicitis and, differentiation, 289 
Peristaltic wave in pyloric obstruction, 213 
method of obtaining, 213 
Peritoneal puncture, 821 
Peritoneum, diseases of, 196 
sepsis of, in newborn, 174 
tuberculosis of, 397 
Peritonitis, acute, appendicitis and, differ- 
entiation, 289 
general, 291 
diagnosis, differential, 293 
duration, 292 
intussusception and, differentiation, 
293 
pathology, 292 
prognosis, 292 
symptoms, 292 
treatment, 293 
in lobar pneumonia, 360 
leukocytosis in, 434 
tuberculous, chronic. 760. See also 
Tuberculous peritonitis, chronic. 
Peritonsillar abscess, 318 
Pernicious anemia, 445. See also Anemia, 
'pernicious. 
Peroneus sign in spasmophilia, 541 
Persistent anal membrane, 299 
cough, 310 
Perthes’ disease, 796 
Pertussis, 674. See also Whooping-cough. 
Petechial fever, 610 
smallpox, 668 
Peterson on mental development of new- 
born, 38 
Petit mal type of epilepsy, 584 
Phagocytic index, 861 
Pharyngeal tonsil, 314 
Pharyngitis, simple, 313 
Phenolsulphonephthalein test of renal func- 
tion, 828 
Phimosis, 511 
as cause of convulsions, 535 
Phosphorus content of blood, determina- 
tion, 830 
Phthisis, 394. See also Tuberculosis, pul- 
monary. 
Physical training, 133 
Physically subnormal child, 140-146. See 
also Subnormal child, physically. 
Physician, care of, in visiting infectious and 
contagious diseases, 666 
Physiologic congestion of thyroid gland, 
462 
leukocytosis, 432 
requirements and food properties, 19 
Picking of finger-tips, 530 
Pigeon breast in rickets, 123 
Pigmentary moles, 657 
Pineal gland, disease of, 477 
tumors of, 816 
Pin-worm, 294 
Pirquet’s tuberculin test, 824 
Pituitary gland, 475 
tumors of, 816 
Plasmodium malariae, 724 
Pleura, adherent, as cause of cough, 311 
Pleural puncture, 821 
Pleurisy, appendicitis and, differentiation, 
289 
counterirritation in, 847 
empyema and, differentiation, 391 
primary, 384 
rheumatic, 742 
secondary, 385 
auscultation in, 386 
bacteriology, 385 
counterirritation in, 387 
diagnosis, 386 
etiology, 385 
exploratory puncture in, 387 
pathology, 385 
percussion in, 386 
symptoms, 386 
treatment, 387 
with effusion, treatment, 387 
x-ray in, 387 
with purulent effusion, 388. See also 
Empyema. 
Pleuritic effusion, lobar pneumonia and, 
differentiation, 362 
Pneumococcus vaccine in pneumonia, 864 INDEX 
911 
Pneumonia, 355 
acute appendicitis and, differentiation, 
289 
catarrhal, 368. See also Bronchopneu- 
monia. 
central, 361 
climate in, 833 
fibrinous, 355 
hypostatic, 381 
insufflation, 381 
interstitial, 378 
auscultation in, 379 
diagnosis, 378 
differential diagnosis, 379 
gymnastic exercises in, 381 
inspection in, 378 
pathology, 378 
prognosis, 379 
pulmonary tuberculosis and, differen- 
tiation, 379 
symptoms, 378 
treatment, 380 
leukocytosis in, 433 
lobar, 355 
acidosis in, 361 
alcohol in, 366 
bacterial etiology, 355 
blood transfusion in, 367 
bowels in, 363 
bronchopneumonia and, differentia- 
tion, 372 
clothing in, 363 
cold air in, 363 
complications, 360 
counterirritation in, 363 
delayed crises in, 360 
delirium in, 360 
diagnosis, 361 
differential, 362 
diarrhea in, 360 
diet in, 364 
duration of attack, 359 
empyema in, 361, 389 
etiology, 355 
fever in, treatment, 364 
gavage in, 366 
heart stimulants in, 365 
hypodermic stimulation in, 366 
in scarlet fever, 707 
localization of lesions, 358 
meningitis in, 360 
Murphy drip in, 366 
myocarditis in, 360 
otitis in, 361 
oxygen in, 368 
pathology, 356 
peri-arthritis in, 361 
pericarditis in, 360 
peritonitis in, 360 
physical signs, 362 
pleuritic effusion and, differentiation, 
362 
predisposition to, 356 
prognosis, 361 
serum treatment, 367 
sick-room in, 363 
specific medication in, 366 
stage of congestion in, 356 
of gray hepatization in, 357 
Pneumonia, lobar, stage of red hepatization 
in, 356 
of resolution in, 357 
stupor in, 360 
symptoms, 358 
unfavorable, 357 
temperature in, 358 
low, 359 
treatment, 363 
tympanites in, 359 
treatment, 364 
vomiting in, 360 
pneumococcus vaccine in, 864 
unresolved empyema and, differentia- 
tion, 391 
Pneumothorax, 381 
congenital diaphragmatic hernia and, 
differentiation, 383 
Poisoning, ivy, 627 
rhus, 627 
Poliomyelitis, acute, 587 
abortive, 589 
age incidence, 587 
amyotonia congenita and, differentia- 
tion, 583 
blood in, 589 
bulbar spinal, 589 
cerebral, 589, 590 
cerebrospinal fluid in, 588 
course, 591 
electric reactions in, 591 
etiology, 587 
human serum in, 592 
immunity in, 588 
incubation period, 589 
leukocytosis in, 434 
massage in, 593 
nasal mucous membrane in, 589 
orthopedic treatment, 593 
pathology, 588 
prognosis, 591 
quaratine in, 593 
scurvy and, differentiation, 117 
seasonal influences, 587 
symptoms, 589 
transmission, 587 
treatment, 592 
types of cases, 589 
virus in, 587 
chronic anterior, 577 
Pollen disease, 354 
Pollinosis, 354 
Polycythemia in congenital heart disease, 
437 
Polymorphonuclear neutrophils, 431 
Polyp, umbilical, 176 
Polyuria, persistent, 783 
Porencephalus, 549 
Pork-worm, 295 
Port-wine stain, 657 
Posthemiplegic chorea, 570 
Posture, correct, 800 
Potash, chlorate of, in stomatitis, 188 
dangers, 188 
Potassium iodid, 866 
Pot belly in rickets, 125 
Precocious maturity, 516 
menstruation, 516 
Premature infant, 164 912 
INDEX 
Premature infant, artificial heat for, 164 
feeding of, 165 
fresh air for, 165 
prevention of infection, 165 
room temperature for, 165 
Premenstrual congestion of thyroid gland, 
463 
Prenatal form of cerebral palsy, 565 
Presystolic heart murmur, 405 
Prevention of disease, 133 
Prickly heat, 625 
Private tutor, 132 
Proctitis, 301 
catarrhal, 301 
membranous, 301 
ulcerative, 302 
Progeria, 478 
Progressive amyotrophy, 577. See also 
Muscular atrophy, progressive spinal. 
bulbar paralysis, 578 
muscular atrophies, 577 
myopathies, 579 
course, 582 
diagnosis, 582 
etiology, 579 
facioscapulohumeral type, 579 
Landouzy-Dejerine type, 579 
of Erb’s juvenile type, 579 
pathology, 580 
prognosis, 582 
scapulohumeral type, 579 
symptoms, 581 
treatment, 582 
spinal muscular atrophy, 577. See also 
Muscular atrophy, progressive spinal. 
Prolapse of anus and rectum, 300 
Prophylaxis, 832 
Proprietary foods, 91 
addition of fresh cow’s milk, 92 
beef, 92 
composition of, 92 
dried milk, 91 
Protein estimation of breast milk, 45 
in cow’s milk, 61 
in modified milk, 68 
milk, 88 
dry, 89 
in acute gastro-enteric intoxication, 
240 
in diarrhea, 88 
made from evaporated product, 89 
uses, 88 
reduction of, in constipation of bottle 
fed, 272 
requirement of infant, 73 
sensitization in dermatitis, 644 
therapy, non-specific, 864 
Proteins, function of, 20 
Prune juice, preparation of, 95 
Pseudohemophilia, 447 
Pseudoleukemia, Hodgkin’s disease and, 
differentiation, 462 
Pseudoleukemic anemia of von Jaksch, 441 
Pseudomembranous ileocolitis, 245 
Pseudomuscular hypertrophy, 579 
Pseudoparalysis, syphilitic, 748 
Psoriasis, 655 
Psychic disorders, 548 
Ptosis, 801 
Ptosis, Nicholson’s supporter for, 801 
of stomach in older children, 221-225 
Pulmonary abscess, 394 
gangrene, 393 
tuberculosis, 394. See also Tuberculosis, 
1pulmonary. 
Pulse in cerebrospinal meningitis, 615 
Pump, breast-, 54 
Puncture, cisterna, 823 
exploratory, in secondary pleurisy, 387 
lumbar, 821 
in acute meningitis, 605 
in meningismus, 619 
in tuberculous meningitis, 609 
pericardial, 821 
peritoneal, 821 
pleural, 821 
ventricular, 822 
Purpura, 446 
diagnosis, 448 
fulminans, 446 
hemorrhagic, 446 
Henoch’s, 446 
prognosis, 448 
simple, 446 
splenectomy in, 448 
thrombocytopenic, 447 
treatment, 448 
Purpuric smallpox, 668 
Purulent effusion, pleurisy with, 388. See 
also Empyema. 
Pus in urine, 488 
Pyelitis, 505. See also Pyelocystitis. 
Pyelocystitis, 505 
acute intestinal infection and, differen- 
tiation, 508 
age incidence, 505 
as cause of temperature elevation, 810 
Bacillus coli communis in, 863 
bacterial and associated factors, 505 
diagnosis, 507 
differential, 508 
duration, 508 
etiology, 505 
malaria and, differentiation, 508 
pathology, 506 
sex incidence, 505 
symptoms, 506 
treatment, 508 
typhoid fever and, differentiation, 508 
vaccine treatment, 508 
Pyloric obstruction, 207 
age incidence, 207 
appetite in, 212 
atropin in, 218 
constipation in, 212 
diagnosis, 213 
etiology, 208 
loss in weight in, 212 
non-operative type, management, 217 
pathology, 209 
peristaltic wave in, 213 
method of obtaining, 213 
prognosis, 216 
in combined cases, 216 
in spasmodic cases, 216 
with palpable tumor, 216 
pyloric spasm and, differentiation, 213 
retention of food in, 211 INDEX 
913 
Pyloric obstruction, sex incidence, 208 
symptoms, 211 
treatment, postoperative, 217 
surgical, 217 
tumor in, 213 
vomiting in, 211 
spasm, pyloric stenosis and, differentia- 
tion, 213 
Pylorospasm in older children, 218 
etiology, 219 
symptoms, 220 
treatment, 220 
vomiting in, 199 
Pyonephrosis, 491 
Pyrexia, prevention of, in acute illness, 151 
Pyromania, 548 
Pyuria, 488 
Quarantine in acute poliomyelitis, 593 
in diphtheria, 695 
in influenza, 733 
in measles, 685 
in scarlet fever, 707 
in whooping-cough, 679 
Quiet hip disease, 796 
Quincke’s needle, 822 
Quinin, 867 
in malaria, 726, 727 
Quinsy, 318 
Rachitic rosary, 123 
Rachitis, 118. See also Rickets. 
Rales, 340 
crepitant, 341 
moist, 341 
mucous, 341 
sibilant, 341 
sonorous, 341 
subcrepitant, 341 
Rash, delayed, in measles, 684 
in acute hereditary syphilis, 744 
in chickenpox, 670 
in German measles, 685 
in measles, 681 
in scarlet fever, 704 
septic, resembling scarlet fever, 714 
Raw milk, advantage and value, 65 
Record antitoxin syringe, 694 
history, 158 
Rectal administration of sodium salicyl- 
ate, 737 
feeding, 97 
method of giving, 97 
nourishment not to be used, 98 
to be used, 98 
medication in convulsions, 537 
in laryngismus stridulus, 539 
Rectum and anus, 299 
prolapse of, 300 
inflammation of, 301 
Recurrent bronchitis, 346. See also 
Bronchitis. 
vomiting, 773 
Red cells, 430 
nucleated, 430 
hepatization in lobar pneumonia, 356 
Reflex dermatitis, 651 
Regurgitant heart murmur, 404 
Regurgitation, aortic heart murmur in, 406 
mitral, heart murmur of, 405 
treatment, 427- 
Relaxation as aid to nutrition, 27 
Renal function, Mosenthal’s test of, 828 
phenolsulphonephthalein test for, 828 
Rowntree and Geraghty’s test of, 828 
tests for, 828 
Resolution in lobar pneumonia, 357 
Resonance of chest, 337 
tympanitic, 337 
Respiration, artificial, in asphyxia neona- 
torum, 170, 171 
in cerebrospinal meningitis, 613, 615 
Respiratory tract, diseases of, 306 
Rest treatment of chorea, 573 
Restlessness in acute hereditary syphilis, 
744 
Retention of urine, 482, 483 
Retropharyngeal abscess, acute, 327-330 
complicating tuberculous caries of 
cervical vertebrae, 330 
spasmodic croup and, differentiation, 
33 i 
adenitis, 327 
spasmodic croup and, differentiation, 
331 
Reuben’s table of differentiation of endo- 
crine disorders, 480 
Rhabdomyosarcoma of kidney, 490 
Rheumatic bronchitis, 741 
complex, 738 
diathesis, 738 
bath in, 740 
diet in, 739 
drugs in, 740 
etiology, 739 
treatment, 739 
fever, 734 
drugs in, 737 
etiology, 735 
joint type, symptoms, 735 
local measures, 737 
nodules in, 736 
precaution in, 736 
prognosis, 736 
sodium salicylate in, 737 
special manifestations, 736 
symptoms, 735 
treatment, 736 
nodules, 736 
pleurisy, 742 
Rheumatism, acute, 734. See also Rheu- 
matic fever. 
articular, 735 
counterirritation in, 847 
chorea and, relation, 571 
diplococcus of, 413 
leukocytosis in, 434 
scurvy and, differentiation, 117 
Rheumatoid arthritis, 742 
Rhinitis, acute, 306 
influenza and, differentiation, 307 
measles and, differentiation, 306 
nasal diphtheria and, differentiation, 
306 
specific rhinitis and, differentiation, 
306 914 
INDEX 
Rhinitis, chronic, 308 
in acute hereditary syphilis, 745 
in adenoids, 323 
Rhus poisoning, 627 
Rice-water No. 1, preparation of, 94 
No. 2, preparation of, 95 
Rickets, 118 
after first year, 119 
age incidence, 119 
as cause of convulsions, 534 
association with other diseases, 121 
bone changes in, 121-123 
cod-liver oil in, 127 
craniotabes in, 123 
cretinism and, differentiation, 126 
deformities in, treatment, 128 
diagnosis, 125 
differential, 126 
diet in, 127 
drugs in, 128 
etiology, 119 
diet, 119 
environment, 119 
lack of fat-soluble vitamin, 120 
lack of light, 121 
fetal, 797 
funnel chest in, 125 
Harrison’s grooves in, 123 
head in, 125 
heliotherapy in, 128 
hydrocephalus and, differentiation, 126 
hygiene in, 128 
in breast fed, 119 
mongolianism and, differentiation, 126 
pathogenesis, theories of, 121 
pathology, 121 
pigeon breast in, 123 
pot belly in, 125 
prognosis, 126 
rosary, 123 
saber tibia of, 129 
symptoms, 124 
teeth in, 38, 123 
treatment, 127 
Ringworm, 631 
of scalp, 632 
of tongue, 191 
Roentgen ray as diagnostic aid, 820 
diagnosis of pulmonary tuberculosis, 
396 
examination in status lymphaticus, 
475 
in secondary pleurisy, 387 
treatment of adenoids, 326 
of diseased tonsils, 326 
of status lymphaticus, 475 
of tinea tonsurans, 634 
Rollier on heliotherapy, 399 
Room, sick-, in acute illness, 152 
in bronchopneumonia, 373 
in lobar pneumonia, 363 
temperature for premature infants, 165 
in acute illness, 149 
Rosary, rachitic, 123 
Rose spots in typhoid fever, 717 
Rotch’s percentage method of infant feed- 
ing, 67 
Rotheln, 685 
Round-worms, 293 
Rous and Turner’s method of testing 
donors in blood transfusion, 848 
Rowntree and Geraghty’s phenolsulphone- 
phthalein test of renal function, 828 
Rubbing of finger-tips, 530 
Rubella, 685 
Rumination, 206 
Saber deformity in tardy hereditary 
syphilis, 752 
tibia of rickets, 129 
Saddle nose in tardy hereditary syphilis, 
753 
Salicylate of soda, 866 
Salt solution in acidosis, 772, 773 
Salt-free diet in acute diffuse nephritis, 498 
Salts, ammonium, 867 
Salvarsan in acute hereditary syphilis, 749 
Sanitarium treatment of tuberculosis, 834 
Sarcoma, 816 
embryonal, of kidney, 816 
Scabies, 628 
Scales, baby, 32 
Scalp, ringworm of, 632 
Scapulohumeral type of progressive mus- 
cular atrophy, 579 
Scarlatina, 701. See also Scarlet fever. 
Scarlet fever, 701 
adenitis in, 706 
treatment, 712 
albuminuria in, 707 
angina in, 704 
arthritis in, 707 
treatment, 714 
bowel evacuation in, 710 
bronchopneumonia in, 707 
care of nose and throat in, 712 
cervical adenitis in, 706 
treatment, 712 
clothing in, 709 
complications, 706 
treatment, 712 
control of fever in, 711 
desquamation in, 705 
second, 705 
diagnosis, 706 
Dick test in, 704 
diet in, 709 
diphtheria in, 706 
endocarditis in, 707 
etiology, 702 
extinction test in, 704 
fever in, 704 
German measles and, differentiation, 
686 
heart involvement in, treatment, 713 
history, 701 
incubation period, 704 
kidney of, 495 
laxatives in, 710 
leukocytosis in, 436 
lobar pneumonia in, 707 
milk diet in, 710 
mortality, 707 
myocarditis in, 707 
nephritis in, 707 
treatment, 713 
nursing in, 710 915 
INDEX 
Scarlet fever, oil inunctions in, 711 
otitis in, 707 
treatment, 713 
packs in, 711 
pericarditis in, 707 
prophylaxis, 709 
quarantine in, 707 
quiet in, 711 
rash in, 704 
Schultz and Charlton extinction test 
in, 704 
second attacks, 703 
septic,rash resembling, 714 
serum treatment, 712 
severity, 706 
sick-room in, 709 
specific skin reactions, 704 
stimulants in, 711 
strawberry tongue in, 706 
streptococcus vaccine in, 862 
susceptibility, 703 
symptoms, 704 
transmission, 702 
treatment, 709 
tub-baths in, 711 
urine examinations in, 709 
Schick test in diphtheria, 688-691 
School, 132 
in chorea, 573 
in habit spasm, 576 
Schultz and Charlton extinction test in 
scarlet fever, 704 
Schultze’s method of artificial respiration 
in asphyxia neonatorum, 171 
Schultz’s sign in tetany, 545 
Scientific infant feeding, 59 
Sclerema neonatorum, 167 
scleredema and, differentiation, 168 
scleroderma and, differentiation, 168 
Sclerosis, amyotrophic lateral, 577, 578 
multiple, Friedreich’s ataxia and, differ- 
entiation, 603 
plus nephritis, 494 
Scorbutus, 114. See also Scurvy. 
Scrambled egg stools, 103 
Scraped beef, preparation of, 94 
Scurvy, 114 
Alpine, 787 
diagnosis, differential, 117 
etiology, 114 
pathology, 115 
poliomyelitis and, differentiation, 117 
prognosis, 116 
rheumatism and, differentiation, 117 
symptoms, 115 
syphilis and, differentiation, 117 
trauma and, differentiation, 117 
treatment, 117 
Seborrhea, 653 
capitis, 654 
intertrigo, 654 
sicca, 653 
Second summer, diet in, 134 
Sedatives in acute meningitis, 605 
in convulsions, 537 
Senile chorea, 570 
Sensation in cerebral paralysis, 569 
Sensibility, cutaneous, in newborn infant, 
39 
Sensory effects of multiple neuritis, 594 
Sepsis in newborn, 173 
etiology, 173 
parts most frequently involved, 173 
prognosis, 174 
prophylaxis, 174 
sources of infection, 173 
treatment, 174 
of brain in newborn, 174 
of heart in newborn, 174 
of intestines in newborn, 174 
of joints in newborn, 174 
of lungs in newborn, 174 
of peritoneum in newborn, 174 
of skin in newborn, 174 
of umbilicus in newborn, 173 
Septic rash resembling scarlet fever, 714 
sore throat, 320 
Septicemia, staphylococcus vaccine in, 862 
Serous meningitis, 619 
Serum, Flexner’s, in cerebrospinal meningi- 
tis, 616 
human, in acute poliomyelitis, 592 
treatment, 864 
of acute ileocolitis, 248 
of cerebrospinal meningitis, 616-619 
of erysipelas, 642 
of lobar pneumonia, 367 
of measles, 682 
of scarlet fever, 712 
Seventh to eleventh year, diet from, 136 
Sexual dwarfism, 478 
Shield, nipple-, 47 
vaccination, 859 
Shingles, 638 
Shot-gun vaccines, 864 
Sibilant rales, 341 
Sick-room in acute illness, 152 
in bronchopneumonia, 373 
in lobar pneumonia, 363 
in scarlet fever, 709 
Sight in newborn infant, 38 
Sigmoid, elongated, 256 
Sinus thrombosis, 664 
Sitting erect, 40 
Skimmed milk in acute gastro-enteric in- 
toxication, 238 
Skin, care of, in health, 624 
diseases of, 624 
in cerebrospinal menigitis, 614 
in tardy hereditary syphilis, 751 
reactions, specific, in scarlet fever, 704 
tuberculin, 765 
sepsis of, in newborn, 174 
test in hay-fever, 355 
technic, in acute spasmodic bronchitis, 
353 
von Pirquet’s tuberculin, 824 
Sleep, 28, 40 
for subnormal child, 144 
inspection during, 160 
Sleeping sickness, 619 
Smallpox, 666 
chickenpox and, differentiation, 668 
complications, 669 
confluent, 668 
diagnosis, differential, 668 
diet in, 669 
eruptive stage, 667 916 
INDEX 
Smallpox, etiology, 667 
history, 666 
incubation period, 667 
invasion stage, 667 
involution stage, 668 
isolation in, 669 
mild, 668 
pathology, 667 
petechial, 668 
prognosis, 669 
purpuric, 668 
sequels, 669 
symptoms, 667 
treatment, 669 
prophylaxis, 669 
vaccination in, 669 
varieties, 668 
Smell, sense of, in newborn infant, 39 
Smithes, 306 
Soda bath, 844 
Sodium bicarbonate in acidosis, 772, 851 
in cyclic diarrhea, 778 
vomiting, 776 
salicylate, 866 
in rheumatic fever, 737 
Sonorous rales, 341 
Soor, 189 
Sore throat septic, 320 
streptococcus, 315 
Spasm, habit, 575 
chorea and, differentiation, 572 
of diaphragm, 533 
pyloric, pyloric stenosis and, differentia- 
tion, 213 
Spasmodic bronchitis, acute, 347-354 
croup, 330 
antispasmodics in, 334 
calomel fumigation in, 333 
cold compresses in, 333 
differential diagnosis, 331 
etiology, 330 
expectorants in, 331 
laryngismus stridulus and, differentia- 
tion, 331 
pathology, 330 
retropharyngeal abscess and, differen- 
tiation, 331 
adenitis and, differentiation, 331 
steam inhalations in, 333 
symptoms, 330 
treatment, 331 
Spasmophilia, 540 
Chvostek’s sign in, 541 
latent, 541 
manifest, 541 
peroneus sign in, 541 
Theimich’s sign in, 541 
Trousseau’s sign in, 541 
Spasmus nutans, 524 
Specific gravity of blood in newborn, 430 
parotitis, 672-674 
vaginitis, 518 
Speech, 40 
disturbance of, in cerebral paralysis, 569 
Spermatic cord, hydrocele of, 514 
encysted, 515 
Spina bifida, 555 
Spinal cord, malformations, 549 
meningocele of, 555 
Spinal fluid Wassermann test for syphilis, 
827 
muscular atrophy, progressive, 577. 
See also Muscular atrophy, progressive 
spinal. 
Spine, tuberculosis of, diagnosis, 795 
Spleen, diseases of, 451 
enlargement of, 451 
in acute hereditary syphilis, 745 
in leukemia, 444 
in tardy hereditary syphilis, 754 
in typhoid fever, 716 
tuberculosis of, 397 
Splenectomy in purpura, 448 
Splenic anemia, 451. See also Anemia, 
splenic. 
Splenomegaly, 451 
Splenomyelogenous leukemia, 443 
Sponging, cold, in fever, 840 
in acute illness, 149 
Sprue, 189 
Sputum as diagnostic aid, 820 
care of, in pulmonary tuberculosis, 399 
method of obtaining, in pulmonary 
tuberculosis, 396 
Stain, port-wine, 657 
Stammering, 576 
Standing, 40 
Staphylococcus vaccine, 861 
in antrum disease, 862 
in asthma, 862 
in furunculosis, 862 
in local suppuration, 862 
in osteomyelitis, 862 
in otitis media, 862 
in septicemia, 862 
in styes, 862 
Starch, 20 
and opium in acute ileocolitis, 248 
bath, 844 
digestion, infant’s capacity for, 84 
feeding, 83 
Status lymphaticus, 471 
cause of sudden death in, 473 
diagnosis, 474 
etiology, 472 
pathology, 472 
Roentgen ray examination, 475 
treatment, 475 
surgical treatment, 475 
Steam inhalations in bronchitis, 343 
in bronchopneumonia, 374 
in spasmodic croup, 333 
Stenosis, aortic, heart murmur in, 405 
mitral, heart murmur in, 405 
treatment, 427 
of esophagus, 195 
pyloric, 297. See also Pyloric obstruc- 
tion. 
Stenotic heart murmur, 404 
Sterilization of milk, 63 
Sterilized milk, 63 
Sterilizer, Arnold, 64 
Sternocleidomastoid, hematoma of, in 
newborn, 167 
Still’s disease, 742 
Stimulants, heart, in bronchopneumonia, 
375 
in diphtheria, 696 INDEX 
917 
Stimulants, heart, in lobar pneumonia, 365 
in typhoid fever, 723 
in acute enteric intoxication, 242 
in erysipelas, 641 
in scarlet fever, 711 
Stimulation, hypodermic, in lobar pneu- 
monia, 366 
in acute illness, 152 
Stomach, anatomy of, 196 
capacity of, 196 
cough, 310 
digestion in, 196 
dilatation of, in older children, 221-225 
vomiting in, 199 
diseases of, 196 
feeding, substitutes for, 96 
foreign bodies in, 818 
hemorrhage from, 205 
motility, 197 
ptosis of, in older children, 221-225 
tuberculosis of, 397 
ulceraticn of, 205 
washing, 852. See also Lavage. 
Stomatitis, 186 
aphthous, 186 
bacteriology, 186 
catarrhal, 186 
chlorate of potash in, 188 
dangers, 188 
drugs in, 188 
etiology, 186 
feeding in, 188 
mouth washing in, 187 
mycotic, 189 
necrobiosis in, 187 
prognosis, 187 
symptoms, 186 
treatment, 187 
after ulceration, 188 
ulcerative, 186 
Stone in bladder, 510 
Stools, bacilli in, in pulmonary tuberculo- 
sis, 396 
blood in, 104 
breast milk, 103 
cow’s milk, 103 
curds in, 104 
evidence afforded by, 103 
examination of, 104 
hard constipated, 103 
in hard balls, 103 
incontinence of, 266 
treatment, 267 
loose watery, 103 
mucus in, 103 
scrambled egg, 103 
Strawberry tongue in scarlet fever, 706 
Streptococcus sore throat, 315 
vaccine, 862 
in erysipelas, 862 
in joint affections, 863 
in scarlet fever, 862 
Stricture of esophagus, 195 
Stridor, laryngeal, congenital, 540 
in laryngismus stridulus, 538 
Strychnin, 867 
Stump of umbilical cord, care of, 175 
Stupor in kibar pneumonia, 360 
St. Vitus’ dance, 570. See also Chorea. 
Styes, staphylococcus vaccine in, 862 
Subcrepitant rales, 341 
Subcutaneous emphysema with emphy- 
sema of mediastinum, 384 
inoculation with tuberculin in diag- 
nosis of tuberculosis, 824 
Subnormal child, physically, 140-146 
bathing, 143 
clothing for, 145 
diet after first year, 142 
education for, 145 
entertainment for, 145 
exercise for, 145 
feeding, 141 
fresh air for, 143 
influence of climate on, 144 
midday nap for, 145 
nursery for, 144 
sleep for, 144 
treatment, 140 
weighing, 141 
Suboxidation syndrome, 780-783 
Suction drainage in empyema, 393 
in laryngeal diphtheria, 701 
Sugar determination of breast milk, 45 
in cow’s milk, 60 
in modified milk, 69 
requirement of infant, 73 
Summer camp, 132 
clothing, 835 
instructions for, 835 
resorts, 834 
second, diet in, 134 
water to drink in, 836 
Sunlight, value of, 26 
Sun’s rays, exposure to, in pulmonary 
tuberculosis, 399 
Suppositories in constipation in nurslings, 
271 
Suppression of urine, 482, 483 
measures to prevent, in acute illness, 
151 
Suppuration, local, staphylococcus vaccine 
in, 862 
Suprarenal glands, diseases of, 477 
Symptomatic dwarfism, 478 
infantilism, 478 
Syndrome, effort, 811 
suboxidation, 780-783 
Syphilis, 743 
acquired, 750 
acute hereditary, 744 
acute epiphysitis, in, 748 
arsenicals in, 749 
convalescence in, 750 
eosinophilia in, 435 
fissures in, 747 
hemorrhages in, 748 
liver in, 745 
mercury in, 748, 749 
mucous patches in, 747 
nails in, 748 
neosalvarsan in, 749 
rash in, 745 
restlessness in, 744 
rhinitis in, 745 
salvarsan in, 749 
spleen in, 745 
symptoms, 744 918 
INDEX 
Syphilis, acute hereditary, treatment, 748 
later, 750 
Wassermann test in, 748 
as etiologic factor in hemorrhagic 
diseases of newborn, 182 
bacteriology, 743 
complement fixation test for, 826 
congenital, 744. See also Syphilis, acute 
hereditary. 
deviation test for, 826 
Lange’s colloidal gold test for, 828 
Noguchi’s butyric acid test for, 827 
scurvy and, differentiation, 117 
spinal fluid Wassermann test for, 827 
splenic anemia and, differentiation, 453 
tardy hereditary, 751 
blood-vessels in, 752 
bones in, 752, 753 
ear changes in, 751 
errors in nutrition in, 753 
eye changes in, 751, 754 
Hutchinson’s teeth in, 753 
liver in, 754 
lymph-nodes in, 752, 753 
mixed treatment, 754 
mucous membrane of respiratory 
tract in, 751 
pathology, 751 
saber deformity in, 752 
saddle nose in, 753 
skin changes in, 751 
spleen in, 754 
symptoms, 753 
teeth in, 753 
treatment, 754 
viscera in, 752 
types, 744 
Wassermann test for, 826 
Syphilitic dactylitis, 768 
pseudoparalysis, 748 
Syringomyelocele, 555 
Tabes dorsalis, juvenile, Friedreich’s ataxia 
and, differentiation, 603 
mesenterica, 759 
Tache cer6brale in cerebrospinal menin- 
gitis, 615 
Tachycardia, 407, 408 
Taenia elliptica, 295, 296 
saginata, 295 
solium, 295 
Tapeworm, 295 
Tardy hereditary syphilis, 751 
mlanutrition, 146 
of syphilitic origin, 755 
Tartar emetic, 866 
Taste in newborn infant, 39 
Teeth, 37 
calcification of, 38 
care of, 37 
diseased, 192 
first set, 37 
Hutchinson’s, in tardy hereditary syphi- 
lis, 753 
in rickets, 38, 123 
in tardy hereditary syphilis, 753 
permanent set, 37 
Teething cough, 310 
Temperature, 805 
elevation of, encysted empyema as 
cause, 809 
from active exercise, 808 
infection of mediastinal glands as 
cause, 809 
intestinal infection as cause, 810 
obscure, 808 
otitis as cause, 809 
periodic fever as cause, 809 
pyelitis as cause, 810 
tuberculosis as cause, 809 
typhoid fever as cause, 809 
unexplained, 810 
in lobar pneumonia, 358 
low, in lobar pneumonia, 359 
normal, 805 
room, for premature infants, 165 
in acute illness, 149 
Tenia, 295 
Test meal in gastric hyperacidity, 203 
Testicle, undescended, 513 
inguinal hernia and, differentiation, 
286 
Tetanus antitoxin in tetanus neonatorum, 
178 
neonatorum, 177 
Tetany, 540, 542 
as cause of convulsions, 535 
bath in, 547 
Chvostek’s sign in, 545 
climate in, 547 
cod-liver oil in, 547 
diagnosis, 545 
diet in, 547 
duration, 545 
electric irritability in, 545 
etiology, 542 
hand in, 545 
muscle irritability in, 545 
oil inunctions in, 547 
pathology, 544 
prognosis, 546 
Schultze’s sign in, 545 
symptoms, 544 
tonics in, 547 
treatment, 546 
Trousseau’s sign in, 545 
Theimich’s sign in spasmophilia, 541 
Therapeutic measures, 831 
drugs, 832 
education of mother, 831 
prophylaxis, 832 
Third to fifth year, diet from, 135 
Thirst-hunger in newborn infant, 39 
Thoracentesis, 821 
Thread-worm, 294 
Thrill in diseases of heart, 405 
Throat, diseases of, 306 
examination, 312 
irrigation of, 321 
indications, 321 
procedure, 321 
septic sore, 320 
Thrombocytopenic purpura, 447 
Thrombosis, sinus, 664 
Thrush, 189 
Thumb-sucking, 529 • 
Thymic death, 473 INDEX 
919 
Thymus gland, 470 
anatomy, 470 
enlargement, 471. See also Status 
lymphaticus. 
as cause of convulsions, 534 
percussion of, 474 
physiology, 471 
tuberculosis of, 397 
weight and size, 470 
Thyroid gland, diseases of, 463 
physiologic congestion, 463 
premenstrual congestion, 463 
simple enlargement, 462 
treatment in cretinism, 467-469 
Tibia, saber, of rickets, 129 
Tic, 575 
Tinea circinata, 631 
tonsurans, 632 
Tongue, geographic, 191 
ringworm of, 191 
strawberry, in scarlet fever, 706 
Tonsil, abdominal, 288 
Tonsillar diphtheria, acute follicular ton- 
sillitis and, differentiation, 315, 316 
Tonsillitis, diphtheria and, differentiation, 
692 
follicular, acute, 314 
mixed infection and, differentiation, 
316 
tonsillar diphtheria and, differen- 
tiation, 315, 316 
treatment, 316 
Tonsils, 314 
diseased, permanently, 325 
enlarged, adenoids associated with, 325 
faucial, 314 
hypertrophy of, chronic, 325 
operation for, 325 
x-ray treatment, 326 
lingual, 314 
pharyngeal, 314 
removal of, benefits, 326 
effect upon acute infections. 326 
delicate children, 326 
tubal, 314 
Top milk methods of milk modification, 70 
formulas, 71, 72 
Toxin-antitoxin immunization in diph- 
theria, 688-691 
Tracheal cough, 311 
Tracheitis as cause of cough, 311 
Training, physical, 133 
Transfusion, blood, 848 
in bronchopneumonia, 378 
in cyclic vomiting, 777 
in epidemic encephalitis, 621 
in hemorrhagic diseases of newborn, 
185 
in pneumonia, 367 
in secondary anemia, 440 
in sepsis neonatorum, 175 
indications, 849 
Transitional cells, 431 
Transmissible diseases, 665 
Trauma, scurvy and, differentiation, 117 
Traumatic dermatitis, 649 
laryngitis, 334 
Traveling, milk for, 96 
Treatment of individual, 155 
Trichina spiralis, 297 
Trichinella spiralis, 297 
Trichiniasis, 297 
Trousseau’s sign in spasmophilia, 541 
in tetany, 545 
Tubal tonsils, 314 
Tub-baths for fever, 843 
in scarlet fever, 711 
Tubercle bacilli in stool in pulmonary 
tuberculosis, 396 
Tuberculin in diagnosis of tuberculosis, 824 
cutaneous inoculation, 824 
differential cutaneous reaction, 825 
intradermal test, 825 
subcutaneous inoculation, 824 
skin reactions, 765 
test, Calmette’s, 825 
Detre’s, 825 
Hamburger’s, 824 
in pulmonary tuberculosis, 396 
Mantoux’s, 825 
Moro’s, 825 
von Pirquet’s, 824 
Wolff-Eisner, 825 
treatment of tuberculosis, 863 
Tuberculosis, 756 
abdominal, 759 
acute miliary, typhoid fever and, differ- 
entiation, 718 
as cause of cough, 312 
of temperature elevation, 809 
avenues of entrance of bacillus, 757 
bovine, 756 
climate in, 834 
Hodgkin’s disease and, differentiation, 
462 
incidence of, 767 
leukocytosis in, 433 
milk infection in, 758 
of cervical lymph-nodes, 458 
of hip, diagnosis, 795 
of joints, diagnosis, 794 
of kidney, 490 
of knee-joint, diagnosis, 795 
of mesenteric glands, 759 
of spine, diagnosis, 795 
predisposing causes, 757 
prophylaxis, 758 
pulmonary, 394 
associated lesions, 397 
bacilli in stool in, 396 
bronchitis and, differentiation, 343 
climate in, 397 
D’Espine sign in, 396 
diagnosis, 395 
diet in, 397 
empyema and, differentiation, 391 
heart involvement in, 397 
heliotherapy in, 399 
hygiene in, 398 
interstitial pneumonia and, differen- 
tiation, 379 
intestinal involvement in, 397 
kidney involvement in, 397 
larynx involvement in, 397 
liver involvement in, 397 
obtaining sputum in, 396 
pancreas involvement in, 397 
pathology, 394 920 
INDEX 
Tuberculosis, pulmonary, peritoneal in- 
volvement in, 397 
prognosis, 396 
spleen involvement in, 397 
sputum in, care of, 399 
stomach involvement in, 397 
symptoms, 395 
thymus gland involvement in, 397 
tonics in, 399 
treatment, 397 
tuberculin test in, 396 
x-ray diagnosis, 396 
relative frequency in different sites, 758 
sanitarium treatment, 834 
surgical, heliotherapy in, 764 
tests for, 824 
tuberculin in diagnosis, 824 
cutaneous inoculation, 824 
differential cutaneous reaction, 825 
intradermal test, 825 
subcutaneous inoculation, 824 
skin reactions in, 765 
treatment, 863 
types of infection, 756 
Tuberculous adenitis, 458-461 
dactylitis, 768 
meningitis, 606. See also Meningitis, 
tuberculous. 
peritonitis, chronic, 760 
age incidence, 760 
ascitic type, 761 
diagnosis, 763 
etiology, 760 
fibrous type, 761 
heliotherapy in, 764 
pathology, 760 
plastic type, 761 
prognosis, 763 
symptoms, 761 
treatment, 761 
surgical, 764 
types of bacilli, 760 
of lesions, 761 
tumors of brain, 557 
Tumors, 815 
of adrenal gland, 477 
of brain, 557, 816 
tuberculous, 557 
of kidney, 490 
of pineal gland, 816 
of pituitary gland, 816 
Tunica vaginalis, hydrocele of, 515 
Tussis infantum, 674 
perennis, 674 
Tutor, private, 132 
Twelfth to fifteeth month, diet from, 135 
Tympanites in lobar pneumonia, 359 
treatment, 364 
Tympanitic dulness of chest, 337 
resonance of chest, 337 
Typhoid bacillus, 715 
dead, inoculation of, 863 
fever, 714 
acute miliary tuberculosis and, dif- 
ferentiation, 718 
cause of temperature elevation, 809 
bacteriology, 715 
bathing in, 719, 723 
blood in, 717 
Typhoid fever, complications, 717 
control of fever in, 722 
diagnosis, differential, 717 
diagnostic signs, 717 
suspicious, 717 
diarrhea in, treatment, 722 
diet in, 719 
disposal of excreta in, 719 
drugs in, 721 
empyema and, differentiation, 391 
feeding in, 719 
gastro-intestinal symptoms, 716 
Gruber-Widal reaction in, 715 
heart stimulants in, 723 
hemorrhage in, treatment, 724 
high caloric diet in, 721 
leukocytosis in, 434 
meningitis and, differentiation, 718 
milk in, 719, 720 
mortality, 718 
mouth toilet in, 719 
nervous symptoms, 716 
pathology, 715 
perforation in, treatment, 724 
pulse in, 716 
pyelocystitis and, differentiation, 508 
rose spots in, 717 
spleen in, 716 
symptoms, 716 
temperature in, 717 
treatment, 719 
vaccination against, 718 
advisability, 718 
Widal reaction for, 823 
Typhus syncopalis, 610 
Ulcer, duodenal, 286 
Ulceration at angle of mouth, 191 
of stomach, 205 
Ulcerative ileocolitis, 244 
proctitiSj 302 
stomatitis, 186 
Ulcus Egyptacum, 686 
Syracum, 686 
Umbilical cord, hernia of, 283 
stump of, care of, 175 
granuloma, 175 
hernia, congenital, 283 
polyp, 176 
Umbilicus, hernia at, 283 
sepsis of, in newborn, 173 
Uncinaria, 296 
americana, 296 
Uncinariasis, 296 
Underwood’s disease, 167 
Undescended testicle, 513 
inguinal hernia and, differentiation, 
286 
Unpalatable drugs, 866 
Urea, amount excreted, in acute diffuse 
nephritis, 501 
and urinary nitrogenous constituents of 
urine, estimations, 829 
Uremia in acute diffuse nephritis, 496 
Uremic convulsions, treatment, 501 
Urethra, atresia of, 521 
Uric acid, blood chemistry, 829 
Urination, continence established, 482 INDEX 
921 
Urination, difficult, 482 
painful, 482 
Urine, 481 
ammoniacal, 102 
as diagnostic aid, 820 
blood in, 487 
examination in acute diffuse nephritis, 
497 
illness, 150 
in scarlet fever, 709 
in acute diffuse nephritis, 496 
in diabetes mellitus, 785 
in measles, 683 
incontinence of, 484-487 
ketone bodies in, 779 
method of collecting, 481 
normal variations, 481 
observations on, 481 
pus in, 488 
retention of, 482, 483 
suppression of, 482, 483 
measures to prevent, in acute illness, 
151 
urea and urinary nitrogenous constit- 
uents, estimation, 829 
Urogenital system, diseases of, 481 
Urticaria, 625, 
after antitoxin treatment of diphtheria, 
695 
giant, 626 
Vaccination, 857 
after-treatment, 858 
against typhoid fever, 718 
advisibility, 718 
complications, 859 
constitutional disturbance from, 858 
in smallpox, 669 
local applications, 859 
method, 858 
shield, 859 
site, 857 
Vaccine, cold, 864 
gonococcus, 863 
meningococcus, 863 
pneumococcus, in pneumonia, 864 
preparation of, 861 
shot-gun, 864 
staphylococcus, 861. See also Staphylo- 
coccus vaccine. 
streptococcus, 862. See also Strepto- 
coccus vaccine. 
treatment, 859 
fundamental principles, 859 
of boils, 630 
of cerebrospinal meningitis, 619 
of erysipelas, 642 
of gonorrheal vulvovaginitis, 520 
of pyelocystitis, 508 
of whooping-cough, 679, 864 
Vagina, atresia of, 521 
Vaginal hydrocele, 515 
Vaginitis, specific, 518 
Valvular disease, chronic, of heart, 425 
constructive medication in, 428 
diagnosis, 425 
drugs in, 427 
etiology, 425 
Valvular disease, chronic, of heart, heart 
stimulants in, 428 
prognosis, 426 
symptoms, 425 
treatment, 426 
heart murmurs, 404 
Van Slyke and Bosworth’s method of 
estimating protein in breast milk, 45 
Vapor treatment of influenza, 734 
of measles, 685 
Varicella, 670-672 
Variola, 666. See also Smallpox. 
Vascular nevi, 657 
Venous heart murmurs, 406 
Ventilation in acute illness, 149 
of nursery, 26, 30, 31 
Ventral hernia, 285 
Ventricular puncture, 822 
Vermiform appendix, anatomy, 287 
Vesical calculus, 510 
Vesicular breathing, 338 
distant, 338 
exaggerated, 338, 339 
Vincent’s angina, 319 
Virus in acute poliomyelitis, 587 
Viscera in tardy hereditary syphilis, 752 
Vitamin, fat-sohible, lack of, in etiology 
of rickets, 120 
Vitamins, function of, 21 
Volhard and Fahr’s classification of kidney 
diseases, 493 
Vomiting, 100 
blood, 205 
cyclic, 773. See also Cyclic vomiting. 
habit, 101 
in acute gastric indigestion, 200 
in cerebrospinal meningitis, 613 
in dilatation of stomach, 199 
in gastric hyperacidity, 203 
in icterus, 305 
in infants, management, 198 f 
in lobar pneumonia, 360 
in older children, 199 
etiology, 199 
in pyloric obstruction, 211 
in pylorospasm, 199 
lavage in, 852, 853 
nervous, 101 
obstinate, gavage in, 854 
periodic, 773 
appendicitis and, differentiation, 289 
persistent, in acute gastric indigestion, 
treatment, 201 
recurrent, 773 
treatment of, 101 
varieties of, 100, 101 
von Jaksch, pseudoleukemic anemia of, 441 
Von Pirquet school, feeding method of, 24 
Von Pirquet’s tubercluin test, 824 
Vulvovaginitis, gonorrheal, 518 
simple, 517 
Waddling gait in pseudomuscular hyper- 
trophy, 582 
Warm packs in acute meningitis, 605 
Washing, stomach, 852 
Wassermann test for syphilis, 826 
in acute hereditary syphilis, 748 922 
INDEX 
Wassermann test, spinal fluid, for syphilis, 
827 
Wasting palsy, 577 
Water, drinking of, in acute illness, 150 
early giving of, 46 
function of, 21 
to drink in summer, 836 
Water-pressure in reduction of intussus- 
ception, 279 
Weakened breathing, 339 
Weaning, 55 
care of breasts during, 56 
Weighing infants, 33, 141 
Weight of newborn infant, 33 
of thymus gland, 470 
Werlhof’s disease, 447 
Wet beriberi, 790 
brain in acute gastro-enteric intoxication, 
235 
Wet-nurse, 56 
in acute gastro-enteric intoxication, 
239 
in marasmus, 106 
selection of, 57 
Wheat jelly, preparation of, 94 
Whey feeding, 76 
preparation of, 95 
White cells, 430 
Whooping-cough, 674 
as cause of cough, 312 
bacteriology, 674 
climate in, 833 
complications, 676 
diagnosis, 677 
differential, 677 
Whooping-cough, drugs in, 678 
duration, 676 
fresh air in, 679 
history, 674 
incubation, 676 
infective period, 675 • 
interrupted medication in, 678 
leukocytosis in, 435 
pathology, 676 
prognosis, 677 
quarantine in, 679 
susceptibility, 675 
symptoms, 676 
transmission, 675 
treatment, 678 
vaccine treatment, 679, 864 
Widal-Gruber reaction in typhoid fever, 
715, 823 
Winchel’s disease, 182 
Window-board, 26 
in acute illness, 152 
Wolff-Eisner tuberculin test, 825 
Wood on height and weight ratio for boys 
and girls, 36 
Written directions in acute illness, 153 
x-Ray. See Roentgen ray. 
Yerbazin, 867 
in malaria, 727 
Zona, 638