A practical treatise on the diseases of children

Front matter

A

PRACTICAL TREATISE

DISEASES OF CHILDREN.

Preface To The Third Edition

After three years I experience the great pleasure of placing my treatise on the Diseases of Children, for the third time, before my colleagues and those younger in the profession, and am quite convinced that my labor has not been wholly unappreciated. As a mark of still further recognition, it may be stated that two years ago a Russian translation, under the direction of M. Zelensky, followed the one in Dutch. As regards the improvements and additions, they are not considerable. But the chapter on Diphtheria had to be remodeled, because the description in the first and second editions answered more to the sporadic form resulting from scarlatina, etc., while the epidemic type with which I only became acquainted in the last few years, through personal observation, had not been exhaustively estimated. And now with pleasure I once more present this work to the young practitioner, trusting that it will aid him on the occasions of diagnostic doubt and therapeutic embarrassments, to which every beginner is liable, and elevate the vacillatingconfidence in his medical skill.

ALFRED YOGEL.

Dokpat, October, 1860.

Preface To The American Edition

Towaed the close of 1868 I informed Professor Vogel that I had taken the liberty of translating his excellent treatise on the Diseases of Children ; he kindly and promptly replied, giving his consent to the publication of the translation, informing me at the same time that the work was also in the course of translation into the Polish language, and that the fourth edition of the original was just then in press and would be issued early in the year 1S69. He very considerately forwarded to me the additional articles of the last edition, and recommended their insertion in my translation, in order to make it correspond in all respects to the fourth German edition.

The subjects alluded to are : (1), on the method of preparing the so-called Liebig's soup ; (2), on sclerosis of the sterno-cleido mastoideus muscle ; and (3), on rubeola — this last the author, in common with many eminent European physicians, regards as a separate and distinct disease from morbilli.

The facts of Yogel's " Kinderkrankkeiten " having been translated into three other languages, and of its having attained to the fourth edition in less than eight years, together with the nattering commendations of the critics in various countries, and his belief in its utility and merit and its adaptation to the wants both of the practitioner and the student, must account for the translator having undertaken to render an English version of it.

viii PREFACE TO THE AMERICAN EDITION.

The work will be found to be well up to the present state of pathological knowledge ; complete without unnecessary prolixity y its symptomatology accurate, evidently the result of careful observation of a competent and experienced clinical practitioner. The diagnosis and differential relations of diseases to each other are accurately described, and the therapeutics judicious and discriminating. All polypharmacy is discarded, and only the remedies which appeared useful to the author commended.

"Without in any way detracting from the merit of the numerous works upon the Diseases of Children which exist in our own and other languages, he ventures to assert his belief that the work of Vogel contains much that must gain for it the merited praise of all impartial judges, and prove it to be an invaluable text-book for the student and practitioner, and a safe and useful guide in the difficult but all-important department of Paediatrica.

In the efforts at converting the original into our own vernacular tongue, all thoughts of elegancy as to style have been renounced ; the only object aimed at was to present it in as clear and intelligible language as possible, to make the translation a worthy counterpart of the original, and to express the true ideas and intentions of the illustrious author ; how well I have succeeded, time and the favor which it receives at the hands of the profession of this country will tell.

H. RAPHAEL.

New York, August, 1869.

Contents

PAGE

Preface v

I.— INTRODUCTORY REMARKS.

Chapter I. Anat0mo-pathol0oical Observations Upon The Infantile Organism

A. — Respiration and Circulation.

Ductus Venosus Arantii 1

Ductus Arteriosus Botalli 2

Foramen Ovale 2

Arteria; Umbilicales 2

Thymus Gland 3

B. — Secretions.

Meconium 4

Uric-Acid Infarction 5

Cutaneous Secretion, Seborrhcea Capillitii 6

C. — Growth.

General Growth 7

Fontanels 8

Eruption of the Teeth 11

Chapter II. General Rules For The Examination Of

CHILDREN.

Pulse 17

Thoracic Cavity 19

Abdominal Cavity 21

Cry and Cough 26

Chapter III. Nursing And Care Of Children

Selection of a Wet-nurse 30

Analysis of the Milk 32

Weaning 41

Artificial Nutrition 43

Bathing, Dressing, Residence 48

11.— SPECIAL SUBJECTS.

Chapter I. Diseases Originating Directly As A Re- Sult Of The Delivery

A. Asphyxia Neonatorum 01

B. Atelectasis Pulmouum 54

PAGE

C. Cephalsmatoma 56

D. Diseases of the Navel 58

(1.) Inflammation of the Umbilical

Vessels 59

(2.) Blenorrhcea and Ulceration of

Navel 60

(3.) Gangrene of the Navel 60

(4.) Ulceration of the Umbilical

Stump 61

(5.) Hemorrhage of the Navel.. . . 61

(6.) Hernia; of the Navel 62

E. Trismus and Tetanus of the New-

bom 64

F. Scleroma 67

G. Mehena Neonatorum 70

H. Icterus Neonatorum 72

I. Conjunctivitis Blenorrhoica Neonatorum 73

Chapter II. Diseases Of The Apparatus Of Digestion

A. — Mouth.

(1.) Harelip and Cleft Palate 80

(2.) Constriction of the Mouth. ... 83 (3.) Imperfect Development of the

Tongue 83

(4.) Hypertrophy and Prolapse of

the Tongue 84

(5.) Abnormal Adhesions of the

Tongue 84

(6.) Ranula 85

(7.) Catarrhal Inflammation of the

Mucous Membrane of the

Mouth 87

(8.) Diphtheritis of the Mouth 89

(9.) Putrid Sore Mouth 93

(10.) Scorbutic Inflammation of the

Mucous Membrane of the

Mouth 96

APPENDIX. (a.) Signification of a Coated

Tongue in Children 105

(6.) Difficult Deutition 106

CONTEXTS.

TAGE

B.— Parotis.

(1.) Inflammation of the Parotid

Gland Ill

(2.) Hypertrophy of the Parotid

Gland 116

C. — Pharynx and (Esophagus.

(1.) Angina Tonsillaris 117

(2.1 Hypertrophia Tonsillarum . . . . 119 (3.) Retropharyngeal Abscesses... 120 (4.) Inflammation of the (Esophagus 122

(5.) Congenital Fistula of the Neck. 123 (6.) Sclerosis of the Sterno-cleido-

mastoideus Muscle 124

D. — Stomach and Intestinal Canal. (1.) The Most Important Symptoms of Diseases of the Stomach

and Intestines 124

(a.) Dyspepsia 125

(A.) Bulimia 127

(c.) Vomiting 128

(d.) Flatulence and Colic 131

(e.) Diarrhoea l:j.">

(/.) Constipation 13S

(2.) Catarrh of the Gastric Mucous

Membrane 140

(3.) Toxic Inflammation of the

Stomach 141

(4.) The Perforating Ulcer of the

Stomach 144

(5.) Hemorrhagic Erosions of the

Gastric Mucous Membrane. . . 144 (6.) Catarrhal Inflammation of the

Intestines 150

(7.) Enteritis Folliculosa and Tabes

Mescnterica 156

(».) Dysentery— The Flux 160

(9.) Intussusceptions 163

(10.) Inguinal Hernia 166

(11.) Fissura Ani 168

(12.) Polypi of the Rectum 169

(13.) Prolapsus Ani 170

(14.) Malformations of the Anus and

Rectum 172

(15.) Contagious Diseases with Preponderating Localization upon

the Intestinal Canal 175

(a.) Typhus Abdominalis 175

(o. ) Cholera Asiatiea 195

(16.) Entozoa>, Enthelminthes, Helminthiasis, 'Worm Disease. . . . 201

E. — Liter. (1.) Syphilitic Inflammation of the

Liver 210

(2.) The Fatty Liver 211

(3.) Congenital Anomalies 214

F. — Spleen.

Intermittent Fever 216

PAGE

G. — Peritonaum.

(1.) Peritonitis 219

f 2.1 Ascites 222

(3.) Diseases of the Mesenteric

Glands 224

Chapter III. Diseases Of The Organ's Of Circulation

A. — Heart and Vascular Trunks.

(1.) Congenital Anomalies 224

(2.) Endocarditis, Pericarditis, and

Rheumatismus Acutus 231

(3.) Hydroperieardium 240

B. — Arteries and Veins.

(1.) Erectile Tumors 242

(2.) Thrombi of the Sinuses of the

Dura Mater 244

Chapter IV. Diseases Of Toe Organs Of Respiration

A. — Nasal Cavities.

(1.) Epistaxis, Bleeding of the Nose, 245

(2.) Coryza, Rhinitis, Catarrh 247

(3.) Adventitious Growths in the

Nose 248

(4.) Foreign Bodies in the Nose. . . 250

B. — Larynx and Trachea.

'2.) Pseudo-croup 258

3.) Neuroses of the Larynx 270

(a.) Spasmus Glottidis 270

(6.) Paralysis Glottidis 278

C. — Thyroid Cland.

Struma 279

D. — Thymus Cland.

E. — Lungs.

(1.) Bronchial Catarrh 282

(2.) Pneumonia 289

(.3.) Acquired Atelectasis of the

Lungs 298

(4.) Pulmonary Emphysema 301

(5.) (Edema Pulmonum 303

(6.) Haemorrhage from the Lungs. . 305 (7.) H;emoptoic Pulmonary Infarction 300

(8.) Gangrene of the Lungs 307

(9.) Tuberculosis of the Lungs and

Bronchial Glands 309

(10.) Carcinoma of the Lungs and of

the Mediastinum Anticum. . . 316

(11.) Whooping-cough 318

(12.) Periodic Night-cough 330

•

CONTENTS.

XI

F. — Pleura.

(1.) Pleurisy 331

(2.) Hydrothorax 337

Chapter V. Diseases Of The Nervous System

A. — Brain. (1.) Hydrocephalus Acutus Interims 339

(2.) Meningitis Simplex, Purulenta,

and Encephalitis 359

(3.) Sunstroke 362

(4.) Hydrocephaloid and Irritatio

Cerebri 363

(5.^ Hydrocephalus Chronicus 365

(6.) Encephalocele 370

(7.) Sclerosis of the Brain 372

(8.) Neoplasms of the Brain 372

(a.) Tubercle 373

(b.) Carcinoma 374

(c.) Entozoaj 374

(9.) Congenital Malformations 375

B. — Diseases of the Spinal Cord and Membranes.

(1.) Spinal Mcniugitis and Myelitis.. 376 (2.) Spina Bifida, Uydrorrhachia 380

0. — Disturbances of the Nervous Functions.

(1.) Eclampsia Infantum — Convulsions 383

(2.) Paralysis 390

(3.1 Chorea Minor 395

(4.) Chorea Major 404

(5.) Epilepsy 407

APrEXDIX.

Diseases of the Mind 417

D. — Higher Organs of Sense.

I.— Sight 420

(1.) Epicanthus 420

(2.) Cyclopia 421

(3.) Malformations of the Eyeball... 421

II.— Hearing 423

(1.) Malformation of the Organ of

Hearing 423

(a.) Absence of the Auricula? 423

(6.) Occlusion of the Meatus Audi-

torius 424

(2.) Simple Inflammation of the

Meatus Auditorius 425

(3.) Abscesses in the Meatus Auditorius 428

(4.) Inflammation of the Middle

Ear 429

(S.) Foreign Bodies in the Ear 435

PAGE

Chapter VI. Diseases Of The Bladder And Genital Organs

A. — Kidneys.

(1.) Malformation of the Kidneys .. . 437 (2.) Uric-Acid Infarction of the

New-born 437

(3.) Morbus Brightii 439

(4.) Renal Calculi, Renal Tubercles,

Renal Cysts 444

B. — Bladder.

(1.) Malformation 445

(2.) Cystitis 448

(3.) Incontinentia ITrinas 450

(4.) Ischuria 452

(5.) Vesical Calculi 453

C. — Male Genitals.

I. — Penis 456

(1.) Malformations 456

(2.) Balanitis 458

(3.) Acquired Paraphimosis 459

(4.) Onanism 460

II. — Testis 462

(1.) Cryptorchidia 462

(2.) Hydrocele 463

T>. — Female Genitals.

(1.) Malformations 466

(2.) Catarrh of the Genital Mucous

Membrane 468

(3.) Diphtheritis and Gangrene of

Female Genitals 470

(4.) Vaginal Haemorrhage 471

(5.) Inflammation of the Breasts.. . . 472

Chapter VII. Diseases Of The Skin

n.) Scarlet Fever 474

(2.) Measles 484

(4.) Variola — Small-pox 496

Vaccination 499

(5.) Modified Small-pox, Varioloid

and Varicella, Chicken-pox.. . 505

(6.) Erythema Neonatorum 509

(7.) Erysipelas 510

(8.) Intertrigo (Chafing) 511

(9.) Furunculosis 512

(10.) Scabies— Itch 513

(11.) Mothers' Marks (Congenital

(12.) Burns (Combustio) 517

(13.) Congelatio, Frost-bite, Chilblain 518

Xll

CONTENTS.

PAGE

Chapter VIII. General Diseases Of The Secretions

Dyscrasiw, Cachexies. (1.) Rachitis, Rickets, English Disease, Double Limbs 520

A. Rachitis of the Skull 525

B. Rachitis of the Thotax 527

C. Rachitis of the Pelvis and of

the Extremities 529

(2.) Tuberculosis and Scrofulosis. . . 534 A. The Tuberculous Cachexia. . 535

PAGE

B. The Scrofulous Cachexia 540

(b.) Mucous Membrane and Organs

of Sense 546

Nose 546

Eye 547

Ear 551

(c.) Lymphatic Glands and Subcutaneous Cellular Tissue 551

Id.) Bones 553

(3.) Hereditary Syphilis 586

EXPLANATION TO PLATES.

PLATE I.

I. Placenta. II. Liver: III. Heart. IV. Kidneys. V. Bladder. (1.) Arch of the Aorta and vessels of the neck arising from it. (2.) Ductus arteriosus Botalli. (3.) Arteria pulmonalis. (4.) Ductus venosus Arantii. (5.) Vena cava superior. (6.) Vena cava adscendens. (7.) Vena; pulmonales. (8.) Vena umbilicalis. (9.) Arteria; umbilieales.

PLATE II.

Figs. 1 and 2. Schematic drawings of the Parietal Bone for the demonstration of the

physiological enlargement of the greater fontanel. Fig. 3. Normal human Milk, according to Funkc. Fig. 4. Normal Colostrum, according to Funkc. Figs. 5, 6, and 7. Schematic Sections of various kinds of Cephala?matomte. Fig. 5.

dura matris.

(1.) Scalp. (2.) Galea aponcurotica. (3.) Pericranium. (4.) Cranial bone. (5.) Dura mater. (6.) Bony-ring (only possible in Fig. 5). Fig. 8. Schematic Section of an Umbilical Stump, (a) Stump, (5) the Cutaneous King

surrounding it.

Fig. 9. a and b Schematic Delineation of the so-called Flesh-navel, (a), previous;

(5), after the Cord has fallen off.

PLATE III.

Fig. 1. Impressions of the Teeth in the Tongue in Stomacace.

Fig. 2. Thrush-fungi, according to Kuechenmeister.

(a) Fragment of a detached Thrush-membrane, (6) and (c) Spores, ((7) Thallus filaments with sheaths, («) Free end of a Thallus filament slightly thickened, (g) Thallus filaments, with indentations.

Fig. 3. A, Intussusception of a piece of the Intestines ; B, Schematic Section, according to Foerster. (a) the Intussusceptum, (b) the Reflected portion, and (c) the Sheath, (d) and («) the place of reflection, (/) the dragged in Mesentery.

Fig. 4. Longitudinal Section of the Sacrum and of the Kectum. (1.) Sacrum. (2.) Eectum. (a) upper, (b) middle, aud (e) lower portion of the Bectum. (3.) Peritonaeum. (4.) Uterus. (5.) Vagina. (G.) Labia. (7.) Bladder. (8.) Perinsenm.

xiv EXPLANATION TO PLATES.

Figs. 5, C, 7, 8, and 9. . Schematic sections of irnperforation of the Rectum and of its abnormal terminations : (r), Kectum ; (it), Nates-fold ; (a), Anal-invagination ; (J), Bladder; (v). Vagina.

Fig. 10. Schematic delineation of an Ectopia of the Bladder, according to Foerster. Figs. 11, 12, 13, and 14. Schematic representation of Hydroceles. Fig. 11. Hydrocele canalis vaginalis testiculi aperta. " 12. Hydrocele fundi canalis vaginalis testiculi clauea. " 13. Hydrocele colli canalis vaginalis testiculi aperta. " 14. Hydrocele colli canalis vaginalis testiculi clauea.

(a), Piece of the Peritoneum viewed from within ; ({), Open canalis vaginalis ; (c), Testicle ; (d), Dropsical distension of a portion of the Inguinal Canal.

PLATE IV.

Figs. 1-3. Bothriocephalus latus.

Fig. 1. Head, natural size.

Fig. 2. Magnified head with long neck.

Fig. 3. Single pieces. The sexual opening is seen in the centre of each joint. Figs. 4-7. Tamia solium.

Fig. 4. Head, natural 6ize.

Figs. 5 and G. Magnified Head, seen from the side and from above.

Fig. 7. Joints. The sexual opening is seen at the side. Figs. 8-9. Ascaris lunibricoides, Round-worm.

Fig. 8. A ruptured female of natural size, witli prolapsed intestines. The brownish-colored pouch is the alimentary canal, the white coils are the ovaries.

Fig. 9. The curved tail of the male with double prongs, magnified. Figs. 10-13. Oxyuris vermieularis, Thread-worm.

Figs. 10 and 11. Female, natural size and magnified.

Figs. 12 and 13. Male, magnified and of natural size. Figs. 14 and 15. Trieoeephnlus dispar, Whip-worm, natural size.

Fig. 14. Female. Fig. 15. Male.

PLATE V.

Figs. 1 and 2. Schematic section of (1) normal, and (2) rachitic infantile thorax.

(1.) Sternum. (2.) Costal Cartilages. (3.) Eibs. (4.) Eibs divided by the section. (5.) Intercostal spaces. (6.) Fifth dorsal vertabra. (7.) Heart. (8.) Bulbous, rachitic hypertrophy.

PLATE VI.

Fig. 1. Rachitic costal ends, according to Virchow.

Fig. 2. Sections of the same.

Fig. 3. Section of a rachitic femur.

Figs. 1, 2, 3. (a), bluish layer of large cancellous bony extuberance ; (b), Goblet-shaped tumefaction of the young bones ; (c), Dentated wave-line between the cartilage and bone.

Fig. 4. Rachitic Skull. Craniotabes, according to Elsaesser. On the light-colored places the calcareous salts have disappeared, dura mater and pericranium are in contact with each other.

CHAPTER I. ANATOMO-PATHOLOCxICAL REMARKS UPON THE INFANTILE ORGANISM

A. Respiration and Circulation. — The first act of the new-born is to inspire. Immediately after birth the muscles of inspiration contract, and the air finds its way for the first time into the pulmonary vesicles. The increase in volume of the lungs consequent upon this act gives rise on the one hand to an outward enlargement of the thorax, but on the other to a compression of those internal organs of the chest in juxtaposition with the lungs, i. e., heart, large blood-vessels, and thymus gland, and also to a depression of the diaphragm, whereby a palpable pressure is necessarily exerted upon the abdominal viscera. This sudden change in volume of both thoracic and abdominal viscera, in connection with other physiological alterations, leads doubtless to alterations in the circulation of the different organs, and the following foetal circulation, in fact, becomes established immediately or soon after birth.

(1.) The Ductus Venoms Arantii (Plate L, Fig. 2). — The umbilical vein arising from the placenta (PI. I., Fig. 5), after its entrance through the umbilical ring, runs between the peritonaeum and transversalis muscle to the liver, and through the fossa longitudinalis anterior sinistra backward to the left end of the fossa transversa. Here it divides into two branches, of which one, the larger, communicates with the portal vein, and the smaller, the ductus venosus Arantii, leads into the inf. vena cava (PI. I,, Fig. 3). The duct. ven. Arantii, therefore, connects the vena cava ascendens with the umbilical vein, but this connection, as well as that with the portal vein, ceases as soon as the placenta is expelled from the uterus, and the blood in the 1 umbilical vein has become stagnant, and the first inspiration taken place.

(2.) The Ductus Arteriosus Botalii (PI. I., Fig. 2) is, in the foetus, a communicating canal between the pulmonary artery and the aorta. It arises at the point where the pulmonary artery divides into the two branches, then runs obliquely upward toward the lower border of the arch of the aorta, and joins the latter at a point opposite to where the left subclavian artery dips into it from above. It serves to arrest the blood in its course toward the lungs, and to conduct it from the right side of the heart directly into the great current again. The nearer the end of gestation arrives the smaller this vessel becomes, while the two branches of the pulmonary artery grow larger; the broader, however, this vessel is, so much the narrower is that portion of the aorta which lies between it and the heart. And now the lungs, dilated by the inspiratory muscles, not only draw in air, but also blood from the vessels ; not only the air-vessels, but also the blood-conducting system of vessels, become distended. A stronger and faster bloodcurrent passes from the pulmonary artery toward the lungs ; the artery sends no more blood through the fetal passage communicating' with the aorta {the ductus Botalii), and the latter is so quickly obliterated, that in a child twenty-four to thirty-six hours old it is scarcely large enough to admit a probe.

(3.) The Foramen Ovale. — In the foetus the auricular septum contains an opening (for. ovale), corresponding to the fossa ovalis in the adult. In this opening a semilunar membranous valve (valvula foraminis ovalis) is found, the upper border of which is free. In the foetus this valve closes the foramen very imperfectly, so that a portion of the blood passes directly from the right into the left auricle, and thence, without permeating the lungs, into the general circulation. The nearer the end of gestation arrives, therefore, the smaller this foramen becomes, and the stronger and firmer the valve. After birth, the lungs are suddenly converted into a suction-apparatus, they therefore require a larger quantity of blood for their supply ; the right ventricle also becomes distended, and thus the blood-stream is diverted from the foramen ovale. Although the border of the valve usually remains free for some months, still it is so well developed that it accurately closes the foramen. In children over eight to ten months of age, this border of the valve is generally found united with the corresponding border of the foramen ovale.

(4.) The Umbilical Arteries fart, umbilicales, PL I., Fig. 4). — Having spoken of the umbilical vein in connection with the closure of the duct. ven. Arantii, there only remains to describe the obliteration of the umbilical arteries. The two arteries originate from the corresponding arter. hypogastrica, are thicker than all its other branches, and pass upward along the bladder. They embrace the urachus and with it run upward between the abdominal muscles and peritona?um to the umbilicus. Passing through the umbilical ring, they run spirally in the cord, and reach the placenta, in which they divide and subdivide. As soon as the connection between the uterus and placenta has ceased, thrombi form in the umbilical arteries, reaching almost to their origin from the hypogastrica. These arteries remain pervious for a short distance from their point of origin, and here give off several arter. vesicales ; in the female, in addition the arter. uterinse. The remaining portion, between the arter. vesic. and the ring, ultimately becomes obliterated and converted into a fine white cord.

Together with these mechanical alterations, still more important chemical processes take place from the entrance of air into the lungs. Through the alternate action of air and blood, and the interchange of gases, which the walls of the capillaries lying against the pulmonary alveoli and the walls of the alveoli themselves have to transmit in two opposite directions, both air and blood are so altered, that the former becomes irrespirable, the latter arterial and thus qualified for nutrition. The new-born has now both arterial and venous blood.

Mention must be made here of an organ that solely belongs to the infantile organism, the thymus gland. The thymus is distinguished for great variation in size, weight, consistency, and form.

Embedded in the anterior mediastinum, it is sometimes confined to the space between the upper part of the pericardium and the roots of the large vessels, measuring in width barely half an inch, but sometimes reaching from the thyroid gland down to the diaphragm, and then measuring more than two and a half inches in width. Its principal arteries, according to Jendrassie, are branches derived directly from the large blood-vessels upon which it lies. According to the same author, to whom we are indebted for most of our knowledge concerning this enigmatical organ, the thymus is composed of two, often very unequal, parts, which are united by a membrane formed of several delicate lamina3, in which most of the principal vessels terminate. The form of such a thymus moiety most frequently met with is an oblong, the upper third sometimes thin and rounded, while the rest is more flattened and broader; a larger or smaller portion often curves upward like a horn from the lower end over the outer border of the gland. When the thymus deviates from this form, each half has the shape of thin cord-like stripes, or when of large size is divided into several rounded lobules, intimately united by a tliin parenchymatous structure, lying near or upon each other.

In all instances the anterior surface facing the sternum is convex, the posterior slightly concave. The outer and lower borders are thin, often hem-like ; the inner is blunter, provided with deep fissures, in which, as in a hilum, the blood-vessels dip.

At first the thymus is solid, firm, and granular, but in time becomes converted into a softer mass, in which many cavities may be found containing a fluid that almost always reacts with acid. The softening progresses from the central axis, where the principal veins terminate in an extensive deposit of connective tissue toward the periphery. The gland grows constantly flatter, its cavities approach one another more closely, so that no more of a glandular parenchyma can be seen, and at the time of commencing puberty it has, as a rule, completely disappeared. Exceptionally, however, it may be found in adults, and sometimes even of decided dimension and weight. In tuberculous children it is found infiltrated with tubercular deposit. Carcinoma of the anterior mediastinum, which in children occurs comparatively more frequently than in adults, most probably has its starting-point in the thymus gland. The numerously-repeated statements, that in syphilitic children abscesses are to be found in the thymus, are, according to Jendrassic, based upon an erroneous supposition, for, in most instances, the supposed abscesses are nothing more than the cavities that are regularly developed in the retrograde metamorphosis of the gland, and are also found in children who are perfectly free from syphilis.

B. Secretions. — All the mucous membranes, which in the foetal state produced but a slight amount of secretion, commence after birth to secrete their peculiar fluids. The mouth and nasal cavities become moist and lubricated, the latter often very imperfectly, so that it frequently becomes necessary to remove the dried mucous crusts. The salivary glands, it is true, also secrete a fluid, which, however, has not, as yet, the same perfect chemical properties as in the adult, for it is only able to very slowly convert starch into sugar. The stomach likewise begins to secrete a fluid, which dissolves the caseine contained in the milk of the mother. The liver, which fills up the greater part of the abdominal cavity, secretes a light-brown bile, which gives to the faeces, after the dark-brown meconium has been evacuated, an orange-yellow color.

The generally prevailing opinion, that the meconium is a mixture of bile, intestinal mucus, and intestinal epithelium, has been proven by Foerster's investigations to be incorrect. It consists rather of flat scales, which possess all the characteristics of flat epithelium, and consequently could not have originated in the intestinal canal, resembling in their entity those of the vernix caseosa : and, in addition, of fine hairs, in the same quantity as in the latter, fat-globules of various sizes — evidently cutaneous fat (Hauttalg, smegma cutaneum) peculiar to the vernix caseosa — crystals of cholesterine (which may partly originate in the bile, or may be retrograde jDroducts of the vernix caseosa), and irregular brownish and yellowish lumps and flakes, which give to the meconium its dark color, and without doubt the coloring matter of the bile. It is therefore evident, that the meconium, excepting the last-mentioned substances, which originate in the bile, consists principally of vernix caseosa/ and from this it may be inferred that the foetus from time to time lias swallowed a tolerably large quantity of amnion containing the vernix caseosa in suspension, the water of which is quickly absorbed by the stomach, for none is ever found in it, but the hairs and scales pass through the whole intestinal tract as indigestible substances.

After birth the intestines secrete a certain amount of mucus, an excessiveness or deficiency of which will give rise to diarrhoea or constipation, the first and most frequent diseases to which the nursling is subject.

Quite a severe task is imposed upon the kidneys immediately after birth. In the first few days children drink but very little, the blood consequently can part with only a very small quantity of water, and thus it happens that the uric acid salts, the result of the great metamorphosis of the tissues, quickly accumulate in the urinary tubules, remain undissolved there, and from this too highly concentrated solution the product that has been called the uric acid infarction of the new-born is deposited. The uric acid concretions are yellowish-red or pink-red casts of the pyramids near the papilla?. Generally they appear for the first time on the second day after birth, and last from five to twelve days, but I have also found them in children more than four weeks old. As this condition has been said to exist in the still-born, in very exceptional cases it is true, and, since a considerable number of children who die between, the second and fourteenth days do not exhibit it, no very great medico-legal value can therefore be placed upon it. It is frequently found as a carmine red powder in the diapers of the new-born, an occurrence that has also been noticed by some observing- midwives. Microscopic examination reveals minute columns composed of cylindrical, amorphous, urate of ammonia, and epithelium cells, with here and there solitary rhomboid uric acid crystals. On the daj's this powder is found in the diapers, the children are usually restless, cry on micturition, and have an inflamed meatus. Although its origin and excretion must be regarded as physiological, nevertheless it cannot be denied that kidney gravel, so frequent in children, as well as the occurrence of urinary calculi in childhood, has some connection with it.

The skin, which during fostal life was continuously of the temperature of the maternal blood, with the act of delivery becomes a colder medium, for now it is subject to the impressions of the air, light, and changes of temperature, and also assumes the function of secretion. At birth it has a uniform red color, which, however, between the second and sixth day, changes to a yellowish and then into the ordinary rosy-red tint. The yellowish color is often erroneously regarded as icteric. New-born children are covered almost all over the body, with the exception of the palms of the hands and soles of the feet, with fine, soft, often tolerably long hairs (lanugo), which fall out in the first weeks of life. So, too, the strong hairs upon the head with which children sometimes come into the world, fall out in the first weeks of life, and are only slowly replaced by a fine, generally light-colored growth of hair. Feeble children, of slow development, and those devoid of solid adipose tissue, retain these first hairs much longer than those which develop rapidly. In the first weeks of life the sweat-glands perform their function but very imperfectly ; it is almost impossible to bring a child, under four weeks old, into such a state of transpiration that the perspiration will gather in drops.

On the other hand, from the beginning of the second month up to the end of the first year, the secretion of the sebaceous glands of the scalp in almost all children is increased in amount, forming seborrhea capillitii, which should be classed with the physiological conditions. This seborrhcea capillitii develops very gradually ; at first, the scalp looks as if it had been smeared with tallow or cerate ; upon this hard skin dust and dirt become adherent, and, with the lardaceous secretion of the skin, dry into grayish-white or yellowish and, subsequently, into brown and even black scabs, which crumble easily between the fingers, become detached, and leave the scalp in a healthy, uninjured state, and not even congested. It is not attended by any itching, moisture, or cutaneous infiltration. By a diligent application of olive-oil, and washing the head with soap and water this formation of scabs may be arrested without any danger to health. In many places, in Munich for instance, the midwives have accused this affection of being a noli me tangere. It is but seldom possible to persuade the mothers to try the just-described method of treatment, most of them leaving the brown scabs untouched till the end of the first year, when the seborrhcea ceases spontaneously, and the scabs, by the constant growth of the hair, are separated more and more from the scalp, and finally dry up and crumble away. Afterward, no simple seborrhoea capillitii ever occurs in children.