The diseases of children : medical and surgical

Front matter

lass ook

THE

BY THE SAME AUTHORS.

Preface

TO

THE SECOND EDITION

In the preparation of the Second Edition the whole of the work has been thoroughly revised, and several of the sections have been entirely rewritten. Many clinical reports of interesting cases, and forty new woodcuts — most of them original — have been added.

It has been our aim to keep the work abreast of the most recent knowledge, and to make it present as far as possible a complete account of the Diseases of Childhood. In doing so we have freely utilised the writings and work of writers not only in this country, but also on the Continent and in America.

We must again express our thanks to our colleagues for their kindly help and criticisms, and especially to Dr. H. R. Hutton for generously allowing us to utilise his cases, and for the trouble he has taken in reading many of the proof-sheets ; and also to Mr. A. Wilson for revising the chapter he has written on the Administration of Anaesthetics.

To Dr. W. P. Northrup, of New York, who has undertaken to edit the American edition of this work, we must also express our indebtedness.

To the Board of Governors of the Children's Hospitalwe owe a debt of gratitude for their recognition of the fact that the Hospital was founded for the study of the Diseases of Children as well as for the treatment of Disease.

HENRY ASHBY,

G. A. WRIGHT.

Manchester : September 1892.

PREFACE

The present work is intended to give to senior students and junior medical practitioners a fairly complete, though necessarily condensed, account of the various morbid conditions peculiar to, or chiefly found during, infancy and childhood. Those diseases which are neither special to children nor modified by their occurrence in early life, are either omitted altogether or only briefly considered.

The book is written from a practical point of view, and but little pathological detail will be found in it.

The basis of our work is our experience at the General Hospital for Sick Children, Manchester, an institution at which some 1,200 in-patients and some 10.000 out-patients are annually treated. Our observations have extended over nearly ten years, and during the whole of that time we have been collecting material, both at the Children's Hospital and at the Royal Infirmary, for this purpose.

The original feature of this book is that it is written conjointly by a physician and a surgeon : it is hoped that it presents, therefore, a fairly complete account of disease in children. Though we are well aware that the book is not an exhaustive treatise, we think it will be found practical, and it is at least based on experience, and is not a mere compilation.

The illustrations are almost entirely taken from photographs of cases that have been under our own care ; where this is not so, their source is acknowledged.

We have to tender our cordial thanks to our friends and colleagues.

x Preface

both at the Children's Hospital and at the Royal Infirmary, for their help. Our thanks are also due to successive generations of house surgeons who have kept the records of our cases.

To our colleague, Dr. Hutton, for allowing us without stint the use of his cases, as well as for much help and advice in correcting our proofs, our especial thanks are due : also to Messrs. Southam and Collier, our colleagues at the Royal Infirmary and the Children's Hospital, for their care and kindness in proof-reading. To Mr. Wilson we owe our chapter on Anaesthetics, which is made especially valuable by his large experience in the administration of these agents both at the Children's Hospital and the Royal Infirmary. To Drs. Humphreys and Massiah, our former colleagues, we are also indebted for the use of their notes of cases.

We must also acknowledge the help rendered to us by Messrs. Paine and Benger in connection with the formulae for medicines and external applications given in this work.

We cannot take leave of our work without further acknowledging our indebtedness to the Board of Governors of the Children's Hospital for their generous treatment of us, and especially for enabling us to publish our annual abstracts of cases treated at the Hospital. We also desire to express out appreciation of the value of the work of our sisters and nurses in making observations of cases, and in the preparation of temperature charts.

To Messrs. Longman, our publishers, we are much indebted for their liberality in allowing us to borrow woodcuts from their published works, and for their help in many ways ; we desire also to acknowledge the great pains and skill shown by Mr. Pearson in engraving our photographs.

HENRY ASHBY, G. A. WRIGHT.

Manchester : May, 1889.

Chapter I. The Physiology Of Infancy And Childhood

The periods of life, I ; intra-uterine life, I ; infancy, I ; childhood, 2 ; youth, 2 ; respiration, 3 ; changes in the circulation after birch, 4 ; amount of blood in body, 4 ; pulse, 4 ; alimentary canal, 5 ; urine, 6 ; temperature, 6 ; nervous system, 7 ; sight, 8 ; hearing, 8 ; taste, 8 ; psychical phenomena, 8 ; sleep, 8 ; body weight, 8 ; length, 9 ; dentition, 10 ; mortality, 12.

Chapter II. The Diseases Incident To Birth

Asphyxia neonatorum, 15; apoplexia neonatorum, 18; cephalhematoma, 20; hematoma of the sterno-mastoid, 22 ; obstetrical paralysis, 23 ; icterus neonatorum, 25 ; hemorrhagic diathesis, 26 ; acute fatty degeneration of the newly born, 27 ; Winckel's disease, 28 ; gastro-intestinal hemorrhage, 28 ; hemorrhage from the genital organs, 28 ; diseases of the navel, 29 ; umbilical polypus. 29 ; omphalitis, 30; gangrene of the navel, 31 ; umbilical arteritis, 31 ; umbilical phlebitis, 32 ; umbilical hemorrhage, 32 ; tetanus nascentium, 34 ; sclerema neonatorum, 34 ; oedema neonatorum, 35.

Chapter III. The Hygiene And Diet Of Infants And Children

New-born infants, 36 ; clothing, 37 ; infant feeding, 37 ; wet nurses, 39 ; weaning, 40 ; artificial feeding, 41 ; Meigs's mixture, 42 ; diluted milk, 43 ; barley water, &C, 43 ; whey, 44 ; amount of food, 44 ; feeding-bottles, 44 ; sterilisation, 45 ; peptonised milk, 45 ; condensed milk, 46 ; diet from 6 to 12 months, 47 ; diet from 12 months to 18 months of age, 48.

xii Diseases of CJiildren

Chapter IV. Diseases Of The Digestive System

Examination of the mouth, 50 ; dentition, 50 ; catarrhal stomatitis, 53 ; stomatitis erythematosa, 53 ; aphthae, 53 ; parasitic stomatitis, 54 ; ulcerative stomatitis, 56 ; cancrum oris, 57 ; acute tonsillitis, 58 ; chronic tonsillitis, 61 ; tonsillar calculus, 64 ; nasal adenoids, 64 ; post-pharyngeal abscess, 65 ; stricture of oesophagus, 65 ; swallowing foreign bodies, 67 ; oesophagitis, 67.

CHAPTER V. •DISEASES OF THE DIGESTIVE SYSTEM {continued)

Examination of the abdomen, 69 ; dyspeptic diseases, 70 ; flatulence and colic, 71 ; vomiting, 71 ; diarrhoea, JT, ; constipation, 75 ; acute gastric catarrh, 77 ; acute gastro-intestinal catarrh — zymotic diarrhoea, yj ; acute ileo-colitis, 86.

CHAPTER VI. DISEASES OF THE DIGESTIVE SYSTEM {continued)

Chronic gastro-intestinal catarrh— gastro-intestinal atrophy, 89 ; chronic diarrhoea, 91 ; chronic vomiting, 91 ; treatment, 95 ; diet for indigestion, 96 ; dilatation of stomach, 97 ; malformations of stomach, 99 ; carcinoma of stomach, 99 ; thread worms, 99 ; round worms, 100 ; tape worms, 101 ; ascites, 101.

CHAPTER VII. DISEASES OF THE DIGESTIVE SYSTEM {continued)

Acute peritonitis, 103 ; perityphlitis, 107 ; peritoneal abscesses — intestinal fistula, 108; chronic peritonitis, III; iliac abscess, 114; intussusception, 115; chronic obstruction of the bowels, 123.

CHAPTER VIII. DISEASES OF THE DIGESTIVE SYSTEM {continued)

Tubercular ulceration of the bowels— mesenteric disease, 125 ; congenital obstruction of the bowels, 128 ; imperforate anus, 130 ; deformities of the umbilicus, 134; umbilical hernia, 135; inguinal hernia, 136; prolapsus recti, 139; fistula in ano, 142 ; piles, 142 ; polypus of the rectum, 143.

CHAPTER IX. DISEASES OF THE DIGESTIVE SYSTEM {continued)

Hare-lip, 145; cleft palate, 151 ; macrostoma, 154; macrocheilia, 155 ; microstoma, 155; tongue-tie, 155; macroglossia, 155; ranula, 156; papilloma and condylomata of the tongue, 156 ; hypertrophy and atrophy of the face, 157 ; branchial fistula, 157.

Co mt en ts xiii

Chapter X. Diseases Of The Liver

Congenital stricture of the bile-ducts, 161 ; catarrhal jaundice, 162 ; acute yellowatrophy of the liver, 162 ; cirrhosis of the liver, 165 ; syphilitic cirrhosis, 165 ; fatty liver, 166; tuberculosis of the liver, 166 ; hepatic abscess, 167 ; hydatids, 168 : tumour of the liver, 168.

CHAPTER XL

DISEASES OF THE RESPIRATORY APPARATUS.

The thorax in infancy and childhood, 169 ; laryngismus stridulus — child-crowing - spasm of the glottis, 170 ; spasmodic laryngitis, 174; catarrhal laryngitis, 175 membranous laryngitis, 178 ; tracheotomy, 181 ; intubation of the larynx, 191 chronic laryngitis, 193 ; papilloma of the larynx, 193.

CHAPTER XII. DISEASES OF THE RESPIRATORY APPARATUS {continued)

Bronchitis and catarrh, 194 ; collapse of the lung, 195 ; bronchiectasis and emphysema, 196 ; chronic bronchitis and bronchiectasis, 197 ; broncho -pneumonia, 198 ; secondary pneumonias, 200 ; chronic broncho-pneumonia, 200 ; different types of pneumonias, 202.

CHAPTER XIII. DISEASES OF THE RESPIRATORY APPARATUS (continued)

Croupous pneumonia, 208 ; gangrene of lung, 216 ; abscess of the lung, 216 ; pleurisy and empyema, 217 ; asthma, 228 ; diseases of the bronchial glands, 228 ; mediastinal abscess, 230 ; lymph-adenoma, 230 ; chronic tuberculosis of the lungs, 231 ; fibroid phthisis, 234.

Chapter XIV. The Specific Fevers

Feverishness, 237 ; gland fever, 238 ; scarlet fever, 239 ; surgical scarlet fever, 240 ; mild scarlet fever, 243 ; malignant scarlet fever, 243 ; complications, 245 ; nephritis, 246 ; measles, 254 ; mild form, 257 ; severe form, 257 ; Rotheln or Rubella, 260 ; diphtheria, 264 ; pharyngeal form, 267 ; malignant form, 268 ; nasal diphtheria, 269 ; laryngeal form, 269 ; wound diphtheria, 269 ; complications, 270 ; pseudo-diphtheria, 274 ; epidemic influenza, 275 ; enteric fever, 278 ; complications, 282 ; typhus, 287 ; varicella, 289 ; varicella gangrenosa, 292 ; vaccinia, 293 ; complications, 294 ; varioloid, 295 ; whooping cough, 296 ; complications, 298 ; mumps — parotitis, 302 ; malarial fever, 303.

xiv Diseases of CJiildren

Chapter XV. Diseases Of The Circulatory System

Diseases of the heart, 305 ; pericarditis, 305 ; chronic pericarditis, 307 ; mediastino-pericarditis, 310; congenital heart disease, 311 ; patent foramen ovale, 312; patent septum ventriculorum, 313 ; stenosis of the pulmonary and tricuspid orifices, 314; stenosis of the aorta or mitral valves, 316 ; transposition of the aorta and pulmonary artery, 316 ; endocarditis, 316 ; chronic heart disease, 319 ; acute myocarditis, 321.

CHAPTER XVI. DISEASES OF THE CIRCULATORY SYSTEM {continued)

Naevus, 324 ; stellate naevus, 324 ; port-wine mark, 324 ; cutaneous nrevus, 325 ; subcutaneous naevus, 325 ; mixed naevus, 325 ; simple naevi, 325 ; cavernous naevi, 325 ; lymphatic naevi, 332 ; aneurism, 333.

Chapter XVII. Diseases Of The Blood And Blood-making Organs

Anaemia, 334 ; simple anaemia, 335 ; anaemia splenica, 335 ; idiopathic anaemia, 337 ; scurvy, 338 ; purpura, 338 ; haemophilia, 339 ; Hodgkin's disease, 339 ; leucocythaemia, 340; enlarged spleen, 340; diseases of the retroperitoneal glands, 341.

Chapter XVIII. General Diseases

General tuberculosis, 343 ; acute miliary tuberculosis, 343 ; typhoid form, 343 ; broncho- pneumonic form, 345 ; subacute general tuberculosis, 345 ; scrofula and tuberculosis, 347 ; tubercular adenitis, 349 ; chronic abscess, 355 ; deep cervical cellulitis —angina Ludovici, 356; general surgical tuberculosis, 356; diabetes mellitus, 357 ; polyuria — diabetes insipidus, 358 ; rheumatism, 359,

Chapter XIX

general diseases {continued).

Rickets, 362 ; rickety deformities, 374 ; late rickets, 382 ; lateral curvature of the spine, 388.

Chapter XX

general diseases {continued).

Syphilis, 393 ; acquired syphilis, 393 ; hereditary syphilis, 394.

Contents xv

Chapter XXI. Diseases Of The Nervous System

Introduction, 404 ; clinical examination, 405 ; cerebral congestion, 405 ; tubercular meningitis, 405 ; simple meningitis, 410 ; acute form, 410 ; subacute form, 412 ; cerebro-spinal meningitis, 413 ; latent form, 413 ; chronic meningitis, 418 ; acute hydrocephalus, 419; chronic hydrocephalus, 420 ; hypertrophy of the brain, 422 ; atrophy of the brain — sclerosis of the brain, 423 ; tumours of the brain, 424 ; tumours of the cerebellum, 426 ; of the pons, 427 ; basal ganglia and internal capsule, 428 ; of the cortex, 428 ; of the frontal lobe, 428 ; cerebral abscess, 430 ; cerebral haemorrhage, 433 ; post partum haemorrhage — birth palsy, 433 ; cerebral haemorrhage occurring after birth — acute cerebral palsy, 436 ; embolism, 442 ; thrombosis of the cerebral sinuses and veins, 444 ; arteritis — softening, 445.

CHAPTER XXII. DISEASES OF THE NERVOUS SYSTEM (continued)

Chorea, 446 ; hemichorea, 454 ; epilepsy, 458 ; hysteroid fits, 460 ; post-hemiplegic epilepsy, 460 ; infantile convulsions — eclampsia, 463 ; hysteria, 468 ; headaches, 470.

CHAPTER XXIII. DISEASES OF THE NERVOUS SYSTEM {continued)

Speech anomalies, 473; deaf-mutism, 474; acquired deaf-mutism, 474; physical defects in the mouth, 475 ; mental defect, 475 ; aphasia, 476 ; stammering, 476 ; mental affections in childhood, 477 ; congenital group, 477 ; developmental idiocy, 478; accidental or acquired, 479; cretinoid idiocy, 479; backward children, 480 ; idiocy due to syphilis, 481.

Chapter XXIV

diseases of the nervous system {continued).

Spina bifida, 484; meningocele, 488; spinal meningitis, 490; myelitis, 493; Landry's paralysis, 494 ; hereditary ataxic paraplegia — Friedrich's disease, 495 ; anterior polio-myelitis — acute atrophic paralysis — infantile paralysis, 495 ; tetany, 502 ; nystagmus, 504 ; head-nodding and head-shaking, 504 ; head-banging, 504 ; pseudo-hypertrophic paralysis, 504.

Chapter XXV. Diseases Of The Genito-urinary System

-Congenital anomalies of the kidneys, 508 ; Addison's disease — tuberculosis of the adrenals, 508; haematuria, 508; intermittent hsemoglobinuria, 510; pyuria, 510: lithaemia, 510; tumours of the kidneys, 510; tuberculous kidney, 512; hydronephrosis, 514; renal calculus, 514; acute nephritis, 515; septic nephritis, 516 ; acute parenchymatous nephritis, 516 ; chronic nephritis, 516.

a xvi Diseases of Children

CHAPTER XXVI. DISEASES OF THE GENITOURINARY SYSTEM {continued)

Stone in the bladder, 518; cystitis, 522; incontinence of urine, 523 ; retention, 525 ; malformations of the genito-urinary organs — extroversion of the bladder, 526 ; epispadias, 528 ; hypospadias, 529 ; phimosis, 531 ; balanitis, 532 ; congenital paraphimosis, 533 ; masturbation, 533 ; oedema of the scrotum, 534 ; diseases of the external genitals in females, 534 ; aphthous vulvitis, 535 ; noma pudendi, 535 ; irritable mamma, 536 ; abnormalities in the descent of the testicles, 536 ; supernumerary testicles, 539 ; congenital displacement or hernia of the ovary, 540 ; acute orchitis, 540 ; syphilitic testitis, 540 ; tubercular disease, 540 ; tumours of the testis, 541 ; hydrocele, 542 ; hydrocele in girls, 543 ; varicocele, 544 ; ovarian tumours, 544.

Chapter XXVII. Diseases Of The Bones

Diseases of the bones, 545; acute periostitis, 546; chronic periostitis, 553 ; syphilitic periostitis, 555 ; acute osteomyelitis, 557 ; acute epiphysitis, 558 ; chronic circumscribed osteomyelitis, 560 ; chronic diffuse osteomyelitis, 562 ; strumous dactylitis, 565 ; syphilitic dactylitis, 567 ; leontiasis ossea, 567.

Chapter XXVIII. Diseases Of The Joints

Tubercular disease of the shoulder, 572 ; disease of the elbow joint, 572 ; of the wrist, 573 ; of the ankle, 574 ; acute synovitis, 575; pyaemic joint disease, 576 ; exanthematous synovitis, 576 ; chronic rheumatic arthritis, 576 ; syphilitic synovitis, 577 ; acute suppurative arthritis of infants, 578 ; acute tubercular synovitis, 580 ; sacro-iliac disease, 592 ; disease of the temporo-maxillary joint, 593.

Chapter XXIX. Hip Disease

Hip disease, 595.

Chapter XXX. Spinal Disease

Caries of the spine, 620 ; costo-vertebral disease, 632.

Chapter XXXI. Club-foot, Deformities Of Limbs, Etc

Talipes equino-varus, 634 ; T. valgus, 636 ; T. equinus, 636 ; flat-foot, 645 ; wry-neck or torticollis, 647 ; diseases of muscles, 649 ; various congenital malformations, 650 ; supernumerary digits, 652 ; club-hand, 653 ; web fingers, 654 ; congenital rigidity of joints and contractions, 655 ; congenital dislocations, 656.

Contents xvii

Chapter XXXVI. Diseases Of The Skin

Eczema, 684 ; impetigo, 690 ; seborrhcea, 691 ; erythematous eruptions, 691 ; roseola, 691 ; erythema scarlatiniforme, 692 ; chilblains, 692 ; erythema multiforme, 693 ; erythema nodosum, 693 ; urticaria, 693 ;. urticaria papulosa, 693 ; lichen scrofulosus, 694 ; psoriasis, 694 ; miliaria — sudamina, 694 ; miliaria rubra, 694 ; pemphigus, 694 ; dermatitis, 695 ; tinea tonsurans, 695 ; tinea circinata, 696 ; alopecia areata, 698 ; favus, 698 ; scabies, 698 ; simple onychia, 699; onychia maligna, 699; lupus, 699; papilloma, 700; haiiy and pigmented moles, 700.

Chapter XXXVII. Injuries, Shock, Hemorrhage, Etc

Injuries to the head, 701 ; traumatic cephalhydrocele, 701 ; fracture of the base of the skull, 702 ; injuries to the chest, 702 ; injuries to the abdomen, 702 ; injuries of the limb, 702 ; greenstick fractures, 703 ; ununited fractures, 703 ; separation of' the epiphyses, 704; primary amputations, 710; primary resections, 710; dislocations, 710; burns and scalds, 712; shock, 712; loss of blood, 712; pain, 712; septic diseases, 713.

xviii Diseases of Children

Chapter Xxxviii. Anaesthetics For Children

Local anaesthesia, 715 ; cocaine, 715 ; nitrous oxide, 715; chloroform, 715 ; ether, 716 ; A. C. E. mixture, 716 ; the choice of an anaesthetic, 716 ; preparation, 716 ; method of administration of anaesthetics, 717 ; vomiting, 718 ; anaesthetics in special operations, 719 ; accidents, 721.

FORMULAE 753

INDEX 759

LIST OF ILLUSTRATIONS

FIG.

I. 4- 5« 6

7- 8.

10. 11. 12.

15. 16.

18. 19. 20. 21. 22.

23. 24.

Stomach of a newly born infant (natural size)

Lower jaw of a child at birth, showing dental sacs ,, ,, ,, three years of age

Meningeal haemorrhage in an infant

Double cephalhematoma

Section of a cephalhematoma

Section of ileo-umbilical diverticulum

Fungus of thrush . . . . •

Deformity due to cancrum oris

Temperature chart of epidemic tonsillitis

Hour-glass constriction of stomach

Thread worm .....

Eggs of thread worm ....

Ileo-caecal intusussception

Scheme of lines of union of face .

Double incomplete hare-lip

Severe double hare-lip

Diagrams of hare-lip operation

Macrostoma .....

Supernumerary auricle in neck

Anatomy of child's trachea .

Parker's tracheotomy tube

O'Dwyer's intubation apparatus .

O'Dwyers extractor ....

Temperature chart of broncho-pneumonia

Temperature chart of acute broncho-pneumonia

Temperature chart of acute lobar pneumonia ,, ,, croupous pneumonia

,, ,, croupous pneumonia treated

,, ,, pleuro-pneumonia with empy

Deformity of chest due to empyema

Section of cheesy glands at the bifurcation of the trachea

Temperature chart of acute otitis in an infant

Temperature chart of scarlet fever . ,, ,, mild scarlet fever

,, ,, malignant scarlet fever

,, ,, post-scarlatinal nephritis with cold bath ema

99 100 116

145 146

147 150 155 158

243 244 247

XX

39- 40. 41.

43- 44.

45- 46.

57- 58. 59- 60. 61. 62.

73- 74- 7> 76.

77- 78.

79- 80. 81. 82.

83- 84. 85. 86. 87.

Diseases of CJiildren

Temperature chart of measles . . .

,, ,, broncho-pneumonia with measles

, , , , mild enteric fever . . .

,, ,, ,, with peritonitis

,, ,, typhus fever

,, ,, chicken-pox

Varicella gangrsenosa ....

Temperature chart of modified small-pox Plan of foetal circulation Congenital heart disease

Acute endocarditis .....

Temperature chart of a case of endocarditis .

Mixed nsevus of face . ,

Nsevus of face .......

Orbital nsevus ......

Arterio-venous varix ......

Nsevus lipomatodes .....

Degenerated nsevus of scalp .....

Lymphatic nsevus of foot ....

Miliary tubercles of the choroid ....

Tubercular ulceration of the skin of foot .

Tracing of chest-wall of a rickety boy Enlargement of epiphyses of lower end of radius and Section through enlarged epiphysis in rickets Section through the junction of rib and cartilage in r Transverse section through the shaft of the ulna in r: Rickety deformity of femora ....

Attitude causing deformity in rickets .

Figure showing results of osteotomy

A rickety dwarf ......

Rickety curvature of the spine Knock -knee ....

Attitude producing curvature of tibia Bow-leg .......

General rickety deformities ....

Thomas's splint for genu valgum Lateral curvature of the spine Reclining board for lateral curvature .

Congenital syphilis .....

Destruction of nose, &c, in congenital syphilis Disease of bones in congenital syphilis Syphilitic epiphysitis . . . . .

Tracing of ' Cheyne-Stokes ' respiration Outline of head in chronic hydrocephalus Chronic hydrocephalus ....

Sclerosis of brain ......

Spastic paralysis .......

Results of division of tendo Achillis in spastic paralysis ulna cets cets

List of Illustrations xxi

FIG. • PAGE

89. Section of brain showing old blood cysts ...... 437

9°- ,, ,, ,, 438

91. Brain, showing effects of old meningeal haemorrhage .... 441

92. Section of brain, showing patch of softening, the result of embolism . 442

93. Cyst formed by softening of brain ....... 443

96. Case of cured spina bifida with talipes ....... 487

97. Section of cured spina bifida ........ 487

98. Spina bifida which has undergone spontaneous cure . . . . 488

99. Occipital meningocele ......... 489

100. Frontal meningocele .......... 489

102. Pseudo-hyper trophic paralysis ........ 505

104. New growth in kidney . . . . . . . . ..511

105. Plastic operation for extroversion of bladder ..... 528

106. Undescended testis .......... 537

107. Diagram of hydrocele ......... 542

109. Overgrowth of leg after necrosis . . . . .. . -553

no. Congenital syphilitic disease of both tibia . . ... . 555

in. Epiphysitis of humerus . . . . . . . . .561

113. Overgrowth of thumb from tubercular disease ..... 565

114. Effects of tubercular dactylitis ........ 566

117. Syphilitic synovitis of both wrists . . . . . . -577

"9- » » 585

120. Malposition after excision of knee ........ 587

121. Splint for disease of ankle .... ..... 588

122. Foot after tarsectomy .......... 590

123. ,, excision of os calcis ........ 591

124. Diagram to illustrate hip disease ........ 595

125. Specimen of femoral hip disease ........ 595

126. ,. ,, ,, 596

127. ,, acetabular disease ........ 597

128. Lordosis in hip disease .......... 602

129. Position of limb in second stage of hip disease ..... 604

132. Method of applying extension ........ 611

133. Thomas's splint applied ......... 612

135. Result of excision of hip ......... 616

137. Attitude in spinal caries ......... 624 xxii Diseases of Children

FIG. PAGE

139. Patterns of Thomas's splints for spinal disease, &c 629

140. Thomas's splint applied for caries of spine with abscess . . . 630

141. Talipes equino-varus .......... 635

142. Very severe equino-varus . . . . . . . . . 635

145. Little's tin talipes shoe 640

147. Artificial muscle for flat-foot . . . . . . . . 646

149. Artificial muscle for congenital wry-neck ...... 648

151. Intrauterine amputation . . . . . . . . .652

152. Arrest of development of limb ........ 653

155. Genu recurvatum and talipes calcaneus .... . 655

156. Abnormal position in utero, causing genu recurvatum, &c. . . . 656

157. Congenital dislocation of both hips . . . . . . -657

158. Sarcoma of lower jaw and eyeball ........ 669

159. Enchondroma of spine and fingers ....... 670

160. Multiple enchondromata of finger . . . . . . . . 671

161. Hygroma of neck with macroglossia ....... 672

162. Congenital serous cyst of back . . . . . . . . 672

163. Dermoid cyst of orbit . . ■ . . . . . 673

165. ,, ,, in lachrymal fissure 675

166. Myxo-lipoma of breast . . . . . . . . . . 676

168. Congenital cystic tumour of groin ........ 677

170. Section of congenital sacral tumour ....... 679

173. Hairy mole of the face and scalp ....... 700

174. Separation of the upper epiphysis of the right humerus . . . . 705

175. Plan of the development of the humerus ...... 706

176. Dislocation of patella . . . . . . . . ..711

177. New York Orthopedic Hospital brace for knock-knee and bow-legs . 727

179. Boston Children's Hospital's brace for bow -legs ..... 727

180. The Davis-Taylor long-traction hip-splint ...... 732

181. Taylor's spinal brace with chin-cup ....... 734

182. Arnold's steam milk steriliser . ,. 738

183. Seibert's milk steriliser ......... 739

DISEASES OF CHILDREN.

Chapter I. The Physiology Of Infancy And Childhood

The Periods of Early Xiife. — The life of man is naturally divided into three great epochs — viz. a period of Growth and Developme?it, of Maturity, and of Decline.

The first division includes the periods of early life, Avhen those series of operations are in progress by which the ovum or primitive germ is transformed into the complete organism ; it maybe subdivided into Intra-iiterine Life, Irifancy, Childhood, Youth, and Adolescence.

Intra-uterine life. — During this epoch the embryo depends entirely upon its parent for all its wants. The maternal blood supplies it with material for constructive purposes, carries away its waste products, and renders unnecessary the maintenance of an independent temperature. It is clearly a time of great importance to the future being, and it is necessary that this development should take place under healthy conditions, inasmuch as it is physiologically impossible for an unhealthy or weakly mother to supply the wants of the embryo, and any failure in the nutritive powers of the maternal blood is certain to leave its stamp on the future development of the child. An infant may come into the world fairly well developed and plump, from the presence of more or less stored-up fat, in spite of the weakly state of the mother's health, but it is almost certain sooner or later to exhibit tendencies to disease in the direction of the stock from whence it springs. Not only may the embryo owe a weakly building-up of its tissues to its mother, but it may actually share maternal disease. The foetus may suffer from endocarditis originating in a rheumatic state of its parent, and this lesion, affecting as it usually does the right side of the heart, may lead to malformations, which are only too likely to cut short its career. From its parents also the foetus may receive the virus of syphilis, from which it may suffer during its embryonic life or after birth. It may receive an inheritance of tuberculosis or epilepsy, or a tendency to gout or rheumatism. During foetal life many anomalies may arise from arrested development or an overgrowth in certain directions : cleft palate and hare-lip are instances of the former, and supernumerary fingers and naevoid growths of the latter.

Infancy. — The Romans used the word infa?is in its widest sense, and though, as its derivation implies, it was originally applied to those who could

B not speak, it came to be employed by them for children of much older years. The terms infancy, premiere enfance, and Sauglingsperiode, are most usually applied to the first seven or eight months of life, the time during which the infant is nursed at the breast and before the eruption of the milk-teeth. It is, however, used by some writers to include the whole of the first year. Within the first week or two of life the infant has often to contend with conditions which are peculiar to this period, inasmuch as they depend in one way or another on the act of birth. It may be born asphyxiated in consequence of strangulation by the cord or pressure on the head, or various injuries producing hematomas may take place ; or there may be septic infection in connection with the umbilical cord. The change from placental alimentation to the digestion of food in the infant's stomach is a time of peculiar danger, especially if artificial food is given, and the mortality of infants is much greater during the first week of life than at any other period.

During the first few months of infancy, life is not so purely vegetative as it is during the intra-uterine period, yet the mental faculties are in abeyance and the movements mostly involuntary or reflex.

One consequence of the undeveloped condition of the higher or inhibitory centres is that the reflex centres are less under control than in later years, so that disorderly reflex movements in the form of convulsions are liable to take place on the slightest provocation. Growth at this period is extremely rapid, the weight more than doubling itself during the first six months of life, and a great strain is thus thrown on the alimentary system ; the lymphatic and blood-forming organs are also exceedingly active. It is not surprising, therefore, that the diseases which are most common and fatal at this period are those connected with digestion and absorption. The infant requires much rest, and, indeed, divides its time for the most part between feeding and sleeping. It is during this period that ' wasting,' ' marasmus,' or ' atrophy ' is so common, a result of chronic catarrh of the intestinal tract and a consequent impairment of the digestive organs.

Childhood. — The eruption of the milk-teeth marks an epoch in early life, the term childhood being applied to the period commencing with the first dentition and ending with the commencement of the second, at the sixth or seventh year. The terms seconde enfa?ice and Kindersalter are used in a similar sense. Growth at this period continues to be active, though not proceeding at the same rate as during infancy, but disturbances cf the alimentary system are common, and the children quickly waste if digestion and absorption are interfered wjth.

The osseous and muscular systems are developing so that by the end of the first year the child can crawl or even walk with help. It is at the commencement of this period that rickets, a disease so intimately associated with malnutrition, often makes its appearance. The mental faculties are opening out as the brain develops, and the infant begins to recognise its friends and call them by name. During the period of dentition nervous disturbances are common, and the lesions giving rise to infantile paralysis are apt to take place.

Youth, — The termsyouthjeunesse, and Knabensalter, are generally applied to the period commencing at the second dentition and ending at puberty or

Youth — Respiration 3

about the fourteenth year. During this time the milk-teeth are replaced by the permanent set, the bones become more solid and the muscles better developed, while the mental faculties are exceedingly acute and the mind readily acquires knowledge. As puberty approaches the voice becomes deeper and the sexual organs undergo a marked increase of development. During this period, in which scholastic education is carried on, the memory is exceedingly retentive, perhaps more so than at any other time. Children at this period easily ' outgrow their strength,' the nervous system is readily upset, as is evidenced by the frequency of chorea, and the alimentary canal is apt to suffer from chronic catarrh.