Infantile scurvy

CHAPTER VIII INFANTILE SCURVY Infantile scurvy is often spoken of as if it were a disease of recent discovery and of modern development. Its recognition all over the scientific world is justly associated with the names of two distinguished physicians both connected with the Great Ormond Street Children’s Hospital, the late Dr. Cheadle and Sir Thomas Barlow, to whose investigations is due almost all that is known of the pathology of the disease. But to sup¬ pose that infantile scurvy was unknown, or even that its true nature as a scorbutic condition complicating rickets was unrecognized until the nineteenth century is an error, and one that has crept into many textbooks. As long ago as the middle of the seventeenth century, Glisson, in his Treatise on the Rickets , had not only described the character¬ istic symptoms of infantile scurvy, but, with more accuracy than some of his successors, had recognized that it was scurvy complicated with the rickets and not an acute form of rickets. In the English translation, published in 1651 (p. 249), he says : ‘ The Scurvy complicated with this affect (rickets) hath these signs : (1) They that labour under this affect do impatiently endure Purgations ; but they who are only affected with the Rachites do easily tolerate the same. (2) They are much offended with violent exercises, neither can they at all endure them. But although in this affect (rickets) alone there be a kind of slothfulness and aversation from exercise, yet exercise doth not so manifestly, at least not altogether so manifestly, hurt them as when the Scurvy is conjoyned with the rachites. (3) Upon any concitated and vehement motion they draw not breath without much difficulty, they are vexed with divers pains running through their Joynts, and these they give warn¬ ing of by their crying. ... (4) Tumors do very commonly appear in the Gums. (5) The urin upon the absence of the accustomed Feaver is much more intens and encreased.’ Glisson (ibid., p. 227) actually emphasizes what is not yet sufficiently recognized, that there is no essential connexion INFANTILE SCURVY 109 between infantile scurvy and rickets ; he says, ‘ the Scurvy is sometimes conjoyned with this affect,’ and after mentioning as causes heredity, infection, and the possibility that it may be * produced from the indiscreet and erroneous regiment of the infant ’, though he attributed it chiefly to climatic influences, he adds, * for it (scurvy) scarce holdeth any greater commerce with this Diseas (rickets) than with other diseases of longer continuance.’ Such terms as ‘ scurvy rickets ’, ‘ acute rickets,’ and ‘ haemor¬ rhagic rickets ’—names which would imply that scurvy is a variety of rickets—have been responsible for much confusion. Obscure though the exact aetiology of infantile scurvy may be, it is clear from clinical facts that this affection arises from causes entirely distinct from those which produce rickets ; severity of rickets raises no special probability of scurvy ; indeed the worst cases of scurvy are often associated with very slight rickets, and in some cases with none. Both diseases are due to faults of diet, and it is likely enough that a diet which is faulty in one respect may be faulty in another ; the particular fault which produces rickets may be, and no doubt often is, present when the diet shows also the particular fault which produces scurvy. But the fault is not one and the same ; witness the many infants who suffer with severe rickets after being fed from an early age with potato, which would seem when given at that age to favour if not actually to cause the occurrence of rickets, whereas there is probably no more powerful agent than potato in the prevention or cure of infantile scurvy. The clinical picture of the fully-developed disease is striking enough ; an infant who has been fed upon one of the patent foods, with or without milk, or on milk which has been condensed, sterilized, or otherwise altered, has been ailing for some weeks, has taken food badly and probably lost weight. Moreover the mother says it cries whenever it is touched, and, as she puts it, ‘ has lost the use of its limbs.’ The infant is pale, it lies quiet perhaps until it is approached, when it cries out in obvious dread of being touched ; the legs lie motionless usually with the thighs slightly abducted and everted and the knees slightly flexed ; the arms are less often affected. There may be some swelling of part of one or other of the limbs, obliterating the natural curves. Any handling of the affected limbs causes a piteous cry, evidently of acute pain. If teeth are present the gums around them are swollen and purple, occasionally projecting like a mass of granulations almost completely hiding the teeth, 110 COMMON DISORDERS OF CHILDHOOD and bleeding readily when touched. The urine is perhaps smoky, if not red with blood. Such in outline is the characteristic picture of infantile scurvy, which I shall now consider in more detail, chiefly with reference to diagnosis and treatment. Age-incidence. The age at which infantile scurvy begins is a point of considerable importance in diagnosis. As the accom¬ panying chart of sixty-four cases under my own observation shows, its onset is almost limited to the later half of the first year of life, and in nearly 80 per cent, of the cases the disease begins between the ages of six months and ten months. Fig. 6. Age-incidence of infantile scurvy (sixty-four cases). So marked is this special age-incidence, that given an infant of six to twelve months and a history of tenderness in the limbs, the diagnosis of scurvy should at once suggest itself as a possi¬ bility. In several of the cases in this series the disease had been diagnosed as 4 rheumatism ’—a mistake which ought never to occur, for rheumatism is practically an unknown disease under the age of eighteen months, and indeed is exceedingly rare under the age of three years. This chart shows also that in no case did scurvy begin before the age of five months—a point which distinguishes this disease from many cases of syphilitic epiphysitis which begins most often under the age of three months. Mode of onset. So much stress has been laid upon the INFANTILE SCURVY 111 affection of the gums and upon the tender swellings in the limbs in infantile scurvy that there is danger of forgetting that in many eases there are other more insidious symptoms which may appear some weeks before these obvious mani¬ festations. An infant who has thriven hitherto upon some patent food begins to ail, the weight ceases to rise or actually falls, the feeds are taken badly, and the child is fretful and miserable ; there is no swelling of limbs, perhaps no definite tenderness anywhere, and the gums are perfectly normal; but that these early symptoms indicate scurvy may be shown not only by the rapid improvement within two or three days on antiscorbutic treatment, but also in some cases by the presence of blood in the urine even in this early stage. I doubt whether the onset of scurvy is ever really sudden, but undoubtedly the more pronounced symptoms may appear quite suddenly, and are then apt to be mistaken for the results of traumatism ; for example, an infant, aged eight months, was brought to me because he was ‘ not getting on 5 ; there had been some tenderness in the legs for at least four weeks, but the nature of this had not been recognized ; one morning the child had his usual bath and then went to sleep for a short time: he awoke with the left eye partly closed by great swelling of the lids, which were discoloured and soon looked as if bruised ; it was concluded that during the bathing the child must have struck his eye against the side of the bath. The history, how¬ ever, of feeding with Allenbury and Benger’s foods, the tender¬ ness of the legs, and the presence, as examination showed, of blood in the urine, all pointed to scorbutic haemorrhage, and the rapid disappearance of the swelling and haemorrhage from the lids under antiscorbutic diet confirmed the diagnosis. It would, I think, be rash to assert that the supposition of traumatism is wrong in all such cases. The haemorrhagic tendency of scurvy may well favour the occurrence of haemor¬ rhage from slight traumatism, which would have no such effect in a healthy infant, and this view is supported by the situation of superficial haemorrhages ; for example, in one case the only subcutaneous haemorrhage was over the bony prominence of the sacrum, a part obviously exposed to pressure and jarring ; in another which was sent to me as a case of infantile paralysis the efforts of the doctor to obtain a knee-jerk had resulted in a sub¬ cutaneous haemorrhage over the patella. Limb affection. Perhaps the most striking feature of infantile scurvy is the tenderness of the limbs and loss of movement. These 112 COMMON DISORDERS OF CHILDHOOD symptoms occur much more often in the lower limbs than in the upper. In the sixty-four cases tenderness or swelling was present as follows : in forty-seven in the legs only, in ten in legs and arms, in one in the arm only. In six out of the sixty-four cases there was no tenderness in any of the limbs : the diagnosis in these cases rested on the association of a scorbutic diet with haematuria, confirmed in two, where teeth were present, by affection of the gums, and in all by the rapid cessation of haematuria on antiscorbutic diet. With the tenderness there is sometimes associated some visible or palpable swelling of the affected limb, but in many cases this is so slight that it is easily overlooked ; and as it is the result chiefly of subperiosteal haemorrhage it may be detected only by careful—and, I would add, most gentle—palpation of the bone as a vague, deep thickening. The situation of this thickening is of some importance ; it is not limited to the epiphysial region like an epiphysitis, but extends some distance along the shaft of the bone—a point which should distinguish it also from any joint affection. In my own cases the swelling has been most often about the lower third of the tibia or the femur (Fig. 7), but any part, or the whole, of the shaft may be surrounded by sub¬ periosteal haemorrhage, and occasionally, though much more rarely, similar deep haemorrhage may occur over the flat bones of the skull, producing large bluish swellings on the head which may simulate sarcoma, or over the scapula, as in a specimen in the museum of the Children’s Hospital, Great Ormond Street. The loss of movement in the affected limbs is so marked that the disease had been mistaken more than once in my series for infantile paralysis—a mistake which hardly ought to occur, for the acute tenderness, the severe pain on passive movement, the swelling and local thickening, and the associated conditions of the gums and urine are all features quite foreign to infantile paralysis. The loss of movement is no doubt due partly to fear of the acute pain which movement causes ; but it may also be due partly to mechanical disability, for not only is the periosteum stripped off the bone by the underlying haemorrhage,but, as I have seen in some autopsies on infantile scurvy, the muscles also in severe cases are infiltrated with serum and extravasated blood. Occasionally there is further disablement from separation of epiphyses by extensive haemorrhage at the epiphysial line ; in one case which I examined epiphyses had been separated in all four limbs. This danger of separation of epiphyses, which is due to effusion of blood at the epiphysial junction, is a point to be INFANTILE SCURVY 113 remembered in the handling of these infants with scurvy. Cases have been recorded also in which fracture occurred in the shaft of the bone. (Edema. The occasional occurrence of oedema over the thickened part of the limbs in scurvy is worthy of notice. In the diagnosis between scurvy and suppurative periostitis it might have been thought that oedema pointed to the presence of pus. This is certainly not so ; I have seen well-marked pitting of the skin on gentle pressure in cases of infantile scurvy. Fig. 7. Skiagram of legs in infantile scurvy. Showing haemorrhage surrounding lower two-thirds of femora. Gums. The characteristic appearance of the gums has already been mentioned, but it is to be remembered that any great swelling or discoloration of the gums is by no means a constant feature ; often it requires careful observation to detect the little affection that exists. There may be only a thin purple line or minute patch of red discoloration at the free edge of the gum ; and I have specially noted that in some cases it was only on the posterior edge of the gum behind the tooth, and therefore very easily over¬ looked. It is generally stated that where there are no teeth there is no i STILL 114 COMMON DISORDERS OF CHILDHOOD gum affection ; this is not strictly accurate, for where the teeth are close up to the surface of the gum, but not actually through, I have seen haemorrhage in the gum over them. When teeth are present the gums are not necessarily affected ; in seven out of thirty-nine cases in which teeth were present in my series the gums showed nothing abnormal. Very rarely the gums are markedly affected when there is no other obvious symptom of scurvy. In one of my cases there was no tenderness whatever in the limbs, although the gums showed very marked swelling and purple discoloration. In another some tenderness had been noticed in the legs, but had passed off when I saw the child, whose gums were swollen and purple. In both these cases the existence of scurvy, suggested by the diet and the gums, was proved by the finding of blood in the urine. Palatal haemorrhage. I wish to call attention here par¬ ticularly to a manifestation of scurvy which has not, I think, attracted much notice, namely haemorrhage in the mucous membrane of the hard palate. The discoloration occupies the middle part of the vault of the hard palate ; it has not in my cases extended forward to the alveolar portion, nor backward to the soft palate. The colour varies from a bright blood red to a deep almost black purple. As in the gums, the affected area may become secondarily inflamed and the mucous membrane over it roughened. Such were the appearances in four of my cases, but as I had not looked for this manifestation in the earlier cases I cannot tell in what proportion it is to be found. This palatal haemorrhage is certainly noteworthy, as it may assist diagnosis when it occurs—as in three out of my four cases—in infants who, owing to absence of teeth, show no gum affection. Orbital haemorrhage. ‘ Black eye ’ in an infant six to twelve months old, without obvious traumatism, should sug¬ gest the possibility of scurvy ; but it is not a very frequent symptom. It was present in six out of the sixty-four cases, and in five of these was sufficient to cause protopsis of the eye. Curiously enough, in all six it was the left eye that was affected. The discoloration appears usually chiefly or only in the upper lid. Urinary symptoms. The diagnostic importance of the urine in infantile scurvy is not sufficiently appreciated. Urinary changes are actually more constant than the gum affection, and an examination of the urine will usually clinch the diagnosis if there be any doubt. During the last few years INFANTILE SCURVY 115 I have examined the urine of all cases under my notice as far as possible, and out of 38 cases only 4 showed nothing abnormal. In 12 there was blood only, in 9 blood and casts, in 2 blood and pus, in 2 pus only, and in 9 albumen only ; so that the proportion of cases showing some urinary change was 89 per cent., and the proportion showinghsematuria was 60 per cent. But it must not be supposed that blood is to be detected by the naked-eye appearance of the urine in this proportion of cases. In many the amount of blood was so small that it was seen only by careful microscopic examination ; and when pus was present, although sufficient to attract attention at once under the microscope, it was not sufficient in any of my cases to be detected by the naked eye, although in one there was enough to make the urine slightly turbid. It is generally stated that hsematuria may be the only symptom of infantile scurvy ; and if the haemorrhagic manifestations are to be taken as the only evidence of scurvy, this is certainly so. In three of the cases mentioned above there was no affection of the limbs or gums—in fact, no characteristic symptom except hsematuria ; but in all three there had been wasting recently, and one was fretful and miserable, and another would not take his food ; there were, in fact—as I suspect there usually are in these cases where haematuria is stated to be the only symptom of scurvy—those vague symptoms of disturbed nutrition which I have described as marking the onset of scurvy. The presence of casts in the urine in association with the blood may indicate a nephritis in some cases. As I have pointed out 1 the casts are sometimes numerous, and easily found without centrifuging, and the albuminuria occasionally persists for many weeks or months. The occurrence of pyuria with acid or neutral urine, and without any special evidence of irritability of the bladder* would seem to point to a pyelitis, and this was the clinical condition in three of my cases. The recognition of this pyuria is of some practical importance, for, like the nephritis, it is apt to persist after all the acute symptoms of scurvy have passed away. In one case where the tenderness and loss of movement in the legs had begun to improve within fortyeight hours, and were as usual cured in a few days by anti¬ scorbutic diet, the pyuria persisted nearly five weeks, and during this time the child remained pale, and failed to gain weight until the pyelitis began to subside. Not only may the pyelitis retard the infant’s recovery, but it seems likely that this 1 Lancet, Aug. 13, 1904. I 2 116 COMMON DISORDERS OF CHILDHOOD condition, which when it occurs as a primary affection in infants causes severe pyrexia, may account in some cases for the high temperature which sometimes accompanies infantile scurvy. In a case in which the urine showed pus without blood the tem¬ perature was 104-4° ; and in one of the cases in which the pus was associated with blood, a slighter degree of pyrexia persisted for nine days after antiscorbutic treatment began, although the gum symptoms and tenderness of limbs had rapidly subsided ; the pyuria in this case lasted twelve days. Temperature. Pyrexia in infantile scurvy, although rather the exception than the rule, is by no means a rarity ; the temperature may be raised to 101° to 102° F. when the infant comes under treatment, but it subsides generally within a few days as the acute symptoms of scurvy disappear. In some cases, however, the temperature rises to 103° to 105° F., and, as I have pointed out, this may depend upon the presence of pyelitis. The occurrence of fever in infantile scurvy is worth remembering, for this symptom, like the oedema to which I have referred, has been regarded as point¬ ing to suppurative periostitis—a very serious mistake if it leads to incision, a measure which would only increase the risks of infantile scurvy. If the possibility of scurvy is borne in mind, and the history of feeding and the gums and the urine are investi¬ gated, this error is not likely to arise. Other haemorrhages. Haemorrhage into the skin is quite the exception in infantile scurvy ; it was present in six out of the sixty-four cases, excluding those in which orbital haemorrhage showed as ‘ black eye’ ; in two cases it showed as a linear bruise running downwards and outwards for nearly an inch from just below the inner canthus ; in one the situation was the scar of vaccination. Mucous membranes. I have already mentioned haemorrhage in the mucosa of the hard palate. The visceral mucous mem¬ branes may be similarly affected ; in a specimen figured in the museum of the Children’s Hospital, Great Ormond Street, haemorrhage had occurred into the mucous membrane of the bladder. Bleeding from mucous membranes is not very common ; in three of my cases slight epistaxis had occurred, and in one of these there was bleeding also from one ear. Less rare is the passage of streaks of blood with the stools (noted in eight cases). Visceral hcemorrhage. Post mortem examination showed in one of my cases that extensive haemorrhage may occur in con¬ nexion with viscera, though such an occurrence is probably OXFORD MEDICAL PUBLICATIONS COMMON DISORDERS AND DISEASES OF CHILDHOOD BY GEORGE FREDERIC STILL M.A., M.D. (Cantab.)> F.R.C.P. (Lond.) PROFESSOR OF DISEASES OF CHILDREN, KING’S COLLEGE, LONDON PHYSICIAN FOR DISEASES OF CHILDREN, KING’S COLLEGE HOSPITAL PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND STREET HONORARY MEMBER OF THE AMERICAN PAEDIATRIC SOCIETY THIRD EDITION LONDON HENRY FROWDE Oxford University Press HODDER & STOUGHTON Warwick Square, E.C. PREFACE TO THE THIRD EDITION The preparation of the Third Edition of this work has been under difficulties ; one’s pen, never too ready, laboured ‘invita Minerva’, for was not Mars in the ascendant? Nevertheless, I have striven by addition and correction to increase the usefulness of the book. Dosage has required some modification in conformity with official alterations in the strength of various preparations in the new (1914) edition of the British Pharmacopoeia. A chapter has been added on that curious and little-understood disorder of children, ‘ coeliac disease ’, and one on tuberculous glands in the neck, and by numerous additions to other chapters I have endeavoured to keep abreast of recent advances in medical knowledge. For Medicine there is no abiding in one stay ; like the Athenians, we are always seeking after some new thing ; but we seek it, not because it is new, but in the hope that it is better : only we must beware lest the glamour of novelty put a spurious value upon methods, especially of diagnosis and treatment, which can only be appraised at their true value when time and experience shall have shown their fallacies and limitations. July 1915. G. E. S. PREFACE TO THE SECOND EDITION There is perhaps less of trepidation in a second appear¬ ance than in the first introductory bow. Judgement has been passed, and if some have noted only faults, others have found, with Cervantes, that £ there is no book so bad but something good may be found in it*. But indeed it would be churlish not to acknowledge the many kindly words of appreciation as well as of criticism which have come to me from many lands, from friends known and unknown. These have lightened in no small degree the burden of responsibility which one must needs feel, who sends forth a book intended to be a guide and help in the every-day problems of disease. One cannot but realize that some of the faults and omissions of the earlier edition remain, and must perforce remain, owing to the purpose and character of the book. In particular I must crave indulgence for its apparent egoism—a fault it is true, but one which was inseparable from the object I had in view, which was less to present a formal and impersonal treatise on diseases of children than to extract from my own experience such facts and conclusions as might be helpful to others. In the present edition I have followed this same plan in dealing with several disorders, amongst which may be men¬ tioned enlarged tonsils and adenoid hypertrophy, epilepsj^ asthma and hydrocephalus, which were not included in the previous edition. The rapid march of scientific investigation has necessitated, X. PREFACE TO THE SECOND EDITION even since this book was first published barely two years ago, considerable modification of views on some of the diseases of children, for instance, infantile paralysis and congenital syphilis. Other alterations and additions have been made wherever such changes seemed likely to be of value, and if the revision and extension which the work has undergone add to its usefulness I shall be well content. February 1912. G. F. S. PREFACE TO THE FIRST EDITION The original plan of this work was the putting together of lectures delivered at King’s College Hospital and at the Hospital for Sick Children, Great Ormond Street; and in accordance therewith I had intended to call the volume ‘ Lectures on Diseases of Children But as the patchwork grew it became evident that, if it was to be in any sense a connected whole, it would be well to combine with the lectures other clinical studies, which had been written at various times for other purposes. Some of these studies, as also of the lectures, have appeared already in medical journals or in hospital reports, but only very few in the form in which they now appear, for larger experience has called for modifications and additions, and I have not scrupled to mutilate and transform my progeny until they bear scarce the semblance of their former selves. For the most part, however, these chapters appear now for the first time, and having abandoned my original scheme, I was at a loss to find a name for my ‘ farrago libelli \ It is no systematic treatise, it has no claim to vie with the many textbooks which deal with the whole subject of disease in childhood, nor indeed is it written on the lines which a systematic work demands; I have chosen rather to be selective and discursive as it suited my bent; I have dis¬ regarded altogether that sense of proportion and perspective which is of the very essence of a systematic textbook. My theme is mainly the everyday and the commonplace, the disorders which bulk most largely in the out-patient and in-patient clinics of a children’s hospital, and in the Xll PREFACE TO THE FIRST EDITION routine of private practice. On this ground I have adopted the title ‘ Common Disorders and Diseases of Childhood ’, which at any rate conveys the main purpose of the book. But I have not debarred myself from including some dis¬ orders which cannot by any stretch of the imagination be regarded as common; for instance, infantile scurvy and congenital hypertrophy of the pylorus—conditions which, when they do occur, are apt to be mistaken for much more common disorders. Throughout I have had in view chiefly the practical and clinical aspects of disease, particularly diagnosis and treatment; but where pathology or morbid anatomy had a direct bearing upon any practical point I have not hesi¬ tated to consider it in detail. Coming fresh to the perusal of my work at its finish, I am only too conscious of its many faults and failings. For one thing I notice a monotonous repetition of such phrases as 4 I think ’, and ‘ in my experience 5 ; these, on considera¬ tion, I have left unaltered, for they may serve to remind the reader that the views expressed are for the most part personal opinions based on personal experience, and although, as Oliver Wendell Holmes remarks, 'a man’s opinions are generally worth more than his arguments ’, yet, in things scientific, opinions are only to be accepted in so far as they are found to tally with the observations, not of one man, but of many. For the cases and statistics which I have recorded wherever they seemed to emphasize or illustrate points of practical importance I need make no excuse. In medicine, every addition to the sum of observed facts, though it be but a drop in the ocean of clinical experience, has a value of its own; and for this reason I have endeavoured as far as possible to compile figures and observations from my own case-books rather than to borrow from other writers. PREFACE TO THE FIRST EDITION xm Rut if my direct debt to others can be measured, it is impossible to estimate what I owe indirectly to the writings of far better observers than myself; there is scarcely a writer on diseases of childhood in Great Britain, America, or elsewhere from whom I have not at some time drawn valuable aid in the study of disease in children. Whatever I have consciously borrowed I have tried to acknowledge in the text; but, as I have already implied, the source from which I have chiefly drawn has been my own clinical records, and if I have made no reference to this or that writer’s work it is not for lack of appreciation, but because it would have been inconsistent with the purpose of this book to make it a resume of other people’s observa¬ tions. To the Editors of the Lancet , British Medical Journal , Practitioner , and Clinical Journal, I owe thanks for permission to make use of articles or lectures which I had contributed to their pages, and which I have now used in their original or in modified form. My indebtedness for some of the illustrations is acknowledged in the text: others are inserted by the kind permission of the Lancet , of Dr. L. E. Creasy and of Messrs. Power and Murphy. In conclusion, I must thank the Publishers and Printers for much care and patience in the production of this book, and also Mr. J. K. Murphy, F.R.C.S., for kindly advice on several points. To my sister, Miss A. Still, I am indebted for invaluable assistance in the preparation of charts, the compilation of the index, and other laborious details of publication. G. F. STILL. Harley Street, W. CONTENTS CHAPTER PAGE I. M edical Aspects of Growth and Develop¬ ment in Childhood ..... 1 II. B reast-feeding and its Limitations . . 17 III. The Modification of Cow’s Milk for Infant¬ feeding ....... 30 IV. Curd-indigestion ...... 52 V. O n the Use and Abuse of Condensed Milk and Patent Foods ..... 62 VI. C ommon Faults and Fallacies in Infant¬ feeding ....... 76 VII. P ickets ........ 84 VIII. I nfantile Scurvy ...... 108 IX. F latulence and Colic in Infancy . . . 123 X. I nfantile Marasmus . . . . .132 XI. H ypertrophy of the Pylorus in Infants . 151 XII. A bdominal Pains in Children beyond the Age of Infancy ...... 168 XIII. Indigestion in Children past the Age of Infancy ....... 176 XIV. The Medical Aspect of Dental Caries in Childhood ...... 193 XV. C onstipation in Infancy and Childhood . 201 XVI. I nfantile Diarrhcea ..... 215 XVII. O n so-called Cceliac Disease . . . 236 XVIII. Bilious Attacks, so called, in Children . 247 XIX. F ever of Obscure Causation .... 260 XX. I ntestinal Worms ...... 286 XXI. J aundice in Children ..... 300 XXII. E n larged Tonsils and Adenoids . . . 314 XXIII. Laryngitis Stridulosa, and other Affec¬ tions known as ‘ Croup ’ 326 XVI CONTENTS CHAPTER PAGE XXIV. Asthma in Infancy and Childhood . . 342 XXV. Bronchitis . 353 XXVI. Broncho-pneumonia ..... 363 XXVII. Pneumonia . . . . . .370 XXVIII. Empyema ....... 383 XXIX. Tuberculosis ...... 396 XXX. Abdominal Tuberculosis in Children . 423 XXXI. On Tuberculous Glands in the Neck . 441 XXXII. Tuberculous Meningitis .... 453 XXXIII. Rheumatism ...... 469 XXXIV. Heart Disease in Children : Endocarditis 486 XXXV. Rheumatic Pericarditis in Children . 504 * XXXVI. Chorea ....... 514 XXXVII. Congenital Heart Disease . . . 533 XXXVIII. Nephritis in Children .... 549 XXXIX. Some Urinary Disorders in Childhood . 562 XL. Pyelitis in Infancy and Childhood . . 568 XLI. Mentally Deficient Children . . . 583 XLII. Mongolian Imbecility . . . .611 XLIII. Nervous Children ..... 622 XLIV. Habit-spasm ...... 634 XLV. Convulsive Disorders in Infancy . . 648 XLVI. Epilepsy in Infancy and Childhood . 668 XLVII. Infantile Paralysis ..... 684 XLVIII. The Cerebral Palsies of Childhood . . 701 XLIX. Hydrocephalus . . . . .712 L. Enuresis and Faecal Incontinence . . 726 LI. Disorders of Speech .... 740 LII. Sleeplessness, Loss of Appetite, and some other Symptoms . . . . .755 LIII. Head-nodding with Nystagmus in Infancy 764 LIV. On certain Morbid Habits in Children . 775 LV. Congenital Syphilis . 792 INDEX 840 INDEX Rheumatism ( c ontinued )— symptoms, 472. tonsillitis in, 457, 477. treatment, 484. wasting with, 474. Rheumatism, scarlatinal, 488. Rhubarb, haematuria from, 565. Rhus aromatica for enuresis, 735. Rhythmic movements, 786, 789. in mental deficiency, 586, 789. Rice-water, 44. as milk diluent, 44. for diarrhoea, 228. preparation of, 44. Rickets, 66, 70, 84. abdomen large in, 98. a food disorder, 84, 85, 102. age-incidence of, 88. anaemia with, 99. barley-water causing, 103. baths for, 106. beading of ribs in, 91, 101. bending of bones in, 93. boiled milk not causal of, 102. bronchitis with, 99, 355. carious teeth with, 198. clavicle, deformity in, 93. condensed milk a cause of, 70. contributing causes of, 87. convulsions with, 653. coxa vara in, 93. deficiency of fat, causing, 36, 66, 86, 87, 103. deformities of, preventable, 93, 94. dentition delayed by, 101. diagnosis of, 100. diarrhcea with, 99. dietetic causes of, 85, 103. egg, yolk of, for, 104. epiphysial enlargement in, 92. fontanelle in, 95, 101. frequency of, 84. green-stick fractures in, 93. growth stunted by, 93. head characteristic in, 95. head-sweating in, 101. internal beads, formation of, 92. kyphosis in, 94. laryngismus stridulus in, 98. ligaments lax in, 94. lime-water not preventive of, 44, 45, 88, 103. massage in, 107. mental condition in, 95, 96. muscular symptoms in, 94. nervous symptoms in, 90, 107. newborn with, 100. pain in, 90. phosphorus in, 105. posterior beads in, 92. prevention of, 102. recti, diastasis of, in, 98. Rickets ( c ontinued )— recumbency, value of, in, 94. spasmus nutans with, 768. symptoms, 89. syphilis and, 87, 97. teeth decayed in, 91, 198. tetany with, 658. treatment, 102. Rigor, in pyelitis, 280, 570. rarity of, in infants, 570. replaced by vomiting, 280, 372. Roundworms, 293. convulsions with, 294. family incidence of, 293. fever with, 284. in larynx, 294. treatment, 298. vomited, 293. Salicylate of sodium, for jaundice, 313. for chorea, 528. for pericarditis, 511. toxic effects of, 528. use of, 484. Saline infusion, in diarrhcea, 229. rectal injections, 229, 235. Salix nigra in masturbation, 778. Salvarsan injection, 818. Santonin, administration of, 297. Scarlatinal rheumatism, 488. Scarlet fever with chorea, 516. Scorbutic foods, 119. Screaming, constipation causing, 205. . with colic, 131. with dentition, 11. with diarrhoea, 223. with mental deficiency, 585. Scurvy, 108. age-incidence, 110. boiled milk causing, 120. diagnosis from epiphysitis, 110. diagnosis from infantile paralysis, 112. diagnosis from rheumatism, 110,481. dietetic cause, not same as of rickets, 109. dress in, 122. epiphysis separated in, 112. epiphysitis simulating, 803. Glisson on, 108. gums in, 113. haematuria in, 115. haemorrhages in, 116. limb affection in, 111. mode of onset of, 110. muscles in, 112. nephritis in, 115. oedema in, 113. onset, sudden in, 111. orbital haemorrhage in, 114. palatal haemorrhage in, 114. patent foods causing, 67, 119.