555 DEPARTMENTS PEDIATRICS. IN CHARGE OF HUBERT WORK, M. D., PUEBLO, COL. President of the Colorado State Medical Society; Ex-Member Colorado State Board of Medical Examiners; Objective Diagnosis in Children.-The essentials of diagnosis in diseases of adults comprehends inspection, history, subjective symptoms and physical signs, all of which are to a degree fallible in those of matured structures, but infinitely more likely to mislead when applied to the young, in whom many organs are disproportionate in size and incompletely developed functionally. The yielding, semi-ossified, bony structures through which intra-thoracic diseases must be examined, together with the ceaseless activity of young children and the limited areas accessible to the examiner, are familiar impediments to accuracy. Teachers of physical diagnosis instruct from the adult subject, a further embarrassment to diagnosis in children, and when we remember the absence of personal history and the vagueness of that given by the untrained attendant, the importance of visual inspection becomes apparent. The infant statesman, comedian and idiot are alike without facial expression in health, but contraction of the muscles from pain and the loss of adipose tissue from wasting diseases gives expression to the youngest face, the latter simulating that of senility. A glance will determine the color of the face and lips, the state of the eyes, or defect, if present, and the dark rings under them. But aside from indicating physical distress or malnutrition, the ingenious speculations of Jadelot, by which he proposed the diagnosis of various diseases by facial lines and angles, much as a geometric theorem is demonstrated, has proven to be of little definite value in pediatrics. Squinting is an important and grave sign in acute diseases, because symptomatic of paralysis, or reflex evidence of cerebral disturbance, possibly from accumulation of fluid in the ventricles, or of convulsions. If due to the latter cause it may continue long after the waning of the eclampsia. The corresponding widely dilated pupils not sensible to light, are seen in compression of the brain from whatever cause; accumulation of fluid in the ventricles or subarachnoid spaces are the most common. The same condition to a lesser degree is seen in the cerebral congestions of low fevers and in chlorosis, diseases relatively uncommon in 556 young children. The contracted pupils will at once suggest opium poisoning or acute cerebral congestions, but they are also seen in normal sleep. If due to the congestive state of brain inflammation, there will be intolerance of light, not true, of course, if due to narcotism or coma. The quality of the pupils is said to result from affections of the sympathetic system, which is the probable explanation for Jadelot's statement that "Irregularity of the form of the pupils occurs from the intestinal irritation of worms." The position of the body assumed by the infant is less significant than that of the adult, because less able to associate cause and effect, trace pain to its source, or from weakness it may not be able to assume the posture of least distress; yet it is often very suggestive of the diseased condition. The healthy and tired child will fall asleep in any position, and the new born assumes the posture occupied before birth; but the child that persists in lying on one side of the back with rapid play of the nostrils presents two of the cardinal symptoms of pneumonia; as does lying on the side with legs flexed and arms hugging the chest, suggest the latter stages of tubercular meningitis or kindred cerebral disease. Equally suggestive of forming membranes in the throat is the sitting posture in those old enough, with tearing at the neck, thrusting the hands into the mouth and urgent dyspnea. The child with legs drawn up, otherwise resembling the typhoid wasted adult, is in all probability suffering from abdominal disease. The waking motionless child is not in health. All degrees of activity, from the grimaces. and aimless gesticulations of the newly born to the boisterous play of the lad are signs of health; their absence betokens mental hebetude, a symptom of the gravest cerebral diseases. But it must be remembered that dullness of the gravest seeming nature, even to coma, may disappear in a day or two, proving that it was the reflex manifestation of some digestive disturbance or vaso-motor irregularity, perhaps of a comparatively trivial nature. A premonitory symptom of the exanthemas is stupor. Of so many diseases is it a podrome or a developed symptom that all the aids to diagnosis in the hands of the most experienced observer may not enable him to determine to what extent it is a reflex symptom or a secondary condition, whether independent or coincident. It can be distinguished from sleep, its next of kin, by the greater difficulty in arousing the patient, the dull apathetic countenance, together with querulousness if the strong desire to again lapse into slumber be combated. Sleeping or wakeful quiet, succeeding the restlessness of a feverish child, without decline of the high temperature, indicates cerebral complications or increasing weakness, in either case an unfavorable symptom and easy of observation. In cerebral exudations it is noticeable that the head is constantly rubbed on the pillow, together with pulling 557 of the hair and ears and aimless beating about the head with the hands. Tapping the vertex with the knuckles is a common symptom of uremia, often a companion of its convulsions, The flexed thumb with the hand closed over it is a time-honored precursor of convulsions, but it is also seen in atrophic children to whom eclampsia may not be imminent. It has been said that these are also signs of cerebral atrophy; a statement I have not been able to verify in practice. Boston Med. Surg. Journal, 1894, CXXX 403. An ordinary dose of castor oil may be rendered odorless and tasteless by simply shaking it thoroughly in a flask with warm milk. Gaillard's Med. Journal. Retention of urine in young children may often be relieved by an enema thrown into the rectum, so stimulating both the centers for defecation and the genito-spinal center for urination as to bring about micturition without catheterization. A proceeding always dangerous in young children unless anesthetized. From 1886 to 1890 the Sejournet (Jahrbuch fur Kinderheilkunde): the author was the only physician in a village of four thousand inhabitants. During this time seven hundred and thirty-four children went through the teething process, and in but thirty-seven was there a direct connection. between dentition and illness. He believes that teething exerts but a very small influence upon the health of the child, and that in the cases in which there is an apparent dependence of disease upon dentition, it is usually a coincidence. Battrich (Jahrbuch für Kinderheilkunde): A boy nine and a half years old drank a quarter liter of whiskey. This was shortly followed by dizziness, loss of consciousness and convulsions, which were chronic in character, involving the extremities and the muscles of the face. The pupils were contracted, the head hot, the trunk cool, the pulse slow. The convulsions subsided, but were followed by pulmonary edema, high fever, and extremely rapid perspiration, and death in three days. Mensi (La Riforma Medica, May 29, 1894): The author has employed guaiacol epidermically in a number of cases of pulmonary tuberculosis in children aged from three to twelve years. The success was moderate. Most of the children gained in weight, the temperature was reduced, and there was a general amelioration in the local and constitutional symptoms. The author recommends the drug exhibited in this way as being rapid in its action, easy of application, and well borne by the patients. 558 Holt L. Emmett (N. Y. Med. Rec., 1894, XIL 524): The technique of gavage is very simple. The ordinary apparatus used for stomach washing is all that is required. The catheter should have a double eye, and No. 14 American scale is the best size for infants under six months, and about No. 17 for older children. The child is placed flat upon its back in the crib and the head steadied by an assistant. The tongue is depressed by the left forefinger, and the catheter, previously oiled, is pushed rapidly down the pharynx until nine or ten inches have passed the lips. The funnel is now raised high in the air for a few moments to allow gas from the stomach to escape, and the food is then poured into the funnel and rapidly runs into the stomach. As the last of the food leaves the funnel the catheter is tightly pinched and quickly withdrawn. The time consumed in feeding by gavage is from ten to thirty seconds. Its value has been established in feeding premature infants; in controlling persistent vomiting in very young infants, where the vomiting occurs partly from habit and partly from exaggerated pharyngeal reflex; in acute diseases, as scarlet fever, diphtheria, bronchopneumonia, typhoid and empyema, when for any reason children refuse all food; and in serious brain disease where the patient cannot be fed by ordinary means. Stomach washing is required in conjunction with gavage in most cases in infants; once at least every day the stomach should be washed before feeding. J. T. Williams (British Medical Journal, 1894, I., 800): The patient was a male aged eight months, with a very well marked intussusception. Kneading, inversion with manipulation, injection of warm water and insufflation of air failed to reduce it, and the parents refused consent for a lapaTherefore he injected through a flexible catheter, which was passed into the bowel to the extent of nine inches, first a half pint of water containing a drachm and a half of citric acid, and then the same quantity of water containing two drachms of bicarbonate of soda. The result was the generation of carbonic acid gas within the bowel, and the reduction of the intussusception. It could be easily ascertained what volume of gas is generated by a combination of various acids with carbonates, and it would be of value to know what amount of gas (602) could with safety be rapidly. generated within the bowel; for as these cases call for prompt treatment, it might be necessary, on an emergency, to use such domestic remedies as chalk or washing soda with vinegar (or a Seidlitz powder). Of course this treatment is not free from danger; in a case which is far advanced, and where gangrene has set in, it might cause rupture of the gut. But if the case is taken early, and all other means have failed and permission to do a laparotomy has been refused, one is quite justified in resorting to this mode of treatment. 559 LARYNGOLOGY AND OTOLOGY. IN CHARGE OF WILBUR W. BULETTE, M. D., PUEBLO, COL. Laryngologist and Otologist to Pueblo Hospital; to Pueblo Children's Home; Member American Medical Philadelphia, etc. Treatment of Otomycosis.-Stout (Univ. Med. Mag., May, 1894) in an admirable article giving fully the history, etiology, pathology, diagnosis, ect., of otomycosis, says, that in the treatment there are two objects in view, I, to end the life of the fungus, and 2, to thoroughly cleanse the parts and leave an unfavorable abiding place for parasites, transforming the meatus into a pure and healthy locality which new spores would find sterile and unfit soil for procreation. A few drops of warm sterilized water should be instilled into the canal, and the mass allowed to soak until thoroughly saturated. The ear is then carefully syringed with equal parts of peroxide of hydrogen and hot sterilized water until as much as possible of the mycelium and debris is removed. The syringe most efficient is one with a glass barrel partially encased in metal, holding from half to a fluid ounce, with rings on either side of the barrel case and on piston end, for admittance of index and middle fingers and thumb; the nozzle of small caliber, so it can be delicately guided by hand and eye. The stream from the syringe is directed along the roof of the meatus, with inclination slightly downward and forward, thus gaining advantage of obliquity of drum membrane, and allowing return flow along the floor. To remove adherent scales, a 'very small amount of cotton wound around holder and dipped in peroxide is introduced into the meatus; thus the probe can act as mechanical lever, and the eye can see past the cotton to the point of the carrier. The meatus having been thoroughly cleansed and sterilized, it is insufflated with borax finely powdered and bolted. This line of treatment is used in the Philadelphia Polyclinic, and has proved satisfactory. Ethmoidal Disease.-Bosworth (Medical Record, Oct. 13, 1894) in a valuable and eminently practical article on this subject, says, that he regards ethmoidal disease as not only by far the most frequent of all diseases of the accessory cavities, but as of much more frequent occurrence than we have ordinarily been taught to believe. A very large proportion of the cases of so-called acute rhinitis are really instances of acute ethmoiditis, and that such inflammations as may exist in the nasal mucous membrane is really secondary to the graver and more distressing conditions of the lining membrane of the ethmoidal cells. He divides disease of these cells into |