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•^L-IBRT^RV*

OF

Cooper Medical College

Date

No. 739

Shelf

OIF-I* Ol^

l!i^MBl

\mh\ @B)S)g^% HjaamBMMiB)

THE NEW SYDENHAM SOCIETY.

Instituted MDCCCLVIII.

.VOLUME CXXV.

LECTURES

ON

CHILDREN'S DISEASES.

A HANDBOOK

FOR

PRACTITIONERS AND STUDEJITS

liY

Professor in the University of Berlin; Director of the

Departhsnt for Childrbn*s Diseases in the

Royal CharitIc Hospital, Berlin, etc.

VOLUME FIRST.

Translated from the Fourth Edition (1889)

BY

JOHN THOMSON M.B., F.R.C.P., Edin.,

Estta-PhytUian to the Jtoyat notpital for Sick Children, and Physician for Children' t Di9ea$e» to the Xew Tokh Dispensary^ Edinburgh,

rConboQ : THK NEW SYDENHAM SOCIETY.

MDCCCLXXXIX. 0

n!^^

00

and is wi to be r LibratV ^^

CAL.

, fc the son or

;6T.

PREFACE TO THE FIRST EDITION.

Tms treatise contaiiis almost exclusively the results of experience, pfathered diiriDg tbirty-seven years of practice in- cluding almost ouinternipted work at the polyclinic, in the department of children's diseases. When in 1872, I was placed in charge of the Children's Wards in the Eojal Charite Hospital, I was enabled to an unusual extent to increase the number (already very large) of my observations on all periods of child- hood ; and also to place these on a firm anatomical foundation, in a way which could not have been done in a polyclinic and private practice. It is only because my material has been so exceptionally large, so carefully observed, and drawn from so many classes of the city population, that I dare claim for tbis work, based as it is almost entirely on ray own experience, the title ** Handbook for Practitioners and Students."

It stands to reason, however, that the observations of a single physician must even in the most favourable circumstances presHil some gaps, and that as be fci*ows older and sees more he will always be meeting with new facts which modify the results of bis former experience. Therefore it must not bo expected that every disease which can possibly occur in a child will be found described or even mentioned here. Moreover, I do not think it right that a work on children's diseases should be burdened with the wearisome repetition of matters which are fully treated of in all books on general and special Pathology and Surgery, and which I am entitled to assume are familiar to my clinical class and still more so to my readers. Only those diseases will furnish the subject-matter of this work which either occur far more commonly in childhood or else, when met with at that period, show certain peculiarities as compared with the same affections in adult life. On tbis giound I have excluded variola, which is very rarely met with now-a-days. My passing over vaccination in silence is excusable only on the ground that I could, froyi my

PREFACE TO THE FIBST EDITION.

personal observation, Bcld nothing materia! to tbo innumerable trcatisca already written on tbe subject.

It lias 80 long been the cnstom to write iu tbe form of k'ctures that I need not say anything on that point. There arc draw- backs to this form which I do not overlook ; hut I consider that tbcBo are ontwcighed by its advantages — freedom from restraint and greater ease of reading. Further, the introduction of cases — which here take the place of illustrations — is thereby yery much facihtated. I should ask the reader not to pass over thcso cases, althongh they are very nnmerons ; for I believe they will be of use to him. I have always endeavoured to make them as brief as possible, emphasising tbe pouits bearing on the matter in hand and avoiding the intolerable diffusenesa and tediousnesfi of detailed clinical records.

Any practitioner who has suffered from the undiserimiunling and bewildering way in which the different remedies and modes of treatment are mixed np in most text-bookn, vvilJ, 1 am sure, approve of my having based advice in regard to treatment, like my clinical descriptions, solely on my own experieucep Tbe prescriptions at the end of the book (which arc referred to iu the text as Form. 1, 2 &cO, are not, I consider, out of place iu a scientific work. Older physicians may do without them ; but younger men — to whose wants I have had especial regard— will be glad to have at hand a help of this sort when beginning their practice among children.

I

BerliOj Januartf 1881.

Thk AirrHOtt*

PREFACJ!: TO THE FOURTH EDITION.

In tbc profftoc to tlie Second Edition of this book, which appeared in April 1883 (two years after the First Edition), 1 wrote as follows :— *' 1 have also received from far and near bo raauy expressions of satisfaction and appreciation that, evon had this work met generally with a less favourable reception, I should iitill have felt that there was no occasion in any way to change its f^ronnd plan. By feathering together a lot of expei-imental, anatomical and chemical matter, it is very easy indeed to give to a clinical work a dazzling appearance of the most modern science; I refrain, however, in this edition as in the former one from this kind of display, which is always ready with its h}'potheses and explanations, and perplexes more than it enlightens readers, especially l«}ginners. The stage of transition in which certain of our auxiliary sciences now are, renders extremely necessary, fit any rate for the ends that concern us here, the strictest sifting and criticism. It has been my chief endeavour to bo in every sense true to the reader, to criticise mj own work severely — especially in matters of treatment, for it is in these that one is very apt to go astray ; and out of the large store of observations I have accamuJated, I have sought to lay a sure fooudation for further study,'* I can to-day with a clear conscience repeat those words,

The fact that a Third Edition was called for in 1887 and a Fourth in the course of the present year proves that the method which I adopted was the right one. The steady advance of paediatrics and the continually accumulating results of my own experience, have indeed rendered it necessai'y to recast certain sections of the book as well as to make various additions to it By abbreviating as much as possible whatever was of minor importance and omitting some of the older records of cases, I have endeavoured to gain room for these additions without greatly increasing the size of the work.

B6rHn, September 1888,

Toe Author,

TRANSLATOR'S PREFACE.

OKSIDERINO the oat-BtandiDg position which Prof. Henoch a huuk holds in Germauy, its introduction to English reador« recjnh-es no apology. It is here neither necessary nor desirahle lo compare its merits with those of the many exceHent works on the same subject written iu our own language ; hut everyone will recognise the extreme and permanent Talue which must attach to these lectures as the outcome of foily-five years of untiring clinical work by a man of such spleiidiil powers of observation and judgment oa Prof. Henoch ; and no one who reails tliem can fail to be struck by the wonderfully wide range tif experience and reading which they represent.

In the translation, I have endeavoured to follow the original as closely as possible, except where a somewhat free rendering wm necessary to make the meaning clear. As many of the tterman pharmaceutical preparations differ a good deal iu composition and strength from those used in this country, I have, in many instances, altered the forms of the prescriptions a little to bring tliem into accordance with our own pharmacopoeia, I have also^ in rendering the various weights, measures, and temperatures, converted the terms of the metric system into tliose more commonly used among ourselves. I have adopted Prof. Henoch's method of drawing attention to certain emphatic words and phrases, as well as to the names of authorities, by ** spacing-out " the letters instead of using italics ; this will I believe be found helpful by the reader, although it may at first strike him as nnnsual and even a little perplexing. A full index ^^ill be given at the end of the second volume.

My warmest thanks are duo to my friend Dr. Barbour for in- valuable help of every kind in connection with the translation, and to Mr. \Vm. Macdonald for much literary advice and assistance.

Edinburgh, ilnd March, 1889.

J. T.

CONTENTS.

PAOV Pll&FAClE TO FiBflT EOITION , , T

PnKFACE TO Fourth Editios vii

Trasslator'b Preface ix

iNTttODLtTriOBT AMD METHODS OF BXAMtNATION , , I — 21

CbUdre&'t Di8ea;;€:s— Why worthy of special steely, I ; iofantilQ mortalitj, 2 ; method! of clioical examiniition, 4 ; auscultation, 6 ; percuaBion, G ; rale of breathing, 7; the pulae, 8; the heart, M>; laryngosooptc examination, 10; moubhand thn>at^ 10 ; phyaiological differeiicefl between children and adultp, 11 ; examination of the head, 12; *' brain murmur/* 12^ fontanellca and BUturea, 13 ; buccal cavity, Id ; tongue, 16 ; heart. It* ; temperature, IT ; nriae, 18; ficoei, 19 ; manifestationa of pain, 20 ; attitude durtog .^leep, 2h

SECTION I. DISSAftSa OF KBW-BOBN IKFAKT8.

ICTKRUg KBOKATOIIUM „,.... 23

Symptoms, 23 ; cauaatlon, 24 ; trwitTOent,27 ; complication?, 27 ; obliteration

or absence of excretoxy bile-dnots, 2^. TUJMIDS, OR TbTAI«C8 neosatorum , , 28

Symptoms, 29 j prog^Doais, 30 } post-mortem appearances, 81 ; causation, 31 ;

treatment, 33; certain other con vnleire affections, 24; '^' encephalitia intcr-

Btitiali^f" 34 ; symptoms aod pathology, fib, CKI'HALHJEMATOJIA , 3tJ

In early infancy, 3ri ; pathology and symptoms, 'M ; in older children^ 08 ;

treatmentf 38 ; diugnoEiii, 3H. U.EMATOMA OF TBB STKRNO-MASTOID ».«*..„.*.•. 59

Symptoms, 39 ; pathology, 40 ; treatment, 41. SWELLl>«i OF THE MaUMABV GLASD3 41

Symptoms and pathology, 41 ; treatment-^ 42.

RRT&IPEI.A3 NEONATORUM « ♦ 45

Causation, 4ft ; symptoms, 4& ; oompUcationa, 47 ; treatment, 47 ; erysipelas in older children, 48.

8CL1BKUA KBOSATOntrM , *...♦. 61

Sjmptomf> 5t ; oedema of new-born childreu, 53 ; pathology of oedema, 66; prognosis in both dif eases, 66 ; treatment, 57.

PrMPHI«1*3 NKOitATORFH , 67

Acute form, 57 ; caosation, 60 ; treatment, €1 ; cachectic or syphilitic form, 61.

AVUTBJE OF THE PaLATE 6^1

Appcaranoea and pathology, 63 ; trMtment, tJ4.

[ST.4tVA KCOlfATOBUK.... * G^

BympK^BU, 66 ; pathology, 66 ; treatment, 68 ; nlc«7 of ccBOpiaagQa, 69.

-nil

COHTENTfl.

SECTION IL

DISEASES OF IKFAKCT.

I'AGH

L IXFASTILB ATROPUT *..".■• 70

Development of the inf*nt'« aUtmenlary oanaJj 70 ; breAst twrnu bandfeeding, TO : syraptoniA of atrophy, 71 ; canee?, 73 ; com plications, 7& ; detailed de^ scription of iymptomi, 73 ; duration, 75 : causei of death, 75 ; post-mortem appearnnces, 70 ; prognoeiB, 7<J : hygienic treatment, 77 ; dietetic, 78 ; brea-«t* milk, 78 ; sabatitute* for breaat-milk, 80 ; cow'u milk, 81 ; coHdenwd milk, H3 ; KettJe'B foodj 83 ; other " infant'* foods," 84 ; alcoholic Btimulantei, 84.

IL Thrubh ,. »&

Symptoms, 85 ; pathology, 87 ; cuJtiTfttion-Dxpcrimenta, 89 ; inootalation-ex' potltnenta, DO ; dia^ioaift, 9\ - tn:!atment, 91.

III. HKIlKDFTAnY SyI'HILIS , »- ^^

Symptoms in well- marked cases in infants, 92 ; less typical manifeatatioiu, 94 ; affectionfi of the skin, 94 ; of the mucous membrase, 96 ; of the intestine, 97 ; of the lymphatic glandj», 97 ; of the houtK 97 : psendo-paralysls, 101 ; afFej- liona (if the joint^t. 104 ; of the testiclea, 106 ; of the liTer, 106 ; of the spleen, Ac, 108 ; of Llie iicrroufl sy.Htem, 108 ; of the vafcular system, 1 10 ; progno^i*, 111 ; recnrrctice, lit ; ricketa as a teqncla, 112; origin, 118; vacciuation- t-ypUilis, US; question of heredity, 114; treatment, 117; suckling, 118; ftyphilis in older children, 120 ; ByphUi« tarda, 120 ; condylomata, 121 ; afFec- t^oiiJi of the tongue, skin, lymphatic glands, 122 ; of the boneSf naao-pharynx, teeth, 12.(; treatment, 124.

IV, DYSPKPriC C0KIJITT02«S Ot LXPAXTS , 124

Vomiting of healthy infanta, 121; peculiarities of infant's utomacb, ri4 ; dyspeptic vomiting, 125; dyspepsia intestiRalia, 126 ; caosatloo of dyip^'pstn, t2C; feeding-bottlea, 127 ; nnsaitablii food, 127 ; pathology of dyspepsia, 1V7 ; " fat-diarrbcca," 130; acate dyspepsia, 131 ; " gastro-malacia," 132 ; dietetic treatment, 13^; medicinal treatment, 137,

V. CORTXA OF Infamy .„... ., H2

Syntptonm, 142 ; iu«picioq of syphilis, 142 ; dy^puozi from sacking-in of the tongue, 143 ; treatment, 145 ; diphtheritic coryxa, 145.

VI, RBTliO-rUARYXOBAL ABSCBSS , „ M'»

An uncommon conditioiJ, 1 46 ; pathology and symplomf , 146 ; diagnosis, 147 : ti'vatment, 148; rnpture into pharynx, IM ; into external auditory meatus, 15% ; oausalion, 153.

Vn. Dkstjtios awo its SniPTOMS , , IM

Many diseases attributed to dentition, 161 ; question of reflex irritation, 1&5 ; order of eruption of first teeth, l^to; presence of teetli at lirtb, 156; local morbid symptoms produced by symptoma, 15d ; Ofdcr of eruption of teeth, Mid.

SECTION lU, DissABCa or TifE xsuvora ststcji.

I. iKfjUITILK C0SVCLBIO5a. Itil

Derasgctneati of motor f ondioBa oommontr in infancy than thoie of aenaory, 161; aymptoma, 162; treatment of attack*, ICS; causation, 100; organic dlteaar, 166; ricketa and teething, 167; digestive disordcrt, 167; other ner- Tons phenomena bnmght on by digeatire diiordcTS, 170; li«atm«nt, 171 ; influence cf internal parasites and foreign bodiea m CiOfting eonviilAionff 172; eonraUions nshedng in febrile diteM«v ^^^i un»niia« intermitteni ferer, 174 ; paychical CMuea, 176 ; ooanecUon with epdepay, 175; epiJap^y (a chfldhood, 177 ; further ti«atinent| 17 §.

^^^KK CONTENTS. Xlll

PAOI

II. tiAiinroiAL SPAsaf , „„„ 179

Slight degree observed m heathy cbildmn when acraaming, 1 80 ; ajmptoma, ]80; altem*tea with eclampsia, 181 ; association with ricketSf 182; fainily tendency, 182; frequency of attacka, 183; caiue o! «adden death, 184; eauAationr 184; treatment, 186.

III. Idiopathto Coktracturks , , 187

Frequently af>so<:iated with laryngeal tpasm and conTulsiooii, 187 ; Bymptoma, 187 ; with cerebral tubercuIoaiB, 188 ; with reflex irritatioDy 188 ; relation to tetany, 190; tremor, 191.

IV. SPAaMua NPTAsa— NoDDiiTO Spaam 19«

lUufltratiTe cmm», 192 ; clinical deicription, 194 ; refiex cauMft* IM ; central caoiet, Idh ; with cliorea cnagna, 196 ; treatment of reflex form, 196 ; olher spwmodio oondilfoQa, 1'J6 ; oonvulnre laughter, 196.

V. CHoniA Misoa— St. Vitus' Dakci 197

Symptoms, 197 ; hemiohorea, 199 ; leas common ey mptome, 201 ; oonrw, 202 ; poet-mortem appearances, SOS ; relapsea, 204 ; pathology, 205 ; cauaefi, 206 ', connection with rheum atiam, 207: hMrt^diaeaae, 208; other caiuea, 209; effect of interoomnt diaeasea, 210 ; treatment, 211 ; " chorea electrica,*' 21i{ treatment, 216.

VI. The Hysterical AFrBcrioiVB of Children , 21«

Natare, 216 ; classification, 217 ; firrt claaa— chiefly physical symptoms, 217 ; •ecood olaas^-chieily conTuUive symptoms, 221 ; thkd claaa — co-ordinated movementi, 225 ; fonrth class — with senralgic or trophic duturbaocea, 230 ; bnmatemetiB, 231 ; other aympLoms, 232 ; question of Bimolatian, 232 ; h3'a- lerioal paralyaia, 233 ; causation, 234 ; treatment, 236 ; prognosis, 237.

VIL Pavob NocruRitTTB— Niqkt Tinaoas „. 231»

Symptoms, 239 ; causation, 239 ; treatment, 241.

Vni. PeBIPHERAL PARALTaSE ..*..... * 241

Of fadal nervQ at birth, 241 ; in older children, 242 ; canaea, 243 ; of other cranial nerves, 24^ ; of arm at birth, 246 ; in older chUdieo, 246 ; treatment, 246 ; parsJyBis after oonrolsions, 246.

JX. Spifal Infantile Pasaltbib 247

Symptoms, 247 ; onset, 248 ; further progress, 25'0 ; deformities, 252 ; pathcw logy, 252 ; affection of facial nerve, 25 ti ; diagnosis, 257 ; causes, 2.'V9 ; treat' I nisnt, 259 ; paralysis from Tertebr^ dise^^e, 261 ; sclerosis and spastic spinal paralysis, 262.

X PaEUDO-HTPEBTEOPHlO &rcSCrt.AIl PABALTStS .,*......„., 26.1

Symptoms, 2^8 ; pathology, 265 j treatment, 266.

XI. ArOPLICTtO COMDITIOKB 267

Symptoms, 267 ; onset, 267 ; cerebral htemonrhage, 267 ; haemorrhagic ence- I phaUtta, 268 ; canses of haemorrhage, 269 ; pachymeningitja, 272 ; flmboUnSt 2T2 ; thrombof li«, 273,

XII. Cerebral TusKncirLOeia iT'.i

Frequency of its occorrenoe, 273; dhugnosis, 274; symptoma, 274 ; latency, 276 ; duration, 280 ; pathology, 2S0 ; localisation, 281 ; chronic hydrocephalus, 2^!^4 ; treatment and natural cure, 286,

Xill. TuMouna of thk Braiji 280

Sarcomata, 286 ; gnmmat«, 299 ; other tamoon, 289 ; abeceas, 289.

XIV. Atropbic Ckrkrral Paraltsis .......,..»,.,.. 290

Symptoms and diagnosis, 2?1 ; palliologj' and iUustrmtions, 292; treatment,

CONTENTS.

XV. Cnnomc HtpnoatriiALtTa «..«.«•..«..—. 2i»»

Dkfnotis fruBi rickety cnuiiam, 297 ; iympfcoon, S97 ; craaimii, 297 ; menUl Jevdopmont, 2»9 ; power of motioD, 300 ; pott-niorteiu »pp«*f»ncea, 301 ; puihology, 3U« ; hydroeophaltw extemiw, 903 j pachjinmingitiflt 304 ; trett- m*nt. ^K)7 ; Kcute hydnxsephtaoflf 30d.

XVI. U¥rin.KaiiA of tbk Draw— Thromborw of thi Snrons 31<*

Hihoki0f^ {110 ; utciiol hypeiwmis, 310 ; cuik, aiO ; treatment, 311 ; other t«lWtt»^12 5 ttoxmu bypctvaiift, «13 ; ** bydiw»ph»UMd,*»18; to«ttoent, 314 ? •JaM-Uiro«b<»i«k 915 1 {wiholocri ^^^ ; <ii«gno«3i 316 ; trMtneat, 317.

XVII. TvniuioutJiii KsxtKurrra * SI7

Aotit* tgrdn>c«pli«lait<17 ; dMaicAl form of ihe dtMa»>^ 317 ; ermptoot*, «td ; VKrUiicuu fraoi typM cotan^ 1^ ( v^w oomfaiMd with cxxdbal tabrnm-

Xvin Nt Mnisorrts

I urrrttc«v A36 ; pfttJb«)laficid maaXooiy, 3Jtt ; iponidie oue, 337 ;

*j».^ .V ,r ^^ .v«; t «lkt(Milc tom^ 3a ; UMaapatte ncarv«f7v Ml; earner, 344 ;

XIX. NliVftAMlOOUtttllMWl ^ .,„„.,„«^ ^.^ *^.- M»

Am«9I9 <yilMtMiW Ma^^KMtl**l^¥ tu* Hi ohWIwjH. 313 ; mjgiaift, 319 ; .s^uM^ Mf k fy«|p|«B«t all t

SKOOSIIT.

t. tn

r

iU

>*^l\S' 1 VV»*«

«»

ii^vi iv nil tairn^ AKft

I^.V-Vv/^X

CONTENTS. XV

PAGB VII. CHBOKIC P5BUM0IVIA 414

Follows either broncho-pneamoDU or cronpous pneamonia, 415 ; symptoms, 416 ; termination, 417 ; bronchiectaus, 417 ; treatment, 418.

Viir. Plburist 419

Varieties, 419; latent plenriqr) 419; cerebral symptoms, 419 ; physical signs, 420 ; complications, 424 ; causation, 425 ; termination, 429 ; treatment, 430 ; indications for puncture, 430.

IX. TUBBROVLOSIS OP THE LUSGS 433

Connection between tubercle and caseation, 488 ; pathological anatomy, 434 ; symptoms and diagnosis, 435; latency, 487; caseation of tracheal and bronchial glands, 440 ; diagnosis of disease of bronchial glands, 442 ; termi< nation and complications, 443 ; htemorrhagic diathesis in tuberculosis, 446 ; separate successive attacks, 447 ; treatment, 448.

X. Gakgrexb op the Lukgs 419

Pathology and causation, 419 ; iUnstrative cases, 450.

X r. Whoopiko Cocoh 452

DiagnoAi>«, 452 ; symptoms, 453 ; first stage, 458 ; second stage, 453 ; third stage, 457 ; variations from usual conr»c, 458 ; complications, 460 ; causation, 4(*i2 ; contagion, 463 ; nervous element, 464 ; prognosis, 465 ; treatment, 466.

SECTION V.

DI8EA8IS OP TBB OlilCDLATORV ORGANS.

I. UI8BA8XS OP THE LaRGB BLOOD-VESSELS 470

II. COKGBIIITAL CTAK08I8 471

Causation, 471 ; symptoms, 471 ; diagnosis, 472 ; malformation of the heart >vithout cyanosis, 478 ; prognosis, 471 ; btematomata on valves, 476; treat* ment, 476.

III. Inplammatiox op the Pbrioardicm, Endocardium, ajid Myocardium 476 nheumatic origin, 176 ; latency of heart disease, 477 ; acute cases, 477 ; endocarditis recurrens, 479 ; recovery from endocardiUs, 479 1 endocBiditis preceding rheumatism, 480 ; other causes of endocarditis, 483 ; pericarditis, 485 ; tubercular disease of pericardium, 486 ; myocarditis, 489 ; aneurism of the heart, 490 ; fatty degeneration of heart, 490 ; hypertrophy and dilata- tion, 401 ; treatment of heart-disease, 492.

^'TRODUCTION AND METHODS OF EXAMINATION,

Gentleiten* — ^The treatmeut of Children's Diseases is usually (arded as a special branch of medicine . I hold, however, that this view is scarcely quit© correct, because almost all the diseases of children, with very few exceptions, occur in adults also. Still, these diseases are made a special study of, special cliniques are set apart for them, and they have a copious literature of their own. This is chiefly for the following reasons :

(1) Very raany of the diseases we are dealing with occur in children with far greater frequency and in a much more striking form than in later years (the acute exanthemata, whooping cough, diflereot forms of dyspepsia, tubercular meningitis, &c.) ;

(2) The medical examination of a sick chikl demands a special dexterity which — however much skill one may have in examining adults — can only he acquired by diligent practice amongst children.

Then wo must remember that the young physician especially, whose work almost always lies to begin with ^moug the large families of the lower classes, has at the very commencement of his practice a majority of childi'cn among his patients. This fact, which was not formerly appreciated as it deserved, is now being more and more realised; at least I think I am justified in gathering this from the ever-growing numbers of my clinical class in which there are many young practitioners. It soems all the more striking that our school alone regards the study of Children's Diseases as not being an essential branch of science^ and, sheltering behind long obsolete statutes, grudges a special chair to Piediutrics.

I must, however, at once admit that even the most earnest study of children's diseases and the richest experience will not

1

INTRODUCTION AND METHODS OF EXAMINATION.

always save you from Tery painftil diBappoiiitments in the resnlts of your treatment- Unfortunately tbe conditions of life in early childhood are such that even the most rational treatment of children's diseaBes along with the greatest devotion on the part of the physician is in vain in a terribly larfjo number of cases. The attention of the scientiiic world and the public concern have at all times been turned to the enormous mortality of this period of life, but have not yet been able to cope successfully with this fearful state of things. It has been proved beyond a doubt by statistics that the mortaUty of children is highest in the first months of life, that during the whole of the first year it is twice as larji^e as that of any later year, and that it begins gradually to diminish after the second, and only reaches the usual rate after the fifth year. Of every 1,000 children bom, about 200 die in the first year of life; while the general mor-, tality of the population is about 25 per 1,000.

I can best clLmonstrato this to you by stntitig the following figures : — During the years 1874 — 85» 13,980 children were treated in my department in the Cbaritd, of whom 7t815 were under* nnd 6,lGb over two years of age; there died of the former 5,3r>8 or ftliout 70 per cent,, of the latter only 1,420 or alx)ut 23 per cent. The first half year of life is quite remarkable in this respect, for out of 4,yO:j infants under six months, ^,4(J9 died, that is about 78 per cent* These fearful results agree with those drawn from much wider Btatistics-, but with regard to all of them we must certainly take into account ae unfavourahle factors, the rcaidence ill the hospital and the wretched condition of the majority of the very young children on admission.

This enormous moi-tality of the first two years of life and especially of the first six months is accounted for by two sets of causes, one of which is to be sought for in the natural develop- ment of the child, and the other in its surroundings. As you ai'e aware, the development of the child's body by no means imes to an end at birth ; but on the contrarj^ quite apart from growth, the organism subsequently undergoes most important changes. I need only remind you of the closure of certain fielal blood channels^ the dif)*erentiation of the grey and white matter in the Lmin, the development of the intestinal glandular 8yBtem» the eruption of the teeth and the growth of the bones — processes which of themselves have a tendency to evoke pathological changes in the organs affected. While children of the privi-

ISTU0I>UCT10N AND METHODS OF EXAMINATION.

3

]cg(^i\ € lasses, thoHf^btfully cared for and appropriately fed by affectionate parents, pass thrauf^h thefic tlireaiening evolution- processes more easily, we find that under the unfavourable out- ward conditions of life which exist among the poor, many licious influoneoa tell against the normal development and jt it along pathological lines. The foul air of small over- crowded rooms, the more or less unsuitable ways of feeding which are so injurious to a child's stomach, the influence of cold and hunger, the want of a mother's care (for which that of an unprincipled stranger has only too often been substitnted), are all factors which work "together to hinder the normal pro- cesses of development, and furnish us with those miserable pictures of disease confronting us in the consulting-rooms of parish doctors, in polyclinics, and in the children's departments of hospitals* Many of these unhappy creatures carry with them from the very beginning the germ of death derived from a diseased mother, and fall victims to congenital debility within the first few days afler birth. Many others perish from in- herited syphilis* most become atrophic, being reduced by coDstant diarrhfea; or their numbers are decimated by re- peated attacks of bronchitis, with secondai*y enlargement of the bronchitil glands, ending in caseation and general tuberculosis. Many of theso children are illegitimate, and not a few of the mothers, as I can assure you from my own large experience, send to the hospital the child which has become a burden to them, not because they wish it to be restored to health, but only in the hope — which is too often justified— that they may be freed from it for ever. A large number of children of this class taken into my ward died on the very day of admission. Against such wretched social conditions our efforts as medical men are often powerless, and indeed after we have had some experience of them we are apt from the very first to despair of doing amlhing. The unsolved and almost insoluble problem in connection with this matter— the real causal indication — is how to remove the unfavourable conditions I have alluded to, for against them medicine in itself has no power whatever,*

Wbat ft blosMng Foundling lastitations with ontside nnrBing, carried out on a large scale, Are in mcb cipciiraat»noc«, may be learned wiow from the cioellent report of Epttein on the roRiiltB of the Bohemuin Foondlitig Imttitxition dnrtng 1880 S4 tArrhwf. h'imhrheili,, vii,. Heft 2).

INTBODUCTION AUD METHODS OF EXAMINATION.

We have next to consider the methods of clinical cxami- nation, wbieb, during the first years of life at least, differ essentially from those employed in the case of adults. The cxaraination of children is rendered more difficult by the fact that they cannot talk, or at least are unable to give sufficient infor- mation to the doctor. In private practice we are helped in this respect by having the mother's account, but in hospital we have usually to content ourselves with a purely objective examination, as in the case of a sick animal, without any help from the relatives or clinical history. The difficulty ia further increased by the timidity of the children and tlioir dislike to the pljysician as a stranger. While in examining adults it is best to explore in order one system of organs after another, regardless of the interruptions of the patient, and to finish up with the history of the case, you will frequently have to abandon this method in childhood. For the refractoriness of the little patients obliges yon to seize every favourable moment for the inspection or auscultation of parts which can only be properly examined during a quiet interval, r.r;., the fauces or the heart. In this way the. examination of patients is apt to lose its continuity and become unmethodical ; and this may render the final summing-up of the results obtained more difficult, especially to the inexperienced. On the other hand the anamnesis is naturally much shorter and simpler in children, and this tends to facilitate the gatheringup of the features of the case for a diagnosis. No fixed rules can be laid down for our bearing towards the children. Many physicians, it is true, have more sympathy with children than others, but even those who show most fondness for them w ill be liable often enough to be very considerably put out by their crying and noisiness while they are being examined. This resistance ia to be overcome either by kindness or by firmness, according to the character ol the child and the kind of temper it is in at the time. Tu know how this is to be done will, at the commencement of practice, be Tcry perplexing and difficult, but as our experience grows, the difficulty will bo less felt till at last it becomes sciircely appreci- able. Many children will allow themselves to be kept tolerably quiet while you are examining them if their attention is aroused by holding before them a watch or toy or lighted cundh?, or by giving them a stethoBuope to play with. For especially important ca863 we have in chloroform u means by which we ari; able to

INTRODUCTION AND METHODS OP EXAMINATION.

overcome all resistance ftud to obtain perfect quiet ; it is parti- ciiliirly useful in cases where we httve to examine the abdomen, bladder, or rectum, and in painful joint aifections.

In examining cLildren in the first years of life it is best to hate them in their mother's or nurse's arms io front of the physician, but with thtnr fjtces turned to a window. When it is at all possible I have the children taken out of bed and put in this position even although they are feverish, because one is aided considerably by the co-operation of the nurse, who supports the child and keeps^ it still, as well as by havin^f better light. Often however the child struggles against the hands trying to hold it, moves itself about, and turns and twists so as to make both per- cussion and anscnltatiou extremely dilBcalt. On this account an attempt has been made to follow the child's movements by using a stethoscope, the tube of which is made of india-rubber, and this may certainly be done more easily with this than with a solid instrument. After trying these stethoscopes, however, on many occasions, I have quite given them up because they so often give rise to confusing adventitious souudt^ ; and I there- fore recommend you to use an ordinary stethogcope.

While auscultating, you must always hold the lower end of the stethoscope between your Hiigers, both in order to be sure that it is thoroughly in contact with the chest wall and to avoid exerting too strong pressure with your head, which would at once make the child cry. It U a good plan lo have a circle of india- rubber on the lower end of the stethoscope to modify the pressure ; but it must be often renewed, for it gives rise to creaking sounds when it gets old and worn. Very restless children muat bo auscultated directly by the ear, and in this way the person examining can easily follow even the most extensive movements of the patient if he has a linn grasp of the chest and keeps his head always in contact with it. Many physicians think that their duty is done when they have examined the back, but let me strongly impress upon you never to neglect the front and sides of the chest. In a good many cases I have found the signs of pneumonia under the clavicle when everything behind was normal ; and I have often discovered fine crepitations in the tongue-shaped process of the left lung where it overlaps the pericardium, when they could not bo made out at all, or at least not nearly so distinctly, over other parts of the thorax. The

lyTRODUCTION .^'D METHODS OF EXAMINATION.

front of the clieflt may be examined witli tbe patient citlier sitting or Ijing (the latter especially in the case of very yonng cliildreii) ; but the back ouly while he sits or lies on bis side, never when he is lying on bis face. Tbe cuinpresBion of the abtlomcn caused in this latter position must push up the abdominal organs and diaphragm and so diminish the capacity of the chest ; and, \vb**n the respiratory organs are already affected by disease, not ouly will the dyspncea be increased by this, but sudden death may be cauHed during the examination.

Percussion is far more irksome to many children than auscultation, and the crying which it causes interferes v^ry much with our obtaining definite results. Moreover, every obliquity of posture and every muscular contraction occasions a slight change in the note ; and you will understand from this how careful wo have to bo in estimating jlifferonces in the percussion note when the children are restless. I have very often thought that I made out a difference between the notes on the two sides of thr chest the first time I examined a patient, and have afterwards con- vinced myself of my mistake by repeating my percussion with the thorax at rest and the child nitting straight. In doubtful cases we have in auscultation the best means of controlling our jresulta. You must, moreover, never neglect to percuss both during iuKpiration and expiration, especially in crying children, because in them the parts [icrcasaed are more or less empty of air while the cry lasts, and give a proportionately dull and empty fioand which disappears during iiiHpiration This (as Yogel truly observes) is very specially the case at the extreme base posteriorly, where the liver, forced upwards by crying and strain- ing, may give rise to impairment of the note and consequent fallacy. During such examiuation our patience is ofton sorely tried, and it ma}' be very difficult to avail ourselves quickly, for the purposes of piTcussion, of the inspirations vhicli at hmg intervals inti-rrupt the crying. Besides this* little children have a habit of holding their breath as long as possible, especial] j when they are being auscultated. It is with impatience or even annoyance that we wait for them to draw a breath ; the sign however is a favourable one, because serious affections of iho respiratory organs do not generally allow the patient to hold his breath for any length of time. Crying interferes much lows with auscultation than with percussion ; in fact, I tiud that any abnor*

^r ^ iSTRODlXTION AND METH01>S OF EXAMINATION, 7

mal sounds that are to be found in the lungs are much moi-o Cftsilj heard daring the deep iospirations which occur in the intervals of crying than during quiet breathing. On this account I never put myself much about to quiet a crying child before auscultation, and only require absolute silence from those round about.

As regards percussion I should advise you to let your stroke on the ploximeter be as light as possible. The conditions of the child's thorax aa regards resonance are so favourable, owing chiefly to the elasticity of its walls, that strong percussion may, by setting up simultaneous vibrations in more distant parts, elicit a loud full sound even over parts which no longer coutain air, and which accordingly give only a dull and empty sound with a light stroke. For percussing children I use a small ivory pleximctcr with an ordinary plessor ; and it is not necessary to use a finger of the left hand instead of the pleximeter except in eases of great emaciation (where the intercostal spaces are sunk in) and in percussing the supraclavicular region.^

To judge of tho frequency of the respiration you must examine the child in as quiet a state as possible, best of all daring sleep, if this can be managed. All excitement, crying iVc, tends to render the results unsatisfactory. By laying your one hand very gently on the child's thorax or abdomen while you hold your watch in the other* you may time the rising and falling of the respiration. In woak conditions, even in children who arc not crying, this part of the examination is often inter- fered with by the holdiug of the breath already alluded to, in which pauses of respiration alternate with short breaths rapidly suc- ceeding one another. For this reason it ia very difficult to state the normal number of respirations at a given age, and this accounts for the very diverse statements of different authors. We know that as a general rule it amounts in new-born babies to 32—86 in the minute, that later it sinks to about 30, but that

' Any work la to be gratof ally woloomeKl which g-ive* aa independent and exact obteTTAtions on the poculi&ritiQe of physical diognoHie in ebtldren ; ftnd in thisoon* neolion Sahli's \}ook {Oie toj^yf/m/thischf Prrcfu^sion it» KindtttaUtr: Bom, 1883) deoorreif especial mention. lt« pro^tioAl retultH, howeror, seem to mo scaroelj proportionate to the worlc expended npon it, enpeciaUy in the m&tter of the IMreaadon of the thorax. And indeed I am of opinion that the oontrol of the rarolts of peronuion by an a enl tat ion ta worth far more for the diagnosla than all Bet mlem, which are only too often liable to exoeptiotiB due to chance cironm-

IVids book ( OOOP]

8

INTRODUCTION AND MKTH0D8 OF EXAMINATION.

even in children of 7 or 8 it reinaiDa higher Ihun in ndiilts ; and indeed, like the frequency uf the pulse, it is in inverse ratio to the age of the child.

The action of the child's heart is, to begin with, more rapid ; it is excitable in a high degree by every psychical impression, and dread of the physicittu who is more or less a stranger to him is especially apt to increase tbo pulse-rate — often tn such a degree that to count it is absolutely worthless for diagnosis. The best example of this influence is given ua by children who sufier from jaundice. The slowing of the pulse which is so characteristic of this disease in adults, I have never observed in childhood till about the , seventh year j and I can only account for the fact by supposing that the above-mentioned excitability of the nervous system of the heart fully compeusates for the retarding influence of the bile-acids, Accordiogly, a correct counting of the pulse, especially in very young children, can only he undertaken during sleep. This is easily done if one keeps perfectly still {and lays the point of one's finger softly on the radial arteiy. We must at the same time remember that the pulse is occasionally somewhat irregular during sleep even in perfectly healthy children and that this need not be in any w^ay alarming. Of just as little real importance is the irregidurity or even retardation of the pulse ^>hich is observed (sometimes for weeks) during convalescence from highly febrile diseases (pneumonia, typhoid, measles &c.), unless the cause of it is clearly apparent. One can never get reliable results by counting the pulse in states of debility (iiTespective of exceptional cases and in older children), and hence it arises that the figures given by various authors differ so materially from one another.

On an average, I think we must regard a pulse-rate of 120— ,i40 as normal for the first months of life, and of 100—120 for le second year, after which a gradual decrease takes place. In children of 3 — 6 years of age the pulse still keeps above 90, and it is only after the second dentition that it gradually begins to approach the adult rate. Now, the frequency of the respiration alters in a con-esponding way ; and ho we have always to keep in mind its relation to that of the pulse as 1 : Sj or 4. I repeat, however, that, especially in childhood, Boch calculatianB from averages aro of little or no practical utility, for the rcai«ona, already given. It is only in certain definite circumslances thai

INTRODUCTION AND METHODS OF EXi3£INATI0N.

I

the pill 86 -ra to acquires any diagnostic or prognostic value— for instoDce, the retardation at the heginniDg of tubercular meningitis and the extreme acceleration towards its close, or again the enormous rapidity in scarlet fever. The rhythm and quality of the pulse have always appeared to me to have much greater significance for the physician. The inequality and irregularity of the beats in the first stage of tubercular meningitis and the diminution and gradual disappearance of the pulse-wave in severe diseases, e8]>ecially those of an infectious nature, are points of very great importance to which I shall frequently revert in these lectures.^ Thesamemay bo said of the relation of the pulse to the respirations which normally is 3J or 4:1. If this relation is disturbed for any length of time — ^if for example ^0 — ()0 respirations occur to 120 — 140 beats — you may almost certainly expect to fnid some affection of the respiratory organs. Even to this rule however the physician must be prepared to find exceptions; rickety children with moro or less deformed chests always breathe more quickly than healthy ones, Nervous excitement also may have this effect ; in little children during the first dentition I have occasionally observed a rate of breathing of 60^90 in the minute, which lasted many months with other- wise uninterrupted good healtli, and gradually as teething came to an end tin's w^as replaced by the normal rate : one could only regard such cases as due to a reHex irritation of the respiratory centre. Phenomena of this kind also appear transiently in the course of whooping cough and tuberculosis of the bronchial glands. If the breathing appear not only quicker and shallower but at the same time more laboured, certain of the accessory muscles coming into play and expiration becoming noisy, it is still more significant. Where these conditions exist, physical examination will almost always reveal the presence of bronchitis, pneumonia, ideuris^-, or some other respiratory disease.

The examination of the heart in the early years of life is attended with almost greater difliculties than that of the luugs. The rapid succession of its beats, and the constant crying which goes on during its examination, often make it impossible to speak positively as to the purity of the sounds and the results of

* Hpciciai iufitrumeats for mcMUBunBi? Iho tennion of the pulse in children («^. tbo Spliy^ionumonieter reoommended by von Basch — Archiif/. A'twi/wAe*/*., r., 8. 272 1 cftn hardly to of much use in ordinATy practice.

la

IKTRODUCTIOK AKD METHODS OF EX.4M1XATI0N.

percusBion. We must also avoid pressing with the ear on the stethoscope so firmly as to indent the costal cartilajje, for this may at once render the heart-sounds impure or even blowing. I may also mention that we can hear cardiac murmurs which arc due to valvular k'sions more distinrtly over the lower part of the back in children Ihiin in adults, even although the lower lobes of the lungs are normal.

The laryngOBCopic examination is, however, after all the most trjuDg. In very young children it is nlmost out of the ques- tion, and even from older ones, we usually, if not always, meet with nn amount of resistance very hard to overcome. We may facili- tate the introduction of the mirror by painting the pharj'nx nnd entrance to the larynx with a solution of cocaine (5—10 per cent.) t^ render them non-sensitive ; but even when one does succeed in introducing it properly, and getting it fixed in the right position » its surface soon becomes so obscured by the secretion which is forced up from the throat by crying, coughing, and retching, that it is imposKible to get a distinct image. Although I do not deny that under favourable circumstances many children may be satis- factorily examined by this method, yet I maintain that in a far greater number of cases it yields either no results or else very un- reliable ones. The conclusions which the older authors pretended to draw from the chiiracter of the cry arc even loss to be dependod upon. Its hoarseness or its being replaced by a distressed whimper are the only two conditions to which I can attribute any practical importance, New-borji children, as you know, shed no tears wben they cry ; tbo secretion of the lacbrymal glands must therefore be still deficient at tbis age like that of the salivary glands of which we shall have to speak later on.

After a little practice the examination of the mouth and throat rarely present any difficulties, and I therefore often wonder at the clumsiness with which many physicians perform it. If the cbild does not open his mouth of his own accord when told to do ho, the best thing to do is to push the under lip over the margin of the lower jaw with the forefinger and to press on it Thia also prevcnta the danger of the physieian's being bitten, for every attempt at doing so will bo very painful to the child when his lip is between the finger and his teetb. A little peraeverance will usually soon overcome any difficulty occasioned by the child^s obstinately keeping hia mouth closed, especially if

n

ISTKODUCTIOX A\D METHODS OF EX.\M1KATI0N.

11

you force him to broatlie through the mouth bj compressiug hiB nostrils. As soon as you get your finger over the lower row of teeth, the child usuaUy opens his mouth sufficiently for the mouth and throat to be satisfactorily inspected. In Btubborn cases you can easily accomplish j'our end by using u tonsfue spatula* The main point is to obtain a good illumination of the fauces either by bright daylight, or, where this cannot be had, by a small caudle with its flame fixed in front of a silver spoon held in the same hand. With this simple contrivance, which acts as a reflector and can be got quickly anywhere, one gets a capital light, and I very ofteit make use of it. Nevertheless, you will fi'om time to time come across children who resist all om' efforts to open their mouths with invincible obstinacy, so that at last you have either to give it up, or to attempt to attain 3'oar end by forcing the jaws apart.

In ordur to make the results of your examination available for diagnosis, you must have some knowledge of the points in which certain conditions in childhood, even in a state of health, differ from the same in adults; for otherwise you will be very liubk> to find yourself speaking of normal conditions as pathological.

In the first place I would draw your attention to the differences in character which the normal breath -sound:s present at different ages. During the first weeks and months after birth the breath-sounds are still rather weak, because the short superficial respiration is not eiifticient to drive the air strongly in through the bronchi ; and, for the same reason, percussion at this age gives a less full note ovor the whole chest. About the middle of the first year, how- ever, the breath-sounds begin to acquire those peculiarities which we find under certain cu'cumstances in adults, and call puerile breathing. The breath-sounds have a strikingly sharp, almost blow^ing character : the inspiration is almost tbe only sound heard, the expiration in a state of perfect rest being scarcely if at all audible, though excitement renders it more distinct** The sharp puerile breathing is further exaggerated in cases where the thorax is narrowed bv rachitic deformitv, and it is therefore conceivable

' I niuat here further tneution that in quito heaJlhy uliildren tho jfntitiiiar rhythin whioh i» chamctfristie of respiratory difeeo^e in childhood— ^immcly, » i»rolou^t*d ** punting" oxpiration predominating oyer a quite short inKpirutiou which follow* It like an echo— may occur transiently from fear bJouc.

18

IKTBODUCnoX AKD KETHOM 0¥ KXAXBC^TIOX.

that in hefilihy children also the relatire narrovnem of the thoracie cari^ may give rise to the rotigfa bknrtng character bj slight com- presaion of the Inng when it expands in insptiatum.'

The morbid sounds onginaling in the lungs or pleune u« not, on the whole, diffident from those in adnlts. Onlj one finds mediam, and especially fine erepitationa £ar oflener, fre- quently with this peculiarity that they aie wesj numerous on expiration, while inspiradon is almost enttrdy free from them* The type of respiration in yonng children np to the third year ia mainly abdominal. The diaphragm and abdominal muscles work with remarkable energy, und thus therS often occurs, even in health, a slight indrawing of the epigastrium and lower nbs, which suggests a pathological condition such as we find developed to a far more marked degree in serious respiratorr afiections. In cases of debility one ueed not be alarmed by irregularity of the breathing or even by short pauses; both occur not unfrequeutly in little children. The relative uniTowness of the thorax is in marked contrast to the large size of tlie belly which is so often regarded as a sign of diseaBe by anxious mothers, but in reality is caused only by the comparatively small chest, and by a tendency to the fonuation of gas in the intestinal canal.

Amongst the results which the examination of the head \i<'1(]m, jin auscultatory phenomenon d<?sorves the first mention. In children in whom the greater fontanelle is still open (that is to say» roughly speaking, during the first two years of life) when thoy are at rest, od applying the ear or stethoscope over the large foiittuiello we often hear a more or less luud blowing murmur, synchrouous with the systole of the heart. Since the rottpiratory murmur due to the vibration of the air-stream rushing through the pharynx can also be perceived over the fontanelle as well M eyery sound produced by sobbing, chewing

* Tlio nuplAiu^tum in vim byBftbatier (Etude sur rau^i:ultatmH du poirmfm rh<t If/t 9Hf*tntB; PuiHIm, ItUHi} {m [nigouKmn, but by no means indubitnblc. Apcordinff to Uii» UboriotiM mon*urumimit4 of this author, the capacity of tlu* brotichial brunchcB in aihiU nji«n auil nitirimlA iucroaftcta on the whole from the rontro towards the liJTliiihiiry In chlbljisn, on the other hand, it diminiAhep, *.e. intbctn the lumen of tlio two bruurliri'M winrh Hprinjr from a bronchuH lAken together, id amaller than thnt ■ ' '' Ufoijehud, whilo in udnltn th«* corivir- ' ' Owing to

tilt* ' vt'lof'iiy of tUo uln^atii of air in th** uiniiihcs to.

^ ■ '-<ri?t#. wMlfl ir ■'■■'''-- ^' -- ■- ■ .'' ]

*^'"*i ■ ••■ — , urtilaiiP^w hi .,,,..,,.,. i,. i "W..1. v. *i. I. K ■•[«...- ij^n-*,

iscrniiuliiK tlu« ribrntion uf Ibw air>L*ulninfi an it ra»|i«-« \mni.

4

1

INTEODUOTrON AND METHODS OF EXAMINATION,

^

and swallowing — one must keep one's hand on the pulse while anscultaiing, to avoid errors, especially in children who are breathing very quickly. With some practice one is soon able, even without these precautionSj to bear the systolic mnrmar easily along with the breath -sounds and to distinguish them from one another. In a very small number of cases I have heard the murmur over a closed fontanelle and at other points on the cranium. Others have perceived it also at the posterior and latetiil fontanelles and in the line of the middle meningeal artery (when the fontanelles and sutures were closed), and even over the spinous processes of the cervical vertebra?. The first discoverers of this murmur, the .^jncricans Pisber (1B33) and Whitney (18J3), regarded it as always indicating disease, especially certain brain-diseases; Hennig and Wirthgen on the other band directed attention to the fact of its physio- logical occurrence between the 22nd or 23rd week of life and the time of closure of the fontanelle by ossiiication. As the result of my own numerous investigations/ I agree with these authors in thinking that the murmur is found pretty often even in healthy children when the fontanelle is still open; but especially in ansemic and rachitic subjects,* perhaps because in them the fontanelles and sutures remain open much longer than usuaL The ultimate causes of this murmur are as yet undetermined. Jurascz holds that it arises in the carotid artery, owing to a relative narrowing of the vessel in the carotid groove, while Epstein, on the contrary, is inclined to compare it with a murmur occurring in the same artery in the neck. At any rate, I hold that the so-called '* brain-murmur '* is of no interest from a clinical point of view, and cannot be turned to account for diagnosis.

Of far more importance to us is the condition of the fonta- nelles and sutures of the skull In the normal new-born child the sutures are closed by a thick intermediate substance which sometimes projects like a border, while all the fontanelles are still membranous, so that one can feel with the fiuger the pulsation of the brain through the anterior one. This is

' Beiirugezur Kimderhtilk t Borlin. 18*51, S. 170.

' B o g 0 r also, who haa examined hundrodd of children for this murmur, mainiAlna riew. [Bechvrchts cUnitfUtt tur /«* maladies rfe Penfance, T. 13. : Pi*rb, 1883, L ) ty. also Bob d 0, **" Dio groniio Fontanolle in phyaiolo^isohur and pathologw

INTRODUCTIOK AND METHODS OF EXAHn^ATION.

eflpeciiilly distinct when it expands more than uaual^ so Uiftt membrane projects above the level of the snrronnding bones. This rlistendt'd, olastic and pulsating condition of the anterior fontauelle ib therefore Yataabte in practice as a sign of increased intracranial presaure. On the other hand, the depression of tho fontanelle below the level of the anrronnding Rurfiurc' indicates an ansBmic and collapsed state of the brain snch as oflen occurs in atrophic children and towards the end in exhausting diseases (diarrhcea, cholera)* Under these circumstances we also not at all uncommonly find a displacement of the margin of tho frontal under that of the parietal bone, only, of course, wliile the coronary suture is still membranous, so as to pornjit of such a displacement. While the two lateral and the posterior fontanelles are closed by ossification in the first months after birth, the large anterior fontanello remains open. That it goes on growing in size during the first six months, as was formerly supposed, is disputed by Kassowitz, who maintains, on the contrary, that he has observed a continuous diminution from birth, Tho complete closure ought to take i>lace about the 15th— 24th month. Still, cases are not very rare in which, well into the third year of life, we may find a membranous spot in the region of tbo fontanello that can be covered by the tip of the finger ; and one must not set this down ofT-hand as a morbid ftppesrance. AU other variations, however, — especially a greater and more protracted patency of the greater or lesser fontanelles, a gaping of tbo sutures, or an unusual yielding to pressnre of the margins of tho bones, — must be reckoned as pathological, and will be taken up later with tho consideration of rickets. Tho aame applies to some anomalous forma of tho head which are related to certain diseases (rickets, hydrocephalus), while individual differences in tho form of tho cranium, caused, not by disease, but by abnormal growlh of bone (asymmetry, obh'quity of the median line, dolichocephaly, Jcc.), can only lay claim to clinical interest when at the same time there are symptoms of a cerebral affection (liomiplegia, contractures, backwardness of intelligence). The difference between the adult cranium and that of the child is important, and must always bo borne in mind. During the first two years of life the circum- ference of the vault of the skull exceeds that of the face qnito disproportionately, so that the relation is stated as abont 6 : 1 <tn

4

inthodcctiok and methods of bxamikation.

15

new-born childron oven 8 : 1)> while in adults it is 2^ : 1. We bavG to remember this in order to quiet the anxiety of many mothers who think that their children iiro bydroeephalic ; especially in cases where the above-mentioned disproportion is aggravated by I'aohitic thickening of the cranial hones. Under these circum- stances many children are unusually late of learning to hnld ihoijr head up without support, which in a state of perfect health they can often do by the third month. In this particular, how- ever, there are many exceptions, due chiefly to the greater or less strength of the muscles, especially those of the neck. We must not therefore at once assnme a congenital disease of the brain merely because a child cannot hold its head erect without support when it is five or six months old, unless there happen to be other symptoms present justifying such an assumption— especially want of intellectual development, a staring look, nys- tagmus of the eyeballs, awkward catching movements with the hands, or complete apathy.

In examining the cavity of the mouth in new-born children you will be struck with the dark red colour of the mucous membrauG. This lasts some weeks and then slowly disappears ; it is to be regarded aa a normal appearance. A certain amount of dryness is associated with this hypera?mia because the secretion of the saliva does not take place at the same rate as in older children and adults. liecent researches (Ritter, Schiffcr and Zweifel) pretty unanimously prove that although the saliva is present from birth its quantity is so email that its sugar-forming powur is to be taken into account little or not at all. The salivary secretion first begins to increase perceptibly towards the end of the second month; according to Zweifel secretion usually first begins about this time in the sub- maxillary gland and pancreas, although at birth the parotid contains ptyalin. This deficient secretion of saliva is also the reason why the buccal mucous membrane of infants in the first

mths, if it is not very carefully washed, almost always gives a lewhat acid reaction with litmus-paper, and, even after washing out, is neutral and but rarely alkaline. We shall see later how important these conditions may be in connection with the metbodfl of feeding children.

In very many new-born infants one sees in the median line of the hard palate little yellowish white round or oval nodules

INTRODUCTION AND METHODS OF EXAMIKATIOK*

from the size of a pinbead to that of a millet-seed projecting only a little from the mucous membrane ; tliey are either single or in a row and are sometimes surrouudod by a narrow red border* These nodules are very common in the first four to six weeks of life and have not the slightest patholojrical signiBcance. Bohn regarded them as occluded mucous follicles analofrnus to milium on the outer skin, Guy on and Thierry as epidermoid cysts, and Moldenhauer^ as solid processes of cpitheliam growing into the mucous membrane and glandular tubes in process of development. Epstein,* however, seems recently to have hit upon the right explanation* The investigations of this writer prove that these are spaces filled with epithet iom which have been left after the union of the two halves of the palate.

With regard to the tongue yon will notice that in infants on the breast it is very often spread over with a thin whitieli coating especially after sucking (milk-colouration), Also^ that in many older children it presents a peculiar "mapped" Appearance ; that is to say, the dorsum of the tongue exhibits various greyish- white figures, usually with somewhat raised borders, which are sometimes sinuous, sometimes indented, — and which contrast markedly with the red colour of the normal areas. This state of the tongue (the anatomical cause of which is not yet clear) is due to a superficial irritation of the mucous membrane wdth copious desquamation of epithelium in places. It occurs very often in perfectly healthy chiKlren and has there- fore not the least diagnostic value, and particularly nothing to do ^-ith congenital syphilis.'

The examination of the heart need not detain us long, as the results of it in children agree almost entirely with those in adults. For practii^nl purposes it is Baflicient t^ know that in emaciated children (in the second period of childhood more than in the first two years) the movements of the normal heart are often visible as a pulsation in the fourth and tilth intercostal spaces and that the ribs are more strongly bulged forwards by them than at a later age. One may also very often feel the

Bd. til , Heft 2.

( in drr Mm»dk*ikt» ifc «. it., iS^iuchr. far H^lWndw^ B«|. T. j

• Arthivf. <

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• Ottiaon, "Do I* tUaqiiail»*«m ^jutWlW* Ac * irri>ii« mtnu, <M§ mah^itt dt

INTRODUCTION AND METHODS OF EXAMINATION,

17

apex-beat somewhat outside the nipple-line without there being liny enlargement of the heart. Flattening of the sides of the chest doe to rickets favours these appearances, which seem to depend on the higher level of the diaphragm and the consequently more horizontal position of the heart.

EI have in the next place to treat briefly of the examination of the temperature, urine, andfajces. Onthe value of thermometry in childhood I need not waste words ; its usefulness cannot be over-estimated at an age when cverj^hing depends far more on objective examination than is the case in later life. Unfor- tunately, however, it is only in hospital and private practice that it can be thorougldy turned to account, far at the polyclinic and in the consultation houi*s of paiish doctors it is scarcely possible to take temperatures in a trustworthy manner, owing to the largo ^^number of patients and the want of efficient help. Under these ^Bciicumstancea we must content ourselveSi except in specially ^^ important cases, with estimating the temperature by applying the hand ; and, during the further course of the disease, trust to the accounts of the mothers who generally state correctly the times of exacerbations at least. I usually prefer to take the temperature in the axilla, Although in this position the process takes at least 10—15 minutes (therefore twice as long as in the rectum), still, one must remember that even with every precau- ion it is possible that the thermometer may bo broken in the ectum by a sudden movement — as I hove myself seen happen* you disregard this possibility you certainly save much time by taking the temperature in the rectum ; and on this account I ave often myself done so in private practice, where each dividual child can be thoroughly watched. The variations in mperature in children and adults are the same, except that uring the first three to four months of life it has a marked cndoncy to fall below normal. The heat-production seems at this age to be carried on with less energy, for in very many ases of faulty nutrition, exhausting cachexia or insufiieient nng-activity, we observe the temperature gradually falling nusuoUy low — to SG"^ F. and even lower. Wo have another stance of this peculiarity in the fact that, at the age referred , otherwise highly febrile diseases (e,g* pneumonia) may run eir course with a normal or even subnormal temperature ; of a I have had plenty of proofs in the infants* ward of my

2

AXB

of UiB hospitiaL We need nat, lioweTer, on Uiis make s i^jedal disease under tbe Dune of **Alg!or ims ** as fierTienx has done, siiifie tiiu enormous hll of lempersture may occur under the most direrse oondiiioiia pOMible, tlieae hA\-mg nothing in common ^irilk one another ejuoe^ the final ending is ooUajwe.

Tho examination of the nrine is very difficalt in new- born children and other infants^ hecanse it is always passed intu the diapers and it is vexy difficult to estimate with certainty its amoant and colour from the examination of theae. OceaaionaUy thete occur cases, even at this age, in which it is neoesaaiy to examine the arine for albumen or eTen for sugar; and for this purpose one must either collect it in special apparatus — in little girls in thoroughly cleansed sponges applied over the genitals, in boys in an indiarubber bladder or some such con- trivance fastened round the penis — or endeavour to obtain it by the introduction of a catheter into the bladder, a method which we prefer in hospital practice^* In practice one contents oneself us a rule with judging of the urine of new-bom chUdren from the diapers* The wetting of these gives ns a measure of the nourishment taken, and from a diminished amount of tho secretion we assume (and are usually correct in bo doing) that the child is either taking too little iiouriKhment or is failing to aHMimilate what he has taken. It is only very recently that the urine of newly born infants has been made tbe subject of careful oxamination by Parrot and Hob in % Dohrn^ Martin and Rnge% Cru8e^ Cam6rer^ and others. The results obtained by theae writers do not however altogether agree. It is especially interoatlDg to phyHicians that Martin and Ruge sometimes found a omall amount of albumen in the urine daring the first ten dayw after birtb. In some this was transient, but ia others it k»te(l for several days ; and they are inclined^to connect this condition with the expulsion of the uric-acid infarcts which occur in tlio renal canallculi, and of which we shall speak later

I similaj- results, but Parrot

'HenreJ

yu

1* Cam/ 'l<i. 1.

jnh. •, 1877,11, a aea.

4

4

INTRODUCTION AND METJIQDS OF EXAMINATION.

19

and Robin state that tbey baA'e never, and Dobrn that be has only rarely, found albmninEria in healthy new-born children. In children more than ten days old, Cr u so* never found albumen, although there was a greater amount of mucus than usual in the urine which might be misleading. -

The fieces in infants can also only be examined on the diapers, mixed with the urine. In normal conditions they are almost without odour, so long at least as beef- tea and meat are entirely excluded from the diet. They have a feebly acid reaction, are pretty much the colour and consistence of beateo-up eggs, and are passed imco to four times in the day. Exceptions to this rule, especially a seldoraer or somewhat more frequent evacuation, are not to be regarded as abnormal, unless the consistence of the motions becomes more liquid or their smell acid or offensive. In many children the colour of the fti^ces is not like the yellow of an egg even in the normal state, but inclines rather to a brownish shade. If the cloths are left lying for some time, the yellow colour very often becomes greenish* owing to the oxygen in the air changing the brown bile-pigment into biliverdin, and therefore, in order to form a correct opinion, one most always examine the faeces as fresh as possible. Round about the fsBcea on the diaper we usuaUy see a colourless wet area caused by the urine* I should, however, point out to you here that there are cases of diarrhoea in which fitces of a tolerably normal appear- ance are first passed, and are followed by a more or less large quantity of a watei^ fluid from the rectum. The wetting of the eloths which occurs in such cases may occasion error if one thinks that it is caused by the mine and that the fseccs are normal. I should not have mentioned thia, had I not frequently met with cases in which there was progressing failure of strength along with the above-mentioned appearance of the cloths, the fseceB in the middle being pretty well digested but having round about them a pale, apparently urinous, area. From my own observation I have conyinced myself that in every one of these cases, after the

* Jahrh.f. Kindcrlmnlheitmy 1878, riii., B. 71.

* Hofinoier (TtrcA. -dfcA., Bd. 89, H- 3) refers the inoreiuae in the quaniity of the Ttrine m welt as of the area aod uric acid, to the loss of weight during the inrt daye of life lund the decompoBition of albumen which i^eg on sinmltaneonaly. He also connects the albmninnria of the first day of life with the nric-acid infarcts, while Kibbert iihid.^ Bd. 98, H. 3) sees in the albamlnone etate of the first tuind only a continuation of the tranradation through the glomeruli (aa yet imperfeotlj develope*!) wblcli ocoars in all embryo kidney!*.

20

INTROPUCTION AKD MBTH0D8 OF fiXAMlKATIOK.

cvacaation of more solid £a?cal matter, a larger qaaDtitj of thin turbid fluid was expelled with force from the anus^ — that in fact a condition of diarrhcea was present and accounted for the loss of strength.*

Finall}', I come to the manifestations of pain in little children, which consist almost solely of cries. It is very difii- cnlt — and that not only for the beginner — to distinguish the cry of pain from that which expresses hnn<ijer or some other undis- coverahle source of nneasiness. I consider it qnite unnecessary to detain you at this point — as many authors do — with a descrip- tion of the varions modifications of cries. Such descriptions are of no practical use. Any one can distinguish whether a child is crying lustily or only whimpering feebly, and from this we may jadge of its strength ; likewise whether the voice is clear, or hoarse from an affection of the laryngeal mncoas membrane. Continuons loud crying which does not set up a fit of coughing is always a favourable sign in aflTections of the respiratory organs, because it indicates a relatively small amount of irritability of the respiratoiy mucous membrane. Violent fits of crying with vigorous movements of the lower limbs, especially drawing them up on the belly, usually indicate colic iu infauts. But in spito of these and many other hints derived from experience it is oft^i very difficult to decide whether the cry of a child is really due to puin or lo sonii! other cause. The presence of the doctor is of itself MufHcioni to make many children very uneasy and to cause prolonged crviiig. In doubtful cases, where pressure not only <»n th<t upparentl)' painful apot but on every other part of the body oxoitoH or iueroaseB the cryiug, the only way to gain your end is to wait nntil the child is perfectly <|uiot and then begin the examination over ugaiii. If while duiug this you can manage to divert the child's attention from the place examined, by toys, by a wuich ht^ld before it, or by turning its eyes to bright day- light <at the wiudow), you will often — though not always — bo able to find the spot which is really tender on preaaure* When

. ' Tlic UiVtintiirAi'kcii o( lltit baotorin proMnt iu uiiJk^futcfcft, wbicli wqs fint

U. ». v. . StnllLuit \i

lull]

m

INTBODUGTION AND METHODS OF EXAMINATION. 2t

children cry violently and will not be quieted, it is always well to have them stripped for examination. By doing so I have frequently found the cause of the violent excitement in midges or flea-bites. •

In judging of the condition of new-bom infants and children at the breast, I should further recommend you to observe how the hands are held during sleep. Healthy children at this age sleep, as is well-known, with their arms flexed to such an extent that the hands are directed right upwards and are on a level with the neck or lower jaw. This attitude — ^which is per- haps a reminiscence of intra-uterine life— is changed in the case, of serious illness, and its presence may consequently be regarded as a reassuring sign. I may also remark here that healthy children usuaUy have their eyes tight shut during sleep, but that in not a few the eyelids are noticed to remain slightly apart. One must investigate such conditions in each individual case, for, as we shall see later on, they may have a pathological significance.

SECTION T.

DISEASES OF NEW-BOBN niFAXTS.

I

The period of suckling extends from birth to about the 9th month, when the eruption of the teeth marks its close. One is justified io treating separately the beginning of this period, {.<?., about the first 4 — G weeks of hfe during which we are in the habit of speakieg of the child as ** now-born *' ; for to it belong a number of morbid conditions which later in life do not occur, or are only met with rarely and in an altered form, and which to some extent are connected with what has taken place before birth and with the sudden removal of the child from its mother's womb into the open air.

All new-born children present, in the first days after birth, a more or less intense red colour of the whole skin which is due to hyperflpmia. In many children this gradually becomes paler and passes in about a week into the ordinary colour ; in many others, however, there is a transition stage, the red at first giving place to a more or less deep yellow, and this we designate icterus neonatorum.

Icterus Neonatorum (Jaundice of the new-bom infant).

The yellow colour is usually noticed on the second or thh'd day after birth ; it is almost never equally well-marked all over, but is more strongly developed on certain parts, especially on the forehead, round about the mouth, and on the trunk, rather than on the limbs. The more the redness I have just referred to passes ofi", the more distinct and general is the yellow colour* It usually has a tinge of orange, is not as a rule very intense, and may also be seen on pressure with the finger on the hyperromic skin. It generally lasts several days, then gradually fades, and in the course of 8 — 14 days is replaced by the normal colour.

In examining such children, if you recall the symptoms which the jaundice of later years is wont to present, you will find very

DISEASES OF NEW-BORN INFANTS*

striking diHerencee. The ttrine whicli wets the diapers is pale ; tbe fiEces are yellow or brownish, as in the normal state. The sclerotic, however, which is often very difficult to see owing to tbe energetic way in which the eyelids are kept shut, shows in all cases a distinct yellow colour ; also, the pale spot left for a moment on the rod tissue of the gtim after pressure with the finger exhibits, sometimes indeed very faintly, the yellow tinge which we are accustomed to see in the jaundice of older people* With the exception of the yellow colour of the skin there are no symptoms whatever; hut on the contrary, except of coarse in those cases which are complicated with more serious diseases, oil the functions are in good order, and it is all over within 8 — 10 days. The harmless character of icterus neonatorum and its very great frequency have caused it to be regarded not as a disease at all, but rather as a physiological condition.

The matter of moat importance is to determine what causes the yellow colour of the skin — whether here one has really to do with hile pigment formed in the liver. The opinion originally advanced by French writei*s, tbat the yellow discolouration is not truly bilious, but merely proceeds from the red colour of iha new-born child, can scarcely nowadays be seriously defended. For in icterus neonatorum, not only is the skin coloured yellow, but also the greater pait of tho internal organs. I have convinced myself repeatedly of this fact by post-moi-tem examinations; and Orth* describes a case where even the brain, which in jaundice is ordinarily little or not at all coloured, appeared of a deep yellow. There can therefore be no doubt that the staining of the tissues is caused by a pigment the characteristics of which apparently correspond with those of the bile. The researches of Orth give new support to this view. The observations which had formerly been made of the presence, at least after death, of crystalline pigment in the blood and various organs of new-born infants were confirmed by him ; and he found that this pigment only occurred when ordinary jaundice was present or in process of disappearing.^ This colouring matter is very abundant in tho blood, kidneys, liver, and many other organs ; it occurs in tbe

' *' U«ber do* VovkonunQii ran BiliniMncTTHtiJiiii bei n«iig«borexien Kindern." Vh^ehov'i AreMv, Bd. 63.

• Out of 87 CMM in which Orth found tho p^^inciit, 32 wctre jftondic«tl, and in Jjbm Oltor ft onw tt irw imixMitiblo ij prove that jaitndke had not beco pfnviouAlj

ICTERUS NEONATOnUM,

25

fonn of red rhombic plates, or cylinders, or bundles of needles, and shows the mk'ro-cbomical characteristics of bilirubin : Orth has therefore no hesitation in regarding these crystals as bilirubin formed afler death from bile -pigment formerly in solution in the blood-plasma. How this bile-pigment got into the blood remains indeed unsolved, and on this very question there is siill great difference of opinion. While some regard the jaundice as hiematogenous — arising from the formation of yellow pigment in the blood itself — others accept the theory that it is hepatogenous like ordinary obstructive jaundice. Now although (as I have myself repeatedly seen) one can at the post- mortem in many cases squeeze out little plugs of mucus from the ductus choledochuB, yet the bile-staiuing of the intestinal con- tents and the normal colour of the urine indicate that these plugs ai'e not sufficient to cause any considerable retention of bile, or reabsorption of colouring matter by the liver. Then on the other hand, in many cases one finds the ductus choledochus and hepaticus free from obstructing mucous plugs, and on this account the hromatogenons theory of icterus neonatorum has secured many supporters. But here also there is no satisfactor)' proof of the cause which occasions such a considerable separation of yellow pigment in the blood. This theory would at all events presuppose a very considerable destruction of red corpuscles in the blood, and a corresponding liberation of blood-pigment, from which the htematoidin and bilirubin are derived. We know that the blood of infants is, at birth « relatively richer in red corpuscles than that of older persona (Thomas, Demme) j and Hayom, Helot, and others have also demonstrated, by results obtained from counting the corpuscles in the blood which enter the child's body by the umbilical cord, that these are destroyed in immense numbers. Now, according to Porak* and others, when the umbilical cord is tied after some time (after pulsation has ceased) and a larger amount of blood has found its way from the placenta into the circulation of the new-bora child, there will result this greater destruction of red blood corpuscles, a more abundant formation of pigment in the blood, and accordingly jaundice to a corresponding degree. Others,^

* PorHk, Conaideratioru sur tivlert drs nottvtaux-ni* : Pww, 1878. Sohiicking, A7i«, WochtHtchr,, 1870. No. 30. Violet, Virck, Jrchiv, Bd. 8«, 8. 353. H« f m t i e r , ' * Die Gelbsuclit der Nengoboteneo ' ' : Z^iUchr,/, Ceburttk, u. f. r.. Ba. Tiii.. Ht. 2.

2e

DISEASES OF NEW-BOHN IKFANTS.

again, ascribe tUis action to tlie large consumption of albnmen which takes place during the first dajs of life and occasions a ^'reater destruction of red blood corpuscles ; the insufl5ciency of the liver ceils and biliary passages to meet the increased demands upon them is also to be taken into consideration.'

The reabsorption theory as opposed to the hiematogenons one was pnt on a better footing by the TPork of C r use .* This author found the colour of the urine — when carefully collected — yellower than normal ; and he further discovered by micro-chemical exami- nation that the little yellow bodies {massea jaunes — described first by Virchow, and afterwards by Robin and Parrot, Violet, and others), always found in the urine in icterus neona- torum, either imbedded in epithelial cells, or floating free, or enclosed in hyaline casts, are real bile-pigment. He also states that in all cases of intense jaundice he has discovered bile-pigment in solution in the urine by shaking it op with chloroform — wliich former observers had not succeeded in doing. The theory of the origin of icterus neonatorum which lie puts forward is, however, without anatomical basis. According to Birch -Hi rschfeld* an interstitial cedema of the connective tissue of the liver occurs {owing to venous engorgement) which brings about compression of the bile-ducts, obstruction to the outflow of bile, and reabsorption . The circumstance that this author was always able to discover bile-pigment, and in one case bile-ac ids, in the pericardial fluid although not in the urine, must certainly be regarded as strongly in support of the hepatogenous theor)\ He considers that the bile- colouring of the fieces is due to the continuance for days of the discharge of meconium. The researches of Silbermann* also are in favour of the bepatogenons nature of the jaundice, and according to him it is caused by compression of the bile-capillaries and hiterlobular bile-ducts by the dilated blood ciipillnries and branches of the portal vein. However, we must always bo prepared to meet wilh new views on the nature of this disease.*

The development of jaundice is favoured by prematurity of

' IlArtniflirin. *' Uob«r dfu Ict«>ru»< Nuoiift torum/ * /naug. Din. : Borltii, I883v ntkrMtkm^df, M. 1., 1880, B. ;)S3.

t^koag dar G«lbaacht nouffcborcnor Kind«>r/* FlreA. Arekir. Ud. h7, UeftU, and Sohtilie. H^d. Bd. 81, Hoft I « Arxh/ Kinderh^lk.. riii.. Heft 6. • rWe »^.» Qainoke, Arckitf, esjtfrim, Fatfuttitim •«. /***n^<«»dr, Bd. ll>.

I

ICTERUS NEONATORUM.

27

birth, weakness of the new-boru child, unfavourable conditions at or after birth, the operation of cold, atelectasis of the Itiug tissue, defective respiration, and bad airj these explain the especially frequent occurrence of jaundice in Ijing-in hospitals and foundling institutions, and in children who are nnder the average weight.

One need scarcely speak of treatment since the affection disappears spontaneously. All that is required is good nursing and attention to the bowels when necessary.

Inaconsiderablenumherof cases the Jaundice is complicated by other much graver morbid conditions which are of themselves sufficient to bring about a fatal issue. Many of these children come into the world in the last degree of sickliness, emaciation, and debility ; they exhibit an extensive growth of aphthte on the mouth and gums ; and suifer from the very beginning from vomiting and diarrha?a. In such conditions also I have frequently been able to discover a yellow colour and even the presence of bile in the vomited matters. The most unfavom-able complication is sclerema neonatorum, fortunately a tolerably rare one, A case which occurred in my private practice in July, 1875, seems to me worthy of being noted here on account of the obscure etiology and the unexpectedly favourable result.

A rbild* 1-t days old, had suffered for about 10 days from jaundice, which, during the last few dayn, had suddeTily increased in a marked degree. The motions were dark, black iBh brown, soft, and scanty; theurinestainaon the diapers greenish yellow. There wae also an extensive growth of aphthie reaching Ijack into the pharynx with livid colour of the mucous membrane, and the child was steadily sinking, in spite of having a capital nurse and drink- ing abundantly. One was struck with the great number of miliary red spots which were scattered over the greenish-yellow ajkiu of the neck, bock, and extremities; these did not disappear on preaaure with the finger, here and there projected somewhat, and later on passed off with a alight desquamation. The child recovered, contrary to all expectation, under the admin i strati on of a mixture containing quinine and hydrochloric acid, a mouth- wash of chlorate of potash, and aromatic baths ; and he has since grown up a strong boy.

I have not hitherto had an opportunity of observing a second case of this kind, i.e. of jaundice combined with the haemorrhagic eruption just described. There could be no question that it was not a case of malignant jaundico following puerperal infection

28 DISEASES OF NEW-BOBN INFANTS.

of the umbiiical wotmd ; stUl, neither did the clinical picture entiroly correspond with that of ordinary icterus neonatorum. From the latter we must also distinguish that form of jaundice which occurs in rare cases in new-born infants in consequence of ^ an obliteration or congenital want of the excretory bile- ducts, and which, in every respect, is to be placed along with the obstructive jaundice of older people. In the whole course of my practice I have come across at most three cases of this kind, and of these only two came to a post-mortem.

A child of 4moiith9 old, brought in siiinmer 1850 to the University Cliiiiqup, had suffored from jftuiidice since birth, with perfectly dry, almost milk-white, evacuations and dark bilious urine. One could feel the left lobe of the liver diBtinctly in the epigastriutn^ In spite of all the means used, not only did the jaundice persist, Imt the colour of the skin became steadily g^<^ener, and the child died in a state of extreme emaciation five weeks after it waa first »eeii. After death we found the liver s mailer by at least a third than it usually is at this age; the lobes were of equal size, the left flattened, and reaching right into the left hypochondriura, of a moderately firm consistence, and through and through of an olive- green colour. The gall-bladder wa» present in a rudimentary con* dition, but there was no trace of the bile-ductB to be foinni, and tlie opening of the ductus choledochua into the duodenum could not he discovered.

You find in this case therefore, not only during life, but also after death, all the appearances of a jaundice caused by obstruc- tion within the liver to the outflow of bile, and especially the familial* diminution in size of the formerly enlarged organ, dne to the retrogressive metamorphosis and atrophy of the liver celb. In such cases any treatment is of course out of the question. I shall return afterwards to a case which was apparently the result of a syphilitic periphlebitis.*

In contrast to the mild character of icterus neonatorum, 'which we can scarcely regard as ii disease, the first period after birth presents one of the most violent and fatal of all known maladies —

Trismus, or Tetanui neonatorum.

^Vlthough the phenomena of this disease are essentially thd same as those of tetanus in adults, still they are more or less

' Contimre K. Oflumttcr, ** U*b«r isiiRgvtiitalvn V«rvcliJiiM dcr qtv^vmiti Cizdlcct- ginCe," JnuHs, JMw,; HftU#. imi

TETANUS NEONATORUM.

29

modified by the ohild^s tender age. Most frequently it begins between the 5th and 9th days after birth, but I have once or twice seen the earliest symptoms appear on the 2()th day. Usually the first symptom which strikes those round about the child is the difficulty or impossibility of suckiog ; every attempt to seize the nipple or bottle with its month calls forth a rigid contraction of the muscles of mastication and of the orbicularis oris, which renders sucking impossible. The other facial muscles also take part in the contraction, and the countenance is then disfigured to an extreme degree. At first these spasms occur only paroxys- mally, whenever an attempt at sucking is made, and it is still possible to give the child milk with a teaspoon, but after a few hours the symptoms usually become rapidly worse ; the fits I have described now occur spontaneously also, without evident ^^ cause; in them the forehead gets puckered into furrows, the ^keyebro^VB are wrinkled up, the lids fast shut, the lips drawn into ^^ a point like a proboscis, and surrounded by radiating folds. Soon the pharyngeal muscles participate, and their contraction interferes with the swallowing of milk poured into the mouth ; the attempt to swallow is often accompanied by symptoms of

I choking with cyanoaed visage and arrest of the respii-ation, which In the intervals between the paro2Lysms is usually extremely rapid and shallow. If one endeavours to pass a finger into the liiouth, the jawB are found to bo firmly clenched together owing to rigid contraction of the masseter and temporal muscles ; any attempt to overcome this resistance is invariably followed by the accession or aggravation of the convulsive seizures. It is only in the rarest cases, however, that you find this limited to the groups of muscles already mentioned ; usually there is rigidity of the muscles of the neck and back also, with backward retrac- I lion of the head and complete immobihty of the spinal column, which last one sees most strikingly on grasping the child's body about the middle and supporting it horizontally. The muscles of the upper and lower extremities also often participate more or ess. The arms and legs are extended, their muscles hard and yielding like those of the abdomen » and it is scarcely possible Hex them by force, AM these spastic symptoms show, it is e, intermissions or at least remissions, but they become more ting as the disease progresses, and often, though by no. means ways, are occasioned or considerably intensified by touching thj

80

DISEASES OF NEW-BORN INFAKTS.

patient, or by attempts to admiuister nonrishment or enemata. Slioi*t convulsive seizures which shoot through the trunk and limbs like ekctric shocks are also not uncommon.

Under these circumstances nourishment by the breast or bottle becomes an impossibility. I have only in one case seen a child taking the bottle during the height of the disease and certainly not sufficiently-

The complete interference with the nourishment, combined with the contraction of the muscles above described, which is unquestionably painful, must bring about a rapid sinking. Tlie temperature (the examination of which is important) either remains normal or shows only a moderate rise to 101'-' or 102° F., and in many cases this will be little if at all exceeded in tbo whole course of the disease. Sometimes, however, the tempera- ture rises pretty quickly and finally reaches from 104° to 10G° F. or higher, as in many cases of tetanus in adults. The disease generally exhibits a steadily progi'essive character, but a deceptive appearance of improvement in the symptoms occurs occasionally, either spontaneously or as the result of treatment, but it is wont to be followed, mostly after a very short time, by fresh exacer- bations of the muscular contractions. Finally the child sinks into a state of stupor^ the extremely rapid pulse becomes im- perceptible, and death follows either from exhaustion or from asphyxia duo to tetanic contractions of the inspiratory muscles. The disease lasts from 24 or 36 hours to 9 days according to the severity of the case.

By far the largest proportion of new-bom infants attacked by trismus perish ; you must therefore from the beginning give a bad prognosis. Complete recovery however is by no means impossible^ and 1 haye myself met with one or two cases of it. Just as in adults, so here, the cases in which the temperature is high apparently justify from the first a specially bad prognosis ; and even where the temperature is low (99"^ or 100*^ F, daring the whole course) a fatal termination is common enough. In cases which end favourably the improvement is always qoito gradual, never sudden ; the rigidity of the masoles and the con* vulsive exacerbations disappear slowly ; and in two cases which I myselfobserred one could after three weeks still make out a rigidity of the muscles of the extremities, which offered both to exteiifiion and flexion an almost springlike resistance. In a third

I

TETANTJ8 NEONATORUM,

81

child there was still in the Iteginiitiig of the fourth week a slight stifFneaa of tlie back and closure of the jaws on the introduction of a finger into the mouth ; at the same time the child took the bottle well. None of theso cases, however, were to be accounted very bad ones, even during their acmi' the temperature was only a few points above the normal, and one of the children who was treated as an out-patient was able after the first two days to have milk administered to it by means of a tea-spoon forced between its jaws.

In new-born infants, as in adults, post-mortem examination yields nothing characteristic. The old statements about blood being found in the spinal canal have long ago been disproved; and where this was really found it must be regai-ded as having been the result of venous obstruction brought about by the arrest of the respiration, and not as the cause of the disease. You will not rarely meet with little haemorrhages due to the same cause between the meninges of tbe brain and on tbe serous membranes. The central organs themselves appear normal apart from a more or loss marked venous hypera?raia and its results (ix^dema, miliary hflemorrhuges). That in tetanus we have to do with a heightened reflex activity of the spinal cord is beyond doubt, although the production and aggravation of the spastic symptoms by every stimulation of the sensory nerves (feeling the pulse, touching, <!te.) is not equally well marked in all cases. Further, in trismus neonatorum this symptom is sometimes more pronounced than at others, and is the more easily understood because at this age even in health tbe reflex impulses predominate. According to Soltmann's experiments, performed upon new-born animals daring tbe first period of life, all their movements as a rule take place reflexly without the influence of the will, and all the centres in the brain and spinal cord controlling reflex action are still wanting. In this way then we can explain the extreme frequency of reflex spasms in new-born children, in comparison with those of A later age, but not the cause which gives to this uncontrolled reflex action the peculiar and dangerous form of trismus. The frequency of this form is inconsistent with Soltmann's idea that the excitability of the peripheral nerves in these very first weeks of Ufe is less than in adults, for it is very probable that the exciting cause of tetanus cornea along these nerves. I regard tetanus in new-born children^ as in adults, as the result

32

DISEASES OF NEW-BORK INFANTS.

of TariouB iufluences which cause irritation either over the area of distribution of a single nervo or the whole sum of sensory fibres, and, a predisposition being present, produce the disease by rapidly transmitting this to the spinal cord* As such I should name —

1. Injuries (T. traumaticus) — at this age by far most com- monly affecting; the navel, separation of the umbilical cord, omphalitis ; rarely other injuries, cp, the rite of circumcision. In two cases which occurred in my own practice what remained of the umbilical cord was forcibly torn off on the morning after birfch» and there resulted an umbilical sore suiToonded by au inflamed area. I should add that in this connection I only iiitttch importance to real injuries and not to the *' inflammation of the umbilical arteries " which Scholler laid stress upon some years ago ; this is nothing but thrombosis in them which has partially broken down into detritus, and has nothing whatever to do with trismus.

2. The action of changes of temperature on the skin of the new-born infant — on the one hand taking it out into th(^ cold air too soon (e,rf* to be christened) ; on the other, too hot baths. Thus we have the cases which now and then have been occasioned by midwives who could not appreciate differences in temperature and prepared baths for tbe infant without the aid of a thermometer. This happened for example in Elbing where trismus was for years endemic in the practice of the busiest midwife, and hundreds of new-born children died of it. At last it was discovered that the midwife was unable to distiuiruish between a bath at a temperature of 100^ F. and one at 95- F. ; a bath thermometer was used, and this "epidemic ** of trismus was brought to an eiid.' We can easily understand that many other sources of irritation may still remain undiscovered an( tbat the disease may thus originate apparently without cause? Perhaps its origin in vitiated air (c.//. in Iceland, where it WHS caused by exhalations from whale-blubber, and in the Maternity Hospital in Dublin, from wbich good ventilation has now baniftbcd it) as well as its occurrence as an epidemic in some of the West Indian Islands, is to be explained by one of the causes named* The presence of ulbumen in the urine of new- bom iDfa&ts bus been alluded to above (p. 18) ; and I should add

» Biyhn,Jakrk/ JC^dtrhfili., 1876, ix., 8, 307.

TETlKrs N'EOXATORUM,

SB

that after deatU one not very rarely finds in them the appear- wiuice of parenchymatous nephritis. Although in one case symp- toms were observed (In c[e rale V*) which corresponded on tho whole ^\'ith those of trismus neonat-ornm, and the urine collected contained a largo quantity of albumen and numerous casts, partly hyaline, partly f^'rauular, and partly studded with fatty epithelium, yet at the post-mortem there was more the appearance of enf?ort?ed kidneys with capiUary htemorrhages thanof par- enchvmatous nephritis ; this is readily intelligible in the state of venous engorgement, which in tetanus may aflfect all the organs.

P "We cannot therefore at present maintain that uriemic processes manifest themselves at this age under the form of trismus.

In my opinion therefore trismus neonatorum is, just as one might say of epilepsy, a form of convulsion w^hicli is a unity ouly so far as its manifestatians are concerned, and which may bo cansed by a number of different sources of irritation. To

I discover these causes in each individual case may certainly bo difficult and only possiblt: under favourable circumstances, eg, wthen due to wounds, umbilical sores, changes of temperature. a'he etiology of trismus would gain considerably in certainty should the view expressed by Beuraer- be fully confirmed — namely, that here, as in the traumatic tetanus of adults, we have

Pto do with an infection by " tetanus -bacilli '' which gain entrance to the body by the umbilical wound. Dirty hands or dressings are supposed to carry these bacteria " which are apparently so widely distributed " to the umbilical wound. As a matter of fact the results of Beumer's inoculation experiments have since been confirmed by Peipor.' Should this view be correct, the causes which I have alleged (traumatic and thermic) will only come into oper«tion if the specific bacilli and their products (ptomaines) happen to be present. Even then the treat-

^Maent will always have to contend with the greatest ditBculties ;

^Bbr we know that this same disease, whether of iraumaticj rheumatic, or toxic originj even when it attacks older people who are better able to contend against it, is one of the most danger- ous that we know of»

The only remedy, under which I have seen two cases of trismus

' Oetlttrr. Jahrh./, Paduifrik, viii., S, 173. » Btrl klm. n>»c/iii«lrtW-.,tt8S^ Hd. 81.' f- '

» Omtmthi,/, I fin, fff^l, 188^^:5tQ. 48^

84

DISEASES OF NBW-BOHN IN'FANTS.

Deonatorum recover, is chloral, which X {^ave in doses of gr, J — i every hour. If this medicine cannot be swallowed, one must give it in enemata — gr, iss* every honr. In oth^*r cases the same treatment gave no result, nor did the inh?ilrtlion of chloro- form, which caused at most only a momenLary reliixation of the clenched jaws. From opium (tinct. opii., gtt. § every two hours) I have obsen^ed only a passing effect, lasting as long as the narcosis caused by it. Whenever that ceased, the tetanus re- commenced. From extract of phyaoBtigma, which I have used hypodermically, a i per cent, solution in doses of gr. tV, three or four times a day, I have seen just as little result; while others (Monti) say that they have seen some good from this very drug. Considering the extremely unfavourable results of every method of treatment in this disease, we must insist all the more strongly on careful prophylaxis ; that is, on avoiding as completely as possible all injuries, and everything that can have an irritating influence upon the cutaneous nervous syatem (cold air, too hot baths).

Jiesides trismus, other convulsive seizures localised and general occur in new-born infants, corresponding in every respect to attacks of eclampsia in older children. I mention this because some, on the strength of certain of Vir chow's observations, are inclined to make the conditions which he described answerable for those cerebral symptoms. Under the title ** Encephalitis and Myelitis interstitialis'* he described' a morbid condition of the brain and spiuHl cord which he had observed in children who were still-bom or hnd died soon after birth from the influence of infectious diseases or syphilis, or even without evident cause. This consisted essen- tially in a proliferation and fatty infiltration of the neuralgia cells, which could sometimes he recognised by the naked eye as little soft spots of a yellow or pinkish colour. Hayem and Parrot contirmed the occurrence of these conditions, though not their directly inflammatory signitioince ; and Jastrowitx,* in a work baaed on G6 cases, explained tliem as duo to a physiological fatty degeneration found in eycry fa^tiis, especially in certiiin parts of tlie centre of the brain, and in tho posterior columns of

» Archi9, 18$7. Bd. 38, H, l»« 188S, Bd, M. 9, 47a. Klin. Wvck^nMthr^ 1869, Oct,, Not.

JrcK,/. /*#ycA. *». iVerroi*., 1372, ii., ud UL

4

TETANUS NEONATORUM.

35

the motlullft, wLich reaches its maximum about the 7th month of intnv-at^rine life, then dimiuishet*, and soon after birth dis- appoara. He regards this fulty degeiicrution as morbid* only Vfheu it persists beyond the u or mal time or impUcates other portions of the brain than the white* fiiibstance of the centrum ovale, e.if, the great ganglia, the grey substance of the convolu- iions» or the nuclei of the cranial or spinal nerves. Concerning the etiological conditions of this imperfcL't reabsorption of fat wo are still in the dark. The whole question in spite of repeated investigations* remains as yet unsolved. These conditions have at present only an anatomical interest, since their relation to definite clinical symptoms in new*l)oru children is not yet decided. Farther, a form of keratitis ulcerosa^ which occurs between the 2nd and Sth months, and is described as the result of an '* Encephalitis " of this kind, is by no means established as such.

The same may be said of certain naked-eye changes which one linds sometimes within the cranial cavity in new-born children — cedema and hypenemia of the pia mater and little eochymoses in it. When wo compare clinically the cases in which these post-mortem appearances are observed, wc find do characteriBtic symptoms at all, but often a general clinical picture which we may describe as that of '* congenital debility.** A more or less extreme degree of atrophy, a greyish yellow tint of the skin, extreme weakness and apathy, piteous whining instead of the normal cry, quick shallow breathing, a cyanotic tinge of the extremities and a subnormal temperature ; — such are the symptoms which these unhappy beings are wont to exhibit soon after birth, and under which the majority of them succumb in the first days or weeks of life, unless they have the good fortune to be placed in particularly favourable circumstances. The lot of most of them, alas ! is to be badly nursed or to be sent to a children's hospital where what they need most, human milk and fresh air, cannot be got. My department in the Charite can show, all the year round., a number of such children who in spite of all our efforts die of collapse from steadily increasing heart- faiiore, with or without convulsions. The frequent occurrence of cedema, hyperemia and httle blood extravasations in the pia

KrAinor, *'Uober dim Vorkonunon Ton KumehcnzelJcn im G«hini Neu- [fteboroiujr/* Z/iwcrt,: Berlin, 1885.

• Grftof e uinl Hir^^ohbcrg, Arck,/. Ophth,, xii.j 8. 250, and B«rl */!». K'ocA-

m

DISEASES OF KEW-BOHN INFANTS,

mater in these cases, is in my opinion onlj to be regarded as tlie result of Tcnous obstroction. It is due to the failure of the heart and collapso of the Inngs almost aU'ays present, and is certainly not an active process ; it is not therefore the cause of the Ihial convulsive phenomena* I shall revert to this again ^vhen speaking of the so-called ^'hydrocephaloid " of older childrrn,

Cephallu^matovht.

Your advice will often be asked by anxious mothers about a swelling on tho head of the new-born child which is known by the name of eephalhoBniatoma, and couaista of an effusion of blond between tlie bone and pericranium. It appears to be due to the pressurn which the skull of the foetus suffers in passing through the pt-lvic outlet ; and to produce it, the birth does not need to V*e a specially difficult one. The occurrence of a cephalhff'matoina has also been observed in breech -presentations. In many cases the pressure affects only the scalp and its sub- cutaneous and subaponeurotic connective tissue, and then all that results is a sero-sanguinolent effusion in them forming a moderate-sized doughy tumour, which is kuown to you from obsto tries as the caput succedanenm. If, however, the pressure is cxeitcd more deeply or for a longer time, the pericranium itself is implicnted and the bleeding now takes place between it and the currosponding cranial bono. As a rule this is one of the parietal bones, especially the right, which in the usual presentation of the child is the one most frequently exposed to pressure during birth. The blood which flows from the torn vessels giadually raises the pericranium from the bone and forms a lluctuating swelling on it which does not reach its maximum all at once, but increases In size gradually (as the bleeding goes on slowly) and usually does not come to a stand* still till the third day. Not infrequently the swelling by that time covers the whole parietal bone ; it does not reach beyond, because the sutures of the cranial l>ones to which the peri- cranium is especially 6rmly attached set a limit to its further extension. I have never myself seen a cephalhipmatoma on both sides, but examples are not wanting in medical hteratnrt%

On examination you find a mi>re or less t4inst\ diHtinctly

CEPUlLHiEMATOMA.

37

fluctuatinp tumour usually over the right, more rarely over tbo left parietal iioiie, or over other cranial boues. The sklii covering it in of a normal colour, less couimouly it has a bluisli tinge shioiug through, or it may even he itself infiltrated with hloocL Even when it is very tense you will generally be aUe by sharp pressure with the point of the finger to feel the subjacent bones through it ; although in the lirst few days a hard, some- what projecting border forma round about the tumour which is apt to be mistaken for the edge of an aperture in the cranium, especially when the swelling is small in size. The cephalhiema- toma hardly seems to cause even discomfort to the infant. Only when one presses on it does the child begin to cry, and that is easily explained by the , tenderness of the tightly-stretched soft parts. Moreover the general health remains un disturbed ^ and the reabsorption of the effused blood proceeds rapidly as a rule. Absorption is all the more rapid because the blood in these swellings may remain at least parti}' fluid for a very long time .(more than four weeks). After one week the swelling consider- ably diminishes and the bone can be distinctly felt through it, and in the course of two to four weeks, aeeording to the si 250 of the tumour, it is completely absorbed. During this period of recoTery the above-mentioned bard ring round the tumour continues to be perceptible, only it gets smaller in size simul- taneously with the diminution of the latter. In many cases where the jjrooess of reabsorption occupies a longer time, you experience when you press on the soft parts, which are approaching nearer and nearer to the subjacent bone and heeomiug iipplied lo it, a feehng of crackling, as if you were pressing on parch- ment ; at last the reabsoq>tion is at an end and the pericranium is once more firmly adherent to the bone. The cause of this hard ring at the base of the cephalhieiuutoma is the process of ibono formation which still keeps going on on the inner surface of the separated periosteum, at first taking place most freely I where the periosteum and bone border on one another, that is [round the base of the ttimour. At a later stage little plates of lione fti'e also formed on the inner surface of the raised perios- Iteuui which cause the ub<ive-nientioned sensation of crackling [to the person exumining, and form a sort of shell over tho ^mainder of the effused blood.'

SB

BIBEASSS OF ^KW-BOBK IKF.iNTS.

Cepballm'matomata of a quite similar description to those fn new-Lorn children may also occur in later life from traumatic causes. I have observed sucli in children of 2» 4 and 8 years of age as the result of a Tiolent blow against a lamp-post, or of a fall on the back of the head, occasionally also without any evident cause. The swelling was situated either on the parietal or occipital bone, or covered the entire surface of the latter. Here also the tumour was observed f^radually to increase in size ; and in the case of a boy 8 years old a week after the fall, when the cephalhematoma was fully developed, an additional hiemorrhage accompanied by great swelling took place into the subcutaneous connective tissue of the forehead and eyelids, A week later nothing remained of this but n greenish yellow discolouration » while the immense cephalhicmatoma on the occipital bone after lasting 11 days had Wen reabsorbed, and only a flat swelling scarcely as big as a shilUng was left, sur- rounded by a hard ring of bone.

According to my experience the treatment should be purely expectant. Formerly I used fretjuently to make incisionsp evacuate the blood, and then at once apply pressure with strips of plaster. The result of this was usually good, still I was not always able to prevent suppuration ; and I have repeat4?dly met with cases which had been incised by other practitioners and which presented gaping suppurating sores. Although now this danger is materially lessened by antiseptic dressing, yet I see no reason for opening a swelling \\hich I have idways seen disappear completely by absorption in a few weeks, I should therefore advise you only to incise if the tumour suppuratea spontaneously and threatens to burst ; an event which ia very rare and which I have never myself observed. Under all cir- cumstances, however, it is well to protect the tumour as much as possilde against external injurica by a soft covering (cotton wool) .

Only by the utterly inexperienced could a cephalhflpmatoma be mistaken for a congenital encephalocelo — the protrusion of the brain or cerebral membranes distended with fluid (menin- gocele) through a congenital tt • - - t the cranial bones* This mistake is rendered possibh rent or re;U lluctua-

tioD in such a tumour and tho 1 ^f the bony aperture

which can be felt round ab nosis is ba54*d on

HEMATOMA OF 8TERNO-MA8TOID,

^

ihe fact, tLat the enceplialocele geuerally occurs at a place which is almost never aifected bj ceplialhiematoma in new-born infants, namely on the occipital bone, much seldomer on the glabella or parietal bone. The encephalocele is as a rule smaller,^ and when the hand is laid on it one can make ont a pnlsation proceeding from the craniul contents, as well as a rising and iiUllng with the rcspinition, which never occnrs in cephalhcematoma. In these also by a sharp pressure with the finger we can almost always make out the bonos lying nndcr the flnid, white we can never do so in encephalocele and meningocele.

I The same holds good of the so-called spurious meningocele in which | ^netraling fissures of the cranial bones, usually fractures, have arisen (either before or after birth), and cerebro- spinal fluid has passed out through them under the pericranium. In doubtful cases — andtbese must indeed be extremely rare — we may make certain by an exploratory punctiu-e.

H^natoma of the Sterno-mcutoid,

Vou will not very rarely have children brought to you in the first weeks of life who have a hard roimdish or elongated uneven swelling on one or other side of the neck, very rarely on both sides, corresponding to the anterior division of the sterno- mastoid muscle. The size of it varies, being Bomctimes thai of a pigeon's egg j often however it is larger and of an elongated form — so that I have occasionally found a great part of the anterior border of the muscle hard and knotted^ with band-like processes spreading into neighbouring muscles. Sometimes there occur two or three separate indurations in the border of the muscle. As a general rule the upper half of the muscle is much more frequently affected tban the lower. Occasionally I bave found almost the whole anterior half of it, of a really cartil- aginous hardness throughout its entire extent. The right slerno-mastoid is by far more frequently affected than the other, for out of 80 cases recorded in my jonroals I find 23 of the right side and only 7 of tbe left.

The youngest child I have seen with an aSection of this kind

' Very larfpe nienln|rocele«i {tg. the sbc of u child V heftd) »ra irernerttlly podioa* tftteU And «>oin«wh&t tTaiutparent when held iigntn»*t the light {e/. » 0M« cX thi* kind which I obserrcd — i'fimiU'AnnaIrn, Bd, i., 8. oCM>.

40

1>I8EA6E8 OF NEW-BORN INFANTS,

was three weeks old, the mnjoritj were 4 — ^6 weeks, but 4 h:u reached the ages of 3, 5, and 12 months respectively. In no case did it cause any pain ; in most it was discovered quite acculeu tally while the child wits being washed. Less fre- quently the mother's atteution was tirst attracted by the fact that the child's head was not held straight when it was lyiufT* but had always an inclination to one side, usually the right. This position of the head, however, was by no means always present, and it has seemed to me to he less common the younger the child was.

The nature of this ewolling of the sterno-mastoid muscle becomes clear to us when wc find that almost all the children aflected by it have had an abnormal presentation at birth, which either delayed the labour or rendered arLiticial assistance necessaiy^ Out of 30 cases which I have observed, there had been a breech presentation in 20, and some force had been used in bringing the labour to a conclusion. Of the remaining 10 cases, 7 were born with the norniul presentation, but in all it was expressly stated that the labour was unusually prolonged beoaose the child's shoulders would not engage, and that strong traction was required. In one case the child was bom a«- phyxiated and had been violently swung about in the attempt to resuscitate it. No one, therefore, can doubt that the cauee is to be sought in a forcible stretching and partial laceration of the muscle occurring during or iifter biiih, and that the disease consists in an effusion of blood into the muscular tissue ^jiematoma), followed by myositis, which forms a capsule round it and leads to the formation of a fibrous induration ; this is confirmed by post-mortem examinations (Skrzeczka, Taylor). The use of force in such circumstances occasionally has other effects. Thus in one of my cases there was simultaneously u fracture of the upper arm, and in another, in which the presenting part (nates) Lad exhibited an extensive ecchymosif* immediately aft^r birth, HD apparently paralytic weakness of the right lower extremity.'

As far as my observation goes, the swelling always takes a

* hi oiHi »u?w.h<irn child 1 found ft jfangTcnoun cnvity, about the «i«e of A WfkloQt, on Uio tuft juidw of tho ncok, }a»i nntlor Ih© cnoAUiid prooes** whirb w*« o*ii86d hy the aoparulmto of a black filough, Tbi** hnd yvideni ly bfcn ontWiMl h.v presaUTO wtlbiii the [wlviu duriiiK a. prolottgcd 1al>oitr» o«i»«jijuinif u hjniimtoma and oudiiii^ in [»ecromi«. In thi» cft.40 tho mnsolo wiw» wot irnpl ! only tlic cuperJAo^ut

»uw ^Kikiji. coitneotive tui«ne and tmmjuk) wt?r<

BWELOKG OF MAMMARY GLANDS.

41

favoumble course, gradually dimiDisliing, and at last leaving an induration of a varying size in the muscle which scarcely if at all interferes with its functions. I have never myself seen suppura- tion, but it cannot be denied that a serions disturbance of function may arise from it and I have every reason to assume this as the original cause in a case of torticollis in a girl six years of age, vs-hich dated from the first weeks of life. Also the wry-neck of a boy of seven, which had already betn operated on with partial success, three years before, was due to a hiematoma of this kind, resulting from a breech presentation ; and the retracted scar could still be distinctly recognised in the anterior belly of the muscle* Unfortunately, almost all my cases of haematoma were subsequently lost sight of, aud I saw few of them a second time. In the case of a child of six weeks old, first examined on 31at March, 1873, Iho swelling could be felt distinctly — although it was considerably smaller — on 25th October. The natural cure by the formation of a fibrous indu- ration makes any treatment supertlaous. If you like to order the inunction of iodide of potash ointment over the tumour, you may thereby perhaps gratify the anxious mother and — especially among poor patients — ensure to yourself further olraervation of the case. But no one will anticipate any benefit from this treatment.

Stvdliui) of the Mammoi'if (Hands,

In very many new-born infants you observe swelling of the mammary glands during the first weeks of life. In the position of one or l)uth mum^mie you find a tolerably hard swelling, globular or Id untly -conical in shape, about the size of a pigeon's egg or small walnut, and of the natural colour of the skin. Pressure on this seems to be painful, as it UHually makes the child cry. Now, if you take hold of the base of the swelling with two fingers and compress it laterally with moderate firm- nesSf you see a whitiKh, opalescent drop rising out of the shallow funnel-shaped hollow which exists at its summit ; and this shows under the microscope fat-globules and larger conglomerations made up of them.

To understand how these swellings are formed, one must remomber that all new-boni childreui boys as well as girls, have a secretion from their breasts reaerabling milk, which begins

43

DISEASEfcl OF NEW-BORN INFANTS.

about four days afteir birth. This in usuaJly accompamed by Blight swellieg of the niiinima, goes on iucreasing till the nlDtli' day, then gradually decreases till, about twenty days after birth, U is no longer perceptible, I have, however, in one child fonnd both breasts, four weeks after birth, still much swollen, nodolftr and containing milk. Natalis GuillotS by squeezing tbe mnmniary glands, obtiiiued from a child about fifteen minims of whitish lluid which, under the microscope, presented all the chflraoters of colostrum. According to Sinety 's* investigations on makiug a section of the breasts of new-born children, one finds milk-canals near the surface w^hich are tilled with epithelium. These become wider as they pass inwards, divide, and form cavities containing a flaid resembling colostrum. This process is said to begin during fnetal life, to reach its acme between the fourth and tenth day after birth (in virtue of a stronger develop- ment of the above-mentioned milk canals and cavities), to be Aggravated by squeezing the breasts, and, in rare eases, to last j>08sibly as long as sis to eight wrecks. Epstein* connects this with the active cell-formation and desquamation of the epithelium which take place during fcvtal life in other parts regarded a8 invaginations of the skin, especially in the sebaceous glands, and which appear in the form of vernix caseosa, seborrhiea. or milium. Moreover, according to O ui Hot, this secretion of milk is observed only in strong healthy children, and not in those that are weak and sickly from birth.

Now in new-bom infanta, as in women, the secreting breast may become the seat of morbid processes. One need not, like Bouchut, assume in such a case a ** puerperal " condition of the child, w hen there is absolutely nothing else indicating it to be observed. On the contrary, the purely local process may l»€come aggravated to such a <iegree of inflammation us to bring about firstly a greater swelling of the glands, and then the formation of abscesses in them. In this case the little swelling becomes red, very tender, and fluctuating ; aud a quantity of pus is evacuated either spontaneously or by incision. Since I havf seen this happen two or three times from the swelling liaving been squeezed too hard or very often— whirh uii'l^'vcs rsm .■uillv

fl . 1853.

So IT. 18Ta,

a.

BRTBIPELAS NEONATORUM.

43

are apt to do — I always guard agaiDst any maltreatment, and prefer to have it simply covered with wadding soaked in oil. Under this treatment very considerable tumours disappear with surpriaing rapidity. Should redness or suppuration follow not* withstanding, you may favour the evacuation of the abscess by wami poultices and incisions. Guillot observed three casea ending fatally from complications ; and Bo u chut' saw one cafle with a considerable undermining of the pectoral muscle, which ended fatally, I have myself only once met with an unfavourable termiuution — burrowing of matter and gangrene of the skin over the pectoral muscle in a sickly, wasted child. Strictly cir- cumscribed suppuratiou in the gland may also occur, as was 8hown by the case of a child from the upper part of whose mamma (which was only slightly swollen) a few drops of yellow pus oozed on compression by the fingers, while from the lower part there trickled white milk. In some eases also I have seen the two mammte affected in succession.

Eryxipeltts Neonatorttm ,

There used to bo many who were inclined to deny that the erysipelas of new-born infants was in any sense a distinct disease, and preferred to regard it always as merely a symptom of the condition described under the name of "puerperal infection *' of new-born children.* I have not myself any very extensive ex- perience of this condition, which for obvious reasons occurs most frequently in lying-in hospitals and foundling institutions. This much, however, I think I am justilied in giving as my con- claaion : — that erysipelas in new-bom infants is by no means always to be regarded as a symptom of puerperal infection. In at^ults, erysipelas occurs sometimes as a symptom of serious general diseases — pya&mia, septictemia, typhoid, &c,, — ^sometiraes begins as a local affection proceeding from a wound and of para- sitic nature as proved by recent research (Fehleisen). In the same way we must, I think, distinguish two forms in new- born children. The first and most serious of these is connected, without doubt, with the already mentioned puerperal infection of infants, the various phenomena of which come to be joined to Ihose of erysipelas— rapid collapse, very high temi^erature

* Ttniiiitrot (/«#. malatjifi du novi^eaux-n^t, ^c, 5 cd.. 1867. p. 711*.

* ▼. Hooker, Arckip/, Ojtturccf., Bd, J,. H. 3, 9. 5S3, 1876.

u

DISEASES OF NE\e-BOKK IKFANT8.

(to lOG**^ F.)i jaundice, Tomitiug and purging, inflammations of various serouB membranes {pleura, peritoneum, joints), convul- sions and coma. This is Ihe form of erysipelas which occurs in the children of women who are sufi'ering from sporadic puerperal fever or have died of it (of which I have myself seen several examples). It attacks also on a more extended scale the new- born infants during epidemics of puerperal fever, and in the lying- in hospitals where this disease prevails. The second form has nothing to do with puerperal infection ; at least no connection can be traced with disease of this kind in the mother. At some place or other on the body there is an abrasion, it may be very trifling, which becomes the starting-point of the disease and a true erysipelas traumaticum is dereloped with the well-known tendency to spread*

As at certain times sores of the most diverse kinds are apt to give rise to erysipelas — ^especially in hospitals— while at others this seldom or never happens ; so, the wounds one finds on the bodies of new-born children, when exposed to foul air, unclean- lincss and infectious influences — which are certainly not of a puerperal nature — are very apt to give rise to an attack of the same disease. Hence, also, one meets with the second form of it far seldoraer in private practice where the surroundings arc favourable than among the poor. But even with the best nursing and the most favourable conditions of life, erysipelas neonatorum may developc. As an example of this I shall only mention the case of a Jewish boy in a very welUto-do family, in whom I saw erysipelas starting from the penis after circumcision. It gradually spread over the whole body, produced, after a fortnight, a circumscribed patch of gangrene on the scrotum, then an im- mense abscess on the back; and finally brought about a fatal result with general collapse, jaundice, and symptoms of peritonitis. In this case a puerperal source of infection was out of the question.

The traumatic form also of erysipelas neonatorum may begin during the first few days after birth, Sometimes it occurs iiiucU later. Thus I have seen it begin on the fifteenth day after birih in a child who had had a fall, whose mother was not quite six* teen years old. Verj^ often a raw surface at the umbilicus first gives rise to its development; almost as often, however, the genitals form the starting-point; the anua less frequently. In these cases we have to do less * ^-nunds (except in

<

ERYSIPELAS NEONATOBUM.

45

P

the case of cu'cumcision) than with those red excoriaiious which form in this region on tho parts of the skin which have hocomo the seat of intertrigo, from tho contact of the urine and fiecea, and want of cleanliness. Erysipelas may also orLginato in other regions of the skin, if only abrasions of it are present ; but this is far less common. You will therefore most frequently find erysipelas commencing at the umbilicus, or lower down in the pubic region at the root of the penis, as a more or less bright- red flush spreading over the skin, and a tolerably resistant swell- ing which is bounded by sharply defined borders, is raised a little above tho surrounding healthy skiUj and feels hot to the toucL Pressure, which momentarily lessens tho redness but does not make it quite disappear, evidently pains the child. It is rare to have the process limiting itself to the areas of skin originally affected. iVlmost always the raised margins are pushed gradually onward in diflerent directions ; sometimes aimultaneously on all sides, oftener more towards one side, in which case tho spread of the disease may be quite irregular. Thus, for example, it often happens that it spreads mainly in a downward dirertion, the erysipelatous rash becoming diffused over the thighs, then over the legs down to the feet ; while at first it does not pass upwards beyond the level of the umbilicus. But also in these cases we not uncommonly see the erysipelas beginning suddenly to spread upwards from the anus, and thence over the nates and back till it reaches the upper half of the body. In this way the process may be arrested in all directions and come to an end ; but often it spreads over the whole surface of the skin, even over the face and scalp. Wherever the erysipelas makes its appearance, the skin is bright or dark-red, often glazed, cddematous and firm, sometimes of a board-like hardness, so that it scarcely pits at all ou pressure with the finger. On the upper and lower extremities, the hard ioiiltration of the skin sometimes increases to such an extent that in a few cases I have found it scarcely possible to move them at the joints. In general, bow- ever, tbe redness and tension of the skin do not occnr to such a igh degree on the parts attacked at a later stage as on those first affected ; and at the same time the raised border becomes gradually less marked. In mauy places it may he accompanied by an eruption of vesicles, or of larger buUsB^ filled with yellowish serum, as in the erysipelas bullosum of older individuals.

46

DISEASES OF NEW-BORN INFANTS.

The oedematouB HweHing of the skin and uuderlyiug tisaoe i» most marked on the laser parts, so that tbe penis, scrotom, vnlva, eyelids, hands and feet, appear not only rt ddened but con- siderably swollen. Lines drawn on the red skin with the finger- nail or any blunt object, remain visible for a lon^ time as white streaks ; in one of my cases they were visible for more tlian a quarter of an hoar. As in every case of erysipelas migrans, while the reilness gradually spreads, the parts first affected be- come pale ; and hence it sometimes happens that the chest and neck as well as the legs are still of a bright red, while the inter- mediate parts have resnmed their normal colour ; but this does not protect the bitter fi*om being again affected by a retrograde process as it were. Thus, in a child of live weeks I have seen erysipelas, which had affected the whole body almost np to the neck during three weeks, suddenly attack the scrotum a second time. One finds therefore, not unfrequently, in the stage of decline, when the disease has ceased to spread, patches of redness irregularly distributed and no longer continuous but isolated in the form of numerous islands, — partly on the chest, partly on the back or limbs. Between these the skin is of a normal colour, but generally appears more or less cedematoas and is covered with fmgmeuts of desquamated epithelium or the remains of bullip* Sometimes after the colour has quite faded there remains behind an cede ma spreading over the whole skin, and in eases which are in this stage when they are first brought to the physician doubts may arise concerning the nature of this a?dema, which are only solved by the history of the disease and the traces of desquamation of the epidermis which still remain.

During the course of the disease which I have just depicted, a remittent fever is present in all cases, the evening temperature rising to from 102^ to lOG'^ F., the morning temperature being about 2^F. lower. The pulse is exceedingly quick (up to 170 and more) and small, the breathing correspondingly rapid and superficial. Many children at an early stage refuse nonrishment, especially the breast, even while they will still take milk from a teaspoon. I have seen others take the breast almost as well as when in health. With the arrest of \l ' s the tompera-

ture generally falls rapidly, and the . , h more or lcg«

quickly. On the other hand, should the erysipelas go on spread- ing farther and forthcr over the surface of the skin, the fever

ERYSIPELAS NEaNATORUSI.

r

^

ooiitmues, and we ure very upt to have complications addoil, with morbid conditions of the internal orj^aiis (especially profuse tiiarrhcBai pneumonia, and pcritonitiB), which may put an end to life* The. last-named affection I observed in two non -puerperal cases, witli very considerahle enlarojeraent, tension and tenderness of the abdomen, and frequent vomiting. Probably the inflam- matory process spreads from the skin of the abdomen directly to the peritoneum through the umbilicus, which in such cases is generally swoUon and sore. Apart from these complications, the high fever may so exhaust the strength of the feeble infant that a fatal termination may ensue with symptoms of collapse. One slionld never, however, lose heart, since even in cases of exten- sively spreading erysipelas the children, after weeks of suffering, may get off with their lives and completely recover; athers, however, after having made a good recovery from the erysipelas, fall victims to abscesses and gangrene of the skin arising from it, I have observed this result frequently on the scrotum ; also on the malleoli, on the back (almost a third of it was in one child covered with an immense accumulation of pus), on the arm, and on the external ear. In the case of smaller patches of gangreno of this nature recovery may take place on their separation.

In a child aged three weeks, erysipelas hud spread twelve day** hefore from the umbilicus over the gi'eater part ol the hody, up- wards and downwards. An abscess on the left side of the scrotum remained after this; and wheii it hurst, a deep cavity the size of a florin was left, coutaiii'mg fragments of gangrenous connective tisstie. TliO penis and lower lirabii were o^dcmatoas, and on the left check there wae another extensive red infiltratitm. Under the use of hot jHrnitices, the j^angrenons tissue of the stTotum separated in foui* dayM; while the erysipelas* of which nothing could any longer lie seen on the upper parts of the body, except oil the eheek as men- tioned alx»ve» suddenly spread n second time over the left uj:iprr eiireinity from the elbow to the fingers, and caused a large abaceK« on th«i eUww, which I opened a week hiter. In the end the child rocovei-ed completely.

Tho fact which I have already mentioned above was seen in

this case, viz., that after the disease had apparently ceased

spreading, certain areas of the skin — in this case the left fore-

rm— was suddenly attacked {i^^ain, although no continuity

onld be discovered with an already existing patch and no wound

lislx^ on the part newly alTectciU

Treatment in this dangerons disease is practically powerless.

48

DISEASES OF NEW-BORN INFANTS.

At its commencemoiity when the erysipelas is usually limited to the umbilioal or pahic ref^ion, one may attempt to mitigate the intlamraatory process by large fomentations of lead lotion. Internal remedies — except mild purgatives when the bowels are confined — are quite useless. Should the ervsipelaa bec^in to spread, no medicine of any kind is capable of limiting its ext^^naioji any more than in later life. The only thing that can l>e done is to administer tonic remedies, wiue and decoction of bark ; bat from this I have not seen any really successfnl result. The matter of chief importance, howerer, is whether the erysipelas is arrested or continues to spread ; in the latter case I have no confidence in any medicine. Injections of carbolic acid (1 to 2 p.c.) into the neighbouring healthy tissues have not in my hands done any good ; and on account of the danger of poisoning in the case of such small children, their use seems to me more than c|ue8tionable. Complications must be treated according to their nature ; but when the erysipelas is extensive, they almost always prove fatal at this tender age. Abscesses are to be poulticed, opened as soon as distinct fluctuation is present, and dressed antisepticftUy.

That I may not have to retoru again to this condition, I shall take the liberty of adding here a few words on erysipelas in later infancy and in older children. In them also one almost always finds, on careful examination, an excoriation, which may be regarded as the door of entrance for the infecting bacteria and the starting-point of the disease. The sores which I have found most frequently are, that of vaccination, eczema of the scalp, excoriations on the genital organs or anns, soch as often occur as the result of erythema intertrigo occurring ia, these situations, diphtheria of the vulva, large ecthyma pustules A Jastly, in older children — ^especially those who are scrofulous — chronic rhinitis, with excoriations of the nasal mucous mem- brane. Nothing is more common under the last-mentioned circumstances than a recurrent erysipelas — i.e., one which returns once or even oftener every year. In these cases the erysipelas spreads from the excoriated and scabbed nostrils towards both sides over the cheeks, [^resenting the appearance of red butterflies' wings ; but it docs not usually extend farther. It is not always possible, however, to discover, even by the fno^t careful scarcb, an excoriation as a »Uriing'point. j

ERYSIPELAS NEONATORUM,

I?

TlitiB in a child af ELfteeu months I have eeen erysipelas Btartifig from the right labium majus, on which there was not the slighteat ahrasion of the akin. It spread (with smart fever for ten dajd) with a raised margin over the right lower extremity and descended in paler patches as by leaps* — ue., with unaffected skin between them— down to the inner ankles, while red islands were also noticed here and there on the Hkiii of the abdomen. The attempt to limit it by painting ou collodion failed entirely, and in spite of this It continued to spread for about twenty- two days ; after which recovery took place. — In a child of two and a-half years, the fryaipelad spread for the third time within seven mouths from the anus over both nates, with the formation of nimaerons bulla?, although there was not the slightest abrasion to be seen about the anus. — In a child five months old, the disease seemed to originate from the vagina, which at this tender age was already the aeat of fluor albuR; extension took place upwards and downwards oi'er the whole body, diarrluiea and ]>neumonia came on, and death ensued. — I have also observed it in an infant three months old, the result of an incision situated on the right side of the neck. The erysipelas was accompanied by fever (102^ to 104*^ F.) and extended from the woimd with a thickened raised border over tho right ear, the cheeks and both eyelids, then over the forehead and scalp to the neck, where it came to an end after a week. Tho treatment consisted of compresses of ice-cold lead lotion, later on ice-bag on the head; internall3% quinine (gr. sa. every two hours).

When the erysipelas arises from eczema capitis, it ia apt to remain hidden under the hair and the crnsts on the scalp ; and it reveals itself only by the accompanying fever, the cause of which is not recognised until the erysipelas passes beyond the border of the hair and becomes visible on the forehead or neck, or in the neighbourhood of the ears. In such cases we sometimes have relapses, or rather an extension of the disease on different sides of the eczematons area, e.ff, first over the forehead and then again towards the temples, each extension being nahered in by a fresh accession of fever.

A boy of four yeare^ with eczema capitis, especially on the left side, admitted into my ward in September, 1873. In the night between the 2Gth and 27t,h September, fever with restless* ncss and headache. On the 27th, continuance of these symptoms without p,videiit local cause. Temp. 103' 5° P., ev. 103'8^ F. On the following day redness and swelling of the left side of the head passing beyond the border of the hair and extending to the temple j a&0|rexia, thickly-coated tongue. Emetic. Temperature in the evening 1051'^ F. During the next few days the erysipelas gradually

60

mSBASEB OF NEW-BORN INFANTS.

dimiiiifthed in intensity, the redtiews bec'umo less continuous, tha tenderness less, the fever diminished, and on 1st October the tompeniture was 995^ F. Of the erysipelas there remained TiBiHe only a number of vesicles on the margin of the forehead. On the evening of 11th October the fever recommenced, reached on the morning and evening of the following day 104*9° F.; and erysipelas again appeared, starting from the eczema and extending about an inch and a quarter beyond the border of the hair. An ice Ijag wa«* applied over the reddened area, and the erysipelas ceased spread- ing and faded on the next tlay; on the Hth the Ixiy was free fi'om fever, so that we were able, alter a few days, to take in hand the treatment of the ecsema.

I have repeatedly seen tracheotomy wounds in cases of diphtheria and even other incisions covered with diphtheritic memhrane, hecome the starting-point of erysipelas migrans, which sometimes crept onward till it reached the thorax^ and even the epigastrium. In one infant it took its origin from little pricks which I had made in the scrotum with an ento- mological needle for hydrocele. The scrotum and puhic region soon ufter became deop-red, hai-d and swollen, up to the level of the umbilicus. Gangrene and separation of part of the Bcrotum followed, and the child died in a state of collapse. In many cases erysipelas is developed as the result of vaccination, rarely within the first few days, usually commencing towards tho end of the first or second week, or even later, when the vaccinn- tion sores are already covered by scabs. Only one arm as a rule is aflfected, and in that case a spreading of the erysipelas over the body is less to be dreaded than when both arms are attacked. In one case I have seen it spread upwards as far as the auricle, which became swollen, dark-red, and covered with buUie. In other cases it is impossible to decide w^hether one has to do with the ordinary areola of the vaccine vesicle extending further than usual, or with erysipelas limited to the upper arms. At certain times, and especially in certain localitieu, e.g, foundling institu- tions, vacclnation-erjsipelas may api>ear as an epidemic ; and this is equally likely to occur whether animal or human lymph has been made use of. The treatment of these forms of tho disease is the aame in all particulars as that already mentioned (p. 48).

SCLEREMA NEONATOBUM.

61

Sckrema Neonatorum*

The chief cliaracteristic of this dangerous tlisease, which occurs almost exclusively in lying-in hospitals and foundling institutions and is rare even in them, is an induration and rigidity which the skin of the infant oflfers to pressure with the finger over the greater part of the hody. In the most severe cases one linds a tense induration as if tht3 body had l>een frozen ; but this is not equally well marked in all places. A more or less considerable fall of temperature accompanies this. The children thus affected are feeble, prematurely born and atrophic, and they invariably die.

Such is a brief and very general statement of the features of a complaint concerning which, till the most recent times^ there prevailed a greater confusion of opinion than concerning almost any other disease. Owing to the rarity of the affection and the vague descriptions of it given by most mediral writers, there have been widely differing views among practitioners con- cerning the nature of the disease, and many have no clear conception at all of what is meant by the name sclerema.

The credit of having cleared up this confusion is, in my opinion, pre-eminently due to Parrot, who in his capacity as physician to the Paris Foundling Institution had abundant opportunity for studying the diseases of new-born children. In his work on Athrepsie^ he points out that two morbid conditions ^^ entirely distinct from one another — the real induration and the ^MODdema of new-bom children — have been hitherto almost uni- ^Hrersally confounded with one another, and have been included ^Hln one vague description* He explains this confusion thus : the ^Hreal cell ular-tissue-indurat ion (sclerema) was first described ^^by Underwood, and this designation soon after, in the year 1781, was transferred by An dry to the oedema of new*born children frequently observed in the Paris Foundling Institution.

(1) The true induration (sclerema) occurs, according to

Parrot, exclusively in extremely atrophic (or as he expresses

it athreptic) new-born infants, especially where the atroj)hy

affects children of medium bulk immediately after birth. While

rdinarily the skin in atrophic children fonna broad folds around

' dinl^m det nouveaiux-nit : PftpU, 1S77, p. 110.

K

52

DISKASEB OF KEW-BOBJT tNPAKTS.

thoir limbs, in theso cases it Is very tense and smooth ; it loses its solliiesa; and finally can no longt^r be raised up from the subjacent parts, to which it appears to be firmly attached. This alteration in the intercunients usually starts from the lower extremities, and spreads upwards over the loins and back ; it may, however, in time affect the whole body, even the face. The tension and hardness increase from day to day, and the skin soon acquires the consistence of thick leather. All soft pai-ts then appenr as rigid as wood or stone, there is do pitting on pressure ; the colour of the skin being usually a dirty yellow, slightly cyanotic on tlie extremities. Under these circumstances the limbs become ^d im mobile, are persistently extended, ami only the slight move- ^M ments of the thorax — perhaps also those of the facial muscles — distinguish the condition from that of cadaveric rigidity. When such a child in grasped by the neck and lifted, it may be held out horizontally like a rigid bod3% just as in cases of trismus neonatorum ; for this disease sclerema may be mistaken. especially in cases where the mouth is shut by the lips and cheeks becoming affected, and sucking is prevented. Even where this is not the case, one is apt to suspect, if not trismus, ut h'ast tetanic contractions of all the muscles. I rememl>er CBpecially two sucli children, who lay for weeks in my ward in a rigid condition and in the highest degree of emaciation, but were still able to suck a little, or to take milk from a spoon. They finally died, the temperature steadily fulling to 86"^ F., in one case even to 83*3*^ F. At the post-mortem the brain and gpinal cord, to which we specially directed our attention, were found absolutely normal; while the integument presented the appearance of sclerema. In some other cases I have found this condition not so generally diffused, but confined to the regions of the calves, the adductors of the thighs, the nates, the cheeks, or even the forearms and upper arms ; and in these cases the fall of temperature conld be at once verified, not only by applying the hand to the surface, but idso by introducing the finger into the mouth. Almost all of my cnses were rit the same time more or less jaundiced.

The result of Parrut'y post- ninrlom^ are asfolbiws: — Extreme atrophy with connolidation of tho skin, including the I'ete MaU {^ighi, the cells of which are scarcely visible and form a comptict mass with ill-defined contonrs. In the Bubontaueous fat, the

I

SCLEREiU NEONATOBttM.

fibres of counective tissue are more numerous lliao usual and thicker, and the fat itself is considerably diminished ; the fat- cells are smaller, and their nuclei can be distinctly seen. Most of the fat- cells are, as in every form of atrophy, almost or entirely tleprived of their fat ; they are shrivelled into an oval shape, and have a great resemblance^ to the epidermic-cells of the rcto Malpighi. The blood vessels — especially those of the papiUie of the skin — are narrowed to such an extent that one cannot dis- guish their lumen.

We have, therefore, according to Parrot, a drying* up of the skin with consolidation of its layers, and atrophy of its adipose tissue ; and in certain cases observed in my wards a dissection of the skin yielded quite similar results.

(2) The second form, the oedema of newly-born children, preeeDts an entirely diflcrent picture. While in sclerema the rigid atrophic skin is firmly attached to the sulijacent parts, in oedema exactly the opposite condition obtains ; the skin being raised up and distended by oedematoua infiltration of the subcutaneous connective tissue. Thus we find all the cliniciU symptoms of oedema as they appc4ir at any age, especially swelling of tho affected part occurring either at one part of the Burface only or over thi' whole body, according to the extent of the a^dcma. Most frequently the swelling extends from the legs over the lower half of the body, the penis, the scrotum, or the labia majora ; and the calves sometimes become affected — earlier than the feet. Not uncommonly the trunk, the upper extremities, and the cheeks arc also affected in the same manner; or the swelling may be confined to the dorsum of the hands or feet. All the ofdematous parts are swollen, and feel doughy or hard according to the amount of infiltration and consequent tension of the skin. In extreme degrees the affected parts may thus appear very hard and yield little, if at all, to pressure with the finger, just as in extreme degrees of cedema at a later age. The skin is then usually glossy, while in lesser degi'ees of ojdema it appears dull, and for the most part reddish or yellowish, but sometimes ottled and bluish in places. When the skin is very greatly distended, a certain amount of rigidity of the limbs and of the features may occur, interfering with their mobility ; this disease, however, never presents the same degree of tetanic rigidity and board-liko hardness as sclerema, any more than the consolidation

DISEASES OF KEW BORN INFANTS,

of tLe skin equals tbat of the latter. The body tetnperatnro in oedema is usually vei-j low, and in cases which end unfavourably may reach 86'"" F. or even lower. At the post-mortem one finds an infiltration of the subcutaneous connective tissue with yellowish serous fluid ; while the fat seems consolidated to a reddish-yellow or brownish {:;ranulur mass. Thus, therefore, the anatomical condition also diflfers fundamentnlly from that in sclerema ; in which, on inciaiuf]^ the integuments, not a drop of fluid exudes and only the merest remnant of adipose tissue remains.

In spite of these differences there still exist certain similarities between the two forms ; which, however, concern not the skin- afiection itself, but the symptoms which accompany it. For example, wo have common to both the steadily increasing debihty, the smallnessandimpercebtibility of the pulse, the disappearance of the second sound of the heai't, but very specially the fall of temperature of which we have already spoken. I have myself found the temperature in the axilla 88'3° F ; others bare found it, towards the end, only 71*6° F. External heat pro- duces under these circumstancea either a very temporary warmth or none at all. The voice becomes weak and whining; the breathing slow and interruptetl, or frequent, superficial and noisy — ^owing to the presence of pneumonia, which in these circum- fitances is not as a rule sufficient to raise again the sunken temperature. The children usually lie in a completely apathetic •somnolent condition, and may exhibit towards the end local or general convulsions. Many also have more or less serious attacks of diarrho-a which considerably increase the debility. We find after death vorious compliciitious according to the pre- dominance of this or that symptom ; especially bronchitis, pneu- monia, more or less extensive puhnonai^ collapse, pleurisy, various degrees of enteritis, hyperemia, and small httmorrhagoB of the cerebral membranes and other parts. In one of my cases gastritis hiemorrhagica was fouuil. When we consider the age of the little patients we easily understand that a number of other complications may also o<*cnr ; t'.r/., jaundice, diseases of the umbilicus^ pya?mic and '* puerperal " aifeclions, Ac. We must BOW consider the first-mentioned of thi>se conditions, the true sclerema (which was described a hi »« rigo by Denmnti

and Underwood, and 1 n t .1 v t Ojder its proper

SCLEREMA NEONATOHUM.

55

leaJing) as a dryin^^-tip of the Bkin and adipose tissue (occurriiif,'

IS the resalt of extreme general atrophy?). (Edema neonatonira may be due t*3 just as many pathological

jonditious as tedema in later life. In one set of cases, as above mentioned (p. 4(>), a preceding erysipelaa is the cause of the <i)dema; and it is only thu8 we can account for the dark-red flushes about the pubes and other regioDS of the skin, which have been described by some authors, and the purulent infiltra- tions into the connective tissue and patches of gaogrene wliich have been occasionally found. In another class of cases the oedema is to be regarded as the result of extreme debility of the heart, of feetal myocarditis* or extensive collapse of

he lung; following upon which an engorgement of the venous JBystem of the body and transudation of serum take place. pometimes, also, a nephritic process lies at the root of the [ema, and of this Elsiisser* has already given examples.

*bo following case came under my own observation : — ■

A child of four vveekn athnitted on 24th Miirdi, 1874. Intertrigo in all folds of the akin; well-marked, teuBe oedenia of the fiu'C, and fill the extremities. Pnlsu l;it>. Temperature 97*7'^ F, The urine, obtained willi difllicult}^ was turhid, alhiiminous, and extreruel}- scanty. On the 27th, severe dyspunia arnl eyatiosij*. Pulse 144 — IGU. Temp. lOri^ F. The rcHpiratory orgiuiH i»f>piirently unaf- fected. Death on the 2lHh. At the pes t-raor tern there were found parenchymatous nephritis, serous fluid in the pleura, icardhnn and peritoneum, little haemorrhages on the serous kembrane coveriTis the he^irt, coiisolidiition of the left lower lobe

We see that sclerema and oedema of new-born children have ^At least one pathogenetic point in common — « xtrome debility, >ither congenital, or acquired through causes acting immediately ifler birth. The extremely low temperature is also coonected [with the diniioished energy of the heart-muscle (which has sometimes been found fattily degenerated) \sith the disturbed cir- culation, the weak respiration and atelectasis, and the ititerferenco with the necessary tissue-change. And it is this perhaps that ^asions that peculiar alteration in the subcutaneous adipose iisBue which makes it like solid mutton suet, and which is occa- ionally met with in children who are not very emaciated. It

To UiM cla»i» beloQg'i, «^., the omq deeoribed by Demme lui *' Sclcroin'* (IP Jahn§6«nckt, 8, 75),

56

DIBBA6E8 OF KfiW-BORN UiFAlSTS,

seems to me therefore by no means neoessary to make " in< tiou of the adipose tissue ** a special form of disease, as some writers do.

It follows from the pathogenesis just discussed that joa will obsei've sclerema exclusively, and cedema most frequently, in tbildren who were prematurely born, or wbo from the begin- ning have been placed under the most unfavourable circumstances (cold, bad air, and wretched nourishment). Hence ille- gitimate foundlings, |mrticularly during the cold time of the year, are especially liable to this condition ; while in private practice, aod even in that of a polyclinic, we have far less frequent oppor* tuuities of observiug it. All other causes mentioned are hypo- tbetical. Owing to the frequent occurrence of certain etiological conditions which may occasion on the one hand scleroma and on the other oedema from engorgement, it is conceivable that cases may occur in which both forms come on simultaneously or at least successively in one and the same individual* This fact has aggravated still more the confusion existing in the minds of most authors. Parrot describes au instructive example of this sort: a new-born child which at first presented a partial frdema continued to emaciate under the influence of atrophy and from the re-absorption of the cedema ; and, while the (edematous swelling was still visible on the upper half of the body, true sclerema began on the lower extremities and on the back.

After what has been already said about sclerema, you will bo able to judge of its inrurabilitv. The children die with symp- toms of extreme exhaustion ; not always quickly, for I myself had two such cases under observation in my ward for *2 — 3 weeks* The prognosis of a?dema is somewhat more favourable should the cause of it be curable. Thus, for oedema to follow erysipelas appears on the whole to be most favourable ; although hero also fatal cases are not uncommon. The prognosis in all passive cedemas (which are to be regarded as the expression of extreme cardiac debihty, pulmonary collapse, or nephritis) appears to be altogether bad. In all these cases recovery is exceptional, and the treatment must bo confined to dietetic and hygienic measures. It is of the very greatest importance t6 procure a good nurse and to nourish the child, when it is do longer able to suck, with the nurse'n milk dnwn-off or with good cow's milk. At the same time omr- Uikn to apply

PEMPHiaiTS NEONATORUai.

dl

iciul warmth to its cold body by enveloping it in cotton- wool, ibbing it with warm fiannel, by hot hollies, and by warm aro- matic baths (caniomiJe aud calamus). In the fonndling institu- tion at Moscow they uso for this purpose a metal cradle with double walls, containing warm water,' We may endeavour to maintain the sinking energy of the heart by giving small doses of wine (10 to 15 drops of tokay every hour), but we can scarcely expect very much result from this,

The confusion which till quite recently prevailed in the views concerning ** induration and oedema of the cellular tissue '' was considerably increased by Bouchnt, who connected sclero- derma— a disease sometimes observed in adults and older children — with the sclerema of new-born infants. Scleroderma, however, has nothing in common with our sclerema ; and is in its whole phenomena and course so different from it that one does not understand how Bouchnt^s error could have had any supporters. For further information on this disease, I must refer you to works on Dermatology. It has been repeatedly obsarred in children, and sometimes it has ended favourably.^

Pcmph ifjus Neona torn m ,

This skin-ftflection of new-born children presents very many vaneties in regard to the number, form, situation, and fulness of the bull® ; still, from a clinical standpoint, I consider it sufficient to distinguish two principal forms: the simple (acute) and the cachectic pemphigus*

The former (pemphigus simplex sire acutus) I shall ^t illustrate to you by a few examples from my own practice.

Tlio child of a pliyfticiiiti, hualtby ut Jjii*th, under my obscM-vation i» March, 1873, suffered from the iiiiitb day of life from an eruption of pemphigus, which dt!vc*lupt,'d »4UC€cs!iively, but without definite* order, on t!»e throat, iiwk, trunk, and extremiticH. Only the hands and feet rcTnaiued frc-e. The bulliD attiuued the size of a florin, but varied in some parts from only that of a pea to a hazel- nut> Tliey were somi-glotinlur, rather tengoly filled with yellowish seruni ; in some places thoy wore clo«e together, in others soparnted

■CUmentoweky, ikMerr. Jahvb,/. Pdd,, 1873, i., S. 7. » Crnao, OeMerr. Zeit^f.f. FOd., 1876, ii., S. \^.-Jahrb./,Kindtrkt\lknufl€, il.. 1877» 8, 318. -/6iU . riii.. 187<5, S. 36.— Silbermann, Jahrh,/. K'mtttrktUi., Bd. rr., 18»,

58

DISEASES OF KEW-BORN mPANTS.

by coiiaidoTublc intervftla. The whole number was at least 30 or 40. The intervenrng skiu was of a bright red colour. In the course, oi* the next icw days the contents of the bullae became turbid; not, however, in all of them. Tlie period of tlioir forma- tion lasted altogether 12 days, during which the child — apart from a modem te tracheal ratarrh — was perfectly well ; all fnnrtions were normal. The tera]>erature of the skin was not taken, but it uppeared to be scarcely elevated. Alter many of the bitllse had either burst or dried up, the formation of new ones cettued on the 12th day; the red nkin became pale, and after a week there was nothing left of the whole disease but red patchoa, skinned over and surrounded by a wliitish ring of epidermis. The cliild has ^ince remained free fi^om any return of the di^eaee.

A child of 14 days, to which I wu.h called on the 8th January. I87i (birth nonual), whose father, twelve yciirs before, had had a chancre but had since remained (|uite healthy, suddenly, on the 9th day after birth, in the midnt of pcrfwt hculth became aflFiX'ted by pemphigus. The temp, rose slit^htly and bullm brokr out in succcsaion over all parts of the IxHly, varying fn»m the niae of a sixpence to that of a half*crown or larger. They were serai^globular, transparent, yellow ish, and more or less tensely filled. The fact- also did not remain free, and especially on the forehead* the neigh- bouring bulke ran together and formed enormous elevations of the opidei-rai.**. The wkin of the iKxly was extremely red. The Holes and palms were unaffecttnl in thi.«i case also, except that otic bulla formed on the left palm. Along with this the geuerul health waa unimpaired. The mucoua membrane of the mouth was unaffected, and sueking not interfered with. The formation of biilli© which followed one another in successive cnups, lasted about ten day« ; and recovery followed, as in the tirat case. So that after several days the situation of the bull® was indicated liy thin drj- crusts surrounded by a ring of epidermis, and after these Luid separated the skin remained reddened for a considerable time. No sypliilitic symptoms were ever observed in this ehild subsequently.

In a child three week* old seen at the jwlyclinic in July. 187r». there were numerous bulhe which only reached the size f»f a six- pence; many remained considerably smaller, scarcely the size of a pea. and on the reddened skin smaller vesicles also apfjeared here and there. In this caao the child felt perfectly well and recovered within a fortnight.

In a lM>y 14 days old, brought to the |>olyrrmic 18th ^fai-ph, 187^1, the whole Ixxly waa likewise covered with nnmerou* pemphigun bulliv, a numlwr of which had opinpie, puriform rotitenls. Par* ticularly large bulhe *m tlie hairy scalp. The inguinal glands 'somewhat enlarged; health otherwise pc^oc*l. llwovery I tbiok that these examples will be etiough to bring before you clearly the clinical picture and course of &" '^'""*iR© iu uewi

PEMPHIGUS NEONATORUM.

69

I

bom children ; dioce it is not here my business to enter into a description and explanation of pemphigus in g^eneral. Yon find a rapid development of the eruption in quite healthy children daring the second week of life, Bometimes as early as the second day, an acute course lasting about fourteen days, and a favourable ending. Only rarely have I ohaorved the mucous membrane of the mouth to be also affected; c,g*y in a child two days old there was extensive formation of bulhe on tlio mucous membrane of the lips and hard palate, the epithelium of which was separated from the bleeding corium in the form of large fragments.

Unique uf itw kind was tlic otise of u tbild of dtnf and dumb parents, who, though otbcrwirie well formed, was born with large hiBinorrhagic pempbigu8-bii|he on the lips and tongue, and a few scattered over the rest of the body. This eniption lasted as long as I had the child under observutioii (about a year and a half) eapeciiUly on the tongue and gmns, hut the intervals hetweon the bTdlse became greater, and the tdiild throve very well. This ease. then, was one of congenital pemphigus, and it f^ained fnrthi r interest from the fact that the father's brother suffered from chronic pcmphij^us.

More than once 1 have had occasion tu fear from the large number of the bulhe and the redness of the skin — especially at such a tender age — that complications might occur sirailar to those in extensive burns of the skin ; my fears, liowever, were but seldom justified. Almost all those children recovered. Apart from extreme restlessness and severe itching during the stage of recovery (which one could distinctly recognise from their move- ments) the children did not seem at all ill, A favourable result is, however, by no meaus invariable. Chance i^omplications with inflammatory states of the internal organs* sudden collapne as in severe burns (especially in those where the vesicle formation is very extensive, implicating more than a third part of the skin), or a ftxrunculosis following this disease, have been frequently known to cause death. I would specially emphasise as important the fact that in this form the palms and soles either remain quite free or (as I have seen once or twice) present bollie of an cnormouB size, which implicate the half of the sole, and aro quite difforent from the flaccid purulent bullie of pemphigus gyphiliticuB. Iq certain cases the skin of the face and head remained free from eruption.

m

MS^^ES OF NEW-BOKN INF.WIT8.

The causal conditions aro obscare* The disoase is soi times observed iu lyiug-iu hospitals in an endemic form. Thus, we have the endemic occurrence of it obserTed by Ah 1 fold* in Leipzig, where within two months it attacked 25 children ^d between the second and fourteenth day after birth of totally ^M different couBtitutlons, who were almost all born of healthy mothers. In these cases also, the palms and soles always ^d remained free, while the fingers were sometimes seyerely ^M aSectcJ. Ahlfeld considers that the disease is of a contagions or at leanit mitismatic nature ; though ho is unable to bring forvviud definite proofs of this. Koch* thinks that the con- tagion is carried by the nui-se, because within three months he observed eipht cases of pemphigus which all occurred in tho prnctico of tho same midwife; and ho supplements these obser- vations in a later report^ in which 23 cases of pemphigus aro meotioued from tho practice of the same nurse ; while among 20U new-born children attended to by other midwives, not a single case occurred. Palmer^ has had a similar experience. Both authors have also observed the transmission of the erup- tion to adults, and Koch states that once, ** after many negative results,'' he succeeded, by inoculating with the contents of a bulla, in producing a bulla on his own arm after about 60 hours. Yidal and Blomberg* also report a few successful attem}>ts at inoculation. The epidemic in Leipzig and the sur* rounding districts, described by Moldonhauer* (the same which Ahlfeld observed) ceased when those afiected were strictly isolated. Nobody, however, has any explanation to offer as to the nature of this contagion. Especially it has not been possible hitherto to demonstrate with certainty the presence of fungi or spores in the contents of tho bullte."

I have not yet in my own practice met with pemphigoa neonatorum spreading epidemically, or endemically, in the way described by the authors I have mentioned ; and previously also by Hervieux, Abegg, Olshausen, Klemm^ and others. I bftve always had to do only with sporadic cases, and most

» AteL/. Cfnticot., v., IW. i.. S, ISO. « Jahrb. f, KmdtrMik,, 1873, 8, iW.

• Jnhrfj/. Kiwterh^l., 1875. 3. 425,

• WarUtmb, mrd, Corrt^fumdrntil, No. 10. 1880,

• Om, mdtL No. S», 18W.-J«ArA./. KmHerkeilk., tMJL, 8. 318.

• ij n$chr., lfl«J, No. ai.

• Qi^, «,., . y . . , , .^.-, n., An*l., a 90S.

PEMPHIGUS NEONATORini,

61

I

isertainly in none of tbem did transmission take place from the child to the nurse or to othern. Many others as well have observed this ; and have therefore attempted to discover other causes besides infection. Thus, Bohn^ connects this disease — which uflually arises in the second half of the first week of life — with the exfoliation of the epidermis which is wont to begin about the third day, and terraiuates on an average by the end of the first week- He thinks that during this time any iiritation of the skin — for example, that caused by the clothing but espodally by baths — may transform the physiological into a patholo<]ical process resulting in the formation of buUaj ; and justly cautions against judging of the temperature of a bath by the hand without the aid of a thermometer. Bohn refers to a case of pemphigus which had arisen in this manner from bftths of 101"7'^ h\, which were supposed by a nurse who had lost the sense of temperature to be 95^^ F. ; and the child rapidly recovered when colder baths were used. Dohrn^isof the same opinion, and ascribes to the skin of new-born infants the property of responding to mechanical, chemical, or thermal irritation by an eruption of bnlhe* The very exceptional occur- rence of transmission to those in attendance, and the few attempts at inoculation which have been apparently successful can therefore scarcely be considered to have established the infections nature of pemphigus neonatorum.

The treatment is extremely simple. I restrict myself to luke- warm baths, 90-5^— 93*7^ R, with the addition of bran and gelatine ; and I consider it unnecessary to add corrosive sublimate, as is sometimes recommended.

Pemphigus cachecticus is to be distinguished from tho simple acute condition by its affecting by preference the rogiona where the skin is thin — the neck, axilla, groin, and especially the soles of the feet and palms of the hands. The last, as we have seen above, almost always remain unaffected in the simple form. In a child eight days old, the tip of the nose was the seat of such a bulla. The bullae , which rise on livid spots, are usually only half- tilled and fla-ct^id, and seldom exceed the •ize of a pea or hazel-nut. At the same time their contents appear leaa clear, often purulent, sometimes tinged with blood. New-bom children sometimes bring traces of this eruption vrith

• Jitkrb.f. KmticrheilL, 1876, ix., 8* 304. Arch,/, CfttOdfU li-i 9. X

DISEASES OF NEW-BORN INFANTS.

them into the world (which has affected them during fcetal life) in the form of bullte which have burst and left bchiud them superficial ulcerations ; and this condition usually ]«*ftds to the supposition of congenital syphilis.

In fflct this form of eruption may be held to be one of the earhest sT^mptoms of syphilis, and I myself have records of cases which unquestionably prove this connection.

In a child of 6 months old the formation iif buUn* had coiu- racnced immediately after birth, and during the last months had increased to such an extent that by this time on many parts of the IxhIv, also on the face and the hack of the head, fresh hullic were visihle in some parts, exioriationa and criisits in others.

The dirty complexion, the chronic rhinitis, and latterly mucous papules round the anus, proved that we had here to do with pyphflis.

A jifirl of 6 days old» admitted 5th April, 187P, very atrophic^ exliihited pemjihigus bulte on the whole body,, especially nunj«>rfjas on the soles and palms, also under the nails. There wae also rhinitis with scabs on the nostrils and lips and enlargement of the axillarj^ and inguinal g-landa, Poefc-mortem: Osteochondritis sj'philitica UTiiversalis ; numerous small abscesses in the thymus,

A girl of 14 days, poorly nourished (13th December, 1881). Palroi and soles covered with recent opaque bulla? and rounded excoria- tions, which were surrounded by a ring of epidermis (ruptuj bullae). A few also on the dorsal surface of the hands and foel^ and on the fingers and toes. There waa also rhinitis, and intertrigo near the anus.

A child, 3 weeks old, with coryza, roseola, and pemphigus on the palms and soles, which had arisen 6 days after birth.

Are we then to consider this eruption of buUas (which differs from the first form by an indefinitely chronic course) as a regular indication of syphilis, or to agree with Caillault* that this is only the expression of a deep-rooted cachexia such as one so often observes among the children of the poor, espe- cially thoBo who are wasted and debilitated '? I freely admi.t that I formerly held this view myself, but lately, after having seen a good deal of the disease, I have changed my opinion. All tho cases of this form of pemphigus which I have examined during the last few years have been due to syphilis ; but owing to the wretched state of the children's general health, it was only in rare cases that specific ti-oatment was able to avert death.

APHTHAE OP THE PALATE,

63

Aphtfue of the Palate »

In a former lecture (p. 15) I drew your attention to miliary nod ales on the mncous membrane of the palate, which are met with in many new-born children during the first four to six [weeks of life. At this age if you examine the throat after depressing the tongue (which is not always easily done) you will ^vory often find, on either side of the arch of the palate, just on a level with the pterygoid process and immediately behind the alveolar arch of the upper jaw (where the bone is visible through Lthe thin mucous* membrane), a round or rather more oval [yellowish -white patch surrounded by a red border. These patches are usually quite symmetrical, though sometimes rather bigger on one aide than the other ; occasionally also they have evidently run together and their outline suggests the shape of a breakfast- rolL They seldom exceed § of an inch in their greatest diameter. These ** plaques," which readily bleed when touched with the spatula, are very often found in perfectly healthy children. They gradually lose their gi*eyish -yellow colour, become red and disappear, leaving no trace behind. But in atrophic and cachectic children I have occasionaUy seen them increase in size and depth and pass into real ulcerations which may penetrate even to the bone. In such cases one often sees the mucous membrane of the mouth and palate simultaneously covered with thrush j and the children die in [consequence of the general condition, or from the occurrence of complications.

Theae symmetrical ** plaques " or "aphthie" were formerly tdesoribed, especially by French physicians, but had been for- gotten; and Bednar* was the first again to draw attention to them. It is especially important to remember that these aphthae ^have absolutely nothing to do with syphilis. I should not have mentioned this at all, were I not constantly seeing cases in which physicians unncqnainted with the condition had made this diagnosis, I have always been of the opinion (now shared [hy others) that these aphthae arise simply mechanically from Ihe pressure and fnction exerted on the mucous membrane, (which is very thin in those places) by the tongue in sucking either from the nipple or bottle. According to Parrot,* what

• f>U Kr^tnlh. tie,' Stujeh, und Sautflimjt t Wien, 1850, »., S. 105.

Bi

DISEABEfl OF NEW-BORN INF.U*T8.

occDj-s first is a sponginess of tbe epithelium and a swelliog of mucous membraDe with proliferation of it» nuclei: and afterwards a casting-off of this and the formation of a shallow erosion. It is not correct to regard these aphthii^ as arising from nlcera- tion of the already-mentioned miliary nodules in the palate, which almost always occur only in the raphe and its near neigh- bourhood, while aphthie are situated laterally on the palate. Occasionally, however, ulcerations do also occur in the raphe, either superficial or deeply penetrating, and these may be Regarded as possibly arising from the nodules. The ulcers which occur in this situation, however, are on the whole far ]ess common, and, with comparatively few exceptions, I found them only in atrophic children. They resembled the apbthsB of which we are speaking, in every particular, bat had sometimes a more elongated shape. They occurred generally on the arch of the palate and were sharply defined, rounded, and of a yellowish white or grey colour. Occasionally the subjacent bono was exposed. I cannot share the opinion of Parrot that all ulcers which occur outside the raphe are syphilitic in origin. For example, in a child of six weeks old who died in a state of extreme atrophy without showing a single sign of By|)hili8, I have seen the whole palate covered with such ulcerations, while at the same time there was an abundant growth of thrush in the mouth and on the palate. The ulcers which at first appear yellowish or greyish-white, become at last of a bro\ni colour ; and in some cases bare bone can be felt with the probe.

The nphthfc of the palate being a very frequent " decubital " symptom require treatment only if, under the influence of defec^ tivo nutrition, they are iucreasing in size and depth. In that case I usually paint them with a solution of sulphate of Kinc (1 in 10), or nitrate of silver (1 in 15). I have only three times seen these aphth® after the first three months, in children of 5, D, and 12 moiiths respectively: in whom they were probably occasioned by too strong rubbing (during the cleaning of the moutli) of the pai-ts of the palate affected. Parrot also mentions the case of a child of two and a half years old with measles, who t»6aidcH other irosious and aphtha' in the cavity of the mouth presented two quite characteristic plaques on the palate.

Although Epstein^ and FiachP go perhaps too hr in

mttL Wocktffchr., tSSA, No. 1.% /»iU, ISW, No. 41.

MEL^ENA NEONATORUJI.

tliinklDg that many of tbe affections of the mouth in new-barn children (stomatitis, plarjnes and ulcerations) are the result of mechanical injuries from freqnent cleaning of it, it is well observe the care in cleansing which they enjoin. In some es I have, in fact, been able to observe an unusual spreading f the patches on the palate, due to hard rubbing. An appear- ance may result from this resembling a diphtheritic membrane.

This happened, for exnmplo, in the case of two children in the first week of life, m whom in the first place two patches had appeared at the sides of the palatu and gradually extended so far that thej^ at last ran into one anotlier, and the whole hack part of the arch of the palate was covered by a continuous yellowi»h-grey membrane which ended in a sharply-dcfiued line above the uvula. The latter^ as well as the tonaila, w^aa, however, normal ; and this circumHtance, a« well as the mode of development which I have described, was sufficient to cast doubt on the diagnosis of diph- theria which had been made in one of the cases. As it turned out, the whole disease disappeared witimi ten days without leaving

shind it any loss of gnbstancc.

Melana Neonatorum.

shall conclude the consideration of the diseases affecting new-born children exclusively or generally, with a few remarks on melsena neonatorum, a disease on the whole rare and which I hftve myself had an opportunity of observing in only a few

Ieaeea. This complaint is characterised by hiemorrhages from the stomach and intestine commencing as a rule between the first and seventh days after birth, rarely later. Sometimes only A vomiting of dark blood on several occasions takes place ; and afler this, in spite of the extreme collapse at first, the children pra/Iually recover. In other cases, however, the vomiting of blood returns more frequently and the diapers are saturated by blackish blood from the anus. Sometimes the vomiting of blood is entirely absent and only bloody stools occur following quickly on one another. These contain meconium or fflecal matter to begin with, but later consist solely of fluid and coagulated blooil. Other morbid appearances may be entirely wanting, and the examination of the abdomen yields nothing abnormal. In most c-ases, owing to the repeated copious htemorrbages there follow within 21 — 48 hours, death-like paleness, coldness of the skin,

5

66

mSBASBS OF NEW-BORN INFANTS.

disappearance of the pulse, and death. But a small numbtr recover after Ibe bleeding has ceasod. The mortality, accordiu^r to different authors, varies between 85 and 00 per cent.

The views as to the mode of origin of this dangerous tnalady fary greatly according to the pathological conditions which bav«

Lven rise to it. Billard explains the htipniorrhages an dne to thi hyperflBmia of the mucous membrane of the alimentary tract which is present normally tluring the first days of life, and may be aggravated by any chance disturbance of the venous circulation, e.g., by an asphyxiated condition of the child at birth ^ atelectaain of the lungs, congenital malformation of the heart, or enlargement of the liver and spleen. Others (Kiwisch) blame premature ligature of the umbilical cord ; while in recent times attention baa been directed to little rounded ulcers of the mucous mem- brane of the stomach and intestine. These were kilown by the French authors, Denis, Billard, Rilliet and Barthcz. Barrier and others, and were at a later period described by Vogel, Hecker, Buhl and others among ourselves. There is a diflerence of opinion as to the mode of formation of these til< (an anatomical description of which is to bo found in Parrot' ft" works ^) for some ascribe to them an inflammatory origin, others (Bohn) hold that they proceed from an ulceration of the follicles or from a fatty degeneration of the small arteries (Rehn;. Lastly, Landau,*^ arguing from a case of duodenal ulceration with thrombosis of the umbilical vein, believes in an embolic origin of the ulcers and thinks that they arise from thrombfl which are driven from the ductus arteriosus, or from the umbilical vein into the small arteries of the gastric mucous

lembrane, and bring about gangrene of the affecte<l area. At [the same time, the corrosive action of the gastric juice upon the portion of skin which is excluded from the circulation, is held to promote this gangrene. Asphyxia and iucomploteness of the tirst respirations are of importance in so far as they favour a stagnation of the blood column in the umbilical vein and tbwj

»rmation of thrombi in it. As a matter of course the ulcej tions have in recent years been looked upon as parasitic and as occasioned by deposits of micrococci (Behn^).

' Ue. ciK, p. 247.

« Utbtr Mtttma 4ta Xewftbormen uaje, : Brfjsku, 11174.

* Cftr^ltHt./. Kindtrhamk. IS78, 8. t^

MEL^fiNA NEONATORUM.

67

You see what a vtti*iety of views are hold upon the pathology f nielitna iu infants ; and hence you will conclude that this ^Bffe^tiou may he only a symptom, i.e. may he caused by various anatomical processes, just as in later life. It is most certainly a fact that ulcers of the gastric mucous membrane are pretty common in new-boru children, while meliena is, on the whole, only rarely observed ; and that, further, in the very many cases where multiple ulcers have been found post-mortem, neither vomiting of blood nor bloody motions were present during life. This is all the more remarkable because the contents of the stomach, as I have myself seen in such cases, appear bloody and lackish ; and further, the litLlo ulcers in the mucous membrane may be covered with a la}'er of mucus of a blackish colour, although during life no blood-evacuations had taken place. Even ould wo ascribe the melitna in isolated instances to ulcers in e stomach and intestinal canal (I have myself known one such se in which two ulcers were found in the duodenum *) yet we n by no means do so in the majority of cases.- Kling, in six ses which had ended fatally, found gastric and duodenal ulcers but two, in nil the others only venous or capillary haemorrhages uld bo assumed. I should not, however, underrate the merit of Landau's work. His case of duodenal ulcer and the fact that ha^moiThage from the bowel may arise from embolism of the esenteric artery,^ retdly make it incumbent upon us to examine, tins particular, the arteries of the stomach and bowel in all of mela?na in new-born children. On the other hand, we acknowledge the possibility of hRBmorrhages without ceration when the venous pressure is much increased owing to tt*rference with the respiration. Landau himself admits this, d E pst ein ' 8 experiments prove it ; for he caused blood-cxtrava- s in the mucous membrane of the stomach in animals by nsion of the respiration.^ Finally, I need not do more than ention here that cases of bleeding from the intestine may depend upon a haemorrhagic diathesis, or very likely on "puer-

' Veit, * ffevtMchr mtd. Wochcimchr., 1881 ^ No. 50 1. The child WM Mren weiskn d, and hftd bron^kt ap onJy emaU quauiitiee of coffee-ground material, mid imd tor had rcgtilar Tomitinjur of blood or bloody motioni<.

* •* tJ©lxir Mi'la*na noona^*rum" : /naug.-JJis$., Munchen, 1875.

* Kloli iZ<ir»chr, fUf r/r^/^eA. der Wiener AtrtU, 1859) bae alao obMxred in a d of eight <likyi» old a tlirombofiifl of the mesenteric artery, with effnuon of

ood in the muoooa membrane of the bowel.

* Areh./. erperim. Pofkol^ Bd. ii.

DISEASES OF NEW-BORN INFANTS.

very LaidH

peral infection "; because the bleeding in such cases forms only one link in the great cliain of local and general ajinptoms. Two very interesting cases are mentioned (Eilliet*) of copious bleed- ing from tlie intestine in twins^ who were almost simultaneoasly affected and were reduced to a state of extreme collapse. One might have been inclined in these cases to the diagnosis of a general hiemoiThagic diathesis had the disease not ended in re- covery and both children remained afterwards perfectly free from haemorrhages.

These cases, to which others might be added (Rahn-Eseher, Silbermann),* also show that not only the slight attacks in which the vomiting of blood occurs only once or twice» bat also the very severe ones in which the symptoms of collapse, general coldne disappearance of the pulse, and turning upwards of the eye appear, are still capable of cure. We must, therefore, ( when circumstances seem most unfavourable) always endeavour to arrest the exhausting hiemorrhages. Cold compresses or the application of an ice-bag to the abdomen, the arms and legs being at the same time wrapped in warm flannels, are to be re- commended. The most suitable nourishment, when the children cannot take the breast, is icod milk, given with a teaspoon. Id severe vomiting of blood this method of feeding is on the whole to be preferred to the breast ; because when the latter is given the stomach is readily overfilled, and vomiting occasioned thereby. For medicine I should recommend first the liquor ferri. perchloridi (gtt, ii every two hours in a teaspoonful of oatmeal- water)! second ergo tin (gr. i — j internally or by subcutaneous injection). Enemata are not advisable, because they do not reach the higher portions of the intestine and are rather apt to pro- duce slight tenesmus and fresh bleeding — as happened in the first of Rilliet's cases. As regards prophylactic measures, Landau warns against premature ligature of the umbilical cord ; and it is always best not to tie it until the respiration is fully established and the children cry strongly.

In conclusion I may further remark that new-bom children occasionally pass a little blood upwards or downwards, which has cither been swallowed from sore nipples or an operation on the mouth or throat This blood may also eomo from the nose

^ Gat^ m^., No. 53. 1S48.

MELJENA NEONATORUM. 69

and tbe neiglibouring parts. Its amonnt, however, is alwajs small, and it is scarcely possible to confound it with real melsena. The following case stands quite alone : —

A child of 5 days, admitted Ist October, 1881. Since the 3rd day of life, repeated vomiting of blood and blaek, bloody stools. The child sickly, shrivelled, anaemic. Extremities coli Anal aperture covered with bloody faeces. Pulse imperceptible; tem- perature 87'8° F. Takes no nourishment. Death that evening. F.-M. — General anaemia. Spleen normal. Immediately over the eardia a ring of ulceration, If inches long, surrounding the whole (esophagus. The submucosa remained free; it was swollen and infiltrated with greyish-white matter. The ulcer sharply defined above. Otherwise, everything normal.

We were unable to throw any light upon the origin and nature of this oesophageal ulcer.

DISEASES OP INFANCY,

there is a branny desquamation of the epidermia. At this stuge the organic functious, especially those of the alimentary cani may remtiin quite uuiiiterfcred with or almost so ; and by suitab] lourishment and care wo may still avert the threatened exhaostioi and initiate recovery. In the majority of cases, however, tbe^ possibility of such a favourable turn is excluded by their poor circumstances ; functional disorders of the digestive organs (especially vomiting and diarrha^a) are added ; and finally the last stage developes which precludes all hope, and leaves to the physician when ho sees a number of such children together (as e.g, in my wards), only sadness and resignation.

When the clothes with which the mother has wrapped up tl^ child are thrown back, there looks out from them a yellowish pale face, with peaked chin and projecting bones, and numerous wrinkles (in all directions, especially round the nose and I month and on the forehead) which become more pronounced on every movement of the facial muscles. The e^^es are wide open and staring, or half shot with a dull expression, a perfect .picture of languor, which from time to time is interrupted 'painful distortion of the wrinkled features, by a feeble cry, or hoarse whining sound. The movements are slow, or there are .none at all. And yet the appearance of the face is only, as it 'were, the prelude to the horror excited by the examination of the naked body» which, when one considers the domestic circum- stances causing it, is fitted to make a truly tragic impressioi The shrivelled earth-coloured skin hangs in folds over the bonei which — especially the shoulder-blades, spinal column, ribs and nia^ — ^distinctly mark out the outlines of the skeleton. On the neck and abdomen the skin lies in large folds; and these, owing to their loss of tone, retain their shape (as in Asiatic cholera) for a considerable time, as if they were formed of dough. The fatty tissue seems to have entirely disappeared ; and the muscles {e,g, the gastrocnemii and the adductors of the thighs) feel like thin shrivelled bands. Not unfrequently the skin is erythema- tous on the genitals, anus, and heels; and in various situations — I even on the scalp— it is the seat of abscesses and boils of various Bises. The mucous membrane of the mouth and palate is more or less extensively coated with thrush.

In all cases of atrophy occurring in iufantn at tbc breast or on the bottle^ we must remember that the deficient iintn'iinn r>f th«

INFANTILE ATROPHY.

7S

vfU

k

issues may arise from different canses; and to treat fnlly of infantile atrophy would involve the consideration of no small portion of Paediatrics. Even when all circumstances seem to- indicate a simple atrophy, that is one which has arisen from faulty and insufficient nourishment, we must always inquire whether other causes may not also be acting. First among these causes I should place tuberculosis. Seeing that I shfill have occasion later on to enter fully into this wasting disease, I shall only say here thitt in the first years of life, owing especially to the simultaneous implication of many organs which have the closest relation to blood-formation {tho lungs, the lymphatic glands, the spleen, &c.)i tuberculosis produces mptoms which differ substantially from those of the same dis- ease in later life, inasmuch as the local symptoms of the various organs are of small importance compared with the general inter- ference with nutrition. Certain proof of a hereditary predisposi- tion to tuberculosis and the physical signs of a consolidation of tho lung tissue are the only sufficient grounds for diagnosis; since owing to an accompanying catarrh, crepitations of different kinds may be heard in any case of simple atrophy, and if there is diarrhoea it may depend upon a chronic intestinal catarrh and itfi resaltSi just as well as on a tuberculosis of the intestine^ Although, as a general rule, atrophy in infancy is more commonly ^^ simple than tubercular ; still, in any special case, repeated ^■examination and observation of the course of the disease are ^B&ecessary to establish the diagnosis; and Rilliet and ^Bliarthez' are certainly right in their maxim: "ni les symp- ^Hlomes generaux, ni les symptomes locaux ne peuvent offrir la ^^lumierc sutBaante ; le traitement seul est la pierre de touche I du diagnostic."

I must now complete the general picture of atrophy which I have sketched, by adding a number of individual details* B Very often disturbances of the digestion arise early, either ^■repeated vomiting (immediately or some time aftej' taking ^^nourishment) or morbid alterations of the faeces, which are passed more frequently than in health, are more liquid, and nstead of being bright yellow and of firm consistence present yellow or greenish lumps and streaks. At the same time tho

» L. e,, ii., p. 377.

1>ISeiSRS OF IKPANCT.

secretion of urino usually tHminisbeB, so that tbe child'fi dlapern often appear quite dry or at least considerably less wetted bj urine tbtin ifl tbe case witb a healtby cbikl. This circumstance results for the most part from tbe dimiuisbed appetite of the child. Ho takes less uouriBbmeut and strugf^les against receiv- ing tbe bottle, or, impelled by thirst, drinks ofteoer than u^ued but always only a little ; so that the amount of milk taken — and proportionately that of tbe urine passed — remains considerably below tbe normal. I occasionally, however, have met with cases of polyuria in atrophic children; but I have only exceptionally been able to discover a distinct sugar reaction in the urine — which was collected with some trouble, although others (Parrot,' Robin-) have heen able to ascertain its presence (or at least that of a reducing subsLance) and that of albumen aUboufrh the urine was scanty and dark in colour. Although the quantity of sugar has almost always been small, still cases have occurred where as nmoh as 7 per cent has been found in the urine, and which might therefore bo looked upon as real diabetes. In addition to those symptoms the child is very fretful, cries much, and sleeps less than usuaL As the disease progresses, all the symp- toms increase in severity. The stools, which at first were only nlightly altered, become more ami more liquid, of a dirty-groen i«>lour, very offensive, and contain floccuU, Very rarely is the oppo- site condition, normal, or even diminished frequency of doftocation, ohserved. The appetite is quite gone ; and the child loses even the strength to suck from the bottle or the nipple, and has to be fed with small quantities of milk out of a spoon. The respiratory organs — unless any complications are present— show no abnormal physical signs ; oidy, the breathing hecomes very shallow and weak, like the heart's action — which in the last stages may sink to sixty, or even fewer, pulsations in the minute. The body- toTOperature may finally fall to 85-" F., or lower; and when the Ungw ifl introduced into the child's mouth, it feels a strange coldness. Owing to the weakness of the heart, tbe skin (which has hitherto been of a dirty-yellow tinge) presents on the extremi- tloii (}ip$, Ongera^ toea^ nails) a alight cyanosis. Under these

^ inJifir itlttittipM in ili« urin^ irlueb F^rrM hn** iK>itit«U nuilnrtBtfard to ili«' lunuuni of tho ♦•«*», NiHUiimntii, f»t> Jkc -^ '•* -nirpof nioro iniiK>rC-

«n{H> AH beftntijf tm ttMiiiii».aUAn|r«> thftti for r '^<*<

fiat. mW., nwo, No. t5.

INFANTILE ATROPHY,

75

krcnmstanced we see that the grout foiitauolle sinks beueatli the

■Bvel of the Barroun fling cranial bonos, whereby a depression

^bont a line in depth is formed, and its aize may be more or

less diminished by the approximation of the cranial bones.

The diminution in volnme of the brain and the consequent

decrease in the tension of the cranial capsnle account for the fact

that the edge&i of the bones are made to overlap one another.

'he half-shut eyolidB, towards the end scarcely capable of the

"-elightest movement, complete the picture of fatal collapse, which

often comes on almost unnoticed, because in the last days the

iondition of the child may be already like that of a corpse — the mlse being imperceptible, the akin cold, and the breathing slow nd extremely feeble. In new-born children, during the last ►eriod, that rigid condition of the body which I have described p. 51) as true sclerema, may make its appearance. One can make no definite statements with rega.rd to the duration of atrophy; because it in regulated by the circam-

I stances of the child, it^ original strength, the means of nourish- blent available, and espocially by the complications which may irise. Thus, we often see new-born children die within the first ^eeks or months of life with the symptoms already described ; while older children may prolong their miserable existence for

Bmany months, and succumb only to an exacerbation of the ^iarrhcDa or to an intercurrent acute affection of the lung. Broncho-pneumonia is, under these circumstances one of the commonest causes of death ; and iu these as in other cases, it may b© occasioned by an accidental chill or by food getting into the windpipe, especially when the child always lies on its back, I should draw your attention especially to the fact that, in these ^cases of extreme atrophy and debility, careless feeding, particn- Hkrly the bad habit of leaving such children to themselves when ^■ceding from the bottle, may result in milk being drawn into the ^Bir passages, and consequently in bronchitis and pneumonia^f ^Hndeed death does not rapidly ensue from asphyxia. This may ^hilso tttke place if the children bring up the contents of the ^Kltomach into the mouth, especially during sleep. I have once or twice anfortunately met with such cases in my ward, where, ^^nth the best intentions, it is yet impossible to keep up a con- ^ftUnt oversight of each individual child; and Parrot (he. p« ^B7) mentions cei'tain similar observations on eases of death from

76

DISEASES OP INPANCY.

foand in the langs and

'iMiph^yxiu in wbich chyme ^ chemical action had produced softening of the lung tissue and adjacent diaphrac^n.

In post-mortem examinations of children who have died of Bimple atrophy, we invariably iind nothiDg hut an almost entire absence of subcutaneous and perivisceral fat, attenuation and pallor of the mnscles (mcluding the heart muscle), and usually extreme anemia of all parts.' There is oftt-n extensive atelectasis of the long tissue, owing to the diminished power of inspiration. Among complications, the commonest are broncho-pnenmonia, catarrh and follicular inflammation of the intestinal canal. Owing to the extreme weakness of the heart in the last stage of the disease, one sometimes finds venous engorgement and throm* boeia — especially in the sinuses, in the dura mater, and in the renal veins. Such thrombi may occasion symptoms during life. I shall return to this in another place.

In atrophic children, our estimate of the danger must depend essentially on the degree of the disease and the possibility of re- moving the patient into more favourable conditions. If the atrophy is not too far advanced, and there are no serious complicatiouB^ and if we can exclude any suspicion of tuberculosis and procure for the neglected child good nourishment and nursing, we may still give a good prognosis. It is astonishing in such cases how fiuickly the body may increase in hulk and strength, and the child which had the look of an old man may be transformed into a well -developed thriving infant. On the other hand, in practice among the poor, we can scarcely entertain a hope of attaining the same result by our directions and superintendence, however careful ; and the younger the children the less hope there is. Thus, new-born children run the greatest risk ; they supply most of the fatal cases, and the finer pathological anatomy of the disease is founded especially on the reaulta of post-mortems of cases in which death had occurred in the first weeks or months of life. Although we are bound to acknowledge the very high merit of Parrot's contributions to this subject, yet

• Aooordin^ to the investij^tion* <4 OhltntilUr (*'lT«b*r tWv AltnuiiniM ,1or obuelnen C^rgane boi an Atrtjiphic ^etit'^rbonon Kindom " : /»<> .ti,

1882.) the loaa of fttt iiB principally At tho r-rpcn't? nf tbr un)- .^

tieme, tbe loaa of aJbumati nt tliu vrpi um : )^

while the bfiUii r^mama quite tiiiiifreot«(i, . .>,\f

normftl.

INFANTILE ATROPHY.

I

In my opiDion his works do not authorise one to describe a Dew species of disease under the name of *' atbrepsia " of new-horu children. This, as I have already remarked, is nothing more than our "atrophy,*' and the rapid course depends solely ou the tender age and wretched circumstances present in the case of Parrot's patients. Thus we must explain the one-sidedness of his view, which puts down among the Bymptonis of athrepsia a number of patbologicai appearances which either have nothing at all to do mth atrophy (such as trismus), or may also occur in children who are not atrophic (as thrush) .

In turning to the treatment of atrophy, I do not fail to fecognise the difficulties which stand in the way of thoroughly performing my task. Were I to undertake this in its full extent, I should far exceed the limits assigned me. Indeed, I should have to go into the whole treatment and care of a healthy child, from its birth to its weaning ; because all the mistakes which are committed daring this period in regard to feeding, cleanliness, clothing, &c., are at once reflected in the state of the child's nutrition. I should further have to enter into the spheres of social seieiice and public health, since we can expect the removal, or at least the improvement of the unfavourable con- ditions in which atrophy is most apt to arise, only from compre- hensive regulations imposed by the state and the various local authorities, promoting the general welfare of the poorer classes. Among such we may mention regulations concerning improve- ment of the dwellings, the providing of light and air for that first periotl uf life which needs tbem so much, the possibility of

e mothers feeding and nursing their own children and not

ing obliged to entrust them to strangers who for a small payment undertake a duty which they afterwards either neglect r worse than neglect. Such persons, indeed, ought to come

der the rigour of the law, if their inicjuity could only be

The humane efforts of our time and the wide-spread

pathy which the lot of these unhappy little creatures has

led forth, are steadily doing away with the order of " angel- era *' I have just alluded to. Foundling institutions, creches, children's-refuge societies have been established in many in some munificently, and their beneficent action is of all recognition. But all this is not nearly sufficient

grapple on a large scale with pauperism and its resulting

proved.

rorthy

DlSEiSRS OP EfflSCY.

conditions. Tbas the fulfilment of our Rpparently limited task — the treatment of infantile atropbv — renmins closely bound up with the solntion of this great social problem. You will soon become con?inccd in practice that treatment under the circam- stances I have described can yield but small resalts ; that all your directions are rendered useless by the simple fact that they cannot be carried out, or else by the evil intentions of those iti charge. You must get accustomed to see every year a large number of such children pining away and sinking into the grave, without your being able to hinder it. This result is exemplified most sadly in institutions in which a considerable number of atrophic children are lodged together, hospitals, and all kinds of children's asylums. Only those foundling institutions which adhere to the boarding-out system, i.e., giving the greater part of their children out to nurse in the country, can achieve better resnlts.

Such being the state of matters, I must here contine myself to the discussion of a point which is certainly the chief one, and that which can bo most readily dealt with from the purely medical side, namely, nourishment. I have very little to say on the natural mode of feeding — the mother's breast or that of a nurse. As I am not now lecturing to you on the dietetics of childicn, but on their diseases, I cannot enter more fully into the physiology of feeding, the qualities of human milk, the choice of wet nurses, &c. All these matters have to be con- sidered by me only in their relation to pathological conditions ; and therefore I must first tell you that even when fed in the natural way children may become atrophic if the milk continues to cause dyspeptic symptoms (i.e., vomiting or diarrhtDea), by which, naturally, the absorption of the amount of chyle neceasaiy for normal nutrition cannot but be prevented. On the other hand, cases sometimes occur where the milk of a nurse disagrees with the particular child whom she is hired to suckle ; and in that case the child suffers continuously from digestive dtetorb* anoes, although these may not bo present to a marked degree they retard its development. The same nurse after her dis- missal may Huckle another child with the best possible results ; 80 that one must not assume the presence of some peculiar quality in the milk but mther a peculiar idiosyncracy of the first child, which in its turn may thnvfl «rtromely well with

4

INFANTILE ATROFflT.

19

I com

■pery

If

die

all

n.

kotber wet nurse. Strangcs things sometimes occur even wheu bie mother suckles her own child. Thus, one sometimes notices Ih^t a mother who has already nursed one or more children most ■occesBfiiUy, ia obliged to take a subsequent child from the breast fcecause her milk does not agree with it* And yet one may not he able to find any cause for this. Still, I may observe that it agrees well with infants in general to get good dilated cow's milk from a bottle once or twice daily— or at any rate during the night— ia addition to their mother's milk. This practice, bow- er, I consider justifiable only when the mother herself is ckling and not when there is a hired nurae. Even the commencement of menstraation in those who iire nursing has in many cases no disturbing influence, but it must always ke us careful. Experience alone can decide in these cases. If tbe infant begins to have digestive disturbances (vomiting or diarrhoea) not only transient but coDtinually recurring, and the body-weight ceases to increase or even diminishes, there must no delay in making a change of nurse. In order, however, to recognise the loss of weight early, one must weigh the child carefully at least once every week, estimating the results most cautiously, with due regard to the influence of accessory circum* stances (such as articles of clothing and the contents of the stomach, bowel, and bladder). These weighings can generally only be carried out in institutions or in private practice* In by far tbe greatest number of cases of atrophy which occur in con- nection with the polyclinic or in practice among the poor, we tanst be content with the observation of our own senses.

The sjTnptoms which the children themselves show — dyspepsui and incipient atrophy — seem to me of far more signiticauco than all the methods by which it has been attempted to estimate the nulity of the mother's or nm-se's milk. We certainly learn fi-om 0 microscope, the number, form, and size of the milk globules ; and it is doubtless a very good thing to £lnd those fully formed and in proper number; because, when the globules are small and scanty, they do not as a rule afford the proper amount of Dourishmont.^ But these investigations, although made by the most practised observers, give by no means uniform results as to

' Dog«1 iJahrb,/, Kinder hcilk. J xsii., 8. 256) dcnoribea miUc-grlobuIeB capped «ritb a ^ren^jeatio maiis of a finely granolar, occa(»ioti&Uy uacleated material, which art> Kaiii ii> oocttr in lar^ numbers in the milk of women whose cHldron Biiffor from diarrliaM, (P).

so

DISEASES OF INFANCY.

the influence of the various microscopic differences on Ihe stale oi the child. More difficult still is the chemical estimation of tw milk, which very few practitioners are competent to undertake for themselves in a sufficiently thorough manner. Also the* results of the examination hy no means always agree with thfl clinical observation, since, e.(f., an excessive amount of fat in th« milk may excite dyspepsia in one ehOd, and may be very welH borne by another. I therefore ad\nse you, above all, to makffl the condition of the child the standard whereby td judge the milk ; just as in choosing a wet-nurse it is best to hm guided by the condition of her own cMLd. This, in my opinionJ is the only proper and practical way. You may in this way, of course, be obliged to try three or even more wet nurses for tho same child, but you must not be deterred by such difficulties, or by the inconvenience of repeated inspection of nurses. Th»* success in the end and the consciousness of having done your duty will be your reward. I may also mention that an iu8ufficienc|^ in the amount of milk can be recognised not so much by feelinffl the breasts and noticing what can be pressed out of them as by thd diapers' being dry and ihe child's continuing to cry after it ba|| received the breast, when, had it been properly satisfied it would' have fallen into a c|uiet sleep. In general the quantity of tlie milk diminishes from the beginning of the eighth month afte|| confinement.'

Far more difficult, however, is the situation in the great majority of cases : where, from the reasons repeatedly giveoj the natural mode of nourishment is quite impossible ; and thd infant who is beginning to waste has to be put upon the bottloJ It is inconceivable with what substitutes for milk tho chiidrem of the poor arc fed; but daily experience in the polyclinic id continually affording new proof of the stupidity and barbarity ofl these people. Thin oat-meal water alone, or that mixed with m little millc, or decoctions of meal of all sorts, form tho wretohedj nourishment of many infants from the first days of their lifeJ And even this is not given to them regularly, or as their hungen requires, just because the mothers or nurses have no time on inclination to discharge this duty. I have already mentioned td you (p. 15) the scantiness of the saliviiry ^ in the first!

months of life; and you will uuderHtAnd th g that peuofl

I • Pftfiff or, JaM./, JCificlcrA . . iJ. i, lim, ^H

IKFANTILB ATROPHY.

81

^

Le^ till about the tenth week) absolutely no food which is

omposed of amyloids should be given, because those sub-

tances retjuiro saliya sudicient to change them into sugar. Can

He he surprised, then, that with such a diet from the beginning

the foundation of dyspepsia is laid, the stomach and intestine are

surcharged with undigested masses, and tympanites and diarrhfea

arise? And farther, of course, the«c substances have a very

small nutrient value compared with human milk. Where the

latter cannot be procured we must order cow's milk as the

nly substitute suitable daring the first three months.

his does not, indeed, correspond entirely to human milk for it contains more casein and less sugar ; and hence there is a greater tendency to acid-fermentation, so that oow's milk becomes sour more readily than human milk. The amount of fat in human milk is certainly liable to great variatioUj but is usually less than in cow's milk. A difterence of the utmost importance lies in ihe fact that the casein in human milk is almost quite soluble,

hile that in cow's milk is so only to a small extent, so that the former is easily dissolved by artificial gastric juice and acids, the latter only with great difficulty; that, finally, the casein of cow's milk forms on coagulation a dense coherent curd which is difficult to dissolve, while that of human milk coagulates in small loose flakes (Biedert'). You will understand how im- portant this difference must be for the child*B stomach. The loose coagula of human milk arc much more easily acted upon and dissolved in the stomach by the pepsin and hydrochloric acid of the gastric juice than those of the cow's milk. The fteces of children nourished with the latter will, therefore, always con- tain more undigested casein than those of chikken at the breast ; and, on account of the greater amount of fat in the milk, they will also contain more fat. We cannot remove this drawback as we should wish, even by the much recommended addition of barley- or oat-meal water, gum arable, lactin^ and so on ; although

' Soxhlet, (MUnrhfUfr mM. H'fHrhtnsehr.^ 1886^ Ko, 154 10} U riifht in nttachinicr KT«ftt woiirht to thi«i fact especially, that hniniut milk in the biH>a«t in tih»o\vLie\y jrormleflf, while oow'e milk is always rich in fonnentitiT^ figeats, which have g<ot liito it in the fitrible duriner milking, from the excrementa, d:c. A repofttcd »nd thorough boiling in therefore abaolately nocc^aary, and S. has conntructod a ipe«i»l apparatiut for thiB, which from personal oxperience I can atrougly re<K>a]- Imand to you.

* The addition of lactin, according to the oxp0rim«iit« of Hrynttohak (Arch.

Kinfim-keiti:., 1882, iii., S« 421) i« abaolately i&joriotta.

6

82

DISEASES OF INFANCY.

we may at any rate make up for the other leas import44nt differ^ ences by suitably diluting the milk. In general, daring the- first three months you may take a proportion of one part milk to three parts water ; during the second three months, one to two ; during the third, half and half. From the ninth month onwards you may give 2:1 or quite undiluted milk, which like the water must ahvays be boiled, in order, if possible, to destroy the germs of fermentation contained in it. It ia quite evident that the proportion of dilution which we have given may be modified by the quality of the milk, which unfortunately often leaves much to be desired. The chance of recovery of atrophic children among the poor depends principally upon the procuring of unadulterated fresh cow*s milk; and the public ought to give more atten- tion than they have hitherto given to this point,' on which the well-being of the rising generation so greatly depends. Much more can be effected in this way than by all the recently recommended methods of preserving milk, however meritorious they may be. We must not forget that, in the whole question of artificial nourishment, we are chiefly concerned with the poorer classes, who are unable to bear the least additional expense; and that of all substitutes for human milk, fresh cow's milk is always the cheapest.' Asses' milk, which chemically most resembles human milk, is certainly the dearest substitute. The experiment which was successfully made in Paris* of usiug asses' milk for the feeding of infants in the first six to eight weeks, is therefore all the more deserving of recognition.

Since, however, insuperable difficulties lie in the way of the general employment of asses' milk, cow's milk forma the best substitute for the natural mode of nourishment, not only for the first month but for the whole period of suckling. I con- sider it allowable to give other substitutes only when good milk eithei" cannot be procured in any way or does not agree with tlie children, i.e. when it causes continuous Tomiting and diarrhcea. As a general rule, the latter circumstance does not often occur,

* <jy". Cny rim, *' Uober die Prtiduction von Kindor-nnd Knlimilch in Rt4(]tiNcl]i^<n MilchktiranHt&lteQ " : DfHt^h« Vitrl*\jahr»ekr./. ^emtt. Gtundheitsp/tgf, ix.. 1S7*.*, — Kormann, Jahrb.f. JCiml'^hrill:., N. F.» xiv.. 8. 238, and xy., 8. 300.— AbNtra«-tH on the Bubjoct of *' 1» • ibution* to Iho qaortion of inf antilo oourtBlimetil *' in tho Areh^f. Kindt \ iytnai, 1^1. u,, S. 170 - Bj<«d t?f t, Kimdtr^mUkrmy J0I Saufllinptalfrr : StulUfikrt, 1^80.

» U off maun, Jnkrb.f, KimUrktiik , tri., l^Wfl « Ut,

• Tiirnivr %nd Parrot, Gnttmm'if^ V M

INFANTILE ATROPHY,

83

I

and one may not iinfrequently remedy this state of matters (as I know from experience, and abftll haTe occasion to refer to later on) by having tbe milk boiled and giving it to the child after it has cooled. There are always, however, a number of cases in which even this cold milk cannot be borne, probably on account of the tirm consistence of its coagula, and the consequent difticulty of digesting them. We are then, in default of a wet-nurse, obliged to try other substitutes. Condensed Swiss milk which has recently been so much recommended, is apparently the most available and the best. If we put some of it under the microscope we see tbe field entirely covered with crystals of sugar of milk, which disappear as if by magic whenever wc place a little water on the objeet-j^lass. Wc then see only innumerable well preserved milk* globules. Although I have seen condensed milk used with advantage for months in a few cases, still I can- not recommend this method of feeding ; because the enormous addition of cane sugar which is necessary for the preservation of the milk (89 — id per cent.) frequently produces acid fermentation and diarrhcea. Very recently they have discovered how to diminish very considerably this addition of sugar, so as to avoid the injurious eftects of condensed milk. Still, I have not yet seen any occasion to make use of this expensive preparation.^

Among the numerons artificial substitutes produced in our time, NestU's food, which is prepared in Yevey, has acquired special repute, and is most extensively used. This consists of wheat-meal, yolk of egg, condensed milk and sugar, in such pro- portions that there are 20 parts of nitrogenous matters and 7 parts of salts in 1,000. Usually one boils a tablespoonful of the food with 0 or 10 table spoonfuls of water, and the fluid is given from a bottle. Nestlu'a food may under certain circumstances become tainted, and then it is very injurious. Among others, I n one case of a child whom I was asked to see in the of 1878 on account of incrensing atrophy with whom no cow's milk agi'eed, and in whom obstinate diarrhcea, naturally increasing the atrophy, persisted in spite of tho administration for weeks of Nestle^s food, and of the most varions remedies. I then discovered that the food which waa contained in a tin box, bad not (as it should have) a

' Ha|;enhaoh iCorrtMitontUnzbh der SchwtUer Aerzft, 1883, Ko. 1) and Banso [ArrJLj], KittderheiU-.^ W., S, '212) recommend these 7arieiie« of condensed milk ^lIolAretia, Romrtn-JionifT Milch, 1 in 1(^ to 1 in 0 barley-water I,

84

INFANCY.

Bmell Hke tbat of a rusk, but Bmelt abomiuubly — like old eheeaai I bad a frosli tin seut for at once, and then I found that the food prepared from it agreed ver}' well. From my own experience I can recommend Kes tie's food as a suitable moans of uourbib- ment after the tenth or twelfth week of life, not earlier. Bnt I am by no means alto«jeilier enamonred of iL From experiments which I instituted on other similar infant's foods. «nch as those of Gerber, GiCfey, Liebig, Freriehs, ami Kufck<*, I am inclined to believe that the same value may 1h) Bssigned to all of them, and to preparations from the manufactoms at Cham and Tevey and Muntreux. The lucrative character of ibis business, moreover^ makes it probable that the world will con- tinue to be favoured with new preparations of this sori ; which will in turn excel one another in the endeavour to approiw^h as nearly as possible to the composition of human milk.

Among the other well-known substitutes for mother's milk, I shall only mention here Liebig's food and the cream- mixture recoramcmled by Biedert.^ The former, once fo much extolled, is now quite given up because its pre{>aratioii is far too troublesome to allow it to be f^enerally used in practice among the poor — whom we have chiefly to consider in dis- cussing artificial nourishment. The same may be Bikid of Biedert's cream-mixture, which I ut^ed in my ward for some time for a number of atropine children without being able to convince myself that it was more efficacious than feeding? with cow's milk or Nestle's food, I have not myself sufficient experience of the "artiBciaT' cream-mixture recommended by Biedert, which at any rate is more easy to use; hut it is spoken well of by Monti* and others, though in this case also the price is a drawback owing to tlie poor circumstances of many of our patients.

An excellent aid in the nourishment of atrophic infanta is wine, especially unadulterated tokay. Whether other kinds of wine, such as sherry and malaga which are frequently given, are to be rei^arded as of equal value I shall not decide. I myself always prefer to all other kinds the old Hungarian wine, of which my neYer-to-bc-forgott4?n teacher Romberg used to say thai it was not only a ** lac senile,'* but also a *" lac juvenile," In the first months of life we may give 20 to 25 drops three or four times

t

i

a

TERIBH.

85

daily, nudilutcdy or in a teaspoauful of water. In older childen we may increase the dose to several tcaspoonfulH or more in the day. At the same time one sLoukl for the sake of cleanliness order a warm bath daily (93*^ to 95'^ F.), to which one may add, if the debility is increasing, aromatic infusions (the best being a hand- fal of camomile and sweet calamus infused in hot-water)» Well- ventilated sick-rooms, strict cleanliness, careful regularity in the nursing, all these are (and unfortunately too often remain) *'pia desideria/* which can be attained only in a *;mall minority of the cases.

From drugs we can expect nothing in {itroph3\ It is only when it is distinctly complicated with dtKoi'ders of the respira- tory organs or intestines, that there is any indication for their use. And I must here remark that slight dyspeptic symptoms (vomiting or unnatural, offensive, badly-digested stools) may disappear without the use of medicines as the result of suitable ^m dieting.

I

II. Thruah,

I

The younger the children the ofteuer they suffer from this affection of the mouth and throat. Thus it is cotumouest in new'bom children and during the lirst months of life. But it also often occurs in the second half of the first year, and you will nicctt with it under ccilain conditions much later, even in adults. The appearance of the disease varies according to its degi'ee and the circumstances in which you find it.

First Degree.— On the mucous luembranc of the lips, tongue and cheeks, especially on the folds between the lips and gums and between the cheeks and the alvuolar margin, we find separate, white, sliglitly-projectiug points tmd spots. These can easily be rubbed off with the spatula, but if one uses force in doiog this a drop of blood is left. The mucous racmbrone is otherwise unaltered, and there is no other disorder. This form of tlirush occurs very often in perfectly healthy children if til© necessary cleaning of the month has been neglected, owing to remains of milk being left behind in the above-mentioned folds of mucous membrane, and uflerwarils decomposing. Some

^€s it is not easy at firist sight to de<Mde whetlier we have to do

8G

DISEASES OF INFANCY.

with real tlirnsh or only with reranins of milk, as these haTe almost the same appearance ; the difference is seen when we touch the spots with a spatula, by which the remains of milk (which lie loose on the surface) are at once removed while the spots of thrtiah adhere more firmly to the mucous membrane.

Second Degree.— The whole mucous membrane of the mouth, as well as that of the pharynx, is of a dark purplish-red colour and noticeably dry. All over it — but especially on the tongue, the cheeks, the lips and the hard palate — one sees a great many white points and ajwts of rounded irregular form, which here and there (especially in the above-mentioned folds and on the tongue) run togt^ther into larger patches. The cavity of thd mouth appears to be tender to touch, as the children while sacking often distort their faces painfully, or refuse the breast entirely. At a still more advanced stage we find the toDgaOt cheeks and hard palate covered with a white membranous coat- ing ; while on the hps and gums, and further back on the soft palate and tonsOs, spots of thrash are visible in large numbers. These extreme degrees occur only in atroph i c children or in those exhausted by severe illnesses (diarrhoea, cholerine). Thus w*e may explain the circumstance that the mucous membrane, which was dark-red to begin with, gradually becomes pale from the progi'essing ansBmia. In the last stages of the disease in such children I have found the spots of thrush adhering to a perfectly pale and slightly livid mucous membrane, and therefore less liable to be noticed than when tbc mucous membrane was very vascular. Further, the spots lose their milk-white colour more and more, and often appear dirty -grey or yellowish, the latter colour being duo to bile-staining by vomited matter. Accordingly, ono must look more narrowly to recognise the whole extent of the disease* The longer it lasts, the more firmly do the patches of thrush adhere to the mucoua mem- brane. Among very many cases of this kind, I remember par- ticularly that of a child of four months in a state of extreme collapse with congenital syphilis, and pneumonia of the right' lower lobe ; the whole of the pale mucous membrane of the ' pharynx as well as that of the month was covered with pearl- 1 grey patches of thrush which were so firmly adherent that they I .could only be detached forcibly by means of a pair of forcepg, And With Horne blreding. New>born children with this disease *

THRUSH.

H7

k often present at tlic same time the ulceratioDS ou tlie haid palate wLicli I have already meulioned (p* 6B). When we ex- amine under the microscope a little piece of the thrush well Waed out, wo see that it h principally composed of a numhei' of filaments and spores of fungi. When this was discovered in 1842, hy Berg, a Swedish physician, all previous explanations of the disease as due to intlammatory exudation fell to the ground* HWe can only regard it as of parasitic origin. The filaments ^ appear as long tubes, straight or bent in various directions, trans- parent, with a sharp contour, 50 to 60/i- long and 3 to 4ft broad, H and consisting of various segments articulated to one another. " Almost all of the ripe filaments present one or more branches of the same form springing from those points of the stem-filament where the joints are marked by a septum » The interior of the ^ filaments usually contains some molecular granules, as well as a ^P few little oval bodies — probably spores in process of development, llound the origin of the filaments one almost always sees heaps of roundish or oval spores from which they arise. ^ Besides the fungous elements the microscope shows numerous epithelial iiells, with a vnryiiig number of fat-globules and red blood corpuscles which have become entangled in the patches of thrush on being detached from the mucous membrane*

That is all that thrush shows cJinically, All the syBiptoma which were formerly ascribed to it — especially the violent diarrhcBai vomiting and collapse, of which earlier French authors particularly spoke — ^lo not belong to thrush but to the original disease of which it is a result. I have, therefore, only a few anatomical and pathological remarks to add. Thrush is by no means confined to those areas of the mucous membrane which Are accessible to our clinical examination, it also frequently urs (as the post-mortems show) further down — especially in e lower part of the pharynx, and often in the cesophagua, particularly its lower two-thirds ; there it occurs either in the

* JlathorB «tni differ widelj oonoemuig the botany of thniBh. The tuuno

*oT(linm nlbioann" which hiM b«on attacked by G raw its {DeuUckt Ztitschr,/.

ni'L MttL, 1877, No. 20) iB indeed given up. C/, P 1 a a t ( Seitr. zar fyttem, StdJung

4ts Si>nrjiUzt4: Leipzig, 1885), 8 1 o m p f f J/««cAencr mtd. WochcnMchr., 1886, 8. 627),

Bftg^inaky iVtrtrnf. inner* Mtd,, 30th November, 1886), Klemperer, {Ctntralb.

t. ilin. Mtd.^ 188S, No, 60), PUut, (^V^iu; BHlr. sttr stfttem, SttUung de§ ^€*orpifze4 (n

BotaniJc: Leipciip, 1887). Plaut rotT^rdit the fun^s aa identical with that

%rbicb we And growing on rotten wood^ freah cow^-tluniif and Bwoet fmita— Monilia

adida.

I

EASES OF INFANCY.

same way as in the moutli, or forming a more or less perfect cylinder which, owing to the projecting folds of the raiieous mem- brane, looks like a piece of bark. Thrush of the cesophagns is not usually of a pure-white colour but pearl-grey or yellowii and ends just above the cardiii in a sharp line. I hare foi it on the mucous membrauo of the stomach only in one case, whore it occurred in the form of isolated and somewhat prominent patches. I rauBt, however, admit that such a careful examination of the stomach, as is necessary here was not always made ; and, of course, a large number of our atrophi children showing thrush in the mouth did not come ujid< post-mortem examination. I mention this because Parrot* has not tinfrequently observed thrush in the stomach. To recognise the patches we must iirst remove by a stream of water the thick layer of mucus which covers them ; they then oomt* into view in the form of little papilla>, isolated or aggregat some of which can only be made out with a lens. The li patches often present a central depression ; and from this, as w^ell as from their generally yellow colour, they acquire a decid* resemblance to a favus«cruat. Most commonly the diRcaso found on the posterior wall of the stomach, along the lesser curvature, and in the neighbourhood of the cardia. Here the thrush is so markedly adherent that it is difficult to remove il by a stream of water or by scraping* Beyond the st-oraach thrush only veiy rarely occurs. The observations of Valliex and Soux, made without the help of the microscope, are not conclusive. But those of Robin and Parrot may perhaps be so ; the former having found it an the small intestine, the latter in the caecum on two ooeasions. In thin region, as in the stomach, the acidity of the contents is to be regarded as a condition favouring the growth of the fungus. However this may be. we must in all these cases assume that the germs or filaments of the fungus must have found their way down the pharynx or cesophagus. It is remarkable that the di8< however strongly it is developed in the pharynx, never exteni into the back part of the jiasul cavity^ even in cases of del palate where a direct commuuicatiou exists between the cavitii of the month and nose. It may, however, be fonnA occasionallv on the mucous membrane of tlxo glottis in the form of little

• r.iH-.

223

THRUHH.

8a

ibi

I

patches or strcaka. Since this is the only part of the respiratory mucous membrane which is afTected by thrash, we must agree with Berjt and Lelut that only squamous and not ciliated, epithelium atl'ords a Huitablo soil lor the f^owth of the fungus, hrosh has been found iu the lungs only in very rare cases, and it has then probably developed from germs inspii'cd from the pharynx (Parrot, Bircb-Hirschfeld).

On examining more closely the relation of the fungus to the sub- cent mucous membnino, we find that a part of it lies superficially tween the epithelial cells ; another part penetrates more deeply into the tissue, so that the filaments can be distinctly seen to enter the mucous membrane perpendicularly fWagner* and arret). This fact explains also the very considerable resistance hich one occasionally meets with iu the attempt to detach the ts. The observations of Zenker and Ribbert- on certain rare cases in which it was found in tiie brain, seem to indicate at the fungus may be carried into other parts of the vascular ystem.

Thrush does not seem to develope in a perfectly healthy mouth, or at least it never spreads to any considerable extent. Even in the cases of our tirst degree, we must assume a certain amount of irritation of the mucous membrane from the remains of milk, which decompose and prepare a favourable nidus for the lopment of the germs. This is more distinctly seen in the of the second degree, which are far commoner. In these

lys preceded by a marked dryness and dark-red colour lucouB membrane of the mouth ; the tongue becomes ^tough from projecting papilla?, and it is in these places that the growth of the fungus begins, being favoured by the deficient alkalinity of the mucous membrane. To this feature I have already drawn your attention. The exceedingly small amount of the salivary secretion iu the first months must favour in a high degree the formation of acids in the mouth and drniess of the mcous membrane. This view need not for the present be ikakeu by the cultivation experiments of Kehrer,' according to diich saliva seems to be an excellent medium of nourishment for ic thrush-fungus* The main influences, however, which favour germination of the spores are the child's weakness and

krft /. KiadcrkeiU., 19W, i., 8. 58. fWw W>ii Snarpik : ?I#'i*lctbnnr, 1883.

* Berliner lUfi. IVoehnucKr., 187I», S. 618.

90

DISEASES OF INFANCY.

atropLy; and iu proof of this fact I mfly adduce Del afond*s* experiments on animals. He was never able to transmit thrush by inoculation to the mucous merahraue of the mouth of a healthy well-nourished slieep with copious sahvary secretion; but be succeeded at once when he had weakened the animal hunger, or had chosen for his experiment an animal alreac diseased and with acid saliva. In accordance with this is tht clinical observation that eruptions of thrush, quite similar to those occurring in atrophic infants and those exhausted by diseases of all kinds, occur not uncommonly at a later age, in the last stage of phthisis and in severe cases of typhoid. Among other cases I I'ound in a girl 13 years of age who had died of severe typhoid, not only the pharynx but also the cesophagus as far as the cardta covered with a coating of thrush, which from its dirty-grey colour and the difficulty of closely examining the pharynx had been mistaken during the last days of life for diphtheria. Thus many cases of '* diphtheritic complication " of typhoid which are not examined post-mortem are really cases of thrush of the pharynx ; and this mistake is all the more likely to be made as thrush may occasionally spare the mucous membrane of th© mouth and attack only the palate and pharynx.

Although the spores usually reach the mucous membrane of the mouth along with the food (milk and other fluids) or inspired air, yet direct transmiBsion by the bottle is possible (should its mouth-piece not be repeatedly cleansed every day with the utmost care) and may occasion repeated attacks of thrush in the same child. Be particular, therefore, that the india-rubber mouth-piece of the bottle is carefully washed, left lying in water, and daily cleansed inside with a small brush. Wliether thrush may \*e transmitted from the child's mouth to the nipple of the mother or nurse is a question on which different observers are by no means agreed. Seux* says that out of more than 1,000 cases of thrush, he did not once observe its transmission to the nurse^s nipple; but others — especially Mignot^ — on the strengtli of a few observations, express themselves in favour of such a possibility, chiefly when the nipple is excoriated ; and Delafond, i& his above-mentioned inoculation of sheep, found that tile

* Gai. hMomad,, 1S58, p. 900.

' Jteektrekt* mr let mataSUt da tiifkmt*

* Trniti d« quetqms mntadiH pendant k

^ui9: EWiii. ias&, p. ». d9ti PkJrb. 1S»9« p. 833.

^^^^V THBUSH. 91

oidium might be transmitted by a Iamb to its mother's teat. We muat, therefore* in all circnmstances warn thoae who are suck- ling of the possibility of such a transmiBsion ; and impress npon them as a duty the utmost cleanliness, and especially reqnent washing of the nipple with alkaline flaidn.

cases where one has doubts as to the diagnosis of lah — and these are extremely rare — the microscope alone can lecide by showing the characteristic filaments and spores. I lavo already mentioned that remains of milk-ciird on the mucous membrane are readily distinguished from thrushi because they can be easily wiped off. There is, however, another ludition which is sometimes mistaken for thrush by the inex- perienced ; namely, a membranous desquamation of the epithe- lium of the raucous membrane of the tongue, and especially of the gum, in the form of thin greyish-white layers. The micro- scope in such cases at once proves the error, by showing only ^epithelial cells and an amorphous granular mass but no fungus elements. In a few cases we see these accumulations of epithelium only under the tongue, where they become rolled- up id form a transverse cord of a milk-white colour.

I liave found thiii in two infants; one of whom was thriving and well-noariahed, the other atrupliic, with many cntuneous ahst'essca

id a bed-sore on the elbow. Neithur of the children hud uny jeth, but the mucous membrane of the mouth was reddened all over uud bled rcudily when touched. Tlie white layer under the tongue could be pretty easily removed, only at the freniim it was ©omewhat more firmly adherent* and left a drop of bKw>d behind it. Under the microscope I cimld recogruMe only fat-globulew (really remains of mi!k), epitlielial cells and an amorphous connecting; masSi but no trace of the thruah-fungua ; and it seems to nw that the free desquamation of the epithelium resulting from the hyyteraemia of the mucous membrane had uHHumed this form of a convoluted cord fi'ora the contintial gliding of the under-am*fiice of the tongue over the alveolar border during the process of Bucking.'

It is obvious that the local treatment of thrush affords hope »f success only in cases of our tirst degree. In these a mere mechanical wiping-ofT is generally sufficient. The nurse must

' The Affection of tho frcnum Ungum deeoribed by Ri|?a i GloifofrtnMl'Jt mtm- ht^mfkCMt: NbpoU, llSSl) appoara to mo to bolonir to the saiuo catijiirory ft* these M^ ADd itfi faUikl termination to be m&inly due to tho atrophy &nd weakness of pfttients. I f^e no roa4on to $ot this down m a special epidemic iliaoA^o.

92

DISEASES OF INFANCY.

BOt hesitate to rnh oft' the patches of thrnsh which she sees e«] the mucous membrane, with a piece of Hue linen wrapped round her finger and dipped in cold water — even although it causes a little bleeding. Whenever now eruptions make their appearance, this proceeding must be repeated, and the cavity of the mouth very cai'efully cleaneed in the same way after each nursing; the aflectiou will thus soon be got under. It is a very different matter in cases of the second degree in children who are atrophied and, exhausted. Here also, it is true, you will readily succeed in removing the thrush by simply clean sing, as above; or, even; better, if you neutralise the acid reaction of the month by dipping the linen rag in an alkaline solution instead of in water only (e,g* pot» chlorat,, ac- boric, borax, or sod, benzoat., 5 p,o, Bo!il«! tions in water ; or common salt, a large pinch dissolved in a gUsil of water). In this matter the experience of practitioners hitherto has been quite at variance with the results obtained by Kehrer* in his experiments. For, according to the latter, we should expect the remedies named to favour the growth of the fungus. The general morbid condition which favours the growth of thrash is always the most important matter ; and consequently you will continue to have fresh outbreaks taking pluce in these cases. When this occurs, I have often obtained a good result Irom painting the whole mucous membrane of the mouth with a solu- tion of nitrate of silver (1 or ii p. cJ after the patches hare been wiped off.

II f>^JIeredita ry StjphiUs.

During the period in which we most frequently obaerre the beginning of atrophic conditions and the development of thrnsh, we have also the most abundant opportunity of becoming acquainted with the phenomena of hereditary syphilis. As this disease occurs in very various forms, it seems most suitable io give you first of all a clinical picture of it as you will most frequently see it in practice ; and to discuss later on its varieties and less common conditionn.

The children are brought to you usually in the second or Uiird month of lifo» and appear welb or ill-nourisfaed nccording as they have been suckled or hand-fed. An extreme degree of atrophy (

HEREDITARY SYPHILIS.

<>3

is by no means one of the necessary features of infantile sypliilts; for a large number of children brought to me — esjiecially tJiose on the breast — were well-nourished and of a healthy complexion, although those that were hand-fed certainly showed a tendency

■4o atj'ophy* Extreme degrees of this latter condition were not, Lowever, to be attributed to syphilis alone ; but also to other ffu^tors — hunger and all kinds of misery — -working along with it. ^^ One of the earliest symptoms is a snuffling character ^■Df the respiration, which is caused by swelling of a part ^■pf the nasal mucous membrane lying beyond the reach of ^BMiection; and it is often called '^a cold in the head'* by ^^IKhers. At a later stage, the nostrils become hlockod by yellowish or brownish crusts, and sero-mQcoua discharge some- times slightly blood-stained (coryza syphilitica), and the nose may become somewhat swollen externally. This coryza — which

f)rariea very much in degree — I hold to be one of the most con- stant symptoms of the disease, either preceding the other irrmptoms, or almost always accompanying them. It is only absent in exceptiomd cases. Soon we have in addition bright- ^^ed patches—usually with a brownish tinge— rounded or irrcgu- ^piar in shape, varying between the size of a threepenny -piece and ' ft sixpence. These appear at first singly, and their favourite >08ition8 are the region of the eyebrows, the chin and naso-labial fold, the neighbourhood of the anus, and the pahus and soles [roseola syphihtica). Many of these patches present a branny (Uamation of the epidermiSj or aro covered with large frag- ments of it; others — and in many cases, nearly all — have u glazed and almost varnished appearance when looked at from the ifiides. The patches situated on the chin and nates become [gradually macerated by the repeated action of the secretions rom the mouth or the urine and IWces. And when the epithe- lium is shed they are changed into moist red excoriations which, kken apart from other symptoms, have not in themselves any 'distinct specific character, and may, indeed, be obscured by an erythema surrounding them (intertrigo). In every case, how- ever, the distribution of these excoriations, the patches with Uinbroken skin which occur along with them, and the presence of ■Jie coryza aro sufficient indications to warrant a suspicion of ■yphilis and to justify specific treatment. I If not so treated) the further progress of the disease soon dispels

DISEASES OF INFANCY.

any iiucertamty. The patches now spread over a large part of the body — especially over the forehead, all round abont the moutli, and over the cxtremitieB, In many places they coaleaoe and form lai-ge dasky-rod or brownish-yellow and more or less desfjnamating patches, covered here and there with scabs owing to the dryiD}^-iip of moist excoriations. The palms and soles are generally diffusely reddened, covered with fragments of desqaamated epidermis, and often (the heels especially) present a glossy redness and tension. There al^o occur whitish excoria- tions at the angle of the mouth, and fissures and cracks in the mncons membrunc of the lips (rhagades), which readily bleeti on sucking and on crying. These, along with crusts which cover the eyebrows and with coryza, present a picture w^hich can scarcely be mistaken any longer by the least experienced and which justifies the diagnosis of syphilis without any confes- sion from the parents. In many cases the picture is rendered still more characteristic by the falling- out of the hair, especially the eyebrows, and even the eyelashes. Trous- seau's observation of a browrmess of complexion peculiar to congenital syphilis, I can contirm only for a series of cases where the patients were atrophic; while among many other well- nourished children I have observed a complexion just as white as in health*

You must not expect, however, that all the features of this disease are generally as well marked as I have just described to you. Often only some of them are present, while others are wanting or very slightly indicated. Thus, e.g., I have some- times seen the genital and anal regions quite free from eruption, while the upper parts of the body (sometimes, indeed, only the face) were most typically affected. Further, variations from this typical description of the disease are by no means rare. Th instead of roseola, I have repeatedly observed dark-red roan papules on the soles of the feet, the lower extremities* an^ round about the anus ; or, here and there, dull-red infiUratud spots covered with thin whitish sculeH, occasionally ** figured," — occurring especially on the glabella and on the eyebrows but also on the cheeks and nates. These bordered partly on psoriasis, partly on coudylomatous formations. Occ«- sionally — though only in children in the first weeks of life — we find the remains of buUfe (p. 61) in the form of red spots or

HEREDITARY SYPHILIS.

95

m V mn

excoriations surrounded by a dry mjg of epidermis; soraetimos also there are on the soles aud palms recent, usually flaccid, bullit with turbid purulent contents. In many cases, especially in very young children, I have found along with the signs of ihilis almost the whole skin diflusely reddened and covered ith large yellowish scales of epidermis mixed with sebaceous matter. Least frequently I have observed vesicular and moist [eczematous) forms of eruption as the expression of syphilis; id these have usually seemed to me as if they had been brought about by maltreatment of the papular and macular eruptions, ipecially by scratehing or the contact of irritating secretions and jxcretions. In a child six weeks old an eczema which developed along with a copious roseola on many parts of the body, turned out to be simply the result of very abundant perspiration aud had therefore nothing to do with syphilis. I Lave more frequently ^kbserved deeper ulcerations, covered with scabs, to develope ^H:>ut of the above-mentioned excoriations in the neighbourhood of ^BUio anus and on the scrotum, and also on other parts of tho ^■ddn {i'.g, about the eyebrows, or around the navel), just as the ^"fntertrigo of the inguinal region, which is often present at the I Fame time, shows a tendency towards the formation of whitish- ^Bgrey ulcers with red infiltrated margins. On the other hand, I ^^ave not been able to convince myself of the correctness of the view* that it is only tho condyloma latum (mucous papule) rhich justifies a diagnosis of congenital syphilis. On the con- iTjf I can affirm that in a considerable number of cases and in lite of the most careful examination we could uowbere lind Ihis condition. I by no means consider the mucous papule us me of tho earliest symptoms of the disease ; for, except in isolated ^casefl, I have never observed condylomatous formations till at a later stage— in children already some months old or suffering ^from a relapse of the disease. Under these circumstances, cer- linly, mucous papules occurred frequently enough^especially at Lhe angles of the mouth, on the tongue, under the chin, in the Lguinal folds, round the anus, on the scrotum and vulva; some- times also on the inner and uppermost part of the thigh ; most commonly, on the ala} nasi aud at the outer angles of the eyes. Thus generally they are found in situations where the folds of in lie in contact with one another, and irritation is caused by CaUUalt, TriiiUprnt du maladies dt la /icdii ehet k* em/ants: Fhiu, 1859.

9e

DISEASES OF INFJISCY.

pressure and by accninuUtion of secretions. Their appcannee was the same as thai of those in adalts, and their tendency to become macerated by secretion (saliva, urine, fnpces, swi^ai), was Tery marked ; the epidermic covering of the condylomata being consequfintly shed, they turned gradually into greyiHh-while ftssurod ulcers. In rare cases the condylomata formed con* t in no 11 B masses, which ^ — especially when they occurred on the labia majora — presented a nodular appearance which reminded one of elephantiasis. Onychia was also frequently observed, with thickening and claw -like deformity of the nails, which were finally cast^olf by suppuration of their matrix.

In addition to all these various afiections of the outer skin, the mucous membranes may also present morbid appeanwoes. In addition to the almost constant coryza, I have observed con- junctivitis with purulent secretions (but in no case iritis, which seems to be one of the rarest of all the manifestations of con- genital syphilis), iluor albus, occasionally also redness and swelling of the urethral orifice with pain on micturition. On the dorsum of the tongue there occur, as already mentioned, condylomatons (or rather, perhaps, gummatous), hard, dark projections, mpe* cially towards the back ; and also the tonsils are sometimes the seat of flat ulcerations arising from condylomata. I cannot, however^ regard these alTections of the mouth and throat as common, since in the great majority of my cases these parts presented nothing in the least degree morbid ; and I here warn you once more against regarding the repeatedly-mentioned palate- ulcers of new-bom children as syphilitic in nature. Sometimes wo have, along with the syphilitic afiections of the akin in children, an alteration of the voice — a more or less pro- nounced hoarseness, which iu extreme eases may go on io complete aphonia. In the fallowing case this loss of voice con- stituted almost the only symptom of syphilis which could be aaoertained ; —

Curl r., ffiiir moiitliAi oU\, J*niu«rht to tiiy [X)l\rl»ntc 14lb MftP»!b. 18157, had Hiifftrcd for two monlha frt>Tii honrei'iipgs. nnd Latterly from caiupk'tts nphonia. VV*c' suw lite child crying, but fcarciily hcnrd atiy sound. Na cougli ; hrtMithing ttortniiU )u the pimrjnx and iTii the epfgtoKis notlitng nbiiormal. KxaminHliim with thti laryngoBCojif? iinmicccwsful (Wwldctiburg atti^niptrd it), Tlif chUd was bt»«llhy» well-nonriMbcd. ant^ thrivinic; but tht*m wnrr bro<rni*k Ncam round tbc (• ' <^»Lt^ga4ioii

HEREDITARY SYPHILIS.

97

it was fonitil thut at the age of two months h© had suffered from coryza, with » desquamating macular eruption, which was cured by calomel. Diaguoyis.^ — ^Syphiiitic affection (condylomatous ulcer?) of the Yocnl cords. I ordered mercur, eolub. (Hahncm.) ^. ifp twice daih^ By the 23rd — that is, after 29 days — the voice was clearer; on the 18th April quite normal. After-treatment with syr. ferr, iod. No I't-tum of the disease by Decemher*

As to the natnre of the laryngeal affection in this casei I Bliall not hazard an opinion, I have no experience of pericliondritia ^cf the epiglottis or caries of the thyroid cartilage, such as have ^casionally been described* Just as little Lave I seen of the ^syphilis of the intestine in new-born children, which has recently been spoken of a good deal. This consists in gomma- tons indarations of the mnscular and mucous coats, sometimes ring-shaped, which encircle and narrow^ the lumen of the small intestine, and usually correspond in position to Peyer's patches^ partly also in coudylomatous growths and ulceration of the patches and in cellular infiltration of the smaller arteries to their obliteration and causing ana?mic gangrene.^ In the meantime, 'these conditions do not appear to have any clinical importance, since a case of this kind reported by Schimmer^ (recovery of a case of diarrhoea nnder specific treatment) cannot be held to Ihave demonstrated this.

Slight enlargements of the lymphatic glands (from the size

of a pea to that of a bean), which are moveable, may often if

lot always be found on close examination. Sometimes there are

'only a few behind the ears or at the lower end of the upper arm,

^or a number massed together in the cervical, axillary and inguinal

»gions. These masses of glands are always among the most

itjactable features of the disease, and also often persist after it

Bs cured. In these cases, certainly, it is doubtful whether these

glandular enlargements do not form a chance complication

lepending on other causes. I can by no means agree with

lednar, who regards the swelling of the lymphatic glands as

utremely rare, and says that he himself has only once

observed it.

Syphilitic affections of the osseous system were formerly

red to be very rare. A few cases of destruction of the bones

• 0»©r,.4rf:AtV/*, Dtrmnt.u,Syphiiui,lS7l,S. 1.— Jurgons, Jtthrti./. KinderhtiUti IS81, rrii.j 8. 126.— Mr&ook, VitrteijahvHchr./. Dermat. «, S^pkUitf 1883, S. 209.

* Arehivf, iMrmai, u, .SgpkUu^ 1873, No. 2.

7

I

■

of the nose (vomer and turbinated bones), or of i>ertostiiis of iLv femur and otber long bones, have been described ; but ther*» Beems to have been no idea that these conditions occur in earl v chiJdhood just as often as in adults, and under certain conditions even oflener. A case of this kind waa observed and described by me in the year 1861' : —

Anna 6., 2 moncbs old; atrophic, although on the breael : brcmglit to my polyclinic on 4ih April, because «ho had not moved her arms for 14 days. Both up}>er extremities lay flaccid and motionlcfiSf even when the child moved its legs and body in difl^crcnt directions. Xot the slightest movement of the fingers could ever be made out. If one lifted up the 1 e f t a r m and then lei it go, it fell down without any resistance, like that of a dead body ; while, if the same were done to the right arm, there were stiU obaervable eome alight traces of resistance. Seusibility and tem- perature of both Anaa normal. Both con clyles and the entire lower third of the left humerus much swollen^ on the inner Mc of it a moveable gland about the ^ize of a pea is fell. Cervical, njtillary and inguinal glanda partly swollen and hard. Tlie Holes of the feet — especially about the heels — red, glaaed, slightly desquamating. Nostrils obstructed ; breathing ^uutDing ; someiime.1 a slight bloody and purulent discharge. Tho mother owned to having suffered re[)eatedly from her throat and from a iikjn eruption during her pregnancy, and had marked alopecia. Treatment: — mere, solub. (Hahnem.) gr. J twice daily; inunctione • >f UJig. pot. iofl. into the swollen part. On the 11th (in 8 day») the >• welling of the bones had di.4appeared, the coryza was less, and tho ftrm« moveable to a very alight degree. Under the continued iiH« of tho mediciues along with camomile- baths imd tokay wine, raplil improvement ensued. Ou the 16th the mobility of the arms v,wi iiTHc more fjuite nomiiil and the eory«a entirely gone. The nt« IV iiry wikM now chftugcd ftir ayr. fcrri. iod, (gtt. v., twice daily). I >. ' - V I fiMUirl that all nyphilitic affiH'tiona hr*d disappeared,

ah '.f liirophy Htill continned. Further history unknown.

The following cases obBCrved by roe recovered in just the same wiiiy 1—

A child of »l i-rtjopEht to the polyclinic un lUh February.

IM7K with hrow» II* nf tlic ttkin. HuTid-fed, but prutty well

lloti> ImImhI Knr thn««v wrrku roryza, liMsurc» on the lips, and Mil y i«li III oil fill ihc» tlngern and tiK'H. All the nail« much thickened, ili^fftrintit, liMil nlivfiity much loowmnl from their beds. The tcr- riikniil ptitilutiKi*** xiivorml with ttralcg of epidermis; much deequa- matiofi of iliii aifili«ii, iMia of tho palma. TUo loft arm, which

• IhitHI^ tar Xfa«f«r4#fM.. MttUa. IMI, 8. 198.

UEnEOlTARY StPHlUS.

M

n h&nging flac'Lid for a week, ii uw incapaVile of move- ment. The lower tliird of the humerus much swollen fttiil tender. The right teHticlo Jari^tr and hjirder than the left. All fanctiona normal. Treatmeni :— Citlomel ^\ \ twice daily. On 26th mobility of arms retiirnefl, sttrllirig diraiiiishcd by about one half; fissures and coryzii almost hoalenL The nailn have iihnost all falkm off» the new nails j^'owing under them. To con- tinue the treatment.

Child of 8 months, brnught to |mlyilinir 20th May, lH7t>, 1^^ with a relapse of .nyphilis. Pa[tular niul macular erujjtion on the ^v rhin and the upper lip; severe fantiffles and eoryza. Swelling of ^H the lower epiphysis of the riy?ht humerus, with difficulty ^H iu moving it and pain on preasure. The left arm mn'mnh ^^ft Mercurial treatment, KnrtlitT course unkno^vii.

^^ While in these cases only the lower end of the humeras was the seat of the syphilitic periostitis and ostitis, the following cases show lat other long bones may also he attacked in the same way : —

Child of 10 weeks, hroiight 1 8th November, 1877, with coryxa, obstruction of the u«)sti i!<^ by scabs, and f^lftzed, red, Hat f^junbi Heated papules round the anus and on the nates. Tender Hwellinia^ of the lower epiphyKci* of the radius and ulna on the leftside; also of middle phalanx of left middle fingerj and of first and second phalanges of right finger. Mercurial treat- ment. 27th December: — With exception of epiphysial swelling, child h.is almost quite recovered. Phalanges of fingers almost quite iiormaL Treatment contiJiued.

Child of 3 months, brought to the polyclinic on 7th Juuo, 1875; well- nourished and thriving. Intertrigo with erosions rtmud the anus and genitaln. Coryza almost since birth, with purulent discharge and crusts nt the nasal apertures. For 1 weeks sweUing «if upper epiphyses of bones of the right forearm. Tendt?r on pressure. Joint unalViK-tocl. Right artn hangs flaccid and is very little moved. All other bones af)]mrently normal. Mer- curial treatment. Marked improvemont l>v end of June. Further course unknown.

Child of 12 weeks, brought 18lh June, 1879; eoryza, enlarge- ment of lower epiphyses of the radius and ulna on lx)th sides; most marked on the left. Both arms incapable of movement. Roseola on the whole body. Fissures on the palms and dcsquama- tian of the soles. Course unknown.

Child of 3 months, brought 2Kth November, 187J*. Well- Dottrbhed, by mother. Swelling of epiphyses of all cx' tromitiee; complete immobility of the anus. Legs flat^cid. No other ayphilitic symptome. Mercurial treatment. Movement of arms improved after 6 days. Swelling of epiphyses also soon diminished. Did not return for treatment.

100

DISEASES OP INFANCY.

You see that uot only may the epiphyses of the diflferent

long bones be diBtinctly enlarged, but also those of the digrital

phalanges. Such cases closely resemble 08toom3'eliti8 (pfedar-

throcace) — i.e., a hard swelling, covered at first by skin of normal

colonr which is not adherent to it, but in the course of time

becomes red, breaks out in little tifitnlous openings and afU^

suppurating for years heals at last with a funnel-shaped cicatrix,

I haye seen this several times in addition to case i, especially tn

relapses of hereditary syphilis in the first and second years of

life J but in every case on the fingers, never on tho toes. In a

child of four weeks, who presented no signs of syphilis except

corvzfl, there was considerable enlargement of the middle phalanx

of the third ftnger on the right hand and swelling of the upper

epiphyses of the left humerus and radius with paralysis of the

left arm, only the lingers of which could be moved. In another

<;hild of six months there was enlargement of the first plialanges

-of three fingers besides other syphilitic symptoms^ — all the

4?piphyses of the upper extremities being normal. Other authors *

have receutly treated of tbis *' dactylitis/' which must always be

regarded as a comparatively rare coudition. Still, you must not

forget in the cases of osteomyelitis which you meet with in future

that this aflfection is not always a scrofulous one» but may also be

due to congenital syphilis. On the other hand I must warn you

against being too ready to regard epiphysial swellings as syphilitic,

especially those at tho lower ends of the radius and ulna, even

when other suspicious symptoms are present ; tbey may he due to

rickets, especially in infants who have passed the first half year.

In these cases the enlarged epiphyses are unafiected by mercurial

treatment, while the essentially syphilitic symptoms disapp<*Hr.

Child of 7 months, brought 21>th Jjuiuarj, 1870. Wull-

nourished, pale. Coryxa since birth. Eight weeks after birth u

macular eruption, cured by baths (?). bat alwuyt* returniug. N<tw,

nHght roseola on the fiice, h(?ttd, haiktis, uml feet. Numcroua rondy-

(omnia on the itiuer nurfncc of right thigh, round the aiiiiH, on

scrotum and nates. For f*omo w<»oks, mftrkrd eT>largem«*ut of

lower epiphyses of bone** of the lower anu on IxJth sides. Crjuiial

sutures still open with verj soft liorders. Kpiph^Nial BWoHing »i

tho junetion of th«> cowto-rhemdroiii articiihititih^. MercuriuJ

treatment. On 17th February e%'ervthing rwovered fmm. ^i. ^r.t

the swollingB of the epiphyses, which remain unaltcrcfl

LJ Taylor, %>*»/«>«? le^wnn qf <Af owiwi tftfun- Kew York* 187^.— Ltt«il^

HEREDlTiRY SYPHILIS.

101

You mnat always tiy in fluch casea to investigate carefully 'Whether a combination of ricketB and sypliilis is not present ; althongh this is cei-tainly uiiUBual during the first six months. In the first few months you may Lave less hcsitatiou in rej^ard* inji^ and treating such enlargements of tlie epiphyses as ayphilitic. I craimot regard as of muf!i significance a difference in the form of the swelling (Taylor characterises the syphilitic as having a *• sudden, abrupt " commencement) ; hut certainly the fact (which I have often observed) that the epiphysial swelling may occur on one side only in a^^jihilis — which is never the case in ricketB — is of importance.

In most of the cases here given you will have noted a difficulty in movement or a complete immobility of the

I Upper extremities, so that when the arms were raised and then let go they fell heavily as if lifeless (syphilitic pseudo- paralysis). The first author, as far as I know, who appre- ciated this symptom was Beduar^ in whose table of (j8 cases of pereditary syphilis, paresis of the arms is noted sixteen times, that ofthe legs once, that of all the limbs twice. His dcscrip- ^tioij agrecB entirely with the symptomB observed in our cases. ^B^edn^r seems inclined— though he nowhere asserts it definitely ^m — to regard this paresis as a myopathic alTection entirely due ^B to a relaxed state of the muscles. I am not able to give a satis* fiactory explanation of this paralysis. It is certainly not a central aflection ; but at the same time the view that the imobility is caused by pain is open to doubt. Because in not few cases of this kind 1 have not been able, either by passive lovcments of the affected limb or by pressure on it» to elicit tuy expression of pain. This much is certain, that iu all my jes the diminution of the swelling was rapidly followed by return of the mobility of the limb. One might, of course, on le contrary lay stress on the fact that Bedn^r does not kention enlargement of the epiphyses in any of his cases of mresis, also that in my first case the arm which was not swollen was likewise paretic, and that I have frequently seen paralysis of ne arm only while the epiphyses on both sides were markedly jnkrged. I can even adduce from my own experience two or Lhree cases in which paresis existed apart from any observable iffection of the bone.

* Kranlhtittn der StuffeiMntntn u.i.if, Wion, 1853, iv., S. 2'J7.

W2

DISK AS lis OF re FANCY.

Child of t> weeks, with yeUowish-rotl, somowhut de«*quj roticuln on the anna and U^lt.s, face and body ; durk-red f^luzetl desqnftmatiiig pahn8 and solets ; coryza tind conjiiuctivitis. Both arms liiy complttely flaccid; only the fingers showiyl some slight movcmt'iit. Nowhere any Mwollitig of the honea. 'Vhc raert'urial treatment, which liad been begun in the Univeriiity palycliuic on 10th July, 18(5*), had alicady by the 16th ciiui»t«d » diauppouranec of the eruption, and freer movement of tht upper limby.

Child of I) miintlis, bi-nuj^bt it* n\y pnlyeliTiie 15th January, 1879. The mother had already aborted 1 times. A rms and leg* h'ing immobile and tiaerid, ahmtst nince birth. Corystn with "snuffles" and discharge; a few spots v>t roHtHtla on the face And round the amies. Ko sswelling of the bones. Mercurial treatmciil. Oti 4th Feltruary roryssa and sp<»ri4 eured, Arms and legs frooly moved, but the latter cannot be fully extended at the knee-juitlt«. owinj? to resistance of the Hexors. Treatment roiUinucd.

Child of t) weekff, bmnght 2fth July, 1879. CorywK tutlm red. p^laxed, and desqunmatiiiig. Roseola roun<l the uuujs. fipipby* aea not enlarged. For the lust S dayw, arms (laeeid and immobiUs Kvery jaissive movenient excites irying. Further course im* known.

Child of 8 weekf^. Slight roseola; intertrigo ulccroea; fiiKsiires of the under lips; coryKa, Both arras par»ly«<»il. Unci id, EpiiihyHCs nut fjwollen. I)id not come bai'k.

By tlio researches of Wegiier' we are brought somcnvliat nearer to the explatiation of thcfie **p8eodo-paralyaes" affecting hy preference the npper extremities with or without swelling of epiphyses. In syphilitic new-born infants and young children one finds — according to his investigations — almost iorariably in the long bones, at the point of junction of the diaphysis with the cartikge of the epiphysis, ii iniuhid process consisting in an excessive proliferation of the carlilago colls, and a retarded ossification of the already calcifiod fiubstanco- Along with this the formation of new hlood-vessels in the hones is either altogether arrested or takes place very inipcrfeetly ; and from want of nutrition the cells arc gradually destroyed bjr fat-melaniorphosiH and shrivelling. The result of this pro COSH is seen on section, as a narrow, somewhat juggod line of yellowish or orange colour running along the margin of the epiphysial cartilage, .\ccording to Wegner It is formed by necrotic tissue aud soparateo the diaphysis from

HBnEDITARY SYPHILIS,

103

^Vthe epaphysls, and may lead to a complete separation of tlie ^ latter by au ** inflttinmaton^* suppurative complicatiou/' The process always makes its appearance in several places at once, particularly often at the lower end of the femur, in the bones of tlie legs aad forearms, and in the ribs ; and sometimes in all the long bones. Meanwhile thu ossihcation of the epi- physial cartilage proceeds irregularly, and the cartilage cells — I which in healthy bones are arrun^'ed in rows^urt' partly put out of order or are completely disinte<^ratetl and replaced by groups of small cells. These observations were confirmed by Waldeyer and Kobner;^ but they, as also Taylor, rcjyfard the 3'ellow zone not as a necrobiosis caused by deficient vascularity, but as a gummatous process due to the enormous proliferation of new cells which, by compressing the vessels, occasions the death of the intermediate tissue and the consequent separation of the epiphysis from the diaphysis. Whatever its correct explanation^ may be, the imiK>rtant fact (from a clinical point of view) remains, that we have here a morbid process at the epiphysial line which, although it certainly occasions recognisable symptoms ^■during life in only a very small proportion of the cases ^B iswelling» pain, immobility), yet has an infiuenceon the mobiUty ^Bof the affected hrabs which, even where other symptoms are ^■i^-anting, must not bo underestimated, A separation of the epiphysis observable during life is rare, and is manifested by abnormal mobility at^ the epiphysial line and an unusual '•dangling** of the hand (Kobner and Waldeyer). I have . myself been ahle only in one instance^ to make out ci'epitatiou ^ftut the affected place. Moreover the change described at the ^^line of junction of the epiphyses does not always affect all parts ^BrquflUy. In a child of two months, the epiphyses of whose ^■forearms were distinctly smaller during life, it was well-marked ^■in these situations only while in the otlier bones it was merely indicated. In a child of thirty days old there was but little of ^Kt to be seen in any of the bones examined/ Perhaps in this

^^» K>r(rJU4(r*« Arvhiv, Bd. 55,

^^HB|i0oording to Hftub and Vo rag nth ( rircAoic'i JrcAir, BJ., l^i, Heft 2) we

^^piSto do. cliiufl.v. with iw mflftinzaiitory process is the curtitago, which aau»ea

^Hft«»ut«A to appear in it.

^B ' Troisier, {Lnion «hlff., 1883, No. 104) and Kremex ("Boitr. snr syphil,

^HEpipl^»enl6itun|:** : DtJuerL, Berlin, 1884) describe such ca«e«.

^B ' Aocording to Kobner and Waldeyer even iu the uaaeiB wber« thore are no

f uaked-eye ehanire in the epiphjACK, these may bo certainly recogniMed by the

Ill October, 1878t ■& ftpparmtl^r heshh^ md thrtrisg diild of P wedca wm brvmgbt to the potyrlinic. B^ signs ol tjpkS&B, In Ike Rgioti of %ht eiKtlomi proceBa Utere wva m woond tbft sue ctf a wKiUiag with • grcj coaling; m il*« middle of it m 6s%ukinm

l» flfid Omd in JS o«l ol 4B HMintei foBtH**, MOW of which ««s«

» Gaterbock, Lan§tmUdL't Ardkw, B-1 ixiii., Htfl 2 ABd Rl. rxxi.. Heft 2.

' ^w «U Mut/r/rinA m^rboM mrtk'obur p9t t^fiidt trwf>>gfig r Nftfioii, 1882. Tkft ol»f«6l«r« of It, tux*or>liii« to 8 o m tu • Aft ; - Very cftrly oonnneiioeBMnt ; oaolieida ; VlTflW on morotoffnt, fnvvr <to l(l2'2i: esUrftfinonl of ••mraJ fodnlt (evptfdally •joinU) with •JIfrH tnrai.] rmlxMUM Mit! n<*«- t*f tem(i, Ihtratioo 18 dayii to S| mODthii. BooQvery iioimiblA umler irp«ietlle treatment fntQitcitioiii of tanig, h^-ilrkrir. wifl fKjt, iod ,K In two v^mm*, iKctro wn* fomn! at ihii p<)*(i*0ir taflamawtiou of tk» ■rnoriAl cii[j«nIo, ««iro>pixrQl(rnt MiidAticm into Mm» carii if hypcrirmi* »n(l nirc<f*et(ati of the neighbottriag

HEHEDITARY SYPHILIS.

105

opening, from which on expii*ation there issued pus along with a few air-bubbles, which had evidently entered from outside. A probe touched rough bare bone (sternum). According to the mother's statement, an abscesn had formed a week after birth and had opened. T did not see the child again till 2lBt Febnuiry, 1879. The tistula had completely healed nfter the eifoliation of a piece of bone ; but the child now had coryza, fissures of the lips and angles of the mouth, spots of roseola, and erosions round the anus and on the genitals.

Whether the necrosis of the sternum in this case was really to be regarded as a manifestation of syphilis I shall not yeuture to decide; because I have never hitlierto observed a specific bone disease coming on soon aft^r birth and preceding all other symptoms of the disease by months. Also, the bone ai!i?ction was recovered from without specific treatment.

Infantile sjq>bi]i8 does not limit its action to the skin, mucous membranes and bones. Other organs also, as in adults, may be aflFected ; amongst these the testicles and liver may be specified AS parts when implication is discoverable during life as well as st-mortem. The aifection of the testicle was partially unknown tintil very recently. Heunig aud Taylor mention it only in- cidentally; and Despres* was the lirst to describe carefully three cases, in children of from seven months to three years of age, one of whom was examined post-mortem by Cornil and found to have hypertrophy of the tunica albuginea with intersti- tial orchitis and epididymitis. In the comparatively short time since 1874 I have myself met with at least twelve cases, of some L of which I have already elsewhere* published accounts. Never ^Kbeglect, therefore, in every case of infaotile 8}"[jhiHs to examine ^Bfebe tcsticleH carefully* The testicle thus affected is more or less ^Beuhirged, bard and firm; likewise somewhat uneven and nodular > The size varies from that of a hazel to that of a chestnut. I iiavc found both testicles affected in four cases, the left alone in four, and the right alone in two. The youngest bild was three months, the oldest was suffering from a relapse f syphilis and was two and a half years old. Only one case was xamined post-mortem.

Boy of 24 year 8, brought to the hospital in the end of Sep- t*hi1m r 187(5, with raucous papules at the unua and pporiasi*

' Bttlkt. tk ia sor. ehir.f 1875.

» /VW#r*^ S^fitfchr.f. pmct. .1W., 1S77. No. 11.

106

DISEASEfl OF IK FANCY-

Ky]>hilitica. Both testicles markedly ouliirgeil luitl nodular- Treatment l>y inunction fgrs. 10 ung. hydrarg, (Liiij). Afier tkirty inunctions, all the symptoraa disappeared, except that the t««tictc!^ remained unchanged. Death on 25th December from cbolcTH infantum. P.-3f-^Both testicles very large and firm. The micro- scope showed an extensive bypw?rtrophy of the interstitial connoctire tissue in the testicle, most marked in the con»n*t Higbniori. Gumma nowhere to be discovered.

There was therefore in this, as in one of Despres* cases and in others recently obserN'ed by Hutinel*' interstitial orcliitia, and partial epididymitis; and of eonrse when ibis has gone on to the formation of fibrous tissue, it will resiBt nil treatment. Only in an early staj,'e you may expe*:t that resolntiDn may occor, a! though perhaps not always complete ; and of this I have fully convinced myself in four cases. In jnst the aamc way the liver may also be attacked by an interstitial iuflammatiou. with or witliont formation of gummatous nodules ; but this in a number of cases is only recognised post-mortem.*

A girl of 7 days, illegitimfttc, born in the I'harite. Fatlicr syphilitic. On examination of the child wc fouud ro«eola» and psoriasis of the palms and solefi. thtjrhs, loj?3, and imU^. Extr<?ini> atrophy, no enlargement of liver. Death from collapse, 2uth November, 1875. P.-if.— In tor Kt it iul hepatitiw; hvcr somo- what enlarged, very tt»ugh, smooth. Acini not visible; wliitiah bandH cotiHisting of coimective tissue paHHiTig through the f)aren* chyma in all directionn. Cortical Hul>htaiico of kidneys extremely firm. Haemorrhages in fnndufl of stomach, Imth outside mid in; its mucous membrane covered with a coherent membrane-like layer of blood-8tainod mucus. The yellow zone in the epiphyses of sevonil of the bones ; periowtitic deposit on the right humerus. All dtaphyses extremely hard.

Wliile in this case the interstitial hepatitis was only revealed by the poBtrmortem and even the bjvmorrhagic catarrh of the fundus of the stomach — possibly a result of engorgement of tlie portal vein — caused no symptom ; in other cases an enlarge- ment of the liver was noticeable, which confirmed the diagno^iii.

Felix L,, 3 montUe old, wna affected lit the age of src weckit with a macular eruption which gmdimlly sprend oter th«> whoW body. In pliices* blebs of the size of a pea occurred, lillod with

' Seeue mentMeiit^ 8, 1S78.

HEREIMTABY SYPHlLm.

107

ttirbid fluid. Intortrij^o on tlie scrotum and in the neigh bunrhiLHid of auue. About four weeks previously, also coryza and hoiiraeneijii. On 15th March, 1864, I discovered u considerable enlargement of the liver, along with nil the usual sjrraptomst of congenital ayphilifj. The liver reached down to the level of the umbilicus, whcpo its Hharp murgiji eould be diKtinctly t'elt, and wa« visible tit eaeh respiration through the wasted abdominal wftlls. Stirface aiuooth; not tender to touch. The liver-dulness eitondcd un the loft side right over to that of the spleen. Mercurial troutmeul, with no results. Tin* ntrophy increased and death ensued on Sr^th. At the poat- mortem t!»e liver was found to be eonHidembly eolarj^ed, with uumcrouj^ vvhitiah*yellow patches and baud.s of various siscs scattered through it- Microscopic examination of thetio by Prof. Kleb.s showed the appearance of interstitial hepatitis. Spleen and kidney uornml on microscopic examinationt Child uf 0 weeks (7th February. 1881). Mcidinitc jaundice since birth, sclerotic and mucous merabrniics affected. Fiecea and urine contain l>ile. Liver prominent and HmrH>tli. No Rigns of ^ayphiiis. Advancing ntrophy. Treatment with calomel uusuc- ,ce38fub Collapse and death, 28th February. F.-M, — Liver very large and thick, olive-green and tough. Aciui i*eparated from one another by white band^ of couTiective tissue, the immense number of which is better seen under tlio microscope (interstitial lie|>a- titip). Scattered effusions of blood iu the mucou.s rnembnine of the stomach and boweL Chai-acteristic syphilitic zone in nil the jpiphyses of the riljs. No signs of syphilis elsewhere. Soon aftci' ,this ca^e, 1 hud another identical one which was further remark- siblc, because the motlKT brtd already lost three children from ihts i»ame Uver-aiTection with jaundire.

Iu tliese cases there is usually ouly n moderate degree of

uuudico or none at all ; but if the process of indunttion allects

not only tlie intorstitial tisHQe bat also the porta hupatis, the

janiidice may reach a very high degree and present a greenish

[tint, I have seen one such case, which must have arisen during

intra-uterino life/ iu a child ten weeks old, who since birth

[had had a hard uneven liver, intense jaundice with quite colour-

leas motions, and an enlarged spleen, and whose gall-bladder and

fbilc-tluctB were found post-mortem to have been entirely truus-

formed into thick tibrous masses filling the portal fissures. It iu

(/. fieok *• ouui {Ftnff. mt*l. U'oehmteki;, 18S4, ^) ;— A f oe in a of eight months, ^brotrn iDAAoef in the liver, an the hlle-dnct« and gull-bLiilder, and in the p&acreiui, itli miliary g^nnimatoui* dcpoeiitH, int^ri-ttitial orchiti:^ And {*pididyinitirt. — do • Eiiii^o Fiille von Syphllii* eongonit^ " : /*tM., BerUa, 1SS5.- P. Mey or, l\indorpoliklinilf der K.Chiirit^^BU Borlin." Bfvlinrrliini$chr WnchenMchr., to.

109

DISEASES OF IKFANCY.

only in tlie minority of the cases, as far as my experience that interstitial or gummatous disease of the liver can made out clinically; and even at the post-moilem they may in many cases be overlooked on merely naked-eve ex- amination. Ascites also, which is such a usual symptom of interstitial hepatitis (cirrhosis) is almost always absent in these cases. The case published by De passe," in which the fluid in the abdominal cavity communicated with the tunica vaginalis and was evacuated by these punctures (one through the scrotum), is therefore all the more remarkable. This case is also noticeable owing to the success of the specific treatment (which usually has no effect) even although in the 8th year the liver was still con* siderably enlarged.

The spleen is often also affected in congenital syphilis by hyperplasia, induration, and perisplenitiH adhesiva ; and I have mvself repeatedly seen it more or less considerably enlarged in such chililren, and once iu a very atrophic child of six weeks, and ftgain in one of two months, with roseola and palpable enlargement of the liver. One must not, however, forget that the spleen is not unfrequently found to be hypertropied in infants who are uot^ syphilitic, and, therefore, the combination of syphilis and ei ment of the spleen may in many cases be accidental.* H^-per- trophy of the connective tissue occurs also in the kidneys, supra-renals and pancreas; but has no more clinical interest than the gummatous nodules which are sometimes found in thymus, in the langs, and even iu the heart. Abscessei of the thymuB-gland on which P. Dubois laid great weight I have seen twice, in the form of multiple collections of pus scarcely the size of a pea. The children presented at the same time many pemphigus-buUte, especially on the palms and soles, and they died in the firBt weeks of life.

The implication of the nervous centres, especially of the brain and its vessels, by syphilis has aroused much interest in our time; but my own experience seems to indicate that it occurs much more frequently in adults tlian in children.' In rare cases I have seen contractnrea improved or cured by 8[iecitic treat-

* fUmie mtnt. AoAt, 1R8A, {>, 300,

• Hft.Und, Arckirf. XindetkeiU., Bd. iv., a 2»7. ' Chiari (IfiM^r m«dL IfWAciucrAr., No. 17 ^ 18. 1«^1 » aiMtcrlbex d c«ii««

irlti* iiyphUiticiii f»f the YeM*>i^U of tW tirtun in ■. ohihl of 15 months vritli hoteiMij^ry wyirhiUn,— Barlow (Lfme^f, 1877 aukramp.

HBREDITABY SYPHILIS,

103

meut. My first case of this kind * was tliat of a boy ageJ fourteen months, who was brought to ray polyclinic on 24th Nov. 1867.

On cxiunination he was fomid to liave contracture of the li^ht arm at the «ll>ow-joiiit, of the finders of the right hand, and of both lower extremities at the knee-joLiitg, Unahle to stand* sit. or ^rnsp with the ri^hfc hand. Biceps hrachii and flexors of the legB ex- tremely' tense. Ever}- attempt to extend the liml>H caused violent crying. The child had also papule** ronnd the anua and on the scrotum, excoriiitions of the nlm nai*i and of the nuglea of the mouth, eory;ta, enlur]^t/nient of the ehivieuhir and axillary glanda. The child was said U) hiive suflered for months from severe coryza, from an *' eruption of blebn " and ulcers ; and, when three weeks old, from epileptic tiin for several daja. The contractions were said to have gradually developed after these. When the child had taken mercury for about a month it coiiJd on 23rd December open the right hand and alno bend the knee. Gradual improvement till 3rd February, 18t>8. On 27th, change to pot. iod. On ;^Oth

March, Ijcgiin to walk and to use unknown.

igbt arm. Further progresw

The influence of the anti-s\']>hilitic treatment is here nnmis- takeable. Still, it is quest ionablo whether the contractui-08 should really be regarded as a cerebral aflection and connected with the fits which the child had formerly had, or as a niy4)pathic afi'ection quite independent of the nervons system and caused by an interstitial myositis such as occasionally occurs in syphilitic adults. That the latter may occur in congenital syphilis seems to me to be proved by the following case : —

In a syphilitic child of 4 mouths (brought to the polyclinic October, 1874), there was a stiff contraction and hardness of the flexora at the Ijack of Imth thigha, «o that the limba were held continaouBly in a state of eemi-liexion. The leg could be only partially extended at the knee. The use of mercury for deveral weeks brought about complete recoyery ; firat of the skin eruptions, and finiilly of the contractions also.

I have never been able to observe essentially cerebral symptoms in infantile syphilis,— neither the chronic menin- gitis described by Somma,^ nor paralysis of one or more extremities, nor convulsive seizures. And although such things may occur, it is still very doubtful whether one is justified in attributing them to syphilis. The following is a case in point: —

* BeUriffe tw Kinder htiU:, X, F, BerUn, 1988, S. 421, ' Climea pediahica di Xapoli, 1877,

no

DiSEASBd OF IXFJLSCY,

(n a child of 2 ycare (admitt^^d to one of the childmr* fmttil ♦Jth NoTcniber, 1877) tberc W4i« — along with o»t« ^^"4

iinustirtl psychical conditiou, alternating precotity :i *^>^y»|

but without any interference vrith motility* At the F.*At. (aftiTl dwith from diphth<*rLn) we found scTcral nodtihir tuznonrs nbottlJ the SUMS of a cherry under the pia mater, and in different parts of the cerebrum and cei'elielltrai. They were of a ^t^y colour, and tmnsparcnt at the periphery ; the centre partly fatty, partlll calcifieil. A similar deposit was found in the upper part of Uif left kidney. Since tubercle was nowhere present and pertoM teal dopoeiU wore found on 1x>th tibia?, 1 was im lined to re^rn the brain-tumours as s^^philitic gummata; and they were conJ sidcred j^nch ou being examined at the pathological insiitttte tm the Charity?, I

CoQBidering that the diagnosis hetween gummata tind tul>crclJ caunot he made with perfect certainty with the roicroscape aloaeJ and tbut the clinical 8>Tnptom8 with the progress of the case uuffl tiimlly the result of the treatment have a much higher valaaJ from a diagnostic point of yiew, we must be very sceptical iJ judf^ng of 8uch cases. At any rate it seems strange that, ij spite of the great number of children with congenital syphilis ■ have seen, I have practically never been able to find cerebnifl BvniptomB which could with certainty be referred to s i " . Any connection between chronic hydrocephtilas and co) i

syphilis seema to me extremely improbable on acooant of tM jBeflectiTcnoBS of mercurials in the former disease. Even tha case of '•ditVuse insular sclerosis" which Buss' has described HoeniH to be by no means beyond a doubt as far as its com nectioii with hereditary syphilis is concerned. I

III other regions of the vascular system changes bava f>ci5nflionally l>een found in new-born children, which rcctUd 'Mho MVpbilitit. ftlTections** of the blood vessels of the brainJ 'VhuH, Hchijtz' describoR the small arteries of the kidneys and Hkiti a« being much narrowed, their walls considerably thickener by hvj^ertrophy of thr^ muscular coat and adventititia ; and hJ ascribcH to this the mimeroua little ecohymoses which, i» htn casd of a proniature cliild, hi? found in tiie skin, subcuJ inn'^otin conncH'tivo tissue, muscles, kidneys and other partifJ I'iHohrH* reiioArch<»s, however, render it very doubtful whethdl

' tlpvt. Ifin n'ii^hfHtrhr,, 1887. No., Ifi ti> W). I

^^- • fyafm- nul. It orA#fi#rAr., Jg78, Noa. 4i. 4<J, ^J

^^m ■ Arch, f. KiHfiwrMit , riil, - ^M

UEUliUlTARY rtVPfllLIS.

Ill

^theSe vftscnlar ehiingcs arc really caused by 8>^hilis. He rcpfards

^tbia state of the small arteries in new-born children as the

^fcormal condition and thinks it has nothing to da with hiemor-

^Kbage. Mracek* on the other hand ijays that in children with

^^yphilis hi«morrhagica he has fonnd the walls of the small and

mcdinm-sized veins thickened by a proliferation of their nuclei,

and the lumen narrowed or even obliterated. While the matter

is thus undecided we cannot, iu the meantime at least, recognise

ftoy real anatomical foundation for the yiew which Bebrend^

has endeavoured to advance, viz., that there is a hsemorrhagic

form of syphilis neonatorum.

The progress and termination of the case in congenital LMyphilis depends, according to all experience, less on the nature ^Hr the symptoms than on the state of the patient's nutrition. ^nyphilitic infants fortunate enough to receive their natural ^^nourishment from the mother or wet-nurse, usually thrive well when treated specifically, and have the best prospects of complete recovery. But all hand* fed children, especially such as have from birth been weak and atrophic, I consider to be in great danger; indeed these latter may almost bo given up for lost. ^Yhile iu private practice, and even in the polyclinic, out of a very large number of syphilitic children I have lost only a fow, and that from chance complications, in the children's wards of the Charite, where every one of the cases was extremely atrophied, almost all I have seen ended fatally. Not uncom- monly death came quite suddenly. Trousseau has already drawn attention to this ; but in my opinion it is nothing very ^fitrange, sinc^j sudden death is a common enough event in atrophic ^Kbildren. Under propitious circumstances, the disease often ^^takes a favourable turn with surprising rapidity. One is ^^stonitthcd to see eruptions, condylomata and bony swellings ^■iminish within five or six days under the influence of mercury, ^Hmd after a few weeks disappear entirely. But I should hero ^Oram you against over-estimating the results of your treatment. Reearrenoe of the disease is extremely common in infantile ^■tjrphilis ; and, especially in polyclinics where the children are so

^^ ' Jakrh.f, KiniUrheifl., xxxil, S. 191.

^^B Vitrfe/jahrtchr, /. Dermatologit und'AnhhUif^ XSb4. I will oiily rcmarlt that ^^■noiifr Bchrend'fl caAcs th«ro uro tm>Mii ^vftich Ih^ro Wtiv vtt' fnthirgod spleen ^^^Ih xjurpar* ; and the«o often occMr/4^|Mil»l»«NYl»f'l'« th«re^ i* no >»ypjuli«. Q". sdao ^fcotfimen.iAfrf., 1883,8,509. UUHi .

ifw*

112

IXIBSASE3 OF INFANCY

often removed from further observation on the first disappearance of the Bymptoms, one has opportunities of convincing oneself of this fact.

A child of 6 weelcs, brought 7th Januar}-, 1874, with ihatij symptoms of sj-philis, Re<JOTery towards eud of FebrimrVt under mercury. Brought again 10th April, with symptoms of rocurronoe of the dibeofie which have existed three chiys. Recovery on S8llk Recurrence on 18th June.

Boy of 2 years, born of a syphilitic mother, all of wboot <"bildren were infected. Infantile sj-philis in the 2od month. A few Weeks later treated in the polyclinic foS* eroaiona at the utigW of the mouth and on the toujtrue. Recurrence on loth Mar. 1874 . — For 8 weeks condylomata at the anus and on the doi*;$uin of the tongue, which towards the back appears hard, intiJtratedandutf «i dark*red colour, and towards the front 18 covere<l with a greyiah* white coating. At the end of June, recovery under mercury. On 14th November, recurrence of the condylomata at the anu;;. On 9th January, 1875, recurrence again^ requiring new trcatmeut.

Girl of 5 yeare, with mucous papules at the anus, and enlarge* ment of the ingaiinal glands. First outbreak of sjrphilis at the &th week ; 2nd, at 1) years ; 3rd, at end of 5th year.

One should not^ therefore^ at once discontinue the treatment on the disappearance of all e^Tuptoms, but should always carry it on for some weeks. But even this does not remove &U danger of recurrence. In most cases, however, one succeeds in curing the disease completely within the first or at least the second year; and I have gathered a sufficient number of observations from private practice to be able to assert that by this time tlie thing is really at an end. You must, however, always lie pre- pared for a fresh outbreak of the disease, even in the later years of childhood. And under these circumstances doubts may arise as to whether we have a recurrence of congenital syphiUa, a direct infection, or a so-called ''syphilis tarda'' (to which 1 shall return later). But even in the cases ^i-here the disaaae has been thoroughly cured by continuous treatment from iho very beginning, thero yet not uncommonly remains a deranj ment of the constitution favouring the development of ricketi I have frequently seen thia disea&e come on after recover)' from congenital syphilis In children situated in the moat favourable circumstances and nursed with the greatest care. But I must protest against the incomprehensible opinion of Parrot, who regards rickets as invariably the result of syphilis.

I

HEREDITARY BTPHILIS.

118

The difficulty of establishing with certainty tho origin of infantile syphilis is often very great, although its diagnosis is so easy. All cases which bavo arisen within the first two months of life, must, with extremely few exceptions, be regarded as hereditary. I have already stated (p. 61) that hereditary syphilis sometimes appears in the form of pemphigus, even during the first days of life ; and some of the cases already given show that as early as the first two weeks other svphilitic skin affections and coryza may make their appearance. Jtfach oflener, however, the children present no striking peculiarity during the first fonr to six weeks j and it is only later that nymptoms begin to he observed* After the second — or still more after the third month— it is rare for them to appear for the first time;' and when they occur still later, it is always doubtful whether it is not a case of recurrence or of direct trans- mission. The latter is certainly not easy to establish ; and, especially under those circumstances which render confession on the part of the parents diflicult or impossible, an attempt is often made to turn the physician's thoughts from the subject of heredity, and deceive him by false statements about n syphilitic wet-nurse or other attendant having infected the child. I by no means deny the possibility of such infection ; v«»t, out of the cases of this kind which I have myself met with, there has not been a single one so certainly proved that I was able absolutely to exclude a hereditary origin. In poor families, however, I have certainly observed the direct infection of infanta by syphilitic women living in the same house and, consequently, brought much into contact with them j perhaps sometimes duo to the use of sponges and other toilet articles in common. On the other hand, the infection of the child during birth, from the getrital organs of the mother being affected with S3T>hiHa (syphilis adnata), which was formerly often assumed, — is veiy doubtful : for example, Trousseau's case, in which he ascribed oa ** indurated chancre "on a chiUrs nates to contact with the ulcerated vulva of tlto mother. I have not myself seen any case of this kind; nor yet one of iufection by vaccination which in our time has raised so much dust, under the name of •' Byphilis vaccipulls/' Since the contagiousness of secondary

' KoTget found, ia 21J> cwjics. the oarlieat symptoms 118 tioiofl in tho first, ami 217 liwes tmford frbd of tUlnl month ; bat only 32 timea after tbftt.

8

U4

DISEASES OF ISTASCS,

jypbilis has been proved beyond doabt, one can certainly do longer dispate the possibility of the transmission of the disease by iuoculatioD with vaccine lymph derived from a syphilitic cbtltl, whether any blood is mixed with it (Viennois) or not* And it cannot be deaied that many of the cases of vaccination- syphilis which that author gives seem to prove it* Still, the point remains a matter of controversy, and I do not consider niyHiOf called upon here to give a definite judgment upon it — all ilio more because, m I mentioned before^ I have never myself met with a single well- authenticated case. I have, indeed^ ncen many castas in which, after vaccination, ulcers appeared at iho Moro, unci various eruptions, which might very easily have boon mistaken for syphihs by inexperienced and superficial obHc^rvors, but which had no connection whatever with it. Of th(* frequency of these errors I am perfectly convinced ; and I would refer, as a positive proof of this, to the work of •1()uk(jfTHky' ; be saw fifty-seven children who bad been viu'cinated from eleven syphilitic infants remain absolutely free from the disease. I should also remind you that syphilid doCH not interfere with the regular development of the vaccine Vesicle ; but that where hitherto latent it may become manifest owing to an injury^ such as vaccination is, — and a false assump- tion of tranHniiBBion by the lymph may thus arise. I am even U^HH afraid of tranHmissiou by the milk of a syphilitic nurse, so long as ber nipple is healthy. At the same time, one would of coiirHO be as unwilling to choose a suspected nurse as to make use of vaccine lymph from a child which then or previously had preaonted symptoms of syphihs.

With rare exceptions, therefore, all the cases of syphil occurring during the first months of life, are to be regarded hereditary. The study of this heredity has long been pursned with especial zoal^ ; and if in spite of this medical ^mters at Uio present day are as yet by no means unanimous and differ witloly on many pdints*, the fact merely proves how difficult it is to g«il rid of all doubt in matters which from their very nature can only become known by the confeBsion of those interested.

tru4;iiiJi; dui M^iiUilia,' Jyihr'-j, A"«'.'" fnj'i, , Ij.l. ^jn^, j: «-», -•* :i3

HEREDITABY SYPHILIS,

116

K

m

H

Every day brings us new examples of the fact that, especially in

syphilis, those concerned are but seldom to bo fully trnstedj and

e phyaiciaDj in spite of the utmost care, is here liable to vexa-

lOUB deception. I have myself met with cases where not only

was the diagnosis of congenital syphilis beyond doubt, but the

post-mortem, also, gave the fullest confirmation of this — and

et both parents persistently denied ever having been sv]ibilitic.

e know for certain that syphilis may be inherited from the

ther as well as from the mother. The father transmits the

isease immediately through the semen with which he impreg-

ates his wife, — the mother, through the ovum from which the

'oetus developes* ; in this case, the parents must be the subjects

of secondary syphilis. Primary affections can only have an

influence in infecting the child in so far as they lead to the

development of secondary symptoms in the mother during her

pregnancy — an origin of congenital sj-philis which by many

writers (e.<7, Kassowitz) is positively denied. I do not cou-

ider it by any means settled whether they are right in doing so,

vrhether an infection of the fcetus by the blood which nourishes

it IS possible in the case of a mother becoming syphilitic during

pregnancy ; but I think the latter is very probable. Those who

deny such transmission by the blood naturally discredit the

possibility of a non-syphilitic mother becoming infected through

the blood of her fa'tus which derives its syphilis from the

father ; others hold this to be certainly possible. Hutchinson

and Foumier allege from their experience that women who

ave married syphilitic men frequently do not become infected

til they conceive and not so long as the marriage

remains unfruitful. Some recent observations of Behrend*,

also, seem to bo in favour of the view that such a ** placental

infection " does take place sometimes, but is by no means a

ecessary occurrence. Be that as it may, this much at any rate

B certain — that syphilitic mothers are exceedingly liable to

abortion, or to give birth prematurely to non-viable infants,

boSG epidermis, often macerated and detached, is sometimes

istaken for the product of a foetal pemphigus. This tendency

* The Btropto<joi?oi in tho c»*piUarie« doHcrihod by Knsisowitt ojul Hoob- \ger i H'i«i», fw#t#i, Bhtter^ 18SG, I — I) »rv roarnrJeU by moi*t imtlioritie* itd not

klhogcuptie.

* IkrL kUn, IVackeMjichf,, 1881, 8. 107.

116 DISEASES OF INFANCY.

to abortion is due to endometritis decidualis, thickening of the placenta, or circumscribed gummatous growths in it (Virchow), — perhaps also to atheroma or endarteritis syphilitica of the umbilical vein ( W i n c k e 1) . The knowledge of this is of import- ance for d iagnosis, because in cases where the presence of con- genital syphilis is doubtful, it helps to turn the scale in its favonr. By time, and by repeated specific treatment, the disguise in the parents may be weakened or temporarily cured. And this explains the fact that at the earlier period of such marriages the tendency to abortion is strongest, and gradually decreases as time goes on ; also, that the first-born children are apt to be the most severely affected, and the later ones may be quite healthy. Not uncommonly we also observe a remarkable alternation of healthy and s\7)hilitic children, which can only be explained by the fact that the s}'philis in the parents manifests itself afresh periodically, and at other times remains in a condition of latency which does not endanger the health of the foetus. In this manner the possibility of hereditary transmission may continue for a very long time. Kassowitz estimates it at ten to fourteen years ; but the following case of my own shows that even twenty years may have passed.

The futbor of the cliild at the time of his ninrriage hadachauoro not yet completely healed. Ilic first chiUl, Iwni a year after the marriiif^e, was waid to have Hiiffered repeate«lly from swellings on the tihias ; and I myself observed in the same chihl, "when Rlie hiul pfTo^-n to a pirl of 17, another extensive periostial swelHnf^ mi the left humeruB. The mother horHelf had suffered repeatedly during her twenty years of married life from suspiciouR sore throats and obstinate ulcers in the neighbourhood of the knee- joints, which always required treatment with pot. iod. and decoct. sarso) CO. (Germ. P.) to remove them. During this long time she bore two other children who were quite healthy ; but subse- quently she had several abortions. In the 20th year of her married life she was delivered of a boy who, 14 days after birth, was affected ))y well-marked manifestations of congenital fiyi>hili8, and had to be subjected to a long course of mercurj-. Later, ho l>ecame extremely rickety, 8u£fere<l frefpicntly from convulsions and laryngeal spasm, but in the end- thanks to first-rate nursing — grew up a healthy youth.

I am at present uncertain whether it is possible to recognise from the form of infantile syphilis whether it originates from tho father or mother. Tho opinion of Btirensprung, Hccker and

IIEELMTJIIIY SVinilLia.

117

Keyfiel\that sypliilis of the internal organs— especially of iLo liver — proves heredity from tbo father's side, appears to xue by no means certainly estahlished, for one has to bear in mind the insuperable diflacnlties in the way of our obtaining a reliable history here.

I come now to the treatment of the disease. I may sum up [tb© result of my large experience in this department in this Bbort sentence — the only reliable remedy in infantile syphilis is mercury. Its action, as I have already mentioned, [is often really wonderful, and its rapidity extremely surprising. fKeitber iodide of potash nor iodide of iron, which sire recommended 'by many, are com]>aruble to mercury. Of its prcpuriitifms I prefer to all others, for patients of this early age, calomel and mercurous oxide (Germ. P.) in doses of gr, | — i, morning and evening. The latter occasiouallV — and especially at the beginning of the treatment — causes vomiting. Any other mode of giving the mercury ^such as the mercurialisation of the nurse .or even of a milk-giving animal — I consider inadmissible ; all jibe more so, as it is by no means certain that the mercury is I transmitted by the milk. A t any rate, certniu experiments in this jclirection undertaken by Kahler* showed that the milk of three mothers under treatment by inunction was completely free from >iuercury. Inunctions uf mercurial ointment or subcutaneous ^injections of perchloride of mercury are only indicated where •tliere are no extensive syphilitic eruptions, or where intestinal [cumplicutions (diarrbcea and vomiting) forbid the internal use ){ the drag. All the patients with whom I have used inunction [were already more than two years old, and were suffering from [a relapse of syphilis, which generally manifested itself more )y condylomatons formations than by extensive likiii eruptions i(inmjction of grs, x. — xx. unguent, hvdrarg, daily). I have injected perchloride of inerjury suboutam ously in these cases, tuvith good r^'sults ; I shall return to this in consideriyg the syphilis )of older children. Perchloride of mercury baths (grs. xv.

a bath) 1 have used frequently, but with no constant etfect.

therefore recommend them only for those cases in which idvanced atrophy, vomiting or diarrhoea make the internal idministration of mercury inadvisable.

Coudylomatous excrescences are to be dusted with calomel, or,

JlftJ^er. rtr:JL JnUUit/mzhK, lt7«i No. 21, * Ati zft, rurrrrinrndtnt^,, 1875. No, 23.

IW

DISEASED nF INFANCY.

if they aro already ulcerated, puiuted daily with a solatio^M nitrate of silver (gi*8. xvi to the ,^i), I also recommeud tbis latter to you for tbe nasal mQcoiis membrane, sboald the corrsa obstinately resist iDternal remedies . lu most cases, however, luterDa! treatment suffices to cure it.

The extreme importance of tbo natural method of nourisb- ment for syphilitic infants has been already mentioned. Any artificial method ia objectionable for niich children, although unfortunately it is often unavoidable ; and it may also be well borne as long as we have to do with strong children.^ It will be readily understood that if the mother herself is syphilitic she need have no hesitation in nursing her own chihl. It is another matter when there ai'e absolutely no si«^D8 of the disease to be found on the mother, and when any previous syphilitic affection is denied. Under these conditions — which are nut at all common —the mother should be allowed to nourish her child only if its lips and mouth present no morbid appearances (rhagades, or cond} lomata) . Tbe same holds true in the ease of a wet nurse ; for there can be no doubt that such a child may transmit s>^hilis to the excoriated nipple of a healthy nurse, and that specific ulcers on the breast may arise in this way and be followed by secondary symptoms. Even the secretion from coryza must not be altogether disregarded as an unimportant matter in deciding whether the child shall be allowed to taiie the breast (Roger). Certainly tlie observations of Gunsburg^ seem to be quite against such an infection, since out of thirty-one wet nurses of 9>i)hiiitic children (one nurse within two years suckled as many as eleven), he did not soo a single one become affected. Thence he concludes that congenital syphilis is never trans- mitted to the person who suckle**, and that all the eases in which this is said to have taken place are to be explained by the fact that tbe children were suffering from acquired syphilis. This opinion, however, seems to me to be somewhat forced ; and as cases have been observed of healthy wet-nurses being infected by children who were indubitably sutt^ring from congenital

* In tho " HoKpice den enfAni»*&i«leto(i " lu Pariiei, oxporim»nt«! h%vo ito&u m»A» Tooently i»t Pnrrot** "tiirgiwition ) in nouri«hij>ip sypMliti<' rlin«\rrMi w-ith *§»•«* milk— tbo rhiiilron utiokitiif thi« h-hui'* t«»t } »tkil tli wore rnnisli

better thau thorte of haiid-reiu-intr. ^T. Winn, **],; i uounidorio

d© rhoHpico de« cnfant*.iL-««i«ti*(!/* Thrft: Pli.rlH, IHJ'a.

HEREDITARY SYPHILIS.

IP

^

ajrphilis, I consider it extremely problGinatica.1 ; and therefore I advise yoa to exercise cantion. To my thinking, the physician is botind t45 point out to the wet-nurse the poBsibility of an infection. It then lies with herself to decide whether she will oxpose herself to this danger for the sake of remnnoration. In this way, certainly, the most awkward family secrets may be dis- closed, and the physician accused of indiscretion ; still, I think that all these considerations must not induce ns to expose a healthy nurse to the risk of s^^^hilitic affection without her knowledge. It is not, of com'se, necessary to use the name "syphilis" to the nurse; it is enough if one explains to her that it is an infectious skin eruption. Almost all nurses are quite willing to enter into the engagement on this understand- ing and in most cases they remain free from syphilis. I myself, at any rate, have as yet never known of any nurse becoming infected in this way, although several of the children nursed ivere affected in a high degree with congenital syphilis. The greatest cleanliness and, still more, the most careful attention to any excoriations occurring on the breast, are to be impressed on the wet-nurse as a duty. Tho child may have difficulty in sucking owing to fissures on the lips and severe coryza ; still, I have never seen danger in the matter of nutrition arise from this.

Finally, a word or two on the physician's conduct to the parents. WTiile in poor practice and in that of the polyclinic a candid statement by the physician has scarcely ever any bad result, in the upper classes of society such a statement is apt to lead to serious consequences in the family* I therefore advise you if you are not confided in spontaneously, and if you are sure that the mother is quite innocent, to take the father only into your confidence. Fortunately the disease is so characteristic that confession on the part of the parents is unnecessary for diagnosis, and the proper treatment may be entered on at otioe. Still it is always a matter of the greatest importance to ascertain the parents' state of health, for it is only by thorough specific treatment that we can prevent the subsequent offspring from becoming likewise syphilitic.

In spite, however, of this characteristic group of symptoms, cases do occasionally occur in which even the most experienced physician is unable to make the diagnosis of sj-philis with

120

DISEABES OF INFANCY

certainty. In such cases it would be liigLly indiBcreet to agitato tho parents by obscure bints and qucstiouiiigs. Suppose, for example, one were to observe iutertHj^ioous ri?dne8a about tbe imus and genitals, witb suporticial rounded excoriations here and there in tbe middle of it. This intertrigo, in Bpitei of cleanliness, gradually spreads over the lower part of tbe back or over tbe greater part of the body, while the reddened skin becomes covered with yeliowiBh-wbite scales, consisting of desquamated epithelial cells mixed with Bebum. Or there may arise in tbe intertngtnou« folds of tbe skill — especially in the inguinal region — deep elon* gated ulcers covered with a greyish-white coating. Perha])8, also, coryza or red spots in various situations may appeal*— still furthoT unsettling the diagnosis. In most cases of this kind you will be guarded against error by tbe fact that the lips and the angles of the mouth remain free. But it will do no barm whatever if, to quiet your professional conscience, you begin mercurial treat- ment ; and this will very soon show whether there is anv syphilis present

I close this chapter with a few remarks un the syphilis of older children, of which I have seen a considerable numlK'i- of cases, especially in my department in the hospital.

Tbe thirty-nine children , on whose cases I huve founded the fol lowiug description, were between two and fourteen years of agc^aud (with the exception of eight) were all girls. On the most careful <[UCHtioning it was found with certainty in only six cases that tlie syphilitic symptoms were to bo regarded as due to a recurrence of congenital syphilis which had already shown itself in the first months of life. In all otbei* cases no connection of this kind could be certainly traced ; and therefore, under the cu-cum- Btancofl, we were left in doubt whether we had to do with a hereditary disease or with one acquired by later infection and iatentionally concealed by tbe relatives. In any case I should raUu^r acknowledge this doubt than as»ume a so-called •*sypbilift tarda,"— a form which is said to be hereditary, although it only maki^s its appearance for tho flrat time in older childreu botwecu the eighth and twelfth years or even later. That suci syphilis tarda may possibly occur I shall certainly not denyi for the theory hm the support of oonscicutioua observers ; but I have never in my own esp^ni'nco met with a sing indubitidde case of it. Fo '>uld recognise as such on!

:

MKlUimTAJlY bYFHlLlS*

121

a case in which I myself had boon able to verify, by continuous

serviitioD from birth, the abscoce of ull syphihtic symptoms in

rly life ; and, at the same time, the absence of s\*pbilis in the

rente. For the statements of the hitter are almost always

unreliable, and often even intentionnlly misleading*

In eight girls, between four and twelve years, the symptoms could be referred with perfect precisian to an assault, or at least to an attempt at one ; but the statement of the eldest of these children (12 years) that she was assaulted by a man while asleep on a stair seemed very questionable, owing to the extremely bold air of the patient. Only in two cases was the hymen found torn ; in all the others it was intact, so that a complete immissio penis could not have taken place, although the whole neighbourhood of the hymen as far as the inner surfaces of the labia was in many ^reddened and tender, and there was more or less fluor albus.* ^HEd two sisters (of 9 and 11 years) the disease was said to be ^Herived from a syphilitic nurse. One of them had been infected ^Biy her at the ago of two years, and had then transmitted the ^BiBease to her sister, who was continually with hen As the ^^arents here w^ere undoubtedly worthy of credit, tliis case may serve to impress strongly on you the necessity for caution in the I choice of servants and nurses. I have also known chOdren from L^wo to five years of age become infected from having to do with ^B^^^r^ ^^^ w<^re affected w*ith congenital syphiliK, or with proati- f tutes who had taken lodgings with poor families. The source of iofectiou in all such cases lies partly in the caressing of the children by syphilitic persons, partly in the use in common of uges and other toilet articles and household necessaries, or in eir sleeping together.

The symptoms with which syphilis begins in later childhood

o not essentially differ from those in adults. The only thing

orthy of note seems to be the predominance of condylo-

atous forms. Although I can by no means agree with

Violet*"" that under these circuai stances sypliQitic eruptions

ever occur ; >et 1 must allow^ that he is j'ight in saying that

ucous papules on the skin and mucous membrane constitute

< In throe girla, of 4, ii, and 12 yuaro, I ub»erved, an the reftolt of on att<.*tiipl«il MMtllt, not indeed HypliilJM, but a rDoro or lesti cunt^iderable inflammation of tb^ vultm trjtli flaot olbus and numerous wart^ on tbe labia.

f ^kUi* imfantiU: PartM. 1874,

122

DISEASES OF INFAKCY,

by far the commonest form of maDifestation of the disease t\i this age. The mucous papules appear in more or less thick masses about the anus or on the labia majora, not uncommonly - — partly softened and ulcerated — on their inner surface. In the hitter situation they sometimes form f|uito nodular masses « dis- figuring the whole labium. In two girls, of 12 and 13, 1 hare seen a thick mass of raucous papules curring backwards on each side and extending from the commissure of the labia majora as far as the anus» and laterally reaching the folds of the groin. Also, the inner surfaces of the thighs, the nates, the folds of the skio between the neck and chest, and even the outer layer of the prepuce, were sometimes the seat of these gi'owths ; besides which, there also very frequently appeared, at the corners of the mouth, on the mucous membrane of the tonsils and of the adjacent palate (less commonly of the cheeks) whitish coodylo- matous growths partly eroded and partly cleft with fissures (rhagades). The upper and under lips were likewise sometimes the seat of rhagades, with infiltrations round them. Especially frequent, however, were gummatous changes on the dorsum of the tongue, in the form of round or more angular infiltrations of the mucous membrane, varying in size ; which, by their darker colour and greater resistance, contrasted with the sur- rounding tissue. They sometimes projected above the surface, and in such cases (which were comparatively rare) they were somewhat white and opaque, or else eroded at their most prominent part. In two sisters, of 9 and 11, the almost exact correspondence in the gummatous atfection of the tongue was very striking.

The relative rarity of syphilitic eruptions has been already mentioned. That they may occur is proved, however, by several cases in which a fine scaly roseola of the forehead, of the hairj* iMsalp, of the body and extremities, with psoriasis palmaris and plantaris, was observed. In a girl of six years old and one of four years, with condylomata of the uvula, i>haryngeal ulcers and a gumma of the tongue, there was psoriasis guttata extending over almost the whole body* There was a similar eruption in a boy of 7 years, who presented at the same time condylomata at the anus^ on the tonsils, and in the middle line of the palate. Tho lymphatic glands were usually slightly enlarged and moTeable, and in several ^t of the Tisiblo glands (Uia ,

I

BEEEDITAHT SYPHILIS.

123

I

cervical, occipital, cubital and inguiual) were distinctl}^ swollen. have often observed affections of the osseous system.

A girl 12 years old, brought 2rith June, 1879, had complained for a ycur of violent pains m the right upper arm, especially during ,fehe Dight. The humerus was swollen to twice its usual size, largest 'towurds the middle, uneven and angular, very tender on prcvssni-e. At the age of three years, syphilitic infect ion ; later, affections of the throat (P). A few glands in the neck and in the axilla enlarged. ChUd previously treated, but di.scase always recurs. Further course mjknown.

A girl of 11 years, brought 3rd November, 1874. For H years very tender swelling of considerable size oii the right tibia ; and violent pains at night. Gliuuis under the jaw enlarged. No other aypliilitic symptom. Pot. iod. On 2.5th, marked improve- ment. On 20th July, 1875. no trace of former troulile. In the course of the following year (the girl was under treatment at the polyclinic fur mitral incompetence) repeated slight relapses, re- quiring the renewed use of pot. iod.

A boy of 7 years, brought 15th February, 1876. Mother syphilitic. During the last 8 week:* a somewhat pointed exostosis haa gradually been growing on the spina men talis. It is now the size of a pigeon's egg — scarcely tender, and has already occaaioncd an abscesH of the superjacent integument. Swelling of the bones of the nose, dry corjza, enlargement of glanda. Already he has had repeated syphilitic symptoms. Did not return for treatment.

Considerable defects in the pharynx, complete destruction of the nvnla, adhesion of the soft palate to the back wall of the pharynx, destructive ulceration of the nasal septum and of the hjird palate, I have only exceptionally observed. The alteration of the teeth which has been strongly emphasised by Hatchin- 4ion (the upper incisors short, narrow, widely separated, and notched) and is said to be connected with an alveolar periostitis, I should not regard as a certain si^n of syphilis tarda — all the more because this condition of the incisors occurs not uncom- monly in children who arc absolutely free from syphilis. In the same way the further working out of this idea by Parrot* seems extremely questionable ; I should be much more inclined to regard the alterations in the form of the teeth as rachitic. SyphiUtic caries of the bones of the skull, and the formation of gummata in the brain I have never observed;- but I have

^ Gat. deg %iY., 1881, No. 74, 76, 80.

■ Cr. D emme , No. 90. Jahrtibencht, Ac, S.

121

DISS1SB8 OP IKPAKCT.

uerUiuly often seen <imjloid degeneration of the liver ^nd kidneys, of which I shall speak later.

The treatment in every case was mercurial, except in the scry rare iiiBtanees in which there was nothing bat a bone aflfec- tion- In these cases we first tried iodide of potash, which rripiiiJy relieved the pains and reduced the swelling of the bones, but hardly ever prevented relapses. In other cases we at once bad recourse to mercniy, either in the form of inunction with UJor«:uiiul ointment (j^rs. x^-^-xx* daily), of which » on an average, Ji or Jii were used; ur else injections of perehloride of iiiurcury (gr, in — i\i), which were contiiiiiGd for about a fortiiif(ht» and only once, in a boy of 4 years old, caused a moderate degree of mercurial stomatitis. Mucous papules were effectually treated by touching with nitrate of silver^ or by dusl- in|( with calomel.

lY. — Thi' Dyspeptic Conditions of In/ants.

licfori' turniuff to the morbid conditions which I class together under the term '* ilyspoptic," I must direct your attention to a «ymptom whii*h aj>pear8, certainly, to be pathological, but which Oiu'UrK Hu f^^q^1enily, that we can scarcely regard it as such — I m<:«u the vomiiing of infants. This is entirely dae to over- f(roedy aucking tnther of the breast or of the bottle, whereby the f^tuiiiiu'h becninoM overloaded, and then gets rid of the surjilns mill* l»y It kiud of regurgitation without much apparent effort. Aecording as this takes place immediately after sucking or after an iiiti^rval of wonie minuteH, the milk returns either uncurdled or, more freijuentJy, mixed with curds. This may be repeHknl alter rrtch aucking, or may occur more rarely; depending upon thu iuniMnit of nonriflhmt>nt which the child takes. Movements, t'ijf,, rocking the child uu the iirms Ac, favours the prooew, which, ufi 1 have eaid, occurs in innumerable children and seems ill bn nil ii|ipi>intni( lit of Nature's to guard aguinst the develop* lueiiL of dywp<'pti«; conditions by the speedy discharge of the wufplus quantity of nourishment. This regurgitation is favoured liy certiiin vhnnv ' peruliur to the stomach of infants up

to abuut thii luii 1, Uftincly by iti5 more vertical jwsition

as Well as by the small development of the fundus and of the greater curvature aw compared with tiieir development in later

DYSPEPTIC CONDITIONS OF INFANTS.

125

years — owing to wbich the capacity of the stomacli is relatively smaller. So long, therefore, as the children remain, in spite of this vomiting, healthy and thriving in other reRpccts, there is no tMJcasion for medical interference. We may reassure the anxious mother, advise her to give the child the hreast or hottle at longer intervals and for a shorter time, to let it lie quit'tly in bed immediately after sucking — and especially forbid nil violent movement of the child. Improvement will generally soon take place, and will be favoured in some degree also by the further normal development of the stomach.'

Not uncommonly, however, cases occur in which the vomiting, which at first seemed to be merely of this simple form, assumes more serious significance, while at the same time weighing the child shows that it has ceased growing, and very soon the signs of incipient atrophy prove that we have to do with some- thing more than a mere regurgitation of surplus milk. Under these circumstances vomiting takes place even after com- paratively small quantities of milk. It is only after much persuasion on the part of the nurse that the child can be got to suck for a short time ; and even then there ia vomiting im- mediately or shortly afterwards, of uncnrdled in* but slightly coagulated milk. In such cases the physician may remain for some days in anxious doubt as to whether he has to do with a djspeptic condition or with the commencement of a cerebral a fife ct ion, especially of tubercular meningitia. I intend to return to this in dcKcribing that disease, and shall only mention here that the vomiting of dyspepsia is usually preceded and accompanied by eructations which betoken an amount of gag- formation in the Btomach, unusual at this age and that it may have a sour or oflensive smell. As a rule, the vomited milk is mixed with more or less tough mucus — a feature which I consider of especial importance. In the first days, or even weeks of this condition (which I call dyspepsia gas trie a) the motions may retnia almost their normal condition ; or at roost present a greenish or brownish colour. But generally they also are mixed with mucus and have an nnusually offensive smclL Their

• Uffolmann {ffftndfnwk <ttr prirttUn «, fy^tntl JJygiene dts Kindt*: Loipxi^, USl, B. 2S3) sriveis u oit«»c of romiting tn fl.n infftnt which woa cau&ed hy waph- inir out lt« bottle with lcad(*c »hot. The milk contaiscd Iea<l and traces! of &r^«nic. In obfltitmto eAa«0« hear ench poseibiliticB in mind.

126

DISEASES OF IXPAKCT.

frequency, however, is usnally not increased. As a rule, tliese children suflfer much from flatulence, and before this is got rid of the abdomen is general!}^ mach distended, especially in the region of the transverse colon.

In another set of cases (dyspepsia intestinalis) there is either no vomiting at all, or it is so infrequent as to be of secondary importance. The dyspeptic symptoms manifest them* selves in connection with the intestines. Many childi^n take violent fits of screaming, writhe, turn np their eyes, and exhibit "lightning contractions," or convulsive trembling of the armtf' and legs, and do not become quiet until some of the flatus has been discharged with a loud noise (colica flatulenta*). The motions, which at first had the appearance described above, soon become looser and more frequent, and contain a quantity of yel- low or greenish coloured flakes and lumps, consisting of casein, lime-salts and fat, with more or less tough mucus. They have ^ a greenish (even a spinach -green) colour (biliverdin), and hav6 either a sour, or oftener a highly offensive ammoniacal smell.* In the 24 hours there may be 15 — 20 such stools, for the most part with a strong acid reaction ; but usually their number is limited ]

r Jo 5 or 6, at least in the early stage of the disease. The p|)petite is diminished ; the tongue is sometimes clean, at other times covered with a greyish-white fur. The secretion of urine is diminished. Wlienover such symptoms are observed in an infant, you must at once carefully investigate their causes. For only by their i removal, and not by medicines, is the dyspepsia to be perma* • nently cured. In the first place we have to consider how the child is frd ; because as a matter of experience improper feeding is almost always the cause of such derangements. Hand -fed I infants are, as a matter of course, the most frequent subjects of I tliiw dyspepsia. Bud quality or adulteration of the milk is often to I bUnio ; still oftener, feeding with uuHuituble farinaceous subsU- I lutes for milk at a period when tlie secretion of saliva is not

H ' llmi tufautH uitif nl«o hAVO doUe from othor oansi'S •v,.? . from lead-

W ]i*Si\^ Till* vMiv thtr n««* nf t ho noriK!', load* J

B fom«'»i1ii<i<t»>« U» > .«.«il ft Iftji! I

H |ioMi«l, or lu iilknliiH* «UMMm>r

H «tn ♦)!•■ ' ' ' " ^'> til I' II ■ ■ Ti ur •• rihra ir, i- mu-ij wnlff^

tnBBSPTlC CONDITIONS OF INFANTS,

127

fficient to justify their use. You must direct special atteDtion to those feediiij^-bottles, so much in use among the poor, the mouth- pieces of which commanicate with the interior of the bottle by a j Darrow indiarubber tube. Owing to insufficient cleaning of this ' tube, 80 that remains of milk-curd are loft in it, the milk taken I by the child is charged in passing through the tube with the Lgerms of fermentation and the causes of dyspepsia. I have ^Bbserved this so frequently in the polyclinic that I absolutely ^^rbid the use of such feeding-bottles, unless assurance of the most carofal cleanliness can be given. But even children on 1 the breast are by no means exempt. An alteration (even although incapable of chemical or physical demonstration) of the milk of the mother or nnrse — whether due to disturbances of temper, or excessive bodily exertion, want of nourishment, or recurrence of menstruation — may, as experience shows, produce dyspepsia in the child. From among many others I may men- tion as a striking example, a child of 4 months who throve splendidly with his nurse, until she got suppurative tonsillitis, v?hich caused her very great pain and kept her from sleep* The child forthwith had diaiTho3a, 5 — 6 loose, green, foetid motions daily, until the tonsillar abscess burst. From that day the child's dyspepsia disappeared. I have already mentioned that the most inconceivable errors in the feeding of children are of quite common occmTenco among the lower classes, although

N comparatively rare among educated people. Little children who ■re being fed from the breast or bottle are often allowed to share m the ordinary food of the family — potatoes variously cooked, cabbage, peas and beans, apples, grapes or plums are very often given to these children ; and I have also had cases where Bansages, pancakes, i^c, had been used as foud. In such circiim- stanoea one cannot wonder that dyspeptic conditions are amongst the commonest of infantile diseases, especially among the lower chisses. This disease is particularly apt to occur at weaning, when there comes a change of food — whether this takes place ly at the end of the first year or, through the force of circum- noes (arrest of mammary socretion, or illness) a few months afterbirth (diarrhcea ablactatorum).

What, then, is taking place in the stomach and intestine ?

i8 qQL»»tion has received ditforent answers at dilferent periods*

bo view generally prevalent in furmer times, of an ** acid-

so the

§Otm WmOX i0 utfitiin of digiestiioci lijdiicct imtaliMcnM in Om irat]ilMi of tlie nfnmfh ud mtostiiM!. wttli tOfiooB

§m!ft!ikm oi I&06IU. Then» tfaroa^ the alkmlun nfttoii! of IbU mucng^ Ub* bydrochlorie Acid of the gmslrie jmoe which is neeoB- §mf far ikmiiiaI digettioD is n^ntnUised* ao ih^l it can oo bngar if|i*rAte upon ilw conleotaof Uie ilfliBMii in the oomal ii»oair : MfMl tkMr« riBoH ten^nialire pnocesoes, with the eseewvo frr<irJ If Hioa iff! cf belie and fiomllj of butjiic lu^ £ilijr mils. '11iir«« firoe^MMtf either come to an end id the stooifteh (d. §§Myim)t or (whi4ih is more oooimoii) exteod stiU fuither 4lHVBWariJ» inio the inteiitioal can&l (d. iQtegtiiudi8>. For we mn iieniljr iifidemUlid that if nil the fermeDtiuK cootcfiis of the fi are not cTocQutcd b}* vomiting, tbe fermentetton mittt ilM dinrtM? AH H^H>u A« the abnormal coDteota wilh thuir Ifuftiiii Iff furnioutatioij reach the iutestiDe aud come in cootael with ita rotitrnt«. Tlui lioajiab fiuiell from the ruouih, the iiia««t« tit rnii'u* tii the vomit (which also geaerally smells aoor). lliM Uilui • '♦♦ their irritatinjS! characur (which ig apt to

m " • • r. ;..^ iiiiirul bljo auuM), tiie lUtuJcucc and passage of

fii \*y iliH tttiriM. aa well aa the Hatus discharged from the

Nli»Nirt«>li hII II iitnto the clinical ',f

tloilM oftlM' "t ' ^ ^«. 1 HbalUurti _,ii^

at mII of !)• iniipfution of tbo vc^mitoU mattvrfi and the

i

i

DYSPEPTIC CONDITIONS OP INFANTS,

129

motions ; because, in spito of many reaearclies, some of which are most worthy of recognition, we haye not yet been able to establiwh with certainty the forms of the micro-orgjanisms with which we are here Bpecially concerned. Besides, for the practical ]>h3^8ician this difficult and tedious examination is unnecessary, since the clinical and etii>logical rehitions are all that is required for diiignosis. Sometimes such au fiuliir^ement of the stomach occum as to be distinctly recognisable by the eye and by pal- pati*m. In such rases I Intve tihsurvt'd offensive eructations and flukes of a yellow (butter) colour iu the mass of milk and mncus which was incessantly boin^; vomited. The introduction of a simple stomach tube (Nelaton's catbeter), which I have repeatedly tried in tlioso cases, ami always easily managed, at once brouftht abaut the evacuation of thfise masses, and invariably cau^^ed a rapid collapse of the greatly tHstended epigastrium. These f* rmentative processes are, however, by no means peculiar to early infancy. At a later aire, also, even in adults we often High see similar processes occur owing to overloading of the lach with food and drink, injuriotia in its quantity or quality. These conditions are described under the names of status gaslricus, biliosus, saburralis, diarrha»a stc^rcoralis. Sec. But while in older cbiblren and adults the morbid process generally ends with the (.liscliar^e of the ferraentinj,' substances upwards or downwards, aod tlierefore almost always is quickly over; this rapid termination occurs in infants only when the diet is at once regulated as it should bo. Limiting the amount of food by leas frequently giving the breast, substituting for it boiled water with a little gum-arabic dissolved in it, feeding with a solution of white of egg or with greatly diluted cow's milk, often suffice to remove the complaint in a few days. But, nn flirt onately, the conditions are frequently ill-adapted for protecting children from fresh attacks of the same kind. Only too often the dyspeptic symptoms are disregarded for a long tiuae, and among the lower classes usually referred to teething, Mhich they have nothing at all to do. Without calling in ledicttl man, the mothers attempt to remove them by giving farinaceous food — oatmeal-water, gruel, &c.— and in this way matters grow worse. Thus the unnaturnl foetid evacuations, and often the vomiting also, last for weeks, resulling in steadily in* oreaaitig atrophy, as I have described (p. 71). The further

xsmscr.

iHanumtd €hkMj hj tke

1^.

bjr tihe poiAilil^ of

Tkm

"•y EO

bedhig and traalaieiiU gitilig hMet And worae

ttike

s opders ftra followed

moire

of the femortiaig

11 aided tawlut Ibe praloD^ed iirUalioD indneo a permaniuit At Ibe post-mortcai ddkbao we iiid aieu of bTpenemis and swelliiig of the mtaktv^ in wfakii bolh ibe aolttarj glands and the Ffljw^a palebca ficyatl man than nsiial abore the lonl of ibc taoeooB meoibnaie — in a woid, tbe appeaianoe of obroosc intestinal eatarrb^ to wfaicb I sball refer mofe particxdarlj lortber on. In judging of this in any giren ease, mm most nerar loM sigbi of tbe Uci that we have here to do not with a primaiy diiWMe of tbe mncoaa membrane, but with a secondary affiectioo which mnst be regarded as arising from a ehemical pcoeees. Sometimes too althongb tbe disease has lasted for months tbe change in tbe mneons membrane is extremely slight, and only disooTerable on earefol examinatioD.

A special kind of dyspepsia has been leoenily described by Demme^ and more especially by Biedert*, nnder tbe name of •' fat-dlarrbcpa/' This is characterised by tbe copious discbarge of motions, poor in bik, with a shining, fatty look or even ao asbestos^like appearance. Tbe chemical examination of these rcreals a great increase in the amount of £at (40 to 67 per cry,'. of the dry substaDce) ; while even by the microscope a consi !• r able increase of fat is made out. This condition, which may occur with either natural or arti6cial feeding, and which if chrontc must lead to atrophy, is referred by Biedort to a ^-catarrh of the duodenum hindenDg the fat-digestiug secretions (bile and pancreatic jaice) from entering the bowel, so that mo8t of the fat in the food is discharged in an undigested state and nutrition suffers materially. Although I have myself repeatedly observed such fatty motions, jot in the absence of chemioal and anatomical renearch I am not in a position to criticise the pro- priety of regarding this " fut-diurrlicea ** as a separate form of dv^psis. 1 shall only remark ihiit the absence of jaundice*

' Jukrt^btr. dei JtnnerWhf Kinderitjntstlt r&n, 1874, 1877, 1880, 1888. JnkrbJ Km*itfhHfk^ B<L xii

DYSPLPTIC CONDITIONS OF INFANTS.

IM

-seems to me to teil against Biedert^s view. iDdeed, the cou- siderationa against it formerly brought forward (hy Uffelmaun) liaye received fresh support from receut researches* into the varitttionB in the amount of fat and its occasional presence in large (juantitiea in the fieces of healthy infants and those Buffering from diarrhtea or from febrile affections. The whole qaestiun, theu, is not yet ripe for judgment, in spite of seeming therapeutic results — to which I shall return soon.

When the dyspepsia of infants is acute from the beginninj^, it commences, sometimes, with such violent symptoms that after Bome days a critical and even fatal state of exhaustion may ensne. The clinical picture is then very similar to that which you will become acquainted with later on, in the description uf cholera infantum. But the cases to which I here ailude all occurred sporadically, and in the winter time, — that is to say, at a time when true cholera does not usually appear. Here alt^o Uie cause may almost always be found in faults in the feed- ing of a very obvious kind ; and this ako happens in well-to- do families, where utterly unditrestible dainties are given with the best intentions to little children by indulgent relatives Of hy servants* Violent vomiting, profuse, loose, fa?tid evacuations (following one another in rapid succession and becoming more and more clear and colourless), intense thirst, alteration of the featnresi a very marked sinking-in of the eyes, low temperaturo of the skin, disappearance of the pulse and depression of tho fontanelle, and tinally convulsive fits, occut as in cholera — where, however, these symptoms are due to an epidemic aud presumably infectious iniiuenco. The cause of the rapid col- lapse lies probably in the violent watery diarrhoDa and vomiting, caused by the irritating action of the fermenting Bubatances on the mucous membrane, and by the reflexly-increased peristalsig. This very great loss of water explains on the one liand the rapid re-absorption of the fluids of the body, which causes the sinking in of the features aud tlie depression of the fontanelle, and on the other hand the extreme weakness of the heart which finds expression in the apathy and somnolence (arterial aniemia and Tenous hypertemia of the brain) with the disappearance of the pnlge and the fall of the temperature. Such cases may be just

* Tachernoff, Jahrh. f. KinderheiU:., Bd. xxii., 8- 1.— Kramtityk., ifti'rf., 8. 2T0.

132

DISEASES OF INFANCY.

as fatal as epidemic cholera in the Bninmer luoDtbs. Btill, aa a matter of experience, their prognosis, ^'enerally, is raorc fuvour- able, because when the deleterious contents of the bowel have been expelled with violent symptoms, the disease usually cea»ea and the child again recovers strength. In the event of a fntal issue the post-mortem shows, as a rule, either extremely alight catarrhal changes in the mucous membrane of the st4>mach and intestine, or none at all ; at times only an extreme paleness, corresponding to the general ancemia, with perhaps slight swelling of the follicles.

Under these circiimstancea we must always be prepared to ' meet with the ]ieculiar alteration of tlie stomach which, under the name of "gelatinous softening of the stomach (gastromalacia)'* has occupied physicians for many years. The slightest degree of this — and we meet with it pretty often — consists of a pulpy softness of the mucous membrane of the fundus and also of the posterior wall of the Rtomach, so that it can be scraped away with the handle of the scalpel like a thick solution of gum. Thus, the parts affected are just those which in the uBoal position of the dead bodv, are most exposed to the action of the stomach's contents. Less frequently, th© softening affects all the coats of the stomach, and they are then transformed into a kind of grey, reddish, or dark brownish semi- transparent jelly, which has the smell of butyric acid and reddens litmus-paper. Generally, they are still held together by the serous coat ; but this also may give way previous to the post-murtem ; and we then find in the situation of the fuudus, nothing left but a few fragments mixed with jelly-like masncs and the contents of the stomach. There is not a truce of any inflammatory process to be found anywhere; and the miiro- scope shows in the softened parts ouly some epithelial ct^lls mixed with a mucus-like substance, and a few blood-vesseU still intact and filled with dark clots. The question so long disputfd as to whether gastroinalacia is really a disease or merely a chemical iteration of the stomach which takes place after death, is now tuoqnestionably settled in favour of tho latter view. We baro here to do with a post-mortem digestion of the coats of the stomach by its contents, and we can therefore only expect to find it where food had recently been taken and death ensued during digestion, Thns also tho fact that aomo-

DYSPEPl'IC CONDITIONS OF INFANTS.

133

^

iimee not only the fandua of the stomach hut also the contiguous organs — spleeu, left kidney, omentnm and dittphnigm» and even the lower lobe of the left lung, are fouud more or less digested and floftened. We can easily explain how this condition was in former times regarded as morbid and furnished with a complete symptomatology, correHpondiug exactly with thaj of acute dyspepsia, or cholera. For in these diseases abnormal fermen- tative processes of the stomach's contents form the chief feature, and hence after death a destructive influence ou its walls will ho much more easily exerted than in other morbid conditions.

The fatal results which we have seen ensuing in dyspepsia neglected at its commencement, make it our duty to enter at once upon serious treatment of the case, which can only he carried out with a fair prospect of success where the circum- stances of the little patients are favourable and our orders are carefully attended to. To the children of the poor, our aid often comes loo late ; and even when it is sought In time we meet with hindrances hard to remove — chief amongst which is the lack of proper nourishment.

In acute cases, we often reach the sick-bed only after uatur« has by violent vomiting and diarrhoea already got rid oi' the injurious contents of the alimentary canal. We now find the^ child simply exhausted, and we bave nothing further to do but to superintend the regulation of the diet. If the child is on the breast, we must first — if no positive defect can be found in the diet^ — keep in mind the possihility of an injurious change in the milk. Changes of temper and over-exertion on the part of the nurse, occasion only a temporary change in the milk; and the child may therefore be put back to the breast whenever the dyspeptic evacuations have ceased. Wo must, how*n'er» espe- cially guard against over-feeding, which is only too often to blame in cases of dyspepsia. Mother's milk requires two hours, at least, for its digestion : cow*8 milk certainly longer. And these intervals must therefore be carefuUy observed, before the child is fed again* Unfortunately in practice one often meets with fiiolish obstinacy on this point ; but the researches of

• AJtiioii^h Epitcin, {Archie f. KiuHei^hrill\, Bd, It.), found on WAihing out tho fltomaoh of sereral healthy obildren of sevcroi]! wevlcH old, who hiul drunk 1— SI oi« of their mother*)! milk, th&t thu etomach waa neuAllj empty after 1 — 1| bo«n— dUU, I cannot make ap my miitd to change from the practice above

Biedert' «who proved tLat the amonnt of noaiiBhroent taketi in the first months, especially l»v bund^fed children, often fiir exceeds the amount really needed) show bow very necessary it is for n 8 to do all we can to check this foolifih popular error, and to reduce the quantity.* Under these circurastancee I have seen attncks resemhling collapse in infants, ulso pallor, and symptoms like those of fainting, and these rapidly disappeared when the superfluous milk was vomited up. Restriction of the amwint of nourishment is all the more necessary x\heu dyspepsia already exists. It is therefore always well to forbid the breast entirely for 24 — B6 hours ; or only to allow it to be taken less frequently than usual ; or to give instead of it a little gruel or barley-water, or, still belter, the solution of white of e<»g, recommended by- Bern nie (the whites of *2 en:*;s to IJ ]nnts of water with a little sugar and cognac). Should the recurrence of menstruation iu the nurse always occasion dyspepsia in the child, there remains no remedy except a change of nurse or weaning. However, in tne majority of cases I have observed no l»!id eflccta on ihc milk from menstruation : and therefore I have but eeldom had occasion to dismiss a nurse on this ground. It is the same with acute diseases of Ihc nurse; which as I have shown you from « striking example (p. 127) may possibly originate dyspepsia, but by no means do so invariably. It is only when the acute disease of the nurse is presumubly to be a short and slight one, that W6 may put the child who is suftcring from dyspepsia on the bottle for the time being. But if such is not the case, you must at once try to procure another nurse. Should the child, however, be hand-fed, you will— after the attack is over— cautioaaly tiy again its usual food, if you consider it suitable. If relapsea^. occur, a change of food must, naturally, be tried ; and in thi ease the first question for consideration is whether we sliould now have a wet-nurse, instead of the artificial feeding which has been used siuce birth or for some lime pa.st. If the parents circumstances allow it, you aliould advise a nurse* It is true I hat there are many difficulties to be met in such ii case : for the children, liaving become accustomed to the bottle and the ease with which the milk flowed from it, prefer it to sucking the

♦ Jnhrh./. KinderheilX:, irii . 8. 251. 38g ; ill . S. *>!.

• EioGMivo <ituintitift« of milk: will iuittirft.Uy •lao twim »tt incraoAii io Om^ AcnouRt of arinv. Pol^arin »c»mlt>. ia tho ncighbourhoo*! of the ifiml'.ittlH •«

hS.'l.

olMdtnui-

illt*"rt-<«r«»,

DTSrEPTIC CONDITIONS OF INFANTS.

I

reast, to which they are unaccustomed and which they often tively refuse. Still, if we only have patience, we Bhall erally succeed in getting over this difficulty and accustoming the child to the hrcast. I have seen children even 3 — 4 months old, who had been hand-fed from birth, take to the breast without much ado. Of course the thing is not always at an end even then. For the nurse^s milk may, for various reasons (p. 127)i disagi'ee with the child and occasion dyspeptic symptoms; so that a new nin-sc hus to be provided. Guses are by no means rare of such a child having three or more nurses in succession » before a suitable one was found.

The guiding rules for the dietetic treatment of infantile dyspepsia can only be laid down in a very general way. For you will often come upon cases in which, through obscure causes, the application of these rules becomes impossible, and such ust be treated on some other method. Thus, I have sometimes ad cases of dyspepsia which persisted in spite of a repeated bange of nurse, and yielded only on the children being eaned. With others who have hitherto been exclusively find-fed, even cow's milk (which I have nlways regarded as he best substitute for the breast : p. 81) caused dyspepsia, o that one had to give it up or replace it by some other form of ourishmtjnt such as the abovti-mL'Utioned (p. 84) infant foods, t the same time the idea of many physicians that good cow's milk is not digested under such circumstances, is not generally ustified. 1 advise you to be guidi^d here, less by theoretical pinion than by practical experience, and to make repeated trials with cow's milk before having recourse to any other substi- tute. Hmw frequently have infants with dyspeptic diarrhcea been roDght to me, who, through dread of cow's milk, had been fed on oat-meal water and thin gruel, aud wlio were in conse- ce becoming moro and more wasted, I confidently advised iltat they should be put again on cow's milk, and I have very often leen the motions and the general condition improve every day when ey did so. Experience, however, has taught nie that in these s the milk is often more easily digested cold than arm — probubly because it is in this state Icbb liable to ferment, t should therefore be allowed to cool after it has been boiled ; d, especially in acute dyspepsia, should bo put in ico d jrircii to tho phitdren qnite cold. Most children take it

136

DxasABEs or infancy.

willingly, many even greedily ; and wheneyer tbey begin to refuse Uio cold milk and aguiu abow an incliniition for tbe wurm, I regard it as a sign of returning health. Aa long, however, as dyspeptic vomiting continues it will be well to give the children cold milk from a spoon, because drinking it from the bottle i^ apt to cause overloading of the stomach and vomiting.

Child of 10 months, weaned six weeks befortv sufftrinj5 \\ weeks from diiirrhcDa, for which hydrochloric acid had been used with vurying success. On 19th December, 1864, suddeii exacerba- tion, numerous loose bright-yellow rootiona ; occasional vomiting. Continual rcstlcBsncsa, slight sinking of the ft^turos, abdomen iiurmal, but tender on pressure. Latterlj^ <inly veal-toA bad been piven instead of milk; but neither this nor smiill doses of opium nor calomel hiul any favourable result. Within 24 hours tlierr were about 20 motions and frequent vomiting; at the same time hi^h fever and unqucnchaJ»lc thirst. Milk and arrowroot given on 22nd caused rei>eated vomiting and still more severe diarrhcco. I MOW ordered 2 or 3 dessert-spionfuls of iced milk every bour, and to quench the thirst little pieces of ice frequently and ire-cold w»ter slightly sweetened. As medicine ui emulsion of ulmondi?. likewise iced, was ordered in teaspoonful doses. On the follow* ing day, already n marked improvement; rest and sleep for flovoral hours; pulse and temperature normal; thirst con8ideni}»li lessened. Vomiting had oidy taken place once, nfter vioieut crying, »md tlie It motions which had been passed were perfectly normal. On 24th, complete convalescence; and the child now refufted the cold milk which it had hitherto taken greedily, and again lihuwed u desire for tbe uHual lukewarm milk mixed with arrowroot. The anorexia, which still continued, with a thick white fur on the tongue, yielded in the course of a week to small doses or tinct. rhui.

Child U., one year old, suffering from dysptptie diarrhuMi which hiwl followed on weaning 14 days l>efore. On 12th Novcmbcn W7%^i I found the child collapsed, cohl. with scarcely perceptible pulse. MilK and all other drinks were at once vomited; 12 — K'» loose, brownish, offensive motions daily. Treatment :^iccd milk jm spoonfuU, 2 camomile baths daily, insmutbi subnitnitis gr.

I'Vcry 2 bourtt. On 14th no more vomiting; rold milk is taken |free<lily and well borne. Still 0 — 7 evacuatiotin daily, with a ptitrid timell. Treatment changed to creasote gtt. ivBS., aq. J ii,. A tcu»paonftil every 2 liourt*. Hccovery after four dn3'a.

Such examples (of which I hare now collected a large number^ kinly encourage the trial of ic^ milk aa a form of uouriah- lent in tljo acute ily«pcp>;ia of infnnls. Even in this form, towever, the milk has not always a fafonrable effect ; and it ta

DYSPEPTIC CONDITIONS OP mFANTS.

137

then necessary to substitute other drinkB — solution of white of egg, aoupa, barley water, decoctions of salep, arrowroot, or ** infanta' food." In persisteut vomitinf^, we may also attempt to administer the nourishment per rectum, and I have twice or thrice tried this by means of enemata of peptone (about a teaspoonfuj in half a cup of beef-tea). 1 have, however, had no success from this, probably because the veiy active peristaltic movemeutB of the bowel were still further increased by the enematai, which were at once rejected almost unaltered. I have myself no experience of peptone given by the mouth, which is praised by Escherieh. The washing* out of the stomach recom- mended by Epstein and others* in obstinate vomitiiig of young children, which according to my experience is generally easy to perform (p. l*2l», I consider worth a trial even in older children, especially when the stomach is evidently distended, and gross errors in diet are known to have been coramitled. I have not yet had sufficient experience of this method to justify me in speaking decisively about it* It is certain that recovery often occurs without washing-out of the stomach ; this proceeding, however, cannot do any harm whatever, and may accelerate re- covery by rapidly getting rid of fermenting materials. Still we should be on our guard against over-estimating this method of treatment. In many of my cases, indeed, a single washing- out was sufficient to arrest an obstinate attack of vomiting ; but far oftoucr the treatment was unsuccessful, although frequently re- peated. The miserable condition of the majority of the patients in my children's ward may, however, be to blame for this want of success.

As to modicinal treatment : — in recent cases of dyspepsia (that is, such as have not lasted more than a week), whether the dyspepsia is shown by vomiting or by diarrha^a, or by both, I should recommend calomel as the first remedy. This should be given, according to the child's age, in doses of gr. j^ — \ every three hours with pulv. acacia?, grs. viii. (Form. 2). Altliough nothing dctinite can be said as to the way in which this medicine operates, its action is probably anti-fi^rmentative. The state- ment that the calomel is changed into perchloride by the

• " XJebor MairenmisHpalnngoii boi Sauglingen/ ' Arckiv f. KindtrktUl.i Bd. ir, fahrb,/, Kiniicrheilk\^ Mvii. S. 113«— Lorey, ih'u\. xivi. S. 44.— Ehrin^, ibid, S.258.

138 DISEASES OF INFANCY.

chloride of sodium in the contents of the stomach and bowel, is correct only in so far that such a change takes place veiy gradually, and only when large quantities of calomel remain in the bowel for a long time. In the present cases, however, neither of these conditions is fulfilled. Let ns, therefore, hold to the therapeutic action ^\hich has been ascertained practically. Cessation of the vomiting and improvement of the motions (diminution of the foBtor, and more pulpy consistence) occur frequently by the second or third day of its use, and in many cases there is no need of any other remedy. Perhaps the purgative effect, although it is but slight, which even such small doses of calomel have upon infants, may be regarded as a favour- able accessory action ; since in such cases, the first point is to remove the abnormal contents of the bowel as quickly as possible from the body. Should the affection have already lasted a week or longer, we cannot promise ourselves such good results from calomel as in perfectly fresh cases ; still, even in this case, the medicine is worth a trial, for I at any rate have never observed any injurious effects from its use.^

Next to calomel, in my experience, stands hydrochloric iicid (Form. 3), which in not quite recent cases may also be given with good effect. The action of this medicine, as the experiments of Schottin^ prove, is strongly anti-fermontative. Ke showed in the case of fermenting fluids in a hot chamber, that the luetic acid — as well as butyric acid — fermentation is immediately arrested by adding sulphuric acid, and does not begin again until the acid has been neutralised by an alkali. "Hydrochloric acid acts much more favourably, because it is also able to dissolve the proteids in the slomach, and take the place of the gastric juice which is wanting." In fresh cases vou must not add any opium, for its constipating effect is apt to cause great distension of the bowel with gas. But if several days have elapsed and the loose motions still con- tinue, you may then assume that after the injurious contents Lave been got rid of, there remains an irritated condition of the mucous membrane, and an increased peristalsis. W'hen this is so, the addition of tinct. opii (about gtt. iv.— v. to the mix-

* (y. on the action of calomel on fermentativo proceeaes, &c., TT&sailieff, Zeitsekr.f. pkysiol. Chemie, yi., S. 112.

* Ktthler, Bandb. despkytiol. Tkerapeutil-: Qiittmeen. 1876, S. 882.

^^^KM DYSPEPTIC CONDITIONS OF INFANTS. 139

pre) is very beneficial — doubtiesB because this, by lessening Bte peristalsis, affords time for the Lydroebloric acid to take permanent effect.

Tbe results wLich I obtained with calomel and hydrochloric acid and published some time ago*, have since then received coufirmation iu iuuumeruble cases. NeverthdesB, there are still maDy physicians who prefer alkuline remedies, especially bicar- nute of Boda, to acids. But, altbouj:?h this medicine may porarily neutralise the acid of the fermenting contents of the ch, it cannot reach the fermenting process itself, and I can erefore recommend neither it nor other alkaline medicines, I ve not experimented Bufficientlv with benzoate of soda^ Which is praised as an antiseptic) to be able to ^ive a definite udgment as tu its value. Ik-iu*^ contcntinl with the success I 'Obtained with culomel and hvdrocbloric acid I have not looked for other remedies. Where these remedies fail, however, I onld ccHoinly recommend creasote on account of its strong ti-fermeutativc action, especially in cases iu which vomiting is a prominent feature* But, if only given in sufficient doses (Form. 4), it is also effectual in those cases where, after the violent symptoms are over, there still continue to be thin, ensivc motions which are not improved by hydrochloric acid, following eases show that we need not be afi*aid even of doses.

A boy of 7 months, hand-fed. For some days l>fwk, vomiting of milk partly tiuid nnd partly curded^ with a sour »mell. Also frequent auur-smL-lliug motiouB, resembling " weiss Bier." Hydro- chloric acid alonCt »iui uLso along with tinct. opiL* was uiisuc- ccafiful. I ueit tried ereawuti gtt. vii., s^Tupi sirapl. 5 iii,, aquam ad 3 ii., a tcaspooiiful every 2 luiura. After 2 days, ceasatton of the romitingj hut persistence of the diarrhrea, whirh was after- wards cured by small doses t>f opium.

A girl of G weeks, baud-fed. During the last 24 houra, dittrrhiua and vomiting after every drink. The vomited matter aroeUs very eour. Creasote, gtt. iv. in 3 ii., a teaapoonful every 2 JiourM. After 4 days, only 1 — 2 norma! motions ; no more vomiting.

In children, therefore, of bix weeks and seven months re-

ciively the dose was i and 4 drop ; since 511. of fluid

present about Itl tcaspoorifuls. Besides the drags I have

Btitrnar s»r Kinder heitk., X.F., 8. 293.

Eaoborich. Centra ibt / itnrfvriofnije w. i. ip., ii,, 1E87, No, 21.

140

or EfFASCY,

nxmedj which in mr opicioii oceapT the first ptace among remedieg for this disease^ I ha^e alao made trial, both in thfi hospital and in priTate pnctioe, of other medkuies which have a high repatation for their antifermenlatiTe aeiion — nameljg chloral hydrate (1 per cent, solmion or more), carbolie acid, aqna chlori and resorcin* The first of these was SQc- eessfol (althoti>;h not inTariahly) in caow of djspeptic Tomiting. The oUier three I hare quite giten np ; and I consider the continued nse of carbolic acid especially, as not unattended with danger. Naphthalin, which has been occasiooaUy praised Tery recently, I hare not seen occasion to use from the reports given of it. Just as little did the pepsin (so much recom* mended of late) meet my expectations ; and this may perhaps have been because we are nnable to det4?rmin6 the indications for its administration in each individual case. Tbii^ remedy, how* ewer, can evidently be of use only where the dyspeptic fermenta- tion is produced either by diminished secretion of gastric juice or at least by a deficient amount of pepsin in it. These changes can only be estimated (und tbut merely approximately) when the contents of the stomach are removed by a tabe and examined chemically, which generally is quii^ impracticable in ordinary practice. Uoder these circumstances, the use of pep- sin in infantile dyspepsia must always remain an experiment which we can try either Ht the begiDning or after other remedies have been used without result, but oue whose success is to be regarded merely as a happy chance. I prescribe pepsin either alone (gr. i. — iss.) or along with hydrochloric acid (Form. 6) in the form of the essence of pepsin to be had of any chemist. Naturally, pepsin can only exercise its efftjct where substances contain iug protein — especially milk — are still being taken. It must therefore always be given half-an-hour before or after food*

Richard K., 10 weeks old, hand-fed, poorly nourished, brought 7th Deeemlwr, 1860. For soma days buck, no sleejn frequent colic, daily 1() — 12 loose gre<*n motions, excoriating the ni\u» \ slight flAtuk'ut distcnuion, no voniititig, no fever. Calomel ustrtl, without result. fepHirii (gr. i. :J — 4 tunes doily j bntught about rts.ovcrj after 12 donot* On 13th April, l8tJ7, brought iigwui to tlie poly- clinic on uerount of voniititig whenever food Wtta taken. This had lasted for *>mo wueks. Tlirunh in the mouth* PefiKiUi gr. i 4 timeii daily. By 16th nmrkcil nbatcTncnt of the vomiting 4 on 23rd» completo rocover**

I

DYSPEPTIC CONDITIONS OF INFANTS.

141

Girl of 15 weeks, brought 6th May. 1873— liand- fed. For 4 weeks past, vomiting (especially frequent after taking milk) and diarrhoea. Great reatlesauesSt a certain amount of wasting, great thirat, motions very offensive. Pepsin, gr. l, 4 times daily. Recovery on l-lth. Now only 3 normal motiona daily.

Boy of 6 weeks, on the breast, brought 19th Jan., 1874. Violent vomiting after each drink; froquont green offensive evatiuations. Calomel without effect. On 24th, pepsin, grs. iv., aq. destilL, syr. simph, ana 3 vii,, acidi hydrochlor. gtt. x., a teaspoon ful every 2 hours. On 27th, vomiting much lees frequent, and not till 10 or 15 minutes after taking the breast. Motions bettor. Pepsin increased to grs. xxiii. in the mixture. Recovery on 3Ist.

Thus we Bee tliat under certain circum stances pepsin has

results ; and we may in dyspepsia have to try, one after

another, all the remedies which are accredited by previous

practice. In one case one drag, in another another, will prove

the more eff»*ctaal, without our being able to discover the reason

of this difference. Besides the r^^medies already named there

are several others, which will be described under the heading

Diarrhfjta; especially subnitrate of bismuth (raagisterium

biamuthi). The suitable time ftjr the administration of this

drng is, I think, the moment when the presL'nce of particles of

mucus in the motions Indicates that the chemical processes are

jL^eginning to cause a catarrhal condition of the mucous mem-

^Arane of the intestine. To children in the ^rst year bismuth.

^Babnit., gr. j — gr. lii.^ with pulv. acaciie, grs. viii., may be

^"^ven 5 — 6 times daily ; and when the disease has lasted for a

I week I have often seen an increased eflcct from the addition of

^Kxtr. opii., gr. Vs. Later on, also, if the symptoms of chronic

^Bitestiual catarrh are becoming constantly more apparent, bis-

^fkuth proves to be one of our most reliable remedies. Nitrate

of silver, also, (gr. i in ^iiisa.) undoubtedly does good service in

many cases of dyspeptic diarrhoea, and is therefore always worth

a trial when the disease is very obstinate. After recovery, I

recommend rhubarb as a tonic for the digestion. It Hhould be

used for some weeks in the form of vinum rbei (gtt. v. — xv.,

8 — 4 times dally, according to age).*

' I b&ve no experienoe of transifnfli on, which Demra« (18. B^rickt after dU Tkdfitfkeit dtt JMiHtrachen KimUrh.^pitnU,^ 1890, S. 42) haa tried fHjquently (6 ^rammeti of blcxHl, 5—8 timo4) and with partial eaoce«a. D cmme himBolf apeaks f*ry roaervedlj about this method, which is said to rai«H> the depreaaad SQtritloD.

142

T. Carfsm aflt^mmU,

Tbe ^'nlf'^'fiK* ffffiwUffUfi^nf of tlie BIQ00BS nenrinsoA •of i&aU » ilkiovii to ft marfcad d^grefi in the ddld, in idMMD MMn afWr Virtb And in the first we^» of liJe contact with the lir cxettas 6«qiieiit reflex sneezing. Any dull the ehild, eopaeiall j from cafdeoaMos in wtthing or H, f«sdilj occ— lOPB A eorjzm with onvflliiig braolhiof •ad mierf nmeoos discharge which, if eieoaliness is not care- foUj aUended to, dries into reUowiah-hiown entsts aboat the Bostrila, sod tDiaiena with the eatnaee of air* This tendency to eoryza ii also foood in infimts thioo^OQt the whole of tho first jear. After what I hare already said (p. 93), jou will nndar- ataodthat inall such eaaes a aoapteioo of hereditary syphilis occurs to the pbjsician — especially as oofyxa may form the mtj first symptom of syphilis and precede all its other manifesia- tioos by we^ks. For this reason we are obliged in ererj pro- tracted case of eoryza, to examine the child and its parents in r^rd to this matter ; so that, shoald our snspidon be confimied, ^odfic treatment — which in that ease alone is of any nse — nuy be ooromonced.

Now, althoagh syphilitic cofyza may bring with it tho sMiie risks as any onlintLry non-specific cor^fza — still, this Teryaeldora happens. In niost eases it is only one link in a chain of symptoms, and does not claim to be of specially great signifi- cance. Serious symptoms^ which may become fatal in varioos mayHf occur fur more frer|Qently in the simple corjza duo to a coliK Thit ilttii(,'er to the child lies chiefiy in the fact that the cor>3sa may at this ago extend downwards with great rapidity^ to tbci inuc4>tii» niombrnno of the larynx and trachea, and e?en to thai of the lironchi. lIoarseneHi of the cry, coaghing, foTor and dyspntiia otUifi develope within a few days. Examination then shows mom or less wide*sprcad bronchitis or hroncho-pneomonia. On the other hand, the catarrhal swelliug of the raucous mem hrane of the noH<? which causes considerable contraction of tho iibild^s already iiufKcioutly narrow nasal cavity, may result in more or l(!B8 oxtrctmo d} Hpntua. This gives an alarming character to any tracheal or brcnpliial cotarrh which is combined with coryza^ <iv<*u when percussion and aoscaltatioti do not seem to jnstifyj

i

CUUVZi, or IHPANTS.

143

npprebensian. Bat even in cases of simple uncomplicated coryza W6 flometimes Lave sudden attack a of dyspncEa, which are apt to perplex the phjsiciau who has been hastily Biimmoned and is unacquainted with the child's previous condition. Boachut describes svmploms of asphyxia as having occurred in the following way: — The cliild was unable to breathe throuj^h f, the obstructed nostrils ; it had, therefore, to breathe tbrongh the mouth with such force that tho tongue was suddenly jerked back during the process, and the lower surface of its tip pressed igaiUBt the hard palate, thus necessarily obstructing the passage of air into tho throat. This explanation of the sucking-in of the tongue by violent inspiration is held by many authors— among others, by Kussmaul and Honsell ;* and the possibilily of its occuxronce, especially when the frenum is long and loose, cannot be denied. Personally. I have ouly once met with this indrawing of the tongue. It was not in a case of coryza, but in a violent attack of spasmus glottidis in which I could only with difficulty reach the root of the tongue with my forefinger, it being firmly pressed against the palate and curled upon itself. In coryza of very 3*oung cblklreu I have always been obliged to regard the dyspnooa as the result of the blocking of the nasi*! cavity; and in very acute cases I have known it reach snch a degree that it might have been mistaken for croup.'^

In March* 1861, I was called to see a child of 7 weoka^ who h&<l l«en attacked by violent dyspncea about li hours previously. According to the account given by t!ie alarmed parents, the child had been perfectly well a few hours before and bad been taken out in a strong eagt wind. Almost imraedifltely after returaiing. the attacks bad eomc on without any evident occasion — not even that of sucking. Aa the worst of it wajg over by the time I arrived, I thougbt it might have been an attack of spasmus glottidis, and in order to decide tliis I bml the child put to the breast. At oncu :\ fresh and even more violent attack reaulteil, almost as severe a^ one sees in croup, With an expression of extreme anxiety on ity cyanotic face, with open month and violent action of all the inppi- rntory muse leg, the child gasped for lireath ; and at each Ra«p n whistling uoi«e was heard which obviously proceeded from ih^ nose. The cavity of the pharynx was completely free. After a few minutes, a gradual cesaatitm took plo^c, sleep soon following—

» tfe»(ct und P/eufftr't Zntsckr. 3 Rtihe., Bd. ixlii,, S. 230, 1865.

' In A ciuie of Evphilitic ooryxa |^Ven by Haasin^ {Jahrb.f. KinJerkeiU',, xsii

r 4iS), it wa%^ even necoeaarj to perform t ra o he o t o m y.

144

DI8BJLSBS OF INFANCY*

during which both insplr&tlon and expiration were by a snuffling noise. The lower pwt of the noac wua sotnewhai swollen. During the next 12 hours I had the child fed only with the spoon, had warm oil rubbed over the bridge of the noso, and gave calomel, gr. ^, every 2 hours. During the following days A mnco-purulent discharge made its appearance from thenofle, but disappeared again after a few days.

In cases of this kind — which are nlways rare — the nptd development of catarrhal swelling of the miicoaa memhrane is especially noteworthy, being analogons to that which so frpqnently occurs dnrin^ the night in adults in the coarse of a violent cold in the head (especially wheo in a recambent position) and inter- feres with breathing through the nose. Here also the secretion is arrested when the swelling increases ; and, as a rule, raising oneself to a sitting posture is the first thing to bring relief, as everyone has probably experienced for himself. In the case just mentioned also, the dyspncea was best relieved by carrying the little patient about in an upright posture. To my mind, there is a decided analogy between these cases of acute corysa, so-called false croup, and certain very acute attacks of bronchial catarrh to which I shall have an occasion to return later on. According to the recent experience of specialists. it is conceivable that catarrhal irritation of the mucous membrane of the nose may also excite reflexly a spastic contraction of the bronchial muscles ; and this may give rise to such violent symp- toms as in the case interference with sacking depend upon breathing through the nose, and finding this no longer possible, has to let go the nipple or mouthpiece of the bottle frequently in order to breathe through the mouth ; and in this way its nutrition is in course of time seriously interfered with. For the same reason, in severe coryza it is during sacking that the violent attacks of dyspncea occur.

Coryza nearly always attacks both nasal cavities at onco It ia but rarely limited to one side. For example, I observed* in June 1874, a child of 8 weeks, formerly perfectly healtliy and certainly free from any suspicion of syphilis, wbicb had auffored for about a fortnight from a yellowish watery discharge from the right nasal cavity, while the left was quite unaifected. Pressure on the right side of the nose promoted Uie discharge. A]c»ng with this there was snufHinf? respiration and dyspncea doling

<

I

id this may give rise to such violent symp- ^ just given. Another danger lies in the H king. The child during this act has to "

RETRO- PH AH YNGEAL ABSCESS*

145

ing, BO that the child was often obliged to let go the nipple. Brush JDg out the riffht nasal cavity with a solution of nitrate of ilter effected a cure in 14 days.

Tho examples given contain all I have to say to you on the treat- ment of coryza. The nourishment of the child demands your attention above everytbiuf^ else. If sucking is interfered with by dyspncea, you must either have the mother's milk artificially drawn off, or have cow's milk given with a spoon ; and I have always found this satisfactory. A case recorded by Kuss- m&ul is likely to remain unique : — a child of 6 months having to be fed for a whole week by means of an oesophageal tube, owing to the drawing-iu of the tongue already spoken of. For

internal use in very acute cases of coryza, I recommend calomel, \T. 7 — i, every 2 hours, even where there is no suspicion of yphilis. In slighter attacks, however, we nerd do nothing leyond keeping the lumen of the nostrils free by applying oil and emoving the scabs. If the disease takes a more chronic course, [ood effects will be gained by painting the inside of the nose with a solution of nitrate of silver (2 per c«nt).

We shall discuss later on diphtheritic eorvza» which is by

no means rare during in fancy. I only remark here in regard to

it that in every case of coryza in a young child, if one wishes to

^^uard against surprises of a very serious nature, a daily

^Bxamination of the pharynx is indispensable.

YI. — Retro-pharifngeal Ahcess, The reason why this disense is still practically unknown to

^thi

tuany physicians, lies chiefly in the fact that its occurrence is very ncommoD. In spite of the large amount of clinical materia! at ny dinposal, I have records of only about 65 cases. Thus it is that tlioso physicians who do not see any large number of sick Udren are generally unacquainted with this disease, and so sually fail to recognise the first case presented to them. On o other hand, any one who has had the opportunity of watch- iuj^ cloeely even a single case of retro-pharNngeal abscess is tolerably well insured against future error in dingnoais. For the clinical picture of the disease is indelibly impressed upon his mind^ and the recollection of this single experience makes the diagnosis easy to him.

10

DIBEASKS OF IKFANCT.

This digease coiiBists of aD abscess in the coDuective tissae between the cervical spine and the pharynx, which almost alimjn developes somewhat insidiously and gradually forms a inmoar projecting more or lesa into the cavity of the pharynx, thus occasioning interference with deglutition and in a greater de-gree witii respiration.

My 6rst case of this kind I observed as early as 1850/ and 1 readily adrait that I owed iny diagnosis of it entirely to tbf oircomstance that I had chanced a few duys previously to rcail two cases of this kind published by Fleming in the Dublin Journal for Feb. 1850. This first one, along with two other ciiscH^ will be found recorded in the book published by Rom- berg and myself (" Klinische Warhnehmungen nnd Beobach- tnngon": Btrlin 1851, S. 120), and the description tlien given has since required no alteration in spite of numerous subsequent observations. In almost all my cases, the children were still in tbiJir first year or but little beyond it. The majority were much less than a year old, the youngest being only four months. In only two cases were the children aged 2 and 81 respectively: and these, as it chanced » came to the polyclinic on the same day (26Lh July 1880)* The disease in its early stages is very obscure ; crying, rostlessness and frequent refusal of the breast or bottle aie tlie first symptoms, and from these alone no diagnosis can be made. We may, indeed » assume that there must be pain is iWrtll owing from the beginning. But dysphagia is a symptom which cannot be made out at first in children who are too young t(} complain : although only a pained expression of the features during drinking may arouse suspicion. But this is often absent, even when the lumour is fully developed as is also the regurgitation of liquids. The first symptom which I regard as really suspi- cious is a snoring character of the breathing, especially during sleep ; and this very symptom causes the inexperienced to reganl the (H>mplairit as a cold in the head — which, indeed, does at times, though by no means always, accompany it. The inspec- tion of the pharynx— which in these circumstances ev<^ry oonseientions physician ought to make — usually reveals nothing, or, at most, a swelling and redness of the mucous membrane of the throat, which is covered by mucus ; and one is satisfied witJi the diagnosis of a catarrhal swelling of the turbinated bones.

* Cn^ftgrt Wuchtfttehr.. Jon*, l^>

RETBO PHARYNGEAL ABSCEBg,

147

^

Generally it is from 10 days to a fortniglit or more before the abscess by its Bize seriously interferes with the breathing. Next the sleep is disturbed ; the child sleeps with its mouth open, but "wakes often and gasps for breath. Gradually however a fresh set of symptoms commences, which is apt to mislead one unacquainted with the disease by its resemhlnnce to severe laryogeal catarrh or even croup. The respiration becomes laboured, tlie accessory musclos of inspiration act strongly, while each inspiration and expiration is accompanied by a snorinij: noise. When the child attempts to drink, attacks of choking may occur and the Iif|uid is often rejected again from the month and nose. In extreme forma of this disease the countenance is distressed and may present a cyanotic hue. Formerly the absence of cough and the quite normal sound of the voice appeared to me very important symptoms, for I thought that I found in them an essential difference from croup. Further experience, however, baa taught me that those are by no means constant, and thai cases sometimes occur in which hoarseness and cou^h are present owing to an accompanying catarrh. The duty of examining locally therefore becomes all the tnore imperative, In many cases of retro-pharyngeal abscess a diffuse swelling is visible on one or both sides of the upper part of the neck; and several swollen lymphatic glands may also be felt, which from their superticial position look as if forced outwards from within. The external jugular veins arc often much distended. All these symptoms, however, are in no way characteristic; a sure diagnosis cnQ only rest on an examination of the pharynx by means of the finger introduced over the tongue into the throat, imd on that alone. In infants who have teeth this examination is more difUcult, because they often bite the 6nger ; and in these oases I generally use a metal ring as a protection. You must ftlso be prepared to find in very extreme dyspnoea that not only may symptoms of asphyxia but even convulsions, bo excited by the local examination, as Fleming has noted, Still, I have managed in every case, and without great difficulty, to feel the abscess quite distinctly as a swelling in the throat projecting forward from the spinal column* It is aitaated either at the upper part, so that one comes upon it just behind the velum, or else (which is much more undesirable) deeper down at the level of the epiglottis or even lower. The swelling is generally of a

148 DISEASES OF IKFANCT.

roiipded form, more rarely oval, distinctly fluctaating, aboat the size of a walnut, and situated either in the median line or a little to one side of it. TMienever you feel this you may bo sure of the diagnosis. For other fluctuating swellings with the symp- toms described and having an acute course, occur only except tionally in this region in such young children.^ The diagnosis being made, there can be no question about the treatment. I should strongly recommend you not to delay for a moment the i n c i s i o n of the swelling as soon as fluctuation has been distinctly made out. For, although the dyspnoea, which has arisen owing to the entrance of air into the larynx being obstructed, may not as yet have reached an imminently dangerous degree, still you can never be sure that the tumour may not burst of its own accord and some of its contents be drawn into the larynx with the inspiration. It happened in my otu experience that a colleague, who for the sake of a clinical demonstration wished to '* preserve " a case of this kind till the following day, paid the penalty of this delay in the sudden death of the child from suffocation during the night. Cases such as this and the one given by Noll — where the abscess was allowed to remain unopened for 7 days after it was discovered, and ended fatally by bursting into the a?sophagus, and by extension of suppuration — must bo adduced as warnings and examples.

Thus, then, there is only one remedy — immediate incision. In ielII the cases I have had hitherto, I have performed this with a straight bistoury or, if the abscess was situated low down, with a curved one, or else with a tenotomy knife enveloped almost to the point in paper or sticking-plaster. The head of the child, who ought to be sitting upright, is to be firmly held by an assistant or nurse. The tongue must then be depressed by the forefinger of the left hand, which may be protected by a metal ring when the children have teeth ; in such a manner that the point of the finger touches the swelling and feels it plainly. Then, using the finger as a director, the knife is to be carefully guided along it to its tip — that is; to the tumour, which is then io be boldly incised. The cavity of the throat becomes at once filled with yellow matter and a quantity also is expelled from the

' * Cf. <^., the caeo of a lipoma behind the pharynx (Tajlor, Lancet^ 1876, ii., ^bat of an abac ess between the tongue and epiglottis (Panlj^ A7m, !ffo. 22, 1877).

HE nio-paARvxaBAL abscess.

W

H nose. The email woiiml is to bo ontixrged in wiiLilrawiu^ tbo knifd. To facilitate tlte expulsion of the matlcr, ilio cliil^^s Uead sLoulJ ut ouee be bent forvvards. When Iho incision lias Ibeen made, the trouble in tlie majority of cases is at an end, ai^ n more speedy and surprising change cun scarcely bo imagined

I than that from the extreme dyspiitea, tbreatenin;:; immediate death, to a feelinj^ of perfect well'beini::^. Ahnost always, I have seen the difilculty of breathing vanish as by ma^e, the swelling on the neck speedily disappeaVj the turgidity of tlie jugular veins diminish, and — even after a few minutes — the child which had seemed past recovery now looking about it brightly, and willingly taking the breast which it had so long refused. The matter is not always, however, disponed of so speedily and smoothly. In several cases I have met with much greater difficulty — due for the most part, to the abscess being situated I deep down. In these cases I could only with difliculty reach it IK^vith the point of the forefinger, and get the curved bistoiir}' iFdo\ni far enough. Especially in very young children, in whom the mouth and throat were extremely small, T have often found H it very difficult, because every time an operation wasi attempted, ^ violent attacks uf suffocation were caused by the passage of the finger over the larynx.* The breathing stopped, tlie child be- H came ej'anotic, the eyes turned up, the pulse became irregular ^ and small, and there was nothing for it but to withdraw the finger quickly and 8o restore respiration. I have never, how-

»»<»ver, given up the attempt, and have always been fortunate ^nongh to gain my point in the end ; except in one case where Ptlie abscess was situated so low down behind the lowest part of the pharynx that I was doubtful of the result from the very iK'ginning. For opening these very deeply situated retro- iryngcal and relro-txjsophageal abscesses, a guarded phar>Tigo- »me is to be recommended ; but I have never used it myself. 'he greater facility of introduction, the lees danger of wounding >ther parts of the mouth and throat, and the possibility of reacliing a much greater depth with the instrument, ought to make it decidedly preferable for this kind of abscess, I have oUo repeatedly observed canes in which a single incision of the abscess was not snflSeient. It very often re-tilled even on the

' I hare aJrniiHly publisbod one enob e*a« in my '* BtUra^ :ur Kiftdcrhtitki^ndt^** W./: • Berlin. 1»««. S. 260.

IM

DISEASES OF INFA>'CY,

following; day, probably owing to the opening being too small. The symptoms were renewed, and a socontl operation bad be performed wliich almost alwaya resnltej in a complete cnre. Only in one case was I obliged to open the abseess a third time but I should mention that the eecoud time I had made nse my finger-nail inBtead of a bistoury — a method which is sionally employed, but which I cannot recommend, incision, I advise you to have the cavity of the nose and throat syringed with tepid water. There certainly is a possible danger of these Huids being drawn into the larynx daring the operation/ but nothing of the kind occurred in any of my cases ; nor yet have I ever observed any bad results from milk getting into the incision.

If the operation is not performed at once, as I have alreadj said, a spontaneous rupture may take place daring sleep and the pas be drawn into the air-passages, causing fatal suflbcation, or, as I have once seen, rapidly fatal pneumonia. Or again^ the matter may gravitate downwards behind the pharynx or ccsoph even as fur a» the mediastinum, and death then ensnes from haustion due to the extensive suppuration. In the following case the suppuration spread at the same time down to the outer part of the neck.

A weak, emaciated child of 10 months was brought on 2iid April 1875, to my polyclinic. It was said to have been unahle to swallow properly for about a fortnight. Also there was snoring and in places a wheezing breath-sound ; u large amount of mucua in the throat, and diiluBO swelling in both Hubmaxillary regions — in which a few enlarged lymphatic glands (the largest being of thp size of a walnut) could be felt. Veins on the temple unusually prominent. On introducing the finger, I felt, on a level with the epiglottii?, a fluctuating tumour, the Riase of a walnut, projecting into the pharynx from behind. This 1 at once incised, and copious discharge of pu.s followed. In the next few days marked improve^ tnont of all the flymptoms, but the discharge of pus from the wound still persisted, the external swelling diminished very little, and the eiilftrgement of the glands was unchanged. On the 9th, I coold rrmke out on each nide of th«! ui>per cervical region a laj^ Huctuating swelling. The left of these was opened at once» tho right on tho 11th, after tho ctiild had lioen taken into the Chiril^ From both inciaionti there ytuh an fsnormotiit amount of pus dU<

' For ft few cams of thia kind wh iaapiration of pufl, »ee Ti'tnoia,

'Ut owln^topocoroonio following I«I7, p. ITl

RETRO' PHABYNOEiJi AfiSCEBB.

151

cbargcd; but the wounds did not heal, the suppuration cx>ntlnucd >tli iueide and outside, while craacmtiou and collftpac advanced dly. Death on tbo l&th. At the post-mortem a large collec- tion of pus wua found behind the pbarjnx and OBsopha^is, which extended on both eidcH into the submaxillary regions, and had here been opened externally. Further, there waa limited broncho- pneumonia, enlargement of the meHenteric glande, and Hmall iuberclea in the liver. Vertebral column normal/

You Bee from this that suppuration originally confined to the ^retro-pharyngoal connective tissue may also extend laterally^ and penetrating through between the muscles may appear externally on the neck. I have only once had an opportunity of observinf? .41 rapture of the abscess into the pharynx.

Pale, emaciated child of 15 montliH brought to my polyclinic lOth January, 1865, Complete aphonia during the laetSdaya; coughing and hoarBeneaa for some time proviouHly. Breathing noisy, eepecially during Mleep. Pharynx red and lull of mucua. No tumour to be discovered either inaide or outaide. Catarrh of the bronchi ; dyspnoea; inability to continue Hucking for any time. No dysphagia; moderate fever. Death on 1 kh with diflBculty in breathing. P.-M. — On separating the larynx from the hyoid bone, A large quantity of yellow pua spurted out, Heeming to come from 'll hole (the Htze of a pea at leaat) in the back wall of the pharynx. Thij* hole had quite the appearance of a round gOHtric ulcer, and was situated juat at the junction of the pharynx and cDSophagus. Pus continued to flow out of it. When the coBOphagiis waa disaectod we found an extensive collection of pus between it and the vertebral column, extending from the atlui) to the eizth cervical vertebra. This whole extent waa covered with fragments of gangi'enoua connective tissue. The spinal column ahowcd no morbid alteration. Little fimbriated maaBCS were aituated upon and under the vocal corda, and turned out to be tubercular. There wae also cascoua degeneration of the bronchial glanda, and tuber- culosis of the lunga.

ThiR case shows that if the retro-pharyngeal ahscess ruptures

into the pharynx, its diagnosis may become impossible ; for then

the pus for the most part escapes through the ruptured point

Into the oesophagus and is swallowed. Thi^refore, no swelling

^Bneed necessarily occur, either externally or into the pharynx.

^V Still more uncommon — in my experience — than retro-pharyn-

B geal abscesses, are those which form on the lateral walls of

' In each csaaea— which are trory rate At »ny time— i»ar»l jaia of the t*ciftl aerve may cwcax from proaaare of the pus on th^ region of the tftylomaato il fonunen (Bokai).

153

DISEASEf? OF INFAKCr.

the pharynx, between it and the soft parts of the tK^ck, consi'-

I ijucutly forming a lluctuating tumour on the ri^ht or left sitlr hehiufl and under the tonsils. In two cases a rupture of tbo abscess took place into the external auditory meatns. But this is certainly an extremely rare occurrence.

On 10th April, 1874-, a mtdical friend of nunc consult«.»d hm about an affection of the neck from >Tliich hh cliild fiet. 15 inoiithr» » had sniFcred for aev€ii'al days. The chief symptoms were frctful'j^H iiesy, dysphagia, crying at each attempt to swallow, moderate fcvrf^^H and noii^y hrciithiiig during sleep. The left tonsil was s^omemhat ' enlarged and much reddened. Immediately K'bind and benetith if on the hitcral wall of the phai-ynx a red fluctuating tumour coulil 1»€ fiecn and felt. Also externally, nnder the mastoid process* tht-n- was a diffuse swelling. No difficulty of breath iug obscrvabh*. Wlien on the 12th I eatarained again with a view to incitftug thr

I abscess and presHcd rather firmly on the swelling. » stream of

yellow pus ntreaked with blood suddenly spnrted i>ut of the I ear, whereupon the tumour at once disappeared, so that no ope tion was ncces.sary. On the 13th the pus continued to flow in moderate quantity from the ear. especially on pressure beneath thr mastoid process. The child was perfectly well, slept without snoring, the tonsil was almost normal, and no ti-ace of the tumotir

I waa any longer perceptible. No disturbance of the hotwiua rcsulte*!.

As the nurse eaid that she had noticed a discharge of matter from the ear some days before, it may be taken as certain that the abscess on the lateral wall of the pharynx had gradually worked its way through the loose oonuective tissue to the meatust ftudilorius and hud broken through it at a number of points* Squeezing the tumour had suddenly completed the rupture. The second case, which was observed at the polyclinic (May, 1881), had a quite analogous course. Bokai' also describes a similar one: only in it the abscess had already been opened from the inside and had since re-filled ; and on pressure it at once discliargod through the left ear, after which complete recovery ensued.

It is rare for phlegmonous Abacci»f«eti of the couiioctivi* tieisuc of the neck to open int^i thr pharynx. But I hns*> observed thiH in one boy of Tj ycfii '

(llth April. 1881) with n ri>ry ^ from the angle of tiic ja . tpuia.

Jsm

TBO-PUABYKGEAL

ua

K

front as far vm the second rib. Scarlet fever and diphtlieria couTtl be excluded. The phftryiij; was reddened ; its right laturttl wall was pressed inwards and the uvula disjtlaced towards the lefl. Dysphagia, copious secretion of snHvn. Eveninp teini>eratme» 104'2'^ P. On the 12th, spontaneous rupture of the abseess inln the pharynx, the child spitting out a quantity of offensive pus an«l blood, and fragments of tissue. Ternp. normal. On the 13th an incision made uiio the neck, on account of tiuctuation, and some offensive pus let out. Drainage. On the 25th, recover}-. — In two other cases I have seen a siihm axillary phleginon (which had de- veloped a,? the result of scarlet fever} rupture into the pharynx before an incision was made. Of this 1 shall again have to speak in treating of gCJirlatinaJ

With very few exceptions, all the cases I have observed belong

to tho class of idiopathic abscesses, j.r., to those which occur

perfectly healthy children independeutly of any other illness.

few children were perhaps somew]iat atropliic, but there were

o abscesses in any other part of tho body. Nor yet was there

J disease of the cervical vertebra? or any general condition

wing to which the abscess could have developed. The etiolofry

f all these cases is, therefore^ involved in complete obscurity,

And the sapposition of Bokai and others, that the inflammation

and suppurAtion of the retro-pharyngeal connective tissue o^ip;i^

ated in the lymphatic f^dauds in front of the spinal column, is

by no means certainly proved. I myself, indeed, had one case

of a child of 3 years who sttil showed distinct scars of scroftilous

glandular abscesses in both submaxillary regions. Still I do

ot consider this sufficient to warrant us in referring the abscess

ith absolute certainty to retro-pharyngeal adenitis.

I only twice observed the formation of an abscess arising from

spondylitis of the cervical vertebrnp. In a child of H

years, which since the beginning of December, 1874, had been

observed to move its hea,d with difficulty and pain and to hold

very stiffly, I found these symptoms markedly increased

n oth April, 1875; and in addition there were difficult^' in

wallowingt laboured and snoring breathing during sleep, and

abscess the size of a wahmt situated very low down on the

ack wall of the pharynx. It was incised the same day and

considerable quantity of pus was evacuated, Tho diagnosis

spinal caries was afterwards confirmed by the appearance of

' Bokiii rnitl Li?wan«lowj»ky d^ttcribe tdmilAi' eru-c« {Kiln, UVAfnfrAr , 1882.

154

DISEASES OF IKrA^Cl.

absoesses on the back and neck, by paralysis of tlie arms and paresis of the lower extremities. Another case, obserrcd in tbe polyclinic, had a quite similar course.

Vn. — Dentition and iti SymptomB.

Altiiongh tht^ eruption of the teeth generally indicates the end of the period of Riu-kling, and Nature herself thus gires UH to understand that the exclusively liquid food may now be exchanged for a somewhat more solid dietary, the obligation to such a change of food is not by any means imperative. As a rule the first tooth appear between the 7th and 9th months, and yet it is cuBtomary for the mother or wet-nurse to give the breaet till the end of the 9th month at least (and generally still longer), even when the cbiMreu have ^ot all their incisors. When this is done the nurse may certainly be injured by the child biting the nipple ; and for the child itself, unpleasant coD- sequences may result from this, as we may learn from a caac which I observed :— a healthy child of one year being frightened by the sudden scream of the mother on being bitten, started violently, and immediately had an attack of convulsions.

Every physician knows from experience that the most diTeiw disorders of infants, especially of those in the first half yenr of life, are attributed by the relatives to **the teeth.'* Super- stition and indolence here lend a hand, especially in practice among the poor, to produce all sorts of mischief which it is often ?ery difficult to undo afterwards. Every attack of diarrhcea or convulsions which occurs in those children, is put down to '* the teeth ; " and is accordingly either neglected or even regarded as salutary. The physician's aid is often only called in when it is too late. This old-standing tradition, still in full force among the laity in spite of the improvement of education, is now most positively contradicted by a largo number of medical men of the present day. Teething, they hold, is a physiological process, which cannot be the occasion of any morbid symptoms, and everything formerly regarded as such is a delusion, caused by illnesses happening to occur along with them, without having anything at all to do with it* It may howttver be questioned whether this positive denial ia altogether warranted, and whiJe 1 very fully acknowledge has rendered in limiting ibo

i

DENl'XTION AN1> ITS BYMPTOMS.

155

diaeasea af teethinpr/' I cannot help thinking that there is a want of moderation in this view. We know that dentition occurs in the following way : — the growing fang of the tooth gradually pushes on the already complete crown, and forces it out of the aheolus after it has burst through the overlying gum which has heon gradually thinned by the increasing pressure. Is it, then, so very inconceivable that this gradually advancing process should exert an irritating action on the dental branches of the fifth nerve, and occasion reflex symptoms ex- tending not only to the province of the motor» but also to that of the vaso-motor nerves ? It seems to me quite conceivable, and I certainly consider it is going too far to deny utterly the possibility of convukions being caused by the irritation of teeth- ing. I shall supply instances later on where, e.g., partial con- tractions of the muscles of the throat and neck were undoubtedly connected with the eruption of a group of teeth. Also the in- disputable fact that obstinate vomiting, diarrhoea, a spasmodic cough, or eczema of the face, which for days or weeks has defied all treatment, will all disappear as soon as one or a couple of teeth emerge from the alveolus, and this can only be explained by the reflex action from the dental branches of the fifth upon the peris- talsis, the vagus or the vaso-motor nerves. We must guard agiiinat throwing overboard the views of our medical predecessors with that presumption which has become the fashion with a section of the younger school ; — and also against putting forward principles without such practical experience as is necessary, and can only he the result of a long professional life and very numerous personal observations. It is a matter of Cuct that a large number of children aro out of sorts during the cutting of each group of teeth, cry a great deal (evidently from pain), are restless during sleep, and cease to gain weight* ; they may also have a flabby skin, a pale complexion, urine milky from the presence of urates, and even slight variations of temperature.

Although generally the first tooth appears between the 7th and 9th month, examples are not wanting of teething taking place much earlier. I have frequently seen cases in which one or two incisors had already come through by the end of the 2ad or 8rd month, or a little later. More commonly, how-

reft the process is rather delayed, and even in children who

' D*tito. JtikrbJ. Kindet^^lk., Bd. XT., 1883, S. ei,— Stftege, tM., a. 'kiS,

DIS£ASEB OP IKFAXCY.

are perfectly liealthj and quite free from rickets, we sometimes do not 8oe the first tooth until the 10th or 11th month* You will ftlBO Lave heard of another nbnorraality, which in certain Lifttorie personages was regarded as presaging a vigorous and mast4?rful disposition, — I mean being already provided with teeth at birth. According to my observations we can distinguish two forms of this phenomenon. In the first form we see one or t^o pointed, more or less hook-shaped teeth, wbicht being only im- bedded in a fold of the gum, arfe from the beginning loose and easily moved. As a rule they are the two middle incisors of the lower jaw; and in one child (five weeks old) they appearetl ulmost normal in shape, but had serrated and grooved edgc^, Probably in snch cases the tooth-germ had not only had a pre- mature development, but also an abnormally superficial position, so that the crown came through before the root had reacheil maturity, I have always removed such teeth immediately, and without difficulty, with a pair of forceps, for they generally injure the nipple and ulso the under surface of the child's tongue, on which there miiy appear one or two ulcerations corre- sponding to the teeth. In one case only, where these ulcets healed under the application of a eolation of sulphate of zinc — 2 per cent.,— tlie teeth gradually became more firmly fixed in the alveolus, and I therefore let them alone. But I do not know what became of them finally. In the second form I have found real teeth firmly set in the alveolus, distinguished, however, from the normal ones which appeared later on by their rough surface and yellowish colour — due to their want of enam These teeth require greater force for their removal, and 1 adv you rather to leave them untouched until they become loo: but as soon as this happens 1 think they should be cxtmetod, in 8uch cases I have always observed a morbid process' lo the alveolus which can only be cured by the removal of thtf tooth* The following cases may serve as tvumuLM *.f iImc

form : —

Girl of 3 iiioiit.tu-ii, brought to thu | ui4 Jud ^V|^n^,

1875k There had Ucii a tooth in the I. jrnr fit Ktrtk,

rjttnwtod oil thu otii thiv. Sooii idlvv tln-ri: whs <•

Iijft che<?k. On fiaminalion n mur k- d thickoiutiK (i jaw vttiH found, al#o W>riiloiJ ^ un tht? alvKjIar r t

tit which piw OOMtL Duut. (•«» ft'owi tlic Iwn iw_ ;y

jind fiom n H»»tuU fMt.u|ifl|yf^i^^s ibf marj^u of iho orlnt. The

igu

i

DENTITION AND ITS STUTTOHB.

1«7

pua was extremely oflfensiv<i. Fluctuating abscess in the region of the left zygomafcic arch. On the 2()fch, separatioti of several piocei of dead bone from the alveolar margin ; later on, artificial removnl of a larger Bcquestriira. Further coiiriie uuknoivD.

Girl of 5 month a, brought .1th October. 1877, Hftd developed A pain fa! swelling on the left check after the forcible extract itin of A tooth whieh was present at birth in the left upper jaw. On examination, the uppt^r jaw was found to be thickened and tender, and there were tiatuloua openings on the left alveolar border and a discharge of pus from the left nostril. Did not return for treat- ment.

Boy of 2 months, brought -tth January, 187i*. The whole left ^iialf of I he lower jaw much swollen, very tender on pressurtv, the

im dark-red and swollen. Pressure under the jaw caused f* flow of pua into the raouth — and this also oeturrcd spontaneoush. In the region of the first niohir, there was a small hole in the gum

it of which the pua came, and a probe puased into it came agaitiKt

>mething hard. It was stated that the tirst left incisor had come through at the age of wix weeks — that is to aay, Hiniul- tuneoualy with the commencement of the Bwelling and suppu- ration. When the child was brought a second time, on the 15th, the tirst molar had completely emerged from the opening men* tioned. Both teeth were pretty loose in the jaw, and had to be extracted. Unfortunately I had no further opportunity of observing thi« ehihrg cane.

A child of i:i days (10th January, 1884), took ill on 4th day of life, without apjKirent cause. The margin of the lower alveolus ttwollcu, red, covered with pus, which oo2,es out oil prenaure as from a sponge. During the last few daya both lower central incisorti have appeared and V»een abstracted, leaving behind two suppurating cavities. The teeth consist only of a crown coming to a point below without a root.

Th« last two cases, in which wo have to do not so much with »uget)ital teeth as ^nth extremely premature deiititioD, appear

nie to throw light on the whole process, as they make it pro- ihle that periostitis of the alveolar margin, whether id 10 npper or lower jaw, forces the crown of the tooth out by

•oiling and exudation inside the alveolus. Accordingly, I con- idcr periostitis to ha the primary cause, and not the result of le violent extraction of the tooth, as I once thought. And I kink the iirftt cases may also be so regariled. How this diaeaso

the houL\ occurring at birth or saoii after, was occasioned, I

LU&t leave tindecided. At any rate, in all four cases hcreditarv

typhi lis could be with certainty excluded. The extraction of

IGO

BXBBASB8 OF INFAXCT.

ijeyernl weeks (6—8) after them the central iucisors of tbe upper row follow. Next come tbe upper lateral, and after some weeks the lower lateral inciBors ; and in normal circiimstancea they lire usually tlirou^b by the end of the first year. Variations from this order are not at all uncommon ; c.g,^ tbe upper incison may be the first to appear, and tbe lower ones come after them. Tbe gioup of four front molars generally appears between the 15tb and tbe 18th month, but in rare cases they develop — at least in part — before the complete cutting of the lateral incisors* Between the 18th and 20th month there follows, as a rule, tbe cutting of tbe four canine or eye-teeth, which fill up tbe gup between tbe molars and incisors. After tbe lonpfest pause— Hometimea of several months— the four posterior molars appear between the 20th and 26th month, and complete the process. This finishes the first dentition. All this, however, applies only to healthy children. Teething is very often delayed owing to a bad constitution, especially rickets, the first in- cisors appearing only at the end of the first year, or even much later ; and the whole process may be prolonpfed far into the third year of life, owiu^ to the intervals between tbe different groupa l)eing also longer. One child (set* 5 years) who was not rickety tthowed a very rare abnormality, the two upper outer incisors appearing for the first time in the 4th and 5th years respec* tively, I cannot here enter upon all the possible abnormalities of the first dentition. I may just mention however the occa- sional occurrenco of two teeth in place of one r — for example, this happened in one of my patients in the case of the right eye- l^oth, in whom instead of one there were two eye-teeth— ono situated in front and ulmoct normal, and tbe other placed somewhat obliquely bebind, smaller and more pointed.

We have now concluded tbe pathology of very early infancy, and pass to tbe consideration of tliose diseases which affect childhood generally, from early infancy upwards. Thft variations in the clinical sAmptoraB due to their more tender agv wiD at the same time receive due consideration.

161

SECTION HI,

DISEASES OF THE NERVOUS SYSTEM.

L^ — Infantile Convulsions,

iiij

IS

gp Him

The patholoofy of the nervous system derives a large and most important part of its material from childhood. The liahility of e nervous system in children io disease does not, however, atiect H its parts equally. Whilst, of the central organs, the brain is pre-eminently subject to a very great number of diaeasea* the spinal cord— apjart from its congenital affections (spina bifida) and infantile spinal jiaralysis — is much o^ore rarely atfectcd* ong the so-called neuroses, those of the sensory functions (neuralgia and aniesthcaia) are jery unimportant compared with the derangements of the motor funcLionn, espeoinily convulsions hich constitute one of the most frequent maladies of childhood om birth to about the end of the third year. It has been attempted in various ways, even by experiments (Soltmann) ^ explain this extraordinary tendency of the organism in child- iiood to convulsive attacks. Although Soltmann proves that the strong tendency to reflex manifestationa in the very early ife of animab^ — up to the lOlh day~depend8 on the absence of entres m the brain and spinal cord coutralliug reflex action/ till the great tendoucy to convulsions which is also present in older children — in the 2nd and J3rd year — cannot be explained this way. If wo keep to cliuical observation we find this tendency to reflex convulsions confirmed as a matter of daily ex- perience. If you watch a little child quietly for some time, you ill sjee how its whole i)ody twitches spasmodically at any sudden oise or unexpected touch ; and how during violent screaming it comes suddenly breathless from laryngeal spasm. We also see ow frequently simple indigestion causes general convulsions ough the reflex irritation proceeding from the stomach and

• Cf., on the otber haml, the eipcnniouts of TarohAnofT (Cenimlbl/. Kindtr' ii » IS7H. S. \K^\. Lt'moinc, Marcttcci and Panoth {Biotoff, CeMfm/t/,, 188$).

11

162

DISEASES OF THE NERVOUS SYSTEM,

intestinal canal, ^wbich under Bimilar circumstancea in adolts would eertrthily be a very exceptional occurrence.

Tlie symptoms of convulsions, or eclampsia inttintiiis us it is usually called, vary in no way from those of an epileptic seizure. The attack commonly begins by the eyeballs tuiuiug upwards or to the side, or with a strange fixed look, while con- sciousness disappears* Twitchings of the facial muscles follow, sometimes unilateral — the mouth being drawn to one side ; tbeu the jaws are firmly closed by trismus, or owing to spasm of the pterygoids are moved from side to side on one another causing grinding of the teeth. Chewing movements are also sometimeB observed. Tetanic rigidity of the extremities, interrupted more or less frequently by spasmodic twitchings like those excited by an electric current, almost always occurs. The fingers arc generally strongly flexed and can only be extended with difficalty ; the feet are dorsi-flexed or in the position of pes equiuus, accord* ing as the extensors or flexors are most affected by the convulsive rigidity. The muscles of the trunk also participate ; retraction or rolling about of the head, contraction of the respiratory muscles with alarming pauses in the respiration alternating with very rapid superficial breathing, rigidity of the abdominal muscles, involuntary expulsion of the uriue and faeces— all theso are, if not invariable, at least frequent accompaniments. Aftar ft very few seconds the distorted face becomes somewhat cyanotic round the nose and mouth> and the saliva is forced out from between the lips in the form of froth by the violent action of tlM muscles of the tongue and those of mastication, and by cheeks. In older children who have teeth this froth is oi mixed with blood owing to the tongue being bitten. Tl Bymptoms, which alarm the parents extremely — especially they ore inexperienced — last, as a rule, only a few miiiutee, tbe spasms then diminish gradually in intensity and frequency ; the stiffeued limbs are relaxed, the face becomes quieter, the colour returns, and at length only slight spasmodic contractions from time to time passing over the unconscious c ^ ' V : rtind ua of the storm that has passed — like the distant 1 and faint

peals after the thunderstorm is over. But this quiet is but temporary and deceptive. Even before the child has recovcwkl from its stupor, the attack begins again with renewed fury ; and in this way the convulsions may be repeated three or four tiine«»

INFAJJTILE CONVDLSrONB.

1G3

I one after unother, while ia the invervals the comatose couditiuii und complete loss of consciousness and sensation continue. The pereiBtence of the ycIUk scnsibUity may in such circumstances easily mislead ; for touching the conjunctiva often produces con- traction of the orbicularis, and sprinkling' with cold water excites reflex contractions. But in many cases this symptom is absent, and I could then lay the point of n}y linger on the ocular con- janctiva i^ithout observing the sHghtest movement of the eyelids. "We must not, however, at once regard this want of reflex sensi- bility as a fatal sign, as m>my do regard it ; for I have seen a number of children who displayed this symptom and yet recovered ^^ completely. The duration uf the paroxysm is of much greater ^■;significanco. These attacks, interrupted only by short periods ^B-of coma, may go ou for bours, and you can readily understand ^^tbat under these circumstancea tbo arrest of the respiration, the ^Preiious engorgement in the brain, and tinulJy, the complete ex- ^^ haastion of the child's strength may lead to death. But even

I then, the fatal issue is not always inevitable, and every physician will recall cases of this khid which, in spite of coavalsions re- curring constantly during many hours, days, and ovon weeks, ended nevertheless in complete recovery. Ordinary attacks, lasting only a few minutes, are often over by the time the physician arrives. He then usually finds the child comatose, and this con(htion passes imperceptibly into a healthy sleep which may last several horn's, or even a whole

i night, and from which the child wakens apparently quite well tind looking as if nothing had happened. Still, we must hero be always ou our guard. An attack of eclampsia seldom occurs alone ; sooner or later, we must expect a repetition of it, and the cases are not nncommou in which the distressing spectacle is repeated daily or perhaps twice a day. In many other cases, however, weeks and months pass before a new attack occurs. When Tou ai'c summuned to such a case and find the child ! Btill in convulsions, there is no time for finding out from the terrilied bystanders details as to the origin of the malady. ^' What is wanted from you is to stop the convulsions at once, ^m and, fortunately, no exact anamnesis is needed to guide one in ^H treating the attack. Causal indications must here first of all ^Hgivc way to vital ones, and I know of no remedy which fidfils ^Bthe latter more certainly than do inhalations of chloro-

164

DISEASES OF THB KEKVOUS SYSTEM,

form. Do not waste time with other things, snch aft cbJoml b.vdrate, purgative enemata, cold compresses, the applictitlon of leeches to the head, A*c. ; but always use chloroform at once» when you wish to arrest an attack exceeding the average duration (*,c. over 5 minates). A tcaspoonful of chloroform poured on a handkerchief and held before the child's nose so as not to exclude sufficient air, is often quite enough. Even after a ft*w inspirations the convulsive excitement is calmed, and the inhalation may be confidently continued until the eouvulsions have entirely ceased. The pulse and respiration of the child must be narrowly watched of course during this time, in order that the inhtilution may be stopped at once if need be, I have never myself met with any unpleasant effect, although I have used chloroform in many cases of eclampsia, even in children only a few mouths old. In one such child who had more than 40 attacks in the conrse of one day, each time as soon as a new attack set in I ordered chloroform ; two or three inhalations of the vapour always sutHced to allay the convulsive inov«>- ments at once, and next day (after a good night's rest) the child — apart from great exhaustion — was perfectly well. I bnTo even ventured repeatedly in these cases to teach the relatives how to administer chloroform, and instructed them to give it %vheMever new attacks occurred; and I have never yet had to repent this confidence. It is indeed impossible — unless tho physician can sit with the child the whole day long — to hav« skilled aid at hand whenever it is required ; and so the only resource is to venture the experiment with the relatives,— or, better stiU, with a good nurse. I never regard cyanotic dis* colouration of the face due to convulsions as contra -indicating chloroform. The discolouration always disappears as soon a« the remedy begins to act. Nor yet have I refrained from using chloroform for convulsions in the course of broncho-pneumonia. The convulsions soon cease, while tho lung disease pursues its conrse. I must not, however, conceal from you that chlorofonu is not an absolutely certain remedy for convulsions. Apart from tlie fact that it genendly acts as a mere palliative and is not ablt> to prevent the repetition of the convulsions, I have also found it practically useless in a few very violent cases :— the pauses which the inhalations produced acarcely lusted two or three minnUiSy and the attack tinally ended nation atid death. Yon most

INFAKTILE CONVULSIONS,

165

also take care not to give this remedy if you find tlie clnld already collapsed with the pulse very small and rapid and the extremities begiuiiing to become cold, l^uch cases, however, form bat a small minority, aud need not restrain one from strongly H recommending the use of chloroform. On the other hand, the ^ compression of the carotids recommended by Parry, Bland,

» Trousseau, and otLers, which I have myself frequently tried* gives far too uncertain results to merit serious consideration. As soon as the attack of eclampsia to which you have been summoned has ended either spontaneously or by the aid of chloroform inhalations, — the question arises as to the cause of ^. the disease ; for only by realising the causal indications will you ^■be in a position to guard ugainst the return of the attack. It is ^^ not my business here to enter fully into the pathology of

I epileptiform attacks generally. I would only remind you of this, that experiments have certainly indicated a. threefold origin of such attacks : — antemia of the brain owing to contraction ot the smullest cerebral arteries (K us sm a ul and Tenner); the division of the spinal cord or sciatic nerve on one side, followed by irritation of the corresponding side of the fiice (Brown- iSequard) ; and blows on the head resulting in slight extra- vasation of blood in the medulla oblongata (Westphal). In eonsidering the pathology of infantile convulsions some value — according to my thinking — may be attached to the first and the third of those series of experiments, On the one hand a few

■ examples are recorded of a violent fall or blow on the head causing epileptiform attacks in a child, — and those even re- earring habitually, and I have myself observed two such cases.

»0n the other hanch aiiiemia of the brain in exhausting diseases, owing to cardiac debility (the convulsions of inanition) or a spasmodic contraction of the small cerebral arteries witlianiemia may bo assumed when we have to do with a condition of relief H^ irritation or with a febrile attack commencing with convulsions, ^KThcso explanations however cannot, I think, by any means be ^■regarded as exlnxusting the pathology of eclampsia. I should ^■ouly remind you of the fact that during the attack we frequently ^Bobserve increased tension, prominence, and very marked pulsa- ^Vlion of the gi*eat fontanellc — symptoms wliich rather point to ^Bl)}])enemiii than to antemia of the brain.

^M Beitr, mr KinderheUt. , X.F. : Berlin, 1878, S, 97.

166

DISEASES OF THE NERVOUS BT8TEM.

We now turn to tlie etiological conditions of ecUmpsia as ascertained from clinical experience. The first questiou which meets you in every case is one very important for the prognosis, namely — Whether tho convulsions arise from organic disease of the brain or not *?— a questiou you cannot at oner decide, more especially if you are unacquainted with the child. When the convulsions are anilateral^ this has been regardeii as in favour of a cerebral origin, and I grant that this is in general correct, provided that when tho attacks recur, the same side of the body is always affected and tho other remains free. Along with this however one must not overltxjk that occasional]) convnlaions occur on both sides when only one side of the brain is affected {e.g. in tubercle), and that on the other band uni- lateral convulsions have been observed in cases where no real cerebral disease is present. I have repeatedly seen the first attack under these circumstances, conBned to one side of the face or to one half of the body, or else the paroxysm only con- sisting of rotatory motions of the head with rolling of tho eyet and spasmodic contractions of one arm; and tho spasms only appeared later on the other side of the body also. In a child of 8 years, who died of intussusception, I observed, on the day of death, convulsions affecting the right side of the face and body exclusively. Nevertheless the unilateral character of the con- vulsions is always an important feature, making it incumbent on us to examine the child very thoroughly, in the intervals between tlie fits, for any afl*ection of the brain, and to make very exact enqniries as to the history. At the same time you must not forget that many diseases of the brain (j'.ff. tubercle andd tumours) may for a long time, oven for many months, only" reveal their presence by attacks of eclampsia recurring from time to time, until suddenly hemiplegia or coma makes the mistake manifest. It is often difficult for the physician to give an opinion, wnd I would specially point out that oven in reflex convulHions (especially in little children) apparently serious symptoms may iiften occur in the intervals; — tho child is palhd, apathetic, never smiles, starts frequently, and thero arc increased pulsation of the fontanelle and slight elevations «»f temperature. A cantiouiJ physiciim will always do well to delay giving a deiluite opinion " until he has been reassured by further obaerrattoD and tho non- appearance of more 86rioa»^u||M} sjmirtitnui. j

IKFANTILE C0NTUL8I05S.

167

■ In all cases of convulsions recurriog more or less frequently, I would rceommeiKl you to direct your attoutioo in the first place

I to the osseous system. According to my cxpcricuce, the kendencj to convnlsions is favoured by nothing so strongly as hy |ricketBj and, tauj^'ht by innumerable cases, I always make a point in the case of every child who comes under my treatment for eclampsia, of immediately examining the epiphyses of the ribs ^und of the bones of the forearm, and also the skull In most ^fchildren between six months and the middle of the third year, I have found indications of rickets more or lees well marked. Almost always in these cases there are simultaneously attacks of laryngeal spasm, which either usher in the convulsive attacks or alternate with them. Only rarely is the eclampsia anaccomponied by laryngeal spasm. Wherein this tendency of rickety children to convulsions consists, is as yet undeter- mined. It w^ould be rash to make the deficient nourishment ^^f the nerve centres responsible for it; for eclampsia occurs just ^Bs readily in rickety children who are well nourished as in ^Uiose that are atrophic. But at any rate, in such children ^^*e must be prepared for the recurrence of the attacks, for which definite causes can he assigned only in a very few

I cases. [ In my opinion rickets is a much more influential factor in this disease than dentition, which so often gets the bkme for con* Tulsions occurring about that period. We might with as much justice derive rickets itself from teething — an idea which w^ould occur to no rational being. It is only rarely that convul- sions are observed in teething children who are not rickety. Quite definite reUex causes must therefore be discoverable. With these causes, as I have already re- marked (p. 155) we may certainly class cutting of the teeth under specially unfavourable circumstances ; but such cases are at all events rare and hard to prove. You must not allow yonr- ik^elf to be diverted from the careful investigation of other causes ^nvhich are much more frequently operative, by the mothers' ^Bmbit of calling their children's convulsions " teething tits/* ^■Among these causes, an irritated condition of the diges- ^Htive organs undoubtedly occupies the first place. Even in ^^bew-born children and infants, we see convulsive attacks not ^^Bnnfreqnently occur reflexly during dyspepsia ; and especially

1C8

DISEABEB OF THE NERVOUS SYSTEM.

unskilful artifieial feeding — ^ftlon^ with over-feeding — ^may l»e the scarce of most vident attacks of eclampsia.

In a child of th'isi kind, aged 4 months, to whom more than ? puitfi of cow's mUk had been given daily, and had produced extreme flatulent distension, I saw numerous convulsive attacks occur during IG consecutive days. Xot uncommonly they were repeated 50 — 60 times In one da3% so that there were ua intervals to speak of. The attacks genenUIy Ijegan irith tenesmus and flushing of the face., or with rumhlinj? noifi«« in the uhdomen, iind the motions consinted of light clayoy masses, mixed with large, hard hiraps of casein. After the dele- I terious contents of the bowel hnd been cleared out by castor oil

I and enemata, and the flatulent distension removed, it wa« foand

possible aUo to lower the state of enormously increased reflex cxcitttbility, and to put an end to the fits by the cautious U8o of chloroform inhalations (ice<l comprcHses on the head). IMm chiM was theu put to nurse, and throve well, but remaine<l perraanentJr extremely feeble-minded.

This was one of the cases in which the convulsions occurred unilaterally from the first (movement of the head towards tJie right, and twitching of the right arm) and thus a suspicion of real hrain disease had heen aroused* The further course showed that the convulsions were reflex and originated in the intestinal canal ; and in this connection I would call attention to the tenesmus, and rumbling in the abdomen which almost always preceded the convulsions, as well as to the character of the motions. It was so evident here that the eclampsia depended on the disturbance of the digestion, that even the backwardness in psychical development afterwards ascertained cannot bo rcgnrdcd us proving primary brain ilisease, but nmst rather be looked upon as the result of the innnmerable convulsive attacks. I have seen the arrest of psychical development in another child also, who before ibo occurrence of the eclampsia was perfectly normal in tliis respect, although extremely rickety. In this ca.M> ftliw}, hundreds of convalsive attacks were observed in the space of some weeks, and it appeared a miracle that life was preserved. Neither paralysis nor any oUier symptom of chronic cerebral diioasQ ever occurred ; only aphasia and mental hebetude n»mained, and after a yearns interval showed but slight improve- tnent. We may therefore assjume that convulsions occurring in unuNUal numbers and many times daily for weeks, may impair the psychical tuiergiea of a previously healUiy brain for a long

INFANTILE CONVULSIONS.

im

I

time, or may even injure it permanently to a considerable extent Fortunately, cases of each severity and long dm-ation are yery rare.

To the same category belong the cases of infants in whom eclampsia occurs soon after violent excitement or abuse of alcohol on the part of the mother or nnrse, so far as they are to he regarrled as exclusive!}' caused hy a change in the milk injurious to the child^s digestive organs. At a later period of childhood, up to the second dentition, very violent couvulsivo attacks may be caused by overloading of the stomach and intes- tine by food injurious either in f|UHlity or quantity. Out of the long series of cases of this kind which I have observedj the following may serve as examples : —

Child of 3 ^ y ea r 8. At mid-d:iy iinlulged Ijirgely in cuciirober- snhul and |jliinjs- In the ovoiiiiiy; convulsive tits, which, with i«ter\'alH of conm, Instc'd ahont 2 houra. L'ohl compress ts to the head, cncmata, un crn€«tic when the comu had passed off.

Child of 2 yoary, healthy. Took ill on 3rd October with shivering, Durinpf the night, violent fever. On the 4th, about 9 »nd 12 o'clock, convulsive attacks. After these complete anorexia, yellow-coated tongue, nausea. Emetic ; later, infusion of senna. Recovery.

A child of 2 years, on I7tli March, ate a larpjo quantity of " sauerkruiit/* where^ipon followed marked flatulent diHtenaiou and unusual slee|)ineas. These symptoms were still present on the morning of tlio 18th. Suddenly nausea and vomiting took phice^ and, about 11 o'clock, violent convulsive fits, which lasted with abort intcrvftlfl till 2 o'clock. Two cncmata were g^ivcii, which brouj^ht away soniu hard scybala. Alraut 2 IKK 1 found the cliild still completely nncoTiMcious — the eyelids firmly cloHcd iind difficult to ofwii — tlie jaws clenched, the respiration accompanied by a ruttling jsouiul and irregular, from time to time still some slig^ht apafiraodic movements of the extremities, pnlse 1*20, very fulL Treatment: — Sinapism, cold comprcBsea to the bead, 4 lecidies behind the ears, calomel, gr. i. every 2 hours. At 0 o'clock wvero after-bleeding, return of consciousness, urine parsed, and child waiit^ to eat. Quiet sleep during the last { hour. No motion of the Ijowela. Infns. semife 5 i»- On 10th, after a fi-ee ovucuation the chihl foela quite weiL The convulsions did not rctarti.

Boy of 6 years, admitted 30th Octoljer, 1)^82. Kpiloptic attacks following an attack of diarrhoja. Avhich during the last 2i hoiifJi are oftcTi repeated with intcnah of coma. Loss of C0naeiau(»no88 complete, pupils diluted and sluggish, pulse 124,

170

DISEASES OF THE NERVOUS ST9TBM.

small and irregalar j toupue thickly furred, T. 98(5^ F, Irrigatiou of tlie intestine, ico-cap to the bead. Ou Slst return of const*ious- noBS and gpecfh ; no more convulsions. Still repeated romitiitg and offensive motions. Purgatives. On 2Dd NoTemlx?r, quite well

In the last child we see the coma lasting more than 24 Lours after the cGSsatioo of the convnlsioua, and it is just such cases that, on account of the suspicion of meningitis which they aroase^ may not only bo very dtsqnioting to one beginning practice, but may even cause anxiety to an experienced physician. This happened to myself and a colleague with whom I treated the following case : —

Boy It, 5i years old. who had frequently Ijeforo Ijcen aCTocteil by hejulat^lio and vomiting owing to dietetic errors. Otherwise perfectly healthy. In Derember, 1884, he took a violent atta4.'k <A vomiting and fever after an overloatling of the stoniueh, and next day had 3 severe epileptiform fitM, followed hy deep coma. Thia lasted uninterruptedly for almo8t 3 day* with fever, btil with regular pulse and without returrenrc of the eonvul»ion». lu wpite of much hesitation, there was still sueh strong KU.'^picion of meningitif^ that we next ordered wet-cupping to the neck, an ice- hag, inunetion of hlue ointment also calomel and infu& «cnnir MTjth syr, rhamui. The raotionj^, which were pnssed in lied, were always ejctremely offensive and contained numerou** scybulic*. After Jl days the boy awakened, looked alwut him intelligently. recogniHcil those uround him, hut was eompletcly apliaBii% though without paralysis of any part of the body. No more fever. After a few days he l>egan to speak a few words with difficulty, as il memory failed him. There was also atill f nrrcd tongue mid small appetite (aeitl hyilrochlor.V After about 10 davK. eomplet*' recovery.

The eourae was i)uicker and more favourable in the foUowiog case, which shows at the same time that under such circuin- sUncoif the convulsions may be entirely absent, and in phic^ of them wo may lind only drowsiness, aphasia, &c.

In Oetoher, 1882. I wa^ conHuUed by a mcdiciil friend about a boy of 0 y t'ttrw, who some iUiy9 befori* h«d taken a largo quantity of raw fruit, cakes, Ac, and liiwl iM-en at tucked dnriug the foUowitig night by profuse diarrhtear Copious evijeujitinn of pMrtially fUgcuted matter took pbt'e involuntarily duriug Kemi>unroti^ HciooBnes**. T<)ward« morning, fever, clouding of intelligence, aphatiia, and a h taring look. At midday inerouHO of thuiM^ n^ptomn to aueh an eittent that lUf "lUfipieiou of brnin*4ifiea»<-

INFANTILE CONVULSIONS.

171

became very strong. After calomel, several more green, alimy motions. During the evening, return of perception and of apeech. Next day, nfter quiet sleep, complete reeovery, except that the tongue wfte fnrreii

The followinof case, however (certainly a very unusual one), hows also that consciousness may remain quite unaffected and he speech alone be interfered with in the form of aphasia.

On 12tli July, 1881, a lioy 3 years was brought to the ]>f*ly- clinic, who — according to the account of his alarmed mother — bad been quite well till an hour hetore, but since that tune had not been ablu to i*peak a single word. It was, in fiict, impoa* siblc to make the child speak. Only on being pinched he uttered the sounds " Au ! " Hm look was unusually staring, but other- wise nothing morbid could bt.; discovered. After half an hour violent vomiting took place suddenly, whereupon several cherries were brought up almost rpiite uuehangtib and immediately after speech was quite restored.'

Cases like this of pure aphasia can hardly bo explained other- 180 than by reflex irritation from the stomach, while for the more complicated cases (convulsions, coma, I'tc.) the '* auto- infection " (first saggested by Senator-) of the orgauiam by the poisonous products (ptomaines) formed in the intestine, may come into consideration**

From the cases I have given, yon may see at the same time e kind of treatment to employ — emetics and purgatives, lomel and castor oil, infus. Kennjp, Sec, (Form. G and 7) are ihe remedies given to remove the irritating "materia peccans " m the stomach and intestines. When the abdomen is more xtremely distended and tense* it is well — even while the erebral symptoms coutiuue — to give an enema of milk and oney (2 : 1), or irrigations of cohl water, in order to empty the ntestine as quickly as possible* Bloodletting is not generally to be recommended.* Although I employed it in a few of the nses given, it was cither where I was afraid that the malady A tjuite analogona oiwc wa«4 obsonrcd by Sieguiund {Bcrl. i/i«. WocheHtchr., *«J. 8.3351.

iff. M'ocA^McAr., 1868, No. 24: Zeiisehr,/. l/m. Med,, Bd. vii., H. 3. 0 idet^ thnt noetono hft<l Homethini; to do with the occurrence of tiU tding to Baginftkjr'a invoBtigntiona (Arch./, KiHderhtiil\^iT., 1) to

aaver yet Hoon occaaion to Oiic tlie atomAoh-puiup, lu reconunendod Cathy yilirtck und Virehow't Jiihre*btrkhi, IB7S, \i., 8. 02t>) in order to let it fgikH mid flaids and, if tteed \)e, to inJAOt *n «nietic. Bat if the !«tonmch waa di0tend4id I ihould not hcwitAto to 4if9^difiQmatk4i^ §** •

COOI

»'pt>

172

DISEASES OF TEE NERTOUS STSTEV.

miglit turn out to be meningitis, or — in cases where diagnosis was certain — because we were obliged to Assume considerable amount of venous engorgement in the brm, and meninges, on account of the extremely long doration of the convulsions (^.7. from 11 to 2 o'clock in the third cm^)* In order to avert, as far as possible, the evil effect of this, I' ordered the application of a few leeches ; and I recommend thi«, procedure to jou in similar cases, which are by no means rare

In a rliild of 14 years, who hud eaten large quantities of tuniip, coiivuUiona set in towards evening, wliich, with short intenraU, lasted lill the morning, when violent vomiting and dinrrbt**- ofcurred spontaneously. In a hoy of 4 ywirs tlio iittncks^ alout^j with the comatose intervale, lusted 24 hours, and eau8<>d great ^ anxiet}^.

A few leeches to the head, and cold compresses or an ice^hiig in addition, are to he recommended under these circumstances as a prophylactic means, but only in robust children. In general, however, the application of an ice-hag is quite suflicient.

The old tradition that internal parasites (ascarides^ oxyurides, and taenia?}, like dyspeptic conditions, frequently give rise to convulsions, still lingers in the belief of mothers and even of many physicians. I shall by no means deny Iho possibility of this connection, seeing that there are so many cases described, and especially as a few observations of this kind have been quite recently recorded ; but my personal experience is quite at fault here, I have not seen a single case of eclampaia which I could trace with certainty to the irritation of wormB, but I am quite ready to admit that the use of anthelminthics is ad\nsablc for children in whom worms are known to have been present previously, or at least are suspected. Just as little hav<* I ever an opportunity of discovering foreign bodies in the oar. akin or nasal cavity causing the fits — as others have reportotl. But I shall give you later on an example in which the irritation of small concretions in the aropoietic organs was the cau*e of tlie convalflions. You will tlierefort- do well in doubtful cases to have those things in mind and investigate accordingly.

A fybrile condition precediDg the eclamptic attack and continuing after it is especially significant for diftgnoKing iu etiology. Even in the cases of dyspeptic convulsiuua of wbiob we have just apoken, fever may be present, but under thoM

I

INFANTILE CONVULSIONS,

178

circumstauceB you must never neglect the examination of other organs, for acute diseases of these not uncommonly bepfin in childhood with fever and violent convulsions. In the first rank I would here name primary pneumonia, and next to it pleurisy and enteritis, and in considering these diseases I shall give you examples of this mode of onset. I ^-ill only remark here that the diagnosis of pneumonia hegiiming in this manner is often at first difficalt and even impossible, because on physical examination of the chest at this early stage there is as yet no real abnormality to be discovered ; so that wo may remain in uncertainty for some days as to whether it may not be an acute

t inflammatory disease of the brain. As soon, however, as the symptoms of respiratory disease become more prominent, the cerebral symptoms usually become less so, and we recognise that the latter were only the prelude to the pneumonia. It is pot quite clear in what manner the convulsions arise in such cases. They might just as well be ascribed to reflex irrita- ^^tion proceeding from the lungs, the pleura or the intestine, aa ^mto the high temperature which in children of an irritable ^iiabit is of itself sufficient to produce convulsions. In two children of 0 and 8 years, who were extremely feverish from simple tonsillitis, I witnessed repeated attacks of eclampsia take place on the first day, causing great anxiety to the friends and to myself. On the following day, however, the fits ceased along with the fever, and did not return. In one of the cases ^■ibe parents stated that this had occurred two or three times ^Hbefore. Fau re' publishes a similar observation from Bar thez's elinique. Thus we see that even trivial local affections, if only ^■Ihey are preceded by intense fever, may at first be accompanied ^By eclampsia, and it is therefore only natural to ascribe it to the ^■ever. If we consider that the rigor of fever is itself a con- ^^mlsive phenomenon, we shall not find anything very surprising I in the fact that in very irritable subjects it becomes aggravated ^Hnto regular convulsive fits. The convulsions which at times ^ftccnr in the initial stages of acute infections diseases ^Hmeasles, small-pox, scarlet fever) probably belong to the same ^Hehrile category. But it is conceivable that in them the infective ^Braterial circulating in the blood may contribute its own share.

^^K^Fftore, '* De retpeottttioti et da niglme danfl Ub malftdi&s uguea doa

174

DlfiSASBS OF THB KBRV0U8 BY^TEHf.

lu nil these cases the convulsions can only be treatetl sym[i- tomatically by the application of an ice-bag to the head, cold baths (88" — 81*5^ F.) evacnant enemata and mild purgatiteg. One must just wait and sec what will develop from these initiiil convnlsions, and direct the further treatment accordingly.

Uraemia, to which I shall return nnder AVfj/ififtV, is another of the acute diseases which begin with violent convulsions, and intermittent fever (in children especially with tolerable frequency) is another which may suddenly commeuco in the same way. As a rule it is only the first attack that talies this course, and it may easily be mistaken for simple eclampsia, until the appearance of the ordinary intermittent attacks discloses the error. Far more rarely, even the first or sftoond attack of this convulsive form of the disease, presents all the symptoms of pernicious intermittent fever, which is '" extremely dangerous condition.

The following case observed by me will illustrate this you*: —

A healthy girl of 9 yoars complained on the Frirhiy before Whit* Sunday, 1871, about 10 a.3I. for the first time of dotible vis ion; »oon after, of cold hands; her iiitelligeuce wus also soon affected. She no longer recognised those arotnid her, but misitook one jxirsoti for another, and about 1 o'clock took u convulsive lit, which— Hccording to the description — aecmcd to be completely cpileptifunu This, with internals of coma, lasted for obout au hour. Then slcqi came on ; after which the patient — apart from slight headache^ appeared quite well. As she had never before had an attnck of thitj kind, and no epilepsy hod occurred in her family, and a« indigcstifui also could certainly hm excluded, iiiterontlt-nt fever occurred to me. all the more reitddy bccati^u the familj lived on the canal, \^ here malarious digrases are not unconunon. Kcit day passed without any event. On Huuday, nt 4 r.M., however, th<f attack recurred (tortiaii). 1 wns my»cU' present when iho child began to wander in her »}>ewh. Suddenly blie ceased to recognise thotto ai'ound her, mistaking one person for another, tier hand^ were cold, and in the free Lntervnlb which were obi*erv<*d the complain rd of giddiness and doublu vision. An hour aftorwardfl another violent epileptiform attack occurred, lasting contiiutottglr till 6 o*clock. 1 nuw found the child cyanotic, pulse .small luid very rapid; and — as 1 hepitiUcd to u»o chloroform under lh««e] circimiHtancett — I guve lirttt an injection of morph. acetat., gr» |» Soon after, however^ eueouraged by the co-operation of an t!xpc»

INFANTILE 0OXTUL610NS.

175

ricnced colleague, I gave chloroform inhnlations. Tbe very first inhnliitioius were sufficient to arrest the convnlyions. The child Ijecame quiet, the cyanoaia diaappeured, uiid peaceful sleep set in^ lasted 10 hours, and the child waa quite well wheo she awoke.

Aa I was now convinced that I had to do with a case of inter- mittens pemiciosa, I at once ordered quin. sulph., grs. ivss. every 3 hours (grs. xxiiss. on the first day), in order to prevent a third attac^k, if possible. On the necond day she had gr. iias. every "2 hours ; on the 3rd, gr. lj| — so that in the first week after the attack about 92 grs. of quinine were given. The result waa that no further attack occurred \ only on Tuesday at raidday the child had headache and giddiness and commenced to shiver; hut this condition did not last heyojtd 20 nuiiutes. Since that time I have ^Seen this patient frequently enough to be able to answer for her

srfect health.

lu addition- to the causes already described, psychical anses also may produce couvuIgioDB in children with a very table nervous system, especially a sudden start, more rarely fear ; and I would refer many cases in which convulsions have ensued after a fall on the head, more to the fright than to the injury. Under tbcse circumstances it is not always limited to one attack ; on the contrary, there may be frequent recurrences. Thus on 5th January, 1878, a child of one year whom I have already mentionetl, who had been perfectly well and in whose family epilepsy was unknown, was brought to mo at the poly- clinic. Five months before, the child while sucking bad bitten its mother's breast with its two incisors (wbicb were prema- urely developed), and, when she screamed violently, at once fell to severe convulsions, its whole body being affected in the fit. These convulsions had since then been repeated four times without any cause and without any tendency to rickets being bservable. Huch cases cannot but rouse anxiety lest the isease should become habitual and develop into epilepsy.^ xperience shows that epilepsy very frequently begins in child - ood. Surely, therefore, no one can pretend to determino with tainty whether eonvnlsive attacks — especially those which veal no cause — ^havo only a temporary significance, or indicate

* Attotig the oiuKi of reflM epilepsy in children, ono puhHahod by Demme

* \rtA9r*d9» Bvntr Kindfr*jhtaU, 1870) ia espoeially rcmarkftble. The p*tient

.-J ft boy at 1 years whose attacks at onco di8appcared after the oxtirpation of a

r 0 c t A I p o 1 y p a e. An att4>inpt, which wiiH made on the day before the operation .

draw out the polypns with the point of tho index finger, canned an epileptic

iM'ting' abont 3 minntcH.

176 DISEASES OF TEE NEfiYOUS SYSTEM.

the beginning of habitual epilepsy. In these cases the attacks are not inYariably continuous, for the conYulsions may come on in infancy, and make long pauses before they reappear in riper years. Among others I obserYcd a boy of 12 who had suffered from epileptic attacks in his second and third year, then remained unaffected till his 11th year, and after the interval of another year was again attacked by epilepsy. In this case mental hebetude seemed to be the. aura; and in this condition he was still able to go down to the street, where he fell dov^n in couYulsions. The diagnostic features of inveterate epilepsy, namely, diminution of brain-energy, loss of memory and altera- tion of character are not to be expected at the commencement of the malady in children (except in congenital atrophy of the brain accompanied by epileptic fits), and therefore can scarcely be of any value for distinguishing a transitory eclampsia from incipient epilepsy. Among the cases of real epilepsy which I have seen develop in childhood, the following appear to me worthy of notice : —

In a boy of 10 years, who after an attack of " inflammation of the brain" in hia 2nd year, had retained hallucinations (esj)ecially the constant reappearance of a sheep). Epileptic attacks came on in the end of the 3rd year, wi£h a sensation of giddiness as the aura.

In two other cases, the attacks commenced 5 weeks and 2 mouths respectively after a head-injury (a blow against a tree and bruise by a carriage-wheel). Both children complained frequently of headaches, and were somewhat backward in intelligence, and in the 2nd case the attacks were preceded by nausea as an aura.

In a child of 3 years epileptic attacks had commenced one year subscfiuent to a fall, when a knitting-needle had entered beneath the chin and penetrated to the floor of the mouth.

A child of 3 years took his first fit a few hours after seeing the corj^.se of a favourite brother.

A healthy-looking little girl of 13 years had had a convulsive attack in the first year of life, which recurred in the 3rd and 12th years. She learnt to speak first in her 6th year. Since the 7th year, attacks of a peculiar convulsive character in the throat, namely, the sensation of choking in the larynx occurring in fits ; exj^irationa rapidly following on one another; staring look, and slight mental hebetude. Every attack ended in violent palpitation of the heart, after lasting a few seconds. Sometimes 10 — 12 such fits occurred in one day, while on the other hand some weeks ])a8scd without any occurring. Intelligence and memory weak.

INFASTILE COKVDLSIONS.

177

M«n$ole^a laughing ofton come on. Froquent pain in the neck. Xo molimina menstraalift noticed. It is said that after violent i.'j^tistaxis these attacks ceased for Rome time. Local blood-letting from the neck and purgatives had no effect, for instead of these attacks regular epileptic paroxyvsms eoon 8et in, preceded by vomiting and spasms in the throat as aura; so that the latter, whicli had lasted for alKJut 6 years only as abortive attacks now tiirued out to be an aura in the sphere of the vagus.

A girl of 12 years had suffered for the last 5 years from epilepsy. The aura in every fit was a noise in the ears — cs]>ecially in the right ear — which wakened her out of sleep. The attacks occurred tJiily in the night-time.

In a boy of 14, who had been an epileptic for several years, the aura con.sisted in fits of winking with both eyelids and nodding of the head. Before the epilepsy commenced this aura had existed HH a separate disease in fitn which sometimes lasted for an hour.

A child of 3 years, whose brother is imbecile, suffered for some months from epileptic fits, with the following aura — in the midst « jf play the child would suddenly run to a certain point, staring and apparently blind, and then fell to the ground unconscious, with convulsive mavements of the muscles of the eyes and of the urms.

A girl of 11 years, in whose family mania and epilepsy are hereditary, had after a severe fright begun (9 months ago) to be delirious at night and to sing loudly. Later on there were added [luinful spasmodic contractions of the legs, gradually also of the unus, face, and eyes. Finally there set in regular epileptic attacks iKith by day and nighf;„ but never as yet occurring out-of-doors. Any mental strain or slight punishment readily produced an attack* At night she often suffered from bulimia and then ^^K greedily swallowed food without knowing what she was doing. ^^B In a healthy girl of 12, with no hereditary tendency, 5 epileptic ^^y^t9 had taken place in the last ms. months or so. These occurred ^^^bnly when the eyes were shut, e.g. when washing horaclf I^V or when asleep. Then there would set in convulsive movements ^^H of both arms, more rarely of the legs ; and we were able to produce ^^m this anra in the ward by telling the patient to shut her eyes. ^M When her eyes were opened the aura also disappeared. The aura I^P always began with a tremor of the eyelids. Was the action of the " light important to the brain 9 Further course unknown.

I consider it superfluous to discuss epilepsy here in detail, as

differs in childhood in no way from the same disease in adults.

sases I have given — only some of which were hereditary —

ite especially the various kinds of aura, which in a few of

iiym existed for years as an apparently independent disease, and

dy revealed tbcir real nature later on by the development of

12

ASi> » !rHE KEEVorS «wrrg«r

il"'* .11 k.

- 'iitss^cr^ iicvac jtm in all cftaes Kiiere nawoB -i-ij- izsiL urmr in rnildrBn otfaenriBe bealthy — be ' ^.i^^ IiiXilikfi. of TAit Lead or fresy luJlncinatioiis i'^*' "■^>*^ aiiT3i.>*Tnfcliiie£ — not to take the matter .1 v^ li nunc liuc tiH^ nuiT lie the jfremmaUxj y--^-^'-^ Ii fioiiH- af njT easiefi I liare also obserred "*:'■'*- - • ■ ■ — r *-^*- "^ aiiat-kft, lira in tJie intervals also; ui.^ U: r: r:.-, - U.T >.— .1^-1 'trniiainl.TiliBlic'' srinptomB, Fir.i :.? j::...:^ .r: .: :n-w iinniic uh- nig^i, creeping under tlie

.1-. J'. : .-.J .1 ti;: -.-,7 ;.: -^i^^ fLTjiii-ure, all when half asleep,

:.!: ■ V :: u.t : . Ls-j. -sih-sf t-iLf? entirfcjT, or ai least partly, in :. >'».!::■: -i.-. T-.5... tz. :rrr«s:si:iut impijse to jnmp abont tlie :.■-■-:> -.. ..,*_: :.ii :. sl^ vi^ ^ ii^T3j Toioe. Sametimes the

-r_r.:-_ r-.i.i^vs j^l:! l Lt^li ks xc- 1* caDed ^^eicstasT": as, :.: JLr'Li..-:. -^ u f-r_ .:' II Tt-^rs vho in the intemds appeaml .: >. ^: -.:.:. i^I £.-.:: iz. rriifeKini: ibe wurd "what?" You :^ -r-. T t :i : :^ > • :!:.: l11 1!^*=.= vf-Jt cases of real epOepsr and not L's'-.:..:.. :^'-i :! :i.f . vlii-h we shall disenss pi^sentlr. .^1 - - .1.11 1^. :. .....Lr?:t: — :rc frequenilv in this form

*.--- !'.ii- -:::--.: =7 -:»:•?. m:.:. Frrawoms, hcweTer, are bv no ::-'...L^ ;«r.-il.i^ :. ^:l--.v?t ij soer in childhood, bm are observed '.L .. ::1:? ^Is. All :Li.: I Trir:^^ here was to make yon i. . iz..-'.':-! "i:^ ::.e i:±-.~.::Tr5 wi::ch we cneonnter in many «:--'» :l liirL.^iLj :ic=: fr;::: FiEiple eclampsia.'

!:_ '.. L'.!-rf:.L I LiTr: ::« sli a few :herapeatic observations, f: !:.:•: :LyT'_- ilrt-;_v jrlvtn p. 171 » are only concerned with <:.u:h'ri fji c'.-vu'.j:.'L5 wLerc :Lrre are decided causal indications. L'iifor:'iEiaV:ly. L.-'Vctct. there are many convolsions the proxi- iLii\*: caij-io of ■.vli.'cli is noi to If found. This is especiallv the o;a^'; in tiios'r so rornmon in rickety children, with or withont ];irvri^'«;ul np.-isiij. In tLese cases the troatmeot of the rickets is rirituiuly, J think, the chief matter; and when the convulsive iitlui:kK only occur seldom and in a mild form, I always think it \n>x to difcjn-jfiird them and to give iron, codliver oil, and luke- v.iiir/i ImtliH \wtii salt or decoction of malt: to this I shall return 111 ;|;<:itkinti: of ricketfi. You will find cases, however, often Mjoui'li in your pnictiec in which the convulsions are so numerous ' A't i^» Mill ifiHii<;rii;u of 'IraiikonncHK on the part of the purcnts, or the i-if'f ,fi<ivi'. u-j: of al<:olio] by Iho chiM in occa><ionmg opilepfiy, cf. Demme, 22. Jiihi rahft h ht iUm Jrnnt.r'ac.htn Kintlrrfpitah : Btm', 1885, I have not m^aelf u yvt iiini Willi II n'my^U' wnll authenticated caflo of thin kind.

LARYNGEAL SPASM,

179

*

I

and severe tbat they — at least for the moment — may be regarded ftB forming the chief disease, and demand to be considered before anythin<4 else. I must freely confess, that in such circumatanees onr art has no great results to boast of. I Icdow of no remedy certain to prevent the retnrn of the attacks; and yon will therefore pardon me if I serve np to yon once more the confused medley of inrfticient drags which have been recommended for centuries. Many physicians to this day swear by the prepara- tions of zinc, especially the oxide, sulphate and valerianate. But from my own experience I cannot recognise these remedies as superior in any way to many others which have become obsolete; and in fact I have long ago given them up, along with asafcBtida and musk. Of greater importance appear to be two remedies which have come largely into use in recent times — bromide of potash and chloraL I am very far from ascribing to them a specific action; and unfortunately I have had cases in which they did little or no good. On the other hand we [.cannot deny that theso remedies have a quieting iuHueuce on the 'irritated nervous system ; and they are therefore always worth a trial. I prescribe pot. brom. gi's. ivss — xv. (according to age) thrice daily (Form. 8). Chloral hydrate internally gi". i. — ii.,

V in the form of encmata in doses of grs. iii. — viii. (Form. 9).

ith these doses, even in childhood, no soporific eflfect follows,

»8 a rule; such effects, moreover, need not be feared in the

ircumstances because children mth a tendency to eclampsia are

apt to be rather sleepless or at least very restless and

Therefore when the restlessness and sleeplessness are

great and the fits constantly recurring, it may be necessary

to order a fall dose of chloral (grs. xv.) or even to give

morphia.

II. LanpKjeal Spasm.

iong the convulsive conditions of cluldhood affecting a limited nervous area, but having a tendency to become general any moment, laryngeal spasm is by far the most importunt. tt is commoner in boys than in girls, and occurs almost excloaively lietween the 6th and 24th months. Beyond this ftge I have hardly ever observed laryngeal spasm ; but often

180

DISEASES OF THE NERVDUS BT3TEK.

before Ibe 6th month , in children of 5—C} weeks or even oolj a few days old.

You may iu fact observe, even in a healthy child, many of the featureji of this atfection, when in the midst of violent and noiiy crying there is a sudden quiet and the child lies with its head thrown buck, ita fac^ dark red or somewhat cyanotic, the breath* ing arrested and the hmbs stiffly extended. Excessive screaniiug, alon^ with passionate excitement, seems in such a case to caaa(!> a spasm of certain of the muscles of respiration^ which as a role, gives place to an entirely normal condition after a few seconds. This is analogous to other spasms occasioned by OTer-atralDiDi; of the affected muscles (writer's, shoemaker's, and milker's cramp &c.). When morbid conditions exist there is not neces- sarily any such cause for the eonvuisions. for often enough we see the attacks take place during complete rest, even on waking from sleep. But any overstraining of the respiratorf organs, especially screaming, always acts in this way — sacb aa is due to psychical infioonces, anger and fright. In order to demonstrate an attack to my pupils in the ward I usually mako the child scream by pressing on tlie lar^ux, and this almofit always succeeds.

The simplest form of the attack consists in a momentary stoppage of the breathing, in apncea lasting only a few seconds. followed hj a few crowing or whistling inspirations. Between this and the severest form there are countless gradations, which it would be impossible to describe individually* Tlie sudden stopping of tlie breathing is common to alL The child generally throws itself back violently; its face is pale with a somewhat cyanotic tinge round the mouth and nostrils, the arma and legs are often stretched out, the fingers are doubled up into the palm, and the toes sometimes flexed upon the solos or q\w extended. The return of respiration is announced by laboured and whistling breaths, first faint, afterwards louder. "With ihesd the attack ends after lasting some seconds. The occurrence of the " crowing *' indicates the abatement of the paroxysm seeing that it is cansiyd by the air rushing through the still contractml glottis. 80 long as the spasm remaiuK, there can be ii'. * " ijg at all, and consequently no ** crowing," Those attu iv-

foro arc mont to be dreaded in which the apncna is prt>tract4Hi beyond the usual thno and there is no whistling sound at all»

L-VRYNOEAL SPASM.

181

^Bn sncb the complete stoppage of the i-espiratioD may be fatal almost iDstantaneously from asphyxia; aotl in estimating the

•prognosis this fact must be kept in mind from the beginning- For a child may suffer for weeks from slight transitory attacks which scarcely arouse anxiety, until all of a sudilen and t[uite ■ unexpectedly an attack occurs causing instant tkmth. Be there- Before always on your guard in your practice, and in every attack ^■>f laryngeal spasm that you meet with — however slight it may ^^ppear to be — forewarn the relatives of the possibility of a fatal issue.

But the fact must not be overlooked that this convulsive affec- tion may extend further. The name " laryngeal apasm " has become naturalised, but, strictly speaking, it is far from being correct. For, although in slighter degrees the whole attack

kmay consist solely in a more or less transitory spasm of the brj'teuoid muscles (r.f. exclusively in the sphere of the recurrent '' liir}i3geal) ; still, we very often see the spasm passing ou to

I other parts of the respiratory system (muscles of thorax, dia- ||ihragm), and in this way there may be occasioned complete liptia?a, or striking iiTeguIaritics of breathing {f.ij, inspirations following rapidly ou one another without any noticeable ex- pirations). In addition to this, the ocular ncr\-es often eno^lgh participate (turning up of the eyeballs) and the spreading of the ^irritation to a wider area is indicated by the contractions of the ^BnuBcles of the tingers and toes, so often observed in such ^Pnttacks, or even of the flexors of the forearm, whieh I have B-myself seen very distinctly ; r.//. iu a boy of 5 months. Once Bor twice I have even observed trismus- like contractions of the masseters and temporal muscles during the attacks, and in these cases the attack only wanted loss of sensation and consciousness ^kio stamp it as eclampsia. So far as an opinion on the matter can Hbe attempted— considering the shortness of attack and the ^Bteuder age of the patient — I really believe that iu severe cases ^■^f spasm of the glottis there must bo a brief period during which ^Bbonsciousness is lost. At any rate, cases do occur in which ^■chihlren after an attack lie for 10^-15 minutes as if in a stupor. ^■Therefore^ it need not appear surprising that attacks of hiryngeal ^^npasm very often alternate with fits of eclampsia, aud tlmt ^^^kyasmus glottidis often appears first, and general convulsions ^ppeedlly follow. I have sometimes observed the above-mentioned

182

DISEASES OF THE NEBVOUS SYSTKll.

contracture of the fiiiijera and toes persisting during tlie intervals. The combination of laryngeal spusuis with eclampsia is so fre- quent that in un earlier work 1 wns able to distinguish 46 cft»^s out of 61, as cases in which both afl'ectioiiR occurred, while only 15 presented Ifiryngeal spasm alone. Since then, the number of my observations has increased very much, but the proportion I have given has always remained the same. In every case of laryngeal spasm, therefore, I usually forewarn the parents that general convulsions may suddenly sot in.

You will remember the connection which exists between eclampsia and rachitis, whether the former occurs alone or is combined with laryngeal spasm (p. 167). This connection, in rickets especially, is so well marked that in every ease I at onee examine the cranial bones and the epiphyses of the ribs and ex- tremities, and I very rarely fail to iiud raehitic changes in them* Even in infants of 3 — 4 months— in whom rickety changes are not very common — I have repeatedly found that whi:re there was laryngeal spasm, the cranial sutures were widely open, and the bones were soft near them and yielded to pressure, the epiphvses of the ribs being already distinctly swollen. From my own ex- perience I can boldly assert that at least two thirds of the children who suflcr from laryngeal spasm are rickety, and I most therefore regard this connection as something more than a mer^ chance coincidence* This also explains the family tendency to spasmus glottidis occasionally met with. Only in exceptional cases have I seen rickets limited to the cranial bones, the ossific-a- tion of which was then considerably retarded. For example, in a sickly little boy of 7 months who had previously been 8}'phililic, the large size of the head and wide sutures and fontauellws, combined with the frequent attacks of laryngeal spasms and eclampsia, suggested hydrocephalus ; but this apprehension wa» proved groundless by the patient's complete recovery. WTien Elsiisser wrote his book on **Cranio-tabes" — of Mhich I shall have more to say under Hicketit — he allowed himself to be misled by the softness and partial wearing away of the cranial bones (especially of the occiput and the parietal bonea) into making !arvnge»l spasm (*" tetanus apnoicus*' as he inappropriately call* it) dependent on ihia disease of the bone ; and he aKsumed thAt when the children were lying, the brain was not sulBcieuUy pm- lectc^d against pressure by the softened bonce, I can assure yott

LABYXGEAL SPASM .

183

P

iimi I have exitmined boudreds of cases for craiiio-tabeB, and have only very rarely found the condition described bv Elsiisser, At any rate, we must alBO regard it as a rachitic Hymptom, and only from this point of view is its connection with spasmus ^lottidis to ho coDBidcred. Tho frequency of the attacks— which in general admits of ^reat variation ^may he incredibly great in rickety children. In the coui-se of a single day, 20 or even SO attacks not nufrequently occur. Every fi'ight, eveiy attempt to drink, every fit of crying occasions one, and it is iu such states of extreme irritability that we have to fear the occurrence of general convulsions at any moment. If this condition lasts for weeks or months, getting alternately better and worse but with- 4itlt free intervals of any duration, complete exhaustion may «nsue, to which tho cliild at last succumbs.

A boy of mic year, very aniemic and rickety, vrheu I first saw him in Dwcmber, 18tJy, bad already been suffering for 1 month 8 from attacks of spasmus glottjdis, which hittorly Imd alternated with eclampsia. During tlie lu,'?t few weckst the latter hadl»ccomy very prominent, 8o that Lsometiinea Ifj^lG attacks of convulsions occurred within the 24 Lours, llio child was evidently becoming collapsed. The moat diverse remedies — even crucial incisiona into ifaegumB (which I allowed in deference to the physician in charge) — Were quite unsuccessful. Only exceptionally did intervals of 12 — 18 hours occur. BVom the middle of December to the end of March, more than tJUU tits of eclampsia were observed, alter- nating with laryngeal spasm. Tlie constant current was also quite without effei't; and the child died in a state of collapse in the beginning of May. after the cutting of the first incisor tooth.

In other cases death occurs suddenly^ as I have already men- tioned, from complete apucua ; but thiH mode of termination — according to my experience — is not so common as you might think, '\i\1ieu it does occur, it is usuaUy extremely sudden, in the midst of perfect health— just as iu cases where a foreign body has found its way into the glottis. The already-mentioned (p. 1-13) 8ucking-iu and turning-up of the tongue towards the hard palate have also been blamed for this, and I will not that the forcible inspirations, which occur especially when spasm is becoming relaxed, render such an occurrence ublo, since 1 have myself clearly observed it in one case.

A rickety child of ouo year, in my ward, Buffering from spasmus giottidis, was being au.scultated hy me on its back on acc4)iml uf

184

mSElBES OF THE JfERVOUS 9YSTE3f.

broncLial catarrh j and the imrse was truiking it bend very luucit forward. Suddenly euch a violent attai-k of n[>iuea act in that the child at once liecamc very cyanotic. Sprinkling witli cold waWr caused the respiration to return, hnt lu spite of the -whistling and lalKiriouH broithing, the condition threatened every moment to*»nd fatally* I quickly passed my finger into the child's mouth, and found the tip of the tongue so firmly pressed ugainst the poUU that I was obliged to use considerable force in order to get piutt the root of the tongue. T tlieii drew it quickly forword; and thr respiration at once resumed its normal cliaracter.

Cttses sucli as this may induce one to re^rd the sncking-iu of the tongnc as the astial cause of ftpnopic symptoms in laryngeal apasm. I consider this as quite unjustifiable, how- ever, for in very many cases I found on exaniination of tbe mouth — which was alincst always open — that the position of ibe tongue was perfectly normal. Its being nucked in is tbcrcfon? assuredly only an accidental and rare complication ; but still it must not be over-looked > for — as the above case shows — it may be a very important circumstance in the treatment.

There is a third class of cases, in which death finally enstscft from a violent and protracted attack of eclampsia, or from its consequences. In the post-mortem, which I have performeil in several eases of this kind, extreme venous congestion of the pia mater, was always found, generally also of tbe brain ; once or twice cedema of tbo pia mater and serous efiTusiou into the ventricles. But I regard these as tbe rcsulii simply of cousiderahle venous engorgements occuring dariog the convulsions, for they were always found most strongly marked where, in addition to spasmus gloitidis and cdampsiap there was a third factor favouring engorgement (viz. whooping- cough). I have observed this complication not nnfi*eqnently, and it either accompanied convulsive attacks which bad alreadT lasted a considerable time, or the whooping-cough came flr«i and the spasmus glottidis only set in when it was abating. Tlio complication is of course merely accidental, for whooping-cough can only occur from specific infection. But the combination of these diseases with one another favours tbe occurrence of general convulsions very much indeed, and in my experience justifies an unfavourable prognosis,

To the uncertain relationship between rachitis and spasmus glottidis I need not return aft^r what has been already said

LARYNGEAL 8PASlf,

1H5

(p, 167). The fact remains, altlioogh its explanation is want- ing, and all attempts at explanation— ti.^r. the most recent by Oppenlieimer', are strained ajul higlily contestable. Poorly nourished delicate children — and, of course, those of the poor especially — are most apt to be affected ; but well-developed apparently thriving children are by no means exempt. If only the tendency is present, the spasm occurs either spontaneously or from reflex irritation^ and in this respect the eruption of the teeth {p. 155) is undeniably of some importance, although it may be ver}' much overestimated. The same may be said of derangements of digestion, of constipation, and of diarrhoea.

E. R., 11 TJioulby obi, weaiiud in middle of March, 1875. A few days after, dys politic diiirrlnca and nt tbe same tinic attncka of 8]rjismus glottidii*, along with nlmost continuous coiitrat'lure uf the tiugers and toes^ — \vhi<'h liiJ^ted Uiiritig the intervals nho. Violent screiiming, biwl temper. Frerjiieot attaekt*. even during bleep. After lukewarm Iji^tlin and small doses of calomel, constipation set in bo thiit cneraata became necosjjiiry. On the SSth, tongue thickly coated, anorexift, offensive diarrhoM Bgaii), along with which the attacks of laryngeal Kpasm (which were already much diminished) commenced anew very violently* Ilydrochloric acid caused nipid improvement. Ncatl<^'a food given, which watt well borne, mnil was continued from this time. After 4 weeks, recover)*, only slight racliitii- bone-changes being left.

Among the retlex causes, the infltient'o of cold and of catarrh of the upper air-paasagus must also be mentioned as very important. This is showE by the special prevalence of the malady during the cold season of the year. I have always observed by far the greatest number of rases — in the polyclinic as well as in private practice — during the months from January to May inclusive ; and I therefore urgently warn the mothers of children with a tendency to laryngeal spasm, not to expose them to cold air* A relapse of the disease may at once result, especially if there is cat^irrh of the larynx or trachea. In these cases the inspiratory ** crowing" acquires a harsh character, which is easily explained by the catarrhal affection of the glottis.

All these causes, and perhaps also others less evident, may produce laryngeal spasm even iu children who are suifering from no rickety conditions. But as far as my experience goes, theso cases are infinitely less common than those complicated with rickets. The high degree of reflex irritability, already normally

• Dtuttches Arck./. llm, Mtd . Bd, xxi. : H. 5 and 6.

18G

DISEASES OF THE 2«ERVOU8 SYSTEM.

present at that age, appears therefore to be greatly intenaifie(i by rickets. AnythmfT else that has been written on the etiology of laryngeal spasm is either hypothetical or positively incorrect ; particularly the view that the diseaRe arises from eulargemeut of the th}Tniis gland (asthma thymicum) ; which view still has its supporters, 1 could never observe any such enlargem««nt, cither at the post-mortem or by percussion duruig life ; and H haB been made almost certain by Friedlebeu's researchen thai thymus glands, which were formerly thought to be hypertrophied, were perfectly normal.

The prospects with which one approaches the treatment of spasmus glottidis arc not very encouraging ; aa yon now know there are dangers for which you must prepare the relatives from the first. On the other Land you can reassure them by tcdling them that the majority of cases end in complete recovery, althoagb they may last for months owing to rei>eated relapses. Thia result will be best attained* in my opinion, by improving the general health, i,e. by removing the rickety tendency. I therefore usually make this my chief aim, except where the too frequent recurrence of the attacks ctdls for special treatment. With regard to the latter I can only repeat what I have said about eclampsia (p. 178). Neither bromide of potash nor ehloml have given me reliable results. Even although the success at the beginning of the treatment is sometimes surprising, it is not sufficiently permanent; and wo must always bo prepared for relapses in spite of the continued use of the remedy. I have seen no good effect from zinc, nnd I consider the reports of its fiuccess to be entirely erroneous. In some cases musk has seemed to me to have a soothing effect, and slightly to diminish the frequency of the attacks ; but in others it was absolutely worthless. I have given as a rule tincture of musk, gtt. x. every hour, or every two hours. But when it la desiiable to bring to an end as quickly as possible the enormous frequency of tlie attacks which is exhausting the child, I have no hesitation in employing morphia (Form. 10). Whenever the child becomes qaiel and drowsy you should stop the medicine in order to avoid the ritk of poisonous symptoms. With proper care, liowovpr» I have never known anything of this sort to occur, ami with this drug 1 have frequently had the gratification of quieting the symptoms for a considerable time and rescuing from imminent doAtli

IDIOPATHIC C0NTUACTUR£8.

187

wl

who had been given up for lost. As to the troatmeut of the separate attacks, only in rare cases will jou be able to practice it ; for before you arrive either the fit is over or the chiM has been suflocated. For this reasou also the recom- endation of tracheotomy for the emergency can hardly be ref,'arded as practical. It is however advisable to instruct the relatives as to what they should do on the occurrence of mi attack. The sprinklm*^ of cold water on the face and chest nuay at once put a stop to the threatening aputua, and it should always be tried by the rehitivet^ its well as the drawing forward of the tongue already recommended (p. 18^1), Artificial renpira- tion is more dithcult; and it, as well as the faradisation of the phrenic nerve, oaght only to bo attempted by a medical man.

Attention to the cause of tbe reflex irritation is the matter which first claims our consideration incases where the alleviation of symptoms is not an immediate necessity^ — protection from cold air, attention to any catarrh that may be present, purfjjitives when there is constipation, anti-dyspeptic remedies when thcro dyspeptic diarrhcea. Scarification of the gums, when there is ritation from teething, is — as I have already said — utterly effectual. Above all things, however, I recommend to you the treatment of the underlying tendency by anti*rachitic medies— pure warm air, salt and malt baths, iron and cod- ver oil. Of these I shall speak more fully under liickets.

HI. Idiopathir Contritihi

fi H.

You will remember that during atinrKH ut spasmus glottidia ipoatic contractmes of the fingers and toes are often obaerved, id sometimes persist in the intervals between the attacks. Inch contractures may also occur independently of spasmus flottidis and extend to wider areas of the muscular system. They occur in general under the same circumstances as eclamptic attacks; not uncommonly they alternate with these and with laryngeal spasm ; and they are either only passing or else may last many hours, even days. Most frequently we find the fingers td toes Hexed on the palms and soles ; less commonly, ex- ided* Sometimes, however, the joints of the hands and feet also implicated, or the elbow-joint^BO that the forearm

188

DISEASES OP THE KEBV0U8 SYSTEM.

appears flexed upon the humerus, the hand upon the forearai, ftnd the foot upwards or else towards the sole. The cryiog of the children seems to indicate that the contracture is painfal, eapeciallj if you try to extend the stiffly contracted muscles. In cases wliere this condition lasts for many hours, days or eren weeks, I have not uncommonly observed oedema or a cyanotic tinge of the backs of the hands and feet; and this is to l>c traced to the pressure of the contracted muscles on the inter- muscukr veins. Actual ecchymoses such as Bouchut descriU'4», I have only seen in one case, which I shall give presently. At first the contractures only come on in paroxysms ; but later on they generally become more or less continuous. In sleep they are usually relaxed; and, like Bouchut, I have very rarely seen cases where this did not occur. The circumstance that they ai*e almost always bilateral, may, as in the case of con- vulsions (p. 166), be held to indicate their purely neinrous and innocent nature. A unilateral onset, on the other liand, must always arouse suspicion of an affection of the opposite side of the brain ; and I have often seen these unilateral contractures uccur- riufj as a symptom of cerebral tuberculosis, frequently com* bined with paralysis and tremor. The following case seems indeed to favour the view that unilateral contracture may occur as the result of reflex irritation. Still, owing to its incomplete- ness, it cannot be regarded as a proof.

On 24th November, 1876, an otherwise healthy infmic u/ U months, was brought to ray jiolycdinic. Fire weeks before, the first tootli had appeared, and had been rapidly followed by throe others. On exumiiiution. I fotmd coiitrac-turc of tht? right lower extremity at tho hip and knee joints. This was found both when the child was lying on its back, and when we attempted to niitke it stund ; and the foot assumed somewhat the sumo fio^itiau as i^i coxitis, but to a much greater degree. Tlie ntteinpt to extend the b'nib was difficult nnd cuumc<1 loud ttireamiiig. Aeeording to the mother's steteraotit, this eontnieture had hitherto appeared before the eruption of every tooth, nnd Uftd c o m e t o u n end when the tooth was fully cut. The toea «!«■ • « »r.. stiffly flexed upon tho «iole. For 14 dnya there Imd biien dy diarrhoea and colic. In the middle of Decemlicr ihin cttnuuKu wna ntiW unchnngcd. Unfortunutely I lost sight of the cbildi

In two other cases I have seen contractnres of the fingers And toes bating altncst contionously for a week during tbe cmptian

IDIOPATHIC CONTRACTURES.

189

of the upper lateral incisors, and vanishing at once wlien these had appeared.

The reflex irritation, wliich 18 here in the dental nerve, may also be situated in the course of other nerves ; and dyspeptic conditions are especially to he mentioned as causes^ jnat as in eclampsia (p. 167) — flatulent distension, hard slimy feces or dyspeptic diarrhoea. I have myself repeatedly seen cases of this kind, and many such have been described.^ In rare cases the iiropoietic organs are the seat of the reflex irritation.*

Child of 5 months, on the breast, emaciated, sjiid to have cried lotidly em'li time bpfure passing nrinc over since hirth. On 10th October, 1B»>1, exam^ined for tirst time. A fit of eclampi*ia a fortnight before, repeated a week afterwards. The toes of both f cot had remained persistently flexed on the 8olc erer since the first attack. After the second the fingers and knee joint.s were affected by sirailur contracturcw. Stiffiieas of the affected flexors J attempts to extend very difficult. The muscles of the throat and neck are also rigid, m that the head is moved with ditficwlty, For the Uist 3 weeks round frngmout.s of the 8izc of a pin's head rccognisctl us uric ucid coucrctious, have Wen seen on the diapers which were soaked with dark coloured urine. On vnriou« parts of tiin body there were purpuric spot.H on the akin, which were »iiid to have appeared imm€^difttely after the con- vulsions. On the 17th after a wann mult bath and the passage of other li similar concretions, the contractures ceased, and there wore repeated spasmodic contractions in the upper and lower extremities. (Edema of the lower eyelids, of the left leg and f«>ot ; fresh purpuric .spots of the size of a threcpeuny-pteco on the head and chest. I did not see the child again till 2Ut November, when I found no trace remaining of the former condition. Two and a lialf yearfl biter, when the child was lirought to me again, they had not returned. Tlie treatment consisted in malt baths and umall doses of iron.

In this case we find, as I have already mentioned, little hffimorrhages and partial oedema resulting from the persistent contractnre. The attack began with convulsions of an eclamptic natnre, and the contractures were noticed soon after. You sec therefore that the two symptoms had a like significance ; and in fact the diflerenco between them conflisted solely in the conscious-

' Q\ f.</„ Koppe '* Zur Lehro ¥on dor Artlirogrj^msia dea Sliai^lingBaHerv,'" Afthiv/. Kindci'heitk.f Bfl, ii., 140. A Bimilar coso was obHorred in an adalt bj HioifQl {('tnttalbi., 1874, No. 12), in which a cure w&a obtained by tr«Atmont fo? tapewora,

• Vi^ mj Btitt^fjt xur Kindtrh«%tl\, K.F,: Berlin, 1868, 8, 3S7.

190

DISEASES OF THK NERVOUS SYSTEM.

ness being retained in the one and not in the other. If US consider the period of unconsciousness to be due to spaemoM contmction of the small arteries of the brain, causing nccessaiiip arterial anti^mia of it, then we should only have to dispose of this affection of the arteries, and the distiuctiou between the eelaiDptie attacks and the contractures we are speaking of would be pracki* cally removed, since a tonic form of the latter also occurs not uncommonly iu ordinary convulsiye fits. The occasional very lonp; duration of the contractures causes only an apparent differ- ence; since, as we have aeon, even convulsive attacks may last for days, separated from one another by short periods of comM For these reasons I regard contractures as essentially identidi with convulsions — as a kind of abortive form of them — and in regard to their etiology and trefitment I can only refer you to what was said on the subject of eclampsia. This view is also strengthened by the fact that contractures, like convulsions, are especially common in rickety children. They also, like eclampsia, occaBionally have an intermittent type. I bare already elsewhere^ published two cases of this kind. ■

In a girl of 3 years there occurred, nbout 7o'elook every «vetiiH for H fortnight, stiiT contractures of ull four extromitii'S ; t-bean^ were extremely flexed at the elbow joints, the legs wrre drawn Op upon the abdomen, and the feet aBsumed the form of talipes Tsrag. Thc8C attacks were accompanied liy r dark red flush on the face, and by load (^creaming, and lasted 2 boors, after which the child fell Oiileep and was quite well till the following evenings Qainino stopjicd the attacks in a short time. — In another ca«e, affacting a boy of 6 ycnrii, there had occurred Hcvenil days before a stiff con- tracture of the right fiterno-mastoid, with tortieolllj*. Thi» gradually increased every day about 3 p.m., and linuJly lieoamo quite ri},;^id, hvMting till evening when it disappeared, not return* ing till next afternoon. In thia case also the use of quinine cunsfd rapid recovery,*

ifany writers clasps the contractures which wo have been con- sidering, along with tetany. This disease, very obsctire in it« nature and by no meana constant in its symptoms, does occur in children^ but is generally more common in adults ; and I have therefore no occasion to discuss it here. In my opinion it ij^ well to separate the contractures in children which I have just

• /.. r.. 8. 101.

' Folliet luitl Simon {Rtrw vunt. frrr,, ISSSf), gire qn'tU •imilar imam tC Caput objfitipnm intcnmit^nii. f|

IDIOPATHIC contiucti:res.

191

sscribed entirely from tetany, ab they are far more nearly ^ltttO(l to cclftinpsia than to it. lu particnlar, I have never been lie, in the cases of idiopathic contracture in children which have ►rae under my notice,* to make out the sign of tetany described Trousseau and conlirraed by others — namely, the prodac- Ion of the contracture by pressure on the main artery or the ffve of the affected limb.

Permit me to take this opporLimity of adding a few words on

the rarest convulsive symptom in childhood, namely, tremor.

While in adults and in old people this condition is often observed

either us an independent disease (tremor senilis, potatorum,

^mercurial is, &c.), or as an accompaniment of serious central

iseasea (paralysis agitana, sclerosis of the spinal cord), I have

lund tremor in cbildhood only in typhus and in other serious

ifectious diseases, but especially affectin^r paralysed and con-

racted limbs in tuberculosis of the brain, in basilar menin^tis,

id other cerebral diseases.* I have only once seen a general

smor without any serious symptoms accompanying it; and it

idecL favourably.

On 5th February, 1^7^, a child of I't months was brought to tho polyclinic. It wiia well iKJiirlshcd ami Jmd formerly been healthy but was eaid to h/ive .suffered from infljitumation of the lunpj 4 weeky before, Alxmt 14 "lays bufore, u continuous trembling hml set in in both bunds and feet and also in the head (which wftR uanally nomuwhat retracted, but could easily be moved for- wards mid from wide to side). The child rried very often and for long periods, aa if it felt pain ; and ita cry also, instead of being suataineil, had a quavering character, analogous to the tremor of the extrpmitk's. Since the beginning of this condition the child had lost tho powi-r of standing, but was able to grjisp and hold toys in \tn litth.' tri'tubliu^ hands. It seemed to foci quite well and all the organic functions were noruiuL After adraiftsion into tho childi'en'8 waixl, the condition at first remained unchanged. On the lytli, tho tremor began U) diminish, and by the 20th it had complctoly diBHpj>cared, The treatment consisted in tho ad- miniatration of chloml hydrate (gr. i.).

' Tho tetany in iiifviit« dof^cribed by Baginaky ^wliioh, however, I can only

9|fard Af« a «ijyn]ptoni of vArions irrttatod oonditionfl, sometiiiiev oentra), flome-

lOK reflex— aad not at all a» au iiulcpendoat disease) I have novor hitherto

worred with ccrtuialy {ArchU*/. fyintUrheiU\, BJ. vii.).

Dommc pnblijtkes ono intorosting caae il9. Jahr($her,^ 8. 36), of ^neral

lor in » child of i moatlu, which laicttod till tbtf lltb month and wfti meociated

"with liackwiirt1ne»« of tho mental doirolopment.

192

PISEA9E8 OP THE NEBVOrS 8TSTEM.

I cannot suggest any cause for the trembling in this extreioeljr rare case. Considering the very good general health of the child, I thought that I must assume some reflex irritation connected with dentition as the cause. I am still of this opinion, in spite of the fact that no teeth were cut while he was under our obser* vation. We may readily imagine that the tooth in process of growth presses upon and irritates the alveolar nerves for n considerable time, thus producing reflex symptoms; but the further advance of the tooth, even before its complete eniptioD, again frees the nerves from pressure. This view of the origin of tremor forces itself on me wlieu I compare the case with oiUars in which similar movements occur as the result of the said irrita- tion, although these are more strongly marked and are eonfined to certain groups of muscles, I refer to the spasmodic conditroo which has recently attracted attention under tho name of Spasmus nutans*

IV. Spasmus NtUans (Nodding Spasm).

4

My lirst observations of this condition were published in the year'l851.»

The children affected were of the age of (j and 8 mouths respoc- tively. There was a contbiuous rocking of the head liatkwardi* and forwards, which gave the children the appearance of tiie well- known Chinese maiidtirin dolU- In one of the paticuta tho eyoa also were occtisionally up-tumed- During sleep tho moTementj ceased. While awake, they only ccaaod for a short timo if tho child'a attention waa in any way attracted. When they were forcibly chcTked hy holding the heiid, great restlesHness and crying foUowwL The mouth was hot^ the .^alivtiry setTction ])rof use. In Ijoth cnnes the treatment had no effect. The eruption of the teeth (in the Bret case, of the first incisor) brought imniediute recovery after a diu-ation of 3 tnontIi8 and several wccka respectively.

About the same time Faber and Ebert^ described one or two (]uite similar cases, and when the attention of medical men was once aroused, it soon appeared that the affection was by no meims very rare. From the cases of this kind which I have niysrlf observed since then, I give the following : —

Child of 9 months haa had almost contitiuous uuddtng mort*-

• Komborg antl H^DOch, KiinUcke Berlin, 1831, 8. 57. « Anrutten Jtr Ckarit^, i , 1850.

truArAeAiMM^jm und B*nhnckhtM/gn^ 7

BPA.&MUB NUTANS.

193

TQCUtft of the head while awake, with slight rotation towiinls the r^ht. Complete cesBation during sleep. Along with the nodding, there wa« continuous nystagmus of the right eye, in which the movement was strongest towards the inner side. After a few weeks the movements of the head ceased, owing to the eruption >f a t<x>th, while the nystagmus perfii^ted.

Child of one year. Same appearances as in tlie former case; ])Ut instead of nystagmus there wuh convergent strahismus of the right eye. After a [)erii)d of et'ssatton following t!ie eniption of 2 teeth, the affLftion retiirtu'd. the chihi having snffered from cholera infantum and hronchial eatarrli. Spontaneous recovery ofter 14 days.

Child of 6 months, lirought to the polyclinic, IRth January, 1877. Generally healthy. The convulsive condition had lasted 3 or 4 weeks. At first it was intermittent, now almost continuous, bot ceasing entirely during sleep, Thf? movements consisted of a nodding forwartls, comhiried with a slight rotation of tlie head from right to left. Ocular muscles not affected. Tlie 2 lower central incisors shone through the gum. Further eour.HC un- known.

Child of 10 months, healthy, with two teeth. For three months there had been continuous rotating motions of the head from one side to the other, combined with a slight forward nodding movement. Cessation during sleep. If one attracted the child*8 attention hv holding anything in front of it, or forcibly fixed its liead* the head-movements ceased, but nystagmus at once commenced in l>oth eyes. Course unknown.

Boy of 1 year, with 7 teeth, examined by me along with a c'olletiguo on the Ulth February. 1878. For about M-days frequent weak rotatory movements of the head from right to left, coml lined with slight nodding. There was almost continuous nystagmus of the left eye. General health gmid. After a few weeks spon- taneous recovery — whether due to a fresh eruption nf teeth or not, I could not discover.

Girl of IQ months, hejilthy. Spa.smns nutans for 14 days, with slight rotation of the head towards the right. Movements iilmost continuous, only ceasing during sleep. Whenever one fixes the head the movements ceased, atid a slight nystagmus of the right eye set in ; not present at other times. Two incisors in the lower jaw, the upper in process of eruption. Course un- known.

Child of 9 months, rickety, formerly subject to couvuLslonM ajid laryngeal spasm ; now healthy^ with normal dentition (2 in- cisors). The nodding movements in this case were not confined lu tU© head hut also affected the whole upper part of the bod^, oecurrcd in fits several timej^ daily, and were somotiraes so violent that the head was l)ent down almost on to the knees. Spasmodic

194

mSEi&ES OF THE XERTOU8 SYSTEM.

moveraeuta of the oyos sometimes occompumed the afcta^k, Aft^rr 14 days the attrwrks diminished in severity and frequencT'. FurtbtT course unknown.

All tliesc cases show that the movements characterisiiG of spasmus nutans are almost never confined to the proper muscle of nodding (sterno-maatoid), but also aftect the muscles which rotate the head. Nodding and more or less distinct rotation — generally towards the same side — are almost always combined. Indeed in many eases I have found the rotating movement by far the more marked, and the nodding very slight. In almost all the children there were also spasmodic movements of the ransjeles of the eyes, generally nystagmus— only rarely strabismus or rolling movement; the latter usually affect- ing both eyes, and only very seldom confined to the eye on tbe side to which the head is rotated (unilateral spasm). The movements generally continue steadily ; much less frequently they come on in tits, and they uhvays cease during sleep. One may usually check the nodding and rotatory movements for the moment by holding the head or by arresting the attention; bat when this is done the nystagmus becomes more marked, or appears for the first time, if it was not present before. Only in the last of my cases were the trunk-muscles also affected, so that the whole upper part of the bf>dy kept swaying forwards rhylh- micidly after the manner of a Mandarin doll.

That the reflex irritation proceeds from dentition in cer- tain of these children is proved by the disiippcarance of tlic Rpastic s^iiiptoms when the teeth come through. Also the age of the little patients — they were all between 0 and 12 months — seems to point to this. The oldest child I have treated with spasmus nutans was in its 3rd year, but its hack molars had not yet appeared. On the other hand, I cannot be sure that this WU8 the cause in some of my cases which did not return for further treatment, especially since we may well suppose thai other kinds of refiex irritation are quite as likely as teething to excite spasmus nutans. From an anatomical and physiological point of view the frequent combination with nystagmus, lc«« commonly with strabismus, is interesting. This combination has also been mentioned by other observers (Ebert und Demroe), and seems to indicate that the root-nuclei of the

yinal accessory and of the upper spinal nerves supplying the

4 I

SPASMUS NUTANS.

195

afibcteJ muscles of the tLroat and neck, stand iu very close relation to those of tb© oculttr uen'es (oeulo-motoiias). A few cases affecting older patients give further confirmation of this relationship.

On 26tb March, 1879, a boy of 12 years was brought to the hoftpital, wbo since the second year of his life had bevn deaf and dumb, as the result of an atta-ck of cerebiNi-spiiial tutiungitis. Hib intelligence was unaffected, and he had developed a talent for drawing iu an eminent depiree. This boy had almotsit continuoiiH raovementa of the head, rotating towardn the left, combined with slight nodding and with permanent nyKtngrous — which increased to a remarkable degree whenuTer one attempted to fix his head. The general health wa^ii undisturhed ; tmd I was unable to form a conjecture as to the cauwe of these symptoms which externally corresponded entirely with Ihone of spasmus nutans, the more so as the boy did not come btwk. — Quite similar was the caae of a boy of 9 years, in whom diaturbutjcett of speech were also present, without any cause being discoverable. — Finally, I have observed in a boy of 10, otherwiBC healthy, an inclination of the head towards tho right, with rotatory moveraent8 occurring eyeiy few minutes, These were always combined with an up4nrning of the eyeballs, And had originated about U years heforo, aH the result of a fright, 'prolonged application of electricity and residence in the ward pro- duced good results, although not complete recovery.

We mast distinguish from tho reflex variety a much more ^lierious form of spasmus nutans, depending unquestiooahly on a tentral disease of the brain. The very first description given llnglish authors (Newnham and Will shire) related to cases, in which mental disturbances and epileptic fits were comhined with nodding movements, not only of the head hut of whole upper part of the body. These swaying movements >f the hody either occurred iu fits (at the rate of 50 — 100 per ^minute), or else they were more continuous, and in that case less severe. They invariably ended fatally; but, so far as I am aware, there are no reliable accounts of post-mortems. I have myself observed only one case of this nature, in which the morbid morements came on some days after a fall ou the occiput, and death suddenly followed; a post-mortem was unfortunately fused. ^ I may also mention here the not uncommon cases m which there occurs, in weak and imbecile children, a frequent falling forward of the upper part of the body,

» Cf, Hocbhalt, Jahrh. f, KinderkeiU., liii,, S, 99.

196

DIBEi.BBS OF THE NERVOUS STSTElf.

with a sprawling out of arms and a Bqainting of the eyes. Too will now Bee that all cases of spasmus nutans are not to be judged in the same way; and I shall have occasion » later on, to rofur to a third form which I have sometimes met with as ooe link in a chain of Bpastic symptoms which one is accastomed to group torjether under the name ** Chorea Magna."

It will be seen, from the cases given ahove, that the treat- ment of the reflex form must be purely expectant. If you wish to try the remedies usually recommended for conrulsions (p. 179) you may do so; but remember that they can promise no result till the source of the reflex irritation — which is usually dentition — is removed.

I will also mention in passing that I have frequently noticed more or less continuous swaying movements in the upper part of the body iu little children due to the excitement caused by mastarbation. These movements are of course voluntary, and must not be confused with the real spasmus nutans. The otber local spasmodic afl'ections which occur in children, whether of the muscles of the neck, extremities, or face (the latter especially occur refiexly in connection with eye- diseases), resorahle completely those in adults. In these cases also, the inliaence of dentition is not to be dismissed off-hand. Thus, in a child of a year and a half I observed, twice ninniufij, conjunctivitis palpebralis with very violent convulsive closure of both eyelida (the eyes were only opened in the dark); this took place eachi time during the eruption of a group of teeth, and lasted 2 — S^ weeks.

I may also be allowed to say a few words on another, Tery ibhiI spasmodic affection, because I have never yet met with it in adults. I refer to a kind of convulsive laughter, of which I have seen 3 cases, in which the reflex irritation started from the intestinal canal. The 2 first of these— which I have elsewhere described* — affected the children of two sisters.

Child of 4 weeks, on the breast, during the previoasH had moderate diarrlima^ Some days before had - movements of the iniiscles of the face and trunk, the child laughed loudly, to the nKJth*>r'»< grwit iiinrni. Thuj tit8 lasted about 5 miuutus, und ix;earred 3 or 4 tirnetf d«iily« Diirmg the internals tbciT was frequent violent Btr»iiiing, tM

^ mtr<ig% mr Kimdtfheilk,, X.K, ISeS, S. 6S.

CHOREA MINOR— ST. VITUS DANCE.

197

face was deeply flushed, and the child sohbed without any scream- ing. Small doaea of ipecac, and opium cured these symptoms in 7 liny 8.

Child of 18 days, on the breast. Constipation, extreme roRtleganeds, crying, drawing up the k^ga, tiirniiig up of the eye- balla, clenching of the hand^s, with loud laughtf r. Flatulent diBtensiim of the abdomen. After warm bathy. inunctions of oil, and a dose of castor^oil, copious motions took place. The attm:ks ceased entirely. They recurred ttix months after. Kecovery under the same treatment.

Child of iS months. Diarrlueu for about a week. At the same time.almf»t!t every night spasmodic contrHctiouH of the eyes and hands, AIho often during the day loud langliing, with "crowing** inspirations in the intervals between. When the diarrhoaa was stopped, the fitn of laughter eoa^sed, while the spas- modic contntctifniH still sometimes retuniod. Final recovei*y.

\.— Chorea Minor—SL Vitus* Dance.

Chorea is about the coimiionest of all the Uourtiaes afleetiiig children after the commencement of the second denti- tion, i,i\ from about the <Jth year to near piibert}^ Its occur- rence earlier than this is mocli less common ; still, I have myself seen several cases in children of 4 and 5, one even in a girl of 3, following rheumulisuK Adults are only exceptLonally affected (it being most eomnum in pregnant women) ; but into this I need not enter here. The number of girls affected exceeds that of hoys to a marked degree.

The symptoms of chorea are so peculiar that any one who has

seen them once will hardly confuse it with any other convulsive

condition. In very well marked cases w^e tind the whole of th©'

child's body in a state of constant restlessness and motion, re-

.minding one of the sprawling movements of a jointed doll, and,

ideed, looking not a little comical. As a rule, the extremitiea

\re most severely affected ; the arms and hands can scarcely be

tept still for a moment. They are continually performiDg

iprawling movements and wonderful contortions. The shoulders

re sometimes raised, sometimes sunk, the head drawn down to

le side, and more or less rotated. The facial muscles also

>articipate, the eyes are alternately shut and opened, the forehead

wrinkled, and (iuickly smoothed again. The corners of the

louth are twisted to one side or the other. The lower limba

are often still able to support and carr^* the body ; but in many

198

DISEASES OF THE NERTOUS STSTBM,

caBes> the sprawling and fihambling is so great tliat walking is more or less dif^cnlt, and tbo children often stumble and faU. In severe cases, indeed, not only walking and standing, bat even sittiDg is rendered impossible. If you ask the child to put out its tongue, it often does so with a jerk, and dmwf it in again in the same sudden way. But even when the children are able to keep it out for some seconds, you may still always notice distinct muscukr contractions in it. The speech also becomes stammering and indistinct, oTiing to the muscles of the tongue becoming aflected ; and in severe cases it is quite abolished. In such cases, in spite of the utmost endeavours — during which the muscular movemonts of the face and of the rest of the body are markedly increased — the children are un- able to pronounce a single word, and this is the sjmptom which usually makes the parents most anxious. The fear, so often expressed, that the child may remain dumb, is never justified, however; and you may with perfect confidence hold out the prospect of complete restoration of the speech. The reflexes, especially the patellar re 11 ex, I have generally found increased — in one girl of 8 years to such a de;(ree that even a slight tap on the tendon caused marked contractions of the quadriceps.

This description of the disease, which applies to a large number of the cases, is subject to many variations, both in degree and distribution of the convulsive movements. Very often the latter are not so severe as those I have described, remaining during the whole course of the disease comparatively weak> and only becoming more troublesome when the patients pass from a state of quiet into one of movement. Even in this slight degree of the disease all parts do not equally participate ; whole groups of muscles may remain completely unaflfected. From this very slight degree of the disease, up to its strongest develop* ment, there are a number of gradations in which you may observe an ever increasing severity and duration of the spasttr movements. Finally, in the most extreme form, their energy and persistence is so great tliat almost all the muscles, froBI head to foot, perform itn uninterrupted series of tlie mott grotesque movements, which scarcely leave the body at rest for a moment, and jerk it about in every directii»n — even Hgainal the corners of the bed-posts— causing bruiKea in many plaeei. I have seen patients covered with bruises all over, and hafo

CHOREA MINCE — ST. VITUS DANCE.

199

"all u aj

ven knoi\*n them to be pitched out of bed; aud I have fre- quently had to have the bed padded with thick cushions, in order to preveot more serious iujuries, lu one case a large abscess formed over the left shoulder-blade, and had to bo opened. Swallowing also may be rendered difficult, and in that e some of the food is rejected. In these very violent cases e muscles of the eye also become affected, so that the eye- alls acquire a rolling movement. On the other hand I have never been able distinctly to observe the altornato dilatation and contraction of the pupils mentioned by some authors'^ as coming on quite independently of the inUucnce of light aiifl ombined with diminished power of vision durinj:,' dilatation.

In many cases of chorea you lind the movements much more marked on one side of the body than the other, or the disease may only affect one side, while the other remains entirely un- affected (hemichorea). This limitation is either seen only at e beginninfj, or persists till the end of the disease. Still, a ort time ago I saw a boy of 14 whose extremities on the right ido were Tery severely affected during an attack of chorea last- g 0 weeks, while those on the left side did not show a trace of the disease. The nmscular bundles of the tongue, exhibit distinct movements on both sides, even in cases of hemichorea, and this is to bo explained by the numerous crossings of these bundles. The apprehensions usually aroused by the occurrence of convnlsions, or contractures on one side only (p. 166) need not — as far as my experience goes — be entertained in hemi- chorea, to which in general I can attach no more serious im- portance than to that occurring on both sides.

The movements of chorea, even in the most violent cases, are I hardly ever equally sustained, for they vary in intensity from ^kay to day, and from hour to hour. Often when we think there ^B8 a distinct improvement, the disease suddenly takes another Vlwd turn. Under all circumstances, any purposive move- ment tends to make the chorea worse; any attempt to write, io take hold of small articles, to raise the arms above the head, Ac, causes the choreic movements to increase considerably. Even looking hxedly at anything may have the same effect, as I have observed in one case^ which was distinguished by the fact

' Cftdei ilo Gfttai court, TuitO- cHni'tw Hft mnhuiim <lf Ven/anct, T. ii., p. 215 : Pftris. IS82.

200

DISEASES OF THE NERVOUS SYSTEM.

tbftt the CHiulur muscles were affected. These cbiidren «n% therefore, quite unfit for nil occupations re^juiring the use* uf tbeir fiofjers — writing, sewing, pluyiug the piano, &c, ; wlieu they attempt to write, the pen jerks about, splnttering the ink over tbe paper. In severe cases every attempt to speiik or to sit up causes most violent agp^ravation of the symptoms, ami even passive movements — such as the attempt to raise the children out of ibe horizontal position, kc. — may occasion ■ severe convulsive movements. Many are unable to eat win assistance, and have to be fed because they are tinable to hold the spoon lirmly, or can only bring it to the mouth in a round- about way, spilling the contents in the process. Every **cou- tageoufl " excitement — e.ff, laughing — ^at once produces a litely griuiaee (at any rute in the most severe forms of the diseiLse),^™ and ulso an increase of all the movemeuLs. Embarrassmen^^^ produces the same effect, and also the consciousness of being ^ observed ; although a few patients uuder those very cLrcumslauces have more control of the muscular restlessness than others. In almost every case, however, quiet sleep produces a com- plete cessation of the movements; even when very violent they cease then, and do not begin again until the child awakens. Only in a very few cases have I known them to persist daring sleep, and then they were but slight: the children threw them- selves restleHsly hither and tliiLher with slight sprawling move* ments. The conditions of these exceptional cases, however, are unknown to me, and they cannot be held to interfere with the general rule. It is most important that the sleep be quiet aad deep, for should it be disturbed the movements may certainly continue throughout, and even with great severity. In this we see a definite indication for treatment, namely, to procure quiet nights for the child, so as to arrest the movements at least for a number of hours. Fits of terror with a feeling of oppression, and a somewhat irregular action of the heart, which came on in a girl of 11 years daring the first sleep (although the heart appeared normal) lasted half an hour, and aggravated the choreic movements, but did not delay complete recovery. I have always been struck by the fact that in spite of the violent movemf^nt^ going on nil day long, there was no appearance of the child's bt?iuj fatigued. If you just try to imagine such violent movemetiM being earned on for bo long volnntarily, you will at once mM

CHOREA MINOR — 8T. VITUS DAJ^CE.

201

that the tLing, if not altogether impossible, would certainly produce the most extreme exbaustiou. lu a few sevc^re cases where we were able to take temperature*ohservations (there was always a risk of the thermometer beiDf; broken), we were unable

I;to itjakc out any increase of temperature, in spite of the pro- ionj^ed violence of the attack, L These are the main features in the cliuical pit'ture of chorea. IkU other Kjniptoms which have been described^ I re^^ard as neither characteriBtic nor well-ebtabUshed. Amoug these we liave e.fi. the tenderness of the spinouB processes of certain

Ijcervical vertebne, especial!}' of the upper onea ; or again, the jpossibility of int-reasiu*j the morbid movements by pressure on [Certain nerves (the brachial plexus or the crural nerve). Apart 4 from the choreic niovenaeiits, the general health of the chibiren is exceileut, their fuiictiouB are in good order, and altlnjuf^h some of them appear pale and delicate, this is by no means either a constaut or necessary feature. Sensory disturbances ,> almost never occur. Two cases i girls of 11 and 1*2) in whirh ^nlong with hemichorea I observed anaesthesia and analgesia ^Respectively of one side of the body and alteration of the psychical condition, had such au appeantucL' of hynteria that I was inclined to regard them not as ordinary chorea, but rather the form described by Trousseau as *• chort-o hysteriquo** — which only resembles chorea^ in some of its symplonis. The children sometimes complain of weakness of one of the arms, but I have never seen complete paralysis. They wt^ve almost always jj^able to make any movements I wisbed^ at least to a certain |H|ilegree. In a very few cases there was more marked paresis, ^■especially of one arm, and this in one case was so considerable that for da\8 the child was obliged to lift the paretic limb with the other hand. In another child tbe right arm could for weeks ouly be raised to the horizontal position with difficulty, and the pressure of the right band was feeble, although tbe move- ments on the right side of the ipody were less marked than those on the left* The cause of this jtaresis is still unknown, and its occurrence is very rare ; and although mothers often describe the child's illness as '* paralysis," this is only because they are

For the first of my ca^cfl, v. Ktin. Wf>ch*n»chr„ 18S3, S.802; iii»o Oppenhoim and TbomBcn lArchif/. Psjuchintrie^ Bd. iv., H. 3) havo seen chorea oomo on in boy nfter rioltmt ment&l excitement^ witli oompk*to homiiuuBsthosift.

201J

DISEASES OF THE NEBVOUB SYSTEM.

impressed by the iDability to move the hands and arms in the ordinary way. On the other harnl, I have occasionallr fooEd the mental disposition altered ; the children were irritabld, peevish and passionate, but only very rarely does it reach tfa^ point of complete derangement of the intellect, and when it does, this nsually takes the form of ecstatic dcliriom, I remember only one well-marked case of this kind, iu a girl of 10 years, who had been snilering for many weeks from a moderately severe attack of chorea, and who had periods of ecstasy during which she assumed the rdU of a '* princess/' demanded till sorts of services from those around her, and harangued them on the subject. This abnormal menial con- dition disappeared along with the chorea. A fjirl of 8 ye«r« who took ehoreiL in the conrse of an attack of acute rhomoatism. became delirious also, lost her senses, cried and screame*!. Still, these symptoms occur — as is well known — in exceptional cases of rheumatism even when there ia no chorea. Loss of memory, mental hebetude, and local ansesthesia, of which some authors speak, I have never myself observed.

The course of the disease is sltnost always very protnict<Hl, lasting for many weeks, oftt'U for several months. As a rule, its first development is described as being very gradual and scarcely noticeable. Unsteady movements of one hand, or dis- tortions of the facial muscles are the lirst things that attract uttention ; and, not unfrequenlly school children are punished by ifpxoriint teachers for these, and for blotting their copy-books. One poor girl came to my ward with streaks of blood on her haods, caused by blows with a ruler. The severity and extent of the movements gradually increases, until after 4 or 5 wceka they reach their hij[jhest point and then they gradually diminish ; 80 that some months pass before recovery is complete. In rare cases the disease lusts for 9 months or longer (eitber primary or as a relapse), getting now better, now worse, but presenting no complication whatever. As a rule, cases which develop slowly and are of moderate severity have a stronger tendency to bc'come chronic, while I have occasionally seen some which commenced with violent symptoms and presented the moat extreme form of the disease, end favourably within 6 weeks. Cases lasting '* for years *' always rouse suspicion that there is more the matter with them ihnn ordiunry chorea minor.

^

CHOREA MINOR — ST. VITUS DANCE.

I have met with two caeos af this kind ; oiiu {December, 1880) was that of a boy of 7, who was said to have become affected in th« Ijeginning of his 2iid year; the mthor Iniy was 8 years old, and the disease was said to have lawtcd four yearj*, and to have ariecn after an attack of tj^phoid. Tlie disease differs from ordinary chorea in its commencinp at such a very early rige» and eapcLMally in the circumsttuice that attempts at co-ordination (which in ordinary chorea aggravate the muHcular roBtlcw8ni.''S8), in Iwith of these cases arrested the movements. The aame thing happened in the cases of hysterical chorea which I ftUiidedto fp. 201).

Chorea ends fatally only in the very rare eases wliicb have an extremely violent course; and death usually takes place in A state of coma, which sets in along with delirium and most violent convulsive movements. I have only seen this termina- tion in three cases out of all the chorea patients wIjo have come under my care, and in one of these the disease was complicated with incompetence of the mitral valve.

An ana?mic" girl of 10 jeara, about whom 1 wa^i consulte<i on 6th May, 1876, hud wuffured fur 10 weeks from an att^ick of chorea which was increasing in severity. It had got worse during the ]»re- vioiiH 4 weekH eBpeeially. Violent continuoua movements, necessi- tating conatant confinement to bed. Complete cessation during alctep. For alKJut '^ weeks* mental diilneBK, great upathy, inability' to Hit upright ; when attemy»ting to do so. the npjier part of the l>ody 8wayed hither and thither. Failure of Kight and hearing, puralytir dysphagia, ao that ahe had to be fed with nn cBsophagcal tube. Clioreic movementri during th<' hifit few days ntill persisting to a moderate extent. PnUe extremely small — 50-60 in the minute; notlnng abnormal dij*covered in the heari. Constipation, extreme emaciation. All treatment unsuccessful. Death a week after, in a state of r<ill:ip!<c. Post-mortem refused.

The post-mortem was also unfortunately refused in hoth the

►ther cases. Still I may remark that the changes found in the

^central organs in the cases of chorea wliich have ended fatally,

lave heen in no respect characteristic. The microscopic

changes recently described in the great ganglion cells, in the

spinal cord J and peripheral nerves, stand in need of confirmation.*

»I have never yet met with cases of incurable chorea — in ' Thero in an intcrojRting oafte doaeribed by Nanwerck (*' Uobor Chorea": Jfstia, lStK*>), in which mieroscopio iBflnramfttofy aroftti (in the form of pori- [^.TMcnlAr o^oamulaticins) of «])mU Fonod celb) weT« found in th<^ medulla oblonj|{uta Wtul in ihff whit« matter of the corehram, Ukewi»e nmall Im-morrhAguH and degvae- ration of novae of tho n<»rvo ftbres in the ft^inal cord.

Wi\ DISEASES OF TH£ KBETOUS STSTBlt. V

confine the name '* cbprea *' to the definite neurosis wbich, with few exeeptious, is peculiar to childhood ; and in other cases — where similar movements may arise under various circumstances — to speak of such as " chorea-like." Among these nndoabtedly are certain affections of the central organs, especially of tbg brain. In a few cases of cerebral tuberculosis I have observafl along with hemiplegia, or with partial paralysis of one arm, almost continuous automatic movements very like those of chorea in the affected limb. To the same category belongs the ** post-paralytic " hemichorea in hemiplegic and anssthetic limbS) the scat of which is placed by Charcot in the corona radiata (?); likewise the condition of '^athetosis,'* which is allied to choreic movements. Occasionally also cases haiH been observed, in adults (much less commonly in children), OT chronic chorea extending? over many years; in which after death various changes were found in the brain and spinal cord, ejj. sclerosis in the cervical cord in a girl of 14 years who had suffered from congenital chorea (Eisenlohr^).

In the vast majority of cases of chorea in children we mad exclude any material affection of the central organs, as indeeo" might be expected from the almost invariably favourable termi- nation of the disease. One must, with Nauwcrck (see p. *203, nott.')t aBsume that the inflammatory changes in the central nervous system which he found may be recovered from, without any traces worth mentioning being left behind. Without deny- ing the possibility of this assumption, I still prefer to regard chorea as always a ** neurosis," probably arising from an irritated condition of the co-ordination-centres. The causes of this condition of irritation certainly elude our observation in many cases. Very often, in spite of the most careful search, you will not be able to find any cause. A few cases in whiol the father and the aunt have suffered repeatedly from chorea not seem to me conclusive. As a rule the children are healthy in other respects, and the composition of the blood seems normi In many cases, however, we find ana? mi a, with pallor of skin and mucous membranes, venous bruits in the neck» And general weakness. Fright or fear (psychical improsnouB) hm frequently been the occasion of chorea developing.

• Cmtraiii,/, Sfn^enhtiU,^ IB&),

CHORKi. MINOR— ST. VlTVti DANCB.

207

A girl of 12 years had been bo torriiied by it dog leaping upon her that for two or three dny;j> Khc wjix almost speechless. Chrjrca sr-t hi immediatHly after. — ^In u girl »if 11 ywirrt it occurred after ii frif^ht LiaiistKl by a straiiije man foiuiti^ into the houiie.— A girl ol' 12 years t<^ik chorea after liathinp: in the sea for thr tirKt tirne. when flhe had beeij nrncb frightened and bad struggled much. — A jyirl of 10 years, who, while sittinp; in a eloaet was exceedingly frightened by a boy flinging open the door» showed the first signs of chorea next morning, — Another girl, suifering from s])inal caries, was very much terrified by being suspended in the prmiess of applying a Sayre*8 jm-ket, and took chorea that evening. — In a girl of 5 years the first movements appeared on the day after the Sedan holiday, during which shr had been very much frightened by the loud reports of the cannon. I have frequently seeTi the disease come on after a blow or a fall, and in these cases attribute much more importance to the fright than to the trifling injury. Mental over-exertion at school I have never been able to ascertain with certainty as a cause. It is much more likely to bo due t«i dread of the teatsher or fear of threatened puninhment.

Mast certainly, however, rhenmatism in obo of its varioun 'forms moat be regarded as one of the commonest causes of chorea. The observation on tbia subject published by French aud Eoghsli writers (Bouteille, See, Hughes, Bright and others) did not at first receive from ns the attention tbey desen^ed, and we have only gradually loarncd to estimate their value. In 184G, lBi>l and 1868,^ I published a number of cases of this rheumatic

k chorea myself^ and since that time I have had abundant oppor- tunity, both in hospital and private practice, of observing its peqnent occurrence. Roger's* work especially contains abun- flant material. It is most frequently during the subsidence of, or convalescence from, acute rheumatism that chorea levelopes ; and I should advise you always to be prepared for the lility of its onset. Very rarely, indeed, I have observril jborea during the most acute stage of the polyarthritis ; aiul leii the most violent pain is caused by the continuous move- lents of the affected joints* The children cry and scream aiul fet into a state of the utmost eitci I eraent. Occasionally we observe an alternation of the two afToctions, as in a case of Roger's where dx attacks of acute rheurnatiijm and five of chorea were counteil.

• Botiiborir and Henoch. KUnifchr KrffebnUtf,, S, 20.— Alao their KlUi/nr/tt fnkmekmmu^ wfirf B^oiwhtunfftn, H, tiO.— Henoob, Beitrtlge sur KmJ^thtVk,^

f„ S. 105. « Arch, g^ de ifelrf., 18«6. Deo., et seq.

U08

DISEASES OF THE KEBVOUS 8T8TE3I.

Bat algo apparently alight rheumatic conditions may hs followed by chorea, wandering pains with slight swelling of single joints lasting only a few days and scarcely accompanied by any fever, or even by simple pains in the back, calves, or Tarious joints without either swelling or fever. I have frequently noticed that the reappearance of such rheumatic conditions during the coarse of chorea has aggravated the movements although Uw^y were in courne of subsiding. Cases even occur in which a quite limited rheumatio affection, e,(j. torticollis, is followed by chores. Id one boy of 14, with rigbi hemichorea, the preceding pains and swelling had been entirely confined to the joints of the hands and feet on the right side ; but this is by no means always the case* Less commonly, chorea appears first, and rheumatism only sets in later; as in one of the cases mentioned to illustrate relapses (p. 204), where an attack of acute rheumatism ydih endocarditis came on for the first time after the foarth attack of chorea. I have observed the same thing in the following cases : —

A girl ol 12, who took fhoron when in perfect health. Had repeated painful swollitigM of the joiiitB of the feet «nd tiuuds and vague pains ill the limba throughout its course, which laatinl 3 months.

A girl of 1*2, admitted into the ward with chorea, 18th December, 1872, waa discharged cured iu the begiijnisig of February. Thpro was no trace of rheumatism whatever, and the heart was found lo bo perfectly normal. In November. 1875, she had an attack of acute rheumatism, followed in December by a violent relapse of the chorea* When examined in the polyclinic, incompetence of the mitral valve was discovered.

In ft V»oy of 10 years, admitted with chorea in October, 1885» who had never formerly suffered from rhcumatinm, there occnrred, at the beginning of hia i^rd week in tlie hospital, {minful swellitigs of the joints of both feet, accompanied hj moderate fever (1015' P F.)t to which was soon added a systoUc mitral murmur.

You will see from these cases that the chorea may be the first expression of the rheumatic affection, and that it readily recurs if such an affection developes in a child who has previously bad chorea. That in these circumBlancos we may often find y a I v n 1 ar affection of the heart, often of the mitral, leas frequently of the aortic vaWes^ is easily explained by the well-known conziectioo between rheumatism and the endocardium. I therefore conaider it

OHCmEA MINOR— ST. VITTJB' DANOB.

209

HT duty in every case of chorea to examme the heart carefully ; Bid I have often enough found valvular disease and its resnltB, Blich had not been revealed by auy subjective eymptom — in no ■be by palpitation. I would especially draw attention to the Bot that we must guard againat mistaking ansemic for organic eardiac murmurs, since in such cases we very often have to do ¥rith anaemic children. When, however, it is maintained that B. such cases chorea is always the result of the heart- Tffection^ — arising either reflexly or from embolic processes occurring in the great cerebral ganglia — I hold this to be quite erroneous; because I have frequently known cases of chorea Si^eumatica in which the heart was absolutely una fife cted. B short time ago I saw a girl of 14 who within live years had Bd two attacks of acute rhenmntism followed by chorea, but ^hose heart showed not the slightest abnormality. Experience shows, moreover, that where there is valvular disease, and the relatives declare that there has Iveen no rheumatic affection, it has often really been overlooked owing to its trifling nature. It is also conceivable that chorea may run its course as the expression of rheumatism, with endocarditis, and without the occurrence of pains or joioi*swellings (Bo tret, See, Roger), In this way we may explain the undeniable cases in which a murmur has hen found in chorea without a history' of past rheumatism — ^art from the fact that valvular disease may be quite accidental, or even congenital. The embolic processes in the corpus stria- tum and its neighbourhood would certainly have quite other results, and would hardly end so quickly in complete recovery as is seen in almost all such cases of chorea — as every physician who has many children under his treatment will acknowledge. Therefore, in my opinion, the heart-affoction has nothing to do with chorea, but both are due to the same cause — rheu- matism— which appears to act in an unexplained way on the co-ordinating centres.

Chorea also occurs much more rarely as a sequela of acute infectious diseases. Thus I have seen it in two girls a few weeks after measles, in an ansemic boy of 8 abont a fortnight Bier recovery from diphtheria, and in four other children in ^pnnection with scarlet fever. As a general rule, however, Bhold (in opposition to Bouchut) that the occurrence of chorea B & sequela of scarlet fever is rare, and I have never been able B \^

210

DI8E1SES OF THE NBBV0U8 STBTSV.

to confirm hiB Btatoment that under tbese circumstances chorea occaflionally only lasts 6 — 8 hours. Two of my cases accom- panied Bcarlet fever, and were therefore not seqaelie. In a girl of 7 who had already had chorea once, it recurred daring the ernpiive stage of scarlet fever ; while in the other case thnv

were important complications,

*

On 2iid February, 1876, 1 was con suited about a boy of 3 j«an, who had suffered durinjoj the first weeks of scarlet fever from painful Hwclliugs uf the joints of the feet, ktiee£« and manj of Ibe fingers. A few days afterwards severe chorea developed, whicli bad lasted for l\ weeks when I saw the child. On eramination w« found a loud ayfltolic murmur at the apex, very violent ttction of the heart, and high temperature, rising towards evening* At end of 3rd week, haemorrhngic nephritis, ending fatally from ^demauf the lungw- The boy had never before suffered from choraa, and his heart had been quite normal.

This case might support the view of those who regard endo- carditis as itself a cause of chorea, were it not that chorea, as we have just seen, occurs also during and after scarlet fever without any heart-diseaee. The synovitis which has also been observed in other similar cases * is certainly significant whether we regard it as a condition of reflex irritation, or as one of a Beries of pycemic symptoms which may result in "chorea-like" movements (p. 205),

I have never yet met with any case of chorea in a child which was caused by reflex irritation, and which could therefore be placed alongside of chorea gravidarum. Irritation from wormSi or in connection with the genital organs, is much more frequently assumed as a cause than the facts warrant ; at least, I have never yet succeeded in curing chorea by anthelminthics, even although worms were expelled by their use; nor by an operation for phimosis.

How do intercurrent diseases affect chorea? This ques- tion has been answered in various ways, and the following cases prove that nothing definite can really be said on the subject

Boy of 9, admitted 27th January, 1873, with rhoroa of unknown duration. UcAVi normal but pul«e irregular aod intrf in Ittent. On 6th February an attack of indigestion, witli colic, high fever

' Litton, *'B«iirigo Kor Afitiolo^ ddr Chorw xL, S. H.

Cbarttc^AiuxnJffn, .<^

CHOBEA UIKOB — 8T. VITUB DAHCB.

211

(1058° F.). An emetic. Next day, T. 100° P., bat chorea very severe. During the nest few days acute pleurisy developed on the left side. On 10th February eoneiderable decrease in the chrjreic movements. Pulse alwaya hIow and irregiilsir. Oil 2nd Miirch chorea almost quite gone. A rebipse dating from 17th May. *ubo always t>8, somewhat irregular. Pleuritic exudation almoit ^entirely re-abaorhed. Recovery after a fortnight.

Boy of 13 (10th February, 1873). Right-sided chorea for last 8 daya without kuown t-AU-se. No rheumatism, heart normal ; altogether quita healthy. In apite of the most approved remedies, the disease lasted till the end of May, when it began to subside. On Isfe June, dislocation of the Bhoulder-joint from a fall on the elbow- Immodiately after its reduction— which was very painful — the chorea wan found to have completely and permanently disappeared. In tlie enaumg autumn, acute rheumatism, with endocarditis, but without any recurrence of the chorea.

Boy of 7 years treated for chorea in the hospital. Systolic murmur in the mitral area. An acuta tonsillitis with temp. 104° F, had no intinence whatever on the chorea.

Girl of 10 treated for ehorea in the hospital (also tubercular). Neither an inter-current dipthcritic sore throat (temp. 102'9^ — 104^ F.) nor an attack of measles ensuing had any influence whatever on the chorea. — I hiive observed the same in a girl who- took scarlet fever and brfmrho-pneumunia during an attack of chorea (T. 104'^) ; indeed, iu one girl of 11 the movements increased markedly in severity when the scarlet-fever rash appeared.

You see, then, that febrile affections certainly do not always cQt short the disease as eome maintain. The rapid diaappear- ance after the dislocation is very remarkable, but you must re- member that the chorea had already lasted four months and was in process of subsiding, so that in all probability it would have disappeared about this time spontaneously. This natural cure of the disease after an average duration of three months is another source of difficulty in judging of the treatment employed, and nders desirable the strictest criticism of the mimerous remedies ;liat have been recommended. At a certain stage all these appear to be of use, because the disease is in process of spontaneous re. You will therefore consider it excuBable if I do not dis- ss further remedies to which I attach ahsolntely no value ; and unfortunately I must answer entirely in the negative the ques- n whether there is a remedy which is certain to cut short e course of chorea. I should certainly give the first place to rsenic* which^ — on Romberg's recommendation — I have used ever since I began practice. But even this remedy has no con-

212

DISBA6ES OF THE NEBYOUS BTBTBll.

slant action. lo spite of its prolonged use, I hare freqaonilj seen tbe Jiseaso persist for months, altbougU in the majoritjof cases a moderating influence on tlie violence of the mevemeots was soon noticeable ; and many cases treated w ith tUia drug ended favourably in a comparatively short time (5 — 6 iireeks). Ac- cording to my experience, arsenic suits all cases of choTWi— rlienmatic as well as any other — ^unless it u conLraindicaled by derangement of the stomach or bowels. It has appetu-od to me to be especially useful in anaemic patients. I always Drdtfr ^ or 3 drops of Fowler's solution (Form. 11) thrice daily — aboat an hour after breakfast, dinner and supper— and when it ttU giren thus, I have very seldom been callej npon to discoutiaoe the medicine owing to nausea and diarrh4Pa. Most children c«o bear arsenic very well for many weeks ; and I therefore look npoa all the apprehensions luul warnings which have been expreaeed, as old wives' stories invented by the ignorant. Neither have I ever seen zoster frora the use of this drug.* I have no ex- perience of the hypodtTQjic atlmiiiislration of arse.uio which some recommend.- I should use it however in cases where iba stomach was unable to bear the drug. The addition of opium (about n^w of the tiucture to the mixture recommended al>ovc) has appeared to me to increase the action of the arsenic in some very violent cases. In oases where Fowler*8 solution has no effect I have repeatedly seen an unexpectedly rapid action from the use of arsenious acid (gr. j^^ to gr. A dliily) in the form of pills (Form. 11a).

Should the violent movements continue .through Uie uiglit owing to sleeplessness, I recommend you to ^vo eblorftl hydrate (gis. viiss.— grs. xxiii). To some children snffeTiikg from a very violent form of the disease, we even gave this doM two or three times a day, and this soon induced sleep and consequent diminution of the movements. In a girl of 10 yrarg, however, an eruption very like that of Fcarlet fever took place OTer a large part of the body, as^thc reault of the chloral.

' Bokal, Jahrb.f, KinH^rhfitl., Ud. Xii,. S. 411.— Guiiittt, I'/ac/. xxiiL. S* 21*.

' Garin, Arrhiv/, J(indtrhtiU:.,i., S.335. Iiijo4'tio!i of 1 :, <lri>r,* of FowllirV •olution oTery 3 or 4 il»ya or eTcn daily. Beocnt < utw lnfir» ciu«d

after about 18 injootioos.— Frab wald, Juhrh./^ a g \2. rtn^am^

ttieiid« lol. Fowl., aq. dout., ec^na) partR—l diviMon of nyrniKM U\ t.« li^

iooreaadd dtuly by one diviBicm tip to B or 10 dirUiona ; tlipu Ut lu i la

tbtiame way.

CHOUEA AllXOR — 8T. VITUS DAKCB,

213

Chloral is ODiy suitable under these circumstances as u first step in the trealmeiH, and must give place to arsenic aft^r a certain amoant of quietnesB and sleep have l>eeu obtained.

The purgative treatment, so popular formerly, as well as tli©

ase of tarUir emetic have ail fallen more or less into disuse,

rhich is certainly justitied, coDhiderinf; the delicate anaemic

inetitolion of many choreic children. Where, however, tiiis

contra-indication is not present, and the patients bick nt*ithi'f

blood nor fat, the use of purgatives has seemed to me

advantageous. In such cases I begin with two or three days

^^barging, and also later on I stop tlie arsenic every w^eek for 24

^Konrs, and give instead 1 or l^ spoouiuls of ol. riciui or infus.

^HenuzB. From the many other remedies recommended you need

^Kot, as far as my experience shows, expect atiy good results ; nor

P^^et from large doses of bromide of potash or strychnia, which

(following Trousseau's example) I have repeatedly tried both

■^nternally and hypodermically Cgr. V;t — s^s)-

^V Although tbe action of the latter in one case surprised me>

I was soon convinced that its success was only apparent and

^Bceidental. I can say just as litth.^ in favour of ether spray

^Hp tbe spinal column, sulphur baths (|iss — ^iiiss to the bath)

^Br the constant current, of which others speak in very high

»nDfi.

Mental exertion is to be avoided if possible while the chorea

lasts ; school attendance must therefore be discontinued, the

ore so because their scboolfellows are very apt to mock choreic

dren. I have never known of the disease being transmitted

er children, but some have asserted that this may occur —

ally in schools and institutions— owing to mimicry. In

cases you must keep the patient in his bed, and have it

padded with cushions to avoid bruises* The more speedy recovery

hospital as compared with private practice is perhaps due to

e children being kept constantly in bed for a longer time.

A few new I'onK^dieB 1 hAVC hod no occaaion to trj'-^od. Mlioyl., enerinei, roncyajuitje Mvd ftntipyrin, A trial of e serine (ph;aoetiginiD6 )* wliiah wo ie in K girl of 12, caused tho moat uupleftMOUit symptomH of poiBomcff (coUupB^, )wiLin|jr, profane Kweatinff. imporcoptible ptdne) within 15 minutce, although the *L' yiivLif small <KT. ill h3'p''^<'"oi<^*Hy) **i<i ^^ child only »lowly recovered from liH L'onditioii andcr the n»e of 8timuljuit«. A second trial, in a joung-erhoy, hatl ximilttr li^lthough not quite bo aerere resnlt.— An ti pyrin (np to jfT«. ilvi- in io lUy) hM very recently been rtrongly praii^d by Le^rour and Dupn* roCTM,.Mnn».1888>.

214

DISEASES OF THE KERV0U8 kSYSTKH.

We may further recommend nourisbiDg diet, pure air, cold fric- tions in the morning (as long as the children do not resent it ; if they do, warm baths are better), suitable gymnastics and, finally, a preparation of iron (Form. V2).

This seems the moat suitable place to mention a .condition ,which is often confonnded with eliorea by medical men and *^e8cribed aa^ such, but which— apart from its much greater rarity — ia eBsentially separated from it by its symptoms. I have already elsewhere described it as ** chorea electrica/*' und Hennig* also has described similar cases under this name.' In this form yon never find those hurried co-ordinated movementSi aggravated by purposive muscular action, which form the very essence of chorea. The patients remain perfectly quiet ; but from time to time *' lightning " spasms occur — especially in the muscles of neck and shoulders, but also in other parts — resembling very closely those caused by a weak faradic current. As a rule they are only slight, and are gone so rapidly that some- times very careful observation is necessary to see them at all* In addition to the four cases given in the above-mentioned work, i liave since met with several others quite similar. Alt4->gelher 1 imvc had more than a dozen such cases, both in boys and girls, all between 9 and 15. When the patients are stripped, one can readily see and feel the rapid spasmodic contractions of the individual muscles ; and when the tongue is put out, it shows in some cases vermicular movements similar to those in ordiuary chorea. Each individual contraction lasts but a moment, but the intervals vary greatly. Occasionally the next contraction foUows in a few seconds ; in other cases after several minutes, especially if the patient's attention is otherwise taken up. The speech is unaflfected, and the ability to write, sew, Sec, is UDiin* paired, except when these actions are momentarily interrupted by the spasmodic movements of the arm. One half of the body is occasionally more severely affected than the other. In 0Q4> girl of 16 years, the con tractions were limited to the right aide of the body and fu.ce, and they were so often repeated that they considerably interfered with her WTiting or doing work with her

' Lfhrlt. d, Krafiik. tk* Kindr*.. 3 Aufl.. itUH, S. »13. * Trouas^ftiu itiimi^ut S^c^ ii^ »|i|,»«m[ to hikT« mdlcatod ftJuJofoat )d« 4«»oription of ** Tie no& doaloarvus. '

i

I

I

CHOKED UIKOR— ST. TITV8 DANCE.

215

right hand. Moreover, tho power of Biovemeiit remained perfectly normal, and there were no other morbid appearances whatever. Only in one of the cases did the movements persist luring sleep, hnt they were weaker and leas frequent. In all the other cases tht^y complclelj ceased as in chorea. In a hoy of 1 1 there were spasmodic conlractions of the head, by which the face was turned upward and to the left. These were sometimes ac- companied by winking of both eyes and twitching of the left ear. It turned out that this boy had suffered for some weeks, a year previously, from spasmodic winking of both eyes. In one case the occipito-frontalis muscle was also affected hy '' lightning " contractions. In a boy of 10 years, whose whole body was convulsed by these spasmodic contraciions while hla head was jilmost quite unaffected, there occurred along with each shock a spasmodic inspiration accompanied by a gurgling noise, indicating implication of the diaphragm, perhaps also of the glottis. Generally the speech was unimpaired, or at moat only interrupted Mi the moment of the shock.

According to the history in one case, it appeared that the child id had epileptic convulsions until two years before, and the spasmodic twilcbings had set in when these disappeared. In two other cases, tearing pains in the limbs and acute articular rheu- matism had preceded ; and in one girl of 14, violent screaming fits. A girl of 11 became affected alter a fall on the head when she was walking on stilts. In two cases the cause was said to have been fright* from the violent slamming of a door, and from seeing a person hanged. Frequently, however, I was unable to find any noteworthy points in the history, and therefore was at

(first tempted to regard it as altogether the result of a habit, I believe that these contractions also — like chorea and epilepsy — sre merely different manifestations of the various kinds of direct or retlcx irritation in the nerve centres. Thus it may happen that in rare cases very surprising combinations of eonvnlsive symptoms appear, generally accompanied by blepharo- spasm (continuous winking movements).

On 6th March. 1879, a boy of 10 was brought to oay polyclinic, who had suffered from the foUowiiig symptomg since he was 3 years old— that is, for 7 years. The left side of the body, capec^ially tho wm, showed almost inceasaiit cht>rca-liko movements; bttt the arm alao from time to time took fits of spasmodic con-

21 r>

DISEASES OF THE KEBT0U8 STSTEH.

traction just as occurs in an epileptic attack. The left side of the face had also previously been affected ; but tliis was no lonj^r tho case; and thii lower cstreraity had also become quieter. Complete cessation during sleep* He could take hold of nothing with the fingers of the left hand, but he could retain anythtn;; with them. Intelligence and general health [perfectly nomiik). Electricity was i^aid to have formerly had a good effect. Did n«j* return for treatment.

Thus we find Lore a combination of roal choreic movements with clooic convulsions, the pathogenesis of which is utterly obscure. Unfortunately this was the rule iii the cases of cboren olectrica that I have observed. The treatment conld ibeti** fore only be empirical and not very hopeful. Onk in one case have I seen a markedly good effect from bromide of potash; it also succeeded in a relaps^e which took place as the result of a feverish gastric attack. In none of the other cases did I get any good result from this or from any other remedy. Arsenic, atropine, injeotiouB of strychnia, aild extract of phygostigma, all remained unsuccessful. I should most strongly recommend the continuous use of the galvanio current, as in a few cftsea thiB certainly had a favourable effect. In two cases it even brought about corapleto recovery ; but for the permanence of the cure I cannot answer.^

VI. — The Hysterical Affections of Chihlrtn.

I

You will have learned from the study of disease in adults thul the remarkable nervous symptoms which we are wont to group together under tbo name '* hysteria," do not always deservi^ thifl designation, which implies a connection with the female genital system. You know that in many hysterical women even the most careful examination of the genital organs revruls no abnormality, and that quite similar symptoms are obscnredi though much less commonly, in the male sex. You will now see that even childhood is by no means exempt from them.^ I

' C&dct do O ARaioourt (/. c, p. 256) praiB«>a the action of deotricity <indiic««i ctuTGi&t), while Bergeron 8aj« thati he ha» seen good rcsoit^ from iho u<«< <>f antini, tart. (gr. | given at onc«l, *,«., an ematio. Be r land, Tkhit : — TordeoB, Journai mid. tU Bruxelle*, 1880— Bom a k [Bert, ^/la. il 1881, No. 21—23) enrod a caac that I obaerred by g»]vanio treatment oantma«ii for 9 montba.

' (y, Smidt, ** Ueber das Yorkonunen too Hyutfirie bei Kindflrn/* Mu^. t.

TUE UYBTERICAIi AFFECTIONS OF CHILDREN.

217

^,

do not know what more suitable name could be applied to the somewhat remarkable phenomena we have here to deal with, ami my only excuse is that we also know next to nothing about the real hysteria in adults, that all theoriea advanced on the Bubject break down, and that one must he cooteut to include under the le name a combination of the most varied neurotic symptoms -motor, sensory, payehical, and even trophic — which may form contmviaUy chanf^iDg combinations, and alternate with one another. The starLiuf^ point of these symptoms, and the nature of their essential connection with one another, remains entirely unknown to us, and the favourite supposition — of increased reflex excitability of a " nervous " disposition^ — ia not well calculated to fill up the gaps in onr knowledge.

We find quite the same in children also, boys as well m girls — although the latter are somewhat more frequently affected, t am convinced that the following desciipLion will be attacked on many sides, because it includes in one group a number of morbid conditions which are usually treated as differ- ing from one another — such as chorea magna, catalepsy, voice- |8pasm and many others. I grant that I may be wrong in this, but consider that my view is favoured by the circumstiiuce that in practice we not uncommonly find transitions from one form to another and combinations of tbem, so that one may readily ^^be at a loss what name to apply to any given case. The ex- l^fcerienced practitioner will understand this and appreciate it, ^Eind set more value upon this fact than on any objections ^Bldvanced by mere theorists. Considering the great diversity of ^Bbe symptoms and their numerons variations, even in one and ^^■^0 same patient, it seems to me quite impossible to sketch a ^Bkral compreheusive picture of the ** hysterical' * conditions of children. I can, therefore, only endeavour to give you in ^■onthne certain classes of cases from my own practice, which ^nllastrate as far as possible the diflerent forms. ^^■Abe first class comprises those cases in which the psychical ^T^optoms predominate' — complete cessation of conscious- ness, h all uci nations and delirium, pavor nocturnus and diuruus. To this category belong almost all the conditions described

riiMficrAriV^v, XT., 1880, l.—Vengniez "De rhystorio chea lea enfantfl," Tkise: n», ISSTf— ft work from tho school of Charcot, Tory rich in clinical tnatenal. >Biee«nf9ld« "'Ueber Uyeterie bei Kindem," Dk*.; Kiel, 1837.

S18

DI8EABEB OF THE NEBVuUS ST8TBM.

under the name catalepsy or eclipsis. CoB8cionsne«8 is suddeulf lost, or at least considerublj weakeDed, and the children remaio sitting or staiidiag with a siariDg look, or with ap-tumed eye- halla, and *;[rudua]ly gink on the floor if not caoght hold of. More rarely they are still able to go about in a semi-conscious cod- dition as in a dream, sometimes talking to themseWes tinin- telHgibly. A little patient of this kind fell on the street and went right through the window of a cellar. In* other cases the eyes are closed^ the expression of the face un- altered and the colour pale ; the normal condition of the poise, however, and of the heart's impulse, and the unaltered tem- perature, distiiiguish the condition from syncope. After a few seconds — or at most, a few minutes — it is over, and the child feelrt perfectly well. Many are quite unaware that tlicy have had such an attack, others remember the begioning of it, and others again only parLially lose consciousneBS, so that althouf^ unable to speak, they see and hear everything that takes place around them as if half asleep. After the attack they generaDy on with the employment in which they have been interrapt^d, «s if nothing had liappeneJ. Only exceptionally have I found -during the attack that exaggeration of the muscular lone, which in the catalepsy of adults is known as 'Mlexibilitas cerea** of the limbs — in wLich they remain in whatever position they aro* placed. The attacks almost always occur very irregularly, some- times five, six, or even more times a day, at other times only €very few days or weeks, without any definite cause being dis- coverable. The trouhiesome thing for the physician is that he can never be absolutely sure that those wiD not degenerate into epileptic attacks; hut this does not take place aB a rule. Although in the hospital and polyclinic we cannot jilways observe the final results of these cases — and indeed I have many times failed to do so — still, in private practice I have often had the opportunity of ascertaining that they did recover in the end, after many months of alternate imprcivenwiiit and relapse* I am, therefore, always in the habit of giving • good prognosis, unless there happens to be hereditary predis- position to epilepsy, or real epileptic fits have already occarred.

Thi« was the case, for itiHlaiicc, in a girl cif 10, i^ ^ »n4

several epileptic fits six years previously. Three mt-ii im,

another of thcHo had occurred; and since then ai(«cka bad

I

1

I

TUB HTSTERIOAL AFFECTIONS OF CHXLDRBN.

210

occnrred every 2 or 3 weeks, which were Rimotiiiced by a sensation of itcliing in the hands -and feet, and only consisted of a mental chariget wandering uhnut m a state of iincoiiseioiisness, delirium. and hellucination.s. Alt}Kmg:h in this cnac no coDTHilaious at all were observed one cannot doubt the epileptit- nature of the condi- tion, which might at any moment have g^ven phtte to a regular fit.»

Even the occTirrence of convulsive symptoms should not |at once make us anxious* in a few cases in which repeated iattaekg of the kind described occurred in the day time — loss of consciousnesH with unintelligible speech and vacant staring — delirium was often observed diiraig the night, with slight twitchings of difterent parts of the body, diiring which many of the children sat up in beii without knowing what they were doing. A few of the following laaes show that such a compli- leation may occur during the daytime.

Girl of 12 yeurs, admitti'd Iht NovenilH-n IB81. Hud always been healLlky, with the exc«"]/tiou of an attat-k of pneumonia in her 6th year. Since August attacks of palpitation and pains in the region of the heart. Almost immediately after a violent fright caused by almy who was going to hit her, these 8ymptomy were replaced hy maniacal attack.s^ — she screamed pa«t«ionat<'ly. clenched her tiists and stanipcil her feet and stared wildly round. Any fright, even the voice of tlu; bny or tliat of his relatives, induced these nttacks. Intervals of perfect sanity. About a fort- night Iw'fore admission into the wurd these attacks had suddenly diftap{>eared, and the third phfise of the disea-sc now began, charac- tftfi.sed Ijy attacks of extreme apathy and a kind of drcara*life. She wandered alxiut unconsciously, Bceing and hearing nothing, staring into space, sinking helplessly on to the floor, and from time to time tixik violent fit a of laughing and weeping, winking of the eyelid,*, and quivering of the right arm. Several of theae fits hi the d»iy, with free intervals. h?leep and gei«:ral health undiwLurlK'd. Treatment : rei»t in bed for aomv weeks, and dail}- warm biiths lai^tijig half an h(jur. Improvement and, in the end, recovery. No return of the disease by March. 1882. Menstruation had not yet set in.

A boy of 9 years, of perfectly healthy family, was suddenly affected by giddiness in August, 1865, while taking Bait-baths. In the end of January, 1866, the first of the attacks, about to be described, took place and the}" recurred iu April and Augofit. Suddenly, without cause and without premonitory symptoms he complained of giddincsa, which was occasionally no violent that he fell down. Hi« look U-cwme wtaring, his head wry hot and

* Cf,A flimil&r doubtful c&se which I have pabliahed iu the Charite*Annaitn, fid. it.. 8. 616.

DXBEABE8 OF TH£ KERV0U8 SYSTEM.

delirium ensued, which seemed to lie alvrftys occasioned by the same hulluciiiationB. The \ioy saw on all sides great ** c«pl?oanl»'* and armed meu pro8>:ing upon him; and at the ^aine time hiA bands could be seeu to twitch gli^htly. An attack of this kitul lasted 2 or 3 da^'s, not indeed oontinuously, but interrupted by intervals of quiet — in which, however, consciousness wiis never perfectly clear. Thp attack ended suddenly, and the boy at onco said that it was all over. With the exception of headache, ho was perfectly well in the free intervals; all his organic functions were normal. I ordered him to take bromide of potash for a frw montha. In the night of the 23rd December^ i.e. after an interval of 4r months, he again had a fit, ushering in an eruption of meiisles on the 26th. Since that time no fit has Ijoeii observed. The headaches, also, have long since disappeared, and the boy has grown up perfectly healthy, an*l is now an officer.

Boy of 13, convalescent from perityphlitis. Admitted in Octolier, 1883. Three weeks ago repeated genenit convuleions with scmi-nncniisciousnesa. Since then only slight partial con* vulaions, rolling of the eyes, headaches, sudden fits of som&am* bull am with hallucinations, clapping his hands. Otberwis*? quite well. Gradual improvement. After 2 months was dis- charged cured.

Girl of S (admitted 27th NovemWr, 1879). Attacks of glnhti« hystericus during the fnist year, which commenced with an aum rising from the umbilidis to the neck. Rolling of the eyes, scnu- uiiconftciout*nesH, falling to the ground, and hatluciuations of variou.* kinds occurring several times in the day. At the i^amc time greab restlessness, rapid articulation, change of colour and an erotic tendency, which was 8h«>wn by a certain coquetry and by hi*r frequently asking the houtDe physician to kiss her and to prp8« hard on her abdomen.

Girl of 12 years, had twice had chores. During the hi*l three months (sometimes every day. and sometimea with 6~8 days* interval, eypecitilly after any mental disturbanoo) sbc had had attacks of fruntal headache, followed soon after \ty religious fancies and halluciuatioup, iShe ihtan spoke of God, saw an angel come floating down, cnlled her mother Eve, t^iktxg hymnu interspersed with secular ssongis, did not recognise hef relations, and stared vacantly before her. She had no rocolle*'- tion of those fit«, which lasted 15 — H*) minutes. Free intervals. After a few weeks these fits disappt^ared and were replaced by convulsive contractions of the fa<'e and upper ertrcmtti< without loaa of cotieciousness, but with loes of speech* Tlic were ushered in and .•w'companied Ijy vertical htHxhichc. T threat of sending the child from hor jMirent* to her gnindnjothi in the country had a sfK'cdy effect. The fits diminishod quickly, and after some days entiri'Iy ceaned.

Girl of 9 yours, admitted 8th July. 1881, Hi%d always licen

THB HYSTERICAL ArFEOTIOXS OP CHILDREN

221

^K very subject to frights. Nine weeks liefore the school -teovcher ^^^^^luul poniiahed her by strikinjE^ her on tho hands till they became ^^^VswoLlen and painful. Soon after, " nervous fever " {?), Ever ^V since, her wits had been confused, she answered slowly and ^m indistinctly, occ&aionftlly also had cntuleptic attacks with rigidity ^M Bnd aphaflia. Great weakness and pallor. Organs and functions ^H normal. Speech slow. Before Pfwaking phe first opened her ^H mouth wide and then articulated lalxiriouHly and indistinctly. ^H Memory good. Movements weak ; can neither stand nor walk. ^^L Skin hyperiesthetic in many places. Enuresis nocturna, some- ^^^■Ltime^ alrto diuruii^ Application of the farad ic current to the ^^^^^pinal column. On the 11th she could walk with a little support. ^H^ On 12th, occawional delirium. She saya she sees snakes creep* ^H ing iii at tht^ windows. Cold affu^iionrt. On 17th. everything ^H T\ormal ; on 30tli« discharged cured.

^P The second class includes those cases in which the con- "vulaiye symptoms predoraintttc. These are sometimes cou-

Itincd to a certain nervous area ; e.tj. in an anaemic girl of 8 years they occurred in the form of violent fits of hiccough, •which histed from one to two weeks, and only ceased during sleep. More frequently they aliected the vocal organs or in- cluded in their action all the muscles of the body to a greater or less degree. The e$3ential character of these general attacks (which are usually called " bystero-epilepsy " to distinguish them from real epilepsy) seems to me to consist chiefly in the fact that consciousness, and the functions of the senses are re- tained, or at least not completely lost, and that the attack is »fteii complicated by fits of crying and screaming.

Anna H.. 9 years i»Id. ijrought 31, st December. 1878. Of healthy family. Had only .suffered from three convulsive fifce in her 4-th year During the last tluee weeks jshe had at irregular Intervals suddenly uttered a cry^ — about every 5^15 minutes — which could only l>e compared to the roar of a wild beast. Com- plete cessation during sleep. The attempt to cough only ended id a bellowing noise. Health otherwise [wrfcctly good. Arsenic, chlorab and pot. brom. were of no use. Recovery, from the applica- lion of the galvanic current after a few sittings.^Alao in a hoy of 8 years, who for some weeks had had such violent attacks of convulsive acrearaing, that on the e*treet one could hear the screaming from his house on the second flat. The use of electricity produced an unexpectedly rapid recovery.

An auBBmic girl of 12 complained of conntant dryness in her throat, so that she had to keep drinking. Urine normal. If her thirst was not at once satisfied, fits of crying and screaming

222

DISEASES OF THE NEETOUS STSTBlff.

soon ensued and lasted some minntea. — In a healthy girl of 12, T obseryed attacks of violent dyspntsa with loud screaming* which after some minntea gave place to striking-oat with the hands and feet. In other cases (girls of 10» 12, and 13 yc^rs) violent spasmodic attacks of coughing took place with whistling inspiration, lasting for hours and audible through several rooms, without any ac!foin|>anying symptoms except a feeling of oppression over the stomach and larynx.

While in theee and similar cases there was nothing bi voice-spasm, io other children this was only the precursor or accompaniment of the spasmodic contractions which I have described as "chorea electrica *' (p. 214). In other cases th« voice-spasm was accompanied by convalsions or paralytic symptoms, and we learn from the following observations that the same sudden changes of nervous symptoms from one extreme to another, which we see so often in hysterical women, maj occur in childhood also.

Girl of 9 years. For about 5 months, several attacks daily, both in the daytime and at night. They began with loud groan- ing or granting, then rotation of her head took place to right or left, so that yhe looked over her shoulder ; and she aiuLioualy complained that some one was standing l>ehind her-. Conscionsnesji confused. When she was firmly taken hold of she at once came to herself. General health perfectly good. Further course uiiknowiL Boy of 10 years, brought to ray consulting room, 15th March, 187&. Since his 3rd year, and without any recognisable cause he had had short but violent convulsive spasms of the whoU upper part oF the body, in which his head was thrown forward and shaken from side to side. These attacks, which sometimes occurred every few minutes, and often at longer intervals, were also In- variably combined with a cooing and clucking sound (voico- Bpasm). Any embarrassment increased the frequency and severity of these attacks, while movement in the open air and play almoirt entirely removed them. Complete cessation during sleep. Daring the last 7 years these convulsions had never completely ceaaed« but had Bometimes been milder and less frequent. Other- wise quite normal ; no neurotic tendency in the family. Tbo continued application of the galvanic current during a year by M, Meyer on my recommendation, caused in the end ao unlooked for amount of improvement. Only the <^lightcst trace of the attacks was left, and the voice-spasm qspecially had com- pletely disappcttred. There was still, however, a great tendttucy to recurrence.'

Bt. Meyer. DU Ettiriekat m ikrtr Anwmuimngtn mtf prqAi, M^dkU,^ 4 AalL,

1883, S. 386.

THE HTSTERICAIi AFFECTIONS OF CHILDREK.

22d

Marie S., 11 years old, had Buffered from dyspepsia since New Year, 1878. In the cud of February, 1879, attacks of eructation came on, which recurred very frequeutly for three weeks and sometimes lasted the whole day. They suddenly disappeared in the middle of Mart^h. and were replaced by the conditioii which led to my being consulted. The child — delicate, pale and wasted — lay in the corner of a sofa with a jjcuvish, pained expression of face, and at every expiration uttpred a half whimpering, half squeaking sound without, however, ever sheddin|i: a single tear. This voice-npusm — for such I coiwidered it to be — on rare occasions disappeared after a few eructatioiiK; and during this short interval the features at once assumed a f|uieter and more cheerful expression — from which we niiRbt infer a combination of the voicc-spasra with a similar condition of the facial muscles. The application of the galvanic current had no more effect than chloral or the Ems-water wMich was prescribed for the dyspepsia. On 26th March the latter disappeared quiUs suddenly, the tongue became clean, the appetite excellpnt ; the other conditions remained as they were. Inhalations o chloroform rapidly produced com- plete cessation of the voicc-spasTn — even when the narcosis was slight, but after 8 — 1*) minutes it occurred again in the old way. Only during sleep did the spusm completely disappear, and the harassed par<?ntH cinibl tlii*n recover themselves from the depress- ing impressions of the whole day. In the l>eginning of April the sound suddenly changed its character. It became a hollow groan; and at the same time the face lost its peevish expression, the features became natural, and the child was at last able to smile again. The speech, however, was interfered with, and it wiis only with diflficulty that we <*cmld draw a few words from the child. Tlie application of a <"old sponge to the neck (which we ordered neveral times a day for 1.5—20 minutes), had no effect whatever; and the voice-apasm, which was somcwliut altered, persisted almost unchanged (except during the night). To this was now added a paralytic weakness of all the muscles, which made it impossible to bold up the head iinsupported or to walk one step alone. On every attempt to do so, the legs tottered as if ataxic. It was striking to see the perseverance with which the child lay t he whole day on the sofa, and cut out paper dolls. In* jectiuns of ntrychnia into the neck (gr. ^^^ daily) and chalybeate Wttter had no real effect. !She was soon able, indeed* to walk Bomcwhftt Iwitter; Imt otherwise her condition was unchanged. Speech was almost entirely gone, and every attempt to speak caused convulsive movements of the face, as in a case of violent stammering. An intercurrent febrile catarrh was also without efftn^t ; but the cough soon assumed a raetaltic and 8|>asmo<iic character. On 18th April, the child became suddenly able to K|M"ak, although only in whispers, to walk a little with- out support, and to hold her head up. The voice-spasm became

224

DlBBAflES OF THE NERVOUS SYSTEM.

weaker daily and by the Ist May it had quite disappeared The speech now loud ftnd diatmct, walking much better, and iht appearance ^eatly improved. But the ?pa«modic cough con- tinued— every few minutes a panting inspiration occurring which was followed by a single croaking or rather whistling coiiglj; during wleep this alao diKappeared. Under the rontintied uae of strychnia injections (gr. g^ daily), the cough vrtis nl«o improrfd by the 29th, and recovery might be said to 1* complete with tho exception of occasional eructations. A slight relapse which took place some months later, had the same favourable terminatioiL

Boy M.. P vearB old. During the winter and wpring of 1B83 suffered much from migraine^ soraetimeB Bevcrtil days at a tiiaa. Pale, but otherwise healthy. In May, 1883, he slept in one room- ing, and in spite of all exertions could not bt» wakened. He was at once roused by making him inhale ammonia. After n few days the attacks recurred frequently,* always dnring sleep. His whole body became drawn togother aa in empro^thotonus; he kept grunting like a pig, and wa8 continually shoving htm- self upwards in the bed eo that he had to be brought down. In- halations of ammonia promptly arrested the attack, bat It recurred immediately and lasted 1—2 hours. Also spouianeon* sneezing or coughing would at once stop the attack. Warm Wtha with a cold douche and cold-water treatment in Elgersburg pro* duced a j>ermanent cure, after the fits had recurred during acToral weeks with over diminiahing frequency and intensity.

Not only the laryngeal muscles, bat also other mnscles of re- spiration may be the scat of spasmodic contractions, which come on in the form of asthmatic attacks, with rapid and shallow, or else deep breathing, in which the accessory muscles of respira- tion participate* Such attacks also occur during the night, and are often combined with palpitation and hypersesthesia of the prfBCordiul region, so that they may seem to be due to cardiac disease. In these cases alao we may have mental disturbancefl (delirium and hallucinations) and spasmodic contractions of the muscles of the face, eyes, and extremities, with iutorTals which are quite free trom all morbid symptoms, during which nothing can be made out — on physical examination at least.

Girl of 10 years, with a ** nervous '* lather. Fii'jst attack t>a 31st December. 1883, and by 30th .fanuary* 18Si, there had hwn 4 attacks, alwaya on Sundays. Tljcy consist in a c<mfltri 'he

pharynx with dysfpnusa, qtiick ehxillow breathitig »uil to

Kpeak. She could only give utterunce t(» innr .1*.

Poroeption and conaciouiueHH were normal, but >1 tal

or temporal headache, which ofton occurred during th«i jntiirvAhi

i

THE HYSTEaiCAIi AFFECTIONS OF CHILDREN.

225

also. Duration one or two hours. Occasional uausea and vomit- ing after the fit. All organs normal on esaminatiou. Gradual improvomeiit. Complete recovery after some months.

Girl of 12 years, normally developed but not yet menstruated, perfectly healthy. Had coraplaiiied of headaches for some weeks. On the morning of 8th February, 1882, after a good night repeated attacks of convulsive contractioes of the upper extremities without loag of consciousness. In the afternoon whe aUo began to flcream violently and furiou3l3%to spring u]> in bed, to be delirious (talking of going up a wooded hill) and did not recognise her relatives. After 8 o'clock, sudden cessation of symptoms and a quiet night. Next morning a few leaser attacks of the same kind. Then an undisturbed interval of 10 days, after which there suddenly took place (while she was taking a walk and without any apparent cause) inspiratory spasm — lalxiured rapid breathing, with harsh almost croupy inspiration, and distorted features. This ceased during the night. During the following days there were frequent repetitions, and then it passed ofif, giving place to paresis of the lower extremities (inability to walk). On 4th Jdarch, she suddenly became able to walk, and has remained per- tly well since.

The cases of the third claaa are the mont surprising, and are accordingly apt to be regarded as simulation* In them the attacks take the form of co-ordinated movements (jumping, rtmning, climbing, &c.), occurring spasmodically, either at quite Qooertain intervals or after a de&uito type. As a rule we also obserre daring these attacks certain psychical changes— great excitement^ screaming, hallucinations, and delirium^ — while during the intervals there is usually only an altered disposition, great irritability, unusual cheerfulness, or more frequently a tendency to cry. There may, however, be no symptoms in the intervals, and the child is then perfectly weU, except during the Beizares. These cases are usually spoken of as chorea magna ater St. Titus' Dance), and in fact they deserve this name uch more than the ordinary chorea. The name *" St. Vitus' Dance/' was first applied to an epidemic which occurred in chwabia in the end of the 14th century, which was characterised ly a rage for dancing, combined with ecstatic s3*mptoms. The remedy recommended was a pilgrimage to St. Yitus' Chapel in the neighbourhood of Ulm. Sydenham afterwards transferred the name '* St, Vitus' Dance " to ordinary ^chorea, for which Bonteille introduced the latter name in 1810.

I have met

Beizi

^Tgre

^Bnuc

D

The most extreme case of chorea magna which

226

L8ES OP THE NEBT0U8 STBTKIf.

with, I described many years ago.^ The most anasual thing about this case was its long duration; from the oceorrence of the first attack to complete recovery it lasted 5 Tears. I hare never since then observed such an obstinate easR of the disease* or one with such varied symptoms. The most diverse manifes- tation of altered nerve functions were here combijied in one clinical picture — mental imtability, hallucinations, aiv!

fits of jumping and running, opisthotonus, choreic in- tf,

partial hyperffisthesia of tho scalp, and a kind of •'cloirvoy ance*' which enabled the patient to deter mine exactly before- hand the number and order of the involuntary movements (a fact which I have fre-quently observed in such cases).

As regards the duration of tho disease and the diversity of the symptoms, this remarkable case is most nearly approached by the following one : —

Bo 3' of 9i yeara. lutcrmittoiit fever one year 1>' < r

spaBm of the orbicularis palptbraiiim mascle. On ;^> -i,

1882, he suddenly fell down on his way to school aiwi ii u: t hn trarried home. The attack recmn-ed on 4th, 15th, U'th^ and Sli^d September. He douhled himself up, sat or lay cowering, with intelligence unaffected, but unable to make any inovemenl of the head or limbs on account of severe pain. Ko contmctwipewc Duration about 20 minutes, after which he jumped up and wimt ou playing as if nothing had happened. Healthy in the iiiterviiliw liut could not sit atiU, fidgeted about in his fhair, made chorea- like raovementH and bad hyperaesthesia of the bark townrda the right side, where in tho beginnirjg of OctoV»ci* ft patch of herpes iippeared about the size of a florin. In October the flt» betaiue- more frequent, occurred ivithout cnuse at varying timfis ol tliO day, and clianged their character. After a short prelimiaar)' stage, during which the boy sat still and stared, he doubled him- self up as formerly, but continued unable to walk after i^e attack liad subsided, having to sup]Jort himself by t»bles. cliuhi»» itc, and dragging his legs after him. r> nr,

occasionally accompani«?d by aphaaia and by ^^

hoarse coughing. The paresis of the legs u a\

rapidly after a few shrill inspirations quite Ilk ^ iia,

and during tho intervals the power of movement was nurnrnl id every respect. In Noveml>er all these conditio ■''- rm-.w] ,M giving place to a state of somnambulifim ; ho -I during the clay, and made violent muiicular mu

'V i-jiij-rTtH a*

' Romberg und Henoch, KHnuche Wnhmrhiinmiftn and BwhofUmi^tm < Berlin, 1851, S. 77 : lujd the iBt and 2nd ediiionp of the proMriit work which <oo< Uin » full history of the ca«e, p. 199.

TllE BY8TEE1CAL AFFECTIONS OF CHILDREN.

227

swimming, threw about ever)'tbing he got hold of, and afterwards hid them away in his bed, ifcc, without knowing what hf wn» about. In the intervals he was quite well, good-humoured, and went for walks which lusted hours. In December all morbid symptoms had disappeared; apfwirent recovery till 8th January, 1883, when he suddenly after a motion of the b«w*t?ls fell down pale and speechlesH in the closet and eould not walk till n»>on on the following day, A fright from swaUowing a pin was given as the cause. Nothing followed, the boy waw quite well and spent some months in the Harz. After September, however* he com- plained of frequent attacks of headache with slight convulsive movcmcnt.-i and lo8t his good tempier, Tii January, 1884, more serious siyuiptoms ngnin a]>peared. He had uttacks resembling Rynco])e, and doubled him.st'lf up aflei* every motion of his boweb, even after micturition. He abo had painful sensations passing down from his knees to hia feet ; with s])aamotlic rigidity of the fingers when he tried to take hold of anything, and his sleep was disturbed. His general health wa« perfectly good. Thoac attacks also disappeared after a short time, and .-«ince then— as Far as I have lK?eu able to learn — the boy has remained healthy. In this case, then, during a year and a half there occurred varyir.g symptoms connected with every part of the nervous system, w^ith long intervals of almost perfect health,

It is but nfttiiral that under these cireumatances— especially in the first-mentioned case — simulatiou shonld occur to one; bat careful and continued observations put thia snspicion entirely out of the question. It is also ab.soluteIy impossible that the child's strength should have sufficed for this sort of simulation. This enormous capacity of the muscles for work, which is quite abnormal, I consitler an essential charactGristic of this remarkalde alTectiou, and I have been astonished to find it in other cases also.

In a boy of 8 years, who hud been perfectly healthy till 3 inontliB befure, the trouble l»egan with a state of nervous restless- ness, lusting for about t> weeks* which gradually passed into Htrtacku of chorea magna. These at first only occurred b^^ night^ Inter on during tho day also. After an aura, consiatiug of a aensa- tiou of painful pre»pui"e over the right eye, the boy begau to run, Hpring, and stamp about continuously, uttering from time to time a piercing scream. During the attack conseiousnosB wa*j confused, but not lost. After a few minutes this euded with a violent trerobliug and uhaking of the whole body, whereupon the l»oy awoko as if out of a deep dream. Involuntary micturition ifclao not uiicommonly occurred during the attack* Cau»cs and further course unknown.

228

DISEASES OF THE NEBV0U8 SYSTEM.

An iinsBmic girl of 13 yeBra, wliora I treated alon^ with Romberg, had uo morbid sjrmptoma wbatevcr during the fore- noon. Between 3 and 6 p.m., however, attiicks occurred every dnY* in which spasmus nutans (p, 192} was the principal symptom, while the mental condition was entirely unaffected. There were nodding and swaying rooveraents of the head and whole uppcT part of the body, fully 40—50 in the minute, with short pauses at intervals of an hour, and thty lafcted 8o continuously that tho possibility of such muscular exertion was almost inconceivablo. The attac'k ended about 6 o'clock. Duj*ation of the di&ca^e at least 4 weeks, after which all sorts of other hysterical fljmptonib remained— extreme weakness, globus, tenderness of the scalp, and 80 on. The appearance of menstruation finally brought al)ont complete ref^orery. I have since seen the patient again &h a healthy wife and mother.

A girl of 9 years, healthy, with the exception of repeated sore-throats, was brought to me on 22nd Novemljer, 1878. A yenT before she hud had 4 " fits " with drawing of the mouth to one Bide, but without loss of consciousness. In the beginning of Octol>er, half an hour after having her tonsils Cttuteriaed with nitrate of silver, she took a " fit," in which she repeatedly 8 prang up into an upright position, with extremely quick dyspno&ic breathing, accompftuied by a stenotic sound ; this lasted only a few seconds. ThousandB of such attacks were said to ha%*e '<K3curred since that time, during the day only. Pot. brom. and C|uinine had had no effect.

Emil S., 10 years old, presenting over 100 exostoses on all his l>one8, which had developed since he was 9 months old, had ^uifered during some years pa^t from occasional attacks of niigrainc, wuth vomiting. He was violent and irritable, hut diligent and amtiitious at school. On 4th May, 1830, an attack of heada^^hc, lasting from morning till midday. About 2 o'clock this suddenly became worse again and there was redness of the faoe» convulsions of the whole body, biting movements of the jaws^ rolling of the eyes, and slight mental derangement (mistaking ona person for another). All movements strikingly bnrricd and forcible. Duration of the attack \\ hours, after winch the child became quite quiet and the appetite returned. From 5 to 7.S0 a second and more violent attack. Ctre^t tenderness to pressure in the upper cervical region. Quiet night, sleep without any spas* modic contractions. Next day, between 6 a,k, and 3 p.m., four similar attacks, in which the patient threw himself with great energy out of his own bed into that next him. This was followed by a complete cessation of symptoniH, and the child seemed quite well till next morning, when, at 7 i..3i., a trifling and very transient ttack took place. Since that time tho '1- rncd,

id this boy, as 1 have had repeated oppoi i ■ uili

hn« grown up a healthy young man.

THE HYSTERICAL AFFECTIONS OF CHILDREN,

229

^

^

I lu a healthy boy of 12 years (November, 1870), the trouhle

began with extreme hyperBBStheaia of the whole front wall

I of the chest. The reg^ion bounded by the clavicle and the

^K lower miirgin of the thorrti, and laterally by the axillary line, was

^H so tender that he could scarcely bear even a slight touch. After

i about 4 weeks this hyperwstheaia suddenly disnpyicared, and was

replaced by violent attacks of spasmodic coughing, reeeiiihliiig

those of whooping-cough, in which the prolonged inspirations

were accompanied by a whistling noise {wpasniufl glottidis).

During these attacks, which occurred several times a day at

I irregular intervals, and seemed to threaten suilocutioii, and of

I which I wftw frcqneutly a witness, the hoy sprung up with such

energy that it was with difficulty that he could be held down.

1 Injections of morphia were the only thing that relieved him. He

seemed well in the intervals apart from a certain iri'itability of

I disposition. After 6 weeks all morbid symptomj^t suddenly

I dmappeared ; they recurred once later on for a nhort time, and

then disappeared for good. Course of treatment in Bad Landeck.

This case is pecolittr in this, that the beginning of the disease was annomiced by a sensory neurosis, which I have never observed in this form except here. It is especially worthy of note that the liypersesthesia was bihit-cra!, and not confined to the area of distribniion of one or more particular nerves, but affected the front and whole side of the thorax.

To this series we must also allocate the rare cases mentioned ou p. 201, in which choreic movementa are combined with uni- lateral ansesthcsia, which again disappears with surprising rapidity, or else makes its appc^aranee on the other side of the body (transferred). I cannot deny that partial anaesthesia or analgesia, also limitations of the field of vision (hemianopsia, &c.), may occur in the most diverse hysterical conditions of children more frequently than I have hitherto thought, either because I have not examined many cases in this particular, or because this examination is extremely difficult, and readily admits of error,' Only in very few cases was I able to convince m3'8elf of a bilateral amesthesia, e.g. in the case of a girl of 12,. whose left nasal cartilage we could pierce with a needle without- her feeling it.

' Cf. Barlow's article iBiif. Med. Joutttal^ I>©c. 3, 1881 j ** On Hy»t6rioal Aiial^e«iA in Children.*' Barlow rocommonda the galvanic current for the examination. P«ugnies*s Then*, mentioned on p. 217, nott, oontain« a series of oMCfi in which anvsthoHia of the akin and organs of sense were observed in children of 10—15 years in jnst the aame way as in adults.

ISO

DISEASES OF THE NERVOTTS SISTEV*

The fourth class includes the cases— rare in my experience — in which neuralgic or trophic distarbaDces ar« the

most prDmineiit s3'mptomB.

GottliuJf K., 04 years, examined May 2od, 1878, A fresh- looking. l.oiUtliy boy. Measles 4 weeks ago with normal course. A fort- night Ago, while wrestling, another boy fell on tlie top of hiiu A Week after, tits of pain began in his abdomen, which havt gone on gutting worne. Tliey affected the whole ab<lomon, <viri its lateral regions, and were so severe that the ehiJ<l sjcreanjfti ulouil anit rulleii about violently in iHid. GrAdnall3- the ^rreaming and rolling about became ao marked that the paini» eea*ed l« Ijc tho most prominent i<ymj»tom. The frequency of the attacks increased daily, and they were only interrupted by very tihort fren intervals. Temp. lUO't" — ^101*3^ F. Pulse ftomewhal rapid, coaI^hI tongue, footor oris ; urine abundant, dark, normal. Bowpltt reguUfr anorexia. Nothing abuornml in the abdomen. On the other hand* extreme byperji'sthesia of the skin over it and of th* whole front of the thorax, so that violent pain waw cmised if one rained up a foUl of the ^kin. Treatment: — Warm bran* baths, acid, hydrochlor. ; in the evening, morphia. >'ext day (;Vil May) the attacks diminished in frequency and severity' ^^"^ "M hours almost no urine pa^aed, except when tho bowel« were moved. HyjMjrajsthegia unchanged, and wa« now found aUo in tbf face in the area of distribution of the fir&t brauch of the fifth nerve on 1>oth siden. After the 4rth, rapid diminution of the byperft^sthosia and of the attacks of pain; abundant dihoharge of urine and fjcces; a|)pctitc ; no fever. On the 8th, rompiete recovery.

In a girl of 12 years, who had lately begun to mentttruate (23rii April, 1879) violent attacks oT cardialgia had occrurrcd daily for the hist fortnight, which lasted for several houi*», and were accompanied by uniiiterrupteil crying and screaming, which put the whole houiHebold in a »tate of eieitement. Other- wise healthy, but of peeviah disposition and extreme nervous irritability. Mor|jhia, here also, rapidly had a soothing effect.

Girl of II years. unUHtially early developed, but has not yet menstruated, Iler mother died of plitbisiw. In S' ' .1878,

I was cousulted on nccounl of frequent attacks of i Tvhieh

were often a^'cornpanicd luward» cveuing by an iucluiiition to voraitt In February, \H79, 1 saw her again. Ten dny« b»»ft»rc. she had violent ri'tching, with ha»matemegiM m ,\ un-

oatiiucAS, during whii'h aliuut half a cupful of bla^ i li1o<>d

waa brought ii]t, mixed with much mucus. This had recurred ©very aecond evening about 8.30. The attack laated alKini a | htmr and never occurred during the djiy. Owing to MOusatlona tn titt region of tho right raimm^, I froqaontly «x«uuned the biiigs along

THE HT8TBRICAL AFFE0TI0N8 OF CHILDREN.

281

with the phjBiciau in charge, but never found anything to excite suspicion^ During the last 4 dajg the haimatemesis had occurred ever J evening at the aame time— alxjut 8.30. The motions never contained blood. Food was well borne, never pjiving rise tO pain in the stomach. Neither quinine in large doses (grs. xv.) iior remedies given fur the gagtric condition, an ice-bag, opium, milk diet, liq. ferri perchlar., nor ergotin* had the slightest effect.

The peculitir charatctor of the girl, her premature development, h§r inclination to stay in bed, and tlie fiict— wljic!i her father himself acknowledged— that she had l>et>n extremely spoilt from childliood, at once led me to suspect that we hiul either to do with simulation or hysteria. There was no reason for the former, and exaraiiifttion of the teeth, throat, tongue, &c.> revealed nothing which could be regarded fta the source of the vomited blood. Also the physician in charge hud himself witnessed an evetiiug attack, and was convinced that there wiw no simulation. We could therefore only think of hysteriH, and I was further strengthened in thia supposition by the fart that the ha'tnatemesiB occurred l)j duy for the first time on the 12th, about 2 p.m., subsequently to mental excitement. We therefore ordered the patient to leave lior bed, to take a drive every day, and recommended that all medicine should be given up and all anxiety dismissed. In the middle of May I jnet father and daughter taking a walk, and the former told me that since my lawt visit there had been no other attack, and that the girl was perfectly well. Her good health con- ltnu<*d the whole sumnier, while she wfun in the country. Only ,1 ^ V rarely^and always after mental excitement— did slight

li vsia t^ccuj'. After her return home the s-ame eieries of

fiymptomsj occurring in the evening, again appeared, hut not so regularly aa before. Ergotin injections, which the doctor ordered, had evidently a psychical e£f»?ct,for the mere threat of repeating ivlhem later on (e.</. in August, 1880) when traces of hasmatemesis

fain apyieared, wftg Buflicient to cause immediate recovery.

This is the only case iu which I have seen hji?matemesis ftccompanying a liysterical affection, although such cases bare

lasionally been reported by other authors.^ As I have seen

aemoptysis without lang disease in a hysterical patient, I pgard the occurrence of hf^raatcmosis under simihir circum-

mces as equally possible. The process is indeed difficult to explain, and may always remain a matter of hypothesis. But rben I remember the sudden blushing which may take place rom mental emotion^ and recall the case of one epileptic child

CJ'. Hiitherj, "^^ CootributioiiA h IV^tadn dnti hejnorrhagitiB sarvcaaat dans 1« lfraro|Mhthiqu«H": /Hii., No. 56.

282

DISEASES OF THB KBRTOUS SYSTEM.

whose attacks alwa3'8 began with extreme flushing of the whole skLD as aura, I think I maj assume that it is possible for hyper* iemia and hiemorrhages to take place into the lungs or stomacb from an irritation affecting the vaso-motor nenres of these organs. The periodic occurrence of hsematemesis in oar case is not sorprisingy seeing that in some of the cases of chorea magna formerly published the convulsions took place in the most typically periodic way. I may mention here also the case of a boy of 9 years who had his ** hysterical'* convulsions regukrly about noon and at 5 p.m., and in whom there could be do suspicion of simulation.

The cases I have given will suffice to place before you a clinical picture of this remarkable condition in its various forms. These cases do not, indcedi exhaust all the moditications, and I might have given you from ray own practice examples of nmiiT other variations and combinations of symptoms — cases of aphonia, aphasia^ globus^ hiccou<;h, and dysphagia. Thus we find pub- lished accounts of neuralgia in the joints, ovarian pain, and localised hyperesthesia and ansesthesia, in no way difiering from those in hysterical adults.' Their strange and inexplicable character always, of course, excites a suspicion of simnlatiou; and indeed we cannot be sufficiently cautious in this particular, eren in the case of children.* I have myself met with a few such eases; among others that of a girl of 12 (25th Feb., 1879)* wbo had suffered for two years from frequent cataleptic attacks, and had latterly taken them three or four times in the day, but from the moment she was admitted into the children s ward to the time of her discharge (that is, for at least 2 weeks) had not a single fit. Apart, however, from the fact that cases of this kind are not. in my opinion, to be regarded off-hand as cases of inten- tional malingering, but rather as an expression of the " hys- terical " nervous derangement, I can assure you tbat in all the cases given above, the suspicion of simulation could be absolutely excluded; and it was just the same in many analogous cases recorded by other writers. I cannot, therefore, entirely agree with Roger when he says, "pour les praoticiens experts en pathologie infantile, toute neurose dite par imitation est uno

' Hoecnstein [Be>< iHn, lVoch*nsckr„ 1882, S. 522) de«ci: irkabl*

oawin which thore WM Tomitinff of ■cybatomi fticttft duii ikck.

» 8, Abelili. CefUraiseitun^f, KimterkeHJc., 1878. S. »7.

THE HYSTERICAli AFFECTIONS OF CHTLDREN*

288

^nearose par BimolatioD." The complete cessation of the fits in ^febe child just mentioned during her residence in tho hospital ^Baunot be taken as a proof of malingering, as we know for certain Hkbat radical changes in the surrounding conditions not uncom- monly produce a temporary or even lasting improvement of this "nervous" state.

Occasionally the resemblance to the hysteria of adults is even more striking, as in the following case : —

On 5th Novcml>er, 1876, a girl of 11 years appeared at the poly- oHnic, who Imd been quite blind since hor 2iid year as the result of bilateral keratitis and atrophia Imlbi. Being healthy till 2| years 0^, she was sent to school, where she showed the utmost applica- tion and overworked herself. Soon after, she took attticka of headache, with vomiting, so that slie had to leave the schooi She took to muBJc with all the more energy; she hud a marked tjilent for it, and now played the piano for more than 3 lioura daily — of course, only by ear. For some months she hatl com- plained of fludden shooting pains in the forehead, and giddiness (so that she fell) alteraating with violeiit colicky pains round the urabilicua and attacks of rapid dyspna?ic breathing. All these symptoma occurred every day repeatedly, and at once whenever you spoke to the child about them. At the same time her mental character did not at all correspond to her age, for she was precocious, extremely talkative, and very circumstantial in de- scribing her symptoms. Partirulurly striking and amusing was the fact that she always repeated ejcactly the la«t word of anything her mother said. At the same time she slept 12 hours con- tinuously without being troubled by a trace of nervous sjTiiptoraa* General health perfectly good. No sign observable of the develop- ment of puberty. Further course unknown.

I have also several times had occasion to observe cases of hysterical paralysis of the lower extremities in children, especially in girls of 11 — 13, even more marked than in the ^BBasofi given on p. 223 and p. 225. Sometimes violent fits of ^^ryiug, lasting for weeks, or other hysterical conditions had ^fcreceded the paralysis ; and it came on after they disappeared, ^^ust as in adults. In lying and sitting the limbs could be moved ^almost as well as in the normal condition, and the sensibility as Hprell as the function of the sphincters was intact. The children, ^^owevor, obstinately maintained that they could not stand or I walk, and when they tried to do so, their strength failed and they sank to the ground unless supported. The suspicion of

284

DI6EA6KS OF THE N£BV0T7S gnrgTBU.

spine disease, which causes anxiety to the parents in such could be at once discarded, and in fact these pamlyaea diM^ peared after a few weeks, either spoctaneously or as th© resnli of psychical improssions. But sometimes they were t«plac6d br other nervous symptoms. '

Quite as obscure iis the pathology of all these outwttdly dissimilar but essentialjy identical conditions is their eii* ology. In hardly any case have I been able to find qtdte definite causes. The influence of emotional conditions — particularly fright — in causing relapses, must be acknowled^. One of these girls suddenly took a violent hysterical convahiit« attack (the first for weeks) during my lecture on her oii»e, at which she was present. In general it is commoner in females and at the time of puberty, and accordingly all these affections, especially chorea magna, have been closely identified witli the latter* Since, however, even boys and young children between the ages of 9 and 11 years are by no means exempt, it is evident that there may be other forma besides those due to development* arising from other causes. One naturally turns first to irritation connected with the genital system, and thus we hear mastar* bat ion spoken of by many as the principal cause of these nervous disturbances/- 1 do not by any means deny that, with a strongly-marked **noi*vouB predisposition," this vice if persisted in may assume impoi^tance as a cause; but, considering how common it is, we sbould certainly meet with cases such as we are speaking of far oftener than we do, if that view w^re correct. We are at any rate always justified in keeping this cause dis- tinctly in mind. You will scarcely believe that many childn*n in the second year of life, or even earlier, practice masturbation* either with the hand or by rubbing the thighs together, bo as t(^ cause distinct erection of the penis. It is often also produced by the already mentioned rhythmical swaying of the upper part of the body while sitting (p. 196). At this ago the evil can »litl very easily be cured by sharp supervision, but it is mocli mon difficult in older children, who in some cases will avail themseltaB of every unwatched moment to indulge in the vice. I resnembcr

• rr. Blegel I /f«i>4. Ar,/ Itin, J/«hI„ Bd , tI., H. 5>, wI»o glTcs fivo eaM* of UiU piurttljrws with oonlrftcturen, An.

* J *cobi , *• On Tna^t^u-ltMitioniuMl hyat«ria in joung oHIdren " i Ai ofOlntttHfiM, 4<j„ Yiii. *; u» 3, iSTC.-HirachBprting, Jukrb,/, Still.. 460.

THE HYSTERICAL AFFECTIONS OF CHILDREN.

2d5

one girl of 8 years, who altbough she did not nae ber bauds, yet by rubbing tbe genital organs on tba edge of tbe cbair on wliicU she Bat, worked herself into a state of great excitement, which was manifested by her fluBhed cheeks, sparkling eyes, and rapid breathing. The diagnosis, however, is not always so easy, and

e most careful observation is necessary, especially when they

e going to sleep, in order to surprise them in jlaijnjntf. Tho discovery of a few spots on the linen is by no means sufficient

r a positive diagnosis. I have tried in all cases of hysteria

d oborea magna to investigate this point, but in not a single

ease have 1 been perfectly sure that the cause was to be found

masturbation. We must always be content with the possi-

ity or probabiHty which already play too large apart in etiology,

evertbeless, you will do well always to keep mastui-lmtion in mind, and, whenever it is found to be present, to put a stop to it if possible* For even although it may not constitute the real cause of the disease, still by the over-exeitemcnt of the nervous tem which it occasions, it may prepare the way for its develop-

lent and retard recovery. How serious such an oy«r-excite- tnent may become, we see from the foUomng case :^

Carl A., 7 years old, admitted into tlie cbildreirs ward on Jrsth January, 187^1, had practiced masturbation since his fifth year. The habit had been induced by sleeping for a long time with a female relative, who hod taught it him, Gi'adually iucrcnaing

ability, enuresis noctunia, sleeplessness, and — during the last ►rtnight — inability to walk. He could neither ait, stand, nor walk unless supjiortcjd. Even when supported he soon began to Bway about, complained of piddinesp, and his gait was distinctly ataxic, like that in tabes dorsali^?. On shutting his eyes, the Kymptoms were markedly increased. In bed, all raovements of the legs were free, although less energetic than in normal health. SeusibiUty mtact. The plantar reflex movements, however, were weaker and slower than usual Urine and faeces retained with difficulty, and sometimes passed involuntarOy. Ana?niiii and moderate emaciation. Treatment: — A luke-warm bath for 10 minutes daily, with cold shower over the head and back, the Btrictest aupervision of the patient, and the prevention of every attempt at masturbation. By 23rd marked improvement in walking, eeseation of enuresis. On Gist scarcely the slightest unsteadiness in the gait noticealilc. Complete recovery by middle of February.

^ys

The extremely rapid and favourable progress of this case, which

286

DISSABBS OF THE NERVOUS BTSTElf.

syvUSDt m mUMym

inred isS

at the begmning showed symptoniB of advanced tabes dof»li» Bneb as I had never boforo met with in a child, proves thmi no dogeueration but only a functional disturbance existed. We Mtt then, that constant irritation of the genital nerves io chUdren may cause paresis of the lower extremities with ataxic sympioiM* diminished muscular sense, and diminished energy of the cenlrta analogous to the hysterical paralyses in women which are eaoaed by morbid conditions of the sexual organs, or even in the of such by depressing general influence on the nervons ^rsten and which under favourable circumstanceB have a similsHj fnvourable course. To the same class also belong the paxiMis and ataxia of the lower limbs which is occasionally observed in children with extreme phimosis, and the consequent genital irri tation which this excites, and which is cured by an operation.'

Most of the children who presented one or other form of the hysterical conditions we have been speaking about, were of deli- cate constitution, thin, and more or less anaemic. Only the minority were well nourished* We could almost always find some fault in the bringing* up which had prepared a favoumbk soil for the later neurosis. Children who are brought up with unusual care and indulgence — round whom, so to speak, the whole household turns — who are surrounded by extremely in- dulgent persons ready to give in to all their humours, and whose J^ slightest complaint was taken up with exaggerated solicitude^ and made much of, are especially liable to these extraordinary ' diseases. Under these circumstances a sort of hypochond- riasis occasionally sets in. I witnessed this especially in one very spoilt, delicate boy, of 8 years. He attended to his own health with the most anxious solicitude — examined his tongnc» ^ every spot that appeared on his body, &c. In a disposition ofH this sort, or where there is a hereditary tendency, or it ^ least a neurotic predisposition in the family, all irri- talion acting powerfully on the nervous system, every kind emotion, excessive mental strain, ambition at school, ill-treat- ment from parents, and finally also the instinct of imitation may bring the disease to itH full development*

From the cases I have given, you will have seen tliat undcrj these circumstances medicinal treatment cannot promise any]

' OetUrr, Jukrh,/, PaJiatrik.ru., 1876, 2. Heft, AnnaJ. 8. 188.— XirA./. JTr hdlk,^ Tin., S. 460,

THE HTSTEBICAI. AFFECTIONS OF CHILJDEEN.

237

result, I know of no medicine which has done me real serrice except chloral (in doses of gra. viiss — xv) and morphia (by the mouth and by subcutaneous injection, gr. tw — 1)* I have found these occasionally of some use in palliating the violent spastic symptoms. The inhalations of chloroform which I have tried in attacks of screaming and other voice-spasms had never more than a passing effect. In many cases — for example, in those of spasmodic running and jumping — even these remedies can only be used with difficulty — if at all — during the paroxysms ; or they may fail to act. Under such circamstances we must just let the attack run its course, only taking care that the patients get no injury from the nature and severity of their movements. Sometimes by a sudden violent impression^ — e*g. by splashing the face with cold water, or by speaking loudly and roughly — we may pat a stop to the fit. Still, this by no means always occurs. We have jost as little power to shorten the courgo of the disease by any remedies. Even when the periodicity of the attacks was most distinctly marked, I have seen no action whatever either from quinine or arsenic. Considering the frequency of au under- lying anaemic condition in such cases, it is always well to treat the children with small doses of iron, or to give arsenic as in chorea ; for this medicine in small doses continued for a long time exerts a distinctly beneficial influence on the anaemic con- gtitntion. Soothing baths of lukewarm water, with soap or "bolus alba'* (IJ — 4 02. to each bath) continued as long as possible (half an hour), nourishing food and fresh air are to be strongly recommended, but unfortunately cannot always be obtained. In affections of the voice the galvanic current should be tried. It occasionally produces rapid recovery, hut some- times has no effect, or may even aggravate the disease. Not uncommonly all manipulations of this kind — the appHcation of electricity, the introduction of an oesophageal tube, a subcu- taneous injection, even a laryngoscopic examination and, above all, the threat of repeating these measures — act with wonderful rapidity ; their influence being, of course^ only psychical. One must not however expect too much from this rapid improve- ment; for it may be followed by sudden aggravation of the Bymptoms. Fortunately we are in a position to reassure the rehitives from the beginning as to the result, and indeed I

f opinion that the more extraordinary and incompre-

238

mSBiSES OF THE KEtlVOUS STSTBlff.

benfiible the symptoms are, and the more tLoroo^Uf they change, the more certainly can a favourable prog- nosis be given. You may therefore always give a iBort favourable opmion of cases of so-called chorea magna» of voiee- spasm and hysterical paralyses. But tht^ cataleptic form (ow first class") is always a cause for anxiety^ becRUse of the poflsl* bility of its turning into epilepsy (p. 218). At any rate I ftdviw you to prepare the relatives for quite unexpected symptomn. Where there is now pamlysis there may in a few days be a coo* vnlsive affection, a sensoiT neui'osis, or a psychical change* ; and this sometimes takes place even during an attack.

After recovery, you will do well to continue the tonie trwU ment, and, where circumsUnces allow it, to order chalybeate baths, or else simple warm baths in fresh mountain or forett air. As to the latter, I recommend especially the warm batbi of SehlunjLjenbud in Taunus, Landeck in Silesia, and T - -l»ftd

in Bohemia. For chalybeate baths, which are indi. hen

ansDmia 19 a prominent symptom, I would advise Bchwalbaob, Pyrmont, Dnburff, Flinsberg: and, in Switzerland, the high springs of Tarasp and 8fc, Moritz.

I have no doubt that by this treatment with baths and change of air, the recui-rence of the conditions we are speakiit "^ be

prevented, and their course so fur shortened. II ;ij»t

under favourable circumstances a coui^ee lasting over a numl^er of years, as for example in our case on p. 226, will hardly isrtt occur. When the disease is extremely obstinate, howovec, nothing remains but to remove the patient from his accustomed surroundings at home, into others which are quite now to liirn, either in a hospital or in a strange family* The mem change of abode is not in itself sufficient, unless the companion- ahip of the mother, or accustomed nurse is also denied, Schoal attendance is, of oom'se, to be forbidden whilo the diseage Imstmt nnd, even after recovery, every mental strain is to be carefully avoided. Jn girls about the age of pubertti the appt*arnnce ofl menstruation calls for special rest and care. We learn from tbo case on p. 226 that when puberty is fully < -^ i ven

unusually chronic conditions of this kind mav c],

NiOHf TERROnS— fAVOR N0CTURNU8*

230

Vn. Pavor Noctunuis (Night Terrors).

I ex]

tb« the

PBoD

This is the name given to a contlition which, owing to tho

larm which it causes the patients, often disturbs the well-earned

»8t of the physician. In the middle of deep sleep— oftenest in

the first hours of the night — the children suddenly start up

and cry violently and continuously, and catch at the tiir with their

hands, or else sit in hed ataring in front of them with an anxions

expression, and uttering words that are hard to make out, or

(together unintelligible, Many tremble in all their limbs,

irow themselves in terror into tho anns of the frightened

mother or nurse, cling to them without distinctly recognising

them and call out for light, and it is only with diflTiculty that

they can be quieted* After a short pause tho scene is repeated, not

icommonly several times in succession, so that half an hour or

mger may pass before complete rest ensues, and the exhausted

child falls soimd asleep again. As a rale, the remainder of the

Hmigbt is passed in quiet sleep, and when the child awakes it

^Knows nothing of what occurred in the night, and does not

^■pemember the physician who sat by his bedside during the

^Bttaek. These attacks are now repeated at irregular intervals,

^Bomctimes every night, sometimes only twice or tkrice a week, or

still seldomer. It is exceptional to have two attacks in tbo

i samo night. Dunng the day, the children show no symptoms

that one can connect with the nightly paroxysms. I have only

onoe had the opportunity of observing a case of this kind —

between 11 and 12 in the forenoon- -in a child who had fallen

I ^a sleep on a sofa. The duration of this disease, which so

^fcriolently disturbs the child's relatives, is quite indefinite. While

^■tn some cases the thing is all over in a few attacks, in others the

attacks are repeated daring many weeks or even months ; but

ley finally disappear without leaving any bad rcsoUs. In an

iipmic girl of 7 years who was otherwise quite healthy, tho

attacks had lasted two years, with maximum intervals of 8 days,

»ut had increased in frequency since she began attending school.

Although I have placed this affection here, immediately after

le " hysterical '* conditions, it is not at all because I consider

lem to be nearly related to one another. I havo indeed seen

240

DISEASES OF THE NBBV0U8 SY8TBK.

pavor nocturnus come on, in a few cases, in children who bad been spoUt, and had been rendered b}*per8ensitive by a bringing- up which predisposed them to hysterical derangements, and who suffered at the same time from headaches, palpitation, fainting fits, &c. Bat this however was just as rare as it wag to night- terrors due to real epilepsy; which I found to be the i in a girl of 10. In this case several epileptic fits had taken place three years before, at intervals of 8 — 10 days. They then ceased till Jannary, 1882, when suddenly several fits again occorred, which in Febrnary were accompanied by hallacinations and screaming. In March they disappeared spontaneously, anil were replaced by attacks of pavor noctumns, occasionally occur- ring twice in one night, I have never yet met with pavor preceding and accompanying regular psychoses, which h perhaps due to the small number of cases of mental affections which I have met uvith in children.

In general we meet with pavor noctumns almost exclusive!)' in young children, in whom we find it occurring till near the time of the second dentition; while "hysterical*' conditions usually begin after this period. In this condition also there ts none of that mental change which is so important an element to , hysteria. The whole trouble consists in the nocturnal attacks described, and to me at least it has always appeared as if a terrifying bad dream had frightened the children out of] their sleep, and still haunted them when half awake. It is evident that visions and hallucinations are factors, as the children often describe them quite definitely. I have heard thorn call out to take away the chains, to drive away the wild beasts, that they would be run over, &c. Sometimes, agaln^ > they try to jump out of bed to escape from the cause of their terror. A boy of four years who was violently frightened by a j bee had an attack of night terror on the night after, daring which he fancied that a fish was continually threatening him. This was repeated several nights consecutively, and! finally the child would not enter the bedroom, and always wanted to be out of doors. The more active the child's fancy i«, and the more it is excited by the favourite thrilling tales of { nurses, the more readily will the pavor come on ; and ibis (acij is one which should be laid to heart by those who have cluLr^^oj of children. I

TERIPHERAL PAIIALYSES*

241

Ouc of the rare cases of pavor diurnus which I hftve seen uffecteii the son of an fictor (7 years old), a iier\'ou9, iimemic, delicate child. For some months aa many as 10 or 20 attacksi took p!iu"e daily, but never during the night. The child wuuld shut hiH eye8 and stop hia earB, crying, '* 1 'm afiTiid I" and clinging to his mother. Duration oniy a few aeconda. Otherwise healthy, and, in particular, free from other hysterical symptoran. In a *' nervous *' child of tj, who had suffered from pavor noctumua fof 7 months, with intervals of about a fortnight, attacks occurred occasionally by day witli hallucinations. Unfortunately, l>tJth these cases were lost Kight of.

I cannot share West*8 opinion, that disturbances of digestion are generally the cause of night-torrora. I have ■ but rarely been able to assure myself that the cure of such dyspeptic conditions as might happen to be present caused a rapid disappearance of the pavor ; e.g, in a boy of 8, who during an attack of gastric catarrh had night-terrors Bxe nights running. On the other hand, most of the cases presented no disturbanc© whatever of the digestive organs. Nor could I discover any abnormal condition of the respiratory and circu-

■ latory organs.^ In many cases there is an undeniable family predisposition i children of nervous parents are more likely to be affected. As I was unable to ascertain the causes in most

»of the cases, I confined myself to forbidding every excitement of the child's fancy by evening stories, and ordering a dose of bromide of potash (grs. viiss — xv.) at bedtime ; and this

Ifleemed to me to exert a soothing influence. I have not yet tried morphia or chloral, but I would have no hesitation in using these remedies in severe cases.

VIII. Peripheral Pm'alj/scs,

I

In children, as in adults, the facial nerve is that most fre- quently affected by peripheral paralysis. It not uncommonly appears in the earliest childhood, immediately after birth. The mouth is drawn to the unaffected side in crying, and the eye of the paralysed side often remains open. The exact symptoms depend on whether the cause of the paralysis affects the labial and palpebral branches of the facial nen-e, or leaves the latter unaffected. This cause is the pressure of forceps • Silbermtiun, Jahrb,j\ Kindetkeilk.t Bd. ix., 8. 206.

16

DISEASES OF THE NERVOUS SYSTEM.

at birtli, which in such cases sometimes leaves behind a stndl ecchyinosis in the parotid region. The twislinfj: of the mouth generally causes the utmost alarm to nurses and parents, os it is regarded as a sign of apoplexy. You may, however, calm the fears of the relatives by the assurance that the pnml 11

probably disappear within a few w^eeks, as soon aa the - >u-

tion of blood is absorbed or the nerve hag recovered from the effects of compression, I say " probably,'* for you cannot foretell a favourable termination with absolute certainty. In a few cases the pressure of the forceps appears to have been so severe and lasting in its effects that degenerative processi?* (fatty degeneration of the nerve fibres) take place in the facial nerve J and these are not always recovered from, bat canat* paralysis lasting for a whole life-time. I have myself observe*! one such case, in a girl of 13 years, and Parrot and Troisier' have furnished anatomical proof of the fact.

Much more rarely we find congenital paralysis of the facial nerve, wifcli which the pressure of the forceps has nothing to do. I ha%e seen this only once, in a boy of 10 years, who was bona without artificial aid, and exhibited paralysis of the left facial nerve immediately after birth. All its branches were paralysed* also the left half of the soft palate and the hearing was lost in the left ear, although no disease of it had ever been found, A prolonged treatment by galvanism was entirely unsuccessful. Similar congenital cases have also been published, but their pathology is not sufficiently explained.

Unilateral paralysis occurring in later childhood has a general correspondence T^ith the cases with which you are familiar in adults, and I shall not discuss them farther. I would point out to you, however, that in order to observe these symptoms it is necessary (in children almost more than in adults) to make the features move in the expression of some sudden emotion. While the chiUrs face is at rest you obserra no striking change ; but when it cries, screams, or 1' ■ he asymmetry of the two sides becomes apparent. The \ ; i m of the soft palate is often particularly difficult in cbildr<«n, lukl wo have sometimes to W content with a rapid glance. The causes, as well as the general symptoms, agree entirely witli

* **Kotie ntir rftnntomiti |iiitho]r>8iquff He U ii«ml.v«iic fft^^iftle tie* itiittvc«u-n#«|** Arch, fie Tocufogut, Attif, 1876. JB

PERIPHERAL PABALY8E8.

243

those of facial paralysis in adults. Rlieumatism as a cause la here aluo moro frequently taken for granted tluin proved. Still cases are not uncommon in w1hl4i the action of a cold drau«:»ht of air — especially when the skin is perftpiring — is cndently the eanae. More frequently, I Lave seen the scars of ahscessea, or enlarged glands, behind and under the ear in the region of the stylo- mastoid foramen, cause paralysis by their pressure on the branch of the facial which issues from it.

Child of 2 years, with complete paralysis of all the branches of the left facial jsupplyiiig the face. In the ueighbourhood of the stylo-raastoid foramen, a deep sinuous abscess issuing from a lymphatic gland. Aftor it wa« opened there remained a con- sidcrahle swelling anii xntiltration of the connective tinijue. From 25th February, 18(51. tliis was painted with tincture of iodine. On the 7th March there was cunsitlerable diminution of the swelling; but the ])araly>si.s was unchanged. Continuation of the jminting* and also, internally, iodi gr. |, pot. iodid. grs. xr., synipi jiiinpl. 3 vIbs., aq. destill. ad ^ iii., a dessert-spoonful i times a tlay. In the beginning of April, complete recovery.

Such cases occasionally ocx^ur even in very young children. Thus I have seen imralysin of the right facial nerve in tWM cliildren of o and 11 months reKpeetively. In the latter, enhirgoment, of the glands, with ditfuao swelling of the connective tissue, muhl be made out in front of, beliind. and under the etir, while in the first case very careful esflmination was needed in order to make out the deep-seated induration under the mastoid process. — In a hoy of 4 years, paralysis of the labial and nasal branches of the left facial resulted from the pressure of a large abscess in front of the ear, which developed during convalescence from typhoid fever. The pttralvs^is disuppeiired almost suddenly when the abscess burst into the external auditory canal and discharged its f>us into it.

We must* however, reg:nd caries of the petrous bone destroying the nerve-trunk in the Fallopian canal, as the me fit cause of facial iiaralysis in childhood. The 18 cases of this kind which 1 have seen all agree in this 1^, — that in everyone of them all the facial branches of the re were paralysed, while unilateral paralysis of the soft was not always present ; for in a number of these cases le uvala was quite straight, and the movement of the palate enniil on the two sides. We must notice in these cases not only the oblique position of the uvula, but alno the movement of me half of the velum on breathing and phonating, whereby the

244 DISEASES OF THE NERVOUS SYSTEM.

soft palate is twisted to oue side. Where this symiitom is abseut, we may couclade that the destruction of the Fallopian canal has not taken place till after the greater petrosal uerre has left it. Deafness in the affected ear is very difficult, if not impossible, to make oat in little children. The otorrhoea, which is always present, sometimes combined with bleeding, is all the more important, and along with the matter there are often discharged from the anditory meatus little or pretty- large pieces of bone, or even auditory ossicles, clean as if dissected. The presence of a deeply destructive process is also indicated by a tender swelling of the temporal bone behind the ear, also by redness and fistulous openings. This cause of paralysis some- times occurs at a very early age. I have seen it begin even in the third and fifth months, and either rapidly prove fatal with symptoms of general tuberculosis, or else continue for years, till at last death was caused by complications, especially tubercu- losis of the brain or other organs, meningitis, or sinus-throm- bosis. The longer the paralysis continues the more atrophic do the facial muscles become, and in one child thus affected I found them shrivelled to thin brownish-yellow bands. At the post-mortem of the cases I have met with, there has always been xtensive caries or cario-necrotic destruction of the petrous bone, liich sometimes reached to the dura mater. But even in the es where there was a carious cavity close under it, this mem- 1 * ne itself was intact, or at most somewhat dark in colour, so It a perforation of the caries into the cranial cavity had tainly not occurred. On the other hand I have repeatedly r'^ud pachymeningitis and localised purulent arachnitis. A 1 seanestrum could sometimes be extracted from the external Vt rv meatus at the post-mortem, and then when the auricle auditory ^^ ^^^^^ ^^^ .^^ ^ considerable cavity occupying

was rem ^^^ petrous bone. In a few cases we could

'^? 'trices of dead bone even during life, either from the fa nr from a fistulous opening in the mastoid portion of meatus or irom ^^^ abscesses and fistula behind the

'^'- wCvs communicated with the interior of the carious auricle always ^^^^^^^.^ ^^^^ ^^^^.^ ^^^ ^^ 3 ^^^

^r' tinarear ias almost completely separated from the head tVSt a"r gangrenous fissure, and from this we were able J 'emove a sequestrum t in. long and i in. broad.

PERIPHERAL PARALYSES.

245

I

;t all tbo cbiltlren in whom I observed this pai'alysis were also tubercular, and died sooner or later. In one of these cases there were immerous nodules (ranging in size from tliat of a millet to that of a hemp-seed) on the dtira mater of the middle cranial fossa. Less commonly the caries arose from the neglect of a simple otitis media, especially when this was a sequela of scarlet fever ; and I therefore recommend you when children are recovering from scarlet fever always to pay special attention to any otorrhcea that may remain. Some of the cases which I have had to do with showed that the destructive process, which begins in the middle ear and spreads to the hones, may have a surprisingly short course, and may lead to caries of the petrous bone with facial paralysis even io a few weeks after recover\^ from scarlet fever.

The peripheral paralysis of other cranial neiTCs is much less common in children, and presents in them even less that is characteristic than facial paralysis does. This is also true of the paralysis of the spinal nerves due to local causes. Among these there is only one that arises at birth, and which on account of this causation culls for remark here. Not only on the facial nerve but also on the brachial plexus, the forceps may exert BO strong a pressure that paralysis of one or more groups of muscles in the affected arm may take place. Kogcr ' describes one such case in which ininirrliutely after birth the facial nerve

{and one arm were both paralysed. The impress of the forceps over the clavicles was still visible, and after death — which soon followed — crtiisions of blootl were found both in the neighbourhoml B of the stylo- mastoid foramen, and in that of the brachial plexus. Other olistelrical jirocesscs may however also have the same effect as the pressure of the forceps, cspeciiilly ditlicult extractions or violent dragging of the arm, along with wliich dislocation or fracture of the humerus has been occasionally observed. The hjematoma of the sterno- mastoid formerly mentioned (p. ft9) tQAy also occur under these circumstances. This *' congenital *' (or really *' artificial ") paralysis of the upper extremity may, like that of the facial nerve, either pass off rapidly or — should

Ifiegencrated processes have been set up in the nerves of the arm >y the cause of tbe paralysis — continue many years or even lurin;^; the wbole lifetime. It may also be combined with f^ensorj-

• Jnmtt /. Kindti-h'tinHk., 18«H, S, 405.

ue

DISEASES OF THE NERVQV8 SYaTBttt.

tliaturbftnees. Thus I have observed, in a child of fife, anresihesia occurring with the paralysis on the ulnar side of the forearm. The position of the arjn, whiL-li is due to the cou true- tion of the antagoniiitic mnscles, varies according to the muscles aflfeeted. Most frequently there h rotation inwards with mark&d pronation ot the hand, owing to the action of the pectoralu, suhscapularis and latiasimnB dorsi boing stronger than that of the parnlysed infraspinatus. The faradic irritability of the paralysed muscles rapidly disappears and atrophy of the affected limb soon sets in, in which — as I have frequently seen— even the bones may participate, so that finally the scapula and the bones of the arm and hand are considerably shortened as com* pared with those of the healthy side and the whole limb appeans stunted. Nothing can be expected from treatment, except in the enrlient stages of the disease. The continuous application of electricity, especially the galvanic current, may still be of use so long as the nerves are not fattily degenerated and the muscles arc still capable of reacting. At a later stage we can exi*ect nothing either from this or any other remedy whatever.

An excessive stretching of the brachial j)lexus may in Inter childhood, as in adults, occasion paralysis or at least paresis of the upper extremity sometimes lasting for weeks or months. I have observed, for example, paresis of this kind in the left arm in a little girl whose arm had been violently wrenched backwards and outwards while her jacket w»as being put on. The movement of the limbs, especially upwards and outwards was extremely limited, and it was only after several weeks of the contJDUous application of stimulating friction and finally of electricity, that the function of the deltoid was com- pletely restored. Such cases, if the cause is obscure, may occasion gi'eat anxiety ; since not only the parents but even the conscientious physician may not be able to exclude a cerebrml origin of the paralysis until the improvement decidedly begins. The same muy be said of the paresis or paralysis of an upper or lower extremity which children occasionally have for some days after violent ootiTulBive attacks. It is not possible in these cases to determine at once whether wo Imve to do with a parsing tlisturbance of motion or with a cerebral disease, since, as w« shall see presently, very serious cerebral diseases— especially tubercle — are not uncommonly announced by the suddtm oc-

SPINAL INFANTILE PARALYSIS.

247

cmrrence of convulsions, which leave paralyBiB behind when they go off It disappears again after some time, then returns quite unexpectedly ; or the true nature of the disease may ho revealed by the onset of tubercular meniBgitis. I therefore advise you in the diaofnosis of all kicalised paralyses, when their peripheral origin 18 not beyond doubt, to be very guarded and to keep in mind the possibility of a central disease even although no farther symptoms of such should be present.

One must of course also, under these circumstances, always

remember the possibility of an injury of the affected joints, of

a dislocation or subluxation of the jomts of the shoulder and

forearm, even of fractures of the bones, and examine carefully

for these conditions. I should not have mentioned this had I

not several times found in the polyclinic that these traumatic

ftflcctions had been ealled paresis by careless practitioners. The

contrary sometimes occurs in the lower limbs, whore a dragging

if the leg or a slight limp is falselj' ascribed to commencing

tcoxitiB, when it is only the result of the bruising of the muscles

['by II fall, and disappears in a short time if the child is made to

rest.

IX. Spinal If{f(intUe Paralt^sh,

This disease — which, before its patholog)' was known, was described by the name of " essential paralysis '* — derives its particular interest from its comparative commonness, and from

Iihe severe effects which it has during the whole lifetime of the patient. Most of the cases you meet with affect children between one-and-a-half and four. The j>arents state that the ^hild some weeks or months before lost the power of an arm or leg, or even of several limbs. On examination, we find iu a cer- tain proportion of the cases that the affected limb is really quite lUotionlesB. The child does not make the slightest attempt to grasp anything or to stand on his feet. The w^hole limb is as flaccid as that of a doll, so that you can throw it about in all directions without resistance* The sensibility, on the other ^iiand, is almost always unimpaired. In other cases the paralysis already beginning to diminish. Certain movements of the imb can be performed, others are quite impossible. Thus, for

248

MSEA5E3 OF THE XEKTOTS STSTEM.

exjunple, the ioreann can be prettj ivell flexed «n<] extended ti Ibe elbow joini sod the bind fti the wrist, while moTomeiita of the upper arm oatwuds mad npwmrds, and the pronntioii tad gapinmlioii of the hand are either quite impossible or can onlf be efeet^ to a rerr limits ' ^ All tliis liine the chiid ft

naiiallj qnite well; all its s are iii good order, atvd ifin

appearanoe generallj tery good. The sphineters of the bladder uid bowel are only ezeeptionallv afieeted. The commencemeiit of the malady is almost always described by the relatives in ibd_ same way as in the following casea, which I ^ve as examplea.

On the 2*nh July. 1S74. & girl of i /tJiirs w«« Ijnia^ht svlting room. Formerly healthy^ «be bad tnkeii tl) au ._ . . in September^ 1^73^ — ^that is, ftlioat lOiDOiitlis before — with rioUat ferer, the temperatare rising to ll»5^ F. The child compUtii#d at the same time of headache aud waM drowsy. Tbere were ne *r local symptofns. After 2 days, the trmpemturc fell. Wh/tn tried to stand up, wc Doticed |iaralT^)i« of both lower c>t' 't remit ies aodof the right arm. In the rounse of 3 or 4 dayi power returned to the legs; she roold then walk, but the arm remained paralysed, and on esarainaiioii it presented the characteristic symptoms which we are about to describe*

Child of 1| years, brought to the polyclinic on 15th October. 1881- Three weeks previously, ferer hLsting for several days. Tins was snccecded by paralysis of all four eztrcmtti^9« When brought to me, the moTement* of the arms had alr«^y almost returned to the normal state, but the paraplegia r«*maiiied uncluuiged. One week Uiter th» was also tol^ II

moved, while the right wa<» c%m {mralysed. i v

perfectly normal.

This is the usual eourae. In the midst of perfect health the children become fererish (occasionally the temperatare is rery high), they comphtin of headache if they are old enough, aud are somewhat drowsy. More rarely they lie in a regularly -> ,

half-conscious state, out of which they can onlv'xrith di dc

msed by shaking; or they may even'show couml&ive moTem'ents id contraclures. Still more rarely Uie disease Ih^ub with courulsive ht«, and iu one of my cases th«e were mpeatod 7 or 8 t^mca in ouo n.ght AAer a few days^or a week at moi -this cond.uou paaaea off. and the p^nta aro alarmoTlJ

For tmrticoUw on tlw Jo«^lim|i„„ ../ » ^ t* ^ i

and ibcir rvUtion to «v»rT«»pc>j<i|^^ ^ * »5*rtala frrtmfM of »a«!«le*.

SPniAL INFANTILE PARALYSIS.

249

finding that one or more limbs cannot now he moved. In a less nnmerons class of cases the preliminary febrile stage seems not to occur at all, and the piiralysis comes on almost suddenly, without any premonitory symptoms, iu the morning after a good night's sleep. Without wishing to deny that this form of onset occurs, I still think that the relatives — especially in the lower classes^ often overlook shght preliminary disturbances. Now, as to the seat of the paralysis, either both legs and one arm* or a leg and an arm on different sides, rarely an arm and leg on the same side muy he alYected (iu a hemiplegic form); or still more rarely it may be both arms, and more frequently both lower limbs, and sometimes fven all four extremities. The paralysis is also often confined from the lirst to one limb only. The characteristic point however is, that the paralysis almost always reaches its worst at the very beginning; all the harm that is done» is done at once (as in the apoplectic paralysis of adults), or at least in the first 24 — 48 hours. After that there is a distinct tendency towards improvement. Only quite exceptionally have I been told that the paralysis continued to increase after the first week, or passed after some days from one of the lower extremities to the other, which Duchenue lilso observed. The power of motion is in many cases very rapidly recovered, as in those just given. Even after a few days, or after a week, one or other limb is once more able to exercise its functions ; or some groups of muscles in a limb may be capable of motion, while others remain absolutely paralysed, HO that we have an incomplete paralysis of the affected limb. In the upper extremity, the muscles of the shoulder and upprr arm are especially affected, less commonly those of the forearm, so tliat the hand and fingers can generally be moved ; while in the lower extremity, the muscles of the leg, supplied by tlie peroneal nerve, and in the thigh, the quadriceps muscle, are especially apt to be paralysed. After some weeks the paralysis 18 oftener still confined to a single group of muscles in one arm or one leg, but in these they usually remain with a sad persist- ence. After many months, and even years, the condition may be unaltered, and it not nnfrequently remains so for the whole lifetime. In other cases, however, the paralytic symptoms, after remaining for months, improve in a moat surprising way, as *'.//, in tlie following case : —

250

DISEA8ES OF THE NERVOUS SYSTEM.

Child of 2 years, brought to th© poljcliuic on 17th ALirdti. 1882, Seven months l)efore, fever lusting souu? itttyn, sud general malaiae. This was Huceeeded by [wiralysis of tht? rauHrlw of the nerk and of all four extremities. After some we<?kN th>' head could again be held up, hut tho parnlysis of the npp»*r ami lower extromities porsiRted almost unchanjjed for t h reo month*. »o that the child could not grasp au^^thing, and vfns uimUle {** leiive its hcd. After this time the paralysis of the right umi and left leg disappeared under electrical treutraeut; finally ul«o thill of the right lower limb and of the left forearm, so th.at when hi* was hhowu in the hosjiital there xras nothing to !«• r»i \n%

paralysis and atrophy of the upjier arm. ct*pc*ciully of t I

Wheu tbc! paralysis has existed for some weeks, uj months, a number of additional symptoms appear which lausl be regarded us quite characteristic, and which at once place the diiigiiosis of the disease beyond a doubt. These symptoms are : increasing atrophy of the paralysed extremity» diminution of its temperature and of its electrn-niuscular excitability* The paralysed limb diminishes steadily in circanaference owin^' to wasting of the muscles. The region of the deltoid and the shoulder muscles, ef=*pecially, wastes iu u very marked manner. so that a space may be fclt between the acromion and the head of the humerus, and tho shoulder seen from behind looks much flatter than the healthy one. The upper arm and forearm also become wasted aa a whole, all the muscles are shrivelled and thin and the ligaments strikingly loose, so that the affected limb may appear a little longer than the healthy one. In very fat children the atrophy of the muscles may appear less than it really is, owing to the amount of adipose tissue. When tJiie hand is applied we feel distinctly the lowered temperature of the paralysed limb compared with that of the healthy one; and we have been able by a suitably-constructed thermometer, to measure this diminution, which may amount to VS^ F« The behaviour of the muscles to the electric current is also very charactenatic I have DO experience of the increased faradic and galvanic reac- tion which some (Benedikt) h«ve observed daring the initial stage of the disease. When the paralysis is present howcvir the reaction disappears almost as completely as in peripheral paralysis — that to faradic electricity especially early v<l.;i.. tht^ galvanic current still acts, and may even cause an • lod

reaction (reaction of degeneration). Occasionally eveii ou tht»

BPINAI^ INFANTILE PAKALYS18.

251

iiftli (lay after the onset of the paralysis (and more frequently ?r one week) some of the muscles contract but feebly, others lot at all to the faradic current. This is always a bad si^, for when the muscles cease to react some weeks afte-r the onset of le disease, they usually remain incapable of reaction during the ^bole life. The further tbe degeneration of the muscles proceeds, the weaker does the reaction to the ^'alvanic current become^ until fiDally it also entirely disappears.* The plantar retlex (on tickling the soles) is usually absent, as also tbe patellar retlex

I (knee-phenomenon). Still we must remember that even in Wealthy children the latter is more difficult to obtain, on account ^f their stniggUng, and especially stretchin^^ out tbeir le^^s, and therefore it more frequently fails us than in adults/- I In addition to the atrophy of tbe muscles, an arrest of growth 111 the bones is also observed, so that the limb appears shorter than the healthy one. This arrest of development of the bones, Duchenne and Volkmann have pointed out, does not always proceed pari passu with the degree and extent of the paralysis id of the musctdar atrophy. The latter may be very well larked, and yet the limbs scarcely appear sliortened; while in ime cases, where paralysis and atrophy are only very limited, ic growth of the bone may be arrested to a considerable extent, 'his fact, according to Charcot, is in favour of the direct ifluence of the central disease on the nutrition of the osseous retem.

If the paralysis is not recovered from within ten or twelve

lonths from its commencement, there is generally but little

)pe of any recovery taking plnco at all. About this time a new

jries of symptoms usually develops. As the paralysis and

>phy do not aft'ect all tbe muscles of a limb equally, but are

* iy. on Una ftnbject, 8e«ligmiillcr, Gerhardt's JIanM. d, Kinderlmnlk.^ B*l. T„ Abth. 1, 2. Hilftc, S. 68.

» Eu leu burg yltfutgche Ztifithri/t /, ittHtkt. Med,, 1878, No. 31; wid Ntmrof, 7entrnlhf,, No, 8, 1882 ^ in 12^i ctiiMren between I and 5 yean* of age found the

Kyc-ytbenomenon ub^iGnt on both widee in S'iiS per wjnt., and on one side in 2'42

>r ocnt. Vitlt also Haane, Btifi\ zur Stati/ftU- tier Iteffc^e t>ei Kittd^rn^ Dm,: XreiUwaiA, 1882.— Blooh, \,Arch,f. Ptijthlittru a. Ntr&tnkmnkk.^ xii., 1882) and 'arago, Arch.f. Kinikrheiik., viii,, S. 3851. Poliy-aeu* \ Archiv f, Pjit/vMatne^ Iv., H. 2) found only I oat of 2,103 children in whom he wa« neroraVd© to obtain Ipatcllar reflex, while Zo is ing^ yUehtr dax Kmephdnometi u.fjp.^ JUas. : Halle. 1887) tiled entirely t:> find it in only I'i per cent, of hi.^ Ciu*os, ulthoiig-U it wa« of ton idistinot or much diminished (altogether in about 11 per ccnt,i. We arc cvi- itly not yet in a po^ition to «ipoak dogmatically on this matter.

252

DISEASES OF THE NERVOUS BTBTBM.

almost always confined to single muscles or groups of m' deformities are prmluced by contraction of the opposio* muscles which have not lost their tone and contractility* In the great majority this takes the form of pes equinus, but we mif also haye pes varus, club-hand, and other abnormal posturts of h the upper and lower extremities. This explanation of the d<" V| formities as due to the contraction of the antagontstio moiclec, was generally accepted until very recently, and still has mioy supporters. Hiiter and Volkmann were the first to ley to replace it by a mechanical explanation, according to which the deformities are supposed to be due to the position and weight of the limbs; while others (Hitzig) take into account in their h explanation the contraction of the connective tisane ^f tiie^| muscles whose nutrition has been interfered with. However " this may l)e, when the deformities commence the disease may V»e ref^arded as having reached its last staj^e ; and wa have then only to do with a crippling which the patient will have to carry with him to the very end of his life.

The anatomical researches (to which the first impulse was given by C o r ni 1 ♦ L ah o r d e » and Charcot in the 8ali)ctriere in Paris in 1HG3-4) prove that the former views of the nature of the disease — that it was an ** essential *' affection, or a disease of the peripheral nerves or of the muscles — were incorrect. They have entirely confirmed the supposition of those physicians (Heine) who regarded the spinal cord as the real seat of origin. Almost all the anatomical observations, indeed, were made ou the lat^r stages of the disease, generally even on adults and oM people, who had carried the infantile paralysis into old age. All the obseiTations, however, prove this fact beyond a donbt, that we have to do with an inflammatory process of the grey substance of the anterior horns of the spinal cord, which may extend into the antero-lateral column. Sltgliti changes in the posterior horns have also been found in excep- tional cases. We find patches of myelitis either in the uppr or lower part of the cord, according to the position of the paralysis especially in the cervical and lumbar enlargements. In com paratively recent cases—as in those described by Boger an<l| Damaschino* — in which the paralysis had existed for two aiid{ six months respectively, these patches ha<l a letigUs of jiImhi

I

8PINAL INFANTILE P.UIALYSIS.

253

1"

i

or

i

— 1| ctm.» and a breadtb, at their widest part, of 1—2 mm. ey were of a soft consistence and reddisli colour, and under the microscope showed an increase of the capillaries, a thickening of the walls of the blood vessels with n profuse formation of nuclei in them, and yery numerous granular cells. The multi- polar fjauglion cells of the anterior horns, and the motor root-libres passing from them wore atrophic ; and slight sclerosis

f the white anterior and lateral columnsi was to bo found.

oth's case,^ which had lasted Heveral months, was a (juite

milar one ; hat in it the patch implicated on the ri^ht aide not only the antero-lateral column, but also the posterior column. A case recently published by Archambault and Dama-

chino^ is of especial importance, because the post-mortem

ok place on the 20th day after the commencement of the

isease.

pHraIysii3 of the left lepj. SenBibility normal ; all reflcics absent. Pttrei<is of the right ami; psiralyaia of the neck; fiirftdic reaeticm entirely absent. Deuth tVom measles ami ljr<jjic'ho-|jiicLimonia. t,'M.—\\\ the grey a?uerior horns* of the cervical and hiinlMir I'Ogioiis thero were ypvenil very small |)abches uf softeiung; Vi?a.sela uver-disjtended with hlood ; iiiiuieroiLd j^-aiiulur cells ; the giiiigliuii cells very atrophic. In the anterior nerve-roots and at their point of origin in the grey anterior horns and white anterior columns, the medulkry sheath and the axis-cylinder were wanting, llie nerve aheathew were partly emfity and partly contained medullary uubatftncc which stained bltck with osmic acid, exactly as in nerves which have been divided.

oi

I

The older the trouble is, the more prominent is the appearance on which Charcot laid especial weight, namely, the atrophy f the multipolar ganglion cells, combined with sclerosis f the grey anterior horns and atrophy of the motor root-tibres ussing out of them. In old cases, especially when the post- mortem 18 not made till an advanced age, we may have a diifuso atrophy of the anterior horns and of the white substanco of the antero-lateral columns, with disappearance of the large nglion cells and development of numerous corpora amylacea [Charcot, Leyden*), even an arrest of development and atrophy

• Virohow'a Archie, 1873, Bd. 58, 8, 263. V'uk olao P. Suhultae, Ntwol Cen- i/W.,i.,No. 19.

Rtifm meni. dtn maiaditi de Ven/ance: V4vr,, 1883.

KHniU der /iKclmmarkdranlh. ; Berlint 1875.

254

DISEASES OF THE NEHVOUS SYSTEM.

of the motor area of the cortex on the side of the brain op|!io»ifce to the paralysis.'

As regards the muscular atrophy which plays so iniporliiut

a part in this diaoase — a large part of the primitive bundles sr^m

simply to atrophy in the earh'er stages without undergoing fiitt?

degeueratiou (Damaschino, Vol k maun and Steadeuerl.

The accumulation of fat in the sheaths of sarcolemma beginu •!

a later period, filling the place of the primitive bundles whicb

have disappeai'ed ; and at the same time also, in the tnterstiotM

between them — sometimes to such an extent that the atrophy of

the muscles is concealed by it, and their volumn appears normal

or even increased (Laborde, Charcot). This formation of fill

is, however, by no means invariable ; it may be present in BOine

muscles and almost completely ahaent in others, iu which caw

the interstitial connective tissue appears more or less hy^jertru-

phied. The appearance of the muscles to the naked eye varies

according to these differences. They are either thin and pale-

reddish or yellowish ; or else bulky% and in that case they se^m

to be almost entirely converted into fat. Wlien tliore ia g^nml

emaciation, moreover, this fat also disappears and the atrophy

of the muscles is then all tlie more distinct. The nerve-roots

Mud nerve-trunks, also, have not uncommonly boea found

atrophied in the paralysed parts, and they then appeared attenu-

atod and grey ; while in other cases the thickening of sheaths

and the increase of interstitial connective tissue and fat concealed

the atrophy.*

The appearances hoing such as I have described^ there can no longer be any donbt that spinal infantile paralysis is to be at- tributed to a myelitic process occurring in patches, which is most apt to affect the gi'ey substance of the cervical horns, especially the cervical and lumbar enlargement,* In course of time the process may, as already remarked, spread to the antero-lateral columns, and may indeed occur in a diffuse form both above and below J and in a few cases an affection of the grey substance of the posterior horn has even been observed — which explains the

• Rumpf « Arch./. Py^-kiairit, Bd. xvi., Hoft 2, -Sand or, iKwru f^mjU* 4t Charcot: T. iv., Paris, 1887, p. 38.

^ ty*, on tb(» chnnges m the mcscles and faorrot, Kt««li]olir, f>KMttihM Arckh/, ai0i,MeJ,, Bd. xiTi,, S, 543,

• lCuB»miitil ibcrefore propo»cd to niuna the ()i8«iM *• Ptoliomyditii neutm auierior/*

BPINAL INFANTILE PARALYSIS,

250

let that occasionally disturbanceB of the seneory functions

jttntefithesia, pains) have been observed — but this is always an

'exceptional occurrence. I have myself met ^ith one case of this

I kind, in which the f^'reater part of the paralysed leg showed Iohs bf sensibility ; while in another child of two years (18 July 1879) Hie disease had begun three weeks before, with four days of fever l^nd severe pain in the left aim. The arm on the fifth day was jgnite paralysed, but still retained sensibihty. Theso sensory derangements — especially as occurring in the first stage of the disease — have been already mentioned by D uch enne , K e n n e dy, Yulpian and others ; but very little attention has been paid to ^■tliem, owinpf to the fact that they are very difficult to make out, ^fcspecially in children who are too young to speak. The implica- ^HUoD of the sphincters of the bladder and bowel has only been ^"observed in exceptional cases. I have also repeatedly seen the muscles of the neck affected. Thus in a child of three, after febrile initial stage lasting two days, there suddenly appeared tralysis of the right upper extremity, and of the cervical mus- cles on the right side. The head could no longer be held upright, mt rolled about in all directions, and when the child was lying (own he could only move it to the left side. This paralysis dis- appeared after a week, while that of the arm continued and was )on accompanied by atrophy of the deltoid and shoulder muscles id by diminution of teraiieraturo.

All authors agree in saying that the brain is not affected.

Leyden* expressly says that the facial and hypoglossal nerves

id the eye-muscles have never been found implicated, and that

he has only in one case found a small sclerotic patch in the

ledulla oblongata, which bad caused no symptonm during life.

'bese facts seem to me to make the fulknviug case all the more

fmportant.

Ttprtliii M.» 2J years old. lirought to niy polyclinic Dn 1st May« 187'i. Three weeka befoce, she hud .-vtidden fever v^rith vomiting iiiid pcTKi«teiit ih'owsiness. These itymptoins continued 2 days. On tho second duy weakness of the right hiind was already notice- ftbk', and on the third paralysis of the whole; right arm. Drowsi- neaa continued far 3 days after this. The child then seemed wgll,

* Lftnrcnt, '* SytnptAniBH pp(Smonitoiirc*de la p&ralyne spinale lugTii^/' TAiw /\ir«V. 1837,

• l«c Gitu ii., 8. 555.

256

DISEASES OF THE NERVOUS SYSTEM.

but there was paralysis of the right arm and of a portion of thi

left facial nerve. The latter had not (juite disopp- * ' en T examined the cbild- The left eye still i'omftino<i half-c; «b«*

acrcamed or cried, and the mouth was ?oniew)i:it dniwn l*> side. The right jirm hung down flaccid, the apjier arm \^ immovable, tlie forearm movuble at the olliow joint ; the udducitot) of the thumb was the only movement possible in the lumd. Tl»r rauacles on the left side of the face gave the normal roacttoa t^ the faradic current, while in the right upper extremity only thr 8exor and adductor pollicis and some Bngers were movwi. All the other muscles gave a yery weak react ioQ or nane at all. Th** galvanic cuiTent waa not tried for want of the uppanitns, 8<m9i* bility, bulk and temperature normah From May to the md of October the faradic cuiTent was applied almost diuh% mhI finallT brought about a marked imjirovement. The flexion of the oUnjw and wrist joints, the movcmctit of the thumb and of thr Uh and 5th fingers almost normal. On the other hand the arm could iMit be moved outwards or backwards. The deltoid and mii^cle^ of th« shoulder much wa.sted, and the whole right extremity colder than the left. The ilnd and 3rd fingers stitHy flexed and could U* voluntarily extended. The facial nerve had recovered its functional activity completely by the middle of May, without electric lirat' ment. I did not see the child again till 28th April, 1879. At that time she had lj«en treated with electricity for nearly a y*^r, and hi\d made considerable progress, so that the arm cnnld now be moved backwards and outwariU. The atrophy w»« still unchanged, and the right hand markedly h mailer than tin-' left.

The characters of spinal infantile paralysis are in this cts^ very well-marked, and the implication of the facial nerv<» forme, therefore, an exceptional feature not hitherto descrilied. I must assume that in this case at first, aimnltaueously with the patch of myelitis which appeared in the right imterior horn of the cervical enlargement, a very limited patch of oncephalitia had developed in the neighbourhood of the nucleus of tbe left facial nerve. The latter after a few weeks un.l complete resohition, while the myelitic process persisted] and led to partial atrophy of the ganglion cells. When one members that other ftpinal affections — for example, n '" ' >5clerosi8 — are not at all uncommonly comhined with aij changes in the brain, one cannot really see why Iho should not occur in infantile spinal paralysis. The occutrenc of coma and con\iiUiond in many cases w^th a febrile initial stage, is in fact in favour of thu view that the hratn may

SPIKAL INFANTILE PARALYSIS.

257

more often affected in this disease than we are wont to suppose,*

The symptoms of spinal infantile paralysis are so well-marked and characteristic, that it is scarcely impossible, if one exercises any care at all, to confound it with any other form of cerebral oi- spinal paralysis. The febrile initial stage, the sudden onset of the paralysis (which ia almost never progressive, but always retrogressive, and from being widely extended at first rapidly diminiBlieB till it is contiiu'd to a more limited area)» the almost iBTariable immunity of the sensory functions and of the sphinc- ters, the rapid disappearance of the reaction of the muscles to the faradic current, the early atrophy and fall of tempera- ture, and, finally, the deformity— all these are found thus com- bined in no other disease. I therefore consider it sapertluous to discuss here, one by one, the diseases which might possibly be mistaken for it The question, however, arises — whether all the cases which present the clinical characters of spinal infantile paralysis are really caused by these disseminated patches of myelitis as they have formerly been described to be. In fact, it cannot be denied that peripheral paralysis of single limbs — of one arm, or of one lower extremity — may resemble perfectly in its clinical characters the central affection which we are consider- ing. From the effect of i n j o rie a, especially from over-stretcliiii*^ or compression of a nerve -trunk (p- 245), and dislocation of the shoulder-joint, paralysis may arise and be accompanied after a short time by atrophy of the muscles and loss of their reaction to faradic electricity, just as in certain caaes of peripheral paralysis of the facial nerve. Duchenne has already pointed out this congenital dislocation of the humerus as an affection similar in its symptoms to infantile paralysis. One thing however is wanting in all these cases of paralysis, namely, the febrile pre- monitory' stage, sometimes accompanied by cerebral symptoms. Many years ago Kennedy described cases of paralysis which arose quite suddenly without any warning in perfectly healthy children. In some of the cases the children went to bed well and wakened in the morning with paralysis of a lower and upper

' SeoUgmUller givea % o^ae not nnlLke my own {Jahrb. f. Kmderkeilk, xii.. 1878, 8. 348). BiBenlohr girM another {Arck./. Payckiatnt und XtrvtnArankk., Bd. ix, and z), which wna not really a cajie of spinal but of *' bulbar " paralysis ; and in it atrophy of the ganglion cells of the left anterior facial nnclciia wa^ dia-

VI

258

DISEASES OF THE NEBVOUS STSTBM.

extremity, wbich as a rule again disappeared after a varying perioil (the BO-called temporary paralysis), but might also take the same coarse as spinal iufantile paralysis. In such cases, cue looks for local causes, without, however, always 6mling ihmkl and in that case we either assume that the head has pressed on the nerves of the arm during sleep, or that there has been a cbiiL. or reflex irritation from teething — though the assumption h*j» generally not much to go upon. The teething, at any rate, which is blamed by English writers, I have not been able in od»* single case to make sure of as the cause of sach paralysis. At any rate these cases of paralysis which Kennedy has described are very various in their origin, and a small proportion of them seems really to belong to the class of spinal infantile paral^

Uncertainty in the diagnosis can only arise when we have' imralysis of one limb along with atrophy of the muscles and of their reaction to electricity. For when the paralysis ts extensive there can be no doubt that it is due to myelitis.

I'he only disease which can possibly be mistaken for tbia is the "atrophic cerebral paralysis" which I shall describe presently. But in the latter we are generally guided in the diagnosis by the implication of cranial nerves, mental derange- ment, and the condition as regards electrical reaction,

I think I ought to mention that cases of simple atrophy of one or other extremity, occasionally occur with somewhat lowered temperature, at the first glance reminding one of spinal infantik paralysis, but in Mhich the muscular strength is little if at all impaired, and the electric reaction is normal — where, therefoM, there is no paralysis whatever. Such cases of atrophy may depend on a defect of primary formation ; as, for example, in a girl of 7 years, always healthy, but left-handed, whose right hand, left thigh and leg had always been to a certain extent atrophied, without the strength ha^'ing sufl*ered, and without nervous symptoms ever having been observed at any time. In such cases all the tissues — bones, muscles, and fat— in the aflfecled extremities show a weaker development than the corre- sponding normal limb. In another case-^that of a child of 7 months— the atrophy of the left leg and foot was tlie result of the nmbilxcal cord having been twisted round it in a spinl manner. Here also neither the motility nor the electro-muscnbr contractihty had in any way snflfcred. In some cases of thii

4

I

SriNAL INFANTILE PAPkALYSlS.

259

kind tLo mothers had not uoticed Uic u trophy at all, and it wus first discovered accidentally in the hospital.

We know prncticuJly nothing about the cuubLw ul spiual infanlUe paralysis. The disease m-ts in its a rule qnite suddenly, and in the midst of perfect, health, and even in spite of the most cai*cful investigation we hardly ever succeed in finding anything which could have occasionod it. In one of my cases a fall into water was given as the caoae. Occasionally we observe the Bymptoms of tjpinal paralysis after i n f e c t i o u s diseases^ for example, after scarlet fever, measles, smullpox, typhoid, or pneumonia. In most of these eases recovery takes place; still, atrophy may appear during the further progress of the case, and it must for the present remain undecided whether the pathology of these cases is quite the same as that of infantile spinal paralysis. I may simply mention in passing that the lutter. thoagb much rarer, yet may occur in adults and present all its usual symptoms.

In most cases the physician is not called in until the disease has already lasted some weeks. If you are summoned in the iicute premonitory- stage, you never know, of course, whether npiual paralysis is about to dcvclope, because you find nothing bat more or less high fever, with or without cerebral symptoms. If the hitter are present we should apply an ice-bag to the head, in ver)^ severe cases a few leeches behind the ears, or to the temples, and order purgatives (calomel, gr. { — j every three hours, or mist, sennae co* &c.). When, however, the paralysis has declared itself, I no longer expect any result from internal treatment. Experience teaches that nothing can favour recovery from the poi-alysis and prevent atrophy, except electrical treat* ment begun as early as i?ossible. Although some, c,;/. Heine and Vol km an n, maintain that electricity is not of very much use, or that all hope is to be given up if it produces no result within a year, this view confiicts with the gi'cat success which Dachenne and others have hud, who have succeeded, even after the expiry of a year, in obtaining results by persistent treatment ; and the case given above (p, 255) is another proof of the same fact. We can, therefore, only give the advice to per- BeTcre ; but this is just the very point where many parents fail, and even many physicians also. We may begin the electrical treatment a rery few weeks after the onset of the disease. The

260

DISEASES OF THE NERVOUS SYSTEM.

galvanic current is recommended* very properly, for tkis earlj stage, becanse the faradic is too irritatlDg and painful for cbildren, and, besides, the reaction to it may already be macb diminished, or even altogether wanting, while the galvanic current has still a distinct action. According to the rich ci* perience of Duchenne — who, however, only used the fanidir current — the treatment at the commencement must be vi^ry cautious. It must begin with a weak current, be applied only thrice a week, and continued each time for not lonj^er than finv, or at most ten, minutes. In the later stage the faradic suits ^ well, perhaps even better, than the constant current ; for it is then our object to excite the muscular fibres which have not yet

■degenerated by a pow^erful stimulus, and to favour their natri-

' tion. I repeat, that the treatment in obstinate cases must be persevered in for years before the case is given up for hopelesfi. Along with electricity, massage and gymnastics are to l»d recommended; and these, when properly used, by occasio; regular exercise of the muscles which are not yet complete' incapable of contraction, have the power of strengthening their function, as well as of favouring their nutrition, Pu the later stages, we have to avail ourselves of orthopaidt surgery, in the form of apparatus and operations (tenotomy}. We may thereby endeavour on the one hand to prevent de- formities and support the atrophied muscles, and on the other to remove the contractures of the opposing muscles. It is the old cases of infantile paralysis that furnish a targe pro- portion of the material in the orthopaedic institutes, and Heine's celebrated work* which has done so much to introduce sound views on the subject of infantile spinal paralysiR, is its the outcome of bis orthopaedic observations. The manufactui of such apparatus, as well as the form of gymnastics to bi employed, must be suited to each individual case, and in most

"^cases the physician should get advice and assistance from an experienced orthopiedic surgeon and a clever instrument maker. Among the lower classes I have on several occasions f i «i-

'telligent fathers, who of their own accord had coi ,1

apparatus which in spite of its simplicity and cheapness answered the purpose pretty well.

Although the recovery of the electrical reaction is alvrayi ao

r * Spmak Kinikrl4kmmnf^ Mon^ffrofikif,, 2 Anfl. : Stattipifi«

SPIK^ INFANTILE TiJULYSIS.

261

»

extremely gootl eigu, atill, experience sbowB ibat tbis reacLion (to both kinds of current) may still he absent wlieu tbe first traces of voluntary movement be^du to make tbeir appearance, and we must tben continue tbe application of electricity all tbc more steadily. Otbor metliotls of trcatnient I cannot recom- mend to you, I have no faitb in tbe use of iodide of potasb, either at the beginning or later on, and tbe injections of strychnia (gr. 3V — 21 gr. daily) which are occasionally recom* mended, have bo far-^iit my bands at leasts bad no effect. Wliat can, however, be recommended — where circumstances allow of it — is to send such children during Ibe finest part of the year into tlio frcHb mountain or forest air, and to order brine or chalybeate baths, which by the large amount of carbonic acid which they contain, liuve a Btimulatiug influence on the cutaneous st-usory nerves, and in tbis way act retlexly on tbe motor functions, if there should be any normal muscular tissue left. But neither Rehrae and Naubeim, nor Schwalbacb, Pyr- mont, and Driburg, nor. finally, the equaDy famous indifierent thermal waters (Gastein, Wildbad, Ragaz, and others) will do any gootl whatever, apart from their action on the general health, nfter the case is old, the ganglion cells already atrophied, and the muscles in a state of contracture and fatty degeneration. Undur these circumstanceH nothing is any longer of use, and the patients spend the rest of tlieir lives as cripples.

Spinal infantile paralysis is tbe only disease of tbe spinal cord which is especially liable to affect children, and in doing so pre- sents certain characteristic symptoms. The only otber spinal disease which plays an important part on account of its frequency in childhood is th*^ paraplegia resulting from disease of the vertebroe. But it difters in no way from the same condition in adults. There is the less need for discussing it here, as the vertebral disease which occasions it is fully considered in all irgical works, and also because the ti'eatment almost entirely levoJvcs upon tbe surgeon. It is certain tbat in cliildhood many jther diseases of the spinal cord do occur which occasion paralysis, mch as intlammatory processes, haemorrhages, tubercle, even lumours of different kinds ; although they are much less »mmoD than in adults. These conditions do not present any- ling peculiar or characteristic in children. Their symptoms are \e same, and their special diagnosis is in most cases just as

263

tvISEASES OF THE KERVOUS Sygt^M,

difttcult— in fact as imposaiblc — as in lutpr life. There ure Iwo diseases in particular, the occurreure of which in childhooil h within recent times excited considerable interest —s c I e ro 8 i 8 ai the so-called "spastic spinal paralysis." The fomier Ii«s been verified post-mortem in children, although but rarelj; and we are indebted especially to Friedreich for our lnioiiied«^ of a condition of sclerosis of the posterior columns fhroagWrn their entire length, with the occasional implication of the Ititcml and anterior columns. This condition devfilopes hereditarily* especially about the time of puberty, is distinguished clinicallv by ataxic movements of the lower extremities to be^fin with, later also by interference with speech, paralyses of the eye- muscles, nystagmus and loss of the reflexes, and has axk ex- tremely protracted course, lasting as long as 30 years. Spastic Bpinal paralysis, as is well-known in adults also, is httlo more than a group of symptoms corresponding to no quite definite pathological change. Such cases — which are characterised by a chronic pare«is of both lower limbs (rarely of the upper), existing even from the first year of life, and especially by contractors of individual groups of muscles — ^I have frequently met with in children. In tliese cases especially on trying to stand or walk, the attempt to plant the foot on the ground at once prodiicctl trembling and a rigid contracture of the calf-muscles, with the feet in the posture of pes equinus, and from the stiffness of its legs the child could only walk with much labour on the fore part of its feet, which were somewhat inverted — and even then only if supported or led. In many cases, moreover, there was such a contraction of the adductors of the thighs that they were almost crossed over one another, so that all locomotion was rendered impossible. This contracture also persisted when the child was at rest, and prevented active as well as passive separation of the thighs. The patellar tendon-reflex was generally exaggernloJ, the electro-muscular contractility, the sensibility, and the power of the sphincters not lessened, and no atrophy was n* ' ' • Unfortunately all these cases passed from under my ol- n,

nnd remained anatomically uncompleted. The numerous caseti of

' StttfHrmallur (QorhmtAi'm ffnndh.d. Kinderlrankh. S. 107) hA.1 obdorvcl ' " .1 with uti

totUM of bulbar par' 'iiluc sj*!!!

Abtti. 1. 9. M»lPt#.

PSEUDO-HYPERTROPmC MXJ8CITL.\TI PAR.iLYSIS.

2G3

I

this kind published by Seeligmiiller,' Forster,= Maydl,^and d'Heilly,* have succeeded just as little iu throwing light on this obscure subject. These writers, and also I myself have observed (though by no means constantly) a complication of the paralysis with deficient mental development — even idiooy,^ — stuttering or stammering, and spasmodic distortion of the face ; and this leads to the conclusion that the brain may participate, or that it may even be the point of origin of such a series of symptoms. In fact I shall lu-caeutly have occasion to give you an example iu which very considerable alterations of structure were found h\ the cerebral cortex at the post-mortem, I need scarcely remind you that under these circumstances a secondary degeneration of the fibres which arise in the diseased portion of the brain may spread to the spinal cord, and can be demonstrated microscopically* It is, moreover, possible in a certain proportion of these obscure cases by means of tenotomy and orthopiedic surgery, to bring about a certain degree of improvement in the walking, although not recovery.

ues< ■ Ori

X. Pseudo'fitfpcrtrophic Muscular Parali/nf,

his disease, first mentioned by Duchenne,^ but first described accui'atcly fi'om an anatomical point of view by Oriesinger,** iovariably originates during childhood, but may prolonged into youth or adult age. When the disease is well eloped, the symptoms are very characteristic. The muscles of the calves, buttocks and thighs — especially the first — are of unusual bulk, and frequently also of a remarkably hard consistence. Those of the chest, arms and shoulders are wasted and flabby, but not throughout their whole extent ; for on closer examination we also find nodular thickenings hero and

' lieuUeke med. H'ochetuckr.^ 1876, Noa. 16 Riid ll.—Jahrh.f. KindtrkeiU^y idi., 1878. « Jahrh./, KimderheitA., it., 8, 261.

' Boppreoht, ''Uober ftngeborene GUedorattirre and flp^stische Contraotur," iVolkmiinn'a Samminnp klin. Vorttafft, 198. — Mftydl, Kmigt FAlk von fpattU' \ckrr eerebrtupin filer Pttrafyite ltd Kindem : VVion, 1883.

rrH«ilIy, 'Rurne mens, dea nialndies de renfanoe," Die., ISW.—Nnof, l>i$ »pa$t. SinnatparatyfMt im KintitMlttr, i ZUrli^h^ 1885.

• Kltdruution locntUh, 2. c«dit., p. 353, And Arch *;,^>. Janv.— M»i, 1968,

• Arch, d, ffiilkunde.. 1865, vi.. 8. I,

204

DISEASES OF THE NBRTOUB SYSTEM.

tbere iu the delloitl, bicopSi and triceps bracUii. The recti ttbf!t>- jTiinis jiud the lumbar and doriEal muBcles, also, are often thickened, though not to the same degree as those of the lower limbs. Iu a few cases— <?.(?. iu one observed by Bergeron — all the mu9cle|| with the exception of the pectorals and sterno-mastoids were hjpertrophied, so that the child looked like an athlete. The patients' gait is very peculiar. They walk with their legs apar$a waddling, and only touch the ground with the fore part of tha^ foot, which is in the posture of pes equinus. At the same time the natural lordosis of the lumbar vei-tebrte is much exaggerate^ tforming a concavity like a saddle) omng to the weakness oP the erectores spinae.

If you make the patient lie dowTi on the ground and get up again, you notice that he *' climbs up his own legs/' as the phmse goes; that is to say, he first brings himself into il position which enables him to use bis hands as a lever to nuiw himself with, and linally manages to do this by placing his haodft^ firmly on the ground, then supporting them on the thighs, in Ihis way raising up the upper part of his body. In the late8t| Itage in which the weakness of the upper extremities reaches aoj extreme degree, this mode of raising himself becomes, on that account, no longer possible, I have hitherto had the opi of observing this rare disease only in six cases, and in i ^ ^ •• of them there was this peculiar method of rising up. All the patient's movements are in general clumsy, awkwaid and laboriously and they become weaker as the disease progresses. The electro*^ muscular excitability increases steadily with the progress of the disease. At the same time the adipose tissue, especially in th<|j lower limbs, may be well preserved, but when marasmus finallyi sets in it disappears. The atrophied muscles in the upper part of the body often present fibrillary twitchings similar to thosd^ in progressive muscular atrophy in adults. The skin of tbo^ lower extremities not uncommonly presents a marbled appear- ance, owing to venous engorgement, and a lowered temperature, but an increased secretion of sweat, Altuiy of these patients are mentally weak and their speech is slow, aud in rare cases aon increase in the bulk of the tongiie is said to have been observed ,

The development of this disease always dates, as I have already remarked, from the middle pcritxl of childhood, and it liaa been expressly stated by some that they have noticed tho

PSEUPO-HYPERTROPHIC MUSCULAR PARALYSIS.

265

slowness of the eliildren's nioTements wken tbey were even joonger. We see most of the patientB for tlie first time in the more advanced stage when they are 7 — 10 years old, and often much older. The diagnosis does not become certain until the bulk of the calf museles has become distinctly increased. In the earlier stage, when this is still absent and we notice nothing but the peculiar gait antl the above-mentioned character- istic method of rising up from the ground, mq can only suspect the presence of the disease. Still, in very recent times, the diagnosis has been established even at this early stage by the examination of a fragment of muscle, ' The general health may remain unimpaired. The case observed by Demme of a boy of 10 years with a slow pulse (44^ — 60), and a considerable amount of sugar in the urine (which however was not always present) stands alone as yet.* If the general health remains unimpaired, the disease may last 10 — 20 years, in the coarse of which time it often becomes arrested, but no real process of recovery takes place. If the patients do not die from a chance complication, they generally succamb in the end to the in- creasing atrophy and weakness of the respiratory mnscles, or to marasmus.

tThe pathological process in the muscles is very similar to it with which we are acquainted in spinal infantile paralysis, and in progressive muscular atrophy. We have essentially a diminution in bulk of the muscular fibres, which in the apparently hj^ertropbied parts (calves and thighs) is replaced by a deposit of interstitial fat, and hy connective tissue (atrophia musculorum adiposa). This compensation may also occur locally in the atrophied muscles in the upper part of the body (deltoid, A:cO in the form of isolated nodules ; and there are also ft few hypertrophied primitive bundles between them. In what manner this atrophy is caused — whether by the primary forma- tion of connective tissue between the bundles, as Charcot and Duchenne consider probable (paralyHie myoscli-rosique), or in

*er ways — cannot as yet be determined. Also the changes in spinal cord occasionally described (the presence of a copious finely-granular substance and many corpora amylacea, especially in the lateral columns and disappearance of a large number of the

• Bonrdel, " ReTue inon%. dea mnlaA, de ronfanco,*' Fevr., 1885, p. 54. ' 15, Jithrttlfti*, d, Btmti' Kinderfpit4iUf 1877.

266

DISEASES OF THE KERTO

large frangUon cells in the anterior borns) are b3- no meuis t© W regarded as canatant or essential. We discover notbiiig d» morbid on examining the pcnpberal neiTes and the sympatbeUe, altbongh even here neuritic changes have occasionalk bewi observed^ It iw only ovvin<( to the interference w^ith muTBBMOt that I have decided to place this affoction along with tho nerrow diseases ; for from a purely anatomical point of ri^w it is to be regarded as a primary affection of the muscles** I Mgm with those writers (Soidel, Erb^) who regard this duettse ii really an infantile or juvenile progreasive moseaUr atrophy, which differs from the form observed in adults m that it does not as in them begin first in the iuterosseoui nnisclea of the hand and in the musclea of the thumb, but n«j those of the back and lower cxtremitiea, sometimes ewo b tliose of the face.^

The progressive atrophy of the muscular fibres which finally renders many of the sarcolemma-sheaths quite emptj, corrt- t^pouds to the diminution of the electric reaction, which is e'luolly noticeable in the wasted and in the thickened mudcl««' Uu the other hand tlie skin reflexes and sensibility romaiu ^le fiumc. Indeed Steidel and Wagner made out a prolongatiou t»f the sensation of touch as compared with the normal condition.

It is worthy of note that with few exceptions {e,(j, the cases of two young women between 20 and 80 described by Lutz*) all the patients have been boys. OccaBionally there have been i Hoveral children in one family. Apart from this inexplicable^ (hereditary?) predisposition, all the other causes which hanj been suggested (unfavourable circumstances, scrofulous or rachitic cachexia) are open to doubt. I have unfortanately nothing favourable to tell you about the results of treatment The administration of me<licine has just as little effect as the compression of the calves by bandages recommended bv^ Grie singer, which may at most interfert^ wntli tho compenstttoryi formation of fat, but can scarcely be supposed to have any effect | on the muscular atrophy. Electricity, especially galranifim.j

' rf. Ktingar, tttuiMtku Arekip/. kiU. i/erf., Bd ixli., H»lt2. I

•' Erb, litutuhft Arcki^/, Win. Mtd.^ Bd. xxxir,, H. 5 tmU 6.— B««». WibJ WVAtfiMfA., 1887. No. 4. 1

' O. Hcutnov, *' Kin fiATftdoxar F*ll Ton infantOer tiro«rf««itr«tr Miuktfe^j tTOphie '* : LeipnuT. 1S87. j

* Hirtoh. Virohow /alnMtcrrc%^ \^m, n,. S. ^1 ; 1S07. it, 8. SR8. ^B

APOPLECTIC CONDITIONS.

267

iwayB worth a trml- lu one case which preflent^d all the eymptoms of the comraeBcino^ disease, I saw these disappear nnder this treatment in 5 — 6 months, Bourdel also reports a caae of this kind.

XI. Apoplectic Conditione.

ases of paralysis proceeding from the brain are observed in

children fur more frequently tban those arisinfr from the spinal

cord ; and their general characters— the hemiplpgic form and

the long persistence of the electric reaction in the paralysed

muscle — are just the same as iu adults. Atrophy of the muscles

j may also accompany the paralysis ; but this developes very

^^lowly, seldom attains to the high degree in which it is found

^■n spinal infantile paralysis, and appears to proceed more from

^fciactivity and long disuse of the muscles than from any inter-

BBerence witli the trophic influence of the nerves. It is frL-quently

accompanied by contractures due to excessive action of the non-

paralysed muscles, or oftener to direct central irritation, and

Nalso by tremor and automatic movements. I The onset of hemiplegia takes place iu many cases quite iBuddenly in the midst of upparently undisturbed health, { and we are then disposed to look for its cause=— as in adults

— in a haemorrhage into the brain or in an embolic process.

Both these processes, however, are comparatively rare in child- ^hood, and hemiplegia occurring suddenly is — in spite of its ^Kpoplectic appearance— much more frequently the expression ^^f long-standing brain disease, especially of tuberculosis II cerebri.

^H Let us first consider cerebral hemorrhage as a cause of ^^udden hemiplegia* The rarity of its occurrence iu childhood is I principally to be traced to the fact that the most frequent cause ^bf the condition in adults — namely, the fatty degeneration of the ^Krteries of the brain and the formation of small uncurisms in ^^hem — is extremely rare in children. Borne of the cases ' described as ** ha?morrhage '* seem to me rather to be cases of

encephalic deposits with a considerable admixture of blood.

In this manner, I belieye, we mast explain the following

case : —

some dmjs, Mlmiucd bio

cpsADB of the ex-

reri^iit «timlMst«u.

T, 101'3** F. TW

cttpfping. riuepBT hftd t>o effact

wHliui Mid viil>^

a«l iwl^ riid eire«lcs mad jmuhe^ Ttm

Dm mrtmcm iht oortax waa foond to \m

in otben ilMt

doBe logKlicr^ «»»

TW lietta-sBbBtAiilM alEeetid

«r m p«lpj eonialiaoe. At Um Imm

yf tbe p» DMUrr

tkr c^iMHim aad in tln^ Sjrli

Ib Iks CKK «« pmQt bid A larihr aMu&gitis combined witb

ksmarrbagic ejieepbalitifi*

in the diaesaes of diiidreo, «iiO haw hmd a totj kri^ aoMMuit of matemi ai oomnaaiid — Gveraattl^ Bec^merel. Billard, Rilltet, and Barthes — all ackao^irfga IImI tbev hrnvt seen renr few caae« of aimple C4vebnd bfunoctba^. nnderslaiidtng as suth those which coa]d Va eltnicallr reeogaiaad ; tot I hare myself often onongh met wilh small capUlaiy hinoiihagea due to fcnbeiniloais of ibo hrain, fnWirmlai' BMuqpiis, 8inos>thiomboai«, and other But anoe these capilkry bsxnorrhagae wtxe^ their by no BvmpUMna whaioTer, ihey hare only a pAlho- logical inUstesl. I have hitherto had no experienoe of hiig«r ot»rehfml hsmorrhages in children eonfirmed bj post-moi examin^ion. The few oaecA which I hare puUiibed olaew caaiiot be nsgardad aa quite condosire, seeing thai Ihej wen not obaerred up to the end. The same holds good of the follow- ing eaaes, although the diagnosis ts probably that of hiemorrhsgic apopleij.

APOPLECTIC CONDITIONS.

'269

roy of 7 years, fell suddenly from bis chuir, during a moul, and was at once paralysed on the right side of his body. Later on, steady lessening of the paralyais, which T was aUle fco follow for 10 months. Tlie lower extremity improved more quickly and decidedly than the upper, in w^hich the rigid contractioti of the tiesors of the fingers gave a clawdike appearance to the lianil and rendered it ahuost uselcfis. Dipping the hand in warnj water removed the contractures, and the extensors then acted pretty

jely. At first there was also a*phasia, which so far passed off fcliat after 10 minutes the hoy coiihi speak a few words. When the tongue was put out, it inclined distinctly towards the paralysed side. The sensibility and intelligence were completely normal, likewise the organs of circulation, as far as could bo ascertained by examination.

Id the case of a child of I4 years the course was quite similar. [Suddenly on a hot summer day, while in perfect health, he becBme mconscious while lying in his pei*arabulator, and at once showed right hemiplegia of the body and face. In coui^© of time, after about a year and a half, power of movement was almost quite restored to the leg by electric treatment, while the arm still showed partial paresis. The facial nerve recovered soon after the attack. Tlicre were never any symptoms of irritation in the panilyscd parts, and the general health was always quite good.

In these ca^es the cause of the disease remained unknown ; but in a child of 3 years who aufFered from yery severe whoop- ing-cough, I saw convulsions and coma occar after a particu- ^Jarly violent attack. These lasted for 9 hours, and left heLind ^B^iem hemiplegia of the left side. This continued several vveekH, ^■She arm and leg hcing flabby and quite incapable of movement. ^■The face was unaffected. Other writers also' have published similar cases which ended favourably , and considering the ^^hflemorrhages which so often occur from whooping cough, in the ^fconneotive tissue of the eyelids and conjunctivre, from the nosts and even from the ears^ — we may asaume almost with certainty that this was really a case of cerebral htemorrhage.

In the following case I believe that we must assume a t^emorrhage in the brain as the result of an injury : —

Boy of 4 years. On 7th August, 1879, ho fell from a bridge

about twelve feet high, on to the railway lines. Loss of conscious-

haemorrhage from the mouth and nose. After he whs

fv^^fBOr^, Jahrh.f. Kinderhtia,, x. 400., OtMUrr. ZHttchr., 1876, i«,, S. 138. ^CaRin {f^az. det Kfip., 37, 1881) foand under mmitar droam»taiioea 6^ ox. of blood b«tw«eii ih& bonea and dani mater over the left oocipital tnfuit^ intarniim).

270 DISEASES OF THE NERVOUS STSTEU.

tuken humo, fi*e(|uciit vomiting of matter mixed with blood. Oa the 8tb, lulmittcd into tho ward ; then quite conscious. Ecchy- mosis behind the right cur. Incomplete ptosis on the right side. Marked dilation and sluggishness of the right pupil, and paresis of the right arm. Pulse somewhat irregular, 80— 92. Temperature 98" 1° F. Steady improvement from the fifth day. Ptosis and paresis of the arm disappeared after 8 days. DiiFe^ encc of the pupils still noticeable on 24th. On this date he left hiy bed, and dragging of the right leg was noticed. On Slst he was discharged quite cured. Treatment: ice-bag to the head, re- peated doses of castor oil.

In a few cases of purpura Ltcmorrbagica also, apoplex}' has bceu known to occur in children. Mauthner publishes a case of this kind with a post-mortem. I have only one case recorded, which, however, Avas not fully confirmed as there was no post- mortem.

Child of 7 years. Scarlet fever 4 years before, followed by dropsy. Duiing the last year, purpura with repeated haemor- rliages from the mouth, nose, ears, eyes, bowel and kidneys. At the same time great weakness and loss of appetite. No enlarge- ment of the spleen. After treatment for 9 days, sudden violent convulsions and coma. Soon after, left hemiplegia with paralysis of the fneial. Death in the evening. Post-mortem not permitted.

Whether the extravasation — which in this case cannot of course bo doubted — occurred in the brain matter itself, as in Mauthner 's case, or between the membranes, must remain undecided. That the latter may happen we learn from an English casc^ in which efi'usion of blood was found between the dura mater and tho arachnoid in a boy with pnrpon, who died in a state of coma.

In the following case, also, in which aphasia was the only symptom, I think we must certainly assume the presence of a limited cerebral haemorrhage :—

On May 29th, 1878, 1 was consulted in the neighbourhood of Berlin, about a boy of 3 years who had suffered for 10 weeks — in- cluding an intei-val of 3 weeks — from intermittent fever. The last attack of intermittent fever had occurred a fortnight before, just one day after the boy had suffered a concussion of the brain from a fall on the head. His relatives being unwilling to defer a projected journey into the country, the boy had to travel

I Jown.f. Kinderlrankk.^ iv., 8. 318.

APOPLECTIC CONDITIONS.

271

during the hot stage and was seized in the i-ailway carriage with eclamptic c o 11 V II Is ion w, wbiih foTitinuoduhnojst without interrais' sion fur 7 hours. When he awaked from tlie comn, a iiitirked inter- ference with speech was at once noticed, which ijawsed after 24 hours into complete aphasia. At firet there was also head- ache and increased temperature of the head, which, however, soon disappeared after iced-compreases, and the use of calomel. With the exception of the aphasia, the child waa quite well ; no paralytic s^^mptoms were ever noticed* On the day of my viait the hoy had pronounced the word " aof " for the first time, hut was still uuahle to give any answers to ray fiuestiouj^, although he was quite sensi- ble and iutelligcnt, and he could only iudicate what he meant by aigiis, The comforting assurance of rapid recovery which 1 gave the piareots was speedily conJii'med, After a very few weeks the power of speech gradually returned, and recovery was complete in a fortnight.

If we consider the concurrence in this case of vaiious circum- stances favotmng hypertemia of tEe brain— the previotia con- tssioD and the exciting railway journey during the hot stage of itennittent fever — we cannot Imt aKsuiue the occarrence of jmorrhage in consequence of extreme hypertemia, and its site >uld probably have been found in the second or third left )ntal couvolntion. The absence of other paralysis cannot bo regarded as weighing much against this supposition! for imples are not wanting in which small blood extravasations in 10 brain (confirmed post-mortem) only revealed their presence quite localised paralysis — for example, of the facial nerve. ''e need not be surijrised that the supposed cerebral hiiemorrhage in this case, as in some of the others just given, manifested itself first by violent convulsive sj^nptoma, seeing that these occur young children much more commonly in connection isith irebral hiemorrbages than in adults. The small extravasations [ready mentioned, which are found in the form of clusters of d spots, or in a mass as large as a pea — especially in the isoe of the pia mater and the cortex, more rarely in other more central parts of the brain — often give no evidence during fe of their existence except convulsions, which are not ifiieient for a certain diagnosis. This is true not only of le capillary hiemorrhages of the brain and pia mater observed in iphyxiated new-born children and in the first weeks of life, but Iso of those ivhich we frequently Ond in older children in the ^pillary form, or in tho form of spots, as a result of severe ooti-

272

DISEASES OF THE NEBV0U8 SYSTBtf.

stitutional diseases (typhns, dlpbtberia. scarlet fercr, &€.)• or localised brain diseases (especially tuberculosis of the bnis lod tubercular meumgitis). All of tbese b^emorrluiges caanot le diagnosed, because tbeir symptoms caoDot be separated btm those of jjfcneral diseases, and there may ofteu be no aympUMDi at all. In tubercular meningitis, particularly, I have fre^ii#nUf found considemble extravasations in the pia, several times also in the substnnce of the brain — f.//. in the commissares of the third ventricle— without any corresponding change in \h» ordinary symptoms. I therefore consider it is not worth whik to linger any longer over these conditions as they have no clinicil value. The rare cases of larger hemorrhages, however, occunio^ in older children with sudden hemiplegia do not present either anatomically or clinically any difference worth mentioning from the apoplexy of adults. The same is true of the luomorrluige* which occasionally occur suddenly in the space between tbt dura mater and the arachnoid from external i nj ur ie s (a p op I exit meningea). At the same time I would remark that thediseiM described by French observers (Legend re, Rilliet tod Barthez) by the name of " hmmorrhagies dans la cavite de Faracbnoide/' is not now regarded funongst us as simplt^ haemorrhage, but as pachymeningitis, tbat is, as inflamniatiou of the inner surface of the dura mater accompanied by small htemorrhages.

In childhood, as among adults, cerebral paralysis may lake place suddenly from embolic processes* Although this ia far less common, still medical literature contains a number of cmskm m which (with the well-known symptoms) clots were carried from the left side of the heart or even from the pulmonary veins through the circulation into the carotid and its branches, especially the Sylvian artery, and occasioned a more or le» extensive patch of softening in the area of brain supplied by it. Since in such cases the paralysis makes its appearance with apoplectic symptoms, owing to the sudden aniemia which takes place in the affected areas of the brain, we encounter here the same diffi- eulties of diagnosis as in adults, and it is only possible to deier- mine approximately whether we have to do with an eilibollaill or a hiernorrbago, if we are able, liy examining the henii^ to fiod Bomething that supports the diagnosis (endocarditiflt TalmUr lUlllie). If we find no murmur in the heart, thia by no

CEHEBRAL TUBEHCULOSIS.

273

excludes the possibility of an embolism, for the tbroQibus from which the embolus has arisen may also have been situated between the trabecule of the left ventricle, in the left Ruricalar appendix, or even in the pulmonary vein, and may have found its way from these into the left side of the heart and into the aorta. A case of this kind was nnder observation in my wai^d. The patient was a boy of 2§, suffering from chronic pneumonia and caseous degeneration of the bronchial glands, in whom right hemiplegia had suddenly appeared along with contracture. After death we found embolism of the left Sylvian artery, with extensive softening of the corresponding cerebral hemisphere. The source of the embolus was not the heart— which was quite normal — ^but one of the branches of the right pulmonary vein, which was fiUed with thrombi.

In another case, to which I shall return later, left hemiplegia iKJcnrred during the stage of collapse in diphtheria. The cause revealed by the port-raortem was the formation of a thrombus in the left auricular appendix, and an embolism in the S^dvian artery which had proceeded from it*

Thrombi of this kind also frequently occur at the time of deathj owing to the diminished propulsive power of the heart. In a girl of 9 years with tubercalosis I found, along with buflfy clots in both cavities of the heart, obstruction of one of the principal branches of the right pulmonary artery, of both vertebral arteries, and of the right Sylvian artery by embolism, without any further alteration of their tissue.

Finally, the sudden onset of hemiplegia may also be due to diseases of the brain, which either may have remained quite j latent for a considerable period, or may have revealed their pre- ! sence by other cerebral symptoms, especially by convulsive attacks. Among these diseases, the one we have next to con- sider occupies decidedly the first place.

^M Of all chronic diseases of the brain occurring in childhood, this is undoubtedly the most frequent ; indeed its frequency ia so great that we will seldom go wrong if, when chronic cerebral

18

I

XIL Cerebral Tuberculom,

DISEASES OF THB NEBV0U8 SYSTEH.

Bymptoms exist, we make the diagnosis of tubercle. Tubarde occars in the brain, as well as in other organs, in children at » very early period of life. The assertion of Riiliet and Bart he z that this disease is never observed before the tiiiid year, is to be explained by the circmnstance that these auihon only saw children over two years of age in their hospital* Among 14 of my cases there were 12 between 9 months ami 2 years of age, and Demme has foand a tubercular nod ale iLe size of a hazel-nut in one of the cerebellar hemispheres in a child of 23 days, whose mother had tuberculosis. ^

The diagnosis of cerebral tubercle is supported by nk characteristic group of symptoms and circumstances. In the first place, the children affected are almost uever quite healthy, but generally bear traces of scrofula or tuberculosis. I have re- peatedly met with eczematous eruptions, ophthalmia, otorrhcpa, enlarged lymphatic glands, osteomyelitis in the fingers and toi-s or in other bones, and — above all — caries of the petrous bouts as accompaniments of cerebral tuberculosis. Of course these morbid conditions are not always present at the moment whi'n the cerebral symptoms commence, but it is quite suflBcient that the children should have suffered from them at an earlier period, that traces are still discoverable, or even that other members of the same family have died of ** lung- or gland-disease.'* These points in the history make the diagnosis very much easier, and thus it happens that this may often present greater difficulties iu a hospital — where children concerning whom we have no history often come under treatment — than in a polyclinic or in private practice. If we inquire carefully of the relatives, we will find in almost every case that the child has not been per- fectly free from '* scrofulous " symptoms.

Follo\iiug upon conditions of this kind, there now sudden^ occurs, in many cases, an epileptic fit^ which may recur afiM an indefinite interval. In children who are still in the period of the first dentition, or especially in those who are rachitic, it Is scarcely possible to distinguish these convulsions from the com- paratively harmless ones already described (p* 161). We must therefore pay particular attention to the child's condition during the intervals, whicii may even last for many mouths. Every cerebml sjmptora observed during these intonala ia important

CEREDIUIi TUBERCULOSIS.

275

^

for the diagiiOBis. Even very young children, but mare com- monly older ontis, often complain of headache occurring in tits like mi<^*aine, not uncommonly aloD^^ with vomiting, wliich forces thu chiklren either to lie still or to support the head with the hands* In others a squint hitherto unobser^'ed appears, usually iu one eye, and this among poor people is often either not noticed at all or else put down to a had habit. Suddenly, after one of the above-mentioned convulsive attacks — occasionally also without their occurrence — there occurs paralysis of a single limb, or hemiplegia, with or with- out implication of the facial or ocular nerves. Here, as iu all central forms of paralysis of the facial, only certain branches — esiMJcially those to the lips— are wont to be paralysed. Paralysis of the third is indicated by ptosis, divergent stra- bismus and dilatation of the pupil ; that of the sixth by an inward squint and inability to turn the eyeball outward. This paralysis may also disappear after some diiVH or weeks, and one who is inexperienced is very apt to regard them as the remains of the epileptic attack, until there is a repetition of the symptoms,, which may very possibly prove rapidly fatal,

Martha M,,* "2 years old, rickety ami Mcixifuloiipi, Rcpeatedl eonvulnive attacks, iimliility to hold the head upright, irritable temper. On 29th June, 1804, a renewHl of the convukions coii- fined to the left side of the body, which was found to be paralysed immt^diately afterwards. Cranml ner^'es and sensi* bility normal. 1 ditignosed tuberciiIoBis of the right hemisphere, with hyperaemia in the neighhourhood. Calomel, gr. i every ^ hours, and 4 leeelies apphed to the head. Marked improvement by 1st July; by the 8th, the [mralysta has quite diBftppoared, On the 26th again violent convulsions on the left side, lasting' tUrtie hours, followed l>y roma hnt without immlysia. On 16th October another fit» lasting 5 hours. A short fit in Fehruary, IHrtr'), and on the ISOlh March a very severe one ending in coma and death.

Post-mortem t murked hypcncmia of the piu mater, eapecially on the left Hide, 8mull occhymoses at some points. Some aerum in the ventricles. In the posterior lobes of the right hemisj»here, in the white Mibstance, a greyifih-ycllow tnherele of thv size of a pea, »mTonnded by a thin capsule of connective tissue* No tuber- rnlar meningiti.s. Milim-y tuberculosis of the pleuni. and caaeoUB enlargement of the bronchial glands.

2T6

6le8A8EB or TQS IffBAVOUS subtsv.

I would specially draw your attentiou in thk case to the one- sideduess of the eoavolaions already spoked of (p. 166jr which still further justifies the diagnosis of serious disease of the opposite hemisphere, when^ — as was the case her© — it Wrtf behind a p u r a I y s i s of the side on which the couTulsions occii ! ^ ' ^1 This case is also an example of the so-called "solitary tul^ c cle"; for nowhere else in the brain was there any similar for- mation. You must not, however, he misled by this * belief that it is only in the ease of solitarj^ tuberdt-s, or v disease is confined to one half of the brain, that unilateril convulsions and hemiplegia occur, as we certainly mij^ht e^peeti^ The following case showa, on the contrarj*, that tabercultu- disetaM of both hemispheres may be accompanied by hemiplegia. I

Otto A., 24 jenrs old, (ubnitted into my ward Octxilier 24th, 1876. A convulsive attack a year before. Four days l»cfopai admission, sudden left hemiplegia with implicattou of tM left facial nerve. Daring the next few <lay« devrlofimoitt of tubercular nieninjntii>i. Death on 3(>th,

Post-mortem: numerous adhesions betwtMjn the dura an4J pia mater. Many tubercular nodules, from tfie sise of a huxcltl nut to thot of a walnut in the cortical aubFtnnce of lioll* hemispheres (ti iu the right, 4 in the left), and an ei^ually Urj^ one in the posterior part of the left half of the ccrebtdlum. TuUr- cular meningitis.

You see that in this case it was only the tubercular n 'ril

the ri^ht hemisphere that produced paralysis of the 0]>p< If I

of the body, while those in the left, although they proved on anatomical examination to be exactly the same as on the rl^hij side, exerted no influence on the motor fanctious. Tins bririgp us to a weighty point in the pathology of cerebral tuberculosis— namely, its latency. As, in the case just given, tnlh ' ii of the left hemisphere was not revealed by any syraptoi- v

life, in like manner even more extensive cerebral tubercuiosis may remain completely latent during life, nnd only ba dis- covered incidentally at the post-mortem. Indeed my own experience inclines me to hold that multiple tuberculoaia is far more sabject to this latency than the solitary form. Tho. following cases observed by me may serve as esaoiples, I

Boy of 4 yeafft, with phthisifl polmonum. No cerobnd syoip" r toms ever observed- Death from rapid Imttilar m<»nin|^tts. J

CEBEBRAL TUBERCULOSIS.

277

p. 'It, — BesideB the moitingitia^ a tuberculftr mass, the size of a pijBreou^s egg, oil the convexity of the right frontal lobe ; one of Kimilar size on the anterior surfuco of the right corpus striatum ; hjially, Q maRa of tubercle aa lai*ge as an orange between the cere- Ijellum and the tentorium cerebelli— -soft^ fissured in the inside, and slightly adherent.'

Child of 14 months. Caries uf the right ]>ctrous bone with jwralyHia of the right facial nerve, and nmiierous enlarged glaud.H. Mo cerebral symptoms ever observed. Phthisis. De^ith from rupture of a small apical cavity andjpncuraothorax. At the P.-M. n moch fiHfured and softened tubercular mass^the size of a wahiut, was found on the surface of the right frontal lobe; a still larger one on the surface of the occipital lobe, and a third of equal size at the jjeriphery of the latter near the ba.se. Ako on the surface of the left hemiBphere iiumerou.s large tubercular nodules with cavities filled with detritus and calcareous concretions of the size of a pea. The left lobe of the cerebellum almost entirely con- verted into a soft caseous mass.*

Child of 2 years, admitted to my ward on April 17th, 1874, with caries of the right upper and lower limbs* Aniemia and emaciation; otherwise no striking sjiiiptoms. Development of tubercular meningiti.H dating from April 2Rth. Death on 5th Ma}-. P,-M* — In the vermiform process of .the eerebelluHi* extending into both its hemispheres, a tubercular mass the size of a walnut, with numerous recent tulK-rcles in its neighbourhood. In both occifiital lobes, nodulch from the size of an almond to that of a hazebnut.*

Child of 1 year, admitted September 28th, 1878. Hitherto always healthy, but 10 days ago took ill with n-pcated cou- Yulsions, followed rapidly bj' left-sided hemiparesis. On admis- sion* all the symptoms of tubercular meningitis in the last stage (roma, pupils dilated and no longer ivacting, pulse ItiO and very small, ic). At the same time frequent spasmodic contmctions of the left side of the fare, hemiparesis and rigiility of tlie limlvN on the left side. Abdomen tense and distended. Death on 8th Uciolicr with grt^at rise of temperature (KKj^*^ F.). P.-M.—Thc pia mater on the left side of the convexity of the brain iuHltrated with caseous matter in a Sf»ace as large lis a sixpence juist outside the median fissure. The caseous nt^ules extended for some millimetres into the grey substance of the cerebral cortex The rest of the brain free from tubeJTle. Extensive tubei-cular raeniugitis of the base and convexity with acute hydrocephalus. Likewise caseous degeneration of the lironchial glands, miliarr

• Bmtr^e, N. M, S. 67.

« Jmm.f Kinderkranik., viii., 1847, S. im.

* Chnritf Annnlen^ Juhrff., iv., 8. 44^8.

278

DISEASES OF THE KBEVOl't* BYST£M.

tuberculosis of the left Iting, of the lirer mid f pleciu and ctiromir ftdhesire tubercular peritonitis.*

A rickety child of 1 year, admitted on June lOtlu \^7A with all the symptoms of tubercular lueuiii^it is. Was said t^ bAtir been alwaj-s healthy. Illness began 8 days previously wttb repeated convulsions. No paralysis, but almont cotiiiituoof chorea-like mo%omeutB of the ri^^ht arm and log (Hexioo n*A eitensiou, pronation and supination, and tnovemcnta lu aJJ directions). Death on i*6tii. P.-if.— Tuben-nloj^iw of the lang» and pleura, liver, spleen, kidneys, of the dinphmgni and ban*- marrow. Caseous degeneration of the bronchial glands. t^st^H masses in the left lung. Miliary tuberculosis of the basilar dflH mater, tubercular meningitis, and masses of tubercle the sixe of • hazel-nut in the middle division of the left optic tlialamas.

Id these and other similftr cases there was always present Hi the same time an advanced tuberculosis and casciition of other organs; and it has already been maiDtaiued by Rilliot and Bar the z that it is just nnder such circumstauces that cerebral tubercle is most frequently latent. I therefore still adhere to the opinion which I expressed a« early as 1808,* that in ehildreti suffering from exteusiTc tubercular degenemtion of tlie lymphatic glands, lungs, abdominal organs or bones, who die with symp- toms of tubt:rcular meningitis of normal — or more frequently abnormal — course, tuberculosis of the cerebrum or cerebellam may also be assumed with sufficient probability, even should tliis never have revealed its existence by any definite symptoms. Tliia probability is all the greater if the petrous buno is one of ibaso that are carious.

The occurrence of cerebral tuberculosis with repeated epilepti- form attacks and accompanying hemiplegia is, however, only one of the forms under which the disease presents itself. In another class of cases, paresis of one side gradually appears, steadily increases, and is often combined with tremor or contracture uf one or both limbs. Or, the disease may begiu with strabiatniiSv localised contractures (either of the Umbs or of the mnscl^a

' The etrikingr fact tlmt in thii^ eiwe tbe pumlyti*? »ihI cnnvnlnirc eymptani* ooetirred on the an me »uli» on which tho oortii?a) tutiorntaM worp ••tinnt<»d, doc* not reqaire for it« eTptoiuilion the aA«umptioii of <ui iuoom|i1<^t*« * > th«

pynumdiU flbfe«». Tw iny mind the wjliUrj' tuborolen -whirh wr«n' i—

bad nothing wlmtotor to do with thc«o ^^iiptouiR ; for tlu* Ult* r m^i^ur ii«ra oooojTed inthecoarA« of Any tnbercuUr m(*uitufitirt« «v<jn if th«w hud l,««n tnhorole in the Unum**ub«tauioe.

• BtUrut/f, X K, 8. 00.

CEREBBAL TUBERCULOSIS,

279

of the neck) and other cerebral sjmptoms- — e^g. attacks of head- ache with vomiting, momentary loss of consciousness, without accompanying paralytic symptoms, aphasia and hallu* cinations of hearin^^. Not until many months, or even years, have passed — during which the condition hag undergone many variations, does the fatal issue take pl«ce in the form of \iolent convulsions or tubercular meningitis. The following cases observed in my wards and chosen from among many others* will illustrate this form to you better than a detailed description.

Carl Sell.. U yeara old, admitted uii .hiuuury l-jth, 1874 Thin and pale. The disease eomracnccd 7 niontlLH beforo with a tremor of the right hand. Two months later paresis of the whole right i^ide of the body, and of the right facial nerve. Since November, 1872^ almost continuous contracture of the right ann at the elbow- joint. On adraiasiou, rigid contracture of all four eitremitie^ righfc-yided paralysis and tremor of the left hand* DevelojWient of tubercular meningitis. Dettth on 21st. P.-M, — A tulicreulju' dcjn>j<it tlio size of a walnut near the powterior aurface of the right heniijsphere of tho cerebel- lum» On the convexity of the left fronlul lobe, a caseoUM noduUr iiii. in diamoter extending inwards right through the convolution to the white substance. Hydrocephalus internus. At the posterior I>art of tho loft roqjus striatum 3 tubercular masses the hIzg of a pea, close under the ejKjndyma. Both optic tljalarni converted at their upper part into a nodular caaeon.s mtiss-

Wilhelm J., 2 years old, jidmitted on April 3rd, 187o. Coughingand wasting for the hiMt ti months; rickety. Continuous trembling, frequently sIho raorc marked spasmodic contrac- tions of the rigfit arm and .side of the face, the mouth being drawn upwards and to the right. No immlyaiH to be obserrcd. Sensibility apparently norraaK Symptoms of con- solidation in the lungs. After a few days, increase of tho tremor, the head and right lower limb being then also affected. The rau.9cle» of the chest and abdomen, a« well as the cremaster on the right side, presented distinct spasmodic tontractiona recurring at ^hort intervals. Slight j)ttreHiM of the* right arm. On April 6th. continuou.s contracture of the right thumb. On tho 7th, nystagmus of the right eye. Ueath with high temperature and collapse. P.-itf.— (Edema of the pia mater, especially on the convexity of the left hemisphere, and in ib numerous miliary tubercles arc embedded. Right in front of the fissure of Rolando, about its middle, a yellow tubei-cularmass of the «i»e of a haxel-nut in the cerelmil substance, which was to some degree softened in its neighbourhood. Pulmonary phthitJiH, Ac.

or TSB IfEETOUS SYSTEM.

The darftiion of UieiliMtaev afi &r as we can jti<l^ ai^ TaiT much* In some euca naiiy moatlis (»reTen year g maj elapse» from tlte appearanea of Qm ini oympUmis, lielbre daalii oecnn ; while ia otbeta tba fiiat ajniptoiBa are obaened a compantiirdj akdn time before deaths In Ihefe caaoa, tiicriefore we taaal assoioe tlsat the disease b^ feukained latent niiUI reiichin<r its laal slif^ I hare freqaentlj seen the first sympioms of c«rebral iubcfeMi e.f « coiiTolaiTe attacks wilh or willioQl hemipk<ria — ^pasa almost imipadialelv mto aymploms of tobereolar meningitis, vhidi was the immediate canae of death aod was as a role murked in these cases by an nnasoaUv riolent course. Other cases end in an axtiemelT proimcted and vioJent attack of conrnlmons, or death maj be doe to the advance of cooeomh&ut tnberculosis of other organs withont meningitis.

The casea giren have already illastr&ted to yon the patbo- logical conditions. Tubercle of \A brain appears most fre* (jnentlT as greyish-yellow caseous nodules, ranging from the awM of a pea to that of a hasel-nut, usually globular, but sometioiOT also uneven in shape, most fre<|ueDtly situated in the grey siabatance of the brainy in the cortex^ the great gangUu, the pi^Qs Varolii and the oerebellnm, but is by no means unlaiown io the white eubatanoe, corpora quadrigemina, crura cerebri, &c^ The tubercles of the cortex which lie immediately under tb<* arachnoid and pia mater can scarcely be distinguished from those which originate in the membranes themselves and penetrate from them into the oortiokl substance — which, clinically, comes t

^«aine Uiing. In both cases we find the arachooid auJ dura n

1 •overlying the cortical tubercles more or less adherent to one another, so that on our removing the dura mater a portion of th^ tubercle is apt to remain attucbcd to it. Sometimes the siafl of the nodules is much greater. I have myself seen them as big us a w*alnut^ and even bigger ; and these whvu cut int" ' v

^no longer presented a homogeneous caseuus appear^i contained fissures and cavities filled witli a whey>like fluid* In one child I even found on the outer snrfaco of tlie righU optic thalamus, a tubercular mass as large as a h(*>u'8 egga f^U of fissures, and in other eases there was diffuse caseous filegeuemtion of the cortex or caseous metamorphosis of an cntifM ^cerebellur hemisphere* Calcification of cerebral tumours ill not a common occurrence ; I hara observed only two caaea of it,

CEREBBAL TUBEECULOSIB.

281

le of whicli has already bceii mentioned. In the oUier caso a knbercular nodule of the cerebellum contained ver^* bard col- ireons particles.

In large tubercular masses we can generally, on carefnl [amination, distinctly make out that they Imve arisen from the mfluence of small nodules lying close together. The interior — tpart from the fissures already mentioned— is partly firm and Lomogeneons, partly granular and friable. The outer layer is >ften thin, groyish-white» and transparent, and numerous m iliary lodnles can be discovered in it. It is partly through the con- fluence of these, and partly by a chronic caseous encephalitis that the larger nodules seem to be developed. Smaller tubercles are not unfreqiiently encased in a thin capsule of connective tissne, while the larger ones are usually more diflfuse and are imbedded in the extremely vascular, moist and softened brain- snbfitance. The number of brain tubercles varies greatly. Most rai'ely we find only one (solitary tubercle), usually L^everal scattered through different pai*ts of the brain, occasionally ^ftery many (a dozen or more), and of this I have already given ^Bxamples. In most cases we also find Hymptoms of tubercu* ^^ar meningitis and accumulation of serum in the ventricles — which we shall speak of later on — and not uncommonly small schymosea in the pia mater or brain*substance. I have >pe» ted ly observed that the accumulation of miliary nodules in le pia mater was most marked in the immediate neighbour- of the caseous nodules, especially on the convexity. More less advanced tuberculosis and caseation of other organs is jnerally, but by no means invariably, present also. In the caso Iready mentioned (p. 276) in which a dozen large tubercles rerc found in the brain, only a few miliary nodules were found the right lung, while all the other organs were perfectly free >m disease.

The question, whether we can diagnose from the symptoms in

rhat part of the brain the tubercular mass is situated, does not

irictly spejiking concern us here, seeing that the conditions are

ime as in adults. I refer you, therefore, to a paper of miue

led in the Charite-Annalen (Jahrgang IV.) from which you

find that in spite of the knowledge recently acquired by

iperiments, the diagnosis of the localisation of cerebral tubercle

is still far from being established ; and the latency already dis-

S8 or T8R KESTOrS SYSTEM.

aibrds anothier proof of this, I hjiYe, howeTcr, recordi of three esses in which a soliUir tubercle of one frontal lobia resisted in sjmpbOMOB of irritjilioii or paralysis on the opposite side of Ibi hodr; and we mmj oertaiolj condade from Ibis that these amp- loiDs may be caused bj ditinaoo aflfoetiog exclnsivelj the convoln- I liave mentioned. I say adTisedly "may/* for it is nol t

of neeeasity. I hare often enoagh seen exactly the stme moilttd conditions — hemiplegia and contractnres — in caaes at iht p(wit«iOTtem of whieh this aiea of the cortex was periecyy DonDal, while there ipere tnberenlar masses in the greatest varic^ of dber eitttalionis in the eerebrom or cerebellnm . Althoo^fa tlui large nnmber of these masses must make all efforts to arriTe at a local diagnosis Tain, still even soHtary tubercles ofUm present symptoms at variance with the results of experinientJiI lesesich. I therefore advise yon U> exercise the atmost caution in local diagnosis — and especially not to overestimate tli« " motor centres of the cortex '' of which so much is being ma^ln at present — if you do not wish to find yourself nnpleasanllT mistaken at the post-mortem. It would be useless labonr lu discuss here certain cases of solitary tubercle from whldi conclusions have been drawn as to tbe functions of different parts of the brain ; for on this subject the greatest diversity of opinion exists on all sides, I will only refer here to the case, raentiowfd on p. 27S, of solitary tubercle of the left optic thalamus, whicU was accompanied by chorea-like movements of tbe ri>(ht side of the body. Quite independent of the fact that the latter only set in during the final meningitis (and^ according to my experience, can only be ascribed to this), I have often seen cases of tuberculosiB of the optic thalami in wbich no move* ments whatever of tliis kind appeared. One of these may \t^ given here.

Hedwig F., 4 years nld^ admitted on April 24th, 1881, Healthy until middle of February. Seemed out of sorts nfter • fftll on the forehead, A fortnight later, left infcerual atruljiHinUk* frecjueiit vomiting, giddiness. Laier, retrftction of thti heiid, iind coiitrnctures nt the hip and kneo-jointsi, whfcft) diHappeared under thloruforro, sometimes also viuitsliod fipon- tanoounly. Htsttduchcs, drtiwrsiuejis. In May, »hort ejM'""* *' Attackn* Int June, Alight I^ft ptosis, increaHing am) with nyMtawinuw. lUh Juno, nouro-rotinitis in ' ' fith AuKuat, ronmiencvmcnt of tulKTCular m*

CEREBRAL TUBERCULOSIS.

268

on tlic 11th with external high temperature at the last (104*7 —

Post-mortem: basilar tuberLuliir meningitis, acute hytlrot-L- phaluH, The left optie thalatnits reddened and nodular, the rigi>t smooth; both contain several caseouB nodules suri'ounded by a grejifth-red ti^nsparent layer. One of these in the left thalamus, is the 8ize of a hazel-nut and reaches to the surface. In the vermi- form proces4s of the cerehplltim there is a caseous nodule with soft centre, of the sixe of a small walnut, and in each hemixsphei'C of the cerebellum a tubercular mass of the sixe of a hazel-nut Spinal cord normal.

On the other hand I have ohserveil choreic movementB in one caae in which the central ganglia of the brain were quite unaffected, and only the cerebellar peduncle was the seat of the tubercular mass.

Child of 2 year.H, admitted on August 6tb, 188^1. Well- nourished. Scarlet fever 8 months ago, soon followed by chorea- like movements in the left Hide-. *Slight left convergent atmbis- rauH, ti-eraor of the tongue when extruded, contracture of the left arm at the elbow, and of the left leg at the knee-joint, Athetosis- movements of the finger.s and foot of left side. These ceased during sleep, but continued con.stantly when the child was awake. Both eitremities were paitilysed. the cervical glands swolleu, some of them suppuniting. In the left orbiculari:!^ j>al|)ebnirum there were continuous spasmodic movements when awake. From 2yth September, fever, vomiting, increasing coma. On the IJOth, death, with temi>erftturc 1041^3 F.

P.-M, — Solitary tubercle the size of a hazel-nut in the right cerebellar peduncle.

The regions of tlie pons and corpora quailrigemina seem ^to me to be those in lesions of wliicli an approximate diagnosiK is soonest possible, from the simultaneous or successive affection of several nerves whose nuclei are situated in this region* The simultaneous paralysis of one or both oculo -motor nervcs» of the optic, facial, and abducens — which are either principal gymptonis or at least precede the liemiplegia— strongly favour this locjil diagnosis ; and in this connection I would refer you to some obBorvations I have published on tuberculosis of the corpora qnadrigemina and pons,' in connection with which I have discussed the other cases of the kind which have been published. I shall add to these another case of tuberculosis of the cerebral peduncle, which shows that herci as in tumours of the pons,

' Btitr, T. Kintierheitl\^ N, K, S. 72. -Chariti' Anna ten, Bd. it.

284

DUSKASES OF THE NBBYOUS STSTEIC.

80. Tlulr

m

n

owing to presanpe on the ne^hbomng ocalo-motor mtu, paralysis of it may occur along with crossed paralyeia of th* extremitiee.

Max Sch., 3 years old. admitted oii 2e)tli Marcb, V healthy parents, but himself Bcroful^os. aud for m lo sickly. For 9 weekis tremor of left hand, which had spread to the whole arm, combined with controcttj elbow-joint. For sijt weeks tremor of left leg aklso became aggravated on the attempt to gni^p anything, bat ctasui during sleep. Fingers flexed. No paral^'sia. At the ptosis of the right eyelid, marked dilatation of the right and tliverj^cnt j^trabismus. so that the ripht eyeball was iaj outward.* and could not be brought inwards Ijeyond the midcUclu*. Facial nerve unaffected. After recovering from an attack af scarlet fever in the ward, in the middle of April the boy hoauat steadily more apathetic and uninterested. On 25th he algo bc<at»v affected by ptosis, mydriasis, and divergent str / , if tbr le

eye; and died on 8th May of measles and bron non

P.-Ji/.— In the right crua cerebri a hard tubcicuJur ma** the KiEc of a cheiTj% pn>jocting into the third ventricle. At th*> l»»r, the right ocnlo-motor nerve is flattened by the pre<»«nrc of iht tubercular mass and is thinned and gn*yi«h in colour. In the apex of the left lung, a cavity the size of a walnut in which thert it large ha If -dissolved ca&eotLS plug. Broncho-pneamuuia, lai^ngiiU. No tubercle el &e where.

I have yet to treat of a pretty common seqaela of cerebrai

tubercle, namely, chronic hydrocephalos. It is SQppoftiyl

that the tubercular nodules^ especially those sitaatetl in the

middle lobe of the cerebellum, or between it and the «^ntoriom

cere belli, may, by pressure on the veina of Galen and their chid

branches, produce engorgement and exudation into tiie ventriclei*

This may l>e indicated even daring life by increased size of

the head, even when the sutures are already closed. The

lirst case of this kind that I met with, was that of a girl of S, in

whom cnlargciiunit of tbe head, impaired intelligcnccMind blind-

noj»a of both eyes were ailded to the symptoms of cerebral

tubarc]^. Voii Graefe discorered neuro-retinitia as the eauso

of bltndn<'8s, along with marked sweUing of tlie papilla, and

loriuoHity of the veina. As no post-mortem was made, howeTer»

ii WNB liot ancrrUiikcil whether the ttmioar which prodocul this

rrmtiU by f ' luborcnlar or of famo other

naliirc. I doais of tho middb lobe of

4

CBBBBBAL TUBEBCULOSIS.

285

le cerebellum was fouud along with a moderate distension of

ic veutricles. However, only to tlie second of these cases can

inch value be assigned in this connoctioii, as it alone presented

no tubercular meningitis. The followinff case, observed in my

\tdf is moro to the purpose : —

Clara G., 3 yeapK old, formerly healthy. For al>out 0 monlhy, gradually increasing enlargement of tbe head, to which had IjMBen added a slowly increasing right- sided hemiplegia. The latter no longer so marked as foraierly, so tliat the right anm especially could now be pretty well used. She ha^il luid whiwping cough for 7 weeka. Admitted into hosjiifcal on January 1th, IH7R Head hydrocephalic, circumforencc 2l\ inches; fontanelle widely open and extending into the sntnres; tense and elastic. Eyes woraewhat protruding. Drowsiness. Violent attacks of whoopin^jf cough, diffuse hronchial catarrh, remittent fever increasing in i*e verity until death, which t«xik place on the 15th. Tempemtur*^ towards the end lOoP F. Pulso 16<3 and somewhat iiregular. Post-mortem: ver>- markeii chronic hydrocci>liftlns of the Tcntricles, with compreRsion of the brain-substance, flattening of the convolutions and extreme distensinn of the skull. The distance iMJtflTCen the parietal eminences was about 6 inches ; the sutures extremely wide with very marked serrations gaping in some places, and fibrous. The left hemisjdiere of the cerelielhim con- verted almost entirely into a homogeneous yellowish-white caseous mass, surrounded by a narrow border of healthy substance. Nothing else of importance.

This tubercular mass had undoubtedly existed in a latent

condition for a considerable time, before it occasioned hemiparesis

and produced eui^orgement by the increasing pressure on the

»ins. The mesial position of the nodules in the line of the

fena magna is consequently not absolutely necessary ; for any

tumonr lying to the right or loft of it may, by increasing the

iteral pressure, produce engorgement in the area of distribution

►f the neighbouring veins. This can be made out in the most

LTarious cerebral tumours bj' moans of the ophthalmoscope. We

mst, however, consider whether the mechanical explanation

►f chronic hydrocephalus as being due to compression of the reins

tbe only one which will account for all such coses ; or whether

a state of irritation originating in the pia mater covering it, and

transmitted through the velum interpositura to the ependyma of

the ventricles, may not also have to be considered as a factor in

the caadatioQ of the serous exudation.

285

DISEASES OF THE NEBVOU^; SYSTEM.

To Bpeak of efiectlTe treatment of cerebral tubercle course, out of the question. Neither by iodide of potash (tbe favourite drug), uor by other auti-scrofulous remedies eao wi remove caseous nodules fi'om the brain when they are OBoe developed. We must, however, acknowledge that a nainrel cure is possible — especially in the case of solitury tubercle— and you may therefore always, although only with Tery sUght prospect of success, attempt to favour this process as mu ! possible by a tonic line of treatment (iodide of iron, codi. oil, saline baths, fresh air, nouiishing diet), and by preveni the patient from being exposed to injurious influences, temporary improvement (disappearance of the paralysis, loi intermission of the fits, &c.)* must not— as some of tbe casai have given mil show — lead you to suppose that recovery ht»' taken place. And indeed such a supposition is generally vented by the accompanying tuberculosis of other organs, <'rt8t\ however, becomes quite hopeless whenever the first cei signs of tubercular menmgitis appear. Epileptiform att with or without febrile symptoms, which occur suddenly in coui*se of the disease, and are followed by coma or even 1( paralysis, are always to be regarded with suspicion; becai tubercular meningitis not uncommonly begins with these veiy aymptoms. We must remember, however, that the same uymptoms may arise from sudden hyperjemia or localised oncephaUtia in the immediate neighbourhood of tubercles. Therefore we must not neglect to order some leeches to head, iced compresses and purgatives (Form. 7). Under tl triMitmeut the threatening symptoms occasionally pass off, aftt«r some time death is caused by a fresh attack or by tube culur meningitis.

pre-

XrU. TuT/u>ur8 qf the Brain.

1 hiivc bgt little to tell you of ecrebral tumours in chiltbei vm they n^Mcmblc, in all respects, those occurring in later hi Tho dilYeront forms of sarcoma are those most frequenl found ; and they dovelope either in the middle of the cerebi •ubatAnoo — oivpocially iu the pons Varolii and ita neighbourhc ^or grow fVom tbe cranial bimeN, mul in t^ interfere wi(

TUMOURS OF THE BR UN.

287

le brain by pressure. I have myself records of sevenil such Lses with post-mortems, and others whiuli ure incomplete from lere having been no examination of the body*

Alice G., 6 years old, admitted into the >vai*d, .luly l<)tb, 1874.' Violent headaches for some months, especially in the left frontal region. Bilateral amaurosis for t> weckj<, which developed within a few days. On examination we found incom- plete ptOHiB oii the left Bide, eom]»lcte iiiimohility of the left eye, the pnpil of which wan dilateil hikI did not react. The right eye i-oukl he well moved, the i>u|iil equally dilated. 'Neuro-retl* nitis in i)oth ej^es. Occasional jiain in the loft ua^al iiiviiy, from which there was a ^eyish purulent (li.seharge» Geiierul health good till the '21th when the child hecanjo nffocted by a jjovere attaik of Bcarlet fever. Death on August 2nd.

Post-mortem: a myTco-narcoma^ialf the size of the fi«t» originating in the bonca of the middle eerebrtil fossa, and com- pletely tilling it— had gi'uwn into the upper part of the left iiaAiil cavity after jK-netrating the lamintt eriljrosa, and had aurroniuhnl the optic chiasma and all the ocular nerves on the left side. Brain and meninges normal, hut pressed upward a little.

The post-mortem explains perfectly the amaurosis of both

lyes, the pftralysis of all the muscles of the left, and the purulent

scretion from the left nasal cavity. The absence of all paralytic

Ijmptoms in the extremities, in spite of the compression of the

irain sabstance from the base, is worthj' of note.

Anton H., 11 years old, hnrnght to the ho.sphal on June 26th. 1872.* Formerly healthy except fur occasional headache. Six years before, excitement and chill during a fire. A week later complete right ptosis, swaying gait, increase of headaches. On examination there was ptosis of the right side, moderate dilatation of both pupils, stupid look, great rpKtleB,*neHK, frequent rotatory movement of the head, especially from right to left. Upper extremitiea coald be u.sed, though only feebly. Could not walk without support. When .supported under \hA\i armpits he eouM hhufflc along laboriouKly in an ataxic manner. When lying, the lower extremities could be freely moved. The sensibility di- minished at some places on the right leg. Speech faltering, .scarcely intelligible. Swallowing difficult. Vision unaffected, intelligence unimpaired, P. 54 — 84. After some days spce<*h even less distinct, the movoraents of the head more forcible, the

* Chariit'Annakn^ Jahrg^ i., S. 561.

« Churii^'AnnaUn^ Jahr^ y {., 8. 562. *od Soheibe, iMHt/vml'diu. flSer Uimg^' rMwatiU im KintUtatUr : Berlin. 1873.

2B8

Z>1S£A&£S OF THE KSKVOU8 SYSTEM.

miztd confused. On July 4th. sadden luns ol oonsctoitsiicm cod

asphyxia. Artificial respiration aud faradisation ,1 "

tinued stcfldily for 2 hours, Imd hot a i>asding effi ■ increased* diminished cyanosis). Death in the afteriHMJti.

P. -if-— Dura nittter very tensc» bmin flattened. In the rtgioo of the pons Varolii a hirj^e shapeless tumour of tho size oft testicle, involving the pons and the left superior cert-bral pcduvM reddish-grey soft ; within it a cavity, the size of a cht^nj'stMtf; filled with a spong)-, sulphur-yellow mass. Chronic hydr«r- phalus of the ventricles. Under- the miero6co}>e the tiii»(«r was found to be a large-celled earcoma, the processes of irhirk could be traced right into the crura cerebri.

Anna D», 11 yeni*s old, admitted into the ward on May 1876, Had always been healthy except for an attack of monia 4 3'ears previously. For a considerable tinic (/*) incrc«kaiii|> uncertainty of gait. Since April of that year squinting of right eye, and giddincHSJ. Nausea, occasionally vomiting. On cxamiiii* tion, her gait was found to be exceedingly uncertain aJiti staggering, especially when the eyes were closed. Woiilit/ aad sensibility almost unimpaired. Paralysis of thu left abdu* cens with internal atrabiiimus and inability to turn the <*}"• «ul' wards. Pupils noi-mal and brain unaffected, but grt^'^ *^

dulness. Speech nasal and indistinct. Fluids soi iv*

turned through the nose when she w&9 drinking. Soil paUit hanging loose, but little moved in breathing and pboiiatin^- During the next few days vomiting, very difficult defanaktiaiL retention of urine (met by the introduction of a cailiote-r), 8p^er)i less distinct, and swallowing daily more difilenlt. On the 81K, the right abduceus alao paralysed. Intelligence i^tradily de- creasing, drowsinesg. Pulse usually 80— 1<J0, occaaionally faiiling to iH and under, and irregular. From the 24th ouwurd*. coro* plete apathy. Nutrient enemata because of Lnability to »wallt>w. Sinking of strength. Death on 29th from oedema of the lub|o*. By rom])aring with the previouy case I wa« led to make ihr diagnosis of tumour of the pons Varolii.

P.'M. — Tlie pons enlarged to twice its usual *izc. The medulla oblongata— ec^pecially on the right side — also <*iilAiged» but only to a hlight degree. Pons soft, fluctuating at certain points. On sectitni several tumours from the si»o of a bean to that of a cherry, of medulhirj* consistence and grfryUh^red rolour, not circumscribed from the surrounding tissue. On exariiitmtion these were found to be .«fftrronjatoua. No other ab normal itiiM finv where,

The two last cases, on account of tht^ir having a symptoms in common (bilatfmil paraly«i« of th« f ardysis of tbe muacies of '

.la, ith dJ&tiU ftwmiiowiiig

TUMOURS OF THE BRAIN.

289

ind indbtinct speech, ataxia of the lower extremities) may Ifiim a certain importance in coniiDetioii with the dlagnosiB of diseases of the pons.

The occurrence of gummatous tumours in the brain in children is also occasionally mentioned, and indeed one can see BO reason why childhood should be exempt from these manifesta- tions of syphilis. I should, however, point out to yon that the Uagnosis of these tumours from tubercle is often very difficult, md that even the microscope may fail ua, so that many tubercular ►asses in the brain may pass for gummata, and vicC'Versd. Iven tnbercle-baciDi cannot bo regarded as quite ceiiain criteria in such cases ; since they perish in old caseous nodules, and on the other hand similar microbes have been found in syphilitic >roduct8. In such cases the caseous condition of othei* organs especially of the lungs and bronchial glanda-^put the presence [of tubercle beyond doubt* If indubitable signs of syphilis are lot present at the same time, and the complete absence of tubercle in the other organs is ascertained by a very careful post-mortem, I should be very slow, especially in children, to liagnose gummata in the brain at the post-mortem ; for they are ixtremely rare at this age compared to tubercle. I have hitherto let with only one undoubted case, so far as I am aware, and it has already been given (p. 110).

Other varieties of tumour (glioma, medullary sarcoma, echiuo-

;occr, cj'sticercQs), which have occasionally occurred in the brain

children, do not present anything characteristic, nor do the

ncephalitic focal lesions, which end in softening of the

^rain^substance or in the formation of abscesses. All these

conditions are the same in children as in adults, and I therefore

link it unnecessary to discuss them further here. Abscesses

>f the brain are not very uncommon in children, since injuries

-which are a very common cause of them^ — -are more frequently

encountered at this ago than in later life. Besides, we have to

take into account here, the greater frequency of caries of the

letrous bone, the tendency of which to cause abscesses is well

lown. My personal observations are confined to the already-

lentioned association of cerebral tubercle with disease of this

)one. On the other hand I have seen an enormous abscess of

_tlie brain in a scrofulous girl of 12, which involved almost the

rhole frontal lobe of the right hemisphere, occurring along with

DISEASES OF TUB KEBVOUS STSTEM-

caries of the lamina cribroEa of the ethmoid* In iMs there had for many weeks been violent attacks of neuralgic jmic in the region of the right supraorbital nerve, which c -' ^ ^]j U relieTcd by the injection of morphia, while the \ '^virt

almost quite free from morbid symptoms, and only the pre8S8N> on the orbital margin — especially towards the nasal side — mBotH pain. Quite suddenly violent epileptic conTuisious, coma ttnd hemiplegia set in, and caused death within a few days.* YtiO see from this that the diseases of the nasal cavity (chnofiic rhinitis) in children should be treated with no less care tbin those of the ear» the dangerous character of which has Icog been recognised^

XrV, Atrophic Cerebral Paralyms*

A cerebral form of infantile paralysis may, Uke the ** »pii peniBt to a late period of life, and then for the first time under the physician's observation. It is much oftener^ boi ever, seen first during childhood, even during the early yean life. The childreo present tbe s^-mptoms of more or less com] hemiplegia, with or without implication of the facial or oth< cranial nerves. Tlie upper extremity is generally more seriouslj afl'ected in regard to its movements than the lower, the being often still used in walking, although dragging aomewhat The paralysis is either congenital, that is, appears immedistel] after birth, or it arises in the first period of life, between the 8ri' and 12th months, or even later; and the parents usually teU m that it came on after an attack of "infiammation of the brain/^j i.e. as a rule, after a febrile comatose preliminary stage, laslli from a day to a week, with more or less violent convulsio&f^ which— OS we have seen above (p. 248J)— but seldom usher iftl spinal infiintilo paralysis. In course of time, liowever, contra^* lure and atrophy of the paralysed parts graduaUy developo in the cerebral paralysis we are speaking of also: and these psrts fiually appear not only colder, thinner, and more ^hriTclled than the healthy ones, but also shorter and stQUted in growth* This disease difiers from •the epiaal form, firnt, iii its iorariably unilateral character, socQSAiMftd more imju^inlly by the loog^

ATROPHIC CEREBRAL P4JIALYSI8.

291

ai

1 (

ersistence of tlie electrical reaction iu the paralysed muscIeSi bich does not disappear till their atrophy is extremely advanced until, in fact, scarcely any normal muscular tissue is left. In e cerebral form the atrophy of the lirabs takes place, almost always very slowly, aiul only after the disease has lasted many ears, and it rarely reaches the extreme degree which spinal aralysis so often presents. Still, in many cases I have seen a ry marked shortening of the affected limb and diniination in izo of the hand and fingers.^ Sensory disturbances are in these cases also rarely observed. In one case (a boy of 7 years) in which the disease had begun at the.age of 18 months, anrostbesia of the paralysed arm was said to have been present at first, and to have aftei-wards disappeared. Here also as in the spinal form, the head of the humenis sometimes falls out of the glenoid cavity, so that the finger can be inserted between the joint and the head of the bone. The paralysed upper extremity frequently Bhows athetosis-movementa of the fingers, especially on purposive muscular action. The development of speech also suffers more or less, likewise that of the intelligence, which may present 11 the intermediate stages from slight stupidity to regular idiocy, ery frequently epileptiform attacks are also added, which complete the clinical picture of the disease. As already men- tioned, such children, who are only a burden to thi;ir relatives, may reach the age of 20 years or more ; but usually they die sooner, either in a convulsive attack, in coma, or from tke results of a chance complication.

The invariably incurable character of this disease is due to the anatomical conditions present. For we have here an atrophy T complete absence of certain areas of the brain; for example, f some of the convolutions of ono hemisphere, of a half or a hole lobe, of the great cerebral ganglia, ifec, which are replaced such cases by an accumulation of serum » often accompanied by a thickening of the cranial bones. I described a most typical caitt of this kind in my graduation thesis.-

Girl of If* year.s lioalthy at Uirth. Convulsions at tjie age of ;i months, leading behind tliem right hcmiple^i**. Liitcr, atrophy of both the affect^ limha, which were regiikrly jstiinted. Seii-

Cy: Saeliffmallcp, J^hfh.f, Kind^rkHtk, JV. F., xlu.,S. 356.— FCritdf , /6fU HonocL, lJ€ atrophia C€rtbri : BeroUni, 1842.

DISEASES OF TBS ITSEVOUS BY8TBX.

sibiltty normikL Cranial nerves not paralysed. FiagerB AtiOedL lutcllisrenee Almost «t the point of idiocy. Spei^ch momonjlljilcr. but quite free. Death from phthisis.

P..3/.— The left half of the skull 1 inrli amaller than the righL The left frontal bone thickened, 'llw middk' and upper |mrl *>f the left hemisphere w»4i quite obsent, Iteing repb»ced hj n ctsI filW with st?rum, which extended to the hiteral ventricle. The btti* wifcs much dilated and filled with serum. The corpus striatttm Ami the optic thftlamus were shrivelled to hftlf their norni»l bie», llii» ntrophy was continued partially in a cross direction, the optic trwt, the corpus alhicantium, the cnia cerebri, the left side of thf i*oi» tmd the pyramid on the right «ide, appearing ron«idrnk!ik thinner ; of the pyramid, e«peciftlly, scarcely i part remained!.

In all these cases we fiud an atrophy of the pyramidal tncUi caused by a retrogressive metamorphosis (with a breakiug down into gnmolar cells), which arises iu the atrophic area of Ult Vraiu. and may be followed as it crosses over into the oppoisitp hull of the Bpinul cord. On the other hand we have no thoroogUly clear insight into the essential uatnre of the disease itself. Cusoft like that given above, may also be congenital. It would seem then that we have a meuiugO'encepbalitic and hteinor* rhagic process arising either during foDtal life or just after birth, by which the affected part of the brain is disintegrated t In course of time, owing to an inflammatory reaction in the imme- diate neighbourhood » a capsule like the wall of a eyst forms round the disintegrated mass of brain substance; which gradual^ undergoes fatty degeneration, and is absorbed, leaving in its place a more or less clear senun as the contents of the c^iii.' In other cases we find varieties difloriug more or less from tbift form, the development of which, however, must be explaioaij in the same way,

Elizabeth R., 12 years old, admittCHi into th* • on Plh

January, 1879. Had suffered {.ince curly childhooti * Hjubrly

recurring epileptiform fits; sometimes 3— -5 in one day. then week» without any. Tliere had ulso existed aa long tm fhc cnnhl remember, paralysis of thf right side. e»}iccially* of Uioann. 8hew»9 admitted on account of phthisis pulmonalis. The flt« which wei'e observed in the hwpiul were of a diitinctly L-fiilti^iiic chanicter, and affceted chiefly the right * ' thr

head, cye.K, and right fariiil nr«rvo. 'llie par;i uW

nnly Iw used to n verj^ limited extent, aiid *A*wi WA*jid t«> a,

*Kandrat, />Jt PtirmvtjtMk* K4mt imat^miteht Stw^ : Qmm^ jfflii

ATROPHIC CEREBRAL PARALYSIS.

293

moderate degree and Rlightly flexed at the en>ow. Death took ]i]ace on 2«5th, and at the P.-M, the following rhjinges in the brain were found : — pia mater on the convexity of both hemispheres markedly cederaiitous. All the convolutions on the left side very small and narrow, sulri very deep. In the sulci between the 2nd and 3rd frontal convolution, an well as in the central fissure, the pia raater was thickened, and could only be removed with very great difficulty* The affected convolutions were ex- treraoly narrow, and presented a depression and a rust- brown colour, which was evidently d»ie to former haamorrliages. On the rij?ht side everything normal. The above-mentioned depres- sion was tilled with serous fluid, over which the at*achnojd stretched.

In this case an original fauUiu formation (smallnees of all the convolutions of the left convexity) seems to have been accom- panied at a later period by a hiemorrhatifie and exudative affection of the membranog in the situation described. From the pressixre >f the cxudotion there resulted atrophy and depression of tlio intal convolutions, and they were gradually replaced by serum, bth in this case and in the following one, we see symptoms of iralysis and irritation arising on the opposite side of the body roni the affection of the anterior part of the cortex ; while in le second of the following cases, the temporal and parietal lobes seined to be far more affected than the frontal region* '

Margaretho G,, 5 years old, admitted into the hospital July lUh, 187'X Healthy till 18 months old. About this time ft violent shock caused by the breaking of an axle daring a drive. Some days later, sudden left hemiplegia after a warm bath. In couTBe of time improvement, and good mental development. Diaturljftncc of 8peech, dating from spring, 1875; words which were formerly spoken Huently could no longer Im? pronounced. At the same time, change of character ; destructive mania and great violence. Cmit staggering and uncertain. The hemiplegia was now only mAnife&ited by less energyof the loft limbs, which are atrophied. Death on 24th September froru diphtheria, R -if,— Pia mater on right side over the upjjer frontal convolution considerably thickened, whitish, and opaque, adhering at this phvco extremely firmly to the brain substance, which seemed waHit'd and very hard. The whole right upper frontal convolution markedly atrophied; the atrophy of the rest of frontal lobe waa somewhat less, but atill very noticeable. The atrophied convolution was likewise peculiarly trannparent and of a very bright red colour, except in its posterior third, which waa whitish and very uneven. Everything else normal,

Mk. Tlie Imtt h^mi^

•U

id Um {ik eartnl itke a btedte* fufl of

thmr wmUs nuidi thirJkipaed mmd |»pUbl«d on tbe

Or BQfv carolbl irramf— tion we find flat tin mU'Ophy

ffom thb tem|^orml lolie baekvmrds tti m cottiidfniUi»

fMA of ike pur let ml lobe sad forwmrd to the Imreei portkMk^

lH»tk rcntrftl conralutionm. On taci«io<i itxta

iad that thrrr wim. iil»o « tomidtomhkt Mroph/ Ol line

■nbvtAeoe, la tliu mtoaticm tbe Umiti-MulieUiici} wns

.grejr. Kotigh* rrfj nuiculftr. nt added with fHtle, IwrdUli uodnl

[nckrroeaa). Tlie right hetiiitf|»b4^ro aiiaCFuiKHl. mitlt Uie «:

ntroplij of A |«ftrt ol the parioi*] li>be.

Moro raro Uian Uio cases I hAve jost gfvou an tuj^e biUtorAl Atrophy of tjia brain sabsiaDoe, wbich mav eaufi4»^ ftyiuptocift OD both ftidcs of tba body.

ATBOPmO CEBBBRAL PARALYSIS*

295

A boy of 6 years old.' ftdmittod on July 20th, 1874. Had had measles when 0 months old. Soon after, *' convulsions," which were frequently repeated during 8 days, then became lees frequent, and finall}* only occurred very seldom. Immediately after tlie first conruldive attack the present disease had developed- Actual paralysis was nowhere noticeable, although there was exteusive rigidity of the muscles. When he was lying, both lower extremities were Htiff, with slight flexion at the knee-joints. Any attempt at flexion or extension was rendered difficult by the state of tension of the flexors and extensors. The iipjier cx- tremitioa, especial!}- the right, flexed at the o11m>w -joint. Extension was very difficult, and could not be effected b}- the patient himself. As fioon as the boy was placed on his feet and encouraged to walk, there at once resulted a rigid contraction of the calf-muack'Sj with the foot in a position of [les equinus, and at the same time marked dorsiflexion of the toes, so that standing and walking were abso- lutely impossible. Slight contractni'e also in the joints of the hands and fingers. Purposeless, chorea-like movements noticeable on the attempt to take hold of anjrthing. Speech stuttering, laborious, difficult to understand; mental energy much weakened. Otherwise normal in all respects. Death from diphtheria on the 12th. P.'M. — The right arm, measuring from the axilla to the styloid process of the ratlin?, was shortened to the extent of one inch; and there was atrophy of the muscles. The cranial vertex slightly asymmetrical, the right parietal bone being more arched and larger than the left, and the obltf]ne diameter (from the left side in front to the right l>ehind) larger than tlie corre- sponding diameter on the other aide. Dura mater normal. Fia mater on the frontal 1ol>ea on both sides of the incisnra magna thickened, opaque, and distended like a bladder by a clear fluid, and when this was let out the affected part of the brain appeared aunk in. The first and partly also the second frontal convolution on both sides vras atrophied, being scarcely ^ as broad as in the normal state; very soft and uniformly greyish-red on section. The adjacent parts of the medulla had the same characters and were alMo atrophied, Tlie third frontal convolution only affected to a slight degree ; insula normal. Corpus callosura, fornix and septum lucidum cousiderably atrophied. Lateral ventricles much dilated, distended with serum, especially their auterior horns, which took tip more room than all the rest of the lateral ventricles, Ependj-ma of all the ventricles much thickened, tough, and covered with little prominences. Otherwise nothing abnormal.

Tbas many cases of "spastic spinal paralysis" which have not been exarained post-mortem may have depended on such a bilateral deficiency of the braia substance, especially those

* ChanU-AwMhn, Jahr^, i., S. 5C7.

DISSASXS OF THB KKBTOrS SYSTEM.

thfti were accompanied by a weakened or quite mined ijDt€Uecl (p. 363),

On microscopic examination of the atropliied gyri in these casef • |We find sclerosis taking place, uf^, destruction &nd finally ilii^ f^pearance of the real nerve elements^ in the place of which there 'is an inierstitiai growth of the neuroglia, fatty granular cells and more or less numerous corpora amylacea. There arc also oBm hicmatoidiD crystals which indicate that there liad onginaBy been a haemorrhagic process. These areas of sclerotic atrop&y seem* then, to represent the last remains of inflammatory aod hivmorrhagic processes, which have occurred daring tctisd life during the earliest childhood ; and to them there may also added an exudative inflammation of the pia mater which exetta pressure on nnderlying tissue. The cases I have giveD, many others, show that under these circumstances the mast be absolutely bad, and treatment of no avail. If yon wish to do something iu deference to the parents* wishes, use of electricity is the only thing that remains, and in these it may arrest the muscular atrophy even better than in infantile spinal paralysis. Frictions of the limbs, stimulating baths, gymnastics may also be used iu this as in the latter diaei The physician, however, loses heai-t in those cases much sooner, on account of the impairment of the intellect which takes place at the same time, and which may progress to idiocy^ and the un- fortunate child is finally left to his fate as,a burden to his fiimilr. That sclerotic patches (sclerose en plaques) may occur in children in other parts of the brain besides the cortical layer, is a &ct,^ although it is of rare occurrence and I have never myself observed it. The majority of the cases published arc, ho^r^-* • of no value ; because no accounts of post-mortems are ;: In the symptoms described I find nothing that is characteiititic, at least nothing which might not have been observed ul^o i| other chronic diseases of the brain iu children (tubercle, tumoui <«hronic meningitis). The connection with syphilis, which Moucorvo aseumes, is in no way proved.

* T«D C»U Hf>«iieinak«>r, IkatteAu Ardkiv /. kHm. iffit, zziiL, 8. MSj Fi mtcr, I, c, S, 272— Ptcrrc Mftrio, HtemediMni,, 1888, K«. 7.— Moncori

Richmrdi^ro, ^ci^rtm mctphaJi^vt primitii't 4t Frn^'imct: Pifcrin, 1- t,

Ac. i Lffipsig a. Wieu, Idbl,

CHRONIC HYDROCEPHALUfl.

297

8

I

XV. Chronic Hydrocepludus,

The only certain symptom of ihlB discaBo is the more or less rapidly p^rowmg size of the head due to increasiiig pressure of fin id tilling the cereb ml ventrides (more rarely the space between he dura mater and arachnoid). Slight degrees of hydi-ocephalna ill which thtre is no enlargement of the head, are beyond the reach of diagnosis. More than 3 ounces of fluid may be found in the dUatcd ventricle of children who have died from variona cachectic diseases, especially tubcr^^ulosis, without the suspicion of this condition having been suggested by any sign during life. But it is not of such cases that we have here to peak.

On the other hand, however, an unusually large size of the head must not of itself mislead you into at once assuming the presence of hydrocephalus. Children have often enough been brought to me who, to their parents* alarm, had been declared hydrocephalic by medical men because their head was very large, and the fontanelles and sutures not yet closed ; and yet I was 800U able to comfort the parents with the assurance that their anxiety was groundless — that there was no hydrocephalus, but only a rickety form of the skull which had misled the doctor. I grant that the diagnosis is occasionally difficult if one takes into consideration the largo size and arrested ossification of the skull ; but careful observation of the mental comlition, the movements and the looks, will soon guide you to a conclusion. Only in those cases in which there is a combination of rickets with hydrocephalus can there long exist any doubt as to the diagnosis.

Most children with chronic hydrocephalus come under medical observation during the first six months of life. For the steady increase of the size of the head, with which the growth of the rest of the body does not keep pace, soon rouses the relatives' attention. The increase of size is not very considerable at first, 80 that one may make the mistake of denying it altogether, and taking for granted that the mother has been misled by the com- pflratively large size of the head which is a constant feature of early childhood. Measareraenta, however, soon decide the matter. They are taken with a centimetre-measure in the following way : (1) the circumference of the head (tho glabella and occipital

298

DISEASES OF THE NERYOirB SYSTEM.

taberosity being taken as the central points)/ (2) tbe transrerec diameter (from one mastoid process to the other, orer the TertrtJ* and (3) the longitudinal diameter (from root of the nose ovier the vertex to the occipital tuberosity). We can then from tifne to time make out an increase of one centimetre and more. Mo«t hydrocephalic crania are distinguished by a marked prominence of the frontal bone, and a lateral bulging of the pariet&I bone, which is especially noticeable when one looks at the skull from abore. Only exceptionally have I met with a dolichocephalic 9h*pe, Lt,, an elongation of the longitudinal diameter with lat/Mil flattening of the skull combined with extreme hTd]t>Oflp]ifths. We almost always see the subcutaneoua veins of the head sUwd- ing out like blue cords. On palpation of the sknll, we getieffi% find that the process of ossification is arrested. All ib# fontanelles, especially the great one, are widely open, the sntures gaping 80 that we can feel the fibrous membrane which stretches between the bones pressed outwards by the pressure of the cere- bral fluid, elastic and more or less distinctly fluctuating. Sorae- times — ^but only in very extreme congenital cases, or those whidi have arisen very early, in which the formation of bone was stiQ extremely deficient— I have felt scattered islands of bone withifl the fluctuatiDg membrane joining the cranial bones. In one of these cases the membrane just above the flat portion of the occipital bone, was prolonged into n round divcrticulam the size of a walnut, which — as we found on puncture— was filled ^ith fluid and was evidently a meningocele. The asstmip* tion that there was also external hydrocephalus in this case— t.^., an accumulation of fluid under the dura mater^was eon* firmed by the post-mortem.

Much more rarely — indeed only in quite exceptional casea — have I met with a normal condition of the 086ificatioD» or even an unusual thickness of the skull although it was so much enlarged. In one case this appeared chiefly in the region of the temporal bone and gave to the skull a striking appearaoca of breadth.

Owing to the marked increase in aize, the head gradually b^ comes so heavy that the child cannot hold it np. \Mus«i It it

I

«

' Id new-born cUildren the circnnifareDce rjt otin.» from 6—12 luoaths i^bout ISO otm.. wbicli it raaoLes About

<-«, on an Arwimg^^

laurun).

ia

CHRONIC HTDBOCEPHALDS.

299

not sapported it follows the law of gravity and aways from side to side* The huge proportions of tlie head contrast strongly with the sraall size of the face, which owing to the steady wast- ing becomes stUl smaller, and assumes an almost triangular shape. At the same time one is struck by the pecnliar staring look, or by the downward direction of the eyeballs (which was pointed out by the old physicians) so that the iris is covered by the lower lid and a considerable extent of the npper portion of the sclerotic is always visible. The view that this position of the eyeball — which, moreover, is not always present — ^always arises from a pressing downward of the arbital plate of the frontal bone is doubtful for this reason, that in that case a diminution of space iu the orbit and consequent exophthalmus would always result. As a fact we not uncommonly find a certain degree of the latter, and then we also find by palpation that the bony roof of the orbit is as thin as a piece of parchment, and at the post-mortem this appears to form an extremely obtuse angle with the other portion of the frontal bone. But this does not always occur ; for in two cases in which the direction of the eyes certainly gave one reason to assume such pressing downward of the orbital plate, I found to my surprise at the post-mortem that the latter was in its normal position ; although it is con- ceivable that the very tliin bone which was pressed downward during life had returned to its normal position after the removal of the brain that was weighing upon it. The downward direction of the eyeball may, however, also be caused by a partial paralysis

!of the ocnlo-motor nerve, namely, of those branehea which supply the rectus superior ; bo that the action of the rectus inferior pre- ponderates. The paralysis of other branches of the same nerve also occur, and occasion instead of a downward direction of the eye, a divergent squint or some other abnormal position, or more or less well-marked ptosis. It is but very rarely that we find both the direction of vision and the position of the eyeball quite unaffected. On examination with the ophthalmoscope we generally find a pressure-atrophy of the optic disc and dilatation of the retinal veins owing to the interference with the backward flow of blood into the cavernous sinus which the compression causes. In most cases the mental development remains in a very backward condition. The children are extremely apathetic, seem neither to see nor hear distinctly and do not recognise

iVB 8TSTBM*

ifiocj — Ibe sftlifm triekling TroiD the half- BAoeniiiig the skin of tlie lower lip aiul r.is bj BomeAnsalwaTs iL^case; i]ide«<d si tli« anMicmt of iiitelligeiicv nud eren in advanoetl cases of L3 drocephalns. Thus I hmre ohaerffd « diBd of 14 mth « Tery extreme form of vbo neognised tbcee Monad him, called " papa " ud "^ and fiidlowBd wi^ hia eytM annhing held tiefare him* ETen a few weeks ImCmv death, which look place with violent Ibe Timo was fnite onimpaired, the child spoke os (ore, reeogoised hk moytfr and smiled lo her. I haTe fre-

mUj met with gjtnil*!' eases, and thev maj serre to warn os not h^ too gieal stms^ in cawip of chronic hydrocephalus, on tLeiid Deeeasaffily eoanplete arteal of the intellectual developmcnlJ The power of motion in the npper limbs is nsoally not inch affected. Bat we maj perhaps notice that the children oa| \g to grasp anything, make incongruous moTemenlsl rhich hare a distinct resemblance to thoae of ehoresa. On th«^ hand panqilegia is Terj often present, both legs lieing| lither completelj paralysed, or at least aQable to bear thil ;ight of the body. Standing and walking — and often even itting — unsupported, is out of the question, and most of thej ildren, if you try to set them ou their feet, crost; their le^l (which arc looeely hanging down) without attempting a siiigk But to this rule, also, there are exceptions ; and caseu ive been published in which the power of moTement in th^ lower extremities was almost perfectly retained. ConYulsive attacks of Tsrious kinds, spasmus <jrlottidLs, strabismus, nyaiag*^ mus, conxTdsive contraction of the boily with a tendency to taSm forwards, and, finally, general epileptiform fits and contractaresJ are often added. At the same time, all the organic fanctions — ^ reRpiration, circulation, and digestion — may remain perfectly normal for years. Yet the state of nutrition suffers consider* ably, and the children finally become wasted, which causes tlio, 8ixe of the head to become all the more striking by eontrast*! In a child of six months a large bed-aore formed on the right I jiarieial bone and ear o^iug to the heavy head lying continually on tbo right side* Now, idthough most of these children die during the first years of life from atrophy and marasmus, or in a

CHRONIC IIYDnOCEPHALUS,

801

convnlaive fit — still joii must give a cautious prognosis as to the duration of the diseaae. Apparently desperate cases have in not a few instances attained the age of 5 — 0 years and more ; and we have also examples of the patients living to adolescence, or even much longer* Rarely cases have heen observed to end in the fluid rupturing into the space hetween the dura mater and arachnoid, or even externally through the vault of the cranium. I have, however, no personal experience of this ending.

At the post-mortem we find, firstly, a more or less marked thinning of the cranial bones due to the pressure of the dis- tended brain, and it may often he recognisable during life by palpation. In a child of 9 months, who was not backward to any extent in his iutelligencCj and did not show anywhere a trace of paralysis, I found this thinning ver}^ marked, the diploe gone, and the bone so transparent that yve could make out dis- tinctly through it the colour of the dura mater and its blood- vessels. Further, the fontanelles and sutures gape widely, and the spaces of the latter are closed by fibrous membrane of a finger-breadth or even more in width, which contain scattered points of bono. The cerebrum consists of two more or less fiaccid undulating sacs — the enormously distended lateral ventricles filled with serous fluid and surrounded by a shell gf condensed hmin substance, which is sometimes only a few

ktimetres in thickness* The amount of fluid averages from 9 to 18 oz., hut may even reach 2 pints or more. Albumen is generally only present ill small quantities. In the surrounding shell to which the hrain-suhstanco of the hemi- spheres is compressed, we still see the limits of the grey and white matter. Both the convolutions and the large cerebral ganglia are flattened by the pressure. The third and fourth ventricles are frequently dilated and filled with fluid. I have also seen the fifth ventricle repeatedly affected by this dropsical dilatation. We almost always find the central structures (corpus callosum, fornix, Ac.) of unusually firm consistence if the brain be examined in as fresh a condition as possible. The epond}Tna of the ventricles generally has a finely granular surface, and appears as if dusted over with extremely fine, grey, transparent granules, which under the microscope are found to bo due to hypertrophy of its tissu '. Only sel lorn do we find fragments of

mSSASBS OF THB KSHTOCS SlSTEtf,

tibrmoQs Ijmpb obstmcting the foramen of Moiiro» aod cooie- i|oeiiUj interfering ^ith the commanication of the v«ntndet with one another, or inflammatory thickening of the choroid plexus. The de*]:ree of the morbid changes deaocribed Tarj, of course, very much ; the dilatation of the yen Ir ides and tb« thickneBS of the compressed brain-subatanoe presenta the grealefil differences. The following case may serve as an example of an mrasoally extreme condition : — M

Anna P., 3 mouths old, admitted March 26th, 1877. inji

chroDic hydrooephaloa. Tolerably well-noiirished, Cirtrtunfirrriica

of the head 45, longitudinal diameter 25, tmnsTerao diAmcCcr i7

centimetres. Eyeballs directed downwards. So ncr\'oua symp*

loma noticed. The child took the bottle quite normally, cried

. much and lustily^ a«d its whole behaviour differed in no way from

^^th&t of a healthy child. Collapse and broncho-pneumoma. com-

^B meucttig on April 3rd ; death on 7th.

P»- J/.— After removal of the upper portion of the very thin dolichocephalic cranium, and division of the dum mater, we saw into a ventricle completely filled with 6uid« at the bottom of which an elongated lump represented the re* mainder of the brain. On closer examination we found that the cerebral hemispheres had almost entirely disappeared. (J&der the dura mater, which had remained normal, there appeared— only in certain places — very thin plates, bands and strips, covert^ by.a membrane resembling the pia mater — all that remained of tha hemispheres which had disappeared and were rcj3lace<l by clear watery fluid filling the whole cranial cavity. The tunorphoua maaa on the floor of the cranium consiitted of the remainder of the great cerebral ganglia, and the oerebelluui and spinal cord were connected with it in the normal way. llicsc [nai-ts, as well as the cranial nerves and vessels, were quite unafft^ted.

AlthoQgh in this child the compression of the substance of the honuBpherea had gone on until they had almost qoite dis* appear€tl, ive yet sec all the functions acting normally, and the wholo condition differing in no way from that of a healthy child of the same age. Exactly the same condition was foand at the post-mortem of another ca^» in which the power of motion wm just as little interfered with. A ''psycho-motor centre^L was certainly out of the qaestion here. The cases, thorofoifl famish a clinical proof of the view that the actions of the tusuM born child must be regarded as involuntary (reflex^ aiiioiiiatie)«fl

The pathology of chronic bydrocephalos is still by no BiOiH thoroughly explained* It is certain thot in a oumbar pf cuSP

CHBONIC HYDR0CEFHALU8.

308

the discaso is congenital, i.e. deTelopos daring fcDtal life. Under these circumstances a serious obstruction to birth may arise, which must be removed by operation. In these eases we sometimes find various kinds of arrested development — defecta of the corpus callosum, fornix, &c. ; likewise spina bifida, club-feet and hands, c^'C. Much more frequently^ however, the children come into the world apparently healtby^ and it is some months after birth before the relatives are struck by the unusual growth of the cranium. What, then, is taking place here? The peculiar granular hypertrophied condition of the ependyma — which can sometimes even be torn off from the wall of the ventricle in tough strips— points to the occurrence of an insidious inflammatory condition of it, which either begins in foetal life, or else not until some time after birth, and is so little noticeable that the first sign of the disease is the distension of the head by the steadily increasing pressure of the fiuid in the ventricle.' This inflammatory theory does not, however, fit all cases, because the granular condition of the epondyma may be absent, and with it everything that is in favour of an irritative process having existed within the ventricles. In the same way causes of compression (c,^*, tumours, of which we have already spoken on p. 284) are met with in a very small number of cases ; and least commonly in those that are congenital, or have arisen very early, and we have then nothing left but to content ourselves with the unsatisfactory supposition of a *' malformation,'* or of an ezces- Bive " secretion of cerebro-spinal fluid/* Those who support the inflammatory theory usually go upon the rare cases of hydro- cephalus which may arise in somewhat older children, L«, about the second half of the first year, after symptoms of meningitis. I have myself seen some cases of this kind, but they ore only of value as proof when tlie position of the fluid within the ventricles and the alteration of the ependyma is verified by a post-mortem. Should this not take place, we remain in doubt as to whether the case was really one of hydrops v^ntriculorum, or of an accumulation of fluid between the membranes (hydro- cephalus meningealis aire extornus) — to distinguish

' I caimot dnd any oonnection with congenital sypht lie saoli m is oo4m«ionally aaeumed ; at least I hare not Heeii the sligrhteat effect from ppecifio treatment in the very f e w ca«ea of chronic bydrocephaliia in wMch iypliilii eould be ascertained ^Sandot, jerpiitiMiw, JamiAr, 1847, p. 4&\.

304

DISEASES OF THE NERVOUS SYSTBM.

wbicli, clinically, from iBternal bydroci^pbiilus is a tnatter of the gi-eatest difficalty. I Uways think that the abseoce, or at letst the slight development of the cerebral 6ympk>tn8 — especiaUta satisfactory state of the mental powers — are points in favour tfft diagnosis of hydrocephalus externus.

Some French writers (Legondre, Killiet and Bartliez^ml others) have described this hydrocephalus meniogealiSf aa I bd^e already remarked (p. 27*2), as the second stage of ** btemorrha^ into the cavity of the arachnoid.' Accurding to our present virr, we have to do here not with a primary biemorrhage, but with m inflammatory process accompanied by blood-extravacatioii on the inner surface of the dura mater (pachymeningitif), which occurs pretty often in children nith moderate soverity mil extent, though not so commonly as in old people, I hafe under various circumstances found more or less thick fibrinotu dopositSj coloured with blood, on the inner sarfaco of the dun mater, along with the accumulation of a varying amount of reddish serum between this and the pia mater, although durioig life there had been no definite series of symptoms suggesting the presence of such a condition. There were present only the ordinary symptoms of meningitis — drowsiness, strabismus, dilatation of the pupils, cervical rigidity, screaming, &c,, andil is proved by experience • that these also may be absent even in extreme cases* On the other hand, I have hitherto met with only two cases of pachymeningitis which corresponded to those observed by the French writers, i,«., where the mass of the exuded fluid had by its pressure distended the cranial capsule 80 as to produce hydrocephalus.

Otto R., 10 montha old, extremely atrophic and atiauatc* admitted September 5th, 1883, with a considerahJe dt^greo ol hydrocephalus (very large bead, widely open fontftiicllep JnlflfiF gence backniird) and rickets. Death on Septomher 16lh*

P.-M. — Vault of the cranium strikingly largo, cajiccifttly tW parietal bonefi which corre»poiided in Kixt^ to thaHO of » child ol 3 or 3 years. On sawing through the skiiU, about lOJ oz, of cJcar yellowi&h-red fluid cacAped» although the brain itftolf wn« not in the slightei^t degroe damuged, On rt'inovnl uf the vutik nf tin* cranium a third membrane was found betiteen lit nd

pia muter which enveloped tho whole bmin nith the • «*(

'^ UOB&B, JoArh/* KintltrkfiU,, 1675^ yL— BilUot ot Bttrtb«s, iM^ciUi

CHRONIC HYDROCEPHALUS,

305

the pot^terior fossa, and could be raised up from the ititernal surface of the dura mater «a a transpureiit, colourless and but slightly va»culAr menjljraiie. Pia mater delicate and thin all over. In some places adherent to the false membrane. Vessela empty of blood. The brain did not fill the cranial cavity, but, after the fluid had been run off, the convexity appeai*ed to be sevenil centi- metres from the bonea. Ventricles of m<>derate size; empty, brain very ameraic, otherwise unchanged. All the other organs normal with the exception of rickety changes in the l>oncs» and peri- splenitis adhesiva.

In this case, therefore, the origin of the hydrocepbalas in pachymeni Dgitis was proved beyond doubt by the post-mortem (false membrftBe, blood-stained serum). Likewise in a girl of six months with extremely hydrocephalic cranium, backward intelligence^ and contractures of the muscles of the eyes and extremities, we found after death " pachymeningitis pseudo- membranacea htemorrhagica/* mtb fibrous thickening of the arachnoid and pia.

In the follomng case, which ended in recovery, the in- flammatory ori^n of the hydrocephalus is beyond a douht^ but it most remain unsettled whether the fluid was in the ventricles or in the meningeal space, or in both places at once/

Paul W., 3 years and 2 months old, broiight to mo for first time on February l-lth, 1861. Formerly healthy. During last 8 weeks complaints of pain in the head and neck, tendency to head- retraction, irregular rise of temperature in the eveuinj^, pallor and emAciation. On examination we found : inability to hold up the head, which was retracted; pain in the neck on pressure and movement ; frontal headache. Walking and standing impossible, but no paralysis. Anorexia and obstniction. In the afternoon moderate fever, pulse 96 — 100 and regular. Antiphlogistic treat- ment (leeches and inunctions of mercurial ointment into the

;ciput and neck) produced by the I9th an improvement in the itare of the head. But on the 2<)th, got worse again : vomiting,

iolent pain in the forehead and neck and marked retraction of the [(calomel, gr. i thrice daily). Exftccrbations of the pain occurred, especially between 11 and 3 p.m., along with rise of temjK'rnturo (blieter the size of half-a-crown on the occiput). Slight improvement from the use of quinine, hut vomiting, grinding of teeth during sleep, and a certain degree of incontinence of urine appeared for the first time. It was not till Maivh 22nd that the fever and attacks of pain had rjuite disappeared and the head could then bo

Bmir. tur Kin^erMiiK S, F., 8. SB.

W

806

DISEASES OF THE KBRVOUS SYSTEM,

tBOTod forward; Imt it now appeannl mikrkodly enlAricadt aol

nn exAmiiuitiou we fouud diii^itridis of tlic r ^#,

Tbc4«? ai»pcai*aticc;s increiwrd daily, so llmt on ti _ iM

WHS obligt'd to wear one of his father'n Imte itmiradnf his own. The sagittal suture gnpcd. And yielded soiDrvbal • *n pn"Ks?un\ nltbough tlic Tiiother htwl al)«errrd tluil tbiii ma wtS^m tho other 8Uluvt?s h»d been tirmly closed in the sccQiid yi!«rcif life. Weok piUsatioM in the position of the fontniicULV lutdlt^fset quite uortDAl, the right arm weiiker thou the left, whieh wan aIami exclusively used. Puis*? regubr (calomel* gr. | twice dml) tttl uug. hydnirg., grs. vi. to he ruhlicd into the Hcn\p daily}. Mtv "21 duyw (April It') the diameter of the head niichajisred* hut it wv held well up wnd no longer retracted. The rij^lit niTii wbm oowcsrfly moved. Gciiei-al health uunffectcd. (Tretttinetit on th4» mot lines rontiuued for 4 weeks with rodliver oil, a, drsgert«»poaiird twice duily.) In the middle of ifrty the child began tu wjilk, aod on June 1 Ith. e.\oepting for the lai^* si*c of the hejid, oveirltacr of the dij^ease had disappeared. The t^uinrcs nltxiiMl/ sbovid eomnieneing ossitication. In May, 1863 — i.c , *2\ fefitt «IWr the heffinning of the disease— T again .saw the child. Id peHeGl health ; all the cranial sutures had become ossified.

A\liat seems to me especially remarkable \u this ease is \i$ I'act tLat even at the age of three, when the ossificnr: he

HiUures and foDtanelles was already completed, the iij ;j|

pressure was sufUcieDtly strong to force these oxice moi$ apart. I have seen the same thing happen, but limited to Um coronal suture, in a boy of 7, in whom hydrocephalus W developed with considerable increase of the siEe of the henil, as a result of a fall two years before. Guelis. Killict and Bar they., and others mention this \ery rare occurrence. Perhaps this very circumstance, which relieves the brain (rma a part of the pressure, must be looked upon as favourable in so far that it may prevent the onset of serious cerebral ^ytiiptomii. At any rate* our case shows that even when the amount of fluid present is very larf^e, re'ab80i']>tion and final recovery is still possible — if the starting point of the disease was meninptig. It is very hard to conceive in vhat manner tJie empty spaca^ which must be created by the re-absorption of a considemlilo amount of fluid in the ventricles^ can possibly be Hllod up^ Kin«0 ihe bniiu «ubjitance which had born compressed to a : ft

conld hardly expand into its former bulk. This consiik :....,, ^h. to my mind, tu fnvour of tlie above-mentioned case being one of extorual hydivccphalun (^ uiugitis, the braiti, whidi

CHRONIC HYDROCEPHALXre.

ao7

was only slightly compressed from the outside^ Laving no difficulty in again expnnding after the re-ahBorption of the fluid. The ossitication of the fihroua tissue of the sutures then took place f^radaolly, spreading pnrtly from the margin of the cranial bones and partly from Wormian bones. I found exactly the same condition in a Russian girl, nine years old, of excellent mental powers, whose head had enlarged very greatly after an attack of meningitis in her second year hat finally became completely ossified*

The case I have given illustrates to you the treatment which you should employ in this disease. At first local blood* letting is to be recommended hy means of a few leeches applied behind the ears or to the temples, also iced compresses to the head, and purgatives, the beat being calomel (gr. i^i) several times daily. Later on, when the inflammatory stage is passed and our chief object is to bring about the absorption of the fluid, I should recommend the continued administration of small doses of mercury, inunction of blue ointment into the head and neck (grs. x, in the day) and painting with iodoform- collodion (1 : 16). Also iodide of potash (Form. 13) continued for a long time is useful in such cases. Antiphlogistic treatment, however, is only suitable for the very rare cases in which we have ourselves hud the opportunity of obBerving the early inflamma- tory stage. On the other hand, I consider chronic hydrocephalus of the ventricles as invariably incurable when it has caused considerable increase in the size of the head. The results which Goelis thinks he has obtained from his mercurial inunctions, appear to me, from my experiencei extremely doubtful and founded on fallacy. Read, for instance, his fourth case, * which was said to be completely cured after 80 days' treatment, and which certainly was not hydrocephalus at all, but only diphtheritic paralysis, I, at any rate, have obtained no results whatever with Goelis^s method, nor from iodide of potash nor from painting the head with tincture of iodine or with iodo- fonn-collodion, and I can promise you no better success from the compression of the cranium by strips of sticking-plaster, or from puncture through the fontanelle (to one side of the middle line). In the cases where these proceedings have been

Pratt Ahhandl. Slier dU voriHigticha'tn KranlhtiUn du kindHcktn AUwt, ii,, 8.

214.

808

DlSEAilES OF THE KKBV0U8 STSTEU.

of Qse (and they were exceptional) it !b po8diMe^ for the given above, that ther^ may have been only external hjiirtv cephalas J Those who have an inclination to aperste ooat gratify it, as the clanger of meningitis is not very great ; but out will do well to abandon from the very beginning any hope ol a radical cure. In five cases in which we performed panetnief ii had no eflfect whatever.

Gustav P., 3 moutha old, admitted into the hosrpitii) on Jvilj I3th, 1878. A few weeks after birth, increase in sise of the betii, and spasmodic twitching of the eye-muscles. On ikdmimioa diatinft hydroce]»hahi8. Circuinference of head 40| etra-, \oagh tudirial diameter 24 etm., tramtvi^rse diameter 23 ctm. On tie 18th, puncture of the right lateral ventricle inth ift by[iod«fiiir syringe and evnciuition of more than an ounco of a slighilf albuminous fluid. Procure applied immediately »fter by dln|B of sticking-plaster. By the 2l8t, no after-s^Tnptonis. On lhi« date a aecond puncture ; introduction of amodtum-aiiajed ezplortsg canula one inch from the middle line in the lateral nnglo of the large fontanelle and right into the left lateral venti-iclo, follovnl bf the application of Dieulafoy^s aspirator. 4koz. of fluid n^norcd Couvulsions in the course of the following night. Doith on 22od.

P.'M. — Chronic internal hydroceiihalas, also fluid betweeo tbf dura and pia mater. No trace of the puncture to lie found. Nc meningitis.

A child of one year, admitted on June 2l8i, 1881^. with (congenital) chronic hydrocephalua and rickets. Cr ntg

of the head 5P, transverse diameter 21 ctm. At ; iitj*

request 6 punctures were nmdc in the coronal future with ait aspirating needle about three finger-brcadthB to the right Of left of the middle line.

First puncture on 23rd June. 3Jost. of clear H aid removed. which (according to Prof. Salkow»ky's examiimtion) bad a neutral reaction, remained clear on boiling, Imt when it wm heated and acetic acid and ho<1. chlorid were added, it liocaiiM cloudy and showed tracer of albumen ; it gave no sugar retirtloa. Convulsions in the evening lasting 3 hours; temp, up to 108*5^ f. Fever, contractnrea and tremor lasting 9 dayi» ; miWr l)«at (be child see^ned well.

Second puncture on July 6th. About 7 ox. remowd. TV fontanelle subgided considemhly.

Third puncture on July I2th. About 7 ot remorwd. 13^

* fiftbn, **VtlMr oiiifMho ehnmiMlid HrdnMophalfa im «nt»«i ICitul«Hltaf ' i'erkamtiJmpm if. f>m§r909**/^ iitnerc Med, Ir.

CHBONIC HYDROCEPHALUS,

809

drachma of the fluid mixed with 15 minima tiiict* iodi injected tlirough the trocar. The child remained well, with the exception of slight rigidity of the limbs.

Three other punctures on July 19th. August Ut and 9th. Each time 8^ — lOioz. of fluid roraoved. Injection of tinct. iodi as ftboTC. No cerebral eijmptoras. Circumference of the head unchanged. After the 15th, broncho- pneumonia and diarrhoea. Death on 29th. rost*m.ortem refused.

I shall take this opportunity of saying a few words on acute hydrocephalus, which formerly occupied such an importaDt place in psediatrics. The vast majority of the cases described under this name are really cases of tubercular meniDgitis, and I shall discuss them later on in considering it. Far more Irorely, acute hydrocephalus accompanies simple basic meningitis, iding iuto the ventricles along the choroid plexus. If one ytrncts these cases there remain hut few in which jou can Bpeak clinically of a rapidly-recurring exudation into the ventricles, or between the meninges. One finds, to he sure, at [the post-mortem of many children, effusion of serum with Lfiioderftte distention of the ventricles, which, if one may judge from the symptom?, can only have taken place within a short time of death — a few days or even less ; and it is especially children with acute miliary tuberculosis, Bright's disease, and scarlatinal dropsy who most frequently present this form of acute hydro- cephalus. Such cases, however, cannot be diagnoBed with certainty, for exactly the same symptoms may be caused, with- out accumulation of fluid in the ventricles, by cedema of the pia mater, or of the brain itself— which is not uncommon under the same circumstanceB. Coma, conyulsions, fdtal issue |WJthin a few hours or days— all these are not in themselves suffi- cient to form a special disease, as, for example, Go el is has mdeavoured to make out with his " Serous Apoplexy " (hydro- feephalus acutissimus). Let us rather admit that our powers re, as yet at least, limited here, and that acute serouK effusion rithin the cranium — whether into the yentriclesi between the lembranes, into the pia mater or into the substance of the >rain — may be suspected from the circumstances in which the itients die, but cannot be diagnosed with any certainty from le above-mentioned cerebral symptoms.

310

DISBASB8 OF THE NEHVOUS SYSTEM,

XYI. Hypenemia qf the Brain, — ThromhosU of the Sinu^fi,

We loam from poat^mortem exarainations that the amonut of blood contained in a child's brain varies very much — thutiill conceivable degrees occur, from a slight filling of the vessds of the pia mater and a pale ana?mic colour of the grey substanca to the most minute injection of the vessels vdth Domeroas points of blood seen on section of the brain* It is^ however, vain lo attempt to connect these different states of the vascular systiim with definite symptoms. One can only smile when some writoin go so far as to pretend to diatuiguish even clinically hypersBmii of the pia raater from that of the brain. We must alao lUwa^t remember that hjper^emia found post-mortem may just as vrell he the result as the cause of fatal cerebral symptoma^ — i\g,t of very violent and protracted convulsions. Even pur© reHei convulsions may, by the accompanying interference with lint respiration, finally occasion engorgement of the cerebral leim^ ending in aidema of the pia mater and brain, with serous extida- tiou into tbe ventricles or between the dura and pia mater.

Hyporiemia of the brain and its membranes niay arise, like any other hypermmia, either from increased blood pressure in tito arteries or from an engorged stiite of the cerebral veins. The former we may expect in hypertrophy of the left ventricle and as the preliminary state of inflammatory processes (meningitis), along with which it falls to be considered clinically. LikewiiU.v local causes of irritation (tubercular masses or tumours) appesr capable of fjausing ** meningitic " symptoms (fever^ vomitings drowsiness, convulsions) by exciting byperamift from time lo time in their immediate neighbourhood. Theso sympiami rapidly subside either spontaneously or under antiphlogistic treatment ; but they may also* by their frequent repetition, lead U> ** intlammatory-hfemoirhagic" softening or to encapsulation from proliferation of tbe connective tissue. Thus far we stand on th* firm ground of pathology. But we not uncommonly meet with cases in practice, which^ — when wo take all the circumstances into account — can hardly be explained otberwise than by arterial hypern?mia of the brain, although the exact mode of it« occnnntncc IS not always rjuito clear and there is fortunately no opportutiiiy for anatomical coufirmatiou. Among the causes of this eonditiuii

HYPEREMIA OF THE BBAIX.

311

I

wliicli hero demand our consideration, injuries nre tliose HQOBt frequently met with. The child may become torpid or completely unconscious immediately after a fall on the head. We do not yet know for certabi on what stale of tbe brain the symptoms depend which are usually known as "concussion of the brain/' In three such cases which I have published elsewhere/ the children were perfectly well immediutely after the faD, and the symptoms only set in after some hours or days. These were as follows : — continuous headache, apathy, drowsiness, ya\^Tiing, change of colour, restlessness at night, anorexia, repeated vomit- ing, and fever, the pulse rising to 140 — IGO in the minute but remaining reguhir. One of these children Buffered at the same time from attacks of night^terrors, so that he jumped out of bed and ran to the light (probably owing to terrifying dreams) j and these recurred from time to time for some weeks after recovery. The rapid onset of these symptoms after an injury to the cranium, and especiaily the surprisingly rapid result of antiphlogistic treatment, make the diagnosis in this ease certain, I think. The application of a few leeches behind the oars (the bites of which 1 did not allow to bleed afterwards, in order to avoid ^ixcessive loss of blood) was suflieient to give considerable relief 4^ the symptoms. The ha^raatophobic line of treatment which Las come into fashion in our time is here to Ije avoided. We can draw blood directly from the cranial cavity by means of the cmissaria Santorini, and we must not hesitate to do so ; becanee these preliminary symptoms if neglected may result in regular meningitis. At the same time we must apply an ice-cap con- tinuously to the head and produce copious evacuations by giving calomel or mist, seunfo co,, and syrapas rhamni (Form. 7). Under this treatment I have seen complete recovery after 36 — 48 ours. In the two following cases, also, hypertrmia due to cerebral concussion seems to have been the cause of the symp- tom s.

Boy of 0 years, remained unconHCious for 24 ImurH after falling frcJTU a vehicle on to tiie l«vck of hi,^ hcml. No wountl discovi'mble. Kycs fixedly directed to llie r'i^ht, inipils did not react. No fever j temperature 98'2° F. Puke tmall, 1<X> and irregular; repeuted vomiting. After 24 hours, hcftduehe, frequent vomiting and irregularity of pulse remained. Other wise

neitr. zur Kinderheilk^ N. K, 8. 2,

812

DISEABEB OF THE NERVOUS SYSTEM.

well. These symptoms lasted for » wliole wvHjk and then dinp* pcared, leaving the child perfectly welL Treatmout : — i Itwikm behind the ear^ ice-cap, calomel.

Boy of (5 years, after a fall from a high stair on A- 1881, loss of consciousness and vomiting, lastiog thr ^ night. Next raorniiig return of consciotiancss, fmt a|Mthy ami double vision. CEderaa, ccchymosea and desquamation of tlic skin over the right half of the face, a considerable ccpbAUucmn' toma over the right parietal lK>ne. Pube 84, somewluvt i r regi Still occasional voraitijig; other^vifie welL Continuoas appli< nf an ice-cap, repealed pui*gatives. Bccovery by 12th Hayt a slight thickening is still noticeable in the situation of i\ c cphalhaematoraa.

In this case I tUoaght that I migbt omit local blood-letting m account of the severe hajmorrbage which had taken pla^o from the vessels of the pericranium. As a matter of course tliia must generally be omitted while the actual symptoms of coa- cussion (uncouBciousuess, great pallor, small pulse, coldness (A the skin) last^ and stimulants are rather to be used.

If you consider that the symptoms of hyperemia of the bniB occur after a fall on the head only in a comparatiYcly small nam* ber of children, whUe the majority remain quite free from thci or are only slightly stunned, you may assume that besides ihi sererity of the concusfiion an individual pre-dispoaition dilatation of the small blood vessels is an important factor. As a matter of fact, a certain number of my patients had shortly^ before recovered from whooping-cough or chronic pueumonin, oi else came of a tubercular family. The conformation of tlio era* nium must also he considered; for little children with mem*-^ hranous fontaneUes and sutures seem generally to escape the bad efifects of concnssion more easily than older ones^ whose cratiifti bones are already completely ossified.

In a smaller series of cases ^we see symptoms of hypertemia the brain come on without any discoverable traumatic cause ian< we may even be able to exclude such causes entirely), especially in children about the period of the first dentition. Thes< symptoms are — ^fever, drowsiness alternating with gr^t RMitle9S« ness, bad temper, apathy^ ' i convulsive m-

body, inability to hold up i i, ten^e and t^t ; ^: ^ '

mtanelje, elevated temperature of the head, aud likewise vomiting

only mention this as a fact, without being able to proTe that

BYP£IL£11IA OF THE BEAIK.

313

symptoma depend on dentition ; but I would remind you that we often find along with it extreme hyperaBmia of the buccal mucous membrane, increased secretion of saliva, erythema and papules on the skin and the face, and catarrh of the conjunctiva and bronchi. Purgatives (small doses of calomel) and cold compresses to the head aic in these cases usually suMcient to remove the symptoms within a few days. Still, we do not always attain our end so easily. Every physician has had cases in which the symptoms lave graduaUy got worse and assumed the characters of menin- itis by the addition of convulsions, head-retraction and coma. Finally, excessive mental exertion must be mentioned as a source of cerebral hyperemia. This oocurs as the result of over-excitement of an organ which is in a state of development. Although under these circumstances the hysterical symptoms, already considered^ and neuralgic headaches are wont to occur more frequently, still there are plenty of cases in which hjper- smic symptoms also have made their appearance after mental jxertion. I have elsewhere^ published the case of a boy of 9, :ho from such a cause was affected not only by violent headache and photophobia, but also by giddiness, anorexia, nausea, sigh- ing, constipation, pains in the neck, intermittent pulse, and Staggering gait. Emetics and quinine had no effect whatever, but the application of five leeches and of an ice-bag to the head Aud the use of purgatives were followed by rapid improvement.

The second form of cerebral byperffimia is caused by

'mechanical engorgement of the intracranial venous system.

^Valvular disease of the heart, with dilatation of the right

^■rentricle, compression of the large venous trunks by enlarged

^■glands inside the thorax or in the throat, but especially throm-

^Plbosis of tho cerebral sinuses^ may gradually give rise to this

hyperaemia ; and extreme cardiac debility, from exhausting

diseases, may cause it in a more acute form. In cases of this

latter kind, anoomiaof the brain is often assumed during life as

the cause of the symptoms. As a matter of fact the debilitated

cardiac muscle is unable to drive the normal amount of arterial

blood into the small cerebral arteries, and the consequent

letardAtion of the circulation causes a venous engorgement

ifhich finally leads to oedema of the pia mater and eeroos

iffasion into the ventricles. The clinical picture of ** *

^ Beitr, z, Kintkrhnlk.. JV; F„ B, 0.

K

314 DISBASBB OF THE NBBY0U8 BYSTBll.

ceplialoid " sketched by Marshall Hall is made up therefore of the symptoms of arterial ansBmia along with those of venoiu hypersemia of the brain. Its characteristic symptoms are: advancing apathy and drowsiness, half-closed eyes, flattening or depression of the great fontanelle, opacity of the cornea from fragments of mucns and drying np of the tissue, great weakness of the pulse and fall of temperature (especially at the extremities) — symptoms which depend only partially on venous hyi>er8emia of the brain, and partially on the cardiac debility and general collapse. The development of this series of s37nptoms is caused especially by continuous diarrhoea or very acute cholera infantum.

C h i Id o f G mo 11 1 li s. Diarrhoja for nearly 3 months. Admitted on October 3rd, 1873, in a state of extreme collapse. Drowsy, with waxen pallor; eyes 8uuk in, staring, and sometimes turned upwards. Thready pulse. During the next few days fall of temperature to 96*8° F. in spite of stimulating treatment ; pulse almost imperceptible, dimness of both corncie ; coma. Death on Octi^lK'r oth. i'.-Jlf. — Enlargement of Peyer's patches. Catarrh and thickening of the mucous membrane of the large intestine, especially in the descending colon and rectum, with nuroerons follicular ulcers. Fatty liver and fatty degeneration of the renal epithelium. Heart and lungs normal. All veins of the pi» mater enormously engorged, pia mater oedematons. Ku- racroua ])oints of blood on section of the brain. All the sinuses (piite unaffected.

The treatment of such cases must not, of course, be depress* ing, or else it would only further diminish the heart's energy, thereby increasing the venous engorgement of the brain. Our chief endeavour must be rather to strengthen the heart's energy in order to restore the circulation as soon as possible to its normal condition. Repeated doses of wine (a teaspoonful of Hungarian wine, port or sherry every 1 — 2 hours), warm baths (95° F.) rendered stimulating by the addition of mustard, with cold compresses to the head or douching of it with cold water, are to be used. We must of course treat by suitable remedies any source of collapse that still continues ; in most cases this is diarrhoea. In many cases, however, this has already ceased by the time the cerebral symptoms make their appearance. We may, then, at once attempt to strengthen the heart by stimulants. According to my experience, the best of

^

HYPBRBMIA OP THE BRAIN. — THROMBOSIS OF THE SIKUSGS. 315

n

ese is camphor (^rs. f — grs. lii. e?ery 2 hours, according to age, in the form of powder or emulsion, Form. li). Should neither camphor nor wine be sufficient to keep the heart going, I do not expect to succeed with any other remedies. Musk, and espe- cially the much-praised preparations of ammonia, I have found practically useless. Milk and strong beef- tea, yolk of egg beaten up with wine must be given to the child at short intervals. The prognosis, however, is always extremely Berious, and a largo number of these children, in spite of all our exer- tions, die in a state of coma often with convulsions.

The retardation of the venous blood-stream leads not uu- frequently to complete stagnation and coagulation of the blood in the large cerebral sinuses — to ''maraBmic" thrombosis. We most frequently find the longitudinal, less frequently the other sinuses, filled with more or less decolourised tough thrombi, which may be followed to a greater or less distance to the communicating veins, and must coDBiderably increase he venous engorgement in the brain and pia mater as well as the danger of serous effusion. Any other sinus-throm- bosis acts, of course, in the same way, whether it is caused by compression of the sinus, or by inflammation spreading from the neighbouring cranial bones. The petrosal and trans- verse sinuses especially are exposed to the influence of the adjacent petrous bones when carious, and the thrombi in them occasionally extend far into the jugular vein. That this process may take place without any change being visible on the free surface of the dura mater, is proved by the following case : —

Girl of 9 years, admitted into the hospital on February 2nd, 1877. Otitis media eince her tirHt year; perforation of the mem- briuie, through which one could see a red pulsating surface covered with puB. CouBtant eevere hfinlachc; no fever. Enr washed out under ohloroform. In tiie night between the 4th ami .'tth Februnry, stiddeijly great restlessnesK, delirium and screaming. On the .5th, coma ; pulse 116, regular ; temp. 101 '3® F. Next day continuation of the same condition, eon^mlsive contraction in the hmhs on the right side. Pulse 1:52, small; deep coma; temperaturp KXH^ F. ; reap. 60. Copious )>er8piration. Death. P.^JkT — Marked <Bdemn of the brain, pia ranter normal. Transverse sinilfet and right inferior petri»Hi»l sinus containing thrcimbu ''^•* ripht petrouH bono eariouH. The* cariew es-toinln to cIoh*' dura mater, in which sitaation then* wa« an almcettti tli pea. The dura mator itself was perfectly i

■ombi

816 I>ISEAS£6 OF THE NEBVOUS 6T0TB1I.

^H Fareiichjmatous nephritis. A portion of the iloum, ntnriy ^ ^H iuchc'H loiig, dark-red m colour and covered with a dipbthcdti^H

^f mcTnbranc. Liver fatty. ^H

r I have frequently observed the fact that caries of one of tk

craukl bonesj especially the petrous, may extend bo as to tutcli close up to the dura mater without affecting that membra&e itself. It remains for a long time unaffected and glistening, aaJ yet the neighbouring petrosal sinus may be the seat of a throm- bosis, which is to be explained^ either from small thrombi haTiDg been carried into it from the veins in the boneSr or their having projected into it. The sinua-thrombosis which occasionally observed as the result of severe suppurating ec«cmi capitis is also to be explained in the same way (continQoaa

^^ormation of thrombi through the emissaria Santorini).

^M Much trouble has been taken to render the diagnosis of sinus-thrombosis possible. Gerhardt and HugueDiD lay especial stress on the fact tbat in thrombosis of the transvcrfi^j

I sinus, or at the commencement of the internal jugular vein, th(

Hpxternal jugulars appear less Elled on the affected than on tl healtby side, because their contents arc more easily discbi into the empty intenial jugular. Again, in thrombosis of thaj cavernous sinus, the engorged condition of the ophthalmic veil is said to be indicated by venous hyperiemia of the fundua of eye, slight exophthalmos, and cedema of the upper lid or of tht' whole side of the face. Although I have repeatetUy Looked out for the symptoms recorded I have never been ablo to convince myself that they really occur, — perhaps beeaose (itt Gerhardt himself admits) the cervical veins do not always present the degree of turgesconce necessaiy for making out tho^ difference between them. Still it appears to me that carefc examination of the veins of the throat and eyes, and olt examination and careful noting of any unilateral cedoma in th^ face, promise more for the diagnosis in cases wbere there is a suspicion of sinus-thrombosis than do the signs ^\uich these writers give for thrombosis of the pulmonary artery. That this condition and its results (hsBmorrhagic infarct) may ocei i. jm thrombosis of the sinus by means of embolism, is In* deed beyond doubt, and it has also been proved anatomically but in a child the diagnosis of this embolism under the eureom'

^^ttauees in which it occurs (t.f. when various kinds of combral

rnyi*

the^ efol^l losftV

thiiV

TITBERCtTLAR BfENINGITlg,

817

iisturbancea arc present) is so difficult that it is only in very exceptional cases that wo can establiBh during life that it is connected with sinus-thrombosis. Under these circumstances treatment is of course out of the qnestioo, since even in a case where the diagnosis baa been put beyond doubt, no one would expect to be able to remove the tbromboeis.

X'NTI. Tubercular Memngitis,

I This is one of the commonest and most fatal of the diseaBefl Rffecting childhood. As soon as you observe the first certain signs of it, you may confidently foretell a fatal issue ; and, although in doubtful cases the physician leaves no stone unturned

tin order to arrive at a sure diagnosis, this is not, unfortunately, because he has any successful treatment in view, but only to Bssure himself of the certainty of the sad issue for which he has to prepare the patient's friends. If we compare the relatively numerous successful results given by the authors of the older

^■tvorks on "hydrocephalus acutus ** with our own, we see at once that physicians formerly described and treated under that collective name a number of different morbid conditions (simple cerebral hyperemia, meningitis simplex, typhoid). Now-a-days, however, when our diai^osis has become more exact, and wo limit our conception of acute hydrocephalus to tubercular meningitis, we can only look back with a smile to the modes of treatment which wore recommended and in their time held in high estimation. The incurability of this form of meningitis is indeed expressed in the very designation "tubercular/' Meningitis of this nature is fatal, from its combination with tubercle of the pia mater and of many other organs. It is not a merely loeal disease, but one which extends over many important parts— in a word, it is a ** terminal *' form of tuberculosis.

The description of this disease is difBcult on account of the numerous variations in its course ; and, in spite of the large amount of material at my command, I can scarcely hope to be able to give you a complete, comprehensive, and clear account of

iLit. I think it will be most suitable to describe to you first of all

^Kho Ufioal "olassical" form of th^ disease, as I may call it, and

"^ater on doBcribo its varieties.

CILL

mi]

DISEASES OF THE KBBYOUS SYSTBV*

The real outbreak of the disease is in many cases preceded bji

remonitory stage , which may last for creaks or even te months* The child becomes emaciated and flabby ; the moysff notices this in washing him, and cannot acconnt for it. The general health is often meanwhile unaffected, while in other eaitt various derangements occur — capricious appetite, lassitude, Ttn- ing temper, irre^lar rises of temperature — indefinite symptams the significance of which, in spite of the most careful eumi nation, the physician is at a loss to estimate. These symptoms announce the slow development of tubercle in rarious organs and therefore, in taking the history in such cases we mo always invcstigato whetlier there is a hereditary tendency tuberculosis ; for the discovery of this may serve to shed some light on the obscure significance of the sj-mptoms. We mnsl not, however, forgot that a family tendency to tuberculosis is bf no means necessary ; for hypertrophy and caseation of the bronchial and mesenteric glands may eidst as the result of chronic catarrh, whooping-cough, measles, typhoid, or repetUd attacks of diarrhcea, and may finally form a centre of miliary tubercular infection. Caseous processes in superficial lympbatio glands or in bones (spondylitis and osteomyelitis) may h«?e similarly important infiuence. We must hold to these liacti which are the result of innumerable well-established obserratioo from the clinical point of view, and leave their connection wi tubercular bacilli to be determined by further invest I * con hardly be doubted that invasion of the bacilli mn^ j»lace

m the intestine, the lungs, the skin (eczema), or the nasal ucous membrane, and finally lead to meningeal tuberculosis., lu this matter the nose deserves special attention,* as its lym*l phatic spaces communicate with the meninges through thffl ethmoid bone. Moreover, the above mentioned preliminary symi)toms are not at all constant. In spite of careful investi*] gations I have often enough been told by mothers that theifl chikhen had been perfectly ^vell up to the time of the actuttll commencement of the disease ; and their thriving, well 'nourished] appearance supported the statement. ~^H

■ • (/.Demme'B ca»o (A7ifi. WocK^nMehr.^ 18S0^ No* 15 1, in which a tab««a]iid IbiBTiA intli diBcluEi^ oontftimng ImioiUi praoeded the meiuiigiii* hy a \aag Uaini,] vithout uny hdruditory predlffpoation, mwI without therv htiog Any e«**oe«|

D6

I

TXIBEBCULAR MBNINOITIB,

319

H The onset of tlie disease occurs almost suddenly, with com- plaiDts of headaclie, especially in the forebead, and with vomiting — usually repeated several times during the first few days, and sometimes occurring after every attempt to eat or drink. Detinite characters have been ascribed to this kind

»of Yomitiu^', but I cannot confirm them. I have seen jt take place in the upright as well as the horizontal position, sometimes

without warning and sometimes accompanied by much retching, ^^1 cannot therefore see any real difference in the characters of ^■cerebral vomiting from that which is gastric. It is just this ^vpoint in the diagnosis, however, that we are first called upon to ^l consider. The symptoms of the first half or whole week are in ^wrery many cases so like those of a slight case of gastric fevei*, ^^that many experienced physicians who have seen numbers of

such children die are by no means secure from such mistakes.

I The general apathy, the loss of inclination for play, the head- iiche, the tendency oT the head to become retnicted, and especially the inclination to lie down, the more or less thickly-coated toiiguej the loss of appetite with vomiting and constipation, and, finally the irregular rises of temperature — all of these symptoms are so equivocal that we may be in doubt whether the case is one of commencing meningitis, or some feverish stomach-complaint, or whether it is not even the commencement of typhuid fever.

»In tubercular meningitis the children often show a striking per- sistence in picking at their lips, boring in their nose and rubbing their eyes; but even this peculiar and inexplicabli; symptom is common to all the conditions just mentioned. As long, therefore, as yon are not quito certain you must beware of telling the parents that the matter is one of no importance, and that it all arises from nothing but a "bad stomach" — a mistake which the iriexperi- H enced readily fall into. It is much better to leave the possibility Kof cerebral disease open, for parents never forgive a physician for ^^Ma false prognosis, even although he afterwards tries to shield ^Pbimself by saying that the " stomach-complaint '* has finally ^^Kgone on to hydrocephalus <

^B The uncertainty, however, generally lasts— for the experienced ^■physician at least — only a few days. By the end of the first week ^■nt latest more nnmistakeable signs of the danger threatening ^■igenerAMy set in, and cannot but attract your attention. Among ^Mhose I reckon especially a frequently recurring deep sighing —

DISEASES OF THE NBBT0U8 BTBTEBI.

which has almost never deceived mo — and the characteristie alteration Of the pulse — hoth of these being of course caused by irritation of the origin of the vagas at the base of the bndn. The poise becomes slower, and at the same time irregular, likewise unequal in the strength of its individual beats. This symptom I regard as decisive under the circumstances I hare described even if its appearance is only transient. There is scarcely any other disease of children in which the pulse varies so much in its character as it does in this. In the course of one day its rate changes repeatedly and considerably. Slight movements are sufficient to cause an increase of 20 or more beats, while the varying temperature — to which I shall presently return— has no influence on the pulse. The rate varies much between 96 and 120, and occasionally falls to 80, 72, and even less. But although this symptom is so important, we must also bear in mind that just the same may also occur in trifling stomach complaints, owing to reflex irritation of the vagus. Of this, however, I have only seen one instance, viz., the follow- ing case : —

In a hoy of 9 years, whom I treated in April, 1867, at the licginniug of an attack of fchrilc dyspepsia, the pulse fell, on the tlay following the use of an emetic, from 120 to 80, even when awake and in the sitting posture; during the next few days to 52 — 18, and presented at the same time marked intermissions. The persistent frontal headache, sleepiness, and indolence made mc very anxious ; but complete recovery of the gastric condition took place after a week under the use of sod. bicarb, with tinct. rhei, the pulse at the same time regaining its normal mte and regularity.

On the other hand I have frequently met with irregularity of the pulse without any great retardation, due to gastric or intestinal disturbance ; for example, in a girl of 7 years who was feverish for only 24 hours (temp. 103'3° F.), had repeated vomiting and purging, and presented herpes labialis on the upper lip. The pulse in this case was 88 — 96, when the tempera- ture fell, and was very irregular, intermitting after every third or fourth boat. This lasted for 9 days with diminishing distinct- ness and then suddenly disappeared. Occasionally even in meningitis the retardation of the pulse is absent, and we only notice its irregularity. Of this I have elsewhere published some

TUBEHCULAE MENINGITIS.

821

ob

xamples^' Such cases arc, however, rare upon the whole ; and where irregukriiy ie combine d with retardation you may always be prepared for the further development of tubercular meningitis. The hardness and vibratiug^ character of the pulse (pulsu;* tardus) pointed out by Rilliet and Barthez, I regard as in no way characteristic^ although I have frequently been able to observe it in the radial artery, and likewise just as distinctly er the ^eat fontanelle when it was still open. The retardation d irregularity of the pulse usually last till about the middle of the cond week, and then give place to a steadily increasing rapidity with regular rhythm. During this time the symptoms already described gradually increase in severity. The headache is rarely 8o violent as to make the children cry out and press their hands to their foreheads. Many scarcely complain at all of their head, but of pain in the ears^ in the throat, the abdomen, the knee or other parts, although nothing abuormal can be found iu them on examination. When the headache is present, it is generally •ggi'avated by coughing. Occasionally also there seems to be a eling of giddiness making the children think they are going to fall, even when they are sitting or l}ing down, and they beseech those standing by to keep hold of them. The apathy and drowsi* ness slowly increases, being sometimes interrupted by restless- ness, loud screaming, also perhaps by slight delirium. If we wake the child when in this condition— which we can still easily do — we find the intellect clear so that it answers questions, and ta oat the tongue when desired. The disappearance of childish stinacy and the indiflereuce towards the physician who used to received with screaming, and towards Ids manipulations, is ways a bad sign, and may, especially iu doubtfid cases, become iportant from a diagnostic point of view. The influence on rtain secretory and trophic processes at this stage is also re* arkable. Actively suppurating eczema on the head or other rta not uncommonly dries up, copious secretion from the sal mucous membrane becomes arrested, previously existing iarrha?a ceases, and in two cases I have seen well-marked largemeut of the cervical glands, which had existed for a con- derable time, disappear within a few days under the influence h( meningitis.

In many of the patients (though by no means in alh we oJ

* Btitr, ztte KinthriieiUi',, X, F^S

32*2 DISEASES OF THE NERT0U8 8TSTEV.

about the middle of the second week, or perhaps even earlier, symptoms of irritation of certain of the cranial neryes wBieb have become directly affected by the inflammatory irritation of the base, most frequently convergent strabismnB and grinding of the teeth. Whether the chewing movements which begin about the same time and are somewhat characteristic of tlie disease, are also to be referred to irritation of the portio minor of the fifth nerve, seems to me to be donbtfa], beeanse in this case wo would rather expect trismus (which as t matter of fact, docs occasionally occur). Slight retraction of the head is sometimes noticed even at this stage. The colour of the face changes, sudden flushes passing over it from time to time. The drowsy condition very gradually passes into coma; it becomes more and more difficult to waken the child, until at last it lies in a state of complete unconsciousness, making no response when called to. The eyes are half closed, one leg generally stretched out while the other is flexed at the knee, the hands lying on the genital organs, which are occasionally in t state of erection. The child utters deep sighs from time to time, or even a piercing cry (the well-known but by no means constant '*cn* hifdrnurphaUquc ** of Coindet). About this time the pupils dilate, often one more markedly than the other, and they react to light either very sluggishly or not at all. On the conjunctiva bulbi we see leashes of enlarged blood vessels running towards the cornea, and fragments of mucus; ^-adually also cloudiness of the cornea appears, especially of its lower segment which is not covered by the half-closed eyelids, and is exposed continuously to the air, owing to the absence of motion in the lids. The reflex sensibility of the skin dis- appears like that of the conjunctiva, so that, e.g. a gentle stroking on the inner side of the thigh no longer occasions contraction of the cremastcr. In addition we have automatic movements of the hands to tlio head, pendulum-movements of one upper or lower extremity, and rigid contracture of the muscles of the neck, and of those of mastication, so that it becomes difficult to give the child a drink. On more careful examination we also not uncommonly find some rigidity or paralysis of one or other side of the body. When there is paralysis the limb on being raised falls down without resistance, and lies motionless as if dead, while that on the other side is often jerked about in

TUDERCULAB MENINGITIS.

823

i

Here

II directions as in chorea. TLe constipation wliicli bas generally

2en present op to this time, and wbich yields only with difficulty

to purgatives, is often replaced in this last stage of the disease

}}y involuntary loose motions. The abdomen steadily sinks in

the region of the umbilicns, so that it comes to have a

lollowed out appearance, with the costal margins and iliac

jrcsts projecting, and the vertebral column can be easily felt

through it. lletentlon of urine sometimes occurs to such a

defrrec that a catheter has to be UBed. The pulse-rnte continues

to increase from about the middle of the second week, and its

rb}lhm again becomes regular. The rate gradually increases to

'180 — ^200 and more, and the pulse becomes smaller and more

JiDicult to feel. The respiration^ the implication of which has

ahready been indicated by tho above-mentioned deep sighing,

^Almost always presents during tho last 24 — 48 hours the

^fcheyne-Stokes character— cither in its well-known classical form

^Mr else modified to some extent. Thus I have seen, after a

^BpansG in the breathing lasting for a quarter of a minute, first a

^^cep sighing inspiration occur, followed by 2 — 3 superficial

breaths and then another pause. The number of respirations

in the minute may therefore ho only 7 — 5, and this infrequency

I of tho respiration, along with the extreme weakness of the heart Ipulse 180 — 200 scarcely perceptible), explains the cyanotic dis- iolouration of the face, of the visible mucous membranes, and l^f the points of the fingers and toes, which often comes on about this time. In many cases tho face becomes dark red ^iluriug the last few days» and profuse perspiration covers the ^Jfcrehead and cheeks iu clear drops. On the other bund, I have had but few opportunities of observing the skin eruptions which other wnters have mentioned (erythema and papules) — I saw one child of 2 years who in the last few days presented an rythema annulare extending over the whole hotly. To these ^ymptomsy which indicate the fatal termination of the disease, le re are very often added epileptiform convulsions iu tho ist 24 — 48 hours. These either affect the whole musculnr stem of the body in violent paroxysms j or they occur only on 10 side, being sometimes confined to the facial muscles ; or they msist merely in weak contractlona of the limbs. In tnanv cases [id contractures of the muscles ne neck also occur, or a conditi

3i24

DISEASES or THE KERV0U8 SYSTEM.

ilistiiiclly iu tlie movementB of tbe Lanils vrtiich contuiQc after tbe onset of coma. It is always well to warn tLe parents of tlie possible occurrence of convulsions towards the end, even altbougb no spastic phenomena have been obscrvfti durinp the previous course of the disease. I have bat raidyj found them entirely absent. The death-agony is alwajs nn«l usually long, whether convulsions occur or not. It frequently j lasts for several days and — what is all tbe more piinful furl the parents — it occasionally happens that in the midst of tliiaj last hopeless stage there suddenly appear surprising and in-| explicable signs of apparent improvement. The utieonsciea«| luid comatose patient suddenly manifests a return of his meiitjif| activity. lie turns his liead to bis mother when she calls ul him, opens his eyes, takes his food once more, or may evcij begin to sit up again and catch at toys held in front of him. l\ have several times convinced myself of the correctness of thUJ old obscr\'ation. I therefore warn you not to Over-estimate] these fiivourable signs. After a few hours the child relapKes' into his former condition, and dies from progressing collapse (paralysis of the heart) with convulsions or deep coma — a fortH night or three weeks, as a rule, after the first occurrence on the vomiting, |

We have yet to mention shortly the relations of tubercularl meningitis with regard to temperature. Invest igntion^i which I have instituted during the last few years, and which ij have already partly published,* go to establish the fact that tbiM disciise possesses no characteristic temperature-curve at all, hull that very considerable variation a occur throughout it« whole course. The evening temperature nearly always ex J ceeds that of the morning, more or less ; it is rarely tin? aaro^ J and only exceptionally somewhat lower. At the same time ihoi temperature Is always about a medium height, rarely exceeding] 102*'2^ F.t and in many cases reaching this level only on a ver^ few days. I have indeed observed cases in which daring th^ whole course of the disease, or at least for several days, IhJ temperature did not rise above the normal at all, or only did «d very slightly ♦ On Uie other hand, according to my ob»ervat»o]fl the temperature rises rapidly— in the majority of caHi-nJ although not invariably — on the day before the last or tdstt^M

TDBEBCULAR MENINGITIS.

^'25

tbe Ittgt day of the disease to a considerable height— to 104^ F. or even to lOTB'^ F. It nearly always remjiins at lliis lerel till death, in rare cases falling juat before the end to 100*4^ F.^102-2'^ F. I have not yet inyestigated the condition of tbe temperature after death. ^ This sodden rise of tempera* ture just before or during the death-rtgony, cannot possibly be regarded as an ordinary exacerbation of fever, for during the whole coarse of the disease the fever plays only a secondary part, and therefore we cannot suppose that it would suddenly rise to snch a high degree just at the very last when the symptoms of

tcollapso^ heart failure (pulse 200, small) — were setthig in. Nor yet can we regard the final con\Til8ion8 or any chance inflani- matory complication in the respiratory organs as answerable for it* I think I have proved thi^ conclusively in my paper (\. v, page 510), Two or three times I have observed violent convul- sions some days before death, with a temperature of 100*8^ P., while during the last days there were no convulsions, althougli the temperature was 104° P, and over. In a few cases, also, where recent pnenmonia was found at the post-mortem, I have noticed that this final elevation of temperature did not occur, while in all the other cases acute affections of the respiratory organs were not found, and yet this rise of temperature during the death-agony took place. This symptom — which occurs not only in tubercular meningitis, but also in adults who die with

• I give a few temperature «1mrtA an oianjp'ex ; —

Loniffe S.	, 1 year oJd,	admitted	H.,	i years old	, admitted	on 0
cm 89th Sept..	1878 1—	t.	April	1878	M.			K.
2&thScpt.	IWi..	101*3	tith AfirU	^			1013
aHh ..	007.	HH-3	7th		IIDT*			loni
IrtOct.	IW'7	1<X>8	8th		mo			m'2
2m!	!«¥• i	100'4	IH-h		lori			luia
' 3ra .	!ni 7	99-7	li>th		1)8'2			UO'f.
4th .	liM( >;	lfi2-2	11th		100 4			JOO'II
5th „	HMHi	1020	lilth		im>"8			101 ;,
Gth ,	10 18	HJ2 2	KltK		irn D	11 o	cioc-k	UfHi
7th ..	Hil(»	105*8				4	,^	io:io
Hth „	nm2	Death				6 9	-	UUh mi

In a child of 2 yeantt o4imtt«d on July Ifllh, 188V tho ifrnporainro m,\m ttmuA

be lOO'S* F. only on the evoiUAg of the liith nrul 17th. From iUvu In IIm. :frMt

WM alwaye nonnul or eTon viihiumiml. On ih*« nveninir of tin* '21ih iUm Iumi

btim» toddcnly rofe to lOi-4^ F. ({»til«o 180), an<l on thn ^Ih < thn rlny nf »<wmMO

TkftM examples may wIRf^ ; very many of n»y mMo* pr—miU*A •IfiilUr ««of»«1Mi«n»

3*26 DISEASES OF THE NEBYOUS SYSTEM.

paralysis of the cerebral fanetions — I can only explain by the assamption that there is paralysis of the supposed heat-con- troUingcentre, which is sitoated at the j anetion of the brain and spinal cord. If this is paralysed, the temperature of the body, which is now no longer kept in check, must reach an ex^ traordinary height. You will find this subject farther worked out in my paper already referred to, in which I have also gathered together the results of experiments which supported my view. Less commonly the temperature falls abnormally low before the end (from 96-8° F. to 82-4 F.>), which is to be referred to paralysis of the heat-producing centre.

In describing the course of the disease I have disregarded the customary division of the disease into regular stages; because I consider all attempts at such a division as useless, whether they rest on anatomical or clinical principles. We may perhaps distinguish a stage of irritation and one of paralysis ; but even this division is by no means thoroughly justified. For, as we Iiavc seen, irritative symptoms — e.g., convulsions — often enough appear for the first time during the last stage. If we take into consideration, moreover, the cases with an abnormal course and the numerous varieties, to which I shall presently recur, we see tlmt the division into stages is misleading and had best be abandoned.

The variations from the typical normal course in this disease arc, in fact, so numerous that we are much less likely to be correct in our diagnosis if we try to form our judgments according to one model case. Even physicians who think they know meningitis thoroughly are always coming upon new variations in its course which may cause confusion and can- not be explained anatomically. I have occasionally found a series of symptoms lasting for 10 — 12 days which resembled those of infantile typhoid very closely. Sometimes the children utter a piercing cry — day and night, almost without intermission— driving the parents to distraction, and then they suddenly fall into a state of coma. The initial vomiting, which is justly regarded with apprehension, may be entirely

' Gnandinger, Jahrb,/. Kinderheilk.t 1880, zv., S. 45P.— Turin, ihid^ wr 1880, S. 24.— Loeb, Deutaches Archiv /, kli»,Afed., 1888, S.443.— BaUban, VtUr den Gang de* Temp^ratur bet Meningitii tub,, Ac. : Heidelbex:gr> 1884.— B oka i^ Jiakrb, f. KindtrkeUk., Bd. xxi., S. 440.

TUBEnCULAK MENIKOrrfS,

827

absent, while in other cases it coutmues with the gieatest violeuoe for 0 — 10 days or longer, and there may be such shght symptoms of any other kind pointing to cerebral disease that the phyBician who sees the child once or at most twice a day may quite over* look them. One chihl of this kind I used always to find sitting up in bed when I visited him, apparently taking an interest in everything and eagerly looking at picture books. His eyes were clear and there was not the shghtest drowsiiioss, nor anything but the obstinate vomiting, to cause anxiety to the parents or physician. The inequality and irregularity of the pulse, how- ever, confirmed the diagnosis, which was soon estiiblished. When the vomiting is thus obstinate, the children often complain also of pain in the region of the stomach, and this may still further mislead the physician. EapeciiilJy in little children iji the first and second years of life, obstinate vomiting without any other threatening symptom seems to me to deserve the fullest attention. For in such children it is most likely to be resfarded as due to dyspepsia, imtil after some time the sadden occur- rence of drowsiness, squint, ptosis and couvulsious, clear up the mistake in a very unpleasant manner. Even the obatinute con- stipation which we generally have to deal with is not a symptom always to be depended on. I have rei>eatedly met with cases which began with vomiting and dtarrha-a and were therefore regarded as cholera infantum, until after *J-i — 3G hours obstruc- tion set in, while the vomiting either persisted or likewise dis- appeared. I have also occasionally seen diarrhoea due to follicu- lar or tubercular ulceration of the intestine persist in spite of the development of meningitis. Instead of the usual hollowing out of ihe abdomen, I have sometimes observed a more or loss extreme condition of flatulent distension, which is generally dae to a concomitant chronic tubercular peritonitis. The rule which is applicable to the pulse (moderate acceleration during the first few days followed by retardation and irregularity, and fiaolty increasing rate and regularity of the beats) only holds good in the majority of the cases. I have already previously (p. 820) pointed out to you the variations in the character of the pulse, and I w^ould add that in several cases in the very last stage wben epileptiform convulsions had already set in, I have found a pulse-rate of only 70, 76, 92, and 96. In one child of two years, a marked diminution in the secretion of urine took

328 DISEASES OF THE NERVOUS SYSTEIT.

place, and for two or three weeks formed the only premouitorjr Hymptom. This child only passed its water (which was Donxud) on ce in the 24 hours, and the hladder was not distended. It was only the increasing apathy and drowsiness that determined me to make the diagnosis of meningitis, which was confirmed by the further progress and by the post-mortem.

According to Legendre and Billiet and Barthez the character of the symptoms suffers material modification according as the meningitis affects an apparently healthy child or one already affected with advanced tuberculosis or phthisis. Only in the former case does the above described *' classic " course take place, while in the latter, the disease has amuchmore violent onset, with much quicker succession of the symptoms, resembhng meningitis simplex. In my own practice I have frequently had the opportunity of confirming their statements.

Anne H.. JJ years old, brought to me on October 2nd, 1862. Since Augunt, diarrhoea,, weakness, and ansemia, steady wasting, cough, dulness, with 'sharp rales and bronchophony in the left supra-spinous fossa ; fever, eczema on many parts of the body. On 24th November, sudden epileptiform convulsions; in tlio evening, vomiting, cessation of the diarrhoea, rapid irregular pulse. The eczema rapidly disappeared. Within the next few days drowsiness, coma, repeated coiivulsions. Death on the '28th — that is, on the 5th day after the first appearance of oercbi'al .symptoms. P. -M. — Basilar tubercular meningitis, internal liydrocephalus, extreme amount of tubercle in both lungs. Cavities in both upper lobes; follicular enteritis, &c.

I have most frequently observed this very acute course u she red in by violent epileptiform convulsions in cases which were com- plicated with tuberculosis of the substance of the brain itself. I have indeed often been able to diagnose from such a course the presence of this complication before the post-mortem took place, even though I was unacquainted with the former condition of the child. You will find several cases of this kind brought together in my paper on cerebral tuberculosis.^ Exceptions to this rule, however, are not uncommon. On the one hand the disease may take its usual course notwithstanding the presence of a considerable degree of tuberculosis of the brain or of advanced phthisis ; while on the other hand it may have an unusually acute course where there is as yet no real phUiisical

' Charitd'Annalen, Jakrg. ir., S. 480.

TUBERCULAR MENINGITIS,

329

I

disiiitegratiou.* This course, wliich very closely resembles that of purulent meningitis, is partiLnlftrly apt to occur in little children in the first or second years of lite ; take for instance the following caset in wliich the whole process ran its course in B days.

Karl M., [> months old. adinittca on Marcli 18th, 187P. Heidtby child. Took ill 2 diiys before, refusing tho breast, Toraitiiig, feverinli. Drowsiucsa and extreme aj withy. IVmjJCi'atiirp, lOl'P — 101*8^ F.; pulse, l:tJ, regular. On the 19th and 2Uth iiicreaBC of the di-owiiirit'Sfc) ; puLse, 156; eyes often lixed, turned upwards; ulmost continuous twitchings of the upjK'r liiuhf*. In the luuj^s notliJnfT to l>o made out but catarrh. On 21st, pulse 200; temp. lOt}*^'^ t\; rigid extension of the nnuK, with tremor; rcRpimtion frequent iind jioi^y. Deuth mi 22nd, with tem[)eniJ:ure of K>tj*2^ F. and imjKrceptible ]jultfc.

J\*M,— V'rji nmter iiewr the lon^j^itudinul JiwHure greyish-yellovv. floudy, very thickly sltidded %vith railinry nctdules, still more- mArkod at the hnne, etjy>erial!ly in the Syh'iiin iir4S«re, Yentricles ilistonded 1»y a Ini-ge rpmntity of c-leHr seriiin» Brain siUghtly li'domatous. Milijiry tuberculo-siw of both hings and of tlie liver and Hpleen, Bjonehiai, tiiieheid, and mostuteric glands caseous.

We are not able sufficiently to explain the variations in the course of the disease from its pathological anatomy. The post-mortem conditions seem to be just the same whether the disease has a normal or an abnorraal course ; and the differences miiFt therefore consist in finer modifications of structure which can scarcely he demonstrated. These affect sometimes one part of the brain, sometimes another, although their occurrence has not yet been proved beyond a doubt. Li support of this idea I shall only refer to the observations of Kendu,^ who in a series of cases found thmmbosis of the Sylvian artery resulting from the sur- rounding tubercular infltimmatioD, and little patches of softening in its area of distribution (corinis striatum &c.) with which he yfAH able to connect the paralysis observed during life* In several cases characterised by an unusually acute course suggesting simple meningitis, I have m^'self found tho inflammatory products deposited on the convexity of tho hemispheres to a greater extent than on the base which is generally its favourite seat. In one of these children, indeed, this part was almost entirely unaffected, rom this it follows that we must not regard the terms " meningitis

Vide my *' Btiirn^e tut Kiniitrhtill'., iV.F.," S. -14. RttkerchtA elm, tt anat. gu.

parafift

a la mMinffitt tuhtrculr"'

l«, 1874.

S30

DISEASES OF THE KERVOUS SYSTEM.

tuberculosa** aDtl "meningitis bBsilaris" as quite eqaiTalent: but the vanatioiis iu the course of the disease caUDot depeod o& this nlone, for I have also often enough found the oonfeu^ affected in the same way in cases with the onUuary proloflfii

VIn the great majoi-ity of cases the affection of tho bitit cerebri is certainly the characteristic feature of the diaeaad. In these cases we find a cloudy greenish-grey gelatinous infilttulla& of the pia uiater, iu the space between the optic chiasma and iht medulla oblongata, which surrounds the ci'auial nerrea as tb«f pass out and may undoubtedly g^ive rise dirtsctly t i •Icmis of

irritiition and paralysis iu them. In this urliood,

especially inside the Sylvian fissure there is a cloudy, redematoiM infilti*ation, and here also particularly we find more or less numerous grey or gieyish -yellow miliaiy tubercles inibcddcHl, about the size of a pin's head or less; and these are moaidcarU seen when we draw the pia mater carefully out of the fissures. According as these tubercular granulations are recent or old the} arc smooth and soft or somewhat hard and projecting. SimUar miliary tubercles of the pia mater are also not uncommonly met with, often in very great numbers, iu the choroid plexuses of tlit ventricles, on the convexity and inner surface of the hemispbeiVi — the pia mater at the same time often appearing extremely cloudy owing to serous infiltration, and streaks of exudation being deposited along the larger veins, either as greyish 'VaUuw pus or in the form of caseous maases. I have but rarely met with small miliary nodules on the inner surface of the dura mater also. On microscopical examination of these nodules wc find almost invariably the tubercular bacilli. The vessels of the iwa mater are, as a rule, more or less congested, and when it ia drami out of the fissures little particles of softened cortical sulmtanee are apt to remain firmly adherent to it* We also find here and there, strips of adhesion between the arachnoid and doru mal«r or accumulation of serum between tho two monjbranes, or blood* stained infiltration into the pia mater. The brain aaUstaucd itself is generally anrcmic, rarely hyi>erfemic ; the ventricles nftt markedly diatended by the accumulation of serous fiuid aiid tlieir walls as well as tho central structures of the brain (coqmii callosum, septum &o.) are often— but by no means olwAfs — retv much softened or even broken down into a cream*lik6

TrfiEBCULAB MENINGITIK.

381

>

floating in the cerebral fluid. In rare cases I lia%'e found little ecchymoses, especially in the neighbourhood of the third ventricle. These conditions are not, however, invariably foond, as the accumulation of serum in the ventricles and their dilatation may mlso bo absent ; so that tubercular meningitis is not necessarily accompanied by '* acute hydrocephalus." In this case the cream- ILke softening in the neighbourhood of the ventricles is also absent, and indeed it can only be regarded as a post-mortem appearance duo to maceration by the accumulated serum.

In a small number of the cases, although we find indications of iuflammation in the pia mater of the base and likewise of the convexity — diffuse cloudiness and thickening, ojdema or gelati- Dous infiltration with or without hydrocephalus of the ventricle — yet in spite of the most careful investigation we nowhere discover miliary nodules in the pia mater, although they may he widely distributed in other organs (spleen, liver and lungs). I ^Te myself met with such cases, and Hilliet and Barthez, %o observed eleven of the same, put them down as tubercular meningitis — most properly, I think, because the presence of ary tubercles in other organs, and the peculiar character of tiie inflammatory prodoct marks them as such. It follows from this that those inflammatory products may also occur spontaDCOusly, apart from the irritation of the miliary granulations; just as there is also, on the other hand, no lack of cases of acute tubercnlosis in which, in spite of numerous miliary tubercles, there are no signs of inflammation at all to be made out in the pia mater. I shall return to these cases when discussing tuberculosis.

I have seen only a single case where tlie tubercles were limited

to tlio pia mater to the exclusion of all other organs;

nd although similar observations have been published by other

ritors, e.ff. by Bouchut, we cannot help suspecting that the

post-mortems were not quite as exhaustive as they might Lave

been. I will only recall the fact that wo have repeatedly found

tubercles in the marrow, which would assuredly have been

overlooked by the older observers. I have also only in rare cases

found the disease very limited in its extent ; for example, in a

child of 2J years with numerous tubercular masses in the

nd tubercular meningitis, there were only very few scaI

miliary nodules in the right lung. Again, in a child oL 2

332 DISEASES OF THE KERVOUS SYSTEM.

tubercular meningitis of tbe base and convexity, I fotind onlr one single caseous deposit in the mesenteric glands ; in a child of 9 months only one caseous mass the size of a hazel-nut in one of the bronchial glands; in a boy of 11 years, only one indurated bronchial gland the size of a hazel-nut containing small calcareous particles, all the other organs being perfectly normal. Far ofbener I have found tubercular changes simol- taneously in many other parts of the body, the most constant feature being a more or less extensive caseous degeneration of the bronchial glands. Tuberculosis and caseous processes are also found in the mesenteric and other lymphatic glands, in the brain, lungs, pleurae, peritoneum, spleen, liver, and kidneys, and even in the epididymis and in the genital organs in littlo girls. In more recent times tuberculosis of the choroid has excited great interest, because at first when the fact of its occurrence was announced by Cohnheim and von Graefe-it was thought that an absolutely certain criterion had been found for the diagnosis of tubercular meningitis and acute miliary tuberculosis. The ophthalmoscopic examination began therefore to be regarded as the most important diagnostic proceeding in this disease; and the discovery of one or more greyish-white granules or patches in the fundus was held to be decisive in all cases where the diagnosis was doubtful. The latter opinion is, indeed, quite justified, and I have frequently been able to convince myself of the importance of this examination. By it I have frequentlT found tubercles in the choroid a considerable time before the onset of the serious cerebral symptoms, and while the disease was still in the preliminary stage of vague indisposition ; and I was thus enabled to realise the serious nature of the case. Unfortunately the choroid, as was afterwards found, is by no means constantly affected*; and ofthis I have been frequently convinced by post-mortems. We must, therefore, by no means regard a negative result of examination of the eyes as disprov- ing the presence of meningitis ; but, at the same time, a positive result may certainly be regarded as of the greatest diagnostic

' Heinz el {Jahrb.f. Kinderhtilk., Bd. viii., 1875, S, 355) in 31 oases of baail&r tnbercalar meningitis did not once find ohoroid-tnbercle either during life or after death, although in 15 cases there was nenro-retinitis and *' choked disc " — the latter being probably cansed by the pressure of the hydrocephalic Tentriclcs.— Money {Lancet ^ zix., 1883, Vol. ii.), found tubercle of the choroid only 12 times at the post*mortem out of 42 cases of tubercular meningitis.

tUBEKCULAR MENIN'GITIS,

833

I ItU

nguificance. The spinal cortl also does not escape j for its pia mater often presents eraptious of tubercle and inflammatory iroducts. In a boy of 8 we found the Bpinal araclinoid markodly thickened on the posterior aspect as low down as the himbar enlargement and infiltrated with pus, but free from tubercle as far as could be seen on naked-eye examtuatiou. Probably this com- plication would be found more frequently if we would take the trouble to open the vertebral canal at every post-mortem.' The assumption that the onset of violent convulsions, contractures, _iiud h)"penesthesia depends only on such an affection of the spinal lembrimeB, is, however, unfounded ; for in one case where the 'predominance of these convulsive symptoms was marked, the spinal

tcord was found to be perfectly normal at the post-mortem. We liave often found considerable at^cumulations of fieces in the large Intestine ; in one boy of four the whole ccecum on both sides of khe ileoca?cal valve was distended by a fiecal mass an inch and a half in length.

As to the etiology of the disease I have only a few wordji to add. Although children with a hereditary predisposition to tuberculosis, or those who are sutTering from scrofulous conditions, phthisis, or chronic suppurations connected with bone, arc most liable to the disease, you will nevertheless very often see well- nourished and apparently healthy children fall victims to it* It Is only since the discovery of the tubercle-bacillus that we lave recognised the possibility of these cases arising from direct ufection; positive proof of this will very seldom be found ►ossible. In general, all the ways in which the bacilli may enter le body and set up tuberculosis are also of significance as 'garJs the origin of tubercular meningitis (the mucous merabrano ►f the digestive and respiratory tract, and the skin). Of especial importance is the fact, which innumerable observations have ^ontirmed, that the bacillary infection of the pia mater may start in apparently quite healthy children from very limited caseous, tubercular deposits in the lymphatic, mesenteric, or bronchial jlands, which have existed for many months or even years without giving rise to any symptom whatever. The assumption of a traumatic cause, especially of a fall

'iF. Sobaltaie hii« c*rofally ej^miniid Uiose Bpinal obiuigoB miotowjopicaUy in caaoK of bajtUar tubercular nicningitifi^Mrhich, howpver. occurred in adulta \ fieri, Ififi, iVoekentchr., 1876. New, I mu\ 2),

DISEASES OF THB KERVOUS 8T8TBM.

■ VI

on the head (to which the parents always incline), is quite mistaken under these circumstanceB, and i« generallv on a mere chance coincidence. At the same time it cannot denied that a concussion of the brain is more likely to be follow by otlier hyperiemic conditions and their results in children wi a tubercular tendency than in others (p. 312).

I have, unfortunately, nothing favourable to tell you as to tbc results of t r e a t m e n t . All physicians who go thoroughlj into the diagnoais will agree with me in this, that they regard even case of tubercular meningitis as lost from the beginning ; and they are not mistaken in this prognosis. The few eases orf recovery which hare been published are therefore to be receiTed with the greatest reserve. The possibility of recovery tuinly cannot be denied. When w^e remember that in tubercu subjects every pleurisy or peritonitis does not prove fatal, an further, that the danger of the disease does not arise from miliarr nodules in the pia mater, which are not uncommonly quite late' we can only refer the enonnons mortality of meningitis to t cAUBeB. The first of these is the concomitant, acute tnberculoeis of many other organs ; the second is the local changes which the brain suffers, both from softening of the grey substanc* immediately under the pia mater^ and from the increas pressure of the dilated ventricles. When it has once r this stage any idea of recovery is of course out of the qnesti On the other hand I do not regard it as impossible to about recovery by opportune treatment at the beginning the case when the miliary tuberculosis is not general but locali as our main object at this stage is to anest the commenci inflammation of the pia mater, and to prevent a more extensi exudation, which might affect the cortical substance of the bm It is true that this attempt only succeeds in extremely few* but I believe, nevertheless, that it is always worth while to m it, except in cases where, owing to the presence of ad^^mnced plithisis or of the signs of tuberculosis of the brain itsolf, tl evidently useless from the very first.

I have elsewhere' published some eases which presented all the symptoms of tbe first stage of tubercular m were cured by energetic antiphlogistic treatment. ... , : th eases — that of a cliild of If years*— ended fatally from as ' BfUnifft nw KindtrktHi.: Berlin, ie$l, 8. 13. luitl .Vm rofa*^ 180, 8

casei^

M

TUBERCULAR MEN1KOIT18.

335

meDingitis three years after tlie first illness ; - a Lrotber of bis having in the meantime died of Ibis disease^ this fact seemed to me to be in favour of tbo correctness of tbe diagnosis. Hilliet and Bartbez record two cases in wbieb deatb took place from a second attack occurring two or three years after recovery from the first one ; and nt the post-mortem the old and the recent eruptions of tubercle in the pia mater could be clearly dis- tintjuisbetl. Politzer' also describes the case of a child who bad suffered three years previously from an attack of basilar meningitis, and who — except for persistent emaciation — com-

Ibietely recovered. At tbe post-mortem, besides the recent basilar meningitis, an obsolete indurated patch was found on tbe pons* Although, therefore, these exceptional cases seem to show that even after recovery has taken place a fatal return of the disease is always to be feared sooner or later, this apprehen- I sion most not cause thu physician to take up a passive attitude. H^ therefore order, to begin with, tbe application of 3 — G ^Beeches behind the ears (according to the patient's age), and an ^pce-cap to tbe bead; I also give calomel, gr. i every 2 hours, and — if tbe bowels are not freely opened — follow it by mist, sennje ;60,» or syrupus rhamni, and have blue ointment (grs, v. — x.) ibbed into the neck and throat several times daily. Although n about fifteen years I have seen no result from this mode of peatment, I still consider it my duty to carry it out, and it will sertainly do no barm in a disease which, if left to itself, is levitably fatal. It is of course only to be tried during the first iw days of the disease ; at the later stage neither this nor any rlber kind of treatment can be of any avail. I have also aban- ^cloned tbe extremely painful inunction of tartar emetic ointment ito the head, which used to be so strongly recommended ; and lie application of fly blisters to the neck. Further, the con- Inuona use of iodide of potash which I have tried in innumer- tbU Gases, and tbe repeated and long-continued painting of tbe icad and neck with iodoform-collodion, have been equally far from yielding successful results*

m

DISEASES OF THE NERVOUS SYSTEJf-

XVm. PinnU'ttt Mt'iiimfilis*

Tbe frequency of purulent menin^ritia, wliether afTectm^ membranes of the brain alone or tbose of tbe spiue also at mme time, is not great compared with that of the tabeittil form. Only those physieiana who have had the opportimitv observing epidemic cerebro-spiual meningitis have uuj cousidt able material at their command ; for under ordinary circumstiUK tbe nnmhcr of cases to be observed i^ always very KmulK

Anatomically the disease is generally characttjriaed by absence of all tubercular formations in the brain and ita branes, as well as in any other organs. This does not, of course, exclude the possibiJily of a tubercular subject bei affected accidentally by simple meningitis — t\g, aa the rcsiiU a fmcture of the skulL Apart from these cases and a few otb« — eg. those due to pyaemia — almost every ease of meningitis tubercular subjects assuines the anatomical and cUnicul eh racters described in tbe last chapter ; and even the absence mihary tubercle in tbo pia mater does not violate this rule (p* 881). Simple meningitis affects the convexity of ih« hemif^pheres far more frequently and more severely than dool Iho tubercular form ; but the inflammation often spreads to t\M base also, and extends from this over the medulla oblon^ad more or less deeply into the vertebral canal ((< ; ' il

meningitis). From the base the sero-punilent ini m

spread even as far as the tissue behind tbe eyeballs, IhM occasioning exophthalmos. In addition to marked byjM ' iil the pia mater, ecchymoses of various sizes, and localised u , ifl

of the dura with the pia mater, you find the tissue of the latt^ infiltrated with yellow or yellowish -prrey pus. This partfl follows the course of the larger blood-vcBsels^ partly spreads otfl 60 as to form a layer, and also a varying amount of it may occol free between the pia and dura mater. The grey cortical layer M the brain is frequently adherent at many points to the pia mated softent^d at its periphery by imbibition of serum, h1»o hyiH'n4>mil in places and with capillary InemoiThagcs scattered through ifl Although the ventricles are empty as a rule» thitt im h) um means invariably the ease. I have occasional! v fottxid thrifl

PURULENT MBNIKOITIB.

837

late ■loos

diflteuded by turbid serum coDtaiutiig streaks of purulent

matter, while the epeBdj-ma was at the same time loosened » hut

showed no imporianfc change. In a child of 2 months both the

lateral and the fourth ventricles were filled with thin yellow pus,

id much dilated. When the spinal cord is impHcated w^e find

quite similar purulent infiltration of its pia mater and of the

>8o meshes of the arachnoid, the posterior surface of the

si)innl cord being most severely and extensively affected. Also

the inner surface of the dura mater both in the cranium and in

the spinal canal is in many cases congested aud covered with

pus and blood (pachymeningitis). All the symptoms occur

cqimll)* in the epidemic and sporadic cases of the disease.^

I have as yet had no opportunity myself of observing the

)idemic infectious form on any considerable scale, although

lany times cases of this disease have followed each other so

ipidiy here in Berlin that, taking them along with cases simul-

meously observed by other medical men, I have been obliged

i-xegard them as examples of a miniature epidemic. Two

which came into my ward immediately after one another

the summer of 1885 — one of which ended fatally — occurred

ren in one family. At any rate the so-called sporadic

kBes were at least as common. As far as my experience goes,

a very acute course — which was ormerly held to bo in favour

of this meningitis in contradistinction to the tubercular form

— is by no means a sure criterion ; since, as we have seen,

there are cases which last as long, in fact much longer, than

^those of the tubercular form. The clinical symptoms also

^ftpay vary so much in their severity and combinations that it is

^Bppossiblo to sketch a clinical picture which will apply to every

^Base.

The following may be mentioned as being the main symptoms Mhich con in general be traced like a red thread running ^rough all its varying manifestations : headache in children ^ho are old enough to complain of it, vomiting, stiffness of the les at the back or sidt 8 of the neck, contractures of Iho lities, convulsions, delirium, coma, aud more or less high

Willi reifani to the oocurrence of epecifio bacteria in the ptu of (hif menintf'^^i". the «tatemmits of writer* rary. Many "y ^^'i- '-f »T»i .>^— ^.-r.; Friinkol) of a form ideutlcil with the pneam ^rtb«cl. Attem)iin at cultiration which were mado in l., , itii tho |»na from oae of my casca gave an oiitlroly iMf

838 DI8EA8ES OF TBB MBRYOUS 8TSTEM.

fever. Of these symptoms, however, either one or more may be absent, or else their presence be so slightly marked as to be readily overlooked. The order in which they occur also varies. In a series of cases, well-marked brain symptoms set in at the very beginning — delirium, coma, vomiting, convulsions and cervical rigidity which at once put the diagnosis beyond a doubi. Such cases occasionally have an extremely violent and acute course.

A girl of i> years suddenly, in the niidi$t of iKirfet't health and without discovei-able cause, became affected by violent headache and vomiting. After three hours, general epileptic convul- sions and deep coma. The convulsions ceased after about 12 hours, while the coma i)er8i8ted ; there was high fever. The con- vulHious then recommenced and lasted till death, which took place 48 hours after the commencement of the illness. P.-Jf.— The whole convex surface of the brain covered with a yellow purulent exudation, infiltrating the pia mater, which formed a coherent layer over the frontal lobes, further back followed the course of the vessels and penetrated deeply into all the fissures. Also at the base purulent infiltration in the neighbourhood of tho optic and oculo-motor nerves. Ventricles empty. The remaining organs healthy.

In a boy of 1-5 years vomiting and gcnoml convulsions suddenly begun in the early morning, lasting till 5 p.m. They then ceased for 5 full days, during which there was fever and coma, and then recommenced on the day Iwfoiv death (the 6th day of the disease).

The younger the children are, the oftener does the disease begin with convulsions, which occur one after tho other, and are rapidly followed by coma. In many cases, however, even at this early age an extremely high temperature forms the chief symptom, and for a considerable time supports the diagnosis of typhus until at last unmistakable cerebral symp- toms set in.

Agnes W., aged 8 months, healthy, child of a medical man, took ill on March 8th, 1877, with a single violent fit of vomiting. The child was pale, unwilling to take the breast, and, contrary to it.s usual custom, very quiet. On the following day, however, there was still nothing really morbid to be found. She laughed and jumped in her father's arms almost as happily as ever. On the 10th and 11th the child again became apathetic and voiy feverish, and in the evening the temperature waa 105*4° F., so that we looked for a scarlet fever-rash. On the 4 following

PURtfLENT MEKIK0ITI8.

dS9

tliiyf*, u|i tu the 15ili, tlio high fever foraied tlio otil y nni»oi'tnnt i*vm|>toiu. The tempemtiii'e was aa follows :—

M. E.

On 12th March 104-0 luVa

., IStli „ 1047 107-2

,, 14th „ 1051 104-4

,, 15th „ 104'2 lOl'S

ITie fall of the temperature during the last 2 duys wn» effiTtud hy two cold jmckM. two doses of cfuiiiine (grs. iii. and grs. vi.), and dually liy a imtli of 86*^ F. The diugnosis wavered between t^qdius aivd meningitis ; nnd on the oeeurtion of my first vinit (on tl)i^ I'jth) 1 did not venture to make yp my raind ; hut on the lijth — that is, 8 days after the commencement of ttie vomiting— ii moderate anioont of rigidity appeared in the muscles of the neck, along with turning of the heiid towards the left aiu^ n slight contraction of the right arm at the elbow-joint. Neither by contiraieil iee-oom presses to the head nor by co1idbath.>. [iven twice daily, and enemata, containing quinine (grK, vii^sL rere we now able to bring down the temperuture. Thin kc'|it bi'twtM'o HW-' F. and lO-^a^ F., and only fell temporarily during the 2 last day« to lOl-^*^ F. Pulac between 130 and !&>, always regular. A* now (on the IStli) the neck seemed to be again more eiiftily moved, and the wpleen was found to be much enlarged on [wdpation; as, further, the child— in spite of the crintinued high teToy)eratnre — responde<l readily when called to. and gnisjicd at a watch held in frt>nt of it, we again hewitated in our diagnosis of meningitis. But on the 19th the vomiting returned, and the cervical rigidity and contracture of tlie right ann again act in» making the diagnosiH certain. Convulsions of the whole body, with dark redness of the fare and profiise pei-spiration occurred for the first time on the evening of the 2l8t. During the night frequent screamingand repeated vomiting. On the following day, at 3 p,m», an epileptiform attack, lasting for half an hour; later* energetic chewing and sucking movements ; convergent Btmbismufl, congestion of the conjunctivre. The couvnlaionn nirred on the 2^ird, from 3 — 6 r.M-, and again at 10 r.M., aftfr rhich they continued till death ensued, at 3 p,m,, on the 2Uh. *ulse at the la.st, 2CK>, thready. P. -i/.— Very severe cercbro-spinal raeningitia. About n tablt- *«po<jnful of free pus on the surface of the brain; purulent exudn- fwtf. 1 inches thick between the meyhes of the pia mater; of the brain sulistance, extending about i inches into u.iv\ substance of the brain. Ventricles empty. Sjileen about thrice its normal size. All other organs

* conviilaiona beginning on the 13tli day d previously existcfl iiotldng;!^! ^n^n^

8i0

DISEASES OF THE h'EBVOUS SYBIBM.

high temperature, a certain amount of cervical Hgiditj, cat- tracture of tiie right upper arm, and palpable enltrgeitMiit of the spleen. For theso symptoms, which are sofficietit iot i (liaf^fnosiB^ we arc in some cases kept eo long waiting thmi tt think Booner of the development of tubercular, tlum of pan lent moningitis. This mistake is especially liable to be ctutm liy It pcraiatt'iit low temperature (about 101*3^ F.) and a not TW rapid pulse-rato (04—90) and the pulse may also be irregular. I

Thus in II child of 9 mouths/ rickety but quite free hom tubrnifl vomiting occun^ after Qvory meal for a fortuight bcfoM cervical rigidity made its appcflrancc. At the same tn thcro was liigh fover (pulse 152 regular) almost contintio^ itci*onmtti|7 iitid coutraoturen of the fiiigen« During thft ^ Ua ibiys, roiitinuQi]s cnmn uttd almost unintermptod epik^ptifofH coiivixUioiis. Accoujpanyiiig theso. there was a retuni of ihi vnriiiiiii^« 8itikiti^*iii qf the fontanelle, dilatiition ituil Lmiai^^H of the ptiptls; pulsQ gniall nnil too iiipid to ho eouiitocl. hreJ^^B irivguhir. Druth after 3 wet'kN- At the 1\*M ivc fniind purult'fl mniiiipfitia of the conveiit)* and hiisi% which hful extended to td pia niH-ter of the cervical ci»rd. V(?otrick»« dikitc^l, Allod wn turhid Bontni and pus. Otherwixc nil orgjiiwmormal. Notultcrrfl anywhere, ■

The following case also looked like one of tubercular meniifl gitin, although it began with an attack of convulsions, whicB was referred to a complication with tubercle of the brain, I

Max Th.. 7 months old» rickety; admitted Juim? lUli. l^M After a cou^h which had lasted for some time» Buddetily, 2 wccfl H^o, an opilcptifonu attack occurred- 8ince then« retract i^ of the head, sometimes more marked than at tethers. 'Jlie hiJ and N]iiTial cotuiun formed an acute nnj^h^; the fonrs'^ ' ' Vil bciit forward. At the same time ^rejit a]>athy« left r< J

I.»i8mu8, riglit pupil somewhat dihited hut react«xl well, liiUdrJ olorrho'ft esperiulJ)- ou the right side. Cutarrh of the lurfje bruucU These w)nuptom8 Imd porsiytcd for nearly ihree weeks uucli^^^| Apathy and drowsiness daily increusiu|;: extreme rmacfllH Dorinii; the Iftfli; dny^, coma, |)*j*icorneMl injcrtion, fmi^UKrutA fl mucus on ihe coujuuc'tivn; tcmpci\iture uerer n^-.v,. io»i-|'J lul'H-' F,» iu the last days almost iiormaL (Jphtlml r xaia

iiuittou ucgatire. Death on 2i*th iu coma without > a. I

i'.-Jlf- — No tubcrehj in any organ. Modtriitel> ide^

meningitis, extreme dihitatiou of the lateral and ul iliv luiirM

» Btitr. tur Kinder heitt,, N,F,, ^. ta

PURULENT MENINGITIS.

341

pall

I

vetitridfs, whk-h were filled with thin yellowish pus. Ependyma swollen* Bniiii niiaeinic, a hyptntmic zone round the veiitriclei'. Purulent otitis modia in both ears witli purnleiit intilti'ation ol' the BUiTounding hone.

Id ibis cftse the basilar moniiigltia may have arisen from otiti*8 media and then spread alon«,' the choroid plexus into the ventricle. The disease lasted for five weeks altogether, connilsions occurred only once, at the heginiiiug of the meningitis. Convulsions may, however, he entirely ubsent daring the whole course of c disease, and in that case there occur in their stead con-

r act u re 8 either of the muscles of the neck and back only, or also of the limbs (especially the lower) presenting more or less rigid resistance to extension, and when they are extended the child screams loudly. In one case (a boy of 10 years) there was Also an extremely tender diifuse swelling of the left hand and

ight knee-joint, which slowly disappeared under the use of

ercnrial inunctions.

Ernst P., 7 years old, admitted in Ivoverabcr, 1872, ^^vith catarrh of the larger bronchi and t.N-phoid symptoms. Coma, tongue dry and red, soon becoming brown, lips bluckisli ; eple^ti and liver normal in size. Temp. 102'2^— 103'P F., later 101-8^ F, From the Ctb day after admission cervical rigidity and ."tiff flexion of the lower limbB, dilatution of the left pupil, frequent loud Hcrfuming; later, fiexion of all the fingers and supination of the Lands. Temp, varying from 97'9^— lOO'S'^ F, On the I'itli day, improvement, tongue moister, tremor of the legs, iutelli^^eucc retunnng, appetite better. During the next *2 days, symptoms worse again. Temp, normal. After the ItJth day intelligence quite clear, temp. lOl'S^— 102'2^ F. After the 22nd day all spastic .s^^Tuptoms disappeared, and the child seemed well. Free from fever, Pulwe during the whole ilhie«» vaiyin^ hetM-ccn 104 and 132. Only once (on the 28th day) waw the i^ul sc 16 and temiteratun* 98'2'^' F.

Otto K., 7 years old, admitted in Deeemher, 1872, with gaBtric ssymptoms, pains in the head and body and the abdominal vva!l e\- tremely tense. Prom the -inX to the 7th day violent delbium, drowsiness, complete apathy, temfxi'aturc normal. After the 7lh day, marked improvement, intelligence brighter till the lltb, when thi? ehild got worse again and complained of violent pain in the neck. Moderate cervical rigidity and contracture i>f the adductors of the thigha. Temp. 977^ F. and puhe 6U— 1>4 till ihc evening of the 12th day. The symptoms continued to get worse and considerable hyperBcsthesia of the lower ox- tremitiee came on, with repeated vomiting and severe pain in the

DISEASES OF THE NERVOUS SVSTISM,

buck and loins, the temp, rising at the smne timo to KCtr."^— 1047^ R, the pul«e 110—142. On the 14th day oil the a>»|itoau subsided and the temp, and pulae gradotilly retiirne*] t« ihmr normal condition.

The treatment in both caaes consisted In ih^ i^r'^ioUnl application of leeches to the heud and wet-f«j>pinL' 'H*

spinal eoUiran, warm baths (in the firttt eunt* with r*tl ;9

the head and buck), inunction of mercurial ointnipnt ; iutenwll^ calomel and ntlier purgatives.

Gottfried 8 [> . , 7 years , ill for 3 <h»y8. A dm it t ed on May 28rd 1885, with violent headftche, followed by pftinn in the? neck usd left knee; drowsiness, slight delirium, extreme rigidity •! the neck and spinal column, which increased w^lieu he wa* i«l up. l^ipilij normal. Temp, irM>8*^ p„ pulse IW. but «oon (ell In 84 and became invgular. Lower limbfK slightly rori true ted in a position of flexion; no hypei*a*sthe»ia.

Treritment— 12 wet cups, inunction of nng. b3'dr:apg. j^th. x, i calomel, ^r. k every 3 hours. On 24th, 8 more wet-cii]>». On 2otk. herpes labialis. Temp. lOTl*'^ — lO^l'^ F. Drowsiness alteniatiiu; with free intervals. On 2tkh, disappeiiranec of the CM».t f^.< • ,.r,^ pulse 120 i*egular. Temp, 101'3*^ F, The symptom fl- iiy

Kernig' could be distinctly obeorv*ed, and continued wii n riiTn!'U9ii» ing diKtinctnesis into the period of convalescence. It only iliJt- appeared entii'ely on June 6th. After i^rd June, patierit trier from fever. The cervical rigidity, which wa8 tlien moderate, did itul disappear till the f^li. Latterly pot. iod. was given. Di^dmrged cured.

In these and several otUer cases wLicli I have lately met witht 1 observed the Bymptom describetl by Kernig, i,c, rigidity of the lower oxtremitiea at once came on when wo set the patie&t up in bed, even uhen there was no rigidity when lying (|ui€lly on the backt Further, when the patient was hing on the side, this rigidity was generally set up whenever the thigh was piaoed at anything like a right angle to the body ; there thus occarrod at once a condition of contracture at the knee-joints in an attitndo of flcxion» which tirnily resisted extension but disappeared At once when the patient was put back into the horizontal positioiL I cannot say, however, that this symptom is constant; for il was absent in one severe case in which the diagnosis was con- firmed by a post-mortem — at least so long as the case wnntandcf clmical observation. Even altliotigh the symptom i« n J

gnoiDonic, as it occurs in other cerebral affections I

sannot bo denied that it has some diagnostic value I

' &fA Uim. H'ocAcnieAr., 1884. No. 52.- Bull, ibiit,, tl I

PURULENT MENINGITIS,

343

I

Tery well-marked in a case of tubercular mcuiiigitis which was complicatod by a considerable purulent Bpinal arachnitis. I must agree with B nil that we may often discover a slight degree of this phenomenon even in healthy people, especially if we place the thigh at an acute angle. >

If all cases presented the violent symptoms which I have described, it would be possible, generally, to give a pretty cer- tain diagnosis. Thia, however, is not always the case ; for there i« a moderately severe chronic form of meningitis, eppecially of the infectious variety, which by its long duration and the varying severity of the Bymptoins, may mislead the physician, especially if he is inexperienced. Usually, the course 13 as follows. The children who have hitherto been healthy, take suddenly ill with more or less high temperature, which in the aftta*noon or evening hours may reach from 10:3*1^ to 104*4'^ F. There is violent headache from the beginning, gencraUy frontal ; and this even in young children is often indicated by their atching at the head, moaning and whimjienng. Vomiting ccurs often, but not always. Cervical rigidity with retrac- ioD or lateral obliquity of the head (caput obstipum Hpasticnm) 18 constant, and the latter in one boy was so severe and persistent hat a bedsore farmed on the right oar, on which he always lay. very passive movement of the head gives rise to expressions of pain. Less frequently, rigidity of the niusclea appears in the extremities also, especially the lower ones, and both active and passive movements are interfered with. However, I have very seldom been able to make out distinct hyporaBsthesia in these parts, and it was absent even in some of tiie very acute cases. The patellar retlex in several cases which were carefully examined ia this particular, was well-marked. After about H — 2 weeks the fever diminishes considerably, may even temporally dis-

Dr, Sftchi* of Brieg Uas. in a letter, drnwn my attyntiori to tho followiug ^imnrk of Lan^ioih : " The \ong cxtoniore of the leg ariHinif from the tuborischii krt» too ^hort to itllow of complete eitoufiion at the knee joint when the hip ia bent ^t on acute Miglu/* Houke (Uecnfused this circtunstAnce ttioro fully {Uandatlan ^,: Borlin, 1888, i., S. IVi), The tlirce tnuscloa here concerned, aenttitenili. lOfUs, iemiuit'iwbranoHiis uuil bieopH, are distinctly petmat*?, and contain very flbroii. Tbf y \kUi the-'^'otv* quite incapuble of sueh a stretching as* toint wore ttctively flexed and the knoo -^y thin is not possible. At any itftgitin i« i^Ton greater than in 'cnlnr tone in here morbidly

314

BISEASEB OP THE KERTOT78 STSTSIT.

appear, and tbe appearance af liealth which now aets in seems to JQstifj the relatives in entei*tttining tbe highest Itapes, Bnl Ik cervical rigidity which perfiists although in a dlroisiiiiMd degree, shows that recovery is not yet complete. The fe?er il fact recommences after an interval of one or r ^ 'he

general condition again becomes worse, tlie headar ^ji

contracture become more prominent without any cause for Uw aggravation of tbe condition being discoverable. Sach remisstODi and exacerbations may be frequently repeated. The chiMm become steadily more emaciated and weaker, and the phyiiciaa already suspects tuberculosis of the brain or cervicAl vertebrs?, till after a course of seven, ten, or more weeks, recovery at Iwt takes place. I, at least, have never observed a fatal tentti* nation of such cases, except in some in which the disease bad run its course, without the characteristic remissions, >vith nlmoit equal severity of symptoms for a number of weeks.^

Unfortunately, however, recovery from meningitis is not always complete. Like many other vtTiters I have repeatedly seen deafness or amaurosis in young children, also deaf- rantiam, remain permanently. We refer these deranr '^ ' * • of the organs of sense to neuritic changes, wJucb are s to

depend on the inflammation spreading from the meningcts to the optic and auditory nerves. More recent observations make it probable that this extension may also take place through tbe bands of the dura mater which pass into the petrous bono to ita spongy tissue and from thence to the semicircular canals, setting up ha*morrhagic inflammation there.* Children who become deaf at a very early age, before they have begun to speak, M the result of meningitis, naturally remain dumb also, beeause hearing is absolutely necessary if the child is to learn to speak. In very rare cases amaurosis or deafness may also set in durinii the disease as a symptom which passes off after a few cbiys. In a girl of eight years contracture of the muscloa on the nghl side of the neck (torticollis) persisted unchanged two montlie after recovery from the meningitis.

Among the causes of meningitis— next to epidetiiio in- fluences, to which I shall shortly return — the most importAOl are injuries and diseases of the cranial bones. Evt^Q

* Vide ray p*pAr mi UiU form in Ui« Chariif'Anmitkn, B3. xs. i Bosliiu 1888.

• Lno»«, yii-i!hou}'$ Archie, Bd. 88, 1882, S. 650. -^

PURULENT MENIN0ITI8,

345

liter BeT^re concnssion of the brain from a blow or a full ^inptoiiis of cerebral hypera'mia may set in, as already mentioned

[p. Bll) and may end in meningitis. Far more dangerous are sen res and fractures of the cranial bones, which, besides

llic meningitis, may give rise to more or leas severe hiemorrhage ito the cranial cavity.

Max E., i years old, admitU'd uii lat July, 1875. Had tumbled fl-oin a ground-floor window on to the (street 3 days previously, falling on his head. StU|ior, riglit pupil smaller than the left, nnrmiy bladder distended, reaching to the level of the nml)ilieiK<. Tlie head was turned to the right and rotation to the left was unxionsly avoided and giiarded ngviin^t, T. 103'6° F., P. 120 i-e^rular, R. 30. Bladder emptied by catheter; leeches and ice-bag to the head; piirjj^iitivew. On the fuliowing^diiysaetive delirium, violent pain on swallow inf^ in Fpite of the stupor and tlv normal condition of the pharynx. After 3rd July, pi'ofouiid drowffinesn, but screaming when I'aieed up. Moderate cervical rigidity, »ilight i$pa»modic contraction of the arm^, in* crt^asing pulae-nitc, Hnally uncountable. Death, on evening of 4t\u in a state of coma.

Temp, on 2nd July 103:3 103i3

„ „ 3nl ...... 104-2 104-9

,. 4th 1007 104*5

P. -J/.— Marked hyperfleniia of the pia mater and on the con- vexity; extensive purulent intiltration of it, especially on the left wide. Sides of the Sylvian fissare adherent to one another ; in the pin. mater, especially on the left side, large purulent patches in this sitnation. In the Ijones of the baye of the cranium on the left aide three fissurch traversing the frontal bone, the greater and leKneP win^s of the sphenoid and the temporal bune. lilotwl extra, vasion between the dura mater und the bone corrc.s|K»nding to iho&e fraetun:s.

In this case the absence of all motor derangements — with the :ccption of slight twitchings of the arms, and some contraetnre

the muscles of the neck — is worthy of notice. The pain on »ery movement of the head and on swallowing, may indeed :plained merely by the inevitable movement of the fractured iciits of bone; especially the pains on swallowing, by the rtion of the ptt^'rygo-pharyngeus and stylo-pharyngeus which mat have exerted some traction on the fractured base of the ranium. In this case, also, we found a very high temperature Tsintiug (to 106-7- F.),

W«j may also have menini^ t diseases of

346

DISEASES OF THE NERVOUS SYSTKH.

the cranial bones. Stilly I bave myself but seldom met nitb purulcDt meniDgitig post-mortem, in spite of tUe fact thttt I han observed liumerous cases of caries of the petrous boae. I biw more frequeDtly found the above-mentioned <p. 315) thrombofiiiof the neighbouring sinuses with purulent disintegration and pvKinic Hymptoms, or the hiemorrhagic form of inflammation o( ti< inner surface of the dura mator which is known by tiie name of pachymeniu^'itis, and on which I have already ioucW (pp. 272, 304) . To this class also belong those cases of mcniugiitf_ which arise as the result of a direct injury to the membi the brain or spinal cord, t'.*], from an operation. 1 have with this after puncture of a lar;^'c bydro-meningocele occiput and of a lumbar spina bifida.

:'Uiugittf

»ranfii^^| lave ^^H 3 at ^H

'V\w hitter rase was that of u c hild of 2 months with a dcfcrt f^ rlio saerimi and of the H lower Itimtmr vortobnc, Therf ^w* tibtfidy gangrene of tJie skin covering the turaour* mul tfhctn tlii» was excised the «ac was opened and 2 t»hlc8ponriftils uf sersun evacuated. A euture was inserted and iin iodoform drc*^sing iipplji*il After *2 days, dt'Oth ensued with **jift>»miodie eontr>ictinn« of tlu' lower lirahs and a few general eonvulwiony.and at the iiottt-mortein we found a hbrino-iuirulent ihfilh'ation of the whole* Mpiiial pi» raater up to the. base of ttic hrain. The tenif>erM.turo in thi^CHM* lind sunk to \*3-7^ P,» during the disea^^e ; which is a fiiilher prool of tlie fact that during the MrRt period of life even acute inflatno uiations may run their eour^ with subnormal temperature (p. 17).

I^leniDgitis sometimes developes secondarily in the course of various acute diseases; r.(/. pneumonia, nephritiSjpyiBmit, and septicaemia. As a rule, however, the symptoraa ftn> under these circumstances so complicated by those of the orii^'inal disease that a defuiite diagnosis is verj^ difficult or even impossible. At any rate, the complication of scarlet fever or pneumonia with actual meningitis is rare, and the cerebral symptoms which come on in these and other infections disciiseft are— as we shall see later on — to be regarded either simply as the resttlt of the considerable elevation of temperature or of the viralence of the disease. In these cases generally the presence of meningitis is out of the question, although foroMHrly this desij^nation was very freely bestowed, I w« ' i v poinl

out to you that violent cerebral symptoms v ; ii _^r i;^ and even convulsions may arise in children (Vom otitiB mediii or oven otitis externa, and nmy occasion a false diftgnocia^

PmULENT MENINGITIS.

347

menmgitia until a large quantity of pus sutMenly escapes from the ear, aud the dangerous symptoms rapidly pass off, Tti all cases, therefore, where head -symptoms are present we must hear iii luiud this possibility and carefully examine the external auditory lueatas at least. Firm pressure on the tragus is often sufficient in such a case to set the child a-crying. 1 must, however, accord- ing to my experience hitherto, rc^^ard as rare the cases in which the symptoms of otitis are really such as to be miataken for those of meniugitiK, and as even rarer those in which meniugitic symptoms are caused by rhinitis. Twice — in a boy of three and a girl of four years — I have observed after a fall on the nose, in addition to the local symptoms (s welling, tenderness of the nose and interference with breathing), violent frontal head- ache, high fever, and restk-ssnesa, nocturnal delirium, which came to an end with the rupture of the abscess, and the discharge of blood and pus from the nose. In a number of the cases we are unable to make out any of the causes named, but the disease arises, as the saying is, *' from a whole skin,'" in the midst of perfect health, and it is in those cases that the suspicion of an infectious origin at once occurs to one. The proof of such an assumption is only possible, however, when at the same time and in the same family, or at least neigbbourhood, one or more analogous alTections have recently occurred or actually prevail. Such cases I have met with in no small number, particularly in the summers of 1879 and 1885, and, especially duruig the latter season, almost all the cases came to the hospital from one quarter of the town. It has been olready mentioned (p. 3:^7 Hf^te) tbat in spite of the most recent bacteriological investigations, we are stOl very uncertain as to tbe nature of the infecting material. From a clinical point of view 1 should remark that this form fi^equently has a protracted course interrupted by great remissions, and that after the disappearance of the regular cerebral symptoms a temperature rising to 10:j'l ' F. may persist for days and weeks with marked morning remissions, or complete intermissions quite similar to what occurs in typhoid fever. In one case after apparently complete recovery, death ensued from inanition and increasmg collapse, (tgaiust which all stimulants and tonics proved in effectual.

In the treatment we must seer " " V tbe disease and by the stat*

^

stage

tihe

Ud

DISEASES OF THE KEEVOtS 8T8TEM*

beginning, a thoroughly antipblogistic Une of trentment is rn4 dicatetl, while at a later stogo this is to be avoided and stimulanU are rather to be prefc^rred. The exact period of this change iu the character of the caso, which seenas to depend on the onset of sup4 pnration, is certainly hard to determine, and it is more a nmltcn to be settled by the practical skill of the physician thattJfl theoretical rules. ^H

For very young, badly-nourished, anaemic children, or tSH reduced by illness, we generally use dry cupping, at most ^^^ leeches, according to the age; but the bites must neTer bd allowed to go on bleeding afterwards. For oldi^ children, on the other hand, especially such as are robust, 6 — lOJ leeches are required, or a similar number of wet-cups on thM neck, and perhaps also on the back. Under these en nces-'

I have even repeated the blood-letting when exRa - sell

in, and the state of the strength permitted it. I "warn yoai urgently once more against the lack of energy which is now sol prevalent in the profession, and which induces the proctiUoner rather to stand with his hands in his pockets than to apply j leeches* At the same time, as long as there are no sjinptomsl of collapse, w^e should keep an ice-bag applied to the he^tl, haw , mercurial ointment nibbed into the neck, back, arms, an^j tliighs (grs, V. — x. every 3 horn's), and give calomel internally J gr. I to J every 2 hours. The favourite antipyretics — quinine, | salicylate of soda, antipyrin, cold baths and cold compresses — have in these cases no effect, and scarcely lower the temperature. When there is very great restlessness or violent convulsions, we may try injections of morphia (gr. ^\ — t^), or chloral (Form. 9) J also luke-warm liaths (B8-— 90 5° F.), with cold douche to] the head. When the acute stage is over, I should recommend 1 iodide of potash (Form. 13). During the continued use of this medicine I have frequently seen tbo children awake j out of their comatose condition, the contractures disappear,] and complete recover}^ take place at last. On the other hand* | the derangement of the faculties which remains behind (deaf-^ ncss, loss of speech, amaurosis) almost always r^iaists all tro&t-l ment.

I have made use of this method of treatment in all fomm of . meningitis, including the infections variety, and on thc^ wliotol I am satisfied with it. We possess do specific remedy for this I

NEUBALOIC CONDITIONS.

M9

uuj more tlian for many other infectious diaeasca, the treatment tuuHt therefore be symptomatic. But we must, in regard to this form, remember that it is an infectious disease, and carry out the anti-phlogistic measures with more caution than in those cases where an injury or other causes have given rise to it.

XIX. Nenrahjic Conditiom.

In childhood you will meet with striking,' sensory disturbancea much less frequently than in adults. Anrostbesia, hyperoDs- thosia, and ueuralgia are exceptional in children, and so greatly resemble in all particulars similar conditions met with in later life that it is unnecessary to discuss tliem at length here. Anaesthesia especially is extremely difficult to estimate, even in older children, because the result of the examination is rendered dubious by their terror when the neetlle is used — and this is the ^<;ase even when the patient is blindfolded. Even in serious chronic diseases of the central organs (tumours, tubercle, Hclerosis) I have never been able to ascertain the limits of tlie amesthetic areas so exactly as in adults, and we must be content to base our diagnosis on obsen^ed intellectual and motor derangements. Among the forms of neuralgia in childhood, the only ones which call for special mention are colic — which either comes on with flatulence or along with diarrhoea (p. I2G)^and hemic rania (migraine).

\ Migraine occurs in children — as only the inexperienced will deny — very nearly as often as in adults, and with pretty much the same symptoms. As the result of many years' experience, however, I am inclined to maintain that — especially during the hist 20 years — the frequency of the disease has considerably in- creased. And the cause of this increase is to be found in the excessive demands which the education of the present day makes on the child's brain. The unceasing growth of our city which is always niakiug the enjoyment of country air more difficult of attainment, the mental exertion in schoolrooms which are often overcrowded, and the very few hours left for re- creation which are furtlier encroached upon by home tasks and music lessons — all this, combined with nervousness which is

Tw« elbfldjva wf ike tmme famtlj. ^gcd r«ipv<Ucdj 1^^ Md 8 jvan. k^ oiifcraA far iOBe TYsn fraa w«lI-aBrkMl aftterk* •4 mi^^mim, firaatei fc^Arfcr vU babm* ami vooui ii^ |ibol»- pfadbii^ • fflrifce far Avk qnet ttioBf. Ia ilhe one <mee lisring ikt^ psiBS tkn« was eeiCasir exrikcnrBC and fjvas tgiidiir»M<rf ike hftir <» oamlnit which duftppotfvd diLriniF ihe bilcn«k A&UmIcs act im everr lev Mootk**; daratina i — I dajrx. F^lhcr

Ansniitt, ibOp wludi oftai occurs in claldren, eten so M 5 or 6» uid IS met with efcn non frequently after the the second denddoii, faToiirs the development of tiiignJi)ev& ibeoe cmses is geneimllj oombined with /^ ^* ->. In ibe saittt irmy in the hjstericsl co&ditioiia of v ^ve alresdj giveft

jTOQ illoitirsUons (p.2*20),DerTons bcodache in often complained oC Id ntre C4if$es, cren after the disappearance of snch conditioBSi (aitackfl of hallucinations, spasmodic iwitchiiigs, Ac.), h ith the chttfuoter of inigraiDe persist for some time. On tlio wr hand, the female f^enital system, the diseases which m often occasion headache in later life, Bcan^ely calls i any considenitioii in childhmid. On tljis account the following] cane — which is certninly the only one I have met with — se to nio tttl the more reraarksble.

A girl of 7 y&tkrtt biniught to tho~f»o)y clinic an Sud JantmrJ 1H7I1. Httd KuffiTt'il «inre May, 1S7L*. from ut tucks of na Violent pairiH on thti for<'hf>»i(1 atiil ti injiltM, )muMf«M. proNimlioii, photophobia. Dutntion of uttuck a few haum.

NEURALGIC CONDITIONS.

851

nirroncc irregular. At the saiiic time rcstloss sleep with, frcri«eiit twiti^'hing of the body. Siiu'e Aluy, 1872, there had cxistc^d tluor albiis; the cutraiice to the vagina ranch reddened, hyineu nonual. Treatment—Lead fomentations, injection of zinci sulph. (i per cent.) into the vagina. Internally quinine, luter pot. broni. After various ups and downs all the HjTuptoms disappeared until Deeeraljer, when the tin or a lb us, and with it the attacks nf migniiiie aguin came on. Further course unknown.

In cases of this kiud we must remember that both the Yagimil ^cataiTh ftihl the headacbes may have nriscn from irritatioi) of tlie genital organs by masturbation, and we must iuTestigate this particular. A connection hetween mif^raine and the presence of worms is oftener assumed than the facta justify. However, we will do well to direct our attention to this point, as I have seen a few cases in which headaches disappeared for a length of time after several round worms had been passed.'

In general I have found migraine in children less frequently unilateral than in adults, and more usually in the middle of the forehead. The duration of the attacks varied between a few liours and two days. In the latter ease the intervening nights were [oflen disturbed by restlessness^ sensation of heat and talking during sleep. Vomiting, dread of a bright light and of sound, sometimes also general trembliug and rapid breathing as in the

lysterical attacks described, were common. The intervals were quite irregular in duration, lasting in some cases only a few days and in others for several weeks. Among the determining causes

ion© were more frequent than the close atmosphere and mental [exertion of school, so that many children had to be kept at [loroe. Emotional causes of every kind, fear of punishment, and ^scolding, I have also known to bring on an attack at once* ^AVhen removed from their ordinary surroundings into the country [or into health resorts, they generally remained quite exempt From the attacks, which usually recurred soon after their return

lome. Even after very careful examination and observation, the [most conscientious physician often remains in uncertainty as to 'whether the case is one of migraine or of headache caused by icerebral disease (tubercle, tumour). I have already men-

' On U»e connection of mi^nitio with visual dij*turbancOB iaAthciioina and hypormutropin) a!eo with na»nl affections (Bwelling^ of the turbiiuttctl boneK), X h*tc no peraonnl o«p« rience. CJ\ Blache, Rrvw tiun*., Avril, 1883; and Sonjmorbrodt. Btrt.klin, \Vvcktntchr.,\^^.

U«U,to

i cMirea mwj 6ma ton W csiied on m fldioolt«r Thb majodtf of tEe bidi Ssei bImi tliej we, and dHfaih, ms Boi oqIj tbe tli» T«lo to the , » lo limll l2ie hfom^ and to prolong tiM iKiUdiji powMff T!iegiirf€fiiiiiesiii€giiUtioiwwlikbfamvieTeij FBeentlj bees immed, dttiiig ■! & HnutAlMm of tJio medial work of diddieD, sre tlieteiDfe to be gmtefallj idoiowMiged. We mij expeet moeli mora frtNn the ctnTisg oal of tlioe instmctioiu by thr teodiliig alaC tban from tnj ooarae of obedical treoimeot. Tha nibbing down with eoLl wmler alter geitlu^ up in the morn- iDg, which is ranch reeommended for strengthening the nerroas f jsiein, and which bdeed ia qoiie the recognised trealmeiit, luu in my handa done little or not! hese caaea« Cold halhs

and awinimmg have be>en more . .. ..J. In ani^niic patieuta, iron ifl to be recommended. I know of no specific remedy* Tlifr mnrh citollcd qniniuo and bromide of potash, which I hiivo tried in unmerous cases gave xery variona results (qnljt, aulpli* or mariat,» gra. J thrice dail)v pot* brom,, grs, viiaa^ XV. wlm» thrice daily). A visit to the sea-ardt*, or to hill« and woodfi, and mental rest are more eflicacioua than auj mv>dicine, alihongh ihe good result is in general only temporaiy- The "holiday^colonlca" ^g^^ havo been sturted in oar tiia^

<

NEUBALGIC CONDITIONS. 853

are therefore an inestimable benefit for the poorer classes. We mast always bear in mind, also, that there may be an element of simulation and that the pains may be considerably exaggerated in order to get away from school. When there is a suspicion or certainty of masturbation, a serious representation of the danger — which we may purposely exaggerate —has iii my experience far more influence than punishment with older children.

^^

SECTION IV.

D1SEA8K8 OF THE Respiratoby OnaAKs.

I. InjUimnuttion ojthe N ami M mom Memhnutr. 1*1

ttiuli -

The mucous membrane of the nasal cavit), lar>iix, uoa i^irjiu. 18 extremt'ly subject to cuturrbal tiffectums, espocioU/ to cbildrcu of the lower cl&sses ; these being allowed to expose themselves to all sorts of weather. The symptoms Arc rcn siniilar to those iu adults — swelling and obstruction of the noer followed by increased secretion of muco-puruleiit matter, HOi^zijig, eatarrhal affection of the conjunctiva?, hoarsenesa, rough or ritt^' iug hollow coirgh, with or without rise of temperature. Such 1 catarrh is one of the constant prodromata of measles especiallT, as well as being caused by atmospheric inflaences. And daiiag a measles epidemic you may in fact, from such a catarrh appaaring in a child who has not hftherto had the disease, predict with tiia ;^fate8t probabihty that the eruption is about to follow. Undo all circumstances a catarrh of the upper part of the resplratoi mucous membrane iu very young children, though it may b« slight in degi*ee, is always to he regarded as niuch more serioiis than the same at a later period of life. For experience showt that even a simple cold in the head may in a very short tinirt occasion symptoms of luryngenl obstrnclion, or may extend rapidly into Uio deeper raitiificalions of the bronchi. Infants with corrza, or slight catarrh of the larynx and trachea should not, therefore, be taken out of *bwM>i, nnd imiKf bo rfni-fnlly prntt'ct^^'d rn.m air.

Leris fretjnently Lhun uuusIch, but blill often -t Ariel

fever and diphtheria maycaus* severe inHu li of

nasal mucous membrane, which in both cases is UHuallj eeconil' ary to an already existing ** diphtheritic " afTectiou of the phai^iL

' (^, th« <l»»ori|itioii ..i i»o»yMi ami t>p. 03. 14SL

nit to Ml Ml iaJ4l1

♦JmIM

RHlNtTIS.

855

The uose is more or less swollen, ami an ofTuiisive purulent

creiion flows from it over the upper lip, which as well tw Ihf

ostrils is rethleneJ and excoriatt^d by it Tho parts round tho

ose, as far as the eyelids, are tedematous aud swollen in severe

S68, the conjunctiva is congeBted, and the eye waters much

owing to ohstr action of the nasal duct. It is but seldom, however,

that one can see the diphtheritic membrane in the nose, owin^,' tu

I its always being situated so far up that oven when the ahe nasi

' are held apart it sttll remains out of sight. Far less common Ir,

I the membruue extends so far downwards that it comes into

view— a fact to which I shall return later on. It is even more

^—difficult — usually indeed, imposHihle— to examine the naso-

^Hpharynx at this age with a mirror. The swelling of the nasal

^HuacoUB membrane in those cases is so great that breathing is

^•inore or less interfered with and a snoring noise is caused,

I espeeially during sleep. In general this rhinitis is a bad omen

both in scarlet fever and in diphtlieria ; still, in both these diseases

it often occurs in a less severe form without exertiug any bad

fleet. We shall eee later on that diphtheria may also hogin

ith an aflection of the nasal cavity ; but only once — in the ease

f a daughter of our never- to-lie-forgotton Traube — have I

served an independent rhinitis pseudomembranosa. The

se wliich follows, acfjuires an additional interest from the

rcful observations niade by her fatlier.

Tbe girl, wlio was 8 yours of age, and generally healthy, took ill with liymplonis nf coryza, accompmik^d byimodernte ft.ui.'r. Tin* marked snoring during wleep, and tlie complaints about hooh- thiiig ohstriicting tho breathing u«ir the root of the nose, iudii-Htcd

more coiihidonihle titenosin of the nasal cannl than iisimlly otriirs rith simjjle roryza. Traube himself mude an cxaniiuiitioii ivit)i "the iiiirrrir and found nothing but a catarrhal redness on tin* pharynx and on tht* epiglottis. After a few days tho child r«]K'lled with great difficulty a tough, white masEic of the )«Migth of a Hnger- joi II t, which swelled up when treatetl with

jtic iu;id— thus* showing its fibrinous nature. After a few day>i

tnnoh i*inaUer iuixhh was* ejected, whereupon all difficulty of hreiithing iit once disappeared. The treatment had l>eeii ahnopt >*olely expectant (ivst in bed, and a few doses of calomel).

Wm tUia a ca^ of trae diphtheria confined to the nasal

tys or was it only a non-specific croupous rhinitis ? A chronic form of rhinitis occurs very often in scrofulous

or TBS ttEGFDUTOBT OUGLSS.

cLUdrGii, doDg ritb olber more or less pronoaueed Bjmpt4>tnt o( this cacLexk — erapiioiis on tlie b€ad, opbthalmia, oiofrbffi. eczema in the face and enlargement of tlie cerrical glaiadd. Tb# commonest sjinptoms of this disease are external sviellin)^ of the nose, snuffling and snoring breathing, the trickling of a sern* l)urnlent secretion ont of the excoriated nostri]s» and redoess iml swelling of the upper lip. Not Tincoramonly this cbronic Huititt.*! i^hes rise to repeated attacks of erysipelas, vihicb, eitendioi: from tbe nostrils, spreads over both cbeekg or even Rtill fartlier. forming a wing-like outline (p. 48). But eren where lliere is ao tondeucy to scrofula, cbronic rhinitis may be left as the r^olt of mcuBlea, scarlet foTer, or cTen of very severe caryza. In all socli caBGB^ besides using anti-scrofulous remedies (to which I sliftll return later), I have the nose painted dally with 9 fioInlMBof iiitnito of silver (grs. xvi to Si) atid this usually succeeds.

Tlie application of iodoform, iu powder or as an ointment^ kis ]»roved nseftiL I must also mention iu passing the rhinitis which may he caused by foreign ho dies — peas» beans, &c — ill the nose, and which at first at least is usually one>S]ded.

In a largo number of children there is a marked tendency to catarrhal ufl'cctions of the entrance into the larynt* whi(?h develope very rapidly when the children get corjin In Kuch raises one must he prepared, when the slightest oqtju hc^giuB. for one of the attacks which we are about to desoibtt and which on account of their resemblance to croup have bcea cnlhMl " false croup."

IL FilLsr Cf't^Up.

When yon find that n child has hud ''croap*' 4 or 5 tluieSt )'ou may always he sure that the disease has been false and not Inu* er^nip. Although usually not dungorourf, fahe croup is a Vfrv ttturniing disease and one of the most inconvenient for the phytdiMiiu ; for it i*« *w>i.. ;.>nv npt to cause hlni f-* '-^ ..>.»*,,-4 ••■ Um^ uiphi liiu<».

' suddenly, usually UHlomug

ixui ^.^nutfiing, sneezing) and almost

liUaya In lUa night, oa<^D soon after rntering on the fi»l %\Hf4 T\w olitUrrn h\ " < * • f* a fit of congUin^.

EAL6B cnoitp*

357

The congli is hoarse anil hollow, quite reBembliog that of croup. The hoQ8€hold is at oiice thrown into a state of aharm. Not only the cough, but — almost oven more so — the <leep iuspim* tions which interrupt them, are accompanied bj a distinctly croupy, sawing noise ; nnd this is also heard between the whimpering and crying which little children are wont to set up in these circumstances. The cry itself may at the same time be either quite normal or a little hoarse. During this attack many children sit up in bed with im anxious expression and flushed cheeks, with laboured and noisy breathing, are extremely reBtlesy, and repeatedly catch at their throat. The child is hot, often covered with sweat, the pulse rapid. A lit of this kind usually lasts some minutes, but even after it is over the breathing often remains somewhat noisy and more frequent than in the normal condition. The physician is called in haste. By the time he arrives the child ia usually comparatively quiet, or even asleep, the accessory muscles of respiration taking little or no part in ilie breathing — except for, perhaps, a slight movement of the altB nasi. He may from these facts draw the reassuring con- clusion that the obstruction to the breathing is not of a serious nature, and that as yet, at any rate, it is not a ease of true croup. If one remains some time at the child's bedside, one is very likely to witness a repetition of the attack. At any rate, when the children wake out of sleep they generally begin to cough again with a croupy sound, and when they cry or sob thtnr inspirations are harsh and prolonged. Pressure applied to the larynx ami trachea at once brings about one of these attacks of coughing. The children are generally quite well next day, and there is nothing now except an occasional hoarse ringing cough to remind one of the violent symptoms of tlic night before. Sometimes the same scene is repeated on the following night, and I therefore always prepare the parents for this possibility. In most cases, however, the attacks do not occur after the second night,* and there remains only an ordinary loose cough, which may last 8—14 days. You sec, then, that the course of the disease bt'ing such, there is no danger to he apprehended ; but the troublesome thing is its frequent recurrence. Some

^nuen in which an attivck occnre 12 nighta in 8Ucce»sion, ti» in one obf^erved by mti, *r<! «arely very exceptional {U«^ Crmp nnd IhphfheritU ; Wiyu un.T Leipup, 18»1, 9. 18}.

858

DI^SASBS OF TBK RSSFfBATORT OSO AKS.

children are attacked by it repeatedly iu f lie coarse of a year, and its resembkoce to croup inspires such terror tliat Tfr^ few parents, in 8pite of tbetr pretions acqaaintance with tht (Itseasc, are considerate enougb to leave iLe doctor undistnrbcML When we f^xaminc iLe fanoes in a case of fiala<» eroiip, nt 6qi) at moBt Blight catarrh and redness. By means of a laiTDgval mirror one may make out a swelling of the lower and mm portions of the Tocal cords (inflammatory oedema below the tordH), which rapidly spreads upward, but which may also rrt^^'-^* iu a fc%v hoars.* It appears, therefore, to be a catarrh s] ing downwards from the nasal cavity into the Innmx : an^ with it, as in every coryza, the swelling increages, especial ing sleep, and occasions a sudden awaking with want of bi nuxiourt feeling, and hoarse cough* The dryness of the eou^J. iiiul of the breathing, is usually diminished by warm driokx (ORU-sucre and milk) ; and with the commencemetit of a copioos catarrhal socretioji, all cause of anxiety completely disnpprar^. The physician will therefore do well in such cases not to dispLiT too great energy at once; but rather to take an expoctaot line of treatment. I am in the habit of onlering frequent drinks of warm water or milk, wnth wet compresses, nlw, |K*irhapB, hot poultices to the neck. But under all circumstances thi> fhibln'ii must be kept in bed for two or three days fi ' resulting catarrh has time to dovclope. The continuous ajt^;... tiou of a piece of bacon over the front of the neck is also to be recommended, as it generally causes a slight erjthema or aft eruption of small pustules* In the great majority of cases 1 Imve succeeded very well with the treatment I haro meiitione<l, and I therefore consider the custom of giving an emetic at once in all such cases unwarrantable. Lk families vhcrr false croup i», «o to apeak, endemic— a not very nncommou <»ccurriMioe— the nKithers usually have emetics at hand «o as to bo ablr to give them before the doctor arrives. I must proiM vi»ry atrongly againat this abuse, which weakens the children quit*' uivu ilv. There is no remedy against the ren; -^f

ihv Inuring to cold is of no use ; careful ] i -a

fhHW ehilla is far better. Many e*hildren commeuoe to suffer

• I dam ttM ♦•»»u'ru.n<'*< if i\m |wi» i<u| t ^ 'J p. r, ^nltHnn ..i

ATELECTASIS OF THE LUKOS.

859

from these attacks of ** croup " in tbeir 9th or 10th month. The attacks become less freqaent or less severe, and usually disappear of themselves about the Gth or 7tb years of life. Such chQtlreu must be earefully protectetl from eold weather, and kept iiidoorSj es[>eeially when they have a cold in the head. But oveD this does not always insm-e immunity from false croup.

The development of measles or whooping cough is some- times ushered iii by quite similar iittacks. Both diseases— especially measles— may begin with such au attack; which then passes into an ordinary catarrh, manifesting its real nature in the case of measles after a few days, in that of whooping cough after one or two weeks.

From the description I have given you, you might be inclined to regard fabe croup as in every case a trivial aflectiou, and one free from danger. Bat although this is true of the great majority of cases, you must not be misled into over confidence, or negU^ct keeping an eye on the child for some days after the first attack. Although very rarely, I have occaaionally seen true croup (confirmed by the expulsion of false membrane, or by post-mortem examination) develope in 3G — 48 hours after «uch an attack of false croup. The possibility of this makes it incorabent upon you in every case to keep the children in their rooms till the catarrh is fully developed, ij\ so long as the cough has a slightly croupy character, or a hoarse sound is audible on forced inspiration.

IIL Ateleetmsis of the Lunqs,

In all the respiratory diseases of children, the tendency of the lungs to *' collapse *' is a fact of the very utmost importance. This peculiarity, which is known as *Sitelectasis" consists in the tendency which the pulmonary alveoli have to bocouie empty of air and sink in in such a way that their walls touch one another. At the post-mortem examination of most children who have died of diseases of the respiratory organs and also of many exhausting diseases of other kinds, you come upon sharply defined, bluish - red, or steel-grey patches, varying greatly in si/e, situated on the surface of the lungs, especially along the anterior margin, and the lower and inner border of the lower lobe, likewise on the

DISEASES OF THE BESPIRATORY OEGAKS.

** liiignk," wbich overlaps tbe pericflrditiiD* These are Boml what depresses! below tbe surrouDding letel, they me somelimi quite superficial in position, isolated, and of small sue ; at odii times they are more extensive and run together so »s to tbif elongated areas or rounded patches as bipf as a half-cr(wn, 4 bigger. On section, these patches are tongb and non-crrpitiioll no air-bubbles issue from them, bat only a little bloody floidi and they sink in water. The surface of the section is smuoUij and on it we can easily see the fibrous septa of the lobnlcs ii the form of white streaks. The collapsed portions of lung wen long held to be pneumonic patches ; but with these they realfl have nothing in common, except the "consolidation** of td lung tissue. The nature of the pathological process was finl recognised owing to the simple experiment snggested Id^ Legend re and Bailly of blowing air through a tqbe into thl communicating bronchus. For whereas inilatioti has no efied on pneumonic consolidation, parts which are only eoHnpsol immediately become blown out, and assume a bright red coloun Two factors in the causation of atelectasis may bo indic^itc^ with certainty. In the first place, a lowering of the inspiratof] power which is too weak to drive the air into the nlvooli ; and secondly, the filling of the bronchi with mucus, rendering I difficult for the air to pass through them. When the air can m longer obtain entrance into the alveoli, that which is alreadi contained in them is absotbed by the ciroulating blood » and id alveoli collapse.* You will find the atelectasis most frequeii and most extensive in those cases in which both these factot^ mentioned are at work, ond therefore in all exhausting diseaaei wliich ore accompanied by bronchial catan*h. For this reaFOl we alBo meet with atelectasis under similar circumstances li adultSi eg, in typhus ; but generally it is mnch leas commol and less extensive in them than in little children, whose inspird tion even in health is ccmparatively much weaker. Rickct| 'children with narrow chests are particularly liable to atelectasisl for in them a third fuctor is added to the already pj 1

[causes (weakness of inspiration and bronchial catarrh), yj

m naiTowing of the capacity of the chest, which hinders the fol cxpiUiHi«m of the long«. .\l8o, in stenosis of the laryox, ' tj or lar^^e and small bronchi — whether due to inflamm<i ^ i J • tivbtkvtro. Artkit reaper. WKM

ATELECTASIS OF THE LUS08,

Ml

cicatricial proc<»sses, the presence of foreign bodies, or corDpreS' sioii of the air-passages — immei'ous patches of atelectasis of the Inngs Tiirty occur, from interference with the entrance of jtir into the alveoli, along with the increasiiij:^ weakness of inspiration present during the later course of the disease.

Althoiigli we so often find atelectasis of the longs in children after death, one is rarely able to diagnoso it during life* This diflicnlty of diagnosis is all the more to be regretted, as the addition of atelectasis to those diseases which it is wont to accompany, is by no means a matter of ind»3erence, Althouf^h the assumption that slight hypertemia of the Iniig-iissue resulting finally in broncho-pneumonia occurs in the collapsed areas as the result of deficient atmospherie pressure on the vessels, is not proved — and is indeed rendered doubtful by certain experimental facts* — still, we must always regard the increased insufficiency of the lung from patches of atelectasis as a factor which makes the prognosis very considerably less favourable. The difficulty of the diagnosis is due to the fact that the patches of collapse scattered throagh tljc lung-tisaue occasion no visible signs whatever, as they are completely masked by the air-containing poHious and by the broncljial sounds. Even extensive areas of collapse, e.g, when a large part of the lower lobe is affected, give rise to no physical signs beyond those of consolidation (dull not**, bronchial breathing, &c>), which can in no way be distin- gnished from those of pneumonic consolidation. The only conclusive point for a diagnosis of atelectasis would be the tthscncc of fever, did we not know^ that in little children in a state of extreme exhaustion even pneumonia occurs without rise of temperature; and that, on the other hand, atelectasis very frequently occurs as the result of febrile diseases (bronchitis, croup, Ij'phQs), For these reasons we can never, in my opinion, regard the diagnosis of atelectasis as cei-tain ; for it is at best only probable, although justified by the results of post-mortem experience, /.c by the frequency with which this affection is found in certain diseases and in conditions of exhaustion in chiklren.

The congenital form of atelectasis, which first became known through the work of J org,* is quite different from that

' Tranbe, Jkitt. zut tafi*trmt»t, PathoIo^U und Phj/nhlogitf Hefl I, l^UJ, Etp«riinont 63. * Dit Fi'4iutu»gt imgtbomen Kinde., u. $. w.: Orirnum, 1885,

S62

D1SB&9SB OP THE RBSPUUTOBT GROANS.

which we have jast been consiJeriug. In it we bAte to < A persiHteuce of the fietal condition iu a more extensive portion of the luii^^s. The parts Affected bnvc hecn used iu breathing, and therefore are tough, steel-blue, and sink in water, as is the case in the festal Inng, being thus in ibe condition which we have already seen as acquired by the wcakacM of the inspiration or by the exclusion of air from thtt Atfdoi. For these reasons we usually Kpeak of the latter form of atclccUsb AS a return of the lung-tissue to the "festal condition." la goneralf the causes active in congenital atelectasisi are qmitt tke same an those of the first form ; especially a failing or reiy weak respiration such as occm*s in asphyxia, or in premature aod debilitated children. Obstetricians, therefore, bAre tlie oiQil fi-equent opportunities of observing this affection* wbieh is rudj met with by physicians even in children's hospitab. As A rak^ congenital atelectasis is much more extensive than the acqairel form ; and not only presents distinct sjmptoms oT ' ' ' la

on physical examination, but also causes engoi, us

pulmonari' artery and of the general venous system with ejanotio discoloiiition, owing to material interference with the circulati For the same reason, the closure of the channels of the fa circulation, especially of the foramen ovale, does not alwi occur in the normal way. Many such infants die very soou biith from the atelectasis and the debility which has occtud it. Still, in a certain proportion of the casos in which the consolidation does not affect both lungs to too great nii extent* and the circumstances are otherwise favourabk? (sufficient care, And the choice of a good wet-uurse), one may succeed iu increas- ing the general strength and rendering the collapsed portiou» of lung once more air-containing.

Thns, in May, 18H0, n ehild of 3 \i cek« wa** brouglit to mc. wliO hud licen born promaturcly iu a stutc of extreme d<*bility. U»ii W'cuni*? «'yiuiotic in the first week, ©tid had ^ufffn'd fn»m fccvenl violent iittarktt uf d^*Hpn(j»i. On tho ri^ht wtdt* p08lcri«»rly IhcW WHS diiiiiCKs over ntjnu^t the whole of the :^)iacc between tlic ^ptne and die ticapuhiH The iiomial brcalli-H^HititiH were Ht»f^ent tli«fi*« uTid in their »tej44l crepitntiotiN wen* benrd. 'V\ir^ IfJt Bide itp|K4irvil quite iionnul. 'tli«M'e had never Ikh*ti any fever. A i(uit«b4e nurm

w«3 procu

n-d.

wine HH« gu

'Hie child tlirov^ well. When I iiati»on the ngbl difT< i

^k-i %Ui

INFLAMMATORY AFFECTIONS OF THE LAUYNX AND TRACHEA. 363

vcHicttlur breathiitf^ wuh .still wea^k, Ijiiti distinctly nndible, Iil OctolKT, the fhild (now woll miuriHhod) was found to h&ve only a » light bronchittl catanii.

I believe that this case may be regurded as one of congeuital atelectasis of a large part of the right lower lobe; since the condition existed from birth, there was no fever » and good nourishment was sufficient to remove gmdmillj the threatening symptoms. In the following case, on the other hand, we see a issue, happening under conditions that were extremely

favourable.

A fluid of «i wi'L'ks, left on a duoi-»U*f» in Hevt'if uinti'i' wcath^'r liy a niutluT unknown, and admittcfl into the ward on 8th Jainmr}*. 187'1. Vvry Nnmll and wontt'd ; rynii<i(ir rulour of the li|>8 and eyelids, veinn of the? hi'iui and (ncc <liKtended, rc'f*|)ii"i* tion extremely weak and rtUp<t'rH«iftl, iut«tetttl of a cry only a pktntlvi' whining. Peix-iLsfeion-note all over somewhat impaii"e(l. but nowhere distinctly dull; the breath-aouud only heard very fointly; no i*files. Heart HOunds norrnid. Too w**ak to wnck from the Ijottlc, and had to !>e fed with ii spoon. Thrni<h in the mouth Bud throat. Tempei^ature .sul>n«innal ({^7*2'^ F.). Littie improve- ment, in spite of ^otxl milk, wine, and the bewt nnrsing. A.s ihc ins|nratory movement?! inereaisod in r^trenj:fth, the cyanosis iliisap* ]>eared, but always returned when the re«pii*at(ny movements got weak a^iin. Death on IfUh Febriiar}' in a 8tate of collnpse.

l\'M, — Heart normal. All channels of the frrtiil circulntion cloyed. ThniKh uf the tt»*iophagu.s. Uric iwid infarcts in the kidne^"8. Othei*wi»e everything nomml trscept in the UingH, The greater part of both lower lohei< coHapsed. but in such a manner that air-eoiituining jHirtion.s iire vi^iible Ix^tween the eori- fiioHdated arctis, Ali^o in the other lobes, scattered patches uf atelectasis. Bronchi normal.

IV* Inflammatory AfecHom of the J4arynx and Tnichea*

Acnte catarrh of the upper air-passages either arises suddenly with an attack of false croup, or gradually Mith increasing hoarseness and rough and ringing cough. There are children as well as adults in whom every cough, even when it lasts for weeks, has a hollow metallic sotmd, although they may have no other signs of the larynx being affected; in particular, no alteration of the voice. In considering each indivi<Iuul case, this peculiarity unist be kept in mind, because it is apt to' lead to

TOttT OBOAKS.

On te vlmfe^ m hMem meiatlk ooo^^b ui ■■ % ko«r^e liQskj one; which, ulum •^ Its IlifefciifM of the Toice, is slvuvs &

mA tht §m^s » the littdkflft €r krjax, tlie children not only a Imb as if m paia, hat alao anally gire a coogh with Um» which w« deaerihe &s "craupy." Thi bnng ciTmg or scneamloer — that u to say, what aon air m mfabBd— ia acieoinpam«(l by a sAwm^ aoaad, althoagh the bfaathinf may meanwhile be perfectly quiet, -aitlioQt a liaee ofdjufMaia In the fin4 few days after roeovor ftom aa attack of hhm cvoap I have oltea been horrtc^lly callfd hack beeanse Tiotest laxyageal sTmipioims had re-eommeuoed ; niii IB ihoae caaea I hare alsMst ahrajs found thai a fit of bad temper to the child, with crying aad sgreaming was to be blamed for it. Whenerer the afitatko eeased, the thieateaing ttftnptomi* at DBoe gpheidedi IL is theiefore adTiadde to prepare the parents te theae eiaeeibatioiia, and to lei them kaow that they ore not daagenMia. They are of importanee only ao fiir as th«y tndicati^ thai the ealarrfaal eonditiott in the knmx still exista^ although in proeees of lesolntioii. To tiiese local symptoms loss of appclit4>, coating of the tongne with mocus^ and also oflen a moderate ferer with eTcning exacerbations i^ '^ h

cases always require the physidan's utmost m le

can nerer foretell whether the diseaae may not become tbrt^tc^n- ing within a few boars.

It is under soch circumstances that emetics (Form. 6) — agaiunl the abnse of which in simple cases of false cronp I have just warned yon — hare their proper ase. When these have done their duty you may order an expectorant mixture tForm. 15) aod wrt rompresses round the throat. The child mast be kept in bed till ibo cough lias lost every trace of its croupy character, and tlj<J inspiruiion bus become absolutely noiseless. Uuder this treat- mont the catarrh usually improves witbin a few days ; the couf^h becomes loose and ntltling, the hoarseness disapj^ears, and after ft — 11 dayH, as a rule, recovery is complete. Still, one mn«tt III ways be prepared for the possibility of the disease getting ^(»r»o, us it may do in spito of the most careful iiomng. f^-* UMiuilly this results from some want of care, and it is thcr particularly common in pryiiM|ttong the poor* Then^ the

IKFLllfMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 865

Bisymptoms which hitherto have only appeared sorloas to the initiated^ may withio a few hours reach sach a height as to considerahly endaDger life. This violent aggravation is due either to a rapidly increasing catarrhal swelling, or to a tihrinous exudation on the inflamed mucous morahraue : or, finally, to au cedeniatous or sero-purulout infiltration of the aryta^DO-epiglottideau ligament and its neighbourhood,

» These different pathological conditions give rise to almost the same cHnical symptoms —those of acute laryngeal obstruc- tion, which wo have next to consider* To the symptoms already described — huskiness, hoarse cough, tenderness of the larynx and trachea on pressure, and noisy inspiration and expiration — are now suddenly added dyapntpa, working of the ahe nasi, movement of the head in breathing, and increasing retraction during inspiration of the episternal aud epigastric regions, finally of the whole lower part of the thorax. At the same time, however, the frequency of the respiratory movements is scarcely increased; and even in severe cases it rarely exceeds 24 — 28 in the minute. The individual inspirations and expirations, which are accompanied by on uncomfortable sawing noise, are on the contrary unusually prolonged.^ All this time, the child may feel almost quite well, A girl of 4 years took ill on 30fch March with false croup,

»Li spite of an emetic, the symptoms got worse ; and when she Was brought to the polyclinic on Ist April, there was the most extreme dyspnea, croupy cough, sawing noise with breathing ; but the child, all this notwithstanding, ran and played about the room. The expulsion of dichotomously branched portions of false membrane soon established the fact that it Avas a case oF real croup. The hoarse stridor, wliich in all such cases acconi' panies the inspiration (also often the expiration), may be best

■compared with the to-and-fro noise of a saw in cutting wood. It is not always equally luud. It is less marked after vomiting, pr may even di8apt>ear entirely for a short time; it is nimf marked during sleep, at which time it is so loud that it arrests J ^the physician's attention as soon as he outers the room, and a' ^fcnce announces to him the nature of the malady. ^B During the further course of the disease, should the treatment

^^V ' On thf? sigjiificxncie of tliU symptom, r/. Co1inh«lai, \'tn'!fintuj,fn u'nr

ace

DISEASES OF THB BEaPlElTORY 0liG4XS.

be tinsucc6S3fn1> the symptoms of oLstructioii iuorease itbsmi hourly. The child often catches at his ueck as if trying ta remove the ohBtructiou to the hreathingt and bendn )t« head forcibly backwards. The complexion, whicli has hitherto hero imtural, becomes pale and cyanotic, the eyes are anxionalj ilirected to those around, aB if imploring asBiBtiincer and on the forehead and cheeks clear drops of sweat are often to be aeeii, thooj^h the skin does not appear warmer than nsuiil, jind indre^i is usually colder on the tip of the nose and on the cheeks. Along with the dyspnoea, the hoarsenegg of the voice rapidly becomes more marked and increases till there is complete aphonia; and at the same time the cough which was forraerlv hoarse and ringing, gradually becomes more toneless^ and finally is almoti quite extinguished — at any rate is more visible thao andiUe* Fever is not an important feature in the course of this diaesM; for although it is never quite absent, yet the temperature but seldom reaches a very high degree. It usually varies between lOl'S^ F. and 104- F,, with remissions in the naorniug hours ; while the rate of the pulse is not unfrequently raisecb to 144 or more Lv the child*ft continual restlessness.

The group of symptoms described only permits (as I hati* already mentioned) the diagnosis of acute laryngeal obRtnic- lion. What the cause of this is, cannot at once be decided. First of all you must examine the pharynx carefully, to aseex* tain the presence or absence of diphtheritic patches on the mucous membrane. Should you find tljeso, the diphtheri nature of tht? ol>sfcruction is thereby rendered certain. Shoi yoU| however, find no patches, you must not on that account al once deny the possibility of the disease being diphtheritic ; be* cause, as we hLiJI see afterwards, the patches in the pharvnx may escape oar observation during life, or may have alrcadj fallen off. When it ik possible to use the laryngoscope succe«8' fully, we certainly gain a dearer insight into the nature of the disciise. Bat, considering the difficulty of this cxumiDation in childhood (p. 10), you ciinnot expect to make much of it cjteepl in a small proportion of the cases. If you cnu with certainty exclude diphtlieria, then it must be either simple or psoudo- membranous (fibrinoua) laryngitt- ■ '-^npK For it lias been proved beyond doubt th.ii the i l^^iit dyapiui>a— in

fact, all the symptoms of ci acuta

lNFLA>niATOnV AFFECTIONS OF THE LAHYNX AND THACHEA, 367

lai'jugltis with swellui*,^ of tlic liiryn<Teal mucons memlji'ane

only, and no croupous exiuktion. Such cases are naturally

mach easier to cure hy anti -phlogistic treatment, than the

pseudo- membranous tbrai.

Mftric F.» 6 years old, healthy, look a violent attack of fnK»* rroup on the night of 7th December (during au opidejnit* of meiusles). Nrxt day she seemed well till 1 p.m., when suddenly hucli threatening Kyni|itoms rAtnc on thiit I was Bummonetl in tin* jip'f:y2ite.'<;t haste. Hawing noise witli t'espinition, fiice ryjinotie, coveivd with sweat. Head Ix-nt Ijwwk, forced action of aree.«- sorj* inu.scIeK of respiration, eyelmll** uptnrmHl hot ween the httlf-o|K'n»'d lids; covigh, exciteil at miee hy pre^^ure on the larynx, was i^hort, hoarifie. and aceiimjMHiied by a whistling Hound. Voice hUo htmr.se. Nothing ahriormat in the thrwit ; eonid drink williout difJicully. The vesicular hreathing completely masked by the larynge4il wtridor. Sonorous rhonehuK could be made out at thi^ rixit of the lung only. Pnl>*e 120; skin hot and penspiring. F ordei-ed 6 leech et* over the nianidjrinm stemi, allowing no aftei*- bleeding; and, internally, antim. tart. Igr. I in m\, degtill. every 2 hoiii*s). A« tlu-HL' was no vomiting hy 5 r.M., 1 gave an an emet ie fidl dosejs of pulv. ijKecac, and antim. tart,, after which there was rri)cnted vomiting. At 8 o'clock I found the child somewliat (|uieter. Hitting on itjs mother's knee; the stridor lesy, the voice clearer, und the skin j^erspiring frt^ely. I gave the Holutitin of antimony again, and applied a blistor to the larynx. After n quiet night, I found on the 9th that the stridor had almost quite di**ap|x*ared, the Itrputhing was quiet, atul the cough lessened. After each spoonful uf the medicine, vomiting followed, but uo purging. The blister had niiscd a large Imlla, wiiicli I openeiband nng. hydrarg. wa,s then applied. Ahout 2 i\M, a fresh exacerlm- tion of the laryngeal 8ym]>toms took place, owing to the admiiUHtm- tion of an enema, against which the child struggled violently. Hut when the child was quieted, the.^e symptom.s 8mm Huhsided. From this time onward riipid imjirovcmcnt took place. The eougli lK«amc loose, and disappeared about the loth, under the use of au eipeetorant mixture. You have hero an example of a thing which I have already

(poken of, namely, the development of serious laryngitis from ^hflt was at first false croup ; and at the same time of the

^fBcacy of energetic anti*ph logistic treatment^ which in ich violent cases I cannot too emphatically urge upon you, ^ou should at onco have 2 — 6 leeches (according to the age)

Ipplied over the front of the neck. The best position is just rcr the manubrium stemi, in order, on the one hand to keep 10 region of the larjnx free for further exUrnal application,

370

DISEASES OF THE HCBPniATOBT ORG AKS.

a sero-puralent infiltration of Uie swollen epiglottis aud J|j neigLLonrbood, especially of the arytsDno-cpiglottidean iiguM^I and of the vocal cords — here, we tind on the macons membiflP of the larynx and trachea isolated patches, or larger piece* of false membrane of a greyish, or yellowish-white colour, eiilicr^ ^nKe4ike delicacy, or Imm. or more thick, and in that CMk consisting of several layers — the outer of which (i.e. that fl^ the mucous membrane) is usually the most recently formed, ibI the least tough. This membrane, which is seen microscoptcdL to consist of an extremely fine librinous net-work and ncunei^l yonng cells (epithelium, pus-corpuscles) often extends down Ine trachea, as far as the bifurcation, or even beyond that point into the large and middle-sized bronchi, there forming cylindrieal casts of these tubes which can easily be drawn out of them, at they arc not adherent but lie quite loosely on the surface. VThtn the false membrane is removed we find the mucous membruie more or less reddened and swollen, but occasionally pale and nilh' out a trace of vascularity. Bronchitis and broncho-pnenmooia are almost constant accompaniments, as are likewise emphyscfi» of llie upper, with numerous patches of collapse in the lower lobes.

In regarding croup as the highest development of acnie Lmv* gitis* 1 am directly at variance with those physicinns who n'gnrd it as being invariably diphtheritic, and who absolutely deoj to it any other mode of origin. I grant that fiinee diphtbcm became endemic and epidemic in Germany, croup has ^ i i'li

commoner. But I do not see in this any giound ! /iOfi

the possibility of its originating in any other way. Wo koOv from experiments that the most typical tracheal croup can W produced in rabbits and dogs by various caustics applied tft the mucous membrane, as well as by making them inhale hot steaBi tlirotJgh a cnnnln introduced into the opened trachea. "VVe mat therefore readily assume that in human beings also, strong iiri* tants — such as the inlialation of cold air, or the action of toM on tlio surface of the body^which when slight in T -dIt

caiise catarrh, may, when they act more strongly, pr< ujk

It is liot yet settled whether Weigert and Cohnheini otq right in thinking that if the qiithelinm, which in oatanii alwa>*i« remains intact, dies ond is wrt!*hetl away hy sceretioti, the fibrinous exudation secreted by 1 mucous mem-

I*

INFLAMMATORY AFFECTIONS OF THE LABYNX AND TRACHEA. 371

brane coagulates, thus foniiing the croupous membrftno. The irrilatioD of the infective material of diphtberia — perhaps the iubalation of it from the pharynx— is certainly in thig country the commonest, but by no means the only cause of roup. For any severe catarrh of the larynx may lead to it; and consequently in measles^a disease which from its veiT beginning always occasioDR a catarrh of the larmx and trachea — tliis condition may pass into croup at a very early stage, without there hem^ any question at all of diphtheria.

Boy of Jl years, adiiiittid un 29th Miiy, 18/3, with ineawlts in prcK-ess of eniijtion, Rasli upon the face; pulse, 150; temp., m.* l(>:Vlo F.; c, 104-90 K Severe catarrh of the larynx. Hoarse. almost iimudilile conjjfh ; voice also hoarse. On thc^ must careful exam i nation notliinj? could bo discovfred but a npottt'd reduces of the pidnte and a sirai>k jsorc throat. Treatment; — It^ches over the mutinhriuin yterni ; antim.tart. Marked improvement on the f»»lhiwin^ day:— pulse, lltj; temp, lOM- F. ; resp. 32. Only the lioariicncss wns still nTirhaii^ed, and the mugh had still a laryngeal €hai*after. ThiiH 4 days pus is cd without any fever, during whieh the above-mentioned laryngeal sjTnptoms continued. Suddenly. nn the eveinrig of June -Hh, the temp, again rose to lOl'S'^ F., and on next morning to lOyi"^ F. Aliout midnight ivell-marked croup set in, ko that tracheotomy had to be performed next day at noon during the rlijiiiiue. When the traehea vnia opened we drew out of it a long cast, which reached down tn thi* hifureu- tion. Other fragmeiitH were also eoitgheil up afterwards. The tntelieittomy Uilie wan removed on the lOrh tlay, Comjdete reeov ery.

I have elsewhere published some cases tending to prove the

f^xistence of a primary inflammatory croup unconnected with

diphtheria. The children were aged 7 and 15 mouths respectively ;

kand at the post-mortem, croup of the larynx and trachea was found, without the slightest change in the pharynx. Since then I have had repeated opportunities of observing the fiame thing — not to mention the still more numerous cases in which no post-mortem could be made, and which I tlierofore can- not regard as completely satisfactory proofs ; because there was certainly a possibility of the diphtheria having escaped our notic:» from being situated deep- down in the pharynx. On the other ^siiand^ it must be admitted that the following case is conclusive.

^B Mar R., Ij years old, admitKKl 4th April* 1877. with riekelfl

^H and t»ljght bi'onchiat eatarrb. In the next few davs a fnrthor

)Jti^

872

MSEASBS OF TtIK RBSPIfiATORT DRdAKB.

dxteiuiton of tlic Utter; inticoiis r&les on both Hidc-i, bMb in froii ami behind. Un tlie tiig^ht of fHh — lOtb sudden €rt -^itim

oml Larsh rou^h. On tlie forenoon of the lllh. i It/pwJ

croup. Over the lungs tin- cnjupy Kouitd is htiird, jiropMf^tnl fniQ above — the hi-eathiug U liansh, nnd there \m sibilant rbonrlii behiml. Temp. ia-2'2o F. ; pulse, 144 ; rc^p. 42. lu spiir of «tti fincties* the symptoms got worse on the follonriTi^ djir. The tejaf remnined ut lOiT^ — lOrvrt" P.; reapimtion. 48. Chihl extmacljj languid and drow^nv. Deuth on 12th. P.-M. — Phuryux uu»l^ fected; croup of the larynx iind trachea, unhtna glui;i double broncho-pneumonia; raohitiJ'.

Socli cases, beginning with bronchial catarrh and dcnly passing into tilmnous tracbeo- laryngitis, are described^ under the name of " ascending croup.*' I Lave obsfntnJ manner of onset especially in children in the first yenrs of hfr;- als*o several times in the course of whooping cough and in diifas»j bronchial catarrh occurring along with that tliseaae. Trfteb< otomy under such circumstances is almost always uusQccemfoJ,] owing to the oxtcnsive bronchitis and multiple broncho*] monia.

Ernst G.. 4 3-enr*^ old, ndniitted 'J,Ui Mjm'cIi, 1877. »->ai«l toliB taken ill 8 days hffore with an attHck of falhc croup, und nrvrr I have l>e©n quite well since. Yesterday, at midthiy. sud'ten dy^poo^ came on, rapidly getting worj^e. Oji admission he t*a* ryukiotir und collapsed. AH the »ympl(»ni!j of croup were welhniAritd Only redness and f^light fswelliitg in thr pharynx. Trach eotomj at once, and linie-Mnter inhalations. After *ouie bmtr« |>ief«» false membrane were coughed up. Among these wa^ otir r^llmier which represented a complete cast of the traehen and raencement of both bronchi. I/egHening of the dyspnteA ' *' but increase of the collapse and continuance of the Evening t — jjulse 168; reap. 54. Death during the uighr. i'.- Jl Pharynx unaffected; croup of the larynx »^J^*\ fracb extending into the large bronchi; double h}< chronic fibrous endocai-ditis aortictt; left ventriv li

Elis© W., 34yeai*s old. iidmitted 0th November, lS7(i, with relapse of hereditary sjphiliM, Becorery under corrosive aiiblitnat injections, about Ist Dcecm her. On the 6tJi, huxkine^ t h%mrut cough I rednettH of the pharjTrix ; no fewr. In spite of ImcKi^ rmetics, ami mrrcurial inunctionn^ the symptoms irot w» rafiidlj

%

I but on the 7th t racheotomy hud to lie

ih

khiilat

»f lime-water Hpwy. Dm-inif

there wtt!» a remittent type of t< and the Crf»)«e«cy id the renp. minute i and o double hi

kp (m li^

tu

73 ti

|jpnu«

\ vr(th

JNFLAMAIATORY AFFECTIONS OF THE LABYNX AND TRACHEA. Bid

rules and varying impairment of the |Hn*eusaioii'note. Death on I8th^i.f'.» 11 ihiVH after the tm«'he<it«>my. P,-M. — Pharynx IH-rfcctly normal; croup ul" tho larynx and of the upper p.irt of the trachfii in process of retovrry ; extensive brouchitis and hi'oni'ho-jmewrnonia.

Anna S., 2, ymrs old, udmittcd 2Hth February, 1879, with larj'iigitis, which luid Iftnt* d 2—3 dayt<. Pharynx quite noi-nial. Tntchc'otoray not perfomitd, owing to presence of diffuse bron- ehitis. Death on 2nd March. P.-M. — Diffuse bronchitis and broiidio-piijeuraaniH, Phsi rynx but nhghtly reddened, completely *m<K)th and healthy; eronp of Llie lurvnx and of the trachea, reaehiii|T to the hifurcation.

Ella H., tt months old, after ^ufferiujt; for Homc! montliM from iraeheal catarrh, was adniitted on L'tth March, 1870, with com- mencing croup. The pyniptnms got woi^se ; tracheotomy wn.'* performed on the IJ^th. Fever (1()4° F.) and dyapntua perhi.steil ttfterit. Death on fcjllowing day. P.-M. — Pharynx quite normuL Croup of the larynx. Bronchitis, with numerous pntchew of broneho-pneurmmiti. Caseous de>!fenemliun of the hroiichial glandn and of a pait of the left ni)per hi^be.

lii such cases as these — and I have met witli many others

liiice— is one 'justified in entrenching oneself behind the as-

mptioD that diphtheria has passed over the pharynx and has

jveioped first of all in the larynx and trachea? Such an

kSBtimption I consider quite arbitrary. The unprejudiced observer

rho attentively follows the clinieal development of the disease

lougside of the pathological condiiiuii w ill bo able in every one

these cases to assume a mere local inflammatory process

rhich has nothing to do with infectious diphtheria. The com-

lencement with symptoms of simple tracheal and bronchial

krrh, the absence of pharyngitis and of all premonitory symp-

•ms of infectious dinease, and also of glandular swellings under

le jaw — are sufficiently characteristic. This view of mine is

»t rendered untenable even by the instances in which a case of

imple croup is said to have given rise to diphtheritic affection in

lose near the patientj^ because in these cases it is impossible

rith absolute certainty to exclude other sources of infection*

The clinical symptoms of croup present the most extreme

'gree of the acute obstruction of the larynx increasing hourly in

jverity, and in fatal cases having usually a duration of from 24

lUrs to 3 or 4 days. Even if short remissions occur during

Ls time — generally as the result of artificially produced vomiting

• t.g. Dam me* a 24. mt*l Stricht, 1887, 8, H.

874

DISEASES OF THE RESPIRATOBT OBOAN^

— still, these are almost always deceptive. The dangenl symptoms soou reappear and a steady progression from bad to worse becomes only too evident. In muDy cases the stcudjl/ advancing course is interrupted from time to time l»y attacks of extreme Bnflfocation. The child throws itself riolcaUj back» panting ; the breathing is quite arrested ; the face ii cyanotic ; the little hands are convulsively clenched » and ditiit appears imminent. But after a few second^j and v^ith di^ScnHj the air once more bej^ins to enter the larvn^ with a whislliojf sound, and the child returns to its former state until a aimilflr attack again comes on. Perhaps we have really hero to do will* attacks of spasmus glottidis, excited retlexly by the inflamed mucous membrane. At this stage the sawing respiration isufla audible even outside the door of the sick-room, while the apbouit increases and the croupy cough becomes less frequent and more toneless. The restlessness of the children increases enormoudy; they want out of bed into the nurse's arms ; then they want back again into bed, looking imploringly lor help to those round about This distressing condition is only interrupted by sliort penotU of sleep, in which the laryngeal stridor reaches its loudest. Tbc examination of the lungs yields, usually, no result, owing to tlie sawing noise which drowns all other sounds. At nio^, dry of moist rales are heard at different places : an J, rarely, v of the percussion note, indicating that the lung- tissue i affected. When this is the case, the number of tho respira- tions also— which, in uncomplicated croup, as we saw above, either remains normal or is scarcely increased — is now very much raised, reaching 50 — 70 or more in the 'mintite. Tto symptom alone suffices for the diagnosis of a compIIcaUoQ by diffuse bronchitis or broncho-pneumonia, even shouM ihr hioA examination be without result.

During this violent course, in many cases fragmeuis aim tubes of false membrane are expcdled with much difficulty by coughing and retching; and this is to be regarded ta the only reliable criterion in the diagnosis of trtie croup. All the other symptoms — as I have already said — may be brought about by an extreme degree of simple laryngitis, and especially by '' oedema glottidis." The nature of the expectch rated matters is best seen by letting them flout iu water. WUeii this is done, one finds small or large white fragments — oti$A

INFLAMSXATOEY AFFECTION'S OF THE LARYNX AKD TRACHEA. S75

w.

otcbod at the edges— or sometimes complete tubes, which often either divide dichotomously or even branch in a dendritic manner — thus showing that they represent not only a cast of the trachea, but ftlso of the large and medium bronchi. The expectoration of those fragments or casts takes place, however, only iu about half the cases. Not nncommonly the membrane is extracted by the fingers of the anxious mother from the child's mouth, when it is almost sulTocalcd. Immediately after the expulsion, especially of the larger tubular pieces, great relief is always noticeable, ne must not, however, trust these remissions j for it is just such cases that usually end fatally. The expectoration of den- dritic casts, especially, indicates that the process has spread eeply into the bronchi ; and little bifurcating tubes leave no oubt of the presence of a bronchial croup aflecting even the edium and smaller branches. They have, therefore, under all cumstancos an unfavourable prognostic significance ; for the eeper the croup extends into the air-pasages, the more certainly tal is its course. Besides, one must remember the very rapid e-formation of the expectorated membrane, which may take lace even within a few hours, and which at once brings back the thopncea.

A mi ft B., 7 years old, on 6th Novemljor, 1S72, suddenly became hcMirsc, and li»d roiy«a, nlight cough* und wome fever. On tlie I'ollowiiij^ day, slight obstruetivtj stridor with the breathing. Emetics had no effect. On the 8th, fully developi-d eroni), wilh the pharynx ipiitc iiormn.!. Leeches aud autimany prL'Heril>t'd. On inoruiijg of the f>th, oxpectornt ion of a cast nearly ii inches long, ending helnw in 2 small brunches. After tbit*, miprovcmont took place; the Htndor much less marked, cough and voice tone- lesa ; rcsp. 28; puke, 132. Inunction of unguent, hydrarg. (j^rs. XX, every two hours), blister over the hirynx. In ispitu of thi*. euonnoua iucrcttrti: of the croup*»ymptomi*, dating from midday ; cyrtnosis ; s^-mptoms of asphyxia. About 6 p.m. — thiit ih, after seiirt'elv 10 hourjs — espectnralion of tt not her cast of tlie wholr Icnj^h of the tn^chca, followed by ^tMit alleviation of the 8ymp- touiB. Night quieter. On the following? dny apparent improve- ment ; re&p. 21-; pulse, 132. In the afternoon u fre»h exacerijution ; death during ilio night. Tntehcotomy had not been performed, on account of the length and chnnu'ter of the ca!*ts coughcil up, wliich indicated the prcBence of bronchial croup.

The state of the temperature in croup is in no way "characteristic. As a rule the fever remains moderate in degree,

S76

DISXAJBEB OF THE RE^POUT^RV OB<iAK9\

rifling in Ibe pTcniug to as ranch as 103-l^F. ; while m th morning it is about 100^4 —101 •S'^ F. Still, thero nt am (e./7, ibat given on p, 372) with much higher t€iupenitai«, nM^ ing 104^ F. ttnd over. The addition of pnenmonic complicsuH has seemed to me to he the special causo of lliis. The piib» at first strong, hut as the disease progresses it becoi : ^ - iW, uud in the last stages is often very irregular and ji tit^

especially during inspiration ; and at this stege the r

heeomes extreme, and the face, hands and feet are i

cold sweat. At last the child sinks into a s o m ti o 1 c i owing to the obstructed respiration and the resulting carbonic* acid poisoning. The eyelids are half-closed, the resfninturt movements become shallower, the obstructive stridor ljer<vnii»f ireaker, and the child dies in a state of collapse, — ^som convulsive contractions of the facial or other musv,... i^ aniesthesia, which Bouchut pointed out, is in m? opimoD nothing characteristic ; it is to be explained simply by the coixiii which comes on towards the end.

The idea that croup is absolutely incurable save by irtehcotomy, is by no means carroct. Occasionally, although uot rerj o(l«D, wc meet with cases in which the most threatening symptomi iA croup gradually improve and are recovered from under suiubk treatment without any operative procedure — even whei-tf the ex* pulsion of fragments of false membrane had removed all doalit of the really croupous nature of the complaint. Bat even aiUr the disappearance of the threateniDg sjmpton \t,

once become elated. For, by the long ini' ue

respiratory processes, and the oxidation of the blooti, serioos cisturbane^s of the function of the brain may be left^ even after recovery ; either because the blood does uot quickly ©uongh Recover the qualities necessary for nourishing the brain, or because an engorgement of th« r ' ' ^ " ' ly

a'dema of the pin nuiter or serous traii ^ s

has resulted.

A f)oy uf t> vvuia. who liml ^ ' ^

CTtnip. lavting for 5 duys, dum i-

brane lunl been roughed up, ' »

compWte upbonm— rt'iiiainLHl d< ^

spitoof rt<;ov«sred ftpiKtite, ()« ti»c J4t i)aticnt, who wnn «till vrtiy weak, be- comatose; and :W hours after, dkd mUtr

INFLAMMATOKY AFFECTIONS OF THE LARYl^X AND TRACHEA. ?377

tlj

P,-M. I fmind the larynx luiiltliy, with the exception of slight coiigestian mid swelling «>f tlic miicims wembmno. The biuii( extromcly uiiteiiiii% aiul imicl* scruni in tho veiitricleH and in tin- meshes of the \mi in3iii.'r.

We bail in tliis case, not a state of diplitheritic collapse — which condition wo will become acquainted with later on— but a iiesolt of primary croup. We cannot deny that the energetic liuti-pblogiBtic measures (leeches, repeated emetics, mer* curials) with which, especitdly in former times, we attacked this 'dangerous disease, along with the anorexia and the insuHicient nourishment clue to it, — may oceaaionally have contributed their ^share in prodncing such weakness and aniemia.

I have myself witnessed in a boy of iUvqq years— who hud been niark»-*dly improved by a a cry energetic tine of treatment, Imt was ciihaiiKtcd to an cxtix-mc tlogrcc— a deep sleep romc on, nhii'h wa^ welcomed joyfnily by tbv purcnte. It followed tunoodiatel^' uii the use of ail emetic, wbich had been given on the evening of the 4th day oti aceonnt of a sudden suffocative aeixure. • *a my viftit I fouTul the child, who shortly l)efore had been very restless and breathing noisily, tiow lying motionless in his cot ; the lireuthmg almost biMiidible and iinnsually slow. On ffeliag hi^ pulse, however, 1 perceived that thin was no htialtliy eleep, but a sftatc tjf coma. The pulse was tliready, scarcely perceptible, irregular and uneven; ull extivmitiejs cold, and the eyelids half- shut. Even loml noises rij^hfc at the child's ear8 were not jioHicieiU to bring him to confeciourtiiess ; and it was only after the eontinned use of stimulauiH from 7 p.m. to 11 r,M. tluit thin daiigorous atate of inanition of the braiu was ii'iiiovcd- Mustard-plasters to the neck, back, and calve**, fomentation to the hands and feet with the addition of niusturcb ainmuii. carb- (^'s. "ij overj' 2 hours), and wine; finally, the aj>itlication of ice to the head, which \ only allowed to reinuin an a few seconds at a time, but repeated often— BUrei-eded at la?il beyond our exp^^etations* And when the cej'cbrul fiuicttons retunie*!, htiange to say, nil the croup Hyrnptoma, except a ijlight hoarseness, hnd di>iiippeared for good.

For tho treatment of croup the same rules hold good at the l>eginmng as I have already laid down in the case of acute laryngeal catan-h. If local blood-letting, emetics, tartrate of ntiinony in divided dosen, the energetic use of mereurialH, and the application of a blister over the region of the larynx do not ring about rapid improvement, tho symptoms continue to get orse^ and the commencement of dyspncBic attacks announces an extreme degree of ilic disease, we can then expect nothing

OBQAXd.

is in the haUti of rvljiflf » •B •me ties Im Ikk dkcaatt the more nnplisasaal ts tfe fat ^Mt tlieir meikm ntA oaciMBmoziljr fiiils. Among ottos, I bsre gma to a cliild villi metsles and croap m foil ^am of m^ mmA (^pocacoanh, - n, tart« gr. i. 4^

^flUOki. 5L9 ociTScL oci&ar 58b*) djtr, mortiitig mod

eivsiBg; vitlioiii cfca onei miwiiig Tomiiiz>|^, In soioli €>«•» snlpkato of copper (gt-BS — gr. is eicry 10 mlnaten) occf bat s|HHi from its nsQseatlDg efied it kii BO on anoap* I raiisl, hametet, most deetdedlf dissnado jo« fisoni firBqamtlj npttliit^ emeiics in » child nbo is dreadj exhausted, menlj because of Ihe ooatinoal retnni ot atlacks of saffMataoD. For while ihej are of no ose, they luaj iaeiease the exhaastioo to an extieme degree, and t.^^ in the case given on p. 376) result in aereze cerebral sjmiptoraft. I shooJd also recommeDd too not to keep children with croup c\m* tinoailv in bed ; but to let them oAra be carried Ahotit, for thu relieres them for a lime. Also Ton ahoold administer heeTlia, milk, or wine Terr freqnentlT, in order to combat the increasing exhsusitoQ as mndi as possible* Bat always be e&utioiis; because children with cronp are veijapt to choke while drinking^ and then at once hsTe violent attacks of suffocation.

The onset of the firstthreatening attackof snffocatio ^Ui fact even the forcible indrawingof the lower part of the chest wall on inspiration — is to me the signal tat tracheotomy. This latter symptom — ^whkh is dae to rarefaction of the air in the longs, and the consequent dii ance of the eqailibrium between the intra- and extra- thormcie preBsnre — I consider of especial importance. To delay tht operation longer only increases the exhaostion, the danger of carl>onic-acicl poisoning, and the broncho-pneanionia which is to procGSfl of devL'Iopment. We have therefore operatetl not uncommonly even on the 2n J or 3rtl day of the disease, iiccurd- iu{* to circiuiistauccs. I shfiU return to Ujis when ct- :

diphthetria. According to my experience, the chance 01 .. ./

ttftcr triicheotomy ia much greater in simple primary than in diphtheritic crouj) ; hecaiise in the former wc have oi' !

tihriuuuM iulliunujatioUi hut in the latter a general ilj l^

diHcaao. Out of 22 cases of inilnmmatory (uon^dipb then tic) rroup Vhich wero oj^erated oil during the hiHt few years in my

buokohitis.

879

^

department of the LoBpital, 1 3 recovered ; a fact wLicli of itself proves that we had not to do with diphtheria. Neither the expectoration of false membrane, nor the evideneo of bronchitis or pueuuiouia, do I regard as a contra-indication, for I Imve seen several ehildreu recover from the operation in Hpite of these complications. Since, however, the operation only serves the purpose of allowing air to gain access into the lungs, it ia always well to go on with the mercurial treatment after it, in a moderate degree, and to favour the separation of any false membrane which may still be present in the air passages, by the inhalation of steam through the cannia. Other methods of treatment, such as cauterising with concentrated solutioii of nitrate of silver (by means of a brui^h or a syringe), and the introduction of a tube into the larynx (intubation 0 I have not tried. Tracheotomy is still the treatment which gives the greatest number of successes, and therefore I do not feel inclim^d to exchange it for any other.

V. Bronchitis and Catarrh (d pHcitmonia {Broncho- Pneum<mia)*

One of the commonest diseases of childhood is catarrh, spreading fi*om the bifurcation of the trachea to the mucous membrane of the large and medium bronchi. It is not only common in practice among the poor, where cold and damp play an important part in its causation, but is equally so under more favourable circumstances. The period of the first dentition is that most frequently affected, and this process itself is regarded by many physicians as a cause of the catarrh. That this intluenco is over-estimated, I have already pointed out ; but I cannot deny U»at in many children the eruption of each new group of teeth is accompanied by an attack of catarrh. Perhaps, also, the great frequency of rickets at this age has some influence; for rickety children show a very special tendency to bronchial

* '^Tnbage** of iho larynx, which was first recomrnoudod liy Bouchut ami recently re-iniroduocd by O'D wyer, has many supporters in AniericsA ; still it* reanlts ar« by no mo&UR so gnvtifying as to eiititlo it to tako precedouoo of trachootomy. Cf. *' Intubation of larynx," Mtdical Record: New York. Juno and July, 1887.

OF TAB aBSPlRATOBT ORGIKS.

Cfttonrli, and filiould^ — for reiisoiis wbicli I shall enter into Utrr— be inoieeied from it with especial care.

In very yonng children, even within the first fewmontliB, wc often meet with a peculiar form of tracheal and hronrhiil eatarrh. In this condition they suffer either from a freqoenl hacldng congh (which is at once started hy pressare in the attni* tion of the hiforcation of the trachea), or Btill oftcner from a "'stertor/' which almost constantly accompanies the isspud tion and expiration, and which the mothers call a " stoffioMl' or "rattling in the chest/' The noise is aometlmes 80 loiiil that it makes the parents very anxious, and it depends on ihe quantity of secretion whether the stertorous hreathing is uc- eompanied hy moist rales or is a dry noise like that of crouf. It becomes weaker aftf*r each fit of coughing, and may enlirt'lr disappear, but soon returns. On physical examination we Lcur only hoarse mucous rales or sonorous rhonchi, especially between the shoulder-blades ; but immediately after coughing th* re U usually only hai-sh brenthiug heard, which after u time agttin gives place to niles. All this time, the Httle patients may feel quite well, although most of those I have seen with tliia disease* had rather a pale and flabby appearance. There is never an} fever, the appetite is good ; the only thing causing anxiety to the parents is the occasional cough. As regards the cause, I have sometimes found that the catarrh had been cansed, \A begin with, by a chill immediately or soon after birth — eithtr from a too loKl bath, or a cold room, or from the child being taken out-uf-doors in bad weather. In all the cases whiefa I Lave observed this disease was characterised by great obstinacy* It was many weeks, even months, before wcotciy took place, and this marked tendency to a chronic course is all the more serious because every fresh chill oocasians an exaoerba- tioD, wbich may sometimes be accompanied by fever. With few exceptions, all my ciiscs occurred in connection with the polyclinic* and the comparative want of care on the part of motbers in poor circumstances explains the obstinacy of the catarrb. In a few eases this diaoase reappeared with the cuttiof* of each new gronp of teeth, histed for weeks, and di !

as soon as the teeth came through. As regards trcatui i u.

chief matter is to protect the children from cold and damp, %hih at the same time letting them have pure air to breatbo^ — conditions

DRONCHITIS.

381

which can only be fulMlod in well-to-do famiUeu* From drugs I have seen scurcoly any result; perliaps a little from small bliaters over the mannbrinm, frequently repeated and allowed to heal at once after the bulla had formed. Those who cannot do without giving medicine may try small doses of sulphurated antimony (gr, |, 4 or 5 limes daily).

Catarrh of the trachea and bronchi in children, up lo about the 5th year, differs from that in adnlts only in this,— that ila tendency to a rapid and dangerous extension into the smaller bronchi is far greater; and, therefore, auy catarrh at thia age calls for much more careful nursing. The otherwise praiseworthy endeavours of many mothers to give their children as much freah air as possible, very often lead them into the error of sending them out-of-doors iu bad wuatht^r, even when they are suffering from a cough. We cmiuot too strongly oppose this custom. As a rule, the children in such cases present for days notliing beyond the symptoms of rt simple catarrh, till a fresh chiil either liriugs on the lanngeal conditiou just described, or — more frequently — occasions a regular bron- chitis. We find then, usually, that the cough suddenly becomes worse, the breath shoi-ter, the cxpirutiou noisy, the skin hot ; and generally even before making a local examination we nro able to diagnose bronchitis or broncho-pneumonia.

In all the \ery different degrees of these diseases, and the very numerous transitions from one to the other, coughing always forms one of the most striking symptoms. In nnmy children it seoras to be painful, and they sliow this by crying and making faces as if in pain when they cough. The cough is generally frequent, short, and dry, and is started or aggi'avated by crying. Children who are able to cry for a long time without coughing certainly have not got bronchitis. In bad cases violent attacks of coughing occasionally occur, with a livid redness of the face which reminds one of pertussis. Very young children almost never expectorate, but even in the stage of resolution, when the secretion is most copious, they swallow the sputa. Furtlier, the character of the respiration atlructs the physician's attention. The number of the respirations exceeds the normal in a varying degree, according as the inflam- mation has passed down more or less deeply into the bronchial ratiiifications. In young children 40 — 50 respirations is but a

tlie

to the moiiite. If, tli^ m cUd ittbrealhwiiik

maicM tlie pfajnaan wmiU tin m alvvfv a The qmdKf tbe WetUiu^ tlie AaHa and sbftOover doM it become ; tbe eeeeeBoiy mBades of inspiiBM* (Uiooe of Ike de Mul, Melenf) are Men mt^af^ Hm heid mbo mortes witli etcb breftth ; and tbere is dtsdiicl retmctm with msptratioD^ bocfc at 1} nal Dokdiaiid milke Jew put of ihe chest. £edi

I'.xi ift ftleo aeeooipeiiled bj m TgrQnitng^ iohbJ

(^ p. 9). which I alwmjB regaid es one of the moet taIqaLU pymptomft in the diegBoeis of eeneos le^bsloiry diceecea. Not uncomnionly we een hear, ereo al eeme &leiioe horn the cbeftt^ crowing noisce with the breethiug, end in neanly euit <'ft8(^ on aiiRcqltatioD, sihiknt end sonorone riionchi or hrgt^ niodiuni, tiud tine crepitatioDs, whieh may be either eoofined la thp buck— fiKpcscLilly abont the beeee^ — or ezietid over iU interior and lateral regions also. The distribationof th6i» nouiuIh in of Ii'KH importance than their character. We iiiaT« f\g.t hear Mibilunt and soDoroui rhonchi ahnost all aver the thomx, witbont any great aroauut of dyspucra being present, <twing to the largo or mediam bronchi only being affected; while tine or cvoii medium crepitations, heard over a considerable nr«^a in front an wrdl as l)€hind, give caase for great anuetj,. Oivnfiioniilly tlio crepitations arc only with inspiration or c>ipinitinn ; whilo in other cases they accompany both. The prcuKHion note romains nornval at first. Along with the local fiynipt4^nis there is always more or less fever, the teiiiperatar« vrtiMn>( botween 101" F. and 103° ¥., and in the eveniDg U4i^'hhtf[ rvnt 104^ F. I have not uncommonly found Um liuinuMii i«M\ipcrHture approaching the normal (100^ — 100-4-FJ, >f\W\\v u\ tUn Dvening it rose to 104^ F. Even when exact tlimnoniftvir oKumiuatton is impossible — as in most cases in k\w iH^lj^'oUuie <-tho HtatemcntB of the mothers may bo worib lli|r, MM llifv are in the habit of noticing especially the ** Imiuing akin/* I do not attach any special liV I be rate of tbo pulso^ which varies between 1^ He <|l^«liiy \n of muth mrire importance ; althoagfaj

i

i

i

BRONCHITIS.

383

»

I I

when the disease runs a favoarahle course, this usually presents no abnormality. The altered ratio between the frequency of the pulse and that of the respiration, is always of the greatest significance. For we have no longer 3 or 4 beats of the pulse to one respiration, as in the normal condition, but the number of the latter increases disproportionately: c.//. 60^ — 70 respirations to 144 pulse beats (p. 9). The otber func* lions of the body may remain unaffected in slight cases ; still I liavc often observed diarrbcea as a complication, especially during an epidemic of intestiual catarrb. As the disease gets worse, the appetite also naturally suffers ; infants are prevented from sucking by the dyspnooa, because after a very short time they have to let go the nipple in order to get breath. This circumstance appears to me such a characteristic sign of the severity of the bronchitis that I advise you to let the child take the breast in your presence in order to ascertain how it can suck.

From the above symptoms and phyfiical signs — especially the latter — you may always diagnose with certainty an acute or diffuse bronchitis. Whether there is also an affection of the lung tissue itself (broncho-pneumonia) we cannot diagnose with certainty; but just as little can we exclude it. The explanation of this is to be found in the pathological condition, of which the chief features are the following.

The mucous membrane of the bronchi is to a varying extent reddenedj swollen, and thickened, and sometimes also eroded here and there. This condition often extends right into the emaliest bronchioles, and may either bo uniform or occnr in patches. Their lumen, especially in the lower lobes, is blocked with a tough, yellowish -white, mucous secretion ; and when the disease has lasted long, there is a moderate dilatation even of the peripheral ramifications. Owing to the marked tendency of this affection to spread deeply, there occurs in a number of cases a more or less extensive inflammation of the finest branches (bronchitis capillar is). In these cases, when a section is made through the affected lung, muco-pus exudes from many points, which indicate the sections of the finest bronchial tubes, as out of a sponge. Under these circumstances the inflamma- tion passes, in many situations, to the extremities of the finest bronchioles and to the pulmonary alveoli, which are sometimes

8ftl

LTOBT oaoAjnu

triBiUe onder tb^ palmoiiAfy pleorm ms vhittah-^eOor, milbir l^aitnUtioQfl, resembling iobereles, and from wludi os ssetian there exudes a drop of fluid (bronchi te Tesicalalre of tbe Franoh). There also alwrnra oeeors ai the same lim^: a derekfi^ ment of broDcho-pneomonie deposits, and these at fint as^imc a lobular form eorrcvpotkdiDg to the area of distrilm- tion of the small broAidu. The niimber of these deposits -nnm nccorcting to tbe extent of the bronchitis, aod ther are niofi tVoquontly Bituated in the lower lobe«, and appear as hud thk'kcuings of the site of a pea, bean, or hazel-nat, and of a reddish -brown coloar. or sometimes with a tinge of gtev. At firAt thev arc separated from one another bj air^coaUumug b.rponfinic tissue, bat as they increase in nnmber thejr approtdi ntid fumlly run together into large masses. These nsnally have A wcdgc-sbttpe, and extend upwards from the b^sc of both lower lobes : but they also occur often enough in the apper lobes, and (•Hpociully in the tongue-shaped process of the upper lobe whi<b ovcrlupa tbe pericardium. They may also in the end affect s whoU' lobe, or even the great4?r part of one long. From the sm- fuco of a section made through one of these patches or exteosife consolidations — which, when cut out, sinks in water — there only exudi'B an extremely small amount of fluid when sqaeeaed, and on nncruscopicul examination wc find that the alveoli are filled with maases composed of fatty epithelium and nnmeroos Ivnipliciid colls of various sizes — which also may be U'comini^ Ittlty, iind lb en giVo a greyish-yellow colour to the consolidated area. According to recent researches (Charcot and Cadet*), u rtbrinouH exudation is almost always discoverublo in them. There is always hypenemia of the capillaries In the neighbour- bood uud cell -proliferation in the interstitial connective tissue* lhuphyi>iema of the borders of tbe lung, or of other unaffected por(ion«» and patches of utelecta^is arc usually found ; also not lUkcommouly a more or less extenBive pleurisy and enbit^ ini'iit uf tbr ' 1 and broncbial glands,

Vi\>n\ tin wv nmy giilhor that catarrhal pneomouia

(\fc r 0 n c h o-p n e u m o n i a) , developing from bronchitla^ can only bi* ' ^ ^ I liVflical signs, if tlje patches described aw

\ " Tiiiit*^ i'1itil"iii»* 'I'

IV

• {

'(tRMkiin

M «l 1W tmlpwrNlMvi MMlil tWf |Wkt J

«9tAbi.iiih*«t

CVTARRHAL PNEl'MO^lA,

985

Iftfii

so numerous or ron together to such an exteiii tbat the iut*:r-

mediate air-containiiig tisstie is no longer sufiicient to bide the

symptoms of consolidation. Ab long us tlic patciies are scattered

at considerable intervals tkrough the lung tissue, you will only

ind the signs of hroncliitis^^ — i,i\ more or less widespread

medium or fine crepitations wJiicli, in cases of capillary

bronchitis, can be heard at almost every part of the chest to

which yon apply yonr car* As soon, however, as the consolida •

ion has extended over a larger area of the lung, you have a

jrrcsponding extent of dulnesa, iue sharp rales, bronchial

breathing, and bronchophony. Thest; physical signs usaally

appear first on both sides of the spinCp from the base of tlie long

^to near the spine of the scapula ; not uufret]nently, also, in thu

5gion of the apices, and especially in the tongue- shaped process

"of the left upper lobe. I have repeatedly discovered fiue» sharp

niles over the heart in the latter sooner than over any othi-r

part of the chest. It is noteworthy that sharp rales and diffuso

bronchophony may bo present in those cases even when there is

no distinct dulucss. The percussion may indeed remain i|iiite

normal, or may acquire a tympanitic character — which can only

be explained by supposing that at the periphery of the lung

, there is still a sufficient amount of air-containiug tissue — whilo

^Buscultation is able to discover the signs of consolidation which

^■s present at a gi*cater depth. Such being the case, I would re •

^^ommend you to percuss very lightly (p. 7), since a strong

stroke may, by eliciting a loud sound from the air-containing tissue,

^^bscare any slight impairment which may be present. Now, since

^^t has been established by numerous post-mortems that in every

case of extensive bronchitis in the first years of childhood, more

or less numerons patches of broncho-pneumonia arc nlso present

k- — we must assume that even the absence of all physical signn of consolidation does not in these c^ses exclude the presence of Ironcho-pneumonia in the form of lobular patches. And in bases where such physical signs — even only those of ausculta- tion— are discovered, we may always diagnose cxtoDsiye con- linen k patches of consolidation.

In many cases, however, although there is very severe dyspncDa, we can discover either very few rales or none at all. The percus- sion is normal, and all over the chest we hear the breath-soun<l extremely harsh; or the breath-sound is absent, and one

386

riBEASES or THE RE8PIBATORY OBOAKS,

bears nothing but sibilaut rbonchi. These pbysUsl maj gradually ^ivo place to moist rales, indicating a freer Hon ; or they may last till dcuth — which usaally ensues i W i Jays lator-

Tlie most strikifiji; cianiple uf tbcfii^t form Chat I ItKi-v •e«iiiii 111 a child of 11 inontha, wboBC iX'spimtiuii^* wnv 72 i»itd UTioWnij the ]nil8e 160 mid \evy tiiuall, Hiid who*«j clic^?<t jirtiseiitcd, nil «•*»- u nonnnl iK'n-ussioii-notc and very hari^b l»n'ifct I lijjjlit pr»stcrIoi' lijiHC theiir were a few fino • loTidiiKin iHsUid three full days, in sj>itt» of copin 4Tiustd hy moist com pi*esse« round the ehojst ; ami r: mtiotis fell to iti\ and the pid»€ to VMK Th« coujfh hccmtuc larn'^ fref|Uciit and looser, and, soon after, noisy bn*ttthing and widu- spnad murcni8 ii\le« a|>j>t'»red.^— I met with a I'upidiy fatal of thiM kind itt a ehihl of 11 nioivths, It took ill with n ccmg!t.| ami in 2 days nhowed aU the in*niptoms of an advanced ocnte lonjr iliseasr; Hiid over I he whole thorax unu8iiHl1y barcdi brcathii^i was audible, with oeeusionul erejtital ionr* ht-re nnd there. Aft/r| di-aih, I found in both lunj^K iHimen>n> CAsJiy- inflated cotkpvt^ litttthoH, and the spinal 1 bronchi entering these were fillcul iritli muco-pus. All the other In-onehi were completely free from aertr lion; but their muroiiK memhmae, from the bifurcation d*.«fi r. the smalleiit hm«chc»s» was much i-eddeneil and ijwolleii.

Tbns even without muco- purulent secretion, broncbius Hi*y seriously tbrcateu life, simply by the rapid hypenem Ic swellius of the mutoua membrane, and the consequent narrowing of ib<* lumen of tbe bronchi/'

Tbe deeper the iutlummation spreads into tbe finer broocbiftl ramifications, tbe more numerous tbe lobular patches or larger consolidated areas of broncbo-pneumonia — tlie more, of couiw* will tbe respiratory process and tbe oxidation of tbe blood vhicli depends upon it be interfered with. No efforts of the inspiratarr muscles are sufficient tn foree tbe air into tbe alveoli through the small bronchi which are filled with mucopurulent secretion : benee the pathological condition found in Bucb cases of ntitnerooaj collapsed areas in tbe long. Tbe efficiency of the lun;;s for| respiration must thereby be considerably diminished » and also tbe increased number of shallow respirations (I have in aoiaft cases counted more than 100 in a nuriute) cannot make up forj tbo loss of depth. The breathing is also often irragalar ; fori example, 10 — 15 respirations may follow ona anath^r willij » ('/. RUHet and Bmtih* v ^'^

CATARRHAL rNEUMaNIA,

dm

be

treme rapidity^ autl then a sliort pause take place, remmiliii*^

one of Cheyne-Sfcokes breHtbiiig. The venous coDgestion, a

natural reault of the conHoliilation of tlio lung, and cousequoiit

eiigorgemeut of the ri«rht siJo of the heart, soon gives a cyanotiL"

tinge to the pallid face and visiUe mucous membrauea, and causes

nlargemejiL of the poripberal veins, and sometimes also slight

detna of the eyelids and of the backs of the hands and feet,

ho Ktcady lowering of the heart's energy is indicated by thr

smallness of the pulse, which is exceedingly rapid and disapi>earK

under the finger, as well as by the coldness of the exlreuoities.

About this time also the power of coughing fails through

I weakness, and I always regard it as an extremely unfavourable pymptom if the hitherto harassing attacks of coughing beeomo iraaker or cease entirely, while on auscultation we can ntill hvtir ■harp crepitations all over. When this state of matters is found, B is usually soon followed by the carbonic-acid poisoning which ■ecessarily results from insufficient action of the lungs. Drowsi- Hese, half- closed lids, and up- turned eyeballs, sometimes alst» partial or general convulsions, terminate this distressing condi- ' tlon.

I now return to the tact that daring the whole course of bronchitis and broneho-pnenmonia the fever presents a remit- tent type, which is by no means characteristic, the temperatun' rising in the evenhig, and not uncommonly reaching 104"^ F,. but presenting many variations; thoa a considerable fall of juperature on certain days alternates with sudden, apparently explicable rises. ThcHc variations depend on the fact that tht* intlammatory process is always spreading from the bronchioles to otbcrhithe^'to unaffected lobules, while in other places it may already be in process of resolution, and that each of these^ successive extensions is accompanied by an exacerbation of the fever. In very young children, especially when they are I ^debilitated, the fever is often a very unimportant feature, or ^^kiay even be entirely absent for days at a time, although the ^^hysicul signs indicate a continuance of the inflammatory process. Ill one child of 10 days, with cougenital syphilis, I found the mperaturc generally sub-normal (maximum OU*!"^ F.). In hers it even went as low in the end as 95*9'^ F., a proof of the fact that under these circumstances there is a very great ten- Dcy to collapse^ and even considerable inflammations may run

381)

DISEASES OK THS KESPmiTOAY OUOAXS«

tiieir course without fever^ or even with a sab-normal tempenUurt (p. 17). This stale of thiogs. however, is changed iow&rds tl middle of the first year. lu a child of 5 mouths ^admiu un 5ih May, 1874, with double broucho-pueuniouia) the perature repeatedly rose to 101^'— ^lOi'7" F., the pul^e beicf 210.

Although the pro^^^uosis iu exteusive bronchitis and hrouriio*] pueiimouia is so bad, oue uoL uucommonly sees resolutiou auc recovery take place under apparently most unfavourable circum- stances. The first hopeful sign is diminished freqaeoev ai iucrtsased depth of the respirations. The disease is always to regtirded as one which, even when ending favourably, is wont U he of long duration; in particular, it never ends with regular crisis. Exceptiouul cases occur with a lery rapidly' futul course. Even iu such cases we almost alwaya dud that a bronchial catarrh has lasted for some considerable time hefon the sudden fatal onset of the capillary bronchitis and catarrbiil pneumonia. On an average* the disease lasts 2 — 3 weeb. frequently much longer^ There is an unmistakable teu- dencY for its course to become sub-acnte or eTtn t'hronic, so that many weeks, even several months, may p«s»i before a distinct change for the better sets in. The fever then fulls considerably, or may entirely disappear, except for a slight elevation of temperature at midday and iu the evening; (Lr patches of dulness disap}>ear to a greater or less degree, and the clnid seems almost quite well. But the cough, the wide-spreatl lino crepitations (which occasionally are still sharp in character), iiud the respiration (wliich contiuues to be rapid) indicate lUc persistence of the disease. In oue such case — that of n boy of 7 years — which lasted for months, the muco- purulent sputum {which he had the seusci to cough up) was not uufrt^ijueoUy spotted or streaked with blootl, to the great alarm of the parents, i Here also complete recovery nevertheless ensued. Still, tlm result is frequently fatal v^htn the course is* chronic, although the child's condition may have varied repeatedly during i^cekaj and months. In many can^s of this kind I observed, during sncJi| a course, intervals absol utely f r e e fro m f e v c r and busting for weeks. In those the child which IumI already been di*^i«ired of, rallied considerably, got a better colour, coughed le&s, uul scorned to Ije advancing t<»warJ** recovery. But the persistence i

CATABRHAL PNEt'MONU.

3ft0

of a quite abnormal rate of respiration (50 — 70 in the innte), which was out of keeping wth the apparently satisfactory f^eneral condition, was filways a had sign in those rases. We must not allow ourBelves to hf* misled by these intervals of improvement into gfiving a pfood prognosis. We are warned to he cautions by the persistent fine sharp ralea, heard especially at the hack, and also by the inereastn^^ emaciation of the children. In several of these eases with a chronic courBC finally ending in •h>ath after 2 or 3 months I have found at the post-mortem fatty ileg[eneration of the heart with dilatation of its right ide, along with the appearances of chronic bronchitis and roncho-pneumonia ; and thin especially in cases where tht- ^ < Urease was complicated with wliooping-cough. The grrat ^besistance which the right ventricle had to overcome in doing its ^Hrork, from the long-continning consolidation of the Inng-tissuf! ^Huid Ihe frequent attacks of whooping cough, must certainly )>e ^Bfgnrded as the cause of this degeneration, which has occji- ^^ionally caused death from syncope.

I In cases of hroncho-pneumnuia which have lasted for wt'ok^i <»r

even for months, one not uncommonly finds thickening of the iut4>r8titial connective tissue surrounding the alveoli and sepa- rating the different lobules from one anotlier. The small hronchi passing through the consolidated Inng-tissue are dilated in many

K laces, and sometimes also small abscesses of the lung are [)und, arising from tlie alveoli (uhich are over-distended with onng c^lls and epithelium) having given way and coalesced to >rm large cavities tilled with puriform fluid. This appearance { which is rare, on the whole) cannot he diagnosed during life, owing to the small size of the ahscosst'S. Besides, in such cases then? may be absolutely no fever. Thus in a boy who was admitted into the hospital on March 'iSrd, suffering from broncho- ^■»neumonia of uncertain duration, only twice before death— ^^ifhich took place on Ist April— did 1 tind the temp<jratnro at 10()'4'-' — 102^ F. At other times it was always normal or even suhuormaL At the post-mortem we found broucho-pnenmoniu both lower lobes> esptH'ially extensive in the right one, which 8 ftlmost entirely solid and empty of air. In both lower lobes ere were several abscesses the size of a hazel-nnt, filled til yellow pus. 1 believe that this condition is very apt to be used by foreign bodies getting into the bronchi. At least

kTQItT OMIARft.

kft4 luted for sererml mantlis And iitaih

^ glass hfd ftftd • sirofini

villi mnptoms of gitA

In tii^ &st of tiwai* ciKf

Uwkr vaiifmiiBliltf t^irctiaistaiiflef

in cftscAtioo

of tkeioiltetei! mftlerUl, but I shdl nlm

im llb» e«« AAiiom

hnag flbcMrt a state of irriUtioo of tW S mar alao plaj an important |»rt ' Iwooblio-piiaixiiioitia. Finfi k Ike iiritatioii of eold (a kotn ^aai m ipit) wihiA at limoa cattsea an epidmk along vitk ool^ in the Ii«ad» laiTiifMi throat. Next eow aonml tnlbolioci of vfcieli this afleetioo is often an aller-miiili: rcpedallr measles an<l vhoopiag eongb, and next t4i diplitiieria paitiealarir vben it apnada inta the lonriu Iraobea. Wbrtber incbeolonaT is pedbnnod or no,

alvajB Idfiiia one of tbe woial oomplicaiioita In tbif I it anal ahcaya be bad in mind if tbe rale of tb» reapimtioos, wbicb baa bitberto been normal, snddenU riaeatoSO or ISO in tbe minote. I bdieve that in sacb eaiiea there ii aol Dolv a simple spreadiBf of tbe indammation dewnwarida fnm the tra^bea^ bat that tbe inspiration of diphtheritic matter froia the npper air-passagea pia^ an important pari. In m«^f% UrMiehO'pnemiioBia maj begin evi^n in the stage of eniptioa. Mote fi«(|QentlT» boweTer* it developes after the dtaappearaot'e of tbe rash and the fidl of tbe tempcrattire ; it ts then morr sefeia, and tenia alwajs a tery senotis complication. Th« siini«^ is true of whooping cough, which it may complicate at aor ]>eno*1 of ita ooarae. Less freqnentlr the disease cornea on after scarlet ferer or smalt-pox: while in tfpboid — which i» xlmoat alvtays accompanied by broncbin] raLorrh-^the cotnplioatioa Mftb brancho'pn«M]monia in found oftencr. It is just thoae eaae« doearring along with tho abore-meotioneil infectiooa disamrs, that commojiU hare an utiasually protracted coarai*. and (by their accompanying Meakuesis and wii-tTn r n^ y^^H jyj \^y l^ersistcnt remittent

CATARRHAL PNKUMONIA.

BSt

iular or caseous condiLion of the luDge. Week after week,

tlio rapid respiration, the harasBing cotigh, and the shnqt

catarrhal crepitations defy all treatment; while dnlnesd on

[percuSRJon may either be quite absent or may disappear from the

[oTiginally affected parts of the thorax and re-appear at other

parts of the thorax hitherto normal. These changes, like the

variations of ih*^ temperature (p. 387), are to bo explained by the

clearing up of former infiltrations and the implication of other

hitlierto normal areas. Thns the diagnosis, and with it tho

prognosis, varies with the daily change of the condition ; till

finally, after lasting many weeks or oven months, either the

fever ceases quite unexpectedly and all symptoms clear up, or

[<leath takes place at last with symptoms of phthisis, owing to

the caseation and destruction of the infiltrated material.

AHco N., 12 yt*ar> itld, tiwik ill during ilto t5r.>t dnvM of Dcoemljer. with severL' typhoid. A Imd cougb imd ru(iid breath- ing from tho li<?giivrtiii}^. Ou tho 'lUh day. thn-Htf'niiig Kymptonis of oolhipsc, with pitjfuflc perf<f>]ratinfi (coldivess uf tht* extremitioN, (lijiappeai-aoce c>f the pulse). Alur these -iymptoms had Yyevn i-cmovcd by the u»e of stimiiliints fur several hours, the typhoiii conditton seemed relieved, but fche cough coutiniied. On the right side Ix^hitid, fi-om the apejt ti> helow the spine of the scapulu, ilull pert'uasion-note, hronchial breathing, bronchophony, and fin*- Mhar|) raU'9. On tht* left wide hohiiiil, mucong rales. Ri**** of t(*mper» ;itnn' in the evening eoiitinued, pulne 1*20 — 1^^2, hectic llunh on the elieeka, eraaeiat ion. Tmler the uwe of simple expectorHntH (ammon. ehlorid,, antim. eulph.j, afterwards of codlivcv oil and n strrnf^^then- ing diet, the threatening Kymptom« ^nuhianj disappearid, Percus- «ion Hhnui<t normal for Hrst time on lJ>th January. 1H7I. In the middle of Fehniary complete recovery, which waK fx^naanent.

Pauline 8., <i yearw old, Buffering from modemtely severe typhoid fever, with broncho-pneuuionia of the rig^ht h»wer lo'he. In the 5th week of the diwease wheji convalescence had alrt»ady net in nlie became' ft-verinh again (evening tf^mp. iM^t'P F.) and HevelofM?d diffuse catarrh on both UingM, and liulnettH with slmrp riile8 for a i*eeond time over the ai«a orij^inally afTccted. ThiMi' was aliNo extreme emneiation, very sickly npiu'iyanec, anorexia and bt^wii tongue. The condition lasted three weeks. Then f^radual resolution under the use of quinine, iind Oimlly eomfilete recovery.

I have already puhliahed' three other cases in which the a'oucho-pneumonia had come on after measles and had lasted Tor months in a state resemhling advancing phthisis, hnt at last

• BfifrS^e tur Kintftrheifl,^ iV.F. S. 1 isi

visEigm OF TH£ RcspouxvMnr oboaxs.

IS ootttfiktelj recoTes^ from, so ikai vImh Uie dlildrMi

trotigUt

hmg

tim^ aaer, tbcy looked 90 tbrinag 1 lecureelj reoogniBed tbem. In all tbeoe eM«« ionic memtir itreiigtb£iiiiig diet, vine and codltirer oil ) were of msrked beodL Resides the mfecUous diseases I bare nm-- ' or aei«ft

xhausting conditdons most l)c pointed to as : ^..lig ibe

urrcnoe of bronclio-pDeamouk. Chronic intestioat caiarr ulierculosis, basilar^meningitis, and gaiigr«iioQ8 eobdi^ juug— -especiallj n o ma^ — are the most mipoHaDl. In mj difut' tent in the bogpit&l almost ererj child that dies, shows at liie >9i-mortem more or less extensive Lroucho-pncamooia ; irsf UtI id weak rickety children especially have a tendency to ikii iAease, and I oflen could not help thinking that some iofcdkli tspired along with the hospital air might have domeihifig to il(> ith it. The coarse and termination of the disease haa geo«fa]lj •en more chronic and incarable in hospital than in priTil inictico, or oven in that of the polyclinic. The i^radctallj pro^ rcMsivc spreading of the process over large are^ts of the Jonp, he altemute improvements and exacerbations, the eontiniiallr ?cnrrlug relapses in spite of the best nnrsiiig— are all calcukitd^ iiM the experience of other hospitsl physicians bears ooti to indicate that the atmosphere of the wards may have an onH fHvnurablo iiifiiience. At the same time, one nmst nut ^ \\u* (net tlint the miserable state of nourishment in vvhirii l_ *.

Infants arc brought to mj department has a good deal to do tritU be fiiiluro of the treatment; because the weakness of their' Urtpiratory muHcles favours theoccun'ence of extensive alelectabi^. Hid thereby consitlerably increases the insufficiency of the affectedj uiig. We must also take into account the fact that tht^ childreu iro lying continually on their backs, as is necessary umhr MUch circumstances; and that this favours hypostatic congestiouj ^in the Inwvr uud posterior parts of the lung. Further, imyi ^k u b e r c u 1 *i r t <Mi d e n c y, or r i c k e t y m a I formation of the thorax j ^^BlniiiiiHhing its capacity is of especially bad prognostic significance. ^^Brtmchitis and hmnchopueumonia. aud even apparently trifling ^■Hilds, which would have had a favourable course in hcaltliv^ ^Biildreli may under thestf circumHtanccs end fatuUy. ^H In the nutter of causcH, we have tinally to c^msideranirnuuinn ^Kliioh directly affectn the bronchi and alveoli; nanudy, thc»J ^Ltranert of milk or ntb» r II n*e respiratory orgaiw. ThiJ

Mm

CATJLRRHAL PNEUMONIA.

39a

irm of pneumonia not uncommonly occurs owing to tho fliiula

being drawn into the air-pttssages from the bottle, und by tbeir

^■-' ^oin^ down the wronof way ** in ccrebi-al cases wliicli are accora-

^Ktunied by coma ; but it in specially apt to occur after tracheotomy.

^Briie fact of iti) occurrence in this way has been veritied by

^experiments on animals (division of the vagus or recurrent

laryngeal by Traube, Friedlander and others). One must.

not, however, be too hasty in assuming the presence of lhi« cause ;

nothing but the actual discovery of food or other Ibroign bodies

in the air-passages establishes it beyond doubt.

In many children there is a very marked predisposition to a c u t c b r o n c h i u I c a t a r r h , so that they get it after every slight fhill or col J iu the head. We have therefore here a condition ^bimihu- to that in false croup (p. 356). Such children have at ^Beust one, often several, attacks yearly, which as Rillict and ^HBarthez^ have already remarked "by their short duration, their ^^ repeated occurrence and the severity of the dyfipnceii, together wuh the slightnesa of the fever have some resemblance to asth- a tic attacks in adults/' I have myself repeatedly met with such cases even in very young children, und much oftener still in ^the second period of childhood ; and in these cases I have usually Toimd that the children had already suffered for years from attacks of this affection, which may im called ** recurrent bronchitis/' The causes of this predisposition are as little known to us as those tvliicb so often occasion false croup. I have sometimes found a "rsistent chronic bronchial catarrh from which the acute tttacks arose* More commonly, when the children were examined luring the intervals a perfectly normal and vesicular breath- aind was heard all over.

Buy of '2 yeui-rf, llL'twecn ihc 8th month udd tlic end of ifio *Jiid year lie luid li violent uttarka wliicli began with cnryza ami renclu'd Ihv'ir worwl vrirliiii 2i hmirK. Resp., 70 in the itiiiiute, i%tcriorous, uU the ueeesaory miiselcK in uetion» loud mueons rile* over tlio whole thonix, ijercuHxion uonnal. deathly |mllr*r, !4uffoeutive »ttaek« in the night. Fever and cough very m<Kienite. Attacks occawioniilly comraenee with fulijc croup* Kinetie*^ tilwiiys iieted exec^'dingly welL ITie attack passed into an ordiiiury ciitarrh, which las^ted 1 — '2 weeks.

m)f i^taxxsES OF thb vai^MBMOtmr oroaits. 1

I Cbild of 8 months. The attack began wilb oary$M and

congking. NoU morning the syroittotn? i?<it raptdjy worse i in thf ' evening extreme pallor and orthopiKea ; rcsp., tK» — 70 with harwh ^iridor. Cough flight; temp„ »ciire*'ly milled; pul«tt% snmll* iwtennilti^ai. extremely rapid. All over the tbi>rux harsh brratli- tag, BO rales, petmsfdon nomiaL Kmetie, wiirni moJKt eon nmiid ihe thorax, Winer. Recovery within 4 disyt^. AJn I **rery I veeks a ^imibir attaek, hm not nlwayi* »o Tiolndj During the -kh eompre?**, broncho-piieumOnia derelupitl irtltr threateiiing cerebral symptoinH, but was tiiinlly reeovene*! from. I Bor of 4 rears, broiis^Iit on Hth April, 1878. AlU^k^ oL

I farniiicl\tli« fmiu the 6ih montb, recurring ercry fe«k lUoittkfl [ r t^ft and fever T»nrHtion il — 4 •layw. HeTtp., M

i t. I, 80 and very «nfM<Hicial. Perews«oti noniiall

^^barHh bnvtbing^and sibilaiit rhonehiis all over. Curtd by tafia r ^VnrnHie.

r Girl of Cj year6. For ibc Wt 2 years lieunchitic allari^

iilmoart evi»ry niontk lasting il or 4 dayti. Duriiii? the tntertnU^

•simple ebronie catarrh of the latTf^er lyronehi. Kmigs nnmiNl. I

I Girl of r» years. Heulthy in otber rewfwvtH. Kver «iucfl

I tbe end of the. first year bronehitir iittitck», whSrh dariqfl

the IftM ye«»' b«d returned every 5 or *» »re«'ks unit eontinuid ■

♦by."*. Attack* began with fever ; extnnit* dvitpucrn, R. .V»» P. I III

At the i^mv time remarkably pbuid l*H»k nnd great cbeerfutiiewifl

i Cough violent; percussion normal, harsh sawing hn'sitlntii: .«lfl

I arrr. Ex|¥>ctorant mixture and wet comjnrcgw?**. 1

I have frequently observed as iu tlic first cftae, nu Aittck coinmeucing rb false croup and quickly puBsiiig itito hronchitis. The cronpy breathing m these cages soon hceome*j more whistling or accompained \^ilh moist sounds, itud on ou«^ i:nll4«iioii tliere is found harah indeterminate breathing either alone or else with sibilant and mucons rhonohi. Tho dyspnceta ^s extreme, the rate of breathing 60—80, the pnlae running, th^ colour pale or cyanotic, and the whole appearance so thrententog tb at —especially to the inexperienced — the child seems to he loM^i UlUiough the fever is generally moderate, it may in many cat^ reach a high degree. Real alarm, however, is only justified ^ hen the phyHicnl examination proves with certainty the presence i4 Uxtonsive patches of broncho-pneumonia* Tin* condition 1 luvc nevpr found in such cases ; and I am coniirme<l in my opiui'ild that tbere is here (as in false croup) n rajiid swelling of thfl mucous membrane reaching far into the mcdiiim'^^ined bmucl^ and diminishing their calibre, — ^Uy lianng observed Ihst tti iqnh*

CATABRHAL PKEUMONIA.

395

i>f tbe most th]'43ateuing symptomB i\w attack usuutiy ends very quickly witbiti a few days, uud passes into a simple loose catarrb.

Aiuotj^ othtT c'jiHvs favouring ihi^ view, wa.s tliuL of n Im^v of I year and 3 moiithH, in whom au iiLtnck of this kind i-apidly do- vclojied. On th<L' following day a slight attack (»f fulMC rmnp whioh U«ted IS days with threatcnin** Kymptom.M, then nipidly pft:*sed off IcttvinjiC u slight t-atarrh. In a fortnight thednldgot coryza ii^aio Hud lit once thf stcrtorcmHi breathing, the nijihl n^spiration ami wheezing in tlie rhost filso iM-gun ;»g»iti, juhI jiftfc '2 days di>- jipjHiirfd jn«t as (jnickly.

Still, 1 consider it possible thuba spantic cuiitractiou of the bronchial muscles as iubroncbial astbma may have flomething to do with this condition. I have repeatedly seen children who were never quite free from bronchial catarrh but always had sibilant rhoncbi here and there, enpecially nudihle over the Imck. From time to time, especially following a cold in the head, there arose very nnddenly a vioh^nt asthmatic attack with slight cyanosis of tbe face, without tbe larynx, however, being affected — Le, without hoarseness or croupy inspiration. Unfortunately there was no sputnm at alL All over tbe chest we board sibilant rhonchi and vorj* weak breathing. This alarming (but non-febrile) attack lasted occasionally scarcely half an hour or an hour nnd then disnpi>eared as by niiigie, being replaced by tbe previously existing catarrh. Tbe short duration as well as the sudden onset and equally rapid disappfarance of the attack is in favour of a reflex spasm of the bronchi being present, which many specialists have recently described an depending on stjitea nf irritation of the nasal mucous membrane.

Treatment. Simple catarrh gets well spontaneously, »s in later life, if the child is tjikcn care of and kept in-doors. Still, it i* nearly always 2 or 3 weeks before it quite disappears, especially when it has begun with fever at first. Among medicines, ipecacuanha (Form. li\) is especially recommended by many; and when the cough is violent it may be combined with cberiy- laurcl wat4^r (ni xv — ni xxx), I hardly think this remedy shortens tbe coui-se of tho catarrh, but I do not deny its soothing influence on the cough. It is most suitable when diarrbrea is present at tho same time. When there is constipation and f-^vcr I prefer to give the ipecacuanha in combination with

$m

DI8EA.8ES OF THE RESPIRATORY ORG^XS*

calomel (Form. 17)- I have found this saccefisful iu ouuiv cases of febrile catnrrh and alight hroncho-pneamonia. l

Should the disease, however, bof^in more severely with ^teat ilyspiKca and liigh fever, more energetic treatment seems tu I* demanded. The application of leeches to the thorax and to the epiphyses of the bones of the forearm — which was once tli»* fashion^ias been ahnost entirely abandoned in onr time, becjiti>r the loss of blood is considered too weakening and dangenjual This view is certainly right in regard to the great majoritjP of cases — especially in the sickly children one meets with in hospital and among the poor. It is another nii however* when one has to do with children who were pre^io^^r healthy and plethoric. Former experiences * have shown me thai h>cal blood-letting in moderation has by no means the had resnltjj (anicmia, collapse) which the modern timorous school of practic** iiiiputes to it : and I cannot maintain that my results in bronclm- jmenmonia have become more successful since I banished blotxb letting entirely from my practice. During the hist few years i have again cautiously attempted an antiphlogistic lino of treat- ment, and repeatedly with suprising success. This was don^*, of course, only in the case of children who were vigorous and formerly healthy, and at the commencement of the diseas**, ^ihethcr it arose from an ordinary catarrh or came on during tlic eruptive stage of measles. I nnw however use, instead of h>echeS| wet, or preferably, dry cupping (4 — 8 cups, accordiiiir lo the age) ; because the latter withdraws bloo<l equally well and no after-bleeding is to be feared from it. Since blooddelting i** only to be undertaken in strong children, tho sub-outaneous fat is idways sufficient for the application of the enpping-glaaw^s. I repeat, nevertheless, that these methods must only be used with caution. The great majority of these patients are aickly, rickety and debilitjited by other diseases, and in them any blood-letting would be pernicious and only dry cups can be used.

I should much rather recommend you to have wet compresses applied to tho cheat from the beginning, reaching from ?T ki

to about the ombilicus. A napkin or towel is lu 1. i . n in water at the temperature of the room, rung out and gently applied round the thorax without compressing it at all, and ao nm lo leave the armii free. Over this a sheet of uTidtltnp is pTaceu

i < Iklrr, CM* Kimdrrk«!»,^ X.r., 8. ir.: I

iATARRMAL rXEi'MONU.

S07

and the wlioie is corered with oil-silk, or j^^utta-perclia tissne. NMiou tiic temperature is liigb, I have these compresBcs changctl at least every half-hour, but afterwards let them remain 1 -H hours, atid carry this on coutinaou»ly fur several days and nij^hts. I have fioinetiincs even contiuiied this treatment for a whole week, and in these eases, generally, the water which wiis used cold at first, was afterwards used at a temperature of 100 — 103"' F. The compresses ft[)penr to have a fuvouralde action in three ways : Firstly, hy the deep inspiration which takes place immediately on the application of the cold, driving the air forcibly into the alveoli and possibly preventing atelectasis : secondly, by the couutcr-irritatiou of the Hkln which finally manifests itself in redness, papules and desquamation of the epidennis ; thirdly, by the process of evaporation keeping the ittmosphere round the child moist, and this may be aided by having steam coming from a tea-kottle or spray-apparataa close to the bed. The eoiuprosses also sometimes cause a favourable perspiration, but this must not be excessive* In one child of 11 months, I saw, as the result of such profuse sweating having lasted too long, an onset of threatening symptoms of collapse (extreme pallor, disappfjarance of the pulse, slight cyanosis) ; and these rapidly disappeared wheu the compresses were re- moved, and the sweating ceased under the use of wine. Daring the whole course of the disease it is moreover advisable not to nlluw a child to He continually on its back, but to have il carried about in the arms from time to time, in order if possible to avoid hypostatic congestion.

As to medicines, emetics have always been hold in highest 4»stimation ; and I mutt subscribe to this opinion as far as it applies to otherwise healthy children. In these the disease is always best treated by an emetic, and where careful nursing and observation is possible, I recommend tartar emetic in divided iloses (Form, 18) as really the best, in spite of all that has been said against it. I give a dessert-spoonful of the mixture every hour until vomiting commences ; and then every two hours. Should vomiting or even diarrhoea set in after eich dose, the medicine must at onco be stopped. .Uso, if no vomiting should follow after the first three spoonfuls, I lengthen the intervals to 2 hours in order to avoid a cumulative action, which when it has once set in is difficult to control. This line of treatment, how-

808

DISEASES 07 THE KEBPIRATORY ORGANS.

ever» is quite ansuitubic iu ddicate cbiJclreu when there S Jiarrlicea, and iu an advanced state of the disease; esp<-ctalfy in prttctice among the poor, and in the polyclinic where tlir mothers, being left to themselves, might readily by giving Uus mediciiie carelessly or for too lonp;, occasion exhausting dianrhcMi uud collapse. When, under theso circumstanc*^, the chiif matter is to empty the bronchi which are choked with mucas, Jind to make tlie breathiui,' freer, it iB better to ji^ive a fall emetic of ipecacuanha {Form. G), and to avoid antimony entirely. 111 strong infants I have often at the commencement of thedtseaiv^ given an emetic of vinnm Kutimoniale and oxymel seillo? (Fonn. 19i with good results,* But we must of course avoid the use of all emetics if the symptoms of carbonic acid poisonlug and pros* tnitiou are already present. At that stage the luc^dicines not only fail to act, but may most seriously increase the weakness by exciting diarrheBa, and depressiug the heart's action. Both af the principal modes of action of the emetics— the expulsion of mucus from the bronchi and the production of sufficieutly fall inspirations — are then entirely prevented by its debilitating action.

As soon as numerous rales indicate a copious secretion in the bronchi, and the sinking of the strength forbids a fuU doso of tu imetic, you should give ipecacuanha, infusion of senega, or poly gala amara, and to increase the coughing (and thereby the expiration) you may add aromatic spirit of aromouit. Mustard plasters over the sternum or tho back, and amalJ Hy -blisters on the thorax are to be rocom mended at the sarov time. Milk, bccMea, wine (sherry, tokay and port) must b© gircn alternately, iu order to sustain the strength as much as possible. Should these remedies have no effect and the strength continue to sink, ii combination of camphor and benzoic acid (Form, 21) may be tried, and is often successful. Under these circumstances, also, warm baths (95 — 97*^^^ F,) with cold affusion repeated several times a day, havo a surprisingly good effect, and should therefoie never be neglected.

Finally, u few words more on the treatment of recurrcol bronchitis (p. 393). During the attack, this is no waji difereut from that just discusse<l, and it is just in tlioM

' 1^ flx|ierieuce of A t><>nioriilt iu nliitli im rcoommonil/Ml hx •■ntn*. k» ika^

*tifRciont to enoJ»le mo U\ givM u 4i L'in«tit. T^ I

ini!titiit4Ml, nod whielnlul not tinl*- ' i.v. woni ini rtm of brxmdbo-pnfiunionla I hiivr nuw ^tuU* (rivuu op U»«> dn«i;-

CROUPOUS PNEUMONIA.

aoo

^

that the action of emetics is usually niosl strikiiij^'. In lirtler," however, to prevent tbe frequent recurrcuce of the attacks* tbe best tbiujjj, iiccordiog to my experience, is the use of brine -bath a iu sonic^ watering-place such as Kcicbeuball or Sod en. Of course this treatmeut must be repeated two or throe times, and a visit to the sea-side— epecially on the North Sea (Norderuey, Ostend, Bhiukeuber^be, Sebeveningoii, Heli- goland), is to be recommended &n afler-treatmout. I do not think it right to order wea-air from the very hegimiinf,% because owing to the irritability of the mucous membrane it not uncom- monly oceasious a fresh attack. Instead of the sea-uir, we mny also recommend a visit to one of the lower Alpine resorts (Rrouth, Aussee, Engelberg, Beatenberg, Heidon, tic). From the use of compressed air, which is recommended by many/ I have obsei'ved no good results in the few cases in which I have tried it. Stilly my experience in this matter is not sufficient to warrant a decided judgment.

VI, CroitpoHti Pnnatinnta,

Although catarrhal or broncho-pneumonia Is the commonest inflammatory afr**ction of the lungs in childhood, yet the view which formerly obtained as to the rareness of the croupous form has long been done away with, and rightly too. Between the third and the twelfth year this disease is indeed very common, and also in the first two years of life it is by no means rare. The following description is founded ou 124 of my own cases: in these the age could be determined exactly in 88 only. Of

theae there were :

19 l)etwceii H aiul 3 years.

*3'2 „ 3 „ d ,»

37 „ 0 ,, 1*2 ,

fot of 74 cases there were 18 in the months between May and August 18th, inclusive; from October to April, inclusive, 56 cases.

But in its clinical and pathological aspects the disease corre- spoudfl so entirely with the pneumonia of adults, tl?at I only need bere to enter more closely into a few peculiarities caused by the patienls* youth. You arc aware that in croupous pneumonia

Lasxewttki, Zar pntumatiS'^'ktn Tkerapie dtt Kimfeialttr*^ Ififtfftation

400

or THE RESPCEATOBT ORCIANM.

tke alreoLi of the Icmg are filled with » coherent ^xodatioA ooa* for the tDost part of coagakted ftbrin, Khile in catarrtii] the cont€Dts of the air-celln coDsist of a mixturi^ of ytmog^dlh and of epith€liiLm^ which is mostly fattr. Yon fartbrr knoir that the latter disease always occani at first in lobnlif- patfiheSy eorresponding to the rainilication of the inflamt^l bronehus, and only becomes diffase gradaally hr the oontiiiaBl addition of new patches, while the croujK>n6 form alTeeta, so la speak, all at ODce from the very heginniog* a lat;^ pari of iLf long — ^eren a whole lobe, filling it with solid exudation. Tfar clinical ajmptoma also vary with the difierent pathological ton- da tions. Instead of beiog ushered in by broach iai catarrh, aqJ •^Tadaally increasing iD BeTcrity and extent, like hronelto-pCfia- monia, we find in the croupoas form a rapid, almost sudden development, with violent fever, after the manner in which many acatc infectious diseases are wont to set in. Also the donble-sidedness of the former, depending on the difltiar bronchitis^ separates it from croupous pueaiuonia, which gencrallr occurs only on one side. As to the localisation of the latUr in the upper or lower lobes, in 124 of my cases it affected :

In

II

5

26

47

-40

1*21

the whole right lung, both lower loUi*, thf left upper Iglx*. «, right upper lohe, „ left lower IoFk*. ., right lower lalx*.

niij from this we see the preference of tho discjisc for thL" joarr lobes in childhood also.

The above-mentioned differences cun only claim, 1 to

hold good as n general rule. P^ven patliologically w^. itli

mixed forms. Steffen' maiutainSt in opposition U> Barteln and Ziemsseu , tbc possibility of the product of a lobular pucn* monia being sometimes of a croupous nature. Stciner and also Damascbino^ described patches of a croupous uatinv which were fbund along with broncho-pucumonic patches aud the same lung; and Virchow foimerly htutisl tlifit

• KHnii. der Fintlrrlranlkftfrn, i., S. IKJ.

• •* Don Hi(f''r<»iit.-. fornuH 4«^

\\0 AijlfttK rlutT Ilia itif

CROUPOUS PNBtTMONU.

401

ihc cell'pralifertttion, fibriDOUS exudation may alao occur in the

alveoli owing to an extreme tlegree of irritation. I liavc myself also

met with analogous cnaes ; among which I may especially alliide

to that of a hoy with pleuro-pneumonia of the whole left lobe,

who had at the same time bronchitis and in the right long a

small patch of hroucho-pneiimoma (*/. p, 384), The clinical

^^emptoms, however, are not always so typical as one might fancy

^Hrom the descriptions in the books. Especially in the hospital

^Mud polyclinic, where the children are not bronght for treat-

^Bnent till the disease is fully developed so that its early develop-

m«*nt remains unobserved, wo may be in doubt as to what form

of pneumonia we have really to do with. Suppose, for example, a

tuse in which on physical examination we discover au extensive

Iiiieumonic consolidation of the right lower lobe and a catarrh of ho left lung at the same time. In such a case yon must bear II mind that the patches in broncho-pneumonia may not uncom- Donly run together into a large mass causing actual symptoms if consolidation in one lung only ; while in the other they may remain isolated, so that we can only make out catarrhal sounds. On the other hand, the accompanying catarrh is not altogether characteristic of broncho-pneumonia ; for, especially in children, I ^1 have not unfrequcntly hud occasion to observe croupous pneu- ^ftnonin complicated by bronchial catarrh.

^" In these doubtful eases, the character of the fever is

always a very valuable symptom. I have no hesitation in

■Bubscribing to the conclusions which Ziemssen' drew from his

^investigations aa to the regular course of the fever in croupoua

I pneumonia and its relation to the critical days; and I also igrec with him that the characteristics of the catarrhal form ■re ** its protracted course, with marked variations in the lempemturc during the later stages; the continually-recurring fcxHCcrbations of the fever, each of them corresponding to an idvance of the local process ; the slow fall of the temperature, delayed by small rises; and the protracted resolution of the ^■legnlar consolidation.** All this is certainly true in the ^■iftjority of cases; but by no means in all. Not every ^Broupons pneumonia ends with a crisis ; for we may also have ii ^Aiore " spun -on t " course^ approaching to a chronic condition; ^Btid on the other hand I have occasionally obsc^vod case^ of ^H^ * ** PlQuntis nnd Pneumonio im KindeMltor,'* ldd2, S. 316.

402 DISEASES OF THE RESPIRATORT ORGANS.

pneumonia which had the entire appearance of being catarrhal bat nevertheless had an unexpectedly rapid and faYourable course, so that recovery took place within 5 or 8 days. Those who are interested in this matter may compare cases of this kind which I have elsewhere published.^ Repeated observations since then have only confirmed me in the view I then took. Between well-marked cases of croupous lobar pneumonia on the one hand and broncho-pneumonia on the other, there lies an inter- mediate form which cannot be diagnosed with certainty clinically ; ^ and the question whether it is possible to differentiate the two forms of pneumonia from one another during life in every single case must therefore in my opinion be answered in the negative. Also, the circumstances under which a case of pneumonia developes do not determine the matter; for both primary — i.e. idiopathic — pneumonia and secondary — which comes on in the course of some other acute or chronic disease — may present a croupous character. Thus I have sometimes found croupous pneumonia in children with tuberculosis of the lungs and caseation of the internal glands or other organs; also in acute infectious diseases, especially measles, althougb broncho-pneumonia is very much more frequent in that disease. The most astonishing case, however, that I have had was that of a girl of 12 years suffering from severe typhoid, whose temperature could not be brought down by any antipyretic measures, but kept continuously at 104° F. and higher. After death we found the whole left lung hepatised, almost from top to bottom ; and in the middle of it, at the lower border of the upper lobe, two isolated patches of the size of a bean and a hazel- nut respectively, separated from the neighbouring tissue aiid surrounded by a line of demarcation (dissecting pneumonia). I have already remarked that croupous pneumonia may also develope occasionally from a catarrh, either acute or chronic; in which case catarrhal sounds are heard during the whole course in the affected lung or in both. In the great majority of cases, however, pneumonia begins quite suddenly, as in adults. I have even observed occasionally, in children over 5 years, the rigor which ushers in violent fever, but more frequentlv repeated vomiting. This conmiencQjment, together with the

» JSetfr. tur Kinderheilk., N.F., 8. 161.

* Cy. also Steiner, Praytr Viertefj'ahrKhr., 1862, ii., S. 12.

CROUPOUS PNETJMONU.

408

rapid rise of the temperature to 104^ F, and over (in one ease I abflerred it 106'l^F. on the first evening), is all the more likely to lead to error because tlie respiratory symptoms at this Btage may as yet be completely latent, and inntead of them sjmptom.s often appear which seem to point to the brain beinff affected— especially drowsiticHs, delirium » a dark fluah on the face, and •glistening eyes. Slight pains in the neck also, with congestion of the pharynx and of the pxims are often present at first, and a Klight redness of the skin usually occurring in certain places only (llilliet and Barthez had previously noticed the same), make it all the more perplexing to the phyaiciaii. We first think scarlet fever is about to appear, or gastric fever, or that meningitis is in course of development. Under these circnm- stances you Bhtnild take particular notice of the character of tlit* breathing. Even at this stage a careful observer is struck by the short breathing, which is very rapid in proportion to the pulse-rate, and by the "grantiug'* expiration; although thert^ is not as yet any cough or real dyspnoea. The cough especially may be quite absent at first, and even in the later stuges it may be very slight— probably owing to the bronchi not being affected. The examination of the thorax either yields no abnormality at all, or at most, if one auscultates very attentively, a weakeu i n g of the vesicular breatbing at the affected parts or occasional crepitations on deep inspiration — for example, over the right lower base ; w^hile the percussion-note over the apex in front is somewhat tympanitic.

Kmil A., Ti y«'ni> ♦»I»l. IncHi^ht to the polyctiine lOtli Jiint-; li v«?ry Btroiig rhikl. Four <biy-H previously Kudcleii onset of bigh frver, rompbiiiitH of juiins in all the limbs, apathy, loss of appetite. thiekly-coattMt ton|^i<\ l'ulj4e. Uiii; resp. 144, short. On examina- tion nothing found, but i-ather weak breatbing over the right hum* ami th« |>crcun«ioii'nnte higher and soinewbat t}'mpanitic over the right apex in front. The sUHpieion wbich I expressed to my class that pneumonia was in process of develoi>ment, was confiiTned williin tlic next few diiya. On l*2t}i, fever leas; Bevere cough ; over the right npr\ in front the j>pri*iiKHion as on 10th ; but behind — from rhc spine of the scapula donnwardft and in the axillary region — rxtrerne d^ilnenM and bronchial breathing. On 16th. the fever having fiillen critically, all symptoms wci*e rapidly disap- pearing.

This latency of the physical signs, which may last 4 — 6 days,

or THB

TOBY OUaAStS.

or of ijrpbotd^ I experienoei In ooe oacu l^e fwimooii grmdgally qire^dg (r^m ib« c« Atr« of ibe l«qg to Ike petqihorj ; mud oalj wlwa il Imi nt^ed I^B Tntiftiwi, do tho agns of eoosolidftlioa sppeu dwtnwklj* V^hmmw Uik fetkn iikM, Um gmsirie or eorAifil ■ydi hftfo ImIImHo beat fmoiiiicot aimallx D<yv \ «D. and Ibe dtagwoaia ol oooo becomes elcmr ; bat ia sol until ibe kfwer is distiBctlj on the deellne* ot ohnody ended oritieaDj. I do uoi ebaio ibt of WMMtj vriien Iboi pnoaaionio of tbo njiper lobes 10 c^cct&Dj 1^ to leod to Ibeoe mistakes, since I bovo miss iw^neptiy seen JnJsfMMtion of tbe lower lobes follow sacb s oemso. Tbe broin symptomSt wbieb oaher in sndi (pnemooBie e^iiebnUe), s<cardiii|f to mj experienoe, ffe^fwHy tabs » ijpboid Ibrm, is spstb7» droirsitieoBy giddi- noB|» dsbtiamt dtr km^e. soil, moeb less eommdnlr. <^pn&Mfce conTttlsions.

Ps«li»e S, 4 jmn old, UnMigla on Tllk J«iJy. For Uie Ual f«* dsyrn cooliiin^ fem> «.iid eoogb. On tbe monaing of tbe 6U1, fipeeted coartilstoiis; pdbe, loci; mp. A4: faenMimkift twrmmt mil oTcr; s fipir crcfMtoliQoa oo tli« rig)i*

paiift ia »kc kee^ Qo tlie 8tlv for Ibr : < ii

dij of tbe diBeeer)i> dslnesa u the oppcr pun ol tbe nigbi «id» bdund, wkb dliUiil brHUliing: and lftter» brooclikl bmnlnrsr. Oisis OB tbe 7tb daj.

Aogiiste H^ 4 jvmn aid, admitted lltb lt»5; unwell f> two dsji« vitb boidscbe sfid loss of ftppeiUe. On the Aft of the previotts d»jr« sadden geoend conrulsioaf, 80 TioMil t tbe cbild bad beo» tbrovn out of bed. Delirium ditrtiifi Ibo Bigbl; great apathr ; limlf-clur^ t

Tetop. Ii>l4 >\ ; palfcc, t

dificnh. Cooi^ BCSRvijk A krip; |ml<'ia cif

orer tbe rigbt poatorior hm^ im: ^harp rih>^ wik*

dttooTMvd for firet time on t3kh, while the Itrftiu irm« bcciombig

rlearrr. '*♦' ^^^-^ I'tJi m «x>tBp|ete eriai*. O1 mlfTedr < lifthed, medittm 1

tioroas rb<TIl^ m . 1 n»5« v-<.»*igJ». (*•-?*-* .-^..~.^

HeleDC S^ S jmtn old. adtc Ittor albias. *^ thnvn

l(»*»F.J«T

became eomatb^e, ai

flu Isrh

^ aiid *«-

I TiiuiL

cm •ccooat of

.tw mik*cU

M

CROUPOUS PKEUMONU.

405

ttic eyes, face*, and extreinitioa, lasting 20 miuuics. On riioriiifig ot" i!4ih, temp. lO/i'd^ P»; sore throat still |>i*cseut ; rettp. 60, rapid mul j-yixji'lieial ; on the k-ft side cataiTh, on the riglit dulnet^s, indctci- miuate brfathirig aiul slmrp J-Ales ; later on, broixchiul breathing iu Htipraf^pinons fossa. Persistent high temperature, the brain, liow ever, remaining quite clear; uo return of the convulKion!*. OijiiJ* l*etwecn 6th and 7th chiy.

Otto S., 7 jrAr.s old, suddeiily to*>k ill with hi^h fever and vomiting in the night oj 16th January, On 17th persisteut drowsinesis and apathy, fruiu whielit however, the child can he I'lvsily roused, and tbtii an^werK con-eetly. Temp, always H>F F. and over; at noon reaehed a.s much ad 1067'' F. Quinine, gn i. luwl two hatha of 84-' F. had no effeet. On 19th^wheii I Jirs^t snu the patient — per hi stent fever (lOr^"^ F.), apathy, flushing of the face, injection of Lhe eonjuoctiva, scabs on the Hpa, dry tongue. Reitp, 40, not difficult, but slightly noisy; some cough. On the left side behind,* eH]KH:ually from the spine downwai'ds, and laterftUy, diiluesii, bronchial breathings and bronchophony. On the 20th — Le. between the ihd and llh day — fall of the temp. l«» IUriJ° F., with genenU improvement. On 21iitj it rose again tu 101^ F., with severe rlyH|)ntx«i: rcsp. 60. Crisis on 7th day.

Opinions differ as to the causes of these initial corebrul symptoms. I boliove that the more typUoid symptoms (vomiting, giddiness, headache, apathy, drowBiness, delirium, iDVoluiitary aetion of the bowels, niid dry hrown tongue) are due to the rapid rise Hud continued eknation of the temperature; and that it ift possible, althou^di not proved, that convulsions may also arise in this way in children who are predisposed to them. Likewise no long as we Uave no experimeutul proofs of the action of the recently discovered '* pueumococci " and their ** ptomaine»," we caonot make them answerable for these symptoms. I have never been able to find any connection with a complicating otitis, such as Steiner has drawn attention to; and meningitis ean only be assumed when the cerebral symptoms not only come on at the beginning, hut also persist during the further course of the disease until death. It is well know^n that cerebro- spinal ^meningitis may occur along with pneumonia. The symptoms of the former, however, are in those cases the most prominent, and the pneumonia appears as a chance complication. It always pfieems to me that many of the cases of " recovery from menin- gitis,*' especially from "tubercular meningitis," have been nothing but cases of pneumonia with cerebral symptoms, which jere wrongly diagnosed.

406

OF IBM

OUaiSA,

hi eamiectuni with tiw grmdntl defelopiiiatl of pDMUBooii tram ibe centre of the laitg to its peripfaerr, irfaich caiuet Uir Utencj of the physical sigiiB for aeTerml dAvs, we maj ponsider the form described under tlie naine ""pueomosiia ixiigii&i>'* which I hare repeatedly obserrcd in ehildran. The fihrjaoos couaolidation in these caaea spreads oo wards lij small adfanees, like the rash in eiyatpelaa, trom the partion of Inn^ originally afiected ; and may in iLi^ way gradoally aiTeet ibe entire lobe.

Anna S^ 7 years old, admitted i>ii Hili Febr«iarr wStli pairti* tnonia ot the left lower luW mud vvry liigh t<*nifirrnitttr» (lOt^— ] 06 '6"^ F.}. Next day dtilnc»5 and »liiir|i riles tfvre olmfrv^id orrr tbv loft Uttoral region^ iind roiiunocd unt^hnngicd ; the temp, nsmainivt high. Liesp. 76 — 84; pulse, 141— 1-V». ufwi ii tiiArkrd gikPirie com- plicutiou presoni (thickly cojWi-*! lonpin\ romititiif, f<Ktor ort». dinrrhcuji). On 13tb (the l<»th day of th- ittonwof

ron*»ol idat ion behind aln»ttth' fleftnn^ u -i-S^** P4

nliilo in frunt the dulnr«s^, Kmnchiiil Vm^iihitijir. utid «hjirp rale* I'xti'nded up to the clavicle. CYisiii on tho llth rlnr. On iPtk Kt'hruary romjilete recovery.

Klise B., 5 years old, aJniitUHl on lilHh lA?ceiMlKT. Took ill mmio days before, with fever, vomit in|Z. «lrovr»inr<ui ; no rough' Ro»|j. 36; pulne, 144; temp. ra. 103* h^ P.; cr. UH7'' K. Loofc* like typhuK. On 3rd Jnnnnry I diwoverwl pnciimonia in ibr loft JowiT lob(*. Retip, 52; dy*pnai», BaUi oI*>0.5^F. ; cjhio. AuIpH., firs, XV, On the kh. spreading ot the pncuKitonia iipwnrd^i rind laterally. On **i\\, con^ulidiition «if b*fi upf>er lube» uIku ubHorvable in front, Temp, always tiXtr-' — \i}P F. Oo 7tli, ilijiuppoamuce of fever, temp. J>P'l^ F. (Irtidmil re»f>luiioli, Oo 12th. dulncsa and indeterminate bri^tbing kIiII to be ran*].' '.m* everything utherwiao normal. On 20th, disicluirgcd eurrd.

Ill thoBC, and in several eimilnr cases^ ^^f} couM by plugi<ijiJ ^xninination fuUow the separutp advaiices nf the waudenog pueniMonia, from the ba«e of the lower lobe round the side ta iht> npcx in front. Tliis procesK look 4^ — G dayg. In ibe rtrjit rase tlio tenjperatitrc, wbicb was already falling, rose snddrnly on the livening of Ibe I'ith to 104'2^ F., cfvidently .vvvi»»«; lo tlio biHt advance of the pneumonia to tbe apex of the \\i\\^, and \\ic di»ea8c then ternnnated, lu a boy of nix years 1 bav<» »«H»n pneumonia — hitherto limited to tbo posterior portioo of tbi> rl^bt lobo, but HprtMiding upw < V *

a\iHar,v bm« for tbe first time on the ! snl<»rior part of tbe Inn^

conatdidatioa naar

CROUPaUS PNEUMONIA*

407

the vertobral columu again disappeared. Tlie crisis did not occur till the IHth day. In such cases on© may, therefore — especially when resolution in delayed at the lower part — readily he miBled into assuming the presence of considerable pleural exudation, till the clearing up of the percussion-note over the lower part of the back, or else the appearance of the crisis, establishes the diaj^osis of pneumonia migrans.

I must take this opportunity to remind you that in pneumonia of the upper lol>e dnlness may appear at the base, not due to h sudden spreading of the pneumonia, hut to a pleural exudation which has come from the apex (Trauhe). The complication with pleurisy occurs in chiUlrenjust as fre<juently as in adults, and in older children it is revealed by complaints of pain on coughing, by their lying on the affected side, and by ])crcusBiun and palpation of the intercostal spaces. As a rule, the accom- panying pleurisy and the exudation which it causes do not reach any considerable amount, although the duluess and weak breathing at the lower part of the back, due to the latter, con- tinues far into the period of convalescence. I have also seen ibut in far fewer cases) purulent pleurisy gradually rlcvelope from pneumonia, which— on account of the persistent hectic fever — required puncture, or finally the radical operation for empyema; after which recovery took place. In the case of a girl of 11 years the pleuro-pneumonia was primary, and in a boy of 9 it came on in the course of scarlatinal nephritis. Thn differential diagnosis between pneumonia and pleuritic exudation is especially difficult in children who are too young to speak, because two important symptom a — the vocal fremitus and the rust- coloured sputum— are wanting in them. The former can almost never be obtained distinctly, and for it one lias to avail oneself of the moments when the child is crying loudly. I have never been able before the third year of life to make out the increase or dimiuution of the vocal fremitus with sufficient dis- tinctness to warrant conclusions from it as to the diagnosis. Rust-coloured sputum I have observed almost only in older children, of 8 — 12 years. Only on one occasion have I seen the expectoration streaked with blood in a boy of 4i years.

The course and termination of this form of pneumonia in children resemble those of the disease in adults just as much as do the symptoms. The great majority of cases end favourably

410 DISEASES OF THE BSSPIRATOBT ORGANS.

pale. Unfortunately its microscopic examination was omitted, since from other observations it seems to me probable that there must have been a degeneration of the heart-muscle, due to the diphtheria which had caused the rapid and fatal course of the ])neumonia.

I have already^ published a case which ended favourably with a regular crisis after lasting only three days.

The pneumonia l>egan in this case on 8th April, at 5 A.ac, with high fever ; the boy who was 10 years old and was suffering from catarrh, having exposed himself on the previous day to a keen east wind. On the evening of the 9th the hepatisation of the right lower lobe could be distinctly made out. On the evening of the 10th the temp, was still 104° F.. but at 8 p.m. a warm perspiration set in, which lasted all through the night. On the 11th the fever was gone, and all the symptoms disappeared so rapidly that on the 12th very little dulness could Ikj found.

The following case bad a similar course, but the crisis in it took place in the night between the2ndand3rd days.

Max S., 11} years old, admitted on 27th June, 1876, with non- febrile catarrh. On morning of 30th, sudden high temperature (104*9° F.), resp. 40, pulse 13t). Cough and j)ain on left side ou breathing. Indeterminate breathing below the scapula. On l.«;t J uly dulness, bronchial breathing and sharj) rales. Temp. 104°— IO470 F., resp. 48. In the evening gi'eat weakness. Typically rust -coloured sputum. Next morning (beginning of 3rd dav of disease) after copious perspiration and a good sleep, tLf child felt quite well. Temp. 98()° F., resp. 25, pulse 80. On the 4th, dulness had quite disappeared, and only har.-<h breathing with occasional rales were audible.

A few examples of a still shorter course have also been pub- lished, some even of only one day (Leube, Weil), observed in adults. These cases of so-called "abortive pneumonia" have caused the French physicians — especially Cadet*— to describe acute pulmonary congestion as a special disease. I cannot regard this assumption as justifiable, attractive though it be, because as yet there are no pathological grounds for it. The short course, the rapid change of the physical signs and the speedy resolution are not in my opinion sufficient points of distinction ; for how rapidly within a few days after the crisis the physical signs of true pneumonia can clear up, is shown by the last case. This does

' BeUr. tur Kinderheilk., N.F., 8. 167.

* Loc. cit,f p. 1, and Bevilliod (" NotcB din. sur qnelques maladies des «!ifants " : Paris, 1886, p. 90).

CROUPOUS PNEUMONIA*

411

»ut alwajB happen, indeed ; Imt npurt from ILloho nire cAsen vhich take on a chronic course, I have seen in tbo majority [the clear percusBion not43 and normal breathing retarn after a ^%veek, or at latest after ten or fourteen days — nnless there wan fiome considerable pleuritic exndation keeping up the duhiesn sit the base for a lon^yer time, I bavei only seen three cases that formed an exception to this rule in the renmrkable fact that the physical signs were in process of resolution if'ven before the crisis commenced.

Heinrich S., 0 ycarM old, aihnittcd lUL May. lb"7, Liultby. hi the night, 7th — Kth, Imd comjilaitied much of pain in the hett<l und liplly, and of thirst and fcvt^r ; iTjiontttd %oftiiting. After thiit aiiorexiii, thirst, t'bver dcliriiitu tii uiglit, ftiid slight toii^fh. Tfinp* on adiuU&ion 1U4*7*^ F, ; pained expressiuii of the faec, cheekn tlushoii, i*yes gt-neitilly closed, drowHiiichfi. PuImc lliO, i)f hi^li U'lisioij. ReHpJruliuiiH 60, siipirlk-iiil, Abfloiaen tctidtT <hi pfessuro* Porcusfciion over tbo left side hohind, dull from apex t** bwse ; in this situatinii fine fIum^) nlles. Nothing eLse uhnormivl. Rvening temp. 1U5*P F. The f<jUowing dny brought no ehaiige ; but on KJtb— while the liigli temp, still lasted (HXi'P Fj. the pulac was 120, and the resp. 6U— we found the thilTio.*,H almu8t entirely g<uie, and in.Htctid of the fine sharp erepitations there was nothing to he heniil (uit luuerms riileK. 'Hie liigh temp, (varying between 104.''^ and 104;i>' F.) continued till morn- ing of 16tb, when the tri»in suddenly tiwuk jjlaee itndthe ebiid felt iplite well ; temp, JT'T" F. ; and nipid reeovory followed.

The statement of Grisollc* that in 20 patients with pnenraonia the auscultatory si«^'ns had remarkably improved even during the height of the fever, was criticised unfavourably by other WTiters {e.g. Fox) on the fp-ound that Grisollc had -sti mated the fever by the unreliable iudications of the pulse and not by the thermometer. The case just gfiven, as well as the remark of Sidlo- — that in 37'5 per cent, of the cases the local process, as far as it could be made out by physical examination, came to an end 41 hours ou an average before the onset of I the crisis— goes to support Gri so lie's assertion.

Croupous pneumonia, in children as in adults, is a disease in

whioh the prognosis is exceptionally favourable, unless

it comes on under very unfavourable circumstances (nophritiH,

typhoid, tuberculosis). Otit of 04 of my cases only 7 died, and

' " Trait«S do U pnoumoiuc," n, ^07.

' /Vv/atAm Archiv f, kHn. Uei/., Bd, tiv.. 8. Z48,

412

I>I&EA8£5 OF ?B£ R£SriRAXOR¥ O&GJ^Kd.

af theee one was found at the post-mortem ta have th6wbo]( right long hepatised, anotber had double pleuro-pneamonia pamlent pericarditis^ a third had diffuse peritonitis, and a isnt tuberetilosis in many organs. The greater the extent of disease, the greater is the danger of insaffieiency of breatltifi^- power, and this explains the far more favotirable prognosis of tibrinons pnenmonia, which usually affects only a portion of tht lung, as contrasted with the difinse catarrhal form. For thil reason there is always less cause for anxiety if the pneiunonia k limited to one side, and the symptoms of hepattsation are eoa< fined to the back or front, and do not Bflfect the whole of the lobe. The prognosis is worse if catarrh is predont at Uia' to time, or copious pleuritic effusion ; bat Uio t r 1 11 i o g "pleurisy which is almost always present need cause no anxiiiy. Nor yet need the less common tcnuination of the fever by lysit, ^\hich may lake days (in one case as many as 12 days), although^ with it we cannot exclude the possibility of the consolidatioit lasting for a considerable time, or of its passing into a chronic condition. I have only twice had an opportunity of obserriiigi the termination by the formation of an abscess, and it va* followed by recovery.

Ill April, 187o, I w«s Af$ked to bpc a gvrl 7 year* old* whobiiil

Ijct'Ti formerly quite htalthy and wiu« now wnfffring fr*>ti tmupous piieiuuoTiiii. Bei<id(>K Itejwitiaation of llic wU* lower lolje tliere woi* also dtiliieij^ und broiichitti hn^Hthitig »i the lower pai'l of the left posterior imse. ^HiO criaiB to*jk pbrr t}[\ the 7th day ; (he tefnji. fell to Pt^*^ F. with ropiaUH |>rrKpimtioa and thi-eatciiing symptoms of collapiic, htit only for a few tU^pf- While the signs of coiiHoHdatioTi tit the left Imsc mpidly db' npjicared »iiid the fever returned nnd soon as&nmcHl v, Itrcti** rhanu-ter with intennittent etevfttioi>» of temp. There \vm» ahni persistent cough with t^eiinty mueoiiii expectomtioi. cxhatistiori and extreme cmuciAtion cauf«iiijtf i1m^ r apprehcnsioiifi. At tin* sHiuetime we weiv n m*

cavity on physical exiiitjiimttun ; dulnetssi niitl i^tV^

continued iiweluiiigid on the right side jioutenoHy Imtn the jipinc of the 8ca]>ulu dowinvurdii, while over the iipe\ in front only ppo^ longed expiration could W henrd. On 2(}th May— i,i»„ aboat 5 or 0 weckfi after the commencement of the pneumonia— nn rnoriuon* atnonnt of pure pun wim suddenly disehiirgr>d hy couphime. with i4ymptoms of vuffoOHliori; but the itnioiini, ui. was not metiHUT'cd. £H||^|^iiiii£ lill the mi>rljtd prove^l very gtiMlml^^^^BMP' '^'^ ^ ^'^^ ^^^y ^^*^' «^biUl «aj»]

CROUPOUS PNEUHOKIA,

418

quite well ami no longer requii*ed treatmout. (Inly indeterminati» hrcfttliin^ and a slight dulnenK at tlio ripjlit imsterior base bori* witness to tlio disease which had exi8tcd. From tlie commc^nri- mcnt of the hectic fever the child only received diH-CM^tion of hirk, wine »nd Btreng:thentug ntjurishmcnt ; after the ahscoits hurst into the hrouchi, she spent the greater part of the dny in the ganlen. I found ont that the child i«uhHer|uentIy enjoyed uninterrupted good health. The second case hud a quite Rimilar course.

The mainly expectant treatmeut wliick has recently beeu

rocommeuded in ])neumouifl, is applicable in childron as iii

ftdulis, I never use wet- cupping except where the dyspuwa

is extreme and the disease Tery extensive or complicated

with severe pleurisy, and the violent pam on breathing and

iighing seems to call for it. In lesji rolmst children, however,

y-cupping is quite sufficient. Where the pneuraonia is

Used and the pleuritic complication is either absent or at

ast not A prominent feature, ono may dispense with blood-letting

tirely and use instead the cold wet pack or compresses to

the thorax (p, 397), renewed every half-hour as long as the

high temperature continues, and afterwards every two hours.

IA.n ice-bag applied to the head is to be recommended; but on Iho thorax it is too heavy to he borne. The use of luke-warm ir cold baths, recommended by Jiirgensen especially, I do Bot approve of in children, because, for one thing, I fear their lepressing action on the heart, which is particularly to he tToided in pneumonia ; and especially because I regard them as unnecessary. The maxim *' no quid nituis" is here fully applicable. The vast majority of cases run their course, accord- ^^^g to my experience, without any active treatment. ^f^iere is therefore no reason whatever to expose the children to the risk of collapse, which I have seen result from the cold- water treatment of typhoid in children. It may also be added that 1 have seen just as littlo permanent effect from cold baths (77—81*5'^ F.) during the acme of the fever as from the use of large doses of quinine (grs. viias — xv.), antipyrin (grs* iv. — viiss), or antifebrin (grs. isa— iii.). Although the temperature is brought down considerably for the next few hours, still this fall gJways only temporary, and in order to keep up the action one mat repeat the bath or the antipyrin eveiy 2 or 3 hours— a thod of treatment which, in children, must be strongly con-

41<1 wfsmJkMm or the ftnapiBiTo&Y obgams.

I I eosH 1^ Wore toq t number of cnrres nidb as thi* I

cmperinturc

«^ the iith iUj

1051=* B»tbof 77^ F

9 AJB,

!(«=

Ukb

quimnegrs. tiibb.

IMh

lOM^ . lOSiy* quinine gn. m.

B»ifc of 8V3-F. Mkli • Crises^

I kaiv IbfRiwe ^ndiudlj ftbandoned the ase of quimne tai ilifiyiftto ftlsD. aad eoofine mjself to tlt6 loc«l oseof ^ «NDa|irB8Bes» first lukewmnn then cold lo the If Twi wiD or most order medicine intrr- Mlh-, lilt ^ast tluBg to give is infnsion of digtialis with ttUrmW of f oUsh (Fom* 2[D, which, however, is coolni*tiidi' cvledl Ij giltrk CQiiipliealiau (repeftted bilious romiting, thid tmakei fg^ii, mosm^* Ib thai ease joq had better order hyim- cUocie mii (Fmm* S), or ipeeaeaanha (Form. 16). I only n»c amUiiOBy is I kft^OMOliaBied (p.397) when the gastro-bepatjc ire nry procniaeiii (eoinatiiit frontal pain, retchiog^ WA in then eases it is Teiy snecsraM. Yon maft I tone take cars that the diet is xnodeimtelj noarisluQi and a Utile wine). The coQapse whieh sometinitf ad the crisis is most effectiTelj warded olf b;* lar|^ of wins aod inisstiois of eamphor and other. SttlJ

of SQ^ eolhpos is not eommon.

\1h ikrvmtc Pnntmiinui.

Acn<» |^««naoBia, whether it eads with cn%i8 or Ijiub dots nc4 ilwi^ nrfiifu loeh tapid rosolmion. The physteal fdgan «4 niioBiiilisi of the long ma j oootinnc for weejks, oren fer and in that <wse there is always apprtboDsioo leet

in the huig may orr"-— — * -" — ♦— ns

ittd the fom It

i. (oliowe broucliQ-pnen'

CHRONIC I'NEUMONIA.

41

mouia far more commonly thao it rloes the croupous form, whenever the conditions (hereditary tendency, unfavourable circunisitaiices) favour such n change in the exudation. You will however remember (p. 390) that even when hroucho- fmeiimonia has a very insidious course, with unfiivournhlo symptoms (emaeiation, fever, diarrbtea) a favourable termination, though not expected, is always possible; and I think I may rouclude from certain of my cases that croupous pneumonia ,also may take a similar course.

Max K., 0 yetirs old, admitted into tho ward on 17th Maw li, 1878. with rcxema capitis and hittncliial catarrk On the l^th Kiiddcn dt'velopiiieiit of ci-^npous pncimioina of the rip;ht lower lobe. Temp, 105 1^ F., \mho 160, i'csj>. 4-^. During the following «luys tljt! toin[)pmtiirt' varied iK'twccn 103G°aiid 105*8^ F. Duhiess, Hhtirp ralff* and hronthial bfoallnng over tlio riglit Imck reat'hin*^ to above the wpiue of the sra.pula, and limited by the axillarj' luu*. There was al»odrowaineBs, delirium and rcstlcssnefia. Wet-cuppinp; (on account of pleuritic pain), « old baths, quinine — without ap|wireiit effect. On *25th — *,«., on flth day of the disease — the temp, fell ti> lOQP — 10<)"8° F., which lasted for t days (Ijeis) accomjMinied by copiou? perspiration and an oniptiori of herpet? lahialis. On 31st —the IHh day— <^omplete il i sappL-a ranee of the fever, while the cough Htill ia.sted, and Uu' ^ihyniejil ftij^is in the right lower lobe gradyall}' iiiiprovLti, the dulnean ek-ared up fiomewhat ami the breath soniidH remained iTidetenninate and were accompanied by fine rales. Within a bw dayg. however, a flight evening rinc bcgan^ being tiometimrs also observable in the morning; so that the terap. for a fortnight, np to April 21st, varied between 100" and lOl'P F. While the mtc of the rcsp. was but slightly in- creased (26 to 30, rarely 44)), the cough severe, and there was a great tendency to perspiration, the dulnesa disappeared entirely for the first time towarda the end of April, indeterminate breathing and rtlles being left behind. Alwjut the same time a remittent rise of temp. waM ohs<'rved for a few days (from 26th t(^ iJSth April). The same torjk place from tth to 27th May (temji. always 1008^ — 101*3» F.). Increasing |>alIor and emaciation in spite of a tolerable appetite, and the indeterminate breathing with prolonged expii-ation and ralei*, stiU audible at the affected part, were all the more suspicitins liecause the scanty raucona expectoration waw now frerpiently streaked with blood, and was gradually liecoming purulent* Under the microBCope, however, nothing coukl l*e made out but pus corpuscles imd epithelial cells, never fragments of any other tissue. On 27th May» — 1.0,, 2 months after the Ijeginning of the pneumonia — every- thing had returned to it.*? normal condition, and the child could lie di«charged as cured.

416

r>iaEASE8 OP THE RESPIRATORY 0R01N5.

It 8€eras to me that this slow course of croupous pncQtnoniii tendiuf:; to become cbronic, but ending tinallj in recover}*, occnm more frequently in children than in adults. In the case JQSt given there can be no doubt that the croupous form was present from the first. In others, in which you see the disease only after it has lasted for some time — and therefore bave not observed its first development — it is often impossible to say whether It ortf^inated in the croupous or catarrhal form. Som^ of the cases which I formerly published^ as examples of ** chronic pneumonia " wore made doubtful in this way ; while in others the broncho-pneumonic character was clearly established.

These children were between 1^ and 4 years of age, bat I do not doubt that older people may also be similarly affected. They were pale, more or less emaciated and flabby, with an expression of suffering ; so that their whole aspect indicated the presence of a serious disease. Some weeks or months before — according to the usual history — the illness had commenced with m attack of ** inflammation of the lungs," which was either primary or the result of measles, whooping-cough, or typhoid- Ever since, there had been an obHtinate cough, shortness of breathing, noisy expiration, and a certain amount of fever. Verj' often to these were added anorexia, coated tongue, and dinrrhtra ; and then the emaciation appeared more rapidly. In most eases I have found signs of consolidntion in an upper, more rarely in a lower lobe; dulness on percussion, weak or indetermitiAte breath-sounds, bronchial breathing and bronchophony, a greater or smaller number of sharp rales. The accompanying fever has almost always the remittent type, but may also be misleading from its resemblance to intermittent fever, I shall oercr forget the child of a country gentleman, sent to me with ilio diagnosis of intermittent fever, but whoso emaciation » sliortncM of breath and cough, at the very first glance gave one the impt^^ fiion of a case of lung disease* On examination I found eouftoli* dation of the left upper lobe, the result of a pneumonia some months before. He was completely restored by spending two winters in the south. In cases such as this I have ropeatcnlly seen bloody sputum, although onl}- in the form iS — or

streaks in the muco-purulent matter, which during t nk

course of the disease tho children learned to expectormtc.

I ■

I

CHUOKIC PNEUMOXIA.

417

tu

I

xaminatioD sometimes reveals catarrhal sounds in the other

long also, and from time to time an acute catarrh is added to

the chronic affection, and must be treated very carefully. Under

euch circumstances we are always justified in sugpecfcing phthisis ;

d » certain proportion of the cases do in fact end in this

nfortnnate way, owing to caseous metamorphosis and breakin^^

down of the inflammatory products. But experience has taught

e that cases of this kind even when they seem quite desperate

tnay yet be completely cured. It moy, of course, take a Ion*;

time ; for instance, I hav*' heen uhlv to make ont the remains of

nsolidation after a full year, often after li— 9 months ; while

e other respiratory symptoms had quite disappeared, and the

cneral health and nutrition had been completely restored.

That hroncho-pneunionic couflolidation in particular may last

for many weeks — and even months^ — without becoming; caseous,

1 liavf repeatedly satisfied myself by poat-mortems on children

who had presenti*d the clinical si^^ms of broncho-pncumoniti

uring that length of time. We must therefore admit the

ssibility of the complete absorpt i o n of the fatlily dej^enerated

contents of the alveoli, even after such a long period. On the

)thcr hand the lung may become indurated owing to hyper-

•opby of the interstitial connective tissue ; and here the process

generally stopsJ The proliferatiog interstitial connective tissnt*

jgradually contracts, and the lung becomes indurated andgreyish-

hito or bluish io colour. In young children in particular, the

hole lung or lobe of the lung— especially the upper lobe — may

c changed in this way into a firm mass which creaks on being

t, and in which the obliterated bronchi are distinctly recog-

isable as white bands. When the disease takes this termina-

'tion, the physical signs of consolidation last, of course,

during the patient s life, unless masked by emphysematous dis-

nsion in the neighbourhood. You therefore generally find

hen the upper lobe is the seat of the contraction that the sub-

lavicular region on the affected side is flattened or retracted and

less movable on inspiration than that of the unaffected side.

Occasionally, however, there occur in children as in adults bronchiectases in the contracted portion of lung at

• 8tof f eti [Kimik der Kinderkj-amih, i., 8. 422) deaeriben tlicse procesw* under ft of '' intertititial pneumonin " and is of oiiinion that they mny oeciir both fho eaterrhal and in the 'Miffuse cronpoui*'* form, if thy conr«« i» protraotoiL

418

DI8EABK8 OF THE RE^PIRATOBl 0ROAK6.

the same time. The cases of this kind which I faaye seen sen ted exactly the same features as one sees in adults : — dulnois on percussion, numerous coarse and occasionally sharp riW» flatteninjj of the front of the chest on the side affected, high Icrel of the diaphragm, &c. ; and especially a severe spasmodic cough with copious purulent sputnm which was usually foetid and often mixed with, or even composed alone of blood.*

As to the treatment of chronic pneumonia, I have hut Htll*? to tell you. Our main object is to favour the absorption of the inflammatory products, and to protect the litLle patient from alt injurious influences which might cause fresh catarrh or inflain- nmtion, and might disturb the process of conti'action juat men- tioned, should such contraction be inevitable. IVotectfan fnmi chills and tonic treatment (by bark and cod-liver oil) are the most important means. Although I have eflected little or nothing with quinine — even in regard to the even tog rise of temperature — I have seen good resnlts from the uso of deooctlou of cinchona (Form, 23) continued for months; or from extract of i'inchona {Form. 24), I do not order more than two desfert- spoonfuls of codiiver oil in the day, to avoid causing dy- It is a necessary condition for the use of both these ni that the digestive organs be unaffected. For well*to-do people, the thing which ought to be most strongly recommended is residence in a calm, pm-e, mild atmosphere ; and aevend of my cases in private practice, which seemed at first to justify a very gloomy prognosis, were completely restored by j-. ^ - J A number of winters at Montreux, Meran, or on the i I

Nourishing diet is likewise a matter of the first importaiiico ; and also the careful attention to any attack of dyspepsia or diarrhoea which may tend to interfere with the soocaecfiii treatment.

In cases of extensive Bhrlnkiiig of the lung >*ith brop I have frequently used the much recommended ii turpentine ; but I have only found them yield slight anc quite temporary benefit, or even cause positive harm owiog U

• One c&fte of this kind iwith f»opiou« hirtT* • ♦- .1.,,., — i ;»> «,.. rrurd*

liron deNcribu^l l>y H. Hranii ».'* IMtiufj .

Kincle«a3t*^f." Inattg-Ih^^ : ii..,i.„ i>«i7). . .,, , . ;; .......r

the foriiiAtioti of lui iui f new blo(Ml*T««Kclii in ihut dUaM

which were dennJeU n.t ., an,] in ^lut^-t* of tbcir inuootsii

PLEURISY,

4H>

thtsir seittDg up a fresh catai*rli» which may even be accompanied by fever. I have seen just as little laBtiug result from other inhalations, or from the pneumatic chamber*

Vin. Phur'ny.

Pleurisy in chiklretj iliffers in no essential particular from the same Jisease in later lifi^ It is by no means rare. I have found chronic latent pleurisy, leaving behind more or less extensive adhesions of the pleural surfaces, in a surprisingly large number of the post-mortem examinations I have made in children in the first year of life who were not at all tubercular. I have also often enough discovered pleurisy with effusion in children even of 5 — -J* months with unmistakable symptoms and more frequently after Iheendof the first yeai*. Acute pleurisy withits shaqi pains, hort cough, quick shallow breathing and more or less high fever, in children in ever}* resi>ect similar to that in adults. Older patients localise their pains veiy exactly, while younger children mistake the real seat of the pleuritic paiii and frequently complain of the "belly," although on physical examination we distinctly nd all the signs of pleurisy. Under these circumstances percus- ion also helps in the diagnosis because it generally, like palpation of thd intercostal spaces, excites pain and draws the attention of the physician to the true seat of the disease. Little children who are too young to complain of pain cry when they cough and make faces* as if in pain ; but this symptom is unreliable, and at

!tliis age only physical examination can furniali us with reliable Criteria. Moreover, 1 have occasionally seen older children in prhom the pain was quite absent; €.g,, in a girl of seven who p.as suifering from severe febrile pleurisy with effusion (the whole left side of the chest being filled with fluid), and had not com- plained once of pain, r Acute pleurisy in children is sometimes ushered in by " cere - fcral" symptoms (vomiting, epileptiform convulsions); but far more rarely so than croupous pneumonia. This manner f onset draws away the physician's attention from the real seat the disease. AVe only find this sviiiptom in children of 1— /»

iars.

' Jpnm./, Kindtrh-nnk., B-1., xUi., S, 8, 184».

1*20

DidRAflBs or mz REs?iR^Tc»BY 0Ra.u:a«

Otto N .. 'U ye«w^ old. In the owl of Oetobw, Iftid, ii M on the foivlnMi<l foUowcrti hy ecchyiuosiH. On th»- • of 3fXli

Ortolwr. sudtloii Uif^h fever, whi<-h |>L'rsi«trfl tli le ni|^ht

and Ht 10 \.«. on the 'Mt^l am cpileptifortii sittnok t<>«>k pW' Aftor huJf Hn hour he awoke fr<jin his drowHiiir^K ; hen*iai*lr'", inability to sit ttpnght, or to hold the he»d erect. Fever firwiirt' ing, pulse 100, drowi4iuo8». Aljout 2 o'ehH'k. n Docoiid epilrfit* fonn nttiiek. Ahuui tl uVlcKk scjemorl nil right, at piny. Dutiul^ the night »*oiititmoiis fev^r, voriuted onre, li«'in»ine(l tiboat lb* Siamc till I'tth Novomher ; toi*enooii remiHsLun. «?%*eniii|? exacerla- lion of the fover with eircum8cnlicd reiliie^H of th«? loft ch»ft (KH^'AHionnt flight cuugh. On the ITtth for the first time I determined to exnmine the thonvx; for 1 had hithi'rto neglect^nil to do NO. Uj^iug then a very young nmX inex}M'rieneiHi pnirtitiooerftiHi full of il»e idea of meningitis. 1 itt one<r discovered a eoiwidemW* pleurilie effusion on the right «ide of the thorax. PoiTUi»»ioiidiiK. laterntly jind jiosteriorly over the lower two-thirvU. bnaii h-aouD*!- and voeal fivmitus qnite absent in this area, the intcrcoi<tal wjbmt^* difitcnded ; R. t>^', scartH'ly notic<mbk* on the right Hide; P. Ii4. Cough trifling, generally only in the eviiiing, eoniplaintft of pain ** in the Indly." Liver dinplnrril downManlN. C'liild always lie* on the ttflfeetod side. Urine aVtontbint, eluar. From loth to '27lK hectic eharnrter of fever, emiw'intion, iniirh perMpiration daring the night, (irudual improvement under strengthening diet uml tonie trwitnvent (deeo<'t. cinehon.). ()i» 22nd December lateritJ }w'tvu8ston almo8t uorrnHU |>oHtertor Htill ituttc dull ; breatb-'MiitDd* audible, increase of .strength nnd hulk, In'tter colour, teier enh- aiding. After 2r»th lKvend»er no more night-t>weMt'«. Hceide* thf rinehona, ol. morrhme. 2 de^inert-Rpoonfuls daily. On VHh January, lH+7, vermeil i|uitc welK pOHition of liver normal. stliU Honie imjMvirnuMU below the scapula behind- On l<iih Februnry di«»ehargiHl wtthtjiit any deformity uf the thorax of im{M>rt»nL*e.

Thifi oiioo, wKioh oecurri^d in tbo seoond year of my practicCr iinpr€*«8od 11)0 so much that frot]i that time forvrard I never uegWicd tbooxjimiurttion t»f thi> thorax in any fcbrilo disease, even when no siytnpionis seomiMl to call for it. I cannot safficionUt nrgti ibin upon vdu, for it was only thus that I manage I to atroid tbc wime error in some similar cases** The motbera stiitement —that the Kuuptoma arose innuedinUdy after u fall on the 1um4 — iH the very bi^i thing you should rely upon : for this e\phinalit»i

ifl one of the CoinilKtiifjit simpK because litlb" cluMn u un* nlwin*

falling*

i

Boy of I )

^j rUe bund 14 tlay* U'furc For

S«ir

in.

PLEURISY.

421

drowsiness, high fever with evening t xai'erl>atioiia> V. regular, rapid. Frequent spontatictms vmnitiriir. eiinHtijiation ; inability to hold the heud erect. Fir.«t examined on lUth Jnimary, 1875; thoracic orgnus normal. CesBatiou of the suspiriouB symp- toms after 0 days ; slight congh. Pleural effusion on the left side behiud and below. Ik^-ahsorptiou after "2 weeks.

Ofcto R., 9 years old, brought to the iiolyelinic on 17th M»«reh. Oh the previous afternoon a fall on the head. Heudaehe and vomit* ing ever Hince, especially on changing the ponitioiu Apathy, screaming during sleep. I'upilH normal. Fever; V. ITK), regular. Beiieiith the left scapula tslight impairment on pereuHKion with vehicular breathing, reaching round to t!»e axillwry line. Com- plained greatly of pain at this spot, especially on coughing and on deep inspiration. Teudur on percussion. Digitalis with pot. nitrat., 5 wet cups. On the 18th pain coiisideiiihly abated- On the 24th dulncsa atill continuing, distinct frietiun-soutid. On 21st April ever)^thing normal.

The preliminary brain-symptoms appear tht-reforo, in icb caties, either in the form of lieadachc, vomiting and obstrut- ion, drowaineas and delirium ; or else, in little children* as epileptiform convnlsions similar to those in cronpou.s pneomonia. [ere also the high temperature seems to be the cause of icsc symptomB, since wo find that when it falls and the signs of LUdation become more distinct^ the brain usually bficomcs clear, [ore freqaently the diBease begins with gastric fivrnptoms which may mislead the physician for daye—naUHea, anorexia, lickly coated tongue and complauit at night of pain in the >dy ; and to these jaundice was added in the ca«e of two of my ttients (of whom one was sufteriug from pleurisy on the l«'ft le). A hoy of three years, who had been ill for a week past, ►mplained of pain ld the left ingninal region, while the left half of the thorax was completely iillcd with effusion. In all these cases there were however at least some morbid phenomena which caused anxiety to the parents and led them to Beek medical aid. Those cases are more difficult to recognise which develope sub- acutely or quite gradually, and run their course without any striking symptom of a serious respiratory aflTcction. Cases of latent pleurisy are, as far as my experience goes> more frequent in cliildren than in adults, probably because when tho latter feel ill they get themselves examined ; while in the former, the symptoms, being apparently trifling, ai*e overlooked by parents 10 are not ovcr-carefuh

422

DISKABES OF THit SXSPmATOBT DB6AKS.

Elise B.. 7 years old, hud mcanlcft in aatamn, niuiittif; s |icr> fcctly normal course. In the middle t)f Janunrj the child, who had hitherto been perfectly healthy, began to get feverish cnfj evening, and during the night she wan very hot. thirnty, re^tlcM, and short of breath, while dnrui^ the day she Hocmed pretty wdl. The appetite also waa gradnally lost, atid the ehil<! berame pale. I wa« called in for the first limo on Tith Febrnary. On the h'fl aide from the fifth rilj downwards, t'specinlly hitcntUy and posteriorly, percussion-notc quite dull, nbseueo of brcMth-aauiid, and vocal fremitus ; higher np. puerile breatiiing, lie»pir»tory movements uormaL no cough, no pain; still, when Talked her the child remcmbored that she had geveral tinier felt a jtlighl sStitch in January. Treatment : rest in bed. wnrro ponhiofw to thi* affected side, infus. digital, with pot. acotat. for the souitjr secretion of urine. On the 10th, profuse diuresis, no marr ferw, pcrcusaion clearer. On \si March, cvcrythiiig normal mud tha child Heenied quite well.

in this and similar casos, the parcutn' ueglect was io hlinir. H specially in youiif? children the iuoffoiisive " tc*eth *" are made answerable far the ilhieas, until after woeksiucroasiugeinaoiatioiii shortness of hreaih and cough at lani occasion anxiety and the physician is consultoJ. I must, Iiowevor, unfortunately add ikat in spite of all warning examplcs-^f which 1 have publiahed scvoraP — inexplicahle mistakes are always occurring iii thifi insidious form of pleurisy, even on the part of medical tueu. tl is not ignorance that wo bttve io find fault with, but rather indolencei the shrinking from a thorough examination, anil ibe idea that with such trifling reapiratoiy symptoms no serious disease can exist in the thorax. The ''latency*' of the pleuriav JK owing, not to the nature of the disease, bat l4» the carelessnesH of the physician. EHpocially oflea I have met with such cases in practice among the poor and in children who had ftttendcd a polyclinic— where the large number of the patients is apt to lead to oflf-hand prescribing without I'areful examination. But even physicians in private practice gntlty of such sins of omission.

On Oth Nuvember, 187i^, for cxaniplct a jmU' liuU ' -raa

brought to my polyclinic, who had taken ill with b it 8

days befoit', and who hud Ux'U referred to the ho his

dtx^tor who was well known to mc us conaciealionti t ^.ch^

eould not make out what wm the tnatt^r with bimn^ Tbiapfie*

I

* /0mi^/,Kimit*rh

\ tw Kindgrhti^.^ S\ /% i. 117.

PLEtJRISY.

423

tittoncr acknowledged to me afterwards that be had not exanfuied ihe tliorax even onc<?, bocaudc no symptom seemed to point tit it. lere was certainly no pain at all, and only a «^[uite trivial CiKi;^li ; but the respiration w^s somcwliat r^tiitkened and u rise of temp, took place twice dail}-, Ijctween !)^10 a.m., and bittweeu 5 — G i\M. On oxamination we found the whole left plenml cavity filled with effusion, puphing tlio lienrt to the right. On 27th BVhruary, 1871, there was still some eflujiion to be made out at the base fjehind. Still more blame attached to the phy&ician of a hoy of 4, who Imd given an entirely false explaaatton of the bulging forward of thr chent which was filled with pleuritic exudation, and had declnred that the child must undergo a courfio of orihopsedic treatmpnt.

So miicli for the peculiarities of tlie general course of the disease. In the matter of physical signal, which correspond to ^those in adults, I would only point out the frequent occurrence kf b r o n c h i a 1 breathing in the pleurisy of children ; which , as we learn from post-mortems, occurs without pnetimonic complication, and is simply cnused by the effusion compressing^' the lung* Those who are interested in exphmations, will find ihcm given by Rilliet and Jiarthez,* and Ziem&sen.* I

I shall here only insist upon the fact that especially in recent bases, bronchial breathing is almost in variably heard over those parts of the thorax which are dull, and that only gradually, as llio effusion increases, is it replaced by weakening and tinally fcy complete disappearance of the breatli-sounds. In little Children, therefore, the absence of sputa and the difficulty in making use of the vocal fremitus for diagnostic purposes, always renders it doubtful whether pleurisy or pneumonia is the principal disease ; while in older patients the above-named points Qsually enable us to arrive at a diagnosis. Should bronchial tatarrh happen to be present in such a recent case of pleurisy, lie mucous rules sometimes assume a sharp character from com- pression of the lung tissue, and may — specially in exhausted jverish children — excite a suspicion of phthisical cavities, which kinis out later to have been unjustified. In purulent pleurisy In children especially, the first and second intercostal spaces (in front and close to the sternum) where they are widest and most yielding— often appear abnormally bulged forward, as has Ih-cu Jiorne out by the recent experiments of Kivet* (injection of

•• tjoe, ai,, i„ p. 555. • Loe. eir., S. 71.

* ** Do la Toniwura «ou»-cliivicnlaire dans \e» ipcxtohementB ploui-«u% cliex ifant/' TkrM: Paria, 1880.

424

or THB nB8ni4TOST oaoA^s.

wster into ibe Uionx). Tbe hei thai Ihis regioa is Uu) i|H where ntptsie moBi freqaeoUy occurs agrees with this observstioD.

Motl children with pleoritic effneion lie, as adults do, on Ih^ affected aide. This ia aeen efteo in little children in the iM jear of lifie ; and this aeconnts for the fact that inJanta wtu pleoriay prefer to take whicheTer breast allows them to lie on tha affected side when sucking. I hare obsenred that children with efihaion in the right plenral eayity would onlj take the Irft breast, and rice versd ; otherwise their sucking waa intermpted bj Tiolent dyspncea. In one case of this kind the mother even inade the mistake of supposing that the infant's preference for the left breast indicated something wrong with the right.

Amongthe complications of pleurisy, pericarditis scema to me commoner especially in ver>' young children than in adalt«. In one child of 5 months, I found, besides doable fibrino-puruli^fit ])Ieurisy, a considerable effusion of a similar character in the pericardium. In another child of 8 months who had broncho* pneumonia, especially in the right lung, I found coosidermble pnmlent effusion in the left pleura and in the pericardium, the visceral layer of which was cohered with villous deposits of fibrin, especially on the front of the heart. That tbere had been in this case an extension of the inflammation firom the lelt pleura to the pericardium was proved by the firm adhesion of the outer surface of the latter to the left lung. In the following case, however, there was an old loculated effusion in the right pleural cavity, complicated by clironic pericarditis and endo- cArditifl.

Eloonore P., 3 years old, admitted into the ward on I8tb Hcptember. Poorly nourished, pale. No history whatever ob- tniiiod. T)io right Hide of the thorax dull on j>orrtiA)sioii over }ilmo8t itH whole extent, with the exception of i\\v ii|jp#>r part in front, which gave a somcwhttt clearer not<», Sternam »nd Irft half of the chest normal, Tlic bi-euth-^oinid quit*:; ab(»et»t on tb^t HKht. Injhiitd aiid lit the side; iudct^jrminate over the upper froot with hronchial expimtJon. Right half of the chest I in. narrower than the left, scarcely elevated on breathing. On tho left etide liehind, some nonomna rhonchi. Cardiiw diilnesK somewhat gs* largt*d towurdM tho ri^ht^ ttiH>x-ljeat in the fifth intf'rco«tal space in the nnkmuiillury line, loud oystolic njurmur at th** r»fWT. No fever. IHnj^noj^ix — inromjwtcnce of the njr loa

of the right ventricle, old fibrinous pleurisy I . ith

rontrartlon o' *e cavity. It* tho coumo of tbo next Um

PLEUBIBY.

42;

montiis the elii]tl'«i t^niditioti bccfttne sti'jidily more ^^reithcMl owiTig to i-epcatcd attarks of iiiteBtinnl (.Htarrh, The bronflual catarrh also underwent exacerlmtions from time to time witli (flight riaoa of tempemture. After 25th Jainiary, 187ii, imictjus spittuni mixed with bright red lilood was sometimes cipeetorated. utid at the Hame time verj' distinct sharp rAles. loud bronchial breathing aTrd bronchophony were heard on the right »ide above, near the fitcrnttm, and abo above the clavicles where the per* eusHion-notc was somewliat elearcr. In the last days of January i^he developed typh^nd, whieh ended fatally on 7th Febni»ry-

P.'M. — Fij'ni adbe>ijnti l»etween the pericardium and left lunjr, lliei former thickened, lioth layers finnly adherent to one luiother Mitral valve thickened, stiff nnd incompetent, ]Htth ventricle.** hypertrophied, the rij?ht also dilated. Old librous patch under the endocardium I in. below the aortic orifice. Almost th** whole of the left lunf< vaficular, brown ish-red. Right Um^j much diminished in .«i/e, presHed upward and forward and ai, thia point adherent to the pericardium. At its lateral and pos- terior mari^in an enormous sac with extremely thick and ton{i;h walls which was ho fri-mly adherent, on the inner side to the lutijz. and on the outer to tbo ihomx — tli;«t it Imd to be sepai*ated b\ the knife. In its interim- it contiiincd a quantity of ci-enmy, greyiBh-red matter. The left lung was densely carnificd. Catarrh of the lai^e bronchi. Typhoid.

How the pleurisy, in tliis case, came to be complicated with pericurditis, it m impossible to say. What Wii found was only the result of tbese chronic diseases — the firm ftdheBion of the pericardium to tbo heart, incompetctice of the mitral valve with dilatation of the right ventricle, and a considerable locnlated effttsiou enclosed by a thick membnitie. The retraction of the whole right lung forwards and upwards which seemed to he caused by old adhesions between it and the pericardium^ in thi« case gave rise at the time to an error in diagnosis. For I thought that the bronchial breathing and Rhnrp nllcs heard after the 2Gth January over the upper part of the lung anteriorly, taken along with the bloody expectoration , must be due to the presence of a cavity in the upper lobe^ while we found on post- mortem examination that these phenomena were simply caused by catarrh of the right principal bronchus and by the dense camified lung which rested immediately upon it.

Caries of the ribs is more frequently a cause of pleurisy

in children than in adults. Of this the following case is an

inioresting example *: — I • chnrttiAnnaft^.l. jnhri?., 8. 586.

Pir.

DISEASES OF THE BB8PIRAT0BY ORGAK».

Margaret he M., .^ yeW9 old, admitted on 15th April. She liftd hiui iiumerooE absees&es of ibo counectirc ti^ue over Kirice hirth, anaemia and atropli}-. On adiubi!i»ion enormous ulnt^r an th<i<' sCttlp, abscess the sUc of an aj>]>le ju*.i under the sacrum, ? enlarged glands bi the nec^k and iu the inguinal region. m of the nbHcess, Tvhich healed by 3rd Mhv, The? ulcer on tUo iwadi ■ gmdually cicatrised. The child waA froc from ferer, very }ialf anil weak. Fresh abwc^eses formed iu the neck up till Gth Jntie and were opened. On the 7th June. elo»c to the right breast u roundiiih Bwelliiig, rather more than an inch in diameter, not ix'ddcncd bnt fiuctuating, which gradually grew to the siizc of an apple and waa opened under tlic spniy on the 20th. From X.h\n time Kigh temperature (evening lOl'S"^ — 1(^2'9° F.), which, however. WAS absent for d^iys at a time. Close to the right Mhonlder* blade a new abs^cess of considerable si»e formed; opened 11th i July, and a carious rib was fiilt by the proW. About the i*a.mQ time we found on examination, so far ah this wim prac- t icublc on account of the swelling and painfulnesa of the aftcctcd part, duluess over the right side of the thorax both in front and Ix^liind increasing towards the Imse, abundant cix>pitationa. snoine of which had a nharp character, and indetenninate breathing. On the l*>th vTc obaerved for the tir^t time tliat on deep ex cflpcciully on crying, a tpiantity of pus bubbled out on to : from the abscess wound, mixed with a large qunntity ol a if J hnbljlci<4 Thii* condition continued till licr death on \i^h August.

P.-M, — The vith, tith and 7th ribs on the right side carious; l>etween them (i.<?., within the intei*costal spaces) there wen* a few openings the size of a pea through the costal pleura into a cavity* i IViiciirdium completely adhei*ont to the heart, and right] lung to the pericardium. The right lung ff-lt ver^' tough and J was adhf^rcnt over its whole surface to the chefit-vval]. TVie | pleura ei>stalifi and ptilraonalt:!^ form thick indurated masses of fthrouif tissue. In the immediate neighbourhood of the absccsf- wound on the thorax, there was thn already-mentioned cavifv f»itnnt«Ml between the the two layers of the pleura and filled with about tl tttblespoonfuls of purulent pleuritic effusion. The pub nnuiary jdonra in the neigbboorho<>d of the nmty was wanting, >»o that a probe couhl be passed directl}' into the small brcmrhl Almost tbe whoU* right lung carnified.

The extensive caries of tbo rilis in this case evideinly fonucd the Htartin^'point uf the iibBocsses near them am mn uud shoolder ' blade ha wt'U uh of thu chronic pleurisy. Besides tbe adheHion^ iitid libroUH iiiembrnneB, it gave rise to the cavity filled with puH which commanicntiMl on the outnido \\-itli the nbucess in thr iheMtwnl), uLid fioully^Mtfi had pciictrutcd ih« palmooiinr

PLEURISY.

427

^

inwards by « process of necrosis. In tliia mftniter air was enabled to find its way out of the lung into the cavity aud then outside along with the pus of the abscess. The tirm ;4dhe8ioBs which surrouinled it prevented the occurrence of neumothorax. Here also the inflammation spread from tho leura to the pericardium and cause J complete adhesion of the two layers of the latter to one another and to the right Inng/ I In children tuberculosis and pneumonia (cronpoua more often than cntarrhal) arc also important factors in the causation of pleurisy, "WTien the two diseases are combined, as is so commonly the case, the pleurisy as a rule is least important, and indicates its presence only by pain and by slight effusion at the base (p. 407). Still cases do also occur in which pneumonia, wkich at first was the more promineut condition, yields place to tlie pleoriay, and it clevelopes further and leads to a more or less coDBiderable effusion (pie uro- pneumonia). How rapid th*? pus-formation under these circnmstances may he is shown by the case of a boy of 5 from whose right pleural cavity more than 35 oz. of pu8 were evacuated by puncture on the 6th day of the disease, In hroncho-pneumonia we find when both sides arc affected the pleurisy also is not uncommonly bilateral, both lungs being covered with fibrino-purulent deposit, also perhaps purulent exudation being present in both pleural cavities. Putrid pleurisy I have only observed exceptionally in children (apart from cases where the discharge became offensive after operation), e^g, in tho following case: —

Anna 0,, 11 years old. trwitt^d in the ward in Mivy for pleuro- pneumonia of the left side, diacharRed 26th May. Re-admitted ini 4tli Jane. Rigor 5 days l>ofore, since then persistent fever, cough, pain in the left side in which a conaiilerablo effnsion cotdd be made out. T. 103*1'^ F., R- U, R 124. The left sido of tlie thorax scarcely rose diiniig breathing, 'nie iiitercosli*l Spaces filled out, dulnesw on perciisaion ulraost all over, bronehinl breathing, no vocal fremitus, dulness over the sternum, heait sounds audible roost distinctlj* neur the right border of the tit«riium. Urine scanty, hut otherwiHC normal. Wet-cupping, wet compresses round tho thorax and digitalis were practically

Wo miwt not coitfound with th*BO cases those in whleh pnmlfint plooriwy

farms tbi» pdnuury difieAso an<i carios of tho ribs only arii»e« secondarily ftud

iDfty then lend to aboes^eg in tho chest wall and oomnmnicfttion with th« ploarjil

««Tit/. cy.t *<?^ A ciwe of diaphmgniafcio pleurimy from nij ward, dQflcribed by

aeabasch in the Deri, lUn, ir»>fA«iMcAr, 1883, No. 41.

PJSK&fiSS OP THE BSSPOUTOBT OBGAXB.

On tlie loth owing to the iucreaatDg dyd|)n<m, the* thormx wms punctored with Potain's syringe und Hi uz. «f l^nKntsk-jelloir offeusiTe pus eTxtcuated containing numi:Tou»^ patrcCactive liacteria.. Altbuagb there now ocenrr<*d a partial rr* ' , t'Xpan^ion of the lungs especiailj of their upper part, and the rcfpwj sank to 3^ the fexer still perBisted unchanged and therefore <3ni the l;Hh the radical operation for empyema wa« jicrfonnod, a ' silrer canula was inserted after evacuation of 174 os. of off enai?!* pus and the thoracic cavity was syringtHl out with rarlmtic lottou. Fever now di^ppeared at once (T. 98 6'^— 9i>5° T-U and aftfp t\ days the diaebarge frc»n the pleura was odourless. On the othc^i hand the coi:^ increaaed considerably and the copious grtyish* i yellow, tough, somewhat sweetly-smelling sputum contained din* j tinct elastic fihrcja. On aocouut of the blackish colour of thei unue a Holution of salicylic acid (3:100(») was used fur washing j out after the l->th tiij^tcad of the carbolic lotion, and the tbonbricj wound trc&ted with strict antiseptic precautions. During Ihej next few weekj^ a rifcie of temperature was observed on sevnwf ' occa&ions without any evident cause; for example, on ^h July H.>4i^ F.» but ftftf r ibis attack the child remained quite free fnna.. fever until her diiicharge on Ist May, 1879 — that is, aliout a J^ttrl after ber admi^jsion. The wound on the thorax, from which thttre ] was always a flight dij^charge, closed in Angttst, the general nutrition and health were restored gmdually, and the rate of lireatbing wan soi>n only 20 in the minute, the pul»c 108. While on the front and on the upper part of the side and bark the physical signs had become normal, the lower part of the azillarj region and the liack from the spine of the scapula dowuwarda stiU 1 remained much impaired, and bronchial breathing, 6littr]> ralcM and friction were heard there. The cough also continued with rtsrs trti* ' severity and the eijK'ctoration, which varied in quant r blood from time to time. On every occasion when i the ckild wa* kept in bed for a few days. Elastic fibres. ' wi're no longer found, and on the l»t May, 1879, the patiL:-. _^ lUacharged in very good health, free from cough, but etill with duluees and bronchial breathing in the region of the left lower lolic. The treatment during the last months consisted of inhala- lioii« of carbolic lotion ( 1 |ief cent.), ol. morrhuaj i and pliunli. acH., whenever hiemoptysi^ occurred.

This cast.' was, iu fact, ouc of a circamscritied |Miteh of gHJigrenc at tbc periphery of the poeomouic portioo of ItiR;;. from which tbc germs of putrefaction had fotmd their way into | the plearal cffusiou, atul hud ciiii^ed tt to become putrid. The j fact that neither on phv-* -^ .v ,..wr..if;..n n^^^ when the pandimJ wiis made could ptrn uh* out, t« agtitist tlir^

existence of a Urge com\r 'ic pleural cmvitj

PLEURISY.

4*2i)

niul the gun^oiious pulcli. On tlio other htuul the hypothesis of fiue op6uin*<s iu Lhc pleura of the affocted lung, which hail

I Inter on become elosed hy aflliesions, is more probahleJ After the fur(^ of the putrid ])k'iirisy hy pimcture tmd iucision, the necrotic patch in thfs hnig lasteil for many moijl]if<, and indicated 1L8 pret^ence by repented rehtpses of fever, and hy purulent sputa mixed with hhiodand ehistic tirtstie. At hist reeoven* took place, f»nd Dothiug renmincd hiU ph^sieal signa, which were to he nttrlbnted to an an*a of much-tlnckeued pltmru at the lower part of the left fiide ol the che^t. As I learned later, the child died a year afterwards from an inflammiitory ehest afTeetion. On the

■ other hnnd I have in private jjructice seen a boy of 9 years with n copious right pleuritic effiiBion following pneumonin of the right npl>er lobe, who became very feverish for some time, and began suddenly to expectorate putrid purulent sputum; an inei- biott waa at once made into the thorax, and the pleural cavity

I was treated antiseptieally, and complete recovery finally took place. The chanicteriistic expectoiafion proved that the putrid character of the efl'usion had resulLed from the entrance of septic germs through an opening into the upper lohe of the lung. I have repeatedly also observed pleurisy in children reHulting from acute articular rheumatism, scarlet fever es|K»- cially scarlatinal nephritis, and measles. One of these cases, in which a diagnosis was made only four weeks after recovery fmm measles, was distiuguislied hy complete absence of fever (temp, never alvove 90'5 l'\), although on two occasions more Ithun 15 oz. of greenish -vol low pus were evncuated by puncture. Only once, in a girl of 5, have I seen a purulent pleuritic eirusion in the course of whoo]>ing cough, as the result of a concomilani hmncho-pnoumonin. On the various t e r ni i n n t i o n s of the disease — re-absorption, suppuration, bursting of the empyema externally or internally — and on the resulting defurmity of the thorns, I have nothing new to tell you. The former belief, that deformity of the thorax occurs less frequently in children than in older people, is a mistake. On the contrary, we observe considerabh: rel ruction occurring on the alTected side after insidious purulent elTusion** which fioally burst externally and form suppurating fistulaj 1^ la-i^ting for years, as well as iu cases where there is a formation of

^H ♦ fy\ A, PrBukol, " Uebrr jmtritio Plenritia," Ckaritr- AnnHftn^ i%\, I871». S. a5<i.

430

TklSBASMB or THB IlE8J"IJUTaRT OIlOi3(S«

thick masses of fibroas tissiie between the long luid the cliesl* mdL In a bdj of 14 who had suffered &om plearisy Id his 5th r* I could fill np the whole right pleoral cuTity with my fist.

FibaUt, a few words on treat men I. At the beginciDg of the when there is Tiolent paiu, I consider wet-cupping (the number of cops Taiying according to age), and in weak children, dry-cupping. Next to capping, wet eoiopresses, sQch as I recouunended i» pneninoiiia, are to be used continuously* while we gire intemallj digitalis (Form. 2^) with nitre. Also calomel along with digitalis (Form. 25) is aBeful, especially when there is eonstipation. When the efl'asion increases, diaretic ireatment becomes important, infusion of digitalis with acetate €f polash and Bilin or Wildnng water (8—4 wine- glasses daily) to drink. In the very chronic cj»es, I would recommend decoction yf bark ^Form. 23) with acetate of potash (grs. xxx.), codlivcr oilf whey^ fireah country or mountain air and, daring the winter, rvndmeo in the South, especially on the Riviera.

The gDMter activity of tissne-change in children favours rcabeorption of serous pleuritic effusion generally, more than 18 the case in adults. I have» indeed, reports of a very consider ^able number of cases which recovered perfectly well without surgical aasisiancOp under diuretic and tonic treatment, witUtu some weeks or nM>nths. We should not, therefore, be in too great a hurry to oi>erate. For my own part, I recognise only two imlications as urgently cAUiug for the eracuattoa of the flaid.

(1) A rapid increaae of it, with ocnte displacement of the mtMliAsttnam and considerable aggroYation of the dyspooM^ so that the children are no longer able to maintain the horisontal position for any time, but are obliged often to assume a sitting posture. Under these cii-cnmstances, especially when the effu- «<^ioti is on both sides or when there is a complication with bronchitis or pneumonia, early punctnre is indicated in order to relievo the lung fn>m the pressure of the exudation. As a

le, the Uuid mpidly re mrcumulntcs, but we vnn in that case

a the operation if need bo; off if the symptoms are not

»re» we may qaiotly await the re*a]>sorption of the dnid.

(Jirl of 7 y<*ar^. examiiKMl far firrt limp on 6th July. Fe abciut U wookft acutv plourijiy of ib« left niAtt, wttic^i IumI run it>* cournc from the Ijegiiiniug with*' Tbr Idt itido of

PLECnigY,

4U

I

thorax filled with fluid, ami dull note over the sttemnin. The heart displaced to the riKltt, the left lung !«.ckwards and upwards. Ill front* bronchial breathing; at the side and at the base behind no breathing audible at all. Fcvorvemittont, M. 101 7'^, E. 103*5^ F. and over. In the licginning of the third week of the illness, incroaac of the dyspnfpa, frequent sitting'Up to get breath, pulse small. On the 11th, puncture under antiseptie precautions and evacuation with an aspirating ayringe, which was four times filled with eleiir» greciiii^li serum- During the next few diiy?*. until the I7th, the temperature remained high (1<»4^— 1i>2<j° F:}. while the effusion again increased considerably. Then rapid re-absorj»tion, improvement of general health, diwapjiea ranee of fevei". After the 22nil, free from fever. Reeovery. The defici^jut diurenis w:is eon* siderably improved by infus, digital, and Wildung watiM-.

In tills case, therefore, oiio pancLorc and nspiralion sulliced for tJie cure, and in serous pleurisy I liare frequently observed tbi8. It is also worthy of notice that, although tlie serous ciTusiou rapidly re-accumuhitcs after puncture, the dyspnarie symptoms do not reach the same degree as formerly, and the respiration usually get rapidly iuto its ordinary way of working after a few daysi as if the removal of the pressure frora the plenra by the single puncture bad restored its power of absorption.

(2) The purulent nature of the efl\ision (empyema). The points which were formerly regarded as decisive iu the diagnosis of this condition, e,ff., tho so-called '*cedemu laterale " of the thorax, are almost all valueless. The latter, especially, is very often absent, and is not observed until the pus has already begun to burrow its way outwards, and fomis a localised bulging of the thorax, which is often surrounded by blue distended veins (empyema necessitatis). When this exteriiul rupture does not take placo, we must attach importance to the character of the fever. A persistence of the fover for weeks with afternoon and evening exacerbations, with emaciation and loss of strength, is in favour of the purulent character of the effusion. But even this symptom is not constant ; for, as is shown distinctly by tho case just given (p. 430), the fever may Inst for at least *2i weeks, with afternoon and evening rise of temperature, and yet tho effusion be entirely serous. On the other hand, however, the fever may be quite absent in purulent effusion ns iu the case of empyema after measles given on p. 420. I have records of a whole series of cases of empyema in children between 4 and 9 years of age where there

4d^

DISEASES OF TBE RESPmATOBY ORGAKS.

was absolutely no fever. In a few, indeed, the lemperataro varied between 97*7° and 98*8^ F. The only certain means of recognising the character of the effusion is therefore the explora- tory po net ore, which maybe made without any danger ondef L antiseptic precautions, either with a hypodermic syringe, or li better, with D i e u 1 a f o y ' s aspirator or F r a e n t z o T s trocar, A« soon as the aspirated duid is found to he parnlent we roast gi^e np expectant treatment and undertake nrtilicial cracuation. Further delay might result in rupture of the empyema through the chest-wall or into the lung, and exhaust the patient by continuous hectic fever, or, in the most favourable case, lead to the drying-up of the pus and to caseous matti*r being left in the thoracic cavity which might later act as the starting- point of miliary tuberculosts«. The method of evacuutiou is still II matter of dispute. Every year increases the number of examples of complete recovery after one or more simple ])unctnres. Thus, in the case given above, a single puncture was sufficient for the cure of a serous effusion ; and in the same way I hare also seen in three cases of purulent effusion (one of which was after scarlet fever) the same good result from th procedure without the much recommended washing-out of thorax. The quantity of pus removed in these cases varied from 21 to 52 oz. We should, therefore, always in children begin by trying this mode of treatment. I always use Potain's nspirator, and I can recommend it highly, especially for nse with children. Usually the effusion increases again a few days after tbo aspira- tion, but afterwards it remains stntionnry and at last gradually retrocedes. It is, however, only in a very few cases of empyema that this proceeding will suffice, and after repeatiug it once or twice we see onrselves at last obliged to have recourse U) the raiUcal operation, that is, to opening the thorax by incision, with resection of a portion of rib. As I have already remarked^ I have only in three cases seen a lasting result from one or two j)uncture8. In all the other cases I was obliged to incise ; and any one who has once seen the mui^ses of coagulated fibrin saturated with pus which are removed from tho thoracic cavity by this operation will readily understand why aim}' ntt is

almost never sufficiont. We will best obtain ouU ^ i... .Lepita by making the incision over the base at the back or in iho axilla, and by introdi < < ingo tube or wide silver coDnla.

TUBERCULOSIS OF THE LINGS,

4d3

^A ooanter-openiDg in front is also of great use, especially in

those case§ where we have to remove a large quantity of coiigu-

^^latcd lymph* We endeavour as far as possible to prevunt the

^■jentrance of infectious elements into the thoracic cavity by apply-

^Hlng an antiseptic dressing, and changing it as seldom as possible.

^^ On the other hand, the washing-out of the thorax with carbolic

lotion which was sometime in favour has fallen into disrepute,

owing to carbolic acid poisoning having been observed, and for

I this injections of thymol, horacic and salicylic acids and chloride

^^of zinc have been substituted* These also, however, arc to be

^■liscd as little as possible, unless there is an offensive odour which

^^chIIs for them. The success of the operation — especially in

children^ — has been proved by many cases, and I regard it as

unnecessary for me to give in detail my own experience which is

in favoar of the operation being performed even in apparently

I desperate cases. I cannot impress upon you too urgently the

importance of performing the operation without delay, as soon

as the purulent nature of the effusion has been established and

simple puncture, on two occasions at most, has proved insufficient.

Should the exploratory puncture reveal a putrid effusion, the

radical operation must be undertaken on the spot.

I

IX. Tuhercttiosiit of the h\tng».

The difference of opinion among anatomists as to how tuber- culosis is to be regarded^ especially as to its connection with caseous processes, is not yet fully settled. While one party, supported by Virchow, sharply accentuate the differences l>etween the two conditions, the other — especially the recent French writers (Charcot, Grancher, cVc.) — take a more inter- mediate position which, as I believe, is borne out by the clinical kcts. Unprejudiced observers, and especially practitioners, annot overlook the fact that a clinical proof of the essential onncction of the two processes with one another is furnished y the frequent association of miliary tubercle and caseous egeneration, as well as by the fact (also proved experimentally) at tho former develope from caseous deposits elsewhere ; and tich clinical proof has greater weight than all the results of icroBCopic examination. This proof is far oftener afforded by ildreu in the first years than at a later age. When I recall the

4U

DISEASES OF THE RESPIRATORY OROAKS,

uumborless cases in which I have found miltar)* tubercles in dff^' \un^ or plenra close beside cAseoas patches in the Hing tissue^ or those in which there were miliary tubercles of the pia mater in the immediate neighbourhood of caseous nodules iu Uie brain, while at the same time both conditions were met wiib together in many other organs also— I cannot believe that there is any essential difference between them. Since R. Koch, \he discoverer of the tubercle-bacillus, has proved the occurrence of this pathogenic element in both morbid prodncU, I feel myself more than ever justified in including them both under a common description in the following account.

The s3'mptoms of tuberculosis of the lungs in children wW are past 6 or 7 years of age correspond so entirely with those of later life, that they call for no description here. We shall eoo- corn ourselves, therefore, mainly with the occurrence of the disease in the first years of life, during which we very uflen have an opportunity of observing it, espeinally in practice among the poor and in hospital. The younger the childreji are, tlnj less as a rule does the clinical picture of the disease correspond to that of phthisis pulmonum in older people. For, the local affection remains more or less insignificant in comparison with the general disturbance of nutrition which presents thit Hymptoms of atrophy already described (p. 78), On exatnitt- ing the bodies of little children who have died iu a state of atrophy » I have very often found a large number of tnberrlrt and caseous deposits in the lungs which had remained entirely latent during life, I have also found large cavities occupying the greater part of a lobe in a few children who were only gome months ohl, and who had presented nothing during life bat a progressive emaciation and debility and a slight cough ; so that it was only the examination of the thorax that revealed the advanced destruction of tissue. The fact that the diHt * at

the general nutrition is so much more prominent than p-

toms of local disease, is especially due to the fact that in veir early childhood tuberculosis is generally much more widely distributed than is the case in later life. Caseous depiiaits and nuUary tubercles are almost always present at the samfl time in a large number of organs— in the lymphatic glajids, the spleen, the serou^M||^ne9, the liver, the Iddaert, the bouesi &c. Indi|^^^^H|p[tt£in which scarcely ft «iti^«

TLiBERCULOaiB OF THE LUN08,

435

organ is found free from iiibereular depoBits. All tlies^ changes

may have a more or lens latent course* The main symptom is

atrophy, steadily increafiing from week to week, and this in

many cases is comhined with otorrbcea, et^zematoua eruptions on

e head and other parts of the body, enlargement of the cervitral,

occipital and in^inal glands, often also with multiple (so-called

cold) ahsccsses in the Buhciitaneous tissue. Sint-e, however,

these concomitant conditions occur by no means exclusively in

inbercnlar atrophy, a careful examination of the thorax, even

, when the cough is entirely absent, is indispensable to

I establish a diagnosis.

^H "l^his examination presents far greater difficulties in the phtliisis ^K>f infants than in that of older children or adults. Sometimes ^Bre find nothing abnormal, except harsh breathing or catarrhal ^'ralcs. All signs of consolidation may be absent, and we should I not therefore be justilied in diagnosing anything beyond a chronii: ^Hbronchial catarrh, if it were not that atrophy, Lercditary tendency, ^Hpr enlarged glands, made us suspect that this catarrh was tuber- ^BenJar. In many cases, however, more extensive broncbo-pneu- f mouic patches occur, which under the indnence of unfavourable ^—ikjonditions {i.e., the presence of the tubercle-bacillus in the lung) ^Hsaseate, and then present the ordinary physical signs of consoH* ' dation (duiueRs on percussion, indetermiuate or weak breathing, prolonged and harsh expiration, bronchial breathing, broncho- phony and sharp rules). In later life the development of phthisical rocesses in the Inngs generally takes place from ahove down- rards« and hence the limitation of the physical signs to the upper lobes and their apices gives as valuable criteria for the iagnosis of the early stages. In little children, however, we not ncommonly End an irregular distribution of the tubercles and seous nodules through the whole of the lung tissue ; and on examination of the supra-spinous and subclavicular regions we find but little, while the lower lobes on the other hand show signs of consohdation ; or if these are absent, only catarrhal signs re found throughout. In*egular variations of temperature (which ome less extensive as the child becomes more colkpsed) and dyspeptic symptoms, anorexia and especially diarrhcea, are fre* qnent complications, and are tlierefore all the more likely to mislead the physican. For since — as we have already seen— extensive tuberculosis of the long and even cavities may exist

436

DIgEASEfl OF THE REdPnUTOBT ORGANS.

without any coDgb or marked dvspnoea, the diarrhcBa is thas ftll the more likely to draw our attention away from the respimlorF organs, and we are astonished to find at the po^t ' m thst

ibe principal changes are in the lungs^ while we ha <i.ed to

iiDd them in the intestinal canal. A few examples from vm f^arlv childhood will illustrate to von what I hare been snyiug.

Otto F., 4 moiithe old, hand-fed* Since the Hth week of life, multiple aljsceB^eF over the whole body. For the last 9 weeks increasing atrophy^ and flahbiness, little appetite, cough and »hott breathing. Percuesion-note over the upper part of tb« cb<?»tflH \h}ih ^ided, both in front and behiDd, less clear thon in othj regions. On the right »tdc' ubove, indetermiiiate brt'atbing and bronchophony. K41es on Iwth sides l>ehtnd. P. 1-50. T, oot elevated. At the beginning of the disease, fever wii» said te have been present. Futhcr died from phthisis. Death aftrr 8 days.

P,-M, — Extreme emaciation. Cers'ical and inguintil glands i-nlarged, some of them (mt^eoui?. Partial adhesions of th<^ ficri- cardium to the heart and to the mediaetiniini ; miliary tnlKTclc* on the visceral layers of the former. Left lung freely movaW*". containing numerous grey nodules the size of a jjen. Bight long Hrmly adherent all over. lu the upper lolje a cavity tb*.* miw «f a pigeon's €f[g, communicating with one still larger whlcJi nui backwards. Large and small tubercle* nodules scattered throng the whole lung-tissue. A large caseous deposit in the lower lobe. Swelling and caseation of the tracheal and bronchial glands, one of which contained a cavity. Miliary tuherculosis of the livi«r and its »erou8 covering. Spleen firmly adherent all over to th<! nrigh- Ijouring parts, very large, tubercular both inside and out. A few small nodules under the capsules of the kidneys. Mesenteric glands partially cnseoua. In the ileum a few tlat ulcers with small grey nodules in their edges.

Helene D.,8 months old* Increaaing atrophy for 6 manih*, diarrhoea and coughing. l?*or the Ust 8 days fever, especially in I lie morning hours. P. ll-*-, R. GS, Noisy expirtttion* dyspnu**. Percussion note higher on the right side above lK>th in frind, ami l»ehindf breathing very harsh all over, here and there mueott^ rAlos. Gradual increnRc of the dulness in the places mentioned, hronchial breathing and hronchophony, CEdema of the twoo and feet; collapse. Death after l\ weeks.

P.-Jf.— The right upper lobe firmly^ adlicrvnt to the chc»t wall, i;oseoud almost througlioiit, and containing pretty ]>krv^<< .MiTri^ communicating with one another, ono of which i« t«

the pleura. The mid(U" t* i lower lobes, as w^^ll a u <x.

have miliary tubercle^ I ihroufll^MBi. 11ron>

TUBERCULOSIS OF THE LUNGS.

43:

o:

K

m, one of tbera softonod in the centre. Extreme milian tuberculosis of the apleeti ami peritoneum. Fatty degcncmtion of the liver.

The latency of widely-spread tuberculosis is especially uoticeuble in little ehildreu who finally die of tubercular meningitis. Without any marked pmdromata, in the midst of apparent good health, or at most ushered in by some fiabbiuesh of the skin or muscles which is easily overlooked aud with som<* degree of emaeiation*-the meningitis suddenly appears* At the post-mortem the beginner is then sui'prised to find miliary tubercles and caseous deposits in many of the organs, althoiipfh those had given rise to no symptoms whatever during life.

In older children— from 3 years old until about the time uf the second dentition — we 6nd tuberculosis not uncommonly liegiuning with dyspeptic symptoms. The children lone their appetite, the tongue is always move or less furred, they suffer' often from diarrha?a, become emaciated, and complain of vagne pains in the chest or abdomen long before the cough excites

ttention. At the same time they arc ill-tempered, become

bverish towards the evening, have dry lips and are restless (luring sleep. In the morning and forenoon, however, there is a remission, and nothing indicates tlie latent disease bat slight elevation of temperature and an unusually rapid pu!so.

och cases are very apt to be treated as those of latent pleurisy are (p. 421), and the obscure symptoms — the gradual "falling off" of the children, as the mothers say — is referred to a protracted dyspeptic condition. Under these circumstances a careful

xitmination of the chest cannot bo too urgently recommended. The suspicion of incipient tuberculosis becomes "inore surely

fttablished if a hereditary tendency can be ascertained, if cougli t» in, or if w© can at the same time discover caseous or scrofu- us deposits — e.y?., bone- and joint-suppuration, spinal caries.

landular enlargement and abscesses in the neck or in other purts of the body, chronic inflammation of the eyes, eruptions

a the head, and otorrh<Ea. In any case, after a few months

ocal lung symptoms also, cough, rapid breathing, &c., are sure

to dcvelope so distinctly, that one is forced to examine the lungs.

is having hitherto neglected this examination may however

Rve misled the physician into giving a favourable prognosis, for which th6 afflicted parents will be slow to forgive Mm, Even

438

DISEASES OF THE UKSriRATORY ORO\K3.

ttUhoiigli an early examination may reveal notbing Ter>^ definiu, still wo may often make out chronic eiitarrh, and in sach circum- stances this may justifv us in forewarning the family of the probability of danger. At tliia a*^'e ifroiu 53 years upwards! «»■ almost always find remittent fever (beetle) developing sotmrr or later, wliile in very young children we do not always fiuJ it, and it may be quite absent ; as for example in the followioa rases. H

Puul K., li years old. troatcil in tUv ho*\ntik\ from oth to jAUYi Muy. Extrem*' flubbiiit'ss and wtiHtitig, moderate roujch, \l. ^' (iO. Diiluetis oil both Hides at the b»t*c behind with Hhnrji fAles and irideteTiuiDate breatbitig; dinrrluDit. During the whcili* lirae that the child wa> under (fbservntion, the tern pcraturo anljr msc once (on the evening of l<>t!i May) to 1<X>^ F. ; at otho* times it wuh iiUviiys lielow tln.s. and, in fact, g^^nrrtilly ft ah' normnl. At the pont-mortem we foniid in both lungs mmij tnHCOHs deposits* a few cavities from the sixc of on almond tothftt <tf a plum. niHention of the hroncliial and mesonterie glittjd» ntu\ ti lew tvihereulHr nla-rH in the itih/«tine.

Marie M., 7 months old. treated in the ho)it}>ita) from lOtl* January to Idth Felmiary. Continually incrcfi^titig ttabbiiica* aad emaciation, constant cough and dyspnoja. On the riglit side very harsh indeterminate breathing and niitneron« large and mcditiro crepitations not nliarp in character. Dnhiess nowhct>.^ discover* able. Diarrhoea. During tlie whole time the teinpemttirc wa* seldom over IOU'4^ F., and was ^eueniUy norinul or f^ub-tioMutkl On 14th Febninry, fuver bt^gan for ficft time (1011^ j.\^ ^y^ lUl*2). i»n tlie ir.th the temp, was 1«>2'7^ F,, and on the day of death only ](KP F., the re.sp. 72; the limbs cold antl covered with a blatjih mottling. At the pnst*mortom wo found the left Inng qmt» hewlthy, while the right lung had a number of chhoous u^nlulctt of different sizes scattered through nlmont it*5 v^hole extent and oftn- taincd in its apex one very large nigged cavity. Bronchial gluud» and spleen partly caseous.

This absence of fever scarcely ever occurs in older children. Even without using Uje thermometer we can at once rceognijH." an exacerbation of the fever from the heat of the head aoii hand», the thirst and the increased feeling of malaise. The ivnt* perature rises to 102"2" F,, and the remission in o(Um ashennl in by A slight per? piratiou which, however, is never so ropioos and regular as i n the hectic fever of older patient^s. In miuiy cases 1 have observed i[uite irregnlar temperotar© cnrre* in which the moruin ' oflon higher thaa tht

TrBERCTJLOSIS OF THE LUNG 8,

439

22iid Aiif^ujit	lOO'O	lo:vi
•*2.3nl	1047	m-7
♦'24th	101'8	l-X)-2
2^th	1000	hyjv
2fJtli .:	100-2	lull
*-27tl.	103-3	lOM
2Htlj	08-6	io:.'t?
•2iHb	mitJ	10:M
mh	lOM	lOiO
•:}Ut	io;vi	101-3 ttn.

eveumg. In a girl of 2 years at whose post-mortem we fouml miliary taboreles and extensive caseous processes in both lower • lobes, we had the following temperature chart: —

^^^^H Oq the day« initrkml * the morning t^nip^jraiarc waH tho hi|;liar.

H The diagnosis of this disease in children is further rondorcd

" difficult up to a certain age by the absence of sputa, which

in adults furnish Ji valuable point for the diagnosis owing to th(^

• discovery of elastic fibres, and especially t^V^crcle'bacilli. The cases in which there really is some expectoration ure all the mort? worthy of note. This takes place more by n process of retching or by tiie help of the mother, who draws out the cxpecLonitcd matter with her lingers. Among others I have seen one boy, only H e V e n months old, with extensive caseous degenerution and cavity- formation in the left upper lobe, wLo for months brought up a very large amount of greyish-yellow ftutid sputum, which occasionally contained elastic Hbres but never blood. Haemoptysis in children (apart from that which occurs as the result of tracheotomy) is on the ^vhole a very rare phonomenon before the age of the second dentition, although I cannot confirm the statement of R i 1 1 i e t and B a r t h e z that they huve n e v e r observed blood-spitting before the fith year. I have met with at least a dozen phthisicul children under 5, who on violent coughmg brought up umall fjuantities of blood, and occasionally even as mudi us a teaspoonful, either pure or mixed with mucus and pus. I have only on two occasions seen a copious hsemoptysiH at this age. In one of the cases this was expbiined by the post- mortem : —

On 29th December, 1884, a pule, wasted little girl of 10 months was lidmitted into the hospital. Said to liftvc had moKHlos ami infli»mination of the lung a few months before and to lmv«' w»«ted ever since, but to have coughed bat hitU\ The relatives

i

uo

DISEASES OF THE RESPlfiATOBY OKQJlS^.

«ay that during the last few weeks ?bo has vomiteii Lfluod two occasions, once a small quant it3% the second time a Ia araonnt (filling a small bowl). The motions were 8tUl of u t black colour. There wa« alight impairment under iho left clarjcle here and at other places ou the thorax numeroas crepitations weri heard- Veiy marked amemia and inciinent rickets. In the nigLi between the 5th and t?th January, 1885, there wa* a frenh dis- charge of blood fi'ora the mouth and nose, daring which dcAtI took place.

P.'M. — Left lung firmly adlierent to the costal pletim, Jri id middle of the upper lol^e, which was much consoH<hited and |»rtl caeeons, there was a cavity about the size of a walnut, which nun mnnicated with a bronchus, and, Ix'sides some bloody caseous pulp, contained a roundish tumour (f inches in diameter), Tliis proved to be a thin-walled aneuriHrn, tilled with parietal thrombi^and connected with a branch of the pulmonary artery.'

There are in picdifttric literature a few quite similar cases of aneurism of a branch of the pulmonary artery in the middle of n cavity, ending in rupture and very copious boemoptysis.' On ihc other hand I have never myself met with a case in which the compression or perforation of a branch of the pulmonary arterj^ or vein by caseous bronchial glands at the same time commtiul eating with a bronchus luid occasioned a copious hsemoptysi altbouj^'h such an occurrence htm occasionally been obficrred hf other wTiters.

I shall take this opportunity of saying a few words about tht* great tendency of the tracheal and bronchial glands, especially the hitter, to become enlarged and to easeate. if [tuberclo or caseous processes occur anywhere in a child^s body, wc may almost certainly count upon finding the above-mentioned glands similarly affected. In fact, out of innumerable post- mortems of tubercular cbildren, I can recollect only a fe^r exceptions to this rule; and this proves tljat the tendency of these glands to enlargement and caseation in chiUlron is even ^greater than that of the lungs, Wliile Louis has seen tbc lungs remain unaffected only once in a series of 123 tuber- cular adults, Rilliet and Bartbez ou the other Hand have found them perfectly unaffected in 47 out of 312 ti ^ ,rj

cbildren. I think that the extreme frequency of j^:.,

• Cyi the DifiRcrtation of my pnpil I^r. HoffnQiiff, TeAer Udmrptof Ui $iim>itm Boi-lio, 1885.

* W y « 8 , QH-lardt*» Ilamdy der Ktntitrtr^nkh^ Tk* iU.* 2, S. 807.— Vat Bill •» « Ultteh'VirekQuff Berlckt, }»&&, ii,, 101«— W^it* l$ttHre*, ike.* tH. oditknt, i».«n.

I

TUBERCULOSIS OF THE LtJXGB.

411

eiilargemeDt may be refeiTed to two circumstances : firstly, to the peculiar general predisposition which many children have to glandular enlargement, which we are accustomed to ilcsignate he ** scrofulous *' diathesis ; and secondly, to the fact that

Tonchial catarrh and whooping cough are so very common.

[The irritation of the mucous membrane is transmitted by the

lymphatics to the neighbouring bronchial glands just as in

[intestinal catarrh, typhoid fever, &t"., it is carried to the mesenteric

[lauds. The glandular affection very often forms the chief

lisease in children, while the lungs themselves may contain but few tubercles and deposits. We find the bifurcation of tbe trachea and the krge bronchi surrounded by glands either jparate or conglomerated, sometimes gaUiereJ into masses of the iiAii of a hen's egg. Some of these are simply hypertrophied, Vascular, greyish - red, hut generally either some or all are tubercular or transformed into a whitish-yellow mass. jUso, on ^i*utting into the lungs we frequently find little caseous glands at the bifurcations of the medium-sized bronchi. A few of the [glands show on section a cavity filled with soflened debris, situated either centrally or towards the periphery, whicb» after they become adherent to tbe pulmonary pleura or to the bronchi. raptures into an adjacent lung-cavity or even into one of the laj*ge bronchi. When this occurs, fatal suffocation may result from fragments of caseous matter finding their way into the upper air passages^ Even the rupture of such a gland-cavity into tbe j^ericardium causing fatal pericarditis, has been observed in a few cases. Large bunches of glands at the root of the lungs may even compress the adjacent vessels more or less, especially the pulmonary artery and vein, and their branches, the superior I vena cava, and the common jugular vein, the vagus and its branches. The latter, especially, we occasionally find so sur- I'ounded and flattened by the glands that it is scarcely possible lo follow its course through the mass. Adhesion of some of the glands to the ceaophagus, to the pulmonary artery or » branch t»f it has likewise been observed, by which these parts are not only displaced, but, owing to the pressure, may be grtuiually Ibiuncd

md eventually perforated.

* Fruhwald, J<thrh./, Kimhrkeitl,, Bd. xxiii., 8. 'I^S.^Pptoreen, Ikut^kt rerf. Woekeiuchr.^ 10, 18^. Siioccawful tretttmont of such a cawc by trnylieotomy , Lc«b, Jakrt,/, KUdfrheilk., Bd, xxir,, ]6Stf» S. 353.

442

DISEASES OF THE RESPiBATOBY OROANS,

Cau we, then, diagnose this condition of the bronchittl gUnds (luring life by any definite symptoms? As far as i»y experience goes, X must answer this question in the negatif« far iLe great majority of cases. Certainly we will scarcely evtr l>c mistaken if in a tubercular child we diagnose caseation of tlir lironcUial glands before the post-mortem; but this is only b^'Ciiuae this condition is almost neyer absent in these cases. Hw clioical descriptions which authors ^ive of glandular enldrgemeat have the look of huviug originated in the study and not at thr bedside. It is said that the compression exerted by the glandn i»u the neighbouring parts might readily give rise to prrssune- Hymptoms; and in fact cases do occur in which oedema of the face and dilatation of one or both jugular veins in the neck take ])lace, and likewise hiemoptysis and hjemorrhagic infarction of the lung from pressure ou the pulmonary veins. I have myself, 111 a little girl of IJ years, observed compression of the rigiit bronchus by a mass of tubercular glands the size of a hen's egg» whereby the entrance of air into the right lung was considerably interfered with, and the breath- sounds on this side could only Ic beard extremely faintly. Tbe compression of the vagus and reeurreus also may, as I have frequently noticed,* cause certain nervous symptoms, especially alteration of the voice (hoarse ne»i), fits of spasmodic cough with inspirations like those of whooping* foiigh, also asthmatic attacks wilh whistling breathing and cyanotic discolouration of the face. According to my experieoee T must, however, regard such cases as extremely rare. We bate uften at post-mortems found large masses of caseous bronchial glands, the presence of which had not been revealed during life by a single symptom, the children having presented nothing beyond the well-known features of tubercular meningitis or phthisis. Even the distension of the external jugular veins, to which 80 much importance has been attached, and the csdema ai the face, may occur merely as the result of engorgement of the right side of the heart from extensive constdidatiou of the lungt» wilh(»ut there necessarily being any compression of the 1ar]«9 venous trunks within the thorax. On this account I regard tbe diagnosis of enlarged ghmds during life us very pro bit* ma* tical. I would, however, attach least value of all to the dulne» of the percussion-note over the interscapular region, wbtch ma«T » Eomliorir «i*I H«nooh, KHmnU r.r^hmitJt : K^rlixi, 1840. S. 106.

TUBERCLLOglS OF THE LISG3.

443

insist upoD. I, at least, liavc never yet seen a frlandular tumour 60 large that it could Lave caused a well-marked dulness in this locality. Rilliet and Barthez point out also that large masses of glands in the posterior mediastinum act as good conductors of sounds and intensify to the ear of one who is uuscultating the hack any sound heard from the lun^a, and that on this account we may hear loud hronchial breathiij»^ and sharp rales without the lung itself heiug consolidated or containing cavities. I have not myself as yet met with an error of this kind due to the presence of masses of glands. At any rate percussion would soon clear this up ; for where these sounds were really caused by consolidation of the lungs and by cavities, distinc-t impairment of the note at the buck would scarcely fail to he present. Therefore I cannot admit that there is a quite definite independent series of symptoms indicating enlargement and caseation of the bronchial glands. In most cases the condition can only he suspected, and is therefore merely of pathological interest. Only in exceptional cases can we make a diagnosis with any degree of probability when there are distinct symptoms of pressure on the veins or on the vagus nerve.

The tuberculosis of children up to the beginning of the second dentition is distinguished from that in later life by its acut« course. Cases which arc very chronic and protracted, lasting for years, are extremely rare, and the fatal termination almost always occurs within some months or at most within about a year. This of course is to he accounted for by the wide distribution of the tuberculosis throughout many organs in childhood. In children, also, much oftener than in adults, we have tubercular m e n i n g i t i s , b r 0 n r h o • p n e u m o n i a or pleurisy developing, which bring life to an end sooner than would otherwise have been the case. The pleura is affected, indeed, in tuberculosis almost as often as the piu mater, the disease either taking the form of numerous miliary nodules scattered over the costal and pulmonary pleura, or of large caseous patches on the free surface of the membrane, or in the subserous connective tissue under the costal layer. In t!ie latter case we occasionally see little extra-pleural cavities resulting from the breaking down of these patches, which nniy either rupture into the pleural cavity or after previous adhesion of the pleura to the lung may empty themselves into cavities in the latter or into the bronchi. More or less

lU

DISEASES OF THE KEtfPXRATOBV ORGANS.

extensive adbcBioDs of thu two layers of tlie pleura to one anotlK:! likewise occur very often, while in other cases T^-e have the development of sub-flcute or chronic pleurisy with citiiioup purulent effusion often blood-stiuned. The same may he Baid of the pericardium, the partial or complete udhesion r^ layers of which I have met witli, not unoommonlj, in I children. I shall enter into this more folly later on. The falid sourse of the disease is accelerated in many cases by the rapid development of acute miliary tuberculosift, the symptoms of which are here pretty much the same as in older patients. I'he acute eruption of miliary tuLercles in a more ot less larf;t* number of tissues may, however, take place not only during th<^ course of pulmonary tuberculosis which has hitherto been chroDic luid constitute its fatal termination, but it may also occur iu children who are apparently perfectly healthy, and ai' not at all suspected of a tubercular tendenc3% In both caseti great and sudden variations of temperature with irregubtr exacerbations (occurring sometimes in the morning, somctimts at noon, and sometimes in the evening), very rapid anperficial broathing and harsh breath sounds, to which, nsnally* widch • distributed fine crepitations arc by-and-by added — form the ciiitf .symptoms ; and in the further course of the disease we may ttls< have eulartjfemont of the spleen, roseola, and cerebral symptoms. The fever, however, does not always reach a very high degrei Thus iu a child of 2 years who had hitherto been quite heoltlr I found during two weeks a temperature of only 100 8" — 102"tJ° F. while the rate of respiration was from 60 to 80, although nothiug abnormal could bo discovered on examining the Inng^. It was only in the heginuing of the 3rd week, when convnlsious, hemiparesia, and coma suddenly set in, that the temporatmro rose to 104° F. ; and death took place 2 days after. In tlu' diagnosis w*o may easily be misled by the cerebral symptoms inU» thinking either of typhoid fever or of tubercular moningi- iifff the former especially if there is enlarged spleen and roaeob.

laS

Wilbclm K-, y year* old, brottght to my polyclinic on XUh March with traces of scarlatinal dcsqunmatian. preBonting tl»«' gymptoras of plcnro-pncumonia of the rigJifc lower loHc. DariajB the next few clnys tlic pU'iiri^^y WeiJ-njc rawt* protnineiit. By Ib^ liOth April, however, it w%^ quite gone, so thai iheT9 waa ttotkli left but an impaired ) -vWy imd a very itlight dill

TUBeR€UL08l9 OF THB LUHOS.

445

liehind; vesicular breathing was heard all over. On the 6th

August — that is, 3 months after^thc chiM, who had during' ihe interval remained wdl, was brought aj^aiti to the honpital. D iir iiig t he Ui8t 5 day s , h e a d a c h e, v o m 1 1 i ii g, a iid c o n a t i p a t i * j n * P» 02; T. somewhat elevated. The ]>hyHieal signs unchanged. Persistent constipation, in spite of repeated doses of calomel and Hynipus rhamni and enemata. On the 8th. fi-ecpient vomiting; puUe, 132. On 15th, the spleen not enlarged. Nothing new to be discovered in the chest. Pupils reacted sluggii^hlyi d row si* ncjjs, out of which the Ixiy could not be wakene*L Abdomen somewhat retracted. Test crday afternoon an epileptiform fit, lasting U hours. During the next few dftj;*, incrca.sing coma, froquent perspiration, left pujiil wider than right, R. 48 uneqnnl ; F, 128» On 2l8t, permanent convuLsion.s and cv>nt ractures. Death in the course of the f»*llowing night.

The nature of the symptoms and their .-incce.s.sioii during the o week.s' course of ihe disease were here so characteristic that the diagnosis of tubercular meningitis seemed to me Ijeyond a doubt ; and what did we find at the post-mortem ?

Pia mater hyperaRmic, otherwise quite normal; no trace of inflammation or tuberelevS in it ; much scrum in the dilated ventricles, central parts generally raaccnited (jM>st'iuortem apj>eHr- ance). Bronchial gland.s eiilurged and caseous, right Inng cont- pletcly adherent, pleuni cOtStalis much thickened, scattered over with grey intra-pleural iiodulcii lying together like .stones on a rauseway. The anterior lower Iwi'der of the lung caseous, the posterior portion brown and carnificfl. Left luug sprinkled throughout with innumenible miliafy noduk^s. Liver fatty. Spleen full of miliary tuljcrcles. In the intestine a few small tubercrdar alcerw.

Max R.t li years old, tulmitted into the ward on lUst Marcli. Coma, dry crusted lips, both pupils contracteil, R. irregular, interrupted by pauses. PcrcUBsiun normal, bHrsh breathing all over the chest, with coariie crepitatiynn. Abdomen dii^tendod and apparently tender on preasure. Conistipation. Pulao very small, lU. T. 85-5'' ; towards evening, lOl'S*^ F. The same condition on the 2 following days. On 3rd April, the day of death, T. suddenly rose to 1054, R. 76, V. imperceptible. Cyanosis, trismus, rigidity <»f the neck and of all the limbs. Death at 8 p.m.

F,-M. — Pia mater in a state of venous hypertemia and oedema. No exudation or tubercle anywiierc. Brain very vat^cular, ven- tricles (especially the 4th) filled witli a moderate amount of clesir senim. Yery abundant miliary tuberculosis of the pleura and of both lungs, of the spleen and liver. Bronchial and mesenteric glands enkrged and caseous, likewise the imestinal follicles.

^d both tliese cases, then, we found neither tubercle nor

44^

9ISIUffi8 Of THE IfiifnUTOSt OBGIXS.

exiulAtion in ihe pk mater, and yet during life the cbaracterbtic ffympUnoB of tubercular menicgitis were present ; and in the aeoofid caae there was also the rise of temperature immediateh before death of which we have spoken (p. 325). At the poet- mottem we only fonnd hypereDmia, and^ in the second caae, alio iBdema of the pia mat^r and accnmnlation of 6 aid in the venl thai is, hydrocephalus acutus (p. 809) . to which we could the cerebral symptoms. I have seen one other quite similar that of a child of 9 months, who, during the last few days, prr- aented a tetanic muscular rigidity, so that one could raise the ehild either by the head or feet and hold it almost horizontally. in this case we found at the post-mortem only oedema of the pia mater, and extreme internal hydrocephalus, although then* was mihary tuberculosis of the pleura, lungs, spleen, and liver, and caseation of the bronchial glands. 1 have found the same uppearanees in two other cases of miliary tuberculosis which had iiBsumed a typhoid form at their onset — in the case of child of 3 especially the temperature-curve corresponded exactly to that of typhoid fever that I adhered to this diagno$iji until the post-mortem, at which wo found extensive acule miliary tuberculosis instead of the expected appearance of typhoid. In both cases the cranial cavity was entirely free from tuberculosis, and there was nothing found but hypenemJA of the pia mater with serous distension of the ventricles.

I have only exceptionally seen n hiemorrhagic diathesta resulting from acute miliary tuberculosis.^

Otto K., 4 yeftrs old, adtnittttl 8tli December. 1879. IIi«toiy obscure. Took ill on liiJth November with violent fever aiid hoemorrhages from the mouth and none, which, with short interraisHions, had lasted over Rince. A hcpmorrhftgir diathoHti* liad never been observed before. Pnle, oinainated chilit, to tick • eollapaed, Sclerotie and wkiii *<lig:htl> jaundiced. Cutxiiieouw retTw markedly diHtende*!. Slight Iminny de^tjunmrttion of the f ; miH. Senjtiim uHleTnatiniH. T. lOl*"' F. : H. 40, ^nperHcint, < (ilidomitiiil. On oxamnmtion nothinj? found hut coftr«o crepiiatiotM at the bnrk ; V. ir»<>, small. Flatulent di«tensiou of alnlomen, liver cjk^tending about 2 inehoH below the mur^i of the rih«» spleen uoc to l>c made out. Motions thin, veiy hlnck. pa88e«l involuntarily. Urine iTmoved with the catheter (7 osr.). hrownUh-nxl, ncid, cofi- tainini^ (tome albumen, tio tuljo>ca«tfi, tio wholi> blixid coq3ti«*lt.*;i

jHr»ub»

^ t.f, KimJi,

TUBERCULOSIS OF THE LUNOS.

11

(hii^moglobinurla). Death in a state of collapse on 10th December. Aftci* a few injections of camphor, the fiunctures bled long mul severely.

/*.- Jf^^IVrieardmra pre8cntf<l a few submiliary nodnkfg, hen it- muscle slightly Fatty, a few snbmiliar}' tuWrcles eloac under thi> aortie orifice. An euormoua quantity of the same on both lunji^s. on the pleura, in the spleen (which was enlarged to thi'eo times its usual size), in the kidneys, on the capsule and in the substance tif the liver, which was much cnhirged and fatty. Some of the bronchiiil glands the aizn of a wiihiut and ca^eouH, thoracic duct free friMii tnbcnlc.

I must leave it undeci4c<! whether the hiemon'hages from the inonth and nose observed in this ca«e as woli as the hn?moglo- binuria are really to be nscrilied to the acute miliary tuberculosis. Further observations iviO decide this* With the exception of the above, I have never met with a case of tliis kind, and .Tacubasch has searched medical hterature in vain for another like it. I have indeed obsen-ed one case of a boy who died of ofcncral miliary tuhercnlosis and tnborcular meningitiH, and who during the last few weeks presented numerous purpuric spots, especially on the lower limbs. There were, however, no hajmor- rhages from tho mucous membranes at all*

Occasionally acute miliary tuberculosis develops in a succes- sion of distinct attacks, each of which is accx)mprtnied by more or less hif^^h temperature, while the hitervals between are entirely free from fever. The following case is a characteristic example of this rare form.

Hermann K., 6 ycar.s old, adraittcd to the hospital on '2nd February, 1878. Utterly neglwtcM:!, and affected with chnmie tK'zcma. Some cough, without abnormal physical si^ns. Impmve- ment after malt l>aths. Fmm l:lth — 28th, diarrhcoa, which wu.-* cured by bismuth, siibnit. and argent, nit. After seeming quite well, he suddenly, on 0th March, had anorexia and fever (T. 105-6^ F. ; P. 134 ; H, H very siiperHeial). In the lungs nothing but harsh breathing all over, peiTUSsion normal. The fever lasted unabiited for 4 diiyH, during which time there were twice rigors in the morning. T. only on the morning of the 8th, S*8<5*^ F. ; at other times alwayH 1<J6'2° F. R» rose to 64, without any other abnormal H}'Tnptora8. From lltli March to 8th May — 1\«\ almost ii months — free from fever (only on 4 days did the evening T. rise to 100*4'^ — ^101'5*^ F., at other timcy it was cither normal, or even s^nb* normal). Nothing found on examination. General health good, Ktrongth increoeing. Suddenly, on Kth May, a fresh exnccrbatioTi

UB

DISEASES OP THE BE6PIRAT0RY ORGANS.

of finer (105-4*5 ¥.), lasting 2 diiy» (uctit uinier VH- K.). »iil» r. 1 14—160, and E. tH). From this time cfttArrhal sounds Appounl in both langB, and the rate of perspiration reTauiued -10—^ From 10th — 13th the T. fi.'ll again gmduollj, and remained qnit** normitl till the 25th, while the catarrh and the rapid brtsithini; pcr«if^t<'d, and the abdomen became di&tended with flalulewi' From the 25th there was again an exat?erb«tion of fever (103*1'*— lOi" F.), lasting 5 days. After a few days free from fever, thciT began on 1st Jnne a remittent type of tempemturo (ra. 100-8P; cv. H>2B'3— 103-8° F )^ which latittni without interruption until the da^' of death (5th July), with continual quick P* and B., incren^ing emaciation and weakness, persistent bronchial catarrli, and con* tinuany-recurring diarrhcea- Finally- collapse, u>dcma of the handx and feet, slight dulness on the right hide over the b««e behind, bronchial breathing and shurp rklcs, extreme dyspnoea. Dc»th on 5th July.

At the post-mortem we found extensive pleuritic udhe^iouji, extreme miliary tuberculosis of the pleura, of both lungx, of the whole peritoneum, of the spleen, liver, and both kidneys. Comcoiu consolidation of the base of the right lower lol>e» caaeatl»»ti nf tl..^ bronchial and mesenteric glands.

This case, then, bLows that appareatly inexplicable feverish attacks lasting for several days with very high tern* pcrature, must arouse suspicion of incipieut miliary tuberculosiD, even although thoy are separated from one another by weeks cf complete apyrexia, and although on examining the lunga we liud nothing bat harsh breathing and catarrhal sounds, AVe nuiBt, of course, assume in these cases that there is an invasion of tubercle-bacilli advancing in successive attacks — probnhly Ktartiiig from caseous bronchial or mesenteric glands.

Unfortunately there is but little to say on the treatment *>f tuberculosis in the first years of life. I cannot record rril success in the treatment of a single case presenting the signa of tuberculosis or of far-advanced pulmonary phthisis, although cases of the '* chronic pneumonia/' formerly mentioueil» not uncommonly completely recover. I would refer you to tbo treatment I recommended for the latter (p. 418), which will hertt altto fulfil all the indications. As regards prophylaxis I must especially draw your attention to milk from tubercular w©l- nnrses, or from cows nilh ''perlsucht** (unless the milk has been boiled), as the identity of ** perlsucht " with tnbcrcn- Josia has been esiabUshcd by Koch* a researches. There aie plenty of eases published of infeoti^^s well aa of ariiftoUil

GANGRENE OF TKE LUNOB,

440

production of tuberculosis by inoculation mih the milk of cows with "perlsnchf* (Bollinger, May, Bemme*). The danger, however, is not so very f^reat, because according to the investigations into tlie milk whidi have been made as yet, it is only infectious when the mammflry f^lands themselves contain the "perlaucht*' nodules, which does not often happen. Abelin- says ho has observed a small epidemic in the Stockholm ** Children's House*' resulting from infection. Since we have become acquainted with the tubercle-bacillus, the fact of the disease being contagious has become conceivable, and several of the cases recorded in piBdiatric literature of children being infected by tubercular wet-nurses or attendants, by tubercular operators having sucked the wound of circumcision, &c*, deserve iitU?ntion. I have not myself as yet met with a single certain case of this kind.

X, Gangrene of the Lungs,

Gangrene of the lungs in children differs clinically from the same disease in adults only in this, that the diagnosis is more difficult on account of the frequent absence of sputa. We must also add that less import^ance is to be attached to a gangrenous smell of the breath in children, because in them necrotic processes in the mouth and throat are often present at the same time, and these, quite as readily as pulmonary gan- grene, may give rise to this symptom. Tliis disease, moreover, €eems to occur oftener in children than in adults. It appears as the termination of a croupous pneumonia only in rare cases when the disease ends with the formation of *' sequestra," and these become infected by putrefactive germs which have entered along with the air-current. It is in this way that we must regard the cases given on p. 427, which ended in putrid pleurisy. Gangrene of the lung arises oftener as the result of embolism, septic matters which have been formed in diflercnt parts of the body finding their way into the lungs through the circulation, and there infecting already*exiating

> Jahrr4ber. tl Jenntrxhen Kindempittth, 1S79, S, 27; 1882. S. 48; 188C» S. 21. Sec iklao Stein, Efperlm. Beitr. znr In/ei^iosildt der Mitch perls. KAken : B^.^rlin, 1884.— Absoliately ne^ati vci resaltH were obtainod in the foedin^ expori- mentis of ImbAch, Jahrb.f. KinJrrheUl:, xtiw. S. 2D2,

* Arctic/. Kinderheili.^ iv, 1,

29

450

DISEASES OF THE BEBPIBATORY OBGJkKS.

broncho-pneumonic patches. Thus, e,g. I have obsenred palcbfl of pulmonary gangrene resulting from caries of both petroas bones with offensive discharge, and often from gangrenous processes in the skini such as are not unconunon among the ill-cared-for children of the poor, especially after iufectioBj diseases (measles, scarlet fever, typhoid), also after gaug^rcne M the vulva and of the cheeks. I found a patch of gangrene in the long of a child of 2 J, who had suffered for many weeks from extensive ecthyma cachecticum, resulting in gangrene of the skin. M

Chest atid I>ack so ]n?iietrafced by deep, gangrc^nous ulcCTW, covered with black ueeroaod fragments, that phynical examination of the thorax was out of the questioiL. After d(^th, which took place in a state of collapse (T. 96'!'^ F,), we found at the poat- mortem (6th May, 1879) the following changes in the rc»pirat4>ry apparatus : — Chronic eero-fibrinous pleurisy, raultiple broncho- j)tieumouia, especially on the left side; many offengive, embolic abscesses and htPinorrhagic infarcts in both lungs. Circumacribod patch of gangrene in the left lower lol>e, })artial thrombosia in the course of the pulmonary artery. On account of the imposu* btlity of examining the thoi*ax and the prominence of the cutaneoiis and general i^ymptoms, all these affections had remained latent during life.

Gangi-eue of the lung also arises from direct inhalation of septic matters; for examploj in pneumonia under the above-mentioned circnmstances^ likewise in cases of tnbercniar cavities and abscesses of the liin^s, noma^ and diphtheria of the pharynx. I have frequently observed putrid bronchitis both in scarlatinal necrosis of the pharynx and in true diphtheria, and in the latter I have several times seen a number of gangrenous cavities the size of a pigeon's egg in the centre of a patch of bronchO'pneumonic consolidation. In these cases also ibo disease was not discovered until the post-mortem, for tho gan- grenous odour of the breath during life was of course referred to the necrosis of the pharynx. On the other hand, in Uie case of a phthisicid boy of 4 years, at whoso post-mortem we fonnd several gangrenous canities of various sizes in a cor d

left lung, and putrid pleurisy, I was able to make the^^iu^M-nia during life owing to the extremely offensive smell of his b9>6tth, especially when he coughed. At any rate, the extreme general Weakness, which we find in all exhausting diseaies, is an im-

OANGRENB OF THE LUNGS.

451

W.

portaut factor in the causation of pulmonary gangrene, owing to the retardation of the blood-cniTent and the tendency to throm- boais. In a sickly little boy of 2 years, who was treated in my ward for general eczema, an attat-k of broncho-pneumonia took lace ; at first it caused no anxiety, but after about a fortnight it ended saddenly in extreme collapse, with deathly pallor of the akin, and such a fa?tid odour of the breath that the w^ard was reguJarly poisoned. At the post-mortem we found a gangrrenons patch almost the size of a hen's egg in the right lower lobe surrounded by consolidated tissue. To this class also belong the cases of pulmonary gangrene which result from severe typhoid fever, and of which I shall by-aud*by give you two examples. At the same time we must not forget that under these very circumstances the entrance of food into the air- passages may favour the occun-euce of a septic destruction of the inflam- matory patch.

The orij^iu of the pulmonary gangrene in the following case remained unexplained*

Albert 8t»» 11 years old, admitted 23ih1 Jane, 1881, Formerly healthy. Had taken ill suddenly 10 daya before with a ric^or, folJowed by fever j aftenvard8,£rei|tteitit looye motions and delirium. "When admitted, the boy, who wan otherwise strong and of a good complexion, lay in a state of profouud drowsiness, and could only be roused for a few moments at a time. On examination of the chest, wc found diilness and occasional sharp nVles below the siJJne of the scapula on the right side. Nc euInrRement of the spleen nor roseola. T. 10:31^ F. ; R 120; R. -10. In the evening the T. rose to lOi-i'^ F., the pulse liS. During the following night active delirium and three attacks of rigor, with cyanosis, which (as we afterwards leanied) had also occurred frequently prerions to his admission. On *24tb, gencml eolhipso, cyanosis of the extremities. Vomiting. T. 104"^ F.; P. 160; R> 52. Extreme dy.9pncDa iti the coarse of the following night. Death toward.s morning.

P.'M. — The right aide of the diaphnijrm arched downwards into the a!}dominal cavity* On opening the right pleunil cavity, a quantity of foul-smelling gas escaped. The pleural cavity formed an empty sac» against the median wall of which the hmg lay quite collapsed, and of a dirty greyish-green colour. The coital plcum covered with offensive discharge. In the pleural cavity about 7 oz. of greeniBh*grey offensive matter. In the right lower lobe there was a 3pot Ig inches long by 1} broad, which couUl be recognised even externally as a patch of gaugreuc, and which prceeuts an elongated perforation through the extremely thin pleura. The lower lobe was hepatiaed to a alight extent, and at the

DISEilSES OF THE BB8PIBAT0BY OBOAKS.

base contains a few other gan^enous patches the aise of c^mttj- stones underneath a thin flactoatiiig pleum. At the apex of iho left upper lobe likewise a patch of gangrene the siasc^ of a wsluul, the iTKt of the lung tissue vascular and air-containing. Splc*n considerably enlarged (34 in. long, H in. broad, H in. (hick), bluish-red, soft. In the intestine copiocis epithelial cofttiiig* Peyer'fi patches in place* somewhat swollen, mesenteric glandii slightly enlarged. All other organs normaL

Although there was neither enhirgemeDt of the splc^D not roseola, still tho whole aspect of the ease seemed to jaslifj the diagnosis of typhoid fever with broncho-pneumonia of the right lower lobe. The very slight changes that were found at tlje post-mortem in the Peyer's patches and mesenteric glandi are not, indeed, of much weight against this diagnosis ; sinoe* as we shall see later on, cases of this kind do occur in the typhoid of children, and in them tho spleen is found much enlarged^ Nererthcless, I would not in this case regard the gangrene of the lung as typhoid, hecause, for one thing, the disease had only lasted 10 days, but especially hecanse thd multiple form of the gangrene and the repeated rigors pointed to a septiccemic source, although, to ho sure, no such source was found at the post-mortem. Who knows whether there may not have existed a septic patch somewhere in the osseous system, from which the embolic processes had started. The fatal issue in this case occurred through rupture of a eupcr- iicial patch of gangrene of the lung, followed hy putrid pro- pneumo-thorax, I would especially point out that in this case there was not the slightest suspicious smell in the breath.

XI. Whooping Cough,

Although I close ray account of the Respiratory Diseased with a description of whooping cough (tnssisconvulaiva, pertassi*) I am perfectly well aware that it does not really belong to this section, but indubitably to that of the Infectious Disea^^^. Nevertheless I consider it expedient from a clinical point of view to treat of whooping cough immediately after the duieaaea of the respiratory organs, because its symptoms and lU most serious complications belong mainly to this system.

There are certain signs which may enable the phyaiiu^ku lo

WHOOPING COUGH-

458

diagnose pertassis even before he has beard the child cough ; especially the parents' statement that the child soflfers from a

P cough coming on in fits and especially frequent during the night, and that it is accompanied by crowing and dark red- ness of the face, and ends with retching and vomiting of mucus. The suspicion that we have to do with whooping

» cough is strengthened if we find that the child's face looks puflPy, especially about the lower eyelids, and if the veins of the latter are dilated*

We distinguished three stages in the course of the disease,

B i^hich pass imperceptibly into one another. The first (catarrhal

stage) differs as a rule iu no way from ordinary tracheal or

bronchial catarrh, and therefore does not excite any suspicion of

its being the forerunner of whooping cough, unless there happen

to he an epidemic of that disease or if children of the same family

are already sufiering from it- Less frequently, the cough has a

B I>eculiar character even at this period — a more paroxysmal onset

^^tvith inclination to retL-li towards the end — which may lead us

to suspect incipient whooping cough. The catarrhal stage is in

these cases extremely short, being limited to a few days, and little

children iu the first years of life are, it seems to me, especially

liable to this peculiarity. In general, however, the first stage

lasts 10—12 days. During this time the cough which was at

first purely catarrhal, gradually assumes a paroxysmal character.

As many authors — ctj.^ Lombard and West — say that they

^HiftTd seen this stage lasting 5 — G weeks, I shall not dispute it ;

^ftnt I cannot help thinking that in these cases there was more

probably an ordinary catarrh and that the children became afi'ected

iH^ith whooping cough during its course. In children who have

»* tendency to false croup (p. 358) I have occasionaUy seen

the first stage of whooping cough begin with an attack of that

disease, followed by catarrh which passed into whooping cough.

The second stage (convulsive) presents the acme of the

disease. The characteristic paroxysms now occur with more

or less frequency, being most severe and frequent during the

night* It is these that have given their name to the diseaso,

from the intermittent crowing ('* whooping *') inspiration.

^H Often, but by no means always, the individual attack begins

^Mrith a kind of aura, i.e., with preliminary symptoms by which

^Bie child and those around it are made aware of the approach of

451

DISEASES OF THE BE8PIBAT0HY 0R6AKB*

an attack. The cliild suddenly becomea restleflB, aux^ioas, leave* off eating or playing, sits up quickly if it has been lying down, and clings to its mother or to any fixed object as if it were thus better able to meet the approaching attack- Even in an infant at the breast of 3 weeks I have observed an anxious beating about with the arms before every attack and sometimes also short whistling inspirations; in a boyof 14 weeks hasty evacuation of urine and fieces and in some older children vomiting ushered in the attack. The latter ran hurriedly into the corner of the room and emptied their stomachs, and then tbe paroxysm immediately followed. In a child of 2 years the attack began with restlessness and innomerahle sneezes following rapidly on one another ; and these also recurred towards the end. Oo the other hand a girl of 9 years had for aura much quickened breathing with dyspnoea and noisy expiration ; which condition lasted over an hoar before the paroxysm commenced. Immediately after the attack and in the intervals the breathing was perfectly quiet and only here and there was a slight rale audible. The attack itself consists of coughs foUomng rapidly on one another jind interrupted from time to time by crowing inspiration. The child bends forward while the attack lasts. The quicker the coughs follow on one another (i.f., the fewer the inspirations) the more does the child present the aspect of suffocation— a dark somewhat bluish redness of the face and neck, great distension of the cutanoous veins, and cyanosis of the visible mucous mem- brancs, especially of the tongue. Tears in the eyes, trickling of blood and mucus from the nose, ecchymoses under the conjunctiva and in the subcutaneous connective tissue of the face — are frequent accompaniments and results. The action of the muscles of respiration is considerably increased, especially that of the ubdo- miual muscles and of the hard arched stemo-mastoids. It is only during the crowing inspiration that a momentary abatement of the above-named sjnuptoms takes place, and this is followed at once by an aggravation when a new fit of coughing begins. Thus the succession of suffocative coughs and hurried inspiration:;! is repeated 8 — 6 times, or even oftcner, and after lasting 2 — 3 minttt«K the attack ends eitlier without, or oftcncr with, {]w bringing up of pure or blood-stained bronchial mucus and fragmentn of food, which the mother tries to help oat by putting her finger tnta tbo mouth* One almost always observes a second less serare

4

WffOOPraO COUGH.

455

fcfter quite a Bhort pause ; and this may even be ird, 80 that tlie whole paroxysm really consists iccessivo seizures. Then at hist, for the first time, follows. Willie many, and especially little children , state of complete exhaustion after the attack, the older gt> on with their occupations almost immediately as if bing had happened. The slight influence of the frequent loctornal attacks is especially remarkable. The children jump lip, go through the attack and then at once fall asleep again, without appearing much put out by the frequent intcrrnption of their night's rest. If one examines the chest during the paroxysm one cannot hear the vesicular breathing even during the crowing ioBpiration^ because this conceals all the rest, and the air cannot enter the bronchi in the usual way.

The number of the attacks in the 21 hours varies greatly. While many children during the whole course of the disease never have more than 10 or 12 in the day, others have as many «s 30 — 60. But in these, generally, are included of course the various phases and component parts which as above mentioned form one complete paroxysm* You will understand that the danger of the discttso must increase with the number of the paroxysms, ■ partly from the exhaustion which becomes more and more marked, Hud partly from the repeated venous engorgement which accom- panies each attack and may bo of serious significance. Trous- seau Is therefore right in his advice to note down the number of Attacks on a slate so as to be able to estimate their increase and decrease and, thereby, the danger of the disease. Although the Kjtttacks generally come on spontaneously, still they are easily excited by emotional causes (crying and screaming), by change from the prone to the upright position, and sometimes also by distension of the stomach. I can usually succeed in exciting a paroxysm for the purposes of clinical demonstration either by pressure on the larynx or by examining the pharynx. It is remarkable that if there are a number of such children together (e.g. J in the waiting-room of the polyclinic) the attack of one is very apt to be answered by the others, and a general coughing i^nsues.

The intervals between the attacks are in simple whooping congh entirely free from morbid symptoms. There is no cough whatever, the respiration is quiet, and on examination we find

456

DISEASES OF THE BESPmATOBY OEOAK^*

either normal breath-sounds or at most a fiew catarrhal rhoncbi* We may diagnose the disease ^m the already-mentioned alight cedematous swelling of the eyelids^ and firom the dilatation of the small veins round about the eyeUds which^ after the disease has lasted for some time, are apt to arise owing to the fonstanlly recurring engorgement. From the same source arise the attacks of epistaxis which are sometimes exhausting, the bloody sputa (bronchial hii'iiiorrhage), and the ecchymos under the coujunctivie. The latter usually occur only in s] but they may attain a considerable size, and I hare aeen the whole cornea surrounded by an effusion of blood, quite covering tbe sclerotic, the conjunctiva palpebrarum suffused with blood, and both eyelids of a blackish-blue colour. The pressure of tbe venous engorgement which occurs during the attacks may, how- ever, show itself in other ways also. Any erectile tumours enlarge. When stomatitis is present, htemorrhage may occur from the inflamed gums. In one child who had eczema of the ear, I sai bleeding take place from the affected area of skin during ev( severe attack. Hiemorrhage also occasionally occurs horn iho outer ear, and this is accounted for by a rupture of the tympanmn, which (especially when otitis externa is present) is apt to be ciiused by the force of the air — which is much compressed during the cough — being driven through the Eustachian tube into tbe tympanic cavity. These ruptures, however, almost always recover without leaving any traces, and cases of suppura- tion of the tympanum resulting from such an occurrence are very exceptional. Barrier observed a hiemorrhage between the durm mater and arachnoid as the result of a paroxysm ; and I have already (p. 269) mentioned a case of hemiplegia which occurred during an attack of whooping cough, and which must without doubt be referred to htemorrhage into the brain.* From the violence of the forcible expiration, hernia and prolapsus ani not unfrequently occur. Indeed Cadet® described a case of rupturw of the rectus abdominis with the formation of a birge tumour (btematoma) under the skin of the abdomen, wLii-b under^Ncut gradual resolution.

In very many children who have suffered from wi - uugU

* 8e« ft mmiUf caw of hemiplegia and aphsi<ia In tlic Jakrh.f. h-. < ., l$75, X. 8. *00.— On blin<ltie»i« oocotring after whciopiug oou^b — which 1 h»TO ttjot with myself— *i'>' AlexaRdt>r, Deut^he weof, Wtickentrtir,, 188??, Ko. 11«

• /xw. eiY., ii.. i

WHOOPING COUOH.

457

kfor some leDgth of time we observe a whitish grey erosion or deeper ulceration of the frsennlnm linguse, which may eaase a partial or complete destruction of it. The fact that this nlceTy with very few exceptions, only occurs in those who alreiidy possess incisor teeth, proves that it is dne to the constantly repeated friction which the frrenimi suffers during the attack owing to the tongue being rapidly shot out over the lower median incisors. From a like cause I have several times seen the ulceration also on the lower surface of the tip of the tongue in the neighbourhood of the fnenum, and even

Pon the dorsum of the tongue, in which case the lesion was to be referred to the lower lateral or to the upper incisors. The ulcer, however, is by no moans always present, oven in children who already have teeth, and its occurrence depends especially on the number and severity of the paroxysms, and likewise upon the condition of the fnenulum, ?".<?., whether it is long and loose or short and tight. For in the latter case the

I shooting out of the tongue during the attack, and the consequent friction on the teeth does not occur to an extent snfKcient to denude the frft^num of its epithelium. Since I have directed ray attention more to this point I have also occasionally met with cases of quite similar ulceration of the frienum in children who either had no cough at all or were only suffering from an ordinary

K bronchial catarrh, but had unusually sharp teeth. The duration of this severest stage is, on an average, about 4 weeks ; by the end of this time the nocturnal paroxysms are fdready beginning to diminish in severity and frequency. Gradually the spasmodic and suffocative character of the 1.. paroxysm disappears, the crowing inspirations become shorter and weaker, the final retching ceases, and thus the disease passes almost imperceptibly into the third stage ("stadium

tdecrementi**), which we may regard as another catarrhal Btage. Nothing remains now but a loose cough, which still recalls pertussis by many of its features, especially by its ten- dency to come on in paroxysms and by the unusual redness of the face which it causes. After about 2 or 3 weeks this cough also disappears, and tlie child is completely convalescent. The whole illness has, therefore, an average duration of from 8 to 10 weeks ; and the i>opular belief that whooping cough is not recovered from iu less than 18 weeks is quite erroneous. 1

BI&EA8E3 OF THE BESPIBATOBT OBaJUHa.

speak, however, only of the aTorage duratiou ; for every prac' titioner will have kDOT\'n of cases which lasted 3 — 4 months. But the disease is only rarely continuous in these crises ; for in the middle of the third stage it suddenly takes a fresh start , and then of course lasts much longer. In many cases even after Uu? whooping cough is completely gone, achronic catarrh of the larger hronchi persists ; and whenever this is aggravated hj 1 chance cold or by some other cause (e,(f, measles), the fits of coughing also reappear, and their character still reminds one of whooping cough. Like Billiet and Barthez I have mem attacks of this kind suddenly recur six months or even a year after the commencement of the disease. In one child the whooping cough lasted from July, 1881, to January, 1882, and then a free interval of 3 weeks took place* Then the cough began afresh, and in February it had become so severe that during the night-attacks a teaspoonful of blood was occasionally brought up. A fresli infection in such cases certainly cannot be assumed. We may much more readily imagine a reproduction of the infective material, which has not yet been completely destroyed or eliminated. I have never myself as yet met with a case of a patient taking ill from an undoubted second infectiou of whooping cough, which weighty authorities (Bogor» West, Trousseau) say they have observed ; and I regard with doubt all cases which the relatives have described to me as of this nature. For many cases of simple but chronic tracheal and bronchial catarrh are regarded as whooping cough by the parents, especially if the cough has a rough and slightly whistling character — which is a peculiarity of many children.

In many cases, however, there are considerable varialioiis from the normal course of whooping cough, as I have hitherto described it — variations not only in regard to tl»c paroxysm, but also as to the interval ; so that the disease, which is not in itself a dangerous one, may become serious and threaten the patient's life.

Let us Urst consider the varieties of the paroxysms. I would first draw your attention to the dangerous character of those in whii-h there is a prolonged period of apnoea, dm* ' ' lUo childaimplykeeps coughing and inspires extremal > t.>tt

not at all ; and therefore, of course, no crowing sound is beard. You will observe these cases especially in little children in

I

I

WHOOPING couan.

459

the first year of life, who are by no means exempt from whoop- ing cough ; for I have repeatedly seen the diaeaso in infants^ only a few weeks or months old, who had been infected by older brothers or sisters. The cyanosis rapidly roaches an extreme degree* Buffocation threatens, and may actually cause death — especially if the disease is complicated by dlffiise catarrh or by that and broncho-pneumonia also, I'nder these circum- stances we sometimes have either during the attack, or imme- diately after it, localised spasmodic contractions (squinting of the eyes, contractures of the fingers, toes, arms, &c.), or oven general and fatal convulsions occuring either as the result of the continuous venous engorgement in the brain or of the accumulation of carbonic acid in the blood, which must follow want of sufficient iusipi ration. At the same time we must not omit to mention that the crowing noise during the attack may also be absent in older children without its justifying a bad progDoais, provided only that the paroxysms are short and the cyanosis and suffocative symptoma do not exceed the ordinary degree, or even fall short of it Such cases are not very nncommon, and may even cause the physician to doubt whether ^_ the disease is really whooping cough. Some characteristic ^■feature of the paroxysni may either be wanting fvr only slightly ^vindicated, while all its other characters are there, and at the " same time other members of the family arc suflViing from a similar complaint ('*coqneluchette '^ of the French)*

Brain symptoms may also be caused by the frequent repetition of the severe attacks above mentioned, which so much interfere with the excretion of carbonic acid, and they may persist in the intervals and cause death with symptoms resembling thost? of meningitis.

Wilhelm H., I year old, admitted on Uth Februai^, 1873, with whooping coagh. Very severe attacks with prolonged apasna and epileptiform convulsionp, which at first came on only during thn iiaroxy.sm. hut after the 23rd occurred ako durinpj the intervuJa. On J^rd March convergent strabismus of lioth eyes was noticed for the first time and a staring look; on the 7th repeated ehcwiiig movemeiity. After the I8th droweiness, rigid retraction of the head from contraeturc of the neck-muBcles, from the l£>th also contracture of both arms at the elbow-joint, and of tlie flexorH of the leg; steadily increasing coma which lasted till filMth on the 23rd. After 9th Mii^h there was remittent fever

460

DISEASES OP THE EBSPmiTOBY OBOANS.

(m* 1011''— 101*80 ; ev. H>2-6^— 1035*^ F.), which w«« found ki nrise from a double broncho-pneumonia of the lower lobes. On the right side the physical feigns entirely dkappearecL Wh«ii the coma commenced the paroiysms of whooping cough becsoc weaker but not less frequent, while the cyanosis conaiderwhij increaeed. The resp. did not fall below 50— -<}0, but became we»k and irregular. The temp, of the extremities fell, and b«»d'S..Tt * developed on the occiput and sacrum^.

ThuM we had here strabismuB, staring look, chewing iw^^.v ments, contractiires and coma — a group of symptom* whidi* lasting 3 weeks, decided me to give a diagnoBiw of tul*prru!ar meningitis. And yet at the post-mortem we only found marked hypenemia of the brain substance, and in some plartMi Ledema of the latter. In the left lower lobe there was broncho- pneumonia, and in the right lung only diffuse catarrh. AU the other organy appeared quite healthy. We see therefore, hero, a state of liypcriemia from engorgement in the brain and pia mater, but particularly the carbonic-acid poisoning resulting from the very aevei'O fits of coughing and from the broncho-pneumonia, all bringing about a misleading appearance of bafiilar meningitis. The persistently rapid respiration (60 — 6t»), and the Bteadily increaeing cyanosis are in favour of this view.

Still greaier ilaoger, however, ihaii those of the attack itB<^ may lurk in the intervals. Among all the complications of whooping cough the commonest is difiFuse bronchial catarrh* anJ the broncho-pneumonia which results fi'om it (p. 390). If a child with whooping cough does not seem perfectly w^ell in the intervals between the attacks, but breathes hurriedly and super* ficially, has a noisy expiration and is feverish — j^ou may at once suspect this complication, and your suspicion wnll be confirmed on oxaminfttion of the thorax. Altliough broncho-pneumouia carries off a large number of the children suffering from whooping cough, we must never give up hope, I have »een very yoiing children who were very ill with extensive consolidation on both siiles, comidetely recover even after variations in their conditioii lasting for weeks, and after they had been repeatedly given up. Even the occurrence of measles us a complication under thesd circumstances is liot inevitably fatal, although it makes the fuso much more grave. Much less frequently I hare abserr«l croupous pneumonia and pleurisy ; and we may almost always tind emphysema of the apices and margins of the lung when ihcro IB extensive broncho-pneumonic consolidation. I baT6 never myself seen the rupture of distended alveoli which Ima

WHOOPING COUOH.

461

been occasionally deacribod, and whicli is followed bj inter- lobular emphysema which may spread over the root of the liuijjf

^iiito the neck and over a great part of the trunk. Nor yet have

Hpr seen pnenmothorax.' I have, however, in a child suffering from phthisis, seen a tubercular ulcer in tho riirht main bronchus give way during a paroxysm of whooping cough, and this was followed at once by extreme emphysema of the subcutaneous

^Ktissue of the neck and chest.

J^t Broncho-pneumonia when it complicates whooping cough has — - as I have already mentioned (p. 391) — a tendency to pass into a

I chronic condition and to last for luonths; and then the fits of coughiogmay persist with unduuinished severity. In these very cases I have frequently found afU*r death dilatation and partial fatty degeneration of the right side of the heart— changes which may be explained by the persistent venous engorgement, and by Kthe resistance within the lung-tissue which the heart has to " overcome. Under these circumstance I have repeatedly met with oedema on the back of the hands and feet, and with cases of sudden unexpected death from collapse and syncope. The cardiac debility also probably exj»laiDS the extreme rapidity of the pulse, which has struck rae as a peculiar feature in

(many cases of broncho-pneumonia complicating whooping cough where the temperature was comparatively low. This must not, indeed, be at once set down as a fatal symptom — as the following case teaches— but occurring under these circumstances it always fihows that sudden oJiaustion of the heart's action may easily come on.

^Marga^cthe H,, 14 years old, adiuittt'd on 13th July, 1876, with rickeiM and whoo[»iiig cough which had lasted about 4 weeks. Bn>nchitic ajrmptora.H durinjcf the Inst 5 days and severe dyspncr-a. At both Vjasea behind, «light impainnent with in determinate }>ix'athing and fine crepitations* Fits of cotighiwg only seldom. even during the night-time. After the IHth, the rei*pinition became quieter, the impairment disappeared* and nothing could bo heard behind but sonorous and sibilant rhoncln, while tlie paroxysms of whooping cough (accompanied Ijy vomiting) became worse and worse. After the 21st steady recovery, appetite, uo iyspnoBa. On 24th discharged. Whoopmg cough still pcrsiiiting. During the course of thiw case we observed the followijig relations Ijetween the respiration, pulse and temperature : —

* Broger {Ji§eherck«M clmiqnt* inr fe* maladU* de ren/amce, ij. : Paris, 1883, p. 554), obtained recoTery in a case of this kind bj punoturin^g- ike tborax.

WHOOPING COUOH*

463

only took the form of a catarrhal cough occurring iu roxysms with slight cyanosia. In the yoimger patients, agaLii» here was distinct crowing, and In somo also pretty copious isemoptygis and final Yomiting, Cases often occur of the mother ^ing infected by the children ; still the disease has generally a cry mild form in their case.

There can he no douht that whooping cough is infectious, nd is readily transmitted from one individual to another, so that ly several children in one family suflfer from it at the ie. It is therefore all the more difficult to explain the lat, in my ward where the patients with whooping cough never isolated^ I have only exceptionally observed eases of amission — which fact is entii-ely at variance with Roger's Tience, As to the period of incubation I possess no definite jrience, hut I have frequently observed the fact that if a child ntroduced the disease from school into a family, it took at least j— 12 days before a cough was Jieard among the other children. Kb naturally assumed that the eoutagion reaches the respiratory ■icons membrane along with the inspired air, and thence exerts S action, and so, as a matter of course, bacteria have been de- scribed as the cause of whooping cough*^ However probable bi may be, it cannot be said to have been demonstrated by m conditions described as having been found, as they arc not ibreast of the present state of bacteriology* When we regard rhooping cough as an infectious disease, it naturally follows that

tlook for a feverish premonitory stage analogous to that ad in the acute exanthemata. I cannot altogether deny the Iccurrence of this, but I would remind you that the first stage jtthis, as of every other catarrh, may come on with great severity, H in that case be accompanied by fever. Trousseau also- [peaks of a very acute catarrhal stage, and I myself have fre- mently observed it.

RThe action on the respiratory mucous membrane of this still- mknown infectious material is not confined to the setting up of

t ordinary catarrh of the trachea and of the bifurcation, as many re maintained. I certainly shall not dispute the fact that h a catarrh is present or may be present ; and this condition Letnericb, Jahrb, /, Kin(krh'amlh.y 1870, iii., S. 53*; 1873» 8. 436.— rncliamer, ibid, 1870, x,, S. 174.-Bargef , Bert. kHm, W ri«»hler, Dtutseht ifedicinaU.^ 1886, No. 74, iCIiM^ i., 4&7.

1, —

462

DISEASES OF THE RESPIRATORY ORGANS,

	r.	i:.	T.
13th July	2(M3 ...	. <;o	101-5
Uih „	180 .	. fH)	100'4^ 99'-5
15tb ,.	164	:.o	1013
l(3th .	, 168	01	08-6— 100-4
17th .,	14-1.	/»ti	. 91V5— 100^
18th ..	. . 13C	.V2	100'4
Unh ..	112	!•»	i*90
2(Hh ..	Mi)	4iJ	98-6
21fit .,	120	-W^	1^1
22m\ .	. 108	;?o	99r>

Cbrouii' brouchiftl catarrh and pulaiouary phthisis are not uncomraonly found as the sequelao of whooping cougb, the latter developing from chronic broncho-pneumonia Tvhich has become caseous. As a result of the enlargement and caseation of the bronchial glands which in protracted cii6e« of whooping tough is set up by the accompanying catarrh of the mucous membrane, acute miliai-y tuberculosis or tubercular meningitis sometimes developes even after a lapse of years« when the whooping cough itself has long been forgotten* I may finally mention that in several cases I have seen a deformity of the thorax occur as the result of whooping cough, ainular to that in rickets, namely, a very marked '* pigeon-breast **; and these children had previously been of quite normal conformation and in no way rickety. The occurrence of this deformity is ex- plained, I think, by the excessive atmospheric pressure from without, along with the deficient inspiration and the consequent incomplete expansion of the lung, but, above all, when there is a complication with broncho-pneumonia which keeps up these unfavourable conditions for some length of time.

We know practically nothing of the etiological conditions of whooping cough. It is certain that the disease occurs even in earliest childhood. I have seen it, as already mentioned, in children of 3 — 6 weeks who had been infected by older brothers and sisters. It occurs most frequently between the 2nd and Gth year of life ; still, older children are also often affected, bat adults very^ rarely. In the spring of 1878 I saw a case of whooping cough in a young lad of 16 who had caught th^ in- fection at the con Ermation* class, and later on he infected not only his two sisters of 12 and 14 years respectively, but also hii* mother who was 35 years of age. In her cusr, ljowc?ctr,

WHOOPING COUGH,

Ma

disease only took the fonn of a catarrhal cough occurring iii paroxysms with slight cyanosis. In the younger patients, again, there was distinct crowing, and iu some also pretty copious haemoptysis and final Yomiting. Cases often occur of the mother being infected by the children ; still the disease has generally a very mild form in their case.

There can be no doubt that whooping cough is infections, and is readily transmitted from one individual to another, so that generally several children in one family suffer from it at tho same time. It is therefore all the more difficult to explain tho fact that, in my ward where the pfttients with whooping cough are never isolated, I have only exceptionally observed cases of transmission — which fact is entirely at variance with Eoger's experience. As to the period of incubation I possess no definite experience, but I have frequently observed tho fact that if a child introduced the disease from school into a family, it took at least 10 — 12 days before a cough was heard among the other children. It is naturally assumed that the contagion reaches the respiratory mucous membrane along with the inspired air, and thence exerts its action, and so, as a matter of course, bacteria have been de- scribed as tho cause of whooping cough.* However probable this may be, it cannot be said to have been demonstrated by the conditions described as having been found, as they are not abreast of the present state of bacteriology. When we regard whooping cough as an infectious disease, it naturally follows that we look for a feverish premonitory stage analogous to that found in the acute exanthemata. I cannot altogether deny the occurrence of this, hut I would remind you that the first stage of this, as of every other catan-h, may come on with great severity, and in that case be accompanied by fever. Tronsseau also* speaks of a very acute catarrhal stage, and I myself have fre- quently observed it.

The action on the respiratory mucous membrane of this Btill- uuknown infectious material is not confined to the setting up of an ordinary catarrh of the trachea and of the bifurcation, as many have maintained. I certainly shall not dispute the fact that

tch a catarrh is present or may he present ; and this condition

• Letrerioli, Jahrb. f. Kinderkranlh,, 1870, iii., S. 534; 1873» S. 430.^ ^ecbainer, ibid, 1876, x., S. 174.~Barirer, Bert, liin, Wochtiwkr., 1883, i.— ia»hler, Otutieke MtilkimU^ 1886. No. 74. i..4»7.

AU

D1SBASE8 or TOB RS8PIBAT0BT OBGAKS,

tua in fact been proved, by Wyn^oscopic ex&minaiion to oocor, at least on the mncoos membrane of the lanrnBc and trachea.^ ETeiyone, however, who has once heard a fit of whooping coogb most admit that there is something more in it than the mmt catarrh — namely, a nervous element. It is this that gives the peculiar character to the attacks and manifests itself on the one hand by the spasmodic violence of the expirations, and on the other hand by apnoea, and by the crowing soand of spasmus g^ottidis. I would further remind joii of the symptoms di»- scribed (p. 453) as constituting the aura of the attack, and alao of the almost invariable vomiting. I grant that the retching and vomiting of mucus at the end of the violent paroxysms must he regarded simply as a mechanical act, resulting from the violent COD traction of the abdominal muscles in coughing ; for we fre- quently see the same thing result in children especially from other violent paroxysms of coughing having nothing to do with whooping cough, if the stomach is very full. We must remember^ however, that many children vomit even when the whooping cough is very slight; and likewise that cases occur in which the vomiting forms the most prominent feature of the paroxysm, and may even excite serious anxiety by its persistence. I have known children who, after a short attack with no crowing what- ever, at once brought up the whole contents of the stomach, while others even in the intervals of the paroxysm vomited all their food and gradually sank into a state of serious debility, although no cause for this could be found in the festive organs themselves. Such vomiting cannot be looked upon as other than nervous. It is as yet an open question whether a reflex excitability of the medulla oblongata acting through the vagus is to bo blamed here, and in what way exactly the specific contagion exerts sudi an influence on the central nervous system. It is at any rate certain that pathological anatomy gives us no explanittoD of it, and that other changes which are found post-mortem — especially the much- talked* of enlargement of the bronchial glands — are only to be regarded as sequelae or compli- cations of the disease.

Whooping cough often occurs in more or less extenstvo

* Behn {Wiener mU. Wochetuckr^ 18M, ^ viA iSl UeyQtBlkbUZtileeJkr.f. lUn, MeJ„ i., H«ft 3)> luid Herff {DtuUeUt Arth,/. Urn, AteJ,, Bd. xrcU., No. 3 tmd i), deforibe thift c&tarrli while Boesbnoh (BtrL Urn, UodUiwoAr., IS, tS9Q) ir&« uiii»bl« to Mikfj hltoMlf of its proseno*.

WHOOPIKO GOUOB.

4C5

n

idemic8» which in general are not confined to any particular seaaon of the year. A certain relationship to measlee, which West has drawn attention to, cannot- bo overlooked. We often observe not only tho combination or auccesaioti of the two ^pidemicsi but also tt appears to me that individual patients who are suffering from one of these diseases seem to possess a peculiar predisposition to the other. The combination of these two diseases in one and the same individual is always a serious matter; for in these cases there almost always arises an extensive and particularly obstinate bronclio-pnonmonia tending to become chronic. It is w^orse still if a child who is already sufferinrj from whooping cough and broncho-pneumonia takes measles as well. Id such oases I have seen c^'auosis appear even before the outbreak of the eruption, the measles-rash at once becoming bluish ; and after a few* days death ensued with symp- toms of carbonic-acid poisoniuf^. Nevertheless, as I have already mentioned, even this complication is not uect3ssarily fatal. The combination of whooping cough with diphtheria, which I have not uncommonly seen in tho hospital^ I regard as even more serious ; but even here we must not at once lose courage, lu a girl of II, in whom a complete loss of voice had already made extension of the disease to the lar^>Tix probable, perfect recover}' took place notwithstanding. I may mention that in this case, instt^ad of the crowing inspiration during the paroxysm of the cough, a quite harsh, almost croupy sound was heard, evidently caused by the swelling and roughness of the laryngeal mucoufl membrane. Should tracheotomy have to be performed, the retarding influence of the whooping cough paroxysms is to be feared.^

You will have seen from this description that w^hilo the prognosis in whooping cough is favourable so far as the disease is concerned, yet serious danger to life may arise on the one hand from the extreme youth at which it someiiraes occurs, and on the other from certain of its complications (bronchitis, broncho-pneumonia, convulsions). Further, even after complete recovery easeous deposits may be left behind in the lungs or bronchial glands, and may later on form the starting-iwint of miliary tuberculosis.

' In guc waae the wjurnl broke open ftgaiaaftor 2 months (Boger, hceit, V- 6M).

80

or THE ftKflPnUTO&T O^OkS^.

In Ibc tresiment, onfortniiatelj, yon will not acquire marh credits The enonnous number of remedies recommended irom of old for this diseftse, is of itself safficient to prove their ineffi- ciencT. We do Dot possess anr remedy capable of catting abort the diaeasej especially when at its height ; while in the last stage, when natural recover}- sets in, apparently every remedy is helpful. A second fact worthy of notice is, that whooping coQgh^ like every other infections disease, may occur in a very mnch weakened, so to speak abortive, form, in which it mns its coarse in a much shorter time than asnal, and is recovered from without any other treatment. Every physiciaD, like myself, has met with such cases, I supi>osc (although I regard as somewhat doubtful one mentioned by Trousseau, in which the disease is said to have lasted only for 8 days) ; and therefore I think we cannot be too caatioos in judging of the results of treatment in this disease. You will therefore excuse me if I do not go over the list of all the drugs which during a number of years I have tried, either on my own initiative or acting on the recommendatioQ of other people, and found ineffective. I have now come to put trust only in one, namely morphia (Form. 10), which is far more effieadous than the much- used belladonna — at any rate in relieving the violent attacks, espe- cially those occurring during the night, and in diminishing their frequency. It does not, of course, influence the general course of the disease. In prescribing this remedy, however, especially tn practice among the poor, you must never omit to charge tlia mother to stop the medicine as soon as unusual sleepiness shows itself. Owing to this precaution it has only once hapi)ened in my practice that a child slept uninterruptedly for 18 hours without being disturbed by a single fit of coughing ; the attacks at once set in again when the narcosis passed off. Further, I knew another case of a child (6 months old) being poisoned in some inexplicable way, and who showed symptoma of collapse, narrowing of the pupils, and coma ; fortunately he recovered under the use of cold douches and restorati^-ea. I have always been very cautious in administering the medicine, and I have never yet had any mishap occur, even when giving 1 — 2 teaspoonfuls daily for weeks, X therefore prefer this modicine very much to all other narcotics, and especially to a drug 80 dangerous ftp fttit)pi" *^ I would only recommend

I

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WHOOPfKa COUQH.

467

I the use of morphia in severe cases with at least 20 fits o^curriuf: %'ltbiii 24 hours. The bacteriological explanation of the disease, although uot yet proved, has at least ha^l this effect, that attempts have been made in varions ways to deal directly wilh the supposed pfernia of infection. Inhalations of carbolic acid vapour were first tried (Bnrchard, T homer, and others). These were much praised and replaced the former plan of sending the patients to reside in

k gasworks, ivhich I have always regarded as inadvisablCj owing to the danger of catching cold. My own experience as to this treatment does not allow of my giving a final opinion ; because its results are sometimes strik- ingly favourable, sometimes doubtful, and sometimes there are none at all. I can say, at any rate, that I never knew of it ^_ doing any harm. We may either order a 1 — 3 per cent, solutiuu ^■of carbolic acid to be inhaled from a spray-producer several times ' a day, or if there is anything to prevent this we may charge the air of the nursery with the vapourised solution and hang over the bead of the be<l a sponge saturated with it. We may also order a sponge thus treated to he held before the child's nose several times a day, bo that the vapour may bo inhaled for several minutes. I have entirely given up other forms of inhalation — chlorofonn, benzoin, salicylate of soda, turpentine, I tannin, quinine, A:c. As to the painting of the pharynx ^■and larj'nx with parasiticide (1) substances which has of late been ^^much employed, we may object, to begin with, that we know as ^^ little concerning the position of the bacteria as we know about ^■themselves, and wo can therefore have no means of knowing ^^ whether we really reach them with the brush. The method, however, is certainly worth a further trial, as Moncorvo' says that he has seen good results from painting the entrance to the larynx with a 1^2 solution of resorciu. Also injections of salicylic acid (1:1000) or of corrosive sublimate (1:10,000) into the nose, as well as insufflations of quinine or benzoin into it have been recommended for tlie same purpose.^ Finally, paintini^ D pharynx and larynx with 5 — 15 per cent, solution of muriatL"

* '* De 1* Q&tare de la coqnelache et de son tnut«nient par la rrHun-iiio " : Kio If! Janeiro and Parip^ 18^ and 1885.

* QoldBohmidt, I^eutsche mcd. J?eiV., 1885, Ko. 61.— Miohftdl, Dtvtithe mrd Yookef^hr , No. 5, 1886,

468

DISEASES OF THE RESPIBATORt OROAKfl.

innm-

of cocaine is the most recent form of local treatment.^ Tbia deadens the sensibilitj of the parts, and is said to have frequently brought about a rapid diminution in the frequency and sererity of the attacks. Moncorvo*^ recommends that the two methods shoald be combined (the treatment with resorcine to follow the painting with cocaine).

My own experience with cocaine has not been satisfactory* Several cases (treated iu the ward) which were painted thnce daily were improved for a time, but not permanently. Others treated in the polyclinic (with only one painting daily) were eyen less successfuL I do not think that this tedious and often difficult proceeding deserves the praises wbl.l bestowed upon it.

At any rate you must, I think, relinquish iiiiy idcu i»f c u 1 1 i short the whooping cough attack, and let the parents know fronl the first that nothing can be looked for beyond mere alleviation of the paroxysm* Wlien the weather is fine, as much of the fresh air as possible should be allowed ; on the other hand when it is windy and inclement — and also when the patient hss bronchial catarrh — it is to be strictly forbidden. Very oft^n, indeed, the neglect of this precaution avenges itself by ad attack of broncho-pneumonia. When whooping congh occurs during the summer, you will often be asked whether a change of air might not do the child good. Althongb a number of physicians consider this beneficial and even recommend certain definite localities — eg. residence on the coast of the North Sea — as especially favourable, my own oxpefience does not permit me to agree with this view. I have often sent children who had whooping cough to watering-places with their parents, eitber oo the sea-coast or among the mountains ; but I have scarcely ever seen any good result from so doing. The patients go on cough- ing as before, and the only result in such cases is one not to bo desired — namely, the infection of healthy children who canso in coutdct with the patients at such places. Only iu exceptional cases— as, for instance, in that of my own child — have 1 ttefu au attack of whooping congh which was in process of development , and had already the characteristic paroxysms, entirely disappear

* B»rbillton. Rem* oieiu., Ai»at, 1885.— Prior. Beri l/iw, Wochtnsckr^ ISSiw No. 45. 4li,

• " De I'ranploi du rWorl.v.lmt. luoK« :** Rio, 1S8S.

do CoCoixi6 djUin lo iruiloTnont

1 I

WHOOPING COUGH. 469

in a fortnight spent at Roichenhall. Sacli isolated cases, how- eyer, seem to me (bearing in mind the occurrence of " abortive'"* whooping cough abeadj mentioned) quite insufficient to prove the favourable influence of change of air or the merits of any particular locality. As to the treatment of the complications (eclampsia, broncho-pneumonia) you may consult the prescrip- tions already given for these diseases. Protection from whooping cough could only be guaranteed by the complete isolation of the children ; and this can hardly be carried out in practice, especially since (according to Roger) the isolation must last from 2 to 3 months.

470

SECTION V.

DISEASES QF THE ClltCULATOnY OROAK8.

Pathological changes in the heart are not much rarer in children than in adults. The age causes neither auatomicil nor clinical differences of any essential iraportance» and I may therefore confine myself to a comparatively short description of these diseases.

I, Affections of the Large Blood-iruBcl^,

There is very littlo to say about the affections of the larj;e blood-vessels in children, for these are extremely rart- Although Hodgson has observed ossification of the tempoml artery in a child of 15 months, and Andral calcareous platen in tho aorta in a girl of 5 years— stiO, these are exceptional occur* rences, and I have never had an opportunity of ohsening them; nor have I seen an example of aneurism of the aorta in child- hood.' Also the congenital stenosis of the aorta, which is generally situated in the region of the ductus arteriosus or at the commencement of the descending aorta, are much more frequently diagnosed in youtli, or even later, than in childhood ; although some of them seem to have some connection with tlie involution of the ductus arteriosus which spreads to the aorta. I may take this opportunity of mentioning that the closure of tbis duet (which in new-born children is about the thickness of a branch of the pulmonary artery) is brought about by an end- arteritis obliterans with the formation of new fibrous tissue, thickening of the walls^ and narrowing of the lumen. The process is noticeable on the 9th day after birth, it has usually gone on to the fonnation of a stricture in the middle of the duct by the 14th day ; it then proceeds further in both directions, and is generally completed by the end of the third week. The obliteration of the foramen ovale is completed, in 88 per cent, of

* Out oC 98 dMOB of iitieari«m of tbe ihomeie ikortA» thoro wm only onv luider 2(^ jroflirt ; And among 59 owe* of MieuriKtn of the kbdomiiuil «ort&, tkmrc wm x^i «T<«t) one luider that •«•.

CONGENITAL CITANOSIS.

471

tho cases, by the third month after birth.' Anything which causes a deficient filling of the left ventricle during the first period of life — snch as extensive atelectasis of the lung-tissue, ftctal pneumonia, or stenoBis of the pulmonary artery — must delay the process of closure of the ductus arteriosus. For under these circumstances the blood is continually flowing from the pulmonary artery through the duct into the insufficiently filletl aorta. The delayed obliteration of the duct may therefore in such cases ward off during mouths the evil eflects of the engorge- ment in the right side of the heart and the general venous system which would otherwise have taken place. Tho same may be said of the persistent patency of tho foramen ovale, which, apart from the causes named, may be due to local abnormalities of the foramen or its valve.

IL CotttfenUal Cifanosis.

} The persistent patency of the fee tal channels —ductus arteriosus and foramen ovale — was formerly regarded as the principal cause of congenital cyanosis. As the cause of this was supposed to be the mixture of arterial with venous blood, it was bought that the abnormal colour was due either to the remain- ing open of these channels or to an abnormal communication between the two arteries or ventricles owing to an aperture in the septum between thorn. Now, however, we know that cyanosis also occurs when there is no mixture of the two kinds of blood, and that, on the other hand, such abnormal communications have been found in children — and even m adults — who during life presented no trace of cyanosis. Zeyetmayer*s case is well known, in which the entire ventricular septum was absent, and still there was no cyanosis. Equally well known is that of Breschet, in which the left subclavian artery rose from the pulmonary artery ; and yet the affected arm was normal in colour.

Let us consider cyanosis for a moment. From the time of birth, or at least very soon after it, there appears a bluish-violet tinge on the cheeks, point of the nose, hands and feet, especially on the nails and the visible mucous membranes (tongue, buccal macoufl membrane^ entrance to nostrils, palpebrtd conjunctiva).

^ - — --

.81

w

I

472

DISEASES OF THE CIRCCII.ATOBT OBOAIIS.

Tlua is considerably heightened by screaming, crying, ist&cldng. any energetic movement, or on being exposed to cold air. Bat daring the intervals the cyiiuosis may bo bo slight as scarcely to be noticed by a nou-medical eye. After it has lasted some iimn — but occasionally even in the first months of life — there is developed a club-shaped (or drumstick-like) enlargement of the terminal phalanges of the fingers and toes, and often a claw-like condition of the nails. Two or three times I have noticed alsa that the dark-violet gums presented a spongy character like that seen in scurvy. They bled readily either spontaneously or on being touched, and wore separated from the teeth at their margins. In one girl of 1 J years this appearance was bo nuurkecl that her mother brought her to the hospital on account of it, although she had entirely overlooked the cyanosis. The tempera- ture of the extremities is very low (sometimes as low as 89' 6^ or 82'4° F.), while that of the body as estimated in the rectum is found to be normal. Added to this we often have a condition of general debility, languid movements, sleepiness, backward growth and intelligence, and, fijially, the whole neries of wcll-kno^u symptoms which are characteriatic of the various kinds of heart disease^ — odema of the hands and feet, epistaxis, dyspnooie attacks (especially after violent movement), fainting-fits, enlarge- ment of the Uver and spleen, dc. On physical examination we often observe a very distinct increase in the size of the heart, especially of its right side, systolic or diastolic murmurs, antl perhaps a pulsatile thrill; but in many cases, also, noabnor* mality at all. Other malfomiations may be present at the same time, among which I may mention as rai*e conditions which I have myself observed, obliteration of the auditory meatus, malformation of the external ear, and eccentric position of the two pupils.

From these symptoms wo may, it is true, diagnose with certainty the presence of a congenital malformation of the heart, but in most cases it remains an impossibility to discover the exact nature of the malformation. As I cannot here discuss the foreign treatises on this subject — which indeed ore generally only compilations and criticisms — I wnnld refer those who are interested in this matter to the excellent work of KauchfiiBSi^ who has had at command an unusually laige

I

CONQENITilL CYANOSIS.

473

r

Amouni of material of his own and has also broaglii together almost everything that is known on this sabjact. You mnsi not, however, expect any great practical use from it. The author himself is obliged repeatedly to acknowledge that all endeavours to find definite diagnostic criteria for the different malformations, can only afford at most a more or less probable diagnosis. These malformations consist either in aperturcH by which the two aorioles or ventricles C3mmunicaie with one another, or in larger defects — which in their moat extreme developments take tlie form of complete absence of the septum — or in stenosis and atresia of the conns of the pulmonary artery, of that vessel itself, of the aorta or of the anriculo-ventricular opening ; finally, in trans- positions of the largo blood-vessels, the pulmonary artery arising from the left, the aorta from the right ventricle. The insuperable difficoltiea in the wa}^ of diagnosing these abnormalities are^ moreover, increased by the fact that in the majority of cases there is a combination of two or more of thom; and also that the symptom to which the physician's attention is principally directed — namely, the congenital cyanosis— may be completely absent* This visible symptom does not accompany every malformation of the heart. 1 have often met with such t-hildren in the first months of life or at least in the first year, who either suffered only from attacks of dyspncpa or else presented no cardiac symptoms of any kind, and were brought for treatment only on account of an affection of the lung or boweh Of this, allow me to give one example :—

Child of 30 diiys admitted witli congenital syphilis. From 10th to 21«t March, 1873, a febrile pneumonia of the ri^ht npjwr lobe (T.PT'— P9^F.; R.56— 70). No cyanosis; noabnormalitjof the heart audible. On post-mortem we foiind (Ix^sides the pneu- monia, syphilitic affection of the bones and niterfititial he|iatitig) conisiderable malformation of the heart. The ventricles communiciited with one another by a large af>ertnre, the septum being almost entirely wonting; and that between tbe iiurieles whb very thin. The tricn.spid valve was wanting and the mitral valvo was itmerted at one extremity into the right side of the heart. The arteries norraah'

If the children live for some years, there generally, of course,

' Very t%te indeod are cases tnoh aa tbat obBervod by Barth (fVamct m^., Jaui, 1880)^ in which congtmital endooarditii was disoorered eyen before birth hj aiiKmltation of tlie fastus (Tond blowing tnarmur replacing the fimt •aand).

474

D:hEA.BE8 of THB CIECULATOBY OBGJlNS.

occur more or less marked symptoms, usually with cyauosis* They arise either under the influence of chance respiratory affections, or from endocarditis which developes in connection with the abnormiil apertures or congenitally-affected valves and openings — just aw in adults it arises in the neighbourhood of old valvular disease (endocarditis recurrens). Under these circumstaneeii the hitliorto latent malformations become manifest and we now recognise on examination (which in many cases, is now made for the first time) that there must have existed an abnormaUty of long standing. The cases of stenosis and atresia of the pulmonary artery or its conus usually produce the most marked s^TUptoms, and they also form the commonest cause of congenital cyanosis. In many cases it is impossible to determine whether the stenosis and partial atresia of this artei'y are due to foetal endo- and myocarditis or to a primary' arrest of development to which an inflammatory process has subsequontly been added. This stenosis most always give rise to dilatation of the right side of the heart and considerable engorgement in the entire venous circulation (of which, of coarse, the cyanosis is an expression). The cardiac dalness then extends beyond the right border of the sternum, the heart's impulse is visible and palpable over a larger area than usual, and a ihrill can often be felt along with it. A secondary systolic murmur is ailso auilible over the heart, being loudest over the oriJlce of the pulmonary artery and betw^een that and the clanele ; occasionally also over the whole thorax and back. Variations, however, in the symptoms may be caused by the presence of other malforma- tions of the heart at the same time, which renders the diagnosis more difficult. Nor are examples wanting in which the heart Koumls are quite pure, without a murmur of any kind. The diagnosis of malformations of other parts of the heart is still more difficult ; and you will excuse me, if I do not enter further into particulars regarding it, as in practice the cases for which these hold good are of exceptional occurrence.

As to the course of cases of congenital malformation of the heart we can never predict anything with much certainty. The greater the obstructions to the venous circulation a? * ' '/sa they are counter-balanced by other compensating mail >ui

(apertures in the septum, persistent patency of tho ductus arteriosus) — the shorter will the child's lifo he. Children witli

I

OONOBNITAL CYANOSIS.

475

I

■

I

very marked stenosis of tlie pulmonary artery die early, even although the foramen ovale he still open and there is no cyanosis ; while children with less marked stenosis may grow up to youth or even live beyond that, especially if the fa'tal channels are not closed or if there are apertures in the septum. The same may he said of cases of stenosis of the aorta, which are almost all ohserved (and partially diognosed) for the first time only at a laltr period of life. I have frequently seen febrile diseases {e.(i*f the acute exanthemata) run their course in such ciiildren without doing any harm. The fatal issue takes place at last, in these as in all other diseases of the heart, either suddenly by syncope or from the result of some disease of the respiratory organs which would not of itself have been dangerous to life (diffuse catarrh or pneumonia) , less commonly with symptoms of gradually in- creasing venous engorgement and dropsy. Caseous pneumonia also, which may be associated with similar processes in other organs and with miliary tuberculosis, is sometimes the cause of death, and the immunity of cyanotic patients from tuberculosis of the lunggj alleged by Kokitansky, is certainly not borne out by the actual facts.*

As has been already mentioned, it often occurs that on examin- iog children who have been brought to us on account of some entirely different ailment, we find by chance valvular diseases and their resultH, which are causing either no subjective symp- toms at all or at most a scarcely noticed palpitation or shortness of breath when the patient runs or ascends stairs." Even the most careful history may fail to throw light on the origin of this aifection, and we may be told that the children have always been healthy and have never suftered from rheumatism, scarlet fever or any inflammatory chest affection. We are therefore obliged in such cases, in spite of the absence of cyanosis, to assume that the disease has been congeuital. I shall take this opportunity of romindiug you that in very young, even in new-born children, small spherical projecting blood-extravasations occur on Ihe cardiac valve, especially on the free border of the mitral, as

' Bttuuhf UBfi, /oc. cit, S. 1»2.

* Similarlj, a boy of 8 yoara, on being oxivmiiied daringr * ^Vight attack of arttcalar rhetunatiBm, was found to havQ his heart on the rigbt aide. Thu cardx»c dolnesti and imptdae wera only to be found on the right sido of the atemtmi, the right nippla roae with the ayatola and the firtit Mound w&a aoeompanied by a blowing mammr. The abdominal riaoeTa wore, howeTefi in their namml position.

476

DISEASES OF THB CIBCULATOBT OBGAKS.

described by Lnschka long ago.^ More recently tboso valve- lifematomata liave been investigated by Parrot.* He has met with them often in new -bom children at the venous orifices on both Bides of the heart, in the form of very Bmall projections (in some cases, however, even aa large as a cherr)- stone), black or violet in colour and of globular or conical form. These hfematomaU, which he attributed to a rupture of Lntra-valvulor blood resseb^ are situated under the most superficial layer of the endocardiam. They seem to arise very soon after biith, perhaps even before it, and generally disappear within the first few months of Hie, their covering gradually shrinking^ while at the same time there is a proliferation of the epitbeliuni and connective tissue in the neigh- bourhood. It also appears that small hard nodules covered by epitheUum and either with a broad base or pedunculated, which not uncommonly occur in the same situations and have already been mentioned by Cruveilhier' and others, may grow from the hsematomata. It is, indeed, possible that owing to an abnor- mal process of resolution occurring in such hfematomata, shrivel- ling of the borders of the valves and at the same time stenosis of the ostium, or incompetence of the valves may occur, bxit when these are found in older children, it is no longer possible to ascertain how they arose. The valvular disease would not in that case bo really tongenital, hot would have arisen during the first few months of life.

The treatment of diseases of the heart which are either con- genital or have arisen during the earliest period of childhood* must be limited to enjoining the quietest possible life; and the carrying out even of this prescription in older children — whom it becomes necessary to separate from their playmates- meets with great, even insuperable difficulties* In other rcspecU also, the treatment is exactly the same as that of organic b^ disease.

III. Jnfl^tntmatmi of th** Pencm-dhnnf Endocardium, and Myocardium.

In many cases an attack of acute rheumatism cob be

» Vifek<iw'$ ArchW, li., Heft 2. • Arch, fit phytiol.^ No»i. 4 and S, 187^.

' For uiother <iplikiiAiioo of tho»B '* nodnJiHi ** buiwid on a«V4looaMa^JiaT»l JithrhJ, KinderhtitK 1878, xui., S. 29.

INFLAMMATION OF THE PERICARDIUM, ETC.

477

assigned as the starting-point of organic disease of tbe heart. The time when this disease was regarded as of rare occurrence in childhood has long passed away. Since I shall have to return to this disease on a later occasion, I shall only remark here that although its occurrence in children is, as a rule, less common and less severe than in adults, the complication with endo- or even with pericarditis, is much commoner in them than in adults* Even in quite slight attacks of rheumatism (with hut little rise of temperature) which occasionally appear as hypenea- thesia of the Hmhs or joints without the latter being swollen, you must never neglect to examine the heart. You will often be surprised to find peri- or endocarditic murmurs in these cases, although owing to the apparent slightness of the affection you were not prepared to find them. In cases of advanced valvular disease we very often find from the history that one or more attacks of acute rheumatism — especially in the joints — had occurred months or years before. As these diseases of the valves and their results so completely correspond to the same conditions in adults, it is unnecessary for me to consider their physical signs more fully. With regard to the subjective symp- toms, I shall only mention the fact, that although in adults cases of prolonged compensation and consequent latency of the valvular disease are not rare, the same thing appoars to me to he still commoner in children. No noticeable distress is caused by the violent movements in playing or running up stairs, and in many cases the disease is first discovered by the mother observing the violent motion of the heart when she stiips the children to bath them. It is only when the compensation l>egins to bo disturbed, that the cardiac symptoms, which you arc well aoquainted with, set in ; and these sooner or later bring about the fatal issue. Even from an anatomical point of view the disease is just the same in chOdren as in adults ; in the one case as in the other we find dilatation and hypertrophy of the ventricles, the brownish-red induration of the lungs, the hivmor- rhnfric infarcts, the congested kidneys find livei% the enlargement and induration of the spleen, the fpdema, and the dropsical effusions in the various cavities and in the alveoli of the lungs.

Although in many cases the valvular disease due to rheumatism first appears months or years afterwards, still, on the other hand, examples do occur of a much more acute course.

478

DISEASES OF THB CIBCtrLATOBY ORGANS.

Anna M., 7 years old. Formerly always healthy. Acute articul vheumatUm, especially iu the lower limbs* intheiniiitile of Pecem^ Jjcr, only lasting a few days. Between Christmas and Kew Year when she was feeling quite well again, she suddenly fcU ill onte more, with palpitation, diminished secretion of urine* cough- ing, and frequent pains iti the region of the heart. Admittetl into the ward l'2th February, i.e., aViout two months after the lii>ginning of the illness. On examination we found general anaemia, t'fttarrh in Iwth lobes (especially in the left). congU, and dyspnoHa, ■rhe cardiac dulneas reached to the right border of the stenmin« above to the third rib» on the left to the mammillary line. Heart's impulse heaving and diffuse. Indistinct apex-beat outside thr nianimillary line in the 5th intercostal spac^e. The first sound of the heart obscured by a loud systolic murmur ; Ijoth second sounds pure and unusually loud. Pulse small, 120— 144 ; no fever ; urine very scanty, marked albimiinuria. On the 21st the temperature suddenly rose to 1<H° F.. then fell again rapidly, and by the 24th hud not risen again above 100^ F. On the morning of the 22nil distinct pulsuK bigeminus ; pericardial friction at the left border of the sternum. Increasing collapse (T. 981° F.). slight cyanosis, extremely rapid breathing {B4y Death in the night oi the 24th,

P.-Jlf.^Heart about thrice its normal si«ejx)th ventricle* much dilated and liyfK*rtrophied Aortic und mitral valve« thickene«l along their free margins, somewhat retracted and covered with greyish-red wurty growths. Recent partial adhesions of the twt* hvyers of the pwricardium on the anterior eiirfnce of the septum vcntriculorum. Diffuse bronchial catarrh; oedema and brownish- red induration of the lungs.

In a girl of 7y ears, who in October, 1874, had had u slight attoi^k uf acute rheumatism combined with endocarditis. I found (March. 1875) not only the signs of mitral incompetence, but also even then very considenible hypertrophyand dilatation of both ventricle*.

A boy of 7 (May, 1882) had, 12 weeks after the beginning of a rheumatic attack, shown signs of e3ttreme eccentric h\ hv

with changes in the aortic and mitral valve, and a < it

welbmarked bulging of the prtx^ordial region.

In a \n*y of 10, who took ill in May with an attack of aculv rhcumutisni aud peri*eiid«x*arditis, and since that time had repeated relapses, wc fouttd (on the 10th December^ cyam und all the symptoms of far-advanced heart disease. At the post- mortem we found ijieompetence of the mitral valve, hypertrophy of lioth ventricles, complete ndliesion of the pericardiaro, broi»n induration of the lungs, Stc,

A girl of 10 years took dl with acute rhcumatlsra (witk Alight .ehoreic symptoms) in September, 188<?. By i" Hie o!

November she presented ih** «vmptoma of incon f the

aortic valves and hypers i"ft ventHclo.

INFLAMMATION OF THE PEIUCARIHUM, ETC.

479

You find, therefore, in tbeso cases eccentric hjrpertropby of one or both ventricles already developed as the result of valvular diftease only a few months after the first onset of acute articular rheumatism. In the first case the course was so sudden and acute that compensation was altogether out of the question, and the end was further accelerated by complication with diffuse catarrh and by the recent peri- and endocarditis which were finally added to it. This "endocarditis recurrens" we have often found post-mortem in old cases of valvular disease, which was cither confjcnital as in the case above or else acquired at a later period. Although this process is usually discovered 6rst at the post-mortem, it can occasionally be recognised at thr bod-aide.

Tn SeptcmlM?!*. 187l?, I liad under treAtmciit for acute articular rhcuraati^ra with endocarditis a gir! of 5 j'cara who had previously l»eeTi healthy. After her recovery the systolic mtirmiir at Ihf mitral valve persiHtcd without diHturhing the child's general healthy and of this 1 was able to eonvincc myself after a yearV Interval, in November, 1873. In January, 1875— 1.<?. about H yearw after the beginning of the illness — a fresh endocarditis developed in the already much dilated and hypertrophied heart, manifesting itself by fever, increased loudness of the murmur, and cxtremr dyspnoea* and ending fatally.

On the other hand experience teaches that children get over rheumatic endocarditis better than adults do, and are more likely to recover completely from i ts results. In the whole course of my practice I have only had one adult patient under treatment for rheumatic endocarditis of many months' duration in whom I have observed a musical murmur entirely disappear and complete recovery take place, which I know to have been permanent. " In children recovery is more frequent, althoagh even in them a permanent %alvular lesion remains in the great majority of cases,

Clara F,. ^^ years ohU took ill in Oetobcr, 1871, with rheumatic liains and swelling of the joints of hands and fingers. There wai* high fever, rapid breathing, and at the end of the lat week a loud systolic rournmr at the af>ex, without any change in the percuHBion. Bronchial catarrh. After 14 days, all the Bymptoms had vanished except the murmur, which in spring, 1872, gradually Ijegan to grow fainter, and by Novcml»cr had entirely diBappeared.

Paul H., 6 years old- In beginning of February, 18*)8, he com- plained of pains in the upper part of the abdomen (especially on

DISEA8SS OF TB£ aBCULlTOBT OBOANS* ^H

stooping), dyspepsia, and moderate fever. On the 16ih a warm bath, in which the child took a severe chill. After 1 1 rhi) » violent fever* pain and slight swelling of the joints of the right hand and foot; flexion of the right knee-joint and adduotiou of the thigh. Both of these could only be overcome with severe pain. Dnring the next few days the joints of the hand recovered. h«t f>aiii8 with difficulty of movement appeared in the left thigh. Kever mode* rately persistent, bronchial catarrh, heart unaffected. After a temfwrary improvement all tlie s^^mptoros became worse again. On the 29th high fever, loud diastolic murmur over the heart, especially in the maramillarj- rt^gion, disnppearing as one pHJiued upwards. Vesicant, calomel with digitalis, tloncml improvement. On 22nd March, normal in everj* respect with exception of the atnemia and the persistent diastolic murmur. In the spring uf 1869 this also had entirely disappeared, and the boy remained healthy henceforward.

In the last case we see the endocarditis first appear with the exacerbation of the feyer and other s^inptoms of rheumatiam, an 29tli Febmary; while the first 9 days of the disense passed without any affection of the hearty and wo were akeady expecting convaleseenee to be^n. Such occurrences are hy no means rare.

On lV*th June, 1875, 1 was consulted about a lioy of 5 ycut* nn«j had already been ill for a week, w ith acute art icnlar rheumatism. In the middle of the second week the fever ui»l the pains cease<l for 'A days. Then, however, a fresh exawrljmtion suddenly took placr, and with it an affection of the heart. Pains in the region of the heart and loud friction along the $iternuro, following Ijoth »ountU of the heart, put pericarditis beyond a doubt. By local blood* letting, inunction with mercurial ointment, calomel and digitalis, considerable abatement of all the aymptomsi was brought about after 8 days ; the fever was quite gone, the friction could no longer be heard, but in its place a loud ^yatolic murmur was now audible. Some months afterwardii, when I again examined the chi1d« thiH murmur still existed.

In both of the last cases the hcart-alfection set m for the firBt time along with a fresh exacerbation of the rheumatism, lint eases do sometimes occur in which endocarditis appears as the first sign of the rheumatism, and the joint affection is only fonnd later on.

Paul F.,'>yeurti old, had been out of hovu foinb ,*,

with irregular fever, lo«8 of Bp|K»l ite and linuBually rapi . ig.

tt wa« only b day« ago thakUia ph} tiicinn in charge hud Ltetii a)4p

^

^V INFLAMMATION OP TOB PEEICARDIUU, ETC. 461

to discover a syBtoHe mitral murmur, and therefrom to diaffnoso C'»idocarditi.H. When called in on 13th May, 1875, T wiis nhlc to ' confirm this. The hoy romplained on this day for the first time of imlna in the limhs, jmd in the evening an attwk of multiplo rheumatism suddenly came on in t!ie joints of the feet, knees, find arms, with severe pain, stiffness, swelling and aleeplesgnesa. T. 102*2^—10-1°. No ehange during the next few days, Digilnlis Iried and found Ui8elea8. From 2(5 — 27th May the rheumatiKm spread to other joints. Extreme dy»pno>a; sternum and neigh- lnouring parts dull on pereuasiou, herirt-aouiidH and murmur weaker, bo that a complication with per ic ard ia 1 eff u si on seemed probahle. Death on 3rd June from rapid increase of thi.s con- dition, the pulfto heooming small, the wkiu cyanotic, and the arc;i of dulness rapiilly extending. PoKt-mortem refused.

IJore, then, too s^e the endocarditis not following the onset of ncute articular rheumatism, but preceding it hy at least 5 days; for I ara of opinion that tho indefinite illness which the boy bad suffered from for 12 days was doe to the endocarditis, oven althongb its presence could not bo discovered on physical examination. So long as the endocarditis does not aftect the valves or the openings, no abnormal murmurs may be present. Indeed it is proved by certain cases of endocarditis ulcerosa in adults — c.(j. during the puerperium — that even ulcerative lesions of the valves may exist without being accompanied by adventitious sounds. I shall never forget the wife of a medical man, who for at least a fortnight presented no symptom beyond general malaise and remittent rise of temperature with a very quick pulse ; no organic lesion could be made out anywhere, in spite of the most careful examination. It w^as only after a lapse of 14 days that I discovered a steadily increasing systolic murmur over the lieart and diagnosed endocarditis, which the post-mortem examination confirmed* We tind in children also cases of this kind, which for some time are not recognised, and may readily pass for typboid. In a boy of 3, wbo bad suffered some months before from a slight attack of rbeumatJsm, I found endocarditis, tbe presence of which was only indicated by bigb fever (lOS'T^ — 104'9° F.) during 8—4 days. It was only after tbat period that endocardial murmurs were beard, and they were soon followed b}' friction. The case last given was quite similar to this one (Paul If., p. 460). Tbe occurrence of rheumatic pericarditis, tvbicb appeared as a complication in both cases and wbicb is by

31

462

mSEASES OP THE CmCULATORY OROINS.

110 means rare, may render the diagnosis diffiealt owing to ibe

julilition of its auscultatory signs.

Eniil P., 11 yeiir« old, a1x>iit whom 1 waa tuiisultrd on HUH Dt'cemliier, 1877, had taken ill aliout a week Iw^fort* with a feverish sore throat. A few ilavH iiftei-wards painful swelliuj; tkiul immo* IjiHty of both aiiklcn and knee-joints, for which utid. Mulityl. p>, ivHH. I'vcrv '} hours, was ^ivcn with jtjfiotl rei*nlls. Sin<u- the ITth, ?«iidden violout piuui? in the left side of the rhei>t und iucrtMiAcd IVvei'. P. 132 rt>tulur. Thcie wjik a loud s«y8ioIic murmur nt thn apex which hc'oame Ichs diMtinct alxne. and at ihc sann* time* a frirtion-sonud over the lower half of the Kternum »i.'eom' imnying Ixith sounds of the hearts and extending beyond thi^ I'pigftstrium, and as far as the raanima. PereiiaHinn uiuiltrri'fL KliNter between tlie nipple ami sternum; dio^tali^, Ki'^rht ilaym h»ler The fevt'rand perir ui'dial friet ion liiid disapy>eared. Tlie endocardiiit nnirninr, how(.vci% nmainedunehanpod.andthe ImyHtill ronr]ihiinetl I f Mharp puin», and a feeling of opprL*«ijLon, and was often ohl)>^«?fi to «b*)|> for hreatli in the midi^t of talking. Pot, l<tA. On llrtl January, 187d. tlie ehild *va« well, hut for rheumatie paiitf in llie left shoulder. The mitral murmur was »liil present fur ti yearu after, ho that there must hari) Itcfftt ji^rmaneiit valvubr di^(»Asc.

Corl H., 8 years oM, t<X)k itl in lite end tti Deninbtr with a slight attitek of artieular rhenrn«tiwnj, A few dayti after, entity I'Hrditiij set in (high fever, tiuitk hreJilhing, pain^i in the h'ft xidi* if the chest, und loud Mowing niurnuirts. aeefuiijianying both b.outid» «»t tlto heart), fre-bag and digitnUs, After nomv days no ]>o*rt» Konncls could any longer beheanU lait only twu niurinur*N. Blister. Two days after, the niuriunrK were less loud, and botJi MonnU^ of the heart eould again he mode out; at the s^anie time-^ however. there- wa« pericardial friction at the noddle of the 8t<*ruum Hud at its right border. The eardiae duhu^is^ now gradually ei* tended lieyond the tsternunu and <»n the lilth January p<*SM*hnT to alK)ut t inehca Ix^yond its right Iwjrder, while the dyi^pumn ma^ i*onsidev»bly Aggrnvated hy the oeeurrenee of pjiMi ro- puentn on i» of the hd't lower lobe, P. l^Opn/tty full; K, o«j— iHX llry-rnpptiii;, digitadii), wet con»pres«es, iee-bag over the heart when tli« veven?. Although the diticase hatl taken the h»nn of j- i

migrans, and had alTected the left upper IoIk' by the 17th, there uijvorrhelos^iis oeeurrcd, to our snr|>riHe, » gradttrd imprtn'ement »vf all the thi-catening symptoms. The jieHearitittl frirtion had di< lfc|>|-»ear(xl hy the 16th. The enlarged eardiar duUiouM (]> ' 4j

ll'ITuHion) iHv^oded within itti normal limits, uud by th< •t'hild wa?< able to leave hix Wd, The striking faet ' . *r:vrr, that the a|^»ex Ix'at eould always be fdt ?,l\ the left ni(f|de Vtnc. eren when the child \tu^ lying hh UU ei^bt

I I

INFLAMMATION OF THE PERICARDIUM, ETC.

483

Hide (ndhe^ion). SevomUyeai's after, I foimd on examinatum alt the yymiiUinjs of incurahle vftlve-iliKease.

Ill both cases, tben, pericarditis was added after a few days to uu already-existio^ rbeuruatic eiMlocarditia. Aud the re»ulls of this disease, if we are to judge l*y tbe physical signs, ma}' indeed appear to be recovered from more satisfactorily than those of endocarditis, hut still adhesions of the two layers of the peri- cardium, or of the pericardium to the pleura, may be left behiiKl* As a rule, when pericarditis sets in, we find the friction first over the haae of the heart, while the systolic mnrumr is moat generally found at the apex.

As to the relationship between chorea and rheumatic heart- alfeotions, I have already j^iven my opinion (p. 207), to the effect that both chorea and endocarditis rise from the same source^ namely, from rheumatism— but that the former is not to be !"egardetl as depending ou the heart-disease alone. I would fortber call your attention to the fact that the fundamental rheumatic condition may be very trilling, and may even be quite f)verlooked» especially in children who are only huffenng from vague muscular and articular pains. Likewise, that the secondtiry endocarditis and chorea may be the first conditions that come to the knowledge of the physician ; and be is then inclined to attribute the neurosis to the former alone.

Scarlet fever may cause endocarditis, allliough much less fie- »juently than rheumatism does, and may leave behind a permanent valvular lesion. AUhoogh we must not regard every pass lug systolic murmur that occurs during the course of scarlet fever as a sign of endocarditis,* still it cannot he doubted that it is such when the murmur continues for some time unchanged and is accom- panied by a feverish condition. \\'e observe this complication both during the fever itself and in the course of the subsequent nephritis,

Willy K., o ycnrM old, aihuitlid mi Int Feluuary with Mcarlatiiut simplex. The fever, which pfrfii«ted without UBCortuinable reaBon during; the desquamation temp, (m. 101 '3°; ev. 102*9* i\)

Any liigh feTor may, w ie well known, imk^ th« Hmt sound ^ tbe heart <f?Tnj>orarJIy prolong*c?<l or even 1)!owinp, Wc Inu^t uJao ^nard npiinst miatHkuig frtv »i heart-intinimr a hiLrfih i"€jq>ir.ttorj niuimur ifthicli nccuri i:: *:ikC8 where tUo

4M DISEASES OF THB CIBCULATORY ORGAKS*

fell m end of the 8e<cond week to 101*3^ F, iii the Dvetuug* and tin- child fell quite well. On the 12th February, a short »y«tolir murranr was heard over the heart for the fir»t tiiiie. Thl* hecarac every day more distinct, mid was i^spiciolly loud in thr- region of the apex, and the pulmonary j*eff»nd m^iujkI wh8 aomewliiit accentuated. Apex-beat and duliR-hs iiortiuiL P, IIVJ, some w hut irregular. During the next few davs we heard, Ite^idcs the nystolic miirmnr, a short crackling pound lo the left of the Htenium, on the level of the third rih, during thr height of jn*4pini* tion; but it waa often abo aynchronous with the feyfctole. Tlie origin of this sound wa« the less clear to ine. l>eciiuse, during the next few duvR, it vr»& sometLnies audible, and sonietinikeii htbd disappeared. Ah, however, the temp, again rotse in the evening tiuring this time to 103*6^ F.» 1 ordered 6 wet*cn]>a to l>c applied to the pnecordium. and gave calomel and digitalis. Frum the 17lh tmly slight rise of temperature in the evening; pultnc nonnal, the systolic murmur liecoming weaker. After the child liad ^mt^ through an attack of nephritis, with fiMienia and at»citee« the murmur at the aficx wan 4<til1 audible on 22nd A pril i on the 25ith it had quit** disappeared.

That this was really a case of scarlatinal endocarditis (und, indeed, of slight pericarditis also), is proved by the persistant fever, the rather quick irregular pulse and the systolic murmur, which took two months to disappear entirely. It is to this long duration and slow disappearance of the murmurs that I attach an especial significance, such as cannot be claimed for merely te mpor ary murmurs. Thus, in the course of sc4trkti«al nephritis I have observed two cases in which there was a mitral systolic murmur, only audible for 24—36 hours. In one of llio causes this ^ras associated with in-egnlarily of the pulse, and di** appeared without leaving a trace. In other coses, again, thew< was a reduplication of the first sound or a "galloping rhythm of the heart-sounds, which lasted pome days or even weeks, and then disappeared without leaving a trace. Further, in a caac of scarlatinal synovitis of the acromio-clavicular joints ending in sappuration— in which the diagnosis was confirmed post- mortem—there was a systolic murmur which was only heard during the highly febrile onset of the disease, hut had ceased to be audible by the following day; and at the po- m the

valvular apparatus appeared quite normal. On tL ^ band

it cannot be denied that the scarlatinal joini-affoction^ like the rheomatlc^ ts apt to be associated mth iufliuiiiiuUoffy

I

INFLAMMATION OF THE PERICARDmM, ETC.

485

processes iii the endocardium, less commoBly in the pericar- dium*

Ricliard 8ch., t> years old, ailuutttd into tlic ward with scarkt fovcr un 14t]j Ft'hruary. Com|-ilicutioii with Blight broin-hitil catarrh ; hc«rL tjuite iinuffeetcd. On 19th, Ijeginniiig of deaquamu* tion, fever still continuing (ev. 1026*^ F.), owing to the prostjncc rif bilateral cervical adenitis and of right-sided otitis. On 22nd {T. in. 1038^ ; P. 1<J8) wc heard over the heart a distinct systolic murmur, eapeciftlly loud at the level of the 4th costal cartilajre and the left l>order of the Bternura ; area of dulneas normaJ, apex- Ix'tit in the .5th intercostal apaee abnormally distinct. On the following day, pain in the joints of hands and feet, hut no swelling (T. ev. lOi'V'i R 1IR>— 101). During the next few lUyh. pains also tn the knees, hips*, elbows, and shoulder-s. After 26th. abatement of all tlie symptoms and disappearance of the murmur On 1st March, nothing to be made out Ijeyond the ordinary so-eallcd ** galloping rhythm." From then till the 2r>th A])ril (on which day the ehihl \vvi.n disehurged) no abnormality wuk observed.

•Similarly, iu a chiUI who was Buffering from simple scarlatina, 1 observed a frei^h exacerbutioii of the fever (to 102t»'^ F.), with the onset of synovitis in the joint;* of the hands, lingers, and fet't. during the !seroHd week of thi* disease ; und, 4 days after, a loud systolic luurujur at the a|)ej£, which was still present when the t-hild was discharged from the Charttt?.

That under these circuniHtmiccs chorea may also Bet iu, 1 have ah-eady mentioned (p. 210) » and I have given one of my cases— which, however, does not prove that the latter depends upon the endoearditiB. For chorea has also frequently been observed as a result of scarlet fever where there was no synovitis and no heart-iliHcaao. In considering this fever I shall again have to speak of scarlatinal endocarditis.

I' e r i c a r d i t i 3 (which on the whole is commoner in children than iii adults) may arise from morhid conditions of neigh- bouring parts by the extension of the inflammatory process from these to the pericardium^especially from left pleurisy, less commonly from right pleurisy, pneumonia and caries of the ribs* — as well as from the causes already mentioned (rheumatism, scarlet fever). At the same time there occasionally occurs sero-fibrinous or purulent efttmion in the pericardium ; but, when the disease is chronic, extensive adhesion of the heart

» r/. the CMW grren oo pp, 4ISH and 4S<}.

DISEASES OF THE CIRCtLATaRY OAGAKS.

tu the pericardium is coramoner. And this condition in not nnfrGqneutl3' left beUiod after absorption of the flaiJ eflfasion* I have observed purulent pericarditis aloD^^ witli puruleiil ^pleurisy, especially in very young children ; and in these ctis<'% the diagnosis was rendered very difficult, on the one hand by th** small amount of pus in the pericardium, and on tlio othrr Vjy th^* extensive dulness caused by pleuritic effusion (p. 4*24).

UichHrd L.. 8 months oM. ttdmitted into the ward 10th Mjitth Rickcti*, very nipid. noisy brejithing; ftw*' diHlorti'd with pttin on I'oaghing. Over tho loft side oF the chest ftbsohite duln<^*o* tmd hrotichial brcHthing. No di8|)laceinrnt of the heart to Ik* found ; heart-sounds pure. T. J>P 7^ F. : P, 140; R. mX Diirinfi tht- next few diiyn tho bronchial brcfithing in front diii»pin?ttr«l : th»* breathijij< was now no longer audible*, nnd the duhi*'-v« escteiidcHl about I inchf's Ix-jond the left border of tlie yteniuni, »1lhuii)(b I was unable to make out any distinct displiu-ement of the hvutt to

I the right. Exploration by meany of h liyfXMlerinic »*yriiii»i* on lw«

occasions yirlik'd no result. The tomj>crature iilmoht alwiiVN

[ lemiiined Hubnormttl (DO'S^— 9f»'0° F.) ; K. 54— 6t) ; P. varyinir

much {108— b'»0) extremely snnill. I1»e increasing colUiptM* pn** vented an}* operative ]jrocedure. Deatli on 21st. At tbf post* mortem we found the whole left pleural cavity fillwl with pujulent effusion. Compression of left lung; Hbrino'pnniVnl

I pericarditis Iperieardium not mueh distended, eontaininje !««•

or three table-spoon fuls of pure pus; iiotb hurfaces eovi-red nilh

f recent tibrinoue lymiih).

Endocarditis also may develope under these circamstaucea, 111 a girl of 3 to whom I have already alluded (p. 424) I found, besides an old encapRuled pleuritic eifasion of the right side^ considerable adhesion of the layers of the pericardium, and very marked thickening and iucompetouce of the mitral ralve, with stenosis of the ostium venosom which had even been diagnosed during life. In two other children of 2 and 4 years suffering from extensive broncho-pneumonia of the left lung, there occurred au endocardial systolic murmur which lasted in one case till death, and in the other till after recovery from the lung-affection at least.

Tuberculosis is to be regarded as a frequent cause of pericarditis in childhood. The occurrence of miliary or sub- miliary nodules in the pericardium, especially in it« vi«Cfnil layer, is, according to my experience, certainly not very common in general tab^rculosis ; but pericarditii* with aero- fibrinous or

I

V INFLAMMATION OF THE PERICARDIUM, ETC. 487

iilood'StaiiKKl cffiisiou occasionally occui*8 without these local formations.

Hc'lejio W., 21 mtiHtliK old, :\«l(tiitttMl on ^Otli Mtiy, I88:»; unrnmi*'. hwdly-iiotrrirthtHl, At tht; lowi^r part of the left Ijufdfr ijf the wtorrmm, a douj^liy. u>dematf>iis swelling, with dihited vciiiH. R. itipid, Bupcrticial ; Tmicfi coughiiij^. NunuTfUiw Wiles m Intth lungs. Henrt up}mrently normal, abdomen diatended, T. ln;i-;j^ V. Wit compress to the thorax. On 28th a red, fluetiiatin^ j*wellin.£C appeated to the left of the eiisiforra process, which was opened fni 2!>th, and halt'-a-piiU of thin pus was let out. Drainage and corrosive .sublimate dir^^sin^. Un the JJOth, death in sv state of collHpfee.

1*.' M.-^C\otiv ntider the ensifnrm procetis there \\i\^ a ?iinu.^, which admitted the huger. It had led to preat undermining oF the al)domii»ttl muscles, and extended downwards l>etween thi* ret^tus and the ohlirpiUH exteriuiH abdomiiUB to beneath the uti»- hiliciis, and upwardn an far an the left costal margin. It here ended in a Hstula, which penetrated the diaphiragm in the neigh- boiirhood of the ensiform prt)cesH immediately below the costal nuirgin, and ted into a cavity of the sixe of a he»f.H egg in th«' anterior m<'diiistinum. There wiis another pasjsoge leading alsit into tlo' iiM'dijistiimm over the co.«<tal margin between the r*tlj and 6th riljs, to the left of the Hteriinin. In the mediastinum there wus; a completely encapsided empty absee^.'^-cavity, which communicated al)ove with immerouH blind MinUises, and in it.H thick walla there were numerous tubercles. Bibs and sternum normal. Much sero'fibrinous exudation in the periieardium (eor villn- )^um), occni'ional tubercles in the fterous membrane covering tht« heart ; valves normal, BronchiJil glands caseons, in the lower lobe of the left Inng a caseouH maHS the size of a walnut, with n^imenm.v miliary tubercles io its neighb«jiirhtx)d.

This case seems to have begun with puruleut, tubercuhu' mediastinitis, and this apparently cu used on the one hand ImtTowiijg of pus between the abdorainal muscles, and on the other ncute tubercular peritonitis. In the following case wo find the mediastinum and pericardium free from tubercle, although acute pericarditis had arisen by extension of inflamma- tion from the left pleura, which was highly tubercular, and had in the end caused extensive adhesion of the pericardium. Sucli tulhesions sometimes contain firm fibrinous matters, which are partly caseous and partly studded with tubercle.

Paul M.. 8 years old» admitted htto the hospital on 20th May, 1878. Formerly healthy. Said to hn\e been feverish and out of

488

DISSA8E8 OF THE cmCULiTORT OBaAKS.

flortsfor the last 8 days. Vcrj pale. B* 36; T. 101-5<>i P. 13<*. Iii the region of the heart and for J inches beyond the right bottler of the stenium, loud fi ictioii accompanying both sounds was to be hcAnL Percussion normal j apex-b^kt not distinctly felt. 8 dry-cnpN, ice-bag, digitalis. During the next fow days* the patient complained much of sharp ]>ains in ihr ri>gion of the heart. R. rising to tk*; T. to liWF F, By 24th, the frittion had disappeared, and the cardiac duhiesH now i*eat'hed u]>wnrd8 as far as the 3rd rib, and f inehes to the right of the »teriial tuargiii Pulse very small. A blister to the region of the heart ; cnlomrl gr. i every 2 hours; after the 28th |x)t. iod. grg. ii, llwi t»;m« perature now gradually sank, only temporarily riiiilng ugain to lOi"?'^ in the first days of June, when an attack of traturrh raised the respii-atfoiis again to 60. The puUe, however, gained tii strength, and, although theit^ wat* no change in the percussion, hh again felt » weak difi'iine apex'l>eat on bth June, and also bctird \jiA\t the heart-sou nd« fjnite pure, although weak. Uti r3th June wv could again hour di.stinct friction accompanying both goundn (R. bO — 60; P. 132— 156), and the dulness no longer reiwhtsd the right border of the sternum, while on the left side it did not extend to the mammillary line. On 29th, the friction was Htill audible over the upper part of the sternum, while the soundft seenieil^ pure lower down. T. in the morning normal, in the evening >itiU 100-9^ F. J R. 28—32. On 6th July nothing was left but very faint friction over the sternum, everything el»e normal, and mi the bcjj \M\s discharged aK cured on 7th August. In October he way again brought to the cHninue on account of con^idemblc ascitc*--. The description of this pluijw of the case will bo given under Chronic Tubercular Peritonitis — for that was what was the matter. I may only mention hero that during the whole period ot hii< residence in hospital, up to 5th May, 1879, not the wlighteitt abnormality could be discovered in the }icart« in spite ot frequently wpcated examination. Of the conditions found at the post-mortem, I Mhull only mention those which are internet- ing in thiH connection.

The whole left pleura costal i« thickly-studded with tube^-^ cleg, the pleura pulmonalis less affected. The pleural c4»vitic< empty. The cavity of the peiicardinm entirely oblitcratei by the complete adhesion of itn t>«o layers to uiie another, and th^ heart covered all over by thick tibrous tissue. On careful exam ina^] tion wo found the mu;(icular subntauce at di/TiTcnt piirta of tl anterior wall of the ri|^it ventricle almost lutirrly cunvortct into hbrouti tijiiitne. Pericardium and heart quite free frntol ^nbercle. ValvuUir apparatus perft*ctly unufTecttxl. Tli

jdiastiuum very tedematouf* and thickened. Al*<i t' |>eritouitia atid mcningitia.

In this case we find, as we ofkn do^ adhesion of the entire

p MTOCARDITIS. J^

pericardium, prodaciDg no symptoms whatever ; in partiGulju- no BystoHc in-drawing of the chest wall was observed in any sitnation. The implication of the myocardium, at least that of the right ventricle, took the form in this case not only of peripheral fatty degeneration — which is common in pericai'ditis — hut of interstitial myocarditis with formattou of fibrous tissue; and this is but rarely observed in chUdreu, and could no more have been discovered clinically than could the adhesion of the pericardium. Quite similar to this was the case of a boy of G, who died after measles with symptoms of chronic tubercular l)eritODitIs» and at whose post-mortem, we found, besides this^ tuberculosis of the pleura, lungs and liver, and complete adhesion of the pericardium. This formed two fibrous layers studded with tubercles, between which there were some partially-Gofteneil (^aseous nodules. Here also nothing ubnormal was discovered iu the heart during life ; nor yet in thft, following case— whidi, |k>wever4 had nothing to do with tuberculosis.

f Richard L., ♦"> year« old, admitted on 4-th Fcljriwiry. »Sriirlot fever '2 yeurs wgo ; »iiid to have been only It clays ill (J*). Much cougliiTig mid tlyspnwn. Pallor and emarmtiun, well marked iiHli'inii of the Uivv ttud lower extremities ({'imunforeiice of ubdo- ineu 28 inches). Liver-margin hard, extending '\ fiiiger-breadthi* helofv tlie coital margin. The intercostal 8|Nice8 on the right side t»f the thorax were ex|mnded, bulging out Homewhat ♦ ci renin fere noe ^*2l inches, that of the left only 91- Percuspion dull all over I In* right side; bronchial breathing ami bronthopliony, here and there rather *hiir)) rAlt .- ; eatarrli on the left side above. Sixe of the heart normal, soinidH imi-c but weak; no indrnwing with the Hyntole. Innteadof the jn>cx-lK*at, a more diflfn?i4e impulHe. Urine aeanty, H>i oz. daily, n<irnu>l Digestion gooil, no fiver, V, l;iO, ivgular. On the 7th, after exploratory puncture, halfsi-ptnt of clear fterunt removed from the »*ith right intciTostal h|>aeo by nu;an>4 of Dieula- loy'H ttHptmton This neruin curitained extremely little albu}Dcn« After the IMh* fever (lUVo^ l\), re8tU'»«j»ne8«, great dyBpnara. Death under chloroform Ix'fore the geeoiid puncture.

/*.' Jf. — In the iilKlomen half-a-pint of serum ; the right pteunil cavity likewiHc ijuite full. The right lung the bikc of a nian'M fixt, stolid. Also in tlie left Hide of the che^l alK)Ut half-a-pint ol scrum. Pericardium adherent all ovor; inthefibrouwadhcuionn eattcnj^ivc diNHeminated dry yellow mai*i«ej«. Right ventricle Mraull, with vtry thin walh. mhieh aro fibrouM in ronny placen. KjbroM« tbiekening of the phium all over. Spleen very large. Liver enlarged, iti* tmrfac** uneven, the capnulc sUghlly thick'ned, with

^90 DISEASES OF THE CIRCULATORY ORGANS, ^1

many iibrous bancln passing through it; aTwemie. Inthe jejit- niim *J little ulcers about i inch in dianiHer. KiJtieys jmlumtrii*

large, smooth.

In this case we found nothing of the nature of tobercl© in ahy orjan, for the yelJow nodules (fatty and amorphoos d<*bri«) iu the fibrous tissue of the adherent periciirdium could not be «el down as tubercular without further proof* Although there wan notliing in the history which could bo held to soppurt the assumption of a Rvphilitic origin (snggestod by the fibrona degeneration of many organs and especially of the liver), still, the whole anaiomy of the ease is such that it may almost with certainty be regarded as one of syphilitic perirnrditi** and myocarditis wilh the formation of gunomata in tbr fibrous tif?suc of the poricardinm — examples of which mte very rare in childhood.'

Apart from these cases I have only V€ry rarely seen myocar- d i tie processes iu children :— e.f;* in a boy of 10 years.

Periiianliiii caivity very large, rotitainiitg liaIf*W'tHbl»'si>ooiifnl of blood-»t»*uied tluid, Heart xi^ry large. Wulls nf both vetitrieU-» dense; slight Hbrous thickening of the epicurdium all over, fuid ill some pltt<'e.s i>apillatctl. At the npex of the loft ventricle thirr** was, lM?8idea very extenyjvi- atrophy, an ai»euris«?nal dilutatioM the xixe of u hrtxel-riut. ut whiih point the wall of the heart wit« !*etMTely J inch thiek. Kndoeartlium of the left aiiride romh thickened. Tin' inttnd snul aortJe valves shrivelled and tKKlnlar.

Boring life, in this case, we c<3Uld only make out tie Byoiptonos of valvular disease and hypertrophy of the heart* From an anatomical point of view, however, the case is so far interesting, that it adds one more to the small number of cases of aneurism of the heart which have hitherto be^n observe<l in children. Owing to a localised chronic myocaiditis, which had developed along with endocarditis and inflammation of th»5 epicardium, the afl'ected portion of the muscular tissue had gradually degenerated into a thin layer of tibrous tissue, which was rendered thinner and thinner by the blood -pressure* Ex* fonsivc chronic fatty degeneration of the heart muscle, such as 30 often occurs in adults, either with or without degenerntiou of the coronary arteries, I have never as yet seen even onco in

• Of. Von Datcb in GtrkartU't Unn^hucK tier A'infifrlmnJik,, iv., S. 08.

MYOCARDITIS.

491

^Bcbildhoofl. I liiivc, however, on several occasions ol>s**rved n ^PJocalised fatty tlegeueration^ — eBpei-ially in tlie right ventricle — in ch ildreii witli proloBged w b o o p i n *x-l' o n p[ b and chronic pn emu 0 Ilia (p. 4()1). In such cases it arises as the resuU ol' the resistance which the heart has to overconie in the pylmonar\ circulation : and it may occasion paRsive ililatation of the cavities, r and death by syncope. To the same ehiss also l>elougs the ^■locahded fatty defjeneration, which takes pliice. towards the end ^Bjii bypertrophied hearts in cases of valvular disease. AVhen I ^■come to consider the infectious diseases, I shall return tu ^■Ihe fatty albuminous degeneratioo of the heart-muscle which ^^ occurs pretty often after acute infceiious disease— especially r scarlet fever, dipbtheriu, and typhoitl — and clinically ;4ives rise ^^to 110 symj»toms except perhaps those of rardiac deliility, ^H I have also but rarely met with simple hypertrophy anrl ^^dilatation of the heart in children — twice followin*,' ehronit- ^ nephritis, and twice in veiy youn^ ehildren whose hearts hail ^^ probably been too lur'^^e from birth. In other cases sonjc affcetiou ^B of the valvubir apparatus was generally to be found as the caosr ^ of the h\*pertrophy and dilatation. In a few cases also a recent ^_ attack of nephritis (very specially of searlatinal nephritis) was the ^P cause ; but of this J shall speak again under scarlet fever. Of " the acute furm of dilatation of the heart described by Steffen and others, ihe diagnosis of which rests only on percassion, and which is said to come on in endocarditis (as ihe result of en- ^^ gorgement and overwork of the heart), as well as in infections ^m diseases — I think I have myself observed a few cases. The most distinct of these was one which I shall give by-and-by under scarlet fever. I must, however, admit that in regard to ^^ the majority of these cases I feel a little doubtful, owing to the ^B rapid recovery from the dilatation within a few days. We must ^B always bear in mind how many causes of error in the percus- ^B sion of the pra'cordiuni may arise from the varying degree of ^M expansion of the left hing, and from the restlessness and ^^ screaming of little children. The mere theorist may imagine II that in determining the limits of the heart in childhood, he can ^m arrive at results with mathematical exactness ; but whoever has ^* any considerable experience can only smile at such an idea. Further, we have the fact that even in the dead body the different degrees of contraction and fulness of the heart, as well

wz

DI8EASE8 OF TUB CIUCGLATORY OAOAXS.

as the difference of ago, may leave it doubtfal— in tho leea well* marked cases — whether the case is one of hypertrophy or of dilatation. The old comparison with the fist of the iodividtiti] — aithongh it is generally sufticjont for practice— is yet l»y no means satisfactory for scientific purposes.'

In addition to this consideration we must not omit to men- tion that many children (and, according to ray experience, more boys than girls), from the age of 10 up to puberty, complain of palpitation of the heart, and of shooting pains Ln the cardiac region ; and they also occasionally complain of shortness of breath, and especially of headtiche* I have only been able to discover anffimia in some of the cases, and on examination I have almost always found nothing but a diffuse Leaving cardiac impulse without any change in the normal signs of i>ercuBsiot] and auscultation. As a matter of fact I Lave never seen any- thing bad happen in such casts, as fur as I was able to fuHoir them. Indeed, the bcnrt-symptoms gi-adu ally got less and dis- appeared, and one might have accepted the view — which used often to be expressed — that there was taking place a gradual ttdjusl- ment of the relntions which had existed physiologically during t'bildhood between the heart and the body-weight — if it were not that according to Beneko^s researches the heart is rela- tively snvallest in the years just before puberty, and then rapidly increases wbile puberty is in process of development.

The treatment of heart-disease is the same in children ms in adults. Although the chronic forms (valitilar disea^se followed by hypertrophy) are genei^ally better born*' by children owing to the rarity in them of myocarditic processes and of disease of the vessels, and the patients live to puberty, or even longer, before* any eerious disturbance of compensation aeln in ; still, cases do occur in which active medical treatment becomes nccessaiy on account of distressing symptoms, I have been struck by the commonness ot* autemia in ilieso childivn, and by treating this symptom suitably with preparations of iron (Form. 12) I have often succeeded in relieving at least some of thcsjTnptoras (palpitation, debility), and considerably improving the general condition, although the heart-disease itself rcfiiuintHl unaflected thereby. The iron never had any bad ef)€cte in these casm.

' *y* Beneko, Die ttnatom, Grnudh^en %ltr Const UutioHtainma lien. n^.Won Diuoh, CerUrdt'i Nandb, d, Kindertmnih, iv-, «. »?, *

Mart.

MY0CABDITI8. 493

The treatment of acute (inflammatory) heart-affections mast, of course, he antiphlogistic. We require local blood-letting, ice- hags, calomel, digitalis, and blisters. The cases which I have given will best illustrate to you the action of these remedies. In pericarditis, with an extremely large amount of effusion, the imminent danger may be averted by puncture and aspiration of the pericardium, or else by incision. Examples of this have been published,^ but I myself have no personal experience of the matter.

' Cadet reports 9 ca^es with 5 recoTerics ; BoaonRtein {Berl. IKn. Wochensrhr.f 1881, No. 5), after puncturing uniucces-^fully, incised the pericar- dium, inserted a drain and procured recovery in 10 days; Q use enbaue raise {Revue mens., Janr., 1885, p. 37), West {Jahrb,f, Kinderheiih., xx., 462), and others have reported oases successfully treated by incision and drainage.

END OF VOL. I.

LONDOX: VtirM-d by Ja8. Tavfcorr & Sox, Suffolk Lwi«^, B.C.

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