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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.  < 

•  Vtber  ttit  s 

•  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 


< 


I 


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. 


/'^^''>*^