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THE 

DISEASES OF CHILDREN 



BY THE SAME AUTHORS. 

NOTES ON PHYSIOLOGY FOR THE USE 

OF STUDKNTS. By HerjRv Asunv, M.D., F.R.C.P. 
Sinlh Edition. With 141 Ulustialiuns. Fcp. Svn. price 5J. 

HIP DISEASE IN CHILDHOOD. By G. A. 

WRtciiT, B.A., M.aOxon., F.R.C.S. Eng. WLlh 48 
Original Wooilculs. Svo. piict 101. &/. 

Ixindon: LONGMANS, CREEX, & CO. 



'C 



-I t 

THE 



THE ■.■ , , 




DISEASES OF CHILDREN 



MEDICAL AND SURGICAL 



BV 

HENRY ASHBY, M.D.Lond., F.R.C.P. 

ritVSlClAH TD THR GAHKKAL ri04I'ITAL FOR SJCK CKILDHEN, MAKCHKSTBir 

i.BCTUIKB AHl> EXAUIHVK IN DT^lAliEii OF CHILDFHH IH ThS VICTORIA IMIVERSJTY 

rOHkHLV LKCnrUlM OK PHV5IOLOCV IN TH* OWKNS COLLSCR 

AND W THE LIVCRPODL SCHOOL OP hEDECINH 

AND 

G- A- WRIGHT, B.A-, M.B.Oxon., RR.CS.Eng. 

A&^ISTAHT SL'llUKON TO THH UAKCHIBTai lOVAL ENFIRUAXV 

AND SUFCEON TO THE CHU-UHEn'H HOSFITaL 

■ KAlllHlR in SiTRCSRV Iff THE UHlVERfhlTV OF OXFOWD 

COVBCIFOHDINC HAHBER OF THE AHERICAH OJtTH0l'jAC>rC AftSOClATtOH 



THIRD EDITION 

EDITED FOR AMERICAN STUDENTS 

BY 

WILLIAM PERRY NORTHRUP, A.M., M.D. 

Kity- SCT PlfOFESSOK DESEASe^ OF CKILI^tTBN, BHLLHVL'E HO&plTAL URuICaL COLLEGE 
jtT-TE^^IKC PHYSICIAN NHW VORK FOL' N D L l-VC , WILLARD CAIiKUR, ASU PRRSBVTEPMN HOSFETALS 
COh'fiULT^T^ CHV^IClAN NEW YORK INPAKT A^VLt/hl 
WKMBEll OF THB AGSOCEATJON OF AMERICAN 



NEW YORK 
LONGMANS, GREEN. AND 

LONDON ANU IIUMBAV 
1896 




U,NOMANS, GREEN. AN.. CO. 

CopvwoHT, i4gi. "^ 









THE SURCICAL PART OF THIS BOOK I DEDICATE 
TO MV FATHER 

(7. ji. ivsicaj- 



NOTE TO THE 

SECOND AMERICAN EDITION 



In preparing this edition for the American Reader it has been 
thought best to leave the body of the book intact. The same disease 
differs but little in its course in America and in England ; it is neces- 
sary, therefore, to note only such differences in theory and in treat- 
ment as shall seem to bring the book into accord with present 
American practice. This has been done by means of the Appendix, 
care being taken to refer supplementary matter to its proper connec- 
tion in the main work by page references, and by additions to the 
Index. 

The Formulae (page 8ii) have been entirely rewritten to conform 
to the United States Fharmacopceia. 

The supplementary additions to the Surgical portion of the book 
have been made by Dr. T. Halsted Myers, Attending Ortbopasdic 
Suigeon to St. Luke's Hospital, New York, whose contributions ace 
also embodied in the Appendix. 

The Editor trusts that these additions may still further increase 
the usefulness among American readers of this complete and con- 
densed treatise, which has so quickly passed to its third edition. 

W. P. N. 
Nkw York, i8q6. 



PREFACE 

TO 

THE THIRD EDITION 



In pxepaking the Third Edition the whole of the work has been 
thoroughly revised, and some of the sections, more especially those 
on Infant Feeding, Aniemia, and Chronic Heart Disease, have been 
almost entirely rewritten. Considerable additions have been made to 
the Surgical part, and mention will be found of the more valuable im- 
provements introduced since the last edition in 1892. The book is 
enlarged by over fifty pages, the formulary has been much expanded, 
and fourteen new woodcuts have been added. 

We must again express our thanks to our colleague Dr. H. R. 
HuTTON, and also to our friend Dr. J. S. Bury, for much help and 
kindly criticism. 

HENRY ASHBY. 
G. A. WRIGHT. 
Manchester : Sepirmter, 189;. 



PREFACE 

TO 

THE FIRST EDITION 



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

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

The basis of our work is our experience at the General Hospital 
for Sick Children, Manchester, an institution at which some 1,200 
in-patients and some 10,000 out-patients are annually treated. Our 
observations have extended over nearly ten years, and during the whole 
of that time we have been collecting material both at the Children's 
Hospital and at the Royal Inlirinary for this purpose. 

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

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



Diseases of Children 

We have 10 lender our cordial thanks to out fticnds and rolleagun, 
both at the Children's Hospiutl and at ihc Koyal Infirmary, for their 
help. Our ihanVs arc sUo due lo successive generation* of houic 
iiiigCons Wfho have kepi the TL'Cords of our cases. 

To our colteaf^e, Dr. Hi'TTok, for allowing ua without stint the use 
of his cas&i, a.s well ax for much help and advice in correcting our 
proofs, our cs^ieciol thank.i arc due : alM> to Messrs. Sovtham and 
Cou.tER, our collcajtues nt the Koyal Infirmary and the Children's 
Hoi]>iul, for their care and kindnexK in |>rouf- reading. 1'o Mr. ^\'nAOK 
we owe our chapter on AnKilheticx, which i.t n)a<le especially valuable 
by his large cxiKncnoe in the adminiMrulion of tlienc agents both at the 
Chitdren's Hoctpilal and at the Ro)-al Inrirmary. To Dn. Hi.;mphiieys 
and MASStAir, our former colleague:!, we are also indebted for the use 
of their notes of cases. 

Wc must also acknowledge the help rendered to us by Messrs. I'aixi; 
and Bkncer in conneetion with the forrnulx for medicines and external 
applications given in this work. 

We cannot lake leave of our work wiihout further acknowledging 
our indebtedness to the Boaid of Governors of the Cbildrcii'j Hospital 
for their generous treatment of us, and especially for enabling; us to 
publish our annual abstracts of cases treated at the Hospital. We attm 
desire to expieu our appreciation of the value of the work of our xisters 
uid nuiscs in making ohsii\-ations of cases, and in the preparation of 
lemperatute charu. 

To Meun. Ixivoman, oiir publishers, we arc much indebted for 
their liberality in alloning us to borrow woodcutx from ihcir published 
works, and for their help in many ways ; wc desire also to acknowledge 
the great pains and skill sho«'n by Mr, Peahson in engraving our 
photographs. 

HENRY ASHBV. 
G. A. WRIGHT. 
MANcltnTM : May 1889^ 



CONTENTS 



CHAPTER I 

THE PHYSIOLOGV OF INFANCY AND CHILDHOOU 

The periods of life, I ; intra-ulcrine life, I ; infancy, I ; childhood, 3 ; youth, 2 ; 
respiration, 3 ; changes in the circulation after birth, 4 ; amount of blood ir. 
body, 4 ; pulse, 5 ; alimentary canal, S ; urine, 6 ; temperature, 7 ; nervous 
system, 7 ; sight, S ; hearing, 8 ; taste, 9 ; psychical phenomena, 9 ; sleep, 91 ; 
Iwdy weight, g ; length, to ; dentilinn, 1 1 ; mortality, 13. 



CHAPTER II 

THE DISF.ASES INCIDENT TO BIRTH 

A-physia nc'jnaloiuni, 15 ; apo]ileiia neonatorum, iS ; cephalhitmatoma, 20 ; hctma- 
Irima of the slerno-masloid, 23; olistclrical {mralysis, 24: icterus neonatorum, 
25 : h3;nioirhai;ic diathesis, 27 ; acute fatty degeneration of the newly tjotn. 2S ; 
Winckcl's ciiseasc, 28 ; gastro- intestinal hitmorrhage, 28 ; haimorrhoge from the 
genital organs, 39 ; diseases <i{ the navel, 29 ; uml>ilical (Milypiis, 29 ; omiiha- 
litis, JT ; gangrene cf the ikavel, 31 ; umbilical arteritis, 3^ > umbilical phlebitis, 
32 : umbilical hemorrhage, 33 ; tetanus nascentium, 34 ; sclerema neonatorum. 
35 ; (tdema neonatorum, 36 ; gonorrhrcal ophthalmia, 36. 



CHAPTER III 

THE HYGIENE AND DIET OF INFANTS AND CHILDREN 

Xe»-l-om infants, 37 ; clothing, 38 ; infant feeding, 38 ; wel nurses, 40 ; weaning, 
41 ; arlificiai feeding, 43 ; cow's milk, 43 -, woman's milk, 45 ; cream mixture, 
46 ; dihilc<i milk, 47 ; bailey water, &c.. 48 ; whey, 48 ; |»;|)toniscd milk, 48 ; 
Merili~alii>n, 49 ; cimdensed milk, 50 ; dried milk foods, 51 ; amount of foud, 
52 : feeding-bottles. 52 ; diet from 6 to 12 months, 53 ; diet from 12 months 
1.1 iS months of age, 54. 



xii Diseases of Children 



CHAPTER IV 

DISEASES OF THE DIGESTIVE SYSTEM 

Fxaniiiiniian of the mouth, 55 ; dentilion, 55 ; calairhal stomatitis, 59 ; slomalitii 
ifiythtmatosa, 59 ; Hphlhx, 59 ; paiasilic Elonulilis, 60 ; ulcerative slomalitis, 
6z ; alveolar abscess, 63 ; cancnim oris, 64 ; acute loiuitlilia, 65 ; chronic lon- 
sill'ti;, 69 ; Innsiltar calculus, 71 ; na&al adenoids, 73 \ pharyngitis gangra:nosii, 
72 : post-pharyoE™! alscess, 73 ; stricture of tESophagus, 74 ; swallowing foreign 
bodies, 75 ; tesophogilis, 76. 

CHAPTER V 

DISEASES OF THE DIGESTIVE SVSTEM (COniiltUed) 

lixaminaiion of the abdomen, 77 ; dyspeptic diseases, 78 ; fUiulence and colic, 79 ; 
voniiling, 79 ; diarrhoea, 81 -, constipation, 83 ; acme gastric catarrh, 85 ; 
ncule gaslro-inteslinal catarrh- zymotic diorrhrea, 86 ; acute gastro- enteritis, 95 ; 
acute ileo-co!ifis, 96. 

CHAPTER VI 

DISEASES OF THE DIGESTIVE SYSTEM (continued) 

Chronic gastro-intclinal catarrh — gastro-intestinal atrophy, 98; chronic diarrhrea, 
98 ; chronic vomiting, 100 ; diet for indigestion, 106 ; dilatation of stomach, 107 ; 
malformations of stomach, 108; carcinoma of stomach, 108; ulcer of stomach, 
108; thread worms, 109; round worms, no; tapeworms, no; ascites, lit. 



CHAPTER VII 

DISEASES OF THE DIGESTIVE SYSTEM (continued) 

Acute peritonitis, [13 : peii typhlitis, 117; peritoneal abscesses— intestinal listula, 
1 18 ; chronic peritonitis, r2i ; iliac b1)sccSs, 125 ; inlussuscepti'in, 115 ; chronic 
ohstruction of the bowels, 134. 

CHAPTER VIII 

DISEASES OF THE DIGESTIVE SYSTEM {Clllltittued) 

TiibtTcular ulctralion of the bowels— nicscnleiic disease, 136 ; congenital olisliiiciion 
of the li-iwcK, 140 ; imjietf orate anus, 142; deformities of the umbilicus, 146; 
umbilical hernia, 147 ; inguinal hernia, 147 ; prolapsus recti, 151 ; fistula in 
ano, 154; piles, 154; polypus of the rectum, 155. 



Contents xiii 

CHAPTER IX 

DISEASES OF THE DIGESTIVE SYSTEM {continued) 

ila.tc-lip, IS7 ; cleft palate, l6j ; macrosloma, l66 ; macroclieilia, l66 ; microsloma, 
167; tongue-tie, 167; macioglossia, 167; ranuta, 168; papilloma and condylo- 
mala of the tongue, 16S ; hypertrophy and atiophy of the face, 169 ; brandiial 
fistubc, 169. 

CHAPTER X 

DISEASES OF THE LIVER 

Congenital stricture of the bile-ducts, 173 ; calarrhal jaundice, 174 ; ncitl^ yellow 
atrophy of the livei, 174 ; alcoholic cirrhosis of the liver. 177 ; syphililic cir- 
rhrisis. 177 : &tly liver, 178 ; tuberculosis of the liver, 179 ; hepatic alscess, 180; 
hydatids, iSo ; tumour of the liver, 180. 

CHAPTER XI 

DISEASES OF THE RESPIRATORY APPARATUS 

The thorax in infancy and childhood. 183 ; infantile respiratory spasm, 18] ; lar^'n- 
gismus stridulus— child-crowing—spasm of the glottis, 184; spasmodic lar^'n- 
gilis, 188 ; catarrhal laryngitis, 1S9 ; membranous laryngitis, 192 ; tracheotomy, 
196 ; intubation of the larynx, 306 ; chronic laryngitis, 308 1 papilloma of the 
larynx, 208. 

CHAPTER XII 

DISEASES OF THE RESPIRATORY APPARATUS (eontitttied) 

Hronchitis and catarrh. 210; collapse of the lung, 213 : bronchiec lasts and emphysema. 
II; ; chronic brnnchilis and tn-onchieclasis, 213; linincho- pneumonia, 214; 
iccondar)' pneumonias, 2l6 ; chronic broncho- pneumonia, 317: different l)-])es 
of pneumonias, 219 ; croujmus pneumonia, 225 ; gangrene of lung, 333 ; abscess, 
iif the lung. 334 ; pleurisy and em[iyema, 334 ; asthma, 245 : diseases of the 
briinchiul glands, 246 ; mediastinal abscess, 24S ; l)'mph-adeniiina, 248 ; chronic 
lulKrculiisis of the lungs, 348 ; fibroid phthisis, 251. 

CHAPTER XIII 

THE SPECIFIC FEVERS 

Ktvcrishncss, 254 ; gland fei'er, 355 ; scarlet fever, 257 ; surgical scarlet fever, 258 ; 
mild scarlet fever, 261; malignant scarlet fever. 261 ; complications. 263; 
nephritis, 364 1 measles, 273 ; mild form, 276 ; severe form, 276 ; Rbtheln or 
Kul)ella. 379 ; diphtheria, 283 : pharyngeal form, 386 ; malignant, 28S ; 



xiv Diseases of Childrtn 

nniu) iliphlhi-ria, iSS ; laiyn^eil, 189 : wouikI diphdieria, aSo : fuinplira- 
tixni. 184 1 iiNfuilu'tliiihlbFrU. 194 i q>iitcn)ic tnfliicrirji. 195 1 cnieiicrcvci, 19S! 
cnnipltculions, jOl : ly|)hut, J07 : vahf«IIll, Jloi varicdla gan|;nvnoia, Jl] : 
vwcrnia, Jl j; compliiali'inH. jl^; vuloloiil. Jib : inhoo]Un|l«n^, JI7 ittMl- 
plkalions, 319: mumps— paTDtilti, J32 1 laoUri*! rcTvr, JtJ. 

CHAPTER XIV 
l>t»KASES OF THE ClftCUUATORV SYSTEM 

DU«nt«t nf \)\e hoan, J>S ; congenital heart iIimuc, ji6 ; jmicm brwncn ovhIc, 
317 ; i^tcnl HCpinm vcniticuUiiimi, 319 : tii-n<aU<-rihciHiIini»afyaDdlriaiiipid 
uTJIica, 3191 «l«otnit I'f llic tuitu nr mitral lalvM, 3]0; lnn(|«iiillton »f lh« 
uM» >n<l tnitniiMiary min}'. 331 ; |icric»ilLlU, 331 I codneiuflil'*. Jj6 : i-liionic 
houl i1i>«air, j}<) 1 nculc iiij-imKtilui, jjj ; in(4iB(line:>>pcricaitiki(, 346 ; lUy- 
luud'* iliwfttc, 347. 

CHAPTIiR XV 

D1SK\SES or THE CIRCUU\TORV SVSTKM (awift'wwcj) 

Nkvu*. 349! tIclliUc lucvut. 3491 pnit-wine maik, 3491 cnlincauk luvvii*. 3SO; 
wliCuUiicout nicvtit, jjoi mixal na.-vn(, 350; innple niwi, 310 : cavotnodi 
lucri. JJOi lyiiii-liallf iwrvi. 356: ancuiitm, jjS, 

CHAFPER XVI 
DtSKASRS or THE III.CX>I) AND BlXlOU-MAKIKi: ORCiANS 

Aiunuia. 339 ; HWtdiU ndh Tck-iuu, 360 ; »)inpla miratia, 360 1 i<liu|ttlbic aniemi*. 
361 I icinvy. 361 t «nlai)^tl tplvFii. 363: naxmU iiileiilra. 3(14 : lt'>il):Un'« 
■ILwaw, 366 : lia;iiKi|iIilli<i. 367 ; iHiipiiia timplcx. 369 i ixliosii (hciiitiiitic*, 
JJI i ilitcaaM of (Ivr icua-jirrll<iii(al t;tiintlt, 371, 

CHAPTER XVII 
TUDBRCUI-OiilS, fllARhTIU, KIIEITUATISM 

Acute miliary tulmculuiia. 373 ; Inthiiiil fonn. 373 • liroiiflio pnuumoniir f.Mtn, 375 j 
nilMcuIc cmcrai niTierculiMi^ 37; i iCToruU mil tnlindilnMh, 377 i lubecculai 
adcritiu, 37g; chiunic atiHvu. 3!^ ; ilfitp cervical eelluliiU- tngiui l.mtuvici, 
3861 ^nmt uiTcicil tiitiricutrtLH, 3871 diabcla ntellitui, 38S : |xilyuria — 
lUaticta inupidua, 3S9 1 rheunalinn, 390. 



J 



CHAPTER XVIII 

RicKem 

KickeU. 39): tcxrvy rickctt, 401 : rkkdrHrroniiiliai, 407 ( Ulerickelt, 4(4 ; <MWf 
limy. 419 i laltnlcurraturcarihe i|niic, 411 ; iuileru-poM«tior cufvaluic, 436^ 



Contents xv 

CHAPTER XIX 

SVPHIUS 
Svphilis, 417 ; acquired syphilis, 427 ; hereditary syphilis, 438. 

CHAPTER XX 

DISEASES OF THE NERVOUS SYSTEM 

InlrcMlucliun, 438 ; clinical exam inal inn, 43^ ; cerebral congealian, 439 ; tuberculur 
meningilis, 440 ; simpic meningilis, 444 ; acute fomi, 445 ; subacule forrn, 446; 
cerebro-spinal meningitis, 447 ; latent form, 448 ; chronic meningitis, 453 ; 
acute hydrocephalus, 454 ; chronic hydrocephalus, 454 ; hypeitiophy of the 
brain, 457 ; atrophy of the brain— sclerosis of the biain, 458 ; tumours of the 
lirain, 460 ; t\imoars of the cerebellum, 462 ; of the pons, 465 ; basal ganglia 
an>1 internal capsule, 465 ; of the cortex, 466 ; of the frontal lobe, 466 ; cerebral 
abscess, 467 : cerebral hjemorrhage, 470 ; |xist-partum hjemorrhage— birth palsy, 
471 ; cerebral hiemorthajje occurring after birth— acute cerebral palsy, 473 ; 
medutlary hamiorrhage, 479 ; embolism, 4S0 ; ihrnmbosis of the cerebral siniise!i 
and veins, 483; arteritis— softeiling, 484. 

CHAPTER XXI 

D!S>JVSES OF THE NERVOUS SYSTEM {canlinUtd) 

Chorea, 485 ; hemichorca, 487 ; epilepsy, 497 ; hyaleioiil fits. 499 ; posl-hemi])legic 
ei'ilepsj'. 499 ; infantile convulsions — eclampsia, 502 ; tetany. 507 ; nystagmus, 
509 : head -nud< ling, 509 ; head -banging, 509 ; hysteria, 510 ; headaches, 512. 

CHAPTER XXII 
DISEASES OF THE NERVOUS SYSTEM {amlinued) 

^|ii.-ech anomalies, 515; deaf-mutism. 516: acquired deaf-mutism, 517; physical 
deft-i.ts in tne mouth, jt?; mental defect, 518; aphasia, 518; summering, 
518; mviilal afflictions in childhoiHl, 519; congenital group. 520 ; dcvelop- 
iiirnta! idiocy. 521 ; accidental or acquired, 521 ; cretinoid idii;cy, JIi ; back- 
w.iid children, 523 ; idiocy due to syphilis, 524. 

CHAPTER XXIII 

DISF_\SF.S OF THF. NERVOUS SYSTEM i/OHtinued) 

y.\ini bifida, 517: meningocele, 531; spinal meningitis, 533: parsplcgta, 534; 
mvi-iilis, 536 ; Lamlry's j.aralysis, 537 ; hereditary ataxic |iaraplegia— 
Kritilrich's disease, 538; -inleiior polio-myelitis -acute atrophic paralysis^ 
infantde [laralysis, 539 ; peripheral neuritis, S4S ; pseud o- hypertrophic paralysis, 
545 : juvenile form of muscle atrophy, 54S ; muscle arrophy of [he face, 548 ; 
Thiiin»;n*5 disease, 549. 



xvi 



Distasts (>/ Chiidtrn 



CHAITER XXIV 

DISEASES OF THE CF.NItO-UIIIXARV SYSTEM 

Cdncenitat icionnLlkt of ihc kiilnojrt. %yi; AiUtvm'k ilitiuiw— luUmlmU of the 
adreniii. $50 1 tucmalufii, JJO i aoilc pydili>, 5S1 1 liibicmia, jp ; lumoun 
iif ihr klilncvt, 35a : lulicmilcut kidney, 55$; hydroilrlArtnis, {57; tclut 
caltulut. i%l ', Buuie iie|vhiilii, 558 ; >«|)(ic n«|Jiri)i«, J59 ; oculc parcndiyou- 
kiu» oephtiiU, 559 ; chronic otf hritii, J6(X 



CHAPTF.R XXV 
nsKASKS or thk gknito-urikakv system ((ontinutd) 



A 



Slonc in th« Uulil«(, 56] : cTditia, 566 : incuDlJncnce of urlnr. 5(17 ; rcuniiini, 569 : 
nulfurnuiiiant ir the genilo-uriiiary raipinii— cviinvminci r>[ >hp liljtdiJa, 370 ; 
epaipadus. J73 : bypucfiodittk. $73 • pbiimiti*, j;j i l«bniii[, 576 : roiu«ii(iit 
panphim'iui, ;;; \ nwitiubaltoo, ;;; i mUtnn of ihe Kroiutn, 578 : dit^to 
of the citnniil i:i-iittaU in fcmnlM. 578 ; a|ihitiiiui> tnlTiiit, 579 ; anniB pudoKlE, 
579 t itiilu^lc mitmnra. {So : atmoimiiliiiei in the clnccni of ihc Iciticlr*, 580 1 
•u|>miunmtir7 IcMicin, $8j : cont^mtul dupJaci-mcnt id lirriiU of Ihe cnar7. 
J&l 1 aculc oicliitis, $84 1 iij-i-hiliiie IntitU, fSj i tulmcuUr ditau«, 585 ; 
inmoiin of ihc tolii, 58$ i hj'rtniceli;. 586 1 h)rdiixp|c in girls 5^7 J variooMle, 
5SS ; oriiiati tumuuni, 588. 

CHAFFER XXVI 
Diseases or ihe bonkh 

IKnmci ti iIm! bornn. ^ 1 ooito |Mticalilb, 590 ; chrwiic [icrieatUis, 59S : ij-philille 
pcriMliti», 599: icuic Mlconyclilu. 601 j acute epiphjiriiit, 601 ; chmnie 
ciitBiucribfd <Hic>»in]rtlkl», 604 ; ehmnic illlbtr iiticninjrcliii*, 606 ; sinratou j 
ilaciylitiK, 609 : ifpUlitic daciyliiii, 611 1 Icuiitiauiaaea.tiit. 

CHAITER XXVII 
Disr^ssKs or TftR ;0IHT9 

Tubcfcuinf iliiiriM of ihv thuulitrf , 616 ; duuse of ihr elbow julnl, 616 ; of Ihe 
wrhi. 617 1 nf tbeanlcle. 616: nt-ulc ijrinniiit, 619 ; |))n-iMic juini ditcur, 6101 
eMnlhvlnatmit nfnovili*, 630: chronic thcuinalic nilhritii. 610: iyphllilK 
vraovitii, 6j> I aculc )un>iin(lTe uitirllik vf iiifani*, 611 ; aculc tutiercvUr 
vfnavMn, AJ4 1 ncto iliac diH^uc. £j6 ; dixaso of Ihe l«nt>Jro-m«xlIUr) 
jonil, 6j7 i liyiicria) jotnu, 6}8. 

CHAPTER XXVIII 

HIP mSEASL 



H(|> dbmuc. 6J9. 



Contents xvii 

CHAPTER XXIX 

SPINAL DISEASE 

Cailes of die spine, 664 ; costo-Tertebral diseue, 677. 
CHAPTER XXX 

CLUB-FOOT, DEFORUITIES OF LIMBS, 2TC. 

Talipes eqnino-Taras, 67S ; T. valgus, 6S0 ; T. equinua, 6S0 ; flat-foot, 6Sg ; wry- 
neck or torticollis, 691 ; diseases of moscles, 693 ; tenosTiiovitis. 693 ; various 
congeoital malformations, 694 ; supernumerary digits, 696 ; club-hand, tq^ ; 
web-fingers. 698 ; congenital rigidity of joints and contractions, 699; congeni- 
tal dislocation*, 700. 

CHAPTER XXXI 

DISEASES OF THE NOSE 

Acnte catarrh, 703 ; chronic catarrh, 703 ; nasal polypi, 705 ; malformations, 705 ; 
epistaxis, 706 ; nasal deformity, 706. 

CHAPTER XXXII 

DISEASES OF THE EAR 

Diseases of the external ear, 707 ; affections of (he eilemal meatus, 707 ; inflam- 
mation of the middle ear, 70S ; of the labyrinth, 711 ; intracranial abscess, 711. 

CHAPTER XXXIII 

TUMOUR GROWTH IN CHILDHOOD 

Sarcomata, 713 ; neuroma, 714 ; enchondroma, 715 ; eioslosis. 716 ; cystic tumours, 
716 ; fatty growths, 719 ; giant toot, 720 ; compound congenital tumours, 721 ; 
congenital sacral tumour, 723; lymphoma, 724; cystic growths of the jaws. 725. 

CHAPTER XXXIV 

DISEASES OF THYROID AND THYMUS 
Acnte mlargeinenl of the thyroid, 726 ; golire, 726 ; thymus, 727. 



xviK Diseases of Children 

CHAPTER XXXV 

DISEASES OF THE SKIN 

Eczema, 739; Impetigo, 736; seborrhceB, 737: erylhemalotu emptioos, 737; 
roseola, 738 ; erythema scarUtiniforme. 738 ; chilblains, 738 ; eryihema multi- 
forme, 739 ; erylhema nodosum, 739 ; urticaria. 739 ; urticaria papulosa. 740 ; 
lichen scrofulosum, 740 ; psoriasis, 74a ; pityriasis rubra, 741 ; miliaria — suda- 
miiu, 741 1 miiiaria rubra, 741 ; pcmphisus, 741 ; dermatitis, 741 ; drug erup- 
tions, 743 : tinea tonsurans, 742 ; tinea circinata, 743 ; alopecia areata, 74J ; 
favus, 74S ; scabies, 745 ; simple onychia, 746 ; ouychia maligna, 746 ; lupus, 
746 ; papilloma, 747 ; bairy aod piginenled moles, 747. 

CHAPTER XXXVI 

INJURIES, SHOCK, HEMORRHAGE, ETC. 

Injuries 10 Ihe head, 74S ; traumatic cephalbydrocele, 74S ; fracture of the base of 
the skull, 749 ; injuries of the chest, 749 ; injuries of the abdomen, 749! inju- 
ries of the limbs, 749; greenslick [Tactures, 7So; ununited fractures, 7S0 ; sepa- 
ration of the epiphyses, 751 ; primary amputations, 759; primary resections, 
7S9 ; dislocations, 759 ; bums and scalds. 760 ; shock, 761 ; loss of blood, 761 ; 
pain, 761 ; septic diseases, 7C2. 

CHAPTER XXXVn 

>^N£STHETICS FOR CHILDREN 

Local antesthesia, 764 ; cocaine, 764 ; nitrous oxide, 764 ; chloroform, 764 ; ether, 
765 ; A. C. E. mixture, 765 ; the choice of an anKSthelic, 765 ; preparation, 
76s ; vomiting, 7^7 ; aniEsthetics in special operations, 768 ; accidents, 770. 

APPENDIX 77" 

FORMULiE 811 

INDEX 8si 



LIST OF ILLUSTRATIONS 



I. 

2- 

3- 

4- 

5- 
6. 

"■ 
S. 

9- 
to. 

II. 
II. 
"J- 
14- 
15- 
I (J. 

' 7- 

ig. 

21. 

22. 
2j 



2>(. 
-?■ 

Jl- 

54. 



Stomach ofa nuwly Iwrn infnnt (natuml sizi:) . 

Lower jaw of an infant al birlh, shrming lienlsl sac 

I^wer jaw ofa child alioul three years of nge 

Meningeal h.i'mnrrhafic in .in infant , 

Double cephalh-Tmammn 

."■ioclion (if a ccphalha;ma(oma 

Section of an ileo. umbilical divert iciilnm 

Tbittle for allowing milk to stand 

Infant's feeding-lHitllc .... 

Funpis of thrush 

Deformity of mouth due to cancrum oris 
X'ertical section of human tonsil 
Temper.iture chart of epidemic lonyillltis 
liotiF'glass constriction of stomach 
Thread norm ..... 

K'^s of ihrcail «orm .... 

Iteo-c^vcal inlU5siisi;e]itiiin 

Scheme of lines of union of face 

Double incomplete harc-lip 

Severe (irmble hare-li|t .... 

Dianrams of hare-lip o[ieratioiii. 
Macrostoma ...... 

Supernumerary auricle in neck 

.Anatomy of child's tmchea 

I'arker'i tr.icheolomy tulx; 

O'Dwyers intubation ap|iatatus. 

( (Dm ycr's extractor .... 

TL-iniieialurc chart of broncho -pneumonia . 

acvite fatal broncho-jmeumonia 
,, a ca^ie of acute lolar pneumonia 
,, croupous pneumonia 
„ ,, ,, treated with coli 

,j ,, pic uro- pneumonia followeii by cmpyi 

Dernrniily nf ehcM due to empyema .... 



!>alh 
■ma 



6 
II 

■ 2 
iS 
21 
21 

J" 
47 

53 
6i 

65 

66 
6; 

107 
109 

it>9 

126 

'57 

'S8 
'59 
162 
t66 
170 
198 
202 
Z07 
207 

213 
214 
216 

228 
229 

237 

244 



XX Diseases of Children 

rill. >■«" 

35. Section ut cheesy glands at the bifurcalion of the trachea . . HI 

36. Ttmpcralure chart of :icule ulili* iti nil infant I5S 

37. ,, ,. eiylhemo luiimiim 'S^ 

3S. ,, ,. scatlet fever 260 

3<). ,, ,, mild scarlet fever 161 

40, ., „ nialiiinnnL scofkt fever iti 

41, „ ,, piisl-scflilalinnl nephritis 266 

42, ., ,, rases of measles 274 

43, „ ,, measies with broncho- pncamonia .... 375 

44, „ ,, iiiiM cnlrfie fcvct ....... 299 

45, „ ., enteric fever 301 

46, ,. „ ,, „ with peritoniiis 303 

47, „ ., typhus fever 3°^ 

4S. ,. ,, chicken pox 3" 

49, Varicella g.irn;r3;nnsa 3" 

50. Temperature chart of modified smallpox 3'fi 

jl. i'lan orfi:elal citciilalion 3^^ 

52. Stenosis of pulmonary arleiy 33° 

53 33' 

54. Tem|>er:iluri: chnri of acute cnclocarclili-. 337 

55. Acute tnclocirditiii of miirnl valvei .....-- 33** 
j6. Mixed n.tvns of lace 350 

57. Xierus o' face 35' 

58. Oiliilal n.tvDs 354 

59. Art er!n- venous vnrix 355 

60. N:tviK lijinnialoilc!; 35^ 

61. TJcgeneraicil nn^i-ns of scalp .......-■ 357 

62. I.yni|ihnlic n.xviis of foot 357 

63. Milinr)' tiilKiTculo.sis of (he churnid 374 

64. Tubercular ulceration of the fimi 383 

65. Tracing of chest-wall in rickets 39^ 

66. KnlaiBtmenl of e|iiphyse*of lower cn<l ofraiiiusnnd ulna . . . . 39S 

67. Section through enlarged e|iiphysis in rickets ,,.... 399 

68. Section through ihe junclion of rib and cartilage in rickets ■ . - - 4°4 
6g. Tra.nsvetse (.dciion through the shaft of Ihe ulna in rickets . . 405 

70. Rickety iteforniily ipf the femora 408 

71. Altitude showiiii; "Icfotniily ill riiki'ts 4°^ 

^^. Figure -showing results of osteotomy 408 

73. A riclicty ilwnrf 408 

74. Rickety attitude of sjiinc 409 

75. KnocW-knee - - . 410 

76. Attitude producing curvature "f tibia 4'2 

77. Uowdeg 412 

78. Sin era! rickety defonnilies 4'3 

79. Thomas's fplini for genu valgum 418 

80. Lttlcriil cunature of the spine' 423 

Si. KecliningWiAul for lateral curvature ....... 4IS 

82, Fissures around the mouth in congenital syphilis 429 



List of Illustrations 



XXI 



83- 

S4- 

85. 
86. 
S7. 
SS. 
S9. 
90. 

91. 
91. 

93- 
94. 
95- 
96- 
97- 
98- 
99- 

lOCX 

101. 

103. 
104. 
105. 
106. 
107. 

loS. 
109. 
no. 
in. 

J \2. 
114. 

I'S- 
116. 

117, 

"9- 
120. 

IZI. 
121, 

'IJ- 

114. 
I!5. 

126. 
127. 

J 29. 



Congenilal syphilis .... 
Destruciion of the nose in congenital syphilis 
Disetscs of bone in congenital syphilis . 
Syphilitic epiphysitis .... 

Tracing of ' Cheyne-Stokes ' rcspiralion . 
Chronic hydrocephalus .... 



.Sclerosis of brain .... 
Atrophy of the left side of tlie cerebnitn . 
Tranwerse section of the cerchnini . 

Spastic paralysis 

Keaults of lenoloiny in spastic paralysis 
-Section of brain, showing lilood-Cjits 



Brain, showing rfTecls of old meningeal h:eniorrh.-i(;c 
Medulla, showing hxmorrhage .... 
Transverse section ofniedulla, showing haimorrhage 
Section of brain, showing effects of embolism 
Cyst formed in brain as the result of embolism 

Tetany 

Cretin 



A case of cured spina bifida, with ta1i|K;s . . 
.Scctiiin through a spina bifida cureil '>)■ injruiion 
Sjmntaoeoits cure of spina bifida . 
Otciitiial meningocele ..... 
Kronlal meningocele ..... 
l'seiiilo-hy|)crtro[4iic paralysis .... 



Nrw i^o\i"lh in the kiiiney . ... 

Omjjenital reital 'iarconi.i .... 
Kisvilt c)ra [ilaslie o(wtatinn for eiiroversion of the liladder i 
I'ndescendecl testis seen as a s«fll:ng in the inguinal canal 
Diagram showing the cnmnumcr forms iif hydrocele of 

process 

.\cutc jieriosiitis of the fenuir .... 

Overgrowth of the Ixines of the right leg . 
Sj philitic diwase of lioth libi.-e .... 
Kpiphysitis of the upper end of the right hiimenis 

Multiple tubercular dactylitis 

Overgrowth nf thumb as the result of tiiliercular disease 
Rfiulls of [vil>crcul:ir ilactytilis .... 
Tiilfl^Tciilar disease of the wrist . , 

Tulierrular disease of the ankle ji tint 
Congenital sy|>liiULic synovitis of Ixiih wrists 
Showing the results of eiasion of knee 



I a Ixiy 
the V 



agi 



:;al 



Shi'W ing the result of premature use of limli after ojicralinn 



431 
4JS 
4J3 
434 
443 
4S5 
456 
458 

459 

460 

473 
473 
475 

476 

479 

480 
4S0 
48 1 
482 
50S 
52* 
S'3 
530 
530 
S3I 
532 
53* 
546 

547 
553 
555 
571 
58. 

586 
592 
597 
599 
605 
610 
610 
610 
617 
619 
621 
6x9 
(129 
6J1 



xxii Diseases of Children 

Fir.. _ f luit 

130. Splint for disease of th« ankle anil tarsus 631 

IJI. Keseclion nf (he tarsus 635 

Ijj. Showing the result of excision of the OS ealeis . . . . 636 

133. Diagram showing (he jiarls most frequently affectcil in lii[i disease , . 639 

134. Disease of head of femur . 639 

135. Section of the head of femur, shouin^; disea>ie 640 

136. Sjiecimen, showing disease of the acelabidum 64! 

137. Lordosis in hi |i disease 641) 

138. Tosition of the lindj in the second stage of lujuliscasc . . . . 648 

139. Side view of the same 648 

140. Uryant's splint . 654 

141. Method of applyii^ extension in hip liiseasc ...... 655 

142. Thomas's hij) splint applie<l 656 

143- .1 .. , 656 

144. Result nfcxcisiKn of the liip 660 

145. Caries of the spine 665 

146. Allitude in spinal caries ■ 668 

147. Jury-mast for spina! caries ......... G72 

148. Patterns of I'homas's s]ilints for s]iin.-il disease 673 

149. Caries of the spine treated uith Thomas's splint 674 

ijo. .Severe tali ]»s equi no -vartis . 679 

151. Very severe tili[ies equin<i-i"anis 679 

153. Little's tin splint 684 

153. Artificial muscle applied 6K4 

154. Little's tin talipes shoe 684 

155. .Acquired talipes 688 

156. .Artificial muscle for nal-foot 690 

157. Congenital wrj- neck 691 

158. Artificial muscle for congcnilal «ry-n<ck 691 

159. Double thumh 696 

160. Intra-ulertne amputation 696 

161. Arrest of development of limb ........ 697 

16a. Cluh-hand 698 

163. Double cluh-hand 69S 

164. lienu recurvatum and talipes calcaneus 699 

165. Almormal position in ulero, causing genu recnrvalum, &c. . 700 
t66. Congenital dislocation of both hi|is ........ 701 

167. Sarcoma of lower jaw and eyeball ........ 713 

168. Knchondroma of spine and fingers 714 

169. Multiple enchondromala of finger ........ 71S 

170. Hygroma of neck with macr<^los.sia ........ 716 

171. Congenital serous cj'si of liack .716 

171. nermoi<i cyst (if i>rl>it 717 

17J. „ „ fnrehead 718 

174. „ ,. in lachtjmal fissure . 719 

175. My«o-li|ii)ma of breast 720 

176. Giant foot 720 

177. Congenital cystic tumour of groin 721 



List of Illustrations xxiii 

FIG. FACt 

17S. Congenital sacral tumour 733 

179. Section of congenital sacral tumour ....... 713 

iSo. Lymphoma of neck , 73; 

181. Cj-stic bronchoccle 737 

182. Hairy mole of the face and scalp 747 

153. Separation of the upper epiphysis of the right humerua , , . . ^%^^ 

154. Plan of the development of the humerus 753 

iS;. Separation of trochlear epiphysis of humerus 754 

156. Arrest of grott'Ch of the radius 754 

157. Separation of lower epiphysis of left femur 755 

tSa. Dislocation of the patella 76a 

1S9. Short, large calibre tubes 776 

l<)o. tiuih-up head for granuhitions 778 

191. New York Orihopccdic Hospital brace for knock-knee and boff-Ie£S . 780 

19Z. Knight's bow-ieg brace .... 780 

193. Boston Children's Hospiul's brace for bov-legs 7S0 

194. The Davis-Taylor long traction hip-splint 788 

195. Ilradford-Goldthwaite brace for correcting deformity at the knee . . 7S9 

196. Taylor's spinal brace with chin cup 791 

197. Whitman's flat-fool support 793 

19S. Shaffer's flat-foot support 794 

f Or. Freeman's pasteurizing apparatus 798 

Zoo. } 



DISEASES OF CHILDREN 




CHAPTER I 

TItK MIVsiniX)(-.V OV INrANCV AND CHII IHIOOn 

*ba rario«a ot Satljr &u«.— I'he life of man !* nulurally divided iiilo 
ihr«e gT*at c(H>chs— vii. s period of Grotv/h and liet'tlofimtnt, of Malurily, 

*nte firM divisiim includes the iicrtoiU of early life, when those srries of 
eperatltios art in progreM by nliich the omm or primiii^c j^erni is Ir.tns- 
frmncd into (he cniiipleie orgiinistTi ; il may be subdivided into Intra-Mlerint 
ijf. Jn/-iticr, C^i/.Uiii-d, Vittifk, titiH AiMttantf. 
KBtr»«at«rlo« &l(«.— t^unng this epoch ihe embryo dr-pcnds entirely 
its farrnl for all its uiinls. Tlic maternal blnod lupplirs il nilh 
:erial ^r cnnMructivc ptirposet, carries aw;iy its waste praduas. and 
iders unncce^'uir)' the m^intcnnncc of an independent icmpemtiiTe. It is 
-jtly a time of K"^' impurl.incc lo the future hcinj;, and it is necessary 
llut tlii< dcvclopiTienl shnuld take plnce tmder hcnithy conditions, innsmucb 
a* it is physiolnKic.illy inipottible for an unbi^.-ilthynru-c.-iklyMiolhcrto supply 
the ikani* of the enibrj-o, and any failure in the nuiriiivc powers of the matcr- 
oal blood is certain lo leave its Mamp on thefulucedcvclopinent of the child. 
An mfAnl may come into the world fairly well developed iind plump, from 
tbr ptrs«ncc of more or lrv> siored>up fat, in spile of the weakly 'laie of the 
mollirr'!! health, hut it is almost ccdain sooner or later to exhibit lendenries 
to i]<s«iM in the direction of the slock from Hhence it springs. Not only 
nay the embryo owe a weakly biiilding'iip of its tissues to its mother, but it 
nay aclmlly share maternal disease. The fa'tus may tulTcr from endo- 
cirditis orijfinating inarheiimalicslalcof its parent, and this lesion a lfcclJnk'< 
n It o^iully does, the nifht »ide of the heart, may lead to malformations. 
»hi<rh are only loo likely to cut short its carter, h'rom its parents also the 
tortus may receiic the virus of syphilis, from which it may suffer during its 
embryonic life or lifter birth. )l may receive an inheritance of lubercutosis 
•IT rpilepsy, or n tendency to gout or rheumatism. I>uring filial life many 
MKtmjtici may arise fr<im arrested development or an ovcrt;rowth in certain 
' :>- linns ; c!<-ft pulaie and hnrc-lip are instancei of the former,and supcr- 
■;irj- fingers and n.i-void gnurvilis of the latter. 
innMwjr.— The Romans used the word •nfiins in it^ widest sense, .ind 
.^?i, as its derivation implies, it was originally applied \a those who could 




I 



I 



TIu Physiology of Infmuy atid Childkoott 

noi »|>cAk, ii (-ATI1C III b<- employed by ihet» for children of much iildcrj-ctn.-' 
Tlic IcmiR infiHcy. prtmil'iw rnfiiHif ami Siiuglin^ptrimii are most usually 
npplicd lo ihc firsl seven or citjht niimlhi of life, (he time during which the 
infaiii Ik nursed at the l>rcasl, nnd before the cni|iii»n of (he milk teeth. It 
is, hnwcvct, u»rd by some wrilm lo include the whole of the 6r*t y«nr. 
Within the lirst week or too of life the mf:inE has nficn lo roniend with con* 
diiions which ^are pcculi.ir lo I hiii period, in;»inuch as they depend in one 
way or another on ihc ;ict of birth. It mjiy be bum aiphyiiated in con- 
sequence of stnuigulaiion by the c(ir<l or |>re«sure on the head, or various 
injuries producing h.em.itomas may take place : or there may be septic in* 
fcction in connection with the umbilical curd. I'be ctunge fioin placental 
alinicnlalion \a the digestion of food in the mfant's stomach is a time of 
peculiar danger, esjicciatly if artiAcial food ii given, and the mortality 
of infanta is much x'^cater daring the fint «e«k of life th.in ut any other ■ 
period. I 

During ihe firat few miinthi of infimcy, life is not »o purely vejjeuiivc ai 
It (s during; ihe intra-utcriiit period, ycl the menial (acullifs aii; in abcjauce 
and ihe movemtntti mostly involuntary or letlex. 

On« consequeiKC of the undeveloped condition of the higher or inhibitory 
centres is ih,'ki the rclk-v centres me lets undci ijontrol than In later years, so 
that iJiwrderiy reflex m«ivcment* in the fonti of i:onvuHion*aicli.»hle lotnko 
place on ihc slishicst provoc»iion. Groivth ai this period Is cutrrmdy rapid, 
the weitchi more Ihjin doubling itself durio); the tin) si« months of life, and a 
great strain is ihut throun on ihc attmentAr> system : the lymphatic and 
blood-forming Orleans are also <:xccedini;ly,ictivc. li is not surprising, there- 
fore, iliat the diseases which aie most common and fatal at this period arc 
those connected >vith di^'cstion ^nd absorption. The infant requires much 
test, and, indeed, divider iis time for the ino»i part bct«i%cn fe^lin^ and 
sl«cpin(,'. It is during' thlipcrjod that 'Hasimg.' 'marasmus,' «t "atrophy' is 
so cominon, a result of chronic catanh of the intestinal tract and a con- 
sequent impairment of the diKcitive oigans. 

OMidbood. -The eruption of the milk-teeth marks an epoch in early 
life, the term ehilMiM'ti bcin^- applied to the period commencing witli the ■ 
nrsi dentition and cndin); niih the cominen«emcnt of the second, at the I 
sixth or M-veiilh yeJr. The teims s^inmii mfaiu^ and Kindtrtiillfr are used 
in * similar sense. Growth at tliis period continues to be active, though not 
proceeding at the s.ime rate xs during infancy, but disturbances of the ali- 
mentary system are common, and children quickly waste if digestion .nnd 
nbsoqition are iiiierfeied with. 

The osseous and ntuscukr systems are developing so thai by ih« cod of 
tlic first y<rar tin- child can crawl or even walk with help. It is at the corn- 
inert cenietit of this peiiod that rickets, a disease so intimately .associated 
with indigestion, often ntakes its apjie^irance. 'flic nvcntal faculties atc-fl 
opening out as the litain dcs-elops, and the infant be|;lns to recognise its V 
/ri(rn<ls and call tticni by nan>c. Duiing the period of dentition nervous 
(JiHturb.-in<;<rs are common, and the lesions giving tisc lo infantile paralysis 
re ape to take place. 

^«tttii,— Tlictcinksj"(>M/j(,/mii/«tf and A'lMjt^frAT/ATaregmetaltyapplied - 
• tbc pertiod ccnnn>eDCii>g at the second dentition and eliding at puberty, or ■ 



YuHth — RfsfiriitioiT 

It tlic fourircnilt yrar. niiriny ihU lime ihc milk icclh aic replaced by 
(wnnnncni set, ihc bones bc<rornc mnrc solid and the muscles better 
vclopcd, whik ihc mcntAl fnciillict nrr cxccedinKljr aculc ;iii(l the tnind 
■idily jn|ui(«a knnwicdcc. As pul>criy- (tppronchM tlic voIlc betomci 
'drcpcr xaA the wxual orKvtnx undcrxo a marked iin'rcAsc of development. 
OtifiRK ihis pciind, in which tcholaslic cduc.tiion is carried mi, (be memory 
^^^ cxcceidinjjiy [clcniiic, pc-ihapv more so than nl any oihcr time. Children 
^Hlt this prriod ej^ity 'oiitKinw their «irrn;:lh,' ihc nervous syslcm is readily 
^^bptct, »i^ i« e\'idGnce(l b>' the fic<|ticiicy of chore*, and the alimentary ennal 
^^k Apt to fuHer from chronic catarrh, 

' lti> f t > »Uqo.— Dtirin).' intrvt-utcrine life the respiration of the fictus is 

carried on by n>c-An« of the placenta. The blond of the fa-lu«— us ferns 
oxyii;^') ^ catKcmctl— is supplied in a far more imiicrfect tuannct through 
the iTialcnial Mood, than "hen after birth the oxy>.'en is taken direct from 
Itic air in the vesicles of the lun^s. Inasmuch a<i the fwiiis has no inilv' 
t>«ndeiil temperature to maintain, and iti life is spent in continuous sleep, 
ii« lisuirs require far less nxygcn than it docs after birth. I'his condition 
cf things indnces a tolerance of oxygen starvation, much (greater tlinn in 
ult«, tluit frequently stands >I in good stead during the .ict of birth, when 
lentiil citcuUtion is jieihaps interfered with tlirou)(h pressure on the 
ical cold, anil pulmonary respiration as yet is not possible. Infants 
often bom in a condition of asphyxia, especially after severe labours, and 
c licen known to survive wiihout cither placental or pulmonary respiia- 

II for lo lo 15 minutes, and infants may live for many hours, or even (Lays, 
h the greater patt of iheir lungs in an unexpoinded state. The same 

li-ianre of a venixiscondiiion i)f blond iiccui-s inoihei newly Iwrn animals : 

uv ltii]iin'Sd<|iiatd has shown thdt a neuly bom mouse will recover after 

miniitrt', and a newly bom guinea pig after 11 minutes' immenion in 

3ti->. while an immersion of 3 to 3^ minutes is fatal to the adult animals. 

Ill the newly Imrn the respirations amount 10 about 44 per minute: 

during lite eatly months of life iliey vary from 35 to 40 ]K'r minute \ at the 

cad of the first year and (ommeii<.einent of the second they hate fallen to 

about 3K ; during the third and fourth years they are about 2J : by the 

liftrrnth year tl>ey hate fallen to lo ; in the adult they vaiy fiom 16 to 30.* 

infants and cliihlren, as mi(;ht be expected, give off absolutely less carbonic 
rid than do uduhs, bui relatii*ely more. 
The absorption of oxj-^en is also relatively greater in childhood than in 
dull life : lJ>e oxygen in the exhaled carbonic acid does not represent all 
to inhaled oxygen, the proportion retained being greater in childhood than 
\ .tduli life. 
In the infcinl aivd during the fir^t throe years of life the typo of rcspini- 
tira (» ih« abdominal, the diaphr;igm being the chief nii,>''c1e used in trampiil 
.. 1, the ahdonten rising and falling, and the ribs movinji; but little. 

I >~ OS to- inferior type is present, renpiration lakr's place both by the 

ihe upper sev<!ii nbs by the inlercostals, and xlso by means of the 
ii. ihc chest expanding; and the abdomen moving slightly. 

III K"'* inwaixb puberty the cost o. superior type is present, the upper 
of Ihc rhest moves freely, the lower part .ind the abdomen haidly at all. 

Tbtf v-ita) cubic capacity of the lungs is wi>ulter in proportion to their 




^^m Thf Physiftogy of /n/itnty ami Cliihiluxxt 

^^l in children lh;in in AdulK. This it due ill pan lo ih« rclniivc small- 
ncti of ihcir luiitis and to ihc greater da«iiciiy nnd f^ciiblliiy of ihdr chest 
wall*. 

AMordinK to .Sclinepf and U'iniricli the vixA culnc capacity at difTncnt 

ugn i& shown by ilie follon-ing tabk : 

T 3 to 4 )-ears . . abnut 450 c.c. riioitycjirs. . abuui i.Sooc.fi. 

s„ r « - - .,. 900C.C. 13.. 'J .. - " I.30OC.C 

8 „ ro n ., 1,300 cc. In adults (avcraige) .. 3.300 c.c 

Wllh rc|{ard to the amiNint of carbonic acid given out b)' children, the 
fnlloicinK account of an exptritiii-'nl madi; by the btc l>t. Anguft Smith, of 
Manchester, is of inteie^t. Wc <iiiote his ou-n worxli: ' Four children, three 
bo)"* <if 6, 7, and B )-e;irs tcapectix-tly, and one i;irl of 7, were pui inio the 
lead chambnr which was made fur similar experiments and m order to 
|obicrvc iheiii more carefully l)r, A»hliy sat beiide tliein. They ■■'ere 
r extremely <)uiei, an<l the amount of carbonic add ifiien out hmi enacily one* 
half of thai which evperimcni had given me in previous yeari for a healthy 
man of moderate slreni^h. 'ITie amount Ki»*cn out by Dr. A»hby was 
rxtimatcd in a separate experiment, and subtracted froni thai ^n«n out b)' 
the children, which max etjual in amount to o'36i of a cubic foot per hour for 
each. 

* The children were then put in by themsclve* and became very riotoui 
and active, cau»inK the carbonic acid to rise up for each I» O'Jji of a cubic 
(not. They were then put in a^aio and requeitcd to be »'ery i|uiet. They 
had a few- card* 10 play with, and talked a great dc;il, but were bodil) pretty 
still, upon which the carbonic ;icid fell down nearly to the fmx amount — 
vi». 0'4i3i) of a cubic fn«i, 

' We find that talking raiicd the amount of carbonic acid only ox>S39 of 
a culnc ffioi, whiUt jumping and lautfhinj; raised it o^ 1 6S;, or about three 
time* as inucli.' 

CbaocMin ttto Circulation •ncrsirtto. -The cessation of the placental 
circulation, the inllation of the lun^s with air, and consequently the increased 
amount of bluod passing through the pulmonary anery, lead to a gradual 
Shrinking and obhtcrjtiion of the various fa-tal passages -» ii. the vessels of 
the cord, the ductus venosus ductus arteriosus, arid foramen ovale. These 
ichangcs commence after tlie litsi few respirations hare been taken, and 
'within a week or ten days these pav<agcs are closed. Not infrcc|aently, 
however, one or other of them remain* open for a much longer period, this 
being especially true of the foramen ovale. In 62 cases under I >-ears of 
age oo[»d by I'arrot, n was only completel>' obliterated in 4 : and of \i 
cases between 1 and 9 >'ears, in 36 only was it completely closed. 

With regard lo the <luctus arteriosus. Parrot found that of 1S7 cases of 
I month to 3 years, in 46 it was open, in 1 8 it was paitially closed, and in 1 19 
it was obliterated. The ductus venosus is mostly obliterated within three 
idn}** i according to Quincke its remaining partially o|)en gives rise to icterus. 
I Bload.— During the last few years, many observations have been made 
of the blrmd of the newly lK>rn and also of young infants, uith the object ol 
determining.' the dilTerrnccs as regards the number and character of the 
corpuscles as compared with adults. The results of various observers are 



A 



oDe-nitM(( 
^ (Wdckeii 
^m In Aldi 

^^^TBiiwKe is 

I bUen to 



5 

in tome CAWS hi t-arianoc. and tome care h required !n drawing concliuion*. 
The resuli* KUt^a must noi he tiikm as being univcrMilly correct. The 
nudealcd red btixid corpiist Ira Tound during the early itiunthsofinimuterinc 
life arc only vcri exceptionally lo be seen in ihe blood of Ihe newly bom 
when hiirn m full lime. The red corpuscle?) are niure numerout in the 
newly bnm i'j.000,000 In6,oo0,<wo per cub. mill.) than in the adult, and ulao 
vniy more in 'i;r :H>i)Tnii, In a few weeks this disparity in numbers dis- 
appcars. TIk ()tiAniity of Mb h also greater in the nc»ly burn (Leichen- 
Biemii. The kucocylc^ arc also both relatively and absuhiiely more 
atuncrou*. ; ilw nrvitlcr number are of the small mono- nuclear variety 
{lympbof ; Ics). The«oiinophilc retls arc also increased (Kanttiatkj. 

Tbc amount offibrin-fofineis appears lobe less a« coagulation occurs 
IcM complctdy. 

The amount of blood in the body is relative]/ less than in adults, being 
oDe-nitM(e«nib of the hodv weight, while in the adull il is one-thiricenih 
(Wdckei 

In older children in heahh the blood docs not appear 10 materially difTer 
lh« blood of .vltills. 

— At the end of f'ctal life the number of cardiac contractions per 
Its is about 13: in boys and 140 in girls 1 in the newly born infant n has 
bUen to 130 10 133. Accoiding lo some observations, the pulse rale falls 
notably immediately after the ligature of the cord, In icKain its normal 
number an liour or two Liter. During the week succeeding birth it varies 
from I » to I JO, aj-ing immediately inrteasing the number some 10 lo 30 
br^ii. IVy the second y«nr il has fallen in 1 10, by the fifth to 100, by the 
eilthlh )<-ar m 90, and b\ the tuetfth to So. 

Durinif *l«ep the pulse rate is rtimini*hcd. especially in infants, sometimes 
by an much iu to or :a heats. The pulie h more often irregular in infants 
and children than in .tduhs and thU apan from the intliicncc of disease. 

According; to S')llniann the inhibitor)- action of ihc v.igus is less marked 
in newly iKim ammaU than in adulit. The circulation of the blood in in- 
Caais and thildien i» carried on more rapidly than in ndttlts, and conse- 
qHcDlly the tissues ate lupplied with a superalnindance of iittctial bhmd. 
The tension in the arlcricx is ci>inp;iniiii'ely low.nn account of the relatively 
^^- larj^e ute of the aorta and arterial system generally. 
^B Accurdinj; to ^'ieroTdt a complete circulation t;ike» 

^H In newly horn infunta i: Mconds (134 pulse rate) 

^^L Atf^oycais • '5 ,. ("»7 ) 

^^^^^^K At fotinecn years . 18-6 ,. ( V? ) 

^^M On ai«o«ntt of the prunetiess of the pulse in be influenced by excJlcmcnt 
^^^ dttriag infancy, it is<>f k-s^valueJudiagnosisai this period than in later years. 
( *"— *— *»T c«Bai,— For the Tiist six to tight weeks of life there isver>' 

slight scc-rctti>n of saliva, only sufficient l>eing formed to render the mouth 
tno«si. In the third and fouiih months the secietion is much mote free, so 
ibot ill£lnl^ about this period begin lo dtibble : the amount of secretion bC' 
comes «till l.irger as the penod of dentition approaches, lly the thiid or 
fotmh month the sAliva contains ]>tyalin, and readily convcns cooketl starch 



^ 



iiitA iiialt'j»c, Tlic stomach of the newly bum infatii \\ small, in npncity 
bcin^ nnc or two riuid nuciccs, hy llic end of the (burih wwk from ilirre tu 
Four dunrr;, at three months iilwtit five ounces, and ai ihc end of the lirst 
year ten ounces 'llic Tniisculur Ifiyrt^ of the sion»ch nnd iiilri^licies nrc at 
^rst only :i1i^hily develn(>cd, hence the feebtcnes* of ilic pcritinhir aclion 
and th<.' tendency to the accumul.uinn of K'I^cs in both ihc siomarh and 
bowels- The ^a^iric juice ha^ at fir«i but im|ietfccl dij^rtiivc powers and 
ihr «Inmarh \i in consequence quickly c\haii«ied ; ihr peiiMjllic anion ot 
ibe n-.ilU of (he stomach i* often wry vigorous, and may j(ivc me lo the 
rcguitiitnlion of tlic foati swallowed, especially ii» elif ninli^tc sphincter it 
wciikcr and mote iMsily (jives way in infant* ihan in adulli>. For the fir\t 
few nuinihi ihcdiKCHtive jKiucrs of the pianC[eali<: -ind intcKinal juic«i nre 
cxiKx'dinKly fecblt-, hO that slnirhes and poriiont of nird of <^<>w'» milk will 
pasi thniuxh the whole of the intestine* unchan}[cd. The »ctrctii>n uf bile 
bcKini at an early [leridd of ficial life, piobably uboui ihe third month : the 
bile accumulates in the sinnll intestines and is passed at the niccimiutndutint; 
the fint few days after birth. Il form» daik brown or ttrcmish mnMci, 




Kit. I ftHIMirh cf > Nivly Horn Intmi \imVi>t\ •litl. 

<ritcous and tenaciout, and of a feeble acid reaction, and consiMs of mucui 
holdin)! in sut|>eniiion fatty matters, epithelial celts, biliary pi>.inetilt and 
cholcsieiinc, but no bile-acids. Three or fi>ut ilays after birth the mccotiium 
it succeeded by (he (coldcn yellow semi-ltqui<l stools rharacterittir of the 
healthy infant. This yellow colour is due to the biti-iubin of ibc bik i the 
l^rrcn roloiir sometimes sceii in intesiin.il catarrh depends U|M>n thcoxtdaiian 
uf the bili-iubin and forntation of bili-verdin. Under nonnal circumslAncet 
newly born infants haw two or three stools daily. Tlicirchaiacicr gradually 
changes as the infants jj-et otdei, becoming more and more like the slooU of 
adiUls. 

VHb*. The newly (torn infant tfcnerilly passes watci within ii hours 
of ill btrih -iiid continiKs to do so iome in or is tiroes djily, passing about 
I oj. at a linvc, or about lo nr. in 24 hours. The first urine parsed is cloudy 
from the presence of uric acid and epithelial cells, and is of spcciRc %rv. ity 
looj-iooft ; later it l)econ>es clear and of a li);hl slr.iw coltKir. Il roniaioi 
more uric acid and less urc^i (aliuuc '% per ctnt.j iImii docs that of adults. 

[>urinK (he whole of childlwod the urine is of a paler colour and lower 



^ 



7H«e — yenvus System 



specific ; 



t than iluiinu .iduli )ife ; 



:ill«t I 



(|iianlili«s are also |)a»«d, hui 
on accounl »rf the ililticully of inllcdinj; ih* loul (|iiiimit>'lht: nmounW hnvc 
not been dccunitcly cUriermlne<I. The followins ri);u:res may be Uken a* 

I upproximative : 

^^ft HrtHCT* j-j jrn- nbcul i;->5 M, ixinuiMini j-14 gruniBKntif iiitn !<• )4 bn.) 

^^^ 5-9 .. .. JS-35 ■• U-iff 

^^^K .. 9-'4 .■ ■■ 3S-40 V->9 

^^^^P .\tlal» JO .. .« 

^K TiiiMiiwiiin The irmpcratiirr of nn inliinl at binh (nkc» in the 
^H r«<tu(H is ubmit too* F. ;37~; C, R<vcr, Soinmcr). A fv-n minutes after 
^^k binh tl sink* to 97*. or in weakly infants still louvr : in the cnurM of a few 
^H bnur« it a^tita n«cf and renuins at about qS-S" ¥. Thi« tern pern I it re or a 
^H frndlcm nf a cU-^rec hiKber— ^'8 9>)' t'.— may bo taken a>i the normal recia) 
^H leinpcfatuir during rhildhcwxl and ynmli. for ynunic children. If exact ob- 
^H> MirvatifKi* arc retiiiirrd, the rcrlum i« the best place to insert ihir ihcrmo- 
^^ meter, AS It U diOictili (o keep ilic infant <|iiiei with ;t ihcnnoineier in its 
luilU. It » impormnt to remember thai the rcci^il temperature cxeectls 
that of the iixilU by about T^ I~. Tor most iliiiical obscrvalions the fold nf 
ihc jEToin nr the axilla may be taker). What is also nf importance is the time 
at which II is taken. Accoidinj; in the i:areftil reM^archcs i>f Finlayxon, the 
^ diurnal ranf(e of icmperainre amnutil« to about :* t'., the maximum lirinif 

^K U >lo6 I'.M. and the minimum in the&malHiourtof thenioniing ;lhe nofte 
^^ «f tetnpcraiure in adults )iein>: smneuhai leM. 

' According to Keiti. tlie lowest tcniiienwure is between 4 .ind 5 A.M., increas- 

ing to II A.M.fallinK to I l',w.. then rising to its ititirnal maximum at 6 p.m. 
The mmt recent observations upiin the tcm|>eraluie of children in health 
■•vre nude by the late 1)t. O, .Siijrj;e*. The iwist intereslinx of iheie were 
made upnn imyt simdy children living m the rnimiry. aged rupcoiivdy 1 year 
■lu] : years. 1'bc temperatures were taken at vanoui hnuri> from lu A.M. 10 
mtdniuht, ihr usual range beini; 97-4 to 98*6. Tlie higheit temperature was 
after breakfast, «hen the children were most lively and eager for play. 

The beat of the body is maintained with greater ditficuUy during infancy 
■ban in hli-r lilr. a result due not unly 10 the relatively lai|;er surface, but 
Also lo the much greater vasciitarity of an infant'* skin. Infants and children 
■K mtKh mnrr liable to sitflcc from cold extrcmilie* than are adults. 

Wervoiia •yaiMa.— The closure of the anterior fontanellc takeii place to- 
(•■itls iberndnrf the second ^'ear in Strong aodvigormi!! children: in immature 
and rickety children it ma) be deUved till (he third year, or it may be later, 
Tbe cutnr •rapnciiy of the skull in ncvly bnm infant* is about one-third 
thai of aduli«. vit. joa c.c. : by tbe second )-car it is about ifioo c.c, while 
in tile adult it is about i.joocr. The brain i>f a newly bi>rn infant forms 
abnut 14 per cent, of iis body weight, while in the adult it is only 2J7 pec 
cent The brain doubles its weight durinR the lint year o( life fi4 o». lo 
31t lu I ; by the seventh year it has rcarheri 38 ot. ; by the fourteenth or 
Mamth year 43 01. to 4; o» : the a^erajce bram weitbi of an adntl (mole) 
Mnp aboiit 50 oj. The cerebellum after binh ileii-lop* mote i|ulckly than 
oilier parts nf the btain, the frontal lobes more slowly till »W years of age. 
«ben they dc^«loi> rapidly. 

If tbe brain ufa newly bom infant be examined, ii will be noted that ilt 



^^^^^ The Fliyst^^^o^ttjaS^ and CMlttltooit 

con«istirnc« is miKh Icis Knit than is ihal ni xa iidutt's, nnii it is mucli more 
(eadily injured If plutvU on a plate it »p(c;iilt itself out or moulds icscll 
into iiny shape mure leadily tlun aw adult's brain. 'Ilie pi^ mnlcr is ck- 
ceeilinsly ddicalt- and very easily ili»cci«^ off with a pan of fotttps. )■> 
L colour the brjio t> linlil jjtiiy, oftoii yellouisli from the pti-ienco of bilo pis* 
pments ; ihetc ■» m- will marked differeiici; between the " yrey ' and ■ uhite ' 
sul»tnni-e as in aduli lir-mi. and ilie couvolutjons arc lew distmtily marked. 
Thi^ mullipobr tdli m ilie yruy mailer on the surface are ill develi>|ied, a* 
also is llie pynimid.il bundle of nerve* »liicli tonnei:t them niili ihe baial 
t;an);li:i and internal capsule : on the tontmrjr, ihe iiene elements of the 
cord and Apiiial nerves ure well ilcvcluped. 

From Ihe abuve facts ii is clear ihai while the excito -motor centres in the 
spinal tord iind medulla are well developed at birth, the higher centres on 
the surface of the br^m are imperfect, ;uid so alio are the itninds or nerve- 
paths which connect the higher and lower centres. 71ns aj-rees also with 
ihe experiments of Soltcnaniv. who has shown ex pen mentally that Ihe appli- 
cation of iscime form of irritation, as the induced cijrreni, i<> the surlace of the 
briiins of newly bum animaU doe:) not etuke niov-enients in the face iind 
limbs as it dues in adults. The actions of infonls sucking — crying -swal- 
lowing -breathing:— arc reflex, and inasmuch as they are uncontrolled by Ihe 
inhibitory influence of the highct centres, xfc apt to be disorderly .-ind ex- 
'Cesstvc ; as, liir instiincc, in convulsions. The reflex actions displayed by a 
k brainless fmg ate more violent and tigoraus ilian those displayed »licn the 
f lirain is intact. The rwidiness with whuh the newly horn infants become 
• 'Convulsed is one of the most remnrkaiile features in early life. Hereditary 
intlucncei play an imporlani i>;tit, infants ciiming of a neurotic stock bcinj; 
much more prone tii convulsions from slinht exciting causes than others. .-Vs 
r Ihe higher centres develop, ehanKes come iiter the mental chamcier of the 
y infant, and the rerlex actions iKCume mure and mote under control arul 
dominated by the psychical centres. The movements of newly born infiints 
arc almost entirely rcHcx. though certain ' sjiontaneous' or 'impulsive' 
niuveinents, such as stretching the limbs, occur. 

Wffbt. In the litsi week after birth the infant apparently cannot distin- 
guish objects. Init can light from darkness. .According to I'reyer's examin.i- 
lions, Ihe movements of the eyes are not co-ordinateil at first. KAnigstein. 
frutn an cxuinination of yoo newly bora inf.-ints, states that llicy were .lit 
lij-perntctropic. The colour of the iris is bluisli-gtey or green, but one finds 
also shades of light grey and l>rown. The same investigator lins also 
note<l bloud evtra vacations in the retina, which disappear in a fen days. 
The impils arc v«ry large in the newly born, and sensitive to tight : In later 
ECllihtbood they r.in endure strong light better than can adults. Of the colours, 
Rbihlrcn karn lirst to distinguish white from bbick : in the second year they 
1) to distinguish olher coloun, first red and yellow, later green and blue. 
<l«M(1»t' I" llie ncv'ly bom the mucous membrane of the tympnnum is 
1 len so llut no cavity it prrvenl, consc[[ui-ntly they arc not tery sensitive 
r unds, but sliiill and Mtong soundv make impression, the infants waking 

cries. In the liist months children hear lii^h and sharp sounds better 
tl «lcc|>> Older children can hear very neak ami high sounds which 
Ak no imprcMion on ad id is. 



rasU — Body Weig)tt 9 

w — Newly bom mbAis can distinguiali tweet, biuefi sour, and salt 
ltA»te^ 

ray«talaal VbesaatMi*.— In ihc ^cond monili an 'vaXaxtX kam^ lu hold 
up its hv.id .itkI in.iki.- xiluniary inovcineiiis and lu di^iin^m^li the luicc of 
its friends. At the jid or 4ih n<i;k it can lau^li, .-ind ^niil«!t wlicii lateTiscd. 
In the yA to 4lh iiinmh the infjint nolicvs iti inyi nr ^nyUlin^ il can hold in 
I itb lunds inoslly pulling thein tu iis moiiih. At 7 lu <; munthv ihe child can 
■iX Up, and 3 or 4 tnniiths later ni;!!!^! attcnipls ic> walk : when u jfai old 
u'ell-det'elo))ed chititrcn can walk a few steps wiihoui licl^x Kroni this time 
the chih] begins <o •>!,■)■ a few syllablr^ such as iii-tA. il<i-dif, 6^-tv, withnui 
intich MMkw of appl}'iii;k: them ; then words -.ne leaint. and tiy ihc end of 
the Mcond yc^r most [lillUren c^n string a few words ti>^cther. 

Sl««f ,— The newly born infant sleeps all day c\ccpi when il wakes up 

for food. At a year old the in£ant slce^is liftccnlo sixteen hours ; fiom: 103 

[years, twelve to thirteen hours; from 4 10 ; years, no sleep in ihc day, 

I from ten to eleven hmin at ni^'hl ; from i: to 13 years, ciKht to nine hourii. 

|jnfants sleep li>:hily and arc easily awakened ; at 4 lo ; years of age they 

t ((enerntly Iteai)' slccperii. 

m»*r VTwigbt.— An infant bom ai full term wei^bs from 6 ^ tn 7} llx, 
lb. bcinii an average wci^'hl. f-'or ilic Arst Iwo or three daji of life there 
a loss of 4 ox. to 7 01., then a regular ^ain, so that by ibc 8th or 9th day 
' initial loss has been made good. According lo Gregory, the following 
Brutes' c\p(c«s ihc average daily loss and j;ain diititiu the lirst vix dny» of 

1st day . . loM of 139 grammes or neatly 5 o{. 

snd ,. „ 64 „ ., i\ „ 

3rd „ . gain of 33 „ abool 1 „ 

4»h « . .. so .. V »J ■■ 

S'*" • 50 » •! 'i ■• 

61 1' 3f> ■,, « 'i " 

i:»t Ibeve 5giitcs arc by no mc.in^ universally cortcd is clear from the 
Terentv in weight noie<t by dilTcrcnt observers ; thus, according to Lewis 
lilJi, itt 17" infanis born in the New York Infani Asylum (89 male and 81 
le), the AVctiLKc weight of the boys uas 7 1h. 11 or. and the girls 7 lb. 
I o/w Kiny of these were wet-nursed, and weighed n'hcn one week old, with 
fnlkivring rcMill : 

Increascof weight in 33 ouo 

Loss 13 >. 

Average gain 4-8 ol 

•■ '"MS y3 „ 

Greatest gain >i x 

« low 6 _ 



nrowih during the first year, more especially during the first *ix months, 
_w culri-inely rapid, the inlant doublinK its ucighl in the first six monlhs and 
tbting il durtng the tiril year. Many obsco'ation>> hnic been made on the 
'ightv of children dunni; t)ie fir»l year; the follouin(( table exhibits ihc 
BMKiifaly Kains, being the average of nine infants obscnnl by W. Pfettlcr. who 



l6 Ttit ynysiologjt of infaney and Chit 

■KtTt nuraed at ibc breast at lint, and latertliKwat tupplemenled withcow\ 
milk : 

01. 

■ -31 ■ 

■ 30i . 
. :6| . 
. 36 . 

. 31 

. 31 

. 17 

. 31 

■ =3 

30i 



in month 

and „ 

3"! .. 

4il> « 

S<I> .. 

Nil « 

;th „ 

9ll> n 

loih „ 

I ith „ 

iiih « 



Wtigtt/ itl rati of llu monlAt. 

lb. <n. 

u 

4 
'5 

9t 
■4* 

3) 

i 
lo 

I 

i\ 
o 

7 



8 
10 

II 

'3 
14 
i6 

t7 
l8 

30 
31 
33 



lir»n-lh after ihc end of the lini year is slo«r«r, so tbiil Ibe wciKhl it not 
again doubled till llic end of tlie »ixtb year, and doubled tifcain by the end of 
the fijurteemb.* 

^•■rtb.- The avernitr Icn^ili of n nm ly bom infant is t<) inrhec : It li-is 
<lnubled its Icnpli by the rnd of the founh j-car. 

Murh iniercM and imjiorx.incc i* ati-iirheii i" the incrp.i^e of wcij;ht and 
hei);ht during infancy and childhood; weekly ueinhiiii;*, ei|iei-iallv liurioj! 
the early monihs o( life, givr veiy valuable information wilh re),-anl lo did. 
It must, hon(>ver,al»nys be home in mind that increase in ncittht, eipccially 
if it be due lo an nrcumiilation of fat, doe« not al<ray> indicate tircnKih. ot 
that the food being taken is a KUitablr one. DurinK childhood, undcrt^ulh 
or 1»» of Height musi he looked upon at an indication of dandier and a^ t:\ i> 
dcnce of malntitriiinn. ( )n the oihcr hand, ovcr^'owth without a propotiionaie 
increaiw in Height ihoiiU'. alw3y> be taken a> indic;iii^« of weakness. 

Fi>r fiirlbet information on thit nubject, the reader ii referred lo the ' Life 
Hiitory Album' hy Trancis (lalton. 

The folliiwin}; i% n propciriionatc table of height and weisbt : 



I!Fi|l)ll 



w.iitii 



ll<ii|hi 



WciiSl 



t*- 


ID. 


24 


18 


n 


'9t 


^ 


31 


J? 


a>* 


38 


14 


39 


=5* 


30 


27 


31 


38i 


3» 


30 


33 


i'i 


34 


33 


i? 


341 
36 




<iciii 


Wil^hi 


Irt. 


ih 


49 


62 ( 


SO 


f-s" 


S' 


6r* 


J* 


70 


53 


73* 


54 


75 


5i 


77i 


56 


Xo 


57 


83| 


i« 


«S 


IS 


«7* 
90 



1 



tl 

Ill« noi onJy nf iniemt, but il is imi>orUkni, to bolli w«i){h and mcjtsurr 
Lildrcn ai fre<iuent inicn-aJs. Periods of under or over pnwth arc |icriod» 
'nf danjcer. at lodif siting cither miitnutriiinn or an ovenaxlngof ibcstrengih. 
nwic ihoiiW aho be mninininrd a clow rclntion of hciulu lo weight. 

BanttUaa.— At birth ihc jaw coniatns iht dental mc^ wilh ihc already 
.alriiicd I li'wn* of the tempor<*r>' te*(h. Besides the temporary U-eth. ihete 
li the .iilrihcil rniwn of one of the pcrinanetii sci, ihe fimt molar, wbicli is 
^itlulr<t iinmediaiely behind the last leiiiporary molar. (Sec fig, i.) 

T)iirinjk' the inierva! which elapM-s jjetiecn bitih and their eiuplion, ilic 
erili are undrrgoinj; fuithci develupmeni ; ihe saci liccomc enlarged, so that 
hey arc rradily felt thrwitjh the gum ai rounded swelling's the cdjjc^ of the 
eih be<'onie shaqier, and ihe {nngi are detcloped. As the kngs eloi],gBle, 
Ibe cdifc of the lootb corner nearer to ibc mrlaceof theKum,the latter swells 





nu 



w9ta fr«a 0*t iw« ki^e; f. the njrHl 1i.>lf xcit If urn tht ijii1«r aldt ^ fhe lionc liu ti> 

1H« wH'dClW Aru pannaiifriE malv tnhiikd t^u poa«riLir maluuf th« milk m(. h Uiow, 
Mm ^Ma. Mil ■)■•( Ihc uoof iU> |i<"0*w>l 'uKaar^ -tiiil tuiliii. 



i bectrnit!^ more vascabr, Ihe edge of the tooih appears as a line or jxiini 

eaih ih«itwmt>rane, which finally becomes pcrfbratcd, and thetooUi iscut. 

The temporary set appear for the most part in ("roups in the following 

ict. rtrmt fr»tip— The loivtr tn-o central incisors appear from the 6lh Ifth 

Tfttifith, fiillowedbyapiiase of from three to six weeks, seeond crvop— 11)c 

*n"ir ii|i;tcf iocis««B ale cut at intervals of a week Or (wo. fiont the 8lh-IMh 

•h, follirwi-d by an interv.il of one to three month s. TBlrd fe««»—Tlie 

l;>irrul incisors, the upper and lower front niolais .-ippear at intcivals 

iTuiii till' i:tIi t4th months, followed by a p.lusc of Iwo to three monlhs. 

rttwrvli creor- - 'I'lie canines appear, the u|>per ones usually being Arsi, fn>m 

the iKtb 2oth month, riltu cioap— The povierior molam mostly appear :il 

Ihe jgr of; 3} >-eais. 

The mith wt, when complete, reniain unchanged for several y«aT», though 



The f*hyshlogy of Infimry and Chiliihooit 

ihc pcnn^ncnt set arc );radu.itl)- bvcamtDK developed in iticii tact, rcjtdy in 
ivplacf ibc earlier »M. 

'I'he foUowini; rormiiln exiiibite Ihc relation bccuven ili« tcnipointy and 
pcmuoent sei : 

mo. cfu in. in. ca. mo, 
(CppCT 3 t a I 3 t 1 -lot 

Temporary act i [30 

I Lower z 1 3 | 1 t 2 -10) 



Ponnanent seii 



Upper 



(Lower 



mo. Ik. ca. in. in. ca. bi. mo. 
3 3 I 3 I 3 I 3 3-16) 

3 3 I 3 t > > 3 



.6('' 



Al »ix yean of n.f,r. Ihcrc are a i^reaicr number of tt-clli in the jawi ihitn 
di iuiy a^i'e, there bcinji the milk set and nil the pennanvnt »et except the 
wiidoni teeth. 

It it to be pnrtioilarly noted that during this period a marked increase 
takes place in the length of the juw to provide luom fur the thiee inolan of 




ni. >— l4<nr Itm tt* Child at •loul IhfH yntn, ihnaina (>w nliiUin ol ih* itji>|u>ui 
UCpovUficnt ifcth. The milk icvihof ilic Ticlil >klf tn.T liimon of Ibv Ml un ^hbvn. 
and Aholh* umifiSc prnnaJioT ..•(, ■■cefii Lhc wi.i]hjii. ivoih, irhictii* no< y^t htmr^, 
'ITi* Ikrgr UHi lit*' tS* mi'hi* of iIh jb* l» ihai o' iN'- flr*t jvf iHuntni mnt^i, aim! S1I...V4 
4'id Ivbii.i] II I. Ihc rudiiiiif.i iifihc wtuti] UftlitF, <<^Mn't 'Aiiftlouiy.l 

ihc permanent set. which make their ai))>cAr;inccpoMerioily tothe milk set ; 
the bicu^indi replace the temporary molare (»ce flg. 3). 

While tlic abtnc account represents the iiatc of iliin^ which oblitins 
under normal cundiiiont. yet iniportant deviations both .is to the time of the 
appearance of the teeth thrtiugli the gum and the condition of the tcetit 
tlienueh-cs fie(|ucntly lake place as the result of diseaic or enfeebled nutri- 
tion. Il ii well known that rickets it the most common I'au'ie of dela)-ed 
dentition, and not only are the teeth cut later than usual, but the dc-fcciive 
nuiriiiun which exUis in this sutc fiequciitly interferes with the develop- 
ment of the Icelli ; they may in consci^uence be dwarted or pnnided with a 
(hin or partially delicient layer of enantel, so that tliey t]uick]y become irariout 
after beint; rut. 

The jaw of the infant at Urtli contains the calcified crowns of all the utilk 




Hrion — MorMm 



iiml Chililiuaid 



Ucih 4i)d ttlso ilic cnidlicd vinun of nnr of iKc prrmnneni i,K.\, namely, tlie 
Ant »r *t)X-y«a(-ol(r molar, which coLnnience^ to cakify durictK [lie sixih 
rnonih of initn-uicrinc life. The cakificAtioii rif the pemiLitieiii iiicisors 
roimnraccs when the infant is nbi.iui a inonih old, ihe canines at -^ or 4 

Ii4 of a^ und the bicuspids later, in t)ie <irsi or <tecond yeiit. Tht 

r -1 of the second ptnnnanent tnolar begins to culeif)' iluiing ihc fourili 
or liftli ]«ur. but the wiwloni tiHilh not lill Hbout puberty. 

It 13 |»Liin, th«rcrcife, iliat nny illness otturring during ilie first year, luch 
a> lyphitis, can only AtTect the culcilicaiion of the incisors, caninei, and 
Visibly tite Iiicuspids. ^.See Second Dentition, p. 58.^ 
1'he penniincfit teeth arc cut in the following order : 

MoUu, firi^ 6 yean of .-life 

InciMfs. I'cDtral .... 7 •, I, 

„ latenil .... 8 ., „ 

litcuipid, anterior .... 9 •■ <i 

potteriw .... 10 „ „ 

Cuninei II-12 „ „ 

MoUtk, second 11- 1 j „ „ 

.. third I? :S .. T. 

KartMlKr In >n(«Bor %oA Oltlldlioatf. — In this country, out of every 
I.CMO children l>orn, en .in nvcrjgt (49 die before the end of their fiist yMr 
■if life And 2(>3 l>cfocc tlie age of 5 fwti^. Ilurintc iW next 6ve years, from 
% III 10 ycAn of nxc, 35 die, and iR more hciucen Ihc ages of 10 and 15 
yriirv So tluii out nf the original 1,000, 6S4 will he -ilive on iheir tirtecnih 
irthday ;i&d 316 nill he dead. From these lit;ure-i rl is clear that the 
iort^ihty IS the greatest diiiing Ihc l^rsi ye;ir, and that it rapidly declines as 
iild)»i»d :idvatic<'S. Indeed, the niorlaliiy is the ^calcst during tti<^ lirsi 
4y ai"! MKceeding days after birth ; thus Kor6si, in analysing the ages of 
ini? at dnih, found, out of 16,633 infants burn in I'esih during I'lc 
Ts 1874 and 1S7J, thai ouiof every 1,000 boni, 13 died within 24 lioum ; 
S7 on tlw second day ; 34*3 during Ibe Arsl week ; 36'3 duriai; the second 
ireek ; and 93 during Ihe lirst month, 

Ii appears tliat infant mortulity is slowly decreasing in this country, 
thnugit al a much slower rate than adult mortality. Thus in l^ngland iind 
Walei llw nvottahty during the decades iSji-6oand 1861-70 was eiiual to 
154 Iter i«oo(x In tl)C )-ears 1871 Soit declined to 149, wliiie in 1881 90 it 
«Bk 143. 

The inorulliy of infants differs enormously, and is dependent upon the 

amount of care which is taken in their feeding, and ihe n'^iy in which they 

uv loolcrd after, ak well as upon their jiarentagc. Roughly speaking, it may 

br snirl thai among the rural popuUiton of lirejit britain, and among the well- 

biHla Judters of suburban disliicls. the annual infani mortality :imoiJti(s to 

loaprf 1 ,000, 900 out of every t^^KXliiidten born being alive ai tlie end of 

■■ -irst year. Tliis is ihe average infantile death rate of Norway, which is 

■ 1 'Wf-si of any European touniry, ;ind, indeed, probably in ihc world. 

Ill a lartTc city, such as Manchester or Liverpool, ilie annua] death rate 

j-imng infjinis under a year is 300 per 1,000 birlhs or, '" other word*, one- 

6Ah cd' those born never reach the eod of their lirst year. In the worst and 



J 



14 'fkt Physiology of Infancy nm/ CkUiilwm^^^^^^ 

miMC crowded dislricts ihcic i« lilllr rtniibi ilini tli« iiioriality i> U lusi ]oo 
per 1,00a nnc^tliird of ihoic born ncvr-r living to become a year old. A still 
higlier d«i(h rale prevails among the unfoRunatc clui of illegitinuilc dill- 
(Ittn ; ilic inotialily among Ibcse ainnuitis .it tiin» in some ditiiricik of out 
Urge cities 10 500 pcT 1,000, not more tlun tialf living to be a year old. In- 
deed, (he mortality has in somcdisiricii risen, ai in Salfbrd, lo 710 pen .00a' 

In London ilic r<iic of infiint mortality is about ihe same a« that of the 
couiiio' gt'^erslly, namely, I ;o per i.ooa 'Ihe moiulity is the ».ime in l^aris 
as in London, while in most Coniineniat cities it is higher. In Munich (1884- 
i88q) it averaged J14 |)cr 1,000 ; in llerlin, 368 per \fx>a \ in Kii^ia, 166 : 
and in Ausiiia, ij; {Kahisi. 

As one would naturally cipeiu, child mortality also dilTen gicatly under 
different circumstances ; thus we find In the healthy parin of Hngtand ihc 
tmntial mortality of children under tivc years of age is iiot muie than 50 per 
1,000 (living at th.it age), that is. out of ever)' 10 children lunder fii-e years 
(if age) only one will die during the year -, whilst in the u'orsi diitricts 100 or 
lApD 1 10 per 1 .000 perish 3nnii.illy. 

^P Child mortality is also slowly decreasing in this counit)-. Duiing the 
l«il y«ara 1861-70, the mcim annual death rate of children under five years 
of aite was equal to 68C> per r^oooi During 1871-8011 fell 10 <>y\ per (,000 ; 
while in 1881-90 it felt to ;<)'8 per 1,000. This, however, is jusi twice il>e 
mortality given by AnscH's tables which are based on the experience oJ 
child life an>ung the upper cla^iae^, naniely, 38*3. 

Of ihe causes of death in these cases, it may be lalcen for {.Tanted that 
dtseaies of (he digestive system play a moal important rile ; but statistics 
are more or less untrustwortliy, as the causes of death which appear on death 
certilkalcs are often not to he relied upon for puiposes of classiiicalion. 
Analysing the causes i>f death from J.ooocxscs of infants under two years 
of age, who died wliile under the care rrf the medical officers of our own 
Children's Uiapemao', ue found thai of the fatal cases those connected with 
the digestive system head the list, forming jf per cent, of ihc total number. 
Branchilia and its allies c.auscti death in ! 1 per cent, of the <.isc3 : whooping 
cough in 1: j«r cent. : congenital syphilis in 10 per cent. : and measles in 
9 per cent. 

.-\mon),' the Ici^t frequent causes of death we Und tuberculosis, meningitis, 
diphtheria, nntl various ma I forniation*. We must not forget to ineniion thai 
premature birth accounts lor wime deaths that do not figure in out list, al>d 
those unfortunately too common cases whicli are returned as * found dead 
in bed.' 

InCant mortality ibnuld not be calculated, as is sometimes done, by com- 
paring infant deaths with deaths at all ages, or with the number of persons 
living, inaunuch as in a given population there may be many or few children 
or few old people, but it should be calculated on the infant population, or 
the number of children living at that age. Thus the numlicr of d<-4ihs in 
infants under a year old should be compared with the niind>er of infants 
living at the time, which is usually calculated as the mean of the births 
in that and the preceding >'car. In the tattK way the morlaliiy of children 
under fi^-e years is calculated by comparing iIk dentht^ in ibc )'ear uilh the 
number of children living under 6ve ycnrti of age. 

' -S« Or. John iMbam'i IU.\Uk Rrfvrti fiu- S^t/mi. 




Ill* ii 



CHAin'^K II 

THE DISF..\$liS INCIUF.KT TO IIIKIII 

TilMiK are certain kvioitK which ciin oci^ur only onoe in alilielimc. InaMiiutb 
iu thvy owe (heir on|;in to tbo act <if birt?i, nr to thmc importam rhan^ici 
which oi:i'»r ID the life ctmdtljons nfih*- inTam wticn ii rxcli.iiii^rt the [|ti>et 
dcpcndcfK-i; of inira-ulcrinc life for the h'X'^tcr nclivilyof utl iiidciicndcnc 
cAHlcncc. Tltout.'h niiitiy ofiheM: mailiid (ondiiiani dilTer from imi: mioilier 
in Tunnu)^ ways I'el ihcyarc ^'> intitnntcly iivtcirialcd in (heir pMlh(ilo)i;y and 
et»olO);y Ituit it it inoi.t cnnicnicnl (o diuriiu tlirm ii>;,'(-thcr. tathcr tlun t« 
'cleiiftic litem, »s ii often done, li> ihcir rr»pct;live pUi:e< in (he ortliiixry 
ctatiifitaikm of tliie.-i«e. The an of birth brings ili own tprcial d(tn);crs to 
ill* iRCtnl ii« well iisto the mother, nnd ii ix lutrdly i^iirprii^inii; lo dnd th»l many 
«h on the ihteshdld of life, .ind Ih^it ihe moHjlity durinji; ihr (it6t few 
,ys after hirlh i* jt"*"" tfi^n Ihal of any olhct period. It must also be 
rni- m mind that pattuHiion is not only rctpontihJc for nviiiy infant deatlu. 
but for dam.-iKe dome to the ncn-ous centres by pressure or h«'morrhasi\ 
wliich may l»c irreparable, and if the infant lives it i» |)nr.(lyscd foi life ot ii 
hu|>cU-«» imlieole. These diMUuei uhich arc rimnectcd with parturition arc 
^^■Imi tit miKb inlcrcsl and imiKinancc, in ih.tt many of ihi'm ate i-iiiincittly 
^^Bri'i eiitibic, and are often the iciult of the i^nomnrc of ihc fni'nd>> ur nci^h> 
^^Miar^ who. in the absence of a mcdic.il practitioner nr trained mii^c, ptcbide 
^pln the lyitit:-in nHun, ormny jiosvihlyhe the result of 'meddlewmc iiiidwifeiy.' 
Howei cr ihit may be, many a life is loM juid various morbid condilmni anse 
fiM want of .ihfistance duriii); the later stajfcs of labour, or for the iViinl of 
ijtr jad rlcanliness, or from exposure to contagion diirinx tht I'lfsl ffw daj-a 
>iI,ip!i «n:i"*^d Iwrlh. We will first consider the effect* of asphyxia, m» 
^i-ii!iii'.ii in neiisly born intmt*. 

Aat^bral* ir«aBal»rnm. It is hardly to be exjiected that the ininsition 

i"ii!i pI.M'coi:il to pulmonar)* respiration should be •iccampliihed uiihout 

u>ii<c li^k iif ibc cessatiiin of the one before the com mc nee men t of the other. 

fonisialcly for the infant, as w« have already remarkts], its netMUis centien 

I tiotics generally arc br more tolerant of a venous condition of blood 

I lliey are in after life, ftw during inlra-uierinc life ihe atiation of the 

Iwid is far Ie»» perfectly perfom>ed by the placenta than it is aflrrwaids by 

1bii);» ; and, raorco^-er, there i» a miicture of the placental blood with the 

ttnoiu bliind of ihe inferior vena cava before it is disiiibtited to the body. 

•;■ The infant may die from this cause Iwfore hirili, nt it may be bom 

ifxiated ; (*) asphysia may lupcrveii'' afitr hinh ihiou^'h fnlhiic of 

pulmooao' fcspiniiKm. 




16 



Tlif IHirau-i Ina/ieuf W Birth 



(a) Atph)xiii before btnli is caused by the dc-Mh or fdintnnt at the 
mother, lielnfhmeni of or intcrfprcnre with the placenl.it ciinilation, or 
compression of (he cord. Aspliyxia of ibc fcctiis may be siis;M;ctc<] if the 
fixlal heart bee onirs faint, (he puluiion of (he con! teases or is u'eiik, or if 
meconium is luiMcd. In infani« horn n«phy:«iatc(1 the symptoms t-nry ac> 
cardifif! lo ihe dexree of asphyxia prei^eni ; when slight, Ihc lips are of a 
bhiish lint, the skin lim^ky, the ranjunctiv.i- injecied. ihe limbs sr« motion- 
less, but the mukrulnr tonus \f present, the heart's action is slow and mosily 
visible, (he movemenis of res pi rat ion are sep>im(ed by long intercats, or no 
aitentplsarc made unless loinc sirotig reflex irritaiinn is applied In ibc 
deeprr slAge< of asphjuia (he fice and lips arc pallid, the ex(remitie* blue, 
the muscles of the hnihs and neck have lo« (heir (onus, no attempts are 
made a( respiratory movemmls, or only a fevr inspir.i(nry etfotls accom- 
panied by indrau'lnt; of the ribs nnd epiKa»tniini, but u ithoui any effect in 
expanding the lungs. 

(i) ,\iph)xia nu) 1>c due to catiscK which npera(e after btrth. In rar« 
rases a ki-inorrhnge has (aken place during I>irlh into the 4th ventricle 
(Horroclts), 01 into the siibslance of the mrjliilU, and (htis the re*pira(ory 
centres aic piir.dyscrt. In o(hcr», murusor litiuornmnii h.is l>ei-n sucked in(o 
the air [lassages during the act of binh, or a ha-n>orrhagi- iiuiy havi- taken 
place into llie lonjiS thtmi>;h presMiic dining birth [Spmccr>. Among (he rare 
causes, asphj ii.t m.t)' be due (n .in imprrfcrt development of the diaphrajjin, 
double pleuritic c-fTusion, syphilitic in5ltralion of Ihe lungs and pd-^sure on 
the iriicliea friim enlarxed glands. The commonest cause, howtitr, i» 
weakness or imm.iturity on (he piiri of (he infant, its ribs being wanting in 
rigidity and i(s inspinitory forces feeble, so tha( it (ails to draw in air with 
S(Uficieni power 10 ind-ite the lungs, and (he latter remain to the greater 
part of their ement >n the f<rial or uncvpanded state, <i condition to which 
the icnn of ' a(elec(asis ' is applied. Tliose infants who haic some complete 
physical obstruction to (he emr.ince of air into the lungs necessarily only 
sor\'ivc their birth a few minute* ; either no a((en>pt at respiration is made or 
inspiratory efforw are accompnnied by nxestinn of (he rhcsl walls, ^^(haut 
any air entering the rhesl. I'lemalurc nr weakly infants may survive for 
nuiny hours or evenday^ nitha large portion of their lungs In anunexpnnded 
Slate, They aic extrrmcly feeble, their cry is weak and whimpering, their 
lips and limbs are dusky bimr, and ihcir tem)rratiirc below normal. Their 
respiratory movements .irc confined (o ilighi coniraciions of the diaphragm, 
sometimes arrompanied by indrawing of the n-alU of the chest ; ihey have 
hardly s(reng(h (o luck, and are in a drowsy or tern i-cnmat use condition. 
They frequently suRer from local twiichingi, Icit trften general cont-ulsions. 
If llicy live over forty-eight hciiirs (hey become jaundiced and the limbs 
a.-(lcnuitous. An examiiution of the bodies of such infant* revcalt the 
tunal signs of death from asphyxia ; the blood is dark and duid ; (he right 
heart anci veins distended : the unuxes and membranes of Ihe brain con- 
)[«tcd, and a meningeal h.-eniorrhafje may be pteienl- The lungs will be 
found in a rxmdidon of aieleciasiit or pulmonary apoplexy. In a case which 
we rccendy ennmined in which (he inbnl died siv houra af(cr birtb, both 
huig* »ank in water, were solid everywhere except at the anterior edges, 
where there were clusierit of air-containing lobules and also»imiktexp:(ndcd 



Asphyxia Nfotiatcrum 



>7 



I lOKlrt of a liyhl rvA tcilnur, icailcrvil (i\ er ihc wirfacw of the upper lobe. 

tttitciii ledi'Mi' (i'iplsytd purple solid lunji without a trace of expanded 

I lDbii)«t a condition doc probably tn a puliiii>nary apoplexy occurring' during 

I biflh. In Another case, when; the infant liveil ihtcc days, the iuii(,*i ;ind 

hnrt togellK-r just llnated in water, but the limj;* everywhere had a «>li<l 

fett, uefiiutin); ••trj ilit;hlly : the surfaces uf both lunga were ci)vctv<l with 

ibieDtlcd tubiiks, while the (_-enlr.il jiaris were solid. -X^ a rule, the upper 

Wo are more often expanded than the bases, and the anterior and inferior 

(d|Mand surfaces nmrc than tht teiitnd parts. Care niiivt be taken nol in 

nafiMkd atelectasis of the Uinj! wiih pneumonic consulidaiion ; the latter 

munition ii rare in the newly burn. 

TrttiimtHl. —I. Kenune any niudu* or fiuid from the faucei iind air- 
ptiMti'etbyniiMnsofthe linger or by Miction with a soft india-rubber catheter. 
jniettinK the body nuy be useful. 

1 Aifempi lo excite re*pifi»tion by some fom) of irritation applied to the 
kin. F-'annin^ the face or directing a current of air by tneani of a pair of 
h&am^ )i often of ust This may also Ik- effectually done by placing lite 
iidiat in wami water (toc^F.), and then dashing cold «ater over it by means 
tit sponge or ihc hand, or by slapping it with the wetted comer of a towel, 
M,i/ihc t'arndic ciitreni is at hand, a feeble current may be applied to the 
ili«|ilir«^n and oibcr inspiratory muscles. 

3, If these methods fail, no lime shuiild be lost in directly inflating the 
tu^jts by > soft catheter ))asted into the larynv or by Kicliardson's bellows, 
01 by pnctisin),' atiilkinl respiration by Sylvester's or Schultz's method, 
which ri to be oiniinticd as long as the cardiac sonndi can be heard. 

Active Itcatment nill less often be required in those cases of asphyxia 
fitftrvening afier birth from non-expansion of ihe lungs. Gentle measures 
nay bt undertaken to e>^citc more active respiratory effecis, and to combat 
Ac somnolence b)' means of hoi and cold wuter, or by the application from 
tiBM to lime of stimulating liniments to the chest. Such infants, however, 
ui feebly respond lo out cIToris, and nvcr-ireatinent in this ctireciion may 
' (U> mote hiirm than good ; i>ur ef)'i>rls will mainly have lo be directed 
Ctn^thc itifAnI undci the most favouraliic contbtions for gaining strength 
doally bringing about expansion of the lungs. One of the most im- 
: indications is to maintain its heal. As soon as possible it should be 
iiundrd by cinion n<iol and plarxd before llie lire ; if too feeble to take 
1st. niilk should be drawn from the breast and given the infant by a 
I or small fei-ding hoiilc. It may even be necessary to feed it by p;iss- 
I Noi llorNd. u fofi imlia-rubber catheter (Jacques's patent) into the 
■tcoadi, and thus inimducing. by mean-, of a syringe or funnel, half an ounce 
rfnilk i the catheter must be (|uickly withdiawn to prevent reiUn of the 
Aiid. In the care and nurture of these weakly infants various means have 
bnn a<lopteil : for inMancc, placing them in cradles or ciiik in small rh'im- 
ber^ where the icmper^tiure i* maintained by artificial me-aiis. The Ijest 
kBcnrnof tlitse is the" l"^ouvruiir'of Auvard, which consists of a box, in which 
ibt basket containing the inf.Aric is placed, .tnd m.iinT.iined ni i, temjiemture 
rfieo'' Vmhr. by means of a reservoir of n^rm water hejitetJ by a hprrial 
wangemenl ; a glass li*! covers in the bo\, and veniilaiinn is «ceuted by a 
cantat of air wbtdi bas poued vttt ihc warm wstlci retcrvnir. 

C 




18 



The Disrases Inddeut to Birth 



Apayioiia Neoi»t»mia.~ Orebml li.cmorrlut,'C ncckirhng ■» CBtly life 
is hiirdly ever ilii* icitill of ;i iU|>lurL'd arlcry, hiii ii almml intariiitily ciikiscd 
b)- a veninii coii),'vsiioD, .iimI ukes pbcc friiin t)ic c.ipitiiiTy vc^i^h of the piu 
nuier '>r rhoniid f>!c\usei, 'I'tic ^ncnvs of the youn^ uic i>ut liiible lu suffer 
from ui hen >ma. bill ii-minihcirclii4tkity..iiiil, iiii>r(.-m'cT,iitc noi hkcly tuhatv 
to submit to any uiiutti.il Mr.tin Uam iiii hypt:rlii)|>hic<l hiran. On ihc ulhcr 
band, the pi;i nMlct in early infancy iiciicc('Uin4;ly<leliciilc,iiii<l its capillaries 
fniKitv. ai am be readily deinunsl rated by nolicint; hun ejisily it i» Stripped 
from the bruin b) mcnniof diueciint; forceps, and huw louse itiisconncctioit 
irilh the son braiti subsuincv bvnc4th it. Kuitlicr, oc have alrt^dy alluded 
to the fart that the cetvbrat sinuses aivd t«iii3 become diitcndcd with blood 
in a(pby>^ia ftom t-aiioui causes ~a rupture (A the capillary v«smK of the 




Fif. «.— McninciBl H— Mik«c in u InliiH : duih *n iK* \m*nf mtani Aiy. 

|Ha mater takes place, and hlond ii effused into tlie sub-arachno>d sfwice. 
Thi* effusion, in consetiocncc of the looie connection oi the pia with the 
brain, nviy extend over a large sutface. or hunt into ihe siin-dural s|iacc 
The btiiod clot may cmnptess or lacerate the brain subii.incc. and if the 
iri&nt 111 es f«r .1 few days 11 may be foUoued by sohening. I'he hit-iiiorrlwufe 
mn) take plate duiin^-biTlh.frotnconipretsiun of the umbilical cont, producing 
uptiyxia, jnd is consetpienil) especially common in breech presentations 1 
or tt niay result from prcssunr on ihi- head by the utcnis or the b'adet of the 
forceps 'Speticer). Wc tnusi bear in miiul that the pu tnator is not only 
very dclic.ile and its capillaries easily niptuied if they are iivcr-disiended, 
but abo that ■ stash is verr >pt to occur in iIk snperficul veins on acctiunt 
of their peculiar eonnectioni. < lowers has laid stress on the fact that here 
juccndtnK arteries pass into ascending veins, and, moteovcr. these surface 



^•relni • 



A/vfi/r^ta Neonatorum 



IKCUM 



•9 

win* empty iheimclvcn into ihc siipenor lonj^iiuilitul linus in a forn-ard 
direction iitvd cnnKcqucnily nKaintt tlic blofiii cuncni, 'Hius ilic Sylvian 
vein rnmmenirri in the Iit^iirc of thai name and courses upwaixb lo empty 
iuelf into the superior loni^itiiHinnl sinu*. rcireivint; tlic iowtl veins from tlie 
imitor ate.i tn rotiU, Near it* conimcnrcmcnt the Sylvian vein hiis ton- 
iKciMwu with ibc lupcrior pcitcwil sinus iTrol.-ifdj «nd alsii with ihc l>usi)ar 

SpcnccT ' (omet to the concluunn. as [li« result of an cxnmination of tlic 
nf 130 infnnts horn dead or dylnn soon after birih, that pressure on 
:Ull hy ihc forceps or the uterine «iills [il.iys an impuitiini pari in pro- 
■tadng mctuiiK'^'Al kinnorrhagc. He liclicves thai when tlie bitiies of the 
tfcull ar« ahnoimally wifl and the suiiiies La\. the lower edge of the putiutui 
bcoe ttuy prciis on the Sylvi.in vein or its connections, when the head is 
tobjccted 10 M'^cre pressure (hiring labour, and ih;is a h;en)urrha);e in the 
RoUndic area mqy tic produced (tl^. 4). Ho also ihinks that clamping- uf thi.- 
ioieinal jugular by llic forceps or pressure un the infant's neck by the 
piinuricni canal may give rise to congestion and meningeal hirmorrhagc. 
Ii «nuld appear from the observations of Spencer, that, while these cerebraJ 
hi_ininiiha>(cs arc mo it common in severe and in^tuinenial labours, they 
^■,r nni unknown in labours that are thort and easy. Tlic infant may live 
>^iLir days after (he h.'eniorrliage has taken place, as in a case recorded 
'<> 'ilcN'utC ; ilic laUiur, which was a breech presentation, was easy: the 
Nif .kiliin>; tiecame iire);ulai on t)ic day of birth ; later it suiVcred from con- 
MiiiiiMis. diftii'Ulty of swallowing, left hemiplegia, and cm.i.ution. It died on 
the iwrnty'serondday. Ai ihc/^'jAwr/^OTilie right licniisplieie wascovcred 
b> a clot ' see l>g. 41, xhich was firm and gelatinous, and of a dark colour, 
the convolutions beneath it n«rc in pan destroyed, especially so in the ascend- 
ing frontal ami fiarieia! regions. The clot also invaded the brain substance, 
aoually forming part of the roof of the tentride, whilst the site of the corpus 
Ktitttum and ojiiir thalamus was occupied bya reddish-brown clot mixed with 
toflencd brain t'^SLie, This case is remarkable as showing how long an 
intuit nuy survive an extensive cerebral h;emorrhageand the further damage 
bj the sccindary intlammatory softening which evidently took place. 

These arc msiance^ of fatal cases, but iliere is good reason to liclieve 

t sach cases frciiticntly survive, and bear for the rest of Ihcii li\es traces 
the danuige ilnne to their brains at birth. It is not difficult to imagine 

damn^c wliich a surface ha.-■I^orrhagc may do. It may lead to com- 
of the convolutions, or meningitis, or softening, or it may more 

\f lead to atrophy, or interfere with the develnpmeni of the convolutions. 

I> a case, verified bj-/»«/-iWfW//M, has been recorded by McNutt. The 

1: was bom with the feet presenting, (he labour was tedious, and there 
It dciay in discnvaKcmcni of the bead. Convulsions supervened, lasting 
days ; the child never walked or spoke : there was spastic [laralysis 
sides, except the fare ; it died at two and a half year*. .Vtrophy of 
IfcacQBtrJutinns wtioul the tiswirr of Rolando wn* found at x\i<: ppsl-morUm. 
Similar cases arc tolerably common 1 there is a history of a difficult labour ; 
dw Infant is blue, and perhaps is thought by the midwife t<i be dead ; it may 
bt convulicd. but recovers. There i* probably no marked p.iralysis at iiisl, 

1 OtiMti€al TmitaitiPai, vol. axuli. 

ra 




20 The Diseasts Incident to Birth 

bill nfttr .1 few months it is noticed tli;ii an ami or a leg, or both legs, are 
weak ; ihcn contraction* take place, the Ic};» betoniirn; sdductcd, with lite 
IOCS poiniing, the forcatms mpinated. and the tlbtiws more or less fixed. 
The inlcltigcncc is often affeacd. and the cliilJ is lale in talking;. Such 
coses are common in aiylums. a» recorded by Shuiitviiorih.' Schuliie,* 
Lanjidon Down,' and ()lhcT^. Thai no definite iymplonis of iiienini-ea] 
ha-niotrhagc should be preient at fir^i agrees «ilh what has already l>e«0 
rcmarkeil concernmn the development of the cortical substance, and its 
connection with tlie aanglia at the base of the brain. Not only is the grey 
matter on the surface in an iniinaiuie slate, but so also is its connection with 
the lower part*. It i» only a few months later, when the voluntary power i» 
being put forth, that it is noticed thai there is any difference between oiio 
limb and another. Convulsions may be prtseni, and if there is any marked 
paralysis ii is probably peripheral, being caused by effusion of blood at the 
base i>f ihe brain on the poos or cervical cord. 

Bmnorrtiwn* lot* *t)trr Vl*c«r«.— Spencer found in his fn'tr-mt'rftm 
esiminalion of slillbom i. Iiildn-n iKUnorrhages into the lungs, liver, kidneys, 
intesline*. tesiis, &t. In the lungs the most ffci|uent site was the b.isc, the 
appearance being that of ordinary pulmonary apoplexy, the bieinorrhagic 
portions being solid and of a black red colour on section. If the infant 
lives pneumonia may arise. 

H.tmorrhage Liking place into ilie kidney may cause death during the 
first (ew daj-s of life by >ui)pression of the urine (Spencer), 

M.niiiirrliiige intu the bowels may cause obslnii-lion. 

0«pballkKntatamk.- During binh a hH-moiTh;ige may take place (ram 
the vessels of the peiiosicuin of the skull, and a collection of blood form 
between that membrane and the bone ; more rarely a Iia'morrhage occurs 
betm«cn the occipiio-fronialii ajxineurosis and the iierioslcum, or between 
the skull and the dura mater. The name 'cephalhit-matotna externum' U 
applied to the first two, thus : 



Ccphalha*mai«mA cxtcmuta . 

,. inlemum . 

Meningeal lM.-moribage . . 



" t. Suh. aponeurotic. 

2. Sub periosteal. 

3. Sub-ctiinial. 

4. Sub- arachnoid. 



'H *a H 



Ip the common form the tumotir i« tub- periosteal. The swelling, 
occupyint: a position immediately over a parietal bone, generally the right, 
is usually disctivcrrd for the iinit time a day or (wo .tfter biith. when the 
swollen and (^istoncd head of the infant should begin to assume a mote 
natural shape. .Acrordingto the statistics of Hennig and Hofmokl.acephal- 
h.i'matoma occurs about nnce in cvety Vtco hundred births ; in one hundred 
and tnrnty-seven cases noted hy Hcnnig, it was situated fifiy-seven limes 
over the right jnrietal bone, ihirty-srv-en time over the Icft.tweniy-onelimes 
orCr both, seven tinies over the occipital, three limes over the frontal, and 
twice over tlie lenipotal bone. It form* a more or lets tense clastic tumour, 
neither hot nor tender, and it does not exteivd beyond the limits of the bone 
over which if it situated, inaunuch as the periosteum is fimily attached^ 

■ Brilli* Utdict] JtwmHii. \tA i. iStfi. p. 1)5. • C.rrliuill'i //aMdtn\t. \o\. 11. 

- Britiik Uidnat Jairmal, itA. I. 1877, »b 14. 



^ 



'^tpttalhanMloma JI 

MlhrsstUTO. Th«icalpU not discoloured. The tumour varies In niic fmm 

a «alMt to a Mnal) cmmKC, iiKroucs in bulk fur a fc<r dsyi ^iftct birth, xaA 

tei bigis» ilowiyio diminiah. After it has exisivd fin^ a week or tn-o, 

a ridilt of boae tiHiy generally be fell ai iis circuRircT(.-n(:e. where new bone 

has been thrown out by lh« pviios- 

kan .;«« fig. 6 {"■.. Whtn ili« 

mnmrittxAmincd fnr ihefir^it liinv 

la lbs Mage, it is api to give the 

tnifrenna thai there U -t rirculnr 

dtfttt '■» the p.inctnl hone, through 

■bck a lluid lumour i.i protruding. 

AiiimevetpeectUyin chronic caic^, 

tluo pUiM of bone form here and 

tbet in ihe peiioiieutn forming tbe 

itxrf »f the tumoar and j;'ve riie to 

a ft«&ig of crepitation when it is 

hanikd. In ihe cout»e of n few 

"wb or a month tlie tuiiiour 

shrkki and diMppeurs, leaving for 

peil^ m^ny months a more or 

lew compleie bony ridge, whidi 

iBVktd ihe circumference of the 

Hanow. The ei«)logy of thtM: 

biood-nrcltiags iii not vcrj- clear, but, lilcc other ha-morrhajjct wbidi take pla« 

duriof binh, ihey owe their production in part to aiphyxin, in which there is 

increased tetui on in the cranial veins, and a condiuoii of blood which readily 

aBovs of extra v^aKU inn. From the fnci Ihal ihc [uiuourniosllyofcui-iat iheiite 

otftheciipmsucc«d.-inciini,bcin;<av-cr the ritiht parietal hone in nearly three - 

fewih* (if the casu, it wi>uld .-ippcir that preisuic upon ihe hc^id pla>-ed an 




Ff«. }.— Doublr CnihiHuHiuiaau in aa Inful 
illlli<ull, (an,Y(H aptiliid. 



d. njiJii bail pmljilk 




Wit, L— Saciiaof ■CnlullwHan*u(>«n--<lii(rsiiiiBMicL Hcnni^ <•. I>i>'> nutn ; 
tt iwtiul bOK ; f, polinlnM : i*, owlbculoa oliljtia; 4,mai,y. r, Uaedilm. 

npariiint pan in i<» ctuMiion ; bill, on the other hand, ca^v arc reported 
. whi<-h .1 blood-swclliuB ai^warcrt over .1 parietal bone m a ca'sc of breech 
lentaiion vKunge, McNuil,'. Sni-ill eMrAv.u.aIi(ms, the siiC of « pea or a 
liillin>.', may frequently be yt^n beneath the pcrtowemn in niaViniJ fiifU- 
mwrttmt on newly bom infanit. If ibc caput .luccedaneum be infi*cH, the 
lis«Be« imtnedialely benCiiilh the scalp will be found inlilliatcd with a Jelly. 
like eJfiuion trith numcrout micute harraorrhages scattered through it, :md 



22 



Thf Dhrnstt Imident to Birth 



(Ml ex.iiniiiinK (he piirictnl bon<- numctmiK ^mall h-rmnTrhai^s ninv bo Met) 
bcDcnih ihc pcnottciim, %i>mc lln^^t in th.ipr, conx-«|>andin|.' nitb ihc linM 
oi foramina in the bone litualed near lh« inlcr'PHricul sitlurc or pntlcrlor 
fam.inellc. Arcordinj; tn Fc'n' the cdfces nf i)ic fnnmina pUy -in imporlaat 
pan in vtoundinK llie t'cs«:U dunn){ Inhoiir, and piodurinjj .1 h;i-tni>iYhii^V. 
SK they ate the tncanK of ItniiimillJni; ini.-tll vcin% froti) ihc s<-^1p to llie 
cetcl>r:il Kinuws. It n important tn bear in mind th;it not inftetjiienily nn 
eil^siim of blood external to the skull comniunicales milb an cllution of 
blood between ihe boii« and duia inaier ihniugh one of these opcnii));*, and, 
further, .1 tneniiit;cal li.cmorrha^fc rnay alut take place. 

Three /Msf-uuiricm exatninAtiont nude l>y Kunjje ate winih recording, a» 
illustrating; some of theic innnli ; {i! bwcth pn-seiitalion : delay in dclivBr- 
ing Iteixl ; infant bum in condition of asphyxia ; died on the e>>;hih day rn 
convulsions. 'I'he fioil'mortern ^hon'^'d a ceplulbainatonu over the k-fi 
pcirKtal bone siiimumicd by a bony rid|;c ; •> large lij.-morrhaKe over Ihc 
convexity fA the brnin beneath tlie dtir.i mater, re.ichin); to the bciM' and 
upper part of the cervical <:otd. 12^1 A pieniittur* infant delivered by fbrcc|M 
in ci>iue<|ucncc ol niatcrnal rctanijtsia ; born asphyxiated, died on tite tint 
day ; there w^vi a cephalhirmaiotna over Ihe right parietal l)one, cotriinuni- 
eating thrrni);h a ^i^ure in the lume with a second effusion »1 blixnl beneath 
the bone beti>cen it :ind the dtita tnater, Tliere was also inenin):eal h.eiivur- 
rhagc. (y Infant Ixirn 4sphyiiinte<l. rcjinimalinn. death on the si\ieenth day 
(tmtt luteritii iimbiliiali^ I'licrcnasa cep'ialli.i-matom.i, co\ering the whole 
of tlie right jwirietjl bunr ; a hard buny nail roofed in the (.iri-.-unifercnce of 
the swelling. \ surfji[.eh;cmi)trliji^eliad Ijkcn pl.iceal ihi- b:isc I'f the bmin. 
Tlve iliu^Tiosis is noi Keiierall) a nutter uf dilficuliy. A blood tumour 
beneath llie periosieum is ilisiiiigiiished from a cjiput sticcedaneuni, inaunucb 
as ihe l.iller d<u-s mil lliiriiiaie, disappears in a day or tso, and extends 
beyond the limits of a paiietat lK>ne. It is distinguished from a nveningocele in 
tlut the latter ('■irtcsp'imU to a stiiure it f<>Tiiani-lle. pulsates, artd in<'reases in 
siw when tlie infant eivcs. Very rarely * blood swelling lakes place beneath 
the wnlp, beiueeii the latter and tlie ]>ertosleutn. In such c^ses the sealp is 
diicotooted, no bony nn); would be fnimed, nnd the nwclling tni):ht exteiwl 
beyond ihc sulures. 'I'be ptcigrvosis a« lar lu a ccphath.xiiiatonia is ccirv* 
ccnicd is fa\'Ouniblc. I>ui iiusniucli as it is po^tthle llidt ii is complicated by 
roenin^tciil or cxira-dunil iM-morrhJife the ptn);no(it must be Kuaided, and 
atiy brain sytn|>tonis are iK-retsarily t)t evil omen. 

7VM/JK/fl/.— I'he iteatnient of iheM bloo<l tnctlinKs has been much 
dbctisMd. On (lie oiiie lund, it has l>ccn ur^ird ihai if the cephRlhirmaioron 
is subperiosteal, it sImwM be nspiraicil uiihiml delay while the blood rs 
fluid aiid before cKigiitaiion has inken place, as in this way Ihe lonjj delay 
diirinf; nbich al>M>ipii»n and deposition "f bunc are t;iking pl.icc is .ivmded. 
On llie oilier hand, it lias been poinied out that it ii^ neier possible to tell if 
the blood swellini^ does not communicate with a blood cxinivasaiion within 
the skull. x\\at rendering surgical interference lisky, and inorvorer lluil, 
although .-ibsorpiion of the ciTusci) m-nietial may be tardy, it is both safe and 
uire, alvd a giMHl resutl maybe 'onfidentty toiiked foneard to. Tlie latlcr 
coune is certainly to be recormiiended : surgical ititerltrerKt* in ■ newly Imra 
inlaol always has its ritk, there is atwayi the possibility of introducing 



Stemo-mastifid ffteriiatonitt — 0<iif>itai Hteiititlama 23 

: organisms inl» \\i/f- btood swetlin); by uvpiration. and at tlw.- miut .ill 

h&l ■( iv l>c tfaincd hy Mich a proceeding; isihi? suvin},' 1^11 few weckiofiimc. 

iVc bdicve ihat ntt crphn1h;nnatom.itii an; \ywA siafely tet alone, caro beini; 

alccn 10 |>mlcct Ihem from injury ; ttiiall une^ nr.i)- be sh-iit'd .-ind (iiiinicd 

I cotlndion, of during Miftp some spin! loii<in may be Itepi iipplicd. In 

Tibc tarcM-cni of lhelr^^ppvlratinlt^bl; trealmtntwoitW be ihnt of an ordinary 

I ii1»cc«!i vit eiaciLition of ibi- pii» and draina^it 

BwnMtsma of tbe Btoma-roB*l»td-- If ;m ntlcrnpl bf madeby an un- 

[«ki}ful mi<lwifc (o diicni^.i^i^ I'le alter tominj; liead by pulling on thr Icjjs or 

Ltvaly of the in&int, there ii a ^trant; prnbnbility that injur)' uill be done to 

Hhr neck or otlwr iian, especially as the musclti of the lemi-niphyxijiicd 

finfiint are fl.ibhy and imn-k-i!, and ilie bloud readily ooici out of ihc vessels. 

Surh .in injury doesat limes take plate, jc'""l{ rise to a blootl luinotir within 

IT vhia'hofoneoftheslerno-masl[>idi in consequence of the tearing thiough 

r tooK of ihc fibres oilbe muscles orinjur)' In some nf its ^euels. (t is not 

that nn opportunily nccurs of verifying ibis condition put,! morUm, 

cb a> no «crious conseiiuences arise from the accidejii, bui the 

tigiilioDK of Tordeus, Spencer, and others make it clear that these 

I arc due to local bit-'inorrhatte resultio); from injuries at birth. Jn 

■owitcascK in which ibe infant died of diarrbiea when <\% monclis 

ntrmiMin of Ihc muscle al the Hpoi where the injury had uken place 

I fnttiid. In another case «v had abu the uppnrlunity of a, fxtU-mi'rUm. 

\h\ (east tbre<--loonh^ of these cases are breech pre«rn!jiiion> : in ilie re- 

alniny fouiih, whir h occur in Iiejd ptcscniiition*. the injury is no doubl 

by draKKinx on thr head in order to disengage the 'boulders and 

The sncllin}; in the nri:k may be noticed by the mother 3 fc»i' days 

Iwrth, 01 il may estafie obienalion for some week*, or rien more. On 

rtainitwiton a tutonur about ihe itic of a pincon'i eKj: may be fHi in the upper 

fan of the ri(,'Ul s I emo- mastoid; il is)fcnerally irri->:ular, or pcrh.ipselonijaled, 

tnih.ipe. and if not s«nfor tome time after birth, when ricaiii-.ilioii bus taken 

Iwrd and csriilnninoiis 10 the touch. The left muti-lr is less often 

ijn tile right ; «imrlimes the «ho1e length of the muscle is affected, 

:h -ii;h the IcMon i* gcnenllyin the upiicr p.iil. TIic tumour disappears in 

'V I'lmrse of a few months, hul fur a long lime ,i cicatrix may he felt. 

Tlierc is no irtMitrnent required. These eases nirwtly occur anmn^ the 

■-T,... 'Inkset, oho are attended in their confinement.^ by neighbours or 

midwivct. Injury to the Memomastoid during birth derives its 

I,. |.., i.r.i.e fmmihe fact that such injur)' it likely to be the cause of wry neck 

la lifter life {let TfikiicoLLisV 

e«elrlt»l Swatkiftn*.— Injury toother miucles mayoccur during binh, 

omI wc hate sern in one caw a 'tumour' in connection with the muscles ai 

the back of ihe ncrj: ariting from injury during binh. It «as a head 

pfoeniatitm and there was alsoa sic r 110 -mastoid 'tumour.' The rhild was 

-t:s«ld. Ltltoiir had brcn ptolonyed. head delivered by forceps 

I I idly, and sLibsr<[uently seven- traction was nei'ded to extrjet 

1 HO symmetrical swellings were felt in the mii*i-les .it the Iwck 

It. evidently ductnb.tnuiioma. There was left facial paialysisand 

• !<(* iilio [tAoiy IVisi-r. J/ri/.-('jk>. 7'n»i, >ol. luni who giira aldt ul cunrrruii 
Cliaiia aeil oUint' obMrvilKint xs *t\\ ja fall tmii. 




Tkf Diseitifi Inddfnt to Birth 



paralysis nflhc l«fl »mi. The child un< hcanl of tun yciin Inter, And il wu 
Mid lo h;»v<; roniplctclj- iccuvcrcd. 

obM*uie*l rBrfti^BM, — In ras»«f dcUycd lobnur, uhcrc the forccpt 
h&vc In hr npplird, or where force is usnl to diiCflj!n|{c nn ami or traction 
is Applied lo il, some nctvc* or sirandx <rf nc-nc* nreapt lo be injured either by 
^irccchinKi direct prcMure. or ronjprct.von by cxirava».4tcd blood. The mott 
conimon and best known is nn injury lo one ndbr facial ncncsihrouj^ pire». 
sure excned by one of ihc hbdM of the forceps durini; extraction. A ^cinl 
)mraly*it is thus produced, u'hich .i* a ruk is temporary, and di%nppran in a 
few da>'i( or nerks. The other nnd less ciiniinon fonn, uhich has been de> 
sciibcd by Duchcniic as 'ohsteuiral paralysis.' is due to an injury to one or 
other of ihecordsofthobrnchial [iloms.produrcdby the pressure of the finjicc 
honked in ihc axilla in order to eviraa the ami and shouldei^, or ihrami has 
l)ccn forcibly wrenched ^hcn il has been iitcd to lay hold of tndraK the infant 
through the pelvis. Occasionally :in injury may be done to the brachial ttlcxiK 
n* U'cll as to the facial by the ki'1> of the forceps bladcs.asina r.ise recorded 
by Roger, where the face and ami were paralysed. Afler death nn cfluiion 
of blood Has found at the stylo-mastoid foramen, and also round the cordsot 
the brachial plexus. The cord most often injured is npjiaremly the lil^h cer> 
vicnl ncise, which, as Koss has shoH-n, is readily injnred, at the poiul where 
il descends »s-er the transverse processes of the fifih gind nivlh cervical veT> 
tebne »n its way to join the brachial plexus, by force applied to the arm or 
rtnvicle. The prognosis in paralysis of the nrin from a lesion of the brachin] 
pJcxui is mote xerious than it is in jiaralysit of the face, hut ii »-iII netes- 
Kirily tnr)- according to the anmiint of injury done and the deKiec of ]mni< 
lykis present. The sym|>tams presented by this form of paralysii may be 
illuHtrate<l hy the folUiwing ci^n nhi<:h came under out notice : 

In tiK lit!'l c;uc, the head, according to the mother, was l>(>m Rn>t ; there 
ms then n dela)- ; finally the lel^ arm nss disengaged by the linger hooked in 
the axilla, iind ihc child bom after sonic delay and difficulty. *I*he infant was 
firat »een when seico weeks old. At this time it* arm hung uselei*ly bj' its 
Mde, the elbon' e.vlcnded, the humerus lotatcd inward* and addutlcd. llie 
forearro primated. ihe liand dosed, the |uiralysed muscles being the biceps 
and b«achinfi> aniicus, the infia-spinaiu> and icrc» minor, the deltoid and 
Mipinaion. Ihe niuscka affected were soft and flabby. Tlie ami was 
rcKUlnily galvuni-^ed. ihe Karadir current licing used. Thtec yean afterward* 
(jrcJil improv-emeni had taken place ; tlie elbow could be flexed and the hand 
could be iucd, hut a parenii remained of (he deltoid and uipinalort. In 
lutoiher cute, seen nrst at ten neeks of age. the un>c musctes wei e pEtralyitcd. 
iitiicb impros-emeni took place, but Ihc inlitnl died at w, inonihs old of 
bronchiiii). In a third cnie, which was a (uoiltng, ihe left ami engaged the 
pelsis wiih ihe head, and bad to be brought down by ibe accoucheur, I'he 
ann wa* notice<l to be bruised and useless after birtlC fnfortunaicly this 
case was toji gi);ht ol Iti aiwther caw seen b}- us, both :imi« were alincwt 
completely |uralyM-d, only the lingers in one hand reiainiof; »onie power of 
Ae.xion. Ihe mother had a contracted pcH is, the head pteM-nied, the tnedicat 
Diaa turned and dehvered with much difficulty i theie was also a stemo- 
BMStOiid huinatomn. In two cases re|»oried^Mie by Seeligniuller, the other 
by Tlinrbum— Ihe iMialysti laan »inr« extensive than in the above cases \ 



\ 



■ letertts Wetnatontm 35 

Here tras alio retraction or the eyieball and contrnclion of the pupil of llie 

Bmc ajdc 1'rab.ilily then wa« licrc a mciic iii:i'<.-rr injur) . Involv Ing t)ic 
whole bnubial plexux mid aUn the Kpn pathetic. In some <rai>c8 a tcnipornn' 
Muestheiia ha* been noticed. In the ircaimcnt of ilinc v^sr^ ii must be 
borne in mind that one or mnic nf llie cnrdt of ihc^ l>inchi.il pIcMit has heel) 
injured, accompanied by a local h.t-morrhncr ; and iheicforc, ihc morrAt irsl 
ihc arm tiin bt- kept for ihc firnl (em* week* ihe better. It irems (loubifiil if 
any iharopooinj; or j<nlv;iniMn); of tlic muKrles r.tn at iiTM da mitrh good. 
The treat mem must be rather dial of .-t fractured bone- rest at first, and 
;iflcraa[d« mine or \rvi active movcmcm to excrcisetlic musrlcs and prevcrtt 
(tiffoCKS. Thf arm should be carefully n-inppcd upin colion wool, ficvi-d and 
supponed by l>cint; fixed to the m(Jc. care being taken to present undue 
diiiuibance durlnjc the daily batb. or allowing it lo hnngdoivn and dragon iis 
conncctiont in i(h (he Inmlc It must be home in mind that the circulation 
of blood will be «liiggtth, and easily obstructcii bj ti),'hi bandnging, At the 
end of thrc« weeks, "hen there is reason lo believe ihai absorption of the 
efliiied bliHxl has taken pliice, movements of the aim maybe bcgim, in orrfcr 
10 give th* muscks some exerciw and to call fonh the volnntarj' elTons of 
Ihc child. Galvanism, shampooing,' <lie muscle;. applying stimulant applici- 
tiontto the skin, mu«i be pcrscrcrerl »ilh an long as any improvemem lakes 
[■lace. TIk prognosis in the severe caie« is glooniy as far as the paralysed 
muscles arc ronccmcd, the .-irm remnins in a condition of enlcnsicin and 
pmtuition, and is un.-ibic lo be raited lo the mouth. In other cair>, as in 
the one mentioned, rcco\-<rry Likes place sufficiently m allou of l^exion of ihe 
dbow, though a certain amonnl of ucikness may be left about the shoulder 
and In the supinator of the wrist. In the slighter <:aie« considerable 
iln(IRivciDcni may be evpecried in the course of months or years. 

IwriM Vaoaatorum. Infants often '.iitfcr from a morv or leu |>ro. 
neunced jaumlice uhirh comes on a day or Itvo .ifler birlh. It has been 
Winatcd liy Coniincni.-i! writers ttiat this occun in from 60 to So per 
CMK. o( (be loL-il birth-t ; bnt thc^e observations have been mostly made in 
lyiB};-in hospitals, where it appears to occur much oftcner than in piivate 
pncikr, thou;;h there n little doubt that on account of the slighiness of the 
■ <-iI..w coloration of the skin, and the frequent absence of discotornlion of 
itt iclenitk. it may easily be 01 erIookeiL Jaumlice may arise from or be 
lytaptumatti: of \-arious pathological conditions the principal during the first 
*wk oi life being the following : 1. The common form in which no dise^ise 
(• apparent' -icterus neoniitorum. 2. Jaundice accDm[>anying a condition 
^ seiMiCEtnia or pyxmla ; In acute fatly dei;eneratiun of the newly born : 
Wiockcl's disease. 3. Jaundice due U> c<mgenitid stricture, or nbliiera- 
of the common or hepatic duel, or to sy]]hilitic pcrihepaliiis. The 
fonn to which the name of 'icterus neonulorum ' is generally 

'afpticd difleri from the other forms in not being accompanied by any serious 
fyiDpiams. and in pamng off in a fiew <Uys or ;i wei-k. In tbene cases the 
ircllriw coloration of the skin niakw it* appeaiiuitc on the second day, lei» 
nften the third, rarely eiihtr befoie the second or after the third, :md Lists, 
According (oits intensity, fiom two or three days to ii week, rhcyello«ncs> 

_M first noted nn the face.jround the mouth and chest, then on the uImIoiucd. 
' nn the limbs : it may be easily overlooked, unless presaure is made by 





26 



The Diirases iHdiknl fo Birth 



ihc linger on the U:in. In mild ca«e« the ^clriutics tcmntn unuffcrtrd, anv 
lite iitin« (l(icf> nut Main tlie lincTi ; ilii« \i ihc iiiorc ii»iewotihy. us in ihc 
jaumlicc of adLillt the ^leroiics ate aflccicd ticfore ihi' ftklri is iin(,'t:(1, and 
pigntent in very early present in the urine : probjibly the vasculariiy and 
transjxircncy of ihc infant's skin account fm the ilitTcmKC. When th« 
Jnundii'c in the inf^nl is moir intense, the sclenttics become linked: the 
tirinc stains the iliapers. and bile pi){ment nixy be delected. The stools »re 
tinchangcd jnd conttim the usual qiianiity of bile. In cases which die when 
siiffeiin); fmni this form of jaundice, ihe internal oT^Ans are fuuad stained 
yello"-, espciially the carlila^jei, ihf brain, and in 4 lessei dej^ree the nbdo- 
miiuil I'isccra- llie inajorit)* of infAnts who aic jaundiced appear in perfect 
health ; it has, howtver. been aliened bj- llnfini^KT that infants with ieteius 
do not riiiuiiih as ««ll as other infants, that their loss of weight during the 
lirst r.eek is gteaier than ihai of healthy mfann. ;iiid that a hi)-h«r per- 
ccotnge of urea and uric acid appears in the uiine. Tlie taiise of ihis form 
of jaundice is uncertain : it is much more frequent in lying-m hospiiaU 
llian in private pnictice, and in premaluie neakly infanls with partially 
cxpimd<.'d tunt;s than in full-lime and healthy infants. There have tieen 
many hypothe»e» coneeminx its cause, but none of them are entirely talis- 
factory. One of the moM plausible explanations has been ^ugI;e^led by 
l.>uincke ; heattributes Ihe jaundice to the ductus xTnows remaining pulent, 
thuiallou'in^ same of the portal blood [which conUiins bile piginenisj topou 
into Ihc general cirrulalioo, inwead of all of it being sulnnilled to the nclion 
of ibe li»-cr. Virchow an<l others belie»-c it to he a hinnatogenous jaundice, 
lite bile pigment originating in a <leslruction of blood cotputtcles which it t« 
supposed takes place shortly after birth. 

Wliiic this form of jaundice \i prr if a svmptom of little im|>orlance, and 
in the vast majority of cases tht" infanls do well, it is well to remember that 
occasionally cases occur uhirh are jaundiced shortly after birth, and uhlch 
die about ihe ninth or tenth day wiihoui any definite disease being divmcr- 
able. These cases sometimes occur in the same fanilly. as in the follnvrini; 
remarkable inst.inces : the father and mother were l>oth healthy and in rom- 
fnrtable ci renin stances, there «as no history of s\-philis, the firii and second 
children were never jaundiced, and are at present ahve and well ; the third, 
fourili, fifth, and siuh children l>ecanie jaundiced on the second or third day, 
and died on the ninth i>r ele»*enth day. in .all. the skin and conjunctiva 
were jaundiced, the urine contjiinetl bile pigment, theslooUnierenortiial. The 
fifth child was seen with lAt. C H. I'inder. their medical attendant, nhenfi^'e 
<bys oM ; ii seen>ed :i perfectly healiliy infant, except that it was jaundiced. 
The infant be<-ame vreaker and drowsy, and died conwtose on the ninth day. 
A (Kirtial p<>il-mortem only was obtained : tlie abd0min.1l visrera were bile- 
stained ; the ductus venosus was only partially closed ; there was nothing 
almormal about the bilc'ducis. What is the naiuie of these and siniilar 
cases it is at pre^tent impossible to say. 1'hc diagnosis between icteras 
neonatorum and the jaundice which acciocnpanicK septicemia docs not 
present [uuch di(Kcult>', for in the latter case there would be some suppura- 
tion or phlebitis of the umhilical cord or ecchymosis and s-ariout hiemor- 
rhages. tn acute fatly degeneration .and Winckel's disease tlicreare usually 
cynnosis, purpurii- spot*, and ha.-mo(rhagec. In jaundice from obstniction of 



^Mdnrtf. (he jauDiticc is inicnic unii bite is absent from the 8lnoI&, No\hin(; 
^HBl i^n lie Mid aIiiiui iKe Crcatnicnl of iiif;«nlik jjiundicc. which ciinsifils 
^^wrr in lUicridint: latcfully to the general hejiili of the infunt ilvin in the 
■dminU'raiion «f iiny special dni);. Smnll doies of li>'(l. c. crct. may lie 
kien for its Lmtive tfTecl, «nd to relieve any tendency to mechanical con- 
pfitinn of ihe liver. 

Mwmorrlikclo Slatli«ata. MmDoptalUn WeoDatsraau—ll not infrc- 
iprti'"'. lijijijKns ih.ii " iiliin a fcA >i.iy-, nf liirili ilie infjirn exhibits a irndcncy 
I ti Tlier* may l>e h.eiiiorrhjyes from the nose, siomnrh, howds 

111' ' : -. ■'iikI |icti-thi.r iind ecfhj'moses may make their appearance on the 

bcia. I iniinx of blood, which is perhaps difficult to nirest, in.^iy take place 
■am ihr navel nn the tejiaraliiin of tlie cord. This tendency to bleed i^ no 
Ikwbt 10 be looked upon at raihcr » synipiom ih^n a discatc or (he result of 
Hkra«<>. Ic raniUM b« said that niir knoulrdKc if very cjiart reKnrdint: llic 
■Mditiuns «hieh ^i^ t^M to (he hirniorih.ixic diiithciis in infnnis liut in .1 
HBM nujority of c«»es al leaM ihc infanl is cither syphilllic nr KuffcrK from 
^^fbiniaorfnMnbothcnndition^ The poisons genemled byihc «yphiliiic 
^^^Bttc infection appcir to cause such chanKcs in the blood » );ive ri«e 
^^^Epdroit on the tlit^htest injury, In snmeof ihc case« in which there wiu 
^PM^IBCC of syphilid (!urin>: life, the eviilenrc has liccn foithcominti ;ii the 
WgH^KHeRtH, Atiil, mntroter, syphilis i« not dispmvtrit by no Ic^ioni being 
wtcnVered ia an infani -i frv (Uyt old. 

In w^'cn CMV, tecnnled by Fiichl ' in which h.rmarrhatccx took place 

rb"rily nfter binh from ihc mu<;n-ui membriines or into the skin, there wa> 

«i;<Ifnce of lyphitis ; thcic beinu charaacrisiic rashes on the ikin, eiilatge- 

inl of ihc >pleen, ;ind inlerMilial br|ii.-iiili«. tn one of the author's 

hitwevcr. the only evidence of syphilis «n.% ihc mlarRcmeni of ihe 

I und on inierxiiilxl hcp.-iiili.s. A careful micriHcopi al ciaininatiun of 

ntile blood-veiseli «a* made in the*e ca»es, with the revull that thcy 

' fiMiul nomml, «> that the bleedinj; could not lie ,-iliribulcd to :irlenlis. 

In three eaic» of hinnophilia in infanti recently invesiigatcJ by H. 

^tumiinn,' pyogenic organismi n«te found, and the author Inclines to the 

' ihiit ihe entmnce of the »ei«tc oraanitni* iniii the ivsiem either before 

rduriiii; the ad of oinU h»d much to do with ihe Im-miirrhasic Wale. In 

I ciiictbeinfimt, which wa» illegitimate, suffered fromj.iundice, (lelcchiu^ 

i tkin, mel^ma, and hiemaicmesis ; it died on the lifieenlh day. The 

I vbownl there h^d been capilUiy bleedtni; from the mutmis mem- 

the alimentary canal, enlaT),'ement of the spleen, and interstitial 

, <«yphililic:, .A baderiolojfical examination of the blood showed the 

of the liiicillus pytKyiinttit S. In a necond case, undoubtedly 

^snufBc* and lashi, which mffercd from hicrdinji from the nose and 

[nnd »hii:h died when seven week* old, a harlcrinloH'cal examination 

the pretence of \fa\ cocci, namely, SlaphylAixetis pyogtnts aurrus 

*j and .ilso S/r^fliiVAi-Uf pyageitts. In .t third case, in which the 

uiffcrrd from lyphililic ulcer;ition nf ihe ljbi;i. the infant Miffered 

fKuil flundico nnd v^rioui. h.i'mnnhage^. antl dic<l nn the ninlh day. Both 

Ittdllt and cocci {tttKillm pjfi^in. ft and StafiliyiiK. PypR- aurtus) were 

■ Anhi^ffilf /CiiJffktili. Fkind tiii. 
• tM. BMide all. xta. 



28 



The Disi'itsfS Incidenl to /lirt/i 



found in (he blood. It i* nut easy to u) in the t>rcseni ti.itc of our knou • 
Ictlge whether the bacilli nnd cocci found were accidenully ptxncnt, or 
whether tbcy were directly or indirectly the caiivof llic hinod chanjce uhich 
Ifave riie ii> Ihc blood cximvaiutioni. The bacilti mny enter ihc (a-%A\ (is«uc!^ 
before binh ihrDiiKh the pinccnuil drculaiion or he innniUtcd ni the lintc of 
binh or .iflcrwnrdii lhrou>;h the navel. 

A«aM r«R7 S«i«n«nitiaii of ui* Wawljr aorB.^IIuh], in iS6i, de- 
scribed llif symptoms and morbid an.iromy of n rate disease, occurrinj^ ui 
newly bom Infants to uhich he i{>tvc the name of acute faiiy dcgeitctaiion. 
His ol»er\'Ations have since been cniil^micd by Meeker, Kurstenbut^, RolofT, 
and Rungc, though it cannot be said thnl this condition \\ suiiicicntty wdl 
knon-ii for it lo uke its plac« at a well-defined an<l dcAnitc disease. TIic 
infants sulTcrin^ from it aie generally born in .1 condition of asphyxia with- 
out obvious cause. an<l some die asphyxia led. If they survive, ihcy usually 
(ufFer from more or less cyxnosis. with h;ernorrhage from ihc bowels, 
Momach, or from the navel on the separation of the cord. There is often 
jauDdicc. and blood cMrava«alions take place heneaili ihc ''kin, conjunctiva, 
or mucous membrane of ihc mouih ; there may be neneral icdema ; de-aih 
umnlly takes place wiihin i»o week*. .\x the pcii-morlim minute hirmor- 
rhaitcsarc found in the variou* intern.il orj;ans, which aie »oineiimes jnlil- 
traied with Wood ; the listue* are bile-sinincd. On microscopical rsamina- 
tion nf the tissues '"f the hearl, liver, kidne)4 Se. they are found lo be in a 
condition of faiiy degeneration. The nature of ihe di«cAse is tjuile unknown. 
It is inie(estin>; to note that a similar condition has been obscrccd in newly 
bom pi^s and other domesticated aninul*. 

Wlackal** BUaaa*.— A disease somewhat Mmilar t» the last has lieen 
described as occiitrinK in an epidemic form by Winckcl.and i* cHaraclerifed 
by cyanoais jaundice-, and h;emot{lobiniiria. This epidemic occurred in the 
Foundlinjc Hospital at ()re«dcn in 1S79, nhere twenty- three inliaots were 
jtHiectcd in the courtc of a month. The >yiiipt(>mi noted were lirst of all a 
bluish (ingc on the skin of the litce, body, and limbs, unih a more or less 
iJCtcric linl : in some raicA there were vomilint; and diarrliu;*. The urine 
fkas of a liKhl hronn robnr. uith a sediment cunsi»tm|; of epilhclium and 
catti : the blood conLiined an cxccu of while corpuscles snd tiuiny ({ranular 
bodiei. The symptoms utii^lty bc|[an on the fuurlli d;iy after birth, deiith 
occdrring in one cue in nine hmin, ibmi^h the aver;it;<-' dumlion of the 
disease wju about tmi dayi. The »cclion> showed a yellow stamin^j of tliv 
skin and internal urtjam. The apteen was Urge and hard and daik red ; 
Ihe kidneys were usunllj' dark brown in colour, the niicnisci>pic cK.iminati(»i 
showing their tubulcsto be titled wiihgrHnulHrpi);n>ent. Thcic were (luncti- 
form ha-morrhAges oit the surface of the various internal organs, and fatly 
degeneration of ilto lii'cr and heart. 

Outr«-lBt*sUaBi BwakMTkKa*.— Tlie vomiting of blood, or its |nsMg« 
{)cr aniun, is not an unconimon occurrence 11) the newly born. The moet 
oocnmon cause.cspccially of hxinatemesis, is ihe swalloning of btood ooiing 
front a cracked nipple, which the infant sucks, or from some wmind in the 
infeni's mouth or nose. Large quantities of blood may be snallowed in (his 
way, and vomited in a more or less altered condition, or passed as blackish 
m4sses Willi the fi^-ces. A hemorrhage ma)' have taken place into lh>c 



( 




^^ tiastri}-inUsti*Ml Ummorrhage — Umbilical Polypus 29 

bovd during Ulfjur und the )>luod pii&^eil in th« slooli. A much more 
t^ricius condilian «ii.ti>is when Ihe source of (he biccdini; ix a »nia]l ulcer or 
in lite stoTiHch or duodcnuiii, which niay open a lai^e vessel .-uttl 
e falal hf niOTThage, as in a cuse recorded by (ioodhnrl nn<l anoihcr by 
iwiell. Neuinaua hat recorded a ^omewhnt similar cote in .in infant 
lioin t4 heallhy parenu. which died on the third day frani birth after 
votnilini; blood. At \\k poil- mortem an ulcer wan found in Ihc duodenum. 
In the majority of cu^cs the blecdiny afipiMti m be capillary, due 10 a 
imdcncy 10 h;nnophiIia, "hich haubcendeicribud (p. 27'i. The hii^morrhncc 
in nio»l inMjnces comes on wiihio the first iwenty-fciur hour* ; if the 
Amount of Mood lost is Xar^. Ihe infant quickly becomes p;illid, the skin 
(old, the fontanellcs dcptetsed, and cont-ulsians pcubabty follow. Death 
lally lake:* place wiihin twenty-four hours of the commenccmcm of the 
Dpiomt ; if the infant survives this period and no fresh attack comes on, 
c ii iCAKon In bcticvc Ihcte is no lesion of the stoutach or duodenum, 
there 1* ^>toA h4>pe ih;it Ihe infant mny sur^'ive. The Ireatment would 
lunJI)' de|)cod upon the diagnosis as I« the cause. Sm.ill doses of 
:ottBe fquniter Ki^in to h;ilf i;'->in,>, in syrup, by the mouth or sub- 
lusly, •■nuld be the most likely to be of ser\ice. In any case of 
;C of blond per rectum in an infant, tlie possibility of an invaj{inaiion 
of the intestine must be bunte in mind. 

lOrrtaiMt* iv*n tbe •enlbU Otckd*. — It sometimes happens thaU 

re IS .1 snull oaiing of blood from the v:i^ina durin){ the first few days 

ircceding birth, sufficient to suiii the njpkini. The blood may often be 

i<m Dciiinj; from the va^^na, while no lesion of any kind t^m be detected. 

The dikcharge lasts for a few daj-s only, generally from two lo five, the health 

tA the infant does not suffer, and recovery seems always lo take place. 

Culhngwotth lias colieclcd tliirty-two such cases, T"o of whicii came under 

his ni^-n obsc^^■4lion. He agrees with Cuiiieron in believing that the Weed. 

■i l-i dueiu a conyciliiinof Ihe [lelvic veins, the result <if tlie cessaiton of the 

I jLiiion in the umbilical arlenes when the cord ■alie<l. .^salready stated, 

ihcrc !■» soinclimes u coincident di^chaige of blood from the rectum, due 

apparently to ibe same cauw ^st-e also p. 10). It must not be forgolicn lliat 

.^ of precocious nicnnut,ttii>n imay occur, commencing shoilly afier 

:!ii and continuing monthly aflerwards. 

■toe— ■ «r tb« »*vel. Bepeiwllon of (be Cord.^ — Under ordinary 

Hf rum fiances the umbilical toril -hnvcls up and drups off at a period after 

turih varying from the first to tlie fifth day. thin small cords drj-ing up and 

vparatinu earlier than larKC soft ones (Uouchui) ; ihc cicatrix is not usually 

dry ;ind firm until (he tenth or twelfth day, 

V^MUeal VAlyviM. — Occasiotially. after the cord has separated, a small 
•rd prominent projection is left with a moist surface, and somoiimcs (Holmes) 
1 teir rcniral canal ; iliis ' t>oly|)iis' ts the result in ino'l casrs of incomplete 
■iitKrtn;; of the cord, at oihei times the outgrou-ih it r^iilier of the nature of 
4 dimple granuhiiion polypus from irrit.Atinn, the so-called 'fungus nf the 
mtcl.' Tltc projection, uhcn sn»i1l, is often hidden by ibc «\i:rhangin^ 
sldRafihc part, and may remain for weeks or months, Kiiini; rise to slight 
ibchu^c fmni the scar and [irdiapi cxcotintion of Ihe skin amund. In 
class of cajtes such as one sent to us by Dr. Serra, of Kccles, the 



30 



The DUfasts Incident to Birlh 




pHMtmal pan ortli« cnrd tn^teixl of »lirivrtlinK>ipn>mainct1 axared v.iKcuUr 
pmJFctiuii >«n«? three ii>thci long. On cvamininjt thiscliild %amefive«Tm 
wi-ckt iifict binh. tlieii" niis a 'c<l licvliy iifmnincnrc thtonbavii \\ iiwh Ions 
prngcctint; fram xW nAV«l ; It was ^bour n'S thick a« » ccdnr pencil, Jind it* 
surface appearvd i<> be a mucniisiiicmbranrrxccpi at <nne»p»t wlicreapiiicli 
()f delicate cticicle wa* finiml. I'lic apex of the proirusion wax perforated by 
an orifice nhich readil)- adiniticd an ordinary probe, 4nd the inMruineiil 
cmild be pimed downwards in the middle tine ami swept round on each 
»dc for uime three inches ; It could oitly lie patLtctl tipwardt for about half an 
inch. A (bin water)' niucu!i in Miiall r^uaniitict was discharged, but nn f.ecet 
or urine. Subnequentl)' f.t.'C.il matter ricajjed fioin the orihce. The pro- 
truded n)a<« was liijaiuml and rc- 
mnrcd wilh a good result. This 
GOndiiinn is due no doubt to pertw- 
icnce of ilie t itclline duct in the 
proiimal pan of ilic curd and >l« 
conversion into InteMirtc ; it com- 
munic.itcf with the ileiiri) b>' means 
of Meckel's divcniculum. After the 
distal pan of the cord hjis become 
deiarhrd the end cicnlnses, and n 
prnt.ip'c tjkc* pUce of the whole 
thirknesii of the tube : hence in the 
section in d^. 7 two layers of mucous 
membrane with an intervening mus- 
cular and fibm- cellular layer are 
teen. Such case* are not rare ; we 
have met wtih several, in which the ' proiruiion ' wo> not so larjje a» in the 
above case, but from which there »as a ihin biliary discharge. A section 
iifter excisioD showed trace* of inuscubr 6bres and columnar epitheli.nl 
celU. 

We have seen a similar case in u child of ux j-ears old, but lh« parents 
declined any interference. Huttenbrenner describe* another variety na a 
remnant of tbc allaninis. In these tt is said urine may escai>e exiematly in 
consequence of the urnchus remaining piilcnl. and such case? hatetieen and 
arc spoken of by some writers under the name of * B>T«i>ara«bnB %%\vitm! 
but wc have never seen a case in which there w,is sufficient n Ulciii c of any 
connection with a persistent urnchus. 

The tmtlmtnt of iheie .itfcctinns is «ry simple : for tbc latKcr ones a 
ligature thimld be applied lit^htly riHtnd the Iukc, and the mass cut short 
off: the snialkr ones may be snipped otf with scissors or nibbed down with 
nitrate of silver, or dusted oier for a few dayt with powdered nitrate of lead, 
which wc hai'c fouml an elTcctual remedy, [l must l>e Ten>eiiilK'red thai 
lliect is considerable variation phyiiolnt^cally in the proccu of separation 
of the cord ; in weakly children it h\U olf Utci and the raw surface is skiwr 
Id he.dinjc. Where Ilie cord stump is p(o^ctin|( it is liable to l>e irritated 
by friction and iU healing i^^ iJow ; this is the condition described as 
•so«rlaUiMt. Wlieo a son of ' mucous surface ' remains and f[oes on dis- 
charKmc, the so-called ai«aa»rvbaffift exists, while the j>rescnce of a thick 



Pig. }.— Swlion -d llw>.ginUllul l■l^eIl•culuHI, 
It, fViilfii cuili «wiii»Qaiii wilh Mf^^k'Tt 
JtvtitkuiuTii lined vtlh vilLI :>. iKir^lr,^^' tilU 

^4 tdtnlar gluwit \ </, irmaln, of a\*xulk, 

■MM! ; t. HCIIMI «f UomI'VHuI- ( . jX 11'< 

miHtvljtm mucoiiE Uycn w aUj bc«ii. < Pr- 
Miia'i ant. ) 



tipkalitis — Gangrene 



jr 



BC suirji;:c i>r the »»re hm buL'n dui^ciilW as stampobb iit 
tuo emdaiioB ; in ^onie inMuiicei ii is probultlc llini u tnic 
berilic nicinlirjiie ■^ funned. 
V)>cir iIhtc is uny iprcuilint; ukeralioa after acpiiraiion iif ihc cord, in- 
ttitc ii)f1u«nces sliould be locked for; tliernivchivf miiyxprcud xupcrficiiitly 
' It may lend inwurdi ;ind involve ihv pctiioncum. A mere supcrfici.il v\- 
DrUiiun of ihe »kin anjloj^oui lo inter(ri){» elstnhcrt I* itficn ic<^n in older 
iddicD «s a result ol ditt and neijlecl. Il i« rcadtly cured liy ilic ii|iplir3' 
1 of bone jiowder. 

n^«l« ttleat«Uaa » never fainl unlcu it extendi deeply ; il should be 
rated, wiiKirdins to Rnnxe, by the iipplicnlion of lalicylii; acid and surcli 
■r in 5 fof the milder <-jixc9, or i in 3 if iIiltc it any tloUKhins ; oinimcnis 
ke diiapprn\-ei ot 

OK»kkllus ik n rare condition, \\1urn il cuiiK^ ihc navt^l itself an<l tlic 
Brruunding parts arc inflamcil and nwollrn, the wound rem;iinf unhcnlrd, 
1 tlie skin atound ix red, shiny, (cn»c, and {Minful. The di^cntc ina> 
1 and involve nearly the whole of tlic Abdomen ciilici xupcrficiall> or 
uiHiKhoiit the cotire ihickiwss of the abdominal «all ; the inf.ini Ijccmir* 
ill, the lens arc «lilT and drann up, bieaihing it (lioiacic, and smiitl 
i.i-3»rs may form and burst from time 10 lime. The disease liejiin^ in the 
or third week of life and may la*t for sonic da;» or rv<-n weeks. 
4,-noKis isKood if ibceitenlof iiiisihiff i* small and siippiiralion occur* 
pbad if Ihc di»ca«e i* nideiprcad, and c^pctially if it icndi inuanU 
the peritoneum ; if the navel vessels are jniolved, ^sncinl sepsis 
IfTvne it likely to rcsull. The younjjct the child the K'^atcr is ihe 



cause of this disease is dotibtful. I'rabnbly ii arises from bad 
itemcni of the navel and infection Fiiljp believes some cases to he 
allittc. Is 11 possible (bat Minic may be instances of slnu>:liinK plia^C' 
dxna ? Accordintc to llouchui it is sometimes complicated by bleeding. 
Tn»imcnt coikjsIs in cleanliness and the application of salicylic acid be- 
nr,iih a warm wet diessin^ fKungc]'. All abscesses should be opened early, 
and any iciulency lo KanK'<^c met with stinmlants and aniiseplics. 

•*■«*«»• of the natel begins eillicr as an ulcer or as omphalitis ; it 
« -.ir-v also in cases of cholera infonliim ; as a purely local condition il is 
'>!•-, aisd Wicdcrhdfer believes thai it arises from inlcnsc omphalitis. I'rc- 
naiurt si'i>aialion n| the cord and irritation lend to prmhicc );;>n>;rene. 

The disease usaally liei^ns as a blister coniainini; muddy Auid ; on 
(■iMin^ iliis leai cs an ukcr, or a soic may cxisi from the iirti ; the mischief 
i|i)eid«^ rapidly either superficially nr deeply ; a hiiyhi rtd zone i* seen siir- 
ratmlinK a crnlral sl<iut,'h, which after a lime comet away ; lb ere is rapid 
|«ostralinn iif strrnKth, though but little pyrexia. Recovery from KiinKrcne 
"' '^r- n4vrl IS rare, ih<~>i]>;h somctinies ihc slough separates and tbc cavity 
i.tTc- lip: more often death results from pcriioniiis or exhaustion, or 
>;3nKrene of the bowel ami perforation, which is sometimes met 
< .>iorially a fa'Cal listula is formed.' In many Ciises jfcnirral sepsis 

"•■iirs, anil Killer believes the Kangicne is merely a result of the septic con- 
liKuL In cholera infantum there is sometimes rapid gannrene without any 
■ III unr int)utk.il<)e i^uw all intiiMiMcppllon occurmi ihrau|th n e*«(J Guula. 




32 



Thf Distasfs Inddtat to Birth 



si};n of rcAciJon, and this may occur asi late a» scncraj inanibs aAer birth ; M 
U alw.iys raial. ■ 

'file /retilmenl of ^'an^rcnc consists in frt« siiniulatlon and lh« use en 
antiseptics; nitrate of silver, perchloiidixif iron, and salicylic acid arc reeom- 
inendcd by Kunge, to whme work. ' I lie Krankhciicn der crstcii Lcbcnstagc,' 
n-v are indebted fi>r neatly ;tll our itiformaiion on these diseases. Foccal 
fistula, if the ctiikl suiviies, should be treated as in older children. 

Vml»Ule«a Artarittk.— In fifty-live oubjects of <lisease of the umbilical 
veuelv Kuii^c found lifty-four cases of arteritis, and in only one was there 
{iblebitis alone. Tlic mischief begins as inflammation of the cellular tissue 
round ihe vessels, and then spreads to iheiii, producing thrombosis. Pelvic 
celluliti*. which sometimes occurs, n the result of septic lymphangitis spread- 
ing directly along Ihe cellular tissue, and is not due to embolism. 

Birrh Hirschfeld believed in phlebitis as a common aUcctioi], but Runge 
points «ui that the greaici frequency of arteritis is due to the fact that the 
area oi cellular tissue surrounding the arteries is twice as great as that round 
the veins. Inflammation in cases of atteiiiis may spread lar -ind wide from 
ihe navel, and even rcachihc bl.id(leruriisncig)ibaurhoi>d. Where arteritis 
eviitM the navel prL'sent>i often a projecting di!>ciil(>uied ulcer covered with a 
scab : inmelimes, houcver, the scar is hc.iled and quite natural in appear- 
ance. The dwease may arise cirher before or after separation of the cord, 
and tuppu ration and sloughing may occur. 

Sometimes the lumen of the arteries is seen open, and the vessels are full 
of pus nrbreaking-doun clot ; suppuration Uiually spreads along ihe vesiel* 
at far a* tlie cellulitis extends, beyond this adherent coagula are fuund. At 
limes the arteries are |>oiiched, and the sacs formed are found full of pui ; 
the iniima of the vessels is almays dull and has lost its polish. 

The moil common compKcalion of the disease is pneumonia ; UiJi wu 
found m tu-cnty-lwo of Runge's fifty.five eases ; septic inflammatory Ibd 
may. however, also occur in the liver, spleen, kidneys, itrriluneum. bones, aml^ 
joints, &c Er^-sipclas sonieiimei attacks the part, and slight jaundice i»fl 
common, though severe jaundice with hepatitis is rare. Of Runge's l)Ay-liv<c 
cases, in nine there was arteritis alone, in sixteen there were compllcalioitt, 
such as sjphilis. ' atrophy," cerebral hjumorrliage, Jfcc, and in the remaining 
thirty rases iliere were py.tmic lesioiu. Buhl. Wiederhofer. and Mullet 
differ from Runge in thinking llial usually the discaic aflects only Ihe aUIo- 
men and its v-sccta. I'erilonilis is Id he susjiecleil as soon as diiteiiMOB 
appears. Tetanus is an infrequent complication- .-Vneritis in a discnte of 
dirt and neglect ; it occurs in epidemics, and isofien associated with puerperal 
fever ; it may be inoculated l>y the lochia or decomposing umbilical cord, and J 
has been found associated with ophthalmia neonatorum- It usually runs a ' 
rapid course, lasting from four to eighteen days, and is especially fatal to 
young and pTcm.iture children ; in older infants the prognosis, though bad, 
is not absolutely vo ; in fatal cases death is u^uaUy sudden. ^ 

VaiMtle*! rtttvbttls.— As already pointed oat, umlHtical phlebitis is ■ * 
rate diu-atc. Hitch llirschfeld. in examinations of sixty infants who died of 
septic diteases beginning in the navel, found ekvcn r^ses of phlebitis, four 
cases of limplc ihrombiuit ofihc win. and ihirly-l wo cases od* arteritis, while 
in three instances both the aricrirs and vein were involved. Runge ha* only 
tirice seen phletuiis apart from arteritis. 



I/mMku/ Phlebitis — VutbiliaU Hamorrhage 33 

Th« general appeJiiaocea of phlebitis arc very like those of arieriiis : thera 
) lUckentDg of tlie peritasi-ular titaite, Ihe lumen of (he vein n diiiiinished ; 
is lortuotu and vontum^ pus or K^inious mnlerial, (be intima ik cloudy 
i eroded. Utiually (he whole vein 3,^ fat as the liver n affected, and thcic 
ay be bepalilii : Wicderbofer found (ilJMiin'x cn|»u1c niid the poilnl vein 
botii invol\%d. i'entonitis and imcnue jaundice arc both common. The 
eiiologjr of the discaie i.i the n.ime a.% ihiit of -nricriiit. The symptoms of 
phlebitit Are fever, icteiuc, altered respiration, inspiration being shon, ex- 
piration prolotiKed, while the bre.iihinR is shallow, frctjucni. nnd entirely 
llvnriuk : the upper pan of the abdomen is (umid, and there \s loc'il Icndcr- 
neu, the knees »e ilran-n up, and Ihe child is rcsllet^, It is dilViciill to dia. 
gBOse phlebiliK from aiteriiis ; Ihc intense icterus in the former is the most 
chitract eristic fcaitirc. The disease lusts ontya (cw days, and is always fatal 
from ^'eneral sepsis. Tlic ticntiiicnt of both arteritis and phlebitis consists 
I Ibe app4ic;iik>n of Mlicyliracid or other antiseptic and the use of Stimulants 
I free nourishment, together with carcfol ite.tnliness. 
These diseases appear to be almost imknown in this country at the pre- 
sent day, judging from the absence of any litcrattirc, but tbey arc likely to be 
net with in dirt) ipianers of targe towns. 

irmUllo*! M<eniorrh«K« is to be looked upon asa sym|Uom rather than 
1 disease in itself : it is met with in the shape of bleeding from the umbilical 
sscis themselves, and as a general oozing from tiie raw navel surface. 
Bkeding from the vessels may occur from slipping or imperfect tying of 
jbe ligature round ibe cord : as, for instance, when a thin ligature cuts into the 
eLs. HIeeding,of course, by no means necessarily follows slipping of the 
^nture. o* even failure to tie the ord at all. The aspirating action of breath- 
ing prci-ents any h.L-monhage in most instances, and this is supplemented 
by the cotitraction of the vesseb after birtli. 

Asphyxia may, however, produce some escape of blood as the vascular 

L^pressuie rises in slight de^Tecs of suffocation ; in other instances delicienl 

^^Btusoilar contraction appears to be the cause, hence bleeding ismost common 

^Rb premature children who have been asphyxiated or whose lungs hiivc not ex- 

^■MadetL If it arises from imperfect muscular contraction it may occur some 

Muri af^cT birih . ttofnuina). As the vessels begin to contract at the corxl, 

and the obliteration extends towards the hypogasiriuin, theie is more risk of 

UaediBK if the cord is cut very short. So, too, drying up of the coid tends 

n tMiteratc the vessels, while gangrene and swelling tend to pievcm their 

doture. lllevding may also occur later from rough handling of the navel 

and Kparalion of the scab, AUdangcrfrom thisfotniof h.vmorrliagemay be 

prvrenred by lying the cord firmly with a broad ligature not too near the 

abdncninil wall ; should bleeding occur, pressure or the applicttionof asirin- 

lew potrdcrs, a frtsli ligature or acupressure will arrest it. 

^^ Idiopalliic, or spontaneous bleeding so called, is a very rare occurrence, 

^■lad iu riifjogy is obsctire. Crandidier collected twenty-two cases from 

^"*Brioo» soorces. The bleeding usually occurs about the tilth day, just aftei 

or more rarely before the eoid comes a«-ay,' the btootl trickles from the 

MUbcc of ihe umbilicus, and not from any tlisiitict vessel ; the ooiing may 

b« (ontmuou* or intermittent. The subjects of the affection arc generally 

< ' It mif . hMraxr. e^rne on tn ihr third wrek.*— Mimrr 



ws 



■ 

^kdi! 
^K>css< 

I 

^Ibe hg 

^Ihtntui 



34 



The Diseases fncident to liirtb 



tie^Iihy full'limc children ; Ibcrc it often, liowcver, iljglit iclerui ; in other 
ca»n there is vomc intutiniil <li«iurbance, vnmitinK. colic, Jtc, with deep 
iclcni^, cy.-iDosis and drowsiness before the hlecdinj; occur* l in nny cate 
tlifse symptoms nppc.ir soon afterwards. Bleedini; not >eldom comc» on 
from the Momach oi inicMinef. oi ihcrc may be general purpura, and lomc- 
liin» \\xw is ccdcina of the hands and feet logether viih the umbilical 
h^inorrhage. 

The ^TvAX difficulty or imptuiibility of ttoppins the Sow n chancterifttc 
(if the condition. .Most of the ca»c> <i>e before the second week ; the 
inoriality n put down as 83 per cent, llie infant usually dies conutove, less 
often in ronvulsions. 

l'mbili(.*a!hitm<)rrhi}jei%nN)inptomof»<veraldiieaic? ; probably inhume 
cases, as we have ulrc^ady pointed out, it is due to h;i-inophilia or syphilid. 
I'rivation, drink, and other depre^iint; auscs ae'.int: upon the mother are 
also auigned va teal(m^ for it. Scpliot-niia and ' fatty dexeneraiion of the 
newly bom 'are t-'auic^ that have lieen ettablished hy/"j/wiwV<'jwcTidence. 
The blood in these children dtiei not clot leadily. It is ^id to be a cent- 
moner discaie in America than elsewhere. 

f ressuie by \-ariuus means, such as pads, filling the navel o'ith plaster of 
I'aiis, underpinning, &c, may be tried as itie;mt of treatment with some hope 
of success: cau:iiics and astringents, such ai perchloridc of iron, do not 
appear to be of much use ; the actual cauter)' has succeeded, liliopiithic 
MccdinK is very rarely met with. Furth has, ho«'cver, rollccicd records of 
some cases:' it is somciimes epidemic, Wciis had 31 laici out of 741 
children in nnc year at Prague.' 

For other morbid conditions of the umbilicus, sec ' Deformtties of the 
Umbilictii.' 

TatBBos Waacwntlum. This disease is almost unknown in (his country 
at the present day, altliouuh in {>asl times, nheo less attention was paid to 
X'eneral hygiene in lying in hospitals, it was common, and somciimes was 
the largest factor in infant ini«tility ; it nas al-.o freipient ai nnc time among 
the negro population in Ametica. The disease is identical with the wniuod 
tetanus of adults, and is caused by inoculation of the navel with the tetanus 
bacillus. This b;icillus. as shown by Niculaier, is constantly present in the 
superficial layers of the earth, and it gains entrance to the infant's Ixidy by 
dirty dreuings applied lu the navel. 1'he bacillus multiplies in the neigh- 
bourhood of the navel, and a sir>'chiiine-likc poison is absorbed, which 
gives rise to the inuhcular spasms. The bacilli may be delected in the pus 
of the navel wound, and if the pus be injected into mice they <lie iHih 
tetanic symptoms. 1 KosenbAcli, I'eipcr.j Tetanus (■ nine-day fits ') usually 
appears in the first two weeks i>f life, most commonly from ibe third to 
llie tenth day. the limits, according to West, being from the fifteenth hour 
to tile fifteenth day. The sjfnptoiiis are usually acute, the earliest beinj; 
inability to surk from spasm of (he facial <ind jaw muscles (trisinusj ; general 
c«ntractinns, however, soon occur, the spasms arc continuous, but increase 
ID violciKe at inlctsaU ; in nvMt cases there is no complete rolaiutlon. The 

> Ank. /. Kiadtt*. Ibnd t. |>. 305. 

' hir (•inlirr ilMUIn, vidt * (Hpcr liy |)r, t>>iic>i Minot in th« AmtrHtm /mp. «f 
.U*J. .-hi. UcL 1)50. 



TfdtftMt Nasei'nliuni—SfUn'mit Ntimittorutn 



35 



flL 

aJv 



child olien ullcr* » peculiar whining i:ry. nnd there ■« wdl-marlccd (i^us 
unlnniciit ; the m.-iximum lijipdily is };rncmlly reached in iw-clvc hours, and 
the child di<ii in a ht i>r liccomcs comalotc. 

The «pMms nie mciciiMd by nnj c\p(«iitc to cold and by floisc : cm.icia- 
fton is vcr>' rapod, and ihcrc is oftfii jfttindicc. Dcalh usually occilis in one 
or In-odaj-s ; in rare- uiscs ihe disease i« chronic. HnniKnnt.'t>-s the chronic 
irm bcfiini viih dysenicfy and coldneu nncl pallor of the skin : hence ic has 
en r;il[cd 'n'hile lockjaw.' It rt aitcnded by wasling .ind twitchinKs, •ind 
tas described by Marion Sims as 'Trismoid.' I'nlike the nculc form, vrhieh 
aJvays occurs within ihc first monih of life, the chronic variety inay appear 
at any time within six months, and may be a sei|Vie1 of the acute. 

The diiTjse is readily rccoj^niscd by the spasms ;ind gcnemi rigidity. 

The /rr!v«//tv trtalment consists in the most riijid cleanliness in dress- 
; the n.ivel .■intl (be removal of inwmitary conditions. Opium, chloral, 
bromtde of potassium. i:ann4bis indica, bdladmma, ;ind oihiT drugs have 
been rxrcuiooally luccesjful ; warm baths sometimes relieve the spasms, and 
spiD-iI Icehags arc worth a trial : an^i-stheiici, siitli as uiher anil chloroform, 
are useful lo relieve pain and allow ihe child to he fi;d, but nunc of these 
remcdit> have given any ci>nsl3nl Kiiod result, further ilel.-iili of the disease 
ar.il refcrencci n*i!l be found in the works of Uouchut, Mei^'s and rcjipcr, 
I'eiper.' Haginikv.' 

BelerMua HvooatoruD. — Thisrarediseascispractlcallyunknownoutside 
foundlin); asyltinis and lyint:-in institutions, anil is by no means common 
imder any cittumstances. The chief character! si its of the disease consist 
in an iodumtion of ihe skin and subcutaneous tissues, and marked wasting, 
with ;in abnonnally low tempers in re. The infants at binli may present 
tM> abnormality, and in some cases at least are plump and heatihy-looking ; 
srittiin a few days of their birth ihey begin to waiie, the temperature 
becomes abnormally low, Sj" to 86" W in the tertutn, and the integtimcnta 
become hard and rigid : the change usually bet:ins in ihe luwer extremities 
aad spreads upirards, and involves the trunk, upper extremities, and face. 
In typical instances the skin is of a dirty yellow colour, its surface is hard 
ar»d does not pit, and it cannot be raised from (he aubcuLineous tissues, The 
SBr&rc of the body has a cold feel almost like stone. In some described cases 
the ri^dity of skin has been so great that the infant could be lifted by the 
bMdand heels like a n^'idbiidy. On account of the rigidity of the skin of the 
facc^ sucking IS performed with difficulty, and the infant has lu be fed with a 
•poon. The prognosis is bad. as such infants almost in\ariably die in a few 
im^ In a typical case investigated by Dr. W. v. .N'orihrup, of New York, 
lli< microscopical examination of the skin showed nuthing abnormal. In a 
ooe of l>r. J. W. Ballantyne's there was an increase in tlie number and mm 
rf the connective- 1 issue buniltes and an atrophy of the adipose tissue. 
Langer attributes the rigidity of the integuments to aolidi location of the fiilty 
livtues, in consequence of the abnormally low temperature. In one case, 
hcnsever. reported by Dr. A. (i. Barrs, which he believes to have been of 

nature, the infant, which was a month old when seen by him, made a 
Kcovcry. In this case the skin over the buttocks and thighs was hard 



• DruiKlUi Anhi»/iir klMKkt Midiiin, IM. ilvii. II. i u. z. 
r BttU»tr ktimiukt WiJktKttArift, Kn. 7, 1891, 



Dl 



JIfi 



The Diseasti fneidtnt to Birth 



and rigid, unit coul'l not be raised front the deeper tissues. Bui it appears 
ID have bcert red and shiny, and without the cotd feel «n typical of thai 
ordinary caies of sclerema. Tlic patlio1i)>^ of these catc^ it ill understood. 
It has been BUgrgcsted with rnufh plniisibiliiyth.ii they aii.- akin tn myiadema. 
We have seen a sitiiitni ca^(^ in a, g}i\ iwo uccki old, in which thi: tissues of 
the luck of ihc inmk, :imi-% and \t^t ncre much indurated, ted and shiny. 
They were too hard to pit with the finger. Wc think thai this one, as also 
I)r. Itarrs'. were not identical in nature with tho«c detcribed as sclercnui. 

Vc anfortunatcly loot xiK'ht of out case ; the infant nas apparently liealtby 

nd ihrivinit- 
Sitaoia WoADBUnun. Weakly, e»])eciall) premature, inbnts are apt to 
l>e (L-vieinainus at birth, or become lo soon after. An <cdcinalous condition 
of tilt? ikin and subcutaneous tiMues dilTers (ron\ ncletema in that the former 
readily pits beneath the lini^er, an<l the skin is more iir leis smooth and 
thiny. It ik obviout that cedema may be predentin many different oimdi- 
lioni, and it doei not in itself constitute a diaease. 

OsnoiTbaal opbtbaloil*.- ~ 'rhc)U)>h kirdly within tlie xcopeof thi) work, 
raeiitiun ou^ht perhaps to be made of the dantjer to the infant of infection 
by t;onDrrh(i:ul disiuhargci fiom its mother at binh or shortly after. The 
moil common alTeciion i* that of the eyes, in which a virulent purulent 
ophihaliiita ii produced. The inflammation rapidly spreads to the e)-did«, 
and involves the cnmea, speedily causing opacity, and if allowed to run its 
coiirse unihetked endiiiy in perforation of the cornea, mth escape of ihc 
conients of the g\ti\K and contpleie shriokini; of the eyeball. Many cases 
of total blindness in children are due to tliis cause. In any case where there 
is a suspicion of vat;inal discharge from the mother, an antiseptic douche 
should be carefully used before the birth of the child, and immediately after 
it is born the child's eyes should be examined and carefully washed otii 
wilhasolution of pctchluride of mercury i;i-4,ooo>. followed by a douche of 
boric acid lotion. At the leatt sign of any inllauunation the eyes sho-jld be 
washed ntth a solution of sulphate ol linc (! grains- .\ji. and unless the 
mischief is at once checked a solution of nitriite of silver (lo grains JLj) shotild 
be emploj^d once a day, washing ont again with a iiilutiun of salt dircctljr 
after to prevent too powerful action of the silver. The eyes should he Ijalhed 
ever)- hour day and ni^ht with a lotion of boric acid, and the silver repealed 
if necesMry. It is only by such means that the eyes can be saved in severe 
casc6. Tlie ulmusl care must of counc be taken to use all applications 

horougbly and get rid of eiery panicle of discharge, as well as to avoid 
■ubsequeni reinfcciion. For infantile gonorrh(i.al rheumatism, t'riA- chapter 
on ' UiMases of the Joints.' 



I 

I 



J7 



^ 



^ 



CHAPTER III 

THE KYT.IKNE AMI lilKT OF [Kt'ANTS AND CIIII.I>REK 

S«rB znflMatar^Unc a( ihe first cares of the nurse after the nav«1 
been properly attended to thould be to direct her aitenlinn to the 
i"* eye*, curefully wipiiijt away, by meani of a soft raff, any inucu» or 
vagiflal discharge which may adh<^re, and thoroughly clean^iiny ibe eyelids 
with w*nn water. ThU i* a matter of much imporLincc and should never 
be ncglKtcd. for if conjunctivitis or a purulent ophthalmia be «ei up. much 
iroabte may onftue and some time eUipse before a liealthy suie is again 
attaiBc<L, and Ihe risk of corneal opacities and coiisci|utci loss of sight is by 
no means unall. The temperature of the room in vfhich mother and infant 
«e should be maintained, M least in winter, at 65°, and means be taken to 
tboroughly ventilate it without producinj,' draughts. 

in gi^in^ the intmi its first iKith— necessary on account of the slimy 
whitish secretion with which the infant is covered— care sliould he taken 
that it is done before a nood fire, and that the water of the bath is not too 
warm: the tcmperatureshould not exceed 95°; the infant's skin is exceedingly 
tender, and hot baibs are liable to giie rise to urticaria or even pemphitrus. 
The infant is usually giien a d;iily bath in order to secure cleanliness, 
especuill)' about the genital organs and buttocks which are fouled by con- 
tact with the duipem. and nothing is more likely to give rise to excoriations 
and intertrigo than the skin being smeared with decomposing urine. Some 
infants' skins ate Exrmnti- tender than others and liable toeercma. imd rciiuire 
uuutani care to .-iv<»d irritaiiun. t-'or such, care should be taken in the 
selection of a soap which is free from excess of alkali, such as the best class 
efpure Caxlitc soaps. i>r t.'nna's'mer fatty' soapi,al1 excess being lemovedin 
the bath. The skin should be carcftilly dried with a soft towet. and some fme 
dnning powder applied to the folds of the groin and buttockv This may 
con*i*t of finely pon-d^red maiic or oatmeal mixed with 3 per cent, ot 
^ti^yltc acid, 5 per cent, of horacic (icid or thymol, to pici'cnt any tendency 
to decomposilion. Cure boracic acid, as in the ' Sanitary rose powder,' 
antsrers very well, and as it is »nluble in water is easily removed by w.tshing. 
The dui|irr)i should be of a toft •in<l absorbent maieri.-il : at least a dmen 
shMilil be provided for use during the tncnly-foor hours. 

In the first few days, bcfotr the cord has »^)aratcd. a Runnel binder 
loosety applied is nc«rssar>* t» prnlcci it and keep the dressings in position, 
but nAenwda all binders sluiuld be avoided 1 nt least, nothing iij[ht should 



i 



38 T/if IlygifH^aS^TjK^^nfStit^n^^mMre!^^^^^ 

be upplied round the iibtlmni-n uliicli would cause discomfort to iIh- tUi\A by 
coiiipresxiTi^ ihv xbdominiil viici-r^. The conl niaj be dmnnl u-ith a pad 
ofwowl nool Hflddiiic or lUnigco tissue. 

It is hardly needful lu s^iy iliMt a cut should be jiravidtd for ibc infant 
with a firm maiiicss protected by ;i wal<-Ti«'>of coxiririK. and und«r no 
C'rcuinsLincx-s uhalcver should the inrint be allout-d to »lec|i in hcd wilh ill 

. parents or nuriie : faul accidents thiou^h sufTocatioii of ibc mfanl ben«iith 

> the bcdclnlhc) ;irc constantly ociurrtnij in consequence of the mother falling 

IbsIccp villi her Jnfdnt in hcd with her. 

^ Oi«ttalBB.— All ihc irUithini; should be louse, and .is far as possible con* 
»iiil of wo^x-n or knitted n'uollen material, but it uill have tu be protected 
froml>cint; fnuled by thrdtsrhiir^es by mcaniof napkins, uhich may be tii;ide 

lof ' tn'antdnwn' or similor mAieri.d. 'Ibc tomnion tendency i» to load the 
che»i At\A body with too xiTcal an ammmt of clothes and to leave ibc legs 
and thif[hii inn inucli cvpowd. For the latter, lon^- lomely litling woollen 
dravrcrs coming to t'ncH&itc should boused, carefully proleciedby ihcdiapcK 
from bcinu welled. 

SnltuH roooiBB at tiM BrVkM.— 1'he luttural l<iod of an infant is Ihc milk 
from the breast of its niniher, no kind of foud bciu); thought of fur the first 
cigbl or nine niuiiihs of its life. The mother's health may of course sooner 
or later inicrfeie with the perfomvince of this duty to her infani. but it is of 
great Im)Mirt.incc that it should be aticniptcd, if Fur only a few weeks or 
months, fo) to undertake the ariiiinal lecdiii}; of :in infant from the first is to 
G^iwse it to serious risk. 

The infant should be put to the breast a few houis after birth, niter the 
nioiher has si>mewhal rccoieied fioni the |>ains and f.iiti(iiie of labour, and 
bas had some sleep. It is of much importance that both mother and inlant 

' should get as n^uch iiest at night in possible, .'inO if the infant finitirnlly 
wakes crying, ever)- means should be taken to Uiish it off to »1eep a^ain, 

I ftnd for this a little sweetened u^iter or bailey water n>ay be used, h is not 
unlikely that fur the first few days, es|>ecially in primijuiri^*, llie xupply of 
mitk will be scanty and the infani uill lurdly get iis full supply; but this it 
a matter of litCle iniporunce, and it is in ui^ny respects well noi to overload 
the stomach at first, but to £i\« it an opportunity of gradually acciutominic 
itself to its nen- function. 

From the *ery first il is of imporiance to accuslnnj both infant and 
mother to regular times for feeding. At 6rst, every two hours during the 
daytime will be quite often enough l<>r .in infani of average weight and 
sirengtli. A lonj^r intenal may be taken in the night, so as to gite the 
mothei as long a sleep ai ptMsibte ; ten feedings in the tweniy-fotir hours 
will be MiAicieni. A strong newly bom infani empties [he btrasts in alwtii 
fifteen mimitex, and, during this time, iakc« from i lo ij o/. of milk, the 
total ,>mounl i.tken in the twenty-four houn during the first week bemg lo 
to 13 or. The infant's stomach, ni ihis period, being only c.ipahie of hold- 
ing nlmiil 1} or. {see fig. i ■ uithoul marked diMention, too mpid filling of 
tbe stomach nith fluid is »-cty likely lo give rise lo vomiting. Il i* there- 
fore of iiiipoitance for the inoilier to feed the infant slowly, eitnuling the 
lime to lifteen m twenty minutes. VVc must not forget tlut prohnbly mpid 
abiorpiion is going on during the time the in&nt is being fcA, in strong and 



I 



^ 



^ 



/n/ant FffSng at tht Breast 39 

irhildrm, M>thai it tn^ty oficn linppcn ihai such nill tnkc more than 

The infant's Momjch rapidly tnl.iruM. fid tlic sccrciionof milk incre^iscs 
tiDi« itoc* on : M> th:il. ;i(tcr the lirsl week or two. cijfhi iiuniiii>:\ in ihc 
iiy-four Ikmk* — ihni i». evciy two and s\ half hours cturinn ihc day, and 
JORCT intcnnl nr nijjhl— will be often cnoufjli. From ihc brsinningof the 
lird month till ihc end iif lactation, ocry three hours will l)c often rnoi^h, 
Hune 3 lA 6 ni. hcin)! takrn at n liinr, »nd »oinc lo (o 40 01. :n the tw-cnc}'- 
four hours. Six in ^ven nursings in the (wcniy-four hours will bp Mifficicni. 
Too fTeqiicni ni.ir«in){ is bad for ihc infant, inasmuch as nn overworked 
stomach cnnooi jwo|ht1>' prrfnim iis fiinciions and a dy*pe|>»ia is only loo 
likdy to result ; ilie moihcrs breasts require an inleniil of rest, for, if too 
(miuenily drawn, (he milk is apt lo be unequal in composition, loo watery 
■iter a loot;. xttA too rich and concentraird ^firr >i shon inien'.i). 

Punnif ihc whotc lime the infant isbein>; niiried llic hr.illh of ihc mother 
will necessarily be a <iiiHiion of ihc j{rcaic!i imponancc, as it is impossible 
for A wcakty moiher.or nnc in ilMir^ilib, to |^ve|{iod milk- Tlicfood whirh 
die takes and the life nhich she leads are alt-iniportant. i\nylhiii){ c.iusirtj( 
indiitestion in the mother will he cxircniely likely lo aUcrt the bixasi milk 
and diiiuib the infant'* dit;ci[ive organ*. 

V'skrinus drux'*. such as morphia and Kpsom salts, when Uilcen by the 
moiher, arc e\crcied in the milk, and may of tourse nfi«t the infant. Any 
liittcnt em^Miiiit, luch at a Kieai sorrow or any pmlonKcd amticty stifTercd by 
ihe miiihcr, is very likely to allcr the qu.iliiy of ilic milk, and ihe infjm con- 
»M[uenily suffer*. Indeed, under these clrcimuiance*, the milk may cease 
to be seLretnl. and ihc inf;int have lo be artiliciatly fed. The mother's diet 
nhnuld consul bir);ely of intlk. porridge, loupv potaluet, (iih, and light pud- 
dings, while beef, muiiun, and stewed fniti should be taken in moderation. 
She should aioid all hi);hly seasoned foods. and iht»c difficult to digest, such 
aip(t>tr\', raw fruit, uncixiked vcxeUiblcs. Alcoholic liqiioriareunneensaT)', 
■Ml tea an<l coffee sboutd be taken in moderation. Kxcrcite in the open aii 
b of the KTe.itvsi tinportancc. 

According to Korstci, increasing the amount of fat taken in food does 
MM increase the atituuni of fatly matters in the milk secreted, while proieids 
taken increase the f.iE in milk. For the mother or wet nurse excessive 
i|uaniiiiei of ftmd hhoiili] reiiainly be avoided, and, especially if she is much 
coniincd to the house, much meat should not be taken. 

T1>e milk of the AtM fco' days differs from normal milk in ihai it has n 
lii);her sjierilic gravity, coiii.iins more sahs. less su^'ar. and is contiulated by 
means of heal in consei|uenc<r of the taige amount of albumen which it 
contain^. 'ITiis coloiinini is api to set up more or Icssdyspcpsia or diarrhira. 
In a few days the etces^ivc ((uaniity of alburnrn disappears and the milk 
becomes normal Thcrhan>;es which occur in the qilaliiy of the milk during 
the iHiClation period depend very largely of course on the health of ihc 
miNhcr. Ilurinti ihe later months of lacialinn ihc m'lk becomes paoFer and 
more watery, «iih a tendency, according to rfcil)i;r, to a diminulion of the 
piMCidb and an incrciue of ihe sugar. It mii^i be borne in mind how com- 
(ilriety the secretion of ihe milk is under the inHuence a( Ihc netvout >yxiem, 
jBil, ntoTtover, it rariei from lime to lime from various cause* ; anil more 



4 



40 Tht nygUHeand Did of InjaSumul Childrttt 

or less cauiion must be obsrrveit in dmwing conclustoni n* lo the effect of 
any nnc ourc on the quality of ihc milk. 

The orcurrrtice of mentliuitlinn in n nursing mother or wet nurse i* apt 
in tome «ay or oihct lo nllcr the srcrctioii of the milk, and the infant, in 
eon5«iiience, miiy siitier from colic, tfatulcnce, or iliarrhfi.a. In manj cuet 
the infani doe« nol nppr.-ir to sufTer At all, while in cxccplionnt c^ics the 
inieitio.il dinurhance.-ini) lohtof fleth nreio great th.ii ih(.-([ucstionoru-can- 
ing nuiy have to be enli^ruined. It mny happen that the infant may suiter 
ii ({uod (leal ai one period and nol at the next or ^ucl.-eedi^l{ one>. The 
chemical chanK'e' which occur durinn meniiruation have been inveiiit-ated 
by Mi'eral obserters, hut no conntiint change has been found. In MOW 
cases tlie earcful obtcn-aliont of Kolch have shown ihai the milk during 
ihii i)erio<l is poorer in fai and richer in proieidi, but it ti toleinbty certain 
that this IS nol uniiersally the ease, Monii found that menstruation exetcis<cd 
no consiam ehangc or iniluence or the spediit gravity or the fatty elements 
though in some dses observed b)-hini there wa»an increase in the <iuantiiy 
offal duiiny the penud. 

A» the result of numerous obser^-ation9, Schlichier found thai the eaa«in 
and fat were sliglitly increased, and the proieicU, sugar, and solids were 
dceteased, (luring meniiirualion ; but as juM as t'^vx changes were observed 
from time to time during the interval* between the periods, it is evident the 
changes noted during incnsirtution umnoi be of importance. This author 
regards mensEnuition occurring before the sixth week as likely to nllcct the 
well-being of the infant bv causing serious changes m the milk : on the 
other hand, menstrual ioD^ecurring at a later period is of comparatively 
small importance. J 

'BTet W«i«M.— It nol infrequently luipi>ens that, if an infant's life iaiolM^ 
saved, a wet nutee must lie procured. It inuy happen that a weakly inbnt 
is deprived ofits mother's milk, and a foster mother nmsi be obtained if Its 
hfc it to be tavcd. In some cases, perhaps, an attempt has been made to 4 
feed a j'ount: infant on some ariiticial food, various foods being tried, one 1 
aAcT another, till sevrrc convulsions or coniiniinus diarrhira warn the 
attendants that a leturn to the infant's naiunil f<f)d is ihe only possible 
tetouicc left. Much has been written about ihe advantages and db- 
advantagciof a wet nurse. We may say at once that, in our opinion, there is 
not the least doubt that no aitificial fond yet devised can compare with or 
form a suhrttiiute for lh« milk of a healthy woman. To ailempt to bring up 
a weakly infant from the liist on artificial foo<l is tu e\|wse it to far more 
lerioui rixkt than if it it provided with a healthy wet nurse. Unfortunately 
in this country wei nurtet arc difficult to obtain, and wlien obtained arc not 
always ea^y to manage in the houscliold. At the same time, we ate inclined 
lo think that the character oJ net nurses as a class lias often been jiatnlcd in 
loo black colours : certainly we have known many who ha^'e done their duty 
10 their foster infnntt in a most worthy and exemplary manner. A difli< uliy 
ojien is presented with regard lo the nurse's own child : it is put out to 
nurse, and is depti»'cd not only of its mothei's milk, hut also of its mother's 
care, and is only too likely to go the way that so many ' oui-io-nurse ' babiea 
have gone before. In large cities wet nurses arc usually obtained at the 
workhouM*, wbete many iromcn go to be cottfined. and are often glad to 



)*■>/ Nursfs — IVeiming 



41 



iTom Ibc (lifcipline of the v-orkhotite, and lo obtiun a silualcon in a 
livaic Tamily at good wimcs. 
A wet nurse should noi be above thiriy-fivc i>i below iwcnty-one 
xn at sijEc ; very youiig wet nui«cs arc capccislly to be avnidctl, on 
count of their )ncxpciienc« nnd the diDiculiy in manng^ing ihcm. It is 
iur for the nurse'* in&nt to be a manlh or so older llun the infant to be 
lnG<t. (•teal dispanly of a){e is od objection, as a nurse who )us been 
' or six months before is not likely to inakc n good nurse for a 
I infant, at least not for the whole time that the infant has (a be 
bvi su<^ » nurse may be employed leinporarily in ihc absence of a 
suitable one, A disparity of two or three nmnibs i* no objection, pro- 
I ihe nurse is suitable in oilier ways. A medical c.\ a mi nation of the 
rahotild always be made^ai least, the medic-al aitcndam should satisfy 
nself ibat boih ihc niir«cand bci infant nrr free frxim ditea.ic. There is 
:»iivania^cin ihe nurve'i infant bein^ iwo or three months old. and that is 
ibuliinc n^Hild haveltcen atfordcdfbr any syphilitic ni>h to make it«;ippcar- 
inceon the infant, and ihc infant if strong and vigorous ii reliable evidence of 
the good quality t>f the milk. If possible, an analytic of hi.-i' milk should be 
tnadetipot) several (ircasians. cspeci;illy with regard to the amount of (at 
present in the mitk. Itut, in tpite of all precnutions, we must lie i>repared 
Ji time« i« find thai ibc milk of a wet nurse who in every way appears 
niitahle iloes nc>i;i(;rce with the infant, and thconl) resource is to try another, 
ireal pain* must be taken in the dictini; of ihe nurse, errors l^dng mo%ifre- 
at in the direction of overfcedinf; with ton hide eKcrctsc. Meat once a 
is erM>Uk.'h. beer and porter arc be^I avoided, imd exercise in the open 
' niu'Ll be in^Utrd on. 

No infant iuffering ftnni heredii.iry syphilis should be wet-nuiscd, on 
KKini '4 the risk of its infcclinj; its foster mother. 

V«a«t»c. -The teniflh of time during n'hii:h Ihe infant takes its sole 
ithinent from its mothers breast depends upon a \aricty of circum- 
Wbcn the mciher remains stning anil healthy and has a «ufficicnl 
iy. the time may l>c enlcndcd to eight or nine mouths, or evtn more. 
Among (he wnrkinR classes the lime is often extended much longer than 
this. Infants nho are nver-nurscd are apt to be fat, but arc not ncceuarily 
snong — indeed, thoy often appi^ar rirkciy in a minor dcKTec. In a case re- 
ally cominif under mir nolirc, the mother nunicd her infant entirely at the 
nut for seventeen months. Tlir child wei){h(-d twenty pounds, it showed 
n« of rickets, the epiphyses being moderately enlarged and the ribs 
An examination of the moiher't milk, which was plentiful, showed 
: poof ~ih*^' amount of fat (average of three samples) 17 per cent.; the 
cific gravity was 1031. 

Whenever n-eaning takes place it is wise to do i[ gradtially, in Ihe first 
pbce subsiiluling the bottle for the breast i>ncc or twice in the twenty-four 
bMin, sihI rnrefully watching the result beforc.allcmpling more than this. 
Gnuluatly ani/id.il feeding may he made to take the place of the breast cn- 
ely. It <s well to atoid the honest weather for this change on account of 
' risks of diarrhoea at ihis time. 

Al any time during the period of lactation it may be necessary, on 
Dl of the motber's health, to supplement nursing with other food, or to 



iiet of Infants an/i 



iffH 



42 

jt'ive up nursing nliogetlier. The (|iicstion of wliciher lo give uji nunin}; ■ 
not is ofti'ii ^1 ilifticult one to tleodc. If the muilier is siifi'ctin); from nny 
organii* disease, ilitre unnoi be »ny doubi a§ 10 givin)( up nursinjc lK>th for 
her own sake and that of the infjint. It inay happen tlut the bri^ati milk 
entirely goc*, ^r>A cither a wet nurse mnf^t br obuincd 01 anitici.tl food hv 
substituted; in olhcr ciiW-J^thcdeci^inniKniuch tnnre difTicull : the inbnt does 
not appear to tlirivc, and the fiiuli iiiay be in ihr- quality of ihc nimhcri milk. 

Much uieful infnniiiation may be trained by wcih'hin^ ibc inf;int eicry 
week ; a rcgjuUr x^in nf ; 10 6 ouncrt n ucrk during liie tiri-l three or four 
Jtnd 3 10 4 ouncct from ihe third to ihc «ixth month will indicate ihiit ibe 
infiutt is thriving in xpiic nfiome minor troublci it may be subject to. It 
must be remembered, however, (h.ii the infnni may put on lax without a 
corrc-ipondini; development in ihc other tiuues. One of Sidler's family 
sprinn bal:inces wilh oblong p.-in cnp-ible of weiKliint; 25 \tn. by 1 ounnc 
aniK-cr very well for the |iurp<j«e. 

Vahiable infurmaiion m.iy be obtained by an examination ol Ihe 
milk ; unfurtunaiety, no mere in^pc-ciion or niicroicopiuat examination b of 
any use : an analyxii must be m.idc by a competent dicmtti by oixlinary 
n>elhods, or approiinuitc re:iult!t may be attained b)' the roetbudi referred u> 
below. Moreover, it will be necessary to have several analjiei nude before 
coming to any deRnile conclusiim. Care thould be exerci^d tu Sice thai the 
milk taken for ^irvilyMs ii the middle portion : ibaC is, the infant should be 
put to the breast for five n>inuiC5 or more, and then J-i m. drawn fn>m ihc 
iamc breast by mcin!) of a breast pump. This "ill gt\e a bir sample of 
tlie milk. The tno most important conMituems, as Koich points out, arc the 
amount of fai an<l the amount of proieidi^ prendiL A low propuiTtiun of &t 
and a high j)Toponion of proteids indicate a bad milk. 

The following examples, tAken from Kuich. repment exainple? ti 
{I.) normal milk, (II.) poor milk. 1 III.) uver-rich milk, ;1\'.< lud milk : 



itc will 
bteuii 



Fat . 

Pruteids 
Lactose 
Ash . 

Total siilidi 
Water 





4 
1 1 

7 
ort 

8S 87 

lOO-ICO 


11. 

ISO 
1-40 
4w 

Ot99 

7-99 
9201 

100-00 



,10 
350 

7SO 
0-15 

loo-oo 



IV. 

o-So 
4 SO 
5B0 

>o-39 
89'6i 

■oo<oo 



Recently Monti hA« published ihe tcMilts of bit examination nf the milk 
of 300 women by taking ihe «pex:itic graiity, reaction, and eitimntint; the £it 
by tnejins of Manihand's l.ictobuiyrometcr,' 

r.mmcl Holt has suggested Ihe employment of a creamometer and taking 

' Arthirfilr A'ttiirluUtii'iir. Iluid ii>i. |»Ge 1. We lovr «iii|>lnyn(t<liii ApfUriitiu 
on maty ommIuim, l>otli for cow s xm\ ril>u liiuiuo milk, axvi (I)i>uic1i i-t <vmea tay N 
li Mllifaclory in etrfyreipect.yct. ircircticuiod, )i will give ilie|H;n.viiMfei>irat la.f 
birtjr contcily. 



Artificiiil FMliug—Cox^s MtVi- 



43 



spertRc gVnvii)', -.a ^iaidrs in fonnlnc'an opinion an li> lite quality nrthe 
lulk. [Fox oihtf niohiih «c Appendiv.) 



y 







ArUUclal roodlnR. 

The moist ronvcnicnt sulikiiiuic for hum.-in milk i» the tnillt of ihft' cow. 
e milk of sonn; mhcr nnim^ils, *>icli as ihc goal, bs«, marc, has been uwd 
itli more or lc3S advanURr, bill con\ milk ik likcty In rrm.iin ihc nil but 
iiversal subitiiulf. r.iut's milk has one nr two practical advanUK^t : in 
Uie lim pl^ce, the jfMt is said not to sulTcr from ttibcrculoxii, while the cow 
known to be very liable to lhi« diKea.^c ; and in the second place, for a 
lilf in ihe counti)* having their own ttratt plot, it may beoficn very c«n- 
nt to purch.iM: a milch gnai and fixlder it at linme. A milch i{oaI ii of 
;r*e mutb cheaper than a cow, and lan be kept al pracliially no fxpcn*e. 
le cbenikal diflcrence' bciwern the milk of the row anil that of the goat 
aie not i^rc- oiid ihcie ii no advanla>;r except thai atrrady nienlioncd in 
lobstitutin); {:<»('* milk for cuw'k milk. 

TIm; tnilk of ihc aix much more nearly resembles human milk ihan either 
mitk of the row or );aat. t'nfortnnaiely as«cs' milk is difficult to obtain 
t> tounliy. and it aim cottly. 

a BCUlt. — l*hf milk nf the cow has l>ccn Mudicd more cloiely than 

.ilk uf any other animal, on account of its Kreat importance to Ihc 

cooimunity as an article of conmiercc. As a food its importance !« derived 

ibe (act that it supplirs in due proportion pn^leids. carbo'hydmlcs, 

Iro-cattMiflx, uilis and n-aicr, uhite it contains no wa»Ic products, and, 

irnncT, it ii diceilcd nith comparative ease. It require^ when fresh no 

preparation to render ii fit for rontiiniption. 

Tbc richncM of milk ii influenced in various ways— the matrriali with 

ich the co«s are fed. the length of time diirinK which they have been in 

Ik. ami also by the breed. 'I'hc milk supplied at otir dcHir^, it ix needlea 

say, varies w itli the lioncity of the purveyor and thf cleanliness observed 

ill coUeetion »nd transiL 

I'e Kive here tlirce different analyses of con's milk : (I) a good avenge 

imeil according to Lwds ; (II; a pure milk according to Lsngtoi^ ; 

an a^-crage specimen as supplied by the milkmen of I'aris (Laiiglois) : 




gravity . 



I. 



1019-7 



II. 



Total mlUs 



I2'&l 



13-0 



til. 

loM 

77 



Kat 


375 


4 


334 


l.;Kliiir 


443 


S 


4^2 


I'nitrnU 


■ - 37ft 


y* 


34 


t 


■68 


■6 


■S7 



11-23 



Tliv TmM of milk consiMs princijinlly uf margnrinc and olciiic 1 it is 
pHMcnt in milk as minute jjlcbulcfi, uhich on s^iunding rise to the surface in 



^4 '^^^ Hygient ami Ditt of Infantt and ChUiiren 

ihe rorm of cream. A inicrutcopk'ul examinatiuti of a drop of niitk ditipkiy* 
iIicm: nii»ut« ^lobulci of f:it. xtid alsu uolusiric corpuscles and Eitly 
cpiihclidi cells if the imimal hn.s tcccnMy c^ilvcd. According to mc»c tbt 
tally glolKilM art.- «iir>outidciI by un iilbiiniitious envelope : oilicrt bclte\-c 
milk to be really aii emuUion. In nliich ihc fatty juinicles arc held in 
suspension by tlic jlbuinen and caseinogeii in the milk. The fat con be 
culiRcicd by shaking vilih clhcr, ftftei the addition of a drop or iwu of a 
solution (if ■:nu'>tic [loiash. If milk be lone heated at 100° C. or at a hif-her 
lemperalute. the ctnulsinn is in pari interfered with, and K'o'>ules of buileT 
oil will rife t(i the top if the milk is warmed ; ;i microsropiral examiiuiion 
of surh iiiitk will show the fatty globules have in pan niii together. 

The biotiMa is the member of ilie c.irbo-hydi'ate >,''""P present in millt, 
;ind is destined to be in part converted Into lactic acid in the acomitch, 
uliilst the test is convened mio glucose in the intestines and in ihii kUiie 
enters the blood of the ponn] \ein. 1'l)e fonncr process is tlie result of the 
action of the 'kctic add bacillus;' but ihere itrv numerous vurielics oJ 
micio-organisins which ate capable of conveiiiii]; lactose into Uciic acid, 
luetic acid appears to bcalways present in noinial digestion in the stomach, 
but in some forms of dyspepsia excessive ((uaniiiies ate formed, so tliat some 
infants who ate suffering from chronic dyspepsia have a sttiMis ' sour milk ' 
odour. I'ussibly iliis tancid smell niay be due in part to butyric acid. Lactic 
acid may be decomposed into alcohol andcarbonic acid, and aUoiiiio butyric 
acid and carbonic acid. 'Hie latter two processes probably only take place in 
abnortmil dit;e;tlon. 

The Vroteia* of niilk arc vito in n umber ^caseinogen and lacialbumea 
(Hallibiinoii). In cow's milk thefomier ispreseni in much latget quantities 
than ilie laiicr, ihc reverse holding good in voinan's and asses' milk. 
Caaeiaugcn is precipitated by acetic acid or by saiutating with a neutral salt 
such as sulphate of inagnesi.A ; lacialbunten is congulaicd un boiliD|[. 
I.acialbiimen closely tcscmbles serum albumen, but it ctiagtilnies at n sunie- 
what bi>;lier temperature, 77' C, (Halliburton), h only slowly coagulates at 
this lemperalute, and e^cn at a higher lempeiaturc some time is required to 
fully coagtilaie it. 

If rennei be added lu cow's milk the caseinogen it deooniposedintocaMin 
or curd of milk, whidi is precipitated in dense flakes, and a second proieid, 
the ' wh«7 pr»t«i« ' ithich remains in solution. The presence of lime sails 
is necessary fur iliis change lo take place (Hammarslcn). 

'Whey proteid' is dui precipitated by heat. It is probably this 'whejr 
protcid ' w hich sometimes apt>ears as small curds in the stools of newly bom 
childten and otiie's who aie being fed exclusively on vhcy. 

'I'be curd of con's tiiilk furms a <lensc heavy lunt|>y precipitate !n the 
stomach, differing \tty marltedly from the sofi tlocculeni precipitate from 
woman's tnilk. According lo Langlois ihc fcnnent in the simnach precipi- 
tates Ihe curd but does not dissolve ii. ibe curd pasting; unchanged into the 
intestines, whctc it is convened into peptone by the action of the |xiocrcatic 
juice; ihi( view, honevcr, is not universally arcepieil. Various bacteria have 
Ibc power of converting cawiin into peptone and ptomaines. 

The Salu of milk consiit of potasl^ lime, aii<l sitda in cMiibinatiun with 
pliosphotic acid and chlorine. 



Roman's Milk 



45 



We may know that the mil): iu|>|>lied In our houses is unndiilteiaic^d, 
rtinjj bc«n ntilhcr w.iicrcci nor'lel down' by nilmiviute wiih *kinimc(l 
iitV. Ihii fur ibv tsvkA part we have t(i take In jfooil fniih ihiit ihc cou'^ nic 
nhy and c;irirful]y fed, and lliat the most srrupulnus care has been 
erved with tt);atd iv de;inlincM m the milking of ihc rciws and in <he 
Bveyance and Monjjc i>f the milk. Unruriunatcly. our confidence: is itl 
. misplaced. Wc find thai in the uinicr time the cavr^ are fed nith the 
I of fiircing them to yield the greatesi quanliiy of milk, wiilioui an]* rcKartt 
I itl Huilabiliiy for the food uf infanU : tumipi and hrcwer:i graini beinif 
brti'ely instead of liay, niaiic, or other dr>' fodder. In the summer lime 
C4IW9 ^noK in tield:) which arv perhapi watered b)* town sewage, in 
liich the cows may !ie down and become befouled. The thcdt or byres 
ky be badly ventilated and much lilih may be allowed In accumulate in them, 
ihe cowi may becomu besmirched mith excrement. Small wonder i* it 
>1 the milk nupplied contains liair, fragments of excrement, biti of hay anil 
Mraw, »and and grit, and as a consequenoe of Ibese coniamlnationi, if ke|>i 
■ any trnve, iwami* with organiim*. 
(Jrot aire should be taken to select a milkman who takes a pride in the 
rin£ and clennlinc» of hii c»u% and will ukc tome trouble to deliver 
; as ((uickly as pu3!tible after milking. It i« a ^naA plan lo have a 
priraic milk can, and to get the fanner to milk hi» cow directly into this can 
■tid lo dclivei at (Mice. 

lV«aMU»'B KUk.— Tlicfollou'in^^liljure^.accordin); lo Leeds, represent Ibe 
priocipal iliffrrcnccs bi:tn«cn cow's and a-onuin's milk : 






A«uml daily mlk 


AoerusB woiooii'i milk 


Keaclion 


acid 


alkaline 


Spec i lie gravity 


10:9 


1031 


Fat 


- 37S 


4-13 


LacIosc . 


■ 4-42 


7 


Prnicidt 


- 3-76 


a 


A*h 


■68 


•3 


Baclcfia 


numerous 


absent 



Wa have laken Ihe analyiet (if I'rofesMr l.ecd« of woman's milk as beinK 
vmsc of a larnc number of •ipeciinen», but the lariaiions in different 
I ii ver\- contidcniblr. The analyses g^'vcii by ditTcrent nuihoriiics 
Jiffer lar}[cly. Ui. Luff's aniilyses of twelve wmplcs made for Ur, 
Cbcadiv show on an average a leas rich milk than ihe results of I'rofe&sor 
Lredk' analyM:s given abo>v*c— ri& bt, l'4l ; lactose, 639 : proicids, 3-3$ ; 
»h, H- 

The pnnnpal points lo l>e noted are llic followinf; : (i) The excess of 
pmuids in cow'i milk, and the exceM of curd ic.iscinojcen) over l.ictalbumeii 
tt toni|Kir«d with wiiman's milk. AccncdinK lo Hitt, the amotint of cirrd in 
cmv's milk is J per cenl. 'lactalbumen 7; pfr cenl.>, in woman* milk it is 
«nly -Aj per cent, ^tacinlbumen r; per ccm.], «» that ihe amount of curd is 
nearly five times as gr«it in llie former as in ihc latter. <::) .Smaller ((u.^nlity 
u( Lii imc in cow's milk. (3) The lat is (?^ slifihily hit;hcr in woman's milk. 
-tA-- rbe asbisgreatcr ill cDw's milk. (;) Ily the time the cow's milk rcache* 



46 The Hygii-w and Diet of Infants nnd CMMrtn 

the consumer it is sllghlly .icid and contains numerautt bacteria, while 
nxKiua'a milk i* supplied direct to the iiir»nl, iind is alluline and sterile. 

In sub'jtitiiiii)}; cow's milk for hiimnti milk, we necessarily endeavour to 
imitate the Utter as much as possible. '\'\\k greiit difficulty 10 be overcome 
is the lar^e t|winiity and solidity ai ilic curd which xs ihroun down in cow's 
milk »hen the l.iltcr comes in coni;icl uith the wnlN nf the inf;int's stom;ich. 
\Voiti.ir>'« milk lurdics in soft flakes, which hardly olTcr .wvf resistance uhen 
pressed between the finger ;ind ihuinb, while the curd of com-'s milk, es- 
pecially if the (iirdlmg has been rapid, consists of firm cheesy lumps. The 
dij^eitive juices of the infiint's stomach and iiiteslines ure unable to dissolve 
lliese lumps, and, if not vomited, ihey jwrtially decuinpose un<ler the inflaenee 
of the biicieiia ihey contain, gases and ptomaines ,ire f"rmed, and much 
discoinfurl and perhaps diarrhau or convutgions take place befure ihc de- 
coniposinii curd is passed in ihc stools. Anyone nlio h.is had an opponunity 
of carefully Hatching the eflecis of coiv'* milk ivhcn taken by ;in infant » 
(vw days old, and noted ihc elTect if the milk of a wei nurse is substituted 
for cow's milk, will see at once the difference in the quality of the stools, 
and the immediate ccsi.iiioo of the discomfort and indiscsiion whieh the 
infant is ceriain 10 have suffered when taking ihe cow's milk. The drSiculty 
with regard to the curd Ciio pardy be got over by diluting and peptonising 
or adding malt eitr.ici, but no method Iws been discovered by which cow'* 
milk can he rendered ns di)jcsiible .md nutritive us woman's milk. The 
curd thrown down from condensed milk, nr milk which has been desiccated, 
appears to digest more rtvtdity .ind with less discomfort than the curd of 
finesb con/s milk. 

Omub MUkvN.— While Ihc readiest vvay to prepare an in&nt's food 
from cow's milk is lo dilute with water and add sugar, ii is plain that the 
diluted milk "ill be deficient in fat, as compared with breasi milk. To 
make good thi<' f.it. cream niny be .-xlded. Dm here the practicxl difficuhy 
which confronts us is the uncertainly of obtaining fresh cream ofa definite 
strength. Cream which has been skimmed off milk aficr standing for 
twenty-four hours is too stale for use as inCmi's food, nod much of the 
cream sold in bottles is by no mcatts sterile and of very unccruin slreiigth. 
We believe the best way to prcjiarc .in infant's fi>od rn>in cow's milk in the 
liouiehold so as to render it ns near brcasi milk as possible is In adopt the 
following method, nhich is a modifiC'iiinn of lliat sug>;esied by MeigS'. A 
pint or a pint and a hjlf l>oitlc such ns the one in fig. 8 is lilted lo tlie upper 
mark with milk as soon ns it arrives. A plug of pure rottnn <m)nl is placed 
in ihe neck, arid the Imltic i« allowed in sinnd at the tempcratnrc of an 
ordinary silling-room for two hours. By the end of that limr a certain 
amount of cream will b.ivc rinro to the topL The lower h.itf is then syphoited 
n|T rith a K^at* syphon, and replaced with an ei^ual quantity of a sercn- 
per^Tcnt. solution of sugar of milk.' The milk in the iiottic is then sterilised 
at 160' F. for twenty minutes in Hnwksley'* or a similtrly constnictcd 
steriliser I'sec Apiiendixl. The bottle is then cooled mpidly in running 
Wkterandkcpt in as cool a place us possible. The (bod should be warmed up 



' Tbii may br made npi<ratimalrly bjr laking (w maurrtil oudms oT mUk-sngar nad 
•dilini warm mur 10 mklte nitecn ounce* in all. 



Cream Mixturt- Diluted Milk 



47 



milk to 
Ijotioiii ; 



k 




bdotc using i all 'food wurmtre ' which keep the food nvjii-m for some 
are OD no occoutii lobe uaed. It U well to use the milk within iwenty- 
irs. 
I'erlupri .1 simpler iiieihod lh;in thi- above is Iti iiUow the 
1(1 in .1 ijylimlricil tin mjlh n sm.ill stopcock fitted to the 
ic lower tuU i* dmn n off, after st.inding for Iwo 
urs, ihrnu^'h the itopcock. [f the inilk supplied to 
boutebold be u j-ood 3*«rige one, contaiiiinB, lay, 
S per cent, of fal, then the foo<l as in;itle above will be 
:nd (o contain I'A to 3 per cent of faU 5 to 6 per cent. 
sugar, and 17 "> 2 per cenL of prolcids. A twentieth 
it» volume of time w.iier may be pUired in the boiilc 

ibe infimt is fed. 
A tnofe cerum result can be obtained by the ute of 
cenirifutcal ireiiin separator. 'Phis apparatus i» now 
inch employed bj* the better class of dairymen. A cer- 
tain iiuaniity of milk ii passed through the scpamlor, 
the result bein^; cream and separated niilk, the latter con- 
tatnmi; only a very small perccnt.inc of fat. The nholc 
of the i-teatn is mixed with half the -.eiintnlcd milk, 
and an equal quantity of an & or 9 per cent, solution of %\igar of milk is 
added. 

^me ^epil^Jtots ir.io be arranjred to supply a mixture of the whole cream 

half the separated milk, and if milk and water in equal quantities is 

ippUed in the lepirator instead of pure milk the whole of Ihc cream— 

t is, neatly all the fat in the milk, leaves the sepamlor with one half 

the milk and oater, while the other half is very nearly n'ltt fat. It is 

that tJte former trill luve all the fat, half the curd, half the sugar, 

kalf <lie salts. Sugar can be added— cither milk sugar or cime 

ir. 

Both Biedeit and Kotch have alto slroni;ty recommended mixtures con- 
mint: (ream, milk. lin>e water, and su^ar. Rotrh sti^gesis [he followinif 
mre. 



— )ia— 



r>t.K 



1) ounce 


l.imc water . 


. ^ ounce 


t ounce 


Milk sugar . 


2 teaspoons 


S ouAces 







Cream is mostly digested u'ell by infants if the proportion of fat in the 
is kept below 5 per cent, and too much food is not );iven to the 
bfant. K<"h1 100 rich in &i may give rise to vomiting and dianhii:i, and 
pmdbly cailrii: caiartb. 

Blt«t*a MlUi.— I'ndoubiedly the readiest way [<i prepare an infimt's food 
It lu dilute milk Willi water and lime water, and aild sugar. That food SO 
prtpiird iii inferior to the foods in which cream forms the basis is e^'idcBt, 
}ti It i^atinnt lie denied that very many childcim are brouji'" "P "" diluted 
«ir» milk and .tppear to thrive on it. Many such children pass much curd 
alheif stools without being the wotse f«r il. Tlie poorer classes crinnot 
pt fresh cream, or indeed any cream at all, and have Irom necessity to 
pnjaim iheir infants' food from milk. As we should naturally suppose, it is 



48 The ffygie»e and Did of Infants and C/ii/drrn 

the ncB'ly bom infnntt whnnre most intolcMni of cxiVs milk, Jind i;reiii uie 
is required in adapting ihc Micngth nt the milk to the infant i condition. It 
is necfiwry al first to dilute row's milk with t<ro-ihird« hit};.ir waicr,' one- 
(wciiiieili pnti conM^lintr of nddftd lime wntcr, so as to secure ih»l lite food 
should be faintly alLilinc. \Vc should, however, much prefer to give a newly 
liorn ljal>y whey and cream or dittited pepioniied milk if it is necessity to 
feed it aitilicially. 

After the first three or four weeks, if the infcini'* diRC^tion .-ip|:>c:irs good, 
half milk and half suRat wmer' may be ijiven, (onetweniicih pan being 
lime waicrV From three months of n^ to six month*, one-third part of 
lugnr water ihould be nddi-d. 

Sarl«7 WaUr, Oatmeal vrat«r, *«.— For many j-ciii'i pail it lus be«n 
ihe piarlite lo iiip tcrtain ihiii j;eUliiious Ruidi. sudi Si kirley water, oat- 
meal water, arrowrool water, or tluidi containing maliiwc ami dextrin, to 
dilute milk wiih for infant feeding- All these (luids, txi^cpt perha|H the Uu 
named, contain xmnll quantities of starch. Now it U certain tlul the powers 
of ynuntc infantt far con^-crtint; sianih into sut;ar ore feeble, and if tbe«e 
fluids are used cnrc should be taken in tlicir preparation to avoid any <{uan- 
lity of starch beiiiit preicni. The saliva of infants three or four months old 
has undoubted pnwcrsofsiiitchlninsfurinaiion, andappaicntl) the pancreatic 
and intestinal juices have also, so that by the time tbi* ;i(;e is readied we 
have DflthinK lo fear from thin starchy duids. It has been claimed for these 
gelatinous fluids that when used to dilute milk they play a useful pari in 
prevmiinK the curd fnmi runnmg together into tumps during the lime that 
foajfulation is taking place. It is certainly dillicuU lo demoniitrate this in a 
test lulie, but it is probable that any colloidal or t;e!alinous fluid interferes 
with the rapid dilTuKiun of the acid and curdling ferment lliruugh the fluid, 
and eoiiiequently the curdling ulces place «l<iwly,and ihere is in consvqueiKe 
less tendency to the formation of lum|>s of curd. .Neither »iarch nor mallOM 
is present in the imiur.il fond of inf.uits, yet experience leaches tlut the 
addition aia thin malted food or barIc)' or oatmeal water has a considerable 
nutritive value, and we entertain no doubt on this point. For Infants below 
six mouths of age, we dilute milk more or lest in order to reduce the ami 
of curd present ; in doing so we rcndrr the food poorer in hydroc.irboits 
mother's milk. This diluted milk is rendered more nutritive by the addition 
of malted starch, and this is, in some instances al least, more rvaddy assimi- 
lated than milk diluted with water only. 

VImt-— Whey is a useful substitute for molhai's milk In those cases 
where for a few hours or for a day or two milk fails to appear m ibc bieasts. 
Unboiled whey contains fat, lactalbiimin, ' whey proteid,' Liciose, and sotne 
of the salts of milk. Where a wealc food is required whey often answers 
admirably, when made inrnx/reiA milk. Some sugar of milk may be isdded. 
Care should be taken in preparing tile whey to use rennet or an artificial 
ctirdliii); lluid free from ^n excess of salt, as biinc is often used tu prepua 
the atiiiicial rennet. 

V«»l«aU*a iKiik.— 1'he ptedigcstion of the curd, or rather ilte casein- 
Ogcn of cow's milk, is undoubtedly a useful resort in the aitilMial It'cdinK of 
infants. It can be easily dcmonslrsicd that milk piartially pe|itonised less 
■ 5 p*> CCBL MhilMi of intia tuipir. ' 7 pc* <enl- suluiwo i4 tiillk tugai. 



PiptoHtit-.i Milk ^SlfrilisatioH 4*) 

XAf ctiHIrs on (he uddition of rennet m acid, and (hut the aird thrown 
rn is softer iliaii llui thrown down from fresh row's milk. CHitic^l 
cc also tcsiiAes to its value, eipedally in infants with irritable 
I or (,Msrrtc cntanh. Smnt in&init will, hiiwcvcr, continue 10 pa&s 
I in tl>cir !i(oo!t> while taking pi^plonistd milk prit)>cfly jwcjNired, nnd at 
Tft il ik|>|>eani to disacicc, Cspeciail)- when c.irekiily prepared. Infanlit will 
I often uppear to thrive on it for awhile imd became well noudihed, but 
' eontimiei to be the Mile food for many months together, ihcy arc apt to 
ne anA-miq and suffer from various h;f inorrh;iye». (See Stun'y-rickei*.) 
fireat care should be bestoivcd on its prepartlioo, so thai [lie diffcsiing 
proccKS may be carried far cnouijh, hut n»t luo far. In the latter can: a 
bitter ta.ite become* well marked, which is with difficulty covered. 

The bcfl way 10 prepare this form of food i» to utilise the cre-im mixture 
■Iready tcfcrrcd lo,.-in(laUci the stenhMng apparatus. A reliable peplonising 
nndf^r cnntaininj; ptintreaiiiii- and soda may he added 10 the mixture when 
iiircly wartn(i 10' K.),andlhe leinptnitui-e raised during llie nexl ten mmules 
qaaner of an hour to i6o' F., when ibe proceis is complete. Or the 
Icmpcralute may Iw tarried lo the boitin^; point. 

I'eptoniscd milk fwjd may l>c ptepaietl frmn one of the well-known foods 
^pKptired by Bcnt;er & Co. or tither relinUc Arms. 

MortllHittoa.— Where milk c^n he nbinincd Absolutely frcth and uncon- 
I'UiniiMtcd from tmdoubieclly hcilihy rows, and \i conisumed al once, slcri- 
liiig processes are of cnurw iiTinecc«sar>'. but only inf^inls rci^idrni in the 
counir}-, where cows arc kepi on the premises, CJin ha>'c these advantages. 
r tow's milk, as it is received liy householders in towns, i* usually many hours 
nU befiifc il \s received, and il may be kept, or at least some portions of 
■ it, for twenty'foiir hours longer before the infant lakes il. During this time 
[ihr Uicieria which it bas received by means of various contaminations 
^■nuhtplv enoimousty, especially in hot weather. Mtlk which is acid nnd 
^jnst Ml (lie mm' is, il is needless to say, <|ut<c unfit for Infant^ food. Many of 
' bacicfia foiiixl in sialc milk are probably hArmtcss, or at any mic not 
sively mHChicvous ; oibers which may he present, espedally the 'peptonis- 
; btuiteria,' are unquestionably delcierious, inasmuch as they form during 
eir |[r<twth varioui^ animal poisnn.s of the ptomaine type, which ((ivc rise 
' «hcn takrn to acute diarrhR:a or k'ailrii-cnii'rilij. 

\'Brii>u« paihi>};cntc bacteria may lie present in milk,citber derived from a 
row, or frnm lewa^ie or other contamination emcrinu the milk. 
. :)aeiili may be dcrivcil fr*ini cows sufftrmi; from tuberculosis of the 
-ki, -mi ibcre can be no doubt that liiphihena, st-jrlct fever, typhoid fever, 
I ftHit and mmth disease may be spread ihini;;li contaminated milk. Fortu- 
jrall thcic bacieriaare deslru)-ed .11 a temperature of lioiliny water; indeed, 
I ik jjiKid evidence [hat ihcj' cannot wiilisiand a tempera lure of 70' C. if 
sued for half an hour. Of the taprapbylic Mcteria there are many 
'iv%. There arc the lactic aciti yroup, and with these are the Inityric 
cid producers. Others, which .ite much more impori.int, arnhose which do 
act (Ml tlie lactose, but if present in sufllcieni number* pepionisc the 
trldi, fonnlng |>cpli>nes and albumoses. Milk containioK the Utter if it 
at all «ul« fe-iveii to mice of ^in«a pigs produces diarrheea, wliiit pur* 
ullxiTcs quirklv produce diarrbcca and d«ath. 



I 



so The Hygiene and Diet of Infants and Chtldren ~ 

SleritisiriK' for lioiischoM piirpasos ri^sts on a iomewh.it dilTcrcnl fooling 
iban slcrili^ing in large cst.ibtishmcnti uhiTc Ibc milt: hm lo keep fur miiny 
months. The milk sicrilikcd in the household li^i-. only lobe kept \w iweniy- 
four hours or thereabout*, and therefore so hi^h or continuouii a teinperjiucu 
is ni>i ic(|uiTcd. The succcxt of the itenliiiiis proccM latKcly deptntls ii|ion 
gelling the milk fresh and cleun, and conseiiueoily containing few bacteri* 
and no iporni. It it impoMtbIc in a household to stctiliM stale millc. 
Stale milk it certain to contain many iporcf, and the «porca of some of the 
saprophytic bacteria such us those which attack casein require a lempera- 
ture of ioo-io5°C. or more to destroy them. If the milk can be ptnrured 
fresh and clean and is inletidcd to be consumed within a day or two. a tempera- 
lure of 7o''o(7j"C. is quite highciiou(;h toc^jKise the milk Iol This tempera- 
lure does not affect the lasic or ciDiajjuLitc the la<ulbunien. If milk has 
to be kept a longer time or is not very fresh, it is better to expose it to a 
teinpeiaiUTi- of lOo'C. fur half .in hour. Milk which is long bcaicd at loo" C. 
01 especially a higher temperature suDbrs certain changes, the chief of 
which IS connected with the co.igulaiion of ihc albumen aad tlic partial 
dcstnictiuii uf [he fat cinuUion. In such milks some of the fat floats in ihc 
font! of large globules of butter on the top of the milk when it is wamMMl. A 
brown colour isdct'eluiied on .iccoimt of the pnrtial destruction of the lactose 
Milk loni; heated suffers coagul.ttion less perfectly than taw milk : this is 
due to the precipitation of some of the calcium satis. There can be no 
doubt that the formation of the butter oil Is a disadvantage ; how fur the leu 
perfect coagulation of the curd is an advantaj^e it is iiniKis^iblc in say. 

\''arious forms of apparatus have licen devised for itciilisation in ibe 
household, Ihc best known being on the Soxhiet type. This foim can be 
used for nealing to loo* C. or to the lower temperature of 70* C- 
Hawkslcy ha« also devised a steriliser with a ihermometcr, which is con- 
venient and reliable. (Sec Appendix.) 

CaadeBied Milk. '—Con denied milk hat long been a favourite siibstilule 
for mother's milk among the lower classes, and its use is by no means cnn- 
lined to the lower orders, though It hat had but few defenders among 
medical men. The fact that ^omc brands contain a large proportion of addcil 
cane sugar has condemned it in the eyes of Tnn»t medical n nlcrt, and many 
serious allcgalions have been made against it. It has been accused of pro- 
ducing ectcma, diarrhoea, constipation, rickets, s^Ilrv^'. and it has been 
alleged that while children who hare been brought up on it are fat and 
plump, they readily succumb when attacked nith acute disease. That it is 
a favourite food among the lower classes there can l>e no doubt ; it is con- 
venient, it doet not readily turn Kiur, and it may often be substituted for 
fresh cow's milk, when the latter ciuses vomiting, with good effect. The 
reaion of it* being useful in gastric citarrh, not being vomited when cow's 
milk and a*.iter have been, is j)rob;ibly thai the condensed milk, as generally 
mixed, contains less curd than the mixture of fresh cow'» milk previously 
used ; it seems certain also that the casein of condensed milk is more slowty 
thrown donn than the casein of fresh milk. 

Moreo^Tr, it is sterile, and the but brands have been prepared from fresh 
rich milk. We lielicve that while it may often l>c substituted for fitcsh cow's 
milk with niK'.intage, we should deprecate its use for many months together, 
if given as the sole food. 



Condtnseii Milk^Drieii Milk Foods 



In u«ing condensed millc accurate dircciiani must be given as to (tie 

I simigth to be eniplojxd nnd also as to tlic manner of meaviring It A 

I jiradUAlccI measure should be employed and the mitk poured into it, For an 

in£iDloflhrcciiionihs old il may be diluted i in 3 by ncighl, omhat is nearly 

e<|uiviiknl to this, r in lo by meanirfc It should rarely be used stronger 

than ibia, but it may be nccesary to dilute to i In t; or 30 for very youni; 

, infiinls, or in special cases. 

Diluted to ( in 8 by nei^ht, we shall have the following composition 
l(Ucd»): 

Ceadciusd milk 

I-'ai .... ij-io 

Lactose . lfr6l 

Cane ^lUKar 3l'l6 

Proteidi . 1607 

Aiih .... a-f)! 




Uilulnl I In tby wnghi. 

i-Si 
a-o6 
J78 
i-oi 
•31 



Total solids 



. 69^ 



S-68 



V 



II » imporunt only to u«e a good brand of condensed initk, maimuch a* 
the cbeaiwr fcirms are deficiem in £u. Tite 'Milkmaid' brand contains 
nearly 12 per cent, of Tat, while vome other brands have less than 1 percent. 

Some s-xiA brands of condensed milk may be obtained olthoui added 
lugar. 'n>e foltouin^- i» an analysis of the ■ Viking ' brand ; it will be seen 
ikai It cof responds with a ^oud milk which has been concentrated by driving 
olTlwo-tliirds of llie water. A measuied ounce of this milk weighs 4S0 gre., 
that IS one-ienili more than an ounce of water. It can be diluted fur use 1 In 
4 or 6 b>' ineasurc. 






Uniw*>itnH< 


niiuiiri 




c«ndct»ni milk 


1 Ld a !.>' «*itlii 


Fac . 


. 9*9 


f6i 


Lactose 


• '33 


3'2 


Protetds 


. . S-9 


'■5 


A>h . 


i'9 


■6 



Solids 



34-0 



5S' 



It will be seen by examining the second columns Ihat each of these foods 
■I drtieicni in fat, while the latter it deficient in carbo'hydratcs, but this can 
he ismvdicd by addinj; sugar. It is well to bear in mind thai in all conccn- 
tnied or deticcatcd milks the calcic phosphates arc thrown dniitn in a mote 
ottcH insoluble form, and in preparing the food in the ordinary way are 
mly in piirl redi»nlved. 

SrIMI Milk r»aaa.— The diffiruttics attendant on the prepamlion and 
ttaniKc of ilctilLjcd milk for sale have brouj^ht inlii the market varioun 
prvparallon* od* desiccated milk. These will keep %,naA in any climate, and 
■ccafiy only a small bulk as comi>atc<l with Ii(|uid preparations. They are 
yntiucstionatdy convenient, arc sterile, and their protcids ate more readily 
itiblr than the jwoteids of much that pa^ei as fresh milk. Messrs. 
& llanbury prepare two forms of <lc*iccjted milk fin)d. In these 
pr«|Mrat*o«u the percentage of the prnteids (both curd ^nd albumen), alio 
tat and jugar, is the same as in human milk. In No. afooda^muUtiuantity 
extiact la added. The following analysis is from the * Lancet' : 

Ha 



52 Thf Hygiene and Diet of Ittfants and Childrtn 



Fat ... . u-ii 

LaclOH nnd dcxliin 6;'48 

i'lDieidt . I4-3S 

Salu . . . . 47i 



IiHmmI t If! ( ky atichl 

1-64 
8-19 
178 



Iq using this food accurate directions should bt given for il* ptcpanuion. 
The useful tablespoon should not be u^ed jih .i ini^uturc. but a iA7graduiUed_ 
measure glass. Six mcnsurcd drachms (120 grs. 1 uf No. 1 food weigh hab 
•in ounce, u'at«r is lo be addtrd 10 make up 4 01. in all. 

Tbe composition of No. 2 food is ver>' similar. Nol i is tnost suilabk 
for the first thicc monllis of life, and No. a for the next tliiec mtmihs. No. 3 
food, which consists of a malted starch food and which rcituires mixing with 
fresh milk, is best suited for childien over six months v4'age. 

Oiii own cxixttcnce of these desiccated milk foods is decidedly favourable, 
and they are as a rule much more readily a ssi mi In led than diluted fresh iiiilk,.| 
and in some instances ansuer belter th.in peptonised milk. The]' are certainly 
worthy of a trial in those casc4 where iin itifatii is vomiting or lias curdy iitoots 
while taking diluted fresh milk, at least as a lerii|)orar>' rcsorL 

jLvoBDt «rraod ta b« K<*ea-— The amount of food 10 be given to an 
infant must necessarily depend nol only nn its age, but also on its digestive 
powers and its development. It is evident that it is quite as imporiani 10 
carefully regulate the times of laking food and the amount to be taken, its it 
is to decide upon the nature of I he food. It must ol course be borne in 
niind that the amounts git^n below are for an infant of average weight and 
digestive powers. Neither age nor weight should be taken blindly as a guide 
10 the amount of food an infant should lake. For (be first two or three 
weeks [weight 6 to S lb,;, give 1 10 3 ounces of foo<l every two hours and a 
half in the daytime; 8 boiiles being given, and la to i jounces of food being 
taken in ihc twcnly-fout hours. 

During the second monih (weight 8 to 1 1 tb.), 3 to 4 ounces of food e\'ery 
two hours BJid a half; 8 bottles being tfivcn, and 2D to 30 mmccs being taken 
io the twenty-four hours. 

During the third and fourth moniht (u-cight 1 1 to 14 lb.), 4 Io j ounces 
of food every three bours ; 7 bottles being giwn, and 30 to 3} ounces being 
taken in the twcniy-four hours. 

During the I'lfth and sixth months (weight 14 to t6 lb.>, 6 to 7 ounces of 
food [»ay be given every three hours ; A boitlet being gi^'c". i^nd 3; 10 40 
ounces being taken in the iwenly-fnur hours. 

r*tdlB« SoiilM.— The simplest feeding bottle* are the best, It is wise 
to avoid all those provided with india-rubber tubes, rorks and ihoteiliatha^-e 
indented Icllcra on llicir surfaces. The rubber tube* soon crack and become 
rough inside, cork* absorb some of ihc food and quickly liernmc foul, while 
any indentations on ibc inner surface oJlhe boiilc make it diflicuh 10 scour 
clean with a brush. The l>csl class of bottles nic lho»e with rather wide 
mouths 'see fig, 9) or such as arc supplied with Soxhkt's or Eschcrich's milk 
strriliseit, and arc perfectly plain and fined w iih large teats that can be turned 
in^iidc out for the purpose <rf cleansing, The *m.ill leati supplied with the 
fancy bolllet cannot be re.idily cleaned. The hoiile* aflcr Iwing usc<l should 
be thoroughly cleaned with a brush kept for the purpose, and inverted so that 



Artificial fetiiiHg — Diet from d to \z Months 55 

ihry maydrain and no ijiHimay bcallou'cd togct tnioihem. lEit tmporiant 
that ibe food should not b« ^ivcn 100 hot ; a tempera- 
lure 0^98* F. isi|ui(v warm enough. 

met itwBi * ta 12 BSonttaB.— White loiYic mothers 
arc eiroiij,' tni-uyli, .iin! -ire suilicicnily j;oo(l i)iiisc!slo 
iucklc their children 10 ilie end of the lirsi v-enr, there 
KK many utiveri who be^'in to tlii^' about ihc 6lh or 
7th inonib, artd in such cases il is desirable to supple- 
ment the breaM bj- meians of wime milk foiKl. Ilierc 
is no lack of aniliciat or paicni foods from uhich to 
choose. If the infant is emirely dependent upon arti- 
6cial food, it »lniul<l i:ilce from I J 10 3 pints of good 
to*'* niilk e>«r)' twenty-four houri, between 6 months 
and I year. Whether thii should be given undiluted 
must <le)iend upon the digeilit e powers of the infant, 
which may be h'^u^ed by Its pi>wer of di|;estinc casein 
as determined by -in inspection of its stools and b>- 
iu Browth and wtight. Some form of starchy food 
may be added uitli advantage, (<>r now the digestive 
poven of the infant are sufficiently advanced to form 
dextrine and maltose out of >i.irch, thus foiining a 
valuaMc and easily nisiniilaied carbo-hydrate. Care 
ransi be taken that all Marcjiy mailers are thoroughly 
Mled, so that the starch granules become gelalintsed, 
a* raw starch is less easily digested. 

Barley jelly, whole mc.1l flour, maire, ontmeal, all 
answer very well if thoroughly cooked and made sufficiently thill to pass 
through the tube of nrdinnr^- feeding bottles. 

If the digestion of starch is not prncecdinji; vicll or if curd is being passed 
in the stools, malt extmct i>r ' liynin ' may be added to the food after it ha» 
bc«n boikd, and nllouec) to become jtist cool enough to taste ; it is then set 
aside A>r a few minutes before giving it. Five meals in the twenty-four hours 
•ill, as a rule, he sufficient, some 6 to 8 di. being taken at each meal. The 
Jirtt meal may be taken between 7 and fi a.m. ; the irtonJ, between 10 and 
I r a.M. : the Ih'rtf. t to : p.m. ; (he fourth, from 4 to ; r.M. : and the ^fth, 
the Ia.-it 0)ing at nigbt. There is no harm in giving the in&nt a well-ionslcd 
crust to nibble, but thick foods shoukl not be allowed, and beef tea or eggs 
ore certainly unnecessar)'. .nnd best avoided. 

During the 7tb, 81I1, anil i;th months, j^ ot. to 3 ol wtll be an average 
weekly gain, and by the end of the ^ih month 30 lb. weight maybe reached. 
Dirrin^ the last three months ; 01. to t ^ ox. per week ; and the weight is 
mitaPy over 33 lb. by the end <if the tirst year. 

Il miHl not, howeser, be forgotten iliAi Infants may put on lat wbldl 
natanDy adds to their weight without iheir being ncccswtrily strong and 
hcftlthy. C.-ire must be taken to weigh them at the tame time of day, so tliat 
ibcre may be i>o mistake. 

At twelve months of age, if the child be strong and healthy, tlw bottle 
may l>e gTadu.-illy left off, and food of a more solid character may be substU 
ttitcd, but milk Is still to be the staple fond. 




Ki(, 9. 





54 y^' Hygient ami Did cf Infants ami CfiiMrtn 



I 



Diet tr«in TvotTe BtMitlu t» BiKtiteaB M«iitlt« of A^. 

firsl Hteai,7.y> a.m. Vmt brcjil 5(j|>s with milk. i>( vauncul or bominy 

porridge made with niilk. 
Ste^iJ meni, ii a.m. A drink of milk. 
Third rnfui, 1.30 \'.\\. Bread crumbs and (.Tavy or a lightl)' boiled egg awl 

bread and butter. Sngo or rice puddini;. 
Ftmrlh meal, 5.30 VM. Breiid and milk. 
Fi/lh tiual. Milk 10 diink. 

After eighteen monihs of age, when healthy children have cut (heir first 
sel of di>ub1c tecih, iinall quuDiitin of fish, foui. or meat nwy be allowed. Of 
Hfh, boiled whiiin};. «olc, or cod, carefully ficed from all the bones is rewbly 
taken by most diildrcn. Hoilcd fowl is bciier thjin butcher's meat in early 
childhood, nf the l.tttcr, imdcidoi>c mutton chop&. lorr) into shreds »nd 
mixed wilh bicad crumbs or well-n)dshcd poiatoc^, fonn the liesi and ntou 
diiceMible kind of butcher's mcni. Kicc.sngo, and iapioc;i puddings, stewed 
apjilcx, and presmes of \'arious fruil*, may he allowed. 

Children iinfonunalely arc often ^irnngdy fastidious in iheir tastes, and 
will frc(|ucTitly lakr a dislike to many forms of ihe most digestible foods. It 
it aluays well Ig introduce as much variety .is pnssilile into their diet. For 
older children hominy porridge wilh treacle for hrc.ikf.ist, to be followed by 
small tjuaniiticf of bacon or egg' *''<li cocon or uc.-ik lea, ;ire a> a rule well 
<tigested and arc bcncfieial, proiided that the pnrridgc or bread and milk 
form!! (he /tAr dt r/iitlame of the repast. Soups made in variout ways , 
from meat and ve|[c(ablex form an exceedingly w-holoomc and digestible S 
meal. Pa.itry, as a mie, is bad ; boiled rice with raiuns and ticwcd fruit of ■ 
vutiuus kinds arc much 10 he (xcfcrred. 

When the child is old enough to sit up to table at dinner and take meat 
cu( from u joint, the greateu care should be taken (o sec thai the meat i» 
carefully i^ul up into small pieces befote being put into the mouth, and is 
llioniughly maslicaled before swallnu-iog. Sd iinportani Is this, that if thcTC i* 
any doubt as lo ihe culling up by the nui^. it will be well to insist that nil 
the meal should limi be put through a mincing machine : the gtavy can 
be ;iflerwatds added 10 it. M.isscs of hatf-maslicatcd meat will not b« 
tllgcitcd if hnlied in the usual way, and nill be passed almost unchanged in 
(he f.i^es ; and if the food \\ thus boiled, it is less saiisfyini;. and leads to 
lOMfc than is rc<iiiired by the system being consumed. A stan<l must always 
be made nfaind the common practice of giving children biscuits or ginger- 
bi'c.idal almost all hours of the day. The slomach requires resl hke every 
oihcr organ in the Ixidy, and is certain to become denmged if i««ci things 
are being taken ai all timet. 



5S 



^ 



CHAPTER IV 

UISt-VSES OF THE DIGESTIVE SYSTEM 

a(amta»il«B of Ilia Koutb. — An Inspection of llie cavily oi the mouth 
anil f&uccs in infants And children is of >.'rc»t inigwrtancc, and mistakes in 
(Isi^fiKKis arc exceedingly likely to l>c made if it j» iie^lecicd. In newly born 
inbnis ili« mucous nicinbraiic nf the itioiitb is eoniparutivcly dry, and con- 
tiiia» iu for ihc tirsi two or three montlis of life : ilie secreiion of saliva 
txMimet gniiliMlly frcci as the >;Iniids develop, anij the inli\tii begins to 
<lnbtil«, fk>T it is some time before it Imins to smaIIow its salivu uiid xrt keep 
in (Douih »hut. I'he linini,' of the infatii's motith is :it first of a dull red 
cnknir, and llocculi oJ milk ^re nficii to be seen atiherin^ to it, a^ ilie mofc- 
iMBt» of the lonjiiue anii lipi ate imperfect, and there is but little secreiioo 
ef Aiiid 10 iikaii^e ilic mucous membrane. All through infancy imd early 
fkiUbood ili« miicius membrane is cxcee<lin>,'ly :ipt tu become the seat of 
v4flMsksMfis. Theiiicmbtane IS necessarilyddicate, the epithelium i» easily 
iajuted, and affords a favourable ground Fur the cultivation of cryptoj-amlc 
)!i«irtba and various inicro*or>,Mni sms ; hence the frequency with which we 
fimt parAsittc stomatitis and various superiicial ulcerations iind aphthous 
puclies. 

Inspection of the moiuh of the newly born may reveal various abnorrna- 
fiticv wnnc of minor imporiaticc, such as the small millei-Med nodules 
titokied in the middle of the ronf of (he mouth, a shortened ftarnuni lin^ux, 
M the prrscncc of small rl4-jrswel1injis(r^iii]ta; hcnc-ath the tongue. Atiion^ 
ihranp<iii,im abnormalities maybe mcaiioncd cleft palate, or an abnormally 
bigh arched moL 

All through rarly life there is A tendency to hypenraphy of the I)'mphaiic 
■ttssuvt in ibe naso-ph^trynx and faucc5. It must l>c borne in mind that the 
IMSsage ihrovgh the luso-pliaryax in infants is exceedingly narrow, and (he 
prrsence o4 adenoid cxcTc«cciKc« or cnUrgcd phniyngcal tonsil, which may 
perlufis be congenital, may Mriously interfere with the infant's rcspim- 
■KNi. jiMJ ID wwnc initances seems to excite ' choking iils' or spasm of the 

loll:v 

VcDtliioB.— The intltiencc of dcniiiion upon Ihc hcalih of ihe infant dc- 

itls vrry much upon the child's conniituiion. A strong and ligoroui in&nt 

hieh has been broiighi up at ilic breast will cut its teelh one after another 

il«)Ut trouble, and but for the appe.iinnce nf the tcctli through the ^axt\\ 

ir fncnds will not be aware that dentition is in progress. On ihc other 

il. if thf iiif.inl is rirkcly, weakly, or the victim of hercdiiaiy tendencies, 

nMl of dentition will be a period of <Li>nKer, and the inilalion caused 






b}' the prenurv or the tooih expanding its socket and culling itiioiiyh Uie 
gum is veiy li^ibla lo ^ive rise to various forms of disease, \\x prrccst of 
dratition acting' rather as th« exciting Ihan Ihc predisposing cniise. The 
6rst dentition begins duiiiig the middle of llie Ticst year, and ends Ukujkll)' I>y 
the appeniiince of the poetetior moUrs in the middle »i the ihird year. In 
some, without any known cause, the first teeth make their .-ippcainncc before 
this titiiu ; indceiJ, it is not inf(C(|uem for infants to l>e horn with a looib 
already cut : such teeth, howeiei, are im|>erfectly developed, and contiit 
merely of a thin shell of enninel. Some tiy no means slion^ children cut 
their teeth e.irly. In rickets dentition is delayed : in those c;iscs in whicb 
rickets niakeri its appearance piior lo the sixth nionlh. dentition may not 
commence during the litst je.ir. the infant being toothless at n year old. In 
other cases the infant only becomes rickety loHards the end i>f the fir« 
year, when the incisors ate perhaps through the gum, and then ihrrc follows 
a long dday. 

By Ihc fifth or sinth month saliva is formed in large ciganttlies to that it 
is ftequcntl)' dribbling from ihc mouth, and the infant is constantly puttiitg 
its finger into its innuih, .is if there were «amc sort nf irritntlan going on 
there. .Moreover, white up l'> this period il has taken its food nell and slept 
ihfi whole night without disturbing its mother, it now becomes restless, wakes 
crying, suiTcrs from dyipepiin and tlaiulencc, and is at times fe^-erisb. The 
gums may become tender, the whole murou.t membrane congested, aphlbie 
appear on the tongue, inside the lips, cir on ilie hard pakte, and the inlant is 
feverish and cross li> a <legree. I'erhaps now the edge of a tooth, usually 
one iif the lower middle incisors, will be fell through the gum. Some days 
or even weeks will perhap* elapse before the edge of ihe liioih is aciually 
cut. It is s singular but by no means unusual circumstance for a tooth to 
atlvance so as almost to stretch the mucous membrane of llie mouth, and 
then become stationary for some time. 

Now while it is the almost daily experience of the praciitioncr that 
the process of cutting ihe lirst teeth gives riic lu various troubles, he 
knows also that mothers und nurses are ever ready to atltihute every 
childish illness to the teeth. Many infantile aiUiienls are mysterious in their 
oiigiia, csijcciaily attacks -if fcvciiihne», and in children under two years old 
there is always a luoih ne:irly cut. or ha^ juil been cut. or is about to b* 
rut. to supply the explanation. It is thii popular tendency to attribute 
every childish ailment to the teclh. which cj^plaim the ready sale of 
- teething pou'ders.' The danger is that important errors in diet, a patdk 
of pneumonia, or a meningitis may be overlooked if tlie teeth are allowed to 
explain everything. While it is unwise to sliut our eyes to the disturbance 
and discomfort produced by a stretched and swollen gum. care is needed to 
avod using the explanation of Mootb cutting' to cover ignorance or merely 
to satisfy the clamour of an anxions mother for a definite opinion as regards 
her child'i illness. It is a gixid rule always to leek fur an explanation 
elsewhere than in the tceib. if there is m> local lesion in the gum, such as 
swelling, tenderness, or some ex'idence of inflammation. 

l-'ei>m'iiiiusi.—W)\i:n the gum is swollen and tender prior to tlie cutting 
of a loolh, the infant is apt to be irritable, having fil* of crj-ing without any 
apparent cause, which nothing will pacify ; at first gently nibbing the gum. 



^ Denttttm %f 

^HI^P^nAtc, I>ul at a later »lngc thi« only aggr^iait^ i)i« iroubte from the 
Bcuid) iKtinful $t:iic of the tiutn. The (ever is intercnittcrit, ihe child being 
not and fc^'crUh for llie m«fti pan m night and unable to sleep, while towards 
morain); ii tools dnnn an<l doic* for a few liaurit ; the leinperatuic may 
nacb 102" oi 103', rarely more. Such aitack* may oftco pass awiiy wiihout 
the looch bcinii cut. or may continue for some lime .iftcr the eil^e of iho 
lodth hax appeared, and before the rctt of the tooth h^ii made its way 
ihnMgh. 

Slomatifis. — The mucous membrane of the mmith, more especially that 
pan of the num «hcrc ihc tooth is about lo iippcar, Ihe tongiic, hard palate, 
ud iniidc of the cheeks m,-iy be the >c:il iif ^iiull Mipcrticiat ulccn or Kinall 
)9i>C3 denuded «( cpitbclium, their Hirfnce btin^ of .1 )(rcy or ycUon ihI) 
alow, and their cd^c-s mrroimdcd by a iime of crythcmatout redness. 
ThcM spoil arc evKlcntly sore, and may be ihc cause of the infant refusing 
ibe breast, and crying wiienever liquids containing saline*, such as beef lea, 
tie taken. 

Eaiargsd (^Arjxt'.c.— Occa-sionally it h.-ippens in children predisposed to 
glmdutat enlargement that the irrilalion caused by these nphlhnus palrhcs 
rvn riic to a swelling of the glandi^ either the submaxillary when ihe lower 
jtvilaffcctcd, or the parolidor upper rcrvic.-il lymph.it ic gl-rnds, which receive 
te lyiDph from the upp<:r \i.tr. 'fheic sncllingi in.iy quickly subside, or 
CMlio either acute or chronic suppuration. In the latter case successive 
Uttk being cut keep up tbe source of irriUition. 

tXturhaa.- - During Ibe hot mnnthi of late summer and autumn, the 
ifnuiioii of Icclbing m.iy lie the exciling cause of inteMinat catarrh and 
AtrrhiiA. In infants a transference of a levion from one part of the body. 
a«t especially from one mucous membrane lo another, is c:(Ceedingly 
Ol^i»n ; ihit diarThir.'i is especially common in anitirially fed infants No 
danlkca should be attributed lo tooth cutting, unlets there is some local 
kuou IN the giuus or inouih. 

AwtcAZ/u.—OurinK dentition, especially when lhcinci«ors are being cut» 
obat* seem v-cry prone tn catarrh of the bronchial tubes, which may be 
CMBpticaicd by catarrhal pneumonia. 

Xfuma am/ /jVA/-«.— It constanily happens that infants nho suffer, or 
i» itbk lo suffer, from cciema arc much uorsc while a looih is pressing 
ttriMitb the gum. The cricma very frequently gets well in the intcnals, 
cW face and body being free, until a looth comes near the surface, and there 
II a return of llte eciema, ibc face and forehead llush up and papules appear 
•Inch licgm m oo»e and crust. I.icben in the form of strophulus or urticaria 
u alto common. 

C^m-ii/ii''Hf. — l\ may be taken for granted that no healthy infants sulTer 

Iroat cucivuKions ; those who do are either rickety or the children of neurotic 

(uimts, an<l inherit a tendency to ncr^e disturbance. Spasmodic affeciions 

of variijus Kroupi* of muscles occasionally take place. 

K Trtulmtnt. — Much ronlrnvcrsy has arisen from time 10 time with regard 

B tbe nsc of the );um lancet, and the propriety of employing it in assisting 

Btniition, many praciitioncrs being in the frequent habit of using it, while 

Bllwn bavc nol employed it for years. If the mucnus membrane over the 

looth i» red. swollen, and lender, and tbe edge of the tooth can be felt, much. 



58 



Disfosa of tht Digeslhv SyiUm 



pain and ilitconifmi will be spared the infant by its use, pruuinint;, of 
coune, il i* not a * blcedw,' nor comes of a family in whicli Ibcrena histoo' 
of h;ieinophi1ia. The iclief aflTordud is due in all probability to th« tool 
1o99 of blood, a.% well as lo the relief of tension in the gum. That ii has been 
done often unnecessarily, and thai many troubles are aiiribuieil to dentition 
that have no connection uitli it. it no argument :i};ainsi the use of the Uncct 
in proper cases. Tlie c^■idencc is too strong to be lightly explained away, 
that fits of cryinj;. fet-eiislmess, or even convulsions may be quickly reheved 
by freely Unctit]; n swollen and tender gum. li, pechups, need not be saiil 
titnt it is uselesa to lance the gum unless there i^ evidence that the cutting 
edge of tlie tooth is near the surface, or disappointment will cciiainly follow. 
In one case coming under out notice, in which an upper incisor uas lanced In 
a rickety child, ihe lootb vms not cut till exactly a year after the operation. 
The (everisliness and tenderness in the mouth and sleeplessness may be 
generally relieved by mereurial purges, bminidei, or simple salines (F. I 
and 3). As much as five grains of bromide may be gi*cn if the iiibnt it 
very restless, or two or three grains of chloral hydiate. ur a ntixiure 
coni.iining two and a half grains ofeachinaieaspoonfulofsyrup. Painting 
a tender and swollen gum with .t satur;ited solutiun of Ixomtdc of sodium in 
glycerine and water u-ill often relieve pain. If the gums remain spongy, or 
there h aphthous »tomatitis, borax with linct. myirh may lie usi?d {¥. 3). 

The temporary teeth differ tn sim and haidness in dilfcrcnt c!tildrcn : 
in wenVly rickety children they are not only Intc in appealing, hut 
wben ibey do appear arc dwarfed and consist ot i»ci« shells, quickly 
becoming black and carious, or loose and falling wit of their sockets. In 
other children the enamel appears deficient, and caries occurs early. Great 
catc should .ilways be exercised in the piescn-aiiun of the tirst set i>f teeth. 
A sort tooth brush sliould be Uied every night, and the mouth thoroughly 
cleansed with warm mater, in order to dislodge the fragments of food nhich 
hafc collected betn'ccn the teeth. If the teeth show signs of caries, it is a 
gond plan to use the tooth brush after ewty meal, mining a few dn>psof iin 
Alkaline mixture with the w:\icr I'sp. amnion, aromat. m, sp. vini reel. J^iiJ), 
Whenever it is possible, carious tempomry molars should be properly fiHed. 

TIk ««eaiid denutlan is nut accompnnled b> the same troubles as the 
first, or at ^ny talc to the same degree. The first muUirs^nd inrisors usually 
make their ^ipjicaranee unnbseA<^d, and rarely occasion any inconvenience. 
1'hc second molars may i;>*« more trouble. It soinetinies lutppens that the 
gunts get into an unhealthy slate, being spongy and bleeding readily, wbils 
the teeth bccoinc Ino^o and give p»in during nuislication. It is during this 
pciiod that ukcMtive stomatitis may be present. (>uml>oiU xnny be another 
source of trouble. If it is of impurtance to attend to the cleansing dthc 
tii'Hith during early childhood, it is of still greater importance to do so when 
the permanent teeth are appearing, and no cfTort diould be spared to prevent 
their premature decay. 

The structure of the pormaneni teeth is no doubt inAuented bj- the 
6141c of the health during infancy. We have already referred to the fact 
(pL 1 3^ that illness taking plAce during the tirst year of hfe may atlcci the 
pemtnneni set of incison, canines and tirst molars, while the bicuspids and 
Inti tiro mntars escape. Mr. Hutchinson long ngo pointed out that 



tomntiiis 



59 




dial S/philit often jilic* ris* \o a peculinr ronnftlion of the incisors nf 
pennjineni sci. l*he 'tc^ii irciIi ' fnr lyphilis arc ihc tipper ccntr.il 
ors : the cHcct of thii (llteai« i)t:<:umnK durin;; mf;incy ii to .iircM iheiT 
Jopmciil, cauiiiij; duinlini: ;iml aUo .-i ccntint notch at <hc ciitlinK cd^, 
-liupi ii ■ scrtw -drive f ' form of (oolh ; ihc other incisors mny vharc in 
tanl of d«vplo[wiient, but only in ii iccondary degree. Mr. 1 1 ui chin ton 
I aUo [Hiintctl nut llut Mnmnlitiii occurring ilurin|i infnncy ^ivts rise lo it 
ling or enniDii of the cnanM't. The 'tcsl toolh' for infnnlilc siomnlilis 
Rj; th« lirtt mol.ir, the inriuirt ntsn may I>c ^iTectcd, And they may be 
*«d by a 'tnimvcrK! furrow cioisiiiK all the icpth at the same level.' 
casei the pittiiii; of ihc upper iiirl^cc of the molar prodiiccK well' 
Tucosilici (/rasit'H tn mijmtlon). Other deficiencies of the enamel 
laore or less extent have been detrrihed by French nulhori- Mr. 
K«t£hiii«on hcticv«K that the xtomaiitis xiving ri^c to this condiiion is often 
mrmrial in «» origin, mercury having been ^iven in ihc form of ' teething 
pnxlcra' wr in iiihcr «ayi. Mr, Moon u*ed lo spciik of a ' mercurio- 
'iphtlitic ' louili in »hich theie wra* a wjnl of enamel over 4 senii<lunar 
>{xi(c aear the cutliii}; edge, 4nd in consequence a breaking down of (he 
fumel over \\\\s «ica. M. Maijitot ailribuies eiouon of the lecth to the 
i&ctf of in&ntlte oonvulMoiis, but it i> probable the convulsion* are 
niKidrat only. 

It It b>' no mejtns alvayt ejsy lo explain why some children have good 
tttth «iih perfect enamel, while in others the enamel is defKient and the 
■tnh quickly become carious. I'hcre cAonot be any doubt, however, that a 
may iiiA vi^orniu infnncy and e^rly chiMlinod with n good digestion and 
curfd heiMlJag must favourably inliucncc the development of the teeth ; 
■bfc inibniA «bo KUITer from (iytp(;p(ia and are badly fed will suffer later 
Ahnmbad lecib. No doubt apparent exceptions may occur. 

Dli«u«a o( lite Kontta 

AMrrhKi siomniKii.— Laiaiihal inrUmmatioii of the mouth may be 
franuy, but it \\ tiv):e often ^cond.iry, accompanying dentition. dyapei>si;i, 
pKiMnonui. and other di-e.-iie^i. Siutnaiiiii ii etipeciilty apt to m^ke jii ap- 
pa.-aner iluriiig the first year of life, ihoiiyh it is common during Ihc whole 
•if r!( Id)i»Ml. labnts who are thm svitfei mg, having begun to take the breast. 
:y lei It go and cry, and are apt to stuiT their fingera in iheii tnouihs ; 
feverish and tniuble, the saliva \i incieased in iguantity, and the 
li firels hot if the finger be inserted ; the salivary glands. especiaUy the 
bljuiil, jte swollen and tender On cxummaiion of the oral cavity, 
of iRienw! redness are to be seen ixx ilie mucous membrane iniide 
, on the gums, or hard palate, the tongue is generally bright n;<l 
or t]ie surface is covered with a thick cre4my fur, the edges and tip 
dean and red. I'bis form of stomatitis is often called Sioatatitia 
>te*«. \''ery freqtiently at the seat of these cij'Ibcmatoui patches, 
cxt>daliua of yellowish m greyish secretion takes place, or (bete is a 
of surface where the epithelium is abraded, and stuatl shallow 
are formed. These yellowish patches or ulcers are surrounded by 
nf redness. Huch patches are usually termed AyhttiK, and when 
pVBcnt ibe term ' aphthous stomatitis ' is often applied. Older children aie 




6o 



Diseaifs of the Digestive Systtm 



subject to tbcse aiiacki, und it \% often !>eeii «> alTcct a whole liou»ebalil at 
the same time, the adulu by no iitcun^ always escaping. It U uiicenain iT 
it vi contagious, but it it certainly epidemic ; it i» toinciintes astociaitd 
with ton»i1liiis. There niay be fcvcrishiiesa, the temperature lislns to loj', 
accompanied by tbe appearance of vesicles oti the mucous niembiane of ihe 
lipi, longue, and soft palate ; ihe vesicle* soon disappear, bcint; followed by 
patches of yvllow ejiiuUtion, or a »haliuw uker may remaia. The spot» 
teuiHin sore for several days. Similar attacks have been descnbed a» 
uccuiring both in iiilanis and children from drinkiii)- the unboiled milk of 
cowi stifreiiiit; from ' fool and niouth ' disease ; and in any case nhcrc these 
aflTciclions occur iu a widespread epidemic it is well to make carc/ul int|uiry 
into this as a possible cause. 

Ii )s probable there arc several diaiinct diseases icsulitn^ from S|>eci&c 
micro-organisms included utidcr the tern) ' aphthous siom^tilis.' 

Kmenkel bas found pus cocci, smiAk xi StafA. fiyog. dtrtut xaA tUbut, ^a 
well as ' t^'as-romtini: bacilli,' in slomaiilis. 

iJiiring attacks of tonsillitis, scar let fever, measle^&c. aphihn.- often make 
their appearance on the tonj^uc and inside the lips, white Ihe comers of the 
mimth become excorialed. 

In infants, aphthous patches, two in number, situated on the hard palate^ 
one on cacb side of the median raplu', ne..ir the junction of the hard and toft 
palate, are often seen ; these ate round su|>crficial ulcers ^ \ in. in diameter, 
their base beintc of a ycllowi>h colour and Mirroimdcd by erythema. Thcf 
have been described as Dcdnar's aphtha-, or plaiiuct pn^rj-Koullcnncs by 
I'arrut. They nre produced by the pressure of the hack of the tongue againit 
the hard palate in siickini;- They have nothing to do with syphUis. 

The treatment must depend upon the rause, whether the stomatitb 
depends upon deniiiinn, gastio-intctimal catarrh, or other pathological con- 
dition. In most cases a mild piirfte «ill l>e useful to expel any indigestible 
fiiMMl present in the alimentary canal, to be followed by one or two grain doses 
of chlorate of potash in a little Ktyccrinc and water (f. 4)- 

Locally the spots may be touched with a solution of permanganate ol 
potash ',5 grs. to lbeo(.)or l>oracic acid (i j get. lo theai.,'i. If the ipoii are 
sJi>w in heating, they may be touched with Upi' dirinus. This tatirr consists 
of e>]Ual |iar1s of sulphate of copper, alum, and '.illpet re fused loKciher. TIm 
diet should consist of radk and bailey ■aict made more dituic than usual, 
and for older children milk and sops. Beef tea and saline fluids arc generally 
objected lo on acrouni of causing smarting in the mouth. 

V«rft»Ulo ■loBwilUs. Ttiruata. — This form of stomatitis differs esscit* 
tiallyfroni thcfnrmsatre.idy dnctil>ed, asit is due lo the presence and KTOWtti 
in the epithelium of the moiithofn species of crj-ptogam \OiMum albiciuu\. 
It is especially common in neuly bom infants and in tliMC of a few months 
okl, who are sufTering from some form of wasting disease, and in whom tbe 
mucous membrane of the mouth is in an unhealthy condition. Hut it is also 
found in infants during the last half of the tirst )'cnr, less commonly during 
the second and later years. It appears a* small white distinctly raised 
points or scattered patches on the soft palate, mucous membraneof tbe cheek, 
hps, and tongue. While its chief scat i« the mouth, it has been found in the 
Jbuyna, a-»opliagi», stomach, ctccum, and in one or two instances in the lunys. 



TJims/t 



6t 



If tmcbed with n smHil paint brush, ibc pnich is found lo sdhcre lirmly lo 
the mucnqs mrmbranc and Mtinm be detached s.^ can milk Aocculi. fnr 
»Slrh It may rcudily be miuakcn : if fi>rrihly dctachoti ihcrc is left a red 
nrfacc denuded of epiihclium. The mucous mrmbraiic of ibc mnmh is 
«fl<a red nnd unheallhy arounil ihc paichet, in other r.-i^es it is (|uilc nonn.i]. 
la i&ild c.^ie!^ Ihriie while p.itdien arc small and few in nmnber ; in severe 
ihey bcrome confluent and lar;^, and Ihe surface of the (ontfue and 
.s IS covered with ihi-m. Infents so affccled atv mostly weak and ill, 
oAcn \aOet fTom di.-irrha.-a or Kastrie catarrh u*iih wistin^. It occurs 
ilder childrro in the last days of tuberculosis, tubercular Tneningilis, 
loid, and pneuiminuu 

U a pier e of the while patch he detached and examined microscopicallyi 

d will be foimd to consist nf epithelial cellft, bacteria, yea^t fun(;i, ^nd the 

thread-like fibimenis of various mould fungi. The identity of the fun^-us 

:.:ivr» rise to the disease is a matter of uncertainty, the difficulty of 

j ins i' beinR l.ttgely due to the presence of laiious orpiniiins in the 

»iulc patches. It has been iden- 

cM u tbe OititHm loitis, the 

■Mid liini;us which is present in 

tnir milk ; the cultivations ot 

••i led him lo belicre it to 

- finical with the yeast ftingus 

w »Bie fenuent \Siueif>mmx(*t 

■nni-rmMiV Kecs, who further 

-' i^aied it, believes it In be a 

:.i..<i fua^'u^ iliough nol identical 

skb ilie altos-c ; he gave it the 

Bme of Saaiaromtrft alhiotm. 

The RiifTO-«t]{anism of thrush Is 

"• ■' irrolMbly, as Fracnkel states, 

I. between the yeast fungi 

.'■i.caart>mycfltt) and llic mould 

«r thread fiinui '■HypomyiwUt). It cati be cultivated in syrup, gelatine, 

«r potatoes onA hread pa^te ; under ceriain conditions of nutrition it 

tflteitn to re»emblc the >-east fungi, .is on the surface of the R^laiine; 

vkilrat the bottom of ihe test-tube cultures it n|ipeais more like the ihrend- 

Jltt funns of the mould funiti. It ii aerobic, and lines nol liquefy x^'"'''^^' 

f'laut briieies it to he identical with a fundus ^''oo'ini; on sweet fruit* 

^ r"(ti-n wood (Moniliii omtiiiiit). 

-;.wi usmlly appears in tbe form of fiUmenis made up of cells 

I'tber 3-4 fi bmad and Jo-60 y. long ; these branch in various 

ttons ; oval cells buii out fiom the joint between the elongated celb i 

arr present in these muoitish cells. (Sec fiij, lOii 

I Tftiit mfitt.' It is of mu,;n importance that grc.it cate should be taken to 

Unw the mooth after the infant has taken ilie bottle, especially in a weakly 

nt tif tow vitality, weak alkaline iolutions. just tinged n-ith Condj- s Fluid, 

-'•■1 for this piirijow. 'llns can be done with a largf paint brush or 

\>\ , .ind on (he first symptoms of thrush the hotax lotion (F. 3) or 

I'tution should lie used. As a sironKcr application 10 the pnrssitic 




Kit- lo. -runiUBof 1hTu«h(* v»>. 



6l Diseases of t/u Digtstix-e System 

|Mtcli«s a solution of tulphAt« of cop|>er (i %tt. it> ihe oc} or carbolic acid 
(3 gfi. lo ihc o«.) i* very effcttiinl when Applied willi a paint bnuh, Tlie 
success of ihe iicaimcnl dcpcmU noi only on ilic dctttuciion of ihe runout, 
but .il*o on .in iiiiprnvcmrnl in ihr child's general beitltli. 

ine«T«uve CtoAAtlti*.— Thii form moMly occurs durinjr denttlion, 
and is perhaps mosl crannion during ihc prriod nf ihc second dcntittna, or 
frcm Ihc age of 6v« to ten ycnrs. Tbc children who miTcr from ii in tht 
ae\'C(c fonn ntc unhcallhy, and arc cither rccovcrin); from »nmc iiifpcliou» 
diBrntr, or hav-c been badly fed, or liat-c been exposed to unhealthy lur- 
TODndtngs ; it it also onimon in lubcrculout children. A very «iniil»r Cim- 
dilion is prndnced by fair\-y' rickets, ;ind by chronic mercury nr pho»pl>oni« 
poisoning. The Rrst symptoms conilil in incrcAscd salivation, the gums 
brromc pale, swollen, and iponKy. an<l the breath fotil ; tbc tahvary glan<U 
are twollen xnA painful, and llicrc is often much twcllint; of one or other 
lip. The f)>on(;y gums bleed, and the blood together with the (na>lcr» 
taken as fixid dccninpose. gi^'ii^R 'i*c ''> '^ ^'^O' '^■'1 condition nf the breath. 
The firt.t ]>art of the gums to beafrccicd it usually that near the incisors or 
eye teeth of the lower jan ; the front purl of die gums stilTcr* more tluin iha 
back. The gums sciinetimes swell so as to partly cover up the lecth,irTCgii1;ir 
ulccn form on the swollen gums, which, as they increase, expose llic root* 
of the Icclh : ihc l.i tier become lon^c and perhaps fall oui. Tlie ulceration is 
al tiisi cnnliiied In the gums, but may involve the sulrus betnecn tbc gum 
and chcrit, and also ihc mucous membrane lining the check or the inside of 
the lower lip In mild cases the sympioms arc much less severe than this. 

Necrosis nf the jaw is apt to follow in some of the more sei'cre easel of 
ulcerative stomatitis ; instead of the process erasing, as it usually does, ifac 
mischief spreads and a chrome osteomyelitis of the jaw is set up, much 
intensely fa:iid discharge comes away, the child's health suflers, the cheeks 
becnnie pufly and flabby, the ulceration i>f the gums spreads, and aAcr a 
while it is fi>und that a large piece of jaw, carrying perhaps tivo Oir three 
teeth, is loose ; this is taken an*:iy, and in ionic instances the process Mops ; 
oRen, however, any new bone that may have formed becomes mliltratcd with 
the foul discbarges, and the mischief spreads along the jaw, piece after piece 
is taken away, until at last iheeiilite jaw may have to be removed. We hav« 
removed the nliolc bone from condyle to condyle for this condition. !tlany 
surgeons believe llut the disease begins as a periostitis and not as an 
ulceration of the gums, and tli.-it alveolar abscess is the starling point ; this 
is so someiinies, ihough we think certainly not always.' 

The child's he.ilih maicrially siitfcrs from the discharge and foul state of 
the mouih. In »ne inslancc, after removal of the jaw, the child was sent 
home convalescent, but died suddenly, app,trenily from falling back of the 
tongue. KesKrratioii of the jaw is very imperfect in these case*, for the new 
bone necroses as bst as it fonns. Tlic process cloiely resembles phosphorus 
necrosis, but it is not due lo that poison. 

Tnatment.-Mytt every meal the nxMth should be «-cll rinsed with 
«ann walcr or Condy's Fluid, jnd the gums and letih cleaned with a btl of 
absorbent wool or soft rag, not sponge, so that the s.une bit may never be 

■ lit. \nKf\ Morify lini rrportccl > cue coming an after lyph^d and aSKting ifac 
upptr j»H , Tbc loircr jan ii the one moat cumoioaly allack«d. 



Alwofar Abse^ss 



63 



► 



ngain ; the gums shuuld ihcn be mopped over with tlic glycerine of 

'AX 3 pans to tincture uf myrrh 1 part. Of intcniiil-rcmnlics. by far 

oiust c^ci«nt U chlor,)te of putu^ll, ){iven lit lltF or «l^ ^ruiii doiCi itirco 

liincs a dny. 'n>e diet shuutd cunsi'it of fluids jtid sopii. beef tea and utiier 

nntitisliiti); Itqutdii bein^; tlivun ficdy, c^peci.illy in ibosc cases where the 

diieasc nccurs in the poorly n<mri»bed and underfed. Thi* irejiinicni nil! 

tbually suffice to anot ihe diiease ; but once ihe bune becomes setiously 

involved, in soote case* nothing seems to have any effett. Strong nitric 

•lid, eufbotic acid Jkc. seem to have little power, and the purulent inliltra* 

lion only ce^ases wlien the whole bone has been <k-stroyed. 'Dicsc plan» 

ihiMtld, however, be carefully tried, chloroform be>n^' of course given, und 

NbMqiiently there should be very frequent cleansing; of Ihe mouili with 

iqinl pans od* reciilied spirit and water. As snnii as the disease \\n% censed 

Maprcad, any loss of bone or teeth should be supplied by a pUte niih arti- 

toal teeth, to prevent falling in of Ihe lips and the prematurely senile 

mini nil I thus produced. Even where the nlvcolus alrinc is destroyed, 

tioct no new formation of bone occurs ihe permanent teeth are often 

IvMttticd am) fait out. 

AlTvolBT AbtosBi IS, as might be expected, a very common result of tlie 

Mfkct or Riism.in.igcmeiii of carious teeth. Aflev an attack of toothache 

ikpaininaycompilctely sulisidc. and swelling of (lie face over ciihei' the upper 

(t lower pw rapidly come on. This, of course, menns ihai the inflammatory 

irooto— hitherto limited lo the alveolus, and hence giving rise to great 

fain, beaui»c there is great tension on a large nerve— has extended to 

ik mA pans covering the bone by escape of tlic pu« I'mm the alveolus. 

The pain IS greatly lewened, or ceases altogether. The condition is thought 

ol little importance, and no steps arc i:iken lo obtain advice, as there js 

wloni^r pain, and a swelled &ce is looked upon as ihc natural and proper 

ending tA a toothache. No doubl most of these ca«es get perfectly well 

tl li»t for a time, for the abscess bursts either by the side of the tooth 

oraiorc often through the alveolus and gum, and discharges itself into 

tk iMNith. Finally, the abscess close* up. and all remains quiet till some 

6ilBrc of health or some irritation rouses the carious tooth 10 another 

•Mhnak. In not a few cases, howei'cr, neglect 10 remove the source of 

imation — i-e. ibc carious tooth^givcs rise 10 one or other of the following 

MoUn- Often a sinus tcniams inside the mouth leading through the 

ainoliit to the fang of the dead tooth, and a coiui<ini di'^clurge of a small 

i|uuility nf foul pus takes place niihin Ihe moitih. Such a condition cannot 

bn be prrjiuliriji In a child's health. The breath is foul, and the foul ihiid 

El tvaltowed. poisoning alike the lungs and stomach, and often a child is 

bptaihnK for months, for want nf exir^rtion nf a cariniis tooth, In other 

min. Uie abscess tracks to the surface and is allowed in biiisi there, giving 

cAcn to a lifelong disfigurement, in the «hape of a depressed scar over 

ur ItiH-er jaw. Or, again, a chain nf enlarged lymphatic glands or a 

abscess owe their origm ti> neglect of a carious tooth or alveolar 

Necrtwis of thcjawoficnrc5iili5 from similar neglect. Occasionally, 

■re »ee cases of antral abxctis in children as a result of extension of 

id from a tooth, ihnngh it is perhaps less common in children than we 

taight expect, 'there it a most tmrcasnnabte objection both on the part of 




«4 



Diseases of (fie Digistiit System 



perenti and of «omc denlisti Id extraclion of leelh, even if they are e>> 
lenxivety carious, and even if they are only tempontr)- leetii. Il is difficnh 
ID believe thai the retention nf a dead or cariom temporary loath can <lo any- 
thing bulliamt to the Jaw and the unilertyinj; permanent teelli. It i* perhaps 
still more difliicuU to undentand ihc princlpk on whic^h objcciion ii made 
to the removal ofatoaih while lliete itanabscesspresent. yet it iscon«lantly 
done, and delay ii utjccd lill the nbtct^s is u-ell. In all cai«i a canons 
temporary loaih should he removed at the least tigo of inflatnmaiion .ihoui 
ll Dr if it cauici foul hrealh. In all ca-tet a inciih thai h.-k^ t.'i^'eti rise lo an 
alveolar aluceis ihoukl be removed, and if ils exiracriion does nui empty 
the abKens a free oprninu ihould be made in&ide the month, and ihe abxesi 
cavity and n-holc mouth frequently waihed out with some aniiieptic lotion 
till all K well again. On no account xboutd an abic:e'» be allowed to track 
towards the surface of Ihe Cice, nor should any tooih lie allowed to remain in 
tbc jaw with a sinnv leading down to its fanj;. If antral abtcei!( i) mri with 
or Dccriuit of Ihe jaw, ibey mutt be dealt with l>y the ordinarj- metbodx, 
beating in mind the softness and ihinnevi of rhildren's Ixmes. We hav« 
now (189;) under our care a child with extensile tubcrLuUr disease of both 
antra, which pfoh;ibly aroie from Ihe irritation of carious teeth. 

OanorBiD Ori>. Cancruin oris occurs almost invariably in squalid, half- 
slarved children iifter one of the exanthemata : sometimes, however. 11 mjcttis 
lo have nci such predispoiint; cause. Tbe disease begins as an inflamed 
spot on the inner surface of Ihe i-hcek or upon Ihe gum. the mischief rapidly 
spreads, both in depth anil area, and ihe whole thickness of ihe cheek and 
gum becomes involved. On the outer surface the cheek is twulkn, shining, 
siUr, and jKile, or somct-mes d.irk red, its vessels .ite thrombosed. ;ind mjob 
a black spot appc-ars in the centre i>r ihe pule waxy area : the check is per- 
ferxied, llie black a|>ut becomes a (lefmitc sluugh which pailiAlly Mparalca. 
Then the edges of the (tip become black and the slauKhing »pTe&ds, yn- 
ceded by a lone in which the skin is pale and ti-dematou*. In severe cases 
the whole side of the ficc is rjpidty destroyed, the gums slough aw^y. the jaw 
necroses, and the Iccth drop out. 1'hcic is intense fo^lor of the discharge 
And breath, which poisons the child, rrcquently causing pneumonia and 
death before the process is complete. Dr. Wilks considers that when 
the sloughing attacks the gum first it may be only nn aKgrdvatcd form of 
the ulceration met with in a late condition of scarlet hvet : this is seen 
usually in the lower jaw, while in tnic cjincium oris the upper )aw i« 
Attacked' 

Sansoin hat tiescribcd an or^nism which he found in the Mood Mid 
diseased tissues. Wlien taken front the blood and inoculated into guinci 
pigs and mice, it whs found n;i;ain in ihcir blood.* In a fair nnml>ci of 
instances the process is anestcd and the sloughing erases, the parts clean 
up and heal ra|>iclly, leaving, of course, a more or less severe deformity. In 
fiital cases death is due to exhaustion or sepiir pneumonia. The .iinount 
of |Min and distress suffered is variable, sometimes but little of either exists. 

TVi^fftHC**/. — The treat men t of c annum oHs consists in the fice local 
ftppticaiioo of the acltinl cauicr)', or, better, of pure nitric acid. The child 

■ Aa eircllml dcscripllon and Rgure ore (Inn In Mr. Cmptr FotitcT'i book cm the 
Shij/'jI Ditt>iMi 11/ CAilJrtm. • »M.-C»lr. Turn. 1I78. 



Oinrmm Oris — Afuu Tonsillilh 



65 



«)io<itd bo put tintlcr clilonirorin and ihc pant cnrcfutly drictl with lint ; 
ukkv (lt|>pcil in strong iiiitic acid sbouM ihcn be nihbcd well inrn ilie 
cd|i«« of (lie ^IniighmK pans an<l <wct the wtfncc of the gums after niiiing 
AWuy any loose s!«ugli5 and removing scqiic-Jtr.i. Cnrc musi, of roursr, be 
taken i»nt luAlliim' tlie iwiil to run mcr the sound *kin. Several .-tpprci- 
lion* of the jcid should be made, the pari* being dried after cnrh. After- 
wards -1 little iodoform should be powdered on and the siirfafc smrnted 
■«lt with •utbcitif wl. E. C. Kincsford lim had good reiulis fnim ihi- appli- 
cation i»f peirldoiide of mcrtur^-. but it ha* mil proved univcrially turce**ful.' 
No !««« iRi|>otta»l than the local treatment ii the free AdminiMraiion of 
ilJniuUnis and ahundNnt nouiislimcnt. 
As nurli wiiie or brandy as ibe child 
will take aliout j-4 otincts of bramly 
ID twetfiy-four hour* f'>r a child of livr 
yrJiTki, cat bonate of Ammonia and liatk. 
*%'p' beaten u|> with milk, strong: soup 
and meal extracts ihnuld I;e ^iveii. In 
ihcw cjises, as in phlc>:m<>n<iUB crysi- 
pelj^ patients seem 10 be able 10 take 
aliiii-sl an unlintiled amniiTit and to 
iKii.cuponit. Opium should bc^fiveii, 
Ihi* Kiih <:aution, as il is no< alwa)-t 
itrll h-nni-. If ihechihl ireovers.ihe 
Ls often remediable to 11 con- 
' extciil by a plastic o|)cTaiion. 
lerhapK the most troublesome aficr 
inndition it cloture of the inouth by 
*dhr«ion« ; an attempt to prevent (hi> 
(hfwld lie made during liealin); l>y (he 
at of s<rcw jjajfs or mouth -openers, 
and later, by divi«in« of ilic scar (i»ue ; 
in Mime CMnies even section of the jaw 
and the r^iablithmeiit of a false joint 

maybe requited. It must be c<infe>sed. Iioncver, that ihi: irnttment of 
ihit ciratrM-ul ciwiraotion is far from sati*fnctory, and often no pennnnenl 
food rc»uli is obtained. 

Some cii»e« of ceriical lelluhtis (so-called angina Liidoviii) clonely rc- 
ttmble cancrum oti» ia their results. iT/ffr IJt>RASKUs nc l.vvfit (>t^siK.) 

tenia TotuimUa.^ It if lurdty ptissiMe to cicaKgerale the importance 

u tborouKh r 1.1111 mat ion of the ihiout of a feverish child. es[ieci;illy when 

le i-au\i' .if its illnest isnoiobvHnis. A child, more particularly a young one, 

< not, Ixkr an aduti, volunteer the infunnalion thai its throat 11 soie and 
' during the art of tuallowing, and wdl tvrn deny that ii is soic wlitn 

Plclually sutTering from teteic lonsillilis. Without a careful evamiiu- 
lain il i« i|uiic p<niilitc to mcilook not only toniillilis but scarlet fever or 
diphilteru, eipciiially if there is some cheit complication piesenl to throw 
; ol>*ei»'er "fl" his guard i or he tnay come to the conclusion that a case of 
ilUry 'niiunps,' or croupous pncutnoni.a niih physical nigni delayed, 
' LtMftf, Sept, ts^i. 




fit- ir.— tWi-niill^ multii-K alVtr ncovrty 

fi-tli. unervtii uPit; ,ii1nv,tii*nlly rtmtdWl 
t>v' flA^ii'^'H'.alLtHL. [ir, w'.aLnsaii'icKHc 




66 



Pistasfi of the Digestive Sy.Uem 



is a cue of scarlet Fever. Anyone who h.w had any experience of a fever 
ho^ipitiil will l>t iibic lo call lo mind many cases where trtots have Ixicn 
nude ih[out;U nt-jjlcclinn xn cumine ihe ion»ils ur fioiti *xn\ of kmiwlcclicc 
of tbeir appearance in health and di?icjse. 

Children ate very liable to tomilhtii m iis brnadeil lense. and iKU '\* in 
harmony wiih the fact that the lymphatic syMcm during childhood i» ex- 
tremely active and especially prtine lo inflammation. I'hc ate which (be 
lon&ils fultit is unccrt«in, but, whatever ilieir e.\act function, it is ccrlain 
that tlicy belofi); to the lymphatic system, and they have been Jintly nmi- 
patcd to Peycr'i patches, inftsmiich as they teietnble them in siruciure, con- 
sisting of cont;eries of lymph follicles or so-called 'solitary glands.' They 
have a large blood supply and their lymph 3inu?es freely coinnmnicaie 
with the lymphatics of the inmith and pharynx, and also uith the deep 




Flf. It.— Veriic*! weiloD ef fcuinau ijiiwl i ■ . . i 






UH lf««n iht rtflii : \ lulMintd iluiii iriih hhiiik/./,/. -Aaatms at 
H ; 4. Almiuth^Eit ; ■» HCtiurK^f iii(k04iu^Ai>J duel: (% blaa4't«»vL 

cervical glands siiiuited behind (he angle of the Jaw. Their surfaces arc 
covered with deep deft* or crypts which serve lo incrcnse the surface of the 
Diucou* membrane coveriof; ihein ; these are apt to become filled with thick 
yellowiih secretion, and arc then seen as yclli'w points scattered ov-er the 
surface. One of the functions of the ti>n»il» is probably the formaiionof 
leucocytes, or whitC'blood corpuscles which .-ire shed into the salivary secre- 
tion, and the cheesy secretion formed during infl;imnution consists princi- 
pally of these builics. Tonsillitis occurs under the inihience of many different 
conditions during childhood, and possibly (he prtmeness of the tonsils to 
inllamc is, in part at any rate, the result of their ponitioii at the entrance of 
the fauces, where (lie vnrtous fonns of aerial [loisnns, baciUi or other Kennt, 
would, when inhaled, he especially prone to lod^e. Many of the lyniotic 
disciiscs are accompanied, or, what is a very si)(niftcant fact, arc preceded. 



Acute Tonsillilis 



67 



t»y tocifillitU. Thtii ih« lonsiU arc the seat of inflAmmniion in sc.irlct fever 
and diphtheria. Typhoid fctcr soiiittiiiiei commences wiih a, sore throai,; 
nM-.utes .nnd rothdn arc iTioslI)- aiteiidcil nilh some congestion or caiarrli 
uilUinmalion about the fnuccc The tonsils arc apt to becomft intlnmed as ^ 
the result of cold, as from a wctling or cxpoiurt- to a dr;iughi or keen cast 
wind, and posubly also from *ome jfaMric disluthance. There ran be liltic 
d«ubC aUo th.it loniiltitTs is at times due to inhaling sewer g.m or imwliolc- 
soaw smells. liaUo appears aomciimrs to precede or accompany an attack 
«f acute rheumatism, or pcri-endorardilis. 

The record of toniillar complication i» not complete without reference 
10 the epidemics of sore throats which arc apt to occur in schools, hospitals, 
anil other public institti lions, or wherever many children are brought 




rit. >).-Acuic Toniilliiti a. iMa actJ ihm ran : i. chll<] ocnl 1 yrtry. Thtw 
■voiw»lHkin(w]iatii<pide<ui<ii(MnOiK«i>. «ar1« r<vo> ww n>jt CBHsiaJyo. 
<IbA>4. tml In iw wt vM than ■ ruh. 

Kftiher. Some of tticic qtidcmics have appeared to be tnrKliftcd «carlet 
frvrr or diphtheria, as proved hy their bclonyiny to a ;cartatin.il or diphihe- 
ritie epaileinic which was coctistcnt in the neighbourhood or preceded or 
biUoBnl tlw epidriiiii: of »ore throat*. Bui in other cases il has been clearly 
sbown thai there is an epidemic or infeclious form of soce ihroat which 
tlowly n:snfiblcf both iicarlcl fever and diiihthcria, but which, while similar 
m luany rtjspccts. i» nriiially diitmct, as shown b>' its not protecting from 
citber of the above di*eatcs,' Som« ta9C§ of epidemic sore throat ha»-e 
appcumtty litrti iinctril to the coniutnpiiun of the milk of cowssuffcringfroin 
'foot and itmuih ' disease. Whenever sote ihm.ils occur in a household or 
tchool, \\ve (loisibiliiy that they arc the result of the srarlatinal or diph- 
<WhtK poison should alway* be kept in view, while al ihc same time the milk 



1 Vide TmiiUitii im ^.loJtmili. by C H*ls-Qn>wn, M.U. 



3 



^^^^^p Disaisfs of Ihe Digestive System ^^^^^^| 

supply nnd the sanitary ctmdiiion of the ctublishmcni Khotild be oircMFy 
i II v«3 lighted. 

To whatever cause tl>c loiisillitis is due, whcilicr spnradic nr e|>ideinic, 
lite symptoms arc mosily flic s.irne. Tlie aiinck usiinlty heiiiiM suddenly, 
[Ihougb it is lift en preceded for a few hour* by a fci:linj{ of soreness in sa'aIIow- 
inij. fnlikc sMriei fever, it is iiMi.-ilIy iin.-itiendeci byvomilinif ; itiecvcoiti^ 
icmperalure runs up lo 103" or more, the tonsils .irc swollen and r*d, there 
is much secretion of mucin, nnd in a feu' hours yellow points make thetr 
appearance upon the lonsiU, the rc^uli of Bccteiion retained in I he crypts. 
(Sec li>!. 13.) The lonijuc is furred, bill docs not l)ci:ome of a 'sirawberry' 
ftppeanincc as in scarlet fever. In some cases, instead of the yellow points 
seen on the tnnsiU there is ;< yellowish exudaiinn formed by ihc coalescence 
of the jellow spots on the inner surfaces of ihc tonsils ; this does not adher<'. 
u^!i rule, niih any dc){Ti:cof iirnin<-». and may be reninrcd »'ith a brush. Tbe 
inll.i minatory lesion rcin.iini for the most part toiisillar. and ihowi tnii tilltc 
tcndonc)' to spre-nd (tnd involve ibr nasal mucous membrane or the middle 
C.ir, xnA, uhilc ihe ((lands of ihr an);lc of the jan- may bct'omc cnlar];rd, 
they mre not hard or *uiToiindci! by cellulitis. There i* no true ulceration of 
the tonsils or sloUKhing of the |>:il>Ate, The temperature remains remitiim 
I /or a few days, j^adually n:tumin){ to ni>nnal. 

' Such is the clinirjil biitor)- oT an ailaek ofacnte cjtlarrhnl toniillliis, but 
it muM be icmcm)Krc«l that many such attacks are exceedingly mild, and 
are nccoonpanicd hy but tittle pyrexia, and may perh.ipi come and go n iih- 
out much complnint bem^ inadi: abnut them, .^cuie iimiillitu from any 
causQ is apt to leave the loimU enlar^'ed. and the mucoLi!t membrane 
[ covcrinK them in a cundiiiun of clirinnc catarrh. Kepciitcd aiuickt in 
children liable to Klandular nwdlings, accompanied as they .ire by catarrh 
of the naHt-pharynx in many cuei, gire ritw to various troubles whkh hiII 
be tlcM-'ribed later on. * 

Diitgnosii. — The mo»t important question to coniider, when called 10 
sec acme cftonsitliti*, is whether scarlet fever and diphtheria may Iw ex- 
cluded with certainty ; as, if they can. it it tolerably certain that Ibc case is 
not one u-bich will give rise to any anxiety either on account of the patient 
himself or hii fricndi. L'nfortgnalcly. hoivever, it is not often possible to 
express an opinion without niiigivingi: that which appeari l'> Ik.- a %imple 
' tonsillitis may l>e S4:nilatinal or diphilicriiic in origin. It need hardly be said, 
that the child KulTering from tnnsilhtis should be strip|>ed and a caieful 
examination made of the surface of the body l>y a good light in order in 
\ detect a rash, and the fainti-il rash nould necenaiily ntouie suspicion. In 
I the absence of n rash n certain diagnivtis is often impos>ible, but glai>dular 
LetiUrgeincnt, discharge from ibc noic, much yellow exudation on (he 
nootils, true ulceration '>f the tonsils or soft paLilc iir oliti*. if present, would 
make the diaj^nosis of sairlet fever a probable one. Shiiuld ilesqnamation 
follow, if It is certain there has been no rash, it is of no dia)fnostic import.iiicc. 
If iktphnlis occur in the ihini week, it points to the scarlatinal nature of the 
attack as beyond doubt. ..\ strawberry ion};uc is rarely present in the 
absence of a rash. The difficulty i>f diagnosis between mild diphtheria and 
(onsillilis accompanied b>- greyish exudation is hardly less than that belneen 
lonsilliiis and scarlet fever in the absence of a rash. Albumlnutia, nasal 



Chronie Tonsillitis 



69 



» 



I 



, ^lamliibT (mUrgcmfnl and cellulitis anil ihtpicscnccofLocfflcr's 

illui in itic r^^udiiiinn, nil {lomi to diphihrris 1 if paralysis Ibllow, the 
ugnmii (irdifihihcria is icit.'kin, (See lJiciM'ilt;KiA,,i 

Trealmtnl.—V.wvf aiurk of lonMtliiis during childlinod sliotild be 
:rr4lcd i>ui only with icspcct bm wiih Mispirion, .iiirt ihc ease should »\ 
iDCc be isolated n* fiir .11 >i rt pnuiblc to da 10. It should consuntly be 
brflnirr tllc mind of t>'ic jiractilioncr rh.it the c.ise mny be one of aboTtive 
turki fctvr or diphUierin. ^nd ihiii xhv. ne\i cvat i« which he is called in ihe 
jUinr bnUM-hnldniia)' be iiurnuinc attack ofoneof the iilxtt e zymotic diieaxe'C 
Jli>al«jiy» wixc, wbcn calkd Ui luch Ciuc», to givf a (.iiarded ili.-i|[nc>>i« 
and ptugnosi^ until the caic Ius bct^n utuler nbscnniion for a fen' dayi. 
Thi! palicni \\ tu be conKnc-d 10 hii riiDrn iir to his bed, accuiding tn the 
»eieniy of the attack, and liis diet ^lould cuiuiti "( milk, beef tea. and sopi. 
If there i> much |Min tn tu^illowjoi;, hut fiimentaliunA medicated with bella- 
donna or ofiiuin may he applied i^xlernally and rene»*ed ai fre(|uent intervali- 
fhe (oUviU slx'Uld be painted H'lih a ioluiion of burO'Klyeeridc in wAier 

12.1, nr lodiiK' gi.ij, j;tyterinc Jj, and ivaler }ij ; hbek currant jelly 01 
iKes are aUo utcfut. Salines, -uch a* ihc citrates or chlorates of the 
ica. lombincd wiih j::oiiiic or whtyUic ol' soda. i( there n much fever, 
be iiiven during ibc febnk singe : acid* and ciiichona diuint; con- 
vilestciKC. 

etir*nte Tominmj.— Soiiilled chrome toniillitis, or innullar hypcr- 
Inptiy. IS a ;eiy tH>|ioiiaiu child's diM^ise. thaucb by ni> means limited 
In childhood. The Mffc.:tion ennsiats in an actual ovei^^rowihof the lonsiltar 
Adtnoid tissue, so ihiii the tonsils become greatly enlarged and project nf 
iDunded ot irregular masses in urioiis diiections. Miisi cuminonly they 
fww inwards towartis The middle line, and may leach such a site as to me«t 
ud be ftaiiencil by muiiial pressure ; they inay then almost completely block 
Jbc atiAcc of Ihc pharynx. Ill other iiisunces the* enlarge \criic4Uy and 
bccumc Urge oval masses, piujecting far down into the pharynx «nd upwards 
and biirkuards lonards the |>osicrior nates, la oihcr cases again ihey 
protrude iniiuaids. sc)uraiing (he layers of the soft palate and formings 
lulgmg mass on the rnirfof the tiiouth. Sometimes the surface is almost 
uMMtb, m;irked only by (he oHAces of the tonsillar crypts, iind sometimes it 
■iquitc nigged and irregular. 

Tite civer^Towth i« often accompanied by recurrent aiiadta of acute in- 
ftunmaiiim, in oihri cases there is no pain or acute distress iit anytime. 
Tile secretion of the mucous glands may be retained, and thick pcUctt of 
inspissated rtuiter l>e shut up in (he cr>-|)ts. Occasionally, on cxitmininit 
the rcgH>n of ihe tonsil, instead of the usual ap|)earance, .1 lar^fc yellow mast 
■ill be MTU bUirkmg up lite whole of thai side of the phar>'nx . it in soA and 
Anctuaiing, and on incision gives exit to a latgc (lu.iniity of thick tUMf of 
iMKUA, pus, ( hotrsteiinc, &c. This condition ue liave sometimes iboii^hl 
In be a CO ng emu I mucoid cyst. It is rather alarming at Arst sight, and looki, 
tike a l.irgc .ibscess on the point of bursting. The symptoms are those of 
tonuUar h){>enro])}iy with more or less dysphagia.' 

* ThK caiiu* of latniUu' h}pntropb)' are olitciiro: it liai l«cn tuppotcd 10 lie ibo 
I of imuUno of ndchboonac paiu cnuttng cnlargsnent. a* in othx pans of iba 
faaUc B|ipimiU9, in somt turn pouiblr oonnaclcd with one of (he rianthcni*. In 



70 



Diiftisfs of ikf Digestive SysMn 



The orilinuo- cnbixcd (on^tl i« usu.-ill}' pnlc, and in old cntM bard ani 
soiTi«tinici ulinoii i:Te(nccoii5. The cnl.-ir){cnirni ma)' he fmind ni nny a^ 
from \>\nh f bcinj; sometime* con){cnitnl ) ti> piihcil}', nx more rarely later ; it 
t^vet tise to a dvliiiiie icriei uf symptoms, nil nr mont of whirh are uiually 
prcseoi loyeilicr. There i> a vacoou\. hca\-y look, from obsiiuccion \» 
bruaihin^ and cunM^quenl impetfcci aiiraiion of the blood, aUo iin|)crfect 
-jlevdupincnl, and ofivn itunting of growth ; ihc mouih n kept open, Ihe 
breathinK ii itciioiuus imd in sleep inonng. ThcTte children uiunll)* »teep 
^heavily but retlkasly, often »iartin|f in ilieir sleep ; incontinence of urine i» 
Mmeiinieik prenenl, a reauh, no doubt, of ihr supply of imperfectly aj-ratcd 
vblood to the nervous centres. There i^ usually iihtonir na»al and ofleo 
nural calarrh, from the extension of irriintion from ilic lonsiU lo Ihe neigh- 
bouring mucous iiirf^ci-s. Thi- ^pecch it nasal and indistinct, tlie chest ia 
iiften ill ■(lev el oped, pigeon bicAi. led, or, at pointed out by Ijmbron, has 
the dmphnigmatic coniiriction (M. Mackenzic.i. Recurrent acute tonsil- 
litis is gcneiully complained of, but there is seldom constiini dytpbagia ; 
there is an mcreasc of the ph.iT)'Ti)^r,il mu<nis due to rniarrh, and the breath 
is often foul. Tbe actual dHiirliitg and stuniiTiK from this condition ii some- 
time* very marked. \Vf have seen a diffeienre of iCi'end monllis' growl h ii 
iwiiu, one of uhom had enlarged tonsils, the losi ground l>cing rapidi; 
regained after renio\.il of the glands. 

It is in our experience iruc that enlargement of Ihe loiiiilsi» nearly always 
accomii;inicd l)y the pn-scnce of the closely allied adenoid \eBclaiton in the 
naso- pharynx, to be mentioned prtsenily. Occ;iijonally, hoiwv-cr, either 
may exist n iihoui (he other. Ihe lingual tonsil appears to be tnuch less 
often alTectc<l. or at any rate it very seldom givei rise to any »ymptoins. 
We think it is more common to lind adenoid gronibs without enlargement 
of the tonsils than hypertrophic loniils wiihout adenoids. 

yVriT/iKCA/.-Chronic tonsillar hjiictirophy, when once well esiablisbedt 
13 tittle afTefied by mere local applications or constitutional treatment ; It i$ 
only during an attack of acute indammation that good can be done by such 
means. In the early stages of ibenlTcciion astringents, .such as gl>-cerine of 
Unnln, and Ionics sometimes succeed. The only elTicicnl mode of titat- 
meni is by rem»>'al ; caustics and the actual cauterj* are inferior methods of 
obtainmg the s:ime result. 

For that form of enlaigemenl in which the tonsils project inwaids, or in- 
wards and downwards, nothing is sn efficient, simple, or easy as removal 
ntlh the guillotine.' QilorolbrTn should be given if the child wrtl not allow 
removal uihemisu : there is no objection to it except that it make^ the 
Ofieralion somewhat more troublcn)mc- 

As much lonsi! -ns can readily he rcmo^td should be taken away, but ii i& 

ooi necessary lo remote the whole gland, the p.in left l>ehind usually soor* 

shrinks, lioth tonsils, if enlarged, shojid, if possible, be removed at one utlini;. 

The guillotine cannot be satisfaclunly used unless the tonsils project con- 

olhers pcitia(B lilt result of the iilntruciioii of ilie i:in>,:[lnr iiiucinu {Undt ; or, as tome 
■riicrs ihink. it may l» a mull of Ibc socalW suumout <Iini)i»ii. 

■ KAliDettuck'a li Ihe onr lliul wc ptrfn. UhiukIi Ii m ■ umewtint (ttJlcalc Iiistninu»l 
mm) linblf lo gil out of order . ilioic iisUfllli' sold Aie icio Inrt;r and clumi) Utt coii- 
Vcnloil use. I 







C/itvnU Tonsiititis — TonsUlar Calculus 



71 



^ 



!y (owards iht midiJle line ; in m;in)- cate*, however, its u>e may be 
ca&icr bj- picisiiij; ihe liinsil inwardi niih Ihc finger npplicd lo ihc 
fc jtisi in front of and Ulowllie annleof ilu- jaw.' Where ihc avergronth 
i& uulWAriifr ami tlu.' ^iiiUoline oinnui };riti|> ihe l«n«il, ihc vuUellum And 
([lurded blunt'|>oiiiie<l bisiouiy must be used, tare bcini; taken to keep the 
edjje of lite knife iMrncd 5i>iiie» liJit inward*. In lomc feu* caie* even this i» 
impncticible. «nd it i* duIj- in itie&e rare imtaiKv^ iliat puncture with the 
Pfti(Uelin caiuery shooM be employed; the cauter>' imiy be thrust Ihtoutih 
ihc anicrior pilUr of ilie fauces, or <lirccily into the gUnd between the pillars 

1» one or two points ; *lirinkin}; i* said to usually follow. I'otaija fuia U some- 
limes used, bill \s dan^enius and tedKUis ; scraping anay tlie Con»ils with a 
«b«rp spoon is titc best plan if the ^im\A is tvr>' friable and soft. 

Etelno^-al ofeiilari^ed tonsils while acutely inHnined i» usually condemned. 
Wc have. bowe\'er. doi>r il with >,'ical relief lu the jMticnt ; it is, of courM, 
orach mora painful for 3, few minutes. 

After removal *oire irtcllinj! often foUous, and may lasl for .i week orso, 
IniI »oon Kubtidrs. After free rcmov.il ihc cnhirKcmciii rarely rccuni. Wc 
h*vc, however, xcn iwo m three ins.wnfcs where a re-jjnowih, larifcr even 
ilun the originnl one, hat appeared .ifier a lapse of some monijiv We 
Wi'mid be inclined In look with suspicion upon such eases as possibly indicating 
a tendency 10 lyniphom.iloii.-' jjrowili cUewbere. 

We Itavc unintenti<mal1y enucleated a tonsil W'iih the iinilloline on two 
n three ocGisttui*, the whole gland i*oming away entire initead of bein); cut 
through ; the re>ult w-as, of course, uiitfaciory. It lus recently been pro- 
pMed to revive thxs old method of cnnclc-iiion, hui we think in the mujurity 
tf cases it will not be found practicable. 

After the opemtion iced milk only should be aUowed for the lirHt day, 
and milk and Hift food for the nc\l d.iy or two ; after this the ordinary diet 
uy be gradually returned. I'ainiing the lonnils with glycerine of tannin 
■her the nperatitm \s perhapt useful. 

We have nevrr seen bleeiling follow the operation to any serious extent ; 
•'hen it does occur il usually nrl.tes from injury to Ihe pillars of the fauces, 
*kich are Mimetimcs stretched over the tonsil 10 tightly as to be mdislino. 
A little ice to suck is all tliat it needed in must cases ; should ihcrc be any 
wrere bleeding, pressure or the application of the cautery, or perchloride 
of iron, mi^ht i>e required, injur)- to the carotid is of course, out of the 
question. 

The argument against the excision of loiuils, that the overgrowth subsides 

ak the rhdd grows up, is allo|[elher invalid in any severe case, for the mischief 

10 (be jjeiier.il d«i«lopm«nt, ntid often to the hearing power, is done before 

tonsils subside. There is no foundation for the idea that any wasting 

die testes occurs fnini retnoval of ihe tonsils ; it is much more likely that 

lack of developnieni uould be due 10 the tonsillar enlargement than the 

i-crse. 1'be opcialion is an nllutiether hannless and beneficial one. 

TmboJIIbi OKievlua is a ver)' tare condition, due to coUerlion of secretion 

llrilaiDinatory material and subsc(|ucn[ calcareous degeneration : the tonsil 



* YtelOHflciiMint befetiealeiiull;. tiui i1)>nip>iiiii<: ^land Imjust on its outer tide, 
■I ■ben onlargnl u often niittfktn for Vox tonsil (in-vnt. 



is entarccit, liarti, und often painrul, tlic calculus can l>e felt by a probe, and 
«buu1d be tunicd out of its taviiy. 

For ihe tonncciioiifjf loniilliiiiwiih.ideoilis, ibe reader b (tfcrred In the 
clwpter un Ui&eiun of i)iv l.ymiihutic (Ikinds. 

BaikrsBd OTBla. — Tlie uviiU ii soinctimcs autiiely iTiflame<) as patt of 
11 |>turyii^iii9 or i:bruni<::itly eiiliit^c>(l : in \\\c Uittt ctisr it may tc(|iiir(.- lu be 
9nip|]ci] I'lV. We liavc ahu mci uiili a cattc 'if papilloma ■>' <tic iiviitiL 

V«*«l Adenoid OrftwIhB.-- It uflcn happens ihat .i cliild is brnu^fbt w-illi 
all t)ic sympiomi uf tonsillar hyperttopliy— chioiiic n:ts.Hl taiiiirh. pinched 
iiosc, nasAl ubsttuciion, »iii)rin>;, nasal \«it:c, ilcafn«^4, siupidity, &c. \vidt 
Chronic Tonsillitis ^ and yti the tonsils are little if^t all cnlarg<-d. ur if they 
nrclbcir icmovat dues no) cure ihealteciion. In such cases there is pn>t)ably 
ovcrgrowili i>f the iiust-iiAsal ailcnnid tissue, the ' ph-iiyngtal Itiftiil.' ur 
' /.stuAii^ / ft'»ti/,' sKcallcil, 'this condition, which was firnt dcciibcd by 
Meyer, is %<:ry i:a:ninr>ii in diihlliiind ami is often overlooked ; ii is, Iwiw- 
ever, readily found out and tn.-alcd if us symptoms an- remembered. 

A lint:<M pasted Iwcli into the pharynx nndlumetl tiplirbind the«ofi palate 
to (he posterior narrs will feel wany, sessile, or pcdum*uUiied mastcsabiiui the 
upper lui-faiTc of llie soft palate anit round ibe pixtetior narcs, often almost 
fomplctel,.* blocking: the apertures. 

These excrescences bleed leadily, but arc nol lender to the touch. In 
such cam, xcrapini; ihc masses nvay with a N'olkmaiin'* »poon |mie<l 
through the anirnornni^t and guided by a liniierin the pharynx, i> tbe be« 
lre,ilmenL A Meyer's rinic scr.ipcr or forcep* may be cinplityed if preferred, 
or Lowenburt;'! fiirccpt and (Inllstein's tciaitrr nill be found UKful supple- 
mcnls to Ihc shaqi «piion ; lllcy arc of course used thrmi^h the mouth. It 
is far belter in ihcie cases lo^ivc chlorofonnanddothe ii]ienitiDii tliorniighly 
than waste time, and trouble by incomplete scrapiniis with ihe finKer nail or 
UppI leal ions of the cautery or Mhcr such means. If done ihotnuxMy by the 
ti>Ctllod lecommended. It l^i very rarely ne<essary to rc|ic-at the i>peration, 
ihou^'h occaiianally Kinulbii wi small as to esrapc rrmoial siihsc<|iienlly en- 
large and require tic.-iimeni. It is best to ojjcrate with the child's bead 
thrown well hark ovir the end of the tabic, so that tio blood trickles into tlie 
air passages. Thii operation is one that ihcmld be strongly msistcd upon ; 
it reinov'ci a souice ot many tniubles and much weak hc;dtb. 

The afTectmn is an exceedingly common one. and nuiy be met uith at all 
ages. We have seen it in quite the firii lew months of life, and we belte>'« 
it is sometime* conKcniial. No trcalinent except mechanical removal 
is to be recommended, though the applicaiicin of caustics uuiy id some ciuc* 
be cfrcctual. 

Vkarjnrttt* aaarrMia**.— We have met with two cases of pharyngitU 
in which evtensive ulceration occurred, and which did not appeartobcduc to 
diphtheria, scarlet (ccer. or other jrymoiic iliscasc. One of these cases urai 
a hitherto healthy boy aged nmt > ears, there was little fever, but much indun* 
tion and cellulitis at the angle ol the jaws. When se«n by one of us, it was 
impovsihle cten under chlorofiMm lo gel a good view of llie fauces : there were 
one or two smart hx-morrbagcs from the mouth jiresumably from ulceration, 
Hcuas appaftnuly reco\*cring when a sud<lcn ha-murrliiige occurred, evidently 
from the throat, which proved fatal almuat immediately : no fiott-martem was 



Post f>karyMgfal Absttss 



73 



titnnMd. In the tccnnd <:ni« ibcic 'inxv. no liAinorrhagCh, bui a deep 
irrratinn or Ihc tuniili .ind phaij-nx ; the (li«cnu> much mcmblcd in ilK 
BJCt ami c.nirw );;""K''cnoii>, iioniatiiis, iiniJ proved fatal. 
Vaat-pBttrjBCMl Anscai*.- Abscc^i in ihc pncveric1>ial fascia ■* 
»Ily eilh«r tli« rcnult of cancn of lh« cervical npinci'scc Sl'lNAI. DlSKASE) 
' of Mippuration <A the Ijrmphulic gland* in ihi) t«i;ion fiom irricalion about 
' pharynx of pmienui lurc*, 'Flic lymploms arc dyiphagiii and (U-spna-u, 
ith pail) unit ilribblios of laliva or miiciii ; a pecuhar nasal or palatal 
ancp to live cry i» dcicribeil by I'olitier.' On fxamin.itiim, a m>(i 
tnt iMclltnt: will be fell, and the po^lcriiir wall of the pharynx will be 
teen in project unduly, and poittbly ihi- yellowtih colour of ihe pui may btr 
KTO ihriHtKh Ihc mucoiu incmbrane. When th« nbicew i» due to simple 
miiniuk initai>i>ii it thouU be opened ihruush the inoulli oith a (.'uaided 
Vnilc, the (hiW Iwinj," turned on its fai:e as soon a» ilie incision i* made, lo 
jllon the pus ii>ilo» out icaddy. We have seen poit- pharyngeal inilaniTnu- 
|tiin Kwe li^c lo so much dyapna-a without any visible ixiiiitid); a» to reiidcr 
IfacbcMomy necesMi)'. (Occasionally a larK^ mucous c\'si, such as ih^l 
pbed as occurrinj; in the tonsil, will be found on the [lostcrior wall irf 

»rynx ; fr«c incision i* all lh;il is rr<|itircd for these conditions, tn 

«d«r instiinciM luppumiitm tracks round the ouier side of tlie pharynv 
ftcoi the tonsil or vofi |nLiic nr from suppurating cervical ntl^'"'^ ^^ oilier 
■ushVunii); |iarls. Where then" is eitcinal evidence of abscess \\ is better 
b awkc the opening in ibc neck, so that ibe wound may be tendeicd 
Minic, as in abiccM from spinal disease. Oilier causes of po it- pharyngeal 
ibwns are injuries and pharyngili.i ; it may also nrcur in the couisv of scarlet 
I fcvet nr be Ihc result «f a breaking-down giimina. Many easfs ar« recorded 
^Btfltai as idiopathic : it i« not iinpruluibte that some of these were 
Wiel givcsotiiii as a cauic Con vuUi on s. facial paralysis, );rea I 
ng nf the nc4:lc, and spusm of llie stcriio- mastoid may sotnctimcs ocmii 
(U. MttAeiuii^j. I'he disease lias been mistaken for many ditTcrrnl affcc- 
tNM. piiibably ntost <iften for croup. Kxaminalion of Ihc- ihroai by the c)e 
adtaicer oill always riear upadtiulil in the later stages, ibuU};li, as already 
poiMrd out, the diagnosis may be very obscure at first- 

Wr Iwvc m« with these alKtccsscs iir ijuiic young infaiiii, as well as in 
•Undiildrcn. In the last case that «t: saw a finger passed into the abiccss 
(Mity could lind its way l^elween the vertebni- and the |ilii>r>iu tipivard* 
■nriyioibe base of the skull, and downwards .ilinost to (lie looi of the ncdc 
Tie alrsrr'is was probably the result of suppuialion in a rclro phar^liceal 
*:in; 1 .1, nod caused both dysphagia and dvspnura. 

^' J liagcalatncesssomctiinesoccurs,andiiiaygiveT>seiody*pn(i:a 

iig irachcotoiny, rarely to dysphagia ; i( may be due to sptn.il 
^tension of suppuration from other pails.' It is not %n common in 

Uoi as the retr<v))4iaryngea] abscess; when it otcurs there iv swelling 

' ''iih sides of the neck, dryness of the tbttiai, tenderness and pain on 

ictnrni, witli fever and alteration uf the voire. The abscess may burst 

iiui the ii;iophagus or burrow round the neck. We hare recently met with 

ilirrecmscsuf abscess barstinyiDlotheu-sophagus : ta two caries of the spinCi 

• /nkrttuk/. JilmJe'lUHIt. B. ml II. i. a. 

• kijilrr, Anhifcf PodinlTiii. \'rU i88v 



74 



DiseiiifS of the Digrstiw Sysfnii 



nnd In ibc other tulictculoUK kI'>i<I disease wnt ihc mum; of ih« abiocn. 
Accordinjj lo itailhc/ nnd Killici, n forii) of dn' cnrj'Ui, wiih even coma of 
convulsions, may nrcur, and Ihc onset iruy l>c sudden. Aflcr the Abscets 
has butNi, * [raclion divcrticub,' or stricture of ilic Kiiller, m ly le^sull. Tlie 
proKiia«is is h\A. Fomcnialioii« nnd feeding by enemaia or an cEMiphojicitl 
tube vliould br the c^rly liealincnl, uHib incision at the posterior border t>f 
ih<- Mcrnii-mnsioid as soon a« ihcrr is d^stinrt evidence of suppuration. 

striotnro vr SiophftKii*.— A|i;irt frmn coni;enital mallbnnation*, 
arfopli;ige;tl obMiuction in childicn i> due ciilier to paralysis, or (o cicAtricial 
tilriciur«, tesulting usually from swallow Jng lii>l or corroiivc liquid*, 5uch a» 
potash, liydrochloiic acid, &i:. In sucli cases there is immediaic danger of 
si>ffi>CBtioTi fiom impli&iiion of the Uryn\, as well as moce i>t lc» dy^phagiA 
from pain and swelling. Tticsc trouble*, however, m.iy be iliglii and tran- 
sient, and yet after a liroc ciiatricinl »iTicliiTC may appear, or the obMiuctwa 
may persist from the first. 

In c)>::iiticial strictures there i* a good deal of mutcutar ipA«n pre»enl, 
cithe r c oiittaoily or fro m time to time. andjhUma ybe much i ncFr.i*cd by the 
passage of bougies. In sonic cases it is impossible to pass even a small in- 
stnimcnt viithouEanan.i'sthciic,nn(t yct.ifairsitcdoncmay l>c.idmiiied ulKn 
the child is fully under chloiofomi. .Sometimes at intervals the child is able 
to swallow fairly freely, while at other limes ihc obstruction is almost com- 
pIFtc. The piofuse serreiion of saliva and murus is often very distnruing. 
The most common scat of such contractions is high up in ihc gullet, bui they 
may be very rxicRsive. The position of the siiic^lute may be asccnaincd by 
auscultation during drlnhing, or by ihc passage of bougies,' after ihc history 
of the accident and the dysph.tgia have led to ihe discovciy of ihe ot>fiiuc> 
lion. A careful examinaiinn should be made of the orsophagus, to lind out 
if (Kissiblc Oic c.ilii>re, position, and number of the stticliiics, but bougie* 
mint be useduiili the utniiHi gentleness Wc have had a case of pcrlcH-niion 
of the (esophagus and escape i>f lluid into Ihe pleura in our own (experience. 
In n case which wc san with Mr. T. 11. finder he told us that at one lime 
■narked improvement m poivcr of swallowing fnllowed enliic deprivation of 
atl food by miiulh ; the (hild was supp.->rled for some daya entirely by 
cnrmata, and it is )>ixibaMe ihai absence of irritation caused relaxation of 
mu-tctilar spasm, thoui;h there nas a possibility that the relief was due to a 
iloiighin}; nlTof ihc edge of the cnnslrirting cicatrix .it least in pan, or rt 
m.iy have been merely ihai iberc waii .in interval in ihc progress of the can> 
ttaclion analogous to ihatotcvirting in raiei of malignant disc.isc. Mr. I'inder 
sugKCitcd ihal .ibsiincnce mighl also have diminished the siic of the pouch 
which fotiDs in these cases above ihc stricture, and so abolished ihc valve- 
hkc obstruction to some extent. 

The besi Iteatraenl nf iL-sophageal siriciiirc in such cases is usually that 
by iftndual dilatation with Imugics.^ 1~hc drawback to il is lhal relapse is 
very api to occur as soon as the daily passage of the instTumeni is omitted. 
Forcible dilatation l>y MacCormac's dilaior and internal tesophagotoiny have 

• In Of«.born childmi thi- dmnnce (roni the gumt to ihc cnrrllac orlAcc It about wen 
tnchn iSir Murrll Mjckrmlc), ; 

> Ktllcr rcccinli iliiny ft>c cms under lui> yous «( Sge wtib Iwenty-lbrceenfts, tn>- 
f(a««niPii( 111 thnv c*ms, and Dm dcalJii. (out rrmainins under irratnwnl. J 



SteaUoiutHg ForeigM Bodifs 75 

employed ; ihc inrmtr may be mtM, the liittcr i* lew (bngcmuti. F;ii!- 
tbese, (MopLtiin&tomy tiuy be perforniecl if ihe sinctuie ii hinitud lo ihe 
upper p;tn or ibc vul'cli or if not, ga«tinsiomy ; ibc laiier openilion is ihe 
wifcra nd the more gi-ncr»lly applicuble one. If an opention is to be done, 
not be put otr too lon^'. Ati soon ^» it i« clfMr lb>it diluuiiun is irtsuf- 
MMl tile child Ik luwnt; wcighi, no furilier time should be w;uie<l. 
lecarlyt and done in two $tage»(Howse}, some sutceii ii>jy be txptcicd 
pslrosinmy. iind the rest given to the t'U^'ci by the opcralion mjy 
trwli in tcfior^ilion uf the canal subsequently (Diivies CoUcy), or it may be 
p>uit>le m dilate or ditidc the stricture by ttistninienta passed upwards 
frem the stomach into ihc cesophagus. Cur details of the operations we 
■nui refer 10 thc^cncrjl text-books, in a recent case in which nc performed 
(tMrMlomy (here uas much trou)>!c from regurgitation of tlic food ibroughi 
lutrk fistula. The woimd bccatne unhealthy, and Ihe child died ol 
bcKvcen ilic liver and stomach. 

igcal iiTiclun^ ftum congcniul syphilis, and obstruction fruni 
of abscesses outside the >;ul!et or fioiii tiaction by cicatricial tissue 
^jwria-soplingcal abscess). arc occasionally met with, as in ihcfollow- 
inf taae, in whkh stricture of tite tcsopluigus followed scarlet fever : 

KuHuUi N.> IFL ibm. IukI sairlct (rm >ii mcMiIhi before admiuion, The attack 
mi'-" - < ' , liid IhxMI ami tiipjniiniiim uf cervicul |;lan<li. ShcHSt adniiltid 
^r4il A ' I rr. of itir cEvifthngii?.. tifVen.' vnouRti to hnvr prp^vntt^l >vaL]owmg 

%iA r:.l;n milk »ri<t urtirl. TIk iil»lnit<i"n u'.i> M ttie IcieI of tliR 

a*^! I . .ligtt ooiild nni \x juucd UiioiiEh ii, Thr |))uryni abai>e 

llfiii.' ' ii|t ■ iHniruiion on tlir Irlt liili' uf <lm n™li. Khtwuiublo 

"■ mimrm wilk um! Iii'c ni|i. Hud )tn."icl weight in huipiml. Slie «ai laJieii out. and 
•eui Hl«tiMd ill ihr f<>11o«i>ii|{ CKiuIkt. xhtn thr srmplcRiii, which hue) Iwrii livtirr, 
*mtat wvnc itiHin attcmpliiiK (u imillow tuine npplc, Tbere wu ibcn camplrle 
(ihnaUK. tml iin>lrr chlinufimn a ininll T^lhftvr |No. 3, Iiln|;li9l)| wnt piViK<! IhnniKli 
lit Niuwr. wlitcb mil .ijiimicnll^ eitnidnl lit a cuimilcmtilr illiiiintc When hr.iril 
■^t** )»»n artrmntils, flir ("Utrl rnt I'tr^l unit tiutlt-i mid mulKxl [wlsloc) vrry hi'U, 

oaM nm g*( Aomr> innl. Mhc uMk adl nuuiiihnl. 






■■MllvwinK W»w*igm a«MlM. — It is very common for children to he 
r btiyhi with a histor)' "f having swallowed a farthing or button, or some- 
I ttu^ at the kind, and much alarni is caused to the child and tls friends. 
I Is Buny casct the hiMmy is a mistaken one, in olheis the foreign body 
I iaMet into the «(om.-tch, gives rise to no symptoms, and is voided in a day 
I V ivo with ibr motions. 

Thr onl> treatment recjnired in such cases is 10 f.'ivc the child plenty of 
Wit, |iiitaio4's, soct puddini; 5;c, to provide a sufficient f;ecal ^hcalhinj; for 
lie hjnntrss passage of the body. 

la votnr few itvstancet, however, an angular mass such bs a bone, or some 
4up^nt«d objrri as a pin. may be swallowed, and may be arrested in the 
ttoiyiuc or irsopbagiit. In such case* there is UMially some obvious sign of 
*i prewnce, swch a* pam, dysphagia, rctcbing or vomiting ; possibly some 
Uood-flained ntucu* is brought up. 

If ibrre is no urgent ilyspnce-a,A careful examin.iiion of the fauce* should 

*»t be m«dc, to sec If the object i> not lodged between the )>illar« ; failing 

the fingeT should be passed to Ihe baclc of the throat, and the rwX of 



76 



Disfasts of thf Digestive System 



the tongue and cpigloilis be scarclird, ciifc being lakrn not (o mielKke ilir 
comua uf the hynid fni a foreign body. U nmhing i« fmind, xaA lh« site of 
ibc btxlj' tan l>c felt from the outride of ihc neck, and especially if the mau 
is hird, anguliii, and insoluble, nn tiitcmpt should be made to icmow it 
with Ihc bristle proband or coin caicher, or failini; these, pos§ibl>' with 
asi>ph»)(cal (fircep^, iliough these are inoic d^n^-eroiis. Kailintf these p!an«, 
tbeelioicc lies between an attempt ii>puRhlhefi>iei>,'nbodyoniiilolhr sionuch 
Jind die perfoimance of a'sopli.igoioniy. The lirsi plan should be followed in 
the majority of ciscs. atxi can bf best tTmnH),'cd by the k<^"<'c> steady ute 
of a ^'ood-sitcd bougie. It is applicable to instances where the forci)i;n body 
is soft, smooth, and rounded, .ind not likely to j;ive rise to tioiible In il* pat- 
sa);e thto^yh theiiitc-5iLnri, It mitsl be remembered th^it afcclinKof lorcncu 
and Imlaiinn may remain about ihc fviurcs for snnic time after the piu-iagc 
nnd rcmov;il of .1 foici);n body, and may ■/S\'e rise lu the lielicf ih;>t there is 
still something thcie. In cavei^of swallouinx fi«h boncisaml ihcit bcciiminj 
impncrtcd. doses of hydtorhloric acid <>r iinet,'iir .nnd unler may In.- given, 
but the ieini.-d> is unpleasant and li.-dic>u*. An anieslhelic may be used to 
IciM-n the Hiiromforl of examin^ition. Minetics, as a rule, arc not %<otA 
tre.-ilmcni. 

(Bsvphnsltli.- Infantile a-sophaKili«, fint ducfibcd by Biltard, n u rate 
discaie, mppOMrd to be aiUM:d by irritation from bad milk, iin|>TO|ier feeding, 
or anre nipplci.. The tympiomi are unwillin^fncu to tuck, cryin); and im- 
mediate re){uri:itaiion after beKinninjj ti> luck, and oAen Kinie tenderaest 
about the neck on presMire. The inflamm.ition maybe local orKennnl,and 
may giw rite to ulcem or idoujchint;, and possibly to lubteqiu^nt stricture: 
Tile pn)|!no*i* ii^ I">*) i the tliiciso may come on immediately 4fter. ur even 
Cxiit at birth, [t ii not likely to be miitnkcn fur anylliing cxcrpt (.-ongcnilal 
malfumiation, in which the ubilrtictiou is abnulute. CleanlineM, ciirebl 
fcedii^, and the ;ulininiiitalion of t;Iycerine of borax in tmall doMrs, con- 
Mituie the t> eat mem.' 

Other rare cr>ndiiionK met with are cungt-nilal liyperlropltyof ilie inucou* 
glands and vurix uf the ii;M>phu];uv 

> Sii Morcll Mjdkclll^ 



71 



CHAITKR V 
MSKASTRS or tllK IIKIKSTIVK SYSTEM {epnlimitd 

.aiioD «ttlie Abd«Hten. — /ntjvilion.- 'Ilie iilidDincii in infiinry 

iriHiii.iAply liitytr iind ii u<iuHlly more ditltddtil ilian ihe abdomen 

of idilts, and this is ai oni-c sppuitnt "n inspcciion us ihc mCiini In.* iiripiwil 

n itt cot or cm 1(6 inoihi-i'^ !»(}. An CKAg);i: ration <if iliis i-ondiiiun n oficn 

mil in CMSC6 nf chronic ilyspcptb ni iniesiin.')! cntarrh ; ilicre is great 

dHi«n<iion of I he inicsiincs with ' btiunil wind.' t]i« abdomen bein^' mud) 

-(icm««d in girth ^nd the skin stretched ^nd sliiny. If. as is often the case, 

^_ftnc if more or less wasting of the fatty lissues, the lai^c nbdomen con- 

^B*'!* tlrikTiKcly with the wasted stnd shrivelled fbrin of ilic infant, gt^ \a^ it a 

^Hkry charAcierislic nppcaiancc. The Urjjc liver nf the infant is rcsponsib'c 

^Bto iseae exicni Un the disprnponion-^ile siie nf the ab<lomcii. An insjiection 

if ihe ahd'-meit will reveal any enlaigcd veins on Ihe surface, or ihi-- 

fewiceof tatKc lumoiirs or an cxCMsivc nmniini of lluid in ihc petiioncuin. 

TIm imihiliciis will be examined at ihc umu' limr, and any hernia or local 

ltM« here ttoiccied. InMead "f a distended abdomen, the condition of 

btMu or rctraciion may be present, especially if there is acute cerebral 



P-ttfation—Tht muscular wall of the abdomen is compatalitcly thin. 
Md ku ng^id in infants and young children than it is in nduli^ and con- 
HfKWly palpatmi yield* more certain rcsiill<^, and is of greater vahie as .1 
niun of diagnosis in the former ilinn in the Initcr. Thut in young children 
dKe^ie of the liver, an entargcil spleen or kidney, frees in the colon, a djs- 
Mfcd bUdder, a mallrd and thickened omcnlum, and even enlarged 
■CMneenc glands may be felt by more or less deep pTcmuc by the hand on 
At abdnmi-n. It is nccdlcsi^ to say that the conditions arc not always 
bomtUc : di*iension of the intestines nith jrases so as to bul};c and distend 
k ahdominal waifs will ncce»nrily interfere with julpniion of the abdomen ; 
ten, again, a fractiout and crying child is necessarily difHciili to examine in 
lb way. Hut even under the most unfavournble cinrumitancet, Ihe wami 
Wl, hid AR the abdomen and firmly pressed in, may detect a tuniour or 
MM enlarged organ, and information lie gained which may be of great 
i^raatagc in making a diagnotii. Kven ascertaining Ihe lensentss or in.xity 
■f the abdominal walls is of importance in foi-ming a diagnosis between 
Gtrebal and gastric vomiiing.as in cerebral disc.-iie there is mostly a relaxed 
flhe walls of the abdomen which enables the ed^e of the li\er and 
otiict organs 10 be fvit with abnnnnal distinctness ; while, on iho 




78 



Dhfttsts pf the Digestive System 



«lherhand,in KUtrn-inlcstinal disorders there i> usually more or Icfs distoH 
9ion of the ttamarti .-inil howelt, ilic distended organs intcrfcriDg n-itli iJ 
thorough c:(ploration of the abdominal contents. ?^lpi)tion may gnt] 
A'iiluablc inromintion witli regard to pain and tendeiTicss in the ab<loiM%l 
provided ific ciliscr^er is alive to ilic fallacies ivhich may ar>sc iliroagh Ael 
fractiousness of his little paiieni. | 

Vi^j ptrtuition the invcstigaior it able to con^rm the reMilts obtained by i 
palpation, and gain informntinn not ntliervrisc obtainable ; thus he maynup 
out \yf percussion the niiiline of a dilated ntnmach, or ascertain the llmilS oT 
fluid in (he periloncun). 

Anatomically ihe nbdomco of the infant difTcTs from the adult*! in ikat 
ihc liver n proportionately larner in the newly born infant, oeeopying at 
leasl half of the abdominal tavii)-. The inferior limit of ihc liver it ei»> 
secjnentl)- lower, and the left lobe coven the stomach to a greater cxtcni ia 
the infant than m the adull. l*hc infant's itomad). lo far as slupc it con- 
ocrned, doe* not differ in any important respect from the adult's : the raidiac 
curvature is perhaps lesi hcII nurked, and it coines into closer relation mnlh 
the liver and spleen. As a consequence of the thinness of their watlt, ifae 
siom.-ich and intestines are apt to become dilated during infancy frooi the 
pressure of ^ases given off from tlieir totitenis, aiid-io remain more or tat 
constantly in a distended state. The larye inteslmes — niort specially tlit 
cxcum. :iscendin^ colon, and sigmoid flexure - ate more movable, and con- 
sequcRtly mote easily dragged froi» their normal positiun. in infants tli;in n 
adults. 

Thi* is especially true of ihc sigmoid flexure : for sometimes al an 
autopsy the sigmohd flexure, if distended with gas or f.eces, may be found 
much displaced towards the right &ide. This must be remembered in pil- 
patinK llw abdomen, for fscccs which from their position may appear to be 
in the ileutn or o^vcum itiay in icallly be in a ihiplaced sigmoid flexure. 

Tlie B7Bp«Ftle Dl*eu«> «f iMftaier >nd Cbll<lbe«4.- - No inCist, 
whether fed at tJic breast or with artificial ftrads, escape* having indiscstioo 
in one fwm or another ; various rlyspepiic ailments are certain sooner or 
later to supervene and form no insignificant part of the troublesofan infant's 
life. We have not fat to go to seek an explanat<on of this, I'he alimentary 
canal of an infant is e^iceedlngly intolerant of any fotin of irritation, while, 
■wtlh very slender resourrcs to fall back upon, it has to perform a large 
amount of n-nrk in the digestion of food in order to make good the losses 
inridenl lo life and supply suitable material for the rapid growth which is 
taking place. During- the whole of infancy the digetiivc apparatus is worked 
to its uttermost capacity in digesting the food required for the infant's main- 
tenance and groB-ik, .-uul any overtaxing of its powers is vcrj- likely to be 
follon-ed by disturbed function. The rommonctt causes of indlgenion 
in in&ncy are ptsctically the same as those in .idults, the apjieliic perhaps 
h in excess of the digestive power*, and more food is taken than cnii be 
digested, or the food taken is <>f nn improper qu-nlity : in both cases the 
result is the same, the presence of decomposing (tiod in the alimeniaty canal 
giving rise to vomiting, flatulence, and diarrh<ca. In some cases the 
vomiting points to the stomach being most affected ; in others the passage 
of looM stools conuiiiing imdtgesied food, with much flatulence, indicates 



Flamifnct and Colic — Votmdng 



79 




tbM the unall IntcwinM are involve<!, ilic large bowel wlicn colic, lenesmus, 
and an exci>riatcd cofi<liiion of amis are ptescnt. Before long a caunhnl 
itton of tbc mucous mem lira nc is '>et up, or in the milder tiises perhaps 
re i> a deficKoi secretion of ihe digcsllvc juices, or ihey are impaired in 
ty w> ibai iIk food laXeii undcigocs decomposiiinn, irritates the bnwelt, 
id leads lo its being (|uickl)- cupelled instead of undergoing tlie normal 
ess of digestion and absorption. In discussing iliese dyspeptic condi- 
tions arising during infancy and childhoud, ii is convenient to consider the 
pnxDineni symptoms separaieK', always bearing in mind, however, that ihey 
ve only symptoms of morbid conditions and not diseases. 

^lktaS«a«» and «oUo may be present imaccompanied by tiihcr vomit- 
ing or diarrhcea, both bieasi-led and boiilc-rcd babies alike sulT<^riiig, though 
the liiter do so more frequently. It is the result in many insiances. perhaps 
noitficiguently.ofihe infant taking its food too quickly and in too large <[uanti- 
Im: digestion t^ performed imperfectly, dccnmposiiinn in the small intestines 
miK I. and gases are formed which distend ihe bnucls. The .ibdomcn is 
dsiendcd. tlK infant is restless and cannot sleep, i( i^ constantly crying and 
wsMig about. ;iimI if it brings up or passes lar^e qvianiities of ilatus, ilicre is 
BKh relief tase for the most urgent symptoms m;iy be found in »;ii'ing the 
ab« a leaspoimrtil or iwo of .in equal qtuiniily of lime wnicr and I'innamon 
•MO', or small doses of carbonate of ammonia and soda in pepijcrmint 
•«ier, (It a sinall piece of the compressed skills known as 'soda-minis,' 
d.SMltcd m a little syrup. It nlll l>e necessary, lempnrarily M least, to 

■ he amnont of food which the infant is taking ; this can be done in 
fed children by liiving thcni some sweetened lurley water or whey 
taking the breast and not allowing the breast to be given for too long 

IM ohrn. In attitictalty fed infants the amount of food, especially the 
Mwunt uf curd, must be rcducciil either by dilution with barley water, lime 
■Mtr, or by predigesting the curd. Large enemai.i of warm water 
{■o-t$(U.| aiK) hot fiimenlalions to the abdomen wilt >;encfa1Iy relieve the 
•ntnr case* of colic due to flalulcncc, and a grain of mercury and chalk 
pndcr nmbined with half a grain of Dover's |K>wdcr may he given by the 
■mIl CsLfboiuiic of magnesia w lib syrup nf ginger is often utefiil. 

Twin 1 1 m Vomiting y. a s'cry common c(imt)liiint for which mcdidl aid 
b MughL That this lomiting is rtadily brought about i> hanily to be 
wodered at when it is remembered with what vigour an infant will suck, 
•Ml yei the stomach of a newly burn iitfant cannot hold more th^n a wine- 
;l<Mrfiil uf rtuid niihout being over-distended, and thai, morco\er, during 
tctstiim xcttte pensialiic movements take place, Tlie must fre(|ucni way 
o wUcb food is rejected from the atomach is «bat is termed by mothers 
'pos-cting,' which consists of cnictaiiuns of small quuntiiics of iluid from 
taeifl lime willioui anycffori, the food escaping from ihc corneis of the 
«Inif» mouth in consequence of a too vigorous peristaltic action of the 
iiiMiii ti fluid will also frequently regurgitate during the criictniion of 
'■■■'- f'""! the »totnach. In true vomiting there is moreor less retching, and 
I'. {>f the stomach come up with considerable force. The most fre- 

■ u..<:nf this is an irritnbtecondition of stomach ducloacaiarrhalstale 
<( ilir mucous membrane, ihc curdling ferment is abnormally active, w^hilc 
'..: ili,:i->tive fenncni is present in smaller quantity than usual. Vomiiinj; 



Diifists of l/if Digtslivf SyHfM 



nf^nts who 



takii 



etpecialiy coniinon in ml^nts who are taKinf; cow's milk, and who wn 
un4bl« (i> di^c^t (he \:\r^c <tuantitic« of hard cuid cnninincd in iht- milk, 
tlic slomarh prol>nl>l>- loiilaininB ciiiidi dcmiiipnsinjt ciiiil .ind inimiv 
IjutnciiniM the vomiiinK 's the re*iili nf (ivtT.<ii*(cn*ion. or ihc rnrnmiion i>f 
CKCi"i<iive (jilnnliiii^K nf Kiises, nt of cniighing. The Vflrniiini; of hTcast'Tcil 
infiitili \s often <iu<' lo ihdr being given ihc Vcast at too fVcqueni inicn'ji'*, 
or to siMTc other ■aiit<-, si^ the ingcaiion of unMiitnhl^* food vm tlie p«n 
of the mother ; or she mny hf sufferini; sonic jjrrjit iiiui<'ty, which i« in itwlf 
quite MifTicieni to caufc an sIltTiDiinn in the quality o( iW bira«i milk. 
Vomiiing may Ix" the result oi »omc ronnrniial or acquired obstruction of 
lhebo«e1>i. It muM alio be l>nme in mind ihat vomiiinn: in infants acid 
cbildrcn is frcqiienily reflex, and not due to any lesion of ihc Montarh, hui 
lUe reuili of ci^rtbnil disease, as meningitis or tumour, or iff the iirtfali'in 
cause<l by ciillin^ a tnolh. Vomilint; n soineinnri the Aral, and for a time 
ihc only, «)-int>tam in lulicrcuhir meningili*. and may precede for .1 week, wr 
cixn longer, ;iny marked cercbml syni|i[oni). Keflex vomiting may M lir>t 
be entirely ulldi9lin(;lli^llnble from dyspeptic vomiting ; ibe cond'lioo of the 
Ioni,iie i» no ciiuin guide, ami it is only as the cerebral syinptonu become 
more marked, the ubdomiiui) walls either retracted or in a toneless. Aabby 
condition, thai u diagnmi), ijaii be made. In older children the voiniltng uf 
ar, acuio gaitri<_ catarrh may last for a few da]-^, but tiny long'Cimiinuvd or 
habitual vomiting is iciy suspicious of cerebral disease. Mystcricul lomiting 
is occasionally seen in giiU aliout puberty. Vomiting is usujilly an early 
lyniplom of scarlet lever and also of intluenta. 

The treatment of vomiting must nccrsvnrily depend upon its causc. 
Vomiting in the brea»l-fcd infant, provided ihc mother's manner nf life or diet 
is noi iu fault, it proliably the result of too large quantities of milk lieii>s 
taken and it will gcoerally be lufficieni to inviM ujion regular hours of feed- 
ing at not too fiequrni im.;rv.ils and to give the infant n few icKpoonfulft nf 
twcctcncd lime water before it haa the bre.iit, niih a (l<«e or t«o of hyd. C. 
crcia to act on the bowels. Vmniling in ilit hott leafed infant is morcdifliculi 
l» deal wiiti, especially when a g;istrrc uitarrii exisl>. Tlic infant is under 
these circumstances very intolerant of cow's milk, even « hen Urgcly diluted, 
the mtllc being quickly curdled by the acid mucus in the stomach, »nd the 
hard lumps of curd arc vomited in masses. In the milder cases of vomilinf 
lit infants, it may probably be sufficient to resort 10 dilution of the milk with 
barley water in the pTO|>onion of one-third to two-thirds of the tatter, orio the 
use of Mellin's Food. .Sterilised milk and condensed milk or desiccated itiilk, 
if properly diluted, ate nearly always retained more readily than fresh cow's 
milk by infants who \omit. Whattvcr footi is resotted to, great care iiiiisi 
be taken that ion brge quantities are not given at a time or taken too 
quickly. In severer Ciiics, where no form of frc.vh milk i' tolerated, milk 
peploniscd by the ;tdditiun of Hengei's peptonising powdcn, or the condenhed 
pcptonised milk sent oulin tinsby .Savriry^ Moore, air fretpiently useful.anil 
are rct.-iinc<l when no other form of milk is tolerated. If the vomiting i« 
sei-eic and continued, tlie buttle must be done away with and the infant fed 
by tlie spoon, or a wet nurse may be obtained. In some fonns of severe 
vomiting there is an inability to retain any form of milk, and veal broth or 
lurlcy water must be re ontd to for a while at least. An alkali, such as cw> 



Diarrlma 



8i 



f witli tuo or three grain* of |>«pMnc in poiniler, may be givrn 
dciTc RiCiulii, and i^ often of use ; or faionuth and mix vomica may lie 
Iven. fK. 5.} Wiistiiiig out ihe infant's itoniMcli is often :■ useful expedient ; 
infant ;:casini; to vomit iiRer acid inuciu and dcconiprMin^ curd b.ive 
cfi w;ishcil out, 

Bl»*m«a.— Looseness of the bowels is symptumaiic of many different 
>rs andmorbnl ci)ii<Jii)on*. Anattackof diarrliu'n freigucnily ushert in 
: fwcr, or niay be present iit all stages of Ilic niali^.'n^nt foim ; it nmy 
ipany typhoid Icier: it is often prc*cnt in septica-mi;), empyema. 
T.cmi-i, pcriioniiis. The cnmnionesi fonii in children is (he result of 
I accuntuUiinn of undv^'eslcd food in the intestines, or of some iriLiatint; 
crs taken in the foo<l. Infants nl the breast are liable to suffer from 
Mictwss of the Uim^U soon after hiith on ncrotinl of the colostrum not 
cinK I'ith them ; they jrc also liable to suffer from the taking of ini- 
EiAkkI'xi the pan nf the mnihcr dminx laciation : over-feeding or :i 
tiif WVCfi or (•tlicr stiotit; emotion on the part of the mother, has been 
ksnvn to lie fi>ll<mcd by itiarrh'i'a m the infant. .Aitificially fed iniiinis 
ve much mure liable to siitTur th,'kn infants at the breast. The difficulty 
tvitli which the rur<l of cow's milk is dijfcslcil overtaxes the di);e9iive 
■ets the un<li]{ested curd irril.iies the bowels, And increased peristalsis 
. *et Bp, An inlcsilnal caiairh is soon established, the inf.int is restless, 
Fftensb. and <.annnt be ^01 off to sleep, the abdomen i^ distended uitb gas, 
theleKs ar« drawn up, ami the infant pastct perhaps fire or six stools or 
■on pn diem. 

An examination of the napkin shows, instead of the brijfhl )*ellow homo- 
inWMis stools of the hr^^hhy infint, curdy llaken or other undiitested food, 
iiiliiK'reeni^b slimy liquid which >iaini the diaper. The infant is thirsty, lakes 
>hr bteasl nt the bottle vigorouisty at fint, but is toon talliAcd and pushes it 
imy when nITered. The tongue ii cmiied and the mouth n often the seat 
■'([ihihous htom.-iiitiit. \'omiitnt,' 'nay be preicnl, but is mostly nbt en I. In 
4i»y DC two the inf;in[ betjins to waste, the muscles i>f the limbs urow ftahliy, 
ndihc «kin lunK^i ^binil the thighs in louse folds, and the parts nbinii ihc 
Mn and genitaU become ri-d and frequently laiv. In most c^tscs improic- 
n«it takrk place Jiftcr a few days ; the stools betoLiie mure normal and the 
atuu quickly recovers. Some infants arc liable to such aitarki especially 
•Iwioic but weather, and the final result may be u mure or lei:i chronic con- 
AtMB nf CJtarrh, to end finally in genend niatnulntion from ^-attro-iniciiina! , 
^Kivfihy. kickc^^ ii a very frequent sequence of intestinal catarrh. 

S'ot infrccjuently the symptoms point to a calurrb of ihe laijjc bowel, and 
<M iiHMc nf a dy\cnteric character. Dyienicric diarih<ea may be primary, 
<r fallow un attack of limpte diarrhuia. the j^cncr^il ulVecdon passinj; away 
and IcuvinK a local intlamnialory condition in the colon, sifiinoid flexute, an<l 
, itriiun. 'rhc same fonn of diarrbiva frequently succeed;) whooping cough 
RMuiile^ There is distension of the abdomen, with often more or lesi, 
enio* in the l«ft iliac region on pressure, frequent fKissage of »mall 
•trwiK consislint: largely of mucus, biliary matters, .ind perhaps blood, 
ied b>' much straining and foicin): down and frequently followed by 
jp»e of the rectum. Older children often suffer from this form of catarrh 
bowel, [MSsiiiK luinpy mucoid stooU, and geitiiit; up perhaps 

r. 



82 



7/xrases vf the DigfSliVf System 



Kurcral times in ili« ni(;lit to sit on ih« vessel, only [laMing c 

mucus itr.-jkutl with blood. Dyimlcrii: dutrha-a it apt to become chronic. 

alienimcty belter and u'orsc, until iho |>nii«nl is reduced lo a condilioa of 

n'salinfi- 

Sotiieliinvi dysentciic diiirrho.^ otcuts in epidemic* in winter a* well n* 
io summer. We li.ivc known se^ernl «tich epidemics. 

Older children snnieiinies h.ibilually siilTer frnni wh.tt h.13 been termed 
Mienteric' dinrrlia-Ji, in »liich .1 loose siix)l is jp[ to follou' ilic ingestion ii4 
food. Such cliildren nre generally subject to loose Ixiucls, a diarrlMCal fttooJ 
following any fonn of ctriiemeni, espccinlly .1 fiighi, Ibe immediate cause 
beinj; .\t\ eKaggemicd pcrisialiic .iriion of ihc ileum and colon. 'I'hcre is 
often in such rases a catarrh of the larKC bowel, as evidenced by the cvccM 
of mucus uhicb ihcy pH» : phihUic-il children aUo may tufTcr In ihif nay . A 
form of dianhrra which has Iwcn lermetl ' fat diarrhn-a,' from the presence 
of an exee»ivc i|iianiicy of fai in the itiioU, hat been described, which i\ 
presumably due lo ratarrh of the duodenum and pancreniic duct. 

In the )ili|;hier formi of diarrhtca in in&Bt», where there is not mach 
rcstlenneM, dixtensian of abdcmicn, and not more than four or ^vk loose 
stools during the day, it will be usually suRiacnt 10 undcrfL-cd them for a day 
or two, and %\\-c them lomc mild laxative, as caiior oil or hyd. e. rreia. and 
a simple alkaline mii^lure- Infants at the breast maybe jiivcn a feH- lea- 
spoonfuls of sneutened larley water m lieu of the hreaM, or after ibcy 
have been partially »aiiilied at the breait. Itoidefcd children should have 
their milk niori^ diluted than usual, or a mixture of creiim and barley water 
may l>c subiiiiuitd for the milk. 

ir the putting IS at all severe and eiirdy tnai»i-i arc vomited, or appear in 
the stiHiU. it uill be best al once 10 wilhlioid all milk for a day or (nx>,and la 
substitute some more digeiiibic and less rcrmeiiiablefuod. J'eptonised milk 
will sometimes ans«-er very uell in the less severe forjiii of diarihiea, but it 
must be borne in mind thai in any );i\en case much of ihe curd remains un- 
converted into |>eplonef, and the unchanged curd may often be seen in large 
qunntilies in the stools, even where grcai care has been lakcn m the pepto- 
nising of the f<Mid -, (lepionised milk is of more 9er\'ice in (jasiric catarrh and 
vomiting than in acute diarrhtca. In the severer casek where ibe slooti 
arc freijueni, the blaiidcsi and most iinirriiating foocb must be given ; such, 
for instance, as— 



Arrowroot water 
Whey 
^\1)ite sugar 



3 ounces 



I teaspoonfiil. 



or 



Uarley water 
While of rxg 
While suffar 



to ounces 

) (luiicv 

I or 1 tons|inonfiils 



I 



Citlter of these may Im* j;iv-cn oui of a bottle every few hours, and inamotiati 
accoriling to ajjc. Veal bioih n also vciy useful. 

The medicinal treatment in the early ilagc consists in giving a Uwttivc 
forlhe first twelve or iwenty-(»ur hour*. In these cases Ihe diiirrhizh is 



ft 



fntably the mull of a congMlton of Ihe raurous membrane of the iniesliDe, 
inlef ibe presence of trnutiiis. periiupi pulKic«nt maicdnln, anil ii i% vmcr 10 
ana diminatiun ihanatlcnipi laprvv«ii(iibyiiieaniaf ofiiiunoraslrintccnts. 
Ta dui cod unuUion oj ca^iiur oil or small ilosci of aiiomcl ' { in } irrain) 
luf beciTcn, ihe laiicr Iwinj; prrferabk if IhiMv is »-«miting, on account of 
01 being niore readily fetaintd by ili« siomacli. (,¥. 6.' 

Bj' Ibe cimI of iwcnt)'-four or forty-tight hours ibi^ taxativc will have done 
al itw 00 bt cxpctifd <rf it, ai>d the stooN will be >t|[ow, hamogeneout, 
ud kit freijuent. A svdxtivc nuiy now be useful, udi u bismuth or itnc. 

In ikc majority of cas«s of simple di.irrha-a tbc attack is arresitd by lbe«e 
mcm^Banuily, j liquid dwi iii which mitk is excluded or given ipanngly, 
ladaUi.itivr for a day Of lu'o followed by bisnuith nr linc. It not unfre- 
qMit)r luppens. hon^vcr, that si simple duirrha%t wtlhotit uigcnt symptoms 
|uus Mddeiily into ih« acuic or intlammaiory fomi, or. on ilie other hand, 
hint tnd in a more or less chronic condition of looseness of bowels wiili 
Bubd loss of desh. 

As improvcmeiii latcn place, milk diluted with whey or MHIm's Food nuty 
ttilbwtd in small qtianiiiii's, or, what i» uscfiil and icadity prfpnrcd, milk 
Akud with iwke its bulk or an cqunl quantity of JtirowTooi water (a lea- 
jfoonhil to lOOLjand sweetened with white sugar. Malt cMraci m»y be 
MtA a few mintites before ihc fnod is taken. During convalescence, diluted 
Kidi *iih |M:pstnc Of asirinKcnis arc the best remedies. (F. 9 and i<x) 

OtaaUp^tiBB. - -Constipation is one of ilic minor trouble!) which arc of 
MWfrnjoent occiirmioe during infancy', and for which the advice of the 
(naiuoner is sought. Roth breast-fed and artificially fed infants siiffer. 
ibMEh the latter far more frequent ty and severely I hun the former. The 
kallby Inbnl passes iwo or three semi-liqtiid homogeneous oningc 'coloured 
UMb daily without cflbn or straining, uliilc some infants appear 10 have a 
diSculty in defecatran from uant of cupelling [wwer. but at once pass 
a&iriy heahhy siool if the colon is retleKly siimutaied by inserting a small 
Kfpostlory into the rectum. In the majority of cases, however, in which 
ounipitWHi exiws, the stools are dry and pale with an excessive quantity of 
Bucut, and an evitciiation only nrcurt once a day, or perhaps once every iwn 
orthiwdays. There iMnually much straining before the siool is passed, 
sd perhaps lomc murus tinned with blond may accompany or follow the 
ttoL Infants who suffer much from constipation arc usually wcAkly, 
aamiic, and dj-^pcpiic, but they arc by no nicans always badly nourished 
asfira^ £it is concerned. Rickety children during ihcir second .ind third 
yan mouly lulTer more or leu from consiipaiion. 

It oinxt be home in mind that constipAiion \i, only a symptom, and may 
be ihe remit of grave cerebral <h«cnie, or there may be Mime congenital 
nalfortiution ftf the mteitinc. In the majority of cnaa ii is the result of 
a »ant of lone in the large bowel, which m chronic caie» may be dilated, 
the perist.Tliic action being stuygish and not caiily evoked ; while the intestinal 
juii-ci arc scanty and the bile delicicnl m quantity. Mucus -ippean in these 
children to be setreled in excess. There is apparently also a delicienl 
digestion of ihe curd of milk, the f:ece» contain an abnormal quantity of 
solid matters which accumulate in the colon as it is poivcrleis to expel 



84 



Ditfnses o/ tkf Digtsltve System 



iheni. In some C4»cs consiipatioii is due In a dcAcirncy or (al in Ihc ImkI, 
(he f^cn nominlly cnntnin fai, nnd ii ap|>cais W act as n natural pun.'attve. 
Fluid fcFcc^ in the colon seem much more readily m mritc perixtaliit 
ihaii solid Caxal mttttcrs. Infants who Are constipated usunlly have ab- 
normally diiicndcd abdomens, and ficcal musics may often be hXi in tbr 
Iransvc tic and descending colon. In some cases contiipation i« dixlinctly 
hereditary: mothers who sutler much {mm Diislroubleoficn have infants wlio 
also suffer in this way. ll seems likely ih.it in some instances the mother'* 
or nurse's milk may be poor in quiiliiy, <>nd csjiccially deficient in fat, and 
there may in consequence l>c a small ainotmi of f.Tc.il matter. It must not 
bu forgoiicn that narcotics in small doses conslipaie, and bromidei -lhou]|h 
in IcM degree— have the same effect. 

Il is needless lo remark that mnslipalion is a frequent trouble n»I Mily 
in infanti, but also in holti young and nldrr children. Fat, rickety children, 
who arc laic in walking, very frequently suffer in this way. In uime, con- 
stipation and looseness of bowels alternate nith each other, ll mostly, 
perhaps, ocirurs in those children where milk in too large quanlities is uiven 
and is not well diKesicd, as evidenced by the large solid pasty stools. In 
filder children it occurs in lhc»c who lake liillc excrcitr., and who l»vc large 
appetites : though in some of ihcsc rases il appears to he hcrMlitary. If an 
infant at ihc breast suHcrs from conilipation, care should be taken lo lir^t 
inquire into ihe diet and habits of the mother or wet nurse. An analysis of 
the milk may be made to determine theamniml offal, it may he necessary for 
ihe mother to take mntc in the way of slewed fruits or some laxatiremcdtciitc, 
such at confection of icnna nt caicara. In siime >*aies the in£int*s stools may 
be fairly normal, and tbc infant appears to suffer from a want of expelling 
power ; thii may be ovcrcon\c by gentle friction of the abdomen with the 
oiled hand, or it may be necu-t^uiiy to reilcsly stimulate tbc colon and ab- 
duininal muscles by intruducint; into the rectum .1 ^rnall soap or other sup- 
posllory, or a few diupi of jflycerinc and water. In artificially fed infants of 
feeble digestive powers, treatment is often much less successful. The first 
consideralton is tlic diet : ihii wilt prob.ibly have to be changed in the diicc- 
lion of diiniiiishing the quantity of curd, increasing ihc amount of fat, ami 
adding some fonn of malted food or extract of mail. Oatrnt^nl water, or a 
smalt quantity of finely ground uaimeal added to each bottle, may have the 
desired effect. I'ersistent and carefixlly applied massage to the abdomen by 
a tniincil nurie is of much value in obstinate cases of habitual constipation. 
Knemaia of glycerine and water '.')** 5i) or olive oil are preferable to medi- 
cines for habitual use. tilyccrine suppotitoriCH aie often successful. Uilter 
and nauseous medicines are to be avoided as far as possible, for it Is more 
Hum likely tlicy will not be persevered with by the nurse or friends. In ^ight 
cases iHe to ten grains of the old-bshioned manna, or a leaspoonful or two of 
fluid inaRnesia, may be added lu the focrd as often as is necessary, but it b 
mote than likely boih of these remedies will have been tried by tbc frieiMls 
before medical advice is sought, and indeed they will only be i>f service in 
slight and easily overcome constipation. When these fail, small doses of 
' cahxnel {^ | grain) twice a day for a few days will, if aided by enemata, nfteit 
I HCCMd in bringing about a more aniisfactory state' of things, for a while at 
leatl. 'llie Aind extract ofcascata in live to ten minim doses made intoa 



iCKff Uatfnc Catarrh 



nnlial with Ir. and synip of ifiangc peel is often uscrul for continued use ; 

4, jsU|Ki- ITS, Of injcclto gfyc. jalap.'c res. may be of service. Wc have 

Icflcn fnond Itq, hdaliiK and pcp^ne t>t Ilq. cuoiiymin and pepsine in 

)l) to :o minim Aostt ^cry uMfiil in the conMipaiion of infant* and children. 

la older children ihc diet mu^t be carefull)' rcgulaled ; paltry. »ill meat, 

I aad ■wccts must be forbidden, while oatmc.il, j^ceen cooked vej-elables, 

I Slewed fruii, orange jiilcc, stcned prunes ^and %s, may be ^iven with di*- 

. cteiioo, Spong^intc vnih cold water in the morning, plenty of outdoor 

I eiercise. and only a moderate amount of brain ivork, should be innisted on. 

' Of medicines, the mo«i efficacious Are some of ihe miiicial wateiv, »uch tn 

Rubiniii, jl^.Kiilap, Fiaiu losef. j^ivcii in narm H-atcrnr milk overnight or the 

fitU thin)( in the motciing. Giaiiulcs coninining ^ ^rnin of aq. extract of 

ahm or calomel \ itrain. with ex. coloc. co. f ^rain.are useful ; or ) ){rxin of 

tet. ptxlophylli. Itut wc frequently lind in practice th.it children will neither 

itke mineral wnten mir granules, and we have to fall back on such drug 

>«eettne.-it> at nucara chocolate banbons, or'iamar tndien'loKnges, which 

aie pleasant to take, and in some instance* at lea«i very efiectual. 

,Tbc Ji. and W. tablinds of cascara or cascara comp. or bl-palniiRoldt 

nhetiner) of sulphate of iron and ;ilciei or cjiscam arc readily taken by 

rcbildien- In aniemia oith constipation the old-fashioned mixture of 

krroiis sulphate and mag. sulpb. is very efficacious, but itauseous. {¥. 1 1.) 




at. 

^BMII 



Aonte Oaatrle Calarrli 

If • child is suddenly attacked nith vomiting and hi^h fever, the 
pvbabillty it sitoiig that ihe symptoms are due lo theonsct of some lymotk 
^Kiae, such as scarlet fcxer or epidemic inlluenia, »r to gastric irritation, 
la ialanis the symptoms may indicate the onset of the so-called ' cholera 
iifiMtiBt,' or lymotic dinirh'ta. It i«, of course, c{uitc possible that the 
■voaitiag and fever may be due to a chill ; but it is far more likely to be the 
Xfufc «if Mxne seriout error in diet. In any ^uch case, inquiry must be 
Bade as to the food the child has taken during the few hours preceding the 
UiaCk, as well a« to the poMibiliiy of .1 scarlet-fever infection, and the throat 
tad skin must be cart-fully impeded. In some children there is a »pcci.il 
li.>iljty to the rm-calkd bilious attacks, which are in all probability ically 
■Racks of acute gastric catarrh. There is headache, nausea, vomiting, and 
frte» ; the fctoroach may rejtci first some utidinc-ited food, then mure or less 
hfe-sLained liuicls. In a few days the attack iKisses off, and the child is 
ptrfanpt lirtter in health than it was before the attack, the vomiting and 
■boRiDKb emptying; of the stomach havint; had a distinctly s.iluiaiy elTcct. 
la some cases of acute gastric catarrh there is cunstaiil and uncoiii reliable 

tMnitint; for some day*. 

In acute ifaslro-enteritit, [he result of taking; some toxines from meat or 
lilk. the t omiting, colic, and di^rrhua are often excessive. 
In all OSes of acute gastric catarrh it is important lo j^ivc the Womach 

a tem(H>rary lesi by avoiding all food or fluids, and giving a little ice by tlie 

BMiuth till the vomiting ccaser. Rectal alimentation may be resorted (» if 
essiuy. Veal broth and pcptoniscd milk arc the most likely foods to be 

rtuined by the stonuch, but it is not wise to attempt to yive food by the 




86 



Diseases o/ tlie Digestive System 



stoiTiach lou soon. Siimll Ao^ti o( calomel uiv useful if the bowdx are 
(nnlincd \ dilute hj-drocynnic acid and ^intipyrm ate «Uo UMful in checking 
the vomiting. 



Aeat« a*>lr«-ln(«BllDal Catarrb. lnilaBu>iat«rT ar S^moUo 
Slarrlieaa. Cbolera Xafa&taiD 

With the commencement of the vann w»thcT in June or July there is 
nn inctcaic in the numbei i>f cases ol infantile diarrhua ; and by the time 
ihc end of July or the bejjinning of AuguM is rejithed— especially if the 
weather is close and dry— theic it tolerably certain (o be. in large cities, an 
epidemic prevalence of diarrhu-a. It musi be niilim the experience of all 
that the dinrrhri-nl diseases aic commoner in summer than in winter, and, 
morcnvcr, ihat ihcrc in more diatrha-a in a hoi dry suminer than in a 
•rold and damp one. The following ligurcs thcnv these &cis in a forcible 
manner ; they are taltcn from the records of the Children's Dispensary, 
Manchester : ■ 

Afonthly AdminioH3 of Cuei o/ DiarrJura for tkf yei»r 18801 



January 
Vcbruary . 
March 
April . 
May . 

{una . 
uly . . 
August 
September . 
October 
November . 
December , 







Mf ^1 la*«a 


L tftHV 


N«L*rii«Mii> 


■od ncHii hj<hck4 








II 


a6-4i K. 


14 


— 


34 S2 


>9 


— 


34 57 


z6 


I 


37 iV 


19 


— 


3<> 'H 


4S 


2 


47 7» 


89 


4 


SI 7i 


361 


33 


55-75 


364 


43 


5' 73 


62 


13 


37- jS 


iS 




38 53 


13 


'^ 


33-53 



Total 



9S3 



96 



These figUTes shnvir thai there are at nil limes of the jear a certain 
number of cases being btoiighi for mcdicnl aid on account »f <liar(hii;a, 
the mimbef being faiily constant during the fir»t five mimih* and tbc 
last two month* <>f ihc year ; with the warm weather of June the number 
mcieascs, teaching ils manimiim in the holiest weather of August, tlien 
declining to the nmmal number in the last t»» months of the )-car. The 
year iRSo was a mote than usually hoi summer for ihi» country, but other 
yeant show the same relations between the diairhual diieaae of the winter 
and summer months, though in cooler summers the disproparliDn ii> not so 
k'teai. 

' By * dmiTliaTii ' are ineanl thoK catci in ubivh diarrhcra m^asa preminnit sjmptom. 



I 

^ 



The Mine Mory n lold by the monnliiy ubics of dinirhoea in Berlin 
(DaKtnaky), in New Ynrk (Sicbcn), and alui in li.-iltimiirc (Miller); biit in 
thew cHicii ibe greatest mortality ii in July, winch i« th<^ir liotieit month, 
wbilc in ihiicountry August is usually tin- honest month, ami <lic month when 
diattfawa is most prevalent. The above Uible hears oui the ttenecat nme- 
inent thai diurrtioea beKini to be prevalent wlicniier ihc avtraj;e icinpera- 
iar« of the twenty-four hours reat:hes 60" K,, and whenever tliis avenige 
lanpwature is excceiled t»y only a ftw desrcts. diarrhucji prevails in a wiilu- 
ipread epidemic. 

A similar table showing tlie rorreapundin^ number of cases of broncbial 

(«urrh utvd lirmichiiis would show that these diseases were more preralenc 

Md btui during the cold and damp muniJi!! of the year than in the warm 

ud dry months : and il ha> httn aiyued that, just as bromhjtis is produced 

hT exposure to cold ;iiid damp. >o di>iirh<ra is causedbyahi);h tcni|}er^tiire, 

giving rise to an intestinal catarrh tir loa'hejit stroke.' Duithi-tc aie facts 

to thin* that the explanation is not so simple as thi«. It is certain that 

1 iibkIc KKpoitire tn a high atmospheric tcinpcratutc docs not ^ivc rise to an 

lUnlina) catarrh : thiit hot weather does not at once increase the number 

vfcatcsof di^trliura, but it is only after a biRh tetnpcraiiirc ha* continued for 

tome days; and th^it infants at the breast, especially ihoie under three 

weoHa. tbouKh cxjiosed to the same condition* of temperature, arc only 

cKeptionally attacked. 

Siunoter diarrhcca is much more prevalent and fatal in large cities than 
■ OMntry districts and amnag: the pooicsl classes who live in back-to-back 
hMania cruwded courts and low-lyingdislricts, while it is much less common 
■KNlig the better-housed cLisscb of sodciy, cspi-cially among those who live 
9> ibc country or suburbs and upon 3 high and hr^tcing site. 

Il li most prcialcnt Ijrtwten ilie ages of three months and two years. 
1ht fiiliintt who suffer most .irc llio weakly and dyspeptic ones, "*ho ate 
pnhljn already aufTcrini; front an intestinal catarrh, and who arc badly fed 
>oi improperly cared fat—iuch, for instance, as the illegitimate class of 
■i^Bt* w|«> arc put out to mxrNc. The infants who suffer least are the 
'"■a-frd infants ; thus out of nearly 1,000 fatal cases rceotdcd by Emmet 
lltft,iMly some 3 percent, had bteii breast fed- This immunity ls no doubt 
iWtotbe fact thai the milk they take is 'sterile,' and not swanninj; with 
OKuiiuns as co«- s milk is apt to be. 

The epidemic prevalence of summer diarrh<i:a has l>cen attributed, wilb 

aon or kss plausibility, lit the ingestion of «our milk, unripe fruit, inhalation 

1/ M*cr K^s, emanations from the soil; and possibly each of these may 

mnrUwtc Id tite cases of diarrhcca. 1'hat they arc not the constant and 

avahable cau^ is ccriain.as infants fed on tiour milk by no means int-anably 

■At from dianhiKa. and the epidemic is too widespread 10 be explained on 

ibeunripp fruit ihcorj' ; and, inor«toicr, diarrha-a is not especially prevalent 

■a snmc towns where sewer fffs is constantly present in the houses (Uallard). 

White It is certain that the ordinary lactic acid dianges occurring in milk 

>ben It turns sour arc not the cau^e of dlarrha-a, yet lliere is a strong 

probability tliat milk often is the vehicle by means of which certain micro- 

orgkntsms or jxiisons enter the system, and give rise to the syinpioms which 

■re present m diarrbma. 



i 





88 



Ditfasts of the Digtsth't Systrm 



FliiK^'c has iccenlly shnwn ihat some of th« actnbli' tmcicna H-hich are 
oFtcn pmeni in initk, bcinK derived from cow r.i^rc-t, linyscvdi. ttrcet du«, iicl 
on the cjiicin nnd form pcplonei and ptooiainn uiihniit (utniti); th« milk 
sour. Milk |>cploiiiked by theic biicierin pioduci-'s dinrrhii;.!, .-itid even dcalh 
in mice and ^uiiicn i>iKs. A high tcmpemiutc hvoiirt ihc development of 
these bacicriiL 

'rhiii the dianhiral diseases are epidemic in hot weather is certain- Are 
unyoT the forms aUn infections? In sonw. recorded cftM:t it certainly appears 
thift hai been %a. Dr. lirurc Low ' gives an account of four different out- 
breaks of dinrrhcra in which it nppcars that the ditciiic WA» communicated 
by con taction. 

Ainon|{ the cnnc^lusiant which various obtervcre have arrived at with 
reference to the etiology of summer dianha-a, we may mentmi ihe follow ing. 

Dallaid betie^-es the cnuKc In be ii micro-orKanisin not yei detected or 
Isolated nlilch is conitanily prex-ni in the tupciiicial layers <tf the earth, 
which, entcrinK <he food, develops under fnvciurableiondiliunt -either inside 
or outside the budy— a viiulenl poison or ptomaine. whii:h gi\-e» rise to (be 
symptomi observed in the disease This unknnun micro-organism is sup- 
posed to play the same )>art in producing the disease n* the coinma bacillus 
doe* in Asiatic chiilera. 

A. Baginaky, after an cxhaiisiive experimenl.~il iiKjuin* into the micio- 
organ isms found in ihe stools nf infants siitTrring from diarrhtea, failed to 
find any sjiccific or p,ilhogrnic orgFinisDi. but foiind many saprophytic or 
iiun-pattio);enir bacteria, and he inclines to the belief tlwit the dee om posit ion 
products formed by these vatinus fon»s of micro-organ isRU arc the loxic 
tubstancei which git-e rise (n ihe dist-asc. 

Meincrt, while nrknouiedging that micro-organisms and their tlecom- 
potllion products when present in milk may give rise to an intestinal c-iiarth, 
believes that the arutcr forms of snninier diairh<xa are produced directly by 
the action of a high ii'm|)eiatiire, and are in reality a «ori of heat stroke, 
having noihmg to do with micro-organising or piimiaine poisoning. 

In spite of all the tan* before us, «e arc hoiind lo orknowlcdjiv that we 
have no rerlain knowledge as to hoH a high icmperaiiiir favours the occur- 
rence of di-irrha-a. Although the fart that no pathogenic organism lias been 
delected doc* not disprove its c^istenci', w* art- not >el in a position to 
accept the conclusion Uiat summer diarrhtta is a definite zymotic disease 
like Asiatic cholera or sc^rlcl fever. A lii({h atmovphcric icmpcmture, oiain- 
tained for days and night* together, favours the development of all sons of 
saprophytic organisms, which can grow in cver>' kind of food, both animal 
and vegetable, especially in milk, ami, under certain conditio^is, produce 
poisons Midi as muscarine. «hicli. when laken into the stomach, gii-e rise to 
tm irritant jxiiioning. with fever depression and collapse. It is certain that 
these organisms ran llourish l>oth inside and outside the bod>, and there is 
much lenson for believing that they pUy an. impurtant part in gilding rise lo 
the severer forms of diarrh<ca prcvaknt in the summer. 

^jfjin/Zcnti.- The s}-mptoms may supervene suddenly in an infiuit in 
apinrent health, though more frequently an infant is attacked nbn has 

■ S*i|>|i)cinmi lo the !vtviit<enlti Aniiiinl Kcfiort of ihc IxrdI Giiv«mnKnl Itumnl, 
ini-t«Ul. 



»(ty sulFend fotr a day or iwo from imtitinal disiurbance or has had an 

ark nf dijirrlirL-a a vttk or luo before. 'Die t'mi »yinptom is generally 

ailint: ; this » folluncd by a lome motiun and aciomiianied by more or 

Ins fevct, at iW wunc time ilic infant is resilcss and irriuble, the abdomen 

1* diurndcd "iih (tas, ami ihc legs arc dM>in up. The vorniiinf; in the 

iricwM cases is very distreMlnj;. evecjihinj,' taken being rejccteii immr- 

''.' ii>-'.s, the vomiled matter* cun«islJn>,' of undigested fnoil, and Kul»c(ttientlv 

< < .i^ijilc tnucu^ linttcd njih bile ; ihe stools arc w.ilcry and consist of ilndi- 

^uled food I they are usually .^t lirsl yellow and frothy, or green, containintt 

lumpi or docculi of curd. Later, in severe cases, ihcy consist of little else 

itiiM iliKlitly cotouted water, or resemble the rice stools of cholera, and 

utta attack bccmne* more chronic ihey are of a dirty brown colour and 

leiy oflenslve. The tiinnuc become* co;iicd with a thick white fur, 

ihelhirsi it mostly extreme, the child eagerly lakinc lh(^ bottle or spoon, 

kit nimitrnK immediately aftcrw.nrds ; there is ^.-rcat lesilessncss, the child 

aiydiRe for a short lime, but rarely manat.'ct to ;l:ci ofl" into a sound sleep. 

Hie fever is seldom bi^h and mostly iniermitlcnt. varyinjc from lyf F. lo 

. m'F., in exceptional cases 103" K. or still higher. The siooU become more 

luiliiiare froiuent as the disease advances, sometimes being piissed every few 

1 naMes, pethaps cscapinK unconsciously or beinjj preceded by a short cry or 

It nfRssion of pain on the infani'f face. \'ery often more or less erythema 

I m FKoriaiion occurs nlxiut the anus and Keniials. After u longer or shorter 

lltrad, according lo the aciitcncsi of the cuse, symptoms of colt.ipic make 

IW appearance^ llicre is a clianKe in the infant's face which striku ihe 

■Ml casual observer : Uic eyes arc sunk in the head and kept piirtlyclosed, 

I Attmaaclleis de|>rcsicd, the (ace is pallid or of an earthy tinge, Ihr muscles 

I<'iIn neck and limbs lose Ihcir iimui, and the head rolls about whirn tlic 

\abu is onovc<L 'rherc is no ImiKer any y real rest less n ess, ihe infant is 

IpKralty listless and droo-sy, and takes little or no notice of il« friends. In 

jlbttiagc the vomiting usually ceases, ibe slonls lietoine less frequent and 

|<Muiit|Icr, and ibt abduiiKn become* sunken and Its waits flabby. 

rbt further progress o< I be jitack depends upon whcibcr improvcmeni 
[MS mi if so, the diarrbwa ccatcs, more or leM colour returns lo ihc infant's 
Iho^ii takes notice of its friends, and. though sliU weak, begins lo use ils 
■ Mimdtake its food. In other cises it becomes more eKhausied,ii wastes 
■)f^, {Mraiiiiic siomailtis makes its appearance, and freiiucndy convul- 
^■'wi occur, which ((ulckly briiig the end. The fatal fvcnt is often preceded 
Flhr ocruireiKc of cerebral symptoms, such as conu and Clicync>Stokca 
<ion, a condition which ba^ been termed 'false hydroceph&ius° from 
tmonbtancv to meningitis, and indeed ii is often bclici-cd by the friends 
ntbers thai death has occurred through 'water on the bri^in.' In 
lit tiaie the coma is profound, the pupils dilated, and at times unequal, 
lb* (tipiialions irrcgulai, the child it pulseless, and ihcrc mdy be Iwitchings 
•flbefaccor limbs. The state of llie fontancllc »ill generally assist the 
(Ucdoms in d«<:iding whether the ccicbr&l symptoms arc due to arterial 
Mtcmia of the brain, as iti fake hydrocephalus, or 10 meningitis; in the 
tuatrcjse the fonlanclle ts ilcprcssed bclo«- the level of the cninial liunes, 
■Umixh ill thi: brain oi:ciipics less (pace than ntirmatly, m consequence 
('^tbc arterial tyxem being nearly em|uy, the result of a. failing heart. 



90 Diseases of t!ie Vigesltve Systtm ^^^^^^ 

The length of limc the disc.-iso Usis differs considcnibly. So tnpidly faut 

BtC >omc ailiick* that the tcim chuk-Ta infantum lus bcei) applied to tbeni. 

Wid indeed to a few insLincc:s this rvsemblancc to Asiatic chokra it very 

close indeed. Such r^scs cKxur much m»rc commonly in the tar^c cities (if 

the continents of Kuinpt: and America than in our own cooler climate. 

The lalloH'int; L-aie may be taken as an instance : 

A l«)t of fii» )wir» nf .le*- »n> iNl,rn »iirl'lrnl) ill mlli ><jniitin(t and pui^'iiB M i A.M. 
>nil Ulnl M 1.45 r.u, (III Ihr xinic liny. Wlinii ailinrltnl lu hoi>|ilLil M 11 A.>I.hc<>iks 
C<ini|>lclrly cxjUnpwd : Ilic ;ni|)ils conttoclrd. Ihr roiiiunclii.*' nratty intprititilr, Ihi llpk 
ir>«ir p^illiil, till.- pulbc ctnilil liunlly lie countcf!, (tii: leiiipcrature wai 104' I-'. In tpi«c of 
bninil;r. nrainoitiiii iin<l niiillF i>l nn)yl, lie fnilnl lu mlty, Thr /i>r/nn"f<i>i namioalMI 
lillOB«<l Ihe iKxIy In lie wril ni'unklinl ;IIiil r>|;iiT nuiclia kliiingly lilAtkcil. Tbe iMrrtlnt* 
Wtrc dUlenilnl with s;ii. nnil coni.iinnl 1 small qunniiiy of palf ([vl.-ilinoUB fluKl. tht 
rauci'119 mi.'iii1na'ir of tin- wlmli- |i'iij:ili nf Hit -ilinwiiUry enn.il ia.|]i pink wiili ntrnul* «• 
lr*>M>a(ti)iii of blijod. uiiil ihf xilitojv gliinib wtrc cnUrtrnl. Iliv liiuici (enWBJljt urtmi 
[ult and dty. Tlir ciir nccuiml 111 Augiiit iSito, n haiiinifr which wat unuwully hM. 
and during which iyni(-i«: ilbrihooi uns very pmnknt. 

In a few cases, convulsions may supcr\'enc during llie first few days, uid 
brini; ;ih<iiH 3 fatal termination. In the majority of fatal cases the duration 
ii somewhat longtr, perhaps ji weelt to ten days, the infant p^sst-s ihroufth 
the acute attack, the synipiotns then assume more or Icm of a rtyscnteric 
character, and it succumbs through cxlia 1.1st ion and inanition from a failuie 
of the .ilimcntary canal to rei'uvcr \ii nonnnl functions. Many infants uh» 
escape with life in August, die in Sapieni1>er or OctiAer from giutrt^ 
intcstiial 4ttx)phy, which has followed as the result of the acute aitnclt. 

Campb'iittiiint.^My far the must common complication of acute inl< 
tinnt catarrh is broncho- pneumonia, or bronchitis and collapse of lung. Tlw 
symptoms are apt to lie laicni, bm any dyspna-.» or high tempcmtiire would 
necessarily call for ,1 c:trefiil c-xamination o( the lungs. Thrombosis iif ihs 
cerebral (inu<«s occasionally takes place in the later slagM. but it is com- 
paiativcly rare ; the symptoms ciin«isi in dlMcntion of the veins emptyinff 
into the cjii'enious sinu-' with <rdeniB of the forehead and c)*eli<ls ; there 
will also be ionic spa «m nf the limbs and neck, and convulsion*. AJbu- 
minuna frequently occuri^ during acute diarrhcisi : nephritis and ur.etnic 
convulsions have l>een described by some authors ; but we doubt if the con- 
vuUiims which frequently occur toward* ilte last arc ur«^n»ic. I'entonttit 
(iccasionally occurs, hy9erp)'teKiA may also occur. 

.^<yMi-/(r.--Should the infant recover from the -icute attack, it is by 
means ccrLHtn that cnniplete recovery will take place; for it is extremely 
probable that ^asiro-intestiti.d Jilrophy may Mipcrvcne, or a chronic di.inhu.a 
remain, the result of chionii catarih "ilh follii:uUr ulceration of the colon, 
sigmoid llcxurc, and tteltim. In the latter case the symptom* are those 
djseittenc diarrha;a ; defircatinn is ficqucntly accompanied by much piun 
and stratning. the stools consist of mucus, often tinged itith blood, nr are dark 
brown and liquid. Therccium liccomcs prolapsed, and n sometimes relumed 
with didiculiy, and the child rapidly wa*ies. Not infrequently we see childreiii 
usually under two years of age, who have gone through a severe attack 
diarrlKca, extremely an-emic. and whose (ubcutaneous tissues, including t 
bee, arc Gcdemaious. In such caset a trace of albumen may be found in tl 



luoitd by » coroner to make .) poit-mortfm on a chiki who 
with vofniiinjt, ptifging, .tnd high frvcr, vviih ^rcHt dcprcs- 
Honied by death in a few houf% ; and uc have hccn im^ible to siiy 
iJB, from Ihc poit-HU^Um .ippor.mcc, nhi-ihcr tlie death has bcci» 
lUlignnnt sc*irlcl feiTr or .iriiTc infi.iiiim;itoi-j' rli.irrha-a. TIic pro. 
sbccD «>lve<l in sonic m«.iiircs by the ocriirienrp of sciiiltl fever 
line house shorttj- aftcrwnnls. In the majtiritj- nf cases the appisir- 
KH in ihe Unewt «fnuW suffice for dbRnoiis. 'ITic dini^osis bciivccn 
[cnnd AcvVc eases of cholera inf^iniiim ittiy he difficult, as there tii.-iy 
h Kfflpcratutc in both ; hue in most insLinccs the K.JMro-inlestirial 
tax b mitch inoic m^trkcd in ihc bitcr th.in ilic former, li must be 
h mind that some cont^idcr rholcrn in&ntuni to be really casc« of 

[Dkt.- 

iMuit. — Acute intcslinnl cKtiiirh itiii''I .-i1u»ys r^nik as ;i icrious 
■M only from iu tcndeni:v loprnrc f^^inldiirin); the .ittacrk itself, but 
ill M frc<)i>cntly pas^e^ on into n sul>-iaiir or chronic form of ralairh 
Acceded by airophy. The younger the inf.ini, the more serious the 
s become^ Gsticcially if it bus been anincially fed: in older chUdrfn, 
he attack may be severe and the depression produced vcrj' great. 
Uc ususlJy terminates fiivourably- The onset of cetebral syinploms 
ry anfavouri:ibk auxur\'. and ilie chances are against the infant, 
iKcaseis n(A liopclcss. Convulsionsaregcncrally followed by deaili. 
icmcs in which infant* I.ipsc into the dironic stage the prntrnosis i» 
a ibcy arc nitead)' enh.iintcd by the iicme attack, 
U Amai^my. — If death hnv taken place early in ihc disease, the 
wll nourished and peihajK even ploini\ hut ibc foce reiaina 
ttprcssiun it hnJ during life, the ejes and checks being sunken. 
Cj; the body, minitie h.tinorrhnjjcs are usually preient on ilic sur- 
ie liwifs and hcait. and there is h> posLitir congestion lit tlie bases^ 
is; The mucous niembtanc of the stomach and bowels i» swollen 
fcuoi capillary congestion, ihc congestion often being present in 
ind minute bn-Tnorrhagcs may hjne taken place. The mucous 
t of the LirKC intcMinc i» congested, cspeciallv alont; the summil of 



92 



Diseases of the Digiistiiv System 



colon, there rnay be »uperlicuil ukemtton or CKcoriaiion M the lumtnit* of j 
llic fold* of mucous inembrAnc, or ihe ljo«el mny be piiled niih »lccp but 
smsill tikcn from ilic result!! uf breaking down uiid iliidiatt;c of ibe MlitarjrJ 
fflntidt. Microscopical cxHniinaiian of the intestines aboirs a distensioa oS\ 
the Dctwtirk (if CApillaiiet of ilic villi iind mucous membrane, and anextMla-^ 
tion of leucocytes is n>os[ly present in the sub-mucosa aod betwMn the 
tubules or crypif of I.icberkuhn. Numerous inicro-orKanisms arc presenL 
The xolilnry xlAnds especially in the large bowel are very often in a sute j 
of *DfleninK in ihett centres, or their conienii have diM:harKe(l,ttiving rite to | 
sharply cut ulcers. I 

On exnmininK the brain, no constant or indeed dcRnite lesion is found ; | 
in most caMs the sintiscs are distended wilh blood or occupied by a finn pals I 
cliit, but this condition of cngorgcmrni .*ipj>c.-in lo be ihc result of death 1 
taking place ihrouith ccssniinn of respiration, or durintt a convulsion, and it I 
due to mechanical causes from intcrfercnrc with ilie return of blood to ibt I 
lungiL The symplnms referable in the hrniii diiTinj; the last few hours of I 
life, coma, Chcync-Slokcs respiration, &c., have been attributed toexhaiixtion, ] 
and an anii-niic (attcrial; condition of brain due \a diminished atlrrial tension. I 
The KUKKc^iion that they are due to unemia i^ impmhable, though it is noi I 
unlikely ilicy are due to the ab«(irplion <if ploniainci from ibc alimentary I 
canal. Mtninniii> is cmremcly rate: in one ciise, however, which camel 
under our nouce, lymph was found about the optic comniissutes. I 

TrttilmtHl.—'Xhv most iniporLint part 'if prophykitlii: treatment is «■»- I 
necled with the food which the infant laltci and the purity of Ihc air irtiich I 
h breathes. No weakly infant vtho is being learcd on jiriiticial food and who I 
bat previously sulTered from iniestinai catarrh ougliL if it is possible to avoitl I 
it, to remain in the crowded part oralar|;e town durint; the hot wealher,bDt I 
should be sent away to a bracini; seaudc place, or country iiuatters shoidd I 
be selected among breeiy liills. The greatest care should be exercised bl 
thv selection of puic milk and in tis storage before it is taken by lltti 
patient, as there is little doubt that milk readily nbtorbt (toxious gases, it I 
easily coniaminated by micro-organism* present in the attnospheie. anil I 
clwnges arc set up which render it unfit for food. All milk taken by in&nt* I 
and children during ihe summer months should be c;ircfully sieriliseil in one 1 
of Ihc milk sterilisers sold for Ilie purpose. Care musi .ilso be taken ttuti I 
(he infant is not ^iven f(Hid in excess of its di(;cstive powers, as undixesied I 
curd or olher foods are txccedingly likely to decompose in the alimeniar) I 
c.inal and ),'ive riie to irritation and diarihtca. The stools, both of ioEuai*-! 
»\ the breast and boitle-fcd childten, should be carefully watched, and anjr'l 
Ir.iccs of undigested food or of unusual foulness or looseness of bowels! 
Kliould be the si>:(»il for lessening the amount of food taken. No infant ai I 
Ihc brcaM should be weaned during the continuance of the hoi ucalhei, I 
and if diatrlirra niake^ its appe;irance it should, if possible, be rctumeil to J 
the breast. I 

The indications A>r treatment when the diarrhita has ronimenced are iftl 
the firai place to give a Lixativc lo clear away all irritatin){ or deco(n|)OuB( I 
foods and relieve the congested liowel, and secondly to give food only la I 
small quanitiies and of Ihe blandest chanicter. The first indiciiiion can be 1 
fulfilled by ^ivinif castor oil, as long a^o advocated by Ut. t^eo. Johnson. « J 



ChoUra Iti/nNtuin 



93 



br * ihttC d* two of cuIoomI. Tlie foni>CT iruy be g^ivcn in emulsion in rnm- 

buiaiion "lib an unimlalmjt iiiiliscptic. Jfbor^ck acitlor t-ilicyUi^ of sod;) ; 

(hit Uner helps lo prevcnl i)c<:<>ii>{K>«iM:>n in Iho cmiiUion, and pcilups .ilso 

fb'Mi limilai purt in thc«ioinA>-liinchcckinii put rcfnciivc changes. iV. ta.) 

Thr oil nwy be xivcn by tisdr in half-tc45po<inful nr Iv;is)ioonfu1 doics, 

Itai n i« api Id i:au*c tkkncss. Instead of the mslur oil. csfwciiUly if lli«re 
!• ciw.h sicVnets, inull ti4>scs of <-jlontcl m^y be givcii. jnd on iiccotini of tt» 
maII buOc and lastclru chArai'ict Jl is in many n-spects to be preferred. It 
- ''"rr. ifihcntiack it ii sh.iip one, to give ii in kmutl and repeated <lo9». 
I'.ljr in weakly infiinis : ( to | grain may be civen (u infunts and 
ihildicn every two hnuts, until one or two (-riiin^ have been Ki^en. 
course of twelve bo«rt or more, iiccordiiij; to die iiiiciiiity of tbo 
L'4, ^11 aj^icai.-inccK of undinesled liiod hiII luic disappeared fr04ii tbe 
'he bitci (lerhapt omtinuinsfmgucnl and waiery. Slom.'kch wathin]^ 
iKatkx) of the Urgt^ bowel hiivc been l.irgel)' practised both od ibc 
!3iand In America, and have ihccrealadtantage of removing; dC once 
uDUau of the stomach and lart;e bowl, but no iirigaiioii am reacb tbe 

tQlestinc*. 
L'tiku the infuit be ai the breatt. all iiiitk or milk food» should be 
'it,aad barley water wilb "»hil<-' of tgji wibatiluiccl 'p, Sj]. Tbe inost 
ic tympiiHii at first is frequently the vomitint: ; this may bi- 
ll, following c\cry attempt at feeding, -md it will be ncccsiary to desist 
taaallattcmpu at feeding f«r mirk hours, only moistening the moutb with 
• utuBbnub dipped in ked water. Counter- irritation and hat applications 
ID tbe abdixneo at thii stage itre undoubtedly tetviccable. For this purpose 
i hmment cnmpoted of Ave dropt ot o4l of mustard to ;in ounce of c.-im- 
lAmitd oil m.»y i>c jjrnily rubbed over ibc >(bdom4-n. and spongio-pilrnc 
B leTCTal folds of flaniwl wnm^ out of hot vater applied. Or the spoogio- 
piinc nu> be mtwag out of water at I lo^ in which must.ird has been dilTustd 
a Um proporiion of mo tablespoon full to ^ fialion. 

The medicinal trc^imeut oi .itcute dtanh<m is often tcry unsatisfactory. 
The romiting aiay continue, rbc stools in spite of the most c.trcful dieting 
maybe hioM and frrqueni, and Ihe child may rapidly lose j^round. The drug 
■Itch one is Itinptcd to Ay to is opium in one finrTii or another, in the hopes of 
alb|iiV iniiMRi^ and diminishing; the frc(|ucnt flux from the bowels, vthxh 
ippai ■ ids at iMsl to be the cjusc of ihr child's increasing weftk- 

MMai. < ' It must, however, be boTOC in mi ad tliJt the disease is 

aannhist; more iftan a con^cfied. Irritable state of bowels, in which the 
Cntent* are rapiOly |iassed downwards into the colon and rectum, since the 
fcrrlMia is rather the result of a form of irritant poisonin};, llieic cannot 
kc the least doubi that in niatt)' cases with the cessation of the dlarrhaa the 
tUd btf omes no better, but rapidly passes into a condition of collapse with 
itrcfarjl s^'nipioms. doe in all probubtlity to toiurmia ; or the temperature 
ruei and poeumoDia supervenes. It must, moreover, be admitted that the 
iKatmcni (if the wors« cases at summer dinrihcca by dru^s is often unsuc- 
iBifiit, and this la bonie out by the number of diuji;s which have been 
anpIo)«d. 

The Arag wbkb hiu appeared to us the most successful in the vomlt- 
mg in the early stages is carbolic acid, the glycerine of carbolic «cid being 




94 Distitses of the Digtstiit System ' 

][»'en in drop doiei ei'cty two hours nr t\c\\ oflen«r. Carbolic ncid ha« n 
sedative action on thi- itoiii^irh, and hetpK alio lo check the dccom[io«il><m 
thangc* which go on. Dihcrdrus* of a similar class namely salnl, treosolf, 
resorcin, naphthatin, ha»-e hccn j-ivtn as aniiscpric remedies in ihc hopes of 
'ChcckinK Ihe putrernctive changes in ihe howcl and prcxcntinK ihe Ibnnaiion 
of loxic product*. .Salicylate of soda has also been used by A. Jaoobi. of 
New Vork. and aUo Dr. Emnici Holt ; he gives it in do^es of one lo ibree 
fp'ains ei-erj- two hours arcording to age. Re«orcin may bn sit«n in } la : 
grain dose* diwolvcd in water ocry two hours, Both bismuth in the form 
of carbonate and oxide and line oxide (F. 7 and 8) arc usually ol undoubted 
scnicp. Opium, in ihr rarly stages, \y useless and h&rmfiil, more c<.p«;taUy 
when there is undiycsicd fmid in the stools and where the vomilinK is per- 
sistent. In the l;ittcr stagey if ihe stools continue small and numerous, 
especially if Ihe; approach the dysrntcrir type thelarge howcl being cb>cftr 
involved— opium is of mudi 1 alue in soothing [he paiieni and dimmishing 
irritability. It is best given by enema. The advantage of the former 
method is that it is more slowly absorbed and its topical elTects are useful ; 
one or two enemala of laudanum during llic iweniy-four hours will mosdy 
relieve the irritative diarrhfc-a, when accompanied by straining anil cohclty 
pains without the nccesMty «f omiitinK or altering the mcdirinc given by 
the mouth. Two 10 (i%c drop* iif laudanum may he given in warm decoc- 
tion of starch per rectum 10 an infant of six months to twelve months, the 
effects careftilly watched, anti repeated in the course of six to twelve houn 
if nccettary ; |>o of a grain tif morphia may be given subcuianeoutly 10 1 
child over three years of age. If (here be much fever, tcpi<l sponging, or in 
cases of grciiter severity sponging with ice cold water, may be practised. 

Stimtilanti may be required fram the lirst. but it is wise to reserve them 
for a later stage. es|>ccially as ibey are apt 10 give rise to sickness. Hraady, 
a sound port, or ehainpagne, are the fonnofalcobolicstimuLnntsntosi uscAil 
and Ihcy are usually rettuircd to be given fteelyin the later stages if coll.iptc 
is ibrcatcnetL .\minoaia, camphor, and mu»k are valuable renx^ies if 
symptoms of coltapM have made their appearance. C.imphor may be gives 
in ihc form of spirits of ctmphor. Ilitce or four drops every second boot) 
or musk. (F. ij.; 

Camphor and mu»k arc noi agreeable inedicioes to lake, and are apt to 
cause nausea. 

Kvcn when cuiiviileKCOce it established great care must be exoicind 
for many weeks in the mnnagenient uf the patient : the child is certain 10 
be left with impaired digestive pouen. an*niic, and li.ible 10 g.tsirk nr 
inteitinal di»turlMnce. A ^etete attack will often aiTect ihc chitdS health 
and development for nuiny months, so thai it is late in talking or sunding 
alone, and at 18 months or twu t-eats of age resembles a cliild of iimuntlu 
old or lets. .\Ioreover, the diarrlKira ma)' become chronic or retun) in ■ 
subacute form, and a child may thus be lost who has managed to straggle 
through the jn-imar)' attack. The diet during convalescence rccjuires tho 
most extreme catc, nnd a leturn to milk diet should not be allowed until 
there is evidence of much-improved digestive powers, Uruths and l>eef tea 
made with barle)' or some lighi st^trchy food, mnt juice, scraped undcrdona 
chops, whey, and Mcllm's Food, may Ix: given in moderation. 



Acute Castra-tnteritis 



95 



The minen) acUb, |>epkine wine, decoction of pomegranaic bark, the 
\ci[etibte biiicrs aail aMnn),'enis. will be usL'ful a? iIk child impiovej. 

.VaimiM.irx. - llacc ibc chiW in tht eooleii luom o( the liuuse.uiid ipotii;e 
(requentl) if ihete is much fcvtr. 

Sup all fornii of milk fooil. giving burtey or uirowrout u.iter with white 
«f egg, atMl w»\ )>ro(h : if t)iete is much vuniiiin),' slop all fooil for snine 

I Apply hot fom«n(atioiu or counter- irrilalitin to ihe abdumen. 
Cive ca&lor oil or culomel till nil undigested food has disappeared from 
'M<M>l!i. fiillonted by »;il<>l, /inc. bismuth, nr carbolic iicid. l.iiter. if there 
nach re»tk«ncs5 or ciJic. give opium by the rettuin. In scicrc cnse* 
brudy (K ixber sliinubnt will be required, but it is ^ipi (u cause vomiting;. 

In in^inls at Ihe brsul lessen the quantity of milk taken and ]{ive some 
lutley wilier. 



Acme (Hutro-«aterlUa. PlonuUnc Polionlns 

UodtT ihis head we refer to the Ktutro-inietiinal ditturbance which 
I the ingcAlion of some forid which roniains a vinilcni animal poi«on. 
: coirmonc^l form of fond which comaint %uch poi^ont is rnilk, hul SO 
iv Imiie<l mr-al. •patnaj.'es, muiihrooms or nius^eU. Ptnm.iiiic pojsoniiifj is 
leri^ed by vomiliin;, colic, dinrrh^'.i, fc\'er. and ilic mote irverc case* 
>)ȣ. In an epidrniir ' which we hnd the oppnilunity of obscn'io).', 
1 of 160 individtial^ mere .tllackcd, within n few hours of one another. 
Jli and children were nfTpftrd. in sonic f^milict a^ many as twelve 
«rke<|. It was proved ibat nil those who siitTercd had taken milk 
(mtk tame farm. On invciliKalion Dr. Niven fniind ih.ii the milk from 
aCB* toHerini; fnitn ' (iar^-les.' or infl.imm.ition of the udder, had evidently 
btn the canse of the epidemic^ .Snme of those .ificrted hnd only bad a 
UMll «mininl of milk in their tea. We have seen similar allackt follotvinji; 
Ik ngution of tinned meat by children. It is not certain what fonn of 
Kuro-ucfanisin is the nritpnalor of the tiixines in these c.iscs. and it is un- 
rmaia whetlter the tonincs arc fnrmed inside or outside the body. Gaerlncr 
Kit described a bacillu* which be has cidled h. tHlerilis, And found in *ome 
I cjms ti wuu);r fiiMtnititf. 

Wctbin a few lifiuri of the inception nf Ihe poison there is vomiting, which 
iBRttll) continued, and ievcrcdiarrhn.-a. The colic is very severe sometimes, 
I Ti*e lo fiiintness. "ITie tenipcNiiure may rise to 105' I'"., or m mild 
I ma) harilly rise abin*e normal. Convalescence is mostly protracted, 
^nous is aided by the f'lct th^t several members of the sante family 
chcd, .ind in thote cases where (he milk sgpply is at fault several 
Mill siiHer who have the same milk. Ocetisionally intliicnia lakes 
emic form, and ihe diaKDosis at first m.iy not be easy. Hui the fact 
1 1 members «f a family .ire seiii-d wiihin a few houns of one another, 
I- (iiher rases occur, should always raise the suspicion of ptomaine 
puwiii'DK- The iie.-iimeni will neccss,irily be tn aid tlic syitctn in i;eiliiii{ 
_tid iiT the )»ison as quickly as possible, and then to relieve the exccsltve 
; with teilntivev 

* An <>(vurnTK< c4 Milk InAjctinn.' \jj Dr. J, Ninii. l.at(it. J Ad. ly. 1H4;. 




96 



Diirasts of lltt Digtsiht Sys/im 



AeMo ne«<eoUU>. Sjseaieft* Blarrbua 

Diarrlitca of a dy>enIeTi<^ tharactcr is sometime* Mcondiiry to ncule 
ciitaitlial diiirrhu^, i>r tt nuy fullow meaalei, whooping cwigh, or otbet 
t)inolic diiCdH. [n th«ie chips it is ina»lly chronic or at lbi:R)ost sulMcutr. 
There n »ltiiinin>: at itoul : the evncuaiiim* coniain much mucus .i»d are 
llrciikcd wilh bbixl. l'tol;ipie of the rccliim ii coitiinon. In lomc i:.-ih-i, 
which occur almoM cniirely in nldcr children, ileo-colitii n an e\cec<linKl/ 
acute nnd fatal diienic. Cases of lhi» deicriplion have been recorded by 
tienocb, noodhart, and ICustace .Smith. I'hc onMit it tudden, nith timiiiini;, 
colic, and fever, \\\v. laiier uxually not hi^h ; there is much ttraininK al Wool, 
folloned by the passage fine of fu;cal mailcrt, later blood and mucus only. 
There it mostly >ome .nbdommal lcndernes>, and in some iniunces a purpuric 
or petechial rash on the *kin. There is certain to tw great depression and' 
rjipidly increasinij weakness. There is often delirium at nitihl. At llto 
autopsy the last fc^it or so of the ileum is found to be involved, auA the 
changes are more marked in the colon, but most of alt in the siiiinoid flexure 
and rectum. I'he mucous membninf is swollen and intensely injected unih 
patches of thin membranous exudation, or if the child has lived some day^ 
there i» ulceration of .1 superlicial character. 1*he etloloiiy of these cases 1* 
ob«curc. They occur in ihc hot WYyilher of summer, but their occurrence is 
not limilcd to this time. One of our cases occurred in April, at the heiifhl 
of an epi<lcmic of inlluenta. (.See below.) 

In one case cominK under our notice in a girl nf twelve years, who nat 
fldmiiied to hospital under the [are of our collea);ui-, I)r, llution, the attack 
CMnmcnced with vomiting and diarrhtea, foil owed by delirium, petechia: on 
the skin, and bleeding from the nose. She »as.idmitled lo hospital on the 
sixth day of her illni^ss in a colbpsrd condiiion. with a pulse of iqo and a 
tempnaturc of lo:' Y. ; she passed loose stools containing lonie barti lurnps 
with blood and mucus : later, the epistaxis ag.-un superveneil, Ihc Icmpera- 
turc rose to 104° K., and she died exhuuiied on Ihc ninth day of her illnets- 
Thc poil-mortcm showed (he folds of the mucous membrane of the colon \f» 
be of an ashy-grey colour wilh well-delincd ulcers varpng insiteframaptn's 
head ti> half an inch in riianK'tiT : «ll llie changes u«re more marked belov' 
the sigmoid flexuri.'. 

En another case of a somCHhat similar nature coming under our CJire, 
the symptoms so closely roctnbfcd thotie of an inva{;tnation of the inlesiines, 
that an cxpiorator) Incision was mnde into the abdominal cavity. Cases oT 
intussusception are nix infrctiuenily diagnosed as 'dysentery,' but it is rare 
for the opposite mistake to be made. Tlie case was shonly as follon-s : 

Aiiatt ilft^<^i/it~-l>Mth —.A (my ul mr^e ^rart ofnj^ w(t\ ^xKMrnly *cifnJ (Apnl n, 
■S911 ■iUi pain in tlie .itid<'nien uhrlii a\ Hilitwl, (oUuoixl liy ilic lusugrorUomlsiitf 
niucoi liy 1h« linwvl : )ir onlinurd in lllit uiii, iliiiini; ihv suocnilmg nigliL t(c iiiu 
ndiniltnl <<> lioipitxl noxt il.i^ , .-itiil, in t'pilr ol fumcii lull mis *nil upiiini. hr [-uiwil Iwetv* 
ili»>li. ron>iil>ni: 'ilnnxi miirrh ••( HftxX iini iiiiiciw. Tein|wr>luR 90-100 I''. Afnl 
H. — Tlw irnntiiui nnil bbmily ilouls ciiniiniml. id t|»lc nt liUf rneniiiU •>( matin 
wnHT ■ \\>p Intlot (.rouiilii nuay n tniall i|u,inl>ly .if fiit.-il iiinllers. No liilnour ooulil tm 
fril ; (he nbJuliim m>s rii<i ilidicnilivt ii«i tmili*! In thv toudi. Tcm|>rnitura OT.-WO'' V. 
In the fwDing. u no impniM'mml had \i\tw |i]iKe. and (be boy wtuKil npidlgr tiiikinc. 
it wa> ikddnl 10 nplutr llw nlxloiniiiKl caviijr. in onlsr to rdieit an iim(inn(loa ol lbs 



Acute Ilto-eoHiis 



97 



boa"! if prmcnL Tbb wm done : but no InvngiaAilon wnt found, nnly an Intenwiy con- 
fOMd cnkin. Dnth rolToiinl .iboui c'ltht huurv aficr. At ibe fi-il-mjrtiii iti? siomnch 
WmI wnall intcAllnei. I« uitbin inrnty mcheior Ihr c«'':uni. triv fouml noim-jl ; ihr Init 
loM or two <if itoum wu rounil i-onEivinl, uith pnlchii of Ihni inFXibriniiui ciudailoii. 
Tbc mneoui aunntnnEof llic colon, hitiimiil ilvi^iir. mil rcviuiu u'ii> inivnirlv l]i)<cioil. 
tm iduaes in llw knnit pnrii being mou fnarki;<t. iln^ mlum being lucmonhagtc Tlinc 
Mfv pnMba of ibte ■nccnbianoiu rxulntion, but no uliMn. 

These aeuie case* of dyscntciic diatrhoja nppenr lo occur in children of 
er eight it nine t'cais raihcr ih.-kn in >-oungor children. 
Diagnosis.- Tcncstnut, with p.i^wgc of blood and mucuj by (he bowel, 
1 an infant under a y<-.ii old, i|ioiil<i ccrtVinlj* siig^cst tniu^'^usccpiion talhcr 
ileo-colitii ; iind i cnicful (-xplor.itioii iif ibc tortiini and palpation of 
' abdomen >Ji«uld ccriiijnly be made. In older cliildrcn ihc*c symplom^ 
DiTioite ilM>-co)iti« miher llun invagination ; fever, deltriuni, vomiting, also 
>iot the Kinve way. 

TfYd/m^M/.— In amic ilec-colitis only thcblnnd«M fond Eihould l>c given, 
ich as ttm>u*rooi, ii*e.-Ll broth, or white of egg tnixiiirc. and if there is voinii- 
j. tlK less food git-en the better. Hot l(nnenI;ition« conlaining opium 
bixikl be applied to tbc ahdonicn, nnd evrrj- cfToTI made to nlby ihc inflain- 
Story condition of the colon by minllMnrch and opium enem.ila. Anything 
thai cun possibly irrliale, such as purg.ilivci^ or indigestible food, must 
be avuideO, as likely in incivasc the prrisiaUi« .ind tenesmus. Kive to tni 
(Mitces r4it*im stnrch murilageandborncicacii) unlh lo minims of l:iucl;inum 
na) be gi^-cn to a rhild often years. Slintul.ims arc fcnain to he tcc|uitcd 
Moner or Utcr. In mild or chronic cases itrigalion of the bowel is often of 
ihe greatest s«r\'ice. Thin starchy inucilajiie in.iy he used «itb bismuth 
•side or nitrate, nnd the amount employed should be siiflicienily large to 
nadi the cj-cum. I.axaiives, bs ihubarb and toda or castor-oil emulsion, 
•n alto useful. Gicai caic must be taken in the diet, and all rich foo<l& 
■••iiled. 




£8 



Pistiues of the Digeslive SysUtn 



CHAPTER VI 

niSKANICS or THE Dir.BSTIVE SYSTKU—i^ontiHtuJ) 

'cbr«Dlo CNiBtro>l aMatlnkl Oat^rrb. Oa«tr«-irit«MtlaaI Atropbr 

Ik «ame ciiics a giA^irii: cutiirrli cxisis wilii but liiile evidence «f ihc iniM. 
lines being in anj- way affeclcd, nnd in oilier c;im:» ihi; intcilino miiy be ihc 
only pan of the alimentary cjinal uhich appenre to tuflrr -. but in prrhapi 
the majority of cnw^ especially in infant* and »iniill irhitdren. there i» no 
bharply defined limitation between the two, the whole of the aliment^iry canal 
uppejiring lo be involved. 

The tcrm^ obronlo TomltlDK- ebroBlo aiarrbo**, •tnapl* atrapkr, 
maUintrltloo. itUirapatii. .tic 'riimriimrv ,ipplicd. ^trcor^linx to ihc moit 
prominent symptom iihidi is present ; thu*, rlironi<: vomilinjj is the mmi 
marked and sirikinft s>Tnplom »hirh mny he present in eat^rth of the 
stnmarh ; A iarthira is mostly present, or nt least more or les» lonteiKSs of 
thebouels, in ihc early ttngcsof an inietiinal caun-h, thmiKbiheUller may 
exist without iiny marked diarrhica, or in the later ita^cs there may b« con- 
tlipniion. If the only markrd lytnpiomt are d)tpcpsia and wasting, then 
the term simple atrophy li.is been applied. In all ihne conditions, while 
(he syraptnitii m.iy dilfcr, the unatomiciil xraundwork is ihe same — namely, 
a chronic gastrn- intestinal catarrh, which in later stagci pa&sesinioa gaMro- 
intestinal atrophy. 

Thus, an infant soon nher birth, or perhaps when a few months oil), 
suffers from repented and frequent vomiting, or it suffcis from diarrlicca, or 
if theM flrc abaeni there are other chronic dyspeptic iroiihlcs, such as flatu- 
lence and colic : it fails lo thrive and |;radua1]y wastes, and after a more of 
leu prolracied illnciik, durinK which the naiting becnities extreme, il diet 
«xhau»led or i* carried olTby lomc intercurrent diieasc. In soinc cases the 
course is very *hort, perhaps only a few weeks hut in the majority the disc.ise 
i« chronic und the inlam livei for moiithi, iiufferintt conslanlly from dyS' 
pepsia. unable to iligeii it» food, finally dwindling awa)' -md dying at UsL 
■file less sci-cre cases, eipeti.illy if they come under trcaiiTicni, f;radi*ally 
im prove, and after monthi ofthemo»t careful feeding and niinini; coniptetely 
recover, though »uch cnei uimlty become rickety or arc otherwise ucakly. 
Krcover)- is only poaaiblc during the earlier sLigc* ; if the c^itarrlial stage 
luB passed on into one in uliieh there is :iilvanced atrophy of the ntucous 
membmne of the siomacli and intestines with the secreting glands, recovery 
is ()f course impossible. 



Chronic Intestinal Catarrh 



99 



ExperimcnLiI tetearch ha« thown iImi ihcrc is a diminution in (he amoum 
hydtochloric acid and pepsin sctrc[<'d, while there i* aii esconivc forma- 
m of miK-ut, laciic. acciic, and buiyric acids. Much gas is ifivcn ofT from 
lb» dcuMnpocint; fnod. 

»This xaitto-mtnttiiul atrophy rarely occurs in children over t8 montlu of 
t^t, and indeed U most common in infanis under 6 months. Older children 
niiTcr from chronic intcsilnal catarrh, which rarely goes on to atrophy, though 
it i« frequently the precursor of iubcrculosi« of the mescnlcrie glandJi. 

»ln ilic majority of catev. chrorfic gastroinic^tinal catarrh is ihe result of 
improper feedinj;. Infanu vho come of a healthy stock ant! are nursed at 
ihe breast of healthy mothers rarely, if ever, toffer from il. at lea« as a 
primary disease. It is the Infants who arc fed from the first on cow's milk 
<ir the various forms of surchy foods that chiefly sulTcr, The infant may go 
on fairly well for the first (««■ weeks or more, suffering more or less from 
dyspepsia ; then rnmc« an attack of diarrha-a or vomiting, and forthwith il 
hr jias lo go downhill ; no fooiJ seems to suit it, however often changed, and 
II never reco\cTs its digestii-c poivcrs, which api>ear lo have been hopelessly 
duiugcd. Seme infants appear to get or) fairly well till they suffer from an 
■Hack of hnmcbo' pneumonia, or me.istes, or whooping-cough, which they 
Krvive only to begin gradually to waste. In some fesv instances, more 
specially in iliipen.^ary practice, atrophic infants may be seen of a few 
imm)i» «(d, who have been, according to their mothers' accounts, entirely 
bmW'fed. In iIkm casei the infants have been congenitally weak or pre- 
nian, and very probably the mother's milk hii) been deficient in quality 
ikl ijiuintiiy, or the child may have been fed whenever it cried, and in every 
njf been badly cared for, 

Sjm^tmt.—'tm.ttMtx, The hi*tory which is generally obtained fromsuch 
o«n il that they were suckled for a ft-w wceki or months after birth, then 
IkmMber had to go to work or her milk failed, and Ihe infant wa> made over 
»»i friciMl oT hireling 1» he artificially fed, and from this time it began to 
■»W. t>n cto*s.<]ue»tn>niog the nK)ihcr or taretukfr. it is found that il lias 
knltd on *(>pp«l bread or biscuits, brcausc cows milk did not appear lo 
mvti ti, or It t omilcd the milk curdled, and it has constantly sulTctcd from 
«k, Tixniitng, or more commonly diarrbun. On the other hand, there is 
lOMtiaM It' -nstipation, but this usually has been preceded by diarrhcea ; 
At'' ;,m|>toms being most marked in those sulTcring during the 

ntii: If llur sympliims be analysed, three stages in the course of 

At iliMi^K- in.iy be recognised as first clearly {loinlcd out and emphasised by 
hrpx, »hi>se dcsciipliiin of these cases uncler the name of wthrcpsia leaves 
tMhiag; In be d<rsired. The early symptoms or first stage arc those of a 
■inple gastric or intestinal catarrh, in the second the progressive wasting be- 
tmmhe ifromincnt phenomenon, and in the last stage the infant p.-issi^s into 
Mnluuttcd conditii^n in which cerebral symptoms niake their appearance. 
■int tt^xt. I'he infiint sullers from a simple diarrhce.i or looseness of the 
: (be stools instead of being bright y«IIow and homogeneous, are liquid, 
r, kimI often grc«it in colour, or contain an excess uf mucus ; sometimes 
fwnslsiahnost entirely of stinking curd, or remains of milk; the.ihdomen 
distended with gns and remains constantly in this condition, the tongue is 
auil patchcfaof aphthous stomalltia appear in the mimth. The infant 



lOO Diseases of the Digesfh-e System ^1 

Is restlcM, coDSUuit]^ wliinint,', and uill not sleep nt nighL Frequent ramit* 
ing may be a prominent aymptniTi, ihc milk being rciurncd curdled. The 
li!i>u<:-» become HAbby, and ilicn H.iiiing con>mGnces. In the ui^^md ttai;c 
all The8yn)p[om$arctnierisiri<.'dand ihecharacicri^tic waMJn^ becomes inaoi- 
fest. The stools for t)ic mosi pan ate louse and freijucnt, and consist oi un- 
dl(;eMed food, Iwing ofieii pntc aod putty'likc, u-itli a i>ecu1iar cidoui latoihcr 
tines (heyarcof a darkbrnun colour from ilic presence of altered bile. 1'he 
iofant is mrisily voiucious tii[uld food docs not appear tn satisfy ii, and by 
tlie mistaken kindness of its friends it is fed willi si>p|>cd bread or some thick 
food, a diet which hns the great merit in their eyes of keeping it qtiici for a 
longer time than liquid fnod or diluted milk ; at times it cries incessantly, 
hardly ever appearing tn sleep or nnly doling for a short time unless under 
the inducnrc of a 'soothing syrup' supplied by its nurse. The mouth 
becomes the scat of parasitic stomatitis, the skin is harsh and dry, small hnils 
or a lichennuf rash make their appearance, the buttocks and genitals are raw 
and excoriated. Its icm|>cratuie is below normal, the feet and hands arc 
congested, the face h.is •! pallid earthy lint, and a sickly lactic acid smell is 
given out from the body, especially the abdomen. The wasting is extreme, 
the face being shrivelled, the skin wrinkled and hanging in folds about the 
thighs and arnii. In the lliirii sSagt the infant passes into a mnribtmd 
state ; it is loo feeble to cry loudly, it becomes he.^vy and drowsy, taking 
little notice of anything. It hcccnnet more and more somnolent, and death 
ensues, ptnhably iircceded by muscular twiichings, strabismus, or general 
cons-iitsions. 

If u-<- analyse the principal symptoms nf the disease, we ihall 6nd that 
sometimes one »ympt«m, as diarrhtea, sonictiines another, as vomllint;, i-i the 
moit proininent. In the majority of the oiscs there is more or \vi^diarrkaa 
(hrouyhout the whole course, so that sucli cases would come under the cate- 
gory of obranie dlmrttaoi*. or this chronic i:on<liti<m may alternate uiih the 
acuter form^ The stools at first arc yellow, liquid and frothy, with doccult 
of semi-digested curd ; later they become green, the acid cuDtcnis of the 
intestines acting on the bile pigments ; when the di irthixa lias become chronic 
the stools are either liquid and of a dirty btown colour, or mine often, 
eiti>ecially if milk i» being takcp, they are white and semi-liquid, the Inle 
pigment having disappeared, and they consist of dccompoiing foul- smelling 
curd and mucus. Sometimes the stool* consist almost entirely of mucui, 
the mucous membrane both of the small and large intestine accreting large 
quantities ; the child is constantly p.n»sing stooU of mucus and undigested 
food. 

In some cases cbnmle vcmltlnir is the most iruublesotne symptom, 
there being no diarrhii^a but aiimeiinies coivsiipaiion. Cases of chronic 
vomiting with the consequent malnutrition are at limes most diffiiult to deal 
with. So great is Ilie irritability of the stomach that everything is rejected, 
cither immediately after being taken, or after the lapse of [lerhaps ludf an 
hour. Diluted milk, peptonized preparations, meat juice, cre;mi, and ^i variety 
of patent foods are tried one after another, scpatalely or mixed : each diange 
only ends in disa)>])ointn)ent, the infant becoming more and more wasted. 
Under such circumstances among the poorer classes the infant is given 
some thick fiwd, as sopped bread or com Hour. Vomiting in many cases 



■ie Intestinal Catarrh 



lor 



^ 



to be ibe lesult of the nipiUiiy wiih whicli cow't nii1k is cixigulalcd 
in&u)i'« tiomncl) ;iii<)nr the hard lumps orcurd whicltrire thrown <lown, 
IbU ocmmriK ctcn where (he oiilk is redui^cd id one part of milk to five of 
witcT. In oihcT insUinccs it -tppcars to be due to t)ie tapid cliaogcs occur- 
ring in liic lUKHf of milk, lactic acid being forineil; ihe contents of the 
Uomacb arc rejected, having a stronj; smelt uf sour and tkcomposing milk. 
In the cAtarrhal rnndition of the ihuculis nicrnbraiie of the sloniucli much 
mocut i> formed, while the gastnc juicv is weuk. but ita curdling power 
vndiminislMd. Many such cases go from bad lo worse, no food appearing 
loa^rce, all forms coming up ahk«. It tuu»l not be forgotien. in a case of 
foostant vomiting, iliat it may be due to cerebral disease or some congenital 
-ilcfiect. The prognosis in chinnic vomiting is unfavourable if it commences 
(n on ani6«iall>- reared infant, and becomes [bomughiy established, and \% 
Attociaied with progies«ivc wasting. 

As the child wnties the >ikin Ix-comct rough and harsh and hangs in fuMs 
upon the limbs ^nd trunk, and very frequently, as the anu'inia increases, the 
Uit, haitils, and feet become ocdcmaious. This [i:dema is due to anarinia 
ruber than to anjr kidney complication. An erythematous rash is apt 
to make its appe^irancc about the anus in those cases where there is 
much dtafrlm.'A, and spread o^cr the perineum and ihighs. Small boils and 
ahscesset are also common. Pemphigus may also appear. 

The temperature is cnnstanity below normal, often measuring 96" or 
I 97' F. all through the iwenty.foiir hours. 

CQmf^ii'itiom. -Bronr ho- pneumonia it very common. Tuberculosis of 
itic mcsenicric or mcdin.itin.-il ^landi. may nccur, or there maybe a more 
gcnenl dittribulion of luticrclc throuj;hout the body. It must be boinc in 
■ifld that it is only in the more kcvitc and nci;tcctcd cases thai intcslinal 
csurrtl passes on into .-itrophy 1 in llie m.ijorily of cases the course of the 
lUwiM is intertnittcni, lometimes bciier, at other limes n-orsc, and at the 
child grows older the lymptoms of rickets become grafted on 10 those of u 
ckonic catarrh of the bowels 

•M«r chiur«a.— .\ chronic intestinal imtarrb ii not so letious a disease 
a cbiklrcn o^fr tu'o yean of age as in infants, as ii is rarely followed by :m 
Mmpliic condiiion of ihc glandular apparatus of the stomach and intestines, 
h« takes rather the form of lutbitual indigestion than anything ebe. It is, 
ki*rev«r, apt to be exceedingly chronic in its i:ourse and to be followed by 
•irinus evil consequences, the most serious of which is tubeieulosis of the 
Irsiphatic glantK or tlieie is a constant slate of heallli below par, which in 
<Mlf is a scarce of danger. Chronic cai.trrhal affections of mucous mcm- 
kanes, either of the nose, mouth, respiratory iract, or mitstines, arc ex- 
etedingly apt to be followed by swelling and caseous degeneration of the 
Ifnphatic gt.inds. uiiti which ihe mucous membrane is connected. Tlic 
•leatinol lesion linds its origin for ihe most p.iit in unsuitable food ; the 
Bucoas ntenibrane of the stuuiach and bowels is kept in a constant state of 
■rriiation !)>■ food «hich is too great in quantity or of too indigestible 
(haracter. Weakly thiWreii are especially apt to sulTer, paniculaily those 
•in are brought ujiin our large cities and»hose time 15 spent cither indoors 
w pUymg in the street. Children who suffer habitually from rhinitis 
ehronk lansillitis, or chronic disease of the strumous type, are ibe chief 



* 




suflciers fioni chronic gaslfo*mlri(innl cntaiTh, It in vet)* common in 
rickety cbi Id rcn. Bochihe childicti of the wcll-lo-doandnf ihe pom clasMM 
suffer. 

Symproms.—'liitit is habitual indigestion with pervmed a[q)«li<e, the 
child refusing llsbread and milk and aaving for 'lasly' biKfrnmiK jNtrenti^ 
table, or aliajfcihcr refusing' ii» meals unless its food is htjihij- seasoned : »I 
olhci limes ihc iipjiciiie it excessive. The abdomen is invariably rounded 
from the constsni dimension of Ihc slomach and inicsiincs *iib jjas n'*'en oft 
from the decomposing bnlf-digesied food. TTiis distension i% very ftetiuenily 
BCCO«np(inicd by more or less pain. The face is Kenemlly pale with 
dark nrcol.e .-iniund ihc eyes, fM is absorbed ns the disease pra(-rcMes, ibc 
muscles bcromc il.ibhy, and the emaciation of the child contrasts maikedly 
nilh its lart^c tumid abdomen. Such children have usually coaled tongues, 
at other timci tht.- lon^'uc is red and glaicd, shoH-ing the enlart;cd funtiifortn 
papilUr mure distinctly than usual and n;scmbling tlie 'strawberry tonguo' 
of scarlet fever. Sometimes the surface has a worm-eaten appearance, 
being coaled with a thick fur except in irregular sinuous peaches » here the 
surface is red and ^bixed. The bowels are generally conlined, llie siooU bcint; 
frequently pasty with much mucus ; there arc apt to be iniercurrcnl attacks 
of vomiting and diarrliu;a. Tlierc is very frequently more or less feverish- 
nc:is at night, especially in the subacute cases. Headaches are comiMMI) 
(here is often restlessness at night, grinding of Icelh, and night terrors. ISome* 
times when the disease is subacute, and there is some fei-erishness towards 
evening, the sj'mptnms resemble mild lyphnid fever and constitute what at 
one lime was called * infanlilc intcrmiltcnl fever.' It is important to bear in 
mind th.ii *ul)acuie inietiinnl catarrh may be present with an evening ex- 
acerbation iif tcni[»eratnrc .is Ihc principal symptom and wiih no vomiting 
or diarrhita. An inicrmiiient fcwr during early childhood with no pulmo- 
nary symptoms is probably, if typhoid can be excluded, due to an iniesliiul 
catarrh. It will not fail to he noticed thai diarrha-a is a prominent symptom 
in the majority nf cases of infanis dufleriiig fiom chronic intestinal catarrh, 
while in older children not only is the diarrhoea not ptcsent, but there it 
usually constipation. 1'he explanation of thi» is perhaps not very clear, but 
it must be borne in mind ihat those cases where diarihtea is present and 
excessive arc more acute In character and run a more rapid conrie than ihoM 
mheiethe bowel* am less irritable : there is also more likely to bediarrhicain 
the early stage* where the mucous membtanc is congested, than in iIm later 
stages where the bowels have become mure loteran: of irritation and tlie 
muscular walls nasied through long illness. 

In some cases of intestinal catarib, especially in those which complicaie 
or follow whooping cough, there is an excessive formation of mucus ftoni ilu 
intestinal ualli ; Dr. Kustacc Smith has called special attention to thcs« 
cases under the name of ■ nnoona diaesa*.' The bowels arc usually luooe, 
the stools consisting largely of mucus or an aperient may bring away large 
quantities of muirus. In the worst cases, whcn,ihis form of disease complicates 
whooping "mgh, the prognosis is bad. 

DiagHoat, — The disease most likely lo be confounded with chronic intes- 
tinal catarrh is tuberculosis of ihc mcsenteiic glands. »t the eady stages of 
Itibercular meningitis. During ihc tirsi ihiecor four )-eius of life, it Iwmwiift 




Chronic Intestinal Catarrh 



lOJ 



ihai inf;int» or j-ounc children nic thought in have 'consutn])- 

el».' bct;iu-ie ihcy have caprkioiio appeiiies ' pot-bcllics,' and 

h»»« lost mocfa flesh, when in icniilj- ihey ,irr viiflcring from a chronic inlcs- 
iHul catarrh. That the diagnmis is often diillii'uli i« only wbai \s to be ex- 
pected when it U remembered th.-il an inlcstitinl caiatth ofmorcor less*eveiily 
if the exciting caxai of me5*nteric tuberciilnsi* ; and in an advanced ca^e, tt 
may be quite nnpuiiible to uiy if a lubernilosis of the glands has supervened. 
MncDieric diieaae is, howeici, much less eomiiion than simple intestinal 
atarrh, atvd i« infinitely Ic4s so during the first six month' of lift- ihangasiro- 
■ntcsiinal utiopby. Any evidence of tubercle in ihc lungs, or enlarged veins 
en the surface of the abdomen, or the detection of rounded masses by palpa- 
iwn ill the abdomen, would favour a diagnosis of mrseniciic disease. In 
older children the fact that thote suffering from intrttin.il raianh grind ihe 
Itelh, arc restle** al night, are sujijcci to night terrors and headaches, is 
ufbcient for mosi parenis to become alarmed, fearing thai the child Is eom- 
■WBcing wrih tubercular meningitis. 

AfarHJ AmtloMy.—Chronk Gauro-inttitinal Catarrh. — [n the early 

^KRages there i« swelling, and injection of the mucous membrane of the 

Bllomach, and imall and large intestine. Tlic surface is grey, streaked n iih red, 

V«nd there is an excess of mucus ; the change* arc usually most marked in the 

V deuin and colon, especially about ihc sigmoid ilexnre ; in these places the 

~ ulitary gbnds are enlarged, the mucous membrane is raised in folds, and 

(Aea much injected, and follictiUr ulcciatton may be present. The mi< to- 

Kopical appearances somen bat resemble those already described in acute 

otarth. The surface of the mucous membrane of the stomach is covered 

•ith inast«s of lciicoc>tes and microrocci embedded in mucus. The capil- 

bnn are eveij-whcrc distended, the gastric glamls are sep.-iraied from i.ne 

(Miker by columns of leucocytes effused between ihem, the whole mucous 

! Membrane is swollen, and the muscular la>-cr thickened. 

Similar changes are seen in the intestines, Ieucoc)tes are present in large 
onnbers in the submucosa and between Lieberkuhn's glands, the taller arc 
tuKipreued and finally disappear, so that in places ontymassesof round cells 
■ce seen lakinji the place of the gUnds. A stage of atrophy succeeds that of 
chronic catarrh, and the appearances presented are tboie of a wasting of die 
macMs raembmnc, and a destruction of the sectuiing glands. The chrome 
•mKngof the mucosa, and inlittraiion with leucocytes, have led to a wauling 
lad cicatri«aiion of the lubular glands ; but deaih usuully takes place before 
Ihli stage is reached. 

la infanlitt <>lropky the stomach and iniesiine* are distended with gas, 
Ae fbrmcf is frcctuently dilated, ibe mucous membrane is ever yn here p^de. 
Ae ininiincs arc ihin and iramluceni. This i> especially marked in the 
store advanced rases, the iniesiinal walls art^ exceedingly thin, ibe solitary 
(laiKU and fever's p.ttrhc-: arc w.^iticd and b.ive almost disappeared, wiili 
periiaps brownish *|iois or tircaks where mmuic h:emonliages have taken 
plaec. These appearances will be vaiied with those of chronic caiaiTh 
iccordinK to the amount of atrophy thai lias taken place. The microscopical 
•p^earances show the mticous membrane of the stomach to have undergone 
rutiog, being reduced to perhaps one-quarter its norma! thickness. The 
gaUnc glaiids in places have completely disappeared, in other places they arc 



104 



iiSMsrs of the Digtstht System 



crnnpressed and panly destroyed by round cells nnd yoiini; c Annert i \-e-ttssllP 
libies. 1(1 the small mtesiines ilie appearancrs i*ill be thoic <if chronk 
CAtanh.or these wiili Ihc itddiiion of destniciion of ihc K'^ndul^r ;ip(>ar^iut. 
I'he lubuUr glaitds in pLu'rs have disappciiTcd, or nre comprcxml or dilated 
by a connective-tissue jiiowili, villi have completely disappeared, or only 
tlicincmains arc picsenl.ihe solitary >.'lnndsarcntrophicd or luvcdisappcarttL 
Similar chan);cs may he found in the colon. Parrot has drtcnl>cd varioat 
other lesions in the alimcniaty canal of infants dyinx nithin a few «crk» of 
their binh : such as a spiead of ihc parasitic j;">"ib from the inouih to the 
stomach and intestine, iisually Ihc carcum, The same aiiihiir hai found 
minute circular ulcers in the stomach, from which lia-morrha)fc has laLm 
place, less often lar^^cr and itre);ularl]' shaped ones ; he has also seen the 
mucous membrane of the stomach to be the seat of a diphtheroid exudation. 
In Ihc later sia^'es, when I he blood is profoundly altered, ihromlioiis of (he 
renal vcini, pulmonary reins, or sinuses of the brain may take place. Fatly 
deKenemiion (tltatnn- of Parrot), softcninx. or meningeal haimorrhaice. may 
lake place in the brain. The kidney may be ihc seal of uric acid 
infarcts. 

TreatmfHt.—Xht treatment of chronic i^a&tro- intestinal catarrh in Infanta 
cnnsiits principally in careful feeclin);; the blandest and least irrit:ttmi; 
forms of fooil mu'i be selected, u hile frequent ncit,'liings of the infani should 
be retorted <o in order to ascertain if any progress is beinj; made. In 
infants under four months a wet nurse should be obtained if possiUe. 
Where there is much diarrhoea, milk must be used sparinxly or all<>).'rihcr 
omitted for a white, nsthc hard curds formed in the ttomach are he>'ond ibo 
di([esiive powers of the weakened stomach and inlciiincs. Small tiuantilies 
of x« hey and liarley water, "hitcof v^a and Iwrley water, or the juice of an 
underdone chop, may be ^iven .it short intcnal* diirinx boih day and nijjhL 
Improvement having taken place as rc^aids the diarrhira, milk in >oine 
form or other must be given. Some of ihc forms of desiccated milk already 
rcferrtd lo (ij. ji) m»y be used alternately with rau beef juice and soii»c 
mailed food such as Mcllin's.nnd the cream mixture referred to [p. 46) may 
also be tried. Pepioniscd milk is often of much value under these circnm- 
stances, when marie by mininj; 30*. of boiling decoction of arrowroot with 30* 
of cold milk, addinic two leaspoonfuls of rrram, half a pcptonisin}[ powttn 
^EienKcri, s»eeicninK. and viving it to the infant after it has stood for fiftceN 
minuter. Every care must be taken that the feedinK bottle is clean, and 
the ^)d prepared uith the most scrupiilous care. Whenever the ncaiher 
permilt. the infant must lie taken into the open .ur as much as possible. 
The medicines K'^en must be selected nccordinij I" (he moit prominent 
symptoms. If the stools are loose, contain much mucus and cuni, and are 
finll or ttinkinx. sniall dosrs ai castor-nil einulsTiKi or calomel should be 
Ktven, to be followed by bismuth and small doses of opium. If the Itoott 
are dark biown or j-ellow and verj' liquid, asirin^nts in the form of cxltad 
of lox^'ood, catechu, or |iomci;ianate will Ik of romt service, e^jietially i 
MUtll diMcs of opium arc given by (he boivcl. If ihediarrha-a approach the 
dj-senierjc lyiw, much mucus and blood bcin>; passed with itmininK and 
Ibrcm^ down, enemaia of nitrate of silver and opium and alum or veicciable 
Astringents uiil be useful. (F. ti, 13, 14.) 



inmrc Intfsttnat Ottarfh 



105 



The trcaimcnt of clitoiuc ^'aUiic csiarrli la ioruts when it has become 
coniinned is very often cMieiiiely discuuratfin^'. 

»In Ihc tnilder fotms of vdmilin^ tlic miporiance of diluiin^ the milk so 
in reduce tlic (jUiniliy of ciinl.orof pc|)!oniiini,'lhemilk to gain the same 
«id, must be insturd upon. It is aUo of much impotlaiice not to ^w*. fooJ 
100 (miuently, boil ti> (j've the iionuch a complwc resi for several hoort, 
IfiKvvrer cuca in which milk or "hey, in whatuver form it is given, returns 
war and curdled in a few minutes, other food must be substiluted ai leasi 
fa* a tiine. In such case* Mtllin» food, cither made "iib water or weak veal 
Wh ihaif a ]>ound to the |)int]i, may be ipvcn ; ihc bottle being disconiiuued 
mA the mbnt fed vith a ipoon. Insle;id of veal broth, raw meat juice or 
'lifuid meat ' may be used. After a few days, milk may be again tried, or 
AMU qHantitws of cream may be added to the Mcllin's Tood in lieu of the 
■at juice. In ibii acid condition of sionuicb small dnses of sodil bicarb. 
«d pvpsrne ore often ver>' luefuL (F. 15.) 

la oMer etalMrcB careful dieting is i>f the utmnsT inipnrtnncc, and the firvl 
Jilinilly encountered will prohahly be that the child ha^ been ovcr-indulKcd 
ud Ml >[ioilt by ill parrnii thai i[ Is diffinill 10 get it 10 lake a carefully 
idrcied and restricted diet. In arranKinj; .1 diet it niu«l be borne iii mind 
ILtl the ihitd should take only such <|ti.iniilic:( as ibc impaired date of 
thi diKulive juice> ran drjl with, aiiy exccst bcint; liable to undergo decom- 
tmion in the intcminc:!, and Rive rise to ilatiilence and other troubki. It 
i> abomou imponani in give the stomacha complete re^t dorinc the micr\ als 
tm«t«n meals ; sweet liiK-iiils taken diirin>,' the niominj; or a run on the 
bx&tn at freiiucnt inicn.iU during the day arc fniiiful sources of chronic 
■■dStMioo, and the plainciLi and most porenii>tory directions should be niven 
l«tbe parents by the medical attendant that nmhinj,' whatever should bp 
blta except at rcKubr meals. If the child refuses or only half gels through 
lUhrcalc^i, this ihould by no meant be supplemented by a second edition 
aibt pareni*' uMe, or a tasty lunch to make up for the n)otning'3 deticicncies. 
Iiii*tserb\' far, if the breakfast is but half taken, to lei the child nait till the 
*Ri oKol ; a little stan-ation can do no harm, at any rate much less than 
mr-indnlj-enrc aivd the lormation of bad habits. The importance of fresh 
uiad change of scene in caws of habitual indigestion can hardly be ovcr- 
r«nuicd. The irorst form of exercise is a ■ constitutional ' taken with the 
toicor Ki^vcmess ; outdoor games od* various kinds, gymnastics, riding;, or 
fc»ing, or some form of recreation which will occupy the mind and give an 
iWnt to the exercise, are far preferable to any dull routine. A chan^ic to 
'W lUfide, or some bracing elevated inland site where there is a keen 
■^ lit, will oAcn work wonders in these cases. It must, however, be rc- 
xnliered that such cases are often worse, or there is no improvement, at 
(tni; cliildren wlicn first removed to the seaside are apt to do too much and 
oiieaiBiicli : they Jreovcr-tircd and fretful at ni);bt, and attacks of dyspci>sia 
^^<*lKrlupi edematous or other eruptions occur. A caution is often neccs- 
^1^ to pTCTcni this. 

^H ll 1 nner in most cjiscs to lay down a coniplete diet chart for the gui- 
■Unced'lbe jiarents, though a certain latitude must necessarily be permitted 
■" accMini ai varying: tastes. The following diet tables may be taken as 
*««?*«, which ran l>e moditied accoTdLn$ to circumstances : 



TBo^^^^ Diseases of the Digestive SysKm^^^^^^^^^ 

SIM ror M etUM ar S t« 9 jroara, lndl(aaU«a est aevvFO : ^^ 

Bre>tk/asl, 8 A-M.— A breakrasi cupful (8 oi.) of t>r«iul and milk, made 
from hIio1« nwal bread ; a tcaspoonful of malt cxlraci may b« added ; ihis 
niay be followed two or Ibree timesa week by the yxilkaf a lighlly bolted egg 
on ttri|n of loatl, or a piece of loaii nnd dripping or bacon Ux. 

Dinner, t2 to i P.M.— A broiled mution<:hop,^iiir/)'Mn<Ryi/,orfrvHh«luie 
fiitb, with mashed ixiiaio, ipin.nch, or t'rcmch bcaot ; i» bcfollou-cd by ground 
rice pudding or a bnkcd apple. Milk in diink. 

Titit, 4 In ; P..M. A cup of cocoa and milk, with toast or xUde bread. 

Supper, 7 P.M. — .-X cup of beef ica or mutton broth. 

In the more «et-ere and proiracled raies it is nell la avoid f^rinaceout 
food AS mucli ai posilhlc, as rccommciided hy Dr. Eustace Smith. 

Ilnak/atl, 8 A.M. — Half lo lbr(-c ijuancri. of a pint of ^csh milk, alkali- 
niscd by twenty drops of the sacch.irviicd solution of lime ; a slice of loaxi 
wilh jnlk of cgK, or fresh fish. 

ihnnrr, tz~\ i>.w.— A small mutton chop or boiled aole, a thin *Iioe tA 
W»\k bre«d, uiih half lo a winegbssful of shcrrv- or bitter beer, uvll diluted. 

Tea, 4-^ i>.>l.— Snmc as breakfast. 

Supptr, 7 I'.M.— A cup of beef tea. 

Ill some of these cases of chronic dyspepsia, especially uhcrc the stod* 
Kic pule, the amount of milk which the child takes must be Irsscned in 
quaniiiy— the milk ^ivcn being iDUcb diluted with cocm, of p^ionucd 
milk may be ijiven. 

In all cases of habitual indifjesiion it is of much importance to apoaii* 
ever)' n>ominK with cold or tepid water (6o'-7o'>, kcepinjj the child's fcrt Ift 
watrm water during the process, if it is subject lo cold feci or hu % ituRgiib 
circulation. A shower bath is often of much service. After the nwrning^ 
hath friction wiih as rou^'h a towel as the child's skin can stand should be 
used. The child's dress should consist ofnoollen jj^rincms next to the skiii, 
and every chance nr^eltinj; cold should be avoided. 

The medicines which ate of the greatest value in these cases arc nitric 
acid in combin.ttlon with lielaline and pepsine (nt^xv to il^xxx of lbeli<i.),4r 
cuonymin and pepsine may be given. 

.■\rsenic is often of much value, but requires to Itc giv-cn in incmuinf 
doses to brinti out its full value. For a child of seven years, thrcc' drop doaet 
tna)' be git en. and gradually increased to six drops, or it may be v'it'en i" 
small granules, which are readily taken by childien, prcTerably an hoar after 
food. At the same time ii is well to order a saline puixatit'c, nhicb shall 
keep the bowels relaiic<l rather than loose. 

Alkalies niih senna or rhubarb are often prescnbcd with much advantagOi 
(F. 16. 17, tS.) 

Later, when convalescence ii established, acids and bitten should be 
given. 

If the bowels keep conlmed, a small granule containing half a grain 
aqueous extract of aloes muy be taken at dinner time daily; in ntany cases* 
grain nill be required to keep the bowels well open. This may be supfilc' 
inenled, especially if the stools iitc pale, by an ounce or two of Hunjadi 
WiUcr, lonhich an equal quantity of warm water has been added, lo bo taken 
two or three times a week bcf<»e breakfast, or Rubinal or Friedericlishall 



Dilatation of Sfottifleh 107 

[a wiiWgbsi to n win«Klit(tful in wann water, or a (eaipoonful of 
Ciirlsbad talis, mny be Mkcn bcfntc breakfntt two or three 
m weeic, and decreased w incrcaMd nccoiding to the itate of the 
beirala. 

aUBtettan ef Btemaeb. -Dilataiion of the «t<>inach durinj:; infancjr i( 

centtnoctjr the nrsuli of a lon'^-coniinucd ^■astnc c;itarrh ; in rare cascn it i» 

lecondar>' to a <:oiiKenii.il stenosis of the pylnrus ■»' duodenum, or upper 

pan of the Mnall inteMine. In Ihc minority or caries the dilatntinn laki-s 

fteee npidly, as in acute RnKric or gastro-iiiicilinal catarrh, or in ' cholera. 

iMboima,' but it i» fcir more fTriiuenily found in weakly infants or children 

abo have suffered for nwmtlii from clironic dyspepsia and nho arc prubabty 

uurndcaiMl rickety. It i» ea»y to understand that, if the dit^estive Huids 

are aeak and insuflkicnt tu properly digest the f'lud, the curd of milfc and 

waKhcs decompose in the iiomach. and teases arc ifivcn ol7 in large <iuanti- 

Uefc Tbe coiHlant di^teniiun oi ibc stomach kccp> the muscular walls oa 

the timch, Die muscular Abies become thin and atrophic, and the distended 




'^ i<<~Hoarct*v^0'ii*>^^ ^ tLoniAch, Trmnt ^m InHjfiL of ttrt tt\it*iii\*, {Nariinl uh.) 



'^Cwilini tends to become permanent. The iimseolar inucout membrane. 
«»ri a *»fc tlie ^tundiibr clcmenit, is wasted. The cllect nf a dilated 
(tMttch is It) add tn the dyspeptic trtmblta ; like a dilated and powcrlcw 
UiAln, its I onlcnts become siannant and decompose ; it never thiirouKiily 
■Bpties itself, but always molains much mucin and dei-omposini; rtird 
<* milk. These ddiaicd stomachs wimetimcs reath an enoniioiis size. 
)I(U(brt lerords a MomAch of an infant t«'o weeks old uitli a cajiariiy of 
f)o cc. I'nnrnul, 70 re) ; an infant of thiee inonihi wiih a stomach nf a 
<l(Kity of 485 cc (normal, ijo cc.) ; anoiher of four inonilu, of 500 cc 
^•mal. 180 cci ; and another of ten months of 6;occ (normal, 300 cc). 
nesjtnpioms aic not \eiy definite, and we have on sevenil occasiims dis- 
«*ncd f»st mortem a considerably dilated stuinacli. uhich we had not 
'XKtnl duhnK life. Theie ii chronic dyspepsia, itiscomfori after food, 
'Hramn of the stomach uith tjaMrs, coated tnnyue, and in some caiet 
tbtmc vomiiinK. The di.ixnuili may be difficult : in lomc cases the limits, 
tflte i&Uicd stomach may be mapped out by percuuion, but tliis can only 

ibtdtM if the cohm and small intestines are not distended. If the colon i» 



lOS 



Diseases of the Digestive Sysfem 



much ditt^ndcd, ii will probably be impossible to dislinjjuisU bclwecn llie 
(jrinpnnilic note produced by percussing the itomuth :ind thai pio(lu<:c(l by 
peccui^^intf ihc colon. A splashing sound may »(>[netiini;» be produced by 
shaking the child, in cn\es of dtUicd stomnch. if there is much fluid in the 
stoinsich. The pro);n(uis is nnt necessarily bad, as there can be little do<^t 
thai under favpiirnblc condilinns ihc stumitch may rccoier itself. The 
trcaimenl is that of chronic dyspepsia : vmshing ont is esp<s:ially ui«fiil. 

In rarccASCS there is a coRffcnital slcoosisof the pylotui uithatecoodafy 
dilatation and h>'pcnriiphy of the walls of the sinniacli. Two catc^ are 
recorded by Hirschsprung ; ' one of ibcsc cases lived a munih. ihc other six 
months ; the prominent symptoms were tomtlin^, const i pat ioiv, and proKie*- 
»tv« wasting. At the p^st-ttitrttm in cacli case the pylorus was thickened, 
Ihc ojjcnin^ Mcnoscd «a as only to admit a mcdimn-siicd sound, and the 
6iomac1i dilated and tlic wails hypcrtrophitd. HcD»chel relates two wime- 
what similar cases.' 

Dilaiation of the stoiiuch, sonielimes exireioe in degree, is pnoentis 
congedial obstraciion of ihe duodenum and ileum, (^ee p. i4i-> 

M»l(omatt<ma of ttie Stomaeta. — 'llieie are certainly uncoininon, but 
a slight dc^Tee of liour-Klaii con«triciicin which had been unsuspected during 
life rnay at timea be found at fiosi-moriemt. In a case of our o<irn in 
nhidi we made tlie section, but did not sec the infant during life, there was 
a well-marked coniraclion in the central poriioo of the stomach. (See 
fis- n.) There was a history of constant vomiting during life. 

Oarolnonut of tb« Stomkob. — New ifrowthf in the alimeniar^- caaal 
are excecdinjily rare in r-ifl> life. The best-known case is that recorded by 
Ur. Cull ing worth. In I his case a columnar epithelioma was found in the 
stomach of an infant of Itvc weeks ol<l. W'c have met with one caMt 
but the new growth ua« more duodenal than gastric. The case was shonly 
as follom : 

UlivfT G., *gnl i yian. wax admittnl to luMiilial Sept. t. tSqo. )lr uas a iMi' 
oiill duiaiilrd atxloineii and syiii|)IDin» <if cyttiltn. TTirrr linil Iven nu itxnitin^ 
.rr (liiifHicra The alxlomlnni ilisioiklon w.ii itiiniilcfarilc : tilt Colb of IfUeflJacS WoM 
lir duUnclly ttrtt Otniug^i ilir nlidnminjil wall). Thnr oai nu iniilemcgM, Mill IW tntnaui 
eould be ftll. lie vni itiacli.ifgeil l-'rlirunry Ji. it^i. »c>niiMhAl improrad. hiifiif nuult 
llfsh durinjt liit »l.-iy. lie WJ3 rp-.-idmlUrtl April 33. iSqt. Tnr abdomen wai iliiltfililcd 
anit imdct. nod n tumoui' cuiild W (cll tirlow ihq pdxr of III' livrr. In thr right tA, toA 
atniiii (lur MUDC level B>. Ihe iirabll^niL 'I'liere witfe lhx)iienl nilncla of acrere ot4Mj 
|«lni. Kg crailiully emao.-ilpd, and a\n.\ M.iy'15. yiir fril-m.'rUm itiinifd tlUU'hB 
Imnivme colon nor the hr|iitK (IrtiitT . \hr •luuili'iiuiii iind oinciiluni. nee ounal 
lUKi-llin ; ilio iiomacU wi» dilal«l. niict y(t unlU thlckeneii. The pyWit upeiung }wl 
nilniiiteil tlic tOnfinKT ; un Ihc cantinc itile of ill'' |iy1"rut were (nu (iikill er<ntllu, ibc 
srtr cif pnui oti Ihc duiKlen.il mlc thi-re wai ;in (neguUr eavliy. ihe wnlts ot (Ik tol . 
«(llieilunlcnumIiAv>ii|- been de»miye<M]y » new Kti>wih; InHCr iSoan w*r« MfiW pdffial^ 
liiokint- Itr^wltu ; twiaw Ihrw ilir mui.-ati« mc-intintne unt normal. Mlcraacofiloal 
iiall»n ilimxil Ihr Krootli 10 be ■ cotunmnr cpiibcliomi. 

Oleor or •teoMoh. --Tubercular ulcers of the stomach ocfur in chiktrtn, 
but we hare never seen an ewmple. When pulicrty it passed simple ulcen 
may occur. We Iiax-e known severe haeinatemesis occur from ulcers iu the 
jejunum. 

• JaJtftHiMflir k-iadttkr. pjuid Unilx. H«lt I. 

* AfUiv/. Kiadtrk Band xiii Hrft 1. 



Intfslinul Worms 



109 



I Tte wDrn» wliich moil comnioiity infest children are the thread wormi, 

1 wonn%. anil Lnpe worms, of ithic}) \\\c former nrc the mo« common. 

nirM« ^I7*rtt* lOmyiirn;.— These lioublcsome pcsls inhabit the lower 

bond, namelj t.icuin. culon, sigmoid flexure and rectum, nnd also ilie vaKina, 

an unhealthy stale of ilic mucous membrane wiili sluKKisli bo«cI» appear- 

i to favpuT ibeir development. To the nakeil eye they Appear like short 






%^~Oijur(t rTrymiinUrii, hnulr, Mtghly Rutniltcd. (Qua!n'( ' Dkilooui' uf Mtdiclnt') 

flKcs of *hiie thread ; under a low poivcr the female*, which are the most 
MMerous,are se«n to t:ipcr at c.ieh en(l.;md their uteiine iluci» will be seen 
uegrtun nunietou* oval-ilaped ova. some of the latter coniainin^ embrjos. 
■Rwe parasites gam enhance into the system by the ova being taken in the 
(Md,in|>eTh3|M hkmc frequeiilly by means of Ihcovnudhcrini^ to the fingers 
cfthoK already affected; they ace ihiit conveyed directly or indirectly to 
vbtn. Tlic extrenic fertility of iliesc worms make^ it certain ibai anyone 
»*n a aficcteil » ith thre;id norma and is not of ici upulously cleanly habiis 
•■ lui« ora adhering to the neighbour hood of the anus which may be 
tnoikfrcil by the fingers lo ibe individual's own mouth or to other*. The 
Unpinnx are very uncertain, tli« diagnosis being usually made by the 
ftbcK't friendi detecting the parasites in the chamber vessel used by the 
cbld. The moat common symptom to call attention lo 
ibi pretence of thread worms is the irritation and itching 
i^h they are apt to give rise to at the anus or entrance 
»ti( vagina. Uirb will suffer from excessive discharge 
cfnocns from the vagina, sometimes containing blood. 
frw the presence ofoxyuridcs in the vagina or the tcsult 
ft Kraiching. In many cases the presence of Uiread 
mujM teems to give rise to no symptoms whatever. 
U'ukly .uia-mic children with sluggish bo we is are most rig. .«.— L»s»"f ('j?- 
tAtnufccied- The ireatmem consists m exiHrllmg ihe "i«l,;J™^"; J^ 
■will, preventing their leculiaiKe, ami in improtinglhe •>i»i" (Ouun't 'Dii- 
hAhefibe child soihain is less likelyto p.ov idea favour- '™-'>'''""''°'"- > 
tUtnilbtation ground for these unwelcome gueiis. The tir»i indication i» best 
Wiled by a sharp purge lo expel or eUe 10 drive ihcin into the lower bowel, 
I* b< followed by eneniat:! to detiroy those present m the colon and rectum, 
ndwMhaw.iy any excess of mucui present ; agrain lo t»*o grains of calomel, 
OMmbination with twoor three graim of resinof icamtnony. may be given to 
of three to eight jeari of age overnight; and the following evening, 
well have been well acted upon, an enema of infusion of quassia as 
t u can he given should be uied. Il will be well to repeal the cncmata 
tnryiiihei evening for a week or two. (>reai care should be exercised to 
<**ll)at the child is washed attoul the genitals wiih soap and water after 
odiitool to prevent re- in feci ion. Injections should be used repeatedly lu 




no 



Diseases of the Digtstive System 



^H free (he vagina from any of the«r worm^, if there i» any v.iginitit or iiriialiinL 

^H Weak carbolic acid lotion; «'ill answer vcr>' well, and iom« dilute red cindt 

^H of mercury ointment I'l-j) may be smeared at the enimnceto the vagiau 

^1 The general health nf the child must alto be ihoughi of and a careful JM 

^H presctibed, excels of swcei« and ttarchcs being avoided. If confupadH 

^1 exist, Rubinal or Hunjadi ualcr should be given every other mnmittK bd^| 

^H breakfast, in siltlicieni qii.-inliiy in produce a snft slonl wilhnut pur^ng : ^H 

^H phate of iron, gr. \'), with spirits of ehlomform and orange flower wa^| 

^H twice a day, is often very useful. Cod liver oil in scleclcd cases is ofg(^| 

^1 Kannd VTona* I'Aaearla inmttrlcrtiaea).— The cominon rmind *l^| 

^H measures from four lo twelve inches in length, the females 1>cing MMTie«hlt' ' 

^H longer than the mates ; they ate leddiih white and have more or les» toOD- 

^H blance lo common eatih u-orniv They mostly inh;ibit the small inirsiine^ 

^H but arc apt lo nander into tbe slouiach. lar^e interlines, or even into tbe 

^H gallbladder. Several may exist in the intestine at the same lime, in (» 

^1 ceplionul ift8ianc«s man)' hundreds may be present They gain cnttance 

^1 into the si-siem by means of their ova, which are swallowed with the ftwdj 

^1 the shells surroundint; the ova are dissolved by the gastric juice, setting fitt 

^1 ihc embtyns. The symptoms produced by the presence of round u-enia 

^1 cannot be certainly distinguished from those of dy»i>epiia or inieilinal catartk, 

^B with which ihe ascarides arc so commonly associated. The passaj^e ofi 

^B round wotm pcnectum is often ihenrst thing lo call attention lo Ihc subjed: 

^m on the other hand, mothers often dogmatically assert that their child bv 
^1 worms because he 'picks his nnse' and his ■ food appears to do him no good. 
^1 The latter sjmptoms, it is needless to say, are not diagno»iicof the prcicoee 
H of worms, bul of an unhealthy siaie of the alimentary canal. The prescDee 
^1 of fine or two rounil worm^ rarely produicn any lymplom per te, unless ihey 
^B pn^s into the stomach or bile duct, Inlarger numbers tliey may give risets 
^H foticky pains, especially ai night : diariha-.'). vomiting, and symptoms of ob- 
^V struflion of the bowels have or casionally resulted. In rare instances wonnfl 
H have found (heir u'ay into thr peritoneal cavity and been discharged with 
H ihe coriitntsoranab4tesithroiii;h the abdominal uall. 'Hie treatment isnoi 
^1 a* difficult as ihc di.ignoiis. .Santonin combined with calomel or castor)^ 
H should be given, and is almost certainly successful arier a dose or imo has 
H toecn aiven. Siintonin, gr. j iij, ralonirl, gr. } j, may be given oi-emighi. aaA 
^m 50ine rtuid tiiagncsia or other s.i!inc next nmrning before breakfast. Of tht 
^B ^tnt""'" ti'ssolved in t«" or three teaipoonfuls of castor oil may be givtD 
^E bcftjtxr brc;ikf;iiL The santonin may be repeated once or twice, but not ofiener, 
"„„/»; the phj stoloj-ical cffeas ^.if any have been produced) have paued off. If 
gj,c ^mnloiiin cause vomiting. »maller dMe» should be tried or compotiiui 
gcanintony powder ^ubstituted. 

Vwx>« iv-oria, -xfc fl" c*""""*" '" chiMten as in adults both Ihe rcntf« 
xtf/if^^^f ^n<J 7' nit'.r -iftel^'"'' '""'T *^°""''- '"*""'* ""d yo^ns children less 
oftan uat «•» fios(„ /'^'.npc*'"'"*- ^"' '''*V *■"** ''"" '""""l '" infant* under 
I y-eur tild. •■\trc^ - "^ ■« fir*^ '"■'"**' '" '^^ ^^' ^^ ''"' pasMge of the joints 
>r f^rngltittidt^x ; ^''ort '^,1*. t* Ider children will often eompL.im of pain in 
ep'K.TS(r/u/r, " '^'p .■*I'r^|iar mmpmcn'* ^« f*^!" inside; they are apt also 
■ ^"'^ rrff^'^^oiH various djspepiic synipiomi. The difficulty 



flesh 







/T'"" 



Ascites 



III 



<(di«hMtgMK the greater pan ofihe crutuic U imk giui, but ihchcAdKnoi 

«ne*sil]r eicpeUed, especially thJii of the T^tti* s^ium. The uiixe&s of the 

< batmcBt by tncaitftofihe adminluration of male fccn depends upon the ia- 

I tBtiDc coaiaiiung a& tittle food as poutblc. A dose nf c.iuor oil should be 

. pitn owmtgbt sullicienily lartfe to act freely before morning ; t*«at)' to 

[' i)ErT)dn)psof ethcrial cxinci of male fcm'frahly prepared) shotJld be given 

tn h»lf an imncc of miKJIage nnd w»icf before brcikr^sl ; bfe-altfast should 

nosEst of MHDe light refrcshmmi «ach sn beef ica : ai noon anoiber <l4>se of 

oaoroil should be gi^'en, uhich will net in The r.oumc of tbc day, bringing 

»«IT ll** ioin»dcT, C^rcfol warrh ihould be made for ihc head, bc;inng in 

BiM lint the joints arc likely (o bteak about an inch frtwn the he^d, that the 

lutCf >i about (he site of a large pint head, and ihc ihicknexs of ihc worm 

mtlf ■tai' tlic he^d is only that of a stout thread. 

If, after (.-areful search by a compeicni obser^ cr, the head is nol discovered 
ade Roofs, after a few days the Irraimenl mny be repealed, but it is not 
WB In cnniifliM; to repeat the male fern, as toxic symptoms arc apt to arise. 
>n of pomegratuie root may be tubstiiuted if it is necessary lo con- 
l)w iTcalment. 
AMt«»— Fluid is sometime^ present in the peritoneal cavity of ihc child 
ntLoa dropsy elsewhere, and it may be diiTicn]! ro decide as Co its cause. 
tk£a)!n(»ls nf a»citcs when il forms part cfa general dropty.asin cardiac 
&easeor renal disease, is ejisyand docs not call for special comment. 

An atciiet which is prinuiyinachild is usually the icsu'i of some lesion of 

fc poitoaeum, as chionic peritonitis, or the result of portal obsimctionsuch 

ucnfaous or prrihc pa litis. The detection of » large or rnodemte quantity 

id in tbc peritoneal cavity is not dilTicull. the percussion note being 

in ihe flanks, while the region round the umbilicus is tympanitic 

cooieqttencc of tbc distended intestines fluatin); upn,irds when the patient 

■it on his back -, change of position on to the tide n-ill float the intes- 

10 the higltesi point, and the Aank which ii upperniost will now be 

ivmanL White change of lite p^iiient's poiiiton will ihus cause the HuhI 

k (ntiiate to the lowcsl point if it is free in Itie p;ril'>neul cavity, it 

MS be borne in mind that in chronic peiiioniiis the'c niay be a mailing 

ntetber of the intestines which prevents them from flouting upwards, and 

t-ateqncnlly ihrrc maj be no aJter^tioo in the percussion note after change 

I :• "Hion. The amount of dullness to percussion may vary from da> to day 

.jng in il»c varying disiension of tlw intestines. In ascites tlie super- 

■ rini of ibc abdotnen arc imially enLifged. the skin liecontcs ihiny 

Lrciched if Uic duid is cxicssivc. and often the umbilicus is proirudetl 

~ ;x>uchcd out, font.iining fluid which can be pressed back into lli« 

■Ttnal caviiy. Tile detection of a small (|uanlity of fluid in the abilo- 

n cult, especially when the intestines are much distended wiih 

■■'-. brge bowel is loaded wjih flrccs. ihe latter giving a more 

" lew dull peTGUBKin note in the flknks. Fhicttialion may be fch 

b] ptttang tlic fingFT into the rectum ; fluid may thus be delccied in 

Ihe pdvb. A careful observer is hardly likely lo mistake simp!* dis- 

■nuioa of the tntesiinct wiih gas for ascites; the thrill imparted to the 

cntaiaed fluid by tic^lly '^Pl«ng the flank is absent in the flatulent dlt- 

Knuai, and oa peicutsion ihc abdomen is uatversally tympanitic The 



112 Diseases of the Digestive System 

diagnosis of the cause of the ascites is often difficult, as a large accumula 
of fluid may be due to chronic peritonitisand closelyresembles an ascites 
to portal obstruction. Chronic peritonitis may be quite unaccompaniec 
pain or tenderness from first to last, and the fluid may be excessive, 
matting or induration of the omentum or intestines to be felt through 
abdominal walls, or a slight evening rise in the temperature or signs of tu 
culosis elsewhere (as in the testis), or chronic diarrhcea, would be in fa* 
of chronic peritoneal tuberculosis. A normal temperature, the ascitic t 
freely movable, the general health good, slight jaundice or bile pigmen 
the urine, would be in favour of portal obstruction, as cirrhosis or med 
tinitis. If the fluid is localised by the presence of adhesions, and i 
not occupy the whole peritoneal cavity, it is probably due to tubercuU 
The possibility of hydatids of the peritoneum must be borne in mind. 



113 



ClIAl'TER VII 
DrSCASKK or THK IXUESTflVB S\S1TM—C.(WH>mMf} 

AcBte Peiitonltu 

. general peritonili^ ib not an uncommon disease during infiincv nnd 
(Udhoeil. Il ocean as a pnmary di^cHSc, nnd aIso sproadin^' fiom «omc 
Mhcr pan or onginaiin^ in con'ieC|Ucncc of ihc Icaka^'c of the intestinal 
MUtnis inio the peritoneal ciivicy, or it riiay follow a blow or kick oil 
ih iMotnen. The tous also ^itTcrs from pciitonilis perhnps more sub- 
KOKlhan acute, and the adhesions which are left surrounding and m.itting 
<Ik ii)ir>imei Hte apt to interfere with the (jtowth and development of the 
(ui.tnd Ic.mI to stenosis or obstruction by narrowing ihe bowel or lying 
« up la coits. Acute pciiionilis occurs in tile newly bom, secondary to 
wifwis ot septicar-mi.x ; but such case* are rare in private practice. Apart 
iruni these cases, peiitonitis is not common in infants and jciung children. 
fJ'. WtM mentions a cast of idiopathic peritonitis occurring in ,in infant of 
"wnnwnths. which proved fatal in six days ; the aliack was sudden, ac- 
cnptaied by vomiting and nbdominal distension ; after death, lyniph and 
•WW fluid were found in the abdominal cavity Wc have known it in 
'•Untt and young children to spread from a suppurating mesenicric gland, 
*™ic peritonitis occurs in older children by no means infrequently, super- 
"niog. without known cnu!e, in the midst of apparent hcatth. Some- 
law cold or a more or less severe blow appears to be ihc slartinij! |>oint, 
Atlbe ^/-jswr/fM there is nothing to indicate uhirc the intlammalion 
Ciiniacnc«(L Not infrequently the periioniiis is the result of some lesion in 
*t«(um, vermiform appendix, or mesenteric glands. U sometimes occurs 
Kltbtmilar iiubjrcti : thi:s a pblhitical boy of nine years old was suddenly 
**>tt<l With pain in the abdomen and vomiting, and died in ten d^ys ; al lh<r 
txf-fWi/iti an acute general perilonitii n-a.s present, and .tha adhesions 
^olil peritonitis and »ome calcified mesc:nleric (glands. A cu I e peritonitis 
■*) be caused by ihr spread of inflammalion from other pnrt5, as from the 
l^ia, ui empyema bunting through the diaphragm, from ihc pericardium, 
'nn IB the stomach, duodenum, ileum, or c^^um, or (rom ininssiuccpiion. 
^ nuy occur in the course of typhoid fever from pcrforaiinn of ihc 
Muiaiu and e:xtrava>ation of fieccs. It is rate in ihe counr of iic.-irlct 
fcw, but il is not uncoimmon in the last singes of the succeeding ncphritit, 
<^ urxmic phenomena ha\-e set in ; it is then mostly of a purulent 
Wader. We have seen peritonitis fiosl morftm, which appeared to have 
WctttSed to or been associated with an acute inteiiinal catarrh, with 
*niptc«it ot an inflammatory dinrrhcca or an intestinal ulcer ; and il i>ccm» 

t 




1 14 Distioits of the Digestive System ^| 

probable thai, in «ome cnses, the peritonitis mnybcsecon<btry loiin tntetiiml 
lesion. 

Symptcmt and Cauru.—'Thc iiymptoms of acute peritonitis in the infiM 
»nd child are by no mcnni always n» chiirnctcristic as they aic in the adult, 
and cases will xoraeiiineK occur where extensive peiitonitis ii found at ibc 
potl-morUm which was not tuspccicd during life, eiperi.illy when niper- 
vcning in the course of some other diieatc. 

The ntmck usii.-illy hc^im niih vomiting, sometimes diartha-o, and treal 
pain and icn<icme5.^ in the abdomen referred lo the region of the umbilica* ; 
the amount of tenderness on prcusure varies even in casci uhcre no opium 
h.-is licen ^iven, and where the patient i« under ihe influence of thii druj; pain 
maybe entirely sbscni. Con«iipati(in afler (he ontet i* a marked feature 
when the nttnctt is ntablished, no fuccs and often no wind passing by the 
bowel : the vomiting is constant, the dii^tcn'ion of (he bnwels i-crj' great, mi 
that the coils of distended small inlcsiincs may he seen through ilie alido- 
minal walls and the case may readily be avsitmcd to be obstruction of the 
bowels from some mechanical caD*e. Though no complete obsiruction 
exists, yet the coils of inie-Minc arc seen post niorlem to make sharp turns 
on one another, 'kinks' being formed, which, with the layers <>f lymph on 
their surface, must scriouily impede the passage "^ '*>*''■ contents. The 
paralysis of the muscular coat of the bowel, by diminishing or arresting the 
normal peristaltic movements, further prevent* the onward mo\«meDt of the 
intestinal contents. The vomiting is mostly constant as long as food is 
given ; undigested food, bite, and sour- smelling intestinal contents may be 
brought up, but the vomited matters arc never faecal as they arc in hcmia or 
intussusception. There is usually moderate fever, the temperature being 
loi" to loa' F.,but a normal or subnormal temperature may persist through- 
out the case, and distension is not always ptescnL 

In ihc later sljtges the abdominal distension is often extreme, the coils ivf 
ijislended iniestmearc prominenilydiscetniblethrough the waits of the abdo- 
men, the face becomes pinched and blue, the pulse rjuiclc and thready, and 
the patient dies collapsed, often suddenly at the last. White this is tl>c all 
but iiniiTrsal ending of a case of gen eta I |)crilonitif, when the symploims haiv 
fully declared themselves, cases undoubtedly occur in which the diagnosisof 
peritonitis is made, on account of the distension and pain in the abdonien. 
which gradually rmpioi'e under treatment, and finally recover. There it 
reason lo suppose that cases of acute peiitonitis will occ4sionally get wclU 
even when the attack has been n general one. In other cases the symptoms 
of a IocjI suppunit ion, hectic, local tenderness, and swelling, sticceed to those 
of a gi-neial peritonitis. In such cases, however, there may have been a local 
peritonitis from the first. 

The f<Lilli>wing catics will illustrate some of the abos-e remarks : 

AiUi ^Mffurolivt PeilAvitii.—johii C , ngcd j yean. Tile laiiillj liinory ma (Wtd, 
Hr hftd tifrn a tlroDg boy up lo tlic Unir if hin laud fllniTA. No (»Uw Onlilil lie ■twcnrd 
(or hli ilckncM. I'mr dsys bUon «l»ii»ion lo boipiul h« CDniplainMl al pAln in ibr 
' iionini'h : ' Itwrc was vomiting .ind cnmiiiBiioii. (ia udniiulon to liotpiul un ilv AAh 
diy of till lllncsi, llie face u'cnc -iin aiiMout ci|im.iion. »i >( he nm in pain ; the a-Xiioattn 
was ditundnd und xratr. iinil tympuiiik iin'l iiiidii tn Ihe If.m toufh; hb lep «*rr 
dra«a up : he coniiitnt))' vDinutid dark, sour-inicItiTii;. nimoii f.-tv.-il iiuiT Tht uriaf. 
diawn cfF by a euhtter. containvd nlbiiinen. AH rood uid ilnnk )iy iliv nintuli ««« 




I 



W tpticd. «lld tl> mL>|;i*pn Mn-mrnini ilowi of tlnct. opil every iceond haui lilt thrc« diitn 
tad been civcn. He pudol a mllrvt n>ilil. yirt oni drowiy [ram the •.•Ifeeis or the 
af*MB>. He Rndiutlir nnk. dying on xbe evening of ilic tuili ii«y nf hi* iltnnt A< t\\e 
ftit.mtrttm. otlOpenin|C lh« AlHlomtn. .i (cw oiincn orolleniive pus etcnncil : the %mtiKr 
ollhe uilctUne* wu injected; l)» boovlv htti mallvil l<)|ti-l!iFr willi lymph : then w.i>> no 
TTTHt'llir'"!^ 'Hh' I'aKuin iind vrrmtfcirni appendix uvre normal ; thcie u<?re pntchn 
cf taieoae congouoD oo the niucoi» ualaixil ttic ili-uni, nnil a thnrply cut ukcrtnoi pcr- 
EonMCl. half an inch in diamtier. Mme iwo lc«t abmc (he <n.'ctiin. No ecrtnin came 
>er Ite anMe perlMnitii wat found, nnlCH it be nuumcd — which it indeed not iniprobatile 
— dot aaenMn4iseiisledinihefirnlQslno£e, anil thai the prrilDnlllt «u teconihtry. 

In tbe following case the symptoms closely resembled acute ubsiniction 
rflhc bowel* from sininKulaiion : 

AiMir Gtmtnit I'trilimitii. — /ohn C, aged ij jtu%. wu hcnllhy up In tVbituiry 9, 
«hfi he HM injnml tiy » blow in ihe abdomen ; but ibe injury don noi lerm to have 
%><• rarf severe. He complained <if pain in the lirlly. nnil vDinilud Ihf uinii: cvriiini;. 
lit (OMinoMl «<> vomit five or ta iimei a day lIU hi* wlniiislon to hMplttJ jundci 
Ui. HiUMn)(«lhefl(ltidii)' of hit illntni. He h.id pnunJ not hin^ per roCTun cotoriH a 
wdwaol alter an momn. and ii vna luppoied he hmi tuflering from nn intuiiuiccpuon. 
Qtilndotoa bit fcco wu flushed, ihe ryn ninken: the abdomen unti lii;hliy distended. 
AiniU«' iWBllne ticlntt plainly tncn. He oouiptatncil of (lanixyiint of pain In the 
iMaitMi He TOmilotl fnrcnl matter ihonly after ndmiuion ; there mu pAJn on deep jut- 
piuainlbe iitCht ll>ic foua. but no morkcil Icndctneu. l''uU dows of opium u'cte Riven, 
^ DOl day llhr >ikih o( hit illni-it.i 11 <i.ii ih'.iui;h( ndriMblr lo mak* an nploralory 
<vaf ialo the abdomen (*hirh wiiaoneby Mt. Wnghil; the inleiiioCTwerfdwply 
MMindiaad malted tosirlher will) limph ; no cfRitinctini; l«nd or inviictnaiion watde- 
MM: Ibt uraund w*l clo>ed and a drainnge lube knurted. The lioy gmdually unlc. aitd 
MMUntlyiba nnt dty, Ai the /wr-ixw/rM a |[enaa,1 ncule peiitonitii wat found; no 
OM br It wu made out after j (xireful teareh. 

In the following case, related b)' Sann(!,' acute pcHtonilis was accoinp.inied 
bjrdiirrhcca : 

AaM PtrilfmlHi.- tHarrkm.—A iMy of 14 jpeon. who had alwajF* enjoyed good 
kMtt, ma Miied tnlh thnnring and ht^diichi?. On ih« tliiril day ho hnd diarrlicra and 
fnbihc abdomeii. follownl b) vomiting. <Ii»«flii>on of the a!>damen, and gml tender- 
■Ma; iW vaailinR »niiniiHl, >o that nut only bile but alto the oontmti of the small 
^■Btaa wfM f^ieil. t)i?iih (oak pincc on the fourth day. At the autopiy a general 
■■■*|udiM periloo'Iis oai found, uiihoul nny oUirl Ision. 

In the foltmving cnie the periinnitis wiis second.iry, occ;unin([ in the 
«cne nr Karlalinnl ne|ihtili« : 

Ana A't^rilii : /'mltutifiK-f^antU \V. , .-icril eii-lii yean, uas .illncked with tcarltt 
^■^'ihi Idllial lymptouik Ivin^ vuiniimK, li>|fh fnri, ;iiul mdi. ^ihe <•-,» nilmlllcd lo 
^fmlua IIk third day. 7^ toiudt were aloiigliy ; there viai much jjlandut.ir enl.iri^* 
*<■ lad hich frvrr. Tlie trmperalurr mtit^ rrnm 100° lo ioi-S= K, llll the Iwclflli day, 
*kiKli roMlinl loi'fl^ I-'., and a trace of altnimen appealed in the urine. On the ihir- 
("■ibdiy llie WBperature wu 104" I-'., and only Ibd hundred and lifly i-uliii' <>-n(imolr«t 
<ttm9nt |BMtd. from ilie fmrtuenih lo ihc tlitnnih diiy ihi- urmc pjiued vu oalf 
tawnstr 10 one hundred cubic eenlimeiro daily ; unne eont.iined filinnoiit and epi- 
lUu <MU BchHwilh day, vomiling, irmpt-rnmrc loj'' F. ; onh nMi:(ily cubic eenll- 
"■Matncliie. Nineteenth day. no arinepnned; M^>cle abdominal pain, mpirationt 
)Wni aail ihoncir. abdomr n diMenrlwl And lenae. Twentieth day. tcmpemlure gS* to 
Vft-taitttAoiOtjucd. THKnty^Amday. deaib. At Ihe auiopiy a general Kio^unilent 
WM found ; plnuity of Mt luns ; aeuie tflomerulai nephriti*. 



^ 



ll6 Distajfs of Ike Digeslht System ^^^^^B 

AtMit PtrHatUiL—Voj, I] jean. Mill to lie dd-tcsM. bill ncnt allnlan)ih<nc. n« 
pUjrcd wilt) bii tirollicn on WtdnpHlayiiricniDon.iuniblineaboui on [tirHoot— noddiniM 
biMory of n blow, 'niundi)' he dlil iiui i-ji hit brcnkfui. and wld hir (fH ntk; vomiinl 
urverni limi^ during the ila^. nnd vni Ihoueht to be npiM (t^Din n ititnrilrmi tloniM-li 
Kriiliy RiiMciiiig lomiled. and b much piilii . Uraclt ocled illgblly \ noi much dlMfiuion : 
child died urne cmiini;. 6 v.tl Pml-miprttm . Mfitda;: /mfy i^, iKC^.— SiinK ilK«ni- 
poiillon ; Qmenluiii noinuil : tuificc ot iiiiiili mleil)nn inlenicty injixKil. mou markfll 
beloo umbilictii : lonii! lymph, not ctftaiiiv <iiukn(>lx ; bloodi Msnini tKiavm uiMUnn. 
a few ouDca in pclvit. Vrrmlfonn i|ip«ndlx ' exKmal lurlice liijcncd : no cviifenw nt 
pftil inriammition. !>liuin|[ up of inwtlinei khcnnl lliini n> bv ncmiiil. niKpt tbr hptot 
ibc [Ico-cfcal vutei, which ver« InjKUd ; Ihc appcndu mmcd thick«n«d uid UKtmulma, 
and oonLiJncO wmr niucut iinly, l.unK> ym narinnl ; lH9rt hIm nornuLl : the bluad 
duk And lluid. anil there vicit tninll cvtriinauuciui of blood on lh« luibce of ibc heut. 
In this t-Jhr t^<■ I my [liod rii (iad dnyk fiom iicutc firritimiitk. \ii oxubc could be tMignrA, 
units <t nsiiliol from a blow ulitii pUylng wiUi b>« braihcii ihc daj- bd'oic he wm UliM 
in. There wa'* no bruihin|{ of the Ahdominikl wall. 

Id Ihc following Cii*e Ihc t-j,ai.e of the periioniiU n-aa doubtful, buE ilwrfr 
ik no doubt it km -.try cxicmivc, and it ii a ijuod illuilnition of the value of 
openilion e\-«n in extreme cases. Thi> bay wiu du«ky and tio ill thai vre 
hesitated to operate at all. 

jiemli /Vr-fMmVii ' Oftrntion. /frfiniry. — Frrd A., ngrid I3|. Six vivIdi bafen 
Rdmiuioii wkt kickrd Iiy it hnrw: in llie rittht lide of the abdomen. lie iii«> apparnllf 
not much hurr, .-ind Hai aIlo«>«l Lri his doctor la gel up an lh« fotlaHrinR dnjr. fin 
nccki alter iIil' aixidenl. uii May 17. 1S94. he hnd iiLighl niMlomlnal pulo, tupTMMod lo hr 
due to MUnK cucumber. V'omuing and pain loon rolloured. and wndrrncit in Uw righl 
iliac (dim a (l.ty or lwi> Litir. The luin kiuvnd upwatdk. vomiting Ineimied. and cincmc 
lendcmm ippmcpd in thr left hjipochondrium, with co)1,i[ih. He was admitlfd o* 
June 4. Al Ihul liiiii- he tookeil ivry ill : nniiioni face: puUr (mail ; ahdnmm full, raoip* 
ivry tittle uUh rcspirxiian ; kjci moicd tttrXj ; abdominal uoll] nsid. lendeincu niMi 
maiknl un left <.ti\r ; nuihiiigf ■[•n.-ially to \r. MX on ri|tht >id''- A fnu hcun Ulrr, face 
duaky and blue ; rKI.il enminaiion Tcmled grraler tcsiiluice on the Itfi iiilc than eo 
die fight. Ilw alidorneQ «U opcnrd in iW niiddir line Iwloo the uniliilicu'. ;knil a laiKi 
quantity of drcal pus neaped. 11ie abacm filled up the left iliac fwu, and appavol 
circumacribed. but there n.n retittuicr in thi.' rl|[ht kiile »!«>. He Eiadually improiixl ; 
the ^puniiiy of piu cKoping (roin the lube and it* fosioi lessened, and ihnigh for aonw tlntc 
then mi lenili-rn«» in the rich! iliac icginn, he lt««dily i-ot wvll. and waa bean) of In 
good health four 01 fl«c monthi later. 

l>iagitotis.—/K pleurisy of llic base of one or other i>f ihc lungs it often 
mistaken for pcriioniiis, .is the sh»rp stabbio),' pain \s apt to be referred to the 
abdoincn uherc tlic intcrtosul nerves terminate. In such cnies, U5|ircially 
if the pleurisy involve the diaphragm, the samilarily to peritonitis may be 
i;reat. und it is common to find thai hot fomentations or mustard poultices 
have Iwcn pl.iced up'>n the abdunivn by the friends undci llie ide.i that there is 
peritonitis. Where plcuniy cxiits there \s no real tenderness of the abdomen 
on pressure, and the physical signs of pleurisy or pleuro-pncuinonLi uill be 
delected in the chest. An attack of colic is not often likely to be mistaken 
for peritonitis ; in the fonner there b pain and dislcniiun of ibe abilonten. but 
no tenderness or elevated temperature. An intussusccpnon may be mistaken 
for peritonitis ; but the aiUck of pain is mure sudden in the (onner, .tiKl 
there is not often much tenderness; thcdcleciionufanclongatedtuniourvuuUl 
usually decide the diagnosis. Acute peritonitis is apt to be mistaken for acute 
obstruction of the bowels, such as restills from the constriction of a knuckle of 







Perityphlitis 

■\ by fl 1»n(l. Tht diitcmion of Ihe inT«»linc3 with tialui, the vomiting 
mur-Mndting inietiinnl contents, as well m> compkte obtiruciion ii> ihe 
paiiUige of wind, nuiy be present in both ; there ni:iy be little tenderncu, and 
but slight or no fever. The di;iKn(i«is nmy be icry difficult or imiMsublc, 
ihoagh (hehivlory of ihccaH, Uie absence of liccol vomiting,und Ihe less com- 
pleie obtitruciinn (oibe pauage nf butli lUtuvand fwces in the cxsc of perito- 
ilit, w ill iua;illy help the Ueiiiion. It m hartlly necessary lo add tli.ii it is only 
wme c^^eiof Jcuie ptrilonitii that iht-dirticulty exists, as usually the pain, 
idemeis. and duten&iun of the intestines arc diitgnosiic of peritonitis. 
Mi'riitt Amifcmy. — The tendency lo pus formoiion, which all indamtnn- 
in children exhibit, is noticeable in peritonitis as in acute cases the 
found in Ihe peritoneum is thick ami turbid, or it may rank as pure pus. 
The amount of lymph and fluid varies in different cases; pus or turbid 
terum vnll often be found in uieshcs of lymph between the coilsof intestines, 
a targer collc<:tian being present in tlie pelvis. In all cases of apparent idio> 

»;alhic peritonitis, a careful search sliuuld be m.ide for a loc.il starting point ; 
lhecxcom,inesenteTic,andrelro-pcriloneal glands being carefid I y examined, 
/"nyiww/.-— This is alnnys grave ; the more acute the symptoms, the 
more npMlty the fatal result occuri. The prognosis in any case mostly 
'depends an the diagnosis, for, if acute general peritonitis is present, a fatal 
ttwit ii almost certain. 

tarttyvtaUUs. Am^ndleHlAr Perttoattla. — Instead of a general pcri- 
Koilis taking pUcc, a lucal ind;itnmatory action may be set up, which results 
in iini{ie inflammatory indtiratton going on in many cases to the formaiion 
<f u abscess, or a general peritonitis may supervene. I'be commonest 
kal peritonitis is a lyph to- peritonitis or pcrii>-|)hliiis as it is generally 
aOed. The CA-cum is especially apt to be ihe se;it of irriiaiion. a peculiarity 
vtndin thmbttess on-es to its being a cul-de-sac, in which foreign bodies or 
Mpwied f*ce» ar« apt to lodge, and giie rise lo various forms of trouble. 
I"!!).!)!! bones, iherry stones, aie apl to lodge in tJit- ca-cuni, and gravitate 
initihc cj.*cal appendix, and though th« latter is not nornuiUy traversed by 
llx inieninal coiiicats as tlicy pass downwards, concretion'! are likely to 
' fmiftnin the deposition of ixttX particles inspissated mucuii, phosphates 
<>l'tne. ;ind uilver salts. As a result, ulceration of the c^cum or appendix 
'^myjpito take place> and a petforation lo be followed by a local or 
fKeial pcfitoniiis. In the majority of cases it is now well lecognised that 
[ nn«4t cases the mischief begins in an inllaminaiiun of the appendix due 

SilkriD retained secretion or to the presence of some sulid matter which 
BB) br faf mctl in ihcappcndiK, or enter it from the boii'cl ; occasionally there 
NMbrrciilar dis«nscof the folliclcsof theappendix, but this would give rise to 
■we chronii; symptoms. The symptoms presented by periiyphlitii in the 
<Ud lescntble those presciii in the adult. The attack may begin with 
dknhoa and t>ethaps lomliing, with more or less obscuic pain and tcnder- 
>«» in the slxl'itnen, and feveiishness. It is often cxircmely dilficull to 
Iwtte ilie pjin and tenderness in a small child, .ind it may be quite im- 
|»«ilik at tirsi to tcfei ihc tenderness lo any one spot, specially a» the 
'UnMiRJ tiiui<lcs arc apt to be ritjidty contracted, and the child cries 
■*««1ly it is touched. The state of the bonds varies, sometimes being relaxed, 
^(Att times obstinately cons(i|iated. In the course of a few da>-s, during 



Ii8 



Diseases of the Digestive System 



which time tlic pyrexia cnnilnucs, if a &aii&ractor>* exam i nation can be matU-, 
inoic or kK« rctitiaticc mny be detected by palpation in lli« llinc or lumbiiT 
rrgian, ntid a diillnt'u on gcnib percussion, though this nuiy be masked by 
the disien'ion of Ihc *niall inlestines. The patient may now, ctpctijilly if 
he Iw* been judiciously ireaicd, gtridunlly imprwe, and all pain and tender- 
ness di«.ipprnr in the course of a "cck or iwol On the other hand, the 
icndciness m^y increase, a distinct h.-irdness and induration may he (uli in 
the right ilinc region, the ri^hi 1c^' is dnmn up, and the child cries wtili 
paiii if ii Is moved. The Kubscqucni course of the attack isuni:eilain : ibcte 
may be it gradual subsidence of all the sympioms, or if the abscess i« bm 
i)|>cncd. the hectic fever may cnmiinuc, the child firadually emaciiite. «liile 
the pus which lias been formed it making its way lo the surface, and the 
absceu niay point in ihe iliac re>;inTi, may dixckir);c into the bu«el, or, in 
rare cases, into the bladder or va^na. F\vre* may be found in the pu* di** 
chartcing from ihc iliac abscess, and a f*ral fisiuin rcmli, or all Ihe aijtns of 
general periionili«, abdominal distension, extrcine Icndccnesa, and cotlupte, 
may come on. 

The diagnosis of perityphlitis is often by no means easy, and yet of 
much importance, inasmuch as a mistake in diagnosis may readily co« a 
life. In the earlj slaKcs, the diseases most likely to he confounded wiib it, 
especially in small children, arc copmsiasis or accumulation of lurdened 
farces in ihc ra'cum, and invagination of the intestines; in u later ila(;e, 
«hcn the patient is wen for the first time after an absress hai formed, there 
may be uncertainty as to the source of the pus. Children nho have jinn begun 
to run alone, and aic able lo make frequent excursions into Ihe kitchen, or 
who are fed on all sorts of indigestible food, are especially liable lo suflier 
from an acrumulaiion of hardened fn'ces in the O'cum, which may let up 
mote or le» irriiation, and ^^c rise to sympinmt exceedingly like ihow of 
a pcriiyphlitii. Tliere i« di^tcnsioii of the abdomen, col irky pains, vomitin);, 
slight feietishneu, cnnsiipaiion, or, on Ihe othei hand, di.-itrlura ; ami-il 
must be borne in mind thai looseness of the bowels is (|uiie compatible wiih 
a loaded caecum or laitir iniesline. It may be possible to detect a ttcal 
tumour in the ritjht hunbar region. 7'hr diaifi^osis in a fretful, siioih child 
■nay be exceedingly difficult, but the symptoms of impacted f^i-ccs in (be 
ciecuin will be rather those of colic, tlie p;im coming on ip.itmodically, with 
no pain or tenderness in the intervals; while in pcntjphlilis the p.iin will 
he constant, and the tenderness on deep pressure unniisiakablc In any 
ti-iven case it is far l>ettcr in err on the safe side, and to mistake colic fdrr 
typhlo-perilunitis than to foil into ihe far more serious errxtr of do*ing a child 
suffering from a loc.-xl pcr^loniiisnith putgative«andenemas. An ileo.c-a.-cal 
inva|;inalioii with lis symptoms of sudden obstruction of the bowel is probably 
not verj' likely to be mistaken for perityphlitis ; the sudden attack in an 
in^t in perfect health, the colicky pains, the straining, and passage of blood 
and mucus, and ibe presence of a painless tumour, n-ould in most cases 
present a mistaken <!ia£nosis. To make a diagnosis, an examination under 
chloroform may be iieceuary with the finger in ihe rectum. 

VeiitoDMi AkaecBB. sntsaUnHi rittnt*.— Apart from ihe suppura- 
tion which is liable lo take p!ai e as ihe Ksull of a typhlo-perilonilis, other 
abscesses are tiable lo occur in the abdomen, due in thie majority of cases to 



Ptritoneal Abicess 



119 




^pCiMular inflammHiion and uri);iiiuting in ihe mesenteric, reiro-periionenl, or 

^ncul i;lunds. Local :ilnc«»ic's may nUti «ccur a* ilit result of a blow or 

lUlowing a (lecforaiiun of the inieatioe in lyplioid fever or tubercular ulcera- 

uoiL Ai an initance of a b'l^nilular ab»ce>3 in tbe a1>donicn ilie foUomnK 

HetK may be taken au an example : 

^H AHamimal Aiiitn ' t)ih»<irf/ ■>/ fm 3I UmHlhii. — .\ s'tl of trvEii yarn of agfi 

^^Mi adankMI to bgr^iuLtJ, tuithiK ^uiTj^rri] int thirl'-(in rtjii-g witli ]iitin in the Abilomcn. 

^Bbttr. and vomiltng. Un wlmiition Ihav *ru uime ilullncu Imlow (he umblllcui and 

^^bcu tcndmkcu 1 IIm tnnparaluri^ varird from 100° 10 loa''. The ikiy .-ifirr ihc unibil^cut 

^Ptrame procnlDenl oad Ibe ikln ml ; It pur way and pure piu wu diii-horged. The 

»otMd doalinued lodi9ChAri;r for mini- limr— on fineocculon a ch*i«r mau mu muoved 

Hon Ibe sniu. followed tiy ii fiuh diKtungL.- ul |iut , ihE Mniu finnlly doted on Ibe lorly- 

n|lu)i itey. At tbr <nil or irn m-ths l)ie giil wm l.-it and ilrrinc : ilinv u-u tomr indurj- 

iUb, but DO pain or unilariat IwIoh' the umbllicut. On one occ<ui<in (hen wu mine 

In another case, that of an infant, ieen with Dr. Nibble, of Kendal, it was 
riMKcd a week or two after binli iliat llic abdomen w;ui tnore rounded and 
dulended than luual. When five week* old the abdomen uas inlcnsely (lis- 
khiny, with cnlat){ed vuini on tbe surface, and with lednctis and 
lion of the umbilicus ; the abdunien was resunant all uver, and noihing 
(wld be fell on palpation. A leu days later tbe skin m the umbilicus ^'ave 
aiy.and pm diiclvuged freely. The infanl a few days after died in con- 
tiImoiis. .a large abscess cavity was found at the autopsy, and caseotis 
■Mtaieric glands. 

In Mveral cases wbicb hare come under our notice, with soinovhat 
unilar but more chronic symptoms, there 1ms been evidence that an absce«s 
hilliinncid, probably in a mesenteric gland, and bad opened into the bowel. 
PMbcin); discliarced with diarrlm-al stools. Utiicr cases occur which are 
tv K> means so satis&ciory in their tetminaiions as the above-, bcinj; in 
Buoy initaticGS associated with a chronic tubercular periioniii» or incscn- 
'-nkdiMasc. There ^rc symptotns of abdominal trouble, attacks of vomilinjc 
mldunhira, hectic fcvci and w^isiin^, iin induration and at length an in- 
tuntttory blush around the umbilicus -, the latter becomes pcrfoinled and 
irndtKhargcs. Fieijuenity, sooner or l.iiei, the dii^chnigc becomes f.Ttnl 
fra* the presence of intestinal contents a fistulous opcntnt; having become 
oufalnlicd. In ibc majority of such C^scs the abscess app^irenilyoriginales 
xiMucntcric K^"d, an abscess c.iviiy U formed which is surrounded by 
tOib of iBiall intestine matted io)icihor, and the abscess opens bulb at the 
■■Minn and into the bowel m \amc part of its coinsc ; but as such ca^ei 
<K acsily chninic, opportunities [oc poitmortcat exammatiuns arc not 
ba|te&l, and when an opportunity prc.-.enis itself iheie is so muchinailinti of 
putt that It is diRicult to make out the origin of the abscess. 
Tbe lolkwing case illustrates tliis difficulty : 

Mimi»at Aiutii : f»iai fiitHh. — A girl of lour years uf «(« ■«* In hoipiial. June 
llfltviUnbfeuK abdominal lymptDRu. hectic Jn<l wiuting : in the following l)avcinbi.-r 
<ti n* almiUed ulth a tinui ni ihv uiiiLnlmiia, iliHliuglng put and inii^iing,! cuntenlsi 
"^weiihawng broken ten weeks befocv. I'hc lisiuloui opctimif (ontmui'd 10 dltchaigc 
M>ndiii|niilyolloirCM*OUSf(uon till her draih m (Jtlubei iftOu. .M Ibe fuil-Kertun 
<*ii>aud tpteat Ben lardnixous. 'Ihf umliiliiJl :inui oaiconnralcil (v^lh an aUms 
owy teanuuDC «"• or (wo ounces of piu ino tatocs, and tunoundedoDallsldab)' 




1 zo Diseases of iht Digrstive System 

Inusilaei mniteil lognher : th>i c*vlir communicoud wilh iTii iloum a foot «ad ■ 14 , 
■boirettirciucuni by two opvntnct la/R* tnouEti to udiiiil R little nngcr. Onlhepcrin 
inrfsce of Ihc small Inlcnlnu were enCMCOui nadu1«. ai>pnT(mll]i Itw nmuM of > | 
bibrrculur prrilonitiL In thr iUum nfrr mAii; cioitriun uii'I cikireoiu ranRliu •>( I 
ulcer* ftnt! chcay lolitary glAniU. 

Inthi«case ibt^ perfomtioii of lubi-ccular ulccri or (he suppuralion 
menntcric |$Unds Ivid been ilie cauiie of the absms and fi^luloiH openin 
In sercral cs«e6 cosnin^ under noiice ihc nstulous openings have rioted op 
pcnnancntly, one after discharjjing for «>'en moinlis, .ind in «imc oihcn 
(be ti»tuloui opening has closed, but the paiieiii died of general iul>erculMi& 

Trtalmenf. — As soon as the diagnosis of acuie peritonitis U c-ttablidied 
no time must be loM in administering opium in some form or other, the dote 
being repeated so that not only i^ the pain relieved but the child is rendet«d 
drowsy. The narcotic may be given by the mouth or by subcutaneous injec- 
tion, for a child of ftom one to two years, two or three minims of the 
linciurc may be given and repeated eicry three bouts -, for a child of from 
five to ten years, 6ve to eight drops. \\t cflccts being carefully watched. 
Hot famcniHiions should be applied to the abdomen ; some, however, prclcr 
the application of ice— the former is much more conifoning to the paticnL 
If the voniiling is severe, nil food by the mouth must be stopped And nnty 
small qiuiniiiies of ice allowed ; in many cases ihc <iv>miiin]{ and come- 
quent di^iri^ss of the patient is maintained by giving brgc quantities of 
fluids, Mich as milk and beef lea. Small cnemaia of Ixrcf tea aiu) brandy 
in;iy be given by the bowel, but it must be boi'ne in mind thai Urge 
enemata of any sort ate liable to do harm by selling up pcrisuUis of the 
bow«l. FtM siimutation vith brandy, champagne, or ether, miisi be resorted 
to in the lut siaget. In typhi it l^ and other local fonos of perttonitis, the 
ume treatment must be airriod out— all forms of Isutivcs and enemas must 
be condemned as likely to aggravate the inll.immation ; rest in bed, opium 
fomentations small doses of opium and belladonni^ by the mmiih, the most 
rebirictcd diet, the food being given in the most digestible form and in small 
quantities. As long as ihe stighiest pain or tenderness is present, the mou 
complete lesl mtist be mainlamed and all purgntives and cncnuta avoided. 
The formation of an abscess must be carefully watched for, and surgical pn>- 
cecdingt taken withnut delay if there is any indication of supini ration. 

Siivcc acme purulent peritoniti* is prnciically c(>tiain1y fnial if it becomes 
generalised, it is ofthcuimosi imponancc to provide an outlet fora localised 
abscess rather than allniv it to go on and rupture into the general peritoneal 
cavity. Hence, as soon as it is clear that a local fonn ofinl1nnimalk>n is not 
subsiding under medical treatment, the ^^.tfeti course is to carefully cut down 
upon aivd lei out the matter. In |>eriiyphltlic abscess (' appendicular perito- 
niiis'i. when with fcvci there is local pain, tenderness and induration ai>d 
drawing up of the leg, an incision should be madcjust internal to the antener 
(Ulterior spine of Iheitium .ind tbc successive mnsoibr l.iyrrs divided until 
the oeigbbourhood of the abscess is made clear cither by the sense of fluc- 
tuation or by the oedentntous condition nf the tissues : a director is then 
llirvst in the direction of the suspected cavity, and if pus appears the opening 
is enlarged with dressing (oiccps and the c.tvity drained and trcaied on 
ordinary priivciples (nntiMiptici being used unless the pus is foal). There it 



irom'r PentomUs 



I2T 



^^HQir tn sixh an operation ; crcn if no obaccvi Ik met wifh nnd the 
^^Bbtl cAviiy i« opened, no ill result is likely lo Tollow, nhilc the danger 
•^^ufc «)f an abscess into the general peritoneal c.->vit)- i* tery great. 
Uxjl pctiioneal ab*rcs* else«licrc is mueh more uncommon, thouirh it mny 
ii'nW »itli on tlic left side I'pcrisipmoid ab»i:essi, and this c.nn be mnde out 
vbavci by rectal exa mi nation. The treatment is that of ihc pcriiyphliiic 
coaAtion. Ii is of litile importance in such cjises to make out whether the 
thiail ts JV9\\y ti loc;il pcrilonilts or a collection of matter tn the cellular 
iinae outside the peritoneum, since, if peritoneal, it is usually completely 
shti nCr by ;)dh«siot>s from ihc general cjviiy, and there is no fear of pus 
(to«ii|[ from the "xiund into the peritoneum. Local abscesses elsewhert 
nmibe treated nn similar principles. Should a gencr.il purulent pcriionitit 
ilndy evisi, the (|iiestion of treatment is more uncertain and the pmspeci 
(ir ten bopefiil ; there is, however, hi tie duubi th.tt ihc right course if to 
ifn ibc abdotnen, wash it out wiih some uiiirriuctnt,' antisepile. stich ns 
bsnoc iMion, and drain the peritoneum. Should there be general fn^cal ex- 
liwittlion (rmn perforation of the caical appentlix, or from a typhoid ulcer, 
tkcaM must be IwAeJ upanaa uvll-nigh desperate ; the attempt, however, 
mif be made lo evpose the perforation, suture the intestine:, and in ihe case 
4|Im appcndi.i ienio\-e it and close the end. Cases of iliac abscess ar« 
CMUMd, and operation is almost atwa>^ successful, and though it may b« 
arf iliM these arc a dilTereniclass allege ilier from the local peritonitis group, 
'I >i difficult to distinguish beiw«en the tu*o. and there is certainly a rnsk of 
fofniian into the peritoneum. In appendicular abscess nothing more 
•Md be done than simple incision and dramage ; no attempt should be 
nri( to remove the appendix or look for a aiuse of iJie suppuration except 
'bl ihe ftnger may be gently passed into ihe abscess and any foreign body 
tamed. We luve several tmies found a facal<oncrction lying loose in one 
•(lieie cavities. The greatest care muM be taken not to break down the 
*>l(fMUitsion round the abscess. The opening of a loeai appendicular 
^tee»« it in our experience almost, if not nuite. always a successful operation, 
te <C ii ef course far oihemiscif the suppuration lias been from the lint, 
* b* been fillowed lo become genera! : in such a case, too, a full search 
*« be made for the source of the trouble, and an attempt made to remove 
t vletW by ligature and excision of a perforated appendix, or such other 
MU>u the particular case may require. (Vide also pp. i;j and 13;.) 

la cxMS of recurrent ' appendicular peritonitis ' removal of the appendix 
oodoubiedly the proper course to pursue, since life is in constant danger 
"leag u tbe source of the mischief remains. 

dknola »»THoBiti».— Chronic peritonitis is a comparatively common 
■Action during childhood, and in the vast majority of cases is tubercular. 
Alt* cases <A chronic non- tubercular peritonitis in which the diagnosis has 
^CPnfinncd by * potf-meriem h.ivebeen recorded, notably one by Henoch 
•Wi lan ■ course of six weeks ; at the pustntortem cloudy fluid and orga- 
wmg lymph ««re (bund in the peritonciil cavity. This case seems to have 
•nfnaied itt sMow. Cases also not infrcquenity occur m practice of chronic 
pefttniiis with ascites, in «hich tliere is noevidcnce of tubercle in any organ. 
••* abth completely recover ; this, however, is no bar to the acceptance of 
i^btCtf that such are tubercular, u there is ample poit-mevUm evidence 



1 23 Diseases of the Digestive System 

lo 6hou iliat tubercles and lymph on the surface of the peritoneum majr bc- 
CODK cretaceous or be converted tmo libious tiHUc. Tun forms of chronic 
lubcrctiUr periloniiis are met with in practice, in which for the moat part * 
wcll-ninihed clinical dilTercnce exists, one <lisiint;ui>hcd by tlie large amouM 
of ascitic fluid and in which probably ascites is ihe only s)inptom presenr, 
and the rhfonic ctcairtsin),' form in »hich there i* induraiicm and thicken- 
ing of the great oinenlum and ;i maitlu); (ogelhcr nf nil thc.-ibdoininal organs 
with little or pciliaps no tluid. The same luberciiUr process is fioing oa in 
both casrs, but priKluces in one a large amount iif elfuviim, in tlie uthei le» 
or perhaps no lliiid, bui the effiision of l>-mph and its ^radii;il otgnnikiiion 
nnd cicatrisation. 

Auilu Fofw;.— Chronic peritonitift is by far the most common caaMoT 
Ascites, or rather dropsy cummencin); in the peritoneal cavity during child* 
hood, irthile, as well known, some form of portal obstruction it ihc commooesi 
cause in adults. Ascites due to chronic peritonitis is not cnmnion during 
the first year of life ; not that it does not occur, but the infant die* before the 
chronic stage is reached It a not uncommon dutin>; ihc second year af 
life, and occurs with soine ftequcncy up lo and beyond pubcny. There i* 
generally a history of pain in the abdomen of a more or less obscure kind 
which has been regarded as due to indigestion, probably also both Cct'erikb- 
Dcss and diatrhcca, and then the liclly bej^ins to swell. In sn«K cues tht 
cnlnrgcincni of the nbdomen is the fust symptom which Ic.ids the friends ta 
ihink Anything is urong with Ihc child. On cxaminaticin ^ rounded and dis- 
tended abdomen is found, there is dullness and flue luaiion to be (elt in die 
flanks if the patient is tying on his back ; "hilc ihcrc is a more or less ex- 
tended region of resonance around the umbitiru* where the distended small 
inleslincs arc buoyed up to the stiiface. The lluid may, however, be lucJihscd 
by adhesions. The abdomen is often >:r(-jii1y distended, the skin icnsc and 
shining, the ;ibd(>niinal veins enliir>.'cd .ind loriuoui, iind in youu}- chitdicn 
tile skin ai ihc umbilicus is protruded, and contains liuid which can be )>Tesscil 
back into the abdomen. Thetc is mostly complete abiencc of pain .iivd ten* 
deriiess. the disease is frcquenll)' fcvcrlcss during the greater part of 
luuise, and ihc patient looks rather >is if he n-ere sufTering frum asc iies dM 
10 some obstruction in the portal system. The course of the iliiessc is essen- 
tially chronic, and recovery by no means hopeless, ;is there are not a few 
recorded insianres of complete and prtmancni improvcmeni t>kmg ptect; 

Thus in one cjisc a girl, aged 13 yean, who was in hospital for ftomi 
bvt months, and from whom eight to nine pints of ascitic fluid were rc> 
moved through one of Southey's canulns, completely recuvcrcd, and waft 
fotir years after a strong girl, supponing her moihcr and family by her «tirL 
In several similar cases ue have seen recovery lake j>Iace ; one sulTcred from 
a tubercular testis which discharged through the scrotum and healed. Un 
ibe other hand, such children arc api 10 be carried olT by a tubercular incnin- 
l^tis, or ihc mesenteric glands become cheesy, or a tuberculoois of the lung* 
takes pl.icc: In any case ii will, of course, be necessary to carefully ex-imins 
llie lungs, and a long-corn iniicd hectic and wasting would su^^csl a more 
emended area of luheiculosis. In cites which end in recovery there 
probably a matting Ingeiher of Che iniesiines, ami frequently more or less 
induration may be fell about the gteai omentum or ciccum. In ctses ivhich 



THbercuhr Ptritomm 



133 



Hnf ton(( ttandini;>> occiLMonslly hnppens ihni a pcrihcp.iiiii^ with more 
K le«t cirthosii tA tKe liver inkct place. This u\is the r.-ii>e in w boy of }} 
jcanntbo nai ndmiticd lohfispita] undct the care of Dr. Hutton, niihaitdieii, 
a4eni;i<>f the feet :ind^nkln, j.-iundirc and enUir^ed liver ; at Ihefiost-morlem 
Ibc liver «eij{hcd 15 (m., the capsule w;is thickened and [he surface wiis- 
SKgulat and nmnulat ; on tcciion there u.ts a gte.it excess nf fibrous tissue, 
oA old attd rvireni pcrltocitix and tubctiulnsis of the hings. 

Cualriiing h'orm.— Xn m.iny oises of tubctcular pcriioniti^ there is little 
wnoasr.itei fnmi fint to lad, but lymph is eiTuscd on (he surface of the 
pnitoneal cnvcrinjj of vailou^ orKans, and if the patient live Icing enough, 
6bnNitadhc-iinn> are formed. On ihc post'ittorltm tabic, local ot general 
jtnioiuiu IS fietiuently found in children d} ing of luhevculnsis ; thus, out (if 
lOJ^iZ-JWor/i^wj of lubcrrular children iiVidr during,' the four \-e;trs tH^j B;, 
ibmns peritonitis in 38, though in a rotTtparaiivcly few of these \ias the 
pRiioniti» an early atul important tc^inn. While this form of periioniiis is 
nuall] chiunic, ya Dome caxcs run a more active or subacute i.*uurse. 'Hie 
ortr iympioiiu are pain in the abdomen, motil)- referred to iJie umbilicus, 
i*«a«ttacks of ittknevi and diarThii.-a, hectic, and [heprcserceof indutaiion 
»T irirpiLir. shaped ma-iscs felt Ihrouifh the abdominal H.ills. The amount 
■■' -fvitftie^* on prt'>ture diflcn greatly, being most marked in ihc iicuter 
'-, .iiid btint; ;ib3enl in Ihc chronic onc& But in cases wasted and ex- 
iMwid by acute i1iie4!ie,even a purulent pcritonitii. may be present viithout 
«; f«in or tenderties*. The state of the abdomen varies, it being sometimes 
dnUdcil with wind, at other limes more or lew retracted ; oflen no di?)tinct 
SMWcaii be felt. but on very gentle percussion a distinct loss of reson.tnce. 
mn^cd rewmamie. may be delected over the umbilical region in con*c- 
^IMKeoftbc thitkeiiing and indutntitm of the great omeniuin, or a rt*i«- 
ttci my be Mt on palpation, or bard irregular tumours can be delected, 
ifcc mull of matting together of the onicnitim or intestines. Hectic fever it 
tmlf prvieni, the lempcrature rising 10 lol^ or 103° .it nighi and billing to 
Mnulin the morning, and tnorc or kssgciicial wasting ofihc body ensue* ; 
^ ibc aittoum of fever and wasting present will depend upon the extent to 
*tidllle mesenteric glands and ihniacic viscera .ire affected. Dinrrhcca is 
■Mnnlly u marked tymplom unless tubcrcubr ulceration ha« taken place, 
^tafawqucni course of these <;iscs diftcts much ; in the minority, after 
vculmunthsof hectic, impiovemcm slowly sets in and the patient improves, 
wttimeal least appearing fairly well. In ihn majority the fever continues, 
<^ ■filing becomes more apparent, diarrhoea, and perhaps cough, comes on 
odtbt child sinks. In oihos, the lungs remain free 10 the end. but mesen- 
'■mtiMsse ensues, ulceration of Ihc bowels uikcs place, perhaps I0c.1l abdo- 
Mal jbscrtses form, and the liver, spleen, and kidneys become lardaccous. 
latalyftiur of the thiny-eighl casesoff;ital tubercular pciitonilis mentioned 
»w the lungs and mediastinal glands found entirely free from tubercle. 

/>qf«i(i//*.— The course of chronic tubercular peritonitis is usually lonn, 
••ta* stimc intctcurrenl ditcase, jis iiibetcuUr meningitis, supcn-cnes. 
tUdrtB may be under observation for m.iny months, «ith cither ascites or 
taduiaoo of the umenlum, iiith more or less hectic, and with no evidence 
<f iBiTKlite disease of the lungs, and finally to all appearance completely 
"^Pm. On ibe other hand, the onset of diarrhcca, hccltc, progrcuivc 



T5^^^^ Diseases of the Digestive System 

«inacia(ian, and tiougb, »ith evidence nf lunx miichief, poinu to the exist- 
ence of more or IeB^ generalised lubefculmii, which neccKiaril)' xhiirtem 
the dumiion of ihe illnenik. Albuitilouna, a> puinling to lardooeuu* diieote, 
would be of bad omen. 

Diagmsis.—Whtn a child b presented uith an Bscilei which biis nude 
iti appearance tfradtmll)- without pain ur fever, it i* perhaps not unnatural a 
ailribuie ibe collection} of tluid in tlie abilomcn to obstruclcd portal circa- 
laiion. In an adull ihe cummoneat cause of ascites ii cirrhous of the liver, 
in u child by far the most fic[|iieiii <:;t<i«e is chronic tubercular peritonitis. 
In a jjivcn caseit may be quite imijossible in make a certain diagnosis, inaj- 
niuch as for a nhile the ascites may be the only sj'inpiom present ; there may 
bo a complete absence of pain or tenderness the most cari^ful palpation may 
fail to detect any induration of the omentum. The bowels may lloitl up and 
cause a resonatit note on percussion at the umbilicus uhcn the putient is oa 
his bach, the resonance shifting' to the tlonk H'hich is uppermost when be Tin 
oil liis side. It may be impossible to ftel the edge oS the Itvcr, or map it out 
by percussion. In other cases, however, there will be less difKculty, for 
iheie may he hectic fever, or diarrhu-a, or abdominal pain and tender- 
ness, or after paruccniesis lumps or masses of induration may be felt. A 
family history of luljerciiloais would naturally favour the view of tubercular 
peritonills ; and occasionally tlie presence of a cheesy deposit in a testis will 
decide (be diagnosis. The fact that th^ iluid is eitcysted is in favour oC 
tuberculosis. 

Ji/arii'tt AnatoMy. — Fluid varying; in quantity will be found in a few 
cases : it may be clear or cloudy serum or pus, in which latter case it it 
usually localised : it is not uncommon, on separating the intestines, to linrf 
small local collections of pus. I'uhcrclei and lymph are usually present on 
the (;rca[ amentum and mesentery, mnttin^' the intestines together, bIm 
between the liver and diaphragm and around the spleen ; nhere there Is no 
large collection of lluid, the adhesions arc frcquctttly very extensive ; the io- 
lestincs and stomach may be adhcicni to the abdominal wall, so that on 
«I>ening the abdomen the iniesiiiics are freqiienily cut into^ The inie*- 
tmes, mesentery, great omentum, liver and spleen may be so matted together, 
partly by lymph, partly by libtoid adhesions, ihnt it may he impossible to 
separate them. The intestines may be so adherent and bound dovn ai 
lo form bends and kinks that it is impossible to nnrnvel, Cheesy mescDteric 
glands and tubercular ulcers will very tiki-ly be present. 

Trtatrntnl. — Any pain and tenderness in the abdomen in a child with 
tubercular tendencies should excite apprehension and never be ne^^'ted. 
Rest in bed should Ik enjoined, and a diet consittinj; of beef tea and milk 
should be given. The pain nuy be iclievcd h>' applications of bcSUdonna 
and glyc«rinc covered with cotton wool, or by fomeniaiion*. The bowels 
ahoutd be relieved by cnemata and laxatives rather than purgatives, to 
the chronic stages, when the abdomen contains duid or there is cvidcace 
thickened and indurated omentum or cheesy masses, mercurial applications 
may be used. An oinimcni «f yellow nxide nf merctiry \ia cr4inii to the 
m.), with an equal quantity of un|[. bclladon ».<.■, may be u\cd, with cotton 
wool to rover it. Lin. hydrarg. may be used, but sali^-ation is likely to 
/oilow- if continued for too long a time. Tonics and cod-liver oil emulsioo 



Itttttssus<tftion 



125 



dtould be pv-cn. Chronic purulent periinnitls wheiber tubercular or not, 

ihoold be tT«-atc<l by incintun and ilrainu^'e, if the ctiild's hcallh \% failing' ; 

uul iberc is ^ooA evidence (o iliow that not only may teiiiporarj' relief be 

llm given, but ton(; baling, if not periiianvnl, recovery may Uike place as 

iIk reMill of inciiian. £«-t^n nliere the duid i« not parutenl in ubatinate 

cues drajnaije is <>f service ; it appears IV cause a(llic»iun« and ihui to 

ftevent live re-cuHection of l^uid, while at the lame time cicalriiation talces 

fhce. We hatv liille doubt that, m all cases of ivibercular pcritoniiit 

ii which there is any cimiiderable collection uf lluid, whether purulent or 

vX. the alxliMneii shoiUd be opened and drained as soon as it is evident that 

intpile of Ireatmeni extending »ver some months no iitiiitmenient it lakinK 

[bee. We have Micc«>rully employed this method, and ate imjirextcd with 

ilsTahie; 

Blse Atwooaa. — The occurrence of iliac abscess, right or left, is frc- 
qton in childien. and the various causes of such inisi^bicf should ht borne in 
nod; the principal onet, some of which have been already mentioned, arc 
cvici cflhe ipinc. tubctcubi disease of [lie mcsrntcric glaiuls — in this C&sc 
ihealMceisismore often umbilical — dii^caie of the hip, innominate bones, oc 
uuo-itbic joint, perincphriiic abscess, r^re in children, and the Mill rarer 
QMS of hydatid cysts. Kmpycmata, superficial abscesses and abscMses 
AertMih of injury, 'simjite psoitis ' \-c. are lo he thought of in addition to 
IkM ilnady described as resiiliini; fmm irritntionof iheca:curn or appendix. 
But beside* alt these, it is common to tind iliac abscesses the cause of which 
>amiii( niHCiirc, and it<c are saiisticd thai in many of these cases the suppu- 
nbon i» fitnply due to inilammaiion of lumbar, iliac, or pelvic lymphatic 
Ktadt. JDU AS cervical ab«ce»«e!i occur from irritation of the glands of the 
■d. The source ol irritation is often doubtful, but is sometimes due lo the 
fmence <i worms or other irritating maiicis in the bowels ; sometimes lo ck- 
leuwn from the more superficial lymph glands. The diagnosis can usually 
be node by careful exclusion and by the hisiory : rectal examination is often 
«f aucb i-aluc, by caablini,' the extent and [xliilion of the abscess to be 
mltmit,as well assomriimes by rcvcalinji a source of irritalion. These 
tbrnne* should be opened amiw-piicaliy and dmincd in the u^ual way : it 
rtl «ft« Ije fntind that ihcy mteiid for lonjj distances upwards or down* 
••A into ihc |ielvis. The limb on ilic aiiccicd side should be Steadied by 
U IfHel or by extension. The prognosis is VpnA, provided no permanent 
ptrot of uippuraiion be pre*ent. .Mmost every case that we have seen 
hi tecoiered, and we believe this is largely due to early opening of the 
•tKaws.- 

**M« otatra«U»R or tbe aawoia.— Children occasionally suffer from 
««* obsirtKtion cniiW by twists in the bowel, constricting bands, impar- 
Mt H fo(ei]<n l>o<ltni, and inirm>] hernia ; by far the most frequent cause 
AhsKgvn. an iaiussuiception. 

r SalnsaBaovpUon 

Tl« cocnmonesi uu»c of ob&lructttjn of tlie boweU in in&nts i* the 
ptKaceof an invagination of the bouel. Many reasons have been given for 

I I\m dMails of iooi< of iliewcnio wc nuty refer lo a paper m ihcln'^. of Pa4iatriit, 
I Mtlitt(,andl«llicOfU>>a'i//«9iM/^#U>ia(fJi %\taLanui. Kcbruary 1891. 



126 



Diseases of l/u Digestive System 



thU iomcwhni ficqucnl accidcriL TIjcre I« no doubt thai an« caaic it 
be found in the K'cai irllcx irritability of the niut^cular coal of ibe in£M 
bowel ; vigomut pcrUtakis Is easily set up, and mureuver, llie intcnid 
wall% being thinner during infancy than in lat«r life, an invitKinatioa of a 
lionion of the gut into a lower portioB more t«idily takes place. Th«» 
seen in xtte poif-morUm invajjinaiions so ofico found ; the act of dyinx 
to stimulaic the peristalsis of the bowels, and it is no imeoinmun thing 
find on the /Msf-mar/i/n table many inva);inatioDS in the ileum an indi 
two in length. In some crises an accident, such as faltinK out of bed, 
some rapid movement up and douo in the parent's or nui'se's arms, lias pn 
ceded Btinpioins of nn intussusception, and it is possible that a suddc 
movement mifilit cause a toneless piece of ^ui to become invaninaied. 
must also not he forgotten that the- infant's intestines, es|)ecially ihe caecum 
colon, are more movftbletban those of an adult, having a wider mesenterr. 
consequently one piece of bowel is more easily drag^'ed into anoibcr poniM 
The CKCiling cause of indissusceplion is occasionally found to be 
pol<rpus, or an intlammntory tliickening of the cecum, or some hardcu 
nodule of {ivca\ matter which adheres to the wall of the gtit and sett 
local pehstaUis. We have met wiiJi a case related below in which posst) 
» local peiiioniiis causing thickening of the bowel was the immed.iai« eai 
of the invagination. 

With regard to the frequency of intussusceptions at difleieni ages, i 
has been stated by Pil: that. out of J93 cases i;,l were in iheir firsi year, 
of these 98 ncrefrom 4 to 6 months of age. According to Lciehensicro, 
of 13J cases, 73 were under a year old, and 49 from one to five ytan of 
It is cerMinly the common oipiTience that the majority of cases occur i 
infants under a ;ear, and ilial from 4106 months of age is a very cumraooiii 

In at least three -fouiihii of the caics in infants the invagination is 't\» 
caecal, in the minority of <;asc3 it is ileum into ileum or colon into colon. 

the ileo-ca-cal variety the ileum cnici 
the Citcuin. not through the ileo-c«i 
valve, but the ta-cal valves aic pushe 
before it, so thai the valves ihcmsclTC 
occupy tlie liiwest part, and a» it tranl 
downwards, more and more of the ileiB 
enters, dngt;ing its mcKntery akn 
wiib ii and furmint; the inner tube, itliil 
the middle layer is fucnied by the 
vetted cnrcuni and colon, the cokm all 
fonning the outci layer. The layen 
an iniussusceplion therefore consist 
(I ; an outer Ujer of intestine into whl 
the invnginulion takes place, the 
lonea! coat being external and 
mucoui membrane internal ; (:; a nib 
die biyct continuous with the 
layer at it* upper end, but inmed in^iidc out ^o that the mucoui mrmbi 
is externa) and the peritoneum inicm;il ; (3) an inlem.il layer formed by 
intestine entering the outer layer n-ith its mcicniet)- and vessels, and wbii 




4. t.i?l^(liiB Intn^uiOptfn,!, 



Intttssusecption 



127 



beconiing nipped U tl tnveb dawnwnrdu fnrmt the stoppage. In conse- 

qoeiKe of the me»cn(cr>- becoming dniKKccI in, the included intestine dnea 

Dot lie in the centre of the tonuimng bhi, but is more or less tilted lo one 

nde. A* ■! rriiili of ihe inv^i^iiMtioti, the inner cind middle layers become 

<<iBgCSled iind a'dvitiaious imd of ii d.irk-red colour : blood is extravajaicd 

linm the conijestcd inucoiw membrane .vnA is passed per rectum. In some 

iMC^ Iv-mph is ihrowo out by ihe semus surface* and a local or genenil 

ptrilnnitis l;ik« place. In a few cases, more particularly in the ileum mto 

ilwai variety, slou^liiitg may take place and the invaginaied bowel be 

KfMnled and pissed per rccium, while fieccs mfiy be cxiravasxted or 

■KOt<r>' lake pUcc by a process of cicairisaiion. The extent to which life 

vtbttatened depends very lar^'ely upon the li^htnes^ with which the bowel 

a(i(i)ied und the ciicuUiiort nf blood obstructed, and this ^tppcars to vary 

» t cmsidcraUe extent, so that death [iiay ensue in « few hours with the 

VjVitNanH of cnllnpsc. or, especially in elder children, whert the bowel 

n miy ptnially obsinK'lcd and the circuliitioii of blood through it but 

itthtly iaiCTfcred with, iht coune maj' be chioiiic, ^oin^' on for weeks or 

ttn months. 

.Sjw^/wwj,— An infant of .^ few months who may very probably have 

■vSmi for a few d.tys from s)-mp(onis of bowel irriUtiion, suddenly begins 

Ubckand scream -ts if in violent p.iin which nothing' appears to relieve. It 

'■KflbtipRt 10 vomit cnntiiiunusly, and sitajn as if it wanted 10 pass a stool, 

't«i Mditiii: escapes but a lillle blood and mucus. In ihe intervals between 

|ll(tlUcktof voniitinj; and colic, the inf.tnt may be tolerably quid, bui it is 

'Malb' rettlett nikt moaning as if in pam. An examination of the abdomen 

■I to be fiMNteraiely disicndt-d and tesislenl. though tn some cases we 

liwe lotlccd it to be flaccid, and on careful palpniion in the course of the 

ooton, an inch or so above (he umbilicus .ind towards the left 

hirwhundriac reK>on, an elongated iitmour may be felt, which is movable. 

•■L «i a ndr, nor acutely tender. There may be also a feeling; of want of 

taniaice in the rJKht lumbar region from ihc nbscncc of the oecum and 

•VHidinK colon- In verj* fat infants it may be impossible 10 detect s«ch a 

ibxw. We inust not. however, forget that if an e-irly examination be made 

QiiDPair may be felt, inasmuch as the invaginatcd portion of ileum may 

Ifhtre posted tuo or three iiKhct into the cit:t:um and lie loo dooply to 

Ul If ii iravcli ai far a« the i|)lrnic ficxtitc of the colon, it is tolerably 

(■nin 10 b« frit. In lomc cases as in one related below, no tumour was 

'<t*fler forty'cight hour*. The tectum should be next carefully explored 

**kttt fuller, ami the presence of a tumour there, which is pressiid down 

•Vo Ac child strain*, while the withdrawn finder i* coi-crcd with blood, 

*aAI («t>bl>sh the diagnosis. The imsiiion of the tumour nccessarity ^ arics 

mntdiiiK '" ^^ length of the included gut ; but inasmuch as the colon Is 

AWat llic abdomin.-il wall where it crosses the upper part of the umbilical 

t|Mk,if thif part is involved, as it usually b, the tumour will be most nradity 

Uibrre. The trnipcraiure is mostly normal or subnormal, unless iheic is 

F*)i:<«ilis olicn it may be raised a degree or two. The tumour it usually 

** Muely tender, but if the rase be an acute one, or, in other words, if the 

' {Ui be lightly jammed and its vessels strangulated, the child may 

on its being prrucd. If the catc continues unrelieved, the vomiting. 



I2S 



Dhsases of the Digestive Sysltm 



suainiRS, and distms coniinuc, the child wean an anxiou*, pinched tx\t 
»ii>n, with ftunkeii eyes, Hnd dits with the sympioins o{ colluine. The pei 
at n hitli death lakes place »a(iei ; in infAtiis ii may be " ithin tit-eniy-l 
houi^ more often frotii the third to the fifth day. 

While ilic Jibove <ksrripiion applies to the majority of cases, it mtiH 
borne in mind that ihe sympioin» are at limea far leia vrell marked, to I 
the presence of an iniMsosccptinn may be overlooked; there may be peril 
vomit it));, colicky p^iins and muroid stools, the infant dyvn^ in c.-onvuUiaiix. 
ihc oilier hand, it is possible that an invaciiiaiion mayocciir,and furtima 
right itself before it becomes ti>;hily impacied. 

In older children, where the ileum into ileum variety occurs, the obai 
tion is mostly complete and itic symptonis are those of sirangulaied her 
or constriction of a knuckle of bowet byalibroti» band. The onset ivsudd 
tlic contents of the stomach beinj; first vomited, then the intesiinal contei 
and finally, the \ omit has a distinctly f.i-eal odour : neither mind i»or fa 
are passed pet rcctiuTi, btit in some instances small quantiliei of mu 
and blood. 'ITic atMltmiinal jiatn Is usually of an intermittent and colii 
character; iheabd.nncn is rounded but not tender, at least in the early tiaf 
In ihii case a tumour is not likely to be felt throu^'h the abdoniinal n-atl. 
:uimu<:h as the lower end of the ileum, which is usuall) involved, lie» dec 
and is probabl) covered by distended intestine ; though in one caic 
ported by Herttka, whcic the turnout was sup|)uscd to be due to an ile 
invagination, a sudlint! ^as felt in ihc region of the navel which was ih 
inches lont;, movable and tender ; the child recovered. In these catct 
rect;i1 tumour is present. 

When an ilco-cjtcal intussusception occurs in older children, the coa 
is usually more chronic, and the symptoms less acute. There are attacb 
colic and vomitinf; with obstruction of the bowels, though the tatter » > 
always complete, a« there m.iy he slimy stools p.-isscd with or without Uo 
An el»nh'>ilcd tumour is mostly felt in the usual position, lyinj; actnss the , 
domen immediately above the umbilicuK. If Mtaniculation doe' not occur, 
case may v" on for necks or months. The cauM of the ob»iruct>o« in M 
cases is apt to be overlooked, as the obstruction to Ihe passage of fjccct 
not i:ompleic, and the symptoms not acute, and the tuaiour felt clotdy 
Mmblcs diven^lon of the large bowel with hanl fieccs. 

Morbid Anatomy. — On making a pntt-morirm examination, cu« HI 
be taken to distinguish between an intussusception w hich has lakta pi 
ilurin); life and giien rli« to the s)*mpti>ms noted, and an intutMiU'C|<i 
which i* fu'it-moiiem and caused by the irregul.ir yet vigorous pciiua 
of the bowcU nhich may take place during the act of dying or after da 
In the latter cata the imajjmation involves the ileutn, or at any rate 
small gut, and there arc often several of them. They are rarely n}ore tl 
an inch or two in length, are readily pulled out by gentle traction, and nl 
a ring "f congestion may be seen near the seat of constriction, or where 
gut has been doubled on itself, there is no a-dcma or market! congcstkm 
cITused lymph. \ post-uiorUm invagination does not completely occh 
Ihe passage of ilie gut. In the examination in a case of the ileo-cc 
variety which has 1>ccome strangulated, an elongated mass, dark red 
colour, IS seen lying in the ccMirse of the transverse colon continuous will 



InlHsstisceftioH "^^^^^^ 1 29 

U« lower end, white ih<; ileum wiih iu mcacntcry i» seen to enter nt lis 
r eod ; the a«ccndint£ colon .ind c;ci.*uiii will h.ivc dtuippi:;irc(L In 
ca^« r he c(Hi (.lined KUt cannot be wiihdranii uiiluiuc icarlnt;. a« it h'i!> 
bccotuc rntien ftom K^njirene. lit pna-in^e will, in iin uc:uie c^se, be com> 
^p lcicly occluded, pntily nn account of the a-dcmiiluus and toriKCjied two 
Hfinner I.-ijers, partly by reason of the liliintj un one side of the inner gut 
^HirouKh the diugifing in of its nie*tiiii.Ty. Lymph iniiy be found elTu»cd 
Bbemeen the two peritoneal iurfiici.-s, gluing them iDtjeihcr, and there may l>c 
^ evidence of a more general j>eritonilis. 

In chrank caseit less cungesiiun is seen, the bowel probably i^ not entirely 

ctetructed, and the bowei above is generally hypctlrupbied and its mucous 

BKntbrane in a condition of ulceration. 

^B Dp'ajfwfj?/.— The di:ign(isii in an acute case in an infant is not likely to 

^piiv« n»e to difficulty, inaMnuch a» ihc sudden attack of tumiimg, with pjin, 

" ttitining, anil tlic passage of UIihhI and inutui from die bowel, and the dis- 

(inery «f an elimgated tumour ihioiigh the abilomin.il waW or per rectum, 

tttltt llie caso tolerably clear. We may be mur« in doubt if niih ihc above 

f)«)ptums no tumour can be feti : but we must bear in mind Ihni a sliort 

ik>vcfcal imaginaiioD may be present and lie too deeply in the tight lumbar 

«^m lo be fdt. Uut the ([ueiiion of the presence of an iniu^suscepiinn 

untiimes arisi-s in infants who are sudcring inim symptoms of obitruciion 

Uihc ttoweU of an imccrtain origin, possibly n-itli a certain amount of 

Sickening or re^ist.ince in the ri^hc iliac fosita, which may be due lo the 

■atpnction of ficccs in the Civcuin ot to »n invagination. In all such cases, .i« 

keg «t any doubt c^isls purgatives should be avoi<lcd, and small doses of 

•piuDi )^i'rn to atlay the pain and straining. If there is pain on deep pres- 

iuiT,nii belter to avoid enemata, tiusting rather 10 narcotics. In older 

cbldna il>c eiroi may be made of mistaking an ileo-coliti^ for an invag^ina- 

tnnef the bowel and ivi-*tv*-M (see llco-colitis), or obstruction of the bowels 

hmn Mhw causes may be taken for inlu<.suscc|)tion. ( Viiie ease, p. 134,) 

Trijfmrnt.—'Xht irraimcnt which is lo be adopted must necessarily 

»*MT»icordin>: to the acuicncss of the case and the time the symptoms have 
Inltd. fo« if the bowel has p.ivscil into a gangtenoos condition it is obvious 
Ibt only liartn can be done by merhanical Ircaimcnt, abichmigbt have been 
*f tic (Tieaim »ervicc in an cnrlivr sl.ige. The ijucstion lo ask oneself before 
t*<in>niring treatment is, nliat \s, the slate of the invaKinaiion ? i« the gut 
•tfaly Jammed ? is it gangrenous .' tTnforlunatcly Ihese <|Ucitioiii aic very 
Ucull to answer, inasmuch as in sonic case* Ibc inner layer of bond 
^KMnct lightly impacted from the iirst, and no amount of force applied 
W Attending the bowel per rectum will replace it, while in other cascSi 
««»** has attcndeil inflation of the lower bowel with air several days or 
"9 a week after the onset of symptoms. Thus in a child ' .igcd y months, 
•»fe ibc tare of Dr. J. S. Bury, injections of oil and afterwards of air were 
wpfclBd Iburteen hours from the commencement, but failed 10 reduce the 
■ftpulxm, tbc mfant dying twelve hours later, within Iweniysix hours of 
>b (Met; at the patt-omrlem 'reduction was quite impossible without 
^***^% ihegut :' there was some lymph effused locally. In ibis case, by the 
n4 of iwenty-fbuT hours, the bowel was lightly strangulated, -ind neither 
> AMitat Timtt. Feb. 19, iSSi. 




1 30 Diseases of the Digestive System ^ 

by injectinns nor abcluiiiinal aeetion could (eduction liavc been elftcicd. Such 
A case is no doubl txcept tonal, and il nould probably have I'ndcd fiilallv iindw 
anycitcutn«ancciuiilciin«;thanka,lre|>Iai-i-m('ni touWhai-eboi-n undertaken, 
or laparotomy perfonned wiihinaveiy »hott wne of ihe sptiure. I(y ihe time 
the invaginated portion of the biiwuJ has iravt-lled along ilie colon as fat as the 
tecium, the rntlapsc produccil, cipecially in a tmall infant, » very ^x^x, vbA 
the diflicultiei In the way of repUcemeni arc necestarily much gieatei than 
if only a few inches of bowel are involved. But caiet appear to diflercery 
much in ihe lunount of ledema and coni^tion Lilcing place in Ihe nipped 
bnu-cl, and con.wquently in the difficulty of replacement. While some case*, 
luch ai the one just refeiied to. are acute and inedtKible atmosi from the 
fint, others arc reported in which the intussuiccplion was reducible some days 
afterthe onset of symptoms: in one case, reported by Dr. W. B, Cheadtc.'in 
a boy aged 5} years, the irn agination was successfully reduced by maisagc and 
ihe injection of air on llic seicnth day from the onset. In another case^ 
reported by F. H. Ellioll,' in an infant of 8 month.s. attempts at intervals to 
reduce the invafiinaiion were at first only partially successful, but finally 
succeedecL 

As soon, then, as the exiitence of acute intussusception ha* been ascer- 
tained, it becomes neceisarj- to deci<le without delay whether the patient 
shall be left to nature, or whether mechanical means shall be employwl to 
overcome a mechanical obstruction. 

Recoveries after sjionlancous reduction and after sloughing have been 
recorded, but they are so rare thatwaitinf; for a natural cure means practically 
abandoning the child to almost ccitiiin death, flvcn if recovery by slouch inp 
takes place, the risk of subsequent stricture has to be considered, h is then 
clear that some attempt at reiluciion should be made, and we have the fol- 
lowing plans at our disposji) for this purpose. (ii Inversion of the child, 
combined with external taxis or succussion. The child is held up by the lej^ 
with the head downwards, and an attempt made to draw the contents of the 
abdotiien to the upper pan of the abdominal cavity by kneading and 
stroking with the h.inds through the abdominal w:ill, or by sudden shaking 
movements of the child an attempt is made to dislodge the intussusceplioo. 
It is clear that this plan can only be exi)ecird to succeed when the intussus* 
ceplion is small in extent and recent in fonnailon : it is in such cases Bxinh 
a trial since it is unattended with danger. Chloroform should be given 
during the manipulations. 

(i) Distension of the bo«*cl with fluid or air in the hope of pushing hack 
the invagin.ilion.' If fluid injections are employed an enema iu1>e (itied with 
an anal shield should be pa.sscd into the rectum, and narm water at oil 
allou'cd to flow into the bowel from a »e»«el raited above the Ici'el of the 
p.itient's l:ody. The amount thu* injected must vary with the ago of tbc 
child and the position of Ihe intussusception ; fiy>m one to two pints is about 
the usual quantity, and a fall of from three to siit feet is required. 

Inflatiim l>yair is best managed bypassing the noule of an ordinary pktr 

■ Umni. Oct. sj. 1UI ■ Ibid. Jan. 8. tS8?. 

* Vi4i MoRiDMT, Lmmnt, May 93. iB^i. p. 1144. for an nocounl of espmawitl* npHi 
dlSMiulon. 



f<r licllrtws, fitted witti ilie pipe, inio the rccium, and blnwiiig air in till the 
tumour ifi felt to give way, or it is not «afc to diMend any further. In liuih 
l^mc nieihod^ the ulidomvn should he 03]«fii1ly it.ttirhcd, and a h»n6 kept on 
■ miuSMiKeptMni tuiiiour lo feel for any change in its siie or position, 
The follow^nK caiet illuitnite the success of the:ic methods of ire^t- 
nl: 

tutnvi Kf fti^m ; /ajftfUii a/ Air: itfivatry. — A fine li«lihy iflfam, a month* old. 
I i»fctiiiTj tdtod. on tbeciEntiig of Jiinuary a. witli aniline iwinii .ind lonetniiu. ll 
ItemlaoHSht (ipoa tfiebrMn, with n boiOc oriwo u ciny of con's milk. ITicmMhtr 
ilUUMiae (•>'' Ihv flm IriiM'. inil ilir infiini hhs (-nitinE two lover tMlb, Hit 
' tftn him nn PHFina ulUi a tmoll bill tyim^e. wlikh brout[lil imny a Inryr curdy 
Ml tkotng Ihe ni|:ht l>r <•»> vtry rruIfM, vomilinE IrrquFntly. nnd slnumiig con- 
NuOf, Ml at 7 A.u. puu.'d a Uoody tlool ojth mucuk tullicieni lu taiLiniir in onliiurr 
■cUi. We «n hioi. wiifa Dr. E, H. Smiih. of Knutsfonl, nen morning, January j. 
ttoe beun after the kmutc llti fnu? u.u jiUcid, nui dniwii ur ilitiietwx) ; Ihtre wu 
■otTW; tlw kbikinwii biu Dacvid ami nol disli-ndcd, anil could l>c ouily poilpMod in 
•■I (■■'I- Oa dce|i {Heuure no ela»i[.ited luiiioui wu fult : tlir left end wa> inuit dii- 
UELodmi ((luatnl in the Ted lun>bar ri^ion. juii brlou the ribi .-ind nmi ibe iipol' ilir 
i|>iai < tnulil be trued from kft la riEliI acrot' Ihr,- alilomi-n for luo ur ilinv incbn. 
M i^B^ t— g padiially tail. Ii WAi mevnblp and not ii^adi-r. No lunioui could be 
Ml « ibr i^t himbar regian or |^cI ircIuiii. bul ilur Hiiku-. an lirlnu wilhUniw-ii. uiu 
•wrt alik btood. We at on« (iKidnl la reduot ihc invijcin.iiian. whicb mc bciiciied 
* >^ by dutcniting Ite cuinn Ijy «-Jlrr prr^t'iT, The iiirtn|H )jni>v<l a fu^lurc. iU Ihe 
»H(t rtiWDcd by ibr ildc of the cmhciCT In the rettum wlihout diiicnding ihc colon lu 
WfVeUtUtM. Wo neii tried the indniion of .lir. In iiieuix i>(dn qnltnnr/ HiEglnson'* 
■Ji^lkltebsBe noulc being inwrinl into the rectum; ibc pelvii vnu mlied, and ihe 
l^ntpMly kmndol. kIiUc air unt fnrccd inlo ibc bcmvl by «|iinn>nK tile biill of the 
"•■tfc AAXT foot Of fl'c ujuceia the teniicin la ihe <oloo wm fdt lo lie coniider^iblc, 
■Dlonntol a t;iirK''n)C •>oi»'. *iid th<: luiiiuur ilii.iiipi-urcd, W« vunimiu-il [O pump 
•«••*•, IB llie hope that HO inlj[ht eflcrt the Kinipleic reduction of the lovaginjilion. 
ffc" eiut ntnwd rrtierrd. and uent tn dn-p tut »omp tioim ; hm t'lwnnli evening the 
{Miunad, ami he>pr:nl a renlcu niglit. I'herc ■!> no toiniling; he paMtd per 
iMtM Ibuiu. blood -n-iined mui;u*..-ind a tiiili? ciinl. We mw him ngnin ncil day. 
H. 1%ere vrai wme ibMtcM notiueable m-u on liii faoc : he hail colicky paio* at 
1^; Have ni bo luinaiu' to be felt. A miniin of ir, opli hu given, .md ibe Infant 
■■ itert in a na-Tn laih for len iiiimiiPi. The colon wa* slowly <littcndi,il with warm 
<**>liyffl'Muo< ■ ll'gginun'i syringe, the mf.in; b;ir^g in an iniTiierl poiilian; no 
^■•itlrftfM appeuwl to tv proiliwr'I. thrn hourt later anoilirr miiiitn of Ir, ojiii 
*** ^s. Aa hour later, after anolhei warm balh. he poBol a copioui yellow Ilqiilil 
*°l Fnm Ihi* lime he eonlinurd to improve, ibough for a fiiw day! he wu gniwd at 
I^Mdpftian] itBoIl qatnDlies of blood and muciu In hli (loaU. Small dotes of opium 
** fan lor a lew dayi. 
I'lmianTffini .• Iny/ttVH tf Wattr; Ktttttty. —A hcilltiy inlant of 5 month*, who 
'I '-jwd at the bieoii ior three months, jinil laiierly fed on milk and waler. waiseiatd. 
' '"niagot t'clirikiry f. with >>omiliiig.kndat>ilumi>ia1 piin. He had bccncoiuillpated 
■■•NioMae prerionily. and. for a day or two. more leitleit than UHlal. During the 
*Vllepanal tomv blood per recluTii. Itr vimlmiinl rnwli 111 ihe lame tIaiL' during 
^i^Miy a MMl 9. W« savi bim wnb Dr. Mauiah, ul Uidabuty. on the evening ol the 9lii. 
1^ •« ih> dtslima riaiblo on his face, but he urns pule and wenlirr ihon uiuat. Tbe 
^taM eu KniHlltMBdcd and floceld ; no tumour could l« felt, ihough we were able 
''{••■dmply mto ibe abtfenieii. He tirained at tim?i: and tbe Hngor, iiitjoducnl into 
ttrnctiim. Rtumed eonnd wtlh doili dnconpoiing blood, A minim of it. opil wu 
1^3 taA b* was pat irtli> a warm tilth ; cblnrofonn wai Eivrn. and warm u-alcr injected 
MHtanbr uieani of a Itiggmwini iytln){c. There wai much Mraining and raliunoe 
'In.bai iMi W4S gra'luUr oxer^iae. It was erldeni, on ptmussion, that the water 



i 



^^^^^^ Disrasfs of the Digestive Sj-sfem H 

nochird Ihc uttcniJtnc i:i:ilini amt ccccuiii, lloiing illiicndi-d the boHcl Ihnv timet 9^M 
■lie wKlcr. wc rooliiKl lo unit nnil uw lliceffei'-l, AUet (In lalt injecikin ho vomHod t^^f 
ilcnoriKunui fluiil. l-'oiit liuius iiflcrwatib he iwuod t, tlqutd Mool and made ■ g<^| 
ncovety. 

Tliesc plan» arc open in thr iihjectiont. Iitsi,ihftl ibcre is diMinci dnngcr 
of over-di>teiisi»n and niplurc of (he liond, as thoirn 1>y the DX|>erimcnts of 
Dry^ini an<l others ; secondly, lliat ilic) c.iii only (uccccd wlierc no -idlitsioiu 
hnvc formeil beturcn ihr adjnccnt |Kritonea] nirfttces : and ihinlly, ihat 
even if reduction docs apparently take place it may 1>e incooiptcic or invnfi- 
nation may recur. A cajc of otir own well illuslmlCB this bsl fad. 

/•rmiiniciy/HM .' Alift^imit Satiim: /V>iM. -- Elarold 1'.. ofcd 7 nionlhi. *u ud- 
niltl«d Into tlic Cbildcviri Hotpilal, y\*y 50, iBB*. «tth lyinplomi orBcutc InluwmcqilkMi 
of Ihnv day)' dumlion, Tbr invnginolion laiilil br Ml ciletnally in llic left ilbu nc>>>t. 
aC'il iiitCTaifly por [OCtiim. I'nili-r I'hlntiironn iiit^;iluiii hmi- oiiiplojol without luoooii 
Mil ounoctol ■nWr imre Ihi-n inj^itd through iin imim.rubbCT tuU.- thrrr Irvt long, ailh 
Ulcmull of cnu»nK di>-i(ipiMr.iiio' <jf ihc lunioiit .mil iiicrmv of rr*'tlJiii:P ptnianlyilf- 
Uel«nt in the right iliac nn-n. Itc ilepi <|uici1> for uime boun. imd thvn hr^an lo M(«am 
■gain, amd t)\c inliuHucc^lion roajipmrrd Injrclion w»i ngnin Hppir«nil]r tucnMftU. 
oiul thn cliiM upml a <(ii>ri mgliL The iiol ultmioon (lie i.}inptoni> loippeutil, ~ 
•Kne oofcmorrnlievrd byinjtclian. The nnt dayltae S'nernl condttJon «u worae. 
M It »n^t cliur th.ll no i;<Jiii;ili'lr rirdiiL-duii hail Itikirn pt^c■^. abdomiiiHl m-lton was 
fotiui-d. the intuuuKcplion found urni rrdi^ct'd ; the bowel ms iollamed bul not gait- 
girnout. ihrrr tntc 110 Milhetiuiii. Anil lti< iiiviKin.ition vrM it(»<acval Tlic chUd mak 
and died on hour later. 

ii) Abdominal ficc(ion may he i>ciformcd and ibe obstruction relieved hy 
nioTC direri means. The seclion is besi made tn the mcdinn line lii-'iiur ilic 
umbilicus, (he bladder having been previously einp(icd. As soon iis the 
abdonien is opened, ihc in[ussiisce|)tion should Lie dtaun 10 the surface and 
carefully examined. If the bowel i« in good condition a cuieful attempt 
should be made by gentle traciion in wiihdmw the 'iniussusccptum.' Re- 
durtton i» «nmcltmes he^t managed by sqticeting the lunioiii and dmuinx 
the ' iniusfoicipiens ' off the ' iiitussiiscepium,' rather than by ditcctly jMitlinif 
QUI ihc Invnuinated gut. If this can be done and the l)owel is not 100 mach 
injured for recovery, it should be left 10 ii&elf and the wound doscil. 

/mlmuMJitfUMi ,• Atthmiaal Snimt. — In a caaa Hhlch ho uiw wiili Dr. Co*, et 
Erak*. hilpuiimi. a child of eighth wrckt old. hul lymptomiar tvclvehoun' dniMloik 
Wilb the Mpof Urn, J. J. .ind V. Cox and Hulton, .in nll<-m]il wai mitde (o rrdncr tba 
ItivoCinaiwi by injc^lon : ihii poiiially lucoeodcd. but a ncxiule c«uld >itll be Idl Ki ike 
riglil hypcchondriuni. Wv tliprefon- oprald the abdomen and drew up llui noitaU. 
HUcb eoniiiiled of the eictuni »i(h the imill intoline eniering it. At (hi* point 
bnil bevn rvidr-nity a ptev^oui locnl initftmniaiiun, ^in(c the pans weir muih i 
and induratnl, and the adjAcrnt gUniU wcte rnhirgvil. The iMUMUMviitioti iMd 
nduccd, and nolhing more appearrd nnrr>Hry. The ubiloinrii vru elotml. aad ibr 
child got ijUite Hdl. II. hcnaocr, uiifoitunnldy dird^of jjneumuiita tbiec or (our atwk* 
birr. 

If Ihc bowel, himcvcr, is 1 on much injured lo have » icatonable chance | 
«f recoveiy, ot if the intuMuscepiion is inednrtblc, otic of three courws mu«t 
be foil owed^eii her the boMcl mu*t be ojiened above the liimout and an 
anificial anut made, the invagination being left (o i[scir, or ihc intuxuia- 
■cwtion must be resected and the tuo end» of the gtil sdtchcd (ofeiberi 



(ntussusetftioH 



133 



f, af)«T resection lh« two eiuU may be brnughi nut oT the unund and 

I (o its c<It;ct>. an anilicial iinus bcini; madE:. The t>Lin of liMving the 

Usccptton aluive hui no iidvunugM, itiaunuch a\ ihe injured hoivcl nill 

almost CMtainly act as an trrilanl and al-i up pirriioniiif. The plan of re- 

MClion and HUIiiiing; iDjtelher the end* of the bowel, if successful, giv-ct, of 

ccaree, ihc moot pcifcti rcaiilt : but it i* open to the objeciion that it is lonjj 

and icdHKis. and ihc child ii likely to die ofexIuu*tioii, ami, funhcr, there is 

dumrrofliMka^e even after the iivwl careful suturinj;. If this plan is adopted, 

il i* probably ni»c to uie Senn'i mcihod of lalcnil anasiomoiis, or Barkers 

pbnofrcsecliDnof the iniuuuicepiutn from "iihin the yvil. oronc of the many 

«bCT n>ad«9 of uniimg ihe i-ntU ol ibc bo*el may 1)e employed. Of these 

thuby Murphy'i button is probably Ihc quickcM method ; but m theabiencc 

<lwf at the special appliances, limple direct »utiirc by Lvmben'x mcihod 

Ktti bt nnployed. The least dangerous coutsc i» to resect the tumour and 

hboih ends of the t;ui to the abdominal wound. Subsequently, i.e. after 

w«al ■«elci>, should the child recover, an attempt may be made to restore 

ih tuiaral cluinnel and close the artificial anui by ihe usual method. The 

nrf* of the bowel inayciihcrbe dinected anity from the edyeiof the wound 

aidumicd to one another by sutures. i>r the 'spur '(' t^i>eruii')bctuecn litem 

■i! bt itn>o>'e<l by the entcrotome and 50 the aperture closed, or the two 

odtowy be united by Senn » or other method. This, ihou^h a loa showy 

ffanand one requiring; more prolonged treuimeni, is safer at ilie lime than 

tbtobir nwlbodof immediate union after retiectiou, though in a case where 

tbedtild appeared well able 10 bear the more severe operation, iinniediate 

wntiiibc proper course, especially if suitable appliances arc at hand. The 

■MM care in all cases muit be uken tu prevent the escape of the inicsiinal 

*<«ttnl» into the peritoneal cavity ; ihis is managed by emptying the 

winmiof |{ut dealt with beforeopening li, and kecptt>^' it empty by pressure 

''id ifiistani's lingers or a clamp, such as a pair of forceps shielded »>lh 

*i rtbbtf and fixed ver)- lighilv <'>n the bouel, so as not 10 bruise it. All 

"Md ftc. must be carefully cleaned out of ihc peritoneum, and most 

•■|«M will prefer to use antiseptic measures. 

Oim, then, a case of acute intussusception, inversion and injection 
*Wd 6nt be (,'cnily tried : ' shoidd these means l>e successful as shown by 
■kintels acting, well and good ; if after injection the tumour dis^ippears. it is 
•dltonait for a fe» hours to sec whether the bowels arc relieved. If, how- 
***!. the tumour does no! disappear, or if, in spite of its disappearance, or of 
*We in its absence from the first, the syniploms persist, immediate lnpara> 
"^y "ilh redurlinn of the invagination, if possible, should be performed, 
'■drfoDt reducible the tumour should be resected and dealt with by one of 
■kanbods mentioned. For funhcr details, we must refer to the general 
lu-tMKdcs or to Mr. Ttc>cs' work on Intestinal Obstruction 

ClviNiic ifltutsusceplion is cxccedinRly rare in children, except, perhapi, 
HMefermoifs'Xalled prolapMof the miuin, which is really iniiissusceptioD 
^ilkeuppet into the loner part of the bowel. A chronic invagination may, 
**»e»er, occur cltt'wbcre ; its duration may be wceki or monihs ; Treves 

* II latcolioii pmtr* meo-ulvh ihe child should tie kept undtr Uie InrtuenM of opium, 
■*H Ibi fdrli r>^ed aliove the icvvl of ibe hiod. 



<34 



Ditfiisfs of Ihf Higestiit Sjatftit 



records a case of h >'car'&«iaiKlm)[ and n doubtful anc of many year*' dunitkin. 
We liavohnil a child under ihc joint carcof mir collcAguc Dr. HuilnnBnd 
outKlvcs in nhicli M clirnnic intus6usc«p(i<in of ihc ilco-ciccal variciy cxUtcd 
for a year, and which uliimnicly died of fiixal csiravasniion from Kangwiie 
found at ihe lime of alidniiiinal scciion. The whole luntoui u-a^ M>fl and 
pulpy, ihcre was inictiiiittent const ipat ion, no vomiiinj;, icnomui, im bleed- 
ing, much dimension uiih visible pctittaltii, a1 limen, at othem » flaccid 
abdniucn ; no definite iiimour wat ro be frit in the recium or abdomen, an>l. 
in fact, the sympinmii in [his case, at in most of lbu«e on record, ntcre ^Try 
uncertain, and not at all character) it tc nf intusvuscvplion. Knieruloniy or 
rncciion uas the only ihin^ iHai couM have relieved thii case, and if the 
cympiomK were at all argeni ne itioulil rcvominrnd it m another caw, reduc- 
tion nf ihc invAginalion licint; quite impo^ible. The bouel in these coms 
(omclimcs slnti^hs a»ay aR in the arulc form. In the simple rccia] Curm 
the prolapse is usually reducible, and if iio can be cured by rest, avoidance of 
s(Tainin>;, and, if necessary, the use of the cautery- as in other catcs. It U 
of ihe uimoKi importance thai ihe molion* should he passed in the recumbent 
pasiiion, and shoidd be kept soft by dtisci nf cod-liver oil or hy olivfr-oil 
en«mata.' yide RhciAi. I'roi.ai'sk. Wc have recently (iS9)) (ccn with l>r. 
Con a child in uhnm there were sympiomt sutjueitivc of iniusiUKcepiion, 
thoutfh there was no bleeding or tenesmus. There was obslrtiction, with a 
palpable oval tumour lying on the right fide of ihe umbilicus, and ctoccly 
simulalintt an imuMU«ccplion. We, however, came to the conclusion that 
ibc case was one of tubercular mctcnicric glands, which by pressure or tractioa 
caused the ob*t ruction, and un opening the abdomen this view proved correct ; 
the tumour was a large mast of glands cawating and breaking down, a&tl 
other cnlarjifd >;Unds were found. The manipulation relieved ihc ob- 
siniction, hut the child wat too ill to bear removal of the glandt, and died a 
fen* days later. 

Cbraoic obatmctionoi iHoBawvii.^ Reference liasalrcady been made 
In ihc conslipalion of infanis and older children, due to an atonic conditioa 
cifibe colon ora chronic intestinal catarrh ; but other causet of maciivcboodt 
exist vfhich are attended with serious inconvenience, and even fatal results. 
There is reason to l>clicve that occasionally fibrnusbandt. due to old, pethapc 
a fecial jxriiciniiis, mat together the coils of intestine, more especially the 
lower piirt of the ileum, and <ronxc(|iiently rhcck or tntrrfcre with ihc pCfi- 
siahic action of the howeU, It appcats also (hat nccasiojially the siftmiMd 
meso-colon an*l meso.iccium are shorter iban usual, fining the lower bowel, 
and perhaps more orlcssformint,'a kink ni its naiura) curves, where hordraed 
fivces may lodge and a temporary obslniciion take place. A fatal casck 
which seems to have been due to this cause, is recorded by Dr. Ettuftc« 
Smith, the patient being a boy of & years who died shortly aAer coming 
into hospiial. Whatever may be the cause, cases not infrequenily coow 
under observation where the child has suffcivd from conslipalion all its Wh, 
large accumulations of ficccs taking place in the colon which hav« to be n* 






' Ken larthn iTifiinnaiiDn Mr. Mutrhinson'i p»per in the J/^rf.-fiir. Tivm. 1(74 auf 
btrtfrimlTo. nlioHen, .4n4./ KiiUerktilt. R v. H. 9iinil 10: ib« Ultrr r«eord> tic 
rsecfrcriM ovl of twenty «u«« e41«jiMOIo«ny at ogvi lUixliig from 14 ibys to 14 yews. 



Chronic Obstrtiat^^f the B^avls 

Ktved by encmato, And where the bands, if left \a ihetnselves, only net once 
tuke a u cck. In tome of *uch c.iiei an cnoirnously dilaiett colon hat 
en found after dcnth with sup(>tf;ci.nl ukcr;icion of iis mucous mcinbinnc, 
' cauac nf such dilat^iiion bcmg liy no means clear, li must noi be for- 
gntten al»o thni a rhtonic iniusMincepiion may exist for many months, and 
giic Xit* to ihe »ympioms of chronic ol>*t ruction. A careful examination of 
Ihe abdomen should be |>raciised in nrder la ascen;iin ihe presence of a 
IIRKXif', and to determine if passible il.i n.ituie. whether due lo collections of 
baldened faxet, matting of the omentum and miL-siincs, as In chnmic peri- 
tOMlis, or to the presence of an invagiiiatcd bowel. An cxaininalion of ihc 
rectum shtnitd always be niailc. (See p. 1 27.) The po»il)iti<y of obstiticiion 
bcTiK due to pressure of an abscess or urawth in the peliis, at to the 
presence of a foici^n body in the bowel, must also be borne in mind. 

Tbc value of rectal examination was welt shown in a patient of Ur. 

Umliolm's, in it horn, with si^ns of pcritoniiis, no evidence at all concluiiivc 

CMid be found ni the locality of ilic mischief litl an e.iaminalion of Ihe 

nouai whde Ihe chdd was under chlorofonn was made. A nuss was then 

WtUHif up the pelvis on the right side, and a diagnosis of appendicular 

fcnionius, with the appendix hant{ing over the brim of the true pelvic, was 

utntd at. An incision as for ligature of [he c\Ienial iliac artery atlowcil 

tbc peritoneum to be turned forward, and the abscess was >viih some 

AAcully reached, and opened n-iihoul soiling' the genend cavity of the 

Itrntoeum, which must have been inevitably done if ihe abscess had been 

W)|hl by the usual route. The appendix was felt tyinji in (he abicess 

only. Tbc child was m,iking a good recovery at the lime of our goinj; to 



136 



Diseases of tht Vifffstive Systtm 



CHAPTER Vtn 

DISEASES OF THE DIGESriVE SYSTEM— (wBtfwwftf) 

Tnbttrealar VleerkUoii «r BMrel •ad MesBoteMe IMa«ka« 

In the majority of cases of childfcn liyinB of tubcrculnt liijcAw, tubcrcutof 
ukeii iirc present in the ime^lines, ^ml the rnctentcric j(lands nrc c-nUr|^ 
and 'cheesy' on section. Tliisassori.iiionof ulceration of the intestine* with 
cheesy mesenteric glnnds is so much the rule that it is im)i(>Mib1c to tepantc 
the two clinically, and Jt must also be remembered that analomicnlly the 
*olitary glands antl l'e)«r's jwitchcs nrc lymphatic structures. The frcquciKy 
with which ihesc lesions complicate phthisis or general tuberculosis it thom 
by the fact that in 103 consecutive fitisl-morttmt made ;ii the Crncial 
Hospital for Sick Children, Mancheitcr, on children of all agcf dying of 
tuberculosis '■> ^- there w.ik luhercnlar ulceration of the intestines, in 71 
cheesy mesenteric }.'''i"<l*> '" S5 '""*^ itlccrs and cheesy glands existed 
together, in 7 tubercular ulcere wiihoiii cheesy glands, in 16 chccsj- glands 
without ulcers. These numl>crs,as far as the frequency of lube milar ulcera- 
tion is concerned, do not ovcrUalc the fact, as it is fcit more likely that lh« 
presence of ulcers in the irtrslines. especially if they are sm»ll, should 
be overlooked, than their frctiuency overraied. These statistics also show 
the frequent assnriaiinn of ulceration of the inlcMincs and disease of iht 
mesenteric glands, though this associ.ilion is not constant, and one may 
be found ncravionalty without the Other. Ulceration may exist without the 
mesenteric gl.inds joining in the process, but there is a strong probability, 
amnuniing .-ilinosi in ccnainiy.iliHt if extensive ulceration be present iheglands 
will be found to lie affected. On the other hand, it is certain that ulcera- 
tion is D0I the ncccss-drypiecurt>or of uiescnieric disease; for just as a chronic 
catarrh of the nasal mucous mem'brane ntay in an unbcatih)' subject s«t up 
glHndiilar cnlargemen! and absceis, »o a catarrh of the intestine, if lotig coa- 
liiiucd, is exceedingly apt 10 give rise to mesenteric disease. Allliougb 
mesenteric dise.ise is so commonly found in childtcn Uj-ing with a iride> 
spread disiHbuiioD of tubercle, it is by no means lo common 10 fmd tuber- 
cular disease beginning with s^niptoms of Labei me^enierica.as iscomraooly 
bclie^'ed, for in practice it is constantly found that infants aud children who 
have lubiluAlly di.iiendcd abdomens, with more or less watting, are put down 
as suffering from 'consumption of bowels.' In the greater number of these 
c;iies there is no mesenteric disease, but a chronic and obstinate catarrh of 
the intestines which it perfectly remediable. Ilesides the verj' frequent 



ercular Uletmtion ot 



fntvt 



^37 



hnciAtion of ulccralioi) and mrsenicric diieasc, chronic luberculni perito- 

Infants ami f hildrtn «f al) ages suffer from tuberciilonii of the in(cKiin«« 

Md (laivdc, but it is pcihaj)') leas tomnion before the .igc of one je.ir than 

ihcTwardt. Th« nommon cause of marasmus in infatiis la a gastro-inieMinal 

inophT rnlbcf llun tubercular (lif^ase, such inf.ims succumbing Iwforc ihc 

Utanalar prmess is ici up, though in some c::ises ehccsy gUnds mjy be 

Innd (t has iusi been noied ilmt in at Iciisi ?o per ceni. of cases dying of 

fAttCslMis, disease of the mcienleric glands nas present, and in ralhcr 

nmlhaa 55 per cent tuHertiJar iilcemlion was assorialed with it ; Jl i* ol 

WW inHmi and importance to inquire in how many of ihesc caiet wa« ihe 

lAnnilmis of ibe intestine and j;landt primary, and the tubcrrular letion* 

dmhtre secondary : and in bow many instam-'Ci the tubercular ditCAsc licgan 

*nk)bdMninal symptoms. A primar>' tuberrulosis of the intestine is sug- 

psmt ct tnfectinn by mean* of tubercular bacilli taken in food, as, for 

•Muce, ia the mother's milk or that of a footer ntirte, «r the milk from a 

mWihiIous cow. Direct experiments In feeding young animals with iiiber- 

rthw tnaiCTial, or milk from consumptive cows, have demonstniicd ihe 

p"i«ltliiyof a direct infciriion taking place, though ihcic have been many 

frnuntus with negative results. 

Ot the 103 fatal cases of lubci-rulosis referred to abovR, in 13 or about 
llpfceot. the rariy symi>i>iins were referable to the abdomen ; in a few of 
ikeasei, «\-mptoms of lung mischief were absent during life, and the luogs 
"m fminil free from tubercle, or only slightly affected ; in the majority of 
'imthephytiral signt and symptoms pointed during life 10 lung compli- 
"iliOQs, •hidi supervened sooner or later, and at the po^l-taorum more or 
iHieiefisire pulnionar\' lesions n-ere found, though in some instance* these 
"^ ippureil during the last few Hceks or months of life. Tubercular 
•'"ClaremoM fie(|uently found in the ileum, and in the large bowel, eupcci - 
■%bibene<rutiL In rhroi>rc rases they may he very cxrcnsivc, with much 
^Wn{ together of different coils of intestine and of the omentum by peri- 
txeit The walls of the rw-cum are often much thickened. TTie ulcers, if 
■entire sharply jiunched out ; if chronic, their edgei are thickened and 
npbr, ma«tly running across the gut- The mesonteric glands when 
''■CM ar« enlarged and cheesy ; sometimes a few, at other times near])- all 
'^llinils w«m to have undergone cheesy changes ; occasionally lupiiura- 
*«!»fc» place. The ukcrs may ciraltisc, .ind by puckering the gui give 
^KiomeobsinKtion to the passage of the intestinal contents, especially 
•*tUrgcbo«'cl or al the cj:cum. 

Sjrmftami. — If a child of over two years of age suffers from a chronic 
'*«>«» of the bowels. V illi wasting and hectic, there is a strong probabililjr 
^ ii wffers from abdominal ttibcrculosis. This probability passes more or 
'■'laoacertaitny if it cooies of a tiibenular stock and presents the usual 
•^itiiUr aspect, such as marked pallor, long curved eyelashes, and excessive 
l*rtli of fine itouny haii upon the skin, Tlic abdomen is usually more or 
"' distended «'iih gjs. the superficial veins arc cnlaiged, there may be 
("taiteta on deep pressure, and perhaps some thickening may be felt over 
'^ ixcuas, or some mulling of the omentum. The syinploms are often 
*Md af rordinit as ulceration of the bowels, mcMiflcric disease, t>r chroiuc 



'38 



Distasfs of the Di^tstive Systeiti 



pcrilonitb is extm>ivel}- present. In most utscs of lubccculai ulcentica 
lliere is iroubJMoiTie Uianhtca, though it mutt be borae in mind thai lhi> 
(liurrbcca in many nuct complL-tcly stops fur u while, or, indeed, may be 
absent from (ir»l to last. There is no special lecture about the di.irrhusi of 
lubetcular disease ; there is a i;i^"ci' tendcnc)' ii> looseness, and cotic maj 
coine on after errors in diet, or dirc<:tly nflci food is tiiken, or may appear lu 
be ibe result of cold. The sionls nre mostly tiljii id ;ind brown or yellow wtib 
an excessive quantity of tniiciis and perhaps streaks of blood, but too nintb 
ilre»s must not be laid upon the character of the ^lools. The ton|,'ve ii 
usually clean and red, with enlarged and congcMcd runKirortn papillae. El it 
of course necessary to carefully cx.imiiK- the luni[> in all such case*, as anir 
confiiTuatory evidence of tubcrcii[osi<i there would be of ureat importaiioe 
from a diaj^ostx: point of ticiv. The course of such case* is often chrtmic, 
and Ihey often grcaity improvi- for a while, prohahly on account of the imet- 
linal catarrh which is present unctcr)(oinK improvenicm, or the alcert nujr 
slowly ci<;atriM and heal. On the other hand, there is a constant risk of n 
tubercular nieninjfilis supcrvcniii);, or loine acute lunt; trouble cnrryinK lbc«k 
off. iiooncr or Uicr, however, ihc diarrhica, uastiafi, and hectic reappear, 
the child becomes mote and more pallid, the abdomen more di t tended, ilic 
feel swollen, and the fare pufly. The diarrhiva at the last U often conslanta 
aiul the desire to ^o to sinoi, only a lilllc mucus or liquid faxes pas)Mp< 
is very ditticssing and not easily relieved. The emnrialion at the laM ti 
often extreme. When symptoms of ahdomin.il luberculoiis follow on tbra< 
<3j:lironic tuberculosis of the lungs, the diagnosis is not difikull, and a omtc 
rapid course may be predicted, \\hen the niherculosis of the intestine 
is primatj' and uncomplicLtcd with other trouble, the course may be t'cry 
chronic, extending over several years, iniprovcmeni taking place from lim 
to timc- 

In rare cases sevcrehKinorthagcs may occur from lul>erculartilcentioac 
the intestines. This lakes pbcc, as would naturally be expected, in th 
acute raiher than in llic chronic cases, as in the laic cases thickening .ic» 
cicatrisation takes place. We have knotm fal.tl h.t;morrha)(c from ibe boat 
10 laJte place from a tul>ercular ulcer of the ileum. 

In the following case there nas severe h.rmatemesis, and some dark bk«" 
was alM passed by stool. The ci^c u.is puxiling, as at the liinc th' 
voitiitiitg of blood took place there was nothing in the lungs or abdom 
to suggest tuberculosis. 

Armtt TtOtrfulMii ;' Viitn im tin /tjvmim i Sntrt MnauwawnCn.— WflUan T. 

Ik ita*. ilaassintnt. ,i1«n)taiiroi>|Elioytllliifoniiis)il iietwv bl* Mkidai 



■a )«its. 

■h(n hp cumplninal iliM he mis Inine in his nelii leg , boib kons w<*e pahiM i 
swnlloi. lUmiilctl June iS. lip wu n uvU-tiDUti^ed lioy : «ll thecrx^nt •ror*i 
tiiiappallWwmstHKl ; tlwr* <>■> nu dumliua. The nfliiknecwusBoUeii; Ihcreinal 
tutpii'ion of e«)lj liip dlseuc dd Ibc nf;lil s'lV. TIil- cienioii tnnpmUUn roKbM lOa*! 
Ibf c«iiiii(: Ipnipoislutr i-iinimurd rai'cil a ili-Km-or Iwofoi afMnlnys. ond ibcn I 
ni.rniiil, Hr tomplMliicd for llie nut week or tuool Kital pain in hit knen, On )i(l)r tl. 
»fiet bdi^ng had n Rnod 'liniirr. he sinliicnb •■-miinl kquuility 'rf hrigbl hloort u.th tirft 
Hoi>. nnd quickly txt-jiui^ lilinchixl , Itn'ji- duiing llie <lny he again vcmilnl <luk bl oaJ. 
Hktt om some lendetneu And Trvitinc* roi tin' li-ll li>1r of tlie nbdomen. jus) IkIi 
rib». He rriiaiiml (atcly ndl IIU July tS. when he again vomlied somekulf-pinl o(l 
an<t niucBi: there meretarxequtnuiies of diirliUowtiiib»ttou1>. July jl.— Hehoii 



Tultfrcular Ulctraltaa of HoXLtl 



'39 



•I' i>.> f.-a Hicki : thn* -a ea ixnigh m ibanlia?*. Vrtsra Ihi* ibtle ISI bil dcMli 
... luxiir. i.u}liig liom itio'' lo KiJ' : rAlei w<rc hcud U hu Icnci. 
I \:d, Lind II vjnevkli-ni ho in-.ut «ufri.'ijng fruni jciile luVcrvutotiL He 
tNCttnr •umiirij oiUKtUcd ; IbcTF <iii:rc no fnorr bxRioTTtiogis. Ite WKT 
! frDm a»j iliinhirfl. I>Btlh OKvnni Srplriii'rt i-. Ai (lie fail-marlim. bMb 
Flap vnr MtxIdFil •i(h clatwrt at lobcrcto. tie«>ai<nt( cj««iiii ni itir right •p« : ibe 
igladi ■ci«c«iTOUi. Tbe uomach rai bcallhy -, ihe mncntcnc Klnnds u«ra 
, bm no) uiivoui ^ tborc lasra tome lit)!f, ifccnl, i.hiiTp1f cut liitcrcaUi ulcm la 
[.|bMikltto(l>ieiqunu0i. unI nimtniat olhcn in the itrumand liugc bcnid. Hiliuy 
>aa ihc >p4m M»d bivr. Eairtr lubrrculiu hip itiwuc. 



In ihoM ca»cs nlwrc llie mcM-ntciic KUnris nrc chiefly affcclcil the 

^ifiifMms aK siill IcH dclinitc, iKnii^h this, a& has been poiiiicd out, U nM 

itlwcasci as vmytng drgrcn nf lubcriiular ulccraiioii of the iniestincs 

t chronic cii:«tti«in); fciiionjtift ari: apt lo be prciicni. The symptoms nrc 

FauaOy those oTchroiik imcstinul CiitaiTli. perhaps without marked diarrhuca, 

1 nk*'astiiig atid hectic. It must lie remembered that a distended iibdnmcn 

I ^icb is chionically in this condition, nith suine wtt»iing and an cvcniog 

trbation of tempetatutc. does not neceasaiily iiiCAn mesenteric discawv 

r mole ihan the sigits of a chronic pocunioiiia arc necessarily <o be inicr- 

. u tbe signs of lubeicle ; h« only infer in both cases that tuber- 

I'Bfaii custs if ve ^ei conlitiiiaioiy evidence elsewhere. A history of 

1 lokatlc in the family, the steady proufess of the disease, wasiiog, great 

Ipbt Mnd liectk, Kould help the diagnosis. The suppoied lai^e glaiKls 

iMd be caicfiilly feh for, taking oav not lo mistake farces in the Ur^'c 

'bador indtir.iiionsof the meieniciy or c»xuin for unlai^ed glands. The 

I iipis tbould lie laid on the abdomen below the umbilicus and pushed well 

I ii, and gently mu^ed about ; the mescnictic glands lie deeply, can ratdy lie 

iKOCIIy fell, they are movable, and of siie varying from hiuel nut* to 

■alnUL If ibc abdomen n distended with );.ix, even large groups of jilaiids 

mrttiU, and yet not be fell. An early diaj^oiit is rarely possible by dis- 

ro»fty of cnkir^i-d j;lanil» : it i» only tou'at<ls the close thai they can usually 

'< , iiiien ilie tontts of the abdominal inu«rlcs is diminished and the 

lines nioic or less colUpHd. 

!':.igne}is.-~.\ child with a icmperature raised a few degrees at nighl, 
^•- DMended abdomen, chronic dianhaa, which resists rreatmcni, and 
ta pruduccd wasiinK and marked pallor, is probably the subject of 
(i*ttc«lir ulreration of the inie-siincs. If, M the s.tnie time, local indura- 
■msuoIk: felt m the region of the csrcun* or in other places, or if ihprcarc 
*r»s <i\ tubercular diiease in ih<T hings, the diagnosis becomes still more 
Fnlablc. Moreoi-er, the diarTh<i-a probably persists i[i spile of liquid diet. 
i ID bed, and astrinccni^ and i* only tcmporaiily kept in check by opium- 
Inoiteric diteaic i* much more fre<|i.ientiy diagnuied than discovered /OJ/ 
A pioBrciiivc a.-ntingdue lo chronic lnIe^Ilnal catarrh or gastro- 
nical almphy i« frc<|ucntly .wribuicd to caseous degeneration of the 
imic ftl.inds, and a fatal icmVmation is looketl upon as mevilnble. It 
_ r wdl. hnwever, to l>car in mirtd ilui mesenteric disease is uncommon before 
tigbifr or two jears of age, and. moremcr, great n-asting may be 

6»tlr, rjtanh without mesenteric dise.ue. Ii is bul seldom that 

'^■Keil glandi can be fell ; the diagnosis mainly deperids upon the signs of 




140 



DisfusfS of tfu Digesthv Systfm 



tubercle chewbcrc in ihc Iwdy and upon ilic family hUlory. If (hen liH bem 
iiiocb (lianhn'.T "ilh hectic, nnd symploins of iiluonic peri ton i[ if, fnllowtd 
by extreme watting, there is good rc^si>n to suf^pcct ntcscnieric ditcaM> 

Treatirifat.—'r\K treatment of mbcrcular ukeiailon «nd mesenteric 
disrate Ik xhc ire^inicnt of tubeirtilosis in general. Fresh air ;)nd cirafuj 
diGtinfi arc nll-iinpnriarit. The specinl ircaiinenl consists in kre|>in); ihc 
■dinrr)i<ca in client, ivhilc iiotirishing food ensy of assimilaiion i- Iwing sap- 
plied 111 ihe patient. The class of foods must he selected from tI«MC uhwh 
contain murh nutriment in llitlc bulk, %uch as ci;gs B^b, meat, fnit, milk, 
rather ihiui foodi coatnininj; lar^-e quanlities <if surch and HiKar. If there 
is but Utile diarrhii::), milk may be allowed in modctnte (|Uimtities, but ilie 
amount taken mu^t not be cxc<-ui\'e if much looseness of the bourdx cxht«, 
as too much fluid taken n apt toag^ravaie the diarrluca. In nil mages of the 
diiease minced underdone meat, uhcihcr rhi<-ken. beef, or mutton chop, is 
of great value. The child's portion iiuy be taken from red juicy meat 
found cli»e to the bone in a large joint c^ roast beef. It ^hould be finely 
minced, cut as fine as it is jmsiible to cut it, and gtnvr jioured over 
it before it ii. I.ikcn. Of this, large (|uantilics will be taken re.idily by Ihe 
children, some crumbs of stale bread being given with il ; Init c^en small 
4(uaniities of starch are apt to disagree and jjive rise to Aatulcncc. .An eg^ 
or part of an egg beaten up in milk may be given ontc or twice a day. The 
dinirhcca is be»i kept in check by careful dieting, avoidance of more fooA 
than the child can digest, and if excessive, the food for a while must ccnsilC 
almost enlircly of pounded underdone meat or meat juice. Small do*CS cC 
opinm combined iviih merrurj- and chalk maybe given. I'F. 20, !i.) 

In the later stages small encmata of laudanum and starch may he r^- 
<iutted, but too often the diarrhii-a is quite uncontnillalile. Opium AitDeMa— 
lions are useful. If the diarrhcca is due to the pretence of indigesliblefDod^ 
laxatives such as a powder containing rhubarb and loda should be given^ 
Cod'liver oil, either as an emulsion or in combination with oiher tonics, i» 
useful in all siagca except when the diarrhica i» excessive. (F. 33.) 

C*BKeBltal Obainieilaa or Uio Bawal*.- It is not an uncommon cir- 
cumstance for a newly bom infant to sufTer from complete oltstruclian 
the bowels ; passing no meconium, though the rectum may be normal, an<t 
shortly iifter being put to the breati ii may vomit, lirsi milk, then faUe^ 
and finally meconium. In the meantime the abdomen becomes dis- 
tended, the face pinched, and the infant dies in a few hours, w perfaap* 
linger* for a few days. At the f-oil-mfrUm various obstructive lesions may 
lie found. I'hcre may be a stenosis of the duodenum, jejunum, or more 
frequently the ileum, the gut perhaps being narrowed or even reduced to a 
n)ere band of fibioid tissue nhich (\ms along the free c<lge of tlte mesentery 
fur perhaps »eieral indies, and opens out ayain into rionnal Ixm-el kn«r 
down ; this cicatrisation of a portion ofliowel may have been produced bya 
f'lrul peritonitis, or it is Ihc result of a ma]-di^velopmenL In the followifi); 
<a»e it was apparently Ihe latter : 

C—ginital 0^iltut.'n r/itu Vif^rni-m IIV. T. 0. <it>mta.\ie\ ouei— Itw MMMt 
w*i a hcanby HiCimAn BhohMl had fiiv ehililrm pievionily. Tlir linl vu »tiBborn: lb* 
four Mlim nil Hiffcrcil from ii^nipMiiis of olMruciiMi and died od Ibc third day ailir 
Unk 'I1ie kliili child appniml hmhhy ontl vail nourithnJ at bitih, am) (at Ihr lirs> tm 



Obstruction of the Baveli^^^ 141 

iut vrall- Vi» Ihr IntI (no tiayt ti mu a pKuliar coknii— a tort of Qnui|{i? 
ptfpU ilnL li oA))' vamlifil onw ilionly before duilh ; ti w.is <oniu1i»J before dtaih. 
Al ibe kulofM^ Ibf il->ni.icli m\'\ vpi«rr t»r1 of 1>>0 diiixlciiurii wen iliiU-niktl hIiIi Hurd ; 
UwitaodcMisi nu louB>t la tamiiiAtc In i cal'dc-vic .-ibouc iwo mclin fn>m ibc pylons. 
llienatoT Uir inlcHinra HTT'' well faiinnl itiouEli iiiiull ; itic Liilc iltui (>|iL'noct into Cbv 
toatamu bdon the olHtrucijun. 

Tnihc folkmini; ftiii^ulni cjisc there nvis an obstiuction of thcjcjunuai, 
ptt«uirial>4)' due to .1 fci:ul jiciiionitis and possibly some chronic inAamma- 
iDiv ksioits a/tci bitili : 

O^gmiUI OMrMliim .</ t»t /t^tin; Dilated Slamaii amf DueJtmum.—Vt. H.. 

■CEdi} tnu*, Hrn u-llk Mr. i.\ R. Giaham, ofWiunn. His m^nhn' urvt llw following 

hOBT^ III- «di nuntd nl the biotti for tome niomlit. and cluniig lhi> linie he wu wb- 

IKI W pawdial .altAckt of Umr voinitinB • (hcM alUckt urri- much mnrr M^irrlhaB 

■iMt m* wuny nbjecl 10. The vomiting began Immediately after birth i ibe vomited 

uuoiMMtMDd of curd »nd bile. Thnp altadiB of vomitini; hnvt occurtml .11 inlnvil* 

•ifmktit Iwo nU hit life. Un more Ihui coc occatloa Ihn nllnvlii liatv lioen toieverc 

Mt ksf tuatiiiued thai bh lifs wns il^-ipiirMl of. He hu raniiicd m much ai tix to 

Oftt |<BM la a<M nigbu He Kent, on one oceiuli>n, n voyngc to the MtiiiiermnDin. Iiut 

Ul«t(lifi(kd oo (he lint nppnriunity, oi ihir canitiinl vomrling hnd mi I'lh.-iiiited him 

AilWUkinu In dneget. Soinctliim lir ■>i>ul<l tuSci fmm ixAic andnniite* htil did not 

■Mt bron of diet, ncilcmcni. or uorry. all inrniod lo ncile an .-iicock. A physicnl 

dMlUMn ihowcd A illlftled tliRniub . the uUliimen wi* Mio more or let* illMmdol. 

tWi)W(>uMH and phyikal evunmaiion pointed 10 n dilnlcd itomach, moddnry to ronio 

OfaUil obiimrtioM in the up|icf |i;irt of lllc iKiwel* T)ii: luiiiiiiiiK nlEHck-t coallnunl 

'Wa[ itiF nml four ymi. uji lo ihc time of hit death, when he was nineteen yenn old. 

K'r «• n^Ucd for deUilh of bi« hat illncM 10 Dr. Sulcliff^. uF )<Ttev , whrrt.- he died. 

U)i^Hi) in lui utunl hfjith oo December 6, 1 890, nttd )oine(l In a game of fooihall. 

tVnoK cveniog h« tuil fttc of M» uiual lomiting .itt.ivLt. which tvAt mon: wvere 

teskil. and r>r. iiiilcliife vilIs lent lot. When teen on Uc«tiiber 8. he wiu ciidenlly 

^AvlMtlFewi acnle olrtirtLC-tion of Ehv tKim^lt : ihe vomiimc *'^* eoniin»ou>. :if^i.1 nothing 

*<tpVA(d pel mtijRi, 'Ilirre «4s LDicnsc colUiptc, Denth took piji4:fr nn ihe lounh dajr 

f* W a»a^ Pu-tl-mori/n iMnde by Mr, r.rAhiiin nnd ourtelvn ; "Ilic b^nly w.i» Ihul of 

• mSc.." i.tt linn ynuth. On opming the ibdomen the inioll inimlnci were «en 10 

'**'' i.-il -iinl .if a d.irii purple vrloiir . Ihcr^ «Ti?«nnirlymp)i fti thi' wrfiicr ; 

*!*■ ■' ■■ tlie pTTlioneujiiniii much injecleil, Ph- wliuU- 1>( die niniill micillnw 

••f n«te«itit timiicnUird. thrfi" brini: a niiiiplclc iDlvulUi : Ihe Inil fool or 10 of lb-- 

•^maaiuvl iwooi thm iiine> tnund ^bl^ iij>iicr 11,1 il ol ilic jcjunuin, tlic l.iiiei lieing 

~ " Oi stctf. M that Ihr jrjiinutn. metenleiy. and l^lood'ieuels wire imnEulnteil ; the 

■udracged uimiudk oul I'f lii> |ibcr. The iiiiinediitlc tium o[ dmih wai the 

k prolAl>1\ the reintt of Hiere lomiiiDg. A fiutbrr cMimin.-ition ihoHed Ihe cause 

■ ■fctvnii f»£ atucfcs. TVn" ^li^niAch and iluixirruun vtvrt inimen^plj dLl.iiril And hyjiei- 

L^WW. Ite iluiHireiitn loriliini; like a tetond ilonucb : ax ihe Junciion of ihe dtmdeniim 

^^^^■t)e|iuwiin. the cut <■■» Inund doun unA tairoilnijnj by Hlin^iiJ ;i<llir>uiiiiL fi>r h-nie 

j^^^Boh anil one spot wa> coniraclcd so sa only to admit the foniflngcr. 'Ihe fibniiil 

*D^ iwre pfoxinrjlily (hvmuli of tome inllamiDaloiy ktion taking pUc« bvforv bitth. 

In a few luiKs a to iM in the lowci enil of ihe ileum hji« been found. In 
■M iuUnce^ il nen (.-lotiih or hctnia ha§ uccuricd, or a knuckle of bnwcl 
bt brcn fdunilikd up by tome band or |)CTsi«(eni omphalO'tne«enlcric duel. 

Ob«truciion of the bowcU in infants a few weeks or months old may be 
■btton cntiKRniLil lesion which has caused a [lartial obstiuction, which \% 
wdtrcd cnmpleic by Ihe impaction of hard cuidy feculent matters. 

In aI) ixttn of votniiing u iih »igns of ob»iruclinn of the IwwcU, a care- 
McmnlnniKMt i>f the axim and tectum should be made. 



142 DisMses of the Digestive System " 

iiap«rrar«t« Anna. — The low^r icemen I of ihcUrtrc int«Minc, incliidiay 
lite tijcmoiil flexure and rectum, n very U.ible in imporc.-tnt malfnnn.-iiiiint. 

In Ibc 6nt place ibere m^y be mere in«lp(i«[loii, the aiijnvniit i^cxurc dc- 
McendinK on ibe rij^hi side or in the middle line inicead nf (>n ilie left : thit 
miuld not neceiiarily ^nt rite to any inconvenience during heatlh, uid 
would be mainly of importance should there be any diMase oT tbe l>oirel in 
laier tife. 

The more immediaiely important conditions are the vnriout fornu irf 
obtlruction of the lower bowel from want of development of »on»c part of it, 
or the presence of abnormal openings from imperfect differentiation of the 
digeilive and genito-urinary segments of the clonca. 

Se^ erjl vaiictie* of malfortnaiion :ire found. There may be a vreU-fotmed 
nnus, but communicalien beiwecn thii and the rectum may be cut olT by (he 
presence merely of a membmnc whith bas pcrMsicd from tlie lime wfhen the 
epiblastic invuKition dipped in to meet the intestine. {/mper/onUt re<tHm.) 
Somclime* ihe rectum itself Ih dcriticni altogether or for a varying d>»ut»ce. 
the anus also being undeveloped. In other instance) the retium i» well 
fonned, but ibc anus is absent. { im^frJoraU irowj.) In these varieties ihUB 
i* no exiernal opening at all, and the meconium is rewincd. Soinctt 
the anus is undeveloped, and the rectum, in>tead of ending blindly, i 
into the anterior i>r gcniio-uiinary segiiii-nt. i.e. into the urcthrti or bUdder, 
or, much more commonly in the femHic, into the vesiitiule, not into the 
vagina, as is commonly stated : ihe vngiiia! orifice in these caws is nearly 
nlwaj'i in our expciiencc seen in front of the rcctHt outlet. We luive only 
once met nith a case of the recumi o|iening into the v.igina itself ; ibis wu 
in a child kindly sent us by Dr. CutlingHonh, who thinks it is not kb 
uncommon condition. Bodenhanier, out of 3S7 cases, found 85 opening 
into the vulva or urinary tract, while in 53 there was no anus and the lecitini 
ended blindly ; thc<e arc the tivo most common types. 

Occasionally n ' tahlihc fold of skin ' passing Irmn the scrotum to the 
coccyx obstnicts Inn docs not close tbe anti» (Crippt). Edgehns recotdcda 
more complete case where the anus was double and the rectum imperftmusi 
\Vc have mci with a c;isc where a sin|;Ie anus led up to a double gtit abovv. 
Rarely there is an unnatural anus in the groin or in communication with the 
bladder, or, as in a case nf Krichscn's, a fistula below the umbilicus ; scrotal, 
penile, and perineal fistula.- have also been tnet with as u-cll as con};eniul 
stiictutcof the rectum which was not actually itnpcrforate. lA'ide I'rolafism 
/hi ft.) As a less import nnt condition mere ii),'htnessofiheantistiMyalsaoccur, 

When the anus is present, but there is no communiration with the bo«d. 
the malformation is often overlooked at firet. and it is thoUKhi th.it the infant i« 
limply conitip.-ii«d : in such rn»c» purjtaiivcs are often givin and the child:'K 
distress much increased. Constant crying, distension of the abdomen with 
visible intcMinal coils, and subsetiuently vomiiinn and collapse conw on, anil 
unless an examination with ihclinKcr is made and Ihe obstruction discovered 
Ibe child diet exhausted. On cvuninaiion ii will be found that the Anger 
can only be paiMd a very thort distance ; if the rectimi is developed and 
there is only a membranous jcptum, the bulging nf the gut as the child 
strains u*ill be plainly felt, hut should the bowel end higher up ibU sensation 
may not be distinguishable. 



Imperforate Anus 



"43 



w anaf n abteni :in<l the rFctumemN juit ubove ii. ii» accordinn 
tripp* it uiually docs, the bultnng will iifieti be rr.i<!Hy made «iii, Ijiii if 
e Tectum ends hi)tbci up there may be no itnpuUc ; in »uch casei the peri- 
um is narrmi- and the t'ctvic outlet tni.iller ihiin it ahould be. \^'licn 
ere \s no anu* thi- miuin is x^^^*^'")* nc-ir^r the surface than nhrn an 
Id* \i ilevi-toped, but the tccttun ends blindly. 

Where the rectum endi high up in the pelvia, a (ibr»ui cnrd may be 
Uton^cd dow-nwanU in the pci&iiinn of the natur.il bowel ; this conl was 
bonirht by .Mr. Cuilint; to represent (he iccttiin obliterated by intnt-ui trine 
iloentioD ; in presence, howt*-er. is not comlant,' 

When ihe reciom cndi in ihc utcihra there it piissane or fluid fircet and 

ItM by the urethra, logclhcr wiih absence "f the natuml oriSce. Svibsc- 

i|tait1y, it the child lurvives, there is much itoiilile from obiiruciion of the 

wrthra by fjfdl maitur and from irritiition ict uji by the iltcmipo^td urines 

Kduy* points out that if the opening is into tlK" bladtlcr the mecimium is 

jUnd with the unne, while if il is urethral tlie bowel i:oiUent> may cicape 

lendentlyrf the urine. When the rectal outlet is within the vestibule the 

tit may be sufficiently ri-lieveil for the deformity to escape notice, and 

Kybe no impairment of heiilih: indeed, the presence of such malforma- 

> remain unknown until adviU life. lo many cases, however, ihoUKh 

lb«p(nit»K i> sufikicnt for the escape of the fluid or ioft fieces of child- 

Vwd-it is DM large enough to allow the pJissRge of solid motions, and 

ibnnKtioQ arises later on. lliere is no incontinence of 6eces in these 

[be iiticrnal sphincter preventing involuntary escape. 

f Aiin so Ri-iny other congenital mnl formations, a large number of chil- 

> tie Mbjcct of these defonniiies do not survive birth. Where, however, 

»Uttg child is firand to have no outlet at all for its intestinal contents. 

I ■nwdiate treatment is of coarse neecss.ir)'. although it is said that patients 

i W frown up and relieved the bowels by periodical vomiting of fj.-ccs. 

! A«t09o then as the deforniiiy is recognised, a decision must be come to as 

I H «hii is the best mude of relief. 

j TmitaKM/.— When .1 thin septum alone closes the gut a simple crucial 
I >«ciMa, using a speculum if necessary, and subsettuent dilatation with a 
^lieot the finger, is ;i]l that is reiiuircil. The child, if it survives, may in 
I it^yiitlfcr .iftcru-ards, though nc h.ivc seen a case of a girl of looriz 
I TtMsUwhobnd been operated on )n inf;incy and had not got perfect 
' <wi«low:r the Iwwcis, 

Wfcere the separation Ijctwcen the rectum .tnd the surface is griMier, 
^^■■K of ibedistended gut should be carefully felt for and an incision made 
^•i imox of the coccyx and carried down to the buivel, which should then 
^h«tly opened and brought down and stitched to the skin, unless there a 
■ gneu inision that the stitches are not likely to hold, in which case ibe 
Jigl'ig should be packed with gauu 10 keep it patent, or a lance drainage 
BtuMcried. 

''K no bulginf! car lie felt, an attempt to rcnch the bowel should still be 
iMdebya limibr incision, and the dissection should be carefully carried up- 
*tnli, keeping well back in the hollow of the sacrum and feeling from lime to 



I'oir faika. PM. Sm. Tnmi. lO^. 



' ilnJkhti I// PaJMn\i. 



144 



Diseasfs of the Digestitt System 



limo fnr the liowcl. As it is most inipoilant ih.tt tlie child if 
chlorofnmi should only be given durinj; tlie firrt siep* of the 
and foriiinntcly thi> is tlic nicst painful purt of it. With u similar 
It has Ixrcn ndviied to dcUy operation until the lionclt arc iiaXt 
\i the gut is found, it should be treated as in other casci, or if it 
readily be brnu^ht dmvn, it must be left but kepi pnteni in a tia 
way, nr ii lube ni;iy be kept in throuiili which fa-cea c;in ya%%. An 
and Vemeuil rciucied ihc coccyx and lower part of the MicTum in 
bring ihe gut lo ilic surface, 

Should it be impiiiNiblc to reach the b«uel from below by i 
which may be cariicd to a dtpth of an inch and a lulf. rn no ca»e 
.-uiy blind puncturing' wiih a irucar in hujwi of finding Ihe gut be «mptin«d 
by such Ricfins ihctc ii much more likctihoud of puncturinj- the periionwr 
especially a& it tisually descends lower than in normal ;inaiuniy. EiiJ 
Ul ire' i operation of opening- thebowtl in the groin or AniuMal'» (Calliua'i 
tumbai operation must be pc-rfoiined. As there is some uncertainij' 
xtl these utuii as i« the cuurtic uf the bowel, and as in a crriain prop 
the colon lieain the middle line or to Ihe ridhl side.it is niscr on the whole toi' 
Littre's operation. The danycr of oin-ning the pcnioneum is not so unei|u 
in ibe two plans as mit;bt be itiuu^bt, »ince there is ofleo a niucn 
in iheie ciise^ and the anus is much more cunvmientlr placed 
sclfmanaKCHient in after life ; there is lilile choice in the mailer oft 
belwecnihetuc. Lit tics ope ration then should be selected. The oper 
cDnsi>is in making a venical or oblique incision about two inchei in 1 
in the left groin above and a little external lo ihe middle of IVju 
ligament ; a vcrlicul incision is probably iJic bcn, since, if ihc «g 
flexure doo cross to [he right, a blight upward prolongation of the indlH 
will enable llie surgeon to reach it. The abdominal "'.til hnviriK been ra.< 
through and ihe peritoneum opened, the distended bowel will prcseni at diC 
opening and should be picked up « ith forceps, and treated as in ihc oidin 
<M>lotaniy operation,' If tlie child can bear ihe delay in openinj; the bo" 
the operation should be done in Iwu stages as in gastroslomy ; to AV 
leuk.ige Crtpps suggesii the use of a coarse thread in xiitching the gut (Oil 
edge of the wound : the use of a round sewing needle antwcrt bciici. 

Edmund Uwen bas six times performed I.itlre's operation, tu ic« sikccu- | 
fully : three of his casu died from the operation being too hte. pcriionibt-^ 
Gxisiing at the lime. In two of the instances in which we hat c done inguinil I 
colotomy the result was perfetllys;ilisfailory ; thtf children g«i quite wcll,bBt'l 
one died some months after of bronchitis. It ha* been suggcMcd tliat i 
opening the sigmoid flexure in the groin, a probe should br pas^«d donit-l 
w^rds and an anus made in tlie natural position wiili ihc ^~id«nce of ' 
probe. Onx'n's two successful cases of Littre's operation died after 
perfonnance of this second operation, but Ityrd and KronI«n have 
successful.' 

Curling's siaiistics and opinion are much in t-ivour of the inguinal! 
operation ; Ciipps' liguies are incoodasivc.' Huguicrt npcraiiofl of ojKnii 

' Fcf 3. (icKnpIlon of Uk operation itc nuni irfrr to the fienml ten-boold. 

* Vidt Kelicy. Ank. qi* pitJiurui. Fdanmy i8Sj : tXta GoMr vidt CripTS. 

* I'idi alto Krcfcclcn. An*. /. /C/in. CAir., Langenbcck, 1879. 



Imftr/orote Anus 



'45 



(le (U in the right groin on ibc K>'^<>d of the more frei)uenl ptuiiion i>f the 
aim m the rijjhl sidt than ihe k-fl is not »upparl(.-d by Ciraldit slatiilin, 
epMA by Hotmcs, wh«ic in j j i auiopaici ihc colon uiu in its normal posiiion 
is ^iMiaace^ ; in eighty o^ ihcM Uiue's upeniion hud bet^n performed. 
Mid iae>«rycaj« the sqrmoid flexure WU4 on ihc left wde. Alkin.iif Sheffield, 
Kcwdtacase in which (he sinvU iiitesiine nas upcDird by ihf in);uinul ope- 
cario*, cbe whole colon beioj; nidiineniary ;' and our tollcague. Mr. Whilc- 
IrmI,hS>bs he operated in the left loin on one occasion and found at the 
fnt-mtrttm that the C)L-<:uni had been opened.' 

We h^t opened a coit of lanjc inteilinc by tight inguinal colotomy in 
in idiih, and found that it uai the sigmoid flexure and not the ascending 
«liu thw had been iccuied. 

Cnppi' tabte gives the follon-ing results : 



Of l6 caKS of in)n>'<^ colotomy 



died 



3 „ !uml»»r „ 2 

17 „ puncture n 

8 „ rejection of the coccyx ... 5 
39 „ pcnncal indtion .... 14 

14 „ (ipcraiiun for vagin&l (i.e. vulvar) ani» 1 

3 mttcellaneaus cases ] 



BolMihBiner records eight recoverien out of twenty-five Littrc's opora- 

iicot. 

The iteaih<^ arc mainly due to peritonitis, oc failure of relief. 

Where (here is a 6ttulous upcnini; hcln-ecn the rectum and the bladder 

w URdiia, Little's operation should be perfurnied, unless the gut can be 

nacbcdfraei thi? perineum, uhen possibly the communication with the urinary 

tnct may close spontaneously. When the unnatural anus opens in the 

Rha, in the cases »« have seen il has utually hccn by an orifice in Ihc »de 

ofibcdtiietMled rcciiim and not by a tcrmln.il opening ; that is, the rectum ha* 

hm pouched and projectii^thclon- ihc vulvar aperture. In such conditions 

abtntprobe should he [Mtsed thrDugb the orifice into the gut and made to 

peHaijainst the perineum just in front of the coccyx. .An incision is then 

side Dpon tlie probe, the rcrtiun freely opened anil treated in (he usual 

Wf. IJreal care must be taken to keep the nc« aperture patent, otherwise 

1 il ytoae 10 contract and the fa-cc£ continue to pass bath ways. In some 

it is uid that the vulvar nrificc will contract and close of itself 

Id otiT own cases nc have not found this to occur, and in one of 

^•e pared the edges of the vestibular opening and sutured them : no 

Onaabou^^et, resulted, and u-c aftcrik-^rds laid open the perineum, dissected 

anylhcgut from the vestibular wall, stitched it carefully to the skin, and then 

K>td itp the perineum, with a successful result : the patient was about 6 

.nan eU. Id another instance wc pcrfonned the same upetalion in a child 

of 9 moBlhs, but it died some weeks later of inanition. \Vc have bad 

a t)«d successftU case recently in which power of retention seems well 

prtsctved. Dicifenhach appears to have been tlie lir^t to adopt this plan, 

hidi, however, is often called Kiiiuli's operation. Il is, we thinly well to 

> l^Mut, JuHiary ji, iBiM. ' Pillore adviud openinif ibn c.-kuih. 



146 



Diseases of fhe Digeslht System 



wail until the child is two or three yean old before doing the Mecnd 
<^)eTation. 

One of the dlRicLilties ne have met with in ihcse cases in thai of kcepiag 
the bowels regular eveo when there is quite a free opening : this we l)«)ieve 
to be due to imperfect muscular action, though ihc muKular com of ibe 
bowel is hypertrophicd rn some of these cases. Encmaia, rasior-oil emul- 
sion, >nd occatioiuil more sctivc purges itrc ccquircd under these cirouB- 
stancea. Sometimes uhcn ibe case is one nf vulvar anus a collection of 
hard fieces is found in Ihc intestine nlxive at the lime of [>pcniiion ; iliia 
requires removal, as ihc child is often unable to void il ci«n «iicn a good- 
siaed spcrtuic has been made. 

S»t«raItteB ar tbv Vmbllloa*.— In some cases of cxlro\cr«ion of the 
bladder there is no ti.icc "f .m umbjhcus 10 be seen in after life, ibc »<ar 
being loil in the mnlfonncd nhdnminal wnll. In other caset the umbilicus 
is ahnnrmally large - thai is, n cnniidcrable part of the abdominal tiall 
is forminl 1>y the ilructuret of the cord, and sloughs aw^y uhcn the cord 
shrivels u|} Ko that an actual drficicncy of the abdominal u-all results. In 
two cases of thii condition ue have seen that wrrr o|>ctnlcd upon, one by 
Mr. lion'se and one byciurielves, a portion of the liver protruded I hrough the 
opening and uai covered only by the sinutibint; ii»iie- In our own case we 
dissected away the dead part and closed the abdominal opening by sutures, 
but wiiliuul success : in a third case, under our care, the part »a» simply pro- 
tected from imlation and left, but this child also soon died.' 'flic frequent 
presence of the liver m the hemia has given rise to the najne of He|iaiam- 
phaloi, but the stomach and other viscera arc often included in the protrusion. 
At the third month of intru-utcrinc hfe there is still a coil of intcst>ne 
lying in the umbilical cord outside the abdominal cavity : should thiscoiKlitiaa 
persist, a true congenital umbilical hernia is found. The iinponaacc of thii 
fact is that m ligaltiting the cord the gut might l)c included in the ligature 
strangulated, a mishap that has actually occurred. In slighter cases there 
only a small protrusion standing out from the aMominal uall much like l! 
end of a glove linger ; the l>owcl is reducible and the treatment is that of 
ordinary umbilical hemia. In other instances, oiling to persistence ti tl 
vitetlo- intestinal duct, Meckel's diverticulum remains open, and passi 
to the umbilicus may open there, giving rise to f,T-cal fistula, as in a ci 
our oun where a ligature round llie protrusion, folloncd byihcappli 
strapping to dran- together ihc sides of the orifice, procured closure of lb 
fistul.i.' Edmund OuTO advises emptying the bowel by ftce purging and sub 
sctiuent administration of opium, thus giving time for the fistula to close j b« 
applies a dry pad over the lislula and leaves il undisturbed. Success has 
followed this treatment, but it appears to l>e applicable to older chitdrea 
rather than to infants. Fe<r palrHl tiraiMus ir-c. r/rjJir SuRCKXV Of nu 

L'RIS'ABV ObGAXS, t'/dkalsn Dl.tFJlSf.S OV THE NaVRI- 

^K Congenital hiatus of the abdominal nail may occur in other parts beside 

^V ' Undcnwd raootdt a casa irf re c owiy in which tbc itniiniFni cnniiflnl ■■ poohiefns 
^nnd Twinn snd olticn. have had succmfUl taxt. In a ctw <•( Hrwlic't Pal*, S*ti 
^PTtmu. roL ST.. Usidn tbr hepoLompbslos: there uw diaphragmatic hetnaa wtb MJ 
dcncy ol the pericudium. mil ■ coil of tiimpl la) to contact uilh Ibc heart. ^^B 

' Vide DttMiti t/ Iht XMl—VmMuat fai^fnt. ^H 




Umhilital Htrmit 



H7 



bw unibiliras from stmpk fnilurt of clmorc of the %-cntral Inminir. Of ihis 
klnivcrHon of Ibe liloildcr i\ nti in»ianc«. In mmc caies the recti fail lo 
n>c«l ODit anoihcT in tiic middle line, tmd ventral lietniii may rciiili with great 
»KikiK«( of ihe abdominal wiill. 

WcU-arninti'cd pndt iipplied hy tnrsiat of a bell mu*l be employed to 
ptrveni proirusion, or posiiibiy in some cases ii must be ju«ifi«blc lo cut 
dovn upon nnil xiiich lORciher iho margins of tbc apeniirc, an operation 
ml uf a very serious nature, and not of course neceftiiatinK any injury to 
tint peritoneum. 

OBblU«al SBrnla.— Umbilical bcniiA iheti in childien may be con- 
ptual or act|uired ; in the congenital form it is Konieiimes due to persistence 
nf Ibe faetnl condition Mhcre a coil of howcl lies ouiiidc Ibe .tbdomeii ; in 
ixbn caaci. a« already pointed ooi, it is the result of failure of closure of 
tbevential lamina-. 

The acijiiired form iHiinlly .appears n ithin ibe lirsl ten monlbs of life ; in 
tbnca>e ihe rupture proiiudcs noi tbroti>:h the centre of the icAr. which i» 
ccupied \ty the librou* lem^iins of the vessels, but usually abose it or cvci» 
ikioui^ an independent opening in the linen alba. Asiley, boHever, believe* 
A« the proirUHon i* Kcnorally ibrougb the ring. Both forms of heroi* 
w tetdily reducible jtnd usually con&isl of small inlcsiinc ; ibe amoimt of 
["inMjoo varies from a mere convexity of the nnvel to a prominent glovc- 
Cnjir-likc auiijro»lh. 

Thf ircjtnicnl ron*isls in applying .1 flat pad of nood or poroplasiic felt 
ilort Ihe i'ur of a penny and t"o or three Itincs as thick ; this pad should be 
t*tfnl )• ith flannel and fixed over the umbilicus by a hroail bnnd of slrap- 
F<|( «f irclinK the body or by a soft webbing belt : we prefer the fomicr as 
BMttftcieni .ind less likely lo slip, thougli il is not so comfortable as the 
w. If the pad is worn cnnsinnlly for from one to three months, arcording 
■*<btageof the child, ihc bernin is iisiinlly • radically cured.' In caM» 
*tirkebMinalety resist treatment tbc orifice might be cut down upon and 
**nl A case of irreducible umbilical hernia containing omentum was 
)WcetsliiI]y operated on by Roocroft in a gii'l of '4 years;' but it is clear 
l^aMU cases of umbilical hernia in children Are cured, since Ibe condition 
» hfdly ever seen in young adults. We have had occasion 10 close by 
^uton a median ventral hemin in a child. The result was successful. 

Ilfilital Bomt>.— In^inal hernia is met with in childhood in Ihe fo!~ 
iMagvanetic^ : 

I, Tbc jtinicubir prucess of peritoneum remains widely open and in free 
^nunicattoin wiih the caviiy both of the peritoneum and tunicji kiigiualis : 
'■ran dnceoding into this cavity is b true tofignu'/al hernia, or hernia of 
AtUnuca vaginalis (Tealel. 

I- The tunica vaginalis may bo shut off from the funicular proceis at the 
'Rcr pari of the testicle ; 3 hernia coming down into the patent process '» 
ofcd i/uitifti/nr hernia, or hernia into the funicular process. 

J. Wien tbc same condition as in (i) exisia, but the hernia instead of dc- 

'''Wiiliim along tbc canal of the funicular process puihes down a separate 

(••tb ef pcritonctim behind the procew, the hernia i» called infantile or 

•■tyWd Tbc samo name is given to cases where the funicular pincess i» 

■ LtiNtt. August 1, iSat- 



14S 



Diseases of the Digtstivt Syslent 







oblitenited ai Ibe internal ring or ju&i above the tmiclc. and the «qilutn 
is pu»b«d down «nd inviigm.iicd into ihe lower part of ihc pmcess. In 
the former cam, in culling duwn upon iht bowet from Ihc fioni thicc Uycn 
o{ \itr\loanaai, vii. Iwo funicular and one sac proper, will be found in front 
of the gut ; in llie iiccond cute iwo layers will overlie the bnwcl. 

4. An ardinuryac(|iiited hernia maybe met with. HemiAinajr.ofcoune, 
be complete or incomplete— lliat i:i, it may descend into llic wrotum or only 
distend the can.'il or bulge at the inttrnal ring. 

The lir:tt and second fomis are much ihe cnmmoneiM, and it is luoallir 
impossible 10 be certain which is present unleM ihc pnilt are expoced by 
operation. Where the le&licle is completely wrapped rmind by the hernia 
it is probably (ongtitilal \ where th« testicle remains a distinct bass upon the 
surffkcc of the hernia ii may be ftinicular, though it is not by any me4n« 
always to. We bclTcvc the funicuLai variety is the more fretjuenL Infantile 
or enc>-sted hernia can only be recognised by o|]eration, but it mtiy be tat- 
pecicd if, after reduction ol a hernia, an unusual amount of thickening atoi^ 
the cord remains, or if there it a hydrocele of the cord or an infantile hyi 
ccle in conjunction with a reducible hernia t^nitunniety.an exact dia^' 
of these conditions from one another is not of much importance. 

Hernia may develop at any age ; it is sometime.s noticed immediately after 
bittb ; in other instances it comes down later when, torn failtire of health, or 
bronchitis, or whooping cough, the muscular walls of the nbdomcn become 
relaxed, and Areinaddiiionovctslraincdbyeounhing. violent rr^'ing, straining 
in defecation, mictnrition, &r. So common it it for straining in niirtorition 
to bring down a hernia, ihni it is (|uile certain thai |>hlmoii« is a mo«t fertik 
causr of rupture.' The pteicnrc of a I'akulus or worm» acts in tbc same 
way. Hernia very cimiinnnly acrnmpanic.t ectopia \'csicx. 

A« it well known, inguinal hernia ii sometimes met with in female diH- 
drcn. though not nearly so commonly as in hny«. Of 113 unsclectcd caMS 
ol hernia seen In our out-paiient department, there were^ 

In mide^ . 57 right inguinal, 13 Icf) inguinal, t6dotible, a i>d 9 umbilical 
In females 4 „ „ S - .. "" .. » 9(f>o).. 

Mr. Leader \S'illiams tells us that in his cxpctience in the Maternity Depart- 
ment of St. Mary's Hospital. Manchester, umbilical hernia ts by far lhe= 
commonest variety, and this is no doubt ituc of the first few weclcs in life. 

Mo^i commonly an inguinal rupture in a child contains fmall intestine: 
with or without omentum, perhaps most rominanly without. Other pans o£ 
the intestinal canal arc:, however, not rarely found. We have many timcB- 
during opcnilion found the c:rcum and i-etmiform appendix in a hernia, aniL 
not rarely the appi-ndix can be very distinctly felt ihmugh the covering*- 
without an operation.' The ovaries in giri.i and the bladder in cither sei are 
soineiinie!! protruded. 

(Generally a rupture n msily reducible, but often it ift ttcce«sary to make 
the child lie down before it readily goes back ; it then often does so sponta- 
neously. Violent crying will »ametimc-i make it ijuitc impooible to safely 



> An impon.ini furl (ini poiniodoui by Mr. J. \. Kcmne 

' Vi4i lapeM in the Brii. MtJ, Uur, vol i. iBS/. hf Mr. F. TVivn. and aba by 
pITirnt wi-iim. 



1 



'TCoSce a ht 




laguinat Iferma 



■ce a hemia, aod ih« child must be ([uicicd or anit^theiiscd berorc 
reduciion. 

It muit b« rcinembcTcd iliac, ilioiij^h a% a rule herni;i- arc opaque, a 
tichily ilistcndcd tupiure consiMing onl)' of bowel, »i>d thai full of tlaiut, in 
a tliin-xkinncd child "ill bedistincily translmeiM; this fact was wc believe, 
diit pointed out by Mt, Howse, and we Imve sevcril lirncs spcn it, 

V^u-iotu a bnnmul conditions may cutnpl teat e hemiA ; thus the testis maybe 

miiicly retained Of have impetfocily descended on the umc side. A vaginal 

bydmcele or hydrocele ofilic cord tnay coexist with a heinia, or fluid as in a 

coogenital hydrocele tiiay distend the sac of a cungcnital hernia. The nipiiuc, 

t4 course, may be Miigle or double, and sometimes of ii diAerciil speciet on 

the two aides. We have wen a 'funicular' and a 'con^-enital' hernia on 

<Tfioaite (ides iit the same ctitld- Children ihif iubject of hernia are tin- 

teibtedly often affcLicd with inieuinal ilinurbance, which appears to be 

HQetiines at least due to the hernia. It has, however, been suggested by 

l-i»e thai the hcmia is due to the inlesiinal trouble, and it is undouhicdiy 

Vtt llat mansntic thildrcn with chronic indigeiiion and iircfc-ulat and oJtcn 

aMipatcd bnircls not uncommonly have hemiA- which are not readily cured 

iSthe aiMrilian i* improved. 

Ritf*8tcs in children are occasionally irreducible ; when this is due simply 
MKnoung, as alreiuly pointed nut, rhc difficulty i« eaiily got over, in other 
OKt ibe bcmidi may he oh«[ruclcd by its conicnti ai in adults ; again, 
t^ltoioat to the *ac or to ihc testicle or raauing together of Im™xI to 
l»»el,ot bowel to omentum, may prei'cnt icduciion. In one of our caies a 
bp btmia was ntadc irreducible by the presence of tuberculous mcaentciic 
|tiBdi <riikb had n-idcnlly enlarged aficr their descent, and it was only 
■fcrionoval of some of these and enlargement of the rings that the rupture 
••*lhci»d«»ced: the child recovered, but evidence of tuberculosis, of course, 

•BttlMd 

h is somewhat rare fur a hcmia to become strangulated in childhood. We 

"T^bowcver, met with several such cases ; they differ in no respect from 

fcutaUr condition in the aduli. but considering the extreme tenderness of 

^MUies in children immrd>nlc operation is the wiicMcouric in ptcfcreoce to 

•^Beiii by ice, Ac. Ktcviiiion of the pelvis and abdomen. as ucll as direct 

•"M, sbnukt, (Kitiapt, be first tried, but very gcu'ly ; "C h.^ve known a 

<ttl die of the injury done to n coil of intestine which ".is reduceil before 

I** ditd was seen by ui, and rould only hai c been sitanKu''T^<l f'"' ■■* f^^'* 

**!». The youngest casc^ with which we are .ir»iuainletl were one of ilircc 

iby Halscwood,' and another successful one of our own, and one of four 

1 by Maunder. The sac always rec|uires opening, since tlic neck itself 

itbe roruirkiing pari. Sometimes in an hour-glass aactbeconsiriction 

**f be in the scroinm. 

TV tnalmeHl of hernia in children resolves itself into three questions— 
tw, Ihc removal of all causes lending to produce rupture, such as cough, 
ItiBMis, Jkc ; lecondly, treatment by apparatus ; and lastly, operations. 

Rnpturcs in cliildtcu someiinies get well of themselves without treatment, 
M'niiply by keeping the child lying down and avoiding disturbance of its 

■ L^Htit. Dec itBt- 



ISO 



7israies of tht Digetlive Systfin 



temper and bowel*. In other instnnccs circumcision will prav'enl fiodier 
<tMCcn! o( hernia by icmnving ihf source of «iTainiii|;. 

Kailtng ihei^c mcani, lliv wisest plan is nl once lo ]>ri>vUlc a weU-liltniK 
tnut, A matter which thould be seen to by the surgeon himself, .ind not kft 
to an inilruinent maker. The truss must \x Horn niffht and day n ithout any 
intermiuicin, never bcin): removed on nny account for mtshinf; or ;iny other 
purpose except ti* put aiuithcr on ; this is necessary, because the truss ts in 
children uicd lo cure rup1iire,.-ind not merely InpRtlintcit iisinaduUs. When 
il is absolutely ncccM.-iry lo ch.inge a truss, the new one must be ftol ready, 
ihc finger slipped benenih [he oUl one lo keep pressure upon the cinal aiKl 
then the triui cli^inKcd, the child being kept on its hack and toothed lo pre- 
vent cr>'ing. During the triMlmcnt the skin must be caiefully watched and 
kept dry and unitriiiifcd by ihc fice use of boric acid powder; this can be 
dulled beneath lUe trusiMithuut removing it. A little judicious packing willi 
absorbent wool will serve to i;ike pre^isure off any tender part. Almost XKj 
hernia durinj,' the lint year of life that can lie kept up vithoui once cominc 
down for three months will be petntanenily cured ; after the lint ycv a 
longer time i» rei;uired. 

I'he ordrnaiy tlat pad trusses do ver)- well if the pitrenl* can aflord to fre- 
quently renew them, but they get stiff and hard, and the springs soon iti« 
and rot with the freiiuentsoakiigeof urine, so that they liave to be fretfuently 
cltxog<^d, aad a duplicate should alHa)'s be ai hand in cate of sudden giving 
way, One descent of a hernia undoes all the preceding treatment : this is the 
cardinal rale to impress ugwn the mother or nur>c. The inflatable and tbe 
glycerine pad rubber trusses we have found useful and satisfactory when 
carefully nuuiaged, and ihcy arc not vtAci led b) urine neatly so rapidly as the 
common truss, but they require c.itcful inspection from the first, as tltey ate 
often imperfectly made, and flaws or tears are soon fatal to them, llie hard 
rubber truss is sometimes spoken well of: »e have not tried il. If from 
bad management n sore is produced by truss pressure, careful padding will 
often ai'oid the necessity of leaving off the truss ; but with proper attention 
and cate that the tiuss spring is not <o» strong, it seldom occurs. 

Hydriicele and orchitis we have mote ih.in once seen ,-is the result flf 
wearing a truss ; in such cases we may be sure that the spring is too siroog 
and a dilTercni truvi must be applied. Spicn bandages, wool trusses &c. 
.ire inefficient substitutes for a good truss. The pad of the truss should be 
Aat and nut convex, and peaked trusses are never required ; the abject it to 
prcient the hernia frum enienng the canal, not merely to cus-cr up the 
rupture. 

When a fair trial has been gK'cn to trusMS, different ones being, if 
necessary, employed, and all souices of irritation have been removed and 
still the rupture i-armot be kept up. an operation for its pemianent cute 
should be performed ; it is of course retiuired in only a small percentage of 
cases. 

Of all the various plans, the one we think simplest and as good as any, 
■nd the only oise we shall describe, consists in m:ikini; a free iiu-ision over 
the canal and upper |MirI of the scrolum. cutting' down lotbeMc, redticing the 
lietnui. closing the neck of ihc >ac, and passing silver wire or silk sutures 
through the walls of the canal and twisting lliein upi. To do litis the sac 



Herttia— Prolapsus Rett! IJI 

BWM be opened and the fingrr paucd into the abdomen to make <ure thai 

ibe c&nal \» clear and tu f^idc ihc n<^i-dlc. The needle, which miiM be iii a 

handle, is passed ilirough one »i<!c of the caiia], and f^uided by ihc lintfcr is 

breught out at the ring ; it i« thn-adcd wiih nirc and vithdrawn, then un- 

tItiiMded and pas^d through ibe other tide, ihcn Ibieodcd with the other 

tnd o( tlM same uiie and .-iK^tln u-ithdt»wn ; two or (brec KUIurcx are parted 

la this wAy (ill it ii felt that there arc enough to close the canal, the wires 

•n then iwi&ied up, cut ihort niul their ends well ttimed down into the 

liMues. One edge of ihe sac clo>e up to the wires ix then picked up and 

ihteaded iqioa the needle, and succcui\-e ponions of the surface of the sac 

tn pbdied up and transfixed (like Ihrending them upon a ikeu-ec} until Ihe 

Poller edge is reached ; t]ie needle i> then threaded with caigut or silk and 
mhdnwn, leaving tlie ligature, which when tied putfcers up the sac into 
doiclyapplied folds which lonn adhere, and Ihe sat. is thurau i; hi y obi it crated ; 
^ bf ihii nicans all trouble and disturbance in separating- the sac from ihi: cord 

»Mi'oidrd, and tlie closure is <joite tirm and complete. Sometimes n-c liija- 
Urt Ibe wc before doting the canal ; this is nut i^uiic so e:is>-, and it is not 
* lutlcr ot importance. The silver wires ate left in permanently unless tliey 
Kt ^1 ifritaiion, wlicn they are removed as soon as they are loose, but this 
mMim happens. The woimd should be closed, and will heal by primary 
VM^ Of laie we have used silk in preference to wire, but il requires care- 
U pieparation i if not ihorouKhly sterilised, a troublesome sinus i« likely lo 
I iini^ lad the suture Anally comes away. We prefer (o select the particular 
■BDdciif operation most suited to the case, rather Ihan to confine ourselves 
to uy one method exclusively. There is sometimes a great dc.il of swelling 
'tfiRtbeiiperation, but this ({t^dually subsides and should be looked upon 
'*>*l[aDd siKD of hrm consolidation, For the methods of managing com* 
Nioiions of the operation we must refer in the ordinary' text-books, for 
'■'amended testis to the chapter on that subject. .An omental sac may 
It mtt with ; we have seen a s-cry perfect instance. The man;igeinenl of 
wdiuMs and of adhesioiu differs in no way in Ihe child from lliat of 
iioiiM cucidllions in tlie adult. It is better not to allow a truss 10 be worn 
*'trtbe operation unless there is some special reason for it. 

1^ operation is not free from risk and not aluays successfiU ; we have 
Wooe death from peritonitis coming un some time after the operation, and 
wthail to operate more than onoe in severed cases. In the fatal case ihe 
^ual*as perfectly closeil and the peritoneal surface almost undimplcd. 

fatKiral hernia in children is very rare, we have never seen a case ; on* 
innied by Sabourin in a premature female infant was readily cured by a 
**«. E. fJuven saw one in a boy of 10 yeirs out of T48 Cases of femoral 
'*'nu ' liiaphraginaiit hernia is occisionally met with, 

troiapsuB M«eti.— Slight degrees of prolapse of the rectum are common 
vduldren and are of^cn only liansiior}, occurring perhaps once or twice and 
*M again 1 the more severe forms are much laicr. 

t^lafiM of the reciiun consists in protrusion of more or less of the 
■(nal (nUl ihrough the anus. The slijjhi and most common form is simply 
4 loUniig QUI of a ring of mucous membrane, u hich is readily reducible and 

■ Liimm, June 6. 1SS4. 




152 



Diseases of the Digestive System 



often only conies cIokh «hen ihe thiUl ilniinii. In oibcr casM tli« whole of 
ihc rectal cants fnmi mucous iiK-nibtani.- to perlloiieum ma) be |>roinidcd. 

The first varieiy of prolapie \% usually about half .in inch lon^ and apptan 
as A red mucous ring niih tadkiint,' foldi divcrijiii}; frum tlic central orifice : 
the mucous and cutaneous surfaces shade off inioone another ni ihc margin of 
the proirusion. The second fomi is larser, reaching fiom i>iic lo Iwo incltei 
in lengili, and is ofttn conical in shape, iu biiae being at (he anus ; the folds 
are not radial but iinnular. running loiind [he prolapsed pan ; the orifice i* 
central, and on pastin),' the finger inioii, it is evident that the uholc ihickneis 
of ihe bou'cl. and not nierely raucous nieinbrane, is involved in the prolapse. 
Someiinies ihiii funn of protrusion tcachc)! much larger dinieii^innis even six 
inche* m Icnsih, and in such casts neccssaiily a large poiicli of p«nioncuro 
is carried doHn, and this is mure extensive on the anterior ilutnihe posierier 
aspect of the bowel- In one case Iliui we examined ficil mi-rltm ihcrc was 
a definiic diverticular pouch uith a sharp lunaied edge projecting from ibc 
recio-vesical hollnn down the anterior uali of the rectum ; ii secn>cd to 
us probable that the presence of a coil of bowel in this pouch uould bafc 
much (odo »ilh keeping down the inulapse.' Not only small intestine but 
the ovaries even may be found in ihis peritoneal pouch, which then becomes 
Ihe sac of a rectal hernia ; the cbaiucterisiic gurgling or the presence of a 
solid body felt on nianipulaiing the wall of ihc protrusion may give a clue to 
Ihc extent of the disease. Kccial hernia sometimes come:! down bebisd 
the bowel, or may even protrude through a gap In (be muscular COaU. 
(Kelsey.) This variety of prolapse is someiimes curved as a restitt of 
traction by the mesocolic fold of peritoneum or the aKachnieol of the reclum 
to the vagina. (\'an UuTcn.) In it also the mucous and cutaneous surfaces 
ahade off into one another, ibough the transverse folds of mucous nicmbnuic 
on ihc surface of the prolapse may somewhat obscure the line of junction. 

A so-called third form of prolapsus recti, where the upper pan of the 
rectum or the sigmoid flexure is invaginatcd into (he bond below and pro- 
trudes from the anus, is recognised by its siie and by die presence of a stiloit 
between the prolapse and the anaL ni.irgin. This condition, however, is more 
ninumlly considered as an intussusception than as a prolapse. 

The mucous surface of the protruded gut maybe nearly natural, but more 
often is excoriated and coaled oier with a thick sliiny mucus ; it siMnctiines 
becomes congested and may even slough from irritation or «inslrictii>n by 
the sphincter, though in most cases the anus is -m \ax and patulous th^ii the 
existence of a sphincter at all is hardly felt by a linger passed nithin the 
opening. Bleeding lo snwil amounts often occurs, imd Uiece is much miKaa» 
discharge. 

The njoiions come a"a>' freely, but the irritation and discharge u«aken 
the child, and he loses ticsh and healtli, In most cases the prolapse is re. 
dudbic with more or less difliculiy, but often it returns immediately pressure 
is taken off; in others it remains up until (he child Strains from any cause and 
llien redesc'cnds ; In others a^nin the protiusion after a lime becomes inv- 
ducibte from matting together of the pans and from congestion. 

■ Til* apnimm from this oue Is la Vbr Uneiu Colleer Mutsum ; ihi* drfinite poiitbotr | 
It, to lu u wc know, unilctcrifcol hiihcrtu. I 




a rKtal hernia exists i( is subject lo all ihi^ condiitona of an 
ludinai)' inguinal bcmia, i.e. it may be reducible ursiian^'ulatcd.&c' Occa- 
t.iiull) tlK |>ToljpM slout^jts uDd fwGil lintula icsulti, or ihe m'«I1 may bunt 
in »;:enipts M reduction, 

The cause* of prolapsus iccii are many. lliouj;h it ia obvious thai there 
mull be soroe weakness of the ipliincicr anil lc» aior ani or relaxation of the 
Kcal wall* in these tases. or prolapse would be muLh more frequent than tl is, 
ABjr condilion thai produces violent and consiuni straining may bring on 
p(4apw in « child predisposed to it. The child is generatly miserable and 
•Bidy »ben seen, but this is no doubt partly the result of the irritation. 
riicKHts, contracted meatus urinarius, stone in the bladder, cystitis, con- 
iii[aimi, diarrhoea, worms, polypus recti, violent coughing nil may cautc 
pbpK. Hocckcl believes stricime of Che rectum (o lie a cause, and in 
cteciH «« TtHrnd a tight annular stri<;ture of ihe rectum about one inch 
hmiht anus ; this only admitted the tip of the index linger in a child of 
•tan three years old; the stricture apparently fonncd ihc apex of the 
fibiptt lad may possibly have been a result r:ilher than a cause of the 
pMntion. 

Tht dia£MMis ai prolapsus recti is easy where Die protrusion is large : the 
nttv doubthi) point is u hat extent of rectal wall is included in it. If small 
' wn only be mistaken for pile* or polyiius ; the former are exceedingly rare 
adNMien and never form a complete ring, the l.niter is of course a single 
"<kied, OMially pedunculated »n dling ; a mistake can only occur from lack 
(!( aaniioatiMi. KeUcy Uyi it down that any prolapse over :f inches in 
"■ph contains peritoneum, while the presence of a sulcus serves to dis- 
"Voi(h betitcen the tecond form and the rectal intussusceplioii. The 
'>*Kl>«n of the fold* and the site disiinguisli between the first and second 

Wttstl. 

TV freaimftif oS prolapse consists first in removing Ihe cause of strain- 
">!:.n(it the child should be kept rigidly lying down in bed ; the protrusion 
•"Oil be reduced c.irh lime it comes down, .^ind if it constantly recurs an 
■Itonpi should be made in keep it up by a pnd and T-bandage, or by 
'"^iVg 'he buttocks together «ith a broad piece of plaster. The bowels 
'Witld be kept easily open so as to avoid siiaining. and it i» sometimes 
■■"fcl to nppart the sidct of the amis during defalcation by prcMure or by 
**™g the ikin lightly to one side ; as advised by \'nn llureo, the 
X*WB should be passed into a napkin without the child being allowed 
KiilupL 

FjKmatn of cold waier or asttingcnts, tannin, quassia (i 4 01. of the 
'*'»»«n,', nak bark, sulphate of iron, &c., will do good in many cn»c>, and it 
" *l7 the nw>re seveie forms thai arc not cured by l>cd and the means 
"wre ilewribed ; indeed, simple confinement to lied cures the majority of 
^ children. Should the prolapse be irreducible, an anaesthetic should 
"piwi ; if this Tails and there are no urgent symptoms, 4 warm fomentation 
**' putting the child, if old ertough. upon his hands and knees with the pelvis 
*««d. Kill sometime* succeed. 

If sloughing occurs the prolapse may be pioiecied from irritation, and 
wed over with boracic or salicylic acid, and kept clean. The sloughing 

■ fiJi Kdsty. in xn clatxirBle puprr in ArtAh^ ••/ Pmdialriit. iSSj, 




■S4 



D/mijt's of the Digestitr SysUm 



will very likdr cure the proUpie, bui ii mny be ni (he txpeam of t» 
A Mficiiire, and ihi*, if il is at ihc apex of a long prolajuc, ml) be hi^ 
I jn ;hc rectum when the proirusion is reduced. 

Failinjr milder mcsisures, the actual cauiery should be employed, Imir 
I five narrow lines being drawn in the long axis nf the giii from skin rangi 
|to near the n pen. 

['a<iiicrm's cauiery is (be most useful insirumeni, &nd is better 

nitric acid or nilratt of silver. Only the niii<.-ous membrane of the pmlapt 

should be burnt through, while at (tic «kin niar^'in the cauteo' should b 

bare the sphincter ; sufficient irriialion must be produced lo procure »dh 

, sions between the mucous and mU'^cular coats. Llry^nt sdvises the applici 

lion of nitrate of silver over the whole surfa.e. .Xfter ihc .ipplicjtion il 

' bowel should be reduced and a pad applied. Another uneful plan it 

Icxcite wedge-shaped strips from the margins nf the anus, including a Ixll 

f of the mucous membrane, the b.isc of the wedge being ai the anus; 

\ edges of the wounds arc then brought logcther, and the lesulriog contraciil 

I Aupporis the bowel. We have fotmd this sufncssfui In a v«r>- scirere 

' In leverc and irtcduciblc cases the prolapM: has 1>ccn clamped and remon 

but this should only be done as a last rcsouKC and with the full IcoovMl 

J thni in a large prolapse the peritoneum will pmbably be opened, and tl 

I uimosi care niusi be taken lo reduce any rectal hcmi.i that may exist. If ~ 

[|>eritoncum is wounded it must be cnrerully closed with catgut luiiircs. Tl 

|operaiton is rarely justifiable ; wc havT once done il but unsuccessfully ; it 

[not to be confounded with the meihodof treating prolapse by retnovatoJ'stri 

of mucous membrane in ihc long a<cis of ibe gut by means of the cUmf^ 

method somctlmei employed.' 

The boweU should be open two days after operation, at delay makes 
|firai action very painful. 

riMnta In Ana is an uncommon condition in children, though we ha< 

(everai times met itith it. A>i in adults, it is apt to be associated 

■rculuMx. As pointed out by Mr. Holmes, most of the riMiil;r arc bli 

aal onci ; this i* also out experience. Thi-re is nothing peculiar 

ptithor ihc p.ilholo^-y or ircaimciit. whith is (he wme in children as in adi 

We have, however, recently introduced ihc plan of dividing the sphinci 
|*ni subcutancously clo»e to its aiiachmcni to the tip of ibc roccyx, and tl 
•<:rai)in(; out ihc Isiula. This is a less severe way of dealing with 
tlian the orxlioarj- plan, and is probably sulticicni for all cases likely to 
— met with in children. 

H VUea in children are usually described at unknown, or almost so, 

^^heir occurrence t« no <loubi very rare ; we have, however, seen two cams 

«,\icn)al piles, and Ogsioti, jun., has recorded a case in a child 3 days 

fn Mnother inslaii'c a child u-as brou^jht 10 us for bleeding from the b 

flflt^ on CKninJnation a condition indistinguishable from that of well-dcvel 

')^_.^<*-«xteniai P''^» *■•* '"""'' ■ '*'i'» hiid been giving trouble since the cb 

a- about w >■«-'"' '""' * half old, liut the affection was probably congenilrf 

0l w^ ihrou-ti upon the case by the presence of a large putlali! 

_^£r, c^njngwortb nUIed at the KubologKiil iSoodi of Mnncboti-r. Deoonb* 

£:^^«ifb| ««•> of coRiiiIrt* «sci«joD of a Urte pfolapiM in ■ >'oung Ixdy in which 

l**^*"""! wit* op""""- 



CondrhifMta—Rtdal Polypus 



15$ 



iicd nirvtif on ibc biiltock, quite disimci, and ai a dlttancc froin 
nut, and ptnlxibly ihc caM wai rcsLlly one flf nirvus of the anus. The 
ditue WM nadily cured bf applying ligaiuret ju*t as for piln. There was 
M imoid tUuie higher up, ihoujcti (his is occasionally met niiti. Ligature 
K*C axXaa^ cautery i« ihn hcd tic.-timc-ni. Howard Marth and itniker 
km Rico«ded inttancei : in one the paileni, an adult, uhimatcl)' died of 
hni»n1u|[e. 

CcMdylocnau frcqaentlf ncair in children about llic anus or tcs n^gh- 
bnabood su flat, teuile, pink or pinkish -white ele^-atinn(, or sometimes as 
tujc irretndar in:iues. They arc usually a tn.inifettaiion of congenital syphl- 
K but Mirnclimct, we believe, simply ihc result of din nndirriiation. When 
t)pUitic the local treatment i», of roune, tiibordinaic to the gctieral mea«urc(, 
tadttUiag over w itb cotomel or the application of l>tack unsh uKunllytpecdily 
nrdthcm. Someiimes, ctpecinUy if non-xyphilitic, Ihcy. ire mote obiiinate, 
u^rtuy i«<)uiTelo be vcmped away or treated "ilh the actual caul er;-, nitrate 
tdihtr, ur chcumit acid. 

Valypiis'or tbfl Rcetam Is one of the dtseates which, ihough not abM- 
kuir peculiar to childicn, are by far most commonly fouml in llicm. MoM 

tONioficclal bleeding' in children, apail from thai doc to mcic tenesmus 
MdiurhccA, arc due to polypus ; hence careful search should be made for 
■ luoui in .ill (.46CS where imalietcd blood escapes from the bowel. 
Beml polypi are usually pedunculated rounded bodiesabout the sire of a 
hnlNi ; ibey arc composed <if mjxo-fibromatous or soft fibro-cetlular tissue, 
■ sMne ease« arc adenomata ; in the former form the surface is smooth, 
<kR|;b wmetintes 5Upcr^cially ulcerated or excoriated, and the pedicle is 
■telsag and thin, ihODgh the gmwih in its early stages may be sessile. 
MtMOMta are granular or warty in appearnnce. The anterior w.ill of the 
rxiBn about an inch from the anus is ilic usual scat ofihesc growths i some- 
1*1, boitvver, they are attached liigher up in the bowel, and nuiy be even 
^ndreach of the finger. 

Mypi, lietidc* ihc loss of blood, gi\'c rise to irritation and tenesmus, 
'T'''ti with a inucout difchaigc from ihc gut, and frequently to prolapse. 
^groBth iiscif is often protruded ftcm the anus during draining, and i* 
"oitrmei mistaken for pinlapte or piles ; examination, howei-cr, readily 
*'*Ucsa diagnosis to be made, as the polypus ii quite separate from the 
IWnl mucous lurface. The pcdimculalcd form is best treated by limple 

■— taiHagoA', or a ligature may l>c ajipliedtoihc pedicle, which is then snipped 
l*V«gb with acistors ; 10 do ibis convenicnlty ibc rhild should be anierithc- 
'"■^ind tbe rectum well dihiicd and a >pcculum UM-d ; often during an 
'QWuuon the pedicle is torn ihrou^h and ihc polypus comes auay wiihoui 
^thf irouble, and occasionally the rnau is detached during dc^i^calion and 
^•M with the moiion. The senile form maybe ligatured or snipped olT 
••J r|s baie cauterised. Recurrence of ihc growth is itnprobablc. 

We have met oith rectal polypus in two incmbeis uf one family, iuid 
"^ relates similar caics. 

Octuionally the whole mucous surface of the lower bowel is the seat of 
*»l)r adenomatoui grovibs, as in a icmaikablc case recorded by our 
^'k^oe Ur. Wbiicbead. Permoid cysts have also been found. 

Sai^l superficial tdcers and lissiires aboui the anus arc common in dirly 



iS6 Diseases of the Digestive System 

and in syphilitic children, but theyare more common at a Uttle distance fioaj 
the orifice than actually at the anus. They give rise to pruritus, but seldoaJ 
to the severe symptoms seen in adults ; sometimes there is reflex irrilatics 
of the urinary organs, frequent micturition, &c. In the non-syphilitic atsc% 
cleanliness, the destruction of worms or other irritants, and the applicatioorf 
nitrate of silver are usually sufGcienL Menthol has been recommended te 
the pruritus. Tuberculous ulcers may be met with. Ischio-rectalabscmil 
not very uncommon, and should be opened early; it is probably better tr 
divide the cxtenial sphincter at the time to avoid the risk of tedious bealii| 
or the formation of a fistula. ' 

Rectal ulcers are due to either follicular inflammation, in whidi the 
rectum is involved in common with the rest of the lower gut, or to recutl 
catarrh or the presence of a polypus. The symptoms are seldom nuikedi 
and the condition is consequently not often seen ; vide also PROLAPSK ■■«' 
Dysentery. 

Removal of irritation and improvement of the general condition ai Sv 
intestinal mucous membrane are the only treatment required. 



15? 



CHAPTER l.\ 

OISUSES or THK UtUBSTIVC SYSTEM— (fOWA'HMftO 
M»irormalloDI knd BefornilUea »f tbe SlgciUvo flrcMm 

■ftn-Up. — The upper lip it developed from the fronto-iuiuil pmrcss and 
ttucuilUiy processes which in the nnrnist course of development fuse in 
imi gt tbe mandibular fissure. Should this fiision fail lo lake place on 




I lirwftoT union of thtCue, 4nrl indicu** ihe larigm of (>>c<^IJer m^fofiH' 
^ < *, Ai^. liwrian* gt t"in«riial au'imilnr nwuUc. t.. 11.. Iir,, IV,. indiciM ihc 
™M m ttm «C 4>iaKAu/ MiIuIe. I . u the uienal sudiloiir m«uu> ; or. Ih* otlHiiil 
■^;IH, iIh HADJIbuUr Awuk; HJr^ the |in«i of ToAn*! Iun.|ip; rr, cr*, atuk ih« 
^^f <t wfMiWtl /mitml HmuW. (Pioni Ultnil ^uiiaoi Laiial. Fcl. i. lESl.) 

•^•r both sides, a single or double hare-lip rei|)eciivcly results. If 
'* nmiij ifTOwth of the palatine processes which should take place to 
■^Nntt the lusal and buccal otviues fails, cleft palaie uircun. 



158 



Diseases of (he Digestive System 



The pnemaxLllic arc fonned from the globulnr prcKe»es Ibnniiig tl|| 
angles of the fronlo-nauil process ; hence, should Ihe lateral process wH fdiiB 
niih Uic globular, a clcfi between the pr.rmaxitla and the maxilla will 
result <?n that side, while, if there ii suppression of the two globular ptm 
ceases and septum, medium hare-lip follows ; this, though exceedingly nuc is 
man, ii met with more or less ironstanily in some mammals in which tM 
globular proce»»et fail to unite with one another.' ] 

A» to the actual causes of such arrat of develojimcnt much controicr^f; 
exists. It ii commonly asserted that frights and shocks of various kinds,*! 
well as strong mulemal impreisiom of other sorts occutriBg about (fau 
time of the (Ictelopmcnl of these parts, may detertnino the arrest ofgiovw 
which rcsuhs in such malfi>rmations. Although many instances ha^e btMi 
brought farwiird In shuu a causal relation between t)t« two f«cts, << DnMI 
clc;irly cfiiablishcd that anvthing more than a coincidence really exists. j 
It is, ho»-ev«r, certain that in many cases there is an kert4Hary tendiMft 
10 Mich defects, and it is also certain that ibey are often assocnted wiihothei! 

congenital malformations. It Is asserttd 
that the hereditary tendency is comnumlil 
transmitted on the father's side. 

\'arioui degrees of hare-lip are Ibuml' 
Mr. Lucas believes that conjienitalabMnd 
iif an tipper lateral incisor is sometin4| 
the forerunner nf haic-hp and cleft pal*^ 
in a later generation ; in some iaMAne^ 
there is merely a deficiency of ilie mu^ 
ciilar fibres of the orbicularis, so ibl 
alilinuKh the lip is not actually fissurfij 
ihciv it a furrow from the aboence \ 
muscle and the consequent thinning of iH 
lip which at the AtTrcii-d p^trt consists aa| 
of skin ani] mucous membmnc, often s<im< 
what imperfect in structure, together will 
an intervening layer of connecti«-c tissuej 
In other cases there is a shallow notd 
in the prnlabium or at the anterior nasJ 
orifice, the parts being otherwise aeJ 
formed. Iletwccn thete conditions aoi 
Ihe most severe forms of hure-lip aJl degrees of deformity may exist (ligl 
19 and 2o>. I 

Ai the superficial structures are developed more or less imtepcndently 4 
the bony framework of the fince, harc-hp may occur without any cleft of tU 
palate, and without any separation of the pm-maxilta from (he maxilla. Mori 
commonly, however, if the hnre-lip is complete, i.e. if it extends into ll^ 
nostril on one or both sides, there is also deformity of the bones, eillier noni 
union of the pnonaxitla or single or double cleft palate. Thus there Bin) 
be a mere notch in the line nf the r"'". a cleft through the alveolar mar^ 
on one side, a cleft nmning backwards, on one side of the nasal sepcufl 
through the hard and soft palates, or n double cleft isolating the pnetniixiUl 
• Viit Bland Sulton. t^inil, fetiiuaty t8. iHS. 



/ 



ni. i^^A «imp1< n»« or fjeuhic inrDHi- 
plvtt Har^lii', Thk* !■ nuth '*'fr liimi 
I he coivplelc vtrifiTy. 




Hare-liff —Cleft PahU 



'SP 



(nm the maxillic ami ItAving it pcniTodinK fnim the cnct of the nainl «cptum 

wbilc ihciwuh.-ilvci of the hnid nnd sofl palate nrccomplctcly Mrpnr.itcdnnd 

the iw5al »«ptum is Mcn in ihc middle linear a prnniincni ridifcnoi .m.-irhcd 

todlber »id« uf (he paUlc— fompklr or doiibtC'C!(-ri pulnic- lh<r tcpliim it 

often 9C«n to (^pctofriimlend n^n ridtfrupon llic upprr w,-ill oflhcpIiaryTiK. 

It ift wiudly viid ihal cli-ft p-ibir ix nlvtAyt single, but ibc ii^mi may well be 

filMIMl to lbiu« cjim;» where lh<^ teptum i^ ait;irlied in inic pnUtc proccM 

Ml)r. In fltiicr iiiitancci ihc fjiilure of uninn niny occur only in the loft 

pabte, more often in the -mix. ivjih juxi ihc ]>oslcrior rdge of ibc linrd p.-da(C, 

M in sli)(hter degre«i of the deformity »till ihc uvtil« alonr muy br bifid, or 

iht pablc perf<>nited. In some recorded tams ihc uviiln ha« iHxn abtenL 

Two Mbcr conditions associiiicd with hnre-lipnnd cleft pnUte leipeclivcly 
u?of nireme iinportnncc as regard* Miccc<i»ful operation ; the one n the 
111. side, di«luit«l al4 of the nose found in complete hniC'lip ; llic other i» 
Ibc plcb of the palate uicb, irhich may be cither wide nnd flat or very high 
■nd Mnow : ibe Utter 
Malition \-> ^id to be 
•AaaHnciated with men- 
nl Mdency. 

SMMtimo the pnc- 
iDinlb rArrie« ihc four 
ndwr iccih. und tltcM 
iRifccnfMT tinpauited in 
At (mjecitOK mass in 
«w of coRipleic double 
Mlt-iip In tinnr in- 
uuco, hmever, une in- 
(iKf looih ii atiuchcd lu 
■W mutlta, mnti lom- 
<intJ)r ibc pul«r looth i> 
"ntcsted ahoceiher, ili 
(K lunini; apparently 
Wi lou It) the clefL 

Ktbitivit •)/ Prvmaailla. — Very frequently ther« is tome rotation of 
Aipmnaxilln upon a vcnical aKi), especially in unilaieial cleft ; in siich 
iMthe iccth .ire also rotated and may be »o directed that the outer border, 

• a Mae in6lnnce» the cutliiij; eUse. look* directly forward*. This ponition 
•'ie trtth (Oijuires to be remedied after their coinpleti: exupiion. As, how- 

1 1'«^ hire-tip it now tiHually operated upon before the teeih arc cut, their 
(1)0 potiiion is in «uch ciiset of little impuriaiic« at the time. 

FtrUt l'»(alitjf,~-TUt deformity of simple hurc-lip unaccompanied by 
OllDniutioti of the palate is iinporinni almoki solely on account of ihe 
<W|ui(iMtit, though it inuii be tAinie in mind that many of thcM childien 
^■tother deformities or aic nmkly. and, lliout;h n ilbout anyactual malforma- 
'■^do not scent to huvc tiuffi<:icnt vitality lo make it possible to icar them. 

KI1CB. hoin<:vcr. the failure of tlie union ulTects the palate a» well as thclip, 
tin ill results follow ; the child is unable to suck from mabiliiy 10 produce 

* >*cuum in (he mouth ; its naial pasoa^es atid pharynx are expoMd 10 (lie 
to Md become affected with chronic catsrrii, its ton^jue >s dry and th« air 




>%■ )0>— $tiv* t>oulil> Hmi-IIp. Shoviut iht |najMilnE 

pntmaiilla. 






Hseasfs of the Digeitiv 

cnicrinK lis liing^ is tmperfcdiv wanned. Kvcn when fed with a ipoon tkt 
food often legurgiintes ihrnuifh the nose. Ilrnceio the already ircakljrcn- 
dilion Df the child nic .iddcd thcdnnjfcrs of Jnsufliricni nmrition and ratazrli 
of the rcipiratotj- itact. It ix not, therefarc, to be wondered nt thai oa)f i 
xmall proportion ofchildri^n so afTecied «irvive ; should they do m>, lhey«R 
Mibject to the further dntwlmck of impcrfcci and indivtinct speech. It i> 
alleged that many of these children die finm starvation, which xat^ U 
ptct i-nted liy operation : ue do not think this is true : wc believe tbey wod^ 
die in any case ftoin simple lack of vitality. 

In those cases where the child is tmnble to suck, il should be (ed in u 
upright posture, when the milk is toss likely to rrgiirijitalc through the noK. 
nr one of the special obturamr teals devised by .Mr. Maion aud oihen^ em- 
ployed ; probably the best of these is Oakley Cole*' rubber leat. 

The trtatmtnl ai liare-lip is neceswrily purcl)- opcratiit ; several impot- 
Unt questions have, howc\-er, to be considered In each individual rnt«. FlKt, | 
it is clearly of no use to opecale on an infant that is incapable of living Iron) 
the presence of some other defi>rmity incomiinlihle with life, nor in cases 
U'here the general health of the child is feeble and il is losing weight. sinC* 
anion of the wound nould not take place. No opexation then shuuM toe 
done unless the child is in perfect health, and the time of actually cuttinf 
tooth should be Avoided. 

A^ for pptnttioii.—^ttt conies the question of the liest age for op 
(inn. On the one hand it muit be borne in mind that there is a cert»»n 
amount of risk attending the necessary loss of blond and the shock in a veVY 
yoiiuK infiitit.nnd on the other hand thai, if the deformity i* severe, the eff^^=* 
of closing (he cirfi in the lip as regards moulding the subjacent parts itmC^ 
their nalurni shape will be greater the younger the chjl<l and the softer ttv* 
tissues. At has been ui-ll shoun by Dr. Randon, of Liverpool, and iKhc) 
a most remarkable modelling process in the oultin<: of the upper >«»' talc< 
plarc nAer closure of a harelip, and more than this, the width of the cleA 
a divided palate is much reduced after a lime by uniting the lip. 

Increased facility in feeding and the remoi'al of n hideous deformity a 
Other reasons for early interference, while experience shows that early ope»'^s» " 
tion is not attended with a specially high rale of mortality. -Many infar»** 
die shortly after the operation for hare-lip, but in most of these dealli is d*** 
to malnutrition, not to the operation. 

The common practice now is to oi>emie at any time after the lirM thr^s* 
weeks of life in the kvt severe rasM and a month or two later in the mt»«"* 
seriuui deform itit-*, double bare-lip being dealt «'ith later stilt ; operaiiw*'* 
are, however, often successfully done within the first few days of life. O*"*" 
own prefcreace is not to aperuie before a month in single bare-lip, noc bcfo'''- 
six months in severe deformity. ■ 

Optralion.~\\. is, in our opinion, much belter in all cases to give cWo**''™ 
form for the operation. The coronary arteries should then be controlled toy" 
bulldog forceps or finger pressure, and the lip very frecl)' detached from th^ 
maxilla, the diueciion being carried far outwards along the jaw, upnard' 
nearly to the lower margin of the orbit, and inwards and upwards so as ■<> 
freely detach the ala nasi from the subjacent bone. 

The extent of the separation will, of course, depend tipon the »e»-eriiy of 



3 



Har.--/ij> 



l6l 



: cam; : bat, ai a rate, failure is more often due to iiituflicieni scpRraiton 
liiut to -.xn-)- other fingk cntiiic. 

The bleeding during llii* pan orihc operation is often free, but is easily 
Dnin>)lei1 by pressure, .ind s(n|K iinmediately after Ihc Milcticrt are put in : 

ihi» reAum we snmciinics [wtc the edges of the cleft Iwfore frecinic ihc 

, ih<Mit[h if the parinj; is dime bst it is easier to adjust the edges rxacily. 

is v-cry iinporUnt |o slice anay the sides of tlie cleft freely, and not merely 
I tcnpc them or taXe an»y a thin shaving ; too little is much more often 
' bken away than too much. 

In adjusting the edges of the tinund, the chief points lo nttend to are that 
the proilabial tnarxin on one side eiactly corresponils iviih that on Ilie other; 
Kcondly, ih.ii the highest siiiure is well "ilhin llie nostril, so as to present a 
i;apat the iip|icr m;iTgin,aQd to remedy the tendency in Aliening of the 
ooMnl : thirdly, ii> intcn a suture on the inner and under [iiiiieous) surfarc 
«f the lip ; this mrire than anything else prevents the appearance of an tin- 
UEblly ivotch at ihe l<iw«r end of the line of union. The main sutures should 
it nudr lo include the whole thickness of the lip cuccpt the mucous mem- 

bnoc ; the inicmicdiaic ones niny be only super5cia1, 

Silrcr wife Hiiurcs,iifunlly about three in number, with inte(veoinKlior<e. 

fair Hitches, will be foimd very successful^ and arc, «e ihink, on the whole, 

Hkie-lip pin* are hardly evef necessary, and should noi be used if it is 
rBMble to avoid it. We have no| used them for ycnrs. If the lip is ficcly 
Mfuaied from the upi)er jaw, there will be no tension. Wc me^l somclitnes 
•fp*! pins in temporarily to keep the parts in apposition nhilt the ti-st of Ihc 
!i<X^ are beini; iniiened, and ilieo remote them al the end of Ihe opera- 
nt Ifitie pins ate leftin,ili)ioiddbcfor noi longer than Icirl y -eight hours ; 
■V m of the !tiiiches may be taken out a day or so later, according to ihe 
tanuof irritation set upand the condition of ihc child. Where ihc pourrof 
npiriifeeble, the luiures should he left in longer. Some surgeons prefer silk 
*r|W sutures. The lirsl stitch, if pins arc not used, should be put in uppo- 
iHiiIk pmlabial margin ; ihis answers ihc double purpose of cimirulling Ihc 
fnuty arteries and of fixing; ihc level of adjusimcni of the two sides. If 
••(♦fshare been mcd for contr()lling Ihe bleeding, they should be removed 
P" Won pulling in the stiirhcs. 

ieote surgeons apply a sitipofsttapping over ihe lip after the opemiion,(yr 
■f » Hainsby's truss ; neither is necessary. We prefer to duil ihe wound over 
•*boric powder and le.ive it evposed. The simpping it objectionable in 
|^i:i<iidt to collect blood and mucous disehargc from the noiiril, and ^o (o 
BlMetbe wound, ll is.howwer.iomciimesnise to pot plaster on for foriy- 
*>|lllKnm after rcmovinj; the sutures uniil the union is i.|uite firm, and il is a 
tMpUn i« lay a narrow strip of lint over the line of union beneath ihe plaster. 

if the child has aoi been neaned before the operation, it should be 
•S^td lo luck as soon as ii rccoveis from Ihe chloroform : in such case 
(MaHM be taken to prevent injury to ihc moiher's breast from ihe »irc 
wtHM, In nM>sl esses, however, the child has been boiile or spoon fed. 

In any case U»e harKU must be carefully secured by bandaging them in 
iWdiest uriih a itanncl bandiige or by some sin>ilar means, and watch kept 
4u H titjnry is done to the lip. 

M 



• 



>tsmsfs of the Oigeslit'e System 

The priticip;il inetAnifs of tip(raling fi>r amt^tc hare-lip are -is foilnwt ; 
cod) Ciuc tnuM lie in.inaj;nl acconliii}: to iu special iivvds, ou <me nKlhod 
niuncrini{ in all cniet : 

I, 1'hc cd^-ct of ihc iii(»un; are »iinply pared by a straiglit inciiian and 
brouKhi i<i>.'cthcr. Thii, though antiwerin); ucU In iiome caies, U api to leat« 
a notch >il ilic |i[olHhial m^ir^in unless there n alximlance <>f inuleiiil to u-oric 
with. Ity making the line iif incision sli^hiiy cun-ed, uith the coDcavity 
towaidii ih« dcfi, iht- nc.tchins ru;iy oficn be aviridird (tig. ;i, *,/), 

3, The single il.i|j mcliiod shoHn Jii fij;. It (<■, ./) n often ii^eiful. 

3. MntfiniKne*s iipenitiuii o( turning down t»a opposed lb(i» inay lie em- 
pl[>yc(l : it 'w chiefly useful for ca»e:i whore a notch remains aAer prcvioiB 
t>{)cnit)on (ii, b). 

4. I'crhaps the most ^aerally applicible n>ethi>di are thoie shoun in 

fig. 31 (c d,e f,£^ 





•JL 



,:.A_ 



Pigp ri.'l>iiMr'=ii^* •Slightly >^wr«<1 fmrn i^nv f i\^wii\\i SurcfoO ic "itow ih« mote ii 
nfmhinKind imiilniE iIm wlitn in iln^tlc han-lip lii.>. /, llicunsular Indiiao illoin !«• 
IbMlo lie iuii^<<l ilaAiiviiiijL tii i.iC. n >iiif)e n*p fium tJit IcD >ultii Cnd t» (Is epptvlg 
•Me, Ih t-A 1I4 bice* *I4 phTvt, ifukinK ih« Unc> uf LncHmk hiRHiftlv AVftnotr ineraiifa 
f iJ»<nU«Uiii('Hi(il'< 'rtcurigulu 0|icr«isn ' <>li]i hril. MrJ. jMr*. Ucloler itts). 

5. The more rmnplicnted operations of Tiiraldi* nnd Collix arc wMoaw 
eraplDycd, but it is octasionnlly vcr\' useful in carry the incision round th^ 
ala of the nose in teverc cases ; b}- this mejins the dc|ith of the lip can be 
1,'reatly increased ; thit plan nas, hc believe, lirst employed by Dr. Ran-donp. 
of LiveT|MK>l. Muny other tni-ihods are described. Oncn's is tery kimkL 

In double hiiic-lip two special difKcultivi have Iu be met, tlie auna(iemcRC 
of tlu.- pr.cliibium and of the ])rd.-niaxillii. The pro^lubium may be 

1. Piiicil at iii sides and fn-e exiiemity so ;i» to make a iemicirtuUr or" 
ton^nic-ihiipcd diip uhith is fitted bl^tueen the up|>er pans of the two lateral 
flap*, these hiiviny been previously jwred. 

2. If ton^' etiou>,'h. ihi^ pr.rUbium nuiy be brou);hi down Xa make the 
cnttiit piiTl of Uic lip, living; |ured only at its Mdea, and the lateral flaps are 
then fitted to it instead of to each other. 

3. 1'he <.«niT;il tlap inuy be (eniuvcd nlt0)cciher, and the two ude« brought 
together ihroughuut their oholc length. 

4. The prwiabitim, having been diuecicd away from the pricmauritla, rnvf 



Clfft Polale ~^^^^ 163 

be doubled upon it.i In»e and tunird tip in fcirni n cnlumna for che dosc. 
The first BDd second of ih<-ic pl.in-t arr ibc rrnsi KCTieni!ly >i»cfut 

Tht pnemnnilU in mme c.itrs mny he pushed gcidunllj backwards tiy 

coiuUnt prckiure with n pad brforr ihr Vi.-icr'lip is ni)Frnicd on, or jl nmy he 

forcibly pushed bnck nl once ; ihis is open to the olijcclion pointed out by 

F. M.num, Uut ihc wedging; hack of the pricmn^illn nmy lend 10 keep open 

the cleft in ihc paUte. Removal oC a wcdKc-thapcd piece from the septum 

iM»i 01 nrbicml picc« fmm the prrmaxilta is n plan sometimes adopted. 

TIic m^lhod we prefer where the pra-m.Killa cannot be covrred is (o shell 

oui the l>one, leavint; (he nmtO' periosteum 10 prcsen-e the outline of the lip, 

iu»d ilien bring the lip toci^ther : ' this, wetliink, is certainly belter than entire 

mtiotal irf the prxni^xilla. which ptoduces rtaticningofthelip. Wlieteihe 

pntmavilla is turned upon a vertical avi« so ili^it one edge looks forwards ii 

nuy be forciM) rotated into position, but if the lip can l>c united over the 

pKfixiiim the prominence uill, as Already pointed out, soon diminish. 

Any nnich left at ihc free margin of the lip or at ihc nostril can usually 
becWd by a sid>se<(ueMi operation. Should priioaiy imion fail ihion^'lioui, 
wtQenipt should Ik inudt at once t" procure seiondary .-idhcsion hy ctihcr 
puling ia fresh sulurei, or, if the liisuei ute too son and inflamed to hold 
Am. b>' apptyinjj strapping lo bring the sides together. If the thild's 
tnllh ^s gciod, this will probably succeed : failure is, however, often due to 
ouhiuirttion : in such ca^es union cannot be expected To iK'cur,andase<:ond 
iKmpt ihould be put oUT until the health is improved. It is wiser not to 
■f*nic too soon a see<ind lime 1 many casea tlut look unsatt^aciory aflcr 
'vniinn improve much io lime. 

TT>t parlictilar mode of npei'ating must be selected for each individual 
ix, liKiking especi;illy lo the site of the cenirul portion of the lip in double 
^■lip and to the inequality of the two sides in ihe single dcformiiy. 

CMi y»lat«. — 'Die varieties uf cleft t>alate have already been mcniioiied, 

TV wveter forms are commonly a*aociaied with double hareOip— indeed, ii 

"Wdtobc ver;' rare for double hare-lip looctur wiiliout i;left p;dalc, andno 

^vh ibn is true in the complete forms of h.'ire-lip^ 

Here a brief anount of the modes of treating the deformity can alone be 

Fntrhoice (he operalion should be performed between the fourth and 
WbjtB«, but in the l«s severe cases it may he done as early .is the third 
IWi hctoc this it is not wise 10 aiicmpl it,' unless m cvrcpiion.il cirrum- 
*»«>,Mnce the ri«.k boih of failiiie of ihi- operation and of the child'* 
* h nucb grcatcj, though some surgeons advor.iie opetation in the second 
P»r- At in all plastic operations, ■afc must br taken that ihc child i» in 
•••* hrahb. The other general niles to lie observed arc : the edge* '^ the 
■Ulamt be fiecly pared, all tension must be carefully avoided, the muco- 
HMwuin must be thoroughly loosened at tlie junction of the hard and soft 
Piihlw ID cates of cleft of the velum alone, no hard food must be given till 
"•w u roRiplcie, atid if the operation is only paniiilly successful or fails 
''leRiher, another aiiempi should be niade at the end of three mnnihit. 

' T^ niHliOd «U Inlru'tuccil by Sii W, I'Vn;"s'<'>ii. 

'Mr L'lunoM hoa opeiaicil tuuiMlull)' >n iKa fnivuntble csucs tA cleA irf the fofl 
^tMuianKMiib»od(l. Laiuii. Judi;^. 1887. 




1^4 



Diutues of the DigestitY SysUiii 



Stit(>hyU'r\i/ih}; or the (ipcratitm for cloiiirc of a cleft of ih* soft polMc. 
niniiits III I'lveh' paring; ihe cd^e^ (if the ilcfl tlirpu>;Iioui. then a «il)ic)cni 
noinlier of sutures are passed, iind next i)ic jiii.iihiTKriic "f tbc infi palnit^ in 
ihc hard is rairfult; loosened, «nd iinnlly, the ji-iLitc muidea having *«« 
divided to relieve Icnsiun, the suttiic^ are tijjhlenod u|x The exart mode of 
operating lli*l «■; prefer is as follows. Thr tliild is ann-Mlictited, a )nllow 
is pla<-cd beneath the shoulders, and the h<-ad atlo»*ed to bll riKht Ixitk *a 
that ilie roof of the j)liar>'nx is almost horitonial ; in this iK>»iiion liichl 
colors the innutli well, and the bWd and saliva collect in « pool in tbc 
pharynx insie-.td of initatinf; the Uryiiv. A (;a^ is then inacried, the whole 
of the cleft caiefully pared, jind then from four to Kevcn wire solum arc put 
in in ihc following way: a slightly curved needle in n handle is poncd 
tlirou^'h the edge on one side into the cleft, it is then ihrcndcd with wire and 
withdrawn, the wire is disen^aKed, the needle piiwcd vimibrly thino^h ihc 
olhet side and threaded with the end Jilready p.i«c<i ; ihi* is ihen drawn 
through the *eiond *ide hy removinf; the needle, brin^ioji' the wire across 
the );ap nilh the t»'o ends projeninj; on ihe oi.il surface-.' For the uvula we 
nficn use horsehair sutures. SVhen all the Miiures arc passed an inciiion n 
ni.ide ihroUKh ihc nuii'o.pcrintlcuni oi the h^rd p.)l;ile donn to the lioiw on 
c:tth liiie of the from of ihc cicfl and well away frntii ii,ilieiiiuc(i-pcii<Kteutn 
i» ihen carefully detached fmm ihc hniip ;il] mund the jinlcrior rxiremily (if 
ihc cleft so th.^1 ihc toft pnrtx ari: (\a\\e free and looie. NcxI, boldini^ All 
the sulUJCS lot,'elher in the left band, the pnlalc knife is ctarricd haekwnttls 
and outwards from ihc incixion already made until Ihr levator and tensor 
palali are freely divided and the velum is quite laK. .Sometimes it is u«ll 
to divide the p^daio-^lovius and phnryngctis l>y snippinii ihrnuKh the pillant 
of the faueei. If there is no tension it ii a KOnd pbn to make ibc rcLiKalion 
inciiluns after to'iitiiit; up the wires. A minute or two ii thcnttiven up lo firm 
pressure with a ipon^te upon the palate, so that all bicedliih' may be stopped, 
l-'iiully, the wires ;ire misted up : we usually begin niih Ihc middle n ircn, 
BS ihey bcariension best. The ends arc then cut short, ihe ticfl insi>c4:ted to 
see thai the lips are aecurately adjusted, and that there in ii« tension, and the 
xag is then reinoied. 

Various modilit-aiiuns of the opcnlion are of course well known, nwl will 
be found dcscrilK-d in the Kcnerjit icst-bookt. 

iJuriri); ibe operation ii is importiint to avoid the luc of »pani;e9 as Ion); 
as possible, since moppini; out the pharynx much incrtHtica the amount of 
secretion poured ouL 

Tile •ijler trea/HUH/.— The Iiands must be carofulfj' seturvd lo avoid 
iTijury to the pjilate. and no solid food tihould be given for .1 week. Many 
surgeons give nothing by month at all for fort}' -eight hours, and feed the 
patient by cnem.ita. Othets allow milk from the litsi. and sops after iwn or 
three days; others, again, allow soft solids from thefir^l ; probiibly it is better 
to restrict the diet to milk for lu-o or three da>-s and then allow soup and 
sops till the end of the neck : after this the <trdinar>' diet may be gr^utually 
resumed. avoidinK of course any hard or irritating material. The si itches 
we usiully leaiv to take care of themselves, and nothing mon i» iieeii 

I For knowtedce of ihlt moil ilmnlc plan we arc Indcbiid to oar colbiicuii. Mr. 
Hvdte. 



Cle/i Palate 



i6s 



f(4mi>W rhild probabi)- iptit ihcm mil. If.hnwcvrr, thc!/ are melting up 
lm|il>w, or if iaflvT a few wecli^ ihcy h^ivc nni come nuaj, Ihry should be 
nwt iv d. .\ny liiilc itraniiklmt; pnini or Simnll {irrfoTaiion tcfl M ihe ^interior 
itliniiily of the cWh nill ii^iully heal up of litdf; if il docs not do so the 
<ip[dlaiKin af mtraic «f siircr will (oinciinie« succeed, or in oihcrnMsa 
Kimd liitk opemiion may be re<|uirr(L 

Only one mode of perfomiiiii; the opetntion of Vraw/tl-uiy, w closure 
cj n deft uf the hard palate, oil! be de icti bed here ; In nur experience it n 
mucliminv iui:i-e:tsf ul than Ilie (itherplAns,and if iifaiU therein lessdiflkutty 
inaiccunil openiiion than after the Mi-cal1ed oite»|>bittic mcthnd. 

Upeniiton by mHso-fieriosU<U Ji'ifit con^Uti in larin^ the edges of Ac 
[Irfi thniughuut, then an tnciuon \\ made midway betnxen ihc alveolar margin 
<]f tht palate and ihi; cleA for its nhiilc knifth down to the bone. The bridge 
of uiuCD'pcrKHtcuin between the incitinn and the cirfi is then Mripped off 
!)« bone ^iili a blunt ra*|atoiy completely into the cleft ibtougliout it* 
■holt length : ihii moil be done mint ihorau^'hly, so that there is no tension 
■Faiikeflaps,«liich,ho^c\'er, must not be bruised more than can pouiblybe 
U^ The sutures ate (hen paucd its in the cipcmtion upon the soft 
rabitxnd luistcd upt 

lanseof upenti^in upon the soft jKiktc alone ne prefer the plan of 
piriitfdie cdites fint, then p4«sing the sutures, and then dii-iding the muscles 
W«t iwittin); the uttures ; while in uninoplaiiy ilie edjjes ate fir»t pared, 
thta the fttpa r^iw^d, ami lastly the sutures arc pasu'd and iwiiied up. 

l><|Uite youni; children it is an aihantage, if there is a complete clefi of 
bdlhudaodaofi palates, toclosc the soft palate alunc tint and some inuntlis 
afitr to dove the hard ; the union of ihc veittm tends in draw together the 
•dtlcf the hard palate during groMlh and m^ikcs subsequent closuie of the 
(U mre easy. 0|K-i3tion on a complete cleft of both hard and soft jialales 
thou be tcscrved for older children, ivho can better Iiear the inciciised 
Ktrity cf the more extensive operation. We usually do the whole opem- 
iMilonoe. 

T\*skap* 0f Ikt fialtti^ arch, ainsiAy alluded to, is of imporTance : ihc 
NlbtraiKl aarrouer the arch the easier in most caics i« the closure of ibc 
ddiiKucc there >s propnitionalely nwrc listue to turn across the ^p. 

U letnc children the cleft it so nidc, that is, ihe failure of growth of 
iIk palate processes i« so marked, that it is impossible to cloic the opcnuit; 
briF^isti^ o|>eraiioa ; in such cases an ohturnSor should be litted to the 
W- Opcmlion i*, lwu«ver, ncjirly always pniriieable. 

In seme instances Ihc delkicncy may be lessened by opcfsilion, even 
■iwatik oomplcic (ilosure is itnixissible ; a smaller obturator Is then sufficiem. 
■ Obtorainrs are liable to increase the »i»e uf the opening by pressure 
tcardiilly managed.' 

Tilr rttvll$ of tkt ofifnttion are, in successfi)! cases, that the po»-cr of 
mliuinsj[ is improved, ihc (i>od no longer lending to pass into the nasal 
h«*, and the lendcncy to pharyngeal cai;irth is lessened. The voice ia ool 
"■JtoKcd by the opctaiioo itself, but closure of the cleft renders it possible 
brwAscqucni training to greaily improve sjieeth ; and if mfficwt" «ire is 

' Cqlrf lUMflficnlnn of Sotnen's is prxib«*Iy ilie twsl obwiitor. \1de Brit. Ued. 



1 66 



Diseases of the Digesthf System 



perfc 



tiaiBinK 



taken it nwy be rendered pracii 

the cltCi rcinutns. 

Mr. M^iun'^ plan of completely dividing lli« soft paUtc backwards it 

ilevJKd lo rtiMcdy ihc rixidilj of the vi^liim, »i>ineum»r«sullin); xfteropera- 

lion, wliitli LMierlcTCs »iih tipeci'h 4od dv);1uiiiii>n. 

A high-pitclied TiJdf lo the iinmili soineiimei produce* exactly the Mtnc 

effect uptin speech ma ik-fipaliiie: thi* h;i5 been treated by Mr. Wairington 

Hawaii) by luoscnmtf the muco-periuiieuin and excising; a itiip : lite edt;i!S 

of the wound urv then bron};bt tujjether so ai to lower the pitch of the arriL 

Much inipwveineiii followed in his case,' 

OUtor MairoTDMUima.— Tlitr rarer foniis of congenital nuKoriiHitcm 

of the lipi reiiiiirc little more than meniion here 

A median nvaur* of the upjierlip is of extreme nrily.but does occur; it | 

results from coniplctv siipprc»ion of the low er pan of the pr-rfrunul pniccas* 

(T'/App. 157.158). 

Ctntt of Iho l»w«v U|» )u» 
iicca.ii<m;ilK hetn met wiih, 
asvicllaa a peculiar iiviinmil- 
lary projection on eaih sUle 
of the middle line. In mie 
iiitidincc tlie cleft ran down- 
nnfAi from tlie angle of the 
mollth. Murray is <)ilotcd 
by Mason as haviiij; seen a 
CJsc where jconjjcnitiil aac- 
(iili cxJMied in the loircr lipin 
four raembeis of one bmily. 
A nimitar case is recorded 
l>y Syinpson in the ' Itric 
Med. Ji>ut,' IJeccnibcr 9. 
im. We lutt-e also Men 
more than 00c of ilwsc i:«m& 



X 



I'jf. p>. — M^To-tncnh on Ih4 lr'1 *utr, «iih It fjiini 
(Mr. Sanlluai't cue] 



h, or cunt-cnital enl>trgcm<nl of the mouth, is usually uni- 
lateriil, occurs most commonly in femalfs, an<l is not hercdiiarj ; it nwiy be 
associated with brattchial fistular and supcrnimierary auricles loxeihcr wtili 
haie-Iip, as in a case of our own. In Gucrsani't case, 6);'"^ ^V M.ison in 
' SuiKCry of the Fate.' ihe deformity wa* bilateral and clejirly due to failure 
of union of the su|Krior mnxitUry uith the ftonto-nasal and external nasal 
processes, i.e. ]>ersisicnce irf the lat hrymal fissure.' In the more uitial fnnn 
it is a persislcncr ilicirly of the j-rcal liuccjil aperture from incomplete fusion 
of the superior and inferior maxillary plate*, i.e. of the miLKillary pn^-ess of 
the pi er> go- palatine arch and the lower pan of the mnndrliular arch from 
which Meckel's cartilage and the ioucr jaw ari*e. The ™mlition is easily 
icniedied by jwrinj; and tinning the cd^es of the fiKSurc 10 the re<iuired exicni. 
icaoroobeiUa. or enlargement of the lips, i> occasionally incl with M » 

' Luiiitl. Jiiniuuy is- 1W7. 

■ l-'oi * i]iv.-ittiiiin nn iliii mtijeci. w Mr. llland ^ulloa'» adiniroUe lectona. lj»nMl, 
I clnur)' it. |£$9I. and Tumrrn. lnHMfHl ohJ ifaiijpHiil. it)]. 
' I'iJt «lio tgi. in Ponlri'i MiuiH4mitt"' <l*> fteniittn. 




hrilia —MicronteuiU'- Matroglossia 



M 



\ 



Jial contlilion clue lo Uinptiatk overgrowth or cnlaiRcrf ntucoDs gland 
(dalM N.KVusJ. When ihc rfcfomiiiy is sotficicnily serious lo rc(|uirc treat 
■Mil, a part of (he lip in.iy lie mnnvcti Hihrr liy taking oui a ucdKC-sliaped 
pnenl' the nhitlc lhtckn<;» nf the lip nt hy sptillirtK ihe lip niid removing 
iianofiit thickn«Mand nrienianlssiiiching toKCiher the »kin and mucous 
imnbtanc^ 

Mlercsloma. or conKrnitnlly small mouih, is flrr.isinii.itly <iccii, ftod ocn 
oHnplcit cJiJiurc — iT/Ai-.i/.i. 'Phis is tre.iicd l>y eii!;trging the opening" tii ihe 
ntccuity' Client, slitchinx t<>>.'c(hcr ihc mtirous .ind cutaneous borders, and 
X. >ht tomera bnn);inx a flap of muraus membrane acriMS ihe nn>;lc to ihc 
tbn Siniibr operation.i mny be performed in citscs of ncairicial contnc- 
L trntfter iikeTiilioo, bums, &c. 

■ In ten '^'V ciMi (lie iimxiic til vonh'eniially ahicni. 

^L A rouinan deformity, thouglt nut nc.irly tii lommim n> it is popularly 

^MipMtd to be, it tMiKue-tle 1>T i:nn),'tnil^t shortness of ihc fr.rnum. Wheic 

^^llAinll]' exists the tip of ihe ton^iic i> so lied Aawa ic> ihc floor of the 

nnalt and inner surface of the jaw that it cannot be protruded, and Kiie-kinj; 

HflUlffially inierfered with : slighter dcffrccs of the dcfnmiily often exist, 

*Ue n rare cmcs the tongue it so bnuttd down to the floor of the mouth as 

b Ohtpmciically immobile <;anchyl<ielosi^u«). Ton^rnc-iic iicSMly reen>;niscd 

B b^FnlMiK up the tip with the fin>:er in the child's mouth; its ircninient 

~ nwito in snippin;; ihr'Hii;h the rdtJc of the fr;i.-niim with a pair of blunt- 

V^iiA scif^ors and ihE.-n IcarinK the rest with the Anger nail while the 

■<«|ie it pushed upwards. The division should he madcneai the jaw, and 

('*»<iU Ml be toofi-ce,or possibly the rAnincve*iclsmi|;hi he injurtd, or even, 
"V uld, *|oii){uc-swallowin>:' occur, fmm loosening of the loinjuc iiuisclcs 
■* Iht child's Mibsc<|ucnl cITorts at sucking. .\ more pinbablc danger i& the 
■Kttntncr of ccllultlis. 
Somciimes the tonjiue is malformed, cleft in the middle line, or even 
<nUeil,' or the muscles of one side may be deficient,' eg. as sometimes 
■abcial hf-miatmpby. 
HMiapwl oysM may develop in the median line hetueen thcgenio- 
^(toui as a icsuli of perfisleiKe of the lingual duel which nms from the 
'"mrmcircum loHanlt the isihmtis of the thymid; ihc caviiy of these cj'sts 
Khnd vith cpiihclium and coniains fatty malcml ' (Wafe p. \^o). 

Mur*ti«a*i* is the term applied to a congenital afleciion of the ton^c 

**hiih (he nomtal lymph spaces arc greaily enlarged and there is aUn .in 

••ftiroirth of the conncrlive tissue of the pan ; there i-«, in f.icl, c^ungenitul 

'flplianificctaiis. 71ie result of this is gTe.it cnL-irgcment of Ihe tongue, 

trt niay be kept pioirtiried from ihe moiiih to varying denrees, and liy ils 

ixt un»>cldiness tnlerfcies with siu-king .md hicalhing. We have alio 

.|l*ilh slighter degrees of ihe same rondilion ;iffevling only the subhngual 

■■•mmI resembling mmila. Associated lommonty with marrogloiain is 

'•pwu or one form of " hydroicle of the neck.' This n simply a similar 

**4lJon of the brnphatici of the floor of the mouth and upper jjait of the 

*((k ll apfieafs as a soft, dough)- swelling m the subniaxillai) ic^Jon, and 

* (IndillC, Bril. Mtd. four. Decvmticr %. l89^ 

> Owlel in Ulllaid's UtUdkt lU lliit^it. 

) niaiiil Sitttm. BriL XM. Jnr. February 17, 1SS6. 



I 








£>isfases of the Digestive 

may reach a large size, occupying llic ^rcitcr part of ibe sides and fl 
the neck {viJe diapter on TuMOt'K GhoviTHi. 

In severe cases tlie*c conditions rarely jidiml o* succi.-«sful treatment,' 
children are generally maraimic iind often oilierivise malfomied. Remon: 
of part i>f the languc nitli the i!cra»eur or excision of a ««dge froni it witbl 
subscquf^nt closure of the gap may he ;iilvnipieil. <)alvanu-piinciure. i'l«tn)-| 
1y:ti>,iel(ins,and injections ate all wurlh tliinking of, and pressure and aatrin- 
gatt* arc said lu have done good in some instances, Iimui^heicnictnliered' 
that hytiroina lOiiietiLiio s|)untaiicousl) disappears. 

Slitihtcr degrees of the del'utnmy are occusioniilly met with in oMcr 

patients: in ihctti the condition has a less ulmous connection uiih ilie 

irinpbatics, and apjiears to bu sometimes mere o\'erxn>»*lh of the mucouv 

I connective tissue?. 

, IS the icsult of occlusion of a mucous duct and the fomwtkcL 
ofa retention cyst, rarely it is due (oobstnictionofa»ubtinKual salivary duct. 
It appears as a bliiish-),'rey translucent swelling beneath the toniftie ; it 
is soft, fluctaant. and painless, but piuduccs deformity from pressure of tb« ; 
tongue uim-ards and ihctluorof the tnoutlidowrinardsand. if large, inierfntt^ 
with speech and deglutition. The suelllng contains a clear glairj' tlutd like 
while of v^^', KanulA may lie treated by excision of a part of ihc cyst wall 
or b;' passage of a seton through it ; Iwth methods are frequently successfiri, ' 
liut sometimes fail ; if the;' d" the greater jiart of the cyst »«ll should be 
clipped aoay with scissors and the surface remaining be well scraped oc; 
nibbed over with solid nitrate of siUcr. Kclapselsbelievediobesomciimes 
due to llie cyst being multilociilar. Karer forms of ranub are those due |i* 
enlargement of a bursa beneath the minous meinbtane (bursa of Klcisdi- 
mann), or of the one between the genio-h) oglossi mnscles— tliesc n»ay cun- 
tain melon-seed bodies. Kiumliu connected with the submaxillary dim lia«e 
often been described, but their existence is more than doubtful ; the ddct cnni 
always be made out lying on the surface of iliecjst. Congenital dcrmnid] 
cysts in connection nith the btanchial clefts ate sometimes met «ith in the< 
floor of the mouth : they mayjittain a large sire or remain slatioiuuy foi] 
years ; they contain the usual suliaceous mailer, liatr, &c. 

Aformof cyst arising in connection with the lingual duct which runs (roin 
the (bramen circuin towards the hjxiid Ixme has already been mentioned^ 
It is due lo persistence of the pltarj'ngrAl dit«rtKulum from which ilie thy-^ 
loid gland it developed, tlie ihyrco-glossal duct Viik * Median KiituliC of] 
Neck,' p. J 7a 'Die dermoid and bursal cysts are to be treated by (reel 
inciuon, wTlh scraping and subscijucnt drainage : in some cases the c>'st' 
requites dissecting out through an incision bcUi»' the jaw-. I 

Otber AKtootlona of tbe Toosiie. — VapllloBw aad eandylaBia artM' 
tonri>« ;ire not rareU seen, as uetl as n.cvi and murons tctcntion cysis-' 
I'.ipilloinata may be snipped oOj omdjlomata re({uirc of course sporiAc 
treatment, mucous cysts should be treated like ranula. 

Nitvus of the tongue is not rare {vide fhapter on N.f.vi) ; puncture witli 
the actual cautery is usually the licst tieatmcnl, hut excision of pan of ihej 
tongue may be required. 

Mason Itas described congenita) pendulous fibro-cdUilar lummirs of 
tongue. 




^ Brancftiaf Ftstum I(S(> 

^^yMTtropAy ud Atropbr oTtlM VKoa.— Ill some cam one side of. 
t^c [;>(« i« '.«i;;cniM]h Ii> [>ritr»phieil, and rantimiri to gnw more Tn]>i(lly 
Uua Ibc <>(hct «ittf. N'utliinj; lan l)c dune for ihis deformity unless, pcVhaps,. 
lipMre nf ttx; L-xtornal uroiid nrrt irieil. 

CtHgtitiia} Atrofiky, at rather .tntil of devthpiHtHt of tlie f<ice, is also. 
•KMiwull) s«cn : niusi often il n the rL-»ult uf cither ^diiic ccrcltral deiicicnc)' 
wtf Mine unilaictal legion, such, fivr instunce, as lurticollts; it may occur a't- 
I Uiir(|Btml ilcfoniiily miilliii}; frtiiii injury. 

\ l.'oni;cn;ul «tr«aiB of tlie inoiiiti h.iibeen already ineiiiioiied. but insnmc 
K(MH the ohatruciion is not at the tipi, but at the kvei of the ilium's of die 
nKM. and \% ilcarly due [o nuo-ubsotpnon uf the ^epiuin niaikin^' iwr ilie 
Uwdcal ini«luiiun fmm the pharynx. If this tute coiKlitimi i« met smiIi,. 
■fntetily free iiKiiwn and dilataiiun would relieve die obstruct i fin. 

■ Actual afMcnce of i)ie mouth with deticierit dcvelupnienl of the facial 
^oft, iml in«tatKv« of apertures below the nutund poiition or ou the check,. 
iM't been HK't Hiih. < Vide Billaril, opi dt.) 

Ilallard has recorded t, cate <>f deformiiy of the jaws produced by tbuinb- 
Mkinj, tlic upper jaw bcinK dniwn fot^nardn, iind the lower deprcMcd »{> 
■biibebice ia 'owrhuns.' ' 

BrsaeltfMl riMala*. -Snull oriliccs Iirge enough to permit the pasia^e 
, 'ftfiM'pmtMr for distant cs varying fn>:ii .niuiirlerof an inch id two or three 
LMiinarG someiitnes nici with in the iictk on nnc sid<^ of the niiitdle line. 
llVf eay occur m the immeiiiaic neighbourhood of [hecxicrnalcir or lower 
ld«D in the iH-ck ; the most common poiilion is lajd in be juil above the 
BXmi^aijrubr joint. The line clt.inncl rontinuous «-ilh tJic»e opening* 
BnaSyruni up-nnrds and towjirds iIk.- middle line. A little watery mucous 
|dadat|fe a often secreted from gbndi lining the inleriorof theiiiiMa|;i', and 
Viiiiaid thrtt occasionally there is ii distinct ci>mraunic:atioii with the pharjiix. 
KDntfrilulit-, iibidi are often hcrcdilarj-, m;iy be single, or there maybe 
■tivwihrceof tlK-ni,and Ihcy may be symmetrical. Fragments of cartilage' 
IM)' be found in their neighbourhood, and it is possible thai pharyiii;<al 
■wnuculB nuy result fioin p:itcncy of the interiuil orifice. 
B Tin presence of these fisiulic is due to iniperTecl obliteration of the 

■ hudial defts of einl>ry»nic life. 

P Vftile tiK iTCTvital bniiu:hial listuUe arc nire, it is quite rommon to see 

I <nUfM in H'bnm tJierc is a sninll jicndulous body, like a moltuicims growth, 

1^ iht cheek just in fnml of the external car. .Sometimes there is morv 

*»iioot ijf thcic, and very often -it Ihe base ni the little body is a minute 

■ **! leading :i ihiirl distance inw.inli. We have most often seen these 
I ' ^ffwrnuMntey variola*,' as they arc called, unassoriated with any other 
■Mnni but rn one inst:mce ihi.- child, which had several of these auricles, 
BBpHrtSt rtui iim J . double hare-hp, and cleft pidate,anda small pendulou> 
^■Wrnaetly like one of the auricles upon the lip of Ibc tiosc. Oo\ friend 

*■' ^tluin has recorded a sumewliai jiniilar case (fig. ssl. -ind Mr. J. H. 
"wiwi amither. Cervical 'auricles' are also met "ith '_viJ€ fig. ij), 
lilt cervtcal branchial fistulwr reprcMDt the clefts between the hyoid and 

' AA &r. Tram, ttk xv. 
L , llaNi ncMdt a «a*e in ahleh a rodof Mtttlaseexlned. iiui no liiiul* IfiMk. Stt. 



fk 



.*■"• 



1 70 Diseasfs of the Digfsfi^ 

l1)>T<>liyoicl arches, or betn«en the Ihymh^tiid and sii)>hyoid, or ni;a>R 
iIk subhyoid arch and the upper boundary of the irbcst, while ihc pr« 
anral liituU occunini;. as it sumcltmcs docs, in ibc helix nrcttevitiMi 
10 persisience of one or moic of iht Gssurcs betnten the ' tubcrclei ' 1 
ihe pinna i* tniilt up,' tli« supcmuineniry auricles thcmscK'cs rcpr 
diiplnci^ ot ununiicd ■ tubetclM,' 

The cciminoii ' supemunicrary auricles, which niay or miiy not hav 
pit III Ihcit Uiie.' are th(>u};ht by -Sir J. I'.icei lo be proUiWy >to>wth 
umt.' »|>cn:uUir skin fold ii^ the auricle, rmm iihich they li>cik like 
tached, or they iire auricles dispUced, bui still in ihc line 01 icym 
mandibular arch.'* 

The auriclu, somelime» at least, contain cartilage, aitd llic amoc 
cnchondruma of the jKirotid occurring; in later life with disturlnuci 

development of tlicM pAits h; 
poimcd out by Mr. Jacobtnn.* 

In very rare instances j)n c 
ind with in the mcdiiin line of (I 
or this we have teen fiiur ntta 
our onii and two in the ptactic 
i.[)11e-i);iica ; in vne there wjin 
the skin clo&ely resembling the 
a tracheotomy wouitd. aikd in ihi 
of this, jusi abote the siemtmi 
small oiicning : in the second cti 
was:i ditih^r^-in^ (i^lula over th 
part of ihe thyroid caitila^c. 
median apertures mny he cxpla 
f.iilute of the btjnchtal arches 
in the middle line, or possibl 
deficient closure of ilic ■Kintis cci 
It is. however, most prot>al>le th 
a fistula, the ■ thynv-glnssal d 
''canal of His,' is, in the words of t>r. C. T. Matslull, who has kin 
ns his paper on the subject, -j remnant of the midiUe thyroid nidi 
His. his not difftrull to ima^ne,' hesays, 'tlwi this may gr.iduiUly 
(UUted at its lower end inlo a sac by the secretion of mucus from ih 
the canal, attd that ihisMc ultimately cauMrs the »kin to )[ire way by 
sure tin a sinus is formed,' Or. M.irshall.in his inieictlinv jupcpi 
llut these listuU are not present at birth, but appear biier,a sIroDg 
support iifhis view, u'hich i» now Kcnemlly accepted.* 

As tliesc branchiiil futul^c itivc ri)* lo very little inconvenience, it if 
best lo leave ihcm alone, especially a» they are intractable to trcattni 

> I'Mr Mr. IDaihI Kuiton't Ledum. B'it. MtA /-ntr. FcbniMT 19. t887. m 
Fitmuy len, noit bu l»ok on Tampvr: iB^j. 

' Sit }. PttK^I {.Ut^.-fAir. Traiu. t8;4l, rnxn u-bworilinits ntiUhor«ilrial 
on ihF uilijoci t% vCtxB- 

' Vide GuyiKtfi/rti. 

* JW^SI( J.P.mt. 0|xcit. : *!«) TillauK and oibnt, l^ Pngrtt MfJif. Fel 
1885: Dr. C F. Uanboll. U-i: // .*«*. ««.' Ftn. vol. XKtt. ; alM 
H'if^Ul Xtftrtt. it90, Hnd Snf. .Utd. />wr. May 1890. 



V\t. fj. — ^uprtimmar^f y A<jri«:lt \i\ lh«»(4L. 




Branchiai Fistula, Q'c. 



in 



nbrougMy dcstroyinc thrir sccrciinj; Mirf.ice. The p.i<.s.it;c 
ire dnirn thcnt.c.r [uftint: ii proljr in and il-.cii liitscriing round ii, 
c o* the ^alv:in>c c.iuicr>', i* tl>c pi"" u^iii.illy advi^cd. In ihc 
our mcdbii fihinl^*^, in whirh there »ms a ' pinching ' |win in ihc 
filh totnc trouble sncrccdcil in oblitciaiin^' ii fur n time by scvcrjil 
ns of nilraic of silver fuMcI ti[h>n .1 wire .ind p.iifc<l well up the 
b»c(|ucnil)', hovfct'ct, ffcsh wrreiioii occurred, and even cxdiion 
twirclynire ibc condition; however, complete ciiri»ii>n of ihe whole 
(he on1> ai id! reriam method of rare, nnd ihU mA>' involve k 
troublesome diHenion. 

tumcriry aurkles should l>c simply snipped otT, Thi-y rr>n*ist of 
mI of yellow cbftlic cnnilagc coveicd with inic^umeni, and tire 
vith a iniall artery. 

il of fisiuU-, «>nt;eniiid dermoid cysts mny lie fntind ninrkii^c the 
le various ftutircs &c. of ihc embryo (Wrfc chapter on TimoUK 
. Ckitlon h.is described a rase of rongenitnl p:ipiltomi> in the line 
itchiat lismres ; and cases of piimary c-ircinonui in the neck, pro- 
IE otiicin in relicN i>f the branchial rlcfi^, h.ive hccn rciordciL 
le of these patients the lnwcr ja" is impcrfcrily de^■clc)p(■d. 
ibe beit account of ihe varioui tlcvuiopnii-nlal abninmaliliei uill 
a Bland Suiton'a interesting ' Tumotir.i, Innoccni and M^ilignanl :' 
Cft 1893. 

<n of the digestive tract may be the tejit of con{[cniial malformu- 
Mitiun 10 ibiwe already describcil. CimKcniul Mritture*' and 
i'ol i)i«cc»oph.igUK. tracheal fl5iula,'i.lijpU(.i'muittso/ilie»iom3Cli, 
ID ii( the pyloiui, absence of jxitliuni of the inieitina) canal, and 
>cnt of it« various sesmenl^, an- all met with, and in cenain tase» 
: «omc surgical inipoiumtc ; tlicy cannot, however, be iliicusseil 
itcroiumy might poMibly bt of service in lome ciise* of congtniiul 
deformity where the ob»ltuc(ion was low dowti {vide p. ijo). 

!wi9d Tttmrr maiilunk ic>vn mut in Xiriiitwrn. Vide Path. Sn: Tr-im. 

ma htwMnOr lUiltt llut rangimiliiJ pouthinE ii pvtmnFly nirv_ 
Im «ionitMnnl wllh -iTuphBgaU ilcllucncy uoullj ut the miilillr [hlrd «t Ilie 
ta ponlilanvrot ihe cnibr^oiiii tonttJiiun (Sir \L Mockcnilc}. 




rjjt 



Distasrs of the Livtr 



I 



CHAITEK X 

DISEASES OP THK UVER 

Ik eiuiminiiiK the lit-cr of :«» infant or youn){ child, it mu« b« lK>me in i 
that this orgiSn it propnninn.-iiclyUrKrr in iherhild ihnn in ihc^ittiilt ;it i 
scquemly occupies a ^,m^\cf np.ire in the ^ibdomlnnl mviiy. and ihut to^ 
inexperienced ii miiy nppcnr to he enlnrh'ccl, Hben In rcntity ii i* 
normal »i»c. The fari pninlrd oul liy Sahlf mart noi he forgoticn, i 
thai ihc 3n>,'Ic made hy th<' lovier rib* wilh ihc lip of ihc slrmiim i» nr 
children than adiilli. %a thai more of ihe liver is left untrovered in the foi 
ilun in (he Uilct. Thi« may lead to the liver -ip|>c;irmtc larger than it i 
ii. The upper limit, a» dcicrmined hy pcrcus»ion ; Nupetfinal dullness 1. 1 
10 ihc lifth spare ai the right eilge of the iicmum, In ihe upper border rf( 
sixth rih in the nipple line, the seventh in the .ixillary, and the nintll | 
leriorly, though the deq) <lullne» reaches ioinewhat higher. While lhe« 
of the right lohe doe^ nitt in iin ailull extend lieiow the costal nrrh in) 
rccumlient position, in a rhild it always does. The sin; of the liver can] 
as icadi))' cdimatcd in n child as in an adult by pcrciisiinn if ih« no 
not over-distended : the lower cdgv can, howwer, be much more rcodif J 
in a child than In xn adult hy plarinfc the n-anti hand on tlie abdomoi : 
f!mi1y |>rcss(nx hnrkwsrds and u{>«'ards. In most ca«cs it can be 
determined if the edge is round or shaqi or irrepjUr. 

The liver it not ofirn sni.itlcr than n^itur^l during childhood ; tlisMt 
ill the mrc insiinices of the occtinetice of atule jcllow atrophy or dr 
and even in these rat'es it is by no meiin!i aKvit>-^ dimmished in sue ; i> 
it is frcijuentiy cnliiri;ed, a reiuU whiih is due partly to its vawuUr aaD 
itl vein* being ver>- readily dislcntlcd. and partly also to the reiidy <ra]j 
which it appears to store anay faL 

The best instance of itv eolartjement from mech;inical cauMSi ball 
l>y the congestion wliith *» frequently ikttendi heart disease, where, in i 
(|iience of rcgurgi latum through the Loitra! valves, there A an ohiirociio 
ihr (Miuiird flim of the blood. It is cnlur^-eil also in nicdiatilino-peric 
for a limiLir leason. I'htre appears al>o often t« be a temporary cnt 
and a slu>;Kish drtulation in many cases of chronic inte&tinal t.tt.inh. whe 
there is said to beahinciion.'ilderangemcntof the liver, actiwnpanied bjr lo« 
af appetite and |xtsty cooalipaied stuob delicieiit m bile and an n(.ess o 
pigment and perhaps uric acid in the urine. The liver is fretiuenily ■ 
from the presence of Recess of fat ; more rurely il is amylotd, or ibe 
new gronihs or of abscess. 




Coagatiiol Jnnndke ^^^^ 1 73 

iami^-Tlic roniiixiii (orm of jaundiic occunrinn in newly born 
^ akcati}- bctn discussed ; the rarer fiimi in which jiiundice 'vi due 
I iifihe l>ik dttirts maj- be here r<-(«iTC(l \n, 

t«DlMI Blrlctar* or OMlteratlao of tbe Bll* Bnct«.-)n lh»G 
««» nn "U item I ion <if ilic romninn hcpati - liuit* appcan I" Uke 
tiirh tc.-)(U to a wcondary or biliary cinhriME of the tivcr if the mfani 
fcir a few Rion<h«. The child may die from biiTnocrhaue f"^"' ''"^ 
inittro-inieiiinal ranal during ihc fir«t few d.iy* of lif& Such cases, 
l« common, arc hy no niea»i r;*rc. Among the inoic recent lyrei-<iritcd 
t ibmc >if Wickhain l.cgK and Claister ; we Imvc ^ccri iwn ciuei in 
]lopsie« were made. 

^tpmt. — The infant i* jaundiced frnm binti. ihc )tI1ow colour bc^n|[ 
affisrting tbr «lti«, "injunclivii-, iiiucou4 mcmbmne. and urine ; the 
« (uie and < oinplelcly devoid of bi1c. The infant frrqiienily siiffM* 
nMwrhnKcii, ihc Mools iben bciii>,' black and (lie tkin covirrcd itith 
tw*. In one of our raws the minions were stated by the moiher m l»c 
imediaie'.y afw-r binh. The live t nuy bcenlarsed. Such children 

I for ;> f<ri» monihs ; both of our case* lived to be 4J months i>ld. 
Owing caic illastraies sonic of thcM: points : 

Wu/ .ttimt' ff llrfiU. Drill. UHUtry (VrMhu/f.^ohn 11 , itfrcd 6 ixvki, 
|M la Ibr uui iHiJuiK dfpnrinirnt cm Ocloint j. iSSj, nilli the roltuuiiie hi»- 
(ho lUki lie -lii on bght'tiioiillii <:li:U, bmn allci li ii-ilimu labour. Atnul a 
If I"rth •! "iS ntitiofij lir win j.iuii(lit«d ("ndiiifr KitiiA he wai jvllow whrn 
t wlBt nu iltiik jin<l iiiitiiiail ihr IincTi , (he mooIi wi-ic looic nnd late grcr in 
V •IhI not ' inwfltc.* nnd Iherr nern nni iny ruh. On okaminutinn, nlKn 
M. he MTU drciilT Jaundlonl; ffiiily ncll nounihcd : ihe rdf;e of tlic \iivt nu 
rtiileli bclo"* llw tibh Hkiobct S. — Much thf unii-i ilmtrbirj I rriiililncniiF. 

t milky ttooln- <.>:loticir i^— The ]i<rr li> Enlnrjod. Vac cil)^ tieiii^ fell ncnily an 
I iht uail)iI>K» ; il h>i brrn mcreuing in liw ihi piui wevk -sr lao. Novvm- 
)itv Uill isUicrd 1 ttojl' IWHr. irti'mbtiiiE milk : Mill inlcnacly jHitnrlk-i-d ; it 
i'hti linn, I •erentbcl &. — l-i*Fr (leculL-dli leu : cllanhii-.i noi » troulili^ionie ; 
b» Bntlpr. IVonAhcr 30b^n^Arrhrra hut licrn crv (TcnthlcbJinc > o-^m'ultionfl, 
!■■> 4 mosttii old. He hnd not •! nny limc luflcrid ttDm piupuni or turmor- 

•«<«■.— Itody mirtnicly einociaied anil dcepl) jaundiced : itl iniciiiitl tltiue* 

II Hcarl, niuurulai imllt paJr fHlo-a ; kiilnrss di(|r>. I.ivcr, ■} tn. , ilMtnot 
firjnl : Il erf a duty dark flrren oaluur. turrnci.- IViiely sr4nulai : no iidhci.iani at 
IWlh IV malting of ptirtt in ihrTmurc; it hji^ a Iiiiiie'i fr^l. and cre-rik^viificr the 
liicul: the miiioo thowi a dirt. jiieenTOlourn'Uhiirjftdi d( Ubious iiiiue, much 
^llH normal M*ic. accoinivmyinji ()ir p-irul rmwk : ilie^iiraniliiin' Wil imirkcd 
minave of the laiels m the liuuie. uvl the Ijj^r Ink chtinneia ue more or 
M mm! (onkiin ihivk icr«-(. lirl.-. On (tni'iiiiini! Ilii' idfcnut siirfni".- 1>( tlic \\va, 
MiUcr U iMndiilendnl i.tx'a a non.brtmty niutoid lluid . rii. ducu cui tn- ii.iuhI 
t. ii..ii..tt uiulkt Itiaii nii(iii.i1, i.Jili.' iliicHii ^h^.ltlJ«hu^ i Ihc billet jommj; Ihff 
I .fnial poviioii 11 [KT'linii -iiid oinUi'itii niueui only. Nii inwr nf a 

4iKt cm 1v roimil. Hie [vnliilvcin nnd hPiulii- nn«ty nrrappircnlly 
a>al. MictOKOfiKi-il rt.iininaucjn o( lim ihowi cuxtA of fitmiui liuue »ui- 
l|H«1al trurit ^irul Kitnilct \ tn.iny >[iull liiliar} liucli nir mil rlioki->) with 

*r.— Tlic ohsirxictive jaundite of the newly botn tan be readily 
: from fiinttinnat Jaundice, the only form likely to be confounded 
I)- the stools in the former bcinu colourlesn while ihc laiier contain bile. 



'74 



Diuases of tfie fJver 



Morhid An.itti»ty. — Th«re is muth tin^ici:iiion. llie 
iijicnscly bileilaincd, wilh minuii- !ui:iii(irthui,'e» on iheir 
li\<(.Titi1ioit]y<'iiLir),'ediindo/u dirty (frccn colour ; thesarfaceiaf;TSU»ll>V 
];niiiubitons varying insiie fruin^i millei ivedio.i he in [i seed : iihiuaia 
feet, and f)ii section an txtcst of librous itiandt is seen atconi|unyiBc1 
ponal vcssch— this is moM marked a i tlic^rcui fissure; thcbrt.'eTl 
channcU contain f.'Kvn inspissated 1>ilc. On cxaminiiit; l!ic t-c^ictt mUc 
lmn»vcr»ciivsure, ihc vein and .irtcry sly- tniaci, bat Ibei^all bljddcr is utiallt 
small ;ind contains no l>ile, and ihccnminoii and hepatic duci6.itc cither diii- 
veiled U]> and ne-.irly obliterated or pre.itlydimini^cd in siu. MicrDscopijI 
cuaniinaiion of such livers shows biliary' cirrhnsis. The ctialo|,'y of thtw 
rjysr^ is nbsrurc ; tn sonic cases app;ir«ntly the diKis are never formed, la 
one of (Nir rases the inolbcr had sulTercd from sj-pliilis, but nciilicr <rfl)w 
infants shoucd any syinptoms. It is possible that a calarth of the bile-dixi» 
occutrin); during fci'i^l life or a bluclca^je from iii»piss4ted bile mi),'ht ItailM 
a penn:)ncnt nlistriictioti And obliteration. The cinhosis fallows as « rewit 

Projiniish.~?i\ic\\ tasci are necessarily btal in a few nioiilbs itrtd hwdlf 
adntit of any ireaiinenu 

Catarrbml jBimdloe 

Giildren nf all A|^s are apt to sulTer fmrn a temporary jaundice. > 
dated with gastm-intcstinnl CAtnrrh, attiiliniable to a swollen ronditica i 
llie mucous membr.tnc of tlie duodenum and common bile duct. 

Sjfmptotnt.^Mitr a few days, in which there ate symptoms of d>ij>t(»i»,| 
the conjimcltvsiL- and skin l>C(omc yellow, the urine contains much jngnic*!. 
and the stools arc pale. A few days later the liver may be fell to been- | 
Urged. There .ire rarely the nausea, low lempetature.and slow pulse soofie 
seen in the raurthal jaundice of adults. We have, homever, seen one ■ 
l«'0 rases in which there were jaundice, delirium, drowsiness, ar>d slight fevtfp 
Id which ne suspected acute yellow ^ttrophy, yet they linally recovered, aril ! 
ue uere left in doubt as lo their nature. As a rule, ia the course of j ie*\ 
da)-s or a week all the symptoms dis.jppear. 

The diacnosis of catarrhal jaundice does not usually fjiverisc to diflic 
when it occurs in children. The possibility of the jaundice being ckw 1 
acute yellow atrophy must be borne in mind, and any crchymoses or bralsl 
symptoms would be very lUUKCSlivc of the latter. Jaundi<:educlo cirrtioMi| 
or new growth, or syphilitic disease, could hardly be mistaken, as jaun 
under these circumstances uould not be an e;iily symptom. It ii poaaib 
tliat jaundice may be due to round worms finding iheir w^y into the du 
num, and entcrin): the common duct. 

7>r-i/jw^«/.— The treatment of rai.irrh of the bile-duct* shtMiId be : 
lo that of gastric catarrh ■. the diet tonsislioK of l>eef te;^ bread sop^ lvtt-1 
puddings, and milk. Sulphate <ir phosphate of soda may br fc-i^-cn " ith iafa- 1 
sion of rhubarb two or three times a day. CarUbad salts or FriednchiluB j 
H-ater is uscfiil in keeping (he bowels open. 

Ae«te Tellow Atnpkr of Use klTmr 

Thi* curious .md intcresiinj^ disease appears to occur at all petMMU < 
life, infancy and i:hiIdhood not excepted. Set-eral Continental writen have ' 



taitf Vefftru' Atrophy 175" 

mBS^tctumiiB in ii)fum» <i ftw d.t)*!i uld, but wh«ihcr ili«e wete- 

litililv Imc caiti of ycilo" :iiri)pliy mi) he open to rioiibl, I'ndiiublfdiy, 

1 who .ire j;iitn<lii:i.-<l shortlv after birih die in ibc coui^c iif <i few di>'» 

|«Hln Willi 'iym|rtiims of iiruie diM-.ttc, bui, iw f^r .t« t:itn be judged from 

rniiiiits iIk- iMked-cy'e appcarancet of I he livci :ificT dcntli were ni)[ 

Bftully linimd in actiie yellon- airophy. In such obscure di^cHses ils 

I BORicd After lluhl and Winckcl, jnundiiT occiirc. While this disease 

be sflid lo be romnion .ii .iny lime nf life, it is perhaps rarer in 

than in eiirly adult or middle life, ihoitj;!' i< is vcrj- piobable thai 

I we not infrequently oveitonked, in^simiTh as some of ihe recorded 

' t»M were not dijignMcd diirinx' life. That they .ire not rare is certaiu, as 

III. llylft fifeves has collected seventeen cascB besides one obscn'ed by 

haitclf. Wp have seen iwo casc4, one of uhich occurred in a boy of 4 

■n, uikI we have bad the oppgriiiniiy of «uiiiiiiin){ the liver in a case of 

h. Kiii lion's. 

SymfUntiis.—'VNt dis»sc be«io» injidioiisly ; the fitrM sj-mptoms arc 

rfn those of cnCanhal jaundice, losK of appetite, con Mipal ion, and Jstindice, 

r iliiols arc mouly pnle hut lomclimei (|uitc normal, .md the urine is biic- 

Thc patient iisu,illy tcm.iins in this condilion for a week or two, 

lliK ithich lime neither his friends nor mcdir.-il .-ilti'ud.uii suspect Ihc 

< naluiv of the discatc The liver at this j>cri(id U cnlniifed iimd in 

teases ditlinrily tender. Thenromc distinct cerebral symptoms which 

By not impri'bablybe mistaken for the onset of tuhcicuUrmcninBitis. The 

is iniublc, vomilt repc-itcdly, rambles at ni^ht, is perhaps very 

US Of convulsed 1 thr pupils are gencnilly dilated. There are often 

niisri .tliout the body at thi.- seat of flight itijuriesand oozinj;; of blooit 

1 ihe Riims .ind (i-dema ot the feet and face, .^flcr a fe« days the child 

tinloii •onditiooof coma ; there are also prob.ibly iiiusnilar tniichings, 

lU sevcTikt i;ro"|>s of muscles, as the ma^seiers, am! perhaps local 

Cv The urine may contain leudn and lyrosin. In the later stages 

tfcrtrdiminUhes in siie. but this is nut invariably the case. The folio uini; 

[ idnslmief some of these points : 

11- .llivftyt/ /jiY^,— Slephcii T. , ngnl -t yoirs. Atlmtlleil Supinnlur »7. 

i ^ ' tVfiii. Xrj ^IsXijTj Elf Cf'ni;i'iiiiLil typhilU co»lil tic nhtjiijird. r'athtrr is d 

\iian , loir elrcumstnnco. Child luibcrnmueh ncsltvlnl, nndtificii hiiil m'ufllcimt 

l-vMr «tvkk licfnn^ .idliii^ticin c-liiKl ciink \«ry liitli; iifmiitlmirnl ; Ihvamii' yi'Llow 

lHsipaai^|hhl^]. Kimricvii lUyi 4i^ofornJitn|f hr^.m, nn<l Utrly h<-- h^d bf n <.kUr>uiiA 

l^^lieilgufrr 1(1 ttit mivt, Pn-wtii sliiIr,^J\i(icTU r..;h w>^[1-■11r«v^■pl-,j Vn'n ; mtHlcmlv 

^4a. DtHV U (nkiua i>( both e>i-llili. bick o( liind*. .imi doriuni iil bolli ftri. He 

^tafnulj nii«nblin|C to htiX'Ctf. atiil ilni nni rr.nlily umlenMnil nlint it uiil lo tiini. 

ril .11 (lie tip .inil n)g« mid coaled on d-irium ; he li inny Ui'my. but 

'•Hit hit mitk iiiimcitlati-lvafirr it '• l:ikri>. Alxlomcn toinruhiil ill^ 

I ( ditliiK.'tlr r<.-U bclaiv c<ni,il arch and m i.-pi|jivltiunii, uiid on ptt- 

I iliJi»ii « ntmdi DimMnii to \hv foiirth >i[lici-. T>"- li[> nfthi' uplivn it <cli tieltm 

ttdlk Hmn'xound nonndl : nnmiukcd phyiic^l iIkii In chnt, L'rini' tounl 

I Ictn « In lieH ; tomr t*)nrnt'-l from Ixrrt toMu'meJ bile |)<Emrnt : no athumm : 

■• or Ifnitin uaclcr iiilcdiSMipr. I'lvcn. piuc^I n li.-n t1<>ur> iifti't ndiiiiMion. ■tm 

•d of ■ diik hroua miour. I'upiti dil.slrii. Iiu< ncl l« listil- Pulte. loo. urmk : 

ilttfF. ^ F. .Srcuni] djiy fctf .iiliitr^^ion). — Vunijiiiig ctirtlinucci muM of ittiy. bul 

Irtw pPiMoniFCfl milk nu gintn. 'rrniprniiurc. ^^'-loo a". Third day. — Lcw 

t; h«iiHinhacc from iiic»u(h, ii]>furinitly fioin ituiiii; bcvtcU .uwd onco after 



176 



Diseases of the Liver 



calomel, ulid braMn motkni : ■■» wine putted ror (wcoty-laur tkonri. Tonpaau* 
•>f''-i9i'9*, 97-t*-iiw8'. Founh ■U7.— <.'lij]>l liM tmn ilvllrinuK, Biih kii» nuNOl 
li^IcbiniEt of bifr and nock. TIid niuriili>K> '''(< f'ifxil pirnljM* iiotlciil not affoctaf < 
••yc: ll li well mafkcdu'hrn child ctii-i. hul riol complcic ; no r»rAl5>ii pltcwhml ft$ 
dilnlril anil tluin:i>h ; rhild 'inly >cnil-i;on>diiLii ; >ii'>cnil 1ng>«>l(K'U (Ukuxl dAftolM 
1I1F Hnt llRbl ycllQs, UhT p^iIl- RrF^ col'ijf ; no urine obliini»] ; e>l|;r of lnTrvf>T4 
imrllv (rll li-lun cosi.il jnh, Pulu-. 10;, vT«k : li-nipiT.iliin-. ioi1l= lot'- IM'SV IM 
KJftli dav-' — Mnch wonc ; it quite uncontciDut ; haul nnd vvz\ lumnl to rlflhl ; ttlib* 
Filrndwl ni«l neid ^ iiKumi of jant raiio'iii; toniri.-inl chiulini: nf iritb ; tfod* 
tlrrliii'iui ; no oplic iii-unllh, tnil >«ini nrc fall And tonirwlinl Uinuuuk V\iitit, 1 jo. •* 
lemptraluiv. loitl 'tOO°. I>ivd in nflifnoon. 

Paii-wtitritut ftH<^niy ■(<••> hoiin nFlcr d«th|.— Ifady w«U nnariihed : (Ilia wrr Y^ 
much hypiMi.-iI ic conirrttiiin of dr[H-nili-ni gnrtt of thr hwk 4nd wmt -ind lq[i; '<it4 
Sround' m.iiriinl "•Xing frum mouth: no '(giir morliii ; tl'ijhl irdi-mi : a ItfuiM dt 
lite of a peniijf it viiiHt on Ihc tiitxl.-iirrmlnr rq^ian. trl^ lidr. L'hi-u . no lliwl I 
•dlMuons Infl tide: >i|;lil Uinic on urclion khoMinK imniprout titirill h-mitirrtusnt inHil 
«UACc of lueg: liolh loba nir icor];nl. l-cft lung . thoc i> a vjlid |>atian in il^ 
lote. renchinu nnterior Mirlnw iiiid cfirr^jXnirlinj; in n jK-i'lion Mitli iilmis-nmUM 
lituUi?. ininhing (he wliolc thlclincii t>( the lol*. Iiul noi the inner "t (Ktlrt nllOi ' 
imtlion lhi« wild pniiion conii)>r|k uf rod hi'iinliiiiiinn with n U'lod t\i\ in vnur* uat 
circuniferrncc : losr* IuIk gorgnl njiil (nnlninTH): ininll htr«iarrhn)i«. llraaidu oM 
blood and inucut Kcan. t\ ot. : li*ll lidv conimcwd, coiitainmt; 4 fi^u urinninf ^ 
r>l>n" ; v-.tlUuf lir-.irl luik-yctlou nnd fully ; no rndiKxintitli : h^rtn^nrhiiitft HilothcHl 
oona. Alidoinrti : on otwmne. n fe« ouncaof Inlr-siainnl Owdrvaprd. Miwhin)ltt 
•if tntnll tcwRU <jf mnentcry in ihr tviKlOintiiliiiail •<( ihr Inn ; one bwinixrlMl^ j 
4>f ttMlnul. ^n nicvnlrrr of dctcendjni^ coLon. Stoiivuh oonl4ino4 c^rfln lEnitfl 
itnor)<-num nl^ <lAjkihh contents; n4l of miall nnd Uirgt inC4*tinvl coritainrd pnlrfvfl 
lemi-lluid mntcnii. Splem. 5 o(.. fifni : vimeuhii mlnjgrf Lut nonnat KUal 
4|oL : conn pnlr yrlliiu, nnd lintaiilMrnini; iippc.-imni-f (nmi iHPCncvol tax ; |>yn4 
<onj{mnt. Ibiiln : noMng normal ■■ )uii, liul uHHi-lnllnn* on uittxr twrftiK 
tlocidcdly II.MIciKit : Ihc v«n(ridci An ditlrndvd with luibid finid. and ihir pofit mat 
ntjKvinlly ihc while pnrlluiit. ore toftetKd nnd CMilly uiuli nwar undn j itrOiiB of <nt 
DO Imcn ot I'lni or softening noted elviiti(>re ; no hxmontuge. Ijtvt. ia)(it ' I 
vny tiinp. ^inil cn|>tiile OTinklci on diiuhling up. KikId li-lv : iippot nnd tOBn Mrf) 
Hrc irrcguUr from pmcncv of wme portion) which arc mote dmiitrd ihna o<hm;< 
morv atnaWd porlioiM an pwinith yellow, and ihv ethen red. On i«cllon. M 
nrange-ypIloD' and red ponloni Uv uen : Ihe lobula jut nol miitily 'rrji m (h« )«l 
pcutt. which nrr toft. In ihr rrd. whicli ait firmer. Ihp lulivi cjin be i1lnln)pni>nl. 
centre* iieing briRht n4 Lind (he circuiiilerciicc pnlv. llic IrJt lals vonuin* iBoi««li 
red (orlt A'ld ihr riKhi niurf \'v11oh. Micrrncopiun) eiamtDHIwrn. — krd putTiOH. 
inlntlnljulor tdni, ak nonml. itie nnlls of the InterlotnlUr \vlnt ■.■onUrn BWBX 
lOWoeyls, nnd the uirtnundmK cnnnrclive lltsuv it also infillrated ; Ihr IoImIo «m| 
no hcpMic c«IU. )nii hypcTpIiuix: iironm. leuoocyiet. mnoy nd (nrpatcln. Thr VH 
«apUUrtet nrc v«ty prominent objccit. and ktiu to eoninin epithelium with niwIdiHt 
(OanE auhiliTliian. Vcllciw |x>rlion— Thn lobuln ur Ixr^r ; central ivin normal 1 taf) 
«db nrolloi ; nuclei olncured : Ane Kmnulai cooicnu and lule I'IgmenL Tin: wiit 
intcrlotnlar vpint infilinttc w-iih leucocyir*. DJlijiry dpiliarifi tiulfrd nitli tpliMiOH 



/>rir,^wKfl>.— Malignant jauniticc in unc-trlyvlngecnnnot be diMingiml 
rrom cniArrhni jaun<lii% ; it is only whc-n crrcbra! symptom* appear, t 
there nrc diL-ilcd piipiU. ccchymOfiCis or i:on«iant vomiting, thai the itiipio 
li niietl that there i» lomeihinj; more than wmpic j.tiintlicc. At tliii liaiei 
caie is liable tn W initl;ikeii for mrnintjitit, though the presence orjaund 
and cerebral sympioms should indicate ilw true aaiure of the diteate. 
nay pouibly l>c confounded with pyiKinia, phtaphurus poisoning, or pM 



Cffrhasis of Liver 



177 



I 



writh ^undicR, hut in all the^e the jaundice would na a rule follow and 
M ^Rctdc ihe nttwr symptoins. 

Uprtitt Anatomy, ~ Or|ii"i'' l>ilc-itaitiecl ; li;rm(irthaKCs in variou* orK-'f ». 
Uirr itiull, limp in texture, moMl}'bil«-*tainc(l.ioitic poniorii beiny tireeniih 
]idlM>, nthcrt timnge-red, often buluiny in ^onie part* from ilirinkins in 
tiben. On Mcttnn. there are tiiually arens of red or yellow colour in wbicb 
ttMnilc* ate indi«(incl or entirely imliitin^-uithable. 

TrMtm<f»t. - t'nfnrtunatcly but tittle c^in be laid under this bead, as 
nth cam hai« been invariably fatal. 

Clrr1i»»U of Xlwr 



Alo*k«ll«. — A typiail hobnail Vivei due to akohollsm is necessarily rare 

Airing; ciirly life, at it i& hardly likely thai it nill often happen lh.ii a child 

hu many opipori unities for indiil},'ing in akohnln: drinks 10 any ctccs^. 

CMct of ihi4 sort have, however, been tetmricd by Cnntmcnial nriicrs, nnd 

^E tfrw in this country and also in America, Dr. Wilks relates the case of » 

^■ril nf 8 years who had taken djily for sotiie limc h.tif n pint of gin : she 

B (TCMually suAcrnl from ascites, and at the pfit'tHor/tmA small hobnail liver 

H^ W fiMnd. Cases of cirrhosis lime been reported by I'levichs. Ilatnbcn^r, 

^■Hmraniand others, in which iheie nas a history of alcoholism. Mitchell 

^VOukc' irpons two cases of citrhosisof the liver in children, in which there 

Vnt M htsinry <rf syphilis, luhercle, or akoholiem. A* the tymptomx uf 

H aMKilic cinhotii wlicn it occurs in childhood are the tame in children ai 

Miduliii, no spccL-il dcocriplton \v nci^eil here. 

■rpkiiitl« OInttoaia.— .Sjphiliii is b)' far the coinnioneii aiu»c of inter- 
Mul hepatitii orcurrinK during early life; ihc>iij;b in a large proportion 
(( mrj It {« fouiMl in the /tAwiv/^w room In enact in which it was not 
^hgnoMd durinK life. In tj-philitic Infantt who nrc burn dead, or who 
fc wllhin a (ew monihtof birth, the livt-r ii sometimes found lobe cn- 
ln{ul and firmer than usual, Ihc surface is perhjip* smooth, but the liver 
oit» OS if of Iraihcry ciinsislence, and the lut surface shi>ws the adni to 
I he Irti distinct than normal, and liandi of fibroid tissue- msiy be seen 
through tbc liver substance In lome caites there are no very 
_. aenaiic niicroscopic appearances, and it is only on microscopical exa- 
ttuMn that interstitial hepatitis i<i made nut In a well-marked caie the 
mtaoQ sIvoH's an excessive amount uf connective tissue along <he course of 
At portal vessels and numerous spindle cells and embryonic tissue. In 
■mrtadianccd c.iscs istnnds uf fatly liver cells may be seen surrounded by 
■nlffonnccl connective tissue. Theabove^iptiearancci ate so characteristic 
*' o<n|;e»ital syphilis, that they are dia^nnttic of syphitis when foimd post 
■iM'/zKi. even in the absence of sjinptoms diiriof; life and other conrtnn.itory 
nidmce aftct death. r,ublcr h.ts described .tnothcr fonn of syphilitic liver, 
in which there are mili.irj- jtiimmsta picsent in the liver mostly about the 
«ie of pin*' head*, scattered (hroii|[b the substance or situated in group*, in 
Nnbtnatton with inlcrililtal hepatitis. The •.imill jfummaia consist nf small 
ragnd cell*, and are mostly connecied with the tmatter branches of the porLiI 
■tat or biliary capillarict(liir«ch Hirschfeld). Theteis often also tbickenini; 
■ Urii. Hid. /Mr. June y>, 1R94. 





tmd throniboiii o( iht small vessels, ihc cIiuagH beinji: similar to the arteriti! 
fountl in syphilitic disease of the br.iin. In older children clicciy nndtdr! 
and cicAiricial bnnds of libroid tissue Arc fniind wi ihc surface of the live* 
sii»i1nr to th«i« found in fiyphilitit: diicasc of adull.t. There auty be libroii 
bands and cicatririal liviuc in ihc >;rcal liuure and accoinpany-ing the imru 
vessels into the liver subuancc In some cases there n a peii'hepalitis a 
n«ll n( an intcriiliial hcpaiitiK. 

Synipinms. - In infani.i almost ihe only symptom is an enlarged livei 
having perhapt a harder feel than normal, and in some cases more or le* 
jaundice. In older children the livct may pcrliaps be fell to be enlarged ;mi 
the ed|{e itrenilar ; ihcre will perhaps bt other symptoms pmcni that puin 
lo *yphilii : in a few case* iliere has been ascites from portal obsiruttion 
Much casei have been described by Uhcadk, Norman Moore, «i»d Lewi 
Smith, of New York. 

/'/•i^fjt'^.—Thediai.'nosisof cither alcoholic or syphilitic cirrhoats wmdi 
be ({really assisted by a history of alcoholism or uf syphilis or in the LatM 
case by other evidence of syphilis afforded by the patient. In older children 
the presence of pct:^'ed Iceth, intei'stilial Iceialitis, or scan about the motil! 
would naturally su^igcst that the enlarged liver present was typliilitic If 
ibc absence of other evidence of syphilis in cases of ascites with enlMvei 
liver, il is rarely safe to diaifncue a syphilitic hepalilis, as both ascites fnitt 
chronic periianiiis and portal obti ruction from mcdiastinitis are more comoMM 
than syphilitic cirrhosis. In portal obsiruciion the iplecn is mostly enlarged 

Trtalmtni.- -.\ol much can be expected of anti'iyphiliiic remedies it 
syphilitic ciirhosis. as it is hardly likely fibroid tissue c;m be absorlied. Stil 
it will be wise to give meicury and iodide of potassium by the mouth am 
apply mercuiials locally. The ascites inay be relieved by tapping. 

Miliary tuberculosis, malaria, chronic pcrituniiis, chronic heart disease 
and mcdiastiniiis may all give rise to Intcrsiitial hepatitis in a minor dej^ree 
In cases of inediaslinilis where there has been some obstruction to the rtow 
from the hepalic veins, the liver becomes often cnormousJy enlar|;ed an<! 
BpoAg«-1ike from the dilal.ition of the capillaries and small vessels, and ihett 
is «n excess of fibroid tissue formed. 

Trtatmtnl.—T\\v trcniment of portal obstniciion, the result of a cirrbMit 
liver, is only palliative, for ihcreis but liillc reason lo hope thai even insyphi' 
lilic disease there is much chance of modifying in any uay the fibrous tiMW 
which is sirangul,iting the port-nl ch.-inneU in the liver. Relief mtisi be souglii 
l>y unloading the ponal system by purgativcf: and diuretics and by removinij 
the ascitic Huid by tapping ; ihelaiier is best peifnimcd by means of Soul he/i 
trochan. In syphilitic cases the local inunciion of mercuriaj oinimcni mm! 
oihcr specific treatment should be tried. 



The liver becomes enlarged from bang inlillrated with fat !n seveni 
diiTerent diseases during; in£runcy uid early childhood. It is common lo UmI 
children who are fat, pale, and rickety, with large livers, the edge of the 
right lube rc.iching nearly into the iliac fossa And the left to ibc umbilicas. 
If an oppoduniiy occurs lor a, poil-ttiiMitm cxaminaiion, such livers aicfwnd 



TuberdthsU of the IJvtr 



179 



ilo be tutc and j^rcasy, the loUiles bein^ in<li6iinci, and ihe cells arc seen 
^faucrnK«picnIly t'l be loaded willi fat. Such children ate usually an. imie, 
Hnit luT]{e distended abdoinent, ciwted toiiK>'cs, pasty stools, and suffer froiTi 
^BktuBic indigcsiion. Under a careful dietary, small doses of niercunals and 
Bnliaes, such as Carlsbad or Kubinat n'atcr, improvement gradually ukes 
fbce and the liver diminishes in siic. 



Tn1>«rculo»ls «f tb« Uver 

■Utboilgh it )( exceedinffly common to lind tubercles in the liver in children 
l^sxaf gencnti tnberculoMx, it i> exceedingly rare furchc:3C luberclex to have 
1 littaanyindicaliDn uf i heir presence dutini; life. Tubercul^trdiiea^e »f the 
Ineipncrally t^kea the form cither of grey milittry tubercles ^caitcrcd through 
tlreaigan and oa the»urface,or of cliecsy nodules, rarely largirr llian p<r;i9 or 
» the most vmall iiiarble!i, whicli appear to have a spvciul preference for the 
Mi{tkboutbood of the bile duett. 'Hme caseous inusiei may be found bile 
iOinod pn section, and small cysts formed of diUted bile ducts filled with 
i<U|Mnitd bile m.iybe found ivhiih have been Ciiused by ci)mpr<cssion of the 
AcK Jaundice is ratcly pioduccd unless there are enlarged caseous );I.indH 
attctnnsv«rsc fissure compressing the common duct. In very rare instances 
UMoiH masses ap;>ear to form in the liver, resemblin;; the caseous niiisscs 
wm in ibc brain : ihesc may cause enlargement of the liver and gradually 
uAra doan into a chronic absents. Wc have seen only one case od* ibis 
fcini The histnr>' was as follows ; 

(in«i( T-htradtHi, lhf*lit .Ituiii.—i^iy: air«l (4 yam. fallitr and molhfr 
4M; iKnt Ivisi out of Knglniul ^ ■ilmillnl I>cu-nil>cr ai. tSSo ; mintlv liitd pain 
■ nftn iMk and couch : .in ann-niic tioy ; yvllowiib cc-njunctiv.i ; pain anil iriidnnets 
•tvu tir{i*lic r<Ci<in , dulInEtt In rlgtil nipiiti^ linr to lldli rili, nnd two riichn Iwlow 
"!■ Tntiprrnlurv. tQ '10)". J.inuniy ij.-MJgbl .-ilbumcn in urine : liivr ii la/;^, U 
■ate I* ihr liruch nnd on twreuulon ; ftnv r;Vli.-s >1 b.iie of tlglil lung. I'cniprtiiturc, 
^^•nf, MUh. — Unr rtcniivvly Mndcr, hF|Hil<c n-cion bu1f;ini: , tffi lob.- halfway to 
iMilin; iluMnetiat («>«<•( njclii lung 10 angle oF icupuli ; npluivd Wl lubi.* nf Uvgr 
vAmiq^, only obiainal Uood ; albumco in udnc ; Is unuti^d, iisi.— I'luctuslion felt 
<B*ra , uplniiiDn — chi:. iiii<c obcaiiiad an ounce or two nf iliick |>u>. 3\ — Miiviiuiloii 
^iBtniij tell : opencii Aniiwplimlly. S ot of thick S'^'^V P"* miifd h Itli blood and 
^. IdM intcnixl. fotluwnl iluHiiK cwnlng \ij lugR iliKhnrgi- of piiH. >atli, — Hlu 
I'^'^iitaJi. lumiting : left Il-k i^ry a'dcmmlous far a day or luo. nou d.-iik blue U If 
k*M<tt EMpvnout ; todden dnih. 

'WacrfH).— body emncnlnl ; pus iwdling up from fiilatous opening : led leg much 
•■*•; WIM llili«I in [wrictriUiini. llRu-t non'iuli Ril'it lunn ailhirrnl lo diuphrscni 
'^'FHtb Bod Hbroiu nuuc; no pnc>imoni.i : Ihc diiiphrAgm aUnormnlly r>usnl by ibe 
^^M Hwtr below, aiid is >dhir?nt to 'I by n-cunl ty<''l'h '■ thp liver lia> bn-n pundurMl 
'■'kcM lobciwai lis jiuulion with thi: rtghl on Iti iip|it-( anil ;intvrii>r tarlaec The 
'MjwoptntnK en(«n a very irrtguUi caiity containing pus : [his i-dvlly conuini m-mi- 
'''^chdj niotFrial and irregular niiroui Irnlircuin;, whit-h give it u nomi-muii Appear- 
**0; Kitmutty in the right lolv it a chmy ninu, liic of sn onuigc. titglnnlne lo 
■*■» werm-MiUn. and c<int-ninrn|[ H Utile pu* ; -i tirn other imgular caviiin joining 
**P>>br; no Inrdnccoiu chnng<?. fipLccn rnUigod, lordaMoiu. tntetuncs maitnl 
"VlW 1^ old 4dhctiun». thr iiicKiiierT I'oniaining rn-i.Kvoiii maMti (old poriioniiis 
'^ HCfunilDg glands) : contains cicairica of old itubciculari uli^i^ri ; no recent ulocro- 
"* UnMlprk gUnda in [iUom cnidmuut. Ixfl eilnrnal ili»e vein. aKit-mfttm 
***! UiMyi congestrd. nc<i l.ir<]AHmu ; luags, old scan ax B|>i<«s : pulinoimry ancry 
* laMt-morltm clot, cmboliim. 





I 



Children occasjonally •.urfer from nmUiplc abscMSC*. ihe ttwill of (h 
absorptiur) of somescpiic niftitrinl ftom t lie region irfihc jxirial vein, or (tmi 
some ab^ceM in the immcdinle nclRhlmurhiioct. Thus in nnecnse unctcrot 
cnrc mut[iptc nhsccsscs in ihe liver u'cre evidently sccDiKLiry to .in ulcct i 
llic c;<.'Cjit nppcndiK cnuscd hy n pin which li»d been sw-iUowed. In a v;cnn 
cn»cthcrc»'nsa largehe|i.-iiic;abtccsscomniun)ca[mt;ihmut:h ihcdiaphrafi 
with mi empj-enu in the hkIiI plcurnl cavity : and in a case of Dr. Iltillon 
heimlic abscc^cs were due lu the contiguity of the liver u'ith luppunitin 
relrei- peritoneal gland*. In some cases ivliicli have Ijccn recorded abMrcsM 
in the liver were secondar)' to typhoid ulcers, and in others to the irritaiio 
trf worms which had penctmied into the bile duciv 'ITie symptom* conte 
in enlargement of the liver, extreme lenderness, and inteimitterit (ever. Th 
pro^osii i« had. If pui n found, ii should be evacuated antiteplically. 

HytUtid cysts in llic liver are not uncommon during later childhood, bi 
are decidedly nue before five or six jrears of Bt;e. If theeyst isolanysiicani 
situated in eiilier lolie so ns to come in coniact uith ihe abdominal wall, i 
will form a sinooih, rounded swelling continuous wiih llie liver, neither pnta 
ful nor tender, elastic In the touch, or nniully fltiritiniinK. Diagnosis unde 
such circumstances i« cosy, especially if (he tumour h tapped or as[)iratt<i 
the fluid wiihdraun being of low specific gravity, non'-ilhuminoiis, and com 
taining some of the nolicev or pieres of cjsl wall. If ihe cyst occupy th 
jioKterinr part of the light lobe, it nuy push the dinphragm upwards aj>ddii 
charge into the lung or pleund cAvity ; occnhionally the cytl suppurates— it 
ihii. rase there are hectic fever, pain, and the symptom* of an absceM. 

Trtatmenl, Aspir.-ilinn of llic conienU of the cyst may be suffiricnt 
the l.iiler coll.-ipuci' and (he hydatid is dettroycd. The oprraiion may tuc 
to be icpcnicd, as ihc lysi may fill up wiih serum. If suppuration occur 
incision is re(|uired, and in many ra^cs it is belter lo open the abdomei 
lecure the cyxt to the abdominal noil, And dniin the cavity wilhout an 
previous asjMralion, even if suppuration hns not taken piacc. ^_ 



TBm»or» or th* UtM' 

New growths originniinti in the liver during childhood arc anKwg lU 
{rraicu rarities, though caset of carcinoma, sarcoma, adenoma, and caveraoa 
tumours have been dcKiibcd. An iiitercMing rase of lyniphadenoma of tbi 
liver, the only one »hich we have mel «ith, was admitted to ihc Childrcn'i 

spital, under Or. Humphreys fiiow of Tortiuay), in 1878. 

A boy »i;rrl 14 ;iun fcuffcrw!, (ot * riiunlli Imfon- i.'Oiiiine undpr ikMiCd. with p^K h 
rktbt tiypochandDoc n-i-ion snd w»Iiti£ , he rmlcnl B >ni-IIlflg in Ibe snnw rcKiU 
•boat tiro nr^i brfor« ailiuiulon. \\'Iit7n Imi ddiiiiiicil he wu |utr and Mlknr, b«l «0 

IniURtiocd . the tiivr wu mbitEd. il>v«(lEr nacliiii( nmrly 10 Ihc umliUicui: ibcrc ■•> 1 
■nge b«aay svtDiiig kiiuaied lieiwnn Ihc rl^l eosial <icb Wiil the uinbiticiu ; Itw cupft 
Acbl aUtoniiiM) vnnt Wtre enlnrgnl und lORuOlu. AiplrallMi of Uxe luniDUr ■^VUtH 



^ 



d 



Tumours of the Liver jSi 

nMhiiig bol blood. He wasted, there was a hcclic temperature (gS^-ioa"), and the 
pnilijneiini and right pleura became distended with fluiii. He died seven weeks after 
idniuion. having bad symptoms for thtei- months. At ir^e fast-marlini the abdominal 
utily contained much Ruid. ihe right lobe of ihe [ivor was much enlarged and contained 
a heinisiAeric.ll mass, which on ^.eclion had iht; appearance and consistence of brain 
iisie; there were some haemorrhages into its substance, and fibrous bands passed through 
iL ll was surrounded by a broad zone of compressed livei tissue. There was a mass of 
nbrged Rtands at the fissure. The right pleura was full of fluid. Microscopically the 
meroH'th resembled the structure of lymphatic glands. In this case il was not easy to 
dead? v^rt the growth commenced, but. as in the analogous case of lymphadenomala 
of the kidney, there is a strong probability that it began in the lymph glands of the fissure 
aadgiCT into and compressed Ihe liver siibstance. 



183 



Diseases of the Resfiratcry Apparatus 



CHAPTER XI 

UliWASES OF TKK KK!>I>IRATOIlY APPARATUS 

^« Tbomx In XntKaojr Bnil OMIdtiood.— It is nctcsMry «li«tt 
mining llie <.licr>[ ai :iii iiiCinl or chilli l»i' l)ic liiM time [n have It compl 
Ininr, so iliata ihoruuijh cxAniinaiioii <.jin lie mniit, the infant lyin^ in it 
or on its toother'!! lap ; cite must, nf rouivt, iic tiikcn to h»»-c ihc n>oni 
cicntt>- wRmi, TA infiiinls rcnriily tnkc cold when a Urj,'c surface of the 
is ex|xiscd. and thcj' ari' very «rns>tivc to ilmujihts. 

The H.iy in which the child brc.uhcs should be carefully noiicenL 1 
may be a ' rrowinj^ ' inspiration as in lar>'ni{i^rnijs "r •' n*^)' t>c "intli 
tli«re being an evident obstruction hoili to fillinx and iil»t> cmpiyini 
chesi. The cough may have a mclallic or clan^rinu rinj;. 

On inffifttiKN iX uill l>e nmircd.jf /•>//>', thai an infoot's chesl i« fl 
than an adult's, or, in other uards, ihc anlcro-poitcrior diameter more r 
n|iproarhc:s thr tran^vcne, the ratio liein({ i 2 in nw infant, l-!j dunnn 1 
hood, and 1 -3 or 3| in adults ; the hnriionial section U ihui mure ciicu 
fomi dtirinij infoncy than in later life. Snoniffy, ihi; iinifle vhich the 1 
CttnitaKCS make with the «Eemum ik Ur};cr in childrrii than in adulli, th 
(he lower pun of ihc thoracic ra^e Ik widcnrd out mote ; this may 1>e b 
due to or accent ualed Iiy Ihc abdominal viscera occujiyint; a relalivclyl 
s|Kice and proiinj; the diaphraK>n upwards. This i.s seen in an exJKS* 
form in children who have enlnrKctl livcis and cionitanl ),'a.'teous disie 
of (he stuinach and intestines. .\ny .icquired liefomuty shoul<l be oir 
nutt-d ; various rickety deformities m.iy be present— one side of ilic ches 
l»e contracted from im old pleurisy or empyema, or ilic left civeel m 
l)ult;cd outwards b)' an hyperirophicd heart or distended pericxrdiunkJ 

The position of the cardiae impulse should tic ilctcrmincd. N<w 
jiImi be made of the frequeocv and character of the respiratory mwcn 
whether deep or shalluu , whether one side moves more freely than the 1 
or there is any sinking in of the epit;astrium or inlcrrnstal spaces iiw 
durinif inspiration. It shoukl be bunie in mind that mere freifuen 
rrs|>irntions docs not necessarily mean .iny respiratory disease, but 
l>c dttc to rapidity of the heart's anion arcompanyinj^ hiiih fever o« cj 
fe<:btene*s. Note also if there is any p.iralysis of [he diaphragm or 
coslaU. J 

After insiKCiion it is usual to ptreust the chest, plncinj; nne lint^r^ 
\rii band nK^inst the client w.ilt and siriktnj; it with more or leu 
w-ith the middle (in^'cr or forefinifcr of the r\t;ht hand, taking care thj 
diild lie^ or sits up slraiffhc, for if ilie body be twisted, so ibnt 




CoH^fH/'f't/ Latyngi'al Stridor 



183 



httfCNout more than ihc other, n fallnriousliyper or impaired rcsonsneemiiy 
\k prndurcd. Allllw region* of llif chc^imini he cftrcrtilly examined in luni. 

(Too nioch Mr*H should not hf laid on .i slij{ht)y impnired resonance, «pe- 
oally i( lh« child is rrying, unless ihc rewiU of .1 use lilt a I ion corresponds, 
and > (ilbscqucnl examinntion ronfirms ihc restjlt. A typical ' ccackcd-pot ' 
Mund n rriidily elicited in an infant on .iccoiini of ihc yicidin^ naiuie of the 
thw wnlU quiir apart frorn the presence of cavitic* or any lui>g Inion : 
IjkAiI immc inusi be tnadc of any tpot nhcre there ii dullness or impuited 
Ktonance or h)-)>cr- resonance denoting entpyiictna, but brarinii in niind 
ilntii timei a 'boxy' note ii eltdlod over lun^ in an early siiiKe of pneu- 
muniior acute congeition. It mutt not be for^'illen in examining the 
chnt that the diaphrat;m usually takes a hiKher poMtion in children than in 
aduliv especially when the stomach and inteitines are distended nith gas. 

In auu-ttltation the ear may be placed directly against the chest wall, or 
(■bi ti much mare awvenitnti a bmaura] iteihoscopo wiih :i small chest 

kfiKt may be U»cd. All pari* (if ilie chest should be carefully examined, 
Boling the character of the brcathinn. whether the air \s cnli'rin|{ ci'cry 
pan of llie lun>;s equally, or whether Ihc air is not entering one part freely 
•hile other purtt are hiding ovcnvorked- Weak breathing may be due to an 
Bilf ttai;e uf pneumonia, elTu&ion of fluid, collapse of lung, compresnion ufa 
bronchus or a pncuino' thorax. 

'I'ntnlc' ot harsh breathing is due to a portion of lung being over< 

■*W; it iv ntvcr safe to accept it as a sign of a lesion in the lunj;, as 

Uini 1 student is inclined to do, and, moteovci', the breath tnunds niriy 

■pptarloud and harsh loan ear accustomed only to adults. It is not uncom- 

BMi in jxiunx children to note on one iictasion ihiit the breathing is ucak or 

I ifaunlabscm at wvc liase and Uiud elsewhere, whereas after a fit of cryiiiK, 

B w ibc tusa day, the uvak breathing has completely disapiiearcd ; in tliese 

H tan a bronchus with its branches has liecn tem|ior4rily plugged with 

^1 ntni, mhiclt has become displaced by coughing. Itronchial breathing is 

1^ pMMiit in consolidation of (he lung from pneumonia or tubercular Infitli^i- 

ti^lnil it is also present in the majority of cases in efTusinn of lluid, though 

■ tUtcaseit is tisuatly weAk and distant instead oflidng intense and blowing. 

i^nioiu or amphorii, breathing is not often heard, as cavities of any site 

"•ote in )'orung children. Among the ndvcniiiious sounds, fine crepitation 

■••wly hi»rd in the e^rly stages of pneumonia, the rites being mostly of 

■rtnim site ; they may he 'consonant ' or ' ringing' in character when ron- 

*tttdin ibe ear through solid lung, or subcrepiiant and ill defined when the 

"ntfton IS thick and they have In pais through normal lung to reach the 

**<■ Vocal tcwnancc, or fremitus often gives no dellniie twull in girl* or 

JWH; f hildrcn, though when ihc child is crying violeiiiiythe increased ttin- 

■"teo* the voice heani overalw*eorapcx may be of diagnostic importance. 

''<> needless to add that the physical examination of young children is often 

■W »ilh difficulties on account of their restkssnesi iir fright, and the 

•onincT ma) ha*e his jalience often soiel)- tried, and perhaps may foil to 

*>^in a Mtisfacfoiy examination (com this cause. 

teMUl« B«aplrat«iT Spi»n, C«ac*ollal Ki*rrnt*«l atritfor. — It is 
*Kmcanm>an to meet nith inf.inls .1 few nci-ks old, »bii fri>iii (heir birib 
^ tKtde a peculiar sindtilotis sound, more ojieciall)- during inqiinnian. 



4 





1 84 



JiTtases of 



^esfiiratery A^ratus 



In most Ciscs ili)» stiiie of (hiii(,'« bsi^ for snmc momhs, fciluipa 
.worw, and it t:rii(lu;i1ly dii»|>|ic-Jii!i, iio tlul bcfurc the iiiiiMlc iif the mcothI 
)var is r«ichc<l it has vnlirclv <lisj|>|ic.irc.-(l. It a, tiol diiii^riout lu lift, .ifc i> 
true lai>i%'isi)iu!>. 'Ihiv luiidiiion hii» bc«ii iioicil by »<rver;it wriicrs, iikIuiI- 
inc On. (Ice aiitl IJ. B. Lees, but t)it fullcsi mid must recent iiceMunt hiu 
been given by Ur. J. T hi 111 I son ' lulin. Ate^. Journaf^. The iHSt unlet ho* 
carefully stuili«d live cvises, und iiuiite l)uynK«l exuminatioivs as (iir as ii i>a> | 
possible, but it is rare la be able to KCt n gOoA vi«w of an iiifjini's vttaii 
cords. He clc3C[ibes ihe sliidor as follows : ■ inspiialioii beijiiis uiih a croak- ' 
Idk noise and ends in a hi},'h- pitched tron; uhii:li two of tlie mothen 
itcscribcd as heint; Just like a hen.' In some lases there is an intlr-iwing tt 
the chcsl wall timing inspir;ition and a tendency to |)i|;uon breast. T1i«| 
Iar<m^-«al exaniinatii>iis made b}' Urs. Tliompson and Mcltride slMXicd ihr ' 
epiglottis as far as seen lo be nontial, thou);h in oneca»cih«re wasa clinvnic . 
phnTyiij^-ttis. li Is deaf in most c;iscs the siridulous iioiic is pruduced by a ' 
b|Msni of the miiscles of the larynx, and is apt tu be worse when ihv infiini i» i 
cxcitetl, in this ri'speci resembling' lar^ngismtis. The etiology is l>>- no' 
means elear. 1 1 dues nul seem to be .-^ifciied by drug's. 

In some fen' rjtset ne have nnicd, in addition to a renain amount of noisf r 
respiration in in&ms, ihcrc is a tendency in choke nhcn drinkingt somff of 
the fluid cnicring ihe tniynx by ac<:ident. This con<tili«n, thoii),'h nlarRiing 
lo the friends <'"<■* "t" aplJCiir \o he danj;emiis, .ind >;rndualt) impmvc* m« 
the infant ^nwb older. In ail ihcsc ca>es it is wise to examine carefully luij 
poH-iwsnl adenoids. 



£arpni;l*mn«. tpa-am of tli* Olotlls. ' Olillil Cfowlnc * 

The leiiii biviinisiiius is applied to a |>ecutt>ir form ol lan'nKo-'CKpi 
5paim which nccurt alniosl exdusWIy in rickety infants. In laiynj!' 
there ii no Iciion of the lat^nn, or only in a Mnali minoriiy of cites ii therra 
UrynKeal c^t.irrh ; it i^ usually a piiie ncurotiv and it \s only for ihc sake of 
eonlmslint; il »ilh oiher fomn of Inrynce.il Doubles that it is placed in thia 
section ralhct thanamonjj the convulsive diioidcr*,io which it more pmpcrly 
kclonh's. 

In by far ihe ni.ij[>rity of eases the symptoms of tick*ct« are present, Imt 
vrc mast not in all the cases expect lo find marked entar){cinent ai the 
cp'phyws, especi.illy in infants of a few months old. Kometitnet cninio-labM 
may be detected ; usu.-illy there is some lie.-idin^' of the ribs anil recesskia flf 
the chest walls durin); inspiration. I 

The characteristic feature ni the attack is a sudden 'holdtiiK Of llo 
breath ' fur a feu- seconds ; ihen the glottis Is hurst open, Ihe air rvshinit ifl 
with a striduluus snimd or in a scries of short ' chinks,' Init in many c.tscs 
there is no abnormal sound, the attack cnntisiing cnrin^ly of holdioK 1^ 
breath. 'I"he sei/utc closely resembles, onl>' in an e-'<aKxer;itcil fi>rni, the 
'calch in the bre.iili,' which takes place as a preliminary lo a i{oi>d fit of 
crying, or, as Gay pmnis am, of ra^e or bad Icinper. The condiiiini seem* 
to lie as if ihe expiraiorj* rejpir;itiiry centre discharj:e» for a few seconds an 
CXccKsivc <juanliiy of nersT force, |nndiicin)C a s^nsm of the glottis and of llM 
muscles of expirution, vrhilc Ihe more powerful ins|>itatory centre, as tt is mart 



hvyn^'siMNS 



185 



ml ortrt Mimutiiie*) by ihc inricnsinii vcrMily of the blijod, striws. ns il 
««T,ii>t iiiriMcry. and ai Irnnih, when it *iicitc<ls I'lc ]('<'"'» '» I""!"! «|>cn, 
ud lii ruihr> in ihtouKh 'hp nanow rhiiik. In 11 stvcre allack, not only is 
ikfktlif vIotL-d by ihc :i<l(IiiirIor% of ihc cnrils but ibc cpiKi"lii!< tO")' ^ 
Hi ^y (hi- AnKcr 10 Iw tpaMnoitirnlly iipplioct to the »ii)>cmir apeiliue of ihc 
U^iu.aml the rctplraloiy mu«r]ei^ar(- In a tUIcoftpai.m. 

Stoiim iinri Kortlcy hai-c shown ihai lh<- cxpiralon- rc*[jinilii)ii tcntr« js 
tiMtnl in ihc monkey in ihc corlex, 'jmi pnvtriior lo ihc li>wtr end iif ihc- 
pmciilral »ilinis al Ibc hmc of ihc third fioncil lonvoluiion.' Siiinubtion 
d ibii tci;ian produces adduction nf the vntal cordt, ,-ind if the excitation be 
(««eda) auia){h, ipasm of thv muscles of the fare. nc-V, anij upper limbs. 
TV asie cbverveni failed 10 discover any inspiratory toriex ceniic, but 
fand that c^caalion of ihc accessory nucleus in ihr nicdulU oblouKnia 
imkxA aliductian of the conli^ In rickets the nerve centres ute in nn 
muMc conditioti, and li.ible to libcRiie nene fntcc on the sllt;htcit prm*"- 
olMl la MXnc C3JICS m^ny of ihe cortex centres di*rhnT|;e, and a ^enrrnl 
wrrifeioa is pniduced ; in other r.tses it may be, at limt at any r«t<:, the 
aiwiiny mpiration centre only, and a tynum of the ijlottis is iirmliiccd. 

TW exciting causes are probably many. The communcsi i- ^cme cnio. 
iMiJ di&larbance : a fit ud' crying or uf an>;er may quickly pa^s inlu an 
Mdi ; fright or a sudden Start miiy bnni; one on. Ibc act "f b'*all<)H-inu 
I ibo »omeiirnci to ^ive riie to an iiilank. Dcnliiion, irriiniion of the 
I latmbrant of the pharynx and lar>n\. nasal adenoids, conMipation, 
' ptfhsp* act Ai cxJtlny causes. In an infant n« saw with Dr. I.awton, 
't^clci, the attacks were apparently wone during: lliv lime il «ns sutTcring 
Ibnumc aphtli«ii4 ulcers on tlie soft palate. We have also seen cases 
['Wi wne wori* dunnj; an attack of br0nthi.1l catarrh. We are not 
mitri to attach much importance lo an enlarged tbyinus, swollen bron- 
<hal [bndt or crjnio-labcs a« evciiin^ causes. 

SptfitKmi.— In the milder cases, uhich ;irc the moM common, ihc child's 

■^pnur)' movements are accompanied by a ali^ilit 'ciowint,' sound,' which 

d*)* DM apfKai to distress it, .ind nhich pasies oA' during sleep. Some- 

'>*<» the ciomini; will last for days, and pMss off a^ain for some (iinc- In 

- ■ ■ \iv case* the stridor is present during sleep us well as durin>; the time 

>- >iukl if awake. In ih<r moR severe cases the attaikscomcon .iifreniieni 

""tiah, KtA ate distressing in the extreme ; « ithoiit wamint:, the infant i» 

W»te*crew up its face as if for a crying lit, it holds its brciiih, no air enters, 

••d Itc rcsptraior)- mii.«c1cs arc rijiid and motionless, the veins on ihc face 

*><tal|i become distended with venous blood, the face and lips become 

■^W nf a du>ky tini ; ibcn after ten or more seconds the ohsiniciion lo 

I" <<' eni»in>.' the lungs is overcome, and air ri^shrs into the now open 

i'tii. In some cases wc have noted il'jit while at first the respiratory 

■rtii arc i|uile motionli-ns, in cithers after llic ohsltiiclion has lasted some 

•fWoii, the dtaphra^m bcnim to work sp.Tunotti<-j|Iy, and will often siitcccd 

■fcniBK tbc gtMlis, so ibal for a few leconils air i* .idmittcd ni shoii in- 

^f*^ into the chest : then for a lime the attack is over. I)ut may be hbottly 

■4*rt bjf Jtnoibcr, 

Ttee sewutes, especially ibe more severe ones, arc accompanied by 
^l«>c tpMtitt of ilw limb* : someiinici u-c hare teen in thefc attacks ilie 



lS6 



Dheasfs of (he RcspiralS^ 




infant throw his hancLi up like ;i iltownrnK in.in, anit then, Hfter the Urr«8^ 
spasm i» over, the nerve di»char),'c passes into the liinb«, iitvd ibc Iutii1< 
beoocDc sec. as in tclany-, wiih ihc thumbs lunwd in,an(l thcfcctin^ipoin 
ofcquino-vanis. 

Tlicsc attacks may i-oine <in at all limes of the clay or ni^hl, and on 
slight provocation. \\k liavu alci-ady lererrctl t<i th« most common 
causes ; Ihc tiiosc iinporiant, perhaps, it sonie cniMionnl ditiiirlmnce- I'nd 
of these seixures, as we have already pointed out, is very much like bIuI 
ijikrs ]>l3<:c in ihc cJirly stagn of a lit of ciyinj; ; the facial muMle-t are conj 
lr»:lL-(l, the mouth is open, the btL-aih is held, the air cnlere the chcn (pi« 
modically by Ihi- rontraction of the diapbnKRi. Hi-il>cn .Spcm-cr mnaild 
that an 'ovcrHou' of neive force, undirected by any motive, will manifcitl) 
take the mo^t li.ibiiiial routes ; niid if thoi: du not suffice, will next ovcfflo^ 
irito Ihc less habitual on<^s.' Wi- can easily understand on this principle ild 
a discharge of nei\t^ fori^ from unstable nervous ccnire&may t^ikc the roiilll 
which in inf^tnts produces a };ood cry, ind may overflow into lh« muscks d 
the exiremiiics, producin); a spasmodic condition, i.e. 'tetany.' J 

One point vrc must tiut forget to emphasise, and thai i*, that many of tH 
most severe seizures arc not accompanied, or railver followed, by a definq 
crowing snimtl. li is really ilw less severe ones in which the crouing iq 
(piraiion is best marked ; the dan^'er necessarily dcpendi more upon tbi 
Icnxib of time during which the l>rcaih is forcibly hdd, than upon the manoi 
in which the air again enters. In many of the wortt cases it is admtltfl) 
■ptumodically in sobs, anil not in a lortg-drawn craw. 

Children who sulTcr from lnr}'n>;ismus are not only rickcly.but ;ire neail 
always dyiprpiir. There is often a difficulty in diKcsiing cow"* milk, tl 
stools coniain much undigested curd, ;irid there is chronic distension of ttj 
boivel.-i. They are not infiequenlly well nourished, .is far as lat goci^bil 
their muiclei arc poorly dcvdojK'il. Ii is unncccssnr}- to tay that it J 
anifii Lilly fed intlir>i> who arc the chief sutTcrers from larynx; ism tis. H 

following ca«e iltustr;ttcs some of the points u'c have referred to : 

I 
LMiytifiimtii : ttr'iK-rry. — S. l(.,aGKl loinontht; .iilmitlixl Kfliraiuy »8. MotlitftM 
be has never Imn strong. liAt hnd Ji *eroup7 coogh' since M ilaysold. for Ihe lj«t M 
Wfeki Iwi luul tn.mj choking Als. somi^limpi lu many as twenly <i> onr day. Wdtf 
9 lb. I4 oj. He a imuU I<ir Ins i^ Hnd cinnol hit up : he lui no leclb. fl 
wlilaly <^«i and lenie : no cmnlO'laba ; loinr rrnuion of Che cbnl nalla durteg i 
lion ; no mnrkcd ticKillnjc u( the rlbt. Wliirii illtiurbnl hi- maket a crowing 
inspiration. Diirlne this iimE i\\m 11 miLrkfi indr^wini; o( ihf chnt inill. laMJnf 
fm iiioinciitL M »l)irr ttmrs ilir lin-.ilh is hrld lighlli loi a (cw io«Mids nil be 
Uof in thefaoc. lie wnionlrml ntllk. hnlf o pint, snil irtwy. on* poil and • b^t 
and soma tbubarli nnd sod.1. XtArcb a.— Has hod many ■HAda ot 
betwfen the ailocks Ibsv uvnis 10 be tnonp or l«sa eomlnni spurn. Maieli 4. 
It. lirlliuJuniuv niv. prit. Inumidi et. <i», urn. 4li* hor. lie had >lx altachs 
no gmcml eoniulsUniL From Ihis iklc tic licgan 10 improve. iIib attacks bvcaniof 
He w*ni home on March ar (wvigtii, lo lb. 1 ot). hitung htd no attacks lot undsp' 
nsore. 

Spasm of the glottin is sonietimes Uie catise of death in cases when tl 
obsiniciion is not complete, lis iti the following cnse. A boy of 1 year ol 
liad diiliculty in bre.iihii>g front hiitli, uaK sciied nith a bad aiudi, ami «) 
admitted to hospital ; there was undoubted olmntciion to iiupqraliua 0^ 





Larytt^hmus 



1S7 



rcsai<yn of the chcM walls necessitating tiacheoiDmy. which wii« 
I by much ii-Iier. Dc^ith followed live huurt hier uiihuui iippnreiil 
Al the poil-morltit there iicre nu si^^ns of tickets : there "as i^lih'hi 
Caci^tun nf ihi^ larynx mid the thymus gl:ind ; iill the oilier ur^.ins ivere 
Mthy. Sudden death from spasm of th<.' t;1otii« ticcasionnlly occun in 
anof ititiernlnsiti witli enlarged and caseous nicdiasiinal glands. 
AkyiKV/'. — Tlie rotlouiiiig table gives the chief points : 



r.utu. 

In nchctj' children 
( itiiKinilis ofNgr. 

> In*. Mtd no ooiyM <v 

I lajigat ntarth. 

t*l uy pntoil of Ibe 
' UlHWl. «id aA«n mnitj 

Mb. 
It («th. tntpiRuiom xrr 

■mtaiMiL 

of the IhnlB. 
I « (Metal ooavubiont. 
.Mumanon. 

I MIKfc lUtS > loM ST- 

, Wdh «Bl ftci)<MIMl} rv 
r&uL 



il.tl!e CroKf). 
Kunli ucmii undn- 1 yiars 
of a^. commonai 1-7 

Sligtil fpia. nwslly («iyni 
fttiil laiyngBd OWTh. 

Ttir utliick occvt* M nighL 



Metattk cough, iic'dutoui 
irspiration. viitikliW djv 
pnoca. 

Cdiivtilllont ntrr. 



AitBck pn'ici off m Uxc 
ciiurwi of an liuur or Ihd. 



Karely fntel. 



Mfmimmmt Civif. 

Ovriirt al all *En dnriiiK 

child liood. 

Variulile imnuiit of ferer, 
anil p<Tliiip> lomr tli|ih- 
tlieiin of IhP foiun. 

Motlly wurar al ni|[llL 



Meulllc c«ugh. itlidutoiu. 

frspiralion. itrDgrculvc 

ilyilinti-fl. 
Con villi" Ills nv(F. 



ItMotnoi tt«i<l>>y H ut>c, 
llinii;;)! tiiiiHliunt UMIir 

in lit proKrcis. 
Very oftiii fnwl. 



PngMiiiis. — ^Tlic gteaim.ijorityiif intuits uhosufJei from 'cliiUl ttowing* 
fKma ;ihe progniiii*, howeitt, niuit alH'ay» be a ijuarded (ine,au(] as long 
otktm it any tendency 10 ipasm uf tlieti'^t''* the child eaiiiiot be reijarUed 
owiaf Uangi-r. A 'crowing' child may at any time have general eonvul- 
f Ml lad die in a few nuimenls. Impruvemnit in the child's general condi- 
t'Oft Mil especially of it» ili^slive powers, (|uickly leads lo an ini proven leiit in 
Ih'froHini; ;' this we liave noticed in »e>eml casei uhich nipidly improved 
"ta the careful feeding and attention in the hospital, but ulnch quickly rc- 
''H'tJapin whenih^w'credischatjicd. Aiiiituickof broiichitisor hronclto- 
poiaoMi is very likely lo prove fatal in a child subject to laryn);isnius. 

Ttwtfawji/.— During the vpasmodic staj,!* when the l>iei*lli is lieinu held,, 
•^rfbft most be directed Inwards cxdlinji rxflcxly the inspiratory respi- 
'■'■xyceaire. .\ s|u>n)je well tvclird with cold water maybe dashed intO' 
wftct ; imltinK on the back, nr a vijjoroiK shake, niti toraclimcs be sur- 
*fUkL ll is UMfful lo h.(ie a li.ind fan u'ilhin reach, and use it vigorously 
^OiK an aiiikck to (an ihc face. 

Wthave ftwnd that hookitiK bark Ihc epiglottis with the forefinger has. 
(■niblkiwed by an inspiration. In one of our own cases a child who wa* 
"npea to llie>>c attacks h.ul a severe seizure while under clilomfnmi for the 
'■•Wl of junt-naial aileiiciids and his life wa* only saved b) ihc nipid 
Nii»t«i»wc of inicheoimny. In siich cases a catlieii-r passed inloihelai]-nx 
^■U hAcc to insure ihe entry of a small quantity of air. 



Ttteasfsti/ Ike Respitm^r^A^^aius 

The ni<i«t UMful mnlicinct for icnipniiiry um: Ii> keep the aluch >n 
■check arc chlnml, bromide, ^ind minulc doses nf morphia. We shciuld m); 
frivc thete druxt in ibc xcvrrc fiirmi of vpasms in order to souihe or rtn^ 
Ic&t irriuiblc ihc unvablc ii.iie of the nervous ^viiein. l-'ive graini A 
liroiniHc with two and a half »f chloral may lie givvn tu an infant of i 
momhE, .in<l tcpcaicti «vcr>* lix hours. A drop of liq. niorphiji.' nwiy be ('im 
c»cO' s'" hours, it* elTcL-t being carefully naiclieil. 

1'he moi[ iinpDtt.-ini putt of the ttealinenl is with i«Kitril to llie diei ml 
surrounding* of the thild. It is of the ki^'^'O impoitaiite thi>t ii •AniA 
get fmh uir. A Mcani tcnl and tiui cluic tuoin si tbo oorsi pnitiblr pb(i 
for an infant tiuirering from l>ryn(,'i!>nius. Auhimgeanaytu the tcJisidcom 
works wonden, by impravinK the infjanl'!) digestive poncrsiind (general hratih 
A food or foods must be found mm\ ^'ivcii in iiuantiltcs nbich the (hild kH 
di);eM. li will |>ii>hably be found ih»t llic child i» ukiiiK ""'re milk ihxi \i 
can digest, and is passing laiK'^ p.isiy stools. The »motmt of milk muK te 
<liniinished. I'cpioniscd foods, cre.im mixtures, ibinonimcalgruet, beef juiti 
beef tea wilh ^cgciablcs, .ill hiivc their value in these «se», if given i» 
suitable ()U4imit)es ;ic<:ordiog to the child's digoiivc pow'cra. McdtciDtt 
which assist the digestion .-ind regulate (he liowcis are often neecM*!}: 
extract of mall, rhubnrb and soda, adds ami pepsine,.-ind, abm-c alii cod liitf 
oil, when it ran be taken and digc-$teil. Conttlpation muit be removed If 
a child has laryngismus and post. nasal adenoids, is it safe to (>|>craic? ^Vt 
have scleral times operated with grciic advantage, but it is neteisjiry tu bt 
on the look-out for spasm of the glottis. Intubation may 1>e pcifbrnxd of i 
■catheter passed into the traitlieu, if neteisai)', and artificial mpiniiM 
perftirmed. 



EpuiBioillc X>aTjmgltl«. OatlKirtial Biwani. I*b1b« Or«ap 

This allet-tion diflert from tlielusi descnbed in that iicunsiscsinasHdiko 
bui not complete sicnous of the ylottis associated «itli a larynjceal ot plaiyo- 
KCal catanh. A child, uauully above 3 or j >'cara of age, goes to W 
apparently uell, or there may be a slight Iwarjcness or coM in tbc badl 
after a few hours' sleep he b suddenly awakened uitli alannin^ Eyn)|Xon»<f 
laryngeaj obuructiun. There \% a loud mct:Jlic cough, siridulnus tc4pitall<)> 
more especially with inspiration, llie dyspna'a aitd distress are \'cr>' (iWL 
there is recession of the chest nails, and all ihe aceessory tnuicles are caUrf 
into re(|uiaition. The orthoptKcu and distress are so great Out death s««* 
inimiiicnt. In the course i>f a few minutes, probably Itcfotc the arrinl* 
mcilital assistance, which is hastily summoned, the laryngeal obsltuctiio 
has ceased, and the chdd, tired out by its unwnnteil e-NertioDs, falls uita* 
<|uiel sleep. The symptoms of .-i catarrh or tracheitis penist for some dlf* 
perhaps with some rlangin^: coukIi and n:ore or less pronoitnccd attacks ^ 
dy«pnnM at nigh). Children who ihiit sulTcr are ex ireniely liable loai^ 
currcnce whenever ihcy lake cold, and it is not untnmiiion for inothen 
that their child is ver^- subject to * croup.' Though iliese attacks are abii 
Ibcy are rarely fatal, thus contrasting with larvngismus : but it must l)C 
membeied thai the latter is frci(UL-niIy ,'iuociaied with (jeiwiiU convvlsion^ 
and, moreover, occurs at an age mhen spasm of tlic gloltis is ncc«s*t>lt 




Calarrhiil t% 

Un;;ttaiA Vf Mvvre on acoHint of ibc wvokncis o( ihc icipiraioiy iiiu*cle» 
vA ouit of rigidity in ili« chMt walls. ChiMrto who have chronically 
Idu^td tonsils or luial adcuotds are cxcecdinvb api to sulTct from 
jl^lsModic laryitjfitit. 

I TliTfc nii:kclcs of si>n«mo<lir croup diflcr veo' nmch in «cv«rit>-; tn Mme 
|ow« they arc very mild, but on account of their nccurrinK ai night, 
ltd >be drrad in iihirh .ill (oinns of croup arc held, they are cwccedlngly 
jijH"»JarTn the friends. Several children in the same familymay MiflRer, 
lid Acre is oActi a hisiorj' of ihe«e attacks lo be obtained in othn members 
tflbt&mily. 

TVnj/iiwir/.^Grr-a! care should be c.vcrrimrd to piirtei:! children suhject 
11 wrh atMrks from cold. A damp bntiic or a (Iani|> situation should be 
nndcii, ami cupoiutc to thp told cait »iiid» of iptmu should lie carrfully 
;iir&d aiiamsi, (ircjit benefit is usually derived frum reiidtiice at the lea- 
lAt Cnid t|xinj;in^ wiih tepid stt and water every mormiiK "» ^eliinK up 
tiilirtatly .-usiit in kei-pinj; the thild free from altaclcB. Wann wooller* 
ttatmit should be worn next to the skin, and C4re taken thai the legs arsd 
Ktk 4te nell protected. Enlarged tonsils or adenoids must be removed. 
Dwi^e ibc attack most reltef n given hy appi) ing hot sponges to tlie throat 
«dbj administering an cnwtic of ipecacuanha pontler (; to lo graini) or a 
W^oaoful or two of ipecatiMnha wine. Aj thcdiiW gi-tsoldfr he become* 
teandlcM liable lo the:ie attack), which cease alluseiher before puberty i» 
tudcd. 

CatarrBal X^arrncltta 

CUdrtn of all ages arc lubk to suffer f(v»m a catarrh of ihc Iiir>-nic and 

larkci, though tt is perhapf omsi common and is cenninly mn^i dangcrmic 

AntmdiCtimiivoorihrrc >-cntKnf life. Thesi' altar ki differ inmewhat from 

. IkMC of spasmodic croup just di-scrihcd, inasmuch at ihcte maybe no violent 

navbitiim al night, yet in many cases all (he tympioms are apt to be worse 

U*wil(nrning. In Ixith c.isck there is larvngeal i-atarrh and liiryngeal 

ifun,aiid they differ only m desire ; in the spasmodic variety there is uauatly 

Itdt lanriH, but sev en? attacks tA spasm aS the glottis : in lite catarrhal 

the catarrh i* much more severe, anti perlup^ the spiiuii is not well 

but all these cuiesarc apt to become much worse at nighi-appitrenilv 

(he presence of more or less spiinn. They are iniwlly the rc^ull oJ cold, 

ire to ooW winds or a chill, and ihcy may be assoLiaied with mcaste*, 

belonging to the prcmonitorj' symixom^ or following the disappearunce 

rash. The attack» are prece^lcd for tlse tnosi pjin by coriia, feverish' 

lad cnugb. the liisl suspicious symplom being the cbiinged character of 

ilv(irji-li, which is at first bard or hoarse, and then ;issumcs the characteristic 

L or 'brassy' rhar.icter, which announces that there is sonic stenosis 

: Ir :.ii>-tu. An examination of (he faix.'Ct will probxbly show enlarged 

■id :«(i^csied tcHi^ils with excessive secretion, and if the epigkxtks can be 

RtA, the niuccnis membrane will be fotnsd lo be of a pinl:er colour tluin usual ; 

■M ii b rar«ly possible 10 get a view of the larynx by means of the Iarynf[o< 

rape. .As the sy^'P'"'"* become nsorc marked, the air is heard to cnicrihc 

uynt Kith a hiksii^g smmd, there is dyspnn^ ilse alac nasi work, the cbext 

■alls bll in during inspiration, and tliere is often much disticss. In some 




IQO Oisi'ases of the Respiratory Apparatus 

<H'>M(hc child lias lo b« proppi-U up in bed, un<t pays no liec<l to K*tayi,ilj 
whole attention hci»i; taken up in its eflurts to bre^ithe, The feier I 
vanabic, rarrly \\\^\, usually loo^ U^ 101° ; the puUc i?> ijuick an<t hard 1 
most cases (he symptoms are milder than those just deM^ribcd, there bM 
■only A crnupy cnujfh ni)d some ai'celeraiiun of brcathin);. In the tat 
siati'cs the scrrction bccnmes freer and intico-puruleiu. On the other hu 
the case may become »o ur),'enl tb.ti imulMiion or trBClteoIoniy is reqolrt 
10 Slave olT impending de^ilt, though usunllv the clTccts of Ireaiinenl rend 
this unnccei^Kary. Cnsc^ of simple c^utrhal laryn);itifi >n children t^ 
{irescnt ihc piciuic of «enosi» of the larynx whirh i* seen in the membraan 
variety ; there is pmhably the ' crmipy ' cough and frc<)ucnl hrejilhing, W 
bctn'ccn whilci, csjicriatly after a lii <^ roughing, ihe child is compami: 
<;nnifonable, and falls inin an easy sleep. The prognotis depends upon 
■diaiino^is ; if the case is one of catarrhal larynicitiii and the child ia 
3 or 3 years iif nge, there is strong probability that it will recover, 
younger the child, Ilie greater is the danger. 

7Vm/j«w>i/.— The lirsi appeiirjince of 'iroupy' lyinpiortii should never i 
neglected ; Ihc hard niti illic: tough, when <mi;e htjrd, ^llould be ibc m|[«I 
for placing iht chihl m a warm room, u lii-re the tcmpcrdlure n nminiaini 
at Co' or 65° bi>lh day and night, giving at the same time fluid food or sofi 
•demulcent dnnki, and medicines which piomule diaphoresis, [f the sjni 
lonis beconit mort pioiiounced. the child must be conlinud lo it* col, and| 
tent rigged over it by means of sheets stretched over cords or > clotbl 
huise. so as lo protect the patient from draughts imd a moist ainvosphd 
nmst be seemed by ihc aid of the steam kettle. Some carl)i>lic acid 01 I 
bcnjioin coi may he placed in the kettle. Tlie temperature inside ihe trt 
«hi>uld he maintained .11 almut 70', and slcam from a keltic allowed Jo pU 
freely imo it, so a> to render ihc air thoroughly «arm and moist. The um 
tendency of ihe friends of the patient is 10 overdo the sivam and fluialii 
too high a iempcmtuie,soihat it it not uncommon 10 find the patient alnH 
parboiled. 

During the early stage* of laryngitis when there is much iwdling of ll 
mucous membrane of the lar)'nx, with little secretion, ihe steam gives met 
■or less, at Icasi temporary, relief. This it most marked in the caset of hosptti 
pniients who have been much exposed before being admitted ; in ihcsc c^M 
the amounl of relief given by the sleimi lent is often an im|K>rt:mt elemenli 
the diagnosis of catarrhal vtrmt membranous croup. .-X sicam kettle shoul 
be heated by means of a spirit lamp r.-iiher than by gas or by placing i 
on the lire, as In ihc taller case the pnlienl's cot has to he placed ctoMloA 
^rc. Tlic! products of the combustion of gas arc object i<mable, especially I 
.1 small ruom. Local applications applied over the lar>-nx in the form ( 
hot sponges or ^pongio-piline nrung out of hoi water are often of muri 
sen'icc. 'I1ic sponges should be taken out of (he hoi naier and squeeta 
by uringing in a piece of flannel and uted continuously ; but if this cxhjiittll 
the child 100 much,a piece of spongio-piline maybe secured in situ byUM 
and renewed every half-hour. An emetic in this stage is often of cnocl 
value in relieving Ihe breathing and producing free mpectoiiiiion, ipcci 
cuanh* powder answering ver)- wi-!l. Five grains may be given in synip< 
otaitge peel every ten minute* till vomiting is produced. Stdphaic of coppt 




^^^^» Catarrhal Laryngitis igi 

mjir. 1 In fp. | daies ri:)MMtccl in a few ininutes, will Kcncrally produce 
nwiliiiK- li v% useless to repeal cini'liirv if Ihcy fail Id j^'ivc relief. It need 
tivdlf be Kiid ihiit it n orong (■) ^ni: i-nietici in llie liiler 3(.i);e%, ulicti the 
brattiiiiK has liccoini^ Inbnured .-ind the 1ip« blue or p;il1id ; to give crneiics 
i»dctdi»ecir<nuiii.Uini.-rii!t tii liik f3iiliin.':in(l tuuiutc invaluable limi;. Of 
■wAcinc!!, antimon) unqucsliunubly iiolds ihc first place, und in sllicnic aue^ 
ihtaU be K'ven witli a free liand, though as an emetic il '\% loo ilnw :in<l 
nMNaiinK. Either the wine or lariur emetic niay be tfiveii. in coinbinaiion 
■ibdlr»ie ot pota»li or acetate iif ammonia. <F. 13.) Tartar craetit niay 
U preo in powder or in • ubluids,' gr. ^ to gr. ^ every two or three houia 
tcowdint; 10 i>);c- Itoili ipecacuanha and aconite in small and a']>eiiicd 
Aanue otxeful. 

The only food admis&ibic is milk diluted nith barley n';iter or soda water, 
pi^rahly );ivcn uarm to assist in prudu<.int; perspiration. In must cases of 
OBiiTha) taryngilis relief of ilio mo«t ur),'ent symptom^ fulluns ihii line of 
Uncnoit, llMMgh probably for sevcml days nuny of the symptoms will 
main, with exacerbations at nigjlit ; in stKh cases the antimony may be 
fnhed, naiucatine doses beint; ^i^cn. 

Tile queiiiiin as to uliether intubation or iratheoloiny should be per- 
(MMd i» al«T»y> a dilficull i>"e, iiusmuch as in many case* the inoil urKcnt 
>;«plOfns will diiappeat under tlie iniliieiiceof tre.iliiieni,and the operation, 
mn in the most skilful hnnds, adds .inutlicr element of dan^-er to the cuse. 
Il « inipoMibte 10 lay down any lule for ihe (jerformance of the operation, 
^ontrtcct any one symptom which is to Ik- taken as the signal. Uyspouia 
< TKcsston of the chest wall do not necessarily indicate any immediate 
T.andniost of us will have seen r.iset in mhirh theie haslKcn indrawing 
[ tp«(;asirii»m and rib^ recover uithoui operniinn. If, howe»-cr, the case 
I a later siaxc in which the voice •ilmost disappears, the respiration 
1 laboured, all the rcspirninr)' mu^rlc* joinlnj; in ihe aiicinpt to draw 
I expel it from the chest, while the distress and resllcssnessnreon the 
, it is then quite ccnnin that the time ha* come for nflbrdin^' (clief. 
Ilbeie is niaiked pallor of the face, coma, delirium, or oihcr symptom of 
nu, there it not a ninmeni to Iom. 

k diSruliy is In Lirnc measure <liie to the unccnainiy of our disiKOOUS. 

r arc sitic that we are dc.ilinif »ith a caic of catarrh pure and simple, 

I thna)(h the «ymplomM of Dl»tnict>on arc thrcairninK ue ran alTord tn 

I Mid i^ivc o«ir irKiinicnl a fair trial before prncccdinK to operate, know- 

I thit mui-h of the obitruction is due in spasm, which may al any time 

ily wit»idc. Death from asphyxia must be very rare in a case of 

I Urjntfitis over two or three j-ears of age. But it is comparalively 

1 (hat »« can make a certain dia^nosis~ai limt, at any rale— between 

a) and mcmbianoui laryngitis, as ic may be only after imcheoiomy 

ihetB prtforaicd. and Mimetimes even a day or tH'o later, that membrane 

; up. It i* often not easy ni decide as to the time for operative 

ce, bin in a caw uhere there wa> a history of the child having 

I before from 'croup,' and where the breathioK tended to net wot»c 

and afterward* improved for a while at least, we should delay 

live interference as \an^ ax puMible, in the hope that impcmement 

I take place On the other hand, in u case that steadily gut wone with* 



r92 Piseasfs 0/ the fitspimtory Apj^arnttts 

out »ny intcmihsiDnF, wc thould cerTainI)- advise opcfflltw iiilcrltrcncG in 
lirood lime, as ihcrr uoiitd l>c litilc rtiance of a sikccmAiI i«»i»e 10 the mo 
unleu ihc olistruciion u-cre rcticvi^d. 



Kembrantn* bwyaKltla 

Ii incmbninoui liirj'ngihs :iKvjyj (li[ilithpfiliL- ? Can lli«rc lie diphlbttui 
nf (he lar>'nx willumi nny imiKli membniiic beinK ptcienl? In ihc btmi 
ma}<>riiy o( case^ (Hltc mn be no doubt th;it If iiierobriine lie preient thr 
cnte is one i>f diphihenu,. It mi»[ 4U0 be uiid ibiil in ihe gieul majority *< 
caie*, if there is no tnenibnine, there is no diphlheri.i. but in the prewii 
Slate i>r our Iciioivlecl^c it i> not wise lu tulce up :i (lot>in:iiic poiltion, exi-qii 
in M> fur us in view ctcry ui»c of Iiiij-n^iiiii, whether «>e &nA mciiibnine c 
not, n'ith tlie gtetiicst §uspieion, as all Mich autf* riuiy turn otii in the nul 
Id lie diphihcrin, anil nc inay n-f.Tet nJicn Km lute thai ure <liil nut at flw 
trtMt ilirni as aui'li. Wc thu&i leave the disttissioii of the rrluiinn cf 
tiicni bran oils etiKbtions to dipliihcria to ;> later chnpcer Utc DtriiTHiJiuy 
SytHfifi"ut.—Tbr iniiirtl syinpioms of niembranout cronip, whetltcr ihpb- 
Iheritic or not, Jirc practirally identical, inasmurh asthe>- jrcilio*c nfsienout 
of the Inr^'nx. When ihe larynx is the i>ri(iar>' seat o(theait<irk tlvesjtiipconit 
»rc those of Miairh, with re*iles*nes*, feve richness, and brassy couKh. !■ 
ihc routse nf a day or two, sometimes sooner, there is rtitirc o* lew loatC 
voire and ihe cciuifh has a pcculi^ir linKing or metallic character, which « 
very characterittk. 

It now become* evident that there is tome o!>iiiui:lion in the l.ir^'nx. »» 
■he air rnler* the tmrhca with a hissing or ttridiilnus sound, and the I'hikI » 
ContiantK' endcamurinK to cim^ih simiething up and clulchefi at its iwck a 
if to remove some obstritction. The tonsils arc usually snnlkn, the bi 
retldened, and perhaps Ihc seat of fahc membrane. I'hcrc is marked rest 
lessness ; the child wants to be nursed, then put hack ajpin into its cot. 
Imps icet a few minutes' sleep, nnktiii; up n-tth a hoarse couifh aiwl diflkwll^ 
of hruitliin);. The voice now is nearly lost, the child speaking in a whispr 
and making itself underslood with dif)i<-uliy. There is marked dyspAtcw* 
which lends to increase ns Ihe disease progresses ; tlie a\x nasi dilate, the 
inipimtory muscles ure c^alM into action, an<l the epigastrium and Ini 
lateral region of the chest, ihc inicKostal sptices, and supra-sicnut fosu 1 
drawn in during inspiralion. The cxpirniory dToris are Uboure^t, sn Am^ 
the abdominal muscles act with some fnrcc, and the air cscnjics through lb 
Uryni with a noisy sound. Sn laliour*^ and noisy is iho breathing thai 
can lie heard sontc distance off. While ihc child goes from bad to 
Iherc -ire usually more or less miirktd exaceriiaiions ; the child is 
after a fit of ri)U);hiiHJ, during which mucus or pcrbajis sonte fiKtnl 
actually dislmlgcd, ,AII the symploms arc apl to be worse al night. 

lfr>o relief is obtained the synipioms of toxarmij begin 10 present t! 
selves. There is a marked pallor or lividity about the lips and face ; |ieK— 
spirations break out on the forehead ; the restlessness is "fteii intenw ; il» 
child is perhaps drowsy and delirious, pcfhaps attempting 10 get out nf b«d 
presently complete insensibility comes nn, the pupiU dilate, the attempts 
respiralion become more and more feeble, and death <iuii 



Membranous Laryngitis 



193 



temperature n tiiually rai»cd n dcifrec or twn in the earlier stiiKcx, but m xf 
be labaomul ui ihi? blood bccomci more venous. An examin.iiian nf the 
(heii (loe^ t«w .ilways yield posiiivc reauJts ;u lo ihesiaieof ilie lungs. The 
whistling 01 iiridulous soutid pruiluced in the larynx is heard all over the 
chest, nuskia^ the vciiicuUir breath sounds and making; it diSicult to 
diagntyie tlie rondiiion of the lung. The supraclavicular reKi""* '" fmnt ate 
DSUilly unduly reswunt from the presence of emphysema, while at the bases 
|N>itenorly the resonance i» mostly impaired on aciroimi of ihc lunj; being 
collapsed, or air entering it »*ery imperfectly. The diagnoiis of pneumonia 
l» difikuh in the absence of impaired resonance, us the typical signs may be 
wanting on accoiunt of the »mall supply of air entering the chest : moreover, 
the pi>ctimtH»ie consolidation may be masked by emphysema. It is difficult 
lo diagiioM the presence of membnine in the Imchea and bronchi ; but if 
ifter traclicoiomy lus been perfbnncd the bre:ithing a siill laboured with 
indntwing of the chest uall*. there will be strung reason to suspect thai the 
bronchi arc obstruited.by inembr-ine. 

When the larynx is affected secondarily the symptoms are frequently 
morh less m.trkcd, niotc especially if the menibrane only spreads to [he 
kuynx after it has existed fot some day& in She phnr^'nx or natal murous 
membrane. In this rase Ihc ive.ikncss and deprcssinn which exist before 
the Ur>-ngeal complication supervenes mask the symptom* of laryngenl 
uenuMs. There is uninlly much less dyspn(i:a and distress than when a 
kallhy child is suddenly nitackcd. When the primary scat of the membrane 
n ta the brondii and it ascends to the larynx, the symptoms closel/ 
I •Mmbic punilcnl bronchitis, as in the foUowmg case : 

Anniiiif Difi'hrritii f>OTi/, — Thomoi M.ic., 7 yrors. Roy w-is iiuilB wdl tiU 
l^ntrf 8. lie oomfiLuno] of liii ihraul, and became hOLkisr , lie hiid >tlio n cough. 
(hMmBry 8 br cam? li>lb« "nirait llonpilitl. wliErmnmini^lioii showed lb« cords nnd 
Iqu wiebcakb} . FcliriMry it. — !%ccnliyMr. Wntiiuicoll at Ibe Childrcn'ii Diipciuniy : 
teatauaBd *i|nuie4bronobJtiB«ere nolcti, uul hi^wns sent la hospital Onadn^sdon 
hiii*tll-<»uibhe<l bc7, iom«cl>'«pn>wi. bill ■ (ood colour. Thvv Ik rsi;«Mion of tt» 
^B ptrl of ihf ch«i. Pnbe. loo' : mpimlion, sS"; tcmpFniturc. ^•B'; obtu 
<MMaL Rbtmchl bonl nil over chm. Nu enlori^nl tlunils Ui Iw loll : tromo diUlise 
"*« c( faucn ; no membrane. Stmm (eol : sick twice niter pulv. ipecac. RT. xv. 
'■VBif ta^^^Tbrre \s iiinrr iii;irkoil rr^coviinn th^n j^Mcnlay; hpils *oni? pumlenl 
•Pftl rUo bentil in chest. .\1 noon, luliihalion by Mr. Lea, coughed up iiiuth slriouy 
*t>t Tmpcr4luie ij^'--to\- . no mcrobmnf tVhruary 13. — Rc»pinili"n ciuy ; lube 
"•^talL Teaiprraiurr loi ". Kebnury 15. — Tubctcnioveil ; hi cathes easily, bul cauchs 
y* J«Od deal o( im-iiiih puN. tJrine conlnini a irnoc of -ilhumpn. Kiiljiuury 16. — 
"■^Mnisaeuy: no rrcnsioa ; urine a Urge amount of iilbumi.-n. Intulalion nt 10.45 ; 
■^tMlul* up in a rcw tnlnuMi. Inlubnlion .-i|piin .-it 1 P.M. , miK)i niui-o-piis couched 
* Ttlmiiay 17. — Child mach wonc: grcul pallor. Rrsplrnlion 5*". Urine scatily ; 
W|r<Moual o( iiUjoiiifii ; vvnlc pulse, low len^jon, Febnuiry la —Tnidwoliiiiiy thU 
■"•fct^ppniM incrouing ; nomcnilirane icsii. Child dicdolnlthcnia eoily mominB. 
ft* mrtrm. — Thin mcnibninc ntrmtinK d-mn liie tratlioa and bronciii lo (hi- 
**^ tacschi kn llic tungs; muiJi uiucu* present. Some mcmllfnne on Ibe epigloitb 
■*l»Tt»; mnc oa ihr (nuuM <ir Darn. 

Albuminuria exists in a larue number of c;)$i:s in the early -laKes, in 
*^|>^l in the latter stages ; the mine may be highly albuminous and scanty. 
'*tt»ion*Ity there may be suppression of urine and uni'inic symptoms. 

Ot^gnta't. — The diatimosii of stenosis of the larynx is nut diRictdt, nor it 

O 



i&4 



Diseases of Ihc Resptratoty Apf^tratus 



It likely to be coofoimdcd whli bronchitis or broncho- pnetunonin where the 
obstruction resides in the bionclnnl tubes, or where thete i» exteiwive coo- 
aolidaiion of the liin>;. \\\ laryngeal »icno»ii the air rtuhei ihtoutfh the 
lar>-ni(, giving: rise loa crowing or siridulout Round. etpeciitlljrthirSnj; intpira- 
lion, bti[ there is obstruction to the expinition ntio ; the refpiriilory* move- 
ments are Uboured, as if to m-ercorne the obsirui^tion, and wiih this there i> 
marked recession or sucking In of the ch»t walls during intpicatton. Then; 
is loss or great impniimcni of voice In pncinnoni.-i or bronchial ubttrac- 
tion, the dyspnavi may be great and the respirations frcquml, with much 
in drawing of the chest w.-ill, hut there is no stridor or loss of voice. The 
diagnosis of obstruction of the bronchinl tubes, in addition to stenosis of the 
Urynx, as in those (uses Bhere the membmnc has spread dow-nw.inls or 
nhere there is an actuniulation of tnutus below the larynx, is diffictiJt ami 
uncertain ; bui in all such oises the dyspnu-a will be great, and Iracbeotooi) 
urgently required, and ihe presence of obstructed bronchi would not conira- 
indicate oper;iii»n, as an ujienini; in the tr»chea would litvour the cougbiiw 
up of the obatrtitting materiaL 

The ditTerenti.ildiagnosisorcatiirrhfil.mcmbninous, and diphtheritic croa|> 
isgencinlly a matter of threat difficuliy, nnd unril the case has remained under 
observation for some hours or days often imiiossiblc. Even after tracbcO' 
lomy has been performed, ihc nature of the case may slill be doubtful, inas> 
much as thick tibrinnus mucus may be couched up wiih no distinrt mem- 
brane, and recovery may lake pi arc wit bom ihr diagnosis having been deter- 
mined. The question iif diphtheria or nni diphilieri.t is one of the grvaieM 
importance, but unfortunately there is not much that can be said wiih 
certainty. It is easy to say that in diphtheritic croup iherc it asibeni.-i, 
while in membranous laryngitis the aitack is sthenic in n.-iiure. But, as a 
matter of fact, it occurs in pmclicc that if the primary seat of the diphtheria 
is the larynx, the first and only symptoms are those of stenosis of the larj-nx, 
and the pillur and depression and asthenia which result are due to the 
lOKiiniiia produced by uant of osjgcn, rather ihan by the norking of d>e 
diplilticritit poison. It is for this nuison thai the symptoms of membranous 
fonnalions are ptntticully the same whether produced by diphtheria or not 
11^ however, the larynx is affected after the existence for some days o( 
diphlheria of the buces the symptom! are neceuarily modified. 71i« 
diagnosis of diphtheria when primarily situated in the larynx has often tube 
made less from the symptoms of the patient than from his surroundings. 

If diphtheria is epidemic at the lime, or if the lauces are covered with 
membrane, or there is albumen present in the urine, the <asc is almost cer- 
tainly diphtberiiic. The discovery i>f L-ocffler's D-badllu> in the tecrvtiona 
would place the diagnosis Iwyond doubi. 

Stenosis of the larynx nxay be caused in other ways than by the exudation 
of membrane ; the larynx may he compressed by an abscess situated poi- 
teriorly between the larynx and <rsophagus, or even laterally ; in this cast 
there will be difficuhy of swallowing as well as dyspna». The trachea may 
be compressed Iwlcw tlie larynx by an cnUri^cd thyrmd or new giowib, but 
(he history of the aisc as well as the local enlargement uould disimguUh 
between the i»-o. In infcinis an<l young children spasm of ibe glottis will ia 
rare cuses simulate membranous laryngitis, as in the case t;iven >> iS6V 



Mfmbntnvus Laryttgitis 



195 



The diatrntnii may be diffirult. but the abiencc «f (ever wmild point to 

ipasm ; it i» rare, howcvrr, forany spasmodic alTcclioii to comc on gradually 

i»d pros'*** fr""' had l" woisc, a» 1^ ihc c.^sc wiili diphtheritic Inryngilis. 

[In ibe fnllowinx tHooM-v, prcswite by aliKC-stcs on the tnicliea Jjavc riac 

[to d)'KpniEa ; in one tracheotomy was performed without relief. 

TMrnraikr A^uta *f IJU Tiymtn 1 Pnaitrt tm lit Trattkn; rriKifeUm/.— 
la/fsrct S.,kSrdaoiiwnlh>; lulmilMiI N'oivmbcr 14 . iSga. M<jlhcr illlln *]» bos b«en 
Irom trnnh nnd subject lo hironchiiiv Klve ila|ii aso ibe bcgoa to i-ougli anil 
' bNNtbc alQi cUftculty. HmrMt u ^""^ '^''"l- ■■>d caiiool lir ttii«n ; ha lipB nre blue nl 

On MtelMiaB the child waa Lyanawil and ibtre wiu ourh nrthopnoca ; ih« wnt (ii«o 
tine lawpocolUi of vln. Ipmoe. ia divided doM*. but iJic wu nut >ivk. A r«iw boure 
•Am IndiMtOMiy wn pcrfuriunl liy Mr. Wninuuxiii. bui ii rnilvtl lo rclwvc the linnthiog, 
and ibc died iwa boure o/lcr. 

ffO-atmfitm —On removing the urnmrn an mUrgMl i1i)-mus wu noled, enendln|{ 
frixn tlH upim' turdn of tlie flcrnum m Ilii: liirunsilion n! ihr Itti^hca. nnd tyliijc in nm- 
1»cl i»l<h lliF (Ricfani. and evidently <omprculng IL Some ciieom lyraphnllo gbmdx 
1B0C adlKTOit to Hit rtiaitL Ot\ xction it was tdunfl 10 tvinliiin :k Iflri^ ahfCTM cnvily 
GUad oilb thick pm. Their »ere wme (nllialy luberolei ind bioncho-[)neiiniOnlo in both 
hiwgi. 

Ctrif! -i/ Cert-dal Sfint ; Ahr/ta tamfniiiiix U^ir/iAtgai omJ yVa<*/it.— Rldioid U, 

■■odjynm; MlniiMcd Fctatury 14. it<H- Molhrt sl.nia (or Die lul fotlnight he h.-u 

tailtibmfcinfCougbandwhoeimK : l»gi-» ro«nili>ind latlcunl nighl. On onmliialion 

H WW ndted br had a hanh mcullic cough and hutky voiw : prolongixl npirstion and 

rtuachm all over Ibeebisl. Murch 19. — t'at the \:i>\ wivk lliir linMlhing hkk Imn much 

*<««. DOt^. and BiirV«i]ly ilndulani ; (he coui-h niKlallic, and lame retvuion of the 

thoL April II. — BrcWhra with a Cfouiiy wuml : luu ;iiUck>> i>( ililTiciiU tirotlhing Kt 

MCht : (eti blue and dlsirOKd. Air cnicn the cheii wiih a long-dniwu iibJuil wund. 

a Md, mkI Ibcn tlnwlr goes out. Rnonnnor it boty over Ihr iwmum. Vna puffy ; 

•Uvbuftd vein*. May 14-— t.lpi and flngcn lonieuhiit cyanoted. Sili up •f awake, 

tM wftm atlnp tin down, Ibough nlwnys iEiii«il nicir« or 1r» on plllom. ShtiIIou* 

■4A *nd hqulib birly wril, July iol— Tcnipmturc bcrn Irrcitiilar »\rKr \iu.\ note: 

Wta^ tn loo''. Bniihini; hiu tmprovnl ot laic ; Ihetv <i a tendency to choke when 

tthnlL Septcnilier ii. — .Ml Iiir}ni[r.il lyinploiiii. him iliuppcnml. Chokn ivIiitii lie 

Mi; nn patl-phBiyngBal ohKcu ; no ]uin in ilic neck, but hecnniiat hold hi> hend up, 

■M Ihe lut two nriival ivilrliiii' -irr itry p(omiiii:nl ; he crm with (uiu if tiis head it 

"^IM. Temperuturv 98'^ to 101". Gctolier 15. — Xfuch worie; far lome lime pnai haj 

^•Wtng: brctic leniprRitilrr : had n tuid Jillnrl: of djiiivHm n»rty ihis tnomlng : 

Wik KnniBg. |iu tunning iram ticnt anil fnotiih. Uniih Ocrnber «]. 

ti t 'turtim, — Mrdrastuial glnndn rnLuKed, but not c»Mn>iii : ■ «nia1l cicntrix at the 
■inU k(l lung; Ir-inchUi*. but iiot IuIktcIc. In upper |uiil of the puawrux inRlliu- 
l**^(nd behind the oCMphagUi is an aboeeu ctviiy holilini; .-ilwut tij ; il hai com- 
P^^Bd tfir unoptuiGiiA and openct] into it. P^lerior vr\\ i>r hIdqctu cuvity fcirriied by 
^W ■witti. In poiitloii ol tevcntli ceivieal and upper ihrcc doru.1, the l»dlis havlni; 
Vfieuir dhappcared. 

ftUt/figi'ra/ Ani/omy—The poft-morttm appearances ftinnd in those 
"^Inve died of mcnibranous or diphlheritic croup differ according 10 the 
itWiilitie c»iM of de^iih. In the mnjorily of c.iscs this is due to [he foima- 
■•• rf memWanc IjcIow ihc iracheutomy wound and to the iLtnjfS becomini; 
'^•fced or crkll.ip^icd. In such cnses membrane may be found bcginninf; 
u iW rjhglnttii and cKtendinp dowTiwatds to the smallest brenchi. A» m 
*'^tbe membrane is lou^h .ind firmly adherent 10 ihe epitctoiiis and larynx, 
^<>i8 M^aiated with tlilTictiliy. while lower down the membrane it far let* 

OS 



196 



Disfases of thi Respiratory AppamtMS 



lou^h and i» much more easily dctiicheil ; ihe bronchi (uuslly contain (cnt- 
punitcnl fluid, nnd ihc bases nf thr lungs arc unialty pneumonic or cotliip>e4 
while tlic npiees are cmphyscm.iious. In some cases death results fttwi 
asthenia or from sc-ptir poisoning, the rc^uli of the diphliteritk infection : in 
iuch rjseK the ir;ic1irH and brun<.*)ii m.iy be fri:c froni xecreiion. It i-> ex 
ccediiijjly nue lo find iit ilw posf-uiorlem th.1l the incin)iranr is conline<l lo 
the Inrynx in ihnsc cases where Irachcoiomy has Ijei-n performed. 

TWii/wn/. — Kvcry case of liirynjj'lis occurring in a child should lie at 
once isolated, u:t what may iippear in the early .staKCs to be a initd rate of 
catarrhal laryngitis ria>' in the end prove to be diphtheritic There ,irc miW 
atiacki ofUiphilieri^ of thelarjnx, juM asilwre are mild caics of dipUthera 
of the timsilt .ind fauces. In the early suigei the lecrelion coughed up may 
be miico-purulcni only, and Uter, either before or iifter tracheotomy or in- 
tubation Iw5 bt^tn performed, the secretion may be membranous. 

Much that hn> been suiU under the head of treatment in catarrhal buyn- 
giti» will apply to (he Ireattmcnl of diphtheritic laryngitis, A steam lent 
should be provided, and u'armth and heat should be applied cxterrwlly to 
the larynx, though any bliMerinj; or nbmiiion of the skin must be larehiDy 
avoided. If the case i* ccruinly one of diphiheria.we doubt the value of 
either emetics or etpccioranls. If there is membrane in the larynx there b 
small chance oi' its beinj^ loosened or detached b)' these aieans. But, iissum- 
in}; the case is seen in an early «ia^e, no harm ran be done by an emetic of 
ipecacuanha ; Dr. W. 1'. N'orihrup rccomnicnds the yellow sut|ihatc of 
mercury in 5-graiii doses. Kmetic* in the later sta);c <ii'e uietess and 
harmful. We must chiefly rely nn the application of steam ftuiii a sieaRi' 
spray apparatus rhnrgjcd uiih some antif>eplic, and. above all, in relieving 
the stenosis of the larynx by initihation or irachcoloniy. 'I'hc most useful 
antiseptic is bichloride of mercur\-; carbolic acid, thymol, and oil nf jicpper' 
minlarcaUo u.M:ful. Calomel fu mi t: at ion has l)cenuscd with home succrstin 
America, and is certainly worth a trial. Dr. Northrup recommends ilutia tmi 
be ngged up over the cot by means of sheets, made fairly air-tight and ci 
.ibuui so cubic feel capacity. 15 grams of calomel are volatilised every* two 
houis (or two diiys and two iiighis,and then ai intervals of three hours for Ihe 
next twenty-four Imurs. The calomel is volutilised by means of a tin |>Ialc 
healed by a spirit lamp, and placed over a bowl ofnaiersoas to prev<-nt 6ir 
in case of an upset. This treatmem docs not produce pty^lism; if carried 
on too long stomaiitis diarrhwa, and an».'mia may superrene. The roouilt 
should be kept swablwd oui, and any secretion coughed up must at once 
be removed and disinfected. The medicinal treatment appropriate for 
diphtheria should Ik; ^iven (see iM/r.t\. 'i'hc only food should consist of fluids. 

Traebaotonr-— The operation of opening the trachea in cases of mem- 
branous larj-ngiils must be loottcd upon as a means of relieving the mecha- 
nical obstruction to respiration ; it c>tn in noway influence ibe ci>nstitulioB>l 
c6i:ci« of ihc disc^isc, ihouj;h it may prevent the addition of gradual asphywa 
to the other depressing influences of Ihc poison, Kurihcr, ne may, byibr 
nperaiion, preicnt the spread of ific membrane down the tr;ichea, and thus, 
perhaps, Icuen the riik of abioqiiion of the vims as well as gel lid of the 
obstruction.* What certainly may be loukcd for from the ojKrMion is tbal 

' IV* R, W-, Pirkrr. 




Tracheotomy 

(tenth froni mcclijnicalobtlruaion to thciiiiprrscgmcntofthe windpipe may 
b«: ;ii«rtcil, and ihai the ditirvH caused by d^-spnuM may lo a ^n&x dcg^ree 
be relieved, [immi not be for^ttcn that Inichcoiomy has its own dangers: 
fir»it<ome the risks of ihc npcration itself— lia;niorrha>;c, injury lo iinportxnt 
ncixhlmann}; vlrurturcs, and cnrruncc of blood into the tracheal ; later, ilierc 
art* (he dangers of septir abtcirption, ihc exposure of a raw surface lo tlie 
fttjjhilicriiir poison, imcheilis, pneumoni.t, and *n on, from exposure of the 
tmchrjl murous mcmbninc lo cold ; thnt this is a real danger a paper of 
Uf-ttilk* shows.' 

While we have thus indicated the objections to and the Itnnitcd uses nf 
the fipcntion, wc would )<:t ur^c it:^ perfomiance in all cases where there is 
tcverc dytptuca ; w« h;ii-e no mcins nf knowing; ihni the child u'ill die nf 
aMbotia, we do know that he will die nf sulTnc.-ilinn if iinrclicicd, >ind the 
other (lan^^crt meniiimcd are iill ustially ;ti oidabtc by circful operating and 
lAcT-iiuni^einenl. 

Eurenic proMralion without distinct ciidcnce of .-isphyxia, and the pre- 
I senct of pneumunia or capillary bronchitis, may lie liiejted ujion a* indica- 
iKwn that tracheotomy will be of no avail. If tracheotomy is olherwiie in- 
dkaltd, the presence of bronchitis may not in all caies prevent the operation 
bent uicaWul. We have seen a case in which it succeeded perfectly under 
ibnccircimstancesasCir as relieving the dyapnu;a went, though the child died, 
■h«n apparently convalcsceni, from ulceiation into the innominate artery. 

The youn^-er the child the earlier should tracheotomy be done \ indeed, 
in children under three years once there is membnine in the larynx there 
Mlalthojie bill in tracbcniomy : but sec p. 208. Inasmuch as the operation is 
fciity always one of urgency, wc niiist be prepared lo do it under unfavour- 
'"r drrumstanecs as regards nursing, light, help, and appliances. It is, 
"•ettr, usually |x»«siblc lo improvise fairly serviceable arrangements for 
^ (^ration itself. A drestinji t.ible or the top of a rhcsi of drawers 
in pnatc houses u the uuial oper;tiini; table. Candles give generally 
Ih bet olMainabic light nhen, as is so nfiirn the ra^e, ibc 0[>cmlinn has to 
Rdone at ni](hl, .ind c.ire must be Liken thai the lights arc coiruiicd only 
'•'hose members nf the household whoriinbedc|iendcd upon 10 bear seeing 
'•* npmtion. These niakethifl arrange me nii, together with the small site 
"rf iMtomical relation* of the [laris, the urgency of the case, and the 
■"■etnents of the trachea in dlHicull res ]>i rat ion, make this operation, 
■•"ilth often lightly spoken of, one of the most unxnjus in aurgerj*. 

If possible, ai least one skilled assiilanl should be obtained besides the 
"inthctisl. As regards an;esihelics, il is in our opinion a question lo be 
'*'<M br each ease ; if the child is so asphyxiated as to be unconscious of 
PMlnd not likely 10 struggle, it is far bciiei' to do without an aaanthetic. 
"'ekticseen chlarofarni prove fatal licfoic the o|>eration was begwi ; on 
'"'■Kterhand, If the case is operated upon earlier, and the child is consciout 
'^ tMleu, it is on all grounds licticr to give chlorolbnn, 

He child then should be placed upon a table of convenient height, and 
* Sjhu, if necessary', arranged carefully. Everything required in tlic 
Vwtion shmild be laid out upon a table or chair ready to hand before the 

■ (im/i Kiftrti, ta. lit. lol. •*. 




198 



Diseases of tfu Respiratory Apparatus 



clulcl it taken out of bed, since ut any inamcin ihc moving or the i;ivin|t «( 
Ibc ano^silietic rany increaie KSpliynia iiiid denuoil iTiiUini uclion. 

An Mon Wi the child ia unconsLious, und not beTore, »ince it increius the 
dyspncea, one pillow should Iw hiken Troin beneath the buid und pbced 
under the shoulders, !>o ilut the liciid falU liack and fully oxpcises the froM 
of the neck. I'aiker recommends a wine bottle wrapped in a towel » a 
neck support. The liciiil must be held by ua usiisiant exactly itraiKht, m> 
«s to avoid any cluinc^' of the upeiutor missing the mid line of iIht neck. 
The thyroid cartilage is then to be felt for, und an incision, one and a half 
to two inches in len);th, according to ilie siicof the child, niade in the middle 
line from the bwcr border of the thyroid cartilage downwards nearly to the 







rif.M'— AaianyalCliild'iTnctKEk <Fran 'Cnf'* AHicmy.'] 



lop of the Sternum. The first incision should be carried tbrouKh the sbn 
•ind subcutaneous fat ; llic second assistant should then draw the ednes of 
the wound a|>art with retractors, and ihc opcr^ilot should by lucccxxive cuts 
divide the tissues until he reaches the intermuscular septum betwceti the 
sterao-hyoids or lonrrdown between the stcmo-thyroids : on reaching thii 
he should with a director tear ihrnu)(h the tine of junction, and ihc auiitani 
should t;ikc them up with retractors. The irachcat f.ucia will now be ex- 
posed, and should l>c torn ihrou^h In like manner, and tlie tnichca bared 
The tracheal hoiik is next fixed m the tr^ichca, .ind drawn xliKhily fiirwanb 
so as to steady the windjupr and make ii prominent; a iJwm, lOfneiilut 
rtiund- Mouldered knife—i.c. one Toundcd at the iMck and neirly straight in 
fiont— is then nuide to pierce the trachea, and as soon as it lus entcfcd 



T^ttthfolomy 



199 



I 



adlc is &li|,'hlly dcpre»cd, and the wmilpi{K' is divided from bdow 
VpntAt hn at tmlM l1irc«-4]uancni of an incli. The knife: ii now l;iid 
iiidf, the dilator passed into the ltai;h» iinil o[)cncii, ,-ind the hook rc- 
iMivri ; a free Wait of air an«l tht ilrivijij- imi cificn of muc:m ot of mem- 
bine fiilkmt. If the tr.ichca la frcf Iri'in mcmliriine, ilic irathcotomy lube 
issti with tapes IS then pasatd in liciuccn or abuvt- tbv dilulur bbdus, and 
ihcdilMOr is ramtn^il ; us Mon iis a bla^i of iiir iliiou^h lli? tube >how» thai 
1 is in place, the lape* should be lied round the nctk, and the oper.ilion is 
wtr. The child should be kepi upon the tabic well wrapped up, u-ith a 
■inn iponyc over the rube, for a short lime to recover itself, nnd lliai it may 
let«n that there is no bleeding or oilier complication ; after a quarter <rf 
uhnut the inner tube may be put in aficr ctcnring auny all coughed-up 
Ruiiei. and ihc child should be pui into its cot and the sicam kettle 
wnnfed. 

Such arc the general outlines of (he course of an operation in which there 
hm been no complications and no hurry ; ii is, however, seldom thai such a 
bxiuiable ttate of things occurs, and it will be convenient 10 consider more 
'nJtuil ihe various diHiculiics that may arise. First, then, one or more large 
xini, inferior thyroid or branches of the anterior jugular, m.iy be met with ; 
ti ilirtt II no urgency these may he ligaiuicd, cither before or immediately 
*lcT ilii'iuiin, or fore i pressure tonxps applied. Should, by any rare chance, 
»airt[r>' of any siic l)c wounded, it must of course be treated in the same 
*>)'■ In .ill coxes the veins are necessarily iniensel>' congested when dyipnu-a 
i> nuked. In otxicr to ai-oid danger <rf wounding veins, some surgeons lay 
iiidc the knife aflct the lirsi incision and (ear through the lissucs down to 
dieiachea with dissccitng forceps or director. 

■Xett, the most rigid care muit lie i.tken lo keep in the middle line ; in 
Yiwii, Ui children it n nol difRruIt to miss the ir.ichea, which in them is not 
^r imall, but so soft at 10 be readily coniprcssctl or pu.ihcd aside and m> 
"■^ Everyone has heard nf, if tioi iccn, cases in which ihc disseeliun 
"* ken carried 10 one side oi tlic iracheii, and thus the great vessels &c. 
**t > y ttd. In tracheotomy low down, the anterior jugular vein i» Ihe vessel 
*• likely to be injured. This is, irf course, of minor importance, 

Thr depth of the trachea must aUu be remembered, and the bet that it 
'twdes from the surface ton-anU the lower pari of ihe neck. The deep in- 
"•••ilimuH not be carried too close 10 the siemum.or the innominate vessels 
■A kt endangered, nor must the trachea be opened so high up as to divide 
wttjroid cartilage and probably injure ihe vocal cords ; it is well, however, 
■in lA ton an opening as practicable, in order, if possible, to be clear of 
•ufaiiwlion. 

^i^ieg^rd need be paid to the thyroid t^land, nor should any attempt be 
■"* in children 10 make a 'superior' or ' inferior' tracheotomy. In almost 
^tt} case in uhich the operation has been done examination will show that 
'•^o three rings of the trachea and the cricoid cartilage, together wilh, of 
'Wte, the isthmus of ihc ihyroid gland, have been divided— thai, in fact, 
* lar;D|;o-tin>:healomy has been don^ and this is as good as any utlier 
'ft'aiiim. 

It is Mt by any means necessary to use a imrheal hook ; if it is not em- 
iHtd, tbe hji forefinger should be used as a guide and the trachea steadied 




200 Disfases of the Respiratory ApparatHS ^^^H 

by il or beiwc'cn it anil the left thumb while the knife \\ trattied upwarS^H 
the »iili! of the linger or beiwceii It and (he iliunib ; in man> cases ho««t^| 
(he hook docs uiidoubicdlj- simplify the opei-Ation. ^| 

Il is of grrai importance to have the skin wound very free, both lof|^| 
room for the deeper ticps of the operation and to prevcni (he pouiU^H 
of discharge or ait being pent up lit the ■.ellulai tissue of the wound ;^H 
siitclies should ever be put in. The tiacheal opening should be l*t^H 
median, and vertical ; nothing is gained bya small opening, and much ttoiA^I 
may aiise in inserting the tii))e. The knife should enter the tmelie<i M^H 
what shaipiv, but not with a stab or plunge Khich would cndanget H^ 
posterior wall : cnse^ bnvc been recorded where the knife failed lu pirm 
the mucous mcnibnine, and hence the tube wiis passed into the submuiMu 
(issue : in other instanrcs a lough diphtheritic membrane has been pushed 
before the knife And tube — under either condition, of course, do relief vw 
obtained by ihc opcraiion. 

If there i* any large rollccdon of membrane or of (hick mucus in the 
trachea, the lulic should not be insetted »( once, but the cdgc« of the ttarhcti 
wound should he held apart for the rhild to freely cough out the conicntf <f 
the air pnisiigcs, ;tnd (or the surgeon 10 clear them away Bn<l cxamiiK lie 
surface of the tt;ichca so .in to pi<k off any visible membrane above or bctow 
the opening. P.irkcr advices 'he systcmahc use of the dilator and swabbeac 
nul the (r;irhca .ind l.-irynx with a feather dipped in solution of caibonaicaf 
soda before putting in ihc tube. 

The itacb&d aperture m.iy be held open either with the dilator or *ili 
artery forceps, or G old ing- Bird's dilator may be worri for a time. 

In insetting ihc tube il i* sometimes difficult to get it into the slitlike 
orifice in the itachc.i ; under these circumstances the dilator is useful, or if 
one is not -it hand, one end of the 0|)Ciiing may be depressed by the finger 
so as to make the aperture gape. A bivalte lube is of course tbe easiest to 
insert for (his reason, ihougli it is not by any means the best variety. Tbe 
fnugeon should never be satisfied that the trachea is properly opened tinlcM 
free bliMts of .lir are driven out on coughing, nor ihst the iiii>e is in ihe wind- 
pi|JC unless air and mucus are bloun out through ihc tnbc freely. 

The inttrumeni mosl commonly used to clear the trachea of membnnc 
is <i feather ; some of the shorter tail feathers of a pheasant will be found (he 
bcsi^if ibe longer ones are used, the end which is loo (legible should be fvn 
off. We have had some common brush pipe cleaners lipped with coralline 
for this purpose, and also a miniature bristle pmbang made to sweep out the 
irachea. Membrane can often be picked oui with forceps. Aspirators o^all 
kinds are of use chiefly if noi solely for h!o.>d and the thinner form of nMicua; 
adherent membrane and thick mucus cnnnoi be drawn out by them ; neither 
I* tucking by ihc mouth any better, hence il is not worth the risk to the 
operator, .\nyonc who has tried il will know how impossible it is to sack 
out anything except the fluid material, and et'cn for this auction is orien un- 
mcresfrful. Parker, however, strongly advoc.tics the use of aspirators after 
loosening and softening ihc membrane by i nsi.il la ■ inn of carbonate of soda. 
Where breathing has ceased or is bcci>ming tcry feeble, artilirial respitMioQ 

L ' Sadie carbunac ^J. [tjoeriiM' li), iralvT tu Iviij (Riiher). 



f Tracheotomy ^H^b 2or 

ihrald be perforn>ed, and ir nec«Mar>' a catheter may be passed dnwn the 
incltta and the lung:} mll^ieiL' 

Such are ihc more impiittanl [>oini« .-ilimit ilii- operalion itself in otses 
•tifre eitrrj-thins can be done ilclibcmtelj- and 'IVoussiMu's classical advice, 
'Op^n lemcinent, Irit k-niemcnl." followed. In man)- cases, howei'er, if 
iht opt-raiof is ilow ihe chiW will be dead before ihc trachea js iipvned. and 
if vA uciualty dead the idniost complete asphyxia wit! seriously add i» ilie 
diii);cn of the case. Under such circumstances it is neces5ar>' to cm ilie 
tu|H of ilw opention short ; a free inci&ion ihrou);h ihe sL^in, another duu-n 
IQ ibt Ifiichea, and the third upwards in the trachea itself. We have uflen 
Kill lo operate in this way uiih three cut». usint; no imtrumcnt except the 
\ak and the uacheoioniy tube ; after the fint iwo incisions the lefi fore- 
faprii passed down to the tracheii. which is steadied by it ; the opcnms 
itmdi and the nn^-er kept as a ^uide for ihc tube, which it at once in* 
lenri. Tlie tjnycr -ind thumb may bt usefully employed to push bade the 
limef oa each side and, as it were, press forward the trachea. In some 
OMUhere is free blcedmg fur a moment or two from the engorged veins ; 
ibd mast be neglected, the tube put in at once, and the child instantly 
tumdoveron its face to prevent any blood from running into the trachea : 
UMoeas air enters the lungs freely the circulation is re-established and 
4» tenous bleeding ceases without any treatment. The objection to this 
twileof opcratinx is that it is of course more difficult, and there is some 
nikcf blood getting into the air paSMges; it is, however, necessary in some 
wet In very urgent sufl<Kation the operation may even be done in one 
»o»ion through skin and trachea upwju^s, but this can hardly ever be 
•«««ry, and has several objection*, the chic/ being that in children the 
'n^hca can by no means always be fell through the skin, and there is 
cm likelihood of emphysema from insuflicieiicy of the superficial wound.' 
E'ltn if, the child is apparcnttyj dead before the trnchcA is opened, the 
<>|*niiion should be rapidi)' comirictcd, a Inn^ fenthcr passed down the trachea 
"d"iitLdrawn,and ihc niiificial respiration performed. Recovery will often 
Nlow picn if rc*piralion has cca*e<! for whar appears a very long time- 

llit well to rememberthatvcnouKblccdiiiK in tracheotomy isalways more 
^iiiUble in appearance than in reality, .xnA nhvnys ceases at once after the 
"^litfl IS freely opened. 

Emphytema occurring at the time of the operation is due to too small a 
tba wound or to opening up the cellular tissue in attempts to pass the tube ; 
tnarbc vcr>- cxleiitive and spread don-ninto the thorax ; in such cases it is 
'^'KntiDct feUil from prebnire U|]on the lungx. Champneys has shown cx- 
ftrineually thai there is i^crious daoKcr of mediastinal emphysema and 
fonnno-tiiarax when artificial respiration or sudden violent mspiralory effort 
1 mtiJe a/icr di^ iunn of the deep cervical fascia ; hence the lube or dilator 
'^Wdbe put in i|nickly and the Ciicia disturbed as tittle as possible.' 

A pMsible danger from cntrj- of air into a wounded vein need only be 

' >Ur)tBninss. Artk. PadiMr. ScpKniber iSa^ 

' RL<jciniai« nprmWt by unc iiiriiion iIowiiwjrIi, l-ri-mning by performing tlirmwr. 
''PM menUirsiic. NtUher ililspUuinor opcrAiion uiih ilic ihBrnta,vauicry bni nnyihliiK 
■"nMunsMlh. 

* Ud-Xkir. Tnit. isai. 



Disensf-s 0/ the Respirttlory AppuralHS 

mentioned ; insuni pressure on rhc vein .-ind rapid opening of ihe tndn 
aie I he remedies. 

Opinions differ greatly as li> Ihe bettt form of Eiacheoiomy tube ht 
inunediule use. The bivalve is the easiest to insert : the lobsier-taiM Htl 
of Durham is open 10 ihe objection tliat it \i ver^* difficult to clean ; pmifalUf' 
I*ark«i'« su-callcd an^nilar lube is the best, and ii certainly juuiioiiilcallr ik ' 
most correct ; it luis also tlic advantage of being pulij)ied inside. It i^ 
however, a mailer of little importance ivliat shape of tube is pot in for ikt 
first few hours, provided it is of sulTiciem siie and has a muvable thicU H 
allow ii to lie evenly. The largest siie that the irathea will admit sbe«ij 
always be u«ed to );ivc as much brcailiin^ space aa pussible and to pRi4 
play of the lube in the trachea. I'arlcer has shown that the diameter oftic 
windpipe ii e:xcecdingly variable, and ito lulcs for site in coitcspondcvt 
Willi age can be ^ivi-n. In any case it is advihable to change the lubciiH 
twenty-four or forty-ci(fht hours and ihift gives time for the substiiuiioo iA\ 
Parker's ttibe for any other that may have been used ai the moment. Aits 
niueiy-six hours ihe metal tube can ofien be replaced by a Morraoi tltkrti 
rubber one, or at least a metnl tube of ditfereni length from ihac tint 
ployed, or, belter fX\\\, the tube may be in favouiable cases lel^ out alioce'<ktt> 
As soon »s the trachea has been cleaned and the child has become v^ 
after the opcmtion, i.e. usually in about half an hour or less, the (Ul 

should be removed to the tent, the arraoc^' 
incnt of which h.u lieen already describtd 

The lower part of the iround should b<. 
dusted o\'er iviih iodoform, and a piece ^ 
gaujc slipped beneath the shield of the oAt 
to protect the skin and nyiund from it. If lis 
edge of the shield cms into the wcnmd,lbe' 
lube docs not 6t tvcll and probably the '<amf 
end is pressing upon the trachcti vail: 4 
is either too long in the straight pan or the 
curii'e is wrong. A single layer of gsiirc >tl 
with t-40 caibolic or some other antiseptic solution should be Uid otet 
the mouth of the tube and removed when there is any coughing. 

The child must be constantly uatchcd, and at the least sign of dyspwA 
or any cough the tube should be cleaned wiih a feather, and coughiat 
excited, watching fur the nionicnt when mucus appears ai the mouth of the 
tube to wipe it away before it is drawn in again. The inner tube should be 
put in as soon as the child has settled down, and taken out every half-hon 
or oftener at first to be cleaned- Special watch musi be kept for any suddea 
plugging of the tube by pieces nf detached membrane or thick muciu — a 
frei|ueui cause of sudden de;>ih after tracheotomy — immediate removal of iht 
tube and membrane is required in such circum stances. Abundant discbaixt 
of thin mucus is a good sign, in so far as there is less likelihood of ikut 
being any membmnc in ihe trachcn if free secretion occurs. 

Aftfr-aiiiniigfmtnL — Success in the results of tracheotomy cases dcpeiu}) 
more upon after -management than upon anything else, and if stirgeons coidt 
nurse their own cases the mon.-ility after the operaiion would be much lesa 
Coasiant watchfulness, rtatUitesi Ic rrinove iht tube all^ttktr and ttt^n oil 




Pic *t"-l VUf '• ThU. 




Trachailomy 



203 



tti trtt/ktAi if mcmbmnc cnnlinocs to form, this should be done at least 
once daily ; diviiincl) ndminiiiratinnof «timulAnls, rcg^daiiannfteinpcnitiir* 
indmoiUDK nre cstcniixit, and can only be satisfactorily seen to by tl)« 
Bitcon himself. Cock« ' well iniisl^ upon this, and poinls out thai sudden 
«bili«ction n mmx often due to in«pisfaicd mticus, not to membrane ; this 
ItKkmiKns is secreted generally nbiiui twcnty'rour hours after the operation, 
kA u (he end of three or four day« the discharge becomes ihinncr and 

»vt puriform (Jennings). 
Itii wt\l to fced the child by nutrient cneniaU for the (irsi few hours, but 
if he i» ihirsty a few tcaspoonfiils of iceri milk may be Kiven. During* the 
Sr«! (e» days ihe milk not infrcttucnily conies out in part tltrough the 
Ockotomy cube from imperfect closure of ihc glottis during dcjiUitition, and 
iM,as might be supposed, from any accident lo the a-sophagus ; on account 
<tf this occurrence it has bcw advised lo give more solid food by the motnh. 
A (truin amcKmc of litlc it incuiTcd from this imperfect po<iverof swallouin^', 
a{h«t food may pnsD inioihe lungs nnd set up the so-called 'deglutition 
FBcnmonia ; ' any such danger may be at oided, .is pointed out by Dr. 
HiJWnhan, jun., by feeding ibr child thmuyh a soft cJithcIrr ; from 3 to 6 or. 
rf lulk may be given in this uny every four hourt,' but tbe plan is rarely 

If pouibte the inicheotomy tube should be removed .iliogethcr on Ihe 

hnhor liAh day, but this must depend upon hou far the disease h;is !>ub. 

liiW; if membrane i» still coming iiway, tlip tuhp must remain, and it niiiy 

|k Ac eighth or tenth day before it is koi rid of. If, ai not infretiuenily 

>[9n)i, the dy»pnita rt:iums on closure of the orifice of the lube with ilii- 

' (always supposint; that (he tube has a pcrfonition .it Ihe bend) or on 

■ nmoial, ilte diflicult)' is due to (be jirenencc cither of menibranc or of 

, pngUiion tissue, uhich may form .i pol>|)oi(l mass springing from ihc «iic 

yi Mae paicli of membrane, from the edge of Mie wound, or from an ulcer 

CIO the pre«surc of the tulie. Granulation masses, according to Parker, 

I Bt aott common about the fourth to the eighth day. and may l>e cxpccicd 

lifibtie ate exuberant masses on the margin of the tracheal wound. Morell 

IJbdcnie says they occur from the fifteenth to the thinicih day, never after 

Jho months. Parker treats them by the application of niiraic of wlver. 

[Ibtk patches seen on the nuler tube when it is removed arc said to indicate 

[•'ttwion at the corresponding spot of ibc ir.ichca, an<l should be looke<l 

[*(*■> M an indication for irban^e of the tube in one of dilTcrent length 

I filter}. Or ilic dyipnu:.! may be due to adhesions in the larynx or 

WsWy pnnly^s of the lur>'njjeiil muscles, inflammniory softening of the 

Vdm, or spelling of the niutoiii membrane. 

Wlierc, iJien, the tube cannot be removed entirely after the fifth ilay, the 

'Btulonc siMMild be replaced by a rubber one, or frequent changes made in 

''(invri i>f the tube, and d^ily attempts made lo diajieiisc oith the tube 

*hli{tlWt. Should the obstruction continue, search must be made for its 

'KK; the most eottitnoii is the granulation mass uhich may somctimr-s 

■ Wen on usiti^ the dilator and be removed, its buse being touched with 

Mnie of lilixrr. Failing this, it is well lo wait a ucek or so and allow the 

i^lAregain iirength ; it should then be exa mined under an aniesiheiii:, 

'i««t«y /V^d/Wci.Janwrr >n4. ■ St. lUrHmb-nfi Hrftrls. 1885. 



204 



Diseatts of the Rtspiratety Apparatus 



iind, failing: the Rndin); of tiranulniionn or other obvious cam 
piolir should lie pai«cd Up ihroutth tli« (.Ooiti* from below and a pica 
»i!k rarryinK a smnll sponjic he aii.irhcd to it ; the prolie ftlKiuld then 
drami on through the ttinuih, nnd the ipon^c carried thioui;h the la/ 
sweeps it out, breaks dnivn any adht-^ions, and clears away mucus or 
granulations there inay be. We hate by this means succeeded in rtstoi 
the bri^iihing powers after many attempts at doing without the tube fi 
long time. 

The dati^'-rs, then, of ihc too prolonged retention of ilic lube are 
possible dcvclo|iment of griinulation niiusei and ulcer^iiion of the mud 
which may cither lead to lia-murrluii^e from porfontting Uic innominate ai 
or vein, or to iubiciineni lra<:heal iicnosis from cicatricial stricture. Ro 
in 1859, and Heilly [Le Proj^rit AfMiv.il, Novonbcx 19, i8S4),eMtmate<l 
in about one in live of the leases of iraclieuiomy there in tUceriiliun of 
trachea, but these results arc from/V'j/OTw/i-iwobseri-jiion*. The ulcen 
may be either on llie anterior or posterior wall of t)i<.' trachea <ind |{ives 
to no special ^yinpluins at (hi; time, unlcs^i soinc important veuel ii> ofie 

Somciiincs mere nervousness .ind fear of sutro«:ation prc%'eni the rem 
of llie tube ; in such cases attcmpi!i must be gradually made by the use 
tiilieivitha large fenestra to allou' the passage of air through the larynx, m 
the external orilicc of the lube is close<1 with ihc finger or a coric for gn 
ally increased periods of time. Careful natch must aluays bo kept 11 
Ihetc cases for f«ir of tuddcn asphyxia, which may come on after rem 
of ihc tube, as tonn as ihc tracheal orifice bccomci^ umall, or even lalrf 1 
this from growth nf gmnulaliom frnm the inner «irfacc »f ihc wound, 
such cases the wound ma}' require to l>c reopened and ihi^ tube to be inv 
afreili. In same fewcasc% the tuhc can never be di^)>e^^ed with, and hj 
l>e W'lm pemianenlly ; but mually some cause of ohiliiiction ■:an be U« 
Sometimes a timt^h dense cicatricial membrane fomii about the lower a 
luit of the lar>'nx or upper [larl of the Ir^ichca, and require* removal 
eolargcinent of llie tratheoloniy opening or by ibyiotoniy. IntubatKNi 1 
or wiibuut removal of cicatricial tissue i> effcciual in some cases,' In 
case where the lube has to be l»ng retained, great tare must be lako 
avoid ulceration imd to »ee thai the lube is not corroded : il Itas >ev 
limes happened that ihe tube has dropped olF the itiield and fallen into 
trachea after long wear. 

As to the application of lotions &c (o (he interior of the tradiea i 
operation, the number of specifics is as great as tlut for the ihroai ; the i 
lotion and lime water' do, no doubt, soften the membrane and mucus, 
allow it to be more easily detached ; of ibc other remedies probably the 
is the instilTiition of 1 or j drops of 1 -1000 mercurial solution. The appi 
tions niay be made wtlli a bnish or spray producer, or a drop or iwo irui 
instilled through the tube from lime in time. Sineann^' ilie tube each I 
it is replaced niih iodoform ointment is a good plan. 1lic wound »lioul< 
swablied over daily wiih a solution of pcrchloride of mciGur>' (1-3000), 
then powdered with equal pan* of iodoform and boric acid. 

After the njicraiion (he child io greatly relieved, usually falls asleep, Hk 

' Fiifr ltd* snil Bcouk, l.niml. Jnniiary lOi iS^r, 

* Lime waMT li soon rendered Inefficient b}> iheCOtOf llw Mplrad air. 



^^^^V TraJuolomy ^^^^^^V 205 

KMianirdI Tot tv-cmy-fourorfony-ciKhl hours, ami llicn in raialcasotleulh 
occin, often M)<l<k-nly. 1'hi« sudden d4.-:iih may bv due to vailous cmisc^ ; 
Ibdsm),' of the tube *itli dtlachcd nieinliiaiic or mucus, extenwon downward* 
dtke dttease, possibly irriUlion of the vayus (I'arker;!, simple iisllieniu or 
pMoning by the disease, pncuitioni.-i, or cardiac failure. 

TTieTe is no itotibt thai the majority of tasesof Tniilicoiomy for diphtheria 
<Ji( ; the mortahty varies «iih tht epidemic ami w iih the uper;Uor, for neces- 
arilythc HiTxeon who will only operate in ihe most favounihle cases u*i 11 
bftalowcrmortalitylhan he whojfivcia chance of relief [o less hopeful cases 
ii "ell. Hence statistics are of no value. Il is, however, rou(;hty true that 
J litje proponion of the cases described as t roup recover after iracheotum)', 
■hilc thotc cbssed as diphtheria mostly die. 

\(fi lias a very iinpuitani bcarinj; on the success of the operalien. 
QnUrcn under 3 years cimi pa raiively seldom recover;' the feebleness of 
tlM child, ll>c increased diAitutty of (he opemiion and of the suhseijuent 
Mugftineni, all make the prospect at lliis a(;e uorse. K. W. Parker has 
hdjoptrcent. of successes in his own practice, but this must he considered 
bi bttter than the s^-craKc restih.* 

Afdumbautt, in Ihe Paris Children's Hospital, );ives the following table 
if KulMolomy cases ; 

C^uu Rttot vrin 

I -3 yean 976 104 

3-4 « «io 17S 

4S " 736 174 

S* « 497 148 

above 6 « 54; 198 

F«r the Ketwral man^Kement and feeding of diphiheria casea, at well at 
'Ibe treatment of the fauces and mouth, it* Diphtheria. 
^fati fnrni diphtheria or croup, tracheotomy may luivc to be contidercd 
"^lua of SOrJds n/ tie g/c't/ii, liiUAWy the result of an attempt to drink from 
fWipMH ol a tea kettle. In such cases, as Pr. Wilks has shown, a false 
^nbranc may be produced exactly like that of diphtheria' The »ym- 
((■Bt usaally come cm immediately, and in slight cases soon suluidc if the 
•Ud il kep* in Ijcd in a warni moist iitmo^phere. Sudden spasnt, bronchitis, 
udpceamonia, and the foniiation of false menibniiie are the chief danKen. 
TVtreatmcnt i>f such cases consists in fcccpmy the child in a irachcotomy 
■m md gi^nnj; antimony or an emciit. If the ihdd is steadily getting 
wnt Iracheuiomy should be performed. The luln." nia>' Ije removed 
f on tlie third to ci^jhth day. Si.iiilication is often recommended, but 
,y to write abotLt than to pcrfortii. 

I »ttU«i often ttnd their n-ay into the air passa^ei of children. 
^bud,or grain of maiie, or a plum stone, or other foreign body is held 

' lU tJndn*r, /»kttm\f. Kin4rHuilk. R ii. H. i, rrmrdi j8 prr crnl. <•( iiii i ama 
■''■Ni^iwl 4ip)MhMia,' unil mnii olihe sucMwn '"etv m ilie ucond jcJr of life; and 
^J^.Ankivf. KiiUrrhriU- II. Iv, II. ti. u. hivt oollcclnl iio tuccutiful cue* iindsr 
' *^a. (he youasn) cawi ;ire h wn'ki anil 9 ner-l» respn'tivcl)' ; iIh liitlef. howcnr, 
^^tfai \fM-p>atr)nt!a\ tXKtrtA.StHiiiir tliH. U'oiJk, iSSCh 
'M*. UiJ. Awr. N'ovifmlier 1888. 
'Ci^'r Kifvrti. iKo. vkI RryiKi in Ihe wma nunitxr, 



306 



Disfasts of tkt Respiratory Apparatus 



in the citild's inoulh, .ind a tuddcn ii»pintli»n miiy cau*c it to pas* into iho 
liiT)'!!)'- 1'be Undy inny lndt;e in the upper opt^nint.' of the Lirynx or in the 
liniii, or m»y pass into ihc triichi-^ or ■rithi-c lir(iiti.*hu», usually ibe tiiibL 

I'nrkcr rcrords .-i cnse in uhich ;i i:a»eous lymph^itic gUn<l ulcerated ita-j 
wjiy into awA lilorkcd the tmchea.' 

If ihe biidy \s. in the tii[]-iix t)icre will be dyspnora .iikI more or less hits nfi 
voice, witli htuinc or nnijin>; i*au)th, .vnA if in the trachea pouibly a 
mitlJTi^ luund may be heaid on listening over the front of tbe neck, iadi 
the muveincnt of the body in ibc iriicbta. If ilii; Bubitaflfe is lodged 
broncbui iliere »i11 l>e inipnircd bruih sounds and possibly collapse of 
luiit; on tti<- Siimc side. 

If tlio history i!> clear, iracheotoiny should Mt once tic pcrlbrmcd, ns siMldn 
aspliyniu often co:iii.'s nii qiiiii' unexpectedly ; hence, tirijent iiyinptoms gbttuU 
not be n.iiicd fo)'. The opening in the iraeliea should be free, And thvetlgrn 
should be held .ipan to allow of the ready expulsion of the body, nhicb it 
often blown out ,41 once. Ifihis does not occur, the larynx sliould be MWclMd, 
a probe being passed in from below And the linger made to evplora the 
throat from the inoutli. If the body it lodged below the opening, the cliiM 
should be inveried and shaken, and if this \% unsuccessful an attempi sbtNihl 
be made 10 cviraci the substance ntth forceps or a brush passed down tie 
trachea. HronchltiH and pneumonia usually speedily ie«uk M iho ifovc 
body isnoi renioicd. 

Shiiuld tilt- :iiu-ni]it lilt mninal fail, If the body is in tbe larynx and cannM 
be pusheil ir|t iiiio (he nimith or remoted from hclow, it ts probably lielw 
to follow Mnliiie«'>> iidvicc and divide partially or whollythe thyroid carttlaff 
to as 10 expose and remove ihc impacted maiW ; the opcraiion is likely lo<lA 
leu harm lh:m the.- rrlcniion of the foreign material. If ihc tubtUlloea 
lodged in Ihe tungt, it may pcisiibly be removed at a tecond attempt X 
may become lootened and coughed up ; orcasinnally xuch bodies ulctnK 
iheir way out and may even rc;ich the surface of the chcil. In oihrr (ate* 
death results fmm pneumonia or pulmonary -ibscei*. 

Certain other conditions may demand inichcolomy in children— concMUUl 
syphilitic lar^-ngitis, chtnni>- simple tatyngitit, |vipitloma, or, ai alreadyom- 
tioned, prc«ure of pl);irynt;cal .il)sces.i.ct. 

XalnbAUon of Ibe larT-Bx has been of late )'rars |>rarti«nl by O'Dwyf '■ 
\Vaxh;un, and nihcrs, chiclly in America, as a substitute fur iracheotoniy. h 
hai been urged in it« fatour that it is a leti severe measure than that opn*- 
tion, and is likely to be permitted by friends when a cutting operatkio is R" 
fused ; that ii does not prevent oiKoiiig the trachea later, should that bec«M 
neociwry, and that it is eflicient, while it docs not expose a raw Mir£ic<l* 
the diphtheritic jwison nor allow imu-armcd air to reach the lungs. A speci>l 
Mt of instruments is required for (his plan, t'lom 30 to )o per ceni.* (^ 
successful results have been obtained, but sneral drawbacks to its ufcMt 
admitted, surh as the difficulty of the niani[mlaiion, the liability to dbptu^ 
ment of the tube, and its «h*iriiction by membrane. Our experience oCtl* 
o])eration has shown that .1 litilc practice is reqiiiied 10 learn readily toiiil)<^ 
duce the tube : it is much more difficult to remove the tube from the lan*^ 

• Bril. .Ur.4 /.'Mr. Oulolicc 1, it^ 

• fitlt Wntiwrn, Brit. MU. /tur. Stplembrr 19, iMS. 



fntuhation 



207 



Several improvemcnistui'etKcniTiBiiciii thGikppAnittu,and ihe method has 
no dniibt a coatidrmbtc lliou);h limited field of usefulness. Iniiihaiion. 
*» sogjlc«(«l by Symonds, is ccilHinly useful in some case* where aficr 
iracheolomy there is a diffictiliy In tieitiiig rid of [he lubc.' 

In one Instiuice in mhich vc pcrfomKd liitulMtion upon a living child the 
tetuli uat disnsirtms ; a pociion of llic ineinbrane was pushcil down before 
the mbc, 4nd tlw child instnnil)* choked : it u'as ont^ by immcdiaic tracheo- 
tomy wid the luc cfaniticial respiratloi) thai breathing was rcnorcd 





n^ A- O'UoTir'i lUBbailun Appaiuut, Tlw Tii^uRttiowt ilit 'IniTwiimr* vllh a tub* 
fitl«d oit- A jiepunitc tube i» ^*o ibijwii. 

POlbcn have had *imibr expcricnt c. We ha\c h:i<l some experience of ibe 
I in \-ariou> fomis of larj-ngcal obsiTuciion, iiitd ha\-c 1101 been led I» 
^B veT>- favourable vieu' of iu suliabiliiy fnr oiaes of diphilR'riii where 
[membrane in any quaniiiy is present. Of eleven ca»cs of iiiiubation 
w our cate, in three success followed, in ihrce tnicheoiomy n^aa 
' Bhajaently Miccesxfullr performed, and In lour instances the children died 
« ipile of Incheotoiny. Tha operation appean best adapted fur otaes 



l%)•^ -fm*7ti'> K(tnrlor, Tbc JnlAinl httk Hu Inio ihriube anil b«Ua ilSmJy whoi 
the k^pcr it tkpiwcd by the thumb or ilio optiaur. 

. . there is httle or no false membrane^i.e. certain lyiie* of acute 
[""WK'tis the less it-vete fonns of diphtheria, where tracheotomy is for any 
l*nNn undeiiiablc. and for use in cases where mechanical obstruction 
ItKMku lifter tracltcotainy, or lesulis from cicatricial cnntntction in the 

' I«hir1bfr tUuflt «pr miut reffr loihr MtdUnl Chrmktt lot 1S87. wlwro atsiractt 
I<(bbiuuiu fiaperaon Ibe xAJcciirin be found ; i^Ua totltt ^nUMt 1^ PMMria, inj, 

I WnhaM'i paivT alrmdy rofr/red 10. and ir> the Appcndii cl the pminl worli ;. 
IltelO SUr* Bo^ OO IntHbation. .ind Nonhni|>. Oril. Atnl. /tiur. Dccaaba 99. tifyt. 



208 



DhtMxs of the Rtspiratory Apparatus 



tnr)-nx. Il is cctuinly unsuitable for bronchitic .ind pnuumonk paiienU. 
Kccenily ;i special paiicm nf tthort wide lubet hax been used for c>»et wlxit 
Ihere is much loo*c iiu-mbMnc or UischarKe.' 

Lci>-elt,' linm ii itudy of 8;8 cases opcrnte<l upon al ihe ItoatM C(r 
Htupila! eilher by tracheotomy or intubuDon, ironcluilw : 'In cenenl 
1 would lie K'^id lo atliociitc ihe pcrftinnancc of tt;ichfoiomy tnWeail rf 
iniubinion in most c.isci of icvere latyngciil diphihiTiii, etcept in llie two 
of r.hildren under two year*, v.hcn intuliaucm is lo be |ierfoniieil.' 

The ;ipp;iraiut used for inmbanon. ;irid fisured ;d)tive. c-onsiMs of * 
special lutic wifh an ■ inimducet ' and' cxir.nctor.' The child should bt 
swathed in a blanket ami held upri};lil in the nurd's anus. The niouih * 
held open by a ^.\^, a lube of proper siie lelecled, Ihreadeil, and iti pik( 
itrcwi-d on III the introducer ; Ihe left forefinger p.-issed to the back of iW 
ihraai pulN fonvard the epigloiiis and serves as guide 10 ihe lube. Any 
diniculty ill intioducin^' the iiibc may, we have found, bc^ot over by waitiaie 
for an inspiiaiory elTon on the part of the patient and then slipping in the 
lUbe : this is .1 tittle pniciic^tl point of much value. A» so<m a» the tube a 
in ibc lannx the imraduccr i« withdrAuii with the pilot, and if the tube ■( in 
position the thread mny be aUn withdrawn. Wc arc of opinion tlut il ii»» 
howcA'cr, much better to leave the thread in the tube lo facilitate cxtraciinn 
usually it ^eis up little or no irritation. The tube is then left in pofilion flM 
a time varyin^j fmm .1 few hours to two or three days, BC<Tordiii4[ to tb< 
circumstanre* of the case. If left too long 11 may cause ulceration irft!* 
larynii 01 inichca.' To remove il an anicsthetic may or may not he Ki^er 
ihc extractor is introduced into (he o|>enin|i of the tube, which is then wilt" 
draun. If too small a lube- is u^ed, it may slip inlo the trachea. WiihocJ 
practice the tube is apt 10 be passed inlo the ccsophague. 

.•\ftcr the introduction of the lube, relief, thouKh noc nece«»atily Ihibm 
diatc, is usually speedy. There is sometimes difficulty in feeding, from 
tendency fur fluids lo pass inio the trachea. If this difficulty occurs il oa 
b<- nici by fcc<bn]c the child with its head han)^n){ far hack or by Kivin 
>cmi-solid food. 

ClirMtloKaTrncitt*.-~llathinliinlsand older children suffer fmm chrai» 
hoanenciii, with otLasinniilly acule or subacute exacerbations, with ooo^ 
symptoms. Such c^iic? nuiy t.ikc their origin in a past attack <it attacks 
subacute laryngitis, a certain ^tinount of tbickenint; being left behind. Ot!> 
caics are apparently syphiiiiic. ojictully in infants. Tul>crcular laryngi 
may alao occur, but it is certainly uncumnion. The larj'n\ is also someli: 
affected in oks of chronic pliaryn^iiis where the timsils are colarced 
perhaps poii-nasal (;r<iwths also extsL If the symptoms d(i imk yieU 
MtHagent applications or the use of caustics such as nitrate of siKrr, the^ 
may be so much pmgtcssivi- thickening and dyspnONi Hut tn*chcoti 
tnay be required ; this is, however, very rarely the case. 

VaplilaoM of tb« taryns is a rare affection, consisting in one or mi 
warty (iiiii;rowih'i from ibe ndKhbourhood of the true vouil cords. 
sympioRM arc aphonia and usually intermittent but Increuint; dy^Hi^^ 

> Nonhrup. lirii. MtJ. J»»t, Dfvemlm ap. 1894. 

• The AfrJkal Nrmt, Auguil 17, 1891. 

* Corr. Ltmitl, Mordi s8, (891. 




PapUloma of Ihf. Larynx 



209 



init OB willwut oKious cause. Wh«c Ur jri>,'oscopy i* praeikaWc. inupcc- 
tlon «l>oi*n ihc iirarty mass or masMis ii^iially aboui ihc antctior piirt i>f the 
t{l<>lli& Sudil«n (ibslTUCtion of thi- npcrtuir mny rctull from s|ia»ni set up 
by impaction of a pendulous i;r(ii»-ih bciwc^n ihe cords, or uraduiil .ii|)hyxia 
may cumc on. Three mode-i of tre-ntmcnt are jiu* 11 hie— removal of the 
growths by cndolar>'n);cal opcrution, a meihod applirablu only to late child- 
hood and a<lulis : the ^etond is trji^hcolorny, with i>r without an attempt to 
rrmnvelho growths from tlie tracheotomy wound ; and the third is ihyroiomy, 
ith cxciunn of the warls when fully exposed. Thv last plan, which is Ihc 
plesi, it open to the objection ihni injury is like!)' 10 be done to the vootl 
dK and pcrmanont aphoni;t m<(\' re^uli. Several successful caiea by 
iikcr, Davics-Collcy, and others hate, however, been recorded. On the 
hole, in this disease, it is probably best to perform thyrotomy. 
In two CAMS lately under trcatmeni at the Children's Hospital by our 
le* Dr. Htilton and >[r. Collier, and by ourselves, repwted opcmtion* 
re()uir«d Ijoih in the shape of thyrotomy and of scrapinji out the 
(ftwibt duraugh the laryngeal apcnure. The tendcncj' lo recurrence was very 
■HiVed indeed, and more than once ilic windpi|Jc had 10 be reopened to 
tmmi utITocaiioin af^er the rhildrcn bad appe.)rcd m be convalescent. In 
In6 met it was found impo<siblr to dispense with a lulir. The t.'i'O'^tliS 
'(Mn{ from all pant of ihc interior of the larynx and upper portion of the 
livtua. Iluitnn' points 0111 that cases of spomnncciiis disa|ipcarance of 
lkw[Towths have been recorded after portions had been cou);hcd up, also 
lAir tiDiheototny without further operation, and after an attack nf one of Ihc 
*ufti)i(in»ta. 

' Hulton, Mid. CinM. vol. >. ».«• 1^. 



J 



2IO 



Diuases cf the Respiratory Appitratus 



CHAPTER XU 

DISRASES OP TIIR RP^PIKATOXY API'AHATUS— C(W*/(WW</ 



Sr«Bcliltla *nd Catartli 

Catarrh of Ihc birmchia! luhei n u coiiinKin ^iifti tiim ;il all periotli of life 
iind in every locial ^radc. bul il ii in c;irly irhililbcud ih.it xt is peih.ipt the 
mciit coramon, and it i» ill ihis pttioil ih.ii ii ;iv>umei Ihc t;r«iil«>l im|K<fiance 
from the dineiuei ivbicli s.rc liabk t'j fullon- \\\ ii> intin. In old uge, nlica 
(be lun(^ iire damaged by einj>Iiy»eiiia. and the chest walls luve Ium their 
elasticity, brunchitis ii apt lo be a serious aud often fatal disease ; btil not 
leas v-i i» h in the verj' youn);, in whom the chesi unlU arc alike wanlin); in 
elasticity and nKidity, ihv bioncblat tubes easily collapse, aud the lungs 
t'ery readily join in the iniUniniation. The ^tcaicst liability appears to dcciu 
(lurifl); ihc first two years of life ; certainly at this age it is most fatal. Ex- 
posure to cold is in a Lirge number of cases the cxciiing cause ; climntjc 
influtmccs ar« seen, especially in Ute autumn or early winter, in the larse 
number of cases of chest affections which occur at this period. Tbat the 
larger nunibcr of cases should occur amoiiK the tower and worsi-houted 
class is only what is to be expected, inasmurh as the lives «f the inf.ints and 
rhildrcn arc spent cither in the foul and siiilTy atmosphere of an ot'crcmndcd 
and i1l-t'cnti1atcd bouse, or they arc exposed, imjicrfcctly clad, to all sons of 
weather in the streets. 

The prcdisposinjj causes arc many ; some children MCti) lo inherit a 
irndcnry to bronchial catarrh, and, in spite of the gieaied care and the 
nimt constant ' coddlinti,' suffer every few mnnihK, perhaps for ibc whoJe «S 
the winter, from hronchinl r.-il;irrh or teverr colds, u hich pa«s into hnsnchilis 
with the grciteii rcjdmcxs ; dentition, rickets, mensles, nhoaping cmnirh, 
intettin.ll catarrh frc«|ueni[y play .in iin|Kinant part in the prndurtion of a 
bronchitis. During the time ih.-it .1 tooth is being cut children vem scry 
apt to suffer from catarrh, which in the winter affcns the bronchial tnbet 
and in summer the intestinei. Treasure of the tooth tm the gnms seem* in 
net reflexly in producing .1 oiarrli, sumclimei with more or leu spaun. as 
the child becomes whceiy at niKb>> sibilus being beard all over the chest, 
while in the morning it will be [»crfectly well This may happen seveni 
nights in succession. Rickety children are specially proise 10 sufftr from 
bronchial afleclions. .ind in them it is especially serious on account of the 
softness of the nbs, .-ind the weakness of the muscles orr«pint)On,i«9iillifiK 
in deformed chests and collapsed lung. 

Symptoms and Cotint.—^hK attack is often preceded by n cold in ilic 



BrancJiitis 



9\\ 



koitbe inlani sneezes, its nose runs, and it begins to oiigEi. If ihit 
kMchi^ catarrh which follows is mild, and the cdLirrh docs not extend 
teinad the trachea and Urge bmachi, ihe genera] syntptoins are sli);ht ; 
6tMi»no diuress, no dyipncca, only n tmublesome cou).'h, perhaps sume 
■httDDg dnrtrtg respiration and a sh*i;hily elevated tem^icrAiure at mxht. 
Id ibc more severe attacks in which rhc smaller bronchi. 1 1 tubes are Involved, 
ikit aacotiB membrane bcint; >^wolIen i^ind (lie secretion thick and viiad, 
JnfAn from obstruction to ihe air rnicring ihe lungs will be present. 
Tk prise is hard and accelerated, the nuni)>er of respirations incrcaseU 
■covdinfc to ibc amoiinl of nlniruclinn, the al;c nasi working, the skin 
bititd thcin£utt restless and thirsty. On placing the car Inihe chest, dry 
Intinf nr snoring sounds will be heard during inspiration, as the air rushes 
iliToajh lite pulmonary divisions of (he bmnehi. in the severer ca>cs entirely 
(tnoinng the rct)>irator>' murmur. In the milder aiiaclci rhnnitii nill only 
hbeud a-ilh lomc respirator)- ma\*emcnci, being mni'c c-ipcrially heard at 
ikem4i of the tun};«. 

b iofints and yuang chililren, especially if their rib* are •oftened in 
CMtqaenee of rickets, there a recession of the chest w-^lls, chiefly ai the 
tftpKiiRn and lower lateral re^^ion of ihc chcsl, due to the imperfect filling 
<f At longs, the chest wall falling in in [ilace of the 1u»k* cip.4iiding. In a 
Iwr «aje the sibilant or rhonchial sounds become mixed witli moist rjiles : 
■fcottrenot distinctly and sharply crepitant, as of liubblci paiiing through 
itai Aad, but indistinct bubbling sounds ai i>f ;iir forced ihtough thick 
ttudou mucus. ITie moist sounds succeedmg the drj' pnim lo a freer 
•Kwioiof mucus from the hitherto suolkn und con};e>ieJ aiucuus mem- 
taw, Ib some ciisei in infants mucous bnlibling rales arc liisird from the 
fat. If convnlescence ii <juickly established, the abnormal sounds arc 
indully replaced by llie nomia) respiratory murmur, though rhnnchi or 
tllBMy be heard for some days or weeks. I'ercussion of ihe rliest wall* 
^titS M attack of uncornphcated bronchitis shows the resomincc normal, 
ilkoqfk perhaps (here ntay be some hyper -reumance at the sub-cltivicuUr 
"pw frotn ibc presence of more or less emphysema. 

bmou attacks of bronchitis there is usually more or less disturbance of 
lie 4(«lh'C organs. TIm: Imwcli m.ny be confineil and distended with 
*taiBie(, the tongue is <:»aied, and there is often iiioie or less vumilinf;. 

The fcrtr in uncomplicated cases is never hljih ; there may be an even- 
"•giiieof a degree or two, while the mornmt; Icmperaiure maybe nonnal 
nulneeTnal. especially in "-eakly children. The couj:h. which in the early 
*U{i* it baid, in tlie later staj^es beconics looser, mucus Is coughed up into 
tW pharynx ^tnd then ijuickly swallowed, unless extrsctcd by means of 
Ibt OBrsc's iingcr, Childicn under five years rarely expectorate— mucus ie 
nqghed np, but they have not tlie sen^c in spli It out. 

Aa attack of hronchiii; usu.illy lasts a ivrrk or ten days nnd ends iD 
rmverv. leaving the child subject to a second attack. 

Cvmpiiuttuiiu. — ilronchiiis In Inranit, -md young rliildrrn is frequently 
acCMnpanied by one or more rnm plica lions, the commoncni bring cnllapte 
of ihe luni;, cnianhal pneumonia, bronchiectasis, and emphysema. In a 

Ease it \i almost certain that one, or more often all four, of these com- 
ioits will be found. 
\ - 



ZI2 



Jistttses of the fitsfiratory Appamhis 



Ooltopa* or Xowc.— During' :in attack uf broncliiiis or bruivchal ut.irrfa 
it )» not uncommon to nritc tliai ilii- Tctpii-at»0' inuimur is u'cak ur Al»mi 
overs pOTiionnf luciR— as, for iiiMancc.oncornthn bfisc : then perhaps a(i«r 
a vigorutiB cnii^h a pluj; uf tniinis is dislnri^cil front a \xc^v hrnndius and 

, (he brcaib sounds wilh pcrhnp* »iinif lon^c lillcs, are hcnid trvvt the same 

' atica. At nihcr tinier thcWc-iih sounds nrr absent, and hythc ncxl day llw 
orrfinno' rc^pimiory miimiiir »il| ,-ij[>in be heard. In ihi< caw n plug nf 
thick mticiis lodged in one of ih« larycr (1ivi«ions of the pulmmuity brondii 
prccenii the in};re%* and etircu »f (he air from the lung, but it expdtcd 
and couched up by an extra cflbrt. 

If, however, tbitk mucus \% ilniwn into the imaller bronchi, perhapi 
fillinu up a scrip* of »inall briinchM, ihc inosi poKerful oipiratory effort the 
thild can make fnita lo dear the (Kirtuiled bronchi, especially when the rv- 
ipiraltir)' mu*clcs arc weak and ilie nbs are soft and easily bend. T¥rt> 
lhint;> are now certain lo happen— the Iuhk supplied by the occluded bronchi 
tollapsei an<l more or less dilatation of the branchial tubo anil eniph)'M:inB 
of the neitthbourint: lun^ occurs, unless the cheii nallt fall in In take the 
room of the toll.ipsed lurtK- '•"he Itinj; eullApsts in •:onsc((ueiK'c of iIh! 
nbaurption of the impriioncd air. the air etiietiiig ih«' btood-vcsMb, at 
shown by the experiments of Lichtheiiii. li is tXtM that this txilUptrv of 
lung and vicarious emphysetnn «t least trmporatily daniJi);cs tliv litii;-, omI if 
this shotiUl (KTut li) any }.'rcnt cuicni in hcuic bronchilig, tt addsconsidcfnbljr 
to thedan);ri nf death by asphyxia. 

The sjmpionis to nhicb rolinpfc Ki^'es rise ate not always very ilvliniie. 
and unless tolerably extensive there may Iw no si).'n of its pmemr-. In 
M)me cases it may supervene Middenly, possibly by the su^'kitiji; in of launu 

I which has accumulated in ilie trsrhea durinj; sle<'p into tlw hfoiK'huI lubes 
llic dyspnn;a becoming; uijjcnl, the child* lip* blue ; it nJU .ilaml in iti 
col sirtiKK'injt for bieaib, and convulsions come on which )irtb:<ps |ir(M« 
fAial. In other cases, while the sjmptnms may be .^brniinK f<M lira littK, 
ihex' quickly paw anay, a result due to the mncus brine ex[iclk-«l. If tbe 

■ collapfe i' scattered in p.ilcl]es throughout the lunc, especially if accom' 
panied by emphyvrmii, it will he imimMililc lo ddrrt it by any physii al sifjns : 
there in^iy lic^ hyper- resonance due to the einphpema. weiik breaih tounds. 
>ind perhaps some moist nUes. If any extent of lung is involved, ax part 
of an apex ur base, there will be some loss nf iesn«iance. Init ihi» it mrely 
well marked unless some bnmcho- pneumonia he associated with it, a pncit- 
mnnic patch and a culbined i).iicb lyint; aide by s^ide. I'hc mpiratory 
murmur iwer the collapsed patch ia weak, and rlionchus of roolM suundk may 
be heard. In iiome caies there appears lo be a mixed condiiton of collapse 
with much conitestion of the t-essels and a-denta. or possibly, as M>me authon 
believe, tlii- collapsed lun^ l>ecomes the srat of a low form of pneumiinia, 
Tcucocylcs and epithelioid cells being present in the air saci. 

■roBCbleetBftIa and Bmpbyaeaia,— Dilatation of tbe bronchi frcqucltlly 
takes place duriny acute bronchitis, the walls of the medium sited and unall 
bronchi fieint: thin an<l their calibre mcieased, a rcMilt no doubt due to iit- 
fljmmnlorj- soflcninj; of their wails. Emphysema is alio constantly preicnl 
inaxsociation with dilated bronchial tubes. The chest nallii dunnijan acute 
Attack avtume tlie position of inspiration, and, particularly the infraclavicubr 



A 



213 

TeKio«is,be<:omchy[)er-rc!«»nani.whl1« the expiratory murmur is prolonged. As 
already rcmartccd, conipcnucory cm|>h)-±eina is consta.tiily present in auo- 
ciation with broncho- pneumonia and collapse. Uronchiccia^is lakn place in 
auociaiion with chronic pleurisy and fibroid conditions of lung. 

Cltr«<ll« Br«n«tiina nnd Sronehloelula 

CbiUlren and infitr.ts, liki! ndults, suffer from chronic bronchini catnrtb ; 
they recover ilonly, an<l then perhaps n-ithin a few ucckK another nllark 
supervenes. Some children sIioh- such a tendency In these nlt;ickx that ihcy 
have to be kept prisunets iilmcist nil the nintcr, as eipnsurc to even slight 
c«W is snflicient lo l;iy them by for weeks. Frc(]Ucnl ,ind long-eon tinned 




I 



WnininiiniiMinmnBBfil 



Boy of i iw%. KKOf fy, 

aiiackE of bronchitis are ceruiin sooner or IsUr lo produce einphysemn, 
dilated broncbial tubes '■nd dilatation of the right side of the heart and the 
veiiu whkh empty into it. Such children prcucnt a typi«l piciute; they 
are mostly thin, with rounded drooping shoulders, bancl-shapcd che«», 
enlarged «uperlicial ju^larveinsand often injected capillaries on the cherkj. 
In tome of these more or less dullness may he detected at one hnsc or another, 
and tbeyconstaitlly cough up large quantities of very foul mucus. Such cates 
are an>ihin); but welcome inmate* in a «nrd on account of their extremely 
ffSiiU CK pectoral ion. The*' arc very chronic and not mtuch amenable tn 
matnMllt. We have attempted external drainnne of the dieted bronchial 
lube, boi have not met with much success, as the patient h.^s gradually 
mioIl In ih« milder cases such children with care improve greatly, nnd 



214 



DiiCitsrs cf the Respiratory Affaratus 



ffcquently by puberty lose their icndency to bronchial troubles, and grow iqi, 
if not str<>n);, at l«ii5t not with impaired beallh. On the other hand, there a 
always the ri^k of an intercurrent and perhaps fatal pneumonia; we have 
seen children of this class vith tiiarked einphyiema come regularly inia 
hospital |>erhap« twice in a winter villi aiucks of croupout pneumooia. 
There is a risk of chronic bronchitis passing into a chronic bfoncho- 
pneumonia, the King tissue around ilie dilated bronchi becoming caieout 
and indur.ilcd. There is also the risk of lubi^reuloiis. but we have not oJien 
be«n able to Imcc a connection between chronic bronchitis and lubertlt, 
though those EutTcring from chronic brunchiti:! are often mistaken for 
phthisical subjects. 



■r «n ell o- pn enni anlK 



In many cases the attack begins wuh a bronchial Ottarrb and quidi 
pitsiH on into a broncho-pneumonia, the innainmaiion extending from tb« 



1^ 




lift^v^lli Oiiy. Si Hit Jiait-iiiii Wi Ipfilli IhUCh i^f laikg*uiijioTj fCLKrAlivi] I < I. ' ' 
villi ' crunch javiKk. 

bronchi into the air-cellt. In other aum the bnmchial tymptncus may be 
slight or absent, and (he attark may rinscly resemble a croupous pncamoata. 
ncl%fcen these tuo tyjics all ^md.iiions inay be met with. When the pneu- 
monia supentnes <m bronchitis, all the lymptomi l>ecomc CKaggcmtcd, the 
child is reiileis, the rough shorter ami more harking, the skin hot aivd dry. 
the evening temperature usually reaching 103' or 104* with momiiig icnus- 




leammtta 



kionc of seven] dcgJte3,%o thul tlic fever A$»uine» a reiniiient lype : lomeliTnM 
there are evcnins initcid of uiomint; remisijons, ilie teinponntjrc beina *' 
ill lowest in ihe c\-cnin(,' ; the i]yipnu:i i& usiutlty gtCAl, ihc reipiraliont 
numberini; forty or fifty, but varying uilli tlie aniouut of fever and extent of 
lung m^-olved. If the pneumonia is ciienaive, the face wtars a dislre^se(l 
expressioo, the alx ohm viork vi);orously, llie child lie& wcuk and helpless in 
I its moiber'i *nni, too feeble la cry, or if it resist examination for a while it 
' b loon exhaimed and paasivcly submits. 

An cuuitinaiioa of the clicsi, if made when ihc aiiack is fully developcil 
and iiet'cre, shows (hat the accessory muscles of respiration arc brought inin 
play, the rcspir.iiiuns arc r^ipid and shallow, uith recession of (he ept^aitriuni 
itnd intercostal ipnccs. The percussion note varies accordinj,' to the position 
of ibe cocuol*dai«d lun^' ; ihis may involve an extended portion at one or 
both baies, at an apex, or be scattered in patches over the lungs. To delect 
ihe pneumonic pontons both light and strong' percussion should be pmctiird. 
. ciircfolly comparing any spot where the resonance appears inipaired wich 
|.the opposite side. There may be hyper- resonance, especially anteriorly, 
I tl>c presence of emphysema. A ron>idcml>le amount of pneumoni.i 
ay exist if diffuse or patchy without any definitely impaired resonance. 
ere is never complete dulloe*s in pneumonic consolidation unless much 
nph or some fluid be prcienl. On auicultaiion rlionchi arc usually heanl 
tr the cheM, nhitc over the pneumonic portions t3le» of a mnson^int or 
rinifinK rhancicr are hcanL nhich contrast with iho aubcrcpitant r.tles nf 
• imptc bronchiti*, inasmuch a* ihey are more intense, from the fact of 
(■i( iravrtling to the car ihrough coniolidaied lung, tlven though iio 
■ (!g can be detected by percussion, the presence of consonant 
i.j; nllc) with a [eiiipciature of to^' or 104* points alinon cci- 
>in.v lit jKiciiiiiimi.i. 
In (he early suges the respiiatory murmur is weak, later (here b moMlv 
-iiiarketl t>riini:hial breathing over the dull aicn. If a fatal result in 
kUml to occur, the respirations become mole hurried, the divlicss greater, 
the pulse weaker :ind weaker; rile* and ihonchus arc hean! over the 
• liole chest, ihc heart rtax**. and the child becomes pallid and comatose, 
•l-^h titking [ilaix with *ympi"in* nf lox.imia on .ircouni of the brtmcht 
i«i-o«:iing ilioked .ind the lungs consnUdaiciL The temperature usually 
111 (uwaids tlie cliwe; the child i» frcqtiently convulsed. If, however, the 
; lakesa fatiiiiiabtc turn, lownrdt the end of the first week or earlier 
apcr4tuie appionchcK normal, the breathing is easier, and (he child, 
«if concentiating hi* whole aiicniion on himself, )>egtns to notice 
tbajt about and lo pl.jy nith lil» toyi. The physical signs change but 
>!••)), till- bronchial brcathint; and dUes beiny heard perhaps diuiiift the 
t«wd ur ei-en the tliird week.. 

Vhi\v the above is the <lescrip(lon of a typical attack, (he pneumonia 
••j!* of much le»» u-cll-marked charaaer, The child may seem ill nlih 
^Rfc or nit cough, while there is loss of appetite, coated tongue, and feverish- 
"». ttfecially well marked during the afternoon or evening, An euimina- 
«■«( ike ehe« may at first yield no positive result, yet in a day it will be 
**Mthu there is a poitih of lung at the extreme bnse, axilla, or near the 
'<'**htre (be air does not enter well, and the respiratory murmur is replaced 



irJl- 



2l6 DisMXfS of the Rfspiral^^^ff^^lS^^^ 

by breatbiiij^' of a ttislinctly bronchial chntnclcr. In a few days Of 
the temperature may again become normal. 

Scimeiime^ an attack of broncho- pnmmonia ctnicly siinulltea (he( 
variety, and there may be n doulx as to which eatcgnr?' fo tefcr 
on.ict ina>' bo sudden, accompanied by a convul&lon or leries of con 
the lemperatutc may rise to 104° or ;os° (»ce fig. 30), the physical si 
point 10 an extended portion of lung being involved, and only the d 

the aiuick, the lemperuiute fa) 






■■ 






iluallv by ly>is, uuuld secnt 








1 








cilic that l)i« attack ii niibe 
taiArrhal than the croupous; 
Some ct,wi may from iir»l id 




1 














m 




opirn to doubt. | 
Course. - - WI) lie bronrho- pal 
\'i fifqueotly an acute dixeaic^ 
faUl in a few daj-K or a n-cek, n 
in man)' ca»» it subacute orl 
liutinj," for several WFieckv or ci 
■ind yei ending; in appurentty 1 






1 




W 






^^^1 




1 




[ 


I 








1 




1 


I 




^H 


rifcover^'. In ^omc msitjinees 
lakiM place, ii> be followed 


■ 






l.ipiip. the ic-mpcratare again I 
remittent for n fc»* day* or 






1 


1 


n 




H| The tcmiinaiion of the feicr t 
Q .ilnayt by ly*ii. In ihew pi 
H tascs the po»»ibiliiy of tut>crX 
^H a lo»] cmp) cma must aliia)il 






1 


H 


H 








n 




m mind. J 






»■■ 


II 






SeoftBdarr 'nenmonlM 

lHl.lni.l^. tll■■^li^■ of the broad 




BBBg 


■■ 


■ 


iiiiifU' iiiirii, iii'cur.iH complk 




■1 


1 


n 


1 


jii.iiri |.|L^'_.I3'J3, andmay incon 
be mudified in their courM aj 




■i 


HH 


*ymp torn* the>' present Thu»^ 

tubaraaloaUinayKi^'C ri*^ «> 
Bih bruiicho-pneutnonia, which 
J^' a *hort or protracted course 
'•ii conditioni present csMrniiall) 
" int; cach^other. In wbeoplat 
Bt*aalea. aearlM l*T«r, at| 
jupcrvenc rauscd by the s|iecifl 
y cases at least, b>- the scptit 
i^urrintc in iheie ttiicuies is una 
motlly fibrinous, and in the miI 
ons, *o that small purulent absc( 
■ cases a true croupous pneum 
oniA i» often hafmorrlugic, tina 
ng teen on section of the pDcaml 


n 
*■ 

or 

P 
l> 

Vl 

b< 

of 


(. .. 1-.i,|..- r I..,' . ( . .. -I »L 

3I. IT I'..i:l.ii^ .111 , 1 1 .1'. ■ ,' ■ ' irjti:<lt< 

:»tt 1 1..1.' .' .' 1 'm ^ .. -Li.cpl :i>Di 
■ > r- : '!" ^ !m .. {.Ny^cnUQ 

* \ ll>M^ tlijl V\ h>l<lJ A« 

-" . I'lilL^ Jiilinci. feoutc tf K p 

■urio rsvcr, pneumonia may 
Ijaniim of the fct cr, or. In man 
c5cni. While the pneumonia oc 
roncho- pneumonic forn:, yet it is 
thibits a lettdency to pui formati 
; Ibund pott morlem. In somi 
cur. In diphtherial the pncum 
dark red cxlmaMiied btuod be 

;_ 



trmehe-fmtHmonta 



2!^ 



tn kcvte SBmincr <UBnli<Bk ii pneumonia ii very upt lo ht pivicm iind 
idij to (be |;Hvity of llie :<EE.ick : in tbe ebr*>il« tat«attii«l eatarrb uf 
nduu tbc immediate oiusc of deatli ts riequenil)- un intctciincnc ailAck of 
■oAuiuiuaiw) of the lun);s< 

C*raal« Sr»a«lM«pa«iiBOBt«.— Attacks uf bruncho-pncumonia nre api 
111 bwMne chroniti: in consequence of un iinpeifcci clrarins up of ihe lun^ 
iftd the muhiti]; CAHous dc^eneraiion. Ciiturrlml pneumonia fol1awin)£ 
awMlCf or wbooping cou^h i^ very apt in -in unhe^itiliy cliild or one who- 
inhtriH tubercular tendencies to take * subacute course; a base or, less- 
D<in,4aapcii of a lung remains more or leM dull, the breath sounds srcr 
bianrhtil, moist sounds aie heard, and ihc evening temperature rises to los' 
w lojT.iwiih ni),'hl sueais and eniaiiatjoii. Thii slate of things may go on 
hrimfc«, and it may be impossible lo suy if the caseous changes are pro- 
peuiiif m not. The n«k in such cases is undouliiedly that, although the lunt: 
^ydur up^tbr bronchial glands may become caseous and a general tubcr- 
tdaiiaf the lung, or perhaps tubercular meningitis, fallow. Mo« ca»c» of 
dnoic broncho- pneumonia terminate either in recovery or lubcrculosis, 
llnugh ia »ome insinnrcs they run a very chrunic course resembling a chronic 
phiijii: and ai the poit-morUm dilated bronchi and caseous and fibroid 
cWttiet arc found, but no tubercle, at least no grey granulations. Such cases- 
Mielife!Ucmo«tIy regarded at chronic or Bbroid phthisis; they present in 
ttrir later ttagei the lignsof consolidation of a portion of lung at un apex or 
^.ihecheil wall i.i probably ret rac led, there arc bronchial breatbmg, sliar(F 
r^pai; nlc«, and very fcttid expccloraiion, which is cniixhcd up in large 
fluiiitilie*. Theyare thin, ana-mic,. ire easily put nut of health, have clubbed 
ttcmand dilated rlyht hearts. They are usually very chronic cases. At 
^tahmerian there arc fnund dilated bixinchi lilled uitli thick, foul secrC' 
■s\chc«sy nodules around the broncliial tubes, much libroid and indurated 
liBt limie, and emphysema, In some cases iheie is gangienc of the lun){ 
t«fctete«Ji. Children liablcto bronchitis, or who suffer from it inthcchronic 
fcna, require to be warmly clothed and protected from cold. Residence in a 
*Vm(limale and pure atmosphere during the winter, and at high altitudes 
■fang the summer, should l>c insisted on where [xiuible. A uarm home 
• Rtosary if they have to w inter in this climate. Everj- means must be 
nfltytd which will improve their general health. In the (bllowmg case a. 
<kreNc peeumonta was followed by acute meningitis. 

Hmk /WwtMHtrd. Amrt ifniHfi/ii.— Rose S., acot Jyctn. Child comn of a 
lltairiv lUBtly ; hu lud imile [inFuiiionin wcnil time. She h.ill .ivulc pneumonia 
""mlvnJU ttlorv admiaaion. nrul »?i si-nl lo tlie seasidp. AdmiUed July j. There 
^Mmhcq llic left side bcbiiid, eiimding tfom thi.- spliii: r,{ thi- )>c-j|iiiU la the buc; 
""OMaifB there i* wtnk bnincliial liTiMlhjnK, ^it<il wlinl ii iippnrvniljrrnluicrEpitalidn, 
**fmwe 101°. No sibunicn -. child well nuuiiilicj. liul pale Icmjirrjliirc M\ to 
yt'li a^ the l>Mt d.iy "" fo- Oii July 15 llm ifrnpcnilur* luddpalyrosc to lo^" K. 
'■■*«»i«ing she besuB lu vonm conrinuomly ; lenipemtutr ititr li> laj* V. ; llwre- 
^' »■( pntiiainary l«i(cliinK>. and thm she was tpieririy vani-ubrd. The coavuliioiu. 
"MMBi liu ail^ (be n»l nii>ttiin|[, when ihc dinl, 

ftiltrli-n . — Lufi IoIh: tnlid : tinks in v/nirt ; bioachi coauia much purulent secrv- 
"^ M their wall* Are thickened : cxnt of ri1iniu> ti»ui: in the lung, tpmuling troiu 
■incc I ff MilMAnce d.-iik rvd. soft. And conl.-iiiii lomc small civiiin iii« of peas. 
*°*^«t lUck, •Inutt chcDiy. imi. No obvious lubrrvlr anyvline. Bnin, uaEhno^d 
•■'Jrtwi tituilj. bencMh tt ihere ii in eaccas of fluid of a cloudy yellow linu 




^Sto^^^^^LiiseasfS of the Respiratory Apf^r*ttui 

Sylvian liHum an.' mnlicd uilh tvmi-putulfnl lymph. Bam al lirstn niuck ckad* 
XicllinE bciinith arachnuld. No lulxrvle anywhcrr. 

Prognosit. — [([onclio-pntunioiiia is always ii (lantfiToiis iliMr»se, Imi man 
especial!)* so ill children under j yean of age who are rickeiy or wdklf- 
Thc prognoais is netessiitily serious if ihe pneunionu folliiw any Other d»- 
«asc, as measles, whooping toiiyh. or summer diarrhoia, or when il ocobsb 
scurlei fc%«r ihrouifh iheestension of ihe inflamrnarory process in ibe ifarau. 
In any severe cuse (he (lantt'cr depends upon ilic iim.iunt of luiin imohrt 
and Che loftnos uJ" the chesi walls. It musiaisobereinembercd ihai a yoinf 
child may strut.'glc through the bronchial iifTectiim only to pass into it era- 
dilion of atrophy- the result of a ^asiro'inte^tin.nl catarrh. Both hih'ti atd 
alM very low temperatures are indicative of dani;cr. The pneuroontt oif 
became chrome and tuberculosis supervene. 

MeHast Amalomy.^^^c xpfivixraxiCK^ seen /hu^ Mt^r/inw in the bodies (rf 
children dying of bronchitis and bronchopneumonia are vcn* varii(His,lil 
arc apt in puule those unaccnsiomeil In the autopsies made in children ; vl 
much confusion has existed in the past in reference ti> them, especially il 
confounding the various forms of pneumonia and camificaiion of the ln( 
with collapse. Collapse iif ihehiny is mostly patchy in its distribution, rarH) 
jifleciing any rimtinuous exicni of luny or im-olvirji the whole ihicknen of* 
Iting. It affects the antenor anil inferior ed^ei of the lun){-s, especially dK 
anterior edge of the middle lobe of the riyht side and tongue of ihc kft 
which covers the heart ; it is sometimes piesuni along the positenoi liotdei i( 
the lung; the collapsed porlioai arc depressed bel<i« the siirbce, piifpkn 
colour, and airless. Taken between the finger and thumb, there is no wb" 
stance to be fell as tn pneumoniii. The collapsed portions can be inllaud 
through the bronchi. The collupse is brought about in at lc4Si t«o ««y*— 
cither from occlusion of a imall biunchus by < hic It mucus, i lie air being; fit* 
iniprisooed and then abiorbed by ihc cauillarits. or by feeble iiupinuoiy 
jmwer aided by obstruction to the cnUancc of air, especially when the rih* 
are soft, as in rickets ; in this caae the cheit fidls in during' inspiratioix, In- 
ttiead of the lungs becoming distended ; it is in this way tlai collapse is pm- 
duced along the anterior edges of the lung. The collapsed poriions becone 
u'deinaious front the stagnation nf the circulation : according to same, they 
become pneutntMiic. 

What happens to the collapsed portions of lung in the long run b not 
clear. In most cases, apparently, recover)' takes place ; but we belwv« n 
some cases Rbroid clianges areset u|>,as evidenced by tliosc chronic caaea af 
bronchitis and dilated tubes, ihe l.iiicr surrounded by indur^iied lung. Acute 
emphysema plays an important pan in ihe acute lung disease of childrea. 
II is sometimes produced very tapiiDy: thus, a child niaydieof acute brondm- 
pneumonia complicaiing nicailes in three or four days, and extensive emphy- 
sema maybe preseni, no doubt produced during the |>enod,and contribuiing 
very niaierially to the fatal result (see p. 377). 'Ilic bases of the lungi are 
in an early stage of pneumoniaand collnpse, the upper lubes are overworked, 
the constant coughing con»qucnt on the acute bronchiiis prtkducei crnphy- 
aeinn, and the only remaining nonnal hing is thus daina)^, and a &tal result 
quickly ensues. 

The chief types found tnay be detcribcd shortly in the fiilUm-inK groups: 



Bfvitffio^/'itfumi'ttia 

t AvaM SraaclilU* laavolvlac tb* Bm«Uer Tabe>, C«ll«pBe of Xinagt 

Tlnrlona Minpbjpa<>iiuk> — On opening llio fheal (he tungi ;ire round to be in 
J iT>jnii[ii)in ifi' tl<.-epins|)iraiion ; Ihese nurfjtcmre aiudded over wiihtlusient 
•iiiibul« whkh »ic depressed anil purple in to lour (collapse;, and iviili raiied 
fonMu whicli are of a pule pink eolour lemphytema). On section, thick 
loib^MRileni fraihy mucus exudes from the larifc and small bronclii ; th« 
luitr Miueiiinn contain a leini- membranous exudation. The cut surfoce of 
Ibclunj exudes much blood-sUined ftothy fluid, due (o coDKestion of the 
|to(: ibc lungs Aie crcpitiint, except wlictc coUapie ha> taken place. The 
p^cvtins and right hcun arv much cn^ur);ed, 

:. nMemlanted Broa ebo-pn earn a>lk.— The tjronchial tubcb contata 
(nu,ii ffdih;' fluid, "itc i>r bmh luiiys, Cijieciidly the lower lobci poucriorly, 
laiti ten»-s(iliii feci, but ctepiute, und (lerhaps some nodules of various 
kntmay be (eli. The sec-tion exudes much ticrum, puruleni mucus exudes 
^ibe small bronchi, the cut surface cd* the luii^ has a nviiilcd apiieaiance, 
auinl by clusters of lobules, nhich are gtvy or pale pink and have a ^rm 
U, kkI bright red portions of crepitant \\iei^. The palei' portions are pneu- 
soiK ix>d tolid ; the red portions arc air^cantainin): congested lung, uhich 
ttmmd the |>neum<»nic portions. I'ortions of lun^' uhich are removed will 
Win onirr, but easily break dott-n on thnisirnf; in the linger. The upper 
UmiR cinphysctiijitous. 

> M»Mm 0«n«««U*wd BrsBcbv-pBanmaslk, PlBnrlsy.— The posterior 

"trior or whole i)f i>ne or boili lohc* has .1 scTui-tolid feel, lhoii>rli less *iilid 

tkitta CTOUpKts pneumonia, vrtth but little or no srn^e of CTcpilJlion. The 

l>tei» purp)l*h in colour ; the pleural covering may have minulc birmor- 

■hluon il» nurfacc, or be roughened from the presence of [ymph, The cut 

■Kicaluuawilid feel, )-el it isnolgmnutaras in iruc cToupntis pneumonia, 

^Bnjiljf bir.ikn dflwn t)n pressure niih the finder, and sinks in HMter. It 

Utt nuKiled npfieurance, in consequeurc nf ihc tobulcx lurmunding the ter* 

■■nl bmncbi being pnler in colour and in n bicr Mage of ironinlidation 

*« the iaiervening portion* of lung. There will probably be collapse 

•^ iW mterjor and inferior edges, a* well n« acute emphysema in the 

•»■( pntitinns ; some of the veiiclei arc frequently <listended to the site of 

■*l Wedt, or c\*en peas, and perhaps one here and there is ruptured. In 

' Bill l»tcr stage, especially if the inflammation is mtense, ^is in measles or 

«c»iki fcter, a lobe may be solid, and on the surface beneath the pleura 

I^Bt «r« a number of yellow spots, the siie of millci seeds or larger, uhich 

Bjincking 1,-icld » drop of thick pus. On section, these yellow spots are seen 

IwtTrd through the lung ; they arc the 'griiinea jaunes,' or 'abcfs pcri- 

R<*orhii}ue,' of FrctKh authois.andate, in fact, minute abscesses surrounding 

ihr lermiiul bronchioles, fornicd by the softening of the pneumonic lobule*. 

Hlairiiy with lympb or serum may be present : when the pneumonia isdnuble 

" |lempentiiK usiully runs high. 

be bHowitt]; case iltustrntes this form of pneumonia : 



AiaMr /'fr*n-^«»»rrt»/«, t/jfirf/rtxia. Sai^ritm 0/ Atfiiimf<tii.—Jnbn H.. 

I woNfet: admhlnl .\|ir>l 96, iBh- HJimMhprtLitn he ha* liiTn a liculthy child 

F pimau illiHTi). A(arini|[hlaja tie litatmc III wlih cough niiil fcvirr. Kmtliing 

trry lad at it>|ihtv Hr fiiixtt lierjurnllir. He Is (iLirli' u*Il iinuniUKd : bit 

I lonieialial n-lfBClcd. and miuclei or the neck jre njflcl. The rigbl spri in frodl 



J20 



diseases of the Rtspirafory Apparatus 



■mttbe bate behind are icry dull: bronchml breathing *niIihBrpcTvpiuik«w*bar<)-'" 
tliik arm. Oli thelcfl side l here an- taW. bul no dultiir» ^ Irjutcleu icfWn»Tn>'l 
dnwn from th« nghi ixte bclilnil Tenipcmlure 103'. ^'omiii cdtduuiiIx. .Ipnl >■ - 
(imrnil convultions, miMtly right-iid«d: mailMiI rigidily of tliv DMk • ivmHl oMitk! 
Wril-ninrked latin (Mtralc. April a8.— Very ihwt breathing ; diillnni vX. MBii' 
tbvleft bnto na welUii ihr right. Otyjten givrn. Tcnlp(nllumo6^ Ufattialcd i' 
ApcA ag.— Motlwd retraclluii of lUe nrctt: (onitant v«niiilng. Tfnp«ralura w . 
April 3Q. — 1>nip«mtun tti(ri^ twice during ibe day. Dotih May 1. 

/'tu/'imr/dH.— Right |)lsun>l tuvliy cnnUint Ij at yrllou icrum, and tjrmph On" . 
tfa( lower lobr. which 11 porOy compreiicd and ^inrttr toltd ; uiiprr In'M-tcdid Ml lbete>. 
ribowing l)runi:hi3-|iiiL'nnianE.i inrl ^ iniihy^riiiu m Ftiinl ; low^-r lolir, T)inp^ on Mrf>-''> 
pneumnnin on tcciion. hiacti clmr fluid rKsprd (iiun luriice of the lintin and Itv--' 
wntiiLln : lid li|iT>|ili Anyutictr. .^mi'linoid fluiiijy ; m-ink full, tl was IBg(C(l*i1 '■ 
Ihr lalaot hod mcningillt coinpliialing llic pncunionln^ tml ihia oni not botn* out b) 1 
MUopiy, I 

4. In iBfkota under • m»nttaB a form of pneumonia 19 soiiMtian 
fuuinl wbitli clo« not ii^rtc with ihc .iIiijil- dcscriplion. A lobe, gcncoill J 
one of ihc loner, i» ncmi-snlid, iis siirtiicc deprtssfcl ;incl purple. MitrwioAd. J 
pcihups, by niisL-d craphj-sem.itcms itiiclcs. The cut si'Clton is smooth mI I 
o( a unifiirni plum ciiliiur, the lobules indistiiKl itnd airless, bul tine tung hu | 
not llie solid feci of red hc-puiixaiiim. I 

$. In loniecasL-snodDleBOf Bbrlaaiu paenmoola as large ashanllMK 1 
or walnut*, hard, an<l H-iih a ^nmular surt^ce, mny be found. \Vc hiive >"■ J 
ibia condition m coiinection »jlli nicaslc*. I 

It has already been reniarked Hut clinicnlly broncho- pneumonu MS^I 
times so closely simulates croupous pncMiiiuim that it is difficult 10GI}<*I 
which variety it is to be referred. The s;iiiic difficulty may occur in dw 1 
p0st-morUm mom, (u some tobuLar pneumonias have alowwt the »<>1mI M I 
found in croupout pneumonia, and a microscopic cKaminAiion »hows iWi I 
air vesicles to contain lihrin, .ind yet the section, to the naked «)«, h i^ I 
Ifianular as it ii in red hepnliiation, but mottled, (he duitm of MuliM 
varyinK in lint, -ind mon.- clotcly resembling in appearance the coodiliw »1 
broncho- pneumonia. I 

The tniero -org«nlim« present in the broncho -pneumonia OCCUiniFi] 
in chitdren have been studied by recent observent, more eipeciallr ItI 
Neumann,' Queisner.'^trelitV-tnd I'rudden and Nonhrup. The conunowtf I 
micro -organism found appears to be the rranlccl-Weicb«clbaamdiplococca>>l 
much Icsi often fried lender's bacillus. In Ihc Mptic pneumonias prtKM I 
in scarlet fever, mcailes, nn<I dijihthcria variou* micrococci— incladi>{ | 
Sb^MjKOtais fyfogtws aurem and al&ui, nn<l Str^oeoccas fiytigtnti—*^ I 
UMntly present. I 

In the present slate of our knowlcdj^ it in anwitc to by too mucb ftitlM 
on the presence of these otyanismi in the |incunioaiic luRf[s ; but it mcm 
exceedingly probable that there are several micro- oiganism* which, if M 
conditions are favounible, are capable of giving rue to intUmmaiioa of tM 
lungs. J 

Diitg»otit.—\ clinical disiinclion between the above condilimu b «Afi 
impossible, inasmuch as bronchitis, collapse, emphysema, and CAtanlii 

■ Jtkttmh Kinink. Band xu. p. ajj. ' Lk. sit. Hand nx. p. 977. 

* AttMv f. A'ii^H. Uind ail>, |i. 4M. 



lironehtt-piuutHOHM tai 

FOMBonin may all e\hi in the ^ain<r lung, and more or lcx» mask one 
ttutttt. However, n fc«' poicui nifly l>e umpbimted. In limplp broncliitt» 
■> itinpcraiurc » ratcly hij-li. ihcre ii no impainnenl nf reidniititc. and ilit 
[tiMi MDiuK if present, arc iwdisiiiKi and disLin!. In broncho-piifunionia 
ihr Itn^icRitiirc is higher, usually llicr« is im^iiired u'lonunri?, perhaps 
■ItlTi oc bronchial bmi(hin>;. and the moist sniinds jtv clear, shnri), aod 
rn(i(K, Tlic dia);no«is of collapse is much mntc iinccrlAin uiilc^i much 
l>V it involved ; then there are iminircd resonance and weak and diaiant 
traKhial faunds. 

In ill cases of broiK^ho- pneumonia ivc must hear in mind ihc posaibiliijr 

(f (MM localised rnlleclion of pus being present aver a dull patch, and also 

ifcl ra*< may be one of miliary- inhctclc ai »-ell as broncho- pneumonilt. 

/wa/wrnA— The folds in ihc he.id and branchial citaiThs of children 

al lather for caieful hyjjiene ihjn aclivr irtalnient. Confinement to a ■•ell 

'niRKil and tcnlilatcil looni '>r viiiic of rooms, a« Iohk .is the sympl(im>i of 

mH are prr*cnt Dt thonciii .Tre heard in ilic che-it, h jth a tight, moMly Iluid 

In, Din in many cases be all that it ncces.vir;'. Merely to confine a child 

Ihrbdusc and let it run ;ibotit in cold passages and stand in draui^hia is 

:lHi,And likely to jjiie rise lo another cold before the first has completely 

jH;i]r. Sonic children sre cucccdinKly liable to take rold, and bron- 

i«8 very icadily, and with these extra ctarr must be taken, and tlie 

e of a cold mu« h.ne disappeared before they are penniiicd to go 

ML In ihate cairs » here there is a laryngeal or trachcid catarrh the c0U){h is 

oalroublrtomc, npcdally kcepinj; the {lalicnl an-ake at niKhlnnd disturb- 

hi lie "ihiile linuscbold. Among the houicliold reinctlic* for (roughs which 

Btdnl arc black cumint jelly, glycerine lofenges, hquorice, and jujubes 

■x medicated. A cup of hot hcef tea or cocoa the la&t chin),' at ni|;bi 

i*cn iootlie a troubleiomc cough. In many casci ii will be necciuiry 

r^c inuQ doses of Mime sedaiitc, espec iall>' in the case of oldei children. 

I*(pbi), LiHleia. ac'iniie, bymLvamtts. biomide of ammonium, may be given 

tkis purpuse. made up in the hrin of m tinctus uith syrup of orange or 

•»>inti;lji:ciine. 'Hie morphia and ipecacuanha in^cnges of ihc B.P. made 

•A frert paste or glyccnne Jrlly air v«r>' convenient. Codcia jelly act» 

tedtnitlj well in soothing irtil^hle rouKhv 

TW diet OwKild roiivisl largely of tluids, milk, beef tea, liRht puddings. 
le, barley water, linseed lea, to a^iua^c thirst and tend to produce 
attioB of ilic kidnc) * ami skin, arc likely to be useful ; s.ilines Noch as 
tiiiUt <4 ammonia or |>oiash, or liq. amnion, acel., may also be giten. 

TV prrscDtion of attacks of bronrbial catarrh and colds ii a matter nf 
!'■■• ii iiiipof lance, especially in the ca«c of those who are liable to bronchitis 
' -''itnaiic attacks whenc\-er they take cold. .\ hou^c in a dry and bracing 
iir-.. with nell-narmed livinjt room*, passaged, and bedroom* — while 
iiiiibtioD and sanitation arc carefully lo»k«i after— is a first necessity 
tlie prevention of colds. Care must be taken that siicli children are 
y cluihed with well-filling woollen undcr-gamienis, thai they have 
ly of exercise in the open ait whenever the weather is suitable, while cold 
:tiiS Of the tepid douche in the mnmin); wbiUt standing in warm water ix 
arniiiiJi tervice in promoiingihe circulation in the skin and preventing chills. 
cold* in the head' infectious? It is a common experience chat 





Z22 



Diseases a/ the Respiraiory Apparatus 



alinuii a wl]nl« hnusclinM it nffccicd nt ihc »amc time ar in luccetwoa, md 
lli<-T< can be liule rtoiihi ihal in nomc cato a iimbI catairh p;itM:« rronnw 
child l» nnnlhrr wilhout ihc i.iller having been cxpotcd to any chill. Olhcf 
ciiiiilitinns fit\-aunn^- ihc-ie niucki may br piFsent, but of ihne nnl tv 
nothinj; is known. I'osiihly n cliill m.iy prcdiipoj* the mucous monboM 
to Ukc fa inf].imin;itir>n ur l]cc:(ime a suiubic nidu* for the cultitatiiinof 
hadlli cr oihcr oigamsms present in ihe atinuiphcn;. 

(f ih« cntarrh pa^iscs (lownivnrds Trom the ttachca into the muUertuba, 
ftnd ihc child in c<mstt|ucnL-c ' ivliccMs ' and rhoncbi are heard all oiw 1^ 
cbcsl, the child ihouUI be c:i)nfined to its lied or col, care beiny taken t« htn 
it warmly clothed und in a ^liliiution free from draught*. In the moreMvo* 
cnic^ of btonchilii and catarrhal pneutnonia, npecialljr in small chiMfe&l 
»n of tent ihouUI be fiyged <n er tlie col, or one or two dollies screen* pUctd 
around with shceti hunj; on Ihcin *o as to fonn sido and a toi>f will imnr 
vet)' **ll- The aimoipben- niuii be kept moi»t by inuam of a bremckdi* 
Iceilk. or the sheets which /omi ibe walls of the lent nwy be kepi mitA 
The tempcnitutu in the col should be maintained al ft^io' ni^ht ud 
day. The diet should cumist entirely of Huids if tlie attack i» al all acatt. 
Milk diluted with one-third or one-fourth part of whey, barley water, W Mdl 
water lihnuld fomi (be piincipLiI kind of nourishment ; a cup tA beefM 
onrc or twice a ilay may \x allowed. Moiai, hoi applications to the cta( 
^rc southing tc ihi.'|t.iiiem, and m.iy be applied in ihcfomiof Unseed poullkM 
or romeiilaiions. It iiititl, bouever, be bonie in mind that poiiltices made tf 
unskilled handi may, etpecl.illy in the Cdsc of infanls and >'oung childreic 
do more harm than gixHl : to surround ihc chesi of an infant with a b«i>] 
poultice when the hroncliial tubes air choked with thick mucuj aivd paldo 
of lung An in .1 Mateofvollapse is simply to imitedc.tihbysulTocaiiun. Itt 
pouliicei should be well mixed, being not too licavy nor n)>ptied too hM 
(placing them againtt one* cheek is ihc heti guidcV, carefully kept in po*iMa 
by meant of a flannel binder, an<l renewed at lea*t eveiy four hoan. A 
DUistud poultice is often of gre.it scnice in (he earlif siago ; one Uiblrspoo(rf:d 
of mustard to four or five tablespoonfuU of linticed meal may be uicd, iSi 
poultice remaining on for threeor four liouts. Thiii Micngch is not wllicitaif 
produce more than some redness, and it ran lie renewed or replaced b> t 
simple poultice according to circumstances. For infants and young clnlibrn 
hot fomentations applied by means of spongio-pilinc ordnnncLttcpreferiblt 
to iMiuhicea : they are much mure cleanly, and harm is let^ likely to be d«M 
by their application. Several laven of f1;innel may be used wrung out of 
water, <ir if need lie mustard anil «ater, and coverwl with a pi«c of oiM 
Mlk, the nhole being surrounded by cotton wool. Touliiccsand hot apfiltct- 
lions are of most seiiicc in the early stages, when ihc inucous m<Tmt»aAc b 
swollen and dry and the secretion scanty ; in the later stages ihey are >lM 
useful if the secretion is thick and coughed up with difficulty. 

In the early sUge of bronchitis, if there is much whccting, dytpMc.i, aixl 

distress, .in emetic is of much service, more so, peihaps, in bronchitis than 10 

BMarihal pneumonia. I'ulv. iperae. tn ;-grain doses in syrup of orangi 

Bed may be given to a child under 3 years of age and repealed in a lew 

minulei if it iail to act. The act of vomiting, especially after ipecacuanha, 

will probably be attended by a freer secretion of mticu« and relief to ilw 



BroHtho-pntumcnia 223 

At this period the dcprc^sam cxpccioranis which appntr to 
dinuiiili tcaMon in thu vcisch nnd thus relieve the congested mucoua 
inenbniie4re riokIv used. Of these iintimnny, ip«cHc, >ind aconite Ara 
tsoR fre<)uently u^«(l than any oiherK. In lhi« siaj^e, mhcn the cougb \% 
hirdand sIImUis is ho;inl in the chesi, antimony iii sm.ill icpcaied dosM, 
^Ro/ pruthicing njiuso.t and depression, is of much service, (F. 13.) 

Isuiaiitial iHicumonin aconite in hiilf-miniin or mtiiiin doses is preferable. 
TbtAvK n»y be contintied lor icvcral day*, a-, long as the fever lasts or 
ibcKcmion rcmaiiif wanty or i« couched up with difficuliy. Clivcn with 
oann and iti small dose* there is lilllc fear of iis producing ton great dc- 
fRitiiMi : in feeble children, hovcver, it nuy be well \a |[ive uiinll doses of 
ik»J»l a,\ the same time. Many prefer to jfive ipecac, or, intiead of aconite. 
jwimony, especially in the feeble and cachectic pniients so often met with in 
ik cul-p«ticnl room. Some believe ipecac, combined niih alkalies such a» 
Moibonaic n( potash lo be of especial tiitue when tnucotit rale-s arc hcaid 
in Ac chest, wnd the infant i>r child hits much difficulty in coughin); up 
Ikthklc secrdion which is formed- Simple salines are preferred by some. 
Dr. Uwtt Smith recommends tr. ver;i I ri viridis in half-minim or minim dnses 
nerrttcviulhour. A* lout; as the cnu^hiemainx hard, and the mucous sccic- 
baxuity or difficult to expel, ihe antimony or ipecac, ihoiild be persevered 
M^iBid is far more likely in lie of service Ituin the iiimulaiing mixtures so 
"to prescribed. It is when the catarrh continues, ihe tiHigh Ijecoming 
btiC^tbe secretion ti(|uiiL, and ihe (ever \.% mostly gone, thai carbonate of 
iiMaia, *quil)«, and tercbenc are most likely m be useful. .\i this stage 
fit faaentaiions and pnullices should lie given up in fai nut of a warm 
outn-wool jacket, and stimulating apphcations may be applied to the chest 
j "rfb. Ammania may be usefully combined with digitalis and squills, as in 

Stmlatinti apfitications lo be rubbed into the c)ie»|,wall are useful in 
fwiscing slight redness mithoul being loo severe. (F. 25, F. 26, F. 27.) 
Ibc lin. potass, iodidi c, sapooe It.f . may be used in a similar way. 
lod>dc «f poiaHium i:> often useful in the subacute or chronic stage, aniT 
Micicid and nux roniica aie of much service during convalescence. 

la bronchitis pure and simple tbc temperaiute '» ne\-er 10 excessite as to 

vfriitany ani>p> relic iieutmcnt, but in some cases of acute broncho-pneu- 

■■oa, specially wheie it appro^iches (he croupous type, or when il accom- 

(>■» Blkooping cough ormcas!cs,the temperature isapt to take high (lights. 

Spngisg with tepid water, 'pai'ks,'nt when there is drowsiness or con- 

nfcisas tbc warm baih gradually cooled donn by adding cold water so as 

Ondace it to 60', may be used, Phcnacctin or aniipyrin may be used for 

■Ivmbc purpose with cate, beginning with a small dose, 2 gmint of the 

fenhei for a child of 2 or j years of age. Uoih of thetc antipyretics have 

btoi Bied in small doses frequently repeated, in acute bronchitis and in 

ttmchn-pDcum'onia. .-\n excessively high tempcmtutc, 104°- 105°, is some- 

ihn present in an early stage of pneumonia, accompanied by couvnilsians 

r coou i in ttirh cases no time should be lost in resorting to baths or packs, 

ifcile x^tni; stimubints if necesxary by the retiiun. 

Ucsili usually threatens in bnmchitis or broncho-pneumonia from 

I micrferencc «nib tbc air entering Ihe lungs, asph)itia being pro- 




324 Diseases of the Kispiratory AppariUus 

dacedfWith gr«nl deprcvsUm cf the hen rt'« action. This occurs, o|Kda% I 
younx infants, by ii blacka^-e «f the medium -xitcd and small mbcs by thtl 
mucut uliich is itifficult to evpcl, or t« due tfi capillar)' o1)sirut:iiua, c<ilU|i 
of lung, ncute emphysema, or a larjje irncl of lunj; bwominj; ini-ulvrd la d 
pneumonic pToccii. In youn^ infiinii with i>l>Mniricd Ixonchial tubni 
t)};ht binding' up <if thi! cheM nails by |>outticcs or h.iiwlAKei mutt ' 
avoided ; the poMtion muti bo varied fnnn time in (imr so as lo ^ive ea 
tiui{j full play in turn, and an uccaiional emetic of alum or Mjuills will M 
to Kci rid of the exce4«ive and tenacious secretion. The nurse's finger n 
"be usefully employed in removing the *ecreiion from the back of E 
ibroai nftcr a lil of c(iu);bint;. In suddenly produced dyt|in<m cither fr( 
collap«c of luntj or aoiito pneumonia, when the cirrulntion ihrouxh ihc (un 
1( obMiiicicd and the ri},'lil bean over-d intended, IocaI bleeding by meansi 
a leerh or two it oDen of the );re:atesi sen*ioe, and may he the mouis 
sftvinjc life. One, \<k\\ i>r ihrce leecllea may be applied at ihc lip of I 
ttemuni, and after they fall off the bleeding may if nccenwiry l>e cncourag 
by uurm application*. Musurd baths, or muitatd fomentaitons, 
liirpcntine iitipes iipplied to the chest, are likely to be utefiil in those cat 
uhcrc ihcre i« exieniive pneumonia «'ith much dy«pna-a and cnidl 
dcpret^ion' lurpenitne mu«i be uied tautiouily. Ammonia and di^M 
mutl al«i !>e fteely niten under similar circum^tancev Onyj;cn inhAkt) 
may be rciortcd to, but we (annoi ?.ty (hiit we linvc had murh success with 

The question of the udmini si ration of emetio, .ilcohol, and opiumi l* 
importance. Emetics arc mostly of value in the early itaKC* of laryn);itl» 
bronchitii when the cou^'h is hard and tile breaibin); difRruh on account 
the iwollen toiidition ofihe mii<:ous membrune : a freer secretion follows ll 
administration, and, moreover, the unloadlni,- of the stomach of ihcaccunt 
lated mucus and imdtKCiiod food seems to liave a ifood effect ; ipecitdMiil 
or sulphate of «inc answers best at this sia}-e. Envetict are uimeiini 
uifful in a later stage of bionchitis and 'collapse when llw l>toi>rhial tab 
are choked with mucus, provided thcic is nu pneuinonia ur cysootu ; \a 
y» grains of alum m a lensponnful of synip of M|utlU is prrfetnble 
ipecac or tine at lhi<i linic. .Mum and honey may be t-iven to inl^nts oil 
small brush, Alrohot li unnecc^tKary in the early sta^-es, and it shod 
nlway^ be used with caution in the later sta(;n, for, like opium, it sand) 
the cough and in larec quantities' lis elTect is narcotic ; it i* ihcicfD 
contra' indic.ited eicepr in small doses if iheic is any tendency to cyanot 
Opium in the form of Dover's powder is often of giv.it value if the child 
lesdess and its coukIi irritable, but il is perhaps needless to say it should > 
Tio accoiml be given if there is much d>'spna-.i due to the accumubtiaa 
mucus in the bronchial tubes or if much lung is involved. 

During an acute aii.ick of btomhitis or pneumonia Ihc digestive on!^ 
are very apt to suffer; there may be vomiting, flatulence, and dianhd 
Tliis impaired diiceslion must always be borne in mind nlwn the quesiioo 
ilicling isbeinKdiscUMcd, and care must be laVennonomerloiid ihestonul 
and bowels mith too lar^e a quantity of milk, href tea, &c. An occasioM 
laxativ-c dose of calomel or rhubarb and soda may be useful. 

It is well 10 bear in mind the jiossihility that an infant may recover frd 
vn acme attack of bronchitis, to finally succumb to a i^Mstro-iniesiinal airapl 
dating from the acute bronchial attack. 




Croupous Pncumoma 



325 



% 



Croupous rocumoala 

i§ pnvumonin in iti t>|jiL.il Uw m i • ;< common ilismsc lu children 
nwitute yeanof ^ICC, and docs imt iliiki i.iihcr in iu cuucsi- or morbid 
uaiomy from ilit- aiivick^ in young riduhs ihough ihc morulily is much 
1m. Kcflcrcii<:>' lui^ alrciiily been made (it ihc acutv lobar pncumonin.t of 
inlincyAiu) <:hiMhood, which arr rrcqiic-ntlvclaMcri amon^si Uk- fibrinoid or 
pnuinc (n>ii|iouii pneumoniae on arroiini of ihc cxiL'nt of tiin){ involved and 
jlwof ilictr UTininaiion by crisis. Thai ni^iny of them arc fibrinous to some 
nitnl is certain. a> vtTuKcd fibrin may he *ccn in iicclion:^ prepared for ihu 
ini(mwri|)c, bui in our experience such tunx*^ when seen on ilic post- mar Itm 
abtr w morr ^iHing]- and Uck the complete snlidity of the icd hcpalisaiion 
•itnir croupnuii pncumoma, ami the oulUnei of the lobules arc readily seen 
inomtcifucncc of their di^erint; from one another as la the cxienc la which 
iWj are afTccicd. Moreover, uhile they may contain fibrin, the cellular 
(Hitnt Urjicly piedominutet. Kotiunatdy it ii of liiilc practical moment 
trnbr nhtch dtviuDn lhet<- pncuinoniaii are classed : hybriil r-a.-irt arc certain 
U (Wne under observation both in infancy .-ind <:hildha»il, and uc have 
hquRUly In be content mth devcribini; attacks ai beinK of the ' croupous 
'/Jt'oi of the ' ratArrhal'or ' bmncho-pnuunionic ' type, acconlinjc as their 
rnnpinnit resemble lypiotl attacks of either ibc one or the other. It is the 
JiAiruliy of cUstifyinK hybrid ca.-kes thai makes (he xtatislin of one lioftpital 
•" <W year liable to error when comj^aietl with that (if other hospilali or 
lews. 

The !iuti»tin (ipven below) of our own hospiuil of the cases entered as 
'Mupmis piK-umonia during the years tR^S-iSgj illustrate the comparative 
Hqutncy of ihi- diseAir at dilTcri-n[ a^cs. In this series ofca&es the total 
"fliJity amounted to jJ j>ev ccnt^ the hi);liesi being amont; children ttndcr 
i^cir»ofa(^.> 

TtMe shatt/ing lAt Agts •md Morlality of 708 Ctisti t^ 
Croti/MHi Pi»^mi'iiiii 



TMiliraii j iloS)»n JloiSTWri 

W I imon ToBi I n»ih.' Tvu] ' n«iiu 



113 



2t 



33» 



10 |g MY**'* 
Teial Unitii 



i;S 



t 



Toial iHuht 



708 sf 



tbe tti^ogy of croupous pneumonia is not perhaps quite as simple as it 
*'''u at first siRhl. A schoolboy is exposed to a cold east wind after 
(nimjt hot, or i* chilled by a fall into water, and a few days later develop; 
■"^kuic pnetin»>nia ; ir •■uch cases there can be little doubt thai pneumonia 
"am* *ay w other is the result of a chill. In cnnnciiion, ho«cver, with 
'Bivmirown huepilal statistics do not shoiv much diflercncr in the number 
■f <a«» admilird during' the different months of the year, ihoUKh there it a 

'1W«llgMi3£l»iclr«arrciponil with thotc pir«n by Von Diucb ; in 331 ofhitcaia 
'''■■^■BipMlMMnl* In childien uniler lu yean ofngc the morlalily was 4'S |kt cent. 



Z26 



Diseast's of the Rtspiratory Apparatus 



alight pre(Kin(lcraiic« in favour of March.' Attacks rcrlainly oeoir al i 
limca of jcaf . in ihc namici ii» »cil a* in iht colder tnonihi. On iIip neb 
hunct, it t6 quite rcnitin thni cioiiiinii^ pncutnuni.i n M timiMi ciNclrmic a] 
nlau infcGlinti^, iiltcctiii^ «evenl mcmbcn of the mmc household rw the ua 
street, and in n feu inttnnrcs thcte h3\-e bten nidesprcad cpldrmks, 4«,l 
insianee. during the inilucnM epidemic uf 1S91. Kpidcniict of pneuniM 
iii*i«:istc<l with tonvilliii* have i>ccotred iiischui>t!iiind(i(heTbri[emMitutio 
where the )>;tniinr)- armnxements ha\T^ l^eeii found faulty. It mai be lafc 
for certain th:ti uhik iherc is a fonii of pneutnciniii of the croii|>nu« ty 
which r<.ilIow\ a chill, it inavhc produced by oiher t.nnses, such»infircii<in 
the inhaUtiim of ihc rrankel-Wcuiiseiliiiuni diplococtus ot the indiicn 
bacillus or i' '"■■'1' he par' "f some gcnctiil septic poisonini;. In Mt 
instances acute pncumoni.-i has followed injurv' : ^ blow on the cbeil 01 
fall on the he.-id hu> been folluucd 3 fc'w (U)'s hitcr by a pneumonic ntlati 

It sKins lo us lliiil il is inuTC lliiiii pmbiiWe ihal these inicro'urgania 
Are innipable <>f scttin); up pncuniiMiia in hcahh) hint; <" a normal coiulilM 
but if the iiidiviiliud hns caught cold nr is in .1 Inu «inie of hciitih a sutlal 
soil is pr»duccd, iind If an infecliun take place a pneumonia is the result. 

The pneuinouic diplocorciis apjiciirs to bo .ilniO'l consLuitlj' pr«will 
the sput-k of (.uses of croupous pncumonin in the early «l.iKe, but il is al 
ftKind in the pua from an acute otitis .tnil also in the effusion in ccrebi 
spinal meiitn^ttls. It has been found in the sputa of he.illlty children, 
can haidly 1)C hiitd to be paihogenir nf pnrumoni.), but it is aj^rcll 
capiable of setting up pneumonia under ccrliiin conditions. 

In dilTcTcnt epidemics, or in dilTerrnl years (\t localities, attacks 
pnevtnonui iippe-ir to xnrj' '" their chatncter, sometimes being of I 
Sthenic, someiiines of asthenic i)i>c ; thi« has been speciall)' described 
FojiHcll.' 

Symptoms itHit CnwrvA— The omet is sudden, with s>'mptums not mil 
those oTscdrlct feter ; there is hi^h fever, dyspncca, rapid pulse, headnc 
pain in the s><lc or .'tbilnmeii, short I'oujih, and perhaps vunuiini; 11 
diarrhn:;!. In childicn under three years convulsions are not uncommon 
the onsrl, but ihi-vc arc mri: in older children : the conMilsions may pn 
falid before the atLick of pncimiiin]:i has fully declared itself. Dehriuin li 
be an earl; sjinplom, espcrinlly if the fcvier \^ hi)(h. ISy rhc time a meitl 
exAininalion is rnadi' ihc child i> usually luu ill to lie almiil, and is citltei 
bed or beini: nursed in its iiiothei's arms ; the cheeks are Hushed, the ; 
nasi are mnkinK. the rcspiialions are perhaps doubled, beinx poissibly 
per minute or more, the pulse lit) 10 140, (here is a tempetnluic of 104' 
theicalxiuts, the tonj;ue is dri' and bron ri, and there may be herpetic *esi< 
on the Nps ^md noic. \n cuiitunaiiun of the urine shows il to be dart 
ailour, I uncentiatcd. ciMitainuii; albumen and iui excels irf urea, aitd A<£K^ 
in chloride*. The (ough is dry and hacking- ^md pain is often compUioci 
during the ati ; in )'oun)t children there is no v^qjectoration, in older a 
iberv may be (be usual rusiy spul.-i. The fetcr and dyspniui conlinue, 
child reinaiiiiitg tcry ill till the end of the ucck. uheo, lannlly bcinven 

I 1b tsB lurs o( crtnipoux iinifuiROfiis diinOK tlicyciin itjT-iBS^. Dunu : 
■liKhl uocu la At n' xaA May, 
■ PnriitirKt!. |--!» iW* 



Kill anti tiiiiilt (Iav, the r<;\er ^iiddnity i^Ikiii-s aikI a mnrkcd improvemenC 
Itrs \Ancr in all ()ic symptoms, so ili;it it i» evident |i> itll thai tliC I'liiis hiis 
nir. The crisit i* sotHctimcs marked l>y cnlliipse, ihc child l>ccoinin^ told 
I i"l;immy, w ilh n subiU)niinl iciiippraiurc. 

f'Ariitaf Signi.—.\n cxaminiilion «f the i:hc^l on the fir-« or :iccnn[l day 
of ihr jiMirk «i1l iHuiilly lead to llif ili^coitn- of more or Icfcs cnitscilidjitcd 
lull);. CarvM (wtcuuiun, Mriking nou- lightly, now more fonribly, uill «licil 
a ccrtiiin hi ifli- pitched rioic of impaired teMirvniitc over some jwii tif the 
chest wall, :i\ in the infra-c:U\ iciiUir, ;i(illar>'. or ic;iput;ir region, i» over the 
root cir bitsc of (he Iuuk* ; "n liilcnmj; mvr the iiffctted iirc« siimu depnriuic 
front the iMinnid breath *<mnds will probiibl) be heard. There may he 
Uin|>ly weak ordntanl tireiillimi^i -ii >r the -tii w.\'i not cnlerin}i frc^clyinlo 
ie |Mrt ot ibc )un^ ; there ni^ty be di-jtuHl or intense bn>iithial brc^ithinjCi 
Vurinu^ ulioomMl sounds, ;■« a )ileiiritir rub, iboiithus or, more often, 
icrrpiUnl •» I<>"M- riii).'in){ rAlet, the line f rcpiutioil so common m adults 
|in>: ijenetnll> al>»ent. There are usually increaseiJ voc^l reionanet iind 
lilus though it in not always pnshihlc to eliril thfrtc «i|fns unless the child'! 
n. If titere is murh lung aUcctcd, loud or liar&li bicalli usuiids are lieJird 1 
er the noi) -a Heeled limKiand caiv must be Uikcn not tomlsiiikc these si^fn^l 
\nn ov«r»orked, for those of an affected lunj;. 

The pmiiioii of ihc coniolidation varies coniiderably and docs not 

ectsturily correspond to n lobe, but may iKcupy the whole extent of luti); 

Biervirly nr posteriorly : or the m<t«l marked lign* may l)c tint detected nver 

' nioi of ih« luni; behind ur in the axdia. The left li.ite and riKhi apex ar< 

lliuurite spni% to lie ^Hacked, bill an)' part of the KitiK may be int'olved,] 

(h il mii»t Ik- bonie in mind thai the apicci arc more apt in be atTc<*[ciJ 

tctiildrvn iliaii in .-idiilii.nnd il ii juit al lhi!t ^pol thul early t'lunt are apt to 

TloitkciL In the course of a diij' or Inn, «i>inclimei nol for several, ihc 

b1 ligny Iwcomc mure nuirked, llie dullness Laniiol be niist;ikcii. Ihe 

hiil brc.ilhiny bt-tomes whiffy ami inicnsc; in a feu days more, usu:illy 

iriiis lus armed, coarse loose .rejiitaiit (rtlts aic hcjird which 

; thi- trsolutvm of die pneiimonU- lun){. The dullness and bronchial 

httliili unitids -iiid rAtrt diuippear, but xtme nam of resonance is apt to 

'nanaiot many uecks, as the liin>: rcni^ini> m ^n ledcntatnus siaie. While 

mA it the usual course of i^ienli in an oriliiiar;' r;ise. there arc marked 

™f[tfKes «ilh lejiJid lo the time «hen the physical s'lgm make their appear- 

'Hn, there licinK frc<|iicnily a delay of several days : ihey may even appear 

t> b(t 41 (he fifth day. tl xt important to lemeniber this, for a mistake in 

^■JWn tieasy,asara«iit careful examination of the whole chest may reveal 

■Mhinj tuji^csliic III pneumonia. In such c;ucs there i» a tlruntc )ire>ump- 

*''* <)ttt ihc imcuEiumia is centrally siluiiled. perhaps at ihe root of the 

"'^■Mil lakes some lime 10 approach Ihc surface ; or possibly there m.iy 

Ik*!! jiiiu. inflammatory conxcUion <>f a portion of Iuok and a delay in the 

''^■iVHUiion of libiin into the air lacs. <lften a *ub. tympanitic or ncluallya 

'T'twiilic onle to percussion and neak bronchial brcathinif, or simply 

**Wil mpinttor) sounds, may be all there is to be heard for a tia)- or two. 

•' " n« easy to »ay uhy a lympanilic or ' boxy ' note is elicited oier liin^; 

*• tiUeof atule inflammatory conjiuiion, or in the first siojje of an acute 

**•< pfioiBumifi. bui that it doa occur n« luve often had die nppurtimity 



,228 



Distatts of ific Rfspiralory Apparatus 



'of obsen-inij. In m few cases the ciiw ria>' cinnc 4ii(l tKc child recover 
without the dassical «it;ti» i>r pneutnoni.-i c^cr being prcseni. 

TtMperatiire.—'V\\K icmiictamrc u*uiilly jjocs up siidcluily at the unid 
lo 104" or ( hereabout ft, and during the coun>c of the altnck conlimics hijjli, 
with slight morning' rcrnUnons, lilt ihe c-rii>JK, uhcn the fall is Midden (M^e 
% 31)1 perhaps 4°"' 5°. '"•' subiioriiiid Icinperaiurc ; ihc l.iUrr may lu.t for a 
fcwdayi.and then ihc mirmal line be regained. The day on whirh the crisis 
t-ike» plnte varies Kreatly ; the aiuck may end aboiu the Tounh or ftfih day 
or earlier, but uttinlly ihc rrisis is delayi-d till ilie teventh cir eighth, and ia 
the cteepinii form till the end of the second week or l.iier ; a post-crisiHl 




Ftf^ JT.— T«Ptpcntu»Cli*r1«f iKWcof Cioupoua t'lirumgnU ^tW% upvN tn « fkl of Ifiva ytM« 

lise often occurs (sec fiif. Ji), the tcnipetaiurc rising n few decree* ilic M- 
loiiinj; evcniiit;, becoming nontial the ncut monilng : or .\ lelupie in whk* 
the tcinpenititre tem.iins elevated may l;ike plare in conscquciwi- of anolbc* 
portion of lunj! bein^ uffettcd. I'nit-critinl herlic, prolonged Utt some lUyl 
or weeks, sut-x«>t» the prcieiiLi- of an empyenin or other contplicatmn. In 
(be minority of cn»» the icitipeiiiture falU hy Ij-sis, 

Varittiet.— 'U\t cour»C o( the altark inrics i tli«e %4ricties have been 
emphasised by various writers, ctpccially hy A. Ilajfinsky ; they nuy he 
enumerated at follows: (■] AberUr* »M«ABMDta. -This variety, as the 
name applies, aborts, or the courte comes in a Kiidden tenninaiion by crisis, 
after lastrnt; (wo, ihtee, or fotir days, miMlly niihoui the classical signs of 



1 



Croupous pHeumonin 



2»? 



nia l>eing ilcv doped ; yt-i a cjreful uxaniin^ilion of the lunjj^ nill 

nttiooit &!■« "In-rc ihe breath »(miid» iue weak jnii llic penrusiion 

^W lA^lilIy raiiicd or l\-nipiiniti<. Htqui i^ Lommon on ihc tip* nnd 

■M. (]j CF*«Ft>V "T wandeNnr VnenmonlK li,is hccn cnnipnrcd by 

Indloan altnck of rnsipchi* spreading oii-i the surface of ilic lung. 

Tk tpw ii perhaps the first part affected : ijradually llie inflammaion- 

Form spreads to the hav, and posaiMy tinaily attacks the opposite side. 

JiKbcwes SIM: a|H to Iwvc a chninit rouiif, the crisis being dcU>-cd till the 

fcaft ot fuurteeniti day, or the icmpcnilurc may f.iU by lysis, or a bcttit may 

ttccett) in cotisequcncc ol an empyema btiim present (jj mvlapsisr 




tfcaiod b)- <4ld lialbk CiMi feuzth diL> ; ^m^^Ti^ial im, kuifi^ry. 



Lpf fim jTii*( 



VuvBaalA mucli le^vtnuliri the crcFpin^ fonii. Several rrlApsc^ occur 
»(lcr the crisis lias conie. some patch of jmcumonia occurrin;; in another 
{an of the long. We hai* kmrnn itases in "hidi six or scirn icbpieii have 
ORurreiL In such aises uc nuy suspect pus. i.), Owmbr&t VB«amBDl>.- 
In this fufm cerebtal syniptomi ;iie ptDtiiincnt, while.^in the early sl;i>iei at 
lost, the syniptonis of pneumonia are latent ; there may be toiuuUions, 
deiiiiunt, headache, and <lii>u'&ines!. In »udi case* the fever luuatly runs 
tnjch.and the cerebral «)mpioms may lie due to the high fcierand jioisoned 
Mood. Not unficqiientlv tlic lesion in ilicsc cases w at the ajws. Cough is 
<Ara ahwni. (5) osatrM vanuavni*,— In these cases gastric *yniptoni» 
We mow marked ; the ailark may heg'n wiih ton^iiing, di.irrha*a, coated 




230 



^litases of thf Respiratory Ap/vtr/tfvs 



(ongvc, fcvct, and abdaromnJ i»iin, and a i> only after a day or two, wn9^ 
the rlas^ical signs .ippc-nr, that a diagnati.i of {incumooia is ina«lc- Tbe 
iitUKk may Mtnubte g.istni-inteiiinal catiirrh or perili)nilis. Ibe abdo- 
minnl jxiin b<.-ing due tu (liaphiii^malic ur co«ial pleurisy. (6> VIcNt*— 
paoaniABla.— In thir»c gisfs the si^ns of plturisy pcedoniinati- ; llicic >* 
i.)iar|i lUljbmj; pain, tenderness on percusaion. and tJic tliild screanii wlitn 
ilcogghsor turns ottt in bed. Sijjni of tonsoliditiim An Micctcdcd l>>" 
those of pleuriili: efTusion, or ;in eiiipycnia possibly results. 

Compiictt/ions ami SefK/cc — n^wrimy fn-quenil)' acconipiinies ctoupou* 
pneumonia ; ptrtossion mer ilie dull area and d«-p pressure ^wv juin. anci 
friction sounds an; freijuenlly huitil ; Ihf pleurisy is ;ipt lo bty:uine suppura- 
tive in weakly childn-n, espcfially if the piieiiinoiiia occurs in the tours* of 
scurlct fever, invades, or whooping tou}ih (stc infra';, Perieorttiti* somt- 
limes occurs. Mv9Mvrr«>l*. ^ leniptrjiiice of io}° or 106' uci.a>.ii>njUlT 
taking place, accompanied by cerebr.d syinplutns. ontulsions in inuag 
, children, or stupor and dehriiun in older ones. M«iiincitim is rate, though it 
occurs occauonaliy simultaneously with the pneumonia or follo«'« AS «fC(|uFh, 
)}C)n^ most common in youn^ children, irvptarltta also occurs in ;ivKici»- 
t>on with pncumoniii ; usually the Uller is seconder}' to the former, f bbMM* 
sitmrtimt* aiionipiinics pneumonia, especially of the riwht bate .'*«• p. 33JJ. 
OaosrvB* of tta« tnnc orca*ionaUy supcr\enes and hrin};^ abnut a fktsi 
rciuli ; iliis scrm.v mnsily to oc<iii either in pnfiimonia tccondarx" 10 ncph> 
ritis, or nlicn pneumonia occurs in a subjccl who has iim|>hysunalou« luoyx. 
The posMbxIily of the liini; betn); adherent in ihL- chest and underg<i<n){ an 
indurating or libroid jirorcis nuist lit kept m mind. ,\ chronic condition «f 
aB»e*tliMi may remain . but 1hl^ rs much ci>minuner after catarrluil than ttvrt 
croupous pneumonia. I>lplttb«n« of the fauces may compiic^tc it; udcc 
or twice we li.iie diicinered. In our surprise. Ule in the attack or on iha 
poil-morlem table, false mcmbiane on the fauces, 

frogrwn's. — The jirognosis is favourable in cases of ctuupoui pneiuiKnAi 
when ii is primary and attacks healthy children over three ycanofaget 
Hinoii); such the rnoitaiily is >niall. Uuuhle jineuinonia is necess;iii1y more 
fatal ihaii single, but here the amount of luiin invoked al one lime is nol 
necessarily i;mt, as usually «'liile it is advancing on one side it is lecedtn); 
on llie other ; the danf-er depends on the amount of lung involved, and ihe 
respirations ^iv-e it more or less useful indication of ihiv In a child who 
Jitrejidy suflfers from chronic bronchitis and emphjsemn or cardiac disease^ 
the protfnnsis is mtich worse. Secondary jmeumonia, when it Ml<wt oi 
camplic'iicx K-;trlei fever, measles whooping cout;h, ncphriliK, or foUoB* 
operations or is connected » ith scpiic;cmia, i> ncce»iitily a serious and often 
fatal disease. When mucli plc-urisv accompanies the pneumonia, csjiccialty 
in younji children, the procnosin is less lavourable lh;m in cases of simple 
croupous pneumonia. 

Dtagaoiij.— ln those aues of croupous pneumonia which beKin "illt 
vomiting and liij-h fever, .ind Hhcre the physical signs are delayed, there it 
d ceriain sujiciiiciiil lesembtaixx' to scarlet feier. Tliat such cases are liable 
lo be mistaken for scarlet fever is sliown by the fact llial not unconimunly 
uutcsof acute pneumonia are sent into fevei liospilals cctlilicxi as sulferiag 
I froot scarlet fever. A caicful examination ol the paitcni, and, if uccessar^'. a 



Crtsupcus PntHiHonia 



ni 



I 



% 



of twcniy-four hmirs l>cforc coniinj; (o a decision, wil!, in jlic l.irKC 
hi) trfta'**, prcvc-nt *u<;h iin <tto». In ihc tirsi iinTnty-Coiir Imiirs m ;i 
ihupaltuk of sairirl fever ilicrr mny be hij;h IcmpcniUitp, Mmiitinj;. <Iiar-| 
rhm, Ripid pulM- (nficn i;o\ inmillilis more or !<■" dcvplopctl, no [win inn 
Ihedictt.or diiijjh. The nsli visu>illyRppcArs at ihccnd oCtnTniy-foiir hours. 
la jciiii: pneumonin iliere muy be hi^h fwer, he.idnchc, piiin in th<- clicsi or 
jbdomcn, dyitpna-n, piil^e pcrlups of tJo, pcrlinp^ srinic phy«ic.il sipis in 
ihe (hoi, Boi oftrn mniitinj;, (liarrlm-ii, or tonsillilis. There i» no tush. 
Acule porumonin wiili m^irlied i:crrbral symptoms Blleh ;is (leliriiiin, Wtipor, 
«t hcadichc, wmks on tlie leeth, snd hi>;li fever may be uketi f«r lypliiis. A 
cutAi! (ximin.ition of the toii^'s«'ouldj,'encr.illy decide j in lyphnsdicrc may 
benidencc o< bronchitis ; in pneiimoiiia there would usually he some want 
«finotuinec al an npex or kise, wiih some (li«nin or bronchial hreaihin^, 
tlir ptncQCc «f a rh.ir.if Icrislii' rash on the ihirii ot fourth day wimld decide 
(htdlajjiunis ; ii \% *ell lo rcmemberth.il in chilrii'en typhus is tisuJilly amiM 
iieut In )x>un|{ cliiUlicn iin acute attack of croupous pneHoionia, nith 
N^fricr, conviiUions, drowsiness, or coma, may lie niistakcci for acuie 
<nniii|[iin, or, AS a matter of fact, pnciimoni'i and menini;>ii» may co.cxisi. 
WeihouW, however, heiiiaieiiuh*- presence of pneiiinonis and a icmperaiiire 
**i<»l' nr lO)' (o diagnose incninf;iiis, the ccrcbiwl iymptoms lieiny due (o 
'httufti lempcraliirc and poisoncii blood. In all cases where a younj; ehild 
'iniHdenly iJiken with convulsions and liijth (c^cr, pneumonia should l»e sus- 
pofiol hikI a i-.ireful ewiniinalion of the liinKs made, We must remember 
lh« the tempeiatiiTr may be liiKb, lOi" or 105", as ihc result of only a small 
P<thaf imcumonta. In ttich cam's, especially in inf^^tnts, ibe pncumnni.i may 
bcoitrlotiked and ihc lempcrituiic bc.itiribuied 10 lecihinj;. Tlie ciia(;no»i* 
™*«n(roop'nis pnctimonia and j^rncraltscd btimc bo- pneumonia may not 
^laiyduiini; ''I*': ""^ cannot oflcD do more than say such and ^urh nn 
»Uck ipprniicbcx more iicnrly to ihe croujKius type, when iberc ix n nudiJcn 
"••tiloGil portion of lunu involved, aconiinuiiu.iicmper.-iture,iindacriiis; 
*" it i* more of the catarrhal type ubcn ihcie ii much bn>nchiti*, an inier- 
wirai ttinix^raCure, .ind^rndual subsidence of ihc fever. Tbediffimllydiici 
*" ^vij)i rnti in the poil-morltm ronjn, hs typicid ribriiioiis pneiinionin 
"■ luiches or more widely distributed may be found in one hint; and un' 
^wAltd lobuliir pneumonia in llie other, "hilc both varieties may be present 
mike usic lung. 

ftOulfgy.—Xn croupous pneumonia the lirsi stage ii tb.il of an inftain- 
"'•'My mi^jferrient of an extended portion of lung, the vessels are full, the 
f»inllM>(s jfp tortuou!! and distended, encroachinf! on the ail 'pace in the 
*"»: inilic second ata^te ibe engorycd vessels lelievc themselves by pourinic 
"'''«luor tattj^utnis and sornc corpuscular clemcnrs into the air sacs, which 
"'^'at blix-ked with ^brinc, and a condition of red hcpaiiiaiion tcxults. 
"W f»i hcpntisation. when seen at the fwil-mttrltai, ilifTers from the lohiir , 
'^•'y uf eatanh.il pneumonia in that ii is more solid in ihc touch, and'1 
''<**'ft» u uniformly coloured surface on which the outlines of llie lobules 
''•W be diMinjtuishcd ; in children it is less often j^tanutar than il is in 
***^ U » later itajce yrcy hepatiiaiion is found, ibc lighter colour being 
*• h tJic prciencc of a greater number of corpuscular elements. In lunj; 
■•^itiieof red liepaiiMtion, Frinkcl-Wcichsclbaum diplococi:i may be 



232 



7ismses of the Kesfnratary Affaratas 



ii«unlly delected liy Gnim'& methtHl. In one of our leccni ca»cs tk^vBx 
croupous piH'U mania, in a boy of four \'car« of ngc, ulio died on the caghtb 
dny (having 1>ecn deeply jaundiced for llirec or fnur days), the left lun^ wm 
in * condilion of red and grey hc|>aiiuitinn, «xcepl at ih« cxtrcnvc .ipca. 
There were some localised lirpaliscd patches in the rixl" haw \W »«rii 
ableWolMain eiiltivalion*oi> glyrerinc agar of the Friinkel-W. diplococcii*, 
Staphyh-eoc<ux f'y<>g. aurtnt. and Slivfifotoc. pyngrnes. 

TrMtm^M. — An unmmplic^ited r^*^c ofcraupouv pncuninnia ina child doc» 
not require active Irc-aimcni, a> the counic ii short, and the heart aivd aitcrul 
Hysiem, unlike ihc condiiicni often found in aduliv, are free from dejccncra- 
lions and able lo stand the strum itnjKised upon ihttn. Tbe child >houtd,af 
course, be confined la his bed in :t veil uarincd;md ventilated niom :he&lKN]U 
be allowed only fluid nourishment, such us niitk, barley ^«aIer, and soda water. 
A piece of sponKin-piline or Hannel doubled several times nui>' be urunK oul 
of hoi water, ;ind applied to the chest, t'ouliitcsmay licused,and retain the 
hc»l belier thnn an)lhinK else : but they arc very liable lu slip out of (tliKe, 
and are unsniied for infants on ;K.>count of their ucighl. In the early uagri 
acciniic i* of senicc, one or iwo drops of the lineiurr l>cing ifiven eveiy 
two iir four hours, being njitched carefully lest it produce loo much deprn- 
sion. In miin\ tiises (lo other treatment is required, the aconite lieint 
«o[)ped when tin- crisis comes, [f the temperature is not excessive, no! 
mmh cicctdinn 103°, no special methods of reducing it need be used, » the 
course of ilie fever i» short, and often after the liisi day or two it takes a 
tower runge ; the iitiiial fever in the case of infanisand young chddren bin 
some eases high, and is. appaienlly, Ihc (.auscof the rcrebnti syni|iii>ms, MKh 
as convulsions and coma, from which the}' suffer, and which sometimes pnn« 
fatal. When this is the case, no time should be Iom in reducin>; teiiipcniltiie 
by cold s|ion(:in^, packs. Iiaihs. an ice ha^ to the chest over ihe seat uf the 
pneumonia, or by the adminittraiion of aniipy relict, if the lem|>i-raiurc is 
high — 104° or 105"— ihcre is no need 10 fear any harm accriiing fnnn cold 
water, the simplest mclhod of applyinj; it hcinjt b) •■ponginc the palieitl over 
with cold ivarer, or — what ix more effeclu.il by a p.ick nt 60" or 70° ; this laliet 
can be applied by uringing u lou-el out of cold nuter. folding and apf>l)ing it 
round the chest, or cnve1i>pin|{ Ihe whole body in a weiieti shcei. Thepn>- 
txn may Ik re|ieiiied at inter^alii of an hour mure or le««. If these nicaiis 
prove inefficient, or if, as in the case of convulsions, there is no time to Icnc, 
the cold or nmduiiled bath should be resorted lo, the child iK-ing placed ia a 
w^irm 01 lukcuami batli, and the teaiperaturc of ilic uater gradually loncred 
to 60' K. by adililion i>f cold water or ice ; if the pikticnt become* blue and 
cold he ^ould be removed al once. 

The best anttp)Teiics are quinine and anliAibrin and pbcnacetin, either 
l>cing given in l«ii) or three gr.iin doses to a child of three years ever)* ftiur 
Iiours ; aniifebrin is apt to produce considetviblc depression, nhich, however, 
quickly passes away ; large doses of quinine arc apt lo produce dyspep»iik. 
The cflccis of acuniie on the pulse should be carefully watched ; any sign^ 
of intermission 01 irregularity should Ik- the signal for omitting it, for a while 
al least, and submitting' »ome siniplc saline^ as liq. ammon, ^ccL or rittMis : 
alcohol and stimulant cipecininnts .ire bcM avoided in the early ttages : two 
ur three drop doses of ir. digiiAlii, giscn every four houn, are often useful 



Croupous Pneumonia ajj 

it tk [ulfr ■» poor ; cilralc of caflcinc or »u1pliutic cthrr mny nlso be 
[11 III 

lauuii vr)i«re therrijit itdchiycd (iniiccount of tliciniljimnvilon'pnx^M 
ciicnilin);. a* in ibc rrccpin^ f»nti, iind nlicn the- cliilii sccnii loiv ;in<l ucak, 
ihcrt it iiln-iiyxa Icmptiillon in ^vtv .-immoniji And .-itimul.inl!!, ;ind thcsC ni(i)' 
■I wfflf nksci be ai-Fdcd, i;i|Kviall)- in haspiUll piilieiilt wliu Jirc seen fm' 
ihrl'ii!! timi^ aixcx vmik d;iyi' illnc^ti : but iiut iinprVMion is llial p:itieriis do 
brtur in the in lid mm;! lory atugcs, uben ibc process \s hlill extending, oii 
nilldflan d acunite, antimony, or sjilinei, thiin lliey do I'li .1 tito Slitnu- 
luiti lTcntiiM.-m. An occiiiiimul (lost ofulculi»l mny tlo );iHHt ubcn n cnii- 
[losmK iluMni; \-w lurinful ; ^iltohul in l.ti^e denes aci> as u narcotic, nnd Is 
itOniitd 10 ibo d(««iini'M and lendcnty to deliriLini. Opium in Iho form 
'''Kptailw'ur IJmur's puudcr is of K«at value in calming iliedciirium 
ud »)(«plcMncM, 45 well as sootliins ibe irritable coiiyli and relieving pain 
•bn this is a marited feature, as it ii in Ibe pleuritic cumpllc»tian6. One 
inibct drops of nepenthe or half 10 l"o );rains of Ucnir's powdti may l»c 
(ntnu flight to procure rrsi and sk-c^|>. In double pntumunia, »)kic there 
iiniKh dc]>r<r»ion with a failinj! pulsi-, ether and di){italt^ iimst lie rcjorted 
M Ether may be injected in three or tive drup doses siiljcuiaitemisly. or sp. 
tkritiiul lr. di^lalis may lie );iven cten' feo' houis. Champagne is u I'lxiil 
rmiifijiic tuxk-r these cln-umstances but it may cause vomiim},' if (-iven too 
My,.-ind ii will b« well 10 dilute u «ith soda wjter iu the case of youoi; 

f>ttatr«a« of tti* buag 

CrMipoux pneumonia, »hen it atiacki^ children nirejidy the subject of 
(linnic timnchitis and emphysema, is apt lo tcrminntt- in );an);i'ene of the 
luV- 1^'* wc h;ive itccn on «:v<:ral (ircnsi»n<^ It is apt to fnlloiv pni:umoniii 
Vmndity to Nairlatiniil nrphrilis and alM> u'hoopin); couj;li. The principal 
<i>i|n(»tic syminom is ihc eicccdingly foul biealh ; the icm|>cialiite is 
■■■llrhiKh, »o«nctimcs bcclic. su](j;csling pus, and the piilv^c i< rapid. 'Hie 
iMfBlound M the post-morltm in a state of grey liepatiwiion. brtakin^ 
dm ntn ragged cavitie* and «mellin)( olTciuively. 

'i*V«' '-f ttrtg: /"^igrnroiiiiMMiinii.— Jcncpli I" , ag,tt\ 9 jc«t- M"lhcf slata 

^ W Im mbini 10 tirancbllii m Itic mnlir. On Scptanlwr 10 he i.inir Imin M.-hnoI 

<M(tUUnR <4 a pun iii hit ViAt :inil IeuI nueli. H<' 'I'l* 'xvii s|iiilt<i|,' viwc blood. 

Ciidomoa. .SiTil«in<»T »7. ■B«4, he it a tliin, ileIluiU--lookiiig l»ij. mlh ilulibod 

I "B"!- t^ ruuBlniiliHii lit Ihr'ulieii : Iht tithl tiik hni .i l"'iy lU'ir. I'ltvpl nl IheUur. 

WW«ht<K a dull : (he tuctlli loundimrvcry (bIiiI ; lomi: tnclion u>urnb in llir.~niillii; 

■^MmIt it •iinibil. "ofpl (liat (ht lirratli lOiinds an: tx.igKfnilcd Tlirn- ii iioi miicli 

i^i^Ov. I4M be li kiibttvi (o iiaioiyknii 'if coiichini-, wlii-n hr l)it«|[t iiji ii-'iiii);nkl)1p 

Wli'ln of WT) ('Hill pui. Ort'>1iet i.~l'nnn)iTiii of cbUghing and fiPin! i-iitv-iora- 

- ' "^itf dulknd* at left biuc bchinil. Cniir^tf ^'n^pilnlifin .irii^murly on i^eIU iiilc 

I niclil lilt* iiitKutaiwaiuly in Kn^ral dllleiciit pined-, liut fnili-d 10 fliiil fiiiv 

'Kf'n J.— Mot'li c»tU[iii'. IVniii Oci>ibcr6. 

fim-mfii— — Riu^l lun^ nilhcrcnt 111 Prnnl. In ■xlllary tcgion i]yopiimimillioia% ; 
^ vm foiil ; MiEill aiity tii niiildtc of 1«1v. (ommunioiiiDi! y-n'a lironthii. am) bIm, 
fliwal caciy . itinhn of coni.JriJ^Kiciii iliroiiittioiii llir lunj; lioduiiini; cjiiKrpm.ii. ; iii> 
MIniM lulmic. \jttt luiit; adhi-reiK b«hinil ; leLi-nl pleurii). llnin and olba "cgint 
itum nothini ahnurranl 



234 /}tseases a/ fUe Resf^ratory Ap^raitts 



AbSO«>« or ill B &«!*■ 

I'unjieni cnllcciioos in Uie lung* nrc moitty the reioli of scpck cmboliini 
from *ainr (lisuni juripumiin); centre, at in an otiiii or vixne iilhcr boM 
lesion, nnii .-irc ii^socinlcd n ith j>y:i-mia- The)' are utually small and iituiiid 
«» the sur£icc- Small iibirrtKci mny be sccondar)' lo an ein|>>-ufnu, IlicUuff 
finding its way vi& a small nlxccss mio a bronchial tube. Miiiuie LibscoM 
lire Kinnciiiiies a sc<|ucnce of a broncho- pneumonia sccxmdary lo tcirM 
fever, tnea^ti-s, or whoopinx coti>:h. suppuration talcinK place in the lofcuha 
inimediulely ^urroiindint; the icTininnl brnnchioic« ; here snull ceniro caa< 
Liming pui' >n-ty be found >>ee p. 3i9> 

In both if'>"Ri^n<= ''(i^d nliscrs' of ilic lunK, if lite lesiotiJt are birlgr 
localised, or the disc<isc prngressin);, an allcmpl should be mtAn tt 
urreil the itiiichicf by inritini; and drainin;; the iibsce^s or ),Mngm«U 
cavity. I"i>r ihii pur|K)sc il is necessary to locnl»e the abicevs, (iriil by llw 
pliy3i<:.-il MKOit iii fat a.i may be, and. secondly, b)- exploration trili M 
.•spiiator needle, ihmit;h, if the evidence it oihcru-ise tilrong, failure to dai' 
uff'ptu by ihc aipiraior should not prevent a further exploration; the inciflM 
should be made over the ab>.ccits, and, if necc^imr)', one or dkmv ^iC^iDctiH 
of rib removed ; Ibe Iuhk «bould then lie incised and dnined, and ireatt^M 
4>rdiniiry surjjical principles. We have ind»ed and drained a hydatid ofi4» 
lunj; and ii |iulm<inar>' abscess *\ithconiiderablc relief lo the ihddrcoin<Mll 
instance. 

Vlanrlay vaA Bmpyema 

Thai pleurisy rnuKt be a common di«ea!(e in children i« iJiown by ihl 
frequency uitb which (hi- lunyi art- found adherent lo the cbe»i walls »hei 
nuikin^ rfuf'psics on thitdri^n who \\!i.\v. died from variutis ditieases. lien 
as in (he cjso of iidu)i«. tlie cMdeiice of a |ii<i ptcuri!>v >» <.'i>iKhisive. Veil 
cjtnnoi be said tlut pleurisy i« diiiKnoscd and treated with any Knit 
frequency duriii)- life, [he r«a!>oi) no doubl liein^' thai young children .iic i«l 
able 10 localise aita,i:lc!k of pain, ihai ulien fretful i( is no( easy to ihoriM|hl{ 
examine ilicii ilie?i» by aUKultaiiun. and. moieiiver, Ihc symplomi mayli 
masked by oilier diae^uics in ubich (be pleural le-i>on plays but a sccondai 
pan. 

PIcuHsy, pHmary and acute, occurs At all u^cs dutin); infancy and diiU 
hood, the first year of life being b>- no inc«n» encnipL I( is apt to fol 
expouire lo cold or. not iiifrc(|ucntly. an accident, such as a fall o« bio* 
tiie dicsL ll is, however, far more commonly assncialed itith a crooj 
aitairhal, or septic pneumonia. It uccuis very frequently in connection 
tuberculosis of the limg. 

^w^iun*.— Ileurisy may begin suddenly and run an acme coune, ihi 
more often it is lubamte. The atlaik begins with a short cout{h, fcv 
shallow re^ipiraior)- movcn)ents, (he aiTected »ide mining less (ban ks fell 
accmnpanicd by sharp pain, ohich the child, if old enough \a du m>, refen 
the side or verj- often the cpigar.trium. In infants (he all^ick maybe Ushci 
in by convulsions and its ciiurscmaybe marked by scrc;imtnK >ils. csjiecul 
if tbc child is disturbed. If ihepleunsyises;tcnsiveaadaeuiv, anexamti 



Pleurisy 



235 



Fftp rhetl »how* the rc^pimions 10 be shsllow, nmi the mtrt cmtnu at 

tht iBecicd »i<l<- rklr«ine1y limitrd. whik pcrcussinn or pre*iuri- in tlie 

mrnuHliiJ ipncc^ uiih ihc finger givc« n'M to (rxpre»>'iDns of ac\i\e pnii). 

OnHnciltntion. whilr thr Uicnih sounds .tie loud unA clcir on tlsc noriiuil 

«J(. ihtj- are Ti-c-ik on the aflectcd, nnd perhaps acconi|iiinirtl by a riiciion 

maul The pulKcU quickened and (here is rever, perhaps loo'to 10;", uiik-ss 

l«nimo[tia is preicni, when it i* probably higher. The fiinher roumc of the 

iiudi luriet according lo « heihrr irlTuftiun of serum occurs or not. In the 

Uvr cjsc, in the c«ui-«c of a few days ihe feter siihtidcs, ihc friction sounds 

Jwiprar, thoU};h perhaps «i>me 'xiilrh' (stabbing pain in thr «ick-) remains 

^■■lule. In miinycntM apparently a loc.-il pleurisy (ake« place during ihe 

^nwo/a Ixoncbili* or bronchial caUrrh in which hllle else ihun a sharp 

fumnthe iWIe or abdomen \% prevent. 

tl4 ptetjris}' occurring bctunrn ibe diaphragm and lung the iyinpti>ins ate 
Iwlly «bsi:iire, there i* pain ant! li^ndcriiMT' in ihL- cpigaMric or hepatic 
ki.nith ihwdcic breathing, the abdominal muKlvsand diiiphragni being 
^« -11 (|uiei !x% pa»viblc Should eSiiKion take place in any t|LiAiiliiy, 
^■lof it* pretence (juickly apiie^it. The child will probably lie on the 
PPMlide, M)a»tO(;ivefuU pby to the lung on the »i>i:nd side : tl1t^ infant, 
WHraech pciinlt out. n ilh fluid in the right pleur.il tai ily lakes only the left 
, IHM of its RMlher for a siuiilat reason. On inspection it will be iiitled that 
A( ndr I'Mitjiniii^ ibe effuitd fluid moves less freely than ihe other, and if 
fclladis in the left chcii, the cardiac impulse is displaced lonards ihe 
I mtt ndc. In Ut^e pleural effusions i>n the right side, the impulse may 
iknuitd ton.-irds the left. This displacemenl of ihv cardiac impulse i> 
I if Ipedal value in the <lia|;iiusis of fluid in ihc chest in children, on itccouni 
irfic uncertainty and small value of some of the other physical tigns ; 
1^ tir iiuiancc, the vocal resonance and freniilus, Hhiih yield valuable in- 
I in adults. The position of the bean's impulse is liesi ascertained 
ring tl>c raibre nd' the hand on [he chest nail, and, if necessary, by 
ning by niHCultation the position nf the heart by the comparative 
WMMuf its xounds. It is necessary, however, to remember ih.ii the bran 
My be displaced niiboui any fluid being prci-cm at ihc time of examination, 
M u nuy hav-e been pushed nn one lidc by a fanner effusion and have become 
(>eJ a an abnnrrnal posiliim by fibmui adhesions ; in this case thr lung also 
HI probably be adherent, and a dull mnc may Ijc elicited over rl nliich 
•mnts the presence rf fluid. The he.irt may also be |)ullcd on one side or 
tfnt^\ by a fibroid condition of lung iir chrunic pleurisy. 

ipttcussion of the chest, a dull or much impaired resonance will l>c 
over the area occupied by lluid, while in mosl cases the sub- 
ar rcgimi and frequently also the supra-spinous fossa and possibly a 
tfRji hnween the base of the scapula and the spine will be resonant, often 
■trrewKianL If the elTusion is great the whale side will be completely 



jtoajoni 
^bcing 
^MniMiin 



■fnnjd 

Krd . 
■nnOar 



'snrt 



rw.- 



a sense of resistance on percussion. On auscultation the 
am neak and distant, but usually of a dislini'ily bronchial or 
. icr. In the e^itiicr sUiget of etTusinn the cjipiralof) murmur 
itij dccentiialed and broorbi.il. ihc ail from the comprt-ksed lung 
ii »ere, ca|ietle<l with difiiculty. The breath sounds on the healthy 
cKNfQCcmied. The vmral resonance and fremitus may be absent or 




J 



It 



236 Disftuft of the Rtspiratory Affnralus 

weak, l>ul it may Ik- iinpouibic to elicit .iny informniion m this way, » M 
voic«i> of children, cijwciiilly jprU, arc »-nk. niiii moreover they may aolh 
old rnotih'h to undcrxiitnil wh.il ihcy arc wanted to ilix DurinK <^'y*"& "' 
fnmiiition of value nia> lomclimes lie obtulncd by ;dacinK lix^ band iw Ik 
che«t. Comparative ineasiiretnents of the in*o sides %\vw the iHhic4 
side in recent cate^ In be lar^fer iban the other ; bul (u» mucb value Rig4 
nol be atiiicbed lo nieasuremenl^ as in clirtwiic caic* MHne anwiunt ul n> 
tr»:lii>n niiiy have taken plate. Of more vakie i» tlie eyrtomcttr Intinj; ; ih* 
a* pointed nut bi Dr. S. Gee. sliuns a clinn^C of ihapi.- fioiri iIm.' ell>|itinlll 
(lie more circular form iMtliout ihe cinu infer ctice necc-tuirily bcii)^ initeuti 

.Should a lar^'e amount of l!uid be |kiuic<I out in a short ^|Ktire iif timr, 
will necehMrily ^ive rise to dytptiurj : tile child uill Ititn over tm to It 
nAccied tide or lie upon iis b^ck ; the nix nasi u'orh, and the niimlirr u( 
tpiraliont is increased perhaps tii forty or fifty. If the ariKnuit of fluiil 
smaller in (.juanlily, the rhild may be- tolerably romfotlable whih- l)iq^ 
rctt, but (here ii dyipneca on the xlijchtetl exertion. The amount <-< '•• 
ncits varies ; durinx th<- in dam mat or)- staKU before or durinK tb> 
kerum i* l>cinK poured out the temperature i« usually raised iv>i> "< ili> 
dc|[rees: in the course of a few daysaxradual falliakei place, and ilicK 
be no fcvcT or only a slii;hi elevation at night. 

Un<kr favourable circumitamrcii in a healthy child, the iwniin 
begins to be reabsorbed ; thi« it mually doen in ilic cour>e itf .1 ' 
the heart if displaced rcturniiih' by decrees to iti noniial ponlifKi. 
ihe fluid liecoming loner and lower, till the side ^c^fainait^ norma! 
01. what is much more likely, a somewhat impaired resonance. « bi 
for many neek& The reason of iliis ii doubtless thai llu- rccxparttlvd 
remains for some lime in a sinlden and coi));esied stiiie, and im>1 im 
its pleural surface roninicls adhesions uitli the cbesl null. Dunny 
tXa^t of mbsorplion friction and moist nllcs arc frequently iKatd la 
lun)>,and ibc breath soimdv are weak. In sonic case^. however, thisdi 
rcabsorpciun dots not at once lake place. The tbild's health i> im 
he is an<emiL- and depressed, perhaps thick layer* of Uinph »re covefitiK 
pleural surface of the lung and chest n'all, and conditions are not favnura' 
for the rcalisorplion of the fluid after the in flam irui lion liaS subsided ; 
pouibly the absorption may ■go on extremely slowly, pttri fiauu with 
OTKanitint; of the Ijiiipli which lias been |>oured out Under ihc»e drciM 
stances tnucli dHma(>e may be done, ibe he^irt iiiav' be fixed in a nialpnaiCN 
the liin}- may become lieil ittwn by a ihi<:k kiv-cr of fibroid tissue "h« 
coBtmcting holds the lung in its {frip, while the chcsi falU in and the spii 
bcconirt curved. 

Hut besides a (|iiick rcabsoiplion of the scrum, and a chronic plcori 
nith its slow Course, amither result iii.iy follon. and that is— at leiul (I 
is whni is ntunlly believed —the serum may become pus; this, hon'over, isa 
a rinnmnn rcsiili if the Huid etfiised is at lirst scrum, .ind it rarely Im 
thai it remain* so for some weeks and ihcn finally becomes converieil 
pus. An empyema, ;it a rule, is an cinpveina fmm the first, M Ica^ lite f|i 
dTuscd is turbid- look inj; at first ; m other wortls, it >t thin pir*. and Uler 
bc<-omcs thick pus. It i> no doubt most rommon 10 find that where there 
rvAMtn III believe fluid has existed in live chesi Uit aomt weeks or tanni 



i:.tii/i)Viiiit- 



237 



1 pus uiut wA serum, bui then Jn alt prtilmbiliiy the fluid lias liecn 
he fint axiA hai fiiilcii lo lie ubsorhcil, »herc;is had it bei-n scnim 
a*c liecn. Stnim mav untlriubieilly rciiuiin in ihi: tlicM unaliertd 
tcvks. pcrlufi* months ; hm ihis is uiicomnum txttpl in cases of 
If new grcmthi in the lunx, or in cardiac tliscaie. An cmp)-cina is, 
I nujorily of iniiances ;ii ;iny rale, [he tl-suIc nillier of a pleuro- 
t iban » simple pleuriiy. Tlitf more inicnse llie intlainmation 
likdy il is chat pui, not simple serum, ii poured out, or that 
pdOred nut quickl)' bccoit)c» pu». This is tapocvatly likely tu 
» pl«iTi>-pnemnr>nia follows scarleC fc^'Cr, measles, or whuupinj; 
n<ked any pneumonia of the croupous i> pe. The symptoms KJicn 
lycma are by no means distinctive as lieiiiL-cn |>us and scrum, and 
cfinttc dia),'nosis can be arrived at mitit nn cvplnntory puncture 



'flHHVHIV" Chart of 31 <.-4i,e of fltitnt-CV<EUmDrtilh folli-twcd by tmpyeuu. mi b.\iit\^jS 
^ fii^EMdC fluJil «in div;ov<r*d 141 (hi: \u1h4tay, pUAnnihc 1^ 



> 4tay, pUA nn ihc clbYcnlh day ; un the 



made. In favour of pus in acuie cnscs would he the nccurrence of 
I a (cqiMil of a zymotic discjisi-, especially in ■■ vic«kly child; in 
\tit^ (he presenile of hectic, diatrhcca, & mIIow carihy complexion, 
tnit' <>f o colletiioik of Huid lit cnnneclion tviih the ihett. .\ tollec- 
nilcnt Auid'may be pre*eni in the chevi ;ind f,\\c very few «i)[nk of 
ce, except the phy>iicjl n^m. Il muti be rememhercci ibai in any 
ise of lluid in ihc chest in n rhJId, that fluid is ptuliubly puv, but not 
y 90. The early hifiotj' of an tmpyema is (icnemlly ibal iif .in 
umonw which doe* not r1e;ir up. anil llic presence of pui in the 
ikcly to l>c itwiufi'lil '" lie coniolidatinci of the liiiiK- espetiiilly as 
r be »«ll-iiurked bronchial breathing;. As an ilbisir.ition of this 
ing COM may be viled. 

' iMte yBBTt wu toniahn^Bnl Ttani K-arli-I (ctvr. On the Ihirtr-cittlKh <lny the 
1 me 10*105*. tbtre vai inirnK |u<ii rercrml to the Irft liilp of the cheit and 




238 



Diseturs of the Respiratory Apparatus 



cpicntiriiTiii.npniilly fpli nlKiitfar (iinii-d in btd.thprevni alw tome vmati RaiM 
At ihc kll ii{)r->. On the ihiid d>iy of ihc utlack ihnv w-u iliniiniilirO monmniml 
u-holr trfliiilc. wilti lironthi.il l>tmihini; : no diiipl.icvnirDI of itic tnmx. On ihciiial 
Ihiit V.I* kligtil ilitplKCFRienl of rlu' hriul Iti Ihv tighl, ihc diiUan* oris iIk Mktkal 
much inoTT morknl. th« bnMh lountli mrr faini and bronclunl. On tht dn^l ^ 
IhcirtCntaf lluiil hod Uicrauad. tbrr bcan'i liu|iulte bcinK fell it Ibr li-(l tnrdirifi 
sirrnum : an Fvplonlor)' punt-tiit« ttmui-il iV {imrncv of pus. On the Ktmiimti 
the «hsl H'U Incited uniiiL'titiaiily. ptu iinil much lymph ootpol. a lul>« nm nioi 
nnil tDHiiilijIP rtciiwry entunl (mv Ii( jy, 



It must alwA]rf t>c home in mind if a crciupnus pncuntonia doe* dM 
Up and ihc dulint-ss disiipprnr. nr if the icin)>r[aliirD rcniils in»lcai 
fatting wlicn the time for a, crisis compi, puK may be prcM:m in the 
In %kk\\ casfs ihc ^i){"K "f consolidation of lunjf ^rc uri^dually npbccd 
those (if tluid, ihr Ulicf ttci'umulaling as the pneumonic conmluldiioo i 
appears. 

Vas m.iy hr present in the cheit, yet nut fice in the pleural caiitf.l 
confined by .-i<lhci.ion between the lunijaiid chest nail or (llaphmgni. 
ihan one loiraliscd eintiyema may Ite present on the ume or opposite 
Such locnitied coll<^ctiiins ui4y be p[i-»eiit iii ^ny |uirt. iis .it thcapm in 
the base behind. »r in front b«lwL-eii ibe pvnrardiuin and .-intermr edte 
ihclcfl lung, orbetneen the luii^ and itK' diapliniK'"- These imall cinpjrcfl 
»rc often Muici.Med with brum ch» pneumonitis and dironic lulienvloni 
the lung. It is petfrnly obvious tliHt if ihvue cullectioiu of fluid .nr 
large and Jire sunounded by and burked up by crepitant lung, di 
will be by no meant CJisy, ftUi) il is not surprising that such should be 
on the fiosl-merUm tabic, havinji esraped disrotery during lift:. In 
case- the physical signs arc i»m distinctive ; there "ill motily be a ptfi 
of duUnt-M, wiiti moic or less resist-incc, bin an adherent lunj( vith die 
filiroid tissue btlwccn it and the rhisi i^all vilt ^viv a siiniUr note. 11 
hc«aih »ound> art^ ucak. perli.'»ps bronrhi;«l. When in doubt it w niie 
exploit not using loo fine a iicedle, .is if ihc bore is lou snudl it U j|M 
become blotked « ith a iiake of lymph i>r puv If the l.iyer iif pus is not thii 
the needle may pjss through the pus into lung beyond. 

/>Atjr«flr/).--Thc distinciion bctueen the consolidation of pneumonia 
pleuritic elTuMon in typical rwcs is made readily enough. The uimi 
bronrhinl breathing, with iheclenr, rinuing tSles and im^taired rcsaiunct 
pneumonic consolidation, form .1 m.itked ronlratt 10 ihc weak, dikiani brca 
sounds. » ooden dullness and displ;iccd he;in distinctive of a larjic cffuw 
ofduid. In many cases, houever, no diagnosis is possible vnlhnui an 
pinralory puncture, and even then ;i iieKnlive resuli docs not detinitcly »«l 
the niitttcr. as it is 'juile possible to mis* ihc fluid, A pneumonic lui 
cot-ercd u'iih a thick layer of lymph, ox a. sudden lung covered niih libn 
tixMicand adher«ii to rhc che»t wall, gives a wooden dullness and resisua 
cknely resembling il>at of fluid. On the other h^nd, ivheo rtuid is pnst 
the bronchv.il brwihing is sometimes loud and eicn intense. A good 
to Ibllow is, vhencvct there us a patch uf ilullncsf tliat doe> nni clear U 
especially where there is a hectic or clc^;lled temperature, always 10 Mph) 
by means of a hubcutnncous siringe. The diagnosis between a local ' 
ninull collection of fluid at a bii>e and chiunic pneumonia, cisvous pnetnaoil 



EmfyeuM 



i%9- 



landnbetoilar consolidmion, i»t>ncn Ctrfrmn miy, und indeed it iicnrrati)' 
■Btmsi'bk uithuiit oiplontiun. There maj' lie (Jullncia iiml ii hctiic lem- 
jnalurc, morroi-ei there may lie a iiaicli of impuiretl resoniintc in the a\ilb 
bMc the 3.\)c\ and hawr are reinnani, or both aidei may be atfecicd. 
B In one of D>ir cma there <idt> iiiien:>e bronchia lire.itfainti and incrciMd 
Ilwcal rtMuate uter (he uhole of the rtght luiijj. except at ilic Im>c ; it ua* 
Bwydull all aver. We removed 7 01. of pus and niure Ur^iliied away nfier- 
l-nnb. 

I M^rUii AtH>ttnny.-~\\ is not often thai nil cipportunily oi^am of e\amin- 

Ita; ihc (hesi «f a lIiiM ilut has dicdof uncumplicjiicd pleurisj orempycmn,. 

Iwufhii » conimoci ert<nij;h to lintl boili in a«;iM:i;iiioii uiih (meiimoniu (ir 

libtenutMb The pleurisy liitTcri much in dc^'iec, ftoni a dimply niujchened 

I'MifuT Id a layet of thick iymph; (he adhesions tstiich rttull frain the 

I Kfiniiinf; of the lymph aUo variin^ giiaily ill iiiii^hnc->9 and thickncu. 

IStftrai in varying amount, |x.'rhufis in greater quantity than »a* iii^iiecicd 

lidinn; life, may be found in a&MKiaiioii with piu-iiinoiiia. r«|)ecially in i-uch 

llfecius as ncphritii, se)Hit;:eiiii.t. and smrtcl fet cr. The King correspond inK 

I Id Uit |N>&iti<m ai llie rtuid is <.oll.ip<ied and ;tirk-ss. Tlie i-esul( of a pasl 

fituitr, e>pe<ially when this \\as been rlironit, is Mimciimes seen al ihe/fM/- 

wnlrn in tlie shape of thick fibroid iidhcsinns which cnnipleiety Mirnmnil 

tad miiltraie il>c luii),'. The Utter is I'oniplctcly adherent, aiile», in n 

n«£tnanfciTrtiosi<i, traversed b)' bands of hbroid tissue, and occnpying a 

ptMnn M (he poster ior aspect of the (tiest in omtnct »iih the spine. In 

nki lascs there may be found adhesions conncriin^' both lunK^ with the 

4m( uall and diaphragm, and on cutting tliroii;.'h the liintis ihey appear lo 

.beiiiklk-d ntth catiiies which are in reality dilated bronchial lubes. The 

felltKnnbetueenenipyeniasand tubenulosis it inicreMing and imporiani. I( 

Hi Wicked b>' sometiial tbcsubjcilsnf chronir empyein.it are .ipt to become 

ubtmUr : in mhcr words patients who lUtTer from a rhronic cnip)enin are 

Bfttif todte of phthisis. We do noi ihinL, .11 ica»i a\ far as our experience 

UBM. that (here is any fxal-morifm evidence to support ihi<>. That chroiiie 

neoinKinta may terminate in ttibeiculoiit by the mediastinal glands lietominK 

■■awnut is an almost c^ cry-day eipericnce:, liul ihi* certainly (ine« not apply 

ill>tni|iyem.i. Itailon and I'arker, however, i^tate lh.1t they have met with 

■OWMihcFe ihey Ijeliciedalubeitnliisis was secoiidaiy toa dirdiiircmpyema.' 

BUaiiicd collcclioni of pu> may sointliiiKi be found in crmnettion uilh 

Bhanir lubcrculimi, but in these case? the pus is apparently secondary loihe 

Mfcercular priK'css. 

P Suppara(»e or simple pericarditis may take plaec l>y exlentinn of the 
iintamnuiion Umn the pleura- 

T'/'ilmral. — In the early stages of dry pleurisy where the pain is severe 

■ M is netesianly plated 111 tied, small doses of an anodyne being given 

.ipplioitions applied [o the chc«t. hmatl doses of opiate* relieve (he 

■ il. such as Dover's powder or jSi - 1*1 giain of morphia iii>en siib- 

'luily ; tile latter may be administered to itiildren over four yeai^, but 

I iaf.tnis. Hoi poidiices may be used with less fear than m pneumonia 

' niuili lung is involved. .Strapping the chest on die alTceted side uiih 

> of Itellodonn:! plaster is often wry useful. 

< Di. lluuon hat alwMcn sucheaio. 




540 



Pisfiises of t/tt fifsju'titlorv A/>pamtMS 



The nitriiral course nfii dry pleurisy n low&rcU rcoovcr^, lltr inflwnm.v 
tor>' rondi(i<>n of ihe plcurn luIwidinE, the lymph elTuicil being orvanitd, 
:tn(I the lung becoming adhcrcni la ihr chc^i u'all. 'Xhc mlltcuDni (nii> 
fiitmcd differ vsry much in ihcir RrmncKK and strength, lite Ini^ btrng 
prrhaps pnly Icwwely aitnchcd to ihc parictn, »o ihai its moi-cnientiaieCmlj 
'hiiglilly if nl nil imiwiicd, or lirnily atl.ictied by ihick leather)' ndhaiui. 
^0 thai it c.innoi lie turn away wiihouc damage. In ihc lAiier laM- thr ad- 
hesions arc extensive, the movements of ihc lung arc impaired, it nevn 
properly empties iisctf of ;iir, and it is in c<in*e<|uencc alwuys taoft or fc« 
in a conjiesicd oricdcmatou* condition, and pntsibly becomes Infihnitorf villi 
tibroid lisMie while the broncbial tubes becnnic dtUted. Snch citoct m 
probnbly ibe result of chronic nr subacute pleurisy ; ilic che*t muyaboon- 
tratt and fall in. When an t-ffusion of fluid has occurred, in the vmI 
ni.ijnriiy of CAtcs reab»orpiicin inkci pinrp after the inflammatory coBdiwin 
nf ih<.' pleura hot «ub^ide(l, ;in<l the tension of blood in ihr V4-s«chha)btoinu 
reduced lo nnrnial. I.ife.hoivwci, may hethre.itened from the cuces^of (laid 
ihmwn out ; untler ihcie citcuiiistancti nearly ihc nbole of ihe blood in tht 
bndy is passing thniu),'h tile lounif lung : il ii consequently inlCRsrly CM' 
gcilcd, and may become u;demaIou«. .Moreover, llic right side of the bisn 
it over- distended, and a-i a consequence sudden dciith n api in cnfue. fn 
this re.ison no lime should he lost, if the dj-spmca and diiiii-ss become j:n«i. 
in relieving ihc chesi by the Hithdraval of nome of thr cfl'iised litiiiL Onib 
oiher hand, ihe mere presence of fluid in the chesi, if ihcre ■.trv no Mp» rf 
dUiress, docsnoi necessitate openiiive interference, as in ihegmi mafMil} 
of rascK absorption lakes place in the euuneof afewdaysoranrck. Opa)" 
live inlcrference, ihercfore, is allied for in ali cases where there » dyifM* 
nr orrhopniva when lying quietly in bed, or ivhere there is ir>uch disptMCDinl 
nf the hearl. In those chronic cases where the fluid is not nbforljedorittO 
diminishing in quamity after ibe l.ipse of a few u-ccks, the »eium may br 
remined from the chest by means either <>f the aspirator or by trour (nJ 
runul.i, the small ones introduced by Ur. Southey for the removal nf dc 
Huid in atcilcs answering t*ery well. Whatever method is selected, (hcAoll 
thould be remo^-ed slowly, and ibcie is no necessity to remnve all tlut nut 
he aspirated. I'oo rupici aspiration of the rtuid is apt to lead to blNdiniC 
inin ibc chest from rupture of some of the cupitlary vessels, and may pouMy 
cause emphysema of the lung on account of one part of the lung cxpandiniC 
fiislerihan the other. On the whole, we believe llic bcsl results are obtancci 
by ibc u>e of Smillicy's Irucar and ciinula. One of these may l>e inlrodun<ft 
H'iihout difficulty and wiiliout p:iin if local unafMhesia be produced, a p<c<rn^ 
fine india-rubber lube allitchcd, and the <1uid allowed slowly to drain away' 
fiir a cxnjple of hours or so, lo ii> ao c«s, being chut withdrawn ; if wct j - " 
uiy two canul^e can l>e inserted. In those ciues where the dyspme^ 
is extreme, relief is more tpiitkly obtained l>y aspiration. It may not im-^ 
probably happen [luit the pleural cavity in part tills up again and a Mtnottf 
or;i third rcniov.d be tctioired. In the loss acute crises, where il>cre it « 
urgency and no tcniov.il is 4Iteni]ilcd, the child should )ic confined to brd li 
a Harm room and larefuPy protected from cold. It may b« dnuttted tSmf^ 
dnig tnatcri.illy .lids the re^bsorpiion of tbe elTused fluid, llMKigh the uhbI 
ircitimeni in such ca^ei - ixnniely, giving iodide of potassium inicmally aiul 



^ttntment of Pleurisy end Empyema 



241 



HninKDl of ioriitic niWril u'ith an cqunl ([u.intiiy of ulj'ccrinc cuter- 

illy— .ippiMrs In he ix^rful. Tin; liii. iodi by ilsclf rcqiiines using with care, 

)lly in jmunj! or wwkly childtCTi- 

luiiiral course of an cfujiicma differs fmm lh«t of a simple' serous 

Siision. In a minonij- of cases, csF«'tinKy where ihc empyema is souU 

111 cnnlincd by adhesions, it miy dry ufK^nd ilie inspissated pus in time 

eiirnc cniaceous. fliii this cveni cnn h.inlly lip expected, .ind slimilO it 

kc pUcr, rspccully if the empyem.T be n larifc one, ihc re';ill,.irci>ni|Mmcd 

1 It ii by relnKlion of the chest nnd coinpirt^ion of ihe Kihk, is anything 

III «ftli».fartor)'. The pinscnce of piis in iIir rhesi is inroiisisicnt »ilb ^wxl 

llBlltb. 10 say nolhinj; of ihc risks the puienis nmof ilsbutrowinj; in various 

^Utectioni. The child nith n rhronir undrainrrt rmpypina probably sntTcrs 

Hbm bc<:li>' lever, is an;i-niic nnd sallow, the skin becomes tDiich, the fingers 

^mibbeil, and the chilli «in.icialet. Varirm* olhrr results tnay fotlou- ; the 

pus mny find its uay thrniiKh ihc intcrcoslals -ind point in the fourth or 

th «p<tire. it may then jcradiially undermine the skin and n chronic 

charye talfc place. It in;iy open thrtnijfh the lung into a bronchial inbc 

be tfnulually couched up ; in ihi« Kay recovery may c^enluntly take 

ICC, thouith the proccTSs is a slow one : or an ahsrcss or al>sccs5cs miiy 

in the luni£. An empyema on the riKhl side may, eilhcr by ron- 

rii^uiiy ot bv opening iliroui,'h the diaphra^'ni, give ris; to an ahsrcss in the 

Iher. It may open into the abdomen by Ending its way ihrmigh ihc diaphragm, 

and set up pcriioniii'. The pus may biirrou- any distance, opening through 

the abdominal uall^ or simnlaiing a lumbar abscess. 

Direi'ily a diagnosis of put in the chest is made, arrangements should be 

^ftnde to evacuate it, and this in the vast majority of cases should be by free 

^■Kiiion and drainage. Atpiralion may be tried once or twice in Inral 

BtBipjvmnta, especially in infants and imatl children, but il is iinly in ihe 

Hninorily of c.iscs that il wilt succeed, as ihc cavity usually filU up again 

ml separales the pnrls whiih »houkl be kept In contact if a cure it in reinll. 

Tlie surgical trealmcnl of luppuialion within the pleural caiiiy \% Imscd 

"» t^W ordinarj' |>rincipleii guiding us in the manai;emenl of absccs&t-s else- 

»h»f^ Hence, although il occasionally happens ihiit pleural abscesses dry 

<9iad do not discharge at all, or diiclijirge throoth tht Iimj; or cisewhcra 

"ulttcn held, none of thei* possibililies should be looked fot.and the ire*i- 

■ww practically resolves ilielf inio dipping and free incision, 

1^ f^ing an empyema with a simptc ii-oc-ir and allowing the fluid to drain 

Bf**rUin)sigh a tul>e into an antiseptic lotion is a mode oftrcaimeni that 

" '•Wccessful in certain cases, bui it open to ^cs'eral objections. The cases 

ftn' *\n(\\ Il IS luitahle arc ihoie where the empyema is recent, of small site, 

(oiCinii no tna»^s of liinph or caseous iti.tterial, and uherc ihc lung is not 

MOBdikiint by firm adhesions but is ready in expand on icmovalofthccnm- 

fntninj fluiil; further, it is imporlant for the succesiful cmploytnent of Ibis 

I'miIui (lie pu4 be contained in one cavity only and nut be locul.ilcd. The 

"^tn of tapping are the ri%k of wounding the lung by ihriisling the ttocur 

'"•btinwardi on the one hand, attd on the other the possibility of pushing 

"* 'livkcnesl pkuni or a layer of l)-mph before tfi* troiar so thai the 

"mttii i.»vity is not opened. Theec is also ihe likelihond of ihe canuU 

'"^unmf blocked "ith ly-n^ph or cflscous inalertnl, and of incomplete 

K 




342 



Diseases of the Respiratoiy Appuratns 



enipt^ni; oX llic civily bvcBUte il is lociUutcd or liecause the Iun>; catUKii 
re-espand. 

Aspiration is open to tlw same objections, with ilw ad<lit((>nal one ilwl tf 
too poivcrfiil ^ticiioi) \> employed there l» likely to be blccdifiK f'om the 
surface of the lun^' nr the pleura, and (he cAviiy may become pjini^lly filM 
with dot which reAdily Jectimposes. 

The diUficuliy ofeiiiptyin^ the cavity when the lung cannot reexpxnd b>« 
been ntct b)' Mr. K. \V. I'arkcr by the plan of injecting n<iC]Mtc aii into the 
pleura to replace the pus as \\ Aows nu'ay, or lotions may be used with the 
SMine object : but the plun has ncii mct.And is noi likely to mcei, with iccfkcial 
appi'oxal. Atpiratinn, then, should be employed for siiull, Mngle, recent «n- 
pyeinala.and in «aine few of such cases aficronc or two tapplntt* the pus will 
cease to be secreted. Should there be chronic disease nf the lunif. ca«cotu 
mnierial. (flandular or other, or disease nfthc nbs i>r spine, tince the source of 
irritation remains, pus fomiaticin will go on and R»pimlioiv cannot be Mifneient 
Failing;, (hen, tapping or aspiration, the rctiutininji; retourcc is free incision 
and drainage orthe.ilisccss, Thei;eneral plan ofopcrationtnay be described 
first. And ceitain special points alluded lo afteiwards. 

The incision should be an inch or more in length, and should be: ina<)c 
along tbe lower margin of the space selected, so as to avoid injury to il>e 
intercostal vessel*. The tissues should be gradually cut thTou>;h until ib« 
pleura is rwirhed, all hlceding being arrested before the pleura is ope«i«t. 
If the membrane is not much thickened, a sharp director m.iy be thrust 
through it and used as n guide for the knife : if. however, it is very tough 
and thick, as may be ihc case if the dise^-ise isof long standing, it is better to 
incite il at once with llic knife. As soon as the cavity is reached a pair of 
dressing or »>nu« forceps should be passed in, opened, and the pus alloirrd 
to escape frcel>-. The drainage tube is then to be inserted and secured by a 
thread round the chest unless a special mbc is employed. I'ouibly the 
dreuings will be soaked and require changini; in a few hMirs ; if, howeivr, 
the cavity it fairly emptied and thick wood-wool pads are employed, this U 
not likely to he the case. 

The special points tfl be ronndered arc the position of the incision, the 
dmin.i);c tube, the management of adhesion*, and the washing out of the cbesi. 

Kirit, then, the poiiiion of ihe inciaion. Wlictc (be tmii\'ema is local the 
incision muai of coumc be made a\et ii, and llic lonest convenient »p<« for 
drainage should be chosen. Where the nliolc pleumi ca»*iiy i* Ailed with 
po» a difference of opinion exists ai lo the moii iuilalile spot for the openiii)t. 
Mr. Maiahall .idvoc-jicd an incision in tbe front of the chest, others prefer 
the axillj. We think, bo«eicr. on itic uhcilc, Ibe best place is just behind 
and below ilie angle of the scapula m the eighth intcr»|Kkcc : this >pot 
affords gni>d drainage uben the patient lies on bis back or side, it is not 
quite so convenient for dressing, but it is nearly at the lon-esi point of tbe 
cavity, yet not so low as to risk injury to the diapiita}^, wht<:h is liable to be 
I drawn lip to lake the place of the shr\inken lung/ Unless the incision is 
made ton far back there It no great thickness of muscle to ctit thruugh. 

■ Tlip ohiciilHii thill in cniprenut usually IimIs up at the bMk linl. and that (IteK^H 

a cavar •« liknly \a rpmnin iinclaied In front, has not ta our experience pr»i>e(l • '"^H 

, Ol;)oelioa lo lb: |«Mi«Tiw inclMiidi. ^H 



A* to drnina);!!, tliouh'li in some c;uci wlicre ihc clicsl is very full of 
riuid the inleico»lal ipocca may be »-id«icd and Inil^'in^, yet inucli more oRcn 
lhi»bnol »<>,and the ribs are »o close loKciher iliai it \% difficult to ijel 
a lube into ibc che>i. and trhcn imciied li it liable lo be nipped by procure 
of the rilw. In iuch caseii the rib* ihouUi he priscrf iii>an with cJreising 
forcep(,ai)d a nj;id tube, xuch a* n silver or viiknnite imchcoiomy tube, 
«inpl(i>'ed, or a piece of rib ihould be e^id^ed, whirh is ft far heilcr plan. 
Tile lube should mw project far into ihe pleural caiity, but only jusi enough 
lo be dear of the thickened pleur.i, otherwiic it will f^il lo drain the cni'iiy, 
and may be blocked by prcMure a);^'">t ihe lun^-. A doiil>1c iiibe, or two 
pieces of tubing fixed to^'tiher side by side rilattiun^), arc preferred by »ome 
suTKCons ; the plan is useful if it is imended lo nash out the cbcsi, but in nuny 
[ i:bscs it is open to the objection ^wnn above. 

Alter opening the chnt a linger should be passed in if possible to 

f u!M:«rUm live -ntv of ihe caviiy and to bre:ik don-n any adhesion* i^huiiinj; in 

' localised collci-tions of pus,' ai uell as lo remove any masses of lymph or 

solid maleriat in the caviiy. If the pus u foul or thick and flaky,.as Un^e a 

lube OS pui<>iblc sliould be put in, and all solid and offensive mailer c';4rc- 

fully removed after resection of a portion o\ a rib. Should any blccdini; 

, occiu frotn the intcnrusial vessels, ihey may be picked up or secured by 

. catf-ui 1i},Mture passed round the rib including; the vessel ; this is easily done 

I M-tlh an aneurism needle. Ulceditig fram the ^ranulaiin}; surface of Ihe pleura 

Rafter exploration soon ceases fA itself, but all tlois should be washed out. 

Utinnt; the operation careful watch must be kept by the anKSlheiist that 

[ihe child dix-s not sufl^r from having' lo lie upon The ^ound side, and at any 

&ii;n of failing pulie or respiration ihe child must be turned upon its back or 

tiitrards tti« AiTctrted side. 'Hie nflcr^lreAtitient (if empyema consists in 

, keeping titc cavity aseptio and »e1l dtaiiied : ubMcutlion of (he tube is most 

likely to be due tu ibkev uf lymph in lo slipping of the tube if a rigid one is 

used, to nipping of the utbe by the ribs if rubber i« employed. As regards 

l-<iiashin>; out the chcM It must be rcmcmbeied that there is sv ccitain amount 

|f>f (langci in it : cates of sudden dcnth during the process have several times 

rn recorded, possibly fiom iriii.iiion of cardiac ne^^'es in the wall of the 

(«ity, or fcom sudden dy«pna-a : Ibis risk should dcicr us from washing 

jt an empyema unless the discharge conlinues to be foul, and il should 

<l to ratltion and (he avoidance of any dislensinn of (he caviiy or the use 

' irritanl lotions even in such cases. In free iniisinn of I he chest the npeninjc 

. of course iarj;e enough to admit ;iir readily, hence there is no obstacle to 

nplete emptying "f the cavity. The tube should noi be left out until the 

ischarife has nearly or quite ceased, and exploialion with :i probe has shown 

hnl live caiity is tilled up ; often, though (here is but hide discharge, a good- 

nied cavil)' or a long sinus remains, and if the external wound is allowed to 

close, fresh collections of pus will take place, In a tettain number of cases 

empyema will be poinlmji externally when the case is first seen ; such 

■inting most commonly occurs in the front of the chest from ihc second lo ihc 

fifth space, the matter soniciimcs pushing foiward and pointing through the 

tnuna. If the skin is already thinned the pus should be let oul at this spoi 

^nd the case managed as usual ; if, however, the cavity docs noi drain freely, :l 

* Dr, Fiicgc siatci tluU IocuIhUoq u very rarely found fait lerttm. 



Diseases of ihc Respiratory Apparatus 

long probe sboutd be pa»ecl ilirouxb iht anicricr oritict, anil cm <!"»rn u|ioct sU 
a more dependent »j>oi, and a drainaKf lubi? incited lliere. While admitiin v 
that ihe «ucc«i^ful 1)1.1 lugi^ini-nt of empyema \% not simply a qucUMin 'oC 
draina),'c as in oilier iib«c«»c&, wc ihinic a dependent openini; is a higt«.'\| 
imporiani nuitcr. A free ouilet is absniuiely csscnt'Hl. 

Sonielimcs (he pr«->siirc of the drainage tube causes uker4tcon of one (i1 
tlie ribs : iliis is, however, a mailer of liiilc impnrtance, uDce llw rib mm. 'MI;J 
recovers aficr removal of the itibe. 

In a ceitain praimriinn of cases after drninngeof the empyenu the (Xf 
['doett not become obliiei^tied, Imi remains as a pus'serroiin^ sac ; this is <■ 

either to impcriiM.'i cx|ianuon 
ihc lun^' or insufficient romp^^n' 
satoiy falling in of the rhcM vt^^eUI, 
Under stich conditions lite i^Kis- 
chaige mayti'o onimlclinitrlyi^ nd 
raiisc UrcUccous ctiM-;ise m mil 
hectic fever ; i: i* then nercss**/)- 
to find other means of alton-if^' 
ihc surfdccs of tlic tib^Tss s»c W 
come to^ieihcr. Foi this iwrjid* 
Tcsectiuii uf one of n>ofc ribi 
(E&ibindcr's o^ieniiion ') lias been 
devised. Alihough in childmii 
from the softness and flctibili'y 
of the libs and spine, the chell 
^■encrully falls in readily, thi« i* 
by no means always ibe casie, aad 
llie operation shouki be dose M 
soon as it is clear iliai (M^rei* 
is not being made or tl:e chikfs 
health is failing. Where tlicre \s 
an insufficient opening ftir draia- 
sge, it is nlsii necessnr>' in aooie 
cases to provide a larger onlice 
by removal of (Hirl nfa rib ; and. 
indeed, it it a good practice in 
excise a poitlon of rib in all rasn 
where the child is not so feeble a« 




Fie. M-— DotoiDiiiv of Chm due lo f mpy^mn, 



to niakeeven tliii slight addition to Ihc severity of ihc nperaiioa iindesimble. 

The operation is a simple one ; lo remove a sinjtlc rib, the lowest one in ihe 

cavity should be chosen, usually the tevenih or ciKhih. An incision is made 

along it down In the bone, the pcrioMciim is readily peeled back mith a 

raspatory, and alioiii an inch or more of the tib Ik cui otitniih boneforcep«: 

^bc perioMcum and pleuni arc then inriied parallel with and avotdinj! llw 

Hnicrcostal vc«»cl» : if the ancry it wounded, however, il is easily tccurad 

[.tuiin that the rib it %fixvt. When the rejection i* done to allow coltapse of 

ibe chrjt wall, fr-im two to five libs may have to be icsccied, tnn or lh«« 

< I'jtlindef'* opnBiioii u Kiictl) Ihc removal of a wflici«nt pan of tbc cben Kail lo 
r of oomplcte ooIUpte. 



245 

bi>n« litins ukcn frum cich ; in tuc:h cntc a ((niidnbtcral Anp o{ 
llic solt pjrti ihould be turned foru;ird and ihc ribs Tcmiitc'l one .ificc liic 
uibcr. ThaU);b ii in ;>erh;ip* bciicr in Midi c-iset in icmovc the bone* 
uibjwniMtejIly, the [iciiostciim iliould be cut away before closing ihcwouixl, 

tothrmjsc ii often luppeni tliat ovjjiicaiion r.ipidly lake» place and filli^ up 
Ibc nap in ihc cl)c« wall and so picvcuis the desired collapse. We have 
^'mciimei fwjnd the iaictcoMal vrucU obliterated in tbe^o crises, and ihcre 
k>9 been nn attctul Wcpdinji at all, Marshall has divided the cosul 
cariiLiii'o subcutanc«i.isly with the same ohjeef, but icteeiion is the more 
coniplf^te i>|)er.>iiiin, and it Round* and looks more ("imidable than it it, 
Tlic >utHe<|iicni mnitai^cmcnt of the »otind require no description. Unless 
anemp>i:ma ipctdily icca% ere. more or less retraction of the side necessarily 
Ktc^uIi^ And from this a latcr.il or raibcr, as Lane hai pointed out, .1 true 
^V mtato-UtenkI rurtaturc of the spine follows : this of course ix Inrjiccty 
tttrmediablc, but lome imprm'cmcnt maybe nbtnincd by ircaimcni {vii/e 
L*TEKAI. CUkVATUUI^;. (I'iii. 34.) 

toaunuch Its the ribs arc le«s yicldinj^ ncnr the ani^let, it is belter to 

novc (he bone .is for back as possible up to the edge of the crcnor spin.T. 

f We have tried otteotoiny of the rib at the posterior pnrt at llic same time at 

[ rctcctiofl to allow more complete falling in of ihc cbesi wall, but found little 

vji to l>c gained by this means, since ibr lib is held firmly in place by the 

I aurrounding taft parts. 

Spaunodic aiiihnia is by no means uncommon amon^ children. Ilronchial 

hpasin i* someiiniti secondary to dcnlition ; a child nlien cutting a tooib 

Jbcgins to nbccie, specially louarils eieninj;, and on placing' ihe ear 10 ilic 

t'thcst »ibilus may bi^ heard. A condiiiou of a-ithiii4 or ut^enl dyspucca is 

Srcquenity present in tlie ur.i-mia of sc.-irlatin;ii nephritu and in llic rare 

nf cuniractcd kidnc-y nbich occur in children ; it may be open to 

floubt if in such cases the origin is doi cardiac, ratlicr [ban due to any bntit- 

lbi;il ^pasni. Hysterical cbildicn sometimes have attacks resembling asthma. 

The cvmnvonesi form, however, i> bronchial or spasmodic astlima, lesenibliiig 

MSlhina of adulli ; iheM children are CKCeedingly babtc 10 bronchial 

siarrh. In most of these case* this disease is hercdiUiry, and may begin 

Rs early as two year* of age. 'Die attack begins with the sjuiptums of a 

>ld m the head or a bronchial cjiiarrh lasting for a few bour^ or days, then 

kfi attack ord>-spn(tu occurs, perhaps at nighl-lime ; the child siisup in bed 

'ttnd li^'bts for his brcaili, the breathing is <juick, ihc ahc nasi work, Ihc lips 

lire blur ; tlic attack laMs TrDin a few minuies 10 an hour or two. and is 

L^illowed by freer secretion and relief, fiome attacks are associated not 

kitti htoni'hial eatarrh but with dyspepsia, and have been termed asihiii.'i 

(lyspepticiim l>y Henoch, the child having an asthmatic attack when sutTcnng 

from dyspepsia or after taking improper food. Instances have occurred in 

which cnlarijiMl tonsils and posi-nasal adenoids have appeared to have had 

ji h^nd in producing such attacks. The treatment must be directed to 

prcveni children fiom taking c"l<l or becoming dysjieplic. Some high, 

^bnKinx, dry. inUnd site ittually suits such children belter than the seaside. 

he cuM wii>ds of sprang are especially liable to excite an aiia<-l:. A house 



• 





uiiiforrnly warmrd ih rough oui, «<> ihni the child, wliu ii tieccuarily mnfinc 
mu<'h li> ibc hiiuse, can wander from one room it> awotlicr uiihoui thr iw 
of crold, i« n great .-idmniage. An atiack tnay usually be ictieved by \\ 
bumiiiK of niirnte of pniash pnpen. and by lobelia. ArMCic is tlie \k 
remedy, with cod liver oil between the ailacki. Iodide ol' potasMuni ifi alt 
very u.icful. The boii-eU reijuire aliention : Carlsbad sjli^ or M)titc oiln 
saline aperient being uieful for ibii purpose. Eiilar};ed loniils and poi 
nasal adenoids sh(iul<l be removeiL 



91s««aM of tba SroBelil»l ObtB4* 

The trachea- bronchial jjlands are situated in the middle ntediasiinuni 
close relationxhip uiih the Itachea and bronchi ; they are Hocni; ten 
twelve in number, and ate arranxcd in three ^oti)is ; one set aarroundi I 
triichea, another }:rc)iip is liliuied at the hirutration, and a third around I 
ri(;ht and left bronc:hi. 1*hc pulmonary glands arc situated at tlie root 
the long and accompany ihe bronchi into the substance i>f tlft tunt;. 'I'l'-' 
glands receive the lymphatics ai ihc limgs and bronchi, and like uih 
Ij'mphatic xiands readily bcconic inHamcd and su'nllcn during aitat:ki> O' 
bronchitis and broncho- pneumonia, especially after measles and vboupini.' 
cough, and arc apt to remain chronically enlarged and further to becoiitc^ 
eaaasna and lo •uppatatcL During; ihi^ inttammntory process more ot 
less thiclteninE and matting often lakes place in surrounding parts, so lliJi 
the glands may become adhcicni to the trachea or bronchi or a-sopha£Ut> 
The glands and conneciive tissue in the anterior and posterior media-iiinum 
may also bcrome affecKd, so thai ihc antcin-inicmal edges of the Iting* 
and the whole conirnis of the mediaiiinum may become ihicVencd and 
matted logrihcr. 

C'a«e.iiii>n of the mcdiaslinAl glands is CKCCcdingly common in children, 
and they may be found in litis condition in the bodies of children dying of 
various diseases, but they ate almost imivei§nlly cascou* in those dying rf 
pulmonary lubcrrulosift or chronic catanbal pneumi>nia. In many caiei 
of acute or chronic lubcrculoftis it is I'lear that the disease in ilie glands ii 
older than the tubercle in the hmgs, and has spread fiom the former to the 
latter. In such cases iltc glands have tierome enlarged secondarily to some 
bronchitis or pneumonia, have undergone caseaiion,nnd ihe lungs have been 
infbclcd in consequence of caseaiing bronrb'al or piihnon.ir)' glands, the 
tubcFCtjlar disease spreading into ihc tungs from the root. 

Symf^omt. — In ihc large majority of cases iliere are no diMinctive 
symptoms of caseating mediastinal glands and ptr it iliey are not more 
likely to give rise to symploms than caM^aiing glands in the neck -. I>ul. inas- 
much ns ihcy arc so frequently associated wlili early or clironic tuberculoM 
of ihe lungf, the subjerls of them are hardly likely to present the api>raratKCft 
of health. Occasionally, however, ihey arc found unexpectedly in the bodies 
of children dying of olhcr diseases. With regard to pliysic;il signs, it tnusi 
be clear from a ronsideraiion of the anatomy of the mediastinum that tbo 
gtands lie too deeply to be delected by percussion unless they are ei>i>rmc»u»l)' 
enlarged; this may take plai:e in sarcomaiousenlaigcn>cnt,but rarely in tu))er> 
cnlosis. It hai been asserted that when enlaiged clicy can be delected by A 



/ 




»>nan<re in the mtcnc^ipular rc^nn, coirei.p(irt(tin); to ihr lirM 
(vcttebrj: jlnit, inannuchaiillK ihickpoiicrHir cds*'>'>'^'f>clun){t, 
[ lKJ&* Ac aorta, (ciopUagu*, und u iiium uT inuM:!c, inten-cne bclwcen ihc 
' (bMJtiiMi ihe surficc. ii ii ecTtam lh:it the enlargemctit mmt be very eon- 
tiiOiUe 10 modify ihc pcrtuiiiun noiu in tliii poiiiion. Enbr^-ed giiin<U arc 
swBxIt In Riodify th« teumnnce lichind ihc upper pciri nf ihc jiemum 
iBdad}imii carrilngct. bui in inriinii and yuunu thildr«n the nnterim inc<li> 
HwaiisKcapKd by the ibymns, which would m.-ttkanyenLnigcnirnt nfibe 
)|n|taiicgla]KU ; and in older chiklren, where the ihyniut ii sm.ill. Irmphntic 






if^ 



/ 



i n- Smtaa Ihrautk ■ Urv- 

y ™ ^ llHtt'tH braiKlli irT 



rtYptrcih \ ' 



YwuL^r rlic H^fiib Arc bcginnmc t<> -hnw UKUh 



twill ami bt very much enlarged lo come to the surface and give ri»e to 
*■)■ iMlneit, cm prcd as ihey arc by Ihe anterior e<igcs of t!ic lunj;^ Error 
•■jwuilyariie from a dultni-ss due to a p;isl pleurisy ;iBd toiisequcnl adhe- 
•""•iooK thcanicrior cdgr* of thr. liings. If ihc rcMilli of per>;ussion arc 
^JttUin, UiOM ilctivcd from ainciiUalinn are nec^esiarily more *i>, except m 
»b4e enUrjjcmcm of glands. Of ihc pressure sign*, the most reliable j 
ak l»enlhii))( in one of ihc Iim^s in consequence of pmsurc on the right 
I biancbix ; this sign is of undoublcd i-aliie, but a* there is usually some 
■ l»ion in ihe lungs, this symptom may readily be masked. Attacks 
"f pMwytnial dyipmca, «nd cough with striduloui bre-ilhiDg, may also be 



iiseases of 



ttspimtory 



jyreMnt od actounl of the ncncs l>einK iniolvcd. Sn'cliinK of iIk CiCi 
distension of the jiigiilao have alsn Ix-cn dc^cnhed, but lhc(c .nrc for more 
ffcuiicntly (toe lo ronsijint iou(;hii>i,' Ihan to any preuurc on ihc l.iryi- w\ti% 
tTi ilic cimt. A CA6COUS ),-i.ici(l not initc(|iicn(ly bccoinct iidh«(rni lo ilit 
liachc.t or one of ilic litiinchi, and iikerates into it, .ind CAtcmis inattiT may 
he Kou^ieil u|> : in a few instances it \\^% li.ippcned ihal lhi« Liikc* pVice 
suddcnl^' and dcAth restili^ from plujJK'iS ■>'* ^^ windiHpc. In oitwr 
instances the t;)ands rtiay form An .ibs<:ess wlikh point* in nae of i)k' inter- 
cotlal spaces ilose to the ^lernum. as in a rate unilcf ihc race ol Dr. 
KuKincc Smith, or may open ininihefcsoiihaKH*. In nic of our own CMCta 
mpdlB*Uniil «ba«e» pointed nc;)r ihc left cd^c of ihc slcmum, low down. 

Tl)i^ pulinon.iry glands which acfoinpnny the snial! bronchia! ji'^inds inio 
the lunjrs may become rascous soften, and form ravitici, more especially in 
J,be toner lobes, 1l mini be .icknowlcd>^<l tbnl cniicoux Klnnils an rHrrlf 
!din>;no(icd during life with miyihioK like certainty, piirily »n acciiuni of 
iheir lyin^ deeply, and psrlly from the fnei thai they arc ui comnmnly a»0- 
ciatcd niih chronic lunjj dii^eaie. They rarely iiiuin any large linr, And 
conwquendy do not tnodify thepcrcuMrionnoleoiprcM on ibc veins broadu*' 
or ncn'ca. | 

When, hoHTver, ihr lurdiattinid Kl;)rtdt Iwcome the scat of a tww kto«1^ 
such as lymptuntenaBtB, ihi-CAtc indifferent ; they may become enorRHMialjr 
cnlari^ed sutroun<linj; the vi-ini and bronchi, jiiiin^ nva iii marked dnllneu 
over the sternum .md adjoining rib canil^Kei, and pre»ure ii),'0!> rrom ' 
ini*olvin); die vessels Altackii of [inroxyiTnal brciilhini; are coniitKiD mj 
account of prej-surc nn the recurrent la tyn};c-il and other ner^ts. TIm coutMi 
of Ihc diieuse usually extcn<U over a few month* only, the i>alienl Kelli)^ 
ptoxresiivcly worse. Amonj; ihc early symptoms will iimally be ilMnc irf 
disturbed inner^-Jliim. There arcall.-irksof paroxy&malc<iu^'li, uilh a metal- 
lic rini; and sindutous biealhin}; and nrthopncra. vi \\iM the child lus to i 
be |>n>j)]>ed up to j-ct its breath ; in the later ilagcs the dmrcsD ts often i-ery' 
great. The voice i» altered, perhaps reduced to a whi>|>ci. The reium «if j 
blood to the chest may be interfered " iih on aci:ouiit of the 5Ui>erior ^ena- 
caM being compressed. Rivi»K riM- to a distention of the jilt;ular or aulUr/l 
veins and swelling of the fa(« or amis. Kltiid may lie present iri <me or boilt' 
)>)eural cavities frntn ptrssure on the a):y}{oii vrins. If (be tumour is of any; 
wx. there will be dullness aw the sternum or m Ihc adjoining rc^jion, porli- , 
cuLkrty lo (he lefl edge of the stcniuiii m the upper inieroMtal spaces. In-I 
iCDie bronchial breaihm}; may be heard here. Morcoi-cr, tlw lun^ may b« 
imshed to Ilic Itfi by the encroachment of the tumour, which may bul)^ 
font-ard tlie slerniini and ribs. 



Obronlo Tnl>eroiU»BlB nt tbe Kuni* 



* 



Infancy and Early CliHdieoit— So ai.'C is free from liability to be affected i 
with tubercle : thus Uemtne has found tubercular disease of the mieslinc in, 
an iu/ani of iwenty-nine days. i 

Tuberiular disease is not common in infants of a few inoiuhs old ; at 
litis period ^;isiiu-iiiiestinal airophy is exceediot;ly comaion. and is tuible 
to be misiakcii for tubercular disease on account of ibe uasiinK which takes j 




^ttbercittesis of the Ltts^ 249 

uit in yming cliildicn rarely begins as doet the plithisis of 
dilb 111' 4 tiriniih of lubcTck and .1 condcniuiiioii ^it ihc itpiccs or tlii- lungs, 
'aidiindual cxtcntion ilnnnunrds ukinK pUrc. I>ui ii npt lu be far mure 
tdlciymd in iti diMnbuiion Ixiih in ilic luni<» ;ind in ihc bud)-, ll Is thorc- 
(Mtfaimoii; difficult (o di.lKllo^c by mean* of phy ileal iigns which arc li-as 
diuiKtnc than are thou- of .iduliv It ii nccdli^M to &ay tbal ihi- ^amc 
(ivnl appcanncn are fniind in the bodi« of children n* in -idvilii dying of 
tuttinloiit— jjiey lubcrdc, oscou* m.-i»es, iroo.((rey inliliraiion ^nd fibroid 
Wiut • nce^iivpqiinnlily. and irrriiularraviticii. The distiilmtion. howc»*er, 
MwDj iliiTrn., wiw of tW chief diffcrciiKc* bcinj; ihai in adulis the uilicrcolar 
pwewjo Appear to have a special affinity for the apices ; in early cliildhood 
UlcnBMiiKh predilection, ihc hiliis of the lung or bn«e being frtijuenlly 
iftcial bcfitie llw apex. The bronchial >:1amU me almoist coniianily 
IwdtMemit, wiib also ihc snuill piilmoimry K'ands which accompany the 
buvh^ (he bttet supiMiating and fortning snii^ll raviitcs near the root of 
tkla^ In this way a lubcrcatosis may sprejid Into the lungs from the 
liiht Xo< inftrt|ucntty une or lioth bnses are semi-solid froni c-xseaitng 
pmnnnia oith m^-ged caiitiei. at other tunes ^1 sitnilat state of tbingi is 
^"bA 11 ihc apex. In nthcr cases boih lun^s are (lulled with clusters of 
pcyMyefloo- tubercles surrnundin); the lemiinal bipiiclii. Tlieie nidy l>e 
tiAtnIr on the suif^kce of the picurfi. with moie ox li-is pleurisy or smtill 
lm)i}CRias. Tliealidominjil or^jans ace cvceedingly npi lo be affected : 
rnustes ate fte/iuently found in the liver, spleen and kidneys ; cbecsy 
bKtk h'lands and ulceration of the intestines nte veiy cDinmon in cases 
'jtmaliiiherculosis. Tuberelea arc not infie(|ucnily found on the pcri- 
ni icd oiber serous n^cmbtanes as the pleuia and ineninii-ea of the 
tr-ut. Tubeiciilar diseaM.' nf bone may be fissor iatcd with a ^jenetal dls- 
t((tu1)crclc thrOL^jhuul llie body, 
tk dances found/"!/ atcrUm in ynun^ children suffering from chronic 
MiAituic tnbcrtulosij compiircd with ihose found iu the cliroiiic pliihisia 
f»iiln Duy tic summed np as follows : 

I. ttci^cncy with nhich the lungs tin childieni are invaded with lubci- 
"ibri^its from ilie root o( the lung in consetiuence of an infection from 
'^'•■fcHbroneUial glands. 

a rin(unicy with ubicli ihc Ij-mphatic elands of the bixly- become 

3 FiMjuency with uhicli (•ist-nu degenentmn takes place in the lui^ca, 

■ I»r) lubnrtle bein^; less common. 

I ricqurnry with which the liver, spleen, kidneys, mesenteric Klands, 
R'aMttim, and intestines are ilic scat of lulicrciilar changes. 

{■ I'rti;ijeflcy of tulier. ular meningitis nnd of ciscoos iiiheir Ic in iJir brtiin. 

Sj*tl»mi.~\i ^!t\l: diagnosis of phthisis in the early stages is difficult in 
•**•. "hen il is possiWc lo r-fltefully ausi:ult<ite and percuss ihe apices 
■* •^Hunus, examine the spuin for Iwcilli, and ctoss-qucsiinn the patient 
"■wnrfai; 'I** '•) mp'orni presented, it is necessarily miirh more difficult in 
latRduiH yount; rhild, vibcrc the symptoms are rnicly definite and where 
w kiiobt iiii; ,0 Kidcly fpiGAd ihtoijjihout ihe body. The younjicr the 
"•"^W the m<)tc likely are the symptoms to be nantmg m distinctiveness 
'td iht dia^oiKit 10 be ccjr.sequcnily difficult, frequently nasiing .ind a 




Di'iMtes of lilt Respirm^ 

fatniljr liisloiy of luhcrcdosis 1>«inK ncaily all ihctc \% to %a by. 
paiature is u«ii.illy ht^iic, i)OiTi\al or perhaps >iibnorTniit in ibc ntnniuii 
reaching loi'ot roj" in llie ei'ctiii\(!, ihmijih ihis nwy be rcvctspil. 
mny be diflrrhccii without app.iicnt calist, and various il)'«i>«|)ii(' tiou 
cougb, tbnU);1i this may be nh«citt : perhaps cnlarxnitcnt of uime M 
glaiuU. An cuminalinii of the lim>,'» may r<:vcjt very lilllc. pcHnpi 
want of Tcsiwianrc over the liasc or ape* or in the intc-ri^i'.ipulni rrir 
axilla, with »omcrin](iiij; consonant rAlcsorcTcpilationi There i(pro){i> 
u'axtiii^, wliich in a child of evm a year or c-tKhtcC'D tnnnihs \\ tiH>n 
picious than in an infant a fc^ months ol<l, nhcrc na»in>: if mote 
due in ihronic intcMinal tatanh than lo luhcrrulortit. In lht«c rawi i 
waiiint; i\\i hi-ctir folloH nieAvlcx, uhoopinj; ci}ii>;li. I>iiinchili>>. or brc 
pneumonia, tlirre is a xtronf; snipicion of lubcrculosix. nen llKMijth 
may havi? bcc-n a period of coin|>arali\*i: health intrrxcning Ik-Iutw 
aciilc attack and the hrctir 'uixTtrnin^' ; a family bixior}' of plilliifif ' 
make ihc rase look slill more lllrcaiening. In the later siafn:^ the 
])inm« become mote decisive. The he^lic continue*, the wauiitg \\ 
tcTCs«ive, the cou^h is Iroubtesnme, ihc dianha'a peihapf it uill pf 
parasitic stomatitis makes \\% appearance, the feet, hands and face 1m 
(edematous, and the child is anxmic nnd very w-cak. Exjmiiiali 
the chest u-ill now shnw some marked dullness or loss of rcsotuitci 
some portion of lun^. apex or base, with bronchial breatliinc and shar] 
tonaliri); tAIcs ; often one is surprised la lind how little can t>r de 
it) the chest, even mhen it is evident that the child is far adiaat 
tubercular disease. The typical sijcns of a ca^-it)' can rarely l>c cK 
inasmuch a* the cavities in the hmjjs of infants and >Tun^' chiMicti a 
nftcn lart,'cr than inarblci nr walnuts ; mott firqiienily they hjtc iiti 
and raKK^d wallv ,A crackcd-imt smind mny sometimes hreliciied in 
but on account of the yicldinjf nature rA the chei^l walls in an infiui 
of nn diah^nustic value as regards a cavity. 

Diagnosis. — Whenever wasting occur* ai a prominent ^-tnptom ( 

infancy and childhoud, lubcrcutoM!! is certain to be Ihoujiht of ; * 

occurs in ull dy!>peptic diseases duiin^ infancy, and it tnay simub 

wastiof; of tulitrculosis "hen it nciur* in connection nith cmpyei 

bronchopneumonia in )*uunK children. An cinp)Ynia may rcadilir b 

taken for tubeiculo»is of the lun^ if a careful examination vA iIm: la 

not made, aided if iiccc^^ary by an exploratory puncture, a« there is tn 

hectic, and coui;h- The difficulty in ileciding may be i;rcat nithout ei 

tiOR if the empyema i» localisftd or there ii more than oi>c. .A c 

effution in the pencanliuin may be miitnkcn for tubercular diieaie. 

ol^cn diffirull in cuset of chronic bnmcho- pneumonia, the chronic coti 

following an acute attack, tn decide if a tubercular procc» is goal 

There may l>e wastini; and hectic, and yd after some vceks the lcmp« 

-radually fall, the lung clear up, and the child perfectly rccove 

L«e:> only the progi«* ^ the case will decide the quetiiim. 

r CMiUriTH. — After the age of six years— in iMhcr imrds afl' 

ireinent of the second dentition— chninic tuberculosis in<Kh 

.1) resembles th« chrome pbthiii* of adults than it dnci bcfoi 

n^ ihc child ^ts older tlie rctemblancc beoocnes still mure 



^u^reufosfs of /A/ Lungs 



251 



C*Jib(ol>efot*0ii6 age rnicIyiuflVrfrcinichronicnibereiilosi'ofiJicadiilt type. 
Tbcnil; »yRipt<iRi6 arc those nf cough, Xfr^s of api'ctiic, rii:irtha-.i, waMing, 
tigbsntath, and hcclic: pntjiiciii^ivc Hc-ikncs^ : ilie «yniplom wliich \vc mifs 
Ivlbt nxMl part is h;«-mopiysi6, wtiirh, though 6nmci\m«s prcstrni, is much 
B»w lf tqafnily!il>»<rn[ in i:liil<lrcnlhjnina'liiUsa"'^lPMl>l""'i is expectorated. 
Anfmninatioit cit the rhc^t iiwtj' perhaps disclose some los* of rcsonnnirc at 
twiput lusially thr tifihi;, wiili perhaps some rhonchiis or inoi^t ^nundi, 
wAm may be tmloss i>( rcsnnancc, (iiily the signs of .t chronic or mlxirutc 
bwaAial cutarrh lor^hscd in ilic npcx of a lung : or tlictc may 1>c impaired 
MM— re only, cIdc 10 the pieseni'c of .a thickened pIcurA and adiiercni 
\uf. In lhi» M^ige cliiMre^ ]>eili.ips more nfien iliiin aduhs iinptove ander 
trattntnt and ji caicful hyji;iene,andmiiy be rcsiotcd to perfect health: there 
itibtnilui cvideiKe to demoiiMralc this. If live disease progrcs^M thir 
hectk aad waM>ng cnntinuc, the chitd bec[>n>e4 pallid and weak, the diitr- 
An (itqucnt and truuble^onie, especially following ineaU: the physical 
I ihow an extended niea of hm^ involved, the tubercular infilirntion 
din); ftom the ape\ lowarils the base.and giving rise to eateous dcgene- 
, fibroid changes, and caviialion. The progress of such cdses i» apt 
inete rapid than it it in adults, a fatal result occurring in four 10 
months. In the last stages the emaciation is extreme, the feet 
Rteatem, bed ^ires arc apt to form, and while the patient may linger 
tiihile )f no intercurrent affection brings the end quick1y.it must be 
' in mind that such cases arc exceedingly apt to be brought to a con- 
1 by tubct'Ular meningitis in any stage early or late. The abdominal 
k arc also apt to join in a more extensive spre.iding of tubercle than is 
OM later in life; me*«nicrlc disease, e> tensive ulceration of bowels, 
oicls suba<ute or acute, ai-c apt to be present, and necessarily inlluencc 
of the diiea<ie. Ihemopt] sis, which may be fatal almost imme- 
feccatJoiuJIy occurs ; In other cases blood may be upectoraiod in 
MUidmble quantities, 

SoBtttinK&an »eBt« pktklsU takes plae« without miliary tuberculosis 
Mqj present : the tubercular process taking the fonn of dusteis of gr«y 
AAtnIc lurrouiiding the bronchi, the process beginniog at the apex and 
'tnBiig towards the base, the symptoms being those of a rapid phthisis, 
«p4 extending over a month or two, 

ittieo<th«t hand, 3 abroM p^tbiiia essentially chronic in its cotirse 
rulce ptace. apjtcarlng at times 10 be stationary, or the patient undergoes 
Biideiable impruTemcni, In these cases there is much libruid changeand 
■BO'Crty irtdurailon of lung uith retraction of chest. The physical signs 
^Mop tlowly, there is dullness of an apex, which grtidually becnntes almos 
■^■■■fate, intense bronc:hial breathing, consonant rAles and gradual retraction 
Wlhcafltcted side. The child may fatten nnd appear to fluuiish, and present 
■ iMnu] trmper,ituie, but It is easily exhausted, suffers from dyspnoea oit 
otnion, its ixtr and lips arc turgid, and the ringers become clublicd. In 
* It* cue* iliero is hirmopiysis, but this is the exception. It is passible 
mtheprocevt may become arrested, the lung being converted into fibroid 
Unm, la thn majority of cases the disease is progmslve, and theopposiie 
•^ become* affected. The whole course tnay extend over several yearVt 
nlns bronrhlib or some other iniercurteni disease sujiervenes. 



T?* Diseaus of the RespiMK^^^Smm^^^ \ 

The princijia! clmic;il diflctcncci bciwccn cbronic phthiut in oUerdil- I 

4lrcn and ^ulullt m;iy be summed up a", follows ; I 

I. Ftc(|uency »iib which children in the first Mage rcravcr, I 

a. Fte(|iieney with which the ditc.-ixc is brciughl lo nn nbtitpt IcniuMltm I 

by sotne aciiic atTcciion, a\ tubercular mcninjplis, pleurisy, pcritoniw, m I 

acute mi1i>~)ry tubttculotin. I 

3. Compnr.iiive riirity orhicmnpiysit in ihc early stoiECsaiKlaf tflt]rn||li> I 
in the littler itiiRe*. I 

4. Fiei|iienry of coniplicnlion wiib.nbdomtnnl ttibcrculo^iv I 

5. Comitirjtivcriiriiy ill romp-itcd with (bill iif adulli- of cilcnsive oiiilA I 
in the Iiinjj.i. I 

The fiMt-mnrUm afififwtuKfs an mostly Mmibr to those found wdB I 
similitr circum><Mnce( in .iduli^ Irrcgii1:ir rsKRcd cavities, t-ai)in); ia«ir | 
from ^ hold nui to .1 unlnni, most numerous in Ihc upjKr li>t>cs. with chmf I 
mnv^c nnd fibroid irxluniiiont : the same condition ill the Wx-r kbti a \ 
nn cailier ^ukc, with more or ksK crcpiuni lung. A« n rule there a ■» J 
much grey tubcn-le, but cnseous masses, *omciimcs associated wiUi p«» I 
brnnchi.1l jjrcy or yellow lubercle*. There nte nol often cavilict of hip I 
site. iMit theK occur nl times 1 in one cAse. in a boy of ci^ht yejrs. nboW I 
sufTcied for six inomhs, there was n cavity in the upper iwo<thir<ls ortbckk I 
lunic :is lar^c iis an adult's clenched fist. I'leurisy and small oaUt>:tioa* rf I 
pus arc nut imcanimon. The bronchial gbnds aiv alntosi totwubljM- I 
lafKcd and caseous I 

Insicad of Ihc above, cspeci.illy in the more nciilc cases, the tutigv nVf | 
he everywhere Infiltrated wtlh clusters of peribronchial luberrlcs, m^ | 
crowd Ihc upper lubes, where ragged irrc>!U]ar mvitaiion is contnKScii^ I 
while they iite moie spaiely scatictcd through the lower lohc^ I 

In fibroid phthisis an exieiiMVC pnnion of one or both lun>;s is eiuiiM^ 1 
und solid, bands of tibrous lis-sue run Across, there is much x'rey infilinti« I 
dilated binnchi, caseous glands, and peihajn small ratlged cavities. Ullw I 
portions of lung arc hv'|>cntophic or e:mph}K'niHious, perhaps cumaianf | 
tcatiercd cJusicis of peribronchial tubervlcs. I 

Chees) luhi-ci'lcs are met with consUnily in other organs than the liMgil 
cspccinlly in ihe liter, spleen, and kidneys ; caseous meicntcrii. glandsMl] 
ukcratidn nfthe inie^iincs may also be associated uith lung mischief. 1 

TrM/menf. — The ttealiiient of enlarged and caswms ylaitds is necmtwlri 
the same in large measure as thai i>f early tuberculosis. If a child, say dmi 
from three to sis: ycara of ntfe. suiters from a hacking paroxysnul cough, wj 
slightly feterisb at night, remains ina condition of ili-delincd niaUise, esiwo-j 
ally if be h;i> n-ceiilly suffered from bronchitis whooping cough, or measteJ 
the (uipicion will be riiiscd thai there isciiher caseation of the bronchial glandij 
or an early luberculiMts of the lungs. There can be no ceilainiy ahooi IM 
4liagnoiis. but if ilie family history points to tuberculosis then- ts only tea 
much reattin fur iiiixieiy. 'I'he indicaltons for treatment which suggcA 
tbcnuelven are to place ihu child under conditions in which there wUl be ttMJ 
lea»t possible irrtialion of the lungs and bronchial tubes, and to supply ha 
with nouriihment in suitable qiuinti ties anil lit the most digestihic farai& 
It is neediest in say lliitl ihese indications arc fulfilled with difficulty or onll 
partiall)'. Residence in tbc smoke and din of lar](i] towns nr on duaf 



'M»SS 



*S3 



T, 



y mh^ofls, U alike bad. und if possible tlic child simuld l>c rcnioi-cd lo 

nr brcct} RMmrlaixI litc or br^icing »;isicl4' place. Fresh aii ivhrn ii can 

uken tiihout riifc orct>I(l is of die gre-.ttesi possible .nlv.inu^'c in bradog 

) ibi- drgrstive or{>;in!i. In winiei, if ii be iinpLis>lbI(' to seek a u'urmcr 

Iduw, thocoughty wami and w«ll'\eniil;ited iip.trt merits free Irom drakighis 

MM Ik: u-currd. A <AeI1-u'uini(.>d bitl nut ' sitirTy ' bouse is a ^re;it jdi-an- 

t^e, k& the child mtiy in such u cas« have the ' run ' of the whole house 

riibxii being exposed lo cold pjissMgo and Dpc-ii windows. A Doiirishing, 

\anif ^i«siiniluicd diet shouh] be preKribed, i^i variety being introduced ia 

jrtcr to Ktn\A ilie capricious appciiie often preseni. A ctip of beef lea the 

itatkngst nighl mil often ease [he cou^ti and soothe the child to sleep, 

I Of ipeeni inediciQ;d ireuimcnt. cud liver oil. m;ill c'xtr;iLt, mincrid acids 

Mh ciacbonine and tbc b)iK>pbuipIiilc-s may be prc-icnbed uilh advantage. 

Vu^iii- or j-uaicol is often ptcseribed. Counter -irritants Jic useful; ibey 

> likely to Inn*- mucli elCect on gliuuls which arc actually easeating, 

-.:.....; ^:ndoiibtedly (avounibly influence chronic cat.irfhs of the bronchial 

mcma membranes. Ainon^ the milder onc^, the Iln. pot. iodid. c, saponc 

^'' ■- nilibed into the chest every evening, a piece of "Mvansdoan'' or Inycr 

< >*ool beini; applied. A stronger application may bcm.iilcbydiluiinic 

iiii >•!' ■ith glycerine and H-4ter(P. 27j, and applying ii lo the Mcmiun 

« ihe wbclavicular region e»cry night and coveting it over with j layer of 

Mun HooL Care must be taken not to render the skin sore by applying it 

tin&tqiKTilly on the same spol. 

IW mure argent symptoms present when the nenes arc invohcd by a 
BcdMinal tuRtour — and these are often very disiiessiug — niay be relieved in 
DBf c«ses by n4nn apjflicationi, such as fomeniations, and small doses of 
iKlW'lie or tnurpbia. Relief will probably be obLiined from opiates com* 
'■'n etbcr or chlorofann if the ilyipnica ii due to spnun. Inhalations 
; ifonn, ether, or nitrite of amyl, usially relieve. Small iloses of 
■npcsa ({ivcn subcutaneous! y may be tried. 

Much that lias been said applies to the early stages of all forms of chtonir 
liictailosis of the tung». It is of the greatest poiiibic importiince la recog- 
(IK the disease in its carty stages, when there ii a fair probability tbnt it may 
'»i:Tt7.ied or undergo a natural cure if the conditions are favourable. To 
Am cod an equable tempei.iturc, a pure bracing air, protedion from cold and 
Jutpaitd rapid temperature changes arc of the greatest importance. The 
puntce of tubercle in the lungs naturally |>redisj)oses to catarrhs and local 
pMfRiunus, and exposure to unfavourable conditiun.s likely to favour their 
tottepment is certain greatly to a ggrav.it e the diseas<T. (ireaCcure rallSl 
iUt be taken in lh« ftiod which thy child tak» and in treating any departure 
linn a be.ilihy condition of the child's digestive s)-»wm. A c-onditioo of 
oarth iif the bowels is very often present in (ulwrcular diseases apart from 
Wf local lesHin, and is an important factor in producing the nsting n hich 
KimpiBiri lubcrculosii. 



254 



The Spedfic Fevers 



CHAPTER XIII 

THK SPECIFIC rBVKHS 

V*v*rlBlui»«i. — Children more oAen th.in iidulti nrc Bp* '" ^' " 
atiiiflc^ of ro\ rri^thncis, the lempenilure pcthuji-i risiti); tuddcfil) v. r : 
obvious •::;iu>c, rcmninint; r.iiieil for a day ur twn, much Xo ilic .iLi: 
fri«mU .-ind the nicdioil aUi.-nd;ii)l, and retuminit to normnl w ithn<] 
having 'been obtained iii lo the ciuic. I'trhnpii Ihc fcverij^hii' 
Init cwntinuous for »onie ovvks, rivng in llie evenmif aiuI : 
inorninxi wiiliuul any diagnosis bdni; made. It ii h;itdly n<-i'>lfiii w 
that in any given ciiie no vDi^rt tihuuld be apaicd In tind uul Ibu 
ihc fever, and lo tffeci this ilif tliild ihauld be carefully examined, |i 
being stripped and any li^n of pneumonia carefully looked for, 
skin and ihroai ithould be minutely !icrutini!«d in a good lixhi. 
should lie made ai to what tlie diild hits taken in the way nf foad 
the attack. If the ;iltack it sudden, the icmperalurc ttna^ to 103' iir ii 
or more, epidemic intlucnia, acute pneumonia, «arlct fner, ni acuic Ajv- 
pepsJA from the ingestion of unsuitable food oill doubtlcM be suggeiteiL 

In children under three j-cars uf a|;e, a high temperature with cocr 
may Ik- due 10 .tc uic p[ieuini>nia.and a card'ul examination of the Iimki 
be nude ; in older children there may be no coniniUion*, but utuallt 
pbysiciU signi mv am, dislin>;tive, tlicre ii »umc stitch in the vidr Ml iw 
coughing, with more or less dyspna-a. In acailet fever there 1- 
vomiting and ofien diarthtca. and the appearances m the throdi . 
soon l>ecome ilistinciive. During the lirst twelve or tncmy-fbui h.-un 11 
may be difficult to distinguish between acarlul fever and an acute di-irihirj 
or g;tMro-intcMinal catarrh the result of improper food, at sometimes a 
gailric attack will produce severe symptoms of voniilinx,diarrha.a,and frve». 
Or there may be no diarrhtca or sickness and only fcverishncM. The 
diagnoaii in epidemic influcnia has often to be nvidc from the fact that it is 
prevalent in the house or neighbotiihood rather than from the tympconn, 
whicliare so frequently indefinite : a temperature of 104* or 10;' with convul- 
sions is not uncommon. In many of these cases it it wise to wait bcfcwe 
trivInK a definite opinion. In infants and young children the cause of aa 
unexplained high fetcr may pro^c to be an acute otitis which has been ovtt- 
looked till pus has made its appearance at the external mcaiu ; si»ch cata 
Are very apt at first to be mistaken for meningitis (see fig. 36). 

In some feverish attacks nc have noticed an enlargement of the cervieil 
fllands, cither the deep cervical ni ihcangkof ihejaw, urthcglatKls under the 
upper pan and posterior edge of the stctnu-mastoid, without any appeamnco 



Fttvrisiiness 



255 



f irrilation in tbp lunul or phar^'nx ; po^&ibly ihcrt may be Mich a disease 
a an .tctue iiliotutkic adenitis or Motc poison may perhaps be abwwbrd 
'am tlie phar>tuc and enter (bv glaods u-iihoui setting up any local lesion at 
he point uf abiorptxm. 

Such cases have been described by E. Pfeiffer. Hcubncr, and Rauchfust, 
tmder the name of (i«a« ftv«r. Tlie attack, according to PfcifTcr, is Hidden 
Ukd the fc> cr roodetately high ; iberc is complaint of tenderness in ihc neck, 
and tome of the cer\*ic;ii glandi, u!>ually ibose at ihc posterior border of the 
attntv- most old, or the occipital glands, are ^noUen and tender. In a few 
days Ibe temperature falls »nd tlie glands Iwcuinc normal. In a few instances 
ihf attack ha^ been mure seveie and baa la&ied longer. In these cases no 




abaormal appearances h»\t bceii ULiiLud in the tonsils or nasal mucous 
■onbtnne, Tlie glandi never suppurate. PfcilTcr has noted several of 
dtesc cases in one liouoe al the satne lime, the disease being infcclious or 
cpdcmic 

We are, however, rather inclined to think thai while 'gland fever" does 
tindouhccdiy take place:, it i» nuvly idiopathic, but the result of absorption of 
toiiir tnatcriats from a ntu<:ous membrane. ■(Hand fever' often occurs in 
tcarlrt fever and other \-arious forms of tonsitlitts, the throat mjy be 
apfKircnily welt or hanlly abnormal, y«. the cervical glands may be swollen 
and tender and ihi; patient feverish. 

Acute cerebral congestion or ' sunstroke ' may be accompanied by high 



256 



Tkt Spteific Ftx-tn 



fever, quickly rollowed by dcalb. In many cntet whtrre there are a hifb-' 
tenipcraiure and cerebral symptoms, such ax roraa, deliriuin. <ii [orpot, it n 
often difficult to tay whulher there is some cciebral discatc. oi n ht-ttiei itn' 
hiu'i icmpctntuTC and poi^uncd blood are not cnuting the ceiEbral symixom* 
the biaiii itself bcinK niitnwl. When ihe temperature ri»c» more »lo«lv, 
taking let'ural d;iy^ iti rcuch iti {{reiitcM clevaiion, ai » the case in nieailn, 
typhut, lyphoiil. ,ind smallpox, n dia^iiCHii cannot be made for a few iLi)i,^ 
till characteristic symptoms develop. 'I'be hard cougb, ^uATuMd eyei, nA I 
raih of measles the headache, delirium, and coiiia of ly[)hus, the b»ckaclic, j 
and papules of sm^ltpoi, settle the dia);n<Mi». This ii MMnctime* the catol 
in crvthrm:i nmliisum ; there ate somL- fri^- ^^^lv^ "■' ffirr -.viih no deAntir] 




frMin \v^Ae Piioinb^ntL 'I'he CAUij or the ft<« wu un^nL^vik lUl a i^unjlwr of typKal »*tf» vM 

sympcomi, and ilien ihc characteristic red lUticneit nod«> make tlicii 
appearance : see fig. 37. 

Ihc diagnoii* as to the cauK of fever i>> often vcij diificult whcii the 
^»-cr uMiime^ ilic intermittent or remittent lypc, ^o\Tvf, on Cor nime day* <» 
elcB nithoui Kny diAracterisiii: symptoms dct-vlopin)-. Such cam ane | 
ae*ly dcsicnuted ' low ' or ■ com in tied fever,' and vrfnlc il ■« iwn vntcto; 
> such indi'liiiite teims we must be prepared 10 fmd cases of intermittcni 
er In children in which ii niay be ctiiiic impossible to make a (UugiMsii 
i.aut>-acuiu or ihroriic gastro-inicstinAl cainrrh, creeping pncumimio, a In* ' 
lofcntciic fever, .1 tuliercular peiitortilis or a militii) lubcrculmi*. Rm)^^ 



Starlet Fever 



3S; 



I 



be present. I'bere may be, a* Dr. Koxwell suggests in (he»c caMS, a 
ccmdition of s>:nentl caiarrlt, including both »limciiur>- and res{Hraiory 
tracts. In all vuch cniei a most c.trcftil cx-niiiinatinn should be made of the 
chctt. abdomen, and retina for miliar>' tubercles, in the hope of dclcctinj; 
sDTDcthinj; which •riU thn>u- li^hi on the attack. We vctan not for|[Ct thai 
sotne af these cases of protracted rcmiilent fever arc in reality cases of 
miliary iw loral tubcrculniis in which healing eventually takes place. \S'c 
~ el sore vc have seen such case^ 



Bc«rlct rever 



Scaikt fever ii a tpccitic fever of a highly infectious and dan^erou'i 
ch«raclcr which occun in epidemics, but is always more or less endemic in 
large jK>V>u1alions. It is ca^y to understand the occurrence of epidemics in 
I small population where the fever exhausts ihc soil, as ii were, by aitaclcing 
ill th<»e susceptible to iis influence and then disappears for a while, lo 
>-ail at a later period, when the infection is rc-iniraduccd and the popu- 
cmit.kin> a^ain a number of the unproiccicd. It is mote difficult, 
over, lo understand (be cause of epidemics in large cities where the 
liBCtinn 1% a]wa>-s present, unless we assume the existence of some un- 
: inilucnce which favours the spread of ihe disease at one lime more 
|M>Mhcr by render) n); those who arcunptoicciedby a former attack more 
asually susceptible loilie infection. Thus epidemics of scarlet lever are 
tsoRunon and wideipread m the autumn than at any oiher period, and 
ppcar that at this season either the poison is apt to l>c mure intense 
Inil Miacc^piibiliiy greater. Individual susceptibility varied Kre^ily 
Ktb age ; mfanii under siv nioiitlis of age are rarely attacked, during the 
!Ciind )'car tlif Mjsccplibility is greater, while children during' their fourth 
nd M-scnih jean are moat wften attacked. The susceptibility then uppean 
I diniiniili us age increase*, though, as already remarked, var) ing ^tnmgely 
. time to lime. Thus it may happen that a medical irmn or nunc m.ny 
in contact with scarlet fcver cases for week* or perhaps months with. 
I contractirtg the disease and yet finally take it. In one cast which came 
■ our notice a proljaiioner nurse was engaged in nursing in a scarlet 
ward for six moaths wiiliuul licing ;tttacked ; many months after, while 
Sinjt in a surgicAl ward at another hospital, »he conlnicletl a ^tiiiart attack 
of scarlet fever from a sporadic case arising in the ward. In another case 
a child had a levcre mtack of scarlet fever twcrly-ninc day* after aUmisiion 
to the Karlrt fever ward. In this case it was supposed to have had an attack 
irf scarlet fcver for which it was sent in ; but second attacks of scarlet fcver 
arc rare ; ihcy do, however, undouliledly occur, as in the following case ; 

StorM Ffttr: wrmd n/ydtl.~Tliuniiu K.. ftgcil 6 VRin^ Voiiiili.-d tiiiu* i6, nuh 

day: admitted lO timpitil June m. fhcrp vna a wclliinarkctl nuh. Ibe 

ilomdi afie swollnip with paich*^ of rttjilLiUOn : Ibcrr wpre Iwo or Ihnv ilrurr^t nf Tovcrf 

a few Atji. Diicturgcd Auguit aa He romlwd AueuM si : ndmilled Auguit »t, 

itb a lyplCBl auadi of scarlei rei«r. There was n w«1l-nuiikod ntih, tonsillltlJi. aad 



Scailcl fever isapparemly not soinfeciiousas measle«— a lac^'e number of 
chitdren and adults escape being aiiaclccd ; thus Bicden found in au epidemic 

s 






258 



Tht Sptdfic Fevers 



which prevailed in an iwlatcd village (Ncunliofco) where ihc inhnliiunH 
freely mixed wIiIi axw another, xnd irhere no isoliilion v& ih€ fever (utienii 
was poiiible, iliat about 58 pcmoi. of ihe diildten unprotected by a formei 
attack contracted the di«:nc, ihouyhonlyalwut two-thirdio/iheiehadwdl- 
narked symptoms, (he rest having >iore thioatii only. In diR«rcnt riMdctnkft 
(he numlter attacked variei cxlTcnieU'. 

The moHtiiily varies in diflcreni epidemics ; thus, in llw fcvct inirdof 
the Children's Hospital. Manchesier, it has varied from 6 to aj P»'' cent, la 
different yean durinti the years 1877 87, the averag;e mortality among l,S9l 
tases treated licini( 11 -8 per ccni. Uiinn){ the seven years 1888 18** 
(inclusive) 1,015 casci were treated « ith an avenige mortality of S* percent. 
This aicr.ige mortality closely corre^iramls with the fijjiircs given by Orflie 
of the Riorixlity in the London, Stockwell. and Homerton fe%'e* bospiMb. 
where, in upward* of 10.000 c-iics of scarlet fever, the rMWtality waj la'S 
per cent As in all pn»babi!ity many of the milder caws of frvcr imjvo 
conic into bospiLil at all. 10 per cent, mortality given by W. Scjuire a* the 
average apjxars to be a» nearly correct as puiaible. Age inrtuences the 
mortality verj- conudcrnbly \ the tnorlality is high during (he li«t iliree m 
four years of life, amounting to 15 to 30 per cent. ; it continues high till the 
age of six or seven years is reached, declining after this till the age of 
tH'cniy-one. again increasing after this epoch. 

Are there any morbid rimditions of bofly which predispose to scarlet 
fcvcr ? \'ery little is definitely known about such conditions ; tndivi<lual mii- 
ceptibility varies in the most erriiiic manner, at least is governed l>y nolcnoav 
litH-», and it cannot be said that ill health in any waycithct favours or protects 
from attacks. To this, however, must be added tliat it is our experience that 
operation rase^ and surgical cases with open wounds an- more lialile to iron' 
iTncI the disease than are healthy children. The so-ciillcd SBrKioMi aoarlM 
tvwvt it simply scarlet fcvcr occtirring >n a surgical case (vide infrti). 

The MTong and healthy appear to be as frequently atimked U the 
tt-e.-ikly, and the attacks are often fatal to such : it is bj' no means nncominan 
to see on \\w fioil'mtirUm table children who have succumbed to maligiMitt 
scarlet fever looking fai and plump, and who were apparently in the bat of 
health when attacked. 

The IraHt/erriKi 0/ ia/eelioM from the sick to the healthy takc» place id 
various ways 1 it may be by direct contact, the breath or the exhalations fhnn 
the fcver patient may be inhaled, or it may be carried by means of clothes 
or wearing apparel or bedding which lias l>een in contact ujih the sick. It 
la highly probable also that the excretions of the patient are infective, the 
urine, faeces, and discharges from the ear or nose. From the iniesiigatMMU 
of Power and Klein it seems that the fever may pass from cattle to man by 
means i>f the iinlk of cows »-uffermg from a ftinn of lioi inc fe» er knonn by 
the name of ' sote leati.' Tlic poison of starlet fever appe^irs to retain its 
vitality for many monilis, fever breaking out again and again in hou*et 
which have liecn imperfectly diMnfcdtd. 

/rtatMio». — Muiily two to five days, ilioirgh it may be much less, pcrhapi 
lly a fe«' hour* ; forty-cighl to seventy-two hours is a common period, but 

many cases where slight sore throat precedes for some hours the more 
Jfinitc symptoms tt is impossible to state the period of incubation with 



Seartet Fever 



259 




m. 



In ihe majority i>f cnsn, tf Ihe inilial vniniiing he taken a« ihe 
1 symptom, it will be found lliat the iniubation is under iliire days. It 
nnoi Ix! said with certainty tliai H may not lie more than live daj-s Inx 
such caut inu»l be very exi'epiionat. 

Prtawtiilmry Symptoms.— Xhe imasion So the ease of children is uatulljr 
snddcn. the first lynijiioiti lieioj; nearly aluays voiniiiny -. this m«y comeon 
after a hearty meal. There may alio be iliarrluta. In iildcr children aodin 
udulli there '\* usually nauiea irnot vomiiinK. sore ihroai, headache, shivering, 
awl lois of appetite. ' Sore throat ' with voraitinn in a i.hil<l or aduh is ex- 
liemelystwpiciouiofic.-iilei fever, especially if fever is present. The tcmpc- 
ratuic usually runs up <iuickly to loj" or 104'. and perhaps the patient sits 
over the fire on account of feeling chilly ; in some cases tlieiv is s11),'ht 
delirium. 

An aiiark of vomiiing and diariha:a coming on suddenly with fcverishncss 
(103" (04' K.t is very probably the cointneiiccmeni of scarlet fever, and m 
siMih ta»e* deith may take place within tvifenty-four hours of the onset. 

Sjtmfiloiut and Courif. — Mediiun rora*,^Thc prctnonitory syniptotns 
ve usually folh>ncil within twcnty-fuur hours by the characteristic r.tsh. 
Its IS said to make its appear.iuci- tiisl about the netk, hut there is no cer- 
y abitit this, and traces may be seen (>f it on the bucks of the bunds and 
.Is or on iIh; thighs or alxlivrnen, ulicn it is present nowheic else. In 
cafcs it is first visible on the back. At first the rash is f;i>nt ihoufth 
ly rlianc ten stir, taking two or ihive days to reach its height. In 
crises it disappears in the course of iwenty'fotir iir forty-eight hours 
luvfni; at no time been oiorc thisn a fine t'kiiit rash. Wheii typical tl 
tannoc be mistaken (or an\ other rash. Viewed from a short distance, the 
whole body cxti'piing the face is of a uniform bright ted colour : examined 
cloMl;', iti'onsistsof ainultttudcof re<l taints which correspond withihe hair 
ro(lt(-|cs; these points are 'urrountied hy tones <rf erythematous redness which, 
joining with mie another, give a gcneial difTusc red ap|]earance to the skin. 
Somelinx's the rash ronsisKnf the points only wiilioiil the erythema ; in this 
sc the redness is necessarily less iivid. In rough skins the rash may l}e 
rsely punciiforni : thai is, there is a condition of > gonse skin.' each point 
riK la've and the rash ihercforc coarse, Sudamina are not uncommon. 
In other cusci the raih is patchy on the limbs and when (his is so, the case 
nviy simulate mcaslr%; thr patches consist of clusters of fine papules or point* 
«i ith mui'h surrounding erythema, nhilc nnmial ikin is present between the 
(Mlchci. Sometimes the rash is ba-morrhanir, minute eitmvasations of 
blood lakinif place ini« the skin : this may nrc-ur in mild cases. It is, how- 
er, much more comnion in malign.'ini cases I'urpurir patches nrc not 
icnmmonly (band after death that were not present duiing life. Tnwards 
end of the lir^l week the rash, which hat been fading for scver.U days, is 
cccded t>y tlesquamaiion, n-hich is free or vtjglii according to the intensity 
be rvish. This exfoliation of the epidermis generally goes on for many 
ks being present longer about the hands and feet. The tonsils arc red, 
ullen, and covered «-iih an excesv of mucoid serreiton, yellow |KiJnis 
irrespoi«d>ng to the tonsillar ctj-pis are usually present, sometimes ihctc 
paiclies of yellow exudation: the soft palnte, us'iilA,an(l phatyn* are more 
less i.'on){es ted. The nasal mucous membrane is frequently involved, so 



260 



THf Spfcifie i'ci'trs 



ihal there Is mucli discharjfc from the no»e. Tlte dc«p ceninl gUixU ai 
the iin[,'l« of llie jnw arc usually enlntKcd The connut U roatrd with -x 
thick while fur ; noi infreqiicnlly ihcfc i* a liry glaj^cri c<niral hanil <>n the 
dorsum ; in ihe course of .« few diy' ihc ion>.'\ic clcjins, leAvinj; a red clean 
Klaxcd tortb'Uen'ilh prominent fun>;iforiii p.lpill<f- i.e. ' ihrsimvihcrry longuc.' 
'I'bc eyc3 arc often suffused and the conjunciit.v injcrtr<l, am) w iih ihit there 
is often sleeplessness or delirium, no douhi due lo a con>:eiticd ^uic of the 
ineuiliranes of the brain. In rare cii«ca the delirium ii severe and the 
piitienl VKiltnL 

The pulse is quick,* nrying from i zo to ■ 50,oficnfiki«ier than the temperature 




Fig, 3I.- Tvwptfslure L'hivl oTatiiwor Sc^rUt Ftvnf. maliuH *lia(k- 

•. Kuh pnMDI. 



M. K.. v«< I) )>*■■*■ 



(>r the general vtale of Ihe child ivould have k-d one to expect : the tempe- 
rature varies, mostly reaching 103* or 105* in a modetntely siharp aiiack 
('■X'- "i^'^ '''« uiiue 19 M.-anty, high-colouied. nnit often eonMins a snull 
(lUiintiiy of albumen. In the ( oiiru' of a few ilay», (lerhapi hy the end «f the 
ihird 01 fourth, the :itiai.'k has reached \w hei);ht, :itfd the MymiKoins l>rt,'ia lo 
decline. The rash ^tndu.ill) f.ides. the teiiipi-tuiiiic f^Ils the evcnin); rise* 
being ^mnllcf and the tntinilnj,- rciDis^ions more niiArked ; ihc ion)[uc rhMU, 
ihc faui'ert arc less injected, and ihe appciite ri.-iiimt, llyihecndof ihc &r^ 
week ihc tempcr^lurc has ccirhed normal ; nnyfev'criihne-iswhii*hcoinlir>i*ci 
After ihit siij^^cvli MMiie complicniinn, the cnimmoncil being «n ulcerAlrng or 
&lini^'hy proieu goingonlntheihraal,ini?iiiiim.-iiioniiif i;bndti, ai»dotiii». It 



Scarlet Feivr 



Sfil 



mnxt, hntievn, be ;u]ili-<l th;il .-iliiiclcs of scarlet (cvkt arc extremely iine(|ual 
and no two c«!>cs -m- c\ai:lly alike. 

MiM Soarlct r«*«r.— In i.(im<; cas» ihe preinoniiory vyniploms aie 
xbacnt oi Uie fever is imty ^li);lit anil easily uv«rloi)ketl. and the nnt thiii),' In 
call atienlton n> ihc attaclc t> the rash. It not imficqui-iitly happens e^en 
in bonpitali wiicre the Lhildren are under obsetvatitin, thai ihc ditcovco' of a 
rash is the titsi ihinc noted. The child m.iy occm lo be in ii.i usual health, 
make no cotnpUini of tore thrn.it, and appear lo lake ill nteah well, with 
an c\'cning lUc and a inorninE rcmis*i"n of icmpcniiure, and yet be iiiffer- 
tAK frtmt ■* miUI attack of tcartci fever (fig. j<^). The nsh in aui'h cam 
lb nuvly mcU maiked. but if it n dItTusc and punciifunn and retnains visible 
\ta* iwenlV'four or fi>iiy-ei;ihl hours, the attack is unniisiiikably one of scarlet 
vKf. 'V\vrf is usually -ilijihl loinillitis. The mint clifTicuk cases lo din- 




^'i*. !».— TiBiMAiorr Ctwi "I H -^tilil >url>i Vrm. 11. W,,*cnl ywi. 



I 



gnmc ve i1h»« where there U sore ihrtiai without rash, inasmuch as there 
t» MMhtng characierisii>. about a scarlatinal tonsillitis. 

H«llfm*at Bcitnet '«v«r.— In soine casei death occurs very rapidly, 
peikips within twcntylbur hours, though this is rare. The must nipiU ta,%c 
«hic]i has come under our notice was (hat nf a girl of iweniy mimihs- 

StmtUI Oirr r.ifiilItfilal.—S\\rin\t iiollccd nnl Iii laki' licr dtniirr mclLniidronitlcd 
•Ikr bertta: bcr tnnpernturr. which liad been normil in itii.- niomin);. I>,id risen (o loj* 
tr j.]D(fi|[. 404l : *l 7 f.U. itiL- [mlM- w» 160, (lir iiiiimIh »vrr onl.i rcni , :inrl llierc was 
a tt*y falnl nuJi over the 1iod> : ^llrBIurcIn^•ve(l ihcumFi'^i.-ritnK l>y ikl- midrni mcdicnl 
oSaar, Dr. Kerttisv. l<> l)ie (''•i-'i »ai(l. \(Xl iiiijnifriK llic rmli had (IisA|i|<cftri.-d, lh<? 
UmUs wvie enUii[«il villi .\ pntcli ol MUdaiion oDonir ol Ihrtn. hci piilic nati nripitAlio'i) 
mra rapul. 1m >h* •l"l nii< tn-m rtltriiirJy ill. Slii- i;r^ilu:iM_v ticcdmi: wiitse, Ihe face 
qnaoml. nsplraijon ^upin);. and pulse fnlliiig ; ibe died wun ahcr 5 i-,»l,. twealy-foLl 
hoars kftrr the initiu) tymptom of vomitini^ 

Al the pfit-mffUm one tonsil H'a« «lnu);liine and <;ofi. Dcjith in ibis 
cue, a« in most rapidly fatal case', took place thrnut;b llic hean faitint; 




262 



Thi Spftijlc Pevets 



under the influence of ilie piiiiion ; ihcy may not appcji for a fc« boan nr 
jciii.-i! (Innncr, thtn ^ymptuinsof tynncisisandcoUapse^ciin, iiuicklyfeUnM 
by a fiitiil rcMill. In the grciil inajurily of ;icilie casci dt'Atli doe» ncn nkt 
pliicc: nil the fourth or tin- scvoiiih iliiy i fiy. 40 b- \ in ihcsc ilie tcmpcrmx 
'* hixh, pcrhnp^ ioj° or 106° (here 11 much diarrh<r.i. often i-Mreinc mtlcM- 
lies*, follavred by coniH ; iJie lunnU arc iiiurh «iv(i|]en and tovvred with fod 
secretion, ihere is miicli nasiit ditihiirgc, ihc^tnndiiliir«wc1lin|;and cellulm 
are i;reat, the neck Ijcin^ hard and icnie to the lojcb ; the ^in is of a Mt 
lurid calnur, the extremities cold, and ihc hcan gradually bib. If life if 




P^. 40T, — TrmpctaluK Quel of MAUftnnnl 



SuiWl I'lvn. I>ailli KXiilk dlf. *.ltwh. 



prolonged for a few day* the toiuib and soft palate sluu);h and the lungs 
become ilic seal of septic pneumonia. In another dau of cases in which 
life is prolonged to the end of the second or third week a ronditMin of 
■•»tl«wnita is set u|x The tonbiI» ulcerate, alouttby patches appear on 
the fauces, the K'^nds become enlarged and brawny, the nasal inucoos 
memhranc dischnrKci^ a purulent Accretion, and the conjunctiva; become 
affectenl ; the Icmjicmiure is lemiticnl l>ut continues high, the urine alba- 
minou*. pus welU out from Iwth car*, the child fjradually wa««». and dies 
in the course of icn or founeen days. At the fimt'tiorfrm there arc found 
extensive sloughing about the fauces, picuro-pnetimoiii.-i. and large hienior- 



Scarlet Fevrr 



263 



eyi n-ith Riaauto abscesses In aonii- ca^ea the tiiupenture rtiBBim 
Ihc seomtd or even third week without any local lesion being 
liscovciablc to accimnt (or it. In all lucU caict the lungs should be carefully 
euiinined, and the possibility of tiome septic Inflammation going on in the 
bKlneys shotiM be borac in mind. 

Piv/pwUi.—X ^MAtAfA prii),'no«i4 mtisi always be given in \\v: case of 
yoont: dnhlrrn. the ihruat complications in thete bcini; generally serious. 
Tbe lonsiU iire upi 10 blou^h. and ihcy luvc so Utile power to get rid of the 
fnul sccrriinn which mpidly forms in Ihc phar>'nK and nose th.11 rhey .ire ex- 
cmdy lublc to pneumonia from rxirn&ion from the pharjnK «n<l ^.'landulnT 
ntinn. Dii>rrh<cii if^ ;il»'nys a siMioiis symploni ; uJicn present nl the 
nvt il poiDt* to » sharp attack, in ilic later slii^cs ii i» aUo of rvil au)(ury, 
iiid if u nMfkcd xympiom 11 u-iuntly prc^-it^cs a faul re^uli. Dmwsincst at 
He ons4-r ntul during the rnurie of the all.-iclc is .in iinfavourahle t.yniptnni, as 
|t kiHially iicciim)Kiniei :i hii(h de^c; of f(:\er and a %cvere cnuri.<;. In all 
aisc* u'hrrv tht Itmpenilun- ii mainuiined during the srrond or third week 
ihit [imgriosis niuii be cxtet'dintrly t!W*^'e<l, ;ind the pnssibllily of a fatal 
trphritis aupiTvcninii musi Ik- borne in mind. 

CtHafilii'alions anit Segiu/ir. — Many of ihe<c have already been referred lo : 

(t) The Maalla nuy become (leeplycsca%ali-d, the soft pidatenviy ilough, 

smitll iMiti' i3(<f>earmg throiifjli tile velum. Ii> be folloucd pcrlups by an 

■Imiist cnltre dciitijclion of ihc soft |Mrts ; in ihc rare ca&et when recovery 

□llAHs, L'lcainsaiion ind defonniiy of tlit' sufi palate are the reiulL The 

nfljutiinitHcKi may spre.id to the epiglottis and Ur>'nx, and croupy symptoms 

eionic so ut)-rnt thai irHrhcoinmy is required. The fauces and larynx riuiy 

ec'imc the scitt nl falic mcmbmnc. In rare cases the ukcraiinK process 

the thmai nuy rr.»ch and enter the internal carotid or jujfular vein anil 

alli follow fmni haMnorrha};c. 

(3> Tbe amaBl oBd ceii|(ui«tl««l mnooDa BiMnbnM* may br the scalof 
iinmulion or a Hbrinous cvuilation. A chnmic di'^chniyc from the nose 
I a eonM;(|Uctii cciematous condition of ihc upper lip may he Idt after the 
er. 

(3) MMs. — Tltc inflammation may spread alon^ the Eu-^iarhiitn tube to 
ihc middle ear, and pus be formed in the tympanic cavity, which finds its 

nil by pcifbnilion of the mcmbmne. This may happm during: the fever or 
iurinj; Convalescence. We have known it occur as early a* ihc fourth day, in 
(her casctn hen convalescence is well esiablished. Suppuration in the tym- 
''pantim is one of the common aiuses of a cnnlinued elevated temperature 
aAer ibe disappearance of ihe rjsh ; the child may suffer i en- little jiaJn, and 
the presence of pu.i in ihe eilenwl inc-ilus or slaining ihc linen may be rhe 
first ihinc to c;ill attention to thi's compliciiiion. .\l other time* the child 
will pui its liand to its car and frequently shake its head, as if 10 t;ct rid of 
MMiie source o( irritation. ry;emia and absccues in the lunifs may foHow if 
thrumbous of Ihe lateral sinus occurs. 

(4) The ecrrteal glaada frei|ucnity become enlarged and suppurate, 
«)lhcr duriog the course of the fever or ivhen ihe child is convidcscent. In 
40IDC cases, more especially in weak!> ihildien. much sloughing may go an 
about the i>cck, deep ragged ulcers being formed, expuiing the large vci^sels ; 
Oool hiunorrikagc may occur from the laiier. 




a64 



Tkf Sfeeific Fevers 



(5) Brwiwbo* or pl«ar«-poeaiii«ni« occurs very ffcqucnilr dwiK^ 
the fiecoDil week, :ind is due lu i-iieiisioii tlownunrds of llic lesion fntm 
i^v ihruaL I'ncunionia Tolluucd by vmpyrina niAjr ukc place durini; eon- 
valtscenct 

(6) Srn«Tlii> nndXbetunntiMii. --'Die juinii arc apt (u become swollea 
and tender ;ii ilie end of the lirii or bei^iiiiiinKur the second >w;ck ; those 
most frequently alTccied arc llie umis and small joints of the lund. wbibi 
sometimes ihc syno\ial sliearlis of ilie tei>di>i» ;it the back and in the palsit 
of the Itnnds are attacked. The knees, ankles, soles of the feel, clliows, and 
joints of the cerviial vertebra; may be aRcLied. MovcmenI of tlic uSedtd 
joints causes pain, .tnd tlicy are mostly s»i>Ilcn, rcdiVind tender. The aiftc* 
lion is rarely scveie. bein^ fupiive, and seldom returning 10 ihe umc jotDI- 
Thc knees snmclimca remain swollen for some weeks finm cffusKm into- 
the jciinls. The cases complkalcd niih synovitis are usually severe. thou(U 
exceptions occur. Peri^endocarditis occurs much less ficqucnily tlum la the- 
ordinary form of rheumatism. Synovitis sometimes occurs in associattmv 
with ncplirilis dunnv' ilic second week. Attacks of true rheumjitism are ape 
lo occur during r on tale scene c. but such src more common in jnanK ndultv 
llian in children ; these attacks differ in no particular from ordinary rheu- 
matism, the bean lieinc frequently involved. An attack of scarlet fever durisf 
conv.ilcseence from rheumatism not infrequcnily causes a relapse. 

(7) FfMnla «Dd ■oppnmttoB la tha Jotnta ncraiinn^My occiUf ^ 
any joint may lie -ifTerieil, Sin.h cases arc mostly faiat, though i»ot 
invariably so. 

(8) r*rtoardlUa (ii eadooKr^ltl* may occur trithout joint pAin or 
nephritis fjeinf; present. 

(9) Mapbritia.^No con)plication of scarlet fever c.in vie in imimnancr 
nr inlcrett with nephritis ; and this condition often gives rii« lo much anniet} 
in an olhcruise niild and favourable case. The * initial' albuminuria uhkh 
frequently accnnipanicf the febrile stale in [be first ivcckof ihc disea^'it nM 
of much importartcc, as it i^ usually lempc.rar^' and not due tnany important 
lesion of the kidneys and quickly disapprais as the fever subsides toward* 
the end of the firi,l week. Apart fram ibis febrile alhuniinuria, there are two 
furmo of nephritis which, it is imponnni to bear in mind, are dt^tincl fron 
one another, though they have frequently been confntmdetl an<l much coa- 
fuidon ha.1 arisen in consequence. They may be dittinguiiihcd as i.a] .Septic 
nephritis, (/>) Post-»carlalinnl nephritis. 

{a) Beptte MepbrttlB.- In the xei'ere form* of fitver eomplicaled •'ilk 
sloughing lonsilt and soft palate and much glandulai su-elling the urine i»- 
albummous, frequently highly so ; but il rarely contains blood in appreciate 
quantities or casts ; there arc indeed no rcn.!! sympiomi, or if iberc are 
ihey are so m.iikcd by the general crondiiion of «e|iticieniia that il is diAicuh: 
or impo%iiblc to dificrcntiatc them. There is no dropsy or un«-mic pheno- 
tnena. If the p.ilicnl ^urvii-e till the end of tile second or third week, ». 
more or lcs3 l\pical py.vmic kldni^y ii found al ihe peit-mortirm. Tb^ 

I kidneys arc enlarged, frequenll) verj' much so; thi-y are Habby, of a crttucM. 

I colour on the »ur6ice, with minuli: haemorrhages and usually minulc at> 

sce^se-, (In section the torlcx is of ilic same cream colour miillled ■«! 

: >< .^cls ood |>oinl» of fluid or inspissated pus. This CMidiifoa g 




S(ttriiilittat Xf/t/iritit 

liibqfenn port of a Reiicnl (xmdilion i>f pj-;<rmin.;in(( i* chicHy of interest 
! a doMmlcuiRS thai [hi; kidneys tutTcr during ihe court« of the ditcatc 
iudCuil camequenlly In c;isct nhich recover lire m a condiiion which pre- 
I Ai^oKi to tnSamnutory nRcctkHii during ccmiiilciccncc. 

ifl >B<t acTlattnal W^ptulilB. -Thi«iiilhcfoniiwbirhisli,iblelo!iupCT- 

[ tnKdtnng lh« ihird or foiiith u-ccbt, and which \\ known Kcocrally by the 

toficarUtinal nrpliFiiU. There r-.*ui be little doubt th.ii ihr kidneys arc 

I aOinllf COgBfcd durlnit the course of thefcvcr iliiclf, and for ihc succeeding 

I «al:trtir<^ in rjuryint! o^ihc wailc pmductx fomicd during the fc\cr, and 

> lit i* M iniud>lc conditinn ami prone to take on inflammatnry action, in 

Ikanc way a* the bronchial lubes and Iun>;« arc left in an irritable con- 

. dm ftfief menxles and arc apt to siitTcr frnm inHannnalory attacks : and 

«Uc ii it pm«iblc in both oiscs tliat iicpttriiiv and pnc-unionia rnay tupcr- 

\He in >piie <rf ihexrcatest catc, yet any chill or exposure to cold is extremely 

lfcd)'M produce or detennioe such an alLtrk. 1'bc number of those who 

H&i nric* in diiTcrrni e|ndctnics, and also according to the season anil: 

Ik (3fe which is taken of ihcm diirinjc convalescence. Takinj; an avenigc 

•(irttnU years, uc 6nd about <t per cent- of our hospital pai'ents have 

Bfa t d front pnst-sratlaiinal iiephiiiis. Pniicnls nho have had theprimary 

Iritt bxh in a severe and mild form nmy he attacked ; in the fomier dais 

(fates, eipcrially u here ibcrr has been no period of apyrexia, it i« moslly 

fi(il:in Ihe latter class— a[ Icatt in hnspilal- it is rarely so fatal. The 

ais b usually bad in ihosc cases where the temperature continues 

: during the leconil week, in consci|[icncc of severe ph.iryngt;!! or 

'inflammation, and nhich contract nephritis In the third ueek, the 

pKcalion supcrYcning on ibc ihroai lesions. From the fiiunecnth 

lhrtiuy-&iiib day is iIm coniinoDCst time for nephritis to supcivcne, 

luiil iHUilty begins insidiously, iracei of albumen bcint; present for a 

fa>dl;s btfor« Irfoud and larmier 4|iianli<ies of albumen appear, it is oAcn 

n^Msiblc to determine iIm: kxakx date of tlic commencement of the attack. 

li •tl-niatked caws it ii noticed by the attendants that the child which, 

I kiiice the subsidence of the fever, has been praciically well, becomes restless 

'tieritti M night, ihitsty, ha« a quick [>erb:tps hard pulx', ;ind passes small 

•luinriiies of d;trk-C0juurcd urine. If particular attention h.ts been paid in 

^i iirinc, it will i>robably have been found that it has been diminisliinK iu 

'Haniiiy. ,incl has LTJOtaincd small iiuantities of albumen for a fc" d.a)s ptiof 

lothc dark unne bcinj; pa»ited. .Soinciimes pufliness about the face pre- 

"Aa tbe ap|iearancc of albiuncn in ihe urine The urine may be dark 

wl,tKt usually it is 'anoky,' ami on alluuini^ it lo stand in a tall glass 

*poii;i a (talk Socculeni pn-cipiiale, nol u[»like ihc Hocculi in beef tea. This 

PnipUtt consists of blood coipuiclcs, epithrlmin ^md libiiiious cylinders- 

■"til fcavc been formed in the tubules and conseiiuently may coniain 

(^"IMcks and eptlbelitmi. 1*he supernatant liquid conUins a variable 

*■*••«* of atbaOK-n. somelimcs beniming illmosl solid on being boiled ; 

law oRcn a half to a siith of its lolume of i:oa);ulaIed albumen prc- 

f'f"*e* b>' boiling. It may not contain any blood. E-or a few days the 

uitM ftntiiniiei daikandalbuminousandof high spctificgravity (lOJo-iMS), 

*id diuiinitivcd in qu.mlily, perhaps only a few ouncei per diem ; ihe face 

•"owiej pale and puff)-, ihete may he cedcma of the feci and sctoiuni. and 



266 



The Specific Fcirrs 



inorc or leu soniitintc ; tben, perhaps, .11 the end of a wevk an tDipTOvemcnf 
uk» place, biite <|iiitnliiies nf utinc arc pnsscd with diminished i^ujuiliiio 
'«)f blood and ;iJbuinen, nnd ibc rliild becomes a^ain ton\iik-vc«ni. ihuugh 
lUe urine may contnin some albumen for tvccks or e>en months, and the 
anirmia may coDlinuc (or a like pcrind. 0\\ the other hund, in a mmi^rily uf 
CMC* the nephritis U prolonged and Kyniplonts of onamlft may lupcn'cnr, 
ihc ])uUc becomes slow, the icmpcmcurv subnonnal, the tunc»* dry and 
brown. OAcii there is frequeni vomiting, fomeiimes diunbiKa (»ee %. 41 : , 
hivmorrbagcx may lake plarc from tarious sui£tccs, Mpcciidly tbe itoM : 
there may be amaurosis, muscuUr twitching'*, and perhaps j^neral con- 
vulsions. 

In all dscs of nephritis particular cart should be taken to examine the 
heart, inatmurh as a fal^l irsiilt is more ofli-n broU|;hl about in oMikcquciKii 
iif canJiai: fjilurc than diirclt)' throiij,'h iir.nnii' convutsinii%. Oi>r iif iV 




u^ivuluwt. It«&nptry. 



effects of nephritis is to raisin the icHMon in the blood-vcucb, and this, \ 
continued for ^nycnniiderabk time, is followed bytfiUtaUoa «f ik«fe««R, 
the tension in the aiterial system in combination with malnuirilion Ikid); 
responsible fur this rcsulL Another not uncommon mult in •■dM*i«Hu 
or p«r(c«r<lltla, and jiouibly MBboUaat. Thf |io»ibitily nt daaoi ant^f- 
lioK ■nddenU duiin); the course of ^n 3i*utc or Mukicutc ncgitirilis itimt 
ainuyt be borne in mind ; ibi- |wtient may appear to be doinif fairly »cU, 
peilt-ips silling up in bed ;md pUiying with hii toys, when an .itlnek erf 
<Jysp»i<&i inmci on, the fact lieconici livid or pcillid, the pulie diupficars, aiut 
death quickly tjkcs place. Somelimes alUiki of dynpntea may precede by 
» <lay (IT two the fauil tvciil. Such rjsca have been often described 4S bcinx 
Cital in eonscqueiice iif u;deniii of llie lun^s, the diUlalion of the bfwl 
having bevn mrrlooked ; redema i>( [he luiiKi is present, but it is seinndary 
to the ardiac faituic. The palliolojiy of such caiei is lotembly ckar ; «cuir 
M-phniix, runninj; a \'cry rapid course in consequence of Ibc kidneys bcini; 




itlmoxt rnmpkldy chokctl, usually IcTRiiniilct nilh iiF^t-mlc phi;tiom«ivi : if 
runs a slowci coonc, the irnnion in ihc blood -vrisels thnuvs iicUidunal 
upon the lican, iht- Irft vciiiririe sirunn'ts wiih ihc incri-;u<ti work 
row-n upon it, ihc blnnd bccomci inipovfrishcd and nutrition imi>:>irfd, 
le davities of Ihu hart diliiCc. ;intl linully ihul i)rj,"an jjivtn vmy, often 
iddcnl)' at Ilic last. The amount of dilai.ili'in prtM-'nt iJniukl be tare, 
fulty noted by the pururion of the u\n:x beat, ;ind ihe iniri-eusc of im|>uirfd 
^HnHnuncc. 

^H Timiiiiaiila. pUarlaj, and psHtaalUs may occur in the course of 
^^ncphritis, and pIruTn-pnciimontii, cndinj; in Kiiogicne, may lake plice^ In » 
hw c.-ucs ihc nltaik n exceed int.'ly iiruie. ihe Icinpcmluic b^g hinh, 104' 
10 105% ibc longuc dry and bmun, ihir urine roniiiining much blood ami 
.adbunien. »n<t death nipidly lakini: place. In such cnscs ihcre 'n VK,a.\\\y 
nl pneumonia. In a large nuniher of rases ihc attacks are mild, 
quantity of albumen, perhaps without any blood, m.-ikin^- its appear- 
nny the third week, the face becommg pufly and the child aiiainii.-. 
lUnicn diiappearins in ihe cour^e of a week or iwo, and llic child ufler 
ftroiiitigtii coniaicicente slowly iei.-ainint; its health. 

Tutiil suppression €>f urine i* noi common, a few ounces daily being 

iMlly palseil ; in one of our cases only three i>nntcs of pale albuminous 

i»ir » ;ii Hissed in Ihe ftiur and a half dii>'s which preceded death ; tlicre 

no c.invulaioni. Life is rarely prolonged beyond the fifth day if there 

total ftupprcisiiMi, Death lakes place in many cases without convulsions : 

Mber« tunvulsions may superi^nc and recovery follow ; the convulaions 

(IcpeiKli-nt only upon retained urinary produets, bui aUo upon the 

of the iKri'Oiu ccnlres, which iliffets markedly in difTerent children. 

ij^ntfM. — 'Hk diagnosis of mild cases of ic^ulel fever often prcicnls 

.mo«tlinan' difKculty. and yet Ihe importance of ma kmt; adiaxnoaiiiauften 

I. In hospital or dispeniary praclice case* have mostly lo be Irntied a* 

ifertinui nr non-infecliuus : as there is often no opportumiy of Liking a 

nlddk; tHUfie. they musl he sent into a fevei' ward with the ri»k of contracl- 

nit'lhe dise,ise if the diagnosis is at fault, or<rf infecting others if treated 

with IKm'infcclious CA-in, In private praclici; aniuiig the ivcallhier classes 

il Ruy hr possible to isolate ail suspicious eases, but sudi aio alwa)^ a source 

af anxiety. Il cjinnul be too forcibly impressed lliat di.ignosis in some 

insun^'es is impossible, and thalerrors»*ill occasionally be made by the most 

otfieticnced, though at the siime time il must be acknowledged that mistakes 

arr mo«e frei|ucntly made through carelessness than from an) «.int of know- 

ledice. Ttie most chamci eristic phenomenon is of course the ra^h. and if this 

t» well marked, being diffuse and punciiform, and lasting ai least twenty-four 

«r (bny^cigbl hours, csxn in the absence of lonsiltitii or a high teinpera- 

turr. there i:an hardly be a doubt about the dia);no^s. A measles rash can 

hardly be inisuken for il, except in ihose cases where the lash is iKilchy about 

the limbs, bul in tliese il is usually diffuse and characteristic on the Irunk. 

A scarlet fci'cr rash, however ^lim, usually lasisfor twenty-four hours at least. 

Hi ibis (c9pe<i differing fron; erythematous rashes, which may be present in 

thFetcniiig and gone Ixfure morning. It is;ilwa)-s«'cll when called to see a 

nwh by ATltlicial lighl lo wait for d.iylighl 10 give a definite o|>inion. Il is 

Imponjini 10 bear in mind tliat a rash mote or li:s<, rescnibling scarlet fever 



nccurt in some cases of p]-,t;niiii and tepiicA-min, aNo in diphtheria 
when ii oci'urs, is seplic.i, infltientii, iin<l rubella. A red iinh is somcumc^ 
CRtiBcd )iy hdiiidonnn, nm-nii:, and (|iiininc. To distinifuiiib betw«ea 
wnrUtinal ;ind limptc ionii11iti!> i» mostly inipoixible in the atMcncc of 4 
raih ; ihc 'slniwbcir)' liiiiauc is generally absciil in uim's unaitviidcd "itli 
a raili. Clues i4 KiniilliliH uheie llic nasal iniituui iiuriiibraiit' l>c<xiiiirt 
\n\ iilvcil, 01 \\ lieie lliere 15 extcsiivc <fiiiidalion on llif (uuti-i <>t ^touI>;llin); M 
ilie jofi paUiic, if (liplnhctia can bf entludH. arc probably warlalinal, Iflha 
lymphalic (;lancU al ihe angle of llic jii» become enlarj-eil jih<I tender, icarid 
fever is probabk, Atuic nephritis occuii'in); after nn ^inoiiuimis ntb m 
sore thtoui makes it practical!)- certain that the prin»ai>' "«atk was Ecarht 
fever. 

Afordi'tf Aiuttomy. — In the bodies oT lliose djinu durini; the first fo di)l 
(rflbe ili-ieasc, no gross lesions except those in connection «itli the thraol 
can be detected. One orboih tonsils are rj);^'ed.pcrl)aps sloughy, tl>c)^niJ< 
are enlarged, perhaps be)i;innin^ to suppurate, the iniemal ot^ns Hte i^otgci 
»iili blood, there are minute lut.'iiiorrh;(t'cs on ilieir sutfaccs. The bt^rti 
tiver, and kidneis ate |iak, ibe Pejei's glands arc swollen, and the tiMicouf 
membrane of [he inieslincs mjcfteil. If the child has >iurvivod a week « 
more, ustialty septic chungci Are present : the hmics are in a condiiinn di 
pneumonia more or less advanced, which is sccondar}' to the sloughy thrMl 
and the ^landutar inflammation and rrlhiliiis in ihc neck ; mailtcvl chanj^ 
are also found in the kidnej's if ilie child has sunivcd two or ihrcr- weekl 
In typical cases these are much enlai)jcd. flabby, pale on iIm: lurfn^-e, mil 
minoie h.Tmoi rhagc-s and injected rapillaiies ; on scciiiwi minute abscoM 
may often ))e seen at the busc of the py ramjds. On micrntcopical cxHmina 
lion l.irjic ttaris of kidney substance will l)c fmind inltliratetl with kucocytel 
and niic rixocii {Streptottna pyogenes , will bedctedcd in the cnpilUrie«. I 
death h.;ts been the result of posi-scjirlaiinal nephritis, in the catty ii^tice* tb 
kidneys n-ilt be gmgcd nith blood and deeply stained in con«cttiicnce of ih 
tuhulcs being choked uiih casts and the capillaries distended to their utmoil 
In n later stage the kidneys arc enlarged and pale, dTi]>i>inif iirii>e on wcriiM 
and on close examination it uill lie noted that the Slalpighi^n bodiei w 
cnlaivcd and pale, standing out prominently like grams of sand duticd on t 
the cortex. On microxropical cxxminalion it uill be found that ihcgtnmenf 
ntc cnUr^cd in consequence of containing an increase in the numlMrc iit ihei 
nuclei, in some cases librinoiis thrombi, and in u later ttage Iwing lurrminde 
by a Rbro-ccllular growth which completely «t^angul:1tc^ them aiul produce 
complclc obslnictton. When nephritis i» prcxcnl the cavitiei of (he hea) 
arc found dllaicd ; sometimes there is peri -endocarditis peritonitis, or pne| 
moni.-L. 

No !i[H:dGc niicro-or^'anism has liecn discovered in case* of scarlet Ins 

. we c.-innot doubt that such exist*. One of the reaKin« for it> mm 

Co\-er>- is in all probability iliat it uill not grow on any of the ordiiui 

ullivalion media. There is no diflicully in cultivating various pus coci 

Oin a drop of blood taken from the finger of a scarlet fever patient, b| 

this is alui true of measles and other fcbnlc dise;i>c>. 

TrMliHfHi. —As MWn as scarlet fever is suspected, means must be adopM 
CM llie spread of the disc;uc in the household by isolating the pMlin 



Scarlet Ffver 



2C9 



librae it is pMSiMc to do six It l»abviausly im|K>s)^il>lr tocflcci ihiein tlie 
imnllff class of houses, and indeed cicn in lar^'c and ivcll-apiioinicd houses 
iiitthint liVc pofrc't isnl.ition can Ik tamed nut, the rciiKnal of ihc pnllcnt lo 
* fctn hoipiul Itcinn m ^11 rases ihe wisest court? when i( can he man;ii.'c»i. 
Tn diiniiush ii«ks of inrcction »S fitr J)s it is jins^ihTc, n room on iln- upper 
MIT thoutd he sretlrcd,nr, still boiler, the whole of ihc top l.inriiny should 
U dmoiod to the pniieni and those of the houschoM who .ire in .it tendance 
«i him Ev«r>' aniflc in Ihe room which can be spareH, espcri.illy cur- 
iiinscirpcis, and other woollen coods, should he removed, only rrtnining 
Mcbai are rc<]itircd fnr imnicdintc use. The bedding should eonsist of a 
honduir mnllrcH and warm but lig^ht coverings. The sick-room should 
fat Uric and Mty, ihi- more ruble space the better, provided il can he kept at 
itmiyleiaic tempemturc, and all drauifhu nvoidt.-d. The aiiendants »n ihe 
*i<k thould noi mii: with the other mcmbem of ilic hou»ch<iId, but devote 
ihtmwlvw entirely to ihe w«rk of the sick-room. If there :ite children in 
iSt haute wh<i have not had iriirlet fMer, the question "ill ariic ivhat is best 
uht dme with them. In the lirel place, il is clear that iheyinust not attend 
xhoo) w mi* with other children ; the question of aendiny them iiw-ay muM 
i'ptnd upon \-;«nou.i circumsUinces. Rem;iininn at home unqvicsiionably 
"iirtvt» a risk, and at any time so long as Ihe house rtmaini mfccied they 
""*> Iw attacked. Sendinu them auay involves the risk of their being incu- 
lalmc al the time, and of conveying the infcclion lo another household. 
Hit b«i i-ourve, if it ran be taken, is to send them away to some houseliold 
"linr ihcrc are no children, and whence they can be brought back if ihey ;ivc 
'<**(fc«l after removal. Tii sent! ihciu away lo distant ^.easidc lodgings 
™iMnM be uncrioned under any circumstances ; ll is belter to run the risk 
•f inrMtion al hnmc, than have them sicken away from home amonij 
••■"HtWrt, and become the source nf an outbrc;ik elsewhere. 

At soon ill the diagnosis of scarlet fever is made the cJiild sh<iuld be put 
•• W, anil remain there as long as there is fcier, or, slill lietter, for three 
•wJ". though ihis, in mild ctlscs especially, is difficult to enforce in private 
■■•Wicf. In liospital practice three weeks in bed is the ordinar>' rule ; the 
"bjcctei (his being (oobvi.ite ihc risk of catching cold, and il is belter lo 
« inTT.e4Ut>otu in this respect. The diel for ihe first few weeks should 
'^Uot Urgely of Huids ; il is most important thai the digestive organs should 
*" fe nvcrtixed and thai the excietiir>' apparatus, especially the kidneys, 
■•"iW he active, ioasmuch as ihe wasie products are increase<l during fever, 
^ the poison ulso passes out of the body in this way. During ihe febrile 
P"™, milk i«nd hurley water or milk and soda water is the best food that 
'Mfctjiven ; feverish children taiciy aire for beef tea, and all jellies .ind 
""^i etirwets are unneccvsarj-. One or two pints of nulk suitably diliiied 
««n^f the t««nly-f<>ut hours will be quite sufficient ; if more is attempted, 
'™ot (nny not unlikely he produced. Daily sponging with tepid or cold 
■"tr, to which some Condy's Fluid or oihcr deodorant is added, is of much 
"•Wt Caution should lie exercised in giving li-'ilhs and unless ihc hath 
'aibcbniughl lothe bedside, they had belter be avoided until convalescence 
" «(il estaMished. Whilst desquamation is proceeding, after the sjionging* 
* »Jmi h*ths tlie skin should be gently anointed with gi>-ctniie and stanch, 
•cik carliolic oil, or ung. lanolini with carbolic acid or eucalyptus. 




270 ^^^V The Sfitiific Fevers 

We bii\'« no belier whalvver in (he porailrililf of Tcndenni; ibc iLitinl 
cntitel)- free from infectlim 1>>- iinoinilnt; the skin. \Vc bclicic the iiifrtlni 
of t1ic fever miiy Icaie tlie p:ilieni b) meant of his bcciiih and uluibftiM 
urine. 

The nppliratinn of topical remedies to the thmat niul nnsal mntcu 
membninc is freqiicnily ;i iiwiier of ktimI dilTiculiy in cltildren, iind madt 
ftdroilne*!, and liniiiiei* »ill bi- iiflcn tcquircd. In mild case* where llmtt 
is only n *liulil conyeilioci and mtltinj; of lli<? lonsil*. no local ireatmcol 
need be nllensplcd. i-xctpt perhiip* llic ^uckinK of juecei of ice or ic«l mill 
In older childK-n ilit^ thriiui spr^iy may be uicd if the jKiiienI is suflic: 
docile, but youn^ tliildivn lire .ilm<isl lure to offer .1 certain amount 
resistance when (heir ihroui ii beinK attended to, an<l under these cii 
stances sprayint; in useless, und the ipr^iy is nircly properly directed. Hi 
mopping by meiini of A lar^c paint bru«Ti or lint secured at the end df 
piece of siiik « ill have 10 be re'^unvil to. 5> rin),'in{; the fauces is also ii«Mj 
10 clear away the mucus which is so apt to accumulate both in the faOM 
«nd naMl pass,ij{cf . 

In <iclcc'ting an aniiseplic which is to be used freely as in »y-ritlKin|i « 
spraying, it n well to rcmembeT thai some of it may be «ua1toitTd, airf 
consctjucntly it should nol be vri^- poisonous, while for mopping' or giaiBiinf 
a catisiic or more active poison may be used. In severe <4ses the fmjuad 
cleansing of ihc ihroni is a matter of itreac importance and one apon uhkft 
«re arc inclined to lay much stress ; il is, however, ol^rn attended wull 
cxhauslin)! slrugifles for the patient, and can only be done by po>pcr)f 
trained nurses, the friends nircly havinK the necessary skill or Armnea. 
The mutual antiseptic selected is of leM im|iotlancc than the manner c4mti 
it, the object bcinu to prevent Ihc nmcus and products of decomposition (roo 
accumalaling in the fauces and bein^ drawn into the air passa|[cs «t Iwisf 
absorbccL Kur sj-rin^ng ur mopping, solutions containing chlorine, uU^ 
sodic chlorinata' (1 10 10), sulphurous acid (1 to 10^, boracic arid <;i to i\\ 
bnniKlyceridc (saturated solution in i;l>'CCiine), Ktnilas (l to 40), iicmianK*' 
nalt of puush 11 to 40I, ansiftcr very well. The sulphurous acid has 
disadvantage of frequently runcainin^ sulphuric acid, and conscqi 
Ifivin^' rise to smailin^' if there arc many ctvcka in the lips or excorUi 
about the nose. These can be used every four hount, or more fTc<)ucni 
according lu the seventy of the case. Wli«re there is much exudation, 
klouKhini: of the tonsils or fauces, some strotig caustic solution, as ^lyi 
acidi carbolici, or chinolin a to 5 per cent, in alcohol should be employ 
Nitrate of silver may l>e applied once or twite a d-iy. luvinK first sj rinjjd 
nwa> the mucus -, a saturated solution of salicylic acid in sp. vini recL a 
good prcpatalion for painliOK on. 

Therv IS but lilile rca'«on to believe that the course of ihe fever is riik 
influenced by internal remedies ; in mild c.iscs a saline such as chlotnic 
poiASh is useful, k<^'"K '' ""'>' '" "loderaie doses, as 1 10 $ gts. e\ery fiwi 
or SIX hours; in lar|;cr tlnses ii is apt In be deleterious In more severe CUtI 
the ticaiincnt must lie adapli^d In the symptoms, stimulants l>einc usuallf 
reqtiircd on account of iIh- depression which is so often ptrscnt. Carbooa: ' 
of ammonia, did'itatis, cinchona bark, sejKiraiely or in conibi nation, arc l! 
mint UNcful drugs. Diarrhu:!, if excessive, must be ke])i in check by o\a 



if modcmc. ii li.i(l Itcttcr be left atniic. SIccplcMncss hcadaclic^ 
Mriuiii, arc best reliesed by ;in icr hug lo ihf lit-ad jiid full doses of bro- 
n"ilr, \Vc lift not bcli<-\« iliat binioditic of mcrcufv or otiicr niercurinl salt 
xndhe slijjhmi ii»c in modifying ihc severity of rbe muck. Ii has failed 
tniiitlv in our hnndf. 

When the tciniMratiirc continues hiKh, being 104' 10 105", quifltne in 1 to 
]£[, dwe^ and icpciicd packs, sons 10 n^x ihc skin to aci. luvc itppmrcd 
In » the most useful form of ircniment. The child should he u'nip|M-d up in 
Ji ilicci wninjj nut of water at 60' and rallrd up in a blanket for »n Iwur. 
Tliit mu« be irpeatctl if ihc temperature rnntiniiei liijjh. Coltl spoai;i'))(S' 
are ikn utcfuL Cold bnths requim great care on account of the dcptcsi^ian 
ibti an apl to produce ; if uicd at all, ihc)' should coniitt of the )^adualcct 
laib -thiit ii, the child «hnuld be placed in a bath at 90°, the temperniure 
b(iit^|,-radua1ly reduced 1060" by the addition nf cold nater. Anii-fcbrin or 
utippin may be u»cd, but their cRcct h tcropirary only, and ihey are Apt 
la be accompanied by c(in«idcml>1c deprcs^on of ihc heart. These diu^s 
ucuwdcp)e«sint: for malii:nant cases. The former may be ({ivcninjln jgr. 
iota \a ihcrry or tincluic of orange peel, ;is ii is insoluble in \valcr. Oxy^cB' 
ptihti been i»ed uilh .-\dianta(;e by Crciswcll,' and wc have been welt 
I^cued >ith it in some cases in which we have tried il. 

Il rtriMt, howci cr, he admitted thai the Irealmeni of the severer fiimis of 

>utlii fcfcr is disapimimiiiK and often dithcartenin); ; \n spite of the most 

(^tiKil nmsint;, slimuliinis freely given, anlipyrclirii, liquid nourishmenl of 

AlUinds,.nntiscplics lo ilie faurcx, they jjo from bad to worse, apparently tin- 

mSuniied by all that has Iwxn done for ihcm. On the other luind. it some- 

ypn lupficns that cast-s which at first are most unpromising are nppjircotly 

^■xl by ear^Hul nursinj; and appropnalc treatment, and this fact should 

^fctiuriKce\ery eflbri. In rare, invtanres slou|.'hin)( fauces ivill mend, pncu' 

""MiiMcItir up, tcmperalures which have been hijjjh foriun orc4en three 

*Kb icnKhially fall, and cimptcle recovery ensue. 

IV otitis nhicli ui commonly occurs is usually suppurative from the 

tlhr tympanic tnembr;ine quickly gives way and a free discharge follows. 
<hc should be irciited by ihe insiillniion of warm camphorated oil lo- 
ll a drop or iwo of laudanum bus been added, and hoi fnmentalion». 
oay be applied cxiemally. A single drop of ulyc. acid, mrbotici (H.K), 
UrcAiItt (Iropped into the car so as 10 rc.ich the membrane, usually ^tcs 
tM If, no cvaminaiion wilh iIk- speculum, pus is seen bitl>;inK ibe mem- 
(nnc, an incision should lie made ; but nature usually anticipates ihe- 
uir),'con in this niatter, and so quickly that the opcralton is seldom necessary., 
riicpt in those c.ises where ihe membrane fails 10 jjive n-ay early. The pus- 
Htich formi in tc^arlel fever appears lo penetrate the membrane more quickly 
Ihjkn ibe pus formed in non-febrile <*a-scs. When a dischar)^ exists, caro- 
Amild be taken to keep ihe car syringed out, and loine antiseptic powder. 
iDdi ii> iodo^ra ■iimI boracic acid, blown in. The after IroHimcnt of chronic 
odiit need nrit be gone into here. 

Tbc pce\-enti*e itcatmcnl of post-scarlatinal nephriiis consists in the- 
« care being takcnduring ihcKccond and third weeks 10 avoid cold and 

> /'mfMtiMttr. Octobri iSSa 




■272 ^^^^ TAe Sptdfie I'nrrs ^^^^^^^^^ 

-to krrp Ihe iikin attiiig. and \a iivoicl ii siitiiubling <Iici and nny a\ttht^ 
'11k? child sbniild bf ^ponj-td daily or tinihed, provide) there is nn ni 
•of rhill 1 ihc diet ihoutd be- chieily Huld, milk, light (ludding^t iumI vajfn,mt 
-the bou'cU !(hould be ;icicd upon if nccvs«iry by bxiUii-cs or vilincs wth » 
Utlinlc of soda or (•tauber'i salii. Un the iippt^rance of albumen > nMn 
"purijc nfxcnna nrjnliip should be t;ivcn. and the thild dieued in a Banul 
-night fhin nnd placed beiucen the bhuikel^ salines luch .u cilraie d 
poift'h, liq. nmmon. acei., or Uirtrate of wKki, being jpi-en, Tlie dici ibmU 
con^i^i entirely nf liwrlcy »iiier ;ind (if milk, or :ii any ntc of duidv H« 
packs .1 blanket urung out of lioi uiilcr being u«cd, orliot %apour bub^ 
Kivcn by mciins of Allen's iip|inniiLi!>, ar uann lialhs, are alwiin nteful ia 
acling on the skin .'ind dniwing iiu;iy the blond from the ki<lnc)'s, aad lO 
relieving the inJliimraiitory cnn};esli<m prtitiil. Tlie wnalkr Ibe qulialil<r«f 
mint; piiMcd the nuire vigoiouj slmiild he the packi or baihi. Ten gnnM 
iif jidjorandi leaves, made into an rnfu3ii>n »iib hoi walcr, or ooe-tcaili 
«f a grain of nitrate of pil(icaii>inc subcmancously, may be (pveai beloK 
the pork* once or twice a day. Children beur pilocarpine well, but itt ok 
requires cnte on account of ihe i^rdiac di-presjion it i^ apl to prDdnoe 
Toutticct. to the loin* shiiuld bt- ;ipplied Iwtwccn the packs. l>iympfia( 
«ecni^ snmeltmrs in be useful and may be tiii-d. If the kidncyi^ tiil lo mi, 
-.ind no urine «r only a small quantiiy is nccreird, Xht^k cnemai.t nf nnn 
water will »omelimcs git e relief, urine being p^it^cd at ihc mema n linoc 
Vk|>cl1cd. 

Durinj: Ihe courM of a nephritic Ihe condition of the bcart mint be 
carefully watched, as .ilso must any lemlency to mutculnrtwiichingtabiwt 
the &ric or lunds. Any attacks of dyspmua or evidence of canlinc dilatatiM 
iniisl l>c mel by ihe adminisiiaiion of digiuilit, two to live dropi vwrj t"« 
Uotirt. .Solution of iiiiru-glyccnnc in drop dosn. inhalation of chlorofonm 
or niiraic of amyl may be tried if convulsions siiiienene. 

Ofiaranline. Sin weeks at least— belter two nionlht-rrckonins fi«*t 
the firtit day of the fe%er >1ioulil elapse before a child ronvalcMicni 6uai 
^enrlci fever can be allowed to rejoin his companion^ or go lo -M^sAt 
lodging* ; and not then if Ihe de>i|uainalion is imnmplelc or there is a dit- 
chargc from hii nose or ears. In si> impoiiani a itiatirr a« discharging a 
(Mjnvalcsccnl wratlet fever patient, it is wise to cu on ihc side of cauiioa. 

Mfluita 

Mcaslet is an acute infectious disorder characleriscd by cciyia atxl fetcr 
m the prodromal atage, foltowod by a peculiar paptilar eruption on ihe tel 
ntulbody. 

Measles, like whooping cough. pre\-ail3 ia widcspreail epidemics, ilicoch 
il» epidemics arc of shorter diirntii>n ; but sporadic caiei are always occur- 
ring in lar^e ccnircs of population, Thiseptdemic|>rci-alenccoccun tn Urge 
riiies every eighteen months or two years, though the epidemics tlifler very 
TOtKh in their cMeni and fatatiiy. In these epidemics, when oikc ihe 
di«ea«e enters a household, or indeed a street oralley. hardly anyoix- escapes 
who is not pnilecled by n previous attack, the suffcicn ill nearly all aise* 
tieing young children : the older children and adulu having suflcrcd in pie- 



MeasUs 



27i 



> epidemics. Communities removed from frequent canUd with civiliita- 
tion, and where chcrc has been no epidemic prevalcnl for soitic lime pre- 
viously, invariably suffer severely when the poison of measles i» inlroduocd, 
xtuUs being afiectcd as well as diildren. The most notable instance of ihi* 
in recent times is tlie epidemic of measles in the Fiji Islands in 1875, which 
raged for four months, 40,000 natives dying out of a population of 150,000,' 
njual to upwards of one in e* ery four of ihe popuLition, whereas in London 
in iSSfi, which may be taken as an avenge year, the dealbi from measles 
wcfc five in esfiy 10,000 living (at all ages>, The same Wrulence of an 
epidemic may be seen in a lesser degree in populations, mure especially 
amooK children, in villages or isolated places wlicie there has been no 
epidt-mic for some time previously. The susceplibiliiy to me:isles is eiceed- 

rty H'cat in iinprotei-ied subjects ; thus Biederl," in a sm.nll epidemic 
an ixoUtcd village, found only 14 per cent, of Ihe children who ■■ere 
onproiencil escaped after being exposed to the infection. In the Kante 
IsUnds under similar conditions only 4'; per cent, -ind 1 per cent, eic.ipcd.' 
Tbe same e^pencnce obtains in schools .incl in ihc w.irds nf children's 
llMpiUls, vrherr, if a child has been admitted inciilialint; and temainn till 
the ra«h appears, an epidemic fallows, which ii is ditTiculi to slop until ne.irly 
all of tiM unprotected have been attacked. The epidemics are independent 
of season, and occur in winter as in summer. 

The difeanc, like most other specific fevers, spreads by conLigion, but the 
nature ol thh h.it ni>t been satisfactorily determined, though micro-orjpnismt 
have been nbiaincil from the breath and secretions of patients suffering 
from owaslcs by A. Ransome, Braidwood and V'acher, and Canon and 

■Xickc* 

We have frequently made cultivations of pus cocci from the blood of 

imM with measles, and such can also be detected by staining a dried drop 




I poison is.-»pparently Ki*en off in tlie breath anil other secretions, and 

I conveyed to a distance by its adhering to ibc clothes or person ot a 

tnme or others coming in contact with the skk. The infection, however, 
appcan to be more diffusible or more readily destroyed than the poison of 
smallpox or varicella, a* rarely if ever in our e»:perience Is it introduced mto 
a ward, except b>' those who were admitted mcubaiing, it beinn unlike viiriola 
or vaiicella |)oison in this respect, infection in the latter case appealing to be 
brought in by viiitors. The infection is known to be given out fniui the patient 
veryearlyin the attack— that is,from the first appearance of deliniic symptoms, 
as eoryu and fever- but there is gooti reason 10 believe that Mr, \')icher is 
righi in belie^^ng that measles is infectious dming the incubative stage, 
as well ft* during the febrile and ertiptiic sta^-es. Several instances which 
paint strongly ti> this conclusion have come under our notice. 

tThc monality differs enormously according to the circumstances under 
icb the attacks develop and also in different epidemics. In healthy 
klrcn among the well-to-do class the monality is praciicatly a// ; m the 
tubercular and wasted children to be found in norkhouses, hospitals, and 



t> Cemvy, qnoted by Collie. 



■ MkrhMk/Mr KMnktilkuH^. rol. »iv. p. }(. 
• HriK Mtif. /our. .^prll tj. iS{a. 



374 7^' S/eci^c I-'evfrs 

iunong th« lower classes the nionality i» enomwus, oo disease marc ccruiilj^ 
bein^ attended oiiti a fatul r«&uli. \VilIt;iin Squire pUmii .tt lu to jo[in 
cent, of ihose aiuckcd in crowded wurds. Among dispeiiury iMiienislbc 
iiu>tialityj;cncrallyamoiintsto9or loperccnt. Inourowndisiwnsary.dunitc 
ihe nix years 1880-188$, 1.395 cases ncre treated, with 138 dc.iiltti, makin}!! 
mortality of 9 per cenl. Of the fatal case* 73 per ccoi. were under iwoyon 
[if a|;e, and 9 per ceni. under iix months of age. 

Second attack!! of true measles are not uncommon. We know lai 
family in which one boy lias had a severe attack of measles four iin>e>, > 
boy and girl three times each, and one girl twict : all these attacks wen 
severe. In many cases where there is said to hat-c been a recurrence of 
tneasles, one of the attacks has no doubt been rubella 




Infants arc occasionally bom with the rash of measles »n tbctn.' 
/*k«A»/mi«,— When inoculated ihis appears to be sc*-en or eight day*, 
when contracted in the usual way It i« nio^ily (en to twelve days, the ivh 
appcarini; on the fourternih or sixicenih day. 

Symp/omi. Prodmm-i! Slugt.—'Uit early syinplotns are tlM«e of a 
feverish cdld. The child sneeies. waters at the eye*, Oiere is catarrh of the 
nasal niemhrane, with usii.tlty a hard hftckiii); ur pcihapn croupy cOB^k- 
Someiimcs the lymptoms ate (hose of a catairhnl Uryn^-iti> or bmocbiiik 
On cvcninj: the eyelids the palpebral conjunciit^ ii seen to be red .-iikI cm- 
nested, and the fauces and tonsils are hypera^inic with exccniic tccrvi>o& 
The child is feverish, often acutely ill. the temperature risinj; in the cveiung 
a dcsieeot two and usually falling again in the morning ; this coMimiei, 

) SMildin. Mt.{ual Cinmii It. 'SUy tt^.aaA Bfil. AlBd. Jmr. -nH. l p. tiM. itgo. 






AfeasUs 



2/5 



bc<oming increasingly nurked. till ilit riisli is fully de\-clo|>ciJ. 
SMneiimet i)ier« is a mnikeit reiniMion on the lecund or Ihitd day ^sec 
'■K- 43)- I'^Aen u blotchy leclneis about Uie Tace precedes the papular 
eruption. Earache octaaionally occuts. 

Entfitixv Stii^f- — The cburaci eristic eruption usually makes its nppcar- 
a»ce M th« end of the fourth <Uy, on the foidiead, f^ice^ neck, and 
biKes. The chiM's appearance at this time is so characicrislic ihai in 
mll-nutked cases a glance \a sufficient to establish the diatniosis- The 
lltce is llusbed, the eyes red and waterinj,', there is a short cough, ihc fore- 
head, noie, and cheeks are covered with crops or dusky red papule), sur< 
rounded bjr a n>ne of erythema which contr.-ists with the ncirmal skin 




iig§a§iui 

IBI[ 

liiEiill 



Vetween die groups. The papules can be distinctly seen and (eh, &nd 
thongli not ■ shMly '■ to ihc touch, yet they have often a distinct feeling of 
hardness. The rash on the face is usually both pnirhy and dltcicie, the 
patches being made up of confluent papules, Ihc latter of small groups or 
sifi^e paptiles .iTrangcd at limes in small crescents or semicircles. In 
llMCwincof a day or i wo the rest of the body is more or less covered with 
llu|r)ish ; il is apt to b? confluent with much erythematous redness on the 
dependent surfaces, the extensor »urfac:cs of the arm and thigh, the back 
and tMttocks, and more discrete or spotty on the chest and rest of ilic bn<Iy. 
By the fifth or sixth day the enipiion is at its height, and, hexinnini; 
40 Cute firM on the face and later on the body and limbs, is followed, 

ra 



27(3 



Tlic S/>eaJic Fntrs 



»p«cinlly on the race, by a Rnc Jcsqu-tmniion. My the scvcnih »r rixhtli ihc 
raiih l)at cticnpletcty disuppurcd. leaving at most only an indefinite hmi- 
tlintt i^r staining ovei the body. Tli? icmpcmiure, whirh ha« |>rabaUy 
reached 103' to IDS'* b>- ihv sixth day,<{u\ckly falls to norma) or ihemboMf, 
and the he.idnche and dliicomfori are ^onc and the child seem; greatly 
relieved. In severe casei in u'C^kty chllilren the crisis may l>e .iccntiipanied 
by much exhaustion, but this r.irely happens. Tlw Icmpcralurc rcnuiininK bi|b 
indicates some complication luch as bronchitis or pneumonia (scr ■>)[. 43). 

MlU or ltl-<t««ne(l Keaalea.- \'ery orten ail the symptoms jiic milder 
than those juit described, but at the smiic lime Arc perfectly charariciiMie. 
On the (ithcr haiKl. the attack tnay be so flight as to be recof niscd wiihdiffl- 
ciilly. There may be alinostan entire absence of symploms in live pmdiimul 
stage, or a temiier.itiire only reaching too'or 101*, the roryta and catarrh 
1>cing insit-nificani, white the rash is represented by iI1*(lelincd and charantr- 
less papules uboui the neck, back of the hands, and thiKh«. In niltcr ra'rs 
probably the catarrh and laryngeal symptoms ^rc well markc*!. ilie child 
evidently sufTering from a laT>'ngitis ; this is fotlnivcct by an ■ndelinitc moi- 
tling about the neck and hands as the tar>-nf;c^1 synipioms abale. 

••Tervasd Complloated Meaalea. — Fpidcmics of measles differ greatly 
in the scvcrily of liic inriiviiUnl alUckt. Most of these f.*ljl allaclcs ar* 
characterised by high fever, dry brown lonBi'e.dcliiium. and convulsions, doe 
to an intense hypera-tnia of the iniemal oigans, mote cs|>ccial1y the lungs 
and hrain. The heart's action is deprc<ised, ihe rash ill deiincd, the skin 
dusky, and in some cases markedly petechial. In siu*!) cases death mavl3k« 
place on Ihe iltiid or foiinh day, or improvement may commence at the end 
of a week. In the mnjodiy of casc« mcasle* threttlcns life ihroi-gli the 
tendency to inllamm.tlion of the lungs. The lung symptoms may be pn>- 
minent from the first, or the presence of pneumonia may delay convalescence 
or supervene when the nculc symptoms have paned away. In ihe farmer 
case the lymploms arc those of acute bronchO' pneumonia, the trmperaiure 
continuei high, perhaps 105' or to6% there is marked dyspnau,iihii.ani vtunds 
are heard over the whole chesi, ihc air does mil enter the base* frtely ; the 
tash is icaniy, perhaps only an ill-defined mottling; delirum follo«>ed by 
coma comes on ; the eyelids become ghicd logether with thick scnti-piiruleat 
secreiioo, sordcs appear on ilie inouih. the longue is brown and dry, aad 
unless improvement tak^i pki'.c the child >inks. 

Oatarrbkl or asembranana ]b«r]rssltta is not uncommon in the pre- 
emptive stage, or as the eruption is receding. Tracheotomy may be reijuireil 
if the obstruction to respiration becomes sufficient to threaten life, but it 
must be borne in mind thai an amclioraiion of symptoms generally lakes 
place when the rash appc<tts. In those cases aitendeil with mcmbranov* 
eiLid.ttion ihc laryngitis ^'cnerally follows rather than precedes Ihe eniption. 
OpIiiliitliBta frequently occurs in anaemic and unhealthy children ; corneili* 
I And corne.al ulcers may ^Iso lie met with. Oluaauir eatenvmMita 
I'lnay develop, the deep cer^ic;)! gland being es|>ecially iavuhcd. as in scarlet 
iferer; abrKCsacs are not common, otttla is ver)- camnvon during con- 
IVAlcscencc, suppuration taking pl.ice in the middle ear and the mcmbraiw 
becoming pc^rfomied, 9larrbe»k is not an uncommon complication or 
sequela, eipeci.illy during ihc Iioi weather, though by no mans «xcliisi»l]r 



Miaslcs 



277 



^ 



sa ; K is sipi to become dfienteric in rhnmcter, mucus, blood, and hard lumpy 
fxcM licin^' paMed, with pmlapie i>f ihc bowel. 

The licatth often remain* impaired foiiiconsidcmUc timi: iifter :in iiiutk 
of ipca^lct : it is ilurinij lhi» stngc ih.il Aenie Tuberonloals and Cnooram 
ttrli may arise. The lubcrciilosia icry rreqiicnily appears to lake its rise 
from ei>Uri;ed iiixl cheesy brnnchi^il ^Unds. 

Dii-Xfoi's.- The disease mosi likely in be mistaken for measles b rubella, 
■ he tetter disease closely resembling' mild measles. (Sec RUIIF.1.1.A.} A 
mca&ly Ta»h ii someiin\es picscni in cases of sepiica'mia, tvherc there is 
xuppuratiun a* in cnipycma. 

li la possible lo confound measles with snallpos ihouKf" ibis difficulty is 
more likely 10 amc in the case of adnlisihan children. According lo Collie 
ilicre arc twokindsof am.ilIpnK»}iich it is possiblcio confound with mfcasles, 
vii.iheconiinenceincnIofar[inr)ucnl cascandlhccommcncemcnlof ahiemor- 
rhjigic caMT. The papules m smallpox arc much harder and more shotty, 
iindi. moreover, in a confluent case, the headache, lumb-ir pain, and general 
symptOfn* wmild be more ici'erc. tla-morihagic measles is very rate, and, 
jccordm]; to the wme auihor, would he diflicoU to diagnose from 'black 
smallpox : ' ihe quanliiy and (|uality of ilic vaccination marks should be 
(alccD into oorouni. 

JVorAf/ AiM/vm/.—Thcie is not mu<'.h to be S3i<l under ibis head, inai- 
ail iliere are no poil-tHort<m appcarancics characlerisiic of nieaslcSi 
ibe pruKipal kiion found bemg calatrlial pneumonia ; the ubote of ibe 
internal organs ate Kori^ecl tvith Ulouil, and minute b.i-morrbages are pr«Mnt 
on their suifaccv The mucous membrane of the bronchi is tnientely coo- 
ijcslcd, the surface of the pleura roughened and perhaps covered with lynipb. 
one 01 boib bases beint; solid from cncurrhal pncummiia ; in such case ihu 
pncumoaia resembles ihat found in lii^piitivmia. In some instances croupous 
pnctiiaonia involvinjt a lube or portion of a lobe may be present, or then 
may be patches of croupous pneumonia. Ai other times there is inten&e 
bronchitis, with patches of caiarrbal pneumonia and empb}'sem;L. In all 
CKSm of pneumonia folbuin}; mca.il<-s »hich wc have examined inicro- 
ACOpicJitly wc have found libnnoiis exudalion in ibe air vesicles, in spile of 
ibc pneumonia being apparently of the caianhal variety. 

llic followins post-marUm record taken from one of our note books 
illuMratcs a malignant case :- - 

Mratlti, nH/ixnoHl •,tir.- JfttH. — Child of (leien nionllu ; dcnlli on loiirlli il>y. 

I On icoKnlnf knigs ii U noicd ihsi ihc upper 1obet>rc emphyteniniout on itidr lurfatei ; 

■In die tCMer lobw cmphyicnia nlmnntn wUh collnpK; on sMtion tbi.-rr i>> inlt-mc 

ttaiMlui c4 llwinicha ami bronclii, yrilcm mucut rxudrt (rem ihi' mmuie bronchi; the 

InMp we iMisudjr mnccstcd, iberc ore palcboi of broncho- pneuniOD in in ihe louer lub«>. 

Trtatmtnt.^'So very aiiive ireaiment is needed during an aiLick of 
ilinaiy Mvcrily, but much nay be done to promote the patient's comfort and 
lit pietcnt any complications. He should, of course, be confined to bed .is 
Lmma us measles >s suspected, ihc icinpcraiurc of the room being maintained 
[at &$* F., and if the cough is hard and iiriiaiinji: a steam kettle should be 
trailed into requisiiion to keep the aimosphcrc moiv. The diet should con- 
[»ist of milk diluted nilb barley walcr or leliicr ; in mild cases sops or light 



278 



Tht Sfveifie Fttvrs 



puddings may be allowed, Dcmulccni (irlnks, such i* IwHcy »at«-, iMnoiiMlf, 
black curr.incortnmaiiiiil drinks niJc1licsA''c uicful in nlUyiiit; tl>c irriuimif 
cough. Frequcnily spong^ingt Kith w.iirn water cniiuinln^ a weak solutioo 
of ur or 'Mniias' relieve ilic itching .ind help lobiing out the mi. h. Uurins 
the prc-crtipti\c sia^c, when there mc high fc>Tr, icMlesunci*, coagh. Htid 
frcnut'Ot fiuUc, small doses of ii. aconiti, on" oi two drop* tvcrj' two hmin 
— Cltrcfutly nittchiii),- the fffect, especially after five or sin dotet havr Inxn 
>-ivcn— will be usu;illy attended with relief. Jelly conuinin^ codcia or (inati 
(loses of Dovci's powder niay be ^ivcn to relieve the iTough. Great care 
»hould be exercised (Luring convalescence to prevent cai<:hing cold, especially 
in those who are liable to bronchial catarrh, as the bronchial niiKOiis iiieR)- 
bmnc remains for soMie time in an irritable condiiioo, and eiipOMirc to cohlis 
exceedingly likely to give rise to bronchitis or dianhoca. 

In rases of greater severity, especially those in smM children uhicb nre 
accodipanied by u scanty r»sh, congesiiou of the internal orptits, hi|{h icm- 
, petaiuic, aad broncho.pneunionia, .iiiive tre.itnteni is required. It is neccs' 
sary to get the skin to act efficiently and thus relieve the cot^jcsted internal 
organs ; to this end tepid ipunging. hot pLicki.or mustard baths ntay be rm- 
ployed. For children under two yc.irs uf ;ige the mustard baih if the most 
suitable ; the child being placed for three minutes in a bath of 100° F., one 
tabIC' spoonful of mu^itard 10 the gallon of uater bring itboiit the proper 
strength. The child must be quickly dried and put between blankets ; the 
hnih may bo rcpe.jtcd in a couple of hours if necess'tr>'. Tbe tiin)utatin|{ 
effect of the bath upon the skin is often of grcjt service. Unseed poullictt 
to the chest are to be avoided in the case of youn^ children, unlrv» the attei»- 
dants arc trained nutses ; hot fomcntationsorbmnpouUiccf arc preferable in 
dispens;iry practice aad in the hands of the unskilled, ns being less beavy. 

In older children the hot pack is to be preferred to bnibs. In the earty 
st.iges small doses of antimony, pot. ant. i;m. jhn-^ '^^ * Z^'*^i ^ith sonio 
larturaled soda or ritwte of ammonia, should be given eiery ibrw; or four 
hours, but omillcd if there is nausea. Aconite may be utcfiil, but it muii be 
carefully watched, on account of the depression it is apt to produce if pushed 
too far. Alcohol in the form of whisky or brandy ibould be given tf the 
pulse is small and rapid and the tongue dry and brown. If the coujfh bc> 
comes loose and there is exceuivc secretion from the bronchi, ammonia, 
digitalis, ,-ind alcohol in combination iJioukI be given. 1*be eyes, nose, and 
mouth in itevere cases netiuirc attention ; thry ihouki be liaibed or mopped 
out with warm water ; if there arc any aphthous patches in the mouth xoinc 
hurax in dilute glycerine should be ,-tpplied. Otitic: and glandut.ir inAamma- 
lion may require attention. During convalescence no medicine answcn 
better than nitric ftcid and bark. 

Qti"i'"nti m.^Hov long should quarantine be maintained in a case of 
I 'sles ? 'litis is not an easy question to ansucr, though il is certain that 
[ fection is not given olf from the patient for sn long a period as is the 

I n scarlet fever. In uncomplic.ttcd rases hot baths may be givrn as ihe 

I v^ins to disappear ; iliey arc useful to cleanse the skin and render ilie 

ii more comfortable. It is well for the patient 10 keep hts bed for ten 
' . jnil his room for three weeks ; (hen, if he is quite well in e^wyrespcct, 
ire can tic little danger in liis mixing with his fellows. 'Whvti a c«sc of 



Rubtttn 



279 






I 



Of-can in a hoiisc, it is necessary fur titc mhcr children uiio have 
il Id stop goin^ to school or inixin),' u-iih other children, a» it is 
pmbabic ilic]- nill liavi; cCMiiracied ibi: iliscase : and as mvuslts is infec- 
timtts in it» Miriy iiUi^cs- if not tltinn),' the incuhfition period— they may 
readily br the mean^of gii'in^ ii lo oilier^. For the iamcrc;iioii ii i^unwiM 
ta tend them away from home, though ciirc should tie taken thai they do not 
ccmtc in cimlael with the pxticnt at home. The bedding shuiild be siuied and 
ihc room ocrupicd by the patiuni disinfected at ihc conclusion of tlie iiUiesi. 

Xstb*Ia or Xa1>«]Ia 

Rubella' isaninfectiuiu fever closely resembling' Imt diitmci from inMslcsi 
it is li>i ihc tnust part a milder disorder than ineusle^, and dues ikiI protect 
/rom i(. Ill sotiM epidemics it closely resembles mild ji-arlei fever. 

Etioiogy.^'VliK resemblance between ihese iwodiaea^iw is unmiesiioiiably 
B dose one, and tlierc ii little doubt thai not infieijucnily epidemics of 
rubelU— oral any rate sporadic case»— arc mistaken for meaales, Il hus, 
hiivrcier, been clearly shown by those who have had the opportunity of 
vraiching successive epidemic* of infectious disea^ci in schools and asylunu. 
where ilie satne individuals have been attacked, that rubetU does not 
protect itam either measki or ^icarlei fever, nor do attacks of ibe two Inner 
affioTd any immunity fiom attacks of rubella, 'flic rMcinblance, and yet the 
dillcrem:e, between the wa diseases is «ell put by Dr. VVesi when he says 
' ihey resemble each i>lhcr somewhat as varicell.i and varioia— alike, but not 
the same —not Iwiu sisters indeed, but halfsister; at any ratt' That I hey 
6hould be confounded in practice is not surprising, especially when we re- 
member tlial measles is sometimes an extremely slight disease and the rash 
by no mcani characteristic. In mild atliicks of measles (he con'ai is usually 
aUghi or absent, and the rash little else lh,in ill-detined mottling. 

KubelU occurs in epidemics sometimes being prevalent and widespread, 
as it nas in this country durin); i8So ; at other times sporadic cases crop up 
and there appears but little tendency for the disease to spread. As a result, 
rubella has earned a different diaiacler as regards contagiciusness from 
diAercnt writers who haie observed it, some mainlaining that it5Coni;igic>i«- 
neS9 IS dirousi nil, and others that il is extremely contagious. The truth is 
liat susceplilnlity to its Influence seems to \^!y strangely at ditTerent limes 
atvd in differeni places In .1 way which it is ditficiili to account for. Thus in 
one Incalily there may be an epidemic prevalent : an individual goes to 
another while incubating, he suffers from an ordinary attack and the disease 
docs not sprud, though he comes in contact with many Individuals. There 
islittle doubt, however, that rubella has been confounded « ith some of the nor- 
specilic, non' contagious forms of roseola or rose rash. Age dues not seem 
greatly to influence predisposition ; mfants, children. and adults suffering alike ; 
indeed, in some epidemic^ adults suffer more in proportion to their numbers. 
Thus in an epidemic in the Children's Hospital obset\cd by Dr. I^uiion and 
ourselves, out of tHcoiy-tcven cates, eight were those of lady probationers or 
'sisien,' and nineteen of children ; so that Ihc atlults suffered far more 

I \{e adopt the Icnii rutxllA nt lir>il fuKRMcd, wr l>rlirt«. Iiy W. Si|iiite. ' Epldrnitc 
roMoU.' ahidi has been jiroposed, inlrDducci the amblguoui tvtin t>t ' rcwola.' 





Ike Specific Fewrs 

].-irgely in proportion lo ihcir numlKrrs, though ihcrc can be nodoubt thai ' 
nurses came in contuci uith those suiicrinK iroin ihe diioK much inorc iIm" 
the children. Considerinj; how mudi tartr a ilisc4sc nibclU U than mcAitcs, 
it would Appear that a !>nuller niiinbei of inUividiiuU oho arc unpmicclcd bjr 
a previouj nllack are susctpiiblf to it* influence. 

The relationship of rubella lo measles ami scarlet fever is «n inlcrctting 
q'.tcs(iun, and while vtry lew believe it to be a hybrid diseitsc, the attack 
rcsuliinf! from ihe recepiion by the patient of both »cartailni>l mimI inM*lcfc 
])nii(ins, yet. considerlnj; the close rracmblanct which ii bears lu tiieaslet. 
there is nulhint; inherciiily improbable in the idea ilut the le^cinbliince is 
something more than toincidenlal, ibat the poisons may h-xvc been ilenved 
from one another or frum Ihe same stock at some distant epoch, and have 
become muditied by being eultivatcd under dtOereni condilions. h i» imc-i 
resiin^; to note that lomc observers assert that the cliatscter of an epidemic, 
becomes mudi6ed in the direction of either incaslea or scJirlet fe^-cr if eilfccrj 
of these Is prevailing at the same time. I 

It is a curious fact that there are epidemics of rubella, in which the rash 
closely resembles scarlet fever and not measles, as is generally ihc est*. ' 
Whetlier the two forms are distinct diseases or only varieties of the smdo ' 
disease, it is impossible to say. We caniiol say wlieilier the measles vaficty ' 
protects from the scarlatinal variety. I 

/iiic«A»ft'("».— There has been some uncertainty about the length of tht ^ 
incubatiim period. 1 he cunimnii period is from two to three o-edis, u , 
observed both by VV. Squire and Lewis .Smith. In three cases iromin)( ' 
under our own observation the tune appeared to be sixteen, se^'enleen, ami 
ei);hicen days respectively. 

I'mHcnilory jiYiyv.— In dtildren, as a rule, no prodromal symptoms aie 
obien-cd, tlte rash being ihe first thing to be noticed. In adults whu art 
able to describe tlicir feelings, complaint is made of weariness, hc^idache. and 
backache for iweniy-four hours before the appearance of the rasiL Thcic, 
may be vomiting, corym, slight sure throat, or a tingling sensation of the 
skin of tbc face. .'Xnotlier noteworthy symptom sometimes prcseni is ihe 
RnUrgcinciii of the superRcial lymphatic glands situated along ilie jxisteiior 
edge of the siemu- mastoid, or the submaxillary and occipital glands are tender 
as well as slightly enlarged, and give rise to a certain amount of stifliics*. 
of the neck. Un llie other hand, it is by no means uncommon even in adidt*! 
that Ihe discovery- of a rash is ilic tii-st thing to call attention to the attack, j 
frodroitiitl Sia/^. MoaatCB Tarloty. The lasli usually appears lirsloo. 
the face, and consists of indistinct, ill-defincd papules, forming irregular 
patches of a rose-red colour, which shade away into the colour uj the skin |t 
there may be simply erythematous blotches. The patches of c<HnriueBl| 
papules vary much in site and shape, many perliapt consisting of only a iv». 
p.ipulcs grouped together ; sometimes, on the contiary, tlie whole &ce is nf 
t red colour. The rash is usually also abundant on the neck, chest, baclti 
buttocks, and Acxor surfaces of the arms and thighs : in these situations >t 
is usually less confluent luid patchy than on Ihe face, Ihe rash consiiimg nf 
t^oiips of papules or of single jiapules. Occasionally the confluence o4 Ibfl 
papules and the erytliema which surrounds them give rise to the au»p 



Rubella 



3SI 



Ficwt« (c<rer, especially 10 thac fonn in «liicli the rush is patchy on the 

iliuib). but the rash uT rubella uluays coii^i^its uf piipuli-s. and is nul diffiiie 

Ifimcinieil as ts ihe rjah of scarlet (ever. Kubellii nuhcs undoubiedly 

Ki>' twisidcrably. eipecially in llie conHueiii:).- of the papules ; iui a nilc, 

: (oiouf is <rf a roae-red when it first eometi om, btiiiK of a briyhttr colour 

dit measles ; the papules do not so cumiantlv arian^ic Ihetn&ehes in 

, and ibey ate Icm distinct Than the incitilei juipulvi. I'he rash is 

Sy itMMt intetise on the second iby. hut rcm^iini visible for three or 

r<b}s; by the end of lliis time it Ims inusily Tadcd, often lea\in}; more 

twlci3»tait>it)g of the skin and a li^jhi br.inii) desquamation. The tosh 

tltnjuFnily };ires rise to much itching;. Soinetimes the axillary and tnjfuiiiat 

(UneS becotne enlarged. 

Tlie couise of the attack may be feverless. ihough ustially there is a slight 
rit of temperature, the hiijhest being on the second dayj^Q'to too"; in rare 
cuoit reaches 102'' or loj". The temperature becmnes nunnal as llie rash 
Appears. 

Hypcnemta ti the conjtmcliva and feuces exists in tnany cases, btit it i* 
Did)' as marked a fealuie of the attack us it is in measles. Sometimes a 
<lr!trMjand soiene^of the thniat in swallowmj; is complained of, Miih tiiore 
« leu catarrhal [onsillitit. 

While such may be takco as a typical attack, it must be acknouledited 
thii the attacks of this ex:inthem var>* gieatly in intensity, and the nuh may 
bttenilldclined to admit of a posilife dl.i){nosi.s. In some rate cases, such 
SiIliMi; deKhhed by Dr. Cheadle, ihcrmirtc of the diheaieis that uf a serious 
lUnnt, nith (n.-iTkcd implication of the bijRx and bronchi, the cough bein); 
ant and ciouplikc. In luo of these broncho- pneumonia superiened, 
)ieiMal olhcn earache u-.is n prominent lymptoin. On the other hand, 
I mtf occur of the mildest form, \a wanlinx in character both as regards 
»A tnd coryia, that they m.-i\ be looked upon as of a doubtful nature and 
pobpi forgotten, and oniy h hen they arc succeeded by more typical cases 
, ikio ihc\r character become clear. 

■MiteUiMl vartetjr.— Some years ago we were much punled by finding 
'■ i number i>f what were apparently mild caiei of scarlet fever, when 
[idniitrol to our fe^er ward develi>pcd scarlet fcvet a few days after ilicir 
[■ilmiaion. Shuitly after we noleil a number of patients coming to the oui- 

C^i ilepartinent with diffuse red nishcs, but who were hardly ill .it all, 
I luil been brought on account uf the rash. It loon became apparent 
^Ihuibrrcoai an epidemic of a disease closely resemliliuy scarlet fever y el 
'*<i'KI from it, inasmuch as ii left the paticni still susceptible tu an attack 
•■ Mikt fever. This epidemic was no doubt one of the scailutiniil »'arieiy 
*ilMh. In many of the case* there was a hi^Ioiyof vomiting as an 
^sfmpti>m,complaiTit of sore throat, slight fevcr.anda vtry well-marked 
■ 'hilt the child hardly felt ill at all. The rash uas usuidly copious 
'W)ld not he distinguished from sc.irlet fever tiislies. but was more of a 
™** ^ and less distinctly punctiform in character— that is, there was a 
UiAinn teilneu, without the red points, which correspond with the hair 
||ali> Id, being well mnrknL Still, vie must admit that the rash seen in 
!Cues was indislinguiihable fiom some undoubted scarlet fever rasheiL, 



2$3 



The Sfi-ajfc Fevers 



When onto »uc1i an cpideniic n known to (irctail tire iJijixnnsis mSSSTi 
dtilkuli. 'Hie fever. in;ibii«, and »nre iliroai nrc filight, wltilc thcMsh bof 
oui. In 5Cail«l fcvcf nith a copious nlshthc fcvet i* usually liij^h, llwliW 
araangrj'andswollun.uiKl ibv child iicvidtriUy ill. Milduiits wouldM 
likely W occur tine after another ; some would be ceit^in to be >haip ( 
typicul. UeSijUMniiuiDn folluui the ri-d nnU >i{ lubellu. I>ul it is mel) ai ■ 
marked Ai in typical ca^es of scarlet fever, »licfe the r&»h l)a» been cope 
anil the fe\er ^larp. Some authors lay great siitii on the cnlatgeincai 
the lymphatic ^danda behind the Hienio-majioid, ai^illa, and in);uinal regie 
This is no doubt true, but they ate not universally enlarged ; ■« hi 
cenalnty »een cases of both vaiietics of rulMlla without any lytnptu 
enlar]jeniciit. In some cases and in some epidemics ihc mh is mi 
patcliy ihim the rash described, but wc have not seen many such. It mi 
be borne in mmd that the »carlatmal variety of nibelU is a compatMin 
rare disease, while scarlet fever is a very common one, and thai an i«cl«l 
case of fever with sore throat and a diffuse red rash is far mor« likely m 
scarlet fever than rubella, however mild and uncomplicated it may prow 
be- To l^nd that a child we h.tve declared lo be suAcrin],' from ' Gem 
measles ' has acute nephritis is, to say the le-ist of it. jin unpleasant i 
cover)-. 

Rose rashes, diffuse and patchy, may make their appearance after t 
tiigestion of some improper food, or in hot summer weather. There nmo* 
an absence of both sore Iliioat and fever. The |Mssibiliiy of a red n 
bcin^ due to belladonna must not be forgotten. 

CompiUalictti iiitd ^^^wcAi'.— There aie usually none ; in the more sen 
cases catarrhal di'sordcts, such as coryia, tonsillitis, and broncho- pncunra 
may complicate and succeed the attack. The prognosis is favourable; < 
disc'ise is probably never fatal in healthy children ; in epidemics in hospili 
whetc it attacks children already suilering from and much reduced 
pulmonary affections, it has Hppe;ired to be the inimedialc cause of a b 
result. Ei'en in healthy childieo the health may remain below ptr 
some time afterwards, 

/4'<iA'j)fur>.— Rubella may at limes be mistaken for some ofiheuMMiul 
erythematous or roseulous tusbe-t from which children suflct from «ri 
causes, e*pecinlly indiueatible food, but there is usually no fever. In an 
cases dini^nusis may be dlllicrutt. but the fact that rubella prevails in epidcii 
often ai.iiili in m;ikiiig a diagnotis. The diagnosis beiu'een measles i 
lubcUa in »n individun) caae is at limes impossible : often it is diflk 
inasmuch .it ii must be admitted that llicre is noonc charactertMir sympl 
of rubella, and moreover the rash diffen in different cases. Tlic differcn 
between typical cases of rubella, measles, and scarlet fever are showa 
the table opposite. 

7>v-j/#«*-«/,— Every case of rubella and e»-ery suspicious CMtt tlioatd 
carefully isolated, and conlined to one room, if not to bed. The diet ilia 
consist l.iit;ely of fluids and slops. .X simple saline such as citrate of pot 
may l>e l;i^■cn, and other symptoms must be treated as they arise, 

Qu.iriirriine. -The patient should be isolated for at least three w« 
better if four weeks elapse before lie ii allowed to rejoin his companioiu. 



Diphfhiria 



383 




Diphihcm it nn inrcctioui disorder which is chnmclerised by ihc fnr- 
WUeB of a librinoUK exudaiioo un mucous surTaces. caused by the develop- 
"KH of a peculiar bncillui ; it is iisu:iUy accompanied by .-in;i-ini;i .nnd 
•^onuiniria, and frc<|ticnl!y followed by p^iresis of Vijrious muscles. At the 
'^tytbiestuild of the subject it miiy be as well louttempi tode>-ir the gtnund 
bj ukinK~Are we lo ccnsidfr all fibrinous exudations which baic the 
'hwsdCf* of a 'fnhe membrane' as evidence of the presence of diphtheria? 
'* tliphthcru alirays accoitipnnied by a 'false membtnnc'? Ilolb these 
Vuimt miLti he an»wetcd In ihe negative. Recent observations ricarly 
Jhi* tlut Mhcr mi cm-organ isms besides the D-bncillus are capable of pro- 
dKug fibrinous cxiKlations on the feuccs, and, moreover, ihc D-bacillus has 
t*tn denKKi St rated in the secretions taken from what were apparently non- 
*mbnnouBsorcihroats. Sitll, wemust admit thai mcmbt^nou.i exudations 
mnnJly diphihcrilic, and eliai diphtheria is rarely present in the absence 
*f'UlHineinbrane.' 




iifieei/ 



'^tvfrt 



'DxM dipl)lheri:i ii a highly contauioui diiorder » made c^nin 
dcliuiie evidence ; it is a mntter of common experience ihai the ditui 
jiastes fimii patient to ntirsc, fmm one paiirni lo anniher in th« wardt of I 
iioipilal, ami frnm a sick child lo ilt pLiym.Htcs oi p;iicn1'^ in private bOHMI 
It is certain alsci that the infection can beconvcicd from the t>rk toik 
healthy b/ mt^ans of a third pcnon, the infective paitirles travelling «<itt 
clothes or on the hands f)f the latter. Direct inoculation h4-s taken |fa 
Accident.illy by mean* of small pieces of membrane or the wcictiiwi* all 
ing the moutti, as in sockinti a Irachcotomy wound ; false niembnnc hi 
formed within tn-cniy-foiir hours of an operation at the scsc of the wcun 
There is little doubt also (hat the disease h^s been transfened fromanimi 
In man thioiij^h direct coniHci or by mcan^ of milk fiom cous siifTcnnf fra 
the disease. The L)-bacilIus may teiaiii its vitality for many mixitfas M 
side the body, snd inay be carried any distance in cloilies, bed lincti, at « 
surgical instruments. It is possible that the U-bacillus nuy grow and <N 
velop in sewage, in cesspools, and drains, and re-enter ilie body bf ll 
inhalation of sewer gas, It is a popular notion that Ilicrc is a cliwe at 
nectioii between diphtheria and sewer ^as, and sanitary faults in hou«c*a 
freqiiently credited with beiii),' (')< ciatisc of outbreaks of diphtheria : mmI 
it quite possible that sewur ^»s may give rise to a non-spocific sore thni 
which may form a suitable iiiil for the development of the U-bacdlus. 

Dipliilieria occurs in epidemics, but it is also endemic in sonvc etitet 
rural districts. It is constantly present in such cities as Berlin, I'aris, 
New York, and in some rural dislricls in this country. In its disitiliul: 
and in the varying charsicter of its epiden>ic» it is one of ttic most mj-stci 
diseases with which we are acquamicd, and there Js iwuch about it »1 
requires continued invest it: at ion. '" ■'"* country until recently it has 
more common in the runil than in the uiban districts, ihou^'h it appears 
the present time to be more common no«' in our large towns than foi 
It is especially prevalent in the soulh-easleni and eastern rural disi 
while some others appicar to escape almost entirely, ll makes its ai 
ancc at timet in iiolntcd farmhouses, or vtllat;cs remote from other hal 
lations, and this circumstance h.is sugKcsted the idea that possibly 
infective particles have been conveyed thither by means of the wind (Aii^ 
Jl has occurred in Central Africa far awayfrum any source of infcctit 
But in connection with these singular cases we must nntcniber llui ti 
D-bacillus retainit iix vitality for many months under suitable conditiM 
and may be conveyed any distance an clothes or other articles, and ib 
infect persons long distances anay from the original iourc« of the infectia 

No age is exempt from its attacks, but children between the ages of n 

and eight yeatx are most often attacked, and children of lhes« ages iitt 

readily succumb than do older thildt^i. The disposition to diphthct 

^-^leenis to run in families, members of Ibe same family bctnf; aitaidted 

iiuidc succession or at variable intervals. 

Tlic parts which arc moti often attacked arc the fauces, nasal macc 
neinbrane,lar)*nxaml trachea, ^'innspcnii' and vub a; or, may be, some WM 

ccMmaious skin. The bacillus rntcrt the mouth in eilbirr air or 61 
FSad if condhions arc fovourablc for its development the growth of 
bacillus contmettccs, and membrane for-ms on the lonsili and soft 



Diphtheria 



285 



-ntut Ihue favoumble conditions consist it is difficult lo «ay. Ccr- 
A slijtht sore throat or laryngeal cnlarrh tiftun prcicile* an attack 
ilbeiio, and it ii vcr)- (irotxibk that any injury lo the epiihelium or x 
nUTTtial date may afTurd a suitable soil for the development of the bacillus. 
VTc have known instances in which nasiti di]>iiiheri.-i has supervened in a 
OM of chronic at.Tn.-i, whil« nthcr children exposed lo infection at the 
mat lime vere ty>t attacked. The Vitality nf diRcrent epidemics varies 
tniBtdy : somdinKs whole families arc swept away, as in the epidemic de- 
Kiibol by Trousseau in Solottne, where in one fann, where the reiidentit 
ivbctvci cighiceo, only t«*ix, the father and .1 servant girl, survived. The 
iiteiea xcmf to v.ir%- in intensity, at limes xnA under certain conditions 
ItCMnine atlenunied, at other times rc:4uminc its virulcncy. 

MtfUd Anah'my .im/ Pjtkology.— The membranous exudation which is 

fRMK m diphtheria it of a whilish-grcy irolour, and when fiisl formed is 

fncljridhcTcni inthciiuucshcnenihii. It is in snme cases miher ycllowitb 

Au shite : in mati^;)nt case« it is frequenily brown from bcin^ (tnined 

iyhnirn-down blood. In a fen- day? more or less the mpmbranc brrooics 

tantimt from its Ati.i<-bm<-ni and ran be rcmovnl by mc.-ms of a brush \ if 

fadUy itiiwived ii leaics .1 ra»- surface, which ciuickly heconics again 

cmnd with tnembr.me. .Speaking Krncmlly, membrane adheres more 

iniJyiad i« lew easily dci.idw-d from ibc n^iieous mcmbmnc r>f ibe tonsils 

UJ toA (ulaic tlun fmm the Urynx and trachea, [f n thin section of a 

ptce of membrane .idhrrinK to the sol^ palate be stained with methyl 

Uicind examined with A moderately high power, it will he seen that the 

I, Knbranc consists of a fine neiirorle of fibrin with epithelial cells and 

[ hracyiw in the meshes ; beneath the membrane the papilKi- and connective 

. aiue of the deeper layers of the mucous membrane will be seen to be in- 

I Gbaied with leucocyfes. On the suifarc of the fibrinous exudation ntany 

owi of vaiious kinds arc visible, such as arc commonly to be seen in ibc 

' mnk or alimcniari- r.-inal. I.ocfller's n-b.icilli arc to be seen usually in 

hik tnBt Of masses rmbeddcri in the superficial layers of the false incm- 

bnne; in tome cAse* ihey may be seen in the deeper part of the mcmbnini-- 

nboeatb it. I'nlike the nnilitnx liacilluB, the I)-bacillus lemains lucal, 

uddotSHM penetrate into thci is sues or enter the blood. The D.bucillu* 

ii a non.moiik little tod about the tcnjnh nf the tubercle bacillus, but 

AMb. «i that «hen se>eral jiic joined lojictber they look at first sight not 

nflK streptococci. When fully devclnprd the ends of the bacilli arc 

dutoitid thicker than their central portions, sometimes only one end is 

tollrttij. Two arc often joined together, but not infrei|uently more. They 

*wyti)n!iiierably in shape and siic, accord injj 10 ihcir ageand ihecondiiions 

"•^wlilch ihey hai-e grmnn. The chcmisir>- of the membranes and the 

ptwws formed in the nudAii'Ms and in ihc blood have been studied by 

^auand Yetsin, and more reccnily by Sidney Martin (Ijiw/t. March id, 

|p4li. The latter oljier^-cr has esiablishcd the fact that during the growih 

^of iIk bacilli a (ctment is formed which is capable of digesting proicid$, 

cmim albunKMCs being formed which act ns vindeni poisons on the system. 

"IVm albrnncoes are formicd locally and are then absorbed into the blood; 

bat ii appean the ferment is also present in the blood, and by its action on 

|rik inoceidi uf the blood and liisues albumoses maybe formed in the spleen 



286 



The Specific Fevers 



ins pc^ 



and o[h«r or^ns. Similar poixonn are formed n-hcn the bacilli ore cnl- 
lirattd in blood •.erum i>r in Rciarine. Rmw and N'emin lui»-e shown thai i 
tlif nuiticnl fluids in which (he bacilli liavt K"iw-n arc, nftcr Ihe bacilli hiw 
bnn separated by filtration, injected subcuuncou-ily into guinea pigt, dcsuh 
takes place uith symptoms ortoxR'mia in in'cniy-foiir honi^. If small doMt 
were employed and injected inm rabbits, and a fnta) result did not lab 
place, a puralyiii was often left. The poison appmrs to f;ivc ris« to ilt- 
genenilian of ihc lis&im ; there arc changes in the iivcr cells, the rmiscdw 
fibres of the heail atid other or);ans, and the smaller motor and KBM<]r 
nerves. In the peripheral nerves the while substance i>f Schwann nadeiian 
<legeneratiun. and in places disappears ; the axis cylinder is also allrctMl 
hut in lc>s degree. It is this peripheral degeneration of the neiTcs whicku 
the cause of the paralysis so often noted after an attack of diphtherU. lit 
blood is profoundly altered and its coagulability interfered witti ; htncr 
the hJemorrha^'cs and purpuric condition seen in malignant caMs <i 
diphtheria. The cause of the albuminuria is uncertain ; it may be caMttl 
by the altered st»te of the blood, or be due to the fatty degeneration ufikli 
the renal epithelium undergoes : the amount of albumen present is iu omi 
cases a correct index of the severity of the attack. 

From the above facts it uould appear that the D-bacil)ui is the 
primar>' infeciiic at;em, and that during its srowth it give* rise to the 
fibrinuui exudation ; at the same time a ferment is formed rev^mbling 
»ine which is capable of digesting proieids. This proieid digestion 
both in the membranous exudation and also in the bloixl, albumosei 
fanned, "hich play the part of t irulent poisons, giving rise to rapid tisine 
<legene[aiiun and serious changes in the blood. Tlie relation liet«-ecn iht 
diphtheria of man and that of the domestic animals is interesting imd in- 
jittrtant. Some of our don>eslic animals appear to sufTer not infrequently 
from diphtheria, and may he the means of giving rise to epidemics of buBia 
tliphlheriu. The observations of Kteiu ' have shown that diphtheria may be 
communicated to co»s by subcuianeous injections of rultisationi of baolH 
from the membrune taken from rases of human diphtheria. A wh tender 
swelling forms at the scat of the injeciion, and in some catcx at least a 
number of pimples appear on the udders, which pass through the stage* cf 
pustules and ulcers. The cows sulTer more or leis from fc»cr, and an exieB> 
iive loss of hair takes place. During ibc eruptive .ttage the milk oS smdc 
of the cows was found to contain numerous diphtheria bncitli. In at least 
two epidemics of diphtheria in which the milk coming from a certain dairy 
was suspected of bcmg the caute, it vn\ found on namination of the tow^ 
that they were suffering from an eruptive disorder on their udders liniilarla 
that produced in those cow^ which had been inoculated. Diphthcri.i 
bceiii>ri>du«dby Klein in tuts by feeding them with cultures of the D. 
in milk, ;iru) ep^demiti of diphlheri^ have been observed in cats. 
^H ?usccrpii1ilc of all the domestic animals. Kowli suffer A'Qg, 

^P ipubich closelyrcsembles, if it is not identical with, faun^i^ 

^B ceitl Di p tain erl*.— The tonsils, uvula, and pillars of the U^ctt 

^ .'uriic sites for the (alse membrane in diphllieria. and in by ^ 

^^^^^^^^^&Mllll^l—l IWin r T oX ihe lineal iiyrnioBiaA beard. 



Dif^t/icria 



287 



the i;reat«r number or cases nccurrint; in pniciioc these parts arc affected in 

ihe firat initaoce. The attack, iintikc scnrlct fever, usually begins insidiously. 

The fricndk notice thai the child is ailin],'. it docs not care for its to)-s, it i& 

peevish and Cretful, and towards evening is fevctish. Perhaps ihete is some 

Khndular enbrgcmcnt at the nn^Ics of Ihc jaw, or a discharge from the 

DMe, ot the child is heavy ssd drowsy. In older children there is usually 

scene complaint of sore throat or dil^culty in swallowing' ; the child feels cold 

and ihivery, and sits over the lire trying to keep itself »jtrin An examination 

ol the Cuice?t, if made uithin a few houis of the lirst symptoms, may show 

Mhing very distinctive ; there may be some swelling and excessive redness. 

with scone whitiiti or yellowish exudation in |>oiiits or patches, bu> it may be 

l.^te imp<Msible to decide whether the ca»c is one of diphtheria, ic.irlct 

LInti, or other form of tonsillitis, Usually, however, within twenty-four hours 

1 ol tlic commencement of the illness, iMtclics of membr.nnous exudation may 

1 be Men on the inner surfaces of the tonsils or soft palate ; these are »hitt»h 

M pey and opatiuc. adhering firmly to the surface so that tliey cannot be 

innmed by brushing. If removed by forceps, a raiv bleeding surface is left; 

a jUKe of membrane when removed is seen to be lough and lirm. differing 

j boa the wft cheesy material whicli is present in scarlet fever or lonaillins. 

' Tlw lempctature is rarely higli. being mostly 101^ to 103" F. ; the cvemng 

Mapeiature being, as a rule, a degree or [wo higher than the morning tem- 

pnlurt; In a day or two^ if not from the first, membranous exudation may 

btMcn on the utnita or the pillai^ of the fauces, though the lonsilt may be 

ftUD linl to Inst the only pan affected. The nasal mucous membrane is apt 

lojoiii in the inflammatory process ; a semi -purulent, often bloody discharge 

mbes iti appearance at llie nostrils ; the child makes a snoring noi^^e when 

alop, on account of the obstruction caused by the swelling of the mucous 

ntfflbraneand tlie excessive secretion. At> examination of the urine durinn 

tht lint day or two may be negniive as far as albumen is concenied, Init if 

1 daily examination be made, in the great majority of cases albumen var^'- 

injui amount from a trace to one-half will be found. During Ihe next few 

da)t(iesh pntchci of membrane nuke their appearance on the fauces, the 

oldnenn becoming loosened, tJicn detached, by the process of sloughing 

•liith tats on. In the meantime the glandular enlargement and tender- 

a»* become more marked, and the neck is stiff and all movcmcnis are 

piinfill. The patient becomes weak, ana-mic, and easily exhaunled; there is 

«ft«n mwlce;! ftcior of the bfcaih. In favourable cases, after the tirsi few 

i)»if»«i»iii*ek noncn- membrane fornix, while the old patches disappear, rhe 

wdlinxofthc glands and tonsil* becomes ltss,and the lempcraiure gradually 

Uh. Ihe albuipen aUo gradu.illy diminishes in quantity and finally dis- 

■fptaiL The child remains u-i-ak for a long time, convalescence being only 

t^ly tsiabliihed. On the other hand, in unfavourable cases, instead of an 

■Bpmiiitut lakini: place at the en<l of ibc first week, the symptoms both 

l**! lod K'O^'al become more pronounced ; the amount of urine increases, 

AcpdMUwtaker and perhaps iniemiiiteni, the an.-emia is profound, the 

VMih lery nilcnsire, and noting of blood takes place from ihc mouth and 

***«■ The patient uradually beconit-s exh.iustcd and rrfusci his food. 

I^oiOjrihcliiH hours of life there may be toul lupprenion of uiinc, drowsi- 

ws, ami extreme depression of the heart's action. 



28$ 



The S/vcifie fnvrs 



Mild cases mxf occur in which both tlic locxl and itencnil syrnptonit m 
slight, Thcn;niaybc-incml>ranou»or ydlow-coloured paicheson the lomiK 
the nxoA mucous mfmbmnp rcmjininj; fr« nml llic i^UnduUi cnUivrniffl! 
abscnl, and perh.tiis only a Inirc nf nlboincn in ihc unm;. -Siich pjiiwiii 
may lie sci-n running aboui uiili but little appiMrance nf tllncH ; the \<m 
Inioi]^ may disappcni in a few day*. Ii is imponani to remwnbci ilut i* 
&iich cases pflTalysts may foUii»', or a latal tc«ul< msy come about ihiDUfb 
caidiac failure, 

KmiiBoaDt Dlpbtl>*rla. — Of severe and mali^Tiant cuses of dtphllwni 
ihet^are several types. The attack may bej^in insidiotisly with a dayornm 
of slight illness and then nlarminK «ymptams of cardiac failure may m( ii 
without there having been any excess! vc local leiion. In other cases the alGKlt 
is stormy from the very Bist, perhaps accompanied by vomiting:, anil clotdr 
resembling scarlet fever tn lis mode of attack. Within a few houts of At 
onset there is exiensivc sH-elling at the angles of the jaws, with afnliic 
of stony hardness, a fa'tid, sanguineous discharge ivtucs from the nottrilh 
and it is dilTicult to i^et a view of the throat in consequi-nce of the iwdlin; 
and difficulty in opening the mouth. The tonsils are io swollen as lo i»n<, 
the uvula and soft palate u-dematous and covered with ntore or lesaslouclv* 
looking membrane. The temperature is usually high, bcinc 103' to 104' f- 
and the pulse and heart's action exceedingly feeble. In the course oS xt*l 
or twu, sometimes less, the cellulitis exienils, the cheek* and i±t.^ becoM 
crdematous, and the skin pittas lowiia iliecbvicle.oreven overiheMenx* 
aod cheil "-alls; ilic patient becomes drowsy and cyanotic, and there iwf 
be an erj iliemaii)u:> laili. especially about the neck and clwst. Purpunc 
rashes ate common in nialignnm case^. Death usually occurs in a fewdiyi. 
Such cases resemble malignant scarlet fever, and it m.iy be difficult or ii»- 
possible to itistmpiish between them in the absence of a cbaractcriwic not 
WmbkI 9lplitb*rln.— fn pharyngea] diphtheria the inilammatnry po- 
gcess is apt to spivad to the nasal mucous membrane, especially in v\ti* 
Bftses. Ill some cases, however, the nasal mucous membrane is the 6tsi 
-teat of the exudation, and it may never spread to the tonsils, though it S 
usually 10 be found 10 involve the back of the soft palate aiul the phaTfiK 
more or less. In nasal diphtheria no membrane may be disiinguialicd 
during life ; there may be only a purulent discharge with blood, the pmeni< 
of which in the nasal passages obstructs rc>|>iraiian, giving rise to a bMl 
or sniffling siniml, especially during sleep. In o:isal diphtheria the 
symptoms are usually quite its s<^ere as in faucial diphlheh.'i, and a i;uai 
prognosis must always be given. In cases in which the soft palate^ 
tonsils, and nasal imicous membrane are invohcd, the gencnd sympionii^ 
inc]iidinK the depression and also the albuminuri;i. are well marked, tn 
connection with this form of diphtheria we must bear in mind there i* • 
form of mcmbranoui exudation occurring on the naul mucous meinbmw 
in measles and as a primary djse;uc which is not diphtheria, but which raiU 
a much more favouiable course. .'\nd in some rases at least the membtaM 
fomicd is thinner ntid less adhctrnl tlun it is in diphtheria. Tl>c lenu 
■ Rhinitis fihrinoia' has been applied to these case*. In all case* in which 1 
child is fcvchsh with n diicharRC rn>m the nostrils we bbould be evcecdinglir 
•ittfiiciousof diphtheria, especially if ait epidemic prcv&ilsai the lime. TIm 



|vrv^*ciHS 

rtiarfW 



Diphlheria 



389 



iidMBUtioo nMj' spread from the iumc in ihe cmijunctivii, nnd rncmbrane 
mijhna on ific p;«lpebral conjunrtiva and much purnlcnl ditrhnrgc may 
cnik, "hil* ill* eyelids m»y be m«t.h Rvrollcn. Mcmbianous niiijiinctivilii 
■a Mt usually diphtheritic, bul due to tome locnl irrilaiivc prorc» : Ihc 
holdnlutbancrm.-iy be sri'crc while iheronititulional symptnmE arc •flight. 

I*rr«C*>l I>t»lithartm.->TI»? Urynx may he Ihc scat of the local mani- 
fcsoticai of diphihcna in the first injtanrc, or may become invobed 
tKcodanly to the fauces or other part. The child may in ihc tirM place 
nBnfttmsorc thto;il and feveri^hjicst for tc^eral day«,and theit a metallic 
m^k and uine dy^pniva will viggcui the onset of bryngeal romplic'iinns. 
UBaften Mxnc other part is ihc first lo be involwd : thus we have known.-t 
fUdicf dienibraivo m make ill appearance at the tent nf an ectCHtKt, and 
Anifcwdays afteirwards a diphihcrllic laryngilis supervene. Wc hnvc 
ako^ described (p. 19;; the symptoms prcscnl in biyngcal diphtheria. 
Wtnut coostantly bear in mind thai the? ob»tTiiciinn lO the air passage* 
oowd by ll»e presence of membrane in ihe larynx or IrachcA may modif>' 
(tvitrvbelrn the symptoms of ihe disease bul wc must not OTCrlook the 
Mdncy to Itcart f;il1iirr or the dcprcitslan, as well us the possibility of 
raniii « p.itiilvsis ^upe'vcning. 

Vmm siptatbaHa.— Diphtheritic membrane may be present OD the 
l^ Ingnei ralva. and glam penis. The diphtheria ba<:ilUis is, however, 
inaRUly tuiabic 10 flourUli nn normal skin ; but when ihe cuticle is 
iMtd. u> afier btistcring or in ccicnulokis conditions nhcn a moist rav 
ntfact 11 present, the bacillus readily flourishes. Granulations also aAind a 
conticnu] MiU Tlie bacillus may be inoculaled during an opetation —as, for 
iwQnce, in exdsion of the tonsUs ; «•« have seen a case in which membrane 
fiHiufd Kfithin twcniy-four hours of aa operation for hypospKdias at ihe seat 
cf npcraiiun, vi fatal result occurring- in a few dajs. We liavc sevcril times 
■ten membrane form on gmnulutions at tbe external wound in einpycmat^i- 
!n one of thete c&ses a fatal result followecl. In tracheotomy for diphibcria 
Ihc *«iiad otvd «ltin arutind the wound are apt 10 become the seat of a 
ffanxw depoiit, the inoculation taking plaice by the sputa couched ihrough 
>lK(«be. In newly bom in&nts the granulating surfate left after the ilounhinj; 
*f ibetofd may benotne the seal of a diphlherilit mllammalion. 

Om^italioai <md StfueJcf.—Tbeit. tlioiicli less numerous than those 
KnninK after starlet fe*er, are hardly less important. There is ihe CJl- 
Vaata of the intlammatori' proceu from ttie fauces to ilie neighlMutiag 
pMs-ilnady referred Kv— vii. lu the larynx, nose, middle ear, and lymphatic 
Ibodt; Ihe tatter niay soppotatc besides these. The most noteworthy arc 
■heUlmring : i9t.albaminuna4ndur,einia : md, pneumonia ; jtd, disiuibed 
■MBvatMin of the heart ; 4II1, paralysis. 

I. VkoaUnaris can hardly be said lo be .1 complication of diphtheria, 
■•Hwchasit is abuoit constantly present .xtiome limeorolberuf the course 
■ buei^ nasal, and laryn^'cal ilipbtheiiii. It is, however, frequently absent 
■> nild case* of wound diphtheria. In some epidemic*, accordtRg to som* 
ofcwier*, albuminuria u much commoner Iban in others. Our experience 
ttoaiatf hat been tbat altmriKn it rarely absent from the urine in cases of 
lnKdi|4itheTifi. Tbc albumen antally makes its appcaran<:e from the third 
^ttcti|^(b day. The orioe is mostly norma) in colour and in amount, but 



290 



The S/ifn/if f-'tvers 



a few blond rnrpunclefi xnA cpiihclinl ciliis may be found on mJcrcMcopical 
rxnminaiion in mnny cases. In »amr mnlitntant cate* hicmaluria maybe 
pTcscni. 'I*hc amount n( albumen present form* a rouifh indicatinn of the 
tci'cniy of ibc ra«c ; ;ii Ie>i't after ihi^ tliKcaie hat cxitied for a few dayt. 
The albumirturia U [!iie lo i1ie changei elTcctcd in the blood or in ibe renal 
Cpilhrtiiim of the kidnry by ihc albtimotei or loxalbiiinens i>menl in the 
blood, and the .ininum of nlbi'men in the urine reprcienii^ tn M>me extent 
the amoimt of poisnnint; Rotng on. Supprcuion of urine and unmia 
occur al timet, ihouKh the tt'mptomt present arc not so diuinciivc ai in 
scarlet fe\'cr. a* death motily take* place before the symptoms become well 
mftrked. Vomilinn, perhaps persislent, should always su|;Kett unemin ; ihe 
urine may hccnme scanty and loaded with albumen, and perhaps cease to be 
•tcrried twenty-four or fony-eijcht hours before death. (Mdema, muKCulai 
I'twilchings, or ura-mic convulsions arc rare. In ca»es which recover irace« 
of albunien nuy remain for months, but rhtnnic kidney disuse us a rvnilt of 
(lipblheria is rare. 

s. In sc^eri! cjises of diphihena, pDvamonl* in the cainrThal form U 
common, and is Ihc result of an extenKi->ii of the itiilammaiion front the 
fauces or larynK in the lunji.'S. It is found in nearly all cases of fatal laryit- 
jfcal diphihcria. It is r>ficn hirmorrhagic. 

3. In alt severe cases at the hcifihl of ibc attack the pulse is feeble and 
for the most pan rapid. It soinelimcs happens nl this time that ihe heart's 
action become* irrc){ular, iniermiticnl, or abnormally flow. This comliliiin 
is, however, more conimon during; consatesceiire, or al Ibisl when the mcBi- 
branc is disappe^irinf; and the piiiient apparently iinpro\ inj;. There is oftca 
dyspiKca on the sli);hlcil exertion, an intrrmittenl c^nierinii; action of (be 
heart, and frequently vnmiiin};. Biiiiden c&nitBe •rneoF* >s apt 10 lake 
place. This may occur front any iinuonicd menial disturbance or from 
sume slight exertion, such as getting oui of bed 01 tilling up to uie tbe 
ch.imber vessel. With an irregular action of the heart there U often ctyiiuxn ; 
frequent vomiiinK and slov.- pulse during convalcwence from diphihcria are 
s>'mpiom> of |[reai tjiavity. 

4. A peculiar form of pBralral* if apt to follow not only diphtheria, bat 
also other febrile disorders, as typhoid fever, meatles, and erysi|>cl)is ; it is. 
however, very much more common after diphiberia. The piaral)-sis comes 
on in the majority of cases durinjj ronvalesrcnce, mostly between the third 
and fifth weeks: i( appe-ars lo follow mild raie^ as nftcnas ii dors severe one*. 
Its usuaI course is in attack lh(! soft p.-itate. ihe first s>-mptom^hcin); a retuni 
of fluids ihrough the nose, perhaps only a fen' drops, and a natal twati); bl 
spcakinK ; an enamin.-ition of the soft palate shows that its mo\ements arr 
lets free than usual. In manycase^ a sl));ht |x>resisof the soA paUie, wllicb 
may p.iss off in the course of a W('ek or tuo, is the imly evidence of pntt- 
diphiheiilic paralysis. In othercaseslhe paresis is much more decided ; wbdi 
tlie pdiienl attempts to swallow any Huid, much of it returns ihroUKh the 
anterior nures and some may perhaps enter Ihe >;iottis. tl'vin^ rise m a fit '>f 
choking. Other parts may become alTected ihe pharynt;e.il muscles and 
cnophflKus, so (hat dcKlulition is pcrfomied with difficuhy and the pationi 
has to be fed through a soft caihelec. The pupiU muy beci>mc dilated and 
unequal from paresis of the circular librea of the iris, ibcrc is impairment 






I 



vision, frtwii Ihe ciliari* tnu»cle l»tint; nffcrtfd. TIk; piiresi* may extend 
to any "f nil of (he voluntaiy muscles, so iliai ihi- p.iricni is un.ibic lo 
'^nd or sit up in bed iir even r^isc bit lic;i(l. I'lirlhcr, thr rcspir.-ilory 
ttiuictei, the intercmlaU, nnd dbphragm may be .ifTeclcd, in mnsi in^lnncrcs 
apeedil)- pcnducm); .1 fnul rv&ult. [[ inu:^! be bnrne in mind ih-it in posl- 
diphihcritic piimlyiis ihcte i& rarely compleii- pat.ilysis, but raiher n par1i.1l 
lom of pciircr, combined wilh numbness and srnsniions as of prickings wilh 
*pini and needles.' ilaih lecium and bladder may also become paral)-scd. 
It it impodant 10 bear in mind thai paresis may fiilluw very- mild cases, so 
ibal the jnlient may be seen for the first lime when sulTering from ilic 
parciis and make no mention of sure ihtnat. Surh c.iics irspccially if there 
benot^ire^iiinf ihc^oft palate, maybe very piiiztine, and. If tliercbencaknriis 
of tbcleKsand sta((Eerini{ gait, may be miMnkcn for Iiimmirof the cerebellum 
ar ataxy. The knee rc^ex may be ab-icni in such patients and be many 
monthK lielbrc it make' its reappenr^mcft 

/>/i»p7»n«j. The diagnoiis uf diphtheria in a typical case docs not 
prctenl much difficulty, especially if an cpidemir is pre^'ailinie. The false 
iicmbrane i>n the faures, and the presence of albumen in Ihe urine, render 
e di.-ijcnoMsnf diphtheria practically certain. Ilut then- may he a librinnu« 
kudaiion on the fauces wilh more <ir less fever ; no mine can perhaps be 
ihtaincd, or, if obtained, it may contain no albumen, and we may be in 
doubt :il>aui the diagnosis. There may be a membranous exiidatinn on Ihe 
ton){ue, lip, nnsal mucous membrane, or conjunctiva, wilh no marked con- 
ilulioiul >yniptonis, and «-e may be in doubl as to the tlaliirc of (he «i§e. 
n sHfh rases cllntral distinctions may entitely tail us, it being uncertain if 
ihc case in >|ucstion is one of mild diphiheti.i or ool. \Vc may be cniiiely 
ilependeni tot a dij^no«i« on Ihc detection I'f the IJ-bncillu^ In the mcinbmnc 
»c<:retions. If wc c^n by micro%cnpirnl cxaminntion or by cultivation in 
ilood icriiiti dcinonstrdic the presence of l.neff1er'> Il'bBcilliis in the mem- 
, itw diatpMMis ii certain ; if, on the other hand, only sttcptococci or 
phylocooci arc present, the cisc is not one of diphiheiia (see Appendix^. 
ciiscd of * croup ' or ouena an examination of the secretions, which may 
non-nKmbraiwus, nuy nfien decide the diagnosis in favour of diphtheria. 
iliwrjM of the thro.tt moM likely to be confoundccl with diphthcrin ii 
IS or Dieinbninous tingitia : usually, however, in this dise.isc there 
i» lendeiKy lu spread to the n.isal muious membtvine or the brynx. 
(h«re h Ici^s often vlandubi enlar>:emeiit. 'I~hc onset is mote sudden : 
ic urine is free from .dbumen. It is unnecessary, ixrhapt, to add a woid 
■of uuiion in not excluding diphtheria without vcr>' good reason. Nu 
iillMinten maybe pre^^ent in the urine at Ihe time of exAniination, but be 
pieseni later ; lliere may be a Lomplcte absence of Konslitulional symptoms, 
dnd yet diphtheria 1>e present. A mild casc of diphtheri.i in a household 
■ be followed by a mali>:"^iil one. Uiphllleria is distinguished f(Om 
lei fever by the absence of Ihc rash, ibough an erythematous blush is 
imeni in a few ci.sex In malii^nant scjilci fever the rash may be abseiil, 
the };landuUr swelling and sloughy condition of the throat closely 
re*cinhle diphtheria : iberc may also be a tibrinous exudation as well as 
ibuniinuria. Diagnosis is often impovsiblc. 'I'hc punctiform r^sh, however, 
iMrciy .ibwrit in icarlei fever. 

va 




and 




Progimih.— Diphihcrin \\ one or (he iiiosi fuUiI diseases wilh which we 
bnvc to deil ; liui the mon.-ility difTcn widelir in diflcrent epidemic^. The 
i»o»t laliil n undoubtedly the liir)*ii)(i!4l ; of thcrte probubly nui n>orc Uun 
one caic in ten tecoten without operation — liy cDut;l>in|ir up the meinbrAn?. 
In fauclal di|>hthcri;i the mortahiy may Ik as high as 7{ pet cent. : thr 
younifi^r the child ihc worse the pro|[no»i^ Tile vtron); and hitherto healthy 
shiire the ■x.wnt fate a* the w<Tiikty. Of Cipctially bad au};iiry are lar^e 
quantitii:! of albumen in the iinno. much glandular enlaTyentent. exce»M*e 
nanal diMhurKC a ffutid M^te of the fauce*. vumitinK, and Mi)ipmi)on of 
uiine. A sudden f;dl of the temiier^iiurc to subnunnal. and xr inlermtltcnt 
pul»e. are aim cxttcnicly bad lymplums. Kecovory from a »cicre altiick in 
ubicli there is );icat depte.-ision and niuch albumen in (be tirine ii excep- 
tional, especially in a child under six j-ciirs of axe. Rccm- cry docs, how- 
ever, l.ikc |ila<:e ill iimei. m a|ipiireiitly Impeleis caies. Supptc^iion of 
urine in di])hihcri.i \f- nearlyalwayifaL.il; ihou^fh in odc caie seen by a«, 
in which the li«y had luppreision of urine and nasal hvmorrbaKe. recovery 
fiiudly took |ilacc. .\ fall of tcmpenture in scarlet fever in the absence dT 
nephriil* is rt good Vi^rt ; it is by no means m> in diphtheria, eipcciaUy if 
vomiiinK he present and an increasing quantity of albumen. 

Tmttntfnt. The indications for ircaimcnl are the followinK : i»t. T* 
isolate (he patient in the- rno-A airy room obtainable, ind. To apply anti- 
septics to the fauces or affected parts in order to <lestro)' the bacilli ami 
other micro-organisms, and to prevent decomposition and fcctot. Jrd. To 
antagonise the |xiisons absorbed into the ftjsicni or fonned in the blood- 
4th. To soppiirt the strength of the p.itieiit. and to treat symptoms as they 
Arise. 

JSL The patient may be isolated by sending him a«'«y to a lio^tal for 
Infectious diseases and this ib often ihc best and simpler phin, but it is not 
aln^iys |Ki»si)>k-. If llie paiiFni '» to remain at home, the largest mom 
available on the top landing should be selected, or, still better, two rooms 
adjoining one anutlier, M that the patient can be movcit from one to the 
■ Other, thus allfm ing the unused one to be ventilated. The supply of a Xax^t 
'((tiantity of frt^li air to the patient is of the lirsi imponance. Alt oiker 
(hitdnn in the Iwute should A" ttnt <tWity, htitring in miiul, k&tfn'fr, Ihal 
Ihfy my de imuiatiiti- fie itisi^ft, so Ikal Ikry ihonlH not (it ieitl v.'h<re Iktrt 
art Plhtr i/iUdren, or to a Jislaiice w/tfrt Ihey (atinol te brifughl hatk agaiH 
In cixte Ihey fall tick. Anmngemcnis should be made for di&iafecting aU (he 
CKcreiiuns -ind bed linco of the patient. 

3nd,' There tan l«: no ditfcrcnce of opinion as 10 the imponancc of 

t applying antiseptics to the fouces in order to wash anay the niucus, dccom- 

[: posing blood, :nid remains of foud, and to destroy aa for as possible the 

) niicfo-iirganUius. It is needless to say (hat this antiseptic treatment to be 

of any service should Iw begun early in the disease ; we can ha\ c but 

little hope "f influencing the cour^ic of the disease by local treatment in the 

later stages, but something can be accomplished even then by cleansing the 

motitli of (itiid and decomposing mailers. To propetly carry out the local 

irc-iiment (raine<l nurses art necessary, as the patient's friends rjirely ha^t 

the necessary skill or the firmness to cfliectually carry out the details 

properly ; unfonunately, ii often happens thai even skilled nurses may bil 



N 

* 



T. 

Mi 



Diphtheria 393 

TO accomplish all that we tmiid wish, on account of ihe fructi«u«ncst of the 
paiienl. Tfae mucus nccuniuhtinf; in ilie phur>-nx and uuitTtlik should be 
rniMVovd bj- mean* of a mop of coiton wool aitucbed to a stick, aiid ihe 
antisr]>tic may then be applied by means of a steatn spruy, iuch as SieKcl's, 
or l>y a hand spiay. Failing this a ball syringe "my he uied, larye eoou^h 
to hold 5 or 6 tu., ilic child's head being held forwrard so that the Huid inay 
run oui of il4 mouih. It may be impossibli; wiilioui a iirufii);'* t° *pply 
cither <rf tlkesc : in such taiei wc must be sutiiiied by iht insufflation of 
antiseptic piin-ders, as sulphur ut iodoform and boritacid, or calomel and 
boric acid. Ice ii useful to suck, and the food may be given iced. 

With rc[;;trd to the success of local trealmeni m pharyngeal diphtlicri;i. 
we must remember that many bacilli ate present in the mucus secreted, and 
also in the epithelium, nhiUi uihers ^rc embedded in the tibrinous cxuda* 
lion. \Vc cannoi reasonably hope for the destruction uf all the liadlh 
picMDl, especially those in the membrane, by spmyini; or washing out the 
throal by antiseptic solutions. I'o more elTeciiially apply antiseptics. Ur. 
A. Siebcrt, of New ^'nrk, has devised a son of syringe provided with a 
number of hollow needles, by means of which some antiseptic Huid can 
tie applied into and underneath the membrane. Among the efTectual 
antiseptics or germicides are solutiims of corrosive sublimate (1 to 1,000), 
carbolic acid (1 to 1001, lalicylic acid (i t<i i.ooo^chlonnc water, and Condy'i 
FInid. .Solution of pcrovide of hydrogen is also useful, .ind certainly corrects 
ihc fnrtor cffcclttally. Probably corrosive sublimate is the iiioM effectual of 
all, but it has the disadvantage of being poisonous, and it has an unpleasant 
metallic taste. Wc havclinoivn it when used fornioppirn; (i lo 500} produce 
mcmirial vtomatitit : there can, however, be little fear of ibis if used well 
diluted and trith caution. For pniminK the fauces we use glycerin aci<I. 
caibolici one pan, with two parts of it. iodi. I.ocfflcr hns rcccmly rcrnm- 
mcndcd a 10 per cent, solution of menthol in alcohol, addin>,' i per cent, of 
perchloride of irott. 

CaldiiMl fuRugation, u described on p. 196, ii a convenient wxy <£ usin^ 
mercury. 

Dry apfttications are preferable to lotions in wound iliphtheria. at the 
lalicr are a|>t tofrct the skin and leave a suitable soil fur the bacillus to 
flourish on. SMicylic acid and starch (1 lu :o;i. calomel and starch, or 
VidolbRn and boric acid answer very welt. It is a good plan lo vaporise 
rarliolic actd in the sick-rooni from time to time. 

3rd. The "MTUm treatment,' which we owe to the patient inxestigation of 
llehting and Koux. appears likely to take a perm:menl and important place in 
the treatment of diphtheria : whether this * heitserum ' acts by rendering; the 
titsnes ' immune ' or by anta^nisin^' the diphtheria ptomaines is al present 
an open (|uest>i>iv. In any case it is of the yreaiest importance to commence 
tbeliealment ns soon a* the diagnosis of diphlherin ismadewilhccnainty. .\l 
the present time no directions can he yiven with regard lo dose, a* the dose 
depeiMls upon the strength of the serum, and this appears 10 differ widely, 
No evil effects have been retortled from Ihe serum injections, but erythema, 
irlicana, and joint pain* have Iiecn noted by some obseners. The local 
eatmcnt of the ihroat should l>e continued durini; the injections. 

We have nojjreai belief in the efficacy of cither mercuiic bichloride or 




pot.-i.ix.-c chlnrnt. taken inteinnlly in dijilitheria ; lli« htter h iintloubiedly 
dangcrnoN, ns Dr. A. Jaeohi Ioiik agn ])niTitecl out. We prefer lo uie ilie 
old- fashioned Ir. leiri pcrrhlor. in ihrcc to Ate minim doictcvenfourbatin. 
It mnybc ^.-iven in leninnadc, sodn nnier, or in any way in which (heiuiiciit 
will lake il. I>i}tiu1is, rnAcinc, cncji wine, alcohol, should be nivcn Iram 
ihc fiisi if iheic is much dcprci>ion of rhc sysleni, and in the wor*! inun 
nkohol in the form of brandy or port nine mu« be given with > fiec 
liand. 

4th. The diet iujiplied to the i»ticm muii consist of the most concen' 
irated fonn of nnuribhineni possible, iii in moti case^ then- is),>realdiA>culiy 
in Kciiintt him to take food on aL-cuunt »f ihe discomfort and pain in swallow- 
ing : l)ccf juice, peptonised meal pteparilioDit, milk, and miiticni suppoit- 
lorict m^y be needed. If (here h swelling or cpllul>ti^. the neck should be 
painied nith glycerine and In-ll^iilcinn;) and coveied uiihcolliHiwool. If the 
ifhnds Mippur.iic, inciiirm jnd |iti>pi:r draiiuge muil be resorted to. The 
t;re.atesi careniuslbeexcrdscdduiint; ciinvaleinencc to supply Ihe iMIieni with 
suiuble food andfrcshnir, and to prevent any exerlion on hii part. I'aresisnl 
■he «ofr palate, tienetat pir.dysis, nnd failure of the hcail nuiy conie <m m 
any lime within a month or live weeks of the conimcntTnienl cien in inUA 
cases, and Ihc practitioner i^hciultl t:oi»ianily be on his guard, nnd nam the 
friends against allowing- any excitement or unwonted exertion, Ituring con- 
r>i1c»ccnce quinine, sirydmine, and iron xhnuld tie given. TIk eMiiinuous 
current and musKiKc is of u^c in the pamtyMs whirhfotlowi. Chan^'i- 1» the 
scastdv after live or siK necks reckoned from ihc commence men i of the 
Attack will prmc of great benefit. 

Qn'iriin/iw.—This should be mainuined for ihre« necks in mild ama, 
nnd a month or more in the more oevcrt attacks. 

/Viin/ectitrit.^A lempc'JUir-e of do" C. m a moisi atmosphere i> MifBcicnl 
lo destroy the D-b.icillus, Koi disinfect ion the sintpk-st way is lo boit the 
linen removed from the juitieni, ;md treat his clothes, as fat at poisibtr, in 
the same way. The furniture irf the rooms in which he has been %baal(l 
be xcrublied uiih hot water and carbolic soap, «nd the floors attd walb 
should be imitcd in like manner. Wearintf apparel uhich cannot be boiled 
had best be detiroyed. 

Vicods-dlpbttaorln 

Practitioner! have lonjj l>ccn famiL