THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY THE NEW SYDENHAM SOCIETY. Instituted MDCCCLVIII. VOLUME GXXV. LECTURES ON CHILDREN'S DISEASES. A HANDBOOK PiUCTlTIONERS AND STUDENTS Professor in the University of Berlin ; Director of the Department foe Children's Diseases in the EoTAL Charitk Hospital, Berlin, etc. VOLUME FIRST. Translated from the Fourth Edltioa (1889) BY JOHN THOMSON M.B., F.R.C.P., Edin., K.itri>-riii.shi(in to the Boijal Hospital for Sick Children, and Phijüieian for Chihlnn\ Diseases to the Xcw Town Bispensari/, Ediiihitrgh. THE NEW SYDENHAM SOCIETY. MDOCCLXXXIX. 547 Library mi PREFACE TO THE FIRST EDITION. This treatise contains almost exclusively the results of experience, gathered, during thirty-seven years of practice in- cluding almost uninterrupted work at the polyclinic, in the department of children's diseases. When in 1872, I was placed in charge of the Children's Wards in the Royal Charite Hospital, I was enabled to an unusual extent to increase the number (already very large) of my observations on all periods of child- hood ; and also to place these on a firm anatomical foundation, in a way which could not have been done in a polyclinic and private practice. It is only because my material has been so exceptionally large, so carefully observed, and drawn from so many classes of the city population, that I dare claim for this work, based as it is almost entirely on my own experience, the title "Handbook for Practitioners and Students." It stands to reason, however, that the observations of a single physician must even in the most favourable circumstances present some gaps, and that as he grows older and sees more he will always be meeting with new facts which modify the results of his former experience. Therefore it must not be expected that every disease which can possibly occur in a child will be found described or even mentioned here. Moreover, I do not think it right that a work on children's diseases should be burdened with the wearisome repetition of matters which are fully treated of in all books on general and special Pathology and Surgery, and which I am entitled to assume are familiar to my clinical class and still more so to my readers. Only those diseases will furnish the subject-matter of this work which either occur far more commonly in childhood or else, when met with at that period, show certain peculiarities as compared with the same aflections in adult life. On this ground I have excluded variola, which is very rarely met with now-a-days. My passing over vaccination in silence is excusable only on the gi'ound that I could, from my VI PREFACE TO THE FIRST EDITION. personal Observation, add nothing material to tlie innumerable treatises already written on the subject. It has so long been the custom to write in the form of b clurcs that I need not say anything on that point. There are draw- backs to this form which I do not overlook ; but I consider that these are outweighed by its advantages — freedom from restraint and greater ease of reading. Further, the introduction of cases — which here take the place of illustrations — is thereby very much facilitated. I should ask the reader not to pass over these cases, although they are very numerous ; for I believe they will ])e of use to him. I have always endeavoured to make them as brief as possible, emphasising the points bearing on the matter in hand and avoiding the intolerable diffuseness and tediousncss of detailed clinical records. Any practitioner who has suffered from the undiscriminating and bevdldering way in which the different remedies and modes of treatment are mixed up in most text-books, will, I am sure, approve of my having based advice in regard to treatment, like my clinical descriptions, solely on my own experience. The prescriptions at the end of the book (which arc referred to in the text as Form. 1, 2 tic), are not, I consider, out of place in a scientific work. Older physicians may do without them ; but younger men — to Avhose wants I have had especial regard — will be glad to have at hand a help of this sort when beginning their practice among children. Berlin, Jantiarij 1881. The Author. PREFACE TO THE FOURTH EDITION. In the preface to the Second Edition of this hook, which appeared in April 1883 (two j-ears after the First Edition), I wrote as follows : — " 1 have also received from far and near so many exjn-essions of satisfaction and appreciation that, even had this work met generally with a less favonrahle reception, I should still have felt that there was no occasion in any way to change its ground plan. By gathering together a lot of experimental, anatomical and chemical matter, it is very easy indeed to give to a clinical work a dazzling appearance of the most modern science ; I refrain, however, in this edition as in the former one from this kind of display, which is always ready with its hypotheses and explanations, and perplexes more than it enlightens readers, especially heginners. The stage of transition in which certain of our auxiliary sciences now are, renders extremely necessary, at any rate for the ends that concern us here, the strictest sifting and criticism. It has been my chief endeavour to be in every sense true to the reader, to criticise my own work severely — especially in matters of treatment, for it is in these that one is very apt to go astray ; and out of the large store of observations I have accumulated, I have sought to la}- a sure foundation for further study.'' I can to-day with a clear conscience repeat those words. The fact that a Third Edition was called for in 1887 and a Fourth in the course of the present year proves that the method which I adopted was the right one. The steady advance of paediatrics and the continually accumulating results of my own experience, have indeed rendered it necessary to recast certain sections of the book as well as to make various additions to it. By abbreviating as much as possible w'hatever was of minor importance and omitting some of the older records of cases, I have endeavoured to gain room for these additions without greatly increasing the size of the work. Berlin, September 1888. The Author. TRANSLATOR'S PREFACE. CoNSiDEEiNG the out-standing position which Prof. Henoch's book holds in Germany, its introduction to English readers requires no apology. It is here neither necessary nor desirable to compare its merits with those of the many excellent works on the same subject written in our own language ; but everyone Avill recognise the extreme and permanent value which must attach to these lectures as the outcome of forty-five years of untin'ng clinical work by a man of such splendid powers of observation and judgment as Prof. Henoch ; and no one who reads them can fail to be struck by the wonderfully wide range of experience and reading which they represent. In the translation, I have endeavoured to follow the original as closely as possible, except where a somewhat free rendering was necessary to make the meaning clear. As many of the German pharmaceutical preparations differ a good deal in composition and strength from those used in this country, I have, in many instances, altered the forms of the prescriptions a little to bring them into accordance with our own pharmacopoeia. I have also, in rendering the various weights, measures, and temperatures, converted the terms of the metric system into those more commonly used among ourselves. I have adopted Prof. Henoch's method of drawing attention to certain emphatic words and phrases, as well as to the names of authorities, by "spacing-out" the letters instead of using italics; this will I believe be found helpful by the reader, although it may at first strike him as unusual and even a little perplexing. A full index will be given at the end of the second volume. My warmest thanks are due to my friend Dr. Barbour for in- valuable help of every kind in connection with the translation, and to Mr. Wm. Macdonald for much literary advice and assistance. Edinburgh, 2nd March, 1889. J. T. CONTENTS. TAGE TUEFACE TO FlUST ElKTIOX V Preface to Fourth Editiox vü Translator's Preface ix ISTRODUCTlOX AND METHODS OF EXAMINATJON l — 'J l Children's Diseai^es— Why worthy of special study, 1 ; infantile mortality, -J ; methods of clinical examination, i ; auscultation, 5 ; percussion, C ; rate of breathing, 7 ; the pulse, 8 ; the heart, i) ; larjngoscopic examination, 10 ; mouth and throat, 10 ; physiological differences between children and adult?, 11 ; examination of the head, 12; "brain murmur," 12; fontantl'.es and sutures, 13 ; buccal cavity, 15 ; tongue, IG ; heart, 1(J ; temperature, 17 ; urine, 18 ; faeces, 19 ; manifestations of pain, 20 ; attitude during sleep, 21. SECTION I. diseases of new-born infants. Icterus neonatorum 2^) Symptoms, 23 ; causation, 24 ; treatment, 27 ; complications, 27 ; obliteraliun or absence of excretory bile-ducts, 28. Trismus, or Tetanus neonatorum 2S Symptoms, 21) ; proguosi?, 30 ; post-mortem appearances, 31 ; causation, 31 ; treatment, 33; certain other convulsive affections, 34 ; " encephalitis inter- stitialis," 34 ; symptoms and pathology, 35. Cephalh^ematoma 3i! In earl 3' infancy, 3G ; pathology and symptoms, 3G ; in older children, 38 ; treatment, 38 ; diagnosis, 38. H.ematoma op the Sterjjo-mastoid 39 Symptoms, 39 ; pathology, 40 ; treatment, 41. Swelling of the Mammary Glands 41 Symptoms and pathology, 41 : treatment, 42, Erysipelas neonatorum 43 Causation, 43 ; symptoms, 45 ; complications, 47 ; treatmenf, 47 ; erysipela.s in older children, 48. Sclerema neonatorum ;''l Sjmptoms, 51 ; oedema of new-born children, 53 ; pathology of oedema, 55 ; prognosis in both diseases, 56 ; treatment, 57. Pemphigus neonatorum 57 Acute form, 57 ; causation, CO : treatment, 61 ; cachectic or syphUitic form, Gl. Aphth-e of the Palate C3 Appearances and pathology, 63; treatment, 64. MEL.y.\A NEONATORUM C5 Symptoms, 65 ; pathology, 66 ; treatment, 68 ; ulcer of oesophagus, 69. Xll CONTENTS. SECTION II. DISEASES OF ISFAKCY. PAGE I. IXFANTILK ATROPnr "i^ Development of the infant's alimentary canal, 7U ; breast versus handfeeding, 70 : symptoms of atrophy, 71 ; causes, 73 ; complications, 73 ; detailed de- scription of symptoms, 73 : duration, 7.>; causes of death, 75 ; post-mortem appearances, 76 : prognosis, 70 : hygienic treatment, 77 ; dietetic, 78 ; breast- milk, 78 ; substitutes for breast-milk, 80 ; cow's milk, 81 ; condensed milk, »3 ; Nestle's food, 83 ; other " infant's foods," 84 ; alcoholic stimulants, 84. II. Thrush ?5 Symptoms, 85 ; pathology, 87 ; cultivation-experiments, 89 ; inoculation-ex- periments, 90 ; diagnosis, 91 ; treatment, 91. III. Hereditary Syphilis 92 Symptoms in well-marked cases in infants, 92 : less typical manifestations, 94 ; affections of the skin, 94 ; of the mucous membrane, 96 ; of the intestine, 97 ; of the lymphatic glands, 97 ; of the bones, 97 : pseudoiparalysis, 101 ; affec- tions of the joints, 104 ; of the testicles, 105 : of the liver, 106 : of the spleen, &c., 108 ; of the nervous system, 108 ; of the v.'iscular system, 110 ; prognoiris, 111; recurrence, 111 ; rickets as a sequela, 112; origin, 113; vaccination- syphilis, 113; question of heredity, 114: treatment, 117; suckling, 118; syphilis in older children, 120 ; syphilis tarda, 120 ; condylomata, 121 ; affec- tions of the tongue, skin, lymphatic glands, 122 ; of the bones, naso-pharynx, teeth, 123; treatment, 124. IV. Dyspeptic Conditions of Ikfants 124 Vomiting of healthy infants, 124; peculiarities of infant's stomach, 124; dyspeptic vomiting, 125; dyspepsia intestinalis, 126 ; causation of dyspepsia, 126; feeding-bottles, 127 ; unsuitable food, 127 ; pathology of dyspepsia, 127 ; " fat-diarrhcea," 130; acute dyspepsia, 131 ; " gastro-malacia," 132; die'.etic treatment, 133; medicinal treatment, 137. V. Coryza of Infants 112 Symptoms, 142 ; suspicion of syphilis, 142 ; dyspnoea from sucking-in of the tongue, 143 ; treatment, 145 ; diphtheritic coryza, 145. VI. Eetro-pharyngeal Abscess 145 An uncommon condition, 115 ; pathology and symptoms, 146 ; diagnosis, 147 ; treatment, 148; rupture into pharynx, 151 ; into external auditory meatus, 152 ; ca\isation, 153. VII. Dentition and its Symptoms 154 Many diseases attributed to dentition, 151 ; question of reflex irritation, 155 ; order of eruption of first teeth, 155 ; presence of teeth at lirth, 156; local morbid symptom^ produced by symptoms, 158; orderof erupt ion of teeth, 159. SECTION III. diseases of the neuvovs system. I. Infantile Convulsions ICl Derangements of motor functions commoner in infancy than those of sensory, 161; symptoms, 162; treatment of attacks, 163; causation, 166; organic disease, 166 ; rickets and teething, 167 ; digestive disorders, 167 ; other ner- vous phenomena brought on by digestive disorders, 170 ; treatment, 171 ; influence of internal parasites and foreign bodies in causing convulsions, 172 ; convulsions ushering in febrile diseases, 172 ; urjemia, intermittent fever, 174 ; psychical causes, 175 ; connection with epilepsy, 175; epilepsy in childhood, 177; further treatment, 178. CONTENTS. XIH PAGR IL Laryngeal Spasm 179 Slight degree observed in healthy children when screaming, 180 ; symptom?, 180; alternates with eclampsia, 181 ; association with rickets, 182; family tendency, 182; frequency of attacks, 183; cause of sudden death, 184; causation, 184 ; treatment, 186. III. Idiopathic Contkactctues 187 Frequently associated with laryngeal spasm and convulsions, 187 ; symptoms, 187; with cerebral tuberculosis, 188; with reflex hi'itation, 188; relation to tetany, 19i) ; tremor, I'Jl. IV. Spasmus NaTAN3—N0D0iN(i Spasm 192 Illustrative case?, 192 ; clinical description, 194 ; reflex causes, 194 ; central causes, I9b ; with chorea magna, 190; treatment of rtflex form, 19G ; other spasmodic conditions, 19 5; convulsive laughter, 196. V. Chorea Minor— Sr. Vitus' Dance 197 Symptoms, 197 ; hemichorea, 199 ; less common symptoms, 201 ; course, 202 ; post-mortem appearances, 203 ; relapses, 204 ; pathology, 205 ; causes, 206 ; connection with rheumatism, 207; heart-disease, 208; other causes, 209; effect of intercurrent diseases, 210 ; treatment, 211 ; " chorea electrica," 214 ; treatment, 216. VI. The Hysteuioal Affections op Children .....' 21(1 Nature, 21G ; classification, 217 ; first class — chiefl/ phj^sical symptoms, 217 ; second class — chiefly convulsive symptoms, 221 ; third class — co-ordinated movements, 225 ; fourth class — with neuralgic or trophic disturbances, 230 ; hasmatemesis, 231 ; other symptoms, 232 ; question of simulation, 232 ; hys- terical paralysis, 233 ; causation, 234 ; treatment, 230 ; prognosis, 237. VII. Payor Noctürnus — Night Terrors 239 Symptoms, 239; causation, 239; treatment, 241. VIII. Peripheral Paralyse3 241 Of facial nerve at birth, 241 ; in older children, 242 ; causes, 243 ; of other cranial nerves, 245 ; of arm at birth, 245 ; in older children, 246 ; treatment, 246 ; paralysis after convulsions, 246. IX. Spinal Infantile Paralysis 247 Symptoms, 247; onset, 248; further progress, 250; defoimities, 252; patho- logy, 252 ; affection of facial nerve, 256 ; diagnosis, 257 ; causes, 259 ; treat- ment, 259 ; paralysis from vertebral disease, 2i)l ; sclerosis and spastic spinal paralysis, 262. X. PSEUDO-HYPERTROPHIC MtJSCULAR PARALYSIS 263 Symptoms, 263 ; pathology, 265 ; treatmen*-. 266. XI. Apoplectic Conditions 267 Symptoms, 267 ; onset, 267 ; cerebral hemorrhage, 267 ; hfemoirhagic ence- phalitis, 268 ; causes of haemorrhage, 269 ; pachymeningitis, 272 ; embolism, 272 ; thrombo!-is, 273, XII. Cerebral Tuberculosis 273 Frequency of its occurrence, 273; diagnosis, 274; symptoms, 274 ; latency, 276 ; duration, 280 ; pathology, 280 ; localisation, 281 ; chronic hydrocephalus, 284 ; treatment and natural cure, 286. XIII. Tumours of the Brain 286 Sarcomata, 286 ; gummata, 289 ; other tumours, 289 ; abscess, 289. XIV. Atrophic Cerebral Paralysis 290 Symptoms and diagnosis, 291 ; pathology and illustrations, 292 ; treatment, 296, XIV CONTENTS. PAGE XV. Chronic Hydrocephalus! 21(7 Diagnosis from rickety cranium, 297 ; symptoms, 297 ; cranium, 297 ; mental development, 299 ; power of motion, 300 ; post-mortem appearances, 301 ; pathology, 3u2 ; hydrocephalus externus, 303 ; pachymeningitis, 304 ; treat- ment, 307 ; acute hydrocephalus, 309. XVI. HVPER.EMIA OF THE BUATN — THROMBOSIS OF THE SiNUSES 310 Patholojjy, .'JIO ; arterial hyperajmia, 310 ; cause, 310 ; treatment, 311 ; other causes, 312 ; venous hypersemia, 313 ; '• hydrocephaloid," 313 ; treatment, 314 ; sinus-thrombosis, 315 ; pathology, 315 ; diagnosis, 316 ; treatment, 317. XVII. TCBERCULAR MeXISGITIS 317 Acute hydrocephalus, 317 ; classical form of the disease, 317 ; symptoms, 318 ; variations from typical course, 32(5 ; when combined with cerebral tubercu- losis, 329 ; pathological anatomy, 329 ; causation, 333 ; treatment, 334, XVIir. Pdrulent Meningitis SSC Epidemic occurrence, 336 ; pathological anatomy, 336 ; sporadic case, 337 ; symptoms, 337 ; chronic form, 343 ; incomplete recovery, 344 ; causes, 344 ; treatment, 317. XIX. Neuralgic Conditions 319 Sensory disturbances comparatively rare in childhood, 349 ; migraine, 349 ; cause, 349 ; symptoms, 351 ; treatment, 352. ' SECTION IV. DISEASES OP the RESPIRATORY ORGANS. I. Inflammation of the Nasal Mucous Membrane — Bhinitis 354 Symptoms, 354 ; rhinitis pseudo-membranacea, 355 ; chronic rhinitis, 355 ; treatment, 350. II. False Croup 356 Onset, 356 ; symptoms, 357 ; recurrence, 357 ; treatment, 358 ; occasionally followed by true cioup, 359. III. Atelectasis of the Lungs 359 Pathological anatomy, 369 ; causation, 360 ; diagnosis, 361 ; congenital atelectasis, 361. IV. Inflammatory Affections of the Larynx and Trachea 363 Idiosyncrasy, 36.') ; symptoms, 363 ; treatment, 364 ; laryngeal obstruction, 865 ; its symptoms, 365 ; its diagnosis, 366 ; treatment, 367 ; oedema glottidis, 369 ; relation of croup to diphtheria, 370 ; simple inflammatory croup, 371 ; " ascending croup," 372 ; symptoms of croup, 374 ; permanent injiu-y to the brain, 376 ; treatment, 377 ; indications for tracheotomy, 378. V. Bronchitis and Catarrhal Pneumonia (Broncho-pnedmonia) 379 Predisposing causes, 379 ; in very young children, 380 ; its treatment, 381 ; catarrh of small bronchi, 381 ; symptoms and physical signs, 381 ; diagno.=is between bronchitis and broncho-pneumonia, 383 ; capillary bronchitis, 383 ; broncho-pneun!onia, 381 ; phj-sical diagnosis, 384 ; symptoms, 386 ; tendency to become chronic, 388 ; abscess-formatii. n, 389 ; causation of broncho- pneumon'a, 3'M ; predisposition to bronchial catarrh, 391 ; spastic contraction of bronchial muscles, 395 ; treatment, 395. VI. Croupous Pneumonia 399 Common in childhood, 399 ; pathological anatomy, 399 ; clinical features, 400; mixed forms of pneumonia, 400 ; diagnosis, 401 ; dissecting pneumonia, 402 ; symptoms, 402; pneumonia migrans, 406 ; complication with pleurisy, 407 ; course and termination, 407 ; prognosis, 411 ; tenaaination in abscess- forma- tion, 412 ; treatment, 413. CONTENTS. XV l'AGE VII. Chuokic Pxedmonia 411 Follows either broncho-pneumonia or croupous pneumonia, 415 ; symptoms, 416 ; termination, 417 ; bronchiectasis, 417 ; treatment, 418. YJir. Pleurisy 419 Varieties, 419 ; latent pleurisy, 419 ; cerebral symptoms, 419 ; physical signs, 4"2;? ; complica'.ionr^. 421 : causation, 425 ; termination, 429 ; treatment, 430 ; indications for puncture, 4ö0. JX. TUBERCITLOSIS OB' THE LUNOS 433 Connection between tubercle and caseation, 433; pathological anatouiy, 434 ; symptoms and diagnosis, 435; latency, 437; caseation of tracheal and bronchial glands, 440 ; diagnosis of disease of bronchial glands, 442 ; termi- nation and complications, 443; hsemoirhagic diathesis in tuberculosis, 446; separate successive attacks, 447 ; treatment, 448. X. G.\XGREXE OF THE LUSGS 410 Pathology and causation, 44'.' ; illustrative cases, 450. X '.. WHOonsc CoroH 452 Diagnosis, 452: symptoms, 453 ; first stage, 453; second st^ge, 453; third stage, 457 ; variaiions from usual course, 458 ; complications, 460 ; causation, 402 ; contagion, 463 ; nervous element, 464 ; prognosis, 405 ; treatment, 466. SECTION V. DISEASES OF THE CIRCULATORY ORGAN.«. I. Diseases of the Large Blood-vessels 470 II. Congenital Cyanosis 471 Causation, 471 ; symptoms, 471 ; diagnosis, 472 ; malformation of the heart without cyanosis, 473 ; prognosis, 474 ; liaimatomata on valves, 476 ; treat- ment, 476. in. ISFLAMMATIOX OF THE PERICARDIUM, ENDOCARDIU-M, AND MYOCARDIUM 476 llheumatic origin, 476 ; latency of heart disease, 477 ; acute cases, 477 ; endocarditis recuirens, 479 ; recovery from endocarditis, 479 ; endocarditis P'eceding rheumatism, 480 ; other causes of endoc&rditis, 48;! ; pericarditis, 485; tubercular disease of pericardium, 486 ; myocarditis, 489 ; aneurism of the heart, 490 ; latt}' degeneration of heart, 490 ; hypertrophy and dilata- tion, 491 ; treatment of heart-disease, 492. INTRODUCTION AND METHODS OF EXAMINATION. Gentlemen, — The treatment of Children's Diseases is usually regarded as a special branch of medicine. I hold, however, that this view is scarcely quite correct, because almost all the diseases of children, with very few exceptions, occur in adults also. Still, these diseases are made a special study of, special cliniques are set apart for them, and they have a copious literature of their own. This is chiefly for the following reasons : (1) Very many of the diseases we are dealing with occur in children with far greater frequency and in a much more striking form than in later years (the acute exanthemata, whooping cough, different forms of dyspepsia, tubercular meningitis, &c.) ; (2) The medical examination of a sick child demands a special dexterity which — however much skill one may have in examining adults — can only be acquired b}^ diligent practice amongst children. Then we must remember that the young physician especially, whose work almost always lies to begin with among the large families of the lower classes, has at the very commencement of his practice a majority of children among his patients. This fact, which was not formerly appreciated as it deserved, is now being more and more realised ; at least I think I am justified in gathering this from the ever-growing numbers of my clinical class in which there are many young practitioners. It seems all the more striking that our school alone regards the study of Children's Diseases as not being an essential branch of science, and, sheltering behind long obsolete statutes, grudges a special chair to Paediatrics. I must, however, at once admit that even the most earnest study of children's diseases and the richest experience will not 1 2 INTRODUCTION AND METHODS OF EXAMINATION. always save you from very painful disappointments in the results of your treatment. Unfortunately the conditions of life in early childhood are such that even the most rational treatment of children's diseases along with the gi*eatest devotion on the part of the physician is in vain in a terribly large number of cases. The attention of the scientific world and the public concern have at all times been turned to the enormous mortality of this period of life, but have not yet been able to cope successfully Avith this fearful state of things. It has been proved beyond a doubt by statistics that the mortality of children is highest in the first months of life, that during the whole of the first year it is twice as large as that of any later year, and that it begins gradually to diminish after the second, and only reaches the usual rate after the fifth year. Of every 1,000 children born, about 200 die in the first year of life ; while the general mor- tality of the population is about 25 per 1,000. I can best demonstrate tliis to yon by stating the following figures : — During the years 1874 — 85, 13,980 children were treated in my department in the Charite, of whom 7,815 were under, and 6,165 over two years of age; there died of the former 5,368 or about 70 per cent., of the latter only 1,420 or about 23 per cent. The first half year of life is quite remarkable in this respect, for out of 4,393 infants under six months, 3,409 died, that is about 78 per cent. These fearful results agree with those drawn from much wider statistics; but with regard to all of them we must certainly take into account as unfavourable factors, the residence in the hospital and the wretched condition of the majority of the very young children on admission. This enormous mortality of the first two years of life and especially of the first six months is accounted for by two sets of causes, one of which is to be sought for in the natural develop- ment of the child, and the other in its surroundings. As you are aware, the development of the child's body by no means comes to an end at birth ; but on the contrary, quite apart from growth, the organism subsequently undergoes most important changes. I need only remind you of the closure of certain foetal blood channels, the differentiation of the grey and white matter in the brain, the development of the intestinal glandular system, the eruption of the teeth and the growth of the bones — processes which of themselves have a tendency to evoke pathological changes in the organs aftected. While children of the privi- INTRODUCTION AND METHODS OF EXAMINATION. 3 leged classes, thoughtfully cared for and appropriately fed by affectionate parents, pass through these threatening evolution- processes more easily, we find that under the unfavourable out- ward conditions of life which exist among the poor, many pernicious influences tell against the normal development and direct it along pathological lines. The foul air of small over- crowded rooms, the more or less unsuitable ways of feeding which are so injurious to a child's stomach, the influence of cold and hunger, the want of a mother's care (for which that of an unprincipled stranger has only too often been substituted), are all factors which work together to hinder the normal pro- cesses of development, and furnish us with those miserable pictures of disease confronting us in the consulting-rooms of parish doctors, in polyclinics, and in the children's departments of hospitals. Many of these unhappy creatures carry with them from the very beginning the germ of death derived from a diseased mother, and fall victims to congenital debility within the first few days after birth. Many others perish from in- herited syphilis; most become atrophic, being reduced by constant diarrhoea; or their numbers are decimated by re- peated attacks of bronchitis, with secondary enlargement of the bronchial glands, ending in caseation and general tuberculosis. Many of these children are illegitimate, and not a few of the mothers, as I can assure you from my own large experience, send to the hospital the child which has become a burden to them, not because they wish it to be restored to health, but only in the hope — which is too often justified — that they may be freed from it for ever. A large number of children of this class taken into my ward died on the very day of admission. Against such wretched social conditions our efforts as medical men are often powerless, and indeed after we have had some experience of them we are apt from the very first to despair of doing anything. The unsolved and almost insoluble problem in connection with this matter — the real causal indication — is how to remove the unfavourable conditions I have alluded to, for against them medicine in itself has no power whatever.^ What a blessing Foundling Institutions with outside nursing, carried out on a large scale, are in such circumstances, may be learned anew from the excellent report of Epstein on the results of the Bohemian Foundling Institution during 1880—84 {Archiv/. Kimkrheill:, vii., Heft 2). 4 INTRODUCTION AND METHODS OF EXAMINATION. We have next to consider tbe methods of clinical exami- nation, which, dmiug the first years of life at least, differ essentially from those employed in the case of adults. The examination of children is rendered more difficult by the fact that they cannot talk, or at least are unable to give sufficient infor- mation to the doctor. In private practice we are helped in this respect by having the mother's account, but in hospital we have usually to content ourselves with a purely objective examination, as in the case of a sick animal, without any help from the relatives or clinical history. The difficulty is further increased by the timidity of the children and their dislike to the physician as a stranger. While in examining adults it is best to explore in order one system of organs after another, regardless of the interruptions of the patient, and to finish up with the history of the case, you will frequently have to abandon this method in childhood. For the refractoriness of the little patients obliges you to seize every favourable moment for the inspection or auscultation of parts which can only be properly examined during a quiet interval, e.g., the fauces or the heart. In this way the examination of patients is apt to lose its continuity and become unmethodical ; and this may render the final summing-up of the results obtained more difficult, especially to the inexperienced. On the other hand the anamnesis is naturally much shorter and simpler in children, and this tends to facilitate the gathering-up of the features of the case for a diagnosis. No fixed rules can be laid down for our bearing towards the children. Many physicians, it is true, have more sympathy with children than others, but even those who show most fondness for them will be liable often enough to be very considerably put out by their crying and noisiness while they are being examined. This resistance is to be overcome either by kindness or by firmness, according to the character of the child and the kind of temper it is in at the time. To know how this is to be done will, at the commencement of practice, be very perplexing and difficult, but as our experience grows, the difficulty will be less felt till at last it becomes scarcely appreci- able. Many children will allow themselves to be kept tolerably quiet while you are examining them if their attention is aroused by holding before them a watch or toy or lighted candle, or by giving them a stethoscope to play with. For especially important cases we have in chloroform a means by which we are able to INTRODUCTION AND METHODS OF EXAMINATION. 5 overcome all resistance and to obtain perfect quiet ; it is parti- cularly useful in cases where we have to examine the abdomen, bladder, or rectum, and in painful joint aifections. In examining children in the first years of life it is best to have them in their mother's or nurse's arms in front of the physician, but with their faces turned to a window. When it is at all possible I have the children taken out of bed and put in this position even although they are feverish, because one is aided considerably by the co-operation of the nurse, who supports the child and keeps it still, as well as by having better light. Often however the child struggles against the hands trying to hold it, moves itself about, and turns and twists so as to make both per- cussion and auscultation extremely difficult. On this account an attempt has been made to follow the child's movements by using a stethoscope, the tube of which is made of india-rubber, and this may certainly be done more easily with this than with a solid instrument. After trying these stethoscopes, however, on many occasions, I have quite given them up because they so often give rise to confusing adventitious sounds ; and I there- fore recommend you to use an ordinary stethoscope. "While auscultating, you must always hold the lower end of the stethoscope between your fingers, both in order to be sure that it is thoroughly in contact with the chest wall and to avoid exerting too strong pressure with your head, which would at once make the child cry. It is a good plan to have a circle of india- rubber on the lower end of the stethoscope to modify the pressure ; but it must be often renewed, for it gives rise to creaking sounds when it gets old and worn. Very restless children must be auscultated directly by the ear, and in this way the person examining can easily follow even the most extensive movements of the patient if he has a firm grasp of the chest and keeps his head always in contact with it. Many physicians think that their duty is done when they have examined the back, but let me strongly impress upon you never to neglect the front and sides of the chest. In a good many cases I have found the signs of pneumonia under the clavicle when everything behind was normal ; and I have often discovered fine crepitations in the tongue-shaped process of the left lung where it overlaps the pericardium, when they could not be made out at all, or at least not nearly so distinctly, over other parts of the thorax. The 6 INTRODUCTION AND METHODS OF EXAMINATION. front of the chest may he examiued with the patient either sitting or lying (the latter especially in the case of very young children) ; but the back only while he sits or lies on his side, never when he is lying on his face. The compression of the abdomen caused in this latter position must push up the abdominal organs and diaphragm and so diminish the capacity of the chest ; and, when the respiratory organs are already affected by disease, not only will the dyspnoea be inci'eased by this, but sudden death may be caused during the examination. Percussion is far more irksome to many children than auscultation, and the crying which it causes^interferes very much with our obtaining definite results. Moreover, every obliquity of posture and every muscular contraction occasions a slight change in the note ; and you will understand from this how careful we have to be in estimating differences in the percussion note when the children are restless. I have very often thought that I made out a difference between the notes on the two sides of the chest the first time I examined a patient, and have afterwards con- vinced myself of my mistake by repeating my percussion with the thorax at rest and the child sitting straight. In doubtful cases we have iu auscultation the best means of controlling our results. You must, moreover, never neglect to percuss both during insj)iration and expiration, esj)ecially in crying children, because in them the parts percussed are more or less empty of air while the cry lasts, and give a proportionately dull and empty sound which disappears during inspiration. This (as Yogel truly observes) is very specially the case at the extreme base posteriorly, where the liver, forced upwards by crying and strain- ing, may give rise to impairment of the note and consequent fallacy. During such examination our patience is often sorely tried, and it may be very difficult to avail ourselves quickly, for the purposes of percussion, of the inspirations \Ahich at long intervals interrupt the crying. Besides this, little children have a habit of holding their breath as long as possible, especially when they are being auscultated. It is with impatience or even annoyance that we wait for them to draw a breath ; the sign however is a favourable one, because serious affections of the respiratory organs do not generally allow the patient to hold his breath for any length of time. Crying interferes much less with auscultation than with percussion ; in fact, I find that any abnor- INTRODUCTION AND METHODS OF EXAMINATION. 7 mal sounds that are to be found in the lungs are much more easily heard during the deep inspirations which occur in the intervals of crying than during quiet breathing. On this account I never put myself much about to quiet a crying child before auscultation, and only require absolute silence from those round about. As regards percussion I should advise you to let your stroke on the pleximeter be as light as possible. The conditions of the child's thorax as regards resonance are so favourable, owing chiefly to the elasticity of its w'alls, that strong percussion may, by setting up simultaneous vibrations in more distant parts, elicit a loud full sound even over parts w^hich no longer contain air, and which accordingly give only a dull and empty sound with a light stroke. For percussing children I use a small ivory pleximeter with an ordinary plessor ; and it is not necessary to use a finger of the left hand instead of the pleximeter except in cases of great emaciation (where the intercostal spaces are sunk in) and in percussing the supraclavicular region.^ To judge of the frequency of the respiration you must examine the child in as quiet a state as possible, best of all during sleep, if this can be managed. All excitement, crying &c., tends to render the results unsatisfactory. By laying your one hand very gently on the child's thorax or abdomen while you hold your watch in the other, you may time the rising and falling of the respiration. In weak conditions, even in children who are not crying, this part of the examination is often inter- fered with by the holding of the breath already alluded to, in which pauses of respiration alternate with short breaths rapidly suc- ceeding one another. For this reason it is very difficult to state the normal number of respirations at a given age, and this accounts for the very diverse statements of different authors. We know that as a general rule it amounts in new-born babies to 32 — 36 in the' minute, that later it sinks to about 30, but that ' Any work is to be gratefully welcomed which gives us independent and exact observations on the peculiarities of physical diagnosis in children ; and in this con- nection Sahli's hook {Die topographiscke Percussion im Kindesalter : Bern, 1882) deserves especial mention. Its practical results, however, seem to me scarcely proportionate to the work expended upon it, especially in the matter of the percussion of the thorax. And indeed I am of opinion that the control of the results of percussion by ausciiltation is worth far more for the diagnosis than all set rules, which are only too often liable to exceptions due to chance circum- stances. 8 INTRODUCTION AND METHODS OF EXAMINATION. even iu cliildreu of 7 or 8 it remains higher than in adults ; and indeed, like the frequency of the pulse, it is in inverse ratio to the age of the child. The action of the child's heart is, to begin with, more rapid ; it is excitable in a high degree by every psychical impression, and dread of the physician who is more or less a stranger to him is especially apt to increase the pulse-rate — often to such a degree that to count it is absolutely worthless for diagnosis. The best example of this influence is given us by children who suffer from jaundice. The slowing of the pulse which is so characteristic of this disease in adults, I have never observed in childhood till aboat the seventh year ; and I can only account for the fact by supposing that the above-mentioned excitability of the nervous system of the heart fully compensates for the retarding influence of the bile-acids. Accordingly, a correct counting of the pulse, especially in very young children, can only be undertaken during sleep. This is easily done if one keeps perfectly still [and lays the point of one's finger softly on the radial artery. "We must at the same time remember that the pulse is occasionally somewhat irregular during sleep even in perfectly healthy children and that this need not be in anyway alarming. Of just as little real importance is the irregularity or even retardation of the pulse which is observed (sometimes for weeks) during convalescence from highly febrile diseases (pneumonia, typhoid, measles Sec), unless the cause of it is clearly apparent. One can never get reliable results by counting the pulse in states of debility (irrespective of exceptional cases and in older children), and hence it arises that the figures given by various authors differ so materially from one another. On an average, I think we must regard a pulse-rate of 120 — 140 as normal for the first months of life, and of 100 — 120 for the second year, after^which a gradual decrease takes place. In children of 3 — 6 years of age the pulse still keeps above 90, and it is only after the second dentition that it graduall}- begins to approach the adult rate. Now, the frequency of the respiration alters iu a corresponding way ; and so we have always to keep in mind its relation to that of the pulse as 1 : 83 or 4. I repeat, however, that, especially in childhood, such calculations from averages are of little or no practical utility, for the reasons already given. It is only in certain definite circumstances that INTRODUCTION AND METHODS OF EXAMINATION. \) the pulse- rate acquires any diagnostic or prognostic value — for instance, the retardation at the beginning of tubercular meningitis and the extreme acceleration towards its close, or again the enormous rapidity in scarlet fever. The rhythm and quality of the pulse have always appeared to me to have much greater significance for the physician. The inequality and irregularity of the beats in the first stage of tubercular meningitis and the diminution and gradual disappearance. of the pulse- wave in severe diseases, especially those of an infectious nature, are points of very great importance to which I shall frequently revert in these lectures.^ The same may be said of the relation of the pulse to the respirations Avhich normally is 3| or 4:1. If this relation is disturbed for any length of time — if for example 40 — 60 respirations occur to 120 — 140 beats — you may almost certainly expect to find some affection of the respiratory organs. Even to this rule however the physician must be prepared to find exceptions; rickety children with more or less deformed chests always breathe more quickly than healthy ones, Nervous excitement also may have this effect ; in little children during the first dentition I have occasionally observed a rate of breathing of 60 — 90 in the minute, which lasted many months with other- wise uninterrupted good health, and gradually as teething came to an end this was replaced by the normal rate : one could only regard such cases as due to a reflex irritation of the respiratory centre. Phenomena of this kind also appear transiently in the course of whooping cough and tuberculosis of the bronchial glands. If the breathing appear not only quicker and shallower but at the same time more laboured, certain of the accessory muscles coming into play and expiration becoming noisy, it is still more significant. Where these conditions exist, physical examination will almost always reveal the presence of bronchitis, pneumonia, pleurisy, or some other respiratory disease. The examination of the heart in the early years of life is attended with almost greater difficulties than that of the lungs. The rapid succession of its beats, and the constant crying which goes on during its examination, often make it impossible to speak positively as to the purity of the sounds and the results of ' Special instriunents for measuring the tension of the pulse in children {e.g. the Sphyg-momanometer recommended by von Basch — Archiv/. Kinderheilk., v., S. 272) can hardly be of miich use in ordinary practice. 10 INTRODUCTION AND METHODS OF EXAMINATION. percussioD. We must also avoid pressing with the ear on the stethoscope so firmly as to indent the costal cartilage, for this may at once render the heart-sounds impure or even blosving. I may also mention that we can hear cardiac murmurs which are due to valvular lesions more distinctly over the lower part of the back in children than in adults, even although the lower lobes of the lungs are normal. The laryngoscopic examination is, however, after all the most trying. In very young children it is almost out of the ques- tion, and even from older ones, we usually, if not always, meet with an amount of resistance very hard to overcome. We may facili- tate the introduction of the mirror by painting the pharynx and entrance to the larynx with a solution of cocaine (5 — 10 per cent.) to render them non-sensitive ; but even when one does succeed in introducing it properly, and getting it fixed in the right position, its surface soon becomes so obscured by the secretion which is forced up from the throat by crying, coughing, and retching, that it is impossible to get a distinct image. Although I do not deny that under favourable circumstances many children may be satis- factorily examined by this method, yet I maintain that in a far greater number of cases it yields either no results or else very un- reliable ones. The conclusions which the older authors pretended to draw from the character of the cry are even less to be depended upon. Its hoarseness or its being replaced by a distressed whimper are the only two conditions to which I can attribute any practical importance. New-born children, as you know, shed no tears when they cry ; the secretion of the lachrymal glands must therefore be still deficient at tliis age like that of the salivary glands of which we shall have to speak later on. After a little practice the examination of the mouth and throat rarely present any difiiculties, and I therefore often wonder at the clumsiness with which many physicians perform it. If the child does not open his mouth of his own accord when told to do so, the best thing to do is to push the under lij) over the margin of the lower jaw with the forefinger and to press on it. This also prevents the danger of the physician's being bitten, for every attempt at doing so will be very painful to the child when his lip is between the finger and his teeth. A little perseverance will usually soon overcome any difiiculty occasioned by the child's obstinately keeping his mouth closed, especially if INTRODUCTION AND METHODS OF EXAMINATION. 11 you force him to breathe through the mouth by compressing his nostrils. As soon as you get your finger over the lower row of teeth, the child usually opens his mouth sufficiently for the mouth and throat to be satisfactorily inspected. In stubborn cases you can easily accomplish your end by using a tongue spatula. The main point is to obtain a good illumination of the fauces either by bright daylight, or, where this cannot be had, by a small candle with its flame fixed in front of a silver spoon held in the same hand. With this simple contrivance, which acts as a reflector and can be got quickly anywhere, one gets a capital light, and I very often make use of it. Nevertheless, you Avill from time to time come across children who resist all our efi"orts to open their mouths with invincible obstinacy, so that at last you have either to give it up, or to attempt to attain your end by forcing the jaws apart. In order to make the results of your examination available for diagnosis, you must have some knowledge of the points in which certain conditions in childhood, even in a state of health, difi"er from the same in adults; for otherwise you will be very liable to find yourself speaking of normal conditions as pathological. In the first place I would draw your attention to the diiferences in character which the normal breath-sounds present at difierent ages. During the first weeks and mouths after birth the breath-sounds are still rather weak, because the short superficial respiration is not sufficient to drive the air strongly in through the bronchi ; and, for the same reason, percussion at this age gives a less full note over the whole chest. About the middle of the first year, how- ever, the breath-sounds begin to acquire those peculiarities which we find under certain circumstances in adults, and call puerile breathing. The breath-sounds have a strikingly sharp, almost blowing character ; the inspiration is almost the only sound heard, the expiration in a state of perfect rest being scarcely if at all audible, though excitement renders it more distinct.^ The sharp puerile breathing is further exaggerated in cases where the thorax is narrowed by rachitic deformity, and it is therefore conceivable ' I must here further mention that in quite healthy children the peculiar rhythm which is characteristic of respiratory disease in childhood — namely, a prolonged "grunting" expiration predominating over a quite short inspiration which follows it like an echo — may occur transiently from fear alone. 12 INTRODUCTION AND METHODS OF EXAMINATION. that in healthy children also the relative narrowness of the thoracic cavity may give rise to the rough blowing character by slight com- pression of the lung when it expands in inspiration.^ The morbid sounds originating in the lungs or pleurae are not, on the whole, different from those in adults. Only one finds medium, and especially fine crepitations far oftener, fre- quently with this peculiarity that they are very numerous on expiration, while inspiration is almost entirely free from them. The type of respiration in young children up to the third year is mainly abdominal. The diaphragm and abdominal muscles work with remarkable energy, and thus there often occurs, even in health, a slight indrawing of the epigastrium and lower ribs, which suggests a pathological condition such as we find developed to a far more marked degree in serious respiratory affections. In cases of debility one need not be alarmed by irregularity of the breathing or even by short pauses ; both occur not unfrequently in little children. The relative narrowness of the thorax is in marked contrast to the large size of the belly which is so often regarded as a sign of disease by anxious mothers, but in reality is caused only by the comparatively small chest, and by a tendency to the formation of gas in the intestinal canal. Amongst the results which the examination of the head yields, an auscultatory phenomenon deserves the first mention. In children in whom the greater fontanelle is still open (that is to say, roughly speaking, during the first two years of life) when they are at rest, on applying the ear or stethoscope over the large fontanelle we often hear a more or less loud blowing murmur, synchronous with the systole of the heart. Since the respiratory murmur due to the vibration of the air-stream rushing through the pharynx can also be perceived over the fontanelle as well as every sound produced by sobbing, chewing ' The explanation given by Sabatier {Etude sur V auscultation du poumon ckez les en/ants: Paris, 1863) is ingenious, but by no means indubitable. According to the laborious measurements of this author, the capacity of the bronchial branches in adult men and animals increases on the whole from the centre towards the periphery. In children, on the other hand, it diminishes, i.e. in them the lumen of the two branches which spring from a bronchus taken together, is smaller than that of the primary bronchus, while in adults the converse obtains. Owing to this circumstance the velocity of the stream of air in the bronchi diminishes to- wards the periphery in adults, while in children it increases, and the breath-sound consequently appears rougher. This roughness is further increased by the greater sharpness of the angles of cartilage, which project between two diverging branches, increasing the vibration of the air-column as it rushes past. INTRODUCTION AND METHODS OF EXAMINATION. 13 and swallowing — one must keep one's band on the pulse while auscultating, to avoid errors, especially in children who are breathing very quickly. With some practice one is soon able, even without these precautions, to hear the systolic murmur easily along with the breath-sounds and to distinguish them from one another. In a very small number of cases I have heard the murmur over a closed fontanelle and at other points on the cranium. Others have perceived it also at the posterior and lateral fontanelles and in the line of the middle meningeal artery (when the fontanelles and sutures were closed), and even over the spinous processes of the cervical vertebrae. The first discoverers of this murmur, the Americans Fisher (1833) and Whitney (1843), regarded it as always indicating disease, especially certain brain-diseases; Hennig and Wirthgen on the other hand directed attention to the fact of its physio- logical occurrence between the 22nd or 23rd week of life and the time of closure of the fontanelle by ossification. As the result of my own numerous investigations,^ I agree with these authors in thinking that the murmur is found pretty often even in healthy childi-en when the fontanelle is still open; but especially in ansemic and rachitic subjects,^ perhaps because in them the fontanelles and sutures remain open much longer than usual. The ultimate causes of this murmur are as yet undetermined. Jurascz holds that it arises in the carotid artery, owing to a relative narrowing of the vessel in the carotid groove, while Epstein, on the contrary, is inclined to compare it with a murmur occurring in the same artery in the neck. At any rate, I hold that the so-called " brain -murmur " is of no interest from a clinical point of view, and cannot be turned to account for diagnosis. Of far more importance to us is the condition of the fonta- nelles and sutures of the skull. In the normal new-born child the sutures are closed by a thick intermediate substance which sometimes projects like a border, while all the fontanelles are still membranous, so that one can feel with the finger the pulsation of the brain through the anterior one. This is ' Beiträge zur Kinderheilk : Berlin, 1861, S. 170. * Roger also, who has examined hundreds of children for this murmur, maintains this view. {^Recherches cUniques sur les maladies de I'enfance, T. 11. : Paris, 1883, p. 261.) Cf. also Rohde, "Die grosse Fontanelle in physiologischer und patholog- ischer Beziehung" — Inaug. Diss. •. Halle, 1886, 14 INTRODUCTION AND METHODS OF EXAMINATION. especially distinct when it expands more than usual, so that the membrane projects above the level of the surrounding bones. This distended, elastic and pulsating condition of the anterior fontanelle is therefore valuable in practice as a sign of increased intracranial pressure. On the other hand, the depression of the fontanelle below the level of the surrounding surface indicates an ana?mic and collapsed state of the brain such as often occurs in atrophic children and towards the end in exhausting diseases (diarrhoea, cholera). Under these circumstances we also not at all uncommonly find a displacement of the margin of the frontal under that of the parietal bone, only, of course, while the coronary suture is still membranous, so as to permit of such a displacement. While the two lateral and the posterior fontanelles are closed by ossification in the first months after birth, the large anterior fontanelle remains open. That it goes on growing in size during the first six months, as was formerly supposed, is disputed by Kassowntz, who maintains, on the contrary, that he has observed a continuous diminution from birth. The complete closure ought to take place about the 15th — 24th month. Still, cases are not very rare in which, well into the third year of life, we may find a membranous spot in the region of the fontanelle that can be covered by the tip of the finger ; and one must not set this down off-hand as a morbid appearance. All other variations, however, — especially a greater and more protracted patency of the greater or lesser fontanelles, a gaping of the sutures, or an unusual yielding to pressure of the margins of the bones, — must be reckoned as pathological, and ■will be taken up later with the consideration of rickets. The same applies to some anomalous forms of the head which are related to certain diseases (rickets, hydrocephalus), while individual difterences in the form of the cranium, caused, not by disease, but by abnormal growth of bone (asymmetry, obliquity of the median line, dolichocephaly, &c.), can only lay claim to clinical interest when at the same time there are symptoms of a cerebral affection (hemiplegia, contractures, backwardness of intelligence). The difference between the adult cranium and that of the child is important, and must always be borne in mind. During the first two years of life the circum- ference of the vault of the skull exceeds that of the face quite disproportionately, so that the relation is stated as about 6 : 1 (in INTRODUCTION AND METHODS OF EXAMINATION. 15 new-born children even 8 : 1), while in adults it is 2^ : 1. We have to remember this in order to quiet the anxiety of many mothers who think that their children are hydrocephalic ; especially in cases where the above-mentioned disproportion is aggravated by rachitic thickening of the cranial bones. Under these circum- stances many children are unusually late of learning to hold their head up Avithout support, which in a state of perfect health they can often do by the third month. In this particular, how- ever, there are many exceptions, due chiefly to the greater or less strength of the muscles, especially those of the neck. We must not therefore at once assume a congenital disease of the brain merely because a child cannot hold its head erect without support when it is five or six months old, unless there happen to be other symptoms present justifying such an assumption— especially want of intellectual development, a staring look, nys- tagmus of the eyeballs, awkward catching movements with the hands, or complete apathy. In examining the cavity of the mouth in new-born children you will be struck with the dark red colour of the mucous membrane. This lasts some weeks and then slowly disappears ; it is to be regarded as a normal appearance. A certain amount of dryness is associated with this hypersemia because the secretion of the saliva does not take place at the same rate as in older children and adults. Recent researches (Ritter, Schiffer and Zweifel) pretty unanimously prove that although the saliva is present from birth its quantity is so small that its sugar-forming power is to be taken into account little or not at all. The salivary secretion first begins to increase perceptibly towards the end of the second month; according to Zweifel secretion usually first begins about this time in the sub- maxillary gland and pancreas, although at birth the parotid contains ptyalin. This deficient secretion of saliva is also the reason why the buccal mucous membrane of infants in the first months, if it is not very carefully washed, almost always gives a somewhat acid reaction with litmus-paper, and, even after washing out, is neutral and but rarely alkaline. We shall see later how important these conditions may be in connection with the methods of feeding children. In very many new-born infants one sees in the median line of the hard palate little yellowish white round or oval nodules 16 INTRODUCTION AND METHODS OF EXAMINATION. from the size of a pinhead to that of a millet-seed projecting only a little from the mucous membrane ; they are either single or in a row and are sometimes surrounded by a narrow red border. These nodules are very common in the first four to six weeks of life and have not the slightest pathological significance. Bohn regarded them as occluded mucous follicles analogous to milium on the outer skin, Guyon and Thierry as epidermoid cysts, and Moldenhauer^ as solid processes of epithelium growing into the mucous membrane and glandular tubes in process of development. Epstein," however, seems recently to have hit upon the right explanation. The investigations of this writer prove that these are spaces filled with epithelium which have been left after the union of the tAvo halves of the palate. With regard to the tongue you will notice that in infants on the breast it is very often spread over with a thin whitish coating especially after sucking (milk-colouration). Also, that in many older children it presents a peculiar "mapped" appearance ; that is to say, the dorsum of the tongue exhibits various greyish-white figures, usually with somewhat raised borders, which are sometimes sinuous, sometimes indented, — and which contrast markedly with the red colour of the normal areas. This state of the tongue (the anatomical cause of which is not yet clear) is due to a superficial irritation of the mucous membrane with copious desquamation of epithelium in places. It occurs very often in perfectly healthy children and has there- fore not the least diagnostic value, and particularly nothing to do with congenital syphilis.^ The examination of the heart need not detain us long, as the results of it in children agree almost entirely with those in adults. For practical purposes it is sufficient to know that in emaciated children (in the second period of childhood more than in the first two years) the movements of the normal heart are often visible as a pulsation in the fourth and fifth intercostal spaces and that the ribs are more strongly bulged forwards by them than at a later age. One may also very often feel the ' Archiv/. Gynäcologie, Bd. vii., Heft 2. * lieber die Ejyithelperhn in der Mundhöhle u. s. w., Zeit sehr, für Heilkunde Bd. I. : Prag, 1888. ' Guinon, "De la desquamation epitWliale de"' Revue mens, des maladies de VtTifance, Sept., 1887. INTRODUCTION AND METHODS OF EXAMINATION. 17 apex-beat somewhat outside the nipple-line without there being any enlargement of the heart. Flattening of the sides of the chest due to rickets favours these appearances, which seem to depend on the higher level of the diaphragm and the consequently more horizontal position of the heart. I have in the next place to treat briefly of the examination of the temperature, urine, and faeces. On the value of thermometry in childhood I need not waste words ; its usefulness cannot be over-estimated at an age when everything depends far more on objective examination than is the case in later life. Unfor- tunately, however, it is only in hospital and private practice that it can be thoroughly turned to account, for at the polyclinic and in the consultation hours of parish doctors it is scarcely possible to take temperatures in a trustworthy manner, owing to the large number of patients and the want of efficient help. Under these circumstances we must content ourselves, except in specially important cases, with estimating the temperature by applying the hand ; and, during the further course of the disease, trust to the accounts of the mothers who generally state correctly the times of exacerbations at least. I usually prefer to take the temperature in the axilla. Although in this position the process takes at least 10 — 15 minutes (therefore twice as long as in the rectum) , still, one must remember that even with every precau- tion it is possible that the thermometer may be broken in the rectum by a sudden movement — as I have myself seen happen. If you disregard this possibility you certainly save much time by taking the temperature in the rectum ; and on this account I have often myself done so in private practice, where each individual child can be thoroughly watched. The variations in temperature in children and adults are the same, except that during the first three to four months of life it has a marked tendency to fall below normal. The heat-production seems at this age to be carried on with less energy, for in very many cases of faulty nutrition, exhausting cachexia or insufficient lung-activity, we observe the temperature gradually falling unusually low — to 86° F. and even lowei-. We have another instance of this peculiarity in the fact that, at the age referred to, otherwise highly febrile diseases (e.g. pneumonia) may run their course with a normal or even subnormal temperature ; of this I have had plenty of proofs in the infants' ward of my 2 18 INTRODUCTION AND METHODS OF EXAMINATION. (lepartment of the hospital. We need not, however, on this account make a special disease under the name of "Algor progressivus " as Her vie ux has done, since this enormous fall of temperature may occur under the most diverse conditions possible, these having nothing in common with one another except the final ending in collapse. The examination of the urine is very difficult in new- born children and other infants, because it is always passed into the diapers and it is very difficult to estimate with certainty its amount and colour from the examination of these. Occasionally there occur cases, even at this age, in which it is necessary to examine the urine for albumen or even for sugar; and for this purpose one must either collect it in special apparatus — in little girls in thoroughly cleansed sponges applied over the genitals, in boys in an indiarubber bladder or some such con- trivance fastened round the penis — or endeavour to obtain it by the introduction of a catheter into the bladder, a method which we prefer in hospital practice.^ In practice one contents oneself as a rule with judging of the urine of new-born children from the diapers. The wetting of these gives us a measure of the nourishment taken, and from a diminished amount of the secretion we assume (and are usually correct in so doing) that the child is either taking too little nourishment or is failing to assimilate what he has taken. It is only very recently that the urine of newly born infants has been made the subject of careful examination by Parrot and Robin-, Dohrn^, Martin and Buge*, Cruse^, Camerer^, and others. The results obtained by these writers do not however altogether agree. It is especially interesting to physicians that Martin and Huge sometimes found a small amount of albumen in the urine during the first ten days after birth. In some this Avas transient, but in others it lasted for several days ; and they are inclined^to connect this condition with the expulsion of the uric-acid infarcts which occur in the renal canaliculi, and of which we shall speak later on. Cruse's researches yielded similar results, but Parrot * Cf. Hirschsprung, Jahrbuch/. KhukrkranJck., xis., S. 205. - Comptes rendus, Bd. 82, No. 1. ■•' Monatsschr.f. Geburtsh., Bd. 29. * Ueber das Verhalten von Ham und Nieren der Neugeborenen : Stxittg-iirtj 1875. » Jahrb./. Kinderkranlcheiten, 1877, xi., S. 393. « Ibid., 1880, XV., S. 161. INTRODUCTION AND METHODS OF EXAMINATION. 19 and Robin state that they Lave never, and Dohrn that he has only rarely, found albuminuria in healthy new-born children. In children more than ten days old, Cruse^ never found albumen, although there was a greater amount of mucus than usual in the urine which might be misleading. - The faeces in infants can also only be examined on the diapers, mixed with the urine. In normal conditions they are almost without odour, so long at least as beef-tea and meat are entirely excluded from the diet. They have a feebly acid reaction, are pretty much the colour and consistence of beaten-up eggs, and are passed twice to four times in the day. Exceptions to this rule, especially a seldomer or somewhat more frequent evacuation, are not to be regarded as abnormal, unless the consistence of the motions becomes more liquid or their smell acid or offensive. In many children the colour of the faeces is not like the yellow of an egg even in the normal state, but inclines rather to a brownish shade. If the cloths are left lying for some time, the yellow colour very often becomes greenish, owing to the oxygen in the air changing the brown bile-pigment into biliverdin, and therefore, in order to form a correct opinion, one must always examine the faeces as fresh as possible. Round about the faeces on the diaper we usually see a colourless wet area caused by the urine. I should, however, point out to you here that there are cases of diarrhoea in which fteces of a tolerably normal appear- ance are first passed, and are followed by a more or less large quantity of a watery fluid from the rectum. The wetting of the cloths which occurs in such cases may occasion error if one thinks that it is caused by the urine and that the faeces are normal. I should not have mentioned this, had I not frequently met with cases in which there was progressing failure of strength along with the above-mentioned appearance of the cloths, the faeces in the middle being pretty well digested but having round about them a pale, apparently urinous, area. From my own observation I have convinced myself that in every one of these caseSj after the ' Jahrh.f. Kinderkrankheiten, 1878, xiii., S. 71. - Hof meier ( Virch. Arch., Bd. 89, H. 3) refei-s the increase In the quantity of the urine as well as of the urea and uric acid, to the loss of weight during the first days of life and the decomposition of albumen which goes on simultaneously. He also connects the albuminuria of the first day of life with the uric-acid infarcts, while Ribbert {Ibid., Bd. 98, H. 3) sees in the albuminous state of the first urine only a continuation of the transudation through the glomeruli (as yet imperfectly developed) which occurs in all embryo kidneys. 20 INTRODUCTION AND METHODS OF EXAMINATION. evacuation of more solid fiecal matter, a larger quantity of thin turbid fluid was expelled with force from the anus — that in fact a condition of diarrhoea was present and accounted for the loss of strength.' Finally, I come to the manifestations of pain in little children, which consist almost solely of cries. It is very diffi- cult — and that not only for the beginner — to distinguish the cry of pain from that which expresses hunger or some other undis- coverable source of uneasiness. I consider it quite unnecessary to detain you at this point — as many authors do — "\ntli a descrip- tion of the various modifications of cries. Such descriptions are of no practical use. Any one can distinguish whether a child is crying lustily or only whimpering feebly, and from this we may judge of its strength ; likewise whether the voice is clear, or hoarse from an affection of the laryngeal mucous membrane. Continuous loud crying which does not set up a fit of coughing is always a favourable sign in aftections of the respiratory organs, because it indicates a relatively small amount of irritability of the respiratory mucous membrane. Violent fits of crying with vigorous movements of the lower limbs, especially drawing them up on the belly, usually indicate colic in infants. But in spite of these and many other hints derived from experience it is often very difficult to decide whether the cry of a child is really due to pain or to some other cause. The presence of the doctor is of itself sufficient to make many children very uneasy and to cause prolonged crying. In doubtful cases, where pressure not only on the apparently painful spot but on every other part of the body excites or increases the crying, the only way to gain your end is to wait until the child is perfectly quiet and then begin the examination over again. If while doing this you can manage to divert the child's attention from the place examined, by toys, by a watch held before it, or by turning its eyes to bright day- light (at the window), you will often — though not always — be able to find the spot which is really tender on pressure. When ' The investigation of the bacteria present in milk-fiTjces, which was first entered into by U f f c 1 m a n n, has very recently been again taken up by E s c h e r i c h on an extended scale, and with some success {Die J hirmbacterlen des f<äiiglingsallci' u. .?. to. : Stuttgart, 1886). According to his researches the number of bacteria in inilk-fasces is relatively small — confined to two kinds only — and real putrefaction does not occur in the colon ; the absence of odour in normal milk-fjeces is ia keeping with this. INTnODUCTION AND METHODS OF EXAMINATION. 21 cLildren cry violently and will not be quieted, it is always well to have them stripped for examination. By doing so I have frequently found the cause of the violent excitement in midges or flea-bites. In judging of the condition of new-born infants and children at the breast, I should further recommend you to observe how the hands are held during sleep. Healthy children at this age sleep, as is well-known, with their arms flexed to such an extent that the hands are directed right upwards and are on a level with the neck or lower jaw. This attitude — which is per- haps a reminiscence of intra-uterine life — is changed in the case, of serious illness, and its presence may consequently be regarded as a reassuring sign. I may also remark here that healthy children usually have their eyes tight shut during sleep, but that in not a few the eyelids are noticed to remain slightly apart. One must investigate such conditions in each individual case, for, as we shall see later on, they may have a pathological significance. SECTION I. DISEASES OF NEW-BOBN INFANTS. The period of suckling extends from birth to about the 9th month, when the eruption of the teeth marks its close. One is justified in treating separately the beginning of this period, i.e., about the first 4 — 6 weeks of life during which we are in the habit of speaking of the child as "new-born " ; for to it belong a number of morbid conditions which later in life do not occur, or are only met with rarely and in an altered form, and which to some extent are connected with what has taken place before birth and with the sudden removal of the child from its mother's womb into the open air. All new-born children present, in the first days after birth, a more or less intense red colour of the whole skin which is due to hypera?mia. In many children this gradually becomes paler and passes in about a week into the ordinary colour ; in many others, however, there is a transition stage, the red at first giving place to a more or less deep yellow, and this we designate icterus neonatorum. Icterus Neo7iatoriim (Jaundice of the new-born infant). The yellow colour is usually noticed on the second or thhd day after birth ; it is almost never equally well-marked all over, but is more strongly developed on certain parts, especially on the forehead, round about the mouth, and on the trunk, rather than on the limbs. The more the redness I have just referred to passes off", the more distinct and general is the yellow colour. It usually has a tinge of orange, is not as a rule very intense, and may also be seen on pressure with the finger on the hypercemic skin. It generally lasts several days, then gradually fades, and in the course of 8 — 14 days is replaced by the normal colour. In examining such children, if you recall the symptoms which the jaundice of later years is wont to present, you will find very 24 DISEASES OF NEW-BORN INFANTS. striking diiferences. The urine which wets the diapers is pale ; the faeces are yellow or brownish, as in the normal state. The sclerotic, however, which is often very difficult to see owing to the energetic way in which the eyelids are kept shut, shows in all cases a distinct yellow colour ; also, the pale spot left for a moment on the red tissue of the gum after pressure with the finger exhibits, sometimes indeed very faintly, the yellow tinge which we are accustomed to see in the jaundice of older j^eople. With the exception of the yellow colour of the skin there are no symptoms whatever ; but on the contrary, except of course in those cases which are complicated with more serious diseases, nil the functions are in good order, and it is all over within 8 — 10 days. The harmless character of icterus neonatorum and its very great frequency have caused it to be regarded not as a disease at all, but rather as a physiological condition. The matter of most importance is to determine what causes the yellow colour of the skin — whether here one has really to do with bile pigment formed in the liver. The opinion originally advanced by French writers, that the yellow discolouration is not truly bilious, but merely proceeds from the red colour of the new-born child, can scarcely nowadays be seriously defended. For in icterus neonatorum, not only is the skin coloured .yellow, but also the greater part of the internal organs. I have convinced myself repeatedly of this fact by post-mortem examinations ; and Orth^ describes a case where even the brain, which in jaundice is ordinarily little or not at all coloured, appeared of a deep yellow. There can therefore be no doubt that the staining of the tissues is caused by a jsigment the characteristics of which apparently correspond with those of the bile. The researches of Orth give new support to this view. The observations which had formerly been made of the presence, at least after death, of crystalline pigment in the blood and various organs of new-born infants were confirmed by him ; and he found that this pigment only occurred when ordinary jaundice was present or in process of disappearing.- This colouring matter is very abundant in the blood, kidneys, liver, and many other organs ; it occurs in the ' " Ueber das Vorkommen von Bilimbincrystallin bei neugeborenen Kindern."' Virchow's Archil', Bd. 63. - Out of 37 cases in which Orth found the pigment, 32 were jaundiced, and in the other 5 cases it was impossible tj proTC that jaundice had not been preA'ioiij^ly present. ICTERUS NEONATORUM. 25 form of red rhombic plates, or cylinders, or bundles of needles, and shows the micro-chemical characteristics of bilirubin ; Orth has therefore no hesitation in regarding these crystals as bilirubin formed after death from bile -pigment formerly in solution in the blood-plasma. How this bile-pigment got into the blood remains indeed unsolved, and on this very question there is still great difference of opinion. While some regard the jaundice as hematogenous — arising from the formation of yellow pigment in the blood itself — others accept the theory that it is hepatogenous like ordinary obstructive jaundice. Now although (as I have myself repeatedly seen) one can at the post- mortem in many cases squeeze out little plugs of mucus from the ductus choledochus, yet the bile-staining of the intestinal con- tents and the normal colour of the urine indicate that these plugs are not sufBcient to cause any considerable retention of bile, or reabsorption of colouring matter by the liver. Then on the other hand, in many cases one finds the ductus choledochus and hepaticus free from obstructing mucous plugs, and on this account the ha3matogenous theory of icterus neonatorum has secured many supporters. But here also there is no satisfactory proof of the cause which occasions such a considerable separation of yellow pigment in the blood. This theory would at all events presuppose a v-ery considerable destruction of red corpuscles in the blood, and a corresponding liberation of blood-pigment^ from which the hciematoidin and bilirubin are derived. We know that the blood of infants is, at birth, relatively richer in red corpuscles than that of older persons (Thomas, Demme); and Hayem, Helot, and others have also demonstrated, by results obtained from counting the corpuscles in the blood which enter the child's body by the umbilical cord, that these are destroyed in immense numbers. Now, according to Porak^ and others, when the umbilical cord is tied after some time (after pulsation has ceased) and a larger amount of blood has found its way from the placenta into the circulation of the new-born child, there will result this greater destruction of red blood corpuscles, a more abundant formation of pigment in the blood, and accordingly jaundice to a corresponding degree. Others,- ' Porak, Considerations sui- Tiefere des nouveaux-nes: Paris, 1878. Schiicking, Berl. Klin. Wochenschr., 1879, No. 39. Violet, Virch. Archiv, Bd. 80, S. 353. - Hofmeier, "Die Gelbsucht der Neugeborenen " : Ziitschr.f. Geburtsh. u. s. zo., Bd. TÜi.. Ht. 2. 2G DISEASES OF NEW-BORN INFANTS. again, ascribe this action to the large consumption of albumen which takes place during the first days of life and occasions a greater destruction of red blood corpuscles ; the insufficiency of the liver cells and biliary passages to meet the increased demands upon them is also to be taken into consideration.^ The reabsorption theory as opposed to the htematogenous one was put on a better footing by the work of Cruse .- This author found the colour of the urine — when carefully collected — yellower than normal ; and he further discovered by micro-chemical exami- nation that the little yellow bodies (masses jannes — described first by Yirchow, and afterwards by Eobin and Parrot, Violet, and others), always found in the urine in icterus neona- torum, either imbedded in epithelial cells, or floating free, or enclosed in hyaline casts, are real bile-pigment. He also states that in all cases of intense jaundice he has discovered bile-pigment in solution in the urine by shaking it up with chloroform — which former obseiwers had not succeeded in doing. The theory of the origin of icterus neonatorum which he puts forward is, however, without anatomical basis. According to Birch -Hirschfeld'' an interstitial cedema of the connective tissue of the liver occurs (o'^'ing to venous engorgement) which brings about compression of the bile-ducts, obstruction to the outflow of bile, and reabsorption. The circumstance that this author was always able to discover bile-pigment, and in one case bile-acids, in the pericardial fluid although not in the urine, must certainly be regarded as strongty in support of the hepatogenous theoiy. He considers that the bile-colouring of the ffeces is due to the continuance for days of the discharge of meconium. The researches of Silbermann* also are in favour of the hepatogenous nature of the jaundice, and according to him it is caused by compression of the bile-capillaries and interlobular bile-ducts by the dilated blood capillaries and branches of the portal vein. However, we must always be prepared to meet with new views on the nature of this disease.^ The development of jaundice is favoured by prematurity of ' Haitmann, " Ueber den Icterus Neonatorum," Tnaug.Diss.: Berlin, 1883. - Arckivf. Kinderheilkitnde , Bd. 1., 1880, S. 353. * "Die Entstehimg der Gelbsucht neugeborener Kinder," Vircli. Arckir, Bd. 87, Heft 3, and Schulze, Ibid. Bd. 81, Heft 1. ■* Arch.f. Kinderheillc., viii., Heft 6. ^ Vide e.g., Quincke, Archiv/, experim. Palhologie n. Pharmacle, Bd. 19. ICTERUS NEONATOllUM. 27 birth, weakness of the new-born child, vinfuvourable conditions ut or after birth, the operation of cold, atelectasis of the lung tissue, defective respiration, and bad air ; these explain the especially frequent occurrence of jaundice in lying-in hospitals and foundling institutions, and in children who are under the average weight. One need scarcely speak of treatment since the affection disappears spontaneously. All that is required is good nursing and attention to the bowels when necessary. In a considerable number of cases the jaundice is complicated by other much graver morbid conditions which are of themselves sufficient to bring about a fatal issue. Many of these children come into the world in the last degree of sickliness, emaciation, and debility ; they exhibit an extensive growth of aphthae on the mouth and gums ; and suffer from the very beginning from vomiting and diarrhoea. In such conditions also I have frequently been able to discover a yellow colour and even the presence of bile in the vomited matters. The most unfavourable complication is sclerema neonatorum, fortunately a tolerably rare one. A case which occurred in my private practice in July, 1875, seems to me worthy of being noted here on account of the obscure etiology and the unexpectedly favourable result. A child, 14 days old, had suffered for about 10 days from jaundice, which, during the last few days, had suddenly increased in a marked degi-ee. The motions were dark, blackish brown, soft, and scanty ; the urine stains on the diapers greenish yellow. There was also an extensive growth of aphthae reaching back into the pharynx with livid colour of the mucous membrane, and the child was steadily sinking, in spite of having a capital nurse and drink- ing abundantly. One was struck with the great number of miliary red spots which were scattered over the greenish-yellow skin of the neck, back, and extremities ; these did not disappear on pressure with the finger, here and there projected somewhat, and later on passed off w^ith a slight desquamation. The child recovered, contrary to all expectation, under the administration of a mixture containing quinine and hydrochloric acid, a mouth-wash of chlorate of potash, and aromatic baths ; and he has since grown up a strong boy. I have not hitherto had an opportunity of observing a second case of this kind, i.e. of jaundice combined with the haemorrhagic eruption just described. There could be no question that it was not a case of malignant jaundice following puerperal infection 28 DISEASES OF NEW-BORN INFANTS. of the umbilical wound ; still, neither did the clinical picture entirely correspond with that of ordinary icterus neonatorum. From the latter we must also distinguish that form of jaundice which occurs in rare cases in new-born infants in consequence of an obliteration or congenital want of the excretory bile-ducts, and which, in every respect, is to be placed along with the obstructive jaundice of older people. In the whole course of my practice I have come across at most three cases of this kind, and of these only two came to a post-mortem. A child of 4 months old, brought in summer 1850 to the University Clinique, had suffered from jaundice since birth, with perfectly dry, almost milk-white, evacuations and dark bilious urine. One could feel the left lobe of the liver distinctly in the epigastrium. In spite of all the means used, not only did the jaundice persist, but the coloiir of the skin became steadily greener, and the child died in a state of extreme emaciation five weeks after it was first seen. After death we found the liver smaller by at least a third than it usually is at this age; the lobes were of equal size, the left flattened, and reaching right into the left hypochondrium, of a moderately firm consistence, and through and through of an olive- green colour. The gall-bladder was present in a rudimentary con- dition, but there was no trace of the bile-ducts to be found, and the opening of the ductus choledochus into the duodenum could not be discovered. You find in this case therefore, not only during life, but also after death, all the appearances of a jaundice caused by obstruc- tion within the liver to the outflow of bile, and especially the familiar diminution in size of the formerly enlarged organ, due to the retrogressive metamorphosis and atrophy of the liver cells. In such cases any treatment is of course out of the question. I shall return afterwards to a case which was apparently the result of a syphilitic periphlebitis.^ In contrast to the mild character of icterus neonatorum,'which we can scarcely regard as a disease, the first period after birth presents one of the most violent and fatal of all known maladies — Trismus, or Tetanus neonatorum. Although the phenomena of this disease are essentially the same as those of tetanus in adults, still they are more or less ' Compare E. Gessner, " Ueber congenitaleii Yerschlups der grossen Gallcr.- gänge," Inavg, Diss,: Halle, 1886. TETANUS NEONATORUM. 29 modified by the child's tender age. Most frequently it begins between the 5th and 9th days after birth, but I have once or twice seen the earliest symptoms appear on the 20th day. Usually the first symptom which strikes those round about the child is the difficulty or impossibility of sucking ; every attempt to seize the nipple or bottle with its mouth calls forth a rigid contraction of the muscles of mastication and of the orbicularis oris, which renders sucking impossible. The other facial muscles also take part in the contraction, and the countenance is then disfigured to an extreme degree. At first these spasms occur only paroxys- mally, whenever an attempt at sucking is made, and it is still possible to give the child milk with a teaspoon, but after a few hours the symptoms usually become rapidly worse ; the fits I have described now occur spontaneously also, without evident cause ; in them the forehead gets puckered into furrows, the eyebrows are wrinkled up, the lids fast shut, the lips drawn into a point like a proboscis, and surrounded by radiating folds. Soon the pharyngeal muscles participate, and their contraction interferes with the swallowing of milk poured into the mouth ; the attempt to swallow is often accompanied by symptoms of choking with cyanosed visage and arrest of the respiration, which in the intervals between the paroxysms is usually extremely rapid and shallow. If one endeavours to pass a finger into the mouth, the jaws are found to be firmly clenched together owing to rigid contraction of the masseter and temporal muscles ; any attempt to overcome this resistance is invariably followed by the accession or aggravation of the convulsive seizures. It is only in the rarest cases, however, that you find this limited to the groups of muscles already mentioned ; usually there is rigidity of the muscles of the neck and back also, with backward retrac- tion of the head and complete immobility of the spinal column, which last one sees most strikingly on grasping the child's body about the middle and supporting it horizontally. The muscles of the upper and lower extremities also often participate more or less. The arms and legs are extended, their muscles hard and unyielding like those of the abdomen, and it is scarcely possible to flex them by force. All these spastic symptoms show, it is true, intermissions or at least remissions, but they become more lasting as the disease progresses, and often, though by no means always, are occasioned or considerably intensified by touching the 30 DISEASES OF NEW-BORN INFANTS. patient, or by attempts to administer nourishment or enemata. Short convulsive seizures which shoot through the trunk and limbs like electric shocks are also not uncommon. Under these circumstances nourishment by the breast or bottle becomes an impossibility. I have only in one case seen a child taking the bottle during the height of the disease and certainly not sufficiently. The complete interference Avith the nourishment, combined with the contraction of the muscles above described, which is unquestionably painful, must bring about a rapid sinking. The temperature (the examination of which is important) either remains normal or shows only a moderate rise to 101° or 102° F., and in many cases this will be little if at all exceeded in the whole course of the disease. Sometimes, however, the tempera- ture rises pretty quickly and finally reaches from 104° to 106° F. or higher, as in many cases of tetanus in adults. The disease generally exhibits a steadily progressive character, but a deceptive appearance of improvement in the symptoms occurs occasionally, either spontaneously or as the result of treatment, but it is wont to be followed, mostly after a very short time, by fresh exacer- bations of the muscular contractions. Finally the child sinks into a state of stupor, the extremely rapid pulse becomes im- perceptible, and death follows either from exhaustion or from asphyxia due to tetanic contractions of the inspiratory muscles. The disease lasts from '24 or 36 hours to 9 days according to the severity of the case. By far the largest proportion of new-born infants attacked by trismus perish ; you must therefore from the beginning give a bad prognosis. Complete recovery however is by no means impossible, and I have myself met with one or two cases of it. Just as in adults, so here, the cases in which the temperature is high apparently justify from the first a specially bad prognosis ; and even where the temperature is low (99° or 100° F. during the whole course) a fatal termination is common enough. In cases which end favourably the improvement is always quite gradual, never sudden ; the rigidity of the muscles and the con- vulsive exacerbations disappear slowly ; and in two cases which I myself observed one could after three weeks still make out a rigidity of the muscles of the extremities, which oö'ered both to extension and flexion an almost springlike resistance. In a third TETANUS NEONATOKUir. 31 child there was still iii the beginning of the fourth week a slight stiffness of the back and closure of the jaws on the introduction of a finger into the mouth ; at the same time the child took the bottle well. None of these cases, however, were to be accounted very bad ones, even during their acme the temperature was only a few points above the normal, and one of the children who Avas treated as an out-patient was able after the first two days to have milk administered to it by means of a tea-spoon forced between its jaws. In new-born infants, as in adults, post-mortem examination yields nothing characteristic. The old statements about blood being found in the spinal canal have long ago been disproved; and where this was really found it must be regarded as having been the result of venous obstruction brought about by the arrest of the respiration, and not as the cause of the disease. You will not rarely meet with little haemorrhages due to the same cause between the meninges of the brain and on the serous membranes. The central organs themselves appear normal apart from a more or less marked venous hyperoemia and its results (oedema, miliary haemorrhages). That in tetanus we have to do with a heightened reflex activity of the spinal cord is beyond doubt, although the production and aggravation of the spastic symptoms by every stimulation of the sensory nerves (feeling the pulse, touching, &c.) is not equally well marked in all cases. Further, in trismus neonatorum this symptom is sometimes more pronounced than at others, and is the more easily understood because at this age even in health the reflex impulses predominate. According to Soltmann's experiments, performed upon new-born animals during the first period of life, all their movements as a rule take place reflexly without the influence of the will, and all the centres in the brain and spinal cord controlling reflex action are still wanting. In this way then we can explain the extreme frequency of reflex spasms in new-born children, in comparison with those of a later age, but not the cause which gives to this uncontrolled reflex action the peculiar and dangerous form of trismus. The frequency of this form is inconsistent with Soltmann's idea that the excitability of the peripheral nerves in these very first weeks of life is less than in adults, for it is very probable that the exciting cause of tetanus comes along these nerves. I regard tetanus in new-born children, as in adults, as the result 32 DISEASES OF NEW-BORX INFANTS. of various influences whicli cause irritation either over the area of distribution of a single nerve or the whole sum of sensory fibres, and, a predisposition being present, produce the disease by rapidly transmitting this to the spinal cord. As such I should name — 1. Injuries (T. traumaticus) — at this age by far most com- monly affecting the navel, separation of the umbilical cord, omphalitis ; rarely other injuries, e.g. the rite of circumcision. In two cases which occurred in my own practice what remained of the umbilical cord was forcibly torn off on the morning after birth, and there resulted an umbilical sore surrounded by an inflamed area. I should add that in this connection I only attach importance to real injuries and not to the " inflammation of the umbilical arteries " which Schöller laid stress upon some years ago ; this is nothing but thrombosis in them which has partially broken down into detritus, and has nothing whatever to do with trismus. 2. The action of changes of temperature on the skin of the new-born infant — on the one hand taking it out into the cold air too soon {e.g. to be christened) ; on the other, too hot baths. Thus M'e have the cases which now and then have been occasioned by midwives who could not appreciate diö'erences in temperature and prepared baths for the infant without the aid of a thermometer. This happened for example in Elbing where trismus was for years endemic in the practice of the busiest midwife, and hundreds of new-born children died of it. At last it was discovered that the midwife was unable to distinguish between a bath at a temperature of 106° F. and one at 95° F. ; a bath thermometer was used, and this " epidemic " of trismus was brought to an end.^ We can easily understand that many other sources of irritation may still remain undiscovered and that the disease may thus originate apparently without cause. Perhaps its origin in vitiated air {e.g. in Iceland, where it was caused by exhalations from whale-blubber, and in the Maternity Hospital in Dublin, from which good ventilation has now banished it) as well as its occurrence as an epidemic in some of the West Indian Islands, is to be explained by one of the causes named. The i)resence of albumen in the urine of new- born infants has been alluded to above (p. 18) ; and I should add ' .Bohn , Jahvb.f. Kinderheilk., 1876, is.. S. 307. TETANUS NEONATORUM. 33 that after death one not very rarely finds in them the appear- ance of parenchymatous nephritis. Although in one case symp- toms were observed (Ingerslev^) which corresponded on the whole with those of trismus neonatorum, and the urine collected contained a largo quantity of albumen and numerous casts, partly hyaline, partly granular, and partly studded with fatty epithelium, yet at the post-mortem there was more the appearance of engorged kidneys with capillary haemorrhages than of par- enchymatous nephritis ; this is readily intelligible in the state of venous engorgement, which in tetanus may affect all the organs. We cannot therefore at present maintain that uremic processes manifest themselves at this age under the form of trismus. In my opinion therefore trismus neonatorum is, just as one might say of epilepsy, a form of convulsion which is a unity only so far as its manifestations are concerned, and which may be caused by a number of different sources of irritation. To discover these causes in each individual case may certainly be difficult and only possible under favourable circumstances, e.g. when due to wounds, umbilical sores, changes of temperature. The etiology of trismus would gain considerably in certainty should the view expressed by Beumer^ be fully confirmed — namely, that here, as in the traumatic tetanus of adults, we have to do with an infection by "tetanus-bacilli" which gain entrance to the body by the umbilical wound. Dirty hands or dressings are supposed to carry these bacteria " which are apparently so widely distributed" to the umbilical wound. As a matter of fact the results of Beumer's inoculation experiments have since been confirmed by Peiper.'^ Should this view be correct, the causes which I have alleged (traumatic and thermic) will only come into operation if the specific bacilli and their products (ptomaines) happen to be present. Even then the treat- ment will always have to contend with the greatest difficulties ; for we know that this same disease, whether of traumatic, rheumatic, or toxic origin, even when it attacks older people who are better able to contend against it, is one of the most danger- ous that we know of. The only remedy, under which I have seen two cases of trismus ' Oesterr. Jahrb. f. Padiatrik, viii., S. 173. 2 Btrl. Hin. Wo'^'henschr., 1887, No. 31. ' CentrnW.f. Uin. Med., 1887, No. 42. 34 DISEASES OF NEW-BORN INFANTS. neonatorum recover, is chloral, wbicli J ^ave iu doses of gr. I — i every hour. If this medicine cannot be swallowed, one must give it in enemata — gr. iss. every hour. In other eases the same treatment gave no result, nor did the inhalation of chloro- form, which caused at most only a momentary relaxation of the clenched jaws. From opium (tinct. opii., gtt. f every two hours) I have observed only a passing eflfect, lasting as long as the narcosis caused by it. Whenever that ceased, the tetanus re- commenced. From extract of physostigma, which I have used hypodermically, a ^ per cent, solution in doses of gr. tV, three or four times a day, I have seen just as little result; while others (Monti) say that they have seen some good from this very drug. Considering the extremely unfavourable results of every method of treatment iu this disease, we must insist all the more strongly on careful prophylaxis ; that is, on avoiding as completely as possible all injuries, and everything that can have an irritating influence upon the cutaneous nervous system (cold air, too hot baths). Besides trismus, other convulsive seizures localised and general occur in new-born infants, corresponding in every respect to attacks of eclampsia in older children. I mention this because some, on the strength of certain of Virchow's observations, are inclined to make the conditions which he described answerable for those cerebral symptoms. Under the title "Encephalitis and Myelitis interstitialis " he described' a morbid condition of the brain and spinal cord which he had observed in children who were still-born or had died soon after birth from the influence of infectious diseases or syphilis, or even without evident cause. This consisted essen- tially in a proliferation and fatty infiltration of the neuralgia cells, which could sometimes be recognised by the naked eye as little soft spots of a yellow or pinkish colour. Hay em and Parrot confirmed the occurrence of these conditions, though not their directly inflammatory significance ; and Jastrowitz," in a work based on 65 cases, explained them as due to a physiological fatty degeneration found in every foetus, especially in certain parts of the centre of the brain, and in the posterior columns of > Archiv, 1867, Bd. 38, S. 129; 1868, Bd. U, S. 472. Klin. Wochenschr., 1883, Oct., Nov. Arch. J". Psych, it, Ncrvenk., 1872. ii., and iii. TETANUS NEONATORUM. 35 the medulla, whicli reaches its maximum about the 7th month of intra-uterine life, then diminishes, and soon after birth dis- appears. He regards this fatty degeneration as morbid, only when it persists beyond the normal time or implicates other portions of the brain than the white substance of the centrum ovale, e.g. the great ganglia, the grey substance of the convolu- tions, or the nuclei of the cranial or spinal nerves. Concerning the etiological conditions of this imperfect reabsorption of fat we arc still in the dark. The whole question in spite of repeated investigations^ remains as yet unsolved. These conditions have at present only an anatomical interest, since their relation to definite clinical symptoms in new-born children is not yet decided. Further, a form of keratitis ulcerosa" whicli occurs between the 2nd and 5th months, and is described as the result of an " Encephalitis " of this kind, is by no means established as such. The same may be said of certain naked-eye changes which one finds sometimes within the cranial cavity in new-born children — oedema and hyperaemia of the pia mater and little ecchymoses in it. When we compare clinically the cases in which these post-mortem appearances are observed, we find no characteristic symptoms at all, but often a general clinical picture which we may describe as that of "congenital debility." A more or less extreme degree of atrophy, a greyish yellow tint of the skin, extreme weakness and apathy, piteous whining instead of the normal cry, quick shallow breathing, a cyanotic tinge of the extremities and a subnormal temperature : — such are the symptoms which these unhappy beings are wont to exhibit soon after birth, and under which the majority of them succumb in the first days or weeks of life, unless they have the good fortune to be placed in particularly favourable circumstances. The lot of most of them, alas ! is to be badly nursed or to be sent to a children's hospital where what they need most, human milk and fresh air, cannot be got. My department in the Charite can show, all the year round, a number of such children who in spite of all our efforts die of collapse from steadily increasing heart- failure, with or without convulsions. The frequent occurrence of oedema, hypersemia and little blood extravasations in the pia ' Kramer, " Ueber das Vorkommen von Körnchenzellen im Gehirn Neu- geborener," Dissert.: Berlin, 1885. - Graefe und Hirschberg-, Arch.f. Ophth.^ xii., S. 250, and Berl. Min. Woch- enschr., 1868.' S. 324. 3G DISEASES OF NEW-BORN INFANTS. mater in these cases, is in my opinion only to be regarded as the result of venous obstruction. It is due to the failure of the heart and collapse of the lungs almost always present, and is certainly not an active process ; it is not therefore the cause of the final convulsive phenomena. I shall revert to this again when speaking of the so-called " hydrocephaloid " of older children. Cephalhematoma. Your advice will often be asked by anxious mothers about a swelling on the head of the new-born child which is known by the name of cephalhaematoma, and consists of an eifusion of blood between the bone and pericranium. It appears to be due to the pressure which the skull of the foetus suifers in passing through the pelvic outlet ; and to produce it, the birth does not need to be a specially difficult one. The occurrence of a cephalhrematoma has also been observed in breech-presentations. In many cases the pressure affects only the scalp and its sub- cutaneous and subaponeurotic connective tissue, and then all that results is a sero-sanguinolent effusion in them forming a moderate-sized doughy tumour, which is known to you from obstetrics as the caput succedaneum. If, however, the pressure is exerted more deeply or for a longer time, the pericranium itself is implicated and the bleeding now takes place between it and the corresponding cranial bone. As a rule this is one of the parietal bones, especially the right, which in the usual presentation of the child is the one most frequently exposed to pressure during birth. The blood which flows from the torn vessels gradually raises the pericranium from the bone and forms a fluctuating swelling on it which does not reach its maximum all at once, but increases in size gradually (as the bleeding goes on slowly) and usually does not come to a stand- still till the third day. Not infrequently the swelling by that time covers the whole parietal bone ; it does not reach beyond, because the sutures of the cranial bones to which the peri- cranium is especially firmly attached set a limit to its further extension. I have never myself seen a cephalhasmatoma on both sides, but examples are not wanting in medical literature. On examination you find a more or less tense, distinctly CEPHALH.EMATOMA. 37 fluctuatiüg tumour usually over the right, more rarely over the left parietal bone, or over other cranial bones. The skin covering it is of a normal colour, less commonly it has a bluish tinge shining through, or it may even be itself infiltrated with blood. Even when it is very tense you will generally be able by sharp pressure with the point of the finger to feel the subjacent bones through it ; although in the first few days a hard, some- what projecting border forms round about the tumour which is apt to be mistaken for the edge of an aperture in the cranium, especially when the swelling is small in size. The cephalhaema- toma hardly seems to cause even discomfort to the infant. Only when one presses on it does the child begin to cry, and that is easily explained by the tenderness of the tightly-stretched soft parts. Moreover the general health remains undisturbed, and the reabsorption of the effused blood proceeds rapidly as a rule. Absorption is all the more rapid because the blood in these swellings may remain at least partly fluid for a very long time (more than four weeks). After one week the swelling consider- ably diminishes and the bone can be distinctly felt through it, and in the course of two to four weeks, according to the size of the tumour, it is completely absorbed. During this period of recovery the above-mentioned hard ring round the tumour continues to be perceptible, only it gets smaller in size simul- taneously with the diminution of the latter. In many cases where the process of reabsorption occupies a longer time, you experience when you press on the soft parts, which are approaching nearer and nearer to the subjacent bone and becoming applied to it, a feeling of crackling, as if you were pressing on parch- ment ; at last the reabsorption is at an end and the pericranium is once more firmly adherent to the bone. The cause of this hard ring at the base of the cephalhiematoma is the process of bone formation which still keeps going on on the inner surface of the separated periosteum, at first taking place most freely where the periosteum and bone border on one another, that is round the base of the tumour. At a later stage little plates of bone are also formed on the inner surface of the raised perios- teum which cause the above-mentioned sensation of crackling to the person examining, and form a sort of shell over tho remainder of the efiused blood.^ ' Vi re how, Gesckiciihte, 1, S. 140. 38 DISEASES OF >.EW-BORN INFANTS. Cepballiicmatomata of a quite similar description to tliose in new-born children may also occur in later life from traumatic causes. I have observed such in children of 2, 4 and 8 years of age as the result of a violent blow against a lamp-post, or of a fall on the back of the head, occasionally also without any evident cause. The swelling was situated either on the parietal or occipital bone, or covered the entire surface of the latter. Here also the tumour was observed gradually to increase in size ; and in the case of a boy 8 years old a v,-eok after the fall, when the cephalhematoma was fully developed, an additional haemorrhage accompanied by great swelling took place into the subcutaneous connective tissue of the forehead and eyelids. A week later nothing remained of this but a greenish yellow discolouration, while the immense cephalhsematoma on the occipital bone after lasting 14 days had been reabsorbed, and only a flat swelling scarcely as big as a shilling was left, sur- rounded by a hard ring of bone. According to my experience the treatment should be purely expectant. Formerly I used frequently to make incisions, evacuate the blood, and then at once apply pressure with strips of plaster. The result of this was usually good, still I was not always able to prevent suppuration ; and I have repeatedly met with cases which had been incised by other practitioners and which presented gaping suppurating sores. Although now this danger is materially lessened by antiseptic dressing, yet I see no reason for opening a swelling which I have always seen disappear completely by absorption in a few weeks. I should therefore advise you only to incise if the tumour suppui'ates spontaneously and threatens to burst ; an event which is very rare and which I have never myself observed. Under all cir- cumstances, however, it is well to protect the tumour as much as possible against external injuries by a soft covering (cotton wool) . Only by the utterly inexperienced could a cephalhematoma be mistaken for a congenital encephalocele — the protrusion of the brain or cerebral membranes distended with fluid (menin- gocele) through a congenital aperture in the cranial bones. This mistake is rendered possible by the apparent or real fluctua- tion in such a tumour and the hard border of the bony aperture which can be felt round about it. The dia^^nosis is based on ILEMATOMA OF STEKNO-MASTOID. 39 llie fact, that the encephalocele generally occurs at a place which is almost never affected by cephalhfematoma in new-born infants, namely on the occipital bone, much seldomer on the glabella or parietal bone. The encephalocele is as a rule smaller,^ and when the hand is laid on it one can make out a pulsation proceeding from the cranial contents, as well as a rising and falling with the respiration, which never occurs in cephalhaematoma. In these also by a sharp pressure with the finger we can almost always make out the bones lying under the fluid, while we can never do so in encephalocele and meningocele. The same holds good of the so-called spurious meningocele in which penetrating fissures of the cranial bones, usually fractures, have arisen (either before or after birth), and cerebro- spinal fluid has passed out through them under the pericranium. In doubtful cases — and these must indeed be extremely rare — we may make certain by an exploratory puncture. Heematoma of the Sterno-mastoid. You will not very rarely have children brought to you in the first weeks of life who have a hard roundish or elongated uneven swelling on one or other side of the neck, very rarely on both sides, corresponding to the anterior division of the sterno- mastoid muscle. The size of it varies, being sometimes that of a pigeon's egg; often however it is larger and of an elongated form — so that I have occasionally found a great part of the anterior border of the muscle hard and knotted, with band-like processes spreading into neighbouring muscles. Sometimes there occur two or three separate indurations in the border of the muscle. As a general rule the upper half of the muscle is much more frequently affected than the lower. Occasionally I have found almost the whole anterior half of it of a really cartil- aginous hardness throughout its entire extent. The right sterno-mastoid is by far more frequently affected than the other, for out of 30 cases recorded in my journals I find 23 of the right side and only 7 of the left. The youngest child I have seen with an affection of this kind ' Very large meningoceles (ey. the size of a child's head) are generally pedicu- lated and somewhat transparent when held against the light {cf. a case of this kind which I observed— (■/;«/■*/(-- .4 «nrt^ere, Bd. i,, S. 569). 40 DISEASES OF NEW-BOKN INFANTS. was three weeks old, the majority were 4 — G weeks, but 4 had reached the ages of 3, 5, and 12 months respectively. In no case did it cause any pain ; in most it was discovered quite accidentally while the child was being washed. Less fre- quently the mother's attention was first attracted by the fact that the child's head was not held straight when it was lying, but had always an inclination to one side, usually the right. This position of the head, however, was by no means always present, and it has seemed to me to be less common the younger the child was. The nature of this swelling of the sterno-mastoid muscle becomes clear to us when we find that almost all the children affected by it have had an abnormal presentation at birth, Avhich either delayed the labour or rendered artificial assistance necessary. Out of 30 cases which I have observed, there had been a breech presentation in 20, and some force had been used in bringing the labour to a conclusion. Of the remaining 10 cases, 7 were born with the normal presentation, but in all it was expressly stated that the labour was unusually prolonged because the child's shoulders would not engage, and that strong traction was required. In one case the child was born as- phyxiated and had been violently swung about in the attempt to resuscitate it. No one, therefore, can doubt that the cause is to be sought in a forcible stretching and partial laceration of the muscle occurring during or after birth, and that the disease consists in an effusion of blood into the muscular tissue (h tern atom a), followed by myositis, which forms a capsule round it and leads to the formation of a fibrous induration ; this is confirmed by post-mortem examinations (Skrzeczka, Taylor). The use of force in such circumstances occasionally has other efiects. Thus in one of my cases there was simultaneously a fracture of the upper arm, and in another, in which the presenting part (nates) had exhibited an extensive ecchymosis immediately after birth, an apparently paralytic weakness of the right lower extremity.' As far as my observation goes, the swelling always takes a ' In one new-born child I found a g'angrenons cavity, aboiat the size of a walnwt, on the left side of the neck, just under the mastoid process, which was caused by the separation of a black slough. This had evidently been caused by pressure Avithin the pelvis during a prolonged labour, occasioning a hfematoma and ending in necrosis. In this case the muscle was not implicated, and only the siiper.iacent tissues (skin, connective tissue and fascia) were affected. SWELLING OF MAMMARY GLANDS. 41 favourable course, gradually diminishing, and at last leaving an induration of a varying size in the muscle which scarcely if at all interferes with its functions. I have never myself seen suppura- tion, but it cannot be denied that a serious disturbance of function may arise from it and I have every reason to assume this as the original cause in a case of torticollis in a girl six years of age, which dated from the first weeks of life. Also the wry-neck of a boy of seven, which had already been operated on with partial success, three years before, was due to a haematoma of this liind, resulting from a breech presentation ; and the retracted scar could still be distinctly recognised in the anterior belly of the muscle. Unfortunately, almost all my cases of haematoma were subsequently lost sight of, and I saw few of them a second time. In the case of a child of six weeks old, first examined on 31st March, 1878, the swelling could be felt distinctly — although it was considerably smaller — on 2oth October. The natural cure by the formation of a fibrous indu- ration makes any treatment superfluous. If you like to order the inunction of iodide of potash ointment over the tumour, you may thereby perhaps gratify the anxious mother and — especially among poor patients — ensure to yourself further observation of the case. But no one will anticipate any benefit from this treatment. Sicelling of the Mammary Glands. In very many new-born infants you observe swelling of the mammary glands during the first weeks of life. In the position of one or both mammae you find a tolerably hard swelling, globular or bluntly-conical in shape, about the size of a pigeon's egg or small walnut, and of the natural colour of the skin. Pressure on this seems to be painful, as it usually makes the child cry. Now, if you take hold of the base of the swelling with two fingers and compress it laterally with moderate firm- ness, you see a whitish, opalescent drop rising out of the shallow funnel-shaped hollow which exists at its summit ; and this shows under the microscope fat-globules and larger conglomerations made up of them. To understand how these swellings are formed, one must remember that all new-born children, boys as well as girls, have a secretion from their breasts resembling milk, which begins 42 DISEASES OF NEW-BORN INFANTS. about four days after birth. This is usually accompanied by a slight swelling of the mamma, goes on increasing till the ninth day, then gradually decreases till, about twenty days after birth, it is no longer perceptible. I have, however, in one child found both breasts, four weeks after birth, still much swollen, nodular and containing milk. Natalis Guillot', by squeezing the mammary glands, obtained from a child about fifteen minims of whitish fluid which, under the microscope, presented all the characters of colostrum. According to Sinety's" investigations on making a section of the breasts of new-born children, one finds milk-canals near the surface which are filled with epithelium. These become wider as they pass inwards, divide, and form cavities containing a fluid resembling colostrum. This process is said to begin during fcetal life, to reach its acme between the fourth and tenth day after birth (in virtue of a stronger develop- ment of the above-mentioned milk canals and cavities), to be aggravated by squeezing the breasts, and, in rare cases, to last possibly as long as six to eight M'eeks. Epstein^ connects this with the active cell-formation and desquamation of the ej^ithelium which take place during foetal life in other parts regarded as invaginations of the skin, especially in the sebaceous glands, and which appear in the form of vernix caseosa, seborrhea, or milium. Moreover, according to Guillot, this secretion of milk is observed only in strong healthy children, and not in those that are weak and sickly from birth. Now in new-born infants, as in women, the secreting breast may become the seat of morbid processes. One need not, like Bouchut, assume in such a case a " puerperal " condition of the child, when there is absolutely nothing else indicating it to be observed. On the contrary, the purely local process may become aggravated to such a degree of inflammation as to bring about firstly a greater swelling of the glands, and then the formation of abscesses in them. In this case the little swelling becomes red, very tender, and fluctuating ; and a quantity of pus is evacuated either spontaneously or by incision. Since I have seen this happen two or three times from the swelling having been squeezed too hard or very often — which midwives especially ' Arch, i/e med., 1853. - aus. med., No. 17, 1875. ^ Centralzeitungf. Kinderkrank., Bd. ii., No. 4, S. 53. J ERYSIPELAS NEONATORUM. 43 arc apt to do — I always guard against any maltreatment, and prefer to have it simply covered with wadding soaked in oil. Under this treatment very considerable tumours disappear with surprising rapidity. Should redness or suppuration follow not- withstanding, you may favour the evacuation of the abscess by warm poultices and incisions. Guillot observed three cases ending fatally from complications ; and Bouchut^ saw one case with a considerable undermining of the pectoral muscle, which ended fatally. I have myself only once met with an unfavourable termination — burrowing of matter and gangrene of the skin over the pectoral muscle in a sickly, wasted child. Strictly cir- cumscribed suppuration in the gland may also occur, as was shown by the case of a child from the upper part of whose mamma (which was only slightly swollen) a few drops of yellow pus oozed on compression by the fingers, while from the lower part there trickled white milk. In some cases also I have seen the two mammpe affected in succession. Erysipelas Neonatorum . There used to be many who were inclined to deny that the erysipelas of new-born infants was in any sense a distinct disease, and preferred to regard it always as merely a symptom of the condition described under the name of "puerperal infection " of new-born children.- I have not myself any very extensive ex- perience of this condition, which for obvious reasons occurs most frequently in lying-in hospitals and foundling institutions. This much, however, I think I am justified in giving as my con- clusion : — that erysipelas in new-born infants is by no means always to be regarded as a symptom of puerperal infection. In adults, erysipelas occurs sometimes as a symptom of serious general diseases — pytemia, septicaemia, typhoid, &c., — sometimes begins as a local afi'ection proceeding from a wound and of para- sitic nature as proved by recent research (Fehleisen). In the same way we must, I think, distinguish two forms in new-born children. The first and most serious of these is connected, without doubt, Mith the already mentioned puerperal infection of infants, the various phenomena of which come to be joined to those of erysipelas — rapid collapse, very high temperature ' Tratte prat. des. maladies des nouceaiir-nes, &c., 5 ed., 1867, p. 719. - V. Hecker, Archiv/. Gjna-col, Bd. x., H. 3, S. .333, 1876. 44 DISEASES OF NEW-BORN INFANTS. (to 106'° F.), jaundice, vomiting and purging, inflammations of various serous membranes (pleura, peritoneum, joints), convul- sions and coma. This is the form of erysipelas which occurs in the children of women who are suffering from sporadic puerperal fever or have died of it (of which I have myself seen several examples). It attacks also on a more extended scale the new- born infants during epidemics of puerperal fever, and in the lying- in hospitals Avhere this disease prevails. The second form has nothing to do with puerperal infection ; at least no connection can be traced with disease of this kind in the mother. At some place or other on the body there is an abrasion, it may be very trifling, which becomes the starting-point of the disease and a true erysipelas traumaticum is developed with the well-known tendency to spread. As at certain times sores of the most diverse kinds are apt to give rise to erysipelas — especially in hospitals — while at others this seldom or never happens ; so, the wounds one finds on the bodies of new-born children, when exposed to foul air, unclean- liness and infectious influences — which are certainly not of a puerperal nature — are very apt to give rise to an attack of the same disease. Hence, also, one meets with the second form of it far seldomer in private practice where the surroundings are favourable than among the poor. But even with the best nursing and the most favourable conditions of life, erysipelas neonatorum may develope. As an example of this I shall only mention the case of a Jewish boy in a very well-to-do family, in whom I saw erysipelas starting from the jjenis after circumcision. It gradually spread over the whole body, produced, after a fortnight, a circumscribed patch of gangrene on the scrotum, then an im- mense abscess on the back; and finally brought about a fatal result with general collapse, jaundice, and symptoms of peritonitis. In this case a puerperal source of infection was out of the question. The traumatic form also of erysipelas neonatorum may begin during the first few days after birth. Sometimes it occurs much later. Thus I have seen it begin on the fifteenth day after birth in a child who had had a fall, whose mother was not quite six- teen years old. Yery often a raw surface at the umbilicus first gives rise to its development ; almost as often, however, the genitals form the starting-point; the anus less frequently. In these cases we have to do less with actual wounds (except in ERYSIPELAS NEONATORUM. 45 the case of circumcision) than with those red excoriations which form in this region on the parts of the skin which have become the seat of intertrigo, from the contact of the urine and faeces, and want of cleanliness. Erysipelas may also originate in other regions of the skin, if only abrasions of it are present ; but this is far less common. You will therefore most frequently find erysipelas commencing at the umbilicus, or lower down in the pubic region at the root of the penis, as a more or less bright- red flush spreading over the skin, and a tolerably resistant swell- ing which is bounded by sharply defined borders, is raised a little above the surrounding healthy skin, and feels hot to the touch. Pressure, which momentarily lessens the redness but does not make it quite disappear, evidently pains the child. It is rare to have the process limiting itself to the areas of skin originally affected. Almost always the raised margins are pushed gradually onward in different directions ; sometimes simultaneously on all sides, oftener more towards one side, in which case the spread of the disease may be quite irregular. Thus, for example, it often happens that it spreads mainly in a downward direction, the erysipelatous rash becoming diffused over the thighs, then over the legs down to the feet ; while at first it does not pass upwards beyond the level of the umbilicus. But also in these cases we not uncommonly see the erysipelas beginning suddenly to spread upwards from the anus, and thence over the nates and back till it reaches the upper half of the body. In this way the process may be arrested in all directions and come to an end ; but often it spreads over the whole surface of the skin, even over the face and scalp. Wherever the erysipelas makes its appearance, the skin is bright or dark-red, often glazed, oedematous and firm, sometimes of a board-like hardness, so that it scarcely pits at all on pressure with the finger. On the upper and lower extremities, the hard infiltration of the skin sometimes increases to such an extent that in a few cases I have found it scarcely possible to move them at the joints. In general, how- ever, the redness and tension of the skin do not occur to such a high degree on the parts attacked at a later stage as on those first affected ; and at the same time the raised border becomes gradually less marked. In many places it may be accompanied by an eruption of vesicles, or of larger bullae, filled with yellowish serum, as in the erysipelas bullosum of older individuals. 46 DISEASES OF NEW-BORN INFANTS. The (Edematous swelling of the skin and underlying tissue is most marked on the laxer parts, so that the penis, scrotum, vulva, eyelids, hands and feet, appear not only reddened but con- siderably swollen. Lines drawn on the red skin with the finger- nail or any blunt object, remain visible for a long time as white streaks ; in one of my cases they were visible for more than a quarter of an hour. As in every case of erysipelas migrans, while the redness gradually spreads, the parts first affected be- come pale ; and hence it sometimes happens that the chest and neck as well as the legs are still of a bright red, while the inter- mediate parts have resumed their normal colour ; but this does not protect the latter from being again affected by a retrograde process as it were. Thus, in a child of five Aveeks I have seen erysipelas, which had affected the whole body almost up to the neck during three weeks, suddenly attack the scrotum a second time. One finds therefore, not unfrequently, in the stage of decline, when the disease has ceased to spread, patches of redness irregularly distributed and no longer continuous but isolated in the form of numerous islands, — partly on the chest, partly on the back or limbs. Between these the skin is of a normal colour, but generally appears more or less oedematous and is covered Avith fi-agments of desquamated epithelium or the remains of bullae. Sometimes after the colour has quite faded there remains behind an oedema spreading over the whole skin, and in cases which are in this stage when they are first brought to the physician doubts may arise concerning the nature of this oedema, which are only solved by the history of the disease and the traces of desquamation of the epidermis which still remain. During the course of the disease which I have just depicted, a remittent fever is present in all cases, the evening temperature rising to from 102° to 106° F., the morning temperature being about 2° F. lower. The pulse is exceedingly quick (up to 170 and more) and small, the breathing correspondingly rapid and superficial. Many children at an early stage refuse nourishment, especially the breast, even while they will still take milk from a teaspoon. I have seen others take the breast almost as well as when in health. With the arrest of the erysipelas the tempera- ture generally falls rapidly, and the child recovers more or less quickly. On the other hand, should the erysipelas go on spread- ing further and further over the surface of the skin, the fever ERYSIPELAS NEONATORUM. 47 continues, and wc are very apt to Lave complications added; with morbid conditions of the iuterruil organs (especially profuse diarrhoea, pneumonia, and peritonitis), which may put an end to life. The last-named affection I observed in two non-puerperal cases, with very considerable enlargement, tension and tenderness of the abdomen, and frequent vomiting. Probably the inflam- matory process spreads from the skin of the abdomen directly to the peritoneum through the umbilicus, which in such cases is generally swollen and sore. Apart from these complications, the high fever may so exhaust the strength of the feeble infant that a fatal termination may ensue with symptoms of collapse. One should never, however, lose heart, since even in cases of exten- sively spreading erysipelas the children, after weeks of suffering, may get off with their lives and completely recover ; others, however, after having made a good recovery from the erysipelas, fall victims to abscesses and gangrene of the skin arising from it. I have observed this result frequently on the scrotum ; also on the malleoli, on the back (almost a third of it was in one child covered with an immense accumulation of pus), on the arm, and on the external ear. In the case of smaller patches of gangrene of this nature recovery may take place on their separation. In a child aged three weeks, erysipelas had spread twelve days before from the umbilicus over the gi*eater part of the body, up- wards and downwards. An abscess on the left side of the scrotum remained after this ; and when it biirst, a deep cavity the size of a florin was left, containing fragments of gangi'enous connective tissue. The penis and lower limbs were oedematous, and on the left cheek there was another extensive red infiltration. Under the use of hot poultices, the gangrenous tissue of the scrotum separated in four days ; while the erj'sijoelas, of which nothing could any longer be seen on the upper joarts of the body, except on the cheek as men- tioned above, suddenly spread a second time over the left upper extremity from the elbow to the fingers, and caiised a large abscess on the elbow, which I opened a week later. In the end the child recovered completely. The fact which I have already mentioned above was seen in this case, viz., that after the disease had apparently ceased spreading, certain areas of the skin — in this case the left fore- arm — was suddenly attacked again, although no continuity could be discovered with an already existing patch and no wound existed on the part newly affected. Treatment in this dangerous disease is practically powerless. 48 DISEASES OF NEW-BOEN INFANTS. At its commencement, when the erysipelas is usually limited to the umbilical or pubic region, one may attempt to mitigate the inflammatory process by large fomentations of lead lotion. Internal remedies — except mild purgatives when the bowels are confined — are quite useless. Should the erysipelas begin to spread, no medicine of any kind is capable of limiting its extension any more than in later life. The only thing that can be done is to administer tonic remedies, wine and decoction of bark ; but from this I have not seen any really successful result. The matter of chief importance, however, is whether the erysipelas is arrested or continues to spread ; in the latter case I have no confidence in any medicine. Injections of carbolic acid (1 to '2 p.c.) into the neighbouring healthy tissues have not in my hands done any good ; and on account of the danger of poisoning in the case of such small children, their use seems to me more than questionable. Complications must be treated according to their nature ; but when the erysipelas is extensive, they almost always prove fatal at this tender age. Abscesses are to be poulticed, opened as soon as distinct fluctuation is present, and dressed antiseptically. That I may not have to return again to this condition, I shall take the liberty of adding here a few words on erysipelas in later infancy and in older children. In them also one almost always finds, on careful examination, an excoriation, which may be regarded as the door of entrance for the infecting bacteria and the starting-point of the disease. The sores which I have found most frequently are, that of vaccination, eczema of the scalp, excoriations on the genital organs or arms, such as often occur as the result of erythema intertrigo occurring in these situations, diphtheria of the vulva, large ecthyma pustules ; lastly, in older children — especially those who are scrofulous — chronic rhinitis, with excoriations of the nasal mucous mem- brane. Nothing is more common under the last-mentioned circumstances than a recurrent erysipelas — i.e., one which returns once or even oftener every year. In these cases the erysipelas spreads from the excoriated and scabbed nostrils towards both sides over the cheeks, presenting the appearance of red butterflies' wings ; but it does not usually extend further. It is not always possible, however, to discover, even by the most careful search, an excoriation as a starting-point. ERYSirELÄS NEONATORUM. 49 Thus in a child of fifteen months I have seen erysipelas starting from the right labium majus, on which there was not the slightest abrasion of the skin. It spread (with smart fever for ten daj-s) with a raised margin over the right lower extremity and descended in paler patches as by leaps, — i.e., with unaffected skin between them — down to the inner ankles, while red islands were also noticed here and there on the skin of the abdomen. The attempt to limit it by painting on collodion failed entirely, and in spite of thi.s it continued to spread for about twenty-two days ; after which recovery took place. — In a child of two and a-half years, the erysipelas spread for the third time within seven months from the aims over both nates, with the formation of numerous bulliB, although there was not the slightest al^rasion to be seen about the anus. — In a child five months old, the disease seemed to originate from the vagina, which at this tender age Avas already the seat of fluor albus; extension took place upwards and doAvnwards over the whole body, diarrhoea and pneumonia came on, and death ensued. — I have also observed it in an infant three months old, the result of an incision situated on the right side of the neck. The erysipelas was accompanied by fever (102° to 104° F.) and extended from the wound with a thickened raised border over the inght ear, the cheeks and both eyelids, then over the forehead and scalp to the neck, where it came to an end after a week. The treatment consisted of compresses of ice-cold lead lotion, later an ice-bag on the head; internally, quinine (gr. ss. every two hours). When the erysipelas arises from eczema capitis, it is apt to remain hidden under the hair and the crusts on the scalp ; and it reveals itself only by the accompanying fever, the cause of which is not recognised until the erysipelas passes beyond the border of the hair and becomes visible on the forehead or neck, or in the neighbourhood of the ears. In such cases we sometimes have relapses, or rather an extension of the disease on different sides of the eczematous area, e.g. first over the forehead and then again towards the temples, each extension being ushered in by a fresh accession of fever. A boy of four years, with eczema capitis, especially on the left side, admitted into my ward in September, 1873. In the night between the 26th and 27th September, fever with restless- ness and headache. On the 27th, continuance of these symptoms without evident local cause. Temp. 103-5° F., ev. 103-8° F. On the following day redness and swelling of the left side of the head passing beyond the border of the hair and extending to the temple ; anorexia, thickly-coated tongue. Emetic. Temperature in the evening 105-1° F. During the next few days the erysipelas gradually 4 50 DISEASES OF NEW-BOltN INFANTS. diminished in intensity, tlie i-eduess becamo less continuous, the tenderness less, the fever diminished, and on 1st October the temperature was 99"5° F. Of the ciysipelas there remained visible only a numl)er of vesicles on the margin of the forehead. On the evening of 11th October the fever recommenced, reached on the morning and evening of the following day 1('4"9°F. ; and erysipelas again appeared, starting from the eczema and extending about an inch and a quarter beyond the border of the hair. An ice bag was applied over the reddened area, and the erysipelas ceased spread- ing and faded on the next day; on the 14'th the boy was fi-ee from fever, so that we were able, after a few days, to take in hand the treatment of the eczema. I have repeatedly seen tracheotomy wounds in cases of diphtheria and even other incisions covered with diphtheritic membrane, become the starting-point of erysipelas migi-ans, which sometimes crept onward till it reached the thorax, and even the epigastrium. In one infant it took its origin from little pricks which I had made in the scrotum with an ento- mological needle for hydrocele. The scrotum and pubic region soon after became deep-red, hard and swollen, up to the level of the umbilicus. Gangrene and separation of part of the scrotum followed, and the child died in a state of collapse. In many cases erysipelas is developed as the result of vaccination, rarely within the first few days, usually commencing towards the end of the first or second week, or even later, when the vaccina- tion sores are already covered by scabs. Only one arm as a rule is affected, and in that case a spreading of the erysipelas over the body is less to be dreaded than when both arms are attacked. In one case I have seen it spread upwards as far as the auricle, which became swollen, dark-red, and covered with bullfc. In other cases it is impossible to decide whether one has to do with the ordinary areola of the vaccine vesicle extending further than usual, or with erysipelas limited to the upper arms. At certain times, and especially in certain localities, e.g. foundling institu- tions, vaccination-erysipelas may appear as an epidemic ; and this is equally likely to occur whether animal or human lymph has been made use of. The treatment of these forms of tlic disease is the same in all particulars as that already mentioned (p. 48). SCLEREMA NEONATORUM. 51 Sclerema Neonatorum. The chief characteristic of this dangerous disease, which occurs ahnost exclusively in lying-in hospitals and foundling institutions and is rare even in them, is an induration and rigidity which the skin of the infant offers to pressure with the finger over the greater part of the hody. In the most severe cases one finds a tense induration as if the hody had been frozen ; but this is not equally well marked in all places. A more or less considerable fall of temperature accompanies this. The children thus aftected are feeble, prematurely born and atrophic, and they invariably die. Such is a brief und very general statement of the features of a complaint concerning which, till the most recent times, there prevailed a greater confusion of opinion than concerning almost any other disease. Owing to the rarity of the affection and the vague descriptions of it given by most medical writers^ there have been widely difl'ering views among practitioners con- cerning the nature of the disease, and man}- have no clear conception at all of what is meant by the name sclerema. The credit of having cleared up this confusion is, in my opinion, pre-eminently due to Parrot, who in his capacity as physician to the Paris Foundling Institution had abundant opportunity for studying the diseases of new-born children. In his work on Athrepsic^ he points out that two morbid conditions entirely distinct from one another — the real induration and the oedema of new-born children — have been hitherto almost uni- versally confounded with one another, and have been included in one vague description. He explains this confusion thus : the real cellular-tissue-induration (sclerema) was first described by Underwood, and this designation soon after, in the year 1781, was transferred by Andry to the oedema of new-born children frequently observed in the Paris Foundling Institution. (1) The true induration (sclerema) occurs, according to Parrot, exclusively in extremely atrophic (or as he expresses it athreptic) new-born infants, especially where the atrophy aff'ects children of medium bulk immediately after birth. While ordinarily the skin in atrophic children forms broad folds around ' Clliiigue des nouceaiix-ncs : Paris. 1877. p. IIG. ö'l DISEASES OF NEW-BORN IXFANTS, their limbs, in these cases it is very tense and smooth ; it loses its softness; and finally can no longer be raised up from the subjacent parts, to which it appears to be firmly attached. This alteration in the integuments usually starts from the lower extremities, and spreads upwards over the loins and back ; it may, however, in time affect the whole body, even the face. The tension and hardness increase from day to day, and the skin soon acquires the consistence of thick leather. All' soft parts then appear as rigid as wood or stone, there is no pitting on pressure ; the colour of the skin being usually a dirty yellow, slightly cyanotic on the extremities. Under these circumstances the limbs become immobile, are persistently extended, and only the slight move- ments of the thorax — perhaps also those of the facial muscles — distinguish the condition from that of cadaveric rigidity. When such a child is grasped by the neck and lifted, it may be held out horizontally like a rigid body, just as in cases of trismus neonatorum ; for this disease sclerema may be mistaken, especially in cases where the mouth is shut by the lips and cheeks becoming affected, and sucking is prevented. Even where this is not the case, one is apt to suspect, if not trismus, at least tetanic contractions of all the muscles. I remember especially two such children, who lay for weeks in my ward in a rigid condition and in the highest degree of emaciation, but Avere still able to suck a little, or to take milk from a spoon. They finally died, the temperature steadily falling to 8G F., in one case even to 83"3° F. At the post-mortem the brain and spinal cord, to which we specially directed our attention, were found absolutely normal ; while the integument presented the apj)earance of sclerema. In some other cases I have found this condition not so generally diffused, but confined to the regions of the calves, the adductors of the thighs, the nates, the cheeks, or even the forearms and upper arms ; and in these cases the fall of temperature could be at once verified, not only by applying the hand to the surface, but also by introducing the finger into the mouth. Almost all of my cases were at the same time more or less jaundiced. The result of Parrot's post-mortems are as follows: — Extreme atrophy with consolidation of the skin, including the rete Mal- pighi, the cells of which are scarcely visible and form a compact mass with ill-defined contours. In the subcutaneous fat, the SCLEREMA NEONATORUM. oö fibres of comiective tissue are more numerous tlian usual and thicker, autl the fat itself is considerably diminished ; the fat- cells are smaller, and their nuclei can be distinctly seen. Most of the fat- cells are, as in every form of atrophy, almost or entirely deprived of their fat ; they are shrivelled into an oval shape, and have a great resemblance to the epidermic-cells of the rete Malpighi. The blood vessels — especially those of the papilla;' of the skin — are narrowed to such an extent that one cannot dis- guish their lumen. We have, therefore, according to Parrot, a drying-up of the skin with consolidation of its layers, and atrophy of its adipose tissue ; and in certain cases observed in my wards a dissection of the skin yielded quite similar results. (*2) The second form, the oe d e m a o f n e w 1 y - b o r n c h i 1 d r e n , presents an entirely different picture. While in sclerema the rigid atrophic skin is firmly attached to the subjacent parts, in oedema exactly the opposite condition obtains ; the skin being raised up and distended by edematous infiltration of the subcutaneous connective tissue. Thus we find all the clinical s^'mptoms of a'dema as they appear at any age, especially swelling of the afiected part occurring either at one part of the surface only or over the whole body, according to the extent of the oedema. Most frequently the swelling extends from the legs over the lower half of the body, the penis, the scrotum, or the labia majora ; and the calves sometimes become affected — earlier than the feet. Not uncommonly the trunk, the upper extremities, and the cheeks are also afiected in the same manner ; or the swelling may be confined to the dorsum of the hands or feet. All the edematous parts are swollen, and feel doughy or hard according to the amount of infiltration and consequent tension of the skin. In extreme degrees the afiected parts may thus appear very hard and yield little, if at all, to pressure with the finger, just as in extreme degrees of oedema at a later age. The skin is then usually glossy, while in lesser degrees of oedema it appears dull, and for the most part reddish or yellowish, but sometimes mottled and bluish in places. When the skin is very greatly distended, a certain amount of rigidity of the limbs and of the features may occur, interfering with their mobility ; this disease, however, never presents the same degree of tetanic rigidity and board-like hardness as sclerema, any more than the consolidation 54 DISEASES OF NEW-EOr.X INFANTS. of the skin equals that of the latter. The body temperature in oedema is usually very low, and in cases which end unfavourably may reach 86° F. or even lower. At the post-mortem one finds an infiltration of the subcutaneous connective tissue with yellowish serous fluid ; while the fat seems consolidated to a reddish- yellow or brownish granular mass. Thus, therefore, the anatomical condition also differs fundamentally from that in sclerema ; in which, on incising the integuments, not a drop of fluid exudes and only the merest remnant of adipose tissue remains. In spite of these diflerences there still exist certain similarities between the two forms ; which, however, concern not the skin- affection itself, but the symptoms which accompany it. For example, we have common to both the steadily increasing debility, the smallness and impercebtibility of the pulse, the disappearance of the second sound of the heart, but very specially the fall of temperature of which we have already spoken. I have myself found the temperature in the axilla 88*3° F ; others have found it, towards the end, only 71'6^ F. External heat pro- duces under these circumstances either a very temporary warmth or none at all. The voice becomes weak and whining : the breathing slow and interrupted, or frequent, superficial and noisy — owing to the presence of pneumonia, which in these circum- stances is not as a rule sufficient to raise again the sunken temperature. The children usually lie in a completely apathetic somnolent condition, and may exhibit towards the end local or general convulsions. Many also have more or less serious attacks of diarrhoea which considerably increase the debility. We find after death various complications according to the pre- dominance of this or that symptom ; especially bronchitis, pneu- monia, more or less extensive pulmonary collapse, pleurisy, various degrees of enteritis, hypersemia, and small Inemorrhages of the cerebral membranes and other parts. In one of my cases gastritis hjemorrhagica was found. When we consider the age of the little patients we easily understand that a number of other complications may also occur ; cjj., jaundice, diseases of the umbilicus, pyipmic and " puerperal " affections, itc. We must now consider the first-mentioned of these conditions, the true sclerema (which was described a hundred years ago by Denman and Underwood, and lately again by Parrot under its proper SCLEREMA NEüN.VTOKUM. 55 luauiiin) as a drying-up of the skiu and adipose tissue (occurring cis the result of extreme general atrophy'?). (Edema neonatorum may be due to just as many pathological conditions as oedema in later life. In one set of cases, as above mentioned (p. 46), a preceding erysipelas is the cause of the cedema ; and it is only thus we can account for the dark-red tiushes about the pubes and other regions of the skin, which have been described by some authors, and the purulent infiltra- tions into the connective tissue and patches of gangrene which have been occasionally found. In another class of cases the cedema is to be regarded as the result of extreme debility of the heart, of foetal myocarditis' or extensive collapse of the lung; following upon which an engorgement of the venous system of the body and transudation of serum take place. Sametimes, also, a nephritic process lies at the root of the a?dema, and of this Elsiisser'-^ has already given examples. The following case came under my own observation : — A child of four weeks admitted on 24tli March, 1874. Intertrigo in all folds of the skm; well-marked, tense oedema of the face, and all the extremities. Pulse loo. Temperatui-e 97'7° F. The urine, obtained with difficulty, was turbid, albuminous, and extremely scanty. On the 27th, severe dyspnoea and cyanosis. Pulse 144 — 160. Temp. 101"1° F. The respiratory organs apparently unaf- fected. Death on the 29th. At the post-mortem there were found parenchymatous nephritis, serous fluid in the pleura, pericardium and peritoneum, little hsemorrhages on the serous membrane covering the heart, consolidation of the left lower lobe, AVe see that sclerema and cedema of new-born children have at least one pathogenetic point in common — e xtreme debility, either congenital, or acquired through causes acting immediately after birth. The extremely low temperature is also connected with the diminished energy of the heart-muscle (which has sometimes been found fattily degenerated) with the disturbed cir- culation, the weak respiration and atelectasis, and the interference with the necessary tissue-change. And it is this perhaps that occasions that peculiar alteration in the subcutaneous adipose tissue which makes it like solid mutton suet, and which is occa- sionally met with in children who are not very emaciated. It ' To this class belongs, e.g., the case described by Demme as "Sclerom" (19 Jahresbericht, S. 75). -' Archiv/, physiol. Ileilk., xi., 3, 1852. 56 DISEASES OF NEW-BORN INFANTS. seems to mo therefore by no means necessary to make " iuclii ra- tion of the adipose tissue " a special form of disease, as some writers do. It follows from the pathogenesis just discussed that you will observe sclerema exclusively, and oedema most frequently, in children who were prematurely born, or who from the begin- ning have been placed under the most unfavourable circumstances (cold, bad air, and wretched nourishment). Hence ille- gitimate foundlings, particularly during the cold time of the year, are especially liable to this condition ; while in private practice, and even in that of a polyclinic, we have far less frequent oppor- tunities of observing it. All other causes mentioned are hypo- thetical. Owing to the frequent occurrence of certain etiological conditions which may occasion on the one hand sclerema and on the other oedema from engorgement, it is conceivable that cases may occur in Avhich both forms come on simultaneously or at least successively in one and the same individual. This fact has aggravated still more the confusion existing in the minds of most authors. Parrot describes an instructive example of this sort : a new-born child which at first presented a partial oedema continued to emaciate under the influence of atrophy and from the re-absorption of the oedema ; and, while the ocdematous swelling was still visible on the upper half of the body, true sclerema began on the lower extremities and on the back. After what has been already said about sclerema, you will be able to judge of its incurability. The children die with symp- toms of extreme exhaustion ; not always quickly, for I myself had two such cases under observation in my ward for 2 — 3 weeks. The prognosis of oedema is somewhat more favourable should the cause of it be curable. Thus, for oedema to follow erysipelas appears on the whole to be most favourable ; although here also fatal cases are not uncommon. The prognosis in all i)assive oedemas (which are to be regarded as the expression of extreme cardiac debility, pulmonary collapse, or nephritis) appears to be altogether bad. In all these cases recovery is exceptional, and the treatment must be confined to dietetic and hygienic measures. It is of the very greatest importance to procure a good nurse and to nourish the child, when it is no longer able to suck, with the nurse's milk drawn-off or with good cow's milk. At the same time care must be taken to apply PEMPHIGUS NEONATORUM. 0( artificial warmth to its cold body by enveloping it in cotton-wool, rubbing it with warm flannel, by hot bottles, and by warm aro- matic baths (camomile and calamus). In the foundling institu- tion at Moscow they use for this purpose a metal cradle with double walls, containing warm water.' We may endeavour to maintain the sinking energy of the heart by giving small doses of wine (10 to 15 drops of tokay every hour), but we can scarcely expect very much result from this. The confusion which till quite recently prevailed in the views concerning "induration and oedema of the cellular tissue"' was considerably increased by Bouchut, who connected sclero- derma — a disease sometimes observed in adults and older children — with the sclerema of new-born infants. Scleroderma, however, has nothing in common with our sclerema ; and is in its whole phenomena and course so difierent from it that one does not understand how Bouchut 's error could have had any supporters. For further information on this disease, I must refer you to works on Dermatology. It has been repeatedly observed in children, and sometimes it has ended favourably .- P<'i)q)]iith day after birth, in the midst of perfect health became affected l)y jiemphigus. The temp, rose slightly and bullae bi'oke out in succession over all parts of the body, varying from the size of a sixpence to that of a half-crown or lai'ger. They were semi-globular, transjiarent, yellowish, and more or less tensely filled. The face also did not remain free, and especially on the forehead, the neigh- bouring bullae ran together and formed enormous elevations of the epidermis. The skin of the body was extremely red. The soles and palms were unaffected in this case also, except that one bulla formed on the left palm. Along with this the general health was unimpaired. The mvicous membrane of the mouth was unaffected, and sucking not interfered with. The formation of bullae w-hich followed one another in successive crops, lasted abovit ten daj-s ; and recovery followed, as in the first case. So that after several days the situation of the bullae was indicated by thin diy crusts surrounded by a ring of epidermis, and after these had separated the skin remained reddened for a considerable time. ISTo sj-philitic symptoms were ever observed in this child subsequenth". In a child three weeks old seen at the polyclinic in .July, 187-r). there were numerous bulla» which only reached the size of a six- pence ; many remained considerabh' smaller, scarcely the size of a pea, and on the reddened skin smaller vesicles also appeared here and there. In this case the child felt perfectl}- well and recovered within a fortnight. In a boy 14 days old, brought to the polyclinic 18tli March, 1873, the whole body was likewise covered with numerous pemphigus bull«, a number of which had opaque, puriform contents. Par- ticularlj- large bulla? on the hairy scalp. The inguinal glands somewhat enlarged; health otherwise perfect. Recovery. I think that these examples will be enough to bring before YOU clearly the clinical picture and course of the disease in new- PEMPHIGUS NEONATORUM. 50 born children ; since it is not here my business to enter into a description and explanation of pemphigus in general. You find a rapid development of the eruption in quite healthy children during the second week of life, sometimes as early as the second day, an acute course lasting about fourteen days, and a favourable ending. Only rarely have I observed the mucous membrane of the mouth to be also affected; e.g., in a child two days old there was extensive formation of bullae on the mucous membrane of the lips and hard palate, the epithelium of which was separated from the bleeding corium in the form of large fragments. Unique of its kind was tlic case of a child of deaf and dumb parents, who, though otherwise well formed, was born with large hajmorrhagic pemphigus-bullte on the lips and tongue, and a few scattered over the rest of the body. This eruption lasted as long as I had the child under observation (about a year and a half) especially on the tongvie and gums, but the intervals between the bullas became greater, and the child throve very well. This case, then, was one of congenital pemphigus, and it gained further interest from the fact that the father's bi-other suffered from chronic pemjihigus. More than once I have had occasion to fear from the large number of the bullie and the redness of the skin — especially at such a tender age — that complications might occur similar to those in extensive burns of the skin ; my fears, however, were but seldom justified. Almost all those children recovered. Apart from extreme restlessness and severe itching during the stage of recovery (which one could distinctly recognise from their move- ments) the children did not seem at all ill. A favourable result is, however, by no means invariable. Chance complications with inflammatory states of the internal organs, sudden collapse as in severe burns (especially in those where the vesicle formation is very extensive, implicating more than a third part of the skin), or a furunculosis following this disease, have been frequently known to cause death. I would specially emphasise as important the fact that in this form the palms and soles either remain quite free or (as I have seen once or twice) present bullae of an enormous size, which implicate the half of the sole, and are quite different from the flaccid purulent bullfe of pemphigus syphiliticus. In certain cases the skin of the face and head remained free from eruption. 60 DISEASES OF NEW-BORN INFANTS. The causal conditions are obscure. The disease is some- times observed in lying-in hospitals in an endemic form. Thus, Ave have the endemic occurrence of it observed by Ahlfeld* in Leipzig, Avhere within two months it attacked 25 children between the second and fourteenth day after birth of totally different constitutions, who were almost all born of healthy mothers. In these cases also, the palms and soles always remained free, while the fingers were sometimes severely affected. Ahlfeld considers that the disease is of a contagious or at least miasmatic nature ; though he is unable to bring forward definite proofs of this. Koch*^ thinks that the con- tagion is carried by the nurse, because within three months he observed eight cases of pemphigus which all occurred in the practice of the same midwife ; and he supplements these obser- vations in a later report'' in which 23 cases of pemphigus are mentioned from the practice of the same nurse ; while among 200 new-born children attended to by other midwives, not a single case occurred. Palmer^ has had a similar experience. Both authors have also observed the transmission of the erup- tion to adults, and Koch states that once, " after many negative results," he succeeded, by inoculating with the contents of a bulla, in producing a bulla on his own arm after about 60 hours. Vidal and Blomberg^ also report a few successful attempts at inoculation. The epidemic in Leipzig and the sur- rounding districts, described by Moldenhauer^ (the same which Ahlfeld observed) ceased when those afiected were strictly isolated. Nobody, however, has any explanation to offer as to the nature of this contagion. Especially it has not been possible hitherto to demonstrate with certainty the presence of fungi or spores in the contents of the bullaeJ I have not yet in my own practice met with pemphigus neonatorum spreading epidemically, or endemically, in the way described by the authors I have mentioned ; and previously also by Hervieux, Abegg, Olshausen, Klemm^, and others. I have always had to do only with sporadic cases, and most ' Arch./. Gynikol, v., Bd. i., S. 150. - Jahrb./. KinderheUk.. 1873, S. 413. " 3 Jahrb./. KinderheilL, 1875, S. 425. ■* Wiirttemb. med. Correspondenzbl,, No. 40, 1880. ■^ Gaz. med., No. 29, 1876.— Jahrb./. Kinderheilk., xxii., S. 248. « Arch./. Gynäcol, vi., 1874, S. 369. ' C/. Ziehl, Wiener med. Wochenschr., 1883, No. 51. « Oesterr. Jahrb./. Päd., 1872, ii.. Anal., S. 205. PEMPHIGUS NEONATORUM. Gl certaiiil}' in none of them did transmission take place from the child to the nurse or to others. Manj' others as well have observed this ; and have therefore attempted to discover other causes besides infection. Thus, Bolin^ connects this disease — which usually arises in the second half of the first week of life — with the exfoliation of the epidermis which is wont to begin about the third day, and terminates on an average by the end of the first week. He thinks that during this time any irritation of the skin — for example, that caused by the clothing but especially by baths — may transform the physiological into a pathological process resulting in the formation of bullae ; and justly cautions against judging of the temperature of a bath by the hand without the aid of a thermometer. Bohn refers to a case of pemphigus which had arisen in this manner from baths of 101'7° F., which were supposed by a nurse who had lost the sense of temperature to be 95° F. ; and the child rapidly recovered when colder baths were used. D ohm- is of the same opinion, and ascribes to the skin of new-born infants the property of responding to mechanical, chemical, or thermal irritation by an eruption of bulla?. The very exceptional occur- rence of transmission to those in attendance, and the few attempts at inoculation which have been apparently successful can therefore scarcely be considered to have established the infectious nature of pemphigus neonatorum. The treatment is extremely simple. I restrict myself to luke- warm baths, 90-5°— 93-7° F., with the addition of bran and gelatine ; and I consider it unnecessary to add corrosive sublimate, as is sometimes recommended. Pemphigus cachectic us is to be distinguished from the simple acute condition by its aftecting by preference the regions where the skin is thin — the neck, axilla, groin, and especially the soles of the feet and palms of the hands. The last, as we have seen above, almost always remain unaffected in the simple form. In a child eight days old, the tip of the nose was the seat of such a bulla. The bulhe, which rise on livid spots, are usually only half-filled and flaccid, and seldom exceed the size of a pea or hazel-nut. At the same time their contents appear less clear, often purulent, sometimes tinged with blood. New-born children sometimes bring traces of this eruption with * Jahrh.f. Klnderheill-., 1876, ix., S. 304. Arch.f. Gijnäcol, ix.. S. 3. 02 DISEASES OF NEW-BORN INFANTS. tbcm into the world (which has aft'ected them during fcetal life) in the form of bullae which have burst and left beliind them superficial ulcerations; and this condition usually leads to the supposition of congenital syphilis. In fact this form of eruption may be held to be one of the earliest symptoms of syphilis, and I myself have records of cases which unquestionably prove this connection. In a child of 6 months old the formation of bullaj had com- menced immediately after birth, and during the last months had increased to such an extent that by this time on many parts of the bod}', also on the face and the back of the head, fresh bullae Avere visible in some parts, excoriations and crusts in others. The dirty com])lexion, the chronic rhinitis, and latterly mucous ])apules round the anus, proved that we had here to do with syphilis. A girl of 6 days old, admitted 5th April, 1879, very atrophic, exhibited pemphigus bullae on the whole body, especially numerous on the soles and palms, also under the nails. There was also rhinitis Avith scabs on the nostrils and lips and enlargement of the axillary and inguinal glands. Post-mortem: Osteochondritis syjihilitica universalis ; numerous small abscesses in the thymus. A girl of l-i days, poorly nourished (1.3th December, 1881). Palms and soles covered with recent opaque bullae and rounded excoria- tions, which were surrounded by a ring of epidermis (ruptured bullae). A few also on the dorsal surface of the hands and feet and on the fingers and toes. There Avas also rhinitis, and intertrigo near the anus. A child, 3 Aveeks old, with coryza, roseola, and pemphigus on the ])alms and soles, which had arisen 6 days after birth. Are we then to consider this eruption of bullae (Avhich difters from the first form by an indefinitely chronic course) as a regular indication of syphilis, or to agi-ee with Caillault^ that this is only the expression of a deep-rooted cachexia such as one so often observes among the children of the poor, espe- cially those who are wasted and debilitated ? I freely admit that I formerly held this view myself, but lately, after having seen a good deal of the disease, I have changed my oi^inion. All the cases of this form of pemphigus which I have examined during the last few years have been due to syphilis ; but owing to the Avretched state of the children's general health, it Avas onh' in rare cases that specific treatment was able to avert death. Train prat, des huiladies de la peau cJiez les en'anU : Paris, 1859. APHTH.E OF THE PALATE. (53 Aj)ht]ue of the Palate. Ill a former lecture (p. 15) I drew your attention to miliary nodules on the mucous membrane of the palate, which are met with in many new-horn children during the first four to six weeks of life. At this age if you examine the throat after depressing the tongue (which is not always easily done) you will very often find, on either side of the arch of the palate, just on a level with the pterygoid process and immediately behind the alveolar arch of the upper jaw (where the bone is visible through the thin mucous membrane), a round or rather more oval yellowish-white patch surrounded by a red border. These patches are usually quite symmetrical, though sometimes rather bigger on one side than the other ; occasionally also they have evidently run together and their outline suggests the shape of a breakfast-roll. They seldom exceed § of an inch in their greatest diameter. These " plaques," which readily bleed when touched with the spatula, are veiy often found in perfectly healthy children. They gradually lose their greyish-yellow colour, become red and disappear, leaving no trace behind. But in atrophic and cachectic children I have occasionally seen them increase in size and depth and pass into real ulcerations which may penetrate even to the bone. In such cases one often sees the mucous membrane of the mouth and palate simultaneously covered with thrush ; and the children die in consequence of the general condition, or from the occurrence of complications. These symmetrical " plaques " or " aphthae " were formerly described, especially by French physicians, but had been for- gotten ; and Bednar^ was the first again to draw attention to them. It is especially important to remember that these aphthne have absolutely nothing to do with syphilis. I should not have mentioned this at all, were I not constantly see'ng cases in Avhich physicians unacquainted with the condition had made this diagnosis. I have always been of the opinion (now shared by others) that these aphthae arise simply mechanically from the pressure and friction exerted on the mucous membrane, (which is very thin in those places) by the tongue in sucking cither from the nipple or bottle. According to Parrot,* what ' Die Kraitkh. der Xeujeb. und Säuglinge : Wien. 1850. i., S. 105. -' I.o: elf., p. 207. G4 DISEASES OF NEW-i'.OItX INFANTS. occurs first is a spongiuess of the epithelium and a swelling of mucous membrane with proliferation of its nuclei; and afterwards a casting-off of this and the formation of a shallow erosion. It is not correct to regard these aphtha' as arising from ulcera- tion of the already-mentioned miliary nodules in the palate, which almost always occur only in the raphe and its near neigh- bourhood, while aphthie are situated laterally on the palate. Occasionally, however, ulcerations do also occur in the raphe, either superficial or deeply penetrating, and these may he regarded as possibly arising from the nodules. The ulcers which occur in this situation, however, are on the whole far less common, and, with comparatively few exceptions, I found them only in atrophic children. They resembled the aphthae of which we are speaking, in every particular, but had sometimes a more elongated shape. They occurred generally on the arch of the palate and were sharply defined, rounded, and of a yellowish white or grey colour. Occasionally the subjacent bone was exposed. I cannot share the opinion of Parrot that all ulcers which occur outside the raphe are syphilitic in origin. For example, in a child of six weeks old who died in a state of extreme atrophy without showing a single sign of syphilis, I have seen the whole palate covered with such ulcerations, while at the same time there was an abundant growth of thrush in the mouth and on the palate. The ulcers which at first appear yellowish or greyish-white, become at last of a brown colour : and in some cases bare bone can be felt with the probe. The aphthae of the palate being a very frequent " decubital " symptom require treatment only if, under the influence of defec- tive nutrition, they are increasing in size and depth. In that case I usually paint them with a solution of sulphate of zinc (1 in 10), or nitrate of silver (1 in 15). I have only three times seen these aphthoe after the first three months, in children of 5, 9, and 12 months respectively ; in whom they were probably occasioned by too strong rubbing (during the cleaning of the mouth) of the parts of the palate affected. Parrot also mentions the case of a child of two and a half years old with measles, who besides other erosions and aphthiii in the cavity of the mouth presented two quite characteristic plaques on the palate. Although Epstein^ and Fischl^ go perhaps too far in ' rmger med. Wockenschr., 1884, No. 13. Ibid., 188G. No. 41. MEL^NA NEONATORUM. 65 thinking that many of the affections of the mouth in new-born children (stomatitis, plaques and ulcerations) are the result of mechanical injuries from frequent cleaning of it, it is well to observe the care in cleansing which they enjoin. In some «ases I have, in fact, been able to observe an unusual sj>reading of the patches on the palate, due to hard rubbing. An appear- ance may result from this resembling a diphtheritic membrane. This hajapened, for example, in the case of two children in the first week of life, in whom in the first place two patches had appeared at the sides of the palate and gradually extended so far that they at last ran into one another, and the whole back part of the arch of the palate was covered by a continuous yellowish-grey m:embrane which ended in a sharply-defined line above the uvula. The latter, as well as the tonsils, was, however, normal ; and this circumstance, as well as the mode of development which I have described, was sufiicient to cast doubt on the diagnosis of diph- theria which had been made in one of the cases. As it turned out, the whole disease disappeared within ten days without leaving behind it any loss of substance. Melcena Neonatorum. I shall conclude the consideration of the diseases affecting new-born children exclusively or generally, with a few remarks on melsena neonatorum, a disease on the whole rare and which I have myself had an opportunity of observing in only a few cases. This complaint is characterised by haemorrhages from the stomach and intestine commencing as a rule between the first and seventh days after birth, rarely later. Sometimes only a vomiting of dark blood on several occasions takes place ; and after this, in spite of the extreme collapse at first, the children gradually recover. In other cases, however, the vomiting of blood returns more frequently and the diapers are saturated by blackish blood from the anus. Sometimes the vomiting of blood is entirely absent and only bloody stools occur following quickly on one another. These contain meconium or faecal matter to begin with, but later consist solely of fluid and coagulated blood. Other morbid appearances may be entirely wanting, and the examination of the abdomen yields nothing abnormal. In most cases, owing to the repeated copious haemorrhages there follow within 21 — 48 hours, death-like paleness, coldness of the skin, 5 C6 DISEASES OF NEW-BORN INFANTS. clisappearaucG of the pulse, aad death. But a small number recover after the bleeding has ceased. The mortality, according to dififereut authors, varies between 35 and GO per cent. The views as to the mode of origin of this dangerous malady vary greatly according to the pathological conditions v>hich have given rise to it. Billard explains the haemorrhages as due to the hyperfemia of the mucous membrane of the alimentary tract which is present normally during the first days of life, and may be aggravated by any chance disturbance of the venous circulation, e.g., by an asphyxiated condition of the child at birth, atelectasis of the lungs, congenital malformation of the heart, or enlargement of the liver and spleen. Others (Kiwisch) blame premature ligature of the umbilical cord ; while in recent times attention has been directed to little rounded ulcers of the mucous mem- brane of the stomach and intestine. These were known by the French authors, Denis, Billard, Rilliet and Barthez, Barrier and others, and were at a later period described b}' Vogel, Hecker, Buhl and others among ourselves. There is a difference of opinion as to the mode of formation of these ulcers (an anatomical description of which is to be found in Parrot's works ^) for some ascribe to them an inflammatory origin, others (Bohn) hold that they proceed from an ulceration of the follicles or from a fatty degeneration of the small arteries (Rehn). Lastly, Landau,- arguing from a case of duodenal ulceration with thrombosis of the umbilical vein, believes in an embolic origin of the ulcers and thioks that they arise from thrombi which are driven from the ductus arteriosus, or from the umbilical vein into the small arteries of the gastric mucous membrane, and bring about gangrene of the affected area. At the same time, the corrosive action of the gastric juice upon the portion of skin which is excluded from the circulation, is held to promote this gangrene. Asphyxia and incompleteness of the first respirations are of importance in so far as they favour a stagnation of the blood column in the umbilical vein and the formation of thrombi in it. As a matter of course the ulcera- tions have in recent years been looked upon as parasitic and as occasioned by deposits of micrococci (Rehn^). * Loc. cit., p. 247. * Ueber 3felly — like old cheese. I bad a fresh tin sent for at once, and then I found that the food prepared from it agreed very well. From my own experience I can recommend Nes tie's food as a suitable means of nourish- ment after the tenth or twelfth week of life, not earlier. But I am by no means altogether enamoured of it. From experiments which I instituted on other similar infant's foods, such as those of Gerber, Giffey, Liebig, Frerichs, and Kufeke, I am inclined to beliere that the same value may be assigned to all of them, and to preparations from the manufactories at Cham and Yevey and Montreux. The lucrative character of this business, moreover, makes it probable that the world will con- tinue to be favoured with new preparations of this sort ; which will in turn excel one another in the endeavour to approach as nearly as possible to the composition of human milk. Among the other v>ell-known substitutes for mother's milk, I shall only mention here Liebig's food and the cream- mixture recommended by Biedert.^ The former, once so much extolled, is now quite given up because its preparation is far too troublesome to allow it to be generally used in practice among the poor — whom we have chiefly to consider in dis- cussing artificial nourishment. The same maj' be said of Biedert 's cream-mixture, which I used in my ward for some time for a number of atrophic children without being able to convince myself that it was more efficacious than feeding with cow's milk or Nestle's food. I have not myself sufficient experience of the " artificial " cream-mixture recommended by Biedert, which at any rate is more easy to use; but it is spoken well of by Monti^ and others, though in this case also the price is a drawback owing to the poor circumstances of many of our patients. An excellent aid in the nourishment of atrophic infants is wine, especially unadulterated tokay. Whether other kinds of wine, such as sherry and malaga which are frequently given, are to be regarded as of equal value I shall not decide. I myself always prefer to all other kinds the old Hungarian wine, of which my never-to-be-forgotten teacher Romberg used to say that it was not only a "lac senile," but also a "lac juvenile." In the first months of life we may give 20 to 25 drops three or four times ^ Virchotc's Arclh'. Bd. 60. H. 3 \ind 4. " Arcliivf. Klnderhetlk., Bd. ii. THRUSH. 85 daily, undiluted, or in a teaspoonful of water. In older childen we may increase the dose to several teaspoonfuls or more in the day. At the same time one should for the sake of cleanliness order a warm bath daily (93° to 95° F.), to which one may add, if the debility is increasing, aromatic infusions (the best being a hand- ful of camomile and sweet calamus infused in hot-Avater). Well- ventilated sick-rooms, strict cleanliness, careful regularity in the nursing, all these are (and unfortunately too often remain) "pi a desideria," which can be attained only in a small minority of the cases. From drugs we can expect nothing in atrophy. It is only when it is distinctly complicated with disorders of the respira- tory organs or intestines, that there is any indication for their use. And I must here remark that sliglit dyspeptic symptoms (vomiting or unnatural, offensive, badly-digested stools) may disappear without the use of medicines as the result of suitable dieting. II. Thrash. The younger the children the oftener they suffer from this alfectiou of the mouth and throat. Thus it is commonest in new-born children and during the first months of life. But it also often occurs in the second half of the first year, and you will meet with it under certain conditions much later, even in adults. The appearance of the disease varies according to its degree and the circumstances in which you find it. First Degree. — On the mucous membrane of the lips, tongue and cheeks, especially on the folds between the lips and gums and between the cheeks and the alveolar margin, we find separate, white, slightly-projecting points and spots. These can easily be rubbed oft' with the spatula, but if one uses force in doing this a drop of blood is left. The mucous membrane is otherwise unaltered, and there is no other disorder. This form of thrush occurs very often in perfectly healthy children if the necessary cleaning of the mouth has been neglected, owing to remains of milk being left behind in the above-mentioned folds of mucous membrane, and afterwards decomposing. Some- times it is not easv at first sight to decide whether we have to do 86 DISEASES OF INFAN'CY. with real thrush or only with remains of milk, as these have almost the same appearance ; the diflerence is seen when we touch the spots with a spatula, by which the remains of milk (which lie loose on the surface) are at once removed while the spots of thrush adhere more firmly to the mucous membrane. Second Degkee. — The whole mucous membrane of the mouth, as well as that of the pharynx, is of a dark purplish-red colour and noticeably dry. All over it — but especially on the tongue, the cheeks, the lips and the hard palate — one sees a gi-eat many white points and spots of rounded irregular form, which here and there (especially in the above-mentioned folds and on the tongue) run together into larger patches. The cavity of the mouth appears to be tender to touch, as the children while sucking often distort their faces painfully, or refuse the breast entirely. At a still more advanced stage we find the tongue, cheeks and hard palate covered with a white membranous coat- ing ; while on the lips and gums, and further back on the soft palate and tonsils, spots of thrush are visible in large numbers. These extreme degrees occur only in atrophic children or in those exhausted by severe illnesses (diarrhoea, cholerine). Thus we may explain the circumstance that the mucous membrane, which was dark-red to begin with, graduall}' becomes pale from the progi'essing anasmia. In the last stages of the disease in such children I have found the spots of thrush adhering to a perfectly pale and slightly livid mucous membrane, and therefore less liable to be noticed than when the mucous membrane was very vascular. Further, the spots lose their milk-white colour more and more, and often appear dirty -grey or yellowish, the latter colour being due to bile-staining by vomited matter. Accordingly, one must look more narrowly to recognise the whole extent of the disease. The longer it lasts, the more firmly do the patches of thrush adhere to the mucous mem- brane. Among very many cases of this kind, I remember par- ticularly that of a child of four months in a state of extreme collapse with congenital syphilis, and pneumonia of the right lower lobe ; the Avhole of the pale mucous membrane of the pharynx as well as that of the mouth was covered ^nth pearl- grey patches of thrush which were so firmly adherent that they could only be detached forcibly by means of a pair of forceps, and with some bleeding. New-born children with this disease THRUSH. 87 often present at the same time the ulcerations on the hard palate which I have already mentioned (p. 63). When we ex- amine under the microscope a little piece of the thrush well teased out, we see that it is principally composed of a numher of filaments and spores of fungi. When this was discovered in 1842, by Berg, a Swedish physician, all previous explanations of the disease as due to inflammatory exudation fell to the ground. We can only regard it as of parasitic origin. The filaments appear as long tubes, straight or bent in various directions, trans- parent, with a sharp contour, 50 to 60/u. long and 3 to 4/m broad, and consisting of various segments articulated to one another. Almost all of the ripe filaments present one or more branches of the same form springing from those points of the stem-filament where the joints are marked by a septum. The interior of the filaments usually contains some molecular granules, as well as a few little oval bodies — probably spores in process of development. Bound the origin of the filaments one almost always sees heaps of roundish or oval spores from which they arise. ^ Besides the fungous elements the microscope shows numerous epithelial cells, with a varying number of fat-globules and red blood corpuscles which have become entangled in the patches of thrush on being detached from the mucous membrane. That is all that thrush shows clinically. All the symptoms which were formerly ascribed to it — especially the violent diarrhcea, vomiting and collapse, of which earlier French authors particularly spoke — do not belong to thrush but to the original disease of which it is a result. I have, therefore, only a few anatomical and pathological remarks to add. Thrush is by no means confined to those areas of the mucous membrane which are accessible to our clinical examination, it also frequently occurs (as the post-mortems show) further down — especially in the lower part of the pharynx, and often in the oesophagus, particularly its lower two-thirds ; there it occurs either in the ' Authors still differ widely concerning the botany of thrush. The name ■■o'idium albicans" which has been attacked by Grawitz {Deutsche Zeitschr. f. prakt. Med., 1877, No. 20) is indeed given up. Ct'. Plaut {Beitr, zur system. Stelhinr/ des Soorpilzes : Leipzig, 1885), Stumpf {Miinchtntr med. Wockenschr., 1885, S. 627), Baginsky {Verein/, innere Med., 30th November, 1885), Klemperer, [Cenfralb. f, kiln. Med., 1885, No. 50), Plaut, {Neue Beitr, zur system. Stellung des Som-pilzes in der Botanih: Leipzig, 1887). Plaut regards the fungus a.s identical with that which we find growing on rotten wood, fresh cow-dung and sweet fruits - Monilia Candida. 88 DISEASES OF INFANCY. same way as in the moutli, or forming a more or less perfect cylinder which, owing to the projecting folds of the mucous mem- brane, looks like a piece of bark. Thrush of the a3Sophagus is not usually of a pure-white colour but pearl-grey or yellowish and ends just above the cardia in a sharp line. I have found it on the mucous membrane of the stomach only in one case, where it occurred in the form of isolated and somewhat prominent patches. I must, however, admit that such a careful examination of the stomach, as is necessary here was not always made ; and, of course, a large number of our atrophic children showing thrush in the mouth did not come under post-mortem examination. I mention this because Parrot^ has not unfrequently observed thrush in the stomach. To recognise the patches we must first remove by a stream of water the thick layer of mucus which covers them ; they then come into view in the form of little papilhie, isolated or aggregated, some of which can only be made out with a lens. The larger patches often present a central depression ; and from this, as well as from their generally yellow colour, they acquire a decided resemblance to a favus-crust. Most commonly the disease is found on the posterior wall of the stomach, along the lesser curvature, and in the neighbourhood of the cardia. Here the thrush is so markedly adherent that it is difficult to remove it by a stream of water or by scraping. Beyond the stomach tbrush only very rarely occurs. The observations of Valliex and Seux, made without the help of the microscope, are not conclusive. But those of Robin and Parrot may perhaps be so ; the former having found it in the small intestine, the latter in the c fee um on two occasions. In this region, as in the stomach, the acidity of the contents is to be regarded as a condition favouring the growth of the fungus. However this may be, we must in all these cases assume that the germs or filaments of the fungus must have found their way down from the pharynx or oesophagus. It is remarkable that the disease, however strongly it is developed in the pharynx, never extends into the back part of the nasal cavity, even in cases of cleft palate where a direct communication exists between the cavities of the mouth and nose. It may, however, be found occasionally on the mucous membrane of the glottis in the form of little ' I.oc. rll.. p. 223. THRUSH. 89 patches or streaks. Since this is the only part of the respiratory mucous memhrane which is aflected by thrush, we must agree with Berg and Lelut that only squamous and not ciliated, epithelium atiords a suitable soil for the growth of the fungus. Thrush has been found in the lungs only in very rare cases, and it has then probably developed from germs inspired from the pharynx (Parrot, Birch-Hirschfeld). On examining more closely the relation of the fungus to the sub- jacent mucous membrane, we find that a part of it lies superficially between the epithelial cells ; another part penetrates more deeply into the tissue, so that the filaments can be distinctly seen to enter the mucous membrane perpendicularly (^ Wagner^ and Parrot). This fact explains also the very considerable resistance which one occasionally meets with in the attempt to detach the spots. The observations of Zenker and Ribbert- on certain rare cases in which it was found in the brain, seem to indicate that the fimgas may be carried into other parts of the vascular system. Thrush does not seem to develope in a perfectly healthy mouth, or at least it never spreads to any considerable extent. Even in the cases of our first degree, we must assume a certain amount of irritation of the mucous membrane from the remains of milk, which decompose and prepare a favourable nidus for the development of the germs. This is more distinctly seen in the cases of the second degree, which are far commoner. In these it is always preceded by a marked dryness and dark-red colour of the mucous membrane of the mouth ; the tongue becomes rough from projecting papillae, and it is in these places that the growth of the fungus begins, being favoured by the deficient alkalinity of the mucous membrane. To this feature I have already drawn your attention. The exceedingly small amount of the salivary secretion in the first months must favour in a high degree the formation of acids in the mouth and dryness of the mucous membrane. This view need not for the present be shaken by the cultivation- experiments of Kehrer,^ according to which saliva seems to be an excellent medium of nourishment for the thrush-fungus. The main influences, however, which favour the germination of the spores are the child's weakness and ' Jahrb. f. KinderhellL, 1868, i., S. 58. -' Berliner Uin. U'ocJiensckr., 1870, S. 618. ■' Ueber (hn Soorpih : Heidelberg'. 1883. 90 DISEASES OF INFANCY. atrophy; and in proof of this fact I may adduce De la fond' s^ experiments on animals. He was never able to transmit thrush by inoculation to the mucous membrane of the mouth of a healthy well-nourished sheep with copious salivary secretion ; but he succeeded at once when he had weakened the animal by hunger, or had chosen for his experiment an animal already diseased and with acid saliva. In accordance with this is the clinical observation that eruptions of thrush, quite similar to those occurrinjT in atrojihic infants and those exhausted by diseases of all kinds, occur not uncommonly at a later age, in the last stage of phthisis and in severe cases of typhoid. Among other jcases I found in a girl 13 years of age who had died of severe typhoid, not only the jDharynx but also the oesophagus as far as the cardia covered with a coating of thrush, which from its dirty-grey colour and the difficulty of closely examining the pharynx had been mistaken during the last days of life for diphtheria. Thus many cases of "diphtheritic complication" of typhoid which are not examined post-mortem are really cases of thrush of the pharynx ; and this mistake is all the more likely to be made as thrush may occasionally spare the mucous membrane of the mouth and attack only the palate and pharynx. Although the spores usually reach the mucous membrane of the mouth along with the food (milk and other fluids) or inspu-ed air, yet direct transmission by the bottle is possible (should its mouth-piece not be repeatedly cleansed every day with the utmost care) and may occasion repeated attacks of thrush in the same child. Be particular, therefore, that the india-rubber mouth-piece of the bottle is carefully washed, left lying in water, and daily cleansed inside with a small brush. Whether thrush may be transmitted from the child's mouth to the nipple of the mother or nurse is a question on which diflereut observers are by no means agreed. Seux^ says that out of more than 1,600 cases of thrush, he did not once observe its transmission to the nurse's nipple; but others — especially Mignof — on tlie strength of a few observations, express themselves in favour of such a possibilit}', chiefly when the nipple is excoriated ; and Delafond, in his above-mentioned inoculation of sheep, found that the ' Gaz. hebdomad., 1858, p. 909. - Rec/i€i-ches sw les maladies des en/ants nouveau-ncs : Paris, 1855, p. 29. ' Traill' de quelques maladies pendiinl le premier age : Paris, 1859, p. 223. THRUSH. 91 oidium might be transmitted by a lamb to its mother's teat. We must, therefore, in all circumstances warn those who are suck- ling of the possibility of such a transmission ; and impress upon them as a duty the utmost cleanliness, and especially frequent washing of the nipple with alkaline fluids. In cases where one has doubts as to the diagnosis of thrush — and these are extremely rare — the microscope alone can decide by showing the characteristic filaments and spores. I have already mentioned that remains of milk-curd on the mucous membrane are readily distinguished from thrush, because they can be easily wiped off. There is, however, another condition which is sometimes mistaken for thrush by the inex- perienced ; namel}^ a membranous desquamation of the epithe- lium of the mucous membrane of the tongue, and especially of the gum, in the form of thin greyish-white layers. The micro- scope in such cases at once proves the error, by showing only epithelial cells and an amorphous granular mass but no fungus elements. In a few cases we see these accumulations of epithelium only under the tongue, where they become rolled-up and form a transverse cord of a milk-white colour. I liaA^e found this in two infants ; one of whom was thriving and well-nourished, the other atrophic, with many cutaneous abscesses and a bed-sore on the elbow. Neither of the children had any teeth, but the mucous membrane of the mouth was reddened all over and bled readily when touched. The white layer imder the tongue could be pretty easily removed, only at the frenum it was somewhat more firmly adherent, and left a drop of blood behind it. Under the microscope I could recognise only fat-globules (really remains of milk), epithelial cells and an amorphous connecting mass, but no trace of the thrush-fungus ; and it seems to me that the free desquamation of the epithelium resulting from the hyperaämia of the mucous membrane had assumed this form of a convoluted cord from the continual gliding of the under-surface of the tongue over the alveolar border during the process of «ucking.' It is obvious that the local treatment of thrush affords hope of success only in cases of our first degree. In these a mere mechanical wiping-oft' is generally sufficient. The nurse must ' The affection of the frcnum linguae described by Riga {Glossofrenullte mem- hranacea : Napoli, 1881) appears to me to belong to the same category as these ■cases, and its fatal termination to be mainly due to the atropliy and weakness of the patients. I see no reason to set this down as a special epidemic disease. I 92 DISEASES OF INFANCY. not hesitate to rub off the patches of thrush which she sees on the mucous membrane, with a piece of fine linen wrapped round her finger and dipped in cold water — even although it causes a little bleeding. Whenever new eruptions make their appearance, this proceeding must be repeated, and the cavity of the mouth very carefully cleansed in the same way after each nursing ; the afiection will thus soon be got under. It is a very different matter in cases of the second degree in children who are atrophied and exhausted. Here also, it is true, you will readily succeed in removing the thrush by simply cleansing, as above ; or, even better, if you neutralise the acid reaction of the mouth by dipping the linen rag in an alkaline solution instead of in water only {e.g. pot. chlorat., ac. boric, borax, or sod. benzoat., 5 p.c. solu- tions in water ; or common salt, a large pinch dissolved in a glass of water). In this matter the experience of practitioners hitherto has been quite at variance with the results obtained by Kehrer in his experiments. For, according to the latter, we should expect the remedies named to favour the growth of the fungus. The general morbid condition which favours the growth of thrush is always the most important matter ; and consequently you wäll continue to have fresh outbreaks taking place in these cases. When this occurs, I have often obtained a good result from painting the whole mucous membrane of the mouth with a solu- tion of nitrate of silver (1 or 2 p. c.) after the patches have been wiped off. Iir. — Hereditär II Sjiphili^. During the period in which we most frequently observe the beginning of atrophic conditions and the development of thrush, we have also the most abundant opportunity of becoming acquainted with the phenomena of hereditary syphilis. As this disease occurs in very various forms, it seems most suitable to give you first of all a clinical picture of it as you will most frequently see it in practice ; and to discuss later on its varieties and less common conditions. The children are brought to you usually in the second or third month of life, and appear well- or ill-nourished according as they have been suckled or hand-fed. An extreme degree of atrophy HEREDITARY SYPHILIS. 93 is by no means one of the necessary features of infantile syphilis; for a large number of children brought to me — especially those on the breast — were well-nourished and of a healthy complexion, although those that were hand-fed certainly showed a tendency to atrophy. Extreme degrees of this latter condition were not, however, to be attributed to syjihilis alone ; but also to other factors — hunger and all kinds of misery — working along with it. One of the earliest symptoms is a snuffling character of the respiration, which is caused by swelling of a part of the nasal mucous membrane lying beyond the reach of inspection; and it is often called "a cold in the head" by mothers. At a later stage, the nostrils become blocked by yellowish or brownish crusts, and sero- mucous discharge some- times slightly blood-stained (coryza syphilitica), and the nose may become somewhat swollen externally. This coryza — which varies very much in degree — I hold to be one of the most con- stant symptoms of the disease, either preceding the other symptoms, or almost always accompanying them. It is only absent in exceptional cases. Soon we have in addition bright- red patches — usually with a brownish tinge — rounded or irregu- lar in shape, varying between the size of a threepenny-piece and a sixpence. These appear at first singly, and their favourite positions are the region of the eyebrows, the chin and naso-labial fold, the neighbourhood of the anus, and the palms and soles (roseola syphilitica). Many of these patches present a branny desquamation of the epidermis, or are covered with large frag- ments of it ; others — and in many cases, nearly all — have u glazed and almost varnished appearance when looked at from the sides. The patches situated on the chin and nates become gradually macerated by the repeated action of the secretions from the mouth or the urine and faeces. And when the epithe- lium is shed they are changed into moist red excoriations which, taken apart from other symptoms, have not in themselves any distinct specific character, and may, indeed, be obscured by an erythema surrounding them (intertrigo). In every case, how- ever, the distribution of these excoriations, the patches with unbroken skin which occur along with them, and the presence of the coryza are sufficient indications to warrant a suspicion of syphilis and to justify specific treatment. If not so treated, the further progress of the disease soon dispels 94 DISEASES OF INFANCY. any uncertainty. The patches now spread over a large part of the body — esjiecially over the forehead, all round about the mouth, and over the extremities. In many places they coalesce and form large dusky-red or brownish-yellow and more or less des(|uamating patches, covered here and there with scabs owing to the drying-up of moist excoriations. The palms and soles are generally diffusely reddened, covered with fragments of desquamated epidermis, and often (the heels especially) present a glossy redness and tension. There also occur whitish excoria- tions at the angle of the mouth, and fissures and cracks in the mucous membrane of the lips (rhagades), which readily bleed on sucking and on crying. These, along with crusts which cover the eyebrows and \vith coryza, present a picture which can scarcely be mistaken any longer by the least experienced and Avhich justifies the diagnosis of s}i^)hilis without any confes- sion from the parents. In many cases the picture is rendered still more characteristic by the fa Hing -out of the hair, especially the eyebrows, and even the eyelashes. Trous- seau's observation of a brownness of complexion peculiar to congenital syphilis, I can confirm only for a series of cases where the patients were atrophic; while among many other well- nourished children I have observed a complexion just as white as in health. You must not expect, however, that all the features of this disease are generally as well marked as I have just described to you. Often only some of them are present, while others are wanting or very slightly indicated. Thus, e.g., I have some- times seen the genital and anal regions quite free from eruption, while the upper parts of the body (sometimes, indeed, only the face) were most typically affected. Further, variations from this typical description of the disease are by no means rare. Thus, instead of roseola, I have repeatedly observed dark-red rounded papules on the soles of the feet, the lower extremities, and round about the anus ; or, here and there, dull-red infiltrated spots covered with thin whitish scales, occasionally " figured," — occurring especially on the glabella and on the eyebrows but also on the cheeks and nates. These bordered partly on psoriasis, partly on condylomatous formations. Occa- siouall}' — though only in children in the first weeks of life — we find the remains of bullte (p. 61) in the form of red spots or HEREDITARY SYPHILIS. 95 excoriations surrounded by a dry ring of epidermis ; sometimes also there are on the soles and palms recent, usually flaccid, bullae with turbid purulent contents. In many cases, especially in very young children, I have found along with the signs of syphilis almost the whole skin diffusely reddened and covered with large yellowish scales of epidermis mixed with sehaceous matter. Least frequently I have observed vesicular and moist (eczematous) forms of eruption as the expression of syphilis; and these have usually seemed to me as if they had been brought about by maltreatment of the papular and macular eruptions, especially by scratching or the contact of irritating secretions and excretions. In a child six weeks old an eczema which developed along with a copious roseola on many parts of the body, turned out to be simply the result of very abundant perspiration and had therefore nothing to do with syphilis. I have more frequently observed deeper ulcerations, covered with scabs, to develope out of the above-mentioned excoriations in the neighbourhood of the anus and on the scrotum, and also on other parts of the skin {a.g. about the eyebrows, or around the navel), just as the intertrigo of the inguinal region, which is often present at the i^ame time, shows a tendency towards the formation of whitish- grey ulcers with red infiltrated margins. On the other hand, I have not been able to convince myself of the correctness of the view^ that it is only the condyloma latum (mucous papule) which justifies a diagnosis of congenital syphilis. On the con- trary, I can affirm that in a considerable number of cases and in spite of the most careful examination we could nowhere find this condition. I by no means consider the mucous papule as one of the earliest symptoms of the disease ; for, except in isolated cases, I have never observed condylomatous formations till at a later stage — in children already some months old or suffering from a relapse of the disease. Under these circumstances, cer- tainly, mucous papules occurred frequently enough — especially at the angles of the mouth, on the tongue, under the chin, in the inguinal folds, round the anus, on the scrotum and vulva ; some- times also on the inner and uppermost part of the thigh ; most commonly, on the alne nasi and at the outer angles of the eyes. Thus generally they are found in situations where the folds of skin lie in contact with one another, and irritation is caused by ' Caillaiilt, Traitejvat. des maladies de la peau chez les enfants : Paris, 1859. 96 DISEASES OF INFANCY. pressure and by accumulation of secretions. Their appearance was the same as that of those in adults, and their tendency to become macerated by secretion (saliva, urine, faeces, sweat), was very marked ; the epidermic covering of the condylomata being consequently shed, they turned gradually into greyish-white fissured ulcers. In rare cases the condylomata formed con- tinuous masses, which — especially when they occurred on the labia majora — presented a nodular appearance which reminded one of elephantiasis. Onychia was also frequently observed, with thickening and claw-like deformity of the nails, which were finally cast-off by suppuration of their matrix. In addition to all these various affections of the outer skin, the mucous membranes may also present morbid appearances. In addition to the almost constant coryza, I have observed con- junctivitis with purulent secretions (but in no case iritis, which seems to be one of the rarest of all the manifestations of con- genital syphilis), fluor albus, occasionally also redness and swelling of the urethral orifice with pain on micturition. On the dorsum of the tongue there occur, as already mentioned, condylomatous (or rather, perhaps, gummatous), hard, dark projections, espe- cially towards the back ; and also the tonsils are sometimes the seat of flat ulcerations arising from condylomata. I cannot, however, regard these affections of the mouth and throat as common, since in the great majority of my cases these parts presented nothing in the least degree morbid ; and I here warn you once more against regarding the repeatedly-mentioned palate- ulcers of new-born children as syphilitic in nature. Sometimes we have, along with the svphilitic aftections of the skin in children, an alteration of the voice — a more or less pro- nounced hoarseness, which in extreme cases may go on to complete aphonia. In the following case this loss of voice con- stituted almost the only symptom of syphilis which could be ascertained : — Carl C, four months old, l)rought to m}' polyclinic 14th March, 1867, had suffered for two months from hoarseness, and latterly from complete aphonia. We saw the child crying, Ijut scai-cely heard any sonnd. No cough ; breathing normal. In the pharpix and on the epiglottis nothing abnormal. Examination with the laryngoscope unsuccessful (Waldcnburg attempted it). The child was health)', well-nourished, and thriving ; but there were brownish scars round the anus. On further investigation HEREDITARY SYPHILIS. 97 it was found that at the age of two months he had suffered from coryza, with a desquamating macular eruption, wliich was cured by calomel. Diagnosis. — Syphilitic affection (condylomatous ulcer ? ) of the vocal cords. I ordered mercur. solub. (Hahnem.) gr. T^f twice daily. By the 2.3rd — that is, after 29 days — the voice was clearer ; on the 18th April quite normal. After-treatment with syr. ferr. iod. No return of the disease by December. As to the nature of the laryngeal affection in this case, I shall not hazard an opinion. I have no experience of perichondritis of the epiglottis or caries of the thyroid cartilage, such as have occasionally been described. Just as little have I seen of the syphilis of the intestine in new-born children, which has recently been spoken of a good deal. This consists in gumma- tous indurations of the muscular and mucous coats, sometimes ring-shaped, which encircle and narrow the lumen of the small intestine, and usually correspond in position to Peyer's patches, partly also in condylomatous growths and ulceration of the patches and in cellular infiltration of the smaller arteries to their obliteration and causing anaemic gangrene.^ In the meantime, these conditions do not appear to have any clinical importance, since a case of this kind reported by Schimmer^ (recovery of a case of diarrhoea under specific treatment) cannot be held to have demonstrated this. Slight enlargements of the lymphatic glands (from the size of a pea to that of a bean), which are moveable, may often if not always be found on close examination. Sometimes there are only a few behind the ears or at the lower end of the upper arm, or a number massed together in the cervical, axillary and inguinal regions. These masses of glands are always among the most intractable features of the disease, and also often persist after it is cured. In these cases, certainly, it is doubtful whether these glandular enlargements do not form a chance complication depending on other causes. I can by no means agree with Bednar, who regards the swelling of the lymphatic glands as extremely rare, and says that he himself has only once observed it. Syphilitic affections of the osseous system were formerly believed to be very rare. A few cases of destruction of the bones ' Oser, Archiv f. Dermat. u. Syphilis, 18*71, S. 1. — Jürgens, Jahrb.f.KinderheHk., 1881, xvii., S. 126.— Mracek, Vitrteljahrschr.f. Dermat. u. Syphilis, 1883, S. 209. * Archiv f. Dermat. u. Si/philis, 1873, No. 2. 7 08 DISEASES OF INFANCY. of the nose (vomer and turbinated bones), or of periostitis of the femur and other long bones, have been described ; but there seems to have been no idea that these conditions occur in early childhood just as often as in adults, and under certain conditions even oftener. A case of this kind was observed and described by me in the year 18G1^ : — Anna B., 2 months old; atrophic, although on the breast: brought to my polyclinic on 4th April, because she had not moved her arms for 14 days. Both upper extremities lay flaccid and motionless, even when the child moved its legs and body in different directions. Not the slightest movement of the fingers could ever be made out. If one lifted up the left arm and then let it go, it fell doAvn without any resistance, like that of a dead 'body : while, if the same were done to the right arm, there were still observable some slight traces of resistance. Sensibility and tem- perature of Ijoth arms normal. Bothcondyles andtheentii'c lower third of the left humerus much swollen; on the inner side of it a moveable gland about the size of a pea is felt. Cervical, axillary and inguinal glands partly swollen and hard. The soles of the feet — especially about the heels — red, glazed, slightly desquamating. Jsostrils obstructed ; breathing snuffling ; sometimes a slight blood}- and purulent discharge. The mother owned to having suffered repeatedly from her throat and from a skin eruption during her pregnancy-, and had marked alopecia. Treatment : — mere, solub. (Hahnem.) gi'. f twice daily; inunctions of ung. pot. iod. into the swollen part. On the 11th (in 8 day.«) the swelling of the bones had disappeared, the coryza was less, and the arms moveable to a very slight degree. Under the continued use of the medicines along with camomile-baths and tokay wine, rapid improvement ensued. On the 16th the mobility of the arms was once more quite normal and the coryza entirely gone. The mercury was now changed for syr. ferri. iod. (gtt. v., twice daily). On 21st May I found that all syphilitic affections had disappeared, although the atrophy still continued. Fiu'ther history unknown. The following cases observed by me recovered in just the same way :— A child of 6 weeks, brought to the polj-clinie on 14th February. 1879, with brownish colour of the skin. Hand-fed, but pretty well nourished For three weeks coryza, fissures on the lips, and onychia on all the fingers and toes. All the nails much thickened, deformed, and already much loosened from their beds. The ter- minal phalanges covered with scales of epidermis ; much desqua- mation of the soles, less of the palms. The left arm, whieli ' Beiträge sur Kinderheilk. : Berlin, 1861, S. 192. HEREDITARY SYPIinAS. 90 had been hanging flaccid for a week, now incapable of move- ment. The lower third of the humerus much swollen and tender. The right testicle larger and harder than the left. All functions normal. Treatment: — Calomel gr. ^ twice daily. On 26th mobility of arms returned, swelling diminished by about one half ; fissures and coryza almost healed. The nails have almost all fallen off, the new nails groAvhig under them. To con- tinue the treatment. Child of 8 months, brought to polyclinic 20th May, 1876. with a relapse of s^-philis. Papular and macular eruption on the chin and the upper lip; severe snuffles and coryza. Swelling of the lower epiphysis of the right huinerus, with difficulty in moving it and pain on pressure. The left arm normal. Mercurial treatment. Further course unknown. While in these cases only the lower end of the humerus was the seat of the syphilitic periostitis and ostitis, the following cases shoAv that other long bones may also he attacked in the same way : — Child of 10 Aveeks, brought 18th November, 1877, witli coryza, obstruction of the nostrils by scabs, and glazed, red, flat umbilicated papules round the anus and on the nates. Tender swelling of the lower epiphyses of the radius and ulna on the left side; also of middle phalanx of left middle finger, and of first and second phalanges of right finger. Mercurial treat- ment. 27th December : — With exception of epiphysial swelling, child has almost quite recovered. Phalanges of fingers almost quite normal. Treatment continued. Child of 3 months, bi'ought to the polyclinic on 7th June. 1875 ; well-nourished and thriving. Intertrigo with erosions round the anus and genitals. Corj-za almost since birth, with jDurulent discharge and crusts at the nasal apertures. For 4 weeks swelling of upper epiphyses of bones of the right forearm. Tender on pressure. Joint unaffected. Right arm hangs flaccid and is very little moved. All other bones apparently normal. Mer- curial treatment. Marked improvement by end of June. Further course unknown. Child of 12 weeks, brought 18th June, 1879; coryza, enlarge- ment of lower epiphyses of the radius and ulna on both sides ; most marked on the left. Both arms incapable of movement. Roseola on the whole body. Fissures on the palms and descpiama- tion of the soles. Course unknown. Child of 3 months, brought 28th November, 1879. Well- nourished, by mother. Swelling of epiphyses of all ex- tremities; complete immobility of the arms. Legs flaccid No other syphilitic symptoms. Mercurial treatment. Movement of arms improved after 6 days. Swelling of epiphyses also soon diminished. Did not return for treatment. 100 DISEASES OF INFANCY. You see that not only may tlie epiphyses of the different long bones be distinctly enlarged, but also those of the digital phalanges. Such cases closely resemble osteomyelitis (paedar- throcace) — i.e., a hard swelling, covered at first by skin of normal colour which is not adherent to it, but in the course of time becomes red, breaks out in little fistulous openings and after suppurating for years heals at last with a funnel-shaped cicatrix. I have seen this several times in addition to case 4, especially in relapses of hereditary syphilis in the first and second years of life ; but in every case on the fingers, never on the toes. In a child of four weeks, who presented no signs of syphilis except coryza, there was considerable enlargement of the middle phalanx of the third finger on the right hand and swelling of the upper epiphyses of the left humerus and radius with paralysis of the left arm, only the fingers of which could be moved. In another child of six months there was enlargement of the first phalanges of three fingers besides other syphilitic symptoms — all the epiphyses of the upper extremities being normal. Other authors ^ have recently treated of this " dactylitis," which must always be regarded as a comparatively rare condition. Still, you must not forget in the cases of osteomyelitis which you meet with in future that this aff"ection is not always a scrofulous one, but may also be due to congenital syphilis. On the other hand I must Avarn you against being too ready to regard epiphysial swellings as syphilitic, especially those at the lower ends of the radius and ulna, even when other suspicious symptoms are present ; they may be due to rickets, especially in infants who have passed the first half year. In these cases the enlarged epiphyses are unaff"ected by mercurial treatment, while the essentially syphilitic symptoms disappear. Child of 7 months, brought 29th January, 1876. Well- nourished, pale. Coryza since birth. Eight vfeeks after birth a macular eruption, cured by baths (?), but always returning. Now, ■slight roseola on the face, head, hands, and feet. Numerous condy- lomata on the inner surface of right thigh, round the anus, on scrotum and nates. For some week.s, marked enlargement of lower epiphyses of bones of the lower arm on both sides. Cranial sutures still open with very soft borders. Epiphysial swelling at the junction of the costo-chondroid articulations. Mercurial treatment. On 17th February everything recovered from, except the swellings of the epiphyses, which remain unaltered. ' Taylor, Sf/phil'Uic lesions of the osseous st/stem: New York, 1875. — Lewin, Charite-Annalen, Jahrg. iv. HEREDITARY SYPHILIS. 101 You must always try in such cases to investigate carefully whether a combination of rickets and syphilis is not present ; although this is certainly unusual during the first six months. In the first few months you may have less hesitation in regard- ing and treating such enlargements of the epiphyses as syphilitic. I cannot regard as of much significance a diflerence in the form of the swelling (Taylor characterises the syphilitic as having a " sudden, abrupt " commencement) ; but certainly the fact (which I have often observed) that the epiphysial swelling may occur on one side only in syphilis — Avhich is never the case in rickets — is of importance. In most of the cases here given you will have noted a difficulty in movement or a complete immobility of the upper extremities, so that when the arms were raised and then let go they fell heavily as if lifeless (syphilitic pseudo- paralysis). The first author, as far as I know, who appre- ciated this symptom was Bednar \ in whose table of 68 cases of hereditary syi^hilis, paresis of the arms is noted sixteen times, that of the legs once, that of all the limbs twice. His descrip- tion agrees entirely with the symptoms observed in our cases. Bednar seems inclined — though he nowhere asserts it definitel}' — to regard this paresis as a myopathic aftection entirely due to a relaxed state of the muscles. I am not able to give a satis- factory explanation of this paralysis. It is certainly not a central afi'ection ; but at the same time the view that the immobility is caused by pain is open to doubt. Because in not a few cases of this kind I have not been able, either by passive movements of the aftected limb or by pressure on it, to elicit any expression of pain. This much is certain, that in all my cases the diminution of the swelling was rapidly followed by a return of the mobility of the limb. One might, of course, on the contrary lay stress on the fact that Bednar does not mention enlargement of the epiphyses in any of his cases of paresis, also that in my first case the arm which was not swollen was likewise paretic, and that I have frequently seen paralysis of one arm only while the epiphyses on both sides were markedly enlarged. I can even adduce from my own experience two or three cases in which paresis existed apart from any observable afi'ection of the bone. ' Krankheiten der Nevgehorenen u..<:ir. Wien, 1853, iv., S. 227. 102 DISEASES OF INFANCY. Child of 6 weeks, with yellowish-red, somewhat desquamating roseola on the arms and legs, face and body ; dark-red glazed desquamating palms and soles ; coryza and conjunctivitis. Both arms lay complotelj- flaccid; only the fingers showed some slight movement. Nowhere any swelling of the Irones. The mercurial treatment, which had been ])egun in the University ])olyclinic on 10th July, 1860, had already by the 16th caused a disappearance of the eru])tion, and freer movement of the upper limbs. Child of 3 months, brought to nij- polyclinic 15th January, 1879. The mother had already aborted 4 times. Arms and legs lying immobile and flaccid, almost since birth. Corj-za with '• snuffles " and discharge ; a few spots of roseola on the face and round the anus. No swelling of the bones. Mercurial treatment. On 4th February corj-za and spots cured. Arms and legs freely moved, but the latter cannot be fully extended at the knee-joints, owing to resistance of the flexors. Treatment continiied. Child of 6 weeks, brought 24th July, 1879. Corj-za, soles red, glazed, and desquamating. Roseola round the aniis. Epiphy- ses not enlarged. For the last 8 days, arms flaccid and immobile. Every passive movement excites crying. Further course un- known. Child of 8 weeks. Slight roseola; intertrigo ulcerosa; fissures of the under lips ; coryza. Both arms paralysed, flaccid. Epiphyses not swollen. Did not come back. By the researches of Wegner' Ave are hrought somewhat nearer to the expLination of these "pseudo-paralyses" affecting by jjreference the upper extremities with or without swelling of epiphyses. In syphilitic new-born infants and young children one finds— according to his investigations — almost invariably in the long bones, at the point of junction of the diaphysis with the cartilage of the epiphysis, a morbid process consisting in an excessive proliferation of the cartilage cells, and a retarded ossification of the already calcified substance. Along with this the formation of new blood-vessels in the bones is either altogether arrested or takes place very imperfectly ; and from want of nutrition the cells arc gradually destroyed by fat-metamorphosis and shrivelling. The result of this process is seen on section, as a narrow, somewhat jagged line of yellowish or orange colour running along the margin of the epiphysial cartilage. According to Wegner it is formed by necrotic tissue and separates the diaphysis from ' Virchmo's Arc/iir, Eil. 50, S. :30.5. HEREDITARY SYPHILIS. 103 the epiphysis, and may lead to a comi^leto separation of the latter by an "inflammatory suppurative complication." The process always makes its appearance in several places at once, particularly often at the lower end of the femur, in the bones of the legs and forearms, and in the ribs ; and sometimes in all the long bones. Meanwhile the ossification of the epi- physial cartilage proceeds irregularly, and the cartilage cells — which in healthy bones are arranged in rows — are partly put out of order or are completely disintegrated and replaced by groups of small cells. These observations were confirmed by Waldey er and Köbuer;^ but they, as also Taylor, regard the yellow zone not as a necrobiosis caused by deficient vascularity, but as a gummatous process due to the enormous proliferation of new cells which, by compressing the vessels, occasions the death of the intermediate tissue and the consequent separation of the epiphysis from the diaphysis. Whatever its correct explanation" may be, the important fact (from a clinical point of view) remains, that we have here a morbid process at the epiphysial line which, although it certainly occasions recognisable symptoms during life in only a very small proportion of the cases (swelling, pain, immobility), yet has an influence on the mobility of the affected limbs which, even where other symptoms are wanting, must not be underestimated. A separation of the epiphysis observable during life is rare, and is manifested by abnormal mobility at the epiphysial line and an unusual "dangling" of the hand (Köbner and Waldeyer). I have myself been able only in one instance^ to make out crepitation at the aff'ected place. Moreover the change described at the line of junction of the epiphyses does not always afl"ect all parts equally. In a child of two months, the epiphyses of whose forearms were distinctly smaller during life, it was well-marked in these situations only while in the other bones it was merely indicated. In a child of thirty days old there was but little of it to be seen in any of the bones examined.* Perhaps in this ' Virchow't Archiv, Bd. 55. - According to Haab and Veragiith {Vlrchow's Archiv, Bd., 84, Heft 2) we have to do, chiefly, with an inflammatory process in the cartilage, which cau.ses fissures to appear in it. ^ Troisier, (Union med., 1883, No. 104) and Kremer ("Beltr. zur syphil. Epiphysenlösung " : Dissert., Berlin, 1884) describe such cases. ' According to Kühner and Waldeyer even iu the cases where there are no naked-eye change in the epiphyses, these may be certainly recognised by the 104 DISEASES OF INFANCY. case the mercurial treatment which had been carried on for twenty days with marked success (all eruptions were already cured), had acted beneficially on the bones. I am not myself quite sure of having ever observed the affection of the joints whether following on disease of the epiphyses or not. On the other hand, some writers^ mention having seen purulent inflammation of joints or periarticular abscesses as the result of congenital syphilis. AVithout denying the correctness of their observations, I must point out that, at least in a number of the cases, they may have had to do with inflammation of the joints accidentally complicating hereditary syphilis. Of the subacute form of congenital syphilitic joint affections, of which Spmma- describes six cases, I have hitherto, in spite of my large amount of clinical material, met with only one case, and that not altogether free from doubt. Still, I admit that I havo not yet directed my attention to the joints as carefully as I con- sider necessary after these recent communications. Bouchut and Parrot-^ have also found the diaphyses of the long bones often unusually dense and hard, and frequently the seat of periostitic deposits. Wegner has in rare cases found a gummatous periostitis on the inner side of the cranial bones ; or little gummatous nodules in the pericranium. The nature of the following case of bone-disease affecting the sternum does not seem to me quite clear. lu October, 1878, an apparently healthy and thrivmg child of 8 weeks was brought to the polyclinic. No signs of syphilis. In the region of the ensiforni process there was a wound the size of a shilling with a grey coating ; in the middle of it a fistulous microscope. — Lomer iZeitschr. f. Geburtsh. u. Gynäcol., x., H. 2, 1884) was unable to find them in 13 out of 43 macerated foetuses, some of which were undoubtedly syphilitic. ' Güterbock, Langenbecl's Archiv, Bd. xxiii.. Heft 2 and Bd. xxxi., Heft 2. — Schiiller, Ibid., Bd. xviii.. Heft 2. — Parrot. — Heubner, Virchoio's Archiv, 84, Bd., 1881.— Ä7m. Wochenschr., 1884, S. 548. - Su di una forma morbosa articolare per sifiiide ereditaria: Napoli, 1882. The characters of it, according to Somma are: — Very early commencement ; cachexia ; crying on movement; fever (to 102"2) : enlargement of several joints (especially the knee-joints) with slight local redness and rise of temp. Duration 18 days to 24 months. Recovery possible under specific treatment (inunction of ung. hydrarg. and pot. iod.). In two cases there was found at the post-mortem, inflammation of the synovial capsule, sero-purulent exudation into the cavities,, necrosis of the cartilage, hyperemia and rarefaction of the neighbouring bones. Gummata are also mentioned. Archiv/. Kinderheilk., Bd. ii., S. 433. HEREDITARY SYPHILIS. 105 opening, from which on expiration there issued pus along with a few air-bubbles, which had evidently entered from outside. A probe touched rough bare bone (sternum). According to the mother's statement, an abscess had formed a week after birth and had opened. I did not see the child again till 21st February, 1879. The fistula had completely healed after the exfoliation of a piece of bone ; but the child now had coryza, fissures of the lips and angles of the mouth, spots of roseola, and erosions round the anus and on the genitals. Whether the necrosis of the sternum in this case was really to be regarded as a manifestation of syphilis I shall not venture to decide ; because I have never hitherto observed a specific bone disease coming on soon after birth and preceding all other symptoms of the disease by months. Also, the bone affection was recovered from without specific treatment. Infantile syphilis does not limit its action to the skin, mucous membranes and bones. Other organs also, as in adults, may be affected ; amongst these the testicles and liver may be specified as parts when implication is discoverable during life as well as post-mortem. The affection of the testicle was partially unknown until very recently. Hen nig and Taylor mention it only in- cidentally; and Despres^ was the first to describe carefully three cases, in children of from seven months to three years of age, one of whom was examined post-mortem by Cor nil and found to have hypertrophy of the tunica albuginea with intersti- tial orchitis and epididymitis. In the comparatively short time since 1874 I have myself met with at least twelve cases, of some of which I have already elsewhere" published accounts. Never neglect, therefore, in every case of infantile syphilis to examine the testicles carefully. The testicle thus aff"ected is more or less enlarged, hard and firm; likewise somewhat uneven and nodular. The size varies from that of a hazel to that of a chestnut. I have found both testicles aftected in four cases, the left alone in four, and the right alone in two. The youngest child was three mouths, the oldest was suffering from a relapse of syphilis and was two and a half years old. Only one case was examined post-mortem. Boy of 2^ years, brought to the hospital in the end of Sep- tember, 1876, with mucous papules at the anus and psoriasis ' Bullet, de la soc. chir,, 1875. - Dettfsche Zeifschr. f. pract. }fe(l., 1877. No. 11. lOG DISEASES OF INFANCY. syphilitica. Both testicles markedly enlarged and nodular. Treatment by inunction (grs. 10 ung. hydrarg. daily). After thirty inunctions, all the symptoms disappeared, except that the testicles remained unchanged. Death on 25th December from cholera infantum. P.-M. — Both testicles very large and firm. The micro- scope showed an extensive hypertrophy of the interstitial connective tissue in the testicle, most marked in the cor]ms Highmori. Gumma nowhere to be discovered. There was therefore in this, as in one of De sp res' cases and in others recently observed by Hutinel,' interstitial orchitis, and partial epididymitis; and of course when this has gone on to the formation of fibrous tissue, it will resist all treatment. Only in an early stage you may expect that resolution may occur, although perhaps not always complete ; and of this I have fully convinced myself in four cases. In just the same way the liver may also be attacked by an interstitial inflammation, with or without formation of gummatous nodules ; but this in a number of cases is only recognised post-mo rtem.' A girl of 7 days, illegitimate, born in the Charite. Father syphilitic. On examination of the child we found roseola, and j)soriasis of the palms and soles, thighs, legs, and nates. Extreme atrophy, no enlargement of liver. Death from collapse, 25th November, 1875. P.-M. — Interstitial hepatitis; liver some- what enlarged, very tough, smooth. Acini not visible ; whitish bands consisting of connective tissue passing through the paren- chyma in all directions. Cortical substance of kidneys extremely firm. Haemorrhages in fundus of stomach, both outside and in; its mucous membrane covered with a coherent membrane-like layer of blood-stained mucus. The yellow zone in the epiphyses of several of the bones ; periostitic deposit on the right humerus. All diaphyses extremely hard. While in this case the interstitial hepatitis was only revealed by the post-mortem and even the hfemorrhagic catarrh of the fundus of the stomach — possibly a result of engorgement of the l^ortal vein — caused no symptom; in other cases an enlarge- ment of the liver was noticeable, which confirmed the diagnosis. Felix L., 8 months old, was affected at the age of six weeks with a macular eruption which gradually spread over the whole body. In places blebs of the size of a pea occurred, filled with ' Revue metmuelit, 2, 1878. * Cf.Y. Bareusprung, l>k herediiävt Si/phiUs: Ijerlin, 18(>4. HERKDITARY SYPHILIS. 107 turbid fluid. Intertrigo on the scrotum and iu the neighbourhood of anus. About four weeks previously, also coryza and hoarseness. On 15th March, 1864, I discovered a considerable enlargement of the liver, along with all the usual sj^mptoms of congenital .syphilis. The liver reached down to the level of the umbilicus, Avhere its sharp margin could be distinctl}^ felt, and was visible at each respiration through the wasted abdominal walls. Surface smooth ; not tender to touch. The liver-dulness extended on the left side right over to that of the spleen. Mercurial treatment, with no results. The atrophy increased and death ensued on 25th. At the post-mortem the liver was found to be considerably enlarged, with numerous whitish-yellow patches and bands of various sizes scattered through it. Microscopic examination of these by Prof. Klebs showed the appearance of interstitial hepatitis. Spleen and kidney normal on microscopic examination. Child of 9 weeks (7th February, 1881). Moderate jaundice since birth, sclerotic and mucous membranes affected. Fa3ces and urine contain bile. Liver prominent and smooth. No signs of syphilis. Advancing atrophy. Treatment with calomel unsuc- cessful. Collajjse and death, 28th February. P.-M. — Liver very large and thick, olive-green and tough. Acini separated from one another by white bands of connective tissue, the immense number of which is better seen under the microscope (interstitial hepa- titis). Scattered effusions of Ijlood in the mucous membrane of the stomach and bowel. Characteristic syphilitic zone in all the epiphyses of the ribs. No signs of syphilis elsewhere. Soon after this case, I had another identical one which was further remark- able, because the mother had already lost three children from this same liver-affection with jaundice. In these cases there is usually only a moderate degree of jaundice or none at all ; but if the process of induration affects not only the interstitial tissue but also the porta hepatis, the jaundice may reach a very high degree and present a greenish tint. I have seen one such case, which must have arisen during intra-uterine life,^ in a child ten weeks old, who since birth had had a hard uneven liver, intense jaundice with quite colour- less motions, and an enlarged spleen, and whose gall-bladder and bile-ducts were found post-mortem to have been entirely trans- formed into thick fibrous masses filling the portal fissures. It is ' f'/"- Beck's csise{Praff.mecL WocJtenschr., 1884, 26):— A foetus of eight months. Fibrous masses in the liver, on the bile-ducts and gall-bladder, and in the pancreas, with miliary gummatous deposits, interstitial orchitis and epididymitis. — de Euyter, "Einige Fälle von Syphilis congenita " : />fSA-., Berlin, 1885. — P. Meyer. "Aus der Kinderpoliklinik dor K. Charite zu Berlin." Berliner Hininclie Wochevxckr., 1886. No. 16. 108 DISEASES OF INFANCY. only in the minority of the cases, as far as my experience goes, that interstitial or gummatous disease of the liver can be made out clinically; and even at the post-mortem they may in many cases be overlooked on merely naked-eye ex- amination. Ascites also, which is such a usual symptom of interstitial hepatitis (cirrhosis) is almost always absent in these cases. The case published by Depasse,' in which the fluid in the abdominal cavity communicated with the tunica vaginalis and was evacuated by these punctures (one through the scrotum), is therefore all the more remarkable. This case is also noticeable owing to the success of the specific treatment (which usually has no eöect) even although in the 8th year the liver was still con- siderably enlarged. The spleen is often also affected in congenital syphilis by hyperplasia, induration, and perisplenitis adhesiva ; and I have myself repeatedly seen it more or less considerably enlarged in such children, and once in a very atrophic child of six weeks, and again in one of two months, with roseola and palpable enlargement of the liver. One must not, however, forget that the spleen is not unfrequently found to be hypertropied in infants who are not syphilitic, and, therefore, the combination of syphilis and enlarge- ment of the spleen may in many cases be accidental.^ Hyper- trophy of the connective tissue occurs also in the kidneys, supra-renals and pancreas ; but has no more clinical interest than the gummatous nodules which are sometimes found in the thymus, in the lungs, and even in the heart. Abscesses of the thymus-gland on which P. Dubois laid great weight I have seen twice, in the form of multiple collections of pus scarcely the size of a pea. The children presented at the same time many pemphigus-bullffi, especially on the palms and soles, and they died in the first weeks of life. The implication of the n e r v o u s c e n t r e s , especially of the brain and its vessels, by syphiHs has aroused much interest in our time ; but my own experience seems to indicate that it occurs much more frequently in adults than in children.^ In rare cases I have seen contractures improved or cured by specific treat- ' Revue mens. Aout, 1886, p. 360. ^ Ha si und, Archiv/. KinderlwiW . , Bd. iv., S. 297. ■■' Chiari (Wiener med. Wochenschr., No. 17 & 18, 1881) describes a case of Endarteritis syphilitica of the vessels of the brain in a child of 15 months with, hereditary syphilis. —Barlow {Lancet, 1877) gives a similar case. HEREDITARY SYPHILIS. 109 ment. My first case of this kind * was that of a boy aged fourteen months, who was brought to my polyclinic on 24th Nov. 1867. On examination he was found to have contracture of the right arm at the elbow-joint, of the fingers of the right hand, and of l)oth lower extremities at the knee-joints. Unable to stand, sit, or grasp with the right hand, Biceps brachii and flexors of the legs ex- tremely tense. Every attempt to extend the limbs caused violent crying. The child had also papules round the anus and on the scrotum, excoriations of the alge nasi and of the angles of the mouth, coryza, enlargement of the clavicular and axillary glands. The child was said to have suffered for months from severe coryza, from an " eruption of blebs " and ulcers ; and, when three weeks old, from epileptic fits for several days. The contractions were said to have gradually developed after these. When the child had taken mercury for about a month it could on 23rd December open the right hand and also bend the knee. Gradual improvement till 3rd February, 1868. On 27th, change to pot. iod. On 30th March, began to walk and to use right arm. Further progress unknown. The influence of the anti-syphilitic treatment is here unmis- takeable. Still, it is questionable whether the contractures should really be regarded as a cerebral afi"ection and connected with the fits which the child had formerly had, or as a myopathic affection quite independent of the nervous system and caused by an interstitial myositis such as occasionally occurs in syphilitic adults. That the latter may occur in congenital syphilis seems to me to be proved by the following case : — In a syphilitic child of 4 months (brought to the polyclinic October, 1874), there was a stiff contraction and hardness of the flexors at the back of both thighs, so that the limbs were held continuously in a state of semi-flexion. The leg could be only partially extended at the knee. The use of mercury for several weeks brought about complete recovery ; first of the skin eruptions, and finally of the contractions also. I have never been able to observe essentially cerebral symptoms in infantile syphilis, — neither the chronic menin- gitis described by Somma,- nor paralysis of one or more extremities, nor convulsive seizures. And although such things may occur, it is still very doubtful whether one is justified in attributing them to syphilis. The following is a case in point: — • Beiträge zur Kinderheilk., N. F.: Berlin, 1868, S. 421. ^ Clinica pediatrica di Napoli, 1877. 110 DISEASES OF INFANCY. In a cliild of 2 jcara (admitted to one of the ehildren's wards 6th November, 1877) there was — along with osteomyelitis — an unusual psychical condition, alternating precocity and stupidity, but without any interference Avith inotility. At the P.-M. (after death from diphtheria) we found several nodular tumours about the size of a clierry under the pia mater, and in different parts of the cerebrum and cerebellum. They were of a gi-ey colour, and transparent at the periphery ; the centre partly fatty, partly calcified. A similar deposit was found in the upper part of the left kidney. Since tubercle was nowhere present and perios- teal deposits were found on both tibiae, I was inclined to regard the brain-tumours as syphilitic gummata; and they were con- sidered such on being examined at the pathological institute of the Oharite. Considering that the diagnosis between gummata and tubercle cannot be made with perfect certainty with the microscope alone, and that the clinical symptoms with the progress of the case and finally the result of the treatment have a much higher value from a diagnostic point of view, we must be very sceptical in judging of such cases. At any rate it seems strange that, in spite of the great number of children with congenital syphilis I have seen, I have practically never been able to find cerebral symptoms Avliich could with certainty be referred to syphilis. Any connection between chronic hydrocephalus and congenital syphilis seems to me extremely improbable on account of the inetfectiveness of mercurials in the former disease. Even the case of " diffuse insular sclerosis " which Buss^ has described seems to be by no means beyond a doubt as far as its con- nection with hereditary syphilis is concerned. In other regions of the vascular system changes have occasionally been found in new-born children, which recall "the syphilitic affections" of the blood vessels of the brain. Thus, Schütz'^ describes the small arteries of the kidneys and skin as being much narrowed, their walls considerably thickened by hypertrophy of the muscular coat and adventititia ; and he ascribes to this the numerous little ecchymoses which, in his case of a premature child, he found in the skin, subcu- taneous connective tissue, muscles, kidneys and other parts. Fi sehr s^ researches, however, render it very doubtful whether ' Berl. Min. Wochenschr., 1887, Nos. 49 n. 50. ^ Prager med. Wochenschr., 1878, Nos. 45, 46. ' Arch.f. Kinderheilk., viii. UEKEOITARY «YPHILIS. Ill these vascular changes are really caused by syphilis. He regards this state of the small arteries in ne'.v-born children as the normal condition and thinks it has nothing to do with haemor- rhage. Mracek^ on the other hand says that in children with syphilis haemorrhagica he has found the walls of the small and medium-sized veins thickened by a proliferation of their nuclei, and the lumen narrowed or even obliterated. While the matter is thus undecided we cannot, in the meantime at least, recognise any real anatomical foundation for the view which Behrend^ has endeavoured to advance, viz., that there is a hiemorrhagic form of syphilis neonatorum. The progress and termination of the case in congenital syphilis depends, according to all experience, less on the nature of the symptoms than on the state of the patient's nutrition. Syphilitic infants fortunate enough to receive their natural nourishment from the mother or wet-nurse, usually thrive well when treated specifically, and have the best prospects of complete recovery. But all hand-fed children, especially such as have from birth been weak and atrophic, I consider to be in great danger; indeed these latter may almost be given up for lost. While in private practice, and even in the polyclinic, out of a very large number of syphilitic children I have lost only a few, and that from chance complications, in the children's wards of the Charite, where every one of the cases was extremely atrophied, almost all I have seen ended fatally. Not uncom- monly death came quite suddenly. Trousseau has already drawn attention to this ; but in my opinion it is nothing very strange, since sudden death is a common enough event in atrophic children. Under propitious circumstances, the disease often takes a favourable turn with surprising rapidity. One is astonished to see eruptions, condylomata and bony swellings diminish within five or six days under the influence of mercury, and after a few weeks disappear entirely. But I should here warn you against over-estimating the results of your treatment. Recurrence of the disease is extremely common in infantile syphilis ; and, especially in polyclinics where the children are so ' Jahrb./. KinderheUl-., xxvii., S. 191. Vierteljahrschr. f. Dermatologie und Si/p/tilig, 1884. I will only remark that among Behrend's cases there are two in which there was an enlarged spleen with purpura ; and these often occur together where there is no syphilis. Cy. also Petersen, ibid., 1883, S. 509. 112 DISEASES OF INFANCY. often removed from further observation on the first disappearance of the symptoms, one has opportunities of convincing oneself of this fact. A child of 6 weeks, brought 7th January, 1874, with many symptoms of syphilis. Eecovery towards end of February, under mercur}-. Brought again 10th April, with sj-niptoms of recurrence of the disease which have existed three days. Eecovery on 28th. Recurrence on 18th June. Boy of 2 years, born of a sj-philitic mother, all of whose children were infected. Infantile syphilis in the 2nd month. A few weeks later treated in the polyclinic for erosions at the angles of the mouth and on the tongue. Recurrence on 15th May, 1874 : — For 8 weeks condylomata at the anus and on the dorsum of the tongue, which towards the back appears hard, infiltrated and of a dark-red colour, and towards the front is covered with a greyish- white coating. At the end of June, recovery under mercury. On 14th November, recurrence of the condylomata at the anus. On 9th January, 1875, recurrence again, requiring new treatment. Girl of 5 years, with mucous papules at the anus, and enlarge- ment of the inguinal glands. First outbreak of syphilis at the 5th Aveek ; 2nd, at 1^ years ; 3rd, at end of 5th year. One should not, therefore, at once discontinue the treatment on the disappearance of all symptoms, but should always carry it on for some weeks. But even this does not remove all danger of recurrence. In most cases, however, one succeeds in curing the disease completely within the first or at least the second year; and I have gathered a sufficient number of observations from private practice to be able to assert that by this time the thing is really at an end. You must, however, always be pre- pared for a fresh outbreak of the disease, even in the later years of childhood. And under these circumstances doubts may arise as to whether we have a recurrence of congenital syphilis, a direct infection, or a so-called "syphilis tarda" (to which I shall return later). But even in the cases where the disease has been thoroughly cured by continuous treatment from the very beginning, there yet not uncommonly remains a derange- ment of the constitution favouring the development of rickets. I have frequently seen this disease come on after recovery from congenital syphilis in children situated in the most favourable circumstances and nursed with the greatest care. But I must protest against the incomprehensible opinion of Parrot, who regards rickets as invariably the result of syphilis. HEREDITARY SYPHILIS. 113 The difficulty of establishing with certainty the origin of infantile syphilis is often very great, although its diagnosis is so easy. All cases which have arisen within the first two months of life, must, with extremely few exceptions, he regarded as hereditary. I have already stated (p. 61) that hereditary syphilis sometimes appears in the form of pemphigus, even during the first days of life ; and some of the cases already given show that as early as the first two weeks other syj^hilitic skin affections and coryza may make their appearance. Much oftener, however, the children present no striking peculiarity during the first four to six weeks ; and it is only later that symptoms begin to be observed. After the second — or still more after the third month — it is rare for them to appear for the first time ; ^ and when they occur still later, it is always doubtful whether it is not a case of recurrence or of direct trans- mission. The latter is certainly not easy to establish ; and, especially under those circumstances which render confession on the part of the parents difficult or impossible, an attempt is often made to turn the physician's thoughts from the subject of heredity, and deceive him by false statements about a syphilitic wet-nurse or other attendant having infected the child. I by no means deny the possibility of such infection ; yet, out of the cases of this kind which I have myself met with, there has not been a single one so certainly proved that I was able absolutely to exclude a hereditary origin. In poor families, however, I have certainly observed the direct infection of infants l)y syphilitic Avomen living in the same house and, consequently, brought much into contact with them ; perhaps sometimes due to the use of sponges and other toilet articles in common. On the other hand, the infection of the child during birth, from the genital organs of the mother being afi"ected with syphilis (syphilis adnata), which was formerly often assumed, — is very doubtful : for example, Trousseau's case, in which he ascribed an "indurated chancre " on a child's nates to contact with the ulcerated vulva of the mother. I have not myself seen any case of this kind; nor yet one of infection by vaccination which in our time has raised so much dust, under the name of " syphilis vacciualis." Since the contagiousness of secondary ' Roger found, in 249 cases, the earliest symptoms 118 times in the first, and 217 times before end of third month ; but only 32 times after that. 8 114 DISEASES OF INFANCY. syphilis has been proved beyond doubt, one can certainly no longer dispute the possibility of the transmission of the disease by inoculation with vaccine lymph derived from a syphilitic child, whether any blood is mixed with it (Viennois) or not. And it cannot be denied that many of the cases of vaccination- syphilis which that author gives seem to prove it. Still, the point remains a matter of controversy, and I do not consider myself called upon here to give a definite judgment upon it — all the more because, as I mentioned before, I have never myself met with a single well-authenticated case. I have, indeed, seen many cases in which, after vaccination, ulcers appeared at the sore, and various eruptions, which might very easily have been mistaken for syphilis by inexperienced and superficial observers, but which had no connection whatever with it. Of the frequency of these errors I am perfectly convinced ; and I would refer, as a positive proof of this, to the work of Joukoffsky^ ; he saw fifty-seven children who had been vaccinated from eleven syphilitic infants remain absolutely free from the disease. I should also remind you that syphilis does not interfere with the regular development of the vaccine vesicle ; but that where hitherto latent it may become manifest owing to an injury, such as vaccination is, — and a false assump- tion of transmission by the lymph may thus arise. I am even less afraid of transmission by the milk of a syphilitic nurse, so long as her nipple is healthy. At the same time, one would of course be as unwilling to choose a suspected nurse as to make use of vaccine lymph from a child which then or previously had presented symptoms of syphilis. With rare exceptions, therefore, all the cases of syphilis occurring during the first months of life, are to be regarded as hereditary. The study of this heredity has long been pursued with especial zeal" ; and if in spite of this medical writers at the present day are as yet by no means unanimous and differ widely on many points, the fact merely proves how difiicult it is to get rid of all doubt in matters which from their very nature can only become known by the confession of those interested. ' Oesterr.Jahrh.f. Pädiairü-, v. 2, S. 139. ■■^ Köbner, Klinische und experimentelle Miltheihngen aus der Dermatoloqie und Bypldlidoloiiie : Erlangen, 18C4. — Kassowitz, "lieber Vererbung und Ueber- tragnng der Syphilis," Juhrb f. Kinderlteilk , Bd. xxi., 1^84, S. .^3. HEREDITARY SYPHILIS. 115 Every day brings us new examples of the fact that, especially in syphilis, those concerned are but seldom to be fully trusted, and the physician, in spite of the utmost care, is here liable to vexa- tious deception. I have myself met with cases where not only was the diagnosis of congenital syphilis beyond doubt, but the post-mortem, also, gave the fullest confirmation of this — and yet both parents persistently denied ever having been syphilitic. We know for certain that syphilis may be inherited from the father as well as from the mother. The father transmits the disease immediately through the semen with which he impreg- nates his wife, — the mother, through the ovum from which the foetus developes^ ; in this case, the parents must be the subjects of secondary syphilis. Primary affections can only have an influence in infecting the child in so far as they lead to tiie development of secondary symptoms in the mother during her pregnancy — an origin of congenital syphilis which by many writers {e.g. Kassowitz) is positively denied. I do not con- sider it by any means settled whether they are right in doing so, or whether an infection of the foetus by the blood which nourishes it is possible in the case of a mother becoming syphilitic during pregnancy ; but I think the latter is very probable. Those who deny such transmission by the blood naturally discredit the possibility of a non-syphilitic mother becoming infected through the blood of her foetus which derives its syphilis from the father ; others hold this tobe certainly possible. Hutchinson and Fournier allege fi-om their experience that women who have married syphilitic men frequently do not become infected until they conceive and not so long as the marriage remains unfruitful. Some recent observations of Behrend*^^ also, seem to be in favour of the view that such a " placental infection " does take place sometimes, but is by no means a necessary occurrence. Be that as it may, this much at any rate is certain — that syphilitic mothers are exceedingly liable to abortion, or to give birth prematurely to non-viable infants, whose epidermis, often macerated and detached, is sometimes mistaken for the product of a foetal pemphigus. This tendency ' The streptococci in the capillaries described by Kassowitz and Hoch- singer {Wien. med. Blattei-, 1886, 1—4) are regarded by most authorities as not pathogenetic. - Btrl l-Un. Woche u.'^chr., 1881, S. 107. I IIG DISEASES OF INFANCY. to abortion is due to endometritis decidnalis, thickening of the placenta, or circumscribed gummatous growths in it (Virchow), — ;perhaps also to atheroma or endarteritis syphilitica of the umbilical vein (Winckel). The knowledge of this is of import- ance for diagnosis, because in cases where the presence of con- genital syphilis is doubtful, it helps to turn the scale in its favour. By time, and by repeated specific treatment, the disease in the parents may be weakened or temporarily cared. And this explains the fact that at the earlier period of such marriages the tendency to abortion is strongest, and gradually decreases as time goes on ; also, that the first-born children are apt to be the most severely affected, and the later ones may be quite healthy. Not uncommonly we also observe a remarkable alternation of healthy and syphilitic children, which can only be explained by the fact that the syphilis in the parents manifests itself afresh periodically, and at other times remains in a condition of latency which does not endanger the health of the fcetus. In this manner the possibility of hereditary transmission may continue for a very long time. Kassowitz estimates it at ten to fourteen years ; but the following case of my own shows that even twenty years may have passed. The fatlier of tlie child at the time of his marriage had a chancre not yet completely healed. The first child, born a year after the marriage, was said to have suffered repeatedly from swellings on the tibiae ; and I myself observed in the same child, Avlien she had grown to a girl of 17, another extensive periostial swelling on the left humerus. The mother herself had suffered repeatedly during her twenty years of married life from suspicious sore throats and obstinate ulcers in the neighbourhood of the knee- joints, which always requii-ed treatment with ])ot. iod. and decoct. sarsoo co. (Germ. P.) to remove them. During this long time she bore two other children who were quite healthy; but subse- quentl}- she had several abortions. In the 20th year of her married life she was delivered of a boy Avho, 14 days after birth, ■was affected by well-marked manifestations of congenital syphilis, and had to be subjected to a long course of mercury. Later, he became extremely rickety, suffered frequently from convulsions and larpigeal spasm, but in the end — thanks to first-rate nursing — grew up a healthy youth. I am at present uncertain whether it is possible to recognise from the form of infantile syphilis whether it originates from the father or mother. The opinion of Bärensprung, Hecker and IIEIIKDITAHY SYPHILIS. 117 KeyseP, that syphilis of the internal organs— esi)ecially of the liver — proves heredity from the father's side, appears to me by no means certainly established, for one has to bear in mind the insuperable difficulties in the way of our obtaining a reliable history here. I come now to the treatment of the disease. I may sum up the result of my large experience in this department in this short sentence — the only reliable remedy in infantile syphilis is mercury. Its action, as I have already mentioned, is often really wonderful, and its rapidity extremely surprising. Neither iodide of potash nor iodide of iron, which are recommended by many, are comparable to mercury. Of its preparations I prefer to all others, for patients of this early age, calomel and mercurous oxide (Germ. P.) in doses of gr. -7 — 4, morning and evening. The latter occasionally — and especially at the beginning of the treatment — causes vomiting. Any other mode of giving the mercury — such as the mercurialisatiou of the nurse or even of a milk-giving animal — I consider inadmissible ; all the more so, as it is by no means certain that the mercury is transmitted by the milk. At any rate, ceitahi experiments in this direction uii'lertakcn by Kahler" showed that the milk of three mothers under treatment by inunction was completely free from mercury. luanctions of mercuiiul ointment or subcutaneous injections of perchloride of mercury are only indicated where there are no extensive syphilitic eruptions, or where intestinal complications (diarrhcea and vomiting) forbid the internal use of the drug. All the patients with whom I have used inunction were already more than two years old, and were suffering from a relapse of syphilis, N\hich generally manifested itself more by condylomatous foiniations than by extensive skin eruptions (inunction of grs. x. — xx. unguent, hydrarg. daily). I have injected perchloride of mercury subcutaneously in these cases, with good results ; I shall return to this in considering the syphilis of older children. Perchloride of mercury baths (grs. xv. to a bath) I have used frequently, but with no constant effect. I therefore recommend them only for those cases in which advanced atroph}^, vomiting or diarrha?a make the internal administration of mercury inadvisable. Condylomatous excrescences are to be dusted with calomel, or, ' Botjer. drztl. InttUigenM., 1870, No. 21. ^ Aei it!. Con e.'pondembl., 1875, No. 23. 118 bl.SEASES OK IN'I'ANCY. if they arc already ulcerated, painted daily \vitli a solution of nitrate of silver (grs. xvi to the ^i). I also recommend this latter to you for the nasal mucous membrane, should the coryza obstinately resist internal remedies. In most cases, however, internal treatment suffices to cure it. The extreme importance of the natural method of nourish- ment for syphilitic infants has been already mentioned. Any artificial method is objectionable for such children, although unfortunately it is often unavoidable ; and it may also be well borne as long as we have to do with strong children.^ It will be readily understood that if the mother herself is syphilitic she need have no hesitation in nursing her own child. It is another matter when there are absolutely no signs of the disease to be found on the mother, and when any previous syphilitic affection is denied. Under these conditions — which are not at all common —the mother should be allowed to nourish her child only if its lips and mouth present no morbid appearances (rhagades, or condylomata). The same holds true in the case of a wet nurse ; for there can be no doubt that such a child maj' transmit syphilis to the excoriated nipple of a healthy nurse, and that specific ulcers on the breast may arise in this way and be followed by secondary symptoms. Even the secretion from coryza must not be altogether disregarded as an unimportant matter in deciding whether the child shall be allowed to take the breast (Eoger). Certainly the observations of Günsburg- seem jfco be quite against such an infection, since out of thirty-one wet Äiurses of syphilitic children (one nurse within two years suckled as many as eleven), he did not see a single one become affected. Thence he concludes that congenital syphilis is never trans- mitted to the person who suckles, and that all the cases in which ithi^ is said to have taken place are to be explained by the fact that the children were sufiering from acquired syphilis. This opinion, however, seems to me to be somewhat forced ; and as cases have been observed of healthy wet-nurses being infected by children who were indubitably suffering from congenital ^ In the '■ Hospice des enfants-assistes " in Paris, experiments have been made recently (at Parrot's snggestioni in nourishing syphilitic children with asses' milk— tj|e children sucking the ass's teat; and the results of this were much vbette): tban«those of hand-rearing. Cf. Wins, " L'allaitemont ii la nourricerie «|q I'hospice des enfants-assistes," These: Paris, 18?5. ' Oesteii-. Jahrb./. Kindvvheilk-., 1872. ii., S. 1611, HEREDITARY SYPHILIS. 119 syphilis, I consider it extremely problematical ; and therefore I advise you to exercise caution. To my thinking, the physician is bound to point out to the wet-nurse the possibility of an infection. It then lies with herself to decide whether she will expose herself to this danger for the sake of remuneration. In this way, certainly, the most awkward family secrets may be dis- closed, and the physician accused of indiscretion ; still, I think that all these considerations must not induce us to expose a healthy nurse to the risk of syphilitic aftection without her knowledge. It is not, of course, necessary to use the name *' syphilis" to the nurse; it is enough if one explains to her that it is an infectious skin eruption. Almost all nurses are quite willing to enter into the engagement on this understand- ing and in most cases they remain free from syphilis. I myself, at any rate, have as yet never known of any nurse becoming infected in this way, although several of the children nursed were affected in a high degree with congenital syphilis. The greatest cleanliness and, still more, the most careful attention to any excoriations occurring on the breast, are to be impressed on the wet-nurse as a duty. The child may have difficulty in sucking owing to fissures on the lips and severe coryza ; still, I liave never seen danger in the matter of nutrition arise from this. Finally, a word or two on the physician's conduct to the parents. While in poor practice and in that of the polyclinic a <3andid statement by the physician has scarcely ever any bad result, in the upper classes of society such a statement is apt to lead to serious consequences in the family. I therefore advise you if you are not confided in spontaneously, and if you are sure that the mother is quite innocent, to take the father only into your confidence. Fortunately the disease is so characteristic that confession on the part of the parents is unnecessary for diagnosis, and the proper treatment may be entered on at •once. Still it is always a matter of the greatest importance to ascertain the parents' state of health, for it is only by thorough specific treatment that we can prevent the subsequent offspring from becoming likewise syphilitic. In spite, however, of this characteristic group of symptoms, «ases do occasionally occur in which even the most experienced physician is unable to make the diagnosis of syphilis with 120 DISEASES OF INFANCY. certainty, in such cases it would be bigbly indiscreet to agitato the parents by obscure hints and questionings. Suppose, for example, one were to observe intertriginous redness about the anus and genitals, with superficial rounded excoriations here and there in the middle of it. This intertrigo, in spite of cleanliness, gradually spreads over the lower part of the back or over the greater part of the body, while the reddened skin becomes covered with yellowish-white scales, consisting of desquamated epithelial cells mixed with sebum. Or there may arise in the intertriginous folds of the skin — especially in the inguinal region— deep elon- gated ulcers covered with a greyish-white coating. Perhaps, also, coryza or red spots in various situations may appear— still further unsettling the diagnosis. In most cases of this kind you will be guarded against error by the fact that the lips and the angles of the mouth remain free. But it will do no harm whatever if, to quiet your professional conscience, you begin mercurial treat- ment ; and this will very soon show whether there is any syphilis present. I close this chapter with a few remarks on the syphilis of older children, of which I have seen a considerable number of cases, especially in my department in the hospital. The thirty-nine children, on whose cases I have founded the fol- lowing descrij^tion, were between two and fourteen years of age, and (with the exception of eight) were all girls. On the most careful questioning it was found with certainty in only six cases that the syphilitic symptoms were to be regarded as due to a recurrence of congenital syphilis which had already shown itself in the first months of life. In all other cases no connection of this kind could be certainly traced ; and therefore, under the circum- stances, we were left in doubt whether we had to do with a hereditary disease or with one acquired by later infection and intentionally concealed by the relatives. In any case I should rather acloiowledge this doubt than assume a so-called "syphilis tarda," — a form which is said to be hereditary, although it only makes its appearance for the first time in older children between the eighth and twelfth years or even later. That such syphilis tarda may possibly occur I shall certainly not deny, for the theory has the support of conscientious observers ; but I have never in my own experience met with a single indubitable case of it. Further, I should recognise as such only HKUEDITAKY ÜYI'HILIS. 121 a case in which I myself had heen able to verify, by continuous observation from birth, the absence of all syphilitic symptoms in early life ; and, at the same time, the absence of syphilis in the parents. For the statements of the latter are almost always unreliable, and often even intentionally misleading. In eight girls, between four and twelve years, the symptoms could be referred with perfect precision to an assault, or at least to an attempt at one ; but the statement of the eldest of these children (12 years) that she was assaulted by a man while asleep on a stair seemed very questionable, owing to the extremely bold air of the patient. Only in two cases was the hymen found torn ; in all the others it was intact, so that a complete immissio penis could not have taken place, although the whole neighbourhood of the hymen as far as the inner surfaces of the labia was in many reddened and tender, and there was more or less fluor albus. ^ In two sisters (of 9 and 11 years) the disease was said to be derived from a syphilitic nurse. One of them had been infected by her at the age of two years, and had then transmitted the disease to her sister, who was continually with her. As the parents here were undoubtedly worthy of credit, this case may serve to impress strongly on you the necessity for caution in the choice of servants and nurses. I have also known children from two to five years of age become infected from having to do with others who were aflected with congenital syphilis, or with prosti- tutes who had taken lodgings with poor families. The source of infection in all such cases lies partly in the caressing of the children by syphilitic persons, partly in the use in common of sponges and other toilet articles and household necessaries, or in their sleeping together. The symptoms with which syphilis begins in later childhood do not essentially differ from those in adults. The only thing worthy of note seems to be the predominance of condylo- matous forms. Although I can by no means agree with Violet^ that under these circumstances syphilitic eruptions never occur ; yet I must allow that he is right in saying that mucous papules on the skin and mucous membrane constitute ' In three girls, of 4, 6, and 12 years, I observed, as the residt of an attempted assault, not indeed syphilis, biit a more or less considerable inflammation of the vnlva with fluor albus and niimerous warts on the labia. ^ Syphilis infantile: Paris, 1874. 122 DISEASES OF INFANCY. by far the commonest form of manifestation of the disease at this age. The mucous papules appear in more or less thick masses about the anus or on the labia majora, not uncommonly — partly softened and ulcerated — on their inner surface. In the latter situation they sometimes form quite nodular masses, dis- figuring the whole labium. In two girls, of 12 and 13, I have seen a thick mass of mucous papules curving backwards on each side and extending from the commissure of the labia majora as far as the anus, and laterally reaching the folds of the groin. Also, the inner surfaces of the thighs, the nates, the folds of the skin between the neck and chest, and even the outer layer of the prepuce, were sometimes the scat of these growths ; besides which, there also very frequently appeared, at the corners of the mouth, on the mucous membrane of the tonsils and of the adjacent palate (less commonly of the cheeks) whitish condylo- matous growths partly eroded and partly cleft with fissures (rhagades). The upper and under lips were likewise sometimes the seat of rhagades, with infiltrations round them. Especially frequent, however, were gummatous changes on the dorsum of the tongue, in the form of round or more angular infiltrations of the mucous membrane, varying in size ; which, by their darker colour and greater resistance, contrasted with the sur- rounding tissue. They sometimes projected above the surface, and in such cases (which were comparatively rare) they were somewhat white and opaque, or else eroded at their most prominent part. In two sisters, of 9 and 11, the almost exact correspondence in the gummatous affection of the tongue was very striking. The relative rarity of syphilitic eruptions has been already fiaentioned. That they may occur is proved, however, by several cases in which a fine scaly roseola of the forehead, of the hairy scalp, of the body and extremities, with psoriasis palmaris and plantaris, was observed. In a girl of six years old and one of four years, with condylomata of the uvula, pharyngeal ulcers and a gumma of the tongue, there was psoriasis guttata extending over almost the whole body. There was a similar eruption in a boy of 7 years, who presented at the same time condylomata at the anus, on the tonsils, and in the middle line of the palate. The lymphatic glands were usually slightly enlarged and moveable, and in several cases most of the visible glands (the IlEr.EDITAKY SYPHILIS. 123 cervical, occipital, cubital and inguinal) were distinctly swollen. I have often observed affections of the osseous system. A girl 12 years old, brought 26th June, 1879, had complained for a year of violent pains in the right upper arm, especially during the night. The humerus was swollen to twice its usual size, largest towards the middle, uneven and angular, very tender on pressure. At the age of three years, syphilitic infection ; later, affections of the throat (?). A few glands in the neck and in the axilla enlarged. Child previously treated, but disease ahvaj'-s recvirs. Further course unknown. A girl of 11 years, brought 3rd November, 1874. For IJ years very tender swelling of considerable size on the right tibia ; and violent pains at night. Glands under the jaw enlarged. No other syphilitic symptom. Pot. iod. On 25th, marked improve- ment. On 20th July, 1875, no trace of former trouble. In the course of the following year (the girl was under treatment at the polyclinic for mitral incompetence) repeated slight relapses, re- quiring the renewed use of pot. iod. A boy of 7 years, brought 15th February, 1876. Mother syphilitic. During the last 8 weeks a somewhat pointed exostosis has gradually been growing on the spina mentalis. It is now the size of a pigeon's egg — scarcely tender, and has already occasioned an abscess of the superjacent integument. Swelling of the bones of the nose, dry coryza, enlargement of glands. Already he has had repeated syphilitic symptoms. Did not return for treatment. Considerable defects in the pharynx, complete destruction of the uvula, adhesion of the soft palate to the back wall of the pharynx, destructive ulceration of the nasal septum and of the hard palate, I have only exceptionally observed. The alteration of the teeth which has been strongly emphasised by Hutchin- son (the upper incisors short, narrow, widely separated, and notched) and is said to be connected with an alveolar periostitis, I should not regard as a certain sign of syphilis tarda — all the more because this condition of the incisors occurs not uncom- monly in children who are absolutely free from syphilis. In the same way the further working out of this idea by Parrot^ seems extremely questionable ; I should be much more inclined to regard the alterations in the form of the teeth as rachitic. Syphilitic caries of the bones of the skull, and the formation of ^ummata in the brain I have never observed ;" but I have ' Gaz. des hopif., 1881, No. 74, 78, 80. * Cf. Demme, No. 20. Jahresbericht, &c., S. 80. 121 DISEASES OF IXFAXCY. certainly often seen amyloid degeneration of the liver and kidneys, of which I shall speak later. The treatment in every case was mercurial, except in the very rare instances in which there was nothing but a bone affec- tion. In these cases we first tried iodide of potash, which rapidly relieved the pains and reduced the swelling of the bones, but hardly ever prevented relapses. In other cases we at once had recourse to mercury, either in the form of inunction with mercurial ointment (grs. x. — xx. daily), of which, on an average, 5i or .5ii were used; or else injections of perchloride of mercury (gr. ^V — A)» which were continued for about a fortnight, and only once, in a boy of 4 years old, caused a moderate degree of mercurial stomatitis. Mucous papules were efiectually treated by touching with nitrate of silver, or by dust- ing with calomel. IV. — TIi.c Dyspeptic Conditions of Infants. Before turning to the morbid conditions which I class together under the term "dyspeptic,"' I must direct your attention to a symptom which appears, certainly, to be pathological, but which occurs so frequently, that we can scarcely regard it as such — I mean the vomiting of infants. This is entirely due to over- greedy sucking either of the breast or of the bottle, whereby the stomach becomes overloaded, and then gets rid of the surplus milk by a kind of regurgitation without much apparent effort. According as this takes place immediately after sucking or after an interval of some minutes, the milk returns either uncurdled or, more frequently, mixed with curds. This may be repeated after each sucking, or may occur more rarely ; depending iipon the amount of nourishment which the child takes. Movements, e.g., rocking the child on the arms &c., favoul'S the process, which, as I have said, occurs in innumerable children and seems to be an appointment of Nature's to guard against the develop- ment of dyspeptic conditions by the speedy discharge of the surplus quantity of nourishment. This regurgitation is favoured by certain characteristics peculiar to the stomach of infants up to about the 10th month ; namely by its more vertical position as well as by the small development of the fundus and of the greater curvature as compared with their development in later DYSPEPTIC CONDITIONS OF INFANTS. 125 3'ears — owing to which the capacity of the stomach is relatively smaller. So long, therefore, as the children remain, in spite of this vomiting, healthy and thriving in other respects, there is no occasion for medical interference. We may reassure the anxious mother, advise her to give the child the breast or bottle at longer intervals and for a shorter time, to let it lie quietly in bed immediately after sucking — and especially forbid all violent movement of the child. Improvement will generally soon take place, and will be favoured in some degree also by the further normal development of the stomach.' Not uncommonly, however, cases occur in which the vomiting, which at first seemed to be merely of this simple form, assumes more serious significance, Avhile at the same time weighing the child shows that it has ceased growing, and very soon the signs of incipient atrophy prove that we have to do with some- thing more than a mere regurgitation of surplus milk. Under these circumstances vomiting takes place even after com- paratively small quantities of milk. It is only after much persuasion on the part of the nurse that the child can be got to suck for a short time ; and even then there is vomiting im- mediately or shortly afterwards, of uncurdled or but slightly coagulated milk. In such cases the physician may remain for some days in anxious doubt as to whether he has to do with a dyspeptic condition or with the commencement of a cerebral affection, especially of tubercular meningitis. I intend to return to this in describing that disease, and shall only mention here that the vomiting of dyspepsia is usually preceded and accompanied by eructations which betoken an amount of gas- formation in the stomach, unusual at this age and that it may have a sour or offensive smell. As a rule, the vomited milk is mixed with more or less tough mucus — a feature which I consider of especial importance. In the first days, or even weeks of this condition (which I call dyspepsia gastrica) the motions may retain almost their normal condition ; or at most present a greenish or brownish colour. But generally they also are mixed with mucus and have an unusually oßensive smell. Their ' Uffelmann {Handbuch dtr priraten u. (Jfentl. Hygiene des Khides : Leipzig, 1831, S. 233) gives a case of vomiting in an infant which was caused by wash- ing out its bottle with leaden shot. The milk contained lead and traces of arsenic. In obstinate caseS; bear such possibilities in mind. 126 DISEASES OF INFANCY. frequency, however, is usually not increased. As a rule, these children suffer much from flatulence, and before this is got rid of the abdomen is generally much distended, especially in the region of the transverse colon. In another set of cases (dyspepsia intestinalis) there is either no vomiting at all, or it is so infrequent as to be of secondary importance. The dyspeptic symptoms manifest them- selves in connection with the intestines. Many children take violent fits of screaming, writhe, turn up their eyes, and exhibit "lightning contractions," or convulsive trembling of the arms and legs, and do not become quiet until some of the flatus has been discharged with a loud noise (colica flatulent a*). The motions, which at first had the appearance described above, soon become looser and more frequent, and contain a quantity of yel- low or gi-eenish coloured flakes and lumps, consisting of casein, lime-salts and fat, with more or less tough mucus. They have a greenish (even a spinach-green) colour (biliverdin) , and have either a sour, or oftener a highly offensive ammoniacal smell. - In the 24 hours there may be 15 — 20 such stools, for the most part with a strong acid reaction ; but usually their number is limited to 5 or 6, at least in the early stage of the disease. The appetite is diminished ; the tongue is sometimes clean, at other times covered with a greyish-white fur. The secretion of urine is diminished. Whenever such symptoms are observed in an infant, you must at once carefully investigate their causes. For only by their removal, and not by medicines, is the dyspepsia to be perma- nently cured. In the first place we have to consider how the child is fed ; because as a matter of experience improper feeding is almost always the cause of such derangements. Hand -fed infants are, as a matter of course, the most frequent subjects of this dyspepsia. Bad quality or adulteration of the milk is often to blame ; still oftener, feeding with unsuitable farinaceous substi- tutes for milk at a period when the secretion of saliva is not ' That infants may also have colic from other causes— e.y., from lead- poisoning — is shown by some cases published by Loewy (Wienei' med. Presse, 1883). The causes were : — the use of rouge containing lead by the nurse, lead- fomentations to sore nipples, and a lead stopper lying in the bottle. ■■^ Whether the colour is due to excessive production of acid, as is usually sup- posed, or to alkaline decomposition (Pfeiffer) is not yet settled. The influence on the colour exerted by the bacillus which has been described by French writers (Hayem and others) is even more in need of confirmation. DYSPEPTIC CONDITIONS OF INFANTS. 127 sufficient to justify their use. You must direct special attention to those feeding-bottles, so much in use among the poor, the mouth- pieces of which communicate with the interior of the bottle by a narrow indiarubber tube. Owing to insufficient cleaning of this tube, so that remains of milk-curd are left in it, the milk taken by the child is charged in passing through the tube with the germs of fermentation and the causes of dyspepsia. I have observed this so frequently in the polyclinic that I absolutely forbid the use of such feeding-bottles, unless assurance of the most careful cleanliness can be given. But even children on the breast are by no means exempt. An alteration (even although incapable of chemical or physical demonstration) of the milk of the mother or nurse — whether due to disturbances of temper, or excessive bodily exertion, want of nourishment, or recurrence of menstruation — may, as experience shows, produce dyspepsia in the child. From among many others I may men- tion as a striking example, a child of 4 months who throve splendidly with his nurse, until she got suppurative tonsillitis, which caused her very great pain and kept her from sleep. The child forthwith had diarrhoea, 5 — 6 loose, green, foetid motions daily, until the tonsillar abscess burst. From that day the child's dyspepsia disappeared. I have already mentioned that the most inconceivable errors in the feeding of children are of quite common occurrence among the lower classes, although comparatively rare among educated people. Little children who are being fed from the breast or bottle are often allowed to share in the ordinary food of the family — potatoes variously cooked, cabbage, peas and beans, apples, grapes or plums are very often given to these children ; and I have also had cases Avhere sausages, pancakes, &c., had been used as food. In such circum- stances one cannot wonder that dyspeptic conditions are amongst the commonest of infantile diseases, especially among the lower classes. This disease is particularly apt to occur at weaning, when there comes a change of food — whether this takes place only at the end of the first year or, through the force of circum- stances (arrest of mammary secretion, or illness) a few months aftar birth (d i a r r h oe a a b 1 a c t a t o r u m) . What, then, is taking place in the stomach and intestine ? This question has received different answers at different periods. The view generally prevalent in former times, of an " acid- 128 DISEASES OF INFANCY. formation " in the digestive organs, founded upon the sour smell of the mouth and on the acid condition of the green stools, gave })lace, when pathological anatomy came more to the front in our science, to the anatomical explanation that a "catarrh" of the gastric and intestinal mucous membrane was the cause of the dyspeptic symptoms. At a later period, there was a return to the chemical theory — which in my opinion is the only correct one. We have here, obviously, fermentative and septic pro- cesses in the contents of the stomach and intestine, the final result of which is the excessive production of lactic and fatty acids. The exact manner in which this process takes place cannot yet be laid down with certainty. Although the action of certain bacteria, v.hich gain entrance to the stomach along with the milk and excite fermentation especially in the sugar contained in it, is rendered very probable by the most recent researches,^ still we must also recognise that food which is difficult of digestion or even irritant, may by direct irritation cause in the first place a catarrhal condition of the stomach and intestine, with copious secretion of mucus. Then, through the alkaline nature of this mucus, the hydrochloric acid of the gastric juice which is neces- sary for normal digestion is neutralised, so that it can no longer operate upon the contents of the stomach in the normal manner ; and there result fermentative processes, with the excessive ])roductiou first of lactic and finally of butyric and fatty acids. These processes either come to an end in the stomach (d. gastrica), or (which is more common) extend still further downwards into the intestinal canal (d. intestinalis). For we can easily understand that if all the fermenting contents of the stomach are not evacuated by vomiting, the fermentation must pursue its course as soon as the abnormal contents with their germs of fermentation reach the intestine and come in contact with its contents. The sourish smell from the mouth, the masses of mucus in the vomit (which also generally smells sour), the foetid evacuations, their irritating character (which is apt to occasion erythema round the anus), the flatulence and jmssage of fiietid gases by the anus, as well as the flatus discharged from the stomach — all these symptoms constitute the clinical manifesta- tions of the abnormal chemical process. I shall here say nothing at all of microscopic inspection of the vomited matters and the ' Eschei'ich, Die 1 »armhacterien des Süttglings, 1S86, S. lit». DYSPEPTIC CONDITIONS OF INFANTS. 129 ■motions ; because, in spite of many researches, some of which are most worthy of recognition, we have not j^et been able to establish with certainty the forms of the micro-organisms with which we are here specially concerned. Besides, for the practical physician this difficult and tedious examination is unnecessary, since the clinical and etiological relations are all that is required for diagnosis. Sometimes such an enlargement of the stomach occurs as to be distinctly recognisable by the eye and by pal- pation. In such cases I have observed offensive eructations and flakes of a yellow (butter) colour in the mass of milk and mucus Avhich was incessantly being vomited. The introduction of a simple stomach tube (Nelaton's catheter), which I have repeatedly tried in those cases, and always easily managed, at once brought about the evacuation of these masses, and invariably caused a rapid collapse of the greatly distended epigastrium. These fermentative processes are, however, by no means peculiar to early infancy. At a later age, also, even in adults we often enough see similar processes occur owing to overloading of the stomach with food and drink, injurious in its quantity or quality. These conditions are described under the names of status gastricus, biliosus, saburralis, diarrhoea stercoralis, &c. But while in older children and adults the morbid process generally ends with the discharge of the fermenting substances upwards or downwards, and therefore almost always is quickly over ; this rapid termination occurs in infants only when the diet is at once regulated as it should be. Limiting the amount of food by less frequently giving the breast, substituting for it boiled water with a little gum-arabic dissolved in it, feeding with a solution of white of egg or with greatly diluted cow's milk, often suffice to remove the complaint in a few days. But, unfortunately, the conditions are frequently ill-adapted for protecting children from fresh attacks of the same kind. Only too often the dyspeptic symptoms are disregarded for a long time, and «mong the lower classes usually referred to teething, with which they have nothing at all to do. Without calling iu a medical man, the mothers attempt to remove them by giving farinaceous food — oatmeal-water, gruel, clc — and in this way matters grow worse. Thus the unnatural foetid evacuations, and often the vomiting also, last for weeks, resulting in steadily in- creasing atrophy, as I have described (p. 71). The further 9 130 DISEASES OF INFANCY. course is determined chiefly by the patient's circumstances, i.e. by the possibility of obtaining suitable feeding and treatment. The case may go on alternately getting better and worse for months, according as the physician's orders are followed more or less completely. Finally, an anatomical change is added to what was originally only a chemical one, since the prolonged irritation of the fermenting contents must necessarily induce a permanent catarrhal affection of the mucous membrane. At the post-mortem of such children we find areas of hyperaemia and swelling of the mucous membrane, in which both the solitary glands and the Peyer's patches project more than usual above the level of the mucous membrane — in a word, the appearance of chronic intestinal catarrh, to which I shall refer more particularly further on. In judging of this in any given case, we must never lose sight of the fact that we have here to do not with a primary .disease of the mucous membrane, but with a secondary aff'ection which must be regarded as arising from a chemical process. So7Tietimes too although the disease has lasted for months the change in the mucous membrane is extremely slight, and only discoverable on careful examination. A special kind of dyspepsia has been recently described by Demme^ and more especially by Biedert^, under the name of "fat-diarrhoea." This is characterised by the copious discharge of motions, poor in bile, with a shining, fatty look or even an asbestos-like appearance. The chemical examination of these reveals a great increase in the amount of fat (40 to 67 per cent, of the dry substance) ; while even by the microscope a consider- able increase of fat is made out. This condition, which may occur with either natural or artificial feeding, and which if chronic must lead to atrophy, is referred by Biedert to a catarrh of the duodenum hindering the fat-digesting secretions (bile and pancreatic juice) from entering the bowel, so that most of the fat in the food is discharged in an undigested state and nutrition suffers materially. Although I have myself repeatedly observed such fatty motions, yet in the absence of chemical and anatomical research I am not in a position to criticise the pro- priety of regarding this "fat-diarrhoea" as a separate form of dyspepsia. I shall only remark that the absence of jaundice ' Jahresher. des Jenner^schen Kinderspitals von, 1874, 1877, 1880, 1882. * Jahrb./. Kinderheilk ., Bd. xii., xiv., &c. DYSPEPTIC CONDITIONS OF INFANTS. 131 seems to me to tell against Biedert's view. Indeed, the con- siderations against it formerly brought forward (by Uffelmann) have received fresh support from recent researches' into the variations in the amount of fat and its occasional presence in large quantities in the faeces of healthy infants and those suffering from diarrhoea or from febrile affections. The whole question, then, is not yet ripe for judgment, in spite of seeming therapeutic results — to which I shall return soon. When the dyspepsia of infants is acute from the beginning, it commences, sometimes, with such violent symptoms that after some days a critical and even fatal state of exhaustion may ensue. The clinical picture is then very similar to that which you will become acquainted with later on, in the description of cholera infantum. But the cases to which I here allude all occurred sporadically, and in the winter time, — that is to say, at a time when true cholera does not usually appear. Here also the cause may almost always be found in faults in the feed- ing of a very obvious kind ; and this also happens in well-to- do families, where utterly undigestible dainties are given with the best intentions to little children by indulgent relatives or by servants. Violent vomiting, profuse, loose, foetid evacuations (following one another in rapid succession and becoming more and more clear and colourless), intense thirst, alteration of the features, a very marked sinking-in of the eyes, low temperature of the skin, disappearance of the pulse and depression of the fontanelle, and finally convulsive fits, occur as in cholera — where, however, these symptoms are due to an epidemic and presumably infectious influence. The cause of the rapid col- lapse lies probably in the violent watery diarrhoea and vomiting, caused by the irritating action of the fermenting substances on the mucous membrane, and by the reflexly-increased peristalsis. This very great loss of water explains on the one hand the rapid re-absorption of the fluids of the body, which causes the sinking in of the features and the depression of the fontanelle, and on the other hand the extreme weakness of the heart which finds expression in the apathy and somnolence (arterial ansemia and venous hyperaemia of the brain) with the disappearance of the pulse and the fall of the temperature. Such cases may be just ' Tschernoff, Jahrb. f. Kinderhdlk., Bd. sxii., S. 1.— Kramsztyk., ibid., S. 270. 132 DISEASES OF INFANCY. as fatal as epidemic cholera in the summer months. Still, as a matter of experience, their prognosis, generally, is more favour- able, because when the deleterious contents of the bowel have been expelled with violent symptoms, the disease usually ceases and the child again recovers strength. In the event of a fatal issue the post-mortem shows, as a rule, either extremely slight catarrhal changes in the mucous membrane of the stomach and intestine, or none at all ; at times only an extreme paleness, corresponding to the general anaemia, with perhaps slight swelling of the follicles. Under these circumstances we must always be prepared to meet with the peculiar alteration of the stomach which, under the name of " gelatinous softening of the stomach (gastromalacia)" has occupied physicians for many years. The slightest degree of this — and we meet with it pretty often — consists of a pulpy softness of the mucous membrane of the fundus and also of the posterior wall of the stomach, so that it can be scraped away with the handle of the scalpel like a thick solution of gum. Thus, the parts affected are just those which in the usual position of the dead body, are most exposed to the action of the stomach's contents. Less frequently, the softening affects all the coats of the stomach, and they are then transformed into a kind of grey, reddish, or dark brownish semi- transparent jelly, which has the smell of butyi'ic acid and reddens litmus-paper. Generally, they are still held together by the serous coat ; but this also may give way previous to the post-mortem ; and we then find in the situation of the fundus, nothing left but a few fragments mixed with jelly-like masses and the contents of the stomach. There is not a trace of any inflammatory process to be found anywhere ; and the micro- scope shows in the softened parts only some epithelial cells mixed with a mucus-like substance, and a few blood-vessels still intact and filled with dark clots. The question so long disputed as to whether gastromalacia is really a disease or merely a chemical alteration of the stomach which takes place after death, is now unquestionably settled in favour of the latter view. We have here to do with a post-mortem digestion of the coats of the stomach by its contents, and we can therefore only expect to find it where food had recently been taken and death misued during digestion. Thus also is explained the fact that some- DYSPEPTIC CONDITIONS OF INFANTS. 133 times not only the fundus of the stomach but also the contiguous organs — spleen, left kidney, omentum and diaphragm, and even the lower lobe of the left lung, are found more or less digested and softened. We can easily explain how this condition was in former times regarded as morbid and furnished with a complete symptomatology, corresponding exactly with that of acute dyspepsia, or cholera. For in these diseases abnormal fermen- tative processes of the stomach's contents form the chief feature, and hence after death a destructive influence on its walls will be much more easily exerted than in other morbid conditions. The fatal results which we have seen ensuing in dyspepsia neglected at its commencement, make it our duty to enter at once upon serious treatment of the case, which can only be carried out with a fair prospect of success where the circum- stances of the little patients are favourable and our orders are carefully attended to. To the children of the poor, our aid often comes too late ; and even when it is sought in time we meet with hindrances hard to remove — chief amongst which is the lack of proper nourishment. In acute cases, we often reach the sick-bed only after nature has by violent vomiting and diarrhoea already got rid of the injurious contents of the alimentary canal. We now find the child simply exhausted, and we have nothing further to do but to superintend the regulation of the diet. If the child is on the breast, we must first — if no positive defect can be found in the diet — keep in mind the possibility of an injurious change in the milk. Changes of temper and over-exertion on the part of the nurse, occasion only a temporary change in the milk; and the child may therefore be put back to the breast whenever the dyspeptic evacuations have ceased. We must, how^ever, espe- cially guard against over-feeding, which is only too often to blame in cases of dyspepsia. Mother's milk requires two hours, at least, for its digestion ; cow's milk certainly longer. And these intervals must therefore be carefully observed, before the child is fed again. ^ Unfortunately in practice one often meets with foolish obstinacy on this point ; but the researches of ' Although Epstein, (Archir f. KinderheiUc, Bd. i v.), found on washing out the stomach of several healthy children of several weeks old, who had drunk 1^ 2^ oz. of their mother's milk, that the stomach was usually empty after 1 — IJ hoiirs— still, I cannot make up my mind to change from the practice above recommended. 134 DISEASES OF INFANCY. Uiedert' (who provetl that the amount of nourishment taken in the first months, especially hy hand-fed children, often far exceeds the amount really needed) show how very necessary it is for us to do all we can to check this foolish popular error, and to reduce the quantity.- Cnder these circumstances I have seen attacks resemhling collapse in infants, also pallor, and symptoms like those of fainting, and these rapidly disappeared when the superfluous milk was vomited up. Restriction of the amount of nourishment is all the more necessary when dyspepsia already exists. It is therefore always well to forhid the breast entirely for 24 — 36 hours ; or only to allow it to he taken less frequently than usual ; or to give instead of it a little gruel or barley-water, or, still better, the solution of white of egg, recommended by Dem me (the whites of 2 eggs to 1.^ pints of water with a little sugar and cognac). Should the recurrence of menstruation in the nurse always occasion dyspepsia in the child, there remains no remedy except a change of nurse or weaning. However, in the majority of cases I have observed no bad effects on the milk from menstruation ; and therefore I have but seldom had occasion to dismiss a nurse on this ground. It is the same with acute diseases of the nurse : which as 1 have shown you from a striking example (p. 127) may possibly originate dyspepsia, but by no means do so invariably. It is only when the acute disease of the nurse is presumably to be a short and slight one, that we may put the child who is suffering from dyspepsia on the bottle for the time being. But if such is not the case, you must at once try to procure another nurse. Should the child, however, be hand-fed, you will — after the attack is over — cautiously try again its usual food, if you consider it suitable. If relapses occur, a change of food must, naturally, be tried ; and in this case the first question for consideration is ^^hether we should now have a wet-nurse, inscead of the artificial feeding which has been used since birth or for some time past. If the parents' circumstances allow it, you should advise a nurse. It is true that there are many difficulties to be met in such a case ; for the children, having become accustomed to the bottle and the ease with Avliich the milk flowed from it, prefer it to sucking the ' Jahrb. f. KinderheilL, xvii., S. 251, 288 ; six., S. 291. - Excessive quantities of milk will naturally also cause an increase in tte amount of urine. Polyuria results, which occasions obstinate intertrigo in the neighbourhood of the geuiial-s and anus. DYSPEPTIC CONDITIONS OF INFANTS. 135 In-east, to wliicli they are unaccustomed and which they often positively refuse. Still, if we only have patience, we shall generally succeed in getting over this difficulty and accustoming the child to the breast. I have seen children even 3 — 4 months old, who had been hand-fed from birth, take to the breast without much ado. Of course the thing is not always at an end even then. For the nurse's milk may, for various reasons (p. 127), disagree with the child and occasion dyspeptic symptoms ; so that a new nurse has to be provided. Cases are by no means rare of such a child having three or more nurses in succession, before a suitable one was found. The guiding rules for the dietetic treatment of infantile dyspepsia can only be laid down in a very general way. For you will often come upon cases in which, through obscure causes, the application of these rules becomes impossible, and such must be treated on some other method. Thus, I have sometimes had cases of dyspepsia which persisted in spite of a repeated change of nurse, and yielded only on the children being weaned. With others who have hitherto been exclusively hand-fed, even cow's milk (which I have always regarded as the best substitute for the breast : p. 81) caused dyspepsia, so that one had to give it up or replace it by some other form of nourishment such as the above-mentioned (p. 84) infant foods. At the same time the idea of many physicians that good cow's milk is not digested under such circumstances, is not generally justified. I advise you to be guided here, less by theoretical opinion than by practical experience, and to make repeated trials with cow's milk before having recourse to any other substi- tute. How frequently have infants with dyspeptic diarrhoea been brought to me, who, through dread of cow's milk, had been fed only on oat-meal water and thin gruel, and who were in conse- quence becoming more and more wasted. I confidently advised that they should be put again on cow's milk, and I have very often • seen the motions and the general condition improve every day when they did so. Experience, however, has taught me that in these cases the milk is often more easily digested cold than warm — probabl}' because it is in this state less liable to ferment. It should therefore be allowed to cool after it has been boiled ; and, especially in acute dyspepsia, should be put in ice and given to the children quite cold. Most children take it 136 DISEASES OF INFANCY. willingly, many even greedily ; and whenever tiiey begin to refuse the cold milk and again show an inclination for the warm, I regard it as a sign of returning health. As long, however, as dyspeptic vomiting continues it will be well to give the children cold milk from a spoon, because drinking it from the bottle is apt to cause overloading of the stomach and vomiting. Child of 10 montlis, weaned six weeks before, suffering Ig weeks from diarrhoea, for which hydrochloric acid had been used with varying success. On 19th December, 1864, sudden exacerba- tion, numerous loose bright-yellow motions ; occasional vomiting. Continual restlessness, slight sinking of the features, abdomeu normal, but tender on pressure. Latterly only veal-tea had been given instead of milk ; but neither this nor small doses of opium nor calomel had any favourable result. Within 24 hours there were about 20 motions and frequent vomiting ; at the same time high fever and unc[uenchable thirst. Milk and arrowroot given on 22nd caused rcj^eated vomiting and still more severe diarrhoea. I now ordered 2 or 3 dessert-spoonfuls of iced milk ever}- hour, and to quench the thirst little pieces of ice frequently and ice-cold water slightly sweetened. As medicine an emvilsion of almonds, likewise iced, was ordered in teasjioonful doses. On the follow- ing day, already a marked improvement ; rest and sleep for several hours ; pulse and temperature normal ; thirst considerably lessened. Vomiting had only taken place once, after violent crying, and the 3 motions which had been passed were perfectly normal. On 24th, complete convalescence; and the child now refused the cold milk which it had hitherto taken greedily, and again showed a desire for the usual lukewarm milk mixed with arrowroot. The anorexia, which still continued, with a thick white fur on the tongue, j'ielded in the course of a week to small doses of tinct. rhei. Child H., one year old, suffering from d3-speptic diarrhoea which had followed on weaning 14 days before. On 12th November, 1873, I found the child collapsed, cold, with scarcely perceptible pulse. Milu and all other di-inks were at once vomited ; 12 — 15 loose, brownish, offensive motions dailj'. Treatment : — iced milk in spoonfuls, 2 camomile baths dailj-, bismuthi subnitratis gr. I every 2 hours. On 14th no more vomiting ; cold milk is taken greedily and well borne. Still 6 — 7 evacuations daily, with a putrid smell. Treatment changed to creasote gtt. ivss., aq. 5 ii., a teaspoonful every 2 hours. Recover}- after four days. Such examples (of which I have now collected a large number) certainly encourage the trial of iced milk as a form of nourish- ment in the acute dyspepsia of infants. Even in this form, however, the milk has not always a favourable effect ; and it is DYSPEPTIC CONDITIONS OF INFANTS. 137 then necessary to substitute other drinks — solution of white of egg, soups, barley water, decoctions of salep, arrowroot, or " infants' food." In persistent vomiting, we may also attempt to administer the nourishment per rectum, and I have twice or thrice tried this by means of enemata of peptone (about a teaspoonful in half a cup of beef-tea). I have, however, had no success from this, probably because the very active peristaltic movements of the bowel were still further increased by the enemata, which were at once rejected almost unaltered. I have myself no experience of peptone given by the mouth, which is praised by Escherich. The washing-out of the stomach recom- mended by Epstein and others^ in obstinate vomiting of young children, which according to my experience is generally easy to perform (p. 129), I consider w^orth a trial even in older children, especially when the stomach is evidently distended, and gross errors in diet are known to have been committed. I have not yet had sufficient experience of this method to justify me in speaking decisively about it. It is certain that recovery often occurs without washing-out of the stomach ; this proceeding, however, cannot do any harm whatever, and may accelerate re- covery by rapidly getting rid of fermenting materials. Still we should be on our guard against over-estimating this method of treatment. In many of my cases, indeed, a single washing- out was sufficient to arrest an obstinate attack of vomiting ; but far oftener the treatment was unsuccessful, although frequently re- peated. The miserable condition of the majority of the patients in my children's ward may, however, be to blame for this want of success. As to medicinal treatment : — in recent cases of dyspepsia (that is, such as have not lasted more than a week), whether the dyspepsia is shown by vomiting or by diarrhoea, or by both, I should recommend calomel as the first remedy. This should be given, according to the child's age, in doses of gr. i^ — f every three hours with pulv. acaciie, grs. viii. (Form. 2). Although nothing definite can be said as to the way in which this medicine operates, its action is probably anti-fermentative. The state- ment that the calomel is changed into perchloride by the ' " Ueber MagenaiisspUlungen bei Säuglingen," Archiv f. Ki7iderheilk\,Bä. iv. Jahrb./. KindtrheiU:, xxvii. S. 113. — Lorey, ibid. xxvi. S. 44. — Ehring, ibid. xxvii. S. 258. 138 DISEASES OF INFANCY. chloride of sodium in tlie contents of the stomach and howel, is correct only in so far that such a change takes place very gradually, and only when large quantities of calomel remain in the howel for a long time. In the present cases, however, neither of these conditions is fulfilled. Let us, therefore, hold to the therapeutic action which has heen ascertained practically. Cessation of the vomiting and improvement of the motions (diminution of the foetor, and more pulpy consistence) occur frequently hy the second or third day of its use, and in many cases there is no need of any other remedy. Perhaps the purgative effect, although it is hut slight, which even such small doses of calomel have upon infants, may he regarded as a favour- able accessory action ; since in such cases, the first point is to remove the abnormal contents of the bowel as quickly as possible from the body. Should the affection have already lasted a week or longer, we cannot promise ourselves such good results from calomel as in perfectly fresh cases ; still, even in this case, the medicine is worth a trial, for I at any rate have never observed any injurious effects from its use.^ Next to calomel, in my experience, stands hydrochloric acid (Form. 3), which in not quite recent cases may also be given with good effect. The action of this medicine, as the experiments of Schottin" prove, is strongly anti-fermentative. He showed in the case of fermenting fluids in a hot jchamber, that the lactic acid — as well as butyric acid — fermentation is immediately arrested by adding sulphuric acid, and does not begin again until the acid has been neutralised by an alkali. "Hydrochloric acid acts much more favourably, because it is also able to dissolve the proteids in the stomach, and take the place of the gastric juice which is wanting." In fresh cases }ou must not add any opium, for its constipating effect is apt to cause great distension of the bowel with gas. But if several days have elapsed and the loose motions still con- tinue, you may then assume that after the injurious contents have been got rid of, there remains an irritated condition of the mucous membrane, and an increased peristalsis. When this is so, the addition of tinct. opii (about gtt. iv.— v. to the mix- ' Cf. on the action of calomel on fermentatire processes, &c.. "Wassilieflf. Zeitschr.f.phiiswl. Chemie, vi., S. 112. - Köhler, tlandb. des physiol. Thcrapevtil : Gütting-en. 1876, S. 882. DYSPEPTIC CONDITIONS OF INFANTS. 139 ture) is very beneficial — doubtless because this, by lessening the peristalsis, affords time for the hydrochloric acid to take permanent eft'ect. The results which I obtained with calomel and hydrochloric acid and published some time ago\ have since then received confirmation in innumerable cases. Nevertheless, there are still many physicians who prefer alkaline remedies, especially bicar- bonate of soda, to acids. But, although this medicine may temporarily neutralise the acid of the fermenting contents of the stomach, it cannot reach the fermenting process itself, and I can therefore recommend neither it nor other alkaline medicines. I have not experimented sufiiciently with benzoate of soda" (which is praised as an antiseptic) to be able to give a definite judgment as to its value. Being contented with the success I obtained with calomel and hydrochloric acid I have not looked for other remedies. Where these remedies fail, however, I should certainly recommend creasote on account of its strong anti-fermentative action, especially in cases in which vomiting is a prominent feature. But, if only given in sufficient doses (Form. 4), it is also effectual in those cases where, after the violent symptoms are over, there still continue to be thin, offensive motions which are not improved by hydrochloric acid. The following cases show that we need not be afraid even of large doses. A boy of 7 moutlis, band-fed. For some days back, vomiting of milk partly fluid and partly curded, with a sour smell. Also frequent sour-smelling motions, resembling '"' weiss Bier." Hydro- cliloric- acid alone, and also along with tinct. opii., was unsuc- cessful. I next tried creasoti gtt. vii., syru])i simi^l. 5 iii., aquam ad 5 ii., a teaspoonful every 2 hours. After 2 days, cessation of the vomiting, but persistence of the diarrhoea, which was after- wards cured by small doses of opium. A girl of 6 weeks, hand-fed. During the last 24 hours, diarrhoea and vomiting after every drink. The vomited matter smells very sour. Creasote, gtt. iv. in 5 ii., a teaspoonful every 2 hours. After 4 days, only 1 — 2 normal motions ; no more vomiting. In children, therefore, of six weeks and seven months re- spectively the dose was | and | drop ; since ,^ii. of fluid represent about 16 teaspoonfuls. Besides the drugs I have ' Beiträge zur Kinderkeilk ., X.F., S. 293. - Escherich. Centralbif. Baclerioloyie v. s, w., ii.. 1£S7, No. 21. 140 DISEASES OF INFANCY. named, which in my opinion occupy the first place among the remedies for this disease, I have also made trial, both in the hospital and in private practice, of other medicines which have a high reputation for their antifermentative action — namely, chloral hydrate (1 per cent, solution or more), carbolic acid, aqua chlori and resorcin. The first of these was suc- cessful (although not invariably) in cases of dyspeptic vomiting. The other three I have quite given up ; and I consider the continued use of carbolic acid especially, as not unattended with danger. Naphthalin, which has been occasionally praised very recently, I have not seen occasion to use from the reports given of it. Just as little did the pepsin (so much recom- mended of late) meet my expectations ; and this may perhaps have been because we are unable to determine the indications for its administration in each individual case. This remedy, how- ever, can evidently be of use only where the dyspeptic fermenta- tion is produced either by diminished secretion of gastric juice or at least by a deficient amount of pepsin in it. These changes can only be estimated (and that merely approximately) when the contents of the stomach are removed by a tube and examined chemically, which generally is quite impracticable in ordinary practice. Under these circumstances, the use of pep- sin in infantile dyspepsia must always remain an experiment which we can try either at the beginning or after other remedies have been used without result, but one whose success is to be regarded merely as a happy chance. I prescribe pepsin either alone (gr. i. — iss.) or along with hydrochloric acid (Form. 5) in the form of the essence of pepsin to be had of any chemist. Naturally, pepsin can only exercise its effect where substances containing protein — especially milk — are still being taken. It must therefore always be given half-an-hour before or after food. Kichard K., 10 weeks old, hand-fed, poorly nourished, brought 7th December, 1866. For some days back, no sleep, frequent colic, daily 10 — 12 loose green motions, excoriating the anus ; slight flatulent distension, no vomiting, no fever. Calomel used, without result. Pepsin, (gr. i. 3—4 times daily) brought about recovery after 12 doses. On 13th April, 1867, brought again to the poly- clinic on account of vomiting whenever food was taken. This had lasted for some weeks. Thrush in the mouth. Pe])sin. gr. i. 4 times daily. By 16th marked abatement of the vomiting; on 23rd, comjjletc recovery. DYSPEPTIC CONDITIONS OF INFANTS. 141 Girl of 15 weeks, brought 6tli May, 1873— hand-fed. For 4 weeks past, vomiting (especially frequent after taking milk) and diarrhoea. Great restlessness, a certain amount of wasting, great thirst, motions very offensive. Pepsin, gr. i., 4 times daily. Recovery on 14th. Now only 3 normal motions daily. Boy of 6 weeks, on the breast, brought 19th Jan., 1874. Violent vomiting after each drink; frequent green offensive evacuations. Calomel without effect. On 24th, pepsin, grs. xv., aq. destill., syr. simpl., ana 3 vii., acidi hydrochlor. gtt. x., a teaspoonful every 2 hours. On 27th, vomiting much less frequent, and not till 10 or 15 minutes after taking the breast. Motions better. Pepsin increased to grs. xxiii. in the mixture. Recovery on 31st. Thus we see that under certain circumstances pepsin has good results ; and we may in dyspepsia have to try, one after another, all the remedies which are accredited by previous practice. In one case one drug, in another another, will prove the more effectual, without our being able to discover the reason of this diiference. Besides the remedies already named there are several others, which will be described under the heading Diarrhoea; especially subnitrate of bismuth (magisterium bismuthi). The suitable time for the administration of this drug is, I think, the moment when the presence of particles of mucus in the motions indicates that the chemical processes are beginning to cause a catarrhal condition of the mucous mem- brane of the intestine. To children in the first year bismuth, subnit., gr. § — gr. iii., with pulv. acaciae, grs. viii., may be given 5 — 6 times daily ; and when the disease has lasted for a week I have often seen an increased effect from the addition of extr. opii., gr. ^\. Later on, also, if the symptoms of chronic intestinal catarrli are becoming constantly more apparent, bis- muth proves to be one of our most reliable remedies. Nitrate of silver, also, (gr. I in 5iiiss.) undoubtedly does good service in many cases of dyspeptic diarrhoea, and is therefore always worth a trial when the disease is very obstinate. After recovery, I recommend rhubarb as a tonic for the digestion. It should be used for some weeks in the form of vinum rhei (gtt. v. — xv., 3 — 4 times daily, according to age).^ ' I have no experience of transfusion, which Demme (18. Bericht über die Thätiffkeit des Je7iner' sehen Kinderhospitals., 1880, S. 42) has tried frequently (5 grammes of blood, 5 — 8 times) and with partial success. Demme himself speaks very reservedly about this method, which is said to raise the depressed nutrition. 142 DISEASES OF INFANCY. V. Coryza of Inf a n is . The extreme sensitiveness of the mucous membrane of the nose in infants is shown to a marked degree in the new-born child, in whom soon after birth and in the first weeks of life contact with the air excites frequent reflex sneezing. Any chill affecting the child, especially from carelessness in washing or bathing it, readily occasions a coryza with snuffling l)reathing and watery mucous discharge which, if cleanliness is not care- fully attended to, dries into yellowish-brown crusts about the nostrils^ and interferes with the entrance of air. This tendency to coryza is also found in infants throughout the whole of the first year. After what I have already said (p. 93), you will under- stand that in all such cases a suspicion of hereditary syphilis occurs to the physician — especially as coryza may form the very first symptom of syphilis and precede all its other manifesta- tions by weeks. For this reason we are obliged in every pro- tracted case of coryza, to examine the child and its parents in regard to this matter ; so that, should our siTspicion be confirmed, specific treatment — which in that case alone is of any use — may be commenced. Now, although syphilitic coryza may bring with it the same risks as any ordinary non-specific coryza — still, this very seldom happens. In most cases it is only one link in a chain of symptoms, and does not claim to be of specially great signifi- cance. Serious symptoms, which may become fatal in various ways, occur far more frequently in the simple coryza due to a cold. The danger to the child lies chiefly in the fact that the coryza may at this age extend downwards with great rapidity, to the mucous membrane of the larynx and trachea, and even to that of the bronchi. Hoarseness of the cry, coughing, fever and dyspnosa often develope within a few days. Examination then shows more or less wide-spread bronchitis or broncho-pneumonia. On the other hand, the catarrhal swelling of the mucous mem brane of the nose which causes considerable contraction of the child's already sufficiently narrow nasal cavity, may result in more or less extreme dyspnoea. This gives an alarming character to any tracheal or bronchial catarrh which is combined with coryza, even when percussion and auscultation do not seem to justify COKVZA OF INFANTS. 143 apprehension. But even in cases of simple uncomplicated coryza wo sometimes Lave sudden attacks of dyspnoea, which are apt to perplex the physician who has been hastily summoned and is unacquainted with the child's previous condition. Bouchut describes symptoms of asphyxia as having occurred in the following way : — The child was unable to breathe through the obstructed nostrils ; it had, therefore, to breathe through the mouth with such force that the tongue was suddenly jerked back during the process, and the lower sm*face of its tip pressed against the hard palate, thus necessarily obstructing the passage of air into the. throat. This explanation of the sucking-in of the tongue by violent inspiration is held by many authors — among others, by Kussmaul and Hon sell ;^ and the possibility of its occurrence, especially when the frenum is long and loose, cannot be denied. Personally, I have only once met with this indrawing of the tongue. It was not in a case of coryza, but in a violent attack of spasmus glottidis in which I could only with difficulty reach the root of the tongue with my forefinger, it being firmly pressed against the palate and curled upon itself. In coryza of very young children I have always been obliged to regard the dyspnoea as the result of the blocking of the nasal cavity ; and in very acute cases I have known it reach such a degree that it might have been mistaken for croup.- In March, 1861, I was called to see a child of 7 Aveeks, who had been attacked by violent dyspnoea about 1\ hours previously. According to the account given by the alarmed parents, the child had been perfectly well a few hours before and had been taken out in a strong east wind. Almost immediately after returning, the attacks had come on without any evident occasion — not even that of sucking. As the worst of it was over by the time I arrived, I thought it might have been an attack of spasmus glottidis, and in order to decide this I had the child put to the breast. At once a fresh and even more violent attack resulted, almost as severe as one sees in croup. With an expression of extreme anxiety on its cyanotic face, with open mouth and violent action of all the inspi- ratory muscles, the child gasped for breath ; and at each gasp a whistling noise was heard which obviously proceeded from the nose. The cavity of the jaharynx was completely free. After a few minutes, a gradual cessation took place, sleep soon following — ■ » Henle's und Pfeuffer's Zeitschr. 3 Reihe., Bd. xxiii., S. 230, 1865. ■^ In a case of syphilitic coryza given by Has sing {Jahrb. J'. KinderheilJc., xxiii.. S. 'ißQ). it was even necessary to perform tracheotomy. 144 DISEASES OF INFANCY. during wliicli both inspiration and expiration wore accompanied by a snuffling noise. The lower part of the nose was somewhat swollen. During the next 12 hours I had the child fed only with the spoon, had warm oil rubbed over the bridge of the nose, and gave calomel, gr. J, every 2 hours. During the following days a mu co-purulent discharge made its appearance from the nose, but disappeared again after a few days. In cases of this kind — which are always rare— the rapid development of catarrhal swelling of the mucous membrane is especially noteworthy, being analogous to that which so frequently occurs during the night in adults in the course of a violent cold in the head (especially when in a recumbent position) and inter- feres with breathing through the nose. Here also the secretion is arrested when the swelling increases ; and, as a rule, raising oneself to a sitting posture is the first thing to bring relief, as everyone has probably experienced for himself. In the case just mentioned also, the dyspnoea was best relieved by carrying the little patient about in an upright posture. To my mind, there is a decided analogy between these cases of acute coryza, so-called false croup, and certain very acute attacks of bronchial catarrh to which I shall have an occasion to return later on. According to the recent experience of specialists, it is conceivable that catarrhal irritation of the mucous membrane of the nose may also excite reflexly a spastic contraction of the bronchial muscles ; and this may give rise to such violent symp- toms as in the case just given. Another danger lies in the interference with sucking. The child during this act has to depend upon breathing through the nose, and finding this no longer possible, has to let go the nipple or mouthpiece of the bottle frequently in order to breathe through the mouth ; and in this way its nutrition is in course of time seriously interfered with. For the same reason, in severe coryza it is during sucking that the violent attacks of dyspnoea occur. Coryza nearly always attacks both nasal cavities at once. It is but rarely limited to one side. For example, I observed, in June 1874, a child of 8 weeks, formerly perfectly healthy and certainly free from any suspicion of syphilis, which had suffered for about a fortnight from a yellowish watery discharge from the right nasal cavity, w4iile the left was quite unaffected. Pressure on the right side of the nose promoted the discharge. Along with this there was snuffling respiration and dyspnoea during RETRO-PHARYNGEAL ABSCESS. 145 sucking, so that the child was often obliged to let go the nipple. Brushing out the right nasal cavity with a solution of nitrate of silver effected a cure in 14 days. The examples given contain all I have to say to you on the treat- ment of coryza. The nourishment of the child demands your attention above everything else. If sucking is interfered with by dyspnoea, you must either have the mother's milk artificially drawn off, or have cow's milk given with a spoon ; and I have always found this satisfactory. A case recorded by Kuss- maul is likely to remain unique : — a child of 6 months having to be fed for a whole week by means of an oesophageal tube, owing to the drawing-in of the tongue already spoken of. For internal use in very acute cases of coryza, I recommend calomel, gr. I — i, every 2 hours, even where there is no suspicion of syphilis. In slighter attacks, however, we need do nothing beyond keeping the lumen of the nostrils free by applying oil and removing the scabs. If the disease takes a more chronic course, good effects will be gained by painting the inside of the nose with a solution of nitrate of silver (2 per cent). We shall discuss later on diphtheritic coryza, which is by no means rare during infancy. I only remark here in regard to it that in every case of coryza in a young child, if one wishes to guard against surprises of a very serious nature, a daily examination of the pharynx is indispensable. VI. — Uetro-'pliaryngeal Abscess. The reason why this disease is still practically unknown to many physicians, lies chiefly in the fact that its occurrence is very uncommon. In spite of the lai-ge amount of clinical material at my disposal, I have records of only about 65 cases. Thus it is that those physicians who do not see any lai-ge number of sick children are generally unacquainted with this disease, and so usually fail to recognise the first case presented to them. On the other hand, any one who has had the opportunity of watch- ing closely even a single case of retro-pharyngeal abscess is tolerably well insured against future eri'or in diagnosis. For the clinical picture of the disease is indelibly impressed upon his mind, and the recollection of this single experience makes the diagnosis easy to him. 10 146 DISEASES OF INFANCY. This disease consists of an abscess in the connective tissue between the cervical spine and the pharynx, which ahnost always developes somewhat insidiously and gradually forms a tumour projecting more or less into the cavity of the pharynx, thus occasioning interference with deglutition and in a greater degree with respiration. My first case of this kind I observed as early as 1850,^ and I readily admit that I owed my diagnosis of it entirely to the circumstance that I had chanced a few days previously to read two cases of this kind published by Fleming in the Dublin Journal for Feb. 1850. This first one, along with two other cases, will be found recorded in the book published by Rom- berg and myself ("Klinische Warhnehmungen und Beobach- tungen " : Berlin 1851, S. 120), and the description then given has since required no alteration in spite of numerous subsequent observations. In almost all my cases, the children were still in their first year or but little beyond it. The majority were much less than a year old, the youngest being only four months. In only two cases were the children aged 2 and 3 1 respectively ; and these, as it chanced, came to the polyclinic on the same day (26th July 1880). The disease in its early stages is very obscure ; crying, restlessness and frequent refusal of the breast or bottle are the first symptoms, and from these alone no diagnosis can be made. We may, indeed, assume that there must be pain in swallowing from the beginning. But dysphagia is a symptom which cannot be made out at first in children who are too young to complain ; although only a pained expression of the features during drinking may arouse suspicion. But this is often absent, even when the tumour is fully developed as is also the regurgitation of liquids. The first symptom which I regard as really suspi- cious is a snoring character of the breathing, especially during sleep ; and this very symptom causes the inexperienced to regard the complaint as a cold in the head — which, indeed, does at times, though by no means always, accompany it. The inspec- tion of the pharynx — which in these circumstances every conscientious physician ought to make — usually reveals nothing, or, at most, a swelling and redness of the mucous membrane of the throat, which is covered by mucus ; and one is satisfied with the diagnosis of a catarrhal swelling of the turbinated bones. ' Caspe7''s Wochenschr., June, 1850. EETRO-PHARYNGEAL ABSCESS. 147 Generally it is from 10 days to a fortnight or more before the abscess by its size seriously interferes with the breathing. Next the sleep is disturbed ; the child sleeps with its mouth open, but wakes often and gasps for breath. Gradually however a fresh set of symptoms commences, which is apt to mislead one unacquainted with the disease by its resemblance to severe laryngeal catarrh or even croup. The respiration becomes laboured, the accessory muscles of inspiration act strongly, while each inspiration and expiration is accompanied by a snoring noise. When the child attempts to drink, attacks of choking may occur and the liquid is often rejected again from the mouth and nose. In extreme forms of this disease the countenance is distressed and may present a cyanotic hue. Formerly the absence of cough and the quite normal sound of the voice appeared to me very important symptoms, for I thought that I found in them an essential difference from croup. Further experience, however, has taught me that these are by no means constant, and that cases sometimes occur in which hoarseness and cough are present owing to an accompanying catarrh. The duty of examining locally therefore becomes all the more imperative. In many cases of retro-pharyngeal abscess a diffuse swelling is visible on one or both sides of the upper part of the neck; and several swollen lymphatic glands may also be feltj which from their superficial position look as if forced outwards from within. The external jugular veins are often much distended. All these symptoms, however, are in no way characteristic; a sure diagnosis can only rest on an examination of the pharynx by means of the finger introduced over the tongue into the throat, and on that alone. In infants who have teeth this examination is more difficult, because they often bite the finger ; and in these cases I generally use a metal ring as a protection. You must also be prepared to find in very extreme dyspnoea that not only may symptoms of asphyxia but even convulsions, be excited by the local examination, as Fleming has noted. Still, I have managed in every case, and without great difficulty, to feel the abscess quite distinctly as a swelling in the throat projecting forward from the spinal column. It is situated either at the upper part, so that one comes upon it just behind the velum, or else (which is much more undesirable) deeper down at the level of the epiglottis or even lower. The swelling is generally of a 148 DISEASES OF INFANCY. rounded form, more rarely oval, distinctly fluctuating, about the size of a walnut, and situated either in the median line or a little to one side of it. Whenever you feel this j-ou may be sure of the diagnosis. For other fluctuating swellings with the symp- toms described and having an acute course, occur only excep- tionally in this region in such young children.^ The diagnosis being made, there can be no question about the treatment. I should strongly recommend you not to delay for a moment the incision of the swelling as soon as fluctuation has been distinctly made out. For, although the dyspnoea, which has arisen owing to the entrance of air into the larynx being obstructed, may not as yet have reached an imminently dangerous degree, still you can never be sure that the tumour may not burst of its own accord and some of its contents be drawn into the larynx with the inspiration. It happened in my own experience that a colleague, who for the sake of a clinical demonstration wished to " preserve " a case of this kind till the following day, paid the penalty of this delay in the sudden death of the child from suffocation during the night. Cases such as this and the one given by Noll — where the abscess was allowed to remain unopened for 7 days after it was discovered, and ended fatally by bursting into the oesophagus, and by extension of suppuration — must be adduced as warnings and examples. Thus, then, there is only one remedy — immediate incision. In all the cases I have had hitherto, I have performed this with a straight bistoury or, if the abscess M'as situated low down, with a curved one, or else with a tenotomy knife enveloped almost to the point in paper or sticking-plaster. The head of the child, who ought to be sitting upright, is to be firmly held by an assistant or nurse. The tongue must then be depressed by the forefinger of the left hand, which may be protected by a metal ring when the children have teeth ; in such a manner that the point of the finger touches the swelling and feels it plainly. Then, using the finger as a director, the knife is to be carefully guided along it to its tip — that is, to the tumour, which is then to be boldly incised. The cavity of the throat becomes at once filled with yellow matter and a quantity also is expelled from the ' Of- ^-G-, the case of a lipoma behind the pharynx (Taj'lor, Lancet, 1876, ii., p. 685), or that of an abscess between the tcngue and epiglottis (Pauly, Klin, Wocliehsckr., No. 22, 1877). KETßO-PHARYNGEAL ABSCESS. 149 nose. The small wound is to be enlarged in Avithdrawing the knife. To facilitate the expulsion of the matter, the child's head should at once he bent forwards. When the incision has been made, the trouble in the majority of cases is at an end, and a more speedy and surprising change can scarcely be imagined than that from the extreme dyspnoea, threatening immediate death, to a feeling of perfect well-being. Almost always, I have seen the difficulty of breathing vanish as by magic, the swelling on the neck speedily disappear, the turgidity of the jugular veins diminish, and — even after a few minutes — the child which had seemed past recovery now looking about it brightly, and willingly taking the breast which it had so long refused. The matter is not always, however, disposed of so speedily and smoothly. In several cases I have met with much greater difficulty — due for the most part, to the abscess being situated deep down. In these cases I could only with difficulty reach it with the point of the forefinger, and get the curved bistoury down far enough. Especially in very young children, in whom the mouth and throat were extremely small, I have often found it very difficult, because every time an operation was attempted, violent attacks of suftbcation were caused by the passage of the finger over the larynx.^ The breathing stopped, the child be- came cyanotic, the eyes turned up, the pulse became irregular and small, and there was nothing for it but to withdraw the finger quickly and so restore respiration. I have never, how- ever, given up the attempt, and have always been fortunate enough to gain my point in the end ; except in one case where the abscess was situated so low down behind the lowest part of the pharynx that I was doubtful of the result from the very beginning. For opening these very deeply situated retro- pharyngeal and retro-oesophageal abscesses, a guarded pharyngo- tome is to be recommended ; but I have never used it myself. The greater facility of introduction, the less danger of wounding other parts of the mouth and throat, and the possibility of reaching a much greater depth with the instrument, ought to make it decidedly preferable for this kind of abscess. I have also repeatedly observed cases in which a single incision of the abscess was not sufficient. It very often re-filled even on the ' I have already published one such case in my " Beiträge zvr Kinderheilkunde" N.F.: Berlin, 1868, S. 269. 150 DISEASES OF INFANCY. following clay, probably owing to the opening being too small. The symptoms were renewed, and a second operation had to be performed which almost always resulted in a complete cure. Only in one case was I obliged to open the abscess a third time, but I should mention that the second time I had made use of my finger-nail instead of a bistoury — a method which is occa- sionally employed, but which I cannot recommend. After incision, I advise you to have the cavity of the nose and throat syringed with tepid water. There certainly is a possible danger of these fluids being drawn into the larynx during the operation,^ but nothing of the kind occurred in any of my cases ; nor yet have I ever observed any bad results from milk getting into the incision. If the operation is not performed at once, as I have already said, a spontaneous rupture may take place during sleep and the pus be drawn into the air-passages, causing fatal suffocation, or, as I have once seen, rapidly fatal pneumonia. Or again, the matter may gravitate downwards behind the pharynx or oesophagus, even as far as the mediastinum, and death then ensues from ex- haustion due to the extensive suppuration. In the following case the suppuration spread at the same time down to the outer part of the neck. A weak, emaciated child of 10 months was brought on 2nd April, 1875, to my polyclinic. It was said to have been unable to swallow properly for about a fortnight. Also there was snoring and in places a wheezing breath-sound ; a large amount of mucus in the throat, and diffuse swelling in both submaxillary regions — in which a few enlarged lymphatic glands (the largest being of the •size of a walnut) could be felt. Veins on the temple unusually prominent. On introducing the finger, I felt, on a level with the «epiglottis, a fluctuating tumour, the size of a walnut, projecting into the pharynx froni behind. This I at once incised, and copious discharge of pus followed. In the next few days marked improve- ment of all the symptoms, but the discharge of pus from the wound still persisted, the external swelling diminished very little, and the /enlargement of the glands was unchanged. On the 9th, I could make out on each side of the upper cervical region a large fluctuating swelling. The left of these was opened at once, the right on the lltli, after the child had been taken into the Charite. From both incisions there was an enormous amount of pus dis- ' For a few cases of this kind which ended fatally owing to pneumonia following inspiration of pus, see Temoin, Revue mens., Avril, 1887, p. 172. RETRO- PHARYNGEAL ABSCESS. 151 charged ; but the wouuds did not heal, the suppuration continued both inside and outside, while emaciation and collapse advanced daily. Death on the 19th. At the post-mortem a large collec- tion of pus was found behind the pharynx and oesophagus, which extended on both sides into the submaxillary regions, and had here been opened externally. Further, there was limited broncho- pneumonia, enlargement of the mesenteric glands, and small tubercles in the liver. Vertebral column normal.' You see from this that suppuration originally confined to the retro-pharyngeal connective tissue may also extend laterally, and penetrating through between the muscles may appear externally on the neck. I have only once had an opportunity of observing a rupture of the abscess into the pharynx. Pale, emaciated child of 15 months brought to my polyclinic 10th January, 1865. Complete aphonia during the last 8 days; coughing and hoarseness for some time previously. Breathing noisy, especially during sleep. Pharynx red and full of mucus, ^o tumour to be discovered either inside or outside. Catarrh of the bronchi ; dyspnoea ; inability to continue sucking for any time. ]S'o dysphagia ; moderate fever. Death on 14th with difficulty in breathing. P.-M. — On separating the larynx from the hyoid bone, a large quantity of yellow pus spurted out, seeming to come from a hole (the size of a pea at least) in the back wall of the pharynx. This hole had quite the appearance of a round gastric ulcer, and was situated just at the junction of the pharynx and oesophagus. Pus continued to flow out of it. When the oesophagus was dissected we found an extensive collection of pus between it and the vertebral column, extending from the atlas to the sixth «ervical vertebra. This whole extent was covered with fragments of gangi'enous connective tissue. The spinal column showed no morbid alteration. Little fimbriated masses were situated upon and under the vocal cords, and turned out to be tubercular. There was also caseous degeneration of the bronchial glands, and tuber- culosis of the lungs. This case shows that if the retro-pharyngeal abscess ruptures into the pharynx, its diagnosis may become impossible ; for then the pus for the most part escapes through the ruptured point into the oesophagus and is swallowed. Therefore, no swelling need necessarily occur, either externally or into the pharynx. Still more uncommon — in my experience — than retro-pharyn- geal abscesses, are those which form on the lateral walls of ' In such cases — which are very rare at any time — paralysis of the facial nerve may occur from pressure of the pus on the region of the stylomastoid foramen (Bokai). 152 DISEASES OF INFANCy. the pharynx, between it and the soft parts of the neck, conse- quently forming a fluctuating tumour on the right or left side behind and under the tonsils. In two cases a rupture of the abscess took place into the external auditory meatus. But this is certainly an extremely rare occurrence. On 10th April, 1874, a medical friend of mine consulted me about an affection of the neck from which his child (set. 1-5 months) had suffered for several days. The chief symptoms were fretful- ness, dysphagia, crying at each attempt to swallow, moderate fever, and noisy breathing during sleep. The left tonsil was somewhat enlarged and much reddened. Immediately behind and beneath it on the lateral wall of the pharynx a red fluctuating tumour could be seen and felt. Also externally, under the mastoid process, there was a diffuse swelling. No difficulty of breathing observable. When on the 12th I examined again with a view to incising the abscess and pressed rather firmly on the swelling, a stream of yellow pus streaked with blood suddenly spurted out of the left ear, whereupon the tumour at once disappeared, so that no opera- tion was necessary. On the 1.3th the pus continued to flow in moderate quantity from the ear, especially on pressure beneath the mastoid process. The child was perfectly well, slept without snoring, the tonsil was almost noi-mal, and no trace of the tumour was any longer perceptible. ISTo disturbance of the hearing resulted. As the nurse said that she had noticed a discharge of matter from the ear some days before, it may be taken as certain that the abscess on the lateral wall of the pharynx had gradually worked its way through the loose connective tissue to the meatus auditorius and had broken through it at a number of points. Squeezing the tumour had suddenly completed the rupture. The second case, which was observed at the polyclinic (May, 1881), had a quite analogous course. Bokai^ also describes a similar one : only in it the abscess had already been opened from the inside and had since re-filled ; and on pressure it at once discharged through the left ear, after which complete recovery ensued. It is rare for phlegmonous abscesses of the connective tissue of the neck to open into the pharpix. But I have observed this in one boy of 5 years old, admitted into the hospital (11th April, 1881) with a very large hard infiltration extending from the angle of the jaw on the right side to the scapvila, and in ' Jahrb. f. Kindarkeilk., x., 1876, S. 151. KETRO-PHAKYNGEAL ABSCESS. 153 front as far as the second rib. Scarlet fever and diphtheria could be excluded. The pharynx was reddened ; its right lateral wall was pressed inwards and the uvula displaced towards the left. Dysphagia, copious secretion of saliva. Evening temperature, 104'2° F. On the 12th, spontaneous riipture of the abscess into the pharynx, the child spitting out a quantity of offensive pus and blood, and fragments of tissue. Temp, noi'mal. On the loth an incision made into the neck, on account of fluctuation, and some offensive pus let out. Drainage. On the 25th, recovery. — In two other cases I have seen a submaxillary phlegmon (which had de- veloped as the result of scarlet fever) rupture into the pharynx before an incision was made. Of this I shall again have to speak in treating of scarlatina.* With very few exceptions, all the cases I have observed belong to the class of idiopathic abscesses, i.e., to those which occur in perfectly healthy children independently of any other illness. A few children were perhaps somewhat atrophic, but there were no abscesses in any other part of the body. Nor j-et was there any disease of the cervical vertebrae or any general condition owing to which the abscess could have developed. The etiology of all these cases is, therefore, involved in complete obscurity, and the supposition of Bokai and others, that the inflammation and suppuration of the retro-pharyugeal connective tissue origi- nated in the lymphatic glands in front of the spinal column, is by no means certainly proved. I myself, indeed, had one case of a child of 3 years who still showed distinct scars of scrofulous glandular abscesses in both submaxillary regions. Still I do not consider this sufficient to warrant us in referring the abscess with absolute certainty to retro-pharyngeal adenitis. I only twice observed the formation of an abscess arising from spondylitis of the cervical vertebrae. In a child of Ig years, which since the beginning of December, 1874, had been observed to move its head with difficulty and pain and to hold it very stiffly, I found these symptoms markedly increased on 5th April, 1875 ; and in addition there were difficulty in swallowing, laboured and snoring breathing" during sleep, and an abscess the size of a walnut situated very low down on the back wall of the pharynx. It was incised the same day and a considerable quantity of pus was evacuated. The diagnosis of spinal caries was afterwards confirmed by the appearance of ' Bokai and Lewandowsky describe similar cases (Klin. Wochensckr., 188^, No. 8). .. r 154 DISEASES OF INFANCY. abscesses on the back and neck, by paralysis of the arms and paresis of the lower extremities. Another case, observed in the polyclinic, had a quite similar course. VII. — Dentition and its Symptoms. Although the eruption of the teeth generally indicates the end of the period of suckling, and Nature herself thus gives us to understand that the exclusively liquid food may now be exchanged for a somewhat more solid dietary, the obligation to such a change of food is not by any means imperative. As a rule the first teeth appear between the 7th and 9th months, and yet it is customary for the mother or wet-nurse to give the breast till the end of the 9tli month at least (and generally still longer), even when the children have got all their incisors. When this is done the nurse may certainly be injured by the child biting the nipple ; and for the child itself, unpleasant con- sequences may result from this, as we may learn from a case which I observed : — a healthy child of one year being frightened by the sudden scream of the mother on being bitten, started violently, and immediately had an attack of convulsions. Every physician knows from experience that the most diverse disorders of infants, especially of those in the first half year of life, are attributed by the relatives to "the teeth." Super- stition and indolence here lend a hand, especially in practice among the poor, to produce all sorts of mischief which it is often very difficult to undo afterwards. Every attack of diarrhoea or «onvulsions which occurs in those children, is put down to "the teeth ; " and is accordingly either neglected or even regarded as salutary. The physician's aid is often only called in when it is too late. This old-standing tradition, still in full force among the laity in spite of the improvement of education, is now most positively contradicted by a large number of medical men of the present day. Teething, they hold, is a physiological process, which cannot be the occasion of any morbid symptoms, and everything formerly regarded as such is a delusion, caused by illnesses happening to occur along with them, without having anything at all to do with it. It may however be questioned whether this positive denial is altogether warranted, and while I very fully acknowledge the service it has rendered in limiting the DENTITION AND ITS SYMPTOMS. 155 *' diseases of teething," I cannot help thinking that there is a want of moderation in this view. We know that dentition occurs in the following way : — the growing fang of the tooth gradually pushes on the already complete crown, and forces it out of the alveolus after it has burst through the overlying gum which has been gradually thinned by the increasing pressure. Is it, then, so very inconceivable that this gradually advancing process should exert an irritating action on the dental branches of the fifth nerve, and occasion reflex symptoms ex- tending not only to the province of the motor, but also to that of the vaso-motor nerves ? It seems to me quite conceivable, and I certainly consider it is going too far to deny utterly the possibility of convulsions being caused by the irritation of teeth- ing. I shall supply instances later on where, e.g., partial con- tractions of the muscles of the throat and neck were undoubtedly connected with the eruption of a group of teeth. Also the in- disputable fact that obstinate vomiting, diarrhoea, a spasmodic cough, or eczema of the face, which for days or weeks has defied all treatment, will all disappear as soon as one or a couple of teeth emerge from the alveolus, and this can only be explained by the reflex action from the dental branches of the fifth upon the peris- talsis, the vagus or the vaso-motor nerves. We must guard against throwing overboard the views of our medical predecessors with that presumption which has become the fashion with a section of the younger school ; — and also against putting forward principles without such practical experience as is necessary, and can only be the result of a long professional life and very numerous personal observations. It is a matter of fact that a large number of children are out of sorts during the cutting of each group of teeth, cry a great deal (evidently from pain), are restless during sleep, and cease to gain weight^ ; they may also have a flabby skin, a pale complexion, urine milky from the presence of urates, and even slight variations of temperature. Although generally the first tooth appears between the 7th and 9th month, examples are not wanting of teething taking place much earlier. I have frequently seen cases in which one or two incisors had already come through by the end of the 2nd or 3rd month, or a little later. More commonly, how- proached l:y the following one : — - Boy of 9i years. Intermittent fever one year before; later spasm of the orbicularis palpebrarum muscle. On 28tli August. 1882, he suddenly fell down on his way to school and had to be carried home. The attack recurred on 4th, 15th, 19th, and 22nd September. He doubled himself up, sat or lay cowering, with intelligence unaffected, but vmable to make any movement of the head or limbs on account of severe pain. Xo contracture-'. Duration about 20 minutes, after which he jumped up and went on playing as if nothing had happened. Healthy in the intervals, but could not sit still, fidgeted about in his chair, made chorea- like movements and had hypertesthesia of the back towards the right side, where in the beginning of October a patch of herpes appeared about the size of a florin. In October the fits became more frequent, occurred without cause at varying times of the da}', and changed their character. After a shoi-t preliminary stage, during which the boy sat still and stared, he doubled him- self up as formerly-, but continued unable to walk after the attack had subsided, having to support himself by tables, chairs, &c., and dragging his legs after him. Duration 5 — 1 hour, occasionally accompanied by ajDhasia and by spasmodic attacks of hoarse coughing. The paresis of the legs usually disappeared rajiidly after a few shrill inspirations quite like spasmus glottidis, and during the intervals the power of movement was normal in every respect. In November all these conditions passed off, giving place to a state of somnambulism; he slept a great deal during the day, and made violent muscular movements as if 'Romberg und Henoch, Klinische Wuhrnehmuvgen and Beohachtungen : Berlin, 1851, S. 77 ; and the 1st and 2nd editions of the present work which con- tain a full histor}' of the case. p. 1P9. THE HYSTEUlCAri AFFECTIONS OF CHILDREN. 227 swimming, threw about everything Jie got hokl of, and afterwards hid them away in his bed, &c., witliout knowing what h^e was about. In the intervals he was qute well, good-humoured, and went for walks which lasted hours. In December all morbid symptoms had disappeared; a])parent recovery till 8th January, 1883, when he suddenly after a motion oi the bowels fell down pale and speechless in the closet and could not walk till rioon on the following da}'. A fright from swallowing a pin was given as the cause. Nothing followed, the boy Avas quite well and spent some months in the Harz. After September, however, he com- ]>Iained of frequent attacks of headache with slight convulsive movements and lost his good temper. In January, 1884, more serious symptoms again appeared. He had attacks resembling- syncope, and doubled himself up after every motion of his bowels, even after micturition. He also had ]iaiuful sensations passing down from his knees to his feet ; with spasmodic rigidity of the fingers when he tried to take hold of an3-thing, and his sleep was disturbed. His general health was perfectly good. These attacks also disappeared after a short time, and since then— as far as I have been able to learn— the boy has reniaiiied healthy. In this case, then, during a year and a half there occurred varying symptoms connected with every part of the nervous system, with long intervals of almost perfect liealtli. It is but natural that under these circumstances— especially in the first-mentioned case — simulation should occur to one; but careful and continued observations ]>ut this suspicion entirely out of the question. It is also absolutely impossible that the child's strength should have sufficed for this sort of simulation. This enormous capacity of the muscles for work, which is quite abnormal, I consider an essential characteristic of this remarkable affection, and I have been astonished to find it in other cases also. Ina boy of 8 years, who had 1)een perfectly healthy till 3 months before, the trouble began with a state of nervous restless- 7iess, lasting for ajjout 6 weeks, which gradually passed into attacks of chorea magna. These at first only occurred by night — • later on during the day also. After an aura, consisting of a sensa- tion of painful pressure over the right eye, the boy began to run, spring, and stamp about continuously, uttering from time to time a piercing scream. During the attack consciousness was confused, but not lost. After a few minutes this ended with a violent trembling and shaking of the whole body, whereupon the boy awoke as if out of a deep dream. Involuntary micturition also not uncommonly occurred during the attack. Causes and further coiirse unknown. 228 DISEASES OF THE NERVOUS SYSTEM. An anaemic- girl of 13 years, Avliom I treated along witli Romberg, had no morbid symptoms whatever during the fore- noon. Between 3 and 6 p.m., however, attacks occurred every day, in which spasmus nutans (p. 192) was the principal symptom, while the mental condition was entirely unaffected. There were nodding and swaying movements of the head and whole upper part of the bod}-, fully 40 — 50 in the minute, with short pauses at intervals of an hour, and they lasted so continuously that the possibility of such muscular exertion was almost inconceivable. The attack ended about 6 o'clock. Duration of the disease at least 4 weeks, after which all sorts of other hysterical symptoms remained — extreme weakness, globus, tenderness of the scalp, and so on. The appearance of menstruation finally brought about complete recovery. I haA'e since seen the patient again as a healthy wife and mother. A girl of 9 years, healthy, with the exception of repeated sore-throats, was brought to me on 22nd November, 1878. A year before she had had 4 '" fits " with drawing of the mouth to one side, but without loss of consciousness. In the beginning of October, half an hour after having her tonsils cauterised with nitrate of silver, she took a "fit," in which she repeatedly sprang up into an upright position, with extremely quick dyspnoeic breathing, accom]:)anied by a stenotic sound ; this lasted onlj- a few seconds. Thousands of such attacks were said to have occurred since that time, during the day only. Pot. brom. and quinine had had no effect. Emil S., 10 years old, presenting over 100 exostoses on all his bones, which had developed since he was 9 months old, had suffered during some years past from occasional attacks of migraine, with vomiting. He was violent and irritable, but diligent and amlntious at school. On 4th May, 1869, an attack of headache, lasting from morning till midday. About 2 o'clock thi.s suddenly became worse again and there Avas redness of the face, convulsions of the whole body, biting movements of the jaws, rolling of the eyes, and slight mental derangement (mistaking one person for another). All movements strikingly hurried and forcible. Duration of the attack Ij hours, after which the child became quite quiet and the appetite returned. From 5 to 7.30 a second and more violent attack. Great tenderness to pressure in the upper cervical region. Quiet night, sleep without any spas- modic contractions. Next day, between 6 a.m. and 3 p.m., four similar attacks, in which the patient threw himself with great energy out of his own bed into that next him. This was followed by a complete cessation of symptoms, and the child seemed quite well till next morning, when, at 7 a.m., a trifling and very transient attack took place. Since that time the disease has not returned, and this boy, as I have had re]ieated opportunities of ascertaining, has grown up a healthy young mm. THE HYSTERICAL AFFECTIONS OF CHILDREN. 229 111 a healthy boy of 12 years (November, 1870), the trouble bei^an with extreme hyperagsthesia of the whole front wall of the chest. The region bounded by the clavicle and the lower margin of the thorax, and laterally by the axillary line, was yo tender that he could scarcely bear even a slight touch. After al)Out 4 weeks this hypera3sthesia suddenly disappeared, and was replaced by violent attacks of spasmodic coughing, resembling those of whooping-cough, in which the prolonged inspirations were accompanied by a whistling noise (spasmus glottidis). During these attacks, which occurred several times a day at irregular intervals, and seemed to threaten suffocation, and of which I was frequently a witness, the boy sprung up with such energy that it was with difficulty that he could be held down. Injections of morphia were the only thing that relieved him. He seemed well in the intervals apart from a certain irritability of disposition. After 6 weeks all morbid symptoms suddenly disappeared ; they recurred once later on for a short time, and then disappeared for good. Course of treatment in Bad Landeck. This Case is peculiar in this, that the beginning of the disease was nnuounced by a sensory neurosis, which I have never observed in this form except here. It is especially worthy of note that the hyperaestliesia was bilateral, and not confined to the area of distribution of one or more particular nerves, but aftected the front and whole side of the thorax. To this series we must also tillocate the rare cases mentioned on p. 201, in which choreic movements are combined with uni- lateral anaesthesia, which again disappears with surprising rapidity, or else makes its ajjpearance on the other side of the body (transferred). I cannot deny that partial anaesthesia or analgesia, also limitations of the field of vision (hemianopsia, &c.), may occur in the most diverse hysterical conditions of children more frequently than I have hitherto thought, either because I have not examined many cases in this particular, or because this examination is extremely diflicult, and readily admits of error.' Only in \ery few cases was I able to convince myself of a bilateral anaesthesia, e.g. in the case of a girl of 12, whose left nasal cartilage we could pierce with a needle without her feeling it. ' (/. Barlow" s article (Brit. Med. Journal, Dec. 3, 1881) "On Hystericol Analg-esia in Children." Barlow recommends the g-alvanic current for the examination. Peugniez's Thesis, mentioned on p. 217, note, contains a serie.-i of cases in which anesthesia of the skin and organs of sense were observed in children of 10 —1.5 years in just the same way as in adults. 280 IJISHASKS Ol' THE NERVOUS SYSTEM. The fourLli class iiicliules tlie cases — rare in my experience — in wiiicli neuralgic or trophic disturbances are tlie most promineiit symptoms. Gotthelf K., ()!i year.s, examined May 2ii(l, 1878. A fresh-looking, l.eilthyboy. Mea.sles 4 weeks ago Avith normal course. A fort- night ago, while wrestling, another hoy fell on the top of him. A week after, fits of pain hegan in his ahdomen, which have gone on getting worse. They affected the whole aljdomen, even its lateral regions, and were so severe that the child screamed aloud and rolled ahout violently in hed. Gradually the screaming and rolling ahout became so marked that the pains ceased to be the most j^rominent symptom. The frequency of the attacks increased daily, and thej- were only interrupted by very short free intervals. Temp. 100"4° — 10r3° F. Pulse somewhat rapid, coated tongue, foetor oris ; urine abundant, dark, normal. Bowels regular, anorexia. Xothing abnormal in the abdomen. On the other hand, extreme hyperaisthesia of the skin over it and of the whole front of the thorax, so that violent jiain Avas caused if one raised uj) a fold of the skin. Treatment : — Warm bran- baths, acid, hydrochlor. ; in the evening, morphia. Next day (3rd May) the attacks diminished in frequency and severit}-. For 24 hours almost no urine passed, except when the bowels were moved. Hypera^sthesia unchanged, and was now found also in the face in the area of distril)ution of the first branch of the fifth nerve on both sides. After the 4th, rapid diminution of the hyjiergesthesia and of the attacks of pain ; abundant discharge of urine and fa'ces ; appetite; no fever. On the 8th, comj^lete recovery. In a girl of 12 years, who had lately begun to menstmiate (23rd April, 1879) violent attacks of cardialgia had occurred daily for the last fortnight, which lasted for seA-eral hovirs, and were accompanied by uninterrupted crying and screaming, which put the whole household in a state of excitement. Other- wise healthy, but of peevish disijosition and extreme nervous irritability. Morphia, here also, rapidly had a soothing effect. Girl of 11 years, unusually early developed, but has not yet menstruated. Her mother died of phthisis. In September, 1878, I was consulted on account of frequent attacks of headache, which were often accompanied towards evening by an inclination to vomit. In February, 1879, I saw her again. Ten days before, she had violent retching, Avith ha3matemesis and general un- easiness, during which about half a cupful of blackish-red blood was brought up, niixed with much mucus. This had recurred every second evening about 8.30. The attack lasted about a J hour and never occurred during the day. OAving to sensations in the region of the right mimniv, I freq'icitl}' examined the lungs along THE HYSTERICAL AFFECTIONS OF CHILDREX. 231 witli the jdiytiician in cliargc, but never fuund anj-thiug to excite busijiciou. During the last 4 days the hasmatemesis had occurred every evening at the same time — about 8.30. The motions never contained blood. Food was well borne, never giving rise to jiain in the stomach. Neither quinine in large doses (grs. xv.) nor remedies given for the gastric condition, an ice-bag. opium, milk diet, liq. ferri perchlor., nor ergotin, had the slightest effect. Tlie peculiar character of the girl, her premature development, lior inclination to stay in bed, and the fact — which her father himself acknowledged— that she had been extremely spoilt from childhood, at once led me to suspect that we had either to do with simulation or hysteria. There was no reason for the former, and examination of the teeth, throat, tongue, &c., revealed nothing which could be regarded as the source of the vomited blood. Also the physician in charge had himself witnessed an evening attack, and was convinced that there was no simulation. We could therefore only think of hysteria, and I was further strengthened in this supposition by the fact that the hasmatemesis occurred by d:iy for the first time on the 12th, about 2 p.m., subsequently to mental excitement. We therefore ordered the patient to leave lier bed, to take a driAe every da^-, and recommended that all taedicine should be gi^-en up and all anxiety dismissed. In the i:nddle of May I met fatlier and daughter taking a walk, and the fijrmer told me that since my last visit there had been no other attack, and that the girl was perfectly well. Her good health con- tinued the whole summer, while she was in the country. Only extremely rarely — and ahvays after mental excitement— did slight lu^matemesis occur. After her return home the same series of symptoms, occurring in the evening, again appeared, but not so regularly as before. Ergotin injections, which the doctor ordered, had evidently a jDsychical effect, far the mere threat of repeating them later on {e.g. in August, 1880) when traces of hasmatemesis again aiipeared, was sufficient to cause immediate recovery. This is the only case iu which I have seen hpematemesis accompanying a hysterical aftection, although such cases have occasionally been reported by other authors.^ As I have seen Inemoptysis ^Yithout lung disease in a hysterical j^atient, I regard the occurrence of hfematemesis under similar circum- stances as equally possible. The process is indeed difficult to explain, and may always remain a matter of hypothesis. But when I remember the sudden blushing which may take place IVom mental emotion, and recall the case of one epileptic child ' Vf. Rathery, " Contributions i\ Tetude des hömorrhagies survenant. dans le coursdel'Hysterie :" Union .l/«/.,1880, No. 32, 3.5. - Lancereaux, "Hömorrha^es nouropathiques " : Ibid., No. 5C. 232 DISEASKS OF THE NERVOUS SYSTEM. whose attacks always began with extreme flushing of the whole skin as aura, I think I may assume that it is possible for hyper- semia and hiemorrhages to take place into the lungs or stomach from an irritation affecting the vaso-motor nerves of these organs. The periodic occurrence of hiematemesis in our case is not surprising, seeing that in some of the cases of chorea magna formerly published the convulsions took place in the most typically periodic way. I may mention here also the case of a boy of 9 years who had his "hysterical" convulsions regularly about noon and at 5 p.m., and in whom there could be no suspicion of simulation. The cases I have given will suffice to place before you a clinical picture of this remarkable condition in its various forms. These cases do not, indeed, exhaust all the modifications, and I might have given you from my own practice examples of many other variations and combinations of symptoms — cases of aphonia, aphasia, globus, hiccough, and dysphagia. Thus we find pub- lished accounts of neuralgia in the joints, ovarian pain, and localised hypernesthesia and anaesthesia, in no way diflering from those in hysterical adults.^ Their strange and inexplicable character always, of course, excites a suspicion of simulation; and indeed we cannot be sufficiently cautious in this particular, even in the case of children.^ I have myself met with a few such cases ; among others that of a girl of 12 (25th Feb., 1879), who had sufi"ered for two years from frequent cataleptic attacks, and had latterly taken them three or four times in the day, but from the moment she was admitted into the children's ward to the time of her discharge (that is, for at least 2 weeks) had not a single fit. Apart, however, from the fact that cases of this kind are not, in my opinion, to be regarded off-hand as cases of inten- tional malingering, but rather as an expression of the " hys- terical " nervous derangement, I can assure you that in all the cases given above, the suspicion of simulation could be absolutely excluded; and it was just the same in many analogous cases recorded by other writers. I cannot, therefore, entirely agree with Roger when he sajs, "pour les practiciens experts en pathologic infantile, toute neurose dite par imitation est une ' Roscnstein {Eei'I. fdin. Wochenschr., 1882, S. 522) describes a remarkable case in which there was V o m i t i n g of scybalous fasces diiring' the attack. - S. Ab el in, CentralzeKunrj/. KindtrheUk., 1878, S. 257. THE HYSTERICAL AFFECTIONS OF CHILDREN. 233 iienrose par simulation." The complete cessation of the fits in the child just mentioned during her residence in the hospital cannot be taken as a proof of malingering, as we know for certain that radical changes in the surrounding conditions not uncom- monly produce a temporary or even lasting improvement of this "nervous " state. Occasionally the resemblance to the hysteria of adults is even more striking, as in the following case : — On 5th November, 1876, a girl of 11 years appeared at the pol}'- clinic, who had been qnite blind since her 2nd year as the result of bilateral keratitis and atrojihia bulbi. Being healthy till 2^ years ago, she was sent to school, where she showed the utmost applica- tion and overworked herself. Soon after, she took attacks of headache, with vomiting, so that she had to leave the school. She took to music with all the more energy ; she had a marked talent for it, and now jjlayed the jiiano for more than 3 hours daily — of course, only by ear. For some months she had com- plained of sudden shooting pains in the forehead, and giddiness (so that she fell) altei-nating with violent colicky pains round the umbilicus and attacks of rapid dyspna3ic breathing. All these symptoms occurred every day repeatedly, and at once whenever you spoke to the child about them. At the same time her mental character did not at all con-espond to her age, for she was precocious, estremelj^ talkative, and very circumstantial in de- sci'ibing her symptoms. Particularly striking and amusing was the fact that she always repeated exactly the last word of anything- her mother said. At the same time she slept 12 hours con- tinuously without being troubled by a trace of nervous symptoms. General health perfectly good. No sign observable of the develop- ment of puberty. Further course unknown. I have also several times had occasion to observe cases of hysterical paralysis of the lower extremities in children, especially in girls of 11 — 13, even more marked than in the cases given on p. 223 and p. 225. Sometimes violent fits of crying, lasting for weeks, or other hysterical conditions had preceded the paralysis ; and it came on after they disappeared, just as in adults. In lying and sitting the limbs could be moved almost as well as in the normal condition, and the sensibihty as well as the function of the sphincters was intact. The children, however, obstinately maintained that they could not stand or walk, and v/hen they tried to do so, their strength failed and they sank to the ground unless supported. The suspicion of 234 DISEASES OF THE NERVOUS SYSTEM. spine disease, ^vLicll causes anxiety to tlie parents in such cases, could be at once discarded, and in fact these paralyses disap- peared after a few weeks, either spontaneously or as the result of psychical impressions. But sometimes they were replaced by other nervous symptoms.^ (^uite as obscure as the pathology of all these outwardly dissimilar but essentially identical conditions is their eti- ology. In hardly any case have I been able to find quite definite causes. The influence of emotional conditions — particularly fright — in causing relapses, must be acknowledged. One of these girls suddenly took a violent hysterical convulsive attack (the first for weeks) during my lecture on her case, at which she was present. In general it is commoner in females and at the time of puberty, and accordingly all these affections, especially chorea magna, have been closely identified with the latter. Since, however, even boys and young children between the ages of 9 and 11 years are by no means exempt, it is evident that there may be other forms besides those due to development, arising from other causes. One naturally turns first to irritation connected with the genital system, and thus we hear mastur- bation spoken of by many as the principal cause of these nervous disturbances." 1 do not by any means deny that, with a strongly-marked "nervous predisposition," this vice if persisted in may assume importance as a cause; but, considering how common it is, we should certainly meet with cases such as we are speaking of far oftener than we do, if that view were correct. We are at any rate always justified in keeping this cause dis- tinctly in mind. You will scarcely believe that many children in the second year of life, or even earlier, practice masturbation, either with the hand or by rubbing the thighs together, so as to cause distinct erection of the penis. It is often also produced by the abeady mentioned rhythmical swaying of the upper part of the body while sitting (p. 196). At this age the evil can still very easily be cured by sharp supervision, but it is much more difficult in older children, who in some cases will avail themselves of every un watched moment to indulge in the vice. I remember ' Cf. Eiegel {ZcUsckr. /. kiln. Med., Bd . vi., H. 5), who gives five cases of this paralysis with contractures, &c. ^ Jacobi, " On masturbation and hysteria in young children " : American Journ. of Obstetric.i, dc. viii. ■{■; ix. 3, 1876.— Hirschsprung, Jahrb./. KindevhdU;, ssiii., 460. THE HYSTEIIICAL AFFECTIONS OF CHILDnEN. 235 one girl of 8 years, who although she did uofc use her hands, yet by rubbing the genital organs on the edge of the chair on which she sat, worked herself into a state of great excitement, which was manifested by her flushed cheeks, sparkling eyes, and rapid breathing. The diagnosis, however, is not always so easy, and the most careful observation is necessary, especially when they are going to sleep, in order to surprise them in Jiagrante. The discovery of a few spots on the linen is by no means sufficient for a positive diagnosis. I have tried in all cases of hysteria and chorea magna to investigate this point, but in not a single case have I been perfectly sure that the cause was to be found in masturbation. We must always be content with the possi- bility or probability which already play too large apart in etiology. Nevertheless, you will do well always to keep masturbation in mind, and, whenever it is found to be present, to put a stop to it if possible. For even although it may not constitute the real cause of the disease, still by the over-excitement of the nervous system Avhich it occasions, it may prepare the way for its develop- ment and retard recovery. How serious such an over-excite- ment may become, we see from the following case : — Carl A., 7 years old, admitted into the cliildren s ward on 8tli January, 1873, bad jiracticed masturbation since bis fiftb year. The babit bad been induced by sleeping for a long time witb a female relative, wbo bad taugbt it bim. Gradually increasing debility, enuresis nocturna, sleeplessness, and— during tbe last fortnigbt— inability to walk. He could neitber sit, stand, nor walk unless supported. Even wben supported be soon began to sway about, comi^lained of giddiness, and bis gait was distinctly ataxic, like tbat üi tabes dorsalis. On shutting bis eyes, the symptoms were markedly increased. In bed, all movements of tbe legs were free, although less energetic than in normal health. Sensibility intact. Tbe plantar reflex movements, however, were weaker and slower than usual. Urine and fasces retained witb difficulty, and sometimes passed involuntarily. Ana?mia and moderate emaciation. Treatment:— A luke-warm bath for 10 minutes daily, with cold shower over the head and back, the strictest supervision of the patient, and the prevention of every attempt at masturbation. By 23rd marked improvement in walking, cessation of enuresis. On 31st scarcely tbe slightest unsteadiness in tbe gait noticeable. Comjjlete recovery by middle of Februar}-. The extremely rapid and favourable progress of this case, which 236 DISEASES OF THE NERVOUS SYSTEM. at the befjinuing showed symptoms of advanced tabes dorsalis such as I had never before met with in a child, proves that no degeneration but only a functional disturbance existed. We see, then, that constant irritation of the genital nerves in children may cause paresis of the lower extremities with ataxic symptoms, diminished muscular sense, and diminished energy of the centres analogous to the hysterical paralyses in women which are caused by morbid conditions of the sexual organs, or even in the absence of such by depressing general influence on the nervous system, and which under favourable circumstances have a similarly favourable course. To the same class also belong the paresis and ataxia of the lower limbs which is occasionally observed in children with extreme phimosis, and the consequent genital irri- tation which this excites, and which is cured by an operation.* Most of the children who presented one or other form of the hysterical conditions we have been speaking about, were of deli- cate constitution, thin, and more or less anaemic. Only the minority were well nourished. We could almost always find some fault in the bringing-up which had prepared a favourable soil for the later neurosis. Children who are brought up with unusual care and indulgence — round whom, so to speak, the whole household turns — who are surrounded by extremely in- dulgent persons ready to give in to all their humours, and whose slightest complaint was taken up with exaggerated solicitude and made much of, are especially liable to these extraordinary diseases. Under these circumstances a sort of hypochond- riasis occasionally sets in. I witnessed this especially in one very spoilt, delicate boy, of 8 years. He attended to his own health with the most anxious solicitude — examined his tongue, every spot that appeared on his body, &c. In a disposition of this sort, or where there is a hereditary tendency, or at least a neurotic predisposition in the family, all irri- tation acting powerfully on the nervous system, every kind of emotion, excessive mental strain, ambition at school, ill-treat- ment from parents, and finally also the instinct of imitation may bring the disease to its full development. From the cases I have given, you will have seen that under these circumstances medicinal treatment cannot promise any ' Oesterr. Jahrb./. Pü(U(i(rU;xn., 1876, 2. Heft, Annal. S. 128.— Arch./. Kinder- heiU-., viii., S. 460. THE HYSTERICAL AFFECTIONS OF CHILDREN. 237 real result. I know of no medicine wliicli has clone me real service except chloral (in doses of grs. viiss — xv) and morphia (by the mouth and by subcutaneous injection, gr. t3~~4)- I have found these occasionally of some use in palliating ihe violent spastic symptoms. The inhalations of chloroform which I have tried in attacks of screaming and otlier voice- spasms had never more than a passing effect. In many cases — for example, in those of spasmodic running and jumping— even these remedies can only be used with difficulty — if at all — during the paroxysms ; or they may fail to act. Under such circumstances we must just let the attack run its course, only taking care that the patients get no injury from the nature and severity of their movements. Sometimes by a sudden violent impression — e.g. by splashing the face with cold water, or by speaking loudly and roughly — we may put a stop to the fit. Still, this by no means always occurs. We have just as little power to shorten the course of the disease by any remedies. Even when the periodicity of the attacks was most distinctly marked, I have seen no action whatever either from quinine or arsenic. Considering the frequency of an under- lying ansemic condition in such cases, it is always well to treat the children with small doses of iron, or to give arsenic as in chorea ; for this medicine in small doses continued for a long time exerts a distinctly beneficial influence on the anaemic con- stitution. Soothing baths of lukewarm water, with soap or "bolus alba" (Ig — 4 oz. to each bath) continued as long as possible (half an hour), nourishing food and fresh air are to be strongly recommended, but unfortunately cannot always be obtained. In afiections of the voice the galvanic current should be tried. It occasionally produces rapid recovery, but some- times has no effect, or may even aggravate the disease. Not imcommonly all manipulations of this kind — the application of electricity, the introduction of an oesophageal tube, a subcu- taneous injection, even a laryngoscopic examination and, above all, the threat of repeating these measures — act with wonderful rapidity ; their influence being, of course, only psychical. One must not however expect too much from this rapid improve- ment ; for it may be followed by sudden aggravation of the symptoms. Fortunately we are in a position to reassure the relatives from the beginning as to the result, and indeed I am of opinion that the more extraordinary and iucompre- 238 DISEASES OF THE NERVOUS SYSTEM. hensiblc the symptoms are, and the more tlioroujijhly they change, the more certainly can a favourable prog- nosis be given. You may therefore always give a most favourable opinion of cases of so-called chorea magna, of voice- spasm and hysterical paralyses. But the cataleptic form (our hrst class^ is always a cause for anxiety, because of the possi- bility of its turning into epilepsy (p. 218). At any rate I advise you to prepare the relatives for quite unexpected symptoms. Where there is now paralysis there may in a few days be a con- vulsive affection, a sensory neurosis, or a psychical change ; and tbis sometimes takes place even during an attack. After recovery, you will do well to continue the tonic treat- ment, and, where circumstances allow it, to order chalybeate baths, or else simple warm baths in fresh mountain or forest air. As to the latter, I recommend especially the warm baths of Schlangenbad in Taunus, Landeck in Silesia, and Johannisbad in Bohemia. For chalybeate baths, which are indicated when aniTemia is a prominent symptom, I would advise Schwalliach, Pyrmont, Driburg, Flinsberg ; and, in Switzerland, the high springs of Tarasp and St. Moritz. I have no doubt that by this treatment with baths and change of air, the recurrence of the conditions we are speaking of may be prevented, and their course so far shortened. I believe that under favourable circumstances a course lasting over a number of years, as for example in our case on p. 226, will hardly ever occur. When the disease is extremely obstinate, however, nothing remains but to remove the patient from his accustomed surroundings at home, into others which are quite new to him, either in a hospital or in a strange family. The mere change of abode is not in itself sufficient, unless the companion- ship of the mother, or accustomed nurse is also denied. School attendance is, of course, to be forbidden while the disease lasts; and, even after recovery, every mental strain is to be carefully avoided. In girls about the age of puberty, the appearance of menstruation calls for special rest and care. We learn from the case on p. 226 that when puberty is fully established, even unusually chronic conditions of this kind may end favourably. NlGiir TERRORS— PA VOPv NOjrURNUrf. 239 VII. Parar Xoctnnins (Night Terroi-s). This is the name given to a condition which, owing to the ahirm which it causes the patients, often clistiu'hs the well-earned rest of the physician. In the middle of deep sleep — oftenesfc in the first hours of the night — -the children suddenly start up and cry violently and continuously, and catch at the air with their hands, or else sit in bed staring in front of them with an anxious expression, and uttering words that are hard to make out, or altogether unintelligible. Many tremble in all their limbs, throw themselves in terror into the arms of the frightened mother or nurse, cling to them without distinctly recognising them and call out for light, and it is only with difficulty that they can be quieted. After a short pause the scene is repeated, not uncommonly several times in succession, so that half an hour or longer may pass before complete rest ensues, and the exhausted child falls sound asleep again. As a rule, the remainder of the night is passed in quiet sleep, and when the child awakes it knows nothing of Avhat occurred in the night, and does not remember the physician who sat by his bedside during the attack. These attacks are now repeated at irregular intervals, sometimes every night, sometimes only twice or thrice a week, or still seldomer. It is exceptional to have two attacks in the same night. During the day, the children show no symptoms that one can connect with the nightly paroxysms. I have only once had the opportunity of observing a case of this kind — between 11 and 12 in the forenoon- -in a child who had fallen asleep on a sofa. The duration of this disease, which so violently disturbs the child's relatives, is quite indefinite. While in some cases the thing is all over in a few attacks, in others the attacks are repeated during many weeks or even months ; but they finally disappear without leaving any bad results. In an ansemic girl of 7 years who was otherwise quite healthy, the attacks had lasted two years, with maximum intervals of 8 days, but had increased in frequency since she began attending school. Although I have placed this aftVction here, immediately after the ** hysterical " conditions, it is not at all because I consider them to be nearly related to one another. I have indeed seen 240 DISEASES OF THE NERVOUS SYSTEM. paver nocturuus come on, in a few cases, in children who had been spoilt, and had been rendered hypersensitive by a bringing- np which predisposed them to hysterical derangements, and who suffered at the same time from headaches, palpitation, fainting fits, &c. But this however was just as rare as it was to find night-terrors due to real epilepsy; which I found to be the case in a girl of 10. In this case several epileptic fits had taken place three years before, at intervals of 8 — 10 days. They then ceased till January, 1882, when suddenly several fits again occurred, which in February were accompanied by hallucinations and screaming. In March they disappeared spontaneously, and were replaced by attacks of pavor nocturnus, occasionally occur- ring twice in one night. I have never yet met with pavor preceding and accompanying regular psychoses, which is perhaps due to the small number of cases of mental affections which I have met with in children. In general we meet with pavor nocturnus almost exclusively in young children, in whom we find it occurring till near the time of the second dentition ; while " hysterical " conditions usually begin after this period. In this condition also there is none of that mental change which is so important an element in hysteria. The whole trouble consists in the nocturnal attacks described, and to me at least it has always appeared as if a terrifying bad dream had frightened the children out of their sleep, and still haunted them when half awake. It is evident that visions and hallucinations are factors, as the children often describe them quite definitely. I have heard them call out to take away the chains, to drive away the wild beasts, that they would be run over, &c. Sometimes, again, they try to jump out of bed to escape from the cause of their terror. A boy of four years who was violently frightened by a bee had an attack of night terror on the night after, during which he fancied that a fish was continually threatening him. This was repeated several nights consecutively, and finally the child would not enter the bedroom, and always wanted to be out of doors. The more active the child's fancy is, and the more it is excited b}' the favourite thrilling tales of nurses, the more readily will the pavor come on ; and this fact is one which should be laid to heart by those who have charge of children. TERIPHERAL PARALYSES. 241 One of the rare cases of pa vor diurnus which I have seen affected the son of an actor (7 years old), a nervous, anasmic, delicate child. For some months as many as 10 or 20 attacks took place daily, but never during the night. The child would shut his eyes and stop his ears, crying, " I'm afraid !" and clinging to his mother. Duration only a few seconds. Otherwise healthy, and, in particular, free from other hysterical symptoms. In a " nervous " child of 6, who had suffered from pavor nocturnus for 7 months, with intervals of about a fortnight, attacks occurred occasionally by day with hallucinations. Unfortunately, both these cases were lost sight of. . I cannot share West's opinion, that disturbances of digestion are generally the cause of night-terrors. I have but rarely been able to assure myself that the cure of such dyspeptic conditions as might happen to be present caused a rapid disappearance of the pavor ; e.g. in a boy of 8, who during an attack of gastric catarrh had night-terrors five nights running. On the other hand, most of the cases presented no disturbance whatever of the digestive organs. Nor could I discover any abnormal condition of the respiratory and circu- latory organs.^ In many cases there is an undeniable family predisposition; children of nervous parents are more likely to be affected. As I was unable to ascertain the causes in most of the cases, I confined myself to forbidding every excitement of the child's fancy by evening stories, and ordering a dose of bromide of potash (grs. viiss — xv.) at bedtime ; and this seemed to me to exert a soothing influence. I have not yet tried morphia or chloral, but I would have no hesitation in using these remedies in severe cases. VIII. Peripheral Paralyses. In children, as in adults, the facial nerve is that most fre- quently affected by peripheral paralysis. It not uncommonly appears in the earliest childhood, immediately after birth. The mouth is drawn to the unaffected side in crying, and the ej'e of the paralysed side often remains open. The exact symptoms depend on whether the cause of the paralysis affects the labial and palpebral branches of the facial nerve, or leaves the latter unaffected. This cause is the pressure of forceps • Silbermann, Jahrb. f. Klnderheilh., Bd. xx., S. 266. IG 242 DISEASES OF THE NERVOUS SYSTEM. at birth, which in such cases sometimes leaves behind a small ecchj-mosis in the parotid region. The twisting of the mouth generally causes the utmost alarm to nm-ses and parents, as it is regarded as a sign of apoplex}-. You may, however, calm the fears of the relatives by the assurance that the paralysis will probably disappear within a few weeks, as soon as the extravasa- tion of blood is absorbed or the nerve has recovered from the effects of compression. I say " probably," for you cannot foretell a favourable termination with absolute certainty. In a few cases the pressure of the forceps appears to have been so severe and lasting in its effects that degenerative processes (fatty degeneration of the nerve fibres) take place in the facial nerve ; and these are not always recovered from, but cause paralysis lasting for a whole life-time. I have myself observed one such case, in a girl of 13 years, and Parrot and Troisier' have furnished anatomical proof of the fact. Much more rarely we find congenital paralysis of the facial nerve, with which the jDressure of the forceps has nothing to do. I have seen this only once, in a boy of 10 years, who was born without artificial aid, and exhibited paralysis of the left facial nerve immediately after birth. All its branches were paralysed, also the left half of the soft palate and the hearing was lost in the left ear, although no disease of it had ever been found. A prolonged treatment by galvanism was entirely unsuccessful. Similar congenital cases have also been published, but their pathology is not sufficiently explained. Unilateral paralysis occurring in later childhood has a general correspondence with the cases with which you are familiar in adults, and I shall not discuss them further. I w^ould point out to you, however, that in order to observe these symptoms it is necessary (in children almost more than in adults) to make the features move in the expression of some sudden emotion. While the child's face is at rest you observe no striking change ; but when it cries, screams, or laughs, the asymmetry of the two sides becomes apparent. The inspection of the soft palate is often particularly difiicult in children, and we have sometimes to be content with a rapid glance. The causes, as well as the general symptoms, agi-ee entirely with ' "Note siir I'anatomie pathologiqiie de la paralysie faciale des nonveau-nes," Arch, de Tocologie, Aoi'it, 1876. PERIPHERAL PARALYSES. 243 those of facial paralysis in adults. Rheumatism as a cause is here also more frequently taken for granted than proved. Still cases are not uncommon in which the action of a cold draught of air — especially when the skin is perspiring — is evidently the cause. More frequently, I have seen the scars of abscesses, or enlarged glands, behind and under the ear in the region of the stylo-mastoid foramen, cause paralysis by their pressure on the branch of the facial which issues from it. Child of 2 years, with complete paralysis of all the branches of the left facial supplying the face. In the neighboui^hood of the stylo-mastoid foramen, a deep sinuous abscess issuing from a ly^nphatic gland. After it was opened there remained a con- siderable swelling and infiltration of the connective tissue. From 25th February, 1861, this was painted with tincture of iodine. On the 7th March there was considerable diminution of the swelling ; but the paralysis was unchanged. Continuation of the painting, and also, internally, iodi gr. |, pot. iodid. grs. xv., syrupi simpl. 3 viss., aq. destill. ad J iii., a dessert-spoonful 4 times a day. In the beginning of April, complete recovery. Such cases occasionally occur even in very young children^ Tluxs I have seen paralysis of the right facial nerve in two children of 5 and 11 months respectively. In the latter, enlargement of the glands, with diffuse swelling of the connective tissue, could be made out in front of, behind, and under the ear, while in the first case very careful examination was needed in order to make out the deep-seated induration under the mastoid process. — In a boy of 4 years, paralysis of the labial and nasal branches of the left facial resulted from the pressure of a large abscess in front of the ear, Avhich developed during convalescence from typhoid fever. The paralysis disappeared almost suddenly when the abscess burst into the external auditory canal and discharged its pus into it.. We must, however, regard caries of the petrous bone destroying the nerve-trunk in the Fallopian canal, as the commonest cause of facial paralysis in childhood. The numerous cases of this kind which I have seen all agree in this — that in every one of them all the facial branches of the nerve were paralysed, while unilateral paralysis of the soft palate was not always present ; for in a number of these cases the uvula was quite straight, and the movement of the palate equal on the two sides. We must notice in these cases not only the oblique position of the uvula, but also the movement of one half of the velum on breathing and phonating, whereby the 244 DISEASES OF THE NERVOUS SYSTEM. soft palate is twisted to one side. Where this symptom is absent, we may conclude that the destruction of the Fallopian canal has not taken place till after the greater petrosal nerve has left it. Deafness in the affected ear is very difficult, if not impossible, to make out in little children. The otorrhoea, which is always present, sometimes combined with bleeding, is all the more important, and along with the matter there are often discharged from the auditory meatus little or pretty large pieces of bone, or even auditory ossicles, clean as if dissected. The presence of a deeply destructive process is also indicated by a tender swelling of the temporal bone behind the ear, also by redness and fistulous openings. This cause of paralysis some- times occurs at a very early age. I have seen it begin even in the third and fifth mouths, and either rapidly prove fatal with symptoms of general tuberculosis, or else continue for years, till at last death was caused by complications, especially tubercu- losis of the brain or other organs, meningitis, or sinus-throm- bosis. The longer the paralysis continues the more atrophic do the facial muscles become, and in one child thus affected I found them shrivelled to thin brownish-yellow bands. At the post-mortem of the cases I have met with, there has always been extensive caries or cario-necrotic destruction of the petrous bone, Avhich sometimes reached to the dura mater. But even in the cases where there was a carious cavity close under it, this mem- brane itself was intact, or at most somewhat dark in colour, so that a perforation of the caries into the cranial cavity had certainly not occurred. On the other hand I have repeatedly found pachymeningitis and localised purulent arachnitis. A long sequestrum could sometimes be extracted from the external auditory meatus at the post-mortem, and then when the auricle was removed we could see into a considerable cavity occupying the larger part of the petrous bone. In a few cases we could extract pieces of dead bone even during life, either from the meatus or from a fistulous opening in the mastoid portion of the temporal bone. The abscesses and fistulae behind the auricle always communicated with the interior of the carious bone. In one extremely cachectic and aucemic boy of 3 years the external ear was almost completely separated from the head by a semi-lunar gangrenous fissure, and from this we were able to remove a sequestrum j in. long and 5 in. broad. PERIPHERAL PARALYSES, 245 Almost all the children in whom I observed this paral3sis were also tubercular, and died sooner or later. In one of these cases there were numerous nodules (ranging in size from that of a millet to that of a hemp- seed) on the dura mater of the middle cranial fossa. Less commonly the caries arose from the neglect of a simple otitis media, especially when this was a sequela of scarlet fever ; and I therefore recommend you when children are recovering from scarlet fever always to pay special attention to any otorrhoea that may remain. Some of the cases which I have had to do with showed that the destructive process, which begins in the middle ear and spreads to the bones, may have a surprisingly short course, and may lead to caries of the petrous bone with facial paralysis even in a few weeks after recovery from scarlet fever. The peripheral paralysis of other cranial nerves is much less common in children, and presents in them even less that is characteristic than facial paralysis does. This is also true of the paralysis of the spinal nerves due to local causes. Among these there is only one that arises at birth, and which on account of this causation calls for remark here. Not only on the facial nerve but also on the brachial plexus, the forceps may exert so strong a pressure that paralysis of one or more groups of muscles in the affected arm may take place. Koger ^ describes one such case in which immediately after birth the facial nerve and one arm were both paralysed. The impress of the forceps over the clavicles was still visible, and after death — which soon followed — eftusions of blood were found both in the neighbourhood of the stylo-mastoid foramen, and in that of the brachial plexus. Other obstetrical processes may however also have the same effect as the pressure of the forceps, especially difficult extractions or violent dragging of the arm, along with which dislocation or fracture of the humerus has been occasionally observed. The luiematoma of the sterno-mastoid formerly mentioned (p. 39) may also occur under these circumstances. This " congenital " (or really "artificial ") paralysis of the upper extremity ma}', like that of the facial nerve, either pass off rapidly or — should degenerated processes have been set up in the nerves of the arm by the cause of the paralysis — continue many years or even during the whole lifetime. It may also be combined with sensory ' Jnurn./. Kinderh-ankh., 1864, S. 40o. 246 DISEASES OF THE NERVOUS SYSTEM. disturbances. Tims I have observed, in a child of five, anaesthesia oecurnug with the paralysis on the ulnar side of the forearm. The position of the arm, which is due to the contrac- tion of the antagonistic muscles, varies according to the muscles affected. Most frequently there is rotation inwards with marked pronation of the hand, owing to the action of the pectorals, subscapularis and latissimus dorsi being stronger than that of the paralysed infraspinatus. The faradic irritability of the paralysed muscles rapidly disappears and atrophy of the affected limb soon sets in, in which — as I have frequently seen — even the bones may participate, so that finally the scapula and the bones of the arm and hand are considerably shortened as com- pared with those of the healthy side and the whole limb appears stunted. Nothing can be expected from treatment, except in the earliest stages of the disease. The continuous application of electricity, especially the galvanic current, may still be of use so long as the nerves are not fattily degenerated and the muscles are still capable of reacting. At a later stage we can expect nothing either from this or any other remedy whatever. An excessive stretching of the brachial plexus may in later childhood, as in adults, occasion paralysis or at least paresis of the upper extremity sometimes lasting for weeks or months. I have observed, for example, paresis of this kind in the left arm in a little girl whose arm had been violently wrenched backwards and outwards while her jacket was being put on. The movement of the limbs, especially upwards and outwards was extremely limited, and it was only after several weeks of the continuous application of stimulating friction and finally of electricity, that the function of the deltoid was com- pletely restored. Such cases, if the cause is obscure, may occasion great anxiety ; since not only the parents but even the conscientious physician may not be able to exclude a cerebral origin of the paralysis until the improvement decidedly begins. The same may be said of the paresis or paralysis of an upper or lower extremity which children occasionally have for some days after violent convulsive attacks. It is not possible in these cases to determine at once whether we have to do with a passing disturbance of motion or with a cerebral disease, since, as we shall see presently, very serious cerebral diseases — especially tubercle — are not uncommonly announced by the sudden oc- SPINAL INFANTILE PARALYSIS. 247 currence of convulsions, which leave paralysis behind when they go oft'. It disappears again after some time, then returns quite unexpectedly ; or the true nature of the disease may he revealed by the onset of tubercular meningitis. I therefore advise you in the diagnosis of all localised paralyses, when their peripheral origin is not beyond doubt, to be very guarded and to keep in mind the possibility of a central disease even although no further symptoms of such should be present. One must of course also, under these circumstances, always remember the possibility of an injury of the affected joints, of a dislocation or subluxation of the joints of the shoulder and forearm, even of fractures of the bones, and examine carefully for these conditions. I should not have mentioned this had I not several times found in the polyclinic that these traumatic afiections had been called paresis by careless practitioners. The contrary sometimes occurs in the lower limbs, where a dragging of the leg or a slight limp is falsely ascribed to commencing coxitis, when it is only the result of the bruising of the muscles by a fall, and disappears in a short time if the child is made to rest. IX. Spmal Infantile Paralysis. This disease— which, before its pathology was known, was described by the name of " essential paralysis " — derives its particular interest from its comparative commonness, and from the severe effects which it has during the whole lifetime of the patient. Most of the cases you meet with affect children between one-and-a-half and four. The parents state that the child some weeks or months before lost the power of an arm or leg, or even of several limbs. On examination, we find in a cer- tain proportion of the cases that the affected limb is really quite motionless. The child does not make the slightest attempt to grasp anything or to stand on his feet. The whole limb is as flaccid as that of a doll, so that you can throw it about in all directions without resistance. The sensibility, on the other hand, is almost always unimpaired. In other cases the paralysis is already beginning to diminish. Certain movements of the limb can be performed, others are quite impossible. Thus, for 2i8 DISEASES OF THE NERVOUS SYSTEM. example, the fürearm can be pretty well flexed and extended at the elbow joint and the band at the wrist, while movements of the ujiper arm outwards and upwards, and the pronation and supination of the hand are either quite impossible or can only be effected to a very limited extent.^ All this time the child is usually quite well ; all its functions are in good order, and its appearance generally very good. The sphincters of the bladder and bowel are only exceptionally affected. The commencement of the malady is almost always described by the relatives in the same way as in the following cases, which I give as examples. On the 20111 July, 1874, a gii-1 of 4 j-ears was brought to my con- sulting room. Formerly healthy, she had taken ill suddenly in September, 1873 — that is, about 10 months before— with violent fever, the temperature rising to 105'8° F. The child complained at the same time of headache and was drowsy. There were no other local sjTnptoms. After 2 days, the temperature fell. When she tried to stand up, we noticed paralysis of both lower ex- tremities and of the right arm. In the course of 3 or 4 days power returned to the legs; she could then walk, but the arm remained paralysed, and on examination it presented the characteristic symptoms which we are about to descril^e. Child of 1| 3'ears, brought to the polyclinic on 15th October, 1881. Three weeks previously, fever lasting for several days. This was succeeded by paralysis of all four extremities. A\Tieu brought to me, the movements of the arms had already almost returned to the normal state, but the paraplegia remained unchanged. One week later the left leg was also tolerably well moved, while the right was completely paralysed. Sensibility ])erfectly normal. This is the usual course. In the midst of perfect health the children become feverish (occasionally the temperature is very high), they complain of headache if they are old enough, and are somewhat drowsy. More rarely they lie in a regularly comatose, half-conscious state, out of which they can only with difficulty be roused by shaking; or they may even show convulsive movements and contractures. Still more rarely the disease begins with convulsive fits, and in one of my cases these were repeated 7 or 8 times in one night. After a few days — or a week at most — this condition passes off, and the parents are alarmed by For particulai-s on tlie localisation of paralysis in certain groups of muscles, and their relation to corresponding patches in the spinal cord, vide E. Eeraak, Archie f. Psychiatrie und Nervenlranlh., Bd. ix., Heft 3. SPINAL INFANTILE PARALYSIS. 249 finding that one or more limbs cannot now be moved. In a less numerous class of cases the preliminary febrile stage seems not to occur at all, and the paralysis comes on almost suddenly, without any premonitory symptoms, in the morning after a good night's sleep. Without wishing to deny that this form of onset occurs, I still think that the relatives — especially in the lower classes — often overlook slight preliminary disturbances. Now, as to the seat of the paralysis, either both legs and one arm, or a leg and an arm on different sides, rarely an arm and leg on the same side may be affected (in a hemiplegic form) ; or still more rarely it may be both arms, and more frequently both lower limbs, and sometimes even all four extremities. The paralysis is also often confined from the first to one limb only. The characteristic point however is, that the paralysis almost always reaches its worst at the very beginning; all the harm that is done, is done at once (as in the apoplectic paralysis of adults), or at least in the first 24 — 48 hours. After that there is a distinct tendency towards improvement. Only quite exceptionally have I been told that the paralysis continued to increase after the first week, or passed after some days from one of the lower extremities to the other, which Duchenne also observed. The power of motion is in many cases very rapidly recovered, as in those just given. Even after a few days, or after a week, one or other limb is once more able to exercise its functions ; or some groups of muscles in a limb may be capable of motion, while others remain absolutely paralysed, so that we have an incomplete paral3^sis of the afi'ected limb. In the upper extremity, the muscles of the shoulder and upper arm are especially affected, less commonly those of the forearm, so that the hand and fingers can generally be moved ; while in the lower extremity, the muscles of the leg, supplied by the peroneal nerve, and in the thigh, the quadriceps muscle, are especially apt to be paralysed. After some weeks the paralysis is ofteuer still confined to a single group of muscles in one arm or one leg, but in these they usually remain with a sad persist- ence. After many months, and even years, the condition may be unaltered, and it not unfrequently remains so for the whole lifetime. In other cases, however, the paralytic symptoms, after remaining for months, improve in a most surprising way, as f.fi. in the following case : — 250 DISEASES OF THE NERVOUS SYSTEM. Child of 2 years, brought to the polyclinic on 17th March, 1882. Seven months before, fever lasting some days, and general malaise. This was succeeded by paralysis of the muscles of the neck and of all four extremities. After some weeks the head could again be held up, but the paralysis of the upper and lower extremities persisted almost unchangedfor three months, so that the child could not grasp anything, and was unable to leave its bed. After this time the paralysis of the right arm and left leg disappeared under electrical treatment ; finally also that of the right lower limb and of the left forearm, so that when he was shown in the hospital there was nothing to be made out but paralysis and atrophy of the upper arm, especially of the deltoid. When the paralj'sis has existed for some weeks, or even months, a number of additional symptoms appear which must be regarded as quite characteristic, and which at once place the diagnosis of the disease beyond a doubt. These symptoms are : increasing atrophy of the paralysed extremity, diminution of its temperature and of its electro-muscular excitability. The paralysed limb diminishes steadily in circumference owing to wasting of the muscles. The region of the deltoid and the shoulder muscles, especially, wastes in a very marked manner, so that a space may be felt between the acromion and the head of the humerus, and the shoulder seen from behind looks much flatter than the healthy one. The upper arm and forearm also become wasted as a whole, all the muscles are shrivelled and thin and the ligaments strikingly loose, so that the affected limb may appear a little longer than the healthy one. In very fat children the atrophy of the muscles may appear less than it really is, owing to the amount of adipose tissue. When the hand is applied we feel distinctly the lowered temperature of the paralysed limb compared with that of the healthy one; and we have been able by a suitably-constructed thermometer, to measure this diminution, which may amount to 1'8° F. The behaviour of the muscles to the electric current is also very characteristic. I have no experience of the increased faradic and galvanic reac- tion which some (Benedikt) have observed during the initial stage of the disease. When the paralysis is present however the reaction disappears almost as completely as in peripheral paralysis — that to faradic electricity especially earh^, while the galvanic current still acts, and may even cause an exaggerated reaction (reaction of degeneration). Occasionally even on the SPINAL INFANTILE PARALYSIS. 251 fifth (Tay after the onset of the paralysis (and more frequently after one week) some of the muscles contract but feebly, others not at all to the faradic current. This is always a bad sign, for when the muscles cease to react some weeks after the onset of the disease, they usually remain incapable of reaction during the whole life. The further the degeneration of the muscles proceeds, the weaker does the reaction to the galvanic current become, until finally it also entirely disappears.^ The plantar reflex (on tickling the soles) is usually absent, as also the patellar reflex (knee-phenomenon). Still we must remember that even in healthy children the latter is more difficult to obtain, on account of their struggling, and especially stretching out their legs, and therefore it more frequently fails us than in adults.^ In addition to the atrophy of the muscles, an arrest of growth in the bones is also observed, so that the limb appears shorter than the healthy one. This arrest of development of the bones, as Duchenne and Volkmann have pointed out, does not always proceed pari passu with the degree and extent of the paralysis and of the muscular atrophy. The latter may be very well marked, and yet the limbs scarcely appear shortened; while in some cases, where paralysis and atrophy are only very limited, the growth of the bone may be arrested to a considerable extent. This fact, according to Charcot, is in favour of the direct influence of the central disease on the nutrition of the osseous system. If the paralysis is not recovered from within ten or twelve months from its commencement, there is generally but little hope of any recovery taking place at all. About this time a new series of symptoms usually develops. As the paralysis and atrophy do not aftect all the muscles of a limb equally, but are ' Cy, on this subject, Seeligmiiller , Gerhardt's Ilandb. d. K'mderlrankh., Bd. v., Abth. 1, 2. Hälfte, S. 68. - Eulenburg {Deutsche Zeitschrift /. prakt. Med., 1878, No. 31; and Neurol. Centralbl., No. 8, 1882), in 124 children between 1 and 5 years of age found the knee-phenomenon absent on both sides in 5'65 per cent., and on one side in 2'42 per cent. Vide also Haase, Beitr. zur Statistik der Reflexe hei Kindern, Diss.: Greifswald, 1882. — Bloch, {Arch. f. Psychiatrie u. Nervenkranhh., xii., 1882) and Paragö, Arch. f. Kinderheilk., viii., S. .385). Pelizaeus {Archiv f. Psychiatrie, xiT., H. 2) found only 1 out of 2,403 children in whom he was never able to obtain a patellar reflex, while Z e i s i n g ( Ueber das Kniephänoinen u.s.tc, Diss. : Halle, 1887) failed entirely to find it in only 1"4 per cent, of his cases, althoiigh it was often indistinct or much diminished (altogether in about 11 per cent.). We are evi- dently not yet in a position to speak dogmatically on this matter. 252 DISEASES OF THE NERVOUS SYSTEM. almost always confined to single muscles or groups of muscles, deformities are produced by contraction of the opposing muscles which have not lost their tone and contractility. In the great majority this takes the form of pes equinus, but we may also have pes varus, club-hand, and other abnormal postures of the upper and lower extremities. This explanation of the de- formities as due to the contraction of the antagonistic muscles, was generally accepted until very recently, and still has many supporters. Hüter and Volkmann were the first to try to replace it by a mechanical explanation, according to which the deformities are supposed to be due to the position and weight of the limbs; while others (Hitzig) take into account in their explanation the contraction of the connective tissue of the muscles whose nutrition has been interfered with. However this may be, when the deformities commence the disease may be regarded as having reached its last stage; and we have then only to do with a crippling which the patient will have to carry with him to the very end of his life. The anatomical researches (to which the first impulse was given by Cornil, Laborde, and Charcot in the Salpetriere in Paris in 1863-4) prove that the former views of the nature of the disease — that it was an "essential" affection, or a disease of the peripheral nerves or of the muscles — were incorrect. They have entirely confirmed the supposition of those phj'sicians (Heine) who regarded the spinal cord as the real seat of origin. Almost all the anatomical observations, indeed, were made on the later stages of the disease, generally even on adults and old l^eople, who had carried the infantile paralysis into old age. All the observations, however, prove this fact beyond a doubt, that we have to do with an inflammatory process of the grey substance of the anterior horns of the spinal cord, which may extend into the antero-lateral column. Slight changes in the posterior horns have also been found in excep- tional cases. We find patches of myelitis either in the upper or lower part of the cord, according to the position of the paralysis, especially in the cervical and lumbar enlargements. In com- paratively recent cases — as in those described by Roger and Damaschino^ — in which the paralysis had existed for two and six months respectively, these patches had a length of about ' Gaz.mcd., 1871. SPINAL INFANTILE PARALYSIS. 253 1 — lg ctm., aucl a breadth, at their widest part, of 1 — 2 mm. They were of a soft consistence and reddish colour, and under the microscope showed an increase of the capillaries, a thickening of the walls of the blood vessels with a profuse formation of nuclei in them, and very numerous granular cells. The multi- polar ganglion cells of the anterior horns, and the motor root-fibres passing from them were atrophic ; and slight sclerosis of the white anterior and lateral columns was to be found. Roth's case,^ which had lasted several months, was a quite similar one ; but in it the patch implicated on the right side not only the antero-lateral column, but also the posterior column. A case recently published by Archambault and Dama- schino*^ is of especial importance, because the post-mortem took place on the 26th day after the commencement of the disease. Paralysis of the left leg. Sensibility normal ; all reflexes absent. Paresis of the right arm ; paralysis of the neck; faradic reaction entirely absent. Death from measles and broncho-pneumonia. P.-M. — in the grey anterior horns of the cervical and lumbar regions there were several very small patches of softening ; vessels over-distended with blood ; numerous granular cells ; the ganglion cells very atrophic. In the anterior nerve-roots and at their j^oint of origin in the grey anterior horns and white anterior columns, the medullary sheath and the axis-cylinder were wanting. Ihe nerve sheathes were partly empty and partly contained medullary substance which stained black with osmic acid, exactly as in nerves which have been divided. The older the trouble is, the more prominent is the appearance on which Charcot laid especial weight, namely, the atrophy of the multipolar ganglion cells, combined with sclerosis of the grey anterior horns and atrophy of the motor root-fibres passing out of them. In old cases, especially when the post- mortem is not made till an advanced age, we may have a diifuse atrophy of the anterior horns and of the white substance of the antero-lateral columns, with disappearance of the large ganglion cells and development of numerous corpora amylacea (Charcot, Leyden^), even an arrest of development and atrophy ' Virchow's Archiv, 1873, Bd. 58, S. 263. Vide also F. Schnitze, iVewol. Cen- tralbl., i., No. 19. - Revile mens, des maladies de Venfance: Fevr., 1883. ' Klinik der Rückenmarkskranich. : Berlin, 1875. 254 DISEASES OF THE NERVOUS SYSTEM. of tlie motor area of the cortex on the side of the brain opposite to the paralysis.* As regards the muscular atrophy which plays so important a part in this disease — a large part of the primitive bundles seem simply to atrojihy in the earlier stages without undergoing fatty degeneration (Damaschino, Volkmann and Steudener). The accumulation of fat in the sheaths of sarcolemma begins at a later period, filling the place of the primitive bundles which have disappeared ; and at the same time also, in the interstices between them — sometimes to such an extent that the atrophy of the muscles is concealed by it, and their volumn appears normal or even increased (Laborde, Charcot). This formation of fat is, however, by no means invariable ; it may be present in some muscles and almost completely absent in others, in which case the interstitial connective tissue appears more or less hypertro- jihied. The appearance of the muscles to the naked eye varies according to these differences. They are either thin and pale- reddish or yellowish ; or else bulky, and in that case they seem to be almost entirely converted into fat. When there is general emaciation, moreover, this fat also disappears and the atrophy of the muscles is then all the more distinct. The nerve-roots and nerve-trunks, also, have not uncommonly been found atrophied in the paralysed parts, and they then appeared attenu- ated and grey ; while in other cases the thickening of sheaths and the increase of interstitial connective tissue and fat concealed the atrophy .- The appearances being such as I have described, there can no longer be any doubt that spinal infantile paralysis is to be at- tributed to a myelitic process occurring in patches, which is most apt to affect the grey substance of the cer\ical horns^ especially the cervical and lumbar enlargement.* In course of time the process may, as already remarked, spread to the antero-lateral columns, and may indeed occur in a diffuse form both above and below ; and in a few cases an affection of the grey substance of the posterior horn has even been observed — which explains the ' Rumpf, Arch. f. Fychiatrie, Bel. xvi., Heft 2. — Sander, (Euo-es comj)l. de Charcot: T. iv., Paris, 1887, p. 38. ^ Cf. on the changes in the muscles and nerves, Eisenlohr, Deutsches Archiv/. I.Vin.'AM., Bd. sxvi., S. 543. ^ Kussmaul therefore proposed to name the disease "Poliomyelitis acuta anterior." SPINAL INFANTILE PARALYSIS. 255 fact that occasionally disturbances of the sensory functions (anaesthesia, pains) have been observed — but this is always an exceptional occurrence. I have myself met with one case of this kind, in which the greater part of the paralysed leg showed loss of sensibility ; while in another child of two years (18 July 1879) the disease had begun three weeks before, with four days of fever and severe pain in the left arm. The arm on the fifth day was quite paralysed, but still retained sensibility. These sensory derangements — especially as occurring in the first stage of the disease — have been already mentioned by Duchenne, Kennedy, Vulpian and others ; but very little attention has been paid to them, owing to the fact that they are very difficult to make out, especially in children who are too young to speak. The implica- tion of the sphincters of the bladder and bowel has only been observed in exceptional cases. I have also repeatedly seen the muscles of the neck affected. Thus in a child of three, after a febrile initial stage lasting two days, there suddenly appeared paralysis of the right upper extremity, and of the cervical mus- cles on the right side. The head could no longer be held upright, but rolled about in all directions, and when the child was Ivincr down he could only move it to the left side. This paralysis dis- appeared after a week, while that of the arm continued and was soon accompanied by atrophy of the deltoid and shoulder muscles and by diminution of temperature. All authors agree in saying that the brain is not affected. Ley den" expressly says that the facial and hypoglossal nerves and the eye-muscles have never been found implicated, and that he has only in one case found a small sclerotic patch in the medulla oblongata, which had caused no symptoms during life. These facts seem to me to make the following case all the more important. Bertha M., 2^ years old. brought to my jwl^xlinic on 1st May, 1876. Three weeks before, she had sudden fever with vomiting and persistent drowsiness. Tliese sj-mptoms continued 2 days. On the second day weakness of the right liaud was already notice- able, and on the third paralysis of the whole right arm. Drowsi- ness continued for 3 days after this. The child then seemed well, ' Laurent, " Symptomes premonitoires de la paralysie spinale aigue," These de Paris, 18S7. - Loc. vit.. ii., S. 555. 25G DISEASES OF THE NERVOUS SYSTEM. but there was paralysis of the right arm and of a portion of the left facial nerve. The latter had not quite disappeai'ed when I examined the child. The left eye still remained half-open when she screamed or cried, and the mouth was somewhat drawn to the riglit side. The right arm hung down flaccid, the upper arm was quite immovable, the forearm movable at the elbow joint; the adduction of the thumb was the only movement possible in the hand. The muscles on the left side of the face gave the normal reaction to the faradic current, while in the right upper extremity only the flexor and adductor pollicis and some fingers were moved. All the other muscles gave a very weak reaction or none at all. The galvanic current was not tried for want of the apparatus. Sensi- bility, bulk and temperature normal. From May to the end of October the faradic current was applied almost daily, and finally brought about a marked improvement. The flexion of the elbow and wrist joints, the movement of the thumb and of the 4th and 5th fingers almost normal. On the other hand the arm could not be moved outwards or backwards. The deltoid and muscles of the shoulder much wasted, and the whole right extremity colder than the left. The 2nd and 3rd fingers stiffly flexed and could be voluntarily extended. The facial nerve had recovered its functional activity completely by the middle of May, without electric treat- ment. I did not see the child again till 28th April, 1879. At that time she had been treated with electricity for nearly a year, and had made considerable progress, so that the arm could now be moved backwards and outwards. The atrophy was still unchanged, and the right hand markedly smaller than the left. The characters of spinal infantile paralysis are in this case very well-marked, and the implication of the facial nerve forms, therefore, an exceptional feature not hitherto described. I must assume that in this case at first, simultaneously with the patch of myelitis which appeared in the right anterior horn of the cervical enlargement, a very limited patch of encephalitis had developed in the neighbourhood of the nucleus of the left facial nerve. The latter after a few weeks underwent complete resolution, while the myelitic process persisted longer and led to partial atrophy of the ganglion cells. When one re- members that other spinal affections — for example, multiple sclerosis — are not at all uncommonly combined with analogous changes in the brain, one cannot really see why the same should not occur in infantile spinal paralysis. The occurrence of coma and convulsions in many cases with a febrile initial stage, is in fact in favour of the view that the brain may be SPINAL INFANTILE PARALYSIS. 257 more often affected iu this disease than we are wont to «uppose.^ The symptoms of spinal infantile paralysis are so well-marked and characteristic, that it is scarcely impossible, if one exercises any care at all, to confound it with any other form of cerebral or spinal paralysis. The febrile initial stage, the sudden onset of the paralysis (which is almost never progressive, but always retrogressive, and from being widely extended at first rapidly diminishes till it is confined to a more limited area), the almost invariable immunity of the sensory functions and of the sphinc- ters, the rapid disappearance of the reaction of the muscles to the faradic current, the early atrophy and fall of tempera- ture, and, finally, the deformit}' — all these are found thus com- bined in no other disease. I therefore consider it superfluous to discuss here, one by one, the diseases which might possibly be mistaken for it. The question, however, arises — whether all the cases which present the clinical characters of spinal infantile paralysis are really caused by these disseminated patches of mj'elitis as they have formerly been described to be. In fact, it cannot be denied that peripheral paralysis of single limbs — of one arm, or of one lower extremity — may resemble perfectly in its clinical characters the central affection which we are consider- ing. From the effect of inj uries, especially from over-stretching or compression of a nerve-trunk (p. 245), and dislocation of the shoulder-joint, paralysis may arise and be accompanied after a short time by atrophy of the muscles and loss of their reaction to faradic electricity, just as in certain cases of peripheral paralysis of the facial nerve. Duchenne has already pointed out this congenital dislocation of the humerus as an affection similar in its symptoms to infantile paralysis. One thing however is wanting in all these cases of paralysis, namely, the febrile pre- monitory stage, sometimes accompanied by cerebral symptoms. Many years ago Kennedy described cases of paralysis which arose quite suddenly without any warning in perfectly healthy children. In some of the cases the children went to bed well and wakened in the morning with paralysis of a lower and upper ' Seeligmüller gives a case not unlike my own {Jahrb. f. KinderheilJc . xii., 1878, S. 348). Eisenlohr gives another {Arch./. Psychiatrie und Nervenkrankh., Bd. ix. and x), which was not really a case of spinal but of '' bulbar " paralysis ; and in it atrophy of the ganglion colls of the left anterior facial nucleus was dis- «.'ovorcd. 17 258 DISEASES OF THE NEKVOUS SYSTEM. extremity, which as a rule again disappeared after a varying period (the so-called temporary paralysis), but might also take the same course as spinal infantile paralysis. In such cases, one looks for local causes, without, however, always finding them ; and in that case we either assume that the head has pressed on the nerves of the arm during sleep, or that there has been a chill, or reflex irritation from teething — though the assumption has generally not much to go upon. The teething, at any rate, which is blamed by English writers, I have not beeu able in one single case to make sure of as the cause of such paralysis. At any rate these cases of paralysis which Kennedy has described are very various in their origin, and a small proportion of them seems really to belong to the class of spinal infantile paralysis. Uncertainty in the diagnosis can only arise when we have a paralysis of one limb along with atrophy of the muscles and loss (if their reaction to electricity. For when the paralysis is extensive there can be no doubt that it is due to mj-elitis. The only disease which can possibly be mistaken for this is the "atrophic cerebral paralysis" which I shall describe presently. But in the latter we are generally guided in the diagnosis by the implication of cranial nerves, mental derange- ment, and the condition as regards electrical reaction. I think I ought to mention that cases of simple atrophy of one or other extremity, occasionally occur with somewhat lowered temperature, at the first glance reminding one of spinal infantile paralysis, but in which the muscular strength is little if at all impaired, and the electric reaction is normal — where, therefore, there is no paralysis whatever. Such cases of atrophy may depend on a defect of primary formation ; as, for example, in a girl of 7 years, always healthy, but left-handed, whose right hand, left thigh and leg had always been to a certain extent atrophied, without the strength having suflered, and without nervous symptoms ever having been observed at any time. In such cases all the tissues — bones, muscles, and fat — in the affected extremities show a weaker development than the corre- sponding normal limb. In another case — that of a child of 7 months — the atrophy of the left leg and foot was the result of the umbilical cord having been twisted round it in a spiral manner. Here also neither the motility nor the electro-muscular contractility had in any M-ay suffered. In some cases of this I I SPINAL INFANTILE PARALYSIS. 259 kind the mothers had not noticed tlie atrophy at all, and it was first discovered accidentally in the hospital. We know practically nothing ahout the causes of spinal infantile paralysis. The disease sets in as a rule quite suddenly, and in the midst of perfect health, and even in spite of the most careful investigation wo hardly ever succeed in finding anything which could have occasioned it. In one of my cases a fall into water was given as the cause. Occasionally we observe the symptoms of spinal paralysis after infectious diseases, for example, after scarlet fever, measles, smallpox, typhoid, or pneumonia. In most of these cases recovery takes place ; still, atrophy may appear during the further progress of the case, and it must for the present remain undecided whether the pathology of these cases is quite the same as that of infantile spinal paralysis. I may simply mention in passing that the latter, though much rarer, yet may occur in adults and present all its usual symptoms. In most cases the physician is not called in until the disease has already lasted some weeks. If you are summoned in the acute premonitory stage, you never know, of course, whether spinal paralysis is ahout to develope, because you find nothing hut more or less high fever, wdth or without cerebral symptoms. If the latter are present we should apply an ice-bag to the head, in very severe cases a few leeches behind the ears, or to the temples, and order purgatives (calomel, gr. ^ — | every three hours, or mist, sennae co. Sec). When, however, the paralysis has declared itself, I no longer expect any result from internal treatment. Experience teaches that nothing can favour recovery from the paralysis and prevent atrophy, except electrical treat- ment begun as early as possible. Although some, e.g. Heine and Volkmann, maintain that electricity is not of very much use, or that all hope is to be given up if it produces no result within a year, this view conflicts with the great success which Duchenne and others have had, who have succeeded, even after the expiry of a year, in obtaining results by persistent treatment ; and the case given above (p. '255) is another proof of the same fact. We can, therefore, only give the advice to per- severe ; but this is just the very point where many parents fail, and even many physicians also. We may begin the electrical treatment a very few weeks after the onset of the disease. The 260 DISEASES OF THE NERVOUS SYSTEM. galvanic current is recommended, very properly, for this early stage, because the faradic is too irritating and painful for children, and, besides, the reaction to it may already be much diminished, or even altogether wanting, while the galvanic current has still a distinct action. According to the rich ex- perience of Duchenne — who, however, only used the faradic current — the treatment at the commencement must be vei'y cautious. It must begin with a weak current, be applied only thrice a week, and continued each time for not longer than five, or at most ten, minutes. In the later stage the faradic suits as well, perhaps even better, than the constant current ; for it is then our object to excite the muscular fibres which have not yet degenerated by a powerful stimulus, and to favour their nutri- tion. I repeat, that the treatment in obstinate cases must be persevered in for years before the case is given up for hopeless. Along with electricity, massage and gymnastics are to be recommended ; and these, when properly used, by occasioning regular exercise of the muscles which are not yet completely incapable of contraction, have the power of strengthening their function, as well as of favouring their nutrition. During the later stages, we have to avail ourselves of orthopaedic surgery, in the form of apparatus and operations (tenotomy). We may thereby endeavour on the one hand to prevent de- formities, and support the atrophied muscles, and on the other to remove the contractures of the opposing muscles. It is the old cases of infantile paralysis that furnish a large pro- portion of the material in the orthopaedic institutes, and Heine's celebrated work^ which has done so much to introduce sound views on the subject of infantile spinal paralysis, is itself the outcome of his orthopaedic observations. The manufacture of such apparatus, as well as the form of gymnastics to be employed, must be suited to each individual case, and in most cases the physician should get advice and assistance from an experienced orthopaedic surgeon and a clever instrument maker. Among the lower classes I have on several occasions found in- telligent fathers, who of their own accord had constructed apparatus which in spite of its simplicity and cheapness answered the purpose pretty well. Although the recovery of the electrical reaction is always an ' SjJinale Kinderlähmwiff, Monographie., 2 Aufl. : Stuttgart, 1860. SPINAL INFANTILE PARALYSIS. 2G1 extremely good sign, still, experience shows that this reacLion (to both kinds of current) may still he absent when the first traces of voluntary movement begin to make their appearance, and we must then continue the application of electricity all the more steadily. Other methods of treatment I cannot recom- mend to you. I have no faith in the use of iodide of potash, either at the beginning or later on, and the injections of strychnia (gr. ^V — 2T gi'' daily) which are occasionally recom- mended, have so far — in my hands at least — had no effect. What can, however, be recommended — where circumstances allow of it — is to send such children during the finest part of the year into the fresh mountain or forest air, and to order brine or chalybeate baths, which by the large amount of carbonic acid which they contain, have a stimulating influence on the cutaneous sensory nerves, and in this way act reflexly on the motor functions, if there should be any normal muscular tissue left. But neither Rehme and Nauheim, nor Schwalbach, Pyr- mont, and Driburg, nor, finally, the equally famous indifferent thermal waters (Gastein, Wildbad, Ragaz, and others) will do any good whatever, apart from their action on the general health, after the case is old, the ganglion cells already atrophied, and the muscles in a state of contracture and fatty degeneration . Under these circumstances nothing is any longer of use, and the patients spend the rest of their lives as cripples. Spinal infantile paralysis is the only disease of the spinal cord which is especially liable to afiect children, and in doing so pre- sents certain characteristic symptoms. The only other spinal disease which plays an important part on account of its frequency in childhood is the paraplegia resulting from disease of the vertebrae. But it differs in no way from the same condition in adults. There is the less need for discussing it here, as the vertebral disease which occasions it is fully considered in all surgical works, and also because the treatment almost entirely devolves upon the surgeon. It is certain that in childhood many other diseases of the spinal cord do occur which occasion paralysis, such as inflammatory processes, haemorrhages, tubercle, even tumours of diff"erent kinds ; although they are much less common than in adults. These conditions do not present any- thing peculiar or characteristic in children. Their symptoms are the same, and their special diagnosis is in most cases just as 262 PISKASES OF THE NERVOUS SYSTEM. difficult— ill fact as impossiblo — as in lator life. There are two fliseases in particular, the occurrence of which in cliiklhood has within recent times excited considerable interest —sclerosis and the so-called "spastic spinal paralj'sis." The former has been verified post-mortem in children, although but rarely ; and we are indebted especially to Friedreich for our knowledge of a condition of sclerosis of the posterior columns throughout their entire length, Avith the occasional implication of the Literal and anterior columns. This condition developes hereditarily, especially about the time of puberty, is distinguished clinically by ataxic movements of the lower extremities to begin with, later also by interference with speech, paralyses of the eye- muscles, nystagmus and loss of the reflexes, and has an ex- tremely protracted course, lasting as long as 30 years. Spastic spinal paralysis, as is well-known in adults also, is little more than a group of symptoms corresponding to no quite definite pathological change. Such cases — which are characterised by a chronic paresis of both lower limbs (rarely of the upper), existing even from the first j'ear of life, and especially by contracture of individual groups of muscles — I have frequently met with in children. In these cases especially on trying to stand or walk, the attempt to plant the foot on the ground at once produced trembling and a rigid contracture of the calf-muscles, with the feet in the posture of pes equinus, and from the stiffness of its legs the child could only walk with much labour on the fore part of its feet, which were somewhat inverted — and even then only if supported or led. In many cases, moreover, there was such a contraction of the adductors of the thighs that they were almost crossed over one another, so that all locomotion was rendered impossible. This contracture also persisted when the child was at rest, and prevented active as well as passive separation of the thighs. The patellar tendon-reflex was generally exaggerated, the electro-muscular contractility, the sensibility, and the power of the sphincters not lessened, and no atrophy was noticeable.* Unfortunately all these cases 2)assed from under my observation, and remained anatomically uncompleted. The numerous cases of ' Seeligrmiiller (Gorhardt's I/andb. d. Kindtrlron/./i.. x., Abtli. 1.2. Hälfte, S. 1(J7) has observed 5 cases combined with atrophy of the muscles and symp- toms of bulbar paralysis ("amyotrophic sjiinal paralysis "). >)ut in all of them jjathological confirmation of the diafjnosis was wanting'. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 26B tliis kind published by Seeligmüller,' Fürster,^ Maydl,'' and d'Heilly,* iiave succeeded just as little in throwing light on this obscure subject. These writers, and also I myself have observed (though by no means constantly) a complication of the paralysis with deficient mental development — even idiocy, — stuttering or stammering, and spasmodic distortion of the face ; and this leads to the conclusion that the brain may participate, or that it may even be the point of origin of such a series of symptoms. In fact I shall presently have occasion to give you an example in which very considerable alterations of structure were found in the cerebral cortex at the post-mortem. I need scarcely remind you that under these circumstances a secondary degeneration of the fibres which arise in the diseased portion of the brain may spread to the spinal cord, and can be demonstrated microscopically. It is, moreover, possible in a certain proportion of these obscure cases by means of tenotomy and orthopiedic surgery, to bring about a certain degree of improvement in the walking, although not recovery. X. Pseudo-hypertrojjhic Muscular Paralysis. This disease, first mentioned by Duchenne,^ but first described accurately from an anatomical point of view by Griesinger,^ invariably originates during childhood, but may be prolonged into youth or adult age. When the disease is well developed, the symptoms are very characteristic. The muscles of the calves, buttocks and thighs — especially the first — are of unusual bulk, and frequently also of a remarkably hard consistence. Those of the chest, arms and shoulders are wasted and flabby, but not throughout their whole extent; for on closer examination we also find nodular thickenings here and ' Deutsche med. Wochenschr., 1876, Nos. 16 and 17. — Jahrh.f. Kinderheilh-., xii., 1878. - Jahrb./. Kinderheilk . , xv., S. 261. ' Kupprecht, "Ueber angeborene Gliedei-starre und spasstische Contractur," Volkmann' s Sammlung Hin. Vorträge, 198.— Maydl, Einige Fälle von spastis- cher cerebrospinaltr Paralyse hti Kindern : Wien, 1882. * d'Heilly, "Revue mens, des maladies de l'enfance," Dec., 18Si.— Naef, Die spast. Spinalparalyse im Kindesaller. ; Zürich, 1885. ^ Electrisation localisee, 2. edit., p. 353, and .ir-ch. gen., Janv. — Mai, 1868. " Arch. d. Heilkunde.. 1865, vi., S. 1. SCi DISEASES OF THE NERVOUS SYSTEM. there in the delloid, biceps, iiiul triceps hvachii. The recti abdo- minis and the lumbar and dorsal muscles, also, are often thickened,, though not to the same degree as those of the lower limbs. In a few cases — e.g. in one observed by Bergeron — all the muscles with the exception of the pectorals and sterno-mastoids were liypertrophied, so that the child looked like an athlete. The patients' gait is very peculiar. They walk with their legs apart, waddling, and only touch the ground with the fore part of the foot, which is in the posture of pes equinus. At the same time the natural lordosis of the lumbar vertebras is much exaggerated (forming a concavity like a saddle) owing to the weakness of the erectores spinne. If you make the patient lie down on the ground and get up again, you notice that he "climbs up his own legs," as the phrase goes ; that is to say, he first brings himself into a position which enables him to use his hands as a lever to raise himself with, and finally manages to do this by placing his hands firmly on the ground, then supporting them on the thighs, in this way raising up the upper part of his body. In the latest stage in which the weakness of the upper extremities reaches an extreme degree, this mode of raising himself becomes, on that account, no longer possible. I have hitherto had the opportunity of observing this rare disease only in six cases, and in every one of them there was this peculiar method of rising up. All the patient's movements are in general clumsy, awkward and laborious, and they become weaker as the disease progresses. The electro- muscular excitability increases steadily Avith the progress of the disease. At the same time the adipose tissue, especially in the lower limbs, may be well preserved, but when marasmus finally sets in it disappears. The atrophied muscles in the upper part of the body often present fibrillary twitchings similar to those in progressive muscular atrophy in adults. The skin of the lower extremities not uncommonly presents a marbled appear- ance, owing to venous engorgement, and a lowered temperature» but an increased secretion of sweat. Many of these patients are mentally weak and their speech is slow, and in rare cases an increase in the bulk of the tongue is said to have been observed. The development of this disease always dates, as I have already remarked, from the middle period of childhood, and it has been expressly stated by some that they have noticed the PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 265 slowness of the children's movements when they were even younger. We see most of the patients for the first time in the more advanced stage when they are 7 — 10 years old, and often much older. The diagnosis does not become certain until the bulk of the calf muscles has become distinctly increased. In the earlier stage, when this is still absent and we notice nothing but the peculiar gait and the above-mentioned character- istic method of rising up from the ground, we can only suspect the presence of the disease. Still, in very recent times, the diagnosis has been established even at this early stage by the examination of a fragment of muscle.^ The general health may remain unimpaired. The case observed by Demme of a boy of 10 years with a slow pulse (44 — 60), and a considerable amount of sugar in the urine (which however was not alw'ays present) stands alone as yet.- If the general health remains unimpaired, the disease may last 10 — 20 years, in the course of which time it often becomes arrested, but no real process of recovery takes place. If the patients do not die from a chance complication, they generally succumb in the end to the in- creasing atrophy and weakness of the respiratory muscles, or to marasmus. The pathological process in the muscles is very similar to that with which Ave are acquainted in spinal infantile paralysis, and in progressive muscular atrophy. "We have essentially a diminution in bulk of the muscular fibres, which in the apparently hypertrophied parts (calves and thighs) is replaced by a deposit of interstitial fat, and by connective tissue (atrophia musculorum adiposa). This compensation may also occur locally in the atrophied muscles in the upper part of the body (deltoid, &c.) in the form of isolated nodules ; and there are also a few hypertrophied primitive bundles between them. In what manner this atrophy is caused — whether by the primary forma- tion of connective tissue between the bundles, as Charcot and Duchenne consider probable (paralysie myosclerosique), or in other ways — cannot as yet be determined. Also the changes in the spinal cord occasionally described (the presence of a copious finely-granular substance and many corpora amylacea, especially in the lateral columns and disappearance of a large number of the ' Bourdel , "' Revue mens, des malad, de reiifance,"' Fen"., 1885. p. 54. - 15. Jahresber. d. Berner Kinderspitals, 1877. '2Cy(j DISEASES OF THE NERVOUS SYSTEM. large ganglion cells in the anterior horns) are by no means to be regarded as constant or essential. We discover nothing else morbid on examining the peripheral nerves and the sympathetic, although even here neuritic changes have occasionally been observed. It is only owing to the interference with movement that I have decided to place this affection along with the nervous diseases ; for from a j)urely anatomical point of view it is to be regarded as a primary affection of the muscles.^ I agree with those writers (Seidel, Erb-; who regard this disease as really an infantile or juvenile progressive muscular atrophy, which differs from the form observed in adults in that it does not as in them begin first in the interosseous muscles of the hand and in the muscles of the thumb, but in those of the back and lower extremities, sometimes even in those of the face.^ The progressive atrophy of the muscular fibres which finally renders many of the sarcolemma-sheaths quite empty, corre- sponds to the diminution of the electric reaction, which is equally noticeable in the wasted and in the thickened muscles. On the other hand the skin reflexes and sensibility r»?main the same. Indeed Steidel and Wagner made out a prolongation of the sensation of touch as compared with the normal condition. It is worthy of note that with few exceptions {e.g, the cases of two young women between 20 and 30 described by Lutz*) all the patients have been boys. Occasionally there have been several children in one family. Apart from this inexplicable (hereditary?) predisposition, all the other causes which have lieen suggested (unfavourable circumstances, scrofulous or rachitic cachexia) are open to doubt. I have unfortunately nothing favourable to tell you about the results of treatment. The administration of medicine has just as little effect as the compression of the calves by bandages recommended by Grie singer, which may at most interfere with the compensatory formation of fat, but can scarcely be supposed to have any effect on the muscular atrophy. Electricity, especially galvanism, ' Cf. Krieger, Deutsches Archiv f. klin. Med., Bd. xxü., Heft 2. " Erb, Deutsches Archiv f. Hin. Med., Bd. xsxiv.. H. 5 und 6. — Buss, Klin. Wockensch., 1887, No. 4. ^ O. Heubner, " Eiu paradoxer Fall von infantiler progi-essiver Muskela- trophie " : Leipsic, 1887. * Hirsch-Virchow Jahresbericht. 1866, ii.. S. 2(51 : 1867. ii., S. 293. APOPLECTIC CONDITIONS. 207 is always worth a trial. In one case which presented all the symptoms of the commencing disease, I saw these disappear under this treatment in 5 — 6 months. Bonrdel also reports a case of this kind. XI. Apoplectic Conditions. Cases of paralysis proceeding from the brain are observed in children far more frequently than those arising from the spinal cord ; and their general characters — the hemiplegic form and the long persistence of the electric reaction in the paralysed muscle — are just the same as in adults. Atrophy of the muscles may also accompany the paralysis ; but this developcs very slowly, seldom attains to the high degree in which it is found in spinal infantile paralysis, and appears to proceed more from inactivity and long disuse of the muscles than from any inter- ference with the trophic influence of the nerves. It is frequently accompanied by contractures due to excessive action of the non- paralysed muscles, or oftener to direct central irritation, and also by tremor and automatic movements. The onset of hemiplegia takes place in many cases quite suddenly in the midst of apparently undisturbed health, and we are then disposed to look for its cause— -as in adults — in a haemorrhage into the brain or in an embolic process. Both these processes, however, are comparatively rare in child- hood, and hemiplegia occurring suddenly is — in spite of its apoplectic appearance — much more frequently the expression of long-standing brain disease, especially of tuberculosis cerebri. Let us first consider cerebral haemorrhage as a cause of sudden hemiplegia. The rarity of its occurrence in childhood is principally to be traced to the fact that the most frequent cause of the condition in adults — namely, the fatty degeneration of the arteries of the brain and the formation of small aneurisms in them — is extremely rare in children. Some of the cases described as " haemorrhage " seem to me rather to be cases of encephalic deposits with a considerable admixture of blood. In this manner, I believe, we must explain the following case : — •2()8 DISEASES OF THE NERVOUS SYSTEM. Oscar Z., 3 years old, unwell (?) for some days, admitted iuto the ward 20th February, 1882. Since the j)revious night almost constant convulsions, trismus, tonic and clonic spasms of the ex- tremities, opisthotonos, cervical rigidity, convergent strabismus, complete unconsciousness and coma. P. 144; T. 101'3° F. The fits took place eveiy 10 — 1-5 minutes, accom]5anied by very rapid respiration and copious sweating. Wet-and-dry cupping, vinegar cnemata, an icebag to the head, and chloroform, had no effect. On 21st, the symptoms still continued; T. 101-3° F., ev. 103-1° F. P. small and irregular, 164. Death during the night. P.-M. — Dura mater much distended, reddened within and with- out. All the sinuses very full. Pia mater congested. Convolu- tions flattened. On the parietal surface on both sides, ha^mor- rhagic infiltrations of various sizes in the grey substance, in the form of bluish-red and dark-red streaks and patches. The j)ia mater not implicated. On section the cortex was found to be almost uniformly hgemorrhagic in certain places ; in others there were numerous jDunctifoi-m ha^moi-rhages close together, some reaching the size of a pin-head. The brain-substance affected was disintegrated, soft and of a pulpy consistence. At the base there was hei-e and there ^jurulent infiltration of the pia mater, especially round al^out the chiasma and in the Sylvian fissure. The rest was normal. In this case we really had a basilar meningitis combined with extremely rapidly progressing h hemorrhagic encephalitis. The physicians most experienced in the diseases of children, who have had a very large amount of material at command — Guersant, Becquerel, Billard, Eilliet, and Barthez — all acknowledge that they have seen very few cases of simple cerebral hfemorrhage, understanding as such those which could be clinically recognised; for I have myself often enough met with small capillary haemorrhages due to tuberculosis of the brain, tubercular meningitis, sinus-thrombosis, and other diseases. But since these capillary haemorrhages reveal their presence by no symptoms whatever, they have only a patho- logical interest. I have hitherto had no experience of larger cerebral haemorrhages in children confirmed by post-mortem examination. The few cases which I have published elsewhere * cannot be regarded as quite conclusive, seeing that they were not observed up to the end. The same holds good of the follow- ing cases, although the diagnosis is probably that of hsemorrhagic apoplexy. Beitrüge zur Kinderheill-., N.F., S. 62. APOPLECTIC CONDITIONS. 269 Boy of 7 years, fell suddenly from his chair, during a meal, and Avas at once paralysed on the right side of his body. Later on, steady lessening of the paralysis, which I was able to follow for 10 months. The lower extremitj' improved more quickly and decidedly than the upper; in which the rigid contraction of the flexors of the fingers gave a claw-like appearance to the hand and rendered it almost useless. Dipping the hand in warm water removed the contractiires, and the extensors then acted pretty freely. At first there was also aphasia, which so far passed off that after 10 minutes the boy could speak a few words. When the tongue was put out, it inclined distinctly towards the paralj'sed side. The sensibility and intelligence were completely normal, likewise the organs of circulation, as far as could be ascertained by examination. In the case of a child of 1^ years the course was quite similar. Suddenly on a hot summer day, while in perfect health, he became unconscious while lying in his perambulator, and at once showed right hemiplegia of the body and face. In course of time, after about a year and a half, power of moveruent was almost quite restored to the leg by electric treatment, while the arm still showed partial paresis. The facial nerve I'ecovered soon after the attack. There were never any symptoms of irritation in the paralysed ]iarts, and the general health was always quite good. lu these cases the cause of the disease remained unknown ; but in a child of 3 years who suffered from very severe whoop- ing-cough, I saw convulsions and coma occur after a particu- larly violent attack. These lasted for 9 hours, and left behind them hemiplegia of the left side. This continued several weeks, the arm and leg being flabby and quite incapable of movement. The face was unaff'ected. Other writers also^ have published similar cases which ended favourably, and considering the haemorrhages which so often occur from whooping cough, in the connective tissue of the eyelids and conjunctivae, from the nose, and even from the ears — we may assume almost with certainty that this was really a case of cerebral haemorrhage. In the following case I believe that we must assume a haemorrhage in the brain as the result of an injury : — Boy of 4 years. On 7th August, 1879, he fell from a bridge about twelve feet high, on to the railway lines. Loss of conscious- ness, and haemorrhage from the mouth and nose. After he was » Finlayson, Jahrb./. Kinderhei'k.^ x. 400., Oesterr. Ztitschr., 1876, ii., S. 138. — Casin ((Jaz. des hop., 37, 1881) found under similar circumstances 6.Voz. of fluid blood between the bones and dura mater over the left occipital fossa (cephalhaematoma internum). 270 DISEASES OF THE NERVOUS SYSTEM. taken homo, frequent vomiting ot' mutter mixed with Ijlood. On the 8th, admitted into the ward ; then quite conscious. Ecchy- mosi.s behind the right ear. Incomplete ptosis on the right side. Marked dilation and sluggishness of the right pupil, and paresis of the right arm. Pulse somewhat irregular, 80 — 92. Temperature 98'1° F. Steady improvement from the fifth day. Ptosis and paresis of the arm disappeared after 8 days. Differ- ence of the pupils still noticeable on 24th. On this date he left his bed, and dragging of the right leg was noticed. On 31st he was discharged quite cured. Treat inent : ice-bag to the head, re- peated doses of castor oil. Ill a few cases of purpura hsemorrhagica also, apoplexy has been known to occur in children. Mauthner publishes a case of this kind with a post-mortem. I have only one case recorded, which, however, was not fully con firmed as there was no post- mortem. Child of 7 years. Scarlet fever -i years before, followed by dropsy. During the last year, purpura with repeated haemor- rhages from the mouth, nose, ears, eyes, bowel and kidneys. At the same time great weakness and loss of appetite. No enlarge- ment of the spleen. After treatment for 9 days, sudden violent convulsions and coma. Soon after, left hemiplegia with paralysis of the facial. Death in the evening. Post-mortem not permitted. Whether the extravasation — which in this case cannot of course be doubted — occurred in the brain matter itself, as in Mauthner 's case, or between the membranes, must remain undecided. That the latter may happen we learn from an English case^ in which effusion of blood was found between the dura mater and the arachnoid in a boy with purpura, who died in a state of coma. In the following case, also, in which aphasia was the only symptom, I think we must certainly assume the presence of a limited cerebral hgemorrhage :— On May 29th, 1878, I was consulted in the neighbourhood of Berlin, about a boy of 3 years who had suffered for 10 weeks — in- cluding an interval of 3 weeks — from intermittent fever. The last attack of intermittent fever had occurred a fortnight before, just one day after the boy had suffered a concussion of the brain from a fall on the head. His relatives being unwilling to defer a projected journey into the country, the boy had to travel ' Journ.f. Kinderlrankfi ., iv., S. 318. APül'LECTlC CONDITIONS. 271 during the hot stage and was seized in the railway carriage with eclamptic convulsions, which continued almost without intermis- sion for 7 hours. When he awaked from the coma, a marked inter- ference with speech was at once noticed, which passed after 24 hours into complete aphasia. At first there was also head- ache and increased temperature of the head, which, however, soon disappeared after iced-compresses, and the use of calomel. With the exception of the aphasia, the child Avas quite well ; no jjaralytic symptoms were ever noticed. On the day of my visit the boy had pronounced the word " auf " for the first time, but was still unable to give any answers to my questions, although he was quite sensi- ble and intelligent, and he could only indicate what he meant by signs. The comforting assurance of rapid recovery which I gave the parents was speedily confirmed. After a very few weeks the power of speech gradually returned, and recovery was complete in a fortnight. If we consider the coiicuiTeuce in this case of various circum- stances favouring hyperaemia of the brain — the previous con- cussion and the exciting railway journey during the hot stage of intermittent fever — we cannot hut assume the occurrence of haemorrhage in consequence of extreme hypernemia, and its site would probahly have been found in the second or third left frontal convolution. The absence of other paralysis cannot be regarded as weighing much against this supposition, for examples are not wanting in which small blood extravasations in the brain (confirmed post-mortem) only revealed their presence by quite localised paralysis — for example, of the facial nerve. We need not be surprised that the supposed cerebral haemorrhage in this case, as in some of the others just given, manifested itself first by violent convulsive symptoms, seeing that these occur in young children much more commonly in connection with cerebral haemorrhages than in adults. The small extravasations already mentioned, which are found in the form of clusters of red spots, or in a mass as large as a pea — especially in the tissue of the pia mater and the cortex, more rarely in other more central parts of the brain — often give no evidence during life of their existence except convulsions, which are not sufiicient for a certain diagnosis. This is true not only of the capillary haemorrhages of the brain and pia mater observed in asphyxiated new-born children and in the first weeks of life, but also of those which we frequently find in older children in the capillary form, or in the form of spots, as a result of severe con- 272 DISEASES OF THE NERVOUS SYSTEM. stitutional diseases (typhus, diphtheria, scarlet fever, &c.), or localised brain diseases (especially tuberculosis of the brain and tubercular meningitis). All of these haemorrhages cannot be diagnosed, because their symptoms cannot \)e separated from those of general diseases, and there may often be no symptoms at all. In tubercular meningitis, particularly, I have frequently found considerable extravasations in the pia, several times also in the substance of the brain — c.//. in the commissures of the third ventricle — without any corresponding change in the ordinary symptoms. I therefore consider it is not worth while to linger any longer over these conditions as they have no clinical value. The rare cases of larger hsemorrhages, however, occurring in older children with sudden hemiplegia do not present either anatomically or clinically any difference worth mentioning from the apoplexy of adults. The same is true of the haemorrhages which occasionally occur suddenly in the space between the dura mater and the arachnoid from external injuries(apoplexia meningea). At the same time I would remark that the disease described by French observers (Legendre, Eilliet and Barthez) by the name of " haemorrhagies dans la cavite de I'arachnoide," is not now regarded amongst us as simple hasmorrhage, but as pachymeningitis, that is, as inflammation of the inner surface of the dura mater accompanied by small haemorrhages. In childhood, as among adults, cerebral paralysis may take place suddenly from embolic processes. Although this is far less common, still medical literature contains a number of cases in which (with the well-known symptoms) clots were carried from the left side of the heart or even from the pulmonary veins through the circulation into the carotid and its branches, especially the Sylvian artery, and occasioned a more or less extensive patch of softening in the area of brain supplied by it. Since in such cases the paralysis makes its appearance with apoplectic symptoms, owingtothe sudden anaemia which takes place in the affected areas of the brain, we encounter here the same diffi- culties of diagnosis as in adults, and it is only possible to deter- mine approximately whether we have to do with an embolism or a hemorrhage, if we are able, by examining the heart, to find something that supports the diagnosis (endocarditis, valvular digease). If we find no murmur in the heart, this by no means CEREBRAL TUBERCULOSIS. 273 excludes the possibility of an embolism, for the thrombus from which the embolus has arisen may also have been situated between the trabeculae of the left ventricle, in the left auricular appendix, or even in the pulmonary vein, and may have found its way from these into the left side of the heart and into the aorta. A case of this kind was under observation in my ward. The patient was a boy of 2|, suffering from chronic pneumonia and caseous degeneration of the bronchial glands, in whom right hemiplegia had suddenly appeared along with contracture. After death we found embolism of the left Sylvian artery, with extensive softening of the corresponding cerebral hemisphere. The source of the embolus was not the heart — which was quite normal — but one of the branches of the right pulmonary vein, which was filled with thrombi. In another case, to which I shall return later, left hemiplegia occurred during the stage of collapse in diphtheria. The cause revealed by the port-mortem was the formation of a thrombus in the left auricular appendix, and an embolism in the Sylvian artery which had proceeded from it. Thrombi of this kind also frequently occur at the time of death, owing to the diminished propulsive power of the heart. In a girl of 9 years with tuberculosis I found, along with buffy clots in both cavities of the heart, obstruction of one of the principal branches of the right pulmonary artery, of both vertebral arteries, and of the right Sylvian artery by embolism, without any further alteration of their tissue. Finally, the sudden onset of hemiplegia may also be due to diseases of the brain, which either may have remained quite latent for a considerable period, or may have revealed their pre- sence by other cerebral symptoms, especially by convulsive attacks. Among these diseases, the one we have next to con- sider occupies decidedly the first place. XII. Cerebral Tuberculosis. Of all chronic diseases of the brain occurring in childhood, this is undoubtedly the most frequent ; indeed its frequency is so great that we will seldom go wrong if, when chronic cerebral 18 274 DISEASES OF THE NERVOUS SYSTEM. symptoms exist, we make the diagnosis of tubercle. Tubercle occurs in the brain, as well as in other organs, in children at a very early period of life. The assertion of Rilliet and Barthez that this disease is never observed before the third year, is to be explained by the circumstance that these authors only saw children over two years of age in their hospital. Among 14 of my cases there were 12 between 9 months and 2 years of age, and Dem me has found a tubercular nodule the size of a hazel-nut in one of the cerebellar hemispheres in a child of 23 days, whose mother had tuberculosis. * The diagnosis of cerebral tubercle is supported by a characteristic group of symptoms and circumstances. In the first place, the children afi'ected are almost never quite healthy, but generally bear traces of scrofula or tuberculosis. I have re- peatedly met with eczematous eruptions, ophthalmia, otorrhoea, enlarged lymphatic glands, osteomyelitis in the fingers and toes or in other bones, and — above all — caries of the petrous bone, as accompaniments of cerebral tuberculosis. Of course these morbid conditions are not always present at the moment when the cerebral symptoms commence, but it is quite sufiicient that the children should have suffered from them at an earlier period, that traces are still discoverable, or even that other members of the same family have died of " lung- or gland-disease." These points in the histor}' make the diagnosis very much easier, and thus it happens that this may often present greater difiiculties in a hospital — where children concerning whom we have no history often come under treatment — than in a polyclinic or in private practice. If we inquire carefully of the relatives, we will find in almost every case that the child has not been per- fectly free from " scrofulous " symptoms. Following upon conditions of this kind, there now suddenly occurs, in many cases, an epileptic fit, which may recur after an indefinite interval. In children who are still in the period of the first dentition, or especially in those who are rachitic, it is scarcely possible to distinguish these convulsions from the com- paratively harmless ones already described (p. 161). "We must therefore pay particular attention to the child's condition during the intervals, which may even last for many months. Every cerebral symptom observed during these intervals is important ' 17. Jahresber. d. Berner Kiiiderspitals. CEREBRAL TUBERCULOSIS. 275 for the diagnosis. Even very young children, hut more com- monly older ones, often complain of headache occurring in hts like migraine, not uncommonly along with vomiting, which forces the children either to lie still or to support the head with the hands. In others a squint hitherto unobserved appears, usually in one eye, and this among poor people is often either not noticed at all or else put down to a bad habit. Suddenly, after one of the above-mentioned convulsive attacks — occasionally also without their occurrence — there occurs paralysis of a single limb, or hemiplegia, with or with- out implication of the facial or ocular nerves. Here, as in all central forms of paralysis of the facial, only certain branches — especially those to the lips — are wont to be paralysed. Paralysis of the third is indicated by ptosis, divergent stra- bismus and dilatation of the pupil ; that of the sixth by an inward squint and inability to turn the eyeball outward. This paralysis may also disappear after some days or weeks, and one who is inexperienced is very apt to regard them as the remains of the epileptic attack, until there is a repetition of the symptoms, which may very possibly prove rapidly fatal. Martha M.,' 2 years pld, rickety and scrofulous. Eepeated convulsive attacks, inability to hold the head upright, irritable temper. On 29th June, 1864, a renewal of the convulsions con- fined to the left side of the body, -which was found to be paralysed immediately afterwards. Cranial nerves and sensi- bility normal. I diagnosed «tuberculosis of the right hemisphere, with hypera?mia in the neighbourhood. Calomel, gr. I every 2 hours, and 4 leeches a])plied to the head. Marked improvement by 1st July; by the 8th, the paralysis has quite disappeared. On the 26th again violent convulsions on the left side, lasting three hours, followed by coma but without paralysis. On 16th October another fit, lasting 5 hours. A short fit in February, 1865, and on the 30th March a very severe one ending in coma- and death. Post-mortem: marked hyperemia of the pia mater, especially on the left side. Small ccchymoses at some points. Some serum in the ventricles. In the posterior lobes of the right hemisphere, in the white substance, a greyish-yellow tubercle of the size of a pea, surrounded by a thin capsule of connective tissue. No tuber- cular meningitis. Miliary tuberculosis of the pleura, and caseous enlargement of the bronchial glands. ' Etitr. zur Kinderheilk, N.F., S. 64. 270 DISEASES OF THE NERVOUS SYSTEM. I would specially draw your attention in this case to the one- sidedness of the convulsions already spoken of (p. 1C6), which still further justifies the diagnosis of serious disease of the opposite hemisphere, when — as was the case here — it leaves behind a paralysis of the side on which the convulsions occurred. This case is also an example of the so-called " solitary tuber- cle "; for nowhere else in the brain was there any similar for- mation. You must not, however, be misled by this into the belief that it is only in the case of solitary tubercles, or when the disease is confined to one half of the brain, that unilateral convulsions and hemiplegia occur, as we certainly might expect. The following case shows, on the contrary, that tubercular disease of both hemispheres may be accompanied by hemiplegia. Otto A., 2^ years old, admitted into my ward October 24th, 1876. A convulsive attack a year before. Four days before admission, sudden left hemiplegia with implication of the left facial nerve. During the next few days development of tubercular meningitis. Death on 30th. Post-mortem: numerous adhesions between the dura and pia mater. Many tubercular nodules, from the size of a hazel- nut to that of a walnut in the cortical substance of both hemispheres (6 in the right, 4 in the left), and an equally large one in the posterior part of the left half of the cerebellum. Tuber- cular meningitis. You see that in this case it was only the tubercular masses in the right hemisphere that produced paralysis of the opposite half of the body, while those in the left, although they proved on anatomical examination to be exactly the same as on the right side, exerted no influence on the motor functions. This brings us to a weighty point in the pathology of cerebral tuberculosis — namely, its latency. As, in the case just given, tuberculosis of the left hemisphere was not revealed by a n y symptom during life, in like manner even more extensive cerebral tuberculosis may remain completely latent during life, and only be dis- covered incidentally at the post-mortem. Indeed my own experience inclines me to hold that multiple tuberculosis is far more subject to this latency than the solitary form. The following cases observed by me may serve as examples. Boy of 4 years, with phthisis pulmoiuim. No cerebral symp- toms ever observed. Death from rapid basilar meningitis. CEREBRAL TUBERCULOSIS. 277 P.-M. — Besides the meningitis, a tubercular mass, the size of a pigeon's egg, on the convexity of the right frontal lobe ; one of similar size on the anterior surface of the right corpus striatum ; finally, a mass of tubei-cle as large as an orange between the cere- bellum and the tentorium cerebelli — soft, fissured in the inside, and slightly adherent.' Child of 14 months. Caries of the right petrous bone with paralysis of the right facial nerve, and numerous enlarged glands. No cerebral symptoms ever observed. Phthisis. Death from rupture of a small apical cavity andjpneumothorax. At the P.-M. a much fissured and softened tubercular mass, the size of a walnut, was found on the surface of the right frontal lobe ; a still larger one on the surface of the occipital lobe, and a third of equal size at the periphery of the latter near the base. Also on the surface of the left hemisi:)here numerous large tubercular nodules with cavities filled with detritus and calcareous concretions of the size of a pea. The left lobe of the cerebellum almost entirely con- verted into a soft caseous mass.- Child of 2 years, admitted to mj- ward on April 17th, 1874, with caries of the right upper and lower limbs. Anaemia and emaciation ; otherwise no striking symptoms. Development of tubercular meningitis dating from April 29th. Death on 5th May. P.-M. — In the vermiform process of the cerebellum, extending into both its hemispheres, a tubercular mass the size of a walnut, Avith numerous recent tubercles in its neighbourhood. In both occipital lobes, nodules from the size of an almond to that of a hazel-nut.^ Child of 1 year, admitted September 28th, 1878. Hitherto always healthy, but 10 days ago took ill with repeated con- vulsions, followed rapidly by left-sided hemiparesis. On admis- sion, all the sj'mptoras of tubercular meningitis in the last stage (coma, pupils dilated and no longer reacting, pulse 160 and very small, &c.). At the same time frequent spasmodic contractions of the left side of the face, hemiparesis and rigidity of the limbs on the left side. Abdomen tense and distended. Death on 8th October with great rise of temperature (106"2° F.). P.-M. — The pia mater on the left side of the convexity' of the bi-ain infiltrated with caseous matter in a space as large as a sixpence just outside the median fissure. The caseous nodules extended for some millimetres into the grey substance of the cerebral cortex The rest of the brain free from tubercle. Extensive tubercular meningitis of the base and convexity with acute hydrocephalus. Likew^ise caseous degeneration of the bronchial glands, miliary • Beitrüge, N. F., S. 67. "^ .Journ.f. Kimlerkrankh., viii., 1847, S. 160. ' Ckaritc- Annalen, Jahrg., iv., S. 498. 278 DISEASES OF THE NERVOUb SYSTEM. tuberculosis of the left lung, of the liver and spleen, and chi-onic adhesive tubercular peritonitis.' A rickety child of 1 year, admitted on June 10th, 1878. with all the symptoms of tubercular meningitis. Was said to have been always healthy. Illness began 8 daj's previously with repeated convulsions. No paral^-sis, but almost continuous chorea-like movements of the right arm and leg (flexion and extension, pronation and supination, and movements iu all directions). Death on 26th. P.-M. — Tuberculosis of the lungs and pleura, liver, spleen, kidneys, of the diaphragm and bone- marrow. Caseous degeneration of the bronchial glands, caseous masses in the left lung. Miliary tuberculosis of the basilar dura mater, tubercular meningitis, and masses of tubercle the size of a hazel-nut in the middle division of the left optic thalamus. In these and other similar cases there was always present at the same time an advanced tuherculosis and caseation of other organs ; and it has already been maintained by ßilliet and Barthez that it is just under such circumstances that cerebral tubercle is most frequently latent. I therefore still adhere to the opinion which I expressed as early as 1868,- that in children suffering from extensive tubercular degeneration of the lymphatic glands, lungs, abdominal organs or bones, who die with symp- toms of tubercular meningitis of normal — or more frequentl}' abnormal — course, tuberculosis of the cerebrum or cerebellum may also be assumed with sufficient probability, even should this never have revealed its existence by any definite sym]5toms. This probability is all the greater if the petrous bone is one of those that are carious. The occurrence of cerebral tuberculosis with repeated epilepti- form attacks and accompanying hemiplegia is, however, only one of the forms under which the disease presents itself. In another class of cases, paresis of one side gradually appears, steadily increases, and is often combined with tremor or contracture of one or both limbs. Or, the disease may begin with strabismus, localised contractures (either of the limbs or of the muscles ' The striking fact tliat in this case the paralytic and convulsive symptoms occurred on the same side on which the cortical tubercles were sitiiated, does not require for its explanation the assumption of an incomplete crossing of the pyramidal fibres. To mj' mind the solitary tubercles — which were quite latent — had nothing whatever to do with these symptoms; for the latter might have occurred in the course of anj' tubercular meningitis, even if there had been tubercle in the brain-substance. - Btüräye, X. F., S. 69. CEREBRAL TUBERCULOSIS. 279 of the neck) and other cerebral symptoms — e.g. attacks of head- ache with vomiting, momentary loss of consciousness, •without accompanying paralytic symptoms, aphasia and hallu- cinations of hearing. Not until many months, or even years, have passed — during which the condition has undergone many variations, does the fatal issue take place in the form of violent convulsions or tubercular meningitis. The following cases observed in my wards and chosen from among many others^ will illustrate this form to you better than a detailed description. Carl Sell., 3 years old, admitted on January loth, 1874. Thin and pale. The disease commenced 7 months before with a tremor of the right hand. Two months later paresis of the whole right side of the body, and of the right facial nerve. Since November, 1872, almost continuous contracture of the right arm at the elbow-joint. On admission, rigid contracture of all four extremities, right-sided paralysis and tremor of the left hand. Development of tubercular meningitis. Death on 21st. P.-M. — A tubercular deposit the size of a walnut near the posterior surface of the right hemisphere of the cerel^el- lum. On the convexity of the left frontal lobe, a caseous nodule fin. in diameter extending inwards right through the convolution to the white substance. Hydrocephalus internus. At the posterior part of the left corpus striatum 3 tubercular masses the size of a pea, close under the ependyma. Both optic thalami converted at their upper part into a nodular caseous mass. Wilhelm J., 2 years old, admitted on April 3rd, 1875. Coughing and wasting for the last Ö months; rickety. Continuous trembling, frequently also more marked spasmodic contrac- tions of the right arm and side of the face, the mouth being drawn upwards and to the right. No paralysis to be observed. Sensibility apparently normal. Symptoms of con- solidation in the lungs. After a few days, increase of the tremor, the head and right lower limb being then also affected. The muscles of the chest and abdomen, as well as the cremaster on the right side, presented distinct spasmodic contractions recurring at short intervals. Slight paresis of the right ann. On April 6th, continuous contracture of the right thuml). On the 7th, nystagmus of the right eye. Death with high temperature and collapse. P.-Jlf.— CEdema of the pia mater, especially on the convexity of the left hemisphere, and in it numerous miliary tubercles are embedded. Eight in front of the fissure of Rolando, about its middle, a yellow tubercular mass of the size of a hazel-nut in the cerebral substance, which was to some degree softened in its neighbourhood. Pulmonary phthisis, &c. ' Choj-itr-Annalen, Jahrr/., iv.. 492 et seq. 280 DISEASES OF THE NERVOUS SYSTEM. The duratiou of the disease, as far as we can judge, may vary much. In some cases many months or even years may elapse, from the appearance of the first symptoms, before death occurs ; while in others the first symptoms are observed a comparatively short time before death. In these cases, therefore we must assume that the disease has remained latent until reaching its last stage. I have frequently seen the first symptoms of cerebral tubercle — e.g. convulsive attacks with or without hemiplegia — pass almost immediately into symptoms of tubercular meningitis, which was the immediate cause of death and was as a rule marked in these cases by an unusually violent course. Other cases end in an extremely protracted and violent attack of convulsions, or death may be due to the advance of concomitant tuberculosis of other organs without meningitis. The cases given have already illustrated to you the patho- logical conditions. Tubercle of the braui appears most fre- quently as greyish -yellow caseous nodules, ranging from the size of a pea to that of a hazel-nut, usually globular, but sometimes also uneven in shape, most frequently situated in the grey substance of the brain, in the cortex, the great ganglia, the pons Varolii and the cerebellum, but is by no means unknown in the white substance, corpora quadrigemina, crura cerebri, &c. The tubercles of the cortex which lie immediately under the arachnoid and pia mater can scarcely be distinguished from those which originate in the membranes themselves and penetrate from them into the cortical substance — which, clinically, comes to the same thing. In both cases we find the arachnoid and dura mater overlying the cortical tubercles more or less adherent to one another, so that on our removing the dura mater a portion of the tubercle is apt to remain attached to it. Sometimes the size of the nodules is much greater. I have myself seen them as big as a walnut, and even bigger ; and these when cut into, usually no longer presented a homogeneous caseous appearance, but contained fissures and cavities filled with a whey-like fluid. In one child I even found on the outer surface of the right optic thalamus, a tubercular mass as large as a hen's &g^, full of fissures, and in other cases there was diffuse caseous degeneration of the cortex or caseous metamorphosis of an entire cerebellar hemisphere. Calcification of cerebral tumours is not a common occurrence ; I have observed only two cases of it, CEREBRAL TUBERCULOSIS. 281 one of which has ah-eady heen mentioned. In the other case a tubercular nodule of the cerebellum contained very hard cal- careous particles. In large tubercular masses we can generally, on careful examination, distinctly make out that they have arisen from the confluence of small nodules lying close together. The interior — apart from the fissures already mentioned — is partly firm and homogeneous, partly granular and friable. The outer layer is often thin, greyish-white, and transparent, and numerous miliary nodules can be discovered in it. It is partly through the con- fluence of these, and partly by a chronic caseous encephalitis that the larger nodules seem to be developed. Smaller tubercles are not unfrequently encased in a thin capsule of connective tissue, while the larger ones are usually more diffuse and are imbedded in the extremely vascular, moist and softened brain- substance. The number of brain tubercles varies greatly. Most rarely we find only one (solitary tubercle), usually several scattered through different parts of the brain, occasionally very many (a dozen or more), and of this I have already given examples. In most cases we also find symptoms of tubercu- lar meningitis and accumulation of serum in the ventricles — which we shall speak of later on — and not uncommonly small ecchymoses in the pia mater or brain-substance. I have repeatedly observed that the accumulation of miliary nodules in the pia mater was most marked in the immediate neighbour- hood of the caseous nodules, especially on the convexity. More or less advanced tuberculosis and caseation of other organs is generally, but by no means invariably, present also. In the case already mentioned (p. 276) in which a dozen large tubercles were found in the brain, only a few miliary nodules were found in the right lung, while all the other organs were perfectly free from disease. The question, whether we can diagnose from the symptoms in what part of the brain the tubercular mass is situated, does not strictly speaking concern us here, seeing that the conditions are the same as in adults. I refer you, therefore, to a paper of mine published in the Charite-Annalen (Jahrgang IV.) from which you will find that in spite of the knowledge recently acquired by experiments, the diagnosis of the localisation of cerebral tubercle is still far from being established ; and the latency already dis- 282 DISEASES OF THE NERVOUS SYSTEM. cussed attortls anotlicr proof of this. I have, liowevor, records of three cases in which a solitary tubercle of one frontal lobe resulted in symptoms of irritation or paralysis on the opposite side of the body ; and we may certainly conclude from this that these symp- toms may be caused by disease affecting exclusively the convolu- tions I have mentioned. I say advisedly " may," for it is not a matter of necessity. I have often enough seen exactly the same morbid conditions — hemiplegia and contractures — in cases at the post-mortem of which this area of the cortex was perfectly normal, while there were tubercular masses in the greatest variety of other situations in the cerebrum or cerebellum. Although the large number of these masses must make all efforts to arrive at a local diagnosis vain, still even solitary tubercles often present symptoms at variance with the results of experimental research. I therefore advise you to exercise the utmost caution in local diagnosis — and especially not to over-estimate the " motor centres of the cortex " of which so much is being made at present — if you do not wish to find yourself unpleasantly mistaken at the post-mortem. It would be useless labour to discuss here certain cases of solitary tubercle from which conclusions have been drawn as to the functions of diflerent parts of the brain ; for on this subject the greatest diversity of opinion exists on all sides. I will only refer here to the case, mentioned on p. 278, of solitary tubercle of the left optic thalamus, which was accompanied by chorea-like movements of the right side of the body. Quite independent of the fact that the latter only set in during the final meningitis (and, according to my experience, can only be ascribed to this), I have often seen cases of tuberculosis of the optic thalami in which no move- ments whatever of this kind appeared. One of these may be given here. Hedwig F., 4 year.s old, admitted on April 24th, 1881. Healthy until middle of Februarj-. Seemed out of sorts after a fall on the forehead. A fortnight later, left internal strabismus, frequent vomiting, giddiness. Later, retraction of the head, and contractures at the hip and knee-joints, which disappeared under chloroform, sometimes also vanished spon- taneously. Headaches, drowsiness. In May, short ei^ileptic attacks. 1st June, slight left ptosis, increasing amblyo])ia with nystagmus. 14th June, neuro-retinitis in both ej-es. On 5th August, commencement of tubercular meningitis. Deatli CEREBRAL TUBERCULOSIS. 283 on the 9th with external high temperature at the la.st (104'7 — 106-2° F.). Post-mortem: basihvr tubercnbir meningiti«, acute hydroce- phalus. The left optic thalamus reddened and nodular, the i-iglit smooth; both contain several caseous nodules surrounded by a greyish-red transparent layer. One of these in the left thalamus, is the size of a hazel-nut and reaches to the surface. In the vei'mi- form process of the cerebellum there is a caseous nodule Avith soft centre, of the size of a small walnut, and in each hemisphere of the cerebellum a tubercular mass of the size of a hazel-nut Spinal cord normal. On the other liaud I have observed choreic movements in one case in which the central gangha of the brain were quite unaftected, and only the cerebellar peduncle was the seat of the tubercular mass. Child of 2 years, admitted on August 6th, 1883. Well- nourished. Scarlet fever 8 months ago, soon followed by chorea- like movements in the left side. Slight left convergent strabis- mus, tremor of the tongue when extruded, contracture of the left arm at the elbow, and of the left leg at the knee-joint. Athetosis- movements of the fingers and foot of left side. These ceased during sleep, but continued constantly when the child was awake. Both extremities were paralysed, the cervical glands swollen, some of them sujjpurating. In the left orbicularis paljjebrarum there were continuous spasmodic movements when awake. From 29th September, fever, vomiting, increasing coma. On the 30th, death, with temperature 1049° F. P.-M. — Solitary tubercle the size of a hazel-nut in the right cerebellar peduncle. The regions of the pons and corpora qu adrigem in a seem to me to be those in lesions of which an approximate diagnosis is soonest possible, from the simultaneous or successive affection of several nerves whose nuclei are situated in this region. The simultaneous parah'sis of one or both oculo-raotor nerves, of the optic, facial, and abducens — which are either principal symptoms or at least precede the hemiplegia — strongly favour this local diagnosis ; and in this connection I would refer you to some observations I have published on tuberculosis of the corpora quadrigemina and pons,^ in connection with which I have discussed the other cases of the kind which have been published. I shall add to these another case of tuberculosis of the cerebral peduncle, which shows that here, as in tumours of the pons, ' Beitr. -.. Kinderlieilk., N. F., S. 72. — Charite- Annalen , Bd. iv. 284 DISEASES OF THE NERVOUS SYSTEM. owing to pressure on the neighbouring oculo- motor nerve, paralysis of it may occur along with crossed paralysis of the extremities. ]\Iax Sch., -i years old, admitted on 26th March, 1883. Of lifiilthy parents, but himself scrofulous, and for a long time sickly. For 9 weeks tremor of left hand, which had gradually spread to the whole arm, combined with contracture at the elbow-joint. For six weeks tremor of left leg also. This became aggi*avated on the attempt to grasp anything, but ceased during sleep. Fingers flexed. No paralysis. At the same time ptosis of the right eyelid, marked dilatation of the right pupil, and divergent strabismus, so that the right eyeball was turned outwards and could not be brought inwards beyond the middle line. Facial nerve unaffected. After recovering from an attack of scai'let fever in the ward, in the middle of April the boy became steadily more apathetic and uninterested. On 25th he also became affected by ptosis, mydriasis, and divergent strabismus of the left eye; and died on 8th May of measles and broncho-pneumonia. P.-M. — In the right crus cerebri a hard tubercular mass the size of a cherry, projecting into the third ventricle. At the base, the right oculo-motor nerve is flattened by the pressure of the tubercular mass and is thinned and greyish in colour. In the apex of the left lung, a cavity the size of a walnut in which there is a large half-dissolved caseous plug. Broncho-pneumonia, laryngitis. No tuljercle elsewhere. I have yet to treat of a pretty common sequela of cerebral tubercle, namely, chronic hydrocephalus. It is supposed that the tubercular nodules, especially those situated in the middle lobe of the cerebellum, or between it and the tentorium cerebelli, may, by pressure on the veins of Galen and their chief branches, produce engorgement and exudation into the ventricles. This may be indicated even during life by increased size of the head, even when the sutures are already closed. The first case of this kind that I met with, was that of a girl of 3, in whom enlargement of the head, impaired intelligence, and blind- ness of both eyes were added to the symptoms of cerebral tubercle. Von Graefe discovered neuro-retinitis as the cause of blindness, along with marked swelling of the papilla, and tortuosity of the veins. As no post-mortem was made, however, it was not ascertained whether the tumour which produced this result by pressure on the veins was tubercular or of some other nature. In two other cases ^ tuberculosis of the middle lobe of ' Charlie- A nnahn, iv., S. 498, 499. CEREBRAL TUBERCULOSIS. 285 the cerebellum was found along with a moderate distension of the ventricles. However, only to the second of these cases can much value be assigned in this connection, as it alone presented no tubercular meningitis. The following case, observed in my ward, is more to the purpose : — Clara G., 3 years old, formerly healthy. For about 6 months, gradually increasing enlargement of the head, to which had been added a slowly increasing right-sided hemiplegia. The latter no longer so marked as formerly, so that the right arm esi^ecially could now be pretty well used. She had had whooping cough for 7 weeks. Admitted into hospital on January 4th, 1879. Head hydrocephalic, circumference 2I5 inches ; fontanelle widely open and extending into the sutures ; tense and elastic. Eyes somewhat protruding. Drowsiness. Violent attacks of whooping cough, diffuse bronchial catarrh, remittent fever increasing in severity until death, which took place on the 15th. Temperature towards the end 105" 1° F. Pulse 160 and somewhat irregular. Post-mortem: very marked chronic hydrocephalus of the ventricles, with compression of the bi-ain-substance, flattening of the convolutions and extreme distension of the skull. The distance between the parietal eminences was about 6 inches ; the sutures extremely wide with very marked serrations gaping in some places, and fibrous. The left hemisphere of the cerebellum con- verted almost entirely into a homogeneous yellowish-white caseous mass, surrounded by a narrow border of healthy substance. Nothing else of impoi-tance. This tubercular mass had undoubtedly existed in a latent condition for a considerable time, before it occasioned hemiparesis and produced engorgement by the increasing pressure on the veins. The mesial position of the nodules in the line of the vena magna is consequently not absolutely necessary ; for any tumour lying to the right or left of it may, by increasing the lateral pressure, produce engorgement in the area of distribution of the neighbouring veins. This can be made out in the most various cerebral tumours by means of the ophthalmoscope. We must, however, consider whether the mechanical explanation of chronic hydrocephalus as being due to compression of the veins is the only one which will account for all such cases ; or whether a state of irritation originating in the pia mater covering it, and transmitted through the velum interpositum to the ependyma of the ventricles, may not also have to be considered as a factor in the causation of the serous exudation. 286 DISEASES OF THE NERVOUS SYSTEM. To speak of effective treatment of cerebral tubercle is, of course, out of the question. Neither by iodide of potash (the favourite drug), nor by other anti-scrofulous remedies can we remove caseous nodules from the brain when they are once developed. We must, however, acknowledge that a natural cure is possible — especially in the case of solitary tubercle — and you may therefore always, although only with very slight prospect of success, attempt to favour this process as much as possible by a tonic line of treatment (iodide of iron, codliver oil, saline baths, fresh air, nourishing diet), and by preventing the patient from being exposed to injurious influences. A temporary improvement (disappearance of the paralysis, long intermission of the fits, &c.), must not — as some of the cases I have given will show — lead you to suppose that recovery has taken place. And indeed such a supposition is generally pre- vented by the accompanying tuberculosis of other organs. The case, however, becomes quite hopeless whenever the first certain signs of tubercular meningitis appear. Epileptiform attacks. Avith or without febrile symptoms, which occur suddenly in the course of the disease, and are followed by coma or even local paralysis, are always to be regarded with suspicion; because tubercular meningitis not uncommonly begins with these very symptoms. We must remember, however, that the same symptoms may arise from sudden hypernemia or localised encephalitis in the immediate neighbourhood of tubercles. Tlierefore we must not neglect to order some leeches to the head, iced compresses and purgatives (Form. 7). Under this treatment the threatening symptoms occasionally pass oÖ', till after some time death is caused by a fresh attack or by tuber- cular meninsfitis. XIII. Tumours of the Brain. I have but little to tell you of cerebral tumours in children, as they resemble, in all respects, those occurring in later life. The different forms of sarcoma are those most frequently found ; and they develope either in the middle of the cerebral substance— especially in the pons Varolii and its neighbourhood — or grow from the cranial bones, and in that case interfere with TUMOURS OF THE BRAIX. " 287 the brain by pressure. I have myself records of several such cases with post-mortems, and others which are incomplete from there having been no examination of the body. Alice G., 6 years old, admitted into the ward, July 16th, 1874' A'^iolent headaches for some months, especially in the left frontal region. Bilateral amaurosis for 6 weeks, which developed within a few da3's. On examination we found incom- plete ptosis on the left side, complete immobility of the left eye, the pupil of which was dilated and did not react. The right eye could be well moved, the pupil equally dilated. Neuro-reti- uitis in both eyes. Occasional pain in the left nasal cavity, from Avhich there was a greyish purulent discharge. General health good till the 24th when the child became affected by a severe attack of scarlet fever. Death on August 2nd. Post-mortem: a myxo-sarcoma — half the size of the fist, originating in the bones of the middle cerebral fossa, and com- pletely tilling it — had grown into the upper part of the left nasal cavit}' after penetrating the lamina cribrosa, and had surrounded the optic chiasma and all the ocular nerves on the left side. Brain and meninges normal, but pressed upward a little. The post-mortem explains perfectly the amaurosis of both eyes, the paralysis of all the muscles of the left, and the purulent secretion from the left nasal cavity. The absence of all paralytic symptoms in the extremities, in spite of the compression of the brain substance from the base, is worthy of note. • Anton H., 11 years old, brought to the hospital on June 26th, 1872.^ Formerly healthy except for occasional headache. Six years before, excitement and chill during a fire. A week later complete right ptosis, swaying gait, increase of headaches. On examination there was ptosis of the right side, moderate dilatation of both pupils, stupid look, great restlessness, frequent rotatory movement of the head, especially from right to left. Up])er extremities could be used, though only feeljly. Could not walk Avithout support. When supported under botli annpits he could shuffle along laboriously in an ataxic manner. When lying, the lower extremities could be freely moved. The sensibility di- minished at some places on the right leg. Speech faltering, scarcely intelligible. Swallowing difficult. Vision unaffected, intelligence unimpaired. P. 54 — 84. Aftei" some days speech even less distinct, the movements of the head more forcible, the ' Charite-AnnaJen, Jahrg., i., S. 561. '' Charite-Annalen, Jtikrff., i., S. 562, and Scheibe, Inaiif/uraUdlss. über Hirnge- schwülste im Kindesalter : Berlin, 1873. 288 DISEASES OF THE NERVOUS SYSTEM. mind confused. On July 4th, sudden loss of consciousness and asphyxia. Artificial respiration and fai-adisation although con- tinued steadily for 2 hours, had but a passing effect (pulse-rate increased, diminished cyanosis). Death in the afternoon. J> ,.M. — Dura mater very tense, brain flattened. In the region of the pons Varolii a large shapeless tumour of the size of a testicle, involving the pons and the left superior cerebral peduncle, reddish-grey soft ; within it a cavity, the size of a cherry-stone, filled with a spongj-, sulphur-yelloAV mass. Chronic hjdrocc- phalus of the ventricles. Under the microscope the tumour was found to be a large-celled sarcoma, the processes of which could be traced right into the crura cerebri. Anna D., 11 years old, admitted into the ward on May 4th, 1876. Had always been healthy except for an attack of pneu- monia 4 years previously. For a considerable time (jf) increasing uncertainty of gait. Since April of that year squinting of right eye, and giddiness. Nausea, occasionally vomiting. On examina- tion, her gait was found to be exceedinglj' uncertain and staggering, especially when the eyes were closed. Motility and sensibility almost unimpaired. Paralysis of the left abdu- cens with internal strabismus and inability to turn the eye out- wards. Pupils normal and brain unaffected, but great ajiathy and dulness. Speech nasal and indistinct. Fluids sometimes re- turned through the nose when she was drinking. Soft palate hanging loose, but little moved in breathing and phonating. During the next few days vomiting, very difficult defajcation. retention of urine (met by the introduction of a catheter), speech less distinct, and swallowing daily more difficult. On the 8th. the right abducens also paralysed. Intelligence steadily de- creasing, drowsiness. Pulse usually 80 — 100, occasionally falling to 64 and under, and irregular. From the 24th onwards, com- plete apathy. Nutrient enemata because of inability to swallow. Sinking of strength. Death on 29th from oedema of the lungs. By comparing with the previous case I was led to make the diagnosis of tumour of the pons Varolii. P.-M. — The pons enlarged to twice its usual size. The medulla oblongata— especially on the right side — also enlarged, but only to a slight degi-ee. Pons soft, fluctuating at certain points. On section several tumours from the size of a bean to that of a cheny, of medullary consistence and greyish-red colour, not circumscribed from the surrounding tissue. On examination these were found to be sarcomatous. No other abnormalities anywhere. Tlie two last cases, on account of their having a number of symptoms in common (bilateral paralysis of the abducens, paralysis of the muscles of the palate with difficult swallowing TUMOURS OF THE BRAIN. 289 and indistinct speech, ataxia of the lov/ei- extremities) may claim a certain importance in connection with the diagnosis of diseases of the pons. The occurrence of gummatous tumours in the hrain in children is also occasionally mentioned, and indeed one can see no reason why childhood should be exempt from these manifesta- tions of syphilis. I should, however, point out to you that the diagnosis of these tumours from tubercle is often very difficult, and that even the microscope may fail us, so that many tubercular masses in the brain may pass for gummata, and vice-versa. Even tubercle-bacilli cannot be regarded as quite certain criteria in such cases ; since they perish in old caseous nodules, and on the other hand similar microbes have been found in sj-philitic products. In such cases the caseous condition of other organs — especially of the lungs and bronchial glands — put the presence of tubercle beyond doubt. If indubitable signs of syphilis are not present at the same time, and the complete absence of tubercle in the other organs is ascertained by a very careful post-mortem, I should be very slow, especially in children, to diagnose gummata in the brain at the post-mortem; for they are extremely rare at this age compared to tubercle. I have hitherto met with only one undoubted case, so far as I am aware, and it has already been given (p. 110). Other varieties of tumour (glioma, medullary sarcoma, echino- cocci, Cysticercus), which have occasionally occurred in the brain in children, do not present anything characteristic, nor do the encephalitic focal lesions, which end in softening of the brain-substance or in the formation of abscesses. All these conditions are the same in children as in adults, and I therefore think it unnecessary to discuss them further here. Abscesses of the brain are not very uncommon in children, since injuries — which are a very common cause of them — are more frequently encountered at this age than in later life. Besides, we have to take into account here, the greater frequency of caries of the petrous bone, the tendency of which to cause abscesses is well known. My personal observations are confined to the already- mentioned association of cerebral tubercle with disease of this bone. On the other hand I have seen an enormous abscess of the brain in a scrofulous girl of 12, which involved almost the whole frontal lobe of the right hemisphere, occurring along with 19 290 DISEASES OF THE NERVOUS SYSTEM. caries of the lamina cribrosa of the ethmoid. In this case there had for mauy ^veeks been violent attacks of neuralgic pain in the region of the right supraorbital nerve, Avhich could only be relieved by the injection of morphia, while the intervals were almost quite free from morbid symptoms, and only the pressure on the orbital margin — especially towards the nasal side — caused pain. Quite suddenly violent epileptic convulsions, coma and hemiplegia set in, and caused death within a few days.* You see from this that the diseases of the nasal cavity (chronic rhinitis) in children should be treated with no less care than those of the ear, the dangerous character of which has long been recognised. XIV. Atrophic Cerebral Paralysis. A cerebral form of infantile paralysis may, like the " spinal,'' persist to a late period of life, and then for the first time come under the physician's observation. It is much oftener, how- ever, seen first during childhood, even during the early years of life. The children present the symptoms of more or less complete hemiplegia, with or without implication of the facial or other cranial nerves. The upper extremity is generally more seriously afl'ected in regard to its movements than the lower, the latter being often still used in walking, although dragging somewhat. The paralysis is either congenital, that is, appears immediately after birth, or it arises in the first period of life, between the 3rd and 12111 months, or even later ; and the parents usually tell you that it came on after an attack of "inflammation of the brain,'' i.e. as a rule, after a febrile comatose preliminary stage, lasting from a day to a week, with more or less violent convulsions, Avhich — as we have seen above (p. 248) — but seldom usher in spinal infantile paralysis. In course of time, however, contrac- ture and atrophy of the paralysed parts gradually develope in the cerebral paralysis we are speaking of also; and these parts finally appear not only colder, thinner, and more shrivelled than the healthy ones, but also shorter and stunted in growth. This disease differs from the spinal form, first, in its invariably unilateral character, secondly, and more especially by the long ' Btrl. klin. Wochenscltr., 188'2. No. 15. I ATROPHIC CEREBRAL PARALYSIS. 201 persistence of the electrical reaction in the paralysed muscles, which does not disappear till their atrophy is extremely advanced — until, in fact, scarcely any normal muscular tissue is left. In the cerebral form the atrophy of the limbs takes place, almost always very slowly, and only after the disease has lasted many years, and it rarely reaches the extreme degree which spinal paralysis so often presents. Still, in many cases I have seen a very marked shortening of the aftected limb and diminution in size of the hand and fingers.^ Sensory disturbances are in these cases also rarely observed. In one case (a boy of 7 years) in which the disease had begun at the age of 18 months, anaesthesia of the paralysed arm was said to have been present at first, and to have afterwards disappeared. Here also as in the spinal form, the head of the humerus sometimes falls out of the glenoid cavity, so that the finger can be inserted between the joint and the head of the bone. The paralysed upper extremity frequently shows athetosis-movements of the fingers, especially on purposive muscular action. The development of speech also suffers moi'e or less, likewise that of the intelligence, which may present all the intermediate stages from slight stupidity to regular idiocy. Very frequently epileptiform attacks are also added, which complete the clinical picture of the disease. As already men- tioned, such children, who are only a burden to their relatives, may reach the age of 20 years or more; but usually they die sooner, either in a convulsive attack, in coma, or from the results of a chance complication. The invariably incurable character of this disease is due to the anatomical conditions present. For we have here an atrophy or complete absence of certain areas of the brain; for example, of some of the convolutions of one hemisphere, of a half or a whole lobe, of the great cerebral ganglia, &c., which ire replaced in such cases by an accumulation of serum, often accompanied by a thickening of the cranial bones. I described a most typical case of this kind in my graduation thesis." (iirl of 19 years, healthy at birth. Convulsions at the age of :l months, leaving behind them right hemiplegia. Later, atroplir of both the affeeted limbs, whieh Avere regularly stunted. Sen- ' Cy. Seelig-miillcr, Jahrh.f. Kinde rheilL:, X. F., xiii., S. 356.— Förster, /I>i. Only sei lorn do we find fragments of 302 DISEASES OF THE NERVOUS SYSTEM. fibrinous lympb obstructing tbe foramen of Monro, and conse- quently interfering witb tbe communication of tbe ventricles witb one anotber, or inflammatory tbickening of tbe cboroid plexus. Tbe degree of tbe morbid cbanges described vary, of course, very mucb ; tbe dilatation of tbe ventricles and tbe tbickness of tbe compressed brain-substance presents the greatest difi'erences. Tbe following case may serve as an example of an unusually extreme condition : — Anna P., o months old, admitted March 2üth, 1877, with chronic hydrocephalus. Tolerably well-nourished. Circumference of the head 40, longitudinal diameter 25, transverse diameter 27 centimetres. Eyeballs directed downwards. No nervous symp- toms noticed. The child took the bottle quite normally, cried much and lustily, and its whole behaviour diifered in no vraj from that of a healthy child. Collapse and l)roncho-pneumonia. com- mencing on April 3rd ; death on 7th. P.-M. — After removal of the upper portion of the very thin dolichocephalic cranium, and division of the dura mater, we saw into a ventricle comjjletely filled with fluid, at the bottom of which an elongated lump represented the re- mainder of the brain. On closer examination we found that the cerebral hemispheres had almost entirely disappeared. Under the dura mater, Avhich had remained normal, there appeared — only in certain places — very tliin plates, bands and strips, covered by a membrane resembling the pia mater-^all that remained of the hemispheres which had disappeared and were replaced by clear watery fluid filling the whole cranial cavity. The amor])lious mass on the floor of the cranium consisted of tlie remainder of the great cerebral ganglia, and the cerebellum and spinal cord were connected with it in the normal way. These parts, as well as the cranial ner\es and vessels, were quite unaffected. Although in this child the compression of tbe substance of the hemisi)heres bad gone on until they had almost quite dis- appeared, we yet see all the functions acting normally, and tbe whole condition differing in no way from that of a healthy child of the same age. Exactly the same condition was found at tbe post-mortem of another case, in which the power of motion was just as little interfered witb. A "psycho-motor centre" was certainly out of the question here. The cases, therefore, furnish a clinical proof of the view that the actions of the new- born child must be regarded as involuntary (reflex, automatic). The pathology of chronic hydrocephalus is still by no means thoroughly explained. It is certain that in a number of cases CHRONIC HYDROCEPHALUS, 303 the disease is congenital, i.e. devclopes during foetal life. Under these circumstances a serious obstruction to birth may arise, which must be removed b}' operation. In these cases we sometimes find various kinds of arrested development — defects of the corpus callosum, fornix, ikc. ; likewise spina bifida, club-feet and hands, &c. Much more frequently, however, the children come into the world apparently healthy, and it is some months after birth before the relatives are struck by the unusual growth of the cranium. What, then, is taking place here ? The peculiar granular hypertrophied condition of the ependyma — which can sometimes even be torn oft' from the wall of the ventricle in tough strips — points to the occurrence of an insidious inflammatory condition of it, which either begins in foetal life, or else not until some time after birth, and is so little noticeable that the first sign of the disease is the distension of the head by the steadily increasing pressure of the fluid in the ventricle.* This inflammatory theory does not, however, fit all cases, because the granular condition of the ependyma may be absent, and with it everything that is in favour of an irritative process having existed within the ventricles. In the same way causes of compression {e.g., tumours, of which we have already spoken on p. 28-1) are met with in a very small number of cases ; and least commonly in those that are congenital, or have arisen very early, and we have then nothing left but to content ourselves with the unsatisfactory supposition of a " malformation," or of an exces- sive " secretion of cerebro-spinal fluid." Those who support the inflammatory theory usually go upon the rare cases of hydro- cephalus which may arise in somewhat older children, i.e. about the second half of the first year, after symptoms of meningitis. I have myself seen some cases of this kind, but they are only of value as proof when the position of the fluid within the ventricles and the alteration of the ependyma is verified by a post-mortem. Should this not take place, we remain in doubt as to Avhether the case was really one of hydrops ventriculorum, or of an accumulation of fluid between the membranes (hydro- cephalus meningealis sire externus) — to distinguish ' I eaiuiot fiiinost frequently met with. The child may become torpid or completely unconscious immediately after a fall on the head. We do not yet know for certain on Avhat state of the brain the symptoms depend which are usually known as " concussion of the brain." In three such cases which I have published elsewhere,^ the children were perfectly well immediately after the fall, and the symptoms only set in after some hours or days. These were as follows : — continuous headache, apathy, drowsiness, yawning, change of colour, restlessness at night, anorexia, repeated vomit- ing, and fever, the pulse rising to 140 — 160 in the minute but remaining regular. One of these children suffered at the same time from attacks of night-terrors, so that he jumped out of bed and ran to the light (probably owing to terrifying dreams) ; and these recurred from time to time for some weeks after recovery. The rapid onset of these symptoms after an injury to the cranium, and especiaily the surprisingly rapid result of antiphlogistic treatment, make the diagnosis in this case certain, I think. The application of a few leeches behind the ears (the bites of which 1 did not allow to bleed afterwards, in order to avoid excessive loss of blood) was sufficient to give considerable relief to the symptoms. The ha3matopliobic line of treatment which has come into fashion in our time is here to be avoided. We can draw blood directly from the cranial cavity by means of the emissaria Santorini, and we must not hesitate to do so ; because these preliminary symptoms if neglected may result in regular meningitis. At the same time we must apply an ice-cap con- tinuously to the head and produce copious evacuations by giving calomel or mist, senn» co., and syrupus rhamni (Form. 7). Under this treatment I have seen complete recovery after 36 — 48 hours. In the two following cases, also, hyperemia due to cerebral concussion seems to have been the cause of the symp- toms. Boy of 9 year.s, remained unconscious for 24 hours after falling from a vehicle on to the back of his head. No Avound discoverable. Eyes fixedly directed to the right, pupils did not react. No fever ; temperature 98'2° F. Pulse small, 100 and irregular ; repeated vomiting. After 24 hours, headache, frequent vomiting and irregularity of pulse remained. Otherwise ' Beitr. zur Kinder heilk:, N. F., S. 2. 312 DISEASES OF THE NERVOUS SYSTEM. Avell. TIicsc symptoms lasted for a whole week and then disiip- ])eared, leavmg the child i)crfectly well. Treatment : — 4 leeches l^ehind the ear, ice-cap, calomel. Boy of 6 years, after a fall from a high stair on April 20tli. J881, loss of consciousness and vomiting, lasting through the night. Next morning return of conscioiisness, but apathy and double vision. Qlldema, ecchyraoses and desquamation of tin- skin over the I'iglit half of the face, a considerable cephalliamiu- toma over the right pa,rietal bone. Pulse 84, somewhat irreguhi r. Still occasional vomiting; otherwise well. Continuous a^iplication of an ice-cap, repeated purgatives. Recovery by 12th May. bur a slight thickening is still noticeable in the situation of the ccphalhamiatoma. In this case I thought that I might omit local blood-letting on account of the severe haemorrhage which had taken place from the vessels of the pericranium. As a matter of course this must generally be omitted while the actual symptoms of con- cussion (unconsciousness, great pallor, small pulse, coldness of the skin) last, and stimulants are rather to be used. If you consider that the symptoms of hyperaemia of the brain occur after a fall on the head only in a comparatively small num- ber of children, while the majority remain quite free from them or are only slightly stunned, you may assume that besides the severity of the concussion an individual pre-disposition ti> dilatation of the small blood vessels is an important factor. As a matter of fact, a certain number of my patients had shortly before recovered from whooping-cough or chronic pneumonia, or else came of a tubercular family. The conformation of the cra- nium must also be considered ; for little children with mem- branous fontanelles and sutures seem generally to escape the bad effects of concussion more easily than older ones, whose cranial bones are already completely ossified. In a smaller series of cases we see symptoms of hyperaemia of the brain come on without any discoverable traumatic cause (and we may even be able to exclude such causes entirely), especially in children about the period of the first dentition. These symptoms are — fever, drowsiness alternating with great restless- ness, bad temper, apathy, frequent convulsive movements of the body, inability to hold up the head, tense and strongly-pulsating' fontanelle, elevated temperature of the head, and likewise vomiting. I only mention this as a fact, without being able to prove that these HYPER^EMIA OF THE BRAIN. 313 symptoms depend on dentition ; but I would remind you that we often find along with it extreme hyperaemia of the buccal mucous membrane, increased secretion of saliva, erythema and papules on the skin and the face, and catarrh of the conjunctiva and bronchi. Purgatives (small doses of calomel) and cold compresses to the head are in these cases usually sufficient to remove the symptoms within a few days. Still, we do not always attain our end so easily. Every physician has had cases in which the symptoms have gradually got worse and assumed the characters of menin- gitis by the addition of convulsions, head-retraction and coma. FinalW, excessive mental exertion must be mentioned as a source of cerebral hyperaemia. This occurs as the result of over-excitement of an organ which is in a state of development. Although under these circumstances the hysterical symptoms, already considered, and neuralgic headaches are wont to occur more frequently, still there are plenty of cases in which hyper- ajmic symptoms also have made their appearance after mental exertion. I have elsewhere^ published the case of a boy of 0, wbo from such a cause was affected not only by violent headache and photophobia, but also by giddiness, anorexia, nausea, sigh- ing, constipation, pains in the neck, intermittent pulse, and staggering gait. Emetics and quinine had no effect whatever, but the application of five leeches and of an ice-bag to the head and the use of purgatives were followed by rapid improvement. The second form of cerebral hyperemia is caused by mechanical engorgement of the intracranial venous system. Valvular disease of the heart, with dilatation of the right ventricle, compression of the large venous trunks by enlarged glands inside the thorax or in the throat, but especially throm- bosis of the cerebral sinuses, may gradually give rise to this hyperaemia ; and extreme cardiac debility, from exhausting diseases, may cause it in a more acute form. In cases of this latter kind, antemia of the brain is often assumed during life as the cause of the symptoms. As a matter of fact the debilitated cardiac muscle is unable to drive the normal amount of arterial blood into the small cerebral arteries, and the consequent retardation of the circulation causes a venous engorgement which finally leads to oedema of the pia mater and serous effusion into the ventricles. The clinical picture of " hydro- ' Beitr. x. Kinder htilk., N. F., S. 8. 314 DISEASES OF THK NERVOUS SYSTEM. ccp haloid" sketched hy Marshall Hall is made up therefore of the symptoms of arterial ana3mia along with those of venous hypera)mia of the brain. Its characteristic symptoms are : advancing apathy and drowsiness, half-closed eyes, flattening or depression of the great fontanelle, opacity of the cornea from fragments of mucus and drying up of the tissue, great weakness of the pulse and fall of temperature (especially at the extremities) — symptoms which depend only partially on venous hyperemia of the brain, and partially on the cardiac debility and general collapse. The development of this series of symptoms is caused especially by continuous diarrhoea or very acute cholera infantum. Child of 6 months. Diairlioea for nearly 3 months. Admitted on October 3rd, 1873, in a state of extreme collapse. Drowsy, with waxen pallor ; eyes sunk in, staring, and sometimes turned upwards. Thready pulse. During the next few days fall of temperature to 96'8° F. in spite of stimulating treatment ; pulse tilmost imperceptible, dimness of both corneas ; coma. Death on October 5th. P.-M. — Enlargement of Pej-er's patches. Catarrh and thickening of the mucous membrane of the large intestine, especially in the descending colon and rectum, with numerous follicular ulcers. Fatty liver and fatty degeneration of the renal epithelium. Heart and lungs normal. All veins of the piu mater enormously engorged, jiia mater ojdematous. Nu- merous points of blood on section of the brain. All the sinuses quite unaffected. The treatment of such cases must not, of course, be depress- ing, or else it would only further diminish the heart's energy, thereby increasing the venous engorgement of the brain. Our chief endeavour must be rather to strengthen the heart's energj' in order to restore the circulation as soon as possible to its normal condition. Repeated doses of wine (a teaspoonful of Hungarian wine, port or sherry every 1 — 2 hours), warm baths (95° F.) rendered stimulating by the addition of mustard, with cold compresses to the head or douching of it w'ith cold water, are to be used. We must of course treat by suitable remedies any source of collapse that still continues ; in most cases this is diarrhoea. In many cases, however, this has already ceased by the time the cerebral symptoms make their appearance. We may, then, at once attempt to strengthen the heart by stimulants. According to my experience, the best of HYPEREMIA OF THE BRAIN. — THROMBOSIS OF THE SINUSES. 31Ö those is camphor (grs. f — grs. iii. every 2 hours, according to age, in the form of powder or emulsion, Form. 14). Should neither camphor nor wine be sufficient to keep the heart going, I do not expect to succeed with any other remedies. Musk, and espe- cially the much-praised preparations of ammonia, I have found practically useless. Milk and strong beef-tea, yolk of egg beaten up with wine must be given to the child at short intervals. The prognosis, however, is always extremely serious, and a large number of these children, in spite of all our exer- tions, die in a state of coma often with convulsions. The retardation of the venous blood-stream leads not uu- frequently to complete stagnation and coagulation of the blood in the large cerebral sinuses — to "marasmic" thrombosis. We most frequently find the longitudinal, less frequently the other sinuses, filled with more or less decolourised tough thrombi, which may be followed to a greater or less distance into the communicating veins, and must considerably increase the venous engorgement in the brain and pia mater as well as the danger of serous efl'usion. Any other sinus-throm- bosis acts, of course, in the same way, whether it is caused by compression of the sinus, or by inflammation spreading from the neighbouring cranial bones. The petrosal and trans- verse sinuses especially are exposed to the influence of the adjacent petrous bones when carious, and the thrombi in them occasionally extend far into the jugular vein. That this process may take place without any change being visible on the free surface of the dura mater, is proved by the following case : — Girl of 9 years, admitted into the hospital on February 2ni.!, 1877. Otitis media since her first jeav ; perforation of the mem- brane, through which one could see a red pulsating surface covered with pus. Constant severe headache ; no fever. Ear washed out under chloroform. In the night between the 4th and 5th February, suddenly great restlessness, delirium and screaming. On the 5th, coma ; pulse 116, regular ; temp. 101'3°F. Next day continuation of the same condition, convulsive contraction in the limbs on the right side. Pulse 132, small; deep coma; temperature 100"4° F. ; resp. 60. Copious perspiration. Death. P.-M. — Marked oedema of the brain, pia mater normal. Transverse sinus and right inferior petrosal sinus containing thrombi. The right petrous bone carious. The caries extends to close under the dura mater, in which situation there was an abscess the size of a pea. The dura mater itself was perfectly unaffected. 316 DISEASES OF THE NERVOUS SYSTEM. Parenchymatous nephritis. A portion of the ileum, nearly oü inches long, tiark-red in colour and covered with a diphtheritic membrane. Liver fatty. I liave frequently observed the fact that caries of one of the cranial bones, especially the petrous, may extend so as to reach close up to the dura mater without affecting that membrane itself. It remains for a long time unaffected and glistening, and yet the neighbouring petrosal sinus may be the seat of a throm- bosis, which is to be explained, either from small thrombi having been carried into it from the veins in the bones, or from their having projected into it. The sinus-thrombosis which is occasionally observed as the result of severe suppurating eczema capitis is also to be explained in the same way (continuous formation of thrombi through the emissaria Santorini). Much trouble has been taken to render the diagnosis of sinus-thrombosis possible. Gerhardt and Hugueniu lay especial stress on the fact that in thrombosis of the transverse sinus, or at the commencement of the internal jugular vein, the external jugulars appear less filled on the aflected than on the healthy side, because their contents are more easily discharged into the empty internal jugular. Again, in thrombosis of the cavernous sinus, the engorged condition of the ophthalmic vein is said to be indicated by venous hyperaemia of the fundus of the eye, slight exophthalmos, and oedema of the upper lid or of the whole side of the face. Although I have repeatedly looked out for the symptoms recorded I have never been able to convince myself that they really occur, — perhaps because (as Gerhardt himself admits) the cervical veins do not always present the degree of turgescence necessary for making out the difiference between them. Still it appears to me that careful examination of the veins of the throat and eyes, and close examination and careful noting of any unilateral oedema in the face, promise more for the diagnosis in cases where there is a suspicion of sinus-thrombosis than do the signs which these writers give for thrombosis of the pulmonary artery. That this condition and its results (hfemorrhagic infarct) may occur iVom thrombosis of the sinus by means of embolism, is in- deed beyond doubt, and it has also been proved anatomically ; but in a child the diagnosis of this embolism under the circum- stances in which it occurs (i.e. when various kinds of cerebral TUBERCULAR MENINGITIS. 317 disturbances are present) is so difficult that it is oul}' in very exceptional cases that we can establish during life that it is connected with sinus-thrombosis. Under these circumstances treatment is of course out of the question, since even in a case where the diagnosis has been put beyond doubt, no one would expect to be able to remove the thrombosis. XYII. Tuhercidar Me))in{iitis. This is one of the commonest and most fatal of the diseases affecting childhood. As soon as jon observe the first certain signs of it, you may confidently foretell a fatal issue ; and, although in doubtful cases the physician leaves no stone unturned in order to arrive at a sure diagnosis, this is not, unfortunately, because he has any successful treatment in view, but only to assure himself of the certainty of the sad issue for which he has to prepare the patient's friends. If we compai»e the relatively numerous successful results given by the authors of the older works on "hydrocephalus acutus " with our own, we see at once that physicians formerly described and treated under that collective name a number of different morbid conditions (simple cerebral hyperremia, meningitis simplex, typhoid). Now-a-da^'s, however, when our diagnosis has become more exact, and we limit our conception of acute hydrocephalus to tubercular meningitis, we can only look back with a smile to the modes of treatment which were recommended and in their time held in high estimation. The incurability of this form of meningitis is indeed expressed in the very designation "tubercular." Meningitis of this nature is fatal, from its combination with tubercle of the pia mater and of many other organs. It is not a merely local disease, but one which extends over many important parts — in a word, it is a " terminal " form of tuberculosis. The description of this disease is difficult on account of the numerous variations in its course ; and, in spite of the large amount of material at my command, I can scarcely' hope to be able to give you a complete, comprehensive, and clear account of it. I think it will be most suitable to describe to you first of all the usual " classical " form of the disease, as I may call it, and later on describe its varieties. 318 DISEASES OF THE NERVOUS SYSTEM. The real outbreak of the disease is in many cases preceded by a premonitory stage, which may last for weeks or even for months. The child becomes emaciated and flabby ; the mother notices this in Avashing him, and cannot account for it. The general health is often meanwhile unaflected, while in other cases various derangements occur — capricious appetite, lassitude, vary- ing temj^er, irregular rises of temperature — indefinite symptoms the significance of which, in spite of the most careful exami- nation, the physician is at a loss to estimate. These symptoms announce the slow development of tubercle in various organs ; and therefore, in taking the history in such cases we must always investigate whether there is a hereditary tendency to tuberculosis ; for the discovery of this may serve to shed some light on the obscure significance of the symptoms. We must not, however, forget that a family tendency to tuberculosis is by no means necessary; for hypertrophy and caseation of the bronchial and mesenteric glands may exist as the result of chronic catarrh, whooping-cough, measles, typhoid, or repeated attacks of diarrhea, and may finally form a centre of miliary tubercular infection. Caseous processes in superficial lymphatic glands or in bones (spondylitis and osteomyelitis) may have a similarly important influence. We must hold to these facts which are the result of innumerable well-established observation from the clinical point of view, and leave their connection with tubercular bacilli to be determined by further investigations. It can hardly be doubted that invasion of the bacilli may take place from the intestine, the lungs, the skin (eczema), or the nasal mucous membrane, and finally lead to meningeal tuberculosis. In this matter the nose deserves special attention,* as its lym- phatic spaces communicate with the meninges through the ethmoid bone. Moreover, the above mentioned preliminary symptoms are not at all constant. In spite of careful investi- gations I have often enough been told by mothers that their children had been perfectly well up to the time of the actual commencement of the disease ; and their thriving, well-nourished appearance supported the statement. ' Cf. Dcmme's case {Klin. Wochenschr., 1886, No. 15), in which a tubercular ozeena with discharge containing bacilli preceded the meningitis by a long time, without any hereditary predisposition, and without there being any cascon.- deposit foimd. TUBERCULAR MENINGITIS. 319 The onset of the disease occurs ahnost suddenly, with com- plaints of headache, especially in the forehead, and with vomiting — usually repeated several times during the first few days, and sometimes occurring after every attempt to eat or drink. Definite characters have been ascribed to this kind of vomiting, but I cannot confirm them. I have seen it take place in the upright as well as the horizontal position, sometimes without warning and sometimes accompanied by much retching. I cannot therefore see any real diiference in the characters of cerebral vomiting from that which is gastric. It is just this point in the diagnosis, however, that we are first called upon to consider. The symptoms of the first half or whole week are in very many cases so like those of a slight case of gastric fever, that many experienced physicians who have seen numbers of such children die are by no means secure from such mistakes. The general apathy, the loss of inclination for play, the head- ache, the tendency of the head to become retracted, and especially the inclination to lie down, the more or less thickly-coated tongue, the loss of appetite with vomiting and constipation, and, finally the irregular rises of temperature — all of these symptoms are so equivocal that we may be in doubt whether the case is one of commencing meningitis, or some feverish stomach-complaint, or whether it is not even the commencement of typhoid fever. In tubercular meningitis the children often show a striking per- sistence in picking at their lips, boring in their nose and rubbing their eyes ; but even this peculiar and inexplicable symptom is common to all the conditions just mentioned. As long, therefore, as you are not quite certain you must beware of telling the parents that the matter is one of no importance, and that it all arises from nothing but a "bad stomach" — a mistake which the inexperi- enced readily fall into. It is much better to leave the possibility of cerebral disease open, for parents never forgive a physician for a false prognosis, even although he afterwards tries to shield himself by saying that the "stomach-complaint" has finally gone on to hydrocephalus. The uncertainty', however, generally lasts — for the experienced physician at least — only a few days. By the end of the first week at latest more unmistakeable signs of the danger threatening generally set in, and cannot but attract your attention. Among these I reckon especially a frequently recurring deep sighing — 320 DISEASES OF THE NERVOUS SYSTEM. ^vllicl^ has almost never deceived mc — and the cliaracteristic alteration of the pulse — hoth of these being of course caused IjV irritation of the origin of the vagus at the base of the brain. The pulse becomes slower, and at the same time irregular, likewise unequal in the strength of its individual beats. This symptom I regard as decisive under the circumstances I have described even if its appearance is only transient. There is scarcely any other disease of children in which the pulse varies so much in its character as it does in this. In the course of one day its rate changes repeatedly and considerably. Slight movements are sufficient to cause an increase of 20 or more beats, while the varying temperature — to which I shall presently return — has no influence on the pulse. The rate varies much between 96 and 120, and occasionally falls to 80, 72, and even less. But although this symptom is so important, we must also bear in mind that just the same may also occur in trifling stomach complaints, owing to reflex irritation of the vagus. Of this, however, I have only seen one instance, viz., the follow- ing case : — 111 a boy of 9 years, wliom I treated in April, 18t37, at the Ijeginuing of an attack of febrile dyspejisia, the pulse fell, on the day following the use of an emetic, from 120 to 80, even when awake and in the sitting posture ; during the next few da^'S to 52 — 48, and presented at the same time marked intermissions. The persistent frontal headache, sleepiness, and indolence made me very anxious ; but complete recovery of the gastric condition took place after a week under the use of sod. bicarb, with tinct. rhei, the pulse at the same time regaining its normal rate and regularity. On the other hand I have frequently met with irregularity of the pulse without any great retardation, due to gastric or intestinal disturbance ; for example, in a girl of 7 years who was feverish for only 21 hours (temp. 103*3^ F.). had repeated vomiting and purging, and presented herpes labialis on the upper lip. The pulse in this case was 88 — 96, when the tempera- ture fell, and was very irregular, intermitting after every third or fourth beat. This lasted for 9 days with diminishing distinct- ness and then suddenly disappeared. Occasionally even in meningitis the retardation of the pulse is absent, and we only notice its irregularity. Of this I have elsewhere published some I TUBERCULAR MENINGITIS. 321 examples.^ Such cases are, however, rare upon the whole ; and where irregularity is comhiued with retardation you may always be prepared for the further development of tubercular meningitis. The hardness and vibrating character of the pulse (pulsus tardus) pointed out by Killiet and Barthez, I regard as in no way characteristic, although I have frequently been able to observe it in the radial artery, and likewise just as distinctly over the great fontanelle when it was still open. The retardation and irregularity of the pulse usually last till about the middle of the second week, and then give place to a steadily increasing rapidity with regular rhythm. During this time the symptoms already described gradually increase in severity. The headache is rarely so violent as to make the children cry out and press their hands to their foreheads. Many scarcely complain at all of their head, but of pain in the ears, in the throat, the abdomen, the knee or other parts, although nothing abnormal can be found in them on examination. When the headache is present, it is generally aggravated by coughing. Occasionally also there seems to be a feeling of giddiness making the children think they are going t o fall, even when they are sitting or lying down, and they beseech those standing by to keep hold of them. The apathy and drowsi- ness slowly increases, being sometimes interrupted by restless- ness, loud screaming, also perhaps by slight delirium. If we wake the child when in this condition — which we can still easily do — we find the intellect clear so that it answers questions, and puts out the tongue when desired. The disappearance of childish obstinacy and the indifference towards the physician who used to be received with screaming, and towards his manipulations, is always a bad sign, and may, especially in doubtful cases, become important from a diagnostic point of view. The influence on certain secretory and trophic processes at this stage is also re- markable. Actively suppurating eczema on the head or other parts not uncommonly dries up, copious secretion from the nasal mucous membrane becomes arrested, previously existing diarrhoea ceases, and in two cases I have seen well-marked enlargement of the cervical glands, which had existed for a con- siderable time, disappear within a few days under the influence of meningitis. In many of the patients (though by no means in all) we observe, ' Beiir. zur KbuhrheUk., N. F., S. öl. 21 ;322 DISEASES of the nervous system. about the micltlle of the second week, or perhaps even earlier, symptoms of irritation of certain of the cranial nerves which liave become directly affected by the inflammatory irritation of the base, most frequently convergent strabismus and gi-inding of the teeth. Whether the chewing movements which begin about the same time and are somewhat characteristic of the disease, are also to be referred to irritation of the portio minor of the fifth nerve, seems to me to be doubtful, because in this case we would rather expect trismus (which as a matter of fact, does occasionally occur). Slight retraction of the head is sometimes noticed even at this stage. The colour of the face changes, sudden flushes passing over it from time to time. The drowsy condition very gi-adually passes into coma; it becomes more and more difficult to Avaken the child, until at last it lies in a state of complete unconsciousness, making no response when called to. The eyes are half closed, one leg generally stretched out while the other is flexed at the knee, the hands lying on the genital organs, which are occasionally in a state of erection. The child utters deep sighs from time to time, or even a piercing cry (the well-known but by no means constant " cri hydrencephalique " of Coindet). About this time the pupils dilate, often one more markedly than the other, and they react to light either very sluggishly or not at all. On the conjunctiva bulbi we see leashes of enlarged blood vessels running towards the cornea, and fragments of mucus ; gradually also cloudiness of the cornea appears, especially of its lower segment which is not covered by the half-closed eyelids, and is exposed continuously to the air, owing to the absence of motion in the lids. The reflex sensibility of the skin dis- appears like that of the conjunctiva, so that, e.g. a gentle stroking on the inner side of the thigh no longer occasions contraction of the cremaster. In addition we have automatic movements of the hands to the head, pendulum-movements of one upper or lower extremity, and rigid contracture of the muscles of the neck, and of those of mastication, so that it becomes difficult to give the child a drink. On more careful examination we also not uncommonly find some rigidity or paralysis of one or other side of the body. When there is paralysis the limb on being raised falls down without resistance, and lies motionless as if dead, while that on the other side is often jerked about in TUBERCULAR MENINGITIS. 323 all clirectious as in chorea. The constipation which has generally been present up to this time, and which yields only with difficulty to purgatives, is often replaced in this last stage of the disease by involuntary loose motions. The abdomen steadily sinks in in the region of the umbilicus, so that it comes to have a hollowed out appearance, with the costal margins and iliac crests projecting, and the vertebral column can be easily felt through it. Eetention of urine sometimes occurs to such a degree that a catheter has to be used. The pulse-rate continues to increase from about the middle of the second week, and its rhythm again becomes regular. The rate gradually increases to 180 — 200 and more, and the pulse becomes smaller and more difficult to feel. The respiration, the implication of which has already been indicated by the above-mentioned deep sighing, almost always presents during the last 24 — 48 hours the Cheyne-Stokes character — either in its well-known classical form or else modified to some extent. Thus I have seen, after a pause in the breathing lasting for a quarter of a minute, first a deep sighing inspiration occur, followed by 2 — 3 superficial breaths and then another pause. The number of respirations in the minute may therefore be only 7 — 5, and this infrequency of the respiration, along with the extreme weakness of the heart (pulse 180 — 200 scarcely perceptible), explains the cj-anotic dis- colouration of the face, of the visible mucous membranes, and of the points of the fingers and toes, which often comes on about this time. In many cases the face becomes dark red during the last few days, and profuse perspiration covers the forehead and cheeks in clear drops. On the other hand, I have had but few opportunities of observing the skin eruptions which other writers have mentioned (erythema and papules) — I saw one child of 2 years who in the last few days presented an erythema annulare extending over the whole body. To these symptoms, which indicate the fatal termination of the disease, there are very often added epileptiform convulsions in the last 24 — 48 hours. These either afi"ect the whole muscular system of the body in violent paroxysms ; or they occur only on one side, being sometimes confined to the facial muscles ; or they consist merely in weak contractions of the limbs. In many cases rigid contractures of the muscles of the extremities and of the neck also occur, or a condition of tremor seen most 824 DISEASES OF THE NERVOUS SYSTEM. distinctly in the movements of the hands which continue after the onset of coma. It is always well to warn the parents of the possible occurrence of convulsions towai'ds the end, even although no spastic phenomena have been observed during the previous course of the disease. I have but rarely found them entirely absent. The death-agony is always un- usually long, whether convulsions occur or not. It frequently lasts for several days and — what is all the more painful for the parents — it occasionally happens that in the midst of this last hopeless stage there suddenly appear surprising and in- explicable signs of apparent improvement. The unconscious and comatose patient suddenly manifests a return of his mental activity. He turns his head to his mother when she calls to him, opens his eyes, takes his food once more, or may even begin to sit up again and catch at toys held in front of him. I have several times convinced myself of the correctness of this old observation. I therefore warn you not to over-estimate these favourable signs. After a few hours the child relapses into his former condition, and dies from progressing collapse (paralysis of the heart) with convulsions or deep coma — a fort- night or three weeks, as a rule, after the first occurrence of the vomiting. We have yet to mention shortly the relations of tubercular meningitis with regard to temperature. Investigations which I have instituted during the last few years, and which I have already partly published,' go to establish the fact that this disease possesses no characteristic temperature-curve at all, but that very considerable variations occur throughout its whole course. The evening temperature nearly always ex- ceeds that of the morning, more or less ; it is rarely the same, and only exceptionally somewhat lower. At the same time the temperature is always about a medium height, rarely exceeding 102*2° F., and in many cases reaching this level only on a very few days. I have indeed observed cases in which during the whole course of the disease, or at least for several days, the temperature did not rise above the normal at all, or only did so very slightly. On the other hand, according to my observation the temperature rises rapidly — in the majority of cases, although not invariably — on the day before the last or else on ' C/iaritij-Aiinnleu, Jiiln-g. ir., S.50Ö. TUBERCULAR MENINGITIS. '6'2ö the last clay of the disease to a considerahle height — to 104° F. or even to 1076^ F. It iiearl}' always remains at this level till death, in rare cases falling just hefore the end to 100-4° F.— 102-2° F. I have not yet investigated the condition of the temperature after death. ^ This sudden rise of tempera- ture just before or during the death-agony, cannot possibly be regarded as an ordinary exacerbation of fever, for during the whole course of the disease the fever plays only a secondary part, and therefore we cannot suppose that it would suddenly rise to such a high degree just at the very last w^hen the symptoms of collapse — heart failure (pulse 200, small) — were setting in. Nor yet can we regard the final convulsions or any chance inflam- matory complication in the respiratory organs as answerable for it. I think I have proved this conclusively in my paper (1. c. page 510). Two or three times I have observed violent convul- sions some days before death, with a temperature of 100-8° F., while during the last days there were no convulsions, although the temperature was 104° F. and over. In a few cases, also, where recent pneumonia w^as found at the post-mortem, I have noticed that this final elevation of temperature did not occur, while in all the other cases acute affections of the respiratory organs were not found, and yet this rise of temperature during the death-agony took place. This symptom — which occurs not only in tubercular meningitis, but also in adults who die with ' I give a few temperature charts as examples : — Louise S. , 1 year old, admitted H., 4 years old , admitted on 61 on 29th Sept., 1878 :— April 1878 :— M. E. M. E. 29th Sept. 100-4.. ...101-3 6th April.. — 101-3 30th „ 99-7 .. ... 101-3 7th „ . . 99-5 100-4 1st Oct. 99-7 .. ... 100-8 8th ., ... 99-0 .. 98-2 2iid „ 100-4.. ...100-4 9th „ ...1011 101-3 3rd „ 99-7 .. ... 99-7 10th „ ... 98-2 . 99-5 4th ., 100-6 .. . 102-2 nth „ .100-4 . 1006 5th „ 100-6 .. ...102-0 12th „ ...100-8 . .101-5 6th „ 101-8 .. ... 102-2 13th „ .. .101-3 11 o 'clock... 10-2-6 . 7th „ 1040 . .105-8 4 ., ...103-6 8th „ 106-2 ., ... Death 6 9 „ ...104-5 „ .107-2 In a child of 2 years, admitted on July 16th, 1881, the temperature was found to be 100-8° F. only on the evening of the 16th and 17th. From then to the 27tli it was always normal or even subnormal. On the evening of the 27th the tem- pcratvire suddenly rose to 104-4° F. (pulse 180), and on the 28th (the day of death) to 107-6° F. These examples may suffice ; very many of my cases presented similar conditions. ;32G DISEASES of the nervous system. parah'sis of the cerebral functions — I can only explain by the assumption that there is paralysis of the supposed heat-con- trolling centre, which is situated at the junction of the brain and spinal cord. If this is paralysed, the temperature of the body, which is now no longer kept in check, must reach an ex- traordinary height. You Avill find this subject further worked out in my paper already referred to, in which I have also gathered together the results of experiments which supported my view. Less commonly the temperature falls abnormally low before the end (from*9G-8° F. to 82-4 F.^), which is to be referred to paralysis of the heat-producing centre. In describing the course of the disease I have disregarded the customary division of the disease into regular stages; because I consider all attempts at such a division as useless, whether they rest on anatomical or clinical principles. We may perhaps distinguish a stage of irritation and one of paralysis ; but even this division is by no means thoroughly justified. For, as Ave have seen, irritative symptoms — e.g., convulsions — often enough appear for the first time during the last stage. If we take into consideration, moreover, the cases with an abnormal course and the numerous varieties, to which I shall presently recur, we see that the division into stages is misleading and had best be abandoned. The variations from the typical normal course in this disease are, in fact, so numerous that we are much less likely to be correct in our diagnosis if we try to form our judgments according to one model case. Even physicians v/ho think they know meningitis thoroughly are always coming upon new variations in its course which may cause confusion and can- not be exi^lained anatomically. I have occasionally found a series of symptoms lasti}]g for 10 — 12 days which resembled those of infantile typhoid very closeh'. Sometimes the children utter a piercing cry — day and night, almost without intermission— driving the parents to distraction, and then they suddenly fall into a state of coma. The initial vomiting, which is justly regarded with apprehension, may be entirely ' Gnäiidinger, Jahrb./. Kinderheilk., 1880, xv., S. 15?. — Turin, ibUL, xv 1880, S. 24.— Loeb, Deutsches Archiv f. Mn. Med., 1883, S. 443.— Balaban, L'ebei- den Gang des Tcmpcrahirhei Meningitis ft(b., &c. : Heidelberg, 1SS4. — Bokai, Jahrb. /; Kinderheilk., Bd. xxi., S. 440. TUBERCULAR MENINGITIS. 327 absent, while in other cases it continues with the greatest violence for 9 — 10 days or longer, and there may be such slight symptoms of any other kind pointing to cerebral disease that the physician who sees the child once or at most twice a day may quite over- look them. One child of this kind I used always to find sitting up in bed when I visited him, apparently taking an interest in everything and eagerly looking at picture books. His eyes were clear and there was not the slightest drowsiness, nor anything but the obstinate vomiting, to cause anxiety to the parents or physician. The inequality and irregularity of the pulse, how- ever, confirmed the diagnosis, which was soon established. When the vomiting is thus obstinate, the children often complain also of pain in the region of the stomach, and this may still further mislead the physician. Especially in little children in the first and second years of life, obstinate vomiting without any other threatening symptom seems to me to deserve the fullest attention. For in such children it is most likely to be regarded as due to dyspepsia, until after some time the sudden occur- rence of drowsiness, squint, ptosis and convulsions, clear up the mistake in a very unpleasant manner. Even the obstinate con- stipation which we generally have to deal with is not a symptom always to be depended on. I have repeatedly met with cases which began with vomiting and diarrhoea and were therefore regarded as cholera infantum, until after 24 — 36 hours obstruc- tion set in, while the vomiting either persisted or likewise dis- appeared. I have also occasionally seen diarrhoea due to follicu- lar or tubercular ulceration of the intestine persist in spite of the development of meningitis. Instead of the usual hollowing out of the abdomen, I have sometimes observed a more or less extreme condition of flatulent distension, which is generally due to a concomitant chronic tubercular peritonitis. The rule which is applicable to the pulse (moderate acceleration during the first few days followed by retardation and irregularity, and finally increasing rate and regularity of the beats) only holds good in the majority of the cases. I have already previously (p. 320) pointed out to you the variations in the character of the pulse, and I would add that in several cases in the very last stage when epileptiform convulsions had already set in, I have found a pulse-rate of only 70, 76, 92, and 96. In one child of two vears, a marked diminution in the secretion of urine took 028 DISEASES OF THE NERVOUS SYSTEM. place, ami for two or tliree weeks formed the only premonitory symptom. This child only passed its water (which was normal) once in the 24 hours, and the hladder was not distended. It was only the increasing apathy and drowsiness that determined me to make the diagnosis of meningitis, which was confirmed by the further progress and by the post-mortem. According to Legendre and Rilliet and Barthez the character of the symptoms suffers material modification according as the meningitis afiects an apparently healthy child or one already affected with advanced tuberculosis or phthisis. Only in the former case does the above described " classic " course take place, while in the latter, the disease has a much more violent onset, with much quicker succession of the symptoms, resembling meningitis simplex. In my own practice I have frequently had the opportunity of confirming their statements. Ann (J II., 3 years old, brought to me on Octol)er 2nd, 1862. Since August, diarrhoea, weakness, and anfemia, steady wasting, cough, dulness, with 'sharp rales and bronchophony in the left supra-spinous fossa ; fever, eczema on many parts of the Ijody. On 24th November, sudden epileptiform convulsions; in the evening, vomiting, cessation of the diarrhoea, rapid irregular pulse. The eczema rapidly disappeared. Within the next few days drowsiness, coma, repeated convulsions. Death on the 28th — that is, on the 5th day after the first appearance of cerebral symptoms. P. -M. — Basilar tubercular meningitis, internal liydrocephalus, extreme amount of tubercle in both lungs. Cavities in both upper lobes : follicular enteritis, &c. I have most frequently observed this very acute course ushered in by violent epileptiform convulsions in cases which were com- plicated with tuberculosis of the substance of the brain itself. I have indeed often been able to diagnose from such a course the presence of this complication before the post-mortem took place, even though I was unacquainted with the former condition of the child. You will find several cases of this kind brought together in my paper on cerebral tuberculosis.^ Exceptions to this rule, however, are not uncommon. On the one hand the disease may take its usual course notwithstanding the presence of a considerable degree of tuberculosis of the brain or of advanced phthisis ; while on the other hand it may have an unusually acute course where there is as yet no real phthisical ' Charitc-Annahn, Jahrg. iv., S. 489. TUBERCULAR MENINGITIS. 329 disintegration.^ This course, which very closely resembles that of purulent meningitis, is particularly apt to occur in little children in the first or second years of life ; take for instance the following case, in which the whole process ran its course in G days. Karl M., 9 months old, admitted on March 18th, 1879. Healthy child. Took ill 2 days before, refusing the breast, vomiting, feverish. Drowsiness and extreme apathy. Temperature, 101"1° — 101-8° F. ; pulse, 132, regular. On the 19th and 20th increase of the drowsiness ; pulse, 1.56 ; eyes often fixed, turned upwards ; almost continuous twitchings of the upper limbs. In the lungs nothing to be made out but catarrh. On 21st, pulse 200; temp. 106"2° F.; rigid extension of the arms, with tremor; respiration frequent and noisy. Death on 22nd, with temperature of 106"2° F. and imperceptible pulse. P.-M. — Pia mater near the longitudinal fissure greyish-yellow, cloudy-, very thickly studded with miliary nodules, still more marked at the base, especially in the Sylvian fissure. Ventricles distended by a large cpiantity of clear serum. Brain slightly fedematous. Miliary tuberculosis of both lungs and of the liver and s]:)leen. Bronchial, tracheal, and mesenteric glands caseous. We are not able sufficiently to explain the variations in the course of the disease from its pathological anatomy. The post-mortem conditions seem to be just the same whether the disease has a normal or an abnormal course ; and the differences must therefore consist in finer modifications of structure which can scarcely be demonstrated. These aff"ect sometimes one part of the brain, sometimes another, although their occurrence has not yet been proved beyond a doubt. In support of this idea I shall only refer to the observations of Eendu,^ who in a series of cases found thrombosis of the Sylvian artery resulting from the sur- rounding tubercular inflammation, and little patches of softening in its area of distribution (corpus striatum &c.) with which he was able to connect the paralysis observed during life. In several cases characterised by an unusually acute course suggesting simple meningitis, I have myself found the inflammatory products deposited on the convexity of the hemispheres to a greater extent than on the base Avhicli is generally its favourite seat. In one of these children, indeed, this part was almost entirely unaffected. From this it follows that we must not regard the terms " meningitis ' Vide my " Beiträge zw Kinderlieill- ., N.F." S. 44. - Recherches din, et anai. sur les parahjsies liees ä la miningite t ubcrculevse : Paris, 1874. Oi)0 DISEASES OF THE NERVOUS SYSTEM. tuberculosa " and " meningitis basilaris " as quite equivalent ; but the variations in the course of the disease cannot depend on this alone, for I have also often enough found the convexity affected in the same way in cases with the ordinary prolonged course. In the gi-eat majority of cases the affection of the basis cerebri is certainly the characteristic feature of the disease. In these cases we find a cloudy gi'eenish-grey gelatinous infiltration of the pia mater, in the space between the optic chiasma and the medulla oblongata, which surrounds the cranial nerves as they pass out and may undoubtedly give rise directly to symptoms of irritation and paralysis in them. In this neighbourhood, especially inside the Sylvian fissure there is a cloudy, oedematous infiltration, and here also particularly we find more or less numerous grey or greyish -yellow miliary tubercles imbedded, about the size of a pin's head or less ; and these are most clearly seen when we dravr the pia mater cai-efully out of the fissures. According as these tubercular granulations are recent or old they are smooth and soft or somewhat hard and projecting. Similar miliary tubercles of the pia mater are also not uncommonly met with, often in very great numbers, in the choroid plexuses of the ventricles, on the convexity and inner surface of the hemisphere, — the pia mater at the same time often appearing extremely cloudy owing to serous infiltration, and streaks of exudation being deposited along the larger veins, either as greyish-yellow pus or in the form of caseous masses. I have but rarely met with small miliary nodules on the inner surface of the dura mater also. On microscopical examination of these nodules we find almost invariably the tubercular bacilli. The vessels of the pia mater are, as a rule, more or less congested, and when it is drawn out of the fissures little particles of softened cortical substance are apt to remain firmly adherent to it. We also find here and there, strips of adhesion between the arachnoid and dura mater or accumulation of serum between the two membranes, or blood- stained infiltration into the pia mater. The brain substance itself is generally anaemic, rarely hyperoemic ; the ventricles arc markedly distended by the accumulation of serous fluid and their walls as well as the central structures of the brain (cori^us callosum, septum &c.) are often — but by no means always — very much softened or even broken down into a cream-like mass TUBERCULAR MENINGITIS. 331 floating in the cerebral fluid. In rare cases I have found little ecchymoses, especially in the neighbourhood of the third ventricle. These conditions are not, however, invariably found, as the accumulation of serum in the ventricles and their dilatation may also be absent ; so that tubercular meningitis is not necessarily accompanied by " acute hydrocephalus." In this case the cream- like softening in the neighbourhood of the ventricles is also absent, and indeed it can only be regarded as a post-mortem appearance due to maceration by the accumulated serum. In a small number of the cases, although we find indications of inflammation in the pia mater of the base and like\\dse of the convexity — difi'use cloudiness and thickening, oedema or gelati- nous infiltration with or without hydrocephalus of the ventricle — yet in spite of the most careful investigation we nowhere discover miliary nodules in the pia mater, although they may be widely distributed in other organs (spleen, liver and lungs). I have myself met with such cases, and Rill i et and Barthez, who observed eleven of the same, put them down as tubercular meningitis — most properly, I think, because the presence of miliary tubercles in other organs, and the peculiar character of the inflammatory product marks them as such. It follows from this that these inflammatory products may also occur spontaneously, apart from the irritation of the miliary granulations ; just as there is also, on the other hand, no lack of cases of acute tuberculosis in which, in spite of numerous miliary tubercles, there are no signs of inflammation at all to be made out in the pia mater. I shall return to these cases when discussing tuberculosis. I have seen only a single case where the tubercles were limited to the pia mater to the exclusion of all other organs; and although similar observations have been published by other writers, e.g. by Bouchut, we cannot help suspecting that the post-mortems were not quite as exhaustive as they might have been. I will only recall the fact that we have repeatedly found tubercles in the marrow, which would assuredly have been overlooked by the older observers. I have also only in rare cases found the disease very limited in its extent ; for example, in a child of 2^ years with numerous tubercular masses in the brain and tubercular meningitis, there were only very few scattered miliary nodules in the right lung. Again, in a child of 2 with 332 DISEASES OF THE NERVOUS SYSTEM. tubercular meningitis of tLc base and convexity, I found only one single caseous deposit in the mesenteric glands ; in a child of 9 months only one caseous mass the size of. a hazel-nut in one of the bronchial glands; in a boy of 11 years, only one indurated bronchial gland tlie size of a hazel-nut containing small calcareous particles, all the other organs being perfectly normal. Far oftener I have found tubercular changes simul- taneously in many other parts of the body, the most constant feature being a more or less extensive caseous degeneration of the bronchial glands. Tuberculosis and caseous processes are also found in the mesenteric and other lymphatic glands, in the brain, lungs, pleurae, peritoneum, spleen, liver, and kidneys, and even in the epididymis and in the genital organs in little girls. In more recent times tuberculosis of the choroid has excited great interest, because at first when the fact of its occurrence was announced by Cohnheim and von Graefe it was thought that an absolutely certain criterion had been found for the diagnosis of tubercular meningitis and acute miliary tuberculosis. The ophthalmoscopic examination began therefore to be regarded as the most important diagnostic proceeding in this disease ; and the discovery of one or more greyish-white granules or patches in the fundus was held to be decisive in all cases where the diagnosis was doubtful. The latter opinion is, indeed, quite justified, and I have frequently been able to convince myself of the importance of this examination. By it I have frequently found tubercles in the choroid a considerable time before the onset of the serious cerebral symptoms, and while the disease was still in the preliminary stage of vague indisposition ; and I was thus enabled to realise the serious nature of the case. Unfortunately the choroid, as was afterwards found, is by no means constantly affected ^ ; and of this I have been frequently convinced by post-mortems. We must, therefore, by no means regard a negative result of examination of the ej-es as disprov- ing the presence of meningitis ; but, at the same time, a positive result may certainly be regarded as of the greatest diagnostic ' Heinzcl {Jahrb. f. Kinderkeilk., Bd. viii., 1875, S, 355) in 31 cases of basilar tubercular meningitis did not once find choroid-tubercle either during life or after death, although in 15 cases there was neuro-retinitis and '"choked disc ' ' — the latter being probably caused by the pressure of the hydrocephalic ventricles. — Money {Lancet, xix., 1883, Vol. ii.), found tubercle of the choroid only 12 times at the post-mortem out of 42 cases of tubercular meningitis. TUBERCULAR MENINGITIS. 333 significance. The spinal cord also does not escape; for its pia mater often presents eruptions of tubercle and inflammatory products. In a boy of 8 we found the spinal arachnoid markedly thickened on the posterior aspect as low down as the lumbar enlargement and infiltrated with pus, but free from tubercle as far as could be seen on naked-eye examination. Probably this com- plication would be found more frequently if we would take the trouble to open the vertebral canal at every post-mortem.' The assumption that the onset of violent convulsions, contractures, and hypemesthesia depends only on such an affection of the spinal membranes, is, however, unfounded ; for in one case where the predominance of these convulsive symptoms was marked, the spinal cord was found to be perfectly normal at the post-mortem. We have often found considerable accumulations of fjeces in the large intestine ; in one boy of four the whole coecum on both sides of the ileocoecal valve was distended by a ftecal mass an inch and a half in length. As to the etiology of the disease I have only a feAV words to add. Although children with a hereditary predisposition to tuberculosis, or those who are sufteriug from scrofulous conditions, phthisis, or chronic suppurations connected with bone, are most liable to the disease, you will nevertheless very often see well- nourished and apparently healthy children fall victims to it. It is only since the discovery of the tubercle-bacillus that we have recognised the possibility of these cases ai-ising from direct infection; positive proof of this will very seldom be found possible. In general, all the ways in which the bacilli may enter the body and set up tuberculosis are also of significance as regards the origin of tubercular meningitis (the mucous membrane of the digestive and respiratory tract, and the skin). Of especial importance is the fact, which innumerable observations have confirmed, that the bacillary infection of the pia mater may start in apparently quite healthy children from very limited caseous, tubercular deposits in the lymphatic, mesenteric, or bronchial glands, which have existed for many months or even years without giving rise to any symptom whatever. The assumption of a traumatic cause, especially of a fall ' F. Schultze has carefully examined these spinal changes microscopically in 3 cases of basilar tubercular meningitis— which, however, . occurred in adults {Berl. llin. Wochenschr., 187G. Nos. 1 and 2). 334 DISEASES OF THE NERVOUS SYSTEM. on the head (to which the parents always incline), is usually quite mistaken under these circumstances, and is generally based on a mere chance coincidence. At the same time it cannot be denied that a concussion of the brain is more likely to be followed by other h>^eraemic conditions and their results in children with a tubercular tendency than in others (p. 312). I have, unfortunately, nothing favourable to tell you as to the results of treatment. All physicians who go thoroughly into the diagnosis will agi-ee with me in this, that they regard every case of tubercular meningitis as lost from the beginning ; and they are not mistaken in this prognosis. The few cases of recovery which have been published are therefore to be received with the greatest reserve. The possibility of recovery cer- tainly cannot be denied. "When we remember that in tubercular subjects every pleurisy or peritonitis does not prove fatal, and, further, that the danger of the disease does not arise from miliary nodules in the pia mater, which are not uncommonly quite latent, we can only refer the enormous mortality of meningitis to two causes. The first of these is the concomitant, acute tuberculosis of many other organs ; the second is the local changes which the brain suffers, both from softening of the grey substance immediately under the pia mater, and from the increasing pressure of the dilated ventricles. When it has once reached this stage any idea of recovery is of course out of the question. On the other hand I do not regard it as impossible to bring about recovery by opportune treatment at the beginning of the case when the miliary tuberculosis is not general but localised, as our main object at this stage is to arrest the commencing inflammation of the pia mater, and to prevent a more extensive exudation, which might affect the cortical substance of the brain. It is true that this attempt only succeeds in extremely few cases ; but I believe, nevertheless, that it is always worth while to make it, except in cases Avliere, owing to the presence of advanced phthisis or of the signs of tuberculosis of the brain itself, it is evidently useless from the very first. I have elsewhere^ published some cases which presented all the symptoms of the first stage of tubercular meningitis, and were cured by energetic antiphlogistic treatment. One of these eases — that of a child of If years — ended fatally from an attack ' Beitnige zur Klnderhe'M-. • Berlin, 1861, S. 13, and Neue Folge, 1868, S. 55. TUBERCULAR MENINGITIS. 335 of meningitis three years after the first illness ; a brother of his having in the meantime died of this disease, this fact seemed to me to be in fiivour of the correctness of the diagnosis. Rilliet and Barthez record two cases in which death took j)lace from a second attack occurring two or three years after recovery from the first one ; and at the post-mortem the old and the recent eruptions of tubercle in the pia mater could be clearly dis- tinguished. Politzer* also describes the case of a child who had suffered three years previously from an attack of basilar meningitis, and who — except for persistent emaciation — com- pletely recovered. At the post-mortem, besides the recent basilar meningitis, an obsolete indurated patch was found on the pons. Although, therefore, these exceptional cases seem to show that even after recovery has taken place a fatal return of the disease is always to be feared sooner or later, this apprehen- sion must not cause the physician to take up a passive attitude. I therefore order, to begin with, the application of 3 — 6 leeches behind the ears (according to the patient's age), and an ice-cap to the head ; I also give calomel, gr. | every 2 hours, and — if the bowels are not freely opened — follow it by mist, senute CO., or syrupus rhamni, and have blue ointment (grs. v. — x.) rubbed into the neck and throat several times daily. Although in about fifteen years I have seen no result from this mode of treatment, I still consider it my duty to carry it out, and it will certainly do no harm in a disease which, if left to itself, is inevitably fatal. It is of course only to be tried during the first few days of the disease ; at the later stage neither this nor any other kind of treatment can be of any avail. I have also aban- doned the extremely painful inunction of tartar emetic ointment into the head, which used to be so strongly recommended ; and the application of fly blisters to the neck. Further, the con- tinuous use of iodide of potash which I have tried in innumer- able cases, and the repeated and long-continued painting of the head and neck with iodoform-collodion, have been equally far from yielding successful results. ' Jahrb. f. Kmdevhdll-., 1863, vi., S. 40. 336 DISEASES OF THE NERVOUS SYSTEM. XVIII. Purulent Mcmucßtls. The frequency of purulent meningitis, whether affecting the membranes of the brain alone oi- those of the spine also at the same time, is not great compared with that of the tubercular form. Only those physicians who have had the opportunity of observing epidemic cerebro-spiual meningitis have any consider- able material at their command ; for under ordinary circumstances the number of cases to be observed is always very small. Anatomically the disease is generally characterised by the absence of all tubercular formations in the brain and its mem- branes, as well as in any other organs. This does not, of course, exclude the possibility of a tubercular subject being affected accidentally by simple meningitis — e.g. as the result of a fracture of the skull. Apart from these cases and a few others — e.g. those due to pyaemia — almost every case of meningitis in tubercular subjects assumes the anatomical and clinical cha- racters described in the last chapter ; and even the absence of miliary tubercle in the pia mater does not violate this rule (p. 331). Simple meningitis affects the convexity of the hemispheres far more frequently and more severely than does the tubercular form ; but the inflammation often spreads to the base also, and extends from this over the medulla oblongata more or less deeply into the vertebral canal (cerebro-spinal meningitis). From the base the sero-purulent infiltration may spread even as far as the tissue behind the eyeballs, thus occasioning exophthalmos. In addition to marked hyperaemia of the pia mater, ecchymoses of various sizes, and localised adhesions of the dura with the pia mater, you find the tissue of the latter infiltrated with yellow or yellowish-grey pus. This partly follows the course of the larger blood-vessels, partly spreads out so as to form a layer, and also a varying amount of it may occur free between the pia and dura mater. The grey cortical layer of the brain is frequently adherent at many points to the pia mater, softened at its periphery by imbibition of serum, also hypememic in places and with capillary hajmorrhages scattered through it. Although the ventricles are empty as a rule, this is by no means invariably the case. I have occasionally found them PURULENT MENINGITIS. 337 clis'teuded bj' turbid serum containing streaks of purulent matter, while the ependyma was at the same time loosened, but showed no important change. In a child of 2 months both the lateral and the fourth ventricles were filled with thin yellow pus, and much dilated. When the spinal cord is implicated we find a quite similar purulent infiltration of its pia mater and of the loose meshes of the arachnoid, the posterior surface of the spinal cord being most severely and extensively affected. , Also the inner surface of the dura mater both in the cranium and in the spinal canal is in many cases congested and covered with pus and blood (pachymeningitis). All the symptoms occur equally in the epidemic and sporadic cases of the disease.^ I have as yet had no opportunity myself of observing the epidemic infectious form on any considerable scale, although many times cases of this disease have followed each other so rapidly here in Berlin that, taking them along with cases simul- taneously observed by other medical men, I have been obliged to regard them as examples of a miniature epidemic. Two cases which came into my ward immediately after one another in the summer of 1885 — one of which ended fatally — occurred even in one family. At any rate the so-called sporadic cases were at least as common. As far as my experience goes, a very acute course — which was ormerly held to be in favour of this meningitis in contradistinction to the tubercular form — is by no means a sure criterion ; since, as we ha\e seen, there are cases which last as long, in fact much longer, than those of the tubercular form. The clinical symptoms also may vary so much in their severity and combinations that it is impossible to sketch a clinical picture which will apply to every case. The following may be mentioned as being the main symptoms which can in general be traced like a red thread running through all its varying manifestations : headache in children who are old enough to complain of it, vomiting, stiffness of the muscles at the back or sides of the neck, contractures of the extremities, convulsions, delirium, coma, and more or less high ' With reg-ard to the occurrence of specific bacteria in the pus of this form of meningitis, the statements of writers varj'. Many speak of micrococci, others (A. Frankel) of a form identical with the pncumo-coccus which he has de- scribed. Attempts at cultivation which were made in the Patholog-ical Institute with the pus from one of mv cases gave an entirelj' negative result. 22 338 DISEASES OF THE NERVOL'S SYSTEM. lever. Of these symptoms, liowevev, either one or more may he ahsent, or else their presence he so slightly marked as to he readily overlooked. The order in which they occur also varies. In a series of cases, -well-marked hrain symptoms set in at the very heginning — delirium, coma, vomiting, convulsions and cervical rigidity which at once put the diagnosis bej-ond a doubt. Such cases occasionally have an extremely violent and acute course. A girl of 5 years 8utldoiily, in the midst of perfect health and withovit discoverable cause, became affected by violent headache :nKl vomiting. After three hours, general epileptic convul- sions and deep coma. The convulsions ceased after about 12 liours, while the coma persisted ; there was high fever. The con- vulsions then recommenced and lasted till death, Avhich took place 48 hours after the commencement of the illness. F.-M. — The Avhole convex surface of the bi-ain covered with a yellow ])urulent exudation, infiltrating the pia mater, which formed a coherent layer over the frontal lobes, further back followed the course of the vessels and penetrated deeply into all the fissures. Also at the base purulent infilti^atiou in the neighbourhood of the optic and oculo-motor nerves. Ventricles emptj'. The remaining organs healthy. Tn a boy of li years vomiting and general convulsions suddenly began in the early morning, lasting till 5 P.M. They then ceased for 5 full days, during which there Avas fever and coma, and then recommenced on the day Ixfore death (the 6th day of the disease). The younger the children are, the oftener does the disease begin with convulsions, which occur one after the otlier, and arc rapidly followed by coma. In many cases, however, even at this early age an extremely high temperature forms the chief symptom, and for a considerable time supports the diagnosis of typhus until at last unmistakable cerebral s^'mp- toms set in, Agnes W., aged 8 months, healthy, child of a medical man, took ill on March 8th. 1877, with a single violent fit of vomiting. The child was pale, unwilling to take the breast, and, contrary to its usual custom, very quiet. On the following da}-, however, there was still nothing really morbid to be found. She laughed and jumped in her father's arms almost as happily as ever. On the 10th and 11th the child again became apathetic and very fevei'ish, and in the evening the temperature was 10ö'4° F., so that we looked for a scarlet fever-rash. On the I folloAving PURULENT MENINGITIS. 339 days, tip to the 15th, the high fever formed the only iniportimt symjitoTn. The temperature was as follows :— M. E. (3n 12th March lO-t'O 105-8 ,, 13th , 1047 107-2 „ 14th „ 105-1 104-4 „ 15th , 104-2 101-8 The fall of the temperature during the last 2 days was eftected by two cold packs, two doses of quinine (grs. iii. and grs. vi.), and finally by a bath of 86° F. The diagnosis wavered between typhus and meningitis ; and on the occasion of my first visit (on the 15th) I did not venture to make up my mind ; but on the 16th — that is, 8 days after the commencement of the vomiting — a moderate amount of rigidity appeared in the muscles of the neck, along with turning of the head towards the left and a slight contraction of the right arm at the elbow-joint. Neither by continued ice-compresses to the head nor by cold baths given twice daily, and enemata, containing quinine (grs. viiss). were we now able to bring down the temperature. This kept between 104° F. and 106-5° F., and only fell temporarily during the 2 last days to 101-3° F. Pulse between 130 and 160, always regular. As now (on the 18th) the neck seemed to be again more easily moved, and the spleen was found to be much enlarged on palpation; as, further, the child — in spite of the continued high temperature — responded readily when called to, and grasped at a watch held in front of it, we again hesitated in our diagnosis of meningitis. But on the 19th the vomiting returned, and tlie cervical i-igidity and contnxctui'e of the right arm again set in. making the diagnosis certain. Convulsions of the whole body, with dark redness of the face and profuse perspiration occurred for the first time on the evening of the 21st. During the night frequent screaming and repeated vomiting. On the following day, at 3 p.m., an epileptiform attack, lasting for half an hour ; later, energetic chewing and sucking movements ; convergent strabismus, congestion of the conjunctivae. The convulsions recurred on the 23rd, from 3 — 6 p.m., and again at 10 p.m., after which they continued till death ensued, at 3 p.m., on the 24th. Pulse at the last, 200, thready. P.-M. — Very severe cerebro-spinal meningitis. About a table- spoonful of free pvis on the surface of the brain; purulent exuda- tion f inches thick between the meshes of the pia mater ; softening of the brain substance, extending about | inches into the grey substance of the bi-ain. Ventricles empty. Spleen enlarged to about thrice its normal size. All other organs normal. In this case we find the convulsions beginning on the 13th day of the disease when there had previously existed nothing but a very BIO DISEASES OF TUE- NERVOUS SYSTEM. high temperature, a certain amouut of cervical rigidity, con- tracture of the right upper arm, and palpable enlargement of the spleen. For these symptoms, which are sufficient for a diagnosis, we are in some cases kept so long waiting that we think sooner of the development of tubercular, than of puru- lent meningitis. This mistake is especially liable to be caused by a persistent low temperature (about 101'3° F.) and a not very rapid pulse-rate (64 — 90) and the pulse may also be irregular. Thus in a child of 9 months,' rickety but quite free from tubercle, vomiting occurred after every meal for a fortnight before cervical rigidity made its appearance. At the same time there was high fever (pulse 152 regular) almost continuous screaming and contractures of the fingers. During the 5 last days, continuous coma and almost uninterrupted epileptiform convulsions. Accompanying these, there was a return of the vomiting, sinking-in of the fontanelle, dilatation and immoliility of the pupils ; pulse small and too rapid to be counted, breathing irregulai'. Death after -3 weeks. At the P.-M. we found purulent meningitis of the convexity and base, which had extended to the pia mater of the cervical cord. Ventricles dilated, filled with turbid serum and pus. Otherwise all organs normal. No tubercle anywhere. The following case also looked like one of tubercular menin- gitis, although it began with an attack of convulsions, which was referred to a complication with tubercle of the brain. . Max Th., 7 months old, rickety; admitted June 11th, 1884 After a cough which had lasted for some time, suddenly, 2 weeks ago, an epileptiform attack occui-red. Since then, retraction of the head, sometimes more marked than at others. The head and spinal column formed an acute angle ; the former could not be bent forward. At the same time great apathy, left convergent stra- bismus, right pupil somewhat dilated but reacted avcII. Bilateral otorrhoea especially on the right side. Catarrh of the large bronchi. These sjTuptoms had persisted for nearly three weeks unchanged. Ajjathy and drowsiness daily inci'easing; extreme emaciation. During the last days, coma, pericorneal injection, fragments of mucus on the conjunctiva ; temperature never above 100'4° — - 101"8°F., in the last days almost normal. Ophthalmoscopic exam- ination negative. Death on 29th in coma without convulsions. P.-M. — No tubercle in any organ. Moderate basilar purulent meningitis, extreme dilatation of the lateral and of the fourth ^Eeitr. ::ur KinderlteiU:., NJ\.,S.13. PURULENT MENINGITIS. 341 ventricles, which were filled with thin yellowish pus. Ependyma swollen. Brain anaemic, a hyperaämic zone round the ventricle^-. Purulent otitis media in both ears with purulent infiltration of the surrounding bone. In this case the basilai- meningitis may have arisen from otitis media and then spread along the choroid plexus into the ventricle. The disease lasted for five weeks altogether, convulsions occurred only once, at the beginning of the meningitis. Convulsions may, however, be entirely absent during the whole course of the disease, and in that case there occur in their stead con- tractures either of the muscles of the neck and back only, or also of the limbs (especially the lower) presenting more or less rigid resistance to extension, and when they are extended the child screams loudly. In one case (a boy of 10 years) there was also an extremely tender diffuse swelling of the left hand and right knee-joint, which slowly disappeared under the use of mercurial inunctions. Ernst P., 7 years old, admitted in Kovember, 1872, with catarrh of the larger bronchi and typhoid symptoms. Coma, tongue dry and red, soon Ijecoming brown, lips blackish: spleen and liver normal in size. Temp. 102-2°— 10.3-1° F., later 101-8° F. From the 6th day after admission cervical rigidity and stiff flexion of the lower limbs, dilatation of the left pupil, frequent loud screaming; later, flexion of all the fingers and supination of the hands. Temp, varying from 97"9° — 100-8° F. On the 12th day, improvement, tongue moister, tremor of the legs, intelligence returning, appetite better. During the next 2 days, symptoms worse again. Temp, normal. After the 16tli day intelligence quite clear, temp. 101-3°— 102-2° F. After the 22nd day all spastic symptoms disappeared, and the child seemed w^ell. Free from fever. Pulse during the whole illness vaiying between 104 and 132. Only once (on the 28th day) was the pulse 46 and temperature 98-2° F. Otto K., 7 years old, admitted in December, 1872, with gastric symptoms, pains in the head and body and the abdominal wall ex- tremely tense. From the 3rd to the 7th day violent delirium, drowsiness, complete apathy, temperature normal. After the 7th day, marked improvement, intelligence brighter till the 11th, when the child got worse again and complained of violent pain in the neck; Moderate cervical rigidity and contracture of the adductors of the thighs. Temp. 97-7° F. and pulse 60—64 till the evening of the 12th day. The sjTuptoms continued to get worse and considerable hyperaesthesia of the lower ex- tremities came on, with repeated vomiting and severe pain in the :31-2 DISEASES OF THE NERVOUS SYSTEM. back and loins, the temp, rising at tlie same time to 103"o° — 1047° F., the pulse 110—142. On the 14th day all the .symptom.s subsided and the temp, and pnlso gradually returned to their normal condition. The treatment in both cases consisted in the repeated application of leeches to the head and wet-cupping along the spinal column, warm baths (in the first case with cold douche to the head and back), inunction of mercurial ointment ; internally, calomel and other purgatives. Gottfried Sp., 7 years, ill for 3 days. Admitted on May 23rd, 188Ö, with violent headache, followed by pains in the neck and left knee; drowsiness, slight delirium, extreme rigidity of the neck and spinal column, which increased when he was set up. Pupils normal. Temp. 100-8° F., pulse 100, Imt soon fell to 84 and became irregular. Lower limbs slightly contracted in a position of flexion; no hypera^sthesia. Treatment— 12 wet cups, inunction of uug. hydrarg. grs. x. ; calomel, gr. h every 3 hours. On 24th, 8 more wet-cups. On 25th, herpes labialis. Temp. 101'1° — 103'1° F. Drowsiness alternating with free intervals. On 26th, disappearance of the contractures, ])ulse 120 regular. Temp. 101"3° F. The s^-mptom described by Kernig' could be distinctly observed, and continued with diminish- ing distinctness into the period of convalescence. It only dis- appeared entirely on June 6th. After 3rd June, patient free from fevei'. The cervical rigidity, which was then moderate, did not disappear till the 9th. Latterly pot. iod. was given. Discharged cured. In these and several other cases which I have lately met with, I observed the symptom described by Kernig, i.e. rigidity of the lower extremities at once came on when we set the patient up in bed, even when there was no rigidity when lying quietly on the back. Further, when the patient was lying on the side, this rigidity was generally set up whenever the thigh was placed at anything like a right angle to the body ; there thus occurred at once a condition of contracture at the knee-joints in an attitude of flexion, which firmly resisted extension but disappeared at once when the patient was put back into the horizontal position. I cannot say, however, that this symptom is constant; for it was absent in one severe case in which the diagnosis was con- firmed by a post-mortem — at least so long as the case was under clinical observation. Even although the symptom is not patho- gnomonic, as it occurs in other cerebral afiections also, still it cannot be denied that it has some diagnostic value. It was also ' Berl. Hin. Wockenschr., 1884, No. 52.— Bull, ibid., 1885, No. 47. PURüLEM- MENINGITIS. Mo very wcll-niarkcd in a case of tubercular meningitis wliicli was complicated by a considerable purulent spinal aracbnitis. I must agree with Bull that we may often discover a slight degree of this phenomenon even in healthy people, especially if we place the thigh at an acute angle. ^ If all cases presented the violent symptoms which I have described, it would be possible, generally, to give a pretty cer- tain diagnosis. This, however, is not always the case ; for there is a moderately severe chronic form of meningitis, especially of the infectious variety, which by its long duration and the varying severity of the symptoms, may mislead the physician, especially if he is inexperienced. Usually, the course is as follows. The children who have hitherto been healthy, take suddenly ill with more or less high temperature, which in the afternoon or evening hours may reach from 103*1° to 104*4- F. There is violent headache from the beginning, generali}- frontal; and this even in young children is often indicated by their catching at the head, moaning and whimpering. Vomiting occurs often, but not always. Cervical rigidity with retrac- tion or lateral obliquity of the head (caput obstipum spasticum) is constant, and the latter in one boy Avas so severe and persistent that a bedsore formed on the right ear, on which he always lay. Every passive movement of the head gives rise to expressions of pain. Less frequently, rigidity of the muscles appears in the extremities also, especially the lower ones, and both active and passive movements are interfered with. However, I have very seldom been able to make out distinct hypera^sthesia in these parts, and it was absent even in some of the very acute cases. The patellar reflex in several cases which were carefully examined in this particular, was well-marked. After about 1^ — 2 weeks the fever diminishes considerably, may even temporally dis- ' Dr. Sachs of Brieg has, in a letter, drawn my attention to the followinfr remark of Landois : '• The long- extensors of the leg arising from the tiiber ischii are too short to allow of complete extension at the knee joint when the hip is bent at an acute angle." Henke disciisses this circumstance more fully (Handatlas u. s. w.: Berlin, 1888, i., S. 175). The three muscles here concerned, semitendi- nosus, semimembranosus and biceps, are distinctly pennate, and contain very many short fibres. They are therefore quite incapable of such a stretching aa they would require to undergo if the hip joint were actively flexed and the knee extended at the same time. Even in the dead body this is not possible. At any rate however the resistencc of the muscles in meningitis is even greater than in the normal condition, perhaps because the muscular tone is here morbidly exaggerated. 344 DISEASES OF THE NERVOUS SYSTEM. appear, and the appearance of health which now sets in seems to justify the relatives in entertaining the highest hopes. But the cervical rigidity which persists although in a diminished degree, shows that recovery is not yet complete. The fever in fact recommences after an interval of one or more days, the general condition again hecomes worse, the headache and cervical contracture become more prominent without any cause for this aggravation of the condition being discoverable. Such remissions and exacerbations may be frequently repeated. The children become steadily more emaciated and weaker, and the physician already suspects tuberculosis of the brain or cervical vertebrte, till after a course of seven, ten, or more v/eeks, recovery at last takes place. I, at least, have never observed a fatal termi- nation of such cases, except in some in which the disease had run its course, without the characteristic remissions, with almost equal severity of symptoms for a number of weeks.^ Unfortunately, however, recovery from meningitis is not always complete. Like many other writers I have repeatedly seen deafness or amaurosis in young children, also deaf- mutism, remain permanently. We refer these derangements of the organs of sense to neuritic changes, which are supposed to depend on the inflammation spreading from the meninges to the optic and auditory nerves. More recent observations make it probable that this extension may also take place through the bands of the dura mater which pass into the petrous bone to its spongy tissue and from thence to the semicircular canals, setting up hasmorrhagic inflammation there." Children who become deaf at a very early age, before they have begun to speak, as the result of meningitis, naturally remain dumb also, because hearing is absolutely necessary if the child is to learn to speak. In very rare cases amaurosis or deafness may also set in during the disease as a symptom which passes off after a few days. In a girl of eight years contracture of the muscles on the right side of the neck (torticollis) persisted unchanged two months after recovery from the meningitis. Among the causes of meningitis — next to epidemic in- fluences, to which I shall shortly return — the most important are injuries and diseases of the cranial bones. Even ' Vide my paper on this form in the Chariti-Annahn, Ed. xi. : Berlin, 188C. « Lncae, Vbxhovfs Archiv, Bd. 88, 1882, S. 556. PURULENT MENINGITIS. 815 after severe concussion of the brain from a blow or a fall symptoms of cerebral bypertiemia may set in, as already mentioned (p. 311) and may end in meningitis. Far more dangerous are fissures and fractures of the cranial bones, which, besides the meningitis, may give rise to more or less severe hemorrhage into the cranial cavity. Mux E., 5 years old, admitted on 1st July, 1875. Had tumbled from a ground-floor window on to the street 3 days previously, falling on his head. Stupor, right pupil smaller than the left, urinary bladder distended, reaching to the level of the umbilicus. Tlie head was turned to the right and rotation to the left wa.s anxiously avoided and guarded against. T. 103"6° F., P. 12U I'ogular, K. 30. Bladder emptied by catheter; leeches and ice-bag to the head; purgatives. On the follovving days active delirium, violent pain on swallowing in spite of the stupor and the ]iormal condition of the pharynx. After 8rd July, profound drowsiness, but screaming when raised up. Moderate cervical rigidity, slight spasmodic contraction of the arms, in- creasing pulse-rate, finally uncountable. Death, on evening of Itli. in a state of coma. Temp, on 2nd July 103-3 103-6 „ 3rd „ 104-2 104-9 „ 4th „ 106-7 104-5 r.-M. — Marked hyperemia of the pia mater and on the con- vexity ; extensive pui'ulent infiltration of it, especially on the left side. Sides of the Sylvian fissure adherent to one another ; in the pia mater, especially on the left side, large purulent patches in this situation. In the bones of the base of the cranium on the left side three fissures traversing the frontal bone, the greater and lesser wings of the sphenoid and the temporal bone. Blood extra- vasion ))etween the dura mater and the bone corresponding to these fractures. In this case the absence of all motor derangements — with the exception of slight twitchings of the arms, and some contracture of the muscles of the neck — is worthy of notice. The pain on every movement of the head and on swallowing, may indeed be explained merely by the inevitable movement of the fractured fragments of bone ; especially the pains on swallowing, by the action of the pterygo-pharyngeus and stylo-pharyngeus which must have exerted some traction on the fractured base of the cranium. In this case, also, we found a very high temperature persisting (to 106-7'' F.). We may also have meningitis due to chronic diseases of o46 DISEASES OF THE NERVOUS SYSTEM. the cranial bones. Still, I have myself but seldom met with purulent meningitis post-mortem, in spite of the fact that I have observed numerous cases of caries of the p e t r o u s b o n e. I have more frequently found the above-mentioned (p. 315) thrombosis of the neighbouring sinuses with purulent disintegration and pysemic symptoms, or the hsemorrhagic form of inflammation of the inner surface of the dura mater w'hich is knowai by the name of pachymeningitis, and on which I have already touched (pp. 272, 304). To this class also belong those cases of meningitis! which arise as the result of a direct injury to the membranes of! the brain or spinal cord, c.[i. from an operation. I have met' with this after puncture of a large hydro -meningocele at the occij)ut and of a lumbar spina bifida. The latter case was that of a child of 2 months with a defect of the sacrum and of the 3 lower lumbar vertebra. There was already gangrene of the skin covering the tumour, and when this Avas excised tlie sac was opened and 2 tablespoonfuls of serum evacuated. A suture was inserted and an iodoform dressing applied. After 2 days, death ensued with spasmodic contractions of the lower limbs and a few general convulsions, and at the post-mortem we found a fibrino-purulent infiltration of the whole spinal pia mater up to the base of the brain. The temperature in this case had sunk to 937° F., during the disease ; which is a further proof of the fact that during the first period of life even acute inflam- mations may run their course with subnormal temperature (p. 17). Meningitis sometimes developes secondarily in the course of various acute diseases ; e.g. p n e u m o n i a, n e p h r i t i s, p y fe m i a , and septicaemia. As a rule, however, the symptoms are under these circumstances so complicated by those of the original disease that a definite diagnosis is very difficult or even impossible. At any rate, the complication of scarlet fever or pneumonia with actual meningitis is rare, and the cerebral symptoms which come on in these and other infectious diseases are — as we shall see later on — to be regarded either simply as the result of the considerable elevation of temperature or of the virulence of the disease. In these cases generally the presence of meningitis is out of the question, although formerly this designation was very freely bestowed. I would especially point out to you that violent cerebral symptoms with vomiting and even convulsions may arise in children from otitis media or even otitis externa, and mav occasion a false diagnosis of PUKÜLENT MENINGITIS. 347 meningitis until a large quantity of pus suddenly escapes from the ear, and the dangerous symptoms rapidly pass oft". In all cases, therefore, where head-symptoms are present we must bear in mind this possibility and carefully examine the external auditory meatus at least. Firm pressure on the tragus is often sufficient in such a case to set the child a-crying. I must, however, accord- ing to my experience hitherto, regard as rare the cases in which the symptoms of otitis are really such as to be mistaken for those of meningitis, and as even rarer those in which meningitic symptoms are caused by rhinitis. Twice — in a boy of three and a girl of four years — I have observed after a fall on the nose, in addition to the local symptoms (swelling, tenderness of the nose and interference with breathing), violent frontal head- ache, -high fever, and restlessness, nocturnal delirium, which came to an end with the rupture of the abscess, and the discharge of blood and pus from the nose. In a number of the cases we are unable to make out any of the causes named, but the disease arises, as the saying is, " from a whole skin," in the midst of perfect health, and it is in those cases that the suspicion of an infectious origin at once occurs to one. The proof of such an assumption is onl}' possible, however, when at the same time and in the same family, or at least neighbourhood, one or more analogous affections have recently occurred or actually prevail. Such cases I have met with in no small number, particularly in the summers of 1879 and 1885, and, especially during the latter season, almost all the cases came to the hospital from one quarter of the town. It has been already mentioned (p. 337 7wte) that in spite of the most recent bacteriological investigations, we are still very uncertain as to the nature of the infecting material. From a clinical point of view I should remark that this form frequently has a protracted course interrupted by great remissions, and that after the disappearance of the regular cerebral symptoms a temperature rising to 103*1° F. may persist for days and weeks with marked morning remissions, or complete intermissions, quite similar to what occurs in typhoid fever. In one case, after apparently complete recovery, death ensued from inanition and increasing collapse, against which all stimulants and tonics proved ineff"ectual. In the treatment we must seemingly be guided by the stage of the disease and by the state of the patient's strength. At the 348 DISEASES OF THE NERVOUS SYSTEM. _ beginning, a tliorouglily antiphlogistic line of treatment is in- dicated, while at a later stage this is to be avoided and stimulants are rather to be preferred. The exact period of this change in the character of the case, which seems to depend on the onset of sup- puration, is certainly hard to determine, and it is more a matter to be settled by the practical skill of the physician than byj theoretical rules. I" or very young, badly-nourished, anjemic children, or those reduced by illness, v,e generally use dry cupping, at most 2 — 3 leeches, according to the age; but the bites must never be allowed to go on bleeding afterwards. For older children, on the other hand, especially such as are robust, 6 — 10 leeches are required, or a similar number of Avet-cups on the neck, and perhaps also on the back. Under these circumstances I have even repeated the blood-letting when exacerbations set in, and the state of the strength permitted it. I warn you urgently once more against the lack of energy which is now so prevalent in the profession, and Avhich induces the practitioner rather to stand with his hands in his pockets than to apply leeches. At the same time, as long as there are no symptoms of collapse, we should keep an ice-bag applied to the head, have mercurial ointment rubbed into the neck, back, arms, and thighs (grs. v. — x. every 3 hours), and give calomel internally, gr. 5 to ^ every 2 hours. The favourite antipyretics — quinine, salicylate of soda, antipyrin, cold baths and cold compresses — have in these cases no efi'ect, and scarcely lower the temperature. When there is very great restlessness or violent convulsions, we may try injections of morphia (gr. ^V — tV)? oi' chloral (Form. 9), also luke-warm baths (88° — 90*5° F.), with cold douche to the head. When the acute stage is over, I should recommend iodide of potash (Form. 13). Daring the continued use of this medicine I have frequently seen the children av>-ake out of their comatose condition, the contractures disappear, and complete recovery take place at last. On the other hand, the derangement of the faculties which remains behind (deaf- ness, loss of speech, amaurosis) almost always resists all treat- ment. I have made use of this method of treatment iu all forms of meningitis, including the infectious variety, and on the whole I am satisfied with it. We possess no specific remedy for this NEURALGIC CONDITIONS. 849 anj' more than for many other infectious diseases, the treatment must therefore he symptomatic. But \vc must, in regard to this form, remember that it is an infectious disease, and carry out the anti-phlogistic measures with more caution than in those cases where an injury or other causes have given rise to it. XIX. Neuralgic Conditions. In chiklhood you will meet with striking sensory disturbances much less frequently than in adults. Anaesthesia, hyperfes- thcsia, and neuralgia are exceptional in children, and so greatly resemble in all particulars similar conditions met with in later life that it is unnecessary to discuss them at length here. Aua3sthesia especially is extremely difficult to estimate, even in older children, because the result of the examination is rendered dubious by their terror when the needle is used — and this is the case even when the patient is blindfolded. Even in serious chronic diseases of the central organs (tumours, tubercle, sclerosis) I have never been able to ascertain the limits of the anaesthetic areas so exactly as in adults, and we must be content to base our diagnosis on observed intellectual and motor derangements. Among the forms of neuralgia in childhood, the only ones which call for special mention are colic— which either comes on with flatulence or along with diarrhaa (p. 126) — and he mi crania (migraine). Migraine occurs in children — as only the inexperienced will deny — very nearly as often as in adults, and with pretty much the same symptoms. As the result of many years' experience, however, I am inclined to maintain that — especially during the last 20 years — the frequency of the disease has considerably in- creased. And the cause of this increase is to be found in the excessive demands which the education of the present day makes on the child's brain. The unceasing growth of our city which is always making the enjoyment of country air more difficult of attainment, the mental exertion in schoolrooms which are often overcrowded, and the very few hours left for re- creation which are further encroached upon by home tasks and music lessons — all this, combined with nervousness which is 350 DISEASES OF THE NERVOUS SYSTEM, often inherited, and sometimes acquired through injudicious up- bringing, appears to me the cause of those headaches which Ave so often meet with in boys and girls of about seven and up- wards. Besides this cause, there is also a hereditary tendency to be considered. I have not uncommonly had children under treatmejit for migraine in whom heredity, either from the father's or mother's side, was ascertained beyond doubt. The youngest of these children Mas 2 J years of age, and suffered about every 5 or 6 weeks from attacks of pain over the left eye, which lasted about half an hour, and ceased after vomiting and, less frequently, movement of the bowels had taken place. When such a tendency is present several children of the same family may suffer from this affection. Two children of the same family, aged respectively lU and 8 A'cai-s, had snffered for some j'cars from well-marked attacks of migraine, frontal headache with naiisea and vomiting, photo- ])ho)na, a preference for dark quiet rooms. In the one case during the pains there was ecstatic excitement and great tenderness of the hair on combing, which disappeared during the intervals. Attacks set in every fcAV months ; duration 2—4 days. Father suffers severely from migraine. A me mi a, also, which often occurs in children, even so young as or 6, and is met with even more frequently after the age of the second dentition, favours the development of migraine, in these cases is generally combined with giddiness. In the same way in the hysterical conditions of which I have already given you illustrations (p. 220), nervous headache is often complained of. In rare cases, even after the disappearance of such conditions (attacks of hallucinations, spasmodic twitchings, &c.), headaches with the character of migraine persist for some time. On the other hand, the female genital system, the diseases of which so often occasion headache in later life, scarcely calls for any consideration in childhood. On this account the followinn- case — which is certainly the only one I have met with — seems to me all the more remarkable. A girl of 7 years, brought to the~polyclinic on 2nd Januarj". 1873. Had .suffered since May, 1872, from attacks of migraine. Violent pains on the forehead and temples, nausea, extreme prosti-ation, photophobia. Duration of attack a few hours. Re- MEURALGIC CONDITIONS. 351 currence irregular. At the same time restless sleep with frequent twitching of the body. Since May, 1872, there had existed fluor albus; the entrance to the vagina much reddened, hymen normal. Treatment — Lead fomentations, injection of zinci sulph. (j per cent.) into the vagina. Internally quinine, later pot. broni. After various ups and downs all the sjTnptoms disappeared until Decemiber, when the fluor albus, and with it the attacks of migi-aine again came on. Further coui'se unknown. In cases of this kind we must remember that both the vaginal catarrh and the headaches may have arisen from irritation of the genital organs by masturbation, and we must investigate this particular. A connection between migraine and the presence of worms is oftener assumed than the facts justifj^ However, Ave will do well to direct our attention to this point, as I have seen a few cases in which headaches disappeared for a length of time after several round worms had been passed.* In general I have found migraine in children less frequently unilateral than in adults, and more usually in the middle of the forehead. The duration of the attacks varied between a few hours and two days. In the latter case the intervening nights were often disturbed by restlessness, sensation of heat and talking during sleep. Vomiting, dread of a bright light and of sound, sometimes also general trembling and rapid breathing as in the hysterical attacks described, were common. The intervals were quite irregular in duration, lasting in some cases only a few days and in others for several weeks. Among the determining causes none were more frequent than the close atmosphere and mental exertion of school, so that many children had to be kept at home. Emotional causes of every kind, fear of punishment, and scolding, I have also known to bring on an attack at once. When removed from their ordinary surroundings into the country or into health resorts, they generally remained quite exempt from the attacks, which usually recurred soon after their return home. Even after very careful examination and observation, the most conscientious physician often remains in uncertainty as to Avhether the case is one of migraine or of headache caused by cerebral disease (tubercle, tumour). I have already men- ' On the connection of migraine with visual difsturbances (asthenopia and hypermetropia) also with nasal affections (swelling of the turbinated bones), I have no personal experience. Cf. Blache, Revue men.'., Avril, 1883; and Sommerbrodt, Berl.l.lin. Wochen sehr., \^ö. 352 DISEASES OF THE NERVOUS SYSTEM. tionecl (p. 275) that such affections may for a long time only indicate their presence by headaches which have all the characters of migraine, and the diagnosis can therefore only be established by observation during the intervals, carried on for some time, and by an exact investigation of the etiological conditions which I have already described. According to the nature of these conditions the treatment must be directed. While we are powerless iu regard to the hereditary tendency, we must combat all the more resolutely the influence of mental strain. I do not overlook the difficulties which meet us here. Only under very favourable circumstances can we take the children completely away from school and have them taught by private tutors, so that they ma}" have more time for bodily exercise and be more iu the open air. I have frequently also seen good results when I took the children away from to\\Ti schools and let their further education be carried on in schools or boarding-houses in the country. The majority of the little patients, however, are unfortunately fixed where they are, and the treatment is then all the more difficult, as not only the teachers, but also many ambitious fathers put their veto to the doctor's advice. All that remains then, is to limit the home- tasks, to arrange for regular recreation and to prolong the holidays as much as possible. The government regulations which have very recently been issued, aiming at a limitation of the mental work of children, are therefore to be gratefull}- acknowledged. We may expect much more from the carrying out of these instructions by the teaching staff", than from any course of medical treatment. The rubbing down with cold water after getting up in the morn- ing, which is much recommended for strengthening the nervous system, and which indeed is quite the recognised treatment, has in my hands done little or nothing in these cases. Cold baths and swimming have been more effectual. In annemic patients, iron is to be recommended. I know of no specific remedy. The much extolled quinine and bromide of potash, which I have tried in numerous cases gave very various results (quin, sulph. or muviat., grs. i thrice daily, pot. brom., grs. viiss — XV. also thrice daily). A visit to the sea-side, or to hills and woods, and mental rest are more efficacious than any medicine, although the good result is in general only temporar}-. The " holidav-colonies " which have been started in our time NEURALGIC CONDITIONS. 353 arc therefore an inestimable benefit for the poorer classes. "We must always bear in mind, also, that there may be an element of simulation and that the pains may be considerably exaggerated in order to get away from school. "When there is a suspicion or certainty of masturbation, a serious representation of the danger — which we may purposely exaggerate — has in my experience far more influence than punishment with older children. 23 354 SECTION IV. Diseases of the Respiratory Organs. I. Inflammation of the Nasal Mucous Membrane. Rhinitis.^ The mucous membrane of the nasal cavity, larynx, and bronchi is extremely subject to catarrhal affections, especially in children of the lower classes ; these being allowed to expose themselves to all sorts of weather. The symptoms are very similar to those in adults — swelling and obstruction of the nose followed by increased secretion of muco-purulent matter, sneezing, catarrhal affection of the conjunctivas, hoarseness, rough or ring- ing hollow cough, with or without rise of temperature. Such a catarrh is one of the constant prodromata of measles especially, as well as being caused by atmospheric influences. And during a measles epidemic you may in fact, from such a catarrh appearing in a child who has not hitherto had the disease, predict with the greatest probability that the eruption is about to follow. Under all circumstances a catarrh of the upper part of the respiratory mucous membrane in very young children, though it may be slight in degree, is always to be regarded as much more serious than the same at a later period of life. For experience shows that even a simple cold in the head may in a very short time occasion symptoms of laryngeal obstruction, or may extend rapidly into the deeper ramifications of the bronchi. Infants with coryza, or slight catarrh of the larynx and trachea should not, therefore, l)e taken out of doors, and must be carefully protected from cold air. Less frequently than measles, but still often enough, scarlet fever and diphtheria may caus3 severe infiannnation of the nasal mucous membrane, which in both cases is usually second- ary to an already existing " diphtheritic " affection of the pharynx. ' Cf. the description of coryza neonatorum and syphilitica, p. 142 and pp- 93, 142. RHINITIS. doö The nose is more or less swollen, and an offensive purulent secretion flows from it over the upper lip, which as well as the nostrils is reddened and excoriated by it. The parts round the nose, as far as the eyelids, are oedematous and swollen in severe cases, the conjunctiva is congested, and the eye waters much owing to obstruction of the nasal duct. It is but seldom, however, that one can see the diphtheritic membrane in the nose, owing to its always being situated so far up that even when the ahi; nasi are held apart it still remains out of sight. Far less commonly, the membrane extends so far downwards that it comes into view — a fact to which I shall return later on. It is even more difficult — usually indeed, impossible — to examine the naso- pharynx at this age with a mirror. The swelling of the nasal mucous membrane in those cases is so great that breathing is more or less interfered with and a snoring noise is caused, especially during sleep. In general this rhinitis is a bad omen both in scarlet fever and in diphtheria ; still, in both these diseases it often occurs in a less severe form without exerting any bad efifect. We shall see later on that diphtheria may also begin with an affection of the nasal cavity ; but only once — in the case of a daughter of our never-to-be-forgotten Traube — have I observed an independent rhinitis pseudomembranös a. The case which follows, acquires an additional interest from the careful observations made by her father. The girl, who was 8 years of age, and generally healthj% took ill with symptoms of coryza, accompanied by moderate fever. The marked snoring during sleep, and the complaints about some- thing obstructing the breathing near the root of the nose, indicated a more considerable stenosis of the nasal canal than usually occui-s with simple coryza. Traube himself made an examination with the mirror and found nothing but a catarrhal redness on tlie pharynx and on the epiglottis. After a few daj's the child expelled with great difficulty a tough, white mass of the length of a finger-joint, which swelled up when treated with acetic acid — thus shoAving its filjrinous nature. After a few days a much smaller mass was ejected, whereupon all difficulty of breathing at once disappeared. The treatment had been almost solely expectant (rest in l)ed, and a few doses of calomel). Was this a case of true diphtheria confined to the nasal cavity, or was it only a non-speciöc croupous rhinitis ? A chronic form of rhinitis occurs very often in scrofulous 3oG DISF.ASES OF THE RESPIRATOllY ORGANS. children, along with other more or less pronounced symptoms of this cachexia — eruptions on the head, ophthalmia, otorrhoea, eczema in the face and enlargement of the cervical glands. The commonest symptoms of this disease are external swelling of the nose, snuffling and snoring breathing, the trickling of a sero- purulent secretion out of the excoriated nostrils, and redness and swelling of the upper lip. Not uncommonly this chronic rhinitis gives rise to repeated attacks of erysipelas, which, extending from the nostrils, spreads over both cheeks or even still further, forming a wing-like outline (p. 48). But even where there is no tendency to scrofula, chronic rhinitis may be left as the result of measles, scarlet fever, or even of very severe coryza. In all such cases, besides using anti-scrofulous remedies (to which I shall return later), I have the nose painted dail}' with a solution of nitrate of silver (grs. xvi to |i) and this usually succeeds. The application of iodoform, in powder or as an ointment, has proved useful. I must also mention in passing the rhinitis which may be caused by foreign bodies — peas, beans, &c. — in the nose, and which at first at least is usually one-sided. In a large number of children there is a marked tendency to catarrhal aÖ'ections of the entrance into the larynx, which develope very rapidly when the children get coryza. In such cases one must be prepared, when the slightest coryza begins, for one of the attacks which we are about to describe, and which on account of their resemblance to croup have been called "false croup." II. Fcihc Croup. When you find that a child has had " croup" 4 or 5 times, you may always be sure that the disease has been false and not true croup. Although usually not dangerous, false croup is a very alarming disease and one of the most inconvenient for the physician ; for it is especially apt to cause him to be roused in the night time. The disease always begins suddenl}-, usually following immediately on a slight coryza (snutiling, sneezing) and almost always in the night, often soon after entering on the first sleep. The children start up from sleep in a fit of coughing. FALSE CROUP. 357 The cough is hoarse and hollow, quite resembling that of croup. The household is at once thrown into a state of alarm. Not only the cough, but — almost even more so — the deep inspira- tions which interrupt them, are accompanied by a distinctly croupy, sawing noise ; and this is also heard between the whimpering and crying which little children are wont to set up in these circumstances. The cry itself may at the same time be either quite normal or a little hoarse. During this attack many children sit up in bed with an anxious expression and flushed cheeks, with laboured and noisy breathing, are extremely restless, and repeatedly catch at their throat. The child is hot, often covered with sweat, the pulse rapid. A fit of this kind usually lasts some minutes, but even after it is over the breathing often remains somewhat noisy and more frequent than in the normal condition. The physician is called in haste. By the time he arrives the child is usually comparatively quiet, or even asleep, the accessory muscles of respiration taking little or no part in the breathing — except for, perhaps, a slight movement of the aliie nasi. He may from these facts draw the reassuring con- clusion that the obstruction to the breathing is not of a serious nature, and that as yet, at any rate, it is not a case of true croup. If one remains some time at the child's bedside, one is very likely to witness a repetition of the attack. At any rate, when the children wake out of sleep they generally begin to cough again with a croupy sound, and when they cry or sob their inspirations are harsh and prolonged. Pressure applied to the larynx and trachea at once brings about one of these attacks of coughing. The children are generally quite well next day, and there is nothing now except an occasional hoarse ringing cough to remind one of the violent symptoms of the night before. Sometimes the same scene is repeated on the following night, and I therefore always prepare the parents for this possibility. In most cases, however, the attacks do not occur after the second night,^ and there remains only an ordinary loose cough, which may last 8 — 14 days. You see, then, that the course of the disease being such, there is no danger to be apprehended ; but the troublesome thing is its frequent recurrence. Some Cases in which an attack occurs 12 nights in succession, as in one observed by Monti, are surely very exceptional {Ueber Croup und Diphtheritis : Wien und Leipzig, 1884, S. 18). 358 DISEASES OF THE RESPIRATORY ORGANS. children are attacked by it repeatedly in the coarse of a single year, and its resemblance to croup inspires such teiTor that very few parents, in spite of their previous acquaintance with the disease, are considerate enough to leave the doctor undisturbed. When we examine the fauces in a case of false croup, we find at most slight catarrh and redness. By means of a laryngeal mirror one may make out a swelling of the lower and inner portions of the vocal cords (inflammatory cedema below the cords), which rapidly spreads upward, but which may also subside in a few hours. ^ It appears, therefore, to be a catarrh spread- ing downwards from the nasal cavity into the larynx ; and along with it, as in every coryza, the swelling increases, especially dur- ing sleep, and occasions a sudden awaking with want of breath, anxious feeling, and hoarse cough. The dryness of the cough, and of the breathing, is usually diminished by Avarm drinks (eau-sucre and milk) ; and with the commencement of a copious catarrhal secretion, all cause of anxiety completely disappears. The physician will therefore do well in such cases not to display too great energy at once ; but rather to take an expectant line of treatment. I am in the habit of ordering frequent drinks of warm water or milk, with wet compresses, also, perhaps, hot poultices to the neck. But under all circumstances the children must be kept in bed for two or three days till the resulting catarrh has time to develope. The continuous applica- tion of a j)iece of bacon over the front of the neck is also to be recommended, as it generally causes a slight erythema or an eruption of small pustules. In the great majority of cases I have succeeded very well with the treatment I have mentioned, and I therefore consider the custom of giving an emetic at once in all such cases unwarrantable. In families where false croup is, so to speak, endemic — a not very uncommon occurrence — the mothers usually have emetics at hand so as to be able to give them before the doctor arrives. I must protest very strongly against this abuse, which weakens the children quite unnecessarily. There is no remedy against the recurrence of the attacks.^ Inuring to cold is of no use ; careful protection from chills is far better. Many children commence to suffer ' Rauchfuas and Delhio, Jahvb.f. Kinderhtill,-.,'BA. 's.s. -' I have no experience of tlie pot. iod. (1—2 p. c. solution) wliicL Monti rt'(3ommendt5. ATELECTASIS OF THE LUNGS. 359 from these attacks of " croup " in their 9th or 10th month. The attacks hecome less frequent or less severe, and usually disappear of themselves about the 6th or 7th years of life. Such children must be carefully protected from cold weather, and kept indoors, especially when they have a cold in the head. But even this does not always insure immunity from false croup. The development of measles or whooping cough is some- times ushered in by quite similar attacks. Both diseases — especially measles —may begin with such an attack ; which then passes into an ordinary catarrh, manifesting its real nature in the case of measles after a few days, in that of whooping cougli after one or two weeks. From the description I have given you, you might be inclined to regard false croup as in every case a trivial affection, and one free from danger. But although this is true of the great majority of cases, you must not be misled into over confidence, or neglect keeping an eye on the child for some days after the first attack. Although very rarely, I have occasionally seen true croup (confirmed by the expulsion of false membrane, or by post-mortem examination) develope in 36 — 48 hours after such an attack of false croup. The possibility of this makes it incumbent upon you in every case to keep the children in their rooms till the catarrh is fully developed, i.e. so long as the cough has a slightly croupy character, or a hoarse sound is audible on forced inspiration. III. Atelectasis of tJte Lungs. In all the respiratory diseases of children, the tendency of the lungs to " collapse " is a fact of the very utmost importance. This peculiarity, which is known as " atelectasis " consists in the tendency which the pulmonary alveoli have to become empty of air and sink in in such a way that their walls touch one another. At the post-mortem examination of most children who have died of diseases of the respiratory organs and also of many exhausting diseases of other kinds, you come upon sharply defined, bluish- red, or steel-grey patches, varying greatly in size, situated on the surface of the lungs, especially along the anterior margin, and the lower and inner border of the lower lobe, likewise on the 3G0 DISEASES OF THE RESriRATORY ORGANS. " lingula," which overhips the pericardium. These are some- what depressed helow the surroundiug level, they are sometimes quite superficial in position, isolated, and of small size ; at other times they are more extensive and run together so as to form elongated areas or rounded patches as big as a half-crown, or bigger. On section, these jiatches are tough and non-crepitant, no air-bubbles issue from them, but only a little bloody fluid ; and they sink in water. The surface of the section is smooth, and on it we can easily see the fibrous septa of the lobules in the form of white streaks. The collapsed portions of lung were long held to be pneumonic patches ; but with these they really have nothing in common, except the "consolidation" of the lung tissue. The nature of the pathological process was first recognised owing to the simple experiment suggested by Legen dre and Bailly of blowing air through a tube into the communicating bronchus. For whereas inflation has no eJBfect on pneumonic consolidation, parts which are only collapsed immediately become blown out, and assume a bright red colour. Two factors in the causation of atelectasis may be indicated with certainty. In the first place, a lowering of the inspiratory power which is too weak to drive the air into the alveoli ; and secondly, the filling of the bronchi with mucus, rendering it difficult for the air to pass through them. When the air can no longer obtain entrance into the alveoli, that which is already contained in them is absorbed by the circulating blood, and the alveoli collapse.^ You will find the atelectasis most frequent and most extensive in those cases in Avhich both these factors mentioned are at work, and therefore in all exhausting diseases which are accompanied by bronchial catarrh. For this reason we also meet with atelectasis under similar circumstances in adults, e.g. in typhus ; but generally it is much less common and less extensive in them than in little children, whose inspira- tion even in health is comparatively much weaker. Eickety children with narrow chests are particularly liable to atelectasis ; for in them a third factor is added to the already mentioned causes (weakness of inspiration and bronchial catarrh), namely, a narrowing of the capacity of the chest, which hinders the full expansion of the lungs. Also, in stenosis of the larynx, trachea, or large and small bronchi — whether due to inflammatory and ' Lichtlieim, Archie/, erper. Path., x., S. 54. ATELECTASIS OF THE LUNGS. 361 cicatricial processes, the presence of foreign bodies, or compres- sion of the air-passages — numerous patches of atelectasis of the lungs may occur, from interference with the entrance of air into the alveoli, along with the increasing weakness of inspiration present during the later course of the disease. Although we so often find atelectasis of the lungs in children after death, one is rarely able to diagnose it during life. This difficulty of diagnosis is all the more to be regretted, as the addition of atelectasis to those diseases which it is Avont to accompany, is by no means a matter of indifference. Although the assumption that slight hyperemia of the lung-tissue resulting finally in broncho-pneumonia occurs in the collapsed areas as the result of deficient atmospheric pressure on the vessels, is not proved — and is indeed rendered doubtful by certain experimental facts ^ — still, we must always regard the increased insufficiency of the lung from patches of atelectasis as a factor which makes the prognosis very considerably less favourable. The difficulty of the diagnosis is due to the fact that the patches of collapse scattered through the lung-tissue occasion no visible signs whatever, as they are completely masked by the air-containing portions and by the bronchial sounds. Even extensive areas of collapse, c.(j. when a large part of the lower lobe is affected, give rise to no physical signs beyond those of consolidation (dull note, bronchial breathing, &c.), which can in no way be distin- guished from those of pneumonic consolidation. The only conclusive point for a diagnosis of atelectasis would be the absence of fever, did we not know that in little children in a state of extreme exhaustion even pneumonia occurs without rise of temperature ; and that, on the other hand, atelectasis very frequently occurs as the result of febrile diseases (bronchitis, croup, typhus). For these reasons we can never, in my opinion, regard the diagnosis of atelectasis as certain ; for it is at best only probable, although justified by the results of post-mortem experience, i.e. by the frequency with which this affection is found in certain diseases and in conditions of exhaustion in children. The congenital form of atelectasis, which first became known through the work of Jörg," is quite different from that ' Traube, Btitr. zur experiment. Pathologie und Physiologie, Heft 1, l8t6, Experiment 63. - Die Fötuslunge im gthornen Kinde., u. s. w.: Grimma, 1835. i}62 DISEASES OF THE RESPIRATORY ORGANS. which we have just heen considering. In it we have to do with a persistence of the foetal condition in a more or less extensive portion of the lungs. The parts affected have not yet been used in breathing, and therefore are tough, steel-blue, and sink in water, as is the case in tlie fatal lung, being thus in the condition which we have already seen as acquired by the weakness of the inspiration or by the exclusion of air from the alveoli. For these reasons we usually speak of the latter form of atelectasis as a return of the lung-tissue to the " foetal condition." In general, the causes active in congenital atelectasis are quite the same as those of the first form ; especially a failing or very- weak respiration such as occurs in asphyxia, or in premature and debilitated children. Obstetricians, therefore, have the most frequent opportunities of observing this affection, which is rarely met with by physicians even in children's hospitals. As a rule, congenital atelectasis is much more extensive than the acquired form ; and not only presents distinct symptoms of consolidation on physical examination, but also causes engorgement of the pulmonary artery and of the general venous system with cyanotic discoloration, owing to material interference with the circulation. For the same reason, the closure of the channels of the foetal circulation, especially of the foramen ovale, does not always occur in the normal way. Many such infants die very soon after birth from the atelectasis and the debility which has occasioned it. Still, in a certain proportion of the cases in which the consolidation does not affect both lungs to too great an extent, and the circumstances are otherwise favourable (sufficient care, and the choice of a good Avet-nurse), one may succeed in increas- ing the general strength and rendering the collapsed portions of lung once more air-containing. Thus, in Maj-, 1880, a child of o weeks was l^roiight to me, who had been born prematui-ely in a state of extreme debility, had become cyanotic in the first week, and had suffered from sevci-al violent attacks of dyspnoea. On the right side posteriorly there was dulness over almost the whole of the space between the si>ine and the scapula. The normal breath-sounds were absent thei'c, and in their stead crepitations were heard. The left side appeared quite normal. There had never been any fever. A suitable nurse was procured, wine was given, and camomile-baths were used. The child throve well. When I examined it again, the percussion- note on the right differed l)ut little from that on the left side ; the INFLAMMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 363 vesicular breathing was still weak, but distinctly audil)le. In October, the child (now well nourished) was found to have only a slight bronchial catarrh. I believe that this case may he regarded as one of congenital atelectasis of a large part of the right lower lohe ; since the condition existed from hirth, there was no fever, and good nom-ishment was suflScient to remove gradually the threatening symptoms. In the following case, on the other hand, we see a fatal issue, happening under conditions that were extremely unfavourable. A child of (3 weeks, left on a doorstep in severe winter Aveather by a mother unknown, and admitted into the ward on 8th January, 1873. Very small and wasted ; cyanotic colour of the lips and eyelids, veins of the head and face distended, I'espii-a- tioii extremely weak and superficial, instead of a cry only a plaintive whining. Percussion-note all over somewhat impaired, but nowhere distinctly dull ; the breath-sound only heard vei-y faintly; no rales. Heart sounds normal. Too weak to suck from the bottle, and had to be fed with a spoon. Thi'ush in the mouth and throat. Tempei-ature subnormal (97"2° F.). Little improve- ment, in spite of good milk, wine, and the best nursing. As tlic inspiratory movements increased in strength, the cyanosis disap- ]ieared, but always returned when the i-espiratory movements got weak again. Death on 16th February in a state of collapse. P.-M. — Heart normal. All channels of the foetal circulation closed. Thrvish of the oesophagus. Uric acid infarcts in the kidneys. Otherwise everything normal except in the lungs. The greater part of both lower lobes coUaj^sed, but in such a manner that air-containing portions are visible between the con- solidated areas. Also in the other lobes, scattered patches of atelectasis. Bronchi normal. IV. Inflammatory Affections of the Larynx and Trachea. Acute catarrh of the upper air-passages either arises suddenly with an attack of false croup, or gradually with increasing hoarseness and rough and ringing cough. There are children as well as adults in whom every cough, even when it lasts for weeks, has a hollow metallic sound, although they may have nc» other signs of the larynx being affected; in particular, no alteration of the voice. In considering each individual case, this peculiarity must be kept in mind, because it is apt to lead to 3G4 DISEASES OF THE RESPIRATORY ORGANS. nnnecessnry anxiety. On the whole, a hollow metallic cough is much less ominous than a hoarse husky one; which, when comhined with more or less thickness of the voice, is always a cause of anxiety. If in such cases you exert a moderate pressure with the finger on the trachea or larynx, the children not only make a face as if in pain, hut also usually give a cough with the rough, hoarse character which we describe as " croupy." The inspiration, especially during crying or screaming — that is to say, when more air is required — is accompanied by a sawing sound, although the breathing may meanwhile be perfectly quiet, without a trace of dyspnoea. In the first few days after recovery from an attack of false croup I have often been hurriedly called back because violent laryngeal symptoms had re-commenced ; and in these cases I have almost always found that a fit of bad temper in the child, with crying and screaming was to be blamed for it. Whenever the agitation ceased, the threatening symptoms at once subsided. It is therefore advisable to prepare the parents for these exacerbations, and to let them know that they are not dangerous. They are of importance only so far as they indicate that the catarrhal condition in the larynx still exists, although in process of resolution. To these local symptoms loss of appetite, coating of the tongue with mucus, and also often a moderate fever with evening exacerbations are added. Such cases always require the physician's utmost attention ; for one can never foretell whether the disease may not become threaten- ing within a few hours. . It is under such circumstances that emetics (Form. 6) — against the abuse of which in simple cases of false croup I have just warned you — have their proper use. When these have done their duty you may order an expectorant mixture (Form. 15) and wet compresses round the throat. The child must be kept in bed till the cough has lost every trace of its croupy character, and the inspiration has become absolutely noiseless. Under this treat- ment the catarrh usually improves within a few days ; the cough becomes loose and rattling, the hoarseness disappears, and after 8 — 14 days, as a rule, recovery is complete. Still, one must always be prepared for the possibility of the disease getting worse, as it may do in spite of the most careful nursing. But usually this results from some want of care, and it is therefore particularly common in practice among the poor. Then, the INFLAMMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 365 symptoms which hitherto have only appeared serious to the initiated, may within a few hours reach such a height as to considerably endanger life. This violent aggravation is due either to a rapidly increasing catarrhal swelling, or to a fibrinous exudation on the inflamed mucous membrane; or, finally, to an oedematous or sero -purulent infiltration of the arytoeno-epiglottidean ligament and its neighbourhood. These different pathological conditions give rise to almost the same clinical symptoms — those of acute laryngeal obstruc- tion, which we have next to consider. To the symptoms already described — huskiness, hoarse cough, tenderness of the larynx and trachea on pressure, and noisy inspiration and expiration — are now suddenly added dyspnoea, w'orking of the alse nasi, movement of the head in breathing, and increasing retraction during inspiration of the episternal and epigastric regions, finally of the whole lower part of the thorax. At the same time, however, the frequency of the respiratory movements is scarcely increased; and even in severe cases it rarely exceeds 24 — 28 in the minute. The individual inspirations and expirations, which are accompanied by an uncomfortable sawing noise, are on the contrary unusually prolonged.' All this time, the child may feel almost quite well. A girl of 4 j^ears took ill on 30tli March with false croup. In spite of an emetic, the symptoms got worse ; and when she was brought to the polyclinic on 1st April, there was the most extreme dyspnoea, croupy cough, sawing noise with breathing ; but the child, all this notwithstanding, ran and played about the room. The expulsion of dichotomously branched portions of false membrane soon established the fact that it was a case of real croup. The hoarse stridor, which in all such cases accom- panies the inspiration (also often the expiration), may be best compared with the to-and-fro noise of a saw in cutting wood. It is not always equally loud. It is less marked after vomiting, or may even disappear entirely for a short time ; it is )ni)st marked during sleep, at which time it is so loud that it arrests the physician's attention as soon as he enters the room, and a!; once announces to him the nature of the malady. During the further course of the disease, should the treatment ' On ths significinca of this symptom, c/. Cohnheim, Vorksunrjen über Ktll'jemtine Pathologie, ii. : Berlin, ISSO, S. 163. 306 DISEASES OF THE RESPIRATORY ORGANS. be unsuccessful, the symptoms of obstruction increase almost hourly. The child often catches at his neck as if trying to remove the obstruction to the breathing, and bends its head forcibly backwards. The complexion, which has hitherto been natural, becomes pale and cyanotic, the eyes are anxiously directed to those around, as if imploring assistance, and on the forehead and cheeks clear drops of sweat are often to be seen, though the skin does not appear warmer than usual, and indeed is usually colder on the tip of the nose and on the cheeks. Along with the dyspncea, the hoarseness of the voice rapidly becomes more marked and increases till there is complete aphonia; and at the same time the cough which was formerly hoarse and ringing, gradually becomes more toneless, and finally is almost quite extinguished — at anj rate is more visible than audible. Fever is not an important feature in the course of this disease ; for although it is never quite absent, j'et the temperature but seldom reaches a very high degree. It usually varies between 101*3^ F. and 104° F., with remissions in the morning hours ; while the rate of the pulse is not unfrequently raised to 144 or more by the child's continual restlessness. The group of symjitoms described only permits (as I have already mentioned^ the diagnosis of acute laryngeal obstruc- tion. "What the cause of this is, cannot at once be decided. First of all you must examine the pharynx carefully, to ascer- tain the presence or absence of diphtheritic patches on the mucous membrane. Should you find these, the diphtheritic nature of the obstruction is thereby rendered certain. Should you, however, find no patches, you must not on that account at once deny the possibility of the disease being diphtheritic ; be- cause, as we shall see afterwards, the patches in the pharynx may escape our observation during life, or may have already fallen off. "When it is possible to use the laryngoscope success- fully, we certainly gain a clearer insight into the nature of the disease. But, considering the difficulty of this examination in childhood (p. 10), you cannot expect to make much of it except in a small proportion of the cases. If you can with certainty exclude diphtheria, then it must be either simple or pseudo- membranous (fibrinous) laryngitis (croup). For it has been proved beyond doubt that the most violent dyspncea — in fact, all the symptoms of croup — may also be caused by acute INFLAMMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 3(J7 laryngitis with swelling of the laryngeal mucoas membrane only, and no croupous exudation. Such cases are naturally much easier to cure by anti-phlogistic treatment, than the pseudo-membranous form. Marie F., ß years old, healthy, took a violent attack of false, croup on the night, of 7th Deceml)er (during an epidemic of measles). Next day she seemed well till 1 p.m., when suddenly such threatening symptoms came on that I was summoned in the greatest haste. Sawing noise with respiration, face cyanotic, covered with sweat. Head bent back, forced action of acces- sory muscles of respiration, eyeballs upturned between the half-opened lids ; cough, excited at once by pressure on tlic larj'nx, was short, hoarse, and accompanied by a whistling sound. Voice also hoarse. iSTothing alniormal in the throat ; could drink without difficulty. The vesicular breathing comjiletely masked by the laryngeal stridor. Sonorous rhonchus could be made out at the root of the lung only. Pulse 120 ; skin hot and perspiring. I ordered 6 leeches over the manubrium sterni, allowing no after- bleeding ; and, internally, antim. tart. (gr. | in aq. destill. every 2 hours). As there was no vomiting by 5 r.M., I gave as ^ emetic full doses of pulv. ipecac, and antim. tart., after which there was repeated vomiting. At 8 o'clock I found the child somcAvhat quietei-, sitting on its mother's knee ; the stridor less, the voice clearer, and the skin perspiring freel}'. I gave the solution of antimony again, and applied a blister to the larynx. After a quiet night, I found on the 9th that the stridor had almost quite disappeared, the breathing was quiet, and the cough lessened. After each spoonful of the medicine, vomiting followed, but no purging. The blister had raised a lai'ge bulla, which I opened, and ung. hydrarg. was then apjilicd. About 2 p.m. a fresh exacerba- tion of the laryngeal symptoms took ])lace, owing to the administra- tion of an enema, against which the child struggled violently. But when the child was quieted, these symptoms soon subsided. From this tinie onward rapid improvement took place. The cough became loose, and disappeared about the 15th, under the use of an expectorant mixture. You have here an example of a thing which I have already spoken of, namely, the development of serious laryngitis from what was at first false croup ; and at the same time of the efficacy of energetic anti- phlogistic treatment, which in such violent cases I cannot too emphatically urge upon you. You should at once have 2 — 6 leeches (according to the age) applied over the front of the neck. The best position is just over the manubrium sterni, in order, on the one hand to keep tha region of the larynx free for further external application, 3G8 DISEASES OF THE RESPIRATORY ORGANS. and, on the other, to avail ourselves of the underlying bone for the compression of the leech-bites should the bleeding be ex- cessive. The after-bleeding of the leech-bites, -which it was formerly the custom to encourage, is inadvisable. When the leeches drop oft" the bleeding should be at once stopped. The use of cold compresses, or of an ice-bag over the larynx, I do not consider sufficient in these cases. I have frequently witnessed a marked alleviation of the most violent dyspnoea even during the blood-letting. The debility and temporary ana3mia which may possibly result from very copious bleeding ought not to deter you ; for the risk of such an occurrence is far less than that which the child is exposed to when death is imminent from inflammatory obstruction. After blood-letting, I give an emetic, or tartrate of antimony in divided doses (Form. 18) which, as we have seen in the above case, by no means always causes vomiting or purging. If the case is carefully watched, and the tartar emetic stopped at once -vrhenever diarrhoea or excessive vomiting sets in, 1% bad results — as far as my exj^erience goes — will ensue. But in practice among the poor, where the remedy has often to be left in careless hands, dangerous symptoms of collapse may certainly sometimes be occasioned. In such cases, therefore, it is always better, instead of continuing to use tartrate of antimony, to give a full dose of some emetic whose action can be more easily counted on and controlled. Inunctions of mercurial oint- ment (grs. X. twice or thrice daily) into the sides of the neck, and finally a blister over the larynx (to the sore which it leaves I generally order ung. hydrag to be applied), complete the list of remedies to be recommended for these severe cases of acute laryn- geal catarrh. The remarkable rapidity with which the threatening symptoms disappear in cases like the one just given and that which follows, proves that it can really be nothing but a catarrlial swelling of the mucous membrane. Paul B., 2 years old, admitted on the evening of 17tli October with extreme dyspnoea. Face cyanotic, eyes prominent, with an anxious expression. Inspiration prolonged and sawing, all the accessory muscles of respiration in action; croupy cough, es- pecially marked at night. Tonsils swollen, no patches on them, voice extremely hoarse. The epiglottis felt normal, pulse 160, temp. 102'5° F. Symptoms had lasted for 2 days. Emetics. Next day the cyanosis and difficulty of breathing were almost gone ; the child sat in bed playing; the cough and inspiration still INFLAMMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 3G9 croupy; temp. 101-8° F. Antim. tart.; inunction with uiig. hydrarg., grs. xxx. in the day. Next day free from fever. A blister applied over the larynx on account of the persisting hoarse- ness and the harsh noise on forced inspiration. Discharged on 2-4th October. If you only consider the troublesome narrowing of tlie nasal cavity which may suddenly take place in any ordinary severe cold in the head from increased swelling of the mucous mem- brane, you will easily understand how in catarrh of the larynx and trachea, very acute swelling may in like manner arise, only with very much more threatening symptoms ; and, under suitable treatment, may almost as quickly subside again. This condition, however, may lead to a fatal termination — all care notwithstanding. For, an extreme serous or sero-purulent infiltration of the vocal cords and of the epiglottis and its folds (the so-called oedema glottidis; better, laryngitis sub- mucosa) is very easily added to any inflammatory process in the neighbourhood of the glottis, thus causing sudden danger of suffocation. Therefore, not only in cases of acute laryngeal catarrh, croup, and laryngeal ulcer, does this danger threaten ; but it is also to be apprehended in severe phar3'ngitis, in abscesses of the tonsils and in deep phlegmonous conditions of the cervical connective tissue. In England a scald of the gullet and of the entrance to the larynx with boiling water which the child has drawn in by sucking the spout of a tea-kettle, is a frequent cause of this laryngitis submucosa ; but I have never myself met with any example of this. In all these cases, when ''oidema glottidis" sets in, the symptoms of dyspnoea and obstruction, already described, reach such a height that suffo- cation is to be apprehended at any moment. Sometimes by introducing the finger deeply one may feel the greatly-swollen epiglottis, or one may even see it projecting upwards behind the tongue. The speedy performance of tracheotomy is now the only means left of saving life. The danger in the acute laryngitis of children lies, however, not so often in the above-mentioned condition, as in the tendency to fibrinous exudation on the inflamed mucous membrane. While in the form we have hitherto been considering, the autopsy shows only more or less dark redness and swelling of the mucous membrane— at most, superficial erosions on it, and 24 370 DISEASES OF THE RESPIRATORY ORGAKS. a sero-purulent infiltration of the swollen epiglottis and its neighbourhood, especially of the arytaeno-epiglottidean ligaments and of the vocal cords — here, we find on the mucous membrane of the larynx and trachea isolated patches, or larger pieces of false membrane of a greyish, or yellowish-white colour, either of gauze-like delicacy, or 1mm. or more thick, and in that case consisting of several layers — the outer of which {i.e. that next the mucous membrane) is usually the most recently formed, and the least tough. This membrane, which is seen microscopically to consist of an extremely fine fibrinous net-work and numerous young cells (epithelium, pus-corpuscles) often extends down the trachea, as far as the bifurcation, or even beyond that point into the large and middle-sized bronchi, there forming cylindrical casts of these tubes which can easily be drawn out of them, as they are not adherent but lie quite loosely on the surface. "\Then the false membrane is removed we find the mucous membrane more or less reddened and swollen, but occasionally pale and with- out a trace of vascularity. Bronchitis and broncho-pneumonia are almost constant accompaniments, as are likewise emphysema of the upper, with numerous patches of collapse in the lower lobes. In regarding croup as the highest development of acute laryn- gitis, I am directly at variance with those physicians who regard it as being invariably diphtheritic, and who absolutely deny to it any other mode of origin. I grant that since diphtheria became endemic and epidemic in Germany, croup has been much commoner. But I do not see in this any ground for denying the possibility of its originating in any other way. We know from experiments that the most typical tracheal croup can be produced in rabbits and dogs by various caustics applied to the mucous membrane, as well as by making them inhale hot steam through a canula introduced into the opened trachea. "SYe may therefore readily assume that in human beings also, strong irri- tants — such as the inhalation of cold air, or the action of cold on the surface of the body — which when slight in degree only cause catarrh, may, when they act more strongly, produce croup. It is not yet settled whether Weigert and Cohnheim are right in thinking that if the epithelium, which in catarrh always remains intact, dies and is washed away by secretion, the fibrinous exudation secreted by the inflamed mucous mem- INFLAMMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 371 brane coagulates, thus forming the croupous membrane. The irritation of the infective material of diphtheria — perhaps the inhalation of it from the pharynx — is certainly in this country the commonest, but by no means the only cause of croup. For any severe catarrh of the larA'nx may lead to it; and consequently in measles — a disease which from its very beginning always occasions a catarrh of the larynx and trachea — this condition may pass into croup at a very early stage, without there being any question at all of diphtheria. Boy of 3 years, admitted on 29th May, 1873, with measles in process of eruption. Rash upon the face; pulse, 150; temp., ni., 103-1° F.; e., 104-9° F. Severe catarrh of the larynx. Hoarse, almost inaudible cough ; voice also hoarse. On the most cai^eful examination nothing could be discovered but a spotted redness of the palate and a simple sore throat. Treatment : — leeches over the manubrium sterni ; antim. tart. Marked improvement on the following day: — pulse, 116; temp. 101-1° F.; resp. 32. Only the hoarseness was still unchanged, and the cough had still a laryngeal character. Thus 4 days passed without any fever, during which the above-mentioned laryngeal symptoms continued. Suddenly, on the evening of June 5th, the temp, again rose to 101-3° F., and on next morning to 103-1° F. About midnight well-marked croup set in, so that tracheotomy had to be performed next day at noon during the clinique. When the trachea was opened we drew out of it a long cast, which reached down to the bifurca- tion. Other fragments were also coughed up afterwards. The tracheotomy tulje was removed on the 10th day. Complete recovery. I have elsewhere published some cases tending to prove the existence of a primary inflammatory croup unconnected with diphtheria. The children were aged 7 and 15 months respectively ; and at the post-mortem, croup of the larynx and trachea was found, without the slightest change in the pharynx. Since then I have had repeated opportunities of observing the same thing — not to mention the still more numerous cases in which no post-mortem could be made, and which I therefore can- not regard as completely satisfactory proofs ; because there was certainly a possibility of the diphtheria having escaped our notice from being situated deep-down in the pharynx. On the other hand, it must be admitted that the following case is conclusive. Max E., 1^ years old, admitted 4th April, 1877, with rickets and slight bronchial catarrh. In the next few days a further 372 DISEASES OF THE RESPIRATORY ORGANS. extension of the latter; mucous rales on both sides, both in front jind behind. On the night of 9th — 10th sudden croupy respiration and harsh cough. On the forenoon of the 11th, fully-developed croup. Over the lungs the croupy sound is heard, propagated from above — the breathing is harsh, and there is sibilant rhonchus behind. Temp. 102'2° F. ; pulse, 144 ; resp. 42. In spite of strong emetics, the sym])toms got worse on the following day. The temp, remained at 104'7° — 105'6^ F. ; respiration, 48. Child extremely languid and drowsy. Death on 12th. F.- 31. — Pliarynx unaf- fected; cronp of the larynx and trachea, oedema glottidis, double broncho-pneumonia ; rachitis. Sucli cases, beginning with bronchial catarrh and sud- denly passing into fibrinous tracheo-laryngitis, are described under the name of " ascending croup." I have observed this manner of onset especially in children in the first years of life ; also several times in the course of whooping cough and in diffuse bronchial catarrh occurring along with that disease. Trache- otomy under such circumstances is almost always unsuccessful, owing to the extensive bronchitis and multiple broncho-pneu- monia. Ernst G., 4 years old, admitted 21st March, 1877. Said to have taken ill 8 days before with an attack of false croup, and never to have been quite well since. Yesterday, at middaj-, sudden dyspnoea came on, rapidly getting worse. On admission he was cj-anotic and collapsed. All the symptoms of croup were well-marked. Only redness and slight swelling in the pharynx. Tracheotomy at once, and lime-water inhalations. After sonic hours pieces of false membrane were coughed np. Among these was one cj'linder which represented a complete cast of the trachea and com- mencement of both bronchi. Lessening of the dyspnoea followed, but increase of the collapse and continuance of the cyanosis. Evening: — pulse 168; resp. 54. Death during the night. F.-M. — Pharynx unaffected; croiTp of the larynx and trachea, extending into the large bronchi; double broncho-pneumonia; chronic fibrous endocarditis aortica ; left ventricle hypertrophied. Elise W., 3i years old, admitted 6th November, 1876, with a relapse of hereditary syphilis. Eecovery under corrosive sublimate injections, about 1st December. On the 6th, huskiness ; hoarse cough ; redness of the pharynx ; no fever. In spite of leeches, emetics, and mercurial inunctions, the symptoms got so rapidly worse that on the 7th tracheotomy had to be performed. After this, inhalations of lime-water spray. During the following da3-s there was a remittent type of temp, (evening, up to 10o"3° F.), and the freqxiency of the resp. rose to 60, finally to 72 in the minute ; and a double broncho-pneumonia developed, with loud INFLAMMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 373 rtlles and varying impairment of the percussion-note. Death on 18th — i.e., 11 days after the tracheotomy. P.-M. — Pharynx perfectly normal; croup of the larynx and of the upper ])art of the trachea in process of recovery; extensive bronchitis« and broncho-pneumonia. Anna S., 2 years old, admitted 2Sth February, 1879, with laryngitis, Avhich had lasted 2 — 3 days. Pharynx quite normal. Tracheotomy not performed, owing to presence of diffuse bron- chitis. Death on 2nd March. P.-M. — Diffuse bronchitis and In'oncho-jDneumonia. Pharynx but slightly reddened, completely smooth and healthy; croup of the larynx and of the trachea, reaching to the bifurcation. Ella S., 6 months old, after suffering for some months from tracheal catarrh, was admitted on 15th March, 1879, with com- mencing croujj. The symptoms got worse ; tracheotomy was performed on the 19th. Fever (101.° F.) and dyspnoea persisted after it. Death on following da}'. P.-M. — Pharynx quite normal. Croup of the larynx. Bronchitis, with numerous patches of broncho-pneumonia. Caseous degeneration of the bronchial glands and of a jiart of the left upper lobe. In such cases as these — and I have met with many others since — is one justified in entrenching oneself behind the as- sumption that diphtheria has passed over the pharynx and has developed first of all in the larynx and trachea ? Such an assumption I consider quite arbitrary. The unprejudiced observer who attentively follows the clinical development of the disease alongside of the pathological condition will be able in every one of these cases to assume a mere local inflammatory process which has nothing to do with infectious diphtheria. The com- mencement with symptoms of simple tracheal and bronchial catarrh, the absence of pharyngitis and of all premonitory symp- toms of infectious disease, and also of glandular swellings under the jaw — are sufficiently characteristic. This view of mine is not rendered untenable even by the instances in which a case of simple croup is said to have given rise to diphtheritic affection in those near the patient,^ because in these cases it is impossible wdth absolute certainty to exclude other sources of infection. The clinical symptoms of croup present themost extreme degree of the acute obstruction of the larynx increasing hourly in severity, and in fatal cases having usually a duration of from 24 hours to 3 or 4 days. Even if short remissions occur during this tiiiie — generally as the result of artificially produced vomiting ' e.tj. Demme's 24. med. Bericht, 1887, S. 14. 374 DISEASES OF THE RESPIKATORY ORGANS. — still, these are almost always deceptive. The dangerous symptoms soon reappear and a steady progression from had to worse becomes only too evident. In many cases the steadily advancing course is interrupted from time to time hy attacks of extreme suß'ocation. The child throws itself violently back, panting ; the breathing is quite arrested ; the face is cyanotic ; the little hands are convulsively clenched, and death appears imminent. But after a few seconds, and with difficulty the air once more begins to enter the larynx with a whistling sound, and the child returns to its former state until a similar attack again comes on. Perhaps we have really here to do with attacks of spasmus giottidis, excited reflexly by the inflamed mucous membrane. At this stage the sawing respiration is often audible even outside the door of the sick-room, while the aphonia increases and the croupy cough becomes less frequent and more toneless. The restlessness of the children increases enormously ; they want out of bed into the nurse's arms ; then they want back again into bed, looking imploringly for help to those round about. This distressing condition is only interrupted by short periods of sleep, in which the laryngeal stridor reaches its loudest. The examination of the lungs yields, usually, no result, owing to the sawing noise which drowns all other sounds. At most, dry or moist rales are heard at different places ; and, rarely, impairment of the percussion note, indicating that the lung-tissue has become affected. When this is the case, the number of the respira- tions also — which, in uncomplicated croup, as we saw above, either remains normal or is scarcely increased — is now very much raised, reaching 50 — 70 or more in the minute. This symptom alone suffices for the diagnosis of a complication by diffuse bronchitis or broncho-pneumonia, even should the local examination be without result. During this violent course, in many cases fragments and tubes of false membrane are expelled with much difficulty by coughing and retching; and this is to be regarded as the only reliable criterion in the diagnosis of true croup. All the other symptoms — as I have already said — may be brought about by an extreme degree of simple laryngitis, and especially by " oedema giottidis." The nature of the expecto- rated matters is best seen by letting them float in water. ' "When this is done, one finds small or large white fragments — often INFLAMMATORY AFFECTIONS OF THE LARYNX AND TRACHEA. 375 notched at the edges — or sometimes complete tubes, which often either divide dichotomously or even branch in a dendritic manner — thus showing that they represent not only a cast of the trachea, but also of the large and medium bronchi. The expectoration of those fragments or casts takes place, however, only in about half the cases. Not uncommonly the membrane is extracted by the fingers of the anxious mother from the child's mouth, when it is almost suffocated. Immediately after the expulsion, especially of the larger tubular pieces, great relief is always noticeable. One must not, however, trust these remissions ; for it is just such cases that usually end fatally. The expectoration of den- dritic casts, especially, indicates that the process has spread deeply into the bronchi ; and little bifurcating tubes leave no doubt of the presence of a bronchial croup aftecting even the medium and smaller branches. They have, therefore, under all circumstances an unfavourable prognostic significance ; for the deeper the croup extends into the air-pasages, the more certainly fatal is its course. Besides, one must remember the very rapid re-formation of the expectorated membrane, which may take place even within a few hours, and which at once brings back the orthopncea. Anna B., 7 years old, on 6tli November, 1872, suddenly became hoarse, and had coryza, slight cough, and some fever. On the following day, slight obstructive stridor with the breathing. Emetics had no effect. On the 8th, fully developed croup, with the pharynx quite normal. Leeches and antimony prescribed. On morning of the 9th, expectoration of a cast nearly 2 inches long, ending below in 2 small branches. After this, improvement took place ; the stridor much less marked, cough and voice tone- less ; resp. 28; pulse, 132. Inunction of unguent, hydrarg. (grs. XX. every two hours), blister over the larynx. In spite of this, enormous inci-ease of the croup-symptoms, dating from midday ; cyanosis; symptoms of asphyxia. About 6 p.m. — that is, after scarcely 10 hours— expectoration of another cast of the whole length of the trachea, followed by great alleviation of the symp- toms. Night quieter. On the following day apparent improve- ment ; resp. 24 ; pulse, 132. In the afternoon a fresh exacerbation ; death during the night. Tracheotomy had not been performed, on account of the length and character of the casts coughed up, which indicated the presence of bronchial croup. The state of the temperature in croup is in no way characteristic. As a rule the fever remains moderate in degree. 376 DISEASES OF THE RESPIRATOKY ORGANS. rising in the evening to as much as 103*1°F. ; while in the morniug it is about 100-1° — 101*5° F. Still, there are cases {€.(1. that given on p. 372) with much higher temperature, reach- ing 104° F. and over. The addition of pneumonic complications has seemed to me to he the special cause of this. The pulse is at first strong, but as the disease progresses it becomes weaker, and in the last stages is often very irregular and intermittent, especially during inspiration ; and at this stage the cyanosis becomes extreme, and the face, hands and feet are covered with cold sweat. At last the child sinks into a somnolent condition owing to the obstructed respiration and the resulting carbonic- acid poisoning. The eyelids are half-closed, the respiratory movements become shallower, the obstructive stridor becomes weaker, and the child dies in a state of collapse, — sometimes -snth convulsive contractions of the facial or other muscles. The anaesthesia, which Bouchut pointed out, is in my opinion nothing characteristic ; it is to be explained simply by the coma which comes on towards the end. The idea that croup is absolutely incurable save by tracheotomy, is by no means correct. Occasionally, although not very often, we meet with cases in which the most threatening symptoms of croup gradually improve and are recovered from under suitable treatment without any operative procedure — even where the ex- pulsion of fragments of false membrane had removed all doubt of the really croupous nature of the complaint. But even after the disappearance of the threatening symptoms one must not at once become elated. For, by the long interference with the respiratory processes, and the oxidation of the blood, serious disturbances of the function of the brain may be left, even after recovery ; either because the blood does not quickly enough recover the qualities necessary for nourishing the brain, or because an engorgement of the cerebral veins, followed by oedema of the pia mater or serous transudation into the ventricles, has resulted, A boy of 8 years, who had recovered from a violent attack of croup, lasting for 5 da3'S, during -vvhich fragments of false mera- bi-ane had been coughed up, and who now suffered only from complete aphonia — remained deathly pale and extremely feeble, in spite of recovered appetite. On the 14th day of the disease, the patient, who was still very weak, became drows}', gi'adually comatose; and 36 hours aftei', died in this condition. At the INFLAMMATORY AFFECTIONS OF THE LAKYNX AND TRACHEA. 377 r.-2[. I found the larynx healthy, with the exception of sliglit congestion and SAvelling of the mucous membrane. The brain extremely anaemic, and much serum in the ventricles and in the meshes of the pia mater. We had iu this ease, not a state of diphtheritic collapse — which condition we will hecome acquainted with later on — but a result of primary croup. We cannot deny that the energetic anti-phlogistic measures (leeches, repeated emetics, mer- curials) with which, especially in former times, we attacked this dangerous disease, along with the anorexia and the insufficient nourishment due to it, — may occasionally have contributed their share iu producing such weakness and anaemia. I have mj-self witnessed in a \)oj of three years — who had been markedly improved by a very energetic line of treatment, but v/as exhausted to an extreme degree— a deep sleep come on, which was welcomed joyfully by the parents. It followed immediately on the use of an emetic, v.'hich had been given on the evening of the 4th day on account of a sudden suffocative seizure. On my visit I found the child, who shortly before had been very restless and breathing noisily, now lying motionless in his cot ; the Ijreathing almost inaudible and unusually slow. On feeling his pulse, however, I perceived that this was no healthy sleep, but a state of coma. The pulse was thready, scarcely perceptible, irregular and uneven ; all extremities cold, and the eyelids half- shut. Even loud noises right at the child's ears were not sufficient to bring him to consciousness ; and it was only after the continued use of stimulants from 7 P.ii. to 11 p.m. that this dangerous state of inanition of the bi'ain was removed. Mustard-plasters to the neck, back, and calves, fomentation to the hands and feet with the addition of mustard, amnion, carb. (grs. 2i every 2 hours), and wine ; finally, the application of ice to the head, which 1 only allowed to remain on a few seconds at a time, but repeated often — succeeded at last Ijeyond our expectatioris. And when the cereljral functions returned, strange to say, all the croup symptoms, except a slight hoarseness, had disappeared for good. For the treatment of croup the same rules hold good at the beginning as I have already laid down in the case of acute laryngeal catarrh. If local blood-letting, emetics, tartrate of antimony iu divided doses, the energetic use of mercurials, and the application of a blister over the region of the larynx do not bring about rapid improvement, the symptoms continue to get worse, and the commencement of dyspnoeic attacks announces an extreme degree of the disease, we can then expect nothing 378 DISEASES OF THE KESPIRATORY ORGANS. further from drugs. The more one is in the hahit of relying on emetics in this disease, the more unpleasant is the fact that their action not uncommonly fails. Among others, I have given to a child with measles and croup a full dose of an emetic (ipecacuanh. 5ss., antimon. tart. gr. i, aq. destillat. 5i., oxymel. scilla; ,5ss.) during one daj', morning and evening, without even once causing vomiting. In such cases, sulphate of copper (gr.ss — gr. iss every 10 minutes) occa- sionally succeeds ; but apart from its nauseating eftect it has no specific action on croup. I must, however, most decidedly dissuade you from frequently repeating emetics in a child who is already exhausted, merely because of the continual return of attacks of suffocation. For while they are of no use, they may increase the exhaustion to an extreme degree, and (as in the case given on p. 376) result in severe cerebral symptoms. I should also recommend j'ou not to keep children with croup con- tinually in bed ; but to let them often be carried about, for this relieves them for a time. Also you should administer beef-tea, milk, or wine very frequently, in order to combat the increasing exhaustion as much as possible. But always be cautious ; because children with croup are very apt to choke while drinking, and then at once have violent attacks of suffocation. The onset of the firstthreateningattackof suffocation — in fact even the forcible indrawing of the lower part of the chest wall on inspiration — is to me the signal for tracheotomy. This latter symptom — which is due to the rarefaction of the air in the lungs, and the consequent disturb- ance of the equilibrium between the intra- and extra-thoracic pressure — I consider of especial importance. To delay the operation longer only increases the exhaustion, the danger of carbonic-acid poisoning, and the broncho-pneumonia which is in process of development. We have therefore operated not uncommonly even on the 2nd or 3rd day of the disease, accord- ing to circumstances. I shall return to this when considering diphtheria. According to my experience, the chance of recovery after tracheotomy is much greater in simple primary than in diphtheritic croup ; because in the former we have only a local fibrinous inflammation, but in the latter a general infectious disease. Out of 22 cases of inflammatory (non-diphtheritic) croup which were operated on during the last few years in my BRONCHITIS. 379 department of the hospital, 13 recovered; a fact which of itself proves that we had not to do with diphtheria. Neither the expectoration of false membrane, nor the evidence of bronchitis or pnemnonia, do I regard as a contra-indication, for I have seen several children recover from the operation in spite of these complications. Since, however, the operation only serves the purpose of allowing air to gain access into the lungs, it is always well to go on with the mercurial treatment after it, in a moderate degree, and to favour the separation of any false membrane which may still be present in the air passages, by the inhalation of steam through the canula. Other methods of treatment, such as cauterising with concentrated solution of nitrate of silver (by means of a brush or a syringe), and the introduction of a tube into the larynx (intubation^) I have not tried. Tracheotomy is still the treatment which gives the greatest number of successes, and therefore I do not feel inclined to exchange it for any other. V. Bronchitis and Catarrhal Pneumonia {Broncho- Pneumonia). One of the commonest diseases of childhood is catarrh, spreading from the bifurcation of the trachea to the mucous membrane of the large and medium bronchi. It is not only common in practice among the poor, where cold and damp play an important part in its causation, but is equally so under more favourable circumstances. The period of the first dentition is that most frequently affected, and this process itself is regarded by many physicians as a cause of the catarrh. That this influence is over-estimated, I have already pointed out ; but I cannot deny that in many children the eruption of each new group of teeth is accompanied by an attack of catarrh. Perhaps, also, the great frequency of rickets at this age has some influence; for rickety children show a very special tendency to bronchial ' "Tubag-e" of the larynx, which was first recommended by Bouchut and recently re-introduced by O'Dwyer, has many supporters in America ; still its results are by no means so gratifying as to entitle it to take precedence of tracheotomy. Cf. " Intubation of larynx," Medical Record: New York, June and July, 1887. ' 380 DISEASES OF THE RESPIEATORY ORGANS, catarrh, and should — for reasons which I shall enter into later — be protected from it with especial care. In very young children, even within the first few months, we often meet with a peculiar form of tracheal and bronchial catarrh. In this condition they suffer either from a frequent hacking cough (which is at once started by pressure in the situa- tion of the bifurcation of the trachea), or still oftener from a " stertor," which almost constantly accompanies the inspira- tion and expiration, and w^hich the mothers call a " stuffiness" or "rattling in the chest." The noise is sometimes so loud that it makes the parents very anxious, and it depends on the quantity of secretion whether the stertorous breathing is ac- companied by moist rales or is a dry noise like that of croup. It becomes weaker after each fit of coughing, and may entirely disappear, but soon returns. On physical examination we hear only hoarse mucous rales or sonorous rhonchi, especially between the shoulder-blades ; but immediately after coughing there is usually only harsh breathing heard, which after a time again gives place to rales. All this time, the little patients may feel quite well, although most of those I have seen with this disease had rather a pale and flabby appearance. There is never any fever, the appetite is good ; the only thing causing anxiety to the parents is the occasional cough. As regards the cause, I have sometimes found that the catarrh had been caused, to begin with, by a chill immediately or soon after birth — either from a too cold bath, or a cold room, or from the child being taken out-of-doors in bad weather. In all the cases which I have observed this disease was characterised by great obstinacy. It. was many weeks, even months, before recovery took place, and this marked tendency to a chronic course is all the more serious because every fi-esh chill occasions an exacerba- tion, which may sometimes be accompanied by fever. With few exceptions, all my cases occurred in connection with the polyclinic, and the comparative want of care on the part of mothers in poor circumstances explains the obstinacy of the catarrh. In a few cases this disease reappeared with the cutting of each new group of teeth, lasted for weeks, and disappeared as soon as the teeth came through. As regards treatment, the chief matter is to protect the children from cold and damp, while at the same time letting them have pure air to breathe — conditions BRONCHITIS. 381 which can only be fulfilled in well-to-do families. From drugs I have seen scarcely any result ; perhaps a little from small blisters over the manubrium, frequently repeated and allowed to heal at once after the bulla had formed. Those who cannot do without giving medicine may try small doses of sulphurated antimony (gr. ], 4 or 5 times daily). Catarrh of the trachea and bronchi in children, up to about the 5th year, differs from that in adults only in this, — that its tendency to a rapid and dangerous extension into the smaller bronchi is far greater; and, therefore, any catarrh at this age calls for much more careful nursing. The otherwise praisev/orthy endeavours of many mothers to give their children as much fresh air as possible, very often lead them into tlie error of sending them out-of-doors in bad weather, even when they are suffering from a cough. We cannot too strongly oppose this custom. As a rule, the children in such cases present for days nothing beyond the symptoms of a simple catarrh, till a fresh chill either brings on the laryngeal condition just described, or — more frequently — occasions a regular bron- chitis. We find then, usually, that the cough suddenly becomes worse, the breath shorter, the expiration noisy, the skin hot ; and generally even before making a local examination we are able to diagnose bronchitis or broncho-pneumonia. In all the very different degrees of these diseases, and the very numerous transitions from one to the other, coughing always forms one of the most striking symptoms. In many children it seems to be painful, and they show this by crying and making faces as if in pain when they cough. The cough is generally frequent, short, and dry, and is started or aggravated by crying. Children who are able to cry for a long time without coughing certainly have not got bronchitis. In bad cases violent attacks of coughing occasionally occur, with a livid redness of the face which reminds one of pertussis. Very young children almost never expectorate, but even in the stage of resolution, when the secretion is most copious, they swallow the sputa. Further, the character of the respiration attracts the physician's attention. The number of the respirations exceeds the normal in a varying degree, according as the inflam- mation has passed down more or less deeply into the bronchial ramifications. In young children 40 — 50 respirations is but a 382 DISEASES OF THE EESPIRATORY ORGANS. moderate number, and indicates that the seat of the disease is the large or medium bronchi ; while the implication of the small and finest branches at once produce a rate of 60 — 80, or more, in the minute. If, then, a child sufiering from catarrh holds its breath while being auscultated — as so often happens — and makes the physician wait, this is always a favourable sign. The quicker the breathing, the shorter and shallower does it become ; the accessory muscles of inspiration (those of the alie nasi, scaleni) are seen acting. The head also moves Avith each breath ; and there is distinct retraction with inspiration, both at the episternal notch and at the lower part of the chest. Each expiration is also accompanied by a "grunting" sound {(■f. p. 9), which I always regard as one of the most valuable symptoms in the diagnosis of serious respiratory diseases. Not uncommonly we can hear, even at some distance from the chest, crowing noises with the breathing, and in nearly every case, on auscultation, sibilant and sonorous rhonchi or large, medium, and fine crepitations, which may be either confined to the back — especially about the bases — or extend over the anterior and lateral regions also. The distribution of these sounds is of less importance than their character. We may, e.g., hear sibilant and sonorous rhonchi almost all over the thorax, without any great amount of dyspnoea being present, owing to the large or medium bronchi only being aö"ected ; while fine or even medium crepitations, heard over a considerable area in front as well as behind, give cause for great anxiety. Occasionally the crepitations are only with inspiration or expiration ; while in other cases they accompany both. The percussion note remains normal at first. Along with the local symptoms there is always more or less fever, the temperature varying between 101° F. and 103° F., and in the evening reaching even 104° F. I have not uncommonly found the morning temperature approaching the normal (100° — 100"4°F.), while in the evening it rose to 104° F. Even when exact thermometric examination is impossible — as in most cases in the polyclinic — the statements of the mothers may be worth something, as they are in the habit of noticing especially the children's " burning skin." I do not attach any special importance to the rate of the pulse, which varies between 120 and 180. Its quality is of much more importance; although. BRONCHITIS. 383 when the disease runs a favourable course, this usually presents no abnormality. The altered ratio between the frequency of the pulse and that of the respiration, is always of the greatest significance. For we have no longer 3 or 4 beats of the pulse to one respiration, as in the normal condition, but the number of the latter increases disproportionately: e.g. 60 — 70 respirations to 144 pulse beats (p. 9). The other func- tions of the body may remain unaffected in slight cases ; still I have often observed diarrhoea as a complication, especially during an epidemic of intestinal catarrh. As the disease gets worse, the appetite also naturally suffers ; infants are prevented from sucking by the dyspnoea, because after a very short time they have to let go the nipple in order to get breath. This circumstance appears to me such a characteristic sign of the severity of the bronchitis that I advise you to let the child take the breast in your presence in order to ascertain how it can suck. From the above symptoms and physical signs — especially the latter — you may always diagnose with certainty an acute or diffuse bronchitis. Whether there is also an affection of the lung tissue itself (broncho-pneumonia) we cannot diagnose with certainty; but just as little can we exclude it. The explanation of this is to be found in the pathological condition, of which the chief features are the following. The mucous membrane of the bronchi is to a varying extent reddened, swollen, and thickened, and sometimes also eroded here and there. This condition often extends right into the smallest bronchioles, and may either be uniform or occur in patches. Their lumen, especially in the lower lobes, is blocked with a tough, yellowish-white, mucous secretion ; and when the disease has lasted long, there is a moderate dilatation even of the peripheral ramifications. Owing to the marked tendency of this affection to spread deeply, there occurs in a number of cases a more or less extensive inflammation of the finest branches (bronchitis capillar is). In these cases, when a section is made through the affected lung, muco-pus exudes from many points, which indicate the sections of the finest bronchial tubes, as out of a sponge. Under these circumstances the inflamma- tion passes, in many situations, to the extremities of the finest bronchioles and to the pulmonary alveoli, which are sometimes 384 DISEASES OF THE RESPIEATOEY ORGANS. visible under the pulmonary pleura as wbitisli-j'ellow, miliary granulations, resembling tubercles, and from wbicb on section tbere exudes a drop of fluid (b rone bite vesiculaire of tbe Freucb). Tbere also always occurs at tbe same time a develop- ment of broncbo-pneumonic deposits, and tbese at first assume a lobular form corresponding to tbe area of distribu- tion of tbe small broncbi. Tbe number of tbese deposits varies according to tbe extent of tbe broncbitis, and tbey are most frequently situated in tbe lower lobes, and appear as bard tbickenings of tbe size of a pea, bean, or bazel-nut, and of a reddisb-brown colour, or sometimes witb a tinge of grey. At first tbey are separated from one anotber by air-containing byperremic tissue, but as tbey increase in number tbey approacli and finally run together into large masses. Tbese usually bave a wedge-shape, and extend upwards from the base of both lower lobes ; but they also occur often enough in the upper lobes, and especially in the tongue-shaped process of the upper lobe which overlaps tbe pericardium. They may also in the end affect a whole lobe, or even the greater part of one lung. From the sur- face of a section made through one of these patches or extensive consolidations — which, when cut out, sinks in ^^■ater — there only exudes an extremely small amount of fluid when squeezed, and on microscopical examination we find that tbe alveoli are filled with masses composed of fatty epithelium and numerous lymphoid cells of various sizes — wbicb also .may be becoming fatty, and then give a greyish-yellow colour to the consolidated area. According to recent researches (Charcot and Cadet^), a fibrinous exudation is almost always discoverable in them. There is always hyperaemia of the capillaries in the neighbour- hood and cell-proliferation in the interstitial connective tissue. Emphysema of the borders of the lung, or of other unaffected portions, and patches of atelectasis are usually found ; also not uncommonly a more or less extensive pleurisy and enlarge- ment of the tracheal and bronchial glands. From tbese facts we may gather that catarrhal pneumonia (broncho-pneumonia), developing from bronchitis, can only be diagnosed by physical signs, if the patches described are ' Cadet de Gassicourt, " Traite clinique des maladies de Icnfance," i., Paris, 1880, p. 152. — The bacteria ia the alveoli described by Tliaon {Revve mens., Fcrr., 1886, p. 93), as the cause of infections broncho-pneumonia, I consider as of no importance until their pathogenetic nature is established. CATARRHAL PNEUMONIA. 385 SO numerous or run together to such an extent that the inter- mediate air-containing tissue is no longer sufficient to hide the symptoms of consolidation. As long as the patches are scattered at considerable intervals through the lung tissue, you will only find the signs of bronchitis — i.e. more or less widespread medium or fine crepitations which, in cases of capillary bronchitis, can be heard at almost every part of the chest to which you apply your ear. As soon, however, as the consolida ■ tion has extended over a larger area of the lung, 3"ou have a corresponding extent of dulness, fine sharp rales, bronchial' breathing, and bronchophony. These physical signs usually appear first on both sides of the spine, from the base of the lung to near the spine of the scapula ; not unfrequently, also, in the region of the apices, and especially in the tongue-shaped process of the left upper lobe. I have repeatedly discovered fine, sharp rales over the heart in the latter sooner than over any other part of the chest. It is noteworthy that sharp rales and diffuse bronchophony may be present in those cases even when there is no distinct dulness. The percussion may indeed remain quite normal, or may acquire a tympanitic character — which can only be explained by supposing that at the periphery of the lung there is still a sufficient amount of air-containing tissue — while auscultation is able to discover the signs of consolidation which is present at a greater depth. Such being the case, I would re- commend you to percuss very lightly (p. 7), since a strong stroke may, by eliciting a loud sound from the air-containing tissue, obscure any slight impairment which may be present. Now, since it has been established by numerous post-mortems that in every case of extensive bronchitis in the first years of childhood, more or less numerous patches of broncho-pneumonia are also present — we must assume that even the absence of all physical signs of consolidation does not in these cases exclude the presence of broncho-pneumonia in the form of lobular patches. And iu cases where such physical signs — even only those of ausculta- tion — are discovered, we may always diagnose extensive con- fluent patches of consolidation. In many cases, however, although there is very severe dyspncca, we can discover either very few rales or none at all. The percus- sion is normal, and all over the chest we hear the breath-sound extremely harsh; or the breath-sound is absent, and one 25 380 DISKASES OF THE RESPIRATORY ORGANS. hears uothin^' Init sibilant rlionchi. These physical signs may gradually give place to moist rales, indicating a freer secre- tion ; or they may last till death — which usually ensues a few- days later. The rao8t striking example of tlie first form that T liave seen was in a child of 11 months, whose resi)initions were 72 and laboured, the pulse 160 and very small, and whose chest presented, all over, a normal peicussion-note and Aerj- harsh breathing : only at the right posterior base there w'ere a fcAV fine crepitations. This condition lasted three full days, in spite of copious diaphoresis, caused by moist compresses round the chest ; and then the rcs])i- r-ations fell to 56, and the pulse to 130. The cough became more frequent and looser, and, soon after, noisy breathing and wide- spread mucous rales aj^pcared. — I met with a rapidly fatal Cil^t• of this kind in a child of 11 months. It took ill with a cough, and in 2 days showed all the symptoms of an advanced acute lung- disease; and over the whole thorax unusually harsh breathing v>as audible, Avith occasional crepitations here and there. After death, I found in both lungs numerous easily-inflated collapsed ]>atches, and the small bronchi entering these were filled Avith niuco-pus. All the other bronchi Avere completely free from secre- tion ; but their mucous membrane, from the bifurcation doAvn to the smallest branches, Avas much reddened and SAvollen. Thus even without muco-purulent secretion, bronchitis may seriously threaten life, simply by the rapid hyperiismic swelling of the mucous membrane, and the consequent narrowing of the lumen of the bronchi.' The deeper the inflammation spreads into the finer bronchial ramifications, the more numerous the lobular patches or larger consolidated areas of broncho-pneumonia — the more, of course, Avill the respiratory process and the oxidation of the blood which depends upon it be interfered with. No eftbrts of the inspirator}' muscles are sufficient to force the air into the alveoli through the small bronchi Avhich are filled with muco-purulent secretion ; hence the pathological condition found in such cases of numerous collapsed areas in the lung.. The efficiency of the lungs for respiration must thereby be considerably diminished, and also the increased number of shallow respirations (I have in some cases counted more than 100 in a minute) cannot make up for the loss of depth. The breathing is also often irregular ; for example, 10 — 15 respirations may follow one another with ' L. c, p. 451. '-\0i DISEASES OF THE RESPIRATORY ORGANS. Child oi' 8 inoiitlis. The attack In-gau with coiyza and coughing. Xext morriiiig the symptom« got rapidly worse; in tlic evening extreme pallor and orthopncea ; res]).. 60 — 70 with harsh stridor. Cough .slight; temp., scarcely i-aised; pulse, small, intermittent, extremely rapid. All over the thoi-ax harsh breath- ing, no rales, jjercussion normal. Emetic, wann moist compi'css round the thorax, blister. Eccoveiy Avithin 4 days. Almost everv 4 weeks a similar attack, but not always so violent. During the 4th compress, broncho-pneumonia developed with tlireatenin.g cerebral symptoms, but was finallj- recovered fi'om. Boy of 4 years, l)rought on 8th April, 1878. Attacks of bronchitis from the öth month, recun-ing everj- few months with severe dyspna^a and fever. Duration 8 — 4 daj's. Resp., in the attack observed, 80 and verj- superficial. Percussion nonnal. harsh bi'eathing and sil>ilant rhonchus all over. Cured by taiiar emetic. Girl of 6 years. For the last "2 years bronchitic attacks almost every month, lasting 3 or 4 days. During the intervals .-simple chronic catari-h of the larger bronchi. Lungs normal. Girl of 5 j-ears. Health}- in other respects. Ever since the end of the first year bronchitic attack.s, which during the last j-ear had returned every o or 6 weeks and continxied 8 days. Attacks began with fe^er ; extreme dyspnoea, E. 56, P. 144. At the same time remarkablj- placid look and gi-eat cheerfulness. Cough violent ; percussion normal, harsh sawnng breathing all over. Expectorant mixture and wet compresses. I have frequently observed as in tlie first ease, an attaclv commencing as false croup and quickly passing into bronchitis. The croupy breathing in these cases soon becomes more whistling or accompanied ^Yith moist sounds, and on aus- cultation there is found harsh indeterminate breathing either alone or else with sibilant and mucous rhonchi. The dyspnoea is extreme, the rate of breathing 60 — 80, the pulse running, the colour pale or cyanotic, and the whole appearance so threatening that — especially to the inexperienced — the child seems to be lost. Although the fever is generally moderate, it may in many cases reach a high degi'ee. Real alarm, however, is only justified when the physical examination proves with certainty the presence of extensive patches of broncho-pneumonia. This condition I have never found in such cases ; and I am confirmed in my opinion that there is here (as in false croup) a rapid swelling of the mucous membrane reaching far into the medium-sized bronchi and diminishiug their calibre, — by having observed that in sj'itc CATAERHAL PNEUMONIA. 395 of the most tbreateuiiig symptoms the attack usually ends very quickly within a few days, and passes into a simple loose catarrh. Among other cases favouring this view, was that of a boy of I year and 3 months, in whom an attack of this kind rapidly de- veloped. On the following day a slight attack of false croup which lasted I2 days with threatening symptoms, then rapidly passed off leaving a slight catarrh. In a fortniglit the childgot coryza again and at once the stertorous breathing, the rapid respiration and wheezing in the chest also began again, and after 2 daj-s dis- n])peared just as quickly. Still, I consider it possible that a spastic contraction of the bronchial m u s c 1 e s as in bronchial asthma may have something to do with this condition. I have rei)eatedly seen children who were never quite free from bronchial catarrh but always had sibilant rhonchi here and there, especially audible over the back. From time to time, especially following a cold in the head, there arose very suddenly a violent asthmatic attack with slight cyanosis of the face, without the larynx, however, being aifected — i.e. without hoarseness or croupy inspiration. Unfortunately there was no sputum at all. All over the chest we heard sibilant rhonchi and very weak breathing. This alarming (but non-febrile) attack lasted occasionally scarcely half an hour or an hour and then disappeared as by magic, being replaced by the previously existing catarrh. The short duration as well as the sudden onset and equally rapid disappearance of the attack is in favour of a reflex spasm of the bronchi being present, which many specialists have recently described as depending on states of irritation of the nasal mucous membrane. Treatment. Simple catarrh gets well spontaneously, as in later life, if the child is taken care of and kept in-doors. Still, it is nearly always 2 or 3 weeks before it quite disappears, especially when it has begun with fever at first. Among medicines, ipecacuanha (Form. 16) is especially recommended by many; and when the cough is violent it may be combined with cherry- laurel Avater (tti xv — ui xxx). I hardly think this remedy shortens the course of the catarrh, but I do not deny its soothing influence on the cough. It is most suitable when diarrhoea is present at the same time. When there is constipation and fever I prefer to give the ipecacuanha in combination with 39<) DISEASES OF THE RESPIRATOEY ORGANS. calomel (Form. 17). I have found this successful m many cases of febrile catarrh and slight broncho-pneumonia. Should the disease, however, begin more severely with great dyspnoea and high fever, more energetic treatment seems to bo demanded. The application of leeches to the thorax and to the epiphyses of the bones of the forearm — which was once the fashion — has been almost entirely abandoned in our time, because the loss of blood is considered too weakening and dangerous. This view is certainly right in regard to the great majority of cases — especially in the sickly children one meets with in hospital and among the poor. It is another matter, however, when one has to do with children who were previously healthy and plethoric. Former experiences* have shown me that local blood-letting in moderation has by no means the bad results (anaemia, collapse) which the modern timorous school of practice imputes to it : and I cannot maintain that my results in broncho- pneumonia have become more successful since I banished blood- letting entirely from my practice. During the last few years I have again cautiously attempted an antiphlogistic line of treat- ment, and repeatedly with suprising success. This was done, of course, only in the case of children who were vigorous and formerly healthy, and at the commencement of the disease, whether it arose from an ordinary catarrh or came on during the eruptive stage of measles. I now however use, instead of leeches, wet, or preferably, dry cupping (4 — 8 cups, according to the age) ; because the latter withdraws blood equally well and no after-bleeding is to be feared from it. Since blood-letting is only to be undertaken in strong children, the sub-cutaneous fat is always sufficient for the application of the cupping-glasses. I repeat, nevertheless, that these methods must only be used with caution. The great majority of these patients are sickly, rickety and debilitated by other diseases, and in them any blood-letting would be pernicious and only dry cups can be used. I should much rather recommend you to have wet compresses applied to the chest from the beginning, reaching from the neck to about the umbilicus. A napkin or towel is to be dipped in water at the temperature of the room, rung out and gently applied round the thorax without compressing it at all, and so as to leave the arms free. Over this a sheet of wadding is placed, ' Be!tr. zia- KindtrheUl-., N.F., S. 173. t;ATARRHAL PNEUMONIA. 397 and the whole is covered with oil-silk, or gutta-percha tissue. When the temperature is high, I have these compresses changed at least every half-hour, but afterwards let them remain 1 — o hours, and carry this on continuously for several days and nights. I have sometimes even continued this treatment for a whole week, and in these cases, generally, the water which was used cold at first, was afterwards used at a temperature of 100 — 103° F. The compresses appear to have a favourable action in three ways : Firstly, by the deep inspiration which takes place immediately on the application of the cold, driving the air forcibly into the alveoli and possibly preventing atelectasis ; secondly, by the counter-irritation of the skin which finally manifests itself in redness, papules and desquamation of the epidermis ; thirdly, by the process of evaporation keeping the atmosphere round the child moist, and this may be aided by having steam coming from a tea-kettle or spray-apparatus close to the bed. The compresses also sometimes cause a favourable perspiration, but this must not be excessive. In one child of 11 months, I saw, as the result of such profuse sweating having lasted too long, an onset of threatening symptoms of collapse (extreme pallor, disappearance of the pulse, slight cyanosis) : and these rapidly disappeared when the compresses were re- moved, and the sweating ceased under the use of wine. During the whole course of the disease it is moreover advisable not to allow a child to lie continually on its back, but to have it carried about in the arms from time to time, in order if possible to avoid hypostatic congestion. As to medicines, emetics have always been held in highest estimation ; and I mufct subscribe to this opinion as far as it applies to otherwise healthy children. In these the disease is always best treated by an emetic, and where careful nursing and observation is possible, I recommend tartar emetic in divided doses (Form. 18) as really the best, in spite of all that has been said against it. I give a dessert-spoonful of the mixture every hour until vomiting commences; and then every two hours. Should vomiting or even diarrhoea set in after eich dose, the medicine must at once be stopped. Also, if no vomiting should follow after the first three spoonfuls, I lengthen the intervals to ^1 hours in order to avoid a cumulative action, which when it has once set in is difficult to control. This line of treatment, how^ • 398 DISEASES OF THE RESPIRATORY ORGAN'S. ever, is quite unsuitable iu delicate children when there is diarrhoea, and iu an advanced state of the disease ; especially in practice among the poor, and in the polyclinic where the mothers, being left to themselves, might readily by giving this medicine carelessly or for too long, occasion exhausting diarrhoea and collapse. When, under these circumstances, the chief matter is to empty the bronchi which are choked with mucus, and to make the breathing freer, it is better to give a full emetic of ipecacuanha (Form. 6), and to avoid antimony entirely. In strong i n f a n t s I have often at the commencement of the disease given an emetic of vinum antimoniale and oxymel scillse (Form. 19) with good results.^ But we must of course avoid the use of all emetics if the symptoms of carbonic acid poisoning and pros- tration are ah-eady present. At that stage the medicines not only fail to act, but may most seriously increase the weakness by exciting diarrhoea, and depressing the heart's action. Both of the principal modes of action of the emetics — the expulsion of mucus from the bronchi and the production of sufficiently full inspirations— are then entirely prevented by its debilitating action. As soon as numerous rales indicate a copious secretion in the bronchi, and the sinking of the strength forbids a full dose of an emetic, you should give ipecacuanha, infusion of senega, or poly gala amara, and to increase the coughing (and thereby the expiration) you may add aromatic spirit of ammonia. Mustard plasters over the sternum or the back, and small fly-blisters on the thorax are to be recommended at the same time. Milk, beef-tea, wine (sherry, tokay and port) must be given alternately, in order to sustain the strength as much as possible. Should these remedies have no eflect and the strength continue to sink, a combination of camphor and benzoic acid (Form. 21) may be tried, and is often successful. Under these circumstances, also, warm baths (95 — 97"2° F.) with cold afi'usion repeated several times a day, have a surprisingly good effect, and should therefore never be neglected. Finally, a few words more on the treatment of recurrent bronchitis (p. 393). During the attack, this is no ways difierent from that just discussed, and it is just in those ' My experience of Apo morphia, which is recommended by some, is not sufficient to enable me to give a decided judgment. The experiments which I instituted, and which did not end satisfactorily, were indeed confined to severe cases of broncho-pneumonia, I have now quite given up the drug. CKOUPOUS PNEUMONIA. iVj') cases that tlie action of ometics is usually most striking. In order, however, to prevent the frequent recurrence of the attacks, the best thing, according to my experience, is the use of brine-baths in some watering-phice such as Reichenhall or Sod en. Of course this treatment must be repeated two or three times, and a visit to the sea-side — epecially on the North Sea (Norderney, Ostend, Blankenberghe, Scheveningen, Heli- goland), is to be recommended as after-treatment. I do not think it right to order sea-air from the very beginning, because owing to the irritability of the mucous membrane it not uncom- monly occasions a fresh attack. Instead of the sea-air, we may also recommend a visit to one of the lower Alpine resorts (Kreuth, Aussee, Engelberg, Beatenberg, Heiden, d-c). From the use of compressed air, which is recommended by many,* I have observed no good results in the few cases in which I have tried it. Still, my experience in this matter is not sufficient to warrant a decided judgment. VI. Croupous Pneumonia. Although catarrhal or broncho-pneumonia is the commonest inflammatory affection of the lungs in childhood, yet the view which formerly obtained as to the rareness of the croupous form has long been done away with, and rightly too. Between the third and the twelfth year this disease is indeed very common, and also in the first two years of life it is by no means rare. The following description is founded on 124 of my own cases ; in these the age could be determined exactly in 88 only. Of these there were : 19 between li and 3 years. Ö-2 „ 3 ,, 6 „ 37 „ 6 ,, 12 , Out of 74 cases there were 18 in the months between May and August 18th, inclusive; from October to April, inclusive, oß cases. But in its clinical and pathological aspects the disease corre- sponds so entirely with the pneumonia of adults, that I only need here to enter more closely into a few peculiarities caused by the patients' youth. You are aware that in croupous pneumonia ' V. Laszewski. Zur pneumatischen Therapie des Kiiidesalttrs, Dissertation Halle, 1886. -100 DISKASES OF THK RESPIRATORY ORGANS. the alveoli of the lung are filled with a coherent exudation con- sisting for the most part of coagulated fibrin, while in catarrhal pneumonia the contents of the air-cells consist of a mixture of young cells and of epithelium, which is mostly fatty. You further know that the latter disease always occurs at first in lobular- patches, corresponding to the ramification of the inflamed bronchus, and only becomes diffuse gradually by the continual addition of new patches, while the croupous form affects, so to speak, all at once from the very beginning, a large part of the lung — even a whole lobe, filling it with solid exudation. The w-eeks after the commencement of the pneumonia — an enormous amount of pure pus was suddenl}- discharged by coughing, with s^-mptoms of suffocation; but the amount, unfortunately, was not measured. From this time all the morbid symptoms im- proved very gradually; so that on the 14th July the child was CROUPOUS PNEUMONIA. 418 (juite well and no longer required treatment. Only indeterminate Ijreathing and a slight dulness at the riglit posterior l)ase bore witness to the disease whieh had existed. From the commence- ment of the hectic fever the child only received decoction of bark, wine and strengthening nourishment ; after the abscess burst into the bronchi, she spent the greater part of the day in the garden. I found out that the child subsequently enjoyed uninterrupted good health. The second case had a quite similar course. The mainly expectant treatment wliicli has recently been recommended in pneumonia, is applicable in children as in adults. I never use wet-cupping except where the dyspna?a is extreme and the disease very extensive or complicated with severe pleurisy, and the violent pain on breathing atid coughing seems to call for it. In less robust children, however, dry-cupping is quite sufficient. Where the pneumonia is localised and the pleuritic complication is either absent or at least not a prominent feature, one may dispense with blood-letting entirely and use instead the cold wet pack or compresses to tho thorax (p. 397), renewed every half-hour as long as the high temperature continues, and afterwards every two hours. An ice-bag applied to the head is to be recommended; but on the thorax it is too heavy to be borne. The use of luke-warm or cold baths, recommended by Jürgen sen especially, I do not approve of in children, because, for one thing, I fear their depressing action on the heart, which is particularly to be avoided in pneumonia ; and especially because I regard them as unnecessary. The maxim " ne quid nimis" is here fully applicable. The vast majority of cases run their course, accord- ing to my experience, without any active treatment. There is therefore no reason whatever to expose the children to the risk of collapse, which I have seen result from the cold- water treatment of typhoid in children. It may also be added that I have seen just as little permanent effect from cold baths (77° — 81*5° F.) during the acme of the fever as from the use of large doses of quinine (grs. viiss — xv.), antipyrin (grs. iv. — viiss), or antifebrin (grs. iss — iii.). Although the temperature is brought dovvn considerably for the next few hours, still this fall is always only temporary, and in order to keep up the action one must repeat the bath or the antipyrin every 2 or 3 hours — a method of treatment which, in children, must be strongly con- 414 DISEASES OF THE RESPIRATORY ORGANS. demned. I could lay before you a number of curves such as tbo following : — On the Temjjeri I tare. M. E. 11th May — 105-1° Bath of 77° F. l-2th 9 A.M. . 12 „ 103-6° . . 104-6° h P.M. 105° quinine grs. viiss. 13th . 103-2° ... 105-1° quinine grs. vii^sj* 14th ., .. 103-2° ... 105-0° quinine grs. xr. loth ^, .. 104° 104-2° Bath of 81-5° F. ^ ,. 16th ,, Crisis. I have therefore gradually abandoned the use of quinine and other antipyretics also, and confine myself to the local use of cold — especially of compresses, first lukewarm then cold to the chest and abdomen. If you will or must order medicine inter- uall}', the best thing to give is infusion of digitalis with nitrate of potash (Form. 22), which, however, is contra-indi- cated by gastric complications (repeated bilious vomiting, thick coated tongue, nausea). In that case vou had better order hvdro- chloric acid (Form. 3), or ipecacunnha (Form. 16). I only use antimony as I have mentioned (p. 397) when the gastro-hepatic symptoms are very prominent (constant frontal pain, retching, foetor oris), but in these cases it is very successful. You must at the same time take care that the diet is moderately nourishing (milk, beef-tea, and a little wine). The collapse which sometimes comes on at the crisis is most effectively warded off by large quantities of wine and injections of camphor and ether. Still the occurrence of such collapse is not common. YII. Chronic Pncuinonia. Acute pneumonia, whether it ends with crisis or lysis does not always undergo such rapid resolution. The physical signs of consolidation of the lung may continue for weeks, even for months ; and in that case there is always apprehension lest changes in the lung may occur — such as caseation, gangrenous disintegration and the formation of phthisical cavities — which seriously endanger life. This result follows broncho-pneu- CHRONIC PNEUMONIA. 415 monia far more commonly than it does the croupous form, whenever the conditions (hereditary tendency, unfavourable circumstances) favour such a change in the exudation. You will however remember (p. 390) that even Mhen broncho- pneumonia has a very insidious course, with unfavourable symptoms (emaciation, fever, diarrhoea) a favourable termination, though not expected, is always possible ; and I think I may conclude from certain of my cases that croupous pneumonia also may take a similar course. Max K., ti years old, admitted into the ward on 17th Marcli. 1873, with eczema capitis and bronchial catarrh. On the l^tli sudden development of croupous pneumonia of the right lower lobe. Temjj. 105"1° F., pulse 160, resp. 44. During the following days the temperature varied between 103"6° and 105'8° F. Dulness. sharp rales and bronchial breathing over the right back reaching to above the spine of the scapula, and limited by the axillary line. There was also drowsiness, delirium and restlessness. Wet-cupping (on account of pleuritic pain), cold baths, quinine — without apparent effect. On 25th — i.e., on 9th day of the disease — the temp, fell to 100° — 100-8° F., which lasted for 4 days (lysis) accompanied by copious perspiration and an erujjtion of herpes labialis. On 31st — the 14th day — complete disappearance of the fever, while the cough still lasted, and the physical signs in the right lower lobe gradually improved, the dulness cleared up somewhat and the breath sounds remained indeterminate and were accompanied by fine rales. Within a few days, however, a slight evening rise began, being sometimes also observable in the morning; so tliat the temp, for a fortnight, up to April 21st, varied between 100^ and 10ri° F. While the rate of the resp. was but slightly in- creased (26 to 30, rarely 40), the cough severe, and there was a great tendency to perspiration, the dulness disappeared entirely for the first time towards the end of April, indeterminate breathing and rales being left behind. About the same time a remittent rise of temp, was observed for a few days (from 26th to 28th April). The same took place from 4th to 27th May (tem]). always 100"8°— 101'3' F.). Increasing pallor and emaciation in spite of a tolerable appetite, and the indeterminate breathing with prolonged expiration and rales, still audible at the affected part, were all the more suspicious because the scanty mucous expectoration was now frequently streaked with blood, and was gradually becoming purulent. Under the microscope, however, nothing could be made out but pus corpuscles and epithelial cells, never fragments of any other tissue. On 27th May. ■ — i.e., 2 months after the beginning of the pneumonia — everj-- thing had returned to its normal condition, and the child could l)e discharofcd as cured. 416 DISEASES OF THE RESPIRATORY ORGANS. It seems to me that this slow course of croupous pneumonia tending to become chronic, hut ending tinally in recovery, occurs more frequently in children than in adults. In the case just given there can be no doubt that the croupous form was present from the first. In others, in which you see the disease onh' after it has lasted for some time — and therefore have not observed its first development — it is often impossible to say whether it originated in the croupous or catarrhal form. Some of the cases which I formerly published' as examples of " chronic pneumonia " were made doubtful in this way ; while in others the broncho-pneumonic character was clearly established. These children were between Ih and 4 j-ears of age, but I do not doubt that older people may also be similarly affected. They were pale, more or less emaciated and flabby, with an expression of suffering ; so that their whole aspect indicated the presence of a serious disease. Some weeks or months before — according to the usual history — the illness had commenced with an attack of " inflammation of the lungs," which was either primary or the result of measles, whooping-cough, or typhoid. Ever since, there had been an obstinate cough, shortness of breathing, noisy expiration, and a certain amount of fever. Very often to these were added anorexia, coated tongue, and diarrhoea ; and then the emaciation appeared more rapidly. In most cases I have found signs of consolidation in an upper, more rarely in a lower lobe; dulness on percussion, weak or indeterminate breath-sounds, bronchial breathing and bronchophony, a greater or smaller number of sharp rales. The accompanying fever has almost always the remittent type, but may also be misleading from its resemblance to intermittent fever. I shall never forget the child of a country gentleman, sent to me with the diagnosis of intermittent fever, but whose emaciation, shortness of breath and cough, at the very first glance gave one the impres- sion of a case of lung disease. On examination I found consoli- dation of the left upper lobe, the result of a pneumonia some months before. He was completely restored by spending two winters in the south. In cases such as this I have repeatedly seen bloody sputum, although only in the form of specks or streaks in the muco-purulent matter, which during the chronic course of the disease the children learned to expectorate. ' Beitr. zur Kinderheilk:, X. F., S. 189. CHRONIC PNEUMONIA. 417 Examination sometimes reveals catarrhal sounds in the other lung also, and from time to time an acute catarrh is added to the chronic affection, and must be treated very carefully. Under such circumstances we are always justified in suspecting phthisis ; and a certain proportion of the cases do in fact end in this unfortunate way, owing to caseous metamorphosis and breaking down of the inflammatory products. But experience has taught me that cases of this kind even when they seem quite desperate may jet be completely cured. It may, of course, take a long time ; for instance, I have been able to make out the remains of consolidation after a full year, often after 6 — 9 months ; while the other respiratory symptoms had quite disappeared, and the general health and nutrition had been completely restored. That broncho-pneumonic consolidation in particular may last for many weeks — and even months — without becoming caseous, I have repeatedly satisfied myself by post-mortems on children who had presented the clinical signs of broncho-pneumonia during that length of time. We must therefore admit the possibility of the complete absorption of the fattily degenerated contents of the alveoli, even after such a long period. On the other hand the lung may become indurated owing to hyper- trophy of the interstitial connective tissue • and here the process generally stops.' The proliferating interstitial connective tissue gradually contracts, and the lung becomes indurated and greyish- white or bluish in colour. In young children in particular, the whole lung or lobe of the lung— especially the upper lobe — may be changed in this way into a firm mass which creaks on being cut, and in which the obliterated bronchi are distinctly recog- nisable as white bands. When the disease takes this termina- tion, the physical signs of consolidation last, of course, during the patient's life, unless masked by emphysematous dis- tension in the neighbourhood. You therefore generally find when the upper lobe is the seat of the contraction that the sub- clavicular region on the affected side is flattened or retracted and less movable on inspiration than that of the unaftected side. Occasionally, however, there occur in children as in adults bronchiectases in the contracted portion of lung at ' Steffen (Klinik der Kindtrkrankh., i., S. 422) describes these processes under the name of " interstitial pneumonia" and is of opinion that they may occur both in the catarrhal and in the "diffuse croupous" form, if the course is protracted. 27 418 DISEASES OF THE HESPIRATORY ORGANS. the same time. The cases of this kind which I have seen pre- sented exactly the same features as one sees iu adults : — dulness on percussion, numerous coarse and occasionally sharp rales, flattening of the front of the chest on the side affected, high level of the diaphragm, &:c. ; and especially a severe spasmodic cough with copious purulent sputum which was usually fcetid and often mixed with, or even composed alone of blood. ^ As to the treatment of chronic pneumonia, I have but little • to tell you. Our main object is to favour the absorption of the iuflammator}" products, and to protect the little patient from all injurious influences which might cause fresh catarrh or inflam- mation, and might disturb the process of contraction just men- tioned, should such contraction be inevitable. Protection from chills and tonic treatment (by bark and cod-liver oil) are the most important means. Although I have efi'ected little or nothing with quinine — even in regard to the evening rise of temperature — I have seen good results from the use of decoction of cinchona (Form. 23) continued for months ; or from extract of cinchona (Form. 24). I do not order more than two dessert- spoonfuls of codliver oil in the day, to avoid causing dyspepsia. It is a necessary condition for the use of both these medicines that the digestive organs be unaff'ected. For well-to-do people, the thing which ought to be most strongly recommended is residence in a calm, pure, mild atmosphere ; and several of my cases in private practice, which seemed at first to justify a >very gloomy prognosis, were completely restored by spending a number of winters at Montreux, Meran, or on the Riviera. Nourishing diet is likewise a matter of the first importance : and also the careful attention to any attack of dysj^epsia or diarrhoea which may tend to interfere with the successful treatment. In cases of extensive shrinking of the lung with bronchiectasis, I have frequently used the much recommended inhalations of turpentine ; but I have only found them yield slight and quite temporary benefit, or even cause positive harm owing to ' One case of this kind (with copiou.s haemoptysis) observed in my wards ha> bcen described by H. Braun ('' Beitrag' z\ir Casuistik der Bronchiectasien im Kindesalt«r." Inaug.-Dhg.: Berlin, 1887). The ca\ise of the hasmorrha-ges was the formation of an immense number of new blood-vessels in the dilated bronchi, which were denuded of their epithelium and. in places, of their mucous membrane aleo. ■ . - I'LEURISY. -119 their setting up a fresh catarrh, which may even be accompanied by fever. 1 have seen just as little lasting result from other inhalations, or from the pneumatic chamber. YIII. Planhy. Pleurisy in children differs in no essential particular from the same disease in later life. It is by no means rare. I have found chronic latent pleurisy, leaving behind more or less extensive adhesions of the pleural surfaces, in a surprisingly large number of the post-mortem examinations I have made in children in the first year of life who were not at all tubercular. I have also often enough discovered pleurisy with eflfusion in children even of 5 — months with unmistakable symptoms and more frequently after the end of the first year. Acute pleurisy with Jts sharp pain s, short cough, quick shallow breathing and more or less high fever, is in children in every respect similar to that in adults. Older patients localise their pains very exactly, while younger children mistake the real seat of the pleuritic pain and frequently complain of the "belh'," although on physical examination we distinctly find all the signs of pleurisy. Under these circumstances percus- sion also helps in the diagnosis because it generally, like palpation of the intercostal spaces, excites pain and draws the attention of the physician to the true seat of the disease. Little children who are too young to complain of pain cry when they cough and make faces as if in pain ; but this symptom is unreliable, and at this age only physical examination can furnish us with reliable criteria. Moreover, I have occasionally seen older children in whom the pain was quite absent ; cjj., in a girl of seven who was suffering from severe febrile pleurisy with eftusion (the whole left side of the chest being filled with fluid), and had not com- plained once of pain. Acute pleurisy in children is sometimes ushered in by " cere- bral" symptoms (vomiting, epileptiform convulsions); but far more rarely so than croupous pneumonia. This manner of onset draws away the physician's attention from the real seat of the disease. We only find this symptom in children of 1—5 years.^ ' Journ.f. Kindm krank., Bd., xiii., S. 2, 1849. 420 DISKASES OF THE RESPIRATORY ORGANS. Otto X., 3| year.s old. In tlie end of Octoljer, 18it3, a füll on the forehead followed by ecchymosi.s. On the evening of 30th October, sudden high fever, which jiersisted througli the night, and at 10 A.M. on the olst an epileptiform attack took place. After half an hour he awoke from his drowsiness; headache, inability to sit upright, or to hold the head erect. Fever persist- ing, pulse 160, drowsiness. About 2 o'clock, a second e])ilepti- form attack. About 6 o'clock seemed all right, at ])lay. During the night continuous fever, vomited once. Remained about the same till 15th j^ovember; forenoon remission, evening exacerba- tion of the fever with circumscribed redness of the left cheek, occasional sl%ht cough. On the 15th for the first time I determined to examine the thorax ; for I had hitherto neglected to do so, being then a very young and inexperienced practitioner and full of the idea of meningitis. 1 at once discovered a considerable pleuritic effusion on the right side of the thorax. Percussion dull, laterally and posteriorly over the lower two-thirds, breath-sounds and vocal fremitus quite absent in this area, the intercostal spaces distended ; E. 60, scarcely noticeable on the right side ; P. 124. Cough trifling, generally only in the evening, complaints of pain " in the belly." Liver displaced downwards. Child always lies on the affected side. Urine aljundant, clear. From 15th to 27th hectic character of fever, emaciation, much perspiration during the night. Gradual improvement under strengthening diet and tonic treatment (decoct, cinchon.). On 22nd December lateral percussion almost normal, posterior still quite dull ; breath-sounds audible, increase of strength and l)ulk, better colour, fever sub- siding. After 2.5th December no more night-sweats. Besides the cinchona, ol. morrlune. 2 dessert-spoonfuls daily. On 10th January, 1847, seemed quite Avell, position of liver normal, still some impairment below the scapula behind. On 14th February discharged without any deformity of the thorax of importance. This case, wliicli occurred in the second year of my practice, impi'essed me so much that from that time forward I never neglected the examination of the thorax in any febrile disease, even when no symptoms seemed to call for it. I cannot sufficiently ur""e this upon you, for it was only thus that I managed to avoid t^e same error in some similar cases. ^ The mother's statement — that the symptoms arose immediately after a fall on the head — is the very last thing you should rely upon ; for this explanation is one of the commonest simply because little children are always falling. Boy of 4 years. Fall on the head 14 daya before. For some • Beth: zur KinderhtHk., .V. F., S. 199. rL?:uRiSY. 421 days di-ow-sincss, high I'fcver with evening exacerbations. P. T'egiilar, rajiid. Frequent spontaneous vomiting, constipation ; inability to hokl the head erect. First examined on 10th January, 1875 ; thoracic organs normal. Cessation of the suspicious symp- toms after 5 days ; slight cough. Pleural effusion on the left side behind and below. Re-absorption after 2 weeks. Otto R., 9 j-ears old, brought to the polyclinic on 17th March. On the previous afternoon a fall on the head. Headache and vomit- ing ever since, especially on changing the position. Apathy, screaming during sleep. Pupils normal. Fever ; P. 15(5, regular. Beneath the left scapula slight impairment on percussion with vesicular breathing, reaching round to the axillaiy line. Com- plained greatly of pain at this spot, especially on coiighing and on deep inspiration. Tender on percussion. Digitalis with pot. nitrat., 5 wet cups. On the 18th pain considerably abated. On the 24th dulness still continuing, distinct friction-sound. On 21st April everything normal. The preliminary brain-symptoms appear therefore, in such cases, either in the form of headache, vomiting and obstruc- tion, drowsiness and delirium ; or else, in little children, as epileptiform convulsions similar to those in croupous pneumonia. Here also the high temperature seems to be the cause of these symptoms, since we find that when it falls and the signs of exudation become more distinct, the brain usually becomes clear. More frequently the disease begins with gastric symptoms which may mislead the physician for days — nausea, anorexia, thickly coated tongue and complaint at night of pain in the body ; and to these jaundice was added in the case of two of my patients (of whom one was suffering from pleurisy on the left side). A boy of three years, who had been ill for a week past, complained of pain in the left inguinal region, while the left half of the thorax was completely filled with effusion. In all these cases there were however at least some morbid phenomena which caused anxiety to the parents and led them to seek medical aid. Those cases are more difficult to recognise which develope sub- acutely or quite gradually, and run their course without any striking symptom of a serious respiratory affection. Cases of latent pleurisy are, as far as my experience goes, more frequent in children than in adults, probably because when the latter feel ill they get themselves examined ; while in the former, the symptoms, being apparently trifling, are overlooked by parents who arc not over-careful. 422 DISKASP^S OF THE RE8PIRAT0IIY ORGANS. Filise B., 7 yoars old. had measles in autumn, i-unniug a per- fectly normal course. In the middle of January tlie child, who had hitherto been perfectly healthy, began to get feverish every evening, and during the night she was very hot, thirsty, restless, and short of breath, while during the day she seemed pretty Avell. The appetite also was gradually lost, and the child became pale. I was called in for the first time on 5th February. On the left side from the fifth rib downiwards, especially latei'ally and posteriorly, percussion-note quite dull, absence of bi-eath-sound, and vocal fremitus ; higher up, puerile breathing. Respiratory movements normal, no cough, no pain; still, when I a.sked her the child remembered that she had several times felt a .slight stitch in January. Treatment : rest in bed, warm poiiltices to the affected side, infus, digital, with pot. acetat. for the scanty secretion of urine. On the 10th, profuse diuresis, no more fever, percussion clearer. On 1st March, everything normal and the child seemed quite well. Ill this and similar cases, the parents' neglect was to Wame. Especially in young children the inoffensive " teeth" are made answerable for the illness, until after weeks increasing emaciation, shortness of breath and cough at last occasion anxiety and the physician is consulted. I must, however, unfortunately add that in spite of all warning examples — of which I have published several^ — inexplicable mistakes are always occurring in this insidious form of pleurisy, even on the part of medical men. It is not ignorance that wo have to find fault with, but rather indolence, the shrinking from a thorough examination, and the idea that with such trifling respiratory symptoms no serious disease can exist in the thorax. The "latency"' of the pleurisy is owing, not to the nature of the disease, but to the carelessness of the phj^sician. Especially often I have met with such cases in practice among the poor and in children who had attended a polyclinic — where the large number of the patients is apt to lead to off-hand prescribing without careful examination. But even physicians in private practice are guilty of such sins of omission. On 6th November, 1873, for example, a pale little boy of JJ was Ijrought to my polyclinic, who had taken ill with fever about 8 days before, and wlio had been referred to the hospital by his doctor who was well known to me as conscientious (" because he could not make out what was the matter with him "). This prac- ' JoHrn.f.Kinderh-anlc, Bd. xiii., S. 1, lg40.— ße(Vr. ~ur Kinderheilk., N. F., S. 107. PLEURISY. 423 titioncr acknowledged to me aftern-ardti that he had not cxamijifd the thorax even once, because no symptom seemed to point to it. There was certainly no jiaiii at all, and onlj- a quite trivial cougli ; but the respiration was somewhat quickened and a rise of temp, took place twice daily, between 0—10 a.m., and between 5— ö r.M. On examination we found the whole left ])leural cavity filled wit!i effusion, pushing the heart to the right. On 27th February, 187 !. there was still some effusion to be made out at the base behind. Still more blame attached to the phj-sician of a boy of 4, who hairth, anajmia and atrophy. On admission enormous ulcer on the scalp, abscess the size of an apple just under the sacrum, numerous enlarged glands in the neck and in the inguinal I'egion. Incision of the abscess, which healed bj- 3rd May. The ulcer on the head gradually cicatrised. The child -vras free from fever, very pale and weak. Fresh abscesses formed in the neck up till 6th June and were opened. On the 7th June, close to the right breast a roundish swelling, rather more than an inch in diameter, not reddened but fluctuating, which gi'adually grew to the size of an apple and was opened under the spray on the 20th. From this time high temperature (evening 101':F — 102"9° F.), which, however, was absent for days at a time. Close to the right shoulder- blade a new abscess of considerable size formed; opened 11th July, and a carious rib was felt by the probe. About the .same time we found on examination, so far as this was prac- ticable on account of the swelling and painfulness of the affected part, dulness over the right side of the thorax both in front and behind increasing towards the base, abundant crepitations, some of which had a sharp character, and indeterminate breathing. On the 10th we observed for the first time that on deep expiration, especially on crying, a quantity of pus Inibbled out on to the chest from the abscess wound, mixed with a large quantity of air- biibbles. This condition continiied till her death on 18th August. P.-M. — The Öth, 6th and 7th ribs on the right side carious: between them {i.e., within the intercostal spaces) there were a few openings the size of a pea through the costal pleura into a cavity. Pericardium completely adherent to the heart, and right lung to the pericardium. The right lung felt very tough and was adherent over its whole surface to the chest-wall. The pleura costalis and pulmonalis form thick indurated masses of fibrous tissue. In the immediate neighbourhood of the abscess- wound on the thorax, there was the already-mentioned cavity situated between the the two layers of the pleura and filled with about 8 tablespoonfuls of purulent pleuritic effusion. The pul- monary pleura in the neighbourhood of the cavity was wanting, so that a probe could be passed directly into the small bronchi. Almost the whole right lung camified. The extensive caries of the ribs in this case evidently formed the starting-point of the abscesses near the mamma and shoulder blade as well as of the chronic pleurisy. Besides the adhesions and fibrous membranes, it gave rise to the cavity filled with pus which communicated on the outside with the abscess in the chest-wall, and finally also it had penetrated the pulmonary PLEURISY. 427 pleura inwards by a process of necrosis. In this manner air was enabled to find its way out of the lung into the cavity and then outside along with the pus of the abscess. The firm adhesions which surrounded it prevented tlie occurrence of pneumothorax. Here also the inflammation spread from the pleura to the pericardium and caused complete adhesion of the two layers of the latter to one another and to the right lung.' In children tuberculosis and pneumonia (croupous more often than catarrhal) are also important factors in the causation of pleurisy. When the two diseases are combined, as is so commonly the case, the pleurisy as a rule is least important, and indicates its presence only by pain and by slight effusion at the base (p. 407). Still cases do also occur in which pneumonia, which at first was the more prominent condition, yields place to the pleurisy, and it developes further and leads to a more or less considerable effusion (pleuro -pneumonia). How rapid the pus-formation under these circumstances may be is shown by the case of a boy of 5 from whose right pleural cavity more than 35 oz. of pus were evacuated by puncture on the Gth day of the disease. In broncho-pneumonia we find when both sides are affected the pleurisy also is not vincommonly bilateral, both lungs being covered Avith fibrino-purulent deposit, also perhaps purulent exudation being present in both pleural cavities. Putrid pleurisy I have only observed exceptionally in children {apart from cases where the discharge became offensive after operation), e.g. in the following case: — Anna O., 11 years old, treated in the ward in May for pleuro- pneumonia of the left side, discharged 26th May. Ke-admitted on 4th June. Rigor .5 days l)efore, since then persistent fever^ cough, pain in the left side in which a considerable effusion could be made out. T. 103-1° E., R. 44, P. 124. The left side of the thorax scarcely rose during breathing. The intercostal spaces filled out, dulness on percussion almost all over, bronchial breathing, no vocal fremitus, dulness over the sternum, heart sounds audible most distinctly near the right border of the sternum. Urine scanty, but otherwise normal. Wet-cupping, wet compresses round the thorax and digitalis were practically ■ ' We miTst not confound with these cases those in which piirnlent pleurisy forms the primary disease and caries of the ribs only arises secondarily and may then lead to abcesses in the chest wall and communication with the pleural cavity. Cf., eg., a case of diaphragmatic pleurisy from my ward, described by .Taciibasch in the Berl Min. »V/tewsc/i»-., 1883, No. 41. 428 DISEASES OF THE RESPIRATORY ORGANS. useless. On the lOtli owing to the increasing dyspmta, tlio thorax was punctured with Potain's syringe and llj oz. of gi'eenish-yellow offensive pus evacuated containing numerous putrefactive bacteria. Altliough tliere now occurred a partial ro- cxpansion of the lungs especially of their upper part, and the res]). sank to 32, the fever still persisted unchanged and therefore on the 13th the radical operation for empyema was performed, a silver canula was inserted after evacuation of 17i oz. of offensive [)us and the tlioracic cavity was syringed out with carbolic lotion. Fever now disa]:)peared at once (T. 98"6° — 99"5° F.), and after 2 days the discharge from the pleura was odourless. On the other hand the cough increased considerably and the copious greyish- yellow, tough, somewhat sweetly-smelling sputum contained dis- tinct elastic fibres. On account of the blackish colour of tho urine a solution of salicylic acid (3:1000) was used for washing out after the 15th instead of the cai-bolic lotion, and the thoracic wound treated with strict antiseptic pi'ecautions. During the next few weeks a rise of temperature was observed on several occasions without any evident cause ; for example, on 9th July 104'9° F., but after this attack the child remained quite free from fever until her discharge on 1st May, 1879 — that is, aboiit a year after her admission. The wound on the thorax, from which there was always a slight discharge, closed in August, the general nutrition and health were restored gradually, and the rate of breathing was soon only 20 in the minute, the pulse lOS. AVhile on the front and on the upper part of the side and back th«^ physical signs had become normal, the lower part of the axillary region and the back from the spine of the scapula downwards still i-emained much impaired, and bronchial Ijreathing, sharp rales and friction were heard thei'e. The cough also continued with varying severity and the expectoration, which varied in quantity, contained l)lood from time to time. On every occasion when this occurred the child was kept in bed for a few days. Elastic fibres, however, were no longer found, and on the 1st May, 1879, the patient was discharged in very good health, free from cough, but still with dulness and bronchial breathing in the region of the left lower lobe. The treatment during the last months consisted of inhala- tions of carbolic lotion (1 per cent.), ol. morrhua) ; and plumb, acct., whenever haemoptysis occurred. This case was, in fact, one of a circumscribed patcli of gangrene at the periphery of the pneumonic portion of lung, from which the germs of putrefaction had found their way into the pleural effusion, and had caused it to become putrid. The fact that neither on physical examination nor when the puncture was made could pneumothorax be made out, is against the existence of a large communication between the pleural cavity PLEURISY. 421) jiud the gangrenous patch. On the other hand the hypothesis of fine openings in the pleura of the affected lung, which had later on become closed by adhesions, is more probable.^ After tlie cure of the putrid pleurisy by puncture and incision, the necrotic patch in the lung lasted for many months, and indicated its presence by repeated relapses of fever, and by purulent sputa mixed with blood and elastic tissue. At last recovery took place, and nothing remained but physical signs, which were to be attributed to an area of much-thickened pleura at the lower part of the left side of the chest. As I learned later, the child died a year afterwards from an inflammatory chest affection. On the other hand I have in private practice seen a boy of 9 years with a copious right pleuritic eflusion following pneumonia of the right upper lobe, who became very feverish for some time, and began suddenly to expectorate putrid purulent sputum; an inci- sion was at once made into the thorax, and the pleural cavity was treated antiscptically, and complete recovery finally took place. The characteristic expectoration proved that the putrid character of the effusion had resulted from the entrance of septic germs through an opening into the upper lobe of the lung. I have repeatedly also observed pleurisy in children resulting from acute articular rheumatism, scarlet fever espe- cially scarlatinal nephritis, and measles. One of these cases, in which a diagnosis was made only four weeks after recovery from measles, was distinguished by complete absence of fever (temp, never above 99"5° F.), although on two occasions more than 15 oz. of greenish-yellow pus were evacuated by puncture. Only once, in a girl of 5, have I seen a purulent pleuritic effusion in the course of whooping cough, as the result of a concomitant broncho-pneumonia. On the various terminations of the disease— re-absorption, suppuration, bursting of the empyema externally or internally — and on the resulting deformity of the thorax, I have nothing new to tell you. The former belief, that deformity of the thorax occurs less frequently in children than in older peoj^le, is a mistake. On the contrary, we observe considerable retraction occurring on the affected side after insidious purulent efiusions which finally burst externally and form suppurating fistulae lasting for years, as well as in cases where there is a formation of • Cf. A. Fränkel, '' Ueber putride Pleuritis," CharUeAnnalen, iv.. 1879, S. 25C. 430 DiHEASES OF THE RESPIRATORY ORGANS. thick masses of fibrous tissue between the lung and the chest- wall. In a boy of 14 wlio had suffered from pleurisy in his oth year, I could fill up the whole right pleural cavity with my fist. Finally, a few words on treatment. At the beginning of the disease when there is violent pain, I consider wet-cupping necessary (the number of cups varying according to age), and in weak children, dry-cui3ping. Next to cupping, wet compresses, such as I recommended for pneumonia, are to be used continuously, while we give internally digitalis (Form. 22) with nitre. Also calomel along with digitalis (Form. 25) is useful, especially when there is constipation. When the efi"usion increases, diuretic treatment becomes important, infusion of digitalis with acetate of potash and Bilin or "VVildung water (3 — 4 wine-glasses daily) to drink. In the very chronic cases, I would recommend decoction of bark (Form. 23) with acetate of potash (grs. xxx.), codliver oil, whey, fresh country or mountain air and, during the winter, residence in the South, especially on the Riviera. The greater activity of tissue-change in children favours the reabsorption of serous pleuritic eftusion generally, more than is the case in adults. I have, indeed, reports of a very consider- able number of cases which recovered perfectly well without surgical assistance, under diuretic and tonic treatment, within some weeks or months. We should not, therefore, be in too great a hurry to operate. For my own part, I recognise only two indications as urgently calling for the evacuation of the fluid. (1) A rapid increase of it, with acute displacement of the mediastinum and considerable aggravation of the dyspncea, so that the children are no longer able to maintain the horizontal position for any time, but are obliged often to assume a sitting posture. Under these circumstances, especially when the efi'u- sion is on both sides or when there is a complication with bronchitis or pneumonia, early puncture is indicated in order to relieve the lung from the pressure of the exudation. As a rule, the fluid rapidly re-accumulates, but we can in that case repeat the operation if need be ; or, if the symptoms are not severe, we may quietly await the re-absorption of the fluid. Uirl of 7 years, examined for first time on 6th July. For about I5 weeks acute })lei;risy of the left side, which liad run its bourse from the beginning without any pain. The left side' of the PLEURISY. 431 thorax filled with fluid, and dull note over the stt-rnura. The heart displaced to the right, the left lung backwards and upwards. In front, bronchial breathing ; at the side and at the base behind no breathing audible at all. Fever remittent, M. 1017^, E. 103'5° F. and over. In the beginning of the third week of the illness, increase of the dysjjuooa, frequent sitting-ujj to get breath, pulsi- small. On the lltli, puncture under antisejjtic precautions and evacuation with an aspii-ating syringe, which was four times filled with clear, greenish serum. During the next few days, until the 17th, the temperature remained high (100-4°— 102-f)° F.). while the effusion again increased consideraljly. Then rapid i-c-absorj)tion. improvement of general health, disappearance of fever. After the 22nd, free from fever. Recovery. The deficient diuresis was con- siderably improved by infus, digital, and Wildung w.itor. Ill this case, therefore, one puncture and aspiration sufficed for the cure, and in serous pleurisy I have frequently observed this. It is also worthy of notice that, although the serous effusion rapidly re-accumulates after puncture, the dyspnoeic symptoms do not reach the same degree as formerly, and the respiration usually get rapidl}' into its ordinary way of Avorking after a few days, as if the removal of the pressure from the pleura by the single puncture had restored its power of absorption. (2) The purulent nature of the effusion (empyema). The points which were formerly regarded as decisive in the diagnosis of this condition, ('.(/., the so-called "oedema laterale" of the thorax, are almost all valueless. The latter, especially, is very often absent, and is not observed until the pus has already begun to burrow its way outwards, and forms a localised bulging of the thorax, which is often surrounded by blue distended veins (empyema necessitatis). When this external rupture does not take place, we must attach importance to the character of the fever. A persistence of the fever for weeks with afternoon and evening exacerbations, with emaciation and loss of strength, is in favour of the purulent character of the effusion. But even this symptom is not constant ; for, as is shown distinctly by the case just giren (p. 430), the fever may last for at least 2 .J weeks, with afternoon and evening rise of temperature, and yet the effusion be entirely serous. On the other hand, however, the fever may be quite absent in purulent effusion as in the case of empyema after measles given on p. 429. I have records of a whole series of cases of empyema in children between 4 and years of age where there 432 DISEASES OF THE RESPIRATORY ORGANS. was absolutely no fever. In a few, indeed, the temperature varied between 97"7^ and 988^ F. The only certain means of recognising the character of the effusion is therefore the explora- tory puncture, which maybe made without any dangerunder antiseptic precautions, either with a hypodermic syringe, or better, with D i e u 1 a f o y ' s aspirator orFraentzel's trocar. As soon as the aspirated fluid is found to be purulent we must give up expectant treatment and undertake artificial evacuation. Further delay might result in rupture of the empyema through the chest-wall or into the lung, and exhaust the patient by continuous hectic fever, or, in the most favourable case, lead to the drying-up of the pus and to caseous matter being left in the thoracic cavity which might later act as the starting- point of miliary tuberculosis. The method of evacuation is still a matter of dispute. Every year increases the number of examples of complete recovery after one or more simple punctures. Thus, in the case given above, a single puncture was sufficient for the cure of a serous effusion ; and in the same way I have also seen in three cases of purulent effusion (one of which was after scarlet fever) the same good result from this procedure without the much recommended washing-out of the thorax. The quantity of pus removed in these cases varied from 21 to 52 oz. We should, therefore, always in children begin by trying this mode of treatment. I always use Potain 's aspirator, and I can recommend it highly, especially for use with children, usually the effusion increases again a few days after the aspira- tion, but afterwards it remains stationary and at last gradually retrocedes. It is, however, only in a very few cases of empyema that this proceeding ^vill suffice, and after repeating it once or twice we see ourselves at last obliged to have recourse to the radical operation, that is, to opening the thorax by incision, with resection of a portion of rib. As I have already remarked, I have only in three cases seen a lasting result from one or two punctures. In all the other cases I was obliged to incise ; and any one who has once seen the masses of coagulated fibrin saturated with pus which are removed from the thoracic cavity by this operation will readily understand why simple puncture is almost never sufficient. We will best obtain outlet for the pus by making the incision over the base at the back or in the axilla, and by introducing a drainage-tube or wide silver canula. TUBERCULOSIS OF THE LUNGS. 433 A counter-opening in front is also of great use, especially in those cases where we have to remove a large quantity of coagu- lated lymph. We endeavour as far as possible to prevent the entrance of infectious elements into the thoracic cavity by apply- ing an antiseptic dressing, and changing it as seldom as possible. On the other hand, the washing-out of the thorax with carbolic lotion which was sometime in favour has fallen into disrepute, owing to carbolic acid poisoning having been observed, and for this injections of thymol, boracic and salicylic acids and chloride of zinc have been substituted. These also, however, are to be used as little as possible, unless there is an offensive odour which calls for them. The success of the operation — especially in children — has been proved by many cases, and I regard it as unnecessary for me to give in detail my own experience which is in favour of the operation being performed even in apparently desperate cases. I cannot impress upon you too urgently the importance of performing the operation without delay, as soon as the purulent nature of the effusion has been established and simple puncture, on two occasions at most, has proved insufficient. Should the exploratory puncture reveal a putrid effusion, the radical operation must be undertaken on the spot. IX. Tuberculosis of the Lungs. The difference of opinion among anatomists as to how tuber- culosis is to be regarded, especially as to its connection with caseous processes, is not yet fully settled. \Miile one party, supported by Vir chow, sharply accentuate the differences between the two conditions, the other — especially the recent French writers (Charcot, Grancher, &c.) — take a more inter- mediate position which, as I believe, is borne out by the clinical fiicts. Unprejudiced observers, and especially practitioners, cannot overlook the fact that a clinical proof of the essential connection of the two processes with one another is furnished by the frequent association of miliary tubercle and caseous degeneration, as well as by the fact (also proved experimentally) that the former develope from caseous deposits elsewhere ; and such clinical proof has greater weight than all the results of microscopic examination. This proof is far oftener afforded by children in the first years than at a later age. When I recall the 28 434 DISEASES OF THE RESPIKATORY ORGANS. numberless cases in which I have found mihary tubercles in the lung or pleura close beside caseous patches in the lung tissue, or those in which there were miliary tubercles of the pia mater in the immediate neighbourhood of caseous nodules in the brain, while at the same time both conditions were met with together in many other organs also — I cannot believe that there is any essential differeneo between them. Since E. Koch, the discoverer of the tubercle-bacillus, has proved the occurrence of this pathogenic element in both morbid products, I feel myself more than ever justified in including them both under a common description in tbe following account. The symptoms of tuberculosis of the lungs in children who arc past 6 or 7 years of age correspond so entirely with those of later life, that they call for no description here. We shall con- cern ouiselvcs, therefore, mainly Avith the occurrence of the disease in the first years of life, during which we very often have an oj)portunity of observing it, especially in practice among the poor and in hospital. The younger the children are, the less as a rule does the clinical picture of the disease correspond to that of phthisis pulmonum in older people. For, the local aft'ection remains more or less insignificant in comparison with the general disturbance of nutrition which presents the symptoms of atrophy already described (p. 73). On examin- ing the bodies of little children who have died in a state of iitrophy, I have very often found a large number of tubercles and caseous deposits in the lungs which had remained entirely latent during life. I have also found large cavities occupying the greater part of a lobe in a few* children who were only some months old, and who had presented nothing during life but a progressive emaciation and debility and a slight cough ; so that it was only the examination of the thorax that revealed the advanced destruction of tissue. The fact that the disturbance of the general nutrition is so much more prominent than the symp- toms of local disease, is especially due to the fact that in very early childhood tuberculosis is generally much more widely distributed than is the case in later life. Caseous deposits und miliary tubercles are almost always present at the same time in a large number of organs — in the lymphatic glands, the spleen, the serous membranes, the liver, the kidneys, the bones, &c. Indeed cases occur in which scarcely a single TUBERCULOSIS OF THE LUNGS. 435 organ is found free from tubercular deposits. All these changes may have a more or less latent course. The main symptom is atrophy, steadily increasing from week to week, and this in many cases is combined with otorrhcea, eczematous eruptions on the head and other parts of the body, enlargement of the cervical, occipital and inguinal glands, often also with multiple (so-called cold) abscesses in the subcutaneous tissue. Since, however, these concomitant conditions occur by no means exclusively in tubercular atrophy, a careful examination of the thorax, even when the cough is entirely absent, is indispensable to establish a diagnosis. This examination presents far greater difficulties in the phthisis of infants than in that of older children or adults. Sometimes we lind nothing abnormal, except harsh breathing or catarrhal rales. All signs of consolidation may be absent, and we should not therefore be justified in diagnosing anything beyond a chronic bronchial catarrh, if it were not that atrophy, hereditary tendency, or enlarged glands, made us suspect that this catarrh was tuber- cular. In many cases, however, more extensive broncho-pneu- monic patches occur, which under the influence of unfavourable conditions {i.e., the presence of the tubercle-bacillus in the lung) caseate, and then present the ordinary physical signs of consoli- dation (duluess on percussion, indeterminate or weak breathing,, prolonged and harsh expiration, bronchial breathing, broncho- phony and sharp rules). In later life the development of phthisical processes in the lungs generally takes place from above down- wards, and hence the limitation of the physical signs to the upper lobes and their apices gives us valuable criteria for the diagnosis of the early stages. In little children, however, we not uncommonly find an irregular distribution of the tubercles and caseous nodules through the whole of the lung tissue ; and on examination of the supra-spinous and subclavicular regions we find but little, while the lower lobes on the other hand show signs of consolidation ; or if these are absent, only catarrhal signs are found throughout. Irregular variations of temperature (which become less extensive as the child becomes more collapsed) and dyspeptic symptoms, anorexia and especially diarrhoea, are fre- quent complications, and are therefore all the more likely to mislead the physican. For since — as we have already seen — extensive tuberculosis of the lung and even cavities m a y exist 436 DISEASES OF THE RESPIRATORY ORGANS. without any cough or marked dyspncea, the diarrhoea is thus all the more likely to draw our attention away from the respiratory organs, and we are astonished to find at the post-mortem that the principal changes are in the lungs, while we had expected to find them in the intestinal canal. A few examples from very early childhood will illustrate to you what I have been saying. Otto F., 4 months old, hand-fed. Since tlic 6th week of lite, multiple abscesses over the whole body. For the last 9 weeks increasing atrophy, and flabbiness, little appetite, cough and short breathing. Percussion-note over the upper part of the chest on both sides, both in front and behind, less clear than in other regions. On the right side above, indeterminate breathing and bronchophony. Rales on both sides behind. P. 150, T. not elevated. At the beginning of the disease, fever Avas said to have been present. Father died from phthisis. Death after 8 days. P.-M. — Extreme emaciation. Cervical and inguinal glands i-nlarged, some of them caseous. Partial adhesions of the peri- cardium to the heart and to the mediastinvim ; miliaiy tubercles on the visceral layers of the former. Left lung freely movable, containing numerous grey nodules the size of a pea. Eight lung fii-mly adherent all over. In the upper lobe a cavity the size of a pigeon's egg, communicating with one still larger which ran backwards. Large and small tubercle-nodules scattered through the whole lung-tissue. A large caseous deposit m the lower lobe. Swelling and caseation of the tracheal and bronchial glands, one of which contained a cavity. Miliary tuberculosis of the liver and its serous covering. Spleen firml}- adherent all over to the neigh- t)ouring parts, very large, tubercular both inside and out. A few small nodules under the capsules of the kidneys. Mesenteric glands partially caseous. In the ileum a few flat ulcers with small grey nodules in their edges. Helene D., 8 months old. Increasing atrophy for 6 months, diarrhoea a,nd coughing. For the last 8 days fever, especially in the morning hours. P. 114, E. 68. Noisy expiration, dyspna?a. Percussion note higher on the right side above both in front and behind, breathing very harsh all ovei*, here and there mucous rales. Gradual increase of the dulness in the places mentioned, bronchial breathing and bronchophon3^ QCdema of the face and feet ; collapse. Death after 3 weeks. P.-M. — The right upper lobe firmly adherent to the chest wall, caseous almost throughout, and containing pretty large cavities communicating with one another, oi^e of which reaches almost to the pleura. The middle and lower lobes, as well as the left lung, have miliary tubei-cles scattered through them. Bronchial glands TUBERCULOSIS OF THE LUNGS. 437 caseous, one of them Bofteucd in tlio centre. Extreme miliary tuberculosis of the spleen and peritoneum. Fatty degeneration of the liver. The latency of widely- spread tubei'culosis is especially noticeable in little children who finally die of tubercular meningitis. Without any marked prodromata, in the midst of apparent good health, or at most ushered in by some flabbiness of the skin or muscles which is easily overlooked and with some degree of emaciation — the meningitis suddenly appears. At the post-mortem the beginner is then surprised to find miliary tubercles and caseous deposits in many of the organs, although these had given rise to no symptoms whatever during life. In older children — from 3 years old until about the time of the second dentition — we find tuberculosis not uncommonly beginning with dyspeptic symptoms. The children lose their appetite, the tougue is always more or less furred, they suffer often from diarrhoea, become emaciated, and complain of vague pains in the chest or abdomen long before the cough excites attention. At the same time they are ill-tempered, become feverish towards the evening, have dry lips and are restless during sleep. In the morning and forenoon, however, there is a remission, and nothing indicates the latent disease but a slight elevation of temperature and an unusually rapid pulse. Such cases are very apt to be treated as those of latent pleurisy are (p. 421), and the obscure symptoms — the gradual "falling ofl'" of the children, as the mothers say — is referred to a protracted dyspeptic condition. Under these circumstances a careful examination of the chest cannot be too urgently recommended. The suspicion of incipient tuberculosis becomes more surely established if a hereditary tendency can be ascertained, if cough sets in, or if we can at the same time discover caseous or scrofu- lous deposits — e.g., bone- and joint-suppuration, spinal caries, glandular enlargement and abscesses in the neck or in other parts of the body, chronic inflammation of the eyes, eruptions on the head, and otorrhoea. In any case, after a few mouths local lung symptoms also, cough, rapid breathing, ä:c., are sure to develope so distinctly, that one is forced to examine the lungs. His having hitherto neglected this examination may how^ever have misled the physician into giving a favourable prognosis, for which the afHicted parents will be slow to forgive him. Even 483 DISEASES OF THE RESPIRATORY ORGANS. iilthougb an early examination may reveal notliin«,' very definite, still we may often make out chronic catarrh, and in such circum- stances this may justify us in fore naming the family of the probability of danger. At this age (from 3 years upwards) we almost always find remittent fever (hectic) developing sooner or later, while in very young children we do not always find it, and it may l)c quite absent ; as for example in the following cases. Paul K.. 1\ years old, treated in the lio.spital from 5th to 30th May. Extreme flabbiness and Avasting. moderate cough, E.. 50 — 60. Dulness on both sides at the ba.se behind with sharp rales and indeterminate breathing ; diarrhcea. During the whole time that the child was under observation, the temperature only rose once (on the evening of lOtb May) to 100° ¥.; at other times it was always below this, and, in fact, generally sub- normal. At the post-mortem we foimd in both lungs many caseous de])osits, a few cavities from the size of an almond to that of a plum, caseation of the bronchial and mesenteric glands and a few tubercular ulcers in the intestine. Marie M., 7 months old, treated in the hospital from 10th •January to 16th February. Continually increasing flabbiness and emaciation, constant cough and dyspnoea. On the right side ver}- harsh indeterminate breathing and numerous large and medium crepitations not sharp in character. Dulness nowhere discover- able. Diarrhoea. During the whole time the temperature was seldom over 100"4° F., and was s;enerally normal or snb-normal. On 14th February, fever began for first time (101-1° F., ev. 104-2). On the 15th the temp, was 102-7° F., and on the da}- of death only 100° F., the resp. 72 ; the limbs cold and covered with a bluish mottling. At the post-mortem we found the left lung quite healthy, while the right lung had a luimber of caseous nodules of different sizes scattered through almost its whole extent and con- tained in its apex one ver}- large ragged cavity. Bj-onchial glands and spleen partly caseous. This absence of fever scarcely ever occurs in older children. Even without using the thermometer we can at once recognise an exacerbation of the fever from the heat of the head and hands, the thirst and the increased feeling of malaise. The tem- perature rises to 102"2° F., and the remission is often ushered in by a slight perspiration which, however, is never so copious and regular as i n the hectic fever of older patients. lu many cases I have observed quite irregular temperature curves in which the morning temperature was often higher than the TUBERCULOSIS OF THE LUNGS. 439 eveuing. In a girl of 2 years at whose post-mortem we found miliary tubercles and extensive caseous processes in both lower lobes, we had the following temperature chart : — M. E. 22nrl August 100-0 1031 *23rd 1047 99-7 *24th 101-8 .. 100-2 25th 100-0 100-9 26th ,; 100-2 101-1 *27th 103-3 101-1 28th 98-6 105-3 *29th 103-6 . . 103-1 30th 101-1 .... .... 104-0 *31st 103-1 101-3 &c. On the days marked * the morning temperature was the higher. The diagnosis of this disease in children is further rendered diflficult up to a certain age by the absence of sputa, which in adults furnish a valuable point for the diagnosis owing to the discovery of elastic fibres, and especially tubercle-bacilli. The cases in which there really is some expectoration are all the more worthy of note. This takes place more by a process of retching or by the help of the mother, who draws out the expectorated matter with her fingers. Among others I have seen one boy, only seven months old, with extensive caseous degeneration and cavity-formation in the left upper lobe, who for months brought up a very large amount of greyish-yellow foetid sputum, which occasionally contained elastic fibres but never blood. Hasmoptysis in children (apart from that which occurs as the result of tracheotomy) is on the whole a very rare phenomenon before the age of the second dentition, although I cannot confirm the statement of Rilliet and Barthez that they have never observed blood-spitting before the 6th year. I have met with at least a dozen phthisical children under 5, who on violent coughing brought up small quantities of blood, and occasionally even as much as a teaspoonful, either pure or mixed with mucus and pus. I have only on two occasions seen a copious haemoptysis at this age. In one of the cases this was explained by the post- mortem : — On 29th December, 1884, a pale, wasted little girl of 10 moiith.s was admitted into the hospital. Said to have had measles and inflammation of the lung a few months before and to have wasted ever since, but to have coughed but little. The relative.s 440 DISEASES OF THE RESPIRATORY ORGANS. say that d^^ring the last few weeks she has vomited blood on tAvo occasions, once a small quantity, the second time a large amount (filling a small bowl). The motions were still of a tarry black colour. There Avas slight impairment under the left clavicle : here and at other places on the thorax numerous crepitations wen- heard. Very marked anajmia and incipient rickets. In the night between the 5th and 6th January, 1885, there was a fresh dis- charge of blood from the mouth and nose, during which death took place. P.-M. — Left luftg firmly adlierent to the costal pleura. In the middle of the upper lobe, which was much consolidated and partly caseous, thei'e was a ca^aty about the size of a walnut, which com- municated with a bronchus, and, besides some bloody caseous pulp, contained a roundish tumour (§ inches in diameter). This proved to be a thin-walled aneurism, filled with parietal thrombi, and connected with a branch of the pulmonary artery.' There are in peediatric literature a few quite similar cases of aueurism of a branch of the pulmonary artery in the middle of a cavity, ending in rupture and very copious haemoptysis.^ On the; other hand I have never myself met with a case in which the compression or perforation of a branch of the pulmonary artery or vein by caseous bronchial glands at the same time communi- cating with a bronchus had occasioned a copious hfemoptysis, although such an occurrence has occasionally been observed by other writers. I shall take this opportunity of saying a few words about the great tendency of the tracheal and bronchial glands, especially the latter, to become enlarged and to caseate. If tubercle or caseous processes occur anywhere in a child's body, we may almost certainly count upon finding the above-mentioned glands similarly aftected. In fact, out of innumerable post- mortems of tubercular children, I can recollect only a few exceptions to this rule ; and this proves that the tendency of these glands to enlargement and caseation in children is even greater than that of the lungs. While Louis has seen the lungs remain unaffected only once in a series of 123 tuber- cular adults, Killiet and Barth ez on the other hand have found them perfectly unaffected in 47 out of 312 tubercular children. I think that the extreme frequency of glandular ' Cf. the Dissertsvtion of my pupil Dr. Hoffnung, Ueber Hämoptoe bei Kindern : Berlin, 1885. ' W y s s , Gerhardt's Handh. der KinderkranlL, Th. iii. , 2, S. 807.— Ra s m u s s e n . Birsch-Virchow's Bericht, 1869, ii.. 101.— West, Lectures, &c., vH. edition, p. 530. r TUBERCULOSIS OF THE LUNGS. ill eulargement may be referred to two circumstances: ürstly, to the peculiar general pi-edisposition which many children have to glandular enlargement, which we are accustomed to designate the " scrofulous " diathesis ; and secondly, to the fact that bronchial catarrh and whooping cough are so very common. The irritation of the mucotis membrane is transmitted by the lymphatics to the neighbouring bronchial glands just as in intestinal catarrh, typhoid fever, &c., it is carried to the mesenteric glands. The glandular afiection very often forms the chief disease in children, while the lungs themselves may contain but few tubercles and deposits. We find the bifurcation of the trachea and the large bronchi surrounded by glands either separate or conglomerated, sometimes gathered into masses of the size of a hen's egg. Some of these are simply hypertrophied, vascular, greyish-red, but generally either some or all are tubercular or transformed into a whitish-yellow mass. Also, on cutting into the lungs we frequently find little caseous glands at the bifurcations of the medium-sized bronchi. A few of the glands show on section a cavity filled with softened debris, situated either centrally or towards the periphery, which, after they become adherent to the pulmonary pleura or to the bronchi, ruptures into an adjacent lung-cavity or even into one of the large bronchi. When this occurs, fatal suffocation may result from fragments of caseous matter finding their way into the upper air passages.^ Even the rupture of such a gland-cavity into the pericardium causing fatal pericarditis, has been observed in a few cases. Large bunches of glands at the root of the lungs may even compress the adjacent vessels more or less, especially the pulmonary artery and vein, and their branches, the superior vena cava, and the common jugular vein, the vagus and its branches. The latter, especially, we occasionally find so sur- rounded and flattened by the glands that it is scarcely possible to follow its course through the mass. Adhesion of some of the glands to the oesophagus, to the pulmonary artery or a branch of it has likewise been observed, by which these parts are not only displaced, but, owing to the pressure, may be gradually thinned and eventually perforated. ' Friihwald, Jahrh.f. KinderhtUl:, Bd. sxiii., S. "423.— Petersen, Deuttxfit nied. Wochensehr., 10, 1885. Saccessfiil treatment of such a cuse by traeheotoiuy. — Lccb, Jahrb./. Kinderheilk., Bd. xsiv., 1886, S. 353. 442 DISEASES OF THE RESPIRATORY ORGAN'S. Can we, then, diagnose this condition of the bronchial glands during life by any definite symptoms'? As far as my experience goes, I must answer this question in the negative for the great majority of cases. Certainly we will scarcely ever be mistaken if in a tubercular child we diagnose caseation of the bronchial glands before the post-mortem; but this is only because this condition is almost never absent in these cases. The clinical descriptions which authors give of glandular enlargement have the look of having originated in the study and not at the bedside. It is said that the compression exerted by the glands un the neighbouring parts might readily give rise to pressure- symptoms; and in fact cases do occur in which oedema of the face and dilatation of one or both jugular veins in the neck take jjlace, and likewise Iniemoptysis and luemorrhagic infarction of the lung from pressure on the pulmonary veins. I liaAc myself, in a little girl of li years, observed compression of the right bronchus by a mass of tubercular glands the size of a hen's egg, whereby the entrance of air into the right lung was considerably interfered with, and the breath-sounds on this side could only be heard extremely faintly. The compression of the vagus and recurrens also may, as I have frequently noticed,^ cause certain nervous symptoms, especially alteration of the voice (hoarseness), lits of spasmodic cough with inspirations like those of whooping- cough, also asthmatic attacks with whistling breathing and cyanotic discolouration of the face. According to my experience I must, however, regard such cases as extremel}' rare. We have often at post-mortems found large masses of caseous bronchial glands, the presence of which had not been revealed during life by a single symptom, the children having presented nothing beyond the well-known features of tubercular meningitis or phthisis. Even the distension of the external jugular veins, to Avhich so much importance has been attached, and the oedema of the face, may occur merely as the result of engorgement of the right side qf the heart from extensive consolidation of the lungs, without there necessaril}^ being any compression of the large Venous trunks within the thorax. On this account I regard the diagnosis of enlarged glands during life as very problema- tical. I would, however, attach least value of all to the dulness of the percussion-note over the inter-scapular region, which many ' Romberg and Henoch, Klinische Ergehnisse : Berlin. 184G, S. 1C.">. TUBERCULOSIS OF THK LUNGS. 443 insist upon. I, at least, have never yet seen a glandular tumour so large that it could have caused a well-marked dulness in this locality. Killiet and Barthez point out also that large masses of glands in the posterior mediastinum act as good conductors of sound, and intensify to the ear of one who is auscultating the back any sound heard from the lungs, and that on this account we may hear loud bronchial breathing and sharp rales without the lung itself being consolidated or containing cavities. I have not myself as yet met with an error of this kind due to the presence of masses of glands. At any rate percussion would soon clear this up ; for where these sounds were really caused by consolidation of the lungs and by cavities, distinct impairment of the note at the back would scarcely fail to be present. Therefore I cannot admit that there is a quite definite independent series of symptoms indicating enlargement and caseation of the bronchial glands. In most cases the condition can only be suspected, and is therefore merely of pathological interest. Only in exceptional cases can we make a diagnosis with any degree of probability wlien there are distinct symptoms of pressure on the veins or on the vagus nerve. The tuberculosis of children up to the beginning of the second dentition is distinguished from that in later life by its acute course. Cases which are very chronic and protracted, lasting for years, are extremely rare, and the fatal termination almost always occurs within some months or at most within about a year. This of course is to be accounted for by the wide distribution of the tuberculosis throughout many organs in childhood. In children, also, much oftener than in adults, we have tubercular meningitis, broncho-pneumonia or pleurisy developing, which bring life to an end sooner than would otherwise have been the case. The pleura is affected, indeed, in tuberculosis almost as often as the pia mater, the disease either taking the form of numerous mihary nodules scattered over the costal and pulmonary pleura, or of large caseous patches on the free surface of the membrane, or in the subserous connective tissue under the costal layer. In the latter case we occasionally see little extra-pleural cavities resulting from the breaking down of these patches, which may either rupture into the pleural cavity or after previous adhesion of the pleura to the lung may empty themselves into cavities in the latter or into the bronchi. More or less ^44 DISEASES OF THE RESPIRATORY ORGANS. extensive adhesions of the two layers of the pleura to one another likewise occur very often, while in other cases we have the development of sub-acute or chronic pleurisy with copious purulent effusion often hlood-stained. The same may he said of the pericardium, the partial or complete adhesion of the two layers of which I have met with, not uncommonly, in tubercular children. I shall enter into this more fully later on. The fatal course of the disease is accelerated in many cases by the rapid development of acute miliary tuberculosis, the symptoms of which are here pretty much the same as in older patients. The acute eruption of miliary tubercles in a more ov less large number of tissues may, however, take place not only during the course of pulmonary tuberculosis which has hitherto been chronic and constitute its fatal termination, but it may also occur in children who are apparently perfectly healthy, and are not at all suspected of a tubercular tendency. In both cases great and sudden variations of temperature with irregular exacerbations (occurring sometimes in the morning, sometimes at noon, and sometimes in the evening), very rapid superficial breathing and harsh breath sounds, to which, usually, widely- distributed fine crepitations are by-and-by added — form the chief symptoms ; and in the further course of the disease we may also have enlargement of the spleen, roseola, and cerebral symptoms. The fever, however, does not always reach a very high degree. Thus in a child of 2 years who had hitherto been quite healthy I found during two weeks a temperature of only 1008 — 102*2'' F. while the rate of respiration was from 60 to 80, although nothing abnormal could be discovered on examining the lungs. It was only in the beginning of the 3rd week, when convulsions, heraiparesis, and coma suddenly set in, that the temperature rose to 104° F. ; and death took place 2 days after. In the diagnosis we may easily be misled by the cerebral symptoms into thinking either of typhoid fever or of tubercular meningi- tis; the former especiall}' if there is enlarged spleen and roseola. Wilhelm K., 3 years old, brought to my polyclinic on 15th March with traces of scarlatinal desquamation, presenting the symptoms of pleuro-pneumonia of the right lower lobe. During the next few days the pleurisy became more prominent. By the iiOth April, however, it was quite gone, so that there was nothing left but an impaired note laterally and a very slight dulnes.« TUBERCULOSIS OF THE LUNöi^. 445 behind ; vesicular breatliing was heard all over. On the Gth August— that is, 3 months after— the child, who had during the interval remained well, was brought again to the hospital. During the last 5 days, headache, vomiting, and constipation. P. 92 ; T. somewhat elevated. The physical signs unchanged. Persistent constipation, in spite of repeated doses of calomel and sj-rupus rhamni and enemata. On the 8th, frequent vomiting; pulse. 132. On 15th, the spleen not enlarged. Nothing new to be discovered in the chest. Pupils reacted sluggishly; drowsi- ness, out of which the boy could not be wakened. Abdomen somewhat retracted. Yesterday afternoon an epileptiform fit, lasting 3 hours. During the next few days, increasing coma, frequent perspiration, left pupil wider than right. R. 48 unequal ; P. 128. On 21st, permanent convulsions and contractures. Death in the course of the following night. The nature of the symptoms and their succession during the 3 weeks' course of the disease were here so characteristic that the diagnosis of tubercular meningitis seemed to me beyond a doubt ; and what did we find at the post-mortem ? Pia mater hyperajmic, otherwise quite normal; no trace of inflammation or tubercles in it ; much serum in the dilated ventricles, central parts generally macerated (post-mortem appear- ance). Bronchial glands enlarged and caseous, right lung com- pletely adherent, pleura costalis much thickened, scattered over with grey intra-pleural nodules lying together like stones on a causeway. The anterior lower border of the lung caseous, the posterior portion brown and carnified. Left lung sprinkled throughout with innuTuerable miliary nodules. Liver fatty. Spleen full of miliary tubercles. In the intestine a few small tubercular ulcers. Max R., la years old, admitted into the ward on 31st March. Coma, dry crusted lips, both pupils contracted, R. itTegular, interrupted by pauses. Percussion normal, harsh In-eathing all over the chest, with coarse crepitations. Abdomen distended and apparently tender on pressure. Constipation. Pulse very small, lU. T. 85-5° ; towards evening, 101-3° F. The same condition on the 2 following days. On 3rd April, the day of death, T. suddenly rose to 105-4, R. 76, P. imperceptible. Cyanosis, trismus, rigidity of the neck and of all the limbs. Death at 8 p.m. P.-M. — Pia mater in a state of venous hyperajmia and oedema. No exudation or tubercle anj-where. Brain very vascular, ven- tricles (especially the 4th) filled with a moderate amount of clear serum. Very abundant miliary tuberculosis of the pleura and of both lungs, of the spleen and liver. Bronchial and mesenteric glands enlarged and caseous, likewise the intestinal follicles. In both these cases, then, we found neither tubercle nor 44G DISEASES OF THE RESPIRATORY ORGANS. oxutlation in the pia muter, arul yet during life the characteristic symptoms of tubercular meningitis were present ; and in the second case there was also the rise of temperature immediately before death of which we have spoken (p. 325). At the post- mortem we only found hypericmia, and, in the second case, also ««dema of the pia mater and accumulation of fluid in the ventricles, that is, hydrocephalus acutus (p. 309), to which we could ascribe the cerebral symptoms. I have seen one other quite similar case, that of a child of 9 months, who, during the last few days, pre- sented a tetanic muscular rigidity, so that one could raise the child either by the head or feet and hold it almost horizontally. In this case we found at the post-mortem only oedema of the pia mater, and extreme internal hydrocephalus, although there was miliary tuberculosis of the pleura, lungs, spleen, and liver, and caseation of the bronchial glands. I have found the same appearances in two other cases of miliary tuberculosis which had assumed a typhoid form at their onset — in the case of one child of 3 especially the temperature-curve corresponded so exactly to that of typhoid fever that I adhered to this diagnosis until the post-mortem, at which we found extensive acute miliary tuberculosis instead of the expected appearance of typhoid. In both cases the cranial cavity was entirely free from tuberculosis, and there was nothing found but hyperemia of the pia mater with serous distension of the ventricles. I have only exceptionally seen a haemorrhagic diathesis resulting from acute miliary tuberculosis.^ Otto K., 4 years old, admitted 8th December, 1879. History obscure. Took ill on 26th November -with violent fever and hasmorrhages from the mouth and nose, which, with short intermissions, had lasted ever since. A ha^mon-hagic diathesis liad never been obsei'ved before. Pale, emaciated child, much collapsed. Sclerotic and skin slightly jaundiced. Cutaneous veins markedly distended. Slight branny desquamation of the epider- mis. Scrotum oedematous. T.-lOlv'' F. ; E. 40, superficial, costo- iibdominal. On examination nothing found but coarse crepitations at the back ; P. 156, small. Flatulent distension of abdomen, liver extending about 2 inches below the margin of the rilis, spleen not to be made out. Motions thin, very black, passed involuntarily. Urine removed with the catheter (7 oz.), brownish-red, acid, con- taining some albumen, no tube-casts, no whole blood corpuscles; ' Jactibasch, Jahr//, f. KtudevhtUI.-.. xv.. S. 167. TUBERCULOSIS OF THE LUNGS. 1-17 (hiiimogloljinuria). Death in a state of collapse on 10th Decenihct-. After a few injections of camphor, the punctures bled long and ^th „ ... 112 20th „ ... 116 21st ,. ... 120 22nd .. ... 108 li. T. 60 ... ... 101-5 60 ... . . . 100-4- - 99-5 50 ... ... 101-3 64 ... ... 98-6- -100-4 56 ... ... 99-5- -100-8 52 ... ... 100-4 40 ... . . . 99-0 40 ... ... 98-6 44 ... ... 99-1 30 ... 99-5 Chronic bronchial catarrh and jDulmonary phthisis are not uncommonly found as the sequelae of whooping cough, the latter developing from chronic broncho-pneumonia which has become caseous. As a result of the enlargement and caseation of the bronchial glands which in protracted cases of whooping cough is set up by the accompanying catarrh of the mucous membrane, acute miliary tuberculosis or tubercular meningitis sometimes developes even after a lapse of years, when the whooping cough itself has long been forgotten. I may finally mention that in several cases I have seen a deformity of the thorax occur as the result of whooping cough, similar to that in rickets, namely, a very marked "pigeon-breast "; and these children had previously been of quite normal conformation and in no way rickety. The occurrence of this deformity is ex- plained, I think, by the excessive atmospheric pressure from without, along with the deficient inspiration and the consequent incomplete expansion of the lung, but, above all, when there is a complication with broncho-pneumonia which keeps up these unfavourable conditions for some length of time. We know practically nothing of the etiological conditions of whooping cough. It is certain that the disease occurs even in earliest childhood. I have seen it, as already mentioned, in children of B — G weeks who had been infected by older brothers and sisters. It occurs most frequently between the 2nd and 6th year of life ; still, older children are also often aflected, but adults very rarely. In the spring of 1878 I saw a case of whooping cough in a young lad of 16 who had caught the in- fection at the confirmation-class, and later on he infected not only his two sisters of 12 and 14 years respectively, but also his mother Avho was 35 years of age. In her case, however, the WHOOPING COUGH. 4G3 disease only took the form of a catarrlial cough occurring in paroxysms with slight cyanosis. In the younger patients, again, there was distinct crowing, and in some also pretty copious haemoptysis and final vomiting. Cases often occur of the mother being infected by the children ; still the disease has generally a very mild form in their case. There can be no doubt that whooping cough is infectious, and is readily transmitted from one individual to another, so that generally several children in one family sufler from it at the same time. It is therefore all the more difficult to explain the fact that, in my ward where the patients with whooping cough are nes-er isolated, I have only exceptionally observed cases of transmission — which fact is entirely at variance with Roger's experience. As to the period of incubation I possess no definite experience, but I have frequently observed the fact that if a child introduced the disease from school into a family, it took at least 10 — 12 days before a cough was heard among the other children. It is naturally assumed that the contagion reaches the respiratory mucous membrane along with the inspired air, and thence exerts its action, and so, as a matter of course, bacteria have been de- scribed as the cause of whooping cough. ^ However probable this may be, it cannot be said to have been demonstrated by the conditions described as having been found, as they are not abreast of the present state of bacteriology. When we regard whooping cough as an infectious disease, it naturally follows that we look for a feverish premonitory stage analogous to that found in the acute exanthemata. I cannot altogether deny the occurrence of this, but I would remind you that the first stage of this, as of every other catarrh, may come on with great severity, and in that case be accompanied by fever. Trousseau also" speaks of a very acute catarrhal stage, and I myself have fre- quently observed it. The action on the respiratory mucous membrane of this still- unknown infectious material is not confined to the setting up of an ordinary catarrh of the trachea and of the bifurcation, as many have maintained. I certainly shall not dispute the fact that such a catarrh is present or may be present ; and this condition 'Letzerich, Jahrh. f. Kinderkranhh., 1870, iii., S. 534; 1873, S. 436.— Tschamer, ibid, 1876, x., S. 174.— Burger. BerL Hin. ]Vochenschr., 1883, i.— Deichler, Deutsche Medicinah., 1886, No. 74. * Clinirjue i., 497. 464 DISEASES OF THE RESPIRATORY ORGANS. has in fact been proved, by laryngoscopic examination to occur, at least on the mucous membrane of the larynx and trachea.^ Everyone, however, who has once heard a fit of whooping cough must admit that there is something more in it than the mere catarrh — namely, a nervous element. It is this that gives the peculiar character to the attacks and manifests itself on the one hand by the spasmodic violence of the expirations, and on the other hand by apnoea, and by the crowing sound of spasmus glottidis. I would further remind you of the symptoms de- scribed (p. 453) as constituting the aura of the attack, and also of the almost invariable vomiting. I grant that the retching and vomiting of mucus at the end of the violent paroxysms must be regarded simply as a mechanical act, resulting from the violent contraction of the abdominal muscles in coughing ; for we fre- quently see the same thing result in children especially from other violent paroxysms of coughing having nothing to do with whooping cough, if the stomach is very full. AVe must remember, however, that many children vomit even when the whooping cough is very slight; and likewise that cases occur in which the vomiting forms the most prominent feature of the paroxysm, and may even excite serious anxiety by its persistence. I have known children who, after a short attack with no crowing what- ever, at once brought up the whole contents of the stomach, while others even in the intervals of the paroxysm vomited all their food and gradually sank into a state of serious debility, although no cause for this could be found in the digestive organs themselves. Such vomiting cannot be looked upon as other than nervous. It is as yet an open question whether a reflex excitability of the medulla oblongata acting through the vagus is to be blamed here, and in what way exactly the specific contagion exerts such an influence on the central nervous system. It is at any rate certain that pathological anatomy gives us no explanation of it, and that other changes which are found post-mortem — especially the much-talked-of enlargement of the bronchial glands — are only to be regarded as sequelae or compli- cations of the disease. A\'Iiooping cough often occurs in more or less extensive ' Eehn {Wiener med. Wockenschr., 1866, 52 und 53), Me jer-Küni {Zeitschr. f. lUn. Med., i., Heft 3), and Herff {Deutsches Arch./. Uin. Med., Btl. xxxix., No. 3 und 4), describe this catarrh while Eossbach {Berl. kUn. Wochenschr.t 18, 1880) was unable to satisfy himself of its presence. WHOOPING COUGH. 4G5 epidemics, wliicli in general are not confined to any particular «eason of the j-ear. A certain relationship to measles, which West has drawn attention to, cannot be overlooked. We often observe not only the combination or succession of the two epidemics, but also it appears to me that individual patients who are suffering from one of these diseases seem to possess a peculiar predisposition to the other. The combination of these two diseases in one and the same individual is always a serious matter; for in these cases there almost always arises an extensive and particularly obstinate broncho-pneumonia tending to become chronic. It is worse still if a child who is already suffering from whooping cough and broncho-pneumonia takes measles as well. In such cases I have seen c^'anosis appear even before the outbreak of the eruption, the measles-rash at once becoming bluish ; and after a few days death ensued with symp- toms of carbonic-acid poisoning. Nevertheless, as I have already mentioned, even this complication is not necessarily fatal. The combination of whooping cough with diphtheria, which I have not uncommonly seen in the hospital, I regard as even more serious ; but even here we must not at once lose courage. In a girl of 11, in whom a complete loss of voice had already made extension of the disease to the larynx probable, perfect recovery took place notwithstanding. I may mention that in this case, instead of the crowing inspiration during the paroxysm of the cough, a quite harsh, almost croupy sound was heard, evidently caused by the sn'elling and roughness of the laryngeal mucous membrane. Should tracheotomy have to be performed, the retarding influence of the whooping cough paroxysms is to be feared.^ You will have seen from this description that while the prognosis in whooping cough is favourable so far as the disease is concerned, yet serious danger to life may arise on the one hand from the extreme youth at which it sometimes occurs, and on the other from certain of its complications (bronchitis, broncho-pneumonia, convulsions). Further, even after complete recovery caseous deposits may be left behind in the lungs or bronchial glands, and may later on form the starting-point of miliary tuberculosis. ' Iti one case the wound broke open again after 2 months (Eogcr, loc.cit., p. G14). 30 466 DISEASES OF THE RESPIRATORY ORGANS. In the treatment, unfortunately, you will not acquire much credit. The enormous number of remedies recommended from of old for this disease, is of itself sufficient to prove their ineffi- ciency. We do not possess any remedy capable of cutting short the disease, especially when at its height ; while in the last stage, when natural recovery sets in, apparently every remedy is helpful. A second fact worthy of notice is, that whooping cough, like every other infectious disease, may occur in a very much weakened, so to speak abortive, form, in which it runs its course in a much shorter time than usual, and is recovered from without any other treatment. Every physician, like myself, has met with such cases, I suppose (although I regard as somewhat doubtful one mentioned by Trousseau, in which the disease is said to have lasted only for 3 days) ; and therefore I think we cannot be too cautious in judging of the results of treatment in this disease. YoU will therefore excuse me if I do not go over the list of all the drugs which during a number of years I have tried, either on my own initiative or acting on the recommendation of other people, and found ineffective. I have now come to put trust only in one, namely morphia (Form. 10), which is far more efficacious than the much- used belladonna — at any rate in relieving the violent attacks, espe- cially those occurring during the night, and in diminishing their frequency. It does not, of course, influence the general course of the disease. In prescribing this remedy, however, especially in practice among the poor, you must never omit to charge the mother to stop the medicine as soon as unusual sleepiness shows itself. Owing to this precaution it has only once happened in my practice that a child slept uninterruptedly for 1 8 h ou r s without being disturbed by a single fit of coughing ; the attacks at once set in again when the narcosis passed off. Further, I knew another case of a child (6 months old) being poisoned in some inexplicable way, and who showed symptoms of collapse, narrowing of the pupils, and coma ; fortunately he recovered under the use of cold douches and restoratives. I have always been very cautious in administering the medicine, and I have never yet had any mishap occur, even when giving 1 — 2 teaspoonfuls daily for weeks. I therefore prefer this medicine very much to all other narcotics, and especially to a drug so dangerous as atropine. Still I would only recommend WHOOPINQ COUGH. 467 the use of morphia in severe cases with at least 20 fits occurring within 24 hours. The bacteriological explanation of the disease, although not yet proved, has at least had this effect, that attempts have been made in various ways to deal directly with the supposed germs of infection. Inhalations of carbolic acid vapour were first tried (B u r c h a r d , T h o r n e r , and others). These were much praised and replaced the former plan of sending the patients to reside in gasworks, which I have always regarded as inadvisable, owing to the danger of catching cold. My own experience as to this treatment does not allow of my giving a final opinion ; because its results are sometimes strik- ingly favourable, sometimes doubtful, and sometimes there are none at all. I can say, at any rate, that I never knew of it doing any harm. We may either order a 1 — 3 per cent, solution of carbolic acid to be inhaled from a spray-producer several times a day, or if there is anything to prevent this we may charge the air of the nursery with the vapourised solution and hang over the head of the bed a sponge saturated with it. We may also order a sponge thus treated to be held before the child's nose several times a day, so that the vapour may be inhaled for several minutes. I have entirely given up other forms of inhalation — chloroform, benzoin, salicylate of soda, turpentine, tannin, quinine, &c. As to the painting of the pharynx and larynx with parasiticide (!) substances which has of late been much employed, we may object, to begin with, that we know as little concerning the position of the bacteria as we know about themselves, and we can therefore have no means of knowing whether we really reach them with the brush. The method, however, is certainly worth a further trial, as Moncorvo^ says that he has seen good results from painting the entrance to the larynx with a 1 — 2 solution of resorcin. Also injections of salicylic acid (1:1000) or of corrosive sublimate (1:10,000) into the nose, as well as insufflations of quinine or benzoin into it have been recommended for the same purpose .^ Finally, painting the pharynx and larynx with 5 — 15 per cent, solution of muriate • " De la nature de la coqiieluche et de son traitement par la rcsorcine '' : Eio de Janeiro and Paris, 1883 and 1885. 2 Goldsclimidt, Beidscke med. Zeit., 1885, No. 61.— Michael, Deutsche med Wochenschr., No. 5, 1886. 4:08 DISEASES OF THE RESPIRATORY ORGANS. of cocaine is the most recent form of local treatment.^ This deadens the sensibilit,y of the parts, and is said to have frequently brought about a rapid diminution in the frequency and severity of the attacks. Moncorvo''' recommends that the two methods should be combined (the treatment with resorcine to follow the painting with cocaine). My own experience with cocaine has not been satisfactory. Several cases (treated in the ward) which were painted thrice daily were improved for a time, but not permanently. Others treated in the polj'clinic (with only one painting daily) were even less successful. I do not think that this tedious and often difficult proceeding deserves the praises which many have bestowed upon it. At any rate you must, I think, relinquish any idea of cutting short the whooping cough attack, and let the parents know from the first that nothing can be looked for beyond mere alleviation of the paroxysm. When the w'eather is fine, as much of the fresh air as possible should be allowed ; on the other hand when it is windy and inclement — and also when the patient has bronchial catarrh — it is to be strictly forbidden. Very often, indeed, the neglect of this precaution avenges itself by an attack of broncho-pneumonia. When whooping cough occurs during the summer, you will often be asked whether a change of air might not do the child good. Although a number of physicians consider this beneficial and even recommend certain definite localities — e.g. residence on the coast of tlie North Sea — as especially favourable, my own experience does not permit me to agree with this view. I have often sent children who had whooping cough to watering-places with their parents, either on the sea-coast or among the mountains ; but I have scarcely ever seen any good result from so doing. The patients go on cough- ing as before, and the only result in such cases is one not to be desired — namely, the infection of healthy children who came in contact with the patients at such places. Only in exceptional cases — as, for instance, in that of my own child — have I seen an attack of whooping cough which was in process of development, and had already the characteristic paroxysms, entirely disappear ' Barbillion, Herne mens., AOiit, 1885. — Prior, Berl.klin. Wochenschr.. 1885, No. 45, 46. - ''Deremploi du Chlorhyclratc de Cocaine dans le traitenient d.- la coqno- luclie :" Rio, 1885. WHOOPING COUGH. 469 in a fortniglit spent at Reichenhall. SucL isolated cases, how- ever, seem to me (bearing in mind the occurrence of " abortive " whooping cough ah-eady mentioned) quite insufficient to prove the favourable influence of change of air or the merits of any particular locality. As to the treatment of the complications (eclampsia, broncho-pneumonia) you may consult the prescrip- tions already given for these diseases. Protection from whooping cough could only be guaranteed by the complete isolation of the children ; and this can hardly be carried out in practice, especially since (according to Roger) the isolation must last from 2 to 3 months. 470 SECTION V. DISEASES OF THE CIKCULATORY ORGANS. Pathological changes in the heart are not much rarer in children than in adults. The age causes neither anatomical nor clinical differences of any essential importance, and I may therefore confine myself to a comparatively short description of these diseases. I. Affections of the Large Blood-vessels. There is very little to say about the affections of the large hlood-vessels in children, for these are extremely rare. Although Hodgson has observed ossification of the temporal artery in a child of 15 months, and Andral calcareous plates in the aorta in a girl of 5 years — still, these are exceptional occur- rences, and I have never had an opportunity of observing them ; nor have I seen an example of aneurism of the aorta in child- hood.^ Also the congenital stenosis of the aorta, which is generally situated in the region of the ductus arteriosus or at the commencement of the descending aorta^ are much more frequently diagnosed in youth, or even later, than in childhood ; although some of them seem to have some connection with the involution of the ductus arteriosus which spreads to the aorta. I may take this opportunity of mentioning that the closure of this duct (which in new-born children is about the thickness of a branch of the pulmonary artery) is brought about by an end- arteritis obliterans with the formation of new fibrous tissue, thickening of the walls^ and narrowing of the lumen. The process is noticeable on the 9th day after birth, it has usually gone on to the formation of a stricture in the middle of the duct by the 14th day ; it then proceeds further in both directions, and is generally completed by the end of the third week. The obliteration of the foramen ovale is completed, in 88 per cent, of ' Out of 98 cases of aneurism of the thoracic aorta, there was only one under 20 years ; and among 59 cases of aneurism of the abdominal aorta, there was not even one under that age. CONGENITAL CYANOSIS. 471 the cases, by the thh-cl month after bh-th.^ Anything which causes a deficient filHng of the left ventricle during the first period of life— such as extensive atelectasis of the lung-tissue, loetal pneumonia, or stenosis of the pulmonary artery — must delay the process of closure of the ductus arteriosus. For under these circumstances the blood is continually flowing from the pulmonary artery through the duct into the insufficiently filled aorta. The delayed obliteration of the duct may therefore in such cases ward oif during months the evil efi'ects of the engorge- ment in the right side of the heart and the general venous system which would otherwise have taken place. The same may be said of the persistent patency of the foramen ovale, which, apart from the causes named, may be due to local abnormalities of the foramen or its valve. II. Congenital Cyanosis. The persistent patency of the foetal channels — ductus arteriosus and foramen ovale — was formerly regarded as the principal cause of congenital cyanosis. As the cause of this was supposed to be the mixture of arterial with venous blood, it was thought that the abnormal colour was due either to the remain- ing open of these channels or to an abnormal communication between the tAvo arteries or ventricles owing to an aperture in the septum between them. Now, however, we know that cyanosis also occurs when there is no mixture of the two kinds of blood, and that, on the other hand, such abnormal communications have been found in children — and even in adults — who during life presented no trace of cyanosis. Zeyetmayer's case is well known, in which the entire ventricular septum was absent, and still there was no cyanosis. Equally well known is that of Breschet, in which the left subclavian artery rose from the pulmonary artery ; and yet the affected arm was normal in colour. Let us consider cyanosis for a moment. From the time of birth, or at least very soon after it, there appears a bluish-violet tinge on the cheeks, point of the nose, hands and feet, especially on the nails and the visible mucous membranes (tongue, buccal mucous membrane, entrance to nostrils, palpebral conjunctiva). ' Theremin, Revue mens., Fevr., 1878. 472 DISEASES OF THE CIRCULATORY ORGANS. This is considerably heightened by screaming, crying, sucking, any energetic movement, or on being exposed to cold air. But during the intervals the cyanosis may be so slight as scarcely to be noticed by a non-medical eye. After it has lasted some time — but occasionally even in the first months of life — there is developed a club-shaped (or drumstick-like) enlargement of the terminal phalanges of the fingers and toes, and often a claw-like condition of the nails. Two or three times I have noticed also that the dark-violet gums presented a spongy character like that seen in scurvy. They bled readily either spontaneously or on being touched, and were separated from the teeth at their margins. In one girl of 1^ years this appearance was so marked that her mother brought her to the hospital on account of it, although she had entirely overlooked the cyanosis. The tempera- ture of the extremities is very low (sometimes as low as 89 '6^ or 82*4° F.), while that of the body as estimated in the rectum is found to be normal. Added to this we often have a condition of general debility, languid movements, sleepiness, backward gi-owth and intelligence, and, finally, the whole series of well-known symptoms which are characteristic of the various kinds of heart disease — oedema of the hands and feet, epistaxis, dyspnoeic attacks (especially after violent movement), fainting-fits, enlarge- ment of the liver and spleen, &c. On physical examination we often observe a very distinct increase in the size of the heart, especially of its right side, systolic or diastolic murmurs, and perhaps a pulsatile thrill; but in many cases, also, no abnor- mality at all. Other malformations may be present at the same time, among which I may mention as rare conditions which I have myself observed, obliteration of the auditory meatus, malformation of the external ear, and eccentric position of the two pupils. From these symptoms we may, it is true, diagnose with certainty the presence of a congenital malformation of the heart, but in most cases it remains an impossibility to discover the exact nature of the malformation. As I cannot here discuss the foreign treatises on this subject — which indeed are generally only compilations and criticisms — I would refer those who are interested in this matter to the excellent work of Rauch fuss,* who has had at command an unusually large ' Gerhardt., Handb,/, Kinderlranlh. iv., 1878. CONGENITAL CYANOSIS. 473 amount of material of his own and has also brought together almost everything that is known on this subject. You must not, however, expect any great practical use from it. The author himself is obliged repeatedly to acknowledge that all endeavours to find definite diagnostic criteria for the dilBferent malformations, can only afford at most a more or less probable diagnosis. These malformations consist either in apertures by which the two auricles or ventricles communicate with one another, or in larger defects — which in their most extreme developments take the form of complete absence of the septum — or in stenosis and atresia of the Conus of the pulmonary artery, of that vessel itself, of the aorta or of the auriculo- ventricular opening ; finally, in trans- positions of the large blood-vessels, the pulmonary artery arising from the left, the aorta from the right ventricle. The insuperable difficulties in the way of diagnosing these abnormalities are, moreover, increased by the fact that in the majority of cases there is a combination of two or more of them; and also that the symptom to which the physician's attention is principally directed — namely, the congenital cyanosis— may be completely absent. This visible symptom does not accompany every malformation of the heart. I have often met with such children in the first months of life or at least in the first year, who either suffered only from attacks of dyspnoea or else presented no cardiac symptoms of any kind, and were brought for treatment only on account of an aftection of the lung or bowel. Of this, allow mo to give one example : — Child of 30 days admitted witli congenital syphilis. From 19tli to 21st March, 1873, a febrile pneumonia of the right upper lobe (T. 97°— -99° F. ; K.56— 70). No cyanosis; no abnormality of the heart audible. On post-mortem we found (besides the pneu- monia, syphilitic affection of the bones and interstitial hepatitis) considerable malformation of the heart. The ventricles communicated with one another by a large aperture, the septum being almost entirely wanting; and that between the auricles was very thin. The tricuspid valve was wanting and the mitral valve was inserted at one extremity into the right side of the heart. The arteries normal.' If the children live for some years, there generally, of course, ' Very rare indeed are cases such as that observed by Barth {France med., Jiini, 1880), in which congenital endocarditis was discovered even before birth by a-iscultation of the foetus (loud blowing murmur replacing the first sound). 474 DISEASES OF THE CIRCULATORY ORGANS. occur more or less marked symptoms, usually with cyanosis. They arise either under the influence of chance respiratory afiections, or from endocarditis which developes in connection with the abnormal apertures or congenitally-afiected valves and openings — ^just as in adults it arises in the neighbourhood of old valvular disease (endocarditis recurrens). Under these circumstances the hitherto latent malformations become manifest and we now recognise on examination (which in many cases, is now made for the first time) that there must have existed an abnormality of long standing. The cases of stenosis and atresia of the pulmonary artery or its conus usually produce the most marked symptoms, and they also form the commonest cause of congenital cyanosis. In many cases it is impossible to determine whether the stenosis and partial atresia of this artery are due to foetal endo- and myocarditis or to a primary arrest of development to which an inflammatory process has subsequently been added. This stenosis must always give rise to dilatation of the right side of the heart and considerable engorgement in the entire venous circulation (of which, of course, the cyanosis is an expression). The cardiac dulness then extends beyond the right border of the sternum, the heart's impulse is visible and palpable over a larger area than usual, and a thrill can often be felt along with it. A secondary systolic murmur is also audible over the heart, being loudest over the orifice of the pulmonary artery and between that and the clavicle ; occasionally also over the whole thorax and back. Variations, however, in the symptoms may be caused by the presence of other malforma- tions of the heart at the same time, which renders the diagnosis more difiicult. Nor are examples wanting in which the heart sounds are quite pure, without a murmur of any kind. The diagnosis of malformations of other parts of the heart is still more difficult ; and you will excuse me, if I do not enter further into particulars regarding it, as in practice the cases for which these hold good are of exceptional occurrence. As to the course of cases of congenital malformation of the heart we can never predict anything with much certainty. The greater the obstructions to the venous circulation and the less they are counter-balanced by other compensating malformations (apertures in the septum, persistent patency of the ductus arteriosus) — the shorter will the child's life be. Children with CONGENITAL CYANOSIS. 475 very marked stenosis of the pulmonary artery die early, even although the foramen ovale be still open and there is no cyanosis ; while children with less marked stenosis may grow up to youth or even live beyond that, especially if the foetal channels are not closed or if there are apertures in the septum. The same may be said of cases of stenosis of the aorta, which are almost all observed (and partially diagnosed) for the first time only at a late period of life. I have frequently seen febrile diseases (c.if/., the acute exanthemata) run their course in such children without doing any harm. The fatal issue takes place at last, in these as in all other diseases of the heart, either suddenly by syncope or from the result of some disease of the respiratory organs which would not of itself have been dangerous to life (diffuse catarrh or pneumonia), less commonly with symptoms of gradually in- creasing venous engorgement and dropsy. Caseous pneumonia also, which may be associated with similar processes in other organs and with miliary tuberculosis, is sometimes the cause of death, and the immunity of cyanotic patients fi-om tuberculosis of the lungs, alleged by Rokitansky, is certainly not borne out by the actual facts. ^ As has been already mentioned, it often occurs that on examin- ing children who have been brought to us on account of some entirely different ailment, we find by chance valvular diseases and their results, which are causing either no subjective symp- toms at all or at most a scarcely noticed palpitation or shortness of breath when the patient runs or ascends stairs." Even the most careful history may fail to throw light on the origin of this affection, and we may be told that the children have always been healthy and have never suffered from rheumatism, scarlet fever or any inflammatory chest affection. We are therefore obliged in such cases, in spite of the absence of cyanosis, to assume that the disease has been congenital. I shall take this opportunity of reminding you that in very young, even in new-born children, small spherical projecting blood-extravasations occur on the cardiac valve, especially on the free border of the mitral, as ' ßauchfuss, loc. cit., S. 92. - Similarly, a boy of 8 years, on being examined during a slight attack of articular rheumatism, was found to have his heart on the right side. The cardiac dulness and impulse were only to be found on the right side of the sternum, the right nipple rose with the systole and the first sound was accompanied by a blowing murmur. The abdominal viscera were, however, in their normal position. 476 DISEASES OF THE CIRCULATORY ORGANS. described by Luschka long ago.^ More recently those valve- hfematomata have been investigated by P a r r o t.^ He has met with them often in new-born children at the venous orifices on both sides of the heart, in the form of very small projections (in some cases, however, even as large as a cherry-stone), black or violet in colour and of globular or conical form. These hsematomata, which he attributed to a rupture of intra-valvular blood vessels, are situated under the most superficial layer of the endocardium. They seem to arise very soon after birth, perhaps even before it, and generally disappear within the first few months of life, their covering gradually shrinking, while at the same time there is a proliferation of the epithelium and connective tissue in the neigh- bourhood. It also appears that small hard nodules covered by epithelium and either with a broad base or pedunculated, which not uncommonly occur in the same situations and have already been mentioned by Cruveilhier' and others, may grow from the haematomata. It is, indeed, possible that owing to an abnor- mal process of resolution occurring in such haematomata, shrivel- ling of the borders of the valves and at the same time stenosis of the ostium, or incompetence of the valves may occur, but Avhen these are found in older children, it is no longer possible to ascertain how they arose. The valvular disease would not in that case be really congenital, but would have arisen during the first few months of life. The treatment of diseases of the heart which are either con- genital or have arisen during the earliest period of childhood, must be limited to enjoining the quietest possible life; and the carrying out even of this prescription in older children — whom it becomes necessary to separate from their playmates — meets with great, even insuperable difiiculties. In other respects also, the treatment is exactly the same as that of organic heart- disease. III. Inflammation of the Pericardium, Endocardium, and Myocardium. In many cases an attack of acute rheumatism can be ' Virchmo's Archiv, xi., Heft 2. * Arch, dephysiol., Nos. 4 and 5, 1874. ' For another explanation of these " nodules" based on development, see Pott. Jahrb. f. Kinderheill:, 1878, siii., S. 29. INFLAMMATION OF THE PERICARDIUM, ETC. 477 assigned as the starting-poiut of organic disease of the heart. The time when this disease was regarded as of rare occurrence in childhood has long passed away. Since I shall have to return to this disease on a later occasion, I shall only remark here that although its occurrence in children is, as a rule, less common and less severe than in adults, the complication with endo- or even with pericarditis, is much commoner in them than in adults. Even in quite slight attacks of rheumatism (with but little rise of temperature) which occasionally appear as hypera^s- thesia of the limbs or joints without the latter being swollen, you must never neglect to examine the heart. You will often be surprised to find peri- or endocarditic murmurs in these cases, although owing to the apparent slightness of the afi"ection you were not prepared to find them. In cases of advanced valvular disease we very often find from the history that one or more attacks of acute rheumatism — especially in the joints — had occurred months or years before. As these diseases of the valves and their results so completely correspond to the same conditions in adults, it is unnecessary for me to consider their physical signs more fully. "With regard to the subjective symp- toms, I shall only mention the fact, that although in adults oases of prolonged compensation and consequent latency of the valvular disease are not rare, the same thing appears to me to be still commoner in children. No noticeable distress is caused by the violent movements in playing or running up stairs, and in many cases the disease is first discovered by the mother observing the violent motion of the heart when she strips the children to bath them. It is only when the compensation begins to be disturbed, that the cardiac symptoms, which you are well acquainted with, set in ; and these sooner or later bring about the fatal issue. Even from an anatomical point of view the disease is just the same in children as in adults ; in the one case as in the other we find dilatation and hypertrophy of the ventricles, the brownish-red induration of the lungs, the hemor- rhagic infarcts, the congested kidneys and liver, the enlargement and induration of the spleen, the «dema, and the dropsical effusions in the various cavities and in the alveoli of the lungs. Although in many cases the valvular disease due to rheumatism first appears months or years afterwards, still, on the other hand, examples do occur of a much more acute course. 478 DISEASES OF THE CIRCULATORY ORGANS. Anna M., 7 years old. Formerly always healthy. Acute articular rheumatism, eepecially in the lower limbs, in the middle of Decem- ber, only lasting a few days. Between Christmas and New Year when she was feeling quite well again, she suddenly fell ill once more, with palpitation, diminished secretion of urine, cough- ing, and frequent pains in the region of the heart. Admitted into the ward 12th February, i.e., about two months after the beginning of the illness. On examination we found general anaemia, catarrh in both lobes (especially in the left), cough, and dyspnoea. The cardiac dulness reached to the right border of the sternum, above to the third rib, on the left to the niammillary line. Heart's impulse heaving and diffuse. Indistinct apex-beat outside the mammillary line in the 5th intercostal space. The first sound of the heart obscured by a loud systolic murmur ; both second sounds -pure and unusually loud. Pulse small, 120 — 144 ; no fever ; urine very scanty, marked albuminuria. On the 21st the temperature suddenly rose to 104° F., then fell again rapidly, and by the 24th had not risen again above 100° F. On the morning of the 22nd distinct pulsus bigeminus ; pericardial friction at the left border of the sternum. Increasing collapse (T. 98'1° F.), slight cyanosis, extremely rapid breathing (84). Death in the night of the 24th. P.-M. — Heart about thrice its normal size, both ventricles much dilated and hypertrophied. Aortic and mitral valves thickened along their free margins, somewhat retracted and covered with greyish-red Avarty growths. Recent partial adhesions of the two layers of the pericardium on the anterior surface of the septum ventriculorum. Diffuse bronchial catarrh; oedema and bro^ATiish- red induration of the lungs. In a girl of 7 years, who in October, 1874, had had a slight attack of acute rheumatism combined with endocarditis, I found (March. 1875) not only the signs of mitral incompetence, but also even then very considerable hypertrophy and dilatation of both ventricles. A boy of 7 (May, 1882) had, 12 weeks after the beginning of a rheumatic attack, shown signs of extreme eccentric hypertrophy with changes in the aortic and mitral valve, and a consequent Avell-marked bulging of the precordial region. In a boy of 10, who took ill in May with an attack of acute rheumatism and peri-endocarditis, and since that time had had repeated relapses, we found (on the 19th December) cyanosis and all the symptoms of far-advanced heart disease. At the post- mortem we found incompetence of the mitral valve, hypertrophj- of both ventricles, complete adhesion of the pericardium, brown induration of the lungs, etc. A girl of 10 years took ill with acute rheumatism (with slight choreic symptoms) in September, 1886. By the middle of November she presented the sjTnptoms of incompetence of the aortic valves and hj-pertrophy of the left ventricle. INFLAMMATION OF THE PERICARDIUM, ETC. 479 You find, therefore, in these cases eccentric hypertrophy of one or both ventricles ah-eady developed as the result of valvular disease only a few months after the first onset of acute articular rheumatism. In the first case the course was so sudden and acute that compensation was altogether out of the question, and the end was further accelerated by complication with diffuse catarrh and by the recent peri- and endocarditis which were finally added to it. This "endocarditis recurrens" we have often found post-mortem in old cases of valvular disease, which was either congenital as in the case above or else acquired at a later period. Although this process is usually discovered first at the post-mortem, it can occasionally be recognised at the bed-side. In September, 1872, I had under treatment for acute articular I'lieumatism with endocarditis a girl of 5 j-ears who had previously been healthy. After her recovery the systolic murmur at the mitral valve persisted without disturbing the child's general health, and of this I was able to convince myself after a year's interval, in November, 1873. In January, 1875 — i.e. about 3 years after the beginning of the illness — a fresh endocarditis developed in the already much dilated and hypertrophied heart, manifesting itself by fever, increased loudness of the murmur, and extreme dyspnoea, and ending fatally. On the other hand experience teaches that children get over rheumatic endocarditis better than adults do, and are more likely to recover completely from its results. In the whole course of ray practice I have only had one adult patient under treatment for rheumatic endocarditis of many months' duration in whom I have observed a musical murmur entirely disappear and complete recovery take place, which I know to have been permanent. In children recovery is more frequent, although even in them a permanent valvular lesion remains in the great majority of cases. Clara F., 3 years old, took ill in October, 1871, with rheumatic pains and swelling of the joints of hands and fingers. There was high fever, rapid breathing, and at the end of the 1st week a loud systolic murmur at the apex, without any change in the percussion. Bronchial catarrh. After 14 days, all the symptoms had vanished except the murmur, which in spring, 1872, gradually began to grow fainter, and by November had entirely disappeared. Paul H., 6 years old. In beginning of February, 1868, he com- plained of pains in the upper part of the abdomen (especially on 480 DISEASES OF THE CIRCULATORY ORGANS. Stooping), dyspepsia, and moderate fever. On the loth a warm bath, in which the child took a severe chill. After 1| days violent fever, pain and slight swelling of the joints of the right hand and foot ; flexion of the right knee-joint and adduction of the thigh. Both of these could only Ije overcome with severe pain. During the next few days the joints of the hand recovered, but pains with difficulty of movement appeared in the left thigh. Fever mode- rately persistent, bronchial catarrh, heart unaffected. After a temporary improvement all the symptoms became worse again. On the 29th high fever, loud diastolic murmur over the heart, especially in the mammillary region, disappearing as one passed upwards. Vesicant, calomel with digitalis. General improvement. On 22nd March, normal in ever}^ respect with exception of the anaemia and the persistent diastolic murmur. In the spring of 1869 this also had entirely disappeared, and the boy remained healthy henceforward. In the last case we see the endocarditis first appear with the exacerbation of the fever and other symptoms of rheumatism, on 29th February; while the first 9 days of the disease passed without any afiection of the heart, and we were already expecting convalescence to begin. Such occurrences are by no means rare. On 19th June, 1875, I was consulted about a boy of o years who had already been ill for a week, with acute articular rheumatism. In the middle of the second week the fever and the pains ceased for 3 daj's. Then, however, a fresh exacerbation suddenly took place, and with it an affection of the heart. Pains in the region of the heart and loud friction along the sternum, following both sounds of the heart, put pericarditis beyond a doubt. By local blood- letting, inunction with mercurial ointment, calomel and digitalis, considerable abatement of all the symptoms was brought about after 8 days ; the fever was quite gone, the friction could no longer be heard, but in its place a loud sj'stolic murmi^r was now audible. Some months afterwards, when I again examined the child, this murmur still existed. In both of the last cases the heart-affection set in for the first time along with a fresh exacerbation of the rheumatism. But cases do sometimes occur in which endocarditis appears as the first sign of the rheumatism, and the joint afi'ection is only found later on. Paul ¥., 5 years old, had been out of sorts for about 12 days, with irregular fever, loss of appetite and unusually rapid breathing. It was only 5 days ago that the phj'sician in charge had been able INFLAMMATION OF THE PERICARDIUM, ETC. 481 to discover a systolic mitral murmur, and therefrom to diagnose endocarditis. When called in on 13th May, 1875, I was able to confirm this. The boy complained on this day for the first time of pains in the limbs, and in the evening an attack of multiple rheumatism suddenly came on in the joints of the feet, knees, and arms, with severe pain, stiffness, swelling and sleeplessness. T. 102"2° — 104°. No change during the next few days. Digitalis tried and found useless. From 26 — 27th May the rheumatism spread to other joints. Extreme dyspnoea; sternum and neigh- bouring parts dull on ])ercussion, heart-sounds and murmur weaker, so that a complication with pericardial effusion seemed probable. Death on 3rd June from rapid increase of this con- dition, the pulse becoming small, the skin cyanotic, and the area of dulness rapidly extending. Post-mortem refused. Here, then, you see the endocarditis not following the onset of acute articular rheumatism, but preceding it by at least 5 days; for I am of opinion that the indefinite illness which the boy had suffered from for 12 days was due to the endocarditis, oven although its presence could not be discovered on physical examination. So long as the endocarditis does not affect the valves or the openings, no abnormal mm-murs may be present. Indeed it is proved by certain cases of endocarditis ulcerosa in adults — e.'j. during the puerperium — that even ulcerative lesions of the valves may exist without being accompanied by adventitious sounds. I shall never forget the wife of a medical man> who for at least a fortnight presented no symptom beyond general malaise and remittent rise of temperature with a very quick pulse ; no organic lesion could be made out anywhere, in spite of the most careful examination. It was only after a lapse of 14 days that I discovered a steadily increasing systolic murmur over the heart and diagnosed endocarditis, which the post-mortem examination confirmed. We find in children also cases of this kind, which for some time are not recognised, and may readily pass for typhoid. In a boy of 3, who had suffered some months before from a slight attack of rheumatism, I found endocarditis, the presence of which was only indicated by high fever (103' 1° — 104-9^ F.) during 3—4 days. It was only after that period that endocardial murmurs were heard, and they were soon followed by friction. The case last given was quite similar to this one (Paul F., p. 480). The occurrence of rheumatic pericarditis, which appeared as a compHcation in both cases and Avhich is by 482 DISEASES OF THE CIRCULATORY ORGANS. no means rare, may render the diagnosis difficult owing to the addition of its auscultatory signs. Emil P.. 11 years old, about whom I was consulted on 19th December, 1877, had taken ill about a week before with a feverish sore throat. A few days afterwards painful swelling and immo- bility of both ankles and knee-joints, for which acid, salicyl. gi's. ivss. every 3 hours, was given with good results. Since the 17th, sudden violent pains in the left side of the chest and increased fever. P. 132 regular. There was a loud systolic murmur at the apex which became less distinct above, and at the same time a friction-sound over the lower half of the sternum accom- panying both sounds of the heart, and extending beyond the epigastrium, and as far as the mamma. Percussion unaltered. Blister between the nipple and sterniim; digitalis. Eight days later the fever and pericardial friction had disappeared. The endocardial murmur, however, remained unchanged, and the boy still complained of sharp pains, and a feeling of oppression, and was often obliged to stop for breath in the midst of talking. Pot. iod. On 3rd January, 1878, the child was well, but for rheumatic pains in the left shoulder. The mitral murmur was still present for 2 years after, so that there must have been permanent valvular disease. Carl S., 8 years old, took ill in the end of December with a slight attack of articular rheumatism. A few days after, endo- carditis set in (high fever, quick breathing, pains in the left side of the chest, and loud blowing murmurs, accompanying both sounds of the heart). Ice-bag and digitalis. After some days no heart- sounds could any longer be heard, but only two murmurs. Blister. Two days after, the murmurs were less loud, and both sounds of the heart could again be made out ; at the same time, however, there was pericardial friction at the middle of the sternum and at its right border. The cardiac dulness now gradually ex- tended beyond the sternum, and on the 13th January reached to about f inches beyond its right border, while the dyspnoea Avas considerably aggi-avated by the occurrence of p 1 e u r o - p n e u m o n i a of the left lower lobe. P. 150 pretty full ; E. 50 — 60. Dry-cupping, digitalis, wet compresses, ice-bag over the heart when the pain was severe. Although the disease had taken the form of pneumonia migrans, and had affected the left upjier lobe by the 17th, there nevertheless occiirred, to our surprise, a gradual improvement of all the threatening symptoms. The pericardial friction had dis- appeared l)y the 15th. The enlarged cardiac dulness (pericardial effusion) receded within its normal limits, and by the 27th the child was able to leave his bed. The striking fact remained, how- ever, that the apex beat could always be felt | — 1^ inches outside the left nipple line, even when the child was lying on his right INFLAMMATION OF THE PEKICARDIUM, ETC. 483 side (adhesion). Several years after, I found on examination all the symptoms of incurable valve-disease. In both cases, then, pericarditis was added after a few days to an already-existing rheumatic endocarditis. And the results of this disease, if we are to judge by the physical signs, may indeed appear to be recovered from more satisfactorily than those of endocarditis, but still adhesions of the two layers of the peri- cardium, or of the pericardium to the pleura, may be left behind. As a rule, when pericarditis sets in, we find the friction first over the base of the heart, while the systolic murmur is most generally found at the apex. As to the relationship between chorea and rheumatic heart- affections, I have already given my opinion (p. 207), to the efiect that both chorea and endocarditis rise from the same source — namely, from rheumatism — but that the former is not to be regarded as depending on the heart-disease alone. I would further call your attention to the fact that the fundamental rheumatic condition may be very trifling, and may even be quite overlooked, especially in children who are only suff'ering from vague muscular and articular pains. Likewise, that the secondary endocarditis and chorea may be the first conditions that come to the knowledge of the physician ; and he is then inclined to attribute the neurosis to the former alone. Scarlet fever may cause endocarditis, although much less fre- quently than rheumatism does, and may leave behind a permanent valvular lesion. Although we must not regard every passing systolic murmur that occurs during the course of scarlet fever as a sign of endocarditis,^ still it cannot be doubted that it is such when the murmur continues for some time unchanged and is accom- panied by a feverish condition. We observe this complication both during the fever itself and in the course of the subsequent nephritis. Willy K., 5 years old, admitted on 1st February with scarlatina simplex. The fever, which persisted without ascertainable reason during the desquamation temp. (m. 101'3° ; ev. 102-9° F.) ' Any high fever may, as is well known, make the first sound of the heart temporarily prolonged or even blowing. We must also guard against mistaking for a heart-murmur a harsh respiratory mvirmur which occiirs in cases where the breathing is much accelerated. 484 DISEASES OF THE CIRCULATORY ORGANS. fell in end of the second week to 10ro° F. in the evening, and the child felt quite well. On the 12th February, a short systolic murmur was heard over the heart for the first time. This became every day more distinct, and was especially loud in the region of the ape?c, and the jiulmonarj' second sound was somewhat accentuated. Apex-beat and dulness normal. P. 136, somewhat irregular. During the next few days we heard, l)esides the systolic murmur, a short crackling sound to the left of the sternum, on the level of the third rib, during the height of inspira- tion ; but it was often also synchronous with the systole. The origin of this sound was the less clear to me, because, during the next few days, it was sometimes audible, and sometimes had disappeared. As, however, the temp, again rose in the evening during this time to 103'6° F., I ordered 6 wet-cups to be applied to the prjBcordium, and gave calomel and digitalis. From the 17tli only slight rise of temperature in the evening ; pulse normal, the systolic murmur becoming weaker. After the child had gone through an attack of nephritis, with oedema and ascites, the murmur at the apex was still audible on 22nd April; on the 2C)tli it had quite disappeared. That tliis was really a case of scarlatinal endocarditis (and, indeed, of slight pericarditis also), is proved by the persistent fcver, the rather quick irregular pulse and the systolic murmur, which took two months to disappear entirely. It is to this long duration and slow disappearance of the murmurs that I attach an especial significance, such as cannot be claimed for merely temporary murmurs. Thus, in the course of scarlatinal nephritis I have observed two cases in which there was a mitral systolic murmur, only audible for 24 — 36 hours. In one of the cases this was associated with irregularity of the pulse, and dis- appeared without leaving a trace. In other cases, again, there was a reduplication of the first sound or a '"'galloping rhythm " of the heart-sounds, which lasted some days or even weeks, and then disappeared without leaving a trace. Further, in a case of scarlatinal synovitis of the acromio-clavicular joints ending in suppuration — in which the diagnosis was confirmed post- mortem—there was a systolic murmur which was only heard during the highly febrile onset of the disease, but had ceased to be audible by the following day ; and at the post-mortem the valvular apparatus appeared quite normal. On the other hand it cannot be denied that the scarlatinal joint-afi"ection, like the rheumatic, is apt to be associated with inflammatory INFLAMMATION OF THE PERICARDIUM, ETC. 485 processes iu the endocardium, less commoüly in the pericar- dium. Richard Sch., years old, admitted into the ward Avith scurltt fever on 14th February. Complication with slight bronchial catarrh ; heart quite unaffected. On 19th, beginning of desquama- tion, fever still continuing (ev. 102-6° F.), owing to the presence of bilateral cervical adenitis and of right-sided otitis. On 22nd (T. ni. 103-8°; P. 108) we heard over the heart a distinct systolic murmur, especially loud at the level of the 4th costal cartilage and the left border of the sternum ; area of dulness normal, u])cx- beat in the 5th intercostal space abnormally distinct. On the following day, pain in the joints of hands and feet, but no swelling (T. ev. 104-4" ; P. 100—104). During the next few days, pains also in the knees, hips, elbows, and shoulders. After 2titli. abatement of all the symptoms and disappearance of the murmur On 1st March, nothing to bo made out beyond the ordinary so-called '* galloping rhythm." From then till the 25th A])ril (on which day the child Avas discharged) no abnormality aysis observed. Similarly, iu a child Avho Avas suffering from simple scarlatina, 1 observed a fresh exacei-bation of the fever (to 102-6° F.), with the onset of synovitis in the joints of the hands, fingers, and feet, during the second week of the disease ; and, 4 days after, a loud systolic murmur at the apex, Avhich Avas still present Avhen tlic child Avas dischaj-gcd from the Charite. That under these circumstances chorea may also set in, I have already mentioned (p. 210), and I have given one of my cases— which, hoAvever, does not prove that the latter depends upon the endocarditis. For chorea has also frequently been observed as a result of scarlet fever Avhere there was no synovitis and no heart-disease. In considering this fever I shall again have to speak of scarlatinal endocarditis. Pericarditis (which on the Avhole is commoner in children than in adults) may arise from morbid conditions of neigh- bouring parts by the extension of the inflammatory process from these to the pericardium — especially from left pleurisy, less commonly from right pleurisy, pneumonia and caries of the ribs^ — as Avell as from the causes already mentioned (rheumatism, scarlet fever). At the same time there occasionally occurs sero-fibrinous or purulent effusion in the pericardium ; but, when the disease is chronic, extensive adhesion of the heart ' Cf. tlie cases given on pp. 424 and 426. 48Ö DISEASES OF THE CIRCULATORY ORGANS. to the pericardium is commoner. And this condition is not uufrequently left behind after absorption of the fluid effusion. I have observed purulent pericarditis along with purulent pleurisy, especially in very young children ; and in these cases the diagnosis was rendered very difficult, on the one hand by the small amount of pus in the pericardium, and on the other by the extensive dulness caused by pleuritic effusion (p. 424). Richard L., 8 months old, admitted into the ward 10th March. Rickets, very rapid, noisy breathing ; face distorted with jjain on coughing. Over the left side of the chest absolute dulness and bronchial breathing. No displacement of the heart to be found ; heart-sounds pure. T. 997° F. ; P. 140; R. öO. During tlie next few days the bronchial breathing in front disappeared ; the breathing was now no longer audible, and the dulness extended about I inches beyond the left border of the sternum, although I was unable to make out any distinct displacement of the heart to the right. Exploration by means of a hj-podermic s^n-inge on two occasions yielded no result. The temperature almost always remained subnormal (96-8o— 99-0° F.); R. -54^60; P. varying much (108 — 156) extremely small. The increasing collapse pre- vented any operative procedure. Death on 21st. At the post- mortem we found the whole left pleural cavity filled with purulent effusion. Compression of left lung; fibrino-purulent pericarditis (pericardium not much distended, containing two or three table-spoonfuls of jDure pus; both surfaces covered with recent fibrinous lymph). Endocarditis also may develope under these circumstances. In a girl of 3 to whom I have already alluded (p. 424) I found, besides an old encapsuled pleuritic effusion of the right side, considerable adhesion of the layers of the pericardium, and very marked thickening and incompetence of the mitral valve, with stenosis of the ostium venosum which had even been diagnosed during life. In two other children of 2 and 4 years suffering from extensive broncho-pneumonia of the left lung, there occurred an endocardial systolic murmur which lasted in one case till death, and in the other till after recovery from the lung-affection at least. Tuberculosis is to be regarded as a frequent cause of pericarditis in childhood. The occurrence of miliary or sub- miliary nodules in the pericardium, especially in its visceral layer, is, according to my experience, certainly not very common in general tuberculosis ; but pericarditis with sero-fibrinous or INFLAMMATION OF THE PERICAKDIUM, ETC. 487 blood- stained effusion occasionally occurs without these local formations. Helene W., 21 months old, admitted on 26tli May, 1883; anaemic, badly-nourished. At the lower part of the left border of the sternum, a doughy, oedematous swelling, with dilated veins. R. rapid, superficial ; much coughing. Numerous rales in both lungs. Heart apparently normal, abdomen distended. T. 103'5° F. Wet compress to the thorax. On 28th a red, fluctuating swelling appeared to the left of the ensiform process, which was opened on 29th, and half-a-pint of thin pus was let out. Drainage and corrosive sublimate dressing. On the 30th, death in a state of collapse. P.-M. — Close under the ensiform process tliere was a sinus, which admitted the finger. It had led to great undermining of the abdominal muscles, and extended downwards between the rectus and the obliquus externus abdominis to beneath the um- bilicus, and upwards as far as the left costal margin. It here ended in a fistula, which penetrated the diaphragm in the neigh- bourhood of the ensiform process immediately Ijelow the costal margin, and led into a cavity of the size of a hen's egg in the anterior mediastinum. There was another passage leading also into the mediastinum over the costal margin between the 5tli and 6th ribs, to the left of the sternum. In the mediastinum there was a completely encapsuled empty abscess-cavity, which communicated above with numerous blind sinuses, and in its thick walls there were numerous tubercles. Ribs and sternum normal. Much sero-fibrinous exudation in the pericardium (cor villo- sum), occasional tubercles in the serous meml^rane covering the heart ; valves normal. Bronchial glands caseous, in the lower lobe of the left lung a caseous mass the size of a walnut, with numerous miliary tubercles in its neighbourhood. This case seems to have begun with purulent, tubercular mediastinitis, and this apparently caused on the one hand burrowing of pus between the abdominal muscles, and on the other acute tubercular peritonitis. In the following case we find the mediastinum and pericardium free from tubercle, although acute pericarditis had arisen by extension of inflamma- tion from the left pleura, which was highly tubercular, and had in the end caused extensive adhesion of the pericardium. Such adhesions sometimes contain firm fibrinous matters, which are partly caseous and partly studded with tubercle. Pa 111 M., 8 years old, admitted into the hospital on 20th May. 1878. Formerly healthy. Said to have been feverish and oiit of 488 DISEASES OF THE CIRCULATORY- ORGANS. J : sorts for the last 8 days. Very pale. E. 36 ; T. lOl-ö« ; P. 13(3. In the region of the heart and for § inches beyond the right border of the sternum, loud friction accompanying both sounds, was to be heard. Percussion normal ; apex-beat not distinctly felt. 8 dry-cups, ice-bag, digitalis. During the next few days the patient complained much of sharp pains in the region of the heart. E. rising to 60; T. to 103-1° F. By 24th, the friction had disappeared, and the cardiac dulness now reached upwards as far as the 3rd rib, and | inches to the right of the sternal margin. Pulse very small. A blister to the region of the heart ; calomel gr. ^ every 2 hours ; after the 28th pot. iod. grs. ii. The toni- ])erature now gradually sank, only temporarily rising again to ]02'7° in the first days of June, when an attack of catarrh raised the respirations again to 60. The pulse, however, gained in strength, and, although there was no change in the percussion, wc, again felt a weak diffuse apex-beat on 6th June, and also heard both the heart-sounds cjuite pure, although weak. On 13th June avc could again hear distinct friction accompanying both sounds (E. 50 — 60 ; P. 132 — 156), and the dulness no longer reached the right border of the sternum, while on the left side it did not extend to the mammillar}' line. On 29th, the friction was still audible over the upper j)art of the sternum, while the sounds seemed pure lower down. T. in the morning normal, in the evening still 100-9° P. ; E. 28—32. On 6th July nothing was left but very faint friction over the sternum, everything else normal, and so the boy Avas discharged as cured on 7th August. In October he was again brought to the clinique on account of considerable ascites. The description of this phase of the case vrill be given under Chronic Tubercular Peritonitis — for that was what was the matter. I may only mention here that during the whole period of his residence in hosj^ital, up to 5th May, 1879, not the slightest abnormality could be discovered in the heart, in spite of frequently repeated examination. Of the conditions found at the post-mortem, I shall only mention those which are interest- ing in this connection. The Avhole left pleura cos talis thickly-studded with tuber- cles, the pleura pulmonalis less affected. The pleural cavities empty. The cavity of the pericardium entirely obliterated, by the complete adhesion of its two layers to one another, and the heart covered all over by thick fibrous tissue. On careful examina- tion we found the muscular substance at different parts of the anterior wall of the right ventricle almost entirely converted into fibrous tissue. Pericardium and heart quite free from tubercle. Valvular apparatus perfectly unaffected. The anterior mediastinum very oedematous and thickened. Also tubercular peritonitis and meningitis. In this case we find, as we often do, adhesion of the entire MYOCARDITIS. . >... 489 pcricardium, produciDg u symptoms whatever ; in particular no systolic in-drawing of the chest wall was observed in any situation. The implication of the myocardium, at least that o( the right ventricle, took the form in this case not only of ])eripheral fatty degeneration — which is common in pericarditis — l)nt of interstitial myocarditis with formation of fibrous tissue ; and this is but rarely observed in children, and could no more have been discovered cliiiically than could the adhesion of the pericardium. Quite similar to this was the case of a boy of G, who died after measles with symptoms of chronic tubercular peritonitis, and at whose post-mortem we found, besides this, tuberculosis of the pleura, lungs and liver,. and complete adhesion of the pericardium. This formed two fibrous layers studded with tubercles, between which there were some partially-softened caseous nodules. Here also nothing abnormal was discovered in the heart during life ; nor yet in the following case — which, however, had nothing to do with tuberculosis. Eichard L., 5 years old, admitted on -Itli Feln-uary. ScaiUi. lever 2 years ago; said to have been only 14 days ill (?). Much coughing and dyspnoea. Pallor and emaciation, well marked