1877.] MORE COMMON DISEASES OF EARLY LIFE. 395

Article III.- -Practical Observations on some of the more common Bis- eases of Early Life. By Charles Bell, M.D., Fellow of the Loyal College of Physicians, Edinburgh, &c.

THE CONGENITAL DISEASES.

The diseases of early life are of two kinds, the congenital and the post-partum. The congenital, as the name indicates, commence in ntero, and are generally observable on the birth of the child. They are extremely interesting and important in their character, as 011 many of them depends the non-viability of the child. They have been divided into two classes, the one comprehending the diseases and malformations which in many instances may be remedied or removed by art, and are therefore quite compatible with extra-

uterine life; the other class is irremediable by human means, and are incompatible with extra-uterine life, and in consequence they form a subject of interest more especially to the physiologist and pathologist. Our present object is, however, to consider and illus- trate the first class, and to point out the proper mode of treatment in each form of disease. But in order that we may fully under- stand the character of those diseases and malformations, it is

necessary that we should trace the development of the foetus in utero, and have a thorough knowledge of the appearance and condition of the well-formed and healthy child at the full period of pregnancy.

Until near the end of the first month of gestation, the foetus is

merely a gelatinous semi-transparent flocculent amorphous mass of a grayish colour, measuring about the tenth of an inch in length. Burton compares it to a barley-corn; Casper, 011 the other hand, asserts that it is six lines in length; that the eyes are like little points; there is an outline of the mouth, and the heart and liver can be distinguished, and are large in proportion. Walter seems to support this description, and states that the liver is as heavy as the whole body. The appearance of the ovum is more especially interesting, as

miscarriages are extremely frequent at the end of the first month of gestation, and they are liable to be mistaken for the return of the catamenia; but their true nature becomes apparent by the excessive debility which is liable to accompany them, and by the character of the discharge, which always contains clots.

The Third Month.?At this period the foetus measures 3 inches in length, and weighs, according to Dr Hamilton, three ounces. Casper asserts, however, that it weighs only one ounce. The features are still very imperfectly developed, and the eyelids are idlierent. The head is large in proportion to the body, and is leavier. The umbilical cord is more fully developed, and the jenis and clitoris are large, and the latter organ protrudes beyond

396 DR CHARLES BELL ON SOME OF THE [NOV.

the nymphse, which are thick and pulpy. The brain, the medulla oblongata, and the supra renal capsules can now be distinguished. The humerus is 3|- lines in length, the ulna is the same, but the radius is only 2? lines. The femur and tibia are from 2 to 3 lines, and the fibula-like radius is only 2?.

The Fourth Month.?According to Beck, the foetus measures at this period from 4 to G inches in length, and weighs from 4 to 5 ounces; but Casper considers that it is only from 2 to 3 ounces. The skin, according to Billiard,1 is transparent and colourless. The sex can now be distinguished without the aid of a glass. The heart is about the size of a millet seed, and is of a globular form. Haller asserts, however, that it is not apparent until the vena porta and some of the other large bloodvessels are formed, and that at first it resembles a large vein. The umbilicus is now situated near the pubis, and the intestines contain meconium of a grayish white appearance. The bones of the upper extremity are equal in length and measure about 8 lines, while those of the lower extremity are much shorter, the femur and tibia being only from 4 to 5 lines. There is no appearance of hair nor nails.

The Fifth Month.?In the opinion of some authors, the fcetus was a subject of interest merely in a physiological point of view, in consequence of the difference of opinion entertained by many in regard to the precise period when it becomes endowed with life.

Hippocrates imagined that the male fcetus became animated thirty days after impregnation, but the female not until forty-two days. According to the ideas of the Stoics, the soul was not united to the body until the birth of the child, when respiration was fully established. Previous to this taking place, the child was considered merely as "partes viscerum matris." Upon this principle the law of England seems to have been established, hence abortion produced previous to quickening is considered a minor crime, which was punished only by being put in the pillory; but when induced after quickening, it becomes a capital crime punishable by hanging. It is important to ascertain wdiether or not quickening has taken place, not only in a legal point of view, but on the grounds of humanity. This

very important fact was formerly ascertained, according to law, by means of a jury of matrons chosen at random from among those who might be in the immediate neighbourhood of the court.

According to Casper, the fcetus in the fifth month measures from 10 to 11 inches in length, and weighs about 10 ounces; but Beck asserts that it measures only from 7 to 9 inches, and weighs from 7 to 10 ounces. The nails are now distinct, and there is a slight appearance of downy hair on the head. The bile is in considerable quantity, and the meconium has a green colour. The humerus measures from 13 to 15 lines, the radius 12, and the ulna 13. The whole of the bones of the lower extremity are of the same length, measuring about 12 lines. The external ear is

1 Op. cit., p. 62.

1877.] MORE COMMON DISEASES OF EARLY LIFE. 397

now formed. The brain is still a pulpy mass, without furrows or convolutions. From this time the length of the child affords a pretty good idea of the period of gestation, as its length in inches is double the number of months.

The Sixth Month.?There is considerable difference of opinion among forensic authors in regard to the size of the fetus at this period. Casper states that it varies from 12 to 13 inches in length, and weighs from a pound to a pound and three-quarters. Beck asserts that it is only 10 inches in length, and weighs 2 pounds; and Taylor assigns from 9 to 10 inches as its length, and from 1 to

2 pounds as its weight. The skin has a purplish hue, and is

pliant, especially in the palms of the hands and the soles of the feet. The scrotum is slightly developed, but the testicles are still in the abdomen. The clitoris is prominent, and the nymphse are still protuberant. The eyelids are closed, and the eyes are covered with the membrana papillaris. There is a scanty appearance of eye- lashes and eyebrows, as well as of hair on the head. The head is more in proportion with the body, and the brain is firmer. The liver is large, and the gall-bladder contains colourless bile. The

lungs are small, pale, and compact, occupying the upper and pos- terior part of the chest. There is now a thin deposit of fat under the integuments. The heart and liver are comparatively large. The intestines contain only a small quantity of meconium. The bladder is small, and pyriform in shape.

Although all the organs are now more developed and perfect in shape, the fcetus is still not viable, and therefore delivery at this period is called abortion. Dr Eadford asserts, however, that he had a case of a child born at the sixth month which lived two years ; but he must have been deceived in regard to the period of

gestation. The Seventh Month.?The foetus is now decidedly viable, and its

organs are so far perfect that it can carry on extra-uterine life.

Delivery at this stage of gestation, however, is called premature. The skin is of a rosy hue, and in general it is covered pretty thickly with subaceous matter of white colour. The eyelids are separated, and the membrana papillaris has disappeared. The hair is dark and more profuse. The nails are more complete, and of firmer texture. Its length is 15 inches, and its weight varies from 3 pounds to 3 pounds and a half. The centre of its length is nearer the sternum than the umbilicus. The fontenelles are large. The brain is firmer and slightly furrowed. The humerus is from 20 to 22 lines in length, and the radius is from 17 to 18. The lower extremities are of equal length with the arms.

The Eighth Month.?Casper considers this the most important period in embryonic life in the forensic point of view, because, according to "

statutory declaration," the fcetus is indubitably viable. It measures 1(3 inches in length, and the centre of the body is nearer the umbilicus than to the sternum, and weighs from

398 DR CHARLES BELL ON SOME OF THE [NOV.

3 to 4 pounds. The skin is firmer, and is covered with short white hair. The testes are often on the point of passing through the abdominal ring. The vulva are separated, so that the clitoris is

exposed. The nails now reach the points of the fingers. The humerus is from 23 to 24 lines in length, and the radius is from 18 to 19, and the ulna is from 22 to 23, the femur 24, and the tibia and fibula from 21 to 23 lines. The furrows in the brain are more distinct, and the spinal cord is firmer; the lungs of deeper colour, and the liver is at a greater distance from the navel. The

gall bladder is full of yellow bile. The Ninth Month.?The ossification of the bones is now more

perfect, and the fontenelles are much diminished in size. The hair is more profuse, and of a darker colour. The length of the foetus is from 18 to 20 inches, and its weight averages in this country about 7 pounds, although on the Continent it is considerably less. Baudelocque states that foetuses of 3 pounds are more common in France than those of 9 pounds. In Paris, the extreme weights were 3 pounds and 10? pounds. I)r Joseph Clarke states that when the foetuses exceed 7 pounds they generally are male, while those weighing under this are females. Dr Croft delivered a foetus 15 pounds; Dr Ramsbotham, senior, one 16^- pounds. Dr Jewel mentions one delivered by midwife 20 pounds. Dr Owen refers to one 1 7 pounds 12 ounces, and measuring 24 inches in length. Dr Meadows, not to be beat by these marvellous cases, relates a case of a foetus measuring 32 inches and weighing 18 pounds 2 ounces. It lived only four hours. At the end of the ninth month and one week, or the tenth lunar

month, the foetus is considered to have attained maturity, as all its organs are then more developed, rendering it fully qualified for extra-uterine life. In studying the appearance of the foetus at this period of gestation, the attention ought first to be directed to the forms and measurement of the head, for on it being in due pro- portion to the diameters of the pelvis depends the safety of parturi- tion to both mother and child. In the well-formed foetus, the long diameter of the head, measuring from the os frontis to the occiput, is from 4 to 4| inches; the transverse diameter, extending from one parietal bone to the other, is 3^ inches; the oblique, or occipito mental, is 5 inches; the cervico bregmatic, extending from the summit of the head to the mastoid process of the temporal bone, is from 4 to 4| inches; the traclielo bregmatic is 3| inches. Of these various measurements, the most important are the longitudinal and the transverse, which ought to bear a due correspondence with the ordinary proportions of a well-formed pelvis. Next in importance to the measurements of the head are those

of the shoulders and nates, although they seldom offer any serious impediment to the birth of the child. When uncompressed, the shoulders usually measure from 4| to 5| inches across; while the nates is from 4 to 5 inches in this country. In Germany, however, Casper states that the diameter of the nates is only 3? inches.

1877.] MORE COMMON DISEASES OF EARLY LIFE. 399

In tlie fully-developed foetus at birth, the centre of the body is at the navel, which, according to Casper, is midway between the

pubis and the ensiform cartilage in the male ; but as age advances, it gradually approaches the pubis, where it is generally found at puberty. In the healthy child the skin is of a uniform rosy hue, indicating the activity of circulation near the surface. The redness

gradually loses its brightness, and becomes of a yellow colour, which is known to nurses as the yellow gum; although it has been erroneously considered by some authors as a species of jaundice. It is interesting to observe, that when the child is placed on a bed immediately after birth, it shows a great inclination to assume the same position it occupied when in the womb, a circumstance which seems to prove the greater strength and activity of the flexor muscles ; in consequence, tlie head is drawn towards the chest, and the limbs and upper extremities are bent upon themselves. The

precise period when the extensor and flexor muscles become

equalized so as to enable the child to assume new postures is very variable. Billiard considered that the movements of the child are at first entirely automaton, but that they gradually acquire the power of voluntary motion, when the child is enabled to stretch its hands towards objects which attract its notice; and its head, in place of rolling about like an ill-sewed-on button, becomes fixed at the will of the infant. At the same time, the eyes follow any object which attract its attention with more vivacity. It is im-

portant the mother should be fully aware of this fact, in order that she may guard against having the crib placed with its side to the light, by which the child is induced to turn its eyes in one direc- tion too often, and acquire a habit of squinting.

Having briefly referred to the gradual development of the fcetus, and to the more striking peculiarities of the well-formed healthy child at birth, we shall now proceed to examine those abnormal con- ditions which are most frequently met with in the new-born child. That the diseases which occur in the latter period of pregnancy are of serious consequence is fully proved by the number of still-born children, which in England amounts to 1 in 18 or 20 of legitimate children, and 1 in 8 or 10 of the illegitimate. In male children the mortality is much greater than among the female, being in proportion of 140 to 100.

ABSENCE OF THE SKIN.

Deficiency or entire absence of the skin is one of the most remarkable of tlie congenital diseases, and it has attracted tlie attention of accoucheurs from the time of Hippocrates, who treated of it with his usual acuteness and observation. When tlie de-

ficiency is partial, or of limited extent, there is a probability of the child's life being preserved, by the surface becoming cicatrized; but if it is extensive, or if it is accompanied by imperfection of the walls of the abdomen, chest, or cranium, the case is hopeless, and

400 DR CHARLES BELL ON SOME OF TIIE [NOV.

will prove fatal in a short time. In considering this disease, it is

important to distinguish it from the peculiar redness and exfolia- tion of the skin which occasionally occurs soon after birth, which requires scarcely any treatment hey end cleanliness and the applica- tion of violet powder, while the other demands the utmost atten- tion and skill in its treatment. It fortunately happens, however, that it is of rare occurrence.

Treatment.?When the deficiency of skin is of limited extent, and unaccompanied by any of the complications above referred to, it should be treated in the same manner as a scald. Therefore the best applications are the linimentum calcis, collodium flexile, or

medicated cotton wool. The child should be well nursed.

CAPUT SUCCEDANEUM OR CEPHALyETOMA NEONATUM.

This is the most common of all the tumours met with in the new-born child, and although in general it is extremely harmless in its character, from its appearance it is often a source of great anxiety to the mother. It ought not to be treated as of no import- ance, because it is possible that other bloody tumours of more

dangerous nature may be mistaken for it. Therefore the accou- cheur ought to be very cautious in forming and expressing his opinion in regard to it. The propriety of this is well illustrated in a case reported by Dr West, which terminated fatally. When the tumour was first seen by Dr West sixteen days after birth of the child, it occupied the whole of the right parietal bone. It was

irregular in shape, and measured 12 inches in circumference, and it had not the bony ridge which is so characteristic of caput succedaneum. He ordered it to be bandaged by means of adhesive straps, and cold lotions to be frequently applied. The child seemed to do well for a time, but died eight days after this treat- ment was adopted. On examination after death, the tumour was found filled widi coagulated blood, and there was blood effused between the cranium and the dura matter more than half an inch

thick, and occupying the entire fossa of the parietal bone, in which there was a fissure.

There cannot be a doubt that this interesting case was the result of an acci lent, which had fractured the parietal bone and ruptured a hi oodvessel.

I'r Bedford men l ions a very similar case, in which the tumour was supposed iivt to have formed until twenty-four hours after birth. It was cnly the size of a walnut when first observed; but when J )r Eedford saw it five weeks after, it was as large as half the chill's head. The true cap'ut succedaneum seldom or never attains to so great a

size as the turn ours just referred to. It is soft, elastic, and slightly fluctulent in the centre, and is surrounded by a ridge of bony hardness, which is liable to be mistaken by the inexperienced for the edge of a fractured bone. It is unquestionably a congenital

1877.] MORE COMMON DISEASES OF EARLY LIFE. 401

tumour, and it always indicates tlie presenting part of the child. It is found, therefore, almost on every part which is more especi- ally pressed upon by the cervix uteri during labour; but it is found most frequently on the parietal bones, especially the right one. It is invariably the result of pressure, hence it resembles an eccliy- mosis both in character and colour. Its duration is very variable, as it sometimes remains stationary for some time; but in general absorption commences immediately in the centre, and in conse- quence the bony ridge is rendered more distinct. The size of the tumour gradually diminishes, so that in the course of a few weeks it entirely disappears. In some instances, however, it remains for a considerable time, and is attended with a sort of crackling sensa- tion when pressed on by the finger, almost as if we were pressing a piece of tinsel. This condition led Chelius1 to consider it as

pathognomonic of ossification of the pericranium. When the tumour is large it is liable to be mistaken during

labour for the bag of waters. I once, when a very young practi- tioner, committed this error. The labour was tedious, although the patient had had a large family. When I arrived the first

stage of labour was well advanced, and 011 examination I found a large fluctuating tumour, which had quite the feel of the bag of waters. Under the erroneous impression that I should hasten the labour, I scratched what I took for the membranes, but I soon discovered my mistake and desisted. I gave a dose of ergot which soon terminated the labour. On examining the child's head I found a large bluish tumour occupying the upper part of the right parietal bone, and extending a short way 011 the occiput; and on the most prominent part there wras a slight abrasion, the mark made by my nail. The tumour remained of nearly the same size for several days, when absorption commenced, and at the end of five weeks there was no trace of either the tumour or the scratch.

Cause.?This swelling is the obvious result of pressure of the

unyielding cervix uteri; hence it is most frequently met with in tedious labour. The resistance of the cervix to the advance of the foetal head ruptures some of the bloodvessels of the scalp. The effused blood soon coagulates round the edge forming; the hard O OO

ridge, while the blood in the centre remains fluid. Treatment.?It was the custom at one time to lay open the

tumour by an incision, and to empty it of its contents, or to apply caustic for the purpose of inducing suppuration. With such treat- ment it is not surprising that many cases proved fatal. The treat- ment in the generality of cases now is to leave them entirely to nature, unless they should prove tedious, or be of unusual size, when an evaporating lotion may be employed, such as the

following:?- 1 Medico-Chirurgical Transactions, vol. xxviii. p. 410

VOL. XXIII.?NO. V. 3 E

402 DIl CHARLES BELL ON SOME OF THE [NOV.

l]c Muriat. ammonia?, 3j. Aceti diluti, :i. ss.

Sp. camphors, |j. M. ft. lotio.

In general, however, sncli applications are more for the purpose of showing that you are not neglecting the case than from their being absolutely necessary.

ENCEPHALOCELE.

This tumour differs from the caput succedaneum not only in its general appearance and character, but in its locality, being usually situated on one of the fontanelles, or one of the sutures. Foster1 asserts that it is generally situated in the mesial line at the back of the head, and varies in size from that of an egg to twice that of a child's head. When it attains such dimensions, it must be when it is complicated with hydrocephalus. It may farther be distinguished from caput succedaneum by being entirely colourless and free from fluctuation, and by its pulsating synchro- nously with the heart.

Cause.?It is the result of malformation, or deficiency in the development of the bones of the cranium, in consequence of which the brain is allowed to protrude from the skull under the

integuments. In some cases it disappears under pressure ; but this is a dangerous practice, as it is liable to produce convulsions. It is not necessarily a fatal malformation, as the bones may extend and enclose the brain; although it is decidedly a congenital imperfec- tion, it is sometimes not observed until some time after birth. It is

frequently complicated with other diseases, more especially spina bifida, hare-lip, club-foot, and softening of the spinal cord; all such

complication renders the case more hopeless and unmanageable, as they indicate a remarkable degree of imperfection in the child's constitution. In some cases the tumour is entirely denuded of

hair, and when complicated with hydrocephalus the pulsation is less apparent. It may prove fatal at an early period in conse- quence of the integuments being ruptured, an instance of which is reported by Foster,2 but it was cured. When the integuments become ruptured the case generally terminates in convulsions.3

Treatment.?A great variety of treatment has been suggested, such as excision, ligature, puncturing, and compression. The results of excision and puncturing are far from being encourag- ing, and therefore neither ought to be adopted; and although pressure has been successful in two cases, it is attended with great risk of producing fatal convulsions. The use of the ligature has long been laid aside in consequence of the danger attending it.

The mode of applying pressure is by means of a plate of ivory, silver, or lead, which should be retained on the tumour by a band-

1 Op. cit., p. 307. a Op. cit. et loci. 3 Coley, op. cit., p. 402.

1877.] MORE COMMON DISEASES OF EARLY LIFE. 403

age. Some have suggested, in place of either of the above- named substances, that a piece of leather softened in water

should be bound down on the tumour. Underwood recom-

mended that a piece of sheet-lead pierced with holes should be sowed in the inside of the child's cap.1 This idea is now out of date, as it is not the custom in the present day for children to wear caps.

If pressure is to be had recourse to, it ought to be extremely gentle at first, and increased very gradually; at the same time great attention must be paid to its effects, lest convulsions come on, in which case it must be removed. But if it is not attended by any unfavourable symptoms, it should be continued until the tumour sinks below the level of the bone, when it is possible that ossification may extend and a cure be accom-

plished. Meningocele.?This is a tumour which communicates with the

brain, and partakes very much of the same nature as encephalocele. It is formed of the membranes of the brain, and is filled with fluid. It may be complicated with encephalocele. According to Mr Holmes, the cause of both these diseases appears to be hydro- cephalus

"

causing a protrusion of the membranes of foetal cra-

nium." " Therefore in all cases of encephalocele or meningocele it is to be apprehended that it is more or less hydrocephalus," and that the tumour " is part of one of the ventricles," or communicates more or less directly with them, and that dropsy of that part of ihe brain exists. The anatomy of these tumours embraces?1st, their situation;

2d, their form ; 3d, their contents. The ordinary situation is in the occipital region, and it protrudes through the expanded portion of the occipital bone behind the foramen magnum. The bridge which separates the tumour from the foramen magnum is only mem- branous in general; and in some cases the tumour passes through the foramen itself. Although the occiput is the most common situation of these tumours, they may occur through any of the sutures.

It is of importance to observe the form of these tumours, as on it depends our forming a correct diagnosis as to the chance of

effecting a cure. Their contents are also of importance in this respect. If pulsation be felt in them, it is obvious that they contain cerebral matter. They are sometimes almost transparent like

hydrocele, in consequence of their containing merely subarach- noidean fluid. But even in such a case there is no certainty that they do not retain a portion of the brain which extends just beyond the cranium, the tumour being a combination of encephalocele and meningocele.

If the tumour is pedunculated and transparent, it is probable it is a simple meningocele ; but if it is sessile and pulsating, it is

1 Op. cit., p. 555.

404 DR CHARLES BELL ON SOME OF THE [NOV.

undoubtedly an encephalocele. This will be rendered more cer- tain by pressure, when cerebral symptoms will be prolonged.

Treatment.?When there is reason to suppose that a portion of the brain forms a portion of the tumour, an operation would be certainly fatal; our only remedies, therefore, are evaporating and cooling lotions.

CYANOSIS, OR BLUE DISEASE.

This disease is discovered very soon after birth, and is indicated by the blue colour and low temperature of the skin; occasional

difficulty of breathing, during which the skin becomes of a deeper tint; the pulse is intermittent, and sometimes deep syncope comes 011: succession of these paroxysms may recur until death closes the scene. They may be of a milder character, and the child's life may be prolonged. If this is the case, whatever agitates the child, or hurries its circulation, is apt to bring 011 a paroxysm of more or less severity.

Cause.?It was believed by most authors that this disease was the result of the foetal condition of the heart and bloodvessels ; but many modern authors have opposed this opinion. Corvisart informs us that he has met with this disease when there was no malformation of the heart; or, in other words, when there was no communication between the right and the left sides of the heart by means of the foramen ovale. On the other hand, Dr J. Crampton refers1 to cases in which "there was 110 blueness, although the opening between the auricles and ventricles must have been unclosed for many years." Billiard supports this view of the

disease, and he reports many dissections of cases in which children had died at different ages, and in all of them the foramen ovale and the ductus arteriosus were quite patent.2 He therefore con- siders that this disease depends 011 imperfect oxygenation of the blood, which may arise from causes quite irrespective of any malformation of the heart. This celebrated author has divided his researches 011 this subject into the following heads, namely, the period at which the foetal openings are obliterated, their mode of obliteration, and the physiological and pathological consequences resulting from these changes.

1st. The Obliteration of the Foetal Openings. In nineteen

children, he found at the age of one day the foramen ovale com- pletely open in fourteen; in two it had begun to close, and in two it was closed. In the same children the ductus arteriosus was free and filled with blood in thirteen; in four it began to close, and in two it was completely closed.

In twenty two children of two days old, fifteen had the foramen ovale perfectly open; it was partly closed in three, and entirely closed in four. The ductus arteriosus was open in

1 Maunsel and Evans, p. 197. 2 Op. cit., p. 444.

1877.] MORE COMMON DISEASES OF EARLY LIFE. 405

thirteen; in six it bad begun to close, and in tbree it was

entirely closed. In twenty two cliildrcn three days old, tbe foramen ovale was

open in fourteen ; in five it was partially open, or rather oblitera- tion had commenced; and it was entirely closed in three. The ductus arteriosus was open in fifteen ; obliteration had commenced in five, and it was completed in two, in which the foramen ovale was also closed.

In twenty-seven children of four days old, the foramen ovale was open in thirteen, but not to the same extent in all. The ductus arteriosus was open in fifteen.1

Casper corroborates these facts by stating that " the foramen

ovale is not fully closed before the second month ;" and " the duc-

tus arteriosus is perfectly pervious for the first three or four days." 2

From these facts it is obvious that cyanosis is not entirely the result of the fcetal state of the heart and bloodvessels, and therefore we must look for some other cause; and it is probable that it will be found in some circumstances with the undue oxida- tion of the blood, and that the seat of the disease is in the lungs, and bears a striking similarity in its nature to atelectasis.

Treatment.?The most satisfactory mode of treating this disease, and the only one which gives the slightest hope of benefit, is to

give the advantages of pure air and a good nurse, at the same time the child ought to be warmly clothed, and every means used to keep up its temperature. Although the child's life may be pro- longed for a few years, experience gives no hope of a thorough cure, and too often its life is one of great distress to itself and anxiety to others, from the frequent occurrence of the paroxysms already described.

ATELECTASIS PULMONUM.

This disease was first described by J org, who gave it its peculiar name. It was at one time considered a rare disease, but Taylor3 statesthatit is of more frequent occurrence than is generally supposed. It is clearly the result of a congenital imperfection of the lungs, which prevents their becoming fully expanded by respiration. The defect is most frequently met with in the posterior lower edge of the inferior lobes, the middle lobe of the right lung, and the lower edge of the upper lobes. The parts affected have a purple appearance, and are depressed under the sound parts of the lungs. They are solid to the touch, and they convey neither a feeling of friability nor crepitation on being pressed; and when cut into

they have a hepatic smoothness. They emit no air-bubbles when put in water, and immediately sink, having in every respect the character of the fcetal lungs. As in cyanosis, the foramen ovale and

1 Op. cit., p. 473. 2 A Handbook of the Practice of Forensic Medicine. Trans, by Dr Balfour,

vol. iii. p. 85. 3 Op. cit., p. 438.

406 DIl CHARLES BELL ON SOME OF TIIE [NOV.

ductus arteriosus are still open. The breathing is feeble and op- pressed, and the child is unable to suck, although it swallows when liquid is put into its mouth. If it cries, its voice is weak and has a wailing or whimpering sound. The skin is pale or has a leaden hue. The infant moves its limbs feebly, and in general it lies in a relaxed and drowsy state. In the more favourable cases all these symptoms gradually disappear, the breathing becomes less oppressed, and is slower and fuller, and in time the child acquires the power of sucking, and its strength improves, and it moves more freely, and its voice is more natural. These favourable symp- toms are rare, however, and it far more frequently happens that the weakness increases, and the child sinks or dies in convulsions.

Meigs states that even in the most favourable cases, in which the alarming symptoms disappear early, they are very apt to return, and the child remains long in a feeble state

1

Cause.?This is most uncertain, and in consequence it has been supposed to arise from a variety of causes, such as natural debility of constitution, multiple pregnancy, excessive labour, and when it comes on long after birth, it may be the consequence of impure air, close atmosphere, or too heavy clothing.2

Treatment.?The great object of our treatment is to produce full expansion of the lungs. For the accomplishment of this some

very questionable remedies have been suggested. Maunsel and Evanson have advised that we should endeavour to promote more perfect respiration by means of friction, and stimulating the intes- tines by castor oil, or if there is much mucus obstructing the bronchi, it may be advisible to excite vomiting by administering a drachm of the vini ipecacuanha^.3 To give an emetic to a child in such a feeble condition as has been represented, would be a very hazardous proceeding, from the great depression likely to be induced. There-

fore, if it is necessary to clear the chest by means of vomiting, it ought to be effected otherwise than by an emetic, and probably irritating the fauces by means of a feather or camel-hair pencil would be better. Meigs4 recommends invigorating remedies, such as keeping the nursery at the temperature of 70? or 75?, putting warm clothing on the child, at the same time putting it in an inclined position, the head and shoulders being raised to an angle of 45?. A good nurse should be got for the child, and if it cannot suck, it should be fed with her milk by means of a spoon until it is able to take the breast. Five drops of brandy should be put in the milk and given occasionally. Huxham's tincture of bark, or quarter of a grain of quinine, may be given three times a day. Electricity might be used with advantage, also artificial respira- tion. Dr West relates an interesting case of this disease which occurred

in a child of three weeks of age, which, however, proved fatal.5 1 Diseases of Children, p. 114. 2 Meigs, op. cit. p. 23. 3 Op. cit., p. 182. 4 Op. cit., p. 114-23. 5 Op. cit., p. 267.

1877.] MOliE COMMON DISEASES OF EARLY LIFE. 407

ASPHYXIA NEONATORUM, OR STILL-BORN.

A cliild may be still-born from two distinct causes, although the symptoms may be very similar. In the one case, Cruveilhier1 in- forms us that the asphyxia arises from engorgement of the brain, the result of tedious labour and long-continued pressure of the fcetal head; in the other case, the respiration is temporarily sus- pended by debility and want of energy on the part of the child. This powerlessness may continue for some time, and if not properly managed may prove fatal.

Treatment.?It is of importance for the accoucheur to distinguish between the two causes of asphyxia, for the treatment which may be beneficial in the one case would be most injurious in the other. The appearance of the child in general at once indicates the true nature of the case. If the asphyxia is the result of congestion, the child will be strong and robust-looking, and its face will have a swollen and deep-purple hue. If the cord is still pulsating, it

ought to be cut, and allowed to bleed to a greater or less extent, according as the respiration improves. It is seldom necessary, how-

ever, to allow more than one or two teaspoonfuls of blood to escape. When exhaustion is the cause, the child will be pale and feeble, its mouth open, its limbs flaccid and relaxed, and the cord pulseless. In such a case the child should be separated immediately, its mouth and throat freed from mucus, and artificial respiration in- duced. This may be done either on Marshall Hall's plan, or the child should be put alternately into hot and cold water, and have stimulants applied to its nose, and the breast rubbed with spirits. The efforts to induce respiration should be continued for some time, as they may ultimately prove successful, a circumstance which was fully verified in a child I recently delivered. It gave scarcely any sign of life for upwards of an hour, but by continuing the treatment here recommended it ultimately revived and became a healthy child. The following case, reported by Maunsel and Evanson, holds out increased encouragement to persevere in the means of resuscitation for at least an hour. The child, having been born by spontaneous evolution along with the placenta, seemed to be still-born, and in consequence

" it was placed in a corner of the apartment without being separated from the pla- centa, and allowed to remain exposed to the cold air for nearly an hour, when, upon an accidental examination, the heart was found to beat feebly, and the proper means being employed, resuscitation was effected, and life prolonged for twenty-four hours."2

1 Anat. Pathologique, liv. 15, p. 1. 2 Diseases of Children, p. 179.

(To be continued.)