RETROSPECT.

41

ON CHILDREN'S DISEASES.

BY ANNIE E. CLARK, M.D.

1. On the influence of the season of the year on the frequency of Rachitis.-By Dr. Rudolph Fischl (Prag. Med. Wochenschr., XIII., 4, 1888).—Dr. Fischl has observed that the number of cases of Rachitis increases steadily from January until May, when the number declines again until December. He considers that this points to the importance of fresh air in rachitis, the disease becoming most prevalent when the children are confined in close rooms.

2. Dyspepsia and the Green Diarrhea of Infants. (Revue de Méd., Dec. 1887, and Jan. 1888).—Dr. A. Lesage, in a series of articles, calls attention to the importance of making sharper distinctions in the treatment of infantile diarrhoea. He makes the following classification :—

:

1. Acute Diarrhoea : (a) Alimentary, in which the stools are yellow, small in amount, and containing much undigested food : in these cases purgatives are indicated. (b) Infectious. The stools are frequent, yellow, neutral or acid in reaction, often foetid, and contain large numbers of microbes. Intestinal antiseptics, preceded or not, by a purgative, is the treatment for this form. Dr. Lesage considers lactic acid the best antiseptic to give. He gives a teaspoonful of a two per cent. solution every quarter hour to an hour according to the frequency of the stools.

2. Lienteric Diarrhoea.-In this the stools are white at first and of some consistency; later they are liquid, but still white, unless occasionally green with bile. Astringents, opiates and alkalies will do no good, the trouble lies in an alteration in the secretion of the

Pancreatine or trypsine

pancreas, and sometimes of the liver.

should be given.

3. Reflex Diarrhoea from Dentition. The stools are serous, yellow, and do not contain food. Opiates, rhatany, and lactic acid are the best drugs for this form.

4. Green or Bilious Diarrhoea.-The stools are green and very acid. This type often occurs during the first month. Purgatives do no good. Alkalies should be given, such as Sod. Bicarb. and sometimes opiates and astringents must be added.

5. Green Bacillary Diarrhoea.-The stools, though green, do not contain bile, but a specific bacillus ; they are but slightly acid. Fever is often present with it. This form is rare before the first month, and very often occurs in epidemics. Lactic acid is the best antiseptic for it.

3. Intubation of Larynx.-F. E. Waxham, M.D., Chicago, read a paper at the ninth International Medical Congress strongly advocating this operation. He asserts that it saves as large a proportion of cases as by tracheotomy in all ages, and a much larger proportion among children under three years of age. In proof of this he reports 1,007 cases with 266 recoveries, or 26'54 per cent. The age was recorded in 661 cases, namely, 277 patients under three years of age with 49 recoveries, or 17.68 per cent., and 384 patients over three and under fourteen years with 132 recoveries, or 34'37 per cent.

In the New York Med. Rev., Oct. 29th, 1887, Dr. O'Dwyer gives a table of fifty cases of croup, in private practice, treated by intubation of the larynx, with a description of the method and dangers incident to it. In no case was intubation resorted to until the dyspnoea was so urgent as to indicate impending suffocation. Of the fifty cases twelve recovered after wearing the tube for a time varying from two days to ten. The average time in favourable cases was about five days; but age must be considered in determining the removal of the tube-the younger the child the longer it will need the tube.

When loose membrane exists below the tube-indicated by

a flapping sound with a somewhat croupy cough-the tube must be left in position until the membrane has had time to dissolve and disappear. The tube should be removed whenever urgent secondary dyspnoea occurs. Each attempt at introduction of the tube should be limited to ten or fifteen seconds, or there will be danger to the patient of apnoea.

Coughing out the tube before the stenosis has been permanently relieved is seldom attended with danger, as the dyspnoea is usually relieved for some hours. In one case in which the child swallowed the tube it was passed per rectum the third day.

Among the difficulties and dangers of the operation which Dr. O'Dwyer points out is the difficulty of performing it, which, unless unusual manual dexterity and knowledge of the anatomy of the parts is possessed, can only be overcome by frequent practice on the cadaver and the digital examination of the larynx of healthy children. Without this skill and knowledge, even if the operator succeeds in inserting the tube, he risks either injuring the soft parts or perforating the trachea, and will have difficulty in extracting the tube, especially when the head of it rests low down in the larynx,

There is also the danger of peeling up and pushing the membrane down ahead of the tube and thus occluding it, in this case the tube must be immediately removed, when, if the membrane is not ejected, the trachea forceps devised for the purpose may be introduced and the membrane removed, or tracheotomy must be performed.

The tube may cause difficulty in swallowing, which can be met by great care in the selection of the tube, which should always be too small rather than too large a tube; the food given must be semi-solid. The employment of a tube with an artificial epiglottis is also of great service in swallowing.

CARDIAC DISEASES.

BY EDGAR HOGBEN, B.A., M.D.

The Presystolic Murmur.-An accepted canon in cardiac medicine has recently been made the subject of attack at the hands of Dr. Dickinson. The discussion upon the method of production of the presystolic murmur has been generally regarded as finally settled in the view that the sound is generated at the mitral orifice by the systolic movement of the auricle, and that it preceded both the systolic movement of the ventricle and the natural first sound of the heart. In an able paper in the Lancet, 1887, vol. II., pp. 650, 695, Dr. Dickinson combats the accepted explanation. He believes that the ordinary presystolic bruit is really ventriculo-systolic in point of time on the grounds that both the murmur and thrill may be demonstrated to be coincident with the early part of ventricular systole. Besides the often advanced objection that auricular contraction is too weak and brief to cause the loud, harsh, characteristic bruit in question, he also points out that in the case of double mitral disease, obstructive and regurgitant murmurs which ought to be distinct are inseparably blended, the presystolic running continuously into the systolic. In this connection he contrasts the double murmur in lesions of the aortic valves, in which case the two murmurs are separated by a short interval corresponding to the point of time at which the reversal of the blood current takes place. He describes the characteristic R-r-r-p (so called presystolic) murmur as indicating regurgitation through a stenosed but ultimately closing mitral orifice, and he recognises the true mitral obstructive murmur which accompanies ventricular diastole and follows the second sound of the heart as the only true auriculo-systolic.

On the other hand, Dr. Bristowe entirely accepts the orthodox explanation of the production of the presystolic murmur, and in a paper contributed to the Lancet, 1887, vol. II., pp. 952, he vindicates its position as auriculo-systolic, and he points out at the same time that the murmurs of obstructive mitral disease, of

which there are three, viz: early, middle, and late diastolic, may be regarded as parts of a potential murmur filling up the whole diastolic period. "They are the fitful, and in a sense accidental, roarings of a continuous torrent."

Failure of the heart in valvular disease.-Dr. Mitchell Bruce, in the Practitioner, Jan. 1888, discusses the etiology, prognosis, and treatment of a train of symptoms of cardiac distress which is regarded as evidence of the occurrence of failure of the heart. Among the causes of imperfect compensation he enumerates: (1) muscular overwork; (2) nervous causes; (3) imperfect blood supply, either from a general impoverished condition of the blood, or from disease of the coronary arteries; (4) the occurrence of intercurrent maladies, more especially rheumatism and lung diseases; (5) causes peculiar to women; (6) cardiac poisons; (7) increase of the valvular lesion from a fresh accession of endocarditis; (8) the limit of compensation. The prognosis of course varies in individual cases, and the author deprecates routine methods of treatment.

Presystolic murmur in cases of Aortic Regurgitation without mitral lesion.-Some years ago, Dr. Austin Flint called attention to the occurrence of a presystolic murmur in the mitral area in certain cases of aortic regurgitation without mitral lesion. His explanation of the clinical fact was that the regurgitant stream caused a complete closure of the mitral orifice by floating up and approximating the valvular curtains, and that the mitral direct stream in passing between the curtains thus brought in contact throws them into vibration and gives rise to the characteristic "blubbering" murmur. Dr. Byrom Bramwell, in the American Journal of the Medical Sciences, March 1888, records a case of aortic regurgitation with a presystolic thrill and murmur in the mitral area. He is persuaded that no mitral stenosis existed in the case from the fact that cardiographic tracings showed a rapid elevation of the lever after the diastolic fall with the production of an unusually large wave in the diastolic portion of the tracing. This large wave, according to Dr. Bramwell, suggests that the rapid filling of the left ventricle was not merely due to aortic regurgitation, but was in