Clinical Pediatrics

Front matter

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CLINICAL PEDIATRICS

By

SECTION I PAGE CoNGENITAL MALFORMATIONS . 17

Meningocele, Encephalocele and Hydrencephalocele, 17—Malformations of the Cranium, 19—Protrusion of the Ears, 19—Cervical Fistule and Cysts, 19 —Cystic Hygroma of the Neck, 20—Harelip, 21—Cleft Palate, 2 1—Ranula, 22—Congenital Hypertrophy of the Tongue, 22—Tongue-tie, 22—Congenital Malformations of the Chest, 22—Spina Bifida, 23—Diaphragmatic Hernia, 27—Congenital Laryngeal Stridor, 28—Congenital Malformations of the Esophagus, 29—Congenital Malformations of the Stomach, 32—Congenital Malformations of the Intestines, 39—Congenital Malformations of the Bile Ducts, 41—Congenital Cystic Kidneys, 43—Congenital Malformations of the Urachus, 43—-Congenital Malformations of the External Genitals, “a To oan Malformations of the Extremities, 48—Nevi, 50—Mongolian pots, 51.

SECTION II inte INJURIBS. . .. 2.4. % 2 the New-born, 57—Visceral Hemorrhage in the New-born, 59—Fractures, 60.

Section III

Disnases or THE New-BORN........ 61 natorum, 61—Sclerema Neonatorum, 62—Diseases of the Navel, 63—Inflammation of the Umbilical Vessels, 64—Septic Infection of the New-born, ‘65—Pemphigus Neonatorum, 68—Dermatitis Exfoliativa. Ritter’s Disease, 69—Erysipelas Neonatorum, 69—Intestinal Toxemia of the New-born, 70— Icterus Neonatorum, 72—Erythema Neonatorum, 73—Dehydration Fever of the New-born. Inanition Fever, 74—Hemorrhagic Disease of the Newborn, 75—Congenital Atelectasis of the Lungs, 79—Uric Acid Infections, 81 —Umbilical Hernia, 82—Ventral and Epigastric Hernias, 83—Inguinal Hernia, 84—Femoral Hernia, 86.

Section IV

LR ENRON cb he ge RR BS, 4p oes er ce ee es ere ee ef Growth and Development, 87—Food Requirements of Infants and Children, 97—Physiology of Digestion, 105—Bacteriology of the Digestive Tract, 109—The Stools in Infancy and Early Childhood, 112—Breast Feeding, 120 —Chemistry and Biology of Human Milk, 120—General Considerations and Technic, 123—Wet Nurses, 139—Artificial Feeding, 142—Chemistry and Biology of Cow’s Milk, 142—Principles of Artificial Feeding, 147— The Prescribing of Modified Milk, 166—Special Preparations of Milk and the Proprietary Foods, 178—Feeding During the Latter Part of the First Year and in the Second Year, 187—Feeding after Two Years, 190.

SECTION V ites OneN TERI TION eee ts seen eo ee eel. ee Ue ee 199 Malnutrition, 199—Obesity, 202—Premature Infants, 204—Seurvy, 212— Rickets, 221—Spasmophilia, 233—Acid Intoxication, 238.

14 CONTENTS

SECTION VI PAGE Moutm .°. poh es ns ie, ae ee chs ge ees ian ie 244—-Aphthous Stomatitis, 245— Ulcerative and Gangrenous Stomatitis and Noma, 246—Thrush, 248—Disturbances of Dentition, 249.

SECTION VII 252

ISHASES OF THD. GASTRO-ENTERIC TRACT... > « . % +0: = 4 =) e as Sola : Perechanieal’ 253—Contraction and Dilatation of the Stomach, 253— Dilatation of the Colon, 254—Intussusception, 258—Fissure of the Anus, 261— Prolapse of the Rectum, 261—Hemorrhoids, 262—Traumatic, 262—Gastric and Duodenal Ulcers, 262—Nervous, 263—Nervous Disorders of the Gastro-enteric Tract, 263—Spasm of the Pylorus, 265—Disturbances of Digestion, 268—Indigestion in Infancy, 269—Indigestion in Childhood, 291—Infectious, 299—Infectious Diarrhea, 299—Cholera Infantum, 309—Chronic Colitis, 311—Proctitis, 312—Appendicitis, 313—Unclassified, 319—Recurrent Vomiting, 319—Constipation, 323—Incontinence of Feces, 331—Intestinal Parasites, 332.

SECTION VIII

Tun Spuctric Inrecrious Dismasts. . 2. . 1). = ste apa a ee Tuberculosis, 337—Syphilis, 361—Influenza, 373—Typhoid Fever, 377— Malaria, 386—Whooping-cough, 388—Diphtheria, 397—Mumps, 411— Scarlet Fever, 415—Measles, 425—German Measles, 433—Infantile Roseola, 435—Chicken-pox, 436—Vaccinia-Vaccination, 439.

SECTION IX

DiIsEASES OF THE UPPER RESPIRATORY TRACT AND Its ADNEXA....... . 442 Adenoids, 442—Acute Nasopharyngitis, 446—Chronic Nasopharyngitis, 450 —Infections of the Ethmoid Cells, Frontal Sinuses and Maxillary Antra, 451—Retropharyngeal Abscess, 451—Otitis Media, 453—Foreign Bodies in the Nose and Ears, 459—Nasal Polypi, 460—Deviation of the Nasal Septum, 460—Acute Catarrhal and Acute Follicular Tonsilitis, 460—-Membranous Tonsilitis, 464—Vincent’s Angina, 466—Peritonsillar Abscess, 467—Chronic Hypertrophy and Disease of the Tonsils, 468—Cervical Adenitis, 470—Acute Catarrhal Laryngitis, 472.

SECTION X

Dismasis or THe LUNGS AND PLEURA J 24,5. 2 | | 20 cue ee The Chest and Its Development, 475—The Lungs and Their Development, 476—Physical Examination of the Lungs, 476—Acute Tracheitis, 484— Foreign Bodies in the Trachea and Bronchi, 485—Acute Bronchitis, 486— Chronic Bronchitis, 492—Bronchiectasis, 494—Bronchial Asthma, 496— Bronchopneumonia, 502—Lobar Pneumonia, 513—Chronic Interstitial

Pneumonia, 529—Abscess of the Lung, 532—Pleurisy, 533— —Pneumothorax, 547. a SEE Te ee

SECTION XI

Disnases OF THE HEART AND PERICARDIUM. .........2...... S51

The Development of the Heart, 551—The Fetal Circulation, 551—Changes in the Circulation after Birth, 552—Size and Growth of the Heart, 552— Physical Examination of the Heart, 554—Congenital Heart Disease, 557— Acute Endocarditis, 561—Chronic Orificial Lesions of the Heart, 568— Myocarditis, 573—Dilatation of the Heart, 575—Functional Disorders of the Heart, 576—Inorganic Cardiac Murmurs, 576—Acute Pericarditis, 579— Pericarditis with Effusion, 582—Adherent Pericardium, 587, ,

SECTION XII

DISEASES OF THE LivER AND GALL-BLADD Size, Location and Examination of thetseee 590—Fatty Liver, 592—Amy. es : é aminat , 990—Fatty Liver, 592—Amya peseneration of the Liver, 592—Passive Congestion of the Liver, 593 uberculosis of the Liver, 593--Syphilis of the Liver, 593—Acute Yellow

CONTENTS V5

PAGE

Atrophy of the Liver, 594—Cysts of the Liver, 594—Abscess of the Liver, 594—Malignant Disease of the Liver, 595—Cirrhosis of the Liver, 596—

Acute Infectious (Catarrhal) Jaundice, 597—Di f - ‘ Pe Cubic bon iseases of the Gall-bladder

SECTION XIII

DISEASES OF THE SELEMN 2h ie eee Ee | ee et | | AGO T Size, Location and Examination of the Spleen, 601—Enlargement of the Spleen, 601—Banti’s Disease, 603—Gaucher’s Disease, 605.

SECTION XIV

EEE STI EO DE ae Pe Da a ee een re Physiology and Pathology of the Blood and Blood-forming Organs in Early Life, 606—The Blood in Infancy and Childhood, 609—Leucocytosis, 611— Anemia, 611—Secondary, 612—Congenital, 614—Alimentary, 614—From Hemorrhage, 616—Mild and Moderate Secondary, 617—Severe Secondary, 618—Hemolytic Jaundice, 623—Leukemia, 624—Chloroma, 628—Hodgkin’s Disease, 628—Purpura Hemorrhagica, 629—Symptomatic and Idiopathic Purpura, 631—Hemophilia, 633.

SECTION XV

DISH ASHSVOn THE KIDNEYSAND BLADDER &. 4. < ba 42s tae eee a ees 9 O89 Location and Physical Examination of the Kidneys and Bladder, 635—The Urine and Its Secretion in Infancy and Childhood, 636—Orthostatic Albuminuria, 641—Nephritis, 642—Perinephritis, 654—Malignant Disease of the Kidney, 655—Tuberculosis of the Kidneys, 658—Amzyloid Disease of the Kidneys, 659—Calculi, 659—Hydronephrosis and Pyonephrosis, 661— Floating Kidney, 661—Pyelitis, 662—Urethritis and Vulvovaginitis 667— Enuresis, 668.

SECTION XVI

DISEASES OF THE NERVOUS SysTEM....... ARE a fo Soe toe ae on ee The Development of the Nervous System, 672—Examination of the Nervous System, 673—Peculiarities of Disease of the Nervous System in Early Life, 680—General and Functional Nervous Diseases, 680—Convulsions, 680— Idiopathic Epilepsy, 684—Chorea, 688—Habit Spasms, 693—Nystagmus and Spasmus Nutans, 694—Hysteria, 695—Headaches, 696—Disturbances of Sleep, 697—Bad Habits, 698—Masturbation, 701—Thomsen’s Disease, 702—Diseases of the Brain, 703—Acute Encephalitis, 703—Hydrocephalus, 707—Cerebral Paralysis, 713—Cerebellar Ataxias, 717—Diseases due to Lesions of the Corpus Striatum, 717—Tumors of the Brain, 718—Abscess of the Brain, 720—Feeblemindedness, 721—Diseases of the Meninges, 729 —Meningismus and Serous Meningitis, 729—Meningitis due to Pyogenic Organisms, 730—Pneumococcus Meningitis, 730—Influenza Meningitis, 731—Meningococcus Meningitis, 731—Tuberculous_ Meningitis, 739— Diseases of the Spinal Cord, 744—Paralyses due to Injury _to the Spinal Cord during Birth, 745—Syringomyelia, 746—Friedreich’s Disease, 746— Progressive Muscular Atrophy, 747—Progressive Muscular Dystrophies, 749 —Amyotonia Congenita, 751—Acute Poliomyelitis, 753—Diseases of the Peripheral Nerves, 765— Multiple Neuritis, 765—Diphtheritic Paralysis, 765 —*¥acial Paralysis, 768.

SECTION XVII

DISEASES OF THE GLANDS OF INTERNAL SECRETION... . . PS eae oth, RAL Diseases of the Thymus, 770—Enlargement of the Thymus, 771—Status Lymphaticus, 772—Diseases of the Thyroid Gland, 773—Goiter, 774—Exophthalmic Goiter, 774—Cretinism, 774—Hypothyroidism and Hyperthyroidism, 777—Diseases of the Pituitary Gland, 77 8—Lorain-Levi Type of Infantilism, 779—Froéhlich’s Syndrome, 779— Diabetes Insipidus, 780— Diseases of the Adrenal Bodies, 781—Diseases of the Pineal Body, 782— Diseases of the Pancreas, 783—Diabetes Mellitus, 783.

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SECTION XVIII

. 788

DISEASES OF THE SKIN. . ..: . oes atts Se, te eee meee Pk eo ee (es Miliaria, 803—Urticaria, 804—Dermatitis, 805—Intertrigo, 806—Eczema, 808—Seborrhoea_ Capitis, 813—Impetigo Contagiosa, 813—Furunculosis, 814—Erythema Nodosum, 815.

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Index

CLINICAL PEDIATRICS.

Section I Congenital Malformations Meningocele, Encephalocele And Hydrencephalocele

In these conditions there is a protrusion of some portion of the cranial contents through an opening in the skull. The hernia almost always occurs through one of the normal openings of the skull, at the junction of some of the cranial bones or in a suture. The most common locations are in the median line in the occipital region or a little to one side of the median line at the root of the nose. If the tumor is made up of the meninges and cerebrospinal fluid, it is called a meningocele; if it contains brain tissue, it is an encephalocele; if it contains a portion of a distended lateral ventricle inside of the brain tissue, it is an hydrencephalocele. These tumors are presumably due to an intrauterine increase in the intracerebral pressure. The cause of this increase in pressure may or may not be still active after birth. The tumor may be covered only with the meninges, which may or may not be ulcerated, or with skin. If it is covered with skin, there is usually no hair onit. Itis always present at birth. It is likely to increase in size, if it is a meningocele, not so likely to, if it is an encephalocele or an hydrencephalocele. It varies in size from that of a walnut to that of the patient’s head.

A meningocele has a smooth surface, is symmetrical, is pedunculated, fluctuates and is translucent. It seldom pulsates. It can always be partly and sometimes completely reduced. Pressure on it causes bulging of the anterior fontanelle and symptoms of cerebral irritation, such as crying, twitching, rigidity and convulsions. An encephalocele is usually small. Itis ordinarily smooth and symmetrical. It is not pedunculated, does not fluctuate and is not translucent. It usually pulsates. It may or may not be reducible, pressure causes bulging of the anterior fontanelle. Pressure on it always produces symptoms of cerebral irritation. An hydrencephalocele is large and irregular in shape. It is pedunculated and:semi-translucent. Fluctuation is more or less distinct. It usually does not pulsate. It is not reducible. Pressure on it does not usually cause any bulging of the anterior fontanelle or symptoms of cerebral irritation.

Diagnosis.—Confusion sometimes arises between these tumors and caput succedaneum and cephalhematoma. Caput succedaneum is an edema of the scalp and is present at birth. It is situated at the location of the presenting part, is largest at the base, is covered with skin and hair, pits on pressure and is not fluctuant nor translucent. Pressure on it does not cause bulging of the fontanelle nor symptoms of cerebral irritation. It gradually diminishes in size and is gone in a few days. A cephalhematoma is not present at birth, but develops soon after. It is

2 17 he cranial bones. hemorrhage between the periosteum and one of t ones ARs aaa aoe attached ae the ede et ne sis oe imited to one bone, usually one 0 tals. auighie and hair, is largest a este sige ees Panes ec: sure on it does not cause bulging of the an ; ae fo cerebral irritation. After a few days a boney nde 1s Reece palpable at the edge of the tumor. The tumor begins rene ‘ size in a few days or a week and is gone In a few weeks. z oe ares teristics of these tumors are borne in mind there should be no di eu y in differentiating between them. A fatty twmor or a nevus May some oe be present at birth and occupy one of the positions where ene es and allied tumors are usually located. If the characteristics of t ce tumors are kept in mind and it is remembered that the meningoceles an

Fie, 1—Meningocele.

allied tumors originate inside the skull and protrude out from it, while fatty tumors and nevi originate outside of it, there will be no difficulty in distinguishing between them. :

Prognosis.—If these tumors are covered only by membrane, ulceration is almost certain to take place in a short time with, sooner or later, rupture of the sac. Death may then occur at once from loss of cerebrospinal fluid or, if not, is almost certain to in a short time from meningeal infection. In very rare instances, if the tumor is a meningocele, healing, with recovery, may occur. When these tumors are covered with skin, there is, of course, no danger of rupture. Sometimes a meningocele will gradually diminish in size and recovery take place. If the tumors are encephaloceles or hydrencephaloceles, there is no possibility of any diminution in their size or of recovery. In fact, both are liable to grow larger. Pressure or a blow on the tumor may at any time increase the symptoms or even cause death.

Treatment.—There is no medical treatment for these tumors. External applications and pressure can do nothing but harm. Whatever is

MALFORMATIONS OF THE CRANIUM 19 done inust be surgical. It is usually a comparatively simple matter to tie off a meningocele, although there is always the possibility that death may occur during the operation from loss of cerebrospinal fluid or soon after it from infection. Moreover, if the operation is successful, hydropone us is likely to develop, if the original cause of the hernia is still active.

In certain instances, when an encephalocele is small, it is possible to remove it. If the portion of brain removed is a part of one of the so-called ‘‘silent areas” of the brain, no ill effects may result from the removal. When an encephalocele is large, the chances of a successful operation are small, but the outlook for the future is so poor without an operation that it is wise to operate and take what little chance there is. An hydrencephalocele is, of course, inoperable. Finally, meningoceles should be operated upon; encephaloceles, unless very large, should be operated upon; hydrencephaloceles must be let alone.

MALFORMATIONS OF THE CRANIUM

There are a number of other congenital malformations of the cranium, none of which is of much clinical importance. Anencephalia, a condition in which, on account of a failure of development, more or less of the brain and cranium are lacking, is merely a pathologic curiosity, as it is incompatible with life. Most babies with this malformation are born dead. The others live but a few hours or days. The causes of congenital hydrocephalus are the same as when it develops later. The diagnosis, prognosis and treatment are also the same, and consequently deserve no special consideration. Asymmetry of the cranium and face not due to injury, edema or hemorrhage, is not very uncommon. ‘The tendency is always toward improvement, and in most instances the malformation is not noticeable in adult life. There is no treatment for it.

PROTRUSION OF THE EARS

Protrusion of the ears, a trivial malformation , but one which troubles mothers much, is not uncommon. Although the protrusion often seems to increase, especially in middle childhood, the comparative infrequency of protruding ears in adults seems to show that the natural tendency is to spontaneous disappearance of the deformity. There is no doubt, however, that if the baby is allowed to lie with the ear turned forward, the deformity increases. Care should be taken, therefore, to see that the ear is turned backward when the baby lies on it. It is also probable that keeping the ears flat on the head with a cap or some simple apparatus does tend to improve the condition. If the deformity is extreme, it can be readily overcome by removing a semilunar piece of skin from the back of the ear and another from the side of the head and stitching the ear back.

CERVICAL FISTULZ AND CYSTS

The clinical evidences of a cervical fistula are a dimple in the neck, with or without a watery, somewhat glairy, discharge. The opening is usually along the anterior border of the sterno-cleido-mastoid muscle, but may be in the median line. If lateral, it is more often on the right than on the left and, whether lateral or median, is usually below the level of the hyoid bone. The discharge resembles saliva, contains columnar and squamous epithelial cells, often irritates the skin and sometimes forms crusts over the opening. Thelateral fistulae are due to failure of closure of the branchial clefts; the median may be due either to imperfect closure of the sinus praecervicalis or to persistence of the thyro-glossal duct of His. These fistulae are lined with epithelium of various sorts. They may end blindly or may connect with the pharynx.

If the external opening of a cervical fistula becomes closed or if there is a fistulous tract without an external opening, the secretions of the tract may be retained and form acyst. The tumor may or may not be present at birth. It increases in size after birth, may be either lateral or median, and is covered with skin. It is almost always unilocular and is fluctuant or semi-fluctuant.

Treatment.—The treatment is entirely operative. Unless the fistulous tract is entirely removed, recurrence is almost certain. The operation is almost always more serious and difficult than is anticipated, because of the length and situation of the fistulous tract. Unless the discharge is considerable or the tumor deforming, it is probably wise, therefore, not to interfere.

CYSTIC HYGROMA OF THE NECK

_ _ A cystic hygroma is a lymphangioma of the neck. It is usually situated on the side of the neck. It is present at birth and may be large

Fie. 2.—Cystic hygroma of the neck.

ee HS ey with delivery. Its tendency is to increase in size a a ernally and internally. Increase in size internally may cause eh SPW aa and deglutition. The tumor is multilocular sometimes ; i ae see ane semifluctuant, but never fluctuant. It is covered Treatment.—These tumors should b 1 se e removed as soon as th ition of the infant will warrant it, because of the tendency to henna © size internally, which makes their removal more difficult. The tumor

HARELIP ii must be entirely removed, because, if it is not, it will recur. The operation is always a very difficult and dangerous one.

HARELIP

_Etiology.—Harelip is due to the failure of the maxillary processes to unite with the nasofrontal process. Hence the fissure is always to one side of the median line. The processes may fail to unite on either one or both sides. Harelip may be, therefore, either single or double. The fissure may be very slight at the edge of the lip or deep, extending into the nose. It. is often associated with cleft palate, but either condition may occur alone.

Symptomatology.—Except for the deformity, harelip causes no symptoms, unless it interferes with nursing. It may then cause considerable disturbance of the nutrition from an insufficient supply of food.

Treatment.—Harelip should be operated upon when the baby is three or four weeks old, if its general condition warrants it. If it does not, as soon after this time as it does. If the deformity interferes with nursing, the baby must be given breast milk or modified milk with a Breck feeder, spoon, or dropper, or, if necessary, be fed through a tube.

CLEFT PALATE

Etiology.—Cleft palate is due to the failure of the ridges which grow out from the inner surfaces of the two portions of the upper jaw to form the roof of the mouth to unite in the median line. The failure to unite may occur at any point or be complete. As union begins anteriorly and extends backward, it is uncommon to find defects in the hard palate without involvement of the soft. The slightest degree of cleft palate is the bifid wula.

Symptomatology.—Cleft palate is a severe condition in that it almost always interferes with or prevents nursing from either the breast or bottle and hence causes serious disturbance of the nutrition, which may even be fatal. There is very likely to be an infection of the nasal passages as the result of irritation from the food which gets into them. This infection is liable to extend into the ears and nasal adnexa as well as to the mouth. Thrush is also a not uncommon accompaniment. Disturbances of the digestion and infections of the lungs often develop secondarily and not infrequently prove fatal.

Treatment.—If the baby is unable to suck, as it usually is, it must be fed in some other way. ‘There is a nipple with a soft rubber flange on each side which sometimes works very well, the wings closing the defect in the palate. Some babies can take their food from a Breck feeder, others have to be fed with a spoon or a dropper. They often take their food better, if the head is turned to one side or tipped back. If there is much difficulty in feeding, it is advisable to use a stomach tube, as this method of feeding not only insures a sufficient supply of food but saves the baby’s strength and diminishes the dangers of infection. If possible, the mother’s milk should be expressed and given to the baby, as it is even more important for these than for normal babies to get breast milk. It is important to keep the mouth and nose clean. This can be done with water, boracic acid solution or some mild alkaline wash. It must be remembered, however, that it is very easy to do more harm than good by too vigorous attempts at cleanliness. If thrush or other infections of the mouth and nose develop, they are to be treated by the usual methods. The best time for operation is at about eighteen months.

Jag CONGENITAL MALFORMATIONS

RANULA

A ranula is a soft, semifluctuant, spherical or elongated, bluish swelling in the floor of the mouth beside the frenum of the tongue. _It may be single or double. It may be congenital or develop at any time during childhood or adult life. The tumor is not tender and causes inconvenience only because of its size. It isa cyst due to the retention of the secretion of a mucous gland as the result of the blocking of its duct. The contents are a thick, glairy, colorless fluid. :

The best treatment is the complete removal of the sac. It is useless to aspirate or incise the tumor, as the fluid invariably re-collects.

CONGENITAL HYPERTROPHY OF THE TONGUE

Congenital hypertrophy of the tongue, or macroglossia, is usually bilateral, but may be unilateral. The hypertrophy is usually due to dilatation of the lymph vessels, but sometimes to that of the blood vessels. It is occasionally due to an overgrowth of connective tissue. It is never a sign of cretinism or Mongolian idiocy, as the enlargement of the tongue in cretinism is not marked at birth and that in Mongolian idiocy does not appear until childhood.

When the enlargement is lymphangiomatous or angiomatous, the treatment must be operative and carried out as soon as the infant is old enough to bear the operation, because the tendency of these growths is to increase rapidly in size. When it is due to an overgrowth of connective tissue, it is wise to delay the operation for a time, unless the tongue is very large, because there is a chance that the tongue may become smaller or that it may not increase in size and that the child may “‘erow to the tongue.”

TONGUE-TIE

This name is applied to the condition in which the frenum of the tongue is short and prevents the normal protrusion of the tongue. It is evident that there may be all degrees of this malformation. If the shortening of the frenum is extreme, it may interfere with sucking and talking. Such interference is in my experience very unusual and certainly does not occur, if the tongue can be protruded beyond the gums. If there is difficulty in sucking, the cause is much more often to be found in the nose or nasopharynx. If there is delay in talking, the child is usually either backward or feeble-minded. If the speech is indistinct, the cause is generally to be found in the nervous system, not in the tongue.

_ Treatment.—The treatment is, of course, to cut the frenum. This is seldom necessary, however, and there is no doubt that many more frenums have been cut unnecessarily than for good cause. Fortunately it seems to do but little harm to cut the frenum, even when it is already longenough. In performing this operation the lower part of the tongue is pushed up and guarded with the perforated flange of a director. The frenum is then cut as deeply as desired with scissors. The cut should be made near the gum in order to avoid cutti i : ; run close to the tongue. ing the ranine arteries, which

CONGENITAL MALFORMATIONS OF THE CHEST

The chest may be malformed in many ways, but most of these mal-

See are very uncommon and of little clinical importance. A few of them, however, are worthy of mention.

SPINA BIFIDA 23

Funnel Chest.—In funnel chest there is a depression of the sternum with an increase in the lateral diameter of the chest. This malformation is congenital, but is usually not noticed until the baby is one or two years old. It is often hereditary and familial. It causes no symptoms and can not be remedied. A similiar condition may develop in connection with rickets, when there is interference with the entrance of air into the lungs as the result of adenoids or some other obstruction to respiration. In such instances there are other signs of rickets and usually the characteristic facies of adenoids.

Cervical Ribs.—A cervical rib seldom causes any symptoms and is usually overlooked. It may, however, sometimes be seen and felt as a prominence in the neck and be mistaken for an enlarged gland or some form of new growth. It may also, by pressing on an artery, cause pallor and coldness of the arm or, by pressure on nerve trunks,. cause pain, numbness or tingling in the arm. Such symptoms should suggest the possibility that there may be a cervical rib. The diagnosis can easily be made with the aid of the Roentgen ray. The treatment is, of course, surgical.

Sprengel’s Deformity, or Congenital Elevation of the Scapula, is not very uncommon, but is usually overlooked or misinterpreted. .Inthis condition one scapula is higher than the other and rotated outward. The scapula is usually malformed and there are often associated malformations of the ribs. The treatment is surgical.

SPINA BIFIDA

Spina bifida is a condition in which there is a lack of closure of one or more of the vertebral arches. This defect may occur anywhere in

* Fig. 3.—Sprengel’s deformity. Spina bifida occulta.

the vertebral column, but is most common in the lower dorsal and lumbar regions. It occurs next most frequently in the neck. I have seen one instance in which the defect was in the upper dorsal region and the hernia through it protruded into the right chest, giving the physical signs of fluid in the upper chest.

Spina Piddas Oeculta Wher there is no hernia through the defect in the arches and it is covered with skin, the condition is usually spoken of as spina bifida occulta. In such instances, however, there is quite likely to be a mole or a growth of hair in the area over the defect. In fact, a large mole or a localized growth of hair over the spine should always ibility of this defect. There are usually no other sympeee en aentaitte but I have seen both enuresvs and incontinence of feces, presumably as the result of some involvement of the nerve ie This abnormality should, therefore, always be thought of as a possible cause in intractable cases of incontinence of either urine or feces, and sought for by physical examination | and the Roentgen ray. Unfortunately, there is nothing to be done, if it is discovered.

Fia. 4.—Spina bifida occulta. Sprengel’s Fie. 5.—Spina bifida occulta. deformity.

SPINAL MENINGOCELE, MENINGO-MYELOCELE AND SYRINGO-MYELOCELE

There may be a hernia of the contents of the vertebral canal through the spina bifida. It is to these hernie that the term ‘‘spina bifida”’ is usually and improperly applied. If the sac contains only cerebrospinal fluid, it is a spinal meningocele; if it contains parts or the whole of the spinal cord, it is a meningo-myelocele; if, as sometimes happens, the coverings of the sac are made up of the meninges and cord spread out about the distended central canal of the cord, it is a syringo-myelocele. The meningo-myelocele is much the most common form. The hernia may be covered with normal skin, by the membranes of the cord, or by a combination of the two. If the membranes make up the covering, they are almost certain to become ulcerated in a short time. Except in spinal meningoceles, there are likely to be deformities and spasm or paralysis of the lower extremities, as the result of the involvement of the cord or nerve fibres in the sac. Paralysis of the perineum and of the sphincters of the anus is also common. Pressure on these tumors often causes bulging of the anterior fontanelle and symptoms of cerebral and spinal irritation.

Diagnosis.—It is possible that a large nevus or a fatty tumor, which happened to be located over the back bone, might be mistaken for one of these tumors. If the difference in origin and contents of the tumors are borne in mind, there should be, however, no difficulty in distinguishing

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SPINA BIFIDA 25 between them. A roentgenogram of the spine will settle the question at once and conclusively.

Prognosis.—There is no danger of rupture of the sac when these tumors are covered with skin. A blow or a fall on the sac may, however, cause great discomfort and possibly prove fatal. There is, moreover, no ‘probability of improvement in any paralysis or spasm which may be

Fig. 6.—Cervical meningocele.

present. In some instances, when the skin extends well on to the sac, it may gradually grow in and replace the membranous coverings. In general, however, when the sac is made up wholly or in part of membrane, ulceration occurs in spite of the greatest care and, sooner or later, rupture. When rupture occurs, the infant almost always dies, either at once or after some hours or days from the loss of cerebrospinal fluid, or from a

4 |

Fie. 7.—Lumbar meningo-myelocele. Dislocation of hips.

secondary ascending meningitis. In very rare instances, however, the sac becomes puckered down after it ruptures, heals and recovery occurs.

In such cases, also, there is not likely to be any improvement in the spasm or paralysis and secondary hydrocephalus may later develop. There is a reasonable chance that, in spite of the dangers from loss of cerebrospinal fluid and infection, the sac may be successfully removed in spinal meningocele and healing take place. There is great danger, however, increased cerebrospinal pressure, which originally prevented the ae of the vertebral folaitn may still be present and cause a secondary hydrocephalus. There is some chance of a successful oes a a meningo-myelocele, but there is very little chance of relieving as ne paralysis or spasm and great probability of increasing them by a : a injuring the cord or nerves. If the perineum and the panamprors oe e anus are paralyzed, an operation almost never does any good. othing can be done, of course, for a syringo-myelocele.