tion; the lower part of the thorax below the nipple, at the same time, will be seen to be actually retracted. One part of the lung receives no air at all; another (more commonly the upper lobe, or a portion of it) receives air, but a less quantity than usual, owing to the emphysematous condition there existing."

With respect to the diagnosis, Hewitt says:

"The movements of the chest are markedly influenced by the presence of emphysema. Emphysema, of what may be called acute form, developing itself in the lungs of infants or young children during an attack of bronchitis, most commonly attacks the upper lobes of the lungs. Here the want of expansion beneath the clavicles, the greater resonance on percussion, and the feeble respiratory murmur, are diagnostic of the presence of the lesion. Dr. Jenner states that he has observed a falling in or subsidence of the supra-clavicular region during inspiration, in cases where the apices are affected; and my own observations enable me to confirm this statement. Below the clavicles the emphysema may most surely be recognized; for in this situation the lung is most liable to be extensively affected. At other situations, the mixture of emphysema with apneumatosis renders the diagnosis more difficult, the results offered by percussion are less valuable, and the auscultatory signs are less significative. "An intensification of the natural respiratory murmur is not heard over parts of the lung which are truly emphysematous; rather course rhonchi may be heard masking more or less completely the natural respiratory sound; but these rhonchi themselves are not of much value as tests of the presence or absence of emphysema. The presence, at any situation, of signs indicative of apneumatosis, such as dulness, finish rhonchus or complete absence of respiratory murmur, is almost or quite sufficient to warrant the conclusion that emphysema is also present, and in such cases the signs of emphysema have only to be looked for, to be at once made out.

"Inasmuch as emphysema is rarely unaccompanied by apneumatosis, it is a matter of difficulty, as before remarked, to define precisely the share of each in the production of the various symptoms observed. The dyspnoea present in bronchitis in young children is peculiar, the expiratory act occurring first, and the interval following the inspiratory act.

"When emphysema is present to a considerable degree, the expiratory' type of respiration is intensified; the respirations are eminently shallow in character, the cough is short, stifled and weak; and coincidently with these, the physical signs of emphysema at the apices, and of collapse at the lower portions of the lungs, may be satisfactorily made out. What of the symptoms and of the distress which the patient is laboring under, cannot be set down to the airless state of certain parts of the lungs, and to the obstructed condition of the air-tubes, must then be attributed to the emphysema, the emphysema affecting, let it be remembered, not limited portions of the lung's surface, but often spread over entire lobes. Orthopnoea, and great distress are, in young children, generally due rather to the presence of extensive emphysema than to those other conditions which produce difficulty of respiration in bronchitis. As the child grows older, the lungs less readily become collapsed, and less readily, for this reason, does this acute form of emphysema occur. In weakly children the sternum often projects at the same time that the chest is laterally retracted, one diameter of the chest being increased to make up for the diminution of another.

66

Of the symptoms of chronic emphysema in childhood there is little to be said, the characters of the disease differing in few essential particulars from those observed at a later period of life. As in the adult, the patient is liable to frequent attacks of bronchitis, evidently dependent on the existence of the emphysematous condition of the lungs. The rapidity with which severe dyspnoea supervenes on an apparently slight attack of bronchitis is, in ordinary cases, a good test of the presence of emphysema.

"Much more might here be said in reference to other symptoms which are produced in part or altogether, by the existence of emphysema, but the general indication thus given of the part emphysema ordinarily plays in giving rise to

symptoms usually referred to other conditions, has been thought sufficient for the present purpose."

ART. 174. Some observations on the Dystrophia of Children. By Dr. R. KUTTNER, of Dresden.

(Journ. für Kinderkrankh., April, 1858; and Dublin Quarterly Journal of Medicine, August, 1856.)

In our daily intercourse, and, to some extent even in the field of science, the term atrophy has undoubtedly received far too wide an application and been confounded in its signification. Considering the phenomenon of far-advanced emaciation as the essential feature, a number of morbid conditions in little children have been only too often comprised under the name atrophy, which are marked by a deep depression of nutrition; and children have been looked upon as atrophic, who, on a more accurate examination, and stricter employment of the term, would be recognized as suffering from a general dyscrasia or an organic affection. The correction of this abuse and the restoration of the word atrophy to its original more limited signification is, however, by no means so idle or unessential a matter as it may, perhaps, appear to many, but has, in addition to the greater accuracy in diagnosis to be thereby attained, also its special value in medical treatment.

The true atrophy, or-as we much more correctly denominate it-the dystrophia of children as an independent form of disease, pædodystrophia, pæda trophia, may, according to the signification of the word, necessarily comprise only that state of depressed nutrition and general exhaustion, which in little children is occasioned by the insufficient amount or the unsuitable nature of the food. This essential original dystrophy is, therefore, to be strictly distinguished from all those states of emaciation and exhaustion which, occurring as the product of morbid processes, bear a purely symptomatic, secondary character. While in the latter (dystrophia symptomatica) the eye of the physician must be constantly directed to the casual morbid condition, at one time a long-continued local affection, especially of the organs of digestion or respiration, at another a general dyscrasia, as tuberculosis or inherited syphilis; in the former (dystrophia morbus) the organization is originally, and, so far as morbid states do not accidentally concur, giving rise to complications, thoroughly normal, and suffers only from the want of the formative material so necessary to it. In the one case the physician must meet the affection by combating a morbid state; in the other, by administering suitable nourishment.

The development of genuine dystrophy is, as the organism constantly needs the access of nutritive matter, evidently possible at any time of life, but at no age is the tendency to it greater than in the earliest infancy. For, on the one hand, the delicate digestive organs of the child are by nature for a long time destined to one particular form of food, the mother's or the nurse's milk, all substitutes for which are only too apt to be insufficient; while on the other, the infantile system growing most rapidly, the more quickly and sensitively feels the want of suitable formative material. But dystrophy is exemplified not merely most frequently, but most accurately, in the young child, who, still for the most part free from products of disease, and still unaffected by exhausting bodily exertion or distracting mental affections, which, at a more advanced period of life, usually accompany a state of privation, and greatly modify its phenomena, only physically feels and exhibits the want of nourishment. For these reasons dystrophy has certainly been correctly admitted specially into the pathology of childhood, and considered as a particular affection of the earliest period of life, the time of suckling.

It is of practical importance to distinguish two species of dysentery according to their origin, whether the latter be attributable to a simple deficiency of nourishment (dystrophia simplex), or whether the nature of the food is at the same time unsuited and irritating to the delicate digestive organs of the child (dystrophia dyspeptica). The former, of course, occurs almost only in sucklings, starving on the ill-supplied breast of the mother or the nurse; the latter, by

far the most common, is mostly the sad result of artificial feeding, which carries numberless children to the grave.*

A detailed description of the phenomena characteristic of the dystrophy of children might be superfluous to the readers of these pages: I shall, therefore, allude to only the most essential symptoms. Occupying the first place among them in a material point of view is the manifest deficiency of blood, exhibiting itself in the general paleness and in the diminished bodily heat. Hand in hand with it goes the insufficient metamorphosis of tissue, which, commencing with general relaxation and flaccidity, gradually leads to the complete disappearance of the cushion of fat, and finally gives the little sufferers an old or ape-like appearance. Among functional phenomena we have a constant craving for food, thrusting the little hands into the mouth; unceasing restlessness by day and night, which yields for only a short time to the administration of food, and at last passes into the highest degree of listless exhaustion; lastly, a very great dimunition of the urine often giving rise through the acridity of the concentrated secretion, to a kind of dysuria, and a frequently torpid, solid and scanty alvine discharge, which is watery and diarrhoeal only when catarrh of the bowel exists. This collection of symptoms presents the idea of dystrophy in its simplest form. In dystrophia dyspeptica we observe, of course, in addition, the phenomena of deranged digestive powers and of the collection of indigestible matters in the stomach and intestinal canal, by which these organs are brought almost into a state of chronic catarrhal irritation. Therefore, vomiting, the occasional formation of acid flatulence, and diarrhoea, erythema of the cavity of the mouth, with the development of fungi and of sores around the anus, appear as concomitant symptoms, which undergo numerous modifications in form and intensity according to the different nature of the deficiency in the nourishment. As secondary attendants on dystrophy, especially on its dyspeptic form, convulsive phenomena of all kinds may certainly occur, but they are in reality much rarer than is popularly supposed, the entire train of symptoms being only too readily attributed, not to its real cause, but to so-called inward spasms, and for these assistance is demanded. Public institutions, such as our Foundling Hospital, afford hundreds of opportunities of making observations of this kind. At one time the poor starved little ones are brought to seek relief for their constant uneasiness, their crying and their want of sleep; at another time, for their urinary affections; at another, for derangement of the bowels; but most frequently for the supposed inward spasms.

The post-mortem examinations in simple dystrophy present nothing characteristic in addition to the highest degree of deficiency of blood, as well as in general of insufficient nutrition of all the tissues. In dystrophia dyspeptica, on the contrary, we find traces of a catarrhal condition of the gastric and intestinal mucous membrane, with swelling and black punctation of Peyer's glands, or actual bursting and ulcerous destruction of the same. The fundus

of the stomach, as well as some parts of the intestinal canal, are often found in a state of gelatinous softening, in consequence of the presence of contents which have passed into a state of acid fermentation, while the liver appears at one time anæmic, at another overloaded with dark blood, but the bile is always remarkably thin and pale. That complicating morbid conditions, frequently hastening or directly causing death, which leave their traces in the dead body, as for example pneumonia and cerebral affections, must be distinguished from pure dystrophy, is self-evident. The swelling and hardening of the mesenteric glands in atrophic patients, on which so much stress was formerly laid (as Dr. Stiebel, jun., also has shown in his treatise On the Condition of the Mesenteric Glands in Childhood, and their relation to the atrophy of the first year of life,' Frankfort-on-the-Main, 1854), are by no means constant, and at least in no case constitute an essential post-mortem appearance in dystrophy, often as the latter is considered and described as tabes mesenterica.

It is principally poor little children, committed to nurses, who are liable to this fate. A statistical table, deduced from the reports of the Foundling Hospital, shows, that while among the children under their mothers' care, the mortality among children under two years of age did not amount to quite 19 per cent., in those under the charge of nurses it attained 29 per cent.; and was generally caused by dystrophy.

As I have already remarked in the beginning of this paper, dystrophy is among the most frequent causes of death in the first year of life, as a very considerable number of artificially fed children fall a sacrifice to it. Notwithstanding, the prognosis is not at all so unfavorable as one might at the first glance suppose, and in every case it is much better than in the symptomatic variety caused by diseases. It is truly surprising how quickly and completely such children often recover, and, indeed, even within a few weeks become so changed as not to be recognized, so soon as food adapted to their digestive organs and sufficient for their wants, has been supplied. If it is possible to transfer the suckling languishing on the empty breast of its mother, or the child wasting away on unsuitable artificial food, to a good nurse, care should be taken that if the latter appears unequal to her task, she should be exchanged for a better, the consequence of which will be the disappearance in a short time of all the symptoms arising from the insufficient supply of its wants, and the often rapid transformation of the little image of misery into the round, soft forms characteristic of infancy.

From what has been said it is evident that from the nature of the case, the treatment of dystrophy is not to be pharmaceutic, but that the entire task of the physician consists in the administration of nourishment quantitatively and qualitatively suited to the wants of the child. It is attributable only to imperfect knowledge of the affection, and of its causes, that the treatment is so often actually different. All those far-famed children's powders and syrups, with which nurses, and even physicians are so ready, to combat particular symptoms, are as unavailing as tonics, astringents, or narcotics. They are only signs of a false diagnosis, and easily contribute to aggravate the patient's state. Unfortunately, it is, however, often impossible to procure for the little sufferers the only efficacious remedy-sufficient and suitable nourishment-which mostly can be found only in a good nurse. This is particularly the case in public institutions, which, destined for the service of the poorer classes, are most frequently resorted to on the behalf of such sufferers, and yet can do nothing more than give suitable advice to the mothers or nurses. With the above view, we are in the habit of recommending, in the Dresden Foundling Hospital, for starving sucklings, the contemporaneous administration of good cow's milk, so as fully to satisfy the children, and, in those who are artificially fed, of regulating the diet as far as possible according to the principles which I have already published in my aphorisms on the feeding of little children. Medicines I give only according to special indications, as in cases where complications exist. Instead of them, I have derived great benefit, especially in dystrophia dyspeptica, from administering, three or four times a day, from eight to ten drops of Malaga, Hungary, or port wine, to the little patients; and this plan I can under such circumstances the more strongly recommend, as, by prescribing the wine in the form of a medicine, the physician will no longer appear as an idle spectator, in the eyes of relatives, so often desirous of the administration of medicine. That this small quantity cannot act as a nutrient* is evident, but it acts as a condiment to the digestive organs, and makes them more capable of digesting and assimilating the food which is supplied often in sufficient quantity, but in a state of unsuitable preparation and admixture. Thus, at least, I believe the remarkable effect of wine under the circumstances above mentioned, which has been confirmed by hundreds of cases, is to be explained. When the dystrophy is removed, wine is of course again left off, as in well-fed, plethoric children it only too easily induces an insidious cerebral affection, even though given in small but long-continued doses.

* It is well known that Kletzinsky has discovered a considerable amount of lime in Malaga and Tokay wines, and that he ascribes to this fact a considerable share of their beneficial action.

ART. 175.-Galvanism in Incontinence of Urine in Children.
By Mr. SIMON, Surgeon to St. Thomas's Hospital.

(Medical Times and Gazette, Nov. 14, 1858.)

Mr. Simon, it appears, has treated successfully some cases of incontinence of urine in children by means of galvanism, the current being passed along a catheter which has been previously introduced into the bladder. The cases were those of incontinence from simple atony, and not those arising from irritable bladder.