very slight pain in the belly, this became swollen; and on admission, a large

ted quantity of fluid, causing dyspnoea, was detected; no fever being present, and

the digestive organs continuing in a normal condition. These cases are exactly

All analogous to those of acute hydrothorax depending on pleurisy, as these do on peritonitis-a pleurisy, however, in which the effusion is so great and so rapid, te that death ensues if paracentesis thoracis be not resorted to. There is the same difference between acute febrile peritonitis (almost always fatal) in which the inflammatory symptoms are violent and the effusion small, and the peritonitis with little fever and much effusion, as between acute febrile pleurisy and acute hydrothorax. In hydrothorax, however, we can remove the mechanical obstru tion to respiration by paracentesis, which is a harmless operation; but in this form of ascites, thongh the prognosis is as favourable, our procedure must be different. In fact, the experience of M. Trousseau and his colleagues is entirely unfavourable to paracentesis abdominis in children the operation almost always terminating fatally. Even in the adult, the repeated tappings which sometimes take place are usually performed on women, and are in fact, operations on ovarian

eysts, and not upon the peritoneal cavity. In men, as in children, it is the peritoneal cavity itself that is opened, and the prognosis is much more unfavourable. In the child, when it is not complicated by tubercular disease, the treatment of this ascites is best accomplished by giving small doses of calomel, until the gums are slightly swollen, and keeping a hemlock cataplasm applied to the abdomen day and night. If resolution does not quickly occur, the surface of the abdomen should be painted with iodine.-P.H.B.]

1ST. ON THE JAUNDICE OF INFANTS.

Jaundice is a phenomenon which is very frequently observed amongst the newly-born, and which has up to the present time been described as an essential disease. This is a mistake. The jaundice of infants always results from a slight or severe inflammatory affection of the liver which obstructs the circulation of the bile and causes its passage into the blood. We shall not, then, describe icterus as a special disease, but rather as a symptom of the organic alteration of the liver, and principally as a symptom of acute hepatitis.

[M. Bouchut is probably incorrect in his statement that icterus always results from an iuflammatory affection of the liver; in many cases it appears most likely due to the passive state of congestion so frequently observed in the liver of new-born children, to which Billard drew attention some years ago, and also stated that such a condition would, in most cases, only be known after death, as during life it afforded no special symptoms for its diagnosis. In Bednár's late

work (Op. Cit. Dritter Theile; p. 133) it is also laid down that it is impossible to diagnosticate hyperæmia of the liver, if it be uncomplicated with increase of size of the organ.-P.H.B.]

2ND. ON ACUTE HEPATITIS.

A

Hewle

Hepatitis is the term given to inflammation of the liver. It is a very frequent disease in the newly-born infant, a few days after its birth. One third of the children who come into the world are 1/3 C affected by it, and up to the present time it has been described under the name of its principal symptom, which is jaundice. The hepatitis of infants may be the result of compression of the ru body of the fœtus in the process of accouchement, or of contusion of the liver at the moment of parturition. It may be brought on by a the impression of the external atmosphere on the skin, and especially on the general and cutaneous circulation. Lastly, as I have several causes:times observed, it is the result of the umbilical phlebitis which succeeds the ligature of the cord, and which extends from the umbilicus, where Cossen, it originates, to the veins of the liver. It has also been observed in the course of enteritis and sclerema.

affected

Contusion [According to West, the icterus of new-born children is generally a trivial flete, affection, not usually dependent on intestinal disorder, but on imperfect perform

ance of the functions of the skin and respiratory organs. In the Dublin Lying-in 144y,

Hospital, where the children are defended by the most watchful care from the evils either of cold or of a vitiated atmosphere, the occurrence of infantile jaundice is rare; while at the Foundling Hospital, at Paris, jaundice is so common that few infants escape it for almost all of them have been exposed to the action of cold and bad air while inmates of it-causes which interfere very seriously with WIL the due performances of the functions of the skin and of the respiratory organs. Sometimes, however, it is a very serious affection, dependent on congenital absence of the hepatic or cystic biliary ducts, or on the obstruction of those ducts by inspissated bile; these cases are remarkable as being characterized by a tendency to hæmorrhage, which takes place most frequently from the umbilicus, either before or soon after the separation of the funis, and speedily prove fatal.

Two cases of infantile icterus have lately occurred, caused, according to Mr. Lee, by the non-closure of the ductus venosus. "The greater part of the blood 24 tende. from which the bile is secreted, instead of passing through the liver, is transmitted

directly to the heart. As this open channel affords a much more ready passage lauition

for the blood of the portal vein, than the complicated circulation through the liver, it is probable that nearly the whole of the blood from the portal vein passed to the

general circulation in this way. These would then be available for the purpose

of the secretion of the bile, only the small quantity which would find its way through the portal circulation in the liver, and the blood sent to the liver by the hepatic artery. The quantity of blood from which it would be possible that the bile could be secreted, would be thus very much less than natural, and the necessary consequence of this would be, that the bile would accumulate in the system, as in fact it was found to do in the two cases which have been read." One of these cases was attended by uncontrollable hæmorrhage, and in the other, in which erysipelas and purulent deposits occurred, the umbilical vein was found distended

with a curdy puriform fluid, which extended into some of the subdivisions of the vena portæ in the liver. (Med. Times and Gazette; p. 333, 1854.)—P.H.B.]

The liver then is very swollen and gorged with black liquid blood. The vessels of the liver as well as those of the abdomen are filled with it; there is even sometimes an exudation of this liquid into the gall bladder and sometimes into the duodenum. The bile is a little yellow and more abundant than usual, for it is known that in the newly-born, the bile, instead of being yellow, is, on the contrary, of a very deep, blackish, green colour.

The tissue of the liver is granular, bluish red, always a little softened, and often adherent by means of false membranes; it sometimes contains small abscesses in its interior, but only in cases of severe hepatitis. Baumes, and Dr. Martin of Lyons (quoted by Richard), have related several cases of it. This last has observed not only abscesses in the liver but also other purulent collections in the scrotum, palm of the hands, and muscles, indeed all the characteristics of purulent absorption. It is a matter of regret that in these cases Dr. Martin has not paid sufficient attention to the state of the umbilical vein. 4 This vein sometimes presents unequivocal traces of inflammation; it is filled with a soft clot, slightly adherent and separated from the walls by pus. In many cases even the suppuration exists in the sheath of the vessel and is observed beneath the peritoneum and the abdominal wall.

The skin is yellow, as is also the cellular tissue and the subcutaneous adipose tissue. The colouring extends to the deep organs, the intestine, the internal muscles, the bones, the heart, the spinal cord and brain, &c., which is not to be wondered at, since the icteric suffusion is general. On this point there are only differences of degree; if the jaundice is but of slight intensity, it exists chiefly in the superficial and vascular parts, as the skin; when it is more considerable it is everywhere observed. However, it is said that this is not always the case, and they pretend to have seen, what I have not met with myself, local jaundice, jaundice of the deep parts, and of one organ in particular, without jaundice of the skin; thus, Billard states that he has twice observed the yellow colour of the fat in newly-born children, and he adds, that when the thigh was incised transversely, the incision of the stump presented a circular yellow line, situated in the subcutaneous adipose tissue, whilst neither the skin externally, nor the muscles centrally, were tinged yellow. Before this dissection there was no suspicion of the child being jaundiced. The periosteum and the tissue of the bones have also been observed of a yellow tint, with or without general jaundice.

It is impossible that Billard can be deceived as to the phenomena which he relates, and we may accept, on his testimony, what he

Here

observes on the yellow colour of certain tissues without general jaundice, but there is probably some mistake in the interpretation of mthe facts. Local jaundice is so foreign to the laws of pathology that it is difficult to accept it as a true jaundice; we do not understand it, for then this disease does not consist in the passage of the colouring here is matter of the bile into the blood. It is probable that Billard has uid to

been the dupe of his senses, and that, guided by a simple phenomenon, the yellow colour, he has met with diseases of an entirely different la locul nature, and that he has referred to jaundice local alterations of colourundin in certain tissues, alterations independent of the affection we are now considering.

SYMPTOMS.

The acute hepatitis of infants presents itself under two distinct forms, her dink the one common the other malignant; the first is feeble and slight, the other, on the contrary, is very serious and very intense. Acute feeble hepatitis, or common hepatitis, is developed amongst one third of children shortly after birth. It is announced by a yellowish us colouring, which is mixed with the red colour of the skin common to # all new-born children, and thence becomes difficult to be distinguished. The skin is of a reddish yellow, and if the finger is applied on the and surface instead of becoming white it becomes yellow under

pressure,

Division. "Commen

and immediately assumes the reddish tint again. At a later period, tulegu at the end of two or three days, the jaundice is very apparent, the red colour of the skin vanishes, and the icteric tint remains.

This colour exists in other places besides the skin. It is also observed on the conjunctivæ, on the inferior surface of the tongue, and in the urine, which we cannot collect, it is true, but it gives to the linen a characteristic yellow colour. The fæcal matters preserve their appearance, and do not become at all greyish as in the adult.

The abdomen is slightly tense and painful over the right hypochondrium, pressure causes pain, and the liver extends beyond its limits laterally. The skin is moderately warm, the pulse from 110 to 120, the digestive functions are otherwise in a very good state.

At the end of six or ten days the yellow colour begins to disappear, to give place to the natural rosy tint of the skin of young children. Common hepatitis and the jaundice which accompanies it are distinguished from the physiological yellowish colour of the skin of the newly-born, by the yellow colour being much more decided, much more general, and observed at the same time on the conjunctivæ and on the buccal mucous membrane in the jaundice of hepatitis, whilst this is not the case in what is termed the yellowish colouring of the skin of the newly-born.

This form of hepatitis is not at all serious, and its progress is never obstructed by important symptoms.

И

السلامة

Levering

TREATMENT.

Common hepatitis, or, as some call it, the icterus of infants, should be treated by tepid baths, either simple or aromatic, for one half hour, and repeated once or twice a day. Slight frictions should be made with spirits over the abdomen and the region of the liver. The children should also be wrapped in flannel. These means are sufficient to cause the disappearance of the disease in a few days.

When it is accompanied by enteritis or sclerema, the medicines recommended in the chapter devoted to these diseases should be made use of.

ON MALIGNANT OR SEVERE HEPATITIS.

This second form of acute hepatitis is more rarely met with than the preceding, and most physicians have probably never observed it; CLC Baumes, Richard de Nancy, Martin of Lyons, and Heinke, have related some cases of it.

Grave or malignant hepatitis becomes developed under precisely the same conditions as common hepatitis, only its anatomical lesions, progress, and fatal termination separate it in an absolute manner, to the same extent as we must distinguish common variola, scarlatina, and measles from malignant scarlatina and variola, &c.

Here, as we have previously remarked, the anatomical lesion is no longer simply a general icterus with sanguineous congestion of the liver, accompanied with hypertrophy of the organ, which takes place in common hepatitis; there is, in addition, considerable softening, and partial decoloration of the hepatic lobules, and here and there collections of pus disseminated in the lobes of the liver. Baumes, Richard, and Martin of Lyons, have, as I have before observed, reported several instances of multiple abscesses of the liver, with or without abscesses in other regions of the body.

In this last case it is very probable that the hepatitis is the consequence of umbilical phlebitis, and that the disseminated abscesses are the anatomical manifestation of purulent infection.

Newly-born children attacked with malignant hepatitis are feverish; their face is flushed, the skin of the body warm, red, yellowish, then completely yellow; the conjunctivæ and the under surface of the tongue yellowish, the urine highly coloured with yellow, tinging the linen. The jaundice is always perfectly evident.

The abdomen is hard, tense, painful at the right hypochondrium, and the swollen liver much exceeds its limits. The children have nausea, sometimes reject reddish matters, and void an abundant meconium, of a dark colour, or only a meconium discoloured yellow. According to Heinke, these matters are often grey, which seems to me to be opposed to the result of all observers.