ORIGINAL ARTICLES ON THE MENTAL HEBETUDE OR STUPOR OF PUL- BY ARTHUR DEVOE, M.D., O hard and fast adhesion to the theory of the causa NR tion of pneumonia by the diplococcus of Fraenkel has resulted in a generally accepted theory or formula of this disease, but certain class distinctions as to the bedside phenomena in the case of children as compared with adults are helpful for both diagnosis and treatment. A leading symptom in time and in the burden of its significance has been observed and commented on by nearly all writers on the subject of pneumonia in children. Does the general treatment employed with these little sufferers indicate that the origin and commands of this symptom have been duly interpreted and obeyed? Such is the burden of the inquiry here attempted. Clinical and didactic teachings represent the child in an early or incipient stage of pneumonia in picturesque and varied terms as lethargic, comatose; child lies in torpor; child lies quietly in its cradle in a seemingly somnolent state; lies in bed with eyes closed as if in sleep; child dozes and starts up fretfully to be soon again in troubled sleep, overcome by drowsiness. Child of eight was lying in bed very quietly in a very somnolent state and responded to questions very slowly and with eyes closed. Child of three years in comatose condition, temperature 106°, etc. A recent writer1 says that a pneumonia of the utmost virulence may demonstrate itself with but a single patch of of consolidation, and in the so-styled cases of cerebral pneumonia one may find a temperature of 106° with no apparent indications of inflammatory approach in the lung tissue. A standard authority2 says the child at this period lies with eyes shut, apparently in a half-conscious state, fretful if spoken to or aroused, so that the physician would be led to to suspect the presence of cerebral disease. A classical German writer3 on pediatrics tells us that in the large majority of cases pneumonia begins suddenly. He has occasionally noticed the initial chill in children over five years, and more frequently, repeated vomiting. This onset and the rapid rise of temperature may lead to error, as the respiratory symptoms may be entirely latent and cerebral symptoms appear, especially somnolence, delirium, dark-red face, glistening eyes. Examination of the chest gives either negative results, or, at the most, shows diminished vesicular breathing in the affected portion. This latency of the physical signs, which may continue from four to six days, in connection. with the predominance of cerebral or gastric symptoms, readily leads to the erroneous diagnosis of meningitis or the beginning of typhoid fever. One American text-book4 refers to the sympathetic disturbances of the stomach and bowels as obscuring the chest symptoms, and further on asserts that in young children the fatal termination is more frequent than recovery. The same writer says one form of croupous pneumonia differing in its course from the usual character of the disease in its severe cerebral symptoms, and peculiar to children, has been described as cerebral pneumonia. It possesses more the character of a meningitis than a pneumonia, and two varieties of it have been described-the eclamptic and the meningeal—according to the predominance of convulsions or delirium. Many writers note that the kidneys in pneumonia frequently give evidence of irritation and restricted function and all authorities might testify that the skin is morbidly hot or cold, overlying a tardy and unequal capillary circulation. Now, how shall we account for the mental dullness and sopor of incipient and developed pneumonia in children? Leaving the more or less hypothetical pneumococcus out of our reckonings we have a general condition of inefficient elimination via the skin, kidneys, bowels and lungs, resulting in a degree of uremia and antointoxication from the oppression of which the exceptionally impressionable child-brain manifests stupor associated with morbid irritation. Worms, diarrhea, intestinal obstruction, various infectious fevers and preputial irritations have been cited as causative of spasmodic trouble in children. Milder forms of intestinal irritation and indigestion in children have been held responsible for more specialized brain and motor reflexes resulting in defects of speech, severe and somewhat prolonged stuttering having been cured by the correction of intestinal errors. The nervous responsibilities of child-life which are centered in the due performance of the digestive functions far outweigh those of the natural relations and conditions of adult life. It is not strange that the child's brain in pneumonia should be more oppressed than the adult's. We may hereby readily understand why the so-called cerebral pneumonia is named as a disease peculiar to childhood, and also find clearer explanation of the fact that a final diagnosis may vibrate between pneumonia, meningitis and typhoid fever. Dr. Osler5 writes of the depressing action of the toxins in pneumonia on cardio-respiratory centers." In the pneumonia of children we should bear in mind the depressing effects of toxins and intestinal irritants on the conscious and general motor centers of the brain. The thesis may be conceded that croupous pneumonia is the result of infection of the blood by pneumococci; nevertheless the full fruition of that infection in developed pneumonia may be avoided by removing burdensome and poisonous matter from the body before the maturity of inflammatory action in the lung. This theory may not suit some of the adherents of the special germ theory but it is in line with the accepted belief that the healthy portion of our race resists the ever present bacillus tuberculosis and the Klebs-Loeffler germ by force of vital energy and good functional service in the elimination. If the child is seriously ill and exhibiting mental torpor and irritation we should not wait to make a positive diagnosis. of an existing pneumonia, meningitis or typhoid fever, but should proceed at once to assist elimination by unloading the bowels and promoting the action of all the eliminating organs, at the same time favoring an equal and just circulation of the blood in the general capillary system. In cases where the temperature is high cold water compresses should be placed around the chest and over the shoulders, at the same time protecting the brain by cold water applied to the forehead and nape of the neck. Any physician who will stand repeatedly at the bedside of his little pneumonia patient and witness the removal by cool ing enemas, say temperature 65° F., of offensive fecal matter, will not long remain in doubt as to whether the aggregate of toxic material and elements of toxic and gastric irritation have been lessened by the process. The impossibility of effecting complete intestinal asepsis seems to have discouraged attention to this subject. But the complete, the ideal, is not to be attained even in our cleansing of the hands and surgical instruments. Interiorly, the abatement of the mass of material and toxic pressure relieves the capillary circulation and gives new impulse to the unstripped muscular fibers. Moreover the suitable variation of temperature of the injected waters may give physiologic impulse just as surface stimulation is realized by hot or by cold baths, to fit the case. Besides the exceptional delicacy and activity of the childbrain in its relations to digestive processes, there are other reasons which should impel the physician in charge to secure prompt intestinal asepsis for his small pneumonia patients. Children are less cleanly in their habits than adults, less careful to guard the digestive tract from impurities taken into the mouth, or to avoid such. Children's mouths are also more foul than is the case with the average adult by reason of toxic generating carious teeth, whence flow toxic matters reaching the stomach and intestines and influencing the blood. From all of which it is urged that the prima via in children, from the buccal cavity down, should be effectively cleansed at every bed side where a feverish patient is confined. 1. 2. 3. J. J. Morrissey, M.D., New York. "Hyperpyrexia in Pneu monia." J. L. Smith, M.D. Text-book, 5th edition, p. 581. Dr. Edward Henoch, Diseases of Children. W. Wood & Co., 1882, N METHODS OF CARRYING BABIES. By A. D. MEWBORN, M.D., New York. WOWHERE in the world can one study woman as a burden carrier better than at Ellis Island. Here the selfishness of man has free play, untrammeled by the criticisms of conventional society. While the "lord of creation" may swing airily along with his tickets and passport, his wife must bring the baggage and babies. The means by which she seeks to economize her forces and her conservatism in adhering to time-honored customs are perhaps best shown in the way she carries her offspring. The most primitive manner was to carry the child on the back of the mother. Mason* says that in the tropics, "where the savage mother, being usually unclothed, ex cept with a sash, girdle, or apron, the child had to straddle the mother's hips as best he could and hold on to the girdle. When a shawl of any kind was used the rider could crawl into that; and when the mother, in addition to being locomotive and passengercar, had also freight to carry, the youngster rode on the top of the freight." It is interesting to note that among the animals most nearly resembling man in structure-the anthropoidsthe mother travels always with the young holding on to her neck or riding on the hips, the long hair of the mother enabling her to dispense with shawl or girdle. Slavonic Woman and Child *Mason.-Woman's Share in Primitive Culture. |