20. Jaundice.-Icterus Infantilis.

It is not unusual for the whole surface of an infant's body, as well as the tunica conjunctiva, to acquire, two or three days after birth, a yellow hue, more or less intense, which, in the course of a few days, in general, gradually disappears. (Icterus neonatorum.) It is an affection of very little importance, appearing to depend upon a temporary excess of the coloring matter of the bile in the serum of the blood, unattended with disease of the liver, or any of the other organs. In some cases, it has appeared to us to be connected with the want of a free evacuation of the meconium. Occasionally, the discoloration of the skin will be accompanied with a good deal of drowsiness, and an evident sense of uneasiness of the surface. Nothing more is required in any case, than a dose of castor oil, or a grain or two of calomel, and the same quantity of rhubarb, with the daily use of the warm bath.

In some cases the skin of the infant is marked by dull-yellow, irregular blotches (maculæ hepatica), more or less extensive; sometimes occupying the greater part of the surface. The color of the blotches varies in intensity; in cases where there exists considerable derangement of the alimentary canal, they occasionally assume a very dark hue (melasma)—they are sometimes accompanied with a prickling or tingling sensation.

The disease appears to be most generally connected with derangement of the digestive organs-the discoloration of the skin being dependent upon a morbid secretion from the cutaneous vessels. It has little or no affinity with jaundice. Considerable debility and languor, and indications of a disordered state of the alimentary canal, generally precede its occurrence.

Its removal is to be effected by such means as are calculated to restore the regular and healthy functions of the digestive organs, and to improve the health of the infant generally. In all cases, the breastmilk of a healthy nurse, pure fresh air, and daily use of the warm. bath, with gentle friction of the surface, are important parts of the

treatment.

Genuine jaundice, with intense yellowness of the skin and tunica conjunctiva, nausea or vomiting, costiveness-the evacuations, when procured, being white or clay-colored-and a deep yellow color of the urine, may occur in infants from congenital obstruction or malformation of the biliary ducts. Under such circumstances, the disease is incurable, and sooner or later will prove fatal.

In the Northern Journal of Medicine, Dr. A. B. Campbell relates three cases of icterus in new born infants, all of which terminated fatally. In two, the disease was found to depend on congenital absence of the hepatic and cystic ducts, and in the other upon obstruction of the common biliary duct by inspissated bile. In the first case the jaundiced hue of the skin appeared the day after birth: the infant, however, continued well until the ninth day-though the evacuations from the bowels were white: a hemorrhage from the umbilicus then occurred, and returned on the following day, when the child died. The gall-bladder was found to be a shut sac, the hepatic and cystic

ducts being both wanting the blood was tinged with bile. In the second case, the symptoms occurred early-no hemorrhage took place. The infant wasted away, while its abdomen enlarged at both hypochondriac regions. The patient lived until the sixth month, being attacked immediately preceding its death with violent diarrhoea and vomiting of a fluid like coffee grounds. The liver was large-the gall bladder, as well as the ducts, was absent-the blood and various tissues were tinged with bile. The third case closely resembled the first. Hemorrhage from the umbilicus occurred on the seventh day, and returned at intervals until the eleventh, when the child sunk into a comatose state and died. The whole amount of blood discharged did not exceed an ounce and a half. The gall-bladder was full of bile, the escape of which was prevented by a plug of inspissated bile, which filled the common duct. The brother of this infant died at the same age and with similar symptoms.

Similar morbid phenomena, with the addition of pain and tenderness of the epigastrium, vomiting of the food soon after it is swallowed, or, if retained, violent paroxysms of pain, occurring an hour or two after it is taken, may be produced in infants by inflammation, acute or subacute, of the mucous membrane of the duodenum. Here the treatment must be directed entirely to the removal of the latter disease: mild mucilaginous fluids in small quantities, a few leeches to the epigastrium, followed by warm fomentations, or an emollient cataplasm. After the inflammation has been, in this manner, reduced, a blister should be applied to the epigastrium, and kept on for two or three hours, and then replaced by a soft bread and milk poultice, and, internally, very minute doses of calomel and ipecacuanha should be given three or four times a day.

In many cases, however we have certainly met with a great number-the jaundice of infants is dependent upon a state of hyperæmia, or of subacute inflammation of the liver. In these cases, the color of the skin and eyes is of a dirty yellow-the surface is harsh and dry; the urine is charged with bilious matter; the stools are dry and clay colored; the countenance has an anxious, distressed expression, and the infant is apt to fall into a languid, drowsy state; there is considerable thirst, acidity of stomach, flatulence, and frequent griping or colicky pains; and with these symptoms, there is always more or less fulness of the right hypochondriac region, with great tenderness upon pressure. The disease, in general, assumes a chronic character, and is attended with considerable and progressive emaciation, and with tumefaction and hardness of the abdomen; frequently with oedema of the lower extremities, and sometimes with effusion within the peritoneal cavity. The tongue, which was at first coated with a thin layer of yellowish mucus, becomes, in the progress of the disease, dry, and of a dark-brown color. Induration of the subcutaneous cellular texture occasionally occurs, and more frequently purpura, either simple or hemorrhagic.

This form of jaundice is, in general, produced by the same causes which give rise, in infancy, to derangement of the digestive organs. When depending upon hyperæmia of the liver, it is usually connected

with the indications of a general plethoric condition of the system, and a very languid circulation. It has been supposed by Eberle most apt to occur in infants who, when born, present a turgid and livid appearance of the face and body, and an oppressed state of the brain; which have not been sufficiently relieved by a flow of blood from the divided vessels of the cord.

The treatment must be governed by the character of the symptoms in each case. When simple hyperemia of the liver exists, an emetic of ipecacuanha should be given, and repeated in a day or two, if circumstances require it. The emetic should be succeeded by the warm bath, and gentle friction over the whole surface of the abdomen, and by a grain or two of calomel, followed by castor oil, or magnesia and rhubarb. The bowels should be kept regularly open by divided doses of calomel, magnesia, and ipecacuanha, given three times a day, with an occasional dose of castor oil, the activity of which may be increased by a few drops of turpentine. The warm bath should be repeated daily, and the infant allowed the benefit of a free, pure, atmosphere.

When the case is marked by symptoms indicative of hepatic inflammation, a few leeches should be applied to the right hypochondrium, and followed by an emollient cataplasm. The leeches may be repeated, after a short interval, if the fulness and tenderness of the right hypochondrium continue with little abatement. Calomel should be administered in the same manner as directed above. After the hepatic inflammation has been somewhat reduced, the warm bath, followed by a blister over the liver, will, in general, be found of decided advantage; the blister should be removed in three hours, and the part to which it has been applied covered with a soft emollient poultice. When the calomel produces irritation of the intestines, we may combine it with small doses of the extract of hyoscyamus,' which in no degree interferes with its action upon the bowels. The use of the calomel, with an occasional purgative of castor oil and turpentine, should be continued, until natural, bilious stools are procured, when it should be suspended, and the freedom of the bowels maintained by the use of the citrate of magnesia and rhubarb, or castor oil.

1R.-Calomel. gr. iij.
Ipecacuanhæ, gr. ij.

Magnes. calc. gr. xxxvj.

Ext. hyoscyami, gr. iv.-M. f. ch. No. xij.

In the chronic form of infantile jaundice, the warm bath, followed by frictions, blisters to the right hypochondrium, and a cautious use of calomel and ipecacuanha, in alterative doses, are the remedies from which the most benefit is to be anticipated. The carbonate of soda, may, in many cases, be administered with advantage; a grain or two should be given every two or three hours, dissolved in a teaspoonful of carbonated water, or in the same quantity of a weak infusion of hops; or, it may be given in combination with taraxacum.1 We have seen

very striking advantage result, in many of the chronic cases of jaundice occurring in infants, from the taraxacum, in combination with the vegetable alkalies; whilst in other cases, again, we have given it in

tolerably large doses, and continued its use for some time, without any benefit whatever.

In the chronic form of infantile jaundice, if there is considerable flatulence of the intestines, with frequent griping or colicky pains, the turpentine has, in our hands, succeeded the best in removing the tendency to the formation of gas, and relieving the suffering of the patient. We have, generally, at the same time that we administered the turpentine in the dose of from five to ten drops, according to the age of the patient, every three hours-directed a dose of extract of hyoscyamus, in combination with ipecacuanha and carbonate of soda, three times a day, and a camphorated mercurial plaster over the whole of the right hypochondrium.

'B.—Taraxaci, Jij.

Bicarb. sodæ, gr. xxiv.-xxx.
Aquæ, 3ij.

Syrup. limon. 3ij.-M.

Dose, a teaspoonful every four hours.

2

R.-Extr. hyoscyami, gr. iv.—vj.
Ipecacuanhæ, gr. ij.—iij.
Bicarb. sodæ, gr. xxiv.-xxxvi.
M. f. pil. No. xij.

When we have succeeded in procuring natural, bilions discharges from the bowels, and the skin begins to assume its natural hue, the restoration of the patient's strength may be promoted by some light tonic; either the cold infusion of bark, or the sulphate of quinia, or some preparation of iron, as the proto-carbonate or the tincture of the sesquichloride; with a light vegetable diet, the warm bath daily, gentle exercise in the open air, and occasional doses of some mild purgative, to keep the bowels regular if they are inclined to costiveness.

21. Purulent Ophthalmia.-Ophthalmia neonatorum. —

Infantile Conjunctivitis.

The purulent ophthalmia of infants commences, usually within a few days after birth generally between the third and seventh. We have seen it, however, upon the second day, and, occasionally, not until the third week.

The first indication of the disease is, generally, the eyelids becoming glued together during the night, with swelling and redness externally. When the lid is raised there occurs a gush of tears, and its conjunctiva is found to be uniformly red, slightly thickened, and covered often with a somewhat tenacious, transparent coating.

As the disease proceeds, the lids become more constantly aggluti nated; an increased secretion from the surface of the inflamed conjunctiva takes place, of a thick, purulent matter, a portion of which exudes from between the lids, but the greater part is retained, causing a considerable bulging of the palpebræ-the integuments of which assume a dark-red hue. The child becomes fretful and uneasy, and manifests the utmost intolerance of light-keeping the eyes firmly and constantly closed, and averted from the light. The tumefaction and redness of the conjunctiva rapidly increase, and extend over the globe of the eye. Every separation of the eyelids is attended with a gush of purulent matter, which sometimes is so copiously effused as to burst open the firmly-closed lids, and run down the cheek in large drops. The thickening of the conjunctiva often becomes so considerable, in

the course of three or four days, as to rise up around the cornea, nearly concealing it, or causing it to appear as if sunk deep into the eye.

The intumescence of the conjunctiva causes it to become everted upon every attempt to examine the affected organ, or every time the child cries. Not unfrequently, the constant pressure of the orbicularis muscle renders the eversion permanent.

The discharge from the eye is generally of a pale straw-color; sometimes of a deeper yellow; and, not unfrequently, it assumes a greenish hue; it is said, in some cases, to be ichorous, or mixed with blood. An ichorous state of the discharge we have never seen; but, occasionally, have known a small amount of blood to be mixed with it.

A slight hazy condition of the cornea very generally occurs, and this may continue for a week or longer, without any permanent destruction of its transparency. About the tenth or twelfth day, sometimes later, purulent infiltration of the cornea, however, takes place; or an interstitial deposit in the conjunctival layer or substance of the cornea. When purulent infiltration occurs, ulceration may ensue, either of the entire cornea, or of a small, circumscribed portion of it, giving place to prolapsus of the hyaloid coat, or of the iris only. When an interstitial deposit takes place, complete opacity of a part, or of the whole of the cornea may result, or a thin, bluish-gray film may form over its surface. When a considerable portion of the cornea is destroyed by ulceration, the humors of the eye ordinarily escape, and the globe collapses.

There appear to be two forms of purulent ophthalmia, as it occurs in children; one in which the inflammation is confined exclusively to the conjunctiva of the lids; another in which the conjunctiva of the eyeball becomes equally involved in the disease. In the first, the disease is of a much milder character, and is seldom attended with any very serious injury to the eye; occasionally, however, it is equally severe in its symptoms, and protracted in its course, as when the inflammation affects the whole of the conjunctiva. We have repeatedly seen the inflammation confined, for a number of days, to the palpebral conjunctiva, and then suddenly extend over the ball of the eye, and be quickly followed by infiltration and ulceration of the cornea.

In cases where neither complete opacity or extensive ulceration of the cornea occur, adhesion of the iris to the latter may take place; or an opaque spot, not larger than the head of a small pin, may be formed in the centre of the anterior hemisphere of the capsule of the lens. Both eyes are generally attacked, either simultaneously, or within a very short interval of each other.

The result, favorable or unfavorable, of infantile purulent ophthal mia, will depend pretty much upon the greater or less violence of the attack, and the period at which the treatment is commenced. In its early stages, the disease is by no means difficult to cure; but in its advanced stages, it is seldom arrested, until more or less injury to the eye has taken place. So long as the cornea retains its transparency, there is a possibility of saving the eye; when ulceration or purulent infiltration of the cornea has occurred, although the inflammation may still be removed, the sight will be permanently destroyed.