Leonard Findlay

Icterus Neonatorum: Its Incidence and Cause

In spite of the frequency of icterus neonatorum and the work done to elucidate the problems connected with it, there still remains much divergence of opinion regarding its incidence and pathogenesis. Estimates of the incidence vary from 40 to 80 per cent. of the nYewborn. Since the detection of jaundice is influenced by many factors, such as the vascularity of the skin and the nature of the light in which the observation is made, and since there are several definitions of jaundice, such varying estimates are not surprising. Icterus neonatorum has been ascribed to excessive haemolysis of the blood, to immaturity of the liver, to increased viscosity of the bile, and to the breakdown of the mothers blood in the placenta. The hypothesis that the jaundice was hepatic in origin has been replaced by one that it is caused by excessive haemolysis. Since bilirubin is a product of the breakdown of haemoglobin, all jaundice may be said to be the result of haemolysis, but the evidence of excessive haemolysis as a cause of icterus neonatorum is inconclusive. During the past year, in the course of biochemical and haematological investigations of haemolysis, there occurred an opportunity to study newborn babies, and an investigation of icterus neonatorum was undertaken, (1) to determine the incidence, (2) to try to detect any difference in the rate of haemolysis in jaundiced and non-jaundiced infants, and (3) to seek evidence of impairment or immaturity of liver function.

Bronchiectasis in Childhood: Its Symptomatology, Course and Cause.

INTRODUCTION. There are three conditions, viz: bronchiectasis, chronic or unresolved pneumonia, and pulmonary tuberculosis, which have always given, and still do give rise to difficulty in their differentiation. Until recently the finding of the tubercle bacillus has been our chief, if not our only aid, in this differentiation , though from a knowledge that such is not always positive many cases of bronchiectasis and simple chronic pneumonia, at least in childhood, have been certified as cases of pulmonary tuberculosis and admitted to Sanatoria. It might be thought that with the advent of radiology great assistance would have been rendered in this direction, but when we recall that any consolidation of lung tissue will obstruct the passage of the X-rays and cast a shadow the limitations of this method of examination will be apparent. Nevertheless, if one appreciates the usual course of pulmonary tuberculosis during childhood, X-ray examination of the chest does givc considerable help. Pulmonary tuberculosis as it is met with by the paediatrician is on the

Atelectatic or compensatory bronchiectasis

Atelectasis or collapse of the lung as a cause of bronchiectasis is not by any means a recent idea. Reynaud, as long ago as 18351, in a comprehensive study of bronchial obstruction, noted that dilatation of the lumen might be present both proximal and distal to the obstruction. The dilatation proximal to the obstruction he ascribed to the increased force of the inspired air held up at the obstruction and that beyond the obstruction he considered was due to the bronchi attempting to fill the space vacated by the collapsed lung.

Osteomyelitis of the spine following lumbar puncture

Case report The patient was a boy aged one month who was admitted to the Radcliffe Infirmary, Oxford, on March 6. 1942. He was the second child of healthy parents, born on February 2 with a weight of 6 lb. after a normal pregnancy. He was breast fed and progressed satisfactorily till the age of three weeks when he developed a cold in the head and a rash on the face and buttocks. At first the child did not seem seriously upset, for he continued to take his feeds well without any vomiting and to have regular and normal evacuation of the bowel. Two or three days before coming under observation, however, he had been manifestly ill, refusing the breast and seeming breathless; and for twenty-four hours the left eye had been discharging. On admission to hospital he was noted to be a small, wasted and dehydrated infant weighing 51 lb. The temperature (rectal) was subnormal -96F. There was much excoriation of the cheeks, a profuse nasal discharge, purulent conjunctivitis of the left eye and ulceration of the buttocks, scrotum and legs, apparently of a septic nature. Examination of the chest revealed poor air entry and scme moist and dry rales generally, but no dullness to percussion. The abdomen was distended with the liver palpable one finger-breadth below the costal margin, but the spleen could not be felt. There were no abnormal neurological signs. The urine presented a deposit of urates, but contained no albumin, blood or pus. Blood count: Hb. 100 per cent., red blood cells 4,240,C00. white blcod cells 4,000 per c.mm. A provisional diagnosis of generalized bronchitis following an upper respiratory infection in a marantic and badly cared for infant was made. Next day. however, slight nuchal rigidity was present, and during a routine examination the child had two short convulsive seizures. each lasting about a minute. This change in the clinical picture raised the question of meningitis and the necessity fcr an examination of the cerebro-spinal fluid. Lumbar puncture was attempted on two cccasions. but no fluid was obtained. and at the time. frcm the grating of the needle, the operator was conscious that the vertebral column had been injured. On the following day (March 8) the child seemed better: there had been no recurrence of convulsions. the conjuncti-al discharge was less profuse, the septic condition of the skin had improved. he was taking his feeds well and had gained some weight: there was, however. slight fever (101 6F.). Although the childs general condition continued to improve. fever. varxing betw-een 101F. and 103F.. persisted. and on March I11 i.e. four days after the attempted lumbar puncture, the needle track was observed to have become infected, and was discharging pus from which the staphylococcus aureus was grown. On this date the bacteriologist reported that the discharge from the eye revealed the presence of a gramnegative diplococcus indistinguishable from the gonococcus, and in consequence sulphapyridine (M & B 693) was administered by mouth in addition to argyrol 10 per cent., which had been applied locally to the eye since admission. On this date it was also learned that the Wassermann and Kahn tests were negative. In spite of the administration of sulphapyridine. fever persisted and the local infection at the seat of the lumbar puncture continued to advance. By March 14 a fluctuant swelling requiring incision had developed. Nevertheless, the childs general condition had improved still further, the eye had cleared, the septic state of the skin had almost completely healed, he had continued to take his feeds well and to increase in weight. In view of this general improvement, the apparent localization of the infection to the subcutaneous tissues surrounding the needle track, and especially because the etiological organism was the staphylococcus aureus against which sulphapyridine is not particularlv effective, treatment with this drug was interrupted. Thereafter, the local infection rather improved. probably because of the incision of the abscess and the better drainage, and within three days fever had disappeared. However, three daYs later (March 25) fever returned and examination now revealed swelling of the lumbar region of the spinal column and an x-ray picture showed destruction of the bodies of the second and third lumbar vertebrae and the intervening intervertebral disc space. Treatment with sulphathiazole was now instituted and continued for six days. Within twelve hours of the presentation of this drug the fever subsided. and with the exception of a slight and occasional rise duLring the following two weeks, the temperature continued w-ithin normal limits. In spite of the absence of fever. the local condition of the spine persisted unchanged. and on March 30, oedema of the left leg below the knee made its appearance. and a fedays later, the right leg was also noted to be oedematous. The swelling of the left leg extended to the thigh and lowver abdomen with considerable glandular enlargement in the groin. Finally, the scrotum was also oedematous. At this stage the left femur felt thickened and x-rav examination revealed periostitis of the shaft, and subluxation of the left hip joint. On April 13 a sxwelling on the palmar aspect of the second finger of the left hand was observed which x-ray examina-

Otitis Media as an Aetiological Factor in Gastro-Enteritis

The idea that otitis media is a possible factor in the actiology of acute gastro-enteritis is by no means of recent date. Ever since the sixties of last century this is a view which has been stressed periodically, and, although not generally accepted, it has received support particularly of otologists anld morbid anatomists. One of the most remarkable features in the pathology of childrens diseases is the absence of any naked-eye or microscopic lesion in the alimentary tract of children dying of severe gastro-enteritis. It is the case of pneumonia, pyelo-nephritis or niarasmus with a terminal or passing diarrhoea which presents an abnormality of the gut. Frequently, however, although in my opinion not so often as is generally stated, pus is found in one or both ears. Occasionally a suppurative nephritis may be detected but the most common post-mortem finding is broncho-pneumonia. From the localization and histological characters it is possible to express an opinion regarding the age and type of the pneumonia, but unfortunately this is not so in the case of otitis. So far as I am aware, one cannot decide from the morbid anatomy the duration of the inflammation of the middle ear, and thus whether it was, or was not, in existence prior to the onset of the gastroenteric symptoms. This of course is the crux of the matter. No doubt the adherents of the hypothesis that otitis media is the cause of gastro-enteritis are influenced by the doctrine of focal sepsis, which has been a favourite explanation of any disease of still undecided aetiology, as pernicious anaemia and rheumatoid arthritis amply testify. In contrast to otologists and morbid anatomists, paediatricians for the most part have been sceptical that in focal sepsis, of which otitis media is only one example, is to be found a serious cause of gastro-enteritis, and for this scepticism there are several good reasons. In the first place, it must be remembered that of all the functions during infancy nutrition is the most important. At no other period of life is growth so rapid. Digestion and