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Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh

Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh

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Description: With the in-depth coverage you need, this text helps you provide quality treatment for neonates, infants and pediatric patients. It discusses the principles of neonatal and pediatric respiratory care while emphasizing clinical application. Not only is this edition updated with the latest advances in perinatal and pediatric medicine, but it adds a new chapter on pediatric thoracic trauma plus new user-friendly features to simplify learning. 1. Front Matter 2. Dedication 3. Contributors 4. Reviewers 5. Preface 6. AUDIENCE 7. New to this Edition 8. LEARNING AIDS 9. Evolve Resources—http://evolve.elsevier.com/Walsh/perinatal/ 10. For the Instructor 11. For Students 12. ACKNOWLEDGMENTS 13. Section I Fetal Development, Assessment, and Delivery 14. Chapter 1 Fetal Lung Development 15. LEARNING OBJECTIVES 16. STAGES OF LUNG DEVELOPMENT 17. Embryonal Stage 18. TABLE 1-1 Classification of Stages of Human Intrauterine Lung Growth 19. Pseudoglandular Stage 20. FIGURE 1-1 Embryonal stage of lung development: the trachea and major bronchi at A to C, 4 weeks; D and E, 5 weeks; F, 6 weeks; G, 8 weeks. 21. Canalicular Stage 22. FIGURE 1-2 Canalicular stage of lung development at 22 weeks of gestation. A terminal bronchiole (bottom left) leads into a prospective acinus. Note that branches are sparse. 23. Saccular Stage 24. Alveolar Stage 25. POSTNATAL LUNG GROWTH 26. FIGURE 1-3 Saccular stage of lung development at 29 weeks of gestation. Secondary crests (arrows) begin to divide saccules into smaller compartments.
27. FIGURE 1-4 Alveolar stage of lung development at 36 weeks of gestation. Note the double capillary network (solid arrows, center and right) and the single capillary layer (arrow at left). 28. FIGURE 1-5 Alveolar stage of lung development at 36 weeks of gestation: thin-walled alveoli are present. 29. FACTORS AFFECTING PRENATAL AND POSTNATAL LUNG GROWTH 30. ABNORMAL LUNG DEVELOPMENT 31. PULMONARY HYPOPLASIA 32. ALVEOLAR CELL DEVELOPMENT AND SURFACTANT PRODUCTION 33. FETAL LUNG LIQUID 34. ASSESSMENT QUESTIONS 35. References 36. Chapter 2 Fetal Gas Exchange and Circulation 37. LEARNING OBJECTIVES 38. MATERNAL-FETAL GAS EXCHANGE 39. FIGURE 2-1 Implanted human embryo, approximately day 28, showing the relationship of the chorion, amnion, and chorionic villi. The umbilical cord and tail are difficult to differentiate in this view. 40. Box 2-1 Origin of the Various Tissue Systems From the Three Embryonic Germ Layers* 41. ECTODERM 42. MESODERM 43. ENDODERM 44. CARDIOVASCULAR DEVELOPMENT 45. Early Development 46. TABLE 2-1 Timetable of Significant Events During Fetal Heart Development 47. Chamber Development 48. FIGURE 2-2 Formation of the primordial heart chambers after fusion of the heart tubes at a gestational age of 3 weeks. 49. FIGURE 2-3 A, Sagittal view of the developing heart during week 4, showing the position of the atrium, bulbus cordis, ventricles, and endocardial cushions merging from the ventral and dorsal sides. B, Traditional view of the developing heart during weeks 4 to 5, showing budding interventricular septum, fused endocardial cushions. septum primum, and the left and right atria. The ventricular septum continues to fold and grow upward between the ventricles. 50. Maturation 51. FIGURE 2-4 Frontal view of the fetal heart between weeks 5 and 6, showing the development of the four chambers nearing completion. The arrow shows the one- way path through the foramen ovale. 52. FIGURE 2-5 Frontal view (right) and side view (left) schematics of the foramen ovale. The septum primum forms the flap, and the septum secundum remains open to form the foramen ovale. The arrows show the one-way path through the foramen ovale. 53. FETAL CIRCULATION AND FETAL SHUNTS
54. FIGURE 2-6 A diagram of the fetal circulation, showing blood containing oxygen and nourishment moving from the placenta to the fetal heart and through the three fetal shunts: the ductus venosus, the foramen ovale, and the ductus arteriosus. 55. TRANSITION TO EXTRAUTERINE LIFE 56. ASSESSMENT QUESTIONS 57. References 58. Chapter 3 Antenatal Assessment and High-risk Delivery 59. LEARNING OBJECTIVES 60. MATERNAL HISTORY AND RISK FACTORS 61. Preterm Birth 62. Cervical Insufficiency 63. Toxic Habits in Pregnancy 64. Alcohol 65. Smoking 66. Cocaine 67. Hypertension and Diabetes Mellitus 68. Hypertension 69. Diabetes 70. Pregestational Diabetes 71. Gestational Diabetes Mellitus 72. Infectious Diseases 73. Group B Streptococcus 74. Herpes Simplex Virus 75. Hepatitis B Virus and Human Immunodeficiency Virus 76. HIV 77. HBV 78. Fetal Membranes, Umbilical Cord, and Placenta 79. Disorders of Amniotic Fluid Volume 80. Mode of Delivery 81. Breech Presentation 82. Assisted Vaginal Delivery 83. Cesarean Delivery 84. ANTENATAL ASSESSMENT 85. Ultrasound 86. FIGURE 3-1 Ultrasound picture of a fetus at 23 weeks of gestation (top), with a Doppler study of the fetal heart (bottom). Dop, Doppler; Fr, frame; Freq, frequency; PRF, pulse-repetition frequency; SV, sample volume; WF, wall filter. 87. Amniocentesis 88. Nonstress Test and Contraction Stress Test 89. FIGURE 3-2 A nonstress test recording, produced with a cardiotocograph. A, The fetal heart rate (FHR) is recorded with an ultrasound probe as changes in beats per minute (bpm) over time. B, Uterine contractions (UC) are recorded with a pressure transducer as changes in pressure (mm Hg) over time. In this case the nonstress test is reactive, indicating normal uteroplacental function. 90. Fetal Biophysical Profile 91. INTRAPARTUM MONITORING
92. HIGH-RISK CONDITIONS 93. Preterm Labor 94. TABLE 3-1 Biophysical Profile Scoring 95. FIGURE 3-3 Early decelerations (coinciding with uterine contraction) are usually due to fetal head compression and pose little threat to the fetus. 96. FIGURE 3-4 Variable decelerations are the most common. They are due to cord compression and have different configurations. Repetitive severe variable decelerations are associated with increased risk of fetal hypoxia. 97. FIGURE 3-5 Late decelerations are due to uteroplacental insufficiency. They usually begin at the peak of the contraction and are associated with fetal distress. 98. TABLE 3-2 Normal Values for Fetal Scalp Blood and Umbilical Cord Blood Gases 99. Postterm Pregnancy 100. ASSESSMENT QUESTIONS 101. References 102. Chapter 4 Neonatal Assessment and Resuscitation 103. LEARNING OBJECTIVES 104. PREPARATION 105. Box 4-1 Perinatal Factors Associated With Increased Risk of Neonatal Depression 106. ANTEPARTUM (FETOMATERNAL) 107. INTRAPARTUM 108. STABILIZING THE NEONATE 109. Drying and Warming 110. FIGURE 4-1 Correct and incorrect head positions for resuscitation. 111. Clearing the Airway 112. FIGURE 4-2 Meconium aspirator, with an endotracheal tube attached to one end and a suction source attached at the other end. 113. Providing Stimulation 114. ASSESSING THE NEONATE 115. Respiration 116. Heart Rate 117. Skin Color 118. Apgar Score 119. FIGURE 4-3 Algorithm for resuscitation of the newborn. HR, Heart rate (beats/min). 120. TABLE 4-1 Apgar Scoring 121. Apgar Score in the Very Low Birth Weight Infant 122. RESUSCITATING THE NEONATE 123. Oxygen Administration 124. Ventilation 125. FIGURE 4-4 Correct technique for holding a mask to the face of a newborn. Note that fingers do not touch the neck or soft tissue under the chin. 126. FIGURE 4-5 Incorrect technique for holding a mask to the face of a newborn. Note that the fingers are touching the neck and soft tissue under the chin, causing airway obstruction.
127. TABLE 4-2 Advantages and Disadvantages of Three Devices for Delivering Positive-pressure Ventilation to Neonates 128. Chest Compressions 129. Medications 130. Epinephrine 131. Volume Expanders 132. Naloxone 133. Sodium Bicarbonate 134. Postresuscitation Care 135. Ethical Considerations 136. Assessment Questions 137. References 138. Section II Assessment and Monitoring of the Neonatal and Pediatric Patient 139. Chapter 5 Examination and Assessment of the Neonatal Patient 140. LEARNING OBJECTIVES 141. GESTATIONAL AGE AND SIZE ASSESSMENT 142. FIGURE 5-1 Ballard examination for estimating gestational age, using scores determined on the basis of neurologic and physical signs. 143. PHYSICAL EXAMINATION 144. FIGURE 5-2 Overview of conditions producing neonatal morbidity and mortality by birth weight and gestational age. RDS, Respiratory distress syndrome. 145. Vital Signs 146. TABLE 5-1 Normal Values for Vital Signs in the Neonatal Patient 147. General Inspection 148. FIGURE 5-3 “Waiter's tip” positioning of the left arm of an infant with brachial plexus injury from a traumatic delivery. 149. Respiratory Function 150. TABLE 5-2 Common Dermal Findings in the Neonatal Patient 151. FIGURE 5-4 Silverman scoring system for assessing the magnitude of respiratory distress. Exp., Expiratory; insp., inspiratory; retract., retraction. 152. Chest and Cardiovascular System 153. TABLE 5-3 Signs of Respiratory Distress in the Neonatal Patient 154. Abdomen 155. FIGURE 5-5 Infant with prune-belly syndrome. 156. Head and Neck 157. Musculoskeletal System, Spine, and Extremities 158. FIGURE 5-6 Infant with an open spinal defect. 159. FIGURE 5-7 Infant with myelomeningocele. 160. Cry 161. NEUROLOGIC ASSESSMENT 162. LABORATORY ASSESSMENT 163. TABLE 5-4 Laboratory Values in the Neonatal Patient 164. Box 5-1 “Red Flags” in Neonatal Patients 165. RESPIRATORY 166. CARDIAC 167. RENAL
168. GASTROINTESTINAL 169. METABOLIC 170. GENERAL 171. ASSESSMENT QUESTIONS 172. References 173. Chapter 6 Examination and Assessment of the Pediatric Patient 174. LEARNING OBJECTIVES 175. PATIENT HISTORY 176. Chief Complaint 177. New Patient History 178. Box 6-1 New Patient History 179. CHIEF COMPLAINT OR PRIMARY REASON FOR VISIT 180. History of Present Illness 181. Past Medical History 182. Review of Symptoms 183. Family History 184. Social and Environmental Histories 185. Follow-up or Established Patient History 186. Box 6-2 Follow-up or Established Patient History 187. CHIEF COMPLAINT AND/OR PREVIOUS DIAGNOSIS OR PROBLEM 188. Interim History 189. Review of Key Components 190. PULMONARY EXAMINATION 191. Box 6-3 Pulmonary Examination 192. Inspection 193. TABLE 6-1 Normal Respiratory Rates in Sleeping and Awake Pediatric Patients 194. FIGURE 6-1 Head bobbing. 195. Palpation 196. FIGURE 6-2 Intercostal retractions. Soft tissue between the ribs is pulled inward (retracted) because of the extremely high negative pleural pressure. 197. FIGURE 6-3 Suprasternal retractions. Soft tissue in the suprasternal space is retracted because of high negative pressure, most often caused by the patient's attempt to breathe against an airway obstruction. 198. Percussion 199. FIGURE 6-4 Subcostal/substernal retractions. Airway obstruction results in a pulling inward of the lower costal margins. The abdomen is protruding (1), and there is a sunken substernal notch (2). See-saw movement of the chest and stomach is also present. 200. FIGURE 6-5 Technique for determining tracheal position in the older child. 201. Auscultation 202. NONPULMONARY EXAMINATION 203. Box 6-4 Nonpulmonary Examination: Findings Possibly Associated With Pulmonary Disease 204. GENERAL 205. EARS, EYES, NOSE, THROAT
206. HEART 207. ABDOMEN 208. SKIN 209. EXTREMITIES 210. FIGURE 6-6 A, Normal finger viewed from above and in profile, and the changes occurring in established clubbing, viewed from above and in profile. B, The finger on the left demonstrates normal profile (ABC) and normal hyponychial (ABD) nail-fold angles of 169 and 183 degrees, respectively. The clubbed finger on the right shows increased profile and hyponychial nail-fold angles of 191 and 203 degrees, respectively. C, Distal phalangeal finger depth (DPD)/interphalangeal finger depth (IPD) represents the phalangeal depth ratio. In normal fingers, the IPD is greater than the DPD. In clubbing, this relationship is reversed. D, Schamroth sign: in the absence of clubbing, opposition of the index fingers nail-to-nail creates a diamond-shaped window (arrowhead). In clubbed fingers, the loss of the profile angle due to an increase in tissue at the nail bed causes obliteration of this space (arrowhead). 211. LABORATORY TESTING 212. Box 6-5 Laboratory Evaluation 213. THE HEALTH CARE TEAM 214. CASE STUDIES 215. CASE 1 216. Family History 217. CASE 2 218. CASE 3 219. Box 6-6 History Taking in the Pediatric Patient With Asthma 220. MANIFESTATIONS 221. AGGRAVATING FACTORS 222. ALLEVIATING FACTORS 223. ASSOCIATED CONDITIONS (REVIEW OF SYMPTOMS) 224. FAMILY HISTORY 225. ENVIRONMENTAL EXPOSURES 226. ASSESSMENT QUESTIONS 227. References 228. Chapter 7 Pulmonary Function Testing and Bedside Pulmonary Mechanics 229. LEARNING OBJECTIVES 230. DEFINITIONS 231. SPECIAL CONSIDERATIONS 232. Neonatal Testing 233. Pediatric Testing 234. Instrumentation 235. Selection of Data for Analysis 236. MECHANICS OF BREATHING IN NEWBORNS 237. FIGURE 7-1 A pneumotachometer with a pulmonary function testing (PFT) computer system. As gas flow passes through the restrictive element, the difference in pressure between P1 and P2 is converted to a flow measurement. The flow rate over time is then converted to volume measurement. 238. Lung Inflation and Transpulmonary Pressure
239. NEONATAL PULMONARY FUNCTION TESTING IN THE LABORATORY 240. Measuring Static Compliance and Airway Resistance 241. Measuring Functional Residual Capacity 242. FIGURE 7-2 Volume–pressure loops of tidal breathing at various levels of functional residual capacity (FRC): a, low FRC; b, normal FRC; c, elevated FRC. 243. Helium Dilution Method 244. Nitrogen Washout Method 245. Plethysmography 246. Measuring Maximal Expiratory Flow by Rapid Thoracic Compression Technique 247. FIGURE 7-3 Partial expiratory flow–volume (PEFV) curves with identification of maximal expiratory flow at FRC (VmaxFRC), demonstrating a normal resting tidal breath and one with flow limitation. A, Normal; B, abnormal (flow limited). 248. PEDIATRIC PULMONARY FUNCTION TESTING IN THE LABORATORY 249. Standard Spirometry 250. Flow–Volume Loop 251. FIGURE 7-4 A normal standard time–volume spirometry graph, depicting the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75). 252. FIGURE 7-5 Normal flow–volume loop, showing both the expiratory and the inspiratory loops. The usual flow rates are identified. Note that no forced expiratory volume in 1 second (FEV1) is evident because there is no time axis. FEF50, Forced expiratory flow at 50% of vital capacity; FVC, forced vital capacity; PEFR, peak expiratory flow rate; RV, residual volume; TLC, total lung capacity. 253. FIGURE 7-6 This expiratory flow–volume loop demonstrates the patient's failure to exhale completely to residual volume (RV). This will artificially decrease FVC and increase FEF50. 254. FIGURE 7-7 Comparison of a forced expiratory flow–volume curve starting from 100% of total lung capacity (TLC) with a curve starting at 75% of TLC. The computer software will have no way of knowing that the smaller curve was not started at 100% TLC and will start the smaller curve at zero volume. This artificially decreases FVC, PEFR, and FEF50. A, Both curves start at TLC, as displayed by the computer. B, The curves, if matched at RV, would reflect that the smaller curve was not started at full lung volume. Clinicians must do their best to ensure that the patient starts the expiratory maneuver at 100% TLC. 255. Forced Vital Capacity, Forced Expiratory Volume, and Ratio of Forced Expiratory Volume to Forced Vital Capacity 256. Forced Expiratory Flow at 25% to 75% and at 50% of Vital Capacity 257. TABLE 7-1 Pulmonary Function Measurements in Children 258. Spirometric Values 259. FIGURE 7-8 Prebronchodilator and postbronchodilator expiratory loops produced by a 5-year-old patient with asthma. The prebronchodilator curve is slightly concave with respect to the volume axis, which is not evident on the postbronchodilator curve. The FEF50 is the only prebronchodilator measurement below the expected normal range of variability; it increased by 70% after bronchodilator therapy. FEF50, Forced expiratory flow at 50% of vital capacity; FEV1,
forced expiratory volume in 1 second; FVC, forced vital capacity; PEFR, peak expiratory flow rate. 260. TABLE 7-2 Characterization of Obstructive and Restrictive Patterns in Pulmonary Function Testing 261. Lung Volumes 262. FIGURE 7-9 Body plethysmography “box.” 263. FIGURE 7-10 Graphic display of the subdivisions of total lung capacity (TLC), from quiet tidal breathing on the left to maximal inhalation and exhalation on the right. ERV, Expiratory reserve volume; FRC, functional residual capacity; IC, inspiratory capacity; RV, residual volume; VC, vital capacity; VT, tidal volume. 264. Provocation Tests 265. TABLE 7-3 Positive Methacholine Challenge in a 7-year-old Girl With Chronic Cough* 266. MEASURING PULMONARY MECHANICS AT THE BEDSIDE 267. Calculated Parameters 268. Tidal Volume 269. Respiratory Frequency 270. Minute Ventilation 271. Rapid Shallow Breathing Index 272. Inspiratory and Expiratory Times 273. Lung Compliance 274. Airway Resistance 275. Time Constants 276. FIGURE 7-11 Tracing of pressure, flow, and volume over time (in seconds). Exp, Expiration; Insp, inspiration. 277. Pressure, Flow, and Volume Over Time 278. Flow–Volume Loops 279. FIGURE 7-12 Patterns of flow–volume loops. A, Normal; B, restrictive; C, obstructive. 280. FIGURE 7-13 Flow–volume loops showing various forms of airway obstruction. A, Fixed obstruction; B, variable extrathoracic obstruction; C, variable intrathoracic obstruction. 281. Pressure–Volume Loops 282. FIGURE 7-14 Pressure–volume loops demonstrating normal and decreased lung compliance. A, Normal lung compliance; B, decreased lung compliance. 283. Lung Overdistention 284. FIGURE 7-15 Pressure–volume loops demonstrating overdistention. Note the “penguin” or “bird's beak” appearance in the shape of the loops. These loops demonstrate idealized slopes (dashed lines) for change in compliance for the entire breath (C) and change in compliance in the last 20% of inspiratory pressure (C20). The C20/C ratio identifies lung overdistention. 285. Work of Breathing 286. Other Bedside Tests 287. Vital Capacity 288. Peak Expiratory Flow Rate 289. Maximal Inspiratory Pressure
290. Complex Bedside Measurements 291. SUMMARY 292. ASSESSMENT QUESTIONS 293. References 294. Chapter 8 Radiographic Assessment 295. LEARNING OBJECTIVES 296. RADIOGRAPHIC TECHNIQUE 297. FIGURE 8-1 Expiratory frontal chest radiograph shows normal decrease in left lung volume. Tooth (arrow) obstructs the right mainstem bronchus and causes air trapping in the right lung. 298. NORMAL CHEST ANATOMY 299. FIGURE 8-2 A, Left lower lobe pneumonia abuts the diaphragm, leading to nonvisualization of the normal edge of the diaphragm. The cardiac border is demarcated because the lingula (a segment of the upper lobe of the left lung) is normally aerated. B, Only the right hemidiaphragm is visualized because the left is obscured by the left lower lobe pneumonia. Major fissure appears as an edge (arrow). 300. FIGURE 8-3 Normal frontal view of the chest demonstrating the thoracic inlet (1), carina (the point at which the trachea splits into the two mainstem bronchi) (2), the aortic arch (3), and pulmonary hila (4). 301. FIGURE 8-4 Normal thymus abuts the minor fissure (arrow) and has a curved lateral margin. 302. FIGURE 8-5 A, Infant with respiratory distress syndrome on lower ventilator setting. B, Same infant on higher ventilator setting. 303. POSITIONING OF LINES AND TUBES 304. AIRWAY OBSTRUCTION 305. FIGURE 8-6 Enlarged tonsils (arrow) appear to hang down into the hypopharynx. The nasopharynx (arrowhead) is narrowed from enlarged adenoids located posterior and superior. 306. FIGURE 8-7 “Steepling” of the subglottic airway is caused by croup. 307. FIGURE 8-8 Enlarged epiglottis (arrow) appears as a “thumb” projecting into the airway. 308. FIGURE 8-9 Hypopharynx and trachea are displaced away from the cervical spine by a retropharyngeal abscess. 309. FIGURE 8-10 Edema from a coin in the upper esophagus causes marked narrowing of the adjacent trachea. The child presented with stridor and difficulty with swallowing. 310. RESPIRATORY DISTRESS IN THE NEWBORN 311. FIGURE 8-11 Even after intubation, the lungs are hypoinflated and have a granular pattern with faint air bronchograms in this infant with respiratory distress syndrome. 312. Box 8-1 Respiratory Distress in the Newborn 313. FIGURE 8-12 Large left pneumothorax appears black and outlines the partially collapsed left lung and left cardiac border (arrow). 314. FIGURE 8-13 Pneumomediastinum elevates the left lobe of the thymus to produce a “spinnaker sail” in this child, who also has a large left pneumothorax.
315. FIGURE 8-14 Massive pulmonary interstitial emphysema throughout the left lung causes shift of the mediastinum to the right and downward displacement of the left hemidiaphragm. 316. FIGURE 8-15 Meconium aspiration appears as a coarse asymmetric pattern. Enlargement of the heart may be secondary to fluid overload in this infant. 317. FIGURE 8-16 Group B streptococcal pneumonia presents in this infant with hyperinflation, small right pleural effusion (arrow), and hazy infiltrative pattern. 318. FIGURE 8-17 Multiple “cysts” in the left hemithorax are air-filled loops of bowel that herniated through a defect in the left hemidiaphragm. The abdomen is scaphoid from decreased bowel content. 319. ATELECTASIS 320. FIGURE 8-18 Left upper lobe collapse causes elevation of the left hemidiaphragm and crowding of the left ribs from volume loss. The cardiac and superior mediastinal borders are indistinct because of the “silhouette sign” while the diaphragm remains demarcated by the aerated left lower lobe. 321. FIGURE 8-19 Collapsed right middle lobe appears as a triangular wedge of increased density extending anteriorly and inferiorly toward the anterior chest wall and diaphragm. 322. PNEUMONIA 323. FIGURE 8-20 Round pneumonia (arrow) in the left lower lobe simulates a mass. 324. ASTHMA 325. CYSTIC FIBROSIS 326. FIGURE 8-21 Coarse interstitial markings, hyperinflation, bronchiectasis, mucous plugging (arrow), atelectasis (arrowhead), and enlarged pulmonary hila are all demonstrated in this child with cystic fibrosis. 327. FIGURE 8-22 Pneumonia was the precipitating precursor to acute respiratory distress syndrome, with densely consolidated lungs and air bronchograms (arrow). 328. ACUTE RESPIRATORY DISTRESS SYNDROME 329. CHEST TRAUMA 330. FIGURE 8-23 Trauma to the chest resulted in extensive bilateral air leaks and densely consolidated pulmonary contusions. Multiple rib fractures are present. 331. Assessment Questions 332. References 333. Chapter 9 Pediatric Flexible Bronchoscopy 334. LEARNING OBJECTIVES 335. INDICATIONS 336. Diagnostic Bronchoscopy 337. Stridor 338. Box 9-1 Indications for Flexible Bronchoscopy 339. DIAGNOSTIC 340. Airway Anatomy Evaluation 341. Bronchoalveolar Lavage and Biopsy 342. Cytopathology 343. Microbiology 344. Foreign Body Aspiration
345. Hemoptysis 346. THERAPEUTIC 347. Wheeze 348. Cough 349. Radiographic Abnormalities 350. Foreign Body Aspiration 351. Hemoptysis 352. Inhalation Injury 353. Therapeutic Bronchoscopy 354. CONTRAINDICATIONS 355. Box 9-2 Contraindications to Flexible Bronchoscopy 356. ABSOLUTE CONTRAINDICATIONS 357. RELATIVE CONTRAINDICATIONS 358. EQUIPMENT 359. Flexible Bronchoscope 360. Insertion Tube 361. FIGURE 9-1 Three different sizes of pediatric flexible bronchoscopes. Top to bottom: 4.5-, 3.6-, and 2.2-mm outer diameter. Note that all scopes have similar working tube lengths. 362. Control Head and Eyepiece 363. Light Source Connector 364. Video Recording Equipment 365. PREPARATION 366. Equipment and Supplies 367. Box 9-3 Equipment and Supplies for Pediatric Flexible Bronchoscopy 368. FIGURE 9-2 Necessary equipment for basic pediatric flexible bronchoscopy includes bronchoscope, attached suction tube, 2% lidocaine jelly, lidocaine spray, three 1-ml aliquots of 1% lidocaine solution, Luken trap, gauze pads, and three to five 10-ml aliquots of normal saline for bronchoalveolar lavage. These items are placed on a clean drape on top of a portable bronchoscopy cart. 369. Patient 370. Personnel 371. PROCEDURE 372. Conscious Sedation 373. Topical Anesthesia 374. Patient Monitoring 375. Technique 376. POSTPROCEDURAL MONITORING AND COMPLICATIONS 377. EQUIPMENT MAINTENANCE 378. FIGURE 9-3 Correct placement of flexible bronchoscope in STERIS cleaning apparatus, used for chemical sterilization of the instrument. 379. COMPARISON WITH RIGID BRONCHOSCOPY 380. Assessment Questions 381. References 382. Chapter 10 Invasive Blood Gas Analysis and Cardiovascular Monitoring 383. LEARNING OBJECTIVES
384. BLOOD GAS SAMPLING 385. Pain Control 386. FIGURE 10-1 Arterial sites that may be used for peripheral artery puncture in infants and children. 387. Box 10-1 Indications for Blood Gas Analysis 388. Arterial Sampling Sites 389. Modified Allen's Test 390. ARTERIAL PUNCTURE 391. Procedure 392. Box 10-2 Equipment for Arterial Puncture and Blood Gas Collection 393. Contraindications 394. Complications 395. CAPILLARY BLOOD GAS SAMPLES 396. Puncture Sites 397. FIGURE 10-2 Recommended puncture sites (shaded areas) in infant's heel to obtain capillary blood for analysis. 398. FIGURE 10-3 Technique for grasping the finger for a capillary puncture, with recommended site for puncture indicated (shaded area). 399. Procedure 400. Box 10-3 Equipment for Capillary Puncture and Blood Gas Collection 401. FIGURE 10-4 Technique for stabilizing the heel for a capillary puncture. 402. Contraindications 403. Complications 404. ARTERIAL CATHETERS 405. Umbilical Artery Catheterization 406. FIGURE 10-5 An indwelling arterial line and continuous infusion/flush system used to monitor blood pressure and obtain blood gas samples. Exploded view shows a three-way stop-cock system. A, Normal position with stop-cock off to sampling port allows continuous monitoring of blood pressure and flushing of the line if using a (pig tail) flush system. B, Position to draw blood or inject flush solution to the patient with stop-cock turned off to flush solution. C, Position to flush sample port with stop-cock off to patient. All ports are closed at all intermediary positions 407. Peripheral Artery Catheterization 408. Procedure for Sampling 409. Complications 410. Measurements 411. CONTINUOUS INVASIVE BLOOD GAS MONITORING 412. FIGURE 10-6 An ex vivo in-line continuous blood gas monitor designed for use in critically ill newborn infants. 413. CENTRAL VENOUS CATHETERS 414. Monitoring Sites 415. Procedure 416. Complications 417. Measurements 418. PULMONARY ARTERY CATHETERIZATION
419. FIGURE 10-7 Conventional pulmonary artery (Swan-Ganz) thermodilution catheter. 420. Procedure 421. FIGURE 10-8 Examples of pressure waveform patterns at various locations in and around the heart. A, Central venous pressure; B, right ventricular pressure; C, pulmonary artery pressure; D, pulmonary capillary wedge pressure. 422. FIGURE 10-9 Pressure waveforms as the catheter travels through the right atrium (RA), right ventricle (RV), and pulmonary artery (PA), becoming wedged (pulmonary capillary wedge pressure [PCWP]). 423. Complications 424. Measurements 425. Box 10-4 Normal Pressure Values From Pulmonary Artery Catheters 426. Cardiac Output 427. TABLE 10-1 Normal Ranges of Derived Hemodynamic Parameters 428. NONINVASIVE MEASUREMENT OF CARDIAC OUTPUT AND PERFUSION 429. PATIENT INFORMATION 430. FREQUENCY 431. TABLE 10-2 Approximate Normal Range of Arterial Blood Gas Values 432. BLOOD GAS INTERPRETATION 433. Acid–Base Balance 434. Oxygenation 435. TABLE 10-3 Laboratory Values for Acid–base Disturbances 436. Box 10-5 Causes of Metabolic Acidosis 437. Box 10-6 Causes of Metabolic Alkalosis 438. Box 10-7 Causes of Respiratory Acidosis 439. LUNG DISEASE 440. IMPAIRED LUNG MOTION 441. APNEA 442. OTHER 443. Box 10-8 Causes of Respiratory Alkalosis 444. FIGURE 10-10 Oxyhemoglobin dissociation curve, illustrating the P50 value (Po2 at 50% saturation) with the effects of right and left shifts of the curve. As the curve shifts to the right, the oxygen affinity of hemoglobin decreases, more oxygen is released at a given Po2, and the P50 value increases. When the curve shifts to the left, there is increased oxygen affinity, less oxygen is released at a given Po2, and the P50 value decreases. 445. TABLE 10-4 Factors That May Shift Oxyhemoglobin Dissociation Curve 446. FIGURE 10-11 Components of oxygen delivery. 447. ABNORMAL HEMOGLOBIN 448. ASSESSMENT QUESTIONS 449. References 450. Chapter 11 Noninvasive Monitoring in Neonatal and Pediatric Care 451. LEARNING OBJECTIVES 452. PULSE OXIMETRY 453. Principles of Operation
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from mechanical pressure on the brain or spinal marrow, but which in the cases cited depend on disorder of the digestive organs. It is impossible to exaggerate the interest or importance of these cases; not only from the fact that they almost certainly would have led to organic disease, but also for the value of that practical discrimination which they exemplify. Again, the very treatment which would have been proper, which had sometimes been begun, and which was not inappropriate to cases of organic disease, with which the symptoms were in part identical, would have inevitably, in the cases in question, only served to exasperate the very conditions they were designed to relieve, and to hasten those processes against which they were intended to guard. No one can understand the force of these cases, without recollecting the intense difficulty of ascertaining that point at which disorder ceases to be merely functional, and at which organic disease begins. This is of all things the most difficult to determine in the whole circle of physiological or pathological inquiry. The symptoms alone are absolutely useless in any case of real difficulty. Of that Abernethy was well aware, and he did much to guard us against the error into which a reliance on them was calculated to lead. He knew that organs which were diseased would sometimes afford indications not distinguishable from those of health; and that, conversely, organs essentially sound would sometimes only afford those signs which were indicative of disorder. We have, we trust, made some little progress in this very difficult branch of inquiry; and although it is true that organic disease not unfrequently escapes detection during life, yet, so far as we have observed, it is only in those cases in which there is, notwithstanding the daily lessons of experience, an improper reliance on what are called the symptoms. We assert, without the least hesitation, that organic diseases should seldom elude detection where the investigation is sufficiently comprehensive; but it must include all the facts of the case, the early history, and such circumstances which, however remote, have been over and over again proved to be
capable of exerting an influence on the body; an investigation which, however vainly pleaded for in medical science, however regarded as too exacting, involves nothing more in principle than is required as a matter of course in all other scientific investigations. When these conditions are observed, it is very rarely that we cannot detect organic affections in organs in which there may be no present symptoms. In relation to the extent to which they may be affected, it is true we have yet much to learn; still, if cases be judged of not by the history merely, nor by the symptoms merely, but by both in conjunction, and if to these be added a careful observation of the amount of work that the organs are separately or collectively doing, as compared with their natural proportions; together with a careful estimate of that which the actions of any visible disease may be eliminating from the body; then, indeed, we have good ground for hope that means will be opened to us of distinguishing more accurately various states of the system; and additional principles and powers disclosed of readjusting the disturbed balance of the various functions, which is the essential element of disease. [29] "History of the Inductive Sciences." [30] Butler's "Analogy."
CHAPTER XVI. "MY BOOK" CONTINUED. "La première chose qui s'offre à l'Homme quand il se regarde, c'est son corps. Mais pour comprendre ce qu'elle est, il faut qu'il la compare avec tout ce qui est au-dessus de lui, et tout ce qui est au-dessous, afin de reconnoître ses justes bornes."—Pascal, Pensées, Nature des Hommes, vol. ii, p. 57. Abernethy, in impressing any anatomical fact, would sometimes say that we carried about with us in our own bodies excellent means of refreshing our impressions on many points of anatomy; but we may say this in a much more extensive sense with regard to the interpretation of that for which anatomy is alone useful—namely, the uses or functions of the body. It would be very possible for any observant person, who was moderately versed in the ordinary principles of correct reasoning, to detect many defects in medical investigations and practice; in the correction of which many of Abernethy's practical contributions consisted; but the mind, restlessly impatient to arrive at conclusions, often overlooks the most important facts, and deduces inferences directly from the evidence of the eye or other senses, without submitting it to such test as the intellectual faculty can alone supply. Nothing can exceed the mischief of this in serious matters, nor the absurdity of it, when we think awhile.
We should hardly refrain from laughter if we saw a man try to see with the point of his nose, or endeavour to examine the odour of a rose by his ear, or to listen with his eye; yet this is not a whit more absurd than to try to deduce conclusions from the impressions furnished by the eye, which can alone be afforded by the rational faculty. Nothing is more common than this sort of fallacy, nothing more easy than its correction; but then people must bestow at least a little of that time on their highest faculties which they so lavishly expend on inferior powers. How much time we consume, for example, in the study of various languages—those instruments for the communication of ideas—as compared with that bestowed on the collecting and marshalling of ideas themselves; which is little better than grasping at the shadow, and losing the substance; or, to use a humorous illustration, like a friend of our own, who, having a new dog, sent his servant forthwith to purchase sundry articles for him, in the shape of kennel, chains, engraved collars and food; all of which, at some expense, he safely accomplished to his master's satisfaction, expressing his sorrow at the same time for having accidentally lost the dog! It is curious, however, to observe how the real business of the human mind is shadowed forth in the very abuses of its powers; nothing so bad but it is charged with a certain quantity of good; no error so great but carries with it the element of its own correction. The mind in its greatest aberrations is followed by the shadow of its real duty, which as it were waits on the time when clearer views shall burst on it. Nothing shows the real tendencies of mind more than its restless desire to arrive at some conclusion, some tangible evidence of its highest functions. It is the impulse of this instinct— the ungoverned abuse of a high faculty, impatient for illegitimate fruition—which lies at the bottom of much false reasoning, and which blinds men, even of great power, to obstacles which are luminously evident to the most ordinary capacity. Important as the next series of illustrations cited by Abernethy are, the conclusions he deduced from them were the necessary sequences of clear and correct reasoning on familiar and established facts.
The illustrations in question were those afforded by various cases of injuries of the head, in which certain consequences, however exceptional they may be, are too commonly referred to the abstract nature of the injury. We see that a man has a blow, we see that he does not recover in the usual way in which we have known many others to recover; but we do not, perhaps, consider that if a similar—nay, perhaps an identical force produces very different effects in different cases, the cause will probably not be in the nature or direction of the force so much as the condition of the body. Now the value of these cases of Abernethy's consists, first, in impressing the influence of this condition as modifying—in other words, sustaining—the disturbance consequent on injuries (in their origin) purely mechanical; and secondly, in showing that, in the cases in question, that condition depended on a disordered state of the digestive organs. We hardly know any cases more valuable than those in question. When a patient receives a blow, and, the immediate consequences having subsided, there still remains an impairment of sense or motion, the most usual thing, and no doubt very often the true view, is to refer it all to lesion of nervous structure. It is therefore of the highest consequence to know the facts of these cases. They not only prevent the hasty institution of treatment which would be injurious; not only secure the patient from being abandoned in despair; but supply at the same time the clues to a rational treatment, and the hope of a favourable issue. There can now be few observant surgeons who have not met with cases in illustration of these circumstances; and yet I know not to whom the perusal of Mr. Abernethy's cases might not be useful. It is not without regret that I forego transcribing at least one of them; forgetful how impossible it is to do Abernethy full justice in a work intended for all readers. In his "Book," the cases in question begin at page 97, and occupy but a few pages. The next class of cases, from which Abernethy illustrates the prevailing influence of the digestive organs, receives additional importance from the imperfect manner in which the phenomena have been interpreted in a vast variety of diseases; like small-pox
and others, ascribed to the action of particular poisons. We may possibly have an opportunity of saying something more on this subject; but we may remark that when any disease has been presented to the physician or surgeon, supposed to be the result of specific poisons, it is just the last case in which any special attention is paid to the digestive organs. Now Abernethy observed that disorders of the digestive organs would sometimes produce diseases resembling maladies said to result from specific poisons. This is about the first indication or hint of that which, duly carried out by an advancing science, will, we trust, ere long, demonstrate what to us has long appeared only part of a general law. Of this we may by and by say a little more, when we endeavour to show the small quantity of truth which there is mixed with some of the prevailing errors; and how their occasional success results from blundering, as it were, on small portions of the principles enunciated by Abernethy. In the meantime, we may refer to the illustration afforded by small-pox of the remarkable influence of the digestive organs in diseases called specific. We adduce this, because it is one which is popularly familiar, and a disease that, had it been studied under any but one particular phase, would have proved, of all others, the most instructive. There is no malady, under certain circumstances, more extensively fatal. In the Spanish conquest in America—a history scarcely less interesting in a medical than in a moral point of view—it seems that not all the cruelties of the Spaniards were more destructive than the small-pox. In less than a century after the arrival of Columbus, it was computed that it had destroyed more than half the population; and in one year (1590), it so spread along the coast of Peru, that it swept away nearly the whole of the Indians, the Mulattoes, and the Mestichos, in the cities of Potosi and De la Hay31. As is well known, before the discovery of vaccination, persons were inoculated with the small-pox, because it was found that the disease could be thus rendered comparatively harmless; whilst, if it was taken naturally, as it was termed, it was always serious, and too
frequently extremely fatal. The preparation for inoculation consisted of measures addressed to the digestive organs. Now the effect may be judged of by this fact: Inoculation was at first violently opposed; and, in reply to the alleged safety of it, an opponent wrote to prove that one in one hundred and eighty-two had died of it. I wish we could say so of many other diseases. That such persons had, nevertheless, the genuine malady, was proved by the fact they were capable of infecting others (unprepared) with the disease in its most malignant form. But our notions of the mode in which the laws of the animal economy deal with injurious influences of this kind, are mischievously conventional. What quantities, for example, of mercury, in its different forms, have been administered in almost all diseases; and yet unquestionably there is a great deal of false reasoning in regard to this poison. Effects are attributed to it as mercury, which only belong to it in its general character of an injurious agent. All the (so-called) specific effects of it, most of which are become popularly familiar, may occur without any mercury at all. We have seen them induced by aloes, by scammony; and in a case where no medicine had been given, and where the only detectable poison was one which was to be sure bad enough, an enormously loaded liver. We are obliged to say but little here in connection with this subject. Abernethy's cases were very important in relation to the influence of the digestive organs, although he did not see the generalization to which, as it appears to us, they help to conduct the pathologist. The subject is too extensive for discussion here. We will attempt something of a popular view of it, when we endeavour to explain the fallacy to which we have already referred. Abernethy next adduces various illustrations from cases of other diseases; as indurations, tumours, carbuncles, scrofulous affections, and others; in proof of the dependence of a "numerous and dissimilar progeny" of so-called local diseases, on that "fruitful parent," disorder of the digestive organs. Of one of the most interesting and remarkable cases of tumour, Mr. Abernethy did not
live to see the termination. It was of a lady who consulted him previous to the proposed infliction of an operation. She had been recommended by my father, in the country, to consult Abernethy before submitting to it; because he disapproved of it, as did Abernethy—not because they doubted of the nature of the disease, but because it was not confined to the part on which it was proposed to operate. The lady used to call on Abernethy when she came to town; and after his death she came to me—as she said, just to report her condition. She had at times various disturbances of her digestive organs; but always from some imprudence; for, although habitually very simple in her habits, she would be sometimes careless or forgetful. She died at a very advanced age—between seventy and eighty— but there had been no return of the disease for which she had originally consulted Abernethy, nor had she undergone any operation. It is a significant circumstance, too, that she had a sister who died of cancer. The whole of the cases are, however, scarcely less valuable. In the fifth section, he treats of disorders of parts having continuity of surface with the alimentary canal, certain affections of the nose, of the eye, and of the gullet or œsophagus. His observations on the latter are especially valuable. They strike at that meddling practice which is too common in the treatment of diseases of these parts. Many of us have recommended a practice which, without neglecting either, relies less on manipulatory proceedings, and more on measures directed to the general health, in such cases; as producing effects which are not to be obtained by other means; but, if we are to judge from the medical periodicals, without much success; so inveterate is the habit of imagining that, whatever the causes of disease may be, if the results be but mechanical, mechanical means can alone be applicable. Public attention, and the perusal of such cases as those of Abernethy, can alone correct these errors.
Lastly, he describes the results of his dissections as bearing on the whole subject. Here he shows, that whilst disordered function may take place coincidentally with, or as a consequence of, change of structure, yet that such change, so as to afford visible or detectable departures from natural appearances, is by no means necessary, in organs which, during life, had afforded the most incontrovertible evidence of impaired function. He also shows that disease has terminated in disorder which had its original seat in the digestive organs. And again—that, in cases where the cause of death had been in the abrogated function of the brain, he found no actual disease in that organ, but in the abdominal viscera. He very justly observes that the conclusions he has drawn can be neither ascertained nor disproved by anatomical evidence alone. He mentions especially, and illustrates by a remarkably successful case, how diseases of the lungs may be engendered by disorders of the digestive organs, and entirely subdued by correction of that disorder. He speaks also suggestively of the possibility of that which is certainly now an established fact. He says: "In cases of diseased lungs, where no disease of the digestive organs is discovered, yet considerable disorder does exist, and may continue for many years without any organic disease being apparent; it is possible that such disorder may excite disease of the lungs, and thus produce a severer disease of the latter organs than what existed in the former. Accurate attention to the digestive organs may determine this important subject, and lead to the prevention and cure of the sympathetic diseases which I have mentioned." "This attention must not be merely of that general kind which adverts only to the quality of the ingesta, &c., but one which more strictly observes whether the viscera" (that is, reader, not merely the stomach, not merely the digestive organs, but the whole viscera of the body) "and whether these secretions are healthy or otherwise." After speaking of the heart also, as affected by the digestive organs; and of the infinity of diseases which arise from the reciprocal disturbance excited between them and the brain;—he says: "But even these are not the worst consequences. The disorder of the sensorium, excited and
aggravated (by the means which he has described), affects the mind. The operations of the intellect become enfeebled, perplexed, and perverted; the temper and disposition, irritable, unbenevolent, and desponding. The moral character and conduct appears even to be liable to be affected by these circumstances. The individual in this case is not the only sufferer, but the evil extends to his connections and to society. The subject, therefore, appears to me to be of such importance, that no apology need be offered for this imperfect attempt to place it under general contemplation." Here is that suggestion which, when carried out, leads to the detection of cases of insanity which depend on disturbances of the digestive organs. Lastly, as if, notwithstanding his own previous attention to the important question of the influence of the digestive organs in disease, he felt that the inquiry had grown upon him in consequence of Mr. Boodle's endeavour to concentrate his attention to the subject, he concludes by expressing his past obligations to Mr. Boodle; for he says, with admirable modesty and candour, "for Mr. Boodle first instructed me how to detect disorders of the digestive organs, when their local symptoms were so trivial as to be unnoticed by the patient." He urges Mr. Boodle to publish also his own observations on the subject, because any remarks from one who observes the progress of disease "with such sagacity and accuracy, cannot but be interesting." We are quite aware how feeble our attempt has been to do justice to this admirable book. But nothing can do that but a careful study of the various principles which it either suggests, dimly shadows forth, or deeply and beautifully unfolds. Through not a very short life, we have had ample opportunity of testing these principles by the bedside, and of endeavouring to connect some of them with the laws in obedience to which they occur; and we are free to declare our impression that when the book is studied with the requisite previous knowledge, and freedom from preconceived opinion; and when tested and carried out in principle, as distinguished from any adhesion to mere matters of detail; we think it infinitely more valuable than all other professional works
whatever. In examining the truths it unfolds, or in our humble endeavours elsewhere at a more analytical or extended application of them, like Abernethy, we have rested our reasoning wholly on facts and observations which are acknowledged and indisputable. Whilst other views have only led to a practice in the highest degree empirical, or, what is worse, conjectural, those of Abernethy's lead often directly, but always when duly studied, to a practice at once clear, definite, and in the sense in which we shall qualify the word "positive,"—that is, one which gives us the power (when we really have the management of the case) of predicting the success or failure; which is at least a ripple indicative of a coming science. In order, however, to carry out this clearly, we shall at once add what we think necessary to the profession and the public on the subject. The general relation of Abernethy's labours to a real and definite science will be better developed in our concluding Summary; when we may have an opportunity of stating what further appears to have been done, and what is yet required. It will have been perhaps already observed that Abernethy's views involve a few very simple propositions: first, that disturbance of a part is competent to disturb the whole system; and conversely, that disturbance of the whole system is competent to disturb any part. That the disturbance may commence in the brain or nervous system, may then disturb the various organs, and that these may again by reflected action disturb the brain, and so reciprocally; and that in all these cases tranquillity of the digestive organs is of the very first consequence; not merely from its abstract importance, but from the influence it exerts on the state of the nervous system. With respect to any influences immediately directed to the nervous system, these we apprehend to be few and simple; some kinds of medicine, are, no doubt, in particular cases useful, none are susceptible of general application. None of them are certain; and sedatives of all kinds, which appear to have the most direct influence on the nervous system, either require to be employed with the utmost caution, or are in the highest degree objectionable. But there
are other direct influences, certainly; and very important they are. Quiet, avoidance of disturbing external impressions, whether of light, sound, temperature, &c. whether in fact of mind or body; but, in the majority of mankind, how few of them we can, in a strictly philosophical sense, command. We are therefore driven to other sources of disturbance; and in the digestive organs we find those on which we can exert great influence, and in which tranquillity, however procured or under whatever circumstances, is certain, pro tanto, to relieve the whole system. This Abernethy attempted, and with a success which was remarkable in no cases more than those which had resisted all more ordinary modes of proceeding; by general measures, by simplicity of diet, by occasional solicitation of this or that organ, by air and exercise, and measures which were directed to the general health. No doubt in some cases he failed, and so we shall in many; but let us look boldly at the cause, and see whether we do not fail a great deal more from our own ignorance than from any natural impossibility. To examine the question, we must for the moment forget our admiration of Abernethy; be no longer dazzled by his genius, but look only to our duty; endeavour to discover his defects, or rather those of the state of the question when he left us, and see what further investigation has afforded in aid of supplying them. In the first place, we must examine a little further that proposition which we have seen both in Hunter and Abernethy under different forms. Hunter says the disturbance of the organ sympathizing is sometimes more prominent than that of the organ with which it sympathizes. Abernethy says that the organ primarily affected is sometimes very little apparently disturbed, or not even perceptibly so. Now, from both these statements, we find that there may be no signs in the primarily affected organ; which, practically rendered, is nothing more or less than saying that in many cases we must not seek for the primarily affected organ where the symptoms are; and this is a great fact: because, although it does not necessarily teach
us what we must do, it exposes the broken reed on which so many rely. Now the further point, which, as we would contend, time and labour have supplied, is first this—that what Hunter had mentioned as one feature in the history of the sympathies of different organs, and Abernethy as an occasional or not unfrequent occurrence, is, in disorders of any standing, and with the exception of mechanical injury, in fact the rule—the symptoms of disorder being almost never in the primary organ; nay, even organic change (disease) is for the most part first seen in a secondarily affected organ. In regard to primarily affected parts, the skin only excepted, they will be found, in the vast majority of cases, to be one or other of the digestive organs. I will endeavour to render the cause of this intelligible. A minute examination of what happens in a living person, especially if it be extended to some thousands of cases, will soon disclose to the most unlettered person a few instructive facts, showing that Nature has a regular plan of dealing with all injurious influences, which, however various many of the details may be, is in general character exquisitely simple, surprisingly beautiful, and intelligibly conservative; and that the various modes on which she exercises this plan, from the cradle to the grave, are, in frequency, directly in the order of their conservative tendency. Let us explain. There is no dearth of illustration; the facts are bewilderingly abundant; the difficulty is which to choose, and how to give them an intelligible general expression. Let us take a single case. We know that if a mote gets into the eye, there is irritation, immediately there is flow of blood to the part, a gland pours forth an abundant supply of tears, and the substance is probably washed out. Very well; we say that is intelligible. But suppose you have the vapour of turpentine, or any other irritant, the same thing happens; but still you cannot give quite the same mechanical explanation. Again—substances which affect the mouth, nose, and stomach, will irritate the eye without any contact, and cause a flow of tears.
Lastly, you know that affections of the mind will do this, and where even we have no mechanical irritant at all. In all these cases there has been activity of the vessels of the eye, and in all it has been relieved by secretion. Now this is the universal mode throughout the body; all irritation of the organs is attended by secretion; and where this is done, there is no disorder; or rather, the disorder is relieved: but if organs are irritated continuously, another thing happens, and that is, that an organ becomes unable to secrete constantly more than is natural, and then some other organ, less irritated in the commencement, takes on an additional duty—that is, the duty of the animal economy is still done, but not equally distributed. This is the state in which most people are in crowded cities, and who live in the ordinary luxury or the ordinary habits of civilized society, according to the section to which they may belong. It is easy, in such cases, to detect those differences which distinguish this state from what is called condition or perfect health, as we have elsewhere shown32. But of course there is a limit to this power in organs of taking on additional or compensating actions; and when this limit is exceeded, then those actions are instituted which we call Disease. The site is seldom found to be that of the original disturbance; and usually for a very plain reason—because there it would be more dangerous, or fatal. It would be scarcely less serious in many cases, even though placed on organs secondarily affected; and therefore it is more usually determined to the surface of the body; where, taking them simply in the order of their greatest number, or frequency, we find the first class of diseased appearances, and which strikingly impress the real nature of the law. They are the most numerous, most obviously dependent on general disturbance, and most conservative, as being least fatal. Diseases of the skin are those to which we allude, and which, in the characters I have mentioned, exceed all other diseases.
Again—the next surface is that involution of the skin which covers the eye, and which lines the mouth, throat, and the whole of the interior surface of the respiratory tubes and the digestive organs. Here again we find the next seat of greatest frequency, and the conservative tendency, to coincide. We need only refer to the comparative frequency of what are called colds, ordinary sore throat, and so forth; as contrasted with those more serious diseases which occur in the corresponding surfaces of the respiratory organs and alimentary canal. In tracing diseases onwards in the order of their number, we never lose sight of this conservative tendency. When organs become involved in disease, we find that, for once that the substance of the organ is so affected, the membrane covering it is affected a hundred, perhaps a thousand times. This is equally observable with respect to the brain, heart, lungs, digestive organs, and some other parts; and it is of great importance practically to know how readily affections are transferred from the lining of the alimentary canal and other parts to the membrane covering it, rather than to the intermediate texture of the organ; again impressing, though now in a dangerous type truly, the conservative tendency of the law. Finally, then, we arrive at diseases of Organs; and here we see this conservative tendency still typed in the site first chosen, which is almost always (where we can distinguish the two structures) not so much in the actual tissue of the organ as in that which connects it together—what we term the cellular tissue. This is remarkable in the lungs; where tubercular deposits are first seated; not in the essential structures of the organs, but in those by which they are joined together. All those various depositions also which are called tumours, generally begin in, and are frequently confined to, the cellular tissue; and even though there is, in certain malignant forms of tumour, a disposition to locate themselves in organs, there is a very curious tendency towards such, as may have already fulfilled their purposes in the animal economy.
We might multiply these illustrations to a tedious extent. We might show, for example, in the eye, how curiously the greatest number of diseases in that organ are placed in structures least dangerous to the organ; and even when the organ is spoiled, so to speak, how much more frequently this is in relation to its function as an optical instrument, than to the structure which forms the link with the brain, as an organ of sensation. I must, however, refer those who wish to see more of the subject, to the work33 in which it is more fully discussed, under the term, "The Law of Inflammation," which is a bad phrase, as imperfectly expressing the law; but as the greatest evils it exposes occur in cases of Inflammation, and as it shows the essential nature of that process to be entirely distinct from the characters which had been usually ascribed to it, every one of which may be absent so that expression was somewhat hastily given to the generalization which seemed best to express a great practical fact. To return to the bearing of all this on Abernethy's views, and in relation to organs primarily or secondarily affected. In obedience to the conservative law to which I have above alluded, defective function in one organ is usually accompanied by increased action in some other; and thus it happens that the symptoms are almost always in one organ, whilst the cause, or originally injurious influence, has acted on another. The general reader will, of course, understand that we are not speaking of direct mechanical injury to an organ. Now all the most recondite diseases of the kidney are already acknowledged by many to be seated in a secondarily affected organ. Still the practice is, in too many instances, a strange mixture of that which is in accordance with the true view, more or less marred by much that is in opposition to it; because it often includes that which is certain more or less to disturb the organ which it should be the object to tranquillize or relieve. In the same manner, the lungs and heart are continually disordered, and ultimately diseased, from causes which primarily act on the liver; and I have seen such a case treated with cod-liver oil and bitter ales, with a result which could not but be disastrous. The
liver sends an enormous quantity of blood to the heart and lungs, from which it ought previously to have extracted a certain quantity of carbon (bile). If this be not done, the heart and lungs are oppressed both by the quantity and the quality of the blood sent to them. If nothing happen in either of the various sites I have mentioned, the blood must be got rid of; and it is so. In many cases, a vessel gives way; or blood is poured out from a vessel; or blood is employed in building up the structures of disease; but then the symptoms are frequently altogether in the chest, and not a sign of anything wrong in the liver. I cannot go on with the multitudinous illustrations of these principles. The law is to determine injurious influences to the surface. Deposition in the cellular tissue of the lung is bad enough; but it is better—that is, less certainly fatal—there, than in the respiratory tubes: and that is the explanation. But now comes the practical point. How is the primary organ to be got at? because that is the way to carry out the removal of the impediments to the sanative processes of nature, which, in many cases, no mere general treatment can accomplish. This is to be found by an examination into the whole (that is, the former as well as the more recent) history of the case, and adding the further test of a real and careful observation of all the secretions. By going back to the former life of the patient, we shall seldom fail to discover the various influences to which he has been subjected, and the organs to which they have been originally addressed. Having made up our minds, from our previous knowledge of injurious influences, on what organ they will most probably have acted, we now test this, not merely by inquiry after symptoms—and it may be not by symptoms at all—but by careful observation of the actual work of the suspected organ. In this way we almost certainly discover the real offender; in other words, the organ primarily affected. This is of immense importance; for we confidently affirm that one single beneficial impression made on it will do more in a short time—nay, in some rare instances, in a single day—than years
of routine treatment, that has been, nevertheless, of good general tendency. In treating it—i. e. the primary organ—however, great discrimination is necessary. If it be already organically affected, that treatment which would be, under other circumstances, necessary, becomes either objectionable, or requiring the utmost caution. For although an organ diseased in structure will, under some circumstances, as Abernethy long ago observed, yield its characteristic secretion, yet, unless we know the extent of the disease, which is just the thing we can almost never be certain about, excitement of it is never without danger. We should therefore excite the primary organ with more or less energy, with more or less caution, or not at all, according to circumstances. If we determine on not exciting it, we should then act on organs with which it has ordinarily closest community of function, or on whose integrity we can most depend. For choice, we prefer organs which, in a natural state, have nearest identity of function, as having the readiest sympathy, it may be, with each other. Yet so universal is the sympathy between all the organs, that there is no one that will not, under certain circumstances, or which may not be induced, perhaps, by judicious management, to take on compensating actions. We must not here pursue this subject further. We have endeavoured to sketch certain extensions of the views of Mr. Abernethy, and can only refer the profession and the public, for the facts and arguments which demonstrate and illustrate them, to those works in which they have been enunciated34. They have now been subjected to severer trials, and abundant criticisms. So far as we know, they have not been shaken; but if there be any merit in them, if they shall have made any nearer approach to a definite science, or sketched the proofs that Induction alone can place us in a position to talk of science at all, they are still sequences which have been arrived at by a steady analysis of Abernethy's views. It was he who taught us, in our pupil days, first to think on such subjects; to him we owe the first glimpse we ever had of the imperfect state of medical and surgical science; and if we do not wholly owe to him the
means by which we conceive it can alone be rendered more perfect and satisfactory, he has at least in part exemplified the application of them. If we have made some advances on what he left us, and added to his beautiful and simple general views, something more definite on some points, something more analytical on others,—still, inasmuch as they are clear deductions from the views he has left us, and from such views alone, such advances remind us that the study of his principles serves but to demonstrate their increasing usefulness, and to augment the sum of our obligations. SECTION. Mr. Abernethy's book "On the Constitutional Origin of Local Diseases" had an extensive circulation, and excited a great deal of attention from the public as well as the profession. As a work which may be read as it were in two days, so as a person read it with one or other subject, it produced a great variety of impressions. It may be read simply as a narrative of a number of facts, with the inferences immediately deducible from them. All this is plain and intelligible at once to anybody, and of great practical value; but the work contains numerous observations of a suggestive kind, which require careful thought, and some previous knowledge, to enable a person to estimate their value, or to trace their onward relations. The impression made by the work on different minds varied, of course, with the reader, his information, and, in some sort, with the spirit in which it was studied. Some, who had, in their solitary rides, and in the equally solitary responsibilities of country practice, been obliged to think for themselves, recognized, in the orderly statement of clearly enunciated views, facts and principles
which they had already seen exemplified in their own experience, and hailed with admiration and pleasure a book which realized their own ideas, and supplied a rational explanation of their truth and value. Some, who had never thought much on the subject, and were very ill-disposed to begin, regarded his ideas as exaggerated, and hastily dismissed the subjects, with the conclusion that he was a clever man, but too full of theory, and too much disposed to look to the stomach or the digestive organs. Others, making very little distinction between what they heard of the man, the book, or his practice, and probably not having seen either, but deriving only a kind of dreamy notion of a clever man with many peculiarities, would say that he was mad, or an enthusiast. Still, a great many of the thinking portion of the public and the profession held a different tone. The book was recognized as an intelligible enunciation of definite views—rather a new thing in medical science. The application of them became more and more general; his pupils were everywhere disseminating them, more or less, in the navy, in the army, in the provinces, and in America. Still, it must not be imagined that his principles became diffused with that rapidity which might have been inferred from his numerous and attentive class. Constituted as medical education is, but more especially as it was at that time—for it is slowly improving—pupils were almost entirely absorbed in the conventional requisitions for examination. There, they were not questioned as to the laws of the animal economy, nor any laws at all, nor even on any real axioms in approximation to them; but simply as to plain anatomy, the relative situation of parts, and such of the ordinary surgery of the day as had received the approbation of the Examiners, who were, for the time, the authorities in the profession. Therefore, out of a large number, there were comparatively few whose attentions were not too much absorbed by the prescribed curriculum of hospital routine to study principles: a curriculum constructed as if the object were to see how much could be learnt in a short time, without detriment to the very moderate requisitions of the examination at the College of Surgeons.
But if comparatively few had time to study Abernethy's lectures at the time, a great many had treasured up his remarks. As the impressions we receive in our childhood, before we are capable of thinking of their value, are vividly rekindled by the experience of real life, so many of the more suggestive lessons of Abernethy's lectures, which passed comparatively unheeded at the time, or were swamped in the "getting up" of the requisitions for an examination at the College, recurred in after days in all their force and truthfulness. Many, however, with more time, and perhaps more zeal, endeavoured to thoroughly master his views; and now and then he was gratified by evidence, that time had only served to mature the conviction of the pupils—in dedications and other complimentary recognitions, in the works of such of them as had been induced to publish any portion of their own experience. However various, too, the impressions made by his book, there are two things certain; viz. that he was much talked of, and the book had an extensive sale, went through several editions, and served to give the public some notion of those principles which he was so beautifully unfolding to the younger portions of the profession in his lectures. Besides, although there were not wanting those who spoke disparagingly of him, still, as an old and very far-seeing colleague of our own used to say, with perhaps too much truth, when canvassing the various difficulties of a medical man's progress in the metropolis, "A man had better be spoken ill of, than not spoken of at all." He was now beginning to be very largely consulted. The Public had "got hold of him," as we once heard a fashionable physician phrase it, and he soon obtained a large practice. A great many consulted him for very good reasons, and probably many for little better reason than that he was the fashion. Abernethy had now an amount of practice to which neither he nor any other man could do full justice. Finding it impossible to make people understand his views in the time usually allotted for consultation, he now referred his patients to his book, and especially page 72. This has been made the subject of a great deal of quizzing, and of something besides, not altogether quite so good-natured. For
our parts, we think it the most natural thing in the world to refer a patient to a book, which may contain more in full the principles we desire them to understand, than we can hope to find opportunity to explain at the time of consultation. We think that if asking a few questions, and writing a prescription (and we are here only thinking of a reasonably fair average time visit), be worth a guinea, the explaining a principle, or so placing a plan before a patient that his following it may be assisted and secured, is worth fifty times as much; and it came particularly well from Abernethy, one of whose lessons, and a most excellent lesson too, was the remark, "That if a medical man thought he had done his duty when he had written a prescription, and a patient regarded his as fulfilled when he had swallowed it, they were both deceived." As we are convinced that, cæteris paribus, success in medical treatment is indefinitely promoted by both patient and surgeon clearly understanding each other as to principles, we think it would be of great use if every medical man, who has any definite principles of practice, were to explain them in short printed digests. Nay, we have sometimes thought it would be useful to both parties, if, in addition to the inquiries and advice given at consultation, a medical man should have brief printed digests of the general nature and relations of most of the well-defined diseases. A careful perusal of one of these would help the patients to comprehend the nature and objects of the advice given, tend to the diffusion of useful knowledge, and in time help them to understand whether their treatment were conducted on scientific views, or merely a respectable sort of empiricism. What is here intended might be printed on a sheet of note paper; and, whilst it would be of great service to the patient, would form no bad test of the clearness and definite principles of the medical attendant. There is no doubt that Abernethy did good service by referring patients to his book. It led some to think for themselves, and it also assisted, pro tanto, in doing away with that absurd idea which supposes something in medical practice inappreciable by the public.
At this time, whilst, with a considerable indifference to money, he was making a large income, still he was obliged to work hard for it. He had as yet no emolument from the Hospital; he was still only an assistant surgeon. The tenacity of office, of which assistant surgeons so commonly complain, they have themselves seldom failed to exercise when they have become surgeons (Mr. Abernethy, however, excepted). The long tenure of office by his senior (Sir James Earle) wearied him, and was at times a source of not very agreeable discussions. On one occasion, Sir James was reported to have given Abernethy to understand that, on the occurrence of a certain event, on which he would obtain an accession of property, he, Sir James, would certainly resign the surgeoncy of the hospital. About the time that the event occurred, he happened one day to call on Abernethy, and was reminded of what he had been understood to have promised. Sir James, however, having, we suppose, a different impression of the facts, denied ever having given such a pledge. The affirmative and negative were more than once exchanged, and not in the most courteous manner. When Sir James was going to take his leave, Abernethy opened the door for him, and, as he had always something quaint or humorous to close a conversation with, he said, at parting, "Well, Sir James, it comes to this: you say that you did not promise to resign the surgeoncy of the hospital; I, on the contrary, affirm that you did: now all I have to add is, —— the liar!" In 1813, Abernethy accepted the surgeoncy of Christ's Hospital, which he held until 1828, a short time before he retired from practice. In 1814, he was appointed Professor of Anatomy and Surgery to the College of Surgeons—an appointment which could be, at this period, of little service to him, whatever lustre it might reflect on the College, where he gave lectures with a result which has not always followed on that appointment: namely, of still adding to his reputation. He was one of the few who addressed the elders of the profession without impressing the conviction that he had been too
much employed in addressing pupils. He had given lectures two years in succession, when, in 1816, circumstances occurred which will occupy us for some little time. A new scene will be opening upon us; and this suggests the period (1815–16) as convenient for taking a retrospect, and a sort of general view of Abernethy's position. [31] Clench's History. Letter from Ch. Uslano, to Gonsalvo de Solano, July, 1590. [32] "Health and Disease." See Treatise on Tumours. [33] "Medicine and Surgery One Inductive Science." London, 1838. Highley. [34] "Medicine and Surgery One Inductive Science;" and "On Tumours," Art. "Treatment of Organs."
CHAPTER XVII. "Sperat infestis, metuit secundis, Alteram sortem bene preparatum Pectus." Hor. "Whoe'er enjoys th' untroubled breast, With Virtue's tranquil wisdom blest, With hope the gloomy hour can cheer, And temper happiness with fear." When we look abroad amongst mankind—nay, even in the contracted sphere of our own experience—it is interesting to observe the varied current of human life in different cases. In some, from the cradle to the grave, life has been beset with difficulties; it has been a continued struggle; the breath seems to have been first drawn, and finally yielded up, amidst the multifarious oppositions and agitations of adversity. In other instances, life seems like an easy, smoothly gliding stream, gently bearing Man on to what had appeared to be the haven of his wishes; and the little voyage has been begun and completed without the appearance of a ripple. All varieties are, no doubt, the result of constantly operating laws. Of these, many are probably inscrutable by us; many more, no doubt, escape our observation. The unforeseen nature of many events confers the character of mystery on any attempt at foresight; yet, when we take a careful retrospect of a life, it is curious to observe how naturally the secondary causes appear to have produced the results by which they were followed; but which, beforehand, no one had thought of predicting.
Varied, however, as is the course of human life, few men have arrived at eminence without difficulty. We do not mean that ephemeral prominence of "position" which makes them marked in their day; but that which leaves the impression of their minds on the age in which they lived, or on the science or other pursuit which they had chosen—original minds, who have enlarged the boundaries of our knowledge. Such men usually have the ample gifts of nature with which they are endowed, somewhat counterbalanced by the difficulty experienced in the successful application of them. Abernethy had not been altogether exempt from such difficulties. With a sensitive organization, he had had to make his own way; he had experienced the difficulties which attend the advocacy of opinions and principles which were opposed to, or at all events different from, those generally entertained. He had had to encounter that misconstruction, misrepresentation, ridicule, even malice—save the mark!—which are too frequently provoked by any attempts to tell people that there is something more correct than the notions which they have been accustomed to value. Still, when we compare Abernethy's course with that of many—we had almost said most—benefactors to science, he might be said to have been a fortunate man. If a man has power, and a "place to stand on"—and Abernethy had both—truth will tell at last. A retired spot, a room in an obscure street, near St. Bartholomew's, had been by his unaided talents expanded into a theatre within the walls of the hospital. This was becoming again crowded; and, although it formed a satisfactory arena for the development and illustration of his principles, the increasing audiences were significant of the coming necessity of a still larger building; which was, in fact, a few years afterwards, constructed. He had indeed arrived, as we imagine, at a point which was comparatively smooth water, and which we are inclined to regard as the zenith of his career. In the opening of his beautiful lectures at the College, Abernethy, in one of his warm and earnest endeavours to animate
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Test Bank for Perinatal and Pediatric Respiratory Care, 3rd Edition: Walsh

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    Test Bank forPerinatal and Pediatric Respiratory Care, 3rd Edition: Walsh Full download chapter at: https://testbankbell.com/product/test-bank-for- perinatal-and-pediatric-respiratory-care-3rd-edition-walsh/
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    Description: With the in-depthcoverage you need, this text helps you provide quality treatment for neonates, infants and pediatric patients. It discusses the principles of neonatal and pediatric respiratory care while emphasizing clinical application. Not only is this edition updated with the latest advances in perinatal and pediatric medicine, but it adds a new chapter on pediatric thoracic trauma plus new user-friendly features to simplify learning. 1. Front Matter 2. Dedication 3. Contributors 4. Reviewers 5. Preface 6. AUDIENCE 7. New to this Edition 8. LEARNING AIDS 9. Evolve Resources—http://evolve.elsevier.com/Walsh/perinatal/ 10. For the Instructor 11. For Students 12. ACKNOWLEDGMENTS 13. Section I Fetal Development, Assessment, and Delivery 14. Chapter 1 Fetal Lung Development 15. LEARNING OBJECTIVES 16. STAGES OF LUNG DEVELOPMENT 17. Embryonal Stage 18. TABLE 1-1 Classification of Stages of Human Intrauterine Lung Growth 19. Pseudoglandular Stage 20. FIGURE 1-1 Embryonal stage of lung development: the trachea and major bronchi at A to C, 4 weeks; D and E, 5 weeks; F, 6 weeks; G, 8 weeks. 21. Canalicular Stage 22. FIGURE 1-2 Canalicular stage of lung development at 22 weeks of gestation. A terminal bronchiole (bottom left) leads into a prospective acinus. Note that branches are sparse. 23. Saccular Stage 24. Alveolar Stage 25. POSTNATAL LUNG GROWTH 26. FIGURE 1-3 Saccular stage of lung development at 29 weeks of gestation. Secondary crests (arrows) begin to divide saccules into smaller compartments.
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    27. FIGURE 1-4Alveolar stage of lung development at 36 weeks of gestation. Note the double capillary network (solid arrows, center and right) and the single capillary layer (arrow at left). 28. FIGURE 1-5 Alveolar stage of lung development at 36 weeks of gestation: thin-walled alveoli are present. 29. FACTORS AFFECTING PRENATAL AND POSTNATAL LUNG GROWTH 30. ABNORMAL LUNG DEVELOPMENT 31. PULMONARY HYPOPLASIA 32. ALVEOLAR CELL DEVELOPMENT AND SURFACTANT PRODUCTION 33. FETAL LUNG LIQUID 34. ASSESSMENT QUESTIONS 35. References 36. Chapter 2 Fetal Gas Exchange and Circulation 37. LEARNING OBJECTIVES 38. MATERNAL-FETAL GAS EXCHANGE 39. FIGURE 2-1 Implanted human embryo, approximately day 28, showing the relationship of the chorion, amnion, and chorionic villi. The umbilical cord and tail are difficult to differentiate in this view. 40. Box 2-1 Origin of the Various Tissue Systems From the Three Embryonic Germ Layers* 41. ECTODERM 42. MESODERM 43. ENDODERM 44. CARDIOVASCULAR DEVELOPMENT 45. Early Development 46. TABLE 2-1 Timetable of Significant Events During Fetal Heart Development 47. Chamber Development 48. FIGURE 2-2 Formation of the primordial heart chambers after fusion of the heart tubes at a gestational age of 3 weeks. 49. FIGURE 2-3 A, Sagittal view of the developing heart during week 4, showing the position of the atrium, bulbus cordis, ventricles, and endocardial cushions merging from the ventral and dorsal sides. B, Traditional view of the developing heart during weeks 4 to 5, showing budding interventricular septum, fused endocardial cushions. septum primum, and the left and right atria. The ventricular septum continues to fold and grow upward between the ventricles. 50. Maturation 51. FIGURE 2-4 Frontal view of the fetal heart between weeks 5 and 6, showing the development of the four chambers nearing completion. The arrow shows the one- way path through the foramen ovale. 52. FIGURE 2-5 Frontal view (right) and side view (left) schematics of the foramen ovale. The septum primum forms the flap, and the septum secundum remains open to form the foramen ovale. The arrows show the one-way path through the foramen ovale. 53. FETAL CIRCULATION AND FETAL SHUNTS
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    54. FIGURE 2-6A diagram of the fetal circulation, showing blood containing oxygen and nourishment moving from the placenta to the fetal heart and through the three fetal shunts: the ductus venosus, the foramen ovale, and the ductus arteriosus. 55. TRANSITION TO EXTRAUTERINE LIFE 56. ASSESSMENT QUESTIONS 57. References 58. Chapter 3 Antenatal Assessment and High-risk Delivery 59. LEARNING OBJECTIVES 60. MATERNAL HISTORY AND RISK FACTORS 61. Preterm Birth 62. Cervical Insufficiency 63. Toxic Habits in Pregnancy 64. Alcohol 65. Smoking 66. Cocaine 67. Hypertension and Diabetes Mellitus 68. Hypertension 69. Diabetes 70. Pregestational Diabetes 71. Gestational Diabetes Mellitus 72. Infectious Diseases 73. Group B Streptococcus 74. Herpes Simplex Virus 75. Hepatitis B Virus and Human Immunodeficiency Virus 76. HIV 77. HBV 78. Fetal Membranes, Umbilical Cord, and Placenta 79. Disorders of Amniotic Fluid Volume 80. Mode of Delivery 81. Breech Presentation 82. Assisted Vaginal Delivery 83. Cesarean Delivery 84. ANTENATAL ASSESSMENT 85. Ultrasound 86. FIGURE 3-1 Ultrasound picture of a fetus at 23 weeks of gestation (top), with a Doppler study of the fetal heart (bottom). Dop, Doppler; Fr, frame; Freq, frequency; PRF, pulse-repetition frequency; SV, sample volume; WF, wall filter. 87. Amniocentesis 88. Nonstress Test and Contraction Stress Test 89. FIGURE 3-2 A nonstress test recording, produced with a cardiotocograph. A, The fetal heart rate (FHR) is recorded with an ultrasound probe as changes in beats per minute (bpm) over time. B, Uterine contractions (UC) are recorded with a pressure transducer as changes in pressure (mm Hg) over time. In this case the nonstress test is reactive, indicating normal uteroplacental function. 90. Fetal Biophysical Profile 91. INTRAPARTUM MONITORING
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    92. HIGH-RISK CONDITIONS 93.Preterm Labor 94. TABLE 3-1 Biophysical Profile Scoring 95. FIGURE 3-3 Early decelerations (coinciding with uterine contraction) are usually due to fetal head compression and pose little threat to the fetus. 96. FIGURE 3-4 Variable decelerations are the most common. They are due to cord compression and have different configurations. Repetitive severe variable decelerations are associated with increased risk of fetal hypoxia. 97. FIGURE 3-5 Late decelerations are due to uteroplacental insufficiency. They usually begin at the peak of the contraction and are associated with fetal distress. 98. TABLE 3-2 Normal Values for Fetal Scalp Blood and Umbilical Cord Blood Gases 99. Postterm Pregnancy 100. ASSESSMENT QUESTIONS 101. References 102. Chapter 4 Neonatal Assessment and Resuscitation 103. LEARNING OBJECTIVES 104. PREPARATION 105. Box 4-1 Perinatal Factors Associated With Increased Risk of Neonatal Depression 106. ANTEPARTUM (FETOMATERNAL) 107. INTRAPARTUM 108. STABILIZING THE NEONATE 109. Drying and Warming 110. FIGURE 4-1 Correct and incorrect head positions for resuscitation. 111. Clearing the Airway 112. FIGURE 4-2 Meconium aspirator, with an endotracheal tube attached to one end and a suction source attached at the other end. 113. Providing Stimulation 114. ASSESSING THE NEONATE 115. Respiration 116. Heart Rate 117. Skin Color 118. Apgar Score 119. FIGURE 4-3 Algorithm for resuscitation of the newborn. HR, Heart rate (beats/min). 120. TABLE 4-1 Apgar Scoring 121. Apgar Score in the Very Low Birth Weight Infant 122. RESUSCITATING THE NEONATE 123. Oxygen Administration 124. Ventilation 125. FIGURE 4-4 Correct technique for holding a mask to the face of a newborn. Note that fingers do not touch the neck or soft tissue under the chin. 126. FIGURE 4-5 Incorrect technique for holding a mask to the face of a newborn. Note that the fingers are touching the neck and soft tissue under the chin, causing airway obstruction.
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    127. TABLE 4-2Advantages and Disadvantages of Three Devices for Delivering Positive-pressure Ventilation to Neonates 128. Chest Compressions 129. Medications 130. Epinephrine 131. Volume Expanders 132. Naloxone 133. Sodium Bicarbonate 134. Postresuscitation Care 135. Ethical Considerations 136. Assessment Questions 137. References 138. Section II Assessment and Monitoring of the Neonatal and Pediatric Patient 139. Chapter 5 Examination and Assessment of the Neonatal Patient 140. LEARNING OBJECTIVES 141. GESTATIONAL AGE AND SIZE ASSESSMENT 142. FIGURE 5-1 Ballard examination for estimating gestational age, using scores determined on the basis of neurologic and physical signs. 143. PHYSICAL EXAMINATION 144. FIGURE 5-2 Overview of conditions producing neonatal morbidity and mortality by birth weight and gestational age. RDS, Respiratory distress syndrome. 145. Vital Signs 146. TABLE 5-1 Normal Values for Vital Signs in the Neonatal Patient 147. General Inspection 148. FIGURE 5-3 “Waiter's tip” positioning of the left arm of an infant with brachial plexus injury from a traumatic delivery. 149. Respiratory Function 150. TABLE 5-2 Common Dermal Findings in the Neonatal Patient 151. FIGURE 5-4 Silverman scoring system for assessing the magnitude of respiratory distress. Exp., Expiratory; insp., inspiratory; retract., retraction. 152. Chest and Cardiovascular System 153. TABLE 5-3 Signs of Respiratory Distress in the Neonatal Patient 154. Abdomen 155. FIGURE 5-5 Infant with prune-belly syndrome. 156. Head and Neck 157. Musculoskeletal System, Spine, and Extremities 158. FIGURE 5-6 Infant with an open spinal defect. 159. FIGURE 5-7 Infant with myelomeningocele. 160. Cry 161. NEUROLOGIC ASSESSMENT 162. LABORATORY ASSESSMENT 163. TABLE 5-4 Laboratory Values in the Neonatal Patient 164. Box 5-1 “Red Flags” in Neonatal Patients 165. RESPIRATORY 166. CARDIAC 167. RENAL
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    168. GASTROINTESTINAL 169. METABOLIC 170.GENERAL 171. ASSESSMENT QUESTIONS 172. References 173. Chapter 6 Examination and Assessment of the Pediatric Patient 174. LEARNING OBJECTIVES 175. PATIENT HISTORY 176. Chief Complaint 177. New Patient History 178. Box 6-1 New Patient History 179. CHIEF COMPLAINT OR PRIMARY REASON FOR VISIT 180. History of Present Illness 181. Past Medical History 182. Review of Symptoms 183. Family History 184. Social and Environmental Histories 185. Follow-up or Established Patient History 186. Box 6-2 Follow-up or Established Patient History 187. CHIEF COMPLAINT AND/OR PREVIOUS DIAGNOSIS OR PROBLEM 188. Interim History 189. Review of Key Components 190. PULMONARY EXAMINATION 191. Box 6-3 Pulmonary Examination 192. Inspection 193. TABLE 6-1 Normal Respiratory Rates in Sleeping and Awake Pediatric Patients 194. FIGURE 6-1 Head bobbing. 195. Palpation 196. FIGURE 6-2 Intercostal retractions. Soft tissue between the ribs is pulled inward (retracted) because of the extremely high negative pleural pressure. 197. FIGURE 6-3 Suprasternal retractions. Soft tissue in the suprasternal space is retracted because of high negative pressure, most often caused by the patient's attempt to breathe against an airway obstruction. 198. Percussion 199. FIGURE 6-4 Subcostal/substernal retractions. Airway obstruction results in a pulling inward of the lower costal margins. The abdomen is protruding (1), and there is a sunken substernal notch (2). See-saw movement of the chest and stomach is also present. 200. FIGURE 6-5 Technique for determining tracheal position in the older child. 201. Auscultation 202. NONPULMONARY EXAMINATION 203. Box 6-4 Nonpulmonary Examination: Findings Possibly Associated With Pulmonary Disease 204. GENERAL 205. EARS, EYES, NOSE, THROAT
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    206. HEART 207. ABDOMEN 208.SKIN 209. EXTREMITIES 210. FIGURE 6-6 A, Normal finger viewed from above and in profile, and the changes occurring in established clubbing, viewed from above and in profile. B, The finger on the left demonstrates normal profile (ABC) and normal hyponychial (ABD) nail-fold angles of 169 and 183 degrees, respectively. The clubbed finger on the right shows increased profile and hyponychial nail-fold angles of 191 and 203 degrees, respectively. C, Distal phalangeal finger depth (DPD)/interphalangeal finger depth (IPD) represents the phalangeal depth ratio. In normal fingers, the IPD is greater than the DPD. In clubbing, this relationship is reversed. D, Schamroth sign: in the absence of clubbing, opposition of the index fingers nail-to-nail creates a diamond-shaped window (arrowhead). In clubbed fingers, the loss of the profile angle due to an increase in tissue at the nail bed causes obliteration of this space (arrowhead). 211. LABORATORY TESTING 212. Box 6-5 Laboratory Evaluation 213. THE HEALTH CARE TEAM 214. CASE STUDIES 215. CASE 1 216. Family History 217. CASE 2 218. CASE 3 219. Box 6-6 History Taking in the Pediatric Patient With Asthma 220. MANIFESTATIONS 221. AGGRAVATING FACTORS 222. ALLEVIATING FACTORS 223. ASSOCIATED CONDITIONS (REVIEW OF SYMPTOMS) 224. FAMILY HISTORY 225. ENVIRONMENTAL EXPOSURES 226. ASSESSMENT QUESTIONS 227. References 228. Chapter 7 Pulmonary Function Testing and Bedside Pulmonary Mechanics 229. LEARNING OBJECTIVES 230. DEFINITIONS 231. SPECIAL CONSIDERATIONS 232. Neonatal Testing 233. Pediatric Testing 234. Instrumentation 235. Selection of Data for Analysis 236. MECHANICS OF BREATHING IN NEWBORNS 237. FIGURE 7-1 A pneumotachometer with a pulmonary function testing (PFT) computer system. As gas flow passes through the restrictive element, the difference in pressure between P1 and P2 is converted to a flow measurement. The flow rate over time is then converted to volume measurement. 238. Lung Inflation and Transpulmonary Pressure
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    239. NEONATAL PULMONARYFUNCTION TESTING IN THE LABORATORY 240. Measuring Static Compliance and Airway Resistance 241. Measuring Functional Residual Capacity 242. FIGURE 7-2 Volume–pressure loops of tidal breathing at various levels of functional residual capacity (FRC): a, low FRC; b, normal FRC; c, elevated FRC. 243. Helium Dilution Method 244. Nitrogen Washout Method 245. Plethysmography 246. Measuring Maximal Expiratory Flow by Rapid Thoracic Compression Technique 247. FIGURE 7-3 Partial expiratory flow–volume (PEFV) curves with identification of maximal expiratory flow at FRC (VmaxFRC), demonstrating a normal resting tidal breath and one with flow limitation. A, Normal; B, abnormal (flow limited). 248. PEDIATRIC PULMONARY FUNCTION TESTING IN THE LABORATORY 249. Standard Spirometry 250. Flow–Volume Loop 251. FIGURE 7-4 A normal standard time–volume spirometry graph, depicting the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75). 252. FIGURE 7-5 Normal flow–volume loop, showing both the expiratory and the inspiratory loops. The usual flow rates are identified. Note that no forced expiratory volume in 1 second (FEV1) is evident because there is no time axis. FEF50, Forced expiratory flow at 50% of vital capacity; FVC, forced vital capacity; PEFR, peak expiratory flow rate; RV, residual volume; TLC, total lung capacity. 253. FIGURE 7-6 This expiratory flow–volume loop demonstrates the patient's failure to exhale completely to residual volume (RV). This will artificially decrease FVC and increase FEF50. 254. FIGURE 7-7 Comparison of a forced expiratory flow–volume curve starting from 100% of total lung capacity (TLC) with a curve starting at 75% of TLC. The computer software will have no way of knowing that the smaller curve was not started at 100% TLC and will start the smaller curve at zero volume. This artificially decreases FVC, PEFR, and FEF50. A, Both curves start at TLC, as displayed by the computer. B, The curves, if matched at RV, would reflect that the smaller curve was not started at full lung volume. Clinicians must do their best to ensure that the patient starts the expiratory maneuver at 100% TLC. 255. Forced Vital Capacity, Forced Expiratory Volume, and Ratio of Forced Expiratory Volume to Forced Vital Capacity 256. Forced Expiratory Flow at 25% to 75% and at 50% of Vital Capacity 257. TABLE 7-1 Pulmonary Function Measurements in Children 258. Spirometric Values 259. FIGURE 7-8 Prebronchodilator and postbronchodilator expiratory loops produced by a 5-year-old patient with asthma. The prebronchodilator curve is slightly concave with respect to the volume axis, which is not evident on the postbronchodilator curve. The FEF50 is the only prebronchodilator measurement below the expected normal range of variability; it increased by 70% after bronchodilator therapy. FEF50, Forced expiratory flow at 50% of vital capacity; FEV1,
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    forced expiratory volumein 1 second; FVC, forced vital capacity; PEFR, peak expiratory flow rate. 260. TABLE 7-2 Characterization of Obstructive and Restrictive Patterns in Pulmonary Function Testing 261. Lung Volumes 262. FIGURE 7-9 Body plethysmography “box.” 263. FIGURE 7-10 Graphic display of the subdivisions of total lung capacity (TLC), from quiet tidal breathing on the left to maximal inhalation and exhalation on the right. ERV, Expiratory reserve volume; FRC, functional residual capacity; IC, inspiratory capacity; RV, residual volume; VC, vital capacity; VT, tidal volume. 264. Provocation Tests 265. TABLE 7-3 Positive Methacholine Challenge in a 7-year-old Girl With Chronic Cough* 266. MEASURING PULMONARY MECHANICS AT THE BEDSIDE 267. Calculated Parameters 268. Tidal Volume 269. Respiratory Frequency 270. Minute Ventilation 271. Rapid Shallow Breathing Index 272. Inspiratory and Expiratory Times 273. Lung Compliance 274. Airway Resistance 275. Time Constants 276. FIGURE 7-11 Tracing of pressure, flow, and volume over time (in seconds). Exp, Expiration; Insp, inspiration. 277. Pressure, Flow, and Volume Over Time 278. Flow–Volume Loops 279. FIGURE 7-12 Patterns of flow–volume loops. A, Normal; B, restrictive; C, obstructive. 280. FIGURE 7-13 Flow–volume loops showing various forms of airway obstruction. A, Fixed obstruction; B, variable extrathoracic obstruction; C, variable intrathoracic obstruction. 281. Pressure–Volume Loops 282. FIGURE 7-14 Pressure–volume loops demonstrating normal and decreased lung compliance. A, Normal lung compliance; B, decreased lung compliance. 283. Lung Overdistention 284. FIGURE 7-15 Pressure–volume loops demonstrating overdistention. Note the “penguin” or “bird's beak” appearance in the shape of the loops. These loops demonstrate idealized slopes (dashed lines) for change in compliance for the entire breath (C) and change in compliance in the last 20% of inspiratory pressure (C20). The C20/C ratio identifies lung overdistention. 285. Work of Breathing 286. Other Bedside Tests 287. Vital Capacity 288. Peak Expiratory Flow Rate 289. Maximal Inspiratory Pressure
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    290. Complex BedsideMeasurements 291. SUMMARY 292. ASSESSMENT QUESTIONS 293. References 294. Chapter 8 Radiographic Assessment 295. LEARNING OBJECTIVES 296. RADIOGRAPHIC TECHNIQUE 297. FIGURE 8-1 Expiratory frontal chest radiograph shows normal decrease in left lung volume. Tooth (arrow) obstructs the right mainstem bronchus and causes air trapping in the right lung. 298. NORMAL CHEST ANATOMY 299. FIGURE 8-2 A, Left lower lobe pneumonia abuts the diaphragm, leading to nonvisualization of the normal edge of the diaphragm. The cardiac border is demarcated because the lingula (a segment of the upper lobe of the left lung) is normally aerated. B, Only the right hemidiaphragm is visualized because the left is obscured by the left lower lobe pneumonia. Major fissure appears as an edge (arrow). 300. FIGURE 8-3 Normal frontal view of the chest demonstrating the thoracic inlet (1), carina (the point at which the trachea splits into the two mainstem bronchi) (2), the aortic arch (3), and pulmonary hila (4). 301. FIGURE 8-4 Normal thymus abuts the minor fissure (arrow) and has a curved lateral margin. 302. FIGURE 8-5 A, Infant with respiratory distress syndrome on lower ventilator setting. B, Same infant on higher ventilator setting. 303. POSITIONING OF LINES AND TUBES 304. AIRWAY OBSTRUCTION 305. FIGURE 8-6 Enlarged tonsils (arrow) appear to hang down into the hypopharynx. The nasopharynx (arrowhead) is narrowed from enlarged adenoids located posterior and superior. 306. FIGURE 8-7 “Steepling” of the subglottic airway is caused by croup. 307. FIGURE 8-8 Enlarged epiglottis (arrow) appears as a “thumb” projecting into the airway. 308. FIGURE 8-9 Hypopharynx and trachea are displaced away from the cervical spine by a retropharyngeal abscess. 309. FIGURE 8-10 Edema from a coin in the upper esophagus causes marked narrowing of the adjacent trachea. The child presented with stridor and difficulty with swallowing. 310. RESPIRATORY DISTRESS IN THE NEWBORN 311. FIGURE 8-11 Even after intubation, the lungs are hypoinflated and have a granular pattern with faint air bronchograms in this infant with respiratory distress syndrome. 312. Box 8-1 Respiratory Distress in the Newborn 313. FIGURE 8-12 Large left pneumothorax appears black and outlines the partially collapsed left lung and left cardiac border (arrow). 314. FIGURE 8-13 Pneumomediastinum elevates the left lobe of the thymus to produce a “spinnaker sail” in this child, who also has a large left pneumothorax.
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    315. FIGURE 8-14Massive pulmonary interstitial emphysema throughout the left lung causes shift of the mediastinum to the right and downward displacement of the left hemidiaphragm. 316. FIGURE 8-15 Meconium aspiration appears as a coarse asymmetric pattern. Enlargement of the heart may be secondary to fluid overload in this infant. 317. FIGURE 8-16 Group B streptococcal pneumonia presents in this infant with hyperinflation, small right pleural effusion (arrow), and hazy infiltrative pattern. 318. FIGURE 8-17 Multiple “cysts” in the left hemithorax are air-filled loops of bowel that herniated through a defect in the left hemidiaphragm. The abdomen is scaphoid from decreased bowel content. 319. ATELECTASIS 320. FIGURE 8-18 Left upper lobe collapse causes elevation of the left hemidiaphragm and crowding of the left ribs from volume loss. The cardiac and superior mediastinal borders are indistinct because of the “silhouette sign” while the diaphragm remains demarcated by the aerated left lower lobe. 321. FIGURE 8-19 Collapsed right middle lobe appears as a triangular wedge of increased density extending anteriorly and inferiorly toward the anterior chest wall and diaphragm. 322. PNEUMONIA 323. FIGURE 8-20 Round pneumonia (arrow) in the left lower lobe simulates a mass. 324. ASTHMA 325. CYSTIC FIBROSIS 326. FIGURE 8-21 Coarse interstitial markings, hyperinflation, bronchiectasis, mucous plugging (arrow), atelectasis (arrowhead), and enlarged pulmonary hila are all demonstrated in this child with cystic fibrosis. 327. FIGURE 8-22 Pneumonia was the precipitating precursor to acute respiratory distress syndrome, with densely consolidated lungs and air bronchograms (arrow). 328. ACUTE RESPIRATORY DISTRESS SYNDROME 329. CHEST TRAUMA 330. FIGURE 8-23 Trauma to the chest resulted in extensive bilateral air leaks and densely consolidated pulmonary contusions. Multiple rib fractures are present. 331. Assessment Questions 332. References 333. Chapter 9 Pediatric Flexible Bronchoscopy 334. LEARNING OBJECTIVES 335. INDICATIONS 336. Diagnostic Bronchoscopy 337. Stridor 338. Box 9-1 Indications for Flexible Bronchoscopy 339. DIAGNOSTIC 340. Airway Anatomy Evaluation 341. Bronchoalveolar Lavage and Biopsy 342. Cytopathology 343. Microbiology 344. Foreign Body Aspiration
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    345. Hemoptysis 346. THERAPEUTIC 347.Wheeze 348. Cough 349. Radiographic Abnormalities 350. Foreign Body Aspiration 351. Hemoptysis 352. Inhalation Injury 353. Therapeutic Bronchoscopy 354. CONTRAINDICATIONS 355. Box 9-2 Contraindications to Flexible Bronchoscopy 356. ABSOLUTE CONTRAINDICATIONS 357. RELATIVE CONTRAINDICATIONS 358. EQUIPMENT 359. Flexible Bronchoscope 360. Insertion Tube 361. FIGURE 9-1 Three different sizes of pediatric flexible bronchoscopes. Top to bottom: 4.5-, 3.6-, and 2.2-mm outer diameter. Note that all scopes have similar working tube lengths. 362. Control Head and Eyepiece 363. Light Source Connector 364. Video Recording Equipment 365. PREPARATION 366. Equipment and Supplies 367. Box 9-3 Equipment and Supplies for Pediatric Flexible Bronchoscopy 368. FIGURE 9-2 Necessary equipment for basic pediatric flexible bronchoscopy includes bronchoscope, attached suction tube, 2% lidocaine jelly, lidocaine spray, three 1-ml aliquots of 1% lidocaine solution, Luken trap, gauze pads, and three to five 10-ml aliquots of normal saline for bronchoalveolar lavage. These items are placed on a clean drape on top of a portable bronchoscopy cart. 369. Patient 370. Personnel 371. PROCEDURE 372. Conscious Sedation 373. Topical Anesthesia 374. Patient Monitoring 375. Technique 376. POSTPROCEDURAL MONITORING AND COMPLICATIONS 377. EQUIPMENT MAINTENANCE 378. FIGURE 9-3 Correct placement of flexible bronchoscope in STERIS cleaning apparatus, used for chemical sterilization of the instrument. 379. COMPARISON WITH RIGID BRONCHOSCOPY 380. Assessment Questions 381. References 382. Chapter 10 Invasive Blood Gas Analysis and Cardiovascular Monitoring 383. LEARNING OBJECTIVES
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    384. BLOOD GASSAMPLING 385. Pain Control 386. FIGURE 10-1 Arterial sites that may be used for peripheral artery puncture in infants and children. 387. Box 10-1 Indications for Blood Gas Analysis 388. Arterial Sampling Sites 389. Modified Allen's Test 390. ARTERIAL PUNCTURE 391. Procedure 392. Box 10-2 Equipment for Arterial Puncture and Blood Gas Collection 393. Contraindications 394. Complications 395. CAPILLARY BLOOD GAS SAMPLES 396. Puncture Sites 397. FIGURE 10-2 Recommended puncture sites (shaded areas) in infant's heel to obtain capillary blood for analysis. 398. FIGURE 10-3 Technique for grasping the finger for a capillary puncture, with recommended site for puncture indicated (shaded area). 399. Procedure 400. Box 10-3 Equipment for Capillary Puncture and Blood Gas Collection 401. FIGURE 10-4 Technique for stabilizing the heel for a capillary puncture. 402. Contraindications 403. Complications 404. ARTERIAL CATHETERS 405. Umbilical Artery Catheterization 406. FIGURE 10-5 An indwelling arterial line and continuous infusion/flush system used to monitor blood pressure and obtain blood gas samples. Exploded view shows a three-way stop-cock system. A, Normal position with stop-cock off to sampling port allows continuous monitoring of blood pressure and flushing of the line if using a (pig tail) flush system. B, Position to draw blood or inject flush solution to the patient with stop-cock turned off to flush solution. C, Position to flush sample port with stop-cock off to patient. All ports are closed at all intermediary positions 407. Peripheral Artery Catheterization 408. Procedure for Sampling 409. Complications 410. Measurements 411. CONTINUOUS INVASIVE BLOOD GAS MONITORING 412. FIGURE 10-6 An ex vivo in-line continuous blood gas monitor designed for use in critically ill newborn infants. 413. CENTRAL VENOUS CATHETERS 414. Monitoring Sites 415. Procedure 416. Complications 417. Measurements 418. PULMONARY ARTERY CATHETERIZATION
  • 19.
    419. FIGURE 10-7Conventional pulmonary artery (Swan-Ganz) thermodilution catheter. 420. Procedure 421. FIGURE 10-8 Examples of pressure waveform patterns at various locations in and around the heart. A, Central venous pressure; B, right ventricular pressure; C, pulmonary artery pressure; D, pulmonary capillary wedge pressure. 422. FIGURE 10-9 Pressure waveforms as the catheter travels through the right atrium (RA), right ventricle (RV), and pulmonary artery (PA), becoming wedged (pulmonary capillary wedge pressure [PCWP]). 423. Complications 424. Measurements 425. Box 10-4 Normal Pressure Values From Pulmonary Artery Catheters 426. Cardiac Output 427. TABLE 10-1 Normal Ranges of Derived Hemodynamic Parameters 428. NONINVASIVE MEASUREMENT OF CARDIAC OUTPUT AND PERFUSION 429. PATIENT INFORMATION 430. FREQUENCY 431. TABLE 10-2 Approximate Normal Range of Arterial Blood Gas Values 432. BLOOD GAS INTERPRETATION 433. Acid–Base Balance 434. Oxygenation 435. TABLE 10-3 Laboratory Values for Acid–base Disturbances 436. Box 10-5 Causes of Metabolic Acidosis 437. Box 10-6 Causes of Metabolic Alkalosis 438. Box 10-7 Causes of Respiratory Acidosis 439. LUNG DISEASE 440. IMPAIRED LUNG MOTION 441. APNEA 442. OTHER 443. Box 10-8 Causes of Respiratory Alkalosis 444. FIGURE 10-10 Oxyhemoglobin dissociation curve, illustrating the P50 value (Po2 at 50% saturation) with the effects of right and left shifts of the curve. As the curve shifts to the right, the oxygen affinity of hemoglobin decreases, more oxygen is released at a given Po2, and the P50 value increases. When the curve shifts to the left, there is increased oxygen affinity, less oxygen is released at a given Po2, and the P50 value decreases. 445. TABLE 10-4 Factors That May Shift Oxyhemoglobin Dissociation Curve 446. FIGURE 10-11 Components of oxygen delivery. 447. ABNORMAL HEMOGLOBIN 448. ASSESSMENT QUESTIONS 449. References 450. Chapter 11 Noninvasive Monitoring in Neonatal and Pediatric Care 451. LEARNING OBJECTIVES 452. PULSE OXIMETRY 453. Principles of Operation
  • 20.
    Exploring the Varietyof Random Documents with Different Content
  • 21.
    from mechanical pressureon the brain or spinal marrow, but which in the cases cited depend on disorder of the digestive organs. It is impossible to exaggerate the interest or importance of these cases; not only from the fact that they almost certainly would have led to organic disease, but also for the value of that practical discrimination which they exemplify. Again, the very treatment which would have been proper, which had sometimes been begun, and which was not inappropriate to cases of organic disease, with which the symptoms were in part identical, would have inevitably, in the cases in question, only served to exasperate the very conditions they were designed to relieve, and to hasten those processes against which they were intended to guard. No one can understand the force of these cases, without recollecting the intense difficulty of ascertaining that point at which disorder ceases to be merely functional, and at which organic disease begins. This is of all things the most difficult to determine in the whole circle of physiological or pathological inquiry. The symptoms alone are absolutely useless in any case of real difficulty. Of that Abernethy was well aware, and he did much to guard us against the error into which a reliance on them was calculated to lead. He knew that organs which were diseased would sometimes afford indications not distinguishable from those of health; and that, conversely, organs essentially sound would sometimes only afford those signs which were indicative of disorder. We have, we trust, made some little progress in this very difficult branch of inquiry; and although it is true that organic disease not unfrequently escapes detection during life, yet, so far as we have observed, it is only in those cases in which there is, notwithstanding the daily lessons of experience, an improper reliance on what are called the symptoms. We assert, without the least hesitation, that organic diseases should seldom elude detection where the investigation is sufficiently comprehensive; but it must include all the facts of the case, the early history, and such circumstances which, however remote, have been over and over again proved to be
  • 22.
    capable of exertingan influence on the body; an investigation which, however vainly pleaded for in medical science, however regarded as too exacting, involves nothing more in principle than is required as a matter of course in all other scientific investigations. When these conditions are observed, it is very rarely that we cannot detect organic affections in organs in which there may be no present symptoms. In relation to the extent to which they may be affected, it is true we have yet much to learn; still, if cases be judged of not by the history merely, nor by the symptoms merely, but by both in conjunction, and if to these be added a careful observation of the amount of work that the organs are separately or collectively doing, as compared with their natural proportions; together with a careful estimate of that which the actions of any visible disease may be eliminating from the body; then, indeed, we have good ground for hope that means will be opened to us of distinguishing more accurately various states of the system; and additional principles and powers disclosed of readjusting the disturbed balance of the various functions, which is the essential element of disease. [29] "History of the Inductive Sciences." [30] Butler's "Analogy."
  • 23.
    CHAPTER XVI. "MY BOOK"CONTINUED. "La première chose qui s'offre à l'Homme quand il se regarde, c'est son corps. Mais pour comprendre ce qu'elle est, il faut qu'il la compare avec tout ce qui est au-dessus de lui, et tout ce qui est au-dessous, afin de reconnoître ses justes bornes."—Pascal, Pensées, Nature des Hommes, vol. ii, p. 57. Abernethy, in impressing any anatomical fact, would sometimes say that we carried about with us in our own bodies excellent means of refreshing our impressions on many points of anatomy; but we may say this in a much more extensive sense with regard to the interpretation of that for which anatomy is alone useful—namely, the uses or functions of the body. It would be very possible for any observant person, who was moderately versed in the ordinary principles of correct reasoning, to detect many defects in medical investigations and practice; in the correction of which many of Abernethy's practical contributions consisted; but the mind, restlessly impatient to arrive at conclusions, often overlooks the most important facts, and deduces inferences directly from the evidence of the eye or other senses, without submitting it to such test as the intellectual faculty can alone supply. Nothing can exceed the mischief of this in serious matters, nor the absurdity of it, when we think awhile.
  • 24.
    We should hardlyrefrain from laughter if we saw a man try to see with the point of his nose, or endeavour to examine the odour of a rose by his ear, or to listen with his eye; yet this is not a whit more absurd than to try to deduce conclusions from the impressions furnished by the eye, which can alone be afforded by the rational faculty. Nothing is more common than this sort of fallacy, nothing more easy than its correction; but then people must bestow at least a little of that time on their highest faculties which they so lavishly expend on inferior powers. How much time we consume, for example, in the study of various languages—those instruments for the communication of ideas—as compared with that bestowed on the collecting and marshalling of ideas themselves; which is little better than grasping at the shadow, and losing the substance; or, to use a humorous illustration, like a friend of our own, who, having a new dog, sent his servant forthwith to purchase sundry articles for him, in the shape of kennel, chains, engraved collars and food; all of which, at some expense, he safely accomplished to his master's satisfaction, expressing his sorrow at the same time for having accidentally lost the dog! It is curious, however, to observe how the real business of the human mind is shadowed forth in the very abuses of its powers; nothing so bad but it is charged with a certain quantity of good; no error so great but carries with it the element of its own correction. The mind in its greatest aberrations is followed by the shadow of its real duty, which as it were waits on the time when clearer views shall burst on it. Nothing shows the real tendencies of mind more than its restless desire to arrive at some conclusion, some tangible evidence of its highest functions. It is the impulse of this instinct— the ungoverned abuse of a high faculty, impatient for illegitimate fruition—which lies at the bottom of much false reasoning, and which blinds men, even of great power, to obstacles which are luminously evident to the most ordinary capacity. Important as the next series of illustrations cited by Abernethy are, the conclusions he deduced from them were the necessary sequences of clear and correct reasoning on familiar and established facts.
  • 25.
    The illustrations inquestion were those afforded by various cases of injuries of the head, in which certain consequences, however exceptional they may be, are too commonly referred to the abstract nature of the injury. We see that a man has a blow, we see that he does not recover in the usual way in which we have known many others to recover; but we do not, perhaps, consider that if a similar—nay, perhaps an identical force produces very different effects in different cases, the cause will probably not be in the nature or direction of the force so much as the condition of the body. Now the value of these cases of Abernethy's consists, first, in impressing the influence of this condition as modifying—in other words, sustaining—the disturbance consequent on injuries (in their origin) purely mechanical; and secondly, in showing that, in the cases in question, that condition depended on a disordered state of the digestive organs. We hardly know any cases more valuable than those in question. When a patient receives a blow, and, the immediate consequences having subsided, there still remains an impairment of sense or motion, the most usual thing, and no doubt very often the true view, is to refer it all to lesion of nervous structure. It is therefore of the highest consequence to know the facts of these cases. They not only prevent the hasty institution of treatment which would be injurious; not only secure the patient from being abandoned in despair; but supply at the same time the clues to a rational treatment, and the hope of a favourable issue. There can now be few observant surgeons who have not met with cases in illustration of these circumstances; and yet I know not to whom the perusal of Mr. Abernethy's cases might not be useful. It is not without regret that I forego transcribing at least one of them; forgetful how impossible it is to do Abernethy full justice in a work intended for all readers. In his "Book," the cases in question begin at page 97, and occupy but a few pages. The next class of cases, from which Abernethy illustrates the prevailing influence of the digestive organs, receives additional importance from the imperfect manner in which the phenomena have been interpreted in a vast variety of diseases; like small-pox
  • 26.
    and others, ascribedto the action of particular poisons. We may possibly have an opportunity of saying something more on this subject; but we may remark that when any disease has been presented to the physician or surgeon, supposed to be the result of specific poisons, it is just the last case in which any special attention is paid to the digestive organs. Now Abernethy observed that disorders of the digestive organs would sometimes produce diseases resembling maladies said to result from specific poisons. This is about the first indication or hint of that which, duly carried out by an advancing science, will, we trust, ere long, demonstrate what to us has long appeared only part of a general law. Of this we may by and by say a little more, when we endeavour to show the small quantity of truth which there is mixed with some of the prevailing errors; and how their occasional success results from blundering, as it were, on small portions of the principles enunciated by Abernethy. In the meantime, we may refer to the illustration afforded by small-pox of the remarkable influence of the digestive organs in diseases called specific. We adduce this, because it is one which is popularly familiar, and a disease that, had it been studied under any but one particular phase, would have proved, of all others, the most instructive. There is no malady, under certain circumstances, more extensively fatal. In the Spanish conquest in America—a history scarcely less interesting in a medical than in a moral point of view—it seems that not all the cruelties of the Spaniards were more destructive than the small-pox. In less than a century after the arrival of Columbus, it was computed that it had destroyed more than half the population; and in one year (1590), it so spread along the coast of Peru, that it swept away nearly the whole of the Indians, the Mulattoes, and the Mestichos, in the cities of Potosi and De la Hay31. As is well known, before the discovery of vaccination, persons were inoculated with the small-pox, because it was found that the disease could be thus rendered comparatively harmless; whilst, if it was taken naturally, as it was termed, it was always serious, and too
  • 27.
    frequently extremely fatal.The preparation for inoculation consisted of measures addressed to the digestive organs. Now the effect may be judged of by this fact: Inoculation was at first violently opposed; and, in reply to the alleged safety of it, an opponent wrote to prove that one in one hundred and eighty-two had died of it. I wish we could say so of many other diseases. That such persons had, nevertheless, the genuine malady, was proved by the fact they were capable of infecting others (unprepared) with the disease in its most malignant form. But our notions of the mode in which the laws of the animal economy deal with injurious influences of this kind, are mischievously conventional. What quantities, for example, of mercury, in its different forms, have been administered in almost all diseases; and yet unquestionably there is a great deal of false reasoning in regard to this poison. Effects are attributed to it as mercury, which only belong to it in its general character of an injurious agent. All the (so-called) specific effects of it, most of which are become popularly familiar, may occur without any mercury at all. We have seen them induced by aloes, by scammony; and in a case where no medicine had been given, and where the only detectable poison was one which was to be sure bad enough, an enormously loaded liver. We are obliged to say but little here in connection with this subject. Abernethy's cases were very important in relation to the influence of the digestive organs, although he did not see the generalization to which, as it appears to us, they help to conduct the pathologist. The subject is too extensive for discussion here. We will attempt something of a popular view of it, when we endeavour to explain the fallacy to which we have already referred. Abernethy next adduces various illustrations from cases of other diseases; as indurations, tumours, carbuncles, scrofulous affections, and others; in proof of the dependence of a "numerous and dissimilar progeny" of so-called local diseases, on that "fruitful parent," disorder of the digestive organs. Of one of the most interesting and remarkable cases of tumour, Mr. Abernethy did not
  • 28.
    live to seethe termination. It was of a lady who consulted him previous to the proposed infliction of an operation. She had been recommended by my father, in the country, to consult Abernethy before submitting to it; because he disapproved of it, as did Abernethy—not because they doubted of the nature of the disease, but because it was not confined to the part on which it was proposed to operate. The lady used to call on Abernethy when she came to town; and after his death she came to me—as she said, just to report her condition. She had at times various disturbances of her digestive organs; but always from some imprudence; for, although habitually very simple in her habits, she would be sometimes careless or forgetful. She died at a very advanced age—between seventy and eighty— but there had been no return of the disease for which she had originally consulted Abernethy, nor had she undergone any operation. It is a significant circumstance, too, that she had a sister who died of cancer. The whole of the cases are, however, scarcely less valuable. In the fifth section, he treats of disorders of parts having continuity of surface with the alimentary canal, certain affections of the nose, of the eye, and of the gullet or œsophagus. His observations on the latter are especially valuable. They strike at that meddling practice which is too common in the treatment of diseases of these parts. Many of us have recommended a practice which, without neglecting either, relies less on manipulatory proceedings, and more on measures directed to the general health, in such cases; as producing effects which are not to be obtained by other means; but, if we are to judge from the medical periodicals, without much success; so inveterate is the habit of imagining that, whatever the causes of disease may be, if the results be but mechanical, mechanical means can alone be applicable. Public attention, and the perusal of such cases as those of Abernethy, can alone correct these errors.
  • 29.
    Lastly, he describesthe results of his dissections as bearing on the whole subject. Here he shows, that whilst disordered function may take place coincidentally with, or as a consequence of, change of structure, yet that such change, so as to afford visible or detectable departures from natural appearances, is by no means necessary, in organs which, during life, had afforded the most incontrovertible evidence of impaired function. He also shows that disease has terminated in disorder which had its original seat in the digestive organs. And again—that, in cases where the cause of death had been in the abrogated function of the brain, he found no actual disease in that organ, but in the abdominal viscera. He very justly observes that the conclusions he has drawn can be neither ascertained nor disproved by anatomical evidence alone. He mentions especially, and illustrates by a remarkably successful case, how diseases of the lungs may be engendered by disorders of the digestive organs, and entirely subdued by correction of that disorder. He speaks also suggestively of the possibility of that which is certainly now an established fact. He says: "In cases of diseased lungs, where no disease of the digestive organs is discovered, yet considerable disorder does exist, and may continue for many years without any organic disease being apparent; it is possible that such disorder may excite disease of the lungs, and thus produce a severer disease of the latter organs than what existed in the former. Accurate attention to the digestive organs may determine this important subject, and lead to the prevention and cure of the sympathetic diseases which I have mentioned." "This attention must not be merely of that general kind which adverts only to the quality of the ingesta, &c., but one which more strictly observes whether the viscera" (that is, reader, not merely the stomach, not merely the digestive organs, but the whole viscera of the body) "and whether these secretions are healthy or otherwise." After speaking of the heart also, as affected by the digestive organs; and of the infinity of diseases which arise from the reciprocal disturbance excited between them and the brain;—he says: "But even these are not the worst consequences. The disorder of the sensorium, excited and
  • 30.
    aggravated (by themeans which he has described), affects the mind. The operations of the intellect become enfeebled, perplexed, and perverted; the temper and disposition, irritable, unbenevolent, and desponding. The moral character and conduct appears even to be liable to be affected by these circumstances. The individual in this case is not the only sufferer, but the evil extends to his connections and to society. The subject, therefore, appears to me to be of such importance, that no apology need be offered for this imperfect attempt to place it under general contemplation." Here is that suggestion which, when carried out, leads to the detection of cases of insanity which depend on disturbances of the digestive organs. Lastly, as if, notwithstanding his own previous attention to the important question of the influence of the digestive organs in disease, he felt that the inquiry had grown upon him in consequence of Mr. Boodle's endeavour to concentrate his attention to the subject, he concludes by expressing his past obligations to Mr. Boodle; for he says, with admirable modesty and candour, "for Mr. Boodle first instructed me how to detect disorders of the digestive organs, when their local symptoms were so trivial as to be unnoticed by the patient." He urges Mr. Boodle to publish also his own observations on the subject, because any remarks from one who observes the progress of disease "with such sagacity and accuracy, cannot but be interesting." We are quite aware how feeble our attempt has been to do justice to this admirable book. But nothing can do that but a careful study of the various principles which it either suggests, dimly shadows forth, or deeply and beautifully unfolds. Through not a very short life, we have had ample opportunity of testing these principles by the bedside, and of endeavouring to connect some of them with the laws in obedience to which they occur; and we are free to declare our impression that when the book is studied with the requisite previous knowledge, and freedom from preconceived opinion; and when tested and carried out in principle, as distinguished from any adhesion to mere matters of detail; we think it infinitely more valuable than all other professional works
  • 31.
    whatever. In examiningthe truths it unfolds, or in our humble endeavours elsewhere at a more analytical or extended application of them, like Abernethy, we have rested our reasoning wholly on facts and observations which are acknowledged and indisputable. Whilst other views have only led to a practice in the highest degree empirical, or, what is worse, conjectural, those of Abernethy's lead often directly, but always when duly studied, to a practice at once clear, definite, and in the sense in which we shall qualify the word "positive,"—that is, one which gives us the power (when we really have the management of the case) of predicting the success or failure; which is at least a ripple indicative of a coming science. In order, however, to carry out this clearly, we shall at once add what we think necessary to the profession and the public on the subject. The general relation of Abernethy's labours to a real and definite science will be better developed in our concluding Summary; when we may have an opportunity of stating what further appears to have been done, and what is yet required. It will have been perhaps already observed that Abernethy's views involve a few very simple propositions: first, that disturbance of a part is competent to disturb the whole system; and conversely, that disturbance of the whole system is competent to disturb any part. That the disturbance may commence in the brain or nervous system, may then disturb the various organs, and that these may again by reflected action disturb the brain, and so reciprocally; and that in all these cases tranquillity of the digestive organs is of the very first consequence; not merely from its abstract importance, but from the influence it exerts on the state of the nervous system. With respect to any influences immediately directed to the nervous system, these we apprehend to be few and simple; some kinds of medicine, are, no doubt, in particular cases useful, none are susceptible of general application. None of them are certain; and sedatives of all kinds, which appear to have the most direct influence on the nervous system, either require to be employed with the utmost caution, or are in the highest degree objectionable. But there
  • 32.
    are other directinfluences, certainly; and very important they are. Quiet, avoidance of disturbing external impressions, whether of light, sound, temperature, &c. whether in fact of mind or body; but, in the majority of mankind, how few of them we can, in a strictly philosophical sense, command. We are therefore driven to other sources of disturbance; and in the digestive organs we find those on which we can exert great influence, and in which tranquillity, however procured or under whatever circumstances, is certain, pro tanto, to relieve the whole system. This Abernethy attempted, and with a success which was remarkable in no cases more than those which had resisted all more ordinary modes of proceeding; by general measures, by simplicity of diet, by occasional solicitation of this or that organ, by air and exercise, and measures which were directed to the general health. No doubt in some cases he failed, and so we shall in many; but let us look boldly at the cause, and see whether we do not fail a great deal more from our own ignorance than from any natural impossibility. To examine the question, we must for the moment forget our admiration of Abernethy; be no longer dazzled by his genius, but look only to our duty; endeavour to discover his defects, or rather those of the state of the question when he left us, and see what further investigation has afforded in aid of supplying them. In the first place, we must examine a little further that proposition which we have seen both in Hunter and Abernethy under different forms. Hunter says the disturbance of the organ sympathizing is sometimes more prominent than that of the organ with which it sympathizes. Abernethy says that the organ primarily affected is sometimes very little apparently disturbed, or not even perceptibly so. Now, from both these statements, we find that there may be no signs in the primarily affected organ; which, practically rendered, is nothing more or less than saying that in many cases we must not seek for the primarily affected organ where the symptoms are; and this is a great fact: because, although it does not necessarily teach
  • 33.
    us what wemust do, it exposes the broken reed on which so many rely. Now the further point, which, as we would contend, time and labour have supplied, is first this—that what Hunter had mentioned as one feature in the history of the sympathies of different organs, and Abernethy as an occasional or not unfrequent occurrence, is, in disorders of any standing, and with the exception of mechanical injury, in fact the rule—the symptoms of disorder being almost never in the primary organ; nay, even organic change (disease) is for the most part first seen in a secondarily affected organ. In regard to primarily affected parts, the skin only excepted, they will be found, in the vast majority of cases, to be one or other of the digestive organs. I will endeavour to render the cause of this intelligible. A minute examination of what happens in a living person, especially if it be extended to some thousands of cases, will soon disclose to the most unlettered person a few instructive facts, showing that Nature has a regular plan of dealing with all injurious influences, which, however various many of the details may be, is in general character exquisitely simple, surprisingly beautiful, and intelligibly conservative; and that the various modes on which she exercises this plan, from the cradle to the grave, are, in frequency, directly in the order of their conservative tendency. Let us explain. There is no dearth of illustration; the facts are bewilderingly abundant; the difficulty is which to choose, and how to give them an intelligible general expression. Let us take a single case. We know that if a mote gets into the eye, there is irritation, immediately there is flow of blood to the part, a gland pours forth an abundant supply of tears, and the substance is probably washed out. Very well; we say that is intelligible. But suppose you have the vapour of turpentine, or any other irritant, the same thing happens; but still you cannot give quite the same mechanical explanation. Again—substances which affect the mouth, nose, and stomach, will irritate the eye without any contact, and cause a flow of tears.
  • 34.
    Lastly, you knowthat affections of the mind will do this, and where even we have no mechanical irritant at all. In all these cases there has been activity of the vessels of the eye, and in all it has been relieved by secretion. Now this is the universal mode throughout the body; all irritation of the organs is attended by secretion; and where this is done, there is no disorder; or rather, the disorder is relieved: but if organs are irritated continuously, another thing happens, and that is, that an organ becomes unable to secrete constantly more than is natural, and then some other organ, less irritated in the commencement, takes on an additional duty—that is, the duty of the animal economy is still done, but not equally distributed. This is the state in which most people are in crowded cities, and who live in the ordinary luxury or the ordinary habits of civilized society, according to the section to which they may belong. It is easy, in such cases, to detect those differences which distinguish this state from what is called condition or perfect health, as we have elsewhere shown32. But of course there is a limit to this power in organs of taking on additional or compensating actions; and when this limit is exceeded, then those actions are instituted which we call Disease. The site is seldom found to be that of the original disturbance; and usually for a very plain reason—because there it would be more dangerous, or fatal. It would be scarcely less serious in many cases, even though placed on organs secondarily affected; and therefore it is more usually determined to the surface of the body; where, taking them simply in the order of their greatest number, or frequency, we find the first class of diseased appearances, and which strikingly impress the real nature of the law. They are the most numerous, most obviously dependent on general disturbance, and most conservative, as being least fatal. Diseases of the skin are those to which we allude, and which, in the characters I have mentioned, exceed all other diseases.
  • 35.
    Again—the next surfaceis that involution of the skin which covers the eye, and which lines the mouth, throat, and the whole of the interior surface of the respiratory tubes and the digestive organs. Here again we find the next seat of greatest frequency, and the conservative tendency, to coincide. We need only refer to the comparative frequency of what are called colds, ordinary sore throat, and so forth; as contrasted with those more serious diseases which occur in the corresponding surfaces of the respiratory organs and alimentary canal. In tracing diseases onwards in the order of their number, we never lose sight of this conservative tendency. When organs become involved in disease, we find that, for once that the substance of the organ is so affected, the membrane covering it is affected a hundred, perhaps a thousand times. This is equally observable with respect to the brain, heart, lungs, digestive organs, and some other parts; and it is of great importance practically to know how readily affections are transferred from the lining of the alimentary canal and other parts to the membrane covering it, rather than to the intermediate texture of the organ; again impressing, though now in a dangerous type truly, the conservative tendency of the law. Finally, then, we arrive at diseases of Organs; and here we see this conservative tendency still typed in the site first chosen, which is almost always (where we can distinguish the two structures) not so much in the actual tissue of the organ as in that which connects it together—what we term the cellular tissue. This is remarkable in the lungs; where tubercular deposits are first seated; not in the essential structures of the organs, but in those by which they are joined together. All those various depositions also which are called tumours, generally begin in, and are frequently confined to, the cellular tissue; and even though there is, in certain malignant forms of tumour, a disposition to locate themselves in organs, there is a very curious tendency towards such, as may have already fulfilled their purposes in the animal economy.
  • 36.
    We might multiplythese illustrations to a tedious extent. We might show, for example, in the eye, how curiously the greatest number of diseases in that organ are placed in structures least dangerous to the organ; and even when the organ is spoiled, so to speak, how much more frequently this is in relation to its function as an optical instrument, than to the structure which forms the link with the brain, as an organ of sensation. I must, however, refer those who wish to see more of the subject, to the work33 in which it is more fully discussed, under the term, "The Law of Inflammation," which is a bad phrase, as imperfectly expressing the law; but as the greatest evils it exposes occur in cases of Inflammation, and as it shows the essential nature of that process to be entirely distinct from the characters which had been usually ascribed to it, every one of which may be absent so that expression was somewhat hastily given to the generalization which seemed best to express a great practical fact. To return to the bearing of all this on Abernethy's views, and in relation to organs primarily or secondarily affected. In obedience to the conservative law to which I have above alluded, defective function in one organ is usually accompanied by increased action in some other; and thus it happens that the symptoms are almost always in one organ, whilst the cause, or originally injurious influence, has acted on another. The general reader will, of course, understand that we are not speaking of direct mechanical injury to an organ. Now all the most recondite diseases of the kidney are already acknowledged by many to be seated in a secondarily affected organ. Still the practice is, in too many instances, a strange mixture of that which is in accordance with the true view, more or less marred by much that is in opposition to it; because it often includes that which is certain more or less to disturb the organ which it should be the object to tranquillize or relieve. In the same manner, the lungs and heart are continually disordered, and ultimately diseased, from causes which primarily act on the liver; and I have seen such a case treated with cod-liver oil and bitter ales, with a result which could not but be disastrous. The
  • 37.
    liver sends anenormous quantity of blood to the heart and lungs, from which it ought previously to have extracted a certain quantity of carbon (bile). If this be not done, the heart and lungs are oppressed both by the quantity and the quality of the blood sent to them. If nothing happen in either of the various sites I have mentioned, the blood must be got rid of; and it is so. In many cases, a vessel gives way; or blood is poured out from a vessel; or blood is employed in building up the structures of disease; but then the symptoms are frequently altogether in the chest, and not a sign of anything wrong in the liver. I cannot go on with the multitudinous illustrations of these principles. The law is to determine injurious influences to the surface. Deposition in the cellular tissue of the lung is bad enough; but it is better—that is, less certainly fatal—there, than in the respiratory tubes: and that is the explanation. But now comes the practical point. How is the primary organ to be got at? because that is the way to carry out the removal of the impediments to the sanative processes of nature, which, in many cases, no mere general treatment can accomplish. This is to be found by an examination into the whole (that is, the former as well as the more recent) history of the case, and adding the further test of a real and careful observation of all the secretions. By going back to the former life of the patient, we shall seldom fail to discover the various influences to which he has been subjected, and the organs to which they have been originally addressed. Having made up our minds, from our previous knowledge of injurious influences, on what organ they will most probably have acted, we now test this, not merely by inquiry after symptoms—and it may be not by symptoms at all—but by careful observation of the actual work of the suspected organ. In this way we almost certainly discover the real offender; in other words, the organ primarily affected. This is of immense importance; for we confidently affirm that one single beneficial impression made on it will do more in a short time—nay, in some rare instances, in a single day—than years
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    of routine treatment,that has been, nevertheless, of good general tendency. In treating it—i. e. the primary organ—however, great discrimination is necessary. If it be already organically affected, that treatment which would be, under other circumstances, necessary, becomes either objectionable, or requiring the utmost caution. For although an organ diseased in structure will, under some circumstances, as Abernethy long ago observed, yield its characteristic secretion, yet, unless we know the extent of the disease, which is just the thing we can almost never be certain about, excitement of it is never without danger. We should therefore excite the primary organ with more or less energy, with more or less caution, or not at all, according to circumstances. If we determine on not exciting it, we should then act on organs with which it has ordinarily closest community of function, or on whose integrity we can most depend. For choice, we prefer organs which, in a natural state, have nearest identity of function, as having the readiest sympathy, it may be, with each other. Yet so universal is the sympathy between all the organs, that there is no one that will not, under certain circumstances, or which may not be induced, perhaps, by judicious management, to take on compensating actions. We must not here pursue this subject further. We have endeavoured to sketch certain extensions of the views of Mr. Abernethy, and can only refer the profession and the public, for the facts and arguments which demonstrate and illustrate them, to those works in which they have been enunciated34. They have now been subjected to severer trials, and abundant criticisms. So far as we know, they have not been shaken; but if there be any merit in them, if they shall have made any nearer approach to a definite science, or sketched the proofs that Induction alone can place us in a position to talk of science at all, they are still sequences which have been arrived at by a steady analysis of Abernethy's views. It was he who taught us, in our pupil days, first to think on such subjects; to him we owe the first glimpse we ever had of the imperfect state of medical and surgical science; and if we do not wholly owe to him the
  • 39.
    means by whichwe conceive it can alone be rendered more perfect and satisfactory, he has at least in part exemplified the application of them. If we have made some advances on what he left us, and added to his beautiful and simple general views, something more definite on some points, something more analytical on others,—still, inasmuch as they are clear deductions from the views he has left us, and from such views alone, such advances remind us that the study of his principles serves but to demonstrate their increasing usefulness, and to augment the sum of our obligations. SECTION. Mr. Abernethy's book "On the Constitutional Origin of Local Diseases" had an extensive circulation, and excited a great deal of attention from the public as well as the profession. As a work which may be read as it were in two days, so as a person read it with one or other subject, it produced a great variety of impressions. It may be read simply as a narrative of a number of facts, with the inferences immediately deducible from them. All this is plain and intelligible at once to anybody, and of great practical value; but the work contains numerous observations of a suggestive kind, which require careful thought, and some previous knowledge, to enable a person to estimate their value, or to trace their onward relations. The impression made by the work on different minds varied, of course, with the reader, his information, and, in some sort, with the spirit in which it was studied. Some, who had, in their solitary rides, and in the equally solitary responsibilities of country practice, been obliged to think for themselves, recognized, in the orderly statement of clearly enunciated views, facts and principles
  • 40.
    which they hadalready seen exemplified in their own experience, and hailed with admiration and pleasure a book which realized their own ideas, and supplied a rational explanation of their truth and value. Some, who had never thought much on the subject, and were very ill-disposed to begin, regarded his ideas as exaggerated, and hastily dismissed the subjects, with the conclusion that he was a clever man, but too full of theory, and too much disposed to look to the stomach or the digestive organs. Others, making very little distinction between what they heard of the man, the book, or his practice, and probably not having seen either, but deriving only a kind of dreamy notion of a clever man with many peculiarities, would say that he was mad, or an enthusiast. Still, a great many of the thinking portion of the public and the profession held a different tone. The book was recognized as an intelligible enunciation of definite views—rather a new thing in medical science. The application of them became more and more general; his pupils were everywhere disseminating them, more or less, in the navy, in the army, in the provinces, and in America. Still, it must not be imagined that his principles became diffused with that rapidity which might have been inferred from his numerous and attentive class. Constituted as medical education is, but more especially as it was at that time—for it is slowly improving—pupils were almost entirely absorbed in the conventional requisitions for examination. There, they were not questioned as to the laws of the animal economy, nor any laws at all, nor even on any real axioms in approximation to them; but simply as to plain anatomy, the relative situation of parts, and such of the ordinary surgery of the day as had received the approbation of the Examiners, who were, for the time, the authorities in the profession. Therefore, out of a large number, there were comparatively few whose attentions were not too much absorbed by the prescribed curriculum of hospital routine to study principles: a curriculum constructed as if the object were to see how much could be learnt in a short time, without detriment to the very moderate requisitions of the examination at the College of Surgeons.
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    But if comparativelyfew had time to study Abernethy's lectures at the time, a great many had treasured up his remarks. As the impressions we receive in our childhood, before we are capable of thinking of their value, are vividly rekindled by the experience of real life, so many of the more suggestive lessons of Abernethy's lectures, which passed comparatively unheeded at the time, or were swamped in the "getting up" of the requisitions for an examination at the College, recurred in after days in all their force and truthfulness. Many, however, with more time, and perhaps more zeal, endeavoured to thoroughly master his views; and now and then he was gratified by evidence, that time had only served to mature the conviction of the pupils—in dedications and other complimentary recognitions, in the works of such of them as had been induced to publish any portion of their own experience. However various, too, the impressions made by his book, there are two things certain; viz. that he was much talked of, and the book had an extensive sale, went through several editions, and served to give the public some notion of those principles which he was so beautifully unfolding to the younger portions of the profession in his lectures. Besides, although there were not wanting those who spoke disparagingly of him, still, as an old and very far-seeing colleague of our own used to say, with perhaps too much truth, when canvassing the various difficulties of a medical man's progress in the metropolis, "A man had better be spoken ill of, than not spoken of at all." He was now beginning to be very largely consulted. The Public had "got hold of him," as we once heard a fashionable physician phrase it, and he soon obtained a large practice. A great many consulted him for very good reasons, and probably many for little better reason than that he was the fashion. Abernethy had now an amount of practice to which neither he nor any other man could do full justice. Finding it impossible to make people understand his views in the time usually allotted for consultation, he now referred his patients to his book, and especially page 72. This has been made the subject of a great deal of quizzing, and of something besides, not altogether quite so good-natured. For
  • 42.
    our parts, wethink it the most natural thing in the world to refer a patient to a book, which may contain more in full the principles we desire them to understand, than we can hope to find opportunity to explain at the time of consultation. We think that if asking a few questions, and writing a prescription (and we are here only thinking of a reasonably fair average time visit), be worth a guinea, the explaining a principle, or so placing a plan before a patient that his following it may be assisted and secured, is worth fifty times as much; and it came particularly well from Abernethy, one of whose lessons, and a most excellent lesson too, was the remark, "That if a medical man thought he had done his duty when he had written a prescription, and a patient regarded his as fulfilled when he had swallowed it, they were both deceived." As we are convinced that, cæteris paribus, success in medical treatment is indefinitely promoted by both patient and surgeon clearly understanding each other as to principles, we think it would be of great use if every medical man, who has any definite principles of practice, were to explain them in short printed digests. Nay, we have sometimes thought it would be useful to both parties, if, in addition to the inquiries and advice given at consultation, a medical man should have brief printed digests of the general nature and relations of most of the well-defined diseases. A careful perusal of one of these would help the patients to comprehend the nature and objects of the advice given, tend to the diffusion of useful knowledge, and in time help them to understand whether their treatment were conducted on scientific views, or merely a respectable sort of empiricism. What is here intended might be printed on a sheet of note paper; and, whilst it would be of great service to the patient, would form no bad test of the clearness and definite principles of the medical attendant. There is no doubt that Abernethy did good service by referring patients to his book. It led some to think for themselves, and it also assisted, pro tanto, in doing away with that absurd idea which supposes something in medical practice inappreciable by the public.
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    At this time,whilst, with a considerable indifference to money, he was making a large income, still he was obliged to work hard for it. He had as yet no emolument from the Hospital; he was still only an assistant surgeon. The tenacity of office, of which assistant surgeons so commonly complain, they have themselves seldom failed to exercise when they have become surgeons (Mr. Abernethy, however, excepted). The long tenure of office by his senior (Sir James Earle) wearied him, and was at times a source of not very agreeable discussions. On one occasion, Sir James was reported to have given Abernethy to understand that, on the occurrence of a certain event, on which he would obtain an accession of property, he, Sir James, would certainly resign the surgeoncy of the hospital. About the time that the event occurred, he happened one day to call on Abernethy, and was reminded of what he had been understood to have promised. Sir James, however, having, we suppose, a different impression of the facts, denied ever having given such a pledge. The affirmative and negative were more than once exchanged, and not in the most courteous manner. When Sir James was going to take his leave, Abernethy opened the door for him, and, as he had always something quaint or humorous to close a conversation with, he said, at parting, "Well, Sir James, it comes to this: you say that you did not promise to resign the surgeoncy of the hospital; I, on the contrary, affirm that you did: now all I have to add is, —— the liar!" In 1813, Abernethy accepted the surgeoncy of Christ's Hospital, which he held until 1828, a short time before he retired from practice. In 1814, he was appointed Professor of Anatomy and Surgery to the College of Surgeons—an appointment which could be, at this period, of little service to him, whatever lustre it might reflect on the College, where he gave lectures with a result which has not always followed on that appointment: namely, of still adding to his reputation. He was one of the few who addressed the elders of the profession without impressing the conviction that he had been too
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    much employed inaddressing pupils. He had given lectures two years in succession, when, in 1816, circumstances occurred which will occupy us for some little time. A new scene will be opening upon us; and this suggests the period (1815–16) as convenient for taking a retrospect, and a sort of general view of Abernethy's position. [31] Clench's History. Letter from Ch. Uslano, to Gonsalvo de Solano, July, 1590. [32] "Health and Disease." See Treatise on Tumours. [33] "Medicine and Surgery One Inductive Science." London, 1838. Highley. [34] "Medicine and Surgery One Inductive Science;" and "On Tumours," Art. "Treatment of Organs."
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    CHAPTER XVII. "Sperat infestis,metuit secundis, Alteram sortem bene preparatum Pectus." Hor. "Whoe'er enjoys th' untroubled breast, With Virtue's tranquil wisdom blest, With hope the gloomy hour can cheer, And temper happiness with fear." When we look abroad amongst mankind—nay, even in the contracted sphere of our own experience—it is interesting to observe the varied current of human life in different cases. In some, from the cradle to the grave, life has been beset with difficulties; it has been a continued struggle; the breath seems to have been first drawn, and finally yielded up, amidst the multifarious oppositions and agitations of adversity. In other instances, life seems like an easy, smoothly gliding stream, gently bearing Man on to what had appeared to be the haven of his wishes; and the little voyage has been begun and completed without the appearance of a ripple. All varieties are, no doubt, the result of constantly operating laws. Of these, many are probably inscrutable by us; many more, no doubt, escape our observation. The unforeseen nature of many events confers the character of mystery on any attempt at foresight; yet, when we take a careful retrospect of a life, it is curious to observe how naturally the secondary causes appear to have produced the results by which they were followed; but which, beforehand, no one had thought of predicting.
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    Varied, however, asis the course of human life, few men have arrived at eminence without difficulty. We do not mean that ephemeral prominence of "position" which makes them marked in their day; but that which leaves the impression of their minds on the age in which they lived, or on the science or other pursuit which they had chosen—original minds, who have enlarged the boundaries of our knowledge. Such men usually have the ample gifts of nature with which they are endowed, somewhat counterbalanced by the difficulty experienced in the successful application of them. Abernethy had not been altogether exempt from such difficulties. With a sensitive organization, he had had to make his own way; he had experienced the difficulties which attend the advocacy of opinions and principles which were opposed to, or at all events different from, those generally entertained. He had had to encounter that misconstruction, misrepresentation, ridicule, even malice—save the mark!—which are too frequently provoked by any attempts to tell people that there is something more correct than the notions which they have been accustomed to value. Still, when we compare Abernethy's course with that of many—we had almost said most—benefactors to science, he might be said to have been a fortunate man. If a man has power, and a "place to stand on"—and Abernethy had both—truth will tell at last. A retired spot, a room in an obscure street, near St. Bartholomew's, had been by his unaided talents expanded into a theatre within the walls of the hospital. This was becoming again crowded; and, although it formed a satisfactory arena for the development and illustration of his principles, the increasing audiences were significant of the coming necessity of a still larger building; which was, in fact, a few years afterwards, constructed. He had indeed arrived, as we imagine, at a point which was comparatively smooth water, and which we are inclined to regard as the zenith of his career. In the opening of his beautiful lectures at the College, Abernethy, in one of his warm and earnest endeavours to animate
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