£\ASI.\S 3457 WS 100 R476d 1892 48820570R NLPI 05252136 7 NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE !•» ^ » Section, 1 } NLM052521387 The Students' Quiz Series. A series covering the essential subjects of a thorough medical education, arranged in form of question and answer. By qualified teachers and examiners in New York. Illustrations wherever desirable. Priced at uniform low rate of $1.00, except double numbers on Anatortiy and Surgery, which are 'priced at $1.75 each. ANATOMY {Double Number)—By Fred. J. Brockway, M. D., Ass't Demonstrator of Anatomy, College of Physicians and Surgeons, New York, and A. O'Malley, M.D., Instructor in Surgery, New York Polyclinie. $1.75. • PHYSIOLOGY—By F. A. Manning, M.D., Attending Surgeon, Manhattan Hospital, N.Y. $1.00. CHEMISTRY AND PHYSICS—By Joseph Struthers, Ph. B., Columbia College School of Mines, N.Y., and D. W. Ward, Ph.B., Columbia College School of Minos, N. Y., and Chas. H. Willmarth, M. S. $1. HISTOLOGY, PATHOLOGY AND BAC- TERIOLOGY—By Bennett S. Beach, M.D., Lecturer on Histology, Pathology and Bacteriology, New York Polyclinic. 81.00. MATERIA MEDICA AND THERAPEU- TICS—By L. F. Warner, M.D., Attend- ing Physician St. Bartholomew's Dispen- sary, N.Y. $1.00. PRACTICE OF MEDlCINE-By Edwin T. Doubleday. M.D., Member N.Y. Patho- logical Society, and J. D. Nagel, M.D., Member N. Y. County Medical Associa- tion. $1.00. SURGERY {Double Number)—By R. A. Sands, M.D., Assistant Demonstrator of Anatomy, College of Physicians and Surgeons, N. Y. $1.75. GENITO-URINARY AND VENEREAL DISEASES—By Chas. H. Chetwood, M.D., Visiting Surgeon, Demilt Dispen- sary, Department of Surgery and Genito- urinary Diseases, New York. $1.00, DISEASES OF THE SKIN-By Charles C.Ransom, M..D., Assistant Dermatolo- gist, Vanderbilt Clinic, N. Y. $1.00. DISEASES OF THE EYE, EAR, THROAT AND NOSE—By Frank E. Miller, M.D., Throat Surgeon, Vanderbilt Clinic, N. Y., and James P. McEvoy, M. D., Throat Surgeon, Bellevue Hospital, Out- Patient Department, New York, and J. E. Weeks, M. D., Lecturer on Oph- thalmology and Otology, Bellevue Hos- pital Medical College, New York. $1.00. OBSTETRICS —By Charles W. Hayt, M. D., House Physician, Nursery and Child's Hospital, New York. $1.00. GYNECOLOGY—By G. W. Bratenahl, M.D., Assistant in Gynecology, Vander- bilt Clinic, New York, and Sinclair Tousey, M. D., Assistant Surgeon, Out- Patient Department, Roosevelt Hospital New York. $1.00. DISEASES OF CHILDREN—By C. A. Rhodes, M.D., Instructor in Diseases of Children, N. Y. Post-Graduate Medical College. $1.00. LEA BROTHERS & CO.. PUBLISHERS, PHILADELPHIA. Th? Students* Quiz Series. DISEASES OF CHILDREN. A MANUAL FOR STUDENTS AND PRACTITIONERS. BY C. ALEXANDER RHODES, M. D., Instructor in Diseases of Children, New York Post-Graduate Medical College. SERIES EDITED BY BERN B. GALLAUDET, M.D., Demonstrator of Anatomy, College of Physicians and Surgeons, New York; Visiting Surgeon Bellevue Hospital, New York. PHILADELPHIA: LEA BROTHERS & CO. loo Ml fed Entered according to Act of Congress, in the year 1892, by LEA BROTHERS & CO., In the Office of the Librarian of Congress, at Washington. All rights reserved. Westcott & Thomson, William J. Dornan, Stereoiypers and Electrolypers, Philada. Printer, Philada. PREFACE. In compiling this Compend on the Diseases of Children a large number of authors have been consulted, their opinions compared, and of these only such as were regarded as the latest and best have been retained. Among these authorities are—Keating's Encyclopedia of the Diseases of Children; J. Lewis Smith, Eustace Smith, Jacobi, Vogel, Meigs and Pepper; on general subjects, Pepper's System of Medicine; Reynold's System of Medicine; Osier, Loom is, Flint, Watson, Roberts, etc.; Buck's Reference Handbook of the Medical Sciences. Among periodicals, Medical Record, New York Medical Journal, Archives of Pediatrics, and London Lancet have been consulted. Credit is due Dr. John Doming for the excellent articles on Stomatitis and Enuresis. It is trusted that the student and practitioner will fully appreciate that the intent of this Compend is simply to present a summary of the diseases of children, and therefore its use is recommended only after a careful reading of the standard books from which its subject-matter has been taken. C. A. R. 1126 Park Avenue, \ New York City. ' CONTENTS. GENEKAL ANATOMICAL AND PHYSIOLOGICAL CON- SIDERATIONS ...................... 17 THE DEVELOPMENT OF THE CHILD.......... 19 EXAMINATION OF THE CHILD.............. 21 CARE AND FEEDING OF THE CHILD.......... 23 DISEASES OF CHILDREN: Diseases of the New-born : Asphyxia Neonatorum; Atelectasis Pulmonum; Cephalsematoma; Diseases of the Navel; Trismus and Tetanus of the New-born; Scleroma; Melsena Neonatorum; Conjunctivitis Neonatorum; Mastitis Neonatorum; Hare-lip and Cleft Palate; Constriction of the Mouth ; Deformities of the Tongue................. ........ 27 Organic Diseases: Stomatitis; Pityriasis Linguae; Parotis; Tonsil- litis ; Hypertrophy of the Tonsils; Retropharyngeal Abscess; In- flammation of the Oesophagus; Congenital Fistula of the Neck; Sclerosis of the Sterno-cleido-mastoid Muscle; Diseases of the Stomach and Intestines; Diseases of the Liver; Diseases of the Spleen; Peritonitis; Ascites; Diseases of the Mesenteric Glands; Diseases of the Heart; Rheumatism; Diseases of the Blood-ves- sels ; Diseases of the Nose and Throat; Diseases of the Thyroid Gland ; Diseases of the Thymus Gland; Diseases of the Bronchi and Lungs; Diseases of the Pleura; Diseases of the Brain; Dis- eases of the Spinal Cord ; Functional Nervous Diseases; Diseases of the Mind; Diseases of the Eye ; Diseases of the Ear; Diseases 5 6 CONTENTS. PAGE of the Kidneys; Diseases of the Bladder; Diseases of the Penis; Diseases of the Testicles; Diseases of the Female Genitals ... 38 The Exanthemata: Scarlet Fever; Measles; Rubeola; Variola; Varioloid; Varicella....................115 General Diseases: Diphtheria; Typhoid Fever; Typhus Fever; Cerebro-spinal Meningitis; Asiatic Cholera; Mumps; Erysipe- las; Intermittent Fever; Diabetes Insipidus; Diabetes Mellitus; Rickets ; Hereditary Syphilis ; Tuberculosis : (Pott's Disease ; Tuberculosis of the Joints; Morbus Coxse; White Swelling; Inflammation of the Ankle- and Elbow-joints)........125 Skin Diseases........................153 DISEASES OF CHILDREN. GENERAL ANATOMICAL AND PHYSIOLOGICAL CON- SIDERATIONS. Describe the changes in the vascular system at birth. With the establishment of respiration an increased supply of blood rushes through the pulmonary artery into the lungs, and the placental circulation is cut off. The foramen ovale closes about the tenth day, a valvular fold rising up on the left side of its margin and above the upper part; this fold becomes adherent to the margin of the foramen, but a permanent opening may remain. The ductus arteriosus closes from the fourth to the tenth day, forming an impervious cord connecting the pulmonary artery to the concavity of the arch of the aorta. The umbilical or hypogastric arteries consist of two portions: that from the bladder to the internal iliac remains pervious, as the superior vesical; that from the fundus of the bladder to the umbilicus closes from the second to the fifth day, forming the anterior ligament of the bladder. The umbilical vein and ductus venosus close from the second to the fifth day, the umbilical vein forming the round ligament to the liver, the ductus venosus existing as a fibrous cord in the fissure of the ductus venosus. Describe the general condition of the child at birth. The skin, covered with vernix caseosa, is livid, but changes to a deep red; in a few days it may become yellow, but in about two weeks has the normal pink tinge. Fine, soft hairs cover the body, but fall out by the third week, and are not replaced; the coarse hair on the scalp is shed by the third or fourth week, and replaced by a softer growth. The lachrymal and sudoriparous glands are not active until about the third month. 2 DC 17 18 DISEASES OF CHILDEEN. The sebaceous glands secrete early, especially on the scalp. Subcutaneous fat is abundant, internal fat scanty. Muscl.es small and soft, riot firm until the sixth month. Bones contain an excess of organic matter. Stomach small and vertical; hence easy emesis. Small intestine at birth nine feet five inches long; grows two feet per month during the first two months. Large intestine at birth one foot ten inches long; ascending and transverse colons short, descending colon and sigmoid flexure comparatively long; large intestine at one year two feet six inches long. Liver very large; occupies the greater part of the abdominal cavity. Pancreas comparatively normal. Kidneys at birth lobulated; gradually change to the adult form by the close of infancy, but comparatively larger. Heart small. Large arteries larger in proportion than in the adult. Lungs comparatively normal. Lymphatic system largely developed ; the glands numerous and large. Thymus gland increases from birth to second year; remains stationary till eighth year, then rapidly decreases. Brain soft, homogeneous, and of uniform color during the first month; after the first month the gray matter appears. Spinal cord: the centres of motion and circulation are more developed than the centres of sensation. Testicles: these descend during the ninth month of gestation, and should be in the scrotum at birth. Describe the various secretions at birth. Secretions from the mucous membranes commence early. Saliva is very small in amount till the third or fourth month, and at first from the parotid gland only; the submaxillary gland does not secrete until the third month. Gastric follicles secrete fluid capable of digesting casein. Intestinal mucus abundant; intestinal villi large and numerous, but Lieberkiihn's and Peyer's glands, though present, are not developed for some months. Pancreatic fluid is deficient during the first months. Bile is quite abundant and of a light-brown color. THE DEVELOPMENT OP THE CHILD. 19 Urine is secreted before birth; after birth it may be passed in small quantities. It occasionally contains uric acid and urates, depositing a pinkish-red powder in the diapers, and causing fretful- ness on voiding. Meconium is dark brown, almost black, consisting of flat, epi- thelium-like scales, fine hairs, and fat-globules from the vernix caseosa in the amniotic fluid, and cholesterin crystals, and irregu- lar brown and yellow lumps and flakes. What is the condition of the blood ? The blood at birth is proportionately less in amount'than in the adult: it contains more haemoglobin and less fibrin ; the haemo- globin decreases up to six months, remains stationary until the sixth year, then increases again ; the fibrin rapidly increases. After the first few months the infant has more blood in proportion to its weight than the adult, but it contains less fibrin, albumin, salts, and haemoglobin, and more white blood-corpuscles, than adult blood. Describe the pulse and respirations. The pulse is very rapid at birth ; more rapid in the female than male. The average during the first week is—asleep, 122 ; awake. 126; excited, 148: during the first month—asleep, 118; awake, 139; excited, 152: at six months—asleep, 109; awake, 127; ex- cited, 156: toward close of infancy—asleep, 90 to 95; awake. 95 to 105. The respirations are abdominal; average during the first week, 39 ; from the second month to the second year, 35 ; from the second year to the tenth year, asleep, 18; awake, 23. THE DEVELOPMENT OF THE CHILD. Describe the development of the child. The average weight at birth is—male, 7 lbs, 11 oz.; female, 7 lbs. 4 oz. Weight is lost during the first few days. The average gain is—during first three months. 4| oz. per week ; from three to six months, 4 oz. per week; from six to nine months, 3 oz. per week; from nine to twelve months, 2? oz. per week. The growth is most rapid during the first weeks: during first 20 DISEASES OF CHILDREN. year, 6 to 7 or 10 inches ; from fourth to sixteenth year, 2 inches per year; from sixteenth to seventeenth year, 1 \ inches; from seventeenth to twentieth year, 1 inch per year. The head is not raised until the sixth to the eighth week. The child sits erect at from four to seven months; stands alone at from ten to twelve months; and walks at from twelve to fifteen months. The teeth begin to erupt at six to seven months. The anterior fontanelle is smallest at birth, increases in size up to the ninth month, remains stationary for two or three months, then decreases, and should be closed by the sixteenth to the eigh- teenth month. The first movements are reflex and impulsive. Suckling is instinctive. The will-power awakens about the third month, evidenced by the holding of the head erect. Voluntary grasping commences about the fourth month. Taste and smell are among the first special senses to appear. The child takes its food and rejects other things, showing mem- ory and judgment. Hearing: all children are born deaf; no sound is noticed during the first six hours ; the deafness is due to closure of the Eustachian tube, absence of air in the middle ear, and obliquity of the tym- panum. Sight, light, and darkness are appreciated from birth; after six weeks the eyes follow a light, and at three months appreciate objects. Speech is hereditary and imitative: at first only meaningless sounds are made; gradually the voice is modulated, the vowels are used, and articulate, imitative sounds are made; by the end of the first year single words are spoken, soon two or three words are joined together, and finally complete sentences are formed. Describe the eruption of the teeth. The eruption of the, teeth begins with those in the lower jaw first, those in the upper jaw quickly following. Central incisors erupt from 6th to 7th month. Lateral incisors " " 7th to 10th " < Anterior molars « " 12th to 14th « ber, ten in each Canineg u u Uth to 20th <( J I Posterior molars " " 18th to 36th " Deciduous teeth twenty in num- EXAMINATION OF THE CHILD. 21 First molars erupt at 6? years. Central incisors " 7 Lateral incisors " 8 First bicuspids " 9 Second bicuspids " 10 Canines " 11 to 12 years Second molars " 12 to 13 " Wisdom teeth " 17 to 25 " Permanent teeth thirty - two in number, sixteen in each jaw. EXAMINATION OF THE CHILD. Mention the methods of examining a child. Of the Sleeping Child.—Is the position natural and easy? Is the face flushed or pale, and is the expression natural or painful ? Are the lips pale or bluish? Is the skin dry or moist? and is the moisture general or on the head? Is the child quiet, or does it moan, start, twitch, or grind the teeth ? Are the nostrils quiet or moving ? Are the eyes closed, partly closed, or staring ? Count the respirations and pulse, and notice their character. Note the size, shape, and temperature of the head, the appearance of the superficial veins, and whether the fontanelle is opened, closed, pulsating, distended, or retracted. Does the child awake smiling or frowning, pleasant or peevish ? Is the face on awakening flushed or pale? Are the pupils dilated, contracted, or unequal? Are there rings around the eyes? Of the Child Awake.—Have the child entirely stripped. In the healthy child the skin is mottled, smooth, and elastic, the muscles are firm, the arms and legs move freely and continuously, and the child kicks and crows. Is the skin healthy, or are there eruptions? Examine especially the anus. Are the muscles firm or flabby? Do the arms and legs move freely? Are the joints enlarged? Is there snuffling ? Count the respirations and note their character : in a healthy child the respiration is abdominal, with no recession of the chest-wall. Note the expression of the face : in cerebral troubles the brow will be knitted and scowling and the eyes rolling, fixed or staring; in thoracic troubles the alae nasi will move, there will be a blue circle around the mouth and dark rings under the eyes; in abdominal troubles the corners of the mouth will be drawn down, the lips livid or pale, and the cheeks sunken and pale. Note 22 DISEASES OF CHILDREN. the gestures: in cerebral troubles the child puts his hand to his head and pulls at his hair, rolls the head on the pillow and beats the air aimlessly; in abdominal troubles the legs are drawn up, the face is anxious, cheeks sunken, he picks at the bed-clothes; in throat troubles he picks at the throat and puts his hands in his mouth. Note the cry: in cerebral troubles it is sharp, shrill, and solitary ; in croup it is hoarse, brassy, metallic, crowing; in laryn- geal stenosis it is hoarse and stertorous; in earache it is obstinate and continuous; in pneumonia and capillary bronchitis it is labored and peevish, and attended with a short, suppressed cough ; in pleu- risy it is a loud, shrill cry, attendant upon coughing; in intestinal troubles and tubercular meningitis it is moaning, wailing; in ex- haustion from disease and debility it is faint, weak, and moaning; hunger causes obstinate, continuous crying; constipation causes crying attended with wriggling and writhing. Handle the child: is the head symmetrical ? are the fontanelles and sutures normal ? is there craniotabes ? Is the neck swollen ? are the cervical glands enlarged ? Is the thorax symmetrical ? is there pigeon-breast ? is there beading of the ribs ? is vocal fremitus normal ? is the cardiac impulse diffused or accentuated ? Is the abdomen protuberant, flat, or depressed? are the walls resistant or yielding? are any tumors present ? can the spleen or liver be felt ? is the umbilicus normal ? Are the testicles in the scrotum ? is there hernia or hydrocele ? are there tumors in the groin ? are the inguinal glands enlarged ? Examine the penis for phimosis, adhesions, and balan- itis ; the vulva and vagina for atresia, vaginitis, and foreign bodies; the anus for hemorrhoids, polypi, fistulae, fissures, condylomata, and oxyuris. Is the spine curved ? are there protuberances and tender points along the spine ? Examine the lungs, using in their order palpation, auscultation, percussion ; begin in each case at the back—percuss lightly. Examine the throat. Note the appearance of the tongue: a white fur, with curded spots, indicates dyspepsia and intestinal troubles; a heavy white fur, fever; a yellow fur, liver and stomach troubles of long standing; a brown fur, a low typhoid condition; a red, dry, hot tongue, inflammation of mouth (►" and stomach ; a pale flabby tongue, with marks of teeth, debility ; aphthae, neglect, starvation ; papillae white and prominent at tip (strawberry tongue), scarlatina. Take the temperature in the rectum : at birth and for twenty-four hours thereafter the average— is 100.4° F.; forty-eight hours after birth it is 98.6° F. In healtli it falls at night, beginning between 7 and 9 P. m., reaches the CARE AND FEEDING OF THE CHILD. 23 minimum about 2 A. m., then gradually rises to normal. An ab- normal temperature indicates disease. A fall toward evening in fevers and inflammations is a good symptom, but if the pulse and other symptoms are aggravated it is unfavorable. Note the fre- quency and character of the pulse: watch it for at least two minutes. Examine the stools—frequency, color, consistency, con- stituents, odor, reaction; healthy stools are homogeneous and pasty, unformed, of a light, orange-yellow color, acid reaction, and have a very faint odor of sour milk ; they number three to four daily for the first two weeks, two to three daily up to six months, and then about two daily up to one year. Examine the urine: does it stain the diaper, and what color ? is there any sediment in the diaper? Note the odor and reaction. Are there any symptoms attending micturition ? Examine the expectoration as to color, odor, consistency, tenacity. CARE AND FEEDING OF THE CHILD. Describe the general care of children. The(yernix caseosa)should have some fat applied to it, when it can be removed with a soft, warm, damp cloth. Then the child can be bathed with warm water and soap. Every child should be bathed daily. As it grows older a quick cold sponging after the bath is a stimulant to the skin and will pro- tect it against sudden changes of temperature. During the second and third years three or four baths weekly, and after that two or three baths weekly, are sufficient. At the first dressing the umbilical cord must be protected against being dragged upon, and the chest and abdomen must not be so constricted as to impede respiration. The body-clothing should consist of light, soft wool. The clothing should not be too heavy ; the legs and arms must be given as much freedom as possible. The binder is not necessary after the cord sloughs. As the child grows the clothing should be warm, but not cumbersome. When the child walks the shoes should be long with broad soles. Children born in summer should go outdoors during the second or third week ; those born in winter, not until they are two or two and a half months, and then at noonday. Older children cannot 24 DISEASES OF CHILDREN. go outdoors too much ; on bright sunny days they should spend the whole day in the open air. A child should spend the first eight days in a darkened room ; after two weeks its eyes can stand the light. The nursery should be bright and sunny, with plenty of win- dows, a southern exposure if possible ; well ventilated, warmed by an open fireplace ; containing no water-pipes or sewer connections ; the floor painted or covered with linoleum and rugs ; no cooking should be done in the room, and it should be thoroughly aired for one or two hours each morning. The child's bed should be in the middle of the room. Describe infant feeding. The child should be put to the breast as soon after it is born as the mother's condition will permit. Milk does not appear in the human breast until about forty-eight hours, but the colostrum will satisfy the child and assist in the removal of the meconium. The nursings should be regular from the start—not oftener than every two hours during the first three months, two hours and a half during the second three months, and after six months the intervals should be lengthened to three hours. The child should not sleep in the bed with its mother, nor suckle as it pleases during the night; the mother should nurse it at her bed-hour, again about 2 or 3 A. M., and at daylight. The child should receive no other food but breast- milk until it is twelve to fourteen months old. Weaning should not occur in hot weather. The child should nurse alternately on the two breasts. It should nurse until it falls asleep. At first the child takes but a couple of drachms at each nursing, but the quantity steadily increases, until at six months it takes two to two and a half ounces each time. It should receive water to drink. Menstruation and pregnancy are not indications for weaning. If the mother's milk fails, improve her dietary: milk, malt liquors,- electricity, poultices of castor-oil leaves, etc. are recommended as galactagoguejs. Next to the mother's milk comes that of the wet- nurse. The preferable age is between twenty and thirty ; the choice between a blonde and brunette cannot always be made, but if possi- ble choose a woman of a happy, bright disposition. The age of the milk is not of so much importance as the quality and quantity: to obtain this empty the breasts, and have the woman return in two or three hours: repeat the operation and compare the two results. CARE AND FEEDING OF THE CHILD. 25 Examine the wet-nurse thoroughly, especially the pharynx and gen- itals ; reject one with syphilis or tuberculosis; take only a healthy woman with a clear, healthy skin. Examine her child if it be pos- sible. The moral influence of the wet-nurse in the family must be considered : wet-nurses have separated husbands and wives. Do not allow the wet-nurse to be pampered; she must have j)lain, whole- some food, a daily bath, outdoor exercise, no excitement, a healthy, cheerful sleeping-room. If human milk is not obtainable, the milk of some one of the domestic animals should be used, that of the ass, goat, or cow. The former is nearest in its resemblance to human milk, but the last is most easily obtained. The milk from a dairy is preferable to the milk from a single cow, unless that cow is positively free from tuberculosis. The milk of the common red cow is better than that of the Jersey or Alderney, as that of these latter is too rich. The comparative analysis of human and cow's milk, according to Vernois and Becquerel, give— Human Milk. Cow's Milk. Specific gravity........1.032 1.033 Water in 100 parts......88.91 86.41 Sugar " " ......4.36 3.80 Butter " " ......2.67 3.61 Casein and extractives .... 3.92 5.51 Salts " " .....13 .66 Reaction. alkaline. ' acid. The excess of casein in cow's milk requires that the milk shall be modified so as to resemble human milk and become more easy of digestion by the infant. To accomplish this object numerous formulae have been suggested. Those of Meigs and Botch seem to come nearest to meeting the indications. These indications are the reduction of the percentage of casein by adding water ; this reduces all the other constituents. The percentage of butter is restored by adding cream, that of the sugar by adding sugar of milk, and the acidity is corrected by adding lime-water. Meigs's formula is—milk 1 part, cream 2 parts, lime-water 2 parts, sugar-water 3 parts: the sugar-water consists of ^171 of milk-sugar to 1 pint of water. Botch's formula is—milk §j, centrifugal cream giss, lime-water ^ss, boiled water gv, milk-sugar 1 measure (3-|). Leeds's formula is—milk and water each 1 gill, rich cream 2 table- 26 DISEASES OF CHILDREN. spoons, milk-sugar 200 grs., extractum pancreaticum 1J gr., sodium bicarbonate 4 gr.: this is put in the nursing-bottle and stood for twenty minutes in water having a temperature of 115° to 125° F.; feed at once. Numerous and various attenuants are used: gelatin, arrow-root, barley, oatmeal, rice-paste, baked flour, cracker-dust, flour-ball, etc. Condensed milk is recommended by some, in the proportions of 1 part milk to 15 parts water in early infancy, later 1 to 10; the canned milk should not be used, as it contains cane-sugar. Patent baby-foods are proprietary articles, hence secret; they are likely to be old and musty and are always expensive. Sterilizing the milk destroys the bacteria and so prevents the formation of ptomaines and fermentation ; it is claimed that a tem- perature of 212° F. devitalizes the milk, while a temperature of 167° F. protects the milk without devitalizing it. The nursing-bottle should hold eight ounces, and the rubber nip- 'ple should fit directly over the mouth of the bottle; there should be no tube. At least six bottles should be provided, and these should be boiled daily for one hour; the nipples should be turned and washed after using, and kept in a solution of bicarbonate of soda. Weaning should be commenced at twelve to fourteen months, and should be gradual. One nursing each day is omitted, and other food substituted, until the day nursing is entirely stopped, and then the night nursing should be given up. Milk should be the principal article of food during infancy and early childhood; it should be drunk at each meal, and fed in pud- dings, custards, with the different cereals, farinacea, bread, and crackers. In addition, soft boiled eggs, baked potatoes, cooked fruits, meat broths, meat gravy, and an abundance of butter may be allowed. DISEASES OF CHILDREN. DISEASES OF THE NEW-BORN. ASPHYXIA NEONATORUM. Define asphyxia neonatorum. It is that condition of the new-born in which the inspiratory muscles fail to contract or else imperfectly contract, so that breath- ing does not commence. Give some of the causes. Twisting of the umbilical cord around the child's neck ; compres- sion of the cord between the child and its mother's pelvis; early detachment of the placenta; injury to the skull; plugging of air- passages with blood or mucus ; feeble parents ; exhausting diseases of mother; early delivery ; compression of large blood-vessels of neck, producing the apoplectic form. What are the post-mortem conditions? The chief lesions are extravasations of blood between the men- inges or into the brain. Describe the symptoms. The cardiac pulsations continue, though the child does not breathe. There are two varieties of asphyxia: in one the child is cyanotic, with a thick blue tongue protruding from the mouth and projecting eyeballs; in the other the child is pale and limp; the extremities hang down and the lower jaw drops ; the cardiac pulsa- tions are very feeble; the respirations, if present, are short and spasmodic; the sphincters are relaxed. The respirations and heart- beats grow feebler, and usually death" follows in a few hours. What is the prognosis ? Grave: unless speedy and proper assistance is instituted, life will cease in a few hours. 27 28 DISEASES OF THE NEW-BORN. Give the treatment. Cleanse the mouth; induce coughing by tickling the epiglottis ; irritate the skin by dipping the child alternately in hot and cold water, also by slapping the buttocks, and by pouring upon the skin brandy, ether, vinegar, or cologne. If the child is cyanosed, allow some blood to escape from the funis. Inflation of air by means of a catheter passed into the trachea; electricity. Place the child on its right side with the upper half of the body elevated. Artificial respiration. Persevere as long as the heart beats. It may take from one to three hours to restore the child. ATELECTASIS PULMONTJM. Define atelectasis pulmonum. It is that condition of the child's lungs after birth in which the alveoli remain collapsed and airless, as in the foetal state. What are the causes of this condition ? Asphyxia ; premature and feeble children ; too rapid deliveries ; inhalation of too cold air. What is the morbid anatomy? Scattered through the lungs, but mostly at the bases posteriorly, are bluish-red, compact spots, which do not crepitate, and sink in water; the cut surfaces are smooth, regular, and not granular. These atelectatic spots generally affect the lobules; rarely is an entire lung or even a lobe involved. The spots can be inflated, differentiating them from lobular pneumonia. Give the symptoms. The child is born asphyxiated or breathes superficially from its birth ; its cry is weak and moaning ; it cannot nurse continuously ; it may be cyanotic or have a pale, cool skin ; it will sleep much; the pupils, slightly dilated, act slowly; the pulse is feeble and slow. Percussion is not abnormal unless the atelectasis is very extensive; crepitant rales may be heard, but rarely bronchial breathing. After a few days spasmodic contractions of the facial muscles occur, followed by general convulsions; the respiratory efforts grow feebler; the child's skin gets cooler; and death occurs by degrees or else suddenly in a convulsive seizure. Give the treatment. Cause every child at birth to cry loudly and continuously. CEPHAL^MATOMA. 29 If atelectasis develops, keep the child in a room of uniform temperature, warmly clothed, and surrounded with hot bottles; change the position frequently; have the child nurse frequently; make it cry and vomit: artificial respiration can be tried. CEPHALHEMATOMA. Define cephalaematoma. Cephalaematoma is a soft, painless, fluctuating tumor upon the scalp, due to an extravasation of blood between the pericranium and bone. Give the etiology. Pressure of the dilated os uteri upon the scalp, producing ecchymosis ; injury during delivery; protracted labor, producing caput succedaneum ; thinness and friability of the cranial vessels. What are the symptoms? The child is generally born with a caput succedaneum : after this disappears a swelling remains for about six days, and as this subsides a tumor will be found, generally on the right parietal bone, the size of an apple. It is never located over a suture. After a few days a bony ring forms at the margin of the tumor between the periosteum and the bone, and bone is deposited upon the surface of the pericranium facing the extravasation ; this ridge of bone can be felt by the finger, as can also the thickening of the wall of the tumor. The tumor gradually becomes harder and flatter, and in from three to six months but slight inequality is noticed, and the scalp is perfectly movable. From what conditions should it be distinguished ? From caput succedaneum : this generally lasts but twelve to twenty-four hours, pits on pressure, and does not fluctuate. From hernia cerebri congenita: this appears in the sutures and fonta- nelles bulges when the child cries, and induces convulsions. From'vascular tumors: these rarely occur on the scalp, do not fluctuate, and have no bony ring. What is the prognosis ? Good except where a true cephalaematoma is complicated with an extravasation of blood upon the internal surface of the skull; which condition is followed by convulsions, paralysis, and death. 30 DISEASES OF THE NEW-BORN. Give the treatment. The treatment should be expectant: if the tumor is left to itself, and not interfered with, its contents will be absorbed in from three to six months, causing no pain or inconvenience to the child. DISEASES OP THE NAVEL. Describe inflammation of the umbilical vessels. The gelatinous substance around the vessels beneath the abdomi- nal muscles becomes purulent and decomposed, and pressure around the navel causes a few drops of serum or sero-pus to appear. There are generally a rise of temperature and restlessness from the pain and inflammation. This pus may be absorbed, producing pyaemia, or erysipelas of the abdominal walls may occur; in this case death occurs in a few days. If the pus is not absorbed, the discharge ceases and the navel heals after some weeks. What is the treatment? Cleanliness, syringing the parts frequently with warm water, preventing the formation of crusts, removing the child from the infected room, feeding the child by a wet-nurse or artificially; check diarrhoea if any exists. Describe blennorrhoea and ulceration of the navel. A mucous discharge exudes from the navel, due to lack of clean- liness or maltreatment. If this condition continues, the surround- ing abdomen becomes excoriated, inflamed, and ulcerated ; the ulcer may perforate, causing peritonitis and death. Give the treatment. Compresses of solutions of lead or silver nitrate will often arrest the trouble at the commencement. Look after the child's diges- tion. Describe gangrene of the navel. Gangrene generally follows inflammation or ulceration of the navel. The part is converted into a grayish-brown slough; the surrounding skin becomes loose, peels off, exposing the tissues beneath, of a bluish color; bloody serum exudes; peritonitis and sometimes perforation of the intestine, with escape of faeces, bring the case to a fatal termination. In some rare cases the gangrene becomes circumscribed, the slough separates, and healthy granula- tions heal the wound. DISEASES OF THE NAVEL. 31 Give the treatment. Strict cleanliness, and chlorine-water or myrrh as a deodorizer. A wet-nurse or artificial feeding, and support the patient with wine. Describe ulceration of the navel. Ulceration of the navel is a pediculated excrescence which some- times appears after the cord has separated and before the cicatrix has formed, and interferes with its forming. As a result of this the surrounding skin becomes excoriated and gangrene may super- vene. In the treatment the excoriations should be cleansed, and healed with lead-water compresses, and the stump removed by excision or ligation; any resulting hemorrhage can be checked by silver nitrate. Describe hemorrhage of the navel. A very rare accident, generally indicative of a hemorrhagic di- athesis. After the cord sloughs off blood oozes, drop by drop, from the navel; it coagulates slowly; the child becomes anaemic; pe- techiae appear, and will be found on the pleurae and pericardium. It is usually fatal. In the treatment haemostatics are of no service. Transfixing the wound with two needles and a figure-of-eight ligature may be tried, or filling the wound with a solution of plaster of Paris. Describe congenital rupture of the navel, and give synonyms. Exomphalus ; Omphalocele congenita ; Rupture of the umbilical cord. It is a protrusion at the navel of a portion of the intestine or of the liver, or both, due to a lack of development of the ab- dominal walls during intra-uterine life. If the hernia contains intestine alone, as a rule it cannot be reduced, and is followed by gangrene, peritonitis, and death; but if it contain intestine and liver, the liver by its density prevents constriction of the intes- tine ; lience it may be returned and recovery ensue; also if it con- tain liver alone, it can be reduced. The treatment consists in reducing the hernia if possible, pro- tecting the navel with lint covered with some simple ointment, and nourishing the child. Describe acquired rupture of the navel, and give synonyms. Hernia umbilicalis; Omphalocele acquisita; Rupture of the umbilical ring. This condition generally occurs some weeks or 32 DISEASES OF THE NEW-BORN. months after the cord has sloughed off. It is found mostly in thin children or those suffering from flatulence or some intercur- rent disease which puts a strain upon the abdominal walls, as ob- stipatio or pertussis. The umbilical ring is stretched, and a knuckle of small intestine, covered with peritoneum, slips through the open- ing, distending the skin at the umbilicus into a white, glistening tumor of variable size. The treatment consists in reducing the hernia and retaining the bowel in the abdomen by means of a properly fitting truss or a compress and strip of plaster. TRISMUS AND TETANUS OP THE NEW-BORN. Define trismus and tetanus of the new-born, and give synonyms. Trismus nascentium ; Trismus neonatorum ; Nine-day fits ; Lock- jaw. A condition of spastic closure of the lower jaw and rigidity of the entire body. What are the causes? It is endemic in certain localities, as in some parts of the tropics, and sometimes epidemic in institutions. It is supposed to be due to some septic poison, pressure upon the medulla, uraemia, exposure to change of temperature, injury to a nerve as the cicatrix forms at the umbilicus, inflammation of the umbilical vessels. Describe the symptoms. At some time during the first five days after the cord sloughs off the child becomes restless, starts in its sleep, cries, wants to nurse, but abandons the breast immediately. In a few hours it is unable to open its mouth, the muscles of mastication become rigid, the lips are compressed, the brow and cheeks wrinkled, the eyes closed and surrounded by bluish rings, the head retracted, the skin turgid, and it is unable to swallow. These symptoms may tem- porarily abate. Then the muscles get more rigid, other groups are involved, sometimes the entire body becomes stiff, and death fol- lows in from one to eight days from suffocation or exhaustion. Give the treatment. Prophylaxis is the best treatment: use every care with the cord and remove every suspicious element. If the disease develops, support the patient, treat the navel antiseptically, prevent or cor- rect the convulsions by narcotics and antispasmodics, as opium, chloral, etc. SCLEROMA. 33 SCLEROMA. Define scleroma, and give synonyms. (Edema neonatorum ; Induratio telae cellulosae; Induration of the cellular tissue. It consists of a hardening of the integument during the first weeks of infancy. Give the etiology. The causes are obscure. In most cases it is associated with pneumonia or some derangement of the circulatory apparatus. It occurs mostly in premature children or those who are poorly nourished, and in the winter. Give the symptoms. The disease begins on the calves of the legs, which become swollen, hard, and stiff, with increase of redness and decrease of temperature. The swelling extends to the feet and upward upon the thighs, abdomen, skipping the thorax, to the face and arms. The redness soon fades to a yellowish tinge; the skin becomes dry, but is not exfoliated, and the surface is deathly cold. At the commencement the skin is movable and oedematous, but later these signs disappear. The temperature is very low (93° F.), respira- tions are slow, voice and cry weak ; the action of the heart is feeble, second sound almost lost, pulse small and slow; the bowels and bladder are torpid; suckling is difficult; cutaneous sensation is lost; and finally death results from exhaustion, attended by a flow of bloody serum from the mouth and nose. If recovery takes place, the respirations are the first to improve; they become deeper and easier; the heart's action gets stronger; the appetite increases; and the oedema clears up, beginning first at the face. The swelling of the legs and feet is the last to disappear; it will remain here for some time after the other parts are normal. As long as the feet are swollen there is danger. The redness and the wrinkled condition of the skin remain for some time. What changes are found post-mortem? The changes are chiefly in the skin and connective tissue: the other organs are not generally affected. Lobular pneumonia may be present, and there may be serous fluid in the pleura.and peri- toneum. The changes in the skin are oedematous; the part is blue and hard; upon section black, semifluid blood flows from the skin, and from the cellular tissue a yellow, serous fluid resembling 3-D. C. 34 DISEASES OF THE NEW-BORN. dropsical fluid. The parts become soft after the escape of this fluid. Give the treatment. Stimulate the child, nourish him as thoroughly as possible, and keep the body temperature elevated by artificial heat, MELiENA NEONATORUM. Define melaena neonatorum. Melsena neonatorum is hemorrhage from the stomach and bowels during the first few days of infant life. What are the causes? Haemophilia, perforating gastric or duodenal ulcer, thinness of the walls of the mesenteric arteries and their branches, causing rup- ture from the turgescence of these vessels, due to the sudden closure of the umbilical arteries. Describe the symptoms. Between the first and third days of life the child vomits blood and passes bloody stools, either fluid or lumpy (coagulated). Col- lapse rapidly supervenes, with blue, cold skin, flickering pulse, and all the symptoms of profound anaemia. About 50 per cent, re- cover. After death the stomach and intestines are filled with clot- ted blood, while the tissues and organs are blanched. What is the treatment ? Iced milk and cold applications to abdomen (Rilliet), or artificial heat to draw the blood to the surface; support and nourish the child; haemostatics. ICTERUS NEONATORUM. Describe icterus neonatorum. Icterus neonatorum is due to the retention of the coloring mat- ter of the bile in the blood, and thereby results the staining of all the tissues—bones, muscles, skin, conjunctivae. Pus, if present, and the urine partake of this staining, but the faeces are not changed, but retain their yellowish or greenish tint. Slight fever is present, and the healing of the navel will be delayed. True icterus, which is usually fatal, is due to inflammation of the umbilical or portal vein and to small abscesses in the liver. CONJUNCTIVITIS NEONATORUM. 35 These cases progress rapidly, become atrophied, and die from diarrhoea. Simple icterus is due to a catarrhal duodenitis or occlusion of the bile-ducts ; it lasts but a few days, produces no disturbance of the system, and tends to recovery. Treatment of the pernicious variety will avail nothing. The milder form will recover if the digestion and bowels are kept in order. CONJUNCTIVITIS NEONATORUM. Define conjunctivitis neonatorum. A purulent inflammation of the conjunctiva, with effusion of plastic exudate into the parenchyma, coming on soon after birth. It may involve one or both eyes. The pus is intensely contagious. Two varieties are recognized. What are the causes? Infection from blennorrhoeic vaginal mucus during delivery or contagion in institutions where the disease is epidemic. Describe the two varieties. The first variety runs a rapid and aggravated course. It has three grades : In the first there are redness and swelling of the lids, with secretion of more or less pus, which soon changes to a thin serous discharge containing flakes and fibres. In the second grade the redness and swelling are more intense, and the ocular conjunc- tiva becomes involved; the discharge is thin and excoriates the skin. In the third grade the conditions are still more aggravated : the swelling and excoriation of the skin extend; the pus is more profuse, sometimes mixed with blood ; the ocular conjunctiva be- comes infiltrated, surrounding the cornea with a red ring. The second variety is more chronic and attended with less dis- charge. It has two grades : In the first there are slight inflamma- tion and a discharge, slight roughening of the conjunctiva, and photophobia, In the second the palpebral conjunctiva is studded with small warty growths, which bleed easily and may continue for months if not treated. Toward the orbital border they develop into large cockscomb granulations. The disease does not always run through all three degrees ; it may stop at the second or even the first. It may be slow, or so rapid that in twenty-four hours the eyes are destroyed. If it stops 36 DISEASES OF THE NEW-BORN. at the first stage, no serious results follow. If at the second, the disease will be more chronic, the discharge and the enlarged papil- lae lasting for some months, followed by deformities and enlarge- ment of the lids. In this stage small ulcers may develop on the cornea. The third is always dangerous;, the cornea becomes in- volved, the ulceration commencing at the centre and having a tendency to perforate, causing prolapsus of the iris and destruction of the eye. What is the prognosis ? This depends upon the condition of the cornea: the later that becomes involved, the more hopeful is the case, though the condi- tion is always serious. Give the treatment. Cleanliness at the time of delivery, the vaginal douche, and care- fully washing the eyes and face as soon as the head is born, using plain warm water, or, if there is any suspicion of infection, a solu- tion of silver nitrate (gr. j to an ounce of water), If the disease develops in only one eye, protect the sound one. Keep the dis- eased eye clean, and use as collyria solutions of silver nitrate (gr. j to the ounce), corrosive sublimate (gr. ss to the ounce), zinc sulphate (gr. j to the ounce), boracic acid (1 to 2 per cent.). Many cases recover spontaneously. MASTITIS NEONATORUM. Describe mastitis neonatorum. The breasts of many children at birth contain a small quantity of thin milk. With boys this disappears in a couple of weeks, but with girls its presence is continuous. Any injury to the gland dur- ing delivery, or bruising the gland and squeezing out the milk (an unnecessary procedure), starts an inflammation that produces red- ness, swelling, pain, and, in some cases, suppuration. After the abscess bursts the gland remains indurated for a few weeks, then returns to its normal condition. Some extreme cases assume an erysipelatous condition, with deep ulceration and sinuses that may destroy the gland. In the treatment prevent the inflammation if possible : if, how- ever, the breasts swell, anoint them with olive oil and cover with a dressing of thin muslin and cotton-wool; if pus forms, use poul- HARE-LIP AND CLEFT PALATE. 37 tices to hasten the suppuration, and make incision early, avoiding the nipple and the lacteal ducts. HARE-LIP AND CLEFT PALATE. Define hare-lip and cleft palate, and give the synonyms. Labium leporinum and palatum fissum. Hare-lip is a congeni- tal splitting of the upper lip; cleft palate is a congenital fissure of the hard palate. Describe the causes and effects of these deformities. The causes are arrest of development during foetal life. The upper lip is formed from two lateral and one central portion : if these fail to unite, hare-lip occurs on one or both sides, never in the centre of the lip, and the fissure generally extends into the corresponding nostril. The hard palate is formed from the two superior maxillary bones : if these fail to unite, cleft palate results. The effects are : difficult suckling, particularly in cleft palate; the nipple cannot be properly grasped, and the milk will escape through the nose; obliquity of the position of the teeth as they erupt; and indistinct speech. What is the treatment? . The treatment is surgical. If the child can get no nourishment, and is consequently losing ground, the operation should be done at once. But if the child is strong and thriving, the operation can be delayed for a few months, but not longer than six months, be- cause of the eruption of the teeth and the increased activity of the child jeopardizing the dressings. Freshen the edges, and in hare-lip use the hare-lip pins and figure-of-eight ligature ; in cleft palate use the continuous deep suture, but do not draw this too tight or it will interfere with the exudation of plastic material. A scar always results. CONSTRICTION OP THE MOUTH. Describe constriction of the mouth. Synonym.—Microstoma. Some children are born with very small mouths or without any opening. In these cases an operation is at once demanded. But constriction of the mouth is most frequently due to syphilis, the cicatrices resulting from the healing of the mucous patches causing the constriction. 38 ORGANIC DISEASES. The treatment pertains first to the eradication of the syphilis, then an operation upon the mouth. From each corner of the mouth remove a piece of skin, myrtle-leaf-shaped, cut through the mucous membrane, turn it over upon the raw surfaces, and stitch the edges together. DEFORMITIES OF THE TONGUE. Describe the most common deformities of the tongue, and give the treatment. Defectus linguae, imperfect development of the tongue: The tongue may be indented, fissured, or divided into two distinct portions. Except in extreme cases no interference is necessary. Prolapsus linguae, hypertrophy and prolapse of the tongue : The tongue may be so enlarged as to completely fill the mouth and pro- trude between the lips, interfering with suckling, and later with speech. The teeth erupt irregularly, the saliva accumulates and decomposes, ulceration of the mucous membrane results. The treatment is by astringents, as alum; or amputation. Adhsesio linguae, abnormal adhesions of the tongue: This may consist of a short fraenum or the under surface of the tongue may be adherent to the floor of the mouth. The results are interference with suckling, and later with speech. The treatment for short fraenum, or tongue-tie, is to snip the mu- cous membrane with scissors and tear the tongue loose with the finger- nail. Where the tongue is attached to the floor of the mouth, the operation is long, tedious, and bloody, and not always successful. Ranula is a mucous cyst situated by the side of the fraenum linguae. Its size varies. It may be so large as to press the tongue against the hard palate and so interfere with nursing and breathing. Its growth is gradual. It may be single or multiple. The treatment consists in snipping off the top of the tumor, empty- ing the sac, and cauterizing the interior with the solid stick of silver nitrate. ORGANIC DISEASES. STOMATITIS. Give the synonyms of catarrhal stomatitis. Simple stomatitis ; Erythematous stomatitis. Define catarrhal stomatitis. A non-ulcerative or non-exudative inflammation, of varying in- tensity, of the mucous membrane of the mouth. STOMATITIS. 39 Mention its causes. Irritants taken into the mouth, as too hot fluids, dirty teething- rings, sugar-teats, or substances the child may pick up from the floor, the abuse of mercury, digestive disturbances, scarlatina, measles. Give its morbid anatomy. Hyperaemia and swelling of the mucous membrane of the mouth, with increased secretion from the mucous and salivary glands. What are the symptoms of catarrhal stomatitis. Abnormal heat, redness, and swelling of the buccal mucous membrane, with at first dryness, but later a profuse secretion from the mouth ; slight elevation of temperature ; restlessness and pain, particularly when anything is introduced into the mouth. In se- vere cases children refuse food. Give the prognosis of catarrhal stomatitis. Good. Duration will depend upon cause. How should it be treated? Remove existing cause; attention to hygiene and diet; correct digestive secretions;. mild antiseptic mouth-wash, boric acid or borax ; chlorate of potassium locally and internally. Give the synonyms of follicular stomatitis. Aphthous stomatitis ; Vesicular stomatitis ; Croupous stomatitis ; Aphthae. Define follicular stomatitis. A form of stomatitis resulting in the formation of small and characteristic ulcers, running an acute course and tending to re- covery. Give the etiology of follicular stomatitis. Said to be caused by gastro-intestinal derangements, cold, irrita- tion of objects placed in the mouth. Real nature of the malady not known: thought by some to be an infectious disease ; by others, a mere herpetic eruption and dependent upon the causes that pro- duce herpes. Give the morbid anatomy of follicular stomatitis. On the inner surface of the cheeks or lips or the edges of the tongue, but never on the gums, appear pearly-gray vesicles, vary- 40 ORGANIC DISEASES. ing from six to twelve in number, and about the size of a large pin's head, which are filled with a fibrinous exudate. By rupture of the vesicle or by friction the exudate is removed, leaving a small ulcer with a grayish-yellow surface, which heals in a few days. Several ulcers may coalesce. What are the symptoms? Ararying in degree with the intensity of the malady : they are slight fever, furred tongue, pain in the mouth, especially on taking food, increased flow of buccal secretions, and in some cases slightly disagreeable odor to the breath. (See Morbid Anatomy.') Give prognosis of follicular stomatitis. Good. When improperly managed may go on to ulcerative stomatitis. Give its treatment. Attention to diet and general condition of patient; mouth should be kept clean ; chlorate of potassium internally. What are the synonyms of ulcerative stomatitis ? Stomatitis ulcerosa;' Stomacace ; Putrid sore mouth; Mundfaule. Define ulcerative stomatitis. A form of inflammation of the buccal mucous membrane, result- ing in extensive ulceration, particularly of the gums, and accom- panied with foetor of the breath. What is its etiology ? Most common between the second and seventh year. May be communicated by direct contact. Caused by abuse of mercury, diseased teeth, improper food, bad hygiene, or by any exhausting disease, notably measles. Give the morbid anatomy of ulcerative stomatitis. Usually not observed prior to the ulcerative stage. The process involves the gums, contiguous surfaces of the lips, cheeks, and edges of the tongue. The dorsum of the tongue and palate gene- rally escape. The mucous membrane is swollen and of a red or deep livid hue. Ulceration begins along the dental edge of the gum, and may involve the whole gum, laying bare the teeth and part of the cheek. The ulcer presents a grayish or yellowish-gray appearance and irregular outline, and bleeds at the slightest touch. Microscopic examination of the ulcer shows a necrosis of the tissues STOMATITIS. 41 extending to variable depths below the surface, with infiltration of leucocytes, indistinctness of normal tissue-elements, and swarms of micrococci and other bacteria. The cervical lymphatic glands in the affected sides are often swollen. What are the symptoms? Pain and tenderness of the mouth to a degree to interfere with the patient's taking sufficient nourishment; excessive flow of the buccal secretions, which are irritating, with intensely foetid odor; occasional bleeding from mouth. In some cases there is general con- stitutional disturbance with moderate elevation of temperature. What is the prognosis of ulcerative stomatitis ? It is not of itself a fatal disease, although death may occur from the condition which has favored its occurrence. The affection may persist for months. Give the treatment of ulcerative stomatitis. Proper attention to the general hygiene and nutrition of the patient, with the most scrupulous cleanliness of the mouth. Use as mouth-washes: carbolic acid (5 gr. to the ounce), boric acid (10 to 15 gr. to the ounce), permanganate of potassium, peroxide of hydrogen (1 part to 4 or 6 of water). When there is much bleed- ing astringent solutions should be used. The parts may be painted with a 4 per cent, solution of cocaine when painful enough to pre- vent the taking of food. Internally, chlorate of potassium acts almost as a specific if given in large but safe doses. Define cancrum oris. It is a rapidly progressive gangrene of the cheek or gum. It occurs rather infrequently and is usually secondary. Recovery, which is rare, is accompanied by loss of tissue which is perma- nent. What are its synonyms? Noma ; Gangrene of the mouth ; Gangraena oris ; Oral gangrene ; Wangenbrand ; Gangrenous, stomatitis. Give the etiology of cancrum oris. It is most prevalent between the ages of two and five years, and occurs most frequently in females. It occurs also in children whose vitality has been reduced in consequence of unhygienic surroundings or some severe constitutional disease, as scarlatina, measles, dysentery, etc. 42 ORGANIC DISEASES. Describe its morbid anatomy. The mucous membrane on the inner surface of the cheek first presents a sloughing ulcer, followed by a brawny induration of the tissues of the cheek. This induration, extending to the skin, gives rise to a livid, glazed appearance of the integument, which later becomes black, and perforation of the cheek ensues. This slough- ing process may extend and involve the whole side of the face and the bones of the jaws. The nerves generally escape destruction. The blood-vessels are filled with thrombi early in the disease, and hemorrhage is quite exceptional. Lingard has discovered in cases of noma a thread-like bacillus; Sansom has described refractile, pseudo-crystalline, motile bodies in the blood; Wharton mentions a case in which there was extensive colitis. Pneumonia, pleurisy. purulent pericarditis, peritonitis, gangrene of the lungs, skin, geni- tals, or extremities may coexist with noma. Give the symptoms of cancrum oris. At first the temperature elevation is not marked, but may rise to 103° or 104° F. later on, in consequence of septic absorption. In mild cases the degree of prostration is not marked. In severe cases the constitutional disturbance is great, the pulse rapid, and the prostration extreme, death taking place in from ten to fourteen days. There is an extremely pungent, foetid odor from the mouth, which becomes more pronounced as the disease progresses, The flow of the buccal secretion is increased, and soon becomes thick and sanious. Diarrhoea is of frequent occurrence. When recovery takes place the edges of the wound, after separation of the slough, begin to show granulations, and healing takes place with much cicatricial deformity. What is the prognosis? About 75 per cent, of the cases terminate fatally. Give the treatment of cancrum oris. Support patient's strength with nutritious food, stimulants, and tonics. Locally, the actual cautery, fuming nitric acid, bromine, chloride of zinc, etc. to destroy the gangrenous process; sub- nitrate of bismuth dusted over the parts; antiseptic lotions to overcome fcetor, as solutions of carbolic acid, chlorinated soda, eucalyptol, terebene, or of Condy's fluid. Internally, chlorate of potassium in large doses. STOMATITIS. 43 Define parasitic stomatitis. An affection of the mucous membrane of the mouth, character- ized by the development of certain fungi, and associated with a previously unhealthy state of its lining membrane. What are the synonyms of parasitic stomatitis ? Thrush ; Sprue ; White mouth. Give the etiology of parasitic stomatitis. This affection, although most commonly observed in young chil- dren, may occur at any age in the later stages of some protract- ed illness, as tuberculosis, diabetes, etc. It is dependent upon a fungus, the saccharomyces albicans or oidium albicans (Robin), a member of the order of Saccharomycetae, or yeast fungi. In con- sists of mycelium-like filaments, from the ends of which spring spherical or ovoid torula-cells. The disease does not occur on a healthy mucous membrane. The use of an improper diet, unclean- liness of the mouth, the acid fermentation of particles of food, or the development of a catarrhal stomatitis predisposes to the affection. The spores are conveyed to the mouth by means of dirty nipples, sugar-teats, etc., and perhaps through the atmosphere. The fungus develops in the superficial layers of the mucous membrane. The affection appears as small pearly-white spots that soon coalesce: appears at first on the dorsum of the tongue, and may spread to the rest of the entire mouth, and perhaps extend to the stomach and intestines (Parrot). The patches may be removed, leaving the mucous surface intact; usually, however, there is some catarrhal stomatitis. What are the symptoms of parasitic stomatitis ? There are no symptoms per se. The symptoms generally attrib- uted to it are those of the accompanying disorder. They may be those of catarrhal stomatitis. There is usually evidence of malnu- trition, with diarrhoea. The stools are acid and irritating, and cause an erythema of the buttocks (intertrigo). Give the treatment of parasitic stomatitis. Attention to the hygiene and diet of the patient, cleanliness of nursing-bottles, nipples, etc. Locally, borax or sulphite of sodium (a drachm to the ounce of water). 44 ORGANIC DISEASES. PITYRIASIS LINGU-EJ. Describe pityriasis linguae. A white-coated tongue is found in all children during the first weeks of life, entirely independent of any digestive disturbance. The tongue also becomes coated in affections of the mouth, throat, and digestive tract, acute diseases, and febrile disturbances ; but a thickly-coated tongue is very rare in children. Pityriasis linguae consists of white spots, of varying sizes and shapes, scattered irreg- ularly over the dorsum of the tongue, with normal tissue between. This condition may last for months and produce no disturbance of the system. It is due to a change in the epithelium. The treatment should take into consideration the diet, the condi- tion of the bowels, and the cleanliness of the mouth. PAROTIS. Define parotis. Parotis is an hypertrophy of the parotid gland, and may be benign or malignant. The benign variety develops slowly as a rule, the skin over the swelling is movable, and the pain is very slight, if any. Fibroid, cystic, or adipose tumors may develop in the gland. The malignant variety consists of fibroid or medullary carcinoma in the parenchyma of the gland, but secondary to the disease in other organs. As the disease progresses the tumor produces press- ure upon the neighboring vessels and organs. The mass is immov- able and hard in the fibroid, soft in the medullary variety.. Give the treatment. Simple hypertrophy of the gland can be reduced by iodine; cystic and adipose tumors require the knife. The malignant variety requires the general treatment for cancer in the adult. TONSILLITIS. Give the definition of tonsillitis. An acute inflammation of one or both tonsils. What are the varieties of tonsillitis ? Catarrhal, follicular, parenchymatous or suppurative, and rheu- matic. Give some of the causes of tonsillitis. Predisposing causes: hereditary, rheumatism, syphilis, scrofula, previous attacks, atmospheric changes, lowered vitality. Direct HYPERTROPHY OF THE TONSILS. 45 causes: taking cold, acute febrile diseases, traumatism, foreign bodies. What are the symptoms? Headache, malaise, chill, fever, temperature 103° to 105° F. at the beginning, pain in the epigastrium, pulse 120 to 160; throat feels dry and tender, difficult and painful deglutition, altered voice, offensive breath, pain in the ear, with deafness and noises in the ear; loss of appetite, thirst, constipation, restlessness; tongue coated. May have a rash. On inspection one or both tonsils will be seen to be swollen and much inflamed; the inflammation gener- ally extends to the surrounding structures. After a few hours white or yellowish spots are seen scattered over the surface of the tonsil: these collections of mucus are very tenacious, but when removed leave the open mouth of the follicle clean and shining. If at the end of six to ten days the inflammation does not subside, a chill will occur, indicative of suppuration, and the case will develop into a quinsy; in which case the swelling of the tonsil will be increased, and if not treated gangrene may follow. From what diseases must tonsillitis be differentiated? From diphtheria and scarlet fever. What is the prognosis ? Good as to recovery: death sometimes occurs in quinsy from suffocation, due to escape of the pus during sleep. One attack predisposes to another. What is the treatment ? Mild cases require no treatment. In others the remedies advised are aconite, tinctura ferri chloridi, emetics, guaiac, salicylate of sodium. Locally, steam inhalations and hot fomentations or suck- ing cracked ice and ice poultices; gargles or sprays of plain hot water, or solutions of permanganate of potash, peroxide of hydro- gen, etc. In quinsy evacuate the pus early. During convalescence tonics and astringent sprays. For hypertrophied tonsils practise excision. HYPERTROPHY OF THE TONSILS. Describe hypertrophy of the tonsils. Hypertrophy of the tonsils is an equal enlargement of both glands, of hereditary origin, occurring early in life, and, from 46 ORGANIC DISEASES. pressure upon adjacent parts, producing tinnitus aurium, nasal voice, snoring sleep, and interference with breathing and swallow- ing. This condition of the tonsils predisposes to acute angina, and is often attended by diseases of the skin, eyes, and bones. Before puberty the growth of the gland ceases. As regards treatment, the milder forms call for no interference. In the severer forms cod-liver oil is of service, and painting the gland with some astringent or cauterizing it with silver nitrate, or ablation of the gland by means of the tonsillitome or the gal- vano-cautery, or puncture of the gland with the cautery-needle. In ablation avoid the internal carotid artery, which lies internal to and behind the tonsil. RETROPHARYNGEAL ABSCESS. Define retropharyngeal abscess, and give the symptoms. Abscess of the posterior wall of the pharynx may be idiopathic or produced by inflammation of the pharynx and of the cellular tissue surrounding it, as a result of suppurating cervical glands or caries of the cervical vertebrae. The symptoms are: painful deglutition, stiff neck, nasal voice, retraction of the head, difficult breathing if the head is bent forward, fever and restlessness. Examination of the pharynx shows the mucous membrane of a bluish color and bulging of the wall, causing constriction, or the abscess may extend upward be- yond the level of the soft palate, or downward, displacing the larynx. On palpation fluctuation will be detected. As the dis- ease advances swallowing and breathing become more difficult, and the respirations are loud and stertorous. In the variety caused by suppurating cervical glands these glands will be found in addition to the other symptoms ; and in the variety due to the vertebral caries that disease will have preceded the symptoms for some months. Of the different varieties, that due to the vertebral caries is the most common. The prognosis is doubtful. In vertebral caries it is very bad. Describe the treatment. Before pus has appeared ice, leeches, and stimulants can be tried, but as soon as pus forms a free incision must be made. In verte- bral caries some authors advise deferring incision as long as possible, as the entrance of air is supposed to hasten the disease of the bone. INFLAMMATION OF THE OESOPHAGUS, ETC. 47 INFLAMMATION OF THE CESOPHAGUS. Describe inflammation of the oesophagus. Inflammation of the mucous membrane of the oesophagus is most frequently caused by the passage of some hard substance, as metal or bone, or some hot or corroding substance, like hot water, acids, lye, though it may be caused by the extension of diseases of the mouth or throat. The symptoms are—burning pain in the oesophagus, neck, back, and praecordia; painful swallowing, intense thirst, retching and vomiting. Ulcers may form and be followed by stricture. The treatment depends upon the cause. If a foreign body is in the oesophagus, the attempt should be made to remove it; care should be exercised lest it be pushed through the wall of the oesoph- agus. If a corrosive fluid has been swallowed, antidotes should be administered,- the thirst appeased with cracked ice, and the pain relieved by fomentations to the neck, and opium internally. Stric- tures require the use of bougies. Inflammations due to acute dis- eases take the treatment for the disease. CONGENITAL FISTULA OF THE NECK. Describe congenital fistula of the neck. Congenital fistula of the neck is a fistulous tract extending from the side of the neck, usually near the junction of the clavicle and sternum, to the commencement of the oesophagus near the epi- glottis. It is supposed to be due to the failure to close of the second or third gill-fissure. It discharges a thick, tenacious mucus during mastication. No treatment, except surgical in some cases, has as yet served to correct this deformity. SCLEROSIS OF THE STERNO-CLEIDO-MASTOID MUSCLE. Describe sclerosis of the sterno-cleido-mastoid muscle. A cord-like thickening of one of the sterno-cleido-mastoid mus- cles, occurring during the first weeks of infant life, and upon one side only. The thickening is in the muscle, and is movable; it is from half an inch to one inch long. Its course is not known. It quickly disappears under the use of iodine. 48 ORGANIC DISEASES. DISEASES OF THE STOMACH AND INTESTINES. What are some of the most common symptoms attending dis- eases of the stomach and intestines ? Dyspepsia, bulimia, vomiting, flatulence and colic, diarrhoea, and constipation. What is meant by dyspepsia ? By dyspepsia, or difficult digestion, is meant a complete or partial loss of appetite, with retarded digestion of the food taken ; which indigested food generates gases that disturb the alimentary canal, causing pain and fulness, the condition generally terminating with vomiting and a return to health. The causes are changes in the digestive organs or secretions, nervous influences, or irritation of food; the most frequent cause is changes in the quantity or quality of the digestive fluids. What is the treatment $f dyspepsia ? Withhold all food for a few hours to give the stomach rest, and carefully return to a selected diet. Seek the cause of the dys- pepsia, and prescribe remedies accordingly. Hyperacidity of the gastric juice requires alkalies, soda, lime, or magnesia; inflamma- tion of the mucous membrane, bismuth, calomel, small doses, or nitrate of silver, small doses ; for irritating ingesta use emetics, mucilaginous broths, and calomel. Dyspepsia attending acute febrile diseases requires no special treatment other than dietary. What is meant by bulimia? Bulimia, ravenous hunger, or greediness, is a morbid increase of the appetite, due to bad habits of feeding or it is symptomatic of hypertrophy of the mesenteric glands or chronic cerebral disease. The children are pale, anaemic, of stunted growth, and have fre- quent foul-smelling stools. At the autopsy the stomach will be found distended and with thickened walls. The treatment consists in regulating the quantity and quality of the food, giving only such as can be easily digested. Describe the different forms of vomiting in children. The vomiting of nurslings is attended with no symptoms or bad effects: the anatomy of the infant's stomach is such that the milk easily flows out if the child is dandled or the stomach overfilled. In artificially-fed children vomiting is due to digestive disturbances, and attended with nausea, restlessness, and fever, the vomited mat- DISEASES OF THE STOMACH AND INTESTINES. 49 ter consisting of mucus mixed with the food. The vomiting of older children, if due to gastric disturbance, is attended with nausea and extreme depression : if the prodromata of some acute febrile dis-, ease, it is not so profound, though still retching in character; if due to cerebral disease, it is projectile—without any warming the contents of the stomach gush from the mouth. What treatment is indicated in vomiting? The vomiting of nurslings requires no interference, unless it is continuous and affects the child's health, in which case shorten the length of the nursing and keep the child quiet afterward. Arti- ficially-fed children require inspection and correction of the food, and to quiet the stomach lime, magnesia, or calomel. In acute dis- eases and cerebral affections the vomiting is a part of the history, and will cease without treatment. Vomiting due to gastric dis- turbances requires an emetic, followed by^vashing out of the stom- ach, bismuth or calomel to allay the irritability of the viscus, and regulation of the diet. Define flatulence, and give its causes. Flatulence is an abnormal accumulation of gas in the stomach and bowels. The causes are an increase of the natural gases, which peristalsis has failed to remove, or their retention by mechanical obstructions, or gases generated by fermentation. Meteorism is the name given to the acute form, and flatulence or tympanites to the chronic. What symptoms attend this condition? Distension of the abdomen, which, if very great, will cause dys- pnoea and interference with the circulation ; pain or colic, intermit- tent in character and attended with distortion of the countenance, flexing of the limbs on the abdomen, extreme restlessness, loud cries, and sometimes convulsions. It generally ends with the escape of gas and faeces and vomiting. The abdomen will be tympanitic. What treatment is indicated in flatulence? To remove the gas as rapidly as possible. For this purpose use enema of warm water with or without olive or castor oil; cold water or warm chamomile tea; massage of the bowels; keep the patient warm with blankets or hot bottles; regulate the diet, For the colic use antispasmodics or narcotics, and then treat the cause. If due to indigestible food, evacuate the stomach and give a purge; 4—D. C. 50 ORGANIC DISEASES. if due to faecal impaction, a cathartic and possibly an enema will be required; if due to mechanical obstructions or if toxic, the treatment will be indicated by the conditions present, What is diarrhoea, and what are the causes ? Diarrhoea is a change in the quantity and quality of the faecal dis- charges. The causes are indiscretions in diet, atmospheric changes, diseased conditions in some part of the digestive apparatus, inter- current disease, etc. Describe the various forms of diarrhoea. Diarrhoea simplex: the stools are increased in number, are softer than normal, but yellow. Diarrhoea lienterica: the stools contain undigested food. Diarrhoea ablactatorum: the stools are bright yellow and very thin and watery; they are odorless and neutral or alkaline; in a test-tube they separate into a clear portion above and a flocculent mass below ; the microscope shows remnants of undigested food. fragments of epithelium, and brown globules of various sizes ; albu- min is not found unless blood is present; triple phosphates are found in alkaline stools. Diarrhoea with green stools: due to the presence of converted coloring matter of the bile. Diarrhoea containing mucus in shreds and lumps, which the microscope shows to contain mucus-corpuscles, epithelium, and granular masses. These evacuations are painful. Diarrhoea with gray or clay-colored stools: due to the absence of the coloring matters of the bile. Diarrhoea with intensely foetid stools: generally due to enteri- tis folliculosa, and attended by intense pain in evacuation and ery- thema intertrigo. Diarrhoea with pus in the stools; rare, except following dysen- tery or in ulceration of the intestines. What is the treatment of diarrhoea ? In many cases correction of the diet and removal of the offend- ing material by means of a purge will suffice for a cure. Others will require an astringent after the purge; others, again, demand treatment of the primary disease that has induced the diarrhoea. Describe constipation, and give the causes. If the bowels do not discharge their contents twice a day in DISEASES OF THE STOMACH AND INTESTINES. 51 young children and once a day in older children, the condition is known as constipation. The causes are deficient intestinal mucus, too much starchy food, astringent foods or medicines, too little fluids taken into the sys- tem, or an excessive discharge of perspiration and urine, decreased peristalsis, mechanical obstructions. The symptoms attending this condition are perverted appetite or anorexia, restlessness, gaseous accumulation distending the abdo- men, in extreme cases displacing the viscera, eructations of gas, vomiting, emaciation. Give the treatment of constipation. In the simplest form regulating the diet, baths, friction of the skin, and limited exercise will often suffice. Before drugs are resorted to attempts should be made to correct the trouble with enemata, soap or glycerin suppositories, massage of the bowels, prac- tised by gentle pressure with the tips of the fingers along the whole course of the colon. Of drugs, commence with the simplest laxa- tives, and stop their use as soon as possible. In every case of ob- stinate constipation examine the patient carefully for obstruction. Describe catarrh of the mucous membrane of the stomach. Gastritis catarrhalis, catarrhus ventriculi, is an inflammation of the gastric mucous membrane, attended by an increased secretion of mucus, and produced by errors in diet, irritants of various kinds, acute diseases, changes in the stomach-wall, etc. The symptoms manifested are—continuous pain in the stomach, increased by pressure and warm fluids, relieved by cold fluids; gas- eous distension of the epigastric region, with increase of tempera- ture at that point; vomiting of clear glairy mucus if the stomach is empty ; frequent vomiting of the food; later in the disease, ema- ciation. The bowels, urine, and circulation are not much dis- arranged. Give the treatment. Regulate the diet, give milk, and, to correct the increased secre- tion of mucus and check the vomiting, nitrate of silver or creasote is the most serviceable remedy. Describe toxic inflammation of the stomach. This condition arises from the swallowing of poisonous acids or alkalies, which cause erosion and destruction of tissue, followed, if recovery takes place, by cicatrices and strictures. 52 ORGANIC DISEASES. The symptoms are—intense pain, nausea, vomiting, the vomited matter being bloody ; bloody saliva, loss of voice, painful swallow- ing, convulsions, cold perspiration, small pulse, cyanosis, bloody stools if the intestines are involved; if recovery occurs, there will be marked emaciation. Give the treatment. For caustic alkalies use vegetable acids or olive oil; for corrosive acids use alkalies, as magnesia or chalk, or soap-water. Check the pain with opium and nourish the child with cold milk. Describe perforating ulcer of the stomach. This condition is rare in young children: it is occasionally met with in chlorotic girls about the time of puberty, its symptoms and treatment being the same as in the adult. Describe hemorrhagic erosions of the mucous membrane of the stomach. This condition is found post-mortem, and as it occurs in so many different diseases, it has no particular symptoms of its own : it is most frequently met with in atrophic and tuberculous children. The affection consists of spots of extravasated blood of varying sizes, covered with brownish, fibrinous flakes, the mucous mem- brane having a bluish color, and sometimes, from loss of tissue, the spots are depressed. Describe softening of the stomach. Gastro-malacia, or softening of the stomach, is purely a post- mortem condition, in which the coats of the stomach are softened and destroyed by ulcerative processes or the formation of pseudo- plasma. The seat of the trouble is the most dependent portion of the viscus. Two varieties are found, a light and a dark one, de- pending upon the quantity of blood in the stomach-walls at death. The softening may be slight or extensive, sometimes perforating the stomach and allowing its contents to escape into the peritoneal cavity, sometimes extending to adjoining organs. Define catarrhal inflammation of the intestines, and give the causes. Intestinal catarrh (catarrhus intestinalis) is an inflammatory pro- cess involving the mucous, and sometimes the submucous, coats of the intestine, of an acute or chronic character, and caused by im- proper or indigestible food ; derangements of the wet-nurse • stoma- DISEASES OF THE STOMACH AND INTESTINES. 53* titis, causing increased salivary and mucous secretion ; exposures to cold; and weaning: in older children it is due to errors in diet, un- ripe fruit, etc. Describe the appearance of the intestinal canal. The mucous membrane is turgid and injected; the solitary glands are swollen and prominent—if the disease is chronic they will have ruptured; the epithelium is cast off; the mucous mem- brane is swollen, and in the chronic form the submucous and mus- cular coats are thickened; the mesenteric glands are sometimes reddened, but never infiltrated and hypertrophied. Give the symptoms. The child is fretful and restless, crying continuously and refusing its food: if the disease is confined to the small intestine, there will be but slight pain ; if to the large intestine, the pain will be severe and attended with tenesmus. Diarrhoea is the most prominent symptom : the stools are watery and very frequent, of the normal color at first, but soon changing to a pale yellowish or grayish tint, and without any odor. The abdomen is distended, tympanitic, and painful around the navel. The urine is diminished, high-colored, and contains the double urates of soda. There are intense thirst and anorexia. There is no acceleration of temperature while the diarrhoea lasts, but if the diarrhoea is profuse, symptoms of collapse may appear; after the diarrhoea ceases a fever of reaction may su- pervene. During convalescence the stools are hard or slimy and very offensive. Catarrh of the stomach and bronchitis are the most frequent complications. The prognosis is not unfavorable unless the disease runs into enteritis folliculosa. Give the treatment of catarrhal inflammation of the intestines. Dietetic; all errors should be corrected; no milk should be allowed, except in the case of a breast-fed child, and not then if the mother or wet-nurse is out of order, in which case put her under treatment. Withhold all food from the child for a few hours, and then only give animal broths or albumin-water until the diarrhoea ceases, when the former diet of milk or other food can be gradually resumed. If there is undigested food in the intestine, this should be removed by means of castor oil or calomel or an enema. Then astringents can be used—opium, bismuth, nitrate of k54 ORGANIC DISEASES. silver, calomel, or mercury with chalk, in small doses ; pulv. ipecac. et opii comp., pulv. cretae comp. Of these opium ranks first. Define enteritis folliculosa, and give the causes. An inflammatory process involving the mucous and submucous tissues, the solitary glands and Peyer's patches, and extending to the mesenteric glands. It is also known as strumous enteritis and tabes mesenterica. The cause is a tuberculous diathesis : in such patients causes that would excite a simple enteritis in non-tubercular patients produce a follicular enteritis. Describe the lesions in the intestines. The submucous tissue is infiltrated ; the mucous coat shows evi- dences of catarrh; the solitary glands and Peyer's patches are swollen and prominent—some at the site of the swelling of the fol- licles are ruptured; the mesentery is injected, its glands enlarged, and on section show a red or yellow-white surface, depending upon the length of the disease; in the yellowish-white glands the con- nective tissue is increased. Pigmentation of the mucous membrane is slight. The enlarged glands, at first dry, hard, and cheesy, afterward soften and form ulcers. Give the symptoms of enteritis folliculosa. The symptoms at first are those of intestinal catarrh, with the difference that the stools remain liquid, have a putrid odor, and erode the anus and adjacent parts. There are high temperature, intense thirst, tongue coated white or else dry and shiny ; stomatitis later, vomiting in some cases, rapid emaciation ; in very young children overlapping of the cranial bones, especially the occipital and parietal; tympanitic distension of abdomen, disturbed sleep, sometimes convulsions; toward the end obstinate constipation suc- ceeds the diarrhoea. In some cases the enlarged mesenteric glands can be felt through the abdominal walls. What are the differential diagnosis and prognosis? From tubercular meningitis and tubercular peritonitis: in tuber- cular meningitis the abdomen is retracted; there are constipation, projectile vomiting, slow pulse, and contracted or dilated pupils. Tubercular peritonitis has more pain and a more rigid abdomen. The prognosis is always unfavorable. DISEASES OF THE STOMACH AND INTESTINES. 55 What is the treatment of enteritis folliculosa? Give the child good breast-milk; check the diarrhoea; cod-liver oil, flannel bandage to the bowels, anodyne poultices to relieve the pain. Define dysentery, and give the causes. Dysentery is an inflammatory disease of the large intestine, attended with mucus and bloody stools and tenesmus. The dis- ease may be epidemic or sporadic; the causes similar to those for intestinal catarrh. The sporadic form is also known as colitis and ileo-colitis. Describe the symptoms of dysentery. The symptoms of the two varieties are similar, those of the epi- demic being more severe and dangerous. The disease commences as a simple diarrhoea. After a few days the character of the stools changes : they contain lumps or granules of glairy mucus, and soon streaks of blood appear or a bloody stool is passed; the blood is pink or bright red; as the mucus increases the faecal matter decreases. In the epidemic variety ulcers form, and as they rup- ture pus and sloughed mucous membrane are mixed with the stools, giving them a dirty grayish color and putrid odor. The number of the stools varies from three or four to twenty or thirty in the twenty-four hours, depending upon the severity of the attack. Pain around the navel and along the course of the colon is present. Tenesmus is present, and often so intense as to produce prolapse of the rectum. In bad cases paralysis of the rectum may occur. Vomiting occasionally occurs, more particularly in the epidemic form. Fever occurs late. Delirium and convulsions may occur. Emaciation is marked, especially in the epidemic form. There is intense thirst; the appetite is lost. The most frequent complications of the sporadic form are lobular pneumonia and tabes mesenterica; of the epidemic form, perfora- tion of the intestines and peritonitis, pyaemia, strictures of the intestines, hepatic abscesses, and icterus. The course of the disease is four to six days for the sporadic, ten to fourteen days for the epidemic, form. Give the treatment of dysentery. Warmth and regulation of the diet, breast-milk for infants if pos- . sible ; in older children or those artificially fed. mucilaginous broths. Of drugs, opium by enema or the mouth, calomel alone or with 56 ORGANIC DISEASES. opium, ipecac, nitrate of silver, alum, vegetable astringents; washing out the bowels. Define intussusception, and give the causes. Intussusception, or invagination of the intestines, is the slipping of one portion of the bowel into another. The cause is a contraction of some portion of the bowel, as from paralysis, or the weakening of some portion of the bowel, as from protracted catarrh, and increased peristalsis, pulling the larger over the smaller portion. The intussusception consists of the three layers: the outer, or sheath, the intussuscipiens; the inner and the middle, together called the intussusceptum. The outer and middle have their mucous surfaces together, the inner and middle their peritoneal surfaces. The invagination generally takes place from above down- ward. The results are disturbed circulation in the invaginated mesentery, oedema and hyperaemia of the invaginated bowel, and inflammation and plastic exudation upon the peritoneal covering of the overlapping tube. The oedema of the invaginated tube may be so great as to occlude the bowel, stercoraceous vomiting resulting. What are the symptoms of intussusception ? Intense colicky pains, tympanitic distension of abdomen, some- times a tumor can be felt; constipation, sometimes diarrhoea with bloody stools ; vomiting, which as the obstruction increases becomes stercoraceous; collapse and death in three or four days from peri- tonitis or gangrene of the constricted bowel. Spontaneous recovery sometimes occurs, but the bowel is always constricted at the point of invagination. What is the treatment of intussusception ? Absolute rest, restricted diet, the avoidance of laxatives, ca- thartics, or anything that will increase the peristalsis. Gaseous inflations may be tried, but laparotomy offers the best chance for recovery. Describe inguinal hernia in children. The various forms of herniae found in the adult are met with in children, but the most frequent is the congenital. In this a por- tion of the bowel descends through the processus vaginalis, which has failed to close after the descent of the testicle, and lodges in DISEASES OF THE STOMACH AND INTESTINES. " 57 the tunica vaginalis in contact with the testicle. The coverings are the scrotum, the tunica vaginalis, and the intervening tissues. Rarely is there any omentum in the sac. In some cases hydrocele complicates the case. The lesion is produced by straining, crying, coughing, muscular action, etc. It presents an oval, soft, com- pressible, non-fluctuating tumor, not transparent. As it returns after reduction, the swelling commences at the top of the scrotum, whereas hydrocele commences at the bottom. The testicle is in relation to the mass and cannot be separated. The neck of the tumor is constricted. If hydrocele is also present, the fluid can be forced back into the abdominal cavity by lifting the scrotum, and then the hernia can be detected. In girls the bowel escapes into one of the labia majora through the inguinal canal, which, being open for the passage of the round ligament, has failed to close before birth. What is the treatment of inguinal hernia ? The treatment is by means of properly-applied trusses and correc- tion of the affection that caused the rupture. Some cases recover spontaneously. Describe fissure of the anus. Fissure of the anus may occur in nurslings as well as older children. It consists of little cracks, sometimes so small as to be found with difficulty, in the folds of the anus, due to injury caused by hardened faeces and straining, and producing pain at stool and sometimes blood-stained faecal masses, or a few drops of blood may pass. The symptom that attracts attention is the pain at and after stool. The treatment consists in regulating the bowels and cauterizing the fissure with silver nitrate or carbolic acid. Describe rectal polypi. Rectal polypi are generally of the mucous variety: they are situated near the anus, cause pain and hemorrhage at stool, and will sometimes protrude from the anus. They can easily be felt by introducing the finger into the rectum. The disease is rare. The treatment consists in the removal of the growth. Describe prolapsus ani. Prolapsus ani is an escape of the lower folds of the mucous membrane into the anus. It is produced by prolonged diarrhoea, 58 ORGANIC DISEASES. causing swelling and sagging of the mucous coats of the bowel and relaxation of the sphincter, or constipation and straining, forcing the bowel down. It presents a puffy mass of a blue or pink color, and with a central opening or a section several inches in length. It is attended with pain. The treatment consists in restoring the prolapsed bowel, begin- ning at the centre, using ice and some simple ointment to aid the manoeuvre, and correcting the condition that caused the trouble. Describe constriction of the anus. Constriction of the anus is rarely noticeable during the first year of life unless the child becomes constipated ; later, as the stools become formed, it may appear. The passage of the stools is dif- ficult or impossible, and tympanites, or even stenosis, may occur. Injections or laxatives will correct the constipation, and the symp- toms will disappear. Sometimes the opening is so small that it is necessary to make an incision, and to stretch the anus and keep it open with plugs of cotton or oakum. Describe imperforate anus. This condition is noticed by a failure of the child to pass meconium, distension of the abdomen, and restlessness. The de- formity is of several varieties: the simplest is where the rectum ends blindly at the skin, and a simple incision relieves the dif- ficulty ; or the anus may exist, but have failed to unite with the rectum ; or the rectum may terminate in the vagina or bladder; or the rectum does not exist at all, a portion of the large intestine only being present and terminating near the umbilicus. The cause is retarded development. The treatment consists in a surgical operation. What worms are found in the alimentary canal of children ? Taenia solium; taenia mediocanellata ; bothriocephalus latus; ascaris lumbricoides; oxyuris vermicularis; and tricocephalus dispar. Give a brief description of each variety of intestinal worm. Taenia solium—also known as taenia cucurbitina, chain-worm, lon» tape-worm—class of Cestodiae, is a yellowish-white, tape-like, jointed worm, from fifteen to thirty feet long and three to five lines wide. The head is very small, globular or bulbous, with a slightly promi- nent conical snout, surrounded by a double row of curved silicious hooks, from twelve to fifteen in each row, and farther back four DISEASES OF THE STOMACH AND INTESTINES. 59 suckers symmetrically arranged. The neck is very slender, from half an inch to an inch long, marked transversely; the segments, at first very small, much broader than long, gradually become flat- tened and square, then longer than broad, and narrower at the anterior extremity; the corners are blunt. The male and female organs open by one orifice, situated laterally, now on one border, now on the other, but not regularly alternating. New joints con- stantly form at the head, while at the tail old joints are cast off, appearing singly in the stools. Taenia mediocanellata, class of Cestodiae, resembles taenia solium, but longer, head larger, flattened in front, four powerful and promi- nent suckers, but neither snout nor hooks; links broader, thicker, and firmer; sexual organs more developed and divided, their orifice near the posterior border. Bothriocephalus latus—also known as taenia lata, the broad tape- worm—dass of Cestodiae, resembles the others, but is much larger, head club-shaped, without hooks or snout, but with two longitudinal slits or suckers, one on each side, neck very short, segments broad, of a brownish color, the sexual organs in the centre and separate; the male anterior ova are brown. The sections are not cast off singly, but in numbers joined together. Ascaris lumbricoides—also known as round-worms—class of Nematodiae, a long cylindrical worm, tapering to the ends, of a reddish, grayish-red, or yellowish-white color, from five to sixteen inches long and one to three lines in diameter ; head separated from the body 'by a circular depression ; has three small prominences, with the mouth between, lined with numerous teeth. The body has transverse markings. Sexes separate : the male is shorter and curved posteriorly, where the sexual organs are placed, indicated by a couple of very fine small white hairs ; the female is straighter, thicker at the hinder extremity, and has the sexual opening about the end of the anterior third. Oxyuris vermicularis, also known as ascaris vermicularis—pin- worm, thread-worm—class of Nematodiae, is small and fusiform, males from one to two lines long, females about five lines, whitish or yellowish white, with fine transverse striae ; head has a terminal mouth, with three lips, and a wing-like expansion on the dorsal and ventral surfaces. The male is rolled up posteriorly, where the sex- ual organs are; the female is straight, with the sexual organs at the junction of the anterfor and middle thirds. Tricocephalus dispar—also known as whip-worm—class of Nema- 60 ORGANIC DISEASES. todiae, thread-like in form, from one to two inches long, anterior end hair-like, with a simple terminal mouth ; posterior end thickened. The male is smaller and coiled posteriorly, having the penis at the end; the female is larger, thicker, and only slightly curved, and has posteriorly a simple, straight vagina, with a uterus containing an immense number of ova. Where are the different varieties of worms found ? All the varieties of tape-worm occupy the small intestine; rarely do they enter the large intestine or stomach. The round-worms occupy the small intestine, but often travel into the large intestine, rarely into the stomach, oesophagus, mouth, etc. The pin-worms occupy the rectum and lower part of the colon ; they often migrate around the anus into the vagina, urethra, and under the prepuce, also into the small intestine and stomach. The whip-worms occupy the caecum, sometimes the colon, rarely the ileum. Tape-worms are generally found singly, rarely two or three; of the round-worms there are usually five to ten, sometimes two or , three hundred; of the pin-worms collections of hundreds or thou- sands are found; the vhip-ivorms are not numerous, but sometimes several hundred will be found. What is the origin of these parasites ? No ova develop in the alimentary canal, but escape in the stools, enter the alimentary canal of domestic animals in their food or drink, there rupture ; the released embryo buries itself in the mucous membrane, works its way into the tissues, and develops into a head, neck, and bladder-like appendage : in this condition it is taken into the human alimentary canal, attaches itself to the mucous membrane, the bladder drops off, and the worm commences to grow. These parasites enter the system in raw or underdone meat, the taenia solium in pig's flesh, the taenia mediocanellata in beef, the bothriocephalus latus in fish or mollusks. The ascaris lumbricoides and oxyuris vermicularis are conveyed in water, vege- tables, fruit, and impure starchy substances. What symptoms are caused by these parasites ? Pain, gnawing or boring in character, increased by salty, sour, or aromatic food, relieved by milk and fatty food ; the appetite may be diminished; vomiting occurs in some cases; irregularity of the DISEASES OF THE LIVER. 61 stools; irritation of the genitalia when the oxyuri have invaded those parts, causing leucorrhoea in girls and balanitis in boys, itch- ing of the mons and anus, dilatation of the pupils, and convulsions. But it must not be forgotten that these general symptoms are com- mon to children, and upon them a probable diagnosis only can be made: the surest symptom is the presence of the worms or their segments in the stools; the oxyuri will often be found around the anus. Describe the treatment of intestinal worms. The treatment consists in removing the parasites. With the tape- worm it is absolutely necessary that the head be removed, and the worm must be carefully examined to ascertain that fact. Against the tape-worm, male fern, kousso, pomegranate, kamala, pumpkin- seed are used; of these, the first two are probably the most effica- cious ; against the round-worm, santonin, calomel, pink-root, cow- hage, and wormseed, of which the first two, combined in proper doses, are most often successful; against pin-worms, enemata of plain water, continued daily for a few weeks, or water containing some intense bitter, as quassia or quinine, or salt water, or water contain- ing a few drops of turpentine or camphor—these latter to be re- peated every other day until no more worms are seen—will be all that is required. After the expulsion of the parasites the child will generally begin to mend if it has run down any, but if neces- sary, treatment should be instituted. DISEASES OF THE LIVER. What affections of the liver manifest themselves in children? Aside from icterus neonatorum, syphilitic inflammation of the liver and fatty liver are the most frequent lesions. Other diseases of the liver are very rare in children, and when they do occur their history and treatment are the same as for the corresponding affec- tions in the adult. Describe syphilitic inflammation of the liver. The liver presents a roughened, uneven appearance; its perito- neal covering is indurated; on section spots are found of a firmer consistency than the normal tissue, of a pale color, and composed of granules, oil-globules, and a few liver-cells. The symptoms pertain chiefly to the primary disease: condylo- mata around the anus and at the angles of the mouth; the exan- 62 ORGANIC DISEASES. thema and ozaena ; nutrition is interfered with, and there is marked emaciation; the skin has a grayish, earthy hue, instead of being icteric; the nodular masses on the surface of the liver can some- times be felt, and its free border is thickened and more rounded than in health. Fibrous degeneration of the kidney and anasarca sometimes complicate. Treatment avails but little, as these children generally perish, especially if fed artificially: the best results are obtained from inunctions with mercury. Define fatty liver, and give the pathology. Fatty liver is that condition of the organ in which the fat in the hepatic cells is greatly increased, producing changes in the color and consistency of the organ. It does not occur primarily, but as a complication of some of the wasting diseases, as tuberculosis, rickets, syphilis, chronic intestinal catarrh, etc., and is due to the changes in the blood, which becomes overloaded with fat, which is absorbed during the progressive emaciation. The organ is larger, flattened, with thickened, rounded edges; its upper surface is smooth, white, glistening, and doughy, the impress of the finger remaining; on section the color is yellowish-red or pale yellow, and the fat clings to the knife. The fat consists of olein, margarin. and traces of cholesterin, and in quantity may reach 43 to 44 per cent. In milder cases the fat involves individual scattered cells, giving the cut surface of the liver a mottled appearance. The sugar-forming and bile-secreting functions of the liver are not interfered with. Give the symptoms and treatment of fatty liver. The symptoms referable to the liver are rather obscure. There may be enlargement, and if this occurs in the course of a tubercu- losis, rachitis, etc., and is accompanied with distension of the abdo- men, flatulence, and diarrhoea, a diagnosis can be made. The treatment resolves itself into the removal of the disease causing the trouble. What are the most significant malformations of the liver ? Of the changes in form there are—quadrangular, triangular, flat, or round; the division into lobes may be absent or multiplied. The liver may be absent: this occurs especially in acephalae; it may be double, which occurs in diplogenetic monsters. It may go up into the right pleural' cavity through a congenital fissure of the DISEASES OF THE SPLEEN.—PERITONITIS. 63 diaphragm ; or it may be exposed through rupture of the umbilical cord ; and it may be transposed where the other viscera are trans- posed. DISEASES OF THE SPLEEN. Describe the affections of the spleen in children. Primary affections are extremely rare. Some acute diseases, as typhoid, are attended by inflammation of this organ, but enlarge- ments of the gland are mostly met with in chronic diseases, as rickets, intermittent fever, etc. Palpation of the spleen is impos- sible, except in cases of extreme enlargement: in such cases, if the abdominal walls are very thin, the organ and its hilus can be felt. Percussion of the spleen is difficult, unless it is enlarged, because so small a portion approaches the chest-wall. The centre of the spleen lies in the ninth intercostal space, at a point crossed by a line dropped from the posterior axillary border to the great tro- chanter. The treatment of splenic enlargements depends upon the treat- ment of the disease producing the hypertrophy. PERITONITIS. Define peritonitis in children, and give the etiology. Peritonitis is an inflammation of the whole or a part of the serous membrane that lines the abdominal cavity and covers the viscera contained therein. The idiopathic form is extremely rare. In very young children some affection of the navel, as inflammation of the umbilical vessels, is the most frequent cause; in older children the disease is due to injury, as burns, wounds, perforation of intestines or stomach, intussusception, strangulated hernia, etc.; tuberculosis is sometimes a cause. The disease may be acute or chronic, local- ized or general, or metastatic. What are the pathological appearances in peritonitis? At different portions of the peritoneum capillary injection and plastic exudation will be found: this is most marked where the surfaces of the intestines come in contact, and often leads to adhe- sions. In that form of localized peritonitis due to inflammation of the umbilical vessels the inflammatory process is found around the umbilical ring and on the concave surface of the liver, and as a re- sult of the plastic exudation adhesions form between the liver and the adjoining viscera. 64 ORGANIC DISEASES. Give the symptoms of peritonitis. Abdominal pain, aggravated by pressure and motion, and pro- ducing interrupted crying: continuous crying puts the abdominal muscles in motion and intensifies the pain. The child's position is the dorsal decubitus with extended legs, or they may be flexed. Tympanites, occasionally vomiting, diarrhoea, anorexia, thirst; urine may be retained or passed a few drops at a time; fever high ; pulse small and rapid; respirations superficial, frequent; face pallid ; there may be convulsions. Lobular pneumonia is the most frequent complication. What is the prognosis ? The prognosis is generally bad. In nurslings, or where it is due to inflammation around the umbilicus or of the umbilical vessels, it is usually fatal in from one to three days; peritonitis due to per- foration is generally rapidly fatal; tubercular peritonitis is chronic in the majority of cases, and may not be recovered from. Give the treatment of peritonitis. Absolute rest and strict hygienic and dietetic principles must obtain ; poultices, opium, quinine, stimulation. Where the disease commences at the navel, this part must be kept absolutely antisep- tic. The traumatic form may be benefited by the use of leeches and small doses of calomel. ASCITES. Give the definition and causes of ascites in children. Ascites is an accumulation of serous fluid in the peritoneal sac. In children it is always secondary to some other disease. In very young children the amount is very small. Describe the morbid appearances. The fluid has a yellowish color, sometimes red from admixture of blood; it contains albumin and the salts of the blood. Evi- dences of peritonitis more or less marked are also present: these consist of opacities and exudative material. The heart or kidneys will generally show the cause of the ascites. Give the symptoms. Abdominal distension, except in mild cases; skin stretched and shining; percussion dulness; fluctuation; navel prominent; fre- DISEASES OF THE MESENTERIC GLANDS, ETC. 65 f|uent desire to urinate, but only small quantities of urine are passed, of a dark color; bowels loose; slight perspiration. The prognosis is generally bad, except in cases complicating the acute fevers. What is the treatment of ascites ? This depends upon the primary disease. Generally speaking, the treatment should be stimulating—good diet, alcohol, iron, etc.; diu- retics and diaphoretics. DISEASES OF THE MESENTERIC GLANDS. What are the chief changes in the mesenteric glands due to dis- ease? In tabes mesenterica the glands are first hypertrophied and indu- rated, then atrophied; in older children and where the disease lasts long enough they undergo cheesy degeneration and ulcers form. In typhoid the glands hypertrophy, and sometimes abscesses form. DISEASES OF THE HEART. Describe the most common congenital abnormities of the heart. Absence of the heart occurs in monstrosities in whom the upper part of the trunk is absent. A double heart occurs in double monsters. Abnormal position of the heart in cases of transposition, or the heart may be in the centre of the chest. Exposure of the heart from absence of the chest-walls in whole or in part; or from defects in the diaphragm the heart may be found in the abdominal cavity. The heart may be broad, cylindrical, or fissured, small or large. Through failure of the septa to form there may be one auricle and one ventricle, or two auricles and one ventricle, or one auricle and two ventricles; or because of irregular formations of the septa the auricle of one side may communicate with the ventricle of the other side. The pulmonary artery may be absent or constricted at its origin, and dilated beyond the ductus arteriosus. The aorta may be misshapen or completely closed. The aorta may supply the upper part of the body, aud the pul- monary artery, through the patent ductus arteriosus, the lower part. 5—D. C. 66 ORGANIC DISEASES. The aorta may arise from the right ventricle, the pulmonary artery from the left, or both may arise from one ventricle. The aorta may have two equal or unequal roots, one from the left, the other from the right, ventricle. The bulb of the aorta may be very much enlarged, acting as a third ventricle. The ductus arteriosus may remain permeable, may be absent, or may develop into a permanent vessel. The venae cavae and pulmonary veins may be transposed or may terminate in one auricle. The valves may be thickened, hypertrophied, cartilaginous, or absent. The foramen ovale may be patent or prematurely closed. The columnae carneae and chordae tendineae may be increased in number or wrongly inserted. What symptoms attend these malformations? Where the heart is absent or double or exposed, or the large vessels are transposed, the children perish at birth or soon after. Changes in the conformation of the heart or its component parts do not interfere with a child's existence, but the derangement of the circulation retards its development and its life is short. With the milder degrees of malformations adult life, and even old age, may be reached. Where the deformities of the heart or vessels are extreme the children are born asphyxiated, and soon die from atelectasis of the lungs; they are cyanotic, cold, sleep most of the time, cough, have a bluish tongue ; the cry is low and interrupted. In milder forms of abnormities or if the children survive, other symptoms appear: pigeon breast from lack of development of the pectoral muscles; bulbous fingers with claw-nails, from impeded circulation ; enlarge- ment of the veins of the skin and cardiac palpitation ; short breath on exertion, epistaxis and haemoptysis, anasarca and albuminuria. Excepting hypertrophy, which can be easily detected, the form of lesion present can only be surmised. What is the treatment of malformations of the heart ? The treatment comprises regulation of the food, clothing, and exercise of the patient, and the avoidance of depleting remedies in the treatment of any intercurrent disease. DISEASES OF THE HEART. 67 Define endocarditis, and give the varieties and causes. Endocarditis is an inflammation of the lining membrane of the heart. It may be simple or ulcerative. The causes are rheumatism, scarlet fever, diphtheria, pleurisy, pneumonia, Bright's disease, pyaemia, septicaemia, and cardiac inflammations. Give the pathology. The inflammatory process commences in the connective tissue, and the exudation forces its way through the endocardium to its surface, appearing at first as red spots, which become elevated, causing roughening of the surface; upon these roughened spots the fibrin of the blood is collected. The exudation may be ab- sorbed, but this is rare: it generally remains, and produces perma- nent changes in the lining of the heart, most marked at the valves ; or shreds of the exudation or of the fibrin are washed away in the current, and form thrombi in some other part of- the body : the most frequent locations for these are in the spleen, kidneys, and brain. In the ulcerative form the spots of exudation pass through the various stages of ulceration, terminating in perforation or de- struction of the valves or their appendages. The left side is most frequently affected. Describe the symptoms of endocarditis. In the simple form, where the exudation is slight or is absorbed, the symptoms, both subjective and objective, are so meagre as to have no diagnostic value. In the other forms pain, if present, is very slight; palpitation, increased by crying and exertion, and dyspnoea are always present, also restlessness and anxiety, and oppression of the chest, fever, emaciation, and nervous phenomena, even to delirium. Examination of the heart shows enlargement, with extension of impulse and a mitral systolic murmur; there may be an aortic systolic murmur as well, and a stenosis at the mitral valve may also occur, but these last two are rare; the right side of the heart is very rarely affected. What is the differential diagnosis and prognosis? From functional disorders, anaemic murmurs, and pericarditis. Entire recovery is extremely rare: a cardiac lesion more or less severe results in most every case; death sometimes occurs from exhaustion or emboli, but more often from some complication. 68 ORGANIC DISEASES. What is the treatment of endocarditis ? As the disease is always secondary, the treatment must be of the primary affection, but insist upon absolute rest, regulate the diet, attend to the condition of the bowels, and protect the surface from changes of temperature; mild counter-irritation over the heart; opium if restlessness is extreme; and digitalis, aconite, gelsemium, carbonate of ammonium, strophanthus, sulphate of spar- teine, etc., according to their indications, may be tried. The resulting heart lesion requires careful attention, and the avoidance of all things on the part of the patient that will tend to make it worse. Define pericarditis, and give the varieties and causes. Pericarditis is an inflammation of the pericardium. It may be circumscribed or general, and is fibrinous, purulent, or tuberculous. It may be due to injury, extension of inflammation from neighbor- ing parts, rheumatism, scarlatina, tuberculosis, the eruptive fevers, kidney trouble, pyaemia, pleurisy, peritonitis, etc. Describe the pathology. Though the disease may be circumscribed at the beginning, start- ing on the parietal or visceral surface, its tendency is to spread, so that it is more frequently found as a general affection. The inflam- mation is immediately followed by a plastic exudation. In the fibrinous form the two surfaces are thickly coated with a shaggy, yellowish-white membrane, which unites the two surfaces in whole or in part. This exudation becomes organized and vascular, and with it there is an effusion of yellowish flocculent fluid; later this fluid is absorbed and the two surfaces become more or less firmly attached, or in the circumscribed form the friction between them will cause the exudation to be rubbed off and disappear, leaving only fibrinous spots. In the purulent form the conditions are the same as in the fibrin- ous, but the fluid degenerates into pus, or may have been pus at the start. In the pyaemic pericarditis in new-born children attend- ing inflammation of the umbilical veins and peritonitis, the fluid is thin, of a brownish-red color, and contains grayish-brown lymph- flakes. In the tuberculous form tubercles, slightly larger than the mil- iary tubercles of the lungs, are found in the pericardium, isolated or in groups. DISEASES OF THE HEART. 69 Give the symptoms of pericarditis. The subjective symptoms are often very mild: in general there are severe pain, dyspnoea, oppression of the chest, rapid pulse, cya- nosis, and nervous phenomena, as fainting, delirium, etc. The physical signs are those of enlargement, the friction-sound, displacement of apex-beat, and, if the fluid accumulation is extensive, intensified beat and irregular rhythm. The friction-sound must be differentiated from an endocardial murmur; its character and time in relation to the beats of the heart will aid in making the distinc- tion. The pulse, at first strong, rapid, and incompressible, later becomes small and compressible. If the effusion is large, there will be undulating movements in the jugulars, or even bulging at the end of systole, from damming back of the blood, due to the inability of the right auricle to dilate because of the pressure upon it of the fluid. What is the prognosis ? Recovery without any lesions, which is extremely rare, or re- covery with a crippled heart from adhesions, dilatation of the cham- bers, etc., or death, which is usually sudden. Give the differential diagnosis. From endocarditis, hydropericardium, pleurisy, cardiac hyper- trophy. Give the treatment of pericarditis. Treat the primary disease. For the pericarditis, when the diag- nosis is certain, fomentations and opium until the fluid appears, then mild counter-irritation over the heart, tonics, stimulants, regu- late the diet; absolute rest; digitalis, strophanthus, sparteine, oxy- gen, tr. ferri chloridi; paracentesis in extreme cases. During con- valescence and afterward extreme care in exercise, diet, etc. Such a patient should be watched for a long time. Pyaemic pericarditis of the new-born is generally fatal, and no treatment avails any- thing. Define hydropericardium, and give the causes and pathology. Hydropericardium is a non-inflammatory accumulation of serum in the pericardium. It may be caused by defects in the heart, but it is most frequently a part of general dropsy due to cardiac or renal disease ; its most common cause is scarlatinal nephritis. The pericardium shows nothing abnormal: there is merely accumulation 70 ORGANIC DISEASES. of yellow serum of from one to four ounces in amount; the heart- muscle is more yellow than red. What symptoms attend this disease ? There are no. symptoms unless the effusion is extensive. Then there will be oppression of the chest with difficult breathing, and the general symptoms of dropsy and pericarditis except the absence of the friction-sound. The prognosis depends upon the cause: where this is disease of the heart, a fatal result follows; where scarlatina is the cause, re- covery can be attained by proper treatment. What is the treatment of hydropericardium ? The treatment pertains to the primary disease; for the dropsy diuretics are of the most service. RHEUMATISM. Define rheumatism, and give the synonyms and causes. Rheumatism is a specific febrile disease, attended with multiple inflammation of the large joints and fibrous tissues, the heart, and other organs. The synonyms are—Rheumatic fever; Acute rheumatic arthri- tis ; Polyarthritis rheumatica. The causes are exciting and predisposing. The predisposing causes are heredity, a rheumatic diathesis, age (rare under five, most frequent between fifteen and thirty, but found at all ages, in one case twenty-five days old), the temperate zone, sex (more fre- quent in males), previous ill health. The exciting .causes are sud- den changes of temperature, errors in diet, acute diseases, as scarlet fever, diphtheria, dysentery, etc. " Growing pains " may be due to rheumatism. Give the pathology. Various theories have been held. It is admitted that some mor- bific principle enters the blood. The opinion that this is uric acid or lactic acid is losing ground. The most generally accepted opin- ions at present are that it is some affection of the nervous system and that it is caused by a micro-organism. What are the symptoms ? High fever, rapid pulse, great thirst, restlessness, anorexia, cos- tiveness ; urine passed in small quantities, dark colored, loaded with DISEASES OF THE BLOOD-VESSELS. 71 urates ; profuse perspiration, sudamina. The fever lasts eight to ten days unless complications occur.- The joints are swollen, red, and extremely painful; generally the knees are first affected, then the ankles, next the elbows, wrists, and spinal column. The joints never suppurate ; the swellings disappear and leave no trace behind. The diagnosis is made upon the fever, the swelling and pain in the joint and their wandering from one joint to another. The disease lasts about fourteen days if no complications occur; these prolong the disease and may give it a fatal termination. The prognosis as to recovery is good. If the heart is affected, it may be crippled for life. Give the treatment of rheumatism. Rest in bed, protection from currents of air, flannel to the skin, the joints wrapped in cotton, diet milk and beef-tea, lemonade or barley-water, stimulants if needed, alkalies, bicarbonate of potash or soda, or the citrate or tartrate of potash or soda, combined with citric acid or lemon-juice, opium or morphia, salicylate of soda, salicylic acid, salicin, salol, bromide of ammonium, quinine, iodide of potash—are remedies that are used. Hot-air or vapor baths are of service. The joints may be rubbed with olive oil or chloroform liniment or covered with hot fomentations, or blisters may be used. Treat complications. Convalescence must be carefully watched. Quinine as a tonic and to prevent relapses. DISEASES OF THE BLOOD-VESSELS. What diseases of the arteries occur in children ? None. Sometimes anomalies are met with as regards the size of vessels or their complete absence. Describe nsevus vasculosus. Naevus vasculosus, arterial telangiectasis, or erectile tumors, consist of a dilatation of the capillaries of the skin or subcuta- neous tissue, and are usually situated somewhere about the face. On the skin the tumor is red, rough, and irregular; in the subcu- taneous tissue it is doughy and the skin may be normal or perme- ated with vessels. These tumors are generally congenital: very small at birth, they grow rapidly, sometimes attaining a large size. In some cases they will shrivel up and disappear without any treat- ment. Subcutaneous tumors disappear on pressure, sometimes pul- 72 ORGANIC DISEASES. sate and have a buzzing sound, and during crying grow tense and large. What is the treatment of naevus vasculosus ? The cutaneous naevi can be removed by vaccination, which is done by puncturing the excrescence with a needle, and after the slight hemorrhage has stopped smearing the surface with vaccine virus. The course is the same as in ordinary vaccination. This fails where a child has been vaccinated. Other treatment used is puncturing with needles and rubbing with magnesia, oxide of zinc, etc., or with irritating ointments. In the subcutaneous variety pressure, the ligature, or galvano-cautery are the methods resorted to ; the last is probably the most successful. Thrombi are frequently found in the sinuses of the brain in chil- dren at autopsies, but they have slight clinical importance, as it is often uncertain whether they formed before or after death. DISEASES OF THE NOSE AND THROAT. Describe the general symptoms pertaining to diseases of the nose. Snuffling, snoring sleep, evidences of obstruction, as mouth- breathing, nasal voice, a dull expression of face, discharge, some- times attended with marked odor. What is epistaxis? and what are the causes? Epistaxis, or nose-bleed, is a hemorrhage more or less profuse from some portion of the nasal cavities. It is due to the rupture of the capillaries in the mucous membrane, which is generally caused by injury or ulceration. The general causes are hemor- rhagic diathesis, plethora, scrofulosis, chlorosis, cardiac and pul- monary affections, Bright's disease, acute febrile conditions, and it may be " vicarious " in girls at puberty. What are the symptoms ? The hemorrhage itself, appearing either in drops (stillicidium sanguinis) or in a stream (rhinorrhagia). The quantity varies ; as a rule it is small and harmless. Children under three or four'are rarely affected, and then from injuries. Sometimes the blood flows back into the pharynx and is swallowed, causing haematemesis or black, bloody stools. In febrile conditions or venous congestions or when menstruation is due, the hemorrhage is often beneficial' DISEASES OF THE NOSE AND THROAT. 73 in chlorosis it tends to aggravate the trouble. Severe hemorrhage may give rise to profound anaemia. What is the treatment of epistaxis ? Check the hemorrhage. This can be accomplished by pledgets of ice in the nose and ice to the nape of the neck; astringents, as the persulphate of iron, in the nose; if the bleeding point can be seen, touching it with nitrate of silver, solid stick"; tamponing both the anterior and posterior nares. Treat the cachexia. Define coryza, and give its causes. Coryza—rhinitis or catarrh—is a catarrhal inflammation of the mucous membrane of one or both nares, attended with swelling and redness. The causes are mechanical and chemical irritants, changes of tem- perature, infection, and cachexia. Describe the symptoms. The mucous secretion of the nose is largely increased: at first it is thin and liquid, but soon becomes thickened, tenacious, and opaque, in chronic cases inspissated, forming crusts. It is alkaline, and may cause erosion from the amount of soda it contains. If the inflammation extends to the frontal sinuses, fever and pain in the sinuses are present. It may extend through the lachrymal tube, producing conjunctivitis; through the Eustachian tube, producing otitis media; through the larynx into the bronchi, producing capil- lary bronchitis; or through the oesophagus into the stomach and intestines, producing catarrhal gastritis and enteritis. Each of these complications will be manifested by their individual symp- toms. Examination of the nose shows the mucous membrane swollen and congested. The acute form generally terminates in complete recovery in from two to four days; sometimes in cachectic children or from repeated attacks it becomes chronic. It is only in new-born or nursing children that any danger need be apprehended, and here it is due to the occlusion of the nares, interfering with the nursing from the necessity of breathing through the mouth. Give the treatment of coryza. Protect the body from atmospheric changes; generous diet; stimulate the skin by baths and friction; quinine, in some cases opium; soothing applications to the nose; cocaine, menthol, and 74 ORGANIC DISEASES. camphor in benzoinol will be found useful. Treat the complica- tions and cachexia on general principles. Define nasal polypus, and give the causes. A nasal polypus is a new formation in the nose. Two forms are found: a soft, gelatinous tumor, called a mucous polypus, which springs from the surface ; and a firm, hard tumor, called a fibrous polypus, which arises from the submucous tissue or perichondrium. Both are pediculated. If large, they take the shape of the cavity and may hang into the pharynx. They never occur in young chil- dren, and are much rarer than in adults. The causes are as yet unknown. Give the symptoms. While the growths are small there are no symptoms, but when they occlude the nostrils the mouth remains open, the voice is nasal, there is snuffling, smell and taste will be decreased, and there is a continual desire to blow the nose, with increased discharge. The growth can often be seen. The fibrous form may occlude the lachrymal canal and Eustachian tube. Mucous polypi may return after removal; the fibrous forms, if thoroughly removed, do not. What is the treatment of nasal polypus ? The treatment consists in the removal of the growth. The mu- cous polypus can often be removed with forceps: some form of snare is best for either form, though the galvano-cautery is useful in the fibrous variety. The hemorrhage is slight and stops spon- taneously, or may be checked by pieces of ice in the nose. Describe foreign bodies in the nose. Little children have a natural proclivity for putting small objects into the nose, and all sorts of things have been found in this location. Insects will sometimes enter the nasal cavities while the child is asleep, and the round-worm will wander into one of these orifices from the pharynx. If a child puts a foreign body into the nose, it instinctively attempts to remove it, with the result of pushing it farther back. The symptoms are pain and coryza, with an intensely foetid dis- charge if the body has remained for any time. In some rare cases there may be delirium, meningitis, and death. Sneezing will sometimes remove the body, or at least bring it into view, when it can be removed with forceps or a scoop ; in some cases DISEASES OF THE NOSE AND THROAT. 75 chloroform may be needed to quiet an irritable child or where the pain is excessive. Prolonged manipulations are hurtful. Splitting the nose should only be done in extremely urgent cases. Define catarrhal laryngitis, and give the etiology. Catarrhal laryngitis—inflammation of the larynx, pseudo-croup —is a catarrhal inflammation of the mucous membrane of the larynx, sometimes extending to the submucous connective tissue and muscles. The causes are changes of temperature, injuries, irritants, influ- enza, and it may occur as a complication in diphtheria, tonsillitis, measles, rheumatism, etc., and in erysipelas from spreading of the inflammation. Give the symptoms. There is a slight nasal and bronchial catarrh during the day, but the child plays as usual, has a good appetite, and goes to sleep without causing any anxiety; he may cough a little in his sleep, and perhaps snore. Suddenly in the early morning hours he awakens, gasping for breath, with a hoarse, stridulous, barking cough, rough, noisy, stridulous breathing, congested countenance, blue lips, face bathed in perspiration, extreme restlessness (in very young children), with head thrown back on the pillow ; older chil- dren will sit up in bed grasping the knees to fix the pectoral mus- cles. After an hour or two the paroxysm passes and the child drops to sleep, though the croupy breathing and short cough con- tinue. A second attack in the same night is rare. In the morning the child arises and eats his breakfast as usual; during the day the bronchial symptoms continue, and the attacks recur the next and the succeeding nights for from three to eight days, but with decreasing intensity. The pulse is increased during the attack, but fever, with malaise, etc., is not present. The paroxysms never occur in the daytime, probably because the child, being awake, can remove the mucus from the larynx by coughing. Recovery is the rule. It must be differentiated from diphtheritic laryngitis. What is the treatment of catarrhal laryngitis ? An emetic, with a warm bath and inhalations of steam, will often cut short the paroxysms. Afterward warm clothing, an easily- digested diet, and regulation of the bowels are indicated. Hot fo- mentations or the ice-bag to the throat, hot drinks, astringent sprays, 76 ORGANIC DISEASES. and aconite, quinine, bromide of potassium, belladonna, and, for the cough, opium and ipecac. Some extreme cases may require tra- cheotomy. Define laryngismus stridulus, and give the causes. Laryngismus stridulus—suffocative laryngismus, spasmodic croup, spasmus glottidis, spasm of the larynx, etc.—is a complete or incom- plete spasmodic closure of the glottis or vestibule of the larynx. It may be acute or chronic. The exciting causes are nervous, as fright, hysteria; it also occurs during acts of swallowing, coughing, crying, depressing the tongue, etc. The general causes are sex (boys are attacked more frequently than girls); age (occurs in children from six months to three years old); heredity (children of nervous parents); craniotabes ; digestive disturbances. Give the symptoms. A child, previously in normal health, suddenly stops breathing, throws back its head, and tears at its throat with its hands. The mouth is slightly open and produces snapping sounds; the coun- tenance is anxious and congested; the eyes are set and protruding; the body is rigid, or the lower limbs hang limp and powerless. After half a minute to a minute a few whistling inspirations, fol- lowed after a pause by a whistling expiration and normal breathing, end the paroxysm. There may be but the one paroxysm, or several may follow in quick succession. Convulsions may occur if the dis- ease has lasted for some time, in which the upper extremities are strongly flexed and the thumbs adducted, the lower extremities ex- tended and the toes abducted ; opisthotonos may occur. Between the paroxysms, if these have been slight, the child enjoys its nor- mal health; if severe, it is exhausted and irritable, and suffers from anorexia, emaciation, and febrile conditions. The child may die in its first attack or the disease may run through several months, the paroxysms increasing in frequency and intensity, the child finally dying in a paroxysm or from some complication, of which lobular pneumonia is the most frequent; or the attacks may gradually decrease and recovery occur: such a termination is extremely rare, and the children are delicate for a long time. The prognosis is generally unfavorable. What is the treatment of laryngismus stridulus ? During the attack dash cold water in the face, slap the back and DISEASES OF THE THYROID GLAND. 77 buttocks, elevate the epiglottis with the finger, practise artificial respiration and catheterization of the larynx. After the attack has passed, hot baths, hot fomentations to the neck, emetics, and anti- spasmodics to prevent recurrence. Between the paroxysms seek the cause and remove or treat it. Cod-liver oil, alone, or with phosphorus for rickety children ; the bromides for choreic and ner- vous children ; vegetable tonics and regulation of the diet for those who are run down or dyspeptic. Change of air, stimulation of the skin by a daily cold bath, and avoidance of all excitement will be found of service where there is no assignable cause. Describe paralysis glottidis. Paralysis of the glottis is a rare affection in children. It is pro- duced by disease of the central nervous system or from pressure from enlarged lymphatic glands upon the pneumogastric and recur- rent laryngeal nerves. The symptoms are labored, noisy breathing, attended with cough on deep inspiration, with a hoarse voice or complete loss of voice. The disease is chronic, and is attended with bronchitis; sometimes tuberculosis develops with fatal results. The treatment is by cod-liver oil and, locally, iodine, belladonna ointment, etc. to the enlarged glands, to reduce their size if pos- sible ; if these show a tendency to suppurate, poultices and free incision ; in severe cases extirpation of the glands by surgical operation. DISEASES OF THE THYROID GLAND. What diseases affect the thyroid gland? Inflammatory processes from injuries; goitre, congenital, cystic, and hypertrophic. Describe these conditions. In each, enlargement of the gland takes place. The simplest form is where an injury has affected the gland and is amenable to general treatment. The congenital form, where children are born with goitre, is attended with asphyxia or marked interference in breathing at birth; but the growth generally disappears after a few weeks without any treatment. In the hypertrophic form a single lobe or section of a lobe may be involved, the symptoms depending upon the pressure exercised by the enlargement, and affecting only the parts adjacent thereto; 78 ORGANIC DISEASES. in some cases the enlargement surrounds the oesophagus and trachea, producing serious results. In the cystic form the vesicles become enlarged into cysts, with softened walls and containing a thickened yellowish fluid. What is the treatment? Tincture of iodine will often cause the growth to disappear or decrease in size. In some extreme cases extirpation or evacuation of the cyst-contents and injection with iodine may be required. General tonic treatment—cod-liver oil, iron, etc. DISEASES OF THE THYMUS GLAND. What diseases affect the thymus gland in children? Hemorrhages are sometimes found post-mortem ; their cause is uncertain. It was supposed that asthma was in some cases due to pressure of the enlarged gland, but this is regarded as very doubt- ful. The most frequent affections are tuberculosis and cancer. In the former the lesions are found elsewhere, and it is only at the autopsy that the gland will be found diseased. In carcinoma symptoms affecting the heart, lungs, and large blood-vessels will be present, and dulness on percussing the upper portion of the thorax in front. The treatment is that of the disease causing the enlargement. DISEASES OF THE BRONCHI AND LUNGS. Define bronchitis, and give the synonym, varieties, and causes. Bronchitis is a catarrhal inflammation of the mucous membrane lining the bronchial tubes. Synonym.—Bronchial catarrh. Varieties.—Acute, subacute, chronic, and capillary. Causes.—Predisposing : climatic . and temperature changes, im- proper clothing, depleted system, rickets, tuberculosis, and chronic diseases generally ; exciting : irritants, as gases, dust, foreign bodies, exposure to drafts, sudden chilling of the body surface, contagion, as influenza, extension of nasal catarrh, the exanthemata. Describe the pathological appearances. An increase of mucous secretion, which is thin and transparent, or thick, tenacious, and white, gray, yellow, or brown in color, de- pending upon the severity and length of the disease. The mucous membrane is thickened and pink or red in color, depending upon DISEASES OF THE BRONCHI AND LUNGS. 79 the severity of the inflammation; the blood-vessels are injected. In the exanthemata similar lesions are found on the bronchial mucous membrane as upon the skin. The disease may involve only the larger bronchi, or both the large and small, only one lung or both. A lung affected with bronchitis does not collapse when cut open. Give the symptoms, prognosis, and complications. Pain behind the sternum*, in severe cases through the diaphragm after coughing; general malaise; fever, the height depending upon the severity of the attack; cough, at first short, hacking, frequent, and dry—later, violent and attended with the discharge of mucus, which in young children is swallowed; emaciation and dyspnoea in severe and protracted cases. In the chronic form there is no fever; the chief subjective symptom is the cough, which is paroxysmal and attended with the expectoration of dark-colored, foetid sputa. In the capillary form there is always fever, some- times very high, marked dyspnoea, cyanosis, prostration, chilliness, sometimes convulsions, and cough of mild or severe form. The physical examination gives the most satisfactory results. Inspec- tion gives negative results, except in capillary bronchitis, where the increased number of respiratory movements is marked; per- cussion is negative in all forms; palpation reveals the vibrations induced by the rales, but auscultation is of most service. This, in the acute and subacute forms, reveals at the beginning dry, sonor- ous, and sibilant rales, which change their position ; later large and small mucous rales ; in the chronic form the mucous rales are much larger and more abundant, but sonorous and sibilant are also heard ; in the capillary form crepitant rales are heard, generally most abundant posteriorly, and the dry and moist rales at other portions of the lungs. Acute and subacute bronchitis may last from a few days to two weeks ; chronic may last for years; capillary is of short duration, though it may run into pneumonia. The prognosis is generally good: death may occur from suffoca- tion, exhaustion, or complications. The complications are pneumonia, emphysema, acquired atelec- tasis, etc. Give the treatment of bronchitis. In the acute and subacute forms in very young children mild counter-irritants to the chest, as camphorated oil or turpentine, 80 ORGANIC DISEASES. alone or combined, or Stokes's liniment; an occasional emetic, as ipecac, to remove the mucous accumulation from the tubes, anti- spasmodics, etc. In older children counter-irritation and ipecac, paregoric, tolu, squills, ammonium chloride or carbonate, etc. In all cases nourishing diet, stimulants, tonics, rest in an equable temperature, and protection of the surface. In the chronic form terebene or some of the turpentine derivatives, iodide of potassium, anodynes, or possibly nauseant expectorants, cod-liver oil, iron, quinine, tonics, change of air, stimulation of the skin, woollen clothing, nourishing diet. In the capillary form counter-irritation to the chest by the mustard bath, followed by flaxseed jacket- poultice ; absolute rest in bed ; frequent change of position ; aconite if fever runs high ; emetics, ipecac or apomorphine, if quick action is needed ; alcohol, strychnine, oxygen in threatened collapse ; later, nauseating expectorants with ammonium chloride, iodide of potash, etc.; milk diet until convalescence, then highly nutritious; cod- liver oil, change of air. Define pneumonia, and give the causes. Children are affected with both lobar and lobular pneumonia, but the most frequent form, especially in very young children, is the lobular or broncho-pneumonia. Pneumonia is an inflammation of the vesicular structure of the lungs, attended with an exudation into the alveoli, rendering them impervious. The causes are all things that lower the tone of the system, ex- posures to changes of temperature, irritants, existing disease, as the exanthemata, pertussis, diphtheria, bronchitis, influenza, etc. In the new-born it is often pyaemic. The dorsal decubitus is said to induce it. Give the pathology of pneumonia. Lobar pneumonia presents the stages of red and gray hepatiza- tion. The croupous exudation fills the cavities of the alveoli, shut- ting out the air, preventing the lung from collapsing, and giving the cut surface a dry, red, and granular appearance; later, the col- oring matter of the blood-corpuscles in the exudation disappears, cells are formed from the exudation and the alveolar walls, and the color changes from red to gray: this change continues until the exudation becomes milk-like in consistency, and is absorbed, and DISEASES OF THE BRONCHI AND LUNGS. 81 resolution occurs or abscesses or indurations appear. Lobar pneu- monia in children never degenerates into tuberculosis. Lobular* pneumonia is catarrhal, not croupous, in character, and has no stages, as there is no hepatization. The lobules are felt as hard lumps in the lung-tissue; on section they appear bluish red, the color shading off into the surrounding tissue ; the alveolar walls are thickened, and yield a reddish, slightly frothy secretion ; the affected lobules sink if thrown in water; the tissue surrounding the lobules is emphysematous. Evidences of catarrhal bronchitis are also present. If the affected lobules are near the surface of the lung exudations occur on the pleura. Describe the symptoms of pneumonia. Lobular pneumonia commences insidiously as a complication of bronchial catarrh : the cough gets worse, and a fever, mild at first, but intermittent and growing worse until it becomes continuous, appears. The pulse is greatly increased, to 180 or 200; respira- tions are increased, sometimes to 90; they are shallow and attended with recession of the intercostal spaces and movements of the alas nasi, and with a facial expression of suffering. Lobar pneumonia is generally ushered in with a convulsion and extreme prostration ; temperature high and pulse rapid at the start; respiration rapid and shallow, panting in character; movements of alae nasi; face anxious, flush over the malar bones ; cough short and hacking during the first stage, absent or nearly so during the second stage, returns in the third stage, with free expectoration in older children; anorexia, thirst, sometimes diarrhoea, urine de- creased ; the cry is low, moaning, and interrupted; if pleurisy complicates there will be evidences of pain, especially on cough- ing. The physical signs in lobular pneumonia are negative, except the auscultatory ; crepitant rales are heard at the seat of the pneu- monia, and the signs of bronchial catarrh in the other portions of the lungs. In lobar pneumonia over the affected area inspection gives decreased motion and exaggerated on the opposite side; palpation gives increased vocal fremitus, percussion dulness, and on sound side increased resonance ; auscultation gives high-pitched breathing and slight crepitation at the beginning—later, as the consolidation increases, marked bronchial breathing only is heard; then as reso- lution begins the crepitant rale reappears, followed by larger moist 6—D. C. 82 ORGANIC DISEASES. rales and normal vesicular breathing. The sputum, if the child is old enough to expectorate, has the same appearances as in the adult, but infants and most young children swallow the sputum. Lobar pneumonia runs through its three stages in from six to nine days ; lobular pneumonia is generally more rapid, though it may seem longer from the coincident bronchitis. Prognosis.—Children under two bear lobar pneumonia badly; older children go through the disease equally as well as adults. Lobular pneumonia is peculiarly fatal, as the children are already debilitated from the preceding disease. An unfavorable symptom is swelling of the veins on the back of the hands. What treatment is indicated in pneumonia? The bronchitis preceding lobular pneumonia requires prompt and energetic treatment to prevent, if possible, the pneumonia from developing. When either form of pneumonia develops, a flaxseed jacket-poultice, large enough to completely surround the chest and come up over the shoulders, and as hot as can be borne by the nurse's cheek, is most agreeable to the patient, and will hasten the stage of resolution : such a poultice, if an inch thick and put in flannel, will remain hot five to six hours; it should be pinned down the front or tied with tapes. Iced cloths, the ice-bag, or ice-water coil can be used if preferred. Stokes's liniment or the camphorated oil-and-turpentine liniment is of service at the beginning, before the physical signs are positive, and during resolution ; also at the commencement a mustard bath. The condition of the emunctories should be corrected if needful: as a general rule, a dose of calomel puts the system in a better condition to fight the disease. The diet should be concentrated and nutritious, and milk seems to meet these indications; if it disagrees it can be treated with lime-water or barley-water or peptonized. Alcohol will be needed in nearly every case, in some from the start, but the condition of the pulse must guide us in its use. Of drugs few are needed : uncomplicated cases will recover without any medication ; for irritable cough, opium or some of its derivatives, codeine, morphine, etc.; for a flag- ging heart, digitalis, carbonate of ammonium, strophanthus, sparteine, alcohol, oxygen ; for a high temperature and to relieve the conges- tion of the pulmonary mucous membrane, aconite, veratrum, liq. ammon. acetatis. A good all-round mixture is aconite, sweet spirits of nitre, spirits of Mindereri, paregoric, syrup of ginger, and water : in this mixture the aconite should be in small doses, and its effect DISEASES OF THE BRONCHI AND LUNGS. 83 upon the heart watched : to a child one year old not over one-tenth of a minim of the tincture every one to two hours. Cough mix- tures are of no service. Convalescence requires cod-liver oil, iron, increased nutrition, change of air. Define acquired atelectasis of the lungs, and give synonyms and causes. Total or partial absence of air from the alveoli. It may be lim- ited or extensive. Synonyms.—Pulmonary collapse ; Apneumatosis. Causes.—Compression due to rachitic chest deformities, pleural accumulations, hydropericardium, tumors, obstruction of a bron- chial tube, lobular pneumonia. Give the pathological appearances. In a mild form there is merely increased density, but generally the alveoli are obliterated, and at first vascular; soon the density increases to a leathery consistency, of a brown or gray color and liver-like appearance. The lung surrounding these atelectatic spots is emphysematous. What are the symptoms and prognosis? Dyspnoea, more or less cyanosis of fingers and face, rapid, feeble pulse, feeble voice and cough, cold extremities, prostration. The physical signs: percussion negative, unless the disease is exten- sive ; auscultation gives fine crepitant rales. The symptoms of bronchitis or pneumonia if these are present. Prognosis.—The disease is chronic, and the prognosis depends upon the extent, severity, and duration of the attack : it may be recovered from, or it may terminate fatally in a shorter or longer time. Give the treatment of acquired atelectasis. Nutritious diet, best hygienic surroundings, alcohol, cod-liver oil, counter-irritation to chest, heart stimulants; in extreme cases emetics, stimulants, oxygen. Describe pulmonary emphysema in children. Pulmonary emphysema, or dilatation of the alveoli, in children is vesicular and unattended with rupture of the alveolar walls. It is most generally due to pneumonia, atelectasis, or tuberculosis. The affected lung does not collapse, floats in water, feels like an air-cushion, and has a yellowish-gray color. It is produced by an 84 ORGANIC DISEASES. accumulation of air in the cellular tissue. There are no symptoms aside from increased respiration. Barrel-shaped chest does not occur. The treatment is solely tonic. Define pulmonary oedema, and give the cause and pathology. Pulmonary oedema is an effusion of serum into the air-vesicles and interstitial tissue of the lungs. Causes.—Cardiac, pulmonary, and renal diseases, measles, scarlet fever, and miliary tuberculosis. The affected lung does not collapse, is yellowish-gray in color, pits on pressure, crepitates ; a section has a smooth, glistening surface, from which exudes a frothy red or yellow serum. What symptoms attend this condition? Extreme dyspnoea, suffocative attacks, voice low and indistinct, cough loose, pulse small, but not rapid. Physical Signs.—Percussion often unsatisfactory, slight dulness in some cases; auscultation gives moist, sibilant rales over the affected area; sonorous rales in the large bronchi which disappear on coughing. Pulmonary oedema is usually bilateral. The prognosis depends upon the cause ; oedema due to cardiac and chronic pulmonary disease is generally fatal. Give the treatment of pulmonary oedema. It is generally that of the causative disease, but diuretics and diaphoretics are indicated. If the dyspnoea becomes extreme, an emetic will often relieve it. In older children dry cups to the back will be of service. Describe haemoptysis in children. Haemoptysis is rare in children, except as a complication of per- tussis or tuberculosis. The blood always bursts from the mouth and nose in a stream. In pertussis it is a question whether it comes from the lungs or the larynx. The treatment is symptomatic and that of the disease causing the hemorrhage. Describe pulmonary hemorrhagic infarction in children. It always occurs as a complication of purpura, tuberculosis, and cardiac diseases. The infarctions are generally located at the roots of the lungs: they appear as small, distinct, dark-red spots ; a sec- tion is dry, smooth, and granular, and yields on pressure a bloody DISEASES OF THE BRONCHI AND LUNGS. 85 fluid containing fine blood-coagulae; the bronchi adjoining the in- farctions are filled with coagula. The symptoms are indefinite, and resemble those of broncho-pneu- monia. Recovery may occur from absorption of the coagula, or gan- grene of the lung may develop, but the prognosis is generally grave. There is no treatment aside from that of the primary disease. Define gangrene of the lungs, and give the causes and pathology. Gangrene of the lungs is a putrefactive disorganization of the lung-tissue. Causes.—Foreign bodies, traumatic pneumonia, pyaemia, noma, pulmonary infarction, exanthemata, typhoid fever. Pathology.—The gangrene may be diffused or circumscribed : in the diffused form a brown, putrid slough spreads over a large por- tion of the lung, and the tissues become liquefied and infiltrated with a frothy, flocculent, putrid ichor. This condition rarely occurs alone, but is associated with the circumscribed form. In the latter a small portion of the lung is affected: at this point a greenish- black moist slough appears; this slough becomes detached and lies in a gangrenous excavation surrounded by gangrenous ichor, or it dissolves into ichorous fluid surrounded by a sloughing excavation with ragged walls. Circumscribed gangrene occurs mostly on the pleural surface of the lung, and if the detached slough drops into the pleural cavity, it will set up pleuritis and pneumothorax. Hemorrhage from rupture of the blood-vessels passing through the gangrenous cavity sometimes occurs. Give the symptoms and treatment of gangrene of the lungs. Emaciation, often extreme, increased respiration, small, rapid pulse, paleness of skin, prostration, foetor of breath, cough with very offensive expectoration, hemorrhage if a blood-vessel ruptures, sweats, hectic, and delirium in severe cases, followed by death. The physical examination gives circumscribed dulness, bronchial breath- ing, and sibilant and crepitant rales. The treatment in severe cases is of little service. The indications are nourishment, stimulants, tonics, anodynes, and disinfectants— carbolic acid, creasote, thymol, eucalyptol, turpentine, chlorine, ace- tate of lead, etc.; during convalescence cod-liver oil, iron, change of air. Describe periodic nocturnal cough in children. This is a very rare affection. It occurs most often in tuberculous 86 ORGANIC DISEASES. cases, though it may be present in healthy subjects. The child has no paroxysms during the day, but every night, for weeks and months sometimes, it will awaken and cough severely for two or three hours: there is no expectoration, and from sheer exhaustion the child finally falls asleep. In protracted cases the children suf- fer from anorexia and anaemia. In the treatment nourishment, tonics, fresh air, and proper cloth- ing are of most service; antispasmodics, anodynes, and narcotics give only negative results. DISEASES OF THE PLEURA. Define pleurisy, and give the varieties and causes. Pleurisy, or pleuritis, is a partial or general inflammation of the visceral or parietal pleura, or both. It may be acute, subacute, or chronic with effusion; with pus (empyema) or dry. The causes are pneumonia, bronchitis, pericarditis, sudden changes of temperature, the exanthemata, rheumatism, pyaemia, abscess, etc. What are the pathological appearances? In pleurisy before birth or in the new-born the surface of the pleura is covered with a thin whitish or grayish fibrinous exudate that is easily removed, and in the sac is a small quantity of yellow serous effusion. In older children, in the acute form, there will be reddening of the pleura, roughening of its surface from fibrinous exudation, and adhesions between the two surfaces if this exudate becomes organized; in the subacute form the conditions are similar but more intense, and a more or less abundant serous effusion, con- taining flocculi of lymph, occupies the cavity, displacing the lung and adjacent organs. As this effusion disappears adhesions form, sometimes interfering with the proper expansion of the lung. In the chronic form the sero-fibrinous effusion of the subacute variety undergoes purulent degeneration from excessive cell-proliferation from the pleural surface, or plastic material thrown out on the pleural surface undergoes transformation into pus, or a sero-puru- lent fluid accumulates in the cavity. In some rare cases of sup- purative pleurisy the liquid portion of the pus is absorbed and the solid parts become cheesy and calcified. Describe the symptoms of pleurisy. Fever, chill in older children, rapid pulse, anorexia, thirst, insom- nia, restlessness, pain which disappears as the fluid accumulates. DISEASES OF THE PLEURA. 87 cough short and dry, increased respirations, shallow in the acute, labored when effusion occurs, nausea, sometimes vomiting, consti- pation. Physical Examination.—Inspection shows diminished action on the affected side in acute pleurisy: when effusion occurs there will be distension of the chest, bulging of the intercostal spaces, and displacement of the heart and viscera; percussion gives negative results in the acute form: when the effusion appears, flatness over its site, increased resonance at other parts of the lung ; auscultation will give friction-sounds in the acute form, and at the level of the fluid, when effusion occurs, absence of all respiratory sounds below the level of the fluid, bronchial breathing and bronchial catarrh in the lung above the fluid. The hypodermic needle will determine the character of the fluid. Give the prognosis. As to life, it is pretty good, but deformities may occur from absorption of pus and recession of the chest-wall, or from sinuses perforating the chest-wall, or from adhesions displacing the thoracic organs. It will aggravate diseases that it complicates, and may hasten a fatal termination. What is the treatment of pleurisy? In acute pleurisy opium to allay the pain, rest in bed, stimulants, nourishment, and make the patient comfortable ; counter-irritation to the chest. If the-fluid is serum, rest, mild counter-irritation, and salines are about all that is needed; the fluid will disappear without aspiration; empyema requires free incision and drainage. Resection of the rib is not always necessary; washing the cavity is not necessarily indicated unless the pus has a foetor. General tonic treatment during convalescence. Define hydrothorax, and give its etiology. Hydrothorax, or dropsy of the pleura, is a non-inflammatory ac- cumulation of serous fluid in the chest. The causes are general dropsy from cardiac and renal disease and intermittents. It is most usually bilateral. Give the symptoms and treatment of hydrothorax. Dyspnoea, interference with the action of the heart and with oxi- dation of the blood. Anasarca in cardiac and renal troubles precedes the symptoms of hydrothorax ; the intermittents have oedema of 88 ORGANIC DISEASES. lower extremities, enlarged spleen, and the peculiar cachectic appear- ance. Physical examination gives bulging of the intercostal spaces, displacement of apex-beat of the heart, displacement of the lungs, liver, etc., dulness which changes by changing the position of the fluid. It is distinguished from pleurisy with effusion by the absence of pain and friction-sounds and the fact that it is usually bilateral. The prognosis is generally unfavorable. The treatment should be highly nutritious and sustaining, and attempts should be made to remove the fluid by acting on the kid- neys and skin. During convalescence quinine and iron. DISEASES OF THE BRAIN. Give the definition, synonyms, and causes of acute hydrocephalus. Acute hydrocephalus is an inflammation of the meninges of the brain, characterized by the presence of tubercles. Synonyms.—Tubercular meningitis ; Basilar meningitis. Causes.—Predisposing : the tubercular diathesis ; exciting : the exanthemata, diarrhoea, chronic affections of the ear, skin, and scalp, bad food and hygiene, injuries. Describe the appearances post-mortem. The dura mater is rarely affected. The pia mater may be con- gested or pale and infiltrated with serum, fibrin, or pus. Small gray miliary tubercles will be found along the vessels on the con- vexity, but most abundant at the base; the inflammation is most marked at the base, attended with a turbid serous effusion or a thick, yellow, semi-plastic layer; the ventricles are distended with a serous effusion, which flattens the convolutions and causes oedema- tous softening; the ventricular membrane is thick and opaque. Evidences of tuberculosis will be found in other parts of the body. What are the symptoms of acute hydrocephalus ? The premonitory symptoms, which usually last from two to three weeks, are—progressive emaciation, pale face, lustrous eye, drowsi- ness, loss of interest in former amusements, moroseness, peevishness; sleep at night is restless and attended with sudden, frightened cries ; anorexia, constipation, vertigo, unsteady gait, abdominal pain ; slight fever may be present, especially in the evening. As the disease advances these symptoms become aggravated. As effusion commences there will be vomiting, constipation, head- ache, fever, retracted abdomen, slow irritable pulse, irregular breath- DISEASES OF THE BRAIN. 89 ing, pupils contracted, may be strabismus; drowsiness alternates with excitement; mild delirium, cephalic cry, thumbs flexed on the palms; the finger-nail drawn over the skin leaves a red line. After a few days more profound symptoms appear: the head is retracted ; the muscles at back of neck become rigid ; sometimes opis- thotonos ; pupils unequal; pulse slow, irregular, and intermittent; partial or general convulsions ; ptosis, strabismus, local paralysis, or complete hemiplegia; constipation, ischuria, or involuntary evac- uations ; difficult deglutition ; respirations irregular, sighing, and Cheyne-Stokes; anorexia; temperature may be subnormal. Apparent recovery may now occur, but is quickly followed by coma, pulse very rapid and irregular, pupils dilated, fontanelle prom- inent ; paralysis becomes permanent; eclampsia; breathing, sigh- ing and stertorous ; involuntary evacuations ; cold sweats ; abdomen tympanitic, subsultus tendinum; rise of temperature, cyanosis. Death due to coma or asphyxia during a convulsion. What are the prognosis and differential diagnosis? The prognosis is bad : death may be expected in from sixteen to twenty-one days after the initial symptoms. It must be differentiated from typhoid fever, simple meningitis, gastro-enteritis, Bright's disease, and infantile remittent fever. Give the treatment of acute hydrocephalus. Prophylaxis in children of tubercular parents. For the disease itself palliatives and methods that will prolong life, diaphoretics and diuretics, nutritious diet, avoidance of light and noise, anodynes and opiates, ice-cap; control the convulsions; antipyretics if the fever runs high. Define acute meningitis; give its causes and pathology. Simple or purulent inflammation of the meninges, which fre- quently extends to the brain-substance. Causes.—Injuries, extension of inflammation from adjacent parts, as ear, nose, eye ; erysipelas and exanthemata. If the dura mater is involved, the inflammation is circumscribed, and presents on its surface a layer of fibrinous or purulent exudation ; in chronic cases the dura mater is thickened and thrombi form in the sinuses; the inflammation is generally on the pia mater, and penetrates into the convolutions and sulci; it is most marked on the convexity; may extend down the spinal cord; the exudation is yellow or yel- 90 ORGANIC DISEASES. lowish-green, serous, fibrinous, or purulent; if serous and at the same time rich in fibrin, it clings to the pia mater. Give the symptoms and treatment of acute meningitis. Aromiting, constipation, slow pulse, irregular breathing, head- ache, retracted abdomen, fever, delirium, convulsions, emaciation. These symptoms develop rapidly, and the disease runs its course to a fatal termination in from three to six days, thus differing from tubercular meningitis, which it so closely resembles. Recovery may occur, in which case the symptoms gradually abate, but convalescence is protracted and followed by mental weakness. The treatment comprises absolute rest in a darkened room, ice-cap, anodynes and opiates, and mercurials to salivation.. During con- valescence general tonic treatment and absolute mental rest. Describe insolation. In insolation, or sunstroke, the meninges are congested, there is increased effusion into the ventricles, and the brain-substance is softened. The patient complains of intense headache; delirium follows in a few hours ; there are excessive muscular power, flushed face, injected eyes, contracted pupils, pulsation of carotids, hot skin, dry tongue, intense thirst, rapid pulse. If death does not occur within the first few hours, the symptoms gradually abate, the child falls asleep, awakens conscious, and in two or three days health is restored. The treatment consists in the application of the ice-cap, sinapisms to the extremities, stimulating enemata, or cathartics. The prognosis is good. Define cerebral anaemia, and give the causes and pathology. Cerebral anaemia is a condition in which there is a deficiency in the quantity or quality of the blood in the capillaries of the brain. Causes.—Hemorrhages, exhausting discharges, diarrhoea, im- paired nutrition, general anaemia. Pathology.—The brain is pale, soft, and watery; the meninges are infiltrated with serum; sometimes the ventricles contain a nor- mal amount of fluid or they are distended. Give the symptoms and treatment of cerebral anaemia. The child rolls its head or bores it into the pillow, plucks at its head, hair, and ears, scratches its face, grows dull and apathetic • DISEASES OF THE BRAIN. 91 the eyes are half closed and rolled up; the arms are flexed and rigid; thumbs flexed on the palms ; the legs flexed or extended and rigid ; the muscles at the nape of the neck contracted ; tetanic convulsions toward the end; vomiting; anterior fontanelle de- pressed ; cranial bones overlap in very young children; slight anorexia, sometimes greediness ; pulse rapid, respirations increased : incessant crying, changed toward the end to moans. Treatment.—When due to hemorrhage invert the patient, dash cold water in the face, give ammonia, bandage the extremities, transfuse, stimulate; when complicating some disease, treat that, and stimulate the heart, increase the nourishment, and treat the symptoms. Give the definition, causes, and pathology of chronic hydro- cephalus. Chronic hydrocephalus is a cerebral dropsy. The causes are atrophy, or imperfect development, of the brain, chronic passive hyperaemia, weakness of the vascular walls, occlu- sion of one or both lateral sinuses, tuberculosis, rachitis, syphilis, the exanthemata. Pathology.—Serous effusion into the ventricles or upon the sur- face of the brain ; the upper wall of the lateral ventricles may be ruptured ; the brain-substance is softened or toughened, the convo- lutions flattened ; in the congenital form the cranial bones are thin and the fontanelles and sutures wide open. The disease may be congenital or acquired: in the former the enlargement of the head may interfere with delivery. Give the symptoms and treatment of chronic hydrocephalus. The skull is enlarged, largest where the disease began in utero, dome-shaped, and elongated if some of the sutures have closed; the anterior fontanelle, if not closed, will be bulging and pulsate; the eyeballs protrude from pressure upon the superior orbital plate ; the superficial vessels of the scalp are prominent from interference with the circulation ; the face looks small and wizened. In the acquired form there will be fever, outcries, vomiting, headache, o-nashino- of the teeth, delirium, involuntary evacuations ; limbs paralyzed and contracted ; intelligence unimpaired in some cases, in others mental aberration and imbecility ; loss of vision, pupils dilated or contracted, anaesthesia of skin : convulsions usually pre- cede death. Death is due to the cerebral lesions, convulsions, col- 92 ORGANIC DISEASES. lapse, or intercurrent disease. The disease is chronic, and where the effusion is small may last for years. Treatment.—Careful feeding, attention to the clothing and hygiene. Cod-liver oil and general tonic treatment; calomel in small daily doses until purging becomes severe ; diuretics. Strap- ping the head and evacuation of the serous effusion are advocated by some, but the utility of these proceedings is doubtful. Describe encephalocele. Encephalocele is always congenital. It is due to improper development of the cranial bones and distension of the brain, causing prolapse. Its most frequent location is the occipital re- gion, though it may occur at the root of the nose, angle of the eye, anterior fontanelle, in the temporal region, and other localities. The tumor consists of skin devoid of hair, atrophied, and united to the pericranium and meninges ; it contains brain-substance and a large quantity of water. It may be pedunculated or have a broad base, and varies in size from a mere protuberance to that of a child's head. It may burst at birth or the child may live for years, but it interferes with the development of the brain, and such children are apt to be imbecile. The symptoms are purely nervous and due to pressure upon the tumor; they are eclampsia, stupor, and syncope. What treatment is indicated in encephalocele ? Protection of the tumor from injury. In some extremely large growths evacuation of the contents by repeated aspiration so modifies its size that protection is better obtained. An opera- tion for the reduction of the tumor may in some cases be indi- cated. Describe cerebral sclerosis. A rare affection in children. It may be circumscribed or general, a slight hardening or of cartilaginous consistency ; there may be atrophy and textural changes. It is produced by meningeal hemorrhage, purulent meningitis, and in the course of such acute diseases as scarlet fever, typhoid fever, etc. The symptoms in the circumscribed form are epilepsy, idiocy, neuralgias, etc. The treatment is purely symptomatic. Cures are rare, if pos- sible. DISEASES OF THE SPINAL CORD. 93 What cerebral neoplasms are most frequently met with in children ? Tubercles, carcinoma, and entozoa. Describe cerebral tubercles as found in children. They are round or oval, of large size, yellow color, and few in number. Their most frequent location is in the gray substance. They consist of yellow, lardaceous, tough, friable masses, without any cell-formation. The tissue surrounding them is vascular. They are easily removed. They sometimes break down and soften, the contents resembling pus. They are usually complicated with acute miliary tuberculosis, causing death. The prognosis is bad. Describe cerebral carcinoma in children. Extremely rare. The medullary form is most frequently met. It is usually of large size, and in one hemisphere only, or nodules are scattered through the brain-substance. It attacks both the gray and white substance. Its growth is rapid. Its pathological conditions are as in the adult. Prognosis bad. Describe cerebral entozoa in children. Extremely rare. Echinococcus and cysticercus cellulosae have been found. What symptoms attend these conditions? Sometimes none. In cases of tubercles there will be anorexia, vomiting, hemiplegia or paraplegia, amaurosis, deafness, cephalalgia, eclampsia, muscular contractions, and death. In cases of carcinoma there will be cephalalgia, restlessness, stut- tering, amaurosis, deafness, chorea, eclampsia, insomnia, paralysis, exhaustion, and death. In echinococcus and cysticercus there will be epilepsy, chorea, and the usual cerebral symptoms. The treatment is purely symptomatic. DISEASES OF THE SPINAL CORD. Define spinal meningitis, and give the causes and pathology. Spinal meningitis is an inflammation of the spinal meninges. Causes.—Injuries, vertebral caries, exposures to wet and cold, tuberculosis, epidemic cerebro-spinal meningitis, extension from cerebral meningitis, exanthemata, tetanus, chorea, etc. 94 ORGANIC DISEASES. Pathology.—The pia mater is thickened, opaque, hypernemic, and studded with ecchymoses ; the dura mater is congested ; the space between is filled with a sero-fibrinous or purulent exudation ; the exudation is most abundant posteriorly, but it usually envelops the cord; the spinal cord may be pale and anaemic or hyperaemic and softened ; the roots of the nerves are generally involved ; recovery may occur from absorption of the exudation, but the inflammation generally becomes chronic. Give the symptoms. When associated with cerebral meningitis the symptoms are less distinct than when it is uncomplicated. Severe pain in the back, at first located, later diffused; pressure increases ; patient keeps back rigid ; opisthotonos may occur ; chill, followed by fever, nausea, and vomiting ; convulsive muscular twitchings ; abdomen retracted ; constipation ; skin hyperaesthetic ; paralyses more or less complete, sometimes preceded by formication, tingling, and numbness; pro- fuse perspirations. The chronic form generally succeeds the acute : the symptoms are similar, but less severe. The acute form may terminate in death in twenty-four to thirty- six hours, but it usually lasts seven to ten days. Few cases re- cover ; convalescence is slow. The chronic form runs a protracted course, and death may ensue from exhaustion. It must be differentiated from myelitis, tetanus, muscular rheu- matism, cerebro-spinal meningitis. What is the treatment of spinal meningitis ? Rest, protection from noise and strong light, calomel, ice or counter-irritation to the spine, anodynes and narcotics, ergotin and belladonna, iodide of potash, warm baths, nourishment, stimulants if the heart flags. In chronic cases counter-irritants, warm douches, iodide of potassium and mercury; galvanic current to prevent muscular atrophy. Define acute myelitis, and give the etiology and pathology. Acute myelitis is an inflammation of the substance of the spi- nal cord. Causes.—Traumatism, exposure to extreme heat or cold, spinal meningitis, pressure from tumors or displaced vertebrae, the exan- themata, rheumatism, syphilis. Pathology.—The cord is enlarged, softened, discolored, engorged, and ecchymotic; its anatomical elements are destroyed; the adja- DISEASES OF THE SPINAL CORD. 95 cent membranes are congested and adherent to the cord ; later fatty degeneration occurs, and the cord is converted into a yellow or white diffluent mass. Describe the symptoms of acute myelitis. Slight fever, pain in back, aggravated by pressure, constriction around the waist, pulse feeble and irregular, anorexia, cephalalgia, malaise, paraplegia, sensory and motor; formications, followed by anaesthesia, restlessness, loss of control of bladder and rectum, pri- apism, muscular atrophy; if disease is high up, dyspnoea and dys- phagia ; constipation ; later, bed-sores, oedema of paralyzed limbs, spasmodic muscular twitchings and contractions, cystitis, nephritis, and pyelitis. The disease is progressive, and may become chronic. Death may occur in twelve or thirty hours or be delayed two or three weeks. Complete recovery is rare. The disease must be dif- ferentiated from acute spinal meningitis, cerebro-spinal meningitis, spinal hemorrhage, and tetanus. What is the treatment of acute myelitis ? Rest, support and nourish the patient, hot-water bags to spine, ergot, belladonna, diuretics, cathartics; treat symptoms and avoid complications. Give definition, causes, and pathology of infantile spinal paralysis. Infantile spinal paralysis, or acute anterior poliomyelitis, is an inflammation of the anterior horns of the gray matter of the cord. It occurs mostly at from six to fourteen months, rarely later than the fourth year. It is a motor paralysis. Causes.—Injuries, exposure to cold, exanthemata, sometimes ob- scure. Pathology.—There is inflammatory softening of the diseased por- tion of the cord, with medullary hyperaemia and vascular exuda- tions ; the anterior roots of the spinal nerves are shrunken, atrophied, and degenerated ; the vessels are enlarged and their walls thickened. The muscles involved undergo fibroid changes and atrophy, the ten- dons atrophy, the bones become flexible. Give the symptoms. Commences suddenly. Fever, vertigo, cephalalgia, restlessness, nausea vomiting, sometimes delirium, eclampsia, and coma; pain in the back ; paralysis, sometimes without any premonitory symp- tom sometimes following a convulsion. Often a child goes to bed 96 ORGANIC DISEASES. well and awakens with paraplegia: if it commences in one leg, the other is soon affected ; it may attack all four extremities ; the arms are rarely attacked alone, it reaches its height in from ten hours to six or seven days, and in about two weeks begins to diminish. The affected muscles become flaccid and attenuated, and are apt to atrophy. Tendon reflexes are lost, body surface cold and pur- plish, general health good; there may be loss of power over blad- der and rectum. Prognosis good. Differentiate it from progressive muscular atrophy, temporary infantile paralysis, myelitis, rickets, and hemiplegia. Give the treatment of infantile spinal paralysis. Rest, nutritious diet, strychnia, iron, arsenic, quinine, phospho- rus, cod-liver oil, massage, friction, shampooing, galvanism, saline and thermal baths. Define spina bifida, and give the causes and pathology. Spina bifida, or hydrorrhachis, is a congenital tumor on the ver- tebral column, usually in the sacral portion, and is caused by a pro- trusion of the spinal meninges through an opening in the spinal canal. The tumor consists of the membranes of the cord filled with cerebro-spinal fluid and covered with normal or atrophied integument, or none at all; it may be a mere protuberance or a large growth, depending upon the size of the opening. What are the symptoms? The skin is discolored and red. Pressure on the tumor causes pain and may produce tetanic spasms. Large tumors are apt to burst or become gangrenous, followed by purulent meningitis and death. With small tumors children may thrive, but paralysis of the bladder, rectum, and lower extremities follows, ending in death. In some cases the disease complicates congenital hydrocephalus, ectopia of the bladder, and other deformities. What is the treatment of spina bifida ? Protect the tumor from pressure and injury. Various surgical methods have been attempted, as evacuation, injections of iodine, amputation where pedunculated, pressure, etc., but so far without marked success. Some few cases, where the tumor was very small, have attained adult life, but generally these children live but a few days after birth. FUNCTIONAL NERVOUS DISEASES. 97 FUNCTIONAL NERVOUS DISEASES. Define eclampsia, and give the causes in children. Eclampsia, or convulsions, consists in general or partial clonic twitchings of the muscles, attended with more or less unconscious- ness. Causes.—Idiopathic: compression of head during delivery, patho- logical changes in the brain, alcohol, narcotics, insolation, fright, anger, anxiety; intestinal irritations of all kinds, acute febrile diseases of all varieties, heredity, external irritants, and injuries. The disease occurs most frequently during infancy and the first years of life. The attack may be single or multiple. Describe the symptoms. In the milder form the child sleeps with half-closed eyes, show- ing the white sclerotic only ; facial muscles contracted ; breathing rapid, irregular, superficial, or sighing; the limbs tremble and twitch; the legs are drawn up on the abdomen, hands clinched, toes spread out: from this sleep the child awakens with a fright- ened cry and evidences of distress, and after a stool or vomiting and the expelling of flatus it generally rests quietly: if these attacks are frequently repeated, feverish conditions and emacia- tion are apt to supervene. The severer type is usually preceded for a time with these milder symptoms, only in a more aggravated form ; but suddenly a parox- ysm occurs : the child becomes unconscious ; the eyes are squinted, rolled up, or fixed and staring; the facial muscles twitch, the teeth are exposed, there are snapping of the jaws and gnashing of the teeth. The convulsion now becomes general; the muscles of the back are in tonic contracture or tetanic twitchings ; the extremities thrash around; respirations are irregular or stop from spasmus glottidis, in which case death will occur if the spasm does not sub- side ; bleeding from mouth and nose from impeded respiration or injuries; involuntary evacuations; heart contracts; anaesthesia of skin. The paroxysm is of short duration, and is followed by exhaustion and a semi-comatose condition, with anorexia, fever, and injected eyes. The prognosis is generally good, except in very young children. It must be distinguished from epilepsy and chorea. The sequelae liable to occur are strabismus, amaurosis, deafness, imbecility, paralysis. 7—D. C. 98 ORGANIC DISEASES. Give the treatment of eclampsia. Seek the cause and remove or correct it. During the paroxysm have the child stripped ; derivatives to the skin, as mustard bath, together with enema, emetics, and cold effusions to the head, may be sufficient in mild cases; in severe cases chloroform may check the convulsions, but chloral has a better reputation : give 20 to 30 gr. in enema to a child one year old, and repeat in fifteen minutes if necessary. Phlebotomy and constriction of the head in older children are recommended. Between the attacks antispasmodics. The after-treatment is tonic. Describe facial paralysis in children. Facial paralysis in new-born children is most frequently due to instrumental delivery : it may be caused by congenital smallncss or distortion of the petrous bone. That occurring later in life is due to caries of the petrous bone, glandular indurations, or con- tracting cicatrices in the course of the facial nerve. The symptoms are immobility of the paralyzed side of the face. The treatment consists in seeking the cause, and if possible its removal. Give a brief description of essential paralysis. Individual muscles or groups of muscles are frequently paralyzed as a result of injury or disease. The paralysis is generally tran- sient, and manifests itself by loss of motion in the affected part. In protracted cases atrophy is apt to result, and sometimes de- formities. The treatment consists in removing the cause if possible, fara- dism, later galvanism, massage, gymnastics, etc. Give the definition, causes, and pathology of chorea. Chorea is a neurosis characterized by chronic muscular contrac- tions without order or rhythm. Causes.—-Heredity, female sex, feeble constitution, anaemia, chlo- rosis, onanism, rheumatism, scarlet fever, injuries, fright, shock, mental excitement, nervous disturbances. Pathology.—Obscure; hyperaemia of the brain and cord are almost always present; occasionally capillary emboli and thrombi, and minute points of softening in the gray matter of the brain corpora striata, optic thalami, and cord are found. Give the symptoms. Premonitory are rare. In some cases the disposition changes FUNCTIONAL NERVOUS DISEASES. 99 and the memory is weakened. Usually the first symptoms noticed are restlessness and awkwardness, dragging a foot, twitching the shoulders, jerking the head; the first motions are generally uni- lateral, but soon affect both sides. In mild cases, when the dis- ease has fully developed, the child seems awkward and the muscular twitchings are slight. In severe cases every feature and limb is contorted, the muscles are in active motion, teeth and bones will be broken, and the patient runs, jumps, turns somersaults, etc. In all forms the muscular movements are irregular, impulsive, sudden, and involuntary. In some cases patients can neither eat nor sleep, and death from exhaustion results. If laryngeal muscles are affected, voice and deglutition will be interfered with, pupils dilated, special senses blunted, constipation, anaemia, heart's action disturbed, paralysis more or less marked. Prognosis favorable. Differentiate from hysteria, epilepsy, disseminated sclerosis. Give the treatment of chorea. Arsenic, zinc, bromides, chloral, copper, silver salts, strychnine, cimicifuga, cannabis Indica. conium, hyoscyamine, valerian, asa- foetida; mental and bodily rest, good diet, tonics, baths, friction, ether spray to spine ; extreme cases may require chloroform. Give the definition, causes, and pathology of epilepsy. Epilepsy is a disease of the nervous system, characterized by temporary unconsciousness and tonic or clonic convulsions. The mild type is called le petit mat, the severe type le grand mal. Causes.—Heredity, fright, injuries to head, sunstroke, reflex irritations, as tuberculosis, depressed fracture of cranial bones, cryptorchidism, cicatricial contraction, etc. Pathology.—Obscure : the autopsy may prove negative ; usually there is cerebral hyperaemia and such brain lesions as atrophy and hypertrophy, induration and softening, plastic and serous exuda- tions, hemorrhages; tubercles and abscesses have been found, also hernia, exostoses, caries and necroses of cranial bones. Give the symptoms of epilepsy. The aura is rarely noticed in young children. The paroxysm begins usually with an inarticulate cry or moan and with tears flowing from the eyes; the child falls down and is seized with convulsions, tonic or clonic; gnashing the teeth, tetanic jerkings, extremities contracted; face contorted; if the respiratory muscles 100 ORGAN 10 DISEASES. are involved, breathing is interfered with, followed by symptoms due to imperfect aeration of the blood ; the heart is seldom affected ; the tongue is often wounded by the teeth ; involuntary evacuation of the bladder and rectum ; foaming at the mouth: as the parox- ysm subsides perspiration breaks out, the child sighs, and stares about bewildered, then goes to sleep, from which it awakens with a headache and fatigued. The paroxysms differ in degree. In the mildest form—petit mal—there may be merely a momentary loss of consciousness. In the severe form—grand mal—the symptoms may be so severe as to cause bodily injury, resulting in death. In petit mal the attacks return repeatedly through the day, in some cases several times an hour; in grand mebro-spinale (Fr.) ; Genickkrampf (Ger.). What are the causes of cerebro-spinal meningitis? Predisposing causes are—male sex, cold seasons, and fatigue with exposure; also insanitary surroundings. The special cause is unknown. It is not contagious, though epidemic; malaria, unwhole- some food, and changes of temperature have been assigned as causes. What are the symptoms ? There may be prodromata lasting for a couple of hours to several days, but generally the attack is sudden, beginning with a sharp chill or convulsions in very young children, prostration, feverish- ness, vomiting, and intense pains in the head, back, and limbs. These gradually grow worse, and the disease is fully established: there will be headache ; spinal pain ; hyperaesthesia of skin ; rigid flexion of body (opisthotonos) ; clonic convulsions; ptosis; stra- bismus ; paralysis of bladder and rectum, of the muscles of de- glutition, and general paralysis with aphasia; the conjunctivae are congested, sometimes suffused; pupils generally dilated, sometimes contracted or unequal; photophobia, spasmodic movements of the eyeball, blindness, ulceration of the cornea, or cataract in rare cases ; deafness ; loss of smell. The affections of these three senses may be temporary or permanent. There will also be a loss of equilib- rium ; the countenance will be pale and sunken or distorted or set and stupid ; delirium, mild, reasoning, hysterical, or maniacal; coma in fatal cases; vertigo, debility ; tongue generally moist and white —may be brown and dry for a few days; nausea and vomiting; emaciation; anorexia; constipation, in rare cases diarrhoea; fauces inflamed; sometimes the parotid swells, and it may suppurate; aphthae; urine increased or diminished, acid, in some rare cases albumin and sugar; swelling of joints, usually knee, elbow, wrist, and then of fingers and toes ; breathing sighing, labored, and inter- rupted ; oedema of lungs, due to opisthotonos interfering with ex- pansion ; pneumonia; pulse diminished in force and volume, and variable in rate and rhythm ; heart palpitations in some fatal cases; temperature 100° to 103° F., sometimes 105° F.; evening exacer- bations, irregular fluctuations; eruptions not always present— generally petechiae and ecchymoses, also herpes labialis, roseola, and urticaria. The causes of death are convulsions and coma, asphyxia, 132 GENERAL DISEASES. exhaustion, or intercurrent diseases. Convalescence is tardy; in some cases perfect restoration is never attained. What are the complications and sequelae? Inflammations of the eyeball and middle ear, purulent inflamma- tions of joints, bronchitis, pleurisy, pneumonia, pericarditis, endo- carditis, bed-sores; chronic hydrocephalus, blindness, deafness, deaf-mutism. From what should this be differentiated ? From tubercular meningitis, tetanus, typhoid and the other erup- tive fevers. Give the treatment of cerebro-spinal meningitis. Prophylaxis : remove bad hygienic surroundings and isolate the sick; rest in a dark, cool, well-ventilated room, free from noise and confusion : milk diet; ice-water or seltzer-water for thirst; calomel for constipation; if the urine is retained, use the catheter. Bro- mide of potassium and opium or cannabis Indica give best results; if these do not control the convulsions, chloroform. Stimulants for debility. Locally, heat or cold, blisters to nape of neck, or leeches to temples or mastoid processes. Keep body and extrem- ities warm by mustard baths, friction, hot bottles, etc. During convalescence, tonics, vegetable bitters, arsenic, and iron. ASIATIC CHOLERA. Give the definition and synonyms of cholera. Cholera is an epidemic disease characterized by copious watery discharges from the alimentary canal, followed by a tendency to collapse. The synonyms are Cholera algida, asiatica, maligna, and spas- modica. Give the etiology of cholera. Predisposing Causes.—High temperature and excessive moisture, bad sanitary surroundings, impure food and water, impaired health. Exciting Causes.—A specific poison conveyed in water, milk, and food, also by fomites. What are the symptoms? There are two stages—the attack and the reaction; and three classes of symptoms—those of the intestines, the circulation and respiration, and the kidneys. Diarrhoea may precede the attack, ASIATIC CHOLERA. 133 and symptoms of malaise; and often there is no diarrhoea. A child previously healthy is suddenly seized with profuse purging and vomiting, and in a few hours cholera develops, with bright- yellow discharges, cramps, disappearance of pulse, rigors, cyanosis, and suppression of urine. The rice-water discharges are very rare with children. The stools are not copious: five or six thin evacu- ations in an infant may induce dangerous collapse; in marasmic children one stool may be followedby convulsions and death. If the stools become pinkish, it indicates hemorrhage and the prognosis is hopeless. Children under one year rarely recover. The majority of children with cholera rarely vomit—at the most only once or twice ; the act of vomiting is accomplished by very slight exertion ; at first the food, after that the transudations of the gastric mucous membrane mixed with the fluids drunk. The absorbing function of the gastric and intestinal mucous membrane is much diminished, but it may be suddenly restored when transudation is undergoing spontaneous diminution. Abdomen retracted, stomach filled with gas, intestine with fluid. Very little colic, but incessant nausea. The discharges do not redden the anus. The volume of the blood is diminished in, and the fluids disappear from, the parenchymatous organs and serous sacs. The pulse and second sound of the heart disappear, sometimes with the first liquid stool. During the first few hours there is increased action of the heart and pulse. Pulse- less children are generally lost. The veins are filled with semi- fluid blood, and there is capillary stasis, causing cyanosis: healthy children become cyanotic, emaciated children yellowish-gray. The lungs show nothing abnormal, but the breathing is irregular and sighing, and there is intense dyspnoea; the expired air is cool; with the cool breath there will be coolness of the extremities, nose, and forehead, giving an unfavorable prognosis. The urine is either retained or passed in very small quantities ; it contains albumin and casts; the convulsions are probably due to the arrest of the secre- tion of the urine. If children recover from the attack, typhoid symptoms may develop : hot, dry skin, hard and frequent pulse, dry tongue, and symptoms of cerebral congestion. Death is gene- rally due to convulsions or marasmus. What are the complications and sequelae of cholera ? Obstinate vomiting, gastritis, nephritis, enteritis, bronchitis, pneu- monia, pleurisy, inflammation of genitals, corneal ulcer, gangrene, carbuncles, diphtheritic exudation of fauces. 134 GENERAL DISEASES. With what diseases may it be confounded? Diarrhoea, dysentery, cholera infantum, poisons, and cold stage of malarial fevers. What are the indications in treatment? Prophylaxis by strict quarantine and hygiene; keep the child clean and warm; satisfy its thirst by small quantities of water. Children at the breast should.be kept nursing. Drugs indicated, opium, quinine, tannic acid, strychnine, chloral, caffeine, benzoatc of sodium, camphor, stimulants, saline transfusions. WHOOPING COUGH. Give the definition and synonyms of whooping cough. Whooping cough is an acute, infectious disease, characterized by a peculiar paroxysmal cough, having a loud crowing or whooping sound. The synonyms are—Tussis convulsiva ; Pertussis ; Chin-cough ; Kink-cough; Kauchhusten (Ger.); Coqueluche (Fr.); Pertossi (It.). What are the causes of whooping cough ? Predisposing.—Childhood, debility from disease, dampness. Ex- citing.—A peculiar poisonous principle, possibly nricrobic, conveyed in the breath of the affected. What are the symptoms? Incubation varies from two days to two weeks; no symptoms. During the catarrhal stage, which lasts from ten to fifteen days, there will be slight fever, coryza, and anorexia, with a frequent dry cough. The spasmodic stage is characterized by the peculiar cough which gives the name to the disease. This cough consists of a number of loud, quick, spasmodic, forcible expiratory puffs, alternating with prolonged, shrill, inspiratory whoops ; it begins suddenly during the attack; the eyes protrude, the body is bent, the face gets red, cyanosis may appear, the cough may get weaker so as to be hardly heard, and ends with the expulsion of tenacious mucus; in severe cases vomiting occurs. There may be hemor- rhages, involuntary defecation and urination, hernia, prolapsus ani, or convulsions. Between the paroxysms there will be exhaustion, with anorexia, cephalalgia, insomnia, pyrexia, etc. Examination of the lungs shows normal resonance on percussion and dry or MUMPS. 135 moist rales on auscultation. Ulceration of the fraenum linguae. During the stage of decline there is a gradual amelioration of all the symptoms. Give some of the complications and sequelae. Bronchitis and pneumonia, emphysema, rupture of air-vesicles, collapse of lung, convulsions, hernia, cerebral apoplexy, hemor- rhages, pleurisy, phthisis, acute tuberculosis, meningitis, the ex- anthemata. From what diseases must it be differentiated? Bronchitis, naso-pharyngeal catarrh. Give the treatment of whooping cough. During the first stage keep patient warmly clothed in a warm room; give an aperient and diaphoretics. During the second stage use sedatives and antispasmodics, belladonna, opium, hyoscyamus, lobelia, aconite, ether, chloroform, camphor, etc.; emetics: alum, zinc, ipecac, copper, etc.; other drugs recommended are mineral acids, tannic acid, arsenic, strychnine, ergot, bromides and iodides, quinine. Locally,, carbolic acid, quinine, cocaine, counter-irritants, sulphur fumes. The diet must be highly nutritious, and the patient kept out of doors if the weather permits. Treat other symptoms and complications. During convalescence tonics, change of air, good diet. MUMPS. Define mumps, and give some of the synonyms. Mumps is an acute, specific infectious disease, characterized by inflammation and swelling of the parotid gland and metastasis to other organs, as the ovaries and testicles. The synonyms are—Parotitis ; Parotiditis ; Clown's disease; Oreil- lon (Fr.) ; Ziegenpater (Ger.). What are the causes of mumps? Predisposing Causes.—Early life, bad hygiene, season of the year. Exciting Causes.—A peculiar virus of unknown origin, which is highly contagious, propagated by contact or fomites. Give the symptoms of mumps. Incubation, five days, varies up to twenty days; slight malaise with anorexia and cephalalgia. As the disease develops there are tenderness and swelling in the neighborhood of one or both parotid 136 GENERAL DISEASES. glands ; the swelling extends up in front of the ear, behind the ear, and down on to the neck ; the skin may be inflamed and desquama- tion may occur; motion intensifies the pain; speech and hearing impaired ; may have salivation ; may have convulsions. Swelling lasts from four to eight days; profuse perspiration during convales- cence. Abscesses may occur ; neighboring glands may enlarge. The testicle in the male, the ovary, mammae, or uterus in the female, may be affected during or after the parotitis. What are the complications and sequelae of mumps ? Stomatitis, pharyngitis, high temperature, delirium, atrophy of testicle or ovary, epididymitis with occlusion of spermatic duct, pneumonia, meningitis. Give the differential diagnosis. From adenitis cervicis, periodontitis. Give the treatment of mumps. Rest, liquid diet, an aperient; make patient comfortable ; aconite for high temperature. Treat orchitis, ovaritis, etc. on general prin- ciples. ERYSIPELAS. Describe erysipelas in children. . Erysipelas in very young or new-born children is characterized by its tendency to spread rapidly over the entire surface of the body; as fading commences adjoining parts are involved. In other respects and in older children the disease presents the same manifestations as in adults: fever very high; rapid, tense pulse; anorexia, constipation, vomiting; urine decreased and high-colored, sometimes retention or suppression ; nervous phenomena, restless- ness, irritability ; in extreme cases delirium and coma. The affected portion, of skin is scarlet, dark-red, or bluish, tense and shining, infiltrated, hot; pressure causes pain. Causes.—In very young infants infection of the navel, in older children wounds, irritations, contagion. It frequently follows vac- cination, even where every precaution has been exercised. Prognosis.—Young infants succumb early ; in older children the severity of the attack, the tendency to migrate, and the general physical condition modify the prognosis, but it is a grave disease. Treatment.—Nourishing diet and stimulation ; open the bowels with calomel or salines; for the nervous phenomena, morphine ; for INTERMITTENT FEVER. 137 the fever, aconite; for suppression, diuretics, dry cups to the loins, followed by poultices. Tr. ferri chlorid. ranks high in the general treatment of the disease itself; quinine is also advocated. Locally, lead and opium, hamamelis, white paint, ichthyol, aristol, resorcin, Volkman's rail fence, or some of its modifications. INTERMITTENT FEVER. Define intermittent fever, and give the causes and pathology. Intermittent fever—known also as Malarial fever, Malaria, Ague, Fever-and-ague, etc.—is a non-contagious fever, characterized by regularly recurring paroxysms. Cause.—Malarial poisoning, the bacillus malariae. Pathology.—Enlargement of the spleen and liver, effusions into serous cavities, destruction of the red blood-corpuscles, and deposits of brown or black coloring matter in the spleen, liver, brain, kidneys, and mucous membranes. Give the symptoms. Quotidian, tertian, and quartan occur, the first most frequently. The paroxysm of chill, fever, and sweating may be as marked as in the adult, but usually it is modified; instead of the chill the skin is pale, lips and nails blue, extremities cold; vomiting may occur or twitching of the facial muscles or convulsions; this stage may be so short as to pass notice. The hot stage is more marked : the skin is hot, the face flushed ; there is headache ; epigastric pain, anorexia, thirst, nausea, vomiting; fever 105° or 106° F.; strong, diffused cardiac impulse; pulse rapid and tense; restlessness and prostration. The sweating stage is not marked by profuse per- spiration unless the child sleeps; instead there is mere moisture of the skin ; gradual amelioration of all the symptoms. Between the paroxysms the child is restless, irritable, and has a poor appetite. The patients soon become emaciated and anaemic, with white or gray-colored skin, pale mucous surfaces, white-coated tongue, puffy eyelids, poor appetites, loose stools, lassitude, peevishness; they complain of stomach-ache, headache, of being tired ; the spleen and liver are enlarged, the abdomen is tympanitic. Haematuria may be present. In some rare cases neuralgias may occur. Give the treatment of intermittent fever. During the paroxysm make the patient comfortable. Remove the child from the malarial district if possible. Of drugs, quinine 138 GENERAL DISEASES. or some of the other preparations of cinchona ranks first: older children will take the quinine in pills or wafers; younger children and infants will have to take it in solution. Various vehicles have been suggested to hide its bitter taste: the different preparations of liquorice are quite efficacious for this purpose, or the powder may be hidden in the centre of some chocolate paste or the choco- late-quinine troches may be used. Arsenic is of service where there is an idiosyncrasy against quinine and in some chronic cases. DIABETES INSIPIDUS. Give the definition and synonyms of diabetes insipidus. Diabetes insipidus is a disease characterized by the passage of enormous quantities of pale urine of low specific gravity and free from albumin casts or sugar. The synonyms are Polyuria, Polydipsia, Diuresis. What are the causes? Heredity is supposed to be a predisposing cause. Exciting causes: tuberculosis, organic disease of brain or cord, injury to nerve-centres, dilatation of renal vessels from paralysis of muscular coat, exposure. What are the symptoms ? The frequent passage of enormous quantities of pale watery urine, sp. gr. 1001 to 1007, and containing no abnormal constitu- ents ; great thirst and voracious appetite; health generally good. The disease persists for years. Death may occur from a complica- tion. Emaciation and dyspeptic symptoms may precede death. Give the differential diagnosis. From glycosuria and cirrhotic kidney. Give the. treatment of diabetes insipidus. Look after the general health; no restrictions in diet or fluids. Drugs recommended: opium, ergot, iron, belladonna, dilute nitric acid, tannic acid, gallic acid, potassium nitrate, iodide, or bromide. DIABETES MELLITUS. Give the definition and synonyms of diabetes mellitus. Diabetes mellitus is a chronic disease, characterized by an in- RICKETS. 139 creased quantity of urine of high specific gravity and containing grape-sugar. The synonyms are Glycosuria, Melituria. What are the causes of diabetes mellitus ? Obscure. Heredity is supposed to be a predisposing cause. Exciting causes: injury to head or spine, acute febrile disease, exposure to wet and cold, and drinking cold water when heated, excessive use of sugar and starch, pancreatic lesions. Give the symptoms of diabetes mellitus. The frequent passage of large quantities of pale irritating urine, having .a sweet tarste, sp. gr. 1030-1060, and containing sugar in varying percentages ; inflammation or excoriation of the genitals ; excessive thirst; varying appetite, with dyspeptic symptoms; tongue red, dry, and shiny ; gums spongy ; teeth decay early ; breath has a sweet odor ; constipation, with diarrhoea toward the end ; the child emaciates ; the skin is dry and scurfy ; great prostration ; oedema of legs, sometimes extends to other parts; pains in the legs and over the region of the kidneys. Give the differential diagnosis. The persistent presence of the sugar prevents its being mistaken for any other disease. What are the complications? Boils and carbuncles, chronic skin affections, gangrene, phthisis, endocarditis, Bright's disease. What is the prognosis ? Bad. The disease may be kept in abeyance, but it is pro- gressive, and a cure can hardly be expected. Give the treatment of diabetes mellitus. Regulation of the diet; the absolute removal of starch and sugar; proper hygiene. Numerous drugs have been recommended —codein, calcium sulphide, ac. salicylic, ergot. Treat the symp- toms. Iron and cod-liver oil are often of value. RICKETS. Give the definition and synonyms of rickets. Rickets is a constitutional disease, due to perverted nutrition, 140 GENERAL DISEASES. affecting nearly every tissue of the body and resulting in deformi- ties of the bones. The synonyms are—Rachitis ; Rachitisme (Fr.) ; Englische krank- heit (Ger.). What is the etiology of rickets ? Poor food, bad air, absence of sunlight, debilitating diseases, hereditary or racial influences. Give the pathology of rickets. Ossified bones soften ; ossification in cartilaginous parts is re- tarded. In the long bones the new bone deposited beneath the periosteum is soft and deficient in earthy salts ;.the animal matter does not yield gelatin on boiling; the ossification at the epiphyses is slow and irregular; the border of ossification is serrated; the medullary cavity increases, extending beyond the border of ossifi- cation, and is filled with a reddish pulpy matter. As a result of these changes the bone is shorter than normal, has enlarged epiphy- ses, and is easily bent. In the flat bones the circumference is thickened and the centre thinned (craniotabes). The late closing of the fontanelles and the weak union of the sutures, with ridges at their edges, are due to the deposit of the earthy matters at the circumference of the bones. The liver, spleen, and lymphatic glands are enlarged and harder than normal. The brain is hyper- trophied, chiefiy in the white substance. The muscles are flabby and pale ; the ligaments are relaxed. At what age does rickets occur? Rarely before the seventh month or after the seventh year; it may occur during intra-uterine life or as late as puberty. Give the symptoms of rickets. Imperfect nutrition ; appetite good, but patient doesn't thrive. Peevish, wants to be let alone, due to hyperaesthesia of skin. Growth is retarded, loses plumpness, looks puny. Diarrhoea and constipation alternate. Throws off the bed-clothes ; profuse sweat- ing, especially about head and upper part of chest; hair on back of head thin and short; stools very offensive; muscles soft and flabby, ligaments relaxed and joints abnormally movable; late ir- regular dentition—teeth poorly formed and decay early; little if any temperature; marked thirst. During the second stage the bones become softened and deformed, chiefly the lower extremities RICKETS. 141 due to the weight of the body. The symptoms of the first stage continue, but not so severe. The head becomes rectangular (" box- shaped "), elongated, flattened on top and at the sides; occiput projects ; frontal bones prominent, fontanelles open, sutures loosely united; soft spots in occipital bones. Kyphosis, due to weakened spinal muscles and ligaments, and softened vertebral bodies and intervertebral cartilages ; scoliosis. Scapula smaller than normal; clavicle thickened, ends enlarged, curves exaggerated. Deformities of arms, due to supporting body-weight. Enlargement of epiph- yses at wrists. Ribs depressed at cartilaginous junction from atmo- spheric pressure and muscular action, pushing sternum forward (" pigeon-breast") ; lower ribs pushed out by enlarged liver and spleen. " Beading " at cartilaginous ends of ribs from epiphyseal enlargement. Abdomen enlarged ("pot-belly") from accumula- tion of gas in intestine, downward pressure of thoracic organs, and relaxed condition of intestinal and abdominal walls. Sacrum and acetabula are pushed into the pelvis by weight of trunk. Neck of femur forms nearly a right angle with the shaft. Genu val- gum or varum. Malleoli enlarged and prominent. Talipes valgus, due to stretching of plantar fascia and breaking down of arch of foot, with softening of bones of tarsus. During the last stage there is an improvement in all the symp- toms, but the bone-deformities remain permanent and can only be cured by operation. What are the complications and sequelae ? Bronchitis, pneumonia, enteritis, laryngismus stridulus, convul- sions, diarrhoea, chronic hydrocephalus. The chief sequelae are the deformities. Give the differential diagnosis of rickets. From tuberculosis, scrofulosis, and syphilis. What is the prognosis ? Good as to life; few die save from the complications. As to the deformities, the prognosis depends upon the length and severity of the disease. Give the treatment of rickets. Improve the nutrition and hygiene; castor oil' or rhubarb and soda for intestinal derangements; chloral or bromides for nervous 142 GENERAL DISEASES. derangements ; cod-liver oil, phosphorus, lime, iron, quinine, ortho- pedic surgery. HEREDITARY SYPHILIS. Define hereditary syphilis, and give the etiology. Hereditary syphilis is a chronic constitutional disease acquired during foetal life from one or both parents. The cause is a specific virus of bacteriological origin, usually transmitted by the father. If the mother is infected, the pregnancy generally terminates early in abortion or miscarriage. The father may infect his offspring and the mother remain healthy, and nurse her child without be- coming infected ; but a syphilitic child will infect a healthy wet- nurse. A syphilitic father .may beget healthy children. Describe the principal symptoms. This disease presents two forms: in one it develops in utero, in the other soon after birth. In the former the children are either born dead, die soon after birth, or live to suffer from the severe lesions of the disease; in the latter the disease is more susceptible of treatment. Syphilitic children born dead present all the lesions of the skin and mucous membranes, from the simple macules to the pustular eruptions; the skin is macerated and peels off, and frequently de- formities, due to retarded development, are present. Those born alive are weakly and puny, have snuffles; the muscles are soft and flabby; the skin is wrinkled, and either covered with the syphilitic rash or it develops within a few days; mucous patches and condy- lomata are found around the anus and in the mouth ; the angles of the mouth are fissured; the skin peels from the palms of the hands and soles of the feet; there are ophthalmia and offensive coryza. These children soon perish, or, where the symptoms are of a milder type, they may live and the severe symptoms develop later. Some children are born apparently healthy, and only after a few weeks or months do the symptoms develop. Syphilitic children in general are anaemic, emaciated, irritable, restless; the skin is dry, wrinkled, and scurfy, and of a dusky, smoky tinge. The disease affects all the organs and tissues—skin, subcutaneous tissues, glandular structures, mucous membranes, muscles, and bones. On the skin the syphilides are macular, papu- lar, or pustular ; in the subcutaneous tissue abscesses form, and are followed, after rupture, by puckered, pigmented cicatrices ; wasting HEREDITARY SYPHILIS. 143 of this tissue occurs, causing wrinkling and shrivelling of the skin ; in the glandular structures enlargements occur, especially in the spleen ; the lymphatic glands are enlarged, particularly the epi- trochlear and inguinal; gummy tumors develop in the spleen, kid- neys, suprarenal capsules, liver, and lungs ; abscess of the thymus glands may occur; on the mucous surfaces the lesions are similar to those affecting the skin, and the attendant inflammations pro- duce coryza, bronchitis, gastritis, enteritis, etc., with their peculiar symptoms; mucous patches develop in the mouth, on the tongue, hard and soft palate, gums, lips, and cheeks; cracks and fissures at the angles of the mouth, around the margins of the anus, upon the prepuce and vulva; ophthalmia and keratitis ; otorrhoea followed by deafness; coryza with caries of the nasal bones and flattening of the bridge of the nose ; balanitis and leucorrhcea may be pres- ent. The muscular changes pertain more to malnutrition ; the bone- changes resemble those of rickets—epiphyseal enlargements, the shaft shortened and softened, with consequent bending and deform- ity, the periosteum thickened, and tender points developed. The hair is dry and brittle, the nails striated and brittle ; Hutchinson's teeth appear with the second dentition. The affection of the nervous system, due to fibrous and gumma- tous thickenings and infiltrations, is manifested by paralysis more or less localized, epilepsy, hydrocephalus, idiocy, and mental retard- ation. What is the prognosis? In breast-fed children, in whom the disease appears late, the prognosis is good. In bottle-fed children, and in those in whom the symptoms develop at or soon after birth, the prognosis is bad. Children born with the pustular syphiloderm usually last but a few hours. What is the treatment of hereditary syphilis ? Mercury, either by inunctions, calomel, or with chalk. The inunctions may be practised daily, using from ten to twenty grains of mercurial ointment, which may be rubbed in with the hand or smeared on the flannel roller. Calomel or gray powder may be given in doses of ^ to 1 gr. three or four times daily. The mixed treatment of biniodide of mercury and iodide of potassium is also recommended, and also iodide of potassium alone—drop doses of saturated solution. The care of the child as to nutrition, clothing, baths, hygiene, etc. must be closely watched. 144 GENERAL DISEASES. TUBERCULOSIS. Define tuberculosis, and give the etiology and pathology. Tuberculosis is a specific infectious disease accompanied by tubercles, which owe their origin to the bacillus tuberculosis. The causes are heredity and faulty hygiene and food. Among the exciting causes are measles, pneumonia, enteritis, and all debilitat- ing diseases. Pathology.—The tubercle bacilli are rod-shaped micro-organisms about one-third the diameter of a red blood-corpuscle in length, and about five times longer than broad; they are slightly curved, have rounded ends, and are provided with spores: they are found in varying numbers in all tuberculous lesions and in the fluids coming from the parts affected. The tissue-changes effected by the bacilli consist of cell-increase and the formation of giant and epithelioid cells, or inflammatory small-cell infiltration or exudation of serum, fibrin, and red and white blood-corpuscles. The bacilli attack the epithelium cells of the channels which they enter or the white blood-corpuscles or the wandering cells, convert them into epithelioid cells, and start the nucleus of a tubercle. Miliary tuber- cles consist of giant cells in the centre, containing nuclei, surrounded by lymphoid cells, and outside of these and penetrating between them epithelioid cells: in size they range from those so small as to be invisible to the naked eye to those as large as a pea: the small- est are pearly and transparent, the larger white and opaque; they are closely connected to the tissue in which they develop, and are distinct or not according to the density of the tissue; they contain no blood-vessels; caseation, due to the action of the tubercle bacil- lus, begins in the centre and consists of necrosis and destruction of the cell-elements and the formation of a firm, dry, white or grayish-white mass. As a result of the irritation caused by the tubercle and the action of the bacilli the tissue surrounding the tubercle undergoes infiltration and inflammatory exudation, the exudation being fibrinous, hemorrhagic, or purulent; new foci of caseation appear, and, the intervening tissue becoming involved, the tubercular cavity already formed thus steadily increases in size. Tuberculosis is almost always attended with caseation, while the number of the bacilli and the structure of the tissue affected deter- mine whether the tubercle tissue shall occur as miliary tubercles or as a diffuse infiltration: these results in varying degrees of intensity are found in all the organs and tissues involved. TUBERCULOSIS. 145 Describe the symptoms of tuberculosis. Tuberculous children have transparent, white skins, with blue veins, large, lustrous eyes, and bright-red lips, and are precocious and neurotic; or they have large heads, coarse features, thick, flabby skin, and are dull and apathetic. The other symptoms pertain more particularly to the part affected. The general symptoms are pale, sallow, and sad countenance; circumscribed redness of one or both cheeks; blue sclerotic; the "skin is hot and dry, and toward the end flabby and wrinkled, and attended with a bran-like desquamation ; anaemia and emaciation ; digestive disturbances; fever with accelerated pulse and thirst; hectic fever; sweating around the head, dyspnoea if the lungs are much involved or the pulmonary circulation impeded; appetite not always affected; infants under one year will nurse well and remain plump to the end; oedema occurs late about the ankles, and some- times on the face and upper extremities; diarrhoea and stomatitis occur late ; cough and expectoration. In addition to these general symptoms there will be the local symptoms, which relate to the organ, tissue, or joint affected. Describe tuberculosis of the lungs. The changes wrought by the tubercle bacillus consist in the formation of tubercles surrounded by tubercular infiltration; cheesy degeneration of the tubercle; softening and degeneration of the infiltrated tissue ; and, as a result, the formation of cavities whose contents consist-of disintegrated, cheesy detritus and tubercle bacilli. These cavities are of varying size and shape, are crossed by bands of parenchymatous tissue or obliterated blood-vessels (the larger ones communicate with bronchi), and they heal by cicatriza- tion or continue growing until death occurs ; healing by calcification never occurs in children. The other changes in the lungs due to these conditions are gray and red hepatization, oedema, emphysema, etc Percussion reveals dulness only when there is extensive tuber- culous infiltration; with miliary tubercles and tuberculosis of the bronchial glands percussion is negative; with children the apices are rarely affected, so that the dulness will be lower down or late- ral • over cavities the flat percussion note becomes sonorous and tvmnanitic. Auscultation reveals large and small sibilant rales, due to bronchial catarrh, crepitant rales at the edges of consolida- tion, and bronchial breathing at the site of the consolidation ; cav- 10—D. C. 146 GENERAL DISEASES. ernous breathing and gurgling at the site of cavities; in children cavities are small and the signs imperfect. The respirations are increased very slightly in the chronic form, markedly so in the very acute, and attended with dyspnoea and orthopnoea. Cough begins early and lasts through the entire course of the disease: it is dry, short, and hacking at first; later it is moist and spasmodic, resembling whooping cough. Expectoration does not occur in young children, as they swallow the sputum ; in older children its characteristics are the same as in the adult. Haemop- tysis is extremely rare in children. Other symptoms are—pain, referred to the pra:cordium and sternum; extreme emaciation; prominence of superficial veins, especially in the neighborhood of the sternum; bulbous swelling of the finger-tips, due to impeded circulation from stasis in the right side of the heart; oedema of the face if the bronchial glands are enlarged, and dilatation of the vessels of the neck and cyanosis. The other symptoms, *as fever, hectic, etc., belong to tuberculosis in general. The disease appears in an acute and a chronic form : in the one case it is very rapid and appears in other organs besides the lungs; in the other it may be protracted through several years, with remissions and exacerbations, terminating in recovery or in death from general miliary tuberculosis. Give the treatment of tuberculosis. Hygiene, comprising baths, cold sponging, woollen clothing, healthy sleeping- and living-rooms, outdoor exercise, a warm, dry, equable climate; a highly nutritious diet; the avoidance of all debilitating occupations ; correction of any exhausting intercurrent disease; keep the system in the best physical condition. Cod- liver oil, pure if possible; commence with small doses and gradu- ally increase ; linseed oil and cream ; preparations of iron, hypo- phosphites of lime, sodium and iron, iodine, etc. Treat the symp- toms—fever, cough, insomnia, etc. Describe tuberculosis of the skin. This assumes the form of eczema, ecthyma, impetigo, and lupus. The eczema appears as simplex, rubrum, and impetiginous; it most usually attacks the face and scalp; on the latter thick crusts TUBERCULOSIS. 147 form, matting the hairs together; there is usually a corroding exudation ; there is intense pruritus; it is apt to become chronic, and is attended with relapses. The local treatment consists in removing the crusts on the scalp, first softening them with oil, removal of the hair if its presence impedes recovery, and the application of soothing or stimulating ointments—zinc oxide alone or with oil of tar, bismuth, salicylic acid, tannic acid, etc.; restrict or stop the application of water to the parts ; stop the scratching by cutting the nails or covering the hands with mittens. The general treatment is by cod-liver oil, iron, tonics, etc. Impetigo consists of pustules on an inflamed base, drying into thick, brownish scabs. Ecthyma consists of solitary pustules merging into indolent ulcers. The treatment for these is stimulating, especially in ecthyma, and general as in eczema. Lupus appears as hypertrophied spots of integument, as hard, bluish-red tumors, or as deep, uneven ulcers, which may become serpiginous; it appears most frequently upon the face, and is usually chronic. Its treatment must be by escharotics, arsenic, chloride of zinc, phosphorus, etc., or the curette, cod-liver oil, and a generous diet. Describe tuberculosis of the nose, eye, and ear. In the nose there will occur a suppurating eczema or impetigo, causing tumidity of the nose and upper lip ; also ozaena, with a purulent, offensive discharge and the escape of necrosed pieces of bone. The treatment is cleanliness, astringents, and red-precipitate ointment. In the eye styes form on the lids; phlyctenulae develop on the conjunctivae ; keratitis occurs of varying degrees of intensity, and blepharospasm on account of the inflammation. Treatment: Removal of the eyelash will sometimes abort a stye; if it suppurates it must be opened; dusting of calomel in the eye is recommended for phlyctenulae; for keratitis and ophthalmia, oint- ments externally and collyria, with protection of the eye by a shade and avoidance of light, are the indications. In the ear occur otitis externa and interna, with chronic otor- rhoeas and diseases of the bones. 148 GENERAL DISEASES. In the treatment strict cleanliness is the first consideration. Peroxide of hydrogen is recommended for removing the pus, and the application of astringent and soothing powders or lotions. Describe tuberculosis of the lymphatic glands. The manifestations consist of swellings. The glands most usually affected are the cervical, next the axillary and inguinal. These swellings may be simple hypertrophy: if so, there is but slight alteration. If tubercular, the glands contain gray miliary tubercles or large yellow tubercles; these produce softening, ending in sup- puration, with the formation of abscesses and fistulous tracts. The symptoms are referable to the part where the enlarged glands are located, and comprise pain and tenderness, swelling, fluctuating when pus appears, and the escape of a thin, floccu- lent pus, followed by a slowly-healing ulcer having callous, under- mined edges. The treatment must be both general and local. The child must be built up with a generous diet, tonics, cod-liver oil, etc.; locally, tincture of iodine, iodine salve, belladonna ointment, etc. may be applied to retard and diminish the glandular enlargement: if these fail, suppuration must be hastened, the pus evacuated, and the ulcer treated surgically. Describe tuberculosis of the periosteum. The periosteum becomes red, swollen, and spongy, and is covered with a mucous, shreddy exudate which is converted into a grayish- red or white mass, and is adherent to the bone and soft parts. This may terminate in resolution with permanent thickening of the periosteum, or suppuration with or without caries of the bone. The symptoms are pain, swelling, oedema, and fluctuation, fever, impaired nutrition, and emaciation. The prognosis is unfavorable. In the treatment the indications are to support the patient, re- lieve pain, check the process if possible, otherwise hasten suppura- tion, and evacuate the pus early. Describe tuberculosis of the medulla of bones. Tubercular osteomyelitis consists, in addition to the formation of tubercle tissue, in hyperaemia of the medulla, with dark-red dis- coloration and extravasations, sometimes followed by suppuration ; the bone becomes carious and periostitis occurs. The bones of the TUBERCULOSIS. 149 hands and feet are chiefly affected; they are swollen and mis- shapen. The treatment comprises that of the cause, and compression band- ages, or it may be operative. Describe tuberculosis of the bone-structure. Tubercular ostitis may occur in the compact, but chiefly in the cancellous, structure. Inflammation, with hyperaemia and infiltra- tion, starts at some point, but quickly spreads; softening follows, with the formation of a thick, yellow fluid containing cheesy masses and fragments of bone ; cavities result and the bone crum- bles away. This inflammatory process may terminate in resolu- tion, which is extremely rare; suppuration, which ceases before caries has commenced; caries or necrosis. The symptoms are continuous pain, swelling of the part affected, with inflammation and tenderness of the' skin covering it, fluctuat- ing as pus forms. The general symptoms are fever, anorexia, ema- ciation, diarrhoea, disturbed sleep, debility, and weakness. The treatment consists in improving the condition of the pa- tient, allaying pain, hastening resolution by means of derivatives, as setons, vesicants, iodine salve, etc., support and rest of the affected part; if abscesses form and break, assist the discharge of the contents and the healing of the cavities and sinuses by injec- tions or surgical operations. Pott's Disease. Describe Pott's disease of the spine. This is an inflammation of the bodies of one or more vertebrae, end- ing in ulceration and destruction'of the bones. It is tuberculous in character, and is excited usually by traumatic influences. The pro- cess begins in the centre of the body, but quickly spreads, involv- ing the intervertebral cartilages and producing curvature : this may be backward (kyphosis), lateral (scoliosis), or backward and lateral combined (kyphosis-scoliotica). The inflammation extends to the adjacent soft parts, producing abscesses, which often burrow and point at some distance from the spinal lesion. The disease may originate at any point, but its most frequent location is the dorsal region, next the cervical, and least frequently the lumbar and sacral. The symptoms in general comprise spinal pain, epigastric pain (bellyache), tender spots on the spine, rigidity of the spine; the 150 GENERAL DISEASES. child squats, does not bend to pick things up ; a tap on the head causes pain; later the lateral curvature or the projecting spinal process will be discovered. Attendant upon these are irritability, anorexia, sleeplessness, digestive disturbances, fever, emaciation, and anaemia. In addition to these, symptoms appear, depending upon the portion of the part affected: when the disease is in the cervical region the neck is kept stiff, the head rigid and supported by the hand; the neck swells; the upper extremities suffer spas- modic movements or paralysis; the thoracic and digestive organs are deranged ; retropharyngeal abscesses may occur, or destruction of the atlas and axis, in which case death occurs from compression of or tearing the medulla oblongata. When the disease is in the dorsal region the spine is kept rigid and supported by the hands on the thighs; the head is drawn backward and buried between the shoulders ; pains and formications are felt in the lower extremities, followed by spasmodic affections, and later paralysis, constipation, and digestive disturbances; psoas abscesses ; Bright's disease may appear, and paralyses of the sphincters. When the disease is located in the lumbar or sacral regions there will be contraction of the thighs and pelvic abscesses. The treatment must have for its object the building up of the system, the relief of the symptoms, etc., pain, anaemia, obstipatio, etc., the healing of the abscesses, and the support of the spine and correction of deformity by suitably-applied orthopaedic apparatus. Tuberculosis of the Joints. Describe tuberculosis of the joints. The ends of the bones which enter into the joints may be at- tacked by tubercular inflammation, which may terminate in sup- puration and always in caries. This inflammation extends to the joint; perforation occurs ; the cartilages are destroyed and the joint invaded, causing destruction of the synovial membrane and dislocation of the ends of the bones; or the inflammation may begin in the synovial membrane; granulations appear and the membrane becomes thickened, infiltrated, and suppurates; the in- flammation extends to the ligaments and soft parts; the pus, when present, burrows, forming sinuses; the joint swells ; the skin is stretched and shining; the muscles become flabby and undergo fatty degeneration; finally, the cartilages and bones themselves are involved, ending in caries and necrosis. Sometimes the disease be- TUBERCULOSIS. 151 gins in the bones and synovial membrane at the same time. The disease may terminate as an acute affection or become chronic. The symptoms are fever, with chilly sensations, restlessness, anorexia, anaemia; pain, at first intermittent, later constant, ag- gravated by pressure and motion; swelling of the joint; the skin may be unchanged or hot, red, stretched, and showing tor- tuous vessels; fluctuation as pus forms. The disease may termi- nate in recovery without derangement of the function of the joint, recovery with diminution of the joint function, or recovery with dislocation of the bones forming the joint. The treatment consists in improving the physical condition and relieving the symptoms, particularly the pain ; locally, measures to promote absorption of the exudation, as iodine, silver nitrate, setons, the cautery, etc.; the early evacuation of abscesses if the patient's condition permits of it; soothing and healing applications to the resulting sinuses; surgical operations if the joints are badly affected; absolute rest throughout, and the placing of the joint in such a position that the resulting ankylosis may produce the slightest possible inconvenience. Morbus Coxae. Describe morbus coxae. Inflammation of the hip-joint may begin in the head of the femur, the synovial membrane, or soft parts. It may be acute or chronic. In the acute, pain appears suddenly in the hip-joint, extending down the inside of the thigh to the inner side of the knee ; it is increased by pressure and motion, and is worse at night; the thigh is flexed upon the abdomen and rotated inward, the leg shortened ; there are fever, restlessness, and systemic disturbance ; the hip is swollen, and if resolution does not occur suppuration and abscesses follow ; destruction of the head of the femur; luxa- tion of the joint; hectic and pyaemic symptoms supervene, quickly followed by death, or the suppuration may cease and the patient recover with a damaged joint.. In the chronic form the pains are intermittent, the joint is weak, the foot is dragged, there will be vespertine fever ; after a longer or shorter period these symptoms become more marked and the acute form develops, but is not so rapid as where the disease commences as acute: it may terminate in death, but more frequently recovery takes place with shortening of the limb, the formation of a false joint, and more or less impair- ment of the usefulness of the joint. 152 GENERAL DISEASES. The treatment comprises absolute rest of the part by means of a splint or plaster bandage, resection, surgical interference, and sub- sequent application of apparatus to correct the deformity. A gen- eral treatment must also be followed : cod-liver oil, iron, tonics, diet, hygiene, etc. White Swelling. Describe white swelling of the knee. This begins most frequently in the synovial membrane, next in the condyles of the femur, least frequently in the head of the tibia. The symptoms presented are stiffness, swelling, and increased temperature of the part, with pain increased on pressure and mo- tion, and extending down to the foot. The leg is flexed upon the thigh ; the skin is white, tense, and shining: if suppuration begins, abscesses form and the skin becomes red and fluctuation occurs; the pus may burrow up the thigh or down to the ankle; luxation of the joint may occur from destruction of the bones, notably the tibia. The disease may terminate without any marked impairment of the joint; in false ankylosis from ligamentous union of the dis- eased bones; in true ankylosis from bony union; or in death from exhaustion or pyaemia. The treatment is similar to that of the other joints, except that amputation at the thigh may become necessary, or excision of the joint. Inflammation of the Ankle- and Elbow-joints. Describe inflammation of the ankle-joint. The conditions here correspond to those of the other joints : swell- ing, tension of the skin, impaired motion, pain radiating over the foot, suppuration, with caries of the bones or destruction of the joint, with deformity of the foot or ankylosis. The treatment resolves itself into excision of the joint or amputation. Describe inflammation of the elbow-joint. The same conditions of swelling, tension, pain, and impaired motion are present. The forearm is flexed upon the arm midway between pronation and supination ; the forearm and arm are ema- ciated, making the tumefaction at the elbow more prominent. After recovery the joint is deformed and ankylosed. Death sometimes occurs. SKIN DISEASES. 153 In the treatment amputation or excision of the joint must be considered. SKIN DISEASES. Describe erythema papulosum neonatorum. Erythema papulosum consists of small, dark-red papules on a red base, attended with itching, appearing chiefly on the breast and back, and due to local irritants, as the clothing, etc. It lasts but a few days, fourteen at the longest, and is followed by desquamation. There are no constitutional symptoms. It must be differentiated from scarlatina, which it closely resembles. The treatment comprises removal of the cause—i. e. the substitu- tion of soft, unirritating garments—and inunctions. Describe intertrigo. Intertrigo, or chafing, affects the groins, nates, buttocks, axillary region, and folds of the integument in fat children. It is due to heat and moisture, diarrhceal discharges, and urine. It varies in degree from simple redness with moisture to a gangrenous condi- tion. In the most common variety the epidermis is destroyed and the cutis exposed. The treatment consists in strict cleanliness, drying the part thor- oughly, and dusting with some medicated powder. Lycopodium alone or with zinc oxide is one of the best. Other powders, used alone or in combination, are starch, ac. boracic, impure carbonate of zinc (calamina), calcined magnesia, powdered chalk, etc. If the cause is diarrhoea, this must be corrected before the intertrigo will disappear. Describe furunculosis. Single furuncles present the same conditions as in the adult, and require a similar treatment. Frequently children, especially those of tuberculous parents, are attacked by large numbers of small boils, occupying all parts of the body, but especially the head. These spots are very painful, surrounded by a zone of inflamma- tion, and terminate in suppuration, the pus being thick and yellow or sometimes bloody. A core is rarely expelled. The glands in the neighborhood are enlarged and tender. Children with this affection are restless and peevish, lose their appetite, become pale and anaemic, and, if the disease is very extensive or stubborn, will become feverish and take to their beds. In the local treatment the boils should be opened as soon as sup- 154 SKIN DISEASES. puration occurs, after which healing can be hastened by the appli- cation of some simple ointment. Where the hairy scalp is attacked, in which case crusts form, matting the hairs together, these crusts can be softened and the tension on the hairs removed by simple ointments or oily mixtures repeatedly applied to the scalp. The general treatment calls for anodynes, hypnotics, and tonic remedies. Describe pemphigus in children. Pemphigus consists of yellow blebs upon the skin, varying in number and size, most abundant upon the face and trunk, and occurring more frequently in infants than in older children. At first the skin is red ; then the bleb forms ; this bursts or dries up ; a scab remains surrounded by a red areola; when this separates the skin appears normal; no scar results unless diphtheritic in- flammation has attacked the part. The cause of the disease is supposed to be contagion. The treatment is local: inunction of the denuded surface with some simple or antiseptic ointment. Describe scabies. Scabies, or itch, is a disease of the skin produced by the parasite acarus scabiei. The female burrows beneath the skin, where she lays her eggs, which will be seen as a curved, brownish-black line, terminating in a point of inflammation, at which point the insect is located. In recent cases only papules or vesicles will be found where the insect has entered the skin, but has not commenced bur- rowing. The disease involves all parts of the body, but is most marked upon the hands, buttocks, and abdomen. It is attended with intense itching, but young children, not being able to scratch themselves, have the disease in a milder form than older children, in whom the entire body may be covered, as scratching causes the disease to spread. In severity it may vary from a few isolated papules to extensive ulcers due to the coalescing of the pustules. It is extremely contagious, and sometimes very stubborn, resisting all treatment. The treatment consists in thorough scrubbing of the skin with hot water, soap, and a nail-brush, so as to break open all the vesi- cles and pustules, and, after drying the surface, a liberal inunction with sulphur ointment. This should be done at night. In the morning the ointment should be washed off with soap and water, and the child dressed in new or absolutely clean clothes. The SKIN DISEASES. 155 infected clothing should be baked in a hot oven for at least six hours, when it can be washed in the usual way and worn. It is better, however, to burn it. Other remedies used are—inunctions of balsam of Peru at night and a hot bath in the morning, using the same precautions about the clothes ; green soap, zinc-oxide and tar ointments, and sulphur baths. The child's general condition needs improvement with tonics, general diet, etc. Describe congenital naevi. Congenital naevi are due to an excessive deposit of coloring mat- ter in the skin, the color varying from yellow to brown or black. They are of irregular shape and all sizes. The affected skin is generally elevated and covered more or less profusely with hair. They produce no symptoms. The treatment consists of the removal of the deformities: this can be accomplished by surgical interference, electrolysis, vaccina- tion, or the application of some caustic. Describe burns and frost-bites. Burns in children produce the same results as in adults, except that they are more apt to get up a high grade of fever, and pro- duce more marked nervous phenomena, sometimes causing convul- sions. The treatment indicated is soothing applications and protection of the part from the air, simple ointment, lard, linseed oil and lime- water, olive oil, etc., followed by cotton or lint dressings; keep opposing surfaces, as between the fingers and toes, separated; open all blisters, but avoid removing the epidermis ; prevent contractions by apparatus. Treat the constitutional symptoms. Frost-bites in children present chiefly redness, swelling, and itch- ing, or in a more severe form bloody blisters: these conditions are for the most part confined to the feet, and are due to exposure to snow or disregard of cold and wet feet. The simpler forms are best treated by frictions with snow ; after- ward the parts should be anointed with soothing ointments. In the severer forms, where the blisters break, ulcers result, and should be treated as such with stimulating applications. INDEX. A. Acute myelitis, 94, 95 Ascites, 64 Asphyxia, 27 At birth, changes in circulation, condition of blood, 19 general condition, 17 pulse and respiration, 19 various secretions, 18 Atelectasis jpulmonum, 28, 83 B. Balanitis, 111 Bladder, hernia, 108 malformations, 107 Bronchitis, 78, 79 Bulimia, 48 Burns, 155 c. Care and feeding, 23-25 Catarrhus intestinalis, 52, 53 Cephalsematoma, 29 Cerebral anaemia, 90 carcinoma, 93 entozoa, 93 neoplasms, 93 sclerosis, 92 tubercles, 93 Cerebro-spinal meningitis, 130 symptoms, 131 treatment, 132 Chicken-pox, 124 Cholera, symptoms, etc., 132, 133 treatment, 134 Chorea, 98, 99 Cleft palate, 37 Congenital fistula of neck, 47 Conjunctivitis, 35 Constipation, 50 Constriction of anus, 58 Coryza, 73 Cryptorchidism, 112 Cystitis, 108 D. Development, 19 Diabetes insipidus, 138 mellitus, 138 Diarrhoea, 50 Diphtheria, 125 symptoms, 126 treatment, 127 varieties, 126 Dysentery, 55 Dyspepsia, 48 E. Ear, diseases, 102 foreign bodies in, 104 inflammations, 102-104 malformations, 102 Eclampsia, 97 Ectopia, 107 Emphysema, 83 a Endocarditis, 67 Enteritis folliculosa, 54 Enuresis, 109 Epilepsy, 99, 100 Epispadia, 111 Epistaxis, 72, 73 Erysipelas, 136 Erythema, 153 Essential paralysis, 98 . Examination, 21, 22 Eye, diseases, 101, 102 157 158 INDEX. F. Facial paralysis, 98 Female genitals, malformations, Fissure of anus, 57 Flatulence, 49 Frost-bites, 155 G. Gangrene, lungs, 85 Gastritis, 51 H. Haemoptysis, 84 Hare-lip, 37 Heart, abnormities, 65, 66 Hereditary syphilis, 142 Hydrocele, 113 varieties, 113 Hydrocephalus, acute, 88, 89 chronic, 91 Hydropericardium, 69 Hydrothorax, 87 Hypospadia, 111 I. Icterus, 34 Idiocy, 101 Imbecility, 101 Imperforate anus, 58 Infarction, 84 uric-acid, 105 Inguinal hernia, 56 Insanity, 101 Insolation, 90 Intermittent fever, 137 Intertrigo, 153 Intestinal worms, 58-60 Intussusception, 56 Ischuria, 109 K. Kidneys, malformations, 105 L. Laryngismus, 76 Laryngitis, 75 Leucorrhoea, 115 Liver, diseases, 61 fatty, 62 Liver, malformations, 62 syphilis, 61 M. Mastitis, 36 Masturbation, 112 Measles, 118 stages, 119 treatment, 120 varieties, 119 Meatus, urethral, closure, 111 Melaeua, 31 Meningitis, acute, 89, 90 cerebro-spinal, 132 tubercular, 88, 89 Microstoma, 37 Mumps, 135 Myelitis, acute, 94, 95 N. Nsevus, 71 congenital, 155 Nasal polypus, 74 Navel, diseases of, 30, 31 Nephritis, acute, 105, 106 Nocturnal cough, 85 Nose, foreign bodies in, 74 O. (Esophagus, inflammation, 47 P. Paralysis glottidis, 77 Paraphimosis, 111, 112 Parotis, 44 Pemphigus, 154 Pericarditis, 68 Peritonitis, 63 " Phimosis, 110 Pityriasis linguae, 44 Pleurisy, 86, 87 Pneumonia, 80-82 Pott's disease, 149 Prolapsus ani, 57 Pulmonary oedema, 84 K. Eectal polypi, 57 Renal calculi, 107 INDEX. 159 Renal, cysts, 107 tubercles, 107 Retropharyngeal abscess, 46 Rheumatism, 70 Rickets, 139 pathology, 140 symptoms, 140 treatment, 141 Rubeola, 120, 121 S. Scabies, 154 Scarlet fever, 116 eruption, 116 symptoms, 116 treatment, 118 varieties, 117 Scleroma, 33 Sclerosis, sterno-mastoid, 47 Small-pox, 121 Spina bifida, 96 Spinal meningitis, 93, 94 paralysis, 95, 96 Spleen, diseases, 63 Sterno-mastoid sclerosis, 47 Stomach, erosions, 52 softening, 52 ulcer, 52 Stomatitis, 38-43 Suctus voluptabilis, 100 Syphilis, 142 symptoms, 142 treatment, 143 T. Tabes mesenterica, 65 Teeth. 20 Tetanus, 32 Thyroid gland, diseases, 77 Thymus gland, diseases, 78 Tongue, deformities, 38 Tonsillitis, 44 Tonsils, hypertrophy, 45 Trismus, 32 Tubercular meningitis, 88, 89 Tuberculosis, 144 bones, 148, 149 ear, 147 eye, 147 joints, 150 ankle, 152 elbow, 152 morbus coxae, 151 white swelling, 152 lungs, 145 treatment, 146 lymphatic glands, 148 nose, 147 pathology, 144 periosteum, 148 • skin, 146 symptoms, 145 Typhoid fever, 127 complications, 128 lesions, 128 treatment, 129 Typhus fever, 129 treatment, 130 V. Vaginal hemorrhage, 115 Varicella, 124 Variola, 121 stages, 122 symptoms, 122 treatment, 123 varieties, 123 Varioloid, 123, 124 Vesical calculi, 110 Vomiting, 48 w. Weaning, 26 Whooping cough, 134 Worms, intestinal, 58-60 LEA BROTHERS & CO'S LIST OF THE Leading Medical Text-Books Anatomy, Dictionaries. Gray's Anatomy—12th Edition. Colors or Black. Anatomy, Descriptive and Surgical. By Henry Geay, F. E. S., Lecturer on Anatomy at St. George's Hospital, London. Edited by T. Pickering Pick, F. R. C.S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of Surgeons of England. A new American from the eleventh enlarged and improved London edition, thoroughly revised and re-edited by William W. Keen, M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia. To which is added the second American from the latest English edition of Landmarks, Medical and Surgical, by Luther Holden, F. R. C. S. 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In one handsome royal 12mo. volume of 325 pages. Cloth, $2.00. Just ready. Parrish's Pharmacy—Fifth Edition. A Treatise on Pharmacy : Designed as a Text-book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. By Edward Paekish, late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. Fifth edition, thoroughly revised, by Thomas S. "Wiegand, Ph. G. In one handsome octavo volume of 1093 pages, with 256 illustra- tions. Cloth, $5.00 ; leather, $6.00. Stille & Maisch's National Dispensatory—4th Ed. The National Dispensatory. Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. By Alfred Stille, M. D., LL. D., Professor Emeritus of the Theory and Practice of medicine and of Clinical Medicine in the University of Penn- sylvania, and John M. Maisch, Phae. D., Professor of Materia Medica and Botany in Philadelphia College of Pharmacy, Secretary to the Amer- ican Pharmaceutical Association. Fourth edition revised, and covering the new British Pharmacopoeia. In one magnificent imperial octavo vol- ume of 1794 pages, with 311 elaborate engravings. Price in cloth, $7.25 ; leather, raised bands, $8.00; half Russia, $9.00. \* This work will be furnished with Patent Ready Reference Thumb-letter Index for $1.00 in addi- tion to the price in any of the above styles of binding. We thinR. it a matter for congratulation that the profession of medicine and that of pharmacy have shown such appreciation of this great work as to call for four editions within the comparatively brief period of eight years. The matters with which it deals are of so practical a nature that neither the physician nor the pharmacist can do without the latest text-books on them, especially those that are so accurate and comprehensive as this one. The book is in every way creditable both to the au- thors and to the publishers.—New YorkMed- ical Journal, May 21,1887. Therapeutics, flaterra fledica. Hare's Practical Therapeutics—Second Edition. A Text-Book of Practical Therapeutics; With Especial Reference to the Application of Remedial Measures to Disease and their Employment upon a Rational Basis. By Hobaet Amoey Haee, B. Sc, M. D.#, Professor of Materia Medica and Therapeutics in the Jefferson Medical College of Philadelphia; Secretary of the Conven- tion for the Revision of the United States Pharmacopoeia of 1890. With special chapters by Des. G. E. de Schweinitz, Edward Maetin, J. Howaed Reeves and Baeton C. Hirst. New (2d) and revised edition. In one handsome octavo vol. of 650 pages. Cloth, $3.75; leather, $4.75. This work has received the rare distinc- tion among medical works of reaching a second edition six months after its first ap- pearance. Many new prescriptions have alio been inserted to illustrate the best modes of applying remedies. Among other features of this practically helpful treatise which will make reference to it convenient and profitable, are the arrangement of titles of drugs and diseases in alphabetical order, according to their English names; and a dose list of drugs officinal and unofficinal. In addition to the general index, a copious and explanatory index of diseases and rem- edies has been appended which wttl render the contents easily accessible.—The Medical Age, July 10, 1891. Maisch's Materia Medica—New (5th) Ed. Just Ready. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists and Physicians. By John M. Maisch, Phae. D., Professor of Materia Medica and Botany in the Phil- adelphia College or Pharmacy. New (fifth) edition, thoroughly revised. In one very handsome 12mo. volume of 544 pages, with 270 engravings. Cloth, $3.00. Brunton's Therapeutics and Mat. Med.—3d Ed. A Text-Book of Pharmacology, Therapeutics and Materia Medica; Including the Pharmacy, the Physiological Action and Therapeutical Uses of Drugs. By T. Laudeb Beunton, M. D., D. Sc, F. R S., F. R. C. P., Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. Adapted to the U. S. Phar- macopoeia by Feancis H. Williams, M. D., of Harvard University Medical School. Third edition. Octavo, 1305 pages, 230 illustrations. Cloth, $5.50 ; leather, $6.50. Edes' Therapeutics and Materia Medica. A Text-Book of Therapeutics and Materia Medica. Intended for the Use of Students and Practitioners. By Robeet T. Edes M. D., Jackson Professor of Clinical Medicine in Harvard University, Medical Department. Octavo, 544 pages. Cloth, $3.50; leather, $4.50. Practice of fledicine. Lyman's Practice—Just Ready. The Principles and Practice of Medicine. For the Use of Medical Students and Practitioners. By Heney M. Lyman, M. D., Professor of the Principles and Practice of Medicine, Rush Medical Col- lege, Chicago. In one very handsome octavo volume of 925 pages, with 170 illustrations. Cloth, $4.75; sheep, $5.75. The author has undertaken to present in this volume not only the results of his long experience as a practitioner and teacher, but to make it representative of the latest state of knowledge in its department. The work is assured of wide use as an unsurpassed guide for the student and likewise for the practitioner. Flint's Practice—Sixth Edition. A Treatise on the Principles and Practice of Med- icine. Designed for the use of Students and Practitioners of Medicine. By Austin Flint, M. D., LL. D., Professor of the Principles and Prac- tice of Medicine and of Clinical Medicine in Bellevue Hospital Medical College, New York. Sixth edition, thoroughly revised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Je., M. D., LL. D., Professor of Physiology, Bellevue Hospital Medical College, New York. In one very handsome octavo volume of 1160 pages, with illustrations. Cloth, $5.50; leather, $6.50. town, village, or at some cross-roads, is Flint's Practice. We make this statement to a considerable extent from personal observa- No text-book on the principles and prac- tice of medicine has ever met in this country with such general approval by medical stu- dents and practitioners as the work of Pro- fessor Flint. In all the medical colleges of the United States it is the favorite work upon Practice; and, as we have stated be- fore in alluding to it, there is no other medi- cal work that can be so generally found in the libraries of physicians. In every state and territory of this vast country the book that will be most likely to be found in the office of a medical man, whether in city, tion, and it is the testimony also of others. An examination shows that very considera- ble changes have been made in the Rixth edition. The work may undoubtedly be re- garded as fairly representing the present state of the science of medicine, and as reflecting the views of those who exemplify in their practice the present stage of pro- gress of medical art.—Cincinnati Medical News, Oct. 1886. Hartshorne's Essentials—Fifth Edition. Essentials of the Principles and Practice of Medi- cine. A Handbook for Students and Practitioners. By Heney Haets- hoene, M. D., LL. D., lately Professor of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and rewritten. In one royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75; hah'bound, $3.00. An indispensable book. No work ever very useful to students especially. These exhibited a better average of actual practical essentials are most valuable in affording the treatment than this one; and probably not means to see at a glance the whole literature one writer in our day had a better opportu- of any disease, and the most valuable treat- nity than Dr. Hartshorne for condensing all ment.—Chicago Medical Journal and Ez- the views of eminent practitioners into a aminer, April, 1882. 12mo. The numerous illustrations will be Practice of fledicine, Histology, Pathology. Whitla's Dictionary of Treatment. A Dictionary of Treatment; or Therapeutic Index, including Medical and Surgical Therapeutics. By William Whitla, M. D., Professor of Materia Medica and Therapeutics in the Queen's College, Belfast. Revised and adapted to the United States Phar- macopoeia. In one square, octavo volume of 917 pages. Cloth, $4.00. Fothergill's Handbook of Treatment—3d Edition. The Practitioner's Handbook of Treatment; Or, the Principles of Therapeutics. By J. M. Fotheegill, M.D., Edin., M.E.C.P., Lond., Physician to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. vol. of 661 pages. Cloth,*$3.75 ; leather, $4.75. Flint's Auscultation and Percussion—Fifth Edition. A Manual of Auscultation and Percussion; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M. D., LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. Fifth edition. Edited by James C. Wilson, M. D., Lecturer on Physical Diag- nosis in the Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volame of 274 pages, with 12 illustrations. Cloth, $1.75. Gibbes' Pathology and Histology. Practical Pathology and Morbid Histology. By Heneage Gibbes, M. D., Professor of Pathology in the University of Michigan, Medical Department. In one very handsome octavo volume of 314 pages, with 60 illustrations, mostly photographic. Cloth, $2.75. sues the book leaves little to be desired. The work is throughout profusely illustrated This is, in part, an expansion of the little work published by the author some years ago, and his acknowledged skill as a practi- cal microscopist will give weight to his in- structions. Indeed, in fulness of directions as to the modes of investigating morbid tis- with reproductions of micro-photographs. We may say that the practical histologist will gain much useful information from the book.—The London Lancet, January 23,1892. Green's Pathology and Morbid Anatomy—7th Ed. Pathology and Morbid Anatomy. By T. Heney Geeen, M. D., Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hos- pital Medical School, London. Sixth American from the seventh revised English edition. Octavo, 539 pages, with 167 engravings. Cloth, $2.75. It is better adapted to the wants of gen- eral practitioners than any work of the kind with which we are acquainted. The cuts exhibit the appearances of pathological structures just as they are seen through the microscope. The fact that it is so generally employed as a text-book by medical students is evidence that we have not spoken too much in its favor.—Cincinnati Medical News, Octo- ber, 1889. Pathology, Histology, Bacteriology. Payne's General Pathology. A Manual of General Pathology. Designed as an Intro- duction to the Practice of Medicine. By JosEPn F. Payne, M. D., F. R. C. P., Senior Assistant Physician and Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. Octavo of 524 pages, with 152 illustrations and a colored plate. Cloth, $3.50. in those diseases now with reasonable cer- tainty ascribed to pathogenetic microbes. In this department he has been very full and explicit, not only in a descriptive man- ner, but in the technique of investigation. The Appendix, giving methods of research, is alone worth the price of the book, several times over, to every student of pathology.— St. Louis Med. and Surgical Jour., Jan. 1889. Knowing, as a teacher and examiner, the exact needs of medical students, the author has in the work before us prepared for their especial use what we do not hesitate to say is the best introduction to general pathology that we have yet examined. A departure which our author has taken is the greater attention paid to the causation of disease, and more especially to the etiological factors Klein's Histology—Fourth Edition. Elements of Histology. By E. Klein, M. D., F. R. S., Joint Lecturer on General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, London. Fourth edition. In one 12mo. volume of 376 pages, with 194 illustrations. Limp cloth, $1.75. Abbott's Bacteriology. The Principles of Bacteriology: a Practical Manual for Students and Physicians. By A. C. Abbott, M. D., First Assistant, Lab- oratory of Hygiene, Univeisity of Pennsylvania, Philadelphia. In one 12mo. volume of 259 pages, with 32 illustrations. Cloth, $2.00. Just ready, On reading this manual of Dr. Abbott, any one familiar with the subject will readily recognize the fact that the book is not merely a compilation from other works, but one giving evidence of the originality of the author, as well as complete knowledge of the practical details of bacteriology. His "scheme for the study of an organism" furnishes an excellent guide to the student. Of equal importance is the chapter on disin- fectants, antiseptics and skin disinfection. It will form a valuable addition to the litera- ture of laboratory technique and bacterio- logical investigation.—The Therapeutic Ga- zette, May 16,1892. Senn's Surgical Bacteriology—Second Edition. Surgical Bacteriology. By Nicholas Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago. New (second) edition. In one handsome octavo of 268 pages, with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. Coats' Pathology. A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Pathologist to the Glasgow Western Infirmary. In one very handsome octavo volume of 829 pages, with 339 beautiful illustrations. Cloth, $5.50; leather, $6.50. Nervous and flental Diseases, Surgery. Gray on Nervous and Mental Diseases. A Practical Treatise on Nervous and Mental Dis- eases. By Landon Caeter Gray, M. D.. Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. Shortly. rTTHIS work is devoted purely to the practical aspects of nervous and mental -*- diseases, especial care being taken to present the fundamental knowledge essential to a grasp of its subjects and to cast everything in the clearest possible form. The series of illustrations is rich and unique, embracing a large num- ber of photographic engravings of exceptional vividness and interest. By the employment of a style at once concise and clear, and by careful arrangement, the author is enabled to include an exposition of a vast and important subject in a condensed and convenient form. It will be an admirable work for the student as well as for the practitioner. Ross on Nervous Diseases. A Handbook on Diseases of the Nervous System. By James Ross, M. D., F. R. C. P., LL. D., Senior Assistant Physician to the Manchester Royal Infirmary. In one octavo volume of 725 pages, with 184 illustrations. Cloth, $4.50; leather, $5.50. highest praise, and will no doubt be found of the greatest value to the student as well as to the practitioner.—Edinburgh Medical This admirable work is intended for students of medicine and for such medical men as have no time for lengthy treatises. In every part this handbook merits the Journal, Jan. 1887. Roberts' Modern Surgery. The Principles and Practice of Modern Surgery. For the use of Students and Practitioners of Medicine and Surgery. By John B. Roberts, M. D., Professor of Anatomy and Surgery in the Phila- delphia Polyclinic; Professor of the Principles and Practice of Surgery in the Woman's Medical College of Pennsylvania; Lecturer in Anatomy in the University of Pennsylvania. In one very handsome octavo volume of 780 pages, with 501 illustrations. Cloth, $4.50; leather, $5.50. vanced doctrines and methods of practice of the present day. Its general arrangement follows this rule, and the author in his desire This work is a very comprehensive man- ual upon general surgery, and will doubtless meet with a favorable reception by the pro- fession. It has a thoroughly practical charac- ter, the subjects are treated with rare judg- ment, its conclusions are in accord with those of the leading practitioners of the art, and its literature is fully up to all the ad- to be concise and practical is at times almost dogmatic, but this is entirely excusable con- sidering the admirable manner in which he has thus increased the usefulness of his work.—Medical Record, Jan. 17,1891. Erichsen's Surgery—Eighth Edition. The Science and Art of Surgery; Being a Treatise on Surgical Inj uries, Diseases and Operations. By John E. Erichsen, F. R. S., F R C S., Professor of Surgery in University College, London, etc. From the eighth and enlarged English edition. In two large 8vo. volumes of 2316 pages, with 984 engravings on wood. Cloth, $9.00 ; leather, $11.00. Surgery. Ashhurst's Surgery—Fifth Edition. The Principles and Practice of Surgery. By Jonx Ashhurst, Jr., M. D., Barton Professor of Surgery and Clinical Surgery in the University of Penn'a; Surgeon to the Penn'a Hospital, Phila. Fifth edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 1144 pages, with 642 illas. Cloth, $6.00; leather, $7.00. A complete and most excellent work on surgery. It is only necessary to examine it to see at once its excellence and real merit either as text-book for the student or guide for the general practitioner. It fully considers in detail every surgical injury and disease to which the body is liable, and every advance in surgery worth noting is to be found in its proper place. It is un- questionably the best and most complete single volume on surgery, in the English language, and cannot but receive that con- tinued appreciation which its merits justly demand.—Southern Practitioner, Feb. 1890. Druitt's Modern Surgery. Manual of Modern Surgery. By Robert Druitt, M. R. C. S., etc. Twelfth edition, thoroughly revised by Stanley Boyd, M. B., B. S., F. R. C. S. In one 8vo. volume of 965 pages, with 373 illus- trations. Cloth, $4.00; leather, §5.00. Bryant's Surgery—Fourth Edition. The Practice of Surgery. By Thomas Bryant, F.R.C.S., Surgeon and Lecturer on Surgery at Guy's Hospital, London. Fourth American from the fourth and revised English edition. In one large and very handsome imperial octavo volume of 1040 pages, with 727 illustra- tions. Cloth, $6.50 ; leather, $7.50. Wharton's Minor Surgery and Bandaging. Minor Surgery and Bandaging. By Henry R. Whar- ton, M.D., Demonstrator of Surgery and Lecturer on Surgical Diseases of Children in the University of Penna. In one very handsome 12mo. volume of 498 pp., with 403 engravings, many being photographic. Cloth, $3.00. This new work must take a first rank as soon as examined. Bandaging is well de- scribed by words, and the methods are illus- trated by photographic drawing?, so to make plain each step taken in the application of bandages of various kinds to different parts of the body and extremities—including the head. The various operations are likewise described and illustrated, so that it would seem easy for the tyro to do the gravest amputation. The various established opera- tions are described in detail. Hence this work becomes a most valuable companion- book to any of the more pretentious treatises on surgery, where simply the general advice is given to bandage, amputate intubate, operate, etc. For the student and young surgeon, it is a very valuable instruction book from which to learn how to do what may be advised, in general terms, to be done. — Virginia Medical Monthly, October, 1891. Holmes' Treatise on Surgery. A Treatise on Surgery; Its Principles and Practice. By Timothy Holmes, M.A., Surgeon and Lecturer on Surgery at St. George's Hospital, London. From the fifth English edition, edited by T. Pickering Pick, F. R. C. S. In one octavo volume of 997 pages, with 428 illustrations. Cloth, $6.00; leather, $7.00. Surgery. Treves' Operative Surgery. A Manual of Operative Surgery. By Frederick Treves, F. R. C. S., Surgeon and Lecturer on Anatomy at the London Hospital. In two octavo volumes containing 1550 pages, with 422 original engravings. Complete work, cloth, $9.00; leather, $11.00. We have no hesitation in declaring it the best work on the subject in the English language, and indeed in many respects the best in any language. We feel called upon to recommend the book so strongly for the excellent judgment displayed in the arduous task of selecting from among the thousands of varying procedures those most worthy of description; for the way in which the still more difficult task of choosing among the best of those has'been accomplished; and for the simple, clear, straightforward manner in which the information thus gathered from all surgical literature has been con- veyed to the reader.—Annals of Surgery, March, 1892. Smith's Operative Surgery. The Principles and Practice of Operative Surgery. By Stephen Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. Second and thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 1005 illustrations. Cloth, $4.00; leather, $5.00. It can he truly said that as a handbook will its readers, no matter how unusual the for the student, a companion for the sur- subject, consult its pages in vain Its com- geon, and even as a book of reference for the pact form, excellent print, numerous illustra- physician not especially engaged in the tions, and especially its decidedly practical practice of surgery, this volume will long character, all combine to commend it.—Bos- hold a most conspicuous place, and seldom ton Medical and Surgical Journal, May 10, '88. Hamilton on Fractures and Dislocations. A Practical Treatise on Fractures and Dislocations. By Frank H. Hamilton, M. D., LL. D., Surgeon to Bellevue Hospital, New York. New (eighth) edition, revised and edited by Stephen Smith, A. M., M. D., Professor of Chnical Surgery in the University of the City of New York. In one very handsome octavo volume of 832 pages, with 507 illustrations. Cloth, $5.50; leather, $6.50. It is pre-eminently the authority on frac- The more one reads the more one is im- tures and dislocations, and universally pressed with its completeness. The work quoted as such. The additions it has re- has been accomplished, and has been done ceived by its recent revision make it a work clearly, concisely, excellently well.—Boston thoroughly in accordance with modern prac- Medical and Surgical Journal, May 26,1892. tice, theoretically, mechanically, aseptically. Stimson's Operative Surgery. A Manual of Operative Surgery. By Lewis A. Stimson, B. A. M. D., Professor of Clinical Surgery in the Medical Faculty of the University of the City of New York. Second edition. In one very hand- some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. Surgery, Ophthalmology, Otology. Stimson on Fractures and Dislocations. A Treatise on Fractures and Dislocations. In two handsome octavo volumes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, cloth, $5.50 j leather, $7.50. Either volume separately, cloth, $3.00 ; leather, $4.00. The appearance of the second volume marks the completion of the author's origi- nal plan of preparing a work which should present in the fullest manner all that is known on the cognate subjects of Fractures and Dislocations. The volume on Fractures assumed at once the position of authority on the subject, and its companion on Disloca- tions will no doubt be similarly received.— Cincinnati Medical News, May, 1888. Norris & Oliver on the Eye—In Press. A Text-Book of Ophthalmology. By William F. Norris, M. D., Clinical Professor of Ophthalmology in University of Penna., and Charles A. Oliver, M.D. In one octavo volume of about 800 pages, richly illustrated with engravings and colored plates. In press. TN PREPARING this volume the authors have had in view the needs of ■*- students, physicians and specialists. Its concise and clear style, its completeness and the beautiful series of illustrations will at once render it a favorite work with all classes for whom it is intended. Nettleship's Students' Guide to the Eye—5th Ed. Diseases of the Eye. By Edward Nettleship, F.R.C.S., Ophthalmic Surgeon at St. Thomas' Hospital, London. Surgeon to the Royal London (Moorfields) Ophthalmic Hospital. Fourth American from the fifth English edition, thoroughly revised. With a Supplement on the Detection of Color Blindness, by William Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 12mo. volume of 500 pages, with 164 illustrations, selections from Snellen's test-types and formulae, and a colored plate. Cloth, $2.00. It was primarily intended for the use of students, and supplies their needs admir- ably, but it is as useful for the practitioner. It does not presuppose the large amount of recondite knowledge to be present which seems to be assumed in some of our larger works, is not tedious from over-conciseness, and yet covers the more important parts of clinical ophthalmology.—New York Medical Journal, December 13,1890. Burnett on the Ear. The Ear; Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. By Charles H. Burnett, A.M., M.D., Professor of Otology in the Philadel- phia Polyclinic ; President of the American Otological Society. Second edition. In one handsome octavo volume of 580 pages, with 107 illustra- tions. Cloth, $4.00 ; leather, $5-00. Dr. Burnett has fully maintained his rep- utation, for the book is replete with valuable information and suggestions. The revision has been carefully carried out, and much new matter added. Dr. Burnett's- work must be regarded as a very valuable contri- J bution to aural surgery, not only on account of its comprehensiveness, but because it con- tains the results of the careful personal observation and experience of this eminent aural surgeon.—London Lancet, Feb. 21,1885. Urinary, Venereal, Skin. Roberts on Urinary Diseases—Fourth Edition. A Practical Treatise on Urinary and Renal Diseases, including Urinary Deposits. By Sir William Roberts, M. D., Lecturer on Medicine in the Manchester School of Medicine, etc. Fourth American from the fourth London edition. In one handsome octavo of 609 pages, with 81 illustrations. Cloth, $3.50. Jackson on the Skin—Just Ready. The Ready-Reference Handbook of Skin Diseases. By George Thomas Jackson, M. D., Professor of Dermatology, Women's Medical College, New York Infirmary. In one 12mo. volume of 450 pages with 50 illustrations. Cloth, $2.75. This volume is devoted to the art of dermatology, to the practice of this department of medicine in its latest development. No attempt has been made to discuss debatable questions, and pathology and etiology do not receive as full consideration as symptomatology, diagnosis and treatment. The alphabetical arrangement of the different diseases has been adopted as conducive to the greatest possible convenience in use. The pages are illustrated with a large number of engravings, many being photographic and vivid reproductions of actual cases. A handsome lithographic frontis- piece adds to the beauty and usefulness of a volume for which a wide recog- nition is assured. ________________ Culver & Hayden on Venereal Diseases. A Manual of Venereal Diseases. By E M. Culver, M D Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New 'York, and J. R. Hayden, M. D., Chief of Clinic Venereal Depart- ment Vanderbilt Clinic, College of Physicians and Surgeons, New York. In one 12mo. volume of 289 pages, with 33 illustrations. Cloth, $1.75. Hyde on the Skin—Second Edition. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. By J. Nevins Hyde, A.M., M.D., Prof of Dermatology and Venereal Diseases in Rush Med. College, Chicago. Second edition. In one handsome octavo volume of 676 pages, 2 colored plates and 85 beautiful and elaborate illus. Cloth, $4.50 ; leather, $5.50. into his book all the best of that which the past years have brought forth. The pre- scriptions and formulae are given in both common and metric systems. Text and His treatise is like his clinical instruction, admirably arranged, attractive in diction and strikingly practical throughout. No clearer description of the lesions oftne skin is to be met with anywhere. Dr. Hyde has shown himself a comprehensive reader of the latest literature, and has incorporated illustrations are good, and colored plates ot rare cases lend additional attractions.—-Med- teal Press of Western New York, June, 1888. Hardaway's Manual of Skin Diseases. Manual of Skin Diseases. With Special Reference to Diagnosis and Treatment. For the Use of Students and General Practi- tioners By W. A. Hardaway, M. D., Professor of Skin Diseases in the Missouri Medical College, St. Louis. 12mo., 440 pages. Cloth, $3.00. Gynecology. Thomas & Munde on Women—Sixth Edition. A Practical Treatise on the Diseases of "Women. By T. Gaillard Thomas, M. D., LL. D., Emeritus Professor of Diseases of Women in the College of Physicians and Surgeons, New York, and Paul F. Munde, M. D., Professor of Gynecology in the New York Poly- clinic. New (sixth) edition, thoroughly revised and rewritten by Dr Munde\ In one large handsome octavo volume of 824 pages, with 347 illus- trations, of which 201 are new. Cloth, $5.00; leather, $6.00. Probably no treatise ever written by an American author on a medical topic has been accepted by more practitioners, as a standard text-book, or read with pleasure and profit by more medical students than Thomas on the diseases of women. This volume in classic excellence, elegance of dic- tion and scholarly and scientific statement must remain what it long has been, a stand- ard text-book both for practitioner and stu- dent, at home and abroad, and an enduring pride to American gynecologists.—lite Brooklyn Medical Journal, March, 1892. Davenport's Non-Surgical Gynaecology—New Ed. Diseases of Women, a Manual of Won-Surgical Gynaecology. Designed especially for the Ute of Students and General Practitioners. By F. H. Davenport, M. D., Assistant in Gynaecology in the Medical Department of Harvard University, Boston. New (second) edition. In one handsome 12mo. volume of 314 pages, with 106 illustra- tions. Cloth, $1.75. Just ready. Comparatively few practitioners are pre- pared to perform the graver gynecological operations, but all are compelled to deal with the multitudinous ailments of women, and in many instances non-surgical measures are preferable, though neglected by those whose special skill has enlarged the field of opera- tive interference. The present volume deals with nothing which has not stood the actual test of experience, and being concisely and clearly written it conveys a great amount ef information in a convenient space. The demand for two editions in less than three years confirms its usefulness.—The Medical Brief, August, 1892. May on Diseases of Women—Second Edition. A Manual of the Diseases of Women. Being a concise and systematic exposition of the theory and practice of Gynecology. By Charles H. May, M. D., late House Surgeon to Mount Sinai Hospital, New York. Second edition, edited by L. S. Eau, M.D., Attending Gynecol- In one 12mo. volume of 360 pages, ogist at the Harlem Hospital, N. Y. with 31 illustrations. Cloth, $1.75. This is a manual of gynecology in a very condensed form, and the fact that a second edition has been called for indicates that it has met with a favorable reception. It is intended, the author tells us, to aid the stu- dent who after having carefully perused lar- fer works desires to review the subject, and e adds that it may be useful to the prac- titioner who wishes to refresh his memory rapidly but has not the time to consult lar- ger woiks.—The Physician and Surgeon, June, 1890. Obstetrics. Parvin's Obstetrics—Second Edition. The Science and Art of Obstetrics. By Theophilus Parvin, M. D., LL. D., Professor of Obstetrics and the Diseases of Women and Children in Jefferson Medical College, Philadelphia. Second edition. In one handsome 8vo. volume of 701 pages, with 239 engravings and a colored plate. Cloth, $4.25 ; leather, $5.25. The second edition of this work is fully up to the present state of advancement of the obstetric art. Rarely in the range of ob- stetric literature can be found a work which is so comprehensive and yet compact and ripe scholar.—Medical Record, Jan. 17,1891 practical. In such respect it is essentially a text-book of the first merit. The treatment of the subject gives a real value to the work —the individualities of a practical teacher, a skilful obstetrician, a close thinker and a Playfair's Midwifery—Seventh Edition. A Treatise on the Science and Practice of Mid- wifery. By W. S. Playfair, M. D., F. R. C. P., Professor of Obstetric Medicine in King's College, London, etc. Fifth American, from the seventh English edition. Edited, with additions, by Robert P. Harris, M. D. In one handsome octavo volume of 664 pages, with 207 engravings and 5 plates. Cloth, $4.00 ; leather, $5.00. Truly a wonderful book; an epitome of all obstetrical knowledge, full, clear and con- cise. In thirteen years it has reached seven editions. It is perhaps the most popular work of its kind ever presented to the pro- fession. Beginning with the anatomy and physiology of the organs concerned, nothing is left un written that the practical accoucheur should know. It seems that every conceiv- able physiological or pathological condition from the moment of conception to the time of complete involution has had the author's patient attention. The plates and illustra- tions, carefully studied, will teach the sci- ence of midwifery. The reader of this book will have before him the very latest and best of obstetric practice, and also of all the coincident troubles connected therewith.— Southern Practitioner, December, 1889. King's Obstetrics—New Edition. Just Ready. A Manual of Obstetrics. By A. F. A. King, M. D., Pro- fessor of Obstetrics and Diseases of Women in the Medical Department of the Columbian University, Washington, D. C, and in the University of Vermont, etc. New (Fifth) edition with 150 illustrations. Cloth, $2.50. So comprehensive a treats could not be brought within the limits of a book of this size, were not two things especially true. First, Dr. King is a teacher of many years' experience, and knows just how to present his subjects in a manner for them to be best received; and.secondly, he can put his ideas in a clear and concise form. In other words, he knows how to use the English language. He gives us the plain truth, free from un- In one 12mo. volume of 450 pages, necessary ornamentation. Therefore we say there are nine hundred pages of matter be- tween the covers of this manual of four hundred and fifty pages. We cannot imag- ine a better manual for the hard-worked student; while its clean and practical teach- ings make it invaluable to the busy practi- tioner. The illustrations add much to the subject matter.—The National Medical Review, October, 1892. Dis. of Children, fled. Juris., Periodicals. Smith on Children—Seventh Edition. A Treatise on the Diseases of Infancy and Child- hood. By J. Lewis Smith, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. New (seventh) edition, thoroughly revised and rewritten. In one handsome octavo vol- ume of 881 pages, with 51 illustrations. Cloth, $4.50; leather, $5.50. in accordance with the progress of th< times. It still stands foremost as the American text- book. The literary style could not be ex- celled, its advice is always conservative and thorough, and the evidence of research has long since placed its author in the front rank of medical teachers.—The American Journal of the Medical Sciences, Dec. 1891. We have always considered Dr. Smith's book as one of the very best on the subject. It has always been practical—a field book, theoretical where theory has been deduced from practical experience. One seldom fails to find here a practical suggestion after search in other works has been"in vain. In the seventh edition we note a variety of changes Taylor's Medical Jurisprudence—New Edition. A Manual of Medical Jurisprudence. By Alfred S. Taylor, M. D., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. New American from the twelfth English edi- tion. Thoroughly revised by Clark Bell, Esq. , of the New York Bar. Octavo, 800 pages, 56 illus. Cloth, $4.50 ; leather, $5.50. Just ready. Subscription Price Reduced to $4.00 Per Annum. THE nEblOIL NEWS. The Medical News is alive to the wants of medical men in active practice and understands their adequate supply. The great circle of readers thus secured has rendered possible the reduction in the price of The News to Four Dollars per year, so that it is now by far the cheapest as well as the best large weekly journal published in America. In a word The Medical News is a crisp, fresh, weekly newspaper and as such occupies a well-marked sphere of usefulness, distinct and com- plementary to the ideal monthly magazine, The American Journal of the Medical Sciences. TJb American Journal of the HJedical $cience& Published Monthly, at $4.00. Per Annum. Published continuously since 1820, The American Journal has been the medium chosen by the best minds of the profession during this period for the presentation of their ablest papers. It has therefore well earned the praise accorded it by an unquestioned authority—"from this file alone, were all other publications of the press for the last fifty years destroyed,. it would be possible to reproduce the great majority of the real contribu- tions of the world to medical science during that period." LEA BROTHERS & CO., Publishers, 706, 708 & 710 Sansom St., PHILA. WS 100 R476d 1892 48820570R NLM 05255136 7 NATIONAL LIBRARY OF MEOICINE