and into the muscles of the paralysed limb. I have seen this method used without obvious benefit. The injection may be made daily or every other day. I regard it as trifling in importance and not worth the risk of causing local disturbances.

Belton Massey advises in the initial stage blisters over the small of the back when the legs are affected; or at the nape of the neck when the arms are involved. Revulsives have been applied to the affected limbs. This, in my opinion, should be done with the greatest caution, for fear of inducing trophic lesions. When the blistered surfaces are healed the gentle, constant current should be applied over the back for two or three minutes, the poles being placed close together, the positive being above the negative; the current should be interrupted by the commutator, so as to cause contraction of the spinal muscles. In my opinion actual vesication should be avoided.

Nitrate of silver gr.

t.d.s., in pillule, for a child a year old, Care should be taken not to pro

has been lauded by some. duce pigmentation of the skin by long continuance of the drug. It is usually voted valueless. Minute doses of strychnia, gr. bo in pillules, twice or thrice a day, is said to have completely cured in a few weeks cases that resisted all other treatment. This I should strongly doubt.

BELL'S PALSY.-FACIAL PALSY.

Pressure of instruments during delivery, "rheumatic' inflammation from local action of cold, as in riding in the draught in a railway compartment, inflammation associated with otitis or otorrhoea, are important causes of total facial palsy in childhood. Thus the disease has the same causation as in the adult. The symptoms are precisely the same as in the adult, including the reaction of degeneration. This latter is not always observed in the rheumatic cases,

which may recover before any loss of reaction to faradism occurs. The first two causes are favourable to recovery. Recovery never follows the last form when there has been extensive ear disease. I agree with Dr. Gowers in not having seen palatal palsy in association with paralysis of the facial nerve. It is said that the petrosal branches of the facial nerve supply the palate. This is very doubtful (see Gowers' "Diagnosis of Diseases of the Brain," p. 92). True taste is lost in the anterior two-thirds of the tongue, when the nerve is inflamed before the chorda is given off.

Facial palsy from forceps pressure does not need much treatment. The face should be carefully protected as in any infant. Galvanism can rarely be needed for it. It usually subsides spontaneously, as a rule, in less than a week. Rheumatic paralysis should be treated by the constant current, by protection of the face from cold, by stimulant embrocations, care being taken not to overdo them, and by gentle massage along the course of each muscle.

The positive pole of the constant current should be placed on the nerve trunk over the ramus of the jaw, and the negative should be stroked about the face. The strength of the current should not exceed one microampère, at all events at first. If the muscles act to faradism this may be used of the weakest strength necessary to evoke contraction. I have treated half-a-dozen such cases in children with faradism from the first, and there is no risk whatever.

IDIOPATHIC MUSCULAR ATROPHY.- PSEUDO-HYPERTROPHIC PARALYSIS. DUCHENNE'S DISEASE.

Boys are chiefly affected, and frequently more than one boy in the family. Yet the disease is usually transmitted, like hæmophily, through the mother. The disease may have commenced during the first two years of life, but usually later; even as late as puberty, but this is rarer. The hypertrophy

of muscles is due to an overgrowth of the fatty and fibrous interstitial tissue.

Essentially the disease is an atrophy of muscle. Probably it is a myopathy, not a neuropathy. Cold and damp and acute specific fevers should be avoided as they have been set down as exciting causes.

The difficulty in walking, and especially in going upstairs, is a marked symptom.

The small size, absence, or atrophy of the latissimus dorsi and lower part of the great pectoral has been insisted on by Dr. Gowers; my own experience of eight cases corroborates this.

The pseudo-hypertrophy attacks chiefly the calves and buttocks, the deltoid, and infraspinati. The mode of rising from the floor and walking in a fairly marked case are almost pathognomonic. For a complete account of the disease, with illustrations, the reader should consult Gowers' "Manual on Diseases of the Nervous System."

Congenital spastic paraplegia may be mistaken for pseudohypertrophy, for the constant spasm causes considerable hypertrophy of the calves and legs. But in the spastic disease the knee-jerks are excessive instead of being weak or lost; the mode of rising from the ground is not the same, and the tendency for pseudo-hypertrophy is not to get better, which is the opposite of what happens in the spastic disease.

Cases of idiopathic muscular atrophy occur without hypertrophy; the face may be atrophied in these cases, "myopathic face." This is not the case in pseudo-hypertrophy. The two forms do not occur, as a rule, in the same family. Harpooning the muscle by means of a Duchenne trocar with a view to detecting fatty and fibrous overgrowth is not absolutely trustworthy. The treatment is not encouraging. The chronicity of the complaint makes a belief in temporary arrest by the means employed easy to establish. I have employed faradism and galvanism, but without appreciable

result. The mode of using these agencies is described under Infantile Paralysis. Massage and gymnastic exercises are perhaps the best means for endeavouring to strengthen the muscles which have not yet been involved, and also as tending to improve the whole system. But these measures are powerless to prevent the muscular atrophy. "It is possible, that (exercise) may, to some extent, divert the trophic energy from the interstitial tissue, since cessation of muscular exercise is certainly followed by quicker failure of strength" (Gowers).

The passive movements, massage, and exercise are useful also in lessening the tendency to spinal curvature, talipes equinus, and other deformities and muscular contractions. Tenotomy of the tendo Achillis may be employed if the foot cannot be placed flat on the ground after a course of massage and passive extension. "Tenotomy may restore the power of walking for some years, and when contracture returns its removal has a second time set the patient on his feet again" (Gowers).

When the back and chest muscles are wasted, the danger of pulmonary catarrh is increased. Great care should be taken to prevent the patient from catching cold. Every hygienic measure that tends to improve the general health, and the health of all the organs of the body, should be adopted with the utmost obtainable efficiency. Special care will also be required in the treatment of any intercurrent affection which may arise. Arsenic and phosphorus may be prescribed as for Rickets, but neither they nor any other drug has any appreciable influence on the disease.

CHAPTER XVI.

ACUTE SPECIFIC FEVERS.

GENERAL TREATMENT OF FEVERS.

Pyrexia profoundly perturbs the physico-chemical processes of the protoplasm. Of the nature of the perturbation we are but imperfectly informed. The thermogenetic centres and tracts doubtless control the situation. The therapeutist may influence the loss of heat from skin and lungs, or may act directly on the nervous controllers of thermogenesis.

The removal of all restrictions to the action of the various functions of the body is essential. We must husband the vitality by allowing the nervous system, heart, lungs, arteries, liver, kidneys, bowels, and skin to act adequately to the occasion, but by keeping the expenditure of energy at the lowest possible pace.

Consequently all cases of fever are best treated by confining the child to a cot in a capacious chamber at the top of the house, with a single nurse, who must be capable, of good physique, and pleasing presence, and whose dress should be agreeable to the child, and composed of linen or muslin. A large fire in the room secures ventilation, though apt to create currents of air that cause unequal warming of the room. Sanitary stoves will doubtless displace open fires in the scientific future. The room should be kept as a rule at a temperature of 65° F. day and night. A uniform temperature makes the least demands on the various functions of the body. This is important, because the heat-regulating machinery is thrown out of gear in fever. Abundance of fresh air, not too moist