frequently ushered in by severe general symptoms, as restlessLess, crying as if in pain, snuffling and difficult breathing, disturbed sleep, even delirium, very hot skin, an exalted pulse of 140 to 160, frequent sneezing and pain over the forehead, and finally increased secretion. It seldom remains confined to the nostrils, but spreads through the lachrymal passages to the conjunctiva, also downwards to the throat, larynx, and even to the deeper air passages, and by such extension produces difficulty of swallowing, hoarseness and barking cough. It may also pass along the Eustachian tube to the cavity of the ear, and there produce pain and tinnitus. In more advanced children nasal catarrh is an ailment free from much risk, but in those at the breast it is far from being free from anxiety; for in them respiration is mostly carried on through the nose, especially when feeding, and an interruption to the passage may seriously interfere with their nutrition, or even hazard suffocation.

Acute nasal catarrh readily becomes chronic, especially in scrofulous and syphilitic children. Prolonged duration of the disease may produce, by the decomposition of the discharge, ulcers, diphtheritic exudation, or even necrosis of some of the bones of the nostril. The intensely fetid odour emitted by patients suffering in this way enables the disease to be soon detected when they come near. It is usually very obstinate, often incurable, and always produces, sooner or later, impairment or complete destruction of the sense of smell.

Chills, very hot baths, inhalation of air charged with certain chemical or mechanical irritants, also some constitutional discases, especially measles, may excite acute catarrh of the nostrils, whilst the chronic form is commonly kept up by scrofula, syphilis, new formations in, or polypous hypertrophy of the mucous membrane. Obstinate and frequently recurring nasal catarrh in sucklings should always excite suspicion of the existence of some specific taint, even when no other symptoms are present.

Treatment. For the idiopathic nasal catarrh this is usually little more than confinement from the air in a chamber the temperature of which is kept equable, especially in the winter months, when the affection is often epidemic; baths are to be avoided, and care must be taken in the case of sucklings to obviate complete closure of the nostrils. For this purpose the

incrustations on the nostrils ought to be frequently removed by a warm moist sponge, and sneezing excited by pressing a few drops of water into the nostrils. Nurses are in the habit of dropping milk into the nostrils of sucklings, to remove the inspissated mucus, and to smear the bridge of the nose with almond or olive oil. Astringent remedies, such as oxide of zinc, alum, or nitrate of silver, either in solution or in powder, may also be employed locally. In chronic coryza with irritating secretion and in ozana the use of solutions of chloride of lime or permanganate of potash by the syringe or the use of snuffs containing alum or tannin, or of energetic cauterization with nitrate of silver, may prove beneficial. Guersant recommends as a snuff the following mixtures:-White precipitate, 1 part; powder of althea, 15 parts; or calomel, 2 parts, and powdered cinchona bark, 15 parts.

If the coryza is due to a scrofulous condition the usual treatment by cod oil, iodine, iodised mineral waters, iron, and iodide of iron, must be adopted; and if syphilis be suspected, mercury or iodide of potassium are the most likely means to be of service.

In the case of a suckling if the nostrils are so obstructed as to induce danger to life, milk either from the mother or from the cow, must be given by the spoon until the child is in a condition to take the breast.

2. Epistaxis; Blenorrhagia; Bleeding at the Nose

Epistaxis is rarely seen in newborn or suckling children, but in further advanced life, especially towards puberty, it is not an unusual phenomenon. The blood may flow only slowly in drops, or with such rapidity as to form a continuous stream, and it usually issues from one nostril only, rarely from both. If the flow is great in quantity, or if the child be seized while recumbent, the blood may pass into the pharynx, and be either spit out or swallowed, in which latter case it will be digested. The epistaxis is often preceded by such symptoms as headache, giddiness, scintillations of light before the eyes, or tinnitus aurium.

Causes.-These may sometimes be local, as blows, scratching

the mucous membrane with the nails, ulcers, new formations, or diseases of the vessels of the mucous membrane; or they may be general and due to some disproportionate blood-pressure. To this latter class belong the epistaxis seen at the commencement of pyrexial diseases, especially in the acute exanthemata, typhoid fever, diphtheria, parenchymatous nephritis, intermittent fever, in heart disease, hooping-cough, pneumonia, pleuritis, and empyema. As special causes of long-continuing epistaxis are sometimes found in children, hæmophilia or the hæmorrhagic diathesis, purpura simplex and hæmorrhagica, anæmia, chlorosis, and scrofula.

Epistaxis may be of very slight moment, or may be of serious import, according to the nature of its origin; as, for instance, it may be of positive benefit in the acute diseases, whilst in purpura and chlorosis it may be justly considered an element of danger.

Treatment.-A slight hæmorrhage from the nose, especially at the beginning of any acute disease, will seldom require any treatment, though I have seen an epistaxis so severe at the onset of parenchymatous nephritis that it had to be arrested. If the hæmorrhage is very abundant, or is coincident with purpura hæmorrhagica, chlorosis, or scrofula, cold applications must be at once made to the forehead, nose and neck; inject cold water, or place a piece of ice into the bleeding nostril; or should this fail, apply the tampon, either with or without the addition of some astringent, such as alum, or sesquichloride of iron. After such local treatment of course it is necessary that the constitutional affection should be efficiently

treated.

3. New Formations in the Nose and Abscess of the Septum

New formations in the nose in children are only seen in the form of polypi, and even these not frequently, as they are rarely met with before the sixth year.

If we follow the usual classification these polypi are either mucous, sometimes known as soft polypi, from their soft and delicate consistence; or they are formed of connective tissue in the form of fibrous or fibro-sarcomatous polypi, going some

times by the name of hard polypi. The former proceed from the mucous membrane, and are limited to it, whilst the fibrous polypi grow from the periosteum, frequently from the base of the skull, and gradually extend by growth in various directions, sometimes upwards to the floor of the orbit, backwards and downwards to the throat and larynx, or outwards to the cavity of the jaw, and they generally have a broad base.

Symptoms.-Nasal polypi do not produce much disturbance as long as they remain of moderate size; but when the increase of size is so great that the nostrils become plugged up, or if the growth takes any of the specific directions above alluded to, various symptoms are excited. Amongst these are irritation of the nasal mucous membrane with excoriations, hæmorrhage, loss of power of smell, a peculiar nasal tone of voice and breathing through the open mouth, interference with hearing, swallowing and chewing, lachrymation, difficulty of breathing, paroxysms of coughing, and frequent puffing and blowing to make a passage for the air. I had under my care at the Hospital for Children a girl six years old, who suffered from a fibro-sarcomatous, naso-pharyngeal polypus, which grew from the periosteum of the hard palate, closed the entrance to the posterior nares, and extended almost as far as the larynx, occupying the nasal and pharyngeal cavity as a rugged tumour, and pressing the epiglottis down on the chink of the glottis. In spite of several operations attempted for her relief the child died from the tumour, and on section I found similar growths in the lungs and glands of the neck.

Causes. These are, for the most part, quite unknown. Even chronic nasal catarrh cannot be regarded as a cause, for in many cases it is not present, and in others it occurs only secondarily.

Diagnosis. This may be somewhat doubtful at the beginning, but as the tumour grows mistakes become scarcely possible.

Treatment. The only possible method of cure for these tumours is to remove them as early as possible. When they are not of large size, can be seen from the nostrils, and have narrow necks, they may easily be removed by forceps, or by entangling them in a snare, such as devised by Rosencrantz. When the pedicle can be reached by scissors Guersant recommends that method of removal. For the removal of deeply

rooted polypi serious surgical operations have sometimes to be performed, even resection of the upper jaw (Dupuytren, Robert, Lisfranc, Velpeau, and others).

Abscess of the septum comes occasionally, though not frequently, under observation, and may occur in an acute or insidious form, the latter especially in dyscrasic children. When the nostrils are examined, a flattish-round tumour of greater or less size will be observed, which fluctuates and is painful on the slightest touch, and the septum will be found displaced to one or other side. The pain and the obstruction to breathing makes the affection a very troublesome one. Sooner or later the abscess discharges spontaneously, though in scrofulous children this may be long delayed, and may be followed, as in one case which came under my notice, by perforation of the septum. The causes of these abscesses may be catarrhal, traumatic, or dyscrasic.

In the diagnosis care must be taken not to mistake the disease for polypus, but, as a rule, the pain will prevent any such confusion.

Treatment. This consists of the application of poultices to the nose, the insertion of emollient substances into the nostrils, and the early evacuation of the abscess; and when there is suspicion of some dyscrasia that must be treated, especially if there be any affection of the bones.

B. DISEASES OF THE LARYNX

1. Laryngeal Catarrh and Pseudo-croup

The infantile larynx is frequently the seat of disease, due to its smallness and delicacy and to its want of capacity for resisting external influences. Besides these physiological causes there seems to be, in certain individuals, families and even generations, a proclivity to laryngeal diseases, especially to laryngeal catarrh; and this is met with, not only in delicate children begotten by scrofulous parents, but also in children who are in every sense the opposite. Laryngeal catarrh occurs usually in the acute form-rarely in the chronic. The acute form is generally an idiopathic affection, but sometimes it