fourths of that time I was quite unable to decide between typhoid fever and general tuberculosis; but his mode of death, combined with various slight symptoms which could be read more distinctly after-viz., the intolerance of light, the priapism, the muscular tremors, and the pains in his extremities on movement-made the diagnosis without doubt to be cerebro-spinal meningitis.

Another case, a boy, aged five, was admitted with a history of three weeks' illness, chiefly of frontal headache, vomiting, and latterly diarrhoea. His temperature was very high (103°-104°), the condition of one lung was questionable, and he had much delirium. For seventeen days he continued in the same condition, without any definite signs of typhoid fever, and with many of severe cerebral disturbance and fever. He had, however, an occasional typhoidlooking stool, and the temperature ran high for tubercular meningitis; therefore, on the whole, I favored the diagnosis of fever, and so it proved to be. From the seventeenth to the twenty-fourth day the temperature fell, and the child got well.

The third case is that of a girl, aged twelve. She had been subject to sick-headaches for a long time, but worse since a blow on the head a year before. She had also wasted. For five days the headache (frontal) had been very bad, with frequent vomiting and constipation. She was quite clear in her mind, with temp. 100°, pulse 72, exceedingly irregular, but with no intolerance; the fundus of the eye being normal. The disease ran on without declaring itself till pain in the neck developed, then squint, and then coma.

Ulcerative endocarditis will sometimes closely simulate typhoid fever, and is all the more difficult to distinguish, in that the physical signs of valvular lesion are apt to become masked by the formation of fungating vegetations about the diseased apertures. Any previous history of rheumatism,

any evidence of valvular disease, and particularly any evidence that infective maladies of any kind are prevalent, should suggest a careful consideration of this possibility before coming to any definite opinion.

Ostitic pyæmia may simulate typhoid fever, and a case of this kind has recently been in the Evelina Hospital. A child of about eight was admitted, with diarrhoea, much abdominal distension, and the general aspect of severe typhoid. The result showed a very acute pyæmia, with abscesses in parts of the lung.

Of the incubation and other points concerning typhoid fever in general, it is hardly within the scope of the present work to treat; but it may be remarked that, as regards the incubation-which is said to vary from two days to three weeks, and to be most commonly about two weeks-children afford virgin soil, undergo changes of body-heat readily, and therefore may be expected to mature a poison rapidly; an important consideration when tracing the source of infection. Further, it would seem that children are peculiarly sensitive to drain emanations, whilst water and milk, which constitute so large a share of their diet, have been shown to be the more common sources of the introduction of the poison.

Treatment. In the majority of cases the treatment is simple. The child must be kept in bed, its temperature carefully watched, and the diet regulated. The food must be fluid, or pultaceous-such as soaked biscuit, custard, milk, and beef-tea. Should the stomach be inclined to reject these, even lighter materials must be given-milk and limewater, or milk and water, whey and artificially digested milk, or blanc-mange. As regards drugs, a little dilute nitric acid, with syrup, is agreeable and refreshing, and some attach importance to its therapeutic value. Quinine is another remedy much in vogue with some. In cases of moderate duration, no stimulants are necessary; but when the fever

extends to or beyond the third week, and the symptoms have been severe, two, three, or four ounces of wine, or one or two of brandy, in the twenty-four hours, are often needed after the second week. Constipation is not uncommon, and, if associated with any distension of the abdomen, is to be treated by simple enemata, or a small dose of castor-oil. The evacuations should in all cases be treated with some disinfectant, and all soiled linen is to be removed at once and treated in like manner. As regards the more severe cases, the noisy delirium may perhaps indicate the need of stimulants; but the relief afforded is not so decided as in adults, and, as a rule, I do nothing, provided the child is taking its nourishment well. Small doses of Dover's powder or bromide of potassium are sometimes beneficial, and a tepid or warm bath sometimes exercises a calmative and soporific effect. If the temperature is persistently over 103°, frequent resort to tepid sponging, cold sponging, an ice pack, or the tepid or even cold bath is indicated. An ice-cap to the head is occasionally useful in the same way. Quinine may be given in one, two, or three grain doses three times a day, and I have also tried salicin, but without much evident effect. For abdominal distension there is nothing so good as turpentine or terebene. Either of these may be mixed with mucilage of tragacanth, syrup, and cinnamonwater; or mixed with butter and put at the back of the tongue. In this way, five drops of the oil of turpentine or two or three of terebene may often be taken without exciting much resistance. Hillier recommends an enema of assafoetida.

For diarrhoea, five drops of tincture of opium with an ounce of starch-water by enema, is the plan of treatment which seems most generally successful; but two or three grains of Dover's powder, given internally once or twice in the twentyfour hours, will often be equally efficacious. A moderate

diarrhoea, two or three evacuations in the twenty-four hours, is not to be checked. Severe diarrhoea is generally associated with abdominal distension, and indicates severe ulceration; and although it is the general practice to give opiates, I prefer to combine them with such other drugs as may have an antiseptic effect upon the surfaces of the ulcers, such as turpentine, borax, etc. It is further advisable in such cases to see to the quantity of food taken. The diarrhoea may be moderated by reducing the quantity of milk, and giving thin broth of chicken, veal, or mutton. Brand's essence of beef gives a large amount of nourishment in a form which one supposes is absorbed from the upper part of the intestines, and cannot leave much behind to worry the ulcerated surface below.

Bismuth subnitrate and ipecacuanha wine are also of use, and so also the tincture of krameria, extract of logwood, and chalk mixture.

For the bronchitis, a little ipecacuanha wine, with tr. camph. co. and syrup of Tolu, may be given.

As regards treatment by the bath, Henoch makes some very practical remarks. The effects of cold bathing are more pronounced in children than in adults, and consequently the first bath is, in some cases, an experiment, and it may be followed by a gradually falling temperature, until a condition approaching collapse results. This may be obviated by the administration of wine before and after the bath, but more particularly by trusting to tepid rather than cold bathing, and by not prolonging the immersion beyond six or eight minutes.

CHAPTER XVIII.

MALARIAL FEVER.

AGUE is not common in children, and its behavior is sometimes peculiar. For this reason it is likely to be overlooked. It may occur even in infancy, and enlargements of the spleen have been found at birth which have been supposed to be due to the malarial poison. But the disease is more usually seen in those of four years old and upwards, It may sometimes occur in typical form, with cold, hot, and sweating stages. But as a rule well-marked rigors and definite periodicity are absent. Dr. West states that the place of rigors is taken by a condition of extreme nervous depression, sometimes by convulsions. As other peculiarities he notes the long continuance of the hot stage, the absence of any distinct sweating stage, and a continuous form of malaise and even pyrexia. This description will show how easily malarial fever might be mistaken for some continued fever of doubtful nature; an error all the more likely from the infrequent occurrence of the one disease, and the very common occurrence of the other. The acme of the pyrexia, as in adults, may be very high (105°), and possibly this feature might in some cases convey a hint of the true nature of the disease. But more important, as I think, than these anomalies of the more typical symptoms is the necessity of recognizing that malarial anæmia is not uncommon-sometimes associated with enlargement of the spleen, sometimes not-and that extreme anæmia may exist without any history of pre-existing fever. Anæmia is a characteristic