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mation, with consequent ostitis, periostitis, necrosis, and cariesinflammation of the ligaments of the joint and subsequent relaxation and luxation).

There are all grades of severity of this complication of scarlet fever. A certain degree of muscular pain and tenderness is common while the rash is present, but soon subsides as convalescence is established, but when the joints are involved the similarity to rheumatic fever is remarkable; pain, swelling, profuse perspiration, anorexia, with heart complications, as periand endocardial inflammations, which may result in chronic valvular disease. Barwel, in his treatise on joint affections, says synovitis is not an infrequent sequela of scarlet fever, measles, diphtheria and small-pox, and that the conditions like gonorrhoeal joint maladies, has been ascribed to rheumatism, and have even been termed "consecutive rheumatism," but that the only point in their course and condition, which at all resembles rheumatism is, that they are nearly always multiple, that they possess neither the temperature of rheumatism, nor the slightest tendency to involve the cardiac structures. He further states that the temperature never rises in this complication higher than 101° or 102°, more frequently the lower figure; the swelling is not considerable, and involves the periarticular tissues more frequently than the synovial cavity itself. These conditions are no doubt frequently associated with, and co-exist with, scarlatinal rheumatism. The nature of this complication is still an open question, and whether it be really rheumatic or pyæmic is not yet positively determined.

Associated with this rheumatic condition, or in absence of it, there is sometimes observed inflammations of the serous membranes, with sero-plastic or purulent exudations, and while this usually occurs during the progress of the kidney disease it is independent of it, the most infrequent is meningeal inflammation. There may be peritonitis and pleuritis with sero-fibrinous exudation, or pure pus may fill the pleural sac, or the quantity may be insignificant.

The treatment of scarlatinal rheumatism has to be symptomatic-anodynes, to allay pain; diluents, for concentrated urine, and aperients if necessary, and cotton-batton or poultices to the painful joints.

Reynolds, in his system of medicine, says that alkalies are not of any special value. If the inflammation of the joints should result in a synovitis, as is sometimes the case, with or without the formation of pus, the case should be treated, says Zeimssen, with the application of cold and the abstraction of blood, as in all severe joint inflammations, and the treatment of inflammations of serous membranes. Cold should be tried early to prevent excessive exudation. The abstraction of blood is only permissable in the robust, a condition not often observed in these complications of scarlet fever.

Pleuritis with purulent exudation should be relieved by paracentises under the same indications which authorize the operation in the ordinary non-infectious variety. Endocarditis should be controlled by cold to the precardial region, perfect rest, and digitalis or strophanthus for quieting frequency of the pulse. In the only case that has come under my own observation a small blister over the precardial region appeared to relieve the pain and rapid pulse.





GENTLEMEN: You will be called upon to treat convulsions in children so often that I cannot do better than devote this lesson to that subject. Convulsions in children look a great deal alike in most cases, but the cause is very different. Some of such cases are from a central nervous origin, but we will pass that kind over to-day, as we will find enough to do to speak of the simpler kind of convulsions. First, what are the causes of convulsive attacks in children? In eighty out of a hundred cases it will be seen that it is attached to some indigestion due to an alimentation, which is either too abundant or given too often, or else it is some form of food which is not suitable as yet for the tender digestive organs of the baby. I have known a little wine given without thought to an infant, to cause convulsions; and on another occasion, being called to see a baby in a fit (notwithstanding the denial of the nurse that nothing had been given to it), on tickling its throat, and bringing about vomiting, I saw several pieces of chestnut that had been given the child, without thought of doing harm. You must always inquire, also, if the child has been in the habit of having dyspeptic troubles, as predisposition has much to do with these troubles. Also inquire about the intestines; here is a fruitful source of convulsions. Constipation alone has produced them, and the effect of diarrhoea on the nervous system is very well known. Repletion of the intestines will lead to vomiting, so often seen in children's convulsions; and it is sometimes difficult to tell if constipation exists or not, for some children seem to have stools often enough, and yet they do not in reality empty the bowels sufficiently. It is not so often seen that intestinal worms is a cause of convul. sions, yet you will meet some cases; and I have seen some supposed cases of epilepsia cured by a simple purgative bringing away the cause of the trouble, which was nothing but a few round or else flat worms (tenia). Look also for foreign bodies in the ear, or nose, also for burns, or even dresses too tight, or a slight pin cut; all these are causes of fits. Again, in males the presence of the testicle compressed above the abdominal ring, it not having come down yet, is sometimes a cause. If there is a hernia, see that the bandage is not too tightly placed

on it.

The next group of causes is that relating to acute diseases that may be commencing. I shall not go into all the theories that have been given to explain these nervous accidents that are seen in acute diseases of children, as they are not at all certain, and I shall merely say that some think that there is a circulatory trouble in the brain; others, that there is an alteration in the blood; again others, that the microbes are playing about in the baby's circulation. Be this as it may, a convulsion in a child is often a sign of the commencement of an eruptive fever, such as measles, small-pox, or scarlatina, and erysipelas, or even pneumonia.

There are other causes which you will see at times, such as the intermittent forms of fever that begin in convulsions in children in certain parts of the country. A slight hæmorrhag will even bring them on, such as a loss of blood by a badly tied cord causing hæmorrhage at the umbilicus. I call to mind here the case of a little baby that I saw, that was born with a tooth, and as it did not seem very solid in the jaw, and interferred with nursing, the doctor took the tooth out, with the result of not being able to stop the bleeding from it, and also of bringing on convulsions. You must be extremely careful in attempting to make even the slightest operation on very young children. Finally, any cerebral congestion may bring on fits in children.

But I must not forget to strongly impress upon you the necessity of noticing the parents; see if there is chronic alcoholism or hysteria in the mother; and do not neglect to find out if the child has been refused something, as anger may be the cause of the convulsions. I called the attention of the late congress at Washington, when I was in America last year, to the fact that an overlooked cause of nervous attacks in children consists in the fact that people nowadays have a bad habit of spoiling the little ones, and making believe that they are grown up already. They dress them like their elders, while permitting. them to be educated up to things that are far beyond their age. This is a frequent cause of convulsions. It is rather a curious thing that the convulsions you see in children are always more pronounced on one side than the other. The attack is often preceded by prodromes such as that, it will be noticed that the child will be irritable and its face congested, with eyes more or less haggard. Then suddenly it will cry out, stiffen, and lose consciousness. The face is now pale, but it soon becomes congested, the pupils are narrowed, and the eyes are like in a converging strabism. This phase of the attack passes in a few seconds. When the face convulsions come on, the tongue is projected, bitten if there are teeth, and the head is thrown back, while the limbs are thrown about in all directions. Suppression of the urinary function is the rule, but sometimes a slight quantity of urine is voided, and perhaps some fecal matter. In a minute or two all is over, and the child remains in a semi-stupid state, from which it gradually recovers, and it then passes a large quantity of urine. It is rare that only one attack takes place; more often the attacks are renewed, and they may last hours without there being any cerebral lesion. Again, there may be only a partial convulsion in one member, or only the face, and so on.

But how are you to know and distinguish these convulsive attacks from others of the same order, but from different causes? If you are not present during the attack-and that is the ruleit is only by questioning the parents that you can arrive at a diagnosis. If you find out that the child had already a difficulty in walking, or that it has a paresis of one side of the body, then you may suspect cerebral sclerosis; but it is, above all, by the symptoms following such attacks that you can judge best what the exact trouble is. If it is a cerebral sclerosis, you will soon see that the convulsion was only an accident that will show the real trouble by other manifestations before long, that will put you on the right road.

How shall you distinguish eclampsia from epilepsia in chil

dren? Remember that before the age of four or five there is rarely any epilepsia. But in children over five there is a curious thing noticed in regard to epileptic attacks; that is, that the attacks have a particular mode of coming on. They come every three weeks, or every two weeks, but always at regular periods; and more than any other attack, they come on in the night. One observes hysteria, also, at a later age. They are always from twelve to fifteen. Here the difference is striking between the two. The epileptic child is morose, sullen, its intelligence is dulled, it hardly ever laughs or talks much. What a difference with the hysterical child! It is always on the go, it laughs and cries without any preceptible cause. Even young as it may be, it has all sorts of tales to tell on the others, and they are mostly invented lies, more often than not. There is no sort of regularity in its attacks, they will come on at all hours and all times, from the slightest cause. The attacks are also longer than the epileptic child's attacks, lasting often an hour, or even two.

These convulsive attacks, as a rule, are very often not of a serious nature, except those convulsions that come on at the end of some serious malady, such as the attacks during the whooping-cough, or in croup. Having found the cause, no matter how terrifying the attacks are, you can hope for a rapid and sure cure of almost all convulsions in children.







Almost all authors who have written on nervous aphonia have given amongst the causes of paralysis of the vocal cords, tubercle and pleuritic effusion of the apex of the lung; the peritracheal glands being hypertrophied or degenerated. In fact, among the numerous phthisical patients examined by the laryngoscope, on account of affection of the voice, it is not rare to find immobility of one vocal cord with consequent deviation of

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