21. An "aged" countenance in a young child is indicative of pulmonary tuberculosis and chronic enteritis.

22. Strabismus accompanying fever is indicative of acute meningitis. (encephalitis) and will be followed by convulsions.

23. Primary strabismus in a child otherwise healthy, is simply a localized muscular paralysis.

24. Redness and weeping of the eyes, accompanied with fever, indicates the incubation of measles.

25. An infant who is frightened at, or attracted by, an imaginary object, striving to escape from it, or to grasp it, is threatened with some cerebral affection.

26. An infant constantly having its hands in its mouth and biting its fingers, is troubled with difficult teething.

27. Children that cannot stand up at the end of two years, and whose fontanelle remains open, are rachitic.

28. A child who has rapidly lost its plumpness, and whose cheeks are pale and soft and flabby, has had, and still has, diarrhoea.

29. The feeble cry of a new born child indicates a low, vital power, and imminence of death.

30. A prolonged cry very strong, but intermittent, as a rule, indicates acute hydrocephalus.

31. A muffled, hoarse cry, is indicative of the last stage of croup. 32. A disproportionately large belly in an infant of one or two years, indicates rachitis, or chronic enteritis.

33. Jerky, sighing expiration indicates acute pneumonia.

34. Inspiration suddenly arrested at each effort by a convulsive or spasmodic action, indicates acute pleurisy.

35. A short, tremulous and incomplete expiration, accompanied by a long inspiration in every eight or ten, indicates acute peritonitis.

36. Short, incomplete and murmuring respiration indicates simple. or suppurative meningitis.

37. Deep respiration, occurring at long intervals, indicates delirium. 38. Deep, lateral constriction of the base of the thorax, at each respiratory movement during fever, indicates acute pneumonia.

39. Permanent lateral flatness of the thorax, with a series of chondrocostal nodes, indicates rachitis.

Fever.-40. At no other epoch in life is the heart so easily impressed and so variable, as in infancy.

41. Mental impressions increase the movements of the heart as much as fever.

42. Increase of movements of the heart, due to fever, is always accompanied by an increase of body temperature, and this differentiates the increase due to nervous impressions.

43. Fever manifests itself by an acceleration of the pulse, and an elevation of the body heat.

44. Fever, present or past, leaves upon the tongue of an infant a red "pile," due to the turgescence of the capillaries, papillæ, (villous tongue). This is the last trace of the organic movement.

45. An infant having a sad and downcast countenance, and peevish, easy to cry, ever ready to lie down and sleep, who bites his finger nails

and lips, and shakes his head, and strike his limbs against each other, has a fever.

46. Chills are extremely rare in nursing children.

47. Profuse sweating does not occur in children suffering with intermittent fever, it is generally replaced by simple moisture of the skin. 49. Fever is always noticeably remittent in acute diseases of young children.

50. In chronic diseases of young children fever is generally inter mittent.

51. High fever diminishes the quantity of urine, concentrating the solid constituents, rendering it irritating to the urinary passages.

52. Very high fever habitually stops the secretion of tears.

53. The body temperature, measured under the axilla, rises one to three degrees in acute disease of children; under the exclusive influence of the fever, and not from any particular disease, exactly the same as in the adult.

54. Heat production is proportional to the vital force of the new born.

55. Heat production depending upon food and clothing, is lost so easily in weak and feeble children, that death, by cold, is the consequence.

56. Heat production is very much lessened when there is induration. of the cellular tissue of the new born.

Ophthalmoscopy.-57. The eye is simply an expansion of the brain, in which one can often perceive by means of the ophthalmoscope, lesions which indicate those which are occurring in the organ of thought.

58. The purpose of cerebroscopy is to discover, through the eye, that which is taking place in the cerebro-spinal system.

59. Whenever nervous troubles, paralytic, convulsive, or otherwise, are accompanied by lesions of the pupil of the retina, or of the choroid, they are dependent upon a lesion of the brain, its meninges or the spinal cord.

60. Every intracranial obstacle of such a nature as to hinder the venous blood from entering the cavernous sinuses, causes in the retina certain troubles of circulation, secretion, and nutrition, which are of value in diagnosis of certain diseases of the brain.

61. In certain diseases of the brain and of the cord, the great sympathetic exerts an influence upon the circulation of the retina, which produces quite marked lesions, easily ascertained by means of the ophthalmoscope.

Spasm of the Glottis.-62. Brief attacks of suffocation, and asphyxia suddenly occurring without fever, ending with very sharp hiccough, indicate phrenoglottic convulsions, spasm of the glottis.

63. Spasm of the glottis often ceases under the influence of intercurrent disease.

64. Spasm of the glottis may be cured by change of air.

65. Spasms of the glottis followed by general convulsions is fatal. Tetanus.-66. Contraction of the muscles, tetanus of the extremities, without fever, is due to a local affection of the muscular system.

67. Contraction of the extremities, accompanied with trouble of the

sensory nerves, and fever, is symptomatic of diseases of the nerve

centres.

68. Contraction following eclampsia is seated in the muscles.

69. Contraction of the extremities, may lead to atrophy of the muscles, fatty degeneration of these tissues, and articular deformities.

70. Contraction of the extremities often disappears under the influence of elctricity.

Paralysis.-71. Primary paralysis of one or more muscles of the trunk or limbs, accompanied with pain, is usually due to a local affection of the muscular system.

72. Paralysis of one or more muscles following eclampsia, has its seat in the muscles.

73. Partial or general paralysis, following febrile convulsions, is due to a lesion of the nervous centres, or branches.

74. Muscular contraction in children leads to suppurative or fatty degeneration of the muscles, and shortening of the limbs.

75. Any neuroses, whether convulsive, spasmodic, painful or mental, may occur as sequelæ during convalescence from acute inflammatory diseases, virulent or septic.

76. Idiopathic paralysis often occurs after the cure of an acute disease in the course of the convalescence.

77. When an acute inflammatory disease, virulent or septic, has ceased and a simple muscular sensory paralysis manifests itself, it is an idiopathic paraylsis, independent of any organic alteration of the nerves, or of the brain.

MODIFIED Intubation Instruments.—Exhibited to the Chicago Medical Society, February 7, 1887, by F. E. Waxham, M. D., Chicago. I wish to say a few words this evening in regard to intubation of the larynx in connection with the specimens and instruments I have to present. About thirty years ago a new operation was proposed as a substitute for tracheotomy, by M. Bouchut, of France, and so great was the opposition to this new operation, which was styled tubage of the larynx, that a committee headed by Trousseau, appointed by the Academy of

STRUAX&Con

Cut No. 1.-O'Dwyer Tube.

TRUAX&Co.

Cut No. 2.-Waxham's Modified Tube.

Cut No. 3.

Medicine, reported adversely in regard to it, and the operation was so deeply buried in oblivion, that early operators in this country were not even aware of the attempts and failure of Bouchut.

The most earnest advocates of intubation do not consider that the instruments are perfect, indeed the operation is yet in its early infancy, and it may be years before the method is fully and perfectly developed. One of the chief objections to the operation, indeed the only valid objection, is the difficulty of swallowing, the danger caused by the

falling of food and fluid into the bronchial tubes through the canula, and the too frequent occurrence of broncho-pneumonia. I would not exaggerate this danger, but certainly it is true that many patients die of broncho-pneumonia from this source. To overcome this difficulty I have had Messrs. Charles Truax & Co., of this city, modify the O'Dwyer tubes, by making them with smaller heads.

Cut No. 4.

The tube is prevented from slipping into the trachea, by a rubber collar. (See cut No. 3.) To this rubber collar is attached a flap, or artficial epiglottis. (See cut No. 4.) During the act of deglutition the larynx rises and presses against the base of the tongue and the epiglottis, and the pressure of the epiglottis holds the rubber cap, or artificial epiglottis, over the aperture of the tube, thus preventing the dropping of solids into it, and as deglutition ceases, the larynx falls and the elasticity of the rubber throws it upwards. This rubber attachment does not entirely prevent the falling of liquids, of water particularly, into the tube, but it is of very great assistance in swallowing solids and semi-solids. I have used this modification in a number of cases with good results, and I have now a little patient convalescing from a desperate attack of diptheritic croup, in which this modification was used.

I would also present a modification of the mouth gag. (See cut No. 5.) In the old gag the extremities are liable to strike the shoulder, especially if the child is not held well and is allowed to slip down in the lap of the attendant, the extremity of the gag striking the shoulder and throwing it out of the mouth. This gag passes back of the head and we avoid the danger of the gag being displaced by pressure of the shoulder. This gag was first suggested by Dr. McWilliams, of this city, and has been in the market for several months. There is still another danger that may follow the introduction of the tube, and that is the detachment of membrane below the tube, or the pushing of membrane down ahead of the tube when it is introduced. An accident of this nature occurred to me recently; a tube was passed down into the larynx and the respiration at once ceased, the child turned blue and seemed upon the point of death. The tube was at once removed, but the respiration was only slightly improved and the tube was again introduced, with the same result. It was again removed

FRUAX & CO

Cut No. 5.

and the trachea forceps (see cut No. 6) that I have devised for this purpose were introduced into the mouth and a mass of membrane, a perfect cast of the trachea and the two larger bronchial tubes, removed. After the removal of this cast the tube was again introduced, and respiration was easy. Without these forceps an immediate tracheotomy would have been

necessary.

In this connection I present to the Society a membranous cast from the trachea, larynx and bronchial tubes of the late Dr. Newton. This specimen is remarkable not only for its thickness and its extent but for the rapidity of its growth; it was produced within three or four

days after the invasion of the larynx. The fate of Dr. Newton, whose

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Cut No. 6.

early death we all regret most sincerely, teaches us a sad lesson; it teaches us the danger that besets the

faithful physician, and the necessity of taking every possible precaution against the contraction of this hydra headed monster, this justly dreaded disease.

as an

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CHICAGO

To those practicing intubation I would advise that an ordinary rubber cot with the end cut off should be slipped over the forefinger, and then during the operation, if the gag is deplaced, the finger is protected; as additional protection, it will be well for the operator to use a respirator (see cut No. 7.), an ordinary pad of antiseptic gauze with tape attached to secure it in place. This pad should be passed over the mouth and nostrils and should be used by the physician when inspecting the throat or when operating upon a bad diphtheritic case. I believe it is a duty that every physician owes to himself, his family and friends, to take these precautions, especially in the treatment of bad diphtheritic cases.

Cut No. 7.

WHAT To Do in Cases of Poisoning.-By William Murrell, M.D. -If sent for to a case of poisoning go at once-the patient's life may depend on your prompt attendance. If at night, do not stop to dress— scanty attire is permissible on these occasions.

Take your antidote bag or case with you. If you have neglected to provide yourself with one, lose as little time as possible in hunting for what you want. Do not go without a stomach-pump or tube, and remember that you will require your hypodermic syringe, and very likely the solution of atropine. Your knowledge of the treatment of cases of poisoning may be excellent, but if you are without the requisite appliances you are of very little use.

Inquire of the messenger what is the matter. His information will probably be unreliable, but you may get a hint that will enable you to decide at once on a plan of action.

Go straight to your patient and do not waste time in talking to his friends.

Make your diagnosis as quickly as you can, and commence treatment at once. If in doubt you will probably not be far wrong in giving a hypodermic injection of apomorphine or some other good emetic.

Order at once everything you are likely to require, and send for anything you may have forgotten, so that there may be as little delay as possible.

If the room is full of people get rid of them or they will hamper your movements. Do not try to turn them out or they will make a scene and add to your troubles, but give them something to do-tell them to go.