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was constantly greater by a few millimeters than that in the left. The reverse condition was found in four cases. Daily observations in the same children over a period of four weeks often showed variations of from two to ten millimeters.

In anæmia the blood tension was slightly above the normal. In one case it registered from 115 to 125 m. m., and in another during three weeks daily measurements the limits recorded were 110 and 120 m. m. Broadbent calls attention to the high arterial tension in anæmia. There was anæmic bruit in both these cases and in one a soft blowing systolic murmur which was heard distinctly over the apex and pulmonary area.

The condition of the pulse wave pointed against an organic cardiac lesion.

In acute endocarditis the arterial tension is somewhat under the normal. Johann H., aet. 672, was admitted to the hospital November 19, suffering from acute articular rheumatism. On November 24 a light blowing systolic murmur was heard over and confined to the apex. The arterial tension was 80 m. m., and continued low for nearly three weeks. The systolic murmur then became very indistinct and the arterial tension rose and remains between 95 and 100 m. m.

In acute nephritis the increased tension so constant in adults does not appear as marked in children. The following three cases will serve as examples:

Maria H., aet. 8, was admitted in the hospital November 28. There was no history of scarlet fever but patient had had measles two years before. Present illness began a month agu with abdominal pain and swelling of the face and feet. On admission there was no ædema. The heart was slightly enlarged with the apex beat in the fifth intercostal space and cardiac dulness extending 142 cm. outside the left mamillary line. Albumin was plentiful in the urine and granular casts microscopically. The amount excreted in twenty-four hours was from 1,000 to 1,300 c.c. The arterial tension was rather constant at 110 m. m. and several observations were recorded of 118 m. m. The albumen disappeared and on December 14 the blood pressure registered 105 m. m.

Maria L., aet. 6, had measles in 1898 which was followed by varicella. There was no history of scarlet fever. The present illness began November 3, when the mother noticed swelling of the hands and feet. There had been no vomiting or convulsions. On admission, November 10, there was marked ædema of the abdomen, hands and feet. The urine contained much albumen, red and white blood cells, granular and epithelial casts. The twenty-four hours urine measured from 750 to 1,000 c.c. The blood pressure was not taken until November 23, when it registered 100.

There were albumen and blood in the urine. The heart examination was negative. On December 10 albumen was absent from the urine and the blood pressure registered between 85 and 90 m. m.

Rosa B., aet. 7, had suffered from impetigo and extensive eczema capitis for two months. On admission to the hospital November 27 there was general anasarca and albuminuria. The heart was not enlarged. The arterial tension was high130 m. m.-and diminished as the albumin in the urine grew less, and on December 14, when the urinary examination was negative the blood pressure was 110 m. m.

In diphtheria when there is cyanosis and dyspnoea with or without the intubation tube the arterial tension is increased. In several such cases the blood pressure ranged from 125 to 135 m. m. This high tension is explainable by the excess of carbon dioxide in the blood during the laryngeal and tracheal stenosis. Carbon dioxide has about the same action upon the capillaries as digitalis and stimulates the vaso-motor nerves thereby contracting their lumen and raising the blood pressure. In cases in which there were no laryngeal complications there was no change in the arterial tension. In one case the measurement was taken before and after intubation and a difference of 10 m. m. was observed. During convalesence when there is no disturbance of the respiration the tension sank into the normal limits.

The amount of blood pressure can be of great help in diagnosis. A five months old child was brought to the OutPatient Department with puffy lids and general anasarca. It was impossible to obtain a specimen of the urine.

The case was supposed to be post-scarlatinal nephritis as there was some desquamation. The blood pressure in several trials registered 75 m. m. The patient was admitted to the hospital where frequent examinations of the urine failed to reveal any albumen. In the hospital the tension has continued low. The case was diagnosed as a myocardiac affection from the low arterial tension.

These investigations are not claimed to be complete or exhaustive, but will, it is hoped, call the attention of the profession to the importance of arterial blood pressure in children.

In conclusion I would thank Professor Escherich for the permission to make the measurements and for his interest and many valuable suggestions.

REFERENCES.

1. Baginsky. Lehrbuch der Kinderkrankheiten. Ed. 1896, p. 5. 2. Friedmann. Jahrbuch für Kinderheilkunde, Bd. 36, 1893. 3. Gärtner. Wiener medic. Wochenschrift. No. 30, 1899. 4 Gumprecht. 71st Versammlung Deutsche Naturforscher und Aerzte in Munich.

1809 5. Broadbent. The Pulse. Chap. xi.

Correspondence

GRAZ, AUSTRIA.

December 20, 1899. Graz is the Heidelberg of Austria. The natural beauties of the situation and surroundings compare favorably with the Neckar valley. The university here is larger and more modern although not so famous as that of its sister university town. Graz is the fourth city in size in Austria and is somewhat larger than Albany, having a population of 125,000. It is the capital of Styria and is situated on the river Mur. Its altitude makes it a very healthy city in spite of the fact that they have no system of sewerage and the sanitary arrangements are as primitive as those employed ten centu

The university has upwards of two thousand students and seems to attract a very good class of men. The medical department has about seven hundred men enrolled. The professor of internal medicine, Dr. Crouse, was called from Vienna a few years ago and is widely known on account of his many contributions to

contributions to medical journals. Dr. Nicoladoni, the professor of surgery, is more of an operator

Professor Escherich has an international reputation in Pediatrics. The Allgemeine Krankenhaus is very old and contains about a thousand beds. In many respects

ries ago.

than writer.

it is similar to the one in Vienna. This is the only hospital in Graz and different grades of accommodations are offered, the first class paying a gulden and a half per diem, the second one gulden, and the third a few kreuzers. This inevitable continental class distinction is also in vogue about funerals and people can order a first, second or third class display in accordance with their purse or family pride.

The Children's Hospital is a separate building and situated about half a mile from the General Hospital. A few months ago extensive alterations and additions were made so that now it is one of the most complete and best arranged Children's Hospitals in this part of the world. It contains about eighty beds including medical and surgical cases. The laboratories are a special feature and exceedingly well equipped. Original investigations are welcomed and the men given every opportunity for research. The assistants now working there are all engaged in some special work in bacteriology, chemistry or pathology. There has been an atmosphere of work in this building for a number of years. Professor v. Jaksch was the director until 1890, when he was called to Prague, and it was here that he did most of the clinical work necessitated in writing his well known book on Clinical Diagnosis. Professor Escherich is a bacteriologist of no small fame and is the most indefatigable worker I have yet met.

His private practice is swallowed up in his thirst for knowledge and he spends most of his time at work in his private laboratory in the hospital. He takes great interest in his little patients and his morning visits are very thorough and most instructive, as he takes pains to demonstrate the interesting features and frequently throws out valuable hints.

Among many interesting cases is one of acute gonorrhæal urethritis, vaginitis, cystitis and proctitis in a child of six. The patient was brought to the out-patient department with a vaginal discharge which on microscopical examination was rich in gonococci. The child suffered much pain on urination and the urine was cloudy. Stained preparations of the sediment showed pus cells, many of which contained the characteristic gonococci. The stools were observed to contain pus and the microscope revealed here also the presence of the gonococcus. Agar and blood serum cultures made from the urine and fæces contained pure colonies of this microörganism. The primary infection was undoubtedly in the vagina and extended from there into the bladder and rectum. This extension into the rectum is probably often overlooked as it produces few symptoms. Recently a number of cases were reported of gonorrhæal proctitis found in prostitutes. Gonorrhea in children is of lamentable frequency. Its cause is more often accidental than vicious. In the poorer families an infection in either of the parents can very easily be transmitted to the children. Entire families using the same bathing water is a not infrequent source of contagion. The gonococcus seems to have a special virulence on the genitals of small girls.

Surgical treatment in all cases of appendicitis, advised and championed by American surgeons, is looked upon with much disfavor in Austria and Germany. One accustomed to seeing frequent operations preformed for appendicitis is almost startled by the very small number of such operations in the German surgical clinics. Dr. Edgar Van der Veer called attention to this in one of his letters to the ANNALS, and Dr. MacFarlane wrote of the medical treatment employed by Leube in Wurzburg and the wonderful results obtained. In Vienna I saw four cases of appendicitis completely recover in the medical wards and was led 'to make some inquiries concerning the treatment employed and advised by the German school.

Nothnagel, by the way, seriously objects to the term appendicitis and would inflict upon us the word skoikoiditis, of Greek derivation. Four forms of appendicitis are recognized :

1. The catarrhal form which is by far the most frequent. The prognosis in this form is very good.

2. The stenotic form, where, owing to contraction in the lumen of the appendix, there is much pain of a coliky character. The prognosis is considered good.

3. Purulent form. This is generally a perityphlitis and the prognosis is unfavorable.

4. Abscess. This may become encapsulated and open into one of the neighboring organs. Surgical interference is indicated in the third and fourth forms.

In the first stages of the disease the appendix is inflamed

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