fully realized; the dilute nitro-muriatic acid with quinine, gentian, or cascarilla suits very well; it checks the free perspirations, gives tone to the relaxed mucous membranes, strengthens the digestive organs, and so improves the general nutrition.

The French authorities express unbounded confidence in codliver oil, which they appear to regard almost in the light of a specific and to which they attribute the most remarkable results. We must own however, to considerable disappointment in our experience with this agent. In some cases no doubt it greatly improves the general nutrition, but it does not appear to impart any tonic influence, and is not in our judgment to be compared with the more direct tonics, such as steel and quinine. Of late years, a preparation known by the name of Parrish's Chemical Food" has been much extolled; it is a compound syrup of the phosphates of iron, lime, and soda, and certainly seems to do good, but unfortunately it is so nauseous. that in the delicate state of the stomach of a rickety child, it is by no means always retained.

In the matter of diet, we must try to induce the child to take meat twice a day, or concentrated soup may be given in small quantities; egg puddings, or eggs alone, may also be taken with advantage, and some stimulant, such as wine or brandy, will be necessary.

In all cases we must recognize in the rickety child a tendency to debility, and our one object should be to counteract that, and to correct any disorder in the excretions. This requirement will be still more necessary on the occurrence of any of the complications; lowering treatment under these circumstances will signally fail of its purpose, and will not only not help in the cure of the complications, but will materially deepen the rachitic cachexia.

There

With regard to the use of irons, splints, and other mechanical contrivances for supporting the legs of rickety children, many authorities object to them because they believe that the limbs subsequently become straight spontaneously. seems, however, reason to doubt the correctness of this opinion; but all that we are disposed to recommend is that irons or splints be worn, provided they are made with joints corresponding to the hip, knee, and ankle; so that while affording sufficient support for the legs bend because they cannot support the weight of the body-they need not unnecessarily interfere with the natural movements. When there is any tendency to curvature of the spine, a reclining or recumbent position must be adopted for some hours in each day; and if this and other treatment fails mechanical support will have to be resorted to.

IV. THE SYPHILITIC DIATHESIS.

Various hypothesis have been put forward to account for the occurrence of secondary or constitutional syphilis in the infant. It has been thought by some that it might arise from contact of the infant's body with a sore on the mother's genitals at the time of birth; others have attributed it, with more show of reason, to the infant's sucking the breast of a syphilitic nurse; others again explain the fact by supposing that the mother during pregnancy suffered from primary or secondary syphilis, and that her blood-although there is no real admixture of the maternal and foetal blood-infected the infant; lastly, it may be that the taint is derived entirely from the father; the mother always having been, and continuing to be, healthy, unless she becomes infected by the diseased foetus.

It is probable that all these modes of communication may obtain in different cases; certain it is that a child may inherit syphilis from either parent singly; we have seen cases where a syphilitic father has contaminated his offspring without infecting the mother, and in such a case the child may subsequently during lactation infect the mother through a cracked nipple; it is further thought by some observers that the fœtus in utero, syphilitic from the father, may, through placental contact, poison the blool of the mother, and so give rise in her to constitutional symptoms: thus from parent to child, and from child to parent, the syphilitic virus may be communicated and constitutional symptoms result.

Much difference of opinion exists, probably from differences in the facts observed, as to the time when the disease first manifests itself after birth. In some few cases there is no doubt that very unmistakable symptoms are apparent at the time of birth; indeed, not a few cases of abortion are the direct result of syphilitic contamination, many more end in premature labour at the sixth or seventh month, and a certain few are still-born, prematurely or otherwise, in whom evidences of syphilis are apparent in the shape of cutaneous diseases, peritonitis, (according to Sir James Simpson), disease of various viscera, and effusions into the serous cavities. The period when probably the disease more commonly manifests itself is from about the end of the first to the second or third month, it is very rarely later than that, though it has been known to occur even as late as the eighth, and twelfth month. Of 249 cases, symptoms appeared in the first month in 118 cases, before the end of the third month in 217, and in only 32 cases was this date exceeded: so that in nearly half the cases symptoms began in less

than a month after birth, and in seven-eighths of the cases they began before the end of the third month; while in only oneeighth of the cases did they begin after that date: hence, "if the physician has no information of the source from which the syphilis was derived, or if he doubts the authenticity of his information, he will be able, by having recourse to a calculation of probabilities, to decide whether infantile syphilis is hereditary or acquired, according as it shall have manifested itself before or after the third month of life." (Lancereaux).

Symptoms. For the first few weeks after birth, as has been stated, the infant may be to all appearances healthy; then, slowly, symptoms of coryza set in, with a peculiar snuffling respiration, a dry cough, slight difficulty in sucking, and dryness of the lips and mouth. The skin soon becomes dry and has a peculiar colour, "it is neither pallor, nor jaundice, nor the straw-yellow of other cachexias." (Trousseau.) The voice shrill and hoarse-it has been compared to the squeaking of a penny trumpet; the mucous membrane of the mouth and throat becomes affected with superficial ulcerations, and an erythematous blush appears upon the nates, the external genitals, the feet and hands. Should the disease be unchecked, large patches of the skin assume a light-brown colour; the epidermis exfoliates; the parts around the mouth, nostrils, eyes, buttocks, anus, and flexures of the joints become coppercoloured, fissured, and excoriated; the eyes get weak, and the margins of the eyelids sore; the eyelashes, eyebrows, and hair may fall off; the child becomes irritable, wastes rapidly, and daily grows weaker; and often suffers from sickness and diarrhoea, with occasionally bloody stools and general derangement of the digestive functions. As a consequence of all this, the child is always crying, and is never satisfied, though of course as usual it is constantly fed. In some fatal cases, collections of pus have been found-after death-in the thymus gland.

These being in brief the general run of symptoms it may be well to state them somewhat more in detail,-and first with regard to the more obvious external lesions. The colour of the skin is often strikingly characteristic, it is of a peculiar dirty, muddy, or smoky hue, a kind of sallowness to which is added a good deal of what may be called Addisonian or suprarenal capsular discoloration. After a while perhaps some cutaneous eruption will make its appearance, and of the various kinds the most common are erythema, papular eruptions, mucous patches, pustules of different kinds, but especially impetigo and ecthyma, vesicular eruptions, particularly eczema, and lastly, pemphigus, which is often very severe and even

fatal. Of one and all of these it may be said that they are accompanied with a peculiar tawny reddish-brown or coppercoloured discoloration around and about the eruption. They are not usually attended by any itching or irritation. The pustular forms are generally later in their development.

Certain localities are more favoured than others by these syphilitic cutaneous eruptions: the erythemas appear mostly on the buttocks and the external genitalia, in the flexures of joints, behind the ears, and in the parts adjacent to mucous orifices: the mucous patches show the same predilection for these parts. The pustular eruptions vary in their choice, for while impetigo mostly occurs on the face, neck, chest, and upper parts of the body generally, ecthyma on the other hand, more often selects the lower limbs and buttocks; pemphigus again prefers the hands and feet, and this it is which in doubtful cases serve to distinguish the syphilitic from the non-syphilitic variety, for the latter has no such preference, but occurs equally in all parts of the body. The erythema which occurs upon the external genitalia, is peculiar for its tawny coppercolour; and in boys again there is this very striking feature upon which we have often determined a diagnosis-viz., that the scrotum has a very peculiar transparent shiny look, the skin being very thin, and waxy looking.

Another very well-marked feature in the syphilitic child is the condition of the incisor teeth. When the second or permanent set make their appearance, these teeth are found to present the following characters, the central pair of the upper jaw are remarkably short, narrow, and thin, especially at the lower part; after a while this breaks, and there is left a notch, which may continue for many years: besides this the incisor teeth are ribbed as it were horizontally, and this continues throughout the life of the tooth.

The inflammation of the mucous surfaces, especially that of the nose, larynx, and pharynx, together with the conjunctival mucous membrane, is a prominent feature in syphilitic children. In the former it sometimes leads to ulceration, and occasionally the disintegration extends to the nasal cartilages and bones which become flattened, and so the shape of the nose, especially at its upper part, is destroyed. The peculiar "snuffles" which is so marked and early a symptom of syphilis in children, is due to this inflammation of the Schneiderian membrane.

The serous membranes are much less liable to specific inflammations, though several authorities, Sir James Simpson, Wilks, and others, assert that they have met with evidences of peritonitis in the shape of bands of adhesion, &c., in cases of

hereditary syphilis. It does not, however, appear that these were certainly connected with that disease, but the inflammation was of a chronic character and had no apparent relation to tuberculosis.

The organ which seems more than all others prone to degeneracy from hereditary syphilis is the liver. The disease, however, does not show itself usually till rather late, and is of no avail therefore in diagnosis, for the case is generally fully developed before the changes in question begin to be manifest; by this time the child is usually very ill, suffers much from diarrhoea and vomiting, and is a good deal emaciated. Notwithstanding the serious organic changes of the liver, jaundice is a very uncommon result, but ascites and oedema of the lower extremities are not unfrequent phenomena. The appearance which the liver presents is thus described by Gubler: "The liver, more voluminous than in the normal state, is turgid, globular, elastic, hard, and difficult to make an impression upon with the finger, which ends by breaking it without leaving any impression upon its surface; changed in its whole extent or only at certain points, it presents a peculiar yellow colour, comparable to certain pieces of gun flint, and in some cases it is studded with small opaque white grains having the appearance of grains of semolina; on section, its homogeneous tissue shows vascular striæ and opaque grains irregularly disseminated, and yellowish patches more or less large and extensive. Injection shows that the vascular network is almost impermeable. On microscopical examination there is seen in the substance of the gland a quantity, often considerable, sometimes enormous, of fibro-plastic elements in every degree of evolution, and in the midst of which the cells of the parenchyma are dispersed, and, as it were, drowned. This change may occupy only circumscribed parts, be limited to one of the lobes, or invade the whole extent of the organ."

Changes somewhat similar to these are observed also not unfrequently in the lungs, which become the seat of a kind of greyish-white hepatization, the tissue of the lung is completely infiltrated, and so solid as to sink immediately it is put into water, the smaller bronchi are compressed and almost obliterated. The extent of the pulmonary disease varies, it may involve an entire lobe, or even more. In one case related by Portal, "The right lung was almost entirely destroyed by suppuration, there were some abscesses in the upper lobe of the left lung, and the remaining substance of both lower lobes was hard, and resembled shrivelled leather."

Lastly, the glands of the lymphatic system are very com