to suspect the existence of rheumatism must be most carefully watched, especially as regards the state of the heart: we ought to examine this organ stethoscopically every day at least, since even in the very mildest cases mischief may be going on there when least expected.

Nor is it only in cases of rheumatism that all this care is needed, for in a few cases of scarlet fever, in some of measles, and in more of continued fever, cardiac complications are apt to arise. More often still, in regard at least to pericarditis, inflammation is liable to run from the pleura to the cardiac serous membrane; we ought therefore to be especially on our guard when the pleurisy is on the left side of the chest, and our suspicions should be aroused if the child becomes more than usually restless, fidgety, and distressed. These cases are probably not associated with any special blood poisoning.

The Symptoms of pericarditis are the same at all ages, allowance being made for the child's difficulty in referring to the seat of pain, &c. The most constant and prominent symptoms perhaps are, inflammatory fever; pain referred more or less distincly to the region of the heart, often darting through to the left scapula, or upwards to the left clavicle and shoulder, and down the arm; violent palpitation, the motions of the heart being tumultuous, and perceptible even at a distance from the patient; irregularity of the pulse; hurried respira tion; incapacity for lying on the left side, strong pulsation of the carotids; anxiety of countenance, great irritability and restlessness; piercing and distressing cries; and frequently noises in the ears, giddiness, and epistaxis. As the disease advances, there is extreme debility, cough, suffocative paroxysms, occasionally a tendency to syncope, and oedema of the face and extremities. These symptoms are not only often masked in young children by many circumstances, but even in the adult they vary a good deal in different cases. Thus, as Dr. Hope has remarked, if the effusion which results from the inflammation consists almost entirely of coagulable lymph, or if the serum thrown out has been rapidly absorbed and adhesions early effected, the circulation will be less interfered with, and less suffering will result than in those more formidable. cases where there is a copious fluid effusion painfully distending the inflamed membrane, pressing upon the heart, and embarrassing its movements. The symptoms will of course be more urgent if with the pericarditis there be also endocarditis. or carditis.

Though the above mentioned symptoms would undoubtedly be strongly suggestive of pericarditis, we cannot arrive at a

positive opinion, except by auscultation. We shall then findin the earliest stages of the disease-increased intensity of the natural sounds; and if endocarditis coexists, as it so frequently does, a loud systolic bellows-murmur will also be heard. Very early, too, a distinct alternate rubbing, or a to-and-fro sound, as Dr. Wilson terms it, will be audible. The bellows-sound indicates fibrinous deposits in the texture as well as on the surface of the valves, from inflammation of the internal membrane of the heart-the endocardium. The to-and-fro sound is indicative of inflammation of the pericardium: it generally ceases in a few days when this membrane becomes adherent to the heart, as it always does if the patient survives. When copious effusion takes place, we have dullness on percussion over a larger surface than in health; and as long as the fluid remains unabsorbed, a state of hydro-pericardium exists, which may prove fatal. The heart sounds in cases of effusion are generally very weak, and the impulse is also diminished.

There is often very great difficulty experienced in distinguishing between an endo- and an exo-cardial murmur, but where both layers of the pericardium are involved and lymph is formed upon each of them, the friction or rubbing sound is so loud and distinct it can be hardly be mistaken. Moreover, in such cases it can frequently be felt, as well as heard, by a kind of frémissement.

If we classify the physical signs of pericarditis, they will be as follows:

1. Sensations of friction communicated to the hand. 2. Friction sounds, the "attrition murmurs" of Hope. 3. Extension of dullness over the cardiac region resulting from liquid effusion. 4. Friction signs, attended with—or preceded by-valvular murmurs. 5. Signs of eccentric pressure analogous to those of empyema. 6. Signs of excitement of the heart. 7. Signs of weakness or paralysis of the heart.

Prognosis. Pericarditis-especially the rheumatic variety— is not so much to be feared for its immediate danger, though now and then it proves fatal, as for the traces of permanent injury which it leaves behind. The endocarditis which so frequently accompanies it produces especial mischief in the valves of the heart. The danger is great, however, when the morbid action is acute and general; or when it is set up in weak, scrofulous children; or when it supervenes upon a severe attack of scarlatina or measles.

Treatment. In no disease was the lancet used with a more unsparing hand in days gone by, than in inflammation of the pericardium. More extended experience has shown us, how

ever, that this heroic and sure method-as it was deemed-of extinguishing the morbid action, is not only uncertain but often highly dangerous. Formerly too, we were taught the great importance of rapidly getting the system under the influence of mercury, after bleeding. But when we look to the authorities of the present day, what do we learn? The question is well answered by Dr. Markham, who says, "We find one of the most observant and practical physicians amongst us admitting that the firm faith which he himself once reposed in the efficacy of this remedy has been undermined by the truth-telling effects of further experience." The remarks which we have already made on the use of mercury in various inflammatory diseases quite confirm this opinion.

The treatment which we adopt is that practiced by many for the relief of acute rheumatism:-the two principal remedies being opium, and the hot bath. From these agents we believe that we have seen the greatest benefit; and certainly in no instance have the remedies in question been prejudicial. They give great relief to the patient's sufferings, without inducing debility; and they in no way complicate the symptoms. The quantity of opium which will be needed for infants and young children will vary with the severity of the pain and the amount of restlessness; but in all instances very small doses must be given at first, the quantity being increased as the medicine. seems to be well borne. Sometimes one hot bath suffices; in other cases, it is necessary to repeat it daily, for three or four times. Alkaline drinks-F. 240-will also do good.

In most instances it will be necessary to administer a few doses of some purgative; the neutral salts-F. 222, &c.—will generally agree well. At first the nourishment should be light, consisting of gruel, arrowroot, and mutton broth. Directly the strength begins to fail, however, the diet must be made more strengthening; and milk, strong beef-tea, and wine should be allowed. Dr. Stokes-speaking of this disease in adultsstates that he is convinced patients are often lost for want of stimulation at the proper time; and he directs us to give support directly the pulse becomes feeble or intermittent, or the jugular veins become turgid, or pallor and coldness of the surface set in, or a tendency to faint upon exertion is manifested. "It may be laid down as a general principle that there is no local inflammation whatever, the mere existence of which should prevent the use of wine, if circumstances require it. In two cases especially-namely, cerebritis, and pericarditis-we find the greatest timidity in practice with respect to the use of wine. Yet even in the first case it may be required; and in the second

its employment is imperative, when as too often happens, excessive depletion has been resorted to." (Stokes.)

When the effusion into the pericardium is abundant, a blister may be applied over the præcordia; or a succession of blisters may be necessary. The iodide of potassium-F. 38-has been advantageously administered to promote absorption. It has been proposed as a forlorn hope-in obstinate hydro-pericardium, to remove the fluid by paracentesis. M. Aran, physician to the Hôpital St. Antoine, Paris, relates a case of pericarditis with copious effusion, in a young man aged twenty-three, which he treated by an injection of iodine. The pericardium was punctured from below upwards with a capillary trocar in the fifth intercostal space, a little below the spot where the dullness on percussion was well marked; about twenty-eight ounces of a transparent reddish serum, were removed. A mixture, formed of four drachms of tincture of iodine, fifteen grains of iodide of potassium, and an ounce and a half of water, was then injected without causing any pain; a drachm or two was allowed to escape before closing the wound. The fluid having reaccumulated, the operation was performed a second time with a stronger injection, formed of equal parts (fl. oz. 1) of tincture of iodine and water, with one drachm of iodide of potassium. The treatment was successful.

CHAPTER IV.

DISEASES OF THE DIGESTIVE SYSTEM.

I. INTRODUCTORY REMARKS.

WE have already seen in our remarks on the physiology of early life how strikingly peculiar are the digestive organs of infants and children, and in the following pages we shall have ample evidence of the influence of these peculiarities in inducing disease and death. Indeed, no better evidence can be afforded than the fact that of the 21,084 persons of all ages who died in the year 1866 from diseases of the digestive organs, no less than 4494 occurred under fifteen years of age, and of these, 2339 were under one year. Referring to the causes of this high mortality, we find that of the 4494 which occurred under fifteen years of age, 2249 were due to gastritis, enteritis, and peritonitis; and 591 to jaundice; all which seems to show that delicacy of organization and functional activity are the two prime factors in the production of a high death

rate.

In studying the diseases of the digestive organs, it will be convenient, we think, if we take them somewhat in their anatomical order; accordingly we will consider first the

DISEASES OF THE MOUTH AND FAUCES.

1. THE THRUSH.-This affection of the mouth, though very common in young infants, is important only as evidence of impaired nutrition and of a low condition of the vital powers. It is most frequently seen in infants who are artificially fed, or who are suckled by an unhealthy nurse.

Symptoms.-A child who is suffering from thrush is generally fretful and peevish, sometimes refusing his food apparently from the pain experienced in sucking; the bowels are often deranged and frequently relaxed. If we examine the mouth in such a case, we shall find the mucous membrane beset with numberless small white spots, looking like specks of curd, which are most abundant on the inside of the lips, the inner surface of the cheek, on the tongue, and in less quantity on the gums: these specks fall off, but are quickly reproduced. The mucous membrane is generally inflamed and angry-looking, dry,