second, third, or fourth attack. In many cases the series of accidents by which rheumatism manifests itself begins with that of an inflammatory affection of the heart. If the rheumatism is complicated by pericarditis or endocarditis, very often a pleurisy of the left side, or of both sides, is added to them. The rheumatic affection of the brain occurs more rarely in children, and is not so dangerous as in adults. According to observations thus far, this cerebral affection has shown itself only in cases accompanied by chorea, and the question is, if the latter is only an expression or effect of cerebral rheumatism.

In the diagnosis of articular rheumatism in children, we must attend chiefly to the distinction from the so-called “growing pains,” from acute rachitis, and from abscesses in the vicinity of the epiphyses.

The prognosis of acute articular rheumatism in children varies according to the degree of violence, the amount of fever, the greater or less extent of the disease, but especially according to the complications; and it should be remembered, that the seemingly slightest attack may be complicated with the most serious accidents, and even end fatally.

Finally, in respect of treatment, there is no specific remedy, and we must act rationally according to the respective indications.

2. On rheumatism with chorea.

It has already been said that chorea as a complication of rheumatism is peculiar to childhood, and that a combination of the two diseases, or the following of the one upon the other, occur very frequently and can be regarded as the common expression of one and the same pathological condition. That the two belong together results from the observation of those cases, in which one has had the genesis of both diseases before one's eyes. In those cases, also, where chorea occurred during convalescence or soon after recovery from acute rheumatism, this pathological connection has been established, as well as by observation of those cases in which, during the existence of the rheumatism or from its very beginning, chorea was associated with it. Finally it has been established by the study of those cases in which rheumatism and chorea constantly alternated. Most frequently chorea is wont to supervene upon acute rheumatism, when the latter is on the decrease, that is, when its acute stage is about over. Very frequently, also, chorea occurs in those cases where the rheumatism is not firmly localized, where it is not very severe but more wandering, and therefore easily mistaken for “growing pains."

There seems, therefore, to exist in children a sort of compensation between rheumatism and chorea. The milder the rheumatism, the earlier and the more severe will be the chorea; the more violent, acute, extensive the articular rheumatism is, and the more it is accompanied from the beginning or during its course with cardiac disease, the less will usually be the chorea; and in cases where a series of attacks of both diseases alternate, the one often makes up in severity for the measure the other has failed to fill. This intimate connection of chorea with rheumatism in children surely has a determining influence upon the prognosis. If a child is attacked with acute rheumatism, however lightly, chorea is near at hand and lying in ambush, as it were, and on the other hand, a child suffering

from chorea may expect rheumatic troubles. Especially ought, in a prognostic point of view, the easy and frequent development of inflammatory affections of the heart and respiratory organs in the two diseases to be carefully observed. The history of rheumatism in children embraces that of chorea as well, as the latter can not be described without simultaneous discussion of the former,-or rather it is but a single disease which manifests itself in this double form.

3. Method for Local Treatment of Laryngeal Disease. [Sitzungsber. d. niederrhein. Gesellschaft in Bonn. 1866. p. 72.] Dr. OBERNIER, referring to the fact that the local treatment of laryngeal affections is frequently performed unsatisfactorily, recommends the method adopted in the medical clinics of BONN (which however he does not claim to be new). The patient sitting with his face turned toward the window, and his mouth opened, the larynx is illuminated by a laryngeal mirror. The hair-pencil filled with the medicated lotion is then so introduced that its point is held exactly above the entrance to the larynx. A rapid motion of the pencil forward and downward necessarily brings it under the larnyx, which is also made certain by the violent cough (and sometimes spasm of the glottis) it causes. While the latter manifestation is being performed, it is well to let the patient sound a high note. The advantage of this simple and easy method over the blind cauterization of the larynx, both in respect to the rapidity and the completeness of the cure, was established in many cases by comparison. The solution of nitrate of silver usually employed is, according to O.'s opinion, far too weak. He seldom uses a silver lotion of less than hali a drachm to one ounce.

4. Death from the Sequela of Diphtheria. By Dr. MINOT, in Boston Society for Medical Improvement.

[Boston Med. and Surg. Fourn., Nov. 21, 1867.]

The patient, a lady of nervous temperament, 65 years old, had an attack of diphtheria, in July last, while staying at the seashore, for which she was treated by Dr. EDWARD NEWHALL, of Lynn. Tonics and stimulants, combined with energetic local applications, were the means employed, and the patient recovered. Some weeks afterwards, inflammation, followed by ulceration, attacked the cornea of the right eye, which had twice before been subject to the same affection, at intervals of several years, so that its sight was much impaired. At the same time the patient began to lose control over her limbs, so that she neither could stand nor walk without assistance. She also began to transpose her words in speaking, and to use one resembling in sound, but differing in sense from the word she

intended to employ. There was never any difficulty in articulating or in swallowing; nor was there any real paralysis, but rather a weakness and a want of co-ordination of the movements. The pulse was slow in the morning and quicker in the evening, but there was no fever. Appetite moderate; much complaint of want of sleep, though in reality the sleep was not very deficient; occasionally she would sleep the whole night. She came to town towards the end of September, and was first seen by Dr. M. Sept. 29th. She was then able to walk out a little, with assistance, and drove daily in an open carriage. The eye was nearly healed, under Dr. WILLIAMS' care. The memory was somewhat impaired, and at times there was a little delirium. The urine was twice examined for albumen, but none could be detected by nitric acid or heat. The pulse at first was about 60 in the minute, and never arose above 90. The patient could grasp firmly with the hands, but could not hold her teacup without danger of letting it drop. The power of walking failed rapidly. At the same time the delirium increased, and on the 8th of October it amounted to complete mania, the patient laboring under the most extraordinary delusions, and manifesting hostility to all about her. She refused to take food or medicine. Drs. NEWHALL and WILLIAMS saw her in consultation on the evening of the 9th, and as it was impossible to give medicine by the mouth, a few drops of a strong solution of morphia were injected subcutaneously, at about 7 o'clock, soon after which she fell asleep. At 9 1-2 Dr. M. found her sleeping quietly. At 4 A. M., it was found that she was dead. Rigor mortis was complete, and the body was cool, so that death must have taken place some hours previously (probably as early as II o'clock), but so quickly that the attendants, who were constantly in the room, and awake, were not aware of it.

An autopsy was not allowed.

The treatment consisted in the administration of tonics (iron and quinine), sedatives (bromide of potassium), stimulants, and as nourishing a diet as possible. Electricity was begun to be employed, with a view to improving the muscular strength, but the mental condition of the patient made it necessary to suspend it.

5. Tubercle in the Lungs in consequence of Stenosis of the Pulmonary Artery. By Prof. LEBERT, of Breslau.

[Med.-chir. Rundschau, Aug., 1867, from Gaz. hebdomadaire.]

During his studies on the etiology of tuberculosis, L. was surprised at the frequency of lung tubercle in cases of congenital stenosis either of the cone or of the orifice of the pulmonary artery. He collected twenty-five cases-a large number, considering the relative rareness of this condition. The frequent occurrence of tubercles in the lungs is the more surprising, as in cases of disease of the left heart pulmonary tuberculosis can very

seldom be found.

These cases were found up to twenty-five

years of age, equally frequent in males and females.

Clinical examination, as well as pathological anatomy show, in these cases, that we have to deal not with a few discreet granulations, but a tedious, progressive, severe malady. A rapid course, terminating within three or four months is a rare exception, most frequently the disease lasts for several years. The frequent occurrence of hæmoptysis in these cases is worth mentioning. At first, an improvement during the favorable season not rarely takes place, but afterwards marasmus and hectic fever ensue and continue till death. Whereas ordinarily the right lung is first affected with tuberculosis, in stenosis of the pulmonary artery the left lung is the principal seat of the disease.

6.

Clinical Notes on Dropsy of the Peritoneum: Ascites. By S. O. HABERSHON, M.D., Physician to Guy's Hospital, etc. [London Lancet, N. Y. ED. July, 1867.]

The habit of designating disease by the name of one of its symptoms is fraught with many disadvantages; but this is, unfortunately, a practice too frequently adopted. Jaundice is merely a symptom; but it is the name given to a class of diseases, although produced by a variety of conditions. Albuminuria and Bright's disease are terms of general significance; so of others in ordinary use. Thus, also, dropsy of the peritoneum, or ascites, is often simply designated dropsy; and we admit that there is some excuse for applying such an appellation to this effusion into the largest of the serous membranes. Ascites is often associated with anasarca; and it then constitutes a part of the general dropsy. But the varieties of peritoneal effusion are worthy of especial consideration; and it is to this local dropsy, in its several aspects, that I invite attention.

We distinguish several forms of peritoneal effusion

I. From atrophy; as in senile wasting; in exhaustive cachexiae; and in simple anæmia.

2. Ascites from obstruction; as in cirrhosis; in heart disease; in chronic bronchitis; in any obstruction of the vena portæ or vena cava.

3. Ascites from renal disease.

4. From glandular disease, whether affecting the spleen or lymphatic glands, etc.

And although in each of these forms of peritoneal effusion the malady may be produced by some general ailment affecting the whole system, in the last three we have a more especial local manifestation of disease, and I have found these varieties overlooked or imperfectly understood.

1. Atrophic ascites is often present at the close of wasting disease. We find it in the feebleness of old age, in exhaustive cachexiae, and in simple anæmia. The effusion is of a passive kind; but it is sometimes sufficient to call for notice. The circulation in these cases is retarded, or has almost ceased, from failing power, or from fibrinous coagulation in the veins; and slow extravasation then takes place into the serous cavity and areolar tissue. It is a kind of exosmosis, and closely resembles the passage of serum into dependent parts of the body after the circulation has stopped.

2. A second form of ascites may be correctly designated dropsy from obstruction. Any mechanical impediment to the passage of blood from the portal system of vessels produces this variety of ascites. In several instances I have seen cancerous disease extending directly into the inferior cava, and reaching to the right ventricle, thus preventing the exit of blood from the liver, and causing engorgement of the portal circulation; and in another instance this extension took place into the vena portae itself, so that the whole structure of the liver was injected with cancerous product. In these rare cases ascites was present from mechanical hindrance to the course of the blood. More frequently we find obstructive ascites caused by chronic disease of the liver, or of the heart, or of the lungs and bronchi. In the latter varieties the legs become anasarcous, and so also in many cases of hepatic disease, as cirrhosis; for the obstruction affects the whole inferior cava, and in cirrhosis it will be found that contraction of the lobulus Spigelii hinders the free passage of blood from the inferior cava close to the heart. This form of effusion may be merely serous in its character, but, from the long continued congestion of the capillary vessels of the peritoneum, the nutrition of the serous membrane is generally more or less interfered with; the membrane becomes thickened, granular, and in color opaque; and what is of still greater importance to remember (especially in the consideration of operative relief by paracentesis), acute inflammatory changes are very easily induced, and fibro-albuminous product is quickly poured out. I would, en passant, refer to a rare form of passive ascites from obstruction which I have witnessed on two occasions, in which the effusion had a milky aspect, and was in part of a chylous character. In one of these cases the pressure involved the thoracic duct; and in the other the mesenteric lacteal vessels were very much distended, from obstruction in the mesenteric glands.

3. A third form of ascites is that connected with renal disease. Acute albuminuria, whether following scarlet fever or from other cause, is often accompanied by serous effusion into the peritoneum, as one of its symptoms, in common with general anasarca; and there is a great tendency to serous inflammation in this disease, apparently from the presence of urea in the serum. The peritoneum shares in this disposition; so that in an analysis of instances of peritonitis I found that, out of 500 fatal cases, 63 were in connection with renal disease. These instances of ascites with general anasarca do not call for special treatment. As the renal affection subsides the fluid becomes absorbed; and the best mode of treatment is that directed to the relief of the original malady. But there are conditions in which we find renal disease with ascites without general anasarca; I