gentle, passive exercise, and be allowed a mild, easily digested diet; his bowels should be kept perfectly free, and his body be carefully protected from cold or damp.

When cyanosis appears in a new-born child, and persists after respiration is established, it has been recommended by Corvisart to employ gentle frictions over the head and body with a warm, soft cloth, while the infant is held near the fire. The frictions should be perseveringly continued, attention being, at the same time, paid to procure a free evacuation of the meconium.

7.-Intestinal Hemorrhage.

A copious discharge of blood by stool, and in a few cases by vomiting also, is occasionally met with in the new-born infant. It usually occurs between the first and tenth day after birth, but may take place at any time within the first two or three months, and is said to be more frequent in males than in females.

The discharge of blood may occur suddenly, without the slightest premonition, or it may be preceded by paleness of the countenance or a rapid fluctuation in its color, somnolency, slight spasmodic twitchings of the muscles, convulsive respiration, a difficulty of sucking, great prostration, vomiting, or frequent discharges by stool of a thin yellow fluid, tympanites, etc. All of these symptoms, however, are seldom observed to precede the intestinal hemorrhage of infants in one and the same case.

In the new-born infant the meconium may be, at first, mixed with more or less blood; usually, however, the stools consist of blood alone, even from the first. The hemorrhage from the intestine is in many cases accompanied by a vomiting of blood; in a few instances the latter only is present. The amount of blood discharged is often very considerable, rendering the child, in a short time, excessively pale, prostrated and unable to suck-its pulse becoming small and feeble, and its breathing difficult; sometimes there is an attack of convulsions. Etlinger refers to a case in which over one pound of blood was discharged by stool and vomiting within a short time.

The hemorrhage usually ceases by the close of the second day, though it has been known to continue for five days, and even longer. Sometimes the blood poured out into the cavity of the intestines, is not immediately discharged, either by stool or vomiting; in consequence of the change it undergoes whilst it remains within the alimentary canal, it presents when evacuated a dark or black color; occasionally, it is converted into a blackish matter mixed with slimehaving lost all the characteristics of blood; by the aid, however, of the microscope some altered blood corpuscles may still be detected.

In the cases collected by Dr. Rahn-Escher (Gazette Médicale, 1835), after the permanent cessation of the hemorrhage, the patients remained for a long time pale, thin, and feeble, and strongly predisposed to convulsions. One became subsequently rachitic, and another, at the age of twelve months, died from tabes mesenterica and hydrocephalus.

Occasionally, the blood continues to be effused into the alimentary

canal and there accumulates; the patient perishing with all the symptoms of death from profuse hemorrhage, without any blood appearing externally.

A discharge of blood from the bowels during infancy may take place in cases of purpura, which has been known to occur in an infant one month or even three days old. (Richard, Billard, Bouchut.) Bloody stools may also be a symptom of intestinal inflammation or invagination, of polypus of the rectum, or of anal fissures. The intestinal hemorrhage, however, to which we desire to call especial attention, is evidently due to a morbid hyperemia of the mucous membrane existing at birth, or occurring immediately afterwards.

Billard has observed twenty-five cases of simple hyperemia of the intestinal tube, without hemorrhage, in children who had perished within a few hours or days after birth. Fifteen of these had all the external characters of the apoplectic condition of the newly-bornwith symptoms of congestion of the lungs and heart. In fifteen other cases the congestion was attended with intestinal hemorrhage; of these, eight were from one to six days old, four, from six to eight, and three, from ten to eighteen days. Six were boys, and nine girls. The greater number were remarkable for the plethoric condition of the tissues, the general congestion of the integuments, and the engorged state of the large blood vessels and principal viscera. The intestinal canal contained blood in all of them-which was more or less changed -being of a pale or dark red or blackish color-appearing in the form of a thin layer on the mucous coat, or of specks or clots in different parts of the digestive tube.

Intestinal hemorrhage has been supposed to result in the young infant from the compression its body experiences during a tedious labor. That this cannot be so, however, is evident from the fact that the hemorrhage occurs as frequently, or nearly so, after easy and rapid labors as after such as were difficult and protracted. Rilliet refers the disease, 1st, to the congestion of the intestinal tube, a condition which is normal in the new-born infant, and 2d, to some impediment to the speedy and complete establishment of respiration; in consequence of which, the blood, unable to pass freely through the lungs, engorges the other organs, especially the intestines, the vessels of which, already loaded with blood, are unable to support this new tax. A somewhat similar explanation of the mode of production of intestinal hemorrhage in the infant is given by Billard.

These hemorrhages are always to be viewed as serious occurrences in early infancy; the more so the sooner they occur after birth. They are not, however, necessarily fatal, recovery having frequently taken place and, occasionally, under circumstances the most unpromising. Out of thirty-one cases, adding those we have found upon record to those in our own case book, and others furnished us by professional friends, recovery took place in thirteen, and a fatal termination in eighteen. The fatal result often occurs with great rapidity.

In regard to the treatment, Bouchut recommends that when the hemorrhage appears at the moment of birth, which, we may remark, is but seldom the case, and the infant is plethoric, all the tissues ap

pearing to be in a state of engorgement, blood should be allowed to escape from the divided cord previously to the application of the ligature. When the hemorrhage does not appear until some time after birth, with the same plethoric condition of the child, he advises a leech. to be applied to the anus, and even a second, should the congestion not be sufficiently subdued by the first. If, however, no indications of plethora are present, the smallest abstraction of blood will be improper. In the few cases of intestinal hemorrhage in young infants that we have met with, bloodletting was certainly the last remedy that would have suggested itself.

Drs. Rahn-Escher and Rilliet direct the use internally of diluted sulphuric acid in cinnamon water, or, in cases attended with prostration, an emulsion of alum and musk. Both these, however, are of extremely doubtful propriety in patients of so tender an age as those in whom the disease so generally occurs. Diluted alum whey in rose water we have found to act beneficially.

The gentlemen just referred to, direct the patients to be kept in a cool and frequently changed atmosphere, cold compresses being applied to the abdomen-the extremities at the same time being kept comfortably warm.

Enemata of cold water may also be resorted to, but we have little confidence in the various astringent injections that have been recommended-such as solutions of tannin, catechu, extract of rhatany, acetate of lead, or nitrate of silver. In extreme cases, and where the danger of a fatal termination is imminent, they may, however, be tried.

In every instance, the child, if it have strength enough to suck, should be put to the breast; if too weak, it must be fed with the mother's milk drawn in a spoon.

8. Spina Bifida.-Hydro-Rachis.

Hydro-rachis is, strictly speaking, an abnormal accumulation of fluid within the spinal column; it is, in almost every instance, a congenital affection, and may be associated with either hydrocephalus or spina bifida.

In the latter case there are, also, one or more tumors along the spine, generally in its lumbar, occasionally in its dorsal and sacral, but very rarely in its cervical portion. These tumors. vary in size, from that of a hazel-nut to that of the adult head, or the entire spine being bifid, the tumor may occupy its whole length. The tumor is usually globular or ovoid in shape, having either a large base or a narrow neck. In one case, recorded by Brewerton, it was bilobed. It may be invested by the common integuments, in a healthy, uninflamed condition, or the skin covering it may be thin, almost transparent, and crossed by purplish lines, looking as if about to rupture, with a sero-sanguineous fluid exuding through it. Or, the tumor may be empty; its contents having escaped through a very small, ulcerated opening, which is surrounded by a red, rugose, unequal elevation of the skin and subcutaneous tissue. The two latter conditions of the

tumor are much more common than that in which it is covered by healthy skin, and far more dangerous.

The tumor is always situated over a deficiency in the vertebræ, arising, most commonly, from an imperfect development of the lateral arches; occasionally, however, the lateral arches exist, but remain ununited; still more rarely, there may be a complete division of the whole vertebra, body as well as processes. The opening of the vertebra may be confined to one bone, or it may extend to two or more, or occur at different parts of the spine, giving rise to several tumors. It may, as we have already seen, exist throughout the whole extent of the spine.

The tumor itself is formed by a cyst, communicating with the spinal cavity, and filled by a fluid secreted within the latter. In the most favorable cases, its parietes are composed of one or two layers, consisting of the arachnoid membrane, the dura mater, and the common integuments, in a natural condition. More generally, however, its parietes are thickened, inflamed, ulcerated, gangrenous, or covered with fungous granulations, or tufts of hair.

To the touch, the tumor is tense and protuberant, whenever the position of the infant is such as to allow the fluid from within the spinal canal to gravitate towards it, but it is more or less soft and flaccid under opposite circumstances. By gradual pressure, its bulk may be diminished, and if of small size, the whole of its contents may be forced back into the spinal cavity, when the margin of the opening through the vertebræ may be felt with the finger. Pressure upon the tumor very frequently induces a state of coma, or convulsions, and in one case referred to by Dr. M. Hall, pressure, even that resulting from the supine position of the child, invariably produced attacks similar to the croup-like convulsions of laryngismus. In some cases, the tumor has been observed to expand during expiration, and sink during inspiration.

The contents of the tumor may be either a limpid, colorless serosity, or a turbid fluid, often containing albuminous flocculi, or a purulent matter. The fluid of the tumor communicates freely with that within the cavity of the spine. In many cases, there is a free communication between the ventricles of the brain, the intercranial arachnoid cavity, the entire canal of the spine, and the cavity of the external tumor, so that pressure made upon the latter may force the fluid back upon the brain, and cause more or less compression of that organ.

Children affected with spina bifida often present other malformations, as imperforate anus, imperfect or irregular development of the alimentary canal, &c.

When there exists no external opening in the tumor, it being covered by the common integuments, and when the accumulation of fluid within the vertebral canal does not exercise upon the brain, or spinal marrow, a degree of pressure sufficient to interfere with the free exercise of their functions, patients with spina bifida, though generally of a weak and infirm constitution, may exhibit no particular symptoms of disease, and even live to an advanced age, without the occurrence of any serious evil that immediately results from the spinal

tumor. Spina bifida has been observed in patients of almost every age, from ten to fifty years, and upwards.

Generally speaking, however, from a greater or less deficiency in the spinal cord, or other morbid conditions of it or of the brain, the infant is liable to be affected with paralysis of the lower extremities, convulsions, an open state of the sphincters, and difficulty of respiration. He is occasionally unable to take the breast, and sinks gradually into a state of constantly increasing exhaustion; his feet and legs become cold and oedematous, his cries more and more feeble, his pulse extremely quick and feeble, his breathing difficult, and often stertorous, and, finally, death takes place, preceded by convulsions or coma. The larger the tumor, the more intense and rapid is this train of symptoms. When the tumor bursts, inflammation of the membranes of the cord in general very rapidly ensues, and we have then all the symptoms of spinal meningitis, and, in most cases, the patient is very quickly destroyed.

When a small opening in the tumor exists, and a portion of fluid is constantly escaping from it, no very important suffering may result for a length of time. Druitt mentions a case which came under his notice, of a female, twenty-seven years of age, in whom the tumor relieved itself when distended by the exudation of a watery fluid through an exceedingly minute aperture. But, very commonly, the fluid discharged becomes more or less turbid, purulent, or even fetid, and symptoms of spinal inflammation soon occur. When the tumor is of considerable size, its sudden rupture may produce a paroxysm of convulsions, terminating almost immediately in death.

It has been asserted by Dugès, that a rupture of the tumor has taken place in utero, and the opening has again closed, previously to birth. This appears to us, however, to be very doubtful; the case cited in confirmation of it is certainly very far from being conclusive.. After death, the most common appearance met with is a more or less copious effusion of serosity, either between the pia mater and the arachnoid membrane of the spinal marrow, in the arachnoid cavity, or between the dura mater and bony wall of the spinal cavity. When in the first two situations, the effused fluid very generally communicates freely with the ventricles of the brain, and with the arachnoid cavity within the cranium, in which there also exists a morbid effusion of serum. Occasionally, when the tumor is small in size, and covered with the common integuments, in a normal state, the brain is found to be perfectly healthy, the effusion of serum being confined entirely to the spinal canal. Even the medulla spinalis may sometimes present no apparent indications of disease.

The effused fluid is usually perfectly limpid, excepting when meningitis has occurred, when it is generally thick, turbid, and flocculent. It may be of a light yellow, greenish, or dark hue, and is often mixed with pus, or with more or less blood.

When an effusion of fluid exists, at the same time, in the cavity of the cranium, and in that of the spine, the fluid in the former has been found to be of a different color from that in the latter, showing the two to be perfectly distinct. In other cases, the fluid was prevented