by the accidental contact of the matter with their eyes, which may be easily prevented by the most scrupulous cleanliness.

22.-Hydrocele.

Hydrocele in infants may consist in the distension of the vaginal sac of the scrotum with serum; the communication between the sac and the cavity of the abdomen either being obliterated, or still continuing open; or, the accumulation of serum may be confined to the vaginal tunic of the cord, without any communication with the scrotum or abdomen, or with a free communication with the latter. diagnosis is somewhat different in these different cases.

The

In hydrocele of the vaginal sac of the scrotum, the tumor is semidiaphanous, and the testicle, if it has descended, may be felt near its inferior posterior part. If no communication exists between the sac and abdomen, the swelling undergoes no change in its dimensions during crying or coughing; it usually gradually augments in size, presenting a kind of pyramidal form, with the apex towards the ring; and when the integuments of the scrotum are put upon the stretch, their natural rugosity is obliterated, and they become smooth, palecolored, and shining.

If, however, a communication still exists between the scrotal and abdominal cavities, the tumor will increase in size when the child coughs or cries, and pressure upon it will cause the serum by which it is distended, in great part or entirely, to pass upwards into the abdomen; while it immediately returns upon the pressure being removed. In this case, our diagnosis is to be founded upon the semi-diaphanous character of the swelling, the presence of fluctuation, and the inability to feel within it any fold of intestine, or portion of omentum.

In hydrocele of the cord, the tumor most generally occupies a situation midway between the testicle and groin. It is of an oblong figure, perfectly circumscribed, and generally very tense; it undergoes no alteration from change of posture, or during coughing or sneezing. It may be accompanied by an inguinal hernia, and by hydrocele of the scrotal sac, in which case the true character of the disease is rendered very obscure. When the hydrocele is situated higher up on the cord, it often extends upwards within the ring, or by gentle, continued pressure, it may be made to pass within it, the swelling immediately returning upon the pressure being removed. With the exception of a slight dragging sensation, which is the greatest when the hydrocele is low down upon the cord or in the scrotal sac, these tumors are unaccompanied by either pain or uneasiness.

Hydrocele is very generally confined to one side; occasionally, however, it occurs on both.

Children may be born laboring under hydrocele either of the scrotum or cord; but most generally it is not noticed until four or five days, and sometimes even longer, after birth. They are also liable to the occurrence of hydrocele at a later period, from the same causes which produce it in the adult. Notwithstanding the alarm to which these swellings, when they occur in infants and young children, give

rise in the minds of parents and the intimate connections of patients, they are seldom of much importance, and often disappear, after a time, spontaneously.

The female, according to Sacchi (Annali Univers. de Medicina, 1831), is liable to the occurrence of a congenital hydrocele closely resembling that of the male. The swelling is caused by a collection of fluid in the peritoneal sheath of the round ligament which passes through the inguinal canal into the lower part of the labium pudendi. It is at first returnable, but not so after a time.

In young infants, frequently sponging the tumor with a weak solution of the acetate of lead, or with a mixture of two parts of aqua camphorata and one of vinegar, or with a solution of the hydrochlorate of ammonia in camphor water, is, perhaps, the only treatment that it is proper to pursue. If, under this treatment, the swelling does not disappear, when the child has arrived at twelve or eighteen months of age, as well as in those cases in which the swelling appears late in infancy or during childhood, the affusion of cold water-the water being poured upon the hydrocele out of a tea-pot, and from a height-four or five times a day, will very often cause its dispersion. The affusion must be unremittingly persevered in for a considerable time. In this manner we have, in repeated instances, effected a complete cure. The effects of the cold water may be increased, in children over two years of age, by brisk purging, and a simple farinaceous diet. R.-Bitart. potassæ, 3ij.

Jalapa 3j.-M. f. ch. No. xij.

One of which may be given every day, or every other day, according to the effects produced upon the bowels.

Where the hydrocele is of considerable size, and, in place of diminishing, continues steadily to increase in bulk, we have found that puncturing the tumor, and allowing the water gradually to drain off, has, after one or two repetitions, produced a radical cure. We have also seen the introduction, through the tumor, of a seton composed of a few threads of floss silk, effect a perfect cure, as well in cases of scrotal hydrocele, as of hydrocele of the cord, without the occurrence of much pain, or any disagreeable symptoms. The ends of the seton should be loosely tied together, and a thread drawn out every second or third day, until the whole is removed.

Dr. Linhart, in an instructive communication on the subject of hydrocele in young children (Froriep's Notizen, 1856), remarks that when the swelling is met with immediately after birth, a wide communication with the abdominal cavity usually exists, and as there is often a fold of intestine at the upper portion of the swelling, it may happen that hernia and hydrocele alternate-so that two practitioners seeing the case at different times may give a very different diagnosis. Such cases require scarcely any treatment. The serum returns during the horizontal position of the patient, into the cavity of the abdomen, where it is readily absorbed. A compress so applied as to keep the neck of the processus vaginalis closed will generally be proper. When the hydrocele occurs later after birth the swelling is usually more tense, and the communication with the abdomen is either very small or en

tirely closed. When a very small communication still continues, the fluid will often return slowly into the abdomen, requiring, however, it may be, six or eight days for it to do so. These cases are apt to deceive by leading the attendants upon the child to believe that the means employed by them have produced an absorption of the fluid. This deception is the more liable to occur, from the fact, that in consequence of a very great narrowing of the upper mouth of the processus vaginalis, which is often over an inch in length, the return of the fluid cannot be effected by taxis. When entire closure has taken place, the case does not differ from one of ordinary hydrocele.

Absorption, according to Dr. Linhart, may still take place spontaneously, but it can rarely be promoted by the practitioner. The various stimulant washes that have been recommended, are all inoperative, and may act injuriously upon the integuments of the scrotum. In the cases in which they appear to promote absorption, the communication with the abdomen has, in fact, still existed. He believes, however, a cure may be very materially facilitated by a subcutaneous incision of the processus vaginalis, by which the fluid is allowed to escape into the cellular tissue of the scrotum, where it is rapidly absorbed. Dr. Linhart prefers this to any attempt at effecting an obliteration of the vaginal process by means of pressure applied at its neck, which is seldom effectual, even could it be tolerated, or by the employment of injections, which in young children are not without danger.

The discussion as to the particular circumstances under which it may become necessary and proper to resort to the usual surgical means for effecting a cure of hydrocele in the child, by causing the obliteration of the cavity of the tunica vaginalis, does not come within the scope of the present treatise.

23. Paronychia.

Onychia-Panaritium- Whitlow-Felon.

Children are very liable to an inflammation, occurring usually near the end of one of the fingers or toes, or about the edge or root of the nail. It may be seated in the cutis, in the subcutaneous cellular tissue, or in the thecæ or synovial sheaths of the tendons, particularly on the inside of the fingers.

When the inflammation occurs in the cutis, we have usually the symptoms of a slight phlegmon-heat, pain, tension, and redness of the part, with some degree of febrile excitement. The inflammation terminates quickly in suppuration, marked by a semi-transparent elevation of the cuticle. The pus frequently travels around the finger, separating the cuticle to a considerable extent.

When the inflammation is seated in the subcutaneous cellular membrane, the local symptoms are more severe, and there is often a decided febrile reaction, attended with distinct rigors. The suppuration occurs early, but the matter is slow in reaching the surface, and often extends laterally, burrowing beneath the nail. This form of paronychia is generally attended with very severe pain throughout its course.

The affection is of a still more severe character when seated in the thecæ or synovial sheaths. The pain is deep-seated, and generally intense. There are often severe rigors, followed by very decided symptoms of febrile reaction from the very commencement. The swelling is more extensive than in the other forms, often spreading over the whole hand or foot, and even to the forearm or leg.. Distinct red lines or streaks of inflammation-probably inflamed absorbentsextend to the axilla or groin. At this period, in very excitable children, convulsive action often ensues, and very generally extreme restlessness, or delirium. From the unyielding nature of the tissues, the matter formed, in place of reaching the surface, passes along the synovial sheaths, or tendinous thecæ, to the palm of the hand or wrist, or to the sole of the foot; producing intense suffering for weeks; causing the death of the tendons, and destroying the motion of the joints, or even, in some cases, affecting the periosteum, and producing caries of the subjacent bone.

In children of a lymphatic temperament, or of a plethoric, but unhealthy condition of body, the inflammation is often seated in the matrix and soft parts at the root of the nail. (Onychia maligna.) The disease commences with redness, swelling, heat, and tension at the root of the nail; attended with a dull, throbbing pain, great tenderness upon the slightest pressure, and shivering, succeeded by febrile excitement. From the sulcus at the lower part of the nail there soon takes place an oozing of a thin, ichorous fluid, succeeded by ulceration, which spreads round the semicircular edge of the soft parts covering the root of the nail. The ulcer is of an unhealthy appearance, with thin, flabby edges, and covered with a dirty yellowish lymph. The skin becomes separated from the nail, exposing the latter to its very root. The ulceration extending beneath the nail gradually detaches it from the parts below. The surrounding soft parts are swollen, of a dusky red or purplish hue, and intensely sore; bleeding freely upon the slightest touch. When the disease is allowed to proceed, the toe or finger becomes a deformed, bulbous, ulcerated mass, and may continue so for months; exhibiting not the slightest disposition to heal, so long as any portion of the nail remains attached.

Paronychia may occur in perfectly healthy children, without any very apparent cause. In many cases it would appear to be intimately connected with derangement of the digestive and assimilative organs. Its immediate cause is usually either external injury, puncture, contusions or slight wounds, cold, or the retention of some acrid or extraneous substance about the nail.

During the inflammatory stage of paronychia, if any extraneous substance is present, it should be extracted or removed by repeated ablutions with warm water and a sponge, according to its nature. In the superficial variety, the best application is, probably, the common bread-and-milk poultice, frequently repeated, with a brisk purgative internally, and a mild restricted diet. In the cases in which the inflammation is more deeply seated, leeches, saline purgatives, low diet, and perfect rest are required.

If the local inflammation is very considerable, and attended with

much febrile reaction, in robust, plethoric children, a few ounces of blood may be taken from the arm, and some saline diaphoretic with antimony administered.' The free application of leeches to the seat of the disease is the most effectual means of abating the inflammation, and in this manner relieving the extreme pain. The early application of a blister around the affected finger or toe has often arrested the progress of the disease.

1

B.-Sulph. magnes. ziv.
Nitrat. potassæ, 3j.
Tart. ant. gr. j.

Spir. æth. nitr. ziv.
Aquæ, 3iv.-M.

Of which a teaspoonful may be given every three hours.

Various rubefacients have been recommended, as hot water, hot lye, hot turpentine, &c. These, when applied sufficiently early, will often do good. In all cases we should give a preference to the blister. It is hardly necessary to say, that any derangement of the digestive organs that may be present, will require the appropriate remedies for its removal.

In subcuticular paronychia, when suppuration has commenced, it is to be promoted by frequent poultices. When the cuticle is raised by the formation of matter, it should be freely divided, and then cautiously removed as far as it has become separated from the parts beneath. This is an important precaution, as suppuration is very apt to continue, if any portion of the detached cuticle is allowed to remain; and the disease thus to travel around and over a considerable portion of the finger or toe. After the separation of the cuticle, the denuded part dressed with simple cerate, or the cerate of the oxide of zinc, in general, heals very promptly.

In the more deeply seated forms of paronychia, when we find we are unable to arrest the course of the disease, an early and free incision is all-important. If we wait until suppuration has taken place, we not only prolong, unnecessarily, the patient's suffering, but endanger the loss of motion in the affected finger or toe, if not more serious injury. The incision should be made freely, and through the cellular texture of the part, down to the periosteum, and when the tendinous theca is affected, this should be freely divided with the knife. If the matter has burrowed beneath the nail, this should be scraped very thin, and then divided with a pointed histoury. The incision gives almost immediate relief, allows the escape of whatever matter may have already formed, or if suppuration has not commenced, prevents it by arresting the inflammation. After the incision, the diseassd part should be dressed with soft bread-and-milk poultices until it heals.

When deep-seated suppuration has taken place, and one, or perhaps several openings have been formed externally, through which fungous granulations extend and spread out in the form of mushrooms, free incisions are essential to the cure. If the tendons or thecæ are found to be dead or sloughing, the diseased portion should be clipped off with the scissors, with a small portion of that which is yet sound: if