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the remedy, a saline aperient should be given. The following is then given in the morning at 8, 8.30, and 9 A.M.:

After the worm is out it should be examined in order to determine whether the slender portion with the small head has passed. A second dose of the tapeworm remedy may be given in a day or two if the worm has not passed and the patient is not weak from the effects of the first dose. If children vomit the medicine, it may be given by stomach tube. Salicylic acid is also used as a tapeworm remedy.

It is given in divided doses, forty grains in one day, followed by a dose of castor oil.

TUBERCULOUS PERITONITIS IN

CHILDREN

The infection of the peritonæum may come about by way of the circulation or from the gastroenteric or genitourinary tract. It may readily take place in children without an antecedent history of tuberculosis.

The diagnosis of tuberculous peritonitis is based upon the abdominal symptoms, such as distention, pain, and disturbed bowel action, and the presence of fluid and loss of weight, and is made by exclusion, except in those cases in which the tubercle bacilli are found, and then the diagnosis is positive. A febrile rise of temperature of an irregular type has been found in all cases under careful observation. There is nothing characteristic about the temperature curve. The fluid is an inflammatory exudate.

Cases of chronic non-tuberculous serous peritonitis present usually the features of an ordinary ascites, the abdominal fluid being free, whereas it is usually not free in the tuberculous variety. It is rare to find the tubercle bacilli by microscopical examination of puncture fluid. In doubtful cases the opening of the abdomen is indicated and will do no harm. Paroxysmal pain in the abdomen of children, in the absence of chronic appendicitis or abdominal fluid, is not indicative of tuberculous disease and is frequently overcome by dieting and attention to and irrigation of the bowels. (See Worms, Intestinal Indigestion, Membranous Enteritis, etc.)

A routine test with tuberculin in human beings in the present unsatisfactory state of our knowledge of its action is hardly justified.

Clinical Varieties of Tuberculous Peritonitis.-1. Chronic tuberculous ascites (miliary form); 2. Fibrocaseous tuberculous peritonitis; 3. Fibroadhesive tuberculous peritonitis; 4. Tuberculous peritoneal tumors; 5. Tuberculous ulcer of the intestine and appendix with adjacent miliary tuberculosis of the peritoneum; occasionally purulent peritonitis from perforation of a tuberculous ulcer.

TREATMENT.-In the present state of our knowledge, simple laparotomy is the best treatment for tuberculous peritonitis. The opening of the abdomen is, as a rule, followed by an arrest of local disease symptoms, and it may be followed by a disappearance of the tuberculous deposits on the peritonæum, as shown by certain cases in which the abdomen has been opened for some reason or other for the second time. The futility of medicinal treatment was experienced by the writer in a series of forty-one cases which were subsequently treated by operation. Where some form of medication is followed by improvement or cure, one must not forget that spontaneous cures have also been reported and observed in cases presenting all the clinical evidences of the disease. After opening the abdomen direct medication by iodoform emulsion or flushing with normal salt solution may be employed. Finally, the indication is an early operation, which is no doubt of very great benefit to the patient when the tuberculous process is limited to the peritonæum. As regards the establishment of a complete cure, one may be somewhat sceptical, because of the persistence of mild abdominal symptoms, of irritative catarrh or inflammation in the bronchi, lungs, pleuræ, and intestines, in cases which remain under observation after operation. If at the time of operation we have coexisting tuberculosis of the lung or pleura, the ultimate results are unsatisfactory, although some improvement usually takes place for the time being.

DISEASES OF THE RESPIRATORY TRACT IN CHILDREN

INTRODUCTORY REMARKS

This group of ailments centres around the symptom cough. Cough is a reflex phenomenon usually due to irritation in the respiratory tract. The tendency to "colds " and cough is most marked in anæmic, rhachitic,

syphilitic children and in children who are housed and who sleep in overheated rooms, in children of tuberculous antecedents, and in children who have chronic malarial disease, or who are suffering from other chronic ailments. In addition to such general underlying conditions we have local irritation to take into consideration, such as is furnished by the presence of swollen follicles (follicular pharyngitis) or of adenoid vegetations or of enlarged tonsils and peribronchial tuberculous glands.

These statements apply to the entire group of respiratory ailments, and in the management of children subject to "colds" and cough all these points must be taken into consideration. It will not suffice simply to order an expectorant or cough mixture. Children should sleep in cool rooms and not be burdened by heavy woolen underwear, in which they are apt to perspire on the least exertion. It is

important to keep the feet warm by wearing good stockings, but it is bad policy to keep the neck protected by furs and wraps, except in extreme weather. In neurotic children and adults we frequently observe a "nervous cough" which we are unable to locate. In the absence of local and constitutional causes, fresh air and a cool sponge bath daily are to be recommended for such conditions. Hot drinks are good expectorant mixtures, and a water trip, or absence from the dust laden city air is the best cough mixture, even in mild. febrile cases of long standing. For harassing cough at night a few drops of paregoric with wine of ipecac may be appropriate.

Adenoids and large tonsils must be removed, and swollen follicles should be cauterized. In protracted cases one or two doses of quinine may be given as a therapeutic "feeler" for malaria, even in cases in which the blood is free of Plasmodium malaria, and occasionally potassium iodide will promptly check a harassing or long standing cough.

FIG. 64-TUBERCULOUS PERITONITIS WITH CYS-
TIC ACCUMULATION OF FLUID. (Operation.)
No relapse or symptoms after four years.

CATCHING COLD

The rationale of the causation of the ordinary "cold" by reason of localized or general chilling of the body is made plausibly clear by recent studies on the bactericidal power of the blood of animals exposed to cold. It has been found that by chilling the surface it is possible to reduce the number of antibodies in the blood to a very marked degree. This means

that the body is deprived of a goodly proportion of its defensive weapons, and therefore under such conditions it easily falls a prey to infections of all sorts. On the other hand, repeated exposure to slight degrees of cold brought about an increase of antibodies, and this observation therefore affords a theoretical justification of the practically approved methods of "hardening" the body by hydrotherapeutic and other methods of training.

Simple Acute Rhinitis, Pharyngitis, Laryngitis, Tracheitis, and Bronchitis are names given to the mild infectious catarrhs of the upper and lower respiratory tract, according to localization.

The SYMPTOMS are sneezing, lacrymation, coughing, moderate fever, loss of appetite, and a sensation of chilliness with mucopurulent secretion in the terminal stage. The mild forms last two to three days; the severe forms one to two weeks.

A persistent nasal catarrh with excoriation at the nostril is strongly suggestive of diphtheria, and a culture should be made and antitoxine administered if the Klebs-Loeffler bacillus is found.

Mild overlooked nasal diphtheria with a free pharynx and subsequent measles and laryngitis and ultimate diphtheritic croup form a clinical sequence which has surprised many a colleague. The possibility of syphilis should also be borne in mind.

In coryza there is a nasal discharge. In pharyngitis the pharynx is red and dry and there is hoarseness. In rhinitis, pharyngitis, and laryngitis we should examine carefully for diphtheritic patches in the nose and throat. Bronchitis and the measles eruption go hand and hand, as do pharyngitis and scarlet fever.

TREATMENT OF A "COLD."-In uncomplicated mild cases of catarrh in the upper respiratory tract the children are put to bed and a laxative is administered. Hot and cold drinks are given and a fluid diet or fever diet is appropriate. To wash away secretions and disinfect the nasopharynx, a few drops of salt water are poured into the nostrils by means of a spoon, every three to four hours, or an albolene spray may be used for the nose and throat. Older children may take three to five grains of saccharinate of quinine or euquinin. The management of laryngitis with a croupy cough and stridulous breathing is discussed under Croup.

The general hygienic management has been outlined in the introductory remarks. If children do not promptly recover, the urine should be examined and a general careful examination should be made, to detect if possible any further complications. It will not suffice to order cod liver oil and trust to luck, as in the good old days. Incipient tuberculosis can often be recognized by a careful examination, and frequently can be arrested and cured by energetic hygienic and dietetic management.

The Clinical Features of Acute Bronchitis in Children

Bronchitis is an inflammation of the mucous membrane of the bronchi. It may be unilateral, but is usually bilateral. It may be primary and represent an extension of a "cold" beginning in the upper air tract, and it may be secondary to or accompany many other forms of disease and is a common ailment in ill nourished and rhachitic children.

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SYMPTOMS. In the mild form of bronchitis we observe cough, accelerated breathing, a moderate rise of temperature, loss of appetite, vomiting, restlessness, and often a wheezing respiration. In the severe forms, which cannot be distinguished clinically from bronchopneumonia, the dyspnoea is more marked. The respiration may be 60 to 80, with slight cyanosis. The chest is filled with coarse moist râles. Attacks of respiratory failure are observed and occasionally we have the clinical evidence of acute emphysema.

The PROGNOSIS is favorable except in the severe form, which is often fatal to young infants, whereas older children usually get well.

DIFFERENTIAL POINTS.-Bronchitis may be the first symptom of measles and whooping cough and may indicate an irritation from inflamed and enlarged peribronchial glands.

TREATMENT.-A mild bronchitis is managed like any other form of "cold." In the winter the child is put to bed in a room heated to 70° F. and a change from one room to another is advisable. The patient should receive an enema and a warm bath and should have cool water to drink.

DIET. Soft diet for older children. Infants take their usual liquid nourishment. As soon as the febrile stage is over children should be taken out of doors in fine weather. The nasopharynx should be kept moist by instilling ten drops of salt water into each nostril several times a day. In tardy convalescence, two or three grains of quinine in a teaspoonful of compound elixir of taraxacum may be given once or twice for the purpose of counteracting any underlying malarial factor. To check a harassing cough, five to ten drops of paregoric may be given once or twice, particularly at night. In the severe form of bronchitis the treatment is identical with that of bronchopneumonia.

Poultices, jackets, and inhalations are probably useless and are not employed by the writer. The protracted cough during the convalescence stage is favorably influenced by a change of air and mild cauterization of the nasopharynx with a five per cent solution of argentic nitrate. An albolene spray applied through the nostrils often relieves local irritation and cough. Throat Coughs of Children. Hypertrophied tonsils cause a constant cough, which becomes severely spasmodic at times.

Adenoids cause a frequent hacking sort of cough, as in beginning tuberculosis, due to the postnasal catarrh present in such cases.

Cough due to Granular Pharyngitis and its accompanying catarrh is characterized by its onset with emotional disturbance, as at the beginning of laughing or crying. Frequently the cough is of a dry and rasping character and the little patient is compelled to clear his throat frequently, with the expectoration of small pellets of gray sputum.

The treatment is directed to the cause.

BRONCHOPNEUMONIA IN CHILDREN (Catarrhal Pneumonia,

Capillary Bronchitis)

Definition. An infectious, diffuse pulmonary catarrh or inflammation without the typical "hepatization" which is characteristic of lobar pneumonia. The portal of entrance for the various microbes responsible for this condition is the respiratory tract.