broth and farinaceous gruels with their milk after the seventh or eighth month. Whereas chronic intestinal indigestion will often end in scurvy, rhachitis may develop in children who have shown little or no intestinal catarrh and intestinal toxæmia.

Clinical Forms of Rickets.-BONE RICKETS.-Craniotabes (soft cranium); rosary at the ribs; chicken breast; rhachitic spine; curvatures of the spine; bow legs; knock knees; square cranium (caput quadratum, with hydrocephalus combined); deformed clavicles; flat foot; pelvic deformity, etc.; enlargement of the epiphyses, etc.

MUSCLE RICKETS.-In rickets the muscles become flabby and powerless (pseudoparalysis). Children who have walked, fail to walk.

FAT RICKETS. This term is used when children show only slight changes in the bone and are excessively fat. Pot belly is the term in vogue to desig

CHILDREN.

nate the large abdomen of rhachitic children. Of nervous symptoms, we have laryngismus, tetany, convulsions, nystagmus, head nodding, tics, hydrocephalus, sweating of the head.

Generally speaking, rhachitis is accompanied by a tendency to catarrh of all mucous membranes and a feeble resistance to other intercurrent disease.

Rheumatic and scorbutic changes in and near the joints or epiphyses may be distinguished from rhachitic swellings by means of x rays. Rhachitic bone gives only a faint shadow in the x ray print. To discriminate between rickets and joint manifestations of congenital syphilis is difficult, in the absence of a syphilitic history. Infants are frequently rhachitic and syphilitic at one and the same time.

Prophylaxis and Treatment. To prevent a child from becoming rickety, we

must carefully attend to its diet, its digestion, and its hygiene. This involves all that has been said under Infant Feeding, breast, mixed, or bottle feeding. At the end of the seventh month meat broth and gruel with yolk of egg should be fed twice a day in addition to the five bottles of milk food. Children must live outdoors in good weather and sleep in

cool rooms, and they must have a daily movement of the bowels. A similar management must be enforced to prevent children who are rickety from becoming more so. Children a year old and over may have rice, sago, farina, hominy with egg, beef broth, and toast crumbs, and may nibble a chop bone. The milk should be

rich in fat.

Of drugs, iron, arsenic, phosphorus are lauded and appear indicated.

Syr. ferri iodid., 10 drops three times a day.

Fowler's solution, 1 drop three times a day.

Elix. phosph. (U. S. Ph.), 5 to 15 drops three times a day.

Thompson's solution of phosphorus, 10 drops three times a day. Such drugs are to be administered for two to four weeks and then discontinued for a week or two.

The thyreoid therapy, recommended for rhachitis, has been tried by the author in the Babies' Ward of the New York Post Graduate Hospital without showing noteworthy results. Malt preparations and fruit juice are serviceable for children one year old and over.

Bow legs and knock knees are rectified surgically by osteotomy. The results are good. A rhachitic thorax and spine may need gym

nastics and orthopaedic management (see Orthopædics). Fractures of long bones (green stick fractures) and epiphyseal detachments require splinting.. Laryngismus stridulus is managed by means of cold sponge baths and bromide of sodium internally. In a few instances, and in urgent cases, the writer has tubed the larynx for hours and once for a week with very satisfactory results in cases of laryngismus.

SCURVY IN CHILDREN1

Scurvy is an acquired "hæmorrhagic diathesis" from intestinal putrefaction and toxæmia. This view is the more plausible if we remember that in hepatic, renal, and other disease we frequently notice in the later stages "hæmorrhagic" phenomena which we may attribute to the same causes,

1 See collective investigation on Scurvy in America, by the American Pædiatric Society.

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viz., intestinal putrefaction and toxæmia. In adults the lack of fresh vegetables in the diet was formerly looked upon as the causative factor in scurvy. This view is erroneous. The Arctic explorer, Mr. Nansen, personally told the writer that during his three years' trip in the Fram not one case of scurvy developed among his party, and he attributes this remarkable immunity to the careful sterilization of all the perishable food taken along. Pellagra, Maidismus, the so called Alpine scurvy, is due to the use of diseased maize as food. Scurvy in children follows the prolonged use of improper food.

Sterilizing, Pasteurizing, or cooking of milk is not per se responsible for the scurvy condition. Scurvy may develop in infants and children fed on breast milk, cow's milk (raw, sterilized, or Pasteurized), condensed milk, proprietary foods, etc. Out of 379 cases reported, only 12 had scurvy at the breast; all the others were bottle fed. Scurvy may be prevented, therefore, by selecting for each individual bottle fed child the food which it will digest and upon which it will thrive and gain.

Characteristic Symptoms in Scurvy are: Anæmia, pain on motion or handling, discoloration of the gums, subcutaneous and free hæmorrhages, swellings about the joints, spontaneous detachment of the epiphyses from the shafts of the bones, etc. Pain is clearly a very prominent symptom of the disease. Generally it is evident only when the child is moved or tries to move itself. Sometimes it is so intense that the approach of any one to the bedside is sufficient to cause the child to scream out through fear of being touched. The legs are usually flexed.

Local swelling (hæmorrhages) may involve the soft tissues or may be subperiosteal. Protrusion of one or both eyes is probably due to orbital hæmorrhage. The gums are slightly swollen or discolored, spongy and ulcerated, and frequently bleed on being touched. A purpuric eruption and petechiæ are sometimes seen, and occasionally spontaneous hæmorrhages from the gums, nose, bowels, stomach, and genitourinary tract.

Fractures in infantile scurvy are usually separations of the epiphyses merely and are rare. Fever is often present but is not a prominent symptom. Anamia and malnutrition are usually present and the percentage of hæmoglobin is much reduced.

Prognosis is favorable if the disease is recognized in good time.

Treatment.-Change of food, preferably to raw milk in cold weather; fruit juice or hydrochloric acid; cleanliness of the mouth; fresh air; treatment of any underlying cause; bowel washing.

Differential Diagnosis.-It is necessary to make a differential diagnosis between scurvy and the following diseases:

Rheumatic or Gonorrheal Arthritis.-The joints, not the bone shafts, are involved; fever is high; characteristic scurvy symptoms are absent.

Rhachitis.-Rhachitic rosary; no marked pain; no ecchymosis or petechial or spongy gums; rhachitis and scurvy may coexist.

Purpura.-No history of improper feeding; rapid improvement of scurvy under treatment.

Infantile Paralysis. Sudden onset with fever; difference of electrical reaction in the two diseases.

Syphilis may coexist with scurvy. The difference in the history must be taken into consideration.

Stomatitis.-This has none of the associated symptoms of scorbutic sore mouth.

WORMS IN CHILDREN

The alimentary tract in children is apt to harbor three kinds of worms: ROUND WORM (ASCARIS LUMBRICOIDES); PIN OR SEAT WORMS (OXYURIS VERMICULARIS); TAPEWORM (TENIA).

The round worm is brown in color and is from four to eight inches long. It usually inhabits the small intestine.

SYMPTOMS AND DIAGNOSIS.-Colicky pain with occasionally a blood streaked stool may lead one to suspect worms. A positive diagnosis is based upon the passage of the parasite or the recognition of its ova in the stools.

TREATMENT.-A dose of maltine with cascara at night and one grain of santonin with sugar the following morning, to be repeated five or six times for five or six consecutive days.

The pin worm inhabits the large intestine and rectum, and has been found in the appendix (case of Dr. Inslee H. Berry, of New York city). SYMPTOMS AND DIAGNOSIS.-Pin worms produce intense itching at the anus, and may be picked out of the anus in children.

TREATMENT. A strong decoction of garlic in milk is injected with a piston syringe or fountain syringe once or twice a day after a cleansing enema of soap suds. Camphor ice or cold cream may be applied to the anus to overcome the itching and pruritus.

The Tapeworm.-A tapeworm gives symptoms, but the only certain indication of the existence of the worm is the passage of the links or a section of the worm.

TREATMENT.--One week before administering the tapeworm remedy, five drops of oil of turpentine and five drops of compound spirits of ether should be given on sugar three times a day. One day before administering