Present status of pediatrics

Front matter

Boston Medical Library in the Francis A. Countway Library of Medicine --Boston

Open Knowledge Commons and Harvard Medical School

We can not stay amid the ruins." — Emerson

Chapter I — The New-Born and Infant Diet, by L. C

Grosvenor, M. D 1-7

First Toilet, i ; Later Toilet, 2 ; Asphyxia, 3 ; Ophthalmia, 3 ; Malformations, 3 ; Diet, 3 ; Bathing, 4 ; Sleep, 5 ; The Care of the Mother, 5 ; Artificial Feeding, 6.

Chapter III — Reflexes, -by C. A. Weirick, M. D 56-72

Chapter IV — Diseases of the Brain, including Cerebro-spinal Meningitis, by Martin Deschere, M. D. . .73-113 Simple Meningitis, 73 ; Tubercular or Basilar Meningitis, 78; Cerebro-Spinal Meningitis, 84 ; Chronic Hydrocephalus, 8g ; Convulsions, 92 ; Epilepsy, 97; Repertory of Characteristics, 104.

Chapter V — Diseases of the Spinal Cord, by Eugene F

General Considerations, 114; Poliomyelitis Anterior, 115; Acute Myelitis, 117; Chronic Myelitis, 118; Landry's Paralysis, 118; Syringomyelia, 119; Hereditary Ataxia, 119; General Treatment, 120.

Chapter VI — Thoracic Diseases, by Edward R. Snader

General Considerations, 126; Trachitis, 127; Bronchitis, 127; Broncho-Pneumonia, 130; Lobar Pneumonia, 133; Pulmonary Tuberculosis, 135; Asthma, 136; Pleuritis, 137; Purulent Pleuritis, 138; Diseases of

PACtES

Heart, 140; Functional Diseases of Heart, 142; Organic Diseases, 142; Endocarditis, 144; Chronic Endocarditis, 145 ; Myocarditis, 147 ; Diseases of Pericardium, 147.

Chapter VH — Diseases of the Digestive Tract, by Wm.

E. Leonard, M. D 151-181

Catarrhal Stomatitis, 152; Ulcerative Stomatitis, 153; Aphthous Stomatitis, 154; Membranous Stomatitis, 155; Thrush, 155; Cancrum Oris, 157; Dentition, 157; Dyspepsia, 160; Chronic Dyspepsia, 161; Acute Gastritis, 162; Chronic Gastritis, 163; Vomiting, 164; Icterus, 165; Diarrhoea, 167; Entero-Colitis, 170; Diarrhoea of Bacterial Origin, 173; Constipation, 174; Intestinal Parasites, 176; Oxyuris Vermiculosis, 177; Ascaris Lumbricoides, 178; Trichocephalus Dispar, 180; Tape Worm, 180.

Chapter VIII— Diseases of the Urinary Organs, by Alfred

P. Hanchett, M. D 182-195

The Urine, 182; Functional Diseases of Bladder, 184; Enuresis, 187; Lithemia, 189; Renal Calculi, 191; Acute Nephritis, 192; Diabetes Mellitus, 193; Diabetes Insipidus, 194.

Chapter IX — Skin Diseases, by A. M. Linn, M. D 196-215

Erythema, 196; Roseola, 198; Urticaria, 199; Vesicu- Ise, 200 ; Ecthyma, 203 ; Impetigo, 204 ; Prurigo, 205 ; Psoriasis, 206; Nsevus, 206; Lentigo, 207; Leucoderma, 207; Acne, 208; Lupus, 209; Molluscum, 209; Verrucse, 210; Scabies, 210; Syphiloderma, 211; Tinea Favosa, 213; Tinea Tonsurans, 214.

Preface

In presenting this book to the profession, we have not attempted to prepare a text-book or a complete reference book, but simply what its title indicates — a resume of the present status of pediatrics. We believe that this subject, which was so dear to the fathers of our school, and which has been in our practice the entering wedge for many a conversion to our tenets and beliefs, has been of late years sadly neglected. Through this little volume it is our desire to arouse fresh interest in Pediatrics, and to take this opportunity to urge every member of the homoeopathic profession to put himself in close touch with the work by placing upon his shelves, not bye-and-bye, but immediately, all of the recent homoeopathic works upon diseases of children. It is due to those who have done earnest and honest work in this line that they be rewarded by financial appreciation. Fisher's Diseases of Children is a complete and thoroughly praiseworthy work, and no practitioner can complete his library on modern pediatrics without it. Tooker on the same subject is a fit companion piece. If we are successful in bringing to the authors and publishers of our late works on pediatrics renewed recognition, and in awakening in our societies in general, and

X PREFACE.

in the American Institute in particular, an enthusiasm in the study of the diseases of the babes of the world, we shall feel that our work is repaid and that we have at least done our little toward a fitting- memorial this centennial year. The incentives that have been ours during- this work have, we believe, belonged in truth to each contributor to this book, and we wish here to publicly and most gratefully thank each contributor — all busy men — for the untiring help and courtesy that have at all times been ours.

THE EDITORS.

Lincoln, Nebraska,

June io, 1896.

Chapter I. The New-born And Infant Diet

BY LEMUEL C. GROSVENOR, M. D. , PROFESSOR OF OBSTETRICS AND SANITARY SCIENCE, CHICAGO HOMCEOPATHIC MEDICAL COL- LEGE, CHICAGO.

First Toilet. — The first thing which interests us, even before the cord is severed, is baby's first toilet. On coming into the world baby is covered with four substances, — amniotic fluid, the mucous lubricants of the vagina, blood, and vernix caseosa. The first three of these are readily removed, while wet, with a soft towel, and then the baby is oiled with warm sweet oil to soften the wax. After the oil has remained on two or three minutes the fourth coat is easily removed, leaving the baby with a soft, clean, velvety skin, no soap or water having been used. The old teaching that baby should lie about for half an hour and all these substances allowed to dry on, seems to us a pernicious one.

To-day the dressing for the cord is absorbent cotton rather than the historic burnt linen of former years. This makes a soft, kind, antiseptic pad for the navel. The band should be as simple as possible — a single thickness of flannel, without hems, embroidery, or hand painting. Remember always that the only purpose of this bandage is to retain the navel dressing, and it is to be thrown away when the cord comes off. To-day we recognize the fact that the band of the pinning blanket and skirt, together with the navel bandage, are the fruitful causes of ruptures, the teachings of the past to the contrary notwithstanding.

Later Toilet. — The old diaper, nearly a yard square and folded so many times, is a cruel one to baby, overheating the hips and the kidneys, and retaining so closely the liquid and solid excreta, with their emanations, as to cause frequent excoriations of the parts. The new double diaper, eighteen inches square and ten inches square, gives ample protection and is much more kindly.

Among the more intelligent mothers and physicians, the chemise, pinning blanket, and the skirts with their bands are discarded and in their place comes the beautiful princess cut Gertrude suit. This leaves all the organs in the body as free to play their part as in the colt or kitten. Probably 40,000 babies are in this suit to-day. No one can educate the young mothers of the land in these better ways as well as the physician. The wide-awake, up-to-date doctor, rather than grandmother, should be consulted by the young mother in these matters. This simple first toilet being completed, the baby should be laid away in a warm nest for rest.

Asphyxia. — Should baby be born asphyxiated, from long impaction in the straits, perhaps no one thing is so promptly available to restore the child as the hot bath. If the cord has not ceased beating, this bath should be given before severing the cord.

THE NEW-BORN AND INFANT DIET. 3

This is accomplished by placing the pan between the mother's knees, and placing the baby all over in the bath as hot as it can be borne, every few moments adding more hot water. Here the baby is handled, expanding and compressing the chest to imitate respiration. This hot bath keeps the blood limpid, the body warm, and we are soon rewarded by seeing our baby revive. In desperate cases the finger may be lubricated, and the baby's rectum dilated therewith — this will often provoke respiration in seemingly hopeless cases.

Ophthalmia of new-born infants may be prevented by immediately making the eyes absolutely clean by a warm solution of boracic acid. Remember always that a prolific cause of this disease is the poisonous vaginal secretions to which the eyes are exposed in their passage into the world. The cleansing antiseptic vaginal douche in the early part of the labor will save much after trouble in this direction.

Malformations. — Early in the case the doctor should examine the baby from head to feet for any evidences of malformation or disease. An occluded rectum, a hypospadias, a spina-bifida, a harelip, or cleft palate, pluro or syndactylism should not escape his notice. Many of the minor abnormalities may be corrected without the knowledge of the mother.

Diet. — Perhaps no one thing is doing so much to prevent diarrhoea, dysentery, and summer complaint, which so mark the first two years of baby life, as regular feeding. To-day we know that the old teaching, 'Mittle and often," is a blunder, and the advanced physician gives to the young mother valuable lessons in this regard. The young mother is given this formula,— nurse the baby every three hours during the day and once in the night for the first three months, then every four hours, and never again in the night for the balance of the nursing period. Some of the beautiful results of this better way are found to be these, — colics disappear entirely, vomiting ceases, baby has two stools a day instead of six, stools are wholesome and well digested ; there is no cholera infantum next summer and no "teething" by and by. This regular habit should be instituted the first day and not wait till the third day when the milk comes. Why should we tease the baby or annoy the mother before the railk comes? For three excellent reasons. In the first place, the baby is learning how and getting used to nursing; secondly, early nunsing provokes uterine contractions and prevents subinvolution of the uterus ; third, the breasts contain, right at first, a few drops of cholostrum, which act as a cathartic for baby. In this matter of regular nursing do not consult the baby in the least, ask the clock. Experience proves that these regularly fed babies are larger, healthier, happier, than those who eat when they want it, and hang on the breast all night. Crying for food ceases entirely, unless you go past the regular hour. Regular nursing and the new dress have done very much to reduce infantile mortality.

Bathing". — The daily full bath, immersing the baby all over in the warm water, washing it from head to foot without soap, drying it in a warm receiving blanket, dressing it quickly in the warm Gertrude suit, is another great advance over old methods. It

THE NEW-BORN AND INFANT DIET. 5

is easily done in seven minutes, instead of forty-five minutes the old way. This bath should occur on an empty stomach, before nursing rather than after. A good time is just before the second nursing of the day. This kindly, soothing, full bath makes baby contented and happy for all day.

Sleep, that boon to baby life, is to-day receiving much more attention than formerly. Regular habits here are worth as much as in feeding. Then the Creator's two great conditions of rest the world over, darkness and quiet, should be observed. A simple couch, without a pillow, light covering, and pure air are conditions of sweetest rest.

The Care of the Mother. — Many babies die every year from nursing tired, weary, worn out mothers. This fact is coming to be recognized by the best physicians, and as a result more attention is being given to the mother with reference to her ability to make good milk. She is taught that she cannot make a quart and a half of Jersey milk every day without something to make it of. She is encouraged to take three good meals a day, and four little refreshments between. These come the first thing in the morning, the middle of the forenoon, the middle of the afternoon, and on retiring. . She is taught to rest abundantly, and that rested milk makes baby contented and happy, while tired milk makes baby cross and irritable,— therefore she, as a nursing mother, should seek an abundance of sleep. She lies down to nurse her baby, lets the baby lie under her arm and not on it, gives a half, hour to each nursing, and drops to sleep while baby nurses. This is an exceedingly conservative habit as far as the mother's health and beauty are concerned. It rests the organs in the pelvic basket, and keeps her young, rested, and lighthearted. She takes her daily outing in the fresh air, in the sunshine and under the blue sky. She cultivates happy moods and tenses, remembering always that sweet content and happy thoughts improve the quality of the milk, while depressions, passions, envy, jealousy, suspicion, hatred, ill-will, and especially illtemper, poison baby's milk.

Sometimes it happens that the mother is not a ''milker; " perhaps she comes of a race who are not good nursers ; perhaps the breasts in the years from sixteen to twenty developed under the pressure of the corset and so made an imperfect development ; perhaps former mammary abscess has destroyed the breast ; perhaps an unwise nurse, by neglect or inattention to duty, has dissipated it. This failure, from whatever cause, necessitates artificial feeding, and the great question now is — what shall we feed the baby.

Artificial Feeding". — Many of the best physicians regard sterilized milk, properly diluted, as the most natural of all foreign foods, while a very large class of experienced men prefer some artificial food, such as Mellin's Food or Lacto-preparata. No one food suits every stomach, and sometimes we have to feel our way till we find one that suits. In artificial feeding even greater strictness with regard to keeping regular hours should be observed. If during the hot weather of summier or during fevers baby should fret between his meal times, a drink of pure water will

THE NEW-BORN AND INFANT DIET. 7

often quiet him. Whatever foods are given should be given from the bottle and not from the mug, this is a slower, neater, and easier way to feed the baby, as well as more natural. The flat cone bottle and the black or red Davidson nipple are the ones most suited to the purpose. The bottle with a rubber tube is a mena^^e to baby's life, since it is so difficult to keep clean.

So to-day, with the wise physician, much attention is given to those conditions and habits in the nursery which prevent rather than cure disease. To eliminate the terror and drudgery of motherhood and throw around it a halo of loveliness and joy should be the high ambition of every good physician.

PRESENT STATUS OF PEDIATRICS.

Chapter II. Diathetic Diseases

BY JOSEPH P. COBB, M. D. , PROFESSOR OF PEDIATRICS, HAHNEMANN MEDICAL COLLEGE, CHICAGO.

RHACHITIS. — Rhachitis is a disease of infancy and early childhood ; its most marked symptoms appear between the sixth month and the second year ; it may occur at any age and is occasionally congenital; it is closely associated with impaired nutrition and unhygienic surroundings. In this country it is comparatively rarely observed outside of large cities, where the poor and destitute are crowded together in imperfectly ventilated, poorly lighted, and filthily kept tenements, and among those families which cannot obtain suitable food or which do not appreciate the value of proper food for children. Infants nursed by a mother who, from any cause, either constitutional or dietetic, can furnish only a poor, watery, imperfectly organized milk may become rhachitic. Such mothers are usually anaemic to a high degree and their milk when examined has been found lacking in cream and soluble albumen ; it contains relatively a greater proportion of saline ingredients than normal milk, but the different salts do not appear in their proper rela-

DIATHETIC DISEASES — RHACHITIS. 9

tive proportions ; the insoluble albumin, caseine, approaching nearest to its normal amount. Though many mothers furnish imperfect milk, the majority of nurslings manage to escape rhachitis in any pronounced type until they are weaned; where the mother's nutrition is poor this period is apt to occur early in their infancy.

Babies fed upon artificially prepared food from the beginning are the ones who are more prone to develop rhachitis early, and yet they seldom show the marked type until after the sixth month. Nature seems, in the case of many of them, to be able to make an obstinate fight and only to yield when persistently starved out. It appears to be a matter of almost universal agreement, among those whose opportunities for observation among these classes have been the most extensive, that it is the persistent lack of fat — the proper kind of fat — and the lack of the proper saline ingredients in the proper proportions in the infant's food, which at least makes it possible for the disease to develop. The majority of the manufactured foods of the market, and especially those which are intended to be prepared without the addition of fresh milk, present these very conditions ; they contain far too little fat, and the fat that is present is not animal fat ; they may contain an excessive proportion of saline matter (which in itself is a fault), but the salts have not been organized by animal vitalities and materially differ chemically from the salts of the milk. Among the better classes, where unhygienic surroundings are not a prominent etiological factor, the food of the child who has developed rhachitis is almost invariably lO PRESENT STATUS OF PEDIATRICS.

found to have been one of the fat deficient and starch beridden trade compounds ; a compound which claims to contain all of the nutritious ingredients of milk and various cereals in an easily digestible form and which the manufacturer asserts is a " perfect substitute for mother's milk." This observation points its own moral, viz. , that the proper food for infants is milk. It is a question whether unhygienic surroundings alone ever produce rhachitis. Infants and children, like young plants, cannot thrive without sunshine; and like plants, when grown in an atmosphere vitiated by poisonous gases and deprived of sunshine, become sickly, stunted specimens of their kind. These influences, however, though potent factors in developing rhachitis, do not, in the absence of imperfect foods, produce typical examples of the disease.

Anatomical Chang-es. — The deviation from the normal standard of development belonging to rhachitis may be observed in any tissue. It is true that it is more apparent in the osseous system, and for this reason the bony changes have received more attention. The changes wrought in other tissues may, however, be even more serious and affect the child's expectancy even more deeply than those of the bones. Too little attention has been given to the deviation from the normal standard of the blood. Anaemia in some form is usually a part of the rhachitic development, and carries with it its pernicious blood composition. The number of red-blood corpuscles (erythrocytes) is always below the normal proportion and the percentage of h(Einoglobin will vary in the same proportion. The white corpuscles (leucocytes) are also

DIATHETIC DISEASES — RHACHITIS. II

at variance with the normal condition ; they may be simply deficient in number or deficient in development ; in pronounced cases they are abnormal in both of these respects. While these observations are true in varying degrees for all rhachitic children, in the case of those presenting splenic enlargements it becomes a more pronounced factor for evil. In such cases the number of erythrocytes and the percentage of hcejnoglobin have been found less than one-half the normal proportion, while more than three-fourths of the leucocytes have not been developed up to a good working standard. The specific gravity of the blood is below normal and falls in direct ratio to the advance of the disease. This is a condition of the disease, it is true, but it is a pathological difference and one that affects very materially the ability of the organism to do its ordinary work. During infancy the blood of all tissues is taxed the most by extra demands for growth and development, and to its inability to meet these demands may be ascribed in large part the deficiencies of other tissues. There is not space in an article of this character to dwell in extenso upon all of the varied deformities presented by a typically rhachitic child. In reference to the bony changes I wish to make this observation, viz. , that rarely does any one child present all of the possible osseous deformities or peculiarities. The rhachitic rosary is often absent ; so are any marked epiphyseal enlargements. Craniotabes are only present in extreme cases, but cranial bossa with a peculiar cranial contour are in some degree usually present. While the brachycephalic cranium with its fiat top box-like sides, its square appearance and overhanging forehead is the more common type, we should remember that another tj^pe with an exaggeratedly long antero-posterior diameter is equally as characteristic. In this class the craniotabes are not usually to be observed, but the bossa, fiat top, and overhanging forehead are present. Ossification is a twofold process which suffers in rhachitis in both particulars. The cartilaginous and subperiostial cell growth which produces ossification goes on with increased rapidity and in an irregular manner, while the actual ossification is equally irregular or even wanting. The second part of the process, the absorption of preliminary formations and the construction of medullary and other canals, is excessively active. There is a deficiency of building material, and one part is robbed to supply another.

The influence upon the nervous system of the rhachitic anaemia is one of its most baneful and lasting effects. The nervous tissue, like the osseous tissue, does not receive its proper building material ; it is starved, and consequently is improperly developed— the nerve centers seem to suffer the most severely, and certain ones apparently more than others. Rhachitic children are often precocious in their mental development, but they are irritable, easily unbalanced, and more prone to develop some form of nerve stome. In part, we should ascribe the imperfect tissue development to faulty activity of the trophic centers ; next to these nutritive influences I should place those belonging to the inhibitory^ apparatus — the inhibition of reflexes in these children is always im-

DIATHETIC DISEASES — RHACHITIS. 13^

perfect, they do not learn to disregard peripheral impulses which demand no consideration. An impulse which should give rise to only a limited reflex response is not confined to its simple route, but is transferred to other centers and calls out unnecessarily complex reflexes. In a similar way volitional inhibition is not well developed, and there is not the proper mental control even in those whose minds are precociously active. To this lack of inhibitory control and the abnormal irritability of nerve terminations is due the fact that these children are prone to suffer from partial or complete convulsive seizures. Laryngismus stridulus is rarely met with except in rhachitic children, and by many observers is claimed as a diagnostic symptom of the disease. Convulsions, which may occur in any child during early infancy, are liable to follow the rhachitic child through several years of its early life. Convulsions occurring after the end of the first year should always excite a suspicion of this disease.

Whenever tetany is present in infancy it is in rhachitic subjects. Other forms of nervous irritability have been observed in these children, and Erb has pointed out the fact that there is an increased electric excitability of nerves to both f aradism and voltaism ; that the mode of reaction to the voltaic currents is altered, and with positive and negative opening there occurs a prolonged contraction or tetanus. The muscular system is never as well developed; its tissue does not present the normal tonicity, it has not the same power of performing work, and it cannot as readily recuperate after exhaustion of its excitability.

The glandular apparatus suffers both in its structural and functional developments; individual glands may be abnormally large, and this is often the case with the liver, spleen, and pancreas ; this enlargement is due, however, to increase of connective tissue, with a corresponding diminution of active cell structure ; the capability of the gland is usually in reverse ratios to its abnormal developments. Nonassimilation is always a factor of rhachitis, and in the shape of chronic catarrhal gastro-enteritis and persistent dyspeptic diarrhoea may be its herald, or at least its first manifestation. When the disease is well advanced we could hardly expect anything else. Its low standard of blood structure, inefficiency of nervous control, with consequent proneness to venous stases, its tendency to excessive mucous secretions, and its impaired organs and tissues offer all of the conditions possible for impaired food metabolism and assimilation.

Relation to Other Diseases.— While I do not agree with Parrot that rhachitis is always an outcome of syphilis in a preceding generation, my observation has taught me that the disease is frequently developed from syphilitic parentage. The impairm'ent of the mother's nutrition by syphilis seems to offer exceedingly good ground into which to engraft rhachitis ; moreover, both diseases are frequently found co-existing in infants. Children in whom tubercular conditions are either active or latent seem to have an immunity from rhachitis.

Rhachitic children are always catarrhal subjects; they develop acute catarrhs under slight provoca-

DIATHETIC DISEASXS^ — RHACHITIS. I5

tions; catarrhal inflammation in them are liable to affect submucous tissues and be destructive in their course and results, and have a predilection to become chronic.

In the vegetative part of the system I find the primary causes of the development of this disease ; and I am also sure in my own mind that in the vegetative system, and in the character of its works, we shall find its first manifestations. For this reason, except in very advanced cases, the prognosis, so far as life is concerned, is usually favorable. The disease may be arrested in any of its stages, and many vitiated tissues and organs may be brought up to a healthy standard ; bony excrescences may be wholly or in part reabsorbed, crooked bones may be improved by the improvement of muscular tone ; improved nutrition may make it possible for the surgeon to work wonders with a deformed skeleton; abnormally large glands with little physiological capability may be brought to a fair degree of usefulness; and an equipoise of the nervous system, necessary for the maintenance of health, may be acquired.

The '''sine qua non'' for these changes are good food and hygienic surroundings.

I do not in this statement wish to despise or underrate the value of medication. I believe that our knowledge of such remedies as the calcarea compounds, phosphorus SiTidi th.Q phosphates^ iodiumoxi^ the iodides^ and others, often as serviceable, makes it possible for us to obtain results out of the reach of our allopathic friends both as regards time and extent. Yet our remedies will accomplish little if our patient is riot fed properly and has not the chance to make the acquaintance with sunshine.

RHEUMATISM.— The delicate tissues and organization of children exhibit a more extensive area of disturbances under the influence of rheumatism than is found in those of the adult. Rheumatism was formerly supposed to rarely occur in children and never in infants, but more careful observations show that it is as common in children as in adults, and that it is not uncommon during early infancy. In children the phenomena are not limited to the fibrous tissues, the synovial and serous micmbranes. Erythema, tonsillitis, chorea, pleurisy, tendinous nodules are just as frequent manifestations of rheumatism in children as arthritis and pericarditis are in adults; while endocarditis, usually considered in adults as a sequela of the disease, is in childhood a frequent and at times the only phenomenon observed. The various manifestations of rheumatism are in adults apt to be massed together and appear within a few weeks; in children, on the other hand, they show a tendency to be distributed over years, and may be the history of a whole childhood. Arthritis, the most characteristic feature of the disease in adult life, is in children the least prominent, while endocarditis, one of the rarer phenomena in adults, is one of the most frequent and persistent types in children.

Etiolog'y. — The most certain predisposing factor of rheumatism in childhood is hereditary influence. The most common exciting cause is chilling of the surface of the body. The poison of scarlatina seems also to be a direct exciting cause.

DIATHETIC DISEASES RHEUMATISM. 17

Tile exact essential etiological factor of the disease has not been demonstrated. The most commonly accepted theory, that it is due to irritation from the excessive amount of lactic acid present in the system, is not admitted as proven. It is the old question of ^'' post hoc'' and ^^ propter hoc.''

Dr. J. R. Mitchell's theory of its neurotic origin has to-day no common acceptance.

Dr. T. J. Maclagan, in the "Twentieth Century Practice .of Medicine," makes a strong plea for the miasmatic theory of rheumatism.

Dr. Alfred Mantle claims to have found a micrococcus and a small bacillus constantly present in rheumatic lesions. He has made cultures of these micro-organisms and reports successful inoculations. His experiments have been verified by very few and are disputed by others. The fact that endocarditis has been shown to be of microbic origin lends force to this theory.

In the face of all of these conflicting theories we have as universally accepted facts only the clinical features of inheritance and chilling of the surface.

Clinical History. — Acute rheumatism may present itself in a variety of forms, depending upon the organ or tissue most seriously involved. It can be more concisely discussed by describing individually its various types. It should be borne in mind that, especially after the sixth year of life, rheumatism may present itself in the classical way and run an ordinary course. In such cases the onset is sudden, the maximum of the disease is reached in a short time (two or three days), the temperature does not range high (102 to 103 F. ), the course of the disease is short (two to three weeks), new attacks, or seqiielce^ are apt to appear in succeeding years.