Intermittent hectic fever. Death at the end of eight months, after an attack of acute meningitis. This child was not completely deaf, and learnt fresh words every day. 2nd. Another child (Boissonnade) eighteen months old, twelve teeth, thin, weak, ill-developed, had acute otitis, afterwards chronic otitis consequent on a serious attack of bronchitis. The two ears suppurated, and at the end of a year very porous portions of bone escaped from the auditory canal. Intermittent hectic fever became established, and the child, becoming gradually more feeble, died of chronic enteritis, with caries of one of the petrous portions of the temporal bone. The deafness in this child was incomplete; it retained and every day pronounced monosyllables which it could not say the day before; and at length answered questions. Chronic otitis and otorrhoea ought to be treated internally by the iodide of potassium, cod liver oil, antiscorbutic syrup, syrup of bark, syrup of walnut leaves, and externally by mucilaginous or astringent injections. These last are much the most useful, and decoction of strawberry root, of red roses, of walnut leaves, &c., are those which should be employed. [Inflammation of the dura mater is occasionally the result of otorrhoea. Sometimes acute inflammation arises within the tympanum, when there has been no previous disease; the patient has severe headache; at length a gush of matter comes from the external meatus, but the pain does not, as it usually does in such cases, cease; it continues, and even increases in intensity, the patient begins to shiver, he becomes dull and drowsy, slight delirium perhaps occurs, and by degrees he sinks into stupor. In some instances no pus issues externally. Similar symptoms more commonly supervene upon a chronic discharge of purulent matter from the ear. The following examples illustrate the phenomena of this disease: A youth, sixteen years old, applied to the late Dr. Powell (Transactions of the College of Physicians; vol. v) on account of an eruption with an acrid discharge behind the right ear. He had become deaf five years before, after scarlet fever, but no discharge took place at that time from the ear. In the following year, however, he had the measles, and then an abscess formed in the right ear, and after giving him much pain it burst. He had again suffered, three days before Dr. Powell first saw him, a sudden attack of very severe pain in the same ear. The pain quite deprived him of rest; but he had no fever, nor delirium, nor coma. He slept indeed a great deal, but that was the effect of opiates which he took to relieve the pain. This symptom was quieted by the opium, but it always returned with severity if the medicine was suspended. A foetid discharge came from the ear. On the tenth day of this attack, after a most violent paroxysm of pain, his strength rapidly declined, and he died. "When the head was examined the structure of the dura mater was healthy and natural, but beneath this membrane the whole superior surface of the right hemisphere was covered with a layer of coagulable lymph and pus. The vessels of the substance of the brain were not more numerous or loaded than usual, and the brain itself was healthy in every part. In the base of the skull the dura mater adhered to the bone, except at one part of about half an inch diameter, just over the petrous portion of the temporal bone, where it was black and sloughy. The subjacent portion of the bone itself was carious, black, and crumbling, and contained fœtid pus. It will be observed that in this case there was no symptom to mark the extensive mischief within the head, except the pain; the pulse never exceeded seventy-two, 2 the skin was warm and moist; there was neither fever, nor delirium, nor convulsion, Aterinira Dr. Abercrombie (Diseases of the Brain, &c.) relates the case of a girl, aged nine, chron nor coma. who had been liable to attacks of suppuration of the ear, which were usually preceded by severe pain and some fever. She suffered one of these attacks in the left ear in July, 1810. Upon the discharge of matter from the ear she did not obtain ease, as she had done on former occasions, but continued to be affected with pain, which extended over the forehead. When Dr. Abercrombie saw her he found that besides the pain she had some vomiting and impatience of light. Her look was oppressed; the pulse eighty-four. Blood letting, purging, blistering, and mercury Jufler. resulting in Eter: were employed without relief. Two days afterwards there was slight and transient horn delirium, a degree of stupor, and slight convulsions. She lay constantly with both her hands pressed upon her forehead, and moaning from pain, of which there had not been the least alleviation. On the fifth day from the commencement of the discharge she continued sensible, and died suddenly in the afternoon without either squinting, blindness, or coma, the pulse having been always under ninety. A considerable quantity of colourless fluid was found in the ventricles of the brain, which in other respects was healthy. In the left lobe of the cerebellum there was an abscess of considerable extent, containing purulent matter of intolerable fœtor. The dura mater, where it covered this part of the cerebellum, was thickened and spongy, and the bone corresponding to this portion was soft and slightly carious on its inner surface; but there was no communication with the cavity of the ear. There is also an account given of a boy, aged fourteen years, who had been affected for two months with headache and discharge of matter from the right ear. A week before his death the pain increased, and was accompanied by great debility, giddiness, and some vomiting. He continued in this state, without stupor or any other remarkable symptom, until the day of his death, when he was suddenly seized with convulsions and died. An abscess was found in the middle lobe of the right hemisphere of the brain, and another in the cerebellum, and there was extensive caries of the petrous portion of the temporal bone, with effusion of three ounces of fluid in the ventricles.-(Op. Cit.; p. 37.) Watson (Lectures on the Practice of Physic; p. 364) relates two very remarkable instances of diffused inflammation of veins occurring in connection with purulent otorrhoea. The first was a boy, eleven years old, who had a discharge of offensive purulent matter from his ear since an attack of scarlatina four years previous. The day after sleeping on damp grass, he was attacked with headache, shivering, and fever. Strong rigors, followed by heat and perspiration, occurred very regularly for two or three days in succession, suggesting the suspicion that the complaint might be ague; but then pain and swelling of some of the joints came on, and were at first considered rheumatic. However, the true and alarming nature of the case soon became apparent. Abscesses formed in and about the affected joints, and one of these fluctuating swellings was opened, and a considerable quantity of foul, grumous, dark-coloured matter let out. About a fortnight after the child sunk under the continued irritation of the disease. The hip joint presented a frightful specimen of disorganization; it was full of unhealthy sanious pus, the ligamentum teres was destroyed, the articular cartilages were gone, and matter had burrowed extensively among the surrounding muscles. The knee and ankle joints of the same limb were in a similar state. It is curious that the destructive disease of the joints was limited to those of the right lower extremity, while the primary suppuration was in the left ear. Unfortunately the head was not examined, but doubtless the fatal disorder had penetrated from the ear to the dura mater, and in all probability the inflammation had involved the veins or sinuses of the head. The second case was very similar to the above. A lad had pain and tumefaction of the right shoulder, wrists, and foot, with redness of the latter; he also complained of headache, vertigo, drowsiness, and of an occasional feeling of stupor; his skin was hot and dry, his face flushed, his tongue furred, his pulse frequent (112), and his bowels were relaxed; there was a puriform discharge from the right ear. The week before he had been seized with a sharp pain in that ear, which lasted twenty-four hours, when the discharge commenced and the pain was relieved. He then also began to have headache, which had never left him, and to be sometimes dizzy. Three days afterwards what was supposed to be rheumatism commenced in his right foot; the redness was circumscribed and limited to the great toe. After rizors, abscesses formed near the toe, near the shoulder, in the left hip, and in the loins, from which he gradually sunk. On the post mortem examination the articulations of the right shoulder joined, the left hip and the great toe were found diseased and filled with purulent matter. There was purulent infiltration of the lungs, and the mastoid cells of the right temporal bone were filled with pus. Dr. Bruce ( Medical Gazette; 1841) has published two cases, witnessed by himself, of phlebitis of the cerebral sinuses as a result of purulent otorrhoea," and refers to several other instances of the same kind recorded by different authors; and Dr. Griffin has related two examples of otitis with symptoms exactly resembling those of intermittent fever.-(Dublin Journal of Science.) Mr. Toynbee, at a recent meeting of the Pathological Society, showed a case of disease of the brain from caries of the petrous portion of the temporal bone after scarlet fever, the true cause of which was the confinement of the products of ulceration, on account of want of free exit for the matter. In the case exhibited, on one side the membrane tympani was completely destroyed, leaving a free opening for the escape of pus, and no caries of the bone had followed. On the other side, in the same patient, the membrane was only partially destroyed; the products of ulceration had been confined behind it, and caries had followed. There was also anchylosis of the stapes to the fenestra ovalis, and the base of the stapes was expanded and projecting. Foreign bodies are not unfrequently met with in the ears of children, who in moments of distraction and play introduce slate pencil, small stones, peas, glass beads, &c, generally roundish and smooth substances, into the auditory passage, which, if permitted to remain, would give rise to considerable inflammation and deafness. Great gentleness and care should be exercised in the removal of these bodies, which may generally be accomplished by syringing the ear with warm water, and by seizing the foreign body by small forceps or a bent wire or probe. Bodies which by moisture become increased in size, as peas, should be immediately removed; if, however, it happens that the harder bodies cannot be removed by gentle means, they may be allowed to remain, when probably they will become coated with wax, and the passage will enlarge by interstitial absorption, so that it will come away without trouble. Pilcher relates cases in which the foreign bodies were left undisturbed for many years. Fabricius Hildanus witnessed hemicrania, debility of the entire half of the body, obstinate coughs, epilepsy, and wasting of the arm, from the circumstance of a bead having been forced into the ear. Restoration to health followed its abstraction. Sabatier saw typhus fever and 6 death consequent upon the pressure of a pellet of paper in this situation. Power observed protracted salivation and atrophy result from a dossil of wool. Insects may be killed by a drop of oil or solution of acetate of lead, dilute cherry laurel water, or a weak solution of corrosive sublimate.-P.H.B.] BOOK XXII. ON DISEASES OF THE BONES. CHAPTER I. ON RACHITIS. Rachitis is a general disease of the osseous system, characterized by swelling, friability, and softening of bones, whence a great number of the deformities of the skeleton result. Some authors term it osteoporosis, others conjoin it with osteomalachia, under the same denomination. It is a disease, the knowledge of which is due to the labours of the celebrated Glisson, in Ruanit's 1647, and since then to the labours of Haller, Boerhaave, Van Swieten, stic Duverney, Portal, Boyer, Rufz, MM. J. Guerin, Sanski, and still more recently to M. Beylard, in an excellent inaugural dissertation. Malachin I am of the opinion of Boyer and M. Beylard; rachitis and osteomalachia constitute one and the same disease of the bones, & dis. modified by the age of the subjects. I consider that rachitis is the osteomalachia of infancy. CAUSES. Rachitis is sometimes developed in the foetus while yet in its mother's womb, even when her health does not appear changed. The museums of pathological anatomy contain several skeletons of these children rachitic from birth. Rachitis is especially a disease of infancy, which usually makes its appearance between the third and fourth month, and which is generally produced by insufficient food, and residence in cold, damp, or 30 yür and badly lighted places. Thus it is particularly remarked amongst the children of the poor who are weaned early, and who are, before hun the proper age, placed at the family table to be fed with soups, broth, vegetables, meat, &c. These aliments are good, but they should Cold. 4 be reserved until the fitting time. The young child should be suckled for twelve or eighteen months, and commencing at the sixteenth, thin aru Louis, of. the second year, still it is necessary to know how to combine them with milk-food, which should form the indispensable basis of the nourishment in the first two years of existence. Rachitis is a disease of cold and damp climates; it is especially developed in Holland, England, and the north of France. As humidity and cold very much depend upon the absence of the sun, we might also say that the disease we are now considering becomes developed in preference in those subjects who are rarely exposed to the influence of solar light. M. Guerin has studied the etiology of rachitis to a considerable extent, and has made experiments on young dogs with the endeavour to prove that a too nourishing food, and the use of meat in particular, may bring on this disease. He has placed in a dark room, puppies At one month old, and weaned; he has fed them with bread and meat pie, and at the end of two or three months they became rachitic. But here we must take into consideration the darkness and the want of exercise, circumstances which may of themselves alone bring on rachitis. In order to make these experiments conclusive, it would be necessary to institute them, on the one hand, on a series of puppies fed on meat, some running about in a park, others shut up by day, and placed in the most complete obscurity; and on the other hand, on a fresh series of animals differently fed, and placed in similar conditions as regards habitation and exercise. If experiments of this kind are not instituted, it is impossible to come to any conclusion on the subject of the real causes of the disease we are now considering. PATHOLOGICAL ANATOMY. 1st. Stage. This stage, which is that of the invasion of the discase, may be termed—The stage of the softening of the bone. The bones, and especially the long bones, present a rather considerable swelling, especially in the spongy and cartilaginous parts of the extremities, whence the vulgar term of knotty (noueure) applied to rachitis. The swelling is less considerable in the diaphysis; it is equally well marked in the flat bones, but for this it is necessary that the disease should be general. When these bones are incised either transversely or longitudinally, which is very easy on account of their softening, we find all these cells filled with spongy tissue, dilated and containing a gelatinous sanguinolent, blackish liquid, which can be readily washed away with water. In the body of the bone, in the situation when the tissue of the bone is the most compact, that which is called dilatation of the cellules is nothing else than the removal of the osseous lamellæ which constitute the osseous tissue, in such a manner that the bone, in this |