in abeyance, although the perception of light is not entirely lost. The bowels were at first quite costive, and an enema was given soon after the infant entered the hospital. In a day or so they began to act more freely, and finally a condition of diarrhoea ensued, which has proved difficult to check. For two days the infant had six stools in the twenty-four hours, and yesterday eight stools, and to-day blood has been noticed in the discharges. This diarrhoea has come on in spite of careful feeding, the infant being given nothing but sterilized milk, and in the last few days large doses of bismuth subnitrate have been administered. To-day I have tried to control these discharges by injections of bismuth and starch-water. I regard this sanguineous diarrhoea which does not yield readily to treatment as a grave symptom in the case. We evidently have here a case of basilar meningitis in which the prognosis is bad. The unfavorable prognosis may be based upon the fact that the pulse is becoming more irregular, and it is a clinical fact that few cases of meningitis of any kind go on to recovery when the functions of the brain are seriously impaired and the cranial nerves and special senses severely crippled.

The question naturally arises as to the cause of the meningitis in this case, and the relation of the fall to the symptoms. Marked cerebral symptoms do not seem to have come on until a week after the accident, but it is well known that meningitis is very insidious in its early manifestations. The active cerebral symptoms are nearly always preceded by very great fretfulness and restlessness, with intolerance of light and more or less headache. Doubtless a careful observation would have established these symptoms in the week that elapsed before the occurrence of the convulsions.

I believe we can broadly distinguish two leading varieties of meningitis, septic and tubercular. The constitutional disease, cerebro-spinal meningitis, is not here considered. Septic meningitis is produced by pyogenic microbes. These microbes commonly gain entrance through the nose or ears. There may be otitis media, with or without caries of the petrous portion of the temporal bone; or there may be suppurating foci in the nose which communicate with the brain through the cribriform plate of the ethmoid. We may likewise have abscesses or tumors in the brain, and occasionally extension of inflammation from some of the structures in the orbit. Doubtless in not a few cases injury acts by producing a fracture somewhere at the base, and thereby affords entrance for the germs. But septic processes in distant parts of the system may occasionally be responsible for meningitis, as the microbes enter the circulation and are thus carried to the meninges.

In this case there does not appear to have been any discharge from the nose or ears, but still, in some way unknown at present, septic germs have gained entrance to the meningeal surfaces, with the production of inflammation.

In addition to sepsis, the second cause is found in the tuberclebacilli. Tubercular meningitis, however, runs a more subacute course : while the septic meningitis terminates usually before the twentieth day, tubercular inflammation may run for several weeks, or even much longer, presenting exacerbations and remissions. There is often in these cases a history of phthisis in the family; heredity is therefore an important aid to the diagnosis. There is also a history of previous ill health in the child, as well as lymphatic enlargements and other evidences of struma. In fact, the distinction between septic and tubercular meningitis must rest principally upon a careful study of the previous history of the cases and the mode of onset, this being much more gradual and insidious in the latter variety. In well-developed meningitis, where, as already noted, the functions of the brain and special nerves are seriously crippled, the prognosis is about equally bad in both varieties.

The hopeful time for the treatment of meningitis is the prodromal period. By giving a mild mercurial laxative, applying cold cloths to the head, and administering large doses of potassium bromide, you may succeed in some cases in controlling the beginning of the inflammation. At the same time a very careful search must be made for the source of entrance of any septic germs, and to this end the nose and ears must be subjected to careful scrutiny and, if possible, a thorough antiseptic cleansing. The distant organs of the body must also be examined to find a possible source for the microbes that are beginning to affect the meningeal surfaces.

Surgery.

POTT'S DISEASE.

CLINICAL LECTURE DELIVERED AT THE BELLEVUE HOSPITAL.

BY LEWIS A. SAYRE, M.D.,

Professor of Orthopaedic Surgery in the Bellevue Hospital Medical College, New York.

GENTLEMEN,-Two days ago this little child was brought to me from one of the extreme Southern States for the purpose of having a diagnosis made. She had been seen by a number of eminent physicians in the South, and for some months there had been much difficulty experienced in making the diagnosis. The parents have very kindly consented to bring the child here before you to-day in order that you may profit by seeing the case. Whether the long journey from the South has developed the disease still more, or not, I cannot say, but when I first saw the child the diseased condition was quite evident. The child is twenty-one months old, and was perfectly healthy and active up to last May, when she first complained of stomach-ache. Please bear this symptom in mind. She was eating irregularly at the time, and the physician who saw her then thought her trouble was entirely due to indigestion. But attention to the diet did not relieve the stomach-ache. In July another physician saw her, and an examination of the child's body at that time showed a "knuckle" on the back, and consequently a diagnosis was made of spinal disease. At that time she could pick up objects from the floor very naturally, and could move around very actively without complaining of pain in the back. She has never complained of pain in the back, but only of pain in the stomach. This is the rule: stomach-ache, not back-ache. Another physician was called in after the diagnosis of spinal disease was made, but the physicians, I am told, were not positive of their diagnosis, on account of the negative character of some of the tests employed, and because there was no pain in the back. After a while she began to lie around on the floor and to move less actively, and she then complained of feeling "tired." While the family physician

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believed there was spinal disease, he was not sufficiently sure of it to feel justified in putting on a plaster jacket. It is amusing to note that the parents observed that the child walked peculiarly, but they thought she was imitating the peculiar gait of their old fat cook.

Now, watch the way in which this child stoops to pick up an object from the floor; see how she shrugs her shoulders and throws her head back and her chin forward. This stiffness of attitude, this muscular splinting, is in itself a sufficient indication not only of disease of the spinal column, but of the plan of treatment which should be instituted. The child also has a peculiar grunting respiration which is characteristic of spondylitis. As I lay her across my lap, with the arms hanging over one thigh and the legs over my other thigh, and stretch my thighs apart a little, so as to make slight traction on her spine, you see she becomes perfectly comfortable and the grunting respiration ceases.

The physicians who sent this child here thought that there was no disease of the spine, because pressure over the spinous processes produced no pain. You should not expect to elicit pain by such pressure; very often, instead, the pain is diminished by laying the child upon its face and pressing on the knuckle in its back, as this pressure tends to separate the anterior parts of the bodies of the vertebræ where the inflammation exists, and so relieves pain, while by crowding the head and buttocks together these same inflamed vertebræ are pressed more closely together and pain is elicited. Please bear this fact in mind: it is pressure in the long axis of the body that causes pain, and not direct pressure on the knuckle itself, except in unusual instances, where the spinous process itself is inflamed.

Many people think the deformity is the disease; but it is not so, for the disease has been there long before the projection was visible; there has been an inflammatory process which has caused a crumbling away of the anterior portion of the bodies of the vertebræ, and it is this which causes the projection of the spine.

If the disease is detected in its early stages, before the deformity occurs, and proper treatment is then instituted, in many cases recovery will take place without deformity.

This instrument which I hold in my hand is called Seguin's surface thermometer; it is a very delicate test for differences in surface temperature. As I approach the instrument to the diseased area, you can all see that the index rises, showing that there is an increase of surface temperature at this point. It is an exceedingly useful instrument for determining obscure inflammatory action going on in the body.

We shall now apply to this child the only treatment which is proper at present,-namely, rest and extension in the cuirass.

I have frequently had little children brought to me wearing plaster jackets which slipped up and down on their bodies and were simply an additional weight for their already enfeebled spines to carry about. It is almost impossible to apply a plaster jacket to any child under the age of three years and have it of use. Exceptional children may be so large for their age that it is possible to get a sufficient grasp on the ilium, but such cases are very rare, and in the present instance the child is altogether too small to allow the application of any apparatus which will permit it to walk, and the very fact that it is horizontal in its cuirass will greatly improve its chances of recovery, while its small size makes it very easy to care for it in the cuirass, which would not be the case if it were ten or twelve years old.

FIG. 1.

Here is a cuirass,-a wire framework roughly approximating the shape of the body, and padded on the inside like a mattress. The part where the buttocks rest is protected by rubber sheeting. A jury-mast is also applied to the cuirass. The child is bound fast to the apparatus by roller bandages, and the feet secured to the adjustable foot-pieces. If the parents cannot afford to purchase a cuirass, you can make a substitute by placing the child on a piece of paper and making an outline of the body, and from this pattern cutting out a similar apparatus from a piece of board and padding it. It is important that the child should be carefully adjusted so that the anus shall come opposite the opening. (Fig. 1.)

We now fasten the leather head-piece under the chin and occiput, and fasten the upper ends of the strap to the cross-bar, which is attached to the jurymast by means of an elastic strap, and make just sufficient traction on the child's head to overcome the muscular spasm which is always present in disease of any joint. In this child the disease is so high up that it is necessary, in addition to keeping it horizontal and making traction by its head and heels, to hold the shoulders securely back against the cuirass, which I do by means of a little steel rod which passes from the tip of one shoulder across the chest to the other shoulder, the ends terminating in hollow hard-rubber cups, which fit the tips of the shoulders comfort