and artificially, cannot claim to be fully answered to the satisfaction of all. We need not wonder at the uncertainty on these important points amongst the public when, though much has been settled, so much is left to doubt, uncertainty, or even ig. norance, in the profession. Nothing is more vital to the raising of the baby than its hygiene, which comprises more than feeding alone, and has to pay attention to dress, air, sleep, bath, and exercise, both physical and mental. Every one of these topics requires repeated discussion. As to feeding alone, we know that 20 per cent. of all children born alive die before they have completed their first year, and the majority of these 20 per cent. die of diseases of the digestive organs. But not only mortality has to be reduced by sound principles of hygiene. It is not enough that 80 per cent. should survive their first year, it is necessary in the interest of both the young individual and the commonwealth that they should be in good health and prepared to resist unfavorable influences. For life is not the greatest boon unless it be united with health. The hygiene of infancy has to secure a vigorous skin, active lymphatic glands, and nor mal viscera. It has also to supervise the curricle of later years. The determination of the age at which a child ought to be sent to school, and the best mode of instruction at school, belong to the domain of such a special section as it is proposed. And when after all, in the course of untoward events and hygienic errors the young fall sick, the care of the patient, both in private and in public institutions, presents itself for consideration. The topics of children's hospitals and sanitaria suggest themselves as fit subjects for the deliberation of the thoughtful and experienced, not only for the immediate benefit they confer upon the suffering, but also because of their being the only places where certain systems of treatment, such as the antifebrile and antiseptic, can be most successfully applied and tested; and where, finally, the honest searcher for truth in the profession, whether student or practitioner, or even the professional nurse, can alone find the opportunities for observation and instruction.

These are some of the considerations which speak in favor of the establishment of a special pædiatric section. Pædiatric science is no longer, ought no longer to be, a simple attachment to obstetrics and the diseases of women. It has nothing whatever in common with these latter branches. It has but little VOL. XXXI.—46

quite in common with general pathology and therapeutics. Thus a sound theory postulates a special study in a special section. And practice asks for it more than theory itself, for the majority of the general practitioner's patients are infants and children, with a symptomatology of their own, diseases of their own, and therapeutics adapted to their special require

ments.

CHRONIC BRIGHT'S DISEASE IN CHILDREN CAUSED

BY MALARIA.

By SAMUEL C. BUSEY, M.D.,

DISTRICT OF COLUMBIA.

IN a contribution to the American Journal of the Medical Sciences (vol. lxv. p. 123, 1873) I reported several cases of renal disease occurring in children, and believed to have been caused by chronic malarial poisoning. These cases, with one exception, were acute forms of disease, which I thought were curable. In supplementing that contribution I submit the report of three cases of the more chronic and incurable forms of renal disease.

Malaria has been recognized by most authors on kidney affections as an occasional cause, but no one has offered a satisfactory explanation. The general opinion is that the renal disease is secondary, and the immediate effect of blood impoverishment, which is always a characteristic of the malarial cachexia. Whatever may be this relation of cause and effect, one fact is exhibited in all the cases which have come under my observation, that is, that renal disease only occurs as a complication or sequence of miasmatic diseases in those cases which have been either neglected or imperfectly treated. The history of every case shows that the periodic attacks recurred at shorter or longer intervals for a period of several months or years, proving conclusively that the treatment, if any, had been limited to the arrest of a paroxysm or to the interruption of their regular recurrences for a brief period. It is not surprising that cases thus neglected should terminate in some serious organic disease of the liver, spleen, or kidneys. These results are, perhaps, more properly attributable to the blamable neglect of the patient, rather than to any relationship of cause and effect subsisting between miasmata and renal disease.

Another point, of special interest to the clinician, refers to the proper management and medication of the chronic forms.

Cure may be beyond the resources of science, but life may be prolonged for an indefinite period. How best to accomplish this is the important consideration. As a contribution to this branch of the subject I offer the following reports, together with the details of the treatment of each case, and a general summary of my experience in the therapeutic management of similar cases of chronic renal disease.

CASE I.-Harriet R., aged thirteen years, white, admitted to the Children's Hospital, June 30, 1877. Had never had scarlet fever. Two years before a sister and, in August, 1876, her mother had died of dropsy. Six months previous to admission Harriet had chills, which were followed by swelling of the lower extremities and abdomen. Under treatment, these swellings had disappeared. Now has ascites and general anasarca; enlargement of the liver and spleen. Urine passed, 12 ounces. The analysis was omitted from the record. This patient remained in the hospital until September 30, 1878, when she absconded in apparent good health.

At first the treatment consisted of a nutritious diet, a diuretic of sweet spirits of nitre in infusion of juniper berries, and the citrate of iron and quinine; but the anasarca increased, and on August 1st 15 grains of jaborandi were given in infusion three times a day, followed by considerable increase in the quantity of urine, and the gradual disappearance of the fluid accumulations. This, so far as I know, was the first time this drug was administered in such a case. During her long residence in the hospital, it was several times given upon the reappearance of the oedema, with the same good effect. On two different occasions the blatta orientalis was employed with the effect each time of diminishing the amount of urine. At five different times she suffered from uræmic intoxication, which was preceded by a most remarkable dilatation of one, usually the right, or both pupils, and followed by great irritability lasting for a few hours, then screaming, and terminating in unconsciousness. These attacks were always speedily relieved by free diaphoresis, produced by a hot air bath, which was accomplished by packing about her person under cover a number of bottles filled with hot water. As they cooled they were refilled and reinstated, so that a continuous high temperature was maintained as long as desired.

During her stay in the hospital she passed safely through an attack of measles.

CASE II.-John O'L., aged 10 years; white; admitted to Children's Hospital, March 22, 1880. (Notes by Dr. S. S. Adams, House Physician)

Four years previously was taken sick with chills, which had recurred, at shorter or longer intervals, sometimes assuming the tertian and sometimes the quotidian form. During the summer of 1878 he was seized with cough, which still continues. After an attack of chills in the fall of 1879, his face began to swell. Since Christmas last he had continued to swell. Now both lower extremities are enormously enlarged, the anasarca extending upwards, covering the abdomen and back. Some puffiness under both eyes. Until recently appetite good; bowels constipated; pulse small and weak; is pale and anæmic; buccal surface pale; tongue pale and small; stomach dilated; spleen enlarged; left lumbar region dull. Amount of urine passed in twenty-four hours, 4 ounces; 98 per cent. albumen.

Analysis of Urine by Dr. G. N. Acker.-A few blood corpuscles; renal epithelium; a few leucocytes; numerous large hyaline and epithelial casts; some smaller ones; some amyloid casts; hyaline casts in a granular condition; epithelial casts and renal epithelium undergoing fatty degeneration.

Examination of Blood.-Increased number of white corpuscles. A hot bath was ordered, to be followed by free purgation with compound jalap powder. The tincture of digitalis, in 5-drop doses, every four hours, was commenced on March 24th and continued till April 4th, on which day he passed 16 ounces of urine. On the 27th of March he had a chill, and 8 grains of the sulphate of quinia was given daily for several days, followed by 5-grain doses three times daily of the citrate of iron and quinia, which was continued till April 4th. During the time the digitalis was given, notwithstanding the increase in the quantity of urine secreted daily, the prepuce and scrotum became so swelled with oedematous fluid, it became necessary (March 30th) to puncture with a needle. The fluid poured out freely in large quantity. Four days after the suspension of the digitalis (April 4th) the anasarca began to increase rapidly. The digitalis was resumed, but the œdema progressed. On the 10th of April pulmonary œdema set in; the dyspnoea was very distressing. Free catharsis failing to relieve it, the hot bath was repeated, followed by the extract of jaborandi in 3-grain doses every three hours. The relief was slight, and during the