as above. If this aid is desired, arrangements should be made with the State Board of Charity, State House, Boston, Mass.

Fifth. Those who are able are expected to pay according to their means and the accommodations desired. The average cost is from $4.00 to $5.00 per week. For those outside Massachusetts the rate is seldom less than $5.00 per week. If a private nurse or extraordinary attention is required, the charge is graded to fit the conditions. The income from invested funds, and the contributions of charitable people make it possible to offer rates below cost, down to $3.25 per week, in cases unable to pay more. Occasionally children are supported by some society or organization in their own community. In all cases under this fifth head, a bond is required which insures to the Hospital the pay agreed upon.

No other legal papers or proceedings are required, but any suitable case may be received without formality if there is a bed available and the support has been provided for in one of the above ways. Admission blanks and further information will be furnished upon application to the superintendent.

Vicious children, or those with contagious diseases, are not received.

CONVULSIONS IN CHILDREN.

BY J. HERBERT MOORE, M.D., ASSOCIATE PROFESSOR OF DISEASES OF CHIL DREN, BOSTON UNIVERSITY SCHOOL OF MEDICINE.

The workings of nature, within or without the human body, are never of the haphazard order but are always due to definite causes. This is illustrated in the reason why those irregular discharges of nerve force, known as convulsions, are much more common in children especially during the first two years of life, and here the more common the nearer is the infant to the beginning of its existence. This reason lies not so much in the fact that the brain substance at birth is about 14 per cent of the body weight, as against 2.4 per cent in the adult, nor in the fact that it doubles its weight during the first year of life; but the reason of the liability of the infant and young child to convulsions lies in the manner of development of the various parts of the brain during the period of infantile and young child life.

The cerebellum develops more rapidly than any other portion of the brain, and the frontal lobes more slowly. The nerve cells of the cord and spinal nerves are well developed in the infant, but not so the multipolar cells in the gray matter on the surface of the brain, nor the pyramidal bundles of nerves connecting these cells with the basal ganglia and internal capsule. The practical bearing of all this is that this development of the excito-motor centres of the cord and medulla, and the un

developed condition of the higher control centres as well as of the connecting tract between the two, explain the fact that most of the movements of the infant are reflex. This manner of development also explains the proneness of infants to become convulsed when abnormal or additional irritation is present at the seat of origin of these reflex actions, devoid as these latter are of the controlling or inhibitory action of the higher control centres as yet comparatively undeveloped.

When the physician is called to a child in convulsions the problem for him to solve is the cause and essential nature of the same. First, are they due to direct or reflex cerebral irritation? If direct, is this direct cerebral irritation due to abnormal conditions operating within or without the brain?

A valuable diagnostic point right here is the presence or absence of high temperature, and of characteristic symptoms of individual diseases capable of directly irritating the brain substance whether originating within or without the brain. If high temperature be present the only condition originating within the brain capable of producing the convulsions will be acute meningitis, and this will demonstrate its existence by its characteristic symptoms. In cases of this kind the possibility of the presence of otitis should not be lost sight of, nor its necessary treatment of puncture of the drum head. Excluding acute meningitis, convulsions accompanied by high temperature will be found to be due to causes directly irritating the brain, but originating outside the brain; and constituting the toxic irritation of the zymotic diseases, or due to toxins or hyperpyrexia accompanying severe cases of other acute diseases.

Moreover these diseases, whether scarlet fever, diphtheria, influenza, ilio-colitis, pneumonia, or the like, will reveal to the careful diagnostician sufficiently characteristic symptoms to acquaint him with the fact that he is dealing with an acute and severe disease originating outside of the brain; and in a day or two, with careful watching, will present individual symptoms enabling him to diagnose the exact nature of the acute disease.

Of the remaining cerebral diseases producing convulsions by directly irritating the brain, after excluding acute meningitis. with its high temperature, such as hemorrhage, tumor, abscess, hydrocephalus, embolus, thrombosis and epilepsy, they are not only not accompanied by high temperature, and in this connection the lower temperature of tuberculosis meningitis with its evening aggravations should be kept in mind, but they soon present sufficiently characteristic symptoms to distinguish them from the various diseases and disturbances causing convulsions by reflexly irritating the brain.

When the absence of these characteristic symptoms, and of high temperature, has enabled the physician to eliminate the possibility of the convulsions being due to diseases producing

direct irritation of the brain, the problem is solved that the convulsions are due to reflex cerebral irritation; and the cause must be sought in the various conditions of system or individual organ capable of reflexly irritating the brain to the extent of producing these nerve explosions.

In this paper I want to especially emphasize that the most frequent predisposing cause of these reflex convulsions is that condition, in which all the tissues from brain to brawn are so poorly developed and nourished, known as rachitis; and that the exciting cause is gastric or intestinal indigestion, or both, due to the presence or result of indigestible food or improper artificial feeding, which latter in most cases has been the prime cause of the rickets itself. Consequently in cases of convulsions, which do not present definite symptoms of direct cerebral diseases, always give due consideration to the possibility of rickets being the underlying cause.

Another condition often seen in these days of improper artificial feeding by the various proprietary foods of insufficient fat and excessive proteids is a certain type of malnutrition which, with its accompanying stomachic and especially intestinal indigestion, produces upon the brain a spurious form of hydrocephalus. In these cases, which, for some reason, do not take the path of rickets, the low nutritive condition of the system combined with the irritating effect of the undigested food in the digestive tract reflexly produces upon the brain effects which give rise to convulsions and other hydrocephaluslike symptoms which very closely resemble the convulsive seizures of tuberculous meningitis.

The following clinical case well illustrates this last type of cerebral irritation, and is of especial interest, inasmuch as at no time were there any indications of rachitis. This case further teaches us the important lesson that woman's milk, when unsuited to the individual infant, may be as harmful as any equally unsuited artificial food. In this case nothing abnormal was found in the mother's milk, except that it contained an excessive amount of proteids, which factor was the sole cause of the child's sickness. M. C., born Nov. 11, 1904, a perfectly healthy infant weighing eight and three-quarter pounds at birth. Breast fed until Feb. 6. Perfectly well until two weeks from birth, or Nov. 25, when troubled with much colic and aggravated after every nursing, then severe colic set in lasting until nearly time for next feeding. This was accompanied with curds in the stool. Conditions continued until Feb. 6, when baby was taken from breast and fed with proprietary food. Conditions went from bad to worse until Feb. 11. On this date, at 1 A.M., infant awoke with hard breathing, moaning, unconscious and rigid. More or less rigidity for eight hours, followed by convulsions lasting three-quarters of an hour.

After

Saliva running from mouth at beginning of convulsion. the third convulsion in twenty-four hours, infant was reported to present following symptoms: body rigid; carpo-spasm; head turned to left side; Cheyne-Stokes respiration; temperature, 100; pulse 135 and irregular; vomiting; rectal nutritive enemata not retained. Remained in much the same condition until Feb. 13, except as effect of opiate had worn off. On this date baby again put to breast for twenty minutes every two hours. Most of milk retained but infant crying most of the time and in great distress from gas and colic after each nursing, with curds in the stools. Tuberculous meningitis was diagnosed by the physician. in charge. Ice cap put to head brought temperature down to 98°. No convulsions or rigidity from Feb. 12 to 16, but all symptoms of indigestion continued. On Feb. 16, at 8 A.M., convulsions lasting a half hour. Infant reported to awaken from sleep with heavy breathing, short sharp cries, violent twitchings more prominent on left side; left corner of mouth drawn down, pupils dilated, Cheyne-Stokes respiration, very sensitive to slightest sound. Infant now put on Eskay's food, but always vomited before next feeding. At this stage of the case the attending old school physician, with commendable frankness, advised parents to call in any other physician that they might see fit, as he gave up the child to die with tuberculous meningitis. On Feb. 20, I was called in to the case. After carefully observing the baby for an hour, and a study of a complete record of the case taken from an intelligent mother and nurse, I was convinced that the case was one of excessive irritation of the cerebral centres due to the prolonged irritation which had been going on in the intestinal tract from both the breast and proprietary food, which had caused the trouble from its excess of proteids; for the baby's history of indigestion from start to finish had been of the proteid type. The resulting malnutrition, of course, had its influence in bringing about this condition, inasmuch as the baby's weight at this time, over three months from the birth-weight of eight and three-quarter pounds, was only nine and one-half pounds.

Treatment was begun in accordance with this diagnosis, and the baby was at once put on modified milk prepared at the Walker-Gordon Laboratory for two reasons. First, if the baby were to live, fat and proteid nutriment of a digestible type must be furnished at once; and second, there was no way of furnishing sufficient proteid which could be digested than by the laboratory method of splitting the whole proteid, and recombining its whey proteid and caseinogen more after the proportions as they exist in woman's milk. The laboratory feeding was so eminently satisfactory that I give in full the prescriptions used in the case:

The satisfactory and progressive gain in weight, as outlined in the accompanying chart, should also be noted. Right here let me emphasize the great advantage the laboratory method affords in being able to correct the proteids of cow's milk from its indigestible five-sixths caseinogen and only one-sixth lactalbumin into the digestible two-thirds lactalbumin and only onethird caseinogen of woman's milk. Without this assistance of immediately furnishing nutriment to the child, which would not irritate stomach, intestines, and through these the brain, the result of this case would certainly have been fatal.

Of equal advantage in restoring health during the critical weeks which followed in this extreme case were the old guard homoeopathic curative remedies, of which only three were used throughout the case, namely, belladonna, nux vomica, and helleborus; each prescribed at different times in accordance with its indications. I regret space alloted to this paper prevents me from individualizing and demonstrating their respective symptoms and clinical results. Let me merely add that hellebore was especially uselful in "curing" (for I like the word in connection with homoeopathic therapeutics) the abnormal cerebral conditions per se, and nux vomica in taking care of the stomachic and intestinal irritation, as well as of the hypersensitive connecting nerve tracts, hereby reducing excitability to its minimum.

Perfect recovery took place in this case in from two to three months' time, and at present writing the patient is a perfectly healthy child, eighteen months old, with her twelve teeth, and weighing twenty-seven pounds, or five pounds beyond the average for her age.

Another important condition not infrequently giving rise, according to my experience, to convulsions in the young child