but you will be able to judge more surely and clearly of their merits and the times and occasions for their use.

If, then, you hold to the love of your profession, and to the principles we have taught you, you will hold also to your love and loyalty to our school. This we ask of you and urge upon you. As you go from us now, happy in the accomplishment of the aims with which you came to us, you may forget the labor, the care, the grave problems confronting your teachers. But as you meet the cares and responsibilities of your daily professional lives you will not fail to see more and more clearly how vital, how indispensable to your own standing and progress is every aid you can give to our institution. It is the aid that must come, in fact, from your best endeavors in life and practice, from your aim and determination to do your part towards raising the standard of medical education, to give from your knowledge and from your means the assistance the school demands from every one of its alumni. Your diploma must not be looked upon solely as your qualification to practise; it must be to you constant reminder to uphold the honor, the usefulness, and the advancement of the school which has conferred it.

With these few parting words, then, I bid you in the name of your faculty a hearty farewell; and while wishing you every success and blessing, we extend to you the promise of our constant readiness to help and advise you in whatever way in our power, as we look upon you to fill our places when we shall have ceased to practise and to teach.

DISEASE HEREDITY IN RELATION TO CHILDHOOD. BY GRACE E. CROSS, M.D., BOSTON, MASS.

[Read before the Twentieth Century Medical Club, May 2, 1900.]

In announcing the above as the title of the paper and subject of discussion for this evening, I am aware that it suggests, on first thought, less of interest and profit than

would perhaps the name of some acute disease which is of daily familiarity, or that of some obscure and rare pathological condition upon which we are eager to obtain new light.

Nevertheless, I am moved in my selection of this subject by a most profound conviction that in a thorough understanding of the hereditary and congenital disadvantages under which perhaps most of our little patients enter the struggle of life lies the solution of many of the difficulties which we as their physicians encounter in striving to build, upon such foundation material as comes to hand, the most perfect structure possible of mature health.

It is, indeed, necessary that one be equipped to act with promptness and wisdom in the face of those frequent emergencies which occur in the life of the child. Who of us in presence of the frightful laryngeal stenosis of membranous. croup has not felt how all too futile sometimes proves the best that science brings us for its relief? And again, how often have our utmost energy and resource been taxed to counteract the deadly devitalization of cholera infantum and to fan into new strength the flame of life that flickers so feebly; or, in the delirium of meningitis, how have we watched from hour to hour for the slightest change in the little one's condition, hardly knowing whether to pray for life or for death, so often, if life be the issue, does the little brain fail to regain its original strength and power of development?

Indeed, I would not underrate the importance of an approach to perfect knowledge and absolute wisdom in the management of the serious crises of childhood. But in time, if the child passes these, relief comesthe spasm of croup relaxes, the awful choleraic drain ceases, the fever in the brain subsides, and convalescence ensues.

Yet perchance after a time, croup manifests its grim tendency to recurrence, the victim of cholera infantum is overlong in recovering his normal condition, and the convalescent from meningitis continues indefinitely in a vague state of ill health. Is there anything in a more complete knowledge of the child's heredity which shall help us in hastening the

progress of recovery from acute conditions and in lessening the tendency to subsequent onslaughts of disease?

It has long been conceded that scrofulous babies are more subject than others to croupous attacks; incipient tubercular affection is surely a predisposing cause of the bowel and brain troubles of infancy; and for how many ailments and diseases of innocent childhood is responsible that dread scourge syphilis, which most truly "visits the sins of the fathers upon the children"! I have mentioned only a few diseases as being more or less directly affected by hereditary taint, to say nothing of that neutral and unsatisfactory state of malaise, malnutrition, and general lack of vitality in which some children who never have a severe illness go through childhood to perish in adolescence or survive to a lifetime of ill health. But so widely potent is the law of disease heredity that it is limited only by the utmost bounds of the whole pathology of youth.

I believe that our duty as family attendant does not cease with the termination of the acute illness, whatever its character. We perhaps enter the family as accoucheur, and having acquitted ourselves creditably, are called in from time to time, as sickness invades the home. I feel that we have an especial duty to these little ones whom we meet at the very threshold of life, and that we owe it to them, so far as in us lies, to help them onward toward that health of body and mind which, to a great extent, means happiness as well.

I intend to give a few pen pictures of typical dyscrasiæ to serve as centres around which each of you will perhaps gather little groups of children whom you know, and to add a few suggestions of remedial measures which I hope will inspire a profitable discussion as to the best means of combating these morbid congenital conditions.

First, the scrofulous child. He may stand before us in form slender and graceful, in complexion fair, often noticeably white, with the skin so thin and translucent as to show a network of blue veins, and with brilliant, fleeting color quickly mantling cheek and brow upon the least excitement, and as quickly subsiding. The eyeballs are large and promi

nent, the pupils unusually spacious, the sclerotic a lustrous, bluish white, and the eyelashes long and graceful, unless injured by disease. This is the "erethitic" type.

Or again, the child with a scrofulous taint may appear of stunted frame, with enlarged joints and protuberant abdomen, having a thick, sallow skin, eyes dull though sometimes large, with disagreeable, often heavy, coarse features, an unusually large head, thick chin, tumid upper lip, and enlarged cervical glands. His flesh is soft and flabby, and his whole appearance is heavy and listless, though this type is not unfrequently intellectually acute. In coloring he may be either blonde or brunette. This is the "phlegmatic " type of Miller, corresponding to the "torpid" type of the earlier writers.

We shall have little difficulty in assigning certain of our little patients to one or the other of these groups. But how shall we early recognize the scrofulous tendency in the child, and so bring to bear every means in our power to prevent its development? First of all stands the family history. There a tendency in certain directions to attempt to overthrow the heredity doctrine, and to claim that contagion alone is responsible for the propagation of certain constitutional diseases among members of the same family.

Nevertheless, even these writers concede that tuberculosis is hereditary in the sense that children of tuberculous parents inherit tissues which are favorable to the development of the disease. In other words, according to their theory the child supplies the special culture medium, and as according to the latest experiments in the analysis of air, the tuberculous germs are not wanting, especially in the air of cities, the result is practically the same.

I think in the face of figures as well as of observation we are not yet entirely ready to accept so radical a departure. However explainable, statistics show that in a large majority of scrofulous cases, phthisis, syphilis, scrofula, or some other blood dyscrasia is manifest in the parents or ancestors; and in any case, given the knowledge of blood taint in the parents or their ancestors, it becomes the physician's duty to be

on the alert for the slightest indication of a morbid constitutional tendency in the child.

The skin is one of the earliest organs to show the affection - by means of eruptions, chiefly on the head and about the nates, these eruptions being characterized by a tardiness of development and recovery and by a proneness to ulcera

tion.

The mucous membranes are often early affected, manifesting a tendency to chronic inflammation, especially of the nose, ear, and vagina; these inflammations are often characterized by a watery discharge which excoriates the neighboring parts.

The glands, especially the cervical, frequently become involved, the inguinal, axillary, and bronchial less often. We all are familiar with the tedious train of symptoms, the infiltration, the caseous degeneration, the subsequent suppuration, the disfigurement, and the long-delayed convalescence, which so often follows these invasions.

All the above-named conditions are extremely apt to go on to ulcerations of a weak variety, which, nevertheless, cause scars out of all proportion to their violence.

I have used the word "scrofula" in referring to the above conditions, yet we know well that scrofula is, in reality, but a prodromal stage of tuberculosis, under which head must come all cases wherein the scrofulous condition has become localized in one or another tissue, or, as one writer has expressed it, has come to have a "local habitation and a name." The newborn child is rarely the victim of localized tuberculosis; but this condition once established may affect almost any or every organ of the body, and must then receive treatment or palliation as indicated.

It is to the dyscrasia or tendency to scrofula, or tuberculosis, describe it as you will, that I wish especially to direct attention in the matter of treatment. We may recognize that a certain child, with a bad inheritance, is "delicate," though he may have no fixed symptoms towards which to direct treatment. Yet, shall we leave him without attention until some day an acute illness or overstrain shall light up