parts; water, sufficient to make 100 parts. Calomel, one-fourth grain every two hours, is recommended by some physicians, but the patient is liable to become salivated. The room should be warm, a window partly open for ventilation, and the air kept moist by making a hood with a sheet placed over a frame on the bed and allowing the steam from a kettle to pass under it. A liquid diet should be given, and if it impossible for the patient to swallow he should be fed by the rectum. If there is obstruction of the larynx and the patient is blue in the face, intubation or tracheotomy has to be performed. In the first operation a special hollow tube with a thread attached is inserted in the larynx, being guided in place by the finger. If no intubation tube is available, recourse should be had to tracheotomy. The physician grasps the windpipe between the forefinger and thumb of the left hand, pushes the other tissues of the neck to each side, and opens the windpipe in the middle line. All bleeding should be stopped by artery forceps or ligatures before windpipe is opened. This operation requires some skill and should not be performed except as a last resort. The patient should not be allowed to mingle with other persons until a culture has been taken, as described under "Diagnosis," and sent to the city or State department of health and found to be negative-that is, no germs of diphtheria present. The room and its contents should then be disinfected, as described under the heading "Measles."

RHEUMATISM.

There are different forms of rheumatism, and some of the forms have several different names. Acute rheumatism, acute articular rheumatism, inflammatory rheumatism, and rheumatic fever are terms applied to one and the same disease. A milder form of the affection is called subacute rheumatism. In this form the symptoms are less severe, but the disease is more prolonged. It may continue for a long time and become chronic. Chronic rheumatism, however, or the different affections and deformities of joints to which this term is frequently applied, may develop independently of any acute or subacute attack.

The term muscular rheumatism indicates an affection of the muscles as distinguished from joint affections. Lumbago and stiff neck are varieties of muscular rheumatism. The muscles, however, to a greater or less extent, may be involved in any form of rheumatism. Other conditions simulating rheumatism, occurring in connection with or directly due to gonorrhea or to syphilis, are called gonorrheal rheumatism or syphilitic rheumatism, as the case may be.

Rheumatism, either the acute or the chronic form, may be due to the absorption of germs, or poisons produced by them, from abscesses

at the roots of the teeth, or infections in the tonsils, nasal passages, or other parts of the body.

Prevention.—The early removal of adenoids and diseased tonsillar tissue may prevent not only attacks of rheumatism, but inflammation of the valves of the heart, leading to impairment of that organ in after life. The child's teeth should be carefully examined by a dentist, X-ray plates being taken if necessary to discover if there are any abscesses around the roots. Such abscesses should be drained to prevent the absorption of poisons which may be the cause of the rheumatism.

Acute Rheumatism (Rheumatic Fever).

This is a comparatively common disease in all climates within the Temperate Zone. It occurs chiefly during the winter and spring. Exposure to a cold, damp atmosphere is the most frequent exciting cause in persons predisposed to the disease.

It may or may not begin with a chill or with a sore throat. The larger joints are usually affected. Swelling, heat, redness, tenderness, and pain are the chief symptoms. The inflammation is apt to shift from one joint to another. The pain and fever are usually increased in proportion to the number of joints involved. The majority of cases are attended with profuse perspirations, scanty, highly acid urine, coated tongue, and constipation. The heart is frequently involved.

In treating, wrap the joint in cotton or flannel; keep it very quiet— the slightest movement aggravates the pain. Flannel wrung out of hot water and applied to the joint sometimes affords relief. A liniment composed of 10 to 50 per cent of oil of wintergreen in olive oil may be applied on a piece of flannel if the pain is severe, or cold applications may be employed if agreeable to the patient.

Place the patient in a good bed, and let him wear flannel next to his skin. Change the flannel frequently, and bathe the body with tepid water.

For internal medication give salicylate of soda or aspirin in doses of 10 grains every two hours until about eight doses are taken or the pain is relieved; then give it in smaller doses of from 3 to 5 grains every six hours.

The food should be soft and nourishing and given every three hours. Epsom salt should be given to keep the bowels open. The patient should be kept in bed for a few days after the symptoms have subsided. The duration of the disease is very uncertain. The acute symptoms may subside in a few days and the patient may be up and about in a week or 10 days, but relapses are common, and the acute may pass into the subacute or chronic form.

Chronic Rheumatism.

In chronic rheumatism there is stiffness and pain. A cracking or grating sound is frequently produced when the joints are suddenly moved. In severe cases the joints become enlarged and distorted. The deformity is sometimes very great.

The treatment consists chiefly in local application of liniments, etc., which afford relief because of the rubbing (massage) by which they are applied. Severe pain in the joint may be relieved by cold applications (flannel wrung out of iced water, applied to the joint and covered with muslin). Hot applications to the joints are sometimes of value. Belladonna plaster may be applied.

Five to eight grains of iodide of potash in a glass of water may be given three times a day between meals.

The general health should be looked after. The skin should be kept in good condition by frequent baths of tepid water. The bowels should be moved at least once a day. Patient should be allowed good food. Fresh air is also important.

Muscular Rheumatism.

In this disease the muscles most frequently affected are those of the back (lumbago), side of neck (stiff neck or wry neck), and side of chest (pleurodynia). Exposure to cold, sudden cooling of the body-especially after active exercise and sitting in a draft of airare the chief causes or exciting causes.

As a rule there are no symptoms other than the stiffness and pain on motion. The muscles may be slightly swollen and very sensitive. Some times the attacks come on suddenly and apparently without cause, or following a slight twist or strain, as a "kink in the back." or patient may wake up in the morning with a stiff neck.

In treating acute cases salicylate of soda or aspirin may be given in 5 or 10 grain doses every three hours until four or six doses are taken. Apply hot applications, dry heat, hot-water bag, or a hot poultice locally, or the heat may be applied by a flatiron over folds of flannel or a piece of blanket and the rheumatism "ironed out." Later apply liniment with friction (massage). Keep the affected muscles at rest. If the muscles of the chest are affected, apply strips of adhesive plaster, the same as for fractured rib. Acute attacks are of short duration, but relapses are not uncommon, and chronic forms are frequently met with. Good food, fresh air, and attention to the general health are especially important in the treatment of chronic muscular rheumatism.

Gonorrheal Rheumatism (Gonorrheal Inflammation of Joints).

This may occur during an acute attack of gonorrhea, but it is more frequently associated with chronic gonorrhea or gleet. One or several joints may be affected. There may or may not be considerable fever. If only one joint is affected, it is apt to be the knee or the ankle. In chronic cases the pain is sometimes centered in the heel. The attack may begin in the wrist, elbow, or shoulder. The disease is not always limited to the joints. Sometimes the inflammation is in the tissues outside the joint proper, in the sheaths of the tendons of muscles, or in the fascia of the soles of the feet. The swelling is frequently quite marked. In chronic cases there may be effusion ("water on the joint"). In very severe cases suppuration occurs (abscess forms). The eye and the heart may also be seriously involved.

Treatment is not very satisfactory. Keep the joint at rest. Apply a flannel bandage. Change it frequently and wash the joint with hot water and soap. In chronic cases liniments and passive motion should be applied. Tincture of iodine may be painted over the joint. A few drops of oil of wintergreen rubbed gently on the joint before the application of a bandage will often allay the pain. Aspirin, 10 grains every 3 hours, may be given if the pain is severe.

Syphilitic Rheumatism.

This so-called rheumatism is associated with secondary or tertiary syphilis. The joints and the shafts of long bones may be affected— thickened and painful. The pain is always worse at night.

The treatment is by iodide of potash, beginning with 10 grains of iodide of potash three times a day between meals. Good food should be given and the bowels kept open. (See p. 152.)

SMALLPOX.

Smallpox is an acute, contagious disease, characterized by an initial fever and successive stages of eruption. It spreads rapidly among persons unprotected by vaccination. It may be communicated by the breath, by exhalations from the skin, by clothing, or by anything that has been in contact with a person suffering from the disease.

After a period of incubation of from 8 to 14 days, occasionally longer, the disease begins suddenly, usually with a chill, always with severe pain in the back and loins, intense headache, and high fever. Vomiting occurs in many cases. The bowels may or may not be constipated. About the end of the third day or on the fourth day a papular eruption appears on the forehead, and frequently on the lips and the wrists, occasionally in the mouth and throat, and gradually ex

tends to other parts of the body. The eruption begins as a bright red dot or spot slightly elevated above the surrounding skin, enlarging until the second day, when it forms a papule. The papule is hard to the touch, feels like shot under the skin. As soon as the eruption appears the temperature begins to fall, and the distressing symptoms subside. On the fifth or sixth day a small vesicle, with a depression of the center, appears on the top of the papule. The vesicles gradually become distended, the depressed center rounded out, and about the eighth or ninth day the change is completed and the vesicles become pustules. They have a yellowish gray appearance and each pustule is surrounded by a red border. The skin between them is swollen, the eyes may be closed. During this change the temperature rises again, secondary fever sets in, the chief symptoms return, and a day or two later another change begins. The pustules break, matter oozes out, crusts form, first on the face and then over other parts of the body, following the order of the appearance of the eruption. The secondary fever may be quite high in the beginning, but gradually declines as the pustules change into crusts, and in favorable cases seldom lasts more than two or three days. The crusts then rapidly dry and fall off, leaving red spots on the skin and here and there the characteristic pockmarks or pits. The healing of the pustules is usually attended by troublesome itching.

In some cases a diffuse redness of the skin or red spots appear on the abdomen, or on the side of the chest, or on the inner surface of the thighs as early as the second day, but the distinctive papular eruption makes its appearance, as stated, at the end of the third or on the fourth day and nearly always begins on the forehead.

In the confluent form of smallpox the eruption may appear a day earlier and all the symptoms are more severe. The pustules run together and form large brownish scabs, chiefly on the face and head, but also on the hands and feet. The face and neck are greatly swollen, the eyes are closed, the features are distorted. The patient complains of tension and burning of the skin; there is much thirst. The eruption may also appear in the mouth and throat. The secondary fever is high. Delirium may be quite marked. In fatal cases the pulse becomes rapid and feeble, and death occurs about the tenth or eleventh day or later.

In favorable cases, about the eleventh or twelfth day the pustules begin to break. The matter dries and forms crusts which slowly fall off, leaving the skin quite red and in many cases dreadfully scarred and pitted.

The crusts begin to drop off about the fourteenth day, but the process of desquamation may not be completed until the end of the third or fourth week, and the fever may persist during that period. There is a milder form of smallpox called varioloid, in which the symptoms