LIBRARY OF CONGRESS, Shelf JjAS UNITED STATES OE AMERICA. ■ % r-% ^m m % ■ m *% 7«Va ■ *&.*s ■ ■ ■ I /a ■ ■ ji ■ ; DISEASES OF THE DIGESTIVE ORGANS IN INFANCY AND CHILDHOOD. STARR By DR. LOUIS STARK. THE HYGIENE of the NURSERY INCLUDING THE GENERAL RBGIMBN AM) REEDING 01 INFANTS am> I HILDRBM AM) THE DOMESTIC MANAGEMENT OF THE ORDINARY BMBR- C.l NCI I S OF F.AKI V 1 III. Second Edition. Enlarged and Improved. WITH TWENTY-FIVE ILLUSTRATIONS. 12mo. 280 Pages. Cloth, $1.00. *#* Designed for the use of Parents, Nurses, and all interested in the Care and Management of Children. " The volume is entirely in the modern lines of preventive medi- cine — more important in the nursery than in any other time of life ; because constitution building is going on then and there. Jn this admirable treatise, so clearly written that no mother need be de- terred by fear of medical terms from making its teaching her own, Dr. Starr carries out the highest ideal of the modern physician, so to regulate the lives of his professional clients that the occasions are less frequent when he need be called in to act for serious com- plications * * * * With the numerous good treatises on the subject that Philadelphia publications include, this intelligent work is the most distinguished, as it is also the latest work on complete Hygiene of the Nursery." — T/ie Ledger, Philadelphia. " It is addressed to mothers, with the view of giving a series of rules which, applied to the nursery, can hardly fail to maintain good health, give vigor to the frame, and so lessen susceptibility to dis- ease. These are so plainly, sensibly, and we may add attractively given, that any woman of ordinary brain-power should be able to understand them, and by following them to keep her baby well." The Critic, New York. Cmferit ^4ll2huHe. Contoured. Neroes — Sf^Tair ., Solid.£lcick. •■ =■ Sympathetic .. YeUo-to „ — fnrumxHjastric „ Bill? „ = 6lasso-Phfijyruf<>a.l. DIAGRAM ILLUSTRATING THE VARIOUS CONNECTIONS OF THE DENTAL NERVES. Plate 1. DISEASES OF THE DIGESTIVE ORGANS IN INFANCY AND CHILDHOOD. WITH CHAPTERS ON THE INVESTIGATION OF DISEASE; THE DIET AND GENERAL MANAGEMENT OF CHILDREN, AND MASSAGE IN PAEDIATRICS. BY LOUIS STARR, M.D., LATE CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE UNI- VERSITY OF PENNSYLVANIA ; PHYSICIAN TO THE CHILDREN'S HOSPITAL, PHILADELPHIA; CONSULTING PODIATRIST TO THE MATERNITY HOSPITAL, PHILADELPHIA, ETC., ETC. SECOND EDITION— ILLUSTRATED. PHILADELPHIA : P. BLAKISTON, SON & CO., No. 1012 Walnut Street. 1891. Go Copyright, 1891, by Louis Starr, m.d. PRESS OF WM. F. FELL &. CO. 1220-24 SANSON! STREET, PHILADELPHIA. TO PROFESSOR JOHN ASHHURST, Jr., M.D., THIS VOLUME IS DEDICATED, AS A Tribute to his Genius as a Surgeon and Author, and in Grateful Remembrance of Many Acts of Kindness. PREFACE TO THE SECOND EDITION. In preparing this issue of "The Diseases of the Digestive Organs in Infancy and Childhood," the author, while endeavor- ing to bring the general subject-matter thoroughly abreast with the times, has deemed it advisable to make some re-arrangement of the original text and to add a quantity of new material. The chief additions consist of a section on alterations in the odor of the breath in disease ; a section on urine alterations ; a chapter on massage in paediatrics, and a detailed account of second den- tition and its influence on the health in late childhood — a subject heretofore greatly neglected. The author wishes to thank the critics of the first edition of his book for many valuable suggestions, from which he has profited greatly. His thanks are also due to Dr. Wm. M. Powell for his untiring assistance in preparing the copy and in making the index ; to Dr. Robert J. Hess for his aid in proof-reading, and to Prof. Charles B. Nancrede for the diagram illustrating the extended connections of the dental nerves. LOUIS STARR. 1818 South Ritlenhouse Square, Philadelphia. January 1st, 1891. Vll PREFACE TO THE FIRST EDITION It is the author's object, in this book, to give prominence to a class of disorders constituting a large proportion of the ailments of childhood, but often too briefly considered in works on paediatrics. For the successful treatment of the diseases of the digestive organs in infancy and childhood, attention to the general regimen is quite as important as the administration of drugs, and it is upon the former that the student and young practitioner are usually the least thoroughly instructed. So much may be done by the selection of suitable food, by artificial digestion, by regulating the clothing, bathing and other elements of hygiene, that the author, without neglecting thera- peutics, has given greater prominence to these points. The chapter on the investigation of disease does not neces- sarily belong to a work on disorders of the digestive organs, but as so much difficulty is experienced by students in the study of disease in children, it has been incorporated as an aid to such. In the article on the general management of children, the effort has been made to present to the inexperienced results that can only be obtained by much study and practical work. The author is indebted to Dr. Henry D. Harvey for his aid in preparing the index, and to the pencil of Dr. John Madison Taylor for the illustrations. LOUIS STARR. Philadelphia , April, 1886. Vlll CONTENTS PART I. Introduction — page The Investigation of Disease, 17 1. Questioning the Attendants, 18 2. Inspecting the Child, 20 3. Physical Examination, 39 PART II. The General Management of Children — 1. Feeding, 60 2. Bathing, 102 3. Clothing, 105 4. Sleep, 106 5. Exercise, 108 PART III. Massage in Pediatrics, 116 PART IV. Diseases of the Digestive Organs. CHAPTER I. Affections of the Mouth and Throat, 1 24 1. Catarrhal Stomatitis, 124 2. Aphthous Stomatitis, I2 6 3. Ulcerative Stomatitis, 13 * 4. Gangrenous Stomatitis — Noma, 136 ix CONTENTS. PAGE 5. Parasitic Stomatitis — Thrush, 141 6. Dentition, 148 7. Simple Pharyngitis, , 183 8. Superficial Catarrh of the Tonsils, 186 9. Follicular Tonsillitis, , 187 10. Suppurative Tonsillitis, 190 11. Hypertrophy of the Tonsils, 194 12. Retropharyngeal Abscess, 197 CHAPTER II. Affections of the Stomach and Intestines, 199 1. Acute Gastric Catarrh, 199 2. Chronic Gastric Catarrh, 202 3. Ulcer of the Stomach, 211 4. Softening of the Stomach (Gastro-Malacia), 212 5. Chronic Gastro-Intestinal Catarrh, 213 6. Acute Intestinal Catarrh, 227 7. Chronic Intestinal Catarrh — Chronic Entero- Colitis, .... 235 8. Entero-Colitis, 248 9. Cholera Infantum, 258 10. Inflammation of the Colon and Rectum — Dysentery, . . . 264 11. Tubercular Ulceration of the Intestines, 268 12. Colic, 270 13. Habitual Constipation, 273 14. Simple Atrophy, 279 15. Typhlitis and Perityphlitis, 287 16. Intussusception, 296 17. Intestinal Worms, 311 CHAPTER III. Caseous Degeneration and Tuberculosis of the Mesenteric Glands — Tabes Mesenterica, 329 CHAPTER IV. Affections of the Liver, 337 1. Jaundice, 337 2. Congestion of the Liver, 343 3. Fatty Liver, 346 4. Amyloid Liver, 347 CONTENTS. XI PAGE 5. Syphilitic Inflammation of the Liver, 351 6. Cirrhosis of the Liver, 352 7. Suppurative Hepatitis, 357 CHAPTER V. Affections of the Peritoneum, 364 1. Peritonitis, 364 2. Tubercular Peritonitis, 371 3. Ascites, , .... 377 Index, 383 DISEASES OF THE DIGESTIVE ORGANS INFANCY AND CHILDHOOD. PART I.— INTRODUCTION THE INVESTIGATION OF DISEASE. The clinical investigation of disease in children, usually con- sidered so difficult, is in some respects easier than the same study in adults. It is easier because in the child disease is commonly uncom- plicated, rarely has its course and symptoms modified by tissue lesions the result of previous affections, and never by vicious habits, such as the abuse of stimulants and narcotics, or by mental over-work and nerve-strain. The confusing element of mis-stated subjective symptoms is also absent, while correct diag- nosis is greatly aided by the facility with which physical exami- nation of the whole body may be practiced. That there are difficulties to be encountered, and very grave ones too, is equally certain. The absence of speech in the infant deprives us of the important assistance afforded by correctly 2 17 l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. described subjective symptoms, and renders it necessary to look to the mother or nurse for the history of an illness. In older children the case is not much better, since with them words are not prompted by sufficient knowledge or judgment to be of great service. Further, the wilfulness, dislikes, fear and agita- tion of the child are impediments which must be overcome before a satisfactory examination can be made, and which will often tax the skill and patience of the physician to the utmost in the overcoming. Another source of difficulty lies in the activity of growth and development in infants, which renders them liable to be affected by slight causes, and makes disease sudden in its attack, short in its course and intense in its symptoms. The rapid development of the nervous system especially leads to con- fusion. The nerves bind every portion of the frame in a sym- pathy so close that an affection of a single part may cause marked general disturbance, and local symptoms are often reflected, directing attention to organs very distant from those really dis- eased. Finally, the extreme excitability of the nervous system of healthy children often causes a trifling illness to assume an aspect of the greatest gravity, while, on the contrary, the depres- sion of nervous sensibility that attends chronic wasting diseases so obscures the symptoms that a dangerous intercurrent affection may appear trifling or remain altogether latent. The plan of conducting the clinical investigation in children differs materially from the method adopted in adults. It is best to proceed in three regular stages, as follows : ist. Questioning the attendants ; 2d. Inspecting the child \ 3d. Physical exami- nation. 1. Questioning the Attendants. When the patient is under eight or ten years of age, the only way of obtaining a knowledge of the previous history and of what may occur between visits, is carefully to question the mother or nurse. The account must be patiently elicited and listened to, and credited with due reference to the narrator's intelligence. It is well' never entirely to discredit a statement without good THE INVESTIGATION OF DISEASE. 19 reason, for many women, though weak and foolish in other respects, are excellent observers when their powers are guided by affection. Besides, being thoroughly acquainted with their children's habits and dispositions, they will often detect devia- tions from health that the physician might overlook entirely. This part of the examination, particularly when the acquaintance and good will of the child has not previously been obtained, should, if possible, be made before entering the sick-room. By taking this precaution the agitation produced by the prolonged presence of a stranger, and its consequent trouble and delay, will be avoided to a great degree. As there are certain points about which it is always necessary to be informed, the adoption of a definite order of questioning is advisable. The family history as far back as the parents should first be ascertained. Inquiry being chiefly directed to the detection of chronic maladies and transmissible diseases, as tuberculosis and syphilis. If any deaths have occurred, their causation should be investigated, and an inquiry into the occurrence, or the reverse, of previous still-births is often important. Next, an outline of the child's life from birth up to the date of the illness in question must be obtained. This should include the following items : The manner of feeding during infancy ; whether at the breast, or from a bottle, and if the latter, whether cow's milk, condensed milk or the farinacea have formed the basis of the diet. The date of commencement and the regularity of dentition. The general state of health in regard to strength or weakness and liability to illness. The time of occurrence and the nature of any prominent attack of illness, especially of the eruptive fevers. Whether vaccination has been performed or no. The hygienic surroundings; for instance the healthfullness of the locality of residence, the sort of house and room occu- pied—if large, well ventilated, light and dry or the reverse, and the character of the clothing and food. In older child- ren, if at school, the time devoted to study, and if at labor, the nature and the hours of work. 20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. After this it is necessary to fix the time the attack in hand began. The occurrence of some striking symptom, as con- vulsions or violent vomiting, often establishes this point beyond a doubt, but when there is any uncertainty the best plan is to question back, day by day, until a time is reached at which the child was perfectly well, and to date the onset from this period. The most common of the general indications of commencing illness are disturbed sleep and irritability of temper. A perfectly well child sleeps quietly and continuously at night, and is never cross. Having determined, as nearly as possible, the exact time of onset, the next step is to learn the mode of attack and the symptoms and course of the disease prior to the first visit. The questions now must be general, never leading. They must be sufficiently exhaustive to touch upon all the functions of the body, and when a trail is started it must be patiently followed to the end. Alterations in sleep, bodily strength, surface tem- perature, appetite, digestion, urine elimination, respiration and so on, must be sought for, and the account of such deviations from the normal state as vomiting, diarrhoea or cough, will suggest further questions as well as point out the path to be followed in the future examination. This portion of the investigation is closed by an inquiry into the treatment that "may have been already adopted. 2. Inspecting the Child. When the eye and ear of the physician are trained to their work, valuable information can be obtained by simply looking at an ill child and listening to its cry or spoken words. Even while the child is lying asleep or sitting quietly in the nurse's lap many facts may be learned, but this portion of the examina- tion is never complete without an inspection of the naked body. The points thus ascertained consist in alterations in the expres- sion of the face, in decubitus, in the appearances of the body and so on, and may be designated the features of disease. The relative position of the observer and patient during inspection is THE INVESTIGATION OF DISEASE. 21 of importance. If possible the former should stand with his back to, and the latter be so placed that his face is toward, a window or lamp. The light must never be strong enough to dazzle when the countenance is the object of inspection, as this causes distortion of the features. For convenience, the features of disease will be studied under different headings, and since to appreciate them it is necessary to have a knowledge of the healthy aspect, both the normal and abnormal appearances will be described. Face. — The face of a healthy, sleeping child wears an ex- pression of perfect repose. The eyelids are completely closed, the lips slightly parted, and while a faint sound of regular breathing may be heard, there is no perceptible movement of the nostrils. Incomplete closure of the lids with more or less exposure of the whites of the eyes is noted when sleep is ren- dered unsound by moderate pain and during the course of all acute and chronic diseases, particularly when they assume a grave type. Twitching of the lids heralds the approach of a convulsion, and at such times, too, there is often oscillation ot the eyeballs, or squinting. A marked smile, due to contraction of the muscles about the mouth, signifies abdominal pain or colic, and pursing out of the lips and chewing motions of the jaw, gastro-intestinal irritation. Dilatation of the alae nasi, with or without noisy breathing, points to embarrassed respiration, the result of extensive bronchial catarrh, pneumonia or pleurisy with effusion. When awake and passive the healthy infant's face has a look of wondering observation of whatever is going on about it. As age advances the expression of intelligence increases, and every one is familiar with the bright, round, happy face of perfect childhood, so indicative of careless contentment, and so mobile in response to emotions. The picture is altered by the onset of any illness, the change being in proportion to the severity of the attack. An expression of anxiety or of suffering appears, or the features become pinched and lines are seen about the eyes and mouth. Pain most of all 22 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. sets its mark upon the countenance, and by noting the feature affected it is often possible to fix the seat of serious disease. Thus, contraction of the brows denotes pain in the head ; sharp- ness of the nostrils, pain in the chest ; and a drawing of the upper lip, pain in the abdomen. As a rule, the upper third ot the face is modified in expression in affections of the brain, the middle third in diseases of the chest, and the lower third in lesions of the abdominal viscera. M. Jadelot has drawn attention to certain furrows that appear on the face in serious cases, and to the indications that these affond as to the part of the body to be further examined. There are three sets of furrows. First, the oculo-zygomalic, beginning at the inner canthus of the eye and passing outward beneath the lower lid, to be lost a little below the most prominent portion of the cheek. This points to primary or secondary disorder of the cerebro- nervous system. Second, the nasal, starts above the ala of the nose, and, passing downward, forms a semicircle around the angle of the mouth. This may be associated with another line, the ge?ial, which extends from its middle almost to the malar bone. These indicate disease of the gastro-intestinal tract, or other abdominal viscera. Third, the labial, com- mencing at the angle of the mouth and running outward, to be lost in the lower part of the face. This furrow is more shallow than the others. It directs attention to the lungs. These furrows are often present, and when met with are worthy of considera- tion, but their constancy and value have been over-estimated by their discoverer. Pufflness of the eyelids and a fulness of the bridge of the nose, indicate dropsy and should direct attention to the kidneys as the seat of disease. Each of the two prominent diatheses is distin- guished by a peculiar physiognomy. When there is a tuberculous tendency the face is oval and the features delicate ; the hair is fine and silky ; the skin smooth and transparent ; the temporal veins are visible ; the eyelashes are long and curving, the irides large and deep-colored and the sclerotics pearly white or bluish ; finally, a growth of fine hair is often noticeable on the temples THE INVESTIGATION OF DISEASE. 23 and in front of the ears. The general expression is most intelli- gent. In the strumous diathesis, on the contrary, the face is round and heavy ; the complexion doughy ; the upper lip swollen ; the nostrils wide and the alae of the nose thick ; the eyelids are thickened and reddened at their edges ; the hair coarse, and the lymphatic glands of the neck enlarged. A marked disfigurement of the face may indicate one of several diseases, according to its character. For example, broadness of the bridge of the nose, or complete flatness at this point, is sig- nificant of constitutional syphilis. A large, square head and pro- jecting forehead with a face of natural size or smaller, shows that the child has suffered from rickets. An immense globular head, overhanging forehead, and diminutive face with eyeballs pro- jected downward and irides almost concealed by the lower lids, are pathognomonic signs of chronic hydrocephalus. Decubitus. — The complete repose depicted on the countenance of a sleeping child when free from illness is shown also by the posture of the body. The head lies easy on the pillow, the trunk rests on the side slightly inclined backward, the limbs assume various but always most graceful attitudes, and no move- ment is observable but the gentle rise and fall of the abdomen in respiration. In the waking state the child, after early infancy, is rarely still. The movements of the arms, at first awkward, soon become full of purpose as he reaches to handle and examine various objects about him. The legs are idle longer, though these, too, soon begin to be moved about with method, feeling the ground, in preparation, as it were, for creeping and walking. With the onset of disease the scene changes. In acute attacks attended with pain, sleep is no longer restful. The infant is con- tent only when rocked, fondled or "walked" in the nurse's arms. The older child tosses about uneasily in bed, or demands a constant change from the bed to the lap. During the waking hours the movements are purposeless, quick and impatient, the position is constantly shifted and frequent whining complaints are made. As a contrast to this condition of jactitation, at the 24 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. beginning of the specific fevers, children often lie for hours quiet and drowsy upon the bed or lap. In chronic affections attended with debility, the movements become slow and languid, and in stupor and coma there is perfect stillness and immobility. There are certain positions and gestures which have especial significance. Sleeping with the head thrown back, and the mouth open, is a frequent accompaniment of chronic enlargement of the tonsils. A tendency to " sleep high," that is with the head and shoulders elevated by the pillow, indicates impaired pulmonary or cardiac function. So, too, does an upright position in the nurse's arms, with the chest against her breast and the head hanging over her shoulder— a posture assumed by young children. "Sleeping cool," namely, resting only after all the bed-clothing has been kicked off, is an early symptom of rickets. The position termed " en chien de fusil" is a symptom of the advanced stages of cerebral disease, especially tubercular menin- gitis. The child lies upon one side, with the head stretched far back, the arms pressed close to the sides and folded across the chest, the thighs drawn up toward the abdomen, the legs flexed on the thighs and the feet crossed. Restless movements of the head or boring of the head into the pillow also point to cerebral disease. When there is an evident desire to retain one position, as on the back or one side, together with short, quick breathing, some inflammatory change in the respiratory or abdominal organs may be suspected. Persistent lying on the face is an evidence of photophobia. Of the gestures, the frequent carrying of the hand to the head, ear or mouth indicates headache, earache or the pain of denti- tion respectively, and constant rubbing of the nose is a feature of gastro-intestinal irritation. If the thumbs be drawn into the palms of the hands, and the fingers tightly clasped over them, or if the toes be strongly flexed THE INVESTIGATION OF DISEASE. 25 or extended, a convulsion may be expected. The presence of clonic contractions of the muscles, with unconsciousness, indi- cates, of course, a convulsion ; while irregular, badly coordinated, jerky movements — consciousness being retained — attend chorea. In infants the existence of colic is shown by repeated extension and retraction of the legs, clenching of the hands into fists, flexion and extension of the forearms, and a writhing movement of the trunk. The fact of one limb remaining passive while the others are actively moved about, naturally suggests motor paralysis. The Skin. — In the new-born infant the color of the skin varies from a deep to a light shade of red. After the lapse of a week this redness fades away, leaving the surface yellowish-white. Sometimes the yellow hue is so deep that it might readily be mistaken for jaundice were it not for the whiteness of the con- junctivae, and the absence of disordered digestion and other symptoms of ill-health. Usually in a fortnight all discoloration disappears, and the skin assumes its typical appearance. Allow- ing for the natural variations in complexion, the skin of a healthy child is beautifully white, transparent and velvety. The cheeks, palms of the hands and soles of the feet have a delicate pink color, and the general surface is rosy in a warm atmosphere, marbled with faint blue spots or lines, in a cool one. As age advances, the coloring becomes more pronounced, and until the completion of childhood the complexion is much fresher than in adult life. In the inspection alterations of the skin of the face are chiefly noticeable. Lividity of the eyelids and lips is a sign of imper- fect aeration of the blood, and points to pulmonary or cardiac disease. Marked blueness of the whole face is a symptom of morbus cczruleus, and indicates a congenital malformation of the heart. On the other hand, a faint purple tint of the eyelids and around the mouth shows weak circulation merely, or, more fre- quently, deranged digestion. A decided yellow hue of the skin and conjunctivae is seen in jaundice ; an earthy tinge of the face in chronic intestinal dis- 26 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. eases; a waxy pallor in renal diseases, and paleness in any acute or chronic affection attended with exhaustion. Brownish-yellow discoloration of the forehead is significant ot inherited syphilis; a bright, circumscribed flush on one or both cheeks, of inflammation of the lungs or pleura, or of gastrointes- tinal catarrh, according to its occurrence with or without an elevated surface temperature. The cutaneous lesions of certain of the eruptive fevers appear first upon the face ; each of these has its special characteristics. An eruption of herpetic vesicles on the lips may be mentioned as present both in pneumonia and in malarial fevers. Some information may be obtained from the hands. Slight want of proper aeration of the blood is shown by blueness of the finger nails, a greater degree, by cyanosis of the whole hand. Deformity of the nails is a symptom of syphilis : clubbing of the finger tips of chronic lung disease; and redness, swelling and suppuration about the nails of struma. The dropsy of scarlatinal nephritis causes a puffiness and cushiony appearance of the dor- sum of the hands. Often, too, in this condition, the finger ends are glossy, as if smeared with oil, and there is an exfolia- tion of the epidermis about the nails. The last two symptoms frequently serve to confirm a retrospective diagnosis of scarlet fever. Mode of Drinking. — By watching a child taking the breast or bottle, some knowledge can be obtained of the condition both of the mouth and throat, and of the respiratory organs. If there be any soreness of the mouth the nipple is held only for a moment, and then dropped with a cry of pain. When the throat is affected deglutition is performed in a gulping manner, an expression of pain passes over the face, and no more efforts are made than required to satisfy the first pangs of hunger. Under similar circumstances older children drink little and refuse solid food entirely. An infant suffering from the oppression of pneumonia or severe bronchitis, seizes the nipple with avidity, swallows quickly several times, and then pauses for breath. In older patients the THE INVESTIGATION OF DISEASE. 27 act of drinking, which should be continuous, is interrupted in the same way. If the finger be put into the mouth of a healthy baby it will be vigorously sucked for some little time. The diminution of the act of suction during a severe illness is a sign of danger ; its reestablishment a good omen. In conditions of stupor and coma it is noticeably absent. The Cry. — The vocal sound, termed crying, is the chief it not the only means that the young infant possesses of indicating his displeasure, discomfort or suffering. Even long after the powers of speech have been developed, the cry continues to be the main channel of complaint. It may be accepted, as a rule, that a healthy child rarely cries. Of course, some acute pain, as from a fall or accident or blow, will cause crying in the most healthy child, but the storm is quickly over. Nothing like fre- quent, peevish crying or fretfulness is compatible with health, consequently, when this disposition exists, the cause must be looked for in some disease. Incessant, unappeasable crying is due to one of two causes, namely, earache or hunger, and the distinction may readily be made by putting the child to the breast or offering a properly prepared bottle. The hydr encephalic cry, denoting pain in the head, is a sudden, sharp and very loud shriek, occurring at intervals and audible at a considerable distance. Crying during an attack of coughing, or for a brief time afterwards, and at- tended with distortion of the features, indicates pneumonia. In acute pleuritis, the cry also accompanies the cough, but it is pro- duced too by movements of the body and by pressure on the affected side. It is louder, indicative of greater suffering, and sometimes most difficult to check. Intestinal pain causes crying just before or after an evacuation of the bowels, and is associated with wriggling movements of the body and pelvis, and with the eructation or passage of flatus. Conditions of general distress or malaise predispose to fits of fretful crying, the paroxysms being excited by any disturbing influence, or even by merely looking at the little sufferer. 28 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. When the cry has a nasal tone, it indicates swelling of the mucous membrane of th< or other obstru< til lition. Thickening and indistinctness oa urs with pharyngeal affections. A loud, brazen cry is a precursor of spasmodic croup. Hoarse- ness points to a lesion of the laryngeal mucous membrane, either catarrhal or syphilitic in nature. In membranous croup, and in some cases of extreme exhaustion, tin- cry IS taint and inaudible. Finally, in severe croupous pneumonia, in extensive pleura] effusion and in rickets, ordinary disturbing causes are inopera- tive for the l I on of fits of < rying, and there is a -reining unwillingness to cry, on account of the action interfering with the respiratory (unction. The conditions of altered tone apply equally to the articulate voice in children who aie old enough t.> spc\ik. The COUgh, too, roust not 1 Many of its char- acters correspond with the voice and cry. It is brazen in spasmodic croup, suppressed in true croup, hearse- in laryngeal catarrh, and so on. But it rtain featui its own. In bronchitis it is more or !c>s paroxysmal, evidently dry in the early stages, loose and rattling a- the catarrh 4 * breaks up." In the painful pulmonary affections, pneumonia and pleurisy, it choked hack, and whenever it occurs, an ion of pain pa>ses like a cloud over the IS, the peculiar ismodic cough is the pathognomonic symptom, and wl. once heard, immediately stamps the case. Con. always unproductive, that is, unattended by <--\: lion, in children under seven years of age The formation of tear> rarely begins before the third or fourth month of life. Subsequently, an alteration in this secretion may be of aid in forecasting the result of disease. The prognosis is bad when the tears become suppressed ; good when the secretion continues during an illness, or when it reappears after being suppressed. There are three other sources of information which can and should be investigated before proceeding to the physical exam- ination, although, strictly speaking, they do not come under the THE INVESTIGATION OF DISEASE. 29 head of inspection of the child. These are the characters of the faecal evacuations, of the urine, and of the material ejected by vomiting. The Breath. — The breath of a healthy infant or child should be odorless, or as the nurse will say, "sweet," except perhaps immediately after taking nourishment, when it may, for a short time, have the smell of milk or any special food eaten. The persistent presence of an odor, therefore, is abnormal and in- dicates disease. Any morbid condition of the system that prevents the elimi- nation of metamorphosed nitrogenous tissue through the mucous membrane of the intestines, or retards the passage of decom- posing detritus along the bowels, will cause an offensive breath. Under this head are conditions characterized by high tempera- ture, catarrhal inflammations of the gastro-intestinal tract, chronic debilitating diseases, etc. The same result, also, frequently attends structural lesions of the kidneys. The reason for this is, that the system, in order to get rid of poisonous matter — for accumulated waste is poison — and to maintain the balance between the constant construction and destruction of tissue, must throw off elsewhere what the intestinal glands and the kidneys fail to excrete ; so the lungs take on vicarious activity and the expired air becomes tainted with the products of waste. Very often, by the way, the skin takes a part in the abnormal excretory process, and a similar odor is noticed in the per- spiration. Purely local causes of halitosis also exist. These are decayed teeth, caries of the nasal and maxillary bones, ulceration of the mucous membrane of the mouth, nose, larynx, trachea and bronchial tubes, and gangrene of the cheeks. Chronic poisoning by lead, arsenic and mercury, though not very common in childhood, is another cause of ill-smelling breath. To speak in general terms, the breath may become sour, catarrhal, fetid, gangrenous, ammoniacal and stercoraceous. This classification is a rude one, and many subdivisions can be 3Q DM .„ DIGE8T1VI OKGAM U CHILDREN. made of some of the odow. Thus, .lK-rc arc man] wietia of catarrhal and fetid breath, which, whiten less distinctive different conditions, cannot be differentiated in words and m be experienced by the observer's * cognised; once this is done they become valuable symptoms. r breath is nt, in it *ially, when there Btric fermentation. The rai « *« "> ilk « farina, maketlittl. nee in H» ismost Bdedb nandvomitu In chronic romiting, chronk - colitis and thrush the intciw " U m ' the whole mo* I ' , What I btt nhalhreathl numen i les of i [nchr0 ni« he pharynx there is breath, not n »te tar from the patient' I < always more n "»d is ileepof night, asthenthemw which the odor i being rerooi ' n ''' N In ' Should tarrh invade the 1 » deeply, and, . By, should there be ted folhcular tonsillitis, the breath, I havii qnaUty of he that of, I IS very penetrating. This odor, too, ifter steeping. II the onset h tbe breath come, decidedly tanned. Sometimes it ha. a vii other, it n,a*d I in which it had the same i ifter an inl tber. 1 ater in the attack it becomes wur or has the f sulphuret hydrogen. The former is apt to he the case with infants, the latter with older children, who have a more sohd albuminoid l " What is known as a "I breath " has a heavy swei smell It is met with in di~ f high temperature and depends partly upon catarrh of the gastro-intestinal mis membrane, the common attendant of fevers, and partly ujxm THE INVESTIGATION OF DISEASE. 31 the elimination of fever waste. It is very marked and rapid in appearance in scarlatina. In chronic intestinal catarrh with obstinate constipation the breath often has a slightly fecal odor. Simple catarrh of the nasal mucosa when of any standing, gives rise to moderate heaviness, and the same is true of catarrh of the mucous membrane of the mouth — stomatitis — though in the latter affection, mastication and swallowing being difficult, small quantities of food collect in the mouth, and there undergoing decomposition add an element of fetor to the breath. Fetor of the breath is observed in its mildest form in such affections as aphthae and ulcerative stomatitis. It is better de- veloped in ozaenaeand necrosis of the maxillary bones, when the well-known stench of dying bony tissue is added. Decaying teeth give much the same odor, though it is less strong and pene- trating. In all these conditions, however, the fetor differs not only in degree, but in kind. Noma gives rise to a gangrenous odor, and a patient affected with this disease will fill the ward of a hospital, the room in which he lies, or even a whole dwelling, with the most sickening stench. Cases of empyema, with ulceration of the lung and discharge of pus through the bronchial tubes, have an almost equally offensive breath, but here there is often a flavor of garlic combined with that ordinarily due to tissue necrosis. Ammoniacal breath is observed only in patients suffering with uremic poisoning. A purely stercoraceous breath is rare, and when met with is an accompaniment of fecal tumor or of intussusception. The metallic poisons while giving rise to fetor of the breath have no individual characteristics, and it is necessary to look to the history and symptoms of the individual case to determine the special poison. The FiBCAL Evacuations. — The daily number of evacuations natural for a child varies greatly with its age. For the first six weeks there should be three or four stools every twenty-four hours. 32 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. After this time up to the end of the second year, two movements a day is the normal average. Subsequently, the frequency ot defecation is the same as in adults — once per diem — though two or three movements in the same interval often occur, especially after over-feeding or after eating food difficult of digestion, and must be looked upon as conservative rather than as the evidence of ill-health. During the first period the stools have the consistence of thick soup, are yellowish-white, or orange-yellow in color, with some- times a tinge of green, have a faint fecal, slightly sour odor, and are acid in reaction. In the second, they are mushy or imper- {ec\\y formed^ of uniform consistence throughout, brownish-yellow in color, and have a more faecal odor. The last two characters become more marked as additions are made to the diet. After the completion of the first dentition the motions have the same appearance as in adult life, they axt forme d> and brownish in color, with a decided frecal odor. Many alterations occur in disease. The frequency of the move- ments may be inereased, constituting diarrhoea, or lessened, con- stituting constipation. In the former condition the consistency is diminished, in the latter increased. Instead of being uniform throughout, the stool may be mixed, partly liquid partly solid, indicating imperfect digestion, and curds of milk and pieces ot undigested solid food may be mingled with the mass. Flaky, yellowish or yellowish-green evacuations, containing whitish, cheesy lumps, are also met with in cases of indigestion. Scanty, scybalous stools, dark brown or black in color, and mixed with mucus, are characteristic of intestinal catarrh. Doughy, grayish, or clay-colored motions show a deficiency of bile. An intermix- ture of blood, altered blood clots, and shreds of mucous mem- brane, indicate some breach of continuity in the intestinal lining, such as occurs in follicular enteritis, typhoid fever, dysentery and tubercular disease. Watery, almost odorless stools occur in the latter stages of entero-colitis ; most offensive, carrion-like motions, in both catarrhal and tuberculous ulceration of the intestines, THE INVESTIGATION OF DISEASE. 33 and sour-smelling evacuations in the diarrhoea of sucklings. The discovery of worms or their ova in the stools is the certain evi- dence of the existence of intestinal parasites. This mere outline of the changes that may take place will serve to show how much may be learned from the stools, and the importance of making a personal examination of them. The Urine. — It is impossible to make a definite statement as to the number of times the urine is voided by a healthy infant, in each twenty-four hours. In any given case the frequency will differ very much from day to day, depending upon the tempera- ture of the surrounding air, the amount of moisture that it con- tains, and so on. Sometimes it will be necessary to change the diaper every hour during the day and three or four times at night. Again it may remain dry for six, eight, or even ten hours. Neither condition indicates disease, and between the two ex- tremes there is a wide range of variation. Should the urine not be passed for twelve hours or more, a careful examination should be made to discover and remedy retention. As the child grows older the frequency diminishes, and at the age of three years the number of voidings will be reduced to six or eight during the waking hours, and perhaps one at night. When the desire does arise during sleep, the child, if in a normal state, wakes up and demands the chamber, and never passes urine unconsciously. Wetting the bed, therefore, or the involuntary passage of the urine during sleep, is indicative of an abnormal condition and requires investigation. Painful micturition points to inflammation of the urethra, a narrow preputial orifice, a highly acid condition of the excretion, or stone in the bladder. The urine of a healthy infant, while it wets, should not stain the diaper, the fluid being clear and almost colorless. It has a low specific gravity — 1.003 to I -°°6 — and an acid reaction pro- duced by the considerable amount of uric acid it contains.* As * The specific gravity falls markedly during the first few days after birth, on account of the ingestion of food. Alantoin is present in abundance during the 34 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. childhood advances, the adult characters are more and more nearly approached. The normal daily amount excreted cannot be stated absolutely, since it is difficult to collect the urine in infants and very young children, and since, in children of all ages, the flow depends so much upon circumstances quite compatible with average health. Thus it is influenced by the state of the weather, the condition of the various emunctories, the amount of blood pressure in the renal vessels, the state of the nervous system, and the quantity ot solids and liquids consumed. However, from a few observa- tions, I am led to believe that the quantity of urine voided by healthy children from the fourth to the seventh years is not nearly so large as supposed ; eighteen to twenty ounces being the average in several cases in which I have lately made measurements. Increased secretion of urine is a prominent symptom in dia- betes insipidus and mellitus, and as a transient event is encoun- tered after an attack of abdominal pain, an epileptic fit, a par- oxysm of ague and a convulsive seizure. Diminution may result from diarrhoea and vomiting, from extreme prostration due to deficient nutrition or other causes, and from renal congestion, whether occurring in Bright' s disease or in diseases of the heart and liver. In febrile conditions the flow is diminished, while the proportion of solids excreted is normal or increased ; the specific gravity, in consequence, is high. Complete suppression may occur when general prostration and renal congestion become intense. The quantity of solids excreted in health is also subject to great variation. The amount of urea passed by a child is rela- tively greater (1.7) than in the adult. Between the ages of three and six years, according to Uhle, one gramme of urea for every kilogramme of weight is voided every twenty-four hours. Eustace Smith, from a rough calculation based on the specific gravity of the urine, estimates that the solids excreted daily between the first weeks of life. Pyrocatechin (Ebstein and Miiller) is also present, but indican (Senator) is not found in the urine of the newborn. THE INVESTIGATION OF DISEASE. 35 ages of four and ten years, amount to five grains to each pound of weight. The normal acidity of the urine is increased by trifling agencies. A urine so affected deposits urates on cooling, or may indeed be turbid when passed and while still warm. Often the urates are so abundant as to render the fluid thick and milky-looking. In addition to increased acidity, this excess may depend upon an augmented secretion of salts. Over-feeding is the cause of the latter, and this relation of cause and effect must be borne in mind in the treatment of convalescence from acute diseases, during which a turbid urine is often seen. Free uric acid in the form of fine red sand is sometimes observed. Specific gravity and color vary with quantity. Two abnormal ingredients — albumen and blood — are fre- quently present in the urine of children. Albumen, though a frequent attendant of organic kidney dis- ease, by no means always indicates the existence of such a con- dition. It attends many febrile and inflammatory affections; is always to be detected where blood or pus are present, and appears where there is passive congestion of the kidney from chronic disease of the heart, liver or lungs. Again, transient albuminuria may arise from very slight causes. School children often have it during an examination or through- out the time given to preparing for it. Dr. Kinnicutt ascribes this to passing oxaluria or lithuria. It is also seen in children living in ague districts. Sometimes over-fatigue or the mere ingestion of a hearty meal will produce it, and some patients have it habitually after eating. Intermittent albuminuria — albumen being present one day and absent the next — is generally due to an admixture of secre- tions, and often indicates the habit of masturbation. The source of blood in the urine may be the ureters, the blad- der or the urethra, as well as the kidneys. In the first three cases the blood and urine are passed separately, while in renal hemorrhage the two liquids are intimately blended. When large quantities of blood are voided the cause of bleeding is, as 36 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. a rule, either purpura hemorrhagica or a renal calculus. Scarla- tina frequently, and the other exanthemata occasionally, produce bloody urine, through intense renal congestion, and the same result is sometimes brought about by the severe diarrhoea of entero-colitis or cholera infantum, the appearance of blood fol- lowing suppression of the urine. Many special diseases are attended by alterations in the urine. Affections of the kidneys stand, of course, at the head of the list. Acute Bright's disease and scarlatinal nephritis have a urine diminished in quantity ; of high specific gravity ; a smoky, black- ish hue, as if there had been an admixture of soot; with albu- men, blood and epithelial, granular and hyaline tube-casts as abnormal constituents. In chronic Bright* S disease the quantity varies, being either about normal or excessive; the specific gravity is low and the amount of solids diminished; the reac- tion is acid ; uric acid crystals may appear; hyaline and granu- lar casts are quite constant, but albumen is often absent. Sud- den exacerbations produce the characteristics of the acute form of the disease. Passive congestion of the kidneys causes albuminuria with epithelial and blood casts; renal calculus and lithaemia — great acidity, with the deposit of uric acid sand, and sometimes blood and albumen, and sarcoma of the kidney — albumen and blood at times. Simple catarrh of the bladder is attended by an albuminous urine, which is sometimes very offensive and may contain pus, vesical epithelium and phosphates ; the reaction is usually alkaline. Tubercular cystitis gives rise to a cloudy, thick urine, containing a trace of albumen, blood or pus. In incontinence the secretion is, in some cases, highly acid and, on standing, deposits crystals of uric acid. In hydronephrosis the specific gravity is low, the fluid may be either clear or turbid, and is faintly alkaline. The urine salts are reduced in quantity, and crystals of oxalate of lime are often detected by the microscope. THE INVESTIGATION OF DISEASE. 37 In malarial fever there is usually a profuse discharge of limpid fluid at the conclusion of the hot stage. During it, according to Gee, the urea and chloride of sodium are increased, the phos- phates diminished ; after the temperature falls, however, the phos- phates are increased and the urea and chloride of sodium are diminished. Patients living in highly malarious districts often show albumen and blood or its coloring matter in their urine. Throughout the first stage of typhoid fever the urine is scanty, has a high specific gravity and contains an excess of urea and uric acid, but few chlorides. Later it is freer, with diminished density, and may, if the temperature be high, contain albumen. Fevers as a class produce scanty, dense, high-colored urine, cloudy with lithates, and albuminous when an elevated tempera- ture is maintained. Croupous pneumonia gives well-marked changes, the quantity is diminished, the specific gravity high, the urea and uric acid above the average, the chlorides diminished or entirely absent at the extremity of the disease, and albumen often present. After the crisis the chlorides reappear. In diphtheria the urine is usually clear but may be smoky, urea is increased, and albumen and hyaline and granular casts may be discovered ; in membranous croup, on the other hand, it is generally normal. A scanty, high-colored urine, and one which deposits a whitish or pinkish sediment (lithates) on standing, is symptomatic of acute digestive disorder. Uric acid sand is sometimes seen in acute gastric catarrh, an excess of indican in inflammatory diar- rhoea when the small intestines are chiefly involved, and albumen in severe cases of thrush. Suppression attends grave entero- colitis and cholera infantum, while acute peritonitis and, occa- sionally, dysentery and the irritation of seat worms induce retention. In icterus neonatorum the urine is yellow in color, but con- tains no biliary coloring matter. Panot and Robin detected yellow, amorphous masses having different chemical reactions 38 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. from bile pigment, with uric acid; urates; oxalate of lime; hyaline, epithelial and fatty casts and white blood corpuscles. In catarrhal jaundice it is dark yellow, or even brownish, and contains bile coloring matter. Cirrhosis of the liver, in the hypertrophic stage, shows a yellow urine; in the atrophic, a fluid highly acid and filled with lithates and uric acid crystals. Amyloid degeneration is often associated with a similar disease of the kidneys, and the urine is altered in consequence, being copious, pale, lemon-yellow in color, of low specific gravity and containing albumen and hyaline tube casts ; the latter do not present the ordinary color reactions of amyloid material with iodine. Ascites has a scanty, high-colored and sometimes albu- minous urine. Acute articular rheumatism presents a febrile urine, and in rheumatism of the abdominal muscles the urine is reduced in quantity, high colored and very acid. Vomiting. — Both vomiting and regurgitation are of ready pro- duction and frequent occurrence in infancy, on account of the vertical position and cylindrical outline of the stomach at this period of life. Babies suckled at an abundant breast, and who are in the best possible state of health, often vomit habitually. In these cases, the supply of food being large, the infant as it lies at the breast is apt to draw more than it needs and more than it can digest. The stomach rids itself of this over-supply by an act which more nearly resembles regurgitation than vomiting, and which must be regarded as an evidence of health rather than the reverse. There is no violent effort or retching, the material ejected is the breast milk alone, either entirely unaltered or slightly curdled, and there are no symptoms of nausea, such as paleness, languor and faintness. In older children, vomiting may also occur after the stomach has been overladen. If the act be followed by relief from a feel- ing of general distress, headache and epigastric pain, it must not be regarded as a symptom of disease. THE INVESTIGATION OF DISEASE. 39 Vomiting attended with the train of symptoms embraced under the term nausea, is not a pathognomonic symptom. It may indicate disease of the stomach, of the intestines, of the lungs and pleura, and of the brain, or it may be a prodrome of one of the eruptive fevers. Which condition is present can only be determined by watching the case, and by a careful study ot the rational symptoms and physical signs. The character of the ejecta is more definite. For instance, the expulsion of mucus is a symptom of gastric catarrh. The regurgitation of mouthfuls of curdled milk, partially digested food and liquid so sour that it causes a grimace to pass over the face, is an indication of dyspepsia with fermentation and the formation of acid. The appearance of lumbricoid worms in the vomit, a not infrequent occurrence, of course shows conclu- sively the existence of these parasites in the alimentary canal. 3. Physical Examination. The methods of physical exploration in children are identical with those employed in adults, and the results do not differ in kind. Since, however, the object of exploration is to elicit the greatest amount of information with the least possible disturb- ance of the child, and as this very disturbance alters the character of some of the information obtained, it is well to adopt a some- what different order of examination, and one which at first sight may seem irregular. Thus it is best first, to ascertain the character of the respiration and the pulse, then to strip the body to determine the degree of muscular development and the condi- tion of the skin, next, to investigate the physical condition of the lungs, heart and abdominal organs, and last of all to examine the mouth and throat. In this order, then, the normal, as well as the more prominent abnormal features connected with the different organs will be considered. The Respiration. — In children the respiration is chiefly ab- dominal in type, irrespective of sex, and it is not until just before the age of puberty that the movements in the female change, becoming superior costal. Consequently, in estimating the 40 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. number of movements per minute, it is best to place the fingers lightly on the epigastrium. The count should always be made by the watch, and the most convenient time for the observation is while the child sleeps. Soon after birth the number of movements per minute is 44, between the ages of two months and two years, 35, and between two and twelve years, 23. During sleep the frequency is reduced about twenty per cent. Children under two years, while awake, breathe unevenly and irregularly ; there are frequent pauses followed by hurry and precipitation, and some of the movements are shallow, others deep. In sleep there is greater regularity. After the second year the movements become steady and even, like those of adults. All children, however, but particularly the very young, are subject to a great increase in the rapidity of respiration under the excitement of muscular movement and mental emotion. Accelerated breathing occurs during the course of diseases attended by severe febrile symptoms, such as the acute exanthe- mata, the inflammatory and other affections of the thoracic viscera, and in rickets. Acute pulmonary lesions are especially characterized by this alteration, and the more the breathing area is lessened the greater is the increase. Thus, in pneumonia, 60, 80 or 100 movements a minute are not at all unusual. To speak broadly, rapid breathing may be caused by an elevation in the body temperature, by an interference with the blood aeration and by thoracic or abdominal pain. As the increase in frequency may be unattended by any apparent effort, or true dyspnoea, it is well to make a rule of counting the respirations in every case in which the diagnosis is at all doubtful. Diminished frequency, the movements being reduced to 16, 12, or even 8 in the minute, is noted in certain brain affections, as in chronic hydrocephalus, and in the later stages of tubercular meningitis. In such cases the rhythm may be greatly altered — a tidal form being assumed, in which the breathing ebbs and flows, beginning with an act which is scarcely perceptible or THE INVESTIGATION OF DISEASE. 41 audible, gradually growing deeper until a full, noisy respiration is made, and then slowly subsiding into a period of absolute quiet, variable in its duration. This is termed Cheyne-Stokes' respiration. Another form of breathing, in which the alteration is mainly in the rhythm, is termed expiratory respiration. In the normal act, inspiration is immediately succeeded by expiration, and between the latter and the next inspiration there is a period of silence or rest. Expiratory respiration, on the contrary, is char- acterized by the pause coming between inspiration and expira- tion, the expiratory effort, always very marked, being immedi- ately succeeded by the inspiratory. This alteration occurs most frequently in young children, and is an evidence of dangerous pulmonary embarrassment. Perfectly healthy children breathe through the nose, and so softly that it is necessary to place the ear close to the face to hear the breezy sound of the ingoing and outgoing air. A dry, hissing sound, or a moist sound of snuffling indicates partial obstruction of the nasal passages; oral respiration, complete occlusion. Difficult breathing with prolonged inspiration — in- spiratory dysp7ioea — shows an impediment to the entrance of air into the lungs and indicates laryngeal obstruction, due, most commonly, to spasm or to the formation of false membrane. In such cases the inspiratory act is also attended by a loud, piping, or rasping sound. Labored breathing with prolonged wheezing respiration — expiratory dyspnoea* — occurs when the escape of air is impeded. The causative lesion is to be found, not in the larynx, but in the lungs. It may be a bronchial catarrh with excessive secretion, an emphysematous condition of the air vesicles, or asthma. In both forms of dyspncea the movements are slow as well as difficult, and a combination of the two forms is met with in cases of marked laryngeal stenosis. Yawning, one of the modifications of the respiratory act, if it * I prefer to limit the term dyspnoea to difficult or labored respiration, and not to extend it so as to include simple accelerated breathing. 4 42 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. recur frequently, denotes great failure of the vital powers and is an unfavorable prognostic element. The Pulse. — To obtain any reliable data from the pulse it must be felt while the patient is perfectly quiet. The best time is during sleep, but if the child cannot be caught in this condi- tion, advantage may be taken of its placidity while nursing at the breast, feeding from a bottle, or amused by a toy or book. With very young infants it is sometimes impossible to feel the beat of the radial artery, and it is necessary to ascertain the fre- quency of the pulse by directly ausculting the heart. After the second month palpation of the pulse at the wrist in the ordinary way presents no difficulties. The child's pulse differs from ihe adult's by being much more frequent, more irregular, and more irritable, and necessarily of smaller volume. The frequency, or the number of beats per minute, varies with the age. The following is the average rate : — From birth, to the 2d month, 160 to 130. From the 2d to the 6th month, 130 to 120. " " 6th " 1 2th " ... 120 to no. m a Ist a 3d year, no to 100. " "3d " 5th " 100 to 90. u u ^h « Iot b u 90 to 80. " " 10th " 1 2th " 80 to 70. These figures represent the pulse in a waking but passive state. During sleep the frequency is less. Thus between the second and ninth years there are about sixteen beats less per minute while asleep than when awake; between the ninth and twelfth years, eight less ; and between the twelfth and fifteenth years only two less. Below the age of two years the disparity is even greater. The irregularity of the pulse in childhood is confined to an alteration of the rhythm. It is most marked in infants and is greatest during sleep, when the pulse is slowest. The feature of irritability, that' is, the facility with which its frequency is increased by muscular activity and mental excite- THE INVESTIGATION OF DISEASE. 43 ment, is greater in proportion to the youth of the child. A rise of 20, 30 or even 40 beats a minute is not uncommon in early infancy under the excitement of the slightest effort or dis- turbance. On account of these wide variations in health, little sympto- matic meaning need be attached to alterations of the rhythm and frequency while unassociated with other abnormal features. When so associated they become important in diagnosis. Increased frequency is a constant attendant of the febrile state. The extent of the increase corresponds with the degree of elevation of the temperature, though the pulse curve always runs higher than the temperature curve. The more frequent the pulse the higher the fever, is the rule, but in estimating the prognostic value of the increase, the law of the fever in ques- tion must be taken into consideration. For example, in scarla- tina a pulse of 160 is usual and not indicative of special gravity, whereas in measles the same degree of acceleration would be abnormal and show great danger. Jaundice and parenchymatous nephritis are accompanied by a diminution in the rate. Irregularity is met with in diseases of the brain and heart, and sometimes in nervous and anaemic children. The Temperature must be estimated before removing the clothing. No reliable result can be obtained without the use of an accurate clinical thermometer. The instrument is usually placed in the rectum* of the infant and young child; in the axilla of one old enough to understand the importance of keep- ing the arm in a proper attitude. It should remain in position at least five minutes. During the first week of life the temperature fluctuates con- siderably. After that the puerile norm — 98. 5 to 99 F. — is established, but until the fourth or fifth month it is greatly influenced by healthy causes of variation ; the fluctuations rang- ing between .9° and 3. 6°. By the fifth month regular morning * The rectal temperature is normally at least i° higher than the axillary. 44 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. and evening oscillations begin to be noticeable, and certain definite laws are followed. There is a foil in the evening of i° or 2 . The greatest fall occurs between 7 and 9 p.m. and the minimum is reached at, or before, 2 a.m. After 2 a.m. there is a gradual rise, the maximum being reached between 8 and 10 a.m. Throughout the day the oscillation is trifling. These variations are independent of eating and sleeping. In disease there may be either a rise above, or a fall below, the normal standard. Fever is always associated with an elevation of the temperature. Rapid and transient rises attend slight catarrhs and passing indigestions; prolonged rises, inflammatory and essential fevers. The degree of elevation marks the type of the pyrexia. This is moderate when the mercury stands at 102 , severe at 104 or 105 , and very grave above 107 . The duration of the eleva- tion and the peculiar range of the oscillations — for there are oscillations in disease as well as in health — determine the nature of the fever. The febrile oscillations differ from the healthy in that the lowest marking is noticed in the morning, the highest in the evening. Variations in the typical range of any given fever are important prognostic omens — a sudden fall of the tem- perature, together with improvement in the general symptoms, indicates the beginning of convalescence — a similar fall, with an increase of the general symptoms, is a precursor of death. When the morning temperatuie is equal to that of the preceding evening, there is great danger ; if higher, greater danger still. Marked remission in continued fevers is generally a forerunner of convalescence. Abnormal depression of temperature is occasioned by hemor- rhage and by the loss of fluids in cholera infantum or entero- colitis. It is also met with in anaemia, in atrophy from insufficient nourishment, in diseases of the heart and lungs attended by im- perfect blood aeration, and it constantly attends collapse and the death agony. A maintained temperature of 97 is dangerous in children, and for every degree of reduction below this point, the risk to life is more than proportionately increased. THE INVESTIGATION OF DISEASE. 45 While the physician must use the thermometer, to insure accuracy, he can, by placing the hand on the skin, detect gross differences of temperature. Reductions are best appreciated by touching the nose and extremities, while increased heat is most readily felt at the back of the head and in the palms of the hands. Having determined the character of the respiration, pulse and temperature, the next step in the physical examination is to strip the child, in order to ascertain his general development, the condition of his skin, and so on. The General Development. — The healthy child under two years of age is plump of body and round of limb with well- developed fat cushions and firm flesh, and with the head and abdomen large in proportion to the rest of the frame. As age advances, the figure gradually assumes the characteristics of adolescence. To be robust, the newly-born child must have a certain aver- age size and weight. Subsequently, under normal circumstances, there is a regular rate of increase in both of these respects. At birth the length is about 16 inches. Growth is quickest in the first week of life. In the first year there is an increase of from 5 to 6y^ inches; in the second, from 2^3 to 3^ inches; in the third, from 2^ to 23/3 inches; in the fourth, about 2 inches; and from the fifth to the sixteenth years the annual growth amounts to from ifz to 2 inches. The average weight at birth is from 6 to 8 pounds. The daily increase in weight should range from y^ to y^ of an ounce. With these data it is quite possible to estimate what should be the normal size and weight of a child at any age. Consequently, if, on being measured and weighed, he be found to fall short of the normal standard, it is proper to infer the existence of some fault in the nutritive processes. A conclusion still further borne out by a want of rotundity of outline and by flabbiness of the muscles. The age at which the child sits erect, at which it walks, and at which the anterior fontanelle becomes ossified, are points closely connected with the subject of development and nutrition. 46 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. For some time after birth, the child, if noticed while sitting upon the lap, will be observed to hold the head and shoulders forward or to " stoop' ' a little; the spine, from the cervical region to the sacrum, forming a continuous curve with the con- vexity directed backward. Toward the end of the eighth month the position begins to become more erect, and in a few weeks is perfectly so, the spine assuming an almost perpendicular line. Any marked delay in this change indicates general debility. At the end of the fourteenth month the child should be able to walk alone. The spine then assumes the S like curve seen in healthy adults. A delay in walking may be due to systemic weakness or to infantile paralysis affecting one or both legs. If the walking be done on the toes chiefly, if the gait be limping, and especially if knee-pain be complained of, and manipulation of the limbs causes suffering, the chances are that hip-joint dis- ease is commencing. The anterior fontanelle should be ossified or completely closed at some period between the fifteenth and twentieth months. The closure is much retarded in rickets, which is preeminently a disease of mal-nutrition. Hydrocephalus has a like effect. In a state of health, the opening, while still membranous, is level with the cranial bones or very slightly depressed. Conditions of systemic exhaustion cause marked sinking, and this depression is one of the best indications of the necessity of stimulation. Bulg- ing of the fontanelle is a symptom of chronic hydrocephalus. Conditions of the Skin. — The normal color of the integu- ment, and the alterations produced by disease, have already been studied. The other characters possessed by the skin of a healthy child are, a velvety smoothness and softness, a scarcely perceptible moisture, and a great degree of elasticity. Disease causes modifications in texture, in moisture, and in elasticity, and leads to the appearance of various eruptions and to oedema. Mucous disease is attended with a dry, harsh skin, which is muddy in color, and covered, especially on the extensor surfaces of the arms and legs, by a more or less thick layer of exfoliating epi- THE INVESTIGATION OF DISEASE. 47 dermis. Chronic abdominal affections, particularly tuberculosis of the intestines and mesenteric glands, lead to harshness, acridity, scurfiness, and a wrinkled appearance of the skin covering the abdomen and thorax, with enlargement of the superficial abdom- inal veins. Protracted diarrhoea, and still more, vomiting combined with diarrhoea, cause absorption of the subcutaneous fat and wasting of the muscles. The skin becomes too large for the body, is dry, harsh, discolored, and so inelastic that it falls into wrinkles over the joints when the limbs are moved, and if pinched up retains the fold for a long time. The condition of general atrophy popularly known as " marasmus, " presents these features most strikingly. Dryness is a concomitant of the febrile state ; excessive moist- ure, of prostration of the vital forces and collapse. Eruptions appear upon the integument, in the skin diseases proper, in the exanthemata, in constitutional syphilis and in certain digestive disorders. OEdema of the subcutaneous connective tissue may be due to affections of the heart, liver or kidneys. The cardiac variety usually shows itself first in the feet ; the renal, in the eyelids ; the hepatic, in the feet and legs, secondarily to ascites. While examining the surface it is well to look for enlargement of the superficial lymphatic glands and swelling of the joints. The former occurs in scrofula and syphilis ; the latter in rheumatism. Examination of the Abdomen. — To examine this portion of the body the child, still stripped, must be placed on its back, upon the bed or nurse's lap. Quiet is most important, since struggling and crying are attended by such contraction of the abdominal muscles and rigidity of the walls that little can then be learned of the condition of the contained organs. The methods of investigation are those ordinarily employed in physical examination. Palpation or percussion should never be made with cold hands. The abdomen of a healthy child is somewhat prominent, 48 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. uniformly soft, yielding, and painless to the touch, and to percus- sion gives a tympanitic sound, varying in tone according to the region percussed. The tympanitic note being lowest in pitch over the epigastric and left hypochondriac regions, the seat of the stomach ; highest, over the umbilical region, the position of the small intestine. In disease i?ispection reveals any disproportion in the size or form of the abdomen, the state of the integuments, of the super- ficial veins, and of the umbilicus. Palpation shows the tempera- ture, pliability, moisture and tension of the walls, and the presence or absence of tenderness, of fluctuation, and of enlarge- ment of the mesenteric glands, and other solid viscera. Percussion serves to demonstrate the nature of enlargements, whether due to accumulation of gas or liquid, or to solid growths. By it, also, the outline and size of the liver and spleen may be determined. Distention of the abdomen is, in the vast majority of instances, due to flatulence. In children reduced by chronic disease the bowels are usually deranged, the food is badly digested, and the gases set free by the decomposition of the starchy foods accumu- late, owing to feebleness of the intestinal walls, and give rise to much/ swelling and discomfort. Over such an abdomen the skin feels tense, the umbilicus is level or slightly prominent, there is no tenderness on pressure, and percussion is markedly tympanitic. This simple cause of enlargement must be remembered, for a distended abdomen in a wasting child is often falsely attributed to caseation of the mesenteric glands. The latter disease is uncommon at any age, extremely rare under three years, and, moreover, is by no means uniformly attended by distention. On the contrary, unless the glandular disease be excessive, retraction is the rule. When distention does exist it depends upon associ- ated intestinal disorder, and is merely an accidental complication. The only pathognomonic sign is the detection of the tumor caused by the enlarged glands. This is situated in the umbilical region, and is firm, lobulated and slightly tender to the touch. It is most readily detected by gently grasping the abdomen on either side with the hands and slowly bringing the fingers together THE INVESTIGATION OF DISEASE. 49 toward the median line. Percussion over the tumor yields a dull, tympanitic sound. Whenever there is associated flatulence it is difficult or impossible to detect the tumor. Drum-like distention, with great tenderness, and muffled tym- panitic percussion note occur in general peritonitis. Uniform distention, again, may be due to ascites depending upon simple or tubercular peritonitis, kidney disease, or less com- monly, disease of the liver. The abdomen is barrel-shaped, pain- less to the touch, and there is extended fluctuation. Percussion is dull over the position of the fluid, but in nearly every instance there is an area of tympany which changes its position ; moving always to the upper part of the abdomen, in reference to the posture of the patient. This variation is most important in the diagnosis. Localized distention may be traced to gaseous accumulation, to enlargement of the liver and spleen, to faecal accumulation, to circumscribed peritonitis, and to distention of the bladder. Collections of gas are always tympanitic on percussion. The extent of liver dulness is to be estimated by percussion. If the organ extend below the rib margin, the edge can usually be felt by laying the palm of the warmed hand flat upon the abdomen and making gentle pressure downward with the ends of the fingers. An enlarged spleen may be felt by placing the fingers of the right hand on the back, directly below the twelfth rib and outside of the lumbar muscles; the fingers of the left, on the abdomen, directly opposite ; then bringing the hands toward one another. If the hands have been rightly applied, and nothing is felt, the spleen may be considered to be normal in size. The fact that both the liver and spleen, though still unenlarged, may be more readily felt than natural when pressed downward by the dia- phragm, must not be overlooked. A faecal accumulation is distinguished by the absence of ten- derness, by the oblong shape of the tumor, by the situation in the region of the transverse or descending colon, to which its long axis corresponds, and by its shape being capable of some 50 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. modification by pressure. Percussion over such a mass is dull. Distention of the bladder gives rise to a bulging tumor in the hypogastric region, which is elastic to the touch and dull on percussion. A shrunken or scaphoid condition of the abdomen is met with in serious brain affections, notably tubercular meningitis, also in cholera infantum, follicular enteritis and dysentery. Tenderness to pressure indicates inflammatory lesion of the intestines. The presence or absence of this sign in an infant can be determined by forcing the attention, by bringing it before a strong light, for instance, and then making pressure on the abdomen. If crying be produced, there is tenderness, if not, the reverse. Examination of the Chest. — The stethoscope and plex- imeter are unnecessary in examining the lungs. In the case of the heart, the former may be occasionally required, to localize murmurs. When used, it is better to give the instrument to the child to handle and become familiar with, before application. The thoracic end must never be adjusted without being warmed. The quieter the patient the more complete and satisfactory will be the results of the exploration. Unfortunately, though, it is too often necessary for one to do the best possible in the midst of cries and struggling. However, by skilfully seizing oppor- tune moments, much reliable information may be gained. Aid is also derived from the fact that in serious lung affections, as croupous pneumonia, the child is quiet from choice, crying interfering with the respiratory act, upon which his attention is concentrated. The steps of the examination are, first, inspection ; second, auscultation ; third, palpation ; and fourth, percussion. The reason for making the order different from that practiced in adults, is to place the most disturbing element last. Mensura- tion and succussion are infrequently resorted to in children. If required, they are best postponed until the end of the examination. THE INVESTIGATION OF DISEASE. 51 Inspection. — The sitting posture, the child being stripped and in a good light, is the best for this process. Note is to be taken of the shape of the chest, the character of the breathing, and the position of the apex beat of the heart. In the newborn baby, the chest is nearly circular in shape, the antero-posterior diameter being almost as great as the lateral. Later, it gradually becomes elliptical, the lateral diameter in time considerably exceeding the antero-posterior. The intercostal spaces are poorly marked, and the scapulae lie so close that their outline is scarcely perceptible. The circular shape of the chest allows of little lateral expansion, and for this reason the respiration is chiefly abdominal in type. Together with the movement of the abdominal walls, every act of inspi- ration is attended by a certain amount of recession of the lower part of the chest walls, the yielding ribs being forced inward by the pressure of the external air before they can be sufficiently supported by the expanding lung. The rise and fall of the car- diac apex can be seen — except when there is a great accumula- tion of fat — a short distance below and to the right of the left nipple. Disease may alter all of these conditions. The tuberculous diathesis is characterized by a small chest, and one which has either the alar or the flat shape. In rickets the thorax becomes irregularly triangular in outline. Emphysema causes a barrel- shaped chest, with stooping shoulders and round back. Pleuritis with large effusion produces bulging of the affected side, and sometimes prominence of the intercostal spaces. After absorp- tion has taken place there may be marked retraction, sinking of the interspaces, falling of the shoulders, and curvature of the spine toward the healthy side. Cessation of the costal respiratory movements indicates in- flammation of the lung or pleura, or a large pleuritic effusion. Cessation of the abdominal play, inflammation of the peritoneum or of the intestines ; excessive ascites and gaseous accumulations produce the same effect. Rachitic softening of the ribs, and those diseases of the lungs 52 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. and air passages which offer a direct obstacle to the entrance of air, are associated with a great increase in the normal recession of the lower portion of the chest on inspiration. In certain cases, a deep furrow appears across the chest, marking the upper borders of the abdominal viscera. The depth of the furrow indicates the degree of softening and of obstruction to the ingoing air. The position of the apex beat is altered by cardiac diseases, by pleuritis, and occasionally by gaseous distention of the stomach. When the left ventricle is enlarged, it is shifted downward and to the left. Transmitted epigastric pulsation shows enlarge- ment of the right ventricle. An extended impulse is not necessarily a sign of disease, since the chest-walls are so elastic in childhood that the normal impact of the apex is apt to affect a wide area. The effusion of pleurisy pushes the heart to the right or left, while the retraction, after absorption or evacuation, draws it in one or other direction. The apex is pushed upward and to the left in gastric flatulence. Emphysema, by pushing the heart away from the thoracic wall, diminishes or entirely hides the impulse. Auscultation. — With infants, the back of the chest is most conveniently ausculted when the child is held in the nurse's left arm, with his breast against hers, his chin resting upon her left shoulder, his left arm around her neck, and his head kept in position by her disengaged hand. The front, when reclining on the back on a pillow. The sides, when sitting upright on the lap, first one arm and then the other being lifted up to allow the observer's ear to be applied. Older children may be made to take the same position as adults. It is not sufficient to auscult the posterior aspect of the thorax alone, as is stated by some authors. The whole chest should be examined, particularly in doubtful cases. The signs of croupous pneumonia are most frequently discoverable at one or other base, posteriorly ; the friction sound of pleuritis at the junction of the middle and lower third of the chest, laterally ; and the signs of emphysema at the apices, anteriorly. Therefore, THE INVESTIGATION OF DISEASE. 53 unless the exploration be thorough, important lesions may be overlooked. In healthy infants the inspiratory act in ordinary breathing is superficial, and the respiratory murmur, as a consequence, feeble. If, however, a deep inspiration be taken, a frequent occurrence under excitement and during crying, the murmur becomes loud, or assumes the character that Laennec termed puerile breath- ing. After the age of two years this form of respiration is habitual. Puerile breathing is characterized by its intensity, a property depending upon the thinness and elasticity of the chest-walls in childhood. There is no alteration in rhythm, the inspiratory element of the murmur being directly followed by the expira- tory, and this in turn by an interval of silence ; neither is there any change in the pitch or duration of the expiratory sound, which remains lower and shorter than that of inspiration. In other words, puerile respiration is simply a very intense vesicular respiration. The normal respiratory murmur is then feebler in infants, and louder in children over two years old, than in adults. The breathing is loudest over the anterior, lateral and poste- rior inferior regions of the thorax. Faintest over the scapulae and the precordial area. Sometimes the expiratory element is wanting. This absence occurs most frequently in young chil- dren, and is most noticeable over the lower posterior portions of the lungs. In the inter-scapular region, the ear, being directly over the larger bronchi, readily detects a deviation from the vesicular quality. Here the 'inspiratory murmur is loud, harsh and somewhat tubular in character. There is a slight pause between it and the expiratory murmur, and the latter is longer in duration and higher in pitch. There is, in fact, an approach to the bronchial type of breathing, which may always be heard in its purity by listening over the trachea. Sometimes a difference in the breathing can be detected over the apices anteriorly. On the left side the vesicular quality is purer, on the right, the intensity is greater. The difference is 54 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. most decided in the expiratory element, which, also, may be slightly prolonged on the right when compared with the left side. These modifications are due principally to the larger size and more horizontal course of the right primary bronchus. They are perfectly compatible with a normal state of the lungs. Should, however, the conditions at the apices be reversed, and the intensity and prolongation of the expiratory sound be greater on the left side, the commencement of phthisis is indi- cated. If the child speaks, cries, or coughs while the ear is applied to the chest, a muffled rumbling sound, the normal vocal reso- nance, will be heard. At the same time, vibration of the walls, the vocal fremitus, can be felt. To develop the respiratory sounds it is often necessary to instruct the patient how to breathe, and if an infant is being examined, to take advantage of the deep inspirations that. pre- cede coughing, and occur during crying. The cardiac sounds are readily heard when the ear is placed on the praecordia. In young infants the examination is somewhat difficult, on account of the rapid and excitable action of the heart, but after the first year, the circulation becoming slower and more regular, there is little trouble in distinguishing the sounds, and even slight alterations produced in them by disease. The first sound is longer and graver than the second, and the rhythm is ordinarily quite regular. In health the sounds may be heard under both clavicles for a short distance to the right of the sternum, and sometimes over the whole ante- rior surface of the chest. After muscular effort or during agita- tion, the heart sounds may be audible over the posterior aspect of the chest, but they are most distinct in this position when the lower lobe of either lung is consolidated by pneumonic exuda- tion. The latter point is often of great value in distinguishing doubtful cases of pneumonia from pleural effusion. Palpation. — In practicing palpation the palmar surface of the well-warmed hand must be applied to the naked chest. This method of exploration is useful as a means of determining the THE INVESTIGATION OF DISEASE. 55 number of respiratory movements, the degree of expansion of the thoracic walls, the position of the cardiac apex beat, the presence or absence of painful regions and of pleural or bron- chial fremitus, the existence of fluctuation in the intercostal spaces, and the character of vocal fremitus. For the last pur- pose, though, it is hardly worth while to make a separate step in the examination, for the vocal vibrations can be readily distin- guished by the ear when applied to the chest in auscultation. Percussion. — In percussing the different surfaces of the chest, the child must be placed in the same positions as for auscultation. When contrasting the two sides, percussion should be made in identical regions, and during the same period of the respiratory movement. Babies when constrained or when disturbed, hold their breath in the intervals of crying, and as they always do so at the end of an inspiration, this is a favorable time to seize for the comparative examination. The percussion strokes must be lighter than in the adult, but in other respects the operation in no wise differs. In health the resonance will be found to correspond closely with the respiratory murmur. Thus, in infants under one year, the respiratory murmur being feeble, percussion is rather insono- rous. Even at this age the case is different, when a deep breath is taken, and so soon as puerile respiration becomes established the resonance is uniformly intense. With the exception of this greater intensity, the sound is exactly similar to that obtainable in adults. It is always attended, too, by a sensation of elasti- city, appreciated by the finger used as the pleximeter. Different portions of the thorax possess, normally, different degrees of sonorousness. In front, the right side is markedly resonant from the clavicle down to the fifth interspace, or the upper border of the sixth rib in the mammary line, where the liver dulness begins. On the left side the resonance is equally intense, but it is encroached upon by the gastric tympany, which extends upward as high as the seventh or sixth rib, as well as by the area of cardiac dulness. The latter forms an irregular triangle, of which one side is repre- 56 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. sented by a vertical line passing down the middle of the sternum, from the level of the fourth to the sixth rib ; the other, by an oblique line touching the upper extremity of the first, and extending outward to the left, and downward, to terminate at the point of the apex beat ; and the base, by a line drawn from the central point of the lower edge of the sternum (the inferior extremity of the first line), along the sixth costal cartilage, to the apex of the heart. Diminished resonance and elasticity are at once noticeable when the percussion passes from the lung to this area, though the prsecordial dulness is never so decidedly marked in children as it is in adults. Laterally, both supra-axillary regions are very resonant. The upper portions of the infra-axillary regions are a degree less reso- nant, and the lower portions are dull on account of the presence of the liver on the right and the spleen on the left side. The superior border of the liver dulness is found in the seventh inter- space or at the eighth rib ; that of the spleen, at the upper edge of the ninth rib. Gastric tympany may supplant the pulmon- ary resonance over the left infra-axillary region. Posteriorly, there is little resonance in the scapular region, particularly the supra-spinous portions. Over the interscapular space the sound improves, but it is less resonant than anteriorly or laterally. Over the infra-scapular regions the resonance is but little less pure than in front, until the tenth rib is reached on the right side and the liver dulness is again met with. On the left side the resonance extends to the very base, the posterior splenic dulness being detected with difficulty. The right base is, there- fore, naturally less resonant than the left, and this difference is especially marked during expiration, the liver rising higher at that time. Affections of the lungs produce various alterations in the percus- sion sound. The chief of these are the substitution of tympany, of dulness, and of flatness for the normal resonance, and of increased resistance to the finger for elasticity. Cardiac diseases cause changes in both the extent and the shape of the area of praecordial dulness. THE INVESTIGATION OF DISEASE. 57 Examination of the Mouth and Fauces. — This portion of the examination is most apt to cause crying and struggling, but it must never be omitted. In infants, gentle pressure of the fingers upon the chin is sufficient to cause wide opening of the mouth. An older child will frequently open the mouth when requested, but if he refuse, the finger, the handle of a spoon, or some other smooth, flat instrument maybe inserted in the mouth, and downward pressure made upon the tongue, when the jaws will be widely separated. In some cases, when the child is old enough to do as bid, the fauces can be seen by directing the mouth to be opened wide and the tongue to be alternately pro- truded and retracted, or a prolonged sound of "AA" to be made. With the refractory, and always with infants, the tongue has to be held down by a spoon handle or tongue depressor. If there be resistance, the patient must be taken on the lap of the nurse, who holds his back against her breast, directs his face toward a bright light, and controls the movements of his hands and feet. The healthy oral mucous membrane has a deep pink color, and is smooth, moist and warm to the touch. The color is deeper on the lips and cheeks, lighter on the gums. The latter, up to the sixth month, as a rule, have a moderately sharp edge. Sub- sequently, the edge begins to broaden and soften, and the color of the investing mucous membrane deepens to a vivid red, and becomes hot, as the teeth begin to force their way through. The first, or milk teeth, so called from their color, are twenty in number, all told, ten to each jaw ; they make their appearance in the following order, the corresponding teeth appearing a little earlier in the upper jaw * : — The two lower central incisors, from " four upper " " " two lower lateral incisors and the four anterior molars, from " four canines, " " " posterior molars, " *« Upon this point, however, there is little uniformity. 4 to 7 m onthi 5 after 1 Dirth. 8 to 10 a a a 12 to 15 a a a 18 to 24 a a (i 20 to 30 a a a 58 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. The order of eruption of the permanent teeth is as follows The two central incisors of lower jaw, from the 6th to 8th year. " " " " upper " " " 7th to 8th " " four lateral " " " 8th to 9th " " " first bicuspids, " " 9th to 10th " u " canines, " " loth to nth «• " " second bicuspids, " " 1 2th to 13th " These replace the temporary teeth ; those which are developed de novo appear thus : — The four first molars, from the 6th to 7th year. " " second" " " 12th to 13th " u " third " " " 17th to 21st « There are, therefore, twelve more permanent teeth, making thirty-two in all, sixteen in each jaw. The tongue should be freely movable. It is pink in color, and the dorsum, or upper surface, marked in the centre by a slight longitudinal depression, has a velvety appearance, and is soft, moist, and warm to the finger. The velvety nap is due to the numberless hair-like processes of the filiform papillae. There are also scattered over the surface, but most closely at the tip, a number of eminences, the size of a small pin's head, circular in outline, and deeper pink than the general surface — the fungiform papillae. While far back, defining the papillary layer, are the circumvallate papillae, numbering about twelve, and arranged in a V-shaped row. These have the form of an inverted cone, sur- rounded by an annular elevation. The hard palate is roughened anteriorly by transverse ridges. The soft palate is smooth and its mucous membrane is paler than that of the rest of the mouth. The fauces, on the contrary, are redder. In the triangular recess between the half arches of the palate the tonsils can always be seen. They should be about the size and shape of almond kernels, and they present a number of circular openings, the orifices of pouches, into which the follicles open. The uvula is short and tongue-shaped. The posterior wall of the pharynx should be red, smooth and moist. THE INVESTIGATION OF DISEASE. 59 Disease produces a great variety of changes in the mouth, tongue and fauces. Fever makes the mouth hot and dry, and causes the tongue to be frosted or coated. Affections of the gastro-intestinal tract are always attended by coating of the tongue, and the various appearances of this coating are of impor- tant diagnostic and therapeutic significance. Inflammation of the mouth itself, reddens the mucous membrane, makes it hot and tender to the touch, increases its moisture, alters the surface of the tongue and leads to the formation of aphthae, to ulceration, and even to gangrene. The eruptions of scarlet fever, measles, varicella and varioloid make their appearance first on the mucous membrane of the palate and fauces. Irregular dentition indicates faulty nutrition ; delayed denti- tion, rickets; and certain peculiarities in the formation of the permanent teeth, constitutional syphilis. Finally, the conclusive evidences of the existence of diphtheria, of croup, and of the various tonsillar affections, are found in the fauces. PART II.— THE GENERAL MANAGEMENT OF CHILDREN. It is the duty of the child's physician not only to remove dis- ease, but also to manage convalescence and every-day life in such a way that the little subjects confided to his care may be led to complete recovery, and kept in as perfect health as possible. To accomplish these objects, the ability to direct intelligently the daily regimen is much more important than a mere knowledge of drugs and of the principles of therapeutics. The daily regimen embraces several factors ; these are feeding, bathing, clothing, sleep and exercise, and under such headings the subject will be briefly outlined, for little more is possible, in the present chapter. i. Feeding. Age bears so close a relation to the choice of food and the method of feeding, that it will greatly simplify the study of these questions to consider them from the standpoint of the two stages of a child's life, namely, infancy, or the period extending from birth to the age of two and a half years ; and childhood, the time elapsing between completion of the first dentition and puberty. An Infant may be fed in either one of three ways — ist, from the mother's breast ; 2d, from the breast of a wet-nurse ; and 3d, from a bottle, the latter being the method known as artificial or hand-feeding. 1 st. Feeding front the maternal breast. There can be no doubt that this, being the natural, is at the same time the proper method of nourishing the human infant ; and fortunate is the babe that, in our day of advanced civilization and city-living, can draw from 60 THE GENERAL MANAGEMENT OF CHILDREN. 6 1 the breast of a robust mother an abundant supply of pure, health- giving, tissue-building food. It follows, therefore, that every woman who is free from certain contra-indicating diseases, to be mentioned later, should nourish her child solely from her breast up to the age of eight months, and partially to the end of the first year, or, failing in either limit, so long as possible. The infant should be put to the breast as soon as the mother has recovered somewhat from the fatigue of labor — some four or eight hours after birth. Of course no milk can be drawn at this early date, but the babe gets a small quantity of thin, watery fluid, called colostrum, which affords sufficient nourishment, and at the same time, from its laxative properties, clears away the greenish or black, viscid material that collects in the infant's intestinal canal during intra-uterine life. This procedure, too, is of great advantage to the mother, for it insures proper contrac- tion of the womb, draws out the nipples, and encourages the formation of milk. As the secretion of milk is never fully established until the third day after labor, it stands to reason that no food other than the colostrum is required before that time. Hence, the practice of filling the infant's stomach with gruel, sugar and water, and other sweetened mixtures, is more than useless, for it diminishes the activity of sucking and the consequent stimulation of milk production. Put the child to the breast every two hours while the mother is awake, and there need be no fear of starvation. After the third day, should the breasts not yield a supply of milk, a little pure cow's milk diluted with double its quantity of water and sweetened with sugar of milk, may be given every fourth hour, the babe being put to the breast in the meanwhile. So soon as the flow begins, however, the artificial feeding is to be discontinued. Usually on the fourth day milk is secreted and regular lacta- tion commences. Many untrained mothers make a failure of nursing because they know nothing of the manner of giving suck ; of the length of time the child should be kept at the breast; of 62 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. the proper time for, and interval between feeding, and of the importance of regularity. Upon these points the physician should give minute instructions. When giving the breast, the infant must be held partly on its side, on the right or left arm, according to the gland about to be drawn, while the mother must bend her body forward, so that the nipple may fall easily into the child's mouth, and steady the breast with the first and second finger of the disengaged hand, placed above and below the nipple. In case the milk runs too freely — a condition very apt to excite vomiting — the flow is easily regulated by gentle pressure with the supporting fingers. Each of the breasts should be drawn alternately, the contents of one being usually sufficient for a meal ; and a healthy child may be allowed to nurse until satisfied, when he will stop of his own accord, drop the nipple and fall asleep with milk still flowing over his lips. During the first six weeks the breast is required every second hour, from 5 a. m. until 11 p. m. At night the infant should be put in a crib by the mother's bed, or in an adjoining room, under the care of a competent nurse, and there remain quietly until the morning feeding. This secures the mother six hours of uninterrupted repose, a matter of great importance to her general health and consequent capacity for prolonged lactation. As to the infant, he may rebel at first, and wake and cry, so that it is necessary to quiet him with a little milk and water adminis- tered from a bottle ; but often after a few days, and certainly at the end of a week or two, the good habit of sleeping at night is formed, and there is no further trouble. Regularity in meal hours is even of more importance in early than in adult life, on account of the natural feebleness of diges- tion. To secure this, it is only necessary to have a little perse- verance, for infants are such creatures of habit that a short training brings them into the w T ay of expecting food only at cer- tain times, and, when healthy, they wake to suck the breast with almost the precision of the clock. While insisting upon this rule, one must recognize the fact that, although in the vast THE GENERAL MANAGEMENT OF CHILDREN. 6$ majority of instances a two-hours' interval is most suitable up to the second month, there is no absolute law as to the number of daily nursings. Some infants seem to need food less frequently, and it is best to respect their peculiarity and not force the breast upon them so long as they sleep well, do not fret when awake, and thrive generally. Others, again, may require it oftener, every hour and a half, perhaps, and once or twice at night. In these exceptional cases an appropriate schedule can only be made by close observation of individual characteristics. A common and most ruinous mistake is to resort to constant feeding as a means of pacifying crying. Babies certainly do cry from hunger, but just as frequently the crying results from colic, or from the discomfort and pain of indigestion. Every mother should be able to recognize the difference. The cry from hunger usually begins after a sound sleep. It is not peevish, and stops at the sight of the breast, when the infant rouses himself, pre- sents an expression of pleasure, clinches his hands and flexes his limbs. The cry of colic is violent and paroxysmal; the face is livid and wears an expression of suffering ; the abdomen is dis- tended and hard ; the hands and feet are cold ; the legs are drawn up or kicked violently about ; and an explosion of wind from the mouth or bowels ends the attack. A peevish cry, hot skin and sour breath attend indigestion. It stands without saying that the cry of hunger must be relieved by giving food ; but this is the very worst thing to do under other circumstances, for it both breaks up good habits and pro- duces serious mischief. The pain of colic and the discomfort of indigestion are chiefly due to the accumulation of flatus result- ing from the fermentation of food. Mothers soon learn, and unfortunately infants too, that the breast milk temporarily relieves suffering. This it does in the same way as any other warm liquid ; but, unlike a simple fluid, milk only adds more material to the already fermenting contents of the gastrointesti- nal canal, and every nursing is soon followed by more pain, until between crying and sucking and sucking and crying, the infant's life is passed in misery, if not cut short altogether. 64 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Instead of continuous feeding, the plan for relief is to decrease the quantity of food by increasing the intervals between nursing and by abridging the time of lying at the breast, while medi- cines are employed to strike at the root of the evil. After the sixth week the interval between nursing may be slowly increased until, by the fourth month, it reaches three hours. During this period, also, the time of lying at the breast may be gradually lengthened, for the quantity of milk secreted and the child's appetite and capacity for food are all augmented as the days pass by. At the end of the sixth month, feeding every fourth hour suits some children well, but as a rule the three-hour interval must be adhered to from the fourth month to the end of lactation. Many authorities recommend additional artificial feeding, alternating with nursing, after the sixth or eighth month. Such a plan is perfectly proper, if the babe ceases to gain strength and flesh while on the breast. If otherwise, the maxim of not inter- fering with any course that is doing well is as applicable here as elsewhere, and the breast may be relied upon entirely until the time comes for weaning. Should additional nutriment be required, the food must be selected with due reference to age and prepared in the same manner as in regular hand-feeding. The date of weaning cannot be fixed for all cases, since it must depend upon two conditions, — the health of the mother and the development of the child. When the former continues to be robust and the child steadily grows and gains flesh, lac- tation can be prolonged until the tenth or twelfth month. If persevered in longer, the mother's strength begins to fail, her milk is lessened in quantity or becomes poor in quality, the child's nutrition suffers, and he grows pale, thin and flabby, and may develop the disease known as rickets. Change in the manner of feeding may be accomplished gradu- ally or suddenly. In gradual weaning, about four weeks are required to prepare for the absolute withdrawal of the breast. For instance, if suck be given every three hours, from 5 a. m. THE GENERAL MANAGEMENT OF CHILDREN. 65 until iip. m., or seven times a day, there should be, during the first week of preparation, one artificial feeding and six nursings daily; during the second, two and five; during the third, four and three; during the fourth, six and one. Then the breast must be entirely withheld. Carefully prepared milk-food, admin- istered from a bottle, is the best substitute. At the age of tea months a mixture that ordinarily agrees well is : — Cream, f§ss. Milk, fgiv. Sugar of milk, gj. Water, f^iss. This is to be poured into a perfectly clean bottle, warmed in a water bath, and taken through a clean, plain rubber tip. Should the quantity (six fluidounces) be insufficient to satisfy the child's appetite, all the ingredients except the cream may be increased until the mixture measures eight or even twelve fluid- ounces, according to the demand. When such accidents as fever, disordered digestion, with vomiting and diarrhoea, or the actual cutting of one or more teeth occur during the period of preparation, the number of artificial feedings must be reduced, or the breast resumed until the disturbance be passed ; then the course may be begun again and carried to its completion. Usually there is little trouble in weaning infants in this way. Sometimes they become fretful under the change and may refuse food entirely for a day or more ; but a little determination on the part of the mother and the cravings of hunger will soon overcome this difficulty. Occasionally the child refuses to suck milk from a bottle or to drink it from a cup or spoon, in fact seems to object to any form of liquid food except that drawn from the mother, while at the same time he is eager for bread or other solid food. Under these circumstances prepare for each meal a moderate portion of either rice pudding or junket. After these have been taken for a day or two, add to each meal a little milk, reducing the 6 66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. amount of pudding or junket ; stir the whole together and feed from a spoon; next day still further reduce the solid and increase the liquid, and so proceed until finally a taste for milk is cultivated. Sudden weaning is not advisable unless, while the breast is being presented, there is an absolute refusal to take artificial food from either a bottle or a spoon. This is most apt to occur when food has been given too frequently, and when the breast has been used as a means to quiet crying. Sudden weaning is also to be recommended when the mother's health becomes so affected as to render any further sucking a positive peril to the child's life; attacks of erysipelas or of smallpox are instances in point. The physician is often forced to decide upon the advisability of premature weaning. His decision must be made cautiously and after thorough investigation of two propositions, namely : a, the effect of further lactation upon the health of the mother, and by the requirements of the child. a. Lactation being a physiological process is not a drain upon the systemic strength so long as the functions of nutrition are actively performed, but under other circumstances it very fre- quently becomes so. Premature weaning is necessary when the mother is attacked by any acute disease threatening dangerous temporary prostration, such as typhoid or typhus fever. A change must also be made if pulmonary consumption be devel- oped, or, being already present, rapidly advances under the drain of milk secretion. Ordinarily, however, the general con- dition that leads to withdrawal of the breasts is one of simple loss of strength and flesh on the part of the mother. Undoubtedly these indications often warrant the procedure, but every one who has seen much of children's practice must have met with many cases in which the advice to wean has been given carelessly and unnecessarily, and in which the child might have had its natural food had proper attention been given to the health of the mother. If a woman be worn out by household cares ; if she wear her- self out by a round of dinners, balls or shopping, or if she THE GENERAL MANAGEMENT OF CHILDREN. 6 J expose herself to injurious atmospheric conditions and eats im- proper food, she grows weak and thin whether she be nursing or not ; and a woman heedless of her health will probably care little whether she suckles her child or gives it up to a wet-nurse or to the bottle. In addition to making nursing the important duty of her life for the time being, a mother must be as free from household cares as possible. Mental and physical fatigue is to be avoided, sufficient exercise must be taken to maintain a healthy appetite and digestion, and abundant time devoted to rest and sleep. Beyond securing a plentiful supply of plain and easily digestible food, with a judicious- portion of meat, vegetables, and fruit, it is unnecessary to give special attention to the diet. Should the secretion of milk be scanty, it may often be increased by the free use of animal broths, chocolate, gruel, or milk, and sometimes the moderate employment of stimulants, in the form of ale and porter, may be necessary. Such tonics as malt extract, ferrated elixir of cinchona, bitter wine of iron, and the prepa- ration known as "beef, wine and iron," are useful when there is anaemia, or when the general failure of strength cannot be over- come by food and attention to hygienic rules. The ordinary local conditions indicating the necessity of pre- mature weaning, on the mother's account, are fissures of the nipple and mammary abscess. Fissure being usually a unilateral condition, it is only necessary to retire the affected side from duty and nourish the child alter- nately from the unaffected gland and from the bottle until healing takes place, the disabled breast being pumped in the meantime to keep up secretory activity. Should both sides be affected, weaning may be imperative, on account of the extreme pain pro- duced by sucking, though, even under these circumstances, an effort must be made to maintain the flow of milk by regular pump- ing. Sometimes women are able to struggle through the attack by taking advantage of the relief and protection afforded by a nipple-shield. Fissures of the nipple may be preceded by various diseases of 68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. the delicate skin of the part. They result, also, from want of cleanliness or from keeping the nipple too moist, as when con- stant sucking is allowed or when there is a continual flow of milk. They may be prevented by proper attention to the nipple before confinement. During the latter months of pregnancy the clothing covering the breast must be loose, and the wearing of a wire tea- strainer over the nipple to prevent pressure has been recommended by one authority. Each day for three months before labor, the nipples should be washed thoroughly with hot water in the even- ing and anointed with cocoa-butter in the morning. At the same time, should the nipples be small or retracted, the woman must be taught to use her thumb and finger to draw them out. This process is not only an advantage in giving proper size and shape, but brings the skin into good condition without hardening it. The application of alcoholic and astringent lotions is not to be recommended. They tend to harden the tissue, which should be soft and pliable rather than tanned, and render the nipples liable to crack. When a fissure exists, it is best first to see whether or not nursing can be continued by means of a nipple-shield. Should the child refuse this, a good plan is to fill the shield with warm milk and invert it over the nipple. The infant then draws the fluid at once and without difficulty, and will often continue sucking until the breast milk follows. After nursing and re- moving the shield, the nipple must be dried thoroughly with absorbent cotton, and the following lotion applied with a camel's-hair brush : — R. Acid. Boracic, gr. xx. Mucilag. Acaciae, f^j- M. b. On the part of the infant, there are several indications for anticipating the time of withdrawing the mother's breast. It must be done if the occurrence of pregnancy or the recurrence of menstruation render the milk unwholesome ; if the mother contract a dangerous contagious disease, as smallpox, scarlet fever, or erysipelas ; if the mammary glands become inflamed ; if THE GENERAL MANAGEMENT OF CHILDREN. 69 the breast does not afford sufficient nourishment and artificial food be refused; and, finally, if "dentition be markedly delayed and the premonitory symptoms of rickets appear. As to the amount of nourishment, it must be remembered that the breast milk may be of good quality, but so diminished in quantity that it is insufficient; or, while abundant in quantity, so poor in quality that it does not meet the demands of nutrition. Even without a minute examination of the milk, it is possible to form a good idea of which condition is present from the behavior of the infant in the act of sucking. If the milk be good in quality but deficient in quantity, the babe, when put to the breast, seizes the nipple as if famished, and draws upon it vigorously for a time, and then drops it with a scream of rage. On the contrary, should there be an abundant supply of poor milk, the nipple is grasped languidly, the child lies a long time at the breast and falls asleep there. Consideration of the final indication opens the question of the propriety of regulating weaning by the pro- gress of dentition. This is certainly a good guide, but not in the way implied in the old precept, that the child must not be taken from the breast until evolution of the stomach and eye teeth. Insufficient food is one of the chief causes of rickets, and rickets more than any other disease delays dentition ; conse- quently, should the teeth not pierce the gum in time, the infer- ence is for other food rather than a continuance of the faulty maternal supply. Upon deciding to anticipate the time of weaning, the next point to consider is whether the infant shall be brought up by hand or by a wet-nurse. 2d. Feeding by a wet-nurse. The advantage of feeding from the breast of a wet-nurse is that the mother's milk is substituted by the milk of another woman ; in other words, that natural feeding is continued — a matter of moment in all cases, and of inestimable importance with delicate children. The disadvan- tage consists in the difficulty of finding, in a woman belonging to the class from which wet-nurses come, all the moral and physical characters essential to a good substitute, and in the fact 70 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. that a stranger is introduced into the household, often to deceive and annoy the family, and on the slightest provocation to leave her charge to fate or to the tender mercies of another of her kind. For these reasons it is preferable, in the majority of in- stances, to trust to careful bottle-feeding. Nevertheless, as some children must have human milk if their lives are to be saved, the rules for selecting a wet-nurse must be understood. The woman chosen must be strong and robust, but rather spare than fat. Her bill of health must be perfectly free from hereditary tendency to mental or physical disease and from taint of syphilis, consumption or scrofula. She must be cheerful, good-natured, active, careful, and temperate in habits. Her age should be between twenty and thirty years ; she should under- stand the care of an infant and the manner of giving suck ; her child ought to be nearly the same age as the infant to be adopted, and she must be able to afford an abundant supply of good milk. The last quality can be estimated by inspecting the breasts, by examining some of the milk drawn by a pump, and by ascer- taining the condition of the woman's own child. The breasts of a good nurse are not necessarily large, but are firm to the touch and pyriform in shape, with well-developed, prominent nipples, and with the skin distinctly marbled with large blue veins. The milk, which ought to flow readily on pressure or on suction, should be opaque and dull white in color, have a specific gravity of i. 031, an alkaline reaction, and show, when placed under the microscope, a number of minute, equal-sized, fat globules. Its quantity may be ascertained by weighing the child before and after sucking, the normal gain being from three to six ounces. There is, however, no better or more readily applied test of the quality of a nurse than the size, weight, and general development of her own child ; and if it be weak and ill-nourished, no amount of fitness in other respects can warrant her engagement. Even when a woman is found fulfilling in her single person all the required conditions — a rare thing, indeed — it does not necessarily follow that her milk will suit the babe to be suckled. THE GENERAL MANAGEMENT OF CHILDREN. . 7 1 Then changes and new trials must be made until the desired end be attained. The diet of a wet-nurse and the manner of weaning, must be governed by the rules already given for maternal guidance. Personally, I have had such good results from carefully regu- lated bottle-feeding, that I have almost given up the employment of wet-nurses, preferring to regulate the artificial food myself rather than allow an ignorant woman to supplement surreptitiously her deficient supply of breast milk by an unskilfully proportioned food, — an event of not uncommon occurrence. 3d. Artificial feeding. In my experience, there are few American women, especially in the well-to-do classes, who do not look upon the duty of nursing their babies as a pleasant one ; but there are many who are completely unable to do so, and a vast number in whom the secretion of milk fails after a few weeks or months of lactation. They must, therefore, through no fault of their own, resort to a wet-nurse or to artificial feeding. Usually, they select the latter method, with results that vary in direct pro- portion to the care and intelligence displayed in carrying it out. There is no artificial food equal to the milk of a robust woman. The fluids however, secreted from the glands of a feeble or un- healthy mother, though often sufficient in quantity to fill the suckling's stomach and satisfy the cravings of hunger, does not contain enough pabulum to meet the demands of nutrition. In such unfortunate cases, good cows' milk, properly prepared, is a better food than the bad breast milk. More care and trouble, though, are involved in bottle than in breast feeding. If the child has been nourished in the natural way — L e. 9 breast- fed — even for a few weeks, or when the powers of digestion are inherently active, the task is far easier to accomplish. In these cases the stomach and intestinal canal, inactive in fcetal life, are trained to their new duties under normal conditions, and so pre- pared for the digestion of properly selected artificial food. On the contrary, if digestion be naturally feeble, or if the infant must be bottle-fed from the first, great difficulty may be expected, and most skilful handling is necessary. 72 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. To insure success in hand-feeding, it must be remembered that an infant is not nourished alone by the food he swallows, but by that portion of it he digests and assimilates. The best diet, therefore, is one so adapted to age and digestive power that everything eaten will be digested and absorbed. But as children differ as much in constitution as in feature, it is im- possible to formulate exactly a food that will be applicable to every case, or one that needs no change from month to month of progressing growth. As age and strength increase, there is a corresponding development of the gastro-intestinal functions and a demand for more and stronger food. On the other hand, should the system be accidentally reduced by disease, the diges- tion, sympathizing in the general debility, temporarily loses its normal activity and assumes that of an earlier age. In such a case more nourishment is certainly needed to build up the failing strength, but it is to be supplied by giving such food as can be completely assimilated, and not by forcing down strong food merely because it is strong; for the latter, when not vomited, passes through the bowels undigested, and the little creature starves to death in the midst of plenty, or dies from the ill effects of the constant presence of fermenting food in the alimentary canal. On these accounts many changes in diet, as to quality and quantity, must be anticipated and made. Important matters, therefore, to be studied in detail are : a> the selection of a proper substitute for the breast milk ; b, the quantity to be given ; c, the method of preparation ; d, the mode of administration ; and, e, the means of preservation. a. Healthy breast milk must be taken as the type of infants' food, and the nearer an artificial substance can be made to ap- proach it in chemical composition and physical properties, the more perfect it is. Normal breast milk has a specific gravity of 1.031. It is a persistently alkaline fluid, having a somewhat animal, usually disagreeble, and very rarely sweetish taste. It is bluish-white in color and thin and watery in consistence. THE GENERAL MANAGEMENT OF CHILDREN. 73 According to Leeds' very thorough analysis, it contains : — Water, 86.766 per cent. Total solids, 13. 234 Total solids not fat, 9.221 Fat, 4.013 Milk sugar, 6.997 Albuminoids, 2.058 Ash, 0.21 It contains, then, nitrogenous material, carbohydrates, salts and water — all the elements essential to repair tissue waste, to supply new material for growth and to maintain body heat, or, in other words, to constitute a perfect aliment ; and these, too, are so proportioned in the combination as to most easily and completely meet the demands. It must not be supposed, however, that the elements are uni- formly present in the same proportion. On the contrary, the fluid varies both at different periods of lactation and in different individuals. This fact is the most striking feature of the above observer's work, which shows that the most changeable constituent is the albumen, varying from a maximum of 4.86 per cent, to a mini- mum of 0.85 ; the next are the fats and salts, the maximum being about three times the minimum, and the least the sugar. The latter, in fact, varies but little from a standard of about 7 per cent. The function of albumen is nutritive ; that of milk sugar calorifacient ; hence the point seems to be that nature, while allowing a wide range of oscillation in the rapidity of tissue building, carefully provides an available fuel for the constant maintenance of animal heat ; the supply of caloric due to cere- bral impulses and self-originated locomotion being extremely small in early infancy. In seeking a substitute for human milk, one naturally turns to the domestic animals for the source of supply. Between the milk of the ass, cow, goat and ewe there is little choice, so far as com- position is concerned, though, perhaps, asses' milk resembles that of women a little more closely than the others ; nevertheless, 74 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. cows' milk is usually selected, because, being plentiful, it is easily obtained and cheap. Cows' milk* (market milk) has a specific gravity of 1.029, is richer looking — that is, whiter and more opaque than human milk, and is slightly acid in reaction unless perfectly fresh from pasture-fed animals, when it may be neutral or alkaline, and contains — Water, 87.7 per cent. Total solids, 1 2.3 Total solids not fat, 8.48 Fat, 3.75 Milk sugar, 4.42 Albuminoids 3.42 Ash, 0.64 Comparing this analysis with that previously given, it is readily seen that the two fluids differ in specific gravity and reac- FlG. I. * The characters of cow's milk may be determined with sufficient accuracy in the following way : — Provide a urinometer, such as shown in Fig. I, and which can be obtained at any drug shop. To obtain the specific gravity, fill the beaker to such a point with milk that it will float the specific gravity glass, and read the degree of density from the scale at a level with the sur- face of the milk. The chemical reaction is found by inserting a piece of blue litmus paper, which should turn slightly red a few moments after being wet. In ap- plying this test small pieces of litmus paper should be examined under and in the milk, as exposure to air may redden paper dipped in milk though the fluid itself may not be acid. To ascertain the proportion of cream, cut a narrow strip of paper four inches long, and divide the upper half-inch, by cross-markings, into twelve equal parts ; paste this on the beaker with the marked portion uppermost, and the lower edge coming accurately to the bottom of the beaker; then pour in enough milk to come just to the top of the paper, and place the whole aside for twenty-four hours. During, this time the cream rises and appears as a yellow layer at the d b LACTOMETER. top; this layer should have the depth of ten or twelve spaces. THE GENERAL MANAGEMENT OF CHILDREN. 75 tion, and that cows' milk contains more nitrogenous material, but less fat and much less sugar than woman's milk. The nitrogenous material differs in quality as well as in quan- tity. Konig, in a number of analyses that closely correspond with those of Leeds, divides the nitrogenous constituent into three groups; namely, caseine, albumen and albuminoids, basing the division upon the different effects of coagulating agents. Upon this point Leeds remarks : " Whilst by present modes of analysis the separation of the so-called caseine from the so-called albumen is not accurately performed, yet the results are approxi- mately correct (Konig's), and have a very great value in point- ing out the most important of all the differences between the two secretions, which is, that the fraction of the total albu- minoids in cows' milk which is coagulable by acids is far greater (perhaps four times) than the non-coagulable part. "In woman's milk, on the contrary, the reverse is true, and the non-coagulable part much exceeds (perhaps by more than twice) the coagulable portion." This difference is readily tested by adding rennet to the two fluids. In the case of cows' milk the caseine is coagulated into large, firm masses, while with human milk a light, loose curd is formed. In the stomach the acid gastric juice has the same effect, producing in the first instance a coagulum most difficult to digest j in the other, one readily attacked and broken down by the gastro-intestinal solvents. These chemical and physical properties of cows' milk can be altered by various methods of preparation, and unless this be done there are few instances in which it will not prove a poor substi- tute for the natural food. Condensed milk is frequently recommended by physicians and largely used by the laity, on their own responsibility. It keeps better than cows' milk and is supposed to be more readily digested by young infants. The latter supposition is a mistaken one, and arises from the overlooked fact that condensed milk is always given dissolved in a large proportion of water, while cows' milk is too frequently used insufficiently diluted or otherwise im- 76 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. properly prepared. The author is convinced of the accuracy of this statement from a number of years' close study of the subject. Condensed milk contains a large proportion of sugar, forms fat quickly, and thus makes large babies; sugar also counteracts the tendency to constipation — often a troublesome complaint in hand-feeding. These advantages are unquestioned, and, together with the ease of preparation, are those which place it so high in the esteem of monthly nurses. It is equally true, however, that, as a food, it does not contain enough nutrient material to supply the wants of a growing baby. Again, more than half of the saccharine ingredient of this preparation is cane sugar, added for the purpose of preservation, and this material is very liable, when in excess, to ferment in the alimentary canal, giving rise to irritant products that impede digestion. Infants fed upon condensed milk, though fat, are pale, leth- argic and flabby ; although large, they are far from strong ; have little power to resist diseases ; often cut their teeth late, and are very liable to drift into rickets. It must be remembered also that condensed milk, when long kept, or when packed in imper- fect cans, not unfrequently undergoes decomposition, and thus becomes utterly unfit for use. For a temporary change of diet, and as a substitute during travelling or under circumstances in which sound cows' milk cannot be obtained, it may be resorted to with advantage. The farinaceous substances so often selected, especially by the poor, to replace breast-milk, are not only bad foods, but have both directly and indirectly a deleterious effect upon the pro- cesses of nutrition. They are bad for two reasons. First, they differ materially in chemical composition from human milk. For example, in arrow- root, which is the favorite, the proportion of the tissue-building to the heat-producing element is as one to twenty, while in human milk it is about one to five. Secondly, the heat-producing prin- ciple, starch, must be converted into sugar before it can be absorbed. This change is accomplished in the body by the THE GENERAL MANAGEMENT OF CHILDREN. 77 saliva and pancreatic juice, — secretions that are not fully estab- lished until the fourth month. While the starch lies undigested in the gastro-intestinal canal, it is subject to fermentation, resulting in the formation of irritant products that rapidly induce catarrh of the mucous membrane ; a condition directly interfering with the digestion and absorption of food. Again, perfect nutrition demands rapid waste and removal of effete tissues as well as repair of the same. This is effected by oxidation. Now sugars are known to have a much greater affinity for oxygen than albuminates, and when the diet consists of farinaceous material, the small amount of sugar formed and absorbed appropriates oxygen that otherwise would go toward the removal of waste, and so retards the necessary changes. Farinaceous food, as such, is never permissible before the fourth month; earlier, it is only to be employed for its me- chanical action, as an addition to milk preparations. This will be mentioned later. The nutrient value of the cereals and their products as they exist in so-called "infants' foods," has been imperfectly determined. They are undoubtedly useful as mechanical attenuants, but it is very questionable whether any of them, unless prepared with milk, can permanently meet the demands of nutrition. At the same time it is quite probable that the soluble albuminoid sub- stances obtained by Liebig's process have a food value of their own, making them more serviceable than the starches. b. The quantity of food to be allowed each day varies with the appetite and age. Some infants habitually eat little, others much ; as both thrive, the question of the correct amount in a given case must be answered by observation. So long as the child develops with normal rapidity and keeps well, he may be allowed to eat as much or as little as he wants ; for, if food of proper strength be given at proper intervals, the instinctive cravings of hunger, since they represent the wants of the system, rarely lead to excess in either direction. Nevertheless it is well to have some guide. 78 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. During the first four weeks, infants generally require from twelve and-a-half to sixteen fluidounces of food j in the second and third months, about twenty-four fluidounces, and from this time to the twelfth month from two to two and-a-half or even three pints. After the twelfth month the quantity depends upon whether addi- tions be made to the diet, or milk food be used exclusively. When the daily amount reaches three pints, the limit of the capacity of the stomach is usually attained, and the greater demand for nutriment, as growth advances month by month, must be met by adding to the strength of the food rather than by increasing its bulk. These two factors, strength and quantity, are intimately associated throughout the whole period of infancy, and in the earlier months a mere increase in the latter is not always sufficient to maintain the balance of nutrition. As a rule, infants are overfed, and this opens the very inter- esting question of the normal capacity of the stomach at different ages. Rotch has recently written an important paper upon the subject. He states that, by actual measurement, the stomach of an infant five days old holds 25 c.c, or six and-a-quarter fluidrachms, a quantity very far short of that usually forced upon the babe during the first week. Frowlowsky's investigations show that there is a very rapid increase in the capacity of the stomach during the first two months of life, while in the third, fourth and fifth months the increase is slight. Guided by these data, the quantity of food should be rapidly augmented during the first six or eight weeks of life and then held at the same quantity up to the fifth or sixth month. Another con- siderable increase is also demanded between the sixth and the tenth months. While the author has been unable to verify the above measure- ments, and has, on the contrary, found no uniformity in the size of the stomach for given ages, yet the following table (Rotch) is a useful one, and corresponds closely with conclusions drawn from clinical experience. THE GENERAL MANAGEMENT OF CHILDREN. GENERAL RULES FOR FEEDING. 79 Age. Intervals of Feeding. Average Amount at Each Feeding. Average Amount in 24 Hours. First week. 2 hours. i ounce. 10 ounces. One to six weeks. 2% hours. 1% to 2 ounces. 12 to 16 ounces. Six to twelve weeks and possibly to fifth or sixth month. 3 hours. 3 to 4 ounces. 18 to 24 ounces. At six months. 3 hours. 6 ounces. 36 ounces. At ten months. 3 hours. 8 ounces. 40 ounces. c. The object to be accomplished in the preparation of cows* milk is to make it resemble human milk as much as possible in chemical composition and physical properties. To do this, it is necessary to reduce the proportion of caseine, to increase the proportion of fat and sugar, and to overcome the tendency of the caseine to coagulate into large, firm masses upon entering the stomach. Dilution with water is all that need be done to reduce the amount of caseine to the proper level ; but as this diminishes the already insufficient fat and sugar, it is essential to add these materials to the mixture of milk and water. Fat is best added in the form of cream, and of the sugars, either pure white loaf sugar or sugar of milk may be used. The latter is greatly preferable, as it is little apt to ferment, and contains some of the salts of milk, which are of nutritive value. Firm clotting may be prevented by the addition of an alkali or a small quantity of some thickening substance. Lime water is the alkali usually selected. It acts by partially neutralizing the acid of the gastric juice, so that the caseine is coagulated gradually and in small masses, or passes, in great part, unchanged into the intestine, to be there digested by the alkaline 80 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. secretions. As it contains only half a grain of lime to the fluid- ounce, the desired result cannot be attained, unless at least a third part of the milk mixture be lime water. The quantity often used — one or two teaspoonfuls to the bottle of food — has no effect beyond neutralizing the natural acidity of the milk itself. When lime water is constantly employed, it becomes quite an item of expense if procured from the drug shop; this outlay is unnecessary, for it can be made quite as well in the nursery. Take a piece of unslaked lime as large as a walnut, drop it into two quarts of filtered water contained in an earthen vessel, stir thoroughly, allow to settle, and use only from the top, replacing the water and stirring as consumed. Instead of lime water, two to four grains of bicarbonate of sodium may be added to each bottle, or, better still, from five to fifteen drops of the saccharated solution of lime. This solution is made in the following way : — Take of — Slaked lime, t ounce. Refined sugar, in powder, 2 ounces. Distilled water, I pint. Mix the lime and sugar by trituration in a mortar. Transfer the mixture to a bottle containing the water, and having closed this with a cork, shake it occasionally for a few hours. Finally, separate the clear solution with a siphon and keep it in a stoppered bottle. Thickening substances — attenuants, such as barley-water, gela- tine, or one of the digestible prepared foods — act purely me- chanically by getting, as it were, between the particles of caseine during coagulation, preventing their running together and form- ing a large, compact mass. To prepare the former, put two teaspoonfuls of washed pearl barley, with a pint of cold filtered water, into a saucepan, boil slowly down to two-thirds and strain. The liquid obtained does not possess the disadvantages of farinaceous foods generally. To be efficient, it must be used as a diluent instead of, and in the same proportion as, water. Gelatine is prepared in the following way : put a piece of plate THE GENERAL MANAGEMENT OF CHILDREN. 8 1 gelatine, an inch square, into a half-tumblerful of cold water, and let it stand for three hours ; then turn the whole into a teacup, place this in a saucepan half full of water and boil until the gelatine is dissolved. When cold this forms a jelly; from one to two teaspoonfuls may be added to each bottle of milk food. When an " infant's food " is used to act mechanically, care should be taken to select one in which the starch has been con- verted into dextrine and grape sugar by the process of manufac- ture. The articles known as " Mellin's Food " and " Horlick's Food " can be relied upon. One teaspoonful of either dissolved in a tablespoonful of hot water and added to each portion of food, makes a very easily digested mixture. For the successful management of children, the mother or nurse must not only be familiar with the theory of feeding, but must practically understand the methods of preparing food. To this end a schedule of the diet of an infant from birth upward, with a sketch of the modifications that have to be made most fre- quently, will serve as a useful guide. Diet during the first week : — Cream, f ^ ij. Whey, . fgiij. Water (hot), f^iij- Milk sugar, gr. xx. For each portion; to be given every two hours from 5 A. m. to II p. M., and in some cases once or twice at night ; amounting to twelve fluidounces of food per diem. Diet from the second to the sixth week : — Milk, fgss. Cream, f^ij. Milk sugar, gr. xx. Water, fgj. For one portion; to be given every two hours from 5 A. m. to 11 P. M.; amounting to seventeen fluidounces of food per diem. 7 82 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Diet from the sixth week to the end of the second month : — Milk, f'2j,fgij. Cream, f^ss. Milk sugar, g ss. Water, (EhW* For each portion; to be given every two hours; amounting to thirty fluid- ounces per diem. Diet from the beginning of the third month to the sixth month : — Milk, f^iiss. Cream, ^3 SS - Milk sugar, ^j. Water fgj. For each portion; to be given every two and a half hours, or thirty-two fluidounces per diem. Diet during the sixth month ; six meals daily from 6 or 7 a. m. to 9 or 10 P. M. Morning and midday bottles each : — Milk, f 3 ivss. Cream, f^ss. Mellin's Food, 3J. Hot water, f§j. Dissolve the Mellin's F\)od in the hot water and add, with stirring, to the previously mixed milk and cream. Other bottles each : — Milk, f g ivss. Cream, *\5 SS - Milk sugar, ^j. Water, fgj. This gives an equivalent of thirty-six fluidounces of food in a day. In the seventh month the Mellin's Food may be increased to two teaspoonfuls and given three times daily. THE GENERAL MANAGEMENT OF CHILDREN. 8$ Throughout the eighth and ninth months five meals a day will be sufficient. First meal at 7 a. m. : — Milk, f^viss. Cream, f J ss. Milk sugar, ^j. Water, fgj. Second meal at 10.30 a. m. Milk, cream and water in the same proportion \ Mellin's Food, one tablespoonful. Third meal at 2 p. m. — Same as second. Fourth meal at 6 p. m. — Same as second. Fifth meal at 10 p. m. — Same as first. This gives forty fluidounces of food per diem. Instead of Mellin's Food, a teaspoonful of " flour-ball " * may be added. Two meals of flour-ball daily — the second and fourth — are all that can be digested. To prepare these, rub one teaspoonful of the powder with a tablespoonful of milk into a smooth paste, then add a second tablespoonful of milk, constantly rubbing until a cream-like mixture is obtained. Pour this into eight ounces of hot milk, stirring well, and it is then ready for use. The other meals should be composed of milk, cream, sugar of milk and water, as already given. Mellin's Food and flour-ball may be substituted by oatmeal or barley, or any one of the infants' food in which the starch has been converted, by Liebig's process, into dextrine and grape sugar. * To make flour-ball, take a pound of good wheat flour — unbolted, if possible — tie it up very tightly in a strong pudding-bag, place it in a saucepan of water and boil constantly for ten hours; when cold, remove the cloth, cut away the soft, outer covering of dough that has been formed, and reduce the hard-baked interior by grating. In the yellowish- white powder obtained, almost all the starch has been converted into dextrine by the process of cooking, and the proportion of the nitrogenous principle to the calorifacient is as one to five, nearly the same as human miik. 84 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Diet for the tenth and eleventh months : — First meal, 7 a. m. : — Milk, f g viiiss. Cream, f3 ss * Mellin's Food, g ss. (Or flour-ball or barley jelly), gij. Water (used only with Mellin's Food), fgj. Second meal, 10.30 a. m. — A breakfast-cupful of warm milk (eight fluidounces). Third msal, 2 p. m. — The yelk of an egg lightly boiled, with stale bread crumbs. Fourth meal, 6 p. m. — Same as first. Fifth meal, 10 p. m. — Same as second. On alternate days the third meal may consist of a teacupful (six fluidounces) of beef tea* containing a few stale bread crumbs. A further variation can be made by occasionally using mutton, chicken or veal broth instead of beef tea. As much more difficulty is experienced in feeding infants during the first twelve months than during the second, it would be well to pause here to consider what had best be done in case the food described should disagree. If, after feeding, vomiting occur, with the expulsion of large, firm clots of caseine, the effect of adding lime water or barley water must be tried. For instance, at the age of six weeks, make each bottle of: — Miik, f3ifWJ- Cream, f^ss. Milk sugar, 3 ss. Lime water, f Jj, f gij. * Beef tea for an infant is made in the following way : Half a pound of fresh rump-steak, free from fat, is cut into small pieces and put, with one pint of cold water, into a covered, tin saucepan. This must stand by the side of the fire for four hours, then be allowed to simmer gently (never boil) for two hours, and, finally, be thoroughly skimmed to remove all grease. THE GENERAL MANAGEMENT OF CHILDREN. 85 Or of:— Milk fgj,f3ij. Cream, f^ss. Milk sugar, g ss. Barley water, fgj, f^ij. Sometimes, particularly if there be diarrhoea, boiling makes the milk more tolerable, and in this condition it may be used instead of fresh milk in either of the above mixtures. Con- densed milk, too, can be employed temporarily, making each portion of: — Condensed milk, gj. Cream, ■ . . . f g ss. Hot water, fgiiss. Should further alteration be necessary, goats' or asses' milk maybe substituted for cows' milk, the strong odor of the former and the laxative properties of the latter being removed by boil- ing. One ass is capable of nourishing three children for the first three months of life, two children for the fourth and fifth months, and one child after this period to the ninth month. The milk should be used warm from the udder. " Strippings " is another good substitute for cows' milk. It is obtained by re-milking the cow after the ordinary daily supply has been drawn, and contains much cream and but little curd. Assimilable proportions of this are : — Strippings, fgj. Water, f Jij. And if the small amount of caseine, in such a mixture, be still undigested : — Strippings, f^iss. Barley water, fgiss. Another good food is that recommended by Dr. A. V. Meigs. It consists of a combination of two parts of the cream, contain- ing from fourteen to sixteen per cent, of fat ; one part average 86 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. milk; two parts lime water, and three parts sugar water, the latter consisting of seventeen and three-fourths drachms of milk sugar to one pint of water. This makes an alkaline mixture with the percentage of its ingredients closely corresponding to human milk. When, in spite of careful preparation, all of .these foods give rise to indigestion with fever, and the expulsion, by vomiting and diarrhoea, of hard curds from the stomach and intestines, the expedient of predigesting the milk must be resorted to. The best method is to peptonize the milk by pancreatin. That manufactured under the name of extractum pancreatis, by Fair- child Brother & Foster, of New York, has proved most efficient in my hands. To accomplish this artificial digestion, put into a clean quart bottle five grains of extractum pancreatis, fifteen grains of bicarbonate of sodium, and four fluidounces of cool, filtered water; shake thoroughly together, and add a pint of fresh, cool milk. Place the bottle in water, not so hot but that the whole hand can be held in it for a minute without discom- fort, and keep the bottle there for exactly thirty minutes. At the end of that time put the bottle on ice to check further digestion and to keep the milk from spoiling. The fluid obtained, while somewhat less white in color than milk, does not differ from it in taste ; if, however, an acid be added, the caseine, instead of being coagulated into large, firm curds, takes the form of minute, soft flakes, or readily broken-down feathery masses of small size. When the process is carried just to the point described, the case- ine is only partly converted into peptone ; but every succeeding moment of continued warmth lessens the amount of caseine until peptonization is complete. Then the liquid is grayish yellow in color ; has a distinctly bitter taste, and shows no coagulation whatever on the addition of an acid. This artificial digestion, therefore, may be carried just as far as circumstances indicate, although it is ordinarily best to stop it short of complete conver- sion, as children object to the markedly bitter taste, and often, on account of it, absolutely refuse the food. Partial peptoniza- tion, too, is usually sufficient to adapt the milk to ready assimila- THE GENERAL MANAGEMENT OF CHILDREN. 87 tion. To seize the proper moment for arresting the process, the person conducting it must be told to taste the milk from time to time, and as soon as the least bitterness is appreciable, to remove the bottle from the hot water and place it upon ice for cooling and use. Such milk may be sweetened with sugar of milk, and given pure or diluted with water. For an infant of six weeks each meal may consist of: — Peptonized milk, f g iij. Milk sugar, gss. Water, fgj. To this, cream may be added when desirable, and by dimin- ishing the quantity of water and increasing that of milk the strength of the food may be made greater at any time. Although every precaution be taken, the last of a quantity of predigested food is very apt to grow bitter ; and if the attend- ants will take the trouble, it is much better to peptonize every meal separately. This is readily done by obtaining a number of powders of pancreatin and bicarbonate of sodium, so proportioned that each packet shall contain the proper amount for one bottle of food. For example : — R . Extract. Pancreatis, , gr. ix. Sodii Bicarb., gr. xxiv. M. et ft. chart., No. xij. Sig. — Put one powder into a nursing bottle with two fluidounces of filtered water and two fluidounces of fresh sweet milk ; shake together and keep warm in a water-bath for about half an hour before feeding ; sweeten with half a teaspoon ful of milk sugar. The great advantages of partial peptonization are that the necessity for lime water, barley water and thickening substances to keep apart the curd is done away with, and that, when the digestive disturbance requiring a careful preparation of food is removed, an ordinary milk diet can be gradually resumed by regularly diminishing the time artificial digestion is allowed to progress. This changes the caseine in a less and less degree, until, finally, it is taken in its natural form. 88 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Instead of this ordinary peptonizing process, I have for several years past employed the " Peptogenic milk powder," prepared by the chemists already referred to This powder contains a digestive ferment, pancreatin ; an alkali, bicarbonate of sodium, and a due proportion of milk sugar. The mode of employment is as follows : — Take of— Milk, fgij. Water, fgij. Cream, gss. Peptogenic milk powder, I measure.* This mixture is to be heated over a brisk flame to a point that can be comfortably sipped by the preparer (about 115 F.) and kept at this heat for six minutes. When properly prepared, the resultant, so-called " humanized milk," presents the albuminoids in a minutely coagulable and digestible form ; has an alkaline reaction ; contains the proper proportion of salts, milk sugar and fat, and has the appearance of human milk. Leeds gives the following analysis of this prepared milk : — Water, 86.2 per cent. Fat, 4.5 Milk sugar, 7. " Albuminoids, 2. " Ash (salts), 0.3 " This corresponds very closely with his average analysis of human milk. In using this powder, too, one can readily return to a plain milk diet by gradually shortening the time of heating ; in other words, by slowly diminishing predigestion. Great and deserving stress has recently been placed upon a method of preparing, or rather preserving, cows' milk, known as "Sterilization." As milk exists in the healthy cow's udder it is aseptic, L e., * Measure provided with each can of powder. THE GENERAL MANAGEMENT OF CHILDREN, 8 9 free from any poisonous or dangerous ingredient, but during milking, and subsequent handling and transportation, particles of manure or various forms of dirt get into it and are apt to set up fermentation or other injurious change. To deprive these accidentally introduced organic impurities of their activity, or, in other words, to sterilize, it is necessary to subject the fluid to high heat under pressure. Several admirable implements have been devised for conduct- FlG. AUTHOR S STERILIZER. ing the process ; one of the most simple, made after a design of my own, is shown in the accompanying figure. This apparatus is made of tin, and consists of an oblong case provided with a well fitting cover, and having a movable per- forated false bottom (d), which stands a short distance above the true one and has attached a framework capable of holding ten, six-ounce, nursing bottles. On the outside of the case is a row of supports (b) for holding inverted bottles while drying, and at the proper distance below these a gradually inclining 8 90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. gutter (c) for carrying off the drip. A movable water bottle (a) is hung to the side ; in this each bottle of food may be heated at the time of administration. The bottles are made of flint glass and according to the design described on page 96, the graduated markings being especially convenient for measurement and rendering the use of a separate measuring glass unnecessary, a matter of no little moment, as every implement that comes in contact with the milk in sterili- zation must be kept chemically clean. Ten bottles are used, so that the whole supply of milk intended for a day's consumption can be prepared at once. Each bottle is provided with a per- forated rubber cork, which in turn is closed by a well-fitting glass stopper. Sterilization should be performed in the morning as soon as possible after the milk has been served The process is as follows : First, see that the ten bottles are perfectly clean and dry; pour into each six fluidounces (12 tablespoon fuls) of milk; insert the perforated rubber corks, without the glass stoppers, however; remove the false bottom and place the bottles in the frame ; pour into the case enough water to fill it to the height of about two inches ; replace the false bottom carrying the bottles; adjust lid, and put the whole on the kitchen range. Allow the water to boil and, by occasionally removing the lid, ascertain that the expansion that immediately precedes boiling has taken place in the milk, then press the glass stoppers into the perforated corks, and thus hermetically close each bottle. After this, keep the apparatus on the fire and the water boiling for twenty minutes. Finally, remove the false bottom with the bottles ; pour out the water, replace and carry the whole, covered with the lid, to the nursery. When the hour of feeding arrives, put one of the bottles into the attached water bath and heat it to the proper point for administration. The milk may, of course, be diluted with fil- tered water, or receive the additions ordinarily made to adapt it to children of different ages. The tip used — and a tube must not be employed even here — should be thoroughly cleaned and THE GENERAL MANAGEMENT OF CHILDREN. 9 1 immersed for a few moments in boiling water before it is attached to the bottle. So soon as a bottle is emptied — and if the whole of its con- tents be not taken the remainder must be thrown away — it is washed in the ordinary manner with a solution of bicarbonate or salicylate of sodium (see p. 96) and placed in the rack (b) to drain and dry. Milk sterilized by the above process will remain sound for several days, according to some authorities as many as eighteen * when the heating is continued for thirty minutes. Sterilized milk is especially useful in travelling, when fresh milk cannot be obtained ; for use in cities during the heat of summer, when milk is most apt to undergo injurious changes ; for the feeding of delicate children, or for those suffering from disease of the stomach or intestinal canal. A very good process has been inaugurated by some dairymen, in which the milk is sterilized on the farm directly after coming from the cow, and transported to the consumer in the original bottles. This procedure cannot be too highly recommended, provided the care is taken to preserve perfect cleanliness on the part of the original handlers, and to see that the process of sterilization is thoroughly carried out. Sometimes milk, in every form and however carefully pre- pared, ferments soon after being swallowed and excites vomiting, or causes great flatulence and discomfort, while it affords little nourishment. With these cases the best plan is to withhold milk entirely for a time and try some other form of food. The fol- lowing are good substitutes: — Mellin's Food, gj. Hot water, f g iij. For each portion; to be given every two hours at the age of six weeks. * Since writing the above, this statement has been verified by my own experiments. 92 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Veal broth (^ lb of meat to the pint), fgiss. Barley water, fgiss. For one portion. Whey, fgiss. Barley water, fgiss. Milk sugar, 3 ss. A teaspoonful of the juice of raw beef every two hours will usually be retained when everything else is rejected. Such foods are only to be used temporarily until the tendency to fermentation within the alimentary canal ceases ; then milk may be gradually and cautiously resumed. When infants approaching the end of the first year become affected with indigestion, it is often sufficient to reduce the strength and quantity of the food to a point compatible with digestive powers. For instance, at eight months the food may be reduced to that proper for a healthy child of six months, or even less. Here, too, predigestion of the food is very serviceable. If a few grains of extractum pancreatis be added to a gobletful of thick, well-boiled starch gruel, at a temperature of ioo° F., the gelatinous mucilage quickly grows thinner and soon is trans- formed into a 'fluid, the starch having been rendered soluble by the action of the pancreatin ; by still longer contact, the hy- drated starch is converted into dextrine and sugar. Advantage may be taken of this property to render the foods containing starch assimilable. Thus, to a mixture of barley jelly and milk, e. g. Barley jelly, ^ij. Milk sugar, ^j. Warm milk, f^y'n}. Add three grains of extractum pancreatis, and five grains of bicarbonate of sodium, and keep warm for half an hour before administering. The same process may be employed with food containing oat- meal, arrowroot or wheaten flour, with a view of converting the starchy ingredients into digestible elements without materially altering the taste. THE GENERAL MANAGEMENT OF CHILDREN. 93 When the infant has arrived at an age to take meat broths, these too, when digestion is enfeebled, may be readily peptonized. Returning to the regimen of the healthy infant, it will be found that after the first year far less change is required in the food from month to month. Diet from the twelfth to the eighteenth month, five meals per day : — First meal, 7 a.m. — A slice of stale bread, broken and soaked in a breakfast-cup (eight fluidounces) of new milk. Second meal, 10 a.m. — A teacup of milk (six fluidounces) with a soda biscuit or thin slice of buttered bread. Third meal, 2 p.m. — A teacup of beef tea (six fluidounces) with a slice of bread. One good tablespoonful of rice-and-milk pudding. Fourth meal, 6 p.m. — Same as first. Fifth meal, 10 p.m. — One tablespoonful of Mellin's Food with a breakfast-cupful of milk. To alternate with this : — First meal, 7 a.m. — The yelk of an egg lightly boiled, with bread crumbs ; a teacupful of new milk. Second meal, 10 a.m. — A teacupful of milk with a thin slice of buttered bread. Third meal, 2 p.m. — A mashed, baked potato, moistened with four tablespoonfuls of beef tea; two good tablespoonfuls of junket. Fourth meal, 6 p.m. — A breakfast-cupful of new milk with a slice of bread broken up and soaked in it. Fifth meal, 10 p.m. — Same as second. The fifth meal is often unnecessary, and sleep should never be disturbed for it ; at the same time, should the child awake an hour or more before the first meal, he must break his fast upon a cup of warm milk, and not be allowed to go hungry until the set breakfast hour. Diet from eighteen months to the end of two and one-half years, four meals a day : — First meal, 7 a.m. — A breakfast-cupful of new milk ; the yelk of an egg lightly boiled ; two thin slices of bread and butter. 94 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Second meal, n a.m. — A teacupful of milk with a soda biscuit. Third meal, 2 p.m. — A breakfast-cupful of beef tea, mutton or chicken broth ; a thin slice of stale bread ; a saucer of rice-and- milk pudding. Fourth meal, 6.30 p.m. — A breakfast-cupful of milk with bread and butter. On alternate days : — First meal, 7 a.m. — Two tablespoon fuls of thoroughly cooked oatmeal or wheaten grits with sugar and cream ; a teacupful of new milk. Second meal, 11 a.m. — A teacupful of milk with a slice of bread and butter. Third meal, 2 p.m. — One tablespoonful of underdone mutton pounded to a paste ; bread and butter, or mashed baked po- tato, moistened with good plain dish gravy ; a saucer of junket. Fourth meal, 6.30 p.m. — A breakfast-cupful of milk, a slice of soft milk toast, or a slice or two of bread and butter. When sickness supervenes, all that is ordinarily necessary is a reduction of the diet to plain milk, or milk with Mellin's Food. An important point, often neglected, is the matter of drink. Even the youngest infant requires water several times daily, and the demand increases with age. The water must be as pure as possible and should not be too cold. In the heat of summer, however, bits of ice and water moderately cooled by ice can be allowed without harm. The foregoing schedule must, of course, be regarded only as an average. Many children can bear nothing but milk food up to the age of two or even three years, and, provided enough be taken, no fear for their nutrition need be entertained. If a child be thriving on milk, he is never to be forced to take additional food merely because a certain age has been reached ; let the healthy appetite be the guide. A young mother, in her solicitude to do her best, often finds great difficulty in adhering to simple rules in the diet of her child. Mrs. A., who has had great experience with children, having had some herself, tells her that the child would thrive far THE GENERAL MANAGEMENT OF CHILDREN. 95 better if it ate such and such a thing, and did not keep to weak milk foods. Miss B. assures her that her cousin's last child grew much healthier after eating a chop with vegetables and pudding each day. Aunt C. comes with the announcement — which she breaks gently — that she knows the child is simply starving, and the ignorant nurse confirms the statement. Fig. GRADUATED NURSING BOTTLE. All their seemingly convincing theories are very upsetting to a mother who wants only to do what is right. She must bear in mind, however, that some children can eat anything and live ; but she does not know how much better, more robust, and disease-resisting they would be, did they adhere to a simple diet. Let her remember that the so-called " weak milk foods' ' contain those nourishing qualities to which nature, in her wisdom, has o6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. limited the child's powers of digestion. Therefore, young mothers, let well enough alone. d. Success in hand-feeding depends quite as much on the administration as upon the preparation of the food. From birth up to such time as broth, bread, and eggs are added to the diet, all the food should be taken from a bottle. Even after this, as the bottle is a comfort and insures slow feed- ing, it may be allowed for milk preparations, until the child, of his own accord, tires of it. The only feeding apparatus to be admitted to the nursery is the simple bottle and tip. The bottle represented in Figure 3 is made, by my suggestion, by Mr. J. J. Ottinger, of Philadelphia. Its interior surface presents no angles for the collection of milk ; it is easily cleaned, and the graduated scale is convenient for nursery use. All complicated arrangements of rubber and glass tubing are not only an abomination, but a fruitful source of sickness and death. Rather than use them, it is far better to feed the infant with a spoon. In England, a bottle with a long rubber tube is almost universally employed. Should this be abandoned and a simple bottle and a rubber tip used, the objections of some authors to bottle-feeding would vanish. The bottle shaped as above must be of transparent flint glass, so that the slightest foulness can be detected at a glance, and may vary in capacity from six to twelve fluidounces, according to the age of the child. Two should be on hand at a time, to be used alternately. Immediately after a meal the bottle must be thoroughly washed out with scalding water, filled with a solution of bicarbonate or salicylate of sodium — one Fig. 4. m J teaspoonful of either to a pint of water — and thus allowed to stand until next required ; then the soda solution being emptied, it must be thoroughly rinsed with cold water before receiving the food. The tips or nipples, of which there should also be two, must be composed of soft, flexible India-rubber, and a conical shape is to be preferred, as being more readily everted and cleaned; the opening at the point must be BOTTLE TIP. THE GENERAL MANAGEMENT OF CHILDREN. 97 free, but not large enough to permit the milk to flow in a stream without suction. At the end of each feeding the nipple must be removed at once from the bottle, cleansed externally by rub- bing with a stiff brush wet with cold water, everted and treated in the same way, and then placed in cold water and allowed to stand in a cool place until again wanted. While taking these precautions for perfect cleanliness, the nurse must satisfy herself of their efficacy by smelling both the bottle and the tip just before they are used, to be sure of the absence of any sour odor. Next to cleanliness of the feeding apparatus, it is important to insist upon the separate preparation of each meal immediately before it is to be given. The practice of making, in the morning, the whole day's supply of food, though it saves trouble, is a most dangerous one. Changes almost invariably take place in the mixture, and by the close of the day it becomes unfit for con- sumption. When the graduated bottle is not at hand, a common glass graduate, marked for fluidrachms and ounces and holding a pint, should be provided for the nursery. Some moments before meal- time, so as to avoid hurry, measure the different fluid ingredients of the food in this, one after the other ; add the requisite quantity of milk sugar, and mix the whole thoroughly by stirring with a spoon, and pour into the feeding bottle. When the graduated bottle is employed, thorough shaking is sufficient. The food must now be heated to a temperature of about 95° F. This can be done by steeping the bottle in hot water, or by placing it in a water-bath over an alcohol lamp or gas jet. Finally, apply the tip and the meal is ready. When feeding, the child must occupy a half-reclining position in the nurse's lap. The bottle should be held by the nurse, at first horizontally, but gradually more and more tilted up as it is emptied, the object being to keep the neck always full and pre- vent the drawing in and swallowing of air. Ample time, say five, ten or fifteen minutes, according to the quantity of food, should be allowed for the meal. It is best to withdraw the bottle occa- 98 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. sionally for a brief rest, and after the meal is over, sucking from the empty bottle must not be allowed, even for a moment. e. For children residing in cities, an honest dairyman must be found, who will serve sound milk and cream from country cows once every day in winter, and twice during the day in the heat of summer. The milk of ordinary stock cows is more suitable than that from Alderney or Durham breed, as the latter is too rich and, therefore, more difficult to digest. The mixed milk of a good herd is to be preferred to that from a single animal. It is less likely to be affected by peculiarities of feeding, and less liable to variation from alterations in health or different stages of lactation. The care of the herd and of the milk is of great consequence. The cows should be healthy, and the milk of any animal that seems indisposed should not be mixed with that from perfectly healthy animals. The cows must not be fed upon swill or the refuse of breweries, glucose factories, or any other fermented food. They must not be allowed to drink stagnant water, and must not be heated or worried before being milked. The pasture must be free from noxious weeds, and the barn and yard must be kept clean. The udder should be washed, if dirty, before the milking. The milk must be at once thoroughly cooled. This is best accom- plished by placing the can in a tank of cold spring water, or in ice water, the water being the same depth as the milk in the can. It is well to keep the water in the tank flowing ; indeed, this is necessary unless ice water be used. The can should remain un- covered during the cooling and the milk should be gently stirred. The temperature should be reduced to 6o° F. within an hour, and the can must remain in the cold water until the time for deliver- ing. In summer, when ready for delivery, the top should be placed in position and a cloth wet in cold water spread over the can, or refrigerator cans may be used. At no season should the milk be frozen, and at the same time no buyer should receive milk having a temperature over 65 ° F. The milk and cream must be transported from the dairy in THE GENERAL MANAGEMENT OF CHILDREN. 99 perfectly clean vessels. To insure this it is best to provide two sets of small cans ; one set to be thoroughly cleansed and aired while the other is taken away by the milkman to bring back the next supply. So soon as this arrives in the morning, or in the morning and evening in hot weather, the milk should be emptied into separate and absolutely clean earthenware or glass pitchers, and these put at once into a refrigerator reserved exclusively for them. This may stand in some convenient spot near the nursery, but not in it, and especially not in an adjoining bath room. With a good refrigerator there is no difficulty in keeping milk perfectly sweet for twenty-four hours in winter and for twelve hours in summer, except on intensely hot days ; then it may be necessary to scald, lightly boil or sterilize the whole of the supply when received, in order to prevent change. It is a well-known fact that milk is a fluid having active powers of absorption, and that it frequently acts as the medium of trans- mission of the contagion of such diseases as scarlatina, diphtheria and typhoid fever. Doctor V. C. Vaughan has also lately dis- covered in milk a special poison which he terms lyrotoxicon (cheese poison). The clinical elements of interest in these discoveries is the close analogy between the symptoms produced by the experi- mental use of tyrotoxicon and those observed in cholera infantum — an analogy suggestive of the possibility of the latter disease being chiefly due to poisoned milk. This causal relation is scarcely more than a theory, though certain well-known features of the disease seem to bear it out. Thus, the affection occurs at a season when decomposition of milk takes place most rapidly ; it occurs at places where absolutely fresh milk cannot be obtained ; it prevails among classes of people whose surroundings are most favorable to fermentative changes; it is most fatal at an age when there is the greatest dependence upon milk as a food, when the gastro-intestinal mucous membrane is most susceptible ffj. M. S. — To be penciled over the affected surface two or three times daily. A great point in the treatment is to continue the local applications, not only until the eruption has disappeared, but until the skin has become perfectly smooth, soft and altogether normal. Again, to begin the applications early, as the ease and quickness of cure is in proportion to the acuteness and scantiness of the eruption. Crusta lactea may be cured with more or less rapidity by cropping of the hair, softening the crusts with olive oil, apply- ing a poultice of flaxseed over night, and using an ointment containing mercury, as — R. Ung. Hydrargyri Nitratis, 3J-ij- Ung. Aquae Rosse, q. s. ad gj. M. S. — Rub into scalp three times daily. H. Hydrargyri Chloridi Mitis, gr. xxx. Cosmoline, ^j. M. In some instances penciling with the solution of corrosive sub- limate, already mentioned, gives better results. When there is intense redness of the scalp, it is often best to begin with oxide of zinc ointment, reserving the mercurial pre- parations until the inflammation is lessened. When the disease becomes chronic, with thickening of the skin, loss of hair, and the assumption of the squamous form, more stimulating applica- tions are indicated, for instance — R . Ung, Picis Liquidse, Adipis, aa ^iv. M. S. — Apply thrice daily. AFFECTIONS OF THE MOUTH AND THROAT. l6l R. Saponis Mollis, giv, Alcohol dil., f ^ ij. Spt. Lavandulae, tt\,xv. M. et cola. S. — Rub into the skin by means of a piece of flannel or a brush, to remove scales, etc. Inunctions of cosmoline and vaseline are often most beneficial in eczema, and the latter is a good vehicle for the preparations of mercury, zinc, lead, etc. The most dangerous of all the complications attending diffi- cult dentition are the disturbances of the nervous system. These are due to a great increase in the normally excessive susceptibility of the infantile nervous system to reflex influences. They em- brace slight spasms of isolated groups of muscles and general convulsions. Slight spasms are very common, and are observable chiefly during sleep. They are revealed by upturned eyeballs, and half- open eyelids, exposing more or less of the whites of the eyes ; by contraction of the muscles of the face, causing a smile, and by twitching movements of the fingers and limbs. These mani- festations can be prevented and sound sleep secured, by a warm foot-bath at bedtime, with five or ten grains of bromide of potassium. A general convulsion arises suddenly and unexpectedly, and generally begins with tonic spasm of the muscles. The head is thrown back, the spine arched forward, the limbs become rigid, and breathing is suspended. Soon clonic movements set in ; the face, which is flushed, becomes distorted ; foam, sometimes bloody, appears upon the lips ; the limbs are jerked about ; the trunk writhes ; the respiration is unrhythmical and sighing, and consciousness is completely lost. After a time, as the convulsion ends, the face becomes pale, the lips bluish, and the skin moist. There may be but a single convulsion, lasting a few moments, or there may be a number, varying in duration, and following each other at longer or shorter intervals. In some cases, the 14 162 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. child remains in a convulsed condition for several days, passing from one fit into another, with only brief intervals of imperfect calm. Often they pass off without leaving any traces, but may be followed by paralysis, strabismus or idiocy, and may terminate in death. The treatment consists in removing pressure from the gums by the use of the lancet, and the employment of nerve sedatives, as chloral and bromide of potassium. Should it be impossible for the patient to swallow, these drugs may be administered by the rectum, in the following enema : — I£ . Chloral Hydrate, gr.xij. Potassii Bromidi, ^ss. Mucilag. Acaciae, fgj. Aquae, q. s. ad fjjiij. M. S. — One tablespoonful for a dose. The injections are to be repeated every half hour — at the age of one year — until the convulsive movements are checked, or three or four doses are given. If this quantity fail, it is better to omit the chloral for two hours, and then resume it as before ; in the meanwhile continuing the bromide of potassium. So-called dental paralysis is uncommon, and when it does occur can usually be traced to coincident anterior polio-myeli- tis. It is sudden in its onset. After a restless night the child wakes with one arm helpless, or with one arm and one leg power- less ; more infrequently one arm and both legs, or both arms are affected. The means for relief are salt-water baths with fric- tions, attention to the general health, and the use of tonics. Elevations in temperature, with other evidences of slight febrile reaction, are very common during teething. The pyrexia is of short duration, moderate in degree, and readily controlled by hot foot-baths, and diaphoretics, as tincture of aconite root in small doses, or citrate of potassium. In both classes of affections arising from difficult dentition, the question of the propriety of lancing the gums often arises. AFFECTIONS OF THE MOUTH AND THROAT. 163 Many authorities advise postponement of incision until the gum becomes swollen, tense and shining, and the edge of the tooth is perceptible to the touch, just beneath the mucous membrane, or until yellowness of the gum and fluctuation indicate the forma- tion of pus about the approaching tooth. This rule applies merely to cases in which there is little difficulty. For in many instances the greatest discomfort and danger are present while the tooth is yet some distance from the edge of the gum, forcing its way through the deeper and denser tissues. Here the only safe course is to cut deep, and liberate the tooth, repeating the opera- Fig. 7.* Diagram of Lines of Incision in Lancing the Gums. The above diagram plainly shows the lines of incision over the different teeth before erup- tion and after partial eruption. tion if the original incisions heal — -an event of little moment. My own practice in regard to lancing is guided entirely by cir- cumstances. If there be fever, nervous irritability, sleeplessness, vomiting or diarrhoea during the progress of and dependent upon dentition, I invariably lance the gum, — provided the position of the tooth can be established by the touch — making the incision superficial or deep, according to the distance of the tooth from the surface. I feel confident that no one who has once * From " Diseases Incident to First Dentition." James W. White, M. D., D. D. S. 164 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. attempted early lancing, and observed distressing and dangerous symptoms rapidly disappear, will ever hesitate a second time. The form of incision is important. It must be linear in the case of the incisors and canines, and obliquely crucial in that of the molar teeth; the tissues must be divided until the edge of the lancet distinctly touches the tooth. ERUPTION OF THE PERMANENT TEETH. The eruption of the milk teeth, though physiological, as already stated, is so uniformly regarded as dangerous, that both physicians and parents congratulate themselves when infants under their charge pass through this process without trouble, or safely weather the various diseases that may arise during its course. The interval between the fourth and thirtieth months of an in- fant's life — the period of primary dentition — is an era of great and widely extended physical progress. The teeth are advancing ; the follicular apparatus of the stomach and intestinal canal is un- dergoing development in preparation for the digestion and absorp- tion of mixed food ; the cerebro-spinal system is rapidly growing and functionally very active, and the organs and tissues of the whole body are in a state of active change. This period of nor- mal transition must also be one in which there is great suscepti- bility to abnormal change, or disease, provided there be a causal influence at work. Such an influence may either originate out- side of the body, as when there is exposure to cold, or to conta- gion, or come from within in the form of some perversion of a physiological process. Difficult dentition stands prominent in the latter class. While the teeth are advancing, irritation of the gums very often pro- duces stomatitis with fever, and the fever in turn leads to en- feebled digestion and impaired nutrition, conditions that open the way to catarrh of the mucous membrane of the bronchial tubes and gastro-intestinal tract, and to other intercurrent affec- tions. Again the local irritation may be reflected through the widely extended connection of the dental nerves, and give rise to AFFECTIONS OF THE MOUTH AND THROAT. 1 65 well-known disorders of distant organs, and tissues, for example, the brain, eyes, stomach, skin, and so on. To appreciate this widely-extended nervous connection, it is only necessary to study Plate i. This, which, by the way, is purely diagrammatic in character, illustrates the intimate anatomi- cal relations existing between the trifacial, pneumogastric, and glosso-pharyngeal nerves, through the medium of the superior cervical ganglion of the sympathetic and its branches. This gan- glion sends a branch directly to the jugular ganglion of the pneumogastric ; another branch subdividing, sends one filament to join the ganglion of the root of the pneumogastric, while the other goes to the petrous ganglion of the glosso-pharyngeal, and, finally, branches pass between it and the ganglion of the trunk of the par vagum. Two ascending branches from the cervical gan- glion pass to the internal carotid to form the carotid and cavern- ous plexuses ; from these plexuses a filament passes to the under side of the ophthalmic branch of the fifth nerve, a second connects with the ophthalmic ganglion, while other communications with the ophthalmic nerve are formed by a branch passing between the ganglion and nasal branch of the ophthalmic, and the branch of the ophthalmic to the inferior oblique muscle. From the internal carotid plexus a filament reaches the spheno-palatine ganglion con- nected with the superior maxillary through the Vidian nerve. Fila- ments pass to the external carotid, forming a plexus from which those of the middle meningeal and facial arteries are derived. From the middle meningeal plexus a filament passes to the optic ganglion, which is connected with the inferior maxillary nerve, while from the facial plexus a branch reaches the submaxillary ganglion, which, in turn, is connected by several filaments with the gustatory branch of the trifacial nerve. Other communications exist between the Casserian ganglion and the cavernous plexus, the otic ganglion and the glosso-pharyngeal nerve, etc., etc. Next let us trace the routes of transferred irritation. 1. Stomach. — Nerve supply of stomach from terminal branches of the right and left pneumogastric and from the sym- pathetic. 1 66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Irritation from the upper teeth travels, by means of the dental branches of the superior maxillary to the trunk of the superior maxillary division of the fifth pair, by the spheno-palatine branches of this nerve to Meckel's ganglion, and from this ganglion to the carotid plexus of the sympathetic. The carotid plexus being in connection with the superior cervical ganglion of the sympa- thetic, the irritation is transferred to the sympathetic branches which go to the stomach ; and as it sends filaments to the jugular ganglion of the pneumogastric, the irritation reaches the gastric terminations of the vagus (or to Casserian ganglion, to carotid plexus, to superior cervical ganglion). Irritation from the lower teeth passes by the superior dental branches of the inferior maxillary to the trunk of the nerve. This nerve, by its auriculo-temporal branch, is joined to the otic ganglion, and the irritation, after leaving this ganglion, reaches the meningeal plexus, is transferred to the superior cervical ganglion, and then reaches the stomach by the route above in- dicated. Or, by trunk of nerve to Casserian ganglion, from this to carotid plexus and from this to superior cervical ganglion. 2. Intestines. — Same route as above to superior cervical ganglion, and from this by means of sympathetic to the intestines. 3. Glands of Neck. — An irritation from the teeth which reaches the superior cervical ganglion, passes by the outer branches of this ganglion to the four upper cervical spinal nerves. Also passes to middle cervical ganglion and by its outer branches to the fifth and sixth spinal nerves. Also passes to inferior cervical ganglion to seventh and eighth cervical nerves. These nerves are the chief source of supply for the cervical lymphatics. 4. Salivary Glands. — To Parotid. — An irritation from upper teeth is transferred to Meckel's ganglion by spheno-pala- tine branches and from this to carotid plexus, which plexus sends filaments direct to parotid gland. An irritation from the lower teeth reaches the gland by means of the inferior dental branches of the inferior maxillary trunk of AFFECTIONS OF THE MOUTH AND THROAT. 1 67 the inferior maxillary, auriculotemporal branch and parotid branches. Or, as before shown, by the superior cervical ganglion and the carotid plexus, which sends filaments to the gland. To Submaxillary. — An irritation from the upper teeth passes by dental branches and trunk of superior maxillary to Casserian ganglion, from this to carotid plexus, from this to plexus on facial artery, and then to gland. Or, from Casserian ganglion to gustatory branch of inferior maxillary, and by branches of this nerve to the gland. Irritation from lower teeth by inferior dental branches and trunk of inferior maxillary to Casserian ganglion, and from this by gustatory and branches to submaxillary ganglion and gland. Also, by mylohyoid branches of the inferior dental to gland. To Sublingual. — From upper teeth by dental branches and superior maxillary to Casserian ganglion, and from this by gus- tatory and branches to gland. From lower teeth by dental branches and inferior maxillary to Casserian ganglion and from this by gustatory and branches to gland. 5. Lungs. — Nerve supply from anterior and posterior pul- monary plexuses formed by branches from sympathetic and pneumogastric reaches the superior cervical ganglion as indi- cated in No. 1, and is, as there shown, transferred to pneumo- gastric and sympathetic. 6. Eyes. — Irritation reaches carotid plexus from upper teeth as shown in No. i. Filaments from carotid and cavernous plexuses to nerves of the eye. A filament to the under side of the ophthalmic division of the fifth pair. Another joins the oph- thalmic ganglion, and branches pass between this ganglion, the nasal branch of the ophthalmic, and the branch of the ophthalmic which goes to the superior oblique muscle. From the carotid plexus come filaments to the abducens nerve. Irritation from lower teeth to superior cervical ganglion, as shown in No. i. From here to carotid and cavernous plexuses, and to eye as above. 1 68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 7. Ears. — Irritation from upper teeth to Meckel's ganglion as in No. 1. Meckel's ganglion by Vidian supplies part of mucous membrane of Eustachian tube, branches of it join the facial and the facial sends branches to the laxator tympani and stapedius. Or, to superior cervical ganglion, as in No. 1. To the glosso- pharyngeal, to its petrous ganglion, and to Jacobson's nerve, which supplies the fenestra rotunda, fenestra ovale, and lining membrane of Eustachian tube and tympanum. Or, from superior cervial ganglion to ganglion of pneumo- gastric, and by Arnold's nerve to external auditory meatus and membrana tympani. Or, to superior cervial ganglion, to carotid plexus, and from this to tympanum. From lower teeth by dental branches, as in No. 1, and in- ferior maxillary to otic ganglion, and from this a branch goes to tympanum. Or, to otic ganglion, from this to meningeal plexus, from this to superior cervical ganglion, and from this to carotid plexus and tympanum. Or, to Casserian ganglion, from this to carotid plexus, and from this to tympanum. 8. Larynx. — Nerve Supply. — Superior laryngeal branch of pneumogastric and recurrent laryngeal branch of pneumo- gastric and sympathetic reaches pneumogastric and sympathetic as in No. 1. With these conditions fully recognized it is surprising that second dentition has not been accorded the position it deserves, as a cause of ill-health in later childhood. In second dentition the elements of local irritation with fever are quite as potent as before. There is, however, less activity of development or rapidity of change, if we except the radical alteration in the system occasioned by the approach of puberty. Therefore there must be less susceptibility to disease, and this fact, taken with the greater resisting power of advancing age, fully accounts for what every observer will find to be true, namely, that the disorders of this period are less frequent and, as a rule, less dangerous than AFFECTIONS OF THE MOUTH AND THROAT. 1 69 those that attend the cutting of the milk teeth. Nevertheless the etiological relations of the eruption of the permanent teeth will fully repay a careful study. The subject will be considered here in its relation to the time between the fifth year and the establishment of puberty, when childhood is over, and youth or maidenhood begins. The permanent teeth are cut in the following order : — (1) Four first molars, five to six years. (2) Four central incisors, six to eight years. (3) Four lateral incisors, seven to nine years. (4) Four first bicuspids, nine to ten years. (5'^ Four second bicuspids, ten to twelve years. (6) Four canines, eleven to thirteen years. (7) Four second molars, twelve to fourteen years. (8) Four posterior molars (or " wisdom teeth/ ' not entering into this study), seventeen to twenty-one years. Of the twenty-eight teeth cut within the period already men- tioned — the fifth to the fifteenth years — the first and seventh sets are developed de novo, and are more likely to give rise to trouble, particularly of the oral mucous membrane. The other sets take the place of corresponding milk teeth, and appear in very much the same order, the lower central incisors appearing before the upper, the upper lateral incisors before the lower, the upper bicuspids before the lower, etc. Fig. 8 will aid in explaining the process. As these teeth approach the surface, absorption begins in the alveoli and at the roots of the deciduous teeth, and this continues until the teeth are loosened and readily extracted, or if this be not done, until little is left but their crowns. When the first and second molars approach the surface, the gums, just as in primary dentition, become red, swollen, rounded and tender. The salivary secretion is increased, the mouth is hot, the patient complains of aching in the gum, and, on account of tenderness, refuses food requiring mastication. With the other sets there is a gradual loosening of the superimposed temporary teeth, pain on mastication, redness and tumefaction of the gum, 170 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. and augmented flow of saliva. As there is no impairment of the general health, these trifling symptoms must be regarded merely as manifestations of the progress of a physiological process. Such are the normal manifestations. The most common disorders of second dentition, are (a) those of the mouth and throat ; (//) of general nutrition ; (7) of the stomach and intestinal canal ; ( 3 3 * LiUL CP&&a(u ^ 4- 2 2 4? 6 Diagram showing Relation between the Permanent and Temporary Teeth. The figures i, 2, 3, etc., indicate the groups of teeth and the order of their appearance. in character and may either be limited to the position of the advancing tooth or extend throughout the upper and lower jaws — the region supplied by the dental branches of the trifacial nerve. Sometimes the pain is referred to the eye, the ear, the face, or even to the forehead. Pain associated with tenderness most frequently attends the eruption of the first molars ; then there is also redness and marked swelling of the gum, as in pri- mary dentition. The redness and swelling about an advancing tooth or around AFFECTIONS OF THE MOUTH AND THROAT. 171 a loosened milk tooth may, in debilitated or strumous subjects, extend to the mucous membrane of the whole mouth and give rise to catarrhal stomatitis. Again, as one of the first or second molars advances, the mucous membrane of the gum directly over the tooth breaks down and a circular ulcer is formed. This ulcer possesses all the characteristics of the marginal ulcer of ulcerative stomatitis, and is very liable, provided such favoring conditions as scrofula, overcrowding and bad hygiene exist — to run around the alveolar border, and extend to the inside of the cheek. A case has recently been under my care, in which all of the six- year molars were cut in this way, the resulting ulcerative stoma- titis producing considerable discomfort, but yielding readily to treatment. Superficial ulcers upon the edges and tip of the tongue are often encountered. These ulcers correspond in position and number to loosened and perhaps decaying deciduous teeth ; are due to constant irritation of the mucous membrane ; are the seat of moderate pain, and more or less interfere with the movements of the organ in mastication and speech. They vary in shape and size but are generally oval, with the greater diameter — rarely more than half an inch — extending in the direction of the axis of the tongue. Their bases are smooth, red and shining, and their edges red, indented, somewhat indurated and surrounded by a narrow band of white fur formed upon the neighboring healthy epithelium. A boy, ten years old, was recently brought to consult me about the condition of his tongue. Nearly two months before the an- terior deciduous molars had commenced to loosen. Soon after two ulcers appeared upon the tongue at points corresponding to the loose teeth in the lower jaw. These caused considerable dis- comfort and interfered with the movements of his tongue. Six weeks later the four loose teeth were extracted. At the time of his visit the points of the permanent teeth were distinctly visible. The ulcers, which presented the characteristics already described, were present, too, but they were much contracted and evidently in process of healing. This case is a clear illustration 172 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. of the etiology of the condition, and of the rapid effect of the removal of the cause. Loss, or perversion of taste, depending upon reflected irritation of the gustatory and glosso-pharyngeal nerves, has occasionally arisen in my experience. It is a feature that may be readily overlooked in childhood, and without doubt has never received due credit as a cause of the anorexia so often observed during second dentition. Of throat affections, simple hypertrophy of the tonsils and fol- licular tonsillitis seem particularly apt to arise in late childhood. The extension of catarrhal inflammation from the mouth to the throat is certainly an element in the causation of the conditions, though anorexia, imperfect digestion and fever are more potent, as they lead to impaired nutrition and increased susceptibility to the action of cold and bad hygienic surroundings. The treatment of this class of affections must vary with the symptoms presented. Should there be much inflammation and pain about a loose tooth, great relief can be obtained by painting the gum three or four times daily with a solution of — 1J . Cocaine Hydrochlorate, gr. iv. Glycerinae, f ^ ij. Aquae, q. s., ad f^j. M. S. — For local use. When the first or second molars cause the trouble, free lancing with an oblique crucial incision is to be recommended. Much good can also be done in the way of softening the gums and lessening pain by a thorough application of — R. Zinci Chloridi, gr. j. Vin. Opii, f gj. Glycerinae, f^ij. Aquae Rosae, ........ q. s. ad fgj. M. S.— Apply to tender gums with a brush or soft cloth thrice daily. Such measures, too, will be more successful in relieving referred pains than any direct application to the place of reference. AFFECTIONS OF THE MOUTH AND THROAT. 1 73 Catarrhal and ulcerative stomatitis demand the usual methods of treatment. Superficial ulcers on the tongue can often be healed by a daily application of a solution of nitrate of silver (ten grains to one fluidounce) and the frequent use of a borax or chlorate of potas- sium wash (fifteen grains of either to one fluidounce). Should there be much pain and discomfort, the solution of cocaine recommended above may be used two or three times daily. When the deciduous teeth are decayed, however, nothing short of their extraction will cure the ulceration. Nothing can be done for loss or perversion of taste except removing loose teeth and freely lancing the gum over advancing molars. Hypertrophy of the tonsils and follicular tonsillitis must be treated in the same way as when they occur independently of dentition, the question of the propriety of extraction and of lancing being always borne in mind. (<£) After safely passing through primary dentition children usually grow robust and enjoy good health, unless they be attacked by some one of the acute contagious diseases to which their age is liable. This state of affairs may happily endure throughout the remainder of childhood, but it is often sup- planted, during the sixth and following years, by a condition best described as one of " general debility." This ill-health is neither produced by disease of important viscera, as of the lungs, heart, kidneys and digestive organs, nor can bad hygiene be blamed in many cases. For the explanation one must look rather to an impairment of nutrition, resulting from the constitutional strain of cutting the second teeth, from the moderate fever associated with the process, and from the diminished consumption of food, attending oral discomfort and painful mastication. The severity of the symptoms depends somewhat upon the general vigor of the subject, though in my experience it bears little or no relation to the difficulty or ease of cutting the milk teeth. Early in the sixth year, children so affected begin to lose 174 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. their rosy cheeks ; the lips grow pale ; the skin of the body becomes sallow and harsh \ the hair dry and lustreless, and there is moderate loss of flesh with flabbiness of the muscles. The face wears an anxious expression and the temper is unstable ; by day frequent complaints of weariness are made and little interest is taken in play, while at night sleep is restless and there is often slight fever, with a temperature rarely above ioo° F. Pain and discomfort in the mouth are constant symptoms, and as these are increased by mastication, there is apparent anorexia. Examination of the mouth reveals redness, swelling and tender- ness of the gums over advancing molars, or if these have been cut, around loose temporary teeth. The bowels are inclined to constipation and the urine limpid and voided in abundant quan- tity ; the pulse is rather feeble though normal in frequency, and, as a rule, there is no cough nor other alteration in the respiratory function. Careful investigation shows an absence of lesion in the heart, lungs or kidneys, and of disease of the abdominal glands or digestive tract. As the teeth of the advancing group are cut, the symptoms disappear, to return with the approach of each succeeding group, but the anterior molars generally give rise to more marked disturbance than any of the teeth thaj; replace the temporary set. In addition to the ordinary risk of intercurrent disease exist- ing in every case of general debility, the condition just described is very apt to be complicated by bronchitis or catarrh of the gastro- intestinal canal. Pyrexia, although it is comparatively slight in second dentition, accounts for this, for a feverish child is very susceptible to cold, and very liable to have his digestion disordered by food upon which he has previously thriven. The first cause, by driving the blood from the surface, produces bronchitis; the second, by direct and indirect irritation, leads to catarrh of the mucous membrane of the stomach and bowels. This knowledge taken in connection with the course and his- tory of the case and the condition of the mouth, should enable the observer to attribute the illness to its proper source rather than to any complicating affection, although the latter undoubt- AFFECTIONS OF THE MOUTH AND THROAT. 1 75 edly accentuates the symptoms, and may force itself into promi- nence. The negative results of physical exploration of the heart, lungs, and abdominal organs, — particularly the mesenteric glands — and of examination of the urine, are also important in establishing the correct relations of cause and effect. Careful regulation of the diet and the administration of tonics, the methods of treatment that would naturally be suggested, are of little avail, unless oral pain and difficulty of mastication be relieved. Even then, it is often impossible to do more than maintain a moderate degree of health until advancing teeth are completely free. Free lancing of the gums over molars, the application of cocaine to painful gums surrounding loose temporary teeth ; the extraction of these when the substituting teeth are so advanced as to run no risk of impairing the arch of the jaw : regulation of the diet and hygiene, aud the employment of tonics and laxa- tives are the measures to be recommended. The diet must be simple, non-farinaceous and nutritious ) it is better to allow four small meals a day than three large ones. Of tonics a good for- mula is : — R . Tr. Nucis Vomicae, TT^xij. Elix. Cinchon. Ferrat , f^ v j* Syrupi, f§ ss - Aquae, q. s. ad f5iij. M. S. — Two teaspoonfuls thrice daily at the age of six years. Syrup of the iodide of iron, bitter wine of iron and an emulsion of cod-liver oil with lacto-phosphate of lime, are also very use- ful. The best laxatives are fluid extract of senna, which may be combined with the tonic mixtures ; tincture of aloes and myrrh in small doses three times daily, compound licorice powder, glycerine suppositories or laxative tamarinds.* Complicating bronchitis and catarrh of the gastro-intestinal canal demand active attention, and little else can be accomplished until they are relieved. * See Habitual Constipation. 176 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. (V) Disorders of the digestive system, while unattended by such marked symptoms and rarely reaching the same degree of danger as in primary dentition, are among the most common of disturbances produced by the eruption of the second teeth. One cause of this is the intimate sympathy existing between the different portions of the digestive tract, and leading to reflec- tion of irritation from point to point. Another and more active cause has already been indicated. It involves two conditions. First, general depression of vitality — from constitutional strain, fever, and so on — with a corresponding weakening of the func- tion of digestion, so that food previously suitable and easily assimilated, becomes relatively too coarse and "strong," and being more or less imperfectly changed and absorbed, lies in the alimentary canal undergoing fermentation and decomposition with the formation of irritant acids and gases. Second, the well- recognized susceptibility of the gastro-intestinal mucous mem- brane to become inflamed, or to assume the catarrhal state, when subjected to the action of irritants. A susceptibility decided enough under the best of circumstances, but intensely marked if the general health and resisting power be below par. Anorexia, vomiting, acute gastric catarrh, chronic gastro- intestinal catarrh, and diarrhoea are the more common of the digestive disorders attending second dentition. Loss of appe- tite when not due to perversion of taste, generally forms but one member of a group of symptoms depending upon catarrh of the stomach, and can be best studied under this head. The same may be said of vomiting. Of each of these symptoms it is also true, that they may be so prominent as to mask the associated features unless the observer be very careful. Acute gastric catarrh,* in so far as it is related to second denti- tion, is most frequently encountered during the eruption of the six-year molars. The attack of so-called "biliousness" and " indigestion " may or may not be preceded by some indiscre- tion in diet. * For description of this affection and its treatment see page 199. AFFECTIONS OF THE MOUTH AND THROAT. 1 77 It will fully repay the physician to inspect the mouth of every six-year old patient (and upward) suffering from acute indiges- tion, and after making the examination thoroughly to lance swollen gums over advancing molars, and apply soothing lotions to irritated gums about loosened temporary teeth, or order ex- traction if admissible. General treatment must be conducted on the same plan as when the attacks, as is often the case, occur independently of dentition. Chronic gastro-intestinal catarrh owes its origin to second dentition more frequently than to any other cause save whoop- ing-cough. In this condition — so aptly termed by Eustace Smith, "Mucous Diseases'' * — there is a mucous flux from the whole internal surface of the alimentary canal, which mechanic- ally interferes with the digestion and absorption of food and greatly impedes nutrition. It may be met with at any time dur- ing the eruption of the permanent teeth. Diarrhoea is a very constant attendant upon second dentition. It is most apt to arise in the changeable weather of spring and autumn or in the heat of July, August or September. In this respect it resembles the diarrhoea so common with primary den- tition, but unlike the latter, it shows little or no tendency to run into entero-colitis. Two forms are met with, namely catarrhal diarrhoea, and lientery.f The general depression produced by the coming of the second teeth, would naturally favor the development of any constitu- tional tendency, and, having traced the connection in several instances, I have no doubt that not a few cases of tubercular ulceration of the bowels owe something to this etiological factor. (d) Enlargement of the sub-maxillary gland, or one or more of the lymphatic glands of the neck, is a frequent occurrence during the approach of the first molars. Patients so affected may at the same time present other evidences of difficult dentition ; for example, they often show the symptoms of "general debility" * For description of this condition and its treatment see Mucous Diseases. f See Catarrhal Diarrhoea. is I 78 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. already referred to, and often have mucous disease ; but they are quite as frequently perfectly healthy in constitution as strumous. The swelling of the gland or glands is moderate in degree ; there is considerable hardness, moderate tenderness and pain, but the superimposed skin is movable and healthy. There is some tendency to chronic enlargement and induration, though little or none to suppuration, save in scrofulous subjects. Should the gums be thoroughly lanced — and it is often neces- sary to sink the knife blade deep, to free the coming tooth — the glandular swelling soon subsides, though resolution can be has- tened by painting with tincture of iodine, or using the following ointment : — R. Ichthyol 55 j- Lanoline ^j. M. S. — Apply to the enlarged glands three times daily, with rubbing. (e and /) Conjunctival blennorrhoea and otitis, sometimes noticed during primary dentition, have come within my observa- tion, and, from the intimate connection between the nerves of the ear and eye and those of the teeth, it is more than probable that certain other disturbances of these two organs of special sense arise during second dentition, and depend upon dental irritation. Unfortunately so few cases of disease of these two organs come under my notice, and so little attention has been paid to this causal relation by specialists, that I have no data upon which to base conclusions. (g) Herpes of the lips, eczema, and urticaria frequently appear during the eruption of the second teeth. They apparently depend upon gastro-intestinal disturbances and are relieved by measures directed to the cure of disorders of this tract, together with appropriate local treatment, and attention to the teeth and gums. (k) Nasal catarrh, " teething cough," and an increased suscep- tibility to catarrh of the bronchial mucous membrane are the chief affections of the respiratory tract. AFFECTIONS OF THE MOUTH AND THROAT. 1 79 Nasal catarrh is generally sub-acute in type, and is attended by hypertrophy and redness of the Schneiderian membrane. There is a more or less copious discharge, which has a slight, heavy odor, may be composed of thin mucus or muco-pus, and which sometimes dries into thick crusts. This catarrh occasionally runs into ozsena in weak and strumous children. Attention to the teeth, frequent syringing of the nostrils, with insufflation of boracic acid and bismuth (i part to 2), the occa- sional application of a weak solution of nitrate of silver (gr. v- fSj), judicious use of the electro-cautery, and the administration of tonics, constitute the best treatment for the ordinary form of catarrh. Ozaena calls for its special plan of management. " Teething cough' ' is due to reflex irritation of the pneumo- gastric nerve ; it is identical with the " stomach cough" of mucous disease. Bronchitis can never be said to be due directly to dentition. This cause acts only indirectly by reducing general vitality and the power of resisting disease, and thus rendering the delicate bronchial mucous membrane more than ordinarly susceptible to catarrhal inflammation from chilling of the surface and exposure to damp air. An attack of bronchitis may occur with the eruption of one group of permanent teeth, or the attack may be repeated with several successive sets. I have in my mind now, the case of a delicate boy who, in spite of the utmost care on the part of his mother, had a most severe bronchitis during the eruption of the six-year molars, and a second persistent attack while the four central incisors were pushing their way through. Not two months before writing this, he again came under my care suffering from a third attack that promised equal obstinacy. On inspecting the mouth the four lateral temporary incisors were found to be quite loose and their permanent substitutes evidently advancing rapidly. Ex- traction of the loose teeth was ordered, together with a mild expectorant and a tonic mixture, and the catarrh soon subsided. (/) Nervous disorders, both sensory and motor are encountered. Headache is common. The pain is usually temporal and l8o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. unilateral. It may be seated however, in the occipital region or in different parts of the face, and sometimes shifts suddenly from the temporal to the occipital region. It is lancinating, more or less constant, with no distinct intermissions, and during its con- tinuance there is restlessness, anorexia, a frequent, hard pulse, sweating, dilatation of the pupil on the affected side, and perhaps dimness of vision, diplopia and colored or uncolored spectra. One or more painful points can often be detected, and generally there is a hard, tender, moderately enlarged lymphatic gland in the submaxillary or cervical region. These attacks are due to disordered vasomotor innervation, depending upon irritation of the sympathetic nerves and produc- ing irregular contraction or spasm of the vessels — the temporal or occipital artery, as the case may be. The real source of irritation is to be found in the mouth. The mode of action may be twofold. First, from a swollen gum or carious tooth the lymphatic vessels readily convey irritating matter to a neighboring lymph gland, and the irritation here excited acts, in its turn, as a disturber of the sympathetic nerves which furnish the vaso-motor supply to the carotid artery and its branches. This theory of the produc- tion of migraine has the value of the support of T. Lauder Brunton. The other method of production — and this I simply submit for consideration — is one of direct nervous connection; the submaxillary ganglion acting in the case of the lower teeth and the spheno-palatine in the upper, as the medium of transfer of irritation to the vaso-motor nerves. Bromo- caffeine, gelsemium, saline laxatives and tonics may be employed to lessen the severity of the pain, but lancing or ex- traction are the only certain remedial measures. The motor disturbances, while not quite so common as the sensory, are more varied. Reflex spasm and paralysis of the eyelid have been noted.* The former I have frequently seen, but the latter, so far as I can * Brunton. AFFECTIONS OF THE MOUTH AND THROAT. l8l recall, has never fallen within my experience. For the reflex spasms no method of treatment availed until the dental irritation was removed ; and the same statement maybe hazarded, a priori, in regard to paralysis of the lid. More extended paralysis also occurs. In this connection I can do no better than quote the words of Brunton, the correctness of which I can fully confirm. After speaking of paralysis of the eyelid this author states: — "Sometimes, however, paralysis oc- curs of a much more extensive character, in consequence of dental irritation, especially in children. Teething is recognized by Romberg and Henoch * as a frequent cause of paralysis appearing in children without any apparent cause. According to Fliess,f paralysis of this sort occurs more commonly during the period of the second dentition, whereas convulsions generally occur during the first. Its onset is sudden. The child is apparently in good health, but at night it sleeps restlessly, and is a little feverish. Next morning the arm, or more rarely, the leg, is paralyzed. The arm drops ; it is warm but swollen, and of a reddish-blue color. It is quite immovable, but the child suffers little or no pain. Not infrequently paralysis is preceded by choreic move- ments. Sometimes recovery is rapid, but at other times the limb atrophies, and the paralysis may become associated with symp- toms indicating more extensive disturbance of the spinal cord and brain, such as difficulty of breathing, asthma, palpitation, distortion of the face, and squint, ending in coma and death. "It is only in very rare instances that we are able to gain any insight into the pathological anatomy of such cases, because they rarely prove fatal, and even when they do so the secondary changes are generally so considerable as to leave one in doubt as to the exact mode of commencement. This renders all the more valuable the case recorded by Fliess, in which a boy five years old, and apparently quite healthy, found his left arm completely paralyzed on awaking one morning after a restless night. The arm was red, but the boy suffered no pain, and played about * Klinische Wahrnehmungen und Beobachtungen. f Fliess, Journ. der Kinderkr., 1849, J u ly an( l August. 1 82 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. without paying much attention to the arm. The same day he fell from a wagon upon his head, and died in a few hours. Apart from the fracture of the skull which caused his death, the ana- tomical appearances which were found were congestion of the spinal cord, and great reddening and congestion of the meninges near the point of origin of the brachial nerves, where the veins were also much fuller than on the corresponding right side. There was no organic change perceptible, either in the spinal cord or in the brachial nerves. On the other hand, the tumes- cence of the veins extended from the shoulder and neck up to the face, and was very striking in the sub-maxillary region. " This vascular congestion seems to point to vaso-motor dis- turbance of a somewhat similar kind to that which we have already noticed in connection with occipital headache, or with migraine accompanied by subjective appearances of either form or color." * This form of paralysis certainly suggests acute anterior polio- myelitis, though the symptoms are not quite identical and the age is not that at which " infantile palsy " usually occurs. Unfortunately, in all but the mildest cases, which get well quickly, when the paralysis appears the mischief is done and little benefit can be expected from attention to the teeth. The treatment must be conducted on the plan usually adopted in infantile paralysis. As just stated dental irritation sometimes produces choreic movements as prodromata of paralysis, but it much oftener acts as the exciting cause of genuine chorea in nervous children. Approaching molars, or carious, loose milk teeth about to be shed, may be the source of irritation. The causal relation is proved by the fact that the chorea disappears or yields quickly to ordin- ary treatment when the new teeth pierce the gums or are freed by lancing, or when decaying teeth are removed. Epilepsy is another nervous affection which can occasionally be traced to the same source. In such cases one usually finds a history of repeated general convulsions during primary dentition. * Brunton. " Disorders of Digestion," p. 93. AFFECTIONS OF THE MOUTH AND THROAT. 1 83 7. SIMPLE PHARYNGITIS. Catarrh of the mucous membrane covering the soft palate, tonsils and pharynx — simple or erythematous pharyngitis — is a common occurrence in children who have reached the third or fourth year, though it is rarely met with before that age. It may either be primary or secondary in origin. The Anatomical Lesion is hyperaemia of the affected mucous membrane. This is red, swollen, softened, granular, and at times oedematous. Etiology. — The primary form is most prevalent during the winter and spring. Impaired health, from neglect, bad food, or insufficient clothing predispose to an attack; while sudden changes in temperature and exposure to wet and cold are the chief excitants. One attack is often followed by others. The disease is not contagious, but many cases often occur simul- taneously. Secondary pharyngitis, which will not be studied here, constantly accompanies scarlet fever and measles, and often complicates bronchitis and pneumonia. Symptoms. — An attack of simple pharyngitis of ordinary gravity begins with fretfulness and lassitude; the child refuses food, and may vomit once or twice. Fever quickly follows, preceded by rigors, or in children nearing the age of puberty, by a single distinct chill. This fever is quite out of proportion to the local symptoms. The temperature in the course of a few hours rises to 102 or 104 F., and often higher; the pulse runs up to 130 or 140 beats per minute; the respiration is corre- spondingly rapid, though easy, the face is flushed and the skin dry. The voice becomes thick and husky, and there is a teas- ing, unproductive, hoarse cough, which may assume a brazen character toward evening. Older patients may complain of dryness and fulness of the throat, of a sensation leading to frequent efforts at deglutition, or of difficulty and pain in swal- lowing food ; while infants manifest the latter conditions by refusing the breast or bottle. An entire absence of these sub- jective symptoms, however, is common. 1 84 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. On inspection, the mucous surface of the soft palate, uvula, tonsils and pharynx presents a reddened, tumefied, dry, granular appearance, and may be partially covered with flakes of whitish mucus or muco-pus. The tonsils are somewhat swollen, and at times the uvula is oedematous. The lymph glands about the angles of the jaw are slightly enlarged and tender to the touch. On the second day the fever abates, the temperature often falling to the normal line, but there is an elevation on each suc- ceeding evening until the end of the fourth or fifth day, when the attack begins to subside. In the meantime the local symp- toms increase. Throughout, the child is peevish and restless, sleep is disturbed, the tongue is heavily coated, and there is loss of appetite, increased thirst, and a tendency to constipation. In exceptional cases the disease is much more grave in type. These severe attacks begin with vomiting, excessive restlessness or drowsiness, occasionally convulsions, and always high fever, with a temperature reaching 106 or even more, and a rapid and bounding pulse. The affected mucous membrane becomes in- tensely red and covered with a muco-purulent secretion. All the ordinary symptoms are intensified, and in addition there may be mild delirium and a flushing of the entire cutaneous surface, suggesting the scarlatinal rash. These attacks vary in duration from three to eight days, and, notwithstanding the alarming character of the symptoms, usually terminate in recovery. Diagnosis. — It is quite possible to overlook the presence of pharyngitis on account of the frequent absence of symptoms calling attention to the throat. Thus the sudden onset of high fever with rapid pulse and respiration and dry cough would, in the absence of difficult deglutition and pain in the throat, suggest an attack of croupous pneumonia. If, under the same condi- tions, the pharyngitis be ushered in by vomiting, the fever might readily be referrred to a digestive disorder. Such errors are to be avoided only by making a rule to inspect carefully the throat in each doubtful case. A grave case, again, may in the begin- ning be taken for one of scarlet fever, the resemblance being increased by the uniform flushing of the surface. Distinction is AFFECTIONS OF THE MOUTH AND THROAT. 1 85 to be found in the different course of the two diseases, and the non-appearance of certain characteristic symptoms of the ex- anthem. Care must be taken not to confound the white or yellowish- white patches of mucus or muco-pus adhering to the inflamed surface with diphtheritic membrane. The former can be wiped away easily, leaving the mucous membrane intact. Treatment. — If the case be seen on the first day, it is possible greatly to reduce the severity of the attack by giving the child a hot mustard foot-bath,* putting him to bed in a properly-warmed room, and by cautiously administering aconite, with some saline laxative, as a small teaspoonful of magnesia in a wineglassful of strong lemonade. Under such circumstances, tincture of aconite root may be given to a child of four years, in doses of a drop every fifteen minutes until four drops have been taken, and sub- sequently the same dose every hour until an effect is produced on the pulse, or the heat and dryness of the skin are lessened. When the fever has been reduced in this way, or should the case not be seen until the second day, the following may be ordered : — R. Potassii Chloratis, gr. xlviij. Syrupi, , . . . f § ss. Aquae, q. s. ad f^iij. M. S. — One teaspoonful every three hours, in water, for a child of four years. If the fever returns as evening approaches, this mixture should be discontinued, and another foot-bath and a few doses of aconite given ; or some simple diaphoretic may prove sufficient, as liquor potassii citratis, at intervals of an hour during the night. Throughout the attack the diet should consist of milk and farinaceous articles prepared with milk, with a little meat broth as the fever subsides. A daily evacuation of the bowels must be secured, and the child must be kept in bed. * The ordinary strength of such a bath for a child of three or four years is one tablespoonful of mustard-flour to two gallons of water. 16 1 86 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Local treatment must not be neglected. If the child be able, he should gargle the throat every hour with a solution of chlorate of potassium, ten grains to the fluidounce. If too young to do this, the same solution should be applied to the throat at short intervals with a mop of absorbent cotton. Painting the throat daily with a solution of nitrate of silver (gr. v to fgj) hastens the cure. At the same time it is well to redden the skin of the neck with some such liniment as : — R. 01. Terebinthinse, fgj. Ol. Olivse, fgiij. M. S. — Apply twice daily. Grave cases require no alteration of this plan. It is well, if there be great restlessness, to repeat the foot-bath, or even to give several full warm baths of ten minutes' duration. If there be intense inflammation of the pharynx the neck should be envel- oped in a poultice, or in extreme cases a leech may be applied behind each angle of the lower jaw. Clogging of the throat by tenacious mucus demands an emetic. When convalescence begins, the diet must be more liberal, and restoration to perfect health is hastened by administering a bitter tonic, as tincture of nux vomica, or compound tincture of gentian, in appropriate doses, three times daily. 8. SUPERFICIAL CATARRH OF THE TONSILS. In this affection there is a simple hypersemia of the mucous membrane covering the tonsils, accompanied by moderate swel- ling of the glands. It is produced by the same causes, and usually occurs as an element, merely, of general pharyngitis. In the exceptional cases in which it exists in an isolated form, the tonsils will be found reddened and moderately swollen, and several yellowish-white points, due to retained follicular secretion, will be seen on their surfaces. The local subjective, and the general symptoms are the same as those of pharyngitis, and they yield to the same measures of treatment. AFFECTIONS OF THE MOUTH AND THROAT. 1 87 9. FOLLICULAR TONSILLITIS. In this disease there is, in addition to superficial hyperaemia, a catarrh of the lacunae or follicles of the tonsils. According to the extent of the disease, several or all of the follicles become filled with a yellowish-white, curd-like material, consisting of epithelium and pus. When thin, this flows away ; but, when thick, it is removed with difficulty, collects and distends the lacunae, and may undergo desiccation, or even become calcified. The parenchyma of the tonsils becomes hyperaemic, and there is an infiltration of serum and a proliferation of the gland cells. Etiology. — The affection is a common one after the fifth year. It is most apt to be met with in the winter and spring, but it may occur at any season. Exposure to wet and cold is usually considered to be the exciting cause, but an attack may quite as frequently be traced to over-eating, associated with excitement and fatigue. One attack predisposes to others, and I have seen many patients who are invariably affected after gorging them- selves with rich food, pastry or candy. A combination of all of these causes — so well afforded by that worst of institutions, a child's party — invariably produces a crop of cases. Symptoms. — When due to over-eating, the attack usually sets in on the day succeeding the indulgence. It begins with headache, lassitude, pain in the back and legs, and more or less rigor. The tongue becomes frosted ; there is thirst, anorexia and nausea, often followed by vomiting. Toward the evening of the first day the face becomes flushed, the skin hot and dry, and the pulse rapid. The bowels are sluggish, and the urine is scanty, high colored, and lateritious. On the morning of the second day the fever abates, but it returns in the afternoon, and this course is maintained for three or four days, when convalescence is estab- lished. In the meantime the anorexia and constipation continue, the patient sleeps badly ; may even be slightly delirious at night, and, finally, is left so feeble that health is not restored for a week or more. When the affection is due to exposure alone, there is less head- 1 88 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. ache, and no nausea or vomiting. In other respects the course is similar, though the attack is followed by less prostration. Whatever the cause, the local symptoms are the same. They consist of a sensation of dryness and heat in the throat, repeated efforts to clear the throat, difficult and painful deglutition, in- creased salivation, a nasal intonation of the voice, and a heavy, offensive breath. On inspection, a catarrhal condition of the palatine arches and pharynx is observed. The tonsils are en- larged, sometimes sufficiently so as almost to meet one another ; their enveloping mucous membrane is reddened and swollen, and their surface is dotted with yellowish-white points, corresponding in number, shape and size with the follicles involved. These points are sometimes covered and concealed by muco-pus, and may be surrounded by shallow, circular erosions of the mucous membrane. On pressing the tonsils, ill-smelling masses of vary- ing size and consistency may be pressed out. These are also ex- pelled by hawking,/)r are forced out in deglutition and swallowed with the food. In whichever way removed, they leave the orifices of the follicles more widely open and gaping than in health. There is some tenderness on pressure beneath and behind the angles of the jaw. The Diagnosis is easily made from the appearance of the tonsils, and from the fact that gentle pressure with the finger will force out one or more masses of retained secretion — a pathogno- monic sign. There is no doubt that these cases are by some classed as diphtheritic, though none but the most inexperienced could confound the numerous yellowish-white points, of irregular shape and size, depressed below or projecting beyond the well- defined lips of the follicles, and which, as already stated, can be often expelled by pressure on the tonsils, with diphtheritic mem- brane. Again, the difference between this affection and a patchy tonsillar diphtheria — a common enough disease — must strike any careful observer. The Prognosis is always favorable, except that one attack pre- disposes to others, which may lead to chronic hypertrophy of the tonsils. AFFECTIONS OF THE MOUTH AND THROAT. 1 89 Treatment. — If the attack be traced to over-eating, the ad- ministration of an emetic would naturally suggest itself as a pre- liminary. This, however, is rarely necessary, as the initial vom- iting empties the stomach sufficiently. Usually, the first steps are to place the child's feet in a hot mustard bath, then put him to bed, and give, according to the age, one or two grains of calomel at once, or in broken doses if there be much nausea. If, on the first night, the fever be high, tincture of aconite should be resorted to ; if more moderate, an effervescing draught, like the following, will suffice : — R. Acidi Citrici, ^jss Aquae, f g iij. M. S. — Solution No. 1. R. Potassii Bicarbonatis, jjj. Aquae, f* ^ iij . M. S. — Solution No. 2. A teaspoonful of each solution is to be poured into a tablespoon or glass and taken while effervescing. This draught has the advantage of checking nausea at the same time that it reduces fever. Small pieces of ice should be swallowed at short intervals to relieve thirst and lessen the inflammation of the tonsils, and the food must be restricted to small quantities of milk and lime- water (3 to 1), or weak broths in case milk disagrees. On the second day, it is only necessary to look carefully after the diet, to allow nothing but milk and broths ; keep the patient in bed, and give during the day the following: — R. Pulv. Pepsinae, Sodii Bicarbonatis, aa gj. M. et ft. chart. No. xij. S. — One powder every three hours for a child of six years. The effervescing mixture may still be used in the early night if the fever be high enough to require it. Such measures should be continued until convalescence is I90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. established, care being taken to keep the bowels regular with calomel in broken doses. Then the diet may be gradually in- creased and a bitter tonic given. If the cause be exposure to wet and cold, the general treatment must be the same as for pharyngitis. The local treatment embraces counter-irritation of the skin of the neck ; touching the tonsils once daily with a solution of nitrate of silver, gr. v to fgj ; and frequent gargling with :— R. Potassii Chloratis, gr.lxxx. Acid. Carbolici, , gr.ij. Glycerinse, fgj. Aquae, q. s. ad fg viij. M. S. — Use as a gargle every hour. 10. SUPPURATIVE TONSILLITIS. Quinsy is a rare disease in childhood and is scarcely ever met with before the twelfth year. When it does occur, some family predisposition can generally be traced. One of the most com- mon predisposing elements is the rheumatic diathesis. Fatigue and exposure are the exciting causes. It is most frequent during spring and autumn. One attack predisposes to others. It may arise as a primary affection or as a complication of scarlatinous, variolous, or diphtheritic anginas. One or both tonsils may be affected. Morbid Anatomy. — At first there is intense hyperaemia with serous infiltration of the glandular tissue, and the tonsils some- times become swollen to more than double their size. The inflammation may now undergo resolution. Otherwise an in- filtration of small cells takes place, into and between the follicles, into the inter-lacunar connective tissue, and in the capsule. Retrogression is still possible, or failing this a new formation of reticulated substance takes place, resulting in permanent hyper- trophy; a frequent termination of repeated attacks in children. If the inflammation be very intense, an abscess forms, but AFFECTIONS OF THE MOUTH AND THROAT. I9I suppuration is not the usual result of tonsillitis occurring before puberty. With these conditions there is always associated general pharyngitis and often follicular tonsillitis. Symptoms. — The disease begins with rigors or a distinct chill, followed by sneezing, epistaxis, headache, pain along the Eus- tachian tube, loss of appetite, and fever, with languor and mus- cular prostration during the day, and mild delirium at night. Soon the*patient complains of dryness and burning in the throat, difficulty and pain in deglutition, and the voice becomes nasal. If the throat be inspected, the mucous membrane of the soft palate and pharynx is seen to be red and swollen, and one or both tonsils are reddened and enlarged, often presenting several whitish-yellow points of retained follicular secretion. If one tonsil only be affected, the cedematous uvula will be pushed to the opposite side — an important sign. The symptoms gradually increase in severity. The tempera- ture ranges from 99 or ioo° F., in the morning, to 102 or 104 in the evening, and the pulse from no to 120; but the respiration, though snoring, is little increased in frequency. Pain and difficulty in deglutition grow worse ; the voice assumes a peculiar, thick, nasal tone; the breath has a heavy odor; the salivary secretion is increased and dribbles from the mouth ; the tongue is heavily furred, and the bowels are sluggish. The child's face wears an apathetic expression, is red or dusky in hue, and there is dulness of hearing. Talking is painful, and so also is any movement of the jaw. On this account it is difficult to obtain a view of the throat ; but if such be had, the tonsils, when both are affected, are seen to be intensely congested, and so much swollen that they meet ; or, when only one gland is in- volved, it often extends a third of an inch beyond the median line. The day is divided between the listless inaction of pros- tration and the uneasy tossing of discomfort, and the night, between the restlessness of fever and the wandering of delirium. What little sleep is obtained is interrupted by snoring. The crisis usually occurs on the fifth day, although it may be postponed until the eighth. If the tonsillitis ends in resolution 192 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. the fever rapidly subsides, disappearing entirely in twelve hours; the local symptoms simultaneously abate and convalescence is rapid. When the inflammation ends in the formation of new tissue and hypertrophy of the glands, the acute manifestations give place to a train of symptoms to be described in the next section. Finally, if suppuration take place, there is a chill followed by high fever. The abscess soon points toward the mucous surface of the gland, and, unless opened by lancing, is broken by an eifort at deglutition or in an examination of the throat. The quantity of pus discharged is ordinarily small, and is swallowed, as a rule. After the opening of the abscess, the child passes at once from a condition of great distress to one of comparative comfort, and strength and health are soon regained. The Diagnosis of quinsy is unattended with difficulty, and the prognosis, so far as life is concerned, is always good, though the danger of chronic hypertrophy must not be forgotten. Treatment. — If the patient can be seen when the peculiar tone of the voice, the pain in the line of the Eustachian tubes, and the deflection of the uvula indicate the beginning of tonsil- litis, it is possible to abort, or, at least, greatly reduce the inten- sity of the inflammation. For this purpose he must be put to bed, and given a sufficient quantity of wine of ipecacuanha to empty the stomach. Then properly proportioned doses of tinc- ture of aconite root must be administered every half hour until an effect is produced on the temperature and pulse, and small bits of ice must be swallowed at intervals of ten minutes. At the same time it is well to apply a sinapism to the side of the neck corresponding to the affected gland. Since the introduction of cocaine I have often succeeded in aborting tonsillitis by thor- oughly mopping the affected parts three times daily with a four per cent, solution of this drug. Even in cases where this favorable result was not obtained, the cocaine so far allayed pain as to per- mit liquid food to be swallowed with ease. This is an invaluable aid in the treatment of severe quinsy occurring in feeble children. When the case is not seen till later, the indications are to AFFECTIONS OF THE MOUTH AND THROAT. 1 93 encourage resolution or hasten suppuration, and to maintain the strength. To fulfil the first, the neck should be enveloped in a poultice, the throat should be repeatedly gargled with warm water, and steam from an atomizer should be constantly inhaled. The strength is to be kept up by administering all the concen- trated liquid food that it is possible for the patient to swallow and by using suppositories of quinine. The latter may be ordered in this way : — B . Quinioe Bi-sulphatis, gr. xij. Ol. Theobromae, rjiij. M. et ft. supposit. No. xij. S. — Use every four hours for a child six years of age. On account of the difficulty in swallowing it is well to avoid ordering any medicine by the mouth except a diaphoretic, such as the solution of the citrate of potassium, and an occasional dose of some saline laxative. When there is much restlessness or delirium at night, it is well to give bromide of potassium, in ten-grain doses, by the mouth or rectum. If an abscess forms, a somewhat rough pressure of the finger against the involved tonsil will hasten its rupture, but incision is a better method of treatment and often lessens the duration of suffering by twenty-four hours or more. After the crisis is past, the diet must be increased and a tonic ordered as: — R. Tr. Ferri Chloridi, f^j. Quinise Sulphatis, gr. xij. Syrupi Zingiberis, f^J* Aquae, q. s. adfjiij. M. S. — One teaspoonful, in water, three times daily for a child six years old. The subsidence of the tonsils to their normal size is hastened by painting them twice daily with — R. Acidi Tannici, ^j. Glycerinse, fgj. M. 194 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. For prevention, gargles of cold water and astringents, appli- cations of the glycerole of tannin, and measures to maintain a high standard of health and counteract any rheumatic tendency, should be employed. ii. HYPERTROPHY OF THE TONSILS. Chronic enlargement of the tonsils is slow in its development, and must be considerable in degree before giving rise to definite symptoms. Consequently, the disease is rarely recognized before the third or fourth year of life, although its commencement in early infancy is quite possible. It is common between the seventh and twelfth years. Etiology. — Repeated tonsillar inflammation and the irritation attending dentition are the ordinary exciting causes, but it may appear spontaneously in children who are out of health, strumous or syphilitic. As the symptoms are aggravated by any passing- angina, more cases demand treatment during the winter and spring than at other seasons. Symptoms. — The first to attract attention is loud snoring during sleep, due to pressure upon the velum, and obstruction to the passage of air through the posterior nares. At the same time there is a decided nasal twang to the voice. Examination shows marked projection of both tonsils, or, more rarely, of one only ; the follicular orifices are widely open and very distinct, and several of them may present the yellowish-white points of retained secretion. The investing mucous membrane is pale, as a rule, but it may be traversed by arborescent blood vessels. Such a degree of hypertrophy and the accompanying symptoms some- times disappear spontaneously with the development of the mouth and vocal organs attendant upon puberty. When the glands are so much enlarged that they touch in the mid-line of the throat, there are added to the other symptoms a constant hacking cough with labored respiration, and difficulty of hearing, due partially to pressure upon the orifices of the AFFECTIONS OF THE MOUTH AND THROAT. 1 95 Eustachian tubes, and partly to a state of habitual congestion kept up in the surrounding parts. The dyspnoea is much worse at night, and the little patient often starts from sleep in a state of terror. It may be so grave as to threaten life and necessitate tracheotomy. When enlargement — so great as to almost completely obstruct the passage of air through the nose — has existed from an early age, noticeable anatomical changes take place. The nostrils be- come extremely small and compressed, while the superior dental arch retains the narrowness of infancy, not allowing room for the teeth, which, in consequence, overlap one another. The palate, also, becomes unusually high and arched. Furthermore, the obstacle to the free entrance of air prevents the lungs being readily filled in inspiration, so that a partial vacuum is formed between them and the chest-wall, to fill which the external air- pressure forces in the yielding parietes. The effect of external pressure is most marked where the resistance is least, namely, at the base of the thorax, and a constant and long-continued repe- tition of this leads to the production of a gutter of variable depth and three or four inches in width, extending laterally from the lower part of the sternum, and to a projection forward of this bone. Any tendency to pulmonary phthisis is increased by this deformity, and if tubercular disease be present, the impediment to the entrance of air, and the constant irritation of the air pass- ages, maintain a condition most unfavorable to its arrest. Treatment. — Moderate enlargement of the tonsils in a weakly child will sometimes disappear when puberty is passed, or as health is regained under a course of tonics. The best tonic is syrup of the iodide of iron, in doses of ten drops three times daily for a child of eight years of age. It is well to paint the tonsils once every day with one of the following astringents : — &. Tr. Ferri Chloridi, f^j. Glycerinse, q. s. ad fgj. M. R . Liq. Iodinii Comp., f 3 ij. Glycerine, q. s. adfgj. M. 196 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. • When there is marked hypertrophy, the best and most rapid results (next to excision) are obtained by the careful use of the electro-cautery. Children of six or eight years readily submit to this treatment provided thorough cocaine anaesthesia be pro- duced before each application of the heated wire. A gargle containing tannic acid must also be used four times daily, as : — R. Acidi Tannici, '. gss. Glycerinae, f§ ss - Aquae, q. s. ad f^viij. M. Syrup of the iodide of iron should be given three times daily, care being taken not to administer it at the time that the gargle is used. Cod-liver oil is also serviceable. Together with this treatment enough nutritious food must be given to keep up the strength. This can be done with readiness, since, in spite of the size of the tonsils, there is usually no pain, and little difficulty in swallowing. Excision must be practiced when there is excessive enlarge- ment, provided the above measures of reduction have been tho- roughly tested without avail, or if, at any time, there is dangerous interference with respiration. Constant or frequent cough, or the presence of any other symptom suggestive of phthisis, also demands an immediate operation. If, after removal of a portion of the tonsils or their reduction by treatment, the chest is slow to regain its natural form, the use of light dumb-bells and carefully regulated gymnastics are of much service. Dupuytren's method of reducing the sternal pro- minence by placing the child's back against a wall, and pressing it firmly backward with the palm of the hand during each act of expiration, is efficient, notwithstanding its apparent roughness. AFFECTIONS OF THE MOUTH AND THROAT. 1 97 12. RETROPHARYNGEAL ABSCESS. Abscess behind the pharynx is an uncommon disease ; so rare is it, indeed, that in many years' experience at the Children's Hospital I have seen but one case, and this, unfortunately, passed from observation before its termination. Its occurrence is not limited to any age. It results from direct injury ; from disease of the cervical vertebrae ; as a sequel of fever ; or, more frequently, arises idiopathically. The symptoms are difficulty in swallowing and breathing, with a peculiar sound during the latter act. On lying down the res- piratory embarrassment is increased, sometimes to such an extent as to threaten suffocation. There is, also, great stiffness of the neck, retraction and immobility of the head, and a diffuse swell- ing of the lateral cervical surfaces, often greater on one side than the other. ' If now the finger be carried over the root of the tongue, and down toward the pharynx, a firm or fluctuating swelling will be felt, more or less filling the pharyngeal canal, and projecting over the opening of the glottis. On inspecting the throat, the swelling can usually be seen, occupying one or other side or the middle of the pharynx, and pressing forward the uvula and soft palate. The investing mucous membrane may be normal or congested. Sometimes the mouth cannot be suffi- ciently opened to permit of inspection, and at others the abscess is seated so low in the pharynx that no tumor can be seen. Duparcque enumerates three symptoms indicating the forma- tion of an abscess behind the oesophagus, viz.: Severe pain, pro- duced even by moderate pressure on the larynx and upper part of the trachea. The entire suspension of respiration by such pressure. Displacement of the larynx forward and to the right. Fever and cerebral manifestations may or may not be present, and initial symptoms are far from being uniform, so that, unless an examination of the throat be made, the disease may be over- looked in its early stages. Ordinarily, however, the diagnosis can be made without difficulty. I98 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Dr. West, describing the lesions in one of his cases, states : " Immediately on dividing the cervical fascia on the right side, a quantity of thick, yellow, healthy pus passed out. This matter had burrowed close to the oesophagus, to within a little more than an inch of the clavicle, and also in an oblique direction behind the oesophagus toward the left side, completely detaching it from its connections on the right side, though not on the left. It passed up behind the oesophagus and pharynx quite to the base of the skull, a few threads of cellular tissue bathed in pus being all that remained of their posterior attachments. The tonsils were not enlarged, and the glottis was neither red nor swollen, but quite natural.' ' The prognosis is very grave when the disease accompanies cervical caries ; under other circumstances it is favorable. When untreated, the course is prolonged, as the abscess is slow to break spontaneously. Suffocation from the sudden discharge of pus is an exceptional event. The treatment is simple. As soon as the abscess has formed, it must, when within easy reach, be punctured by a bistoury, the blade of which has been carefully wrapped with adhesive plaster to within a fourth of an inch of its point. If the abscess be situated low down, a trocar and canula is the safer instrument to employ. For several days after the operation, occasional pressure must be made by the finger on the tumor, to ensure thorough evacua- tion of the pus. At the same time a general tonic and support- ing treatment is advisable. CHAPTER II. AFFECTIONS OF THE STOMACH AND INTESTINES. The fact that hyperemia is the acknowledged condition of the gastro-intestinal mucous membrane during digestion, and the easily appreciated readiness with which this hyperaemia may pass from a normal to an abnormal degree under the influence of such apparently trifling irritants as food in excessive quantity or of improper quality, has led me to doubt the existence of what is usually termed "simple indigestion " or "functional dyspepsia.' ' The doubt has been strengthened after years of special study of this class of affections in children, and I am now disposed to attribute all forms of disordered digestion to a distinct tissue lesion. This may be, and usually is, a simple catarrh ; but it is none the less a lesion. The fact of its leaving no traces after death, when this event has occurred from other causes, is a poor argument, for no one expects to be able to detect the lesions of simple pharyngitis, for instance, under like circumstances. In consequence of this belief, I have departed somewhat from the usual plan of classifying diseases of the digestive tract. i. ACUTE GASTRIC CATARRH. This is one of the most common ills of childhood, since, in addition to arising idiopathically, it attends every disease in which there is pyrexia, as well as many of those that are apyretic. The Idiopathic Form may occur at any age, but is infrequent in breast-fed infants. Its origin under such circumstances is always traceable to some abnormal condition of the mother's milk. The ordinary predisposing causes are dentition, general 199 200 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. feebleness of constitution, exposure, and imperfect hygiene. Exposure is also an excitant, but the chief of this class of causes is the administration of food that is either bad in quality or excessive in quantity. An attack, too, sometimes directly follows the use of emetic doses of antimony, sulphate of copper or ipe- cacuanha. The Anatomical Lesion is hyperaemia of the mucous mem- brane of the stomach, producing an increased secretion of mucus, and a diminished flow of gastric juice. Symptoms. — An attack of what the nurse calls (i indigestion M comes on in infants after a bottle of changed milk or a " taste " of some unusual food has been given ; in older children after a mixed and indigestible meal, particularly when this has been attended by exposure and excitement. The child, after a few hours, becomes listless, has a hot, dry skin, loses appetite, is thirsty, sleeps restlessly, and, if old enough, complains of head- ache, abdominal discomfort and nausea. Then there is vomiting of sour-smelling, curdled milk, : or of whatever food is in the stomach in a more or less imperfectly digested state. The first act of emesis is easy, but if repeated, as is often the case, there is painful retching, and nothing is expelled save a little bile-stained mucus. Soon the tongue becomes covered, except at the very tip and edges, which are red, with a thick white or yellowish- white fur, through which the fungiform papillae protrude as bright scarlet points. The breath has a heavy or sour odor. There is some fever, the temperature ranging from one to three degrees above normal, and the pulse counting no or 120 per minute. There is moderate tenderness on pressure in the epigastric region. The bowels are confined, and the urine is lessened in quantity and lateritious. These symptoms continue from twenty-four to forty-eight hours. The attack sometimes terminates suddenly, with several loose faecal evacuations. In other cases the fever gradually subsides, the nausea and thirst diminish, the tongue cleans, and the appetite slowly returns, convalescence extending over a period of two or three days. AFFECTIONS OF THE STOMACH AND INTESTINES. 201 The Diagnosis is readily established by the history of the causation, the character of the vomit, the state of the tongue, the moderate fever, the epigastric tenderness, and the course of the attack. The Prognosis is always favorable so far as recovery is con- cerned, but it must be remembered that one attack always in- creases the susceptibility to another. Treatment. — Complete rest, on the nurse's lap for infants, and in bed for older children, is essential. During the first twelve or twenty- four hours there is no inclination for food, and if any be forced it is quickly rejected. Consequently it is better to avoid any attempt at feeding until the stomach becomes settled. Thirst is to be relieved by ice, swallowed in small bits at short intervals, and by frequent small draughts of iced carbonic acid or Vichy water. Such measures are also useful to allay nausea and vomiting, but if these symptoms are at all obstinate, a mustard sinapism, just strong enough to redden the skin, should be applied to the epigastrium, and the following prescription ordered : — R . Liquor. Calcis, Aquae Cinnamomi, aa f § ij. M. S. — One to two teaspoon fuls, according to the age, at in- tervals of 15 to 30 minutes, as necessary. Frequently repeated small doses of the effervescing citrate of potassium, or of the effervescing draught already mentioned (page 189), are efficient. A good plan, too, is to divide the contents of both packages of a Seidlitz powder into a number of equal parts, about twelve for a child of three years; dissolve a portion from each in a small tablespoonful of water, pour them together, and administer in a state of effervescence. This may be repeated, at first, every half-hour, later at longer intervals : rarely more than six or eight doses are required to check the vomiting. This method has the additional advantage of acting gently on the bowels. In those exceptional cases in which, after an unsuitable meal, T7 2Q2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. there is headache, fever, epigastric discomfort, and nausea with- out vomiting, it is necessary, as a preliminary measure, to induce emesis by draughts of warm water or a sufficient dose of syrup or wine of ipecacuanha. When vomiting has ceased and nausea disappeared, the patient must begin to take food. At first one ounce of sound milk diluted with half an ounce, or even an ounce, of lime-water or barley-water may be given every two hours ; and the quantity- increased and the dilution lessened as the stomach regains its functional powers. Weak mutton, veal, or chicken broth, free from grease, and diluted with one-half or an equal quantity of barley-water, sometimes suits when milk cannot be retained. While attention is paid to the diet, care must be taken to secure a free evacuation of the bowels by a mercurial followed by a saline laxative. Beyond this, all that is required is to admin- ister properly-proportioned doses of bicarbonate of sodium and pepsin before each meal, for three or four days, and to gradually increase the diet to its normal standard as healthy digestion is restored. 2. CHRONIC GASTRIC CATARRH. This affection presents so many points of dissimilarity, accord- ing to the age of the patient, that it is desirable to study it under two heads, namely, chronic gastric catarrh in infants, and chronic gastric catarrh in children who have passed the period of first dentition. Further, since chronic catarrh of the stomach is always attended by imperfect gastric digestion, and since food imperfectly digested in the stomach is unfitted for intestinal digestion, and must act as an irritant and lead to intestinal catarrh, it is impossible to absolutely isolate the two conditions in a clinical description. This is so markedly the case in older children that it seems best to defer the study of the second divi- sion of the subject to a later section, headed " chronic gastro- intestinal catarrh," and at present to consider only — AFFECTIONS OF THE STOMACH AND INTESTINES. 203 CHRONIC GASTRIC CATARRH IN INFANTS. This dangerous affection, sometimes termed "chronic vomit- ing," is of common occurrence. Morbid Anatomy. — In the earlier stages there is a simple hyperemia of the gastric mucosa, but a long continuance of this condition thickens and loosens the membrane, changes its color to an ashen-grey, and leads to an excessive formation of tenacious mucus or muco-pus, while greatly lessening the secretion of efficient gastric juice. Coincident enlargement of the gastric glands also gives the' appearance of roughness to the surface of the mucous membrane. Etiology. — The period of life between the third and seventh months furnishes by far the greatest number of cases. Sex and season are not influential. Infants fed entirely at the healthy breast are very rarely affected. The predisposing causes belong to the class of influences that lower the readily depressed vitality of early infancy ; for instance, over-crowding, filth, want of sun-light and fresh air in dwelling- rooms, insufficient clothing, and too early weaning. The one great exciting cause is the administration of unsuitable food. Sometimes the breast-milk departs so much from its normal quality that it acts as an irritant upon the delicate mucous mem- brance and produces catarrh ; or it may flow so freely that the child swallows more than he can digest, and the surplus, having undergone chemical change in the stomach, produces a like result. But the harm commonly arises from the use, in artificial feeding, of food that is either, by its nature, unsuited to the feeble digestive ability of infancy, or which, though good in itself, is rendered hurtful by being kept in unclean vessels, and given from foul or badly constructed bottles. Of the first or essentially bad articles of diet, the farinaceous foods are the most harmful, because, for the digestion of starch, both saliva and pancreatic juice are required, and these secretions are absent until the fourth month and not fully established for some time later. Further, when subjected to the action of a 204 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. ferment, as mucus, in the presence of heat and moisture — con- ditions existing in the stomach — these substances readily undergo fermentation resulting in the formation of acid which acts as an irritant to the susceptible mucous membrane. Consequently, such a diet used, as it too often is, to the exclusion of milk, must be a very active cause of gastric catarrh. The habit of allow- ing or encouraging infants to bolt bits of table-food and drink tea is quite as injurious; perhaps, though, this indiscretion is more apt to produce chronic diarrhoea than chronic vomiting. Perfectly pure milk will be quickly changed and rendered irri- tating and unfit for use by being poured, when delivered by the milk-man, into pitchers or cans not properly cleansed from the remains of the supply of the day before. The smallest quantity of sour milk is sufficient to rapidly produce a like change in several pints of the fresh fluid when mixed with it. The same is true of unclean bottles and tips to which the dregs of former meals adhere in the form of small white curds. In these the change begins as soon as the fresh milk is added, and advances far before the child finishes the meal. A knowledge of the etiological factors explains why by far the greatest sufferers are foundlings, foster-children, children born to poverty, and those belonging to women who engage themselves as wet-nurses, or are obliged to earn their living by working away from home. Symptoms. — The first symptom is vomiting, occurring at ir- regular intervals, and resulting in the expulsion of curdled, sour- smelling milk, or whatever food is in the stomach, stained yellow or green by bile. The characters of the vomit however, soon change, the bile disappearing and only a clear, watery fluid, con- taining fragments of food, being ejected. In addition, there are eructations of sour or even fetid gas. The surface of the body is normal in temperature or cool, the skin is harsh and sal- low, and an eruption of strophulus may cover the trunk and arms. The lips are red and dry, the tongue is coated by a thick, dry, yellow fur, with dull red fungiform papillae protruding at inter- vals; the mouth is parched, thirst is increased, and milk or water AFFECTIONS OF THE STOMACH AND INTESTINES. 205 is taken greedily only to be quickly vomited again. The bowels are constipated, and when an evacuation does occur, it is attended by great straining, and the faeces appear in small, round, hard, light-colored lumps, often enveloped in mucus ; sometimes mode- rate diarrhoea alternates. The abdomen is distended and tym- panitic, and there is great tenderness over the epigastrium. Flesh is rapidly lost, the anterior fontanelle becomes sunken, the child is very fretful, has an aged and anxious expression of face, and a deep furrow may be noticed passing downward from the alae of the nose to encircle the mouth, giving to the lips the appearance of projecting. This condition continues, with occasional brief periods of im- provement, for several months. Then the vomiting becomes more constant, occurring both after food and in the intervals of feed- ing. It is excited by any disturbance, such a trifling act as wip- ing the mouth, for example, being sufficient, to bring on an at- tack. The stomach seems now to have lost its power to even begin the digestion of the blandest food, for if milk be given, it is vomited uncurdled and in the same state as when swallowed. Emaciation progresses very rapidly. The skin, dry and inelastic, hangs in loose folds from the limbs, and is apparently too large for the wasted body. It has a muddy color, and exhales an offensive, sour odor. The face is pinched, the eyes are sunken, though bright, with pearly sclerotics ; the nose is sharp, and the cheeks hollow. The infant lies with the knees drawn up against the ab- domen, and to this position they are at once returned when straightened out ; often the legs are moved about uneasily, in- dicating abdominal pain. There is little sleep either by day or night. Fretfulness is constant, with an occasional breaking out into loud, painful cries, or as weakness increases, into low wait- ings. The tongue is dry and heavily coated, the bowels continue constipated, and, toward the end, the abdomen becomes retrac- ted. The pulse grows weak and frequent in proportion to the failure in general strength, and the temperature falls below nor- mal ; the thermometer, placed in the rectum, often registering but 97 F. The breath is sour, and the scantily secreted saliva, 206 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. perspiration and urine are all very acid. As death draws nearer, the surface is perceptibly cool to the touch, the hands and feet become blue, patches of thrush appear upon the inside of the lips and cheeks, the little patient lies utterly exhausted, dozing or half unconscious, and for several days before the fatal termination, the only evidences of life are the gentle rise and fall of the chest in breathing and the occasional expression of pain that flits across the face. Sometimes, in the last few weeks of the attack, certain of the symptoms become exaggerated, constituting what is termed "spurious hydrocephalus.' ' In this condition there is deep de- pression of the fontanelle, dilated pupils, transient flushing of the face, great languor, heaviness of the head, drowsines, semi- stupor, and even coma with stertorous breathing. Indications of pain and fever are, however, absent, The sunken fontanelle shows a deficiency in the amount of blood in the brain, but, as suggested by Parrot, there may be, in addition to this source of the symptoms, some toxic element analogous to that of uraemia. Thrombosis of the cerebral sinuses and intracranial hemorrhages are also occasionally found after death, but their connection with the ante-mortem phenomena is by no means uniform. When the disease terminates favorably the vomiting occurs at longer and longer intervals, and finally stops entirely, though there is great liability to a return on the slightest indiscretion. Afterward all the other symptoms disappear except the constipa- tion, which is apt to be obstinate. An excessive development of fat is a frequent sequel. Diagnosis. — The protracted course,-the frequent and obstinate vomiting of sour liquid, and the excessive emaciation, mark the disease with sufficient distinctness. The association of vomiting and constipation, and the development of the features of spurious hydrocephalus, are suggestive of tubercular meningitis. This disease is to be excluded by the depressed condition of the fontanelle, the regularity of the pulse, the tympanitic abdomen and the apyrexia. Prognosis. — Chronic vomiting is a dangerous affection, even AFFECTIONS OF THE STOMACH AND INTESTINES. 207 under the best circumstances and an unfavorable result may be expected when the attack begins during the first three months, or occurs in a child who has been hand-fed from birth. The course is prolonged, extending from two to four or even six months. Treatment. — The first and most essential step in the successful management is a careful regulation of the diet. There are two ends to be attained; first, to give the stomach as much rest as pos- sible, and second, if a sour odor of the breath and body indicates that fermentation is going on in the viscus, to stop this process by withholding fermentable materials. In cases of moderate severity, where the vomiting has followed premature weaning, with a substitution of farinaceous food for the natural, a return to the breast is indicated. Or, if this be impracticable, the food must consist exclusively of sterilized milk guarded with lime water or diluted with barley water. For a child of three months a good proportion is two parts of milk to one of lime-water, or equal parts of milk and barley-water. Of either of these mixtures two fluidounces may be given every two hours, though the only guide to the proper quantity is the power of retention ; and if one measure be rejected, less must be given at the next feeding, until the proper amount is ascertained. Subse- quently, it may be increased as the stomach becomes retentive. In more severe and long-standing cases, attended by symptoms of acid fermentation, it is still advisable, with young infants, to try a return to the breast. In doing this, the fact that the mere act of sucking is sometimes sufficient to excite vomiting, must be remembered. So, before discarding the mother's milk as a food, an effort should be made to administer it with a spoon, after pumping it from the breast. It may then be retained and digested. However, the majority of patients in this stage of the disease can digest neither breast-milk nor any of the ordinary preparations of cows' milk, and time and even life may be saved by adopting at once an unfermentable diet, as a mixture of — Fresh Cream, f 3 ss. Whey, fgj. Barley-water, f^j. 208 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Or— Weak veal broth (half a pound to the pint). Thin barley-water; in equal quantities. Either food is best given cold and in small quantities at short intervals. One teaspoonful at a time is enough in bad cases ; but when the amount is so small, the dose must be repeated every ten or fifteen minutes. As improvement occurs, the amount of food and the length of the intervals should both be increased. It is important always to forbid the use of a bottle and feed with a spoon. A careful observance of these details is frequently rewarded by a rapid cessation of the vomiting. After the stomach has been retentive for forty-eight hours an effort may be made to return to a milk diet and the bottle. The change may be begun with what is known among dairymen as " strip- pings/ ' This is the milk obtained by re-milking the cow after the udder has been once unloaded. It contains much cream and little casein. A combination of this sort : — Shippings, fgj. Water, f§ij-; administered every two hours agrees well. This mixture should be used for several days in gradually increasing quantities, until as much as six fluidounces every three hours can be borne with ease, then food of which sterilized milk is the basis may be safely resumed. For example : — Milk, fgiv. Cream, fgij. Milk sugar, gj. Water, fgij.; given from a perfectly clean bottle, every three hours. The substitution of lime-water or barley-water for water is advisable in case of slow digestion with colic ; so, too, is the addition of a teaspoonful of caraway-water if there be flatulence. Another good combination is — AFFECTIONS OF THE STOMACH AND INTESTINES. 209 Milk, f3;iv. Cream, - . . f^ij. Mellin's food, 3J. Water, hot, to dissolve the Mellin's food, . f § ij. These foods are proportioned for infants of about three months. The importance of preparing each meal separately, and imme- diately before it is served, must not be overlooked. The second necessary step is to attend to the clothing and hygiene, A light, long-sleeved, woolen shirt, drawers of the same material, and thick worsted stockings, must be worn ; the latter especially should be insisted on, as it is essential to keep the feet warm. In addition, it is well to envelop the abdomen with a flannel binder. The clothing must be changed at reason- able intervals. Should it become soiled by vomit, it must be taken off at once and carried out of the room. The frequency of such accidents can be much lessened by placing a towel under the child's chin and over his chest, to receive the vomited matter. This, too, when soiled, is to be removed immediately and replaced by another, perfectly dry and fresh. The sick- room must be light and well ventilated, and no articles of body or bed clothing moistened with vomited matter should be allowed to remain in it a moment ; the proper temperature is 68° F. If the feet remain cold in spite of stockings, they should be rubbed from time to time with the dry hand, or with some stimu- lating liniment — oil of turpentine, fSij, and olive oil, fjij ; if this does not warm them, the legs, as far as the knees, may be put in a hot mustard foot-bath for five minutes. Hot flaxseed poultices, made light and dashed with mustard, will, when worn over the belly, relieve pain and fretfulness ; the same result follows repeated applications of the stimulating liniment. To promote free action of the skin, the whole body should be sponged with warm water twice a day, and afterward anointed with warm olive oil, which must be gently rubbed into the surface with the pulps of the fingers. If there be great prostra- tion, a full bath of ioo° F., with or without mustard, may be resorted to, the body being immersed from one to three minutes. 18 2IO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Under such circumstances, it may also be necessary to envelop the legs in cloths wrung out of hot mustard water, and to keep bottles or rubber bags filled with hot water in close contact with the body in order to encourage reaction and maintain a normal temperature. Of medicines, wine of ipecacuanha, in a sufficient dose thor- oughly to rid the stomach of acid contents, prepares the way admirably for other measures, but should never be used when the strength is exhausted. Marked sinking of the fontanelle is always a contraindication. The ordinary means of relieving gastric irritability are of little avail in checking the vomiting in chronic catarrh of the stomach. The remedy that seems to possess most power to accomplish this is liquor potassii arsenitis. The proper dose for a child of three months is half a drop, three times daily, administered simply in a teaspoonful of water or combined with an alkali and aromatic, as: — R . Liquor. Potassii Arsenitis, TT\,xij. Sodii Bicarbonatis, gr.xxiv. Aquae Mentha^ Pip., q. s. ad fg iij. M. S. — One teaspoonful, in a little water, three times daily. When Fowler's solution fails there are several other drugs that may be tried. These are vinum ipecacuanhae, in drop doses every three hours ; calomel, one-sixth of a grain, every four hours ; salicylate of sodium, half a grain every two hours; and tinctura nucis vomicae, half a drop three times daily, combined with bicarbonate of sodium and an aromatic, as in the prescrip- tion just given. While these medicines are being administered, the bowels should be evacuated by laxative enemata. Prostration demands stimulants. The best is old whiskey, which may be given in ten-drop doses every two hours ; but the guide for the dose, as well as for the proper time to commence administration, is the condition of the fontanelle. When convalescence begins, half a drop of tincture of nux AFFECTIONS OF THE STOMACH AND INTESTINES. 211 vomica, or fifteen drops of the ferrated elixir of cinchona, may be prescribed, and the tonic effects of fresh air and sun-light must be utilized by taking the child out of doors when the weather permits. 3. ULCER OF THE STOMACH. This disease is not very uncommon in new-born infants, but is decidedly rare afterward. It may occur as a single, minute, round ulcer, with a perforating tendency as in adults, or as numerous small scattered erosions which stud the surface of the mucous membrane and assume the appearance of ulcerated follicles. The perforating ulcer has been ascribed to all the various causes which are held to be potent in producing the gastric ulcer of adult life, and it is probable that for children after they are weaned the pathology of the two may be the same \ but for new- born infants, circulatory disturbances which ensue somewhat suddenly at birth, the sudden arrest of the placental stream, the gradual development of the pulmonary circulation, associated as it often is with partial atelectasis, so potently predispose to venous stagnation in the abdominal viscera as to give much ground for the belief that congestion, and even ecchymosis, are at the root of the ulceration. The scattered ulceration has been found under such varied clinical conditions that it is impossible to attach any definite meaning to it, although one may suppose with reason that it is the result of some chronic catarrh. Symptoms. — Vomiting of blood and melsena are the only in- dications which point to the existence of an ulcer of the stomach in the infant. A healthy child within a few hours of its birth who begins to vomit blood and to pass pitchy matter per anum, may have a gastric ulcer. More than this we cannot say, for the same symptoms may certainly be present without any ulcer. In the few cases in which a gastric ulcer is present in older children, the symptoms, if definite, should be as in adults — epigastric pain and 212 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. vomiting. The follicular ulcer cannot be diagnosed, and has always been found accidentally upon the post-mortem table. Treatment. — The bleeding in many cases is so quickly fatal that nothing is available ; cold alum whey may be given, and some castor oil, which, by acting upon the bowels, may do some- thing to relieve any local plethora which might exist. Tubercular ulceration of the stomach is occasionally met with, but it has no symptoms apart from those of tabes mesenterica. 4. SOFTENING OF THE STOMACH (GASTRO- MALACIA). This condition has received a great deal of attention, and some of the most distinguished writers upon the diseases of children have credited it with being a distinct disease, but, to my mind, with insufficient reason. Of symptoms it has none which are in any way characteristic, and the appearances found after death are identical with those of post-mortem solution. Whether this, as well as other changes which are cadaveric in their nature, may not at times commence during the last hours of life may perhaps be an open question, but that the change is, in all cases, essen- tially what has been described as post-mortem solution there is no doubt. Goodhart has twice found evidence of a gastric solution of the lung, which had gone on during the life of the patient. Into the appearances of the parts it is needless to enter further than to say that they showed a distinctly peculiar broncho-pneumonia, and that in each case there had been a moribund condition associated with vomiting for some days before death. Now it is obvious that such a condition has no right to the position of a disease ; it would never have occurred had the circulation of the patient been at its proper tension. It was the result of an ebbing life, not a disease, which caused death. So it is with the gastro- malacia of children. It is the result of exhausting disease of any kind, and is virtually, if not literally, a post-mortem change. AFFECTIONS OF THE STOMACH AND INTESTINES. 213 5. CHRONIC GASTRO-INTESTINAL CATARRH. This disease is common in children who have passed the first dentition, and bears to them somewhat the same relation that chronic vomiting does to infants. Among the latter it is very uncommon, perhaps because the anatomical position and greater irritability of the stomach in the early months of life favor the rapid expulsion of improper or partially digested food, and the irritating products of gastric fermentation, which would other- wise, as in older children, pass through the pylorus and induce catarrh of the intestinal mucous membrane. The disease is met with in two forms, differing merely in the degree of catarrh. For convenience, they may be considered separately ; as, habitual indigestion, in which the catarrh is moderate in degree ; and mucous disease, in which it is intense. HABITUAL INDIGESTION. In the rare cases of this disease, where death has resulted from an intercurrent affection, post-mortem examination has revealed the gastro-intestinal mucous membrane, finely injected, reddened in patches, flabby, swollen and covered with a layer of tenacious mucus of variable thickness. In the majority of cases, though, it is probable that the catarrh does not extend beyond the grade that would leave no gross change after death. Etiology. — The predisposing agencies are deficient functional activity of the stomach, either existing simply as a factor of a weak constitution, or resulting from previous disease or ill-directed hand-feeding. Residence in large cities, and dark, close and damp houses ; too little out-door exercise, and too much con- finement and pushing at school; and finally, the eruption of per- manent teeth, belong to this class of causes. They all act by lowering the capacity to digest, and the best food imperfectly digested undergoes chemical changes rendering it irritant and capable of transforming the normal hyperemia of digestion into the congestion of catarrh. Fewer cases are met with in summer 214 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. than in winter, because during the former season children live more out of doors, and the functions of the skin are more active, keeping a larger quantity of blood at the surface — a great safe- guard against catarrh. Season, then, may be added to the pre- disposing influences. The prime exciting cause is unsuitable food. As a rule, especially with children of the poorer classes, among whom the disease is very rife, the fault lies in the food being too strong. These children are allowed to sit at table and partake of what- ever the elders eat, such as meat two or three times a day, with potatoes, bread and butter and tea, none too well prepared or of too good quality. This coarse food, of itself irritating to the delicate lining of the stomach, is also very difficult to digest. The child may have force enough to maintain a fair degree of health against this odds for a while, and some even win in the race, but for most, the time of trouble surely and soon comes. Some portions of the food begin to escape, more or less com- pletely, the solvent action of the gastric juice. The starches and fats, influenced by the heat of the parts and the organic matter present, undergo fermentation, and are converted into acids with the liberation of carbonic acid gas ; the albuminoids become partially decomposed and acrid. These not only irritate the mucous lining of the stomach, but passing into the intestine, act upon its mucous membrane, and cause the same catarrhal lesions there. At first an attack of vomiting and purging, by cleaning out the alimentary canal, puts an end to the catarrh, and the patient is free from symptoms so long as the resulting anorexia restricts his appetite. But a return to the old diet is quickly followed by a relapse, culminating in another natural effort at relief; and so the attacks recur, growing more and more frequent and easily induced, until what was originally an acute and passing indiges- tion becomes chronic. As soon as the catarrh is established and the interior of the canal is covered with tenacious mucus, the disease begins to react upon and increase itself. For, whatever food is taken is soon AFFECTIONS OF THE STOMACH AND INTESTINES. 215 enveloped by mucus, and this coating prevents the free access of the gastric and intestinal juices, which are solvents and antifer- ments. Mucus, too, is in itself a powerful ferment and increases the formation of irritating substances ; further, by covering the interior of the alimentary canal, it prevents the absorption of what little food is digested, leading to malnutrition, with a de- terioration in the quality of the gastric juice and succus entericus, and leaving more material for chemical change. Thus there is a direct and an indirect reaction. Well-to-do children are spared a coarse diet and, in conse- quence, do not suffer so severely. In them bad food takes the form of rich dishes, pastry, sweets and so forth. Exposure to wet and cold has some excitant influence, though, without the aid of bad diet, it is scarcely sufficient to induce an attack. Symptoms. — When the disease is fully developed, the patient has a spare, delicate appearance, the face wears a languid expres- pion and is pale ; the pallor at intervals increasing very much, or again giving place to flushing of one or both cheeks. The hair is crisp and lustreless. The conjunctivae are sometimes natural, but more often slightly yellow. The skin is cool, dry and rough to the touch, and somewhat sallow in hue. The pulse is weak, but otherwise unaltered. The mucous membrane of the mouth is less pink than normal ; the breath has a heavy, disagreeable odor; the tongue is pale, broad and flabby, frequently indented by the teeth, and covered with a thin, white frosting, which grows thicker, and more yellowish toward the posterior part of the dorsum. Through this coating the enlarged fungiform papillae project, and are redder than the rest of the mucous membrane, but not so highly colored as in acute gastric catarrh. Moderate hypertrophy of the tonsils can frequently be observed, and, as a rule, the cervical lymphatic glands are slightly enlarged. The appetite is variable and perverted, the desire being for highly- seasoned food. After eating, eructations of flatus occur, and small quantities of partially digested food, mixed with thin mucus and intensely sour, are from time to time regurgitated 21 6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. from the stomach. Tympanites is a constant symptom, and when the child is stripped the distended abdomen contrasts markedly with the spare trunk and limbs. Pain is uniformly present. It may be constant or paroxysmal, severe and colicky, or only amounting to discomfort, and either general or confined to cer- tain parts of the abdomen. Usually it is paroxysmal, beginning from two to three hours after meals ; if constant, it is subject to exacerbations at these periods. Generally, too, it is only mod- erately severe, and is confined to the left or right hypochon- driac region. The reason for this limitation being, that in both positions, but especially in the first, the colon makes a sharp turn where the gases, liberated by fermentation, become lodged. On account of the mucus covering the faecal masses as well as the in- terior of the bowel, bringing two slippery surfaces together, the peristaltic contractions are less efficacious, and constipation re- sults. Intervals of two, three, or even nine days elapse between the movements, which are attended by considerable straining, and result in the expulsion of a small number of dark, hard lumps enveloped in mucus. The urine, at times, is scanty and high colored, at others, over abundant and light colored. The diminution is apt to attend exacerbations of abdominal pain. During the day the child is listless, disinclined to play and easily tired, while at night he tosses about the bed in a dreamy sleep. To the above symptoms catarrh of the nasal and bronchial mucous membranes is often added. It is usual for the even course of the disease to be broken by vomiting and diarrhoea. In such attacks there may be slight fever, the tongue becomes more heavily coated, the appetite fails and thirst is increased. The vomited matter at first is composed of acid, partially digested food, mixed with stringy mucus; after- ward, if there be much retching, of more or less bile-stained mu- cus alone. The purging, primarily, unloads the bowel of a large quantity of lumpy faeces, apparently the collection of several days; afterward, the stools are made up of mucus and liquid AFFECTIONS OF THE STOMACH AND INTESTINES. 21 fj faeces. Such attacks last one or two days, and are followed by a brief period of improvement. The Diagnosis is easy. The Prognosis is favorable, though, when left to itself, the disease runs a protracted course, improving in summer to return in winter. By the general debility that it produces, it opens the way to intercurrent affections, or the development of hereditary tendencies, and renders both more fatal. MUCOUS DISEASE. This form of chronic gastro-intestinal catarrh occurs much less frequently than the other. It consists of a mucous flux from the whole internal surface of the alimentary canal, which interferes mechanically with the digestion and absorption of food, and so impedes nutrition as to suggest the presence of tubercles. The lesions are identical in kind with those of habitual indigestion, but are much greater in degree. Etiology. — The affection usually arises between the fourth and twelfth years, and has the same predisposing and exciting causes as the milder form. There are two conditions, however, under which the disease is especially apt to arise, namely : the eruption of the permanent teeth, and attacks of whooping cough. The influence of the former is explained by the intimate sym- pathy existing between the different portions of the digestive tract, on account of which the irritation of the mouth during dentition is reflected throughout the intestinal tract, producing increased secretory activity and greater susceptibility to irritants. During the course of whooping cough, the gastro-intestinal mucous membrane is always in a catarrhal state. Much of the tenacious mucus expelled at the end of each paroxysm comes from the stomach. When vomiting occurs, most of the matter ejected is mucus, and the stools contain a quantity of the same substance. As the cough subsides, the secondary catarrh usually disappears, but after severe attacks, and in feeble children, it may continue, and pass into mucous disease. 2l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Symptoms. — As might be expected from what has already been said in regard to lesions and causation, the symptoms, in the main, are those of habitual indigestion greatly magnified. The child is emaciated and muscularly weak. His face is uniformly pale, though subject to great changes in color, and at times a circumscribed crimson flush appears on one or both cheeks ; at others, there is so much pallor, especially about the lips, that fainting seems imminent, and, indeed, it does some- times occur. The eyes are surrounded by bluish circles, which deepen when the face pales. The conjunctivae are muddy, and there is occasional squinting. The skin is markedly sallow, dry and rough to the touch and, by light friction, numerous fine scales of dead epidermis can be removed, and the hair has a lustreless, faded appearance. The cervical lymphatics are notice- ably swollen, though painless. The oral mucous membrane is pale. The tongue, besides being flabby and indented by the teeth, presents an appearance characteristic of the disease. The dorsum, with the exception of an oval space in the centre, is covered with a light gray coat- ing, scarcely thick enough to obscure the natural pale-pink color, and shows clearly the slightly redder fungiform papillae. The oval bare spot, about as large as a cent, is still deeper red, and shines as though varnished. This glossy look, in very severe cases, extends over the whole dorsum, and is due to an excessive secretion from the mucous glands of the mouth. Such a tongue does not lose the natural velvety appearance arising from the fungiform papillae. (See a, Plate 2.) Chronic hypertrophy of the tonsils, with plugging of the folli- cles by retained secretion, is common, and, in part, accounts for the disagreeable odor of the breath. The appetite in the beginning fails, then becomes capricious, and, finally, almost insatiable. The increased desire for food is due partly to a morbid craving, excited by the irritation of the fermenting contents of the stomach and intestines, and partly to the demand of the tissues generally for more nutriment than is supplied by the imperfect digestion and impeded absorption. AFFECTIONS OF THE STOMACH AND INTESTINES. 219 Eating is followed by a sensation of drowsiness, and by eructa- tions of flatus and acid liquid. Tympanitic disteution of the belly is always marked, and the child complains of pain in this portion of the body. The pain may be general, when it amounts to little more than a sensation of soreness, but more frequently it is limited to the left hypo- chondrium, and is stitch-like in character. Either variety may be constant, or present only after meals ; in the former case there is a temporary increase of discomfort after eating. In some instances, paroxysms of severe pain in the neighborhood of the umbilicus occur early in the morning, and occasionally after meals. These are unattended by nausea, purging, or doubling of the body to secure relief, as in colic, but while they last, the pallor of the face is extreme. Constipation is the usual condition of the bowels. Evacu- ations take place at intervals of several days, with much straining, and at times rectal prolapse ; they are scanty, and composed of small, hard, dark-colored lumps, with a large proportion of mucus, and often contain intestinal parasites or their ova. Sometimes the constipation lasts for a week or more at a time, to be followed by a number of free evacuations in quick succession, relieving the bowel of the accumulated faeces ; then comes another period of confinement, another relief, and so on. By day, the patient suffers from headache ; is languid, ill- tempered, and disinclined for study or play. At night, he is restless ; grinds his teeth ; starts from sleep in terror caused by frightful dreams, and often screams or talks incoherently, and for a time is seemingly unconscious of his surroundings. Som- nambulism and nocturnal incontinence of urine are quite common. Stammering is another nervous symptom occasionally encoun- tered. There is no alteration in the temperature ; the pulse is feeble, and there is frequently a slight, dry, hacking cough, entirely in- dependent of pulmonary disease. The urine is diminished during the continuance of severe pain, but is voided in excessive quanti- ties at the termination of the paroxysms. 2 20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. At intervals of two or three weeks violent vomiting and purg- ing occur. During these attacks, which last from one to three days, a large quantity of mucus is rejected ; there is slight fever, and the tongue is changed in appearance, and for the second time assumes a characteristic aspect. It becomes less flabby, more pointed, and covered with a thick, white, feathery fur, except along the sides, where there are several smooth, bright-red, glazed patches of variable size and shape, with irregular, indented edges. A few red fungiform papillae show through the coating. Sometimes the whole dorsum is clean, red, and glazed, as if de- nuded of epithelium. (See b> Plate 2.) Temporary improve- ment follows the clearing-out process, but soon the symptoms return, and slowly grow worse to culminate in another attack. The course of the disease is very chronic, extending over months. There is no regular progression, though the tendency is for the symptoms to grow more and more severe as time elapses. Diagnosis. — Tuberculosis is the condition most likely to be confounded with the disease in question, and the mistake is especially apt to be made when a dry, hacking cough is present. The appearance of the symptoms after whooping cough or dur- ing second dentition; the state of the tongue; the mucous stools; the condition and color of the skin ; the absence of pyrexia except during the attacks of vomiting and purging ; the perio- dicity of these attacks; the diurnal drowsiness and nocturnal terrors, and the irregularity in the course are the distinguishing features. Prognosis. — Mucous disease is not in itself mortal, and is per- fectly amenable to treatment. It is, nevertheles, dangerous from its power to reduce the general nutrition, thus opening the way for more serious intercurrent affections. As the plan of managing both forms of chronic gastrointes- tinal catarrh is the same, it is unnecessary to divide the subject of — Treatment. — Since the exciting cause is perfectly well known and removable, relief may be confidently promised, provided it AFFECTIONS OF THE STOMACH AND INTESTINES. 221 be possible to regulate the diet. There are two rules to be in- sisted upon : first, to stop the supply of all those articles of food that readily undergo fermentation ; and, second, to allow only a moderate quantity of food at a time, so as not to overdistend the stomach, while the meals are increased to four a day, to insure the ingestion of a proper amount of nourishment. All farinaceous substances must be excluded from the dietary save stale or toasted bread, and this, even, must be restricted in amount. Potatoes, peas, beans, turnips, carrots, parsnips, fruit, cakes, pastry, sweetmeats and butter are all in the proscribed list. Of permissible articles, milk, eggs, and lean meat are the chief, though fresh fish, raw oysters, cauliflower tops, spinach, aspara- gus, lettuce and celery can be used without ill effect. With such food to select from, it is easy to write out a suitable diet list and make changes sufficiently often to avoid cloying the appetite by monotony. In writing such lists, it is best to fix the hour, as well as the ingredients, of each meal. For example : — Breakfast, at 7 a m. — One or two tumblerfuls of milk guarded by lime-water* (fgij to fgvj), the yolk of a soft-boiled egg 9 and a single thin slice of stale, unbuttered bread. Luncheon, at 11 a.m. — A cup (fj iv) of beef-tea, or mutton broth, entirely free from fat,f and a thin slice of dry toast. Dinner, at 2.30 p.m. — Broiled mutton chop, entirely free from fat, one or two, according to the size ; a large spoonful of well- boiled spinach, and a slice of stale, dry bread. Supper, at 7 p.m. — One or two tumblerfuls of milk guarded by lime-water, and a slice of dry toast. Filtered water must constitute the drink, though, if the child will take it, half a tumblerful of Vichy at luncheon and dinner can be recommended. * The lime-water is added both for the purpose of retarding coagulation and for its effect upon the mucus in the alimentary canal. f The fat can be completely removed by allowing the broth to stand for a few minutes after it is made, and picking oif the globules of oil as they rise to the surface with a fragment of blotting-paper. 2 22 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Should failing appetite demand a change, another menu must be made, as : — Breakfast. — Milk, a bit of boiled fresh fish, and a thin slice of unbuttered toast. Luncheon. — The soft parts of six or eight small oysters, sea- soned with salt alone, and a Boston cracker. Dinner. — A bit of the breast of a roasted or boiled fowl, a moderate portion of well-boiled cauliflower tops, and a slice of stale, dry bread. Supper. — Milk and dry bread. Further variety can be had by substituting a thin slice of cold roast mutton or beef for the egg or fish at breakfast; at dinner, by running the changes on roast mutton, broiled beef-steak, roast beef, plainly cooked game, and such vegetables as stewed celery, boiled asparagus tops, spinach and cauliflower; by using different sorts of meat broths, and by changing the manner of cooking the eggs. When, in mucous disease, there is great debility, stimulants are indicated. They should be given well diluted and with the meals. Whiskey and old dry sherry are the best. Of the first, one or two teaspoonfuls in a fourth of a tumbler of ice-water may be given with lunch and dinner; of the second, one or two tablespoonfuls with twice as much water at the same meals. Next to regulating the diet it is important to maintain the activity of the skin. This is to be accomplished by baths, in- unctions and proper clothing. Each morning the patient, being in a warm room, should be sponged with water at a temperature of 6o° F., then thoroughly rubbed down with a coarse towel, and the whole body anointed with warm olive oil, which ought to be gently rubbed into the skin with the finger pulps. At bedtime a full bath of ioo°, of five minutes' duration, must be given, and the inunction repeated, after careful drying with friction. In severe cases, where the skin is very dry and rough, the first warm bath should contain a heaped tablespoonful of soda, and with this and soap the whole surface must be thoroughly scrubbed. Woolen underclothing, to cover completely the trunk and AFFECTIONS OF THE STOMACH AND INTESTINES. 223 limbs, and woolen stockings are to be insisted upon. The weight may be changed with the weather, but not the material. This not only keeps the skin warm, full of blood and functionally active, but it also maintains the heat of the whole body and saves force. Children dressed for beauty with four or five inches of bare leg, nine times out of ten suffer from chronic indigestion or bronchitis. First, because chilling of the surface drives the blood toward the interior and puts the mucous membranes in the most favorable conditions for catarrh ; secondly, because so much force is consumed in maintaining the normal temperature in the face of constant chilling that other functions, notably the digestive, must suffer. Parents would appreciate this better if they could be persuaded to try the experiment of sitting, for an hour or so, even in a warm room, in the same degree of naked- ness that they inflict on their children, who are less robust and less able to resist cold. Exercise in the open air on suitable days in winter, and an almost complete out-door life in summer, hastens recovery. The sleeping and living rooms should be large, light, dry, well ventilated and properly warmed. Medicinal treatment is of minor importance, but by no means to be neglected. The indications to be fulfilled are to check the secretion of mucus ; to neutralize the acids formed by fermenta- tion of the food ; to restore the mucous membrane to a normal condition, thereby improving secretion, digestion and appetite, and to secure regular action of the bowels and the expulsion of collected mucus and faeces. These accomplished, strength and health return, though it may be necessary to call in the aid of tonics. Alkalies are the best remedies to check the secretion of mucus, and to liquefy it so that it may more readily be removed. They are also most efficient in neutralizing the acid products of fer- mentation. Simple bitters, too, have some power in lessening the formation of mucus, and considerable influence in arresting fermentation ; at the same time they give tone to the mucous 2 24 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. membrane and stimulate digestion. Laxatives keep the bowels clear. Of the first class, bicarbonate of sodium ; of the second, gentian or calumba ; and of the third, senna or aloes, are to be preferred in treating this disease. In habitual indigestion, a combination like the following will be all that is required : — R. Sodii Bicarbonatis, gj. Ext. Senn?e Fluid., f.^iij* Inf. Gentianae Comp., q. s. ad f^iij. M. S. — Two teaspoonfuls three times daily before eating, at the age of seven years.* Should there be yellowness of the conjunctivae and marked sallowness of the skin, indicating a slight degree of catarrhal jaundice, it is well, at first, to substitute equal doses of chloride of ammonium for the bicarbonate of sodium in this prescription. In mucous disease a similar prescription, with minute doses of iodide of potassium to increase the salivary secretion, may be ordered before meals, as: — R . Potassii Iodidi, gr. vj. Sodii Bicarbonatis, £j. Ext. Sennse Fid., f.^'ij- Inf. Calumbae, q. s. ad f § iij. M. S. — Two teaspoonfuls three times daily before eating. After food, it is well to order from ten to twenty drops of tinc- ture of myrrh in a little water, for its powerful tonic action on the intestinal mucous membrane. Aloes is valuable not alone as a laxative, but in arresting the mucous flux and bracing the mucous membrane. It can be administered in the form of tincture of aloes and myrrh, in doses *A11 of the subjoined prescriptions are proportioned for children of this age. AFFECTIONS OF THE STOMACH AND INTESTINES. 225 of twenty drops, three times daily after eating. Or, if the child be able to swallow a pill, it may be combined thus: — U . Pulv. Ipecacuanha, gr. iv. Pil. Aloes et Myrrhae, gr. xij. Ext. Gentianae, gr. vj. Ext. Taraxaci, gr. xij. M. et ft. pil. No. xij. S. — One pill three times daily an hour after eating. When there is much debility iron is demanded, and if the pro- per form be selected, it may be given in spite of a coated tongue, the usual contraindication. A good formula is: — R. Ferri Sulphatis Exsiccati, gr. xij. Tr. Aloes et Myrrhse, ^E 1V - Syr. Rhei Aromat., q. s. ad f^iij. M. S. — One teaspoonful three times daily after meals. From this prescription there is an astringent action, by the iron and rhubarb, which tends to check the formation of mucus ; a laxative action, by the aloes and rhubarb, keeping the bowels clear of mucus and faeces ; while the myrrh is a direct tonic to the relaxed mucous membrane. If, as the tongue cleans, the improvement under this plan comes to a stand, it is advisable to change to an acid treatment. There are several useful prescriptions, for instance : — R. Pepsin. Saccharat., ^ij. Acidi Muriatici dil., f 3 ij. Aquae Cinnamomi, q. s. ad f^iij. M. S. — One teaspconful three times daily after eating. Or the acid may be combined with a bitter : — R. Acidi Muriatici dil., f^ij. Inf. Gentianae Comp., q. s. ad f^iij. M. S. — One teaspoonful three times daily after meals. *9 2 26 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. R . Quinise Sulphatis, gr. xij. Acidi Muriatici dil., fgij. Aquae Cinnamomi, . . . . q. s. ad f^iij. M. S. — One teaspoonful three times daily after meals. All of these prescriptions must"" be well diluted and taken through a glass tube. During the periodical attacks of vomiting and diarrhoea, so apt to occur in both forms of the disease, the child must be put to bed, restricted to a diet of milk and meat broths, and ordered the following prescription : — R . Pepsinae Saccharat., Sodii Bicarbonatis, aa ^j. Pulv. Aromatici, gr. xij. M. et ft. chart. No. xij. S. — One powder four times daily. The diarrhoea must not be interfered with unless it become excessive, when it may be held under control by adding five grains of subcarbonate of bismuth to each of the alkaline powders. After the tongue becomes normal and the active symptoms have disappeared, the general strength must be built up by a course of tonics. The best, are tincture of nux vomica, ferrated elixir of cinchona, and bitter wine of iron. In order to prevent a relapse, mixed diet must be avoided for at least two months after convalescence is fully established, and to confirm the cure, change of air, by a trip to the sea-shore or mountains, is ad- visable. Both habitual indigestion and mucous disease are occasionally attended by a troublesome symptom that demands brief con- sideration. This is a peculiar cough, which is dry, paroxysmal, and unattended by lesions of the throat or lungs. The par- oxysms are due to reflex causes ; they commence in the early evening, and may, by their repetition, prevent sleep for half the night. On the following day the patient is as well as usual, or coughs only at long intervals, but about bedtime the trouble begins again. So the symptom continues for weeks at a time, AFFECTIONS OF THE STOMACH AND INTESTINES. 227 unless its true nature as a " stomach cough " be recognized and it is properly treated. The paroxysms suggest those of pertussis, though they may be distinguished by the absence of whooping, and of the characteristic expulsion of tenacious mucus at the end of the kinks. Questioning often reveals the fact that the cough is worse after a rich and heavy supper: If proper clothing be worn, the diet carefully regulated, and alkalies prescribed, as for an ordinary case of chronic gastro- intestinal catarrh, improvement is rapid, for in this way the cause is removed. Ordinary cough mixtures do more harm than good, from their tendency to derange digestion ; still, the fatiguing cough must be relieved. This can be done by letting the child wear a small bean-shaped belladonna plaster over the larynx, and administering a dose of one of the following mix- tures every two hours, beginning at four o'clock in the after- noon : — R. Pulv. Aluminis, gr. xlviij. Potassii Bromidi, £ij. Syrupi Zingiberis, Aquae, aa f g iss. M. S. — Dose, one teaspoonful. Or— R . Ext. Belladonnae, gr. ss-j. Pulv. Aluminis, gr. xlviij. Syrupi Zingiberis, Aquae, aa f g iss. M. S. — Dose, one teaspoonful. 6. ACUTE INTESTINAL CATARRH. The condition intended to be indicated by this title is usually called simple or non-inflammatory diarrhoea, and classed as a functional disease. But from its etiology, and from the fact that in certain patients and under certain circumstances it so readily lapses into entero-colitis, it is more than probable that it depends 2 28 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. upon a distinct, though passing lesion — a hyperemia or catanh of the intestinal mucous membrane. This is difficult to demon- strate, partly because the opportunity for post-mortem inspection is rare in simple diarrhoea, and also on account of the well- recognized rapidity with which the appreciable manifestations of mild .forms of catarrh disappear after death. Nevertheless, even those authors who advocate the functional character of the affec- tion, state that in some instances of death, in feeble children or from intercurrent disease, autopsy shows injection, swelling, and relaxation of the mucous membrane, and tumefaction of the intestinal glands. Etiology. — Constitutional feebleness and unfavorable hygienic surroundings, especially residence in crowded, damp, and filthy houses and quarters of cities, increase the liability to attacks of diarrhoea. Many more cases occur in summer than at other seasons of the year. Children of either sex, or of any age, may be affected, though the younger the patient the more serious the disease. In infancy there are numerous exciting causes. Over-feeding, even with healthy breast-milk or well- prepared cows' milk, is one. Ordinarily, in such cases vomiting is so easy that the child gets rid of the surplus and no harm is done ; but if this does not happen, the excess remains undigested ; undergoes change ; acts as an irritant to the intestinal mucous membrane, and causes diarrhoea. Another cause is food of bad quality ; either poor and cholesterin-laden breast-milk, or unsound cows' milk and farinaceous preparations. Here the action is the same as in over- feeding, though more rapid and violent ; this is especially true of the farinacea, on account of their readiness to undergo acid fermentation. Again, exposure to cold and wet, by chilling the surface and determining the blood to the interior of the body and mucous membranes, may lead to an intestinal catarrh in the same way that it does, more frequently, to a bronchial catarrh. Hyperaemia, too, of the mucous membrane of the alimentary tract is attended by a diminution in the secretion of digestive solvents and an increased production of mucus; two conditions most AFFECTIONS OF THE STOMACH AND INTESTINES. 229 favorable to incomplete digestion and fermentation of the food with the formation of irritant products. These, as already seen, are quite capable, in themselves, to cause looseness of the bowels, and must greatly add to the ill effects of exposure. High atmos- pheric temperature is much more influential than low, particu- larly when associated with excessive moisture. Such conditions are powerful depressants to the vital forces; the digestion shares in the general weakness, and much of the food is left to ferment and become irritant. Finally, dentition is a frequent cause. During this process, the whole digestive tract sympathizes with the condition of the mouth, and becomes less able to perform its functions and more susceptible to irritants. After the eruption of the milk teeth the use of unsuitable food and the disturbing influences of second dentition are the chief causes. It is almost unnecessary to call attention to the lesson taught by this study of the etiology. There is, on the one hand, the presence of an irritant as a constant factor ; on the other, a mucous membrane naturally delicate and functionally very active. The conclusion is inevitable, that the ordinary effect must follow, and hyperaemia or catarrh be produced. Symptoms. — In infants, the attack may begin suddenly, or be preceded for twenty-four hours or more by peevishness, languor, faded cheeks, slight abdominal pain, indicated by moaning or fits of crying, and restless, disturbed sleep. Next, the bowels become disturbed. The movements number from four to eight in the twenty-four hours, and usually occur only while food is being taken — from six in the morning to ten o'clock at night. At first they differ from the normal, merely in being more liquid and copious, and having a more offensive odor. As the disease progresses they undergo various changes. Some- times they are composed of a yellowish liquid containing white or yellowish flakes resembling curdled milk. At others, distinct white lumps of undigested curd are mixed with the liquid. Still again, green flakes may appear in a stool having the characters of the first ; and finally, the whole may be of a deep green color, 230 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. and contain small masses of mucus. In exceptional cases a small amount of bright- colored blood may be seen in the evacuations. Often the movements are preceded, for a short time, by pain, but this disappears as soon as the act is accomplished. Occasionally, if the stools be acid, considerable tenesmus attends their expul- sion, and it is under such circumstances that blood is most likely to be voided. The tongue is lightly coated ; there is anorexia ; increased thirst, and occasionally nausea and vomiting. The abdomen is natural in shape, and is soft and painless on palpation. The urine is somewhat lessened in quantity, and high colored. There is no pyrexia, and the pulse is but slightly increased in frequency. The evil effect of several days' continuance of diarrhoea upon the general condition of the child is shown by the pallor of the face, the sunken eyes, the loss of weight and the flabbiness of the muscles. Under proper management the attack terminates in from four to seven days, and strength is soon restored. Simple diarrhoea is more uncommon in older children and much milder in its manifestation. There is slight furring of the tongue, loss of appetite, and abdominal pain of a colicky nature, with more or less frequent evacuations of light yellow, offensive, semi-solid or liquid faecal matter, at times containing masses of partially digested food. The patient is weak and disinclined to exert himself. These attacks last for three or four days, and are followed by little constitutional depression. Diagnosis. — There is no difficulty in distinguishing the disease. The only conditions for which it could possibly be mistaken are tubercular diarrhoea and entero-colitis. The former is excluded by the history and course of the case and by lack of evidence of tuberculosis of other portions of the body ; the latter, by the apyrexia and the non-existence of symptoms indicating intestinal inflammation. Prognosis. — The result of even the more serious attacks in infants is, in the great majority of cases, favorable ; nevertheless, it must not be forgotten that an acute catarrhal diarrhoea, when it occurs in a weak, ill-fed and badly cared-for child during hot AFFECTIONS OF THE STOMACH AND INTESTINES. 23 1 weather, has a tendency to run into entero-colitis, and thus prove fatal. An infant, too, may be so debilitated by previous illness as to be carried off by an attack of ordinary severity. Treatment. — Before entering into the details of the manage- ment of this disease, it is necessary to draw attention to the con- servative nature of the diarrhoea. The frequent, loose and copious stools clear the intestines of irritant matter, and remove the cause of further trouble. Consequently, it is never advisable, early in the course, to completely arrest the evacuations, although at the same time they must be kept well in hand, lest the attack pass into entero-colitis. During dentition, particu- larly, this caution must be observed, for when there are three or four loose passages daily, cerebral symptoms are much less apt to arise. As in other digestive disorders, the most essential step is to attend to the feeding. With infants nursed at a healthy breast it is enough to see that they are not fed too frequently, and to lessen the quantity taken by shortening each act of sucking. If, from any cause, the breast-milk be unsuitable, the babe must be weaned and carefully fed by bottle. In hand-fed babies it is necessary, first, to insist upon the use of the old-fashioned bottle and tip, and to see that they are kept absolutely clean. Next, to banish all farinaceous preparations, used purely as foods, from the diet. This does not preclude the employment of small quantities of arrow-root or barley-water for the purpose of breaking up the milk curd. Thirdly, to direct that the daily supply of milk — the only food to be allowed — must come from one dairy ; be received fresh in the morning, and kept in a separate, perfectly clean vessel, and, if possible, in an especial refrigerator. And finally, to give careful, written orders as to the manner of pre- paring the milk food, and to make a rule that each bottle shall be mixed separately and only immediately before it is required. In hot weather it is advisable to sterilize the whole supply of milk, but this does not affect the principle of the separate preparation of each portion. As guides to the manner of preparing the food, two formulae 232 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. may be given ; they are proportioned for children of four to six months. Unskimmed milk, fg iijss. Cream, fgss. Lime-water, f ^ Ij. Mix these in a clean bottle, and warm by standing in hot water. Five to six bottles to be taken during the day. Or— Unskimmed milk, f ^ iijss. Cream, f^ss. Arrowroot water,* f^ij. Sugar of milk, gj. Mix and treat as before. The quantity is to be reduced and the dilution increased in pro- portion to the youth of the infant, and the reverse as age increases. Sometimes in children of one or two months a cream and whey mixture suits better, as : — Fresh cream, fgj. Whey, fgij. Hot water, f^ij- When there is thirst, cool water and bits of ice ought to be given with moderate freedom. The sleeping room should be airy, well ventilated, and, in hot weather, the coolest the house affords. Soiled diapers, or the vessel containing a stool, must not be left about. In summer the patient should pass the mornings and evenings in the open air, and the hot mid-day in a cool room. A day's excursion on a steamboat, or to the country, if the journey be short, is very beneficial, while a trip to the sea-shore works wonders ; a single day passed in salt air often removing every trace of the disease. Even in winter, if an attack occurs, the child, well wrapped up, * Take one and a half teaspoonfuls of arrowroot, rub it down with a table- spoonful of cold water until smooth, and add, with stirring, a pint Of boiling water. AFFECTIONS OF THE STOMACH AND INTESTINES. 233 should be taken out for an hour at noon on warm, sunny, still days. The daily bath must be continued, and in hot weather a bath morning and evening is none too much. Woolen drawers and shirts of the lightest texture must be worn in summer, and if the diarrhoea prove at all obstinate, the abdomen must be enveloped in a light flannel bandage. The condition of the mouth must always be investigated, and if the gums be hot and swollen, from approaching teeth, lancing is indicated. If there be much pain, with hardness of the gums, relief can be obtained by rubbing them gently at intervals with paregoric and water, ten drops to the teaspoonful, or with a solu- tion of chloride of zinc, one grain to the fluidounce. When these measures are carefully carried out in mild cases, medicines are often unnecessary. In those more severe, it is well to assist nature and begin the treatment with a laxative. Pain, green stools and the presence of blood always indicate this course. The best laxative is castor oil. This not only efficiently clears away the irritating contents of the intestines, but has a second- ary, soothing action upon the mucous membrane. For a child of six months, the dose is a teaspoonful, with five drops of cam- phorated tincture of opium to prevent griping. After this has operated, a teaspoonful of chalk mixture every two hours will complete the cure in some instances. A more effi- cient prescription, however, is : — R . Sodii Bicarbonatis, 3 ss. Syrupi Rhei Aromat., f.l ss « Aquae Menthae Pip., q. s. ad f§iij. M. S. — Teaspoonful every two hours. The great value of rhubarb depends upon its combined laxa- tive and astringent action, precisely what is required in simple diarrhoea. Should the stools still fail to become less frequent and more 20 234 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. natural in color and consistence, resort must be made to opium and astringents. A very good formula is: — R . Tr. Opii Deod., TT\,vj. Bismuth. Sub-nitrat. (Squibb) , £j. Syrupi, fgss. Misturse Cretse, q. s. ad f^ iij. M. S. — Teaspoonful every two hours. The value of calomel in certain cases where the evacuations obstinately remain green and acrid must not be overlooked, though the necessity for its use is rare. It must be employed cautiously and in small doses, and combined with an alkali, thus : — R • Hydrargyri Chloridi Mit., gr. j. Cretae Praeparatae, gj. M. et ft. chart. No. xij. S. — One powder every two hours. Its good effect should be noted in twenty-four hours, then it must be discontinued, and one of the other prescriptions given. When the stools become normal, wine of pepsin must be ordered for a week or more until the digestion is put upon a sound footing. In older children the treatment is very simple. All that is required is a bland diet, perhaps a dose of castor oil, and some mild astringent mixture. For example, let the patient take for breakfast— a soft-boiled egg ; milk guarded with lime-water, and stale, dry bread ; for dinner — some meat broth, free from fat ; stale, dry bread, and rice and milk pudding ; and for supper — milk, and stale, dry bread. The opium and bismuth mixture already given, increased in dose proportionately to the age, is very serviceable, or a combina- tion of aromatic syrup of rhubarb and chalk mixture may be used. As with infants, a course of wine of pepsin, or pepsin with muri- atic acid, should terminate the treatment. AFFECTIONS OF THE STOMACH AND INTESTINES. 235 7. CHRONIC INTESTINAL CATARRH- CHRONIC ENTERO-COLITIS. Chronic diarrhoea, as this condition is frequently termed, is a common and fatal disease in infants. When it occurs after the completion of the first dentition it is less dangerous to life, though it runs a protracted course and interferes greatly with nutrition. Morbid Anatomy. — As with other catarrhs, the absence of appreciable lesions is quite possible; but usually the mucous membrane of the colon is studded with minute, dark spots — the shaven-beard appearance — which the microscope shows to de- pend upon rings of vascular injection around the orifices of the follicles. In some instances there is deep congestion, limited principally to the summits of the longitudinal plicae, while in others, ulcers are also found. These ulcers are shallow, and either elongated and narrow, when they occupy the summits of the plicae, or small and circular, when they are seated between the folds. They are best seen by looking obliquely at the surface of the gut. Together with the ulcers there are numerous pearl-like projections, surrounded by narrow rings of congestion. These are enlarged solitary glands, and it is to their suppuration that the round ulcers are due. The whole mucous membrane is softened and thickened, unless the disease has been of very long duration, when it becomes extremely thin. The mesenteric glands are swollen and may even be caseous. In exceptional cases, the lower portion of the ileum presents the same changes as the large intestine. Etiology. — Entero-colitis, or a series of attacks of simple diarrhoea, may establish chronic diarrhoea ; but the disease fre- quently arises insidiously from the constant action of the great exciting cause — improper food. This cause is most operative in hand-fed infants, and at the time of weaning, but it affects nurs- lings who are supplied with poor breast-milk or allowed to eat bits of table food, and also older children. Exposure to wet and cold is another excitant ; so, too, are 236 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. various acute diseases, notably measles, croupous pneumonia, typhoid fever, variola and scarlet fever. The predisposing agencies are bad hygienic surroundings, particularly over-crowding. In regard to age, the period of greatest liability as well as greatest fatality, is from birth to the end of the second year ; afterward it grows less common as age advances. In our climate the greater number of cases originate in early spring and autumn, when the weather is most change- able ; and late winter, when it is cold and damp. Symptoms. — The first indication of the disease is an alteration in the character of the stools. These assume the color and con- sistence of putty, and are composed of curd and farinaceous mat- ter, with semi-solid faeces, and, at times, mucus and streaks of blood. They are voided with much pain and straining, but are little, if at all, increased in frequency. Their odor is offensive and sour. The face is pale and listless in expression, though the child is sufficiently lively, takes his food well and has no fever. These symptoms continue with trifling change for two or more months, the patient gradually becoming thinner, paler and more languid. Then for the first time diarrhoea, sufficiently marked to arrest the nurse's attention, sets in. The evacuations now have a putrid odor, but vary considerably in other characters from day to day. They may be thin, liquid and brownish like dirty water ; or clay-colored, of the consistence of thin mud ; or watery, with particles of grass-green matter (from altered blood); and finally they may be slimy and contain whitish masses of undi- gested curd or particles of other food. The number of move- ments varies from ten to thirty in twenty-four hours ; their fre- quency depending upon the amount of food taken and, to some degree, upon the weather ; being greater on moist, cold days, than on warm, dry ones. They are preceded by pain, indicated by crying or uneasy movements of the legs, and are attended with straining, sometimes sufficient to cause prolapse of the rectum. The tongue is, usually, natural, though at times the tip and edges are too vividly red and the fungiform papillae too promi- AFFECTIONS OF THE STOMACH AND INTESTINES. 237 nent. The appetite is normal, or even increased ; nevertheless wasting is continuous. The skin grows pale, dry and harsh, and assumes a peculiar earthy tinge, which is deepest over the ab- domen. The eyes are sunken and surrounded by dark circles ; the lips are bloodless and thin ; the nasal lines of Jadelot are marked, and the fontanelle is depressed. The abdomen may be soft and flaccid, but oftener is distended with flatus, and then is the seat of pain, manifested by moaning and twitching of the corners of the mouth. Palpation is painless unless there be ul- ceration ; in the latter case there is tenderness, and the contact of the hand causes borborygmus. The skin on the internal as- pect of the thighs and the nates is reddened by intertrigo, due to the irritant action of the faeces and urine. Prostration is so great that the child lies perfectly passive ; the pulse is feeble and fre- quent ; the temperature is not elevated, but, on the contrary, the hands and feet often feel cold, and have a bluish color. The urine is diminished in quantity and retained for long periods. With occasional brief intervals of improvement the condition gradually grows worse. The stools become more watery ; look like chopped spinach floating in brown, putrid water, and may contain mucus and pus with blood, in brownish-yellow masses. Abdominal distention, tenderness and gurgling, the signs of in- testinal ulceration, are present. The appetite is capricious or lost. The face becomes thin and pinched; the forehead is wrinkled ; the hair dry and lustreless, and the whole expression that of a puny, weak, old man. General wasting progresses until the body seems to consist of little more than the bones, which stand out prominently with the muddy, harsh, flaccid skin hang- ing from them in folds. To this emaciation the distended belly stands in marked contrast. The fontanelle, at this stage, is deeply depressed ; the pulse feeble ; the breathing superficial, and the temperature sub-normal, being sometimes as low as 97. 5 F. in the rectum. As the end approaches, the nasal lines increase in depth ; the lips are red, fissured and encrusted with scales; the tongue dry, 238 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. red and rasp-like from enlarged fungiform papillae, and the whole oral mucous membrane is covered with aphthae or thrush patches. A fetid odor hangs about the body. The feet and hands are cold, purple and cedematous. The little sufferer lies quiet, with half- shut, lustreless eyes ; from time to time an expression of pain flits over his face, but he is too weak to cry. Finally, there is no evi- dence of living, save the slow rise and fall of the chest as the breath comes and goes, and gradually this ceases, so gently that it is difficult to decide upon the exact moment at which life passes away. It is not uncommon for the discharges from the bowels to stop entirely for several days before the fatal termina- tion. This circumstance alone has no favorable significance. Death may result from exhaustion, or several complications may arise and hasten this event. These are serous effusions, hypostatic pneumonia, exanthemata, convulsions, and thrombosis of the cerebral sinuses. Serous effusion may take place into the pleurae, peritoneum and pericardium, but usually occurs in the form of oedema of the feet, hands, and, at times, the face. It is due to the impoverished condition of the blood and want of tonicity in the vascular walls. Hypostatic pneumonia , due to the constant dorsal decubitus, is a common cause of death. The exanthemata are very prone to attack the subjects of chronic diarrhoea, probably on account of the attendant prostra- tion reducing the power of resisting contagion. Convulsions are only dangerous in the early stages of the attack ; later, the nervous irritability is so blunted that this complication is rare. Thrombosis of the sinuses of the brain depends upon the with- drawal of the liquid elements from the blood by the diarrhoea. Water is then absorbed from the brain, lessening its bulk. The resulting vacuum, together with atmospheric pressure from with- out, leads to depression of the fontanelle, and even overlapping of the cranial bones in young subjects. If this be insufficient to compensate, the cerebral sinuses and blood vessels become en- gorged with blood, and as the naturally sluggish current in the AFFECTIONS OF THE STOMACH AND INTESTINES. 239 sinuses is rendered more slow by inspissation of the blood and feebleness of the heart, the conditions for clotting are most favorable. At the autopsy, the clot is usually found in the longi- tudinal sinus, completely obliterating the channel ; it is laminated, whitish, and adherent to the walls of the sinus, which are free from signs of inflammation. The veins that enter the sinus are distended with blood. The symptons preceding death from this complication are difficult respiration; stupor; dilatation of the pupils and strabismus ; spasms of the posterior cervical muscles ; fulness of the jugular veins, and unilateral facial paralysis. When the case tends to recovery, the evacuations become more solid and natural in odor and color ; the latter change being caused by the reappearance of bile. The semi-stupor disappears, and the child grows very irritable, often crying out and shedding tears — a most favorable omen. The flesh, also, begins to return, the buttocks being the first part of the body to show the improve- ment. Diarrhoea is, after a time, succeeded by a constipated condition of the bowels. Convalescence is protracted. Children over two years of age, when affected with chronic diarrhoea, are pale, thin, languid and readily fatigued. Irrita- bility of temper, night terrors, and nocturnal incontinence of urine are common. The tongue is red at the tip and edges, with prominent papillae, and perhaps light frosting. The appetite may be normal, craving or capricious. The stools vary in number from three to twelve in twenty-four hours ; in the former case they are semi-solid, light colored, and mixed with minute masses of green or colorless mucus ; in the latter, they consist of dark liquid, containing lumps of clay-colored faeces ; this variation bears some relation to the state of the weather. The evacuations are always fetid in odor, and the act of defecation is attended by pain and straining. The abdomen is distended by flatus. Feebleness of the pulse is proportionate to the general weakness ; respiration is unaltered, and there is no pyrexia. In some instances the stools are limited to four or five a day, and are composed almost completely of undigested food and mucus. One evacuation occurs in the morning, soon after rising ; 240 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. the others during or immediately after meals. They are preceded by griping pain and by so urgent a desire, that the patient has difficulty in waiting for the chamber or reaching the closet. The condition undoubtedly depends upon great irritability of the intestine and exaggerated peristalsis. Diagnosis. — The diarrhoea of chronic catarrh is to be distin- guished from that of tuberculosis of the intestines ; the only condition with which it is likely to be confounded. Should it begin soon after birth or at weaning ; if there be a history of bad feeding or exposure, and if there be no constant elevation of temperature, the affection is probably catarrhal. A temporary rise in temperature may be caused by the eruption of teeth or other passing irritation, and is of no diagnostic importance. Tuberculous diarrhoea, on the contrary, occurs after the third year, and is attended by pyrexia and enlargement of the mesen- teric glands. On pressure there is tenderness and gurgling in the right iliac fossa, and tension of the abdominal wall over this region. There is also evidence of tuberculosis of the lungs. The evacuations, too, are distinctive ; they are intensely fetid, brown and liquid, when passed, but, on standing, deposit a dark sediment, composed of flocculent matter, with small, black clots of blood, and little masses of mucus, and pus. The presence, therefore, of these features or their absence, while the symptoms of catarrhal diarrhoea are observed, will determine the nature of the affection in. children who have passed the age of infancy. Prognosis. — Chronic intestinal catarrh is fraught with great danger when it attacks children under the age of two years. It is particularly fatal when it follows an acute disease ; when it occurs in syphilitic, rachitic or feeble subjects, and when it is complicated by measles or other exanthem. Unfavorable symp- toms are dryness and roughness of the tongue ; thrush ; anasarca ; features indicating intestinal ulceration, great depression of the fontanelle, and extreme emaciation. Favorable symptoms are normal progression of dentition ; the reappearance of tears ; in- termissions in the diarrhoea, and improvement in the character of the stools and general symptoms. AFFECTIONS OF THE STOMACH AND INTESTINES. 241 Treatment. — As the disease is produced by over-crowding, neglect, exposure, and unsuitable food, the initial measures of treatment must be the regulation of the hygiene, clothing and diet. The sleeping-room must be kept at a uniform temperature — between 64 and 68° F. — it must be dry, well-ventilated, and, if possible, heated, in cold weather, by an open wood-fire, and occupied by no one but the patient and nurse. During the day the patient must be moved to another room, being wrapped in a blanket if cold halls have to be passed. This room should be large, well-ventilated, dry, and kept at the same temperature as the first. After the removal, the windows of the sleeping-room should be opened, and the bed and its linen thoroughly aired and freshened. Soiled diapers or chambers containing stools are to be removed at once, and no cooking is to be done in either room. The child's person must be kept clean, and it is especially important to sponge the perineum and nates with warm water after each movement of the bowels ; and, if there be any red- ness of the skin, to anoint the parts with oxide of zinc ointment, or powder them. It may be impossible to carry out this plan among poor patients, but it can be approximated by keeping the baby clean, out of the kitchen and away from the door-step. As to clothing, the body must be clad in woolen from the neck to the toes, and, as an additional protection, a broad flannel, abdominal belt must be worn. So clothed, the patient may be taken into the open air on dry days, during the early stages of the attack. Soiled garments are to be replaced at once by fresh ones, and diapers must be washed when soiled ; not simply dried and used over again. The diet should vary with the age of the patient. The great principle being to maintain the general nutrition with the least amount of irritation of the intestinal mucous membrane. Infants partly nursed and partly bottle-fed do best when restricted to the breast, provided the latter be healthy. If the diarrhoea does not improve under the change, both the intervals and the time of nursing must be shortened. 242 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. If the infant be hand-fed, every precaution must be taken to insure purity of food and perfect cleanliness of the feeding ap- paratus. The latter must consist of a simple bottle and tip, unless the amount to be given be very small, when a teaspoon can be used. The quantity of food and intervals of feeding always depend upon the degree of diarrhoea ; thus, in very severe cases, not more than a teaspoon fui every fifteen minutes can be allowed. The quality depends upon the age. For an infant under six months, cows' milk and lime-water, in the proportion of one part to two, or in equal quantities, may be tested. If this undergoes acid fermentation, fresh whey and veal or chicken broth, with equal quantities of barley-water, may be substituted. A teaspoonful of Mellin's food, dissolved in whey, barley-water, or diluted broth, makes an admirable food. At the age of six months, a good scale of diet when milk cannot be taken is: — First meal, 7 a.m. — One teaspoonful of Mellin's food dissolved in six ounces of veal broth and barley water, in equal parts. Second meal, 10 a.m. — One tablespoonful of cream in six ounces of freshly prepared whey. Third meal, 1 p.m. — Same as first, with chicken broth in place of veal broth. Fourth meal, 5 p.m. — Same as second. Fifth meal, 10 p.m. — Same as first. After a week or more of improvement, milk may be resumed gradually, in the beginning at the first meal only ; then at the first and last, and so on. Should these foods disagree, they must be discontinued and the child fed upon meat juice. This is prepared by chopping a piece of sirloin steak, free from fat or tendon, into small bits, and, after slightly warming, pressing out the juice with a lemon- squeezer. A teaspoonful, with a little salt, is to be given four times a day, and the quantity gradually increased as the peculiar fetid odor which it imparts to the stools disappears. After the age of six months, the yolk of a raw egg, well beaten with ten drops of brandy, a teaspoonful of cinnamon water, and AFFECTIONS OF THE STOMACH AND INTESTINES. 243 a little white sugar, may be administered once or twice a day, together with the milk, whey, or broth-food. After twelve months, if milk can be taken, the following diet is suitable : — First meal, 7 a.m. — Two teaspoonfuls of Mellin's food dis- solved in six ounces of milk and barley-water, equal parts. Second meal, 10 a.m. — Four ounces of veal broth with two ounces of barley-water. Third meal, 2 p.m. — The yolk of a raw egg, beaten up well with twenty drops of brandy, a teaspoonful of cinnamon water and a little white sugar. Fourth meal, 6 p.m. — Same as second, or four ounces of fresh whey with a tablespoonful of cream. Fifth meal, 10 p.m. — Same as first. It is most important to remember that if the evacuations be very frequent and watery, there can be no set meals, but the food must be given by the teaspoonful at intervals often or fifteen minutes. Also, that between set meals and these minimum quantities, there is a wide range in the amounts and intervals, according to the grade of the symptoms. From older children it is necessary to withhold potatoes and farinaceous vegetables generally ; fruits, sugar, sweetmeats, pastry, hot bread or cakes, butter and all made and highly-seasoned dishes; at the same time the bulk of each meal must be some- what restricted. A good diet is : — For breakfast, at 7.30 a.m. — One or two tumblerfuls of milk warmed and diluted by the addition of a fourth part of hot water ; the yolk of a soft-boiled egg, salted, and a slice of thin, dry toast. For luncheon, at 12 m. — The soft parts of eight raw oysters, flavored by lemon juice, and a Boston cracker. Or in summer a small teacupful of junket, with a cracker. For dinner, at 3 p.m. — A bit of the breast of chicken cut up very fine, or a tender piece of roast beef or beef-steak treated in the same way; with a tablespoonful of well-boiled spinach, 244 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. asparagus tops, cauliflower tops, or stewed celery, and a thin slice of dry, stale bread. For supper, at 7 p.m. — A glass of milk, warmed as at break- fast, and a slice of well-made cream toast. An important rule in all cases is to watch the diet carefully until all danger of a relapse has passed. Baths and external applications are useful. Infants who are not much prostrated should be placed in a hot bath (95°-ioo° F.) every evening for three minutes, then quickly dried, an- ointed over the whole body with warm olive oil, wrapped in a blanket and put to bed. If there be much prostration, the bath must contain mustard, one teaspoonful to the gallon, and the child kept in until the supporting arms of the nurse begin to tingle. When intestinal ulceration is suspected, the belly should be enveloped in a light flax-seed poultice, or, what answers as well, a layer of carded cotton covered with oiled silk. Medicines are to be selected according to the stage of the attack. Early, while the stools are little increased in number, but putty-like and of sour odor, the bowels must be gently acted on by : — R . Pulv. Rhei, , gr. vj. Sodii Bicarbonatis, gr. xij. M. et ft. chart. No. vj. S. — One powder three times daily, for an infant of three to six months. Afterwards — on the succeeding day, usually — the following powder may be administered : — R. Pulv. Ipecacuanhas Comp., gr. iv. Cretse Praeparatse, gr. xxxvj. M. et ft. chart. No. xij. S. — One powder every four hours. AFFECTIONS OF THE STOMACH AND INTESTINES. 245 Or often better :. — R. Tr. Opii Deod., TT\vj. Sodii Bicarb., , . gr. xlviij. Syrupi, f Jss. Aquae Menthae Pip., q. s. adfgiij. M. S. — One teaspoonful every four hours. When the stools become frequent and green, the mixture of opium, bismuth and chalk, already given (page 234), is very useful ; and if tenesmus be very severe, a sedative enema must be used, as: — R. Tr. Opii, gtt. iij. Potass. Bicarb., gr. iij. Mucilag. Amyli., . f§ ss ' M. S. — To be injected into rectum. This may be repeated every six or twelve hours, according to the necessity, taking care that the child — and all children are very susceptible — does not get too much opium. Should the diarrhoea still continue, and the stools become watery and very fetid, astringents are required ; for example : — R. Acid. Sulphurici Aromat., n\xxiv. Liquor. Morphias Sulph., f 3 ij. Elix. Curacoae, fS ss * Aquae, q. s. ad f J iij. M. S. — One teaspoonful every three hours. Or— R . Argenti Nitratis, . . - gr.ss. Syr. Acaciae, fgss. Aquas, q. s. ad f^ iij. M. S. — One teaspoonful every three hours, midway between meals, if possible. Nitrate of silver is most valuable when the stools contain mucus 246 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. and blood, and aphthae or thrush are present. It may be also used as an injection, if there be evidences of ulceration, thus: — R . Argenti Nitratis, gr.j. Aquae, fgj. M. S. — Inject once or twice daily after cleaning out the rectum with an injection of warm water. These injections must be suspended for twenty-four hours after being continued for three days. Prostration and depression of the fontanelle demand stimulants. Ten drops of whiskey in water every two hours is about the average dose, but it may be given oftener and in larger quantities as circumstances require. As soon as the stools become normal in character and fre- quency, the child must be ordered tonics, as :— U . Liquor. Ferri Nitratis, rr\,xxiv. Glycerinae, fgss. Aq. Menthse Pip., q. s. adfgiij. M. S. — One teaspoonful three times daily. Or— 1J . Ferri et Ammonii Citratis, gr.xij. Tr. Gentianae Comp., . . fgj. Spt. Lavandulae Comp., f ^ ij. Syrupi Limonis, q. s. ad f% iij. M. S. — One teaspoonful three times daily. For the constipation of convalescence very small doses of castor oil — twenty drops — may be ordered once or twice daily, but it is best not to interfere unless the bowels have been indolent for twenty-four or forty-eight hours. With older children the medical treatment is more simple. Ordinarily, either of the following prescriptions will suffice : — AFFECTIONS OF THE STOMACH AND INTESTINES. 247 R. Syr. Rhei Aromat, -. . . . f^vj. Sodii Bicarbonatis, f 3 ij. Tr. Opii Deod., n\,xxxvj. Aq. Menthae Pip., . q. s. adfgiij. ' M. S. — One teaspoonful every three hours, for a child from four to six years. Or if the diarrhoea resist : — R. Tr. Krameriae, f^pij* Tr. Opii Camphoratae, * f g ij. Spt. Lavandulae Comp. , f ^ ij. Misturae Cretae, q. s. adfgiij. M. S. — Two teaspoon fuls every three hours. The lienteric form of diarrhoea should not be treated by astringents but by nux vomica followed by arsenic. For in- stance, until the stools become less frequent and urgent and the griping pain diminishes, a good prescription is : — R. Tr. Opii Deod., Tr. Nucis Vomicae, aa TT^xlviij. Aq. Menthae Pip., q. s.adf^iij. M. S. — One teaspoonful before each meal, at the age of six years. Afterward : — R. Liq. Potassii Arsenitis, fgj. Inf. Gentianae Comp., q. s. adf^iij. M. S. — One teaspoonful after each meal. Washing out the intestine is also a useful method of treatment : this will be fully described in the next section (Entero-colitis). During convalescence from chronic diarrhoea, older children do well upon the same tonics as infants, the doses being propor- tionately increased. 248 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 8. ENTERO-COLITIS. {Summer Diarrhoea — Febrile Diarrhoea.*) Entero-colitis, or inflammatory diarrhoea, is the scourge of our large cities during the summer months, when it brings death to hundreds of children, especially among the over-crowded, ill-fed poor. To it is due the popular dread of that period of an infant's life termed " the second summer/' and justly, for among those un- fortunates who are obliged to pass this time in crowded houses, and narrow, filthy streets, the instances of complete escape are very rare. Morbid Anatomy. — The anatomical lesions consist in inflam- matory hyperaemia of the intestinal mucous membrane. This may be distributed over the whole tract, but commonly it is limited to the ileum and colon, and is most intense in the neigh- borhood of the ileo-caecal valve and the sigmoid flexure. The mucous membrane is reddened, swollen and softened. Redness is either general or in the form of arborescent patches about the follicles; while swelling and softening are proportionate to the degree of congestion. The former is sometimes so great at the lower end of the ileum as almost to occlude the valve ; to this has been attributed the vomiting which, in the absence of gastric lesions, is otherwise difficult to explain. The isolated glands are enlarged, and more opaque than normal, having the appearance of grains of white sand scattered over the mucous surface, and the Peyer's patches are tumefied and projecting, with punctated surfaces. On the peritoneal aspect, the gut, in positions corres- ponding to the inflamed glands, presents areas of arborescent in- jection. There is moderate enlargement of the mesenteric glands. From this condition it is but a step to the state of ulceration seen in chronic intestinal catarrh — a not infrequent result of entero-colitis. The stomach, as already hinted, is usually normal in appear- ance ; occasionally its mucous membrane is reddened and thickened, and it is quite possible that this viscus is often the AFFECTIONS OF THE STOMACH AND INTESTINES. 249 seat of a catarrh so moderate in degree as to leave no evidences after death, though sufficient to give rise to vomiting during life. Etiology. — Season, age and locality of residence are impor- tant factors in the causation. Only isolated cases occur in the winter months, and these are met with among the poor, with whom it is a habit, for convenience in watching, to keep infants in the living room, which is also the kitchen ; this is heated by the cooking-stove, and is either intensely hot when the room-door is closed, or too cold when it is left open, in the frequent excursions of the older members of the family to the yard or street. There is, therefore, a constant exposure to sudden and marked changes in temperature. At the same time the air of such a room is contaminated by cooking, by re-breathing, and by the exhalations from soiled clothing and dirty bodies. These are sufficient causes for an attack of entero-colitis. About the middle of May or June, according to the character of the individual season, cases become more common, and as the summer heats are established, in July, August, and the first half of September, the number is augumented to the proportions of an epidemic. Late in September or in October, according, again, to the season, there is a marked diminution, and this increases as winter approaches. During the summer the number of cases and deaths varies with the range of the thermometer ; several successive days with a temperature above 90 F. being attended by a great increase, while a similar period with a temperature below 8o° is followed by a decided decrease. Hot, damp weather is the most productive, and of all months August is the most fatal, both on this account and because a high temperature is main- tained during the night. Infants between the ages of six and eighteen months are by far the commonest sufferers. Their liability depends upon the sympathetic irritation of the alimentary tract attending the cutting of the teeth ; the increased tendency to inflammation produced by the rapid development that the intestinal glands and follicles are simultaneously undergoing, and the fact that 21 250 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. weaning, with its consequent change of diet, usually takes place during this interval. From the eighteenth month to the end of the second year, about one-fourth as many cases occur, and the third period of greatest frequency is from birth to the sixth month. Children over three years are not often attacked. Residence in large cities is almost an essential etiological con- dition ; the vast majority of cases occur where the streets are narrow and more than ordinarily filthy, and where the houses are overcrowded and dirty, and the people poor, ill-fed and un- clean. There must be another factor at work here besides the elevated temperature, since in the open country immediately surrounding affected cities, where the thermometer ranges nearly as high, the disease is of exceptional occurrence. This factor is an atmosphere polluted by poisonous gases and containing count- less bacteria, the result of decomposing organic substances. Another potent agent is bad food. Infants, hand-fed from birth, are the most frequent sufferers ; next, those who are weaned early; in both, the chief injurious articles of diet are sour milk, farinaceous preparations in excess, and "tastes" of table-food. Nursing infants are more exempt, but even with them, too frequent and continuous feeding, or breast-milk of abnormal quality, when other conditions are unfavorable, often produce entero-colitis. Symptoms. — For one or two days prior to the actual attack, the infant is restless and fretful ; his sleep is disturbed by moan- ing or fits of crying; he is paler than usual, and his head and, perhaps, the palms of his hands, feel hot. He also ceases to empty his bottles ; after feeding, eructations of very sour-smell- ing material are apt to occur, and the stools are somewhat more numerous and softer than usual. Next, vomiting and diarrhoea set in. The former occurs after feeding, and, in bad cases, is so obstinate that nothing is re- tained. The matter rejected consists of sour, acid and curdled milk, or other food imperfectly digested. The stools range from six to twenty or more in twenty-four hours, and vary in character from day to day, and even from AFFECTIONS OF THE STOMACH AND INTESTINES. 251 hour to hour. At first, they are semi-solid, homogeneous, yellow in color and neutral in reaction ; then they become more liquid and green, though still homogeneous and neutral, and then the reaction becomes acid without change in the other characters. Often they are semi-fluid, heterogeneous, green with little masses of yellow faeces, and neutral ; or semi-fluid, heterogeneous and green, with fragments of yellowish-white caseine and acid ; or watery, with floating flakes of white, yellow or green matter, and acid. Mucus and blood may be mixed with any of these stools ; the first in stringy masses ; the second, in bright red streaks or merely tingeing the mucus. In severe cases the passages become watery and so colorless as hardly to stain the diapers. The odor at first is faecal, then sour, and finally offensive. The act of defecation is preceded by pain, manifested by the expression of the face, by crying, and by twisting of the trunk and drawing up of the legs. Sometimes there is tenesmus and slight prolapse of the rectum ; it is under these circumstances that blood appears in the stools. The tongue is dry, red at the tip and edges and covered in the centre with a light white coating ; the appetite is diminished and the thirst increased. The abdomen is distended by flatus, and, at times, there is tenderness on pressure. With these features there is pyrexia, moderately high and con- tinuous for the first three or four days, afterward remittent ; the head is especially hot, and the palms of the hands are dry and burning to the touch. The pulse is weak and frequent, beating 120, or even 140 times per minute. The urine is reduced in quantity and passed at long intervals, sometimes only two or three times a day. As the diarrhoea continues the face becomes pale ; the eyes are surrounded by dark circles ; the nasal lines appear ; the fon- tanelle, if still membranous, is depressed ; the fat disappears from the body ; the muscles grow soft and flabby ; the buttocks and inner surfaces of the thighs are reddened by the acid stools and concentrated urine, and there is great feebleness and languor. In grave attacks these changes take place in an incredibly short 252 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. space of time, twenty-four hours being ample to reduce an active, robust infant to a mere shadow of himself. If death approach, the patient, in some cases, grows fretful ; has a dry, burning skin ; rolls the head from side to side ; vomits incessantly ; has strabismus and indolent pupils, and may have convulsions, which are more frequently unilateral than general. In others, there is drowsiness, an apathetic refusal of food, ces- sation of vomiting and diarrhoea, and coolness of the extremities. This difference depends upon the acuteness of the attack, for upon this rests the preservation or loss of nervous irritability. The great diminution of the urinary excretion suggests the possibility of the fatal termination being, in some instances, due to ursemic poisoning. When the attack tends to recovery the vomiting stops ; the motions are less numerous and more faecal ; the skin becomes cooler and more moist ; the urine is excreted freely ; the eyes grow bright ; the child again shows interest in his surroundings ; takes his food better, and rapidly regains flesh and strength. Diagnosis. — The pyrexia, the vomiting, and the frequency and character of the stools, taken in conjunction with the early age of the patient; the season and locality of occurrence; and the almost epidemic prevalence of the disease, make its dis- tinction an easy matter. The portion of the intestinal canal chiefly involved is not so readily determined, though the presence of mucus and blood in the evacuations points to the colon as the seat of inflammation; their absence, by inference, to the small intestine. It is important to differentiate this disease from cholera infantum, which is an infinitely more serious disease. Cholera infantum is sudden in its onset, characterized by a high temperature, from 105 F. to 108 F., uncontrollable vomiting; frequent and profuse serous evacuations ; embarrassed respiration ; frequent and irregular pulse ; marked involvement of the nervous system, and rapid collapse. Often a case will pass in the course of twenty-four hours from blooming health into a condition of almost ante-mortem decomposition. We do not see these changes in entero-colitis. AFFECTIONS OF THE STOMACH AND INTESTINES. 253 Prognosis. — Inflammatory diarrhoea ranks among the most dangerous of the affections of infancy, both from its inherent nature and its tendency to run into chronic entero-colitis. Nevertheless, under appropriate management, a large proportion of cases recover. The outlook is most discouraging when the infant's lot has been cast in poverty ; when it has been hand-fed from, or soon after birth ; and when it has had the bad fortune to be born in the late winter or spring, so that weaning and the time of cutting the more troublesome teeth come together in the second summer. The unfavorable features are high fever, very frequent and watery evacuations, rapid collapse, cerebral symptoms and con- vulsions. An attack may prove fatal in four or five days, or it may be protracted for two weeks. The latter is about the duration of severe cases that terminate in recovery. One attack predisposes to another, an important point to remember in the treatment by change of climate. Treatment. — People with means avoid the dangers of summer diarrhoea by taking their children to the country, sea-shore or mountains, where the air is uncontaminated, the heat less in- tense and the milk pure. Such escape is not open to the children of the poor ; nevertheless, much may be done to preserve their health by keeping them during the day in the fresh air of public parks ; by bathing in cool water ; by proper, cleanly clothing ; good food — for good milk is as cheap as bad — and by attention to the cleanliness of beds and sleeping rooms. This the parents can, and in many cases will do, and if they would only secure well-paved and decently clean streets — for it is impossible to clean ill-paved ones — entero-colitis would become a far less com- mon disease. When an attack occurs during the hot months, the patient, if possible, must be sent at once from the city to the sea-side or country. The locality selected should be near at hand, or the journey will be too fatiguing ; still, it is important to fix upon a place affording a decided change of air and a lower temperature. 254 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. From Philadelphia the infant may be taken to Atlantic City, Cape May, Point Pleasant, Avon or any of the many resorts on the Jersey coast, kept there for two or three weeks and then removed to the New Hampshire hills for the remainder of the summer. A long stay is essential, since a return to town in hot weather is almost certain to be followed by a relapse. If circumstances render it impossible to carry out this most potent of all prescriptions, fresh air must be secured by taking the child to the public squares in the cool of the morning and evening, or by spending the day in the Park, or, better still, by a morning and evening trip on one of the river steamboats. The heat of the day must be spent in as cool a room as can be had. It is of great moment to let the little sufferer rest in bed and not on the hot lap or shoulder, and when out, to wheel him in a coach rather than carry him. Many a stout mother has hastened her infant's death by too fond and constant nursing. The clothing must be as thin as possible, provided, always, that woolen be worn next the skin. Twice or three times a day, in very hot weather, the whole surface of the body should be sponged with water at a tempera- ture of 8o° F., and dried with gentle rubbing. The bracing effect of these baths is greatly increased by the addition of rock salt, or concentrated sea-water if the purse can afford it. These cool spongings must be supplanted by full warm baths when there is much prostration. In regulating the diet, it must be remembered that the pres- ence of fever, with increased thirst, leads the child to take more liquid food than is needed or can be digested ; consequently, it is necessary to specify the quantity as well as the quality of the food. Infants at the breast are to be suckled only at intervals of two or three hours, according to their age, and taken away before they have completely satisfied themselves. Hand-fed babies are to be similarly restricted. As cows' milk must constitute the bulk of their food, it is important to see that it is obtained fresh every day from a reliable dealer, promptly AFFECTIONS OF THE STOMACH AND INTESTINES. 255 sterilized, and administered from an absolutely clean bottle fitted with a simple tip. For example : — Milk, fgiij. Cream, f2 ss# Lime-water, f Jijss. Sugar of milk, 5J. Mix in a clean tin-cup, pour into bottle, adjust tip, and warm by plunging into hot water. Milk, fjiij. Cream, f § ss. Mellin's Food, 3 ij. Hot water, f3y ss * Dissolve the Mellin's food in the hot water, add the milk and cream, and, if necessary, warm as before. Milk, f|iij. Cream, . . . . f^ss. Flour-ball, gj. Water, ...>■' ':,; fgijss. Either one of these foods may be given every three hours to a child of ten or twelve months old. The quantity is less and the dilution greater than for a healthy infant of the same age, because enfeebled digestion demands a proportionate reduction in the amount and strength of the food. When preparations of milk are vomited or passed undigested from the bowels, a whey mixture or strippings can be resorted to, and if these fail, beef-juice, or — Flour-ball, 3 ij. Water, f J vj. Mix, and add — Half the white of a fresh egg. Bits of ice and cool filtered water can be allowed, in modera- tion, to relieve the thirst. If vomiting be persistent, all food must be stopped for from twelve to twenty-four hours, and the thirst quenched by thin 256 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. barley-gruel or Vichy water, — cold, and in small quantities. If the child be at the breast, as soon as vomiting is checked, it can gradually be brought back to its accustomed diet, care being taken that too much food be not taken. In bottle-fed children under two years, it is better to withhold milk entirely ; wine- whey, chicken and mutton broth, Mellin's food with barley- gruel, the juice expressed from raw beefsteak or roast beef, and sometimes raw-scraped beef, should constitute the " no-milk diet." The indications for medical treatment may be grouped under four heads: 1. To clear out the bowels ; 2. To stop decomposi- tion ; 3. To restore healthy action in the alimentary tract ; 4. To treat the consecutive lesions. 1. The bowels should be emptied as completely as possible, as the first step in the treatment, and for precisely the same reasons that the surgeon cleanses a wound thoroughly before ap- plying antiseptic dressing. This rule holds good not only where there is a history of antecedent constipation, or the evidence of the presence of indigestible food in the alimentary tract, but in every case in which there are altered secretions undergoing pu- trefactive changes. The only instances in which the process of cleansing should not be undertaken, because unnecessary, are those where, after two or three fecal or semi-fecal evacuations, the discharges consist of almost pure serum, large in amount, alkaline in reaction, and odorless. To sweep out the intestinal canal nothing compares in effi- cacy with castor-oil. Should the stomach be very irritable, however, it will be necessary to substitute enemata. These should consist of pure water at a temperature of 65 ° Fah., and to be effi- cient must be copious enough to reach the caecal valve, — about one pint in a child of six months, and two pints in one of two years. The injection must be given slowly, with a fountain syringe, the abdomen meanwhile being gently manipulated. Many mild cases can be cured, if taken at the start, by castor- oil and a strict diet alone. 2 and 3. To stop decomposition and restore a healthy action AFFECTIONS OF THE STOMACH AND INTESTINES. 257 in the intestines, the administration of antiseptics and attention to diet are necessary. Antiseptics must be given in small doses lest the stomach re- ject them, and frequently to maintain a continuous action. The best are calomel, salicylate of sodium and naphthalin. Calomel may be prescribed in the following combination : — R . Hydrargyri Chloridi Mit., gr. j£. Bismuthi Subcarbonatis, gr. xxxvj. Pulv. Aromatici, ........... gr. vj. M. Et ft. chart. No. xij. S. — One powder every two hours. Salicylate of sodium is prescribed in doses of from one to three grains every two hours, according to the age, from three months to three years. An aqueous solution is tasteless, and can readily be given in the food or drink; it has a tendency to check rather than occasion vomiting. It may also be substi- tuted for the calomel in the above prescription. Naphthalin, although possessing a strong odor, is not disagree- able to the taste. On account of its insolubility, it is best ad- ministered rubbed up with some moist powder, like sugar of milk. The doses should be larger than those of the salicylate of sodium, — one to five grains, according to the age. Resorcin and bichloride of mercury are also useful antiseptics. Resorcin is bitter, and though freely soluble in water, not easily administered ; the dose is one-half a grain to two grains. The bichloride is given in doses of yi^ to T ^ of a grain, but even in these minute quantities frequently causes vomiting. Counter-irritation by mustard plasters to the belly is useful. Stimulants are required when prostration sets in, and must be given in doses and at intervals adapted to the demands of the case. Applications of oxide of zinc ointment, with cleanliness, cure the intertrigo of the buttocks and thighs most quickly, or, at least, keep it in check until the cause is removed. 4. The essential consecutive lesions are in the colon, and 22 258 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. consist practically of a follicular colitis. When the condition of ulceration is reached, astringents by the mouth are useless, with the possible exception of bismuth. Three things are valuable :— First. As careful attention to the diet as during the acute stages, and in recent cases. Deviation from dietetic rules is the most frequent cause of relapse. Second. The continuance of antiseptics to check intestinal decomposition, and hence stop irritation. Third. The whole large intestine should be washed out once every day, either with pure water at 65 ° F., or with weak anti- septic or astringent solutions. Of the former the best are ben- zoate or salicylate of sodium ; of the latter, nitrate of silver or tannic acid. Attention to diet and hygiene is not to be relaxed when con- valescence is established, and after the measures calculated to check diarrhoea are unnecessary, digestants, as wine of pepsin, and tonics, as the ferrated elixir of cinchona, are still required, to restore health. The exceptional cases that occur in cold weather should, of course, be treated at home in a well-ventilated and warm room ; otherwise, the only alteration to be made in the general plan of management is to envelop the abdomen with light linseed poul- tices, or with cotton covered by oiled silk. 9. CHOLERA INFANTUM. This affection occurs in teething children during hot weather, and is characterized by a sudden onset, high fever, irritability of the stomach, frequent serous evacuations, changes in the respira- tion and pulse, marked symptoms of nerve involvement, and rapid collapse. It is a far less common disease than entero- colitis, and is the analogue of cholera morbus in the adult. Morbid Anatomy. — In cases that run the ordinary course and die early, the gastro-intestinal mucous membrane is congested, AFFECTIONS OF THE STOMACH AND INTESTINES. 259 thickened and softened, and the follicles and Peyer's patches are enlarged. In other words, the appearances indicate the early stage of inflammation, which passes into lesions identical with those of entero-colitis, when the patient, as sometimes happens, survives the choleraic stage and dies, subsequently, from a more protracted diarrhoea. But, in addition to inflammation, there is probably — and this is the important point — some involvement of the sympathetic nerves, leading to dilatation of the capillaries and transudation of serum into the intestine, and to alterations in the pulse, temperature, respiration and urinary excretion. The nature of this is paralytic, so far as the intestine is concerned, and resembles in its results experimental section of the sympa- thetic nerves. It is due, in part, to direct over-stimulation by the irritant contents of the canal, and in part to the nerve exhaustion produced by high atmospheric temperature, one of the essential causes of cholera infantum. The changes in calorifica- tion and in the functions of the heart, lungs, and kidneys, de- pend upon reflected irritation, and also, perhaps, upon the depressing effects of heat on the governing nerve centres. Etiology. — Like entero-colitis, this is a disease of cities, find- ing its victims chiefly among those who live in poverty and squalor. Almost exclusively confined to hot weather, it may occur at any time between the middle of May and the end of September, though the greater proportion of cases originate during the latter half of July, August, and the first half of Sep- tember. Infants from six to twelve months are the most suscep- tible subjects ; it may, however, occur at any age up to two years. The susceptibility of the former age is due to the great functional activity of the intestinal mucous membrane and the rapid devel- opment of the follicles that accompany dentition, rather than the mere act of cutting teeth. The direct causes are high temperature (^5°~95° F. or more) sustained for several days, and especially if associated with a moist atmosphere, exposure to an atmosphere rendered impure by noxious gases and bacilli generated from filth by heat, impure water and bad food. Symptoms. — An attack may arise in the midst of health, or it 260 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. may be preceded by diarrhoea. In either case the onset is sudden. The infant begins to void copious stools. These at first, if there has been no premonitory diarrhoea, contain more or less faecal matter, but they soon become watery. Sometimes they are so serous as to soak away into the diaper without leaving any stain ; at others, they contain a few yellow or green flocculi or little masses of mucus, and, in both instances, are odorless. Again, they are composed of yellow or brown liquid, containing a small proportion of thin, faecal matter, and have a peculiar musty and offensive odor, which clings to the napkins and clothing, and even to the body of the child, in spite of the utmost efforts at cleanliness. The number varies from eight to thirty in twenty- four hours, and they are evacuated with considerable force. At the same time, or soon after, the stomach becomes so irri- table that everything, even to a mouthful of ice-water, is rejected as soon as swallowed, and there is violent retching. Appetite is lost, but there is intense thirst, the patient eagerly drinking when the opportunity offers, and following the glass, as it is removed, with greedy eyes. The tongue, originally moist and lightly frosted, soon becomes dry and pasty, and protrudes from the parched lips. The abdomen is flaccid and indolent. There is great restlessness; the temperature is elevated to 105 or even 108 F. ; the pulse is small and very frequent, counting from 130 to 150 beats per minute ; the breathing becomes irregular and anxious, and the urine is greatly diminished in quantity. With these symptoms there is a marked and appalling change in appearance. Within a few hours, the infant, perhaps plump and rosy before, can scarcely be recognized ; the face becomes pale and pinched \ the eyes and cheeks sunken, and the eyelids and lips permanently parted from loss of muscular contractility ; the fat melts from the body ; the muscles, grow flabby ; the bones appear prominent, and the skin, often greenish or cadaverous in hue, hangs in loose folds. Soon the features of collapse appear. The hands, feet, nose, and even the breath, become cool, the pulse is thready and so AFFECTIONS OF THE STOMACH AND INTESTINES. 26 1 frequent as to be uncountable ; the respiratory movements are more unequal, and there is drowsiness, apathy, and suppression of urine. As life ebbs away, the vomiting stops ; the surface becomes cold and clammy ; the face is set with the lines of death; the respiration is quickened and shallow ; the pulse scarcely per- ceptible, and the patient sinks into a state of semi-coma, with bleared eyes and contracted pupils. In this condition the end may come quietly or be preceded by slight convulsions. The course of the disease, whatever the result, is always very short. It may prove fatal in from one to four days, or the character of the attack may change and death result later from a secondary inflammatory diarrhoea. In case of recovery, the stools, after four or five days, gradually become less copious, frequent and watery, more faecal and of better odor ; vomiting stops ; thirst diminishes ; appetite returns ; the urinary excretion is reestablished ; the temperature and pulse fall; the respiratory movements become rhythmical ; emaciation ceases, and the child, though very feeble, again notices his sur- roundings, and after a week or more of simple diarrhoea, regains a moderate degree of health. Diagnosis. — The character of the stools, the extreme irrita- bility of the stomach ; disturbed respiratory rhythm ; high temperature ; intense thirst and rapid emaciation and collapse, distinguish this from entero-colitis, and from other forms of diarrhoea. There is a certain resemblance between cholera infantum and sunstroke, and, by some, the two conditions have been considered as identical. The forms of similarity, as well as those of dis- similarity, may be seen in the following table : — CHOLERA INFANTUM. SUNSTROKE. Temperature 105 to 108 F. Temperature often 108 F. Pupils contracted. Pupils contracted. Evacuations watery. Evacuations watery. Respiration embarrassed. Respiration embarrassed. Urine scanty. Urine scanty. 262 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. CHOLERA INFANTUM. Cerebral symptoms marked, but secondary Gastro-intestinal symptoms, prece- dent and prominent. Onset rapid. Preceded by diarrhoea or uncomfor- table sensations. Restlessness at onset. Occurs at any time of day or night. Inflammatory lesions of intestines. SUNSTROKE. Cerebral symptoms marked, but primary. Gastro-intestinal symptoms, secon- dary Onset sudden, by a stroke. No such previous history. Stupor from beginning. Occurs only during excessive heat of day. No such lesions. Between epidemic cholera and cholera infantum it is impos- sible to make a diagnosis. Prognosis. — The prospect is most discouraging, and even in seemingly favorable instances the opinion as to the result must be guarded, for though the choleriform symptoms be survived, there is danger from the succeeding diarrhoea. The disease is most fatal in children of the poor, who are badly fed and sub- jected to the worst hygienic influences; conversely, it is more apt to terminate in recovery in the rich, who can be treated in large, airy rooms, fed on good food, and removed to healthy localities. Treatment. — The large and frequent watery evacuations are such a strain upon the system, that it is of the first consequence to replace the waste by food and drink, and at the same time check it by appropriate treatment. The irritability of the stomach is a formidable barrier to alimentation ; nevertheless, every effort must be made to give food in small quantities and at short intervals. Should the infant be at the breast, it may be allowed to nurse for a few minutes, every half-hour or hour. If hand-fed, it may be given the same foods recommended for entero-colitis, or chronic vomiting, in such quantities as can be retained, and at intervals corresponding in frequency to the smallness of the amount. Bits of ice and water should be allowed freely, even though they be rejected as soon as swallowed. AFFECTIONS OF THE STOMACH AND INTESTINES. 263 To check the diarrhoea opium and astringents are necessary. A very serviceable formula is : — R. Liquor. Morphiae Sulph., f^j. Acid. Sulphurici Aromat., rr^xxiv. Elix. Curacoae, f,? ss * Aquae, q. s. ad fgiij. M. S. — One teaspoonful every two hours, for a child of six months old. With this, two drops of laudanum, suspended in two teaspoon- fuls of starch-water, should be administered, by the rectum, every three hours. Two or three times daily a mustard plaster (one part of mustard to five of flour) must be applied over the whole surface of the abdomen, long enough to redden the skin, and the whole body should be sponged several times a day with water at a temperature of 95 ° F. The clothing, diapers and person must be kept perfectly clean ; the sick-room must be as large and airy as can be commanded, and the infant must lie upon abed, and not be constantly nursed upon the lap. If it be possible, the patient should be sent early to the sea-shore or country, as this affords by far the best chance for recovery. Failing in this, morning and evening airings in a coach, or daily steamboat excursions, must be resorted to. Stimulants are needed from the first to ward off prostration. From five to ten drops of whiskey in a teaspoonful of lime-water may be given every two or three hours at the age of six months. When collapse sets in, the quantity of alcohol must be increased, and, if the stomach can bear it, a combination of stimulants is useful, as : — R. Spt. Frumenti, f^ ss - Ammonii Carbonatis, gr. xxiv. Syrupi Acacise, fgj. Aq. Menth. Pip., q. s., ad f^iij. M. S. — One teaspoonful p. r. n. The temperature must be maintained by hot flannel wraps and 264 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. hot water bottles, and the child kept in a horizontal position and disturbed as little as may be. In this stage astringents are still indicated ; but opium must be used with great caution, or even discontinued entirely, when there are cerebral symptoms and semi-coma. In the fortunate instances in which this plan is successful, it is still necessary to treat the succeeding diarrhoea, and finally, to build up the general health by good food, tonics and fresh air. 10. INFLAMMATION OF THE COLON AND RECTUM— DYSENTERY. Dysentery is not a very frequent disease in children, but it may occur in an endemic or epidemic form, and as a sequel of measles, scarlet fever, or variola. Morbid Anatomy. — The mucous membrane of the colon and rectum is swollen, red, softened and even loosened by diffuse suppuration, and the solitary glands are enlarged and ulcerated, while the corresponding peritoneal surface is congested. In severe and epidemic cases, the inflamed surface presents more or less adherent pseudo-membranous patches, which, when removed, leave ulcers of irregular outline and variable depth. Perforation and cicatricial contraction of the intestine are occasional results. Etiology. — Sporadic and endemic cases are produced by the same causes as entero-colitis — excessive heat, bad food, and ex- posure to cold and wet. The epidemic form is certainly infec- tious, and there are grounds for believing that it is also contagious, although the last fact is not yet definitely established. The disease is most common in the second and third years of life, and seems to attack boys more frequently than girls. Symptoms. — Nausea, vomiting, high fever, and acute abdominal pain usher in the attack. Then the bowels become distended. The evacuations are numerous, ranging from four to forty a day ; small in quantity and voided with much straining. At first they AFFECTIONS OF THE STOMACH AND INTESTINES. 265 contain faecal matter, but after a short time are composed entirely of mucus and blood, mixed with yellow or green flocculi, frag- ments of false membrane and pus. The blood may appear in dark red streaks or clots ; in black masses ; as a substance resembling the washings of meat, or merely diffused through the mucus, giving it a uniform red color. Their odor is most offen- sive. The face wears an anxious expression ; there is great restless- ness, sleeplessness, muscular weakness, and rapid emaciation. The tongue is dry, red at the tip and edges, and covered in the centre with a brownish coating. There is anorexia and urgent thirst. The abdomen is distended, tympanitic, and painful on pressure, particularly over the course of the colon. As the attack progresses, tenesmus becomes the most perma- nent symptom ; it occurs without the passage of stools, and is often attended with prolapse of the rectum. Fever gives place to coolness of the surface; restlessness, to semi-stupor; the eyes and cheeks sink ; the face becomes pinched, and death may take place quietly or be preceded by slight convulsions. The duration varies from two or three days in grave cases, to about two weeks in those that result favorably. The Diagnostic features are high fever, tenderness along the track of the large intestine, tenesmus and the number and char- acter of the stools. The Prognosis is favorable in the sporadic form and when there is only slight elevation of temperature and moderately fre- quent stools. Quite the reverse, if there be high fever, great tenesmus, frequent evacuations containing much blood or false membrane and pus ; when there is a tendency to collapse, and when the disease is epidemic. Relapses frequently occur. Treatment. — Children affected with dysentery must be kept at rest in the best room — so far as ventilation and coolness are concerned — that the house affords. Their diet should be liquid, and even this form of food must, on account of the irritability of the stomach, be given in moderate quantities. From four to 266 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. six ounces of whey and cream mixture ; of flour-ball and milk, or arrow-root and milk, may be given every three hours to a child of two years. A good preparation is : — Arrow-root, gj. Hot water, f ^ ss. Mix thoroughly, and add to — Milk, fgij. Cream, f^ss. Water, f^j. Small pieces of ice and moderate quantities of iced filtered water can be allowed to relieve thirst. Two or three times daily the body should be thoroughly sponged with water at a temperature of 95 ° F., and the abdomen must be kept covered with a light flaxseed poultice, over the surface of which a little mustard has been sprinkled ; this must be covered with oiled silk and changed as often as it becomes cold. If the patient be seen early in the attack, the medicinal treat- ment may be begun with a laxative, as : — B . Ol. Ricini, f 3 ijss. Pulv. Acacige, ^ij. Tr. Opii, TT\viij. Aq. Menth. Pip., q. s. ad f^ij. M. S. — One teaspoonful every three hours, at three years of age. After this has been continued for twenty-four hours, there should be marked improvement in the evacuations. If this be not the case, it is well to order the following : — R. Pulv. Ipecac. Comp., gr. vj. Bismuthi Sub-carb., £j. Pulv. Aromat, gr. vj. M. et ft. chart. No. xij. S. — One powder every three hours. With an enema of laudanum — gtt. iij to fgss of warm water — AFFECTIONS OF THE STOMACH AND INTESTINES. 267 every four hours; or a suppository of opium and acetate of lead : — R . Pulv. Opii, gr. ss. Plumbi Acetat., gr.}. Ol. Theobromae, 3J. M. et ft. supposit., No. vj. S. — One to be used every four or six hours. Should these fail, nitrate of silver may be administered by the mouth or rectum. If there be great rectal irritability and quick expulsion of the caustic injections, it is best to follow them with enemas of laudanum. A good formula for administration by the mouth is : — R. Argenti Nitrat., g r -j- Tr. Opii Deod., TT\,xxiv. Syr. Acaciae, f.^j. Aquae, q. s. ad fgiij. M. S. — One teaspoon ful every three hours. For an enema : — R. Argenti Nitrat., . gr.j. Aquae Dest, ^'j- M. S. — Inject twice daily, and allow an interval of twenty-four hours after three days' successive use. To ward off prostration, it is necessary to employ stimulants, in doses and at intervals proportionate to the demands of the case. Should collapse occur, alcohol and artificial heat to main- tain the body temperature are the main resources. When convalescence is established, it is still necessary to guard the diet carefully and to build up the general health with tonics. Of these, the best are quinine with dilute nitro-muriatic acid, or tincture of nux vomica with compound tincture of gentian, followed by ferrated elixir of cinchona, or citrate of iron and quinia. 268 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. ii. TUBERCULAR ULCERATION OF THE IN- TESTINES. This form of ulceration commonly occurs as a complication of pulmonary and abdominal tuberculosis. Gray granulations may or may not be present at the site of lesion, but the special degen- erative process in the intestinal mucous membrane is so intimately associated with tubercle that the term " tubercular ulceration/ ' seems to be warranted. Morbid Anatomy. — The lesions are chiefly confined to the ileum, and primarily affect the solitary follicles and Peyer's patches, particularly those about the ileo-caecal valve. The follicles become enlarged from multiplication of their cell ele- ments, then undergo caseous degeneration and softening, with the formation of isolated ulcers in the case of the solitary glands, and clusters of coalescing ulcers in that of the patches of Peyer. From having, at first, the shape of the follicles and patches, they gradually extend by a similar process of corpuscular infiltration, caseation and softening in the surrounding tissues. The fully- formed ulcers are irregularly oval in shape, with their greatest diameter directed transversely to the axis of the gut ; their edges are indented, thick and somewhat undermined ; their floors are red or gray, and formed by one or the other tissue of the intes- tine, as far down as the peritoneum, according to the depth of destruction. Perforation is rare on account of localized adhesive peritonitis. Gray granulations — a secondary product — may be found in the tunica adventitia of the small arteries and lymph- atics, or on the reddened and cloudy peritoneal surface corres- ponding to the ulcers. Cicatrization takes place rarely, but may be the cause of stricture. The uninvolved mucous membrane is congested, thickened and softened. The mesenteric glands are enlarged and cheesy, and miliary tubercles are usually found in the lungs or else- where. Etiology. — The disease is met with in children who have passed the fourth year, and in whom the tubercular or strumous AFFECTIONS OF THE STOMACH AND INTESTINES. 269 diathesis exists. Bad hygiene, bad food, and exposure, act as predisposing causes, by interfering with general nutrition and paving the way for the development of the diathetic tendency. An unsuitable diet, too, may indirectly lead to this form of ulcer- ation, by bringing about an abnormal condition of the lining membrane of the bowel. Symptoms. — In addition to the features indicating a scrofulous or tubercular tendency, the child, after suffering for a variable time from the symptoms of simple intestinal catarrh, begins to have fever and to pass excessively offensive stools, composed of dirty-brown liquid that, on standing, deposits flocculi, mucus, pus and small, black clots of blood. There is colic preceding the evacuations ; moderate distention of the belly, with tension of the parietes over the right iliac region, and tenderness on pressure there. Abdominal palpation also reveals enlargement of the mesenteric glands, and physical examination of the chest the evidences of pulmonary phthisis. Such cases usually result fatally, after a more or less protracted course, the direct causes of death being tuberculosis of the lungs or of the meninges of the brain. Treatment. — Pure air, warm clothing, good food and tonics comprise the measures of treatment. The best of the tonics is cod-liver oil, which, in these cases, often seems to lessen the tendency to diarrhoea. Half a teaspoonful three times daily is quite enough for a child of five years. It may be given com- bined with maltine, or in an emulsion with lacto-phosphate of lime, or the compound syrup of the hypophosphites. The follow- ing is an admirable formula : — R. Olei Morrhuas, . . fgij. Ext. Malt (dry), giv. Calcii Hypophos., Sodii Hypophos., aa gr. xvj. Potassii Hypophos., gr. viij. Glycerinae, f ^ ij. Pulv. Acaciae, £ij. Aquae, q. s. ad fj§ iv. M. S. — One teaspoonful three times daily. 270 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. In addition to this general treatment, attention must be paid to the intestinal condition. A light flax-seed poultice should be placed over the right iliac region or over the whole abdomen, or a dressing of cotton, covered with oiled-silk, may be used. Internally, sub-nitrate of bismuth with compound ipecacuanha powder and nitrate of silver are useful ; at the same time it is well to administer clysters of laudanum. 12. COLIC. Colicky pains frequently attend dysentery, constipation and other intestinal disorders ; but colic with flatulence so uniformly occurs as a functional affection in children from birth to the end of the third month, and gives so much discomfort both to the infant and its attendants, by causing fretfulness, crying and wake- fulness, that it demands separate consideration. Etiology. — In studying the causation of this condition, it must be remembered that after birth the infant, previously nour- ished through the blood of its mother, begins to take food through a new channel. Hence a new habit has to be formed, in addition to the development of a secreting and absorbing apparatus hitherto inactive. It is during this transition state that food of the best quality may be imperfectly or slowly digested and flatulence and colic result. Food that is at all difficult to digest almost always occasions colic, and hand-fed babies are especially liable to it. Other causes are fulness of the stomach in over-feeding, or the opposite condition of emptiness after nursing at a breast that affords milk in small quantity, and, finally, inherited feebleness of digestive power, and over-sensitiveness of the mucous membrane to the contact of food. Symptoms. — Soon after feeding, the infant becomes restless, kicks his legs about uneasily, twists his body, grunts, or utters a series of piercing cries. The face is congested at first, from the effort of crying, but soon becomes pale, with a tinge of blue AFFECTIONS OF THE STOMACH AND INTESTINES. 271 around the lips. The belly is full and hard, the hands and feet are cold, and, in bad cases, the fontanelle is more or less de- pressed. After a time, varying from a few minutes to an hour, eructations of flatus or of curdled milk occur, and the symptoms disappear for awhile. Such paroxysms may occur at any hour of the day, but are most frequent and severe in the evening and night. There is usually, also, a moderate degree of constipation, or the bowels are irregular. At night the rest is broken by uneasy tossing and whimpering, and during sleep a smile or an expres- sion of pain often flits over the face ; but, in spite of the fretful- ness and discomfort, the infant suffers little in general health, and increases in flesh and strength almost as rapidly as is normal. Treatment. — When the infant is fed at a healthy breast, it is of great importance to insist upon the rule of- feeding only at proper intervals, and absolutely to forbid the habit of putting the child to the breast whenever it cries. Food will be taken when- ever it is offered, and the warm milk entering the stomach relieves the pain for a time, only, however, to increase it later by giving the viscus more work to do, and filling it with material to under- go fermentation with the production of flatus. Consequently, it is much better to resort to one of the preparations to be here- after given for the relief of the pain. Should the child draw but a poor and scanty supply of milk, and the colic be due to emptiness, the breast must be supple- mented by hand-feeding. Under these circumstances, and when the whole feeding is by bottle, much may be done to prevent or relieve the attacks of pain by attention to cleanliness of the feed- ing apparatus; by carefully selecting the ingredients of the food, and by adding an aromatic to the latter. A good food for a child of one month old is : — Milk, . . . f^jss. Cream, f^ij- Barley-water, ^3J SS * Caraway-water, f^j. Sugar of milk, 3 ss. 272 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. These ingredients are to be mixed in a clean vessel, poured into a perfectly clean bottle, and heated to a temperature of about 98 F. in a water-bath.* A little pancreatin and bicarbonate of sodium added to the bottle of food just at the time of its administration produce good results by aiding intestinal digestion. When the bowels are inclined to constipation, the barley-water may be replaced by a gruel made of ground oatmeal (Bethlehem brand). One or two teaspoonfuls of the meal to the quantity of water necessary for each bottle is the proper proportion. In place of this, a teaspoonful of Mellin's food may be added to the requisite quantity of water. The belly should be anointed twice a day with warm olive oil, and enveloped in a broad flannel binder. It is even more im- portant to keep the feet warm, and for this purpose thick socks or long woolen stockings should be worn, and in bad cases, arti- ficial heat must be applied by hot water bottles. Medicines are indicated chiefly during the attacks of pain. A simple and serviceable prescription is ten drops of gin in a tea- spoonful of sweetened warm water. Another is : — R. Sodii Bicarb., . . . gr. xvj. Syrupi, f^ss. Aq. Menth. Pip., q.s. ad fgij. M. S. — One teaspoonful p. r. n. for a child of one month. This is rendered more efficient by the addition of two drops of aromatic spirit of ammonia to each dose, or, in severe cases, one drop of spirit of chloroform. Bromide of potassium and chloral are most useful ; they may be combined as follows : — R . Potassii Bromidi, gr. xvj. Chloral Hydrate, gr. viij. Syrupi, f^ss. Aq. Menthse Pip., q. s. ad f ^ij. M. S. — One teaspoonful for a dose. * A tin-cup half filled with water, placed on an ordinary stand over a gas- burner, makes a good water-bath for nursery use. AFFECTIONS OF THE STOMACH AND INTESTINES. 273 Of this preparation, it is rarely necessary to give more than two or three doses, at intervals of half an hour. It is well to reserve this mixture for severe attacks, and in ordinary cases, to use the gin or the soda mixture. Should the paroxysm be so violent as to lead to depression of the fontanelle and threaten collapse, the infant must be placed in a warm bath for five minutes ; after being removed and carefully dried, he must be wrapped in a blanket ; a flax-seed poultice with a dash of mustard placed over the abdomen ; a hot- water bottle applied to the feet ; the bowels relieved by an enema of warm water, and ten drops of gin or brandy in warm water adminis- tered by the mouth. If the fontanelle still remains depressed, the stimulant must be continued in doses and at intervals propor- tioned to the urgency of the symptoms ; at the same time the soda and ammonia mixture may be given. As a routine treatment to improve digestion, it is well to order fifteen drops of essence of pepsin (Fairchild's) three times daily. 13. HABITUAL CONSTIPATION. In addition to the locking of the bowels that results from mechanical causes, as intussusception, peritoneal adhesions, and so on, or from paralysis of the muscular coat of the intestine in certain nervous diseases, constipation of a functional character is a frequent and often an obstinate condition during childhood. Etiology. — Before the completion of the first dentition, it is more common in hand-fed babies than those nursed at the breast, and is due to the use of milk over-rich in casein ; the abuse of starchy food ; an insufficient supply of water, and often to the action of popular remedies given to relieve colic. With children who have passed the first dentition, constipation arises from faulty habits, and from the employment of a diet that is either bad in quality or unsuitable from its too great sameness. In all cases, inherited sluggishness of the peristaltic movements must be re- membered as a possible cause. 2 3 274 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Symptoms. — These vary greatly in degree. Thus, an infant, instead of the normal number, may have but one evacuation a day, or one, two, and even three days may intervene between the movements. The stools are scanty; composed of hard, dry, whitish lumps, and are voided with much pain and straining. Should the last symptom be severe, it is frequently attended by rectal prolapse and hemorrhage. Other features are colic, abdominal distention, diminished appetite, occasional vomiting, feverishness, fretfulness, restless sleep, and, in bad cases, convul- sions. In older children there may be one scanty passage each day, or a week at a time may elapse without relief. The stools, while lumpy and hard, are dark colored and mixed with mucus. The abdomen is the seat of pain, and may or may not be distended with flatus ; in the latter event, palpation often reveals the pres- ence of hard masses along the course of the descending colon. The tongue is coated ; the appetite capricious ; there is nausea and a sensation of discomfort in the rectum, leading to frequent, though unproductive, straining efforts at defecation. There is also languor, irritability of temper, headache and restless sleep; a muddy complexion and general spareness of frame. Diagnosis. — There is little difficulty in establishing the exist- ence of habitual constipation. One must be cautious, however, not to place too much reliance upon the statement that " the child's bowels are open every day," for in obstinate cases, it is not unusual for daily evacuations of thin, worm-like masses to take place whilst the bulky and hard faeces are retained. Prognosis. — Proper management rarely fails in regulating the action of the bowels, but constipation may prove serious in two ways : first, by leading to faecal accumulation ; second, by gene- rating a condition of general ill-health, during which the child is more exposed to the attack of acute and dangerous disease. Treatment. — In every case the relief of the actual state of retention of faeces in the rectum and the breaking up of the costive habit are the ends to be accomplished. For the former purpose, I prefer the use of purgative enemata AFFECTIONS OF THE STOMACH AND INTESTINES. 275 and suppositories to the administration of the same class of reme- dies by the mouth, particularly when abdominal palpation or digital examination of the rectum show that the retained mass is large and hard. The author's plan is to inject into the rectum, according to the age of the patient, from one to four teaspoonfuls of warm sweet oil ; allow it to remain for six hours, and then use one or more clysters of soap and warm water, or olive oil, soap and warm water.* The preliminary injections of oil soften the faeces, while the clysters — which must vary in bulk from one to six fluidounces, to be adapted to the capacity of the gut — have the additional effect of distending the walls of the rectum, and thus bring about muscular contraction and expulsion of its con- tents. Should the mass present at the anus but be too bulky to escape, more liquid may be injected, and if this fail, it must be broken up by the finger and its passage assisted by gently support- ing the perineum during the straining efforts. In severe cases little result may follow a single application of this method, though a course of one or two oil injections and purgative clysters daily for several successive days will rarely fail to empty the bowel. When the soapy water and oil fail to produce expulsive efforts, the enemata may be rendered more efficient by the addition of a teaspoonful or more of castor oil or oil of turpentine. To make such an enema for a child of two years : — Take— One teaspoonful of oil of turpentine, Two teaspoonfuls of olive oil, The yolk of one egg. Mix thoroughly, and add, with constant stirring, to Four fluidounces of warm water. Another enema which rarely fails to act quickly and efficiently is from one to two fluidrachms of pure glycerine with half a fluidounce of water. *An enema composed of one teaspoonful of common salt to four fluid- ounces of warm water is very efficient. 276 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. All injections must be thrown in gently, and the action of the syringe stopped as soon as pain is produced. In infants, unless the rectum be very full, clysters give no better results, and are far less convenient than suppositories. At the age of two months the following prescription may be ordered : — R. Saponis, gr. vj. Olei Theobromse ^j. M. et. ft. supposit. No. vj. S. — One to be inserted every morning or morning and evening. Or a small glycerine suppository may be used. Careful regulation of the diet is often all that is required to remove the tendency to constipation, and is a most important element of the treatment even in those cases where it is necessary 1 to call in the aid of medicines. Bottle-fed babies must be fed upon cows' milk, so modified by the addition of cream, sugar of milk and water as to be as nearly like human milk as possible ; and, should the bowels still remain confined, some laxative article, as Mellin's food or oat- meal, can be added. An admirable mixture for a child of three months is : — Milk, f'g'&s. Cream, f§ ss ' Sugar of milk, gj. Bethlehem oat-meal (fine powder), ^ij. Water, . . fgiss. In preparing this, the water must be heated — just short of boil- ing — in a tin vessel, and the oat-meal added slowly, with stirring, until a smooth, white mixture is obtained ; the other ingredients are then to be added, and the whole administered from a perfectly clean feeding-bottle. It is usually unnecessary to add the oat- meal to every bottle ; one or two meals of it, each day, being sufficient. During childhood the food selected must be of good quality, thoroughly digestible and varied. Starches and meat are to be allowed in moderation ; pastry, salt meat and sweets forbidden, AFFECTIONS OF THE STOMACH AND INTESTINES. 277 and a judicious use made of such articles as oat-meal or cracked wheat in the form of mush, well-cooked spinach, celery, cabbage and peas, baked apples, stewed prunes, thoroughly ripe peaches and pears, or the juice of oranges. To encourage peristalsis, warm sweet oil may be gently rubbed into the skin of the infant's abdomen twice daily, the natural course of the colon being followed ; and with children more advanced in age, cold spongings of the belly, followed by fric- tions with a coarse towel until the surface is red, are very bene- ficial. The ordinary cathartics, castor oil and rhubarb, are not adapted to the treatment of habitual constipation, because their primary laxative action is followed by a secondary binding effect, and they consequently increase the original trouble. There are, however, other medicines of the same class that are free from this disadvantage, and one of them, or, better, a combination of several of them, may be employed. For infants a very serviceable prescription is : — R . Mannse Opt., ...... Magnesii Carb., aa £ij. Ext. SennseFld., ; . . . . . . . fgss. Syrupi, fgj. Aq. Menth. Pip., . . q. s. ad fgiij. M. S. — A teaspoonful once, twice or three times daily for a child of six months. Or should a sallow skin, yellowish conjunctivae and loaded tongue indicate torpor of the liver : — R . Resinse Podophylli, ............ gr. ss. Alcohol, n\xlviij. Syrupi, . ...... ..... . . q. s. adfgiij. M. S. — A teaspoonful two or three times daily for a child of one year. ....,.■ If it be difficult to make the infant take medicine, manna — which imparts only a sweet taste — may be dissolved in the food, 278 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. and given from the bottle as often as required. Phosphate of sodium — an admirable laxative — can also be administered in the same way, in doses of two to five grains three times each day, at the age of six months. Children of three or four years and upward do best upon aloes and belladonna. Tincture of aloes and myrrh in doses of five drops thrice daily, or in a single dose of ten drops at bedtime, acts well ; but if the patient be old enough to swallow a pill, the following prescription is to be preferred : — R . Ext. Belladonnae, gr. ss. Pil. Aloes et Myrrh., gr. vj. 01. Cari, gtt. iij. Ext. Taraxaci, gr. xij. M. et ft. pil. No. xij. S. — One pill at bedtime for a child of six years. Or the aloes and belladonna may be combined in a mixture,* thus: — R. Tr. Belladonna?, . f^j. Tr. Aloes et Myrrh., f ^ ss. Mucilag. Acaciae, q. s. Aquae Menth. Pip., q. s. ad f^ iij. M. S. — One teaspoonful for a dose. In using aloes and myrrh, it is usually necessary to reduce the dose after a time, as its purgative action increases rather than diminishes with repetition. * A clearer mixture may be made by using a solution of aloes and myrrh in- stead of the officinal tincture. The following is the formula : — R . Aloes, Myrrh, aa gr. ijss. Alcohol, fgss. Glycerinae, fjf j. Aquae, q. s. ad f ^ iij. M. This solution was compounded, at the author's request, by Mr. J. J. Ottinger of Philadelphia. The dose is the same as the tincture. AFFECTIONS OF THE STOMACH AND INTESTINES. 279 Another useful laxative is cascara, in the form of a fluid extract or an elixir ; of the first preparation ten drops, of the second, twenty drops may be given, once or several times daily to a child of six. It does not quickly lose its effects by repetition. I have lately used with much satisfaction a laxative confection, composed of tamarind pulp (gr. xxxvj) and senna in powder (gr. iv), aromatized with aniseed and lemon, and acidulated with tartaric acid. One of these may be eaten every evening, or as often as necessary, by a child of three years of age. They are regarded as sweets rather than medicine, and the little patients eat them readily. Glycerine suppositories may also be used once or even twice a day if occasion require. 14. SIMPLE ATROPHY. Simple atrophy, or, as it is often termed, marasmus, is a con- dition in which there is extreme wasting of the soft tissues of the body, either without special organic lesions or with catarrhal in- flammation of the mucous membrane of the gastro-intestinal canal. Morbid Anatomy. — After death, the muscular and other tissues are found in a state of atrophy, and there is a total dis- appearance of normal fat from the body. Fatty degeneration of the kidneys, lungs and brain may be discovered ; the stomach is sometimes ulcerated, and hemorrhagic effusions into the cra- nium are not uncommon. Etiology. — Wasting usually occurs during the first twelve months of life, though it may begin in the second year, and is most frequently encountered among children of the poor. It arises both in breast-fed babies and in those brought up by hand, being, in either case, due to insufficient nourishment. Food can be insufficient in two ways : first, when it is supplied in amounts too limited to meet the demands of the system ; and second, when it contains a minimum of the elements essential to nutrition, or presents them in a form ill adapted to the feeble 280 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. digestive powers of infancy. For example, nursing infants waste in consequence of feeding either from a breast that yields too little good milk, or from one that secretes abundantly a poor, watery fluid entirely unfit for nourishment. With artificially fed children, on the other hand, it rarely happens that the quan- tity of food is too small ; the fault lies, rather, in the direction of quality. Undiluted cows' milk ; milk thickened with starchy materials ; farinaceous foods, and even table food — meat, vege- tables, and bread — are given to babies a few weeks or months old. Now, all of these are highly nutritious, but the digestive apparatus is not sufficiently developed to prepare them for ab- sorption. They are strong foods, adapted to nourish and strengthen much older children and adults, but as the infant cannot appropriate them, he starves as surely, if more slowly, than when taking no food at all. Such aliment, also, while remaining undigested in the stomach and intestines, undergoes fermentation with the formation of irritant products, causing vomiting or diarrhoea; conditions that still further lower the vital powers and hasten atrophy. It is often possible to trace the disease directly to want of cleanliness in the feeding apparatus, and especially to the use of a form of bottle that has lately been very popular. This bottle has, in place of a plain gum tip, an arrangement of glass and rubber tubing of small calibre. One extremity of the rubber tubing, which is eight or nine inches long, terminates in a small nipple-shaped tip and bone shield ; the other, after penetrating an ornamental rubber cork, is fitted to a bit of glass tubing long enough to extend quite to the bottom of the bottle. By this plan, the trouble of holding the bottle and keeping it at a proper angle during feeding is avoided. The seeming advantage, though, is counterbalanced both by the minor drawback that the child, left to itself, is apt to continue suction long after the bottle is exhausted, thus swallowing a quantity of air, and by the greater disadvantage that the tubing can never be kept clean. For a number of years the author has made it a rule to ask for the bottle of every hand-fed infant presented for treatment, and AFFECTIONS OF THE STOMACH AND INTESTINES. 28 1 few days have passed without his seeing several of the compli- cated contrivances referred to. In almost every instance, not- withstanding the most careful and frequent cleansing, a sour odor could be detected, and if milk were present, it contained numer- ous small curds ; while in cases of carelessness the odor was in- tolerable, and the interior of the tubing was encrusted with a layer of altered curd. With ordinary bottles, on the contrary, alterations in the character of the milk and coating of the interior of the tips were very infrequent. As there is little diffi- culty in keeping the bottles themselves clean, there can be only one reason for this difference, namely, in the old-fashioned in- strument the nipple is readily removed and as easily inverted and cleaned, but in the other there is no way of cleaning thor- oughly the twelve or more inches of fine tubing. The latter cannot be inverted, and the passage of a stream of water, or of a small, stiff brush, only imperfectly removes the milk clinging to the interior. This, of course, soon undergoes decomposition, and in this state quickly inaugurates change in the next supply of milk placed in the bottle. It is evident that a constant sup- ply of food, no matter how good originally, thus rendered acid and partially curdled, must, like an excess of farinaceous or other unsuitable food, produce irritation of the alimentary canal, interfere with the processes of nutrition, and lead to a state in which the features of wasting and disordered digestion are com- bined. The custom of preparing in the morning a supply of food sufficient for the whole day is another fruitful cause of atrophy. If this be done, no matter how carefully the mixture be propor- tioned, or how well adapted to the age and digestion of the child, it becomes unfit for consumption after standing eight or ten hours. The change may or may not be appreciable to the senses, but test-paper will always show acidity and the microscope demonstrate the existence of actively moving bacteria. Finally, food upon which a child has thrived for three or four months, perhaps, can become unsuitable and, consequently, lead 24 282 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. to wasting, if the digestive powers be suddenly reduced by an intercurrent disease. Symptoms. — The clinical features differ materially, according to whether the element of insufficiency be one of quantity or quality. They may, therefore, be divided into two classes, viz : those developed by food that is suitable but not sufficient ; and those resulting from unsuitable food. The first group of symptoms is most frequently encountered in children who have been nursed at the breasts of feeble or over-worked mothers, in whom the milk is often both scanty and of poor quality. There is a gradual loss of plumpness ; the muscles grow flaccid, and there seems to be an arrest of growth. The face is white ; the lips pale and thin, the skin harsh and dry or too moist, and the anterior fontanelle level or slightly depressed. The temper is irritable and sleep restless and disturbed, or the child is abnormally quiet, dozing constantly, and sucking his fingers until they become raw. When nursed, the child seizes the nipple ravenously ; then, if there be little milk, he quickly drops it to cry passionately, as if disappointed at not being able to satisfy his hunger; but if the milk be abundant, though thin, he will lie a long time quietly at the breast and often fall to sleep with the nipple in his mouth. The bowels are inclined to con- stipation, the stools being scanty, hard and dry. Physical signs connected with the chest and abdomen are negative, and no indication of disease of any special organ of the body can be detected. In the second class, features of wasting are associated with those of irritation of the alimentary canal, and the symptoms altogether are much more grave than in cases of the preceding group. The subjects are almost invariably hand-fed infants. Emaciation progresses with a rapidity and to an extent de- pending upon the original strength of the child's constitution ; the age at which artificial feeding is begun, and the sort of food employed. It is often so extreme that an infant several months old weighs less and appears smaller than at birth, and this, even after a large quantity of food, such as it is, has been consumed. AFFECTIONS OF THE STOMACH AND INTESTINES. 283 The combination of great wasting with a voracious appetite, is * very striking, and is only apparently contradictory, since hunger — the demand .of the tissues for reparative material — cannot be appeased by food which, from its bad quality, is incapable of digestion or proper preparation for absorption and assimilation. Unsuitable food, too, by irritating the mucous membrane of the stomach, creates a fictitious appetite. Sooner or later the face becomes pinched, the eyes are sunken, the lips pale, and when moved display a deep furrow about the angles of the mouth ; the facial expression is uneasy or languid, and the anterior fontanelle is deeply depressed. The skin, gen- erally, is dry, harsh and yellowish ; hangs in loose folds over the bones, and may be mottled by an eruption of strophulus or urti- caria, or present red patches of intertrigo in the neighborhood of the genitalia and over the buttocks and inner surface of the thighs. The extremities are cold and the hands claw-like- The tongue is heavily furred or red and dry. With the mucous membrane of the mouth, it may be the seat of aphthous ulcera- tion or thrush deposit. As already stated, the appetite is often ravenous, and the cries of hunger are violent, oft repeated ; and only temporarily silenced by food ; thirst is increased ; colic is common ; the bowels are constipated, and the stools, which are voided with difficulty and straining, are composed of a few light- colored, cheesy lumps, partly covered with greenish mucus. Attacks of acute vomiting and diarrhoea often interrupt the regular course of the disease. At such times there is moderate fever during the night, though, ordinarily, the temperature is subnormal. Again, chronic vomiting and chronic diarrhoea* are apt to arise as complications, and greatly increase the danger of a fatal termination. Sleep is restless and disturbed, and many hours, particularly during the night, are spent in fretful crying. A common group of symptoms connected with the nervous system is " inward spasms. ' ' When these occur, the upper lip becomes livid, some- * See chapters on Chronic Vomiting and Diarrhoea. 284 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. what everted, and tremulous ; the eye-balls rotate or there is a slight squint, and the fingers and toes are strongly flexed. They frequently usher in true convulsions. Sometimes the nervous manifestations are much more complex. Thus, I have seen cases where there was retraction of the head ; boring of the head into the pillow ; an approximation to the " gun-hammer " decubitus ; general hyperesthesia and the tache cerebrale \ all suggestive of tubercular meningitis. Such symp- toms disappear under an appropriate diet, with proper medicinal treatment, and are to be referred to an intensely excitable nerv- ous system ; a condition depending upon insufficient nourishment, and differing merely in degree from that leading to " inward spasms.' ' There is, of course, extreme prostration, the cardiac action is weak and the respiration shallow. The urine is citron-colored or very dark yellow ; has a specific gravity of 1009 to 1012.5 ; a strong, characteristic odor, and is diminished in quantity. It is always cloudy or milky, only becoming clear on the approach of recovery. The sediment deposited on standing, contains variously shaped cylinders ; fatty elements with tinted nuclei ; mucus ; colored uric acid ; urates in a crystallized or amorphous condition ; pigment, etc. The reaction is sometimes highly acid. The proportion of urates is decidedly, that of uric acid notably, and of coloring matter and extractives somewhat in- creased. Albumen is always present in variable quantity and sugar may be also frequently detected.* Death may be preceded by convulsions or the symptoms of spurious hydrocephalus, or may result from prostration. Diagnosis. — Great emaciation may result from inherited syph- ilis or acute tuberculosis, but both of these conditions are attended by characteristic symptoms, rendering their diagnosis a matter of little difficulty. When symptoms resembling those of tubercular meningitis are present, it is often necessary to delay a definite opinion. In * " Parrot and Robin." AFFECTIONS OF THE STOMACH AND INTESTINES. 285 simple atrophy, however, the open fontanelle is level or depressed ; the belly is never scaphoid ; the bowels, though frequently constipated, are never locked ; vomiting is apt to be associated with diarrhoea; the respiration and pulse are regular in rhythm; the temperature, as a rule, is sub-normal ; there is no hydren- cephalic cry, and the antecedent history and the course are different from the tubercular disease. Prognosis. — A vast number of cases die annually in our large cities, yet the results of appropriate management are often rapidly and surprisingly successful. Patients should never be given up unless there be extreme wasting and prostration, or unless the symptoms of spurious hydrocephalus arise; convulsions occur; or obstinate chronic vomiting or diarrhoea be developed. Treatment. — For the arrest of wasting from insufficient nour- ishment, the first thing to be attended to is the diet. Without entering at length into this subject,* it may be stated, as a uni- form rule, that in selecting a diet the object should be to fix upon one suited to the age and digestive powers of the child, so that he may be able to digest, and, therefore, be nourished by, all the food consumed. Generally, infants under twelve months who have to be either partially or entirely " brought up by hand, " do well upon sterilized cows' milk, with lime-water or with barley-water. The food should be administered from a bottle capable of holding half a pint, made of colorless glass, so that the least particle of dirt can be seen, and provided with a soft India-rubber tip. The whole quantity of food intended to be given in a day should never be prepared at once, but each portion must be made separately at the time of administration. Thus, a bottle of the sort described, absolutely clean, may be filled with a mixture of one part of lime-water to two or three of sound milk, or with one part of barley-water to two or three of milk, to either of which may be added from one to two tablespoonfuls of cream and a teaspoonful of pure sugar of milk. The bottle must next be placed in hot * For the details of diet and general management, see Part II. 286 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. water until the contents become warm, when it is ready for the child. The degree of dilution of the milk and the proportion of cream added vary with the age and the feebleness of digestion. Lime- water is the preferable diluent when there is frequent vomiting or acid eructation. Both it and barley-water are of service in preventing the formation of large, compact curds. After digestion has been brought into good condition by such a diet, the food may be cautiously increased to a standard suit- able for a healthy child of the same age. At eight or ten months, from two to four fluidounces of thin mutton or chicken broth, free from grease, may be allowed each day in addition to the milk ; at twelve months, the yolk of a soft-boiled Qgg, rice and milk, and carefully mashed potatoes moistened with gravy ; and at the end of the second year, a small quantity of finely minced meat. Once daily the patient should be bathed in warm water, or, at least, sponged over with warm water, and every morning and evening a teaspoonful of warm olive oil or of cod-liver oil should be rubbed into the skin over the abdomen and chest. At the same time, the belly must be completely covered with a soft flannel binder, and the feet and surface generally kept warm by woolen clothing. In this way attacks of colic, if not entirely prevented, are rendered much less frequent and severe. If there be intertrigo, cleanliness and the free use of oxide of zinc ointment usually suffice to effect a cure. Of medicines, bicarbonate of sodium, pepsin and cod-liver oil are, perhaps, the most useful. Cod-liver oil should not be given until the digestive powers have been brought into a comparatively normal state by proper food, antacids and digestants. The oil is most easily borne when given in emulsion, and may be advan- tageously combined with lacto-phosphate of lime or with the hypophosphites. Such symptoms as constipation, diarrhoea and vomiting de- mand, of course, appropriate treatment. AFFECTIONS OF THE STOMACH AND INTESTINES. 287 15. TYPHLITIS AND PERITYPHLITIS. Destructive inflammation of the coats of the caecum or vermi- form appendix — typhlitis — and of the post-caecal areolar tissue — perityphlitis — are so closely associated that it is best to study them together. In the caecum and appendix the inflammatory process may stop short of ulceration ; may proceed to ulceration with perforation and the production of perityphlitis, or, infrequently, may lead to the latter by simple extension of the morbid process without perforation. The independent and primary origin of perityphlitis is possible, perhaps, but must be extremely rare. Neither condition is, strictly speaking, an affection of childhood ; nevertheless, children between four and twelve years of age are liable, particularly to that form in which perforation of the vermiform appendix occurs. Morbid Anatomy. — In typhlitis without ulceration, a large extent of the mucous lining of the caecum or appendix is the seat of catarrhal inflammation, while the investing peritoneum is opaque and injected, and may form adhesions to the neighboring intestinal loops. When the inflammation advances to ulceration, though a more limited area be affected, there is a tendency to involvement, with destruction, of all the coats of the bowel ; and during this process the peritoneal adhesions may become firmer and more extensive. The result of the perforating ulcer depends upon its position. Should it be situated on the anterior wall of the caecum, the in- testinal contents escape into the peritoneal sack, in spite of the adhesions — which are rarely firm enough to offer an efficient ob- stacle — and produce a rapidly fatal general peritonitis. When, on the contrary, it occupies the posterior aspect, where the wall of the caecum is devoid of peritoneum, the escaping faecal matter enters the post-caecal connective tissue, and causes inflammation, with suppuration, and forms a " faecal abscess." Such abscesses may reopen into the intestine; may extend down the sheath of the psoas muscle, reaching the surface below Poupart's ligament, or may point in the lumbar region or in any situation along the 288 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. iliac crest. Sometimes the ulceration stops before perforation occurs, and the inflammation assumes a chronic form. In such cases, dense peri-caecal adhesions form ; the caecum is contracted in calibre ; has its walls thickened, and its mucous membrane either " almost entirely destroyed or converted into a retiform and trabecular fibroid tissue/ ' * In the appendix the ulcer may be situated at the free extrem- ity, or, more frequently, at some point in the lower third of the canal. As to extent, the loss of substance may be small or involve the whole circumference. A collection of pus may be present in the cavity of the appendix, and it is usual to find a foreign body or intestinal concretion near the position of perfo- ration. While the ulceration is going on, firm adhesions are occasionally formed with the caecum ; the anterior wall of the abdomen, or the tissues of the right iliac fossa. If the first event occurs, the resulting circumscribed abscess opens into the intes- tine ; if the second, it points in the abdominal wall ; and if the third, perityphlitis is set up, with the results already described. Usually, however, there are no adhesions or weak ones, and fatal general peritonitis follows the exit of the concretion and pus. The concretions resemble in shape and size cherry or date stones. They are hard \ often laminated in structure ; have a smooth, waxy-looking surface; are grayish or brown in color, and are composed of earthy phosphates combined with inspis- sated mucus and faecal matter. Pins, shot and splinters of bone, strawberry seeds, hairs and little masses of hardened mucus, may form the nidus of these calculi. These articles, too, illustrate the class of foreign bodies which cause perforation when arrested in the vermiform appendix. Sir William Jenner, quoted by Eustace Smith, attributes the arrest of calculi in the appendix to malposition. "This process, owing to its length and the attachment of its mesentery, may be bent at an angle (instead of being directed upward and inward) so that hardened particles can slip readily into it, but are pre- vented from returning." f * Meigs and Pepper. f " Diseases of Children," 2d Ed., p. 723. AFFECTIONS OF THE STOMACH AND INTESTINES. 289 Etiology. — In addition to peculiar anatomical relations and physiological attributes, which render the segment of intestine in question very prone to disease, a constipated habit is the chief predisposing cause. The existence of the strumous diathesis, too, while it has little influence in increasing the susceptibility to typhlitis, does augment the tendency to ulceration and perfora- tion after inflammation is established. Retention of hardened faecal matter in the caecum, the so- called " typhlitis stercoralis"; accumulation of the seeds of cer- tain fruits, as strawberries or raspberries, in one of the pouches of the caecum ; the passage of these, or of intestinal concretions, or foreign bodies — shot, pins and bone spiculae — into the appen- dix, and the habitual use of coarse, undigestible food, are the most common excitants. Cold and exposure, blows upon the abdomen, and violent exertion with strain of the abdominal muscles, are also sometimes determining causes. In perityphlitis the inflammation is generally produced by the escape of faecal matter into the peri-caecal connective tissue. The perforation occasionally results from the ulceration of typhoid fever or of intestinal tuberculosis. Symptoms.— Simple typhlitis begins suddenly, with pain in the right iliac region, and vomiting. The pain is constant and severe, and is increased by coughing, sneezing, vomiting and by efforts to stand or walk. The vomiting is attended by distressing retching; is often repeated, and the ejections consist, first, of food, and afterwards, of bile-stained fluid. The patient has an anxious face ; lies on his back slightly inclined to the right side, with the right thigh drawn up, and complains if an attempt be made to straighten it. Abdominal respiratory movements are partially suppressed ; the right iliac region is full and even prominent; very tender to the touch and dull on percussion. Palpation, when it can be practiced, reveals a resistant mass occupying the site of the caecum. There is fever, indicated by a coated tongue, extreme thirst, a frequent and somewhat wiry pulse, and a temperature ranging about ioi° or 102 F. The bowels are confined. 290 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. When properly managed, these symptoms disappear in from four to twelve days ; the bowels yield and move freely with the expulsion of masses of hardened faeces ; the vomiting ceases ; the pain abates, and the tenderness and swelling slowly subside. Inflammation of the appendix alone is attended by the same symptoms. The pain, however, is more intense, and evacuation of the bowel is not followed by the same rapid relief. Perityphlitis may be ushered in by the marked symptoms just described. On the contrary, the causal ulceration, as it involves a limited area of the caecum or appendix, may be very latent. In the former instances the vomiting may stop, the bowels may be moved, and the acute pain be superseded by aching, or all discomfort disappear. The tenderness and swelling of the right iliac region, however, remain, although they are materially lessened; the patient looks ill \ has a distressed face, and is list- less. If, as is ordinarily the case, the onset be latent, complaints are made only of dull aching or discomfort in the caecal region. These sensations are subject to exacerbations of a few hours' duration, when the suffering becomes acute and there is vomiting and fever. In the intervals, the general health is somewhat below par; the child, while up and about, takes little interest in play ; is peevish ; has a poor appetite ; is, perhaps, restless, thirsty and feverish at night, and has irregular movements of the bowels — attacks of diarrhoea alternating with constipation. After an indefinite time, in either case, perforation occurs. The event is followed by little change in the symptoms at first, but soon there is more constant and severe pain in the arTected'region, which is increased by movement or pressure ; there is greater fulness, too ; the bowels are confined ; sleep is more restless and disturbed, and there is more pyrexia. The child takes to his bed, where he lies on his back with the right thigh drawn up. If assisted to stand, he rests his whole weight on the left leg, keeping the right bent at the hip and knee and rotated outward, and limps when he walks. There may be pain in the knee, and any rough attempt to move the leg increases the abdominal pain. As suppuration progresses in the peri-caecal tissue, hectic fever AFFECTIONS OF THE STOMACH AND INTESTINES. 29 1 develops, with rigors or chills, followed by profuse sweating ; a dry, brown tongue ; diarrhoea ; sl running, feeble pulse ; prostra- tion and rapid loss of flesh. The abdomen becomes distended and very painful ; the csecal tumor increases in size, but becomes softer ; there is pain in the right knee and ankle, and sometimes oedema of the leg. Should the abscess point toward the surface, the skin becomes swollen ; doughy ; dark-red or purple in hue ; palpation yields emphysematous crepitation, and an incision gives vent to brownish offensive pus and fetid gas. When the abscess reopens into the intestine, the local pain, swelling and tenderness diminish, and the general symptoms improve. The uncommon cases in which perityphlitis occurs without pre- vious typhlitis, are marked by pain ; deep tenderness and mode- rate fulness; but there is no tumor, in the right iliac region. The bowels are irregular, and there is colic and moderate fever. Perforation of the anterior wall of the caecum gives rise to the symptoms of local or general peritonitis, according to the presence or absence of firm adhesions. Ulceration of the appendix is more frequently followed by symptoms of general peritonitis than by those of perityphlitis, and the former may be the first indication of lesion of this portion of the gut. Diagnosis. — A sudden attack of pain referred to the right side of the abdomen; vomiting; constipation; a pinched, anxious face ; fever ; a dorso-lateral decubitus ; flexion of the right thigh, and the presence of an intensely tender tumor in the caecal region, are the characteristic symptoms of typhlitis. Perforative ulceration may be suspected if these symptoms dis- appear and reappear several times, or if, after a free evacuation of the bowels, local pain, tenderness and swelling continue. Intussusception resembles typhlitis in some of its features, but in this condition tenderness is a late symptom ; the tumor is situated more to the left of the abdomen ; sometimes the lower end of the invagination can be felt in rectal examination, and there is severe tenesmus with the expulsion of blood-stained mucus. 292 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. The limping gait, with the pain and tenderness in the right groin which are incident to perityphlitis, may suggest hip-joint disease, particularly if other symptoms be but poorly developed. The distinction, though, can be made without much difficulty. In perityphlitis, although the right thigh is semi-flexed, and can- not be extended without great pain, it is possible, if care be taken, to rotate the head of the bone without causing suffering, and to make pressure on, or. behind, the trochanter without giving discomfort. The patient, too, while avoiding extension, will often freely flex, abduct or adduct the thigh as requested. Again, there is no atrophy of the thigh muscles, no flattening of the buttock on the affected side, and no lowering of the buttock fold or obliteration of the fold of the groin. Finally, the history shows an acute course, and there are usually other symptoms which directly indicate that the disease is situated in the right iliac region. Prognosis. — Simple typhlitis should almost uniformly termi- nate in recovery. The duration of active illness is, as already stated, from four to twelve days, though several weeks often pass before the local tenderness entirely disappears, and the functions of the intestine are restored. Ulcerative destruction of the anterior wall of the caecum generally results in death from general peritonitis in two or three days. Perforation of the appendix is always rapidly fatal. The termination of perityphlitis resulting from perforation depends upon the direction taken by the pus. When the abscess opens upon the surface of the body the mortality is about fifty per cent.; death resulting from exhaustion or extension of inflamma- tion to the peritoneum. A reopening into the intestine is more favorable, and many cases get well. Under any of these circum- stances the course is apt to be prolonged. Treatment. — For prevention, it is necessary to guard against habitual constipation, by a properly selected diet, by regular exercise, and by enforcing the rule of making daily attempts to evacuate the bowels at a fixed hour. Nature may be assisted by AFFECTIONS OF THE STOMACH AND INTESTINES. 293 a teaspoonful of compound licorice powder at bedtime, or one of the following pills : — R . Resin. Podophylli, gr. jss. Ext. Belladonnse, gr. j. Ext. Taraxaci, gr. xij. M. et ft. pil. No. xij. S. — One pill every night for a child of six years. Or— R. Ext. Belladonna, Ext. Nucis Vomicae, aa gr. j. z Ext. Colocynth. Comp., gr. vj. Ol. Cari, gtt. iij. Confec. Rosse, gr, vj. M. et ft. pil No. xij. S. — One pill every night. Should there be a tendency to faecal accumulation laxatives are not to be administered, but the mass is to be removed by purgative enemata. Two teaspoonfuls of table salt to a half pint of warm water, will be efficient for this purpose, or one of the enemata mentioned in treatment of constipation, (p. 275) may be used. A child attacked by typhlitis must be put to bed, and a small pillow placed under the right knee to support the thigh. The iliac region is to be covered with hot flax-seed poultices, or, if the child be robust and the tenderness and pain excessive, two or three leeches may be applied before poulticing. No food but milk, or milk with a little mutton or chicken broth, is allowable, and these are to be given in small quantities at short intervals. A patient six years old may take every two hours: — Milk, fgij. Barley-water, f^>ij- Saccharated Solution of Lime, gtt. xv. Saccharated solution of lime is used as an alkali instead of lime-water, on account of its adding no bulk to the food : it is prepared in this way : — 294 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Take of— Slaked Lime, gj. Refined Sugar, in powder, gij. Distilled Water, f § xvj. Mix the lime and sugar by trituration in a mortar; transfer to a bottle containing the distilled water, cork and shake occasionally for a few hours. Finally, separate the clear solution with a siphon and keep in a stoppered bottle. When broth is used, it may take the place of the milk at three or four feedings during the twenty-four hours. Should the milk or broth not be retained, whey mixtures, peptonized milk, and meat juice can be tried. Thirst is best relieved by small quantities of cold carbonic-acid water and bits of ice. The therapeutic indication is to relieve irritation and arrest excessive peristaltic action of the bowels. This is best accom- plished by a combination of opium and belladonna, as : — R . Tr. Opii., tt\,xxiv. Tr. Belladonnae, tt\xlviij. Aq. Cinnamomi, q. s. ad f^iij. M. S. — One teaspoonful every two hours. The action of these drugs must be constantly pushed, until pain be relieved or the limit of systemic toleration be reached. The second or third dose usually checks vomiting; but should this be not the case, morphia must be administered hypoder- mically in doses of one-sixteenth of a grain at intervals of four or six hours, according to its influence on the pain and its narcotic action. As the pain subsides the bowels act spontaneously. There is one rule in the treatment of typhlitis that must never be forgotten, namely, no purge, no matter how gentle in action, is to be used, either by the mouth or rectum, while the acute symptoms are present. After they disappear, if the bowels be not relieved, enemata of warm water can be given safely, but no purge by the mouth. Furthermore, it is well to withhold the latter for several weeks after convalescence is established, for AFFECTIONS OF THE STOMACH AND INTESTINES. 295 there may be some latent ulceration in progress that can only result favorably through the formation of firm peritoneal adhe- sions, and nothing so surely destroys them, while in the process of development, as a purgative. As soon as the bowels are moved and convalescence begins, the diet may be cautiously increased ', a belladonna plaster sub- stituted for the poultices ; tonics administered, and the patient allowed to sit up in bed, and after a time, as health returns, to be up and about. Very active exertion should be avoided for several months. Perityphlitis demands the same rest in bed, careful dieting, local applications, and avoidance of purgatives. As hectic fever appears, the food must be more nutritious ; eggs, finely minced meat and beef-tea may be added to the milk. Alcoholic stimu- lants are also required with quinine, and, when there is great prostration, carbonate of ammonium. So soon as the abscess points it must be evacuated and a free discharge encouraged. In the after treatment every effort should be made to support the strength by good food, tonics and stimu- lants. It would not be well to leave the question of treatment with- out some more distinct allusion to the intervention of surgery. Peritonitis of every form is passing more and more into the hands of the surgeon, and remarkable successes have of late been recorded in cases which might well have been deemed desperate. Regarded from the point of view of the physician, the subject stands thus : A number — it is difficult to say how many, but probably a large majority — of these cases, if treated judiciously, get perfectly well, and an operation, however successful, might well be called meddlesome. In others the inflammatory process localizes itself; then, if the symptoms indicate no progress toward recovery, or are in any degree urgent, an exploratory incision is not only justifiable, but demanded. Next come those other cases already described, where the peritonitis is general, and in which the life of the child is in the balance. Then it is 296 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. that the experience of other cases, that have struggled through ) the fear that a serious undertaking, such as opening the abdomen, may extinguish the last hope ; the doubt that must exist whether, if an operation be begun, any relief can be afforded, and similar considerations, make confusion when we most need calm judg- ment. We can be wise after the event, and talk glibly of the advantages of early operation, but this is small help to us when the point aimed at is so to time our measures as to be neither too soon nor yet too late. No precise rules can be established ; these cases must remain full of anxiety, of doubt and diffi- culty, and the man of courage and judgment will occasionally save a life by a timely and carefully-conducted operation. So far as advice can be given, it may be said that for a dry peri- tonitis probably no good will come of surgery. If any evidence can be obtained favoring the existence of pus or of serum — for the serum in these cases is irritant and noxious, and often as urgently calls for removal as pus — here, if the right moment can be seized, an incision, and such steps as may be necessary for cleansing the peritoneum, will sometimes prove successful. 16. INTUSSUSCEPTION. In intussusception or invagination one portion of the intestine is forced, from above downward, into another portion imme- diately continuous with it. Apart from faecal accumulation, this is practically the sole cause of intestinal obstruction in infancy. For, although in- stances are on record in which the bowel, in children, has been closed by peritoneal adhesions ; by a twisted vermiform appen- dix, and by morbid growths, these are but pathological curiosi- ties. Two forms are met with, namely : — intussusception without symptoms ; and intussusception with symptoms. AFFECTIONS OF THE STOMACH AND INTESTINES. 297 INTUSSUSCEPTION WITHOUT SYMPTOMS. This condition, which must be regarded rather as an accident than a disease, is frequently encountered in autopsies upon young children who have met death from very diverse affections. Such intussusceptions occur shortly before, or during, the death agony, and are probably produced by irregular and violent con- tractions of the muscular fibres of the gut. They consist simply of an involution of the bowel, without evidence of inflammatory action at the site of lesion, and can be readily reduced by trac- tion. Sometimes there is but one inversion, though usually there are several ; as many as ten or twelve distinct invagina- tions, at distances of a few inches from each other, having been found in the same subject. The length of gut displaced is rarely more than three or four inches. The small bowel is the uniform seat ; and of this division of the intestines, the lower part of the jejunum and the upper part of the ileum, are most frequently involved. Without a post-morten examination, it is impossible to recog- nize the existence of this form of intussusception, on account of the entire absence of symptoms. Nevertheless, its discovery may be anticipated when death has resulted from cerebral or spasmodic diseases, or from acute or chronic entero-colitis. INTUSSUSCEPTION WITH SYMPTOMS. True intussusception is, fortunately, not very frequently met with in children, though it is more common in early infancy than in later childhood, youth or adolescence. Morbid Anatomy. — The probable mechanism of an intus- susception is that a limited portion of the intestine contracts forcibly, and, by elongating and moving forward, enters a non- contracted segment immediately below, drawing in more or less of the latter, together with its mesentery or meso-colon. Next, new peristaltic movements force the invaginated bowel further and further along, until extension is arrested by resistance from 25 298 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. the mesentery, or by secondary inflammatory adhesions. The intussusception must, therefore, be made up of three layers of intestine, one above the other. The outer layer is called the sheath, or intussuscipiens ; the middle and inner ones, the intus- susceptum. Of these, the external and middle have mucous surfaces in contact; the middle and internal, serous surfaces. The involuted mesentery or meso-colon lies between the two last-named layers, and, on account of the firm attachment at its roots, exerts a one-sided traction upon the intussusceptum, curv- ing it upon its axis and drawing the lower opening — which is elongated to a narrow fissure — from the centre toward the side of the sheath. The sheath itself is much folded or puckered, and on this account, with the curving of the intussusceptum, the apparent length of gut involved is always much less than the actual length. This varies from a few inches to several feet ; in extreme cases an intussusception beginning at the ileo-caecal valve, may become apparent .to the touch or sight at the anus. Increase in length is accomplished by peristaltic action from be- hind ; it takes place, always, at the expense of the external layer, and depends, for its degree, upon the force of peristalsis, the width and laxity of the mesentery or meso-colon, and the amount and character of the contents of the intestine behind the seat of involution. The results of an intussusception are, first, occlusion of the lumen of the canal with partial, or generally complete, arrest in the passage of the intestinal contents ; and second, obstruction of the blood current in the middle and inner tubes, due to the pres- sure upon the mesenteric vessels. The obstruction of the circulation leads to deep congestion of the tissues of the intussusceptum ; the mass becomes purple and swollen ; the mucous surfaces exude a bloody material, and soon the opposed serous surfaces are glued together by inflammatory adhesions. Should there be complete strangulation the intussusceptum becomes gangrenous, and, under favorable circumstances, may be detached en masse or in pieces, and discharged through the AFFECTIONS OF THE STOMACH AND INTESTINES. 299 anus. When this occurs, provided firm adhesions have formed, the sheath, being united at its upper extremity to the intestine directly above the point of inversion, forms, with the latter, a continuous tube, notwithstanding the separation of the interven- ing portion. Several accidents may happen during this process. Thus, the inflammation in the opposed serous coats may extend beyond the involution, and give rise to general peritonitis. Or, ulceration and perforation of the sheath may be produced by the pressure and irritation of the free end of the intussusceptum. Again, when adhesions are imperfect, the contents of the intestine may escape into the peritoneal cavity through a rent, resulting from the separation of the sloughing intussusceptum ; and, finally, even after the gangrenous mass is expelled, the adhesions may give way and permit extravasation. Generally, in those fortunate cases in which sloughing is fol- lowed by recovery, no permanent injury results from the cicatri- zation at the point of junction of the sheath and uninvolved intestine. The cicatrix, though at first contracted, gradually stretches and a free passage-way is established. Sometimes intussusception is attended with so little constric- tion of the involuted gut that the passage for the involved intes- tinal contents is quite free enough to allow of the maintenance of life for months, the patient finally dying of exhaustion. In infants the invagination is almost invariably ileo-caecal. The end of the ileum with the ileo-caecal valve is forced into the caecum, and, as the intussusception increases, penetrates further and further into the colon, drawing along more of the ileum, and doubling in, first, the caecum, and then the ascending, or even the transverse and descending portions, of the colon. In some cases a few inches of the gut pass through the ileo-caecal valve before the caecum is inverted. Occasionally an intussusception involves the colon alone, and, very exceptionally, the small in- testine. Upon opening the abdomen, in an ordinary case, much of the colon appears to be wanting, and a tumor is found occupying 300 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. the left side or the left iliac fossa. This mass — the intussuscep- tion — is slate-gray in color; elongated or sausage-shaped, and doughy to the touch. By more or less forcible traction, the in- volution may be reduced, though the gut is usually softened and apt to be torn in the effort. If an incision be made through the sheath, exposing the intussusceptum, two orifices will be observed at the lower end of the latter, one leading through the valve, the other into the cavity of the appendix vermiformis. The invagi- nated intestine is either of a uniform deep red color, resembling a long, firm clot of blood, or presents the appearances common to gangrenous and sloughing tissues. If death has occurred early, there are few evidences of inflammation between the serous surfaces; if later, these are adherent, the adhesions ex- tending a few lines beyond and above the neck of the intussus- ceptum on to the sound intestine. The gut situated above the point of obstruction is usually greatly distended with accumulated faecal matter and flatus; whilst that below is collapsed and empty, or at most, contains a small quantity of mucus, stained with blood, pressed out from the capillaries of the strangulated mass. As the age of the child advances the more likely is the intus- susception to be confined to the small intestine. Etiology. — As already indicated, early age seems to act as a powerful predisposing cause. Of fifty-two cases in children, re- corded by J. Lewis Smith, twenty-three occurred between the ages of three and six months ; eight between the sixth and twelfth months ; and eighteen between the first and twelfth years. Of Leichtenstern's four hundred cases, one-fourth occurred in the first year, after the third month. The greater liability in infancy is due partly to anatomical peculiarities, and partly to the want of regularity and the energy of the intestinal movements. Thus, in infants, the large intestine holds to the abdominal space that it is forced to occupy the relation of about three to one, necessi- tating doubling of the gut upon itself. At this time of life, too, the meso-colon is much wider than in later years, except where it passes over the kidneys, in which position it is very narrow, AFFECTIONS OF THE STOMACH AND INTESTINES. 30I or even almost absent. These two conditions, combined with unrhythmical and violent peristalsis, cannot but favor involution. Many more males are affected than females. Rilliet and Bar- thez record twenty-five cases, all but three in boys, and the statistics of other authorities bear out their figures. The existing causes are imperfectly understood. Attacks have been attributed both to obstinate diarrhoea and prolonged con- stipation ; to the presence of intestinal worms ; to the use of irritating and indigestible food ; and to external violence. Symptoms. — These vary considerably, according to the age of the sufferer and the completeness of intestinal obstruction. In patients under one year the onset is abrupt, whether it occur in the midst of health, or during the course of some derangement of the digestive tract. The child is seized with intense pain in the abdomen, turns excessively pale, screams, and then cries violently, writhing and drawing up his legs. The contents of the stomach are vomited, and usually, unless the bowels have been evacuated just before the attack, there is a single discharge of somewhat liquid feculent matter. After a time the pain passes away, leaving the little sufferer pallid and exhausted. There is now a rest from pain, but not from vomiting ; all food or medicines taken into the stomach are returned at once, either by the easy process of regurgitation, or by violent retching; and if the viscus be empty, the ejections consist of a little bile-stained mucus, or even of blood. Sooner or later — the interval varying from a few minutes to several hours — there is another paroxysm of pain, accompanied by violent tenesmus, resulting in the evacuation of blood and mucus. At this time the abdomen differs little from its normal condi- tion. There is no fulness nor tenderness, nor any tumor ap- preciable to the touch ; on the contrary, gentle friction often relieves the colicky pains, and the child prefers to lie upon its belly. The hands and feet may feel cool, though, otherwise, the temperature of the surface is unaltered. The mind is clear, but the expression of face is anxious, and denotes severe illness. The tongue may be lightly furred, and there is increased thirst, 3 Air insufflation of, 309 A\dd nasi, dilatation of, 21 Alantoin, 33 Albumin, 35 Ammoniacal breath, 31 Amyloid liver, 347 morbid anatomy of, 347 etiology of, 348 symptoms of, 348 Amyloid liver, diagnosis of, 349 prognosis of, 349 treatment of, 349 Anaemia, 44, 1 21-123 Analysis of breast-milk, y^ Anatomical lesion of acute gastric catarrh, 200 of aphthous stomatitis, 126 of catarrhal stomatitis, 124 of simple pharyngitis, 183 of ulcerative stomatitis, 131 Anterior fontanelle, 46 Antiseptics in entero-colitis, 257 Apex beat in pleuritis, 52 Apparatus for gavage, 113 for hand feeding, 96 Aphthous stomatitis, 126 anatomical lesions of, 126 etiology of, 1 26 symptoms of, 127 diagnosis of, 128 treatment of, 128 Arrowroot water, 232 Artificial feeding, 71 Ascaris lumbricoides, 312 egg of, 313 symptoms of, 319 treatment of, 321 Ascites, 377 etiology of, 378 symptoms of, 378 diagnosis of, 379 prognosis of, 380 treatment of, 380 Aspirating hepatic abscess, 363 Asses' milk, 73 383 3^4 INDEX. Asthma, 41 Astringent bath, 1 04 Atrophic cirrhosis, 352 Atrophy, simple, 279 Attendant, questioning the, 18 Auscultation of the chest, 52 Auvard's hatching cradle, 1 1 1 B. Bandage, abdominal, 105 Barley water, 80 Barrel-shaped abdomen, 49 chest, 51 Basham's mixture, modified, 350 Bath, astringent, 104 bran, 104 cold, 103 cooled, 103 hot, 103 mercurial, 104 mustard, 104 nitro muriatic acid, 104 salt water, 104 sod; 104 Bathing, 102 mode of, 102 Bed clothes, 108 Beef juice, raw, 92 tea, 84 Bethlehem oatmeal, in constipation, 276 Bicarbonate of sodium, 80, 87, 88 Blennorrhoea, 178 Boiled milk, 85 Boracic acid, 68 Bothriocephalus latus, 311 Bottle, graduated nursing, 95 Bottle tip, 96 Bran bath, 104 Brandy and egg mixture in intussuscep- tion, 308 Breast-feeding, 60 proper, number per day, 62 milk, analysis of, 73 spec. grav. of, 72 Breath, the, 29 fetor of, 3 1 ill smelling, 29 Breathing, different forms of, 41 puerile, 52 Bridge of nose, broadness of, 23 Bright's disease, 34 Brinton's theory of faecal 303 Bronchitis during dentition, 179 Broth, veal, 92 veal, with barley water, 208 Brows, contraction of, 22 Calculi, intestinal, 288 Cancer of the liver, 363 Cardiac disease, 56 Caseous degeneration and tuberculosis of the mesenteric glands, 329 Casts in the urine, 36 Catarrh, acute intestinal, 227 chronic gastro-intestinal, 213 of the bladder, 36 Catarrhal stomatitis, 124 anatomical lesions of, 124 etiology of, 124 symptoms of, 125 treatment of, 125 Causes of ill smelling breath, 29 Cereal foods, 77 Cerebral disease, 24 Cestodes, 311 Cheese poison in milk, 99 Chest, examination of, 50 inspection of, 51 barrel-shaped, 51 auscultation of, 52 palpation of, 54 percussion of, 55 Cheyne-Stoke's respiration, 41 Child, inspecting the, 20 position of, during feeding, 97 Children, general management of, 60 Childhood, 100 Chlorate of potassium, 134, 135 Cholera infantum, 258 morbid anatomy of, 258 etiology of, 259 symptoms of, 2^9 diagnosis of, 261 prognosis of, 262 treatment of, 262 Chorea, 122, 182 Chronic diarrhoea, 235 enlargement of tonsils, 24, 194 entero-colitis, 235 INDEX. 3S5 Chronic entero colitis, morbid anatomy of, 235 etiology of, 235 symptoms of, 236 diagnosis of, 240 prognosis of, 240 treatment of, 241 gastric catarrh, 202 morbid anatomy of, 203 etiology of, 203 symptoms of, 204 diagnosis of, 206 prognosis of, 206 treatment of, 207 gastro-intestinal catarrh, 213 hydrocephalus, 46 intussusception, 304 lung disease, 26 peritonitis, 364 Cirrhosis of the liver, 352 morbid anatomy of, 352 etiology of, 353 symptoms of, 354 diagnosis of, 355 prognosis of, 355 treatment of, 355 Clinical investigation of disease, 17 thermometer, 43 Clothing, 105 change of, 105 Clotting, to prevent, 79 Clubbing of the ringer tips, 26 Cold bath, 103 Colic, 270 etiology of, 270 symptoms of, 270 treatment of, 271 Collapse, 260, 263, 302 Colon, 299 Condensed milk, 75-85 reared children, 76 Congestion of the liver, 343 morbid anatomy of, 343 etiology of, 343 symptoms of, 343 diagnosis of, 344 prognosis of, 344 treatment of, 345 Conjunctival blennorrhcea, 151 during primaty denti- tion, 178 Constipation, (see Habitual Constipa- tion, 273) Convulsions caused by teething, 16 1 in chronic entero-colitis, 238 Cooled bath, 103 Cough, varieties of, 28 stomach, 227 Cows' milk, analysis of, 74 spec. grav. of, 74 sound, 98 Cream, whey and barley water mix- ture, 207 Crib, the, 108 Croup, 59 Cyanosis, 112 Crying, different characters of, 27 Crusta lactea, 156 Cysticercus cellulosse, 316 Cystitis, tubercular, 361 D. Day nursery, 107 Decubitus, 23 Defecation, frequency of, 32 Deformity of sternum caused by hy- pertrophy of tonsils, 195 Dental paralysis, 162 Dentition, 148 delayed, 150 difficult, 150 irregular, 150 Dermatitis, 155 Development, 45 Diabetes, 34 Diachylon ointment, 159 Diagnosis of acute gastric catarrh, 201 of acute intestinal catarrh, 230 of amyloid liver, 349 of aphthous stomatitis, 128 of ascites, 379 of cholera infantum, 261 of chronic entero-colitis, 240 of chronic gastric catarrh, 206 of cirrhosis of the liver, 335 of congestion of the liver, 344 of dysentery, 265 of entero colitis, 252 of fatty infiltration of the liver, of follicular tonsillitis, 189 3 86 INDEX, Diagnosis of habitual constipation, 274 of habitual indigestion, 217 of intussusception, 305 of jaundice, 339 of mucous disease, 220 of noma, 139 of peritonitis, 368 of simple atrophy, 284 of simple pharyngitis, 184 of suppurative hepatitis, 362 of suppurative tonsillitis, 192 of syphilitic hepatitis, 351 of tabes mesenterica, 332 of thrush, 145 of tubercular peritonitis, 375 of typhlitis, 291 of worms, 319 Diagram showing eruption of milk teeth, 148 showing method of lancing gums, 163 showing relation between the permanent and temporary teeth, 170 Diarrhoea, chronic, 235 during 2d dentition, 177 Diathesis, tuberculous, 22 Diet during 2d dentition, 175 during the first week, 81 during the sixth month, 82 for 8th and 9th months, 8^ for 7th month, 82 for six weeks, 84 for tenth month, 65 for 10th and nth months, 84 from 18 months to 2)4 years, 93 from 2d to the 6th week, 81 from 6th week to the end of 2d month, 82 from 3d to the 6th month, 82 from £ years up, 101 from 1 2th to the 1 8th month, 93 in amyloid liver, 349 in aphthous stomatitis. 129 in ascites, 381 in acute intestinal catarrh, 232 in chronic entero- colitis, 242,243 in cirrhosis of the liver, 356 in colic, 271 in congestion of the liver, 345 in constipation, 276 Diet in dysentery, 266 in entero-colitis, 255 in intussusception, 308 in mucous disease, 221 in peritonitis, 370 in simple pharyngitis, 185 in suppurative hepatitis, 362 in tabes mesenterica, 335 in tapeworm, 324 in tubercular peritonitis, 376 in typhlitis, 293, 294 up to 3^ years, 100 Difficult dentition, 150 complications during, 161 local affections of, 150 sympathetic effects of, 151 Diphtheria, urine in, 37 Disease, features of, 20 investigation of, 17 of the digestive organs, 124 Disorders of the digestive system during 2d dentition, 176 Distention of abdomen, 48 of bladder, 50 Drinking, mode of, 26 Dysentery, 264 morbid anatomy of, 264 etiology of, 264 symptoms of, 264 diagnosis of, 265 prognosis of, 265 treatment of, 265 Dyspnoea, expiratory, 41 inspiratory, 41 E. Ear-ache, 24, 27 Ears, nerve supply of, 168 Eating between meals, 101 Eczema during primary dentition, 154 during second dentition, 178 of the scalp, 156 treatment of, 157 Em 1 eu rage, 116 Egg of ascaris lumbricoides, 313 of oxyuris vermicularis, 312 of tricocephalus dispar, 314 Electricity in paralysis, 1 21 Electro-cautery, 196 Emphysema, 31, 51 INDEX. 387 En chien de fusil, 24 Enemata in enterocolitis, 256 purgative, 274 Entero -colitis (summer diarrhoea), 248 morbid anatomy of, 248 etiology of, 249 symptoms of, 250 diagnosis of, 252 prognosis of, 253 treatment of, 253 chronic, 235 Epidemic cholera, 262 Eruption of milk teeth, 57 of permanent teeth, order of, 169 of permanent teeth, 164 of temporary teeth, 148 Etiology of acute intestinal catarrh, 228 of amyloid liver, 348 of aphthous stomatitis, 126 of ascites, 378 of catarrhal stomatitis, 124 of cholera infantum, 259 of chronic entero-colitis, 235 of chronic gastric catarrh, 203 of cirrhosis of the liver, 353 of colic, 270 of congestion of the liver, 343 of dysentery, 264 of entero-colitis, 249 of fatty degeneration of the liver, 347 of fatty infiltration of the liver, 346 of follicular tonsillitis, 187 of gangrenous stomatitis, 136 of habitual constipation, 273 of habitual indigestion, 213 of hypertrophy of the tonsils, 194 of intussusception, 300 of jaundice, 338 of mucous disease, 217 of peritonitis, 365 of simple atrophy, 279 of simple pharyngitis, 183 of tabes mesenterica, 330 of thrush, 142 of tubercular peritonitis, 372 of tubercular ulceration of the intestines, 268 of typhlitis, 289 of ulcerative stomatitis, 131 Evacuations, fecal, 31 Examination, physical, 39 Exercise, 108 Exhaustion, 299 Expiratory respiration, 41 Explanation of Plate 1, 165 Eyelids, incomplete closure of, 21 lividity of, 25 puffin ess of, 22 twitching of, 21 Eyes, nerve supply of, 167 Eye teeth, 151 Face, the, 21 the change of features in disease, 21 Faecal abscess, 287 accumulation, 49 evacuations, 31 tumor, 31 Faradism, 122 Farinaceous food, 76 Fatty degeneration of the liver, 347 liver, 346 infiltration of the liver, morbid anatomy of, 346 of the liver, symptoms of, 346 of the liver, etiology of, 346 of the liver, prognosis of, 346 of the liver, diagnosis of, 346 Fauces, the, 58 Febrile diarrhoea, 248 Features of disease, 20 Feeding, 60 apparatus, care of, 97 artificial, 71 breast, 60 by a wet nurse, 69 general rules for, 79 intervals of, 64 mistake of constant, 63 Fever, temperature in, 44 Feverish breath, 30 Filtered water, 10 1 Finger-nails, blueness of, 26 deformity of, 26 3 8S INDEX. Fissure of nipple, 67 treatment for, 68 Flour ball, S3 Follicular tonsillitis, 187 etiology of, 187 symptoms of, 187 diagnosis of, 187 prognosis of, 188 treatment of, 189 Fontanelle, 46 bulging of, 46 Fcod, farinaceous, 76 Horlick's, 81 Mellins, 81 preparation of, 97 quantity per diem, 77 Forced enema in intussusception, 309 Fraenum linguae, ulceration of, 150 Friction, 1 17 Formula for acute gastric catarrh, 201 for an alkali in jaundice, 339 for catarrhal stomatitis, 126 for chronic gastric catarrh, 210 for congestion of the liver, 345 for convulsions, 162 for enlarged glands during 2d dentition, 178 for entero- colitis, 257 for jaundice, 342 for painting about loose teeth, 172 for peritonitis, 371 for second dentition, 175 for softening the gums, 172 for tubercular ulceration of the intestines, 269 for urticaria, 154 for vomiting, 153 Formulae for acute intestinal catarrh, 233. 2 34 for amyloid liver, 350 for aphthous stomatitis, 130 for ascaris lumbricoides, 322, 323 for ascites, 380, 381 for cholera infantum, 263 for chronic entero- colitis, 244, 245 for cirrhosis of the liver, 356 for colic, 272 for constipation, 277 for dysentery, 266, 267 for eczema, 158, 159, 160 for follicular tonsillitis, 189, 190 Formulae for hypertrophy of the ton- sils, 195, 196 for intussusception, 307 for laxative, 157 for mucous disease, 224, 225, 226, 227 for oxyuris vermicularis, 321 for simple pharyngitis, 185, 186 for suppurative tonsillitis, 193 for syphilitic hepatitis, 352 for tabes mesenterica, 336 for tapeworm, 324, 325, 326 for thrush, 147 for tubercular peritonitis, 377 for typhlitis, 293, 294 for ulcerative stomatitis, 134 Furrows, facial, 22 Gangrenous stomatitis, 136 etiology of, 136 symptoms of, 136 treatment of, 137 Gastric catarrh, acute, 199 (see Acute Gas. Cat.) chronic (see Chron. Gas. Cat.) Gastro-intestinal catarrh, 260 Gastro-malacia, 212 Gavage, 113 de renfort, 1 14 Gelatine, 80 Genal furrows, 22 General development, 45 Gluten flour, 324 Glycerine suppositories in constipation , 276 Goats' milk, 73 Gradual weaning, 64 Graduated nursing bottle, 95 Growing pains, 123 Growth, 45 Gums, condition of during dentition, 149 "Gun-hammer" decubitus, 284 H Habitual constipation, 273 etiology of, 273 symptoms of, 274 diagnosis of, 274 INDEX. 389 Habitual constipation, prognosis of, 274 treatment of, 274 indigestion, 213 etiology of, 213 symptoms of, 215 diagnosis of, 217 prognosis of, 217 treatment of, 217 Halitosis, 29 Hand-feeding, success in, 96 to insure success in, 72 Hands, movement of, 24 Hard palate, 58 Hatching cradle, 109 Headache during second dentition, 179 Head, shape of, 23 Heavy breath, 30 Hebra's diachylon ointment, 159 Hemorrhage, renal, 35 Hepatitis suppurative, 357 syphilitic, 351 Herpes of the lips during second den- tition, 178 Hip-joint disease, 46 Hob-nailed liver, 352 Horlick's food, 81 Hot bath, 103 Hydrocephalus, spurious, 206 Human milk, substitute for, 73. Humanized milk, analysis of, 88 Hunger, 27 Hydatid disease of the liver, 363 Hydrencephalic cry, 27 Hydrocephalus, 46 Hydronephrosis, 36 Hypertrophic cirrhosis, 353, Hypertrophy of the tonsils, 194 etiology of, 194 symptoms of, 194 treatment of, 195 Hypostatic pneumonia in chronic en- tero-colitis, 238 Icterus, 337 neonatorum, 338 in older children, treatment of, 342 341 Idiopathic form of acute gastric ca- tarrh, 199 Ileo-caecal intussusception, 305 Immature infants, management of, 109 Incontinence, 36 Incubator, 109. Incubators, description of, ill Indican, 34, 37 Indigestion, 200 Infants' food, type of, 72 foods, 77 Inflammation of the colon and rectum (see Dysentery), 264 Injections, medicated, 320 Inspection of chest, 51 of child, 20 Inspiratory respiration, 41 Insufflation of air in intussusception, Intertrigo in simple atrophy, 283 Intestinal concretions, 288 worms, 311 Intestines, nerve supply of, 166 Intussusception, 296 varieties of, 296 morbid anatomy of, 297 without symptoms, 297 with symptoms, 297 results of, 298. strangulation in, 298 etiology of, 300 symptoms of, 301 diagnosis of, 305 prognosis of, 306 treatment of, 306 reduction of, 309 Invagination, 306 Investigation of disease, 17 Inward spasms, 283 J. Jadelot's lines, 22 Jaundice, 337 etiology of, 338 grade of seventy, 338 diagnosis of, 338 due to congenital malformation of the bile ducts, 339 treatment of, 339 Junket, 65 39° INDEX. K. Kidney, sarcoma of, 36 Kidneys, amyloid degeneration of, 38 lesions of, 29 Labial furrows, 22 Lactation, 66 Lactometer, 74 Lancing the gums, 1 63 Laparotomy in intussusception, 309 Laryngeal stenosis, 41 Larynx, nerve supply of, 168 Lavage, 114 Laxative confection, 279 Leeds' analysis of breast milk, 73 Leucorrhcea, 318 Lids, incomplete closure of, 21 Lime, saccharated solution of, 80 water, 80 Lines of Jadelot, 22 Lips, herpes of, 178 puffing of, 5 1 Lithsemia, 36 Lithuria, 35 Liver, abscess of, 357 affections of, 337 amyloid, 347 cancer of, 363 cirrhosis of, 352 congestion of, 343 fatty degeneration of, 347 hydatid disease of, 363 fatty infiltration of, 346 syphilitic inflammation of, 351 tuberculosis of, 363 Lividity of eyelids, 25 Local treatment for simple pharyn- gitis, 186 Loss of taste during second dentition, 172 Lungs, nerve supply of, 167 M. Malarial fever, 37 Mammary abscess, 67 Management of weak and immature infant, 109 Marasmus, 47, 305 Massage, 1 16 a frictions, 117 effects of, 117 in chorea, 122 in chronic gastro-intestinal ca- tarrh, 119 in colic, 120 in constipation, 120 in general debility and anaemia, 121 in infantile paralysis, 121 in pleurisy, 123 in pseudo-hypertrophic paralysis, 123 Masturbation, 35 Maxillary bones, necrosis of, 31 Meckel's ganglion, 166 Meigs' food, 85 Mellin's food, 81 Membranous croup, urine in, 37 Menstruation in nursing woman, 68 Mercurial bath, 104 Method of gavage, 113 of giving suck, 62 Microscopic examination in thrush, Micturition, painful, ^3 Milk, asses', 73 boiled, 85 care of, 98 condensed, 75 cows', analysis of, 74 goats', 73 mixture for chronic gaslric ca- tarrh, 208 mode of drinking, 26 peptonized, 86 poisoning, 100 scanty secretion of, 67 secretion of, 61 sterilized, SS teeth, 57 teeth, the eruption of, 148 transportation of, 98 Morbid anatomy of amyloid liver, 347 of cholera infantum, 258 of chronic entero coiiti>, 235 of chronic gastric catarrh, 203 of cirrhosis of the liver, 352 INDEX. 391 Morbid anatomy of congestion of the liver, 343 of dysentery, 264 of entero-colitis, 248 of fatty degeneration of the liver, 347 of fatty infiltration of the liver, 346 of intussusception, 297 of peritonitis, 364 of simple atrophy, 279 of suppurative tonsillitis, 190 of syphilitic hepatitis, 351 of tabes mesenterica, 329 of thrush, 142 of tubercular peritonitis, 371 of tubercular ulceration of the intestines, 268 of typhlitis, 287 Morbus cceruleus, 25 Mortality from laparotomy in intus susception, 310 Motor paralysis, 25 Mouth and fauces, examination of, 57 inspection of, during second denti- tion, 177 soreness of, 26 Mucous disease, 217 etiology of, 217 symptoms of, 218 diagnosis of, 220 prognosis of, 220 diet for, 221 treatment of, 220 Mustard bath, 104 N. Nails, deformity of, 26 Naphthalin in entero-colitis, 257 Nasal catarrh during second denti- tion, 178 treatment of, 179 Nausea, 39 Necrosis, 135 Nematodes, 31 1 Nephritis, 43 Nervous disorders in dentition, 179 Night-dress, 105 Nipple, fissures of, 67 Niir o-muriatic acid bath, 104 Noma (see Gangrenous stomatitis) , 1 39 pathology and morbid anatomy of, 138 diagnosis of, 139 prognosis of, 140 treatment of, 140 Normal capacity of infant's stomach, 78 Nostrils, sharpness of, 22 Nursing-bottle, 95 mother's diet, 67 regularity in, 62 o. Oculo- zygomatic furrows, 22 GEdema, 112 Oidium albicans, 142 Oil inunction for constipation, 275 Oral pain in second dentition, 170 Otitis, 151, 178 Oxaluria, 35 Oxyuris vermicularis, 312 egg of, 312 symptoms of, 318 treatment of, 320 Ozaena, 1 79 p. Painful micturition, ^^ Palpation of the chest, 54 Pancreatin, 86-87, 88, 92 Papillae, 58 Paracentesis in ascites, 382 Paralysis, dental, 162 during dentition, 181 Parasitic stomatitis (see Thrush), 141 Parenchymatous nephritis, 43 Pathology and morbid anatomy of noma, 138 Peptogenic milk, powder, 88 Peptonization, partial, 87 Peptonized milk, 86 Percussion of the chest, 55 Perforation of the caecum, 291 Peritoneum, affections of, 364 Peritonitis, 364 morbid anatomy of, 364 etiology of, 365 symptoms of, 365 39 2 INDEX. Peritonitis, diagnosis of, 368 prognosis of, 370 treatment of, 370 tubercular, 371 Parasites, intestinal, 33 Permanent teeth, 58 eruption of, 164 order of eruption, 169 Perityphlitis (see Typhlitis, p~ri-), 287 Pertussis, 28 Petrissage, 116 Pharyngitis, simple, 183 Photophobia, 24 Phthisis, 54 Physical examination, 39 Piatt's chloride, 141 Pneumonia, hypostatic, 238 Premature weaning, 66 Process for peptonizing milk, 86 Prognosis of acute gastric catarrh, 201 of acute intestinal catarrh, 230 of amyloid liver, 349 of ascites, 380 of cholera infantum, 262 of chronic entero-colitis, 240 of chronic gastric catarrh, 206 of cirrhosis of the liver, 355 of congestion of the liver, 344 of dysentery, 265 of entero-colitis, 253 of fatty infiltration of the liver, 346 of follicular tonsillitis, 188 of habitual constipation, 274 of habitual indigestion, 217 of intussusception, 306 of mucous disease, 220 of noma, 140 of peritonitis, 370 of simple atrophy, 285 of syphilitic hepatitis, 351 of tabes mesenterica, 333 of thrush, 145 of tubercular peritonitis, 376 of typhlitis, 292 of ulcerative stomatitis, 134 of worms, 319 Pseudo hypertrophic paralysis, 123 Puerile breathing, 53 Pufhness of eyelids, 22 Pulse, variations in, 42 Purpura hemorrhagica, 36 Questioning the attendants, I Quinsy, 190 Raw beef juice, 92 Reaction of the urine, ^^ Red gum, 154 Reflex spasm during dentition, 180 Regimen in acute intestinal catarrh. 232 in amyloid liver, 350 in cholera infantum, 263 in chronic entero-colitis, 241 in chronic gastric catarrh, 209 in dysentery, 266 in entero-colitis, 254 in mucous disease, 222 in simple atrophy, 286 Renal calculus, 36 hemorrhage, 35 Resorcin in entero-colitis, 257 Respiration, 39 character of, 40 expiratory, 41 inspiratory, 41 Retention of urine, 37 Retro-pharyngeal abscess, 197 symptoms of, 197 treatment of, 198 Rheumatism, 47 Rice pudding, 100 Rickets, 59, 69, 119 Rubber shoes, 104 Rules for feeding, 79 Saccharated solution of lime, 80, 294 Salicylate of sodium in entero-colitis, 257 Salt-water bath, 104 Sarcoma of kidney, 36 Scarlet fever, 59, 128 Sclerema, 112 Secondary thrush, 144 Second dentition, disorders of, 170 as a cause of mucous disease, 177 Secretion of milk, 61 INDEX. 393 Serous effusion in chronic entero- colitis, 238 Shoes, 106 Simple atrophy, 279 , morbid anatomy of, 279 etiology of, 279 manner of preparing food in, 281 symptoms of, 282 diagnosis of, 284 prognosis of, 285 treatment of, 285 regimen in, 286 diarrhoea of dentition, 152 pharyngitis, 183 anatomical lesion of, 183 etiology of, 183 symptoms of, 183 diagnosis of, 184 treatment of, 185 Skin, discoloration of, in jaundice, ^8 the, 25 conditions of the, 46 Sleep, 106 Sleeping, different characters of, 24 Sleeping room, 107 Soda bath, 104 Softening of the stomach, 212 Sound cows' milk, 98 Sour breath, 30 Spasms during dentition, 161 inward, 283 Spec. grav. of breast milk, 72 cows' milk, 74 Spinal irritability, 123 Stationary washstand, 107 Statistics from the Maternite, in Paris, 112 Stercoraceous breath, 31 vomiting, 303 Sterilized milk, 88 rules to be observed in its use, 91 uses of, 91 Sterilizer, the author's, 89 Stomach, measurements of infants, 78 nerve supply of, 165 softening of, 212 ulcer of, 211 Stomatitis, aphthous, 126 catarrhal, 124 gangrenous, 136 Stomatitis, parasitic (see Thrush), 141 ulcerative, 13 1 Stools, characters of, 32 Strippings, 85, 208 Strophulus during dentition, 154 Strumous diathesis, 23 wSubmaxillary gland, enlargement of, during second dentition, 177 Sudden weaning, 66 vSummer diarrhoea, 248 Sunstroke, 261 Superficial catarrh of the tonsils, 186 Suppurative hepatitis, 357 report of case, 357 symptoms of, 357 diagnosis of, 362 treatment of, 362 tonsillitis, 190 morbid anatomy of, 190 symptoms of, 191 diagnosis of, 192 treatment of, 192 Symptoms of acute gastric catarrh, 200 of acute intestinal catarrh, 229 of amyloid liver, 348 of aphthous stomatitis, 127 of ascaris lumbricoides,3i9 of ascites, 378 of cholera infantum, 259 of chronic entero-colitis, 237 of chronic gastric catarrh, 204 of cirrhosis of the liver, 354 of colic, 270 of congestion of the liver, 343 of dysentery, 264 of entero-colitis, 250 of fatty infiltration of the liver, 346 of follicular tonsillitis, 187 of mucous disease, 218 of gangrenous stomatitis, 136 of habitual constipation, 274 of habitual indigestion, 215 of hypertrophy of the tonsils, 194 of intussusception, 301 of oxyuris vermicularis, 318 of peritonitis, 365 of retro-pharyngeal abscess, 197 of septic peritonitis, 368 of simple atrophy, 282 33 394 JNDEX. Symptoms of simple pharyngitis 183 of suppurative hepatitis, 357 of suppurative tonsillitis, 191 of tabes mesenterica, 330 of taenia, 319 of thrush, 143 of tubercular peritonitis, 372 of tubercular ulceration of the intestines, 269 of typhlitis, 289 of ulcerative stomatitis, 132 of ulcer of the stomach, 21 1 of syphilitic hepatitis, 351 of worms, 317 Syphilitic hepatitis, 35 1 morbid anatomy of, 351 symptoms of, 351 diagnosis of, 351 prognosis of, 351 treatment of, 352 T. Tabes mesenterica, 329 morbid anatomy of, 329 etiology of, 330 symptoms of, 330 diagnosis of, 332 prognosis of, 3^3 treatment of, 3,34 Taeniae, 314 saginata, 314 e gg° f , 3*5 solium, 316 symptoms of, 319 treatment of, 323 Tanret's Pelletierine for tapeworm, 326 Tapotement, 117 Tarnier's hatching cradle, 1 10 Taste, loss of, 172 Taxis in intussusception, 309 Tears, formation of, 28 suppression of, 28 Teeth, children born with, 149 eruption of the temporary, 148 milk, 57 permanent, 58 premature appearance of, 149 Teething cough, 178 Temperature, 43 of room, 108 variations in, 44 Thermometer, clinical, 43 Throat affections during second denti- tion, 172 Thrombosis of the sinuses of the brain during chronic entero- colitis, 238 Thrush, 141 morbid appearances of, 142 etiology of, 142 symptoms of, 143 secondary, 144 diagnosis of, 145 prognosis of, 145 treatment of, 146 Tongue, 58 in disease, 59 Tonsillitis, follicular, 187 suppurative, 190 Tonsils, excision of, 196 hypertrophy of, 194 Tooth rash, 154 Treatment of acute gastric catarrh, 201 of acute intestinal catarrh, 231 "of amyloid liver, 349 of aphthous stomatitis, 128 of ascaris lumbricoides, 321 of ascites, 380 of catarrhal stomatitis, 125 of cholera infantum, 262 of chronic entero-colitis, 241 of chronic gastric catarrh, 207 of cirrhosis of the liver, 355 of colic, 271 of congestion of the liver, 345 of convulsions during teething, 162 during second dentition, 175 of dysentery, 265 of eczema, 157 of entero colitis, 253 of fatty infiltration of the liver, 347 of fissure of nipple, 68 of follicular tonsillitis, 189 of habitual constipation, 274 of headache during dentition, 180 of hypertrophy of the tonsils, 195 of intussusception, 306 of icterus in older children, 342 of jaundice, 339 of mucous disease, 220 of nasal catarrh, 179 of noma, 140 INDEX. 395 Treatment of oxyuris vermicularis, 320 of peritonitis, 370 of retro-pharyngeal abscess, 198 of simple atrophy, 285 of simple pharyngitis, 185 of superficial ulcers of the tongue, 173 . ... of suppurative hepatitis, 362 tonsillitis, 192 of syphilitic hepatitis, 352 of tabes mesenterica, 334 of taenia, 323 of thrush, 146 of tubercular peritonitis, 376 of tubercular ulceration of the in- testines, 269 of typhlitis, 292 of ulcerative stomatitis, 134 of ulcer of the stomach, 212 of worms, 320 Trichocephalus dispar, 314 egg of, 314 True intussusception, 297 Tubercular meningitis, 284 peritonitis, 371 morbid anatomy of, 371 etiology of, 372 symptoms of, 372 diagnosis of, 375 prognosis of, 376 treatment of, 376 ulceration of the intestines, 268 ulceration of the intestines, mor- bid anatomy of, 268 ulceration of the intestines, etiol- ogy of, 268 ulceration of the intestines, symp- toms of, 269 ulceration of the intestines, treat- ment of, 269 Tuberculosis of the liver, 363 Tuberculous tendency, signs of, 22 Tumor, faecal, 31 Typhlitis, 287 morbid anatomy of, 287 etiology of, 289 % stercoralis, 289 symptoms of, 289 diagnosis of, 291 prognosis of, 292 treatment of, 292 Tyrotoxicon, 99 u. Ulceration of the appendix, 291 of the lungs, 31 Ulcerative stomatitis, 131 anatomical lesions of, 131 etiology of, 131 symptoms of, 132 diagnosis of, 134 prognosis of, 134 treatment of, 134 Ulcer of the stomach, 21 1 symptoms of, 21 1 treatment of, 212 Ulcers of the tongue during second dentition, 171 Uraemic poisoning, 31 Uric acid, 33, 37 Urine the, 33 spec. grav. of, 33 characters of, 33 daily amount voided, 34 abnormal ingredients of, 35 of different diseases, 36 Urinometer, 74 Urticaria during dentition, 153 Uvula the, 58 V. Varicella, 59 Variola, 128 Veal broth, 92 with barley water, 208 Ventilation, 107 Vertigo, 319 Vesicles, herpetic, 26 Vocal fremitus, 54 Vomiting, 38 chronic, 203 during dentition, 153 stercoraceous, 303 w. Walking, delay in, 46 Weak and immature infants, 109 Weaning, 64 sudden, 66 premature, indications for, 66 Wet-nurs£, feeding by, 69 proper woman for a, 70 39^ INDEX. Wet-nurse, examination of, 70 diet of, 7 1 Whey, 81, 207 Whip worms, 314 White gum 154 Whooping cough, 128, 177, 217 Worms, 311 mode of entering the body, 312 symptoms of, 317 Worms, diagnosis of, 319 prognosis of, 319 treatment of, 3 20 Yawning, 41 Yellow discoloration jaundice, 338 of the skin in CATALOGUE No. 7. DECEMBER, 1890. A CATALOGUE OF Books for Students. INCLUDING THE ? QUIZ-COMPENDS ? CONTENTS. PAGE PAGE New Series of Manuals, 2,3,4,5 Obstetrics. . . IO Anatomy, 6 Pathology, Histology, . . 11 Biology, 11 Pharmacy, . . 12 Chemistry, . 6 Physiology, . . I I Children's Diseases, . 7 Practice of Medicine, . 12 Dentistry, 8 Prescription Books, . 12 Dictionaries, 8 ?Quiz-Compends ? • 14,15 Eye Diseases, 8 Skin Diseases, . 12 Electricity, . 9 Surgery, • 13 Gynaecology, 10 Therapeutics, • 9 Hygiene, 9 Urine and Urinary Org ans, 13 Materia Medica, . • 9 Venereal Diseases, • J 3 Medical Jurisprudence, 10 PUBLISHED BY P. 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They have been pre- pared by well-known men, who have had large experience as teachers and writers, and who are, therefore, well informed as to the needs of the student. Their mechanical execution is of the best — good type and paper, handsomely illustrated whenever illustrations are of use, and strongly bound in uniform style. Each book is sold separately at a remarkably low price, and the immediate success of several of the volumes shows that the series has met with popular favor. No. 1. SURGERY. 236 Illustrations. A Manual of the Practice of Surgery. By Wm. J. Walsham, m.d., Asst. Surg, to, and Demonstrator of Surg, in, St. Bartholomew's Hospital, London, etc. 228 Illustrations. Presents the introductory facts in Surgery in clear, precise language, and contains all the latest advances in Pathology, Antiseptics, etc. " It aims to occupy a position midway between the pretentious manual and the cumbersome System of Surgery, and its general character may be summed up in one word — practical." — The Medi- cal Bulletin. "Walsham, besides being an excellent surgeon, is a teacher in its best sense, and having had very great experience in the preparation of candidates for examination, and their subsequent professional career, may be relied upon to have carried out his work successfully. Without following out in detail his arrange- ment, which is excellent, we can at once say that his book is an embodiment of modern ideas neatly strung together, with an amount of careful organization well suited to the candidate, and, indeed, to the practitioner." — British Medical Journal. Price of each Book, Cloth, $3.00; Leather. $3.50. THE NEW SERIES OF MANUALS. No. 2. DISEASES OP WOMEN. 150 Illus. NEW EDITION. The Diseases of Women. Including Diseases of the Bladder and Urethra. By Dr. F. Winckel, Professor of Gynaecology and Director of the Royal University Clinic for Women, in Munich. Second Edition. Re- vised and Edited by Theophilus Parvin, M.D., Professor of Obstetrics and Diseases of Women and Children in Jefferson Medical College. 150 Engrav- ings, most of which are original. " The book will be a valuable one to physicians, and a safe and satisfactory one to put into the hands of students. It is issued in a neat and attractive form, and at a very reasonable price." — Boston Medical and Surgical Journal . No. 3. OBSTETRICS. 227 Illustrations. A Manual of Midwifery. By Alfred Lewis Galabin, M.A., M.D., Obstetric Physician and Lecturer on Mid- wifery and the Diseases of Women at Guy's Hospital, London; Examiner in Midwifery to the Conjoint Examining Board of England, etc. With 227 Illus. " This manual is one we can strongly recommend to aH who desire to study the science as well as the practice of midwifery. Students at the present time not only are expected to know the principles of diagnosis, and the treatment of the various emergen- cies and complications that occur in the practice of midwifery, but find that the tendency is for examiners to ask more questions relating to the science of the subject than was the custom a few years ago. * * * The general standard of the manual is high ; and wherever the science and practice of midwifery are well taught it will be regarded as one of the most important text-books on the subject." — London Practitioner. No. 4. PHYSIOLOGY. Fourth Edition. 321 ILLUSTRATIONS AND A GLOSSARY. A Manual of Physiology. By Gerald F. Yeo, m.d., f.r.c.s., Professor of Physiology in King's College, London. 321 Illustrations and a Glossary of Terms. Fourth American from second English Edition, revised and improved. 758 pages. This volume was specially prepared to furnish students with a new text-book of Physiology, elementary so far as to avoid theories which have not borne the test of time and such details of methods as are unnecessary for students in our medical colleges. " The brief examination I have given it was so favorable that I placed it in the list of text-books recommended in the circular of the University Medical College." — Prof, Lewis A. Stimson, m.d., 37 East 33d Street, New York. Price of each Book, Cloth, $3.00; Leather, $3.50. THE NEW SERIES OF MANUALS. No. 5. ORGANIC CHEMISTRY. Or the Chemistry of the Carbon Compounds. By Prof. Victor von Richter, University of Breslau. Au- thorized translation, from the Fourth German Edition. By Edgar F. Smith, m.a., ph.d. ; Prof, of Chemistry in University of Pennsylvania; Member of the Chem. Socs. of Berlin and Paris. " I must say that this standard treatise is here presented in a remarkably compendious shape."— y. W. Holland , m.d., Professor of Chemistry , Jefferson Medical College , Philadelphia. " This work brings the whole matter, in simple, plain language, to the student in a clear, comprehensive manner. The whole method of the work is one that is more readily grasped than that of older and more famed text-books, and we look forward to the time when, to a great extent, this work will supersede others, on the score of its better adaptation to the wants of both teacher and student." — Pharmaceutical Record, " Prof, von Richter's work has the merit of being singularly clear, well arranged, and for its bulk, comprehensive. Hence, it will, as we find it intimated in the preface, prove useful not merely as a text-book, but as a manual of reference." — The Chemical News, London. No. 6. DISEASES OF CHILDREN. SECOND EDITION. A Manual. By J. F. Goodhart, m.d., Phys. to the Evelina Hospital for Children; Asst. Phys. to Guy's Hospital, London. Second American Edition. Edited and Rearranged by Louis Starr, m.d., Clinical Prof, of Dis. of Children in the Hospital of the Univ. of Pennsylvania, and Physician to the Children's Hos- pital, Phila. Containing many new Prescriptions, a list of over 50 Formulae, conforming to the U. S. Pharma- copoeia, and Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. Illus. " The author has avoided the not uncommon error of writing a book on general medicine and labeling it ' Diseases of Children,' but has steadily kept in view the diseases which seemed to be incidental to childhood, or such points in disease as appear to be so peculiar to or pronounced m children as to justify insistence upon them. * * * A safe and reliable guide, and in many ways admirably adapted to the wants of the student and practitioner." — American Journal of Medical Science. Price of each Book, Cloth, $3.00 ; Leather, $3.50. THE NEW SERIES OF MANUALS. No. 6. Goodhart and Starr : — Continued. " Thoroughly individual, original and earnest, the work ev dently of a close observer and an independent thinker, this book, though small, as a handbook or compendium is by no means made up of bare outlines or standard facts." — The Therapeutic Ga- zette. '* As it is said of some men, so it might be said of some books, that they are 'born to greatness.' This new volume has, we believe, a mission, particularly in the hands of the younger members of the profession. In these days of prolixity in medical literature, it is refreshing to meet with an author who knows both what to say and when he has said it. The work of Dr. Goodhart (admirably conformed, by Dr. Starr, to meet American require- ments) is the nearest approach to clinical teaching without the actual presence of clinical material that we have yet seen." — New York Medical Record. No. 7. PRACTICAL THERAPEUTICS. FOURTH EDITION, WITH AN INDEX OF DISEASES. Practical Therapeutics, considered with reference to Articles of the Materia Medica. Containing, also, an Index of Diseases, with a list of the Medicines applicable as Remedies. By Edward John Waring, m.d., f.r.c.p: Fourth Edition. Rewritten and Re- vised by Dudley W. Buxton, m.d., Asst. to the Prof, of Medicine at University College Hospital. " We wish a copy could be put in the hands of every Student or Practitioner in the country. In our estimation, it is the best book of the kind ever written." — N. Y. Medical Journal. No. 8. MEDICAL JURISPRUDENCE AND TOXICOLOGY. NEW, REVISED AND ENLARGED EDITION. By John J. Reese, m.d., Professor of Medical Jurispru- dence and Toxicology in the University of Pennsyl- vania ; President of the Medical Jurisprudence Society of Phila. ; 2d Edition, Revised and Enlarged. " This admirable text-book." — Amer.Jour. of Med. Sciences. u We lay this volume aside, after a careful perusal of its pages, with the profound impression that it should be in the hands of every doctor and lawyer. It fully meets the wants of all students He has succeeded in admirably condensing into a handy volume all the essential points." — Cincinnati Lancet and Clinic. Price of each Book, Cloth, $3,00 ; Leather, $3.50. 8 STUDENTS' TEXT-BOOKS AND MANUALS. Children: — Continued. Meigs and Pepper. The Diseases of Children. Seventh Edition. 8vo. Cloth, 5.00; Leather, 6.00 Starr. Diseases of the Digestive Organs in Infancy and Childhood. With chapters on the Investigation of Disease, and on the General Management of Children. By Louis Starr, m.d., Clinical Professor of Diseases of Children in the Univer- sity of Pennsylvania. Illus. Second Edition. In Press. DENTISTRY. Fillebrown. Operative Dentistry. 330 Illus. Cloth, 2.50 Flagg's Plastics and Plastic Filling. 3d Ed. Preparing. Gorgas. Dental Medicine. A Manual of Materia Medica and Therapeutics. Third Edition. Cloth, 3.50 Harris. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery and Mechanism. Twelfth Edition. Revised and enlarged by Professor Gorgas. 1028 Illustrations. Cloth, 7.00 ; Leather, 8.00 Richardson's Mechanical Dentistry. Fifth Edition. 569 Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 Sewill. Dental Surgery. 200 Illustrations. 3d Ed. Clo., 3.00 Stocken's Dental Materia Medica. Third Edition. Cloth, 2.50 Taft's Operative Dentistry. Dental Students and Practitioners. Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 Talbot. Irregularities of the Teeth, and their Treatment. Illustrated. 8vo. Second Edition. Cloth, 3.00 Tomes' Dental Anatomy. Third Ed. 191 Illus. Cloth, 4.00 Tomes' Dental Surgery. 3d Edition. Revised. 292 Illus. 772 Pages. Cloth, 5.00 Warren. Compend of Dental Pathology and Dental Medi- cine. Illustrated. Cloth, 1. 00; Interleaved, 1.25 DICTIONARIES. Gould's New Medical Dictionary. Containing the Definition and Pronunciation of all words in Medicine, with many useful Tables etc. ^ Dark Leather, 3.25 ; y 2 Mor., Thumb Index 4.25 Cleaveland's Pronouncing Pocket Medical Lexicon. 31st Edition. Giving correct Pronunciation and Definition. Very small pocket size. Cloth, red edges .75 j pocket-book style, 1.00 LfOngley 's Pocket Dictionary. The Student's Medical Lexicon, giving Definition and Pronunciation of all Terms used in Medi- cine, with an Appendix giving Poisons and Their Antidotes, Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 24rao. Cloth, 1. 00; pocket-book style, 1.25 • See Pages 2 to 5 for list of Students* Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 9 EYE. Arlt. Diseases of the Eye. Including those of the Conjunc- tiva, Cornea, Sclerotic, Iris and Ciliary Body. By Prof. Von Arlt. Translated by Dr. Lyman Ware. Illus. 8vo. Cloth, 2.50 Hartridge on Refraction. 4th Ed. Cloth, 2.00 Meyer. Diseases of the Eye. A complete Manual for Stu- dents and Physicians. 270 Illustrations and two Colored Plates. 8vo. Cloth, 4.50; Leather, 5.50 Fox and Gould. Compend of Diseases of the Eye and Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. Cloth, 1. 00 ; Interleaved for Notes, 1.25 ELECTRICITY. Mason's Compend of Medical and Surgical Electricity. With numerous Illustrations. i2mo. « Cloth, 1.00 HYGIENE. Parkes' (Ed. A.) Practical Hygiene. Seventh Edition, en- larged. Illustrated. 8vo. Cloth, 4.50 Parkes' (L. C.) Manual of Hygiene and Public Health. i2mo. Cloth, 2.50 Wilson's Handbook of Hygiene and Sanitary Science. Sixth Edition. Revised and Illustrated. Cloth, 2.75 MATERIA MEDICA AND THERAPEUTICS. Potter's Compend of Materia Medica, Therapeutics and Prescription Writing. Fifth Edition, revised and improved. Cloth, 1.00; Interleaved for Notes, 1.25 Biddle's Materia Medica. Eleventh Edition. By the late John B. Biddle, m.d., Professor of Materia Medica in Jefferson Medical College, Philadelphia. Revised, and rewritten, by Clement Biddle, m.d., Assist. Surgeon, U. S. N., assisted by Henry Morris, m.d. 8vo., illustrated. Cloth, 4.25; Leather, 5.00 Headland's Action of Medicines. 9th Ed. 8vo. Cloth, 3.00 Potter. Materia Medica, Pharmacy and Therapeutics. Including Action of Medicines, Special Therapeutics, Pharma- cology, etc. Second Edition. Cloth, 4.00; Leather, 5.00 Starr, Walker and Powell. Synopsis of Physiological Action of Medicines, based upon Prof. H. C. Wood's " Materia Medica and Therapeutics/' 3d Ed. Enlarged. Cloth, .75 Waring. Therapeutics. With an Index of Diseases and Remedies. 4th Edition. Revised. Cloth, 3.00 ; Leather, 3.50 See pages 14 and ij for list of ? Quiz- Compends ? 10 STUDENTS' TEXT-BOOKS AND MANUALS. MEDICAL JURISPRUDENCE. Reese. A Text-book of Medical Jurisprudence and Toxi- cology. By John J. Reese, m.d., Professor of Medical Juris- prudence and Toxicology in the Medical Department of the University of Pennsylvania; President of the Medical Juris- prudence Society of Philadelphia ; Physician to St. Joseph's Hospital ; Corresponding Member of The New York Medico- legal Society. 2d Edition. Cloth, 3.00; Leather, 3.50 Woodman and Tidy's Medical Jurisprudence and Toxi- cology. Chromo-Lithographic Plates and 116 Wood engravings. Cloth, 7.50; Leather, 8.50 OBSTETRICS AND GYNECOLOGY. Byford. Diseases of Women. The Practice of Medicine and Surgery, as applied to the Diseases and Accidents Incident to Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology in Rush Medical College and of Obstetrics in the Woman's Med- ical College, etc., and Henry T. Byford, m.d., Surgeon to the Woman's Hospital of Chicago ; Gynaecologist to St. Luke's Hospital, etc. Fourth Edition. Revised, Rewritten and En- larged. With 306 Illustrations, over 100 of which are original. Octavo. 832 pages. Cloth, 5.00 ; Leather, 6.00 Cazeaux and Tarnier's Midwifery. "With Appendix, by Munde. The Theory and Practice of Obstetrics ; including the Diseases of Pregnancy and Parturition, Obstetrical Operations, etc. By P. Cazeaux. Remodeled and rearranged, with revi- sions and additions, by S. Tarnier, m.d., Professor of Obstetrics and Diseases of Women and Children in the Faculty of Medicine of Paris. Eighth American, from the Eighth French and First Italian Edition. Edited by Robert J. Hess, m.d., Physician to the Northern Dispensary, Philadelphia, with an appendix by Paul F. Munde, m.d., Professor of Gynaecology at the N. Y. Polyclinic. Illustrated by Chromo-Lithographs, Lithographs, and other Full-page Plates, seven of which are beautifully colored, and numerous Wood Engravings. Students' Edition. One Vol., 8vo. Cloth, 5.00; Leather, 6.00 Lewers' Diseases of Women. A Practical Text-Book. 139 Illustrations. Second Edition. Cloth, 2.50 Parvin's Winckel's Diseases of Women. Second Edition. Including a Section on Diseases of the Bladder and Urethra. . 150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 Morris. Compend of Gynaecology. Illustrated. Cloth, 1.00 Winckel's Obstetrics. A Text-book on Midwifery, includ- ing the Diseases of Childbed. By Dr. F. Winckel, Professor of Gynaecology, and Director of the Royal University Clinic for Women, in Munich. Authorized Translation, by J. Clifton Edgar, m.d., Lecturer on Obstetrics, University Medical Col- lege, New York, with nearly 200 handsome illustrations, the majority of which are original with this work. Octavo. Cloth, 6.00; Leather, 7.00 Landis' Compend of Obstetrics. Illustrated. 4th edition, enlarged. Cloth, 1.00; Interleaved for Notes, 1.25 J%$°~ See pages 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 11 Obstetrics and Gynecology : — Continued. Galabin's Midwifery. By A. Lewis Galabin, m.d., f.r.c.p. 227 Illustrations. Seepages. Cloth, 3.00; Leather, 3.50 Glisan's Modern Midwifery. 2d Edition. Cloth, 3.00 Rigby's Obstetric Memoranda. 4th Edition. Cloth, .50 Meadows' Manual of Midwifery. Including the Signs and Symptoms of Pregnancy, Obstetric Operations, Diseases of the Puerperal State, etc. 145 Illustrations. 494 pages. Cloth, 2.00 Swayne's Obstetric Aphorisms. For the use of Students commencing Midwifery Practice. 8th Ed. i2mo. Cloth, 1.25 PATHOLOGY. HISTOLOGY. BIOLOGY. Bowlby. Surgical Pathology and Morbid Anatomy, for Students. 135 Illustrations. i2mo. Cloth, 2.00 Davis' Elementary Biology. Illustrated. Cloth, 4.00 Gilliam's Essentials of Pathology. A Handbook for Students. 47 Illustrations. i2mo. Cloth, 2.00 *#* The object of this book is to unfold to the beginner the funda- mentals of pathology in a plain, practical way, and by bringing them within easy comprehension to increase his interest in the study of the subject. Gibbes' Practical Histology and Pathology. Third Edition. Enlarged. i2mo. Cloth, 1.75 Virchow's Post-Mortem Examinations. 2d Ed. Cloth, 1.00 PHYSIOLOGY. Yeo's Physiology. Fourth Edition. The most Popular Stu- dents' Book. By Gerald F. Yeo, m.d., f.r.c.s., Professor of Physiology in King's College, London. Small Octavo. 758 pages. 321 carefully printed Illustrations. With a Full Glossary and Index. See Page 3. Cloth, 3.00; Leather, 3.50 Brubaker's Compend of Physiology. Illustrated. Fifth Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 Stirling. Practical Physiology, including Chemical and Ex- perimental Physiology. 142 Illustrations. Cloth, 2.25 Kirke's Physiology. New 12th Ed. Thoroughly Revised and Enlarged. 502 Illustrations. Cloth, 4.00; Leather, 5.00 Landois' Human Physiology. Including Histology and Micro- scopical Anatomy, and with special reference to Practical Medi- cine. Third Edition. Translated and Edited by Prof. Stirling. 692 Illustrations. Cloth, 6.50; Leather, 7.50 " With this Text-book at his command, no student could fail in his examination." — Lancet, Sanderson's Physiological Laboratory. Being Practical Ex- ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 Tyson's Cell Doctrine. Its History and Present State. Illus- trated. Second Edition. Cloth, 2.00 See pages 14 and 13 for list of ? Quiz-Compends f 12 STUDENTS' TEXT-BOOKS AND MANUALS. PRACTICE. Taylor. Practice of Medicine. A Manual. By Frederick Taylor, m.d., Physician to, and Lecturer on Medicine at, Guy's Hospital, London ; Physician to Evelina Hospital for Sick Chil- dren, and Examiner in Materia Medica and Pharmaceutical Chemistry, University of London. Cloth, 4.00 Roberts' Practice. New Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, m.d. ; m.r.c.p., Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Seventh Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 Hughes. Compend of the Practice of Medicine. 4th Edi- tion. Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25 Part i. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part ii. — Diseases of the Respiratory System, Circulatory System and Nervous System ; Diseases of the Blood, etc. Physician's Edition. Fourth Edition. Including a Section on Skin Diseases. With Index. 1 vol. Full Morocco, Gilt, 2.50 From John A. Robinson, M.D., Assistant to Chair of Clinical Medicine , now Lecturer on Materia Medica, Rush Medical Col- lege, Chicago. " Meets with my hearty approbation as a substitute for the ordinary note books almost universally used by medical students. It is concise, accurate, well arranged and lucid, . . . just the thing for students to use while studying physical diagnosis and the more practical departments of medicine." PRESCRIPTION BOOKS. Wythe's Dose and Symptom Book. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Seventeenth Edition. Completely Revised and Rewritten. Just Ready. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 Pereira's Physician's Prescription Book. Containing Lists of Terms, Phrases, Contractions and Abbreviations used in Prescriptions Explanatory Notes, Grammatical Construction of Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. Sixteenth Edition. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 PHARMACY. Stewart's Compend of Pharmacy. Based upon Remington's Text-Book of Pharmacy. Third Edition, Revised. With new Tables, Index, Etc. Cloth, 1.00; Interleaved for Notes, 1.25 Robinson. Latin Grammar of Pharmacy and Medicine. By H. D. Robinson, ph.d., Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Intro- duction by L. E. Say re, ph.g., Professor of Pharmacy in, and Dean of, the Dept. of Pharmacy, University of Kansas. i2mo. Cloth, 2.00 SKIN DISEASES. Anderson, (McCall) Skin Diseases. A complete Text-Book, with Colored Plates and numerous Wood Engravings. 8vo. Cloth, 4.50; Leather, 5.50 £^~ See pages 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 13 Skin Diseases : — Continued. Van Harlingen on Skin Diseases. A Handbook of the Dis- eases of the Skin, their Diagnosis and Treatment (arranged alpha- betically). By Arthur Van Harlingen, m.d., Clinical Lecturer on Dermatology, Jefferson Medical College ; Prof, of Diseases of the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. With colored and other plates and illustrations. i2mo. Cloth, 2.50 Bulkley. The Skin in Health and Disease. By L. Duncan Bulkley, Physician to the N. Y. Hospital. Illus. ' Cloth, .50 SURGERY AND BANDAGING. Jacobson. Operations in Surgery. A Systematic Handbook for Physicians, Students and Hospital Surgeons. By W. H. A. Jacobson, b a., Oxon. f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- pital ; Surgeon at Royal Hospital for Children and Women, etc. 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 Horwitz's Compend of Surgery, Minor Surgery and Bandaging, Amputations, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules, etc., with Differential Diagnosis and Treatment. By Orville Hokwitz, b.s., m.d., Demonstrator of Surgery, Jefferson Medical College. 4th edition. Enlarged and Rearranged. 136 Illustrations and 84 Formulas. i2mo. Cloth, 1.00; Interleaved for the addition of Notes, 1.25 %* The new Section on Bandaging and Surgical Dressings, con- sists of 32 Pages and 41 Illustrations. Every Bandage of any importance is figured. This, with the Section on Ligation of Arteries, forms an ample Text-book for the Surgical Laboratory. Walsham. Manual of Practical Surgery. For Students and Physicians. By Wm. J. Walsham, m.d., f.r.c.s., Asst. Surg, to, and Dem. of Practical Surg, in, St. Bartholomew's Hospital, Surgeon to Metropolitan Free Hospital, London. With 236 Engravings. See Page 2. Cloth, 3.00; Leather, 3.50 URINE, URINARY ORGANS, ETC. Holland. The Urine, and Common Poisons and The Milk. Chemical and Microscopical, for Laboratory Use. Illus- trated. Third Edition. i2mo. Interleaved. Cloth, 1.00 Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- trations. i2mo. 572 pages. Cloth, 2.75 Marshall and Smith. On the Urine. The Chemical Analysis of the Urine. By John Marshall, m.d., Chemical Laboratory, Univ. of Penna; and Prof. E. F. Smith, ph.d. Col. Plates. Cloth, 1.00 Thompson. Diseases of the Urinary Organs. Eighth London Edition. Illustrated. Cloth, 3.50 Tyson. On the Urine. A Practical Guide to the Examination of Urine. With Colored Plates and Wood Engravings. 6th Ed. Enlarged. i2mo. Cloth, 1.50 Van Niiys, Urine Analysis. Illus. Cloth, 2.00 VENEREAL DISEASES. Hill and Cooper. Student's Manual of Venereal Diseases, with Formulae. Fourth Edition. i2mo. Cloth, 1.00 4®=* See pages 14 and 13 for list of ? Quiz- Commends f NEW AND REVISED EDITIONS. PQUIZ-COMPENDS? The Best Compends for Students' Use in the Quiz Class, and when Pre- paring for Examinations. Compiled in accordance with the latest teachings of promi- nent lecturers and the most popular Text-books. They form a most complete, practical and exhaustive set of manuals, containing information nowhere else col- lected in such a condensed, practical shape. Thoroughly up to the times in every respect, containing many new prescriptions and formulae, and over two hundred and fifty illustrations, many of which have been drawn and engraved specially for this series. The authors have had large experience as quiz-masters and attaches of colleges, with exceptional opportunities for noting the most recent advances and methods. Cloth, each $1.00. Interleaved for Notes, $1.25. No. 1. HUMAN ANATOMY, «' Based upon Gray." Fifth Enlarged Edition, including Visceral Anatomy, formerly published separately. 16 Lithograph Plates, New Tables and 117 other Illustrations. By Samuel O. L. Potter, m.a., m.d., late A. A. Surgeon U. S. Army. Professor of Practice, Cooper Medical College, San Francisco. Nos. 2 and 3. PRACTICE OF MEDICINE. Fourth Edi- tion. By Daniel E. Hughes, m.d., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two parts. Part I. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. Part II. — Diseases of the Respiratory System (including Phy- sical Diagnosis), Circulatory System and Nervous System; Dis- eases of the Blood, etc. *#* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpub- lished. No. 4. PHYSIOLOGY, including Embryology. Fifth Edition. By Albert P. Brubaker, m.d., Prof, of Physiology, Penn'a. College of Dental Surgery ; Demonstrator of Physiology in Jefferson Medical College, Philadelphia. Revised, Enlarged and Illustrated. No. 5. OBSTETRICS. Illustrated. Fourth Edition. By Henry G. Landis, m.d.. Prof, of Obstetrics and Diseases of Women, in Starling Medical College, Columbus, O. Revised Edition. New Illustrations. BLAKISTON'S ? QUIZ-COMPENDS ? No. 6. MATERIA MEDICA, THERAPEUTICS AND PRESCRIPTION WRITING. Fifth Revised Edition. With especial Reference to the Physiological Action of Drugs, and a complete article on Prescription Writing. Based on the Last Revision of the U. S. Pharmacopoeia, and including many unofficinal remedies. By Samuel O. L. Potter, m.a., m.d., late A. A. Surg. U. S. Army; Prof, of Practice, Cooper Medical College, San Francisco. Improved and Enlarged, with Index. No. 7. GYNECOLOGY. A Compend of Diseases of Women. By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. 45 Illustrations. No. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery. By L. Webster Fox, m.d., Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 Formulae. Second Enlarged and Improved Edition. Index. No. 9. SURGERY, Minor Surgery and Bandaging. Illus- trated. Fourth Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations and other operations ; Inflam- mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., Demonstrator of Surgery, Jefferson Medical College. Revised and Enlarged. 84 Formulae and 136 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in Penn'a College of Dental Surgery, Phila. Third Edition, Revised and Rewritten, with Index. No. 11. PHARMACY. Based upon " Remington's Text-book of Pharmacy." By F. E. Stewart, m.d., ph.g., Quiz-Master at Philadelphia College of Pharmacy. Third Edition, Revised. No. 12. VETERINARY ANATOMY AND PHYSIOL- OGY. 29 Illustrations. By Wm. R. Ballou, m.d., Prof, of Equine Anatomy at N. Y. College of Veterinary Surgeons. No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- CINE. Containing all the most noteworthy points of interest to the Dental student. By Geo. W. Warren, d.d.s., Clinical Chief, Penn'a College of Dental Surgery, Philadelphia. Illus. No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. Hatfield, Prof, of Diseases of Children, Chicago Medical College. Colored Plate. Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. These books are constantly revised to keep up with the latest teachings and discoveries, so that they contain all the new methods and principles. No series of books are so complete in detail, concise in language, or so well printed and bound. Each one forms a complete set of notes upon the subject under consideration. Illustrated Descriptive Circular Free. JUST PUBLISHED. GOULD'S NEW Medical Dictionary COMPACT. CONCISE. PRACTICAL. ACCURATE. COMPREHENSIVE UP TO DATE. It contains Tables of the Arteries, Bacilli, Gan glia, Leucomaines, Micrococci, Muscles, Nerves, Plexuses, Ptomaines, etc., etc., that will be found of great use to the student. Small octavo, 520 pages, Half-Dark Leather, . $3.25 With Thumb Index, Half Morocco, marbled edges, 4.25 From J. M. DaCOSTA, M. D., Professor of Practice and Clinical Medicine, Jefferson Medical College, Philadelphia. "I find it an excellent work, doing credit to the learning and discrimination of the author.'*