■ 
 
 m 
 
 m 
 
 ■KmSkct 
 
 9bE 
 
 
 MB 
 
 warn 
 
 wM 
 
 si 
 
 
 ■B 
 
 
 
 H 
 
 s&si 
 
 
LIBRARY OF CONGRESS, 
 
 TU 
 
 Shelf JaJItf 
 
 UNITED STATES OF AMERICA. 
 
DISEASES 
 
 OF THE 
 
 DIGESTIVE ORGANS 
 
 » 
 IN INFANCY AND CHILDHOOD. 
 
 STARR. 
 
DISEASES 
 
 OF THE 
 
 DIGESTIVE ORGANS 
 
 IN 
 
 INFANCY AND CHILDHOOD, 
 
 CHAPTERS ON THE INVESTIGATION OF DISEASE, AND ON 
 THE GENERAL MANAGEMENT OF CHILDREN. 
 
 BY 
 
 V 
 
 LOUIS STARR, M.D., 
 
 CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE UNIVERSITY 
 
 OF PENNSYLVANIA; PHYSICIAN TO THE CHILDREN'S HOSPITAL, 
 
 PHILADELPHIA, ETC., ETC. 
 
 
 WITH COLORED PLATE AND OTHER ILLUSTRATIONS. 
 
 ? 3 $~J 
 
 PHILADELPHIA : 
 
 P. BLAKISTON, SON & CO., 
 
 No. 1012 Walnut Street. 
 1886. 
 
-.< 
 
 
 CO 
 
 Copyright, 1886, by Louis Starr, m.d. 
 
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. 
 
Y.KI 
 
 PREFACE. 
 
 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 child- 
 hood, attention to the general regimen is quite as im- 
 portant as the administration of drugs, and it is upon the 
 former that the student and younger 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 therapeutics, has given greater promi- 
 nence to these points. 
 
 The chapter on the investigation of disease does not 
 necessarily belong to a work on disorders of the digestive 
 organs, but as so much difficulty is experienced by stu- 
 dents in the study of disease in children, it has been 
 
 xiu 
 
XIV PREFACE. 
 
 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. 
 
 1922 Spruce St., Philadelphia. 
 April, 1886. 
 
CONTENTS. 
 
 PART I.-INTR0DUCTI0N. 
 
 PAGE 
 
 THE INVESTIGATION OF DISEASE, .... 17 
 
 1. Questioning the Attendants, . . . . . .18 
 
 2. Inspecting the Child, 21 
 
 3. Physical Examination, 35 
 
 PART II— DISEASES OF THE DIGESTIVE ORGANS. 
 
 CHAPTER I.— AFFECTIONS OF THE MOUTH AND 
 
 THROAT, 59 
 
 1. Catarrhal Stomatitis, . 59 
 
 2. Aphthous Stomatitis, 62 
 
 3. Ulcerative Stomatitis, . 67 
 
 4. Gangrenous Stomatitis — Noma, ..... 72 
 
 5. Parasitic Stomatitis — Thrush, 79 
 
 6. Dentition, 86 
 
 7. Simple Pharyngitis, ........ 103 
 
 8. Superficial Catarrh of the Tonsils, 107 
 
 9. Follicular Tonsillitis, .108 
 
 10. Suppurative Tonsillitis, 112 
 
 11. Hypertrophy of the Tonsils, 116 
 
 12. Retropharyngeal Abscess, 119 
 
 CHAPTER II.— AFFECTIONS OF THE STOMACH AND 
 INTESTINES, . ... 
 
 1. Acute Gastric Catarrh, . 
 
 2. Chronic Gastric Catarrh, 
 
 3. Chronic Gastro-Intestinal Catarrh 
 
 4. Acute Intestinal Catarrh, 
 
 5. Chronic Intestinal Catarrh — Chronic Entero-Coliti 
 
 XV 
 
 122 
 
 122 
 126 
 136 
 152 
 
 161 
 
XVI CONTENTS. 
 
 PAGE 
 
 6. Entero-Colitis, 175 
 
 7. Cholera Infantum, 188 
 
 8. Inflammation of the Colon and Rectum — Dysentery, . 194 
 
 9. Tubercular Ulceration of the Intestines, . . . 198 
 
 10. Colic, 201 
 
 11. Habitual Constipation, 205 
 
 12. Simple Atrophy, 211 
 
 13. Typhlitis and Perityphlitis, 220 
 
 14. Intussusception, 230 
 
 15. Intestinal Worms, 248 
 
 CHAPTER III.— CASEOUS DEGENERATION AND TU- 
 BERCULOSIS OF THE MESENTERIC GLANDS 
 
 —TABES MESENTERICA, 266 
 
 CHAPTER IV.— AFFECTIONS OF THE LIVER, . . 275 
 
 1. Jaundice, 275 
 
 2. Congestion of the Liver, 281 
 
 3. Fatty Liver, 285 
 
 4. Amyloid Liver 287 
 
 5. Syphilitic Inflammation of the Liver, .... 291 
 
 6. Cirrhosis of the Liver, 292 
 
 7. Suppurative Hepatitis, 298 
 
 CHAPTER V.— AFFECTIONS OF THE PERITONEUM, . 306 
 
 1. Peritonitis, 306 
 
 2. Tubercular Peritonitis, 314 
 
 3. Ascites, 322 
 
 PART III— THE GENERAL MANAGEMENT OF 
 CHILDREN. 
 
 1. Feeding, 329 
 
 2. Bathing, 365 
 
 3. Clothing, 368 
 
 4- Sleep, 370 
 
 5. Exercise, 372 
 
 INDEX, 375 
 
DISEASES 
 
 OF 
 
 THE DIGESTIVE ORGANS 
 
 IN 
 
 INFANCY AND CHILDHOOD. 
 
 PART I.— INTRODUCTION. 
 
 THE INVESTIGATION OF DISEASE. 
 
 The clinical investigation of disease in children, usually 
 considered so difficult, is in some respects, easier than the 
 same study in adults. 
 
 It is easier because in the child disease is commonly un- 
 complicated, 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 nar- 
 cotics, or by mental over-work and nerve-strain. The con- 
 fusing element of mis-stated subjective symptoms is also 
 absent, while correct diagnosis is greatly aided by the 
 facility with which physical examination 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 described subjective symptoms, and renders it 
 necessary to look to the mother or nurse for the history of an 
 2 i 7 
 
1 8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 agitation of the child are impediments 
 which must be overcome before a satisfactory examina- 
 tion can be made, and which will often tax the skill 
 and patience of the physician to the utmost in the over- 
 coming. 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 confusion, since it binds every portion of 
 the frame in a sympathy so close that an affection of a single 
 part may cause marked general disturbance, and local symp- 
 toms are often reflected, directing attention to organs very 
 distant from those really diseased. Finally, the extreme ex- 
 citability 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 depression 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 child- 
 ren 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 examination. 
 
 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 ques- 
 
THE INVESTIGATION OF DISEASE. 1 9 
 
 tion 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 dis- 
 credit a statement without good reason, for many women, 
 though weak and foolish in other respects, are excellent 
 observers when their powers are guided by affection. Be- 
 sides, being thoroughly acquainted with their children's 
 habits and dispositions, they will often detect deviations 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 pro- 
 longed 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 detec- 
 tion of chronic maladies and transmissible diseases, as tuber- 
 culosis 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 feed- 
 ing 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 gene- 
 ral state of health in regard to strength, or weakness and 
 
20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 healthfulness 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. 
 
 After this it is necessary to fix the time the attack in 
 hand began. The occurrence of some striking symptom, 
 as convulsions 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 com- 
 mon 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 temperature, appetite, digestion, urine elimi- 
 nation, respiration and so on, must be sought for, and the 
 account of such deviations from the normal state as vomit- 
 ing, diarrhoea or cough, will suggest further questions as 
 well as point out the path to be followed in the future 
 examination. 
 
THE INVESTIGATION OF DISEASE. 21 
 
 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 examination is never complete without 
 an inspection of the naked body. The points thus ascer- 
 tained consist in alterations in the expression 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 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 
 expression 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 rendered unsound by moderate pain 
 and during the course of all acute and chronic diseases, 
 particularly when they assume a grave type. Twitching of 
 
22 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 the lids heralds the approach of a convulsion, and at such 
 times, too, there is often oscillation of 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 res- 
 piration, 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 sets its mark upon the coun- 
 tenance, and by noting the feature affected it is often pos- 
 sible to fix the seat of serious disease. Thus, contraction of 
 the brows denotes pain in the head ; sharpness of the nos- 
 trils, pain in the chest ; and a drawing of the upper lip, pain 
 in the abdomen. As a rule, the upper third of 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 afford as to the part of the body to be further 
 examined. There are three sets of furrows. First, the 
 oculo-zygomatic, beginning at the inner canthus of the eye 
 
THE INVESTIGATION OF DISEASE. 23 
 
 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 genal, 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, commencing at the angle of the mouth and run- 
 ning outward, to be lost in the lower part of the face. This 
 furrow is more shallow than the others. It directs atten- 
 tion to the lungs. These furrows are often present, and 
 when met with are worthy of consideration, but their con- 
 stancy and value have been over-estimated by their dis- 
 coverer. 
 
 Puffiness 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 promi- 
 nent diatheses is distinguished 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 and in front of the ears. The general expression 
 is most intelligent. In the strumous diathesis, on the con- 
 trary, the face is round and heavy ; the complexion doughy ; 
 the upper lip swollen ; the nostrils wide and the alse of the 
 nose thick; the eyelids are thickened and reddened at their 
 edges ; the hair coarse, and the lymphatic glands of the 
 neck enlarged. 
 
24 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 significant of constitutional syphilis. A 
 large, square head and projecting 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 projected down- 
 ward and irides almost concealed by the lower lids, are 
 pathognomonic signs of chronic hydrocephalus. 
 
 Decubitus. — The complete repose depicted on the coun- 
 tenance 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 movement 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 content 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 jactation, at the beginning of the specific 
 
THE INVESTIGATION OF DISEASE. 2$ 
 
 fevers, children often lie for hours quiet and drowsy upon 
 the bed or lap. 
 
 In chronic affections attended with debility, the move- 
 ments 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 im- 
 paired 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 pos- 
 ture 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 tubercu- 
 lar meningitis. 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 breath- 
 ing, some inflammatory change in the respiratory or abdomi- 
 nal 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 
 
26 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 of dentition 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 or extended, a convulsion may be expected. 
 The presence of clonic contractions of the muscles, with 
 unconsciousness, indicates, of course, a convulsion ; while 
 irregular, badly coordinated, jerky .movements — conscious- 
 ness 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 conjunctivae, 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. Allowing 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 ad- 
 vances the coloring becomes more pronounced, and until 
 the completion of childhood the complexion is much fresher 
 than in adult life. 
 
THE INVESTIGATION OF DISEASE. 2J 
 
 In the inspection alterations of the skin of the face are 
 chiefly noticeable. Lividity of the eyelids and lips is a sign 
 of imperfect aeration of the blood and points to pulmonary 
 or cardiac disease. Marked blueness of the whole face is 
 a symptom of morbus cceruleus, 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 frequently, deranged di- 
 gestion. 
 
 A decided yellow hue of the skin and conjunctivae is seen 
 in jaundice ; an earthy tinge of the face in chronic intestinal 
 diseases ; a waxy pallor in renal diseases, and paleness in any 
 acute or chronic affection attended with exhaustion. 
 
 Brownish-yellow discoloration of the forehead is signifi- 
 cant of inherited syphilis ; a bright, circumscribed flush on 
 one or both cheeks, of inflammation of the lungs or pleura, 
 or of gastro-intestinal 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 char- 
 acteristics. 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 pufjfi- 
 ness and cushiony appearance of the dorsum of the hands. 
 Often, too, in this condition, the finger ends are glossy, as if 
 smeared with oil, and there is an exfoliation of the epidermis 
 
28 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 respira- 
 tory 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 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 con- 
 ditions of stupor and coma it is noticeably absent. 
 
 The Cry. — The vocal sound, termed crying, is the chief 
 if 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 never 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 frequent, peevish crying or 
 fretfulness is compatible with health, consequently, when 
 
THE INVESTIGATION OF DISEASE. 20, 
 
 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 offer- 
 ing a properly prepared bottle. The hydr encephalic cry, de- 
 noting 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 attended with distortion of the 
 features, indicates pneumonia. In acute pleuritis, the cry 
 also accompanies the cough, but it is produced also by 
 movements of the body and by pressure on the affected 
 side. It is louder, indicative of greater suffering, and some- 
 times most difficult to check. Intestinal pain causes cry- 
 ing just before or after an evacuation of the bowels, and is 
 associated with wriggling movements of the body and pel- 
 vis, and with the eructation or passage of flatus. Con- 
 ditions of general distress or malaise predispose to fits of 
 fretful crying, the paroxysms being excited by any disturb- 
 ing influence, or even by merely looking at the little 
 sufferer. 
 
 When the cry has a nasal tone, it indicates swelling of 
 the mucous membrane of the nares, or other obstructing 
 condition. Thickening and indistinctness occurs with 
 pharyngeal affections. A loud, brazen cry is a precursor 
 of spasmodic croup. Hoarseness points to a lesion of the 
 laryngeal mucous membrane, either catarrhal or syphilitic in 
 nature. In membranous croup, and in some cases of ex- 
 treme exhaustion, the cry is faint and inaudible. Finally, 
 in severe croupous pneumonia, in extensive pleural effusion 
 and in rickets, ordinary disturbing causes are inoperative for 
 the production of fits of crying, and there is a seeming 
 
30 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 unwillingness to cry, on account of the action interfering 
 with the respiratory function. 
 
 The conditions of altered tone apply equally to the articu- 
 late voice in children who are old enough to speak. 
 
 The cough, too, must not be disregarded. Many of 
 its characters correspond with the voice and cry. It is 
 brazen in spasmodic croup, suppressed in true croup, hoarse 
 in laryngeal catarrh, and so on. But it has certain features 
 of its own. In bronchitis it is more or less paroxysmal, 
 evidently dry in the early stages, loose and rattling as the 
 catarrh " breaks up." In the painful pulmonary affections, 
 pneumonia and pleurisy, it is choked back, and whenever 
 it occurs, an expression of pain passes like a cloud over the 
 face. In pertussis, the peculiar spasmodic cough is the 
 pathognomonic symptom, and when once heard, immedi- 
 ately stamps the case. Cough is always unproductive, that 
 is, unattended by expectoration, in children under seven 
 years of age. 
 
 The formation of tears 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 physi- 
 cal examination, although, strictly speaking, they do not 
 come under the head of inspection of the child. These are 
 the characters of the fsecal evacuations, of the urine, and of 
 the material ejected by vomiting. 
 
 The FAECAL Evacuations. — The daily number of evacua- 
 tions natural for a child varies greatly with its age. For 
 the first six weeks there should be three or four stools 
 
THE INVESTIGATION OF DISEASE. 3 1 
 
 every twenty-four hours. After this time up to the end 
 of the second year, two movements a day is the normal 
 average. Subsequently, the frequency of 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 sometimes a tinge of green, have a faint faecal, slightly 
 sour odor, and are acid in reaction. In the second, they are 
 mushy or imperfectly./^;?^, of uniform consistence through- 
 out, 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 are formed, and brownish in color, with a decided 
 faecal odor. 
 
 Many alterations occur in disease. The frequency of the 
 movements may be increased, constituting diarrhoea, or 
 lessened, constituting constipation. In the former condition 
 the consistency is diminished, in the latter increased. In- 
 stead of being uniform throughout, the stool may be mixed, 
 partly liquid partly solid, indicating imperfect digestion, and 
 curds of milk or pieces of 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 
 intermixture of blood, altered blood clots, and shreds of 
 
32 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 mucous membrane, 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, 
 and sour- smelling evacuations in the diarrhoea of suck- 
 lings. The discovery of worms or their ova in the stools 
 is the certain evidence of the existence of intestinal para- 
 sites. 
 
 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 examina- 
 tion of them. 
 
 The Urine. — It is impossible to make a definite state- 
 ment 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 temperature of the surrounding air, the 
 amount of moisture that it contains, 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 extremes 
 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 INVESTIGATION OF DISEASE. 33 
 
 the bed, therefore, or the involuntary passage of the urine 
 during sleep, is indicative of an abnormal condition and re- 
 quires investigation.* 
 
 The urine of an infant, while it wets, should not stain the 
 diaper. In certain cases of mal-digestion it becomes very 
 concentrated and high-colored, and gives a light yellow 
 tinge to the napkin. When the stain is decidedly yellow, 
 jaundice is indicated, and other symptoms of this condition 
 should be looked for. 
 
 In older children a high-colored urine, and one which 
 deposits a whitish or pinkish sediment on standing, is 
 symptomatic of acute digestive disorder, either catarrhal in 
 its nature, or secondary to some acute febrile affection. A 
 smoky, blackish hue, looking as if there had been an admix- 
 ture of soot, is pathognomonic of acute scarlatinal nephritis ; 
 in this state, too, there is a great diminution in the amount 
 passed. 
 
 Painful micturition points to inflammation of the urethra, 
 a narrow preputial orifice, a highly acid condition of the 
 excretion, or stone in the bladder. 
 
 Chemical tests and microscopical examination reveal 
 many alterations in the urine of children. These have 
 the same significance as analogous changes in the case of 
 adults. 
 
 Vomiting. — Both vomiting and regurgitation are of ready 
 production 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 
 
 * From a few observations, 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. 
 
 3 
 
34 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 regur- 
 gitation 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 feeling of general distress, headache and epi- 
 gastric pain, it must not be regarded as a symptom of dis- 
 ease. 
 
 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 pro- 
 drome of one of the eruptive fevers. Which condition is 
 present can only be determined by watching the case, and 
 by a careful study of the rational symptoms and physical 
 signs. 
 
 The character of the ejecta is more definite. For in- 
 stance, 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 appear- 
 ance of lumbricoid worms in the vomit, a not infrequent 
 occurrence, shows conclusively the existence of these para- 
 sites in the alimentary canal. 
 
THE INVESTIGATION OF DISEASE. 35 
 
 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 disturbance of the child, and since this very dis- 
 turbance alters the character of some of the information 
 obtained, it is well to adopt a somewhat different order of 
 examination, and one which at first sight may seem irregu- 
 lar. 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 condition of 
 the skin, next, to investigate the physical condition of the 
 lungs, heart and abdominal organs, and last of all to exam- 
 ine 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 
 abdominal 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 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 con- 
 venient 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 fre- 
 quency 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 
 
6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 dis- 
 eases attended by severe febrile symptoms, such as the acute 
 exanthemata, 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 ab- 
 dominal 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 diag- 
 nosis 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 audible, gradually growing 
 deeper until a full, noisy respiration is made, and then slowly 
 subsiding into a period of absolute quiet, variable in its du- 
 ration. 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 
 
THE INVESTIGATION OF DISEASE. 37 
 
 expiration, and between the latter and the next inspiration 
 there is a period of silence or rest. Expiratory respiration, 
 on the contrary, is characterized by the pause coming be- 
 tween inspiration and expiration, the expiratory effort, 
 always very marked, being immediately 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 res- 
 piration, complete occlusion. Difficult breathing with pro- 
 longed inspiration — inspiratory dyspnoea — shows an impedi- 
 ment 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 inspira- 
 tory act is also attended by a loud, piping, or rasping sound. 
 Labored breathing with prolonged wheezing respiration — 
 expiratory dysp7tcea * — 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 dyspnoea 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 recur frequently, denotes great failure of the vital powers 
 and is an unfavorable prognostic element. 
 
 * I prefer to limit the term dyspnoea to difficult or labored respiration, and not 
 to extend it to include simple accelerated breathing. 
 
38 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 condition, advantage may be taken of its pla- 
 cidity 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 frequency of the pulse 
 by directly ausculting the heart. After the second month 
 palpation of the pulse at the wrist in the ordinary way pre- 
 sents no difficulties. 
 
 The child's pulse differs from the adult's by being much 
 more frequent, more irregular, and more irritable. 
 
 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. 
 
 u u Ist « 3d year, no to 100. 
 
 " " 3d " 5th " 100 to 90. 
 
 " " 5th " ioth " 90 to 80. 
 
 " " ioth " 12th " 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 
 
THE INVESTIGATION OF DISEASE. 39 
 
 its frequency is increased by muscular activity and mental 
 excitement, is greater in proportion to the youth of the 
 child. A rise of 20, 30 or even 40 beats a minute is not un- 
 common in early infancy under the excitement of the slight- 
 est effort or disturbance. 
 
 On account of these wide variations in health, little symp- 
 tomatic meaning need be attached to alterations of the 
 rhythm and frequency while unassociated with other ab- 
 normal features. When so associated they become import- 
 ant in diagnosis. 
 
 Increased frequency is a constant attendant of the febrile 
 state. The extent of the increase corresponds with the de- 
 gree 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 question must be taken into consideration. For 
 example, in scarlatina a pulse of 160 is usual and not in- 
 dicative 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 of 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 with- 
 out 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 keeping the arm in a proper attitude. It 
 should remain in position at least five minutes. 
 
 * The rectal temperature is normally at least i° higher than the axillary. 
 
40 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 During the first week of life the temperature fluctuates 
 considerably. After that the puerile norme — 98. 5 ° to 99°F. 
 — is established, but until the fourth or fifth month it is 
 greatly influenced by healthy causes of variation ; the fluc- 
 tuations ranging between .9° and 3. 6°. By the fifth month 
 regular morning and evening oscillations begin to be 
 noticeable, and certain definite laws are followed. There is 
 a fall in the evening of i° or 2°. The greatest fall occurs 
 between 7 and 9 p.m. and the minimum is reached at, or be- 
 fore, 2 a.m. After 2 a.m. there is a gradual rise, the maxi- 
 mum being reached between 8 and 10 a.m. Throughout the 
 day the oscillation is trifling. These variations are inde- 
 pendent 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 tem- 
 perature. 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 elevation and the pecu- 
 liar 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 high- 
 est in the evening. Variations in the typical range of any 
 given fever are important prognostic omens— a sudden fall 
 of the temperature, together with improvement in the 
 general symptoms, indicates the beginning of convales- 
 cence — a similar fall, with an increase of the general symp- 
 toms, is a precursor of death. When the morning tem- 
 perature is equal to that of the preceding evening, there is 
 
THE INVESTIGATION OF DISEASE. 4 1 
 
 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- 
 hemorrhage 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 imperfect blood aeration, and it con- 
 stantly 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. 
 
 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 devel- 
 opment, 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 
 average size and weight. Subsequently, under normal cir- 
 cumstances, 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 
 
42 DISEASES OF DIGESTIVE ORGANS IN. CHILDREN. 
 
 year there is an increase of from 5 to 6^ inches; in the 
 second, from 2 2 / l to 3^ inches; in the third, from 2% to 
 2^3 inches; in the fourth, about 2 inches; and from the 
 fifth to the sixteenth years the annual growth amounts to 
 from 1^ 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 x 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. 
 
 For some time after birth, the child, if noticed while si- 
 ting 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 convexity 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 com- 
 
THE INVESTIGATION OF DISEASE. 43 
 
 plained of, and manipulation of the limbs causes suffering, 
 the chances are that hip-joint disease 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 
 and constitutional syphilis have a like effect. In a state of 
 health, the opening, while still membranous, is level with 
 the cranial bones or very slightly depressed. Condi- 
 tions of systemic exhaustion cause marked sinking, and 
 this depression is one of the best indications of the neces- 
 sity of stimulation. Bulging of the fontanelle is a symptom 
 of chronic hydrocephalus. 
 
 Conditions of the Skin. — The normal color of the in- 
 tegument, 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 de- 
 gree of elasticity. 
 
 Disease causes modifications in texture, in moisture, and 
 in elasticity, and leads to the appearance of various erup- 
 tions and to cedema. 
 
 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 thick layer of exfoliating 
 epidermis. Chronic abdominal affections, particularly tu- 
 berculosis of the intestines and mesenteric glands, lead to 
 harshness, acridity, scurfiness, and a wrinkled appearance of 
 the skin covering the abdomen and thorax, with enlarge- 
 ment of the superficial abdominal veins. 
 
 Protracted diarrhoea, and still more, vomiting and diar- 
 rhoea, cause absorption of the subcutaneous fat and wasting 
 of the muscles. The skin becomes too large for the body, 
 
44 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 
 moisture, of prostration of the vital forces and collapse. 
 
 Eruptions appear upon the integument, in the skin dis- 
 eases proper, in the exanthemata, in constitutional syphilis 
 and in certain digestive disorders. 
 
 CEdema 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 enlarge- 
 ment 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 por- 
 tion of the body the child, still stripped, must be placed on 
 its back, upon the bed or nurse's lap. Quiet is most import- 
 ant, since struggling and crying are attended by such con- 
 traction of the abdominal muscles and rigidity of the walls 
 that little can then be learned of the condition of the con- 
 tained 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, 
 uniformly soft, yielding, and painless to the touch, and to 
 percussion gives a tympanitic sound, varying in tone accord- 
 ing to the position percussed. The tympanitic note being 
 lowest in pitch over the epigastric and left hypochondriac 
 
THE INVESTIGATION OF DISEASE. 45 
 
 regions, the seat of the stomach ; highest, over the umbili- 
 cal region, the position of the small intestine. 
 
 In disease inspection reveals any disproportion in the size 
 or form of the abdomen, the state of the integuments, of 
 the superficial veins, and of the umbilicus. Palpation shows 
 the temperature, pliability, moisture and tension of the 
 walls, and the presence or absence of tenderness, of fluctua- 
 tion, and of enlargement 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. 
 
 Distension of the abdomen is, in the vast majority of in- 
 stances, 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 accumulate, owing to feebleness of the intes- 
 tinal 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 pres- 
 sure, 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 
 distension. On the contrary, unless the glandular disease is 
 excessive, retraction is the rule. When distension does exist 
 it depends upon associated 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 
 
4.6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 by gently grasping the abdomen on either side with the 
 hands and slowly bringing the fingers together toward the 
 median line. Percussion over the tumor yields a dull, tym- 
 panitic sound. Whenever there is associated flatulence it is 
 difficult or impossible to detect the tumor. 
 
 Drum-like distension, with great tenderness, and muffled 
 tympanitic percussion note occur in general peritonitis. 
 
 Uniform distension, again, may be due to ascites depend- 
 ing upon simple or tubercular peritonitis, kidney disease, or 
 less commonly, disease of the liver. The abdomen is barrel- 
 shaped, painless to the touch, and there is extended fluctua- 
 tion. 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 distension may be traced to gaseous accumula- 
 tion, to enlargement of the liver and spleen, to faecal accu- 
 mulation, to circumscribed peritonitis, and to distension of 
 the bladder. 
 
 Collections of gas are always tympanitic on percussion. 
 
 The extent of liver dulness is to be estimated by percus- 
 sion. 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 down- 
 ward 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 ap- 
 plied, and nothing is felt, the spleen may be considered to 
 be normal in size. The fact that both the liver and spleen, 
 
THE INVESTIGATION OF DISEASE. 47 
 
 though still unenlarged, may be more readily felt than 
 natural when pressed downward by the diaphragm, must 
 not be overlooked. 
 
 A faecal accumulation is distinguished by the absence of 
 tenderness, by the oblong shape of the tumor, by the situa- 
 tion, in the region of the transverse or descending colon,- to 
 which its long axis corresponds, and by its shape being 
 capable of some modification by pressure. Percussion over 
 such a mass is dull. 
 
 Distension 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 menin- 
 gitis, also in cholera infantum, follicular enteritis and dysen- 
 tery. 
 
 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 bring- 
 ing 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 
 pleximeter 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 op- 
 
4o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 portune moments, much reliable information may be gained. 
 Aid is also derived from the fact that in serious lung affec- 
 tions, 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. 
 Mensuration and succussion are infrequently resorted to in 
 children. If required, they are best postponed until the 
 end of the examination. 
 
 Inspection. — The sitting posture, the child being stripped 
 and in good light, is the best for this process. Note is to be 
 taken of the shape of the chest, the character of the breath- 
 ing, and the position of the apex beat of the heart. 
 
 In the new-born 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 per- 
 ceptible. 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 inspiration 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 
 cardiac apex can be seen, except when there is a great accu- 
 mulation of fat, a short distance below and to the right of 
 the left nipple. 
 
THE INVESTIGATION OF DISEASE. 49 
 
 Disease may alter all of these conditions. The tubercu- 
 lous 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. Emphy- 
 sema 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 absorption 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 
 inflammation 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 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 inspi- 
 ration. 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 disten- 
 sion of the stomach. When the left ventricle is enlarged, 
 it is shifted downward and to the left. Transmitted epi- 
 gastric pulsation shows enlargement 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, 
 4 
 
50 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 push- 
 ing 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 rest- 
 ing 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 
 positions 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 discover- 
 able 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, unless the exploration be thorough, 
 important lesions may be overlooked. 
 
 In healthy infants the inspiratory act in ordinary breath- 
 ing is superficial, and the respiratory murmur, as a conse- 
 quence, 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 breathing. After the age of two 
 years this form of respiration is habitual. 
 
 Puerile breathing is characterized by its intensity, a prop- 
 erty depending upon the thinness and elasticity of the chest- 
 
THE INVESTIGATION OF DISEASE. 5 I 
 
 walls in childhood. There is no alteration in rhythm, the 
 inspiratory element of the murmur being directly followed 
 by the expiratory, 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 
 posterior inferior regions of the thorax. Faintest over the 
 scapulae and the precordial area. Sometimes the expira- 
 tory element is wanting. This absence occurs most fre- 
 quently in young children, 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 
 somew T hat 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 most decided in the expiratory element, which, 
 also, may be slightly prolonged on the right when com- 
 pared with the left side. These modifications are due prin- 
 cipally 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 
 
52 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 of the expiratory sound be greater on the left side, the com- 
 mencement of phthisis is indicated. 
 
 If the child speaks, cries, or coughs while the ear is 
 applied to the chest, a muffled rumbling sound, the normal 
 vocal resonance, 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 
 precede 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 pro- 
 duced 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 anterior surface of the chest. 
 After muscular effort or during agitation, 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 exudation. 
 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 deter- 
 mining the 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 
 
THE INVESTIGATION OF DISEASE. 53 
 
 pleural or bronchial fremitus, the existence of fluctuation in 
 the intercostal spaces, and the character of vocal fremitus. 
 For the last purpose, though, it is hardly worth while to 
 make a separate step in the examination, for the vocal vibra- 
 tions can be readily distinguished 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 con- 
 strained or when disturbed, hold their breath in the intervals 
 of crying, and as they always do so at the end of an in- 
 spiration, this is a favorable time to seize for the compara- 
 tive 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 the year, the respiratory murmur being feeble, per- 
 cussion is rather insonorous. 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 elasticity, appreciated 
 by the finger used as the pleximeter. 
 
 Different portions of the thorax possess, normally, differ- 
 ent 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, 
 
54 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 represented 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 reso- 
 nance and elasticity are at once noticeable when the percus- 
 sion passes from the lung to this area, though the precordial 
 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 resonant, 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 interspace or at the eighth 
 rib ; that of the spleen, at the upper edge of the ninth rib. 
 Gastric tympany may supplant the pulmonary resonance 
 over the left infra-axillary region. 
 
 Posteriorly, there is little resonance in the scapular region, 
 particularly the supra-spinous portions. Over the inter- 
 scapular 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 ex- 
 tends to the very base, the posterior splenic dulness being 
 
THE INVESTIGATION OF DISEASE. 55 
 
 detected with difficulty. The right base is, therefore, 
 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 
 percussion 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 precordial dulness. 
 
 Examination of the Mouth and Fauces. — This portion 
 of the examination is most apt to cause crying and strug- 
 gling, 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 fre- 
 quently open the mouth when requested, but if he refuse, 
 the finger, the handle of a spoon, or some other smooth, 
 flat instrument may be 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 
 protruded and retracted, or a prolonged sound of "Ah " 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 moder- 
 
$6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 ately sharp edge. Subsequently, the edge begins to broaden 
 and soften, and the color of the investing mucous mem- 
 brane 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 follow- 
 ing order, the corresponding teeth appearing a little earlier 
 in the upper jaw* : — 
 
 The two lower central incisors, from 4 to 7 months after birth. 
 " four upper •' " 8 to 10 " " " 
 
 " two lower lateral incisors and 
 
 the four anterior molars, from 12 to 15 " " " 
 
 " four canines, " 18 to 24 " " " 
 
 " " posterior molars, " 20 to 30 " " " 
 
 The order of eruption of the permanent teeth is as fol- 
 lows : — 
 
 The two central incisors of lower jaw, from the 6th to 8th year. 
 
 " " " upper 
 
 four lateral " 
 " first bicuspids, 
 " canines, 
 " second bicuspids, 
 
 7th to 8th 
 
 8th to 9th 
 
 9th to 10th 
 
 10th to nth 
 
 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 " 
 " " third " " " 17th to 2 1st " 
 
 There are, therefore, twelve more permanent teeth, mak- 
 ing 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 
 
 * Upon this point, however, there is little uniformity. 
 
THE INVESTIGATION OF DISEASE. 57 
 
 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, surrounded 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. 
 
 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 important diagnostic and therapeutic significance. In- 
 flammation of the mouth itself, reddens the mucous mem- 
 brane, 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 gan- 
 grene. 
 
 The eruptions of scarlet fever, measles, varicella and vari- 
 
58 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 oloid make their appearance first on the mucous membrane 
 of the palate and fauces. 
 
 Irregular dentition indicates faulty nutrition ; delayed 
 dentition, rickets ; and certain peculiarities in the formation 
 of the permanent teeth, constitutional syphilis. 
 
 Finally, the conclusive evidences of the existence of diph- 
 theria, of croup, and of the various tonsillar affections, are 
 found in the fauces. 
 
PART II.— DISEASES OF THE 
 DIGESTIVE ORGANS. 
 
 CHAPTER I. 
 AFFECTIONS OF THE MOUTH AND THROAT. 
 
 i. CATARRHAL STOMATITIS. 
 
 The Anatomical Lesion in this affection consists of a 
 simple hypersemia of the mucous membrane of the mouth, 
 with its attendant redness, swelling, and altered secretion. 
 This hypersemia varies both in extent and degree. Some- 
 times it is limited to small, circumscribed points of the 
 membrane, at others it extends over large patches, or in- 
 volves the entire surface. In the latter cases, it is most in- 
 tense, the mucous glands of the lips and cheeks participate, 
 becoming enlarged and prominent, and occasionally small 
 herpetic patches appear. 
 
 The disease may be primary or secondary. 
 
 Etiology. — The causes of primary stomatitis are the in- 
 gestion of food or drinks which are acrid and irritating or 
 too hot ; the eruption of teeth ; the presence of decaying 
 teeth; want of cleanliness of the mouth; exposure to cold 
 and wet ; and the use of certain drugs, as mercury, iodine, 
 antimony and arsenic. The secondary form occurs during 
 the course of measles, scarlatina, typhoid fever, and disor- 
 dered conditions of the stomach, particularly those attended 
 
 59 
 
60 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 by acid eructations. Catarrhal stomatitis is also met 
 with in the earlier stages of more serious diseases of the 
 mouth. 
 
 While not limited to any special age, the disease occurs 
 most commonly during dentition, since at this period several 
 of its causes are apt to be simultaneously operative. 
 
 Symptoms. — These are mainly local. The lips are unnatu- 
 rally full and red, and the skin at the angles of the mouth 
 and on the chin may be excoriated by the dribbling saliva. 
 The oral mucous membrane presents either a punctated, a 
 patchy, or a diffuse redness. It is moderately swollen, and 
 hot and tender to the touch. At first the mouth is dry, but 
 soon the salivary flow is increased, the secretion becoming 
 acid in reaction, and sometimes viscid and flocculent. The 
 mucous glands of the cheeks and lips may project as yel- 
 lowish-white or transparent nodules, yielding a drop of mu- 
 cus on pressure. Infrequently, too, isolated collections of 
 small vesicles develop and then quickly dry up, leaving 
 scales behind them. The tongue is either red and smooth, 
 with enlarged and reddened fungiform papillae, or covered 
 with a white frosting, through which the papillae project in 
 scarlet points. The last condition is most frequently seen 
 when the stomatitis is secondary to gastric catarrh. The 
 acts of sucking and eating are painful, and resistance 
 is offered to inspection of the mouth. Cold drinks are 
 craved. 
 
 Restlessness, irritability, slight heat of skin, anorexia — 
 depending chiefly upon the local tenderness — and constipa- 
 tion, are the general symptoms of primary catarrhal stoma- 
 titis. In the secondary variety the general symptoms 
 depend upon, and vary with, the originating disease ; the 
 local features, however, remain the same. 
 
 The course of the disease depends upon the cause, and 
 
AFFECTIONS OF THE MOUTH AND THROAT. 6 1 
 
 the treatment adopted, though it is usually acute, rarely 
 lasting longer than a week. 
 
 Treatment. — After attending to the removal of the ex- 
 citing cause, if this be possible, the diet must be regulated. 
 To sucklings, the breast or the carefully prepared bottle, 
 alone should be allowed, and milk guarded by lime-water 
 must constitute the food of older children. If the act of 
 sucking be so painful as to cause the infant to refuse the 
 breast or bottle, it is necessary to give food, temporarily, 
 from a spoon or glass. 
 
 The mouth should be thoroughly washed, at intervals of 
 an hour while the patient is awake, with a solution of borax 
 or chlorate of potassium in rose water (gr. x to foj). After 
 taking food, particularly, the mouth ought to be cleansed 
 with cool water, and the lotion used. A little mass of 
 absorbent cotton twisted around the end of a probe, or a 
 soft rag folded around the index finger, are the best vehicles 
 for carrying the lotion. 
 
 Regular evacuation of the bowels must be secured by 
 saline laxatives. If the skin be hot and dry, liquor potassii 
 citratis, in doses of a fluidrachm every two or three hours, 
 for a child of a year old, is indicated. When the tongue 
 is heavily frosted, and the stomach disordered, recovery 
 may be much hastened by using the following prescrip- 
 tion : — 
 
 ]J . Sodii Bicarbonatis, gr.xxiv. 
 
 Pulv. Pepsinse, gr.xij. 
 
 Pulv. Aromatici, gr.iij. 
 
 M. et ft. chart. No. xij. 
 S. — One powder four times daily, administered in milk or 
 syrup, for a child between seven and twelve months old. 
 
62 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 2. APHTHOUS STOMATITIS. 
 
 This is a much more common disease than uncompli- 
 cated catarrhal stomatitis, and is most frequently met with 
 in children between the ages of six and fifteen months. 
 
 The Anatomical Lesions are hyperemia of the mucous 
 membrane of the mouth, and the formation of aphtha or 
 small, superficial, yellowish-white ulcers. 
 
 Etiology. — Any condition which reduces the general 
 strength and interferes with nutrition may exert a predis- 
 posing influence. For instance, over-crowding ; residence 
 in damp, ill-ventilated houses or rooms ; insufficient food 
 and clothing ; chronic diseases, especially of the digestive 
 tract ; scrofula and the tuberculous tendency. 
 
 The exciting agencies are, want of proper attention to the 
 cleanliness of the mouth ; foul nursing bottles ; the admin- 
 istration of sour milk, or an excess of farinaceous food, and 
 dentition. After the completion of the first dentition, an 
 indulgence in pastry or candy is often followed by an attack 
 of aphthae, and certain children always suffer after eating 
 some particular article of food, as honey, walnuts, or salted 
 fish. All of these causes are active in the production of a 
 catarrhal state of the stomach, which invariably precedes 
 and attends the disease under consideration. 
 
 The disease is not contagious, though at times a sufficient 
 number of cases occur simultaneously to constitute an 
 epidemic. 
 
 Symptoms. — For twenty-four hours prior to the ap- 
 pearance of aphthae, there is fretfulness, increased thirst 
 and poor appetite, Next, the mouth becomes hot, and a 
 few hours later the ulcers appear, without any previous 
 vesication.* The lips, swollen and vividly red, are held 
 
 * For confirmation of this statement, see Vogel, Ziemssen's Cyclopaedia, 
 Vol. vi, p. 779. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 6$ 
 
 somewhat apart, and clear saliva drops from the mouth, 
 excoriating the skin of the lower lip and chin. The oral 
 mucous membrane is red, swollen, and hot, and presents the 
 characteristic ulcers. These are usually discrete, and make 
 their appearance first on the inside of the lower lip and the 
 edges of the tongue, though they may, subsequently, ex- 
 tend to the cheeks, gums, soft palate, and even the tonsils. 
 Their number varies from one to twenty, and their size, 
 from that of a pin's point to a split pea. The ulcers, oval, 
 round, or, more rarely, linear in shape, are slightly elevated 
 above the surrounding surface, have deeply reddened edges, 
 and whitish or yellowish-white floors. They are exces- 
 sively sensitive, and thus mechanically interfere with sucking, 
 chewing, speaking, or other movement of the mouth. The 
 edges of the tongue are clean and red, while its dorsum is 
 covered with a thick, white coating. 
 
 Together with these local symptoms, there is restlessness, 
 increased pulse rate, elevated surface temperature, dryness 
 of the skin, thirst, anorexia, nausea with frequent eructa- 
 tions of acid liquid and occasional vomiting, and either con- 
 stipation or diarrhoea. The loss of appetite is due both to 
 the painful condition of the mouth and to the disordered 
 state of the stomach. 
 
 When all the ulcers appear simultaneously, the disease 
 runs its course in from four to seven days. The fibro- 
 cellular exudation covering their floors then disappears, 
 leaving the mucous membrane beneath intact but intensely 
 red, though occasionally shallow, clean ulcers are left, which 
 quickly heal. At the same time the local and constitu- 
 tional symptoms rapidly subside. If, on the contrary, the 
 ulcers develop in successive crops, as is sometimes the case, 
 the duration may be prolonged for a fortnight or more. 
 
 There is another form of aphthous stomatitis, termed 
 
64 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 confluent, in which the aphthae are very numerous, and tend 
 to run together, forming large irregular ulcers. The symp- 
 toms are proportionately severe. It occurs secondarily to 
 grave constitutional diseases — namely, measles, variola, 
 scarlet fever, diphtheria, typhoid fever, pneumonia and 
 whooping cough. 
 
 The Diagnosis of the ordinary, discrete form is unat- 
 tended with difficulty. Thrush bears the closest superficial 
 resemblance ; but in this disease the creamy-white spots are 
 slightly raised above the surface, being deposits upon the 
 mucous membrane. There are no ulcerations, the color of 
 the free membrane is rather purplish than scarlet, and 
 finally the thrush fungus is discoverable by the microscope. 
 The graver, confluent form is distinguished from ulcerative 
 stomatitis, by the absence of fetor, and by the different seat 
 and appearance of the lesions. The ulcers in the latter dis- 
 ease always beginning at the margins of the gums, extend 
 rapidly, and present grayish floors. 
 
 Aphthse is usually a mild disorder, recovery taking place 
 quickly and without difficulty. The confluent form, besides 
 running a longer course, is more difficult to cure, on account 
 of the general debility induced by the associated disease. 
 
 Treatment. — Since some disturbance of digestion is con- 
 stantly at the bottom of the local trouble, attention to the 
 feeding apparatus and to the diet is of great importance. 
 Absolute cleanliness of both bottles and tips must be insisted 
 upon, and if a complicated, patent arrangement of rubber 
 and glass tubing has been used with the bottle, it must 
 be at once discarded and a simple rubber tip substituted. 
 Regular hours for meals — the frequency varying with the 
 aere of the child — are as essential as the selection of suitable 
 food, and its administration in proper quantities. 
 
 A child of six months should be fed every three hours, 
 
AFFECTIONS OF THE MOUTH AND THROAT. 65 
 
 between 6 o'clock in the morning and 9 o'clock in the even- 
 ing. A mixture such as the following — 
 
 Sound milk, f^iv- 
 
 Cream, f^j. 
 
 Lime-water, f^ij- 
 
 Sugar of milk, ..... . one teaspoonful (gr. xl); 
 
 may be made immediately before the time of feeding ; poured 
 into an absolutely clean bottle, to which a clean tip is 
 fitted, and the whole placed in a water-bath and heated to 
 a temperature of about ioo° F. This preparation is easily 
 digested, contains enough lime-water to prevent rapid and 
 firm clotting o'f the milk, and is not so great in quan- 
 tity as to over-distend the delicate stomach and cause 
 vomiting. 
 
 Children of two years of age and over should be placed 
 on a simple diet. A breakfast, luncheon and supper of 
 stale bread and milk guarded by lime-water (one part to 
 three) and a mid-day dinner of broth and well-boiled rice. 
 
 The disease usually makes its appearance too long after 
 the causative error of diet, to be stayed by the administration 
 of an emetic. If, however, an overloaded stomach be indi- 
 cated by fever, restlessness, and epigastric pain and disten- 
 sion, a dose of the wine or syrup of ipecacuanha* should be 
 given. If the bowels be constipated a gentle laxative is 
 required. Probably the best is calomel ; for a child from 
 six to twelve months old a powder containing half a grain 
 of the mercurial and five grains of sugar may be placed dry 
 upon the tongue in the evening, to be followed next morn- 
 ing by a small teaspoonful of magnesia in milk or lemon- 
 ade. If, on the contrary, there be diarrhoea, the bowels 
 should be first cleared of irritating materials by a teaspoon- 
 
 * For a child of one year old the emetic dose of wine of ipecacuanha is fifteen 
 drops, of the syrup half a teaspoonful, repeated if necessary. 
 
 5 
 
66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 ful of castor oil, into which five drops of paregoric have 
 been dropped, and the following prescription given : — 
 
 R . Sodii Bicarbonatis, gr.xxiv. 
 
 Syr. Rhei Aromatici, 
 
 Syrupi, aa f^ss. 
 
 Aq. Menthse Piperita? q. s. ad f^iij. 
 
 M. 
 S. — A teaspoonful every three hours. 
 
 The fever, when very moderate in degree, requires only a 
 plentiful supply of cool water to drink, and a hot mustard 
 bath in the evening. The strength of the latter should 
 be one teaspoonful of strong mustard to as much water 
 as will cover the child's legs and hips when in a sitting 
 posture. The duration of the bath should be from five to 
 ten minutes. If the skin be quite hot and dry, a saline 
 diaphoretic is necessary. The best is liquor potassii ci- 
 tratis, in doses of one teaspoonful every two hours. Some- 
 times it is well to add one-quarter of a drop of tincture of 
 aconite to each dose of the potash solution. 
 
 Locally, the best results will be obtained by lightly 
 touching each ulcer with a point of lunar caustic. This 
 causes considerable suffering at the moment of application, 
 but is followed by lessening of the pain and rapid healing. 
 In ordinary cases one such application suffices, in severe, it 
 is necessary to repeat it daily for a week or more. In addi- 
 tion the mouth must be washed thoroughly and frequently, 
 particularly after food is taken, with cool water, or with a 
 solution of chlorate of potassium, as: — 
 
 &. Potassii Chioratis, gr. xx. 
 
 Vini Opii, TT\v. 
 
 Glycerinae, f^j. 
 
 Aquas Rosas, q. s. ad f^j. 
 
 M. 
 
 After the fever has subsided, a digestant will be required 
 
AFFECTIONS OF THE MOUTH AND THROAT. 6j 
 
 for a few days. Thus, half a teaspoonful of wine of pepsin 
 three times daily may be ordered ; or, if there be acidity 
 with a coated tongue, the powder recommended, under the 
 same circumstances, in catarrhal stomatitis. 
 
 The local treatment must be persevered in, until the ulcers 
 have healed and the mucous membrane has returned to its 
 normal condition. 
 
 3. ULCERATIVE STOMATITIS. 
 
 This affection of the mouth is quite common in child- 
 hood. It is usually seen in children between three and eight 
 years of age ; is never met with before the commencement 
 of dentition, and is not contagious, though it sometimes 
 occurs in almost epidemic profusion. 
 
 The Anatomical Lesions consist of parenchymatous 
 inflammation of the gums, and often of the tongue and 
 cheeks, with ulcerative destruction of the mucous mem- 
 brane. Microscopical examination of the floors of the 
 ulcers, reveals pus corpuscles, isolated blood corpuscles, and 
 granulated cells, imbedded in an amorphous, finely granular 
 mass which is filled with bacteria and micrococci. There is 
 no trace of pseudo-membrane. 
 
 Etiology. — As the disease is not contagious there is prob- 
 ably no specific epidemic influence in its causation. When 
 groups of cases, large enough to be classified as epidemics, 
 do occur, they are generally limited to single houses or 
 institutions, and may be traced to bad hygienic surround- 
 ings affecting alike all the inmates. Insufficient or bad 
 food and residence in unhealthy, cold, damp, ill-ventilated 
 houses constitute one set of causes. 
 
 Again, ulcerative stomatitis is very apt to follow in the 
 
68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 wake of typhoid fever, scarlatina, measles, variola and dys- 
 entery, and since each of these primary diseases usually 
 occurs as an epidemic, a similar tendency in the sequel is 
 readily explained. 
 
 A certain amount of reduction of the constitutional vigor 
 seems to be an essential precedent to the development of 
 the disease. Sickly, rickety and scrofulous children are 
 susceptible subjects, and when the gums are loose, soft and 
 hypersemic they are more readily affected than when firm 
 and closely applied around the teeth. 
 
 The presence of decaying teeth, want of cleanliness of the 
 mouth, and the careless administration of such medicines 
 as mercury, lead and phosphorus, are exciting causes. 
 
 Symptoms. — At first there is a sense of heat and pain in 
 the mouth, and the breath grows offensive in odor. Next 
 the gingival mucous membrane, immediately about and be- 
 tween the teeth, becomes red and swollen. The swelling 
 rapidly increases, the points of the gum between the teeth 
 standing out like flasks, and the whole margin becoming so 
 soft and tender that it bleeds upon the lightest touch. In 
 the course of twenty-four hours the edge of the gum, where 
 it touches the teeth, changes from a bright red to a yel- 
 low or yellowish-gray color, and softens, breaking down 
 into ulcers. 
 
 Ulceration generally commences on the external surface 
 of the lower gum, and in the beginning appears as a more 
 or less extended, narrow and indented gray band, follow- 
 ing the line of the teeth. Later it may appear on the outer 
 surface of the upper gum ; on the internal surface of both 
 the lower and upper gums ; on the edges of the tongue, 
 at points where the organ presses against the teeth ; and 
 finally on the cheeks. In the latter position it often hap- 
 pens that the ulceration corresponds exactly with that of 
 
AFFECTIONS OF THE MOUTH AND THROAT. 69 
 
 one or both gingival borders, forming a single or double 
 strip running parallel with the jaws. 
 
 The ulcers are depressed, have a ragged, dirty gray or 
 brownish floor, and intensely red, swollen edges. The un- 
 involved mucous membrane shows the characters of catar- 
 rhal stomatitis. 
 
 When the disease is fully developed, the lips are tumid 
 and red. They are held apart, and a stream of yellowish, 
 sometimes bloody, always ill-smelling, acid and viscid saliva, 
 constantly drips away, excoriating the skin over which it 
 flows. If the mouth be kept closed, as it sometimes is, half 
 an ounce or more of this fetid fluid gushes out whenever 
 the lips are parted in speaking or in taking food. The sub- 
 maxillary glands and the lymph glands of the neck are 
 moderately enlarged, and there is often oedema of the face, 
 limited or general, according to the extent of the ulceration. 
 
 The mouth is the seat of constant burning and pain ; is 
 hot and tender to the touch, and chewing causes great suf- 
 fering. Between and upon the teeth there is a deposit of yel- 
 low unctuous material. The tongue, in addition to present- 
 ing the marginal ulcers, is swollen and heavily coated with a 
 dirty, yellowish-white fur. The speech is thick ; the breath 
 has a characteristic heavy odor; there is loss of appetite, due 
 principally to the pain produced by chewing and the contact 
 of food with the ulcerated mucous membrane ; thirst is mode- 
 rately increased ; and the bowels are normal, or inclined to 
 constipation. The little sufferer is restless and sleeps badly. 
 The pulse is feeble, and there are other evidences of general 
 debility, but there is little febrile reaction, the temperature 
 even in well marked cases, rarely reaching a higher marking 
 than 99.5 ° F. in the evening. 
 
 In severe and protracted attacks, the ulcers increase in 
 breadth and depth, become covered with a gray or brownish 
 
JO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 pulp, and the teeth, deprived of the support of the gum, 
 grow loose and are easily removed from the alveoli. Some- 
 times the periosteum of the jaw is destroyed, and more or 
 less extensive necrosis results. Exceptionally, in very weak 
 and badly nourished children, the stomatitis runs into actual 
 gangrene or noma. 
 
 The symptoms, ordinarily, reach their height in from two 
 to four days, and, under proper treatment, disappear in as 
 many more, the ulcers cleaning off and healing without 
 cicatrization. Severe, or badly managed cases go from bad 
 to worse for a time, and rarely recover under three or four 
 weeks, during which the suffering is extreme. Those in- 
 volving necrosis of the jaw, and those terminating in noma, 
 run a still more protracted course. 
 
 Diagnosis. — The appearances of the gums before ulcera- 
 tion, the position in which this process begins, the character 
 of the individual ulcers, and the odor of the breath, furnish 
 a train of symptoms distinguishing ulcerative stomatitis from 
 any other affection of the mouth. 
 
 The Prognosis, in the vast majority of instances, is most 
 favorable. When necrosis of the jaw occurs the duration is 
 greatly prolonged, but ultimate recovery is the rule. In- 
 tercurrent noma, on the contrary, often leads to the death of 
 the child, and under the best of circumstances leaves its 
 traces in permanent deformity of the face. 
 
 Treatment. — The first step is to improve the sanitary 
 surroundings of the patient, or, if this be impossible, to 
 remove him to healthy quarters. The importance of clean- 
 liness, fresh air, and sunlight, are not to be lightly estimated. 
 
 The diet should be liquid, but nutritious. Apart from the 
 fact that solid food will be refused on account of the pain 
 entailed in its mastication, milk and animal broths are better 
 suited to the somewhat enfeebled digestive powers, and 
 
AFFECTIONS OF THE MOUTH AND THROAT. J\ 
 
 should be relied upon entirely. Cool water ought to be 
 allowed in sufficient quantities to satisfy the thirst. 
 
 Of drugs, chlorate of potassium is the most important, 
 since it ranks almost as a specific for this disease. It may 
 be given alone, simply dissolved in water, or combined with 
 dilute muriatic acid, as in this prescription : — 
 
 R. Potassii Chloratis, . • gr.xlviij. 
 
 Acidi Muiiatici dil., f,5J. 
 
 Syrupi, fj> ss « 
 
 Aquas, q. s. adf^iij. 
 
 M. 
 S. — One teaspoonful, diluted, every two hours, for a 
 
 child three years old. 
 
 In this combination, the chlorate of potassium being 
 eliminated by the salivary glands, constantly comes in con- 
 tact with, and acts as an alterative upon, the ulcers. The 
 muriatic acid aids digestion, and acts as a tonic. If a more 
 decided tonic effect be required, one-quarter to one- half of 
 a grain of sulphate of quinia may be added to each dose. 
 
 Chlorate of potassium, too, constitutes the main element 
 of the local treatment. Its action is somewhat improved 
 by the addition of carbolic acid, as in the following wash : — 
 
 R . Potassii Chloratis, gr.lxxx. 
 
 Acidi Carbolici, g r -i> 
 
 Glycerinee., f^j. 
 
 Aqua?, q. s. adf^viij. 
 
 M. 
 
 A bit of absorbent cotton saturated with this wash should 
 be thoroughly applied to all the ulcers at least once in every 
 hour ; or, at the same intervals, the child may take a quantity 
 into the mouth, move the cheeks and tongue in such a way 
 as to bring it in contact with the whole mucous surface, 
 and then expel it. 
 
J2 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 After the ulcers have healed, the specific treatment 
 may be discontinued, and the patient placed upon a simple 
 tonic, as ferrated elixir of cinchona, in doses of half a flui- 
 drachm three times daily, until the health is perfectly 
 restored. 
 
 As additions to this treatment, iron and stimulants will 
 be required in severe and protracted cases. The tincture of 
 the chloride is the best form of iron. It should be given in 
 doses of three drops (n\,iss) every two hours for a child three 
 years old, and may be combined very well with the mixture 
 of potash, acid and quinine. The best stimulant is whiskey, 
 in doses of one-half to one teaspoonful, in milk or water, 
 every three or four hours. Indolent ulcers may be stimulated 
 to heal by touching them lightly with a solid stick of 
 nitrate of silver. Loosened teeth must always be allowed 
 to remain in position, as they often become firm again after 
 the termination of the disease. 
 
 When necrosis occurs, no change is necessary in the 
 general plan of treatment. Especial attention, however, must 
 be paid to the cleanliness of the mouth, and poultices of 
 flaxseed meal should be kept constantly applied to the cheek 
 of the affected side. Surgical interference may become 
 necessary. 
 
 4. GANGRENOUS STOMATITIS— NOMA. 
 
 This affection consists of a rapid gangrenous destruction 
 of the cheek and adjacent parts, occasionally beginning on 
 the lips, but usually near one corner of the mouth. It is 
 generally asymmetrical, the left cheek being attacked in the 
 majority of instances, but sometimes both cheeks are sim- 
 ultaneously involved. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 73 
 
 Etiology. — Noma is, fortunately, an uncommon disease. 
 Sucklings seem to be exempt from it, and most of the cases 
 occur between the ages of two and twelve years. Girls 
 are more liable to be attacked than boys. It is always of 
 secondary origin, following severe maladies, such as measles, 
 typhoid fever, gastro-intestinal catarrh, ulcerative stomatitis, 
 scarlet fever, smallpox, broncho-pneumonia, tuberculosis, 
 protracted intermittent fever and whooping cough. This 
 order also represents the etiological activity of the diseases 
 mentioned. These, then, may be looked upon as predis- 
 posing causes, but despite the presence of any one of them, 
 noma only occurs in those children who have been pre- 
 viously weak, ill-housed and ill-nourished. 
 
 There is no evidence to show that it is contagious, though 
 it sometimes occurs as an endemic in overcrowded hospital 
 wards and children's homes. These endemics may be ex- 
 plained in the same way as similar outbreaks of ulcerative 
 stomatitis. 
 
 Symptoms. — During convalescence from measles, or other 
 of the diseases mentioned, a nodule, from a quarter to half 
 an inch in diameter, appears spontaneously upon the child's 
 cheek, in the neighborhood of the corner of the mouth. 
 This can be easily detected from the outside, but it is 
 best felt by opening the mouth and grasping the cheek 
 between the thumb and forefinger. It is extremely hard, 
 and very sensitive, especially at the periphery. If the case be 
 seen during the first few hours, the mucous membrane over 
 the mass will be observed to be converted into a flat, ichorous 
 bulla. Usually, however, this membrane is found hanging 
 in ragged shreds from a black, gangrenous base. The skin 
 over the induration is pale or mottled with purple spots, 
 tense, and shiny as if oiled. 
 
 After twenty-four hours, the investing integument becomes 
 
74 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 bluish, the epidermis scales off, and a black eschar forms. 
 This has a tendency to shrink, and in so doing, leaves a 
 linear depression filled with ichor, which separates it from 
 the healthy skin. Notwithstanding this line of demarcation, 
 the tissue destruction rapidly extends, both in superficial 
 area and depth. Soon the cheek is perforated, and a dirty, 
 stinking, ichorous saliva, filled with shreds of broken- 
 down tissue, flows out beside the eschar and over the 
 cheek. At the same time the lips, chin, and uninvolved 
 portions of the cheek become cedematous, the skin being 
 tight and glistening, and the adjacent cervical glands en- 
 larged. 
 
 At the very outset there are few constitutional symptoms. 
 The child complains of little or no pain, persists in his 
 amusements, has a good appetite, a temperature but slightly 
 above the normal, and a pulse but moderately increased in 
 frequency. As the eschar forms, the scene changes, symp- 
 toms of constitutional depression setting in. The face is 
 pale and expressionless on the affected side, the skin cool 
 and dry, the pulse feeble and frequent — sometimes counting 
 1 20 or 140 beats per minute — and there is oedema of the 
 feet. The mind is apathetic, no complaints of pain are 
 made, and at most a sense of discomfort is indicated by con- 
 stant whimpering. The mouth is held partly open, the 
 breath is fetid, the teeth and tongue are covered with 
 sordes, and there is an abundant flow of bloody or dark- 
 colored saliva. Severe hemorrhage never occurs, as the 
 blood vessels are closed at an early stage. The appetite is 
 often retained, the thirst is intense, and the bowels are usu- 
 ally relaxed. In spite of the food taken, the strength 
 rapidly declines, sometimes, though, it is wonderfully re- 
 tained, the patient being able to sit up, and even leave his 
 bed, until a few hours prior to death. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 75 
 
 The air of the sick-room has a characteristic gangrenous 
 odor. 
 
 Perforation of the cheek occurs about the third day of the 
 disease, and many cases die at this time. Others linger 
 until the end of the first or second week. Under these cir- 
 cumstances the gangrene invades the lips as far as the 
 median line, the corresponding ala of the nose, and the 
 cheek as far as the lower eyelids, the tragus, and the infe- 
 rior border of the lower jaw. Extending inward, the gums 
 and periosteum of the jaws are destroyed ; the bone becomes 
 necrotic, and the teeth so loose that they can be readily 
 pushed out by the finger, together with pieces of the alveoli. 
 Finally the cheek is cast off in large, black sloughs, leaving 
 huge openings, with black, ragged, and indurated edges, 
 through which the blackened and necrosed bones and 
 loosened teeth can be seen. The child's face is then 
 unrecognizable ; the symptoms of constitutional depression 
 are greatly intensified ; there is delirium, profuse diarrhoea, 
 purulent and even gangrenous infiltration of the lungs, 
 and occasionally, also, gangrene of the genitalia, in females. 
 Death is the only result to be expected. 
 
 Exceptional cases do recover. In these, the gangrenous 
 edges become clean and covered with granulations, the 
 necrosed bone is thrown off, and after months, cicatrization 
 takes place, with great disfigurement. 
 
 Pathology and Morbid Anatomy. — The fact that noma 
 makes its appearance uniformly at one point, on the cheek, 
 and is unilateral, suggests a localized, causative lesion. 
 The most natural theory, that of embolism of a large arte- 
 rial branch, due to weakness of the cardiac muscle or in- 
 creased coagulability of the blood — effects of the primary 
 disease — is untenable, because, with the given conditions, 
 emboli ought, at least occasionally, to be found in other 
 
y6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 positions, which does not happen. It is necessary to look 
 rather to the nerves ; namely, the trifacial, the facial, or the 
 vaso-motors. That the gangrene is due to a lesion of one 
 of these, seems to be borne out by experiments. Thus, 
 Magendie found that division of the trifacial in dogs caused 
 destruction of the corresponding eyeball, and half of the 
 tongue became dry, brown and fissured, the gums spongy 
 and hemorrhagic, and the teeth loose. " In animals tena- 
 cious of life, the batrachians, for example, the soft portions 
 of the face are cast off in shreds, just as in spontaneous 
 gangrene. After three or four weeks only one-half of the 
 face remains." * 
 
 The body of a child dead from noma has a gangrenous 
 odor and decomposes quickly; the skin is shriveled, and the 
 face and the feet are cedematous. The gangrenous parts 
 are converted into a blackish-brown mass, and the maxil- 
 lary bones are naked, brownish in color and brittle. The 
 nerves, when examined microscopically, are yellowish in 
 color but unaltered in structure, and the blood vessels are 
 thickened and filled with thrombi. In the uninvolved parts 
 of the cheek there is a dense exudation, while the palate, 
 tongue and tonsils are swollen and covered with black scales 
 and crusts. The lungs are the seat of hemorrhagic infarc- 
 tions, lobular or metastatic lobar pneumonia, and sometimes 
 gangrene. The intestines are catarrhal. Evidences of the 
 primary disease may also be present; for example, the 
 lesions of typhoid fever or dysentery. 
 
 Diagnosis. — Noma is readily distinguished from other 
 oral affections by its course, its peculiar and almost uni- 
 formly identical seat and its well marked local features. 
 
 Ulcerative stomatitis is the only other of the class at all 
 likely to be confounded with it. This always begins with 
 * Vogel, Ziemssen's Cyclopaedia, Vol. vi, p. 812. 
 
AFFECTIONS OF THE MOUTH AND THROAT. JJ 
 
 ulceration of the gingival margin, and when the cheek 
 becomes involved, the ulcers situated there are linear in 
 shape and have a grayish floor. There is no sloughing or 
 gangrene of the mucous membrane. The cheek never 
 presents a circumscribed induration, being at most simply 
 cedematous. The skin shows no tension, unctuous appear- 
 ance or discoloration, and perforation of the soft parts never 
 occurs. The breath is fetid but not gangrenous ; salivation 
 is less, and the saliva, though sometimes bloody, is not mixed 
 with shreds of gangrenous tissue. The course is much less 
 rapid, and the ulcers, while they extend in area, retain the 
 same appearances throughout. Finally, the general symp- 
 toms are distinctive, the results of treatment are most satis- 
 factory, and a fatal termination is extremely uncommon. 
 
 Malignant pustule closely resembles noma. The former, 
 however, always begins on the exterior, involving the epi- 
 dermis first and extending through the successive layers of 
 skin to the deep structures. 
 
 The Prognosis is most unfavorable. Vogel sets the 
 mortality at 80 to 90 per cent,* and out of one hundred and 
 two cases that came under the observation of Steiner,f only 
 four recovered. Death may occur at any time between the 
 third and fourteenth day; a rapid course, however, is very 
 much more frequent than the reverse. Even when recovery 
 does take place, the patient is permanently disfigured by 
 scars, or crippled by the development of ectropion, or of re- 
 stricted movement of the jaw, in consequence of cicatricial 
 contraction, or by the loss of teeth and portions of the max- 
 illary bones. Such cases also drag through a very pro- 
 tracted convalescence. 
 
 Treatment is most unsatisfactory. Something can be 
 
 * Ziemssen's Cyclopaedia, Vol. vi, p. 814. 
 I Diseases of Children, p. 218. 
 
yS DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 done in the way of prophylaxis, by a proper management 
 of the known predisposing diseases. Secure sound hygiene 
 in the sick-room ; give good nourishment, and avoid the 
 abuse of mercurials and debilitating treatment generally. 
 
 If, notwithstanding these precautions, noma appears, it is 
 of the first consequence to maintain the strength by the use 
 of concentrated liquid food, tonics and stimulants. When 
 perforation of the cheek takes place, the act of swallowing 
 is mechanically interfered with. It is necessary then to 
 resort to nutritious enemata, suppositories of quinia, and 
 even the rectal administration of stimulants. 
 
 The room in which the treatment is conducted must be 
 large, airy, and so situated as to be exposed, for a part of 
 the day, at least, to the sun's rays. In summer the win- 
 dows should be kept constantly open, and in winter they 
 must be raised for at least fifteen minutes several times 
 daily, the patient being warmly covered in the meantime. 
 The air of the chamber must also be kept as pure as pos- 
 sible by the use of disinfectants. For this purpose cloths 
 saturated with a solution of chlorinated soda or with Piatt's 
 Chlorides, may be hung about the bed. 
 
 Early cauterization with the hot iron, with strong sul- 
 phuric or muriatic acid, or the solid stick of nitrate of silver, 
 is recommended. All sloughs must be removed by scissors. 
 The gangrenous spot should be frequently bathed with a 
 strong solution of chlorate or permanganate of potassium, 
 carbolic acid, or chlorinated lime. Pieces of lint soaked in 
 one- of these solutions, may, with advantage, be left in con- 
 tact with the ulcer, if the child will tolerate a fixed dressing. 
 In case of perforation, much of the wash will run into the 
 mouth, and care must be taken to prevent its being swal- 
 lowed. The mouth must be kept as clean as possible by 
 repeated syringings with a solution of chlorate of potassium 
 
AFFECTIONS OF THE MOUTH AND THROAT. 79 
 
 and carbolic acid, ten grains of the former and one grain of 
 the latter to the fluidounce. 
 
 When recovery occurs, loss of tissue, and the deformities 
 resulting from cicatricial contraction, may be, to some ex- 
 tent, remedied by plastic surgery. 
 
 5. PARASITIC STOMATITIS— THRUSH. 
 
 Thrush is characterized by the appearance of numerous, 
 rapidly-growing, white, curd-like flakes upon the oral mu- 
 cous membrane ; the latter being in a more or less catarrhal 
 condition, injected, swollen, hot and tender to the touch. 
 The flakes are due to the development of a peculiar vege- 
 table parasite, the O'idium Albicans. Thrush occurs both 
 as a primary and a secondary affection. 
 
 Etiology. — The disease attacks sucklings, and is met 
 with most frequently during the first three months of life. 
 Children nursed at a healthy breast are never attacked, and 
 rarely those belonging to the well-to-do classes, because of 
 the attention given to cleanliness of the mouth and feeding 
 apparatus. 
 
 Neglect of this fundamental principle, cleanliness, lies at 
 the foundation of every case of primary thrush. Foulness 
 of the mouth implies a condition in which the secretions 
 and the food clinging to the mucous membrane are under- 
 going acid fermentation, a necessary precedent to the de- 
 velopment of the fungus. Given this condition, thrush 
 originates by contact with other cases, through the media 
 of bottle tips, spoons, tumblers, or cups used in common, 
 and is produced, de novo, by carelessly kept tips and bottles, 
 and, more frequently still, by long nursing tubes which are 
 always partially clogged, acid and ill smelling. 
 
80 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 The secondary form has the same direct causes, but arises 
 during the course of gastro-intestinal disorders, especially 
 those resulting from a too free dietary or the over-use of 
 farinaceous food. It may occur, also, as a complication 
 of diseases that greatly impair the general nutrition, as 
 the exanthemata, tuberculosis, scrofula, spinal caries, etc. 
 The disease is most prevalent during the summer months. 
 
 The Morbid Appearances are the same in both forms. 
 Prior to the appearance of the flakes, the oral mucous 
 membrane is purplish-red and sticky, and its secretion is 
 acid in reaction. The latter shows, under the microscope, 
 numerous spores, egg-shaped, sharply-outlined, and hanging 
 together in twos and threes. Soon, isolated white points, as 
 large as a pin's head, appear on the inside of the cheeks. 
 These rapidly increase in extent and number; involve other 
 parts of the mucous membrane, and often as early as the 
 second or third day, large, white flakes are formed. Later 
 still, the whole cavity of the mouth; and, in some cases, even 
 the pharynx and oesophagus are covered. 
 
 The patches, at first white, may become yellow, and some- 
 times brown, if bleeding occur from rough handling of the 
 mucous membrane. Their surface is somewhat velvety, and 
 they are soft, breaking down like curd under the finger. 
 During the first few days they adhere firmly to the mucous 
 membrane ; afterwards they become quite loose, and can be 
 wiped off readily, leaving the epithelial surface intact. 
 
 Microscopic examination of the fully formed patches 
 reveals numerous irregularly developed fungoid fibres, with 
 laterally branching arms and buds, interspersed with round 
 or oval sporules, and imbedded in an amorphous, granular 
 mass. A hardened section of a patch and mucous mem- 
 brane to which it adheres, shows, in addition to these char- 
 acters, a partial loss of epithelium, and a tendency on the 
 
AFFECTIONS OF THE MOUTH AND THROAT. 8 1 
 
 part of the filaments to penetrate into the mucous glands 
 and between the cells to the deeper layers of the epithelium. 
 
 The fungus seems to grow only upon squamous epithe- 
 lium, so that it is never found in the nasal cavities, the la- 
 rynx or the trachea, and the presence of loose masses of it 
 in the stomach may be regarded as accidental. On the other 
 hand it may be formed upon the lower segment of the rec- 
 tum, the female genitals, and on abraded surfaces about the 
 mouth, chin and neck. 
 
 Symptoms. — The primary form begins with heat, dryness, 
 tenderness, slight swelling and uniform redness of the 
 mucous membrane of the mouth. The redness is combined 
 with a purple tinge which is most marked on the dorsum of 
 the tongue. Here, too, prominence of the fungiform pa- 
 pillae is noticeable. The child takes his food moderately 
 well, but the meals are frequently interrupted on account 
 of the pain caused by sucking. He is fretful and sleeps 
 poorly. The bowels are moderately relaxed, the stools 
 being liquid and yellow in color. In the course of twenty- 
 four hours the thrush patches appear on the inside of the 
 cheeks and then extend to the lips, tongue and palate. While 
 extending, they increase in size, though they usually remain 
 isolated and rarely overstep the limit of the posterior border 
 of the soft palate. With the appearances of the patches, 
 there is increased fretfulness, more pain on sucking, occa- 
 sional vomiting and frequent evacuation of the bowels, the 
 motions becoming green and acid. At some period, varying 
 from six to twelve days from the beginning of the disease, 
 the patches become loose and are removed by the act of 
 sucking or in making applications to the mouth. The mu- 
 cous membrane is left red but free from ulceration, and it 
 soon returns to the normal condition. At the same time 
 the general symptoms subside, and health is soon restored. 
 6 
 
82 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Sometimes there are several crops of the fungus, but those 
 coming last, being less firmly rooted than the first, are dis- 
 lodged quickly and seldom prolong the course of the disease 
 beyond two or three days. 
 
 In secondary thrush a history of previous gastrointes- 
 tinal or other disease will be obtained, together with an ac- 
 count of an immediately preceding diarrhoea and fever. 
 Sometimes, however, the local symptoms are the first indica- 
 tions that the weak, badly-nourished child is ill. The pre- 
 liminary catarrh of the mouth is very marked, the mucous 
 membrane being intensely red and shining. The patches 
 are thick, are apt to change from a white to a yellow or 
 brown color, soon cover the whole oral cavity and frequently 
 extend into the pharynx and down the oesophagus. They 
 retain their attachment to the mucous membrane for a much 
 longer period than in the idiopathic form. When they fall 
 off they are quickly replaced by others, and a succession of 
 crops is the rule up to the termination of the case in death. 
 The mouth is hot, dry and tender to the touch, and through- 
 out presents an acid reaction to chemical tests. 
 
 The appetite is gradually lost ; there is vomiting, either 
 occasional or so constant that every morsel of food taken 
 into the stomach is rejected at once, and obstinate diar- 
 rhoea, the stools being numerous, liquid, green in color 
 and acid. The abdomen is distended by flatus, and is ten- 
 der to pressure, particularly in the epigastrium and right 
 iliac region. Colic is a constant and annoying symptom. 
 The pain is most severe just before or at the moment of an 
 evacuation of the bowels. 
 
 The skin is hot and dry and the frequency of the pulse 
 increased, a rate of 120, 140 or 160 per minute being not 
 unusual. 
 
 The child sleeps badly, is restless and fretful, and when 
 
AFFECTIONS OF THE MOUTH AND THROAT. 83 
 
 the pharynx is covered by the fungus, has a muffled, hoarse 
 cry. The skin grows pale and inelastic, and the folds of the 
 nates, the inner surface of the thighs and the heels are red- 
 dened, and eventually excoriated by the contact of the acid 
 faeces. The strength and flesh are lost rapidly, the anterior 
 fontanelle sinks, the eyeballs lie deep in their sockets 
 and the nose and chin are pointed. Toward the latter end 
 of the attack, which is rarely protracted more than a few 
 weeks, the patient assumes the facies of a little, wrinkled old 
 man. His skin is cool, and he lies in an apathetic condition 
 on the bed or nurse's lap, with scarcely enough strength to 
 whine over his suffering until death, from atrophy, ends the 
 miserable life. 
 
 Diagnosis. — Fragments of curdled milk adhering to the 
 soft palate and cheeks, resemble very closely the thrush 
 patches in their earlier stage. The normal condition of the 
 mucous membrane, and the readiness with which the curds 
 can be wiped away, constitute the distinctive characteristics. 
 
 Aphthous stomatitis bears a certain superficial likeness to 
 thrush, but the differentiation is easily made by noting the 
 fact that the yellowish-white spots of the former are de- 
 pressed below the surface of the mucous membrane, being, 
 in reality, the floors of ulcers, which in time are bounded 
 by dark red borders. 
 
 Microscopic examination is always the crucial test, and 
 the presence or absence of thallus-fibrils and spores decides 
 the question as to the nature of any deposit in the mouth. 
 
 Prognosis. — The primary form is a very trifling affection 
 and almost uniformly ends in recovery. In the secondary 
 form the result is very often unfavorable. This is especially 
 apt to be the case when the disease occurs in a child who 
 has been much weakened by a continued course of improper 
 food. Here, the hope of improvement depends upon the 
 
84 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 rapidity and completeness with which new material for 
 nutrition can be introduced into the system. Anything, 
 therefore, that tends to prevent this introduction deprives 
 the child of his only chance of recovery, and the existence 
 of thrush implies a condition of the digestive tract extremely 
 unfavorable to the assimilation of food. Attendant diar- 
 rhoea aids, too, in precipitating the fatal result. 
 
 The mere presence, then, of the thrush patches is not to 
 be regarded with as much anxiety as the conditions ac- 
 companying their formation. 
 
 Treatment. — Much may be done to prevent the develop- 
 ment of thrush by keeping the mouth clean. A strict rule 
 should be made to wash out a child's mouth directly after 
 each meal. This is best done by a large camel's-hair brush 
 or a soft rag moistened with warm water. The bottles and 
 tips must also be kept immaculately clean. An equally im- 
 portant precaution is to select a proper diet. The question 
 of diet is, of course, a very comprehensive one, and no 
 further consideration can be given it in this place than to 
 state the general law. Babies under six months old, who 
 are unfortunate enough to be deprived of their mother's 
 milk, must be fed upon cows' milk so prepared that it may 
 resemble as nearly as possible human milk. If farinaceous 
 articles be used they must be employed with the object of 
 rendering it more digestible by separating the curd, and not 
 as the staple of the food. The regularity and the length of 
 the intervals between meals ; the selection of the proper 
 quantity of food, and the preparation of each portion im- 
 mediately before it is given, are matters worthy of the most 
 careful attention. * 
 
 Such measures, together with attention to general hy- 
 giene, constitute an important part of the curative treat- 
 
 * See Part III. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 85 
 
 ment after the appearance of the fungus. In idiopathic or 
 mild cases all that is required in the way of general treat- 
 ment will be an alkali combined with a digestant, as in the 
 formula already given for catarrhal and aphthous stoma- 
 titis,* or if the stools be numerous, green and very acid: — 
 
 R. Magnesii Carbonatis, gj. 
 
 Syr. Rhei Aromatici, f 3 ij. 
 
 Syrupi, f J ss. 
 
 Aq. Mentha? Piperita;, q. s. ad f ijiij. 
 
 M. 
 S. — Teaspoonful every two or three hours, for a child three 
 to six months old. 
 
 The local treatment consists in keeping the mouth per- 
 fectly clean. It should be thoroughly washed every hour 
 at least, with a soft rag wrapped around the finger and wet 
 with warm water. Immediately afterward, either one of 
 the following lotions may be applied, upon a fresh piece of 
 rag:— 
 
 R. Sodii Boratis, gr. xxx. 
 
 Glycerinae, fgj. 
 
 Aquae, q. s. ad f ^j. 
 
 M. 
 
 R . Sodii Hyposulphitis, gr. x. 
 
 Aquae Rosa;, fljj. 
 
 M. 
 
 It is essential immediately to destroy the rag or other in- 
 strument used in cleansing the mouth or in carrying the 
 lotion. 
 
 The same principles are applicable to the treatment of 
 secondary thrush. Every means must be employed to 
 arrest the vomiting and diarrhoea, to improve the digestive 
 powers and maintain the strength. There is, however, but 
 one promising remedy for this form of the disease, namely, 
 the employment of a healthy wet nurse. 
 
 * See page 61. 
 
86 
 
 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 6. DENTITION. 
 
 The eruption of the twenty milk teeth may, like other 
 physiological processes, be unattended by noticeable symp- 
 toms, but in many instances it is accomplished with difficulty, 
 giving rise to disturbances which, on the one hand, may be 
 so trifling as simply to annoy the infant, or on the other, so 
 serious as to endanger life. 
 
 Normally the teeth are cut in groups, each effort being 
 succeeded by a pause or period of rest. The following 
 diagram and table show the grouping, the date of eruption, 
 and the duration of the pauses. The numbers, I to 5, in- 
 dicating the groups to which the individual teeth belong 
 and their order of appearance, and the letters, a and b> the 
 precedence of eruption in the different groups. 
 
 Fig. i. — Diagram showing Eruption of Milk Teeth. 
 
 1. 1. Between the 4th and 7th months. Pause of 3 to 9 weeks. 
 
 2. 2. 2. 2. Between the 8th and 10th months. Pause of 6 to 12 weeks. 
 
 3- 3- 3- 3- 3- 3- Between the 12th and 15th months. Pause until the 18th 
 month. 
 
 4. 4. 4. 4. Between the 18th and 24th months. Pause of 2 to 3 months. 
 
 5. 5. 5. 5. Between the 20th and 30th months. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 87 
 
 The pauses are, to say the least, most helpful, giving the 
 infant's system an opportunity to rest after each effort, to 
 recover from any coincident illness and to prepare for the 
 next strain. 
 
 Even under normal conditions the edges of the gums 
 lose their sharpness and become swollen, rounded and red- 
 dened as the teeth approach the surface At the same 
 time the saliva is increased in quantity, and the mouth 
 is unnaturally warm and the seat of abnormal sensations, 
 evidenced by the tendency to bite upon any object that 
 comes to hand — in other words, there is a condition of mild 
 catarrhal stomatitis. The consequent discomfort, though, 
 is not sufficient to interfere with the child's appetite, good 
 humor, or sleep, and when, after a few days, the margin of 
 the tooth is free, all the local symptoms vanish. 
 
 Abnormal dentition is manifested either by departures 
 from the laws of development already stated, or by actual 
 difficulty in the process of cutting. 
 
 The standard rules for the eruption of the teeth may be 
 departed from in three ways : — 
 
 1st. The appearance of the teeth may be premature. 
 Children may be born with one or more of their teeth 
 already cut. These are usually imperfect, and soon fall out, 
 to be replaced at the proper age by well-formed milk teeth. 
 Sometimes, however, they remain permanently, as in a case 
 that came under my own observation. Natal teeth are 
 always incisors. Instances of the lower central incisors 
 being cut in the third month are not uncommon. Girls are 
 more apt than boys to cut their teeth early, and, as an early 
 dentition is likely to be an easy one, the occurrence is to 
 be looked upon as fortunate. 
 
 2d. Dentition may be delayed. This deviation is more 
 frequently seen and of more consequence than the first. 
 
88 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Bottle-fed babies, as a class, are more tardy in cutting their 
 teeth than those reared at the breast. With such, though 
 healthy in every respect, a delay of one or two months is a 
 common and not at all a serious event. On the contrary, 
 whatever the method of feeding, if no teeth have appeared 
 by the end of a year, it may be assumed that the child's 
 general nutrition is faulty, or that rachitis is present. Delay 
 does not necessarily imply difficulty in cutting the teeth, 
 though the two conditions are often associated. 
 
 3d. The teeth may appear out of their regular order. 
 Bottle-fed infants are most likely to show this irregularity, 
 which is of some importance as an indication of general 
 feebleness. In other instances, however, it is merely a 
 family peculiarity, and as such, bears no special significance. 
 
 Difficult Dentition gives rise to two classes of affections, 
 viz. : local, and sympathetic or reflex. 
 
 The third and fourth groups of teeth are most prone to 
 make trouble, and when the child is born at such a time of 
 the year as to bring their eruption during the hot months, 
 illness of some sort may be anticipated. This is often dan- 
 gerous, sometimes fatal, hence the popular dread of the 
 " second summer." 
 
 Local Affections. — Catarrhal stomatitis, already referred 
 to as a physiological occurrence, frequently becomes greatly 
 intensified, and is sometimes associated with enlargement of 
 the submaxillary and cervical lymphatic glands. Aphthous 
 and ulcerative stomatitis develop much more rarely. 
 
 Ulceration of the fraenum linguae often takes place after 
 the cutting of the first lower incisors, being due to direct 
 and continuous friction of the sharp, new teeth. Usually a 
 single, flat, round ulcer, the size of a linseed, is formed. The 
 base is yellow and lardaceous, the edges red and infiltrated. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 89 
 
 At times it is sufficiently painful to interfere with the 
 movements of the tongue, though at others so indolent as 
 to escape notice entirely. Such ulcers, if left to themselves, 
 disappear in from eight to ten days. Their course may be 
 much shortened by touching them lightly with a point of 
 nitrate of silver, and then applying a solution of chlorate of 
 potassium three or four times each day. 
 
 Another very common condition is an excessive increase 
 in the secretion of the fluids of the mouth, attributable to 
 irritation of the mucous and salivary glands. The constant 
 driveling of this fluid reddens and excoriates the skin of the 
 chin and anterior part of the neck. It also soaks the cloth- 
 ing; and the consequent chilling of the thorax both excites 
 and tends to keep up a catarrhal state of the bronchial and 
 mucous membrane. In this way may be explained the fre- 
 quent concurrence of driveling and severe cough in teeth- 
 ing children. The etiological association is further proven 
 by the fact that if the chest be protected by a piece of oiled 
 silk or other waterproof material, placed inside of the 
 clothing, the cough either does not develop or quickly dis- 
 appears if it has been present. If these two results are 
 excepted, slobbering is not to be regarded as unfavorable, 
 for such children rarely have alarming brain symptoms, or 
 severe intestinal catarrh. 
 
 The Sympathetic Effects of difficult dentition show 
 themselves in affections of the eyes and ears, gastrointes- 
 tinal disorders, skin eruptions, nervous affections, and fever. 
 
 Conjunctival blennorrhoea arises frequently during the 
 eruption of the upper canines ; hence the common name, 
 " eye-teeth." This complication may be attributed to an 
 extension of irritation to the antrum of Highmore, the 
 nasal passages, and, finally, to the conjunctiva. The eyelids 
 swell greatly and rapidly, there is difficulty in opening the 
 
90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 eye, a free secretion of a stringy, translucent mucus, and 
 pain and photophobia ; the ball remains intact. It is distin- 
 guished from true blennorrhcea by frequently being unilat- 
 eral, by its non-contagiousness, and by the absence of the 
 characteristic dark-yellow, thick, purulent discharge. Re 
 covery quickly follows the appearance of the point of the 
 tooth, and no treatment is required beyond cleanliness and 
 the application of dry warmth. 
 
 Otitis is not uncommon. It is probably due to irritation 
 conveyed from the inflamed gum to the otic ganglion, and 
 thence deflected to the vessels supplying the tympanic 
 membrane. In consequence, this membrane becomes con- 
 gested, and there is great pain. When the irritation persists, 
 suppurative inflammation is developed in the tympanic cavi- 
 ty, the drum is perforated, and pus flows from the external 
 auditory meatus. The treatment belongs to the domain 
 of aural surgery. 
 
 Simple diarrhoea, with yellow, pultaceous or somewhat 
 greenish stools, is a very common occurrence. It is due 
 either to an intestinal catarrh of mild grade, or to the swal- 
 lowing of large quantities of saliva, the saline constituents 
 of which act as laxatives. Under ordinary circumstances it 
 should not be interfered with, since it is conservative, other 
 complications, especially affections of the brain, being much 
 less likely to arise while it is present. Attention to the diet 
 is necessary. If vomiting be associated or the stools be green, 
 bicarbonate of sodium, or carbonate of magnesium, with an 
 aromatic, may be ordered, and if there be griping it is well 
 to clear out the bowels by a dose of castor oil. The rules 
 are to hold the diarrhoea in check but never arrest it and to 
 avoid the use of opium and astringents as far as possible. 
 
 There can be no doubt, however, that during dentition 
 the mucous membrane of the digestive tract, sympathizing 
 
AFFECTIONS OF THE MOUTH AND THROAT. 9 1 
 
 in the oral irritation, becomes more susceptible to such irri- 
 tants as badly digested or improper food, and that a condi- 
 tion of simple catarrh is apt, under such influences, to pass 
 into one of follicular enteritis, with secondary involvement of 
 the mesenteric glands. This is soon followed by general 
 atrophy (marasmus), frequently terminating in death. Hand- 
 fed infants are particularly prone to be so affected. The 
 symptoms are vomiting, the formation of thrush deposits 
 in the mouth, anorexia, thirst, tympanitic distension of the 
 abdomen, diarrhcea, and rapidly increasing emaciation. The 
 very numerous faecal evacuations are liquid, have a pene- 
 trating, cadaverous odor, and excoriate the anus and sur- 
 rounding parts. This condition demands, and too often 
 resists, the most careful treatment.* 
 
 When vomiting alone occurs as a complication, it may 
 often be relieved, in sucklings, by shortening somewhat the 
 time the child is allowed to lie at the breast, and thus pre- 
 venting over-distension of the stomach. With hand-fed in- 
 fants the same result may be attained by judiciously lessen- 
 ing the quantity of food given at each meal and reducing 
 its strength, by the addition of lime-water. A teaspoon- 
 ful of lime-water every half hour or hour will aid in check- 
 ing the vomiting, and the following prescription is ex- 
 cellent : — 
 
 R. Liq. Calcis, 
 
 Aq. Cinnamomi, aa f^j. 
 
 M. 
 
 S. — One teaspoonful every half hour or hour, for a child of 
 seven months. 
 
 Several forms of cutaneous eruption attend difficult den- 
 tition. They usually appear in children with fair, delicate 
 skins, show some hereditary and family tendency, and must 
 be considered of vaso-motor origin. 
 
 * See sections on the diseases attended by diarrhcea. 
 
92 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 The eruption may be present during the cutting of one 
 set of teeth only, or may continue during the entire denti- 
 tion. In the latter case it improves greatly or disappears in 
 the pauses. The form usually remains unchanged through- 
 out. 
 
 The varieties that may exist are : — 
 
 (a) Urticaria. — This consists of the appearance of a varying 
 number of wheals, chiefly on the trunk and extensor surfaces 
 of the limbs. The wheals are slightly prominent, flattened 
 elevations of the cuticle, varying in size from that of a pea 
 to a bean, somewhat paler than the normal skin but sur- 
 rounded by red areolae gradually fading at the periphery 
 into the healthy skin color. They develop suddenly, mak- 
 ing their appearance especially when the child becomes warm 
 in bed, or is overheated, and are the seat of some burning 
 and intense itching. They last a few hours, and disappear 
 rapidly, leaving the epidermis intact, except for accidental 
 injuries occasioned by scratching. 
 
 Relief comes after a careful regulation of the diet. If 
 the child be bottle-fed the milk must be well guarded with 
 lime-water. If older, and fed on mixed food, it is well to avoid 
 farinaceous articles. The bowels, usually constipated, should 
 be regulated by saline laxatives, and much benefit will result 
 from the use of effervescing citrate of potassium, in doses 
 of one-fourth of a teaspoonful (equal to gr. v), three times 
 daily, for a child of eight months to a year old. The most 
 soothing local application is : — 
 
 R . Sodii Hyposulphitis g ij-iv. 
 
 Aq. Rosae, f % :§ xvj. 
 
 M. 
 
 This is to be sponged over the wheals at short intervals 
 or applied by moistened compresses. 
 
 (b) Strophulus. — This presents itself in two forms, strophu- 
 
AFFECTIONS OF THE MOUTH AND THROAT. 93 
 
 lus intertinctus or red gum, and strophulus albidus or white 
 gum. 
 
 Red gum consists of an eruption, of prominent, red pap- 
 ules, interspersed with small patches of erythema. The 
 papules are scattered over the whole body, but are most 
 abundant on the face, back of the hands and forearms ; they 
 vary considerably in size, though they are rarely larger than 
 a pin's head ; they are the seat of considerable itching, and 
 after their disappearance there is trifling desquamation. 
 It occurs in successive crops, each crop lasting from seven 
 to fourteen days. 
 
 In white gum the papules are pearly-white instead of 
 red, and each elevation is surrounded by a faint red areola. 
 These papules are most numerous on the face, neck and 
 breast; they are smaller than the former, but like them 
 appear in crops, which remain about seven days. 
 
 With the exception of attention to digestion, which is 
 often deranged, little treatment is required. Dusting with 
 bismuth or lycopodium, or anointing with cold cream or 
 simple cerate will relieve the itching. 
 
 (c) Eczema* — In teething children this affection may be 
 found in any one of its various forms. It may extend over 
 the entire surface or be limited to a small area ; its usual 
 position, however, is the face and scalp. 
 
 Facial eczema begins with redness, induration and rough- 
 ness of one or other cheek. There is also intense itching, and 
 even at this early stage the child, if unhampered, will scratch 
 the affected part until it becomes raw and bleeding. Soon 
 minute vesicles or pustules form. 
 
 If the dermatitis be slight the eruption is vesicular. The 
 vesicles may heal spontaneously, or being broken mechani- 
 cally, they discharge a serous fluid which dries into thin 
 
 * This is the form of skin disease usually covered by the term "tooth rash." 
 
94 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 scales or lamellated crusts. These fall off, leaving a reddened, 
 moist, delicate surface, still intensely itchy, and soon to be 
 covered by another crop of vesicles, which undergo the 
 same changes. 
 
 If the inflammation of the skin be more severe, the 
 eruption is pustular. The pustules on breaking, exude a 
 material that dries into thick, yellowish-brown crusts, 
 often extensive enough to cover the whole face, except 
 the eyelids and nose, as with a mask. . In hardening, crack- 
 ing is apt to occur, with the exposure of the red and bleed- 
 ing derm. When these fall, or are scratched off, an intensely 
 red, weeping surface is left, which is soon re-covered by a 
 thinner, lighter-colored crust, resembling that seen in the 
 vesicular form. The neighboring lymph glands are always 
 somewhat enlarged and tender. The process of crust- 
 ing and cleaning off repeats itself again and again, fre- 
 quently dragging through the entire dentition, though 
 subject to improvement or even completely healing during 
 the pauses. 
 
 Sometimes, especially toward its close, the eczema as- 
 sumes the papular form. 
 
 The disease is attended by sensations of discomfort and 
 tension about the face. The itching is continuous but sub- 
 ject to exacerbations in which it is most difficult to keep 
 the child from tearing the skin with his nails. One often 
 leaves a patient with his face covered by a thick crust, to 
 find him at the next visit with clean, red and moist cheeks 
 scarred by nail-scratches, from which the blood drops upon 
 his clothing. The exacerbations occur chiefly at night. 
 Under the circumstances it is but natural that the little suf- 
 ferer should be restless and peevish, should sleep badly, and, 
 from the latter cause, should gradually fail in health and 
 strength. The appetite, too, is often diminished, the digestive 
 
AFFECTIONS OF THE MOUTH AND THROAT. 95 
 
 powers impaired, and the bowels confined. There may be 
 slight febrile reaction toward evening. 
 
 Eczema of the scalp — crusta lactea — -involves at first only 
 a small area, but has a marked tendency to spread. In some 
 cases it appears in the form of minute, disseminated vesicles ; 
 these break and exude their serous contents, which hardens 
 into thin, scaly crusts. If these be removed the skin be- 
 neath will be found to be reddened and moist. In others 
 the vesicles rapidly change into pustules, and when these are 
 broken the puriform fluid dries into thick, yellowish-brown 
 crusts. The underlying skin is red, swollen and painful, 
 and the source of a constant formation of pus, which in dry- 
 ing adds to the thickness of the preexisting crusts. These 
 mat the hairs together, become, day by day, thicker, harder 
 on the external surface and darker in color, from the admix- 
 ture of dust or of blood flowing from wounds caused by 
 scratching. As the hair grows it lifts the crusts from the 
 scalp and the pus finds its way out, running over and ex- 
 coriating the skin of the forehead and neck. From the heat 
 of the head and exposure to the air partial decomposition 
 sets in, attended by a disgusting odor, and in carelessly 
 kept children myriads of lice appear. In well-marked in- 
 stances the crusts completely encase the scalp. The occip- 
 ital and other lymphatic glands are usually enlarged, and 
 occasionally, in strumous children, suppurate. Crusta lactea 
 is no less obstinate then facial eczema. When it runs a 
 protracted course the hair may fall out, but the loss is not 
 permanent. 
 
 There can be no question as to the propriety of healing 
 eczema of the face or scalp as quickly as possible. The 
 idea that the cure of the rash leads to more serious mischief, 
 as meningitis or hydrocephalus, is merely a remnant of the 
 long abandoned doctrine that disease is due to the presence 
 
g6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 of an evil spirit, which if driven from one place will attack 
 another. The objections of some self-important and misin- 
 formed parents to any local application will usually be over- 
 come by the assurance that the eruption is not to be driven 
 in, but cured as it comes out. 
 
 Under the best of conditions, however, tooth rash is 
 difficult to cure, and requires both general and local treat- 
 ment. 
 
 The general treatment demands in the first place attention 
 to the diet. Bottle-fed babies must have their milk well 
 alkalinized with lime-water, and older children must avoid 
 farinaceous and heavy food. Next, conditions of acid dys- 
 pepsia, which, by the way, frequently exist, must be correct- 
 ed by alkalies. Then it is essential to keep the bowels freely 
 moved; for this purpose the following mixture answers 
 well : — 
 
 R . Magnesii Carbonatis, 
 
 Manna? Opt., aa gr. xl. 
 
 Ext. Sennse Fid., Tt\lxxx. 
 
 Syr. Zingiberis, f^ ss - 
 
 Aquae, q. s. ad fj|j. 
 
 M. 
 S. — One teaspoonful once or twice daily, for a child seven 
 months to a year old. 
 
 Finally, certain medicines may be used with advantage. 
 The emulsion of cod-liver oil and lacto-phosphate of lime 
 in debilitated, strumous or rachitic children ; syrup of the 
 iodide of iron in the anaemic; Fowler's solution when the 
 eruption becomes chronic. 
 
 For the successful local treatment of facial eczema it is 
 necessary to have many resources at command ; to make 
 frequent changes as the applications lose their beneficial 
 effects, and to persevere in spite of discouragement. Little 
 progress will be made if the child be allowed to scratch the 
 
AFFECTIONS OF THE MOUTH AND THROAT. 97 
 
 face at will. During the waking hours this is to be pre- 
 vented by careful watching and diversion on the part of the 
 nurse. At night by muffling the hands in thick, soft cloths, 
 or by wrapping a napkin around the body in such a man- 
 ner as to confine the arms, or, better still, by fixing the 
 lower ends of the night-gown sleeves to the diaper, with 
 safety-pins. The latter arrangement allows of some move- 
 ment of the hands but prevents their being lifted to the face. 
 The child quickly becomes accustomed to the partial re- 
 straint. 
 
 As soon as redness, induration and roughness of the 
 skin indicate the onset of the disease, a mucilage made from 
 sassafras pith (never musty or sour), is to be mopped over 
 the surface with a soft rag, at intervals of an hour, or less. 
 After this has dried for five minutes, a thick layer of the 
 ointment of the oxide of zinc should be gently applied with 
 the finger. If the officinal zinc ointment increase the in- 
 flammation, as it sometimes does in young or delicate- 
 skinned babies, it must be diluted one-half, or even three- 
 quarters, with cold cream. The nose, eyes and lips should 
 be kept clean by wiping them with a moistened cloth, 
 but the affected portions of the face must never be washed. 
 Both the mucilage and ointment greatly relieve the itching, 
 and in mild cases are sufficient to effect a cure. 
 
 When vesicles or pustules become abundant, zinc oint- 
 ment is still most serviceable, though it is no longer well to 
 use the mucilage. When the former ceases to be of service, 
 one of the following may be tried : — 
 
 R. Cerat. Plumbi Sub-acetatis, 3 ij. 
 
 Ung. Aquae Rosae, ^vj. 
 
 M. 
 
 R. Bismuthi Sub-nitratls, ^ j — ij. 
 
 Adipis, gvj. 
 
 M. 
 
 7 
 
98 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 R. Glycerinae, f 3 ij. 
 
 Adipis, gvj. 
 
 M. 
 R . Olei Lini, 
 
 Liquor. Calcis, aaf^j. 
 
 M. 
 
 R . Acidi Salicylici, 3 ss. 
 
 Adipis, gj. 
 
 M. 
 
 The first three are more sedative than zinc ointment, the 
 last two more stimulating. 
 
 Hebra's diachylon ointment, useful in very moist eczema, 
 is prepared in the following way : — , 
 
 R. Olei Olivae, f-fj. 
 
 Lithargyri, gij. 
 
 Coque 1. a. in molle, dein adde. 
 
 Olei Lavandulae, rr^viij. 
 
 M. 
 S. — Rub the ointment over the affected spot two or three 
 times daily, or, better, apply upon linen compresses. 
 
 When the patient does not bear salves well, a paste of 
 oxide of zinc with glycerin may be ordered, and sometimes 
 a dusting powder is beneficial, as : — 
 
 R. Zinci Oxidi, gj. 
 
 Amyli, I). 
 
 M. 
 S. — Dust over the affected part frequently. 
 
 In such cases, too, lotions act well. For example, the 
 officinal liquor plumbi sub-acetatis dilutus, or : — 
 
 R. Zinci Sulphatis, gr.j — ij. 
 
 Aquae Rosae, f 5J. 
 
 M. 
 
 R. Sodii Boratis, gr.v-x. 
 
 Glycerinae, f^j. 
 
 Aq. Rosae, q. s. ad f ^j. 
 
 M. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 99 
 
 In chronic cases, especially where there is hypertrophic 
 thickening of the corium, a tendency to the squamous form, 
 and but little redness, wonderful results will be obtained 
 by using either — 
 
 J$. Ung. Hydrargyri Ammoniati, ^ j— iv. 
 
 Ung. Aquae Rosae, q. s. ad ^j. 
 
 M. 
 S. — Apply three or four times daily. 
 
 Or this lotion — 
 
 R . Hydrargyri Chloridi Corrosivi, g r «j _ U« 
 
 A q u ^ fgj. 
 
 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, 
 applying a poultice of flaxseed over night, and using an oint- 
 ment containing mercury, as — 
 
 R. Ung. Hydrargyri Nitratis, 3 j— ij. 
 
 Ung. Aquae Rosae, q. s. ad ^ j. 
 
 M. 
 S. — Rub into scalp three times daily. 
 
 R. Hydrargyri Chloridi Mitis, gr. xxx. 
 
 Adipis, gj. 
 
 M. 
 
 In some instances penciling with the solution of corrosive 
 sublimate, 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 
 

 
 100 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 mercurial preparations 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 applications are indicated, for instance — 
 
 R. Ung. Picis Liquids, 
 
 Adipis, aa ^iv. 
 
 M. 
 S. — Apply thrice daily. 
 
 R. Saponis Mollis, ^iv. 
 
 Alcohol dil f 3 ij. 
 
 Spt. Lavandulae, TTLxv. 
 
 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 bene- 
 ficial 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 
 difficult 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 influ- 
 ences. They embrace slight spasms of isolated groups of 
 muscles, general convulsions, and motor paralysis. 
 
 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 manifestations 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. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 10 1 
 
 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 respira- 
 tion 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 mo- 
 ments, or there may be a number, varying in duration, and 
 following each other at longer or shorter intervals. In 
 some cases, the 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 with- 
 out 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 : — 
 
 R. Chloral Hydrate, gr.xij. 
 
 Potassii Bromidi, % ss. 
 
 Mucilag. Acaciae, f t ^j. 
 
 Aquae, < . q. s. ad f Jiij. 
 
 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. 
 
102 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Dental paralysis is sudden in its onset. After a restless 
 night the child wakes with one arm helpless, or with one 
 arm and one leg powerless ; more infrequently one arm and 
 both legs, or both arms are affected. Generally the paralysis 
 disappears after a few weeks. The means for relief are salt- 
 water baths with frictions, 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 sweet 
 spirit of nitre or citrate of potassium. 
 
 In both classes of affections arising from difficult denti- 
 tion, the question of the propriety of lancing the gums 
 often arises. 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 formation 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 operation if the original incisions heal — an event of little 
 moment. My own practice in regard to lancing is guided 
 entirely by circumstances. If there be fever, nervous irrita- 
 bility, sleeplessness, vomiting ordiarrhcea 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, accord- 
 ing to the distance of the tooth from the surface. I feel 
 
AFFECTIONS OF THE MOUTH AND THROAT. IO3 
 
 confident that no one who has once 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. 
 
 7. SIMPLE PHARYNGITIS. 
 
 Catarrh of the mucous membrane covering the soft 
 palate, tonsils and pharynx — simple or erythematous phar- 
 yngitis — 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 hypersemia of the affected 
 mucous membrane. This is red, swollen, softened, granu- 
 lar, and at times cedematous. 
 
 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 fol- 
 lowed by others. The disease is not contagious, but many 
 cases often occur simultaneously. 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 
 
104 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 correspondingly rapid, though 
 easy, the face is flushed and the skin dry. The voice 
 becomes thick and husky, and there is a teasing, unproduc- 
 tive, 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 swallowing 
 food ; while infants manifest the latter conditions by refus- 
 ing the breast or bottle. An entire absence of these sub- 
 jective symptoms, however, is common. 
 
 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 cedematous. 
 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 
 succeeding evening until the end of the fourth or fifth day, 
 when the attack begins to subside. In the meantime the 
 local symptoms 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 
 
AFFECTIONS OF THE MOUTH AND THROAT. 105 
 
 always high fever, with a temperature reaching 106 or 
 even more, and a rapid and bounding pulse. The affected 
 mucous membrane becomes intensely red and covered 
 with a muco-purulent secretion. All the ordinary symp- 
 toms 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 du- 
 ration 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 symp- 
 toms 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 pneu- 
 monia. If, under the same conditions, the pharyngitis be 
 ushered in by vomiting, the fever might readily be referred 
 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 beginning 
 be taken for one of scarlet fever, the resemblance being 
 increased by the uniform flushing of the surface. Distinc- 
 tion is to be found in the different course of the two dis- 
 eases, and the non-appearance of certain characteristic 
 symptoms of the exanthem. 
 
 Care must be taken not to confound the white or yellow- 
 ish-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 
 
106 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 giving the child a hot mustard foot-bath,* putting him to 
 bed in a properly-warmed room, and by cautiously admin- 
 istering aconite, with some saline laxative, as a small tea- 
 spoonful of magnesia in a wine-glassful of strong lemonade. 
 Under such circumstances, tincture of aconite root may be 
 given to a child of four years, in doses of half a drop every 
 half hour until two drops have been taken, and subse- 
 quently the same dose every hour until an effect is pro- 
 duced 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 : — 
 
 ]£. Potassii Chloratis, gr. xlviij. 
 
 Acid. Muriatici dil., fgi. 
 
 Syrupi, ^E ss ' 
 
 Aquse, 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 spiritus aetheris nitrosi, or 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. 
 
 Local treatment must not be neglected. If the child be 
 able, he should gargle the throat every hour with a solution 
 
 * 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. 
 
AFFECTIONS OF THE MOUTH AND THROAT. IO7 
 
 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 cot- 
 ton. Painting the throat daily with a solution of nitrate of 
 silver (gr. v to f^j) hastens the cure. At the same time it 
 is well to redden the skin of the neck with some such lini- 
 ment as : — 
 
 &. 01. Terebinthinse, fgj. 
 
 01. Olivse, f^iij. 
 
 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 enveloped 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 hyperaemia of the 
 mucous membrane covering the tonsils, accompanied by 
 moderate swelling 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 
 
108 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 exists in an isolated form, the tonsils will be found red- 
 dened 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. 
 
 9. FOLLICULAR TONSILLITIS. 
 
 In this disease there is, in addition to superficial hyper- 
 emia, 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 mate- 
 rial, 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 be- 
 comes 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 pre- 
 disposes to others, and I have seen many patients who are 
 invariably affected after gorging themselves. 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 
 
AFFECTIONS OF THE MOUTH AND THROAT. IO9 
 
 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 lateri- 
 tious. On the morning of the second day the fever abates, 
 but it returns in the afternoon, and this course is maintained 
 foY three or four days, when convalescence is established. 
 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 
 headache 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, increased 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 enlarged, 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 num- 
 ber, 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 varying size and consistency may be pressed 
 
I IO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 out. These are also expelled by hawking, or 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 secre- 
 tion — a pathognomonic sign. There is no doubt that these 
 cases are by some classed as diphtheritic, though none but 
 the most inexperienced could confound the numerous yel- 
 lowish-white points, of irregular shape and size, depressed 
 below or projecting beyond the well-defined lips of the fol- 
 licles, with diphtheritic membrane. 
 
 The Prognosis is always favorable, except that one attack 
 predisposes to others, which may lead to chronic hyper- 
 trophy of the tonsils. 
 
 Treatment. — If the attack be traced to over-eating, the 
 administration of an emetic would naturally suggest itself 
 as a preliminary. This, however, is rarely necessary, as 
 the initial vomiting 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 : — 
 
 &. Acidi Citrici, 3J SS - 
 
 Aquse, f 5 iij. 
 
 M. 
 S.— Solution No. I. 
 
AFFECTIONS OF THE MOUTH AND THROAT. Ill 
 
 R. Potassii Bicarbonatis, gj. 
 
 Aquae, f^iij. 
 
 M. 
 
 S. — Solution No. 2. 
 
 A teaspoonful of each solution is to be poured into a table- 
 spoon 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. Pepsinse, 
 
 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 established, care being taken to keep the bowels regular. 
 Then the diet may be gradually increased 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, f^j. 
 
 Aquae, q. s. ad f 5 viij. 
 
 M. 
 S. — Use as a gargle every hour. 
 
112 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 io, 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. 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 com- 
 plication of scarlatinous, variolous or diphtheritic anginas. 
 One or both tonsils may be affected. 
 
 Morbid Anatomy. — At first there is intense hyper- 
 aemia with serous infiltration of the glandular tissue, and 
 the tonsils sometimes become swollen to more than double 
 their size. The inflammation may now undergo resolution. 
 Otherwise an infiltration 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 hypertrophy; a frequent termination 
 of repeated attacks in children. If the inflammation be 
 very intense, an abscess forms, but suppuration is not the 
 usual result of tonsillitis occurring before puberty. With 
 these conditions there is always associated general pharyn- 
 gitis and often follicular tonsillitis. 
 
 Symptoms. — The disease begins with rigors or a distinct 
 chill, followed by sneezing, epistaxis, headache, pain along 
 the Eustachian tube, loss of appetite, and fever, with languor 
 and muscular prostration during the day, and mild delirium 
 at night. Soon the patient complains of dryness and burn- 
 ing 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 red- 
 dened and enlarged, often presenting several whitish-yellow 
 
AFFECTIONS OF THE MOUTH AND THROAT. II3 
 
 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 tem- 
 perature 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 fre- 
 quency. 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 involved, it often extends a third of an inch beyond the 
 median line. The day is divided between the listless inac- 
 tion of prostration 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 end 
 in resolution the fever rapidly subsides, disappearing en- 
 tirely 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 
 
114 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 fever. The abscess soon points toward the mucous surface 
 of the gland, and is broken by an effort at deglutition or in 
 an examination of the throat. The quantity of pus dis- 
 charged is ordinarily small, and is swallowed, as a rule. After 
 the breaking 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 pecul- 
 iar tone of the voice, the pain in the line of the Eustachian 
 tubes, and the deflection of the uvula indicate the beginning 
 of tonsillitis, it is possible to abate or, at least, greatly 
 reduce the intensity 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 tincture 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. * 
 
 When the case is not seen until later, the indications are 
 to encourage resolution or hasten suppuration, and to main- 
 tain the strength. To fulfil the first, the neck should be 
 enveloped in a poultice, the throat should be repeatedly 
 
 * Within the past year I have often succeeded in aborting tonsillitis by 
 thoroughly mopping the affected parts three times daily with a four per cent. 
 solution of cocaine. Even in cases where this favorable result was not ob- 
 tained, the cocaine so far allayed pain as to permit liquid food to be swallowed 
 with ease. This is an invaluable aid in the treatment of severe quinsy oc- 
 curring in feeble children. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 1 1 5 
 
 gargled with warm water, and steam from an atomizer 
 should be constantly inhaled. The strength is to be kept 
 up by administering all the concentrated liquid food that it 
 is possible for the patient to swallow and by using supposi- 
 tories of quinine. The latter may be ordered in this way : — 
 
 I£. Quinine Bi-sulphatis, gr. xij. 
 
 01. Theobromae, 3"j« 
 
 M. et ft. supposit. No. xij. 
 S. — Use one 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 dia- 
 phoretic, 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 bro- 
 mide of potassium, in ten-grain doses, by the mouth or rectum . 
 
 If an abscess form, a somewhat rough pressure of the 
 finger against the involved tonsil will hasten its rupture. 
 Incision is rarely advisable. 
 
 After the crisis is past, the diet must be increased and a 
 tonic ordered, as: — 
 
 R. Tr. Ferri Chloridi, fgj. 
 
 Quinise Sulphatis, gr. xij. 
 
 Syrupi Zingiberis, f 3 j. 
 
 Aquse, q. s. ad f^iij. 
 
 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 hast- 
 ened by painting them twice daily with : — 
 
 R. Acidi Tannici, £j. 
 
 Glycerinae, f5j. 
 
 M. 
 
 For prevention, gargles of cold water and astringents, 
 applications of the glycerole of tannin, and measures to 
 maintain a high standard of health, should be employed. 
 
Il6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 ii. HYPERTROPHY OF THE TONSILS. 
 
 Chronic enlargement of the tonsils is slow in its de- 
 velopment, and must be considerable in degree before 
 giving rise to definite symptoms. Consequently, the dis- 
 ease 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 irri- 
 tation 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 sea- 
 sons. 
 
 Symptoms. — The first to attract attention is loud snoring 
 during sleep, due to pressure upon the velum, and obstruc- 
 tion 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 often disappear spontane- 
 ously 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 respira- 
 tion, and difficulty of hearing, due partially to pressure upon 
 the orifices of the Eustachian tubes, and partly to a state 
 
AFFECTIONS OF THE MOUTH AND THROAT. Iiy 
 
 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 tra- 
 cheotomy. 
 
 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 become 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 in- 
 spiration, 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 pres- 
 sure is most marked where the resistance is least, namely, 
 at the base of the thorax, and a constant and long-continued 
 repetition of this leads to the production of a gutter of vari- 
 able depth and three or four inches in width, extending 
 laterally from the lower part of the sternum, and to a pro- 
 jection 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 passages, maintain a 
 condition most unfavorable to its arrest. 
 
 Treatment. — Moderate enlargement of the tonsils in a 
 weakly child will often 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 
 
I 1 8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 well to paint the tonsils once every day with one of the fol- 
 lowing astringents : — 
 
 R. Tr. Ferri Chloridi , fgj. 
 
 Glycerinae, q. s. ad f5j. 
 
 M. 
 
 R. Liq. Iodinii Comp., f ^ ij. 
 
 Glycerinae, q. s. ad f5j. 
 
 M. 
 
 When there is marked hypertrophy, I have often had the 
 most successful results from the application of solid nitrate 
 of silver every other day. In making this application, a 
 sharp point of lunar caustic should be thrust into several of 
 the follicles of each gland, and then so thoroughly applied 
 to the whole mucous surface as to leave a thin, white pel- 
 licle. A gargle containing tanic acid must be used four 
 times daily, as : — 
 
 R. Acidi Tannici, gss. 
 
 Glycerinae, f J ss. 
 
 Aquae, q. s. adf^viij. 
 
 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 en- 
 largement, provided the above measures of reduction have 
 been thoroughly tested without avail, or if, at any time, 
 there is dangerous interference with respiration. Con- 
 stant or frequent cough, or the presence of any other 
 symptom suggestive of phthisis, also demands an immediate 
 operation. 
 
AFFECTIONS OF THE MOUTH AND THROAT. I 19 
 
 If, after removal of a portion of the tonsils or their re- 
 duction 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 prominence 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. 
 
 12. RETROPHARYNGEAL ABSCESS. 
 
 Abscess behind the pharynx is an uncommon disease; so 
 rare is it, indeed, that in many years' experience at the Chil- 
 dren's Hospital I have seen but one case, and this, unfor- 
 tunately, 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 breath- 
 ing, with a peculiar sound during the latter act. On lying 
 down the respiratory 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 swelling 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 swell- 
 ing 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 
 
120 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 normal or congested. Sometimes the mouth cannot be 
 sufficiently 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 
 formation of an abscess behind the oesophagus, viz. : Severe 
 pain, produced 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 overlooked in its early stages. Ordinarily, 
 however, the diagnosis can be made without difficulty. 
 
 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 oesoph- 
 agus, 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 con- 
 nections 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 accom- 
 panies cervical caries ; under other circumstances it is fa- 
 vorable. 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. 
 
AFFECTIONS OF THE MOUTH AND THROAT. 121 
 
 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 thor- 
 ough evacuation of the pus. At the same time a general 
 tonic and supporting treatment is advisable. 
 
CHAPTER II. 
 
 AFFECTIONS OF THE STOMACH AND 
 INTESTINES. 
 
 The fact that hyperaemia is the acknowledged condition 
 of the gastro-intestinal mucous membrane during digestion, 
 and the easily appreciated readiness with which this hyper- 
 aemia 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 indi- 
 gestion" 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 argu- 
 ment, 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 
 apy retic. 
 
 122 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 23 
 
 The Idiopathic Form may occur at any age, but is in- 
 frequent in breast-fed infants. Its origin under such cir- 
 cumstances is always traceable to some abnormal condition 
 of the mother's milk. The ordinary predisposing causes 
 are dentition, general 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 ipecacuanha. 
 
 The Anatomical Lesion is hyperaemia of the mucous 
 membrane of the stomach, producing an increased secretion 
 of mucus, and a diminished flow of gastric juice. 
 
 Symptoms. — An attack of what the nurse calls " indiges- 
 tion" 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 headache, 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 ten- 
 
124 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 derness on pressure in the epigastric region. The bowels 
 are confined, and the urine is lessened in quantity and late- 
 ritious. 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. 
 
 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 
 concerned, but it must be remembered that one attack 
 always increases the susceptibility to another. 
 
 Treatment. — Complete rest, on the nurse's lap for in- 
 fants, 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. Con- 
 sequently, 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 fre- 
 quent small draughts of iced carbonic acid or Vichy water. 
 Such measures are also useful to allay nausea and vomit- 
 ing, 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 teaspoonfuls, according to the age, at inter- 
 vals of 15 to 30 minutes, as necessary. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 125 
 
 Frequently repeated small doses of the effervescing 
 citrate of potassium, or of the effervescing draught already 
 mentioned (page 1 10), 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 table- 
 spoonful 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, there is headache, fever, epigastric discomfort, and 
 nausea without 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 administer 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. 
 
126 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 2. CHRONIC GASTRIC CATARRH. 
 
 This affection presents so many points of dissimilarity, 
 according 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 im- 
 perfect 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 impos- 
 sible 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 division 
 of the subject to a later section headed " chronic gastro- 
 intestinal catarrh," and at present to consider only — 
 
 CHRONIC GASTRIC CATARRH IN INFANTS. 
 
 This dangerous affection, sometimes termed " chronic 
 vomiting," is of common occurrence. 
 
 Morbid Anatomy. — In the earlier stages there is a 
 simple hypersemia of the gastric mucosa, but a long contin- 
 uance of this condition thickens and loosens the mem- 
 brane, changes its color to an ashen-gray, 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 sev- 
 enth months furnishes by far the greatest number of cases. 
 Sex and season are not influential. Infants fed entirely at 
 the breast are very rarely affected. 
 
 The predisposing causes belong to the class of influences 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. \2J 
 
 that lowers 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 un- 
 suitable food. Sometimes the breast-milk departs so much 
 from its normal quality that it acts as an irritant upon the 
 delicate mucous membrane 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 com- 
 monly 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 farina- 
 ceous 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 sub- 
 jected to the action of a ferment, as mucus, in the presence 
 of heat and moisture — conditions 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 allowing 
 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 
 
128 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 irritating 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 be- 
 fore. 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 un- 
 clean 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 
 irregular 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, containing 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 sallow, 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 intervals; the 
 mouth is parched, thirst is increased, and milk or water 
 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 moderate diarrhoea alternates. The 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 29 
 
 abdomen is distended and tympanitic, and there is great ten- 
 derness 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 ap- 
 pearance of projecting. 
 
 This condition continues, with occasional brief periods of 
 improvement, for several months. Then the vomiting be- 
 comes more constant, occurring both after food and in the 
 intervals of feeding. It is excited by any disturbance, such 
 a trifling act as wiping the mouth, for example, being suffi- 
 cient to bring on an attack. 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 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 offen- 
 sive, 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 abdomen, and to this position they are at 
 once returned when straightened out; often the legs are 
 moved about uneasily, indicating abdominal pain. There 
 is little sleep either by day or night. Fretfulness is con- 
 stant, with an occasional breaking out into loud, painful 
 cries, or, as weakness increases, into low wailings. The 
 tongue is dry and heavily coated, the bowels continue con- 
 stipated, and, toward the end, the abdomen becomes retracted. 
 The pulse grows weak and frequent in proportion to the 
 failure in general strength, and the temperature falls be- 
 low normal ; the thermometer, placed in the rectum, often 
 9 
 
130 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 registering but gy° F. The breath is sour, and the scantily 
 secreted saliva, 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 depression of the fontanelle, dilated pupils, transient 
 flushing of the face, great languor, heaviness of the head, 
 drowsiness, 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 uraemia. Thrombosis of the cerebral 
 sinuses and intracranial hemorrhages are also occasionally 
 found after death, but their connection with the anti-mortem 
 phenomena are by no means uniform. 
 
 When the disease terminates favorably the vomiting 
 occurs at longer and longer intervals, and finally stops en- 
 tirely, though there is great liability to a return on the 
 slightest indiscretion. Afterward all the other symptoms 
 disappear except the constipation, which is apt to be obsti- 
 nate. An excessive development of fat is a frequent se- 
 quel. 
 
 Diagnosis. — The protracted course, the frequent and obsti- 
 nate vomiting of sour liquid, and the excessive emaciation, 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. I3I 
 
 mark the disease with sufficient distinctness. The associ- 
 ation 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 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 possible, 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 farina- 
 ceous food for the natural, a return to the breast is indi- 
 cated. Or, if this be impracticable, the food must consist 
 exclusively of 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 ascer- 
 tained. Subsequently, it may be increased as the stomach 
 becomes retentive. 
 
132 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 dis- 
 carding 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 prep- 
 arations of cows' milk, and time and even life may be 
 saved by adopting at once an unfermentable diet, as a mix- 
 ture of — 
 
 Whey, .' fgj. 
 
 Fresh cream, f^ ss. 
 
 Water, fgj. 
 
 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 ob- 
 servance 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 33 
 
 much cream and little casein. A combination of this 
 sort : — 
 
 Strippings, . . fgj. 
 
 Water, f ^ i j . ; 
 
 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 ordinary 
 milk is the basis, may be safely resumed. For example : — 
 
 Milk, f£iv. 
 
 Cream, f ^ ij. 
 
 Milk sugar, gj. 
 
 Water, f^ ij. ; 
 
 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 flatu- 
 lence. Another good combination is — 
 
 Milk, fgiv. 
 
 Cream, f ^ ij. 
 
 Mellin's food, gj. 
 
 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 sepa- 
 rately, and immediately 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 cloth- 
 ing must be changed at reasonable intervals. Should it 
 
134 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 tempera- 
 ture 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 
 stimulating liniment — oil of turpentine, f^ij, and olive oil, 
 f g ij ; 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 applica- 
 tions 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 prostration, a full 
 bath of 90 F., with or without mustard, may be resorted 
 to, the body being immersed from one to three minutes. 
 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 
 thoroughly to rid the stomach of acid contents, prepares 
 the way admirably for other measures, but should never be 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 35 
 
 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, lUxij. 
 
 Sodii Bicarbonatis, gr, xxiv. 
 
 Aquae Menthse Pip., q. s. ad f 5 iij. 
 
 M. 
 S. — One teaspoonful, in a little water, three times daily. 
 
 When Fowler's solution fails there are three other drugs 
 that may be tried. These are vinum ipecacuanhas, in drop 
 doses every three hours ; calomel, one-sixth of a grain, every 
 four hours ; and tinctura nucis vomicae, half a drop three 
 times daily, combined with bicarbonate of sodium and an 
 aromatic, as in the prescription just given. 
 
 While these medicines are being administered, the bowels 
 should be evacuated by laxative enemata. 
 
 Prostration demands stimulants. The best is old whis- 
 key, 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 vomica, or fifteen drops of the ferrated elixir of cin- 
 chona, 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. 
 
I36 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 3. CHRONIC GASTRO-INTESTINAL CATARRH. 
 
 This disease is common in children who have passed the 
 first dentition, and bears to them somewhat the same rela- 
 tion 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 otherwise, as in older children, 
 pass through the pylorus and induce catarrh of the intesti- 
 nal mucous membrane. The disease is met with in two 
 forms, differing merely in the degree of catarrh. For con- 
 venience, 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 re- 
 sulted from an intercurrent affection, post-mortem ex- 
 amination has revealed the gastro-intestinal mucous mem- 
 brane, 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 confinement and pushing at school ; 
 and finally, the eruption of the permanent teeth, belong 
 to this class of causes. They all act by lowering the 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 37 
 
 capacity to digest, and the best food imperfectly digested 
 undergoes chemical changes rendering it irritant and capable 
 of transforming the normal hypersemia of digestion into 
 the congestion of catarrh. Fewer cases are met with in 
 summer 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 safeguard against catarrh. Season, 
 then, may be added to the predisposing 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 par- 
 take of whatever 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 
 
I38 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 indigestion 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 enveloped by mucus, and this coating 
 prevents the free access of the gastric and intestinal juices, 
 which are solvents and antiferments. 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 deteriora- 
 tion 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 con- 
 sequence, 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 pa- 
 tient has a spare, delicate appearance, the face wears a lan- 
 guid expression and is pale ; the pallor at intervals increas- 
 ing very much, or again giving place to flushing of one or 
 both cheeks. The hair is crisp and lustreless. The con- 
 junctivae 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 39 
 
 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 papil- 
 lae project, and are redder than the rest of the mucous mem- 
 brane, but not so highly colored as in acute gastric catarrh. 
 Moderate hypertrophy of the tonsils can frequently be ob- 
 served, 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 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 dis- 
 comfort, and either general or confined to certain 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 
 moderately severe, and is confined to the left or right hypo- 
 chondriac 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 interior of the bowel, 
 bringing two slippery surfaces together, the peristaltic con- 
 tractions are less efficacious, and constipation results. In- 
 tervals of two, three, or even nine days elapse between the 
 movements, which are attended by considerable straining, 
 
140 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 ; afterward, if there be much retching, 
 of more or less bile-stained mucus alone. The purging, pri- 
 marily, 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 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 develop- 
 ment 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, 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. I4I 
 
 which interferes mechanically with the digestion and absorp- 
 tion 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, how- 
 ever, under which the disease is 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 
 sympathy 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 sus- 
 ceptibility to irritants. 
 
 During the course of whooping cough, the gastrointes- 
 tinal 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. 
 
 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 mag- 
 nified. 
 
 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 
 
142 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 both cheeks ; at others, there is so much pallor, especially 
 about the lips, that fainting seems imminent, and, indeed, it 
 does sometimes 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 noticeably swollen, though 
 painless. 
 
 The oral mucous membrane is pale. The tongue, besides 
 being flabby and indented by the teeth, presents an ap- 
 pearance characteristic of the disease. The dorsum, with 
 the exception of an oval space in the centre, is covered 
 with a light gray coating, 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 I.) 
 
 Chronic hypertrophy of the tonsils, with plugging of the 
 follicles by retained secretion, is common, and, in part, 
 accounts for the disagreeable odor of the breath. 
 
 The appetite in the beginning fails, then becomes capri- 
 cious, 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 diges- 
 tion and impeded absorption. Eating is followed by a 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 43 
 
 sensation of drowsiness, and by eructations of flatus and 
 acid liquid. 
 
 Tympanitic distension 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 hypochondriurri, 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 discom- 
 fort 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 unat- 
 tended 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 confine- 
 ment, 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 in- 
 coherently, and for a time is seemingly unconscious of his 
 surroundings. Somnambulism and nocturnal incontinence 
 of urine are quite common. Stammering is another nervous 
 symptom occasionally encountered. 
 
144 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 There is no alteration in the temperature ; the pulse is 
 feeble, and there is frequently a slight, dry, hacking cough, 
 entirely independent of pulmonary disease. The urine is 
 diminished during the continuance of severe pain, but is 
 voided in excessive quantities at the termination of the 
 paroxysms. 
 
 At intervals of two or three weeks violent vomiting and 
 purging 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 as- 
 pect. 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 denuded of epithelium. (See b, Plate i.) Temporary im- 
 provement 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 ten- 
 dency is for the symptoms to grow more and more severe 
 as time lapses. 
 
 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 during 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 vomit- 
 ing and purging ; the periodicity of these attacks ; the 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. I45 
 
 diurnal drowsiness and nocturnal terrors, and the irregu- 
 larity in the course are the distinguishing features. 
 
 Prognosis. — Mucous disease is not in itself mortal, and 
 is perfectly amenable to treatment. It is, nevertheless, 
 dangerous from its power to reduce the general nutrition, 
 thus opening the way for more serious intercurrent affec- 
 tions. 
 
 As the plan of managing both forms of chronic gastro- 
 intestinal 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 be possible to regulate the diet. There are two 
 rules to be insisted 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, 
 asparagus, lettuce and celery can be used without ill effect. 
 With such food to select from, it is easy to write out a suit- 
 able 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: — 
 10 
 
I46 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Breakfast, at 7 a.m. — One or two tumblerfuls of milk 
 guarded by lime-water* (f3 ij to f,l vj), the yolk of a soft- 
 boiled egg, and a single thin slice of stale, unbuttered bread. 
 
 Luncheon, at 11 A. m. — A cup (fliv) of beef-tea, or mut- 
 ton 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. 
 
 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, 
 seasoned 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 vege- 
 tables as stewed celery, boiled asparagus tops, spinach and 
 
 * 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 off the globules of oil as they rise to 
 the surface with a fragment of blotting-paper. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. \\J 
 
 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, stimu- 
 lants 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, inunctions 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 thor- 
 oughly scrubbed. 
 
 Woolen underclothing, to cover completely the trunk 
 and 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 favor- 
 
I4o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 able conditions for catarrh ; secondly, because so much 
 force is consumed in maintaining the normal tempera- 
 ture in the face of constant chilling that other functions, 
 notably the digestive, must suffer. Parents would appre- 
 ciate 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 nakedness 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 re- 
 covery. The sleeping and living room 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 fermentation of the food ; to restore the mucous 
 membrane to a normal condition, thereby improving secre- 
 tion, 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 liquify it so that it may more readily be 
 removed. They are also most efficient in neutralizing the 
 acid products of fermentation. Simple bitters, too, have 
 some power in lessening the formation of mucus, and consid- 
 erable influence in arresting fermentation ; at the same time 
 they give tone to the mucous 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 pre- 
 ferred in treating this disease. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 49 
 
 In habitual indigestion, a combination like the following 
 will be all that is required. : — 
 
 R. Sodii Bicarbonatis, gj. 
 
 Ext. Sennae Fluid., f.^hj. 
 
 Inf. Gentians 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 secre- 
 tion, may be ordered before meals, as : — 
 
 R . Potassii Iodidi, gr. vj. 
 
 Sodii Bicarbonatis, gj. 
 
 Ext. Sennae Fid., f 3 iij. 
 
 Inf. Calumbae, q. s. ad f 5 iij. 
 
 M. 
 S. — Two teaspoonfuls three times daily before eating. 
 
 After food, it is well to order from ten to twenty drops 
 of tincture 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 of twenty drops, three times daily after eating. Or, if 
 the child be able to swallow a pill, it may be combined thus : — 
 
 & • Pulv. Ipecacuanhse, 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. 
 * All of the subjoined prescriptions are proportioned for children of this age. 
 
150 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 When there is much debility iron is demanded, and if 
 the proper 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 Myrrhae, f 3 iv. 
 
 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 treat- 
 ment. There are several useful prescriptions, for instance : — 
 
 & . Pepsin. Saccharat., gij. 
 
 Acidi Muriatici dil., f 3 ij. 
 
 Aquae Cinnamomi, q.s. adf5iij. 
 
 M. 
 
 S. — One teaspoonful three times daily after eating. 
 
 Or the acid may be combined with a bitter : — 
 
 R. Acidi Muriatici dil., f 3^ ij- 
 
 Inf. Gentianae Comp., q. s. ad f^iij. 
 
 M. 
 S. — One teaspoonful three times daily after meals. 
 
 R. Quiniae Sulphatis, gr- xij. 
 
 Acidi Muriatici dil., f^ij- 
 
 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. I5I 
 
 be put to bed, restricted to a diet of milk and meat broths, 
 and ordered the following prescription : — 
 
 R. Pepsinse Saccharat., 
 
 Sodii Bicarbonatis, aa 3 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 be- 
 come 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 symp- 
 toms 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 estab- 
 lished, and to confirm the cure, change of air, by a trip 
 to the sea-shore or mountains, is advisable. 
 
 Both habitual indigestion and mucous disease are occa- 
 sionally attended by a troublesome symptom that demands 
 brief consideration. This is a peculiar cough, which is dry, 
 paroxysmal, and unattended by lesions of the throat or 
 lungs. The paroxysms 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, unless its true nature as a "stomach cough" be recog- 
 nized 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 
 
152 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 di- 
 gestion; 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 mixtures every two hours, beginning 
 at four o'clock in the afternoon : — 
 
 Be . Pulv. Aluminis , gr. xlviij . 
 
 Potassii Bromidi, ^ij. 
 
 Syrupi Zingiberis, 
 
 Aquae, aa f jf jss. 
 
 M. 
 S. — Dose, one teaspoonful. 
 
 Or— 
 
 R. Ext. Belladonnse, gr. ss-j. 
 
 Pulv. Aluminis, gr. xlviij. 
 
 Syrupi Zingiberis, 
 
 Aquae, aa f ^jss. 
 
 M, 
 S. — Dose, one teaspoonful. 
 
 4. ACUTE INTESTINAL CATARRH. 
 
 The condition intended to be indicated by this title is 
 usually called simple or non-inflammatory diarrhcea, and 
 classed as a functional disease. But from its etiology, and 
 from the fact that in certain patients and under certain cir- 
 cumstances it so readily lapses into entero-colitis, it is more 
 than probable that it depends upon a distinct, though pass- 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 53 
 
 ing lesion — a hyperaemia or catarrh of the intestinal mucous 
 membrane. This is difficult to demonstrate, 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 au- 
 thors who advocate the functional character of the affection, 
 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 hy- 
 gienic 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 do not happen, the excess remains 
 undigested ; undergoes change ; acts as an irritant to the 
 intestinal mucous membrane, and causes diarrhoea. An- 
 other cause is food of bad quality; either poor and cho- 
 lesterin-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 farinacia, on account of their readi- 
 ness 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, 
 
154 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 solv- 
 ents and an increased production of mucus ; two conditions 
 most 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 loose- 
 ness of the bowels, and must greatly add to the ill effects of 
 exposure. High atmospheric temperature is much more in- 
 fluential than low, particularly 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 unsuit- 
 able 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 func- 
 tionally 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 55 
 
 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 pro- 
 gresses they undergo various changes. Sometimes they 
 are composed of a yellowish liquid containing white or 
 yellowish flakes resembling curdled milk. At others, dis- 
 tinct 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, and contain little 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. Occa- 
 sionally, if the stools be acid, considerable tenesmus attends 
 their expulsion, 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 abdo- 
 men is natural in shape, and is soft and painless on palpa- 
 tion. 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 fur- 
 
6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 ring 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 in- 
 flammation. 
 
 Prognosis. — The result of even the more serious attacks 
 in infants is, in the great majority of cases, favorable ; never- 
 theless, 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 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 man- 
 agement of this disease, it is necessary to draw attention to 
 the conservative nature of the diarrhoea. The frequent, 
 loose and copious stools clear the intestines of irritant mat- 
 ter, and remove the cause of further trouble. Conse- 
 quently, it is never advisable, early in the course, to com- 
 pletely arrest the evacuations, although at the same time 
 they must be kept well in hand, lest the attack pass into 
 entero-colitis. During dentition, particularly, this caution 
 must be observed, for when there are three or four loose 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 57 
 
 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 fre- 
 quently, 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 farina- 
 ceous 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, per- 
 fectly clean vessel, and, if possible, in an especial refrigerator. 
 And finally, to give careful, written orders as to the man- 
 ner of preparing the milk food, and to make a rule that each 
 bottle shall be mixed separately and only immediately be- 
 fore it is required. In hot weather it is often advisable to 
 boil the whole supply of milk, to prevent its souring, 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 may be given ; they are proportioned for children 
 of four to six months. 
 
 Unskimmed milk, f^iijss. 
 
 Cream, f^ss. 
 
 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. 
 
I58 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Or— 
 
 Unskimmed milk, f^iijss. 
 
 Cream, f^ ss - 
 
 Arrowroot- water,* f^ ij. 
 
 Sugar of milk, 3J. 
 
 Mix and treat as before. 
 
 The quantity is to be reduced and the dilution in- 
 creased in proportion 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, f^j. 
 
 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 occur, the child, well wrapped up, 
 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 
 
 * 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. 1 59 
 
 summer, and if the diarrhcea 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 solution 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 secondary, soothing action upon 
 the mucous membrane. For a child of six months, the dose 
 is a teaspoonful, with five drops of camphorated 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 efficient prescription, however, is : — 
 
 R . Sodii Bicarbonatis, 3 ss. 
 
 Syrupi Rhei Aromat., f^ ss » 
 
 Aquae Menthse Pip., q. s. ad f^ iij. 
 
 M. 
 
 S. — Teaspoonful every two hours. 
 
 The great value of rhubarb depends upon its combined 
 laxative and astringent action, precisely what is required in 
 simple diarrhcea. 
 
 Should the stools still fail to become less frequent and 
 more natural in color and consistence, resort must be 
 
l60 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 made to opium and astringents. A very good formula 
 is: — 
 
 R . Tr. Opii Deod., n\vj. 
 
 Bismuth. Sub-nitrat. (Squibb), ^j. 
 
 Syrupi, f^ ss « 
 
 Mistune Cretse, q. s. ad f^iij. 
 
 M. 
 
 S. — Teaspoonful every two hours. 
 
 The value of calomel in certain cases where the evacua- 
 tions obstinately remain green and acrid must not be over- 
 looked, though the necessity for its use is rare. It must be 
 employed cautiously and in small doses, and combined with 
 an alkali, thus: — 
 
 &. Hydrargyri Chloridi Mit, gr. j. 
 
 Cretae Prseparatae, ^j. 
 
 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 
 combination of aromatic syrup of rhubarb and chalk mixture 
 may be used. As with infants, a course of wine of pepsin, 
 or pepsin with muriatic acid, should terminate the treatment. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. l6l 
 
 5. 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 micro- 
 scope shows to depend 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 con- 
 gestion. 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 por- 
 tion 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 
 
 frequently arises insidiously from the constant action of the 
 
 great exciting cause — improper food. This cause is most 
 
 11 
 
1 62 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 operative in hand-fed infants, and at the time of weaning, 
 but it affects nurslings 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 various acute diseases, notably measles, croupous pneu- 
 monia, typhoid fever, variola and scarlet fever. 
 
 The predisposing agencies are bad hygienic surround- 
 ings, 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 changeable; and late 
 winter, when it is cold and damp. 
 
 Symptoms. — The first indication of the disease is an alter- 
 ation in the character of the stools. These assume the 
 color and consistence of putty, and are composed of curd 
 and farinaceous matter, 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 fre- 
 quency. Their odor is offensive and sour. The face is 
 pale and listless in expression, though the child is suffi- 
 ciently 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, suffi- 
 ciently 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 63 
 
 may be slimy and contain whitish masses of undigested 
 curd or particles of other food. The number of movements 
 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 
 prominent. 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 abdomen 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 ulceration ; 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 fasces and urine. Prostra- 
 tion is so great that the child lies perfectly passive ; the 
 pulse is feeble and frequent; the temperature is not ele- 
 vated, 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 con- 
 dition gradually grows worse. The stools become more 
 
164 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 watery; look like chopped spinach floating in brown, putrid 
 water, and may contain mucus and pus with blood, in 
 brownish-yellow masses. Abdominal distension, tenderness 
 and gurgling, the signs of intestinal 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 hanging 
 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, 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 evidence 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 
 termination. This circumstance alone has no favorable 
 significance. 
 
 Death may result from exhaustion, or several complica- 
 tions may arise and hasten this event. These are serous 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 65 
 
 effusions, hypostatic pneumonia, exanthemata, convulsions, 
 and thrombosis of the central sinuses. 
 
 Serous effusion may take place into the pleurae, perito- 
 neum 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 decu- 
 bitus, is a common cause of death. 
 
 The exanthemata are very prone to attack the subjects 
 of chronic diarrhoea, probably on account of the attendant 
 prostration 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 
 withdrawal 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 without, 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 engorged with blood, and as 
 the naturally sluggish current in the 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 longitudinal 
 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 symptoms preceding 
 death from this complication are difficult respiration ; stupor ; 
 dilatation of the pupils and strabismus; spasm of the poste- 
 
1 66 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 rior cervical muscles; fulness of the jugular veins, and uni- 
 lateral 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 improvement. 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. Irri- 
 tability 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 color- 
 less 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 of almost completely undigested 
 food and mucus. One evacuation occurs in the morning, 
 soon after rising ; 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 67 
 
 chamber or reaching the closet. The condition undoubtedly 
 depends upon great irritability of the intestine and exagger- 
 ated peristalsis. 
 
 Diagnosis. — The diarrhoea of chronic catarrh is to be 
 distinguished 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 mesenteric glands. On pressure there is tenderness and 
 gurgling in the right iliac fossa, and tension of the abdomi- 
 nal wall over this region. There is also evidence of tuber- 
 culosis 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 dis- 
 ease; when it occurs in syphilitic, rachitic or feeble subjects, 
 and when it is complicated by measles or other exanthem. 
 Unfavorable symptoms are dryness and roughness of the 
 tongue ; thrush ; anasarca ; features indicating intestinal 
 
1 68 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 ulceration, great depression of the fontanelle, and extreme 
 emaciation. Favorable symptoms are normal progression 
 of dentition ; the reappearance of tears ; intermissions in the 
 diarrhoea, and improvement in the character of the stools 
 and general symptoms. 
 
 Treatment. — As the disease is produced by over-crowd- 
 ing, neglect, exposure and unsuitable food, the initial 
 measures of treatment must be the regulation of the hy- 
 giene, clothing and diet. 
 
 The sleeping-room must be kept at a uniform temperature 
 — between 68° and yo° 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 redness 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 pa- 
 tients, 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, 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 69 
 
 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 do not improve under the change, both the 
 intervals and the time of nursing must be shortened. 
 
 If the infant be hand-fed, every caution must be taken 
 to insure purity of the food and perfect cleanliness of the 
 feeding apparatus. 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 tea- 
 spoonful every fifteen minutes can be allowed. The quality 
 depends upon the age. 
 
 For an infant under six months, cow's milk and lime- 
 water, in the proportion of one part to two, or in equal 
 quantities, may be tested. If this undergo acid fermenta- 
 tion, fresh whey and veal or chicken broth, with equal 
 quantities of barley-water, may be substituted. A tea- 
 spoonful 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. 
 
170 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 re- 
 sumed 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 ten- 
 don, 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 im- 
 parts 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 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 
 dissolved 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. I7I 
 
 be very frequent and watery, there can be no set meals, but 
 the food must be given by the teaspoonful at intervals of 
 ten 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 symp- 
 toms. 
 
 From older children it is necessary to withhold potatoes 
 and farinaceous vegetables generally; fruits, sugar, sweet- 
 meats, pastry, hot bread or cakes, butter and all made and 
 highly-seasoned dishes ; at the same time the bulk of each 
 meal must be somewhat 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 1 2 m. — The soft parts of eight raw oys- 
 ters, 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, 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 
 breakfast, and a slice of well-made cream toast. 
 
 An important rule in all cases is to watch the diet care- 
 fully 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, anointed 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 
 
172 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 num- 
 ber, 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 follow- 
 ing powder may be administered : — 
 
 R. Pulv. Ipecacuanhas Comp., gr. iv. 
 
 Cretae Praeparatse, gr. xxxvj. 
 
 M. et ft. chart. No. xij. 
 S. — One powder every four hours. 
 
 Or often better: — 
 
 R. Tr. Opii Deod., ti\,vj. 
 
 Sodii Bicarb., gr. xlviij. 
 
 Syrupi, f^ss. 
 
 Aquae Mentha? Pip., q. s. adf5iij. 
 
 M. 
 S. — One teaspoonful every four hours. 
 
 When the stools become frequent and green, the mixture 
 of opium, bismuth and chalk, already given (page 160), 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. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 73 
 
 This may be repeated every six or twelve hours, accord- 
 ing 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 be- 
 come watery and very fetid, astringents are required; for 
 example : — 
 
 R . Acid. Sulphurici Aromat, Tt\,xxiv. 
 
 Liquor. Morphiae Sulph., f^ij- 
 
 Elix. Curagoae, f J ss. 
 
 Aquae, q. s. ad fjiij. 
 
 M. 
 S. — One teaspoonful every three hours. 
 
 Or— 
 
 R . Argenti Nitratis, gr.ss. 
 
 Syr. Acaciae, f|> ss - 
 
 Aquae, 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 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. 
 
 A q U3e » f 3J- 
 
 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. 
 
174 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 As soon as the stools become normal in character and 
 frequency, the child must be ordered tonics, as : — 
 
 i& . Liquor. Ferri Nitratis, TT^xxiv. 
 
 Glycerinae, fijss. 
 
 Aq. Menthae Pip., q. s. ad f^iij. 
 
 M. 
 S. — One teaspoonful three times daily. 
 
 Or— 
 
 R. Ferri et Ammonii Citratis, gr. xij. 
 
 Tr. Gentianae Comp., f £j. 
 
 Spt. Lavandulae Comp., f ^ ij. 
 
 Syrupi Limonis, q. s. adf^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 : — 
 
 &. Syr. Rhei Aromat., f ^ vj. 
 
 Sodii Bicarbonatis, gij. 
 
 Tr. Opii Deod., . . . . ■ TTLxxxvj. 
 
 Aq. Menthae Pip., q. s. adf^iij. 
 
 M. 
 S. — One teaspoonful every three hours, for a child from four 
 to six years. 
 
 Or if the diarrhcea resist : — 
 
 1£. Tr. Krameriae, f ^ iij. 
 
 Tr. Opii Camphoratae, f ^ ij. 
 
 Spt. Lavandulae Comp., f 3 ij. 
 
 Misturae Cretae, q. s. ad f^ iij. 
 
 M. 
 S. — Two teaspoonfuls every three hours. 
 
 The lienteric form of diarrhcea should not be treated by 
 astringents but by nux vomica, followed by arsenic. For 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 75 
 
 instance, 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. 
 
 Afterwards : — 
 
 R. Liq. Potassii Arsenitis, f ( ^j. 
 
 Inf. Gentianae Comp., q. s. ad f 5iij. 
 
 M. 
 S. — One teaspoonful after each meal. 
 
 During convalescence from chronic diarrhoea, older chil- 
 dren do well upon the same tonics as infants, the doses 
 being proportionately increased. 
 
 6. ENTERO-COLITIS. 
 
 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 sum- 
 mer," and justly, for among those unfortunates 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 
 inflammatory hyperaemia of the intestinal mucous mem- 
 brane. This may be distributed over the whole tract, but 
 commonly it is limited to the ileum and colon, and is most 
 intense in the neighborhood of the ileo-csecal valve and 
 the sigmoid flexure. The mucous membrane is reddened, 
 
I76 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 corresponding to 
 the inflamed glands, presents areas of arborescent injection. 
 There is moderate enlargement of the mesenteric glands. 
 
 Front this condition it is but a step to the state of ulcera- 
 tion seen in chronic intestinal catarrh — a not infrequent 
 result of entero-colitis. 
 
 The stomach, as already hinted, is usually normal in 
 appearance ; occasionally its mucous membrane is reddened 
 and thickened, and it is quite possible that this viscus is 
 often the 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 
 important 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 watch- 
 ing, 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. \JJ 
 
 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. Two 
 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 augmented to the propor- 
 tions of an epidemic. Late in September or in October, ac- 
 cording, 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 tempera- 
 ture 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 pro- 
 ductive, and of all months August is the most fatal, both on 
 this account and because a high temperature is maintained 
 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 under- 
 going, and the fact that 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 etiologi- 
 cal condition ; the vast majority of cases occur where the 
 12 
 
I78 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 streets are narrow and more than ordinarily filthy, and where 
 the houses are overcrowded and dirty, and the people poor, 
 ill-fed and unclean. 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 excep- 
 tional occurrence. This factor is an atmosphere polluted 
 by poisonous gases and containing countless 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 produces entero-colitis. 
 
 Symptoms. — For one or two days prior to the actual 
 attack, the infant is restless and fretful ; his sleep is dis- 
 turbed by moaning 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, eructa- 
 tions of very sour-smelling material are apt to occur, and 
 the stools are somewhat more numerous and softer than 
 usual. 
 
 Next, vomiting and diarrhoea set it. The former occurs 
 after feeding, and, in bad cases, is so obstinate that nothing 
 is retained. 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 hour to hour. At first, they are semi-solid, 
 homogeneous, yellow in color and neutral in reaction ; then 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 79 
 
 they become more liquid and green, though still homoge- 
 neous 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 yel- 
 low 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 sec- 
 ond, 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 dis- 
 tended by flatus, and, at times, there is tenderness on pres- 
 sure. 
 
 With these features there is pyrexia, moderately high 
 and continuous 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 fontanelle, if still membranous, is depressed; the fat 
 
l80 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 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 uni- 
 lateral than general. In others, there is drowsiness, an 
 apathetic refusal of food, cessation of vomiting and diar- 
 rhoea, 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 in- 
 stances, due to uraemic 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 inter- 
 est in his surroundings ; takes his food better, and rapidly 
 regains flesh and strength. 
 
 Diagnosis. — The pyrexia, the vomiting, and the fre- 
 quency and character of the stools, taken in conjunction 
 with the early age of the patient; the season and local- 
 ity of occurrence; and the almost epidemic prevalence 
 of the disease, make its distinction 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 161 
 
 inflammation ; their absence, by inference, to the small 
 intestine. 
 
 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 dis- 
 couraging 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 
 convulsions. 
 
 An attack may prove fatal in four or five days, or it may 
 be protracted for two weeks. The latter is about the dura- 
 tion 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 intense 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 dur- 
 ing 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 impos- 
 
152 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 sible to clean ill-paved ones — entero-colitis would become a 
 far less common disease. 
 
 When an attack occurs during the hot months, the pa- 
 tient, 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 im- 
 portant to fix upon a place affording a decided change of 
 air and a lower temperature. From Philadelphia the infant 
 may be taken to Cape May, Point Pleasant, Long Branch 
 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 temperature 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 83 
 
 purse can afford it. These cool spongings must be sup- 
 planted by full warm baths when there is much prostration. 
 
 In regulating the diet, it must be remembered that the 
 presence 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 he 
 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 ; received and kept in perfectly clean vessels, and 
 administered from an absolutely clean bottle fitted with a 
 simple tip. In very hot weather, and in houses where ice 
 is scarce, it is well to have the whole day's supply boiled 
 for five minutes as soon as it comes in the morning, to pre- 
 vent its souring. From this a portion is to be taken at 
 each time of feeding and prepared in one of the following 
 ways : — 
 
 Milk, fgiij. 
 
 Cream, f^ss. 
 
 Lime-water, f^ijss. 
 
 Sugar of milk, gj. 
 
 Mix in a clean tin-cup, pour into bottle, adjust tip, and 
 warm by plunging into hot water. 
 
 Milk, fgiij. 
 
 Cream, f^ss. 
 
 Mellin's Food, gij. 
 
 Hot water, f^ijss. 
 
 Dissolve the Mellin's food in the hot water, add the milk 
 and cream, and, if necessary, warm as before. 
 
184 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Milk, fjfiij. 
 
 Cream, f^ ss - 
 
 Flour-ball,* ^j. 
 
 Water, f" ^ ijss. 
 
 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 propor- 
 tionate reduction in the amount and strength of the food. 
 
 When preparations of milk are vomited or passed undi- 
 gested from the bowels, a whey mixture or strippings can 
 be resorted to, and if these fail, beef-juice, or — 
 
 Flour-ball, £ij. 
 
 Water, fgvj. 
 
 Mix, and add — 
 
 Half the white of a fresh egg. 
 
 Bits of ice and cool, filtered water can be allowed, in 
 moderation, to relieve the thirst. 
 
 The medical treatment, should the case be seen early, 
 may be initiated by a laxative. A teaspoonful of castor oil 
 with five drops of paregoric, or the same quantity of spiced 
 syrup of rhubarb, will be sufficient for an infant of one year. 
 Afterward, while the stools are yellow, homogeneous and 
 not very frequent, alkalies and astringents are alone needed, 
 as : — 
 
 R. Sodii Bicarbonatis, gr. xviij. 
 
 Bismuthi Sub-carbonatis (Squibb), .... gr. xxxvj. 
 
 Pulv. Aromat., gr. yj. 
 
 M. et ft. chart. No. xij. 
 S. — One powder every two hours, for a child of one year. 
 
 Or— 
 
 R. Sodii Bicarb., gr. xxxvj. 
 
 Syrupi Rhei Aromat., f :f ss. 
 
 Misturse Cretse, q. s. ad f ^ iij. 
 
 M. 
 S. — One teaspoonful every two hours, at the same age. 
 * For mode of preparing Flour-ball and mixing with water, see Part III. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 85 
 
 When the stools are green, numerous, and acid in reac- 
 tion, the indication for alkalies is still stronger, but small 
 doses of opium should be added, thus : — 
 
 R . Tr. Opii Deod., rr^vj. 
 
 Bismuthi Sub-carb., gr. lxxij. 
 
 Syrupi, f^ ss. 
 
 Misturse Cretse, q. s. adf^iij. 
 
 M. 
 S. — One teaspoonful every two hours. 
 
 R. Pulv. Ipecac. Comp., gr. ij . 
 
 Bismuthi Sub-carb., gr. xxxvj. 
 
 M. et ft. chart. No. xij. 
 S. — One powder every two hours. 
 
 Another good mixture, when there is much pain and heat 
 of skin, is : — 
 
 R. Magnesii Sulphatis, £j. 
 
 Tr. Opii Deod., rt\vj. 
 
 Syrupi, fgj. 
 
 Aq. Menth. Pip., q. s. ad f^iij. 
 
 M. 
 S. — One teaspoonful every two hours. 
 
 At the same time, it is well, two or three times a day, 
 to redden the skin of the whole abdomen with a weak 
 mustard draught — one part of mustard to five of flour. 
 
 When the evacuations are liquid and contain whitish 
 or greenish flakes, the opium and alkaline treatment should 
 be resorted to first; but if, after a fair trial, their char- 
 acter remain unchanged, good results will often be ob- 
 tained by minute doses of calomel, continued from twelve 
 to forty-eight hours, as in the following prescription : — 
 
 R. Pulv. Ipecac. Comp., gr. ij. 
 
 Hydrarg. Chlorid. Mit., gr. j. 
 
 Cretae Praeparatae, gr. xxxvj. 
 
 M. et ft. chart. No. xij. 
 S. — One powder every two hours, or every four hours alter- 
 nating with the opium and bismuth mixture. 
 
1 86 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Under the mercurial the stools become homogeneous 
 and yellow, and the irritability of the stomach is much 
 relieved. If, however, this change is not observed after a 
 forty-eight hours' course, it is useless to push the treat- 
 ment further. 
 
 Very frequent and serous stools demand more powerful 
 astringents, as : — 
 
 &. Acid. Sulph. Aromat., Tt^xxiv. 
 
 Liquor. Morphiae Sulph., f^j. 
 
 Elix. Curacoae, f.^ij- 
 
 Aquae, q. s. ad f^iij. 
 
 M. 
 
 S. — One teaspoonful, diluted, every two hours. 
 
 Or— 
 
 R . Argenti Nitratis, gr. ss. 
 
 Syrupi Acacias, f^ ss « 
 
 Aquae, q. s. ad f 3; iij. 
 
 M. 
 S. — One teaspoonful every two hours. 
 
 Rectal injections are very useful, and sometimes, when 
 the stomach is very irritable, may be the only means of 
 medication. Laudanum, in doses of three drops in a table- 
 spoonful of starch-water, may be given every six hours, or 
 oftener, when the motions are frequent and attended by pain 
 and straining; nitrate of silver when they are serous, or 
 contain mucus, blood or pus. J. Lewis Smith's formula is 
 a good one ; it is : — 
 
 &. Argenti Nitratis, gr. j. 
 
 Bismuthi Sub-nitratis, gj. 
 
 Mucilag. Acacia?, 
 
 Aquae, aa ^ ss. 
 
 M. 
 
 The whole of this is to be used at once, with or without 
 the addition of laudanum, and it may be repeated at inter- 
 vals of twelve hours. These injections must be preceded 
 by enemata of warm water to clean out the bowel, and they 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 87 
 
 must be discontinued for twenty-four hours every third or 
 fourth day. 
 
 When the buttocks and thighs become excoriated, the 
 parts must be kept dry and clean, and protected by frequent 
 applications of oxide of zinc ointment. 
 
 Stimulants are required when there is prostration or col- 
 lapse. Wine of pepsin is to be preferred on account of its com- 
 bined stimulating and digesting qualities, but whiskey or 
 good brandy, if it be possible to get it, can be used. The 
 dose must depend entirely upon the age and the depression 
 to be resisted. 
 
 In cases of recovery, the diet and hygiene must be care- 
 fully watched until all danger of a return has passed ; the 
 astringents are to be gradually dropped, and digestants and 
 tonics ordered. Of the former, a powder composed as fol- 
 lows may be given : — 
 
 R . Pepsin. Sac, 
 
 Sodii Bicarb., aa gr. xxx. 
 
 Pulv. Aromat., gr. vj. 
 
 M. et ft. chart. No. xij. 
 S. — One powder four times daily. 
 
 Or pepsin may be combined with muriatic acid, thus : — 
 
 &. Pepsin. Sac, %). 
 
 Acid. Muriat. dil., f gj. 
 
 Aq. Cinnamoni, q. s. ad f 3 ii j . 
 
 M. 
 S. — One teaspoonful, diluted, three times daily. 
 
 Tonics should not be ordered until the digestion has been 
 righted ; then simple bitters, as tincture of nux and compound 
 tincture of gentian, are to be given, and afterward the citrate 
 of iron and quinia, ferrated elixir of cinchona, or bitter wine 
 of iron. 
 
 The exceptional cases that occur in cold weather should, 
 of course, be treated at home in a well-ventilated and warm 
 
1 88 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 room; otherwise, the only alteration to be made in the 
 general plan of management is to envelop the abdomen with 
 light linseed poultices, or with cotton covered by oiled silk. 
 
 7. 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 respiration and pulse, 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 mem- 
 brane is congested, thickened and softened, and the fol- 
 licles 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 some envolvement of the sympathetic 
 nerves, leading to dilatation of the capillaries and transu- 
 dation 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 
 sympathetic nerves. It is due, in part, to direct over-stimu- 
 lation by the irritant contents of the canal, and in part to 
 the nerve exhaustion produced by high atmospheric tem- 
 perature, one of the essential causes of cholera infantum. 
 The changes in calorification and in the functions of the 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 89 
 
 heart, lungs, and kidneys depend 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, 
 finding its victims chiefly among those who live in pov- 
 erty 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 propor- 
 tion of cases originate during the latter half of July, August, 
 and the first half of September. Infants from six to twelve 
 months are the most susceptible 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 development of 
 the follicles that accompany dentition rather than the mere 
 act of cutting teeth. The direct causes are high temperature 
 (85°-95° F. or more); sustained for several days, and espe- 
 cially 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 may be preceded by diarrhcea. In either case the onset 
 is sudden. The infant begins to void copious stools. These 
 at first, if there has been no premonitory diarrhcea, 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 
 
I9O DISEASES OF DIGESTIVE ORGANS IX CHILDREN. 
 
 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 considera- 
 ble force. 
 
 At the same time, or soon after, the stomach becomes so 
 irritable that everything, even to a mouthful of ice-water, is 
 rejected as soon as swallowed, and there is violent retch- 
 ing. 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, per- 
 haps plump and rosy before, can scarcely be recognized ; the 
 face becomes pale and pinched ; the eyes and cheeks sunken, 
 and the eye-lids 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 frequent as to be uncountable ; the respira- 
 tory 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. I9I 
 
 face is set with the lines of death ; the respiration is 
 quickened and shallow ; the pulse scarcely perceptible, 
 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 con- 
 vulsions. 
 
 The course of the disease, whatever the result, is al- 
 ways 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 diar- 
 rhoea. 
 
 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 surroundings, and 
 after a week or more of simple diarrhoea, regains a mod- 
 erate degree of health. 
 
 Diagnosis. — The character of the stools; the extreme 
 irritability 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 points of similarity as well 
 as those of dissimilarity, may be seen in the following 
 table :— 
 
I92 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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. 
 
 Cerebral symptoms marked, but Cerebral symptoms marked, but 
 
 secondary. primary. 
 
 Gastro-intestinal symptoms, prece- Gastro- intestinal symptoms, sec- 
 dent and prominent. ondary. 
 
 Onset rapid. Onset sudden, by a stroke. 
 
 Preceded by diarrhoea or un- No such previous history, 
 comfortable sensations. 
 
 Restlessness at onset. Stupor from beginning. 
 
 Occurs at any time of day or Occurs only during excessive heat 
 
 night. of day. 
 
 Inflammatory lesions of intestines. No such lesions. 
 
 Between epidemic cholera and cholera infantum it is im- 
 possible 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 choleraform symp- 
 toms be survived, there is danger from the succeeding 
 diarrhoea. The disease is most fatal in children of the 
 poor, who are badly fed and subjected to the worst hy- 
 gienic 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 con- 
 sequence 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 93 
 
 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. 
 
 To check the diarrhoea opium and astringents are neces- 
 sary. A very serviceable formula is : — 
 
 R. Liquor. Morphiae Sulph., f^j. 
 
 Acid. Sulphurici Aromat., TT^xxiv. 
 
 Elix. Curacose, f^ss. 
 
 Aquae, q. s. ad f^iij. 
 
 M. 
 S. — One teaspoonful every two hours, for a child of six 
 
 months old. 
 
 With this, two drops of laudanum, suspended in two tea- 
 spoonfuls 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 a bed, and not be 
 constantly nursed on 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 prostra- 
 tion. From five to ten drops of whiskey in a teaspoonful 
 13 
 
194 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 Acaciae, f^j. 
 
 Aq. Menth. Pip., q. s. ad f 5iij. 
 
 M. 
 S — One teaspoonful p. r. n. 
 
 The temperature must be maintained by hot flannel 
 wraps and hot-water bottles, and the child kept in a hori- 
 zontal 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 en- 
 tirely, 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. 
 
 8. 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 95 
 
 surface presents more or less adherent pseudo-membranous 
 patches, which, when removed, leave ulcers of irregular out- 
 line and variable depth. Perforation and cicatricial contrac- 
 tion 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 exposure to cold and wet. The epidemic form is 
 certainly infectious, 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 be- 
 come distended. The evacuations are numerous, ranging 
 from four to forty a day ; small in quantity and voided with 
 much straining. At first they contain faecal matter, but 
 after a short time are composed entirely of mucus and 
 blood, mixed with yellow or green flocculi, fragments of 
 false membrane and pus. The blood may appear in dark 
 red streaks or clots ; in black masses ; as a substance re- 
 sembling the washings of meat, or merely diffused through 
 the mucus, giving it a uniform red color. Their odor is 
 most offensive. 
 
 The face wears an anxious expression ; there is great rest- 
 lessness, sleeplessness, muscular weakness, and rapid ema- 
 ciation. 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 
 permanent symptom; it occurs without the passage of stools, 
 
I96 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 character of the stools. 
 
 The Prognosis is favorable in the sporadic form and 
 when there is only slight elevation of temperature and 
 moderately frequent stools. Quite the reverse, if there be 
 high fever, great tenesmus, frequent evacuations contain- 
 ing 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 cool- 
 ness are concerned — that the house affords. Their diet 
 should be liquid, and even this form of food must, on ac- 
 count of the irritability of the stomach, be given in mod- 
 erate quantities. From four to 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, f3 ss - 
 
 Water, 13J. 
 
 Small pieces of ice and moderate quantities of iced filtered 
 water can be allowed to relieve thirst. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 97 
 
 Two or three times daily the body should be thoroughly 
 sponged with water at a temperature of 95 °R, and the abdo- 
 men 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 
 treatment may be begun with a laxative, as : — 
 
 R. 01. Ricini, fgijss. 
 
 Pulv. Acacise, ^ij. 
 
 Tr. Opii, TTLviij . 
 
 Aq. Menth. Pip., q. s. ad fgij. 
 
 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 fol- 
 lowing : — 
 
 R. Pulv. Ipecac. Comp., gr. vj. 
 
 Bismuthi Sub-carb., gj. 
 
 Pulv. Aromat., gr. vj. 
 
 M. et ft. chart. No. xij. 
 S. — One powder every three hours. 
 
 With an enema of laudanum — gtt. iij to fSss of warm 
 water — every four hours ; or a suppository of opium and 
 acetate of lead : — 
 
 R . Pulv. Opii, gr. ss. 
 
 Plumbi Acetat., gr. j. 
 
 01. Theobromae, gj. 
 
 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 
 
I90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 follow them with enemas of laudanum. A good formula 
 for administration by the mouth is : — 
 
 U. Argenti Nitrat., g r - j- 
 
 Tr. Opii Deod., Tl\xxiv. 
 
 Syr. Acacise, f ^j. 
 
 Aquae, q. s. ad f 3iij. 
 
 M. 
 
 S. — One teaspoonful every three hours. 
 
 For an enema : — 
 
 R. Argenti Nitrat., gr. j. 
 
 Aquae Dest., f/>ij- 
 
 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 stimu- 
 lants, in doses and at intervals proportionate to the demands 
 of the case. Should collapse occur, alcohol and artificial heat 
 to maintain 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 with compound tincture of 
 gentian, followed by ferrated elixir of cinchona, or citrate 
 of iron and quinia. 
 
 9. TUBERCULAR ULCERATION OF THE IN- 
 TESTINES. 
 
 This form of ulceration commonly occurs as a complica- 
 tion of pulmonary and abdominal tuberculosis. Gray gran- 
 ulations may or may not be present at the site of lesion, 
 but the special degenerative process in the intestinal mucous 
 membrane is so intimately associated with tubercle that the 
 term, " tubercular ulceration," seems to be warranted. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 1 99 
 
 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-csecal 
 valve. The follicles become enlarged from multiplication 
 of their cell elements, 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 intestine, 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 lymphatics, or on the reddened 
 and cloudy peritoneal surface corresponding to the ulcers. 
 Cicatrization takes place rarely, but may be the cause 
 of stricture. 
 
 The uninvolved mucous membrane is congested, thick- 
 ened and softened. The mesenteric glands are enlarged 
 and cheesy, and miliary tubercles are usually found in the 
 lungs or elsewhere. 
 
 Etiology. — The disease is met with in children who 
 have passed the fourth year, and in whom the tubercular or 
 strumous diathesis exists. Bad hygiene, bad food, and ex- 
 posure, act as predisposing causes, by interfering with gen- 
 eral nutrition and paving the way for the development of the 
 diathetic tendency. An unsuitable diet, too, may indirectly 
 
200 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 lead to this form of ulceration, by bringing about an ab- 
 normal 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 offen- 
 sive 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 disten- 
 sion 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 pul- 
 monary phthisis. Such cases usually result fatally, after a 
 more or less protracted course, the direct causes of death be- 
 ing 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 diarrhcea. Half a teaspoonful 
 three times daily is quite enough for a child of five years. 
 It may be given combined with maltine, or in an emulsion 
 with lacto-phosphate of lime, or the compound syrup of the 
 hypophosphites. The following is an admirable formula : — 
 
 R. Olei Morrhuse, f ^ ij. 
 
 Ext. Malt, (Dry) , Jjiv. 
 
 Calcii Hypophos., 
 
 Sodii Hypophos., aa gr. xvj. 
 
 Potassii Hypophos., gr. viij. 
 
 Glycerinse, f ^ ij. 
 
 Pulv. Acaciae, ^ij. 
 
 Aquse, q. s.adf^iv. 
 
 M. 
 S. — One teaspoonful three times daily. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 201 
 
 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. 
 
 10. 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 wakefulness, that it demands separate 
 consideration. 
 
 Etiology. — In studying the causation of this condition, 
 it must be remembered that after birth the infant, previously 
 nourished 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 imper- 
 fectly or slowly digested and flatulence and colic result. 
 
 Food that is at all difficult to digest almost always occa- 
 sions 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-sensitive- 
 ness of the mucous membrane to the contact of food. 
 
202 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Symptoms. — Soon after feeding, the infant becomes rest- 
 less, 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 around the lips. The belly is full and 
 hard, the hands and feet are cold, and, in bad cases, the fon- 
 tanelle is more or less depressed. 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 expression of pain often flits over the face ; but, in 
 spite of the fretfulness 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 whenever it is offered, and the warm milk 
 entering the stomach relieves the pain for a time, only, how- 
 ever, to increase it later by giving the viscus more work to 
 do, and filling it with material to undergo fermentation with 
 the production of flatus. Consequently, it is much better 
 to resort to one of the preparations to be hereafter 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 
 supplemented by hand-feeding. Under these circumstances, 
 and when the whole feeding is by bottle, much may be done 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 203 
 
 to prevent or relieve the attacks of pain by attention to 
 cleanliness of the feeding 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, fgij. 
 
 Cream, f^ij. 
 
 Barley-water, f^ij- 
 
 Caraway-water, fgj. 
 
 Sugar of milk, . . . . , 3 ss * 
 
 These ingredients are to be mixed in a clean vessel, 
 poured into a perfectly clean bottle, and heated to a tem- 
 perature of about 98°F. in a water-bath.* 
 
 When the bowels are inclined to constipation, the barley- 
 water may be replaced by a gruel made of ground oat- 
 meal (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 body should be anointed twice a day with warm olive 
 oil, and enveloped in a broad flannel binder. It is even 
 more important to keep the feet warm, and for this purpose 
 thick socks or long woolen stockings should be worn, and 
 in bad cases, artificial 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 teaspoonful of sweetened warm water. Another is : — 
 
 R. Sodii Bicarb., gr. xvj. 
 
 Syrupi, f^ ss ' 
 
 Aq. Menth. Pip., q. s. ad 'f^ij. 
 
 M. 
 
 S. — One teaspoonful p. r. n. for a child of one month. 
 * A tin-cup half filled with water, placed on an ordinary stand over a gas- 
 burner, makes a good water-bath for nursery use. 
 
204 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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. Mentha? Pip., q. s. ad f^ij. 
 
 M. 
 S. — One teaspoonful for a dose. 
 
 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 ordi- 
 nary 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 administered by the mouth. 
 If the fontanelle still remain depressed, the stimulant must 
 be continued in doses and at intervals proportioned 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 wine of pepsin three times daily. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 205 
 
 ii. 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 func- 
 tional 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, in- 
 herited sluggishness of the peristaltic movements must be 
 remembered as a possible cause. 
 
 Symptoms. — These vary greatly in degree. Thus, an in- 
 fant, 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 disten- 
 sion, diminished appetite, occasional vomiting, feverishness, 
 fretfulness, restless sleep, and, in bad cases, convulsions. 
 
 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, pal- 
 
206 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 pation often reveals the presence of hard masses along the 
 course of the descending colon. The tongue is coated ; the 
 appetite capricious ; there is nausea and a sensation of dis- 
 comfort in the rectum, leading to frequent, though unpro- 
 ductive, 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 
 existence 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 obsti- 
 nate 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 generating a condition of general ill-health, during which 
 the child is more exposed to the attack of acute and dan- 
 gerous 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 and suppositories to the administration of the same 
 class of.remedies 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.* 
 
 * An enema composed of one teaspoonful of common salt to four fluid- 
 ounces of warm water is very efficient. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 207 
 
 The preliminary injections of oil soften the faeces, while the 
 clysters — which must vary in bulk from one to six fluid- 
 ounces, 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 
 contents. 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 supporting 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. 
 
 As with all injections, this must be thrown in gently, and 
 the action of the syringe stopped as soon as pain is pro- 
 duced. 
 
 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, gj. 
 
 M. et ft. supposit. No. vj. 
 S. — One to be inserted every morning or morning and 
 evening. 
 
208 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 to call in the aid of medicines. 
 
 Bottle-fed babies must be fed upon cows' milk, so modi- 
 fied 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 Mel- 
 lin's food or oat-meal, can be added. An admirable mixture 
 for a child of three months is : — 
 
 Milk, Hjiv. 
 
 Cream, f^ ss - 
 
 Sugar of milk, ^j. 
 
 Bethlehem oat-meal (fine powder), gij. 
 
 Water, f^iij- 
 
 In preparing this, the water must be heated — just 
 short of boiling — in a tin vessel, and the oat-meal added 
 slowly, with stirring, until a smooth, white mixture be 
 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, and a judicious use made of such 
 articles as oatmeal 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 ; 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 209 
 
 and with children more advanced in age, cold spongings of 
 the belly, followed by frictions with a coarse towel until the 
 surface is red, are very beneficial. 
 
 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 em- 
 ployed. 
 
 For infants a very serviceable prescription is : — 
 
 R. Mannse Opt., 
 
 Magnesii Carb., . . . . aa >>ij. 
 
 Ext. Sennse Fid., f^ss. 
 
 Sympi, fjfj. 
 
 Aq. Menth. Pip., q.s.ad f^iij. 
 
 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, ff^xlviij. 
 
 Syrupi, q. s. adf^iij. 
 
 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, 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 five or ten grains 
 three times each day, at the age of six months. 
 
 Children of three or four years and upward do best 
 H 
 
210 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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. Belladonna;, 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 mix- 
 ture,* thus : — 
 
 R. Tr. Belladonnse, fgj. 
 
 Tr. Aloes et Myrrh., f^ss. 
 
 Mucilag. Acacias, q. s. 
 
 Aquse Menth. Pip., q. s. ad f^ iij. 
 
 M. 
 S. — One teaspoonful for a dose. 
 
 In using aloes and myrrh, it is usually necessary to re- 
 duce the dose after a time, as its purgative action increases 
 rather than diminishes with repetition. 
 
 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. The taste being pleasant, it may be 
 
 * 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. 
 
 Glycerins, f^j. 
 
 Aqua;, 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. 211 
 
 administered without difficulty, and it does not lose its 
 effects by repetition. 
 
 I have lately used with much satisfaction a laxative con- 
 fection, 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. White 
 wheat gluten suppositories,* melted and remade into one- 
 half the original size for children under two years, are 
 very useful. One may be inserted every evening, every 
 morning and evening, or on alternate days, as the urgency 
 of the case demands. 
 
 12. SIMPLE ATROPHY. 
 
 Simple atrophy, or, as it is often termed, marasmus, is a 
 condition in which there is extreme wasting of the soft tis- 
 sues of the body, either without special organic lesions or 
 with catarrhal inflammation 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 disappearance of normal fat from the body. Fatty 
 degeneration of the kidneys, lungs and brain may be dis- 
 covered ; the stomach is sometimes ulcerated, and hemor- 
 rhagic effusions into the cranium 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 
 
 * Manufactured by the Health Food Co., of N. Y. 
 
212 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 the poor. It arises both in breast-fed babies and in those 
 brought up by hand, being, in either case, due to insuffi- 
 cient 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 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 quantity of food is 
 too small ; the fault lies, rather, in the direction of quality. 
 Undiluted cows' milk ; milk thickened with starchy mate- 
 rials ; farinaceous foods, and even table food — meat, vegeta- 
 bles, and bread — are given to babies a few weeks or months 
 old. Now, all of these are highly nutritious, but the diges- 
 tive apparatus is not sufficiently developed to prepare them 
 for absorption. 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 intes- 
 tines, 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, 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 21 3 
 
 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 few days have passed without his seeing 
 several of the complicated contrivances referred to. In 
 almost every instance, notwithstanding the most careful and 
 frequent cleansing, a sour odor could be detected, and if 
 milk were present, it contained numerous small curds; while 
 in cases of carelessness the odor was intolerable, 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 difficulty in 
 keeping the bottles themselves clean, there can be only one 
 reason for this difference, namely, in the old-fashioned 
 instrument the nipple is readily removed and as easily in- 
 verted and cleaned, but in the other there is no way of 
 cleaning thoroughly 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 
 
214 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 the bottle. It is evident that a constant supply of food, no 
 matter how good originally, thus rendered acid and partially 
 curdled, must, like an excess of farinaceous or other unsuit- 
 able food, produce irritation of the alimentary canal, inter- 
 fere with the processes of nutrition, and lead to a state in 
 which the features of wasting and disordered digestion are 
 combined. 
 
 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 mix- 
 ture be proportioned, 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, conse- 
 quently, lead to wasting, if the digestive powers be suddenly 
 reduced by an intercurrent disease. 
 
 Symptoms. — The clinical features differ materially, accord- 
 ing to whether the element of insufficiency be one of quan- 
 tity 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 en- 
 countered 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 irri- 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 215 
 
 table and sleep restless and disturbed, or the child is abnor- 
 mally 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 constipation, 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 
 depending upon the original strength of the child's consti- 
 tution; 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. 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. Un- 
 suitable 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 fur- 
 
2l6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 row about the angles of the mouth ; the facial expression is 
 uneasy or languid, and the anterior fontanelle is deeply de- 
 pressed. The skin, generally, is dry, harsh and yellowish ; 
 hangs in loose folds over the bones, and may be mottled 
 by an eruption of strophulus or urticaria, 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 mem- 
 brane 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, particu- 
 larly during the night, are spent in fretful crying. A com- 
 mon group of symptoms connected with the nervous 
 system is " inward spasms." When these occur, the upper 
 lip becomes livid, somewhat 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 
 
 * See chapters on Chronic Vomiting and Diarrhoea. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 217 
 
 complex. Thus, I have seen cases where there was retrac- 
 tion 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 symptoms disappear under 
 an appropriate diet, with proper medicinal treatment, and 
 are to be referred to an intensely excitable nervous 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 10 1 2.5 ; a strong, characteristic odor, and is 
 diminished in quantity. It is always cloudy or milky, only 
 becoming clear on the approach of recovery. The sedi- 
 ment 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 
 increased. 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 
 syphilis 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 menin- 
 gitis are present, it is often necessary to delay a definite 
 
 * " Parrot and Robin." 
 
2l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 opinion. In 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 hydrencephalic cry, and the antece- 
 dent history and the course are different from the tubercu- 
 lar 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 hydro- 
 cephalus arise; convulsions occur; or obstinate chronic 
 vomiting or diarrhoea be developed. 
 
 Treatment. — For the arrest of wasting from insufficient 
 nourishment, the first thing to be attended to is the diet. 
 Without entering at length into this subject,* it may be 
 stated, as a uniform 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 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 
 
 * For the details of diet and general management, see Part III. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 219 
 
 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 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 diges- 
 tion. 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 suitable 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 egg, 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 morn- 
 ing 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. 
 
220 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 emul- 
 sion, and may be advantageously combined with lacto-phos- 
 phate of lime or with the hypophosphites. 
 
 Such symptoms as constipation, diarrhoea and vomiting 
 demand, of course, appropriate treatment. 
 
 13. TYPHLITIS AND PERITYPHLITIS. 
 
 Destructive inflammation of the coats of the caecum or 
 vermiform appendix — typhlitis — and of the post-caecal areo- 
 lar 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 vermi- 
 form appendix occurs. 
 
 Morbid Anatomy. — In typhlitis without ulceration, a 
 large extent of the mucous lining of the caecum or appen- 
 dix 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 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 221 
 
 affected, there is a tendency to involvement, with destruc- 
 tion, 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 intestinal contents escape into the peritoneal 
 sack, in spite of the adhesions — which are rarely firm enough 
 to offer an efficient obstacle — 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- 
 caval connective tissue, and causes inflammation, with sup- 
 puration, 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 iliac crest. Sometimes the ulceration 
 stops before perforation occurs, and the inflammation as- 
 sumes 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 
 extremity, or, more frequently, at some point in the lower 
 third of the canal. As tb extent, the loss of substance 
 may be small or involve the whole circumference. A col- 
 lection 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 perforation. While the ulceration is 
 going on, firm adhesions are occasionally formed with the 
 
 * Meigs and Pepper. 
 
222 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 caecum ; the anterior wall of the abdomen, or the tissues of 
 the right iliac fossa. If the first event occur, the resulting 
 circumscribed abscess opens into the intestine ; 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 
 smooth, waxy-looking surface; are grayish or brown in 
 color, and are composed of earthy phosphates combined 
 with inspissated 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 mes- 
 entery, may be bent at an angle (instead of being directed 
 upward and inward) so that hardened particles can slip 
 readily into it, but are prevented from returning." * 
 
 Etiology. — In addition to peculiar anatomical rela- 
 tions and physiological attributes, which render the seg- 
 ment of intestine in question very prone to disease, a con- 
 stipated habit is the chief predisposing cause. The exist- 
 ence of the strumous diathesis, too, while it has little 
 influence in increasing the susceptibility to typhlitis, does 
 augment the tendency to ulceration and perforation after 
 inflammation is established. 
 
 * Diseases of Children, p. 678. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 223 
 
 Retention of hardened faecal matter in the caecum, the 
 so-called " typhlitis stercoralis " ; accumulation of the seeds 
 of certain 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 appendix, 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 ulcer- 
 ation of typhoid fever or of intestinal tuberculosis. 
 
 Symptoms. — Simple typhlitis begins suddenly, with pain 
 in the right iliac region, and vomiting. The pain is con- 
 stant and severe, and is increased by coughing, sneez- 
 ing, vomiting and by efforts to stand or walk. The 
 vomiting is attended by distressing retching ; is often re- 
 peated, and the ejections consist, first, of food, and after- 
 wards, 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. 
 
 When properly managed, these symptoms disappear in 
 from four to twelve days ; the bowels yield and move 
 

 224 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 freely with the expulsion of masses of hardened fasces ; 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 dis- 
 tressed face, and is listless. 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 suffer- 
 ing 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 
 affected region, which is increased by movement or pres- 
 sure ; 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, 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 225 
 
 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 develops, with rigors or chills, followed by 
 profuse sweating ; a dry, brown tongue ; diarrhoea ; a run- 
 ning, feeble pulse ; prostration and rapid loss of flesh. The 
 abdomen becomes distended and very painful ; the caeca! 
 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; pal- 
 pation 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, swell- 
 ing and tenderness diminish, and the general symptoms 
 improve. 
 
 The uncommon cases in which perityphlitis occurs 
 without previous typhlitis, are marked by pain ; deep ten- 
 derness and moderate 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; 
 15 
 
226 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 flexion of the right thigh, and the presence of an intensely 
 tender tumor in the csecal region, are the characteristic 
 symptoms of typhlitis. 
 
 Perforative ulceration may be suspected if these symp- 
 toms disappear 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 fea- 
 tures, but in this condition tenderness is a late symptom ; 
 the tumor is situated more to the left of the abdomen ; some- 
 times the lower end of the invagination can be felt in rectal 
 examination, and there is severe tenesmus with the expul- 
 sion of blood-stained mucus. 
 
 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 cannot 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 pres- 
 sure on, or behind, the trochanter without giving discom- 
 fort. 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 
 terminate in recovery. The duration of active illness is, 
 as already stated, from four to twelve days, though several 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 227 
 
 weeks often pass before the local tenderness entirely dis- 
 appears, 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 ex- 
 tension of inflammation to the peritoneum. A reopening 
 into the intestine is more favorable, and many cases get 
 well. Under any of these circumstances 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 a teaspoonful of compound lico- 
 rice powder at bedtime, or one of the following pills : — 
 
 I£ . Resin. Podophylli, gr. jss. 
 
 Ext. Belladonna?, 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. 
 
 Ext. Colocynth. Comp., gr. vj. 
 
 01. 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 
 
228 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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. 20) 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 3 i j . 
 
 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 : — 
 
 Take of — 
 
 Slaked Lime, ^j. 
 
 Refined Sugar, in powder, ^ij. 
 
 Distilled Water, 13 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, pepton- 
 ized milk, and meat juice can be tried. 
 
 Thirst is best relieved by small quantities of cold car- 
 bonic-acid water and bits of ice. 
 
 The therapeutic indication is to relieve irritation and 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 229 
 
 arrest excessive peristaltic action of the bowels. This is 
 best accomplished by a combination of opium and bella- 
 donna, as : — 
 
 R . Tr. Opii, Tiycxiv. 
 
 Tr. Belladonnse, mjdviij. 
 
 Aq. Cinnamomi, q. s. adf^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 vomit- 
 ing ; but should this be not the case, morphia must be admin- 
 istered hypodermically 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 disap- 
 pear, 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 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 substituted 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. 
 
23O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Perityphlitis demands the same rest in bed, careful diet- 
 ing, 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 stimulants are also required with quinine, 
 and, when there is great prostration, carbonate of ammo- 
 nium. 
 
 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 stimulants. 
 
 14. INTUSSUSCEPTION. 
 
 In intussusception or invagination one portion of the in- 
 testine is forced, from above downward, into another portion 
 immediately continuous with it. 
 
 Apart from faecal accumulation, this is practically the 
 sole cause of intestinal obstruction in infancy. For, 
 although instances are on record in which the bowel, in 
 children, has been closed by peritoneal adhesions ; by a 
 twisted vermiform appendix, and by morbid growths, these 
 are but pathological curiosities. 
 
 Two forms are met with, namely : — intussusception with- 
 out symptoms ; and intussusception with symptoms. 
 
 INTUSSUSCEPTION WITHOUT SYMPTOMS. 
 
 This condition, which must be regarded rather as an 
 accident than a disease, is frequently encountered in autop- 
 sies upon young children who have met death from very 
 diverse affections. 
 
 Such intussusceptions occur shortly before, or during, the 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 23 1 
 
 death agony, and are probably produced by irregular and 
 violent contractions 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 traction. Sometimes there is 
 but one inversion, though usually there are several ; as 
 many as ten or twelve distinct invaginations, 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 fre- 
 quently involved. 
 
 Without a post-mortem examination, it is impossible to 
 recognize 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 in- 
 tussusception is that a limited portion of the intestine con- 
 tracts forcibly, and, by elongating and moving forward, 
 enters a non-contracted segment immediately below, draw- 
 ing in more or less of the latter, together with its mesen- 
 tery or meso-colon, Next, new peristaltic movements 
 force the invaginated bowel further and further along, until 
 extension is arrested by resistance from the mesentery, or 
 by secondary inflammatory adhesions. The intussusception 
 
232 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 intussus- 
 ceptum. 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 attach- 
 ment at its root, exerts a one-sided traction upon the intus- 
 susceptum, curving 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. In- 
 crease in length -is accomplished by peristaltic action from 
 behind; it takes place, always, at the expense of the exter- 
 nal 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 pressure upon the mesenteric vessels. 
 
 The obstruction of the circulation leads to deep conges- 
 tion 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. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 233 
 
 Should there be complete strangulation the intussuscep- 
 tum becomes gangrenous, and, under favorable circum- 
 stances, may be detached en masse or in pieces, and dis- 
 charged through the 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, notwith- 
 standing the separation of the intervening 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 pro- 
 duced 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 gan- 
 grenous mass is expelled, the adhesions may give way and 
 permit extravasation. 
 
 Generally, in those fortunate cases in which sloughing is 
 followed by recovery, no permanent injury results from the 
 cicatrization at the point of junction of the sheath and un- 
 involved intestine. The cicatrix, though at first contracted, 
 gradually stretches and a free passage-way is established. 
 
 Sometimes intussusception is attended with so little con- 
 striction of the involuted gut that the passage for the 
 intestinal 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- 
 cecal. 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 
 
234 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 intestine. 
 
 Upon opening the abdomen, in an ordinary case, much 
 of the colon appears to be wanting, and a tumor is found 
 occupying the left side or the left iliac fossa. This mass — the 
 intussusception — is slate-gray in color; elongated or sausage- 
 shaped, and doughy to the touch. By more or less forcible 
 traction, the involution 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 intus- 
 susceptum, 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 invaginated 
 intestine is either of a uniform deep red color, resem- 
 bling 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 inflam- 
 mation between the serous surfaces ; if later, these are 
 adherent, the adhesions extending a few lines beyond and 
 above the neck of the intussusceptum on to the sound intes- 
 tine. 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 
 intussusception to be confined to the small intestine. 
 
 Etiology. — As already indicated, early age seems to act 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 235 
 
 as a powerful predisposing cause. Of fifty-two cases in 
 children, recorded by J. Lewis Smith, twenty-three oc- 
 curred between the ages of three and six months ; eight 
 between the sixth and twelfth month ; 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 regu- 
 larity 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, necessitating 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, 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 
 Barthez 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 pro- 
 longed constipation ; 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 ob- 
 struction. 
 
 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 draw- 
 
236 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 ing 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 
 condition. There is no fulness nor tenderness, nor any tumor 
 appreciable 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, leading to a greedy consump- 
 tion of the contents of the feeding-bottle, or a ravenous 
 sucking at the breast. There is also restlessness, constant 
 whining or moaning, and an inability to sleep. After a 
 period of twelve or twenty-four hours, in which the par- 
 oxysms of pain and tenesmus have grown more frequent 
 and severe, the abdomen becomes full ; there is tenderness 
 in the left iliac fossa, and if deep pressure be made in this 
 region, during the absence of pain, a distinct swelling may 
 be detected. The tumor gradually becomes more defined ; 
 it is elongated or sausage-shaped ; of doughy consistence ; 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 237 
 
 and ranges in size from that of a hen's egg to that of a 
 clinched fist. Later, it may change its position, moving 
 toward the left side. When easily detected by external 
 palpation, the tumor may be touched by a finger inserted 
 into the rectum, and under these circumstances feels much 
 like the cervix uteri in a vaginal examination. Occasion- 
 ally the lower end of the involuted intestine protrudes from 
 the anus, looking not unlike a prolapsed rectum. 
 
 While these features are developing, vomiting continues, 
 and bloody mucus is expelled, with great straining, from 
 the rectum, but there is no passage of either faeces or 
 flatus. The amount of blood varies considerably ; in some 
 cases there is no more than sufficient to stain the diapers, 
 in others, three or four ounces are voided several times 
 daily. The tongue is red and glazed, or covered with a 
 dry, brown coating ; the pulse becomes frequent and feeble ; 
 the temperature rises to 102 or 103 F*; the abdominal 
 respiratory play is restricted, and the flesh wastes. The 
 urine may be greatly diminished in quantity ; this, how- 
 ever, is by no means a constant condition, and seems to 
 bear no relation to the seat or extent of the intussuscep- 
 tion. 
 
 By the third day symptoms of collapse set in. The 
 face becomes pinched ; the eyes sunken and surrounded by 
 dark circles ; the skin feels cool and clammy, and the ther- 
 mometer indicates a sub-normal temperature. The attacks 
 of vomiting are less frequent; the pain less intense; the 
 bloody evacuations lessen or disappear, and the child lies 
 upon his back, in an apathetic condition, with half-closed 
 eyelids, until the end comes at some time between the 
 fourth and sixth day. Occasionally death is preceded by 
 convulsions. 
 
 If, by any means, the invagination be reduced, the 
 
238 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 vomiting stops, pain disappears, flatus and thin, copious, 
 semi-liquid and offensive stools are voided, and the patient 
 finds rest in sleep. Afterwards there is pallor, languor and 
 weakness, though the appetite quickly returns and flesh 
 and strength are soon regained. 
 
 When older children are attacked the picture differs in 
 some of its details. 
 
 Thus, abdominal distension appears earlier and is more 
 marked. The gut behind the position of obstruction being 
 filled with faeces and flatus is greatly stretched, and the 
 outline of its coils may be distinctly seen and felt through 
 the tense wall of the belly. This is especially the case dur- 
 ing the paroxysms of pain, when, too, waves of peristalsis 
 may be seen, and loud, gurgling sounds heard. The tumor 
 is large and better defined, and the dull percussion sound 
 that it yields contrasts strongly with the general tympany. 
 
 Vomiting is more apt to be stercoraceous. This charac- 
 teristic symptom is absent in many cases, and very natu- 
 rally so ; for, if Brinton's theory be adopted, namely, that 
 faecal vomiting is due to a reverse axial current in the con- 
 tents of the intestine, and not to anti-peristalsis, it is 
 apparent that, for the development of this symptom at all, 
 the obstruction must be either in the large intestine or in 
 the lower part of the ileum. The date of its onset must 
 depend upon the distance of the starting-point of the 
 reverse current, or the obstruction, from the stomach ; upon 
 the rapidity with which the bowel above is filled by inges- 
 tion and secretion; and, should the colon alone be involved, 
 upon the readiness with which the resistance of the ileo- 
 caecal valve is overcome. 
 
 Evacuations of blood are much less uniformly observed. 
 Whether this symptom be present or absent depends solely 
 upon the degree of constriction of the invaginate bowel. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 239 
 
 When the constriction is just sufficient to obstruct the cir- 
 culation and over-fill the vessels, hemorrhage is constant; 
 but when there is actual strangulation, with complete arrest 
 of circulation, no blood escapes. In older children stran- 
 gulation is much more apt to occur than in infants, partly 
 because the invagination more frequently involves the 
 ileum or jejunum — which have a smaller calibre than the 
 colon — and partly from the fact that in them, life being 
 more prolonged after the accident, there is greater oppor- 
 tunity for inflammatory swelling. Hence it is that in this 
 class of cases there is, in many instances, absolute consti- 
 pation without bloody stools, though in others, where the 
 intussusception is ileo-caecal or colic, hemorrhage from the 
 anus may be noticed as an early and permanent feature. 
 
 The blood appears in a liquid form, mixed with mucus, 
 or in small clots. It always has the venous hue, and is 
 darker in color and smaller in quantity, in proportion to 
 the distance of the involution from the anus. 
 
 The older the child the more likely is gangrene, separa- 
 tion and elimination of the invaginated gut, to take place. 
 This result is usually noted during the course of the second 
 week of illness, and can be attributed to the greater power 
 of resistance and tenacity of life displayed by older chil- 
 dren than by infants. It is a fortunate ending, but, unfortu- 
 nately, rarely occurs at any age. After the process 
 of separation is completed, violent straining efforts set in, 
 expelling the black, ill-smelling, gangrenous mass, either 
 in its entirety or in patches and shreds, together with a 
 large quantity of dark, offensive, feculent matter. The 
 child then falls into a deep sleep, and awakes much re- 
 freshed. Thirst diminishes ; the appetite returns ; the par- 
 oxysms of pain cease ; the face expresses ease and comfort, 
 and the path to health is rapidly traversed. 
 
240 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 When death occurs it is usually due to asthenia, and 
 may, as in infants, be preceded by convulsions. General 
 peritonitis is very uncommon. 
 
 In addition to the form of intussusception just described, 
 and which may be termed acute, a variety having a much 
 more prolonged course, is sometimes encountered. 
 
 Chronic Intussusception may occur at any age, and may 
 exist for weeks, or even months, without producing severe 
 illness. It originates most frequently in ileo-csecal intussus- 
 ceptions, and depends upon the inflammatory union of the 
 outer and middle layers, and the restoration of the permea- 
 bility of the inner tube by the complete disappearance of 
 swelling. The patient wastes, has periodical attacks of 
 colicky pain, constipation and vomiting, and occasionally 
 passes a little blood. Palpation reveals a tumor that alters 
 its position, shape and density from time to time, and, on 
 account of hypertrophy of the muscular coat above the 
 partial obstruction, the knuckles of the intestine show dis- 
 tinctly through the emaciated abdominal wall. 
 
 Such cases may end in recovery, by separation ; or in 
 death, by perforative peritonitis ; or by steadily increasing 
 marasmus with chronic diarrhoea. 
 
 Diagnosis. — Intussusception may be strongly suspected 
 when a child in good health, or previously affected with 
 simple diarrhoea, is suddenly seized with violent, paroxys- 
 mal abdominal pain and vomiting, quickly followed by 
 straining efforts, resulting in the evacuation of mucus and 
 blood, and by intense prostration. The suspicion will be 
 reduced to a certainty if, at the same time, it be possible to 
 detect a sausage-shaped tumor on the left side of the belly, 
 or to touch the lower end of the inverted intestine upon 
 rectal exploration. It is necessary to remember, however, 
 that often, at the commencement of the attack, there is a 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 24I 
 
 single loose feculent stool, and also that, in older children, 
 bloody, mucous discharges may be entirely absent. 
 
 The diseases with which intussusception is most likely to 
 be confounded are simple colic, perforative peritonitis, dys- 
 entery and faecal accumulation within the bowel. 
 
 In simple colic, the pain, though often severe, is never 
 distinctly paroxysmal. It is attended by suppression of 
 urine, is relieved by the discharge of flatus per anum, and 
 is followed by copious urination. During the attacks the 
 skin may be hot, and the belly is usually hard and tense. 
 There is no vomiting, tenesmus or discharge of bloody 
 mucus. The misfortune of confounding intussusception 
 with colic can hardly be overestimated ; for a laxative, as 
 castor-oil, while relieving the latter by clearing out the 
 intestinal canal, cannot fail to aggravate the former by 
 increasing the force of the peristaltic contractions. 
 
 In perforative peritonitis there is pyrexia from the be- 
 ginning, the abdomen is distended and tense, and pressure 
 in the right iliac region — since the seat of perforation is 
 usually the vermiform appendix — produces pain. On the 
 other hand, tenesmus and the evacuation of blood and 
 mucus from the rectum are never observed, neither is 
 it possible to detect a tumor by abdominal palpation, 
 nor the lower end of an intussusception by rectal ex- 
 ploration. 
 
 Dysentery presents, in the character of the dejections and 
 the severe pain and tenesmus, features similar to intussus- 
 ception, but it lacks the sudden onset, the obstinate vomit- 
 ing and the abdominal tumor. The two diseases differ, 
 too, in their course. 
 
 A faecal accumulation, as it produces actual occlusion of 
 the intestine, has many symptoms similar to invagination. 
 Thus, there is vomiting, colicky pain, tenesmus, constipa- 
 16 
 
242 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 tion and a tumor. The former accident, however, is pre- 
 ceded, for some time, by the passage of hard and scanty- 
 stools ; while the attendant vomiting is less obstinate ; 
 there are no bloody evacuations ; and the tumor is more 
 superficial, more fixed, and of such consistence that it 
 can be indented by moderately firm pressure with the 
 fingers. A purgative enema, also, rapidly leads to the 
 expulsion of the impacted mass and relieves the symp- 
 toms. 
 
 Prognosis. — Every case of intussusception affords an out- 
 look that is grave in the extreme, though the danger to life de- 
 pends directly upon two factors, namely : the age of the pa- 
 tient attacked, and the acuteness and consequent severity of 
 the symptoms. In children under one year, death almost in- 
 variably results. With those who are older, the constitutional 
 resistance being greater, sloughing of the intussusception is 
 more apt to take place and recovery follow ; but the rarity of 
 this fortunate termination, at any time of life, has already been 
 alluded to. 
 
 Treatment. — In no other disease does the prospect of 
 success rest so much upon an early diagnosis and appro- 
 priate management. 
 
 The indication to be met is the total arrest of all action 
 of the muscular fibres of the intestine. To accomplish this 
 end, the patient must be kept in a state of absolute repose ; 
 must be made to take enough opium to relieve pain and 
 check intestinal peristalsis, and must be carefully and prop- 
 erly fed. 
 
 Opium may be employed alone or in combination with 
 belladonna, and may be administered by the mouth, by the 
 rectum or, in children over a year old, by hypodermic injec- 
 tion. A combination of the two drugs and their administra- 
 tion by the rectum is to be preferred in ordinary cases. For 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 243 
 
 a child of one year the following suppository may be or- 
 dered: — 
 
 R . Ext. Opii, gr. jss. 
 
 Ext. Belladonnae, gr. ss. 
 
 01. Theobromse, gij. 
 
 M. et ft. supposit. No. xij. 
 
 In the beginning, one of these suppositories can be intro- 
 duced every two hours ; but the interval must be lessened 
 or the dose increased to the point necessary to relieve pain 
 and tenesmus. 
 
 When the mouth is selected as the channel of exhibition, 
 
 the opium and belladonna may be prescribed in a mixture, 
 
 as: — 
 
 R. Tr. Opii Deod., f^j. 
 
 Tr. Belladonna, f 3 ss. 
 
 Aquae Anisi, q. s. ad f| iij. 
 
 M. 
 S. — One teaspoonful every two hours (or p. r. n.) for a 
 child of one year of age. 
 
 When the hypodermic method is selected, it is still best 
 to combine the two drugs, thus: — 
 
 R. Morphise Sulphatis, gr. i. 
 
 Atropise Sulphatis, g 1 "- 2V 
 
 Aquae Dest, f^j. 
 
 M. 
 S. — Inject ten minims p. r. n., in a child of six years. 
 
 The application of anodynes to the surface of the abdo- 
 men has certainly some power in relieving pain, and 
 should, consequently, not be neglected. For this purpose 
 a piece of soft flannel, large enough when doubled to cover 
 the whole belly, should be dipped in hot water, wrung 
 moderately dry, sprinkled with a teaspoonful of laudanum, 
 laid over the surface and covered with oiled silk. 
 
 As to food, only so much as is absolutely required to 
 sustain life should be allowed. For the first twenty-four or 
 
244 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 forty-eight hours, especially if there be vomiting, food may 
 be altogether withheld, and a teaspoonful of barley-water 
 or a small bit of ice given every fifteen minutes to allay the 
 thirst. Later, milk and barley-water for infants, and milk, 
 beef-juice or strong beef essence for older children, are 
 admissible ; but always in minimum quantities and at inter- 
 vals of two or three hours. Thus, for a child of one year, 
 half an ounce of milk and barley-water, in equal parts, 
 every two hours, will be quite enough ; while at the age of 
 six years two ounces of milk, one ounce of beef-essence, or 
 half an ounce of beef-juice, every three hours, will suffice. 
 It is well to peptonize the food, as in this way it is prepared 
 for assimilation, and little residue is left in the intestinal 
 canal. Everything must be taken cold. 
 
 When the strength begins to fail, brandy must be admin- 
 istered. The following mixture is a good food and stimu- 
 lant :— 
 
 Brandy, 4 fluidounces. 
 
 Cinnamon water, 4 fluidounces. 
 
 The yolks of two eggs. 
 
 White Sugar, y z ounce. 
 
 Rub the yolks and sugar together, then add the cinna- 
 mon water and spirit. 
 Dose. — A dessertspoonful to two tablespoonfuls every two 
 hours, according to the age. 
 
 Should the patient be seen before the fourth day of the 
 attack, in addition to the above measures of treatment, 
 efforts should be made to reduce the involution mechan- 
 ically. Mechanical interference can be successful only 
 before inflammatory adhesions have formed, and is contra- 
 indicated when there is tenderness over the seat of lesion. 
 There are three possible ways of accomplishing reduction, 
 viz., by taxis, by forced injection of water, and by insuffla- 
 tion of air. To perform either of these successfully the 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 245 
 
 patient, unless an infant under one year, must be previously 
 put thoroughly under the anaesthetic influence of ether. 
 
 Taxis consists in kneading and otherwise manipulating 
 the abdomen with the warmed and oiled hand ; it is usually 
 employed in conjunction with one of the other methods. 
 
 If forced enemata be resorted to, the child is placed 
 upon his back in bed, with the buttocks elevated, so that 
 the trunk is inclined at an angle of 45 degrees. Then, 
 with a Davidson's or Fountain syringe, the physician him- 
 self must inject, carefully and slowly, as much tepid water 
 as the capacity of the intestine will permit. While this 
 is being done, the abdomen must be kneaded in such a 
 manner as to force the water upward along the bowel 
 in the direction of the invagination. At times the ob- 
 struction can be felt to give way ; but the best proofs 
 of this fortunate occurrence are the subsidence of the 
 more urgent symptoms and the onset of sound sleep. 
 Soon, too, there is a discharge of bloody mucus from 
 the rectum, and then a free, offensive, semi-fluid faecal 
 evacuation. 
 
 Insufflation of air is suited to those cases in which the 
 intussusception having descended into the rectum, little or 
 no water can be injected or retained. The apparatus for 
 this purpose consists of a bellows, having its nozzle at- 
 tached, by means of a piece of flexible rubber tubing, to a 
 caoutchouc tube about a foot in length ; the latter is 
 inserted into the rectum, care being taken to secure a 
 perfect fit at the anus by a packing of lint. The air should 
 be pumped in slowly and gently, and during its introduc- 
 tion, taxis is practiced in the same manner as in the forced 
 injection of water. 
 
 Should these measures fail, or should the case be seen 
 for the first time after the third or fourth day, the question 
 
246 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 may arise as to the propriety of laying the abdomen open 
 and reducing the intussusception by direct traction. For 
 the details of the operation of laparotomy, the reader must 
 be referred to works on surgery. Briefly stated, it consists 
 of making an incision in the median line of the abdominal 
 wall ; opening the peritoneum ; finding the intussusception, 
 and working it back at the neck in the same manner that a 
 hernia is reduced. 
 
 The practical results of the operation prove, beyond doubt, 
 that there is very little to be expected from it. This is espe- 
 cially true in the case of infants less than a year old, amongst 
 whom it has been invariably fatal. By its performance, too, 
 the chance of recovery from separation of the strangulated 
 intestine is lost. 
 
 Upon this point, Prof. John Ashhurst, Jr.,* states : — 
 "Inspection of the table (comprising 13 cases of lapa- 
 rotomy, 5 in children), shows, in the first place, that no 
 encouragement is afforded to repeat the operation in very 
 young infants. The only instances in which it has been 
 resorted to during the first year of life have all terminated 
 fatally (Gerson, Wells, Weinlechner). But when it is re- 
 membered that of Pelz's 162 cases (all occurring in chil- 
 dren), no less than 91 were in infants less than a year old, 
 it will be seen how large a proportion of cases must at 
 once be put aside as unfitted for operative treatment. It is 
 very true that the fatality of intussusception at this early 
 age is enormous, the mortality being, according to Leich- 
 tenstein's elaborate statistics, no less than 86 per cent. But 
 the case is very different from that, for instance, of an 
 operation for imperforate rectum ; for in this condition there 
 is necessarily no hope but in an operation ; whereas, in the 
 case of intussusception, experience shows on the one hand 
 * American Journal of Medical Sciences, July, 1874. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 247 
 
 that, even at this age, a certain number do recover without 
 operation, and that, on the other hand, as might be ex- 
 pected, operative treatment is in such cases of no avail. 
 
 " In the second place, the table shows that in what may 
 be called acute cases, those, namely, in which in addition to 
 symptoms of obstruction there are evidences of strangula- 
 tion, such as peritonitis and intestinal hemorrhage, a resort 
 to operative inference will be productive of no benefit. 
 These cases are, on the other hand, as justly remarked by 
 Mr. Hutchinson, precisely those in which there is most 
 hope of recovery by sloughing of the invaginated portion. 
 
 " There remains, then, a limited number of cases, in not 
 very young infants, in which the symptoms are those of 
 obstruction merely, without intestinal hemorrhage or peri- 
 tonitis, and in which, when other measures fail, the question 
 of operation may properly be considered." 
 
 When separation and discharge of the invaginated seg- 
 ment of the intestine takes place, it is necessary to exert 
 the utmost care lest the new-found adhesions be broken 
 down. The patient must lead a passive life ; the food must 
 be readily digestible and restricted in quantity, and all 
 farinaceous and fermentable articles are to be excluded 
 from the dietary. 
 
 In chronic intussusception great reliance can be placed 
 upon the free administration of opium and belladonna, with 
 forced enemata ; or, in proper cases, insufflation of air, and 
 as this condition generally occurs in late childhood, lapa- 
 rotomy, when other measures fail, may be undertaken with 
 more hope of success. 
 
248 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 15. INTESTINAL WORMS. 
 
 The common parasitic worms that find their habitat in 
 the human intestines may be divided into two classes, each 
 including several varieties, namely : — 
 
 {Oxyuris vermicularis. 
 Ascaris lumbricoides. 
 Tricocephalus dispar. 
 
 {Tcenia solium. 
 Tcenia saginata. 
 Bothriocephalus latus (rare). 
 
 Of these, the oxyuris vermicularis — small thread-worm — 
 and the ascaris lumbricoides — long, round worm — are most 
 frequently found in children. The taenia, or tape-worm, is 
 uncommon before the age of six or seven years. 
 
 DESCRIPTION AND MODE OF ENTERING THE BODY, 
 
 Oxyuris Vermicularis. — These worms are silvery-white 
 in color and of small size ; the males being one-sixth of an 
 inch, the females one-half an inch long. To the unaided 
 eye they present the appearance of small, white threads. 
 They inhabit the caecum and whole length of the colon, 
 but are most abundant in the sigmoid flexure and rectum, 
 where they derive nourishment from the faeces, and where, 
 alone, they give rise to symptoms or evidences of their 
 presence. 
 
 Oxyures enter the body by direct passage of the ova 
 into the mouth. They are introduced clinging to fruit and 
 various articles of food, or are conveyed to the lips by the 
 hands of the child previously used to relieve itching, occa- 
 sioned by the presence of the parasites in the neighborhood 
 of the anus. Having entered the stomach, the embryos are 
 liberated by the action of the gastric juice and pass into the 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 249 
 
 Fig. 2. 
 
 Egg of Oxyuris 
 
 Vermicularis. 
 
 small intestine, which they descend with the food, develop- 
 ing so rapidly that they become sex- 
 ually mature by the time they reach the 
 caecum. 
 
 The eggs, as seen by the microscope, 
 are ^ of an inch in length, ovoid and 
 unsymmetrical. They are produced in 
 great numbers, each female giving birth to several broods, 
 numbering from ten to twelve thousand, and they are ex- 
 tremely tenacious of vitality. 
 
 Ascaris Lumbricoides. — This parasite has a certain su- 
 perficial resemblance to the common earth-worm. It is 
 cylindrical, tapering at both extremities, is reddish or brown- 
 ish in color, has a body marked with fine transverse rings, 
 and possesses a peculiar, disagreeable odor independent of 
 the substance in which it lives. The head of the worm pre- 
 sents three prominent labial papillae surrounding the mouth, 
 and the tail is conical. The male is from three to six inches 
 in length and one-eighth of an inch in thickness, with an 
 incurved tail and a penis consisting of a pair of slender, 
 clavate, chitinous spicules, the ends of which protrude from 
 a cloacal aperture at the root of the tail. The female meas- 
 ures from six to fourteen inches in length and one-fourth of 
 an inch irt thickness. The genital aperture is situated on 
 the ventral surface, near the anterior third of the body; the 
 ovarian tubes may be observed as 
 long, tortuous canals, and the uter- 
 ine tubes as short, straight canals; 
 the latter contain many millions of 
 ova. The ripe ova are laid in the 
 
 intestine, and are expelled, with the 
 
 t . , • FlG - 3- 
 
 stools, in great numbers, sometimes Egg of Ascaris Lumbri . 
 
 even in large masses. The eggs coides. 
 
250 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 are -^ of an inch in diameter, and are oval, with a thick, 
 elastic, brownish, double shell and nodulated surface. After 
 expulsion from the rectum, they are very tenacious of life, 
 remaining in a condition capable of development for several 
 years. This is particularly the case when tljey find their way 
 into water or moist earth. Here the embryos slowly de- 
 velop. 
 
 It is not positively known in what way children become 
 infected with the parasite, but impure water is, without 
 doubt, the medium. Recent experiments on both animals 
 and men have demonstrated that infection cannot be directly 
 produced by taking the recently laid, ripe ova into the 
 stomach. It is probable, therefore, that the ova passed by 
 an infected subject, after entering — through drainage or other- 
 wise — moist soil or running water, and undergoing partial 
 development, are eaten by some common, but unknown, 
 minute aquatic animal. Within the bodies of these they are 
 still further developed, so that, when the animalculi are in- 
 gested with impure drinking water, and the embryos liber- 
 ated by the action of the digestive solvents, the latter are in 
 a position rapidly to assume their mature characters. 
 
 Lumbrici inhabit the small intestine principally, though 
 they frequently migrate. Their number in a single indi- 
 vidual may vary from two to several hundreds. 
 
 Tricocephalus Dispar. — The whip-worm, as this para- 
 site is sometimes called, is yellowish- 
 white in color, with the anterior half, or 
 more, of the body attenuated in a hair- 
 Fig. 4. like manner. The male is about one 
 
 Egg of Tricocepha- inch and a half in length, has the thick 
 lus Dispar. por tion of the body enrolled, and a blunt 
 
 tail. The female is two inches long, with a conical tail. 
 The eggs of this worm are laid in the intestine and 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 25 1 
 
 voided with the faeces ; nothing is known of their subse- 
 quent history, or of the method in which the human being 
 is infected. 
 
 Whip-worms inhabit the lower end of the ileum, the cae- 
 cum and the vermiform appendix, and feed on the intestinal 
 contents. They are met with in small colonies, varying in 
 number from two to twelve. Their occurrence is considered 
 to be exceptional in this country, but this may be explained 
 in two ways : first, as they are rarely voided with the faeces, 
 like other worms, they escape ordinary observation ; and 
 second, as their presence gives rise to no symptoms during 
 life, few think of looking for them on the post-mortem 
 table. 
 
 Tjehije infest children over the age of six years with 
 almost the same frequency as adults. Of the three varieties, 
 the tcenia saginata, beef tape-worm, and tcenia solium, pork 
 tape-worm, are the most common, while of these two the 
 former is met with in by far the greater number of cases. 
 
 The tcenia saginata is a soft, yellowish-white, band-like 
 worm, varying in length from six to twenty or more feet. 
 The head has about the bulk of a yellow mustard-seed, is 
 rounded quadrate, and provided with four hemispherical 
 suckers. Between the head and body is a short, unsegmented, 
 flattened neck, narrowest at its upper extremity and gradu- 
 ally broadening as it merges into the body. The latter is dis- 
 tinctly segmented. The first segments are several times 
 wider than long, but become successively 
 larger until the length exceeds the breadth 
 two or three times ; their number may reach 
 twelve hundred, and the largest measure 
 from one-fourth to one-third of an inch in Fig. 5. 
 
 width, and a quarter to a full inch in length. Egg of t ^ nia 
 The parasite is usually solitary. It inhabits 
 
252 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 the small intestine, in which position the segments, as they 
 ripen, are spontaneously detached, some having already 
 expelled their burden of eggs (often numbering 35,000), 
 others still laden. Both eggs and liberated segments then 
 become mixed with the intestinal contents, pass down- 
 ward into the colon, and are finally expelled with the 
 faeces. The mature ova are brown, oval in shape and of 
 minute size; they have a thick inner shell, and an outer 
 longitudinally striated envelope. Each ova contains an 
 embryo — a spherical or oval body — having at one pole 
 three pairs of divergent, boring spiculae. 
 
 In rural districts, it is a very common habit, with both 
 adults and children, to stool in a fence corner, or other 
 more or less secluded spot, at any time there is a call for 
 evacuating the bowels. Should ova-laden tape-worm seg- 
 ments or liberated eggs be contained in the faeces so care- 
 lessly deposited, these are apt to be swallowed by cattle 
 grazing in the neighborhood. Having once entered the 
 stomach, the embryos, liberated from the eggs by the action 
 of the digestive solvents, attach themselves to the mucous 
 membrane of the viscus, perforate it by means of their 
 powerful boring apparatus, and, either directly or through 
 the medium of the blood current, migrate into the tissues 
 of the body, usually the muscles or liver. After attaining 
 their destination, they become fixed and slowly undergo 
 development, dropping the spiculae and being transferred 
 into the larval form or scolex. The scolex consists of a 
 head like that of the mature worm, with a neck terminating 
 in a capacious cyst, within which the head and neck are 
 inverted. In this form each parasite is surrounded by a 
 sack of connective tissue ; the new formation depending 
 upon the presence of the larva, acting like an imbedded 
 foreign body. The flesh, liver and other organs of cattle 
 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 253 
 
 so infected are said to be " measly." Now should measly 
 beef be taken into the stomach insufficiently cooked, or 
 should it be administered raw — a frequent practice in the 
 treatment of certain intestinal diseases — the parasite, during 
 the process of digestion, is liberated from the investing 
 connective tissue envelope, everts its head from the con- 
 taining sack, attaches itself to the mucous membrane of the 
 small intestine, feeds upon the intestinal contents, and, 
 growing from its caudal extremity rapidly develops into 
 a mature tape-worm. The time required for development 
 has been proved by experiment to be less than two months, 
 and the natural duration of life is very protracted. 
 
 Taenia Solium. — This species of tape-worm enters the 
 human body through the medium of measly pork. The 
 methods of propagation and development are identical 
 with those of the taenia saginata. In general appearance, 
 also, the two worms are very similar. The pork tape- 
 worm, however, is white in color and broader and shorter, 
 the usual length being between five and ten feet. The 
 head, which presents the most prominent distinguishing 
 features, is about the size of an ordinary pin ; it is spheroidal 
 in shape, is surmounted by a blunt papilla, encircled by a 
 double row of hooks, and, at the same time, has the four 
 hemispherical suckers to be noticed in the beef tape-worm. 
 The ova are somewhat smaller but otherwise identical, 
 the scolices, long known as Cysticercus celluloses, likewise 
 possess the double row of hooks to the head, and in this 
 way may be distinguished from the larvae of the other 
 variety of taenia. The period occupied in development is 
 about three months ; the length of life probably twelve 
 years or more. 
 
 As in the United States pork is but little used as food 
 in comparison with beef, and when used is usually thor- 
 
254 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 oughly cooked, the difference in the frequency of occur- 
 rence of the two species of worms can be readily explained. 
 In regard to this point, Prof. Leidy states : " Since the 
 writer distinctly recognized the beef tape-worm, within the 
 last twenty years, all the specimens of taeniae, from people 
 of Philadelphia and its vicinity, that have been submitted 
 to him for examination — perhaps in all about fifty — have 
 appeared to belong solely to taenia saginata. The preva- 
 lence of this species with us is no doubt due to the common 
 custom of eating underdone or too rare beef, while the 
 pork tape-worm is comparatively rare, as with us pork is 
 only used in a well-cooked condition." 
 
 Symptoms — These may be divided into two classes : gen- 
 eral and special. 
 
 The general symptoms are those always present, irre- 
 spective of the particular species of worm infecting the pa- 
 tient. They depend not so much upon the mere presence 
 of the parasite, as upon the peculiar condition of the mucous 
 membrane of the alimentary canal which accompanies and 
 is, perhaps, essential to their development and existence. 
 This condition is one of catarrh, with an excessive produc- 
 tion of mucus, or, to give it a definite title, mucous disease; 
 consequently, the general symptoms of worms are similar 
 to those already studied under this head (p. 140). 
 
 The patient wastes, and the face is pale or leaden in hue, 
 dark circle^ surround the orbits, the eye-balls are sunken, the 
 pupils dilated and the upper lip swollen. The skin generally 
 is muddy, covered with dry, epidermic scales, and devoid 
 of natural softness and elasticity. 
 
 The lips and mucous membrane of the mouth are pale, the 
 breath is offensive and the tongue is flabby, with the edges 
 indented by the teeth and the dorsum covered with a thin, 
 slimy coating, or it presents one or other of the conditions 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 255 
 
 described (pp. 142, 144) as pathognomonic of mucous dis- 
 ease. There is often moderate hypertrophy of the tonsils 
 and swelling of the lymphatic glands at the angles of the jaw. 
 The appetite is capricious, sometimes almost absent, and at 
 others insatiable. Nausea, and acid eructations and vomit- 
 ing are common. Constipation is the usual state of the bow- 
 els; occasionally there is tenesmus, with constant unproduc- 
 tive efforts at defecation, and there is a liability to attacks of 
 diarrhoea, attended with great straining and the passage of 
 black, slimy, ill-smelling motions. Free mucus may be 
 discharged from the rectum, and, in girls, from the vagina. 
 The abdomen is always distended, feels hard on palpation, 
 and to percussion yields a tympanitic note. Constant com- 
 plaints are made of pain in the belly, especially in the 
 neighborhood of the umbilicus. Its character varies, being 
 in some cases tearing or cutting ; in others, simply an uneasy, 
 creeping sensation, and in others still, a sensation of cold- 
 ness. 
 
 The urine is frequently voided with pain and difficulty, 
 and may have a turbid, milky appearance. 
 
 The pulse is weak, altered in frequency and occasionally 
 irregular; a harassing, paroxysmal cough may be present, 
 and not uncommonly there is sighing, sobbing and hic- 
 cough. 
 
 The child's temper is altered; he becomes irritable or 
 sullen ; his sleep is broken by bad dreams or night terrors ; 
 and there are many and very diverse nervous manifestations, 
 such as annoying itching of the nose, temporary delirium 
 or stupor, sudden blindness, loss of voice, squinting, fixation 
 of the eye-balls, vertigo and general convulsions. 
 
 These features, of course, are not equally marked in all 
 cases, their degree depending upon the grade of intestinal 
 catarrh. 
 
256 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Special symptoms — those due directly to the presence 
 of the worms — differ according to the species. 
 
 The Oxyures occasion violent itching at the anus, es- 
 pecially at night, when they prevent sleep and lead to 
 troublesome scratching. This irritation, transmitted to the 
 genitalia, combined with the constant application of the 
 hands to these parts, produces erections in the male, and 
 may induce the habit of masturbation in both sexes. Two 
 conditions of the bowels are observed; either forcible but 
 ineffectual straining, often attended by prolapsus ani, or 
 diarrhoea. Finally, the oxyures may, on inspection, be dis- 
 covered moving about in the radiating folds of the anus. 
 
 Occasionally, these parasites migrate into the vagina, 
 uterus, urethra, oesophagus and stomach. When they occupy 
 the vagina, they give rise to leucorrhcea. 
 
 Lumbrici occasion more or less pain in the umbilical re- 
 gion ; also vertigo, convulsions, and even chorea. The irri- 
 tation of their presence may cause chronic diarrhoea, with 
 scanty, offensive, thin, mud-colored stools, voided with much 
 straining, and most numerous during the night. They often 
 migrate into the stomach, whence they are quickly expelled 
 by vomiting. Less frequently they pass into the common 
 bile-duct and gall-bladder ; also the nose, larynx, trachea, 
 larger bronchi, vagina, urethra and bladder; in each position 
 giving rise to symptoms of irritation. They have been 
 found, too, in abscesses communicating with the intestine, 
 having escaped by entering a preexisting fistulous opening, 
 or, perhaps, in some instances, by directly perforating the 
 gut. These abscesses usually occupy the abdominal wall 
 in the umbilical or inguinal regions, or are seated in the 
 substance of the liver. 
 
 As already stated, the Tricocephalus dispar causes no 
 special symptoms. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 257 
 
 Taeniae are attended by sensations of weight and gnawing 
 in the abdomen; occasional attacks of colic, and distension, 
 particularly of the umbilical region. With a huge appetite, 
 there is progressive emaciation and general lassitude. A 
 persistent headache is sometimes a feature, and there may 
 be annoying cramps in the muscles of the legs and arms. 
 
 Diagnosis. — While the occurrence of the symptoms de- 
 tailed strongly indicate the presence of worms, the only 
 positive proofs of their existence are the discovery of the 
 parasites themselves or of their eggs in the stools ; their 
 appearance, as in the case of oxyures, at the margin of the 
 anus ; and their expulsion, as in the case of lumbrici, from 
 the stomach in the act of vomiting. Therefore a purgative, 
 by emptying the intestinal tract and expelling some of the 
 parasites, is the crucial test. 
 
 In some cases the symptoms are severe enough to suggest 
 tuberculosis or tubercular meningitis; though a mistake may 
 be readily avoided by bearing in mind this possibility and 
 applying the test. 
 
 Prognosis. — Intestinal worms rarely cause death. When 
 a fatal termination does occur, it results from convulsions ; 
 from the consequences of the migration of the parasite into 
 the bile-duct and air passages, or from some secondary 
 affection ; proving dangerous because the strength of the 
 frame attacked has been sapped by its guests. 
 
 Treatment. — The diagnosis having been established, 
 either by the spontaneous appearance of the worms or by 
 their discovery after the administration of a dose of calomel 
 or calomel and rhubarb, remedial measures must be directed 
 to the accomplishment of two objects : 1st, the expulsion of 
 the worms; and 2d, the removal of the alkaline mucus — the 
 essential nidus — and the restoration of the alimentary canal 
 to its normal condition. 
 17 
 
258 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 1st. For expelling the parasites, the anthelmintic to be 
 chosen depends upon the infecting species. 
 
 Oxyures, as they inhabit the rectum, are within the reach 
 of enemata, and are best treated by them. The object 
 being to kill the worm, it is essential thoroughly to empty 
 the lower bowel by an enema of warm water, immediately 
 before injecting the parasiticide, so that the latter may 
 come in contact with the mucous membrane, upon which 
 the great mass of the worms lie. One or two medicated 
 injections can be administered daily ; they act best when 
 cold, and their bulk should not be so large as to distend 
 the gut and lead to a quick return ; from one to two fluid- 
 ounces is the proper quantity for a child of two years.* 
 Liquor caicis ; common salt and water, in the proportion of 
 one teaspoonful to a pint; a solution of castile soap, thirty 
 grains to a pint of water ; or one of sulphuret of potassium, 
 twelve grains to a pint ; oil of turpentine in milk ; half a 
 teaspoonful to four fluidounces of pure olive oil; and lard 
 beaten up with water until it become liquid, all constitute 
 good injections, the last two having the property of quickly 
 relieving itching, in addition to their parasiticide action. In 
 my experience, however, the injection of an infusion of quas- 
 sia has been most uniformly successful. It is best to order the 
 quassia chips and have the infusion prepared in the nursery, 
 thus : — 
 
 R. Quassia? (rasped), £ij. 
 
 S. — Place in a porcelain vessel and pour on a pint of boil- 
 ing water, macerate for two hours, then strain and 
 inject two fluidounces once or twice daily. 
 
 With children past the second year the proportion of 
 quassia may be gradually increased to one ounce, at the 
 age of seven. 
 
 * All of the succeeding directions for treatment are adapted to children of 
 this age. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 259 
 
 While employing enemata it is well to aid their action 
 and relieve itching at the anus, by anointing the parts with 
 some mild mercurial ointment, and at the same time push- 
 ing a little into the rectum. A good preparation of this 
 kind is — 
 
 R . Hydrargyri Chloridi Mitis, gr. lxxx. 
 
 Unguenti Petrolei, Jj. 
 
 M. 
 S. — Apply morning and evening. 
 
 When there is intense rectal irritation, an injection of 
 laudanum and starch water (gtt iij to f jj) and cold com- 
 presses applied to the fundament, give great comfort. 
 
 Diarrhcea and tenesmus are to be overcome by the 
 administration of a teaspoonful of castor-oil, with five drops 
 of paregoric once, twice or three times daily, according to 
 circumstances. Should there be constipation, one tea- 
 spoonful of Husband's magnesia, or the appropriate dose of 
 some other saline, must be given every morning until the 
 symptoms disappear. Besides keeping the bowels regular, 
 it is well to secure several free watery evacuations, at inter- 
 vals of three days, for the purpose of dislodging any 
 oxyures that may be inhabiting the upper part of the large 
 intestine, and of clearing away accumulations of mucus ; to 
 accomplish this saline, cathartics are to be selected. 
 
 Against Lumbricoides a number of drugs bear an anthel- 
 mintic reputation. Of these, santonin, spigelia and cheno- 
 podium are the most efficient. To insure the greatest 
 success, the patient for whom either of these medicines is 
 ordered, must be placed on a restricted liquid diet, that the 
 alimentary canal may be as empty as possible ; and during 
 their administration the bowels must be kept active by 
 cathartics, that the dead worms and the ova may be swept 
 away. Broken doses of the purgative chosen can be com- 
 
2(3o DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 bined with the anthelmintic, or an occasional full dose may 
 be given during the course of the treatment. 
 
 Santonin is almost tasteless, and when combined with 
 sugar is readily taken by children; it may be prescribed in 
 the following ways : — 
 
 R. Santonini. gr. vj. 
 
 Sacchari, gr. xxx. 
 
 M. et ft. chart. No. xij. 
 S. — One powder morning and evening, each second dose 
 to be followed by two teaspoonfuls of castor-oil or a 
 purgative dose (gr. j) of calomel. 
 
 Or— 
 
 R. Santonini, gr. vj. 
 
 Hydrarg. Chlorid. Mit., gr. vj. 
 
 Sacchari, gr. xxiv. 
 
 M. et ft. chart. No. xij. 
 S. — One powder morning and evening. 
 
 Santonin sometimes produces xanthopsia, or " yellow- 
 seeing ; " this is of no importance and quickly disappears 
 after the drug is discontinued. It is best, however, to 
 advise the mother or nurse of the possibility Qf this occur- 
 rence. Occasionally, too, it increases the flow of urine and 
 gives the fluid a reddish color. 
 
 Spigelia is a very useful remedy, though as it simply 
 narcotizes the worm it must always be administered in 
 association with a purge. The officinal preparation, ex- 
 tractum spigelian et sennae fluidum, is as good a combina- 
 tion as can be employed; it may be given in doses of one 
 teaspoonful three times daily. If it be desired to make 
 success doubly sure, it is well to add santonin : — 
 
 R . Santonini, gr. iv. 
 
 Ext. Spigeliae et Sennae Fid., f^j ss - 
 
 Syrupi, f,l ss - 
 
 Elix. Simplicis q. s. ad f^iij. 
 
 M. 
 
 S. — Two teaspoonfuls three times daily. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 26 1 
 
 Chenopodium is a very safe, non-irritant anthelmintic, 
 being especially indicated when the evacuations are in- 
 creased in number, are liquid and contain mucus or blood. 
 The volatile oil may be administered dropped upon a lump 
 of white sugar, in doses of five drops three times daily. A 
 purgative is then necessary, every twenty-four or forty- 
 eight hours, or, for convenience, both remedies may be 
 combined in a mixture : — 
 
 R. Olei Chenopodii, f 3 ij. 
 
 OleiRicini, fSJ ss - 
 
 Olei Cinnamomi, tt\v. 
 
 Syr. Acacise, q. s. ad f^iij. 
 
 M. 
 
 S. — One teaspoonful three times daily. 
 
 Should there be reason to suspect ulceration of the 
 bowel, five minims of oil of turpentine added to each dose 
 of this formula will both improve the condition of the 
 mucous membrane and increase the specific action. 
 
 The only disadvantage possessed by oil of chenopodium 
 is that it is not so acceptable to the taste or stomach as 
 either santonin or the liquid extract of spigelia and senna. 
 
 Whip-worms, when detected, can be removed by the 
 same means as lumbricoides. 
 
 Taeniae are the most difficult of the intestinal parasites to 
 eradicate; evacuations of many feet of segments are easily 
 brought about, but reproduction steadily continues until 
 the head is finally expelled. This portion is obstinate in its 
 adherence to the intestinal mucous membrane, and being 
 minute in size is easily shielded from the action of the 
 parasiticide by the tenacious mucus which is always se- 
 creted in excess when a tape-worm is present. 
 
 It is essential, therefore, to diminish, or, if possible, 
 entirely remove, this secretion, before commencing the 
 
262 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 actual treatment. For one week the child * must take the 
 following prescription : — 
 
 R. Ammonii Chloridi, gij. 
 
 Ext. Sennae Fid., f 3 v j- 
 
 Inf. Gentianae Comp., q. s. ad f 5iij. 
 
 M. 
 
 S. — One teaspoonful before each meal. 
 
 At the same time the diet must be restricted, and non- 
 farinaceous in character ; for instance : — 
 
 Breakfast at 8 a.m. — A tumblerful and a half (12 oz.) of 
 milk, with two slices of gluten bread.f 
 
 Luncheon at 12 m. — A teacupful (4 oz.) of milk. 
 
 Dinner at 2.30 p.m. — A bowl (8-12 oz.) of beef, mutton, 
 or chicken broth ; two slices of gluten bread. 
 
 Supper at 7 p.m. — Same as breakfast. 
 
 For drink at dinner or between meals only pure filtered 
 water in small quantities. 
 
 At the end of the week's preparation one of the anthel- 
 mintics particularly adapted to this species of worm may 
 be ordered. Of these there are several : — 
 
 Oleoresin of male fern — oleoresina filicis — mentioned 
 first, because most commonly used and generally efficient, 
 should be given in one or two drachm doses, either floating 
 upon a little (fSss) peppermint water or in a mixture, such 
 as : — 
 
 R. Oleoresinae Filicis, f^ij-iv. 
 
 Syr. Acaciae, f ^ ij. 
 
 Aq. Cinnamomi, q. s. ad f ^j. 
 
 M. 
 S. — Tablespoonful for a dose. 
 
 The plan of administration has much influence on the 
 issue. For the best result, the patient, unless much debili- 
 
 * The succeeding formulae are adapted to children of six years. 
 f Gluten flour can be obtained in any of the larger cities, and is made into 
 bread in the same manner as wheat flour. 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 263 
 
 tated, must, upon the day on which the treatment is insti- 
 tuted, begin a fast after his dinner ; in the evening two 
 fluidrachms of castor-oil should be given ; next morning, 
 after the bowels have been thoroughly evacuated, a dose of 
 fern ; and three hours later, a second dose of castor-oil. A 
 few hours subsequently the worm will probably be ex- 
 pelled. During the interval, occasional sips of water may 
 be allowed to relieve thirst. The nauseating taste of the 
 oleoresin of fern may lead to its quick rejection from the 
 stomach ; in such cases the viscus should be quieted by a 
 few drops (3-5) of McMunn's elixir of opium, and a second 
 dose of the anthelmintic administered after the lapse of 
 half an hour. 
 
 Kameela (Rottlerd) is another good remedy for tape- 
 worm, possessing the advantage of being in itself an aperient, 
 and hence doing its work without the aid of purgatives. 
 The same period of absolute fasting is necessary, as when 
 administering male fern, and on the morning of the day 
 following the beginning of abstinence, two doses of fifteen 
 grains of powdered kameela must be taken, at an interval 
 of three hours. The drug may be exhibited suspended in 
 syrup or in mucilage of acacia, a few drops of some aro- 
 matic oil being added in either case. A capital prescription, 
 containing both kameela and male fern, is : — 
 
 R. Kameelae, gr. xxx. 
 
 Syr. Acaciae, f ^ ij. 
 
 Misce, et adde — 
 
 Oleoresinse Filicis, fgj-ij. 
 
 Aquae Cinnamomi, f ^ j. 
 
 M. 
 S. — To be taken in two doses at an interval of three hours. 
 
 A formula very similar to this has been in long and most 
 successful use at the Children's Hospital, Philadelphia. 
 In some cases, oil of turpentine is very efficient, even 
 
264 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 when the remedies already mentioned fail. This may be 
 given in one large dose, or in small doses frequently 
 repeated. By the former method, from two to four flui- 
 drachms are given in the morning after the usual fast, and 
 followed in three hours by a dessertspoonful of castor-oil, 
 unless the bowels have been previously relieved. To carry 
 out the latter, the following mixture may be used : — 
 
 R . Olei Terebinthinae, 
 
 Mellis, aa f^ss. 
 
 01. Menth. Pip., gtt. vj. 
 
 Mucilag. Acaciae, q. s. ad f^iij. 
 
 M. 
 S. — Two teaspoonfuls every six hours. 
 
 Every second day, preferably in the morning, two grains 
 of calomel must be administered. 
 
 Other useful drugs are pomegranate rind and pumpkin 
 seed; the first in the form of a decoction of the bark of the 
 fresh root (Sij-Oj), six ounces to be taken in three doses 
 one hour apart, while fasting; the second as an electuary, 
 six drachms of the seeds being beaten up with sugar, and 
 taken in one or two doses; a brisk purge must be ordered 
 after either. 
 
 Koosso and its active principle, koossin, are recommended 
 by some authorities. One drachm of the powdered drug 
 suspended in water, or five or ten grains of koossin in 
 capsule are the proper doses for a child of eight years. To 
 prevent nausea, it is better to break the dose into two or 
 four; additional purgative is usually not required. 
 
 After administering the anthelmintic, it is impossible to 
 decide at once whether the tape-worm has been eradicated 
 or not unless the head be discovered in the stools. The 
 physician must not trust to the mother or nurse to find the 
 head, but must look for it himself. The stools immediately 
 
AFFECTIONS OF THE STOMACH AND INTESTINES. 265 
 
 following the action of the parasiticide must, therefore, be 
 preserved until his visit; the chamber in which they are 
 received being filled with water containing a small quantity 
 of carbolic or salicylic acid. This is to be gently shaken in 
 order to separate the worm from the faeces, and then allowed 
 to stand for ten minutes ; during which the parasite, from its 
 greater specific gravity, sinks to the bottom of the vessel. 
 Next, the supernatant liquid is poured off, the vessel refilled 
 with water, and the process repeated until the fluid remains 
 nearly colorless. Then the head, if present, is readily found. 
 Should the head not be discovered, it is impossible, although 
 all symptoms may disappear, to give a positive opinion as to 
 complete expulsion until two or three months have passed. 
 Any return of symptoms requires a second course of treat- 
 ment. 
 
 2d. The removal of the alkaline mucus and the restora- 
 tion of the normal condition of the alimentary canal are to 
 be accomplished by the same attention to diet and the same 
 therapeutic measures recommended when discussing chronic 
 gastro-intestinal catarrh (p. 145). 
 
CHAPTER III. 
 
 CASEOUS DEGENERATION AND TUBERCULO- 
 SIS OF THE MESENTERIC GLANDS— TABES 
 MESENTERICA. 
 
 Cheesy degeneration of the mesenteric glands, existing 
 alone, or in association with tubercular deposit, is far from 
 being a common disease. The majority of cases occur after 
 the third year, and under this age tabes mesenterica is 
 rarely encountered. 
 
 Morbid Anatomy. — The glandular lesions are identical 
 with those so familiar in scrofulous conditions. 
 
 Usually some of the mesenteric glands remain healthy ; 
 and those involved — a variable number — do not present a 
 uniform degree of alteration. A few are simply hyperaemic 
 and slightly swollen from an increase in the corpuscular 
 elements; some are increased in size and spongy in texture ; 
 others, again, are enlarged to the size of walnuts, dense, 
 dry and anaemic looking; and still more are partially or 
 completely converted into opaque, yellow, cheesy masses, 
 and sometimes contain tuberculous deposits. 
 
 The diseased glands may remain isolated, but often unite 
 into an irregular mass of variable size. This mass is situ- 
 ated in mid-abdomen, rests upon the vertebral column, and 
 is movable or fixed according to the freedom or involvement 
 of the mesentery in the swelling. 
 
 Further changes are softening of the caseous material, 
 with suppuration and discharge through the gland capsule 
 — an unusual event; shriveling of the gland into a fibrous 
 mass, through thickening and contraction of the trabecular 
 
 266 
 
CASEOUS DEGENERATION OF MESENTERIC GLANDS. 267 
 
 of the reticulum ; and — quite commonly — a gradual hard- 
 ening and shrinking by the absorption of fluid and the 
 deposition of earthy salts. 
 
 Together with these changes, it is the rule to find scrofu- 
 lous lesions of the superficial lymphatic or bronchial glands, 
 cheesy or tubercular deposits in the lungs, and ulceration 
 of the mucous membrane of the intestinal canal. Some- 
 times, also, tubercular peritonitis and caseous and tubercular 
 deposits in the liver and spleen are discovered at the post- 
 mortem examination. 
 
 Etiology. — As the disease always occurs in strumous 
 subjects, the predisposing causes are the same as those 
 leading to the production of that diathesis. 
 
 The exciting causes are embraced under three heads — 
 imperfect hygiene, disease of other organs, and infection 
 through the milk of diseased cows. 
 
 Children who live in filthy, over-crowded, dark and ill- 
 ventilated houses, are much more likely to be affected than 
 those born to more fortunate surroundings ; but of all hygi- 
 enic factors, coarse, over-stimulating or bad food is the most 
 potent for evil. This acts by irritating the intestinal mucous 
 membrane and producing catarrh and follicular ulceration. 
 
 Tubercular disease of the lungs, scrofulous disease of the 
 cervical and bronchial glands or of the bones and joints, 
 and tubercular ulceration of the bowels, are not only usual 
 associates, but, no doubt, frequent causes of tabes mesen- 
 terica. In addition, measles and scarlet fever, from their 
 tendency to induce inflammation of the mucous membrane 
 of the bowels and glandular hyperemia, must be ranked as 
 exciting agents, and so, also, must difficult dentition and 
 whooping-cough. 
 
 Attention has recently been directed to the possibility of 
 the transmission of tubercle to the intestinal tract by means 
 
268 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 of the milk of diseased cows. In support of this theory, 
 Klebs has made a number of experiments, from which he 
 draws the conclusion that the use of the milk of cows having 
 advanced phthisis, always produces tuberculosis, which be- 
 gins as an intestinal catarrh and extends to the mesenteric 
 glands. 
 
 Symptoms. — The signs elicited by physical exploration of 
 the abdomen, and the symptoms arising from the presence 
 of a large mass of glands are much more characteristic than 
 the general features. The shape of the belly and the tension 
 of its walls may be perfectly normal. Such is generally the 
 condition during the earlier stages of the disease ; later, and 
 particularly when there is intestinal ulceration, there is con- 
 siderable distension. This is due either to the accumulation 
 of flatus in the bowel or to the large size of the glandular 
 tumor. In the first instance, the degree of prominence varies 
 from day to day ; when marked, the wall is tense, percussion 
 is tympanitic, and it is difficult or impossible to grasp the 
 glands ; in the second, the enlargement is constant and 
 greatest in and about the umbilical region ; here there is 
 resistance to the palpating hand rather than tension ; the 
 tumor is easily felt, and percussion over it gives a dull 
 sound ; around it, a tympanitic one. The tumor varies in 
 size from that of a hen's egg to that of a double fist ; it is 
 nodulated, hard, somewhat tender, slightly movable when 
 small, and fixed when large. When of any size, the mass 
 can readily be touched by placing the fingers on the um- 
 bilical region and pressing backward toward the spine. 
 Otherwise, it is well to put one hand on either side of the 
 abdomen and gently bring them together toward the. median 
 line, the patient being placed on his back with his shoulders 
 and thighs elevated so as to relax the parietes ; by this 
 method, it is possible to detect a tumor as small as a walnut. 
 
CASEOUS DEGENERATION OF MESENTERIC GLANDS. 269 
 
 The secondary manifestations of the presence of a large 
 mass of glands in the abdominal cavity are pains and cramps 
 in the legs, due to pressure upon the nerves ; and oedema of 
 the legs and distension of the superficial abdominal veins, 
 from compression of the great venous trunks. The veins 
 are often very prominent, and ramify over the wall of the 
 belly to join those of the thoracic wall, which are also dis- 
 tended. 
 
 If the glands in the notch of the liver be enlarged, direct 
 pressure is exerted upon the portal vein and ascites results ; 
 this, however, is a very unusual symptom. 
 
 Provided the naturally prolonged course of the disease be 
 not abridged by tubercular or other complication, the ten- 
 dency is for the glands to shrink and become calcareous. 
 This change lessens the size of the tumor, diminishes the 
 tension of the parietes, and, by relieving pressure, leads to 
 the disappearance of the secondary derangements. 
 
 Softening is another, but, fortunately, a rare termination. 
 Adhesion may then take place between the gland and a 
 loop of intestine, so that the softened matter is evacuated 
 into the bowel without harmful result; but should the dis- 
 charge be directly into the peritoneal cavity, acute perito- 
 nitis is set up, and death soon follows. 
 
 The general symptoms depend for their development 
 upon the condition of the intestinal mucous membrane. 
 Usually there is scrofulous ulceration, with or without 
 general catarrh. 
 
 If ulceration and catarrh be associated, the child wastes ; 
 grows pale and feeble ; presents a haggard appearance ; is 
 fretful and peevish ; has a capricious appetite and much 
 thirst; complains of wandering pains in the abdomen, and is 
 affected with diarrhoea, attended by the expulsion of offen- 
 sive, dark, watery stools, which, on standing, deposit flaky 
 
27O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 matter, mucus, and small, black blood clots. Sleep is rest- 
 less, and at night the temperature rises one or more degrees 
 above normal. 
 
 When catarrh is absent, the bowels are often constipated ; 
 the patient looks ill ; is pale and languid ; his muscles are 
 flabby, and he has more or less flatulent pain in the belly; 
 but there is no marked wasting and none of the evidences 
 of great impairment of general nutrition. 
 
 Should there be no disease of the mucous lining of the 
 bowels, flesh is retained ; the spirits and strength are good ; 
 the appetite and bowels undisturbed; the temperature normal, 
 and there is nothing to show ill-health save some pallor of 
 the skin. 
 
 Diagnosis. — The only positive proof of the existence of 
 tabes mesenterica is the detection, by palpation, of a glandu- 
 lar tumor. Particular caution must be given against the 
 mistake, so frequently made, of attributing every case of 
 abdominal distension to disease of the mesenteric glands. 
 Prominence of the belly is a frequent symptom in children, 
 and in the vast majority of cases depends upon intestinal 
 catarrh. In this condition there is imperfect digestion 
 and assimilation of food, and, consequently, debility, affect- 
 ing the muscles of the intestines as well as the system 
 generally. Now, imperfectly digested food readily under- 
 goes fermentation, with the production of carbonic-acid gas, 
 and this distends the bowels ; the more so as they are want- 
 ing in tone from the weakness of their muscular coat. Such 
 inflation of the gut must lead, of course, to a prominent 
 abdomen, but one which is uniformly tympanitic on percus- 
 sion, moderately soft and flaccid to the touch, and entirely 
 free from the signs of enlargement of the mesenteric glands. 
 
 Again, distension of the superficial abdominal veins is 
 merely an indication of obstructed circulation in the deep 
 
CASEOUS DEGENERATION OF MESENTERIC GLANDS. 27 1 
 
 venous trunks, and only becomes a symptom of importance 
 in the diagnosis of tabes mesenterica when hepatic disease 
 can be excluded. 
 
 Even should a tumor be felt, the question arises whether 
 it may not be an accumulation of faeces. In the latter 
 there is no tenderness ; the mass occupies the position of 
 the transverse or descending colon, is oblong in shape, with 
 its long diameter corresponding to the axis of the gut in 
 which it is placed, and is so soft that it may be somewhat 
 moulded by the pressure of the fingers. Should there be 
 any doubt, an enema of warm water and soapsuds must 
 be thrown into the bowel and retained for a few moments, 
 by firm pressure upon the anus. When expelled this will 
 bring away a quantity of light-colored, brittle matter, if the 
 mass be due to faecal accumulation ; and the previously 
 detected tumor will be found, on examination, to have dis- 
 appeared or lessened in size. On the other hand, if the 
 tumor be glandular, the expulsion of flatus and faeces, 
 induced by the injection, only renders it still more promi- 
 nent. 
 
 The diagnosis must not be considered completed by the 
 detection of the tumor, but must extend to the discovery 
 or elimination of the different complications : — ulceration of 
 the intestines, tubercular deposits in the lungs and tuber- 
 cular peritonitis. 
 
 Prognosis. — Caseation of the mesenteric glands is dan- 
 gerous, but the danger does not spring from the glandu- 
 lar disease so much as from the affections that produce it, 
 the conditions that accompany it, and the results that fol- 
 low it. In regard to the latter, though, it may be stated 
 that of all the glands in the body the mesenteric are least 
 likely to be followed by ill consequences when diseased ; 
 a fact due to their slight tendency to undergo softening. 
 
272 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 When the sole discoverable lesion is swelling of the 
 glands, and there is no rise in the evening temperature nor 
 marked impairment of nutrition, the hope of subsidence of 
 the enlargement and ultimate recovery, may be reasonably 
 entertained. On the contrary, if there be wasting, diar- 
 rhoea and fever, indicating ulceration of the bowels, sec- 
 ondary, perhaps, to chronic disease of the lungs, the 
 prognosis must be grave. Again, the occurrence of tuber- 
 culous peritonitis renders the prospect most unfavorable. 
 
 Treatment. — Much may be done in the direction of 
 prophylaxis by keeping a strict watch upon the stomach 
 and intestines in scrofulous children, so as to remove any 
 apparently trifling disorder as quickly as possible. Supply- 
 ing good food, fresh, pure air and warm clothing, and main- 
 taining the activity of the skin are also important preventive 
 measures. 
 
 After the disease is established, much can be accom- 
 plished by attention to the diet and general regimen. In 
 regulating the diet, it is necessary to take into consideration 
 the catarrhal state of the intestinal mucous membrane 
 usually present, and the almost useless condition of, at least, 
 a number of the mesenteric glands, and to select those 
 articles which are absorbed in the stomach or taken di- 
 rectly into the blood vessels, without the intermediate 
 action of the lacteals and mesenteric glands. The food 
 must be sufficient to maintain the general strength, but not 
 so abundant as to overtax the process of digestion. The 
 following may be taken as an average daily schedule of 
 both diet and regimen for a child of four years, in whom 
 there is no excessive wasting or weakness : — 
 
 On waking in the morning, say at 7 a.m., a thin slice of 
 dry, stale bread, and three fluidounces of hot veal broth. 
 
 At 8.30 a.m. a cold bath, given in this manner : — being 
 
CASEOUS DEGENERATION OF MESENTERIC GLANDS. 273 
 
 taken from bed, the whole body is briskly shampooed with 
 a soft towel until the surface is aglow. The child is next 
 made to stand in a tub sufficiently filled with hot water to 
 cover his feet and ankles, and two gallons of cold water, 
 containing an ounce of sea-salt or concentrated sea-water, 
 are slowly poured over his shoulders. The skin is then 
 thoroughly dried and rubbed until reaction is established; 
 the child is wrapped in a blanket and put back to bed for 
 half an hour. On rising, the abdomen should be com- 
 pletely enveloped in a flannel binder, and the body clad in 
 woolen underclothing from head to foot. 
 
 At 9.30 a.m., breakfast. — A soft-boiled egg and two slices 
 of stale bread. 
 
 From 10.30 a.m. to 12 m. — A walk or romp in the open air, 
 in good weather. 
 
 At 12 m., lunch. — Half a dozen raw oysters or a bit of 
 sweetbread or fish, and a slice of dry, stale bread. 
 
 At 3 p.m., dinner. — Six fluidounces of beef, mutton or 
 chicken broth ; a bit of minced roast beef, beef-steak, roast 
 mutton, chicken, or wild fowl. A moderate quantity of 
 spinach, stewed celery, boiled cauliflower, or other non- 
 farinaceous vegetable, and one or two slices of dry, stale 
 bread. No dessert except junket occasionally. 
 
 At 7 p.m., supper. — Same as lunch, alternating the fish, 
 sweetbread or oysters. 
 
 Nothing should be taken for drink but filtered water or, 
 better still, good spring water.* 
 
 When there is much emaciation and weakness, the morn- 
 ing bath must be omitted or substituted by a simple warm 
 sponging; and some stimulant, as a teaspoonful of old 
 whiskey, should be given three times daily. 
 
 Diarrhoea demands an exclusive liquid diet, and it is 
 
 * Directions for Philadelphia. 
 18 
 
274 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 advisable to artificially digest the meat broths and milk, 
 which must form the basis of this. 
 
 The most useful drugs are cod-liver oil and the syrup of 
 the iodide of iron, since the indications are to build up the 
 general health and restore the glands to a healthy condi- 
 tion. The former can be given as an emulsion with lacto- 
 phosphate of lime in two- drachm doses three times daily, 
 after eating, at the age of four years ; the latter in fifteen 
 drop doses after meals. Often it is well to administer both 
 preparations together. 
 
 Locally, some good may result from the daily inunction 
 of a weak mercurial or iodine ointment, for example : — 
 
 R. Ung. Iodin. Comp., sjij. 
 
 Ung. Belladonnas, ^j. 
 
 Ung. Aquce Rosse, 3 v. 
 
 M. 
 
 R. Ung. Hydrargyri, giij. 
 
 Adipis, gv. 
 
 M. 
 
 Of either a piece as large as a cherry may be rubbed 
 into the skin over the tumor once every day. 
 
 Other remedies are, of course, required to arrest diar- 
 rhoea, or to relieve the different complications that may 
 arise. 
 
 Should the circumstances of the patient permit, change 
 of residence to some locality having an equable climate, a 
 bracing atmosphere and a dry, porous soil, will greatly 
 assist in effecting a cure. 
 
CHAPTER IV. 
 
 AFFECTIONS OF THE LIVER. 
 
 Hepatic diseases do not occur so frequently during 
 childhood as in adult life. Fatty and amyloid changes are 
 the most common affections ; syphilitic disease, cirrhosis, 
 tubercular deposit and parenchymatous inflammation stand 
 next in the order named ; while echinococcus is very rare, 
 and cancer almost unknown. Jaundice, on the contrary, is 
 often met with, but this condition, though a complex and 
 striking one, is simply an indication of disease of the vis- 
 cus itself, or of its excretory duct. Congestion of the organ 
 is also common. 
 
 i. JAUNDICE. 
 
 Icterus, irrespective of the age at which it occurs, is 
 characterized by yellowness of the skin and conjunctivae, 
 clay-colored stools and yellow-brown urine. During the 
 first few days of life, especially after a difficult and tedious 
 birth, there is apt to be intense congestion of the skin, 
 followed, as the redness fades, by a brownish-yellow discol- 
 oration. This appears on the second or third day, and 
 disappears by the tenth. 
 
 It is not jaundice, for it is entirely independent of liver 
 disorder, and there is no yellowness of the conjunctivae, 
 and no alteration in the faeces or urine. A form of true 
 jaundice, however, does occur in the newly-born, termed 
 icterus neonatorum, which may be studied before describ- 
 ing the condition as it is seen in later childhood. 
 
 275 
 
276 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 ICTERUS NEONATORUM. 
 
 Both mild and dangerous types of this variety of jaun- 
 dice are met with. 
 
 The mild type occurs in infants prematurely born, or weak 
 from other causes ; in those early exposed to the depres- 
 sing action of cold, dampness, and foul air, and particularly 
 in those who are born partly asphyxiated after tedious 
 labor. It is difficult to understand the exact method in 
 which these causes act. Cold undoubtedly produces catarrh 
 of the duodenal mucous membrane, and plugging of the 
 bile-duct by mucus ; the others, the last especially, act, in all 
 probability, by altering the hepatic circulation. At birth 
 there is a sudden transference of the blood-supply from 
 the umbilical to the portal vein ; a change — according to 
 Frerichs — temporarily followed by comparative emptiness 
 of the blood vessels of the liver ; a diminution of vascular 
 tension, and the passage of bile into the blood. Weber 
 attributes the jaundice to pressure from congestion and 
 oedema, the result of an arrest of the circulation in the 
 umbilical vein before the establishment of respiration ; con- 
 ditions present in infants born semi-asphyxiated. Birch- 
 Hirschfeld has demonstrated that a dense areolar sheath 
 surrounds the vessels in the notch of the liver and extends 
 into the viscus along with the portal vein; this becomes 
 cedematous and greatly swollen when there is venous ob- 
 struction in the liver during difficult parturition, and, by 
 pressure, obstructs the flow of bile into the intestine. 
 
 The grade of jaundice in this type varies considerably. 
 Sometimes the yellow discoloration is confined to the face, 
 chest and back; the conjunctivae are but lightly tinged; 
 the urine and faeces are unaltered, and after three or four 
 days the trouble is at an end. In other cases, the yellow- 
 ness extends to the abdomen and arms ; the conjunctivae 
 
AFFECTIONS OF THE LIVER. 2J*] 
 
 are distinctly yellow ; the urine is dark and stains the 
 diapers, but the stools still retain their natural color — 
 golden yellow; the duration is about seven days. The 
 best developed instances present universal and moderately 
 deep discoloration of the skin; the conjunctivae are very 
 yellow; the urine brownish, and the stools clay-colored. 
 With this degree of jaundice, there is malaise, loss of appe- 
 tite, constipation, and enlargement of the liver ; the lower 
 edge of the right lobe often extending below the costal 
 border as far as the umbilicus. 
 
 Occasionally, instead of constipation, there is diarrhoea, 
 with moderate heat and tenderness of the belly, and a quick 
 pulse, indicating severe intestinal catarrh. These cases 
 recover after a fortnight or more, though occasionally 
 diarrhoea arising and persisting in a feeble infant, is suffi- 
 cient to determine a fatal issue. 
 
 The Treatment is simple. The infant must be kept in a 
 warm, well-ventilated room ; the activity of the skin must 
 be maintained by bathing, and chilling prevented by 
 proper clothing. Constipation is to be relieved by fifteen 
 or twenty drops of castor-oil, a soap suppository or an 
 enema, and, if the skin be slow in resuming its normal 
 color, it is well to prescribe an alkali, as : — 
 
 J& . Sodii Bicarbonatis, gr. xxxij. 
 
 Aq. Menth. Pip., 
 
 Syrupi, aaf^ss. 
 
 Aquae, q. s. ad f^ij. 
 
 M. 
 S. — One teaspoonful three times daily. 
 
 The grave type depends upon congenital malformation of 
 the bile-ducts and gall-bladder; compression of the bile- 
 ducts by syphilitic inflammation and growths, and umbilical 
 arteritis and phlebitis. 
 
 a. Congenital malformation is rare, but when it occurs is 
 
278 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 liable to affect several members of the same family in suc- 
 cession; boys suffer twice as often as girls. There are a 
 number of varieties : thus, the gall-duct may be converted 
 into a fibrous cord; the ductus communis may be contracted, 
 obliterated or absent; the gall-bladder may be rudimentary 
 and the ducts absent; or all the ducts may be wanting. 
 Whatever the condition, the result is enlargement of the 
 liver with cirrhotic change, more or less marked in propor- 
 tion to the duration of life. The organ is dark green or 
 almost black in color, feels unnaturally firm to the touch, 
 and under the microscope shows an excess of connective 
 tissue. 
 
 From one to two weeks after birth the retained bile begins 
 to give rise to jaundice ; this appears as a slight yellowness 
 of the skin, and steadily grows more distinct, though it 
 varies considerably in intensity from day to day; at the 
 same time, the conjunctivae are stained and the urine dark 
 colored. After a day or two, the liver begins to encroach 
 upon the abdominal cavity and rapidly enlarges; the spleen, 
 too, increases in size, and these two lesions, together with 
 flatulent distension of the bowels and occasional ascites, 
 produce decided prominence of the belly. In spite of a 
 uniformly good appetite, there is constant wasting. The 
 bowels act sluggishly, the faeces are offensive, clay colored 
 or dark green, from the presence of altered blood, and 
 dilated haemorrhoidal veins can often be seen by inspecting 
 the anus. Another frequent symptom is oozing of blood, 
 either arterial or venous, from the umbilicus. This hemor- 
 rhage is capillary in nature, and usually begins at night, 
 and soon after the fall of the navel string ; an event that 
 occurs between the fifth and ninth day. It may be com- 
 bined with bleeding from the nose, mouth, stomach or 
 bowels, and is exhausting and always difficult to control. 
 
AFFECTIONS OF THE LIVER. 279 
 
 This form of jaundice ends in death. When umbilical 
 hemorrhage occurs, the course is short, varying from a few 
 hours to six or seven days; in other cases, life may be 
 prolonged as many months, and death result from some 
 intercurrent disease. In the latter class, the secreting ele- 
 ments of the liver are so far crippled by the constantly 
 progressing cirrhosis that little bile is found, and the yel- 
 lowness of the surface fades, or almost entirely disappears, 
 before life ends. 
 
 b. Syphilitic inflammation of the liver with its lesions and 
 symptoms will be referred to in another place (see page 
 291). 
 
 c. Inflammation of the umbilical blood vessels is due to 
 blood poisoning. The infecting material in the infant is 
 apparently identical with that producing puerperal fever in 
 the mother, and is possibly caused by bacteria, as two forms 
 of these — spherical and rod-shaped — have been discovered 
 in the blood of infants so affected. In consequence, the 
 liver undergoes marked degenerative changes ; the connec- 
 tive tissue about the portal vein and its branches becomes 
 swollen and presses upon the bile-ducts, and from this, as 
 well as from alterations in the crasis of the blood, jaundice 
 results. 
 
 Discoloration of the skin makes its appearance a few days 
 after birth and rapidly increases ; the urine is very dark, and 
 the stools are scanty and passed at long intervals. The face 
 is livid and pinched; the hands and feet are purple ; petechias 
 appear under the skin ; the abdomen is distended by flatus 
 and by enlargement of the liver and spleen ; there is tender- 
 ness with fluctuation on palpation, and blood or bloody pus 
 exudes from the umbilicus. The tongue is dry, there is 
 little appetite, and the stomach rejects what food is taken, 
 together with quantities of greenish mucus. Pyrexia is 
 
280 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 noticeable from the beginning, and becomes more marked as 
 the disease progresses ; the pulse is quick and the breathing 
 hurried. 
 
 The course is always short, and the invariably fatal ter- 
 mination may be preceded by convulsions and coma. 
 
 Treatment in either variety is most unsatisfactory ; little 
 can be done beyond the employment of measures to main- 
 tain the vital forces as long as possible. Umbilical hemor- 
 rhage may be arrested by the application of Monsell's solu- 
 tion, or, if this fail, by inserting two hair-lip pins through 
 the skin at the root of the navel and twisting a ligature 
 tightly around them in the form of a figure of eight. 
 
 Syphilitic inflammation demands appropriate constitu- 
 tional remedies, and in pyaemic cases the abdominal ten- 
 derness must be relieved by warm fomentations and seda- 
 tive applications. 
 
 ICTERUS IN OLDER CHILDREN. 
 
 Jaundice in late infancy and childhood usually depends 
 upon catarrh, extending from the mucous membrane of the 
 duodenum into the ductus communis; sometimes it is due 
 to plugging of the duct by inspissated bile; and, again, to 
 occlusion by the entrance of a lumbricoid worm. Certain 
 structural lesions of the liver, poisoning by phosphorus and 
 miasmatic influences, also produce it. 
 
 Catarrhal jaundice — the only form necessary to consider 
 in this connection — presents the features so common to, and 
 so characteristic of, the same condition in adults. Briefly 
 stated, there is more or less yellow or brownish-yellow dis- 
 coloration of the skin, with troublesome itching, yellowness 
 of the conjunctivae, porter-like urine, and clay-colored stools, 
 devoid of the natural faecal odor. Other symptoms are 
 anorexia, craving for acid drinks, a yellow-furred tongue, 
 
AFFECTIONS OF THE LIVER. 28 1 
 
 disordered digestion, listlessness, slowness of the pulse, slight 
 reduction of the surface temperature, and disturbed sleep. 
 The liver may be somewhat enlarged, projecting two inches 
 or more below the costal border, and tender, or even pain- 
 ful, on pressure. The result is always favorable, and the 
 duration rarely longer than two or three weeks. 
 
 Treatment. — Warm clothing, daily bathing followed by 
 gentle friction to promote the activity of the skin, and a 
 diet based on the same plan as for intestinal catarrh, are the 
 first requisites. 
 
 The medicinal treatment can be begun by a moderate 
 dose of calomel, followed by a saline ; but if a laxative be 
 required later, the drugs that stimulate the secretion of the 
 liver and act upon the upper bowel must be excluded, and 
 those selected which affect the lower segment, as aloes and 
 castor-oil. 
 
 Duodenal catarrh — the causal factor — is most speedily re- 
 moved by alkalies. Four fluidounces of some saline water, 
 as Kisssingen or Vichy, should be drunk at each meal, and 
 the following mixture taken : — 
 
 R. Ammonii Chloridi, gij. 
 
 Aq. Menth. Pip., . . . . f|iij. 
 
 M. 
 S. — One teaspoonful, diluted, three times daily after meals, 
 for a child six years old. 
 
 Nux vomica is also useful, and two or three drops of the 
 tincture may be administered thrice daily before eating. 
 
 2. CONGESTION OF THE LIVER. 
 
 Congestion of the liver is quite common, especially in 
 children of four years of age and upward. 
 
282 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Morbid Anatomy. — There is an increase in the size, 
 weight and density of the organ, and its peritoneum is 
 tense and shining. On incision, blood flows freely, and the 
 section presents a mottled or " nutmeg " appearance, partly 
 from dilatation of the intra-lobular veins and partly from 
 staining of the cells by retained bile. In long-standing cases, 
 those due to cardiac disease, for example, the cells in 
 immediate proximity to the dilated intra-lobular veins 
 atrophy ; those near them are stained with bile, and those 
 most distant undergo fatty degeneration. In time the 
 atrophied cells disappear ; their place is taken by connective 
 tissue, which shrinks and produces a cirrhotic condition, 
 the surface of the liver becoming granular and the cap- 
 sule thickened. 
 
 Etiology. — Even in health the amount of blood in the 
 hepatic vessels varies from time to time, and there is always 
 a temporary increase during the process of digestion. This 
 normal hyperemia readily becomes abnormal and continu- 
 ous when there is habitual over-feeding ; when the food 
 is highly spiced and too stimulating ; and when insufficient 
 exercise is taken. Congestion is often produced by chills, 
 whether resulting from exposure to cold or from the poison 
 of malarial fever, since, in either case, the blood is driven 
 from the surface to the interior of the body. Again, car- 
 diac disease, by obstructing the return of blood from the 
 lung and overfilling the vena cava and portal vein, is an 
 active cause. 
 
 Symptoms. — The skin is sallow, or together with the 
 conjunctivae distinctly jaundiced. There is malaise ; head- 
 ache ; a yellow, furred tongue ; anorexia ; nausea ; relaxed 
 bowels with clay-colored, offensive stools, and dark-colored 
 urine loaded with lithates. Pain in the right hypochon- 
 drium is usually present, and, as this is increased by turn- 
 
AFFECTIONS OF THE LIVER. 283 
 
 ing upon either side, the patient maintains a dorsal posi- 
 tion ; there is also tenderness in this region, and the suf- 
 fering is increased by coughing or deep breathing. On 
 palpation, the right lobe of the liver can be detected, ex- 
 tending two or three inches beyond the costal border, while 
 at its edge is felt the gall-bladder distended into a pyriform 
 tumor of variable size. At the same time the upper limit 
 of percussion dulness begins in the third interspace, or at 
 the level of the third rib, instead of the fourth interspace, 
 as in health. 
 
 Should the congestion depend upon heart disease, albu- 
 minuria and oedema of the feet and legs are associated. 
 
 Diagnosis. — Many instances of disordered digestion, 
 with the expulsion of putty-like, undigested material from 
 the bowels, are attributed to congestion of the liver, when 
 in reality the gastro-intestinal tract alone is at fault. Such 
 a mistake can be avoided, if it be remembered that to estab- 
 lish the existence of the hepatic disease it is necessary to 
 have enlargement of the organ, with pain and tenderness ; 
 jaundice and clay-colored, offensive stools ; combined with 
 disturbance of the functions of the stomach and intestines. 
 
 Extension of the liver a finger's-breadth or more, below 
 the costal border, does not absolutely indicate enlargement, 
 since this often occurs without disease, in short-chested 
 children, and in those whose chests are contracted and 
 deeply grooved by rickets. Downward displacement and 
 apparent enlargement may also be caused by pleuritic and 
 pericardial effusions, and by emphysema of the lungs. On 
 the other hand, an enlarged liver may be completely under 
 cover of the ribs, for, in addition to being normally high in 
 the thorax, it may be pushed upon by a collection of fluid 
 or a growth in the abdominal cavity, or drawn up through 
 the shrinking of a collapsed or indurated lung. It is 
 
284 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 essential, therefore, to fix the position of the upper limit by 
 percussion, as well as the lower edge by palpation, before 
 forming a conclusion. 
 
 Prognosis. — The course of the affection is short, and 
 there is no danger unless the child be greatly reduced by 
 previous ill-health, or there be cardiac disease. In the 
 latter case, the duration and result correspond to, and de- 
 pend upon, the gravity of the heart lesion. 
 
 Treatment. — The child may be put to bed, or, if not ill 
 enough to be so confined, should be kept within doors. 
 The abdomen must be protected by a flannel binder or a 
 layer of cotton batting covered with oiled silk, and the 
 skin kept active by a daily warm bath, administered, in walk- 
 ing cases, just before retiring to bed. Too much food of 
 any kind is bad ; meat and highly-seasoned dishes are to 
 be excluded from the diet ; and it is best not to extend the 
 list beyond milk, mutton or veal broth, fish, bread and 
 plain light puddings, as rice and milk. 
 
 In the beginning, a child of six or eight years should get 
 the following powder : — 
 
 R . Hydrargyri Chlorid. Mit., gr. ij. 
 
 Pulv. Ipecacuanhas, gr. ss. 
 
 Sacchari, gr. v. 
 
 M. et ft. chart. No. j. 
 S. — To be taken in the evening and followed, next morning, 
 by a teaspoonful of magnesia. 
 
 Subsequently, five grains of chloride of ammonium should 
 be given after food, and a small tumbler (five fluidounces) 
 of Vichy taken with each meal. 
 
 Aloes and the salines are the best remedies to relieve 
 constipation during the course of the attack. 
 
 In cardiac case, treatment must be directed chiefly to the 
 heart; and in those due to malarial poisoning, antiperiodics 
 are of little avail until the hepatic congestion is relieved. 
 
AFFECTIONS OF THE LIVER. 285 
 
 When convalescence is established, regular exercise in 
 the open air must be insisted upon and a plain diet main- 
 tained. Change of air is often most useful to break up the 
 " bilious habit." 
 
 3. FATTY LIVER. 
 
 This condition presents itself in two distinct forms, namely, 
 fatty infiltration and fatty degeneration. 
 
 FATTY INFILTRATION. 
 
 In fatty infiltration, the quantity of fat in the hepatic cells 
 is greatly increased without any alteration in the walls of 
 the cells. 
 
 Morbid Anatomy. — The liver is increased in all its 
 dimensions, its surface is yellowish and oily, its margins 
 rounded and its texture doughy. On section, the cut sur- 
 face is distinctly yellow, mottled with brownish-red spots, 
 and if a bit be put under the microscope, abundant granules 
 and globules of fat are seen. 
 
 Etiology. — One cause of fatty infiltration is an excess of 
 farinaceous food. Then the deposition is physiological and 
 transitory, the excess of hydrocarbons supplied from without 
 being deposited in the liver in the form of fat. The second 
 cause is chronic, exhausting disease, such as tubercle, scrof- 
 ula, rickets, caries of bone, intestinal catarrh and syphilis. 
 Here the fat is absorbed from the subcutaneous and other 
 fat-containing tissues of the body. 
 
 Symptoms. — It is only in well-marked cases that these 
 are developed. An increase in the bulk of the liver with a 
 rounded, inferior margin may be detected by percussion and 
 palpation ; but this is frequently impossible on account of 
 
286 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 the tendency the organ has, from its softness, to fall away 
 from the chest-wall. There is a sense of weight in the right 
 hypochondriac region and disturbed gastro-intestinal func- 
 tion, due to portal obstruction. Jaundice and ascites are 
 absent, and there is neither pain nor tenderness over the 
 viscus. 
 
 The Diagnosis is not difficult when enlargement, softness 
 and blunting of the edge of the viscus can be detected by 
 examination. 
 
 The Prognosis depends upon the cause rather than the 
 degree of change; occurring in the course of a protracted, 
 wasting disease, fatty infiltration shows dangerous impair- 
 ment of nutrition. 
 
 Treatment. — Beyond a rigid exclusion of farinaceous and 
 fatty foods from the dietary, all remedies must be directed 
 to the relief of the originating disease. 
 
 FATTY DEGENERATION. 
 
 Fatty degeneration is a much rarer lesion in children 
 than fatty infiltration. 
 
 Morbid Anatomy. — The liver appears normal to the 
 unassisted eye, but with the aid of the microscope the 
 cells are found to be filled with minute protein or fatty 
 granules, and tend to fragmentation and destruction. The 
 whole, or only isolated portions of the viscus, may be changed 
 in this way. 
 
 Etiology. — The lesion is produced by acute affections, 
 as measles, variola, scarlatina and typhoid fever; by chronic, 
 exhausting diseases, as tubercle, scrofula and rickets; and 
 by accidental poisoning with arsenic or phosphorus. 
 
 There are no characteristic symptoms, the result is inva- 
 riably unfavorable, and no special indications for treatment 
 are presented. 
 
AFFECTIONS OF THE LIVER. 287 
 
 4. AMYLOID LIVER. 
 
 This lesion is moderately common in childhood, and 
 usually occurs as a factor of general amyloid degeneration. 
 
 Morbid Anatomy. — The disease consists in a more or 
 less complete infiltration of the cells by a peculiar trans- 
 lucent, refracting substance, possessing the property of fix- 
 ing iodine and assuming a mahogany-brown color, which, 
 on the application of sulphuric acid, changes to green, blue, 
 violet or red. The infiltration begins in the hepatic arterioles 
 and capillaries, and at first is limited to the middle zone of 
 the lobules ; thence it extends to the periphery and centre, 
 destroying the normal elements of the cells and converting 
 them into irregularly shaped, glassy-looking blocks. Fatty 
 infiltration is often associated. Uniform enlargement; in- 
 creased density; yellowish-gray color; smooth, shining peri- 
 toneum; thin edges, and the exposure, on section, of dry, 
 homogeneous, glistening surfaces, are the gross charac- 
 teristics. 
 
 The spleen, kidneys and lymphatic glands are often simi- 
 larly altered, and sometimes the mucous membrane of the 
 stomach and intestines. 
 
 Etiology. — Amyloid degeneration of the liver is always 
 produced by some chronic disease, attended by suppuration 
 and purulent discharge. Empyema with a fistulous opening 
 in the chest-wall ; dilated bronchi with copious muco-puru- 
 lent expectoration ; scrofulous abscess ; chronic pulmonary 
 tuberculosis ; suppurative diseases of the bones and joints, 
 and constitutional syphilis, are the most frequent causes. 
 It occurs at any age, but is more frequent after the fifth 
 year, and in boys than girls. 
 
 Symptoms. — There are few rational symptoms other than 
 those belonging to the originating disease. Tenderness and 
 pain in the hepatic region are absent, and so, too, are 
 
288 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 jaundice, distension of the superficial abdominal veins and 
 ascites ; except the glands in the fissure of the liver be coin- 
 cidently enlarged by waxy deposit, when, from pressure upon 
 the portal vein and bile-ducts, the last three phenomena may 
 be developed. The patient complains of weight, discom- 
 fort in the right hypochondrium, and is weak, wasted and 
 anaemic, with pale, sallow skin, clubbed fingers and cedema- 
 tous feet and ankles. When the kidneys are involved, the 
 urine is increased in quantity, has a low specific gravity 
 (about 1014), is pale, lemon colored, and contains albumen, 
 and, at times, hyaline tube casts. Dropsy of the extremities 
 is due in great part to this complication. If the stomach 
 and intestines be implicated, there is a tendency to vomit- 
 ing and diarrhoea. 
 
 Physical examination yields very characteristic signs. 
 The abdomen is prominent, especially over the upper third, 
 and both percussion and palpation show that the liver is 
 greatly and uniformly enlarged. The upper margin of dul- 
 ness is higher, by an inch or more, than normal ; while the 
 lower edge of the right lobe, somewhat blunted, but per- 
 fectly well defined, can often be felt as low down as the level 
 of the umbilicus. The portion uncovered by the ribs feels 
 very dense and firm, and perfectly smooth, except where 
 broken by the natural fissures. 
 
 The spleen can often be detected projecting as a hard 
 mass . from beneath the left costal border. The absence of 
 enlargement, however, is no proof against the existence of 
 amyloid change in the organ; in about half the cases there 
 is no alteration in size. 
 
 In course, the disease is always slow. 
 
 Diagnosis. — This is readily made from the physical signs 
 furnished by the liver and spleen ; the absence of jaundice 
 and ascites ; the previous history of cachexia and suppura- 
 
AFFECTIONS OF THE LIVER. 289 
 
 tion ; the character of the urine ; the anaemia, and the gastro- 
 intestinal symptoms. . 
 
 Congestion of the liver with consequent enlargement has 
 a different clinical history, rarely occurring in cachectic or 
 anaemic cases. A fatty liver, while large, is soft and yield- 
 ing to the touch, and is unattended by increase in the size 
 of the spleen or albuminuria. 
 
 Prognosis. — The prospect of ultimate recovery is better 
 in children than in adults, for, provided the cause of the 
 degeneration can be removed, it is quite possible for the 
 liver to return to its natural dimensions and to an apparently 
 healthy condition, through the active reparative power always 
 present in early life. Nevertheless, amyloid change in the 
 liver adds greatly to the danger of the originating disease, 
 and is fatal in most cases. 
 
 Treatment. — It is almost needless to state that atten- 
 tion must first be given to the removal or amelioration 
 of the cause. It is much more difficult to cure the 
 disease when once developed, than to prevent it by 
 checking chronic suppuration, removing carious bone, 
 healing diseased joints, energetically treating constitu- 
 tional syphilis, and building up the health in cachectic 
 subjects. 
 
 To combat the disease itself, the diet must be as nu- 
 tritious as the activity of digestion will permit ; a 
 moderate quantity of alcoholic stimulants must be taken 
 daily; the child must be properly clothed, to prevent 
 chilling, and must live as much as possible in the sun- 
 light and open air, or, if confined to the house, in a light, 
 airy room. Alkalies, iron and iodine are the most useful 
 drugs. 
 
 Of alkalies, chloride of ammonium is the best, and it may 
 be given in combination with a bitter, as : — 
 19 
 
29O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 R . Ammonii Chloridi, 3 ij. 
 
 Inf. Gentianae Comp., f^> u j- 
 
 M. 
 S. — One teaspoonful four times daily at the age of six years. 
 
 It is often well to combine iron with the ammonia salt, 
 for example : — 
 
 R. Tr. Ferri Chloridi, f^j. 
 
 Ammonii Chloridi, ^ij. 
 
 Inf. Calumbse, '. . . q. s. ad f !§ iij. 
 
 M. 
 S. — One teaspoonful three times daily. 
 
 Another good way of administering iron is in the form 
 of a modified Basham's mixture : — 
 
 R. Tr. Ferri Chloridi, f£J. 
 
 Acid. Acetici dil , f ^ jss. 
 
 Liq. Ammonii Acetatis, f 3 x. 
 
 Elix. Aurantii, f, 5 ) v » 
 
 Sympi f|j. 
 
 Aquas, q. s. ad f^yj. 
 
 M. 
 S. — One tablespoonful four times a day. 
 
 This formula is particularly useful when there is kidney 
 complication with oedema. 
 
 Iodine is most efficient if there be a syphilitic taint, it 
 may be given in the form of iodide of potassium, five 
 grains or more three times a day, with a bitter infusion ; or 
 liquor iodinii comp. can be employed in doses of two 
 drops, well diluted, thrice daily. 
 
 Complications must be met as they arise. Vomiting, by 
 ice, cold Apollinaris water, bismuth, and counter-irritation 
 to the epigastrium ; diarrhoea, by vegetable astringents, with 
 small doses of opium ; and dropsy, by diaphoretics and 
 diuretics. 
 
AFFECTIONS OF THE LIVER. 29 1 
 
 5. SYPHILITIC INFLAMMATION OF THE 
 LIVER. 
 
 Syphilitic hepatitis is frequently encountered in the 
 newly-born, though rare in more advanced childhood. 
 
 Morbid Anatomy. — The liver may be the seat of acute 
 swelling, which, without showing marked gross alteration, 
 is associated with a diffused growth of connective tissue 
 elements ; again, there may be a localized gummatous 
 change; and, finally, the inflammatory process may be 
 confined to the septa — peripylephlebitis syphilitica. The 
 proliferation of connective tissue takes place both between 
 the hepatic islands and in their interior, thus differing from 
 cirrhosis, where the increase is only between the lobules. 
 When jaundice occurs, the small bile-ducts are thickened 
 and occluded by epithelial cells, and the organ is enlarged, 
 and brownish-yellow in color. 
 
 Symptoms. — In mild cases these are few and unchar- 
 acteristic ; in those that are grave there are jaundice, 
 ascites, hemorrhage from the umbilicus and intestines, 
 ecchymosis of the skin, subnormal temperature, rapid 
 wasting, and often syphilitic lesions of the skin and 
 mucous membranes. On abdominal exploration, the liver 
 is found to be enlarged and hard, and the spleen increased 
 in size. 
 
 Diagnosis. — The early age, the history of an inherited 
 taint, the association of enlargement of the liver with jaun- 
 dice and ascites, make this a matter of little difficulty in 
 cases that are at all marked. 
 
 Prognosis is unfavorable, though the opinion must rest 
 upon the degree of cachexia. Goodhart states that all of 
 his cases proved remarkably amenable to mercurial treat- 
 ment, but this does not correspond with the experience of 
 other observers. 
 
292 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Should deep jaundice, ascites and hemorrhage occur, 
 death is the almost invariable end. 
 
 Treatment. — As in other syphilitic affections, mercurials 
 must be followed by tonics. One-eighth of a grain of calo- 
 mel, or one grain of mercury with chalk ; may be adminis- 
 tered morning and evening, or ten grains of mercurial oint- 
 ment may be rubbed into the skin once a day, either directly 
 by the fingers of the nurse, or by being smeared upon the 
 flannel binder. 
 
 After the liver has been reduced in bulk and other mani- 
 festations of the poison are under control, syrup of the 
 iodide of iron, in two-drop doses three times daily, is the 
 most efficient tonic. 
 
 Iodide of potassium is also useful ; it acts best when 
 combined with chloride of ammonium, as : — 
 
 R . Potassii Iodidi, gr. xxiv. 
 
 Ammonii Chloridi, gr. xxxvj. 
 
 Syrup. Sarsaparillae Comp., f^ ss « 
 
 Aqua?, q. s. ad f^iij. 
 
 M. 
 
 S. — Teaspoonful three times daily for an infant of one month. 
 
 In those fortunate instances that yield to treatment, 
 splenic enlargement disappears less rapidly than that of the 
 liver, and requires the daily application of compound iodine 
 ointment diluted in the proportion of one part to seven 
 of lard. 
 
 6. CIRRHOSIS OF THE LIVER. 
 
 In childhood, cirrhosis must be classed among the un- 
 common diseases of the liver ; the fact of its occasional 
 occurrence, however, has been abundantly proved by post- 
 mortem examinations. 
 
AFFECTIONS OF THE LIVER. 293 
 
 Morbid Anatomy. — There are two forms, namely, the 
 atrophic and the hypertrophic. 
 
 In atrophic cirrhosis or hob-nailed liver, the organ is 
 contracted and dense in texture, with nodulated surfaces, 
 thin edges and thickened capsule ; on incision the cut sur- 
 face is grayish-yellow in color, and traversed by a distinct 
 fibrous network. The lesion begins as a chronic inflamma- 
 tory condition of the branches of the portal vein, and 
 consists of a rapid development of embryonic cells, with 
 subsequent conversion into fibrous tissue. The new formed 
 tissue follows the branches of the portal vein within the 
 substance of the gland; extends into the inter-lobular 
 spaces and forms meshes of variable size, but always em- 
 braces several lobules. Some enlargement may attend 
 the primary formation of embryonal tissue, but the shrink- 
 ing of cicatricial contraction invariably follows; the cells 
 become flattened and atrophied ; there is a marked reduc- 
 tion in size, and the circulation in the hepatic portal vessels is 
 greatly obstructed. The smaller bile-ducts are little affected, 
 and blood for the nourishment of the organ and for the for- 
 mation of bile is carried by vessels developed in the neoplasm. 
 
 In hypertrophic or biliary cirrhosis, the liver is usually 
 enlarged, perhaps to twice its normal dimensions. It has a 
 smooth surface, a thin edge, and its section is orange-yellow 
 or green. The fibroid growth begins around the in- 
 tralobular branches of the bile-duct, and envelops and 
 isolates separate lobules ; it follows the ramifications of the 
 bile-ducts ; is more diffused than in the atrophic form, and 
 denser and thicker in some portions than in others. The 
 portal circulation is not necessarily embarrassed, but the 
 biliary ducts are obstructed and dilated, and have their 
 epithelial lining increased in thickness. 
 
 In both forms there is enlargement of the spleen, and in 
 
294 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 some cases there is an association of the characteristic 
 lesions. 
 
 Etiology. — The causes are, as yet, ill-determined. Al- 
 coholic excess, the prime factor in adults, is, of course, 
 inoperative in children, except in very rare cases ; some 
 authorities, however, are inclined to look upon the intem- 
 perance of parents as, at least, a predisposing element, and 
 regard the vice of drunkenness as one of the sins of 
 the fathers visited upon their offspring. Congenital de- 
 ficiency of the bile-duct is always attended by cirrhosis. 
 Constitutional syphilis frequently, and general tubercu- 
 losis occasionally, precede it. It is not limited to any 
 sex or age, though more frequent in boys than girls, and 
 oftener met with between the sixth and twelfth years than 
 at an earlier period of life. 
 
 Symptoms. — Both forms are preceded, for a variable time, 
 by the evidences of defective nutrition, but, as might be 
 expected from the different pathological conditions, the 
 after symptoms are dissimilar. With atrophic cirrhosis the 
 child is peevish and restless, sleeps badly at night; has indi- 
 gestion, flatulence and costive bowels ; a pale and pasty 
 complexion, and dark circles about the eyes. His mus- 
 cles grow flabby, there is general wasting, and the urine is 
 thick with lithates, or is very acid and deposits a brick- 
 dust sediment of uric acid. After these symptoms have 
 been present for a period — usually a long one — pain in the 
 region of the liver and ascites are developed. With the 
 ascites there is prominence of the abdomen, dilatation of 
 the superficial abdominal veins, and, at first, enlargement of 
 both the liver and spleen. Soon the liver begins to de- 
 crease in size, but the spleen continues to enlarge.* Weak- 
 
 * If ascites be extreme, it is often difficult to detect the spleen by palpation 
 when the patient is in the ordinary dorsal position, or on the right side. In such 
 cases placing the patient upon the hands and knees entirely removes the difficulty. 
 
AFFECTIONS OF THE LIVER. 295 
 
 ness and loss of flesh are progressive ; the ascites becomes 
 more marked ; there is oedema of the feet and legs ; the 
 skin is sallow, and harsh to the touch; the tongue is 
 coated ; the appetite impaired ; the stomach irritable ; the 
 bowels alternately confined and relaxed ; there is abdominal 
 pain ; hemorrhoidal swellings are noticeable ; hemorrhages 
 occur from the stomach, bowels, nose and gums, and pete- 
 chial spots appear beneath the skin. 
 
 The course is prolonged and interrupted by periods of 
 apparent improvement, during which the ascites diminishes 
 and the patient is free from discomfort, and in some degree 
 recovers health and spirits. 
 
 General dropsy, severe diarrhoea or hemorrhages indi- 
 cate that the end is near. Sometimes intercurrent inflam- 
 mation of the pleura or lungs is the direct cause of 
 death. 
 
 In hypertrophic cirrhosis, the skin, conjunctivae and urine 
 are deeply stained by bile, and the stools, which vary 
 greatly in number and consistency, are clay-colored. The 
 liver and spleen are enlarged, but there is no distension of 
 the superficial abdominal veins, and no ascites. At times 
 the jaundice and enlargement of the liver increase rapidly ; 
 then there is moderate fever with much pain in the right 
 hypochondrium. As the end approaches the pulse be- 
 comes markedly irregular; the tongue grows dry and 
 brown ; the teeth are covered with sordes ; there is com- 
 plete anorexia; rapid wasting; bleeding from the gums, 
 from the stomach or beneath the skin ; apyrexia, drowsi- 
 ness, stupor, and, finally, convulsions. The course is more 
 rapid than in the former variety, but still protracted. 
 Should both forms exist together, there is a combination of 
 jaundice, ascites and distension of the veins in the abdomi- 
 nal wall. 
 
296 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Diagnosis. — The characteristic features of atrophic cir- 
 rhosis are diminution in the area of liver dulness, follow- 
 ing a temporary increase in the bulk of the organ ; 
 enlargement of the spleen ; dilatation of the superficial 
 veins ; ascites ; hemorrhoids ; a dry, earthy skin, and gas- 
 trointestinal hemorrhages, occurring, without fever, in a 
 child who has a history of prolonged ill-health, feebleness 
 and wasting. 
 
 The second and more uncommon variety, while having 
 very much the same preliminary history, presents as its 
 distinguishing marks enlargement of the liver and spleen 
 without ascites; jaundice, with fever; pain in the hepatic 
 region ; and, subsequently, malignant jaundice, with ty- 
 phoid symptoms, rapid wasting, coma and convulsions. 
 
 Acute yellow atrophy, which has many of the symptoms 
 of the final stage of biliary cirrhosis, is distinguished by its 
 abrupt onset and rapid course, and is among the rarest of 
 diseases in children. 
 
 Prognosis. — The result is almost invariably unfavorable, 
 and it is only under the most fortunate conditions that even 
 a temporary improvement can be obtained. 
 
 Treatment. — Before a diagnosis is established, and while 
 the patient is merely suffering from ill-defined symptoms of 
 bad health, with imperfect digestion, hygienic and thera- 
 peutic measures are to be directed to the restoration and 
 preservation of the general strength, and to correcting any 
 disorder of the organic functions. 
 
 When the hepatic affection declares itself, an alkaline or 
 a purely tonic treatment may be adopted. Alkalies are 
 indicated when the hepatic and gastro-intestinal symptoms 
 are in excess of the wasting and general debility; tonics 
 under opposite circumstances. In the former case, the 
 following prescription is useful : — 
 
AFFECTIONS OF THE LIVER. 297 
 
 R. Sodii Bicarb., ^ij. 
 
 Tr. Nucis Vom., n\xviij. 
 
 Inf. Calumbse, q. s. ad f^iij. 
 
 M. 
 S.^— Two teaspoonfuls three times daily, for a child of ten 
 years. 
 
 In the latter, Basham's mixture may be employed, or a 
 combination of iron and quinine, as : — 
 
 R. Quiniee Sulph., gr. xij. 
 
 Tr. Ferri Chloridi, f jjj. 
 
 Syr. Zingib., f gj. 
 
 Aquae, q. s. ad f Sj iij. 
 
 M. 
 S. — Two teaspoonfuls three times daily. 
 
 Both plans must be followed out steadily and continu- 
 ously, to obtain any beneficial results. 
 
 To relieve constipation, from two to four fluidounces of 
 Hunyadi water should be taken every morning on an empty 
 stomach. Diarrhoea can be controlled by sub-carbonate of 
 bismuth, and hemorrhage by gallic acid or aromatic sul- 
 phuric acid. 
 
 It is important to order a liberal diet — milk, eggs, meat 
 and farinaceous foods in full proportion to the capacity of 
 digestion. As in other diseases of the liver, the skin must 
 be kept active by daily warm baths, and chilling prevented 
 by flannel under-clothing. 
 
 If ascites be so great as to impede the action of the dia- 
 phragm, paracentesis must be resorted to at once. A fine 
 trocar or one of Southey's tubes may be used.* The opera- 
 tion should be repeated so soon, and as often, as reaccumu- 
 lation renders it necessary. When performed early enough, 
 it sometimes has, as in adults, more than a merely palliative 
 effect. 
 
 * See section on Ascites. 
 
298 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 7. SUPPURATIVE HEPATITIS. 
 
 Abscess of the liver is an extremely uncommon disease 
 in children. The only case that has ever come under my 
 notice, presented the following clinical history: — 
 
 George , set. 5 years, was first brought to the Dispen- 
 sary of the Children's Hospital on April 27th, 1875, during 
 the service of Dr. George S. Gerhard. Though residing in 
 a malarious locality, and in a poor and filthily-kept house, 
 he had always had good health up to one week previous to 
 the above date, when he began to complain of pain in the 
 region of the umbilicus. Under appropriate treatment he 
 passed several lumbricoid worms, and the pain disappeared. 
 A week later, however, it returned, and as his bowels were 
 constipated, his father administered a tablespoonful of castor- 
 oil; this produced a free evacuation, containing from twenty 
 to thirty lumbrici, many being of large size. After this he 
 seemed to be perfectly well until May 9th, when the pain in 
 the abdomen reappeared; he now began to lose his appe- 
 tite, and a swelling was noticed in the right hypochondriac 
 region. 
 
 When I saw him first, on May 15th, his general appearance 
 was good ; his cheeks having a healthy color, and his body 
 being sufficiently stout. His tongue was lightly coated, and 
 his father stated that his appetite was poor, and that, though 
 his bowels were moved daily, the passages were small. 
 There was no heat of skin or jaundice, the pulse and respi- 
 ratory movements were normal in frequency ; he had no 
 cough, and, on physical examination, no pulmonary or car- 
 diac affection could be detected. His abdomen was tym- 
 panitic, the whole of its upper third was tender to the touch, 
 and in the upper part of the right hypochondrium there was 
 an oval tumor, about as large as a turkey's egg, having its 
 long diameter directed transversely, and projecting at its 
 
AFFECTIONS OF THE LIVER. 299 
 
 most prominent part nearly an inch from the surface of the 
 abdomen. The skin covering this tumor was somewhat 
 cedematous, but was freely movable, and natural in color 
 and temperature, while the tumor itself was hard, tender, 
 completely immovable, and the seat of neither fluctuation 
 nor pulsation. It was surrounded by an area of induration, 
 the boundary of which could not be accurately ascertained 
 on account of the pain produced by palpation, though it 
 appeared to extend from the costal border to the lower third 
 of the right hypochondriac region, and from the median 
 line of the abdomen to the right side. 
 
 The right hypochondrium was dull, except just below the 
 margin of the ribs, where there was slight, probably trans- 
 mitted, tympanitic resonance, detected only by deep per- 
 cussion. The liver dulness began in the ordinary position 
 above, and, on light percussion, was continuous below with 
 that in the hypochondriac region. The patient did not 
 complain of pain except when the swelling was touched, or 
 when the whole body was jarred, as in walking down stairs. 
 On a level surface he was able to walk easily. No history 
 of an injury could be obtained, but on careful questioning it 
 was discovered that throughout the winter he had " coasted " 
 a great deal on his sled, and always rode "belly-bumpers." 
 He was ordered to be kept quiet, and to have a liquid diet, 
 with poultices over the abdomen, and a dose of castor-oil. 
 
 May 1 6th. Had a large passage from the bowels, the 
 evacuation being dark-colored and lumpy; during the night 
 was restless and feverish. 
 
 May 17th. Tongue somewhat cleaner and abdomen less 
 tympanitic. The tumor was more prominent; there was 
 deep-seated fluctuation, and the skin covering the mass was 
 less cedematous, not so freely movable as before, and of a 
 dusky-red hue. Patient walked with his body bent forward, 
 
300 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 as if a more upright posture were painful. Prescribed f5ss 
 of tine, cinchon. comp., three times daily, and an increased 
 diet, at the same time directing his parents not to allow him 
 to get out of bed, and to apply warm poultices continuously 
 to the belly. 
 
 May 19th. Visited him at his home, and found him en- 
 tirely free from fever; his tongue was clean, his appetite 
 had returned, and his bowels had been opened; the stool, 
 which had been kept for inspection, was copious, well formed, 
 and in every way natural. The induration around the tumor, 
 or more properly the abscess, for such it now appeared to 
 be, had extended so as to fill nearly all of the right hypo- 
 chondrium, being almost five inches in transverse diameter. 
 There was well-marked fluctuation, and the skin investing 
 the abscess was tightly adherent over a space about four 
 inches in circumference. The abdominal respiratory move- 
 ments were restricted, and any effort at full inspiration caused 
 pain. There was no sensation of throbbing in the abscess, 
 and the patient seemed to be perfectly comfortable as long 
 as he remained quiet. The abdomen was moderately dis- 
 tended. 
 
 May 2 2d. No change, except that the fluctuation was 
 more superficial, and the integument adherent over a large 
 surface. The former treatment was continued, and as the 
 pulse was more frequent than before, and as he was pale 
 and . languid, a teaspoonful of brandy thrice daily and full 
 diet were ordered. 
 
 May 26th. Found him up and playing about as if nothing 
 was the matter. Having him stripped and placed in bed, the 
 following observations were made : Abscess more prominent 
 than at last note, but more localized ; in its centre there is 
 very superficial fluctuation, extending over an area an inch 
 and a half in diameter and bounded by a firm margin. The 
 
AFFECTIONS OF THE LIVER. 301 
 
 skin covering this space is dark red in color, feels very thin, 
 almost as if it could be broken by the pressure of the finger, 
 and is somewhat hotter than the surrounding integument. 
 About the abscess there is a mass of induration which does 
 not project beyond the level of the rest of the abdomen, 
 but which extends from the lower border of the ribs to the 
 middle of the right lumbar region, and from the mid-line 
 of the abdomen to the right side; its outline is semicircular, 
 the edge being smooth and well defined, so much so that 
 the fingers can be inserted beneath it. The skin is adher- 
 ent over the whole mass, but most so immediately around 
 the position of fluctuation. Both palpation and percussion 
 indicate that it is connected with the right lobe of the liver. 
 There is some pain excited by palpation, though this is 
 much less than formerly. There is no jaundice. No change 
 was made in the treatment. 
 
 May 29th. The abscess was more circumscribed, being 
 about the size of an English walnut, and the pus was still 
 nearer to the surface. As it was impossible to keep the 
 patient quiet, and fearing lest he might rupture the abscess 
 in his play, aspiration was determined upon. Accordingly, 
 a large aspirator needle was introduced to the depth of half 
 an inch. About two drachms of thick, grumous pus, mixed 
 with blood, escaped into the receiver, when the canula be- 
 came plugged, and no more could be withdrawn.* A poul- 
 tice was applied, and the patient ordered to remain in bed 
 during the rest of the day. The operation was followed by 
 no bad symptoms, and the next day he was up, amusing him- 
 self as before. There was, however, considerable discharge 
 of thick pus from the opening left by the aspirator needle. 
 
 * A microscopical examination of a portion of this material revealed pus 
 cells, compound granu e cells, blood corpuscles, and numerous polygonal cells 
 having well-defined nuclei and resembling liver cells. 
 
302 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 June 1st. The wound made by the needle closed. Scarcely 
 any fluctuation could be detected, and there was but little 
 redness of the skin. On passing the finger over the position 
 of the abscess a cup-shaped depression was felt, bordered 
 by a well-defined edge of dense tissue. The induration was 
 reduced ; its lower margin was still semicircular, and could 
 be easily isolated, while the upper margin, on the other 
 hand, could not be discovered, as the mass extended under 
 the ribs. There was hardly any pain on manipulation, and 
 the boy's general condition was very good. 
 
 June 5th. There were no signs of the abscess, except a 
 small spot of dusky redness, and slight retraction and puck- 
 ering of the skin at the point of puncture ; in this situation, 
 also, the integuments were adherent to the parts below. 
 The induration was diminishing, and its edge, which could 
 still be distinctly felt, was approaching the right costal border. 
 All treatment was suspended. 
 
 On October 30th, the child was in excellent health. The 
 skin, for a short distance about the seat of puncture, was 
 somewhat discolored and puckered, and was less freely 
 movable than that of the remainder of the abdomen. Per- 
 cussion and palpation showed that the right lobe of the 
 liver was slightly contracted. 
 
 In reviewing the preceding history, the question that 
 naturally suggests itself is, whether the disease was hepatic 
 abscess, or merely an abscess of the abdominal wall. In 
 the early stage of the former affection, the general symptoms 
 are similar to those observed in acute hepatitis ; jaundice 
 being present only in exceptional instances, while the forma- 
 tion of pus gives rise to rigors, frequency of the pulse, night 
 sweats and fever, the latter often resembling the pyrexia of 
 quotidian or tertian intermittents. The almost entire absence 
 
AFFECTIONS OF THE LIVER. 303 
 
 of constitutional disturbance in this case, however, is no argu- 
 ment against the existence of hepatic abscess ; as it is gen- 
 erally admitted that the symptoms are often very latent, and 
 that in many instances no suspicion of an abscess has been 
 entertained until its discovery by manual exploration, or by 
 the discharge of pus in various directions, and sometimes 
 even not until revealed by post-mortem examination. 
 
 The local symptoms, on the contrary, were well marked ; 
 thus there was localized, though extensive, enlargement of 
 the right lobe of the liver, and toward the upper part of 
 this enlargement there was an ill-defined, oblong tumor 
 extending beyond the level of the abdomen. The skin 
 covering this tumor was at first slightly cedematous, but 
 perfectly movable and normal in color and temperature. 
 From day to day, as the tumor became more circumscribed 
 and approached nearer the surface, the hepatic enlargement 
 increased, and conjointly with the appearance of fluctuation 
 the oedema disappeared, the skin became dusky-red in hue, 
 hotter than the surrounding integument, and adherent. 
 There was also tenderness on pressure ; pain excited by 
 deep inspiration or any jarring movement, and a peculiar 
 bending forward of the body in walking. Again, after the 
 opening of the abscess, all these symptoms subsided, and 
 there was puckering of the skin and rapid reduction in 
 the size of the liver ; its projecting margin remaining semi- 
 circular, smooth, and well defined. Finally, there was slight 
 contraction of the right lobe. 
 
 There are two other points of importance, viz., the de- 
 tection, by palpation, of a smooth edge of dense tissue 
 bordering the area of fluctuation, which gave the impres- 
 sion that the fluid was contained in a cup-shaped cavity in 
 a solid organ, and the microscopical characters of the pus 
 which was removed. 
 
304 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Now, all these symptoms are characteristic of an hepatic 
 abscess, so situated on the convexity of the liver as to point 
 toward the surface of the abdomen ; the adhesion of the 
 integuments being, of course, due to local peritonitis. 
 
 Abscesses of the abdominal wall, on the other hand, be- 
 sides being superficial from the outset, have a different 
 position, being usually seated in the rectus muscle or ad- 
 joining connective tissue, and in the neighborhood of the 
 umbilicus ; at the same time there is generally violent 
 throbbing pain; the redness and tumefaction of the skin are 
 earlier and better developed, and the constitutional symp- 
 toms accompanying the formation of pus are more con- 
 stantly observed than in abscess of the liver. 
 
 The general management of circumscribed hepatitis, prior 
 to the formation of pus — if the symptoms be such as to lead 
 to a diagnosis at this time — simply requires careful regula- 
 tion of the diet, rest, and attention to the various functions 
 of the body, particularly that of the bowels ; for even if 
 the existence of inflammation be ascertained, it is hardly 
 probable that anything can be done to prevent suppuration. 
 
 In relation to the propriety of evacuating hepatic ab- 
 scesses, the bulk of authority is in favor of so doing, when 
 they point externally so as to be detected by palpation, 
 when firm adhesions have formed, and when the pus is 
 near the surface. As to the method of evacuation, a free 
 incision is perhaps preferable to puncture with an aspirator 
 needle ; first, because the pus is often mingled with shreds 
 of connective tissue and broken-down liver substance, 
 liable to obstruct the needle and render it useless ; or, even 
 if all the fluid be withdrawn, to remain and prolong the 
 process of suppuration ; second, as the inelasticity of the 
 walls of the cavity cannot prevent the entrance of air, it is 
 much better to provide a free way of. exit, than to have 
 
AFFECTIONS OF THE LIVER. 305 
 
 the air confined, as it would likely be in the event of the 
 small opening made by the needle becoming closed. For 
 the purposes of exploration, however, the aspirator may be 
 used with advantage. After being opened, the abscess is 
 to be dressed in the ordinary manner, while strict rest 
 should be enjoined, and tonic and supporting measures 
 employed. Subsequently, nutritious diet and exercise in 
 the open air, the latter adapted to the strength of the 
 patient, are much more important than mere medication. 
 
 Tuberculosis of the liver is sometimes associated with 
 tubercular peritonitis, and is commonly encountered at the 
 autopsies of children who have succumbed to acute general 
 tuberculosis. In such cases the liver is anaemic, yellowish 
 and small. Semi-transparent granules (miliary tubercles) 
 are seen upon the capsule and detected by the micro- 
 scope in the connective tissue that surrounds the branches 
 of the portal vein; there is, too, an interstitial hepatitis, with 
 the formation of embryonal and fibrous tissue. There are 
 no definite ^symptoms, and a diagnosis is hardly possible 
 without post-mortem section. 
 
 Hydatid Disease and Cancer are so infrequent in child- 
 hood, and when they do occur present so nearly the symp- 
 toms of the same conditions in adults, that it is unnecessary 
 to devote space to their consideration. 
 
 20 
 
CHAPTER V. 
 AFFECTIONS OF THE PERITONEUM. 
 
 i. PERITONITIS. 
 
 Children, like adults, are subject to attacks of inflamma- 
 tion of the peritoneum. These may be primary or secondary 
 in origin, acute or chronic in course, and general or local 
 in distribution. 
 
 The affection occurs at any age from birth to puberty, 
 and there are indisputable evidences on record of its devel- 
 oping during the later months of intra-uterine life. The 
 primary or essential form is almost uniformly acute and 
 general. Secondary peritonitis, on the contrary, may be 
 either general or local, the inflammation often beginning 
 in a limited area and gradually extending over the whole 
 surface. It is also more common than the primary variety, 
 and, while often acute, more frequently runs a chronic 
 course. 
 
 Morbid Anatomy. — In acute general peritonitis, the 
 blood vessels of the sub-serous tissue of the peritoneum 
 are engorged with blood, and the membrane is reddened, 
 either generally or in patches ; mottled by isolated spots of 
 ecchymosis, and opaque and thickened. Serum, some- 
 times clear, sometimes mixed with pus and flakes of fibrin, 
 fills the abdominal cavity ; or, again, the effusion may be 
 purulent; in either case, it is most abundant in the pelvis 
 and between the mesenteric folds. 
 
 Acute local peritonitis occasions connective tissue hyper- 
 
 306 
 
AFFECTIONS OF THE PERITONEUM. 307 
 
 plasia, omental and intestinal adhesions, and, at times, 
 localized suppuration. 
 
 Chronic general peritonitis gives rise to a sero-fibrinous 
 exudate ; this may be sufficiently abundant to appear as a 
 thick membrane, and in time may undergo fatty, caseous or 
 calcareous degeneration. 
 
 Chronic local peritonitis results in the formation of cir- 
 cumscribed adhesions, membranous exudations of limited 
 extent, and sacculated collections of pus. 
 
 Etiology. — Fcetal peritonitis is caused by syphilis or 
 some specific infection of the mother. During the first few- 
 days of life it may be due to inflammation, suppuration or 
 gangrene of the umbilicus ; to congenital occlusion of the 
 anus ; or to infection from a mother ill with puerperal fever. 
 Later in childhood, primary peritonitis arises from blows 
 upon, or other injuries to the abdomen, and from sudden 
 chilling of the body after violent exercise ; a number of 
 cases having been noted in which the attack could be 
 traced to the act of lying to rest, after an exciting or fa- 
 tiguing game, prone upon damp ground. The secondary 
 form may result from the escape of faecal matter into the 
 abdominal cavity through a perforation of the intestine : — 
 called perforative peritonitis. It may also occur during 
 the course of one of the exanthemata, scarlatina especially 
 — septic peritonitis. Finally, it may be occasioned by ex- 
 tension of inflammation from some one of the abdominal 
 viscera, or from the pleura ; in the last instance there may 
 be an element of sepsis. 
 
 Chronic peritonitis sometimes follows an acute attack 
 but is most often an attendant of tuberculosis and presents 
 the characters of chronicity from the outset. 
 
 Symptoms. — In primary peritonitis, and in other cases of 
 the acute general disease not due to perforation or sepsis, 
 
308 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 the attack begins with more or less rigor, abdominal pain 
 and vomiting. The pain is stinging or lancinating in char- 
 acter, and is limited, at first, to one flank, to the supra- 
 pubic region, or the neighborhood of the umbilicus, but 
 soon becomes general ; it is increased by pressure or by 
 any act calling the abdominal muscles into play, as deep 
 breathing, sneezing, coughing and vomiting. The vomiting 
 is frequent and very violent, producing so much distress 
 and fatigue that after each effort the patient falls back on 
 the pillow with pale, haggard, and sweat-bedewed face ; the 
 material rejected consists, in the beginning, of partially 
 digested food ; later, of bile-stained mucus. 
 
 Fever quickly follows the shivering, and as soon as in- 
 flammation is fully established, the axillary temperature 
 may reach 104 F., although the usual range is from 101 to 
 102 . With the pyrexia there is a frequent, small, wiry 
 pulse, and the breathing assumes the superior costal type ; in 
 some cases (where there is a large effusion) growing 
 hurried and difficult. The child ceases to move his legs, 
 or takes to bed early and lies immovably upon his back, 
 with the knees drawn up. The face is pale and anxious, 
 the nose sharp and the nostrils thin and expanded. The 
 abdomen is distended and passive, so far as respiratory 
 movements are concerned ; palpation yields a certain sense 
 of resistance, sometimes develops fluctuation,* and always 
 excites intense pain; percussion elicits tympany over the 
 upper anterior portion of the belly and dulness over the de- 
 pendent parts, and on auscultation, friction sounds may be 
 heard when there is a fibrinous exudation. 
 
 * When fluctuation is indistinct, Duparcque recommends that the child be 
 placed on one side for a few moments, so that the whole quantity of fluid 
 may gravitate to the depending flank ; then quickly turned upon the back, 
 when dulness and temporary fluctuation will be found at the site of accumu- 
 lation. 
 
AFFECTIONS OF THE PERITONEUM. 3O9 
 
 The tongue is pointed, red at the tip and edges, and 
 covered in the centre with a dry, moderately heavy, brown- 
 white fur. There is anorexia and increased thirst. Con- 
 stipation is the rule if the intestinal peritoneum be in- 
 volved ; then, too, there are frequent attacks of severe 
 griping pain ; on the other hand, there may be diarrhoea, 
 with watery evacuations, if the inflammation be attended 
 by oedema of the sub-mucosa with transudation of. serum 
 into the bowel. 
 
 The urine is high colored and somewhat reduced in 
 quantity and, while ordinarily passed with freedom, is re- 
 tained when the serous coat of the bladder is involved in 
 the inflammation. 
 
 Sleep is disturbed and restless ; in infants there may be 
 convulsions ; in older children, delirium. 
 
 During the course of the attack, which usually extends 
 over a period of seven days, the strength steadily fails ; 
 there is considerable loss of flesh, and the symptoms pres- 
 ent at the onset continue unabated and unchanged. As 
 death approaches vomiting usually stops, but the other 
 symptoms become more and more grave. The patient lies 
 in an apathetic condition, with sunken eyes and half-closed 
 lids; his face is drawn and either pale or cyanosed; the 
 tongue is dry, brown and pointed ; there is marked tym- 
 panites and the pulse is extremely small and frequent. 
 
 Occasionally this variety of acute peritonitis ends in re- 
 covery ; the exuded fluid being either reabsorbed or spon- 
 taneously evacuated through the umbilicus or abdominal 
 wall.* In the first instance, the symptoms subside gradu- 
 ally ; in the second, rapidly; though in both, the course is 
 protracted ; the fistulous openings left after the discharge of 
 pus rarely closing under four or five weeks. 
 
 * M. Gauderon mentions ten such cases, eight of which recovered. 
 
310 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Perforative peritonitis requires separate description, since 
 it has a set of symptoms entirely its own. It is the most 
 common form of the disease in children, and in the ma- 
 jority of cases results from rupture of the vermiform ap- 
 pendix or caecum ; perforation of typhus or tubercular 
 ulcers being exceptional in this class of patients. 
 
 The attack begins suddenly with intense pain in the 
 abdomen, quickly followed by profound collapse. The 
 face soon becomes pale and haggard ; the eyes are deeply 
 sunken, and the hands and feet cold, though the body heat 
 is increased; the rectal temperature ranging to 103 or 
 104. Other features are great thirst, occasional vomiting, 
 a dry, red and pointed tongue ; locked bowels ; a rapid, 
 small, thready pulse ; thoracic respiration, often hurried and 
 difficult, and suppression of urine. From the beginning 
 the belly is greatly distended by gas escaping from the 
 intestine ; the abdominal respiratory movements cease ; 
 palpation is very painful, and percussion yields a uniformly 
 drum-like tympany that extends high up under the ribs, 
 and completely masks the liver dulness. Death almost 
 invariably takes place either on the third or fourth day of 
 illness, and is usually preceded by a few hours' freedom 
 from suffering. 
 
 While this is the ordinary course of perforative perito- 
 nitis, it happens sometimes that the shock is so great that 
 the patient neither feels pain nor complains of tenderness 
 when the abdomen is touched, and there is a general latency 
 in the symptoms. Again, extravasation being limited by 
 preformed adhesions, the inflammatory action is circum- 
 scribed, and the resulting abscess, by pointing and discharg- 
 ing through the abdominal wall or into the intestine, may 
 either end in recovery, or in the production of a permanent 
 faecal fistula. 
 
AFFECTIONS OF THE PERITONEUM. 3II 
 
 In septic peritonitis the symptoms are either inherently 
 latent, or are masked by the collapse that follows the onset 
 of a new inflammation in a patient already debilitated by 
 disease. There is usually rapid prostration, restlessness, and 
 delirium, with a tendency to stupor ; a pale, anxious face ; 
 swollen belly ; persistent watery diarrhoea ; a frequent, wiry 
 pulse, and quick, costal breathing. Pain, tenderness, tension 
 of the abdominal walls, dulness on percussion and fluctua- 
 tion may be entirely absent. Without care, such attacks 
 are readily overlooked. 
 
 Should peritoneal inflammation become chronic the pain 
 lessens and is more paroxysmal in character ; the fever is 
 remittent, with evening exacerbations ; constipation alter- 
 nates with diarrhoea ; there is great emaciation, and death 
 occurs from exhaustion. However, on account of the usual 
 tubercular origin, the symptoms of this form will be more 
 appropriately studied under the head of " tubercular peri- 
 tonitis." 
 
 Local peritonitis is almost uniformly secondary ; that 
 attending inflammation of the caecum and vermiform ap- 
 pendix being the most common in children. 
 
 Diagnosis. — An immovable dorsal decubitus ; a pale, 
 haggard face ; a frequent wiry pulse ; distension, pain and 
 tenderness of the belly, and inactivity of the abdominal 
 muscles in respiration, suffice to render the diagnosis of 
 acute general peritonitis easy. Intense pain, sudden col- 
 lapse and rapid and extreme meteorism characterize the 
 perforative variety. 
 
 In colic there is constipation and vomiting, with severe 
 pain ; but between the paroyxsms there is no abdominal 
 tenderness, and the pulse is never so rapid, small, and 
 wiry, nor is there the fear of movement so noticeable in 
 peritonitis. 
 
312 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Rheumatism of the abdominal muscles is attended by 
 tenderness on pressure ; distressed facial expression ; dorsal 
 decubitus with knees drawn up, and constipation, and thus 
 simulates peritonitis ; but the face is never haggard, there 
 is no vomiting nor hiccough, nor distension of the belly, 
 neither is tenderness extreme. The pulse is soft, compres- 
 sible, and only moderately frequent ; the temperature nearly 
 normal, and the urine scanty, high-colored, acid and scalding. 
 
 It is important to remember that constipation is the rule 
 in peritonitis when the inflammation involves and paralyzes 
 the muscular coat of the bowel ; diarrhoea, when it spreads 
 through the muscular coat to the mucous membrane. 
 
 The great difficulty in diagnosis is experienced with 
 latent peritonitis, whether septic or due to other causes. 
 Suspicion of its existence may be entertained when, in the 
 course of any predisposing disease, the patient suddenly 
 grows pale and haggard, and has a full belly, with a 
 tendency on the part of the abdominal muscles to become 
 rigid on palpation. Restlessness, delirium and stupor, a 
 change in the type of respiration and in the character of 
 the pulse, all strengthen the suspicion. Under these cir- 
 cumstances it is well to practice Duparcque's method for 
 detecting the presence of fluid, and this, if successful, 
 leaves no further doubt. 
 
 In the words of Eustace Smith : " In cases of chronic 
 empyema we should always be on the watch for the occur- 
 rence of peritonitis. If the child, after a period of im- 
 provement, cease all at once to gain ground, and begins to 
 look pale and distressed, with an elevated temperature, a 
 more or less distended belly, and a rapid, wiry pulse, we 
 are justified in suspecting peritonitis, although there be no 
 tension, tenderness or other sign connected with the abdo- 
 men to give support to this opinion." 
 
AFFECTIONS OF THE PERITONEUM. 313 
 
 Prognosis. — This must always be most grave. Perfora- 
 tive peritonitis is invariably fatal. The primary variety, 
 when due to cold, exceptionally ends in recovery, and so, 
 too, does the partial form. 
 
 Treatment. — Absolute rest in bed and quiet surround- 
 ings are essential. Hot applications, in the form of light 
 flax-seed poultices and of turpentine stupes, should be made 
 to the surface of the belly; or, if these fail to give relief, 
 cloths wrung out of ice-water may be applied ; they must 
 be frequently changed, to secure the constant action of 
 cold. Leeching is sometimes of great service in subduing 
 pain, but it is only to be employed with robust subjects 
 and in an early stage of the attack. 
 
 Of drugs, opium alone can be relied upon. It may be 
 exhibited by the mouth, the rectum, or subcutaneously, 
 and can safely be pushed to the point of producing drowsi- 
 ness, with decided contraction of the pupils, provided ease 
 from suffering be not attained before. For a child of six 
 years, three drops of laudanum every two hours, by the 
 mouth or rectum ; and, by hypodermic injection, one-eigh- 
 teenth of a grain of sulphate of morphia, repeated as re- 
 quired, are the average commencing doses. 
 
 Under no circumstances is a purge to be given. Should 
 constipation be obstinate, and the indications urgent to un- 
 load the bowels, a simple enema may be employed. It is 
 a good rule, however, to interfere as little as possible in this 
 way. 
 
 The patient's strength must be sustained by concentrated 
 liquid food in small quantities and at short intervals. Three 
 fluidounces of milk and two fluidounces of beef-tea, alter- 
 nating, every two hours, with the occasional substitution of 
 the yolk of a soft-boiled egg for one or the other, would be 
 a proper diet for a child of six years ; stimulants are also 
 
314 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 necessary, and so soon as there is evidence of failing 
 strength a teaspoonful of good whiskey must be added to 
 each portion of milk. Bits of ice may be allowed from 
 time to time to allay thirst and quiet the stomach. 
 
 Should the inflammation subside, the opium is to be 
 gradually withdrawn and its place supplied by sorbefa- 
 cients and tonics; at first mercury in alterative doses, or 
 iodide of potassium, with quinine ; and, later, syrup of the 
 iodide of iron. At the same time, the hot or cold appli- 
 cation being removed, a weak mercurial ointment should be 
 rubbed into the skin of the belly once or twice daily ; for 
 example : — 
 
 R . Ung. Hydrargyri, 
 
 Ung. Belladonnae, aa t ^ij. 
 
 Adipis, 2iv. 
 
 M. 
 S. — Use locally as directed. 
 
 A most important point is to make no change in the diet, 
 except, perhaps, to increase gradually the quantity of liquid 
 food, until convalescence be fully established. 
 
 2. TUBERCULAR PERITONITIS. 
 
 As a rule, peritonitis due to the presence of tubercle in 
 the abdominal cavity runs a chronic course, and is asso- 
 ciated with tuberculosis of some other organ of the body — 
 of the brain or lungs, for instance; less frequently it occurs 
 as an isolated affection. Acute tubercular peritonitis is not 
 unknown ; it is detected with difficulty during life, and 
 is invariably an element of general tuberculosis. The 
 disease is quite common after the age of seven years, but 
 is rare in earlier childhood and almost never met with in 
 infancy. 
 
AFFECTIONS OF THE PERITONEUM. 315 
 
 Morbid Anatomy. — At the autopsy of a child dead 
 from tubercular peritonitis, the intestines will be found 
 covered by a layer of yellow, greenish or gray lymph, 
 varying in thickness, and either loose and soft in texture or 
 tough. Lymph having the same characters also covers 
 the parietal peritoneum, and extends between the intestinal 
 coils, binding them, more or less firmly, together. The 
 exudate contains caseous masses of variable size; its meshes 
 are filled with greenish-yellow, sometimes bloody, sero- 
 purulent effusion, and a quantity of the same material 
 is usually found in the dependent portions of the abdominal 
 cavity. Removal of the layer of lymph discloses gray and 
 yellow tubercles, studding the surface of the peritoneum, 
 together with masses and broad plates of caseous consist- 
 ence and tuberculous nature. The thickness and extent of 
 the exudation, the number of granulations, and the size of 
 the caseous masses increase with the chronicity of the 
 attack. In acute cases the cheesy collections are absent ; 
 the exudate is comparatively thin, soft and translucent, and 
 the granulations, which vary in size from that of a pin's 
 head to that of a pea, are scattered at intervals through its 
 substance. 
 
 The omentum is shriveled, hard and often firmly bound 
 to the abdominal wall; the mesentery is firm and con- 
 tracted ; the mesenteric glands are enlarged and show 
 evidences of cheesy or tubercular alteration; tubercular 
 ulceration of the bowels is common, and the liver may be 
 increased in size from amyloid or fatty change, and in some 
 instances is cirrhotic. Inspection of other organs of the 
 body usually leads to the discovery of tubercle, though this 
 is not uniformly the case. 
 
 Tubercular peritonitis is not always general in distribu- 
 tion ; when localized the inflammation and inflammatory 
 
3 16 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 products are usually to be observed in the neighborhood of 
 the diaphragm. 
 
 Etiology. — The factors leading to peritoneal tuberculosis 
 are identical with those producing other tubercular affec- 
 tions. The age at which the disease is most prone to 
 occur has already been mentioned. Male children seem to 
 suffer more frequently than those of the opposite sex. 
 
 Symptoms. — The onset is slow and insidious, and the 
 physician is apt to have his attention diverted from the 
 abdomen by more striking manifestations of tuberculosis of 
 the lungs or other organs. Unless such features be pres- 
 ent and precedent, there is but little evidence of failing 
 health in the beginning, and the first symptom to attract 
 notice is an abnormal prominence of the belly. The patient 
 gradually grows dull and listless, looks ill, and, on account 
 of abdominal tenderness and the pain produced by jarring, 
 becomes slow and guarded in his movements. 
 
 Often after the disease is fully developed the child 
 " keeps about," but the face is drawn and wears an expres- 
 sion of anxiety and suffering ; the frame slowly wastes and 
 the skin becomes dry and harsh and loses its healthy hue. 
 Complaints are made of tenderness and griping pains 
 in the abdomen, and the little sufferer takes very char- 
 acteristic precautions to lessen his ills by steadying his 
 belly with his hands in walking, and by moving down- 
 stairs backward so as to pass from step to step on his toes, 
 to avoid jolting. The symptoms denoting disturbance in 
 the functions of the gastro-intestinal tract are inconstant at 
 this stage of the disease; the tongue either shows little 
 alteration or is lightly frosted or more pointed and red than 
 natural ; nausea and vomiting may be entirely absent, 
 and are never so persistent and severe as in simple perito- 
 nitis ; the appetite often remains unimpaired, and the bowels 
 
AFFECTIONS OF THE PERITONEUM. 317 
 
 are alternately relaxed and confined. On the other hand 
 the signs to be detected by abdominal exploration are very 
 constant and characteristic. The belly is oval in shape and 
 somewhat irregularly distended, the greatest enlargement 
 occupying the epigastric and umbilical regions ; the natural 
 folds and furrows are obliterated ; the superficial veins are 
 prominent ; and the integument has a smooth, shining ap- 
 pearance, as if smeared with oil. When the hand is 
 applied to the surface, the recti muscles become tense, in an 
 involuntary effort to protect the tender parts beneath ; 
 some portions of the abdomen feel soft and flaccid ; in 
 others, firm masses are perceptible to the touch; tenderness 
 on pressure is universal, though most marked over the firm 
 masses. Palpation also reveals fluctuation ; this is usually 
 indistinct, though occasionally, when enlarged glands or 
 cheesy masses exert pressure on the portal vein, there is a 
 large collection of fluid in the peritoneal cavity, and the 
 fluctuation wave is readily elicited and very distinct. The 
 edge of the right lobe of the liver can often be felt extend- 
 ing half an inch or more beyond the right costal border. 
 On percussion, tympany will be elicited over the flaccid 
 portions of the abdomen; dulness over the firm masses and 
 flatness over the flanks — in the recumbent position — while, 
 if the patient be rolled to one side, the note on the flank 
 turned uppermost becomes tympanitic. 
 
 The respiratory movements are somewhat increased in 
 frequency and thoracic in type ; the pulse is quickened and 
 feeble in proportion to the general weakness ; the axillary 
 temperature ranges from 98 F. in the morning to 10 1° in the 
 evening ; and there is dysuria with high-colored, but other- 
 wise unaltered, urine. Sometimes, with a large collection of 
 fluid in the peritoneum, there is oedema of the feet and 
 legs ; then, too, the urine may be slightly albuminous. 
 
3 18 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 In time the patient is forced to go to bed, where he lies on 
 his back, or partially turned on one side, with his legs drawn 
 up ; this position is rigidly maintained, for every movement 
 is painful. Now, the wasting is rapid ; the face wears a 
 haggard expression ; the cheeks and temples are hollow, 
 and the skin becomes inelastic and dotted with purpuric 
 spots. The tongue is dry, heavily coated, or red and 
 smooth; the appetite fails and there is urgent thirst. The 
 bowels are in one of two conditions : relaxed, with watery, 
 offensive stools, containing flaky matter and small black 
 clots of blood when there is tubercular ulceration ; obsti- 
 nately confined, when the intestines are pressed upon, or 
 obstructed by adhesions. In the latter case the belly ber 
 comes greatly distended, and there are frequent attacks of 
 severe colicky pain. Under other circumstances, however, 
 the size of the belly may diminish, and then hard, tender 
 lumps are felt in contact with the abdominal wall. The 
 pulse is more frequent and feeble; the evening temperature 
 ranges as high as 103 and 104 , and night sweats are 
 common. 
 
 Death occurs after a lapse of time varying from several 
 months to a year or more. 
 
 The course of the disease is not uniformly progressive, 
 being interrupted by remissions and exacerbations. During 
 the former the tenderness and distension of the abdomen 
 diminish, the appetite returns, nutrition improves, and false 
 hopes arise of rapid recovery. 
 
 Sometimes before death an abscess forms, and pus is dis- 
 charged through the abdominal wall in the neighborhood 
 of the umbilicus ; in other cases the intestines may be per- 
 forated from without, but this complication scarcely has- 
 tens the fatal termination, for extravasation is limited by 
 adhesions between the knuckles of the intestines. Such 
 
AFFECTIONS OF THE PERITONEUM. 319 
 
 complications as tuberculosis of the lungs and cerebral 
 meninges, however, certainly hasten death. 
 
 Acute tubercular peritonitis always occurs as an element 
 of disseminated tuberculosis, and presents the general fea- 
 tures of that condition ; usually there are no local manifes- 
 tations other than abdominal fulness and slight pain — 
 symptoms sufficiently common in children to be altogether 
 indefinite. The course of these acute attacks is measured 
 in little more than a week. 
 
 Diagnosis. — Ordinarily the formation of a correct 
 opinion is not difficult. The distinctive features are the 
 irregular distension of the abdomen ; the smooth, shiny 
 appearance of the investing skin ; tenderness ; unequal 
 resistance to the touch in different positions, and indistinct 
 fluctuation, combined with alterations in the temperature ; 
 impairment of nutrition ; an insidious onset ; a family 
 record of tuberculosis or scrofula ; the presence of the 
 tubercular diathesis, and the existence of symptoms of 
 tubercular deposit in some other organ of the body. In 
 doubtful cases, where there is little distension or tenderness, 
 and fluctuation is absent, it is well to try the effect of a 
 sudden jar; this may be done by directing the child to 
 jump from a low chair to the floor. Free fluctuation is to 
 be regarded as a point in the negative. 
 
 Many children have prominent bellies and suffer severely 
 from abdominal pain, both due to the accumulation of 
 flatus in the intestines, the consequence of a chronic ca- 
 tarrh of the mucous lining. These patients, though pale 
 and flabby, are but little wasted, and express in their faces 
 no trace of severe illness ; they are lively in action ; their 
 temperature is normal ; there is no tenderness or involun- 
 tary contraction of the recti muscles on palpation ; the 
 abdominal distension disappears spontaneously at times, 
 
320 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 and subsides entirely when a non-farinaceous diet is or- 
 dered. There can be no greater mistake than that of 
 attributing every instance of abdominal distension to tuber- 
 culosis. 
 
 As already stated, the diagnosis of the rare acute form is 
 very difficult, and is often only made at the post-mortem 
 table. 
 
 Typhoid fever is the disease most likely to be confounded 
 with it, but the absence of rash and splenic enlargement, 
 and the difference in the degree and course of the fever, 
 should prevent error. 
 
 Prognosis. — This must always be unfavorable. Recov- 
 ery, though possible, is extremely rare. 
 
 Treatment. — While little is to be expected from thera- 
 peutic measures, the physician's ambition will be to 
 obtain a favorable result if he can. To accomplish this 
 end it is necessary, first, to keep the child at perfect rest in 
 bed ; and second, to select a diet that will meet the capacity 
 for digestion, excluding as nearly as may be the farinaceous 
 foods so prone to cause acidity and flatulence, with their 
 attendant suffering. The following is a sample diet list for 
 a patient of seven years : — 
 
 For breakfast, at 7.30 a.m. — The yolk of a soft-boiled 
 egg, a slice of well-toasted bread lightly buttered, and a 
 tumblerful (f^viij) of warm milk. 
 
 For luncheon, at 12 m. — The soft parts of a dozen oysters or 
 a bit offish, or a bowl (f3vj) of good beef-tea, with a biscuit. 
 
 For dinner, at 3 p. m. — Two to four tablespoonfuls of 
 minced mutton or chicken, one or two thin slices of stale 
 buttered bread, eight tablespoonfuls of rice and milk or 
 junket. 
 
 For supper, at 7 p. M. — Two slices of milk-toast and a 
 tumblerful of warm milk. 
 
AFFECTIONS OF THE PERITONEUM. 321 
 
 Such a list can only be used in the earlier stages of the 
 disease ; later, when the appetite fails, it is necessary to 
 resort to liquid food, milk and meat broths, administered in 
 small quantities at short intervals. 
 
 Stimulants — and whiskey is the best — are required from 
 the beginning, and must be given in increasing quantities 
 as the strength fails. 
 
 Of drugs, opium, quinine, and syrup of the iodide of iron 
 with cod-liver oil, when the stomach will bear them, are 
 the most useful. Opium must be given sufficiently freely 
 to relieve pain, and quinine in doses large enough to main- 
 tain the flagging forces. Constipation is to be remedied 
 only by simple enemata, while excessive diarrhcea may be 
 checked by full doses of bismuth combined with ipecacu- 
 anha and opium, as : — 
 
 1$ . Pulv. Ipecacuanhse Comp., gr. xxiv. 
 
 Bismuth. Sub-carb., gj. 
 
 Pulv. Aromat. , gr. xij. 
 
 M. et ft. chart. No. xij. 
 S. — One powder every two or three hours for a child of 
 seven years. 
 
 A good formula for the same purpose is :— 
 
 R . Ext. Haematoxyli, gr. xxx. 
 
 Tr. Opii Deod., TT\xxiv. 
 
 Vin. Ipecacuanha, rTLxxxvj. 
 
 Mist. Cretae, q. s. ad f^iij. 
 
 M. 
 S. — Two teaspoonfuls every three hours. 
 
 Externally, light flax-seed poultices are useful in relieving 
 pain. Sometimes even the lightest poultice is uncomfort- 
 able, then the abdomen may be anointed once daily with — 
 
 R. Ext. Belladonnae, ^ij. 
 
 Glycerinse, f^vj- 
 
 M. 
 
 and covered with a thick layer of cotton batting. 
 21 
 
322 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Should the quantity of fluid in the peritoneum be large, 
 diuretics and diaphoretics are indicated ; if excessive, para- 
 centesis is required. 
 
 3. ASCITES. 
 
 The collection of a quantity of transparent serum in the 
 sack of the peritoneum is not of very common occurrence 
 during childhood. The condition is, probably, always 
 secondary, and must be regarded rather as a symptom than 
 a disease proper ; it is of sufficient import to warrant a 
 brief, separate consideration. 
 
 Etiology. — Ascites is sometimes produced by simple or 
 tubercular inflammation of the peritoneum ; more fre- 
 quently it depends upon obstruction to the return of 
 venous blood, due to diseases of the liver or heart ; to 
 enlargement of the mesenteric glands, and, occasionally, 
 to disease of the lungs ; again, it may be the result of a 
 general hydraemic state of the blood, attending affections of 
 the kidneys and anaemia. It is occasionally impossible to 
 decide upon the preexisting lesion. 
 
 Symptoms. — In a well-developed case the abdomen is 
 distended and globular, the exact shape depending upon 
 the position of the patient, being broader in the recumbent 
 than in the erect posture, as, then, the fluid tends to spread 
 and collect in the flanks. The integument is smooth and 
 shining ; the superficial veins are very distinct, and the 
 normal depression at the umbilicus is either effaced or there 
 is a projection at this point. There is a sense of fulness, 
 with moderate resistance, but no tenderness on palpation ; 
 and if a hand be placed on either side of the belly, and a 
 sharp tap given with one of the fingers, a distinct impulse 
 
AFFECTIONS OF THE PERITONEUM. 323 
 
 — fluctuation wave — is felt by the other hand ; this is not 
 interrupted by pressure, made by an assistant, on the me- 
 dian line. While the child lies upon his back, percussion is 
 tympanitic over the upper anterior parts of the belly, where 
 the intestines float free, and dull elsewhere ; a change in 
 position alters the relation of the areas of tympany and 
 dulness, and the extent of the latter depends entirely upon 
 the amount of fluid present. 
 
 Pain is not a prominent symptom ; if present, it is par- 
 oxysmal, and has the griping character of the colic of intes- 
 tinal indigestion. Such attacks are often attended or followed 
 by moderate diarrhoea ; in the intervals the bowels may be 
 confined. Should the effusion be large the mere weight 
 of the fluid causes discomfort; then, too, respiration is 
 embarrassed, even to the extent of orthopncea ; micturition 
 is painful ; the urine is scanty, high-colored and albumi- 
 nous, and there may be oedema of the genitalia and legs, 
 resulting solely from pressure. 
 
 Cases having an obscure etiology furnish few additional 
 features ; there are no constant or characteristic alterations 
 of the tongue, appetite, appearance of the skin or tempera- 
 ture ; for these, with other rational symptoms, depend upon 
 the determining disease. 
 
 When due to inflammation of the peritoneum, the 
 amount of effusion is small ; the abdomen is tense and 
 tender ; the temperature is usually elevated, and the gen- 
 eral symptoms of acute or chronic peritonitis are more or 
 less marked. 
 
 In hepatic diseases, especially cirrhosis, the effusion is 
 great ; the superficial abdominal veins are very prominent ; 
 the hemorrhoidal veins are distended ; the spleen is often 
 enlarged ; the digestive functions are impaired, and the gen- 
 eral integument has a sallow hue or is decidedly jaundiced. 
 
324 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Cardiac disease causes anasarca and hydrothorax as well 
 as ascites, and these conditions are apt to be associated ; the 
 face is livid ; the lips and finger tips blue ; the jugular veins 
 are distended and pulsating ; there is dyspnoea, and a 
 scanty, albuminous urine, with the physical signs of heart 
 lesion. 
 
 Diagnosis. — There is little difficulty in detecting ascites, 
 unless the effusion be so small that it sinks away into the 
 pelvis or between the folds of the intestine beyond the 
 reach of the examiner's hand. Under these circumstances 
 it is well to try Duparcque's method (see page 308) of in- 
 creasing the distinctness of fluctuation, or to put in practice 
 another plan for the same purpose, namely, placing the 
 patient on the hands and knees so that the fluid may gravi- 
 tate to the most dependent portion of the abdomen — now 
 the neighborhood of the umbilicus — and come within the 
 range of palpation. 
 
 A large belly, produced by flatulent distension of the 
 intestines, may yield indistinct fluctuation, the palpation 
 stroke being transmitted through the bowels; but the 
 imperfect wave is readily interrupted by pressure in the 
 median line, and the results of percussion are quite different 
 from those obtained in ascites. 
 
 The collection of a large quantity of fluid in the pelvis 
 of one or other kidney — hydronephrosis — is attended by 
 abdominal distension, fluctuation, and percussion dulness. 
 The enlargement, however, is more noticeable on the side 
 of the affected kidney ; here, also, there is more resistance 
 and greater dulness, the opposite flank being often tympan- 
 itic; changes of position have little effect in altering the 
 percussion sounds, the umbilicus rarely protrudes, a kidney- 
 shaped outline can often be detected, and tapping liberates 
 a liquid charged with urea. 
 
AFFECTIONS OF THE PERITONEUM. 325 
 
 The Prognosis depends chiefly upon the nature of the 
 originating disease. When this cannot be discovered, the 
 forecast must be based upon the general strength and nu- 
 trition, the condition of the skin, the temperature, and the 
 character of the urine. If the strength be moderately pre- 
 served, the appetite and digestion fairly good, the skin nat- 
 ural in texture and color, the temperature normal, and the 
 urine free and non-albuminous, the prognosis for an ultimate 
 recovery is good, irrespective of the amount of effusion. 
 
 Treatment. — This must, in the main, be regulated by a 
 consideration of the primary disease. Cases of obscure 
 origin, as well as those depending upon anaemia or disease 
 of the liver, are much benefited by full doses of iron. The 
 tincture of the chloride of iron or the dried sulphate are, 
 perhaps, the best preparations to use, and their effect is 
 increased by the addition of quinine. The following is a 
 serviceable formula : — 
 
 R. Ferri Sulph. Exsiccat., . . . gr.xxiv (to be increased to 5 j). 
 
 Quiniae Sulph., gr. xij. 
 
 Acid. Sulphurici dil., . . . rr\xij. 
 
 Syrupi, fgj. 
 
 Aquae Menth. Pip., q. s. ad Hj iij. 
 M. 
 S — Two teaspoonfuls three times daily, taken diluted and 
 after eating, for a child of six years. 
 
 Diuretics can be employed at the same time, if there be 
 no kidney complication, for example : — 
 
 R. Potassii Acetatis, gij. 
 
 Spt. Juniperis Comp., f^ ss - 
 
 Spt. yEtheris Nitrosi, f^vj. 
 
 Syrupi, f|ij. 
 
 Aquas, q. s. ad f 5vj. 
 
 M. 
 S. — Two teaspoonfuls every three hours. 
 
 A combination of acetate of potassium, squill and digitalis 
 is often useful. 
 
326 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Should this class of remedies fail, much may be accom- 
 plished by a properly regulated course of purgatives. For 
 this purpose, thirty grains of compound licorice powder, 
 or ten grains of compound jalap powder, may be given from 
 two to three times daily. Sometimes it is advisable to begin 
 this treatment by two grains of calomel, administered at 
 bedtime, and followed next morning by a teaspoonful of 
 magnesia. 
 
 It is always important to keep the skin active by a daily 
 warm bath, and to maintain an equal surface temperature 
 by woolen underclothing. 
 
 The diet should contain as little fluid as possible ; thus 
 the child may eat : — 
 
 For Breakfast. — A saucer of oat-meal porridge or cracked 
 wheat with cream ; a soft-boiled egg ; two slices of stale 
 bread or toast with butter ; a teacupful (four fluidounces) of 
 milk. 
 
 For Dinner. — A bit of roast chicken, or tenderloin of 
 beef-steak, or roast beef or mutton ; mashed potatoes with 
 gravy, or spinach or cauliflower; two or three slices of stale 
 bread; rice pudding or junket and a glass of filtered water. 
 
 For Supper. — A poached egg on toast, or a bowl of 
 cream toast and a cup of milk. 
 
 Between meals, some water must be taken to relieve 
 thirst, but the less the better. 
 
 When the fluid does not diminish after a thorough trial 
 of ordinary remedies, the peritoneal cavity must be tapped. 
 It is best to make the puncture with a very fine canula ; 
 the instrument having been inserted is left in position ; 
 a rubber tube is attached, and the fluid allowed to drain 
 away slowly for some eight or ten hours, constant and equal 
 pressure being maintained in the meanwhile by a broad 
 bandage. After the canula is removed, the abdomen must 
 
AFFECTIONS OF THE PERITONEUM. 327 
 
 either be strapped or carefully bandaged. The effusion is 
 never entirely removed in this way, but enough is taken to 
 relieve pressure and allow absorption to go on. This method 
 of operation causes so little pain, that, if necessary, but 
 slight objection is offered to its repetition; in very timid 
 subjects, though, it is well to lessen the sensibility of the 
 skin by the momentary application of ice and salt to the 
 point selected for puncture. Paracentesis is often a remedial 
 agent of much value ; though in some cases it is merely 
 palliative. 
 
PART III.— THE GENERAL MANAGE 
 MENT OF CHILDREN. 
 
 It is the duty of the child's physician not only to remove 
 disease, 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 per- 
 fect 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 prin- 
 ciples 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 — a } 
 from the mother's breast; b y from the breast of a wet-nurse; 
 and c, from a bottle, the latter being the method known as 
 artificial or hand-feeding. 
 
 a. The mother's breasts are unquestionably the natural 
 
 329 
 
330 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 source of food-supply for her infant, and the mother's milk 
 the natural and, therefore, the best food. Consequently, 
 every woman who is free from certain contraindicating dis- 
 eases, to be mentioned later, should nourish her child solely 
 in this way for the first eight months of its life and, partially 
 so, up to the end of the first year ; or, failing in either limit, 
 for as long a time 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 colostrum, which affords suffi- 
 cient nourishment, and, at the same time, from its laxa- 
 tive properties, cleans the bowels of meconium. This pro- 
 cedure, too, is of great advantage to the mother, for it in- 
 sures proper uterine contraction, 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, butter and sugar, and other sweetened 
 mixtures, is more than useless, for it diminishes the activity 
 of sucking and the consequent stimulation of milk-produc- 
 tion. Put the child to the breast every two hours while 
 the mother is awake, and there need be no fear of starva- 
 tion. 
 
 After the third day, should the breasts not yield a supply 
 of milk, a little sound cows' 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, 
 artificial feeding is to be discontinued. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 33 1 
 
 Usually on the fourth day milk is secreted and regular 
 lactation 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 at 
 the breast; of the proper time for, and interval between, 
 feeding, and of the importance of regularity. Upon these 
 points the physician must be able, if required, to 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 index and middle 
 finger of the disengaged hand, placed above and be- 
 low the nipple. In case the milk run too freely — a con- 
 dition very apt to excite vomiting — the flow is easily 
 regulated by gentle pressure with the supporting fingers. 
 Each breast should be drawn alternately, the contents 
 of one being 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 running over his lips. 
 
 During the first six weeks, the breast is required every 
 second hour, from 5 a.m. to i i p.m. Then the infant should 
 be put in a crib by the mother's bed, or, better still, in the 
 nurse's room, and there remain quietly until the morning 
 feeding. This secures the mother six hours' 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 
 administered from a bottle ; but often after a few days, and 
 certainly at the end of a week or two, the good custom 
 
332 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 of sleeping at night is formed, and there is no further 
 trouble. 
 
 Regularity in meal hours is of even more importance in 
 early than in adult life, on account of the natural feebleness 
 of digestion. To secure this, it is only necessary to have a 
 little perseverance ; for infants are such creatures of habit, 
 that a short training brings them into the way of expecting 
 food only at certain times, and, when healthy, they wake 
 to suck with almost the precision of the clock. While 
 insisting upon this rule, one must recognize the fact that, 
 although, in the vast majority of instances, a two hours' 
 interval is most suitable up to the middle of the second 
 month, there is no absolute law as to the daily num- 
 ber of 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, per- 
 haps, and even once or twice at night. In these excep- 
 tional 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 of hunger usually begins after a 
 sound sleep, is not peevish, and stops at the sight of the 
 breast, when the infant rouses himself, presents an expres- 
 sion of pleasure, clinches his hands and flexes the limbs. 
 The cry of colic is violent and paroxysmal ; the face is 
 livid, and wears an expression of suffering ; the abdomen is 
 distended and hard ; the hands and feet are cold ; the legs 
 
THE GENERAL MANAGEMENT OF CHILDREN. 333 
 
 are drawn up or kicked violently about ; and an explosion 
 of wind from the mouth or anus ends the attack. A 
 peevish cry, hot skin and sour breath, attend indigestion. 
 
 It stands without the 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 produces serious mischief. The pain of 
 colic and the discomfort of indigestion are chiefly due to the 
 accumulation of flatus resulting 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 gastro-intestinal 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. Instead of 
 continuous feeding, the plan for relief is to decrease the 
 quantity of food by increasing the intervals between nurs- 
 ing, and by abridging the time of lying at the breast, while 
 therapeutic measures are employed to strike at the root of 
 the evil. 
 
 After the sixth week, the interval between nursings 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. 
 
334 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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 interfering 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 exactly fixed for all cases, since it must depend 
 upon two conditions — the health of the mother and the 
 development of the infant. When the former continues to 
 be robust, and the child steadily grows and gains flesh, 
 lactation 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 rickets. 
 
 Change in the manner of feeding may be accomplished 
 gradually 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. to i i p.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 ; and during the 
 fourth, six and one. Then the breast must be entirely with- 
 held. Carefully prepared milk-food, administered from a 
 bottle, is the best substitute. At the age of ten months a 
 mixture that ordinarily agrees well is : — 
 
 Cream, f^ ss - 
 
 Milk, fjijss. 
 
 Sugar of milk, gss. 
 
 Water, f£j. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 335 
 
 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 (four fluidounces) be insufficient to 
 satisfy the child's appetite all the ingredients except the 
 cream may be increased until the mixture measures six, 
 eight or even twelve fluidounces, 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 soon overcome this difficulty, while the breast 
 is being presented at times. 
 
 Sudden weaning is not advisable unless there be 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. The plan 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; 
 rapidly developing pulmonary tuberculosis, and attacks of 
 erysipelas or of variola, are instances in point. 
 
 Ill-health of either the mother or the infant often re- 
 quires premature withdrawal of the breast, thus necessitat- 
 ing wet-nursing or hand-feeding. 
 
 So far as the mother is concerned, lactation must be 
 stopped if it reduce her strength and make her thin and 
 pale. Frequently, women who are unable to nurse their 
 
336 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 children entirely, without sacrificing their health, can safely 
 do so several times in the twenty-four hours ; this partial 
 sucking must be encouraged, for with its assistance hand- 
 feeding becomes a safe and easy task. 
 
 A change must also be made if pulmonary tuberculosis 
 is developed, or, being already present, rapidly advances 
 under the drain of milk-secretion ; and if any acute disease, 
 as typhoid or typhus fever, occasion dangerous temporary 
 prostration. 
 
 On the part of the infant, there are several indications for 
 anticipating the time of withdrawing the mother's breast. 
 Thus, it must be done if the occurrence of pregnancy or 
 the recurrence of menstruation render the milk unwhole- 
 some ; if the mother contract a dangerous contagious 
 disease, as variola, scarlet fever, or erysipelas ; or if the 
 mammary glands become inflamed ; again, if 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 third indication, 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 de- 
 mands of nutrition. Even without a minute examination 
 of the milk, it is possible to form a pretty 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, draws upon it vigorously 
 for a moment or two, 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. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 337 
 
 Consideration of the final indication opens the question 
 of the propriety of regulating weaning by the progress 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 canine 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 
 inference 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. 
 
 b. 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 inesti- 
 mable importance with delicate children. The disadvan- 
 tages consist in the great 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 the fact 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 instances, to 
 trust to careful bottle-feeding. Nevertheless, as some child- 
 ren 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 the taint of syphilis, tubercle or scrofula. She 
 
 22 
 
33^ DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 must be cheerful, good-natured, active, careful and temper- 
 ate in habits. Her age should be between twenty and 
 thirty years ; she should be a multipara, that she may under- 
 stand the care of an infant and the manner of giving suck ; 
 her child ought to be of nearly the same age as the infant 
 about 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 
 ascertaining 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 by 
 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 1032, an alkaline reaction, 
 and show, when placed under the microscope, a number of 
 medium-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 nor more readily applied test of the quality of a nurse 
 than the size, weight and general development of her child, 
 and if it be weak and ill-nourished, no amount of apparent 
 fitness in other respects can warrant her engagement. 
 
 Even when a woman is found fulfilling in her single person 
 all of the above conditions — a rare event, indeed — it does 
 not necessarily follow that her milk will suit the babe to be 
 suckled. Then changes and new trials are in order until 
 the desired end be attained. 
 
 The diet of a wet-nurse must be liberal, including a 
 moderate allowance of vegetables and fruit ; wine or beer 
 may be taken with the mid-day dinner, when there is any 
 failure in the supply of milk. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 339 
 
 Weaning from the wet-nurse is to be commenced at the 
 same time and conducted in the same manner as from the 
 breast of the mother. 
 
 c. 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, through no fault of 
 their own, resort to a wet-nurse or to artificial feeding. 
 Usually they select the last method, with results that vary 
 in direct proportion to the care and intelligence displayed 
 in carrying it out. 
 
 There can be no doubt, though the statement is a bold 
 one and seemingly contrary to nature, that, taking the aver- 
 age, infants properly brought up by hand are better devel- 
 oped and enjoy more perfect health than those completely 
 breast-fed. Of course, there is no artificial food equal to the 
 natural — the sound breast-milk of a robust woman — and a 
 child fed upon this must thrive, if other circumstances be 
 favorable. Unfortunately, the woman who has sufficient 
 health and strength to furnish an abundant supply of good 
 milk during the ten or twelve months of normal lactation 
 is unique in our day, and the great bulk of those who do 
 nurse their children grow pale, thin and feeble, and give milk 
 which, though sufficient in quantity to fill the suckling's 
 stomach and satisfy the cravings of hunger, does not con- 
 tain enough pabulum to meet the demands of nutrition, 
 Such mothers complain that their children are puny, peevish 
 and always ailing, and wonder why their neighbors' babies, 
 fed upon the bottle, are so round, jolly and healthy. The 
 explanation lies in the simple fact, that good cows' milk is 
 a better food than bad breast-milk. 
 
340 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Infants can be reared perfectly well upon the bottle, but 
 much more care and trouble are involved than in breast- 
 feeding. The task is comparatively easy to accomplish when 
 the powers of digestion are inherently active, and especially 
 when artificial feeding is not required until after the child 
 has been suckled for several weeks. In these cases the 
 stomach and intestinal canal, inactive in foetal life, are trained 
 to their new duties under normal conditions, and so 
 prepared for the digestion of properly selected artificial 
 aliment. On the contrary, if digestion be naturally feeble, 
 or if the infant have to be bottle-fed from the first, great 
 difficulty may be expected, and most skillful handling is 
 demanded. 
 
 To insure success in hand-feeding, it is necessary to re- 
 member that an infant is not nourished by the food he simply 
 swallows, but by that portion of it which 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 since children differ as much in consti- 
 tution as in feature, it is impossible exactly to formulate 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 call for 
 more and stronger food. On the other hand, should the 
 system be accidentally reduced by disease, the digestion, 
 sympathizing in the general debility, temporarily loses its 
 normal activity and assumes that of an earlier age. Now, 
 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 
 
THE GENERAL MANAGEMENT OF CHILDREN. 34 1 
 
 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 antici- 
 pated and made. 
 
 Other important matters to be studied in detail are — 1st, 
 the selection of a proper substitute for the breast-milk ; 2d, 
 the quantity to be given ; 3d, the method of preparation ; 
 4th, the mode of administration; and 5th, the means of 
 preservation. 
 
 1st. Healthy breast-milk must be taken as the type of 
 infants' food, and the nearer an artificial substitute can be 
 made to approach it in chemical composition and physical 
 properties, the more perfect is it. 
 
 Normal breast-milk has a specific gravity of about 1032, 
 is alkaline in reaction, as already stated, and is composed 
 of:— 
 
 Water, 889.08 parts. 
 
 Sugar, 43.64 " 
 
 Casein, 39-24 " 
 
 Butter, 26.66 " 
 
 Salts, 1.38 "f 
 
 It contains, then, albumen, 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 meet the de- 
 mands most easily and completely. 
 
 In seeking a substitute, 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 
 
 * See Simple Atrophy. 
 
 f Analysis of MM. Vernois and Becquerel. 
 
342 
 
 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 that of women a little more closely than the others ; never- 
 theless, cows' milk is usually selected, because, being plen- 
 tiful, it is easily obtained and cheap.* 
 
 Cows' milk has a specific gravity of 1033.38, is slightly 
 acid in reaction — unless perfectly fresh from a pasture-fed 
 animal — when it may be neutral or alkaline, and contains: — 
 
 Water, 864.06 parts. 
 
 Sugar, 38.03 " 
 
 Casein, 55.15 " 
 
 Butter, 36.12 " 
 
 Salts, 6.64 " f 
 
 Comparing this analysis with that previously given, it is 
 readily seen that the two fluids differ in specific gravity and 
 reaction, and that cows' milk contains more casein and fat, 
 but less sugar, than woman's milk. 
 
 Another difference of much consequence is, that if rennet 
 be added to cows' milk, the casein coagulates into large, 
 
 * An interesting table, from Vernois and Becquerel, is given by J. Lewis 
 Smith, showing the difference in the composition of human milk and that of 
 the four common domestic animals : — 
 
 Variety of 
 
 Specific 
 Gravity. 
 
 1000 parts contain 
 
 The solids consist of 
 
 Milk. 
 
 Fluids. 
 
 Solids. 
 
 Sugar. 
 
 Butter. 
 
 Casein. 
 
 Salts. 
 
 Woman 
 
 1032.67 
 
 889.08 
 
 110.92 
 
 43- 6 4 
 
 26.66 
 
 39-24 
 
 1.38 
 
 Cow.' 
 
 1033-38 
 
 864.06 
 
 135-94 
 
 38.03 
 
 36.12 
 
 55-15 
 
 6.64 
 
 
 Ass 
 
 IQ34-57 
 
 890.12 
 
 109.88 
 
 50.46 
 
 18-53 
 
 35-65 
 
 5-24 
 
 
 Goat 
 
 I033-53 
 
 844.90 
 
 155-1° 
 
 36.91 
 
 56.87 
 
 55-14 
 
 6.18 
 
 
 
 Ewe 
 
 1040.98 
 
 832.32 
 
 167.68 
 
 39-43 
 
 54 31 
 
 69.78 
 
 7.16 
 
 f Analysis of Vernois and Becquerel. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 343 
 
 firm masses, while with human milk a light, loose curd is 
 formed. In the stomach the gastric juice has the same 
 effect as the rennet ; producing, in the first instance, a coagu- 
 lum most difficult to digest; in the other, one readily at- 
 tacked 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 substitute for the natural food. 
 
 Condensed milk is frequently recommended by physicians, 
 and largely used by the laity, on their own authority, in 
 bottle-feeding. It keeps better than cows' milk, and is sup- 
 posed to be more easily digested by young infants. The 
 latter supposition is a mistaken one, and arises from the 
 overlooked fact that condensed milk is always given dis- 
 solved in a large proportion of water, while cows' milk is 
 too frequently used insufficiently diluted, or otherwise im- 
 properly prepared. The author is convinced of the accuracy 
 of this statement from a number of years' close study of the 
 subject, during which he has seen but two or three instances 
 where properly prepared cows' milk was unsuitable, provided 
 condensed milk could be digested, and he has had little diffi- 
 culty in substituting the former for the latter when the 
 cooperation of the mother and nurse was obtained. 
 
 Condensed milk contains a large proportion of sugar, 
 forms fat quickly, and thus makes large babies ; the sugar 
 also, counteracts a tendency to constipation, often a trouble- 
 some complication of hand-feeding. These advantages 
 are unquestioned, and, together with the ease of prepa- 
 ration, are what place it so high in the esteem of monthly 
 nurses. It is equally true that, as a food, it does not 
 contain enough nutrient material to supply the wants of a 
 growing baby. According to Meigs' analysis, the mixture 
 
344 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 of condensed milk ordinarily used — one teaspoonful to six 
 tablespoonfuls of water — yields : — 
 
 Water, 92.673 parts in 100. 
 
 Fat, 1.095 " " 
 
 Casein, 868 " 
 
 Sugar, 5.206 " " 
 
 Ash, 158 '* " 
 
 It is apparent that the amount of casein and of fat is much 
 less than in either human or cows' milk. The addition of 
 a large proportion of condensed milk would remove this 
 fault, but at the same time would increase the quantity of 
 sugar to a point incompatible with perfect digestion. 
 
 Infants fed upon it, though fat, are pale, lethargic and 
 flabby ; although large, are far from strong ; have little 
 power to resist disease ; cut their teeth late, and are very 
 likely to drift into rickets before the end of the first year. 
 
 Without going further into detail, it is never safe to 
 bring up a child solely on condensed milk. For a tempo- 
 rary change of diet, and as a food during traveling or under 
 circumstances in which sound cows' milk cannot be ob- 
 tained, 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 processes of nutrition. 
 
 They are bad foods for two reasons. First, they differ 
 materially from human milk in chemical composition. For 
 example, in arrowroot, which is the favorite, the proportion 
 of the nitrogenous to the calorifacient element is as one to 
 twenty, while in human milk it is one to four. Secondly, 
 because the calorifacient principle — starch — must be con- 
 verted into sugar before it can be absorbed. This change 
 is accomplished in the body by the saliva and pancreatic 
 
THE GENERAL MANAGEMENT OF CHILDREN. 345 
 
 juices, secretions that are not fully established 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 nutri- 
 tion 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 little sugar formed and absorbed, 
 appropriates oxygen that would otherwise go toward the 
 removal of waste, and so retards the necessary changes. 
 
 Farinaceous food, as such, is never admissible before the 
 fourth month ; earlier, it is only to be employed as an addi- 
 tion to milk preparations for its mechanical action. 
 
 2d. 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 obser- 
 vation. 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 
 regular intervals, the instinctive cravings of hunger, since 
 they represent the wants of the system, rarely lead to ex- 
 cess in either direction. Nevertheless, it is well to have 
 some guide. 
 
 During the first four weeks, infants generally require 
 from twelve and a half to sixteen fluidounces of food ; 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 
 
346 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 the quantity depends upon whether additions be made to 
 the diet or milk food be used exclusively. When the daily 
 amount reach 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 quan- 
 tity, 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. 
 
 3d. The object to be accomplished in the preparation of 
 cows' milk is to make it resemble human milk as nearly as 
 possible in chemical composition and physical properties. 
 To do this, it is necessary to reduce the proportion of 
 cream, to increase the proportion of sugar, and to overcome 
 the tendency of the casein to coagulate into large, firm 
 masses upon entering the stomach. 
 
 Dilution with water is all that need be done to reduce 
 the amount of casein to the proper level ; but as this lessens 
 the quantity of fat below the normal standard, and still 
 further diminishes the already insufficient sugar, it is essen- 
 tial to add fat and sugar 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, 
 though the latter is preferable, as it is little apt to ferment 
 and contains some of the salts of the milk which are of 
 nutritive value. 
 
 The risk of firm clotting may be anticipated by the addi- 
 tion of an alkali, or a small quantity of some thickening 
 substance, as barley-water, gelatine or one of the digestible 
 farinaceous foods. Lime-water is the alkali usually selected. 
 It acts by partially neutralizing the acid of the gastric 
 
THE GENERAL MANAGEMENT OF CHILDREN. 347 
 
 juice, so that the casein is coagulated gradually and in 
 small masses, or passes, in great part unchanged, into the 
 intestine to be there digested by the alkaline secretions. 
 As it contains only half a grain of lime to the fluidounce, 
 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 a 
 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, from two to four grains of bicar- 
 bonate of sodium may be added to each bottle, or, better 
 still, from five to fifteen drops of the saccharated solution of 
 lime. This solution, officinal in the British Pharmacopoeia, 
 under the title of Liquor Calcis Saccharatus, is made in the 
 following way : — 
 
 Take of — 
 
 Slaked Lime , 1 ounce. 
 
 Refined Sugar, in powder, 2 ounces. 
 
 Distilled Water, 1 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 oc- 
 casionally for a few hours. Finally, separate the clear solution with a siphon, 
 and keep it in a stoppered bottle. 
 
 Thickening substances act purely mechanically by get- 
 ting, as it were, between the particles of casein during 
 coagulation, preventing them running together and forming 
 large, compact masses. 
 
348 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Of these materials barley-water is perhaps the best. To 
 prepare it, put two good 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 in- 
 stead of, and in the same proportions as, water. 
 
 Gelatine is prepared in the following way : put a piece of 
 plate gelatine, an inch square, into half a 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 converted into dextrine and grape sugar by the pro- 
 cess of manufacture. The article known as " Mellin's 
 Food " can be relied upon. One teaspoonful of this dis- 
 solved 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 practi- 
 tioner must not only be familiar with the theory of feeding, 
 but must be able to write out precise directions for the prepara- 
 tion of the 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 frequently, will serve as a useful guide. 
 
 Diet during the first week : — 
 
 Cream, f ^ iij. 
 
 Sugar of milk, gr. xv. 
 
 Whey, f.fss, f^ij. 
 
 Water, f^ss, f^ij. 
 
 For each portion; to be given every two hours from 5 a.m. 
 to 1 1 p.m., and in some cases once or twice at night. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 349 
 
 To make whey, add three teaspoonfuls of wine of pepsin 
 to a quart of warm fresh milk, and stand near the fire for two 
 hours, then remove the curd by straining through muslin. 
 
 Diet from the second to the fifth week : — 
 
 Milk, fgss. 
 
 Cream, f 3; ij. 
 
 Sugar of milk, gr. xv. 
 
 Water, fgj. 
 
 For one portion; to be given every two hours from 5 A.M. 
 to II P.M. 
 
 Diet from the fifth week to the end of the second 
 month : — 
 
 Milk, fgj,f3ij. 
 
 Cream, f^ ss. 
 
 Sugar of milk, gr. xxx. 
 
 Water, f^f^J- 
 
 For each portion ; to be given every two hours. 
 
 Diet during the third month : — 
 
 Milk, f^ijss. 
 
 Cream, f^ss. 
 
 Sugar of milk, 3 j. 
 
 Water, f^j. 
 
 For each portion ; to be given every two and a half hours. 
 
 Diet during the fourth and fifth months : — 
 
 Milk, fgiijss. 
 
 Cream, f^ ss > 
 
 Sugar of milk, ^j. 
 
 Water, fgj. 
 
 For each portion ; to be given every three hours. 
 
 Diet during the sixth month, six meals daily. Morning 
 and mid-day bottles, each : — 
 
 Milk, " fgivss. 
 
 Cream, f J>ss. 
 
 Mellin's Food, „ £j. 
 
 Hot water, f ^j. 
 
 Dissolve the Mellin's Food in the hot water, and add, 
 with stirring, to the previously mixed milk and cream. 
 
350 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Other bottles, each : — 
 
 Milk, . f^ivss. 
 
 Cream, f % ss. 
 
 Sugar of milk, ^j. 
 
 Water, fgj. 
 
 In the seventh month the Mellin's Food may be increased 
 to two teaspoonfuls, and given three times daily. 
 
 Throughout the eighth and ninth months five meals a 
 day will be sufficient. 
 
 First meal, at 7 a.m. : — 
 
 Milk, f^vjss. 
 
 Cream, f% ss. 
 
 Sugar of milk, 3_j. 
 
 Water, f-fj. 
 
 Second meal, at 10.30 a.m. — Milk, cream and water in 
 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. 
 
 Instead of Mellin's Food, a teaspoonful of " flour ball " may 
 be added. To make this material, 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 calori- 
 facient is as one to five, nearly the same as in human milk. 
 
 Two meals of flour ball daily — say 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, con- 
 
THE GENERAL MANAGEMENT OF CHILDREN. 35 I 
 
 stantly rubbing until a cream-like mixture is obtained; this 
 is poured into eight ounces of hot milk, stirring well, and 
 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 
 any one of the "infants' foods" in which the starch has 
 been converted into dextrine and grape-sugar, or by oat- 
 meal or barley. A preparation of the latter, highly recom- 
 mended by Eustace Smith, under the name of " barley jelly," 
 is a digestible food. In making it, put two tablespoonfuls 
 of washed pearl barley with a pint and a half of water and 
 slowly boil down to a pint; next, strain out the barley and 
 let the liquid set into a jelly. Two teaspoonfuls of this, 
 dissolved in eight fluidounces of warmed and sweetened 
 milk, are enough for a single feeding, and such a meal may 
 be allowed twice a day. 
 
 Diet for the tenth and eleventh months. 
 
 First meal, 7 a.m. : — 
 
 Milk, f^viijss. 
 
 Cream, f^ ss. 
 
 Mellin's Food, ^ ss. 
 
 (Or flour ball or barley jelly, gij.) 
 
 Water, f£j. 
 
 (To be used only when Mellin's Food is employed.) 
 
 Second meal, 10.30 a.m.— A breakfast-cupful of warm 
 milk (foviij). 
 
 Third meal, 2 p.m. — The yolk 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 tea- 
 cupful (fovj) of beef-tea, containing a few stale bread-crumbs. 
 
 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 
 
352 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 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. 
 
 A further variation can be made by occasionally using 
 mutton, chicken or veal broths instead of beef-tea. 
 
 As much more difficulty is experienced in feeding infants 
 during the first twelve months than during the second, it 
 will 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 casein, the effect of adding lime-water or 
 barley-water must be tried. 
 
 For instance, at the age of six weeks make each bottle 
 
 of:— 
 
 Milk, f£j.f3*J- 
 
 Cream, f^ ss - 
 
 Sugar of milk, 3 ss. 
 
 Lime-water, f^j, f^ij. 
 
 Or of:— 
 
 Milk, f£j.fgij. 
 
 Cream, f^ ss - 
 
 Sugar of milk, g ss. 
 
 Barley-water, f^j,f^ij. 
 
 Sometimes, particularly if there be diarrhoea, boiling 
 makes the milk more digestible, and in this condition it 
 may be used instead of fresh milk in either of the above 
 mixtures. Condensed milk, too, can be employed tempo- 
 rarily, making each portion of — 
 
 Condensed milk, f 3 j. 
 
 Cream, f^ ss - 
 
 Hot water, f i| ijss. 
 
 Should further alteration be necessary, goats' or asses' 
 milk may be substituted for cows' milk, the strong odor of 
 
THE GENERAL MANAGEMENT OF CHILDREN. 353 
 
 the former and the laxative properties of the latter being 
 removed by boiling. 
 
 "Strippings" is another good substitute for cows' milk. 
 It is obtained by remilking the cow after the ordinary daily 
 supply has been drawn, and contains much cream and but 
 little curd. Assimilable proportions of this are : — 
 
 Stoppings, f 3 j. 
 
 Water, f^ij. 
 
 And if the little casein in such a mixture be still un- 
 digested : — 
 
 Strippings, f^j ss « 
 
 Barley-water, f^j ss - 
 
 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 pre-digesting the milk must 
 be resorted to. There are several ways of artificially digest- 
 ing milk. 
 
 One plan * is to add to each fluidounce of milk five 
 grains of pure pepsin and four drops of dilute muriatic 
 acid ; digest in a water-bath, at a temperature of ioo° F., 
 until the mixture becomes clear, then neutralize with bi- 
 carbonate of sodium and the milk is ready for use. 
 
 The best method, and the one now almost uniformly 
 adopted in this country, is to peptonize the milk by pan- 
 creatin.f 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 so hot 
 
 * Recommended by Eustace Smith. 
 
 f That manufactured under the name of Extractum Pancreatis, by Fairchild 
 Brothers & Foster, has proved most efficient in the author's hands. 
 
 23 
 
354 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 that the whole hand can be held in it for a minute without 
 discomfort, 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 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 casein, 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 
 casein is only partially converted into peptone, but every 
 succeeding moment of continued warmth lessens the 
 amount of casein, 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 ordi- 
 narily best to stop it short of complete conversion, 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 
 assimilation. 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 bitter- 
 ness 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. Thus, for an infant of six weeks, each meal 
 may consist of: — 
 
 Peptonized milk, fo"J- 
 
 Sugar of milk, 3 ss. 
 
 Water, fgj. 
 
 To this cream may be added when desirable, and by 
 
THE GENERAL MANAGEMENT OF CHILDREN. 355 
 
 diminishing the quantity of water and increasing that of 
 the milk the strength of the food may be made greater at 
 any time. 
 
 Although every precaution be taken, the last of a 
 quantity of pre-digested food is very apt to grow bitter. 
 And if the attendants will take the trouble, it is much 
 better to peptonize every meal separately. This is readily 
 done by ordering a number of powders of pancreatin and 
 bicarbonate of sodium, so proportioned that each packet 
 shall contain the proper amounts for one bottle of food. 
 For example : — 
 
 R . Ext. Pancreatis, gr. ix. 
 
 Sodii Bicarb., gr. xxiv. 
 
 M. et ft. chart, (waxed papers) No. xij. 
 S. — Put one powder into a nursing bottle with two fluid- 
 ounces 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 teaspoonful 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 
 casein in a less and less degree, until finally it is taken in 
 its natural form. 
 
 Sometimes, milk in every form, and however carefully 
 prepared, 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 following are good substitutes : — 
 
35^ DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Mellin's Food, gj. 
 
 Hot water, f^p\j- 
 
 For each portion ; to be given every two hours at the age 
 of six weeks. 
 
 Veal broth* fg jss. 
 
 Barley-water, f^j ss ' 
 
 For one portion. 
 
 Whey, f^j ss - 
 
 Barley-water, f g jss. 
 
 Sugar of milk, g 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 who are 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 the 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, pre- 
 digestion of the food is most serviceable. If a few grains 
 of extractum pancreatis be added to a gobletful of thick, 
 well-boiled starch gruel, at a temperature of 100° F., the 
 gelatinous mucilage quickly grows thinner and soon is 
 transformed into a fluid, the starch having been rendered 
 soluble by the action of the diastase contained in the pan- 
 creatin ; by still longer contact the hydrated 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.:— 
 
 * Veal broth is to be made of the strength of half a pound of meat to the 
 pint. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 357 
 
 Barley jelly, ^ij. 
 
 Sugar of milk, gj. 
 
 Warm milk, f% viij. 
 
 Add three grains of extractum pancreatis, and five grains 
 of bicarbonate of sodium, and keep warm for about half an 
 hour before feeding. 
 
 The same process may be employed with food containing 
 oat-meal, arrowroot or wheaten flour, with the effect of con- 
 verting the starchy elements into digestible products, and 
 without materially altering the taste. 
 
 When the infant has arrived at an age to take meat 
 broths, these too may be readily peptonized when diges- 
 tion is enfeebled. The recipe for peptonized beef-tea, 
 which may be taken as an example, is : — 
 
 To one-quarter of a pound of minced raw beef, entirely 
 free from fat, add one-half pint of cold water; cook over a slow 
 fire, with constant stirring, until it has boiled a few minutes. 
 Then pour off the liquor and beat or rub the meat to a paste. 
 Put the latter into a jar with one-half pint of cold water, and 
 pour in the liquor previously obtained. Add to 'this mixture 
 thirty grains of extractum pancreatis and twenty grains of 
 bicarbonate of sodium, shake all well together, and keep at 
 a temperature of about I io° F., stirring occasionally, for three 
 hours. Next, boil quickly, strain, and serve as required. 
 
 Returning to the regimen of the healthy infant, it will 
 be found that, after the first year, far less change is re- 
 quired 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 (foviij) of new milk. 
 
 Second meal, 10 a.m. — A teacup of milk (f§vj), with a 
 soda biscuit or thin slice of buttered bread. 
 
358 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Third meal, 2 p.m. — A teacupful of beef-tea (fSyj), with a 
 slice of bread. One good tablespoonful of rice and milk 
 pudding. 
 
 Fourth meal, 6 p.m. — Same as first. 
 
 Fifth meal, io p.m. — One tablespoonful of Mellin's Food 
 with a breakfast-cupful of milk. 
 
 To alternate with this : — 
 
 First meal, 7 a.m. — The yolk 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 boiled potato, moistened 
 with four tablespoonfuls of beef-tea ; two good tablespoon- 
 fuls 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 
 wake an hcur 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 yolk 
 of an egg lightly boiled ; two thin slices of bread and butter. 
 
 Second meal, 1 1 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. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 359 
 
 On alternate days : — 
 
 First meal, 7 a.m. — Two tablespoonfuls of thoroughly 
 cooked oat-meal or wheaten grits with sugar and cream ; a 
 teacupful of new milk. 
 
 Second meal, 1 1 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 a mashed 
 baked potato, 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 occasionally, and 
 the demand increases with age. The water must be as pure 
 as possible, and should not be too cold, although, in the 
 heat of summer, 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 enter- 
 tained. The rule to adopt is, 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. 
 
 4th. 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 ; 
 
360 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 and even after this, as the bottle is a comfort and insures 
 slow feeding, 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, represented in the accompanying figure ; all com- 
 
 Fig. 6. — Feeding-Bottle and Tip. 
 
 plicated 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. 
 
 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 fluid- 
 ounces, according to the age of the child. Two should be 
 on hand at a time, to be used alternately. Immediately after 
 
THE GENERAL MANAGEMENT OF CHILDREN. 36 1 
 
 a meal, the bottle should be thoroughly washed out with 
 scalding water, rilled with a solution of bicarbonate or sali- 
 cylate of sodium — 5j 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 pre- 
 ferred, as being more readily everted and cleaned ; the open- 
 ing at the point must be 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 rubbing 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 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 import- 
 ant to insist upon the separate preparation of each meal 
 immediately before it is to be given. The practice of mak- 
 ing in the morning the whole day's supply of food, though 
 it save 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 consumption. 
 
 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, the different fluid ingredients of the food are to be 
 measured in this, one after the other ; the requisite quantity 
 of milk-sugar is then added, and the whole mixed tho- 
 
362 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 roughly by stirring with a spoon, and poured into the 
 feeding-bottle. The food must now be heated to a temper- 
 ature 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, the tip is applied 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 prevent 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 a meal. It is best to withdraw the bottle 
 occasionally for a brief rest, and after the meal is over, 
 sucking upon the empty bottle must not be allowed, even 
 for a moment. 
 
 5th. 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 a day 
 during the heat of summer. Every cow is subject to 
 changes in health, and 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 pre- 
 ferred 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 milk and cream must be transported from the dairy 
 in perfectly clean vessels. To insure this it is best to pro- 
 vide two sets of small cans, one set to be thoroughly 
 cleansed and aired while the other is taken away by the 
 milk-man to carry back the next supply. So soon as this 
 
THE GENERAL MANAGEMENT OF CHILDREN. 363 
 
 arrives in the morning, or in the morning and evening in 
 hot weather, the cans 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 the milk perfectly sweet for twenty-four hours 
 in winter, and for twelve hours in summer, except on in- 
 tensely hot days ; then it may be necessary to scald or 
 lightly boil the whole of the supply when received, in order 
 to prevent change. 
 
 Children who have cut their milk teeth may be fed for a 
 twelvemonth — namely, up to the age of three and a half 
 years — in the following way : — 
 
 First meal, 7 a.m. — One or two tumblerfuls of milk ; a 
 saucer of thoroughly cooked oat-meal or wheaten grits, and 
 a slice of bread and butter. 
 
 Second meal, 1 1 a.m. (if hungry). — A tumblerful of milk 
 or a teacupful of beef-tea, with a biscuit. 
 
 Third meal, 2 p.m. — A slice of underdone roast beef or 
 mutton, or a bit of roast chicken or turkey, minced as 
 fine as possible ; a baked potato, thoroughly mashed with 
 a fork and moistened with gravy; a slice of bread and 
 butter ; a saucer of junket or rice-and-milk pudding. 
 
 Fourth meal, 7 p.m. — A tumblerful of milk, and one or 
 two slices of well-moistened milk toast. 
 
 From three and a half years up the child must take his 
 meals at the table with his parents, or with some reliable 
 attendant, who will see that he eats leisurely. The diet, 
 while plain, must be varied. The following list will give 
 an idea of the food to be selected : — 
 
364 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 BREAKFAST. 
 
 Every day. One dish only each day. 
 
 Milk. Fresh fish. 
 
 Porridge and cream. Eggs, lightly boiled. 
 
 Bread and butter. poached. 
 
 scrambled, 
 plain omelette. 
 Chicken hash. 
 Stewed kidney. 
 Stewed liver. 
 
 Sound fruits maybe allowed before or after the meal, according to taste, as 
 oranges, grapes without pulp (seeds not to be swallowed), peaches, thoroughly 
 ripe pears, cantaloupes and strawberries. 
 
 DINNER. 
 
 Every day. Two dishes each day. 
 
 Clear soup. Potatoes, baked. 
 
 Meat roasted or boiled mashed, 
 
 and cut into small pieces. Spinach. 
 
 Bread and butter. Stewed celery. 
 
 Cauliflower. 
 Hominy. 
 Macaroni, plain. 
 Peas. 
 
 String-beans, young. 
 Green corn, grated. 
 Junket, rice-and-milk, or other light pudding, and, occasionally, ice cream, 
 may be allowed for dessert. 
 
 SUPPER. 
 
 Every day. 
 Milk. 
 
 Milk toast or bread and butter. 
 Stewed fruit. 
 
 Fried food, highly seasoned or made up dishes, are to be 
 excluded; no condiment but salt is to be used, and the 
 formation of a habit of eating between meals must be 
 avoided. 
 
 Filtered or spring water should be the only drink ; tea, 
 coffee, wine or beer being entirely forbidden. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 365 
 
 As to quantity, a healthy child may be permitted to 
 satisfy his appetite at each meal, under the one condition 
 that he eats slowly and masticates thoroughly. 
 
 In case of illness, the diet must be reduced in quantity 
 and quality, according to the rules that are applicable to 
 adults. 
 
 2. Bathing. 
 
 During the first two and a half years of life a child ought 
 to be bathed once every day. The bath should be given at a 
 regular time, and it is best to select some hour in the early 
 morning, midway between two meals — ten o'clock, for in- 
 stance. The tub should be placed near the fire or in a 
 warm room in winter, and away from currents of air in 
 summer. It should contain enough water to cover the 
 child up to the neck when in a sitting posture, and the 
 temperature must be about 95 ° F. Upon undressing the 
 child, the first step is to wet his head ; then he is to be 
 plunged into the water and thoroughly washed with a soft 
 rag or sponge, and pure, unscented castile soap. After 
 remaining in the water from three to five minutes the 
 surface must be well dried, and rubbed with a flannel cloth 
 or soft towel ; then the body must be enveloped in a light 
 blanket and the infant either returned to his crib to sleep, 
 or kept in the lap for ten or fifteen minutes, until tho- 
 roughly warm and rested, and finally dressed. If there be 
 repugnance to the bath, the tub may be covered over with 
 a blanket, and the child being placed upon it, may be 
 slowly lowered into the water without seeing anything to 
 excite his fears. 
 
 In very hot weather, in addition to the morning full bath, 
 the body may be sponged twice daily, with water, at a 
 temperature of 90 F. ; this, contrary to what might be 
 
366 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 expected, has a greater and more permanent cooling effect 
 than bathing with cold water. 
 
 After the third year, three baths a week are quite suffi- 
 cient. An evening hour is now to be preferred, but the 
 water must still be heated to 90 . 
 
 About the tenth year cooler baths can be begun, from 
 72 to 75 being the proper temperature. The cold sponge 
 or cold plunge is not admissible as a daily routine until 
 youth is well advanced. 
 
 The hot bath — 95 ° to 100° — is employed for various 
 purposes, notably for a derivative action ; to cause diapho- 
 resis, to relieve nervous irritability, and to promote sleep. 
 Whether a full bath or merely a foot-bath be required, five 
 minutes is a sufficient time for immersion; then, with or 
 without drying, according to the degree of sweating desir- 
 able, the whole body, or only the feet and legs in case of 
 a foot-bath, must be enveloped in a blanket, and the child 
 put to bed. To render these baths more stimulating, from 
 a teaspoonful to a tablespoonful of mustard flour may be 
 added, and the child held in the water until the arms of the 
 nurse begin to tingle. 
 
 It is important not to continue a hot bath too long, 
 lest the primary stimulating effect be followed by de- 
 pression. Cold baths, by shocking the system, first pro- 
 duce depression ; but this is temporary, and is followed 
 by reaction, during which the skin grows red, and the 
 pulse becomes fuller and stronger. They have, therefore, 
 a general stimulant and tonic action, promoting nutri- 
 tion and giving tone to the body. On account of the 
 shock, the extent of which depends directly upon the 
 coldness of the water, these baths must be used with 
 caution, and are not to be employed in very young or 
 feeble subjects. 
 
THE GENERAL MANAGEMENT OF CHILDREN. 367 
 
 When giving a cold bath, the child must be stripped in a 
 warm room, and thoroughly rubbed with the palm of the 
 hand until the whole body, especially the spinal region, is 
 warm ; he must then stand in a tub containing enough hot 
 water to cover the feet, and be rapidly sponged with the 
 cold water. The temperature of the latter must never be 
 below 6o°, and the addition of half an ounce of sea-salt or 
 a tablespoonful of concentrated sea-water to the gallon, 
 renders it more stimulating and insures a complete reac- 
 tion. After the sponging, the surface must be thoroughly 
 and quickly dried with a soft towel and shampooed with 
 the open hand until aglow. 
 
 The cooled bath may be employed with advantage in 
 extreme conditions of hyperpyrexia. The child is first 
 immersed in water at 95 °, and this is gradually lowered to 
 70 by the addition of cold water, the process occupying 
 from fifteen to thirty minutes. 
 
 Various medicated baths are employed. Of these the 
 most useful are : — 
 
 The Mustard Bath. 
 
 Take from two drachms to one ounce of powdered mustard ; hot water, two 
 to four gallons. 
 
 Derivative in form of foot-bath ; stimulant as general bath. 
 
 Salt-Water Bath. 
 
 Take two ounces of rock salt, or Tidman's sea-salt, or concentrated sea- 
 water (best) ; water (hot or cold, according to season), four gallons. 
 
 General bath, to be used every morning in chronic tuberculosis, scrofula, 
 rickets and general debility. Bath to be followed by thorough rubbing of the 
 surface, especially over the spine. 
 
 Bran Bath. 
 
 Take one pint of bran, tie up in a muslin bag, place in a quart of water, 
 boil for an hour, squeeze bag thoroughly into the water ; add to four gallons 
 of warm water. 
 
 Useful in eczema and skin diseases. 
 
368 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Nitro- Muriatic Acid Bath. 
 
 Take muriatic acid; one fluidrachm; nitric acid, two fluidrachms ; warm 
 water, four gallons. 
 
 Serviceable in hepatic sluggishness. Make bath in a wooden tub. May be 
 employed as a foot or general bath. 
 
 Mercurial Bath. 
 
 R . Hydrarg. Chlorid. Corros., gr. v. 
 
 Alcohol, f-^ij- 
 
 Aq. Dest., f^j. 
 
 M. 
 
 S. — Add to four gallons of water. Employed in syphilitic 
 skin diseases. 
 
 Soda Bath. 
 
 Take half an ounce of bicarbonate of sodium ; warm water, four gallons. 
 Used in skin affections. 
 
 Astringent Bath. 
 
 Take one pound of oak bark, one quart of water, boil for half an hour, 
 strain and add to four gallons of warm water. 
 
 3. Clothing. 
 
 Infants and young children have little power of resisting 
 cold, and on this account require warm clothing. Too much 
 cannot be said in condemnation of the fashion of allowing 
 children to go, even while in the house, with bare legs and 
 knees. 
 
 Every child is supplied with a certain amount of nerve 
 force to be daily expended in the maintenance of the differ- 
 ent functions of the body — respiration, circulation, diges- 
 tion, calorification, etc. If an excessive proportion of this 
 force be consumed in keeping up the heat of the body, as 
 is the case when so much is left bare, the other functions, 
 especially the digestive, must suffer in consequence. 
 
 During the oppressive heat of summer, the legs may be 
 left uncovered ; but throughout the rest of the year, the 
 whole body must be encased in woolen underclothing. The 
 
THE GENERAL MANAGEMENT OF CHILDREN. 369 
 
 thickness of this must vary, of course, with the season.* 
 Providing this be done, the outer clothing may be left to 
 the taste of the mother; but all garments should fit loosely, 
 that the functions of the different viscera may not be impeded 
 by pressure. 
 
 The best pattern of a winter night-dress is a long, plain 
 slip, with a drawing-string at the bottom, to prevent exposure 
 of the feet and limbs, should the child kick off the bed- 
 covering. This should be made of flannel, or, the more 
 easily washed, Canton flannel. In summer, a loose muslin 
 one may be put on, without the drawing-string. A flannej. 
 under-vest should always be worn at night, light gauze in 
 summer and heavier wool in winter; care must be taken, 
 however, to have one for night alone, discarding that worn 
 in the daytime. 
 
 In infants under a year old, a broad flannel abdominal 
 bandage, extending from the hips well up to the thorax, or, 
 better still, a knitted worsted band shaped to fit the form, 
 is very useful in keeping the abdominal organs warm, aiding 
 digestion, and preventing pain. 
 
 All clothing should be changed sufficiently frequently to 
 insure cleanliness. 
 
 Shoes must be large, well shaped and made of soft leather, 
 with pliable soles, so as to allow the feet to grow freely. 
 
 When dressing a child for exercise in the open air in cold 
 weather, the outer clothing must not be put on until just be- 
 fore leaving the house, and removed immediately on return. 
 
 It is important to protect the head from cold in winter by 
 a close-fitting, thick cap; and from the direct rays of the sun 
 in summer by a broad-brimmed, light straw hat. 
 
 * Drawers, especially adapted for children wearing diapers, can be obtained 
 of the Dress Reform Association. These are made in two pieces, that they 
 may not become wet or soiled. 
 24 
 
370 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 Rubber shoes are necessary in wet weather to keep the 
 feet warm and dry while walking out of doors. 
 
 4. Sleep. 
 
 For some time after birth, infants spend the intervals 
 between being fed, washed and dressed in sleep, and thus 
 pass fully eighteen out of the twenty-four hours. As age 
 advances, the amount of sleep required becomes less, until 
 at two years thirteen hours, and at three years eleven hours, 
 are enough. Any marked diminution in the length of sleep 
 or decided restlessness indicate disease, and demand atten- 
 tion from the physician. This matter, though, is, perhaps, 
 more a question of training than any other item of nursery 
 regimen, and many a mother, by want of judicious firmness, 
 has rendered the early years of her child's life not only a 
 burden to himself, but an annoyance to the entire house- 
 hold. 
 
 One cannot too soon begin to form the good habit of 
 regularity in sleeping hours, and so far as circumstances 
 will admit, the following rules may be enforced : — 
 
 From birth to the end of the sixth or eighth month, the 
 infant must sleep from 1 1 p.m. to 5 a.m., and as many hours 
 during the day as nature demands and the exigencies of 
 feeding, washing and dressing will permit. 
 
 From eight months to the end of two and a half years, a 
 morning nap should be taken, from 12 m. to 1.30 or 2 p.m., 
 the child being undressed and put to bed. The night's rest 
 must begin at 7 p.m. If a late meal be required, the child 
 can be taken up at about ten o'clock, but if past the age 
 for this, he may sleep undisturbed until he wakes of his 
 own accord, some time between 6 and 8 a.m. 
 
 From two and a half to four years, an hour's sleep may 
 or may not be taken in the morning, according to the dis- 
 
THE GENERAL MANAGEMENT OF CHILDREN. 37 I 
 
 position of the subject; but in every case the bed must be 
 occupied from 7.30 p.m. to six or seven o'clock on the fol- 
 lowing morning. 
 
 After the fourth year, few children will sleep in the day- 
 time; they are ready for bed by 8 p.m., and should be 
 allowed to sleep for ten hours or more. 
 
 A later retiring hour than 9 p.m. ought not to be encour- 
 aged until after the twelfth or fifteenth year. 
 
 When feasible, different rooms should be used for the day 
 nursery and the sleeping apartment. The latter should be 
 large, airy, well ventilated, so situated as to be exposed for 
 a certain period each day to the direct rays of the sun, and 
 provided with an open fire-place — for wood, preferably — 
 which serves for both heating and ventilating. It should 
 contain a bed for the nurse and a crib for the child, and be 
 without curtains, heavy hangings or superfluous furniture. 
 A stationary washstand draining into a sewer is not to be 
 permitted in the room, neither should it communicate with 
 a bath-room. Soiled diapers or chamber utensils are to be 
 removed at once, no matter what the time of night. The 
 day nursery should have large windows, protected by blinds, 
 and a southwestern exposure ; all other requisites, with the 
 exception of beds, are the same as in the sleeping room. 
 It is very convenient to have the two chambers adjoining, 
 but capable of entire separation by a door, so that one 
 may be thoroughly aired without chilling the other. This 
 arrangement, too, renders it practicable, by standing the door 
 open and raising the windows in the day nursery, to keep 
 the dormitory cool in hot weather without exposing the 
 child to currents of air. 
 
 If an apartment has to be occupied during both the day 
 and night, it must be vacated for half an hour or more in 
 the evening and well aired before the child is put back to bed. 
 
372 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 
 
 The temperature of the rooms must be as uniform as 
 possible, the proper degree of heat being from 68° to yo° F. 
 
 The crib should have high sides, to prevent the child 
 from falling out and injuring himself, and should be pro- 
 vided with springs and a soft hair mattress, protected 
 by a gum cloth, placed under a double sheet. The bed- 
 clothes must be light in weight, while varying in warmth 
 according to the weather; it is just as important to insist 
 upon cleanliness here as in the clothing of the body. 
 
 5. Exercise. 
 
 A certain amount of muscular exercise is necessary for 
 development and for the proper performance of the digestive 
 functions. Infants, before they are able to stand, will use 
 their muscles sufficiently if, when loosely clad, they are 
 placed upon their backs in a bed and allowed to kick and 
 turn about at pleasure. After the age of nine or ten months, 
 a healthy child will begin to creep ; at the end of a year, 
 he will make efforts at standing, and from four to eight 
 months later, will be able to walk by himself; children, how- 
 ever, present great differences in this respect, and a delay of 
 a few months must not be considered as abnormal. So soon 
 as efforts at creeping are made, there need be no fear that 
 insufficient exercise will be taken; the care should be rather 
 to prevent over-fatigue. 
 
 Fresh air and sun-light are as necessary as muscular 
 exercise. The child must be taken out of doors every 
 day, weather permitting, after arriving at the proper age ; 
 this is four months for children born in the early fall and 
 winter, and one month for those born in summer. 
 
 In cool weather, babies who are unable to walk should 
 be taken out in a coach, or in the nurse's arms, for an hour 
 in the morning and half an hour in the afternoon, while the 
 
THE GENERAL MANAGEMENT OF CHILDREN. 373 
 
 sun is shining. In summer, they may pass the greater part 
 of the waking hours in the open air, provided they be well 
 protected from the direct rays of the sun. 
 
 Children old enough to walk may spend a longer time in 
 the air in winter, and may be out all day in summer. But 
 until the fourth year, it is better to let them play about at 
 will than take a long set walk. 
 
 Until well advanced in childhood, the house is the safest 
 place in damp and rainy weather, when there is a strong 
 east or north wind blowing, and when the thermometer 
 stands below 15 . 
 
INDEX. 
 
 Abdomen, examination of, 44. 
 Abnormal dentition, 87. 
 
 depression of temperature, 41. 
 Abscess of liver, 298. 
 
 retropharyngeal, 119. 
 Absorption of fat, 43. 
 Accelerated breathing, 36. 
 Accumulation, faecal, 47. 
 Acute gastric catarrh, 122-125. 
 intestinal catarrh, 152-160. 
 Affections of the gastro-intestinal mu- 
 cous membrane, tongue in, 57. 
 of the mouth and throat, 59. 
 of the stomach and intestines, 12-2. 
 Age in etiology of aphthous stomatitis, 
 62. 
 of entero-colitis, 162. 
 of gangrenous stomatitis, 73. 
 of parasitic stomatitis, 79. 
 of stomatitis, 60. 
 of ulcerative stomatitis, 67. 
 Alae nasi, dilatation of, 22. 
 
 of nose, thick, 23. 
 Alar chest, 49. 
 Alterations of percussion sound, 55. 
 
 of pulse, 39. 
 Amyloid liver, 287-290. 
 Anaemia, 41. 
 Anaemic children, irregularity of pulse 
 
 in > 39- 
 Anatomical lesions of acute gastric ca- 
 tarrh, 123. 
 
 of aphthous stomatitis, 62. 
 
 of catarrhal stomatitis, 59. 
 
 of simple pharyngitis, 103. 
 
 of ulcerative stomatitis, 67. 
 Anterior fontanelle, 43. 
 Aphthae, 57, 62. 
 Aphthous stomatitis, 62-67. 
 Ascaris lumbricoides, 249. 
 Ascites, 322-327. 
 Asthma, 37. 
 
 Atrophy, 41. 
 
 a result of difficult dentition, 91 
 
 general, skin in, 44. 
 
 simple, 211. 
 Attendants, questioning the, 18. 
 Auscultation, 50. 
 
 B. 
 
 Barrel-shaped abdomen, 46. 
 
 chest, 49. 
 Bathing, 365-368. 
 Beef tape-worm, 251. 
 Bilious habit, 285. 
 Bladder, distension of, 46. 
 Blood in stools, 31. 
 Blueness of face, 27. 
 
 of finger nails, 27. 
 Brain, irregularity of pulse in, 39. 
 Brazen cough, 30. 
 
 cry, 29. 
 Breathing, accelerated, 36. 
 
 difficult, 37. 
 
 diminished frequency of, 36. 
 
 labored, 37. 
 
 puerile, 50. 
 
 tidal, 7,6. 
 Broadness of bridge of nose, 24. 
 Bronchial catarrh, 37. 
 Brows, contraction of, 22. 
 Bulging of fontanelle, 43. 
 
 Cardiac dulness, position of, 54. 
 
 oedema, 44. 
 
 sounds, 52. 
 Caseation of the mesenteric glands, 45. 
 Caseous degeneration and tuberculosis 
 of the mesenteric glands, 266- 
 274. 
 Catarrh, bronchial, 30. 
 Catarrhal jaundice, 280. 
 
 stomatitis, 59-61. 
 
 375 
 
376 
 
 INDEX. 
 
 Cessation of respiratory movements, 49. 
 
 Cestodes, 248. 
 
 Cheek, circumscribed flush on, 27. 
 
 Chest, examination of, 47. 
 
 Chewing motions of jaw, 22. 
 
 Cheyne-Stokes' respiration, 36. 
 
 Child, inspecting the, 21. 
 
 Choked cough, 30. 
 
 Cholera infantum, 41, 47, 1 88-194. 
 
 Chorea, 26. 
 
 Chronic diarrhoea, 161. 
 
 entero- colitis, 161-175. 
 
 gastric catarrh, 126-135. 
 
 hydrocephalus, 24, 43. 
 
 intestinal catarrh, 161-175. 
 
 intussusception, 240. 
 
 vomiting, 126. 
 Circumscribed flush on cheek, 27. 
 
 peritonitis, 46. 
 Cirrhosis of the liver, 292-297. 
 Clay-colored stools, 31. 
 Clonic contraction of the muscles, 26. 
 Closure of the anterior fontanelle, 43. 
 Clothing, 368-370. 
 
 in chronic gastric catarrh, 134. 
 Clubbing of finger tips, 27. 
 Coarse hair, 23. 
 Colic, 26, 82, 201-204. 
 Collapse, 41. 
 
 skin in, 44. 
 Collection of gas, 46. 
 Commencing hip-joint disease, 42. 
 Complexion, doughy, 23. 
 Conditions of the skin, 43. 
 Confluent aphthous stomatitis, 64. 
 Congestion of the liver, 281-285. 
 Conjunctivae, yellow hue of, 27. 
 Conjunctival blenorrhcea during den- 
 tition, 89. 
 Constipation, habitual, 205. 
 
 in habitual indigestion, 139. 
 Constitutional syphilis, 24, 43. 
 Contraction of the brows, 22. 
 Convulsion, a, 26. 
 Convulsions during dentition, 100. 
 
 in chronic diarrhoea, 165. 
 Cough, 30. 
 
 Course of catarrhal stomatitis, 60. 
 Croupous pneumonia, signs of, 50. 
 Crusta lactea, 95. 
 Cry from intestinal pain, 29. 
 
 Cry, hydrencephalic, 29. 
 
 in pleuritis, 29. 
 
 the, 28. 
 Crying, incessant, 29. 
 
 while coughing, 29. 
 Cyanosis of hand, 27. 
 Cysticercus cellulosse, 253. 
 
 D. 
 
 Death agony, 41. 
 
 Deformity of the nails, 27. 
 
 Degree of elevation of the temperature, 
 
 40. 
 Delayed dentition, 58, 87. 
 Delay in walking, 42. 
 Delicate features, 23. 
 Dental paralysis, 102. 
 Dentition, 86-103. 
 
 irregular and faulty, 58. 
 Depression of anterior fontanelle, 43. 
 Description of aphthous stomatitis, 62. 
 
 of catarrhal stomatitis, 59. 
 
 of eczema, 93. 
 
 of follicular tonsillitis, 108. 
 
 of gangrenous stomatitis, 72. 
 
 of parasitic stomatitis, 79. 
 
 of simple pharyngitis, 103. 
 
 of suppurative tonsillitis, 1 12. 
 
 of ulcerative stomatitis, 67. 
 Diagnosis of acute gastric catarrh, 124. 
 
 of acute intestinal catarrh, 156. 
 
 of amyloid liver, 288. 
 
 of aphthous stomatitis, 64. 
 
 of ascites, 324. 
 
 of cholera infantum, 191. 
 
 of chronic entero-colitis, 167. 
 gastric catarrh, 130. 
 
 of cirrhosis of the liver, 296. 
 
 of dysentery, 196. 
 
 of entero-colitis, 180. 
 
 of fatty infiltration of the liver, 286. 
 
 of follicular tonsillitis, no. 
 
 of gangrenous stomatitis, 76. 
 
 of habitual constipation, 206. 
 indigestion, 140. 
 
 of intussusception, 240. 
 
 of mucous disease, 144. 
 
 of parasitic stomatitis, 8^. 
 
 of peritonitis, 311. 
 
 of perityphlitis, 225. 
 
INDEX. 
 
 377 
 
 Diagnosis of simple atrophy, 217. 
 pharyngitis, 105. 
 of suppurative tonsillitis, 114. 
 of syphilitic inflammation of the 
 
 liver, 291. 
 of tabes mesenterica, 270. 
 of tubercular peritonitis, 319. 
 of typhlitis, 225. 
 of ulcerative stomatitis, 70. 
 of worms, 257. 
 Diagram of the eruption of the milk 
 
 teeth, 86. 
 Diarrhoea, chronic, 161. 
 inflammatory, 175. 
 loss of fat in, 43. 
 simple, 152. 
 
 during dentition, 90. 
 Diathesis, strumous, 23. 
 Diet for ascites, 326. 
 
 for chronic gastro-intestinal catarrh, 
 
 146. 
 for tabes mesenterica, 272. 
 for tubercular peritonitis, 320. 
 for ulcerative stomatitis, 70. 
 Differential diagnosis of aphthous and 
 parasitic stomatitis, 83. 
 of aphthous and ulcerative 
 
 stomatitis, 64. 
 of chronic entero colitis and 
 
 tuberculous diarrhoea, 167. 
 of chronic gastric catarrh 
 and tubercular meningitis, 
 
 131. 
 
 of follicular tonsillitis and 
 diphtheria, no. 
 
 of gangrenous and ulcerative 
 stomatitis, 76. 
 
 of gangrenous stomatitis and 
 malignant pustule, 77. 
 
 of intussusception and dysen- 
 tery, 241. 
 
 of intussusception and faecal 
 accumulation, 241. 
 
 of intussusception and perfo- 
 rative peritonitis, 241. 
 
 of intussusception and simple 
 colic, 241. 
 
 of intussusception and typh- 
 litis, 226. 
 
 of simple pharyngitis and 
 diphtheria, 105. 
 
 Differential diagnosis of simple pharyn- 
 gitis and scarlatinal pharyn- 
 gitis, 105. 
 of thrush and aphthous stoma- 
 titis, 64. 
 of tubercular peritonitis and 
 
 typhoid fever, 320. 
 of typhoid fever and tubercu- 
 lar peritonitis, 320. 
 Difficult breathing, 37. 
 
 dentition, 88. 
 Dilatation of alas nasi, 22. 
 Diminished frequency of breathing, 36. 
 Diminution of rate of pulse, 39. 
 Discoloration of forehead, 27. 
 Disease, features of, 21. 
 investigation of, 17. 
 of heart, 41. 
 Diseases of the lungs, 41. 
 Distension, drum-like, of the abdomen, 
 46. 
 of abdomen, 45. 
 of bladder, 46. 
 Doughy complexion, 23. 
 Drawing of upper lip, 22. 
 Drum-like distension of the abdomen, 
 
 46. 
 Dryness of the skin, 44. 
 Dulness of the liver, 46. 
 Duration of aphthous stomatitis, 64. 
 of catarrhal stomatitis, 64. 
 of elevation of temperature, 40. 
 of parasitic stomatitis, 81. 
 of red gum, 93. 
 of simple pharyngitis, 104. 
 of ulcerative stomatitis, 70. 
 of white gum, 93. 
 Dysentery, 47, 194-198. 
 Dyspnoea, expiratory, 37. 
 
 in hypertrophy of the tonsils, 1 17. 
 inspiratory, 37. 
 
 Earache, 29. 
 
 Earthy tinge of face, 27. 
 
 Eczema, 93. 
 
 Effusion of pleurisy, 49. 
 
 Egg of ascaris lumbricoides, 249. 
 
 of oxyuris vermicularis, 249. 
 
 of toenia saginata, 251. 
 
378 
 
 INDEX. 
 
 Egg of tricocephalus dispar, 250. 
 Elevation of temperature, 40. 
 Emphysema, chest in, 49. 
 
 signs of, 50. 
 Emphysematous air vesicles, 37. 
 En chien de fusil, 25. 
 Enema for convulsions, 101. 
 
 for habitual constipation, 206. 
 Enlarged spleen, 46. 
 Enlargement of left ventricle, 49. 
 
 of liver, 46. 
 
 of right ventricle, 49. 
 
 of spleen, 46. 
 
 of superficial abdominal veins, 43. 
 
 of superficial lymphatic glands, 44. 
 Enteritis follicular, 47. 
 Entero-colitis, 41, 175-188. 
 
 stools of, 32. 
 Eruptions, 44. 
 
 on palate and fauces, 57. 
 Etiology of acute intestinal catarrh, 
 
 of amyloid liver, 287. 
 
 of aphthous stomatitis, 52. 
 
 of ascites, 322. 
 
 of catarrhal stomatitis, 59. 
 
 of cholera infantum, 189. 
 
 of chronic entero-colitis, 161. 
 
 of chronic gastric catarrh, 126. 
 
 of cirrhosis of the liver, 294. 
 
 of colic, 201. 
 
 of congestion of the liver, 282. 
 
 of dysentery, 195, 
 
 of entero-colitis, 176. 
 
 of fatty degeneration of the liver, 
 
 286. 
 of fatty infiltration of the liver, 
 
 285. 
 of follicular tonsillitis, 108. 
 of gangrenous stomatitis, 73. 
 of habitual constipation, 205. 
 of habitual indigestion, 136. 
 of hypertrophy of the tonsils, 116. 
 of intussusception, 234. 
 of mucous disease, 141. 
 of parasitic stomatitis, 79. 
 of peritonitis, 307. 
 of perityphlitis, 222. 
 of simple atrophy, 211. 
 of simple pharyngitis, 103. 
 of tabes mesenterica, 267. 
 
 Etiology of tubercular peritonitis, 316. 
 
 of tubercular ulceration of the in- 
 testines, 199. 
 
 of typhlitis, 222. 
 
 of ulcerative stomatitis, 67. 
 Examination of chest, 47. 
 
 of mouth and fauces, 55. 
 
 physical, 35. 
 Exanthemata in chronic diarrhoea, 165. 
 
 skin in, 44. 
 Excessive moisture of the skin, 44. 
 Exercise, 372, 373. 
 Expiratory dyspnoea, 37. 
 
 respiration, 36. 
 Eyeballs, oscillation of, 22. 
 Eyelashes, long and curving, 23. 
 Eyelids, lividity of, 27. 
 
 puffiness of, 23. 
 
 reddened, 23. 
 
 Face, blueness of, 27. 
 
 earthy tinge of, 27. 
 
 lesions of eruptive fevers on, 27. 
 
 lower third of, 22. 
 
 middle third of, 22. 
 
 oval, 23. 
 
 round and heavy, 23. 
 
 the, 21. 
 
 upper third of, 22. 
 Facies in parasitic stomatitis, 8^. 
 Faecal accumulation, 46. 
 
 evacuations, 30. 
 Fat, absorption of, 43. 
 Fatty infiltration of the liver, 285. 
 
 liver, 285, 286. 
 Fauces, examination of, 55. 
 
 the, 57. 
 Features, delicate, 23. 
 
 of disease, 21. 
 Febrile oscillations, 40. 
 
 state, frequency of pulse in, 39. 
 skin in, 44. 
 Feeding, 329-365. 
 
 in aphthous stomatitis, 64. 
 Fever, 40. 
 
 tongue in, 57. 
 Fine hair, 23. 
 
INDEX. 
 
 379 
 
 Finger ends, glossy, in scarlatinal ne- 
 phritis, 27. 
 
 nails, blueness of, 27. 
 
 tips, clubbing of, 27. 
 Flat chest, 49. 
 Flatulence, 45. 
 Follicular enteritis, 47. 
 
 tonsillitis, 108-m. 
 Fontanelle, anterior, 43. 
 Food for chronic gastric catarrh, 132. 
 Forehead, discoloration of, 27. 
 Formula? for food in chronic entero- 
 colitis, 169. 
 
 in colic, 203. 
 
 in entero-colitis, 183. 
 
 in habitual constipation, 208. 
 
 in infancy, 157. 
 Fremitus, vocal, 52. 
 Frequency of pulse, ^8. 
 Fretful crying, 29. 
 Friction sound of pleuritis, 50. 
 Fulness of bridge of the nose, 23. 
 Furrow, genal, 23. 
 
 labial, 23. 
 
 nasal, 23. 
 
 oculo-zygomatic, 22. 
 
 Gangrene, 70. 
 
 of mouth, 57. 
 Gangrenous stomatitis, 72-79. 
 Gas, collections of, 46. 
 Gastric tympany, 54. 
 Genal furrow, 23. 
 General atrophy, skin in, 44. 
 
 debility, 42. 
 
 management of children, 329-373. 
 
 peritonitis, 46. 
 Gestures, 25. 
 Glazed tongue, 142. 
 Globular head, 24. 
 Glossy finger ends, 27. 
 Grave pyrexia, 40. 
 Gross differences in temperature, 41. 
 Growth of child, 41. 
 
 H. 
 
 Habitual constipation, 205-2: 
 Hair, coarse, 23. 
 fine, 23. 
 
 Hand, cyanosis of, 27. 
 Hard palate, 57. 
 Head, globular, 24. 
 
 square, 24. 
 Heart, irregularity of, 39. 
 
 oedema in affections of, 44. 
 Flemorrhage, 41. 
 Hepatic oedema, 44. 
 Hepatitis, suppurative, 298. 
 Herpetic vesicles on lips, 27. 
 High-colored urine, ^. 
 Hip-joint disease, 42. 
 Hoarse cough, 30. 
 Hoarseness, 29. 
 Hunger, 29. 
 
 Hydrencephalic cry, 29. 
 Hydrocephalus, 43. 
 
 chronic, 24. 
 Hypostatic pneumonia, 165. 
 
 Icterus, 275. 
 
 in older children, 280. 
 
 neonatorum, 276. 
 Idiopathic acute gastric catarrh, 123. 
 Imperfect digestion, stools of, 31. 
 Impulse in emphysema, 49. 
 Inaudible cry, 29. 
 Incessant crying, 29. 
 Incomplete closure of the lids, 21. 
 Increased frequency of the pulse, 39. 
 
 heat, 41. 
 Indigestion, habitual, 136. 
 
 stools of, 31. 
 Infantile paralysis, 42. 
 Inflammation of the colon and rectum. 
 194-198. 
 
 of the lungs or pleura, 27. 
 
 of the mouth, 57. 
 Inflammatory diarrhoea, 175. 
 Inherited syphilis, 27. 
 Inspection of the abdomen, 45. 
 
 of the chest, 48. 
 Inspiratory dyspnoea, ^7- 
 Insufficient nourishment, 41. 
 Intensity of puerile breathing, 50. 
 Intestinal catarrh, chronic, 1 61. 
 stools of, 31. 
 
 pain, cry of, 29. 
 
 worms, 248-265. 
 
38o 
 
 INDEX. 
 
 Introduction, 17-58. 
 Intussusception, 230-247. 
 Invagination, 230. 
 Investigation of disease, 17. 
 Irregular appearance of teeth, 88. 
 
 dentition, 58. 
 Irregularity of pulse, 38. 
 Irritability of pulse, 38. 
 
 J- 
 
 Jadelot's furrows, 22. 
 Jaundice, 27, 275-281. 
 
 diminution of rate of pulse in, 39. 
 Jerky movements, 26. 
 Joints, swelling of, 44. 
 
 K. 
 
 Kidneys, cedema in affections of, 44. 
 
 Labial furrow, 23. 
 Labored breathing, 37. 
 Lancing the gums, 102. 
 Laryngeal obstruction, 37. 
 Left ventricle, enlargement of, 49. 
 Length of child at birth, 41. 
 Lesions, anatomical, of aphthous sto- 
 matitis, 62. 
 
 of catarrhal stomatitis, 59. 
 
 of eruptive fevers on face, 27. 
 
 of ulcerative stomatitis, 67. 
 Lice in eczema, 95. 
 Lids, incomplete closure of, 21. 
 
 twitching of, 22. 
 Lips, herpetic vesicles on, 27. 
 
 lividity of, 27. 
 
 pursing out of, 22. 
 
 upper, drawing of, 22. 
 
 upper, swollen, 23. 
 Liver, 45. 
 
 abscess of, 298. 
 
 amyloid, 287. 
 
 cancer of, 305. 
 
 cirrhosis of, 292. 
 
 congestion of, 281. 
 
 dulness, 46, 54. 
 
 enlargement of, 46. 
 
 fatty, 285. 
 
 hy dated disease of, 305. 
 
 Liver, cedema in affections of, 44. 
 
 syphilitic inflammation of, 291. 
 
 tuberculosis of, 305. 
 Lividity of eyelids and lip, 27. 
 Local affections in difficult dentition, 
 
 88. 
 Localized distension of abdomen, 46. 
 Lower third of face, 22. 
 Lumbrici, 250. 
 Lungs, inflammation of, 27. 
 Lymphatic glands, enlargement of, 44. 
 
 M. 
 
 Malarial fevers, 27. 
 Management of children, 329. 
 Marasmus, 211. 
 
 a result of difficult dentition, 91. 
 skin in, 44. 
 Meningitis tubercular, 47. 
 Mesenteric glands, caseation of, 45. 
 
 caseous degeneration of, 266. 
 
 tuberculosis of, 266. 
 Micturition, painful, t,t,. 
 Middle third of face, 22. 
 Milk teeth, 56. 
 Moderate pyrexia, 40. 
 Modifications of skin in disease, 43. 
 Morbid anatomy of amyloid liver, 287. 
 
 of cholera infantum, 188. 
 
 of chronic entero- colitis, 161. 
 
 of chronic gastric catarrh, 
 126. 
 
 of cirrhosis of the liver, 293. 
 
 of congestion of the liver, 
 282. 
 
 of dysentery, 194. 
 
 of entero-colitis, 175. 
 
 of fatty degeneration of the 
 liver, 286. 
 
 of fatty infiltration of the 
 liver, 285. 
 
 of gangrenous stomatitis, 75. 
 
 of intussusception, 231. 
 
 of parasitic stomatitis, 80. 
 
 of peritonitis, 306. 
 
 of perityphlitis, 220. 
 
 of simple atrophy, 211. 
 
 of suppurative tonsillitis, 112. 
 
 of syphilitic inflammation of 
 the liver, 291. 
 
INDEX. 
 
 381 
 
 Morbid anatomy of tabes mesenterica, 
 266. 
 of tubercular peritonitis, 315. 
 of tubercular ulceration of the 
 
 intestines, 199. 
 of typhlitis, 220. 
 Morbus caeruieus, 27. 
 Motor paralysis, 26. 
 Mouth, contraction of muscles about 
 the, 22. 
 examination of, 55. 
 in catarrhal stomatitis, 61. 
 Movements, jerky, 26. 
 Mucous disease, 140. 
 skin in, 43. 
 membrane, oral, 55. 
 Mucus, vomiting of, 34. 
 Muscles, clonic contraction of, 26. 
 
 wasting of, 43. 
 Mustard foot-bath, 106. 
 
 N. 
 
 Nails, deformity of, 27. 
 
 redness about, 27. 
 Nasal cry, 29. 
 
 furrow, 23. 
 Nematodes, 248. 
 Nephritis, diminution of rate of pulse 
 
 in, 39- 
 Nervous children, irregularity of pulse 
 
 in, 39- 
 Noma, 72-79. 
 
 Non-inflammatory diarrhoea, 152. 
 Nose, bridge of, broadness of, 24. 
 
 fulness of bridge, 23. 
 
 rubbing the, 26. 
 Nostrils, sharpness of, 22. 
 
 wide, 23. 
 
 Obstruction, laryngeal, 37. 
 Oculo- zygomatic furrow, 22. 
 GEdema, 44. 
 Offensive stools, 32. 
 Oidium albicans, 79. 
 Oral mucous membrane, 55. 
 
 respiration, 37. 
 Oscillation of eyeballs, 22. 
 
 of temperature, 40. 
 
 Otitis during dentition, 90. 
 
 Oval face, 23. 
 
 Oxyuris vermicularis, 248. 
 
 Painful micturition, 2>3- 
 
 Pain in habitual indigestion, 139. 
 
 Palate, the, 57. 
 
 Paleness, 27. 
 
 Pallor, waxy, 27. 
 
 Palpation of the abdomen, 44. 
 
 of the chest, 52. 
 Paralysis, dental, 102. 
 
 infantile, 42. 
 Parasitic stomatitis, 79-85. 
 Parenchymatous nephritis, diminution 
 
 of rate of pulse in, 39. 
 Paroxysmal cough, 30. 
 Pathognomonic sign of caseation of the 
 
 mesenteric glands, 45. 
 Pathology of gangrenous stomatitis, 75. 
 Percussion of the abdomen, 44. 
 
 of the chest, 53. 
 
 over enlarged mesenteric glands, 
 46. 
 Peritonitis, 306-314. 
 
 circumscribed, 46. 
 
 general, 46. 
 
 tubercular, 314. 
 Perityphlitis, 220-230. 
 Permanent teeth, 56. 
 Pharyngitis, simple, 103. 
 Pharynx, the, 57. 
 Photophobia, 25. 
 Physical examination, 35. 
 Pitch in puerile breathing, 5 1 . 
 Plan of conducting investigation of dis- 
 ease, 18. 
 Pleura, inflammation of, 27. 
 Pleurisy, effusion of, 49. 
 Pleuritis, chest in, 49. 
 
 cry in, 29. 
 
 friction sound of, 50. 
 Pneumonia, 27, 29. 
 
 breathing in, 36. 
 Pork tape- worm, 251. 
 Position of apex beat, 49. 
 
 of cardiac dulness, 54. 
 Prsecordial dulness, 55. 
 Premature appearance of the teeth, 87. 
 
382 
 
 INDEX. 
 
 Prescription for acute gastric catarrh, 
 124. 
 
 for amyloid liver, 289. 
 
 for aphthous stomatitis, 66. 
 
 for ascites, 325. 
 
 for catarrhal stomatitis, 61. 
 
 for cholera infantum, 193. 
 
 for chronic entero-colitis, 172. 
 
 for chronic gastric catarrh, 135. 
 
 for chronic gastro-intestinal catarrh, 
 149. 
 
 for cirrhosis of the liver, 297. 
 
 for colic, 203. 
 
 for dysentery, 197. 
 
 for eczema, 96, 100. 
 
 for entero-colitis, 184. 
 
 for follicular tonsillitis, no. 
 
 for habitual constipation, 209. 
 
 for hypertrophy of the tonsils, 1 18. 
 
 for intussusception, 243. 
 
 for parasitic stomatitis, 85. 
 
 for peritonitis, 314. 
 
 for prevention of perityphlitis, 227. 
 
 for prevention of typhlitis, 227. 
 
 for simple pharyngitis, 106. 
 
 for suppurative tonsillitis, 115. 
 
 for syphilitic inflammation of the 
 liver, 292. 
 
 for tubercular peritonitis, 321. 
 
 for tubercular ulceration of the in- 
 testines, 200. 
 
 for ulcerative stomatitis, 71. 
 
 for urticaria, 92. 
 
 for vomiting during dentition, 91. 
 
 for worms, 258. 
 Prognosis of acute gastric catarrh, 124. 
 
 of acute intestinal catarrh, 156. 
 
 of amyloid liver, 289. 
 
 of ascites, 325. 
 
 of cholera infantum, 192. 
 
 of chronic entero-colitis, 167. 
 
 of chronic gastric catarrh, 131. 
 
 of cirrhosis of liver, 296. 
 
 of congestion of liver, 284. 
 
 of dysentery, 196. 
 
 of entero-colitis, 181. 
 
 of fatty infiltration of the liver, 286. 
 
 of follicular tonsillitis, no. 
 
 of gangrenous stomatitis, 77. 
 
 of habitual constipation, 206. 
 
 of habitual indigestion, 140. 
 
 Prognosis of intussusception, 242. 
 
 of mucous disease, 145. 
 
 of parasitic stomatitis, 83. 
 
 of peritonitis, 313. 
 
 of perityphlitis, 226. 
 
 of simple atrophy, 218. 
 
 of syphilitic inflammation of the 
 liver, 291. 
 
 of tabes mesenterica, 271. 
 
 of tubercular peritonitis, 320. 
 
 of typhlitis, 226. 
 
 of ulcerative stomatitis, 70. 
 
 of worms, 257. 
 Prognostic value of frequency of the 
 
 pulse, 39. 
 Prolonged rise of temperature, 40. 
 Prophylaxis in gangrenous stomatitis, 
 
 78. 
 Prostration of vital forces, skin in, 44. 
 Protracted diarrhoea, loss of fat in, 43. 
 Puerile breathing, 50. 
 Puffiness of eyelids, 23. 
 Pulsation, transmitted epigastric, 49. 
 Pulse, 38. 
 
 frequency of, 38. 
 
 irregularity of, 38. 
 Pursing out of lips, 22. 
 Pyrexia, 40. 
 
 Q. 
 
 Questioning attendants, 18. 
 
 R. 
 
 Rachitic softening of the ribs, 49. 
 Range of oscillations of temperature, 
 
 40. 
 Rapid rise of temperature, 40. 
 Rash, tooth, 93. 
 Rattling cough, 30. 
 Reddened eyelids, 23. 
 Red gum, 93. 
 
 Redness about the nails, 27. 
 Reduction of temperature, 41. 
 Remission of temperature, 41. 
 Renal diseases, pallor in, 27. 
 
 oedema, 44. 
 Resonance, vocal, 52. 
 Respiration, 35. 
 
 Cheyne-Stokes', 36. 
 
 expiratory, 36. 
 
INDEX. 
 
 383 
 
 Respiration, oral, 37. 
 
 puerile, 51. 
 Respiratory movements, cessation of, 
 
 49. 
 Retarded closure of the anterior fonta- 
 
 nelle, 43. 
 Retraction of the abdomen, 45. 
 
 of the chest, 49. 
 Retropharyngeal abscess, 119-121. 
 Rheumatism, 44. 
 Rhythm in puerile breathing, 51. 
 
 of the pulse, 39. 
 Rickets, 24, 43. 
 
 thorax in, 49. 
 Right ventricle, enlargement of, 49. 
 Rises of temperature, 40. 
 Round face, 23. 
 Round worm, 248. 
 Rubbing of nose, 26. 
 
 Scaphoid abdomen, 47. 
 
 Sclerotic, pearly white or bluish, 23. 
 
 Scolex, 252. 
 
 Scrofula, 44. 
 
 Second summer, 88. 
 
 Serous effusions in chronic entero-coli- 
 
 tis, 165. 
 Severe pyrexia, 40. 
 Shape of chest, 48. 
 Sharpness of the nostrils, 22. 
 Signs of croupous pneumonia, 50. 
 
 of emphysema, 50. 
 Simple atrophy, 211-220. 
 
 diarrhoea, 152. 
 
 during dentition, 90. 
 
 pharyngitis, 103-107. 
 Sinking of anterior fontanelle, 43. 
 Skin, conditions of the, 43. 
 
 of healthy child, 26. 
 
 smooth and transparent, 23. 
 
 yellow hue of, 27. 
 Sleep, 25, 370-372. 
 Slight spasms during dentition, 100. 
 Smoky urine, 33. 
 Smooth and transparent skin, 23. 
 Snuffling, 37. 
 Soft palate, 57. 
 Sour liquid, vomiting of, 34. 
 Spasmodic cough, 30. 
 
 Spasms during dentition, 100. 
 Spleen, the, 45. 
 
 enlargement of, 46. 
 Splenic dulness, 54. 
 Spurious hydrocephalus, 130. 
 Square head, 24. 
 Squinting, 22. 
 Stomatitis, aphthous, 62. 
 
 aphthous, confluent, 64. 
 
 catarrhal, 59. 
 
 gangrenous, 72. 
 
 parasitic, 79. 
 
 ulcerative, 67. 
 Stools in chronic entero-colitis, 162. 
 Strophulus, 92. 
 Strumous diathesis, 23. 
 Sudden fall of temperature, 40. 
 Superficial catarrh of the tonsils, 107, 
 
 108. 
 Suppressed cough, 30. 
 Suppurative hepatitis, 298-305. 
 
 tonsillitis, 112-119. 
 Swelling of joints, 44. 
 Swollen upper lip, 23. 
 Sympathetic effects of difficult denti- 
 tion, 89. 
 Symptoms of acute gastric catarrh, 123. 
 
 of acute intestinal catarrh, 154. 
 
 of amyloid liver, 287. 
 
 of aphthous stomatitis, 62. 
 
 of ascites, 322. 
 
 of catarrhal stomatitis, 60. 
 
 of cholera infantum, 189. 
 
 of chronic entero-colitis, 162. 
 
 of chronic gastric catarrh, 128. 
 
 of cirrhosis of the liver, 294. 
 
 of colic, 202. 
 
 of congestion of the liver, 282. 
 
 of dysentery, 195. 
 
 of eczema, 94. 
 
 of entero-colitis, 178. 
 
 of fatty infiltration of the liver, 
 285. 
 
 of follicular tonsillitis, 108. 
 
 of gangrenous stomatitis, 73. 
 
 of habitual constipation, 205. 
 
 of habitual indigestion, 138. 
 
 of hypertrophy of the tonsils, 116. 
 
 of intussusception, 235. 
 
 of mucous disease, 141. 
 
 of parasitic stomatitis, 81. 
 
3^4 
 
 INDEX. 
 
 Symptoms of peritonitis, 307. 
 
 of perityphlitis, 223. 
 
 of retropharyngeal abscess, 120. 
 
 of simple atrophy, 214. 
 
 of simple pharyngitis, 103. 
 
 of suppurative tonsillitis, 112. 
 
 of syphilitic inflammation of the 
 liver, 291. 
 
 of tabes mesenterica, 268. 
 
 of tubercular peritonitis, 316. 
 
 of tubercular ulceration of the in- 
 testines, 200. 
 
 of typhlitis, 223. 
 
 of ulcerative stomatitis, 68. 
 
 of worms, 254. 
 Syphilis, constitutional, 24, 43. 
 
 inherited, 27. 
 Syphilitic inflammation of the liver, 
 
 291, 292. 
 Systemic exhaustion, 43. 
 
 weakness, 42. 
 
 Tabes mesenterica, 266-274. 
 
 Taenia;, 251. 
 
 Taenia saginata, 251. 
 
 Taenia solium, 253. 
 
 Tears, 30. 
 
 Teeth, 86. 
 
 milk, 56. 
 
 permanent, 56. 
 Temperature in simple pharyngitis, 104. 
 
 the, 39. 
 Tendency, tuberculous, 23. 
 Tenderness of abdomen, 47. 
 Thallus, fibrils, 83. 
 Thick alae of the nose, 23. 
 Thorax in rickets, 49. 
 Thread-worm, 248. 
 Thrombosis of sinuses of the brain in 
 
 chronic diarrhoea, 165. 
 Thrush, 79-85. 
 
 patches, 81. 
 Thumbs drawn into palms, 26. 
 Tidal breathing, 36. 
 Tongue in mucous disease, 142. 
 
 in ulcerative stomatitis, 69. 
 
 the, 56. 
 Tonsillitis, follicular, 108. 
 
 suppurative, 112. 
 
 Tonsils, hypertrophy of, 1 16. 
 
 superficial catarrh of, 107. 
 Tooth rash, 93. 
 
 Transient rise of temperature, 40. 
 Transmitted epigastric pain, 49. 
 Treatment of acute gastric catarrh, 124. 
 
 of acute intestinal catarrh, 156. 
 
 of amyloid liver, 289. 
 
 of aphthous stomatitis, 64. 
 
 of ascites, 325. 
 
 of catarrhal stomatitis, 61. 
 
 of cholera infantum, 192. 
 
 of chronic entero-colitis, 168. 
 
 of chronic gastric catarrh, 131. 
 
 of cirrhosis of the liver, 296. 
 
 of colic, 202. 
 
 of congestion of the liver, 284. 
 
 of convulsions during dentition, 
 101. 
 
 of dental paralysis, 102. 
 
 of dysentery, 196. 
 
 of eczema, 96. 
 
 of entero-colitis, 181. 
 
 of fatty infiltration of the liver, 286. 
 
 of follicular tonsillitis, no. 
 
 of gangrenous stomatitis, 77. 
 
 of habitual constipation, 206. 
 
 of hypertrophy of the tonsils, 117. 
 
 of icterus in older children, 281. 
 
 of intussusception, 242. 
 
 of jaundice, 277. 
 
 of mucous disease, 145. 
 
 of parasitic stomatitis, 84. 
 
 of peritonitis, 313. 
 
 of perityphlitis, 227. 
 
 of retropharyngeal abscess, 121. 
 
 of simple atrophy, 218. 
 
 of simple pharyngitis, 105. 
 
 of spasms, 100. 
 
 of strophulus, 93. 
 
 of suppurative tonsillitis, 1 14. 
 
 of syphilitic inflammation of the 
 liver, 292. 
 
 of tabes mesenterica, 272. 
 
 of tubercular peritonitis, 320. 
 
 of tubercular ulceration of the in- 
 testines, 200. 
 
 of typhlitis, 227. 
 
 of ulcerative stomatitis, 70. 
 
 of urticaria, 92. 
 
 of worms, 257. 
 
INDEX. 
 
 385 
 
 Tricocephalus dispar, 250. 
 Tubercular meningitis, 47. 
 
 peritonitis, 314-322. 
 
 ulceration of the intestines, 19S- 
 201. 
 Tuberculosis of the intestines, skin in, 43. 
 
 of the mesenteric glands, 266. 
 Tuberculous diathesis, chest of, 49. 
 
 tendency, 23. 
 Twitching of lids, 21. 
 Typhlitis, 220-230. 
 
 u. 
 
 Ulceration of fraenum linguae, 88. 
 
 of intestines, stools of, 32. 
 
 of mouth, 57. 
 Ulcerative stomatitis, 67-72. 
 Ulcers, aphthous, 63. 
 
 of tubercular ulceration of the- in- 
 testines, 199. 
 Unwillingness to cry, 30. 
 Upper third of face, 22. 
 Urine, the, 32. 
 Urticaria, 92. 
 Uvula, the, 57. 
 
 Variations of temperature, 40. 
 Ventricles, enlargement of, 49. 
 
 I Visible temporal veins, 23. 
 \ Vocal fremitus, 52. 
 
 resonance, 52. 
 Vomiting, 33. 
 
 during dentition, 93. 
 
 in parasitic stomatitis, 82. 
 
 loss of fat in, 43. 
 
 w. 
 
 Walking age, 42. 
 
 on toes, 42. 
 Wasting of muscles, 43. 
 Watery stools, 31. 
 Waxy pallor, 27. 
 Weight of child at birth, 42. 
 Wet-nurse, 86. 
 Whip- worm, 250. 
 White gum, 93. 
 Wide nostrils, 23. 
 Worm-eaten tongue, 142. 
 Worms, 248. 
 
 in stools, 32. 
 
 in vomit, 34. 
 
 Y. 
 
 Yawning, 37. 
 
 Yellow hue of skin and conjunctiva?, 
 
 27. 
 
33 
 
 1 1 
 
 mi 
 
 ■ 
 
 MB 
 
 
 ISKm 
 
 #&:£# 
 
 HL 
 
 ■H 
 
 _JHfl 
 
 "■ '» 
 
 
 
 5?* 
 
 
 ■ 
 
 ran