>t^J'>^^4 .JZ^ Columbia ©nitirrsttp intljeCitpDfiJfttjgork College of $f)pgiciansi anh burgeons; Eibrarp «',i.' \ '^M- A I ^^'^--^■^ DISEASES OF THE DIGESTIVE ORGANS IN INFANCY AND CHILDHOOD. STARR. By dr. LOUIS STARR THE HYGIENE of the NURSERY. INCLUDING THE GENERAL REGIMEN AND FEEDING OF INFANTS AND CHILDREN AND THE DOMESTIC MANAGEMENT OF THE ORDINARY EMER- GENCIES OF EARLY LIFE. Second Edition. Enlarged and Improved. WITH TWENTY-FIVE ILLUSTRATIONS. 12mo. 280 Pages. Cloth, $1.00. *^* Designed for the use of Parents, Nurses, and all interested in the Care and Management of Children. " The volume is entirely in the modern lines of preventive medi- cine — more important in the nursery than in any other time of life ; because constitution building is going on then and there. Jn this admirable treatise, so clearly written that no mother need be de- terred by fear of medical terms from making its teaching ner own, Dr. Starr carries out the highest ideal of the modern physician, so to regulate the lives of his professional clients that the occasions are less frequent when he need be called in to act for serious com- plications * * * * With the numerous good treatises on the subject that Philadelphia publications include, this intelligent work is the most distinguished, as it is also the latest work on complete Hygiene of the Nursery." — The Ledger, PJiiladelpJiia. " It is addressed to mothers, with the view of giving a series of rules which, applied to the nur.sery, can hardly fail to maintain good health, give vigor to the frame, and so lessen susceptibility to dis- ease. These are so plainly, sensibly, and we may add attractively given, that any woman of ordinary brain-power should be able to understand them, and by following them to keep her baby well." The Critic, New York. Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofdigestOOstar Uluf niAfajAM ILLUSTRATINOTHK V/\J^IUIJS CONNKCTIONS OF TIIFl DENTAL NERVES. PlatH 1. DISEASES OF THE DIGESTIVE ORGANS IN' INFANCY AND CHILDHOOD, WITH CHAPTERS ON THE INVESTIGATION OF DISEASE; THE DIET AND GENERAL MANAGEMENT OF CHILDREN, AND MASSAGE IN PAEDIATRICS. BY LOUIS STARR, M. D., LATE CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE UNI- VERSITY OF PENNSYLVANIA ; PHYSICIAN TO THE CHILDREN'S HOSPITAL, PHILADELPHIA ; CONSULTING PODIATRIST TO THE MATERNITY HOSPITAL, PHILADELPHIA, ETC., ETC. SECOND EDITION— ILLUSTRATED. PHILADELPHIA : P. BLAKISTON, SON & CO., No. TO 1 2 Walnut Street. 1891. -^ Sf 2. Copyright, 1891, by Louis Starr, m.d. PRESS OF WM. F. FELL & CO., 1220-24 SANSOM STREET, PHILADELPHIA. TO PROFESSOR JOHN ASHHURST, Jr., M.D., THIS VOLUME IS DEDICATED, AS A Tribute to his Genius as a Surgeon and Author, AND IN Grateful Remembrance of Many Acts of Kindness. PREFACE TO THE SECOND EDITION. In preparing this issue of ''The Diseases of the Digestive Organs in Infancy and Childhood," the author, while endeavor- ing to bring the general subject-matter thoroughly abreast with the times, has deemed it advisable to make some re-arrangement of the original text and to add a quantity of new material. The chief additions consist of a section on alterations in the odor of the breath in disease ; a section on urine alterations ; a chapter on massage in paediatrics, and a detailed account of second den- tition and its influence on the health in late childhood — a subject heretofore greatly neglected. The author wishes to thank the critics of the first edition of his book for many valuable suggestions, from which he has profited greatly. His thanks are also due to Dr. Wm. M. Powell for his untiring assistance in preparing the copy and in making the index ; to Dr. Robert J. Hess for his aid in proof-reading, and to Prof. Charles B. Nancrede for the diagram illustrating the extended connections of the dental nerves. LOUIS STARR. 1818 South Ritienhouse Square, Philadelphia. January ist, i8gi. Vll PREFACE TO THE FIRST EDITION. It is the author's object, in this book, to give prominence to a class of disorders constituting a large proportion of the ailments of childhood, but often too briefly considered in works on paediatrics. For the successful treatment of the diseases of the digestive organs in infancy and childhood, attention to the general regimen is quite as important as the administration of drugs, and it is upon the former that the student and young practitioner are usually the least thoroughly instructed. So much may be done by the selection of suitable food, by artificial digestion, by regulating the clothing, bathing and other elements of hygiene, that the author, without neglecting thera- peutics, has given greater prominence to these points. The chapter on the investigation of disease does not neces- sarily belong to a work on disorders of the digestive organs, but as so much difficulty is experienced by students in the study of disease in children, it has been incorporated as an aid to such. In the article on the general management of children, the effort has been made to present to the inexperienced results that can only be obtained by much study and practical work. The author is indebted to Dr. Henry D. Harvey for his aid in preparing the index, and to the pencil of Dr. John Madison Taylor for the illustrations. LOUIS STARR. Philadelphia, April, 1886. Vlll CONTENTS. PART I. Introduction — page The Investigation of Disease, ; 17 1. Questioning the Attendants, 18 2. Inspecting the ChiJd, 20 3. Physical Examination, 39 PART II. The General Management of Children — 1. Feeding, 60 2. Bathing, 102 3. Clothing, 105 4. Sleep, 106 5. Exercise, 108 PART III. Massage in Pediatrics, 116 PART IV. Diseases of the Digestive Organs. CHAPTER I. Affections of the Mouth and Throat, 124 1. Catarrhal Stomatitis, 124 2. Aphthous Stomatitis, 126 3. Ulcerative Stomatitis, 131 4. Gangrenous Stomatitis — Noma, 136 ix CONTENTS. PAGE 5. Parasitic Stomatitis — Thrush, 141 6. Dentition, 148 7. Simple Pharyngitis, , 183 8. Superficial Catarrh of the Tonsils, 186 9. Follicular Tonsillitis, 187 10. Suppurative Tonsillitis, 190 11. Hypertrophy of the Tonsils, 194 12. Retropharyngeal Abscess, 197 CHAPTER n. Affections of the Stomach and Intestines, 199 1. Acute Gastric Catarrh, 199 2. Chronic Gastric Catarrh, 202 3. Ulcer of the Stomach, 211 4. Softening of the Stomach (Gastro-Malacia), 212 5. Chronic Gastro-Intestinal Catarrh, .., 213 6. Acute Intestinal Catarrh, 227 7. Chronic Intestinal Catarrh — Chronic Entero- Colitis, .... 235 8. Entero-Colitis, 248 9. Cholera Infantum, 258 10. Inflammation of the Colon and Rectum — Dysentery, . . . 264 11. Tubercular Ulceration of the Intestines, 268 12. Colic, 270 13. Habitual Constipation, 273 14. Simple Atrophy, 279 15. Typhlitis and Perityphlitis, 287 16. Intussusception, 296 17. Intestinal Worms, 311 CHAPTER III. Caseous Degeneration and Tuberculosis of the Mesenteric Glands — Tabes Mesenterica, 329 CHAPTER IV. Affections of the Liver, 337 1. Jaundice, 2>31 2. Congestion of the Liver, 343 3. Fatty Liver, 346 4. Amyloid Liver, 347 CONTENTS. XI PAGE 5. Syphilitic Inflammation of the Liver, 351 6. Cirrhosis of the Liver, 352 7. Suppurative Hepatitis, 357 CHAPTER V. Affections of the Peritoneum, 3^4 1 . Peritonitis, •. 3^4 2. Tubercular Peritonitis, 37 1 3. Ascites, 377 Index, • . 3^3 DISEASES THE DIGESTIVE ORGANS INFANCY AND CHILDHOOD. PART I.— INTRODUCTION. THE INVESTIGATION OF DISEASE. The clinical investigation of disease in children, usually con- sidered so difficult, is in some respects easier than the same study in adults. It is easier because in the child disease is commonly uncom- plicated, rarely has its course and symptoms modified by tissue lesions the result of previous aflfections, and never by vicious habits, such as the abuse of stimulants and narcotics, or by mental over-work and nerve-strain. The confusing element of mis-stated subjective symptoms is also absent, while correct diag- nosis is greatly aided by the facility with which physical exami- nation of the whole body may be practiced. That there are difficulties to be encountered, and very grave ones too, is equally certain. The absence of speech in the infant deprives us of the important assistance afforded by correctly 2 17 l8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. described subjective symptoms, and renders it necessary to look to the mother or nurse for the history of an illness. In older children the case is not much better, since with them words are not prompted by sufficient knowledge or judgment to be of great service. Further, the wilfulness, dislikes, fear and agita- tion of the child are impediments which must be overcome before a satisfactory examination can be made, and which will often tax the skill and patience of the physician to the utmost in the overccming. Another source of difficulty lies in the activity of growth and development in infants, which renders them liable to be affected by slight causes, and makes disease sudden in its attack, short in its course and intense in its symptoms. The rapid development of the nervous system especially leads to con- fusion. The nerves bind every portion of the frame in a sym- pathy so close that an affection of a single part may cause marked general disturbance, and local symptoms are often reflected, directing attention to organs very distant from those really dis- eased. Finally, the extreme excitability of the nervous system of healthy children often causes a trifling illness to assume an aspect of the greatest gravity, while, on the contrary, the depres- sion of nervous sensibility that attends chronic wasting diseases so obscures the symptoms that a dangerous intercurrent affection may appear trifling or remain altogether latent. The plan of conducting the clinical investigation in children differs materially from the method adopted in adults. It is best to proceed in three regular stages, as follows : ist. Questioning the attendants ; 2d. Inspecting the child ; 3d. Physical exami- nation. I. Questioning the Attendants. When the patient is under eight or ten years of age, the only way of obtaining a knowledge of the previous history and of what may occur between visits, is carefully to question the mother or nurse. The account must be patiently elicited and listened to, and credited with due reference to the narrator's intelligence. It is well never entirely to discredit a statement without good THE INVESTIGATION OF DISEASE. I9 reason, for many women, though weak and foolish in other respects, are excellent observers when their powers are guided by affection. Besides, being thorouglily acquainted with their children's habits and dispositions, they will often detect devia- tions from health that the physician might overlook entirely. Tills part of the examination, particularly when the acquaintance and good will of the child has not previously been obtained, should, if possible, be made before entering the sick-room. By taking this precaution the agitation produced by the prolonged presence of a stranger, and its consequent trouble and delay, will be avoided to a great degree. As there are certain points about which it is always necessary to be informed, the adoption of a definite order of questioning is advisable. The family history as far back as the parents should first be ascertained. Inquiry being chiefly directed to the detection of chronic maladies and transmissible diseases, as tuberculosis and syphilis. If any deaths have occurred, their causation should be investigated, and an inquiry into the occurrence, or the reverse, of previous still-births is often important. Next, an outline of the child's life from birth up to the date of the illness in question must be obtained. This should include the following items: The manner of feeding during infancy; whether at the breast, or from a bottle, and if the latter, whether cow's milk, condensed milk or the farinacea have formed the basis of the diet. The date of commencement and the regularity of dentition. The general state of health in regard to strength or weakness and liability to illness. The time of occurrence and the nature of any prominent attack of illness, especially of the eruptive fevers. Whether vaccination has been performed or no. The hygienic surroundings; for instance the healthfulness of the locality of residence, the sort of house and room occu- pied — if large, well ventilated, light and dry or the reverse, an4 the character of the clothing and food. In older child- ren, if at school, the time devoted to study, and if at labor, the nature and the hours of work. 20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. After this it is necessary to fix the time the attack in hand began. The occurrence of some striking symptom, as con- vulsions or violent vomiting, often establishes this point beyond a doubt, but when there is any uncertainty the best plan is to question back, day by day, until a time is reached at which the child was perfectly well, and to date the onset from this period. The most common of the general indications of commencing illness are disturbed sleep and irritability of temper. A perfectly well child sleeps quietly and continuously at night, and is never cross. Having determined, as nearly as possible, the exact time of onset, the next step is to learn the mode of attack and the symptoms and course of the disease prior to the first visit. The questions now must be general, never leading. They must be sufficiently exhaustive to touch upon all the functions of the body, and when a trail is started it must be patiently followed to the end. Alterations in sleep, bodily strength, surface tem- perature, appetite, digestion, urine elimination, respiration and so on, must be sought for, and the account of such deviations from the normal state as vomiting, diarrhcea or cough, will suggest further questions as well as point out the path to be followed in the future examination. This portion of the investigation is closed by an inquiry into the treatment that may have been already adopted. 2. Inspecting the Child. When the eye and ear of the physician are trained to their work, valuable information can be obtained by simply looking at an ill child and listening to its cry or spoken words. Even while the child is lying asleep or sitting quietly in the nurse's lap many facts may be learned, but this portion of the examina- tion is never complete without an inspection of the naked body. The points thus ascertained consist in alterations in the expres- sion of the face, in decubitus, in the appearances of the body and so on, and may be designated the features of disease. The relative position of the observer and patient during inspection is THE INVESTIGATION OF DISEASE. 21 of importance. If possible the former should stand with his back to, and the latter be so placed that his fece 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, ihe features of disease will be studied under different headings, and since to appreciate them it is necessary to have a knowledge of the healthy aspect, both the normal and abnormal appearances will be described. Face. — The face of a healthy, sleeping child wears an ex- pression of perfect repose. The eyelids are completely closed, the lips slightly parted, and while a faint sound of regular breathing may be heard, there is no perceptible movement of the nostrils. Incomplete closure of the lids with more or less exposure of the whites of the eyes is noted when sleep is ren- dered unsound by moderate pain and during the course of all acute and chronic diseases, particularly when they assume a grave type. Twitching of the lids heralds the approach of a convulsion, and at such times, too, there is often oscillation ot the eyeballs, or squinting. A marked smile, due to contraction of the muscles about the mouth, signifies abdominal pain or colic, and pursing out of the lips and chewing motions of the jaw, gastro-intestmal irritation. Dilatation of the alse nasi, with or without noisy breathing, points to embarrassed respiration, the result of extensive bronchial catarrh, pneumonia or pleurisy with effusion. When awake and passive the healthy infant's face has a look of wondering observation of whatever is going on about it. As age advances the expression of intelligence increases, and every one is familiar with the bright, round, happy face of perfect childhood, so indicative of careless contentment, and so mobile in response to emotions. The picture is altered by the onset of any illness, the change being in proportion to the severity of the attack. An expression of anxiety or of suffering appears, or the features become pinched and lines are seen about the eyes and mouth. Pain most of all 22 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. sets its mark upon the countenance, and by noting the feature affected it is often possible to fix the seat of serious disease. Thus, contraction of the brows denotes pain in the head ; sharp- ness of the nostrils, pain in the chest ; and a drawing of the upper lip, pain in the abdomen. As a rule, the upper third ot the face is modified in expression in affections of the brain, the middle third in diseases of the chest, and the lower third in lesions of the abdominal viscera. M. Jadelot has drawn attention to certain furrows that appear on the face in serious cases, and to the indications that these 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 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, com- mencing at the angle of the mouth and running outward, to be lost in the lower part of the face. This furrow is more shallow than the others. It directs attention to the lungs. These furrows are often present, and when met with are worthy of considera- tion, but their constancy and value have been over-estimated by their discoverer. Pufiiness of the eyelids and a fulness of the bridge of the nose, indicate dropsy and should direct attention to the kidneys as the seat of disease. Each of the two prominent diatheses is distin- guished by a peculiar physiognomy. When there is a tuberculous tendency the face is oval and the features delicate ; the hair is fine and silky ; the skin smooth and transparent ; the temporal veins are visible ; the eyelashes are long and curving, the irides large and deep-colored and the sclerotics pearly white or bluish ; finally, a growth of fine hair is often noticeable on the temples THE INVESTIGATION OF DISEASE. 23 and in front of the ears. The general expression is most intelli- gent. In the strumous diathesis, on the contrary, the face is round and heavy ; the complexion doughy ; the upper lip swollen ; the nostrils wide and the alae of the nose thick ; the eyelids are thickened and reddened at their edges ; the hair coarse, and the lymphatic glands of the neck enlarged. A marked disfigurement of the face may indicate one of several diseases, according to its character. For example, broadness of the bridge of the nose, or complete flatness at this point, is sig- nificant of constitutional syphilis. A large, square head and pro- jecting forehead with a face of natural size or smaller, shows that the child has suffered from rickets. An immense globular head, overhanging forehead, and diminutive face with eyeballs pro- jected downward and irides almost concealed by the lower lids, are pathognomonic signs of chronic hydrocephalus. Decubitus. — The complete repose depicted on the countenance of a sleeping child when free from illness is shown also by the posture of the body. The head lies easy on the pillow, the trunk rests on the side .slightly inclined backward, the limbs assume various but always most graceful attitudes, and no move- ment is observable but the gentle rise and fall of the abdomen in respiration. In the waking state the child, after early infancy, is rarely still. The movements of the arms, at first awkward, soon become full of purpose as he reaches to handle and examine various objects about him. The legs are idle longer, though these, too, soon begin to be moved about with method, feeling the ground, in preparation, as it were, for creeping and walking. With the onset of disease the scene changes. In acate attacks attended with pain, sleep is no longer restful. The infant is con- tent only when rocked, fondled or "walked" in the nurse's arms. The older child tosses about uneasily in bed, or demands a constant change from the bed to the lap. During the waking hours the movements are purposeless, quick and impatient, the position is constantly shifted and frequent whining complaints are made. As a contrast to this condition of jactitation, at the 24 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. beginning of the specific fevers, children often lie for hours quiet and drowsy upon the bed or lap. In chronic affections attended with debility, the movements become slow and languid, and in stupor and coma there is perfect stillness and immobility. There are certain positions and gestures which have especial significance. Sleeping with the head thrown back, and the mouth open, is a frequent accompaniment of chronic enlargement of the tonsils. A tendency to ^' sleep high," that is with the head and shoulders elevated by the pillow, indicates impaired pulmonary or cardiac function. So, too, does an upright position in the nurse's arms, with the chest against her breast and the head hanging over her shoulder — a posture assumed by young children. "Sleeping cool," namely, resting only after all the bed-clothing has been kicked off, is an early symptom of rickets. The position termed '' en chien de fusil,^^ is a symptom of the advanced stages of cerebral disease, especially tubercular menin- gitis. The child lies upon one side, with the head stretched far back, the arms pressed close to the sides and folded across the chest, the thighs drawn up toward the abdomen, the legs flexed on the thighs and the feet crossed. Restless movements of the head or boring of the head into the pillow also point to cerebral disease. When there is an evident desire to retain one position, as on the back or one side, together with short, quick breathing, some inflammatory change in the respiratory or abdominal organs may be suspected. Persistent lying on the face is an evidence of photophobia. Of the gestures, the frequent carrying of the hand to the head, ear or mouth indicates headache, earache or the pain of denti- tion respectively, and constant rubbing of the nose is a feature of gastro-intestinal irritation. If the thumbs be drawn into the palms of the hands, and the fingers tightly clasped over them, or if the toes be strongly flexed THE INVESTIGATION OF DISEASE. 25 or extended, a convulsion may be expected. The presence of clonic contractions of the muscles, with unconsciousness, indi- cates, of course, a convulsion ; while irregular, badly coordinated, jerky movements — consciousness being retained — attend chorea. In infants the existence of colic is shown by repeated extension and retraction of the legs, clenching of the hands into fists, flexion and extension of the forearms, and a writhing movement of the trunk. The fact of one limb remaining passive while the others are actively moved about, naturally suggests motor paralysis. The Skin. — In the new-born infant the color of the skin varies from a deep to a light shade of red. After the lapse of a week this redness fades away, leaving the surface yellowish-white. Sometimes the yellow hue is so deep that it might readily be mistaken for jaundice were it not for the w^hiteness of the con- junctivae, and the absence of disordered digestion and other symptoms of ill-health. Usually in a fortnight all discoloration disappears, and the skin assumes its typical appearance. Allow- ing for the natural variations in complexion, the skin of a healthy child is beautifully white, transparent and velvety. The cheeks, palms of the hands and soles of the feet have a delicate pink color, and the general surface is rosy in a warm atmosphere, marbled with faint blue spots or lines, in a cool one. As age advances, the coloring becomes more pronounced, and until the completion of childhood the complexion is much fresher than in adult life. In the inspection alterations of the skin of the face are chiefly noticeable. Lividity of the eyelids and lips is a sign of imper- fect aeration of the blood, and points to pulmonary or cardiac disease. Marked blueness of the whole face is a symptom of morbus 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 fre- quently, deranged digestion. A decided yellow hue of the skin and conjunctivae is seen in jaundice; an earthy tinge of the face in chronic intestinal dis- 26 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. eases ; a waxy pallor in renal diseases, and paleness in any acute or chronic affection attended with exhaustion. Brownish-yellow discoloration of the forehead is significant ot inherited syphilis; a bright, circumscribed flush on one or both cheeks, of inflammation of the lungs or pleura, or of gastro-intes- tinal catarrh, according to its occurrence with or without an elevated surface temperature. The cutaneous lesions of certain of the eruptive fevers appear first upon the face ; each of these has its special characteristics. An eruption of herpetic vesicles on the lips maybe mentioned as present both in pneumonia and in malarial fevers. Some information may be obtained from the hands. Slight want of proper aeration of the blood is shown by blueness of the finger nails, a greater degree, by cyanosis of the whole hand. Deformity of the nails is a symptom of syphilis : clubbing of the finger tips of chronic lung disease; and redness, swelling and suppuration about the nails of struma. The dropsy of scarlatinal nephritis causes a puffiness and cushiony appearance of the dor- sum of the hands. Often^ too, in this condition, the finger ends are glossy, as if smeared with oil, and there is an exfolia- tion of the epidermis about the nails. The last two symptoms frequently serve to confirm a retrospective diagnosis of scarlet fever. Mode of Drinking. — By watching a child taking the breast or bottle, some knowledge can be obtained of the condition both of the mouth and throat, and of the respiratory organs. If there be any soreness of the mouth the nipple is held only for a moment, and then dropped with a cry of pain. When the throat is affected deglutition is performed in a gulping manner, an expression of pain passes over the face, and no more efforts are made than required to satisfy the first pangs of hunger. Under similar circumstances older children drink little and refuse solid food entirely. An infant suffering from the oppression of pneumonia or severe bronchitis, seizes the nipple with avidity, swallows quickly several times, and then pauses for breath. In older patients the THE INVESTIGATION OF DISEASE. 27 act of drinking, which should be continuous, is interrupted in the same way. If the finger be put into the mouth of a healthy baby it will be vigorously sucked for some little time. The diminution of the act of suction during a severe illness is a sign of danger ; its reestablishment a good omen. In conditions of stupor and coma it is noticeably absent. The Cry. — The vocal sound, termed crying, is the chief it not the only means that the young infant possesses of indicating his displeasure, discomfort or suffering. Even long after the powers of speech have been developed, the cry continues to be the main channel of complaint. It may be accepted, as a rule, that a healthy child rarely cries. Of course, some acute pain, as from a fall or accident or blow, will cause crying in the most healthy child, but the storm is quickly over. Nothing like fre- quent, peevish crying or fretfulness is compatible with health, consequently, when this disposition exists, the cause must be looked for in some disease. Incessant, unappeasable crying is due to one of two causes, namely, earache or hunger, and the distinction may readily be made by putting the child to the breast or offering a properly prepared bottle. The hydrencephalic cry, denoting pain in the head, is a sudden, sharp and very loud shriek, occurring at intervals and audible at a considerable distance. Crying during an attack of coughing, or for a brief time afterwards, and at- tended with distortion of the features, indicates pneumonia. In acute pleuritis, the cry also accompanies the cough, but it is pro- duced too by movements of the body and by pressure on the affected side. It is louder, indicative of greater suffering, and sometimes most difficult to check. Intestinal pain causes crying just before or after an evacuation of the bowels, and is associated with wriggling movements of the body and pelvis, and with the eructation or passage of flatus. Conditions of general distress or malaise predispose to fits of fretful crying, the paroxysms being excited by any disturbing influence, or even by merely looking at the little suff'erer. 28 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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. Hoarse- ness points to a lesion of the laryngeal mucous membrane, either catarrhal or syphilitic in nature. In membranous croup, and in some cases of extreme exhaustion, the cry is faint and inaudible. Finally, in severe croupous pneumonia, in extensive pleural effusion and in rickets, ordinary disturbing causes are inopera- tive for the production of fits of crying, and there is a seeming unwillingness to cry, on account of the action interfering with the respiratory function. The conditions of altered tone apply equally to the articulate voice in children who are old enough to speak. The cough, too, must not be disregarded. Many of its char- acters 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, immediately 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 physical exam- ination, although, strictly speaking, they do not come under the THE INVESTIGATION OF DISEASE. 29 head of inspection of the child. These are the characters of the faecal evacuations, of the urine, and of the material ejected by vomiting. The Breath. — The breath of a healthy infant or child should be odorless, or as the nurse will say, "sweet," except perhaps immediately after taking nourishment, when it may, for a short time, have the smell of milk or any special food eaten. The persistent presence of an odor, therefore, is abnormal and in- dicates disease. Any morbid condition of the system that prevents the elimi- nation of metamorphosed nitrogenous tissue through the mucous membrane of the intestines, or retards the passage^ of decom- posing detritus along the bowels, will cause an offensive breath. Under this head are conditions characterized by high tempera- ture, catarrhal inflammations of the gastro-intestinal tract, chronic debilitating diseases, etc. The same result, also, frequently attends structural lesions of the kidneys. The reason for this is, that the system, in order to get rid of poisonous matter — for accumulated waste is poison — and to maintain the balance between the constant construction and destruction of tissue, must throw off elsewhere what the intestinal glands and the kidneys fail to excrete ; so the lungs take on vicarious activity and the expired air becomes tainted with the products of waste. Very often, by the way, the skin takes a part in the abnormal excretory process, and a similar odor is noticed in the per- spiration. Purely local causes of halitosis also exist. These are decayed teeth, caries of the nasal and maxillary bones, ulceration of the mucous membrane of the mouth, nose, larynx, trachea and bronchial tubes, and gangrene of the cheeks. Chronic poisoning by lead, arsenic and mercury, though not very common in childhood, is another cause of ill-smelling breath. To speak in general terms, the breath may become sour, catarrhal, fetid, gangrenous, ammoniacal and stercoraceous. This classification is a rude one, and many subdivisions can be 30 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. made of some of the odors. Thus, there are many varieties of catarrhal and fetid breath, which, while more or less distinctive of different conditions, cannot be differentiated in words and must be experienced by the observer's sense of smell to be recognized ; once this is done they become valuable symptoms. Sour breath is present, in infants more especially, when there is gastric fermentation. The variety of, food, whether milk or farinaceous substances, makes little difference in the odor, and it is most perceptible in cases attended by eructation and vomiting. In chronic vomiting, chronic entero-colitis and thrush the intensely acid odor exhaled from the mouth and, in fact, from the whole bpdy, is a most prominent feature. What I have classed as catarrhal breath has, as already stated, numerous shades of difference. In chronic catarrh of the pharynx there is always a " heavy " breath, not noticeable far from the patient's face. The odor is always more marked during sleep and is greatest after the long sleep of night, as then the mucus, to which the odor is due, not being removed by acts of swallowing, collects in larger masses. Should the catarrh invade the follicles deeply, and, especially, should there be associated follicular tonsillitis, the breath, while still having the quality of heaviness, becomes extremely offen- sive, with a scent somewhat like that of decaying cheese, and is very penetrating. This odor, too, is worse after sleeping. At the onset of acute catarrh of the stomach the breath be- comes decidedly tainted. Sometimes it has a vinous odor, at others it is sweetish, and I have attended a number of cases in which it had the same quality as after an inhalation of aether. Later in the attack it becomes sour or has the odor of sulphuretted hydrogen. The former is apt to be the case with infants, the latter with older children, who have a more solid albuminoid diet. What is known as a " feverish breath " has a heavy sweetish smell. It is met witli in diseases of high temperature and depends partly upon catarrh of the gastro-intestinal mucous membrane, the common attendant of fevers, and partly upon THE INVESTIGATION OF DISEASE. 3I the elimination of fever waste. It is very marked and rapid in appearance in scarlatina. In chronic intestinal catarrh with obstinate constipation the breath often has a slightly faecal odor. Simple catarrh of the nasal mucosa when of any standing, gives rise to moderate heaviness, and the Fame is true of catarrh of the mucous membrane of the mouth — stomatitis — though in the latter affection, mastication and swallowing being difficult, small quantities of food collect in the mouth, and there undergoing decomposition add an element of fetor to the breath. Fetor of the breath is observed in its mildest form in such affections as aphthae and ulcerative stomatitis. It is better de- veloped in ozsenae and necrosis of the maxillary bones, when the well-known stench of dying bony tissue is added. Decaying teeth give much the same odor, though it is less strong and pene- trating. In all these conditions, however, the fetor differs not only in degree, but in kind. Noma gives rise to a gangrenous odor, and a patient affected with this disease will fill the ward of a hospital, the room in which he lies, or even a whole dwelling, with the most sickening stench. Cases of empyema, with ulceration of the lung and discharge of pus through the bronchial tubes, have an almost equally offensive breath, but here there is often a flavor of garlic combined with that ordinarily due to tissue necrosis. Ammoniacal breath is observed only in patients suffering with uraemic poisoning. A purely stercoraceous breath is rare, and when met with is an accompaniment of faecal tumor or of intussusception. The metallic poisons while giving rise to fetor of the breath have no individual characteristics, and it is necessary to look to the history and symptoms of the individual case to determine the special poison. The F^cal Evacuations. — The daily number of evacuations natural for a child varies greatly with its age. For the first six weeks there should be three or four stools every twenty-four hours. 32 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. After this time up to. the end of the second year, two movements a day is the normal average. Subsequently, the frequency ot defecation is the same as in adults — once per diem — though two or three movements in the same interval often occur, especially after over-feeding or after eating food difficult of digestion, and must be looked upon as conservative rather than as the evidence of ill-health. During the first period the stools have the consistence of thick soup, are yellowish-white, or orange-yellow in color, with some- times a tinge of green, have a faint faecal, slightly sour odor, and are acid in reaction. In the second, they are mushy or imper- fectly y^rw /. ^., * Measure provided with each can of powder. THE GENERAL MANAGEMENT OF CHILDREN. 89 free from any poisonous or dangerous ingredient, but during milking, and subsequent handling and transportation, particles of manure or various forms of dirt get into it and are apt to set up fermentation or other injurious change. To deprive these accidentally introduced organic impurities of their activity, or, in other words, to sterilize, it is necessary to subject the fluid to high heat under pressure. Several admirable implements have been devised for conduct- FlG. 2. AUTHOR S STERILIZER. ing the process ; one of the most simple, made after a design of my own, is shown in the accompanying figure. This apparatus is made of tin, and consists of an oblong case provided with a well fitting cover, and having a movable per- forated false bottom (d), which stands a short distance above the true one and has attached a framework capable of holding ten, six-ounce, nursing bottles. On the outside of the case is a row of supports (b) for holding inverted bottles while drying, and at the proper distance below these a gradually inclining 90 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. gutter (c) for carrying oif the drip. A movable water bottle (a) is hung to the side ; in this each bottle of food may be heated at the time of administration. The bottles are made of flint glass and according to the design described on page 96, the graduated markings being especially convenient for measurement and rendering the use of a separate measuring glass unnecessary, a matter of no little moment, as every implement that comes in contact with the milk in sterili- zation must be kept chemically clean. Ten bottles are used, so that the whole supply of milk intended for a day's consumption can be prepared at once. Each bottle is provicied with a per- forated rubber cork, which in turn is closed by a well-fitting glass stopper. Sterilization should be performed in the morning as soon as possible after the milk has been served The process is as follows : First, see that the ten bottles are perfectly clean and dry; pour into each six fluidounces (12 tablespoonfuls) of milk; insert the perforated rubber corks, without the glass stoppers, however; remove the false bottom and place the bottles in the frame ; pour into the case enough water to fill it to the height of about two inches ; replace the false bottom carrying the bottles ; adjust lid, and put the whole on the kitchen range. Allow the water to boil and, by occasionally removing the lid, ascertain that the expansion that immediately precedes boiling has taken place in the milk, then press the glass stoppers into the perforated corks, and thus hermetically close each bottle. After this, keep the apparatus on the fire and the water boiling for twenty minutes. Finally, remove the false bottom with the bottles ; pour out the water, replace and carry the whole, covered with the lid, to the nursery. When the hour of feeding arrives, put one of the bottles into the attached water bath and heat it to the proper point for administration. The milk may, of course, be diluted with fil- tered water, or receive the additions ordinarily made to adapt it to children of different ages. The tip used — and a tube must not be employed even here — should be thoroughly cleaned and THE GENERAL MANAGEMENT OF CHILDREN. 9 1 immersed for a fev/ moments in boiling water before it is attached to the bottle. So soon as a bottle is emptied — and if the whole of its con- tents be not taken the remainder must be thrown away — it is washed in the ordinary manner with a solution of bicarbonate or salicylate of sodium (see p. 96) and placed in the rack (b) to drain and dry. Milk sterilized by the above process will remain sound for several days, according to some authorities as many as eighteen * when the heating is continued for thirty minutes. Sterilized milk is especially useful in travelling, when fresh milk cannot be obtained ; for use in cities during the heat of summer, when milk is most apt to undergo injurious changes ; for the feeding of delicate children, or for those suffering from disease of the stomach or intestinal canal. A very good process has been inaugurated by some dairymen, in which the milk is sterilized on the farm directly after coming from the cow, and transported to the consumer in the original bottles. This procedure cannot be too highly recommended, provided the care is taken to preserve perfect cleanliness on the part of the original handlers, and to see that the process of sterilization is thoroughly carried out. Sometimes milk, in every form and however carefully pre- pared, ferments soon after being swallowed and excites vomiting, or causes great flatulence and discomfort, while it affords little nourishment. With these cases the best plan is to withhold milk entirely for a time and try some other form of food. The fol- lowing are good substitutes : — Mellin's Food, gj. Hot water, f^iij- For each portion ; to be given every two hours at the age of six weeks. * Since writing the above, this statement has been verified by my own experiments. 92. DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Veal broth ( J^ ft) of meat to the pint), f^^iss. Barley water, f^iss. For one portion. Whey, f^iss. Barley water, f^iss. Milk sugar, 5 ss. A teaspoonful of the juice of raw beef every two hours will usually be retained when everything else is rejected. Such foods are only to be used temporarily until the tendency to fermentation within the alimentary canal ceases ; then milk may be gradually and cautiously resumed. When infants approaching the end of the first year become affected with indigestion, it is often sufficient to reduce the strength and quantity of the food to a point compatible with digestive powers. For instance, at eight months the food may be reduced to that proper for a healthy child of six months, or even less. Here, too, predigestion of the food is very serviceable. If a few grains of extractum pancreatis be added to a gobletful of thick, well-boiled starch gruel, at a temperature of 100° F., the gelatinous mucilage quickly grows thinner and soon is trans- formed into a fluid, the starch having been rendered soluble by the action of the pancreatin ; by still longer contact, the hy- drated starch is converted into dextrine and sugar. Advantage may be taken of this property to render the foods containing starch assimilable. Thus, to a mixture of barley jelly and milk, Barley jelly, ^ij. Milk sugar, 3J. Warm milk, f ^ viij. Add three grains of extractum pancreatis, and five grains of bicarbonate of sodium, and keep warm for half an hour before administering. The same process may be employed with food containing oat- meal, arrowroot or wheaten flour, with a view of converting the starchy ingredients into digestible elements without materially altering the taste. THE GENERAL MANAGEMENT OF CHILDREN. 93 When the infant has arrived at an age to take meat broths., these too, when digestion is enfeebled, maybe readily peptonized. Returning to the regimen of the healthy infant, it will be found that after the first year far less change is required in the food from month to month. Diet from the twelfth to the eighteenth month, five meals per day : — First meal, 7 a.m. — A slice of stale bread, broken and soaked in a breakfast-cup (eight fluidounces) of new milk. Second meal, 10 a.m. — A teacup of milk (six fluidounces) with a soda biscuit or thin slice of buttered bread. Third meal, 2 p.m. — A teacup of beef tea (six fluidounces) with a slice of bread. One good tablespoonful of rice-and-milk pudding. Fourth meal, 6 p.m. — Same as first. Fifth meal, 10 p.m. — One tablespoonful of Mellin's Food with a breakfast-cupful of milk. To alternate with this : — First meal, 7 a.m. — The yelk of an egg lightly boiled, with bread crumbs ; a teacupful of new milk. Second meal, 10 a.m. — A teacupful of milk with a thin slice of buttered bread. Third meal, 2 p.m. — A mashed, baked potato, moistened with four tablespoonfuls of beef tea; two good tablespoonfuls of junket. Fourth meal, 6 p.m. — A breakfast-cupful of new milk with a slice of bread broken up and soaked in it. Fifth meal, 10 p.m. — Same as second. The fifth meal is often unnecessary, and sleep should never be disturbed for it ; at the same time, should the child awake an hour or more before the first meal, he must break his fast upon a cup of warm milk, and not be allowed to go hungry until the set breakfast hour. Diet from eighteen months to the end of two and one-half years, four meals a day : — First meal, 7 a.m. — A breakfast-cupful of new milk ; the yelk of an egg lightly boiled ; two thin slices of bread and butter. 94- DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Second meal, ii a.m. — A teacupful of milk with a soda biscuit. Third meal, 2 p.m. — A breakfast-cupful of beef tea, mutton or chicken broth ; a thin slice of stale bread ; a saucer of rice-and- milk pudding. Fourth meal, 6.30 p.m. — A breakfast-cupful of milk with bread and butter. On alternate days : — First meal, 7 a.m. — Two tablespoonfuls of thoroughly cooked oatmeal or wheaten grits with sugar and cream ; a teacupful of new milk. Second meal, 11 a.m. — A teacupful of milk with a slice of bread and butter. Third meal, 2 p.m. — One tablespoonful of underdone mutton pounded to a paste ; bread and butter, or mashed baked po- tato, moistened with good plain dish gravy ; a saucer of junket. Fourth meal, 6.30 p.m. — A breakfast-cupful of milk, a slice of soft milk toast, or a slice or two of bread and butter. When sickness supervenes, all that is ordinarily necessary is a reduction of the diet to plain milk, or milk with Mellin's Food. An important point, often neglected, is the matter of drink. Even the youngest infant requires water several times daily, and the demand increases with age. The water must be as pure as possible and should not be too cold. In the heat of summer, however, bits of ice and water moderately cooled by ice can be allowed without harm. The foregoing schedule must, of course, be regarded only as an average. Many children can bear nothing but milk food up to the age of two or even three years, and, provided enough be taken, no fear for their nutrition need be entertained. If a child be thriving on milk, he is never to be forced to take additional food merely because a certain age has been reached ; let the healthy appetite be the guide. A young mother, in her solicitude to do her best, often finds great difficulty in adhering to simple rules in the diet of her child. Mrs. A., who has had great experience with children, having had some herself, tells her that the child would thrive far THE GENERAL MANAGEMENT OF CHILDREN. 95 better if it ate such and such a thing, and did not keep to weak milk foods. Miss B. assures her that her cousin's last child grew much healthier after eating a chop with vegetables and pudding each day. Aunt C. comes with the announcement — which she breaks gently — that she knows the child is simply starving, and the ignorant nuise confirms the statement. Fig. 3. GRADUATED NURSING BOTTLE. All their seemingly convincing theories are very upsetting to a mother who wants only to do what is right. She must bear in mind, however, that some children can eat anything and live ; but she does not know how much better, more robust, and disease-resisting they would be, did they adhere to a simple diet. Let her remember that the so-called " weak milk foods" contain those nourishing qualities to which nature, in her wisdom, has 96. DISEASES OF DIGESTIVE ORGANS IN CHILDREN. limited the child's powers of digestion. Therefore, young mothers, let well enough alone. d. Success in hand-feeding depends quite as much on the administration as upon the preparation of the food. From birth up to such time as broth, bread, and eggs are added to the diet, all the food should be taken from a bottle. Even after this, as the bottle is a comfort and insures slow feed- ing, it may be allowed for milk preparations, until the child, of his own accord, tires of it. The only feeding apparatus to be admitted to the nursery is the simple bottle and tip. The bottle represented in Figure 3 is made, by my suggestion, by Mr. J. J. Ottinger, of Philadelphia. Its interior surface presents no angles for the collection of milk ; it is easily cleaned, and the graduated scale is convenient for nursery use. All complicated arrangements of rubber and glass tubing are not only an abomination, but a fruitful source of sickness and death. Rather than use them, it is far better to feed the infant with a spoon. In England, a bottle with a long rubber tube is almost universally employed. Should this be abandoned and a simple bottle and a rubber tip used, the objections of some authors to bottle-feeding would vanish. The bottle shaped as above must be of transparent flint glass, so that the slightest foulness can be detected at a glance, and may vary in capacity from six to twelve fluidounces, according to the age of the child. Two should be on hand at a time, to be used alternately. Immediately after a meal the bottle must be thoroughly washed out with scalding water, filled with a solution of bicarbonate or salicylate of sodium — one Fig. 4. _ _ ■' teaspoonful of either to a pint of water — and thus allowed to stand until next required ; then the soda solution being emptied, it must be thoroughly rinsed with cold water before receiving the food. The tips or nipples, of which there should also be two, must be composed of soft, flexible India-rubber, and a conical shape is to be preferred, as being more readily everted and cleaned; the opening at the point must be BOTTLE TIP. THE GENERAL MANAGEMENT OF CHILDREN. 97 free, but not large enough to permit the milk to flow in a stream without suction. At the end of each feeding the nipple must be removed at once from the bottle, cleansed externally by rub- bing with a stiff brush wet with cold water, everted and treated in the same way, and then placed in cold water and allowed to stand in a cool place until again wanted. While taking these precautions for perfect cleanliness, the nurse must satisfy herself of their efficacy by smelling both the bottle and the tip just before they are used, to be sure of the absence of any sour odor. Next to cleanliness of the feeding apparatus, it is important to insist upon the separate preparation of each meal immediately before it is to be given. The practice of making, in the morning, the whole day's supply of food, though it saves trouble, is a most dangerous one. Changes almost invariably take place in the mixture, and by the close of the day it becomes unfit for con- sumption. When the graduated bottle is not at hand, a common glass graduate, marked for fluidrachms and ounces and holding a pint, should be provided for the nursery. Some moments before meal- time, so as to avoid hurry, measure the different fluid ingredients of the food in this, one after the other ; add the requisite quantity of milk sugar, and mix the whole thoroughly by stirring with a spoon, and pour into the feeding bottle. When the graduated bottle is employed, thorough shaking is sufficient. The food must now be heated to a temperature of about 95° F. This can be done by steeping the bottle in hot water, or by placing it in a water-bath over an alcohol lamp or gas jet. Fmally, apply the tip and the meal is ready. When feeding, the child must occupy a half-reclining position in the nurse's lap. The bottle should be held by the nurse, at first horizontally, but gradually more and more tilted up as it is emptied, the object being to keep the neck always full and pre- vent the drawing in and swallowing of air. Ample time, say five, ten or fifteen minutes, according to the quantity of food, should be allowed for the meal. It is best to withdraw the bottle occa- 98 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. sionally for a brief rest, and after the meal is over, sucking from the empty bottle must not be allowed, even for a moment. e. For children residing in cities, an honest dairyman must be found, who will serve sound milk and cream from country cows once every day in winter, and twice during the day in the heat of summer. The milk of ordinary stock cows is more suitable than that from Alderney or Durham breed, as the latter is too rich and, therefore, more difficult to digest. The mixed milk of a good herd is to be preferred to that from a single animal. It is less likely to be affected by peculiarities of feeding, and less liable to variation from alterations in health or different stages of lactation. The care of the herd and of the milk is of great consequence. The cows should be healthy, and the milk of any animal that seems indisposed should not be mixed with that from perfectly healthy animals. The cows must not be fed upon swill or the refuse of breweries, glucose factories, or any other fermented food. They must not be allowed to drink stagnant water, and must not be heated or worried before being milked. The pasture must be free from noxious weeds, and the barn and yard must be kept clean. The udder should be washed, if dirty, before the milking. The milk must be at once thoroughly cooled. This is best accom- plished by placing the can in a tank of cold spring water, or in ice water, the water being the same depth as the milk in the can. It is well to keep the water in the tank flowing ; indeed, this is necessary unless ice water be used. The can should remain un- covered during the cooling and the milk should be gently stirred. The temperature should be reduced to 60° F. within an hour, and the can must remain in the cold water until the time for deliver- ing. In summer, when ready for delivery, the top should be placed in position and a cloth wet in cold water spread over the can, or refrigerator cans may be used. At no season should the milk be frozen, and at the same time no buyer should receive milk having a temperature over 65° F. The milk and cream must be transported from the dairy in THE GENERAL MANAGEMENT OF CHILDREN. 99 perfectly clean vessels. To insure this it is best to provide two sets of small cans ; one set to be thoroughly cleansed and aired while the other is taken away by the milkman to bring back the next supply. So soon as this arrives in the morning, or in the morning and evening in hot weather, the milk should be emptied into separate and absolutely clean earthenware or glass pitchers, and these put at once into a refrigerator reserved exclusively for them. This may stand in some convenient spot near the nursery, but not in it, and especially not in an adjoining bath room. With a good refrigerator there is no difficulty in keeping milk perfectly sweet for twenty-four hours in winter and for twelve hours in summer, except on intensely hot days ; then it may be necessary to scald, lightly boil or sterilize the whole of the supply when received, in order to prevent change. It is a well-known fact that milk is a fluid having active powers of absorption, and that it frequently acts as the medium of trans- mission of the contagion of such diseases as scarlatina, diphtheria and typhoid fever. Doctor V. C. Vaughan has also lately dis- covered in milk a special poison which he terms iyrotoxicon (cheese poison). The clinical elements of interest in these discoveries is the close analogy between the symptoms produced by the experi- mental use of tyrotoxicon and those observed in cholera infantum — an analogy suggestive of the possibility of the latter disease being chiefly due to poisoned milk. This causal relation is scarcely more than a theory, though certain well-known features of the disease seem to bear it out. Thus, the aff'ection occurs at a season when decomposition of milk takes place most rapidly ; it occurs at places where absolutely fresh milk cannot be obtained ; it prevails among classes of people whose surroundings are most favorable to fermentative changes; it is most fatal at an age when there is the greatest dependence upon milk as a food, when the gastro-intestinal mucous membrane is most susceptible ,to irritants, and when irritation and nervous fevers are most easily produced. lOO DISEASES OF DIGESTIVE ORGANS IN CHILDREN. Drs. Newton and Wallace, of the New Jersey State Board of Health, have reported a number of cases of poisoning by milk that occurred in different hotels at Long Branch. These ob- servers found that the affected milk was all obtained from one milkman, and that the cows furnishing it were milked at the unusual hours of midnight and noon. The noon milking was immediately placed in cans without being cooled, and ''carted eight miles during the warmest part of the day in a very hot month." It was this milk that produced the poisonous effects, the morning's milk being always good. No statement is made as to the health of the cows or the nature of the poison, but there is a probability of its having been tyrotoxicon, and of this material or its ferment having been generated by the careless collection and transportation of the milk, combined with the high atmos- pheric temperature. Childhood. — 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 oatmeal or wheaten grits, and a slice of bread and butter. Second meal, 11 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 : — THE GENERAL MANAGEMENT OF CHILDREN. lOI BREAKFAST. EVERY DAY. ONE DISH ONLY EACH DAY. Milk. Fresh fish. Eggs, plain omelette. Porridge and cream. Eggs, lightly boiled. Chicken hash. Bread and butter. " poached. Stewed kidney. " scrambled. " liver. Sound fruits may be allowed before and 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. Hominy. Meat, roasted or broiled, " mashed. Macaroni, plain. and cut into small Spinach. Peas. pieces. Stewed celery. String-beans, young. Bread and butter. Cauliflower. Green com, 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 ex- cluded, and no condiment but salt is to be used. Eating, however little, between meals, must be absolutely avoided. Keep a young child from knowing the taste of cakes or bonbons, or, having learned it, let him feel that they are as unattainable as the thousand other things beyond his reach, and he soon ceases to ask for them. Even a piece of bread between meals should be forbidden. His appetite then remains natural, and he will eat proper food at his regular meal hours. Filtered or spring water should be the only drink; tea, coifee, wine or beer being entirely forbidden. As to the 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. 102 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 regu- lar time, and it is best to select some hour in the early morn- ing, midway between two meals — ten o'clock, for instance. 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 un- dressing 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, unseen ted castile soap. After remain- ing 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 minuses, until thoroughly 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 expected, has a greater and more permanent cooling effect than bathing with cold water. After the third year, three baths a week are quite sufficient. 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 GENERAL MANAGEMENT OF CHILDREN. I03 The hot bath — 95° to 100° — is employed for various purposes, notably for a derivative action ; to cause diaphoresis, 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 desirable, 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 teaspoon ful to a tablespoon ful 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 depression. Cold baths, by shocking the system, first produce 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 nutrition 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. 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 reddened ; 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 60°, and the addition of half an ounce of sea-salt or a tablespoonful of con- centrated sea water to the gallon, renders it more stimulating and insures a complete reaction. 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 ex- treme conditions of hyperpyrexia. The child is first immersed in water at 95°, and this is gradually lowered to 70° by the I04 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 Ditman's sea-salt, or concentrated sea-water (best) ; water (liot 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 & muslin bag, place in a quart of water, boil for an hour, squeeze bag thorou_Thly into the water ; add to four gallons of warm water. Useful in eczema and skin diseases. Nitro-Miudatic 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. li. 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. THE GENERAL MANAGEMENT OF CHILDREN. I05 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 different func- tions of the body — respiration, circulation, digestion, calorifi- cation, etc. If an excessive proportion of this force be con- sumed 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 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 dif- ferent 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 w^ashed. Canton flannel. In summer, a loose muslin one may be put on, without the drawing-string. A flannel 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 band- age, 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 pre- venting pain. All clothing should be changed sufficiently frequently to insure cleanliness. 9 Io6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 before 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. 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 thir- teen hours, and at three years eleven hours, are enough. Any marked diminution in the length of sleep or decided restlessness indicates disease, and demands attention 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 household. One cannot too soon begin to form the good habit of regu- larity 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 11 p.m. to 5 a.m., and as many hours daring the day as nature demands and the exigencies of feeding, wash- ing 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 THE GENERAL MANAGEMENT OF CHILDREN. 107 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 dispo- sition of the subject ; but in every case the bed must be occu- pied from 7.30 P.M. to six or seven o'clock on the following morning. After the fourth year, few children will sleep in the daytime ; 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 encouraged 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 drain- ing 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 even- ing and well aired before the child is put back to bed. Io8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. The temperature of the rooms must be as uniform as possible, the proper degree of heat being from 64° to 6S° F. The crib should have high sides, to prevent the child from falling out and injuring himself, and should be provided with springs and a soft hair mattress, protected by a gum cloth, placed under a double sheet. The bedclothes 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 de- velopment 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 however, 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 per- mitting, 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 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 THE GENERAL MANAGEMENT OF CHILDREN. I09 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°. Management OF Weak and Immature Infants. — When pre- mature expulsion of the foetus cannot be checked, children are born in a condition of feebleness requiring particular care. Such children are under weight, breathe and eat imperfectly j have ill- formed organs and badly performed functions ; their skin is soft and delicate, bright red in color, and so transparent that the superficial blood-vessels can often be seen, and their cry is feeble. Their muscles are inert, they hardly seem to contract, and the movements of the limbs are rare and without vigor. The infant, plunged in a sort of stupor, has not even strength enough to suck, the muscles of the cheeks and of the tongue and palate being apparently too weak to perform this act, and deglutition itself is often slow, — -a grave symptom, since the regular accomplishment of thi^ function alone renders life possible. The employment of artificial heat and a well-regulated alimenta- tion are the methods of combating this condition. Warmth and even temperature of the surrounding air are most important. The old method of accomplishing this was to envelop the infant's body and limbs, under the ordinary clothing, with a layer of cotton wadding, and place a fold of the same around the head. Two or three bottles filled with hot water were placed under the blan- kets of the bed, and renewed from time to time as they became cold. An effort was made to maintain the temperature of the chamber at 77° Fahr. All changes of clothing were made before a brisk fire, and two or three times every day massage or friction, either dry or with various stimulating embrocations, was practiced to strengthen the circulation. As an improvement upon this crude and very unsuccessful method, M. Tarnier has devised an apparatus called a ''hatching-cradle." It consists of a box made of wood, sixty-five centimetres long no DISEASES OF DIGESTIVE ORGANS IN CHILDREN. by fifty high and thirty-six wide, with sides twenty-five milli- metres thick. The inside of the box is divided by a partial par- tition into two parts; this partition, which is horizontal, is placed about fifteen centimetres from the bottom. The lower story is intended for hot-water bottles. The cut shows the apparatus. There are two doors ; one is a sliding door on the side of the box to push to either side for the purpose of introducing the hot- water bottles ; the other is at one of the ends (at T in this figure); Fig. 5- TARNIEr's " HATCHING-CRADLE." it does not completely close the orifice, but allows air to enter. The upper part, for the baby, contains the bedding, and is covered with a glass top at V; it should close tightly and be held by two screws at BB. At A is an outlet for the air, to which a small ventilator can be attached. In the opening between the two chambers a wet sponge is placed to keep the air slightly moist, and here also a thermometer is placed to mark the temperature. The heat is supplied by earthenware jugs at M ; they contain a pint of water each ; four or five are required to keep the tempera- ture at the proper point, — 87-90° F. The chamber must be THE GENERAL MANAGEMENT OF CHILDREN. Ill heated to this degree before the infant can be placed in it, and every one and a half or two hours one of the water bottles must be changed in order to maintain a constant temperature. The air passes in by the door, T, is heated by the bottles, and passing by the sponge, E, escapes at A ; the movements of the small ven- tilator in the latter position is the index that the air is circulating. The inflint must be dressed in swaddling clothes, as it has been observed that the temperature is always two or three degrees higher under the clothing than in the chamber itself. Every hour or two, according to the case, the little patient should be taken out to receive food and have its napkins changed. The shorter time occupied in these processes the better. Auvard has suggested an improvement in Tarnier's hatching cradle. In his instrument a cylindrical reservoir of metal takes the place of the hot-water jars in the lower compartment of the couveuse. This reservoir is filled by means of a metallic funnel at one end of the box and communicating with the cylinder through a metallic tube. The overflow of the cylinder is provided for by a curved me- tallic tube at the lower part of the cylinder, beneath the inlet through which the reservoir is filled. The air enters by a register on one side of the couveuse instead of at the end, as in Tarnier's apparatus. The other portions of the apparatus are the same as Tarnier's. The metallic cylinder is capable of holding ten litres of liquid (a litre is a little over a quart). To start the apparatus, about five litres of boiling water should be poured in, after which three litres may be poured in every hour. When jten litres are con- tained in the cylinder, the overflow-pipe carries off the excess. Auvard suggests having two vessels, capable of holding three litres each, keeping one under the escape-pipe and the other over the fire, reheating the water in the vessel filled by the escape- pipe and having it in readiness for the next changes. The two vessels may be thus used alternately, and but little tmie consumed in the heating of the apparatus as compared with that required in the use of Tarnier's invention. 1 12 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. To empty the cylinder, a rubber tube is attached to the escape- pipe, by which it is made to act as a siphon — a small quantity of water poured into the cylinder through the funnel being suffi- cient to start the liquid. The length of time the child remains in a couveuse will vary from fifteen days to three weeks, a month, or even more. It should not be removed permanently until it has acquired suffi- cient vigor to live in the ordinary atmosphere of the apartment. To accustom the child to this atmosphere, it should, as it grows stronger, be removed for an hour at a time from the couveuse during the warmest part of the day. It is best to continue the use of the apparatus at night for some time after the child becomes accustomed by day to removal from the couveuse, for the danger of chilling from changes in the atmosphere is greater at night. Auvard recommends the use of the couveuse in all cases where the vitality of the child is enfeebled either by external causes, as cold, or internal causes, as prematurely congenital feebleness, cyanosis, or ''blue disease," wasting, or other general maladies enfeebling to the newborn. The excellent results obtained by these cradles is shown by the following statistics obtained from the Maternite, in Paris : — WEIGHT OF CHILD. NO. OF INFANTS. NO. THAT LIVED. NO. THAT DIED. 1000-1500 grammes. 1501-2000 " 2001-2500 " 40 112 12 96 lOI 28, or 70 per cent. 35, or 26.7 " II, or 9.8 " Before the introduction of the machine, infants died at the rate of 66 per cent.; since, the average proportion is 36.6 per cent. The healed cradle has also been used with success in the treat- ment of sclerema, oedema and cyanosis attacking the newly born. From the very first day an attempt must be made to put THE GENERAL MANAGEMENT OF CHILDREN. II3 these feeble infants to the breast ; and if they be too weak to suck, the milk may be squeezed into the mouth, or first into a warm spoon and then given to the child. The mother's or nurse's milk, without dilution or addition, is the best food, though if this cannot be obtained asses' milk may be used. This must be mixed with equal quantities of warmed sugar and water — 3 parts to 100. When the cows' milk is employed, the mixture should be one part to three of the same sugared water. M. Tarnier recommends the cows' milk to be prepared thus : The mixture of milk and sweetened water is placed in an air-tight pot, and this is placed in boiling water for half an hour. It is given to the child from a small spoon. When the infant is very small, six to eight grammes (fSij) are enough for a meal ; larger babies require from ten to fifteen grammes (foiiss-foiiiss). There should be at least twelve meals every twenty-four hours. It often happens that the babe will drink badly and throw up half the liquid given. Under this deficient feeding the little sufferer gets rapidly worse, loses weight, and frequently has diarrhoea. In these cases "gavage" is resorted to. The appa- ratus is quite simple, being nothing more than a urethral catheter of red rubber (Nos. 14-16 French), at the open end of which a small glass funnel is adjusted. The infant upon whom gavage is to be practiced is placed on the knee, with its head slightly raised ; the catheter, being wetted, is introduced as far as the base of the tongue, whence, by the instinctive efforts at deglutition, it is carried as far down as the oesophagus and into the stomach. The liquid food is next poured into the funnel, and by its weight soon finds its way into the stomach. After a few seconds the catheter must be removed, and here is the great point in the operation : it must be removed with a rapid motion and at once, for if it be withdrawn slowly all the food introduced will be vomited. The number and quantity of meals thus given must vary with the age and strength of the infant. As a rule, eight grammes (foii) of food every hour will suffice when the subject is small, but there must be aa increase as circumstances require. Mother's 10 114 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. milk is the best in gavage, but other foods may be used if it be impossible to obtain it. Should the gavage be too copious, the infant gains rapidly in weight and size. This increase, however, is due to oedema, and quickly disappears when a proper quantity of food is adminis- tered. When excessive feeding is continued, indigestion soon sets in, and the patient dies of gastritis or enteritis. As soon as the child gains strength this mode of feeding may be alternated with nursing, and gradually breast-feeding may be entirely sub- stituted for it. Nevertheless, the least digestive disturbance in- dicates the necessity of a return to gavage. Even when the child is old enough to nurse, should it be weak, it is useful, besides regularly giving the breast, to resort to gavage three or four times a day. This is what M. Tarnier calls gavage de renfort, as it keeps up the strength of the infant so that it can take the breast and digest well. The absence of the sensation of hunger and of the necessary strength to suck are not contra-indications to this mode of feed- ing ; and by it, together with the use of hatching machines, the actual period of vitality has approached the legal period, which in French law is six months of intra-uterine life. Lavage. — Epstein, of Prague, has practiced lavage of the stomach in nursing children with good results. The apparatus employed consists of an elastic tube joined to a small glass tube, to the other extremity of which another piece of elastic tubing with a wide opening is adapted. Lavage may be practiced a few days after birth without the least danger to the infant. The instrument is inserted while the child is in the dorsal decubitus position, the trunk and arms being enveloped in napkins. The child's mouth is opened by exerting a slight pressure upon the chin, while the larynx is shghtly pressed inward by the index finger of the right hand. The tube having been previously dipped in warm water, it is held as a pen, and the smaller extremity slowly introduced, advancing by the simple, repeated act of deglutition. The contact of the tube with the stomach causes contractions of the walls, thereby expelling a quantity of THE GENERAL MANAGEMENT OF CHILDREN. II5 liquid through the tube, the broad end of which is depressed somewhat until the stomach is empty. The author employs dis- tilled water with a little hydrocarbonate of soda, using from twenty to twenty-five cubic centimeters of the liquid for each lavage. The funnel-shaped end of the tube is raised to pour in the water and lowered to expel it. The washing may be repeated two or three times in succession until the liquid returns nearly clear. Lavage is indicated : i. In cases of repeated vomiting. 2. In cases where there is present an affection of the mouth which is capable of extending to the stomach. 3. In cases of eclampsia caused by indigestible substances. 4. In cases of poisoning. After the lavage the child should remain perfectly quiet for fifteen or twenty minutes before nursing. PART III.— MASSAGE IN PEDIATRICS. Systematic manipulation is of great value both as a means of preserving health and as a scientific method of treating certain diseases in children. Mere rubbing or friction of the surface cannot be included under massage in its literal sense, still, it is a useful form of manipulation, and needs no special instruction, being possible to any intelligent, soft-handed mother or nurse. Massage, on the contrary, is an art, and, like every other art, requires study and patient preparation for its successful practice. It is a powerful remedy too, and, like other agents of its class, as potent for evil as for good in unskilled hands. Therefore, to insure good results, a trained masseuse is necessary — and she must act under the direction of the physician. Massage includes several processes of manipulation. Those given by Murrell, from whose excellent little work* I have taken much of the description of the different '' movements," are effleur- age, petrissage, frictio7t and tapotement. Effleurage is a stroking movement made with the palm of the hand passing with more or less force over the surface of the body centripetally. The movements are made to follow as nearly as possible the direction of the muscle fibres, and for deep-seated tissues the knuckles can be used instead of the palm. This method is of minor value in itself but of great use when combined, as is the rule, with the procedures to be described. Petrissage consists essentially in picking up a portion of muscle or other tissue with both hands, or the fingers of one hand, and subjecting it to firm pressure, at the same time rolling *" Massage as a Mode of Treatment." W. Murrell. Ii6 MASSAGE IN PEDIATRICS. II7 it between the fingers and the subjacent tissues. The hands must move simultaneously and in opposite directions, the skin must move with the hands to avoid giving pain, and the thumb and fingers must be kept wide apart in order to grasp a bulk of tissue, a whole muscle belly, for instance. The manipulation must be uniform, in a direction from the extremities toward the centre of the body, bearing in mind the arrangement of groups of superficial muscles and keeping well in the interstitia. Friction, or massage a frictions, is performed with the tips of the fingers. It is a pressure movement rather than a rubbing. It is always associated with effleurage and, to be of any use, must be performed quickly and readily. Tapotement is a percussion which may be made with the tips of the fingers, their palmar surfaces, the palm of the hand, the back of the half-closed hand, the ulnar or radial border of the hand, or with the hand flexed so as to contain, when brought in contact with the surface of the body, a cushion of air. The hand of the masseuse must be perfectly clean and soft, and the finger nails short and smooth. The length and frequency of the sittings must vary with the individual case. Murrell is in favor of short and frequent seances, and also recommends dry massage, that is, without the use of oil, liniments or ointments ; vaseline especially is to be avoided. Our knowledge of the physiological action of massage is based upon experimental research and clinical experience. Experi- ments were made by Dr. Gopadze (quoted by Murrell) upon four medical students, who were kept in hospital and subjected to systematic manipulations for twenty minutes or more daily. The seance began with effleurage, followed by petrissage, friction and tapotement, and ending with a second effleurage. The results were increased appetite and a notable gain in body weight. The axillary temperature fell, never more than .5°, for about thirty minutes after each massage ; then it rose steadily, and an hour later was generally a degree higher than at the commencement of the operation. The respiratory movements were uniformly increased in frequency, depth and fulness. The pulse varied Il8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. with the kind of ^'movement" used — light surface effleurage increased its frequency, while petrissage made it slower. Zabludowski, experimenting on himself and two servants for eighteen days, noted increased bodily and mental vigor and improved appetite and sleep. Clinical experience shows that massage increases the activity of the circulation, reddens the skin and elevates the tempera- ture in the part manipulated. It also increases the electrical contractility of muscular tissue, and stimulates the flow of lymph in the lymphatic vessels. Muscular stiffness and fatigue are relieved, nervous irritability is calmed, and restless and wakeful patients are soothed by it into refreshing sleep. With these facts at hand, it is not difficult to see what a useful therapeutic agency we possess in skillfully employed massage. By its application we have the power to prevent the atrophy of mus- cles and to augment muscle tone, to build up such tissues as fat and blood, to improve nerve tone both directly by producing a better blood supply and indirectly by relieving irritability and giving rest and sleep, and, finally, to hasten the absorption of waste tissue and of morbid effusions. At the same time it must always be remembered that massage is a powerful remedy. A short seance with gentle movements may do good in infantile palsy, for ex- ample, but it does not follow that by doubling the time or force twice as much benefit will be derived. In fact, the reverse of the proposition is true; short, gentle massage maintains the size and tone of the muscles, while long, forcible manipulation causes them to atrophy quickly. The same truth runs through the whole question and must be observed. Before entering upon the therapeutic application of massage proper, it will be well to revert to the process of simple rubbing, already mentioned. This is of much value as a general hygienic measure. Each day, after the bath, the skin having been thor- oughly dried by a soft, warm towel, the whole surface should be gently rubbed with the palm of the hand, the process occupying about five minutes. This increases the capillary circulation, encourages thorough reaction, aids nutrition and adds vigor to MASSAGE IN PAEDIATRICS. 119 the frame. Weakly children especially thrive under it. In older children, friction with a soft towel may be substituted for hand- rubbing, but this change should not be made before the fifth or sixth year. Sometimes it is well to rub certain portions of the body more thoroughly than others. Thus in rickets the spine should receive especial attention, in indigestion and constipation the abdomen, in weak ankles the feet and legs, etc.; though even in these ca^es the general surface must receive a share. Massage may be employed with advantage in the following diseases of childhood: — {a) Chronic gastro-intestinal catarrh. In this condition the skin is harsh, and often so dry that a shower of epidermic scales falls on the removal of the underclothing, the muscle tone is faulty, general nutrition is impaired, and there is a determination of blood from the surface toward the mucous membranes. To get the skin active, and in this way balance the circulation, is an important step in the reestablishment of normal digestion, secre- tion and excretion, the essentials of perfect nutrition. To accom- plish this, a full, warm bath is administered every evening, just before bedtime, the patient remaining in the water for five min- utes. Then the surface is thoroughly dried and half an ounce of olive oil is gently rubbed into the skin, the child enveloped in a light blanket and put to bed. After a little time diaphoresis begins. So soon as the sweating is free the skin is again dried and the night-dress put on in preparation for sleep. Next morning, at some convenient time after breakfast, the child is sub- jected to twenty minutes' massage (petrissage with effleurage). The inunctions are contmued until the skin becomes soft and active, and massage is employed daily until there is a decided improvement in the amount of flesh and general strength, a period generally of two or three weeks. Afterwards '' move- ments " every third day will be sufficient to complete the cure. In these cases massage not only aids the baths and inunctions in their general action, but directly and powerfully increases I20 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. nutrition and muscle tone, and materially hastens an otherwise slow process of recovery. {b) Constipation. Manipulation is a very efficient remedy in habitual constipation, and there are many cases that can be cured by it, combined with a properly regulated diet, without the use of drugs. Petrissage of the colon is the best method, instructions being given to follow the natural course of the fseces through this portion of the gut ; thus, beginning in the right iliac region to proceed upward to the right hypochondrium, to cross over to the left hypochondrium and then downward to the left iliac region. In this way the ascending transverse and descending colon are manipulated in order. Five or ten minutes every morning, or every morning and evening in obstinate cases, constitute the proper duration and frequency of the applications. The pressuie must be gentle, as delicate tissues are being dealt with. In this condition I have not found the dry method so efficient as the combination of massage with the inunction of warm olive oil or a weak ammonia liniment. The addition of aloes to the liniment, a plan recommended by some authors, has never been necessary in my experience. Sometimes tapotement with the flat hand, the hand partly closed forming a cushion, or with the margin of the hand, is necessary, but the course of the colon must always be followed. The therapeutic action of this mode of treatment is, undoubtedly, threefold: it increases the intestinal and other secretions; it increases the peristaltic action of the intestinal muscular fibres, and it mechanically forces accumulated faecal matter toward the rectum. (f) Colic. Every experienced mother knows how often flatus, the cause of colicky pain, is expelled from the stomach or intestines by gently rubbing the abdomen with the hand. Any approach to scientific manipulation is much more efficient, and two or three minutes' effleurage may be resorted to, as the urgency of the symptoms requires, with the most satisfactory effect. In this connection it must be remembered, also, that MASSAGE IN PEDIATRICS. 121 rubbing of ihe feet to increase the circulation is an important aid in relieving colic. (//) General debility and anaemia. These conditions are much benefited by short, frequently repeated courses of massage. In the convalescence from many diseases, both acute and chronic, in which these states exist, manipulation improves general nutri- tion, and strength is rapidly gained. ( Mellis, aa f^ss. 01. Menth. Pip., gtt. vj. Mucilag. Acaciae, q. s. ad fSiij. M. S. — Two teaspoonfuls every six hours. Every second day, preferably in the morning, two grains of calomel must be administered. Another useful drug is pumpkin seed ; this may be given in the form of 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 it. 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. For a long time the bark of the pomegranate root has been known as a remedy for " taenia," or tape-worm; but the diffi- culty of procuring it fresh, the short time it keeps good, and the unpleasant taste of the decoction, has greatly limited its use. Besides, it has been ascertained that its action is variable, accord- ing to the season of collecting, the age and vigor of the tree, etc. It is this uncertainty that compelled Professor Laboulbene, Member of the Academy of Medicine, who has made the cure of taenia a specialty, and who considers the bark of pomegranate root the best and most efficacious remedy, to say: '' I wish that some one would discover and separate from the tsenicide plants a sure alkaloid always identical, and that would act with cer- tainty, which is something we cannot obtain from pomegranate bark, or from old koosso, which is nearly inert. " Mr. Tanret has found this alkaloid, and for his discovery has been awarded the '' Barbier Prize " by the Academy of Sciences. He calls it Pelletierine, in honor of the illustrious chemist, who, with Caventon, has made numerous discoveries in organic chem- istry of great benefit to humanity. AFFECTIONS OF THE STOMACH AND INTESTINES. 327 Tanret's pelletierine has given the most satisfactory results in the hospitals where it has been tried, for instance, at the Marine Hospitals of Toulon, St. Mandrier, etc., and in Paris, St. Antoine, La Charite, Necker and Beaujon, etc. Dujardin-Beaumetz, Member of the Academy of Medicine, declared to the Society of Therapeutics, that he was successful in thirty-two cases out of thirty-three treated with pelletierine, and Professor Laboulbene was successful in every case in which he used it, fourteen in all. Pelletierine is dispensed in bottles containing the proper dose for an adult, and one dose is usually sufficient. For children from nine to twelve years, half the adult dose is sufficient. In administering the drug, certain preliminaries are indispensable to insure success. When pieces of tape-worm are or have been ejected within a short time after some other remedy has been taken without ex- pelling the head, pelletierine should not be taken until some pieces of the worm are again noticed. In the evening the patient must use a large laxative injection, and place himself on milk diet. The next morning mix the con- tents of a bottle with a glass of sweetened water, and administer at one dose ; three-quarters of an hour to an hour after, give one ounce of compound tincture of jalap, mixed with one-half a glass of sweetened water. For women, the dose should be reduced to 20 grammes, and for children a still further reduction is neces- sary. The purgative, compound tincture of jalap, is the best, but it can be substituted by any other cathartic. If the bowels are not relieved in a few hours after taking the purgative, then take either another purgative or an injection made of sulphate of sodium. A few minutes after having taken pelletierine there will be a sensation of giddiness, and the entire tape-worm will be passed from two to four hours after the remedy has been taken. After administering any 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 328 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. it himself. The stools immediately following the action of the •parasiticide must, therefore, be preserved until his visit ; the chamber in which they are received being filled with water con- taining 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 re- mains 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 treatment. 2d. The removal of the alkaline mucus and the restoration of the normal condition of the alimentary canal are to be accom- plished by the same attention to diet and the same therapeutic measures recommended when discussing chronic gastro-intestinal catarrh (p. 220). CHAPTER III; CASEOUS DEGENERATION AND TUBERCULOSIS 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 com- mon 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 en- larged 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 situated 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 thick- ening and contraction of the trabeculae of the reticulum ; and — quite commonly — a gradual hardening and shrinking by the ab- sorption of fluid and the deposition of earthy salts. Together with these changes, it is the rule to find scrofulous 28 329 ^ 330 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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. Sometimes, 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 pro- duction 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 hygienic factors, coarse, over-stimulating or bad food is the most potent for evil. This acts by irritating the intestinal mucous membrane and pro- ducing catarrh and follicular ulceration. Tubercular disease of the lungs, scrofulous disease of the cer- vical and bronchial glands or of the bones and joints, and tuber- cular ulceration of the bowels, are not only usual associates, but, no doubt, frequent causes of tabes mesenterica. In addition, measles and scarlet fever, from their tendency to induce inflam- mation of the mucous membrane of the bowels and glandular hyperaemia, 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 of the milk of diseased cows. In support of this theory, Klebs has made a number of experiments, from which he draws the con- clusion that the use of the milk of cows having advanced phthisis always produces tuberculosis, which begins 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 CASEOUS DEGENERATION OF MESENTERIC GLANDS. 33 1 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 considerable distention. 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 de- gree of prominence varies from day to day ; when marked, the wall is tense, percussion is tympanitic, and it is difficult or impos- sible to grasp the glands ; in the second, the enlargement is con- stant 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 ten- der, slightly movable \vhen small, and fixed when large. When of considerable size, the mass can readily be touched by placing the fingers on the umbilical 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 shoul- ders and thighs elevated so as to relax the parietes ; by this method, it is possible to detect a tumor as small as a walnut. 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 distention of the superficial abdominal veins, from compres- sion of the great venous trunks. The veins are often very pro- minent, and ramify over the wall of the belly to join those of the thoracic wall, which are also distended. 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 tendency is for the glands to shrink and become calcareous. This change lessens the size of the tumor, diminishes the tension of the 332 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 discharge be directly into the peritoneal cavity, acute peritonitis 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 ; com- plains of wandering pains in the abdomen, and is affected with diarrhoea, attended by the expulsion of offensive, dark, watery stools, which, on standing, deposit flaky matter, mucus, and small, black blood clots. Sleep is restless, 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 impair- ment 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 glandular tumor. Particular caution must be given against the mistake, so frequently made, of attributing every case of abdominal dis- tention 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 CASEOUS DEGENERATION OF MESENTERIC GLANDS. 333 there is imperfect digestion and assimilation of food, and, con- sequently, debility, affecting the muscles of the intestines as well as the system generally. Now, imperfectly digested food readily undergoes 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 in- flation of the gut must lead, of course, to a prominent abdomen, but one which is uniformly tympanitic on percussion, moderately soft and flaccid to the touch, and entirely free from the signs of enlargement of the mesenteric glands. Again, distention of the superficial abdominal veins is merely an indication of obstructed'circulation in the deep 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 ten- derness ; the mass occupies the position of the transverse or de- scending colon, is oblong in shape, with its long diameter corres- ponding 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 de- tected tumor will be found, on examination, to have disappeared or lessened in size. On the other hand, if the tumor be gland- ular, the expulsion of flatus and faeces, induced by the injection, only renders it still more prominent. The diagnosis must not be considered completed by the de- tection of the tumor, but must extend to the discovery or elimi- nation of the different complications — ulceration of the intes- tines, tubercular deposits in the lungs and tubercular peritonitis. Prognosis. — Caseation of the mesenteric glands is dangerous, but the danger does not spring from the glandular disease so much as from the affections that produce it, the conditions that 334 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. accompany it, and the results that follow 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. When the sole discoverable lesion is swelling of the glands, and there is no rise in the evening temperature nor marked impair- ment of nutrition, the hope of subsidence of the enlargement and ultiaiate recovery, may be reasonably entertained. On the con- trary, if there be wasting, diarrhoea and fever, indicating ulcera- tion of the bowels, secondary, perhaps, to chronic disease of the lungs, the prognosis must be grave. ' Again, the occurrence of tuberculous peritonitis renders the prospect most unfavorable. Treatment. — Much may be done in the direction of prophy- laxis 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. Supplying good food, fresh, pure air and warm clothing, and maintaining the activity of the skin are also important preventive measures. After the disease is established, much can be accomplished 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 directly 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 taken from bed, the whole body is briskly shampooed with a soft towel CASEOUS DEGENERATION OF MESENTERIC GLANDS. 335 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. — Haifa dozen raw oysters or a bit of sweet- bread 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, sweet- bread 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 morning bath must be omitted or substituted by a simple warm spong- ing ; and some stimulant, as a teaspoonful of old whiskey, should be given three times daily. Diarrhoea demands an exclusive liquid diet, and it is advi- sable 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 * Directions for Philadelphia. ^;^6 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. health and restore the glands to a healthy condition. The for- mer can be given as an emulsion with lactophosphate 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 : — ]^ . Ung. lodin. Comp., ^ij. Ung. Belladonnse, ^]. Ung. Aquae Rosas, 3 v. M. R. Ung. Hydrargyri, • 5"J- Adipis, ^v. 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 diarrhoea, 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 com- mon 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 viscus 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 character- ized 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 discoloration. This appears on the second or third day, and disappears by the tenth. It is not jaundice, for it is entirely independent of liver dis- order, and there is no yellowness of the conjunctivae, and no alteration in the faeces or urine. A form of true jaundice, how- ever, does occur in the newly-born, termed icterus neonatorum, which may be studied before describing the condition as it is seen in later childhood. 337 338 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. ICTERUS NEONATORUM. Both mild and dangerous types of this variety of jaundice are met with. The tnild type occurs in infants prematurely born, or weak from other causes; in those early exposed to the depressing 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 ; conditions present in infants born semi-asphyxiated. Birch-Hirschfeld has demon- strated 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 oedematous and greatly swollen when there is venous obstruction 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. Some- times 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 yellowness extends to the abdomen and arms; the conjunctivae 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 AFFECTIONS OF THE LIVER. 339 urine brownish, and the stools clay-colored. With this degree of jaundice, there is malaise, loss of appetite, 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 per- sisting in a feeble infant, is sufficient 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 cloth- ing. Constipation is to be relieved by fifteen or twenty drojDS 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: — R . Sodii Bicarbonatis, gr. xxxij. Aq. Menth. Pip., Syrupi, aa f^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 liable to affect several members of the same family in succession ; boys suffer twice as often as girls. There are a number of varie- ties : 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 proportion to the duration of life. The organ is dark green or almost black in color, feels unnaturally firm to the 340 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 consider- ably in intensity from day to day ; at the same time, the con- junctivae 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 distention 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 hemorrhage 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 combined with bleeding from the nose, mouth, stomach or bowels, and . is exhausting and always difficult to control. This form of jaundice ends in death. When umbilical hemor- rhage 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 elements of the liver are so far crippled by the constantly progressing cirrhosis that little bile is found, and the yellowness of tlie surface fades, or almost entirely dis- appears, before life ends. b. Syphilitic inflammation of the liver with its lesions and symptoms will be referred to in another place (see page 351). 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 AFFECTIONS OF THE LIVER. 34I and rod-shaped — have been discovered in the blood of infants so affected. In consequence, the liver undergoes marked degen- erative changes ; the connective 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 ; petechia appear under the skin ; the abdomen is distended by flatus and by enlargement of the liver and spleen ; there is tenderness with fluctuation on palpation, and blood or bloody pus exudes from the umbilicus. The tongue is dry, there is little appetite, and the stomach re- jects what food is taken, together with quantities of greenish mucus. Pyrexia is 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 termina- tion may be preceded by convulsions and coma. Treatment in either variety is most unsatisfactory ] little can be done beyond the employment of measures to maintain the vital forces as long as possible. Umbilical hemorrhage may be arrested by the application of Monsel's solution, or, if this fail, by inserting two hare-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 constitutional remedies, and in pyaemic cases the abdominal tenderness must be relieved by warm fomentations and sedative 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 342 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 discoloration of the skin, with troublesome itching, yellowness of the conjunc- tivae, porter-like urine, and clay- colored stools, devoid of the natural fgecal odor. Other symptoms are anorexia, craving for acid drinks, a yellow-furred tongue, disordered digestion, list- lessness, 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 painful, 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 removed by alkalies. Four fluidounces of some saline water, as Kissingen or Vichy, should be drunk at each meal, and the following mix- ture taken : — R- Ammonii Chloridi, ^ij. 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 tinc- ture may be administered thrice daily before eating. AFFECTIONS OF THE LIVER. 343 2. CONGESTION OF THE LIVER. Congestion of the liver is quite common, especially in children of four years of age and upward. 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 capsule 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 nor- mal hypersemia readily becomes abnormal and continuous 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, cardiac 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 conjunc- tivae distinctly jaundiced. There is malaise; headache; a yel- low, furred tongue ; anorexia ; nausea ; relaxed bowels with clay- colored, offensive stools, and dark-colored urine loaded with lithates. Pain in the right hypochondrium is usually present, and, as this is increased by turning upon either side, the patient maintains a dorsal position ; there is also tenderness in this region, and the suffering is increased by coughing or deep 344 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. breathing. On palpation, the right lobe of the liver can be detected, extending 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, albuminuria 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 establish 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 em- physema 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 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 dura- tion and result correspond to, and depend upon, the gravity of the heart lesion. AFFECTIONS OF THE LIVER. 345 Treatment. — The child may be put to bed, or, if not ill enough to be so confined, should be kept within doors. The abdo- men 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 walking 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, fishj 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., gi"- ij- Pulv. Ipecacuanh^e, gr. ss. Sacchari, gi"- v. M. et ft. chart. No. j. S. — To be taken in ttie 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 consti- pation during the course of the attack. In cardiac cases, 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. When convalescence is established, regular exercise in the open air must be insisted upon and a plain diet maintained. Change of air is often most useful to break up the '^ bilious habit." 29 346 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 dimen- sions, its surface is yellowish and oily, its margins rounded and its texture doughy. On section, the cut surface 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 fari- naceous food. Then the deposition is physiological and transi- tory, 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, scrofula, 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 the tendency the organ has, from its softness, to fall away from the abdominal wall. There is a sense of weight in the right hypochondriac region and disturbed gastro-intestinal function, 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 dis- ease, fatty infiltration shows dangerous impairment of nutrition. AFFECTIONS OF THE LIVER. 347 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 frag- mentation and destruction. The whole, or only isolated por- tions 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 invariably unfavorable, and no special indications for treatment are pre- sented. 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 translucent, refracting substance, possessing the property of fixing iodine and assuming a mahogany-brown color, which, on the application of sulphuric acid, changes to green, blue, violet or red. The infil- tration 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 ele- ments of the cells and converting them into irregularly shaped, glassy-looking blocks. Fatty infiltration is often associated. Uniform enlargement ; increased density ; yellowish-gray color ; 348 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. smooth, shining peritoneum; thin edges, and the exposure, on section, of dry, homogeneous, glistening surfaces, are the gross characteristics. The spleen, kidneys and lymphatic glands are often similarly altered, and sometimes the mucous membrane of the stomach and intestines. Etiology. — Amyloid degeneration of the liver is always pro- duced by some chronic disease, attended by suppuration and purulent discharge. Empyema with a fistulous opening in the chest-wall ; dilated bronchi with copious muco-purulent expec- toration ; 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 jaundice, disten- tion of the superficial abdominal veins and ascites ; except the glands in the fissure of the liver be coincidently 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, discomfort in the right hypochondrium, and is weak, wasted and anaemic, with pale, sallow skin, clubbed fingers and oedematous 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 albu- men, and, at times, hyaline tube casts. Dropsy of the extremi- ties is due in great part to this complication. If the stomach and intestines be implicated, there is a tendency to vomiting 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 uni- formly enlarged. The upper margin of dulness is higher, by an inch or more, than normal ; while the lower edge of the right lobe, somewhat blunted, but perfectly well defined, can often be AFFECTIONS OF THE LIVER. 349 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 enlarge- ment, 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 suppuration ; 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 yielding 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 degenera- tion 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 attention 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 con- stitutional syphilis, and building up the health in cachectic subjects. To combat the disease itself, the diet must be as nutritious as the activity of digestion will permit; a moderate quantity of alcoholic stimulants must be taken daily; the child must be 35 O DISEASES OF DIGESTIVE ORGANS IN CHILDREN. properly clothed, to prevent chilling, and must live as much as possible in the sunlight and open air, or, if confined to the house, in a light, airy room. Alkalies, iron and iodine are the most usefiil drugs. Of alkalies, chloride of ammonium is the best, and it may be given in combination with a bitter, as : — R. Ammonii Chloridi, ^ij. Inf. Genlianae Comp., f^iU- 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 Calumbae, q. s. ad f Jiij. 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^^- Elix. Aurantii, f^v. %rupi, f^j. Aquae, q. s. ad f^vj. M. S. — ;One tablespoonful four times a day. This formula is particularly useful when there is kidney com- plication with oedema. Iodine is most efficient if there be a syphilitic taint; it maybe 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. AFFECTIONS OF THE LIVER. 35 1 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. 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 swell- ing, 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 inflam- matory 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 dif- fering from cirrhosis, where the increase is only between the lobules. When jaundice occurs, the small bile-ducts are thick- ened and occluded by epithelial cells, and the organ is enlarged, and brownish-yellow in color. Symptoms. — In mild cases these are few and uncharacteristic ; in those that are grave there are jaundice, ascites, hemorrhage from the umbilicus and intestines, ecchymosis of the skin, sub- normal 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 in- creased in size. Diagnosis. — The early age, the history of an inherited taint, the association of enlargement of the liver with jaundice 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 treatment, but this* does not correspond with the experience of other observers. 352 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 calomel, or one grain of mercury with chalk; may be administered morn- ing and evening, or ten grains of mercurial ointment 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 manifesta- tions 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 : — ^ . Potassii lodidi, gr. xxiv. Ammonii Chloridi, gr. xxxvj. Syrup. Sarsaparillae Comp., fS^s. Aquae, q. s. adf^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 di- luted in the proportion of one part to seven of lard. 6. CIRRHOSIS OF THE LIVER. In childhood, cirrhosis must be classed among the uncommon diseases of the liver; the fact of its occasional occurrence, how- ever, has been abundantly proved by post-mortem examinations. Morbid Anatomy. — There are two forms, namely, the atro- phic and the hypertrophic. In atrophic cirrhosis or hob-nailed liver, the organ is con- tracted and dense in texture, with nodulated surfaces, thin edges and thickened capsule ; on incision the cut surface is grayish- AFFECTIONS OF THE LIVER. 353 yellow in color, and traversed by a distinct fibrous network. The lesion begins as a chronic inflammatory condition of the branches of the portal vein, and consists of a rapid devel- opment 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 embraces several lobules. Some enlargement may attend the primary formation of embryonal tissue, but the shrinking of cicatricial contraction invariably follows ; the cells become flat- tened and atrophied ; there is a marked reduction in size, and the circulation in the hepatic portal vessels is greatly obstructed. The smaller bile-ducts are little afi'ected, and blood for the nour- ishment of the organ and for the formation of bile is carried by vessels developed in the neoplasm. In hypertrophic or biliary cirrhosis, the liver is usually en- larged, 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 intra-lobular branches of the bile-duct, and envelops and isolates separate lobules ; it fol- lows the ramifications of the bile-ducts ; is more difl"used 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 some cases there is an association of the characteristic lesions. Etiology. — The causes are, as yet, ill-determined. Alcoholic 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 intemperance 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 off'spring. Con- genital deficiency of the bile-duct is always attended by cirrho- sis. Constitutional syphilis frequently, and general tuberculosis occasionally, precede it. It is not limited to any sex or age, 30 354 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. though more frequent in boys than girls, and oftener met with between the sixth and twelfth years than at an earlier period of life. SymptoiMS. — 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 indigestion, flatulence and costive bowels; a pale and pasty complexion, and dark circles about the eyes. His muscles 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 abdomi- nal veins, and, at first, enlargement of both the liver and spleen. Soon the liver begins to decrease in size, but the spleen continues to enlarge."^ Weakness 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 petechial spots appear beneath the skin. The course is prolonged and interruptedby 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 indicate that the end is near. Sometimes intercurrent inflammation of the pleura or lungs is the direct cause of death. * 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. 355 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 distention 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 becomes markedly irregular ; the tongue grows dry and brown ; the teeth are covered with sordes ; there is complete anorexia ; rapid wasting ; bleeding from the gums, from the stomach or beneath the skin ; apyrexia, drowsiness, 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 disten- tion of the veins in the abdominal wall. Diagnosis. — The characteristic features of atrophic cirrhosis are diminution in the area of liver dulness, following 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 gastro-intestinal hemorrhages, occurring, with- out 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, subse- quently, malignant jaundice, with typhoid symptoms, rapid wast- ing, coma and convulsions. Acute yellow atrophy, which has many of the symptoms of the final stage of the 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 tem- porary improvement can be obtained. Treatment. — Before a diagnosis is established, and while the 356 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. patient is merely suffering from ill-defined symptoms of bad health, with imperfect digestion, hygienic and therapeutic meas- ures 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 circum- stances. In the former case, the following prescription is useful : — R. Sodii Bicarb., ^ij. Tr. Nucis Vom., TT\^xviij. Inf. Calumbae, 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 com- bination of iron and quinine, as: — R, Quiniae Sulph., gr. xij. Tr. FeiTi Chloridi, f ^j, Syr. Zingib., f^j* Aquae, q. s. ad f^iij. M. S. — Two teaspoonfuls three times daily. Both plans must be followed out steadily and continuously, 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. Diarrhcjea can be controlled by sub-carbonate of bismuth, and hemorrhage by gallic acid or aromatic sulphuric 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 AFFECTIONS OF THE LIVER. 357 daily warm baths, and chilling prevented by flannel under- clothing. If ascites be so great as to impede the action of the diaphragm, paracentesis must be resorted to at once. A fine trocar or one of Southey's tubes may be used.^ The operation should be repeated so soon, and as often, as reaccumulation renders it neces- sary. When performed early enough, it sometimes has, as in adults, more than a merely palliative effect. 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 , aet. 5 years, was first brought to the Dispensary of the Children's Hospital on April 27th, 1875, during the ser- vice 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 umbili- cus. 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 adminis- tered a tablespoon ful of castor-oil ; this produced a free ev^acua- tion, 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 appetite, 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 respiratory movements were * See section on Ascites. OD 8 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. normal in frequency ; he had no cough, and, on physical exami- nation, no pulmonary or cardiac affection could be detected. His abdomen was tympanitic, the whole of its upper third was tender to the touch, and in the upper part of the right hypo- chondrium there was an oval tumor, about as large as a turkey's egg, having its long diameter directed transversely, and project- ing at its most prominent part nearly an inch from the surface of the abdomen. The skin covering this tumor was somewhat oedematous, but was freely movable, and natural in color and temperature, while the tumor itself was hard, tender, com- pletely 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 abdo- men to the right side. The right hypochondrium was dull, except just below the margin of the ribs, where there was slight, probably transmitted, tympanitic resonance, detected only by deep percussion. The liver dulness began in the ordinary position above, and, on light percussion, was continuous below with that in the hypo- chondriac 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 i6th. Had a large passage from the bowels, the evacua- tion being dark-colored and lumpy ; during the night was rest- less and feverish. May 17th. Tongue somewhat cleaner and abdomen less tympanitic. The tumor was more prominent ; there was deep- AFFECTIONS OF THE LIVER. 359 seated fluctuation, and the skin covering the mass was less oedem- atous, not so freely movable as before, and of a dusky-red hue. Patient walked with his body bent forward, as if a more upright posture was painful. Prescribed f5ss of tinct. cinchon. comp., three times daily, and an increased diet, at the same time direct- ing 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 entirely 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 hypochondrium, being almost five inches in transverse diameter. There was well-marked fluctua- tion, and the skin investing the abscess was tightly adherent over a space about four inches in circumference. The abdominal respiratory movements 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 comfort- able as long as he remained quiet. The abdomen was moder- ately distended. May 22d. 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 teaspoon- ful 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 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 o 60 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 adherent over the whole mass, but most so imme- diately 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 became plugged, and no more could be withdrawn. "*" A poultice 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 himself as before. There was, however, considerable discharge of thick pus from the opening left by the aspirator needle. June ist. The wound made by the needle closed. Scarcely any fluctuation could be detected, and there was but little red- ness 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, * A microscopical examination of a portion of this material revealed pus cells, compound granule cells, blood corpuscles, and numerous polygonal cells having well-defined nuclei and resembling liver cells. AFFECTIONS OF THE LIVER. 36 1 while the upper margin, on the other hand, could not be dis- covered, as the mass extended under the ribs. There was hardly any pain on manipulation, and the boy's general condition was very good. June 5 th. There were no signs of the abscess, except a small spot of dusky redness, and slight retraction and puckering of the skin at the point of puncture ; in this situation, also, the integu- ments 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 sus- pended. On October 30th, the child was in excellent health. The skin, for a short distance about the seat of puncture, was some- what discolored and puckered, and was less freely movable than that of the remainder of the abdomen. Percussion 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 formation 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 of constitutional disturbance in this case, however, is no argument against the existence of hepatic abscess ; as it is generally 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 362 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 pro- jecting margin remaining semicircular, smooth, and well defined. Finally, there was slight contraction of the right lobe. There are two other points of importance, viz., the detection, by palpation, of a smooth edge of dense tissue bordering the area of fluctuation, which gave the impression that the fluid was con- tained in a cup-shaped cavity in a solid organ, and the micro- scopical characters of the pus which was removed. 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, besides being superficial from the outset, have a different position, being usually seated in the rectus muscle or adjoining connective tissue, and in the neighborhood of the umbilicus; at the same time there is generally violent throbbing pain ; the redness and tume- faction of the skin are earlier and better developed, and the constitutional symptoms accompanying the formation of pus are more constantly 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 regulation of the diet, rest, and attention to the various functions of the body, particularly that of the bowels ; for even if the existence of in- flammation be ascertained, it is hardly probable that anything can be done to prevent suppuration. AFFECTIONS OF THE LIVER. ;^6^ In relation to the propriety of evacuating hepatic abscesses, 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 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, how- ever, 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 tuber- cular 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 microscope in the connective tissue that surrounds the branches of the portal vein ; there is, too, an in- terstitial 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 symptoms of the same conditions in adults, that it is unnecessary to devote space to their consideration. CHAPTER V. AFFECTIONS OF THE PERITONEUM. I. PERITONITIS. Children, like adults, are subject to attacks of inflammation 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 developing 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, sometimes 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 hyperplasia, omental and intestinal adhesions, and, at times, localized sup- puration. Chronic general peritonitis gives rise to a sero-fibrinous exu- date ; this may be sufficiently abundant to appear as a thick 364 AFFECTIONS OF THE PERITONEUM. 365 membrane, and in time may undergo fatty, caseous or calcareous degeneration. Chronic local peritonitis results in the formation of circum- scribed adhesions, membranous exudations of limited extent, and sacculated collections of pus. Etiology. — Foetal 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 in- fection from a mother ill with puerperal fever. Later in child- hood, 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 fatiguing 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 peri- tonitis. Finally, it may be occasioned by extension of inflam- mation 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, the attack begins with more or less rigor, abdominal pain and vomiting. The pain is stinging or lancinating in character, and is limited, at first, to one flank, to the supra-pubic region, or the neighbor- hood 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 366 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. rejected consists, in the beginning, of partially digested food; later, of bile-stained mucus. Fever quickly follows the shivering, and as soon as inflamma- tion is fully established, the axillary temperature may reach 104° F. , although the usual range is from 101° to 102°. With the p}Texia there is a frequent, small, wiry pulse, and the breath- ing 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 move- ments are concerned ; palpation yields a certain sense of re- sistance, sometimes develops fluctuation,* and always excites intense pain ; percussion elicits tympany over the upper anterior portion of the belly and dulness over the dependent parts, and on auscultation, friction sounds may be heard when there is a fibrinous exudation. 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. Constipation is the rule if the intestinal peritoneum be involved; then, too, there are frequent attacks of severe griping pain ; on the other hand, there may be diarrhcea, 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 retained when the serous coat of the bladder is involved in the inflammation. Sleep is disturbed and restless ; in infants there may be con- vulsions; in older children, delirium. * 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 accumulation. AFFECTIONS OF THE PERITONEUM. 367 During the course of the attack, which usually extends over a period of seven days, the strength steadily fails; there is con- siderable loss of flesh, and the symptoms present at the onset continue unabated and unchanged. As death approaches vomit- ing 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 tympanites and the pulse is extremely small and frequent. Occasionally this variety of acute peritonitis ends in recovery ; the exuded fluid being either reabsorbed or spontaneously evacuated through the umbilicus or abdominal wall.* In the first instance, the symptoms subside gradually ; in the second, fapidly ; though in both, the course is protracted ; the fistulous openings left after the discharge of pus rarely closing under four or five weeks. 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 majority of cases results from rupture of the vermiform appendix or caecum ; per- foration 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, tliready pulse ; thoracic respira- tion, 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 ; pal- pation is very painful, and percussion yields a uniformly drum- * M, Gauderon mentions ten such cases, eight of which recovered. 368 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 pre- ceded by a few hours' freedom from suffering. While this is the ordinary course of perforative peritonitis, 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 circumscribed, and the resulting abscess, by pointing and discharging through the abdominal wall or into the intestine, may either end in recovery, or in the production of a permanent faecal fistula. In septic peritonitis the symptoms are either inherently latent, or are masked by the collapse that follows the onset of a new in- flammation in a patient already debilitated by disease. There is usually rapid prostration, restlessness, and delirium, with a ten- dency 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 fluctuation may be entirely absent. Without care, such attacks are readily overlooked. Should peritoneal inflammation become chronic the pain les- sens and is more paroxysmal in character ; the fever is remittent, with evening exacerbations ; constipation alternates with diar- rhoea ; there is great emaciation, and death occurs from ex- haustion. However, on account of the usual tubercular origin, the symptoms of this form will be more appropriately studied under the head of " tubercular peritonitis." Local peritonitis is almost uniformly secondary ; that attending inflammation of the caecum and vermiform appendix being the most common in children. Diagnosis. — An immovable dorsal decubitus ; a pale, hag- gard face ; a frequent wiry pulse ; distention, pain and tenderness of the belly, and inactivity of the abdominal muscles in respira- tion, suffice to render the diagnosis of acute general peritonitis AFFECTIONS OF THE PERITONEUM. 369 easy. Intense pain, sudden collapse 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. Rheumatism of the abdominal muscles is attended by tender- ness on pressure ; distressed facial expression ; dorsal decubitus with knees drawn up, and constipation, and thus simulates peri- tonitis; but the face is never haggard, there is no vomiting nor hiccough, nor distention of the belly, neither is tenderness ex- treme. The pulse is soft, compressible, 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 pre- disposing disease, the patient suddenly grows pale and haggard, and has a full belly, with a tendency on the part of the abdomi- nal muscles to become rigid on palpation. Restlessness, delirium and stupor, a change in the type of respiration and in the charac- ter of the pulse, all strengthen the suspicion. Under these cir- cumstances it is well to practice Duparcque's method for detect- ing the presence of fluid, and this, if successful, leaves no further doubt. In the words of Eustace Smith: ''In cases of chronic em- pyema we should always be on the watch for the occurrence of peritonitis. If the child, after a period of improvement, 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, 31 370 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. although there be no tension, tenderness or other sign connected with the abdomen to give support to this opinion," Prognosis. — This must always be most grave. Perforative peri- tonitis 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 surroundings are essential. Hot applications, in the form of light flax-seed poul- tices 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 exhib- ited by the mouth, the rectum, orsubcutaneously, and can safely be pushed to the point of producing drowsiness, 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-eighteenth of a grain of sulphate of morphia, repeated as required, are the average commencing doses. Under no circumstances is a purge to be given. Should con- stipation be obstinate, and the indications urgent to unload 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 fluid- ounces of milk and two fluidounces of beef-tea, alternating, 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 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. AFFECTIONS OF THE PERITONEUM. 371 Should the inflammation subside, the opium is to be gradually withdrawn and its place supplied by sorbefacients 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 application being removed, a weak mer- curial ointment should be rubbed into the skin of the belly once or twice daily ; for example : — R. Ung. Hydrargryi, Ung. Belladonnse, aa ^ij. Adipis, ^iv. 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 associated with tuberculosis of some other organ of the body — of the brain or lungs, for instance ; less frequently it occurs as an isolated affec- tion. 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. 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 372 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. usually found in the dependent portions of the abdominal cavity. Removal of the layer of lymph discloses gray and yellow tuber- cles, studding the surface of the peritoneum, together with masses and broad plates of caseous consistence and tuberculous nature. The thickness and extent of the exudation, the number of granu- lations, 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 translu- cent, 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 contracted; 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 distribution; when localized the inflammation and inflammatory 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 affections. The age at which the disease is most prone to occur has already been mentioned. Male children seem to suff*er 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 present 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. AFFECTIONS OF THE PERITONEUM. 373 Often after the disease is fully developed the child ''keeps about," but the face is drawn and wears an expression 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 characteristic 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 peritonitis ; the appetite often remains unimpaired, and the bowels are alternately relaxed and confined. On the other hand the signs to be detected by abdominal explor- ation are very constant and characteristic. The belly is oval in shape and somewhat irregularly distended, the greatest enlarge- ment occupying the epigastric and umbilical regions; the natural folds and furrows are obliterated ; the superficial veins are promi- nent ; and the integument has a smooth, shining appearance, as if smeared with oil. When the hand is applied to the surface, the recti muscles become tense, in an involuntary effort to pro- tect 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 extending 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 374 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. 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 fre- quency 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 101° in the evening; and there is dysuria with high-colored, but otherwise 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. 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 ulcer- ation ; obstinately confined, when the intestines are pressed upon, or obstructed by adhesions. In the latter case the belly becomes 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 distention of the abdomen diminish, the appetite returns, nutrition improves, and false hopes arise of rapid recovery. AFFECTIONS OF THE PERITONEUM. 375 Sometimes before death an abscess forms, and pus is discharged through the abdominal wall in the neighborhood of the um- bilicus j in other cases the intestines may be perforated from without, but this complication scarcely hastens the fatal termi- nation, for extravasation is limited by adhesions between the knuckles of the intestines. Such 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 features of that condition ; usually there are no local manifestations 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 disten- tion of the abdomen ; the smooth, shiny appearance of the in- vesting 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 symp- toms of tubercular deposit in some other organ of the body. In doubtful cases, where there is little distention 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 catarrh 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 involuntary contraction of the recti muscles on palpation ; the abdominal distention disappears spontaneously at 376 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. times, 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 distention to tuberculosis. 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 dif- ference in the degree and course of the fever, should prevent error. Prognosis. — This must always be unfavorable. Recovery, though possible, is extremely rare. Treatment. — While little is to be expected from therapeutic 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 flatu- lence, 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 tgg, a slice of well-toasted bread lightly buttered, and a tumblerful (fgviij) of warm milk. For luncheon, at 12 m. — The soft parts of a dozen oysters or a bit of fish, or a bowl (f,5vj) 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 tumbler- ful of warm milk. 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. AFFECTIONS OF THE PERITONEUM. 377 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 ]3ain, and quinine in doses large enough to maintain the flagging forces. Constipation is to be remedied only by simple enemata, while excessive diarrhcea may be checked by full doses of bis- muth combined with ipecacuanha and opium, as : — R. Pulv. Ipecacuanhse Comp., ' . . gr. xxiv. Bismuth. Sub-carb., ^j. 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 : — 5t . Ext. HaeraatoxyU, gr. xxx. Tr. Opii Deod., TTLxxiv. Vin. Ipecacuanhge, Tr\^xxxvj. Mist. Cretse, 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 uncomfortable, then the abdomen may be anointed once daily with — R. Ext. Belladonnae, ^ij. Glycerinse, ^3^}' M. and covered with a thick layer of cotton batting. Should the quantity of fluid in the peritoneum be large, diuretics and diaphoretics are indicated ; if excessive, paracen- tesis 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; 32 378 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. it is of sufficient import to warrant a brief, separate considera- tion. Etiology. — Ascites is sometimes produced by simple or tu- bercular inflammation of the peritoneum ; more frequently 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 hydrsemic state of the blood, attend- ing 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 dis- tended and globular, the exact shape depending upon the posi- tion 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 super- ficial 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 senee of fullness, 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 — fluctuation wave — is felt by the other hand ; this is not interrupted by pressure, made by an assistant, on the median line. While the child lies upon its 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 dullness, and the extent of the latter depends entirely upon the amount of fluid present. Pain is not a prominent symptom ; if present, it is paroxysmal, and has the griping character of the colic of intestinal indiges- tion. Such attacks are often attended or followed by moderate diarrhoia ; in the intervals the bowels may be confined. Should the effusion be large the mere weight of the fluid causes discom- fort ; then, too, respiration is embarrassed, even to the extent of orthopn(jea; micturition is painful; the urine is scanty, high- colored and albuminous, and there may be cedema of the geni- talia and legs, resulting solely from pressure. AFFECTIONS OF THE PERITONEUM. 379 Cases having an obscure etiology furnish few additional fea- tures ; there are no constant or characteristic alterations of the tongue, appetite, appearance of the skin or temperature ; for these, with other rational symptoms, depend upon the determin- ing disease. When due to inflammation of the peritoneum, the amount of effusion is small ; the abdomen is tense and tender ; the tempera- ture is usually elevated, and the general symptoms of acute or chronic peritonitis are more or less marked. In hepatic disease, especially cirrhosis, the effusion is great ; the superficial abdominal veins are very prominent ; the hemor- rhoidal veins are distended ; the spleen is often enlarged ; the digestive functions are im^paired, and the general integument has a sallow hue or is decidedly jaundiced. 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 dis- tended and pulsating ; there is dyspnoea, and a scanty, albu- minous urine, with the physical signs of heart lesion. Diagnosis. — There is little difficulty in detecting ascites, un- less the effusion be so small that it sinks away into the pelvis or between the folds of the intestine beyond the reach of the ex- a niner's hand. Under these cir^u.nstances it is well to try Du- pircque's method (see page ^,66^ of increasing the distinctness of fluctuation, or to put in practice another plan for the same pur- pose, namely, placing the patient on the hands and knees so that the fluid may gravitate 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 distention of the intes- tines, 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 380 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. or Other kidney — hydronephrosis — is attended by abdominal distention, fluctuation, and percussion duhiess. The enlarge- ment, however, is more noticeable on the side of the affected kidney : here, also, there is more resistance and greater dullness, the opposite flank being often tympanitic ; 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. The Prognosis depends chiefly upon the nature of the origin- ating disease. When this cannot be discovered, the forecast must be based upon the general strength and nutrition, the con- dition of the skin, the temperature, and the character of the urine. If the strength be moderately preserved, the appetite and digestion fairly good, the skin natural 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 con- sideration 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. Ferii Sulph. Exsiccat. , . gr. xxiv (to be increased to ^j), Quiniae Sulph., gr. xij. Acid. Sulphurici dil., .... TT\^xij. Syrupi, f5J. Aquae Menth. Pip., . , q. s. ad f 5 iij. M. S. — Two teaspoonfuls three times daily, taken diluted and after eating, for a child of six years. Diuretics can be employed at tlie same time, if there be no kidney complication, for example : — AFFECTIONS OF THE PERITONEUM. 38 1 R . Potassii Acetatis, . . . - ^ij. Spt. Juniperis Comp., f^ss. Spt. yElheiis Nitrosi, f^vj. Syrupi, . . f ^ ij- Aquae, q. s. ad f^^ vj. M. S. — Two teaspoonfuls every three hours. A combination of acetate of potassium, squill and digitalis is often useful. Should this class of remedies fail, much may be accomplished by a properly regulated course of purgatives. For this purpose, thirty grains of compound licorice powder, or ten grains of com- pound 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 oatmeal 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 instru- ment having been inserted is left in position ; a rubber tube is 382 DISEASES OF DIGESTIVE ORGANS IN CHILDREN. attached, and the fluid allowed to drain away slowly for some ^ight or ten hours, constant and equal pressure being maintained in the meanwhile by a broad bandage. After the canula is re- moved, the abdomen must either be strapped or carefully band- aged. 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. INDEX. A. Abdomen, barrel -shaped, 49 distention of, 48 examination of, 47 scaphoid, 50 tenderness of, 50 Abdominal respiration, 39 Abnormal dentition, 149 Abscess, mammary, 67 retropharyngeal, 197 Absorption of fat, 47 Accelerated breathing, 40 Acute gastric catarrh, 199 anatomical lesion of, 206 symptoms of, 200 diagnosis of, 201 prognosis of, 20 r treatment of, 201 intestinal catarrh, 227 etiology of, 228 symptoms of, 229 diagnosis of, 230 prognosis of, 230 treatment of, 231 Acute pleuritis, 27 Affections of the liver, 337 of the mouth and throat, 124 of the peritoneum, 364 of the stomach and intestines, , . 199 , Air insufflation of, 309 Alae nasi, dilatation of, 21 Alantoin, 33 Albumin, 35 Ammoniacal breath, 31 Amyloid liver, 347 morbid anatomy of, 347 etiology of, 348 symptoms of, 348 Amyloid liver, diagnosis of, 349 prognosis of, 349 treatment of, 349 Anaemia, 44, 1 21-123 Analysis of breast-milk, 73 Anatomical lesion of acute gasiric catarrh, 2CX) of aphthous stomatitis, 126 of catarrhal stomatitis, 124 of simple pharvng.iis, 183 of ulcerative stomatitis, 131 Anterior fontanelle, 46 Antiseptics m entero-colitis, 257 Apex beat in pleuritis, 52 Apparatus for gavage, 1 13 for hand feeding, 96 Aphthous stomatitis. 126 anatomical lesions of, 126 etiology of, 126 symptoms of, 127 diagnosis of, 128 treatment of, 128 Arrowroot water, 232 Artificial feedmg, 71 Ascaris lumbricoidcs, 312 egg of, 313 symptoms of, 319 treatment of, 321 Ascites, 377 etiology of, 378 symptoms of, 378 diagnosis of, 379 prognosis of, 380 treatment of, 380 Aspirating hepatic abscess, 363 Asses' milk, 73 383 ;S4 INDEX. Asthma, 41 Astringent bath, 104 Atrophic cirrhosis, 352 Atrophy, simple, 279 Attendant, questioning the, 1 8 Auscultation of the chest, 52 Auvard's hatching cradle, 1 1 1 B. Bandage, abdominal, 105 Barley water, 80 Barrel-shaped abdomen, 49 chest, 51 Basham's mixture, modified, 350 Bath, astringent, 104 bran, 104 cold, 103 cooled, 103 hot, 103 mercurial, 104 mustard, 104 nitro mvtrialic acid, 104 salt water, 104 soda, 104 Bathing, 102 mode of, 102 Bed clothes, 108 Beef juice, raw, 92 tea, 84 Bethlehem oatmeal, in constipation, 276 Bicarbonate of sodium, 80, 87, 88 Blennorrhoea, 178 Boiled milk, 85 Boracic acid, 68 Bothriocejjhalus latus, 311 Bottle, graduated nursmg, 95 Bottle tip, 96 Bran bath, 104 Brandy and egg mixture in intussuscep- tion, 308 Breast-feeding, 60 proper, number per day, 62 milk, analysis of, 73 spec. grav. of, 72 Breath, the, 29 fetor of, 31 ill smelling, 29 .Breathing, different forms of, 41 puerile, 52 Bridge of nose, broadness of, 23 Bright's disease, 34 Brinton's theory of fxcal vomiting. Bronchitis during dentition, 179 Broth, veal, 92 veal, with barley water, 208 Brows, contraction of, 22 c. Calculi, intestinal, 288 Cancer of the liver, 363 Cardiac disease, 56 Caseous degeneration and tuberculosis of the mesenteric glands, 329 Casts in the urine, 36 Catarrh, acute intestinal, 227 chronic gastro-intestinal, 213 of the bladder, 36 Catarrhal stomatitis, 124 anatomical lesions of, 124 etiology of, 124 symptoms of, 125 treatment of, 125 Causes of ill smelling breath, 29 Cereal foods, 77 Cerebral disease, 24 Cestodes, 311 Cheese poison in milk, 99 Chest, examination of, 50 inspection of, 51 barrel-shaped, 51 auscultation of, 52 palpation of, 54 percussion of, 55 Che)ne-Stoke's respiration, 41 Child, inspecting the, 20 position of, during feeding, 97 Children, general management of, 60 Childhood, 100 Chlorate of potassium, 134, 135 Cholera infantum, 258 morbid anatomy of, 258 etiology of, 259 symptf;ms of, 2^9 diagnosis of, 261 prognosis of, 262 treatment of, 262 Chorea, 122, 182 Chronic diarrhoea, 235 enlargement of tonsils, 24, 194 entero-colitis, 235 INDEX. 3S5 Chronic entero colitis, morbid anatomy of, 235 etiology of, 235 symptoms of, 236 diagnosis of, 240 prognosis of, 240 treatment of, 241 gastric catarrh, 202 morbid anatomy of, 203 etiology of, 203 symptoms of, 204 diagnosis of, 206 prognosis of, 206 treatment of, 207 gastro-intestinal catarrh, 213 hydrocephalus, 46 intussusception, 304 lung disease, 26 peritonitis, 364 Cirrhosis of the liver, 352 morbid anatomy of, 352 etiology of, 353 symptoms of, 354 diagnosis of, 355 prognosis of, 355 treatment of, 355 Clinical investigation of disease, 17 thermometer, 43 Clothing, 105 change of, 105 Clotting, to prevent, 79 Clubbing of the finger tips, 26 Cold bath, 103 Colic, 270 etiology of, 270 symptoms of, 270 treatment of, 271 Collapse, 260, 263, 302 Colon, 299 Condensed milk, 75-85 reared children, 76 Congestion of the liver, 343 morbid anatomy of, 343 etiology of, 343 symptoms of, 343 diagnosis of, 344 prognosis of, 344 treatment of, 345 Conjunctival blennorrhoea, 151 during primaiy denti- tion, 178 Constipation, (see Habitual Constipa- tion, 273) Convulsions caused by teething, 161 in chronic entero- colitis, 238 Cooled bath, 103 Cough, varieties of, 28 stomach, 227 Cows' milk, analysis of, 74 spec. grav. of, 74 sound, 98 Cream, whey and barley water mix- ture, 207 Crib, the, 108 Croup, 59 Cyanosis, 112 Crying, different characters of, 27 Crusta lactea, 156 Cysticercus cellulosae, 316 Cystitis, tubercular, 361 D. Day nursery, 107 Decubitus, 23 Defecation, frequency of, 32 Deformity of sternum caused by hy- pertrophy of tonsils, 195 Dental paralysis, 162 Dentition, 148 delayed, 150 difficult, 150 irregular, 150 Dermatitis, 155 Development, 45 Diabetes, 34 Diachylon ointment, 159 Diagnosis of acute gastric catarrh, 201 of acute intestinal catarrh, 230 of amyloid liver, 349 of aphthous stomatitis, 128 of ascites, 379 of cholera infantum, 261 of chronic entero-colitis, 240 of chronic gastric catarrh, 206 of cirrhosis of the liver, 335 of congestion of the liver, 344 of dysentery, 265 of entero-colitis, 252 of fatty infiltration of the li\er, 346 of follicular tonsillitis, i8q 386 INDEX. Diagnosis of habitual constipation, 274 of habitual indigestion, 217 of intussusception, 305 of jaundice, 339 of mucous disease, 220 of noma, 139 of peritonitis, 36S of simple atrophy, 284 of simple pharyngitis, 184 of suppurative hepatitis, 362 of suppurative tonsillitis, 192 of syphilitic hepatitis, 351 of tabes mesenterica, 332 of thrush, 145 of tubercular peritonitis, 375 of typhlitis, 291 of worms, 319 Diagram showing eruption of milk teeth, 148 showing method of lancing gums, 163 showing relation between the permanent and temporary teeth, 170 Diarrhoea, chronic, 235 during 2d dentition, 177 Diathesis, tuberculous, 22 Diet during 2d dentition, 175 during the first week, 81 during the sixth month, 82 for 8th and 9th months, 83 for 7th month, 82 for six weeks, 84 for tenth month, 65 for loth and nth months, 84 from 18 months to 2^ years, 93 from 2d to the 6th week, 81 • from 6th week to the end of 2d month, 82 from 3d to the 6th month, 82 from 3j^ years up, 10 1 from 1 2th to the i8th month, 93 in amyloid liver, 349 in aphthous stomatitis, 129 in ascites, 381 in acute intestinal catarrh, 232 in chronic entero-colitis, 242,243 in cirrhosis of the liver, 356 in colic, 271 in congestion of the liver, 345 in constipation, 276 Diet in dysentery, 266 in entero-colitis, 255 in intussusception, 30S in mucous disease, 221 in peritonitis, 370 in simple pharyngitis, 185 in suppurative hej^atitis, 362 in tabes mesenterica, 335 in tapeworm, 324 in tubercular peritonitis, 376 in typhlitis, 293, 294 up to 3)^ years, 100 Difficult dentition, 150 complications during, 161 local affections of, 150 sympathetic effects of, 151 Diphtheria, urine in, 37 Disease, features of, 20 investigation of, 17 of the digestive organs, 124 Disorders of the digestive system during 2d dentition, 176 Distention of abdomen, 48 of bladder, 50 Drinking, mode of, 26 Dysentery, 264 morbid anatomy of, 264 etiology of, 264 symptoms of, 264 diagnosis of, 265 prognosis of, 265 treatment of, 265 Dyspnoea, expiratory, 41 inspiratory, 41 E. Ear ache, 24, 27 Ears, nerve supply of, 168 Eating between meals, loi Eczema during primary dentition, 15 \. during second dentition, 178 of the scalp, 156 treatment of, 157 Effl enrage, 116 Egg of ascaris lumbricoides, 313 of oxyuris vermicularis, 312 of tricocephalus dispar, 314 Electricity in paralysis, 1 21 Electro-cautery, 196 Emphysema, 31, 51 INDEX. 3S7 En chien de fusil, 24 Enemata in entero-colitis, 256 purgative, 274 Entero-colitis (summer diarrhoea), 248 morbid anatomy of, 248 etiology of, 249 symptoms of, 250 diagnosis of, 252 prognosis of, 253 treatment of, 253 chronic, 235 Epidemic cholera, 262 Eruption of milk teeth, 57 of permanent teeth, order of, 169 of permanent teeth, 164 of temporary teeth, 148 Etiology of acute intestinal catarrh, 228 of amyloid liver, 34.8 of aphthous stomatitis, 126 of ascites, 378 of catarrhal stomatitis, 124 of cholera infantum, 259 of chronic entero-colitis, 235 of chronic gastric catarrh, 203 of cirrhosis of the liver, 353 of colic, 270 of congestion of the liver, 343 of dysentery, 264 of entero-colitis, 249 of fatty degeneration of the liver, 347 of fatty infiltration of the liver, 346 of follicular tonsillitis, 187 of gangrenous stomatitis, 136 of habitual constipation, 273 of habitual indigestion, 213 of hypertrophy of the tonsils, 194 of intussusception, 300 of jaundice, 338 of mucous disease, 217 of peritonitis, 365 of simple atrophy, 279 of simple pharyngitis, 183 of tabes mesenterica, 330 of thrush, 142 of tubercular peritonitis, 372 of tubercular ulceration of the intestines, 268 of typhlitis, 289 of ulcerative stomatitis, 131 Evacuations, fecal. 31 Examination, physical, 39 Exercise, 108 Exhaustion, 299 Expiratory respiration, 41 Explanation of Plate I, 165 Eyelids, incomplete closure of, 21 lividity of, 25 pufhness of, 22 twitching of, 21 Eyes, nerve supply of, 167 Eye teeth, 151 F. Face, the, 21 the change of features in disease, 21 Fdecal abscess, 287 accumulation, 49 evacuations, 31 tumor, 31 Faradism, 122 Farinaceous food, 76 Fatty degeneration of the liver, 347 liver, 346 infiltration of the liver, morbid anatomy of. 346 of the liver, symptoms of, 346 of the liver, etiology of, 346 of the liver, prognosis of, 346 of the liver, diagnosis of, 346 Fauces, the, 58 Febrde diarrhoea, 248 Features of disease, 20 Feeding, 60 apparatus, care of, 97 artificial, 71 breast, 60 by a wet nurse, 69 general rules for, 79 intervals of, 64 mistake of constant, 63 Fever, temperature in, 44 Feverish breath, 30 Filtered water, loi Finger-nails, blueness of, 26 , deformity of, 26 ;88 INDEX. Fissure of nipple, 67 treatment for, 68 Flour ball, S3 Follicular tonsillitis, 187 etiology of, 1S7 symptoms of, 1 87 diagnosis of, 187 prognosis of, 188 treatment of, 189 Fontanelle, 46 bulging of, 46 Fcod, farinaceous, 76 Horlick's, 81 Mellin's, 81 preparation of, 97 quantity per diem, 77 Forced enema in intussusception, 309 Fraenum lingure, ulceration of, 150 Friction, 117 P'ormula for acute gastric catarrh, 201 for an alkaU in jaundice, 339 for catarrhal stomatitis, 126 for chronic gastric catarrh, 210 for congestion of the»liver, 345 for convulsions, 162 for enlarged glands during 2d dentition, 178 for entero-colitis, 257 for jaundice, 342 for painting about loose teeth, 172 for peritonitis, 371 for second dentition, 175 for softening the gums, 172 for tubercular ulceration of the intestines, 269 for urticaria, 154 for vomiting, 153 Formulae for acute intestinal catarrh, 233. 234 for amyloid liver, 350 for aphthous stomatitis, 130 for ascaris lumbricoides, 322, 323 for ascites, 380, 381 for cholera infantum, 263 for chronic entero- colitis, 244, 245 for cirrhosis of the liver, 356 for colic, 272 for constipation, 277 for dysentery, 266, 267 for eczema, 158, 159, 160 for follicular tonsillitis, 189, 190 Formula for hypertrophy of the ton- sils, 195, 196 for intussusception, 307 for laxative, 157 for rrucous disease, 224, 225, 226, 227 for oxyuris vermicularis, 321 for simple pharyngitis, 185, 186 for suppurative tonsillitis, 193 for syphilitic hepatitis, 352 for tabes mesenterica, 336 for tapeworm, 324, 325, 326 for thrush, 147 for tubercular peritonitis, 377 for typhlitis, 293, 294 for ulcerative stomatitis, 134 Furrows, facial, 22 G. Gangrenous stomatitis, 136 etiology of, 136 symptoms of, 136 treatment of, 137 Gastric catarrh, acute, 199 (see Acute Gas. Cat.) chronic (see Chron. Gas. Cat.) Gastro-intestinal catarrh, 260 Gastro-malacia, 212 Gavage, 113 de renfort, 1 14 " Gelatine, 80 Genal furrows, 22 General development, 45 Gluten flour, 324 Glycerine suppositories in constipation , 276 Goats' milk, 73 Gradual w^eaning, 64 Graduated nursing bottle, 95 Growing pains, 123 Growth, 45 Gums, condition of during dentition, 149 " Gun-hammer" decubitus, 284 H. Habitual constipation, 273 etiology of, 273 symptoms of, 274 diagnosis of, 274 INDEX. 389 Habitual constipation, prognosis of, 274 treatment of, 274 indigestion, 213 etiology of, 213 symptoms of, 215 diagnosis of, 217 prognosis of, 217 treatment of, 217 Halitosis, 29 Hand-feeding, success in, 96 to insure success in, 72 Hands, movement of, 24 Hard palate, 58 Hatching cradle, 109 Headache during second dentition, 179 Head, shape of, 23 Heavy breath, 30 Hebra's diachylon ointment, 159 ^ Hemorrhage, renal, 35 Hepatitis suppurative, 357 syphilitic, 351 Herpes of the lips during second den- tition, 178 Hip-joint disease, 46 Hob-nailed liver, 352 Horlick's food, 81 Hot bath, 103 Hydrocephalus, spurious, 206 Human milk, substitute for, 73. Humanized milk, analysis of, 88 Hunger, 27 Hydatid disease of the liver, 363 , Hydrencephalic cry, 27 Hydrocephalus, 46 Hydronephrosis, 36 Hypertrophic cirrhosis, 353, Hypertrophy of the tonsils, 194 etiology of, 194 symptoms of, 194 treatment of, 195 Hypostatic pneumonia in chronic en- tero-colitis, 238 I. Icterus, 337 neonatorum, 338 in older children, 341 treatment of, 342 Idiopathic form of acute gastric ca- tarrh, 199 Ileo-Ccccal intussusception, 305 Immature infants, management of, 109 Incontinence, 36 Incubator, 109. Incubators, description of, ill Indican, 34, 37 Indigestion, 200 Infants' food, type of, 72 foods, 77 Inflammation of the colon and rectum (see Dysentery), 264 Injections, medicated, 320 Inspection of chest, 51 of child, 20 Inspiratory respiration, 41 Insufflation of air in intussusception, 309 Intertrigo in simple atrophy, 283 Intestinal concretions, 288 worms, 311 Intestines, nerve supply of, 166 Intussusception, 296 varieties of, 296 morbid anatomy of, 297 without symptoms, 297 with symptoms, 297 results of, 298. strangulation in, 298 etiology of, 300 symptoms of, 30I diagnosis of, 305 prognosis of, 306 treatment of, 306 reduction of, 309 Invagination, 306 Investigation of disease, 17 Inward spasms, 283 J- Jadelot's lines, 22 Jaundice, 337 etiology of, 338 grade of seventy, 338 diagnosis of, 338 due to congenital malformation of the bile ducts, 339 treatment of, 339 Junket, 65 390 INDEX. K. Kidney, sarcoma of, 36 Kidneys, amyloid degeneration of, 38 lesions of, 29 L. Labial furrows, 22 Lactation, 66 Lactometer, 74 Lancing the gums, 163 Laparotomy in intussusception, 309 Laryngeal stenosis, 41 Lar)nx, nerve supply of, 168 Lavage, 114 Laxative confection, 279 Leeds' analysis of breast milk, 73 Leucorrhcea, 318 Lids, incomplete closure of, 21 Lime, saccharated solution of, 80 water, 80 1 .ines of Jadelot, 22 Lips, herpes of, 178 puffing of, 51 Lilhaemia, 36 Lithuria, 35 Liver, abscess of, 357 affections of, 337 amyloid, 347 cancer of, 363 cirrhosis of, 352 congestion of, 343 fatty degeneration of, 347 hydatid disease of, 363 fatty infiltration of, 346 syphilitic inflammation of, 351 tuberculosis of, 363 Lividity of eyelids, 25 Local treatment for simple pharyn- gitis, 186 Loss of taste during second dentition, 172 Lungs, nerve supply of, 167 M. Malarial fever, 37 Mammary abscess, 67 Manaf;ement of weak and immature infant, 109 Marasmus, 47, 305 Massage, 1 16 a frictions, 1 17 effects of, 117 in chorea, 122 in chronic gastro-intestinal ca- tarrh, 119 in colic, 120 in constipation, 120 in general debility and anaemia, 121 in infantile paralysis, I2I in pleurisy, 123 in pseudo-hypertrophic paralysis, 123 Masturbation, 35 Maxillary bones, necrosis of, 31 Meckel's ganglion, 166 Meigs' food, 85 Mellin's food, 81 Membranous croup, urine in, 37 Menstruation in nursing woman, 68 Mercurial bath, 104 Method of gavage, 113 of giving suck, 62 Microscopic examination in thrush, 143 Micturition, painful, 33 Milk, asses', 73 boiled, 85 care of, 98 condensed, 75 cows', analysis of, 74 .goats', 73 mixture for chronic gastric ca- tarrh, 208 mode of drinking, 26 peptonized, 86 poisoning, loo scanty secretion of, 67 secretion of, 61 sterilized, 88 teeth, 57 tectli, the eruption of, 148 transportation of, 98 Morbid anatomy of amyloid liver, 347 of cholera infantum, 258 ()f chronic entero coliti-;, 235 of chronic gastric catarrh, 203 ofciirhi'sis of the liv( r, 352 INDEX. 391 Morbid anatomy of congestion of the liver, 343 of dysentery, 264 of entero-colilis, 248 of fatty degeneration of the liver, 347 of fatty infiltration of the liver, 346 of intussusception, 297 of peritonitis, 364 of simple atrophy, 279 of suppurative tonsillitis, 190 of syphilitic hepatitis, 351 of tabes mesenterica, 329 of thrush, 142 of tubercular peritonitis, 371 of tubercular ulceration of the intestines, 268 of typhlitis, 287 Morbus coeruleus, 25 Mortality from laparotomy in intus susception, 310 Motor paralysis, 25 Mouth and fauces, examination of, 57 inspection of, during second denti- tion, 177 soreness of, 26 Mucous disease, 217 etiology of, 217 symptoms of, 218 diagnosis of, 220 prognosis of, 220 diet for, 221 treatment of, 220 Mustard bath, 104 N. Nails, deformity of, 26 Naphthalin in entero-colitis, 257 Nasal catarrh during second denti- tion, 178 treatment of, 179 Nausea, 39 Necrosis, 135 Nematodes, "31 1 Nephritis, 43 Nervous disorders in dentition, 179 Night-dress, 105 Nipple, fissures of, 67 Niiro-muriatic acid bath, 104 Noma (see Gangrenous stomatitis), 139 pathology and morbid anatomy of, 138 diagnosis of, 139 prognosis of, 140 treatment of, 140 Normal capacity of infant's stomach, Nostrils, sharpness of, 22 Nursing-bottle, 95 mother's diet, 67 regularity in, 62 o. Oculo-zygomatic furrows, 22 GEdema, 112 Oidium albicans, 142 Oil inunction for constipation, 275 Oral pain in second dentition, 170 Otitis, 151, 178 Oxaluria, 35 Oxyuris vermicularis, 312 egg of, 312 symptoms of, 318 treatment of, 320 Ozsena, 179 P. Painful micturition, 33 Palpation of the chest, 54 Pancreatin, 86-87, 88, 92 Papillae, 58 Paracentesis in ascites, 382 Paralysis, dental, 162 during dentition, 181 Parasitic stomatitis (see Thrush), 141 Parenchymatous nephritis, 43 Pathology and morbid anatomy of noma, 138 Peptogenic milk, powder, 88 Pei-tonization, partial, 87 Peptonized milk, 86 Percussion of the chest, 55 Perforation of the caecum, 291 Peritoneum, affections of, 364 Peritonitis, 364 morbid anatomy of, 364 etiology of, 365 symptoms of, 365 392 INDEX. Peritonitis, diagnosis of, 36S prognosis of, 370 treatment of, 370 tubercular, 371 Parasites, intestinal, ^;^ Permanent teeth, 58 eruption of, 164 order of eruption, i6g Perityphlitis (see Typhlitis, p-ri-), 287 Pertussis, 28 Petrissage, 1 16 Pharyngitis, simple, 183 Photophobia, 24 Phthisis, 54 Pnysical examination, 39 Piatt's chloride, 14I Pneumonia, hypostatic, 238 Premature weaning, 66 Process for peptonizing milk, 86 Prognosis of acute gastric catarrh, 201 of acute intestinal catarrh, 230 of amyloid liver, 349 of ascites, 380 of cholera infantum, 262 of chronic entero-colitis, 240 of chronic gastric catarrh, 206 of cirrhosis of the liver, 355 of congestion of the liver, 344 of dysentery, 265 of entero-colitis, 253 of fatty infiltration of the liver, 346 of follicular tonsillitis, 188 of habitual constipation, 274 of habitual indigestion, 217 of intussusception, 306 of mucous disease, 220 of noma, 140 of peritonitis, 370 of simple iatrophy, 285 of syphilitic hepatitis, 351 of tabes mesenterica, 333 of thrush, 145 of tubercular peritonitis, 376 of typhlitis, 292 of ulcerative stomatitis, 134 of worms, 319 Pseudo hypertrophic paralysis, 123 } uerile Ijreathing, 53 Pufifiness of eyelids, 22 Pul-.e, variations in, 42 Purpura hemorrhagica, 36 Q- Questioning the attendants, 18 Quinsy, 190 R. Raw beef juice, 92 Reaction of the urine, ^3 Red gum, 154 Reflex spasm during dentition, 180 Re_^imen in acute intestinal catarrh, 232 in amyloid liver, 350 in cholera infantum, 263 in chronic entero-colitis, 241 in chronic gastric catarrh, 209 in dysentery, 266 in entero-colitis, 254 in mucous disease, 222 in simple atrophy, 286 Renal calculus, 36 hemorrhage, 35 Resorcin in entero-colitis, 257 Respiration, 39 character of, 40 expiratory, 41 inspiratory, 41 Retention of urine, 37 Retro-pharyngeal abscess, 197 symptoms of, 197 treatment of, 198 Rheumatism, 47 Rice pudding, 100 Rickets, 59, 69, 119 Rubber shoes, 104 Rules for feeding, 79 s. Saccharated solution of lime, 80, 294 Salicylate of sodium in entero-colitis, 257 Salt-water bath, 104 Sarcoma of kidney, 36 Scarlet fever, 59, 128 Sclerema, 1 12 Secondary thrush, 144 Second dentition, disorders of, 1 70 as a cause of mucous disease, 177 i Secretion of milk, 61 INDEX. 393 Serous effusion in chronic entero- colitis, 238 Shoes, 106 Simple atrophy, 279 morbid anatomy of, 279 etiology of, 279 manner of preparing food in, 281 symptoms of, 282 diagnosis of, 284 prognosis of, 285 treatment of, 285 regimen in, 286 diarrhoea of dentition, 152 pharyngitis, 183 anatomical lesion of, 183 etiology of, 183 symptoms of, 183 diagnosis of, 184 treatment of, 185 Skin, discoloration of, in jaundice, 338 the, 25 conditions of the, 46 Sleep, 106 Sleeping, different characters of, 24 Sleeping room, 107 Soda bath, 104 Softening of the stomach, 212 Sound cows' milk, 98 Sour breath, 30 Spasms during dentition, 161 ■ inward, 283 Spec. grav. of breast milk, 72 cows' milk, 74 Spinal irritability, 123 Stationary washstand, 107 Statistics from the Maternite, in Paris, 112 Stercoraceous breath, 31 vomiting, 303 Sterilized milk, 88 rules to be observed in its use, 91 uses of, 91 Sterilizer, the author's, 89 Stomach, measurements of infants, 78 nerve supply of, 165 softening of, 212 ulcer of, 211 Stomatitis, aphthous, 126 catarrhal, 124 gangrenous, 136 Stomatitis, parasitic (see Thrush), 141 ulcerative, 131 Stools, characters of, 32 Strippings, 85, 208 Strophulus during dentition, 154 Strumous diathesis, 23 Submaxillary gland, enlargement of, during second dentition, 177 Sudden weaning, 66 Summer diarrhoea, 248 Sunstroke, 261 Superficial catarrh of the tonsils, 1S6 Suppurative hepatitis, 357 report of case, 357 symptoms of, 357 diagnosis of, 362 treatment of, 362 tonsillitis, 190 morbid anatomy of, 190 symptoms of, 19 1 diagnosis of, 192 treatment of, 192 Symptoms of acute gastric catarrh, 200 of acute intestinal catarrh, 229 of amyloid liver, 348 of aphthous stomatitis, 127 of ascaris lumbricoides,3i9 of ascites, 378 of cholera infantum, 259 of chronic entero-colitis, 237 of chronic gastric catarrh, 204 of cirrhosis of the liver, 354 of colic, 270 of congestion of the liver, 343 of dysentery, 264 of entero-colitis, 250 of fatty infiltration of the liver, 346 of follicular tonsillitis, 187 of mucous disease, 218 of gangrenous stomatitis, 136 of habitual constipation, 274 of habitual indigestion, 215 of hypertrophy of the tonsils, 194 of intussusception, 301 of oxyuris vermicularis, 318 of peritonitis, 365 of retro-pharyngeal abscess, 197 of septic peritonitis, 368 of simple atrophy, 282 33 394 INDEX. Symptoms of simple pharyngiiis, 1S3 of suppurative hepatitis, 357 of suppurative tonsillitis, 191 of tabes mesenterica, 330 of taenia, 319 of thrush, 143 of tubercular peritonitis, 372 of tubercular ulceration of the intestines, 269 of typhlitis, 289 of ulcerative stomatitis, 132 of ulcer of the stomach, 21 1 of syphilitic hepatitis, 351 of worms, 317 Syphilitic hepatitis, 351 morbid anatomy of, 351 symptoms of, 351 diagnosis of, 351 prognosis of, 351 treatment of, 352 Tabes mesenterica, 329 morbid anatomy of, 329 etiology of, 330 symptoms of, 330 diagnosis of, 332 prognosis of, ^^^ treatment of, 334 Taeniae, 314 saginata, 314 egg of, 3^5 solium, 316 symptoms of, 319 treatment of, 323 Tanret's Pelletierine for tapeworm, 326 Tapotement, 117 Tarnier's hatching cradle, no Taste, loss of, 172 Taxis in intussusception, 309 Tears, formation of, 28 suppression of, 28 Teeth, children born with, 149 ^ eruption of the temporary, 148 "^ milk, 57 permanent, 58 premature appearance of, 149 Teething cough, 178 Temperature, 43 of room, 108 variations in, 44 Thermometer, clinical, 43 Throat affections during second der.ti- tion, 172 Thron^bosis of the sinuses of the brain during chronic entero- colitis, 238 Thrush, 141 morbid appearances of, 142 etiology of, 142 symptoms of, 143 secondary, 144 diagnosis of, 145 prognosis of, 145 treatment of, 146 Tongue, 58 in disease, 59 Tonsillitis, follicular, 187 suppurative, 190 Tonsils, excision of, 196 hypertrophy of, 194 Tooth rash, 154 Treatment of acute gastric catarrh, 201 of acute intestinal catarrh, 231 of amyloid liver, 349 of aphthous stomatitis, 128 of ascaris lumbricoides, 321 of ascites, 380 of catarrhal stomatitis, 125 of cholera infantum, 262 of chronic entero-colilis, 241 of chronic gastric catarrh, 207 of cirrhosis of the liver, 355 of colic, 271 of congestion of the liver, 345 of convulsions during teething, 162 during second dentition, 175 of dysentery, 265 of eczema, 157 of entero colitis, 253 of fatty infiltration of the liver, 347 of fissure of nipple, 68 of follicular tonsillitis, 189 of habitual constipation, 274 of headache during dentition, 180 of hypertrophy of the tonsils, 195 of intussusception, 306 of icterus in older children, 342 of jaundice, 339 of mucous disease, 220 of nasal catarrh, 179 of noma, 140 INDEX. 395 Treatment ofoxyuris vermicularis, 320 of peritonitis, 370 of retro-pharyngeal abscess, 198 of simple atrophy, 285 of simple pharyngitis, 185 of superficial ulcers of the tongue, of suppurative hepatitis, 362 tonsillitis, 192 of syphilitic hepatitis, 352 of tabes mesenterica, 334 of taenia, 323 of thrush, 146 of tubercular peritonitis, 376 of tubercular ulceration of the in- testines, 269 of typhlitis, 292 of ulcerative stomatitis, 134 of ulcer of the stomach, 212 of worms, 320 Trichocephalus dispar, 314 egg of, 314 True intussusception, 297 Tubercular meningitis, 284 peritonitis, 371 morbid anatomy of, 371 etiology of, 372 symptoms of, 372 diagnosis of, 375 prognosis of, 376 treatment of, 376 ulceration of the intestines, 268 ulceration of the intestines, mor- bid anatomy of, 268 ulceration of the intestines, etiol- ogy of, 268 ulceration of the intestines, symf>- toms of, 269 ulceration of the intestines, treat- ment of, 269 Tuberculosis of the liver, 363 Tuberculous tendency, signs of, 22 Tumor, faecal, 31 Typhlitis, 287 morbid anatomy of, 287 etiology of, 289 stercoralis, 289 symptoms of, 289 ^ diagnosis of, 291 prognosis of, 292 treatment of, 292 Tyrotoxicon, 99 u. Ulceration of the appendix, 291 of the lungs, 31 Ulcerative stomatitis, 131 anatomical lesions of, 131 etiology of, 131 symptoms of, 132 diagnosis of, 134 prognosis of, 134 treatment of, 134 Ulcer of the stomach, 211 symptoms of, 211 treatment of, 212 Ulcers of the tongue during second dentition, 171 Ursemic poisoning, 31 Uric acid, 33, 37 Urine the, ;^^ spec. gray, of, 33 characters of, ^^ daily amount voided, 34 abnormal ingredients of, 35 of different diseases, 36 Urinometer, 74 Urticaria during dentition, 153 Uvula the, 58 V. Varicella, 59 Variola, 128 Veal broth, 92 with barley water, 208 Ventilation, 107 Vertigo, 319 Vesicles, herpetic, 26 Vocal fremitus, 54 Vomiting, 38 chronic, 203 during dentition, 153 stercoraceous, 303 w. Walking, delay in, 46 Weak and immature infants, 109 Weaning, 64 sudden, 66 premature, indications for, 66 Wet-nurse, feeding by, 69 proper woman for a, 70 396 INDEX. Wet-nurse, examination of, 70 diet of, 71 Whey, 81, 207 Whip worms, 314 White gum 154 ^^^looping cough, 128, 177, 217 Worms, 311 mode of entering the body, 312 symptoms of, 317 Worms, diagnosis of, 319 prognosis of, 319 treatment of, 320 Y. Yawning, 41 Yellow discoloration jaundice, 338 of the skin in CATALOGUE No. 7. DECEMBER, 1890. A CATALOGUE OF Books for Students. INCLUDING THE ? QUIZ-COMPENDS ? CONTENTS. PAGE PAGE New Series of Manuals, 2,3,4,5 Obstetrics. . . 10 Anatomy, 6 Pathology, Histology, . II Biology, II Pharmacy, . . 12- Chemistry, . 6 Physiology, . . 11 Children's Diseases, . 7 Practice of Medicine, . 12 Dentistry, 8 Prescription Books, . 12 Dictionaries, 8 ?Quiz-Compends ? • 14, IS Eye Diseases, 8 Skin Diseases, . 12 Electricity, . 9 Surgery, • 13- Gynjecology, 10 Therapeutics, • 9 Hygiene, 9 Urine and Urinary Org ans, 13 Materia Medica, . • 9 Venereal Diseases, • 13. Medical Jurisprudence, 10 PUBLISHED BY P. 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Cloth, 4.00 Roberts' Practice. New Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, m.d. ; m.r.c.p.. Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Seventh Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 Hughes. Compend of the Practice of Medicine. 4th Edi- tion. Two parts, each. Cloth, i.oo; Interleaved for Notes, 1.25 Part i. — Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part ii. — Diseases of the Respiratory System, Circulatory System and Nervous System ; Diseases of the Blood, etc. Physician's Edition. Fourth Edition. Including a Section on Skin Diseases. With Index, i vol. Full Morocco, Gilt, 2.50 Fro7n John A. Robinson, M.D., Assistant to Chair of Clinical Medicine , no^M Lecturer ' Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. Part II. — Diseases of the Respiratory System (including Phy- sical Diagnosis), Circulatory System and Nervous System; Dis- eases of the Blood, etc. *:).* These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpub- lished. No. 4. PHYSIOLOGY, including Embryology. Fifth Edition. By Albert P. Bkubaker, m.d.. Prof, of Physiology, Penn'a College of Dental Surgery ; Demonstrator of Physiology in Jefferson Medical College, Philadelphia. Revised, Enlarged and Illustrated. No. 5. OBSTETRICS. Illustrated. Fourth Edition. By Henky G. Landis, m.d.. Prof, of Obstetrics and Diseases of Women, in Starling Medical College, Columbus, O. Revised Edition. New Illustrations. BLAKISTON'S ? QUIZ-COMPENDS ? No. 6. ■ MATERIA MEDICA, THERAPEUTICS AND PRESCRIPTION WRITING. Fifth Revised Edition. With especial Reference to the Phj'siological Action of Drugs, and a complete article on Prescription Writing. Based on the Last Revision of the U. S. Pharmacopoeia, and including many unofificinal remedies. By Samuel O. L. Potter, m.a., m.d., late A. A. Surg. U. S. Army; Prof, of Practice, Cooper Medical College, San Francisco. Improved and Enlarged, with Index. No. 7. GYN.ffiCOLOGY. A Compend of Diseases of Women. By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. 45 Illustrations. No. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery. By L. Webster Fox, m.d., Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 Formulae. Second Enlarged and Improved Edition. Index. No. 9. SURGERY, Minor Surgery and Bandaging. Illus- trated. Fourth Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations and other operations ; Inflam- mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d.. Demonstrator of Surgery, Jefferson Medical College. Revised and Enlarged. 84 Formulae and 136 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By Henry Leffmann, m.d.. Prof, of Chemistry in Penn'a College of Dental Surgery, Phila. Third Edition, Revised and Rewritten, with Index. No. II. PHARMACY. Based upon " Remington's Text-book of Pharmacy." By F. E. Stewart, m.d., ph.g., Quiz-Master at Philadelphia College of Pharmacy. Third Edition, Revised. No. 12. VETERINARY ANATOMY AND PHYSIOL- OGY. 29 Illustrations. By Wm. R. Ballou, m.d.. Prof, of Equine- Anatomy at N. Y. College of Veterinary Surgeons. No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- CINE. Containing all the most noteworthy points of interest to the Dental student. By Geo. W. Warren, d.d.s., Clinical Chief, Penn'a College of Dental Surgery, Philadelphia. Illus. No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. Hatfield, Prof, of Diseases of Children, Chicago Medical College. Colored Plate. Bound in Clotli, $1. Interleaved, for the Addition of ITotes, $1.25. These books are constantly revised to keep up with the latest teachings and discoveries^ so that they contain all the new methods and principles . No series of books are so cojnplete in detail, concise in language, or so well printed and bound. Each one forms a complete set of notes upon the subject under consideration. Illustrated Descriptive Circular Free. JUST PUBLISHED. GOULD'S NEW Medical Dictionary COMPACT. CONCISE. PRACTICAL. ACCURATE. •'