Diseases of children ; a textbook for the use of students and practitioners of medicine

Preface To The Third Edition

The present work, while based upon the previous editions of the author's Diseases of Children, has been entirely re-written. The bulk of the material is, therefore, new; this applies particularly to the chapters on infant feeding, diseases of the digestive tract, infantile diarrheas and constitutional diseases. It has also been necessary to add a number of new articles, for example — lethargic encephalitis, myatonia congenita, spasmophilia, the exudative diathesis and acidosis. On the other hand, some topics which were discussed in the former edition are omitted as they were of purely surgical interest. Illustrations have also been omitted in an effort to keep down the bulk of the book. The author feels that they are not essential to a work of this size and scope.

The prime objective of the writer has been to present to the profession a work which will answer the purposes of a text-book for students and a reference book for the busy practitioner. He has, therefore, endeavored to give not only a concise description of the diseases of children but also full instructions in the care aud feeding of infants and children and in the treatment of the diseases under discussion.

The homeopathic treatment of the diseases of children is fully discussed and is based upon the author's many years of experience in this field. The indications for the selection of the homeopathic remedy as well as the dosage and method of administration are presented in such a manner that physicians

IV PREFACE

who have not had special training in homeopathic materia medica but who desire to use homeopathic treatment in their practice can get the information and help they are seeking. The chapters on Homeopathic Therapeutics and Homeopathic Prescribing in Diseases of Children have been especially written with this point in mind. The author desires to say, however, that he has felt free to discuss and present all methods of treatment which are generally accepted as possessing specific clinical value irrespective of their mode of action and wherever their use is advisable or is imperative, he has unequivocally recommended them.

Philadelphia, June, 1922.

Preface To The Second Edition

Since the appearance of the first edition of this work a number of important discoveries have been made in the field of Pediatrics, and some significant changes have occurred in the views held at that time regarding the etiology and treatment of not a few of the commonest affections in childhood. Furthermore, it is but fair to say that the writer himself has felt the need for revising some of his views expressed in the former edition, for with riper years and larger experience he has learned the value of conservative methods, and has endeavored to replace the mere possibilities of therapeutics with clinical certainties.

The text has been entirely rewritten, and new matter has been added wherever it was found desirable to amplify any subject. The chapter upon Infant Feeding is practically new, and the aim has been to present in a concise and clear form the most acceptable and modern views upon this subject, which has of late years been made unnecessarily complicated. A chapter upon Diseases of the Ear, 'Nose and Throat has been added, and illustrations have been inserted wherever a picture or a diagram could be advantageously employed to elucidate the text.

I am again indebted to a number of my colleagues for valuable suggestions and friendly co-operation, which, to my mind, is necessary in any work covering so broad a field as that of Pediatrics. Dr. Chas. M. Thomas has kindly read the sections dealing with the diseases affecting the eyes, the ears,

VI PREFACE

the nose and the throat, and has made a few additions to the manuscript. To Dr. Wm, B. Van Lennep I am indebted for assistance in revising the articles upon appendicitis and intussusception, and also for suggestions concerning the treatment of other conditions, wherever this has presented a surgical aspect. Dr. W. D. Bayley has kindly offered some suggestions relative to Mental and Nervous Diseases.

For the excellent index I am indebted to Dr. Ernest A. Farrington, whose painstaking arrangement of the various subjects mentioned and discussed must of necessity add to the practical value of the book. I have also to thank the publishers for their liberality in preparing the many illustrations, and for numerous other courtesies.

I cannot refrain from expressing my appreciation of the kind reception which the first edition received at the hands of the profession and of the students of our colleges, and while my aim has been not to overstep the bounds of a Text-Book, I trust that the busy practitioner will find within these pages all the practical information which he may need.

February, 1906.

Preface To The First Edition

In presenting this work to the profession the author has aimed to make it a purely clinical one.

In the sections on treatment he has endeavored to give his own experience as much as possible, and has sought to exclude all doubtful symptoms and theoretical indications.

The section on Skin Diseases is from the pen of Dr. Leon T. Ashcraft, Lecturer on Venereal Diseases at the Hahnemann College.

In the section on Nervous Diseases, valuable suggestions have been made by Dr. Weston D. Bayley, Lecturer on Mental Diseases and Clinical Instructor in Nervous Diseases at the Hahnemann College.

Philadelphia j 1899.

Table Of Contents

CHAPTEE I.

Hygiene and Nursing.

The New-born — Bathing — Clothing — The Mouth and Teeth — Sleep — The Bowels — Airing — Exercise — Premature and Delicate Infants — The Care and Nursing of Sick Children — Temperature in the Sick Eoom — Clothing in Sickness — Heat — Baths — Packs — Inhalation — Lavage — Irrigation of the Colon and Enemata 1

CHAPTER II. Methods of Clinical Examination

The Period of Infancy and Childhood — Mortality — The History — Physical Examination — Palpation — Percussion — Auscultation — Pulse Temperature, Eespiration — The Urine 10

CHAPTEE III.

Therapeutics.

Homeopathy — Dosage — Prescribing in Diseases of Children 24

CHAPTEE IV.

Infant Feeding.

Anatomy and Physiology of the Digestive Tract — The Stools — Factors Influencing the Character of the Stools — Abnormal Constituents in the Stools — Maternal Nursing — Indications for Mixed Feeding — Indications for Weaning — The Wet-nurse — Metabolism in Infancy — Protein Metabolism — Fat Metabolism — Carbohydrate Metabolism — The Mineral Salts in Metabolism — Artificial Feeding — Caloric Eequirements in Infancy — Calorie Eequirements and Weights According to Age — The Digestibility of Cow's Milk — The Proteins of Cow's milk— The Fat of Cow's Milk— The Carbohydrate of Milk— The Quantity of Food Eequired— Top-Milk Dilutions — Method of Calculating the Ingredients in the Food — Method of Estimating Percentages in a Milk Formula — Method of Estimating the Number of Calories in a Milk Formula — The Use of Lime Water and Other Alkalies — Pasteurization; Boiled Milk — The Preparation of the Food — Feeding During the Second Year —

X CONTENTS

Diet for a Child 1 Year to 18 Months— Diet for a Child 18 Months to 2 Years — Diet for a Child 3 Years and Over — Forbidden Foods — Special Foods and Proprietary Foods 34

CHAPTER V.

Diseases of the Newborn.

Congenital Defects — Asphyxia — Cephalhematoma — Hematoma of the Sterno-mastoid Muscle — Intracranial Hemorrhages — Septic and Other Infections in the New-born — Erysipelas — Tetanus — Gonorrhea — Ophthalmia Neonatorum — Acute Fatty Degeneration, or Buhl's Disease — Acute Hemoglobinuria, or Winkel's Disease — Mastitis — Vaginal Hemorrhage — Icterus Neonatorum — Hemorrhagic Disease of the New-born — Sudden Death in Infants 83

CHAPTER VI.

Diseases of the Mouth.

Dentition — Abnormalities of the Teeth — Stomatitis — Catarrhal Stomatitis — Pityriasis Linguae — Aphthous Stomatitis — Bednar's Aphthae — Aphthae Epizooticae — Ulcerative Stomatitis; Putrid Sore Mouth — Parasitic Stomatitis; Thrush — Gangrenous Stomatitis — Noma — Treatment of Stomatitis 95

CHAPTER VII.

Diseases of the Gastrointestinal Tract.

Introductory — Vomiting — Acute Gastric Indigestion; Dyspepsia — Chronic Indigestion — Coeliae Disease — Mucous Colitis — Infantilism — Hirschsprung's Disease — Acidosis — Cyclic, or Recurrent Vomiting — Hypertrophic Pyloric Stenosis — Diarrhea — Dyspeptic Diarrhea; Acute Intestinal Indigestion — Infectious Diarrhea — Cholera Infantum — Acute Ileocolitis; Dysentery — Membranous Colitis — Special Symptoms and Their Management — Remedies — Constipation — Intussusception — Appendicitis — Intestinal Parasites — Morphology — Ascaris Lumbricoides — Tenia Saginata — Tenia Solium 104

CHAPTER VIII.

Diseases of the Peritoneum.

Acute Peritonitis — Chronic Peritonitis; Tuberculous Peritonitis 161

CHAPTER IX.

Diseases of the Respiratory Tract.

Spasm of the Glottis — Acute Catarrhal Laryngitis; Spasmodic Croup — Acute Bronchitis — Chronic Bronchitis — Bronchial Asthma — Acute

CONTEXTS XI

Bronchopneumonia — Croupous Pneumonia — Cerebral Pneumonia — Wandering Pneumonia — Central Pneumonia — Pneumonia with Gastrointestinal Symptoms — Influenzal Pneumonia — Abortive Pneumonia — Typhoid-Pneumonia — Pleuro-Pneumonia — Complications — Physical Signs — Pulmonary Tuberculosis — Acute Miliary Tuberculosis — Tuberculous Bronchopneumonia — Chronic Pulmonary Tuberculosis — Special Symptoms — Emphysema 165

CHAPTEE X.

Diseases of the Heart and its Membranes.

Introductory — Congenital Diseases and Deformities — Pericarditis — Endocarditis; Valvular Heart Disease — Myocarditis 219

CHAPTER XL

Diseases of the Kidneys and Urinary Tract.

Introductory — Albuminuria — Postural Albuminuria; Lordotic Albuminuria — Edema Without Kidney Lesion — Hematuria; Hemoglobinuria — Acute Nephritis — Chronic Nephritis; Bright 's Disease — Chronic Parenchymatous Nephritis — Chronic Interstitial Nephritis — Diabetes Insipidus — Diabetes Mellitus — Pyelitis — Enuresis — Vulvovaginitis ; Gonorrhea 242

CHAPTER XII.

Diseases of the Skin.

Introductory — Miliaria; Prickly heat — Eczema — Erythema Scarlatinoides — Furunculosis ; Boils — Impetigo Contagioso — Urticaria ; Hives — Vegetable Parasitic Diseases; Tinea — Tinea Tonsurans; Ringworm of the scalp — Tinea Circinata; Ringworm — Animal Parasites — Scabies; Itch 268

CHAPTER XIII.

Diseases of the Blood.

Introductory — Anemia — Chlorosis — Progressive Pernicious Anemia — Leukemia; Pseudo-Leukemia; Splenic Anemia; Hodgkin's Disease — Anemia Infantum Pseudoleukemia Von Jaksch — Hemophilia — Purpura 285

CHAPTER XIV.

Diseases of the Nervous System.

Introductory — Psychoses — Idiocy and Mental Deficiency — Mongolian Idiocy — Sporadic Cretinism — Meningitis — Epidemic Cerebrospinal Meningitis; . Spotted Fever — Tuberculous Meningitis — Lumbar Puncture — Lethargic, or Epidemic Encephalitis — Hydrocephalus — Convulsive Affections — Epilepsy — Chorea — Spasmus Nutans ; Head-

Xll CONTENTS

nodding with Nystagmus — Neuropathic Constitution and Hysteria — Paralytic Affections; Cerebral Palsies — Little's Disease — Acute Poliomyelitis, or Infantile Paralysis — Progressive Muscular Atrophy — Pseudo -hypertrophic Paralysis — Family Ataxia — Syringomyelia — Multiple Cerebro-spinal Sclerosis — Myatonia Congenita — Multiple Neuritis — Headache 304

CHAPTER XV.

Diseases of the Ear, Nose and Throat.

Introductory — < Otitis — Earache — Discharge — Tuberculosis — Influenza — Acute Catarrhal and Acute Purulent Otitis Media — Acute Tonsillitis — Acute Superficial Tonsillitis — Acute Follicular Tonsillitis — Vincent's Angina — Acute Parenchymatous Tonsillitis; Peritonsillar Abscess — Hypertrophy of the Tonsils — Eetro-pharyngeal Abscess — Acute Rhinitis; Pseudo-Membranous Rhinitis — Simple Chronic Rhinitis — Purulent Rhinitis — Hypertrophic Rhinitis; Atrophic Rhinitis — Treatment of Chronic Rhinitis — Adenoid Vegetations of the Naso-pharynx 393

CHAPTER XVI.

Diathetic and Constitutional Diseases.

Marasmus, or Athrepsia; Malnutrition — Rickets; Rachitis — Fetal Rickets — Infantile Scurvy; Barlow's Disease — Exudative Diathesis — Spasmophilia; Tetany — General Convulsions; Infantile Eclampsia — Status Lymphaticus and Enlargement of the Thymus Gland — Tuberculosis — Scrofula — Tuberculous Adenitis — Hereditary Syphilis — Rheumatism 422

CHAPTER XVII.

Acute Infectious Diseases.

Exanthemata — Measles, Rubeola — Scarlet Fever — Rubella — Rubella Scarlatinif orme — Diphtheria — Klebs-Loeffler Bacillus — Diphtheritic Paralysis — Septic Diphtheria — Primary Laryngeal Diphtheria — Pseudo -Diphtheria — The Shick Test — Serum Therapy — Glandular Fever — Typhoid Fever — Abortive Type — Reinfection and Relapses ; Recurrences — Meningitis — Variola ; Varioloid — Vaccinia — Varicella — Varicella Gangrenosa — Pertussis — Parotitis — Secondary Parotitis — Influenza — Bacillus of Pfeiffer — Malaria; Malarial Fever — Masked or Irregular Forms of Malaria and Malarial Cachexia 471

Diseases of Children.

CHAPTER I.

HYGIENE AND NURSING.

The New-born. — The first step in the care of the new-born infant, after respiration has been established, is the care of the eyes. They should be thoroughly cleansed with a warm, saturated solution of boric acid, after which a drop of a 2 per cent solution of nitrate of silver is dropped into each eye according to the method of Crede. By carrying out this prophylactic measure ophthalmia neonatorum can in most instances be prevented.

After the cord has been dusted with powdered boric acid and dressed in sterilized gauze the child should be wiped dry, the body anointed with sweet oil, especially when there is an abundance of vernix caseosa, then wrapped in a warm blanket and laid aside until it is convenient to give it the cleansing bath. Asepsis in the care of the cord is of the greatest importance since the majority of cases of septic infection in the new-born originate at this site. The early dropping of the cord is favored by the use of dry dressings; salves and ointments should not be used. The stump must be carefully dressed until healed.

Bathing. — The full bath should not be given until the cord has fallen off. This usually occurs at the end of the first week. The child should be bathed in a warm room, preferably before an open fireplace. The first bath must be a warm one, approximating the normal body temperature; in hardy children it can gradually be reduced, so that a temperature of 95 degrees F. may be reached, by the end of the sixth month. It should be of short duration and the body dried by light rubbing with a soft towel. The bath is best given in the morning before the second nursing. In children who do not react well the full bath may have to be discontinued and a sponge bath used instead. The use of too much soap or hard rubbing is a mistake and may cause troublesome dryness or irritation of the skin.

Clothing. — The material for the underclothing should be soft and non-irritating. In the summer it may be of cotton and for winter part wool and cotton. The clothing should fit loosely and there should be no constricting bands and heavy seams. Buttons can often be advantageously replaced by tapes. The abdominal binder should not be worn after the third month unless the infant is delicate and underweight or has an umbilical hernia. In the winter the band with shoulder straps may be worn as an extra protection to the infant's abdomen.

The diapers should not be too bulky or applied too tightly. Stockinet is light and more absorbent than linen and less expensive. Stress should be laid upon the importance of promptly removing soiled diapers and carefully washing them and then rinsing in plain water before they are again applied.

The Mouth and Teeth. — In cleansing the baby's mouth great care should be exercised not to injure the delicate mucous membrane and thus invite infection. The use of a swab of cotton dipped in a 2 per cent boric acid solution is a safer procedure than inserting the covered finger into the mouth. In the case of thrush borax should be used in place of boric acid.

The care of the teeth has an important bearing on the child's general health. Indigestion, enlarged tonsils and cervical adenitis are often directly traceable to dental caries. Malocclusion also seriously affects the child's health. As in the case of adults, we should always examine the teeth for a focus of infection in all obscure ailments of possible infectious origin.

Sleep. — The healthy infant is a good sleeper, usually not being awake more than an hour at a time and only waking for the purpose of nursing. After the sixth month it gradually becomes more wide awake during the day, requiring usually one or two naps, and about twelve hours sleep at night until it is a year old. From this time on until the fourth year it should sleep twelve hours at night and have a daily nap.

Children should be carefully trained in regular habits of sleep. The most common causes for disorders of sleep are improper training, indigestion, frequent nursing during the night and sometimes local disturbances such as too much clothing, phimosis and seat-worms.

The Bowels. — The infant can be taught to form the habit of having regular bowel movements by placing it on a chamber held on the nurse's lap and starting the movement with a suppository if necessary. This training can be begun as soon as the infant is able to sit up.

The infant should have a bowel movement once in twenty-four hours at least. If allowed to go over until the next day the movement may become hard and difficult to pass and the anus may be torn. This leads to the development of a fissure with painful defecation and consequent troublesome constipation.

Airing. — The nursery should be sunny and well-ventilated without being draughty. If the child is allowed to crawl the floor should be suitably covered. A pen is an excellent device for keeping the infant out of harm and giving it full opportunity to exercise and learn to walk.

Ventilating the nursery in winter is best accomplished by having the windows open in the adjoining room until the air has been perfectly purified, when the windows should be closed and the communicating door opened to allow a diffusion of the atmosphere from one room to the other. Once a day, however, when the infant is out of the nursery, it should be thoroughly aired.

As a rule, in the spring and fall an infant may be taken out into the fresh air at one month and even earlier during the summer. During cold weather, however, an infant under three months should not he taken out of the house, and after that age only during the sunny hours of the day. The precautions necessary to be observed in taking a child out in its coach are that it be kept out of the wind, that it be sufficiently covered and that the sun does not shine directly into its eyes, but there is no valid objection to allowing a child to sleep in the open air in clement weather providing the above precautions are taken.

Statistics show that infants require more airspace, proportionately, than adults, and that overcrowding is a prolific source of ill-health among children. This is especially the case in institutions and hospitals for children.

Exercise. — The infant gets its exercise in crying and in the non-volitional movements which it performs. Playing with toys and creeping and walking soon become more effective forms of exercise, however. Older children require exercise of a more strenuous kind, such as walks in the open air, games, etc. A cold sponge bath every morning aids greatly in the physical development of the child. Fatigue and over-exertion in all forms of sport and exercise are to be carefully guarded against.

Premature and Delicate Infants. — The period of viability in a premature babe cannot be arbitrarily stated, as the condition of the infant plays an important role as well as its age. The period of viability has been usually fixed at twenty-eight weeks, but premature infants of twenty-four weeks have been successfully raised.

The fetus at the eighth lunar month weighs 3-*- lbs. and measures sixteen inches in length. The skin is wrinkled and the body is covered with lanugo. At the ninth lunar month it weighs 5 lbs. and measures eighteen inches in length. At the tenth lunar month, or term, it weighs 7 lbs. and measures twenty inches in length. The main problems with which we are confronted in caring for the premature infant are to maintain body-heat and to supply suitable nourishment.

Infants weighing four pounds and over can frequently be reared without the use of an incubator. The body should be enveloped in a thick layer of cotton and in place of diapers, pads of gauze should be used. The entire body is then wrapped in a blanket and hot water bags applied to the feet and sides of the body or the infant may be placed upon an electrically heated pad. Daily inunctions with warm oil may be given but no baths.

Breast-feeding is usually essential to the successful rearing of the premature infant. The milk should be drawn from the breast with a pump and collected in a sterile receptacle. It is then best administered to the child with a medicine-dropper, the milk being dropped well back into the pharynx, four drams of nourishment being given every 2 hours. If the infant cannot be made to take sufficient nourishment in this manner, gavage must be employed. If breast-milk cannot be obtained whey may be tried or a weak milk formula of one part boiled milk to two or three parts water and five per cent sugar of milk.

The Care and Nursing of Sick Children. — In all acute illnesses the child should be kept in bed. Infants may occasionally be held in the mother's lap if they are very fretful and especially in the case of bronchopneumonia or protracted intestinal disturbances a change in the position of the patient is desirable. Unnecessary handling of a sick infant must, of course, be avoided. The child should be kept as quiet as possible, both mentally and physically; in the case of a serious illness only one attendant should be with the child at a time.

Temperature of the Sick Room. — The sick room must be kept well ventilated and not too warm, from 60 to 68 degrees F. In the summer an electric fan may be used to keep the air in motion but it should not be directed against the patient. The cold air treatment of pneumonia is only applicable to the lobar variety. Even in these cases it should not be carried to extremes.

Clothing. — In summer a light night shirt is all that is required; in cool weather the patient may also have a light undershirt to wear especially if the windows must be kept wide open. Cotton- jackets, spice-bags and all forms of plasters are obsolete.

Heat. — Heat is perhaps the most useful of all non-medicinal therapeutic measures and has a wide field of applicability. In painful inflammatory conditions it acts promptly by relieving tension and hastening resorption. The old fashioned poultice is rapidly being replaced by hot fomentations. Dry heat is most conveniently applied by means of hot-water bags and heated flannel. It must be remembered that the child's skin is more sensitive and more readily burned than an adult's, for which reason proper precautions must always be taken.

Baths. — By means of the bath we are able to apply heat or cold most rapidly to the entire body. Hot baths are often useful in collapse and asphyxia neonatorum; by adding a tablespoonf ul of powdered mustard to the warm bath we have an excellent means of relieving serious congestion of internal organs, through its derivative effect. The bran bath is most useful in cases of eczema or other excoriating conditions of the skin.

The tepid sponge-bath must be used once or twice daily in all illnesses regardless of the presence of a rash or a chest condition. In case of high fever a cold sponge-bath may be given every two or three hours. The full cold bath is rarely used in children.

Packs. — Packs are highly efficient antipyretics and diaphoretics. The cold pack is applied by wrapping the child in a sheet wrung out of cold water, the sheet being surrounded by a dry blanket. When used to reduce fever it can be reapplied hourly. In pneumonia the pack is often restricted to the chest.

The hot pack is most useful in nephritis and uremia. A light blanket is wrung out of hot water and applied as above.

The hot mustard pack is prepared by adding a little ground mustard to the hot water; it is employed in convulsions, congestion of the lungs and of the brain; also to bring out tardy eruptions. While in the pack the head should be sponged with cold water or water and alcohol.

Inhalation. — The inhalation of steam is very beneficial in respiratory ailments, especially in the case of croup. In the absence of a specially-constructed "croup-kettle," an ordinary tea-kettle heated by an alcohol stove or better, by an electric stove, may be used, the steam being directed under a sheet overhanging the child in the fashion of a tent.

Lavage. — The apparatus for carrying out lavage in children consists of a soft rubber catheter, connected with a piece of rubber tubing two feet long by means of a piece of glass tubing, and a medium sized glass funnel attached to the free end of the rubber tube. This apparatus may also be used for gavage. For the new-born infant a number 14 French soft rubber catheter should be used; in older infants a number 16 French scale is the proper size. In the new-born the catheter reaches the fundus, when introduced to the length of eight inches; in an infant of three months it must be inserted nine inches and in older infants from ten to twelve inches. I am in the habit of enlarging the eye of the catheter to facilitate the passage of mucus and curds. The passage of the tube into the infant's stomach is, as a rule, unaccompanied by any depression and causes only slight discomfort. Lavage is useful in all cases of persistent vomiting and is a necessary diagnostic procedure in certain gastric conditions, notably pyloric stenosis.

Lavage is performed as follows: The infant is held upright and seated on the nurse's lap, and covered with a towel to prevent soiling the clothing. The catheter is then inserted in the pharynx with the right hand, its tip following the index finger of the left hand which presses down the base of the tongue. Wetting the catheter with plain water is sufficient as a rule ; if there be abnormal dryness of the mucous membrane, there is no objection to the use of olive oil. The child may make efforts at deglutition as soon as the catheter reaches the pharynx, in which case it glides down easily into the esophagus. More frequently, however, it gags, interfering with the operation. If we wait for a few seconds until the child draws in its breath, a gentle push will readily cause the catheter to enter the esophagus. The catheter from now on reaches the stomach without difficulty. As soon as the catheter has entered the stomach the funnel should be lowered and the gastric contents permitted to flow out. Warm water or a weak solution of bicarbonate of soda are then poured into the funnel, a few ounces at a time, and allowed to run into the stomach and out again, until the water returns clear.

Irrigation of the Colon and Enemata. — For the relief of simple constipation and for emptying the lower bowel the enema is all that is required. This is best administered by means of a bulb syringe with the child lying upon its back. Soap-suds give the best results with the low enema.

When irrigation of the colon is to be carried out the child is placed on its left side upon a rubber sheet covered with a cloth, the hips being slightly elevated. A soft rubber catheter, number 18 or 20 French scale, is attached to the nozzle of a fountain syringe, lubricated and carefully inserted into the rectum. The water is then allowed to flow in slowly, stopping the stream as the child makes efforts at expulsion. The catheter is gradually inserted further and further into the rectum as the latter is distended by the water, until it has been introduced from six to eight inches. The fluid will usually reach the colon without difficulty, but cannot pass into the ileum, although it is claimed that if the colon is not distended and the water allowed to flow in slowly, a closure of the ileo-cecal valve fails to take place.

From six to eight ounces of warm, normal salt solution should be run into the bowel at a time and then permitted to flow out again through the catheter. After the process has been repeated several times the water usually returns clear and the operation may then be discontinued.

Irrigation of the colon is useful in diarrheal cases, especially if the stools are offensive or contain an abundance of mucus or curds. The same technique is employed when distension of the bowels with water is used in attempting to overcome an intussusception. Enteroclysis is a safe and efficient means of averting circulatory failure in acute infectious conditions, and also for the purpose of aiding the elimination of toxins. This may be carried out according to the technique of Murphy, namely the "Murphy Drip."

CHAPTER II.

METHODS OF CLINICAL EXAMINATION.

The Period of Infancy and Childhood. — Infancy is the early period of childhood, the state of an infant in arms, or the first two years of life. Clinically we divide it into the period of the newborn, the nursing period and the teething period which terminates with the completion of dentition, namely, the end of the second year.

Childhood begins with the termination of the teething period and continues to the time of puberty. Certain diseases, not encountered in infancy now make their appearance, some of which are distinctive of childhood and may therefore properly be spoken of as "diseases of children." The child is, however, also susceptible to many of the diseases of the adult, but its immature anatomical and physiological development so modifies their clinical course that they are quite different from the same disease as observed in the adult.