LECTURE XXXIV.

DISEASES OF THE STOMACH-Vomiting often symptomatic of disease elsewhereoccasionally occurs suddenly in a previously healthy infant without signs of general illness-its treatment-is often one out of many symptoms of indigestion. -Infantile dyspepsia-sometimes connected with general debility of the system; at others, dependent on special disorder of the stomach-its symptoms and

treatment.

SOFTENING OF THE STOMACH-discovered after death in various degrees-different theories as to its nature-great frequency in early infancy-Dr. Elsässer's explanation of this fact-probably not correct to the full extent.

HÆMATEMESIS AND MELENA-Very rare-sometimes connected with injury to the child during labour-their occurrence often difficult of explanation-illustrative cases.-Spurious hæmatemesis.

THE diseases to which the stomach is liable in early life are neither numerous nor important, although its functions are more or less disordered in the course of most of the affections of childhood. Vomiting, indeed, is more frequent in the infant than in the adult, and the greater irritability of the stomach continues even after the first few months of existence are past, and does not completely cease during the early years of childhood. Hence it happens, as we have already seen, that vomiting is sometimes one of the first symptoms of inflammation of the lungs or pleura; while it frequently ushers in the eruptive fevers, and marks the early stages of cerebral disease. Causes more purely local produce a similar effect, and vomiting often attends upon infantile diarrhoea, and is associated with signs of intestinal disorder, especially when such disorder has been excited by improper food. But besides these cases, in which the disorder of the stomach is either the result of disease seated elsewhere, or in which the disturbance of its function is sufficiently explained by the nature of the ingesta, instances are sometimes observed in which the stomach becomes so irritable as almost always to reject its contents, or in which, though the food taken be not brought up again, the organ is unable to effect its digestion.

It sometimes happens that young infants are suddenly seized with

VOMITING IN EARLY INFANCY.

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vomiting, which, though violent, and frequently repeated, is attended by few or no indications of general intestinal disorder. The child in such cases seems still anxious for the breast; but so great is the irritability of the stomach, that the milk is either thrown up unchanged immediately after it has been swallowed, or it is retained only for a very few minutes, and is then rejected in a curdled state; while each application of the child to the breast is followed by the same result. It will generally be found, when this accident takes place in the previously healthy child of a healthy mother, that it has been occasioned by some act of indiscretion on the part of its mother or nurse. She perhaps has been absent from her nursling longer than usual, and, returning tired from a long walk, or from some fatiguing occupation, has at once offered it the breast, and allowed it to suck abundantly; or the infant has been roused from sleep before its customary hour, or it has been over-excited or over-wearied at play, or, in hot weather has been carried about in the sun without proper protection from its rays.

The infant in whom, from any of these causes, vomiting has come on, must at once be taken from the breast, and, for a couple of hours, neither food nor medicine should be given to it. It may then be offered a teaspoonful of cold water; and should the stomach retain this, one or two more spoonfuls may be given in the course of the next half-hour. If this be not rejected, a little isinglass may be dissolved in the water, which must still be given by a teaspoonful at a time, frequently repeated; or cold barley-water may be given in the same manner. In eight or ten hours, if no return of vomiting take place, the experiment may be tried of giving the child its mother's milk, or cow's milk diluted with water, in small quantities, and from a teaspoon. If the food thus given do not occasion sickness, the infant may in from twelve to twenty-four hours be restored to the breast; with the precaution, however, of allowing it to suck only very small quantities at a time, lest the stomach being overloaded, the vomiting should again be produced.

In many instances where the sickness has arisen from some accidental cause, such as those above referred to, the adoption of these precautions will suffice to restore the child's health. If, however, other indications of gastric or intestinal disorder have preceded the sickness, or are associated with it, medicine cannot be wholly dispensed with. According to the age of the child, a quarter, half, or a whole grain of calomel may be laid upon the tongue, while sucking is forbidden, and the plan already recommended is

in other respects strictly carried out. If the vomiting have already continued for several hours before the adoption of any treatment, a small mustard poultice may likewise be applied to the epigastrium. In about a couple of hours after the calomel has been given, the child may have a teaspoonful of a mixture containing small doses of the bicarbonate of potash and chloric ether, or of ether and of hydrocyanic acid; and this may be continued every three or four hours so long as any unusual irritability of the stomach remains.

In

Sickness, however, is not always a solitary symptom, unattended by other indications of gastric disorder, but is sometimes associated with the signs of general impairment of the digestive powers. its graver forms, indigestion is associated with greatly impaired nutrition, and with all those serious results which are characteristic of the atrophy of young children. But it sometimes happens that, though the child does not lose much flesh, yet digestion is ill performed, and various dyspeptic symptoms appear, which would be troublesome rather than alarming, if it were not that they are often connected with the strumous diathesis, and are the first indications of a state of constitution in which, after the lapse of a few months, pulmonary phthisis is very apt to supervene.

In some of these cases there is complete anorexia, the infant caring neither for the breast nor for any other food that may be offered it. It loses the look of health, and grows pale and languid, although it may not have any especial disorder either of the stomach or bowels. It sucks but seldom, and is soon satisfied; and even of the small quantity taken, a portion is often regurgitated almost immediately. This state of things is sometimes brought on by a mother's over-anxious care, who, fearful of her infant taking cold, keeps it in a room too hot or too imperfectly ventilated. It follows, also, in delicate infants on attacks of catarrh or diarrhoea, but is then for the most part a passing evil which time will cure. In the majority of cases, however, the loss of appetite is associated with evidence of the stomach's inability to digest even the small quantity of food taken, and there exists more or less marked gastric or intestinal disorder. Anorexia, too, is far from being a constant attendant upon infantile dyspepsia; but in still more numerous instances, although the power of assimilating the food is in a great measure lost, yet there is an unnatural craving for it, and the infant never seems so comfortable as when sucking. But though it sucks much, the milk evidently does not sit well upon the stomach; for soon after sucking, the child begins to cry, and

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appears to be in much pain until it has vomited. The milk thrown up is curdled, and its rejection is followed by immediate relief; but at the same time by the desire for more food, and the child can often be pacified only by allowing it to suck again. In other cases, vomiting is of much less frequent occurrence, and there is neither craving desire for food, nor much pain after sucking, but the infant is distressed by frequent acid or offensive eructations; its breath has a sour or nauseous smell, and its evacuations have a most fœtid odour. The condition of the bowels that exists in connection with these different forms of dyspepsia is variable. In cases of simple anorexia, the debility of the stomach is participated in by the intestines; their peristaltic action is feeble, and constipation is of frequent occurrence, though the evacuations do not always present any marked deviation from their character in health. Constipation, however, though a frequent, is not an invariable attendant on indigestion, but the bowels in some cases act with due regularity. If the infant be brought up entirely at the breast, the evacuations are usually liquid, of a very pale yellow colour, often extremely offensive, and contain shreds of curdled milk, which, having escaped through the pylorus, pass unchanged along the whole tract of the intestines. In many instances, however, the infant having been observed not to thrive at the breast, arrow-root or other farinaceous food is given to it, which the digestive powers are quite unable to assimilate, and which gives to the motions the appearance of putty or pipe-clay, besmeared more or less abundantly with intestinal mucus. The evacuations are often parti-coloured, and sometimes one or two unhealthy motions are followed by others which appear perfectly natural; while attacks of diarrhoea often come on, and the matters discharged are then watery, of a dark, dirty green colour, and exceedingly offensive odour.

Dyspeptic infants, like dyspeptic adults, often continue to keep up their flesh much better than could be expected, and in many cases eventually grow up to be strong and healthy children. Still, the condition is one that not merely entails considerable suffering upon the child, but, by its continuance, seriously impairs the health, renders the child but little able to bear up against any intercurrent disease, and develops the seeds of latent phthisis.

Within the space that can be allotted to each subject in these lectures, it is not possible to do more than just glance at some of the main points to be borne in mind in the treatment of infantile dyspepsia. Those cases, the chief symptom of which consists in

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TREATMENT OF DYSPEPSIA FROM DEBILITY.

*

the loss of appetite, usually require, and are much benefited by, a generally tonic plan of treatment. All causes unfavourable to health, must be examined into, and, as far as possible, removed. It must be seen that the nursery is well ventilated, and that its temperature is not too high; while it will often be found that no remedy is half so efficacious as change of air. Next, it must not be forgotten that the regurgitation of the food is due in great measure to the weakness and consequent irritability of the stomach; and care must therefore be taken not to overload it. If these two points be attended to, benefit may then be looked for from the administration of tonics. These tonics may either be such as the infusion of orange-peel with a few drops of sulphuric acid and of some tincture; or, should any disposition to diarrhoea have appeared, the extract with the compound tincture of bark will be preferable; † or, if the stomach be very irritable, the liquor cinchonæ in combination with small doses of hydrocyanic acid ‡ may be given with advantage, when any other medicine would be rejected. As the general health improves, the constipated condition of the bowels so usual in these cases will by degrees disappear. Even if the symptom should call for medical interference, it is not by drastic purgatives that its cure must be attempted. A soap suppository will sometimes excite the bowels to daily action; or friction of the abdomen twice a day with warm oil, or with a liniment composed of one part of Linimentum Saponis, one of olive oil, and two of tincture of aloes, will sometimes have the same effect. Should it become necessary to give aperients internally, the decoction of aloes sweetened with liquorice, and mixed with caraway or aniseed water, generally answers the purpose very well; § while the employment of mercurials must be restricted to cases in which there is very evident deficiency in the biliary secretion.

Aq. Cinnamomi, 3ij. M. A teaspoonful three times a day.

Aquæ Anisi, 3ij. M. One or two teaspoonfuls when required.

For a child a year old.