be given in fluid magnesia, with sulphate of iron, as a useful way of combining the opium with a tonic, and at the same time avoiding any too costive effect. The iron is precipitated as green carbonate, but this does not in any way impair the effect. (F. 22.) Easton's syrup in doses of twenty or thirty drops three times a day, may be given afterwards (syrupus ferri et quiniæ et strychniæ phosphatum). It is better than the more usually prescribed Parrish's food under these circumstances, being less liable to upset the stomach.

[Lienteric diarrhoea does not yield to ordinary astringents, and is much increased by laxatives, as castor oil. Opium checks it temporarily, but the best remedies are Fowler's solution and tincture of nux vomica in small doses. At the same time a digestible diet must be ordered at regulated intervals.]

Chronic diarrhoea in infants requires the expenditure of much thought and trouble if the treatment is to be successful. It is often obstinate, and improvement even in favorable cases very fitful. The treatment comprises diet, general hygiene, and medicine. The diet must be regulated upon the lines already laid down for children in health. Chronic diarrhoea is so much a disease of bad or too abundant feeding, that the first duty will probably be to see that starch is eliminated from the diet, or that milk is taken in reduced quantities. If milk should disagree, as it is liable to do even when diluted largely with water, or lime-water, milk and barley-water may be tried, and then whey or thin veal broth. But whatever is given must be in very small quantities, sometimes only a few teaspoonfuls, so as, if possible, to allow of digestion without starting the intestines into muscular action. If under these circumstances the child gains in weight, and the motions become more colored with bile and more consistent, it will probably get well; but the

food must be carefully regulated, and only slowly increased in quantity. As the gastro-intestinal tract becomes more tolerant, so the quantity of food given may be increased, the frequency of the meals decreased, and milk food be gradually reintroduced. In the worst cases all food must be stopped, and raw meat given instead. The directions given by Trousseau are as follows: Take a lean piece of beef or mutton, and after cutting it into small pieces, reduce it to a thick pulp with pestle and mortar. The pulp so made is passed through a fine colander, which will allow nothing to pass save the juice of the meat and fibrinous matter. This is scraped from the external surface of the colander, sweetened; and, to begin with, a teaspoonful may be given three times a day; the quantity being gradually increased till five or six ounces may be taken in the course of the twenty-four hours.

It will often be found, however, that, except for the youngest infants, who take raw meat with avidity, it creates disgust, even when well sweetened. It is then to be given stirred up in a little cold veal broth or thin barley-water. It will usually be readily taken in this way when refused as a pulp. If not, it may be made into small masses, with confection of roses or currant jelly, or it may be mixed with chocolate made with water. At first the meat appears unchanged in the stools, but this soon alters; the meat becomes partially and then entirely digested, and the child gains in weight in proportion.

In what may be called general hygiene, the child must be kept warm and clean. It should be wrapped in flannel and carefully guarded against cold feet and a cold stomach. It should be kept in one temperature, but in as pure air as possible, and all soiled linen should be removed from it at once. Medicines are comparatively of less value. They are by no means to be omitted, but careful diet and warmth

are the essentials. Of drugs, opium is the most generally useful, and this may be well combined with logwood, ipecacuanha and chalk, as in the mistura hæmatoxyli co. of the Guy's Hospital Pharmacopoeia. (F. 23.) A teaspoonful should be given every four hours if the diarrhoea is profuse, and less frequently according to circumstances. Another useful remedy is bismuth.

Sometimes astringents are useful—-gallic acid, sulphate of copper, acetate of lead, may any of them be used according to the formulæ given. (F. 25, 26, 27.) [Nitrate of silver is a most useful drug when the diarrhoea proves obstinate, aphthæ appear in the mouth, and there is much thirst and prostration. One twenty-fourth of a grain may be given, suspended in syrup of acacia, every two hours to a child of two years. Stimulants are also necessary to relieve the tendency to prostration. Whiskey is the best, and it must be given in doses and at intervals proportioned to the demands of the individual case. Ten drops every two hours is about the average initial dose.]

Astringent enemata are recommended by some. They are not often retained, and are but seldom of use.

Nitrate

of silver, one grain to five ounces of water, is recommended by Trousseau; but on the whole I am inclined to prefer equal parts of an infusion of ipecacuanha and decoction of starch; or, starch and tincture of opium-two or three drops of the latter to two ounces of the vehicle.

[Injections of nitrate of silver, which by the way are very serviceable, should be given at intervals of twelve hours and preceded by an enema of warm water to wash out the rectum. After being continued for forty-eight hours, they should be discontinued for a day, during which the patient may receive, at the same intervals, injections of tincture of opium in starch water, three drops to half a fluid ounce at the age of two years.

When improvement sets in tonics must be employed to build up the general health. One of the best to succeed the treatment directed especially to the relief of the diarrhoea is the solution of the nitrate of iron with a mineral acid, for example:

R. Liquor. Ferri Nitratis,

Acidi Nitrici Dil.,

Syrupi Zingiberis,
Aquæ,

ää f3ss.
f3j.

. q. s. ad f3iij. M.

S. One teaspoonful three times daily, for a child of two years.]

Dysentery. This term is applied in England sometimes to chronic ulceration of the colon, sometimes to acute inflammation with the formation of diphtheritic membrane. In either case it is a disease which rarely attacks children, and does not differ from such affections in an adult. Extensive ulceration of the colon is almost always due to tubercular ulceration, though it is possible that it may be an occasional result of chronic diarrhoea. I have only once seen a case of acute colitis. The patient was a girl, aged eleven and a quarter, who had been living badly. She was extremely prostrate, pale, and covered with a purpuric eruption. Her temperature was 100.8°. The spleen large. The bowels were confined at first, but the evacuations soon became watery, and pink from the presence of blood, and she sank rapidly; the temperature rising to 105.6°. The blood showed a reduction of more than one-half of the corpuscles and 65 per cent. of the coloring matter. At the inspection, the lower part of the colon and the rectum were the seat of a severe diphtheritic inflammation. The mucous membrane was swollen, coated with thick adherent membrane, the surface beneath being ecchymosed and bleeding.

Such cases, when they occur, must be treated, like bad cases of acute enteritis, by careful nourishment, stimulants, the dilute mineral acids, quinine, etc. For chronic ulceration the treatment of chronic diarrhoea will apply.

CHAPTER V.

STOMATITIS-THRUSH-CANCRUM ORIS.

Stomatitis.-Four or five different forms of stomatitis have been described, but no useful purpose is gained by such elaboration. It will be sufficient to treat of-1. Stomatitis; 2. Thrush; 3. Cancrum oris. Stomatitis and thrush are often combined.

1. Stomatitis.-Children thus affected are brought with the complaint that their breath is offensive, that they are spitting up blood, or that blood stains their pillow during sleep. It is a disease chiefly of the lower classes, which affects boys and girls of any age from two to nine or ten years, and perhaps is more common in the months of March, April, and May than at other seasons of the year. It has been supposed by some to be due to a milk diet, but this I have not been able to substantiate; nor is it easy to prove that it bears any particular relation to dentition; but so far as my own statistics go it would appear to be more common between the ages of two and three and seven and nine. Henoch puts it as most common between the ninth month and the middle of the third year, but has observed it not seldom in older children, and he considers dentition, both first and second, to have much to do with its occurrence. It occurs in varying degrees of severity, of which I may give examples.

I. The common form is a superficial ulceration of the edges of the gums, the tongue, and the cheeks; the gums being vascular, and fringed with a yellow margin of decaying granulations.