by a very formidable set of symptoms, there is, however, one striking circumstance; this is the uncertainty of the signification of the symptoms. They belong for the most part to peritonitis and to enteritis as well as to intestinal invagination; and in the first case which I have reported, the misconception was complete. I referred the symptoms to peritonitis, which really, in fact, existed, but which was consecutive to the invagi-uasi Tain, nation discovered in the body, and not diagnosed during life. It will be always very difficult to form a diagnosis of intestinal invagination, and teewith the exception of the tumour in the belly or prolapsus by the rectum, the positive diagnosis is impossible. In a like case, the diagnosis can only be conjectural. The intestinal hemorrhage should be especially taken into consideration, which, without being characteristic of the invaginations, may still lead to the suspicion of their existence. The prognosis of invagination of the intestines in young children is extremely serious; from the time that the lesion presents an obstacle to the course of the fœces, it rapidly becomes fatal. In the adult, there are many cases which recover, but most of infants attacked with it, die. Proquides Gad Notwithstanding the unfavourable prognosis above given, we must not merely look on and do nothing against the invagination. We should endeavour, 1st, to reëstablish the course of the excrementitious matters; 2nd, to moderate the inflammation of the intestine and of the peritoneum. We should first prescribe for the children slight purgatives, of a strength proportionate to their age; calomel in the dose of from one to three grains, oil of sweet almonds in the dose of 3 ss to 3j. Then cuti oleaginous enemata with 3 ss of castor oil, or purgative enemata with 3 iiss of chloride of sodium. Mr. Mitchell states that he has once succeeded by introducing a very flexible gum elastic tube as high as possible into the rectum, through which he blew in air, by means of a pair of bellows. The distention of the intestine which resulted caused the disappearance of the presumed volvulus and the symptoms of strangulation, and after several alvine evacuations all went on well. A similar method has succeeded in the adult in the hands of Dr. Bennati; this consists in the injection of a large quantity of tepid water into the rectum and into the intestine by means of a large forcing suction pump, in a continuous stream. These means should be made use of. In the case where phenomena of previous or consecutive inflammation of the intestine exist, they should be treated by slight abstractions of blood from the abdomen, baths, simple and opiated cataplasms, emollient and mucilaginous drinks; lastly, by slight narcotics internally.u! CHAPTER X. ON INTESTINAL HÆMORRHAGE. The hæmorrhages of the alimentary canal are rather rare in the first period of the life of children. They are more frequent in the newly-born than during the months which follow birth. They are the result of evident causes of a special nature, easy to detect and to group, so as to make them the object of important nosographical divisions. CAUSES. Some of these hæmorrhages depend upon a peculiar state of the economy, a general serious state to which Verlhoff has attached his name, which is generally known under the denomination of purpurs hæmorrhagica, and which is the consequence of a considerable change in the blood. Others, and these are the most frequent, are only observed during the first fifteen or twenty days of life, and are referred by the best observers to a sort of passive congestion, the result of the compression of the foetus during the time of the accouchement. Lastly, others are the result of the invagination, or of the acute or chronic inflammation of the intestine. The cases which I here relate are the first with which I am acquainted, and which demonstrate the influence of this last cause in the production of hæmorrhage amongst children also little advanced in age. First variety. The hæmatemesis and melana which sometimes accompany purpura hæmorrhagica have been remarked by M. Richard in a child two years old, affected with this disease. The same observer has also met with melana in a child born only some hours. This child passed black blood with the meconium. It appeared that she continued to void blood thus by the stools, once or twice a day, during twenty days; then the flow diminished a little without being completely arrested, so that the child, very much debilitated, died exsanguine at the end of seven weeks. She had a prolapsus of the rectum, like her eldest sister, nine years old, and numerous spots of purpura on the legs, indicated the nature of the disease. Billard has met with two cases of it, one of which in particular is very interesting. Delarue, of the female sex, was placed alive in the crib of the Enfants Trouvés on the 27th of March, 1826. A notice fastened to the arm stated that she was born three days since; she was strong and of full size, the complexion slightly jaundiced, the respiration little developed, the cry scarcely to be heard; the lower limbs were oedematous. The face, trunk, limbs, and arms were covered with violet petechize thi of various sizes. Their diameter varied from that of a very small speck to the size of a bean. The unequal manner in which they were scattered, the yellowish intervals which the cutaneous surface presented between them, gave to the body a tiger like aspect. She remained two days in this state of inanition, drinking several drops of milk, scarcely ever crying, and breathing but little. She died on ✨{ # !!! the evening of the 29th of March. The post mortem examination was made the next day. Digestive apparatus. The stomach was filled with a rather large quantity of O viscous and black blood; its internal surface, as well as that of the jejunum, were sprinkled with numerous petechiæ, similar to those on the exterior of the body. Effusions of blood were observed in the interior of the intestinal tube, scattered here and there, and the mucous membrane presented, in the points corresponding to these effusions, petechial ecchymoses similar to those of the stomach; the termi- /{! nation of the ilium contained a much blacker and much more diffluent blood; the large intestine was the seat of a very decided follicular eruption; it contained at its termination a considerable quantity of blood; its wall was thick and firm. The spleen, of very large size, was very much gorged with blood; it presented, near the insertion of the short vessels, an oblong and superficial rupture, to the surface of which a rather solid clot of blood adhered. There was found on the ne The heart was very large and gorged with blood; there was an effusion of yellowish serum between the proper substance of the organ and the serous layer which invests it; its surface is sprinkled with petechiae, and they are also observed on the surface of the pleuræ. The foetal openings are still free, the lungs are engorged, the kidneys and the bladder also present numerous ecchymoses. // The brain is the seat of a very considerable congestion. The cellular tissue of the limbs and of the abdominal integuments present large ecchymoses; the blood which forms them is infiltrated and coagulated in the in meshes of this tissue.-Billard, Traité des maladies des enfants; p. 106. M. Gubler, one of my friends, has sent me a case similar to the one just reported. The subject of it was a boy, one month old, who had successively sclerema, discrete variola, and purpura hæmorrhagica; he died of pneumonia. In the midst of these diseases he vomited a clot of black blood, and his linen was stained by a brownish matter, similar to dried blood. In some parts it was easy to collect the crust, and it could be dissolved in water which assumed a reddish tint. In other places, the linen was soiled by blood voided in a liquid state. The whole of the body was covered with spots of purpura, which very clearly indicated the cause of the hæmorrhage. The blood exuded into the intestine, sweated through these vessels under the influence of the same unknown force which had determined the hæmorrhage of the cellular and of the cutaneous tissue. Second variety. The possibility of intestinal hæmorrhages at the time even, or very soon after, birth, has been already pointed out by Fr. Hoffman, Brebis1 and Lafaurie, and has been the subject of more recent researches by Billard,3 MM. Gendrin, Rahn-Escher, Kinwisch," Barrier, Rilliet, &c. 8 4 Ingestion leth Billard has remarked twenty-five cases of passive congestion of the intestinal tube, without hæmorrhage, amongst children who have died some hours or some days after birth. In this state no symptoms connected with the digestive tube have been observed. Fifteen of these children had all the external characteristics of the apoplectic condition of the newly-born, and had only presented symptoms of congestion of the lungs and of the heart. He has only noticed passive intestinal hæmorrhage as a consequence of this congestion in fifteen subjects; eight of these children were from one to six days old; four from six to eight days, and three from ten to eighteen days. Of this number six were boys and nine girls. The greatest number were remarkable for the plethoric state of the tissues and for the general congestion of the integuments. Some, on the contrary, were pale and feeble as in the case after a copious hæmorrhage. In all, the large vessels, the liver, spleen, lungs, and heart were considerably engorged with blood; in nine, the foetal openings were obliterated or on the point of being so; in all the rest they were yet free. In the brain and spinal cord of all, there was a very decided injection of the meninges and of the cerebral pulp. Lastly, in all, the intestinal tube contained blood which was observed to be more of less changed, pale red, dark red, blackish, exuded in a thin layer upon the mucous membrane, or accumulated in specks or in clots in different parts of the digestive tube. Billard very justly refers these bloody evacuations to the state of normal congestion of the intestine of the newly-born, when by chance this state is aggravated by an obstacle to the establishment of the circulation, such as the apoplectic state, the increased size of the liver, spleen, &c. Billard, however, appears to be in error, in considering these hæmorrhages as a very serious symptom, almost necessarily followed by death. This is not always the case. M. Rahn-Escher has published several cases of cure; in one which is especially interesting, there were at the same time abundant vomitings and dejections of blood in a child which at the fourteenth day was completely recovered. As to the facts published by M. Rilliet, their importance has compelled me 1. De vomitu et secessu cruento, etc. (Act. nat. curios.; vol. iv, 1837.) 2. Annales de la Société de Montpellier. 3. Mal. des enfants. 4. Traité de médicine pratique. 5. Observations sur l'hémorrhagie des premières voies. (Gazette médicale, 1835.) 6. Apoplexie abdominale des nouveaux-nés. (Gazette médicale, 1841.) 7. Traité du mal de l'enfance. 8. Gazette médicale. 1848, p. 1029. to reproduce them, and in them many peculiarities worthy of fixing the attention will be observed. M. Rilliet has only once observed intestinal hæmorrhage in the newly-born, and in this case it was in twins who had been very ill, and both of whom perfectly recovered. The following are the cases related by the author himself: Case 1. On the 30th of January, 1846, I was called, at one p.m., to see a newlyborn child which they informed me was in the greatest possible danger. I collected the following history from the nurse, which was afterwards confirmed by Dr. Maunoir: The little boy, born at four o'clock in the morning, was one of twins. The labour was not a very difficult one; however, M. Maunoir thought proper to apply the Cast forceps. The placenta were separate, the liq.-amnii not very abundant. The cord presented nothing remarkable; it was tied in the usual time and manner. The child was of full time, not very large, but well formed, lively, crying loudly, and not all plethoric. All the functions appeared to be in their natural state. The meconium was expelled some hours after the accouchement, in consequence of the administration of/ half a teaspoonful of castor oil. The child had then had some sleep, and had afterwards taken the breast with avidity; in a word, nothing could lead to the suspicion of anything wrong, when the nurse perceived, in changing the linen, that the remainder of the meconium was mixed with a certain quantity of blood. Two hours afterwards, the child passed a copious stool of pure blood, liquid and mixed with clots; at one o'clock in the afternoon, a third stool of blood, of bright colour: it was then that I was called. When I examined the little patient I found it in a deadly pallor. The nurse told me it had wonderfully changed. The pulse was imperceptible, the limbs and ll arms cold; the eyes were habitually closed, as well as the mouth. It could not, nor did it wish to swallow anything; the power of motion was, however, preserved as well as the cry. The belly was tolerably supple, not swollen; pressure did not appear painful; there was neither vomiting nor defecation. The examination of the mouth, after the forcible depression of the lower jaw, did not present any lesion; there were no nervous symptoms. Compresses moistened in cold vinegar were applied on the abdomen, whilst the extremities were enveloped in warm flannels; two enemata with a solution of twelve grains of the extract of rhatany were prescribed. They were nearly immediately returned, accompanied by a considerable quantity of blood. At four o'clock in the afternoon, the child was in the same state; I saw it with Dr. Maunoir, and we prescribed applications to the abdomen of compresses steeped in a strong decoction of rhatany (two ounces to the pint), and enemata with twelve grains of the extract. Like the preceding, they were almost immediately returned and followed by an abundant flow of liquid and coagulated blood. The sixth sanguineous stool was passed at six o'clock in the evening; the application a of compresses was all that was then persisted in. The pulse was of little more power, 120; the child had a slight trembling of the hands and an oscillation of the globes of the eyes, but no convulsions, properly so called. The abdomen was not swollen. From ten o'clock in the evening to the morning of the 31st, eight or ten spoonfuls of cold milk were given it, which remained. At eight o'clock in the morning, it was put to the breast; it easily seized the nipple, at several distinct times; the pulse was regular and easily felt. At noon it passed two slight stools |