If the prophylactic measures have not proved efficient, or, as is more often the case, if we are confronted with the condition of over feeding already fully developed, then the second division of the treatment the dietetic treatment, finds its place. Its fundamental principles are: first, emptying the stomach and bowels of food altered by abnortnal fermentative processes, and second, resting of these overexerted organs. This is best done by giving a bland diet for 12 or 24 hours or perhaps even longer aecording to the duration and severity of the symptoms. This diet consists of boiled water, in case of necessity sweetened with saceharin, or of very weak tea, or, if absolutely necessary in order to not resist the wishes of the family, fennel or chamomile tett. Thus I avoid all other treatment and wait to see whether under the influence of this proceding the vomiting stops, the movements become less in frequency and amount, the passing of gas ceases or becomes much less, and the child becomes quiet. If this is the ease, as it is in a large per centage, then the breast is gradually resumed, and, on the (lay following the period of absolute starvation, may be given twice within 24 hours. Then, if there is no return of the symptoms calling for a repetition of the water diet, it can be given gradually more often until 4 or 31 hour intervals are attained. If the period of withholding food does not lead to a cessation of the vomiting, I next resort to washing out the stomach.
This procedure was introdueed into the therapeutics of infancy by Epstein, in 18SO. Kussmaul's instrument, reduced to correspond with the smaller anatomical conditions, is employed. It consists of a funnel holding about 100 Gm. (31 oz.), and attached to this a rubber tube from to 1 metre (2-3 ft.) in length. A glass tube about the length of the little finger serving as a window connects the rubber tube with a Nelaton catheter (sizes 9-22, Charriere's scale), which has an opening in the side. The catheters opening at the end are condemned by Ep.stein on account of the danger of wounding, and I myself do not like them, because the relatively- small opening is easily obstructed, thus delay ing the operation. The child, rolled up in its pillow which confines its arms, is either laid on its back or held upright; I prefer the latter position, because it almost entirely does away with the possibility of an overflow of the fluid into the air-passages. The catheter is first soaked in lukewarm boiled water, or perhaps in IIeubncr's physio logic salt solution. Water Is allowed to run throttgh funnel and tube in order to expel the air. Then the catheter is introduced along the posterior wall of the pharynx, while the free hand depresses the tongue. It glides clown without the least difficulty, and when the funtlus of the stomach is reached, the funnel is depressed in order to allow the gastric contents to flow out into a vessel placed near by. The funnel being
still held down, is filled with the wash fluid at the body temperature, and is then raised up and held till the fluid has all flowed in, when it is again depressed and the fluid allowed to run out. This is repeated until the wash water comes out entirely clear. I have never encountered disagreeable occurrences in the numberless stomach washings which I have performed in the course of years (an older child reacted violently to the introduction of the catheter, though without further bad results). Consequently I must designate this procedure, especially in the early months with their slight reflex excitability, as a method without danger, and easily practiced. Washing is best performed some hours after the last feeding, and care should be taken, that in the next few hours neither food nor drink be given, as this excites vomiting.
This procedure accomplishes the removal of fermenting material, the washing clean of the mucus covered gastric mucosa, and excitation of the secretion of its glands through the introduction of the tube. Be side this, it exercises a certain influence upon intestinal peristalsis. It is not always sufficient to perform it once, for, especially- in cases of longer duration in which the existence of gastric dilatation is as sumed, it is necessary to repeat it two or three times. The use of special washing fluids, or the pouring in after the end of the washing of medi cated solutions is at least superfluous, and now hardly ever practiced..
The emptying of the bowels, if it has not been attained through the water diet, can be accomplished with mechanical or medicinal means. A useful measure is irrigation, for which an instrument is used which consists of a Nelaton catheter of proper size, connected with a hard-rubber stop-cock, to which is attached a rubber tube about one metre in length, and a graduated glass irrigator holding half a litre.
Other apparatuses, involving tbe introduction of solid instru ments into the rectum, are of little value, and dangerous. The soft instrument, smeared with a clean oil, must be pushed up rather far, as otherwise the internal sphincter will form an obstruction to the outflow of the water. Too high a pressure must not be used (about two feet). The child should be laid on the side, with its legs drawn up against the abdonwn, and a pillow should be put under the hips to raise them. If the outflow does not occur at once, or if it stops, it can be started up again by twisting the tube, or by pushing it up and clown. Boiled water at body temperature is all that is needed for the irrigating fluid, as the form of disease under discussion offers no indication for medi cated irrigations. It is usually sufficient to let half a litre of water flow through, and only in older children (over four or five mouths) is a greater ,itiantity necessary.