lated part, causing distension at or below the umbilicus, with marked flatness of the epigastrium. When the stomach is distended the lower outlines may frequently be determined by palpation, but percussion gives the most reliable information. The practiced ear will, as a rule, note the difference in the percussion note in passing from the stomach to the intestines, as the tension in the stomach and intestine is rarely the same; however, the difference in the note may be so slight as to escape detection. When the stomach is moderately distended with gas the note will be lower than that of the intestines. Extreme gaseous distension, or the presence of other than gaseous contents, gives a flat note. Various methods have been resorted to for the purpose of determining its capacity and defining its boundaries. The stomach may be distended as advised by Moncorvo, by the successive swallowing of proper amounts of bicarbonate of soda and tartaric acid, followed by a tumbler of water, or by direct inflation. The latter is the safe and more preferable method. By the careful introduction and inflation of the stomach with air through a tube, its boundaries and form may readily be recognized by palpation and percussion.

A method which I have found of value in children is to first inflate the colon, then, according to the method of Penzoldt and Dehio, with the patient in the upright position after swallowing several portions of water, or, in the case of infants, distending the stomach with water introduced through a tube, it is readily outlined by means of palpation and percussion. By this means, not only is the size and form of the stomach readily determined, but a dilated colon may be recognized.

The diagnosis of appendicitis has been so thoroughly discussed from every aspect of the subject that it would seem that anything that might be said would be but a repetition of that already oft recounted. The classical signs of the disease, as it occurs in adults, applies as well to the early period of life; how

ever, owing to the fact that intestinal disturbances are much more frequent at this period than in adult life, and that these disturbances are attended at times not only by the classical signs, but the subjective symptoms as well of appendicitis, the difficulty of diagnosis is greatly increased.

I have frequently seen the colicky pain, localized tenderness, and muscular rigidity disappear after free catharsis or intestinal irrigation.

The possibility of fecal inaction and intestinal toxemia should be borne in mind, and this condition eliminated by thorough evacuation of the intestinal canal as a preliminary measure in abdominal examinations. Intussusception may simulate appendicitis, and is differentiated by the subjective symptoms and by the presence of a characteristic "sausage-shape" tumor occurring in the line of the large intestine, and usually to the left of the median line.

In the recognition and etiological differentiation of diseases of the abdominal organs in childhood, the modern methods of diagnosis by microscopy, chemical analysis and hematology are even of greater importance than in adult life. An enlarged spleen may be readily recognized by physical exploration, and the general appearance of anemia may be very apparent, but the diagnosis would not be complete without a knowledge of the existing condition of the corpuscular and other elements of the blood.

Abdominal diagnosis in childhood differs, not so much in the application of the essential methods adopted in adults, as in the peculiarities of developmental conditions upon which the results and conclusions must be based.

INTESTINAL INDIGESTION.

BY W. C. MC MANUS, M. D., OF EDGERTON.

That intestinal indigestion, together with the functional disturbances due to the action of the various microorganisms that invade this tract, has not received the consideration that its importance demands, is apparent from the scant mention of the subject by the authors of the various text-books. On the other hand, gastric digestion has, to my mind, been greatly overestimated. This is perhaps due to the fact that formerly, more importance was attached to the stomach as a digestive organ, and when digestion was impaired remedies were directed to this organ alone. It is now well-known that the entire process of digestion can be carried on successfully without the aid of the stomach, as witnessed in those cases where the stomach has been completely removed. However, it is not the purpose of this paper to underestimate gastric digestion, but simply to point out the importance of intestinal digestion, that we may better appreciate and understand the disturbances which may take place in this part of the alimentary canal.

When we consider the great extent of the digestive tract, and the number of different organs and structures involved in transmuting the various forms of food into liquid and soluble forms, so that they can be utilized by the system, we realize how complicated the processes are, and how difficult it may be to always ascertain from what particular point disturbances may

arise.

To fully understand intestinal indigestion it is necessary to have a thorough and accurate knowledge of the entire process of normal digestion, and also a knowledge of the symptoms produced by pathological changes which occur outside of the intes

tines, such, for instance, as may be produced by a dilated and a prolapsed stomach. We should also be thoroughly familiar with the composition of the various foods.

A detailed description of the function of the alimentary canal would consume too much valuable time, so I will review the salient points briefly. All foods, no matter how elaborate or complicated, are divided into four classes, as follows: 1. Inorganic substances, salts and water.

2. Carbohydrates, including starches and sugars.

For convenience, digestion may be divided into three parts: 1. Mouth-digestion.

2. Gastric or stomach-digestion. 3. Intestinal digestion.

Mouth-digestion is mostly mechanical. Here the food should be comminuted and thoroughly mixed with the saliva which contains the amylolytic enzyme ptyaline. This ferment acts somewhat feebly on starches, changing them to sugar. The food, having been thoroughly masticated, enters the stomach very little changed. Here the food is subjected to a mixing and churning motion, some of the soluble and liquid portions passing quickly into the duodenum. The solid and insoluble particles are retained, to be acted upon by the gastric juice, the principal constituents of which are hydrochloric acid, pepsin and rennin. Here the proteids are in part converted into soluble peptones, cane sugar to dextrose and levulose, and albuminoids. to gelatoses. Perhaps one of the most important functions of the hydrochloric acid is its germicidal action on bacteria which may have been introduced with the food.

Absorption undoubtedly occurs to a considerable extent in the stomach, but the greater part of the food, consisting of the unchanged proteids, peptones, dextrose, levulose, gelatoses,

starches, oils and fats, salt and water, passes from the stomach into the small intestines.

It is a very difficult matter to describe the functions of the small intestines satisfactorily. A description of the isolated processes gives but a vague idea of how the results are accomplished. Each separate process is so intimately connected and blended as to be practically one. We know that all of the changes which have occurred in the stomach are completely and satisfactorily carried on in the small intestines, so that the most important office of the stomach is to act as a reservoir for the reception and preliminary preparation of the food.

The changes which occur after the food has left the stomach are brought about by three digestive agents, the succus entericus, the bile and the pancreatic juice. The succus entericus is not a very abundant secretion. It serves as a lubricant to the mucous membrane and contains three enzymes, one amylolytic, which changes starch into maltose and dextrose, and two inversive, which change maltose into glucose, and saccharose into dextrose and levulose.

The bile is a very abundant secretion. It amounts to about 800 or 900 grams daily. It is alkaline in its reaction. Its chief functions are:

1. A weak solvent of fats.

It combines with fatty acids to form soaps.

2.

5. It increases the intestinal peristalsis.

Its importance as a digestive agent was formerly very much overestimated. At present more importance is attached to it as an excretory agent. Still it plays a very important part in digestion, especially its action in promoting the absorption of fats.

We now come to the most important digestive agent of all,