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ABDOMINAL PAIN IN CHILDHOOD
569 All bath-water is buoyant, whether it is in the patient’s home or in a high-priced spa. , We do not yet know the role of focal infection in most cases of rheumatoid arthritis. A protracted need for narcotics in a patient with joint symptoms suggests neoplasm. Less than 10% of patients with rheumatoid arthritis who become pregnant are relieved of their rheumatoid arthritis for more than 4 to 6 weeks after delivery. The injections of vaccines, sulphur, chaulmoogra oil, foreign proteins or the like will not straighten chronically deformed ankylosed joints.
On the whole, Comroe’s experience with rheumatoid arthritic is encouraging, for though he advises the
physician
he would tell the can be definitely United States, as in England, there is an urgent need of hospital beds for " rheumatic " patients where a well-planned therapeutic programme can be applied without delay. never
to
patient that nine improved. In the
promise
cases
a
cure
out of ten
"
ABDOMINAL PAIN IN CHILDHOOD THERE is probably no more interesting, uncertain, or hazardous clinical domain in childhood than acute conditions in the abdomen, and pain is the presenting symptom, the warning signal that something has gone wrong and that it may be serious." It is this background of possible catastrophe that makes every child patient with abdominal pain such an urgent problem. In his review of abdominal pain in childhood, of which this was the opening sentence, Brennemann1 included tenderness as an essential part of the story, and he put the majority of the more serious abdominal conditions heralded and accompanied by pain into two main categories-those due to obstruction and those due to infection. Colic of infancy he put in a class by itself, pointing out that it is probably more frequent in the breast-fed than in the bottle-fed infant and principally caused either by overfeeding or by the presence of excess of " gas " in the alimentary tract, itself either swallowed air or produced by fermentation. Of the obstructions in early life he stressed the importance of intussusception, with often a deceptive calm after the dramatic onset. A condition I
commonly diagnosed, though described by Brennenot rare, is congenital ano-rectal stricture with increasing distension of the abdomen and screaming attacks, relieved by a brief course of daily digital less
mann as
dilatation.
I
discussing appendicitis, Brennemann voiced the opinion of all children’s physicians who are honest with themselves when he wrote : "I still approached " {i.e., after all his experience) " the acutely painful abdomen in a child with more apprehension and a greater feeling of uncertainty than any other domain in childhood." He described the pain as only rarely intense and the fever as rarely more than a "few degrees." Early residual tenderness at a definite point is important and is usually at McBurney’s point, though with a retrococcal appendix it may be higher or more in the flank. Rectal examination he,regarded as seldom adding anything to a careful abdominal examination. (This is in contrast to teaching in this country often crystallised in the aphorism attributed to Sir Robert Hutchison: "If you’ll put your finger in the rectum you won’t put your foot in it.") The diffuse dull pain in the region of the umbilicus with some tenderness, occurring in the course of upper respiratory throat infections, Brennemann attributed to mesenteric lymphadenitis, but he confessed that he did not know how to distinguish satisfactorily between this condition and appendicitis, adding the warning that more than half of all cases of the latter are causally related to throat infections. In discussing his paper, Joseph Colomb quoted two tips : (1) the patient with diaphragmatic pleurisy or pneumonia is too sick In
too
soon
to have
appendicitis; and (2)
a
child who is
1. Brennemann, J. J. Amer. med. Ass. 1945, 127, 691.
conscious and not forcibly held, who on deep palpation makes no attempt to remove your hand, probably does not have a surgical condition of the abdomen-the converse is not true. Abdominal pain due to food allergy, according to Ratner,2 is caused by spasm of smooth muscle, by weal formation or vascular spasm in the gastro-intestinal wall, or by a combination of these factors. He points out that skin-tests are not helpful. The same point is made by Blamontier,3 who describes an adult whose allergic trouble with mutton appeared to be due to some disintegration product of the meat protein rather than to the protein itself, for whjch skin-tests were negative. Ratner makes his diagnosis rest on careful history-taking, on prompt relief from pain after subcutaneous adrenaline or oral atropine, and on X-ray observations that the suspected article of food will provoke pylorospasm with delayed gastric emptying, and hypertomicity and hyperThe I practise peristalsis of the intestine. allergy," he remarked in discussing his paper later, " the more often I make the diagnosis of no allergy present." His treatment, apart from the avoidance of foods to which the child is sensitive, which may not always be possible, is to give a well-cooked diet, on the view that coagulated albumins cannot act as allergens.’ It is perhaps fitting to end with Brennemann’s closing words : " the majority of abdominal pains ... have, in my experience, been of unknown nature and unknown
longer
aetiology." SCOURGE is said to have begun of. which epidemic in Calcutta among the civilian population, has long been It is essentially a water-borne disease, a curse of India. and outbreaks usually originate from the contamination by carriers of unprotected wells and tanks used for drinking purposes. Widespread epidemics occur in famine years through the failure of the monsoon and winter rains, with resultant scanty and bad water-supplies both for agriculture and for domestic purposes. In India epidemic cholera is more particularly associated, in normal times, with the movements of millions of pilgrims through the densely populated endemic areas. These pilgrims acquire the infection and distribute it as they go on their Some personal protection against infection can be obtained by prophylactic vaccine inoculation ; but this is only temporary, and has to be reinforced by repeated inoculation every few months to maintain the immunity obtained. Equally important in the avoidance of the disease is abstention from all uncooked food or unboiled water or milk, and the seclusion of all foodstuffs from the attentions of the innumerable flies. Water-supplies, apart from the more obvious safeguards against pollution, can be treated with potassium permanganate sufficiently to make them pink-a measure which, when properly and universally applied in rural areas, is held to be a useful check on the spread of the disease. Treatment of cholera is directed towards the correction of the deficiencies created by it and towards combating the toxaemia resultant on the infection. So far no drug can be regarded as exerting a specific action on the cholera vibrio. Sir Leonard Rogers based his original treatment on an appreciation of the pathology of the disease, and his results were very encouraging in that he reduced the fatality-rate considerably. The aim is to replace the fluid and salts lost in the choleraic diarrhoea, to equilibriate the body temperature, and to neutralise as far as possible the toxins produced by the organisms. Anticholera units have been created in India with the necessary personnel and equipment ready to proceed to the epidemic areas when the disease breaks out. Similar units are in existence in the Army in India, and the AN
CHOLERA,
INDIAN
an
way.
2. 3.
Ratner, B. Ibid, p. 692. Blamontier, P. Pr. méd. March 31, 1945, p. 162.
°
On the whole, Comroe’s experience with rheumatoid arthritic is encouraging, for though he advises the
physician
he would tell the can be definitely United States, as in England, there is an urgent need of hospital beds for " rheumatic " patients where a well-planned therapeutic programme can be applied without delay. never
to
patient that nine improved. In the
promise
cases
a
cure
out of ten
"
ABDOMINAL PAIN IN CHILDHOOD THERE is probably no more interesting, uncertain, or hazardous clinical domain in childhood than acute conditions in the abdomen, and pain is the presenting symptom, the warning signal that something has gone wrong and that it may be serious." It is this background of possible catastrophe that makes every child patient with abdominal pain such an urgent problem. In his review of abdominal pain in childhood, of which this was the opening sentence, Brennemann1 included tenderness as an essential part of the story, and he put the majority of the more serious abdominal conditions heralded and accompanied by pain into two main categories-those due to obstruction and those due to infection. Colic of infancy he put in a class by itself, pointing out that it is probably more frequent in the breast-fed than in the bottle-fed infant and principally caused either by overfeeding or by the presence of excess of " gas " in the alimentary tract, itself either swallowed air or produced by fermentation. Of the obstructions in early life he stressed the importance of intussusception, with often a deceptive calm after the dramatic onset. A condition I
commonly diagnosed, though described by Brennenot rare, is congenital ano-rectal stricture with increasing distension of the abdomen and screaming attacks, relieved by a brief course of daily digital less
mann as
dilatation.
I
discussing appendicitis, Brennemann voiced the opinion of all children’s physicians who are honest with themselves when he wrote : "I still approached " {i.e., after all his experience) " the acutely painful abdomen in a child with more apprehension and a greater feeling of uncertainty than any other domain in childhood." He described the pain as only rarely intense and the fever as rarely more than a "few degrees." Early residual tenderness at a definite point is important and is usually at McBurney’s point, though with a retrococcal appendix it may be higher or more in the flank. Rectal examination he,regarded as seldom adding anything to a careful abdominal examination. (This is in contrast to teaching in this country often crystallised in the aphorism attributed to Sir Robert Hutchison: "If you’ll put your finger in the rectum you won’t put your foot in it.") The diffuse dull pain in the region of the umbilicus with some tenderness, occurring in the course of upper respiratory throat infections, Brennemann attributed to mesenteric lymphadenitis, but he confessed that he did not know how to distinguish satisfactorily between this condition and appendicitis, adding the warning that more than half of all cases of the latter are causally related to throat infections. In discussing his paper, Joseph Colomb quoted two tips : (1) the patient with diaphragmatic pleurisy or pneumonia is too sick In
too
soon
to have
appendicitis; and (2)
a
child who is
1. Brennemann, J. J. Amer. med. Ass. 1945, 127, 691.
conscious and not forcibly held, who on deep palpation makes no attempt to remove your hand, probably does not have a surgical condition of the abdomen-the converse is not true. Abdominal pain due to food allergy, according to Ratner,2 is caused by spasm of smooth muscle, by weal formation or vascular spasm in the gastro-intestinal wall, or by a combination of these factors. He points out that skin-tests are not helpful. The same point is made by Blamontier,3 who describes an adult whose allergic trouble with mutton appeared to be due to some disintegration product of the meat protein rather than to the protein itself, for whjch skin-tests were negative. Ratner makes his diagnosis rest on careful history-taking, on prompt relief from pain after subcutaneous adrenaline or oral atropine, and on X-ray observations that the suspected article of food will provoke pylorospasm with delayed gastric emptying, and hypertomicity and hyperThe I practise peristalsis of the intestine. allergy," he remarked in discussing his paper later, " the more often I make the diagnosis of no allergy present." His treatment, apart from the avoidance of foods to which the child is sensitive, which may not always be possible, is to give a well-cooked diet, on the view that coagulated albumins cannot act as allergens.’ It is perhaps fitting to end with Brennemann’s closing words : " the majority of abdominal pains ... have, in my experience, been of unknown nature and unknown
longer
aetiology." SCOURGE is said to have begun of. which epidemic in Calcutta among the civilian population, has long been It is essentially a water-borne disease, a curse of India. and outbreaks usually originate from the contamination by carriers of unprotected wells and tanks used for drinking purposes. Widespread epidemics occur in famine years through the failure of the monsoon and winter rains, with resultant scanty and bad water-supplies both for agriculture and for domestic purposes. In India epidemic cholera is more particularly associated, in normal times, with the movements of millions of pilgrims through the densely populated endemic areas. These pilgrims acquire the infection and distribute it as they go on their Some personal protection against infection can be obtained by prophylactic vaccine inoculation ; but this is only temporary, and has to be reinforced by repeated inoculation every few months to maintain the immunity obtained. Equally important in the avoidance of the disease is abstention from all uncooked food or unboiled water or milk, and the seclusion of all foodstuffs from the attentions of the innumerable flies. Water-supplies, apart from the more obvious safeguards against pollution, can be treated with potassium permanganate sufficiently to make them pink-a measure which, when properly and universally applied in rural areas, is held to be a useful check on the spread of the disease. Treatment of cholera is directed towards the correction of the deficiencies created by it and towards combating the toxaemia resultant on the infection. So far no drug can be regarded as exerting a specific action on the cholera vibrio. Sir Leonard Rogers based his original treatment on an appreciation of the pathology of the disease, and his results were very encouraging in that he reduced the fatality-rate considerably. The aim is to replace the fluid and salts lost in the choleraic diarrhoea, to equilibriate the body temperature, and to neutralise as far as possible the toxins produced by the organisms. Anticholera units have been created in India with the necessary personnel and equipment ready to proceed to the epidemic areas when the disease breaks out. Similar units are in existence in the Army in India, and the AN
CHOLERA,
INDIAN
an
way.
2. 3.
Ratner, B. Ibid, p. 692. Blamontier, P. Pr. méd. March 31, 1945, p. 162.
°