'Hand, foot and mouth' disease

Chicken-pox
The lesions come in three to five successive crops over a period of two to seven days. They are itchy. Most arc on the skin of the trunk but there may be ulcerating vesicles in the mouth. Differential diagnosis is generalized herpes infection, vaccinia, impetigo, drug eruptions, 'hand, foot and mouth' disease, papular urticaria and dermatitis herpetiformis.
Normally no local treatment is required, but itching can be relieved somewhat by a calamine lotion.
All scars following chicken-pox (and smallpox) arc due to scratching with resultant infection.

Molluscum contagiosum
This is a viral infection. There arc small papules which are umbjlicaied and pearly colour in appearance. They tend to be grouped. Treatment is to pierce the lesion with a pointed stick dipped in 1% phenol. If there are large numbers the dermatologist should see the child.

Bullous eruptions
These arc usually due to scalds, urticaria, impetigo, pemphigus and drugs, particularly iodides, penicillin, sulphonamidcs, salicylates, nitrazepam, thiazide diuretics and tricyclic antidepressants. When the skin is peeling off over large areas leaving a 'scalded' appearance, it is usually a toxic epidermal necrolysis. This may be infective in origin (staphylococcal) but is often due to drugs such as sulphonamidc, phenytoin or barbiturates. Paraffin can also give extensive epidermal necrolysis.

Exfoliative dermatitis
This may be caused by phenytoin, barbiturates, carbamez-apine, sulphonamidcs, opiates, gold salts, chloroquine, penicillin, phenothiazincs and streptococcal infection.

Any acute illness and illness after holidays abroad

Any acute illness

The history

When a child presents with an acute illness, it is essential to know its exact duration, and when the child was last perfectly well—and in particular whether he has had the symptoms before. One needs to know whether anyone else in the family (or school friend) has the same symptoms or whether there has been any contact with an infectious disease, what medicines (prescribed or unprescribed) the child has been given (including aspirin), whether there has been a recent immuni­zation, and whether he has recently been abroad. One has to ask specifically about every system of the body—the nose for nasal discharge, the car for pain or discharge, the throat, the chest for a cough, the stomach for vomiting, the bowels for diarrhoea, and the urinary system for frequency, scalding, etc. One asks whether the child has pain anywhere.

If the child has a pain, one needs to have answers to the follow­ing questions: 
1. Where is the pain?
2. Is it always in the same place? The pain of appendicitis may begin in the periumbilical region, and then settle in the right iliac fossa. Otherwise pain which is located first in one place and then in another is less likely to be organic.
3. How severe is it? One wants to know whether it makes the child cry, doubles him up, stops him playing, keeps him awake, or takes him off his food. One asks the mother, 'Would you know that he had the pain if he did not tell you? If the answer is no, it is not likely to be severe.
4. Is it getting better or worse?
5. What brings the pain on, what relieves it? A pleural pain is worse on inspiration.
6. What sort of pain is it? A pleural or peritoneal pain is often stabbing and knife-like in nature.
7. Is it continuous or intermittent? A rhythmical pain coming and going every few minutes suggests an intestinal origin. A child too young to describe it may have episodes in which he looks pale and poorly and then recovers.
8. If the pain comes in attacks, how frequent are the attacks, how long do they last, and are they coming more or less fre­quently? One often finds that the recurrent pain about which the mother is worried lasts moments only, and occurs once every three or four months: it is then not likely to be serious.
9. Are there any associated symptoms, e.g. headache, bowel or urinary symptoms?

Illness after holidays abroad     
Coloured immigrant children may have diseases rarely seen in British children. It is important to know whether they were born abroad and when they were last in their country of origin. If chey have lived in these countries they may harbour a variety of worms, of which ankylostoma, amongst others, is an important cause of debility. If they have been in (heir home country recently, malaria, enteric fever and even cholera have to be considered. Dermal Leishmaniasis is common in parts of Iraq, causing ulceration and scarring on the face or elsewhere. Tuberculosis, now generally unconsidered in British children, certainly has to be considered in coloured children not born in this country.

Sickle cell anaemia occurs amongst American negroes, in parts of India, the West Indies and large parts of Africa: it has such protean manifestations that it has certainly to be remem­bered in the case of coloured children. Thalassacmia occurs in the Mediterranean area, India, Pakistan and Ceylon: it causes anaemia with splenomegaly. Glucose 6 phosphate dehydro­genase deficiency occurs in Greeks, Cypriots, Turks, Chinese, Indians, Saudi Arabians, Filipinos, and Jews from Iraq and Iran. Haemolysis may occur when the child is given anti­malarial drugs, diphenhydramine, nitrofurantoin, salicylates, sulphonamidcs. Vitamin K or other drugs, or when he eats broad beans or acquires certain infections.

When British children arc seen because of illness following a holiday in countries abroad the possibilities to consider are the enteric, dysentery and Salmonella group, malaria and polio­myelitis. Visceral Leishmaniasis, giving PUO and hepato­megaly, can occur after a visit to Malta or other parts of the Mediterranean area from a bite by sandflies.


 

The crying baby and Pyrexia of unknown origin

A distinction must be made between the baby who is said to be 'constantly crying' and has done so for a long time, from the child who is crying with an acute illness.
The usual causes for 'constant crying', other than an acute illness, arc hunger, excessive wind (due to too small a hole in the teat if bottle fed), thirst due to ovcrconccntrated feeds, evening colic (first three or four months only), boredom, the desire to be picked up, excessive heat or cold, or an itchy rash. Often no cause can be found and it is assumed that the pro­blem is one of his developing personality. An erupting tooth, untreated coeliac disease or phenylketonuria, and perhaps other metabolic defects, may also present with crying. 
When a child is brought on account of constant crying, and none of the usual causes can be found, it is important to remember that the mother may be becoming worn out, and that this is a 'pre-battering' situation. 
The sudden development of constant crying in a baby pre­viously well but now ill, may be due to otitis media, urinary tract infection, meningitis or other infection, alimentary tract obstruction, subdural effusion or torsion of a testis. 
Pyrexia of unknown origin 
When the obvious causes of fever have been eliminated, in­cluding in particular otitis media, tonsillitis, urinary tract in­fection or the onset of an acute infectious disease such as measles, infectious mononucleosis, roseola infantum or enteric fever there remain many possible diagnoses to consider. The possibility of meningitis must not be forgotten.
In the newborn, an E. coli or similar septicaemia is an im­portant condition to eliminate. Chronic dehydration, due to one of the causes of polyuria, may cause a rise of temperature. Meningococcal septicaemia may present with high fever, and later on arthritis and a few petechial haemorrhages. Tuber­culosis can usually be eliminated by a tuberculin test, but not always, for the test may be negative in miliary tuberculosis and temporarily negative in measles or other infections: choroidal tubercles can be seen in two out of three children with miliary tuberculosis, and the X-ray of the chest may help to establish the diagnosis of tuberculosis, later confirmed by stomach washings and urine examination.
A perinephric or subphrenic abscess would normally be the sequel of appendicitis. Examination of all bones for tenderness or for areas of slight local warmth with blood cultures, help to eliminate osteitis. Subacute bacterial endocarditis is usually associated with congenital heart disease, of which there arc usually signs. Fever may be a manifestation of chronic liver disease, leukaemia or malignant tumours. Prolonged unex­plained fever may precede the obvious manifestations of rheu­matoid arthritis by many months. Rarer infections to eliminate include toxocara, in which there is often cosinophilia, and tox­oplasmosis.
Fever may be a side-effect of numerous drugs. Malingering is a rare cause of elevation of the temperature. By various means, including rapid rubbing of the bulb of the thermome­ter, the unwary may be deceived. However, a normal white cell count and normal ESR help to eliminate many of the infections. Very occasionally a child has a slightly raised tem­perature, is well, and nothing abnormal is found after full investigation.

Acute abdominal pain, Acute appendicitis and Other causes of abdominal pain

General principles

No symptom presents a greater challenge to the casualty doctor or the family doctor than acute abdominal pain in children. Probably all children sooner or later experience some abdominal pain. The possible causes arc innumerable, and in this section I shall discuss some of the more important ones and some of the difficulties in diagnosis.
One must know when the child had his last bowel action, and whether he is passing flatus. Enquiry should be made about an upper respiratory tract infection in the last few days, and, in all cases, about medicines taken by the child—for they may be the cause of the pain.
The examination must be a full one. The whole body is inspected, e.g. for a rash, such as that of anaphylactoid pur­pura which often predominantly affects the buttocks. The abdomen is inspected before palpation for distension and peri­stalsis. As already emphasized, when palpating the abdomen one watches the child's face for evidence of tenderness on palpation. One auscultates for peristaltic sounds. In all cases the genitalia are examined for a strangulated hernia or torsion of a testis, and in all cases a rectal examination is required.
The most useful special investigations are usually the white  cell count, ESR, urine examination and culture, and where relevant, examination for sickle cell anaemia.
Abdominal pain is regarded particularly seriously if there is also vomiting, if it has lasted for over three hours, if the child looks ill or if the temperature is raised. It is more likely to be significant if the pain is localized than if it is diffuse. A fairly severe pain may precede the development of diarrhoea: and pain may result from a bad cough or from vomiting. The pres­ence of diarrhoea by no means excludes the diagnosis of acute appendicitis or peritonitis or intussusception. The finding of an excess of white cells in a ccntrifuged specimen of urine must not be thought to prove the presence of pyelonephritis; it may occur in pelvic peritonitis and appendicitis. The ESR is often normal in anaphylactoid purpura.
No child with acute abdominal pain should be sent home by a casually doctor without a senior doctor seeing the child. He may have to be re-examined after an interval- If it is thought that he is fit to go home, the family doctor is told on the telephone, the parents are told to bring the child back immediately if there is any reason for anxiety or deterioration, and in any case the child must be seen next day.

Recurrent abdominal pain

This common condition affects mainly school-age children. Many have attacks of central abdominal pain with vomiting, pallor and often fever. It may be related to migraine. The pain may be very severe. In 94% of cases no organic cause is found: but in the remaining 6% the cause may lie in hy­dronephrosis, recurrent volvulus, urinary tract infection, peptic ulcer or other cause. It is not due to a 'grumbling ap­pendix' or 'chronic appendicitis'. The danger in making the diagnosis when a child has had several attacks is the possibility that the present attack is due to a different cause, such as acute appendicitis. It follows that however many attacks the child may have had, a full history and examination are essential. If the attack has passed at the time of examination the parents should be told to bring the child back as soon as another attack has begun.

Acute appendicitis 
It would be much easier for the doctor if all children with acute appendicitis had the symptoms of abdominal pain, vomi­ting, constipation and fever, the pain commencing in the um­bilical area and settling down in the right iliac fossa. Unfortunately the diagnosis is often more difficult. In several studies it was found that about 10% have dysuria (and there may be an excess of white cells and some albumin in the urine) and about 10% have diarrhoea. Appendicitis can occur at any age, and infants with acute appendicitis usually present with diar­rhoea, urinary symptoms and an abdominal mass, often with acetone in the urine, and the white cell count may be normal, though this is unusual. In 40% of 100 cases of perforated appendix, there had been no localization of pain. When the appendix is rctrocaecal, the pain may be in the upper part of the abdomen on the right, or not localized. Occasionally the pain may be in the left iliac fossa. In some cases there is no pain at all. The temperature is not usually high, but may be over 39c in an occasional case. 
It may be difficult or impossible to distinguish acute appen­dicitis from acute

mesenteric lymphadenitis.

Intsussuception 
If all children with intussusception were aged three to nine months, had had severe rhythmical attacks of abdominal pain, vomiting and pallor, with blood in the stool and a palpable sausage­shaped mass, the diagnosis would be easier. Unfortu­natelythere are many variations from this picture: there may be a normal bowel action on the first day, or even diarrhoea; there is often no blood in the stool; in 10% or more there is no pain, but attacks of severe pallor with or without vomiting; and in 10% there is a history of a preceding upper respiratory tract infection; in 10% there may be a high white cell count; and in about 15% the temperature is raised. 
When a child is said to have had one or more attacks of 'looking awful' and perhaps going limp, it is often difficult to decide whether the cause is something like intussusception or if he has had a fit

Torsion of the testis 
This occurs at any age including infancy: the pain may be abdominal or scrota! and often in the groin. An acute painful swelling in the scrotum should be diagnosed as torsion of  the testisuntil   proved otherwise, and referred urgently to the surgeon for exploration

Pain from the urinary tract 
The causes include pyelonephritis, hydronephrosis, renal cal­culus and acute nephritis. The latter can cause abdominal pain.

Other causes of acute abdominal pain 
These include pneumonia and pleurisy (pain being referred to ihe abdomen), infective hepatitis, Meckel's diverticulitis, acute rheumatic fever, sickle cell anaemia, anaphylactoid purpura, and diabetes or associated hypoglycacmia. A pancreatic pseu­docyst may develop around a monih after an upper abdominal injury, causing pain and vomiting.

Investigations 
These must depend on the history and examination, but the most useful ones will usually be microscopy of urine and cul­ture, and a blood count. If there is a possibility of obstruction, erect and supine views of the abdomen may show fluid levels. Do not treat as a urinary tract infection until it has been proved to be one.

Abdominal distension

In the newborn period, a perforation in the alimentary or urin­ary tract should be considered, as well as tumours, cysts and hydronephrosis. Perforation of the stomach is manifested by abdominal distension, vomiting, respiratory distress and mcl-acna, usually around the third day of life. A perforation in the urinary tract, causing ascites, is usually the result of urethral obstruction. One of the features of chloramphenicol toxicity in the newborn (the grey syndrome) is abdominal distension, as­sociated with cyanosis and pallor. In Hirschsprung's disease there is usually abdominal distension, often with alternating constipation and diarrhoea.

When the child is older abdominal distension, more than that commonly seen in the normal toddler, may be due to stcatorr-hoea, gross constipation, ascites or tumour. Diphenoxylate (Lomotil) should not be used in children but can be a cause of otherwise unexplained distension.

Intestinal obstruction may present with abdominal pain (with or without vomiting) and some localized distension of the abdomen (see the section on acute abdominal pain above).

Vomiting, Newborn, Infants, Infancy, Disposal and Haematcmcsis

Because innumerable conditions cause vomiting in childhood, I have picked out some particularly important features and conditions as a guide to diagnosis. 
Probably all children vomit sooner or later. Features of part­icular importance include the following: 
1.Green, bile-stained vomitus. In the newborn this indicates intestinal obstruction until proved otherwise.
2. Persistent vomiting, as distinct from intermittent vomiting.
3. The child becoming unwell, suckling less well, loss of appetite, ceasing to smile (after five or six weeks of age) and drowsiness.
4. Abdominal distension.
5. Visible peristalsis. 
6. Dehydration.
7. Loss of weight.
8. Fever.
9. Headache associated with vomiting.

Newborn

Obstruction may be caused by a meconium plug (often dealt with simply by inserting the little finger in the rectum), oeso­phageal atresia (in which case there may have been hy-dramnios, and the baby is obviously unable to swallow mucus and saliva), duodenal atresia (in which case there is severe vomiting but without abdominal distension) or obstruction farther down the alimentary tract. In Hirschsprung's disease there is often a story that no stool was passed in the first 24 hours and there is constipation or alternating severe diarrhoea and constipation, with abdominal distension: on rectal exam­ination the rectum is empty.

Intracranial causes include cerebral oedema or hae­morrhage, subdural effusion or meningitis. Fullness of the fontanellc and wide separation of the sutures may point to an intracranial cause, but in meningitis there may be no bulging of the jonianelle or neck stiffness: the child is just ill, and there is no other discoverable cause. E. coli septicaemia is another important cause of vomiting and illness in the newborn: there may or may not be evidence of umbilical infection.
Urethral obstruction in the male is manifested by a poor stream of urine and a palpable bladder. Other causes which are rare but treatable are galactosaemia and adrenocortical hy­perplasia. In the latter there may or may not be notable en­largement of the phallus; biochemical investigation will es­tablish the diagnosis.
Vomiting may be due to obstruction in the alimentary tract, including intussusception and strangulated hernia.
Vomiting may be the side-effect of drugs.
A complaint that the baby is constantly vomiting may be one of the early indications of the child abuse syndrome.
Causes of vomiting after infancy include, in particular, infec­tions (especially otitis media, tonsillitis, urinary tract infection, meningitis, whooping cough and gastroenteritis), migraine and the periodic syndrome, travel sickness, intestinal obstruction, appendicitis and the effect of drugs and excessive or unusual food intake. Do not forget the possibility of a cerebral tumor.
In some cases re-examination after an hour or so may help.
Haematemcsis is a rare symptom in children. The new baby may swallow blood from his mother's cracked nipple. (For the test to determine whether the blood is the mother's or the baby's). Older children may vomit blood after epi-staxis, or in association with acute tonsillitis, or as a result of oesophageal varices or gastric ulceration from aspirins. Other causes arc hiatus hernia and reflux, blood diseases, pyloric stenosis (rarely) and drugs other than aspirins.

Infants after the newborn period

Almost all babies bring a small amount of milk up after a feed: some do it more than others. A major cause of vomiting is excess of wind, which in a bottle-fed baby is almost always due to too small a hole in the teat. Congenital pyloric stenosis presents almost always between three and eight weeks of age with the story of one large vomit immediately after or during a feed. Peristalsis can often be seen, and a pea-sized tumour can almost always be felt. After ten weeks of age it is exceedingly rare. The ruminator is hardly likely to present in a casualty department: the baby arches the back and tries to bring the milk up and he may appear to gargle with the milk in the throat. This may be associated with gastro-oesophageal reflux. When a well baby presents with vomiting after every feed, one must know whether there is blood in the vomitus: it would point to a hiatus hernia or reflux. Numerous infections present as vomiting. The principle ones are otitis media, urinary tract infection, whooping cough, 'winter vomiting disease', menin­gitis and gastroenteritis. It is useful to know whether any other child in the family is poorly with vomiting. With regard to whooping cough, the fact that the vomiting is the result of coughing may only be elicited on careful questioning. The virus infection termed 'winter vomiting' occurs in well babies with no fever or diarrhoea. Vomiting may precede diarrhoea in gastroenteritis. Vomiting may be an early symptom of cocliac disease or adrenocortical hyperplasia.

Vomiting after infancy

Causes of vomiting after infancy include, in particular, infec­tions (especially otitis media, tonsillitis, urinary tract infection, meningitis, whooping cough and gastroenteritis), migraine and the periodic syndrome, travel sickness, intestinal obstruction, appendicitis and the effect of drugs and excessive or unusual food intake. Do not forget the possibility of a cerebral tumour.

Disposal (acute cases) 
When in doubt the child hai 10 be admitted. If he is sent home, the family doctor is spoken 10 on the telephone, and the child must be seen again next day.

Haematcmcsis

Haematemcsis is a rare symptom in children. The new baby may swallow blood from his mother's cracked nipple. Older children may vomit blood after epi-staxis, or in association with acute tonsillitis, or as a result of oesophageal varices or gastric ulceration from aspirins. Other causes arc hiatus hernia and reflux, blood diseases, pyloric stenosis (rarely) and drugs other than aspirins.

Diarrhoea

Several conditions arc often confused with gastroenteritis. Many doctors have failed to realize that a fully breast-fed baby has loose stools which arc often bright green, explosive, con­tain mucus and curds (soap plaques), and may be very frequent—up to 24 in 24 hours. Some confuse the loose, green, starvation stools of an underfed baby with gastroenter­itis. Babies with Hirschsprung's disease may present with diarrhea and vomiting. Necrotizing enterocolitis occurs es­pecially in low birth-weight babies who are bottle fed: they have fever, shock, diarrhea, vomiting and abdominal disten­sion. Carbohydrate intolerance is commonly associated with diarrhea. Some children with acute appendicitis, peritonitis and intussusception have diarrhea. Toddlers, aged twelve months to two or three years, sometimes have very loose stools, though well and thriving: the condition is termed the irritable colon syndrome, or 'toddler diarrhea". It has to be distinguished from the various diseases associated with stea-torrhoca. One has seen many children treated by anti-diarrhea medicines for incontinence of faeces and liquid stools leaking out of the anus due to gross constipation. At any age ulcerative colitis may occur: blood and mucus may not appear in the stool for some months after the first attack of diarrhea. Many medicines, such as penicillin by mouth, cause diarrhea.

Diarrhea is not due to teething.

When a child with gastroenteritis is referred to the casualty doctor or family doctor, an important decision has to be made: namely whether he is to be allowed to go home, or whether hospital treatment is required. The first essential is to decide how ill the child is: if he is ill he should be admitted. The next essential is to assess the degree of dehydration, if any.

Dehydration can be very rapid in a baby or young child. It is assessed as follows:

Mild dehydration ( < 5%)—good general condition and some loss of skin turgor.

Moderate (5%)—looks ill with a dry mouth but no per­ipheral circulatory failure.

Severe (10%)—signs of peripheral circulatory failure and gross dehydration.

Over (10%)—the child is severely shocked and mori­bund.

When a baby is overweight it is difficult to assess the dehy­dration. An overweight baby may have severe acidosis and dehydration without apparent loss of tissue turgor, becuuse fatty tissue is largely water-free. Better signs of dehydration in a fat baby arc a dry mouth, a sunken fontanelle and sunken eyes. Ovcrvcntilation suggests hypernatraemic acidosis and one must look for an associated infection, such as otitis media, urinary tract infection or septicaemia.

If a baby's general condition is good and there is only slight loss of tissue turgor, a rectal swab is taken and he is taken off all food for 24 hours (not more) and given an oral electrolyte solution. This can be made with Elcctxosol tablets (eight in a litre of water) or by using Dioralytc sachets. Dioralytc con­tains dextrose in addition to sodium and potassium chloride and sodium bicarbonate, and a sachet is made up to 200 ml with water.

An infant is given 150-200 ml per kg per 24 hours and other feeds. This should not be given for more than 48 hours.

An older child is given 1-3 1 in the 24 hours. The water should be tepid, for iced water increases peristalsis. Antibio­tics arc not given. Even if Sonne dysentery is diagnosed, they are not given, because they prolong the carrier state; the same applies to a salmonella infection. It is futile to prescribe kaolin. Diphenoxylate (Lomotil) should not be prescribed. Do not give mctoclopramide or prochlorperazine.

If the child is sent home, the family doctor is spoken to, and if necessary asked to sec the baby later in the day. The parents are told thai if there is any deterioration in his condition he must be brought to the hospital immediately. He must certainly be seen next day.

If the child is ill with loss of tissue turgor and a depressed fontanclle, he must be admitted. Blood is taken for culture, blood urea and electrolytes and an intravenous line is set up with 045% sodium chloride in 4-8% dextrose. Give 25 ml per kg as fast as the drip will run before admitting the child. If the baby is profoundly shocked give 10 ml per kg plasma by push before attempting replacement of the deficit.

For deficit replacement, 5% dehydration will need 50 ml per kg and 10% dehydration will need 100 ml per kg. Main­tenance is worked out as 2 ml per kg of body weight. The procedure is summarized below: 

0-1 h-----------------→  4 h-----------------→ 12 h--------------------→ 24 h

⅓ replacement             ⅓ replacement          ⅓ replacemen
                                     +                               +                                     maintenance
                                     maintenance              maintenance                  +

                                                       +                        on-going losses

                              on-going losses

The doctor should anticipate the development of convulsions if there is hypertonic dehydration.

Gastroenteritis in a baby or young child must be treated with caution because he can deteriorate with extretne rapidity, collapse and die

Blood in the stool and Rectal prolapse

Introduction

In this section I have picked out some of the common or more important symptoms of disease met with in a casualty depart­ment, giving the chief causes, the important difficulties in di­agnosis, and, where relevant, the management.

Even though the final diagnosis may not be made in the casualty department or in the surgery, I think it adds to the interest of the work if the doctor examining the child has a reasonable knowledge of the possible causes. Potentially serious mistakes may be avoided if he knows the conditions which need further investigation by a pediatrician or pediatric surgeon. 

Blood in the stool

When a baby passes blood in the stool (or vomits blood) in the first two or three days, one must know whether it is the baby's blood or the mother's blood. If necessary the stool or vomitus is filtered, and to the pink solution four or five drops of N/5 NaOH are added: if it is the baby's blood the solution remains pink because the fetal haemoglobin is more resistent 10 alkali, but if it is the mother's blood, the colour changes to yellow. If it is the baby's blood the baby's general condition and haemo­globin is watched. A transfusion may be necessary.

If a rectal thermometer has been used, the bleeding may be due to that.

After the newborn period the commonest causes arc con­stipation, dysentery or salmonella infection, intussusception or ulcerative colitis. Blood from a Meckel's diverticulum is partly red and partly black. Blood may also come from a duplication of the intestine, a polyp, a foreign body or blood disease. Aspirin can cause bleeding.

Blood in the stool has to be distinguished from staining by diazepam syrup, viprynium or red gelatin.                                                                                                                

Rectal prolapse

Rectal prolapse is a relatively common complication of fibro­cystic disease of the pancreas and of meningomyelocele. In otherwise normal children it is usually a self-limiting con­dition, regressing as the child grows. The parents should be shown how to replace the bowel, by elevating the buttocks, inserting a finger previously covered with tissue paper into the lumen of the protruding mass, and pushing it back into the rectum