feature the hard faecal masses may be made out.
The course of the disease is often long drawn out and the patient may be
apparently well save for his intestinal symptoms. Other cases become gradu-
ally emaciated and may die from exhaustion rather than from the disease itself.
The prognosis as regards life is good but as to recovery, especially in cases
of long standing, it is distinctly bad.
Treatment of this disease is unsatisfactory, consequently many drugs have
been recommended as useful. Of these silver nitrate may be mentioned
first. Its dosage is J grain (0.016) three times a day, or it may be given in
I to 1000 aqueous solution in doses of 2 or 3 drachms (8.0-12.0) three times
a day. Other metallic astringents such as copper sulphate, J grain (0.016),
lead acetate, 2 grains (0.132), or zinc sulphate, 2 to 4 grains (0.132 to 0.25)
may be employed. Other drugs, given with the idea of lessening the diarrhoea
by means of inhibiting the fermentive and putrefactive processes going on in
the intestine may be mentioned almost without number. The best of these
are the bismuth salts, especially bismuth naphtholate (orphol), 5 to 15 grains
(0.33-1), bismuth tribromophenolate, 8 grains (0.5) and bismuth tetraiodo-
CHRONIC CATARRHAL ENTERITIS. 385
phenolphthaleinate, 5 to 8 grains (0.33-0.5). The subsalicylate, the sub-
gallate and the subnitrate may also be employed in doses of 10 grains (0.66)
or more, frequently repeated.
The vegetable astringents are less effective than the bismuth salts but in
view of their former popularity may be mentioned. What action they exert,
for we now know that they do not act as astringents when introduced into the
alimentary tract, is due to their tannic acid content. Of these calumba,
catechu, rhatany, campeachy wood, and tannic acid may be mentioned.
Tannalbin, tannocol and tannigen in doses of 8 to 15 grains (0.5-1.0), as
well as the calcium salts — the phosphate, carbonate and salicylate — given
in solution in carbonated water, may be employed. Goto — the powder in
dosage of 10 grains (0.66), or as cotoin, ^ to i grain (0.032-0.065) — is used
empirically.
Neurotic diarrhoeas due to hysteria, the symptom complex of neurasthenia,
migraine, and the climacteric require not only careful management based,
on the underlying cause but call for a further word of comment. The best
results are obtained from the persistent use of the bromides, preferably stron-
tium bromide (free from the barium salts), 60 to 90 grains (4.0-6.0) daily.
After 3 days this may be diminished in quantity and the solution of potassium
arsenite commenced, 3 drops (0.2) thrice daily and increased i drop (0.065)
per day until slight untoward symptoms supervene.
Nephritic or ursemic diarrhoea should be recognized as a salutary effort of
the organism to rid itself of the poisons whose effects we characterize as
"iiraemia." The proper method of dealing with this condition is the admin-
istration of a high intestinal irrigation of normal sodium chloride solution,
in quantity a gallon (4 litres) of a temperature of 112° F. to 116° F. (44.5° to
46.5° C.) through a rectal tube, inserted at least 12 inches, the reservoir be-
ing elevated about 3 feet. If the chronic nephritis is predominatingly paren-
chymatous, the sodium chloride should be replaced by sodium bicarbonate.
Intestinal irrigation will free the bowel from irritating contents, will enable
the kidneys to functionate normally and will stimulate the heart.
Purinaemic diarrhoeas are best combated by 60 grains (4.0) daily of saligenin
tannate, regulation of the diet and inhibition of intestinal fermentation by
intestinal antiseptics until the proteid metabolism is re-established upon a
satisfactory basis.
Malarial diarrhoea is best treated by arsenic, methylthionine hydrochloride
(methylene blue) or a combination of extract of ergot, 2 grains (0.13), berberine
sulphate i grain (0.065) with piperine ^ grain (0.032) 4 times daily.
In patients who have survived the acute onset of cholera, a diarrhoea fre-
quently persists. This is best treated by bismuth tribromophenolate, 90 to
120 grains (6.0-8.0) daily. In addition dried suprarenal extract, 5 grains.
(0.33) 3 times a day will assist in restoring the vascular tone.
25
386 DISEASES OP THE DIGESTIVE SYSTEM AND PERITONEUM.
If bile pigment is present in the stools the disturbance is presumably high
in the intestine and a combination of salicylic acid, 6 grains (0.40) with
the same amount of acid sodium oleate, with 4 grains (0.25) of phenolphthalein
and ^ grain (0.032) of menthol given once daily for several days will disinfect
the bile and remove this cause of intestinal indigestion.
The constipation occurring in chronic entero-colitis must never be allowed
to persist and should be combated by mild rather than drastic measures.
Enemata of warm water, castor oil, calomel or laxative waters such as Hunyadi,
Apenta, etc., are the best means of controlling this symptom. Faecal impac-
tions are best relieved by softening them by quart (litre) injections of warm
olive oU, the patient being in the knee-chest position, or drachm (4.0) doses
of arsenic-free sodium phosphate twice daily by mouth; y^o^ of a grain
(0.0006) of physostigmine salicylate 3 times a day will enable the intestinal
muscularis to recover its tone.
Opium is admissible in the treatment of chronic diarrhoea only, when the
alimentary cana,l has been thoroughly emptied, to check excessive peristalsis.
It should be given hypodermatically, as morphine, in substantial doses, and
not repeated. A prescription for opium, or any of its preparations or alkaloids,
should never be entrusted to patients of the nervous type. There is too
great danger of habit formation.
The extract of denarcotized opium and extract of belladonna have been
recommended as useful in the relief of the abdominal pain from which some
patients sviffer but both these drugs should be employed with utmost caution,
the former on account of the danger of causing the habit, the latter lest toxic
symptoms be induced.
Treatment by means of colonic irrigation is effectual when the chief seat
of the inflammation is the large intestine. A soft rubber rectal tube passed
high into the bowel and attached to a fountain syringe or a large funnel
should be used. Various solutions have been employed in this connection,
those preferable being silver nitrate 1-2 to 1000, boric acid i to 100, sali-
cylic acid 2 to 100, tannin 2-4 to 1000, zinc sulphate 3 to 1000 and mercury
bichloride i to 15,000. The last is irritating and if absorbed is likely to pro-
duce mercurial intoxication, consequently it should be administered with
great caution.
Diet. By far the best diet for chronic entero-colitis is milk, but it cannot
be continued indefinitely. The author reserves its use for between meals and
at bed time. The first choice is a properly peptonized milk, not taken too
cold. For the meals clear meat soups, gruels, eggs, poached on toast, soft-
boiled or raw, fresh butter, sweetbreads, calf's brain, rare, grilled or broiled
steak or lamb chops, fresh chopped beef, with ^ drachm (2.0) of dilute hydro-
chloric acid to each 2 ounces (60.0), oysters and fish, toast, hard rolls, mashed
potatoes and macaroni, will carry the patient well toward the time when a
1
CHOLERA MORBUS. 387
regular mixed diet may be resumed. To be avoided are fruits, raw or soiir,
cooked or sweetened, succulent vegetables, fat meats, all highly seasoned and
indigestible foods, foods leaving much residue, and sugar. All dishes should
be properly cooked and prepared as simply as possible in every way.
Mineral waters seem to have a certain influence upon chronic intestinal
catarrhs. The waters of Carlsbad and Vichy have a considerable vogue
among European clinicians and the waters of Saratoga and of the Virginia
hot springs of our own country may prove quite as beneficial. Water cures
at home are seldom as beneficial as when taken at the springs for the mode
of life, regular diet and exercise at these resorts has an additional favorable
action upon the lesion.
Aside from sojourns at spas, other changes of climate and scene may benefit
the patient.
Hydrotherapeutic procedures have a place in the management of chronic
diarrhoeas and a course of cold water treatment at an institution frequently
acts favorably. Diarrhoeas from cold almost invariably may be relieved by
the daily use of a morning cold bath. The bath should commence with a tem-
perature of 88° F. (31.1° C), and be taken cooler by a degree or so each morn-
ing until 68° F. (20° C.) or even 58° F. (14.5° C.) is reached. A 5 minute
bath followed by a brisk rubbing with a rough towel results in a vigorous
reaction, and the morning bath not only soon becomes a therapeutic necessity
but a luxury as well. In addition an abdominal bandage of flannel shoiild
be constantly worn. Wet abdominal binders and hot or cold compresses
are often useful adjuncts to treatment.
CHOLERA MORBUS.
Synonyms. Cholera Nostras; Sporadic Cholera.
Definition. An acute inflammation of the stomach and intestines charac-
terized by profuse emesis, diarrhoea and severe abdominal cramps.
.Etiology. No micro-organism has yet been proven to be the specific cause
of this disease although it is possible that it may be of bacterial origin. Until
its specific cause is isolated we must consider it to be the result of the ingestion
of impiire, decomposing or indigestible articles of food, such as decayed or
unripe fruit, fish, salads, etc. Attacks of cholera morbus are most frequent
during the hot months and seem to be predisposed to by exposure to draughts
while the body is over-heated.
Pathology. The morbid conditions found in fatal cases of cholera morbus
resemble too closely those of acute enteritis to need separate description.
Symptoms. The onset of cholera morbus frequently takes place in the
night. The patient is seized without warning with nausea, followed by
388 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
vomiting, profuse diarrhoea and severe abdominal cramps. The vomitus
consists at first of the stomach contents followed by bile and later by watery
fluid. The stools are often so frequent as to be almost without interval,
at first they are of the faecal matter contained in the bowel but soon become
very loose and watery. A rise of temperature is infrequent. Thirst due to
the rapid loss of water is marked. The pain is abdominal, paroxysmal and
colicky; the muscles of the limbs later become painful; in severe cases the
patient may fall into a state of collapse, with marked bodily weakness, cold,
clammy skin and weak and rapid heart action.
Death may supervene in rare instances but recovery from the acuity of
the attack within half a day is the rule. The depression, weakness and
irritability of the digestive tract may last for a few days longer.
Treatment. Since the train of symptoms known as cholera morbus is the
result of some irritating substance in the gastro-intestinal tract the first indi-
cation in treatment is to get rid of the cause of the offence. This may be
done by administering calomel in doses of J grain (0.016) every J hour until
6 doses have been taken, or castor oil ^ ounce (15.0). In cases with marked
and frequent vomiting it may be impossible for medication given by mouth
to be retained; here the most approved method of cleansing the intestine
is by high rectal irrigations of warm water.
The severe pain may be controlled by the application of counter-irritation
by means of the mustard or flax-seed poultice or a capsicum plaster to the
abdomen. These should be carefully watched lest they cause blisters. When
relief is not brought about by these means the hypodermatic injection of
morphine may become necessan^ but this remedy shoifld be used with the
greatest caution.
In the later stages of an attack the use of a prescription such as the following
may be indicated: I^ acidi sulphurici aromatici, rr^vi (0.4); extract! haema-
tox}don, rr^vi (0.4); spiritus chloroform! TTLxii (0.8); fluidextracti ipecacuanhas,
nxiii (0.2); s}T:upi zingiberis, q. s. ad 5i (4-o)- Misce et signa, one dose every
2 hours.
The marked thirst must be relieved by supplying water to the tissues either
by high rectal enemata of normal saline or by hypodermatoclysis of the same
solution. The latter process consists in allowing a pint (J litre) or more of
saline to run into the tissues through a needle attached to an irrigation appa-
ratus and plunged into the thigh or buttock, the skin of which has been previ-
ously sterilized and, if advisable, anaesthetized by means of an ethyl chloride
or aether spray. This quantity of the solution wiU be quickly absorbed and
the procedure may be repeated if necessary.
For the vomiting the patient should be given cracked ice to hold in the
mouth, sips of iced champagne or carbonated waters. The tendency to
collapse necessitates the exhibition of hypodermatic stimulation, strychnine,
DIARRHCEAS OF CHILDREN. 389
camphor and aether, etc., the application of heat to the extremities or wrapping
the body in a hot sheet.
Diet. During the acuity of the attack and for a day or more after, the less
eaten the better. As the vomiting ceases the patient may begin to take small
quantities of milk and lime water or milk mixed with a carbonated mineral
water and as progress toward recovery is made soups, toast, soft eggs, etc.,
may be allowed, to be gradually followed by a return to ordinary diet.
DIARRHCEAS OF CHILDREN.
Acute Gastro-enteritis.
Synonyms. Summer Diarrhoea; Gastro-intestinal Catarrh.
Definition. An acute catarrhal inflammation of the gastro-intestinal
tract characterized by vomiting, diarrhoea and a febrile movement.
etiology. The specific cause of this disease is probably bacterial. Various
micro-organisms have been considered to have a part in the production of
this condition, namely the colon baciUus, the streptococcus, the staphylococcus,
the baciUus pyocyaneus, the bacillus proteus and Shiga's bacillus. The
disease is predisposed to by teething, hot weather, unhygienic surroundings
and poor bodily condition. The exciting cause seems usually to be improper
feeding, either in quantity or quality. Not only bottle-fed babies are subject
to the infection but those fed on mother's milk are often attacked, since im-
proper diet, mental excitement, etc., are capable of materially changing the
lacteal secretion and thus causing the digestive disturbance.
Pathology. The gross appearance except for the presence of excessive
mucus is little changed. The mucous lining of the gastro-intestinal tract may
either be pale or hyperaemic and the solitary and agminated follicles of the
smaU intestine may be swollen. Patches of congestion may be observed in
the large intestine. The intestinal waUs are not thickened.
Symptoms. The disease occurs in two chief types, the mild and the severe.
In the former the onset is gradual with symptoms of indigestion, little or no
rise of temperature, restlessness and fretfulness; the stools become more fre-
quent, are diarrhoeal in character, greenish, yellowish or brownish in color,
of bad odor and contain undigested food; later mucus appears.
In the second type the onset may be gradual, with symptoms of digestive
disturbance, or sudden, with a rapid rise of temperature — 102° to 105° F.
(38.9° to 40.5° C.) — hot dry skin, restlessness, and vomiting. There may be
convulsions or stupor. The thirst is often extreme. The vomitus consists
first of undigested food, and if emesis continues after the stomach has become
empty, mucus or bile may be vomited. In certain cases the vomiting may be
390 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
wholly absent. The diarrhcea may not appear for a number of hours after
the onset of the attack. The stools are at first of faecal matter and are accom-
panied by colicky pains and gas; later they become thin, watery and foul; in
color they are grayish, greenish or brownish. They contain mucus after a
few days and may be as many as 15 or 20 during the 24 hours. The child
rapidly becomes weak and emaciated; the disease may prove rapidly fatal or
the symptoms may abate and the condition become subacute. Relapses are
not uncommon and the disease may go on to an entero-colitis.
Treatment. Prophylaxis, in view of the probable infectious character of
the disease, consists in careful attention to the surroundings and hygiene of
infants, especially during the summer, the immediate washing or disinfection
of all soiled napkins, and above all proper feeding, the use of boiled water
for drinking purposes and the boiling of bottles and nipples — in the case of
artificially fed infants — previous to their use on every occasion. Breast
feeding should be encouraged and mothers advised against weaning during
the summer.
The treatment of the attack proper consists in measures calculated to reheve
the digestive tract of its irritating and toxic contents. If the vomiting is per-
sistent the stomach should be washed by means of a soft rubber catheter of
appropriate size attached to a rubber tube of larger calibre, and a funnel. The
lavage should be continued until the water returns clear and it is wise to leave
a little water in the stomach. If the vomitus has been very acid a little sodium
bicarbonate may be added to the water left behind. In children who struggle
against the stomach tube full draughts of boiled water may be substituted.
The small intestine should be relieved of its contents by cathartics. When
vomiting is not a feature, castor oil, 2 drachms (8.0), may be given to a child of
I year while older children may take up to J ounce (15.0). Calomel in divided
doses of ^ to ^ a grain (0.016-0.032) should be given every half hour up to
6 doses. The tablets may be dissolved in a teaspoonful of boiled water and
are wiUingly taken.
The colon should be irrigated with warm normal saline solution. Two quarts
(litre?) should be used and given through a soft catheter passed high into the
bowel. This procedure shotild be carried out twice or thrice during the first
day of the attack and once a day thereafter. Drugs are often unnec-
essary but should they be indicated bismuth subgallate in doses of 3 or 4
grains (0.2-0.25) may be given to a year old child every 3 hoiirs or phenyl
salicylate (salol) in doses of i to 2 grains (0.065-0.13) may be administered.
Antacids, such as lime water, milk of magnesia or chalk mixture are often
useful when h}^eracidity of the stomach with fermentation is present.
In cases with marked prostration stimulation is necessary in the form of
whiskey or brandy given frequently in small amounts fuUy diluted. A half
ounce (15.0) in divided doses during the 24 hours is not too much for a child
CHOLERA INFANTUM. 39 1
of I year. Hot mustard baths and applications of heat are useful and if the
diarrhoea has been profuse enough to deprive the system of a large amount
of water this should be supplied by rectal irrigations or by hypodermatoclysis
of warm normal saline solution.
Diet. Too great emphasis cannot be laid on the statement that no food
should be given for at least 24 hours, or for even longer periods, should the
vomiting continue; cold water should be supplied, however, and thin barley
water or albumin water (the white of one egg in 8 ounces (250.0) of boiled
water) to which a little brandy has been added are allowable. If these are
refused the stomach should be allowed to rest.
Usually after 24 hours the child may be allowed to nurse, but for not longer
than 2 to 3 minutes, at intervals of at least 4 hours. In the intervals barley
or albumin water may be given. Gradually the intervals between breast
feeding may be lessened and the length of the nursing prolonged so that in
4 or 5 days the child is fed as usual.
Bottle-fed infants should be deprived of all milk for several days and barley
or rice water, artificial malted foods, beef or chicken bouillon substituted.
When milk is allowed again it should be boiled, the quantity should be small
and the dilution very weak.
During convalescence the child should be carefully watched and if possible
a change of climate is advantageous. The climate does not seem to matter
particularly, so long as excessively hot neighborhoods are avoided; babies taken
from the city to the country do well and vice versa. All errors in diet should
be studiously guarded against.
Cholera Infantum.
Definition. An acute catarrhal inflammation of the intestinal tract of
very severe t}^e characterized by high temperature, profuse diarrhoea and
great prostration.
Etiology. No specific cause for this disease has been isolated but it seems
to be closely associated with the decomposition of the intestinal contents,
especially if this is impure milk. The predisposing causes are poor general
condition, unhealthy surroundings, etc.; they are similar to those of acute
gastro-enteritis.
Pathology. Post mortem examination reveals no marked abnormality
in the affected intestine.
Symptoms. Cholera infantum usually occurs in children in whom there
has been previous intestinal disturbance. Prostration and fever are often
present before the appearance of the vomiting and diarrhoea. The former
may appear first or both it and the purging may occur simultaneously. The
emesis is frequent, the vomitus at first consisting of the contents of the
392 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
Stomach, then of mucus, serous fluid and later bile. It is brought on by
the ingestion of any food or drink. The patient is very thirsty and eagerly
drinks water only to vomit it almost immediately. The movements from
the bowels are copious, greenish, yellowish or brownish and may be as many
as 20 or 30 in 24 hours. Their odor is, as a rule, not foul but at times is very
offensive, and as the disease progresses they become serous in character.
Nervous symptoms are frequent; at first they are those of excitation of the
nervous system, later they may merge into convulsions, stupor or coma. The
pros^ation is marked and emaciation is rapid. The temperature varies with
the severity of the attack from 102° to 105° F. (38.9° to 40.5° C), the pulse
and respiration are rapid and weak and at times irregular. In the fatal cases
the skin is cold and clammy and the facies typical, the eyes being sunken,
the skin pale and the expression anxious to a marked degree. The cerebral
symptoms may lead to a mistaken diagnosis of brain lesion, but they are
probably the result of the action upon the nervous system of toxins absorbed
from the intestine.
In cases in which recovery takes place the emesis and purging become less
frequent, the constitutional symptoms become ameliorated, the temperature
falls and the nervous symptoms subside. Convalescence is slow and relapses
are very likely to occur.
The prognosis is serious, the outcome in the majority of cases being fatal.
Treatment can hardly be considered satisfactory. The first indication is
to relieve the digestive tract of its toxic contents. This is to be done by means
of gastric lavage and colonic irrigation as described in the section on chronic
catarrhal enteritis (p. 390); the action of piirgatives is too delayed. Drugs
by mouth are vomited, consequently hypodermatic medication must be under-
taken. For the nervous manifestations morphine, gr. J^ to -f^o (0.0012-
0.0006) with atropine, gr. g-g-g- (0.00013) ^^7 be given to a child of i year
of age and may be repeated in an hour if improvement is not noted. For
the pyrexia baths are indicated. They should be begun at 80° F. (26.1° C.)
and reduced to 70° F. (21.1° C), may last from 10 to 30 minutes and may,
if necessary, be repeated every hour or two. When baths, for any reason, are
impossible, wrapping the patient in a wet sheet, or cold water injections may
be substituted, and as an adjunct to the hydrotherapeutic measures, ice com-
presses or an ice cap should be applied to the head.
To supply the fluid lost by emesis and diarrhoea hypodermatoclysis, given
as described under the treatment of acute gastro-enteritis, (p. 388) is indicated.
Eight ounces (250.0) or more of normal saline should be administered in this
fashion every 12 hours.
There should be no attempt to give food or medication, except stimulants,
by the mouth. The patient may suck bits of ice and stimulation by means
of brandy or iced champagne — small amounts frequently repeated — may
ACUTE ENTERO-COLITIS. 393
be administered by this route. If these are not retained hypodermatic
stimulation — brandy or whiskey, camphor, aether, etc. — is indicated.