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James M. (James Meschter) Anders.

A text-book of the practice of medicine online

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serious causal affections of a chronic nature, and occasionally it ulti-
mately proves fatal. The prognosis will depend largely upon the charac-
ter of the etiologic affection, but intestinal catarrh invariably renders
the prospects of life more gloomy.

Treatment. — Kespecting the treatment of this affection the views
of the profession have undergone many changes, even within recent
years ; hence it may be reasonably inferred that our present therapeutic
imethods are by no means satisfactory.



INTESTINAL CATARRH. 835

Hygienic and Dietetic Management. — In the not uncommon mild
cases, due to errors in diet, a mild purgative, followed by proper dietetic
treatment, is all that is required. Albuminous food in liquid form, such
as skimmed milk, weak broths, and even semi-animal articles of
diet, as eggs, oysters, sweet milk with seltzer, are usually well borne. In
the severe forms predigested liquid foods only should be allowed. When
the chief seat of the disease is in the large intestine, we may allow
easily digested starches and certain green vegetables (arrow-root, sago,
lettuce, water-cress) ; the coarser vegetables, all fats, and most fruits
should be withdrawn absolutely. Rest in bed is especially beneficial in
that it serves to keep the abdomen warm and mitigates the pain and
diarrhea, and, in short, cures the disease. Sinapisms should be ap-
plied at the outset until the skin is reddened, succeeded by light linseed
poultices until the local sensitiveness has, in a great measure, subsided ;
after this a flannel band may be applied. The local abstraction of blood
by a few leeches, applied to the abdomen or anus, is beneficial in the
early stages in severe types of enteric catarrh, provided the patient's
strencrth is s!:ood.

Medicinal Treatment. — It is sound practice to prescribe a mild ca-
thartic (castor oil, calomel, or rhubarb, followed by a saline) with a view to
getting rid of decomposable intestinal contents. Combined gastric lavage
and high intestinal irrigation has recently yielded excellent results in
my hands ; it is an appropriate method of overcoming the fermentative
processes that tend to excite and maintain the condition.

If the chief tenderness be localized in the right iliac fossa, corre-
sponding to the course of the colon, a simple enema, slowly given, will
stimulate the boAvel sufficiently and cleanse it more effectually than a
cathartic. Subsequently, chief reliance is to be placed on intestinal
antiseptics and astringents, though it must be recollected that the selec-
tion of internal remedies must, in part, be influenced by the etiologic
indications. For instance, if the cause has been exposure to cold or
wet, besides the efforts directed at the local condition diaphoretics and
febrifuge mixtures are serviceable. I have found the following com-
bination to be of benefit in controlling the local inflammatory action :

^. Salol, 3SS (2.0);

Creasoti, lUx (0.666) ;

Bismuthi salicylat., 3j (4.0).

M. et ft. capsulse No. xx.
Sig. One every three hours.

If pain be troublesome, opium or phenacetin may be combined with
the above formula.

In many instances the secretions of the intestinal tube are decreased
for a considerable period after the most active symptoms have been
subdued. Here we must supplement the natural juices of the bowel ;
this may be satisfactorily accomplished by the following agents :

^. Pancreatin, 3J (4.0);

Sodii bicarb., 5\j (8.0).

M. et ft. chart. No. xij.
Sisf. One an hour after meals.



836 DISEASES OF THE DIGESTIVE SYSTEM.

Ill cases in which the large intestine is chiefly affected, and when the
condition does not yield to internal medicines, treatment by medicated
colonic irrigations are useful. When there is reason to suspect that the
main lesion is in the Inrge bowel, small enemas of starch-water (.sij —
64.0), with laudanum ("HI xx-xxx — 1.33-2.0), every four to six hours,
are also efficacious. If colicky pain be severe, morphin (gr. ^ — 0.008)
should be given hypodei-mically in addition to the measures before sug-
gested. If the diarrhea shows no tendency to abate after forty-eight
hours of the general treatment above outlined, large doses of bismuth
(gr. xxx-lx — 2.0-4.0) every three or four hours should be tried. In my
own hands lead acetate (gr. ij — 0.129), with the extract of opium (gr. ^ —
0.008) in pill-form, has proved a most efficient combination. The thirst
is best relieved by chipped ice in small quantities or by carbonic acid and
Apollinaris waters. For distressing flatulence we may prescribe the
alkaline carbonates, or spirits of ammonia, and some carminative. The
oil of cajeput is a most valuable drug in the treatment of excessive fer-
mentation (Murrell).

In chronic catarrh of the intestines the local treatment is of para-
mount importance. Daily irrigation of the bowel with a weak solution
of some antiseptic agent, as salicylic acid (gr. v-5J — 0.324-32.0),
boracic acid (gr. x-?j— 0.648-32.0), creolin (m v-5J— 0.324-32.0), or
with some such astringent as tannin (gr. v-5J — 0.324 — 32.0), or finally
with an alterative, such as silver nitrate (gr. ^-.^j — 0.016-32.0), will be
found to be serviceable. The latter solution is a most excellent remedy,
but sometimes excites pain if too concentrated. I often use a mild anti-
septic or astringent with the foregoing, giving each on alternate days,
and thus obtain happy results. The only appliance needful is a fountain
syringe with a soft-rubber end-piece, which should be gently introduced
for a considerable distance into the bowel. The fluid used should be
warmed to 90° F. (32.2° C), and the quantity administered at each sit-
ting should be not less than 2 to 3 pints (1-1.5 liters) ; this should be
allowed to flow into the bowel slowly. The patient should, as a rule,
assume the dorsal decubitus, though if the fluid is to be carried as high
up as possible, the knee-elbow position may be assumed or the patient
may be placed on the left side with the hips elevated. Again, turning
him from side to side during the irrigating process may be warmly rec-
ommended.

The same careful attention must be paid to hygienic details, and
especially to the diet, as is directed in the acute form. In addition, flan-
nel should be worn next the skin both in winter and summer. If the
strength will admit of it, cold baths are useful.

A stay at a suitable spa (Saratoga, Bedford, Virginia Springs, Carls-
bad, Kissingen) often produces most satisfactory results.

Among internal agents, zinc oxid (gr. v to x — 0.324-0.648 — t. i. d.),
silver nitrate, lead acetate, and alum, given with tonics, such as strych-
nia, arsenic, and iron, are especially to be recommended.

The management of this troublesome malady depends upon the in-
dications furnished by the causative affections. No method of treatment,
however, can succeed that is not carried out patiently, systematically,
and over long pei'iods of time.



DIARRHEAS OF CHILDREN. 837

DIARRHEAS OF CHILDREN.

ACUTE GASTRO-INTESTINAL CATARRH.

(Acute Gastro-enteric Infection ; Summer Diarrhea ; Gastro-enteritis ; Cholera Infan^

turn ; Mycotic Diarrhea. )

Definition. — This is the usual intestinal trouble that prevails during
the warm summer months. It usually takes the form of an epidemic,
and its course is manifested by a sudden onset, high fever, irritability of
the stomach, frequent Avatery evacuations, and symptoms of nerve-in-
volvement. This form of diarrhea usually follows an attack of acute
indigestion, in which it very frequently has its origin {acute dyspeptic
diarrlieoi). Acute gastro-intestinal catarrh (cholera infantuni) stands
midway between acute indigestion and ileo-colitis.

etiology. — Two important conditions seem to be necessary to influ-
ence the disease — temperature and diet. A general and well-recognized
belief associates special danger with the second summer of children.
Out of nearly 2000 fatal cases collected by Holt, only 3 per cent, were
exclusively breast-fed. Generally speaking, the disease has its origin
in some irregularities in artificial feeding. Heat and season are im-
portant elements in the continuation of the disorder when once com-
menced.

It is seen from May to September, the greatest prevalence occurring
in July. The pauper element of large cities furnishes most instances.

Flexner and Holt' assert that the bacillus dysenterise may be isolated
from the intestinal discharges, and from the intestinal mucosas in a large
percentage of cases developing along the Atlantic coast of the United
States, during the summer months. Holt found bacillus dysenteriae
in 50 per cent, of cases at the Babies' Hospital of New York. The
Flexner-Harris type of bacillus is most often encountered, while the
" Shiga " type is but occasionally recovered. It is common for cultures
to develop streptococci in connection with the bacillus dysenferice, and
both organisms appear to grow luxuriantly together, which renders it
impracticable to decide whether the lesions of the intestine and the
general symptoms depend upon one or both of these organisms.

Booker, Jeffris, and Baginsky affirm that the proteus class of bacteria
are commonly present, and that they possess pathogenic properties. The
"bacillus dysenterii'e " reacts with the serum of infected children.

Patllolog"y. — A catarrhal swelling of the mucosa of the large and
small bowel is present ; the mucosa itself is pink in color from capillary
congestion. . Peyer's patches are enlarged. The whole intestinal tube
shows an early stage of inflammation (ileo-colitis). In addition there
is most likely some involvement of the sympathetic nerves, leading to
dilatation of the capillaries and transudation of serum into the intestine,
and to alterations of the pulse, temperature, and respiration. Its nature
is paralytic, and closely resembles in its results experimental sections
of the sympathetic nerves. The changes in the other organs are slight.
Broncho-pneumonia frequently occurs. The spleen is often swollen, the
brain is anemic, and the kidneys are congested.

^ Rockefeller Institute for Medical Research, 1904.



838 DISEASES OF THE DIGESTIVE SYSTEM.

Symptoms. — Clinically, there are three forms of acute enteric infec-
tion : (1) acute dyspeptic diarrhea; (2) cholera infantum; and (3) ileo-
colitis.

(1) Acute Dyspejyfie Diarrhea. — There may be merely an increase
in the number of stools, with or without fever ; restlessness is usual at
night. This condition may continue for two or three days, when the
stools become more frequent and offensive, containing undigested food
and curds. The odor by this time is very pronounced. Frequently the
disease has a sudden onset, with vomiting, griping pains, and fever,
which may quickly rise to 104°, 105°, or 106° F. (40°-41° C). Con-
vuUions may be the commencement of the attack. The abdomen is
sensitive and swollen, and the child lies Avith its legs fle.xed on the
stomach. The stools consist of grayish or greenish-yellow feces (mixed
with curds, portions of undigested food) and some fluid. In children
two years of age and older the stools may contain unripe fruit or large
curds from excessive drinking of milk. Relapses are frequent, and
during hot weather the frequency of the attacks may lead to a persistent
entero-colitis.

In delicate children a severe attack, especially if it is accompanied by
convulsions, may prove fatal.

(2) Cholera Infantum. — The initial symptoms are sudden. The
child voids immense stools, at first fecal, if no preceding diarrhea have
been present. Soon they become watery, light yellow or greenish in
color ; frequently they are so thin and colorless as to pass through the
napkin without leaving a stain. At times they contain a few yellow
or greenish flocculi or a mass of mucus, and in all cases they are odor-
less. Very often the stools are brown and liquid, with a small quan-
tity of fecal matter, having a peculiar musty odor that clings to the
napkin and child for days. The number of stools per diem may vary
from six to thirty, and a most remarkable feature is the fact that they
are evacuated with considerable force.

The stomach becomes irritable, refusing everything ; even ice is re-
jected as soon as swallowed. The vomitus at first contains bile, while
later it becomes serous. The appetite is, of course, entirely lost ;
intense thirst prevails, the little patient drinking at every chance and
following the receding glass with eager eyes. The tongue, moist at
first, soon becomes drv and pastv ; the abdomen is collapsed. The
temperature is always "high— 105° or even 108° F. (40..5°-42.2° C.) ;
arnd the pulse small and very fre(|uent — 130 to 180 beats per minute.
The breathing is shallow and irregular, and the expression anxious and
staring, but soon becomes dull. The urine becomes dark and scanty.

With this array of symptoms there is a striking and appalling change
in the child's general appearance. Within a feAv liours it can scarcely
be recognized ; the face has become pale and pinched, the eyes and
cheeks sunken, the eyelids and lips wide apart from loss of muscular
control, the muscles flabby, the bones prominent, and the skin greenish
or cadaverous, hanging in loose folds from the wasted frame.

Collapse comes on soon : the hands, feet, nose, and breath become
cool, the respirations more unequal, and there are drowsiness and utter
apathy. When life is near its close, vomiting stops, the whole surface be-
coming cool and clammy as the patient sinks into a state of coma, with



DIARRHEAS OF CHILDREN. 839

injected eyes and contracted pupils. At last the end is reached quickly,
preceded perhaps by a slight convulsion. The duration of the disease is
short ; it may prove fatal in from one to four days.

(3) Ileo-colitis. — This may follow acute dyspeptic diarrhea, cholera
infantum, or complicate the acute infections of childhood. The symp-
toms develop acutely. At the outset there may be vomiting, but it is
not persistent, and the stools are greenish, feculent, often showing masses
of casein. Later the discharges are inci-eased in frequency, are small,
and contain also blood and mucus. In severe cases pain and straining
are distressing features. The abdomen is prominent and there is ten-
derness along the course of the colon. The disease presents high fever.

The cowse is variable. It may be acute — three to six days — terminat-
ing either in convalescence or death due to exhaustion. In other instances
the acute symptoms subside, particularly the fever, while moderate diar-
rhea continues and is attended with marked wasting and debility.
Gradual recovery may ensue, though more commonly relapses occur
and death follows from broncho-pneumonia or an intercurrent acute
attack.

Treatment. — The treatment of acute gastro-intestinal catarrh di-
vides itself into hygienic, dietetic, and medicinal measures. If a child
is attacked in the city during the summer and does not yield to treat-
ment in two or three days, it should be sent to the country or seashore.
In the case of a child under two years this is absolutely imperative.
Fresh air is important in all diarrheal disorders, and all cases should be
kept out of doors as much of the time as possible. Children should be
kept quiet. Bathing is soothing, insures cleanliness, and, what is very-
important, reduces the temperature.

Dietetic treatment is of great importance. It should be remembered
that digestion is arrested in the early stage, hence to give food at this
stage is to do harm. Thirst may be controlled by ice- or albumin-water,
toast-water, or gum-water, with a little brandy.

Medicinal Treatment. — The first step is directed against the acute
indigestion and the active putrefaction going on in the intestine. The
indication, therefore, is to empty thoroughly the alimentary tract as soon
as possible, and no other treatment should be considered until this end
has been accomplished. Whenever vomiting persists the stomach should
be washed. In older children emetics will favor complete emptying of
the stomach, but are never to be given to infants under two years. For
the intestine calomel and soda may be used ; for the colon irrigation :
this is advisable in all cases, as it hastens the effect of the calomel, and
removes at once much irritating and offensive material. Opium should
not be used until the whole intestinal tube is cleansed, and then cau-
tiously. Spirits of chloroform, or camphor, is a better remedy for the
pain than opium in any form. In older children the hypodermic injec-
tion of morphin and atropin in appropriate doses frequently controls
the symptoms. Bowles has used lactic acid in the maximum dose of \\
grains every hour, and found it to control the symptoms in from twenty-
four to foriy-eight hours. Thus far the results of serum treatment have
been disappointing.

Treatment of Cholera Infantum. — In this form of infection of the



840 DISEASES OF THE DIGESTIVE SYSTEM.

intestinal tract we are likely to forget that we are called upon to treat
a case of acute poisoning. The toxic material acts both powerfully and
quickly as a cardiac and systemic depressant. It also acts toxically
upon the nerve-centers, and paralyzes the vaso-motor nerves. According
to Holt, the leading indications are — (a) to empty the stomach and intes-
tines ; (It) to supply the body with fluid to offset the great loss by vomit-
ing and purging ; (<•) to counteract the effect of the poison on the heart
and the nervous system ; {d) to reduce temperature ; and (g) to treat the
symptoms as they arise. In the first condition thorough stomach and
intestinal cleansing is absolutely necessary. Moreover, we cannot depend
on emetics or purgatives to arrest pain and to limit the eff'ect of the poison
on the nervous system; a hypodermic injection of atropin and morphin
is essential. Morphin must be given with discrimination to young chil-
dren, especially when the vomiting and purging are slight ; it is espe-
cially contraindicated Avhen stupor or collapse seems near. Small doses
repeated are better than larger single doses. Holt gives gr. ^5-0" (0.0006)
of morphin, with gr. -g^ (0.00008) of atropin, as the first dose in a child
one year old. In supplying fluid to the exhausted tissues it is useless to
attempt to give them by the mouth, or even by the rectum, as by both
avenues it would be rejected. An injection into the cellular tissues of
the buttocks, back, or thighs of a saline solution (40 grains — 2.59 — of
common salt to a jiint of sterilized water) is the best way to meet the
drain. One pint (half liter) may be used every twenty-four hours, and
larger quantities may often be used with advantage. Baths must be
given to control temperature, and ice-bags should be placed to the head.
Ice-water injections will aid in the control of temperature, and ice-sup-
positories act efficiently when the water is not retained. Stimulants
may be given hypodermically. During the active stage nothing should
be allowed by the mouth except iced brandy or champagne.

The dietetic management and internal treatment of ileo-colitis are
similar to that of the preceding variety. A dose of castor oil or of
calomel is to be promptly administered and followed in a few hours by
copious irrigations of the colon, preferably with tepid saline solution
(strength 7 : 1000). Later a small quantity of a thin starch solution,
to which TTlj to iij of laudanum has been added, may be gently thrown
into the rectum, to be repeated once or twice daily. After the acute
stage is over a weak silver nitrate solution may be employed.

CELIAC DISEASE.
{Diarrhoea Alba : Diarrhoea Ch>/losa.)

Definition. — A form of intestinal catarrh marked by copious fetid
and frothv discharsies resemblino; gruel.

Pathology. — Although ulcers have been noted in the intestine, the
pathology of the disease is not known. Says Osier : This aff'ection re-
sembles somewhat the disease in adults known as " hill diarrhea " or the
"white flux" of India.

Ktiology. — The disease is limited chiefly to children from one to
five years old. The filaria sanguinis hominis has been found in the feces
in cases of diarrhoea chylosa.

Symptoms. — The disease is of slow development, and the character-



CROUPOUS OR DIPHTHERITIC ENTERITIS. . 841

istic feature consists of copious diarrheal (tbougli not watery) stools, re-
sembling gruel or oatmeal-porridge. These are also frothy (frog-sjyawn)
and horribly fetid. The physical signs consist of a moderate distention
of the abdomen and a boggy sensation that is imparted to the palpating
finger. The general features may be summated in gradually increasing
emaciation, debility, and pallor. The disease terminates fatally as a rule.
The treatment is purely symptomatic, unless the presence of para-
sites be suspected, when large antiseptic enemata should be given.



PHLEGMONOUS ENTERITIS.

This is a suppurative inflammation of the submucous layer of the
intestines. It is among the rarest of grave maladies, especially as an
irrelative disease. It may be diffuse or take the form of a circumscribed
abscess. Rarely it occurs as a complicating condition in septico-pyemia
and in malignant types of the exanthemata, resulting in the formation
of abscesses that usually have their seat in the duodenum. Phlegmon-
ous enteritis may be secondary to strangulated hernia or intussusception.

Symptoms. — The local signs simulate closely those of peritonitis.
Among the symptoms vomiting is prominent, though not diagnostic ; it is
always severe, and may become stercoraceous. Pain and tenesmus, when
due to obstruction, are intense. Rigors more or less severe have been
observed. The temperature is high, and its curve is somewhat typical
of the fever, of suppuration. The disease is very fatal, the patient
passing from a condition of extreme prostration to one of utter collapse.

Treatm.ent. — The physician's task is confined to an attempt to sup-
port the powers of the patient and to relieve his inordinate suffering.
The surgeon's aid should be invoked early in cases of obstruction.



CROUPOUS OR DIPHTHERITIC ENTERITIS.

Definition. — An intense inflammation of the intestinal mucosa,_ ac-
companied by a croupous exudate ; it occurs in connection with a variety
of conditions. If from any cause the epithelial covering is destroyed,
agents that set up local inflammation may excite a croupous exudate.

Pathology. — There" are two sets of morbid lesions to be distin-
guished : (1) The first and most important class exhibits a croupous
deposit varying greatly in thickness and in area. Its color is variable,
being sometimes of a grayish or grayish-ivhite hue, frequently grayish-
yellow, and rarely blackish. I have almost invariably seen these lesions
in the colon. (2) In the second group the solitary follicles alone are
inflamed, and covered with diphtheritic deposit.

The etiologic factors may be (a) mechanical irritants (impacted feces, in-
testinal sand, gall-stones); {h) chemical irritants (ammonia, acids, mercury,
arsenic) ; (c) secondary to acute infectious and certain chronic complaints
(Bright's disease, pyemia, carcinoma, diabetes, tuberculosis, and anemias).

Symptoms. — When mechanical irritants give rise to symptoms,
they do not differ from those due to stercoral ulcers, and there is no way
of reoognizing the croupous deposits unless they be discharged per rectum
and are detected in the stools. In cases that arise from the action of irri-



842 DISEASES OF THE DIGESTIVE SYSTEM.

tant poisons vomiting and purging are well marked and the dejections
contain blood-stained mucus. We cannot be certain about the presence
of croupous deposits in toxic cases unless they be found in the dis-
charges. When phlegmonous enteritis occurs as a complicating condi-
tion in infectious diseases, the symptoms are almost completely veiled.
The symptomatology of the follicular variety cannot be separated clini-
cally from that of follicular ulceration.

The treatment is that of the causal conditions or affections.



SPRUE.
{Psilosis.)

This has been defined as " an insidious, chronic, remitting inflamma-
tion of the Avhole or part of the mucous membrane of the alimentary
canal, occurring principally in Europeans who are residing or have
resided in tropical or subtropical climates " (Manson).

The principal morbid changes consist in patchy or general destruc-
tion of ''the surface of the mucosa in all degrees, from slight erosions
to complete disintegration of the villi, glands, and follicles." Conges-
tive, catarrhal, ulcerative, and cirrhotic changes may be all combined in



Online LibraryJames M. (James Meschter) AndersA text-book of the practice of medicine → online text (page 113 of 178)