dietetic preparations is one of the most important duties of the
physician. If called to an infant unfortunately deprived of wholesome
breast-milk, and suffering in consequence from indigestion and
diarrhoea, what diet shall we recommend? My recommendation would be as
follows: Use cow's milk of the best possible quality and peptonized in
the manner stated above, and peptonized in small quantity at a time,
such as a pint, or, better, half a pint. This may be the sole food till
the age of five or six months. Unfortunately, in the cities the milk
that is delivered in the morning is the milking of the preceding
evening, mixed with that of the preceding morning, brought often many
miles from the farms where it is produced. Milk twelve and twenty-four
hours old, notwithstanding the use of ice around the milk-cans, is apt
to undergo some fermentative change before it reaches the nursery. This
prevents the preparation of the best quality of peptonized milk, so
that in some instances during the heated term I have found that the
peptonized milk did not agree as well as the condensed milks, like
Borden's or Nestle's food. Not a few infants suffering from diarrhoeal
maladies seem to do better if some farinaceous food properly prepared
be added to the peptonized milk than when the milk is used alone. It is
better, I think, that the starch, or a considerable part of the starch,
be converted into glucose before the admixture. This can be done if a
few pounds of wheat flour be pressed dry in a bag, so as to form a
ball, and boiled three or four days, as I have elsewhere recommended.
The flour grated from the mass gives a decided sugar reaction to
Fehling's test. For infants under the age of six months one
tablespoonful of the flour thus prepared should be mixed with twelve
tablespoonfuls of water and boiled. When it has been removed from the
fire and become tepid, a small quantity of a good extract of malt, as
Trommer's or Reed & Carnrick's, may advantageously be added to the
gruel to increase the transformation of starch and render it more
digestible. To avoid the time and trouble of preparing the food in this
manner, one of the foods contained in the shops, in which the starch
has been transformed into glucose by the employment of Baron Liebig's
formula, may be used, as Mellin's or Horlick's, instead of the wheat
flour prepared by long boiling. The older the child, the thicker should
be the gruel.
Beef-, mutton-, or chicken-tea should not be employed, at least as it
is ordinarily made, since it is too laxative. Occasionally, for the
older infants, we may allow the expressed juice of beef, raw scraped
beef, or beef-tea prepared by adding half a pound of lean beef, finely
minced, to one pint of cold water, and after allowing it to stand for
half an hour warming it to a temperature not exceeding 110° for another
half hour. By this process the albumen is preserved. Salt should be
added to it, and I am in the habit of adding to it also about seven
drops of dilute muriatic acid to facilitate its digestion. It is
chiefly for infants over the age of ten months that the meat-juices are
proper. A concentrated nutriment, prepared, it is stated, from beef,
mutton, and fruits, has lately been introduced in the shops under the
name Murdoch's Liquid Food. Young {756} infants with dyspeptic and
diarrhoeal symptoms can take it, and it appears to be readily
assimilated, as the quantity given at each feeding is small. It has its
advocates, and it appears to be of some service in cases of weak and
irritable stomach.
But since one of the two important factors in producing the summer
diarrhoea of infants is foul air, it is obvious that measures should be
employed to render the atmosphere in which the infant lives as free as
possible from noxious effluvia. Cleanliness of the person, of the
bedding, and of the house in which the patient resides, the prompt
removal of all refuse animal or vegetable matter, whether within or
around the premises, and allowing the infant to remain a considerable
part of the day in shaded localities where the air is pure, as in the
parks or suburbs of the city, are important measures. In New York great
benefit has resulted from the floating hospital which every second day
during the heated term carries a thousand sick children from the
stifling air of the tenement-houses down the bay and out to the fresh
air of the ocean.
But it is difficult to obtain an atmosphere that is entirely pure in a
large city with its many sources of insalubrity; and all physicians of
experience agree in the propriety of sending infants affected with the
summer diarrhoea to localities in the country which are free from
malaria and sparsely inhabited, in order that they may obtain the
benefits of a purer air. Many are the instances each summer in New York
City of infants removed to the country with intestinal inflammation,
with features haggard and shrunken, with limbs shrivelled and the skin
lying in folds, too weak to raise, or at least hold, their heads from
the pillow, vomiting nearly all the nutriment taken, stools frequent
and thin, resulting in great part from molecular disintegration of the
tissues--presenting, indeed, an appearance seldom observed in any other
disease except in the last stages of phthisis--and returning in late
autumn with the cheerfulness, vigor, and rotundity of health. The
localities usually preferred by the physicians of this city are the
elevated portions of New Jersey and Northern Pennsylvania, the
Highlands of the Hudson, the central and northern parts of New York
State, and Northern New England. Taken to a salubrious locality and
properly fed, the infant soon begins to improve if the disease be still
recent, unless it be exceptionally severe. If the disease have
continued several weeks at the time of the removal, little benefit may
be observed from the country residence until two or more weeks have
elapsed.
An infant weakened and wasted by the summer diarrhoea, removed to a
cool locality in the country, should be warmly dressed and kept indoor
when the heavy night dew is falling. Patients sometimes become worse
from injudicious exposure of this kind, the intestinal catarrh from
which they are suffering being aggravated by taking cold, and perhaps
rendered dysenteric.
Sometimes parents, not noticing the immediate improvement which they
have been led to expect, return to the city without giving the country
fair trial, and the life of the infant is then, as a rule, sacrificed.
Returned to the foul air of the city while the weather is still warm,
it sinks rapidly from an aggravation of the malady. Occasionally, the
change from one rural locality to another, like the change from one
wet-nurse to another, has a salutary effect. The infant, although it
{757} has recovered, should not be brought back while the weather is
still warm. One attack of the disease does not diminish, but increases,
the liability to a second seizure.
Medicinal Treatment.--The summer diarrhoea of infants requires, to some
extent, different treatment in its early and later stages. We have seen
that acids, especially the lactic and butyric, the results of faulty
digestion, are produced abundantly, causing acid stools. In a few days
the inflammatory irritation of the mucous follicles causes such an
exaggerated secretion of mucus which is alkaline that the acid is
nearly or quite neutralized. In the commencement of the attack these
acid and irritating products should be as quickly as possible
neutralized, while we endeavor to prevent their production by improving
the diet and assisting the digestion. In the second stage, when the
fecal matter is less acid and irritating from the large admixture of
mucus, medicines are required to improve digestion and check the
diarrhoea, while the indication for antacids is less urgent. Therefore
it is convenient to consider separately the treatment which is proper
in the commencement or first stage, and that which is required in the
subsequent course of the disease.
First stage, or during the first three or four days, perhaps the first
week.--Occasionally, it is proper to commence the treatment by the
employment of some gentle purgative, especially when the disease begins
abruptly after the use of indigestible and irritating food. A single
dose of castor oil or syrup of rhubarb, or the two mixed, will remove
the irritating substance, and afterward opiates or the remedies
designed to control the disease can be more successfully employed.
Ordinarily, such preliminary treatment is not required. Diarrhoea has
generally continued a few days when the physician is summoned, and no
irritating substance remains save the acid which is so abundantly
generated in the intestines in this disease, and which we have the
means of removing without purgation.
The same general plan of medicinal treatment is appropriate for the
summer diarrhoea of infants as for diarrhoea from other causes; but the
acid fermentation commonly present indicates the need of antacids,
which should be employed in most of the mixtures used in the first
stage as long as the stools have a decidedly acid reaction.
Those who accept the theory that this disease is produced by
micro-organisms which lodge on the gastro-intestinal surface and
produce diarrhoea by their irritating effect are naturally led to
employ antiseptic remedies. Guaita administered for this purpose sodium
benzoate. One drachm or a drachm and a half dissolved in three ounces
of water were administered in twenty-four hours with, it is stated,
good results.[3] I have no experience in the use of antiseptic
remedies.
[Footnote 3: _N.Y. Med. Rec._, May 31, 1884.]
If by the appearance of the stools or the substance ejected from the
stomach, or by the usual test of litmus-paper, the presence of an acid
in an irritating quantity be ascertained or suspected, lime-water or a
little sodium bicarbonate may be added to the food. The creta præparata
of the Pharmacopoeia administered every two hours, or, which is more
convenient, the mistura cretæ, is a useful antacid for such a case. The
chalk should be finely triturated. By the alkalies alone, aided by the
judicious use of stimulants, the disease is sometimes arrested, but,
unless {758} circumstances are favorable and the case be mild, other
remedies are required.
Opium has long been used, and it retains its place as one of the
important remedies in this disease. For the treatment of a young infant
paregoric is a convenient opiate preparation. For the age of one to two
months the dose is from three to five drops; for the age of six months,
twelve drops, repeated every three hours or at longer intervals
according to the state of the patient. After the age of six months the
stronger preparations of opium are more commonly used. The tinctura
opii deodorata or Squibb's liquor opii compositus may be given in doses
of one drop at the age of one year. Dover's powder in doses of
three-fourths of a grain, or the pulvis cretæ comp. cum opio in
three-grain doses every third hour, may be given to an infant of one
year.
Opium is, however, in general best given in mixtures which will be
mentioned hereafter. It quiets the action of the intestines and
diminishes the number of the evacuations. It is contraindicated or
should be used with caution if cerebral symptoms are present. Sometimes
in the commencement of the disease, when it begins abruptly from some
error in diet, with high temperature, drowsiness, twitching of the
limbs--symptoms which threaten eclampsia--opiates should be given
cautiously before free evacuations occur from the bowels and the
offending substance is expelled. Under such circumstances a few doses
of the bromide of potassium are preferable. In the advanced stage of
the disease also, when symptoms of spurious hydrocephalus occur, opium
should be withheld or cautiously administered, since it might tend to
increase the fatal stupor in which severe cases are apt to terminate.
The vegetable astringents, although they have been largely employed in
the treatment of this as well as other forms of infantile diarrhoea,
are, I think, much less frequently prescribed than formerly. I have
entirely discarded them, since they are apt to be vomited and have not
proved efficient in my practice. As a substitute for them the
subnitrate of bismuth has come into use, and in much larger doses than
were formerly employed. While it aids in checking the diarrhoea, it is
an efficient antiemetic and antiseptic. It should be prescribed in ten
or twelve grains for an infant of twelve months; larger doses produce
no ill effect, for its action is almost entirely local and soothing to
the inflamed surface with which it comes in contact. It undergoes a
chemical change in the stomach and intestines, becoming black, being
converted into the bismuth sulphide, and it causes dark stools. Rarely
it gives rise in the infant to the well-known garlicky odor, like that
occasionally observed in adult patients, and which Squibb thinks may be
due to tellurium accidentally associated with the bismuth in its
natural state. For those cases in which the symptoms are chiefly due to
colitis, and the stools contain blood with a large proportion of mucus,
it has been customary to prescribe laudanum or some other form of opium
with castor oil. I prefer, however, the bismuth and opium for such
cases as are more decidedly dysenteric, as well as for cases of the
usual form of intestinal catarrh. In ordering bismuth in these large
doses it is important that a pure article be dispensed.
The following are convenient and useful formulæ for a child of one
year: {759}
Rx. Tinct. opii deodorat. minim xvj;
Bismuth. subnitrat. drachm ij;
Syrupi, fluidrachm ij;
Misturæ cretæ, fluidrachm xiv. Misce.
Shake thoroughly and give one teaspoonful every two to four hours.
Rx. Tinct. opii deodorat. minim xvj;
Bismuth. subnitrat. drachm ij;
Syrupi, fluidounce ss;
Aq. cinnamomi, fluidounce iss. Misce.
Shake bottle; give one teaspoonful every two to four hours.
Rx. Bismuth. subnitrat. drachm ij;
Pulv. cret. comp. c. opio, drachm ss. Misce.
Divid in Chart No. X. Dose, one powder every three hours.
Rx. Bismuth. subnitrat. drachm ij;
Pulv. ipecac. comp. gr. ix. Misce.
Divid in Chart No. XII. Dose, one powder every three hours.
Cholera infantum requires similar treatment to that which is proper for
the ordinary form of the summer diarrhoea, but there is no disease,
unless it is pseudo-membranous croup, in which early and appropriate
treatment is more urgently required, since the tendency is to rapid
sinking and death. As early as possible, therefore, proper instructions
should be given in regard to the feeding, and for an infant between the
ages of eight and twelve months either one of the above prescriptions
should be given or the following:
Rx. Tinct. opii deodorat. minim xvj;
Spts. ammon. aromat. fluidrachm j;
Bismuth. subnitrat. drachm ij;
Syrupi, fluidounce ss;
Misturæ cretæ, fluidounce iss. Misce.
Shake bottle. Give one teaspoonful every two or three hours.
An infant of six months can take one-half the dose, and one of three or
four months one-third or one-fourth the dose, of either of the above
mixtures.
If cerebral symptoms appear, as rolling the head, drowsiness, etc., I
usually write the prescription without the opiate; and with this
omission it may be given more frequently if the case require it, while
the opiate prescribed alone or with bromide of potassium is given
guardedly and at longer intervals. Although every day during the summer
months I have written the above prescriptions, it has been several
years since any case has occurred in my practice which led me to regret
the use of the opiate; but it must not be forgotten that there is
danger in the summer complaint, and especially in cholera infantum, of
the sudden supervention of stupor, amounting even to coma, and ending
fatally. A few instances have come to my knowledge in which, when death
occurred in this way, the friends believed that the melancholy result
was hastened by the medicine. But injury to the patient in this respect
can only occur, in my opinion, through carelessness in not giving
proper attention to his condition. It is chiefly in advanced cases,
when the vital powers are beginning to fail, when the innervation is
deficient, and the cerebral circulation sluggish, that the use of
opiates may involve danger. Explicit and positive directions should
{760} be given to omit the opiate or give it less frequently whenever
the evacuations are checked wholly or partially and signs of stupor
appear.
Second Stage.--The summer complaint in a large proportion of cases
begins in such a gradual way that the treatment which we are about to
recommend is proper in many instances at the first visit of the
physician, who is frequently not summoned till the attack has continued
one or two weeks. The alkaline treatment recommended above for the
diarrhoea in its commencement does not aid digestion sufficiently to
justify its continuance as the main remedy after the first few days. In
a large number of instances, however, one of the above alkaline
mixtures may be given with advantage midway between the nursings or
feedings, while those remedies, presently to be mentioned, which
facilitate digestion and assimilation are given at the time of the
reception of food.
Some physicians of large experience, as Henoch of Berlin, recommend
small doses of calomel, as the twelfth or twentieth of a grain, three
or four times daily for infants with faulty digestion and diarrhoea. To
me, this seems an uncertain remedy, without sufficient indications for
its use, and I have therefore no experience with it. The following are
formulæ which I employ in my own practice, and which have been employed
with apparent good results in the institutions of New York:
Rx. Acid. muriat. dilut. minim xvj;
Pepsinæ saccharat.
(Hawley's or other good pepsin), drachm j;
Bismuth. subnitrat. drachm ij;
Syrupi, fluidrachm ij;
Aquæ, fluidrachm xiv. M.
Shake bottle; give one teaspoonful before each feeding or nursing to an
infant of one year; half a teaspoonful to one of six months.
Rx. Tinct. opii deodorat. minim xvj;
Acid. muriat. dilut. minim xvj;
Pepsinæ saccharat. drachm j;
Bismuth. subnitrat. drachm ij;
Syrupi, fluidrachm ij;
Aquæ, fluidrachm xiv. Misce.
Shake bottle; give one teaspoonful every three hours to a child of one
year; half a teaspoonful to one of six months.
Rx. Pepsinæ saccharat. drachm j-ij;
Bismuth. subnitrat. drachm ij. Misce.
Divid in Chart No. XII. One powder every three hours to a child of one
year; half a powder to one of six months.
I have also obtained apparent benefit from lactopeptin, given as a
substitute for one of the above mixtures before each feeding or
nursing. In several instances which I recall to mind I have ordered as
much as could be placed on a ten-cent piece to be given every second or
third hour, while midway between the feedings in some instances of
considerable diarrhoea one of the mixtures of bismuth and chalk
recommended above was employed, and the result has been good.
Enemata.--It will be recollected, from our remarks on the anatomical
characters, that inflammatory lesions are commonly present in the
entire length of the colon, and that at the sigmoid flexure, where acid
and irritating fecal matter is probably longest delayed in its passage
downward, the colitis is usually most severe. Aware of this fact, I was
{761} led to prescribe at my first visit a large clyster of warm water,
given with the fountain or Davidson's rubber syringe, especially in
cases in which the stools showed mucus or mucus tinged with blood.
This, given with the lower part of the body raised a little above the
level of the shoulders, washes out the large intestine and has a
soothing effect upon its surface. The benzoate of sodium may be added
to the water for its antiseptic effect, as in the following formula:
Rx. Sodii benzoat. drachm j;
Aquæ, pint j. Misce.
In occasional cases in which the stomach is very irritable, so that
medicines given by the mouth are in great part rejected, our reliance
must be largely on rectal medication, and especially on clysters
containing an opiate. Laudanum may be given in this manner with marked
benefit. It may be given mixed with a little starch-water, and the best
instrument for administering it is a small glass or gutta-percha
syringe, the nurse retaining the enema for a time by means of a
compress. Beck in his _Infant Therapeutics_ advises to give by the
clyster twice as much of the opiate as would be required by the mouth.
A somewhat larger proportion may, however, be safely employed. The
following formula for a clyster has given me more satisfaction than any
other medicated enema which I have employed:
Rx. Argent. nitrat. gr. iv;
Bismuth. subnitrat. oz. ss;
Mucilag. acaciæ,
Aquæ, _aa_ fluidounce ij. Misce.
One-quarter to one half of this should be given at a time, with the
addition of as much laudanum as is thought proper; and it should be
retained by the compress. It is especially useful when from the large
amount of mucus or mucus tinged with blood it is probable that the
descending colon is chiefly involved.
Alcoholic stimulants are required almost from the commencement of the
disease, and they should be employed in all protracted cases. Whiskey
or brandy is the best of these stimulants, and it should be given in
small doses at intervals of two hours. I usually order three or four
drops for an infant of one month, and an additional drop or two drops
for each additional month. The stimulant is not only useful in
sustaining the vital powers, but it also aids in relieving the
irritability of the stomach and in preventing hypostasis in depending
portions of the lung and brain, which, as we have seen, is so frequent
in advanced cases.
The vomiting which is so common a symptom in many cases greatly
increases the prostration, and should be immediately relieved if
possible. The following formulæ will be found useful for it:
Rx. Bismuth. subnitrat. drachm ij;
Spts. ammon. aromat. fluidrachm ss-fluidrachm j;
Syrupi,
Aquæ, _aa_ fluidounce j. Misce.
Shake bottle. Dose, one teaspoonful half-hourly or hourly if required,
made cold by a piece of ice.
Rx. Acid. carbolic. gtt. ij;
Liquor. calcis, fluidounce ij. Misce.
Dose, one teaspoonful, with a teaspoonful of milk (breast-milk if the
baby nurse), to be repeated according to the nausea.
{762} Lime-water with an equal quantity of milk often relieves the
nausea when it is due to acids in the stomach, but it is rendered more
effectual in certain cases by the addition of carbolic acid, which
tends to check any fermentative process. Perhaps also some of the
recent antiseptic medicines introduced into our Pharmacopoeia, as the
benzoate of sodium, may be found useful for the vomiting. A minute dose
of tincture of ipecacuanha, as one-eighth of a drop in a teaspoonful of
ice-water, frequently repeated, has also been employed with alleged
benefit.
Of these various antiemetics, my preference is for the bismuth in large
doses, with the aromatic spirits of ammonia, properly diluted, that the
ammonia do not irritate the stomach. Nevertheless, in certain patients
the nausea is very obstinate, and all these remedies fail. In such
cases absolute quiet of the infant on its back, the administration of
but little nutriment at a time, mustard over the epigastrium, and the
use of an occasional small piece of ice or the use of carbonic acid
water with ice in it, may relieve this symptom.
In protracted cases, when the vital powers begin to fail, as indicated
by pallor, more or less emaciation, and loss of strength, the following
is the best tonic mixture with which I am acquainted. It aids in
restraining the diarrhoea, while it increases the appetite and
strength. It should not be prescribed until the inflammation has
assumed a subacute or chronic character:
Rx. Tinct. calumbæ, fluidrachm iij;
Liq. ferri nitratis, minim xxvij;
Syrupi, fluidounce iij. Misce.
Dose, one teaspoonful every three or four hours to an infant of one
year.
{763}
PSEUDO-MEMBRANOUS ENTERITIS.
BY PHILIP S. WALES, M.D.