SOME REMARKS ON THE TREATMENT OF THE SUMMER GASTRO-INTESTINAL DISEASES OF CHILDHOOD. BY J. H. MUSSER, M.D., PHILADELPHIA. REPRINTED FROM THE THERAPEUTIC GAZETTE, JULY, 1886. DETROIT, MICH. : GEORGE S. DAVIS, PUBLISHER. 1886. SOME REMARKS ON TUp Treatment of the Summer Gastro-Intes- tinal Diseases of Childhood. THE outlines of treatment herein indicated have been so eminently satisfactory to the writer during the past four years that it was thought they would be of interest to the profession. No claims to originality are made for the methods, and doubtless the reader will observe only a repetition of what has been said before. Their repetition is ventured upon, however, because of their great value in the writer's experience. The essential to success is the selection and pursuit of a systemic plan of treatment in cases of summer intestinal dis- orders. This, above all, is insisted upon. The summer disorders of childhood are vomiting (acute and chronic indigestion), simple diarrhoea, entero-colitis, and cholera infantum. Vomiting and simple diarrhoea often are present in the same subject and due to the same causes. The causes in gen- eral of all these complaints are extreme heat, improper food, atmospheric changes (cold and dampness), a vitiated atmosphere, and reflex irritation from teething, etc. One or more of these causes preponderates in the respective affections. Their universal presence in va- 2 rious degrees in all the complaints renders it necessary to base a treatment of the ailment on a removal or counter-action of these gen- eral evil influences. What should be done is patent, and therefore, bearing this in mind, the outlines of treatment will be presented. The management common to all these affec- tions will be detailed, and then some few re- marks made on the therapeutics of the indi- vidual affections. GENERAL MANAGEMENT OF THE SUMMER GASTRO-INTESTINAL DISEASES. Diet.-The simplest and blandest articles of nourishment are ordered. In an acute case, as acute vomiting or cholera infantum, the child is taken from the breast, or the usual milk or artificial food is removed, and weak rice-water or barley-water given. The hap- piest results are often seen in the use of these simple means for twenty-four or forty-eight hours. In cholera infantum, brandy alone well diluted is used if the rice-water is not retained or the stage of collapse is imminent. In fact, for twenty-four or forty-eight hours, brandy, sometimes in incredible doses, is given. Five to twenty and thirty drops every half- hour or hour are frequently ordered. After the stomach has regained its strength, stronger nourishment may be used. Four things are relied on,-i. Cream, a teaspoonful to three ounces of warmed water every hour or two, gradually increasing the strength ; 2. Milk, peptonized according to the Fairchild method; 3. The well-known gelatin, cream and milk preparation, recommended by Meigs and Pep- per ; 4. weak chicken-broth. In the more 3 chronic summer ailments this dietary may be resorted to alone. Flour, boiled and baked in a bag until very hard, grated fine and added to milk, is of great service. Not much confi- dence is placed by the writer in the artificial foods or condensed milk. They are of ines- timable value under circumstances which pre- vent the preparation of the above articles. A careful mother, it always seemed to the writer, can supply from her own kitchen the foods which are heralded forth with so much mystery. The suggestions of Keating, Meigs, and many others give timely aid to the anxious mother in the making of foods. It is true, if the parent does not have a refrigerator to keep the milk, and other essential utensils, or the simple knowledge to cook properly, con- densed milk or some " infant's food" are neces- sary. Bathing.-Bathing is used to reduce the temperature, for derivative purposes, and for the sake of cleanliness. Children in close quarters during the hot weather, with even an ordinary gastro-intestinal affection, are or- dered to be bathed in warm or tepid water every two hours, and encouraged to remain in the bath some time. Certain cases of cholera infantum, presenting cerebral symp- toms not unlike thermic fever, have hyper- pyrexia, due to excessive heat. To reduce the temperature is important. Cloths wrung out of ice-water and applied to the head, spine, and abdomen may suffice. Careful spongings with water and alcohol are of emi- nent service. Cold baths, the patient being placed in a bath at ioo°, reducing gradually to 6o°, are at times necessary. It has not 4 been the writer's lot to resort to this method often. It. is our only hope in some cases, however. For derivative purposes the gen- eral warm bath is used. It should be used, if there is fever, irritability, and sufficient strength, two or three times daily. If there is much exhaustion, the baths for cleanliness should be made stimulating by the addition of salt, whiskey, or alcohol. Sea-salt has been of service. External Derivatives.-They are important. A weak mustard-plaster, the familiar spice- plaster, or flannel dipped in Jamaica ginger (5i) in hot water (giii), applied to the abdo- men, may be used. Hot foot-baths and mus- tard foot-baths are of great value. If there is fever and irritability, frequent foot-baths are ordered, and their good action is manifest in quieting the perturbed nervous system. It is of prime importance to keep the abdomen protected. When the stimulating applications are not used, warmed flannel, well fitting, is kept on. The extremities, too, must be pro- tected. Long stockings should be worn, or the feet otherwise clad. In entero-colitis and chronic diarrhoea these precautions are almost essential to successful management. Inunctions.-They are of extreme value, and have saved life in many of the writer's cases. Not only is the absorption of the oil of ser- vice, but, doubtless, by the gentle manipula- tion, all the advantages of massage are se- cured. In the acute or subacute affections, without fever, inunctions are begun at once. In the stage of extreme prostration after cholera infantum, or in the marasmic state that is so liable to ensue, its effects are often 5 magical. Cases of indigestion (chronic vom- iting) respond rapidly to this form of nourish- ment. Inunctions are especially indicated in every case in which there is gradual but pal- pable failure in strength and loss of flesh. In fact, it may be said, in every case of summer affections, either baths or oil inunctions are used by the writer, and the latter in all cases in which the former is not more strongly indi- cated. The only possible exception to this is in cases of sthenic entero-colitis, but if there is much debility following, inunctions are or- dered. In many cases the baths and inunc- tions are used, the baths until the acute febrile symptoms have subsided, the inunctions sub- sequently. The writer orders cod-liver oil once or twice daily, gently rubbed in, and every second day a cleansing bath of alcohol and water. It is of advantage sometimes to anoint with oil at night, and use the cleansing bath in the morning. Stimulants.-But little need be said of stim- ulants. They are indicated on general prin- ciples, and are of great service not Only in cholera infantum, as previously indicated, but in other affections. In gastric affections, a good claret or sherry or whiskey are the best. In diarrhoea, burnt brandy, port, or some as- tringent cordials, as home-made blackberry wine, may replace the others. MEDICINAL TREATMENT OF THE SUMMER GASTRO-INTESTINAL DISEASES. While important, the writer is disposed to think its value is secondary to that of the hygi- enic management. Certain it is that more cases will get well with the management in- 6 dicated above without medicines than with medicines and a disregard for hygienic and dietetic principles. The selection of remedies is usually based by most practitioners on the symptoms. Theories of the nature of the disease guide others, and, if they were based on facts, would be the true indications for rational treatment. The theory of the ptoma- ines is becoming more and more a reality, and if it is proven as the basis of many intestinal disorders, our treatment must be carried on in accordance with such views. Granting it, the plan to pursue is to prevent abnormal de- composition of ingesta in the stomach, to pre- vent abnormal decomposition in the intestines, to remove the products of decomposition, and to antagonize their action. We are not suffi- ciently familiar with the physiological, or rather pathological, action of ptomaines to be able to counteract their evil influence by med- icines. Much work is being done, however, and light will soon be given us. The preven- tion of the decomposition of ingesta and in- testinal products is, we submit, effected by the selection of a proper diet. It will be seen further that calomel is a most important ther- apeutic agent, and what empiricism has taught we now learn from scientific experiment to be correct. No doubt the antiputrefactive power of calomel is one most important reason of its great value. Again, to remove the products of decomposition, we have in calomel a relia- ble agent ; other remedies of a purgative or laxative nature have their place. The subse- quent suggestions are made from clinical ex- perience, and are given devoid of theory. Vomiting, Acute.-Calomel, in small, fre- 7 quently-repeated doses, is one of the best sedatives. One-eighth to one-twentieth of a grain every half-hour is ordered.* If there is fever, pain, or great restlessness, one-twelfth to one-fourth of a grain of Dover's powder may be added.f The value of the drugs is enhanced and their efficacy rendered possible only by the small size and very frequent repe- tition of the dose. The writer places most reliance in the calomel and Dover's powder combination. Often, in simple cases of vom- iting, lime-water and whiskey are of service. For the more chronic forms of vomiting, with calomel subnitrate of bismuth is ordered ; lacto-peptine, or saccharated pepsin, is often used. In some obstinate cases of vomiting my friend Dr. Gittings told the writer he has used a decoction of peach-leaves with success. He has the fresh leaves gathered, and a small handful steeped in boiling water (Oss). The water is decanted, and used freely. The writer's personal experience accords with the above. Again, a weak acid mixture, as the acid solution of pepsin devised by Schaeffer, has been of service in many of my cases. These have been cases of feeble digestion ; an atonic state of the system as well as the * H Hydrarg. chlor, mit., gr. i; Sac. lactis, gr. iii. M. Ft. chart. No. xx. Sig.-One every fifteen or thirty minutes dry on the tongue (infant 3 to 6 months). f H Pulv. Doveri, gr. i; Hydrarg. chlor, mit., gr; i. M. Ft. chart. No. xii. Sig.-One every fifteen minutes until asleep or relieved (child 6 months). 8 stomach being obvious. The glycerin in the preparation may be of advantage in prevent- ing putrefaction in these cases. The general management above indicated is all-important. Simple Diarrhoea.-The simple astringents, the familiar antacids, the occasional use of rhubarb with an antacid, generally suffice. Jardinella's syrup, or the fluid extract of blackberry, is of great value alone or com- bined with other astringents. In the pro- tracted or chronic forms, nitrate of silver in solution is of great service. Carbolic acid with bismuth, where bismuth alone failed, has been of value. A warm abdomen and warm feet are im- portant, as well as a proper diet and good hygiene. Entero-colitis.-With external stimulating applications and care in diet much can be done, but some medicines must be used. These agents are resorted to,-castor oil and laudanum, rhubarb and laudanum, or quinine and calomel. The writer usually commences at once with mist, olei ricini and laudanum, administering a dose every two hours* until the tormina and tenesmus are relieved and the blood and mucus flux checked. If a rhubarb mixture be used, either the sweet tincture or the spiced syrup are the best preparations. In some ob- stinate cases, or cases complicated with mala- ria, or in malarious regions, quinine, in powder * B Mist, olei ricini, Tr. opii deod., gtt. xxiv-xl; 01. cinnamomi, gtt. iv-xi. M. Sig.-Fifteen to twenty drops every two hours (infant 6 months old). 9 or syrup, alternating with small doses of cal- omel and Dover's powder, is essential. As soon as the passages are free from mucus and blood, the tenesmus relieved, astringents and tonics replace the above. The writer has the notes of seven cases of entero-colitis treated with creasote with excellent effect, two resist- ing all other treatment previously. Cholera Infantum.-A very successful run of cases treated by the very frequent use of Dover's powder and calomel, in small doses, dry on the tongue, has made the writer rely chiefly on these drugs. Stimulants, of course, are used. The prescription of morphine and sulphuric acid, long ago advised by Meigs, is one that often checks vomiting, yet so often has the writer been disappointed, all medicine being rejected, that he resorts to placing the powders mentioned above on the tongue. They are so minute that they are readily taken into the pharynx, and the water or stimulant washes them down. If the child sleeps, the powders are not given so fre- quently. The writer has not had the misfor- tune to see the stage of collapse ensue in cholera infantum since instituting the above plans of treatment. He sorrowfully admits that he has never had any cases to recover from the cholera collapse. After the more acute symptoms of cholera infantum are con- trolled, tonics and astringents are used. The writer's experience with small enemas, containing astringents and opiates, has been extremely unsatisfactory. He failed to see any benefit that could not be accounted for by the other drugs. It is to be remarked, finally, that these 10 methods of treatment are not to replace the removal of the sick patient to the sea-shore or mountains. They are especially for the un- fortunates who cannot be removed from the depressing influences of the heat, bad air, and generally unhygienic surroundings. 3705 Powelton Ave., W. Phila.