Cholera Infantum.
Definition:—Cholera infantum is an acute infectious disease of infancy, characterized by diarrhea, and in severe cases by vomiting, rapid emaciation and extreme prostration.
Etiology:—This disease is largely confined to the summer months in temperate zones, and has its acme of occurrence and mortality in the period of greatest heat. Cases may occur as early as April and May, but in June the disease may be said to begin, and the curve rises steadily during July, beginning to decline late in August, and lasting till October.
Children in the crowded portions of cities are more subject to cholera infantum than those in the suburbs and in the country.
The factors producing digestive disorders are directly causative. Artificially fed children are more frequently attacked than those breast fed. A contaminated milk supply is commonly responsible for the disease.
The eating of unripe or decomposing fruit, and of articles unsuited to infantile digestive powers, may precipitate an attack. As suggested above, a period of hot weather will positively influence its occurrence.
The bacterial agents causing the disorder are numerous. In many cases Shiga's bacillus—bacillus dysentereae—is found. In other cases the streptococcus occurs, also the staphylococcus, the bacillus pyocyaneus, and a spirillum, though not the spirillum cholerae asiaticae.
Symptomatology:—Cholera infantum is so named because of its clinical resemblance to Asiatic cholera. The diarrhea is at first muco-purulent, soon becoming watery, and amounts to purging. The stools are voided with force, and vary in number from ten to fifty in twenty-four hours, and are alkaline in reaction. Vomiting occurs, and may soon become nearly incessant.
The pulse is rapid and weak; the temperature taken in the rectum may be found to be as high as 105° to 106° F., while the peripheral temperature may be low. The tongue becomes red and dry; there is intense thirst. The urine is scanty or it may be suppressed. The skin has a mottled appearance from poor capillary circulation; the extremities are usually cold. The child is restless at first, but later becomes listless; the features are drawn and shrunken and the face has often the appearance of extreme age. The eyelids are but partly closed, the mouth is open, and the fontanels are depressed. Not only is prostration present from the beginning, but signs of profound toxemia are marked.
Toward the end of fatal cases the breathing is irregular and the head retracted; the temperature is sub-normal, or there may be hyperpyrexia. Death may occur in twenty-four hours. In cases that recover the disease may pass into an ileo-colitis, or gradual improvement may begin in a few days.
Diagnosis:—From the standpoint of etiology and pathology it is impossible to distinguish this disease from ileocolitis. But its occurrence in the heated season, often in epidemic form, and the uncontrollable diarrhea and vomiting, the serous stools and the symptoms of collapse make cholera infantum a clinical entity easily distinguished and recognized.
Prognosis:—Convalescence, the passing of the disease into a less acute form of enteritis, or death, usually ensues in from one to four days. The prognosis is always grave. The factors that govern the outcome are the age and vitality of the child, the severity of the vomiting and purging and the response to treatment. Very young infants seldom recover unless the disease is early aborted.
Treatment:—In no class of cases that the physician is called upon to treat is there greater care demanded for the determination of the exact conditions present, and for the precise adaptation of the remedies, than in cholera infantum. An exceedingly close watch must be kept for abrupt changes in the indications, which are apt to occur at any time. Also the sudden appearance of complicating conditions must be looked for. The sensitive nervous system of the child must be kept in mind, especially when the case is prolonged, and meningeal complications must be guarded against.
Nothing, however, demands more attention than the diet, as dietary faults, in conjunction with a high temperature, are most frequently to blame for the condition. The adjustment of a prepared or artificial food to the patient, or a preparation of milk foods, or the predigestion of milk, must all be conducted with reference to the demand of the individual patient, and even with as correct a knowledge of these demands as is possible to obtain, it is often necessary to try one food after another, until one is found which will be retained and readily appropriated. Some of these little patients must be taken from the breast, even when the mother has sufficient milk, and put upon an artificially prepared milk.
In a large per cent of these cases, however, the children are bottle fed. There should always be two bottles, if the child is too young to be taught to drink, or if it is not desirable to feed the child with a spoon, which is in every way preferable. These bottles should have a large, open mouth, and the nipple should fit the bottle directly; rubber tubes must always be avoided. The bottle and the nipple should be cleansed and boiled after every feeding, and should be kept immersed in soda water. The food should be given warm, and should be prepared at each feeding.
In severe cases I have for a time discontinued the use of milk and milk foods entirely, and have put the patient upon beef juice or bovinine, a few drops in water, every half hour or hour, for perhaps two or three days, giving the patient very frequently a little cold water to drink, or a little ice in the mouth, if the child is old enough. A small piece of ice wrapped in sterilized gauze may be sucked by even small infants, to allay the intense thirst, with much benefit, as these patients are very thirsty and constantly demand water. When the vomiting is extreme, the drinking of water may cause the vomiting to persist. I have heard it argued that if sufficient cold water be given to reduce somewhat the temperature of the stomach, the vomiting will cease; the patient may at first vomit constantly from the drinking of the water until the stomach is thus temporarily cooled. While this course is advocated by good authorities, it has seemed to me to be too heroic a course for common adoption.
Intestinal irrigation must be practiced in these cases, and no irritating or decomposing substances must be allowed to remain in the intestinal tract.
The fever nearly always demands aconite. This remedy must never be given in large doses, and it must be persisted in for several days if the temperature remains high. It exercises a very wide influence; it does not depress the heart, and it allays directly the irritation of the gastrointestinal mucosa through its influence upon the terminal filaments of the nerves. Another specific remedy is ipecac. It has been my practice to drop five drops of the tincture of each of these remedies into separate glasses and to add three ounces of water to each. These should be given alternately in teaspoonful doses every half hour at the onset. If there is an inclination for the extremities to be cold, and especially if the pupils be dilated, five drops of the tincture of belladonna may be combined with the aconite. If the patient is restless, irritable and sleepless, hyoscyamus, four or five drops, should be added to the ipecac mixture. If nervous excitability is marked and there are muscular twitchings, or if convulsions seem to threaten, the ipecac mixture may be omitted for a while and a mixture of three ounces of water with ten drops of specific gelsemium may be substituted for it.
This course of treatment will usually allay the vomiting with the other symptoms. However, it is often a good plan, demanded by pale mucous membranes and a white-coated tongue, to begin the treatment with the syrup of rhubarb and potassium compound. This may be given at first in single full doses an hour or an hour and a half apart, repeated four or five times before the other treatment is begun; or I have frequently added from one to four drams of this preparation, commonly known among our physicians as the neutralizing cordial, to the three ounce mixture which contains the ipecac, and have administered the remedy in this manner during the first two or three days.
If the vomiting is persistent, I have found nothing better than the mixture of equal parts of ingluvin and bismuth, frequently referred to. I add from twenty to thirty grains of this mixture to half of a glass of cold water, and after stirring thoroughly, I administer a teaspoonful every ten, twenty or thirty minutes, without regard to the vomiting, until that condition abates. Occasional doses are then given as needed.
When the vomiting depends upon nervous irritability, especially if the mucous membranes of the mouth and tongue are dry and red, four or five drops of rhus toxicodendron should be added to four ounces of water, and a teaspoonful given every thirty or forty minutes for a few hours. This will exercise a tranquilizing influence not only upon the stomach, but upon the brain, thus relieving the central irritation.
During the active stage of this disorder irritation at the base of the brain is a common complication. This induces occipital headache or pain. There is an expression of distress upon the face and the head is crowded backward into the pillow and is slowly turned from side to side. Often the little one will keep the hand against the neck or the back of the head, and will moan or cry out with occasional irritable cries. To relieve this the head should be sponged during the course of the fever with warm water. It is a good plan to use hot water occasionally, permitting free evaporation, or using a fan to cool the skin. With these symptoms much care must be exercised in selecting the specific remedy. Gelsemium may be indicated, and rhus toxicodendron will often be demanded, as just stated, and in certain advanced cases, where the patient has become weakened, the tincture of calabar bean will be needed with which to ward off meningeal complications. Passiflora exercises a very desirable influence where there is no cerebral congestion. It relieves irritation, conduces to tranquility, and promotes sleep, which is greatly to be desired. I have obtained excellent results, when the nervous irritation was excessive, from ten or fifteen drops of a mixture of sodium bromid and chloral hydrate, two drams of each in an ounce of water. A single dose of this may be given, especially if convulsions are threatened, and repeated if necessary.
The treatment of the indications as named usually relieves the diarrhea if the gastrointestinal irritation is overcome by irrigation at the start. I have controlled many cases during the first thirty-six or forty-eight hours with aconite and ipecac alone, washing out the lower bowel occasionally after a free bowel movement. Sometimes this flushing should be repeated after each movement for three or four movements, when the movements will occur at much longer intervals, or cease entirely for perhaps twenty-four or thirty-six hours.
It is but seldom that astringents are needed or are to be advised in cholera infantum. The indications for arsenite of copper will be present in most cases, and this agent will effectually control the bowel movement. Some authors declare that there is a positive necessity for stimulating the action of the liver in all of these cases, and advise calomel or podophyllin or other stimulants for this purpose. With us these agents seem to be contraindicated. If such stimulation is plainly needed, small doses of sodium phosphate, or often the external persistent application of heat alone will be in every way sufficient.
The convalescence of these patients must be conducted with great care, if the food be correctly adjusted, but little tonic treatment will be necessary, but the child must be kept warm in cool weather and cool in warm weather, an equable temperature being maintained if possible. The use of nux vomica in small doses, or two or three drops of the tincture of the chlorid of iron in a little water, every two hours, or an inunction of quinin over the abdomen and chest every morning for a week or ten days, will usually be sufficient.
When the condition is extreme and the prostration is severe, hypodermoclysis with the normal salt solution, carefully administered, will supply the deficient fluids in the circulation, and will at once stimulate the action of the heart and the nervous system and favorably increase the functional action of all the organs of nutrition. This may be repeated each day for a few days. Carefully administered enemas of the normal salt solution will prevent extreme prostration, and will assist in correcting other serious conditions which have resulted from the sharpness of the attack. With the younger children this method is preferable to hypodermoclysis, except where a fatal issue is imminent.
