SUMMER DIARRHCEA 
IN INFANTS: 
Being an Analysis of the Cases Treated at the 
Sea-Shore Home during the Summers 
of 1887,1888, and 1889. 
BY 
CHARLES W. TOWNSEND, M.D., 
BOSTON. 
\_Reprinted from the Archives of Pediatrics, November, 1890.2 SUMMER DIARRH(EA IN INFANTS: 
BEING AN 
ANALYSIS OF THE CASES TREATED AT THE 
SEA-SHORE HOME DURING THE SUM- 
MERS OF 1887, 1888, AND 1889. 
There are no diseases occurring among infants whose treat- 
ment is more perplexing than that of the diarrhoeal diseases 
which every summer play such havoc among the residents of 
large cities. The Sea-Shore Home at Winthrop receives from 
Boston during the summer months infants suffering from these 
diseases, and my endeavor in this paper will be to analyze the 
cases of the last three years, in order to arrive, if possible, at 
some conclusions as to methods of treatment. Although the 
number of cases is not large, my excuse for offering this report 
to your consideration is the fact that careful records were kept 
of each case, including daily record of weight, and thus my 
conclusions are obtained as much as possible from definite data, 
and not from general impressions which are apt to be so mis- 
leading. For these records I am greatly indebted to my 
house-officers, Dr. A. C. Stannard, Dr. A. S. Thayer, and Dr. 
E. J. Tilton, to whom I wish to express my thanks, and also 
to the sisters of St. Margaret, who have so intelligently con- 
ducted the nursing. 
The diarrhoeal diseases I have, for the sake of convenience, 
divided into three forms, which I shall define rather arbitrarily: 
first, cholera infantum, meaning by that an acute, probably 
specific, and general disease characterized by profuse watery 
purging and vomiting, and a high temperature, running a 
rapid course, and ending in death or recovery in from twenty- 
four to seventy-two hours. Second, gastro-intestinal catarrh, 
a disease characterized by vomiting and diarrhoea, the vomiting 
and stools often containing mucus. The temperature is either 2 
Summer Diarrhoea in Infants. 
normal or slightly elevated, and the disease lasts from a few 
days to months. Third, intestinal catarrh, in which the intes- 
tines are alone affected. 
Let me here enter my protest against the loose way in which 
the term cholera infantum is used, even by physicians who 
know better, and let them not refer to intestinal catarrhs that 
have lasted for weeks as cases of this disease. 
During the three summers there were 236 cases of diarrhoeal 
diseases at the Home, of which, 11, or four and a half per- 
cent., were classed under the head of cholera infantum; 77, or 
thirty-two and a half per cent., were cases of gastro-intestinal 
catarrh ; and 148, or sixty-two per cent., were cases of intes- 
tinal catarrh. 
Cholera infantum (11 cases).-Of these, 7, or sixty-four per 
cent., died. Four died within eight hours of entrance, being 
admitted moribund. The duration, both in the fatal and non- 
fatal cases, was fifty-one hours, omitting one case, where active 
symptoms ceased on the second day, but where death ensued 
on the ninth day from gastro-intestinal catarrh and collapse. 
The temperature was recorded in five cases, reaching in all 
105° F. or over, in one case 107° F. 
The four cases that recovered began after an interval of 
one to four days to rapidly gain in weight; the average daily 
gain for five and one-third days for all these cases was found 
to be as much as ninety grammes (three ounces). This would 
serve to emphasize the fact that cholera infantum is a disease 
without appreciable local lesions; and although it may be fol- 
lowed by gastro-intestinal catarrh, which may prove fatal (as 
in the case noted above), it may, on the other hand, be 
promptly and entirely recovered from. 
All of the fatal cases and two of those who recovered were 
on the bottle; the two others who recovered were partly 
nursed and partly fed artificially. 
The average age of the cases was eight months ; the extremes 
being three and twelve months for those that recovered, and 
one and a half and twenty months for those that died. 
The treatment was essentially the same in all the cases, 
namely, brandy by the mouth in large and frequent doses, and 
occasionally subcutaneously; the application of warmth by Summer Diarrhoea in Infants. 
3 
means of hot-water bottles to the extremities; of cold to the 
head, where this was indicated, and the administration of 
water in large quantities, to make up for the drain on the 
blood caused by the watery discharges. White of egg and 
beef-juice were also given-as soon as they could be borne. 
During the first summer, two cases of cholera infantum 
began at the Home, due unquestionably to the fact that the 
food was not sterilized. In the last two years the food has 
been sterilized, and since then no case has arisen at the Home. 
These two cases are very instructive. Both children had en- 
tirely recovered from intestinal catarrh, and were gainjng 
weight on a diet of milk and barley-water; in both the attack 
was suddenly ushered in by profuse watery purging and vom- 
iting, both went into a rapid collapse, had convulsions, and 
died in twenty-four hours. The hourly temperature chart of 
the child, aged twenty months, is here given. 
DAYS OF 
MONTH. 
107° 
106° 
.105° 
104° 
103° 
102° 
101° 
100° 
*99° 
98° 
97° 
96" 
95° 
90 
80 
70 
60 
50 
45 
40 
TEM PERATURE. 
PULSE. 4 
Summer Diarrhoea in Infants. 
Gastro-intestinal catarrh (77 cases)-Intestinal catarrh (148 
cases).-Of the former, 37 were discharged well, 20 relieved, 
14 not relieved, and 6 died. Of the latter, 121 were dis- 
charged well, 23 relieved, 4 not relieved, none died. 
Observations on temperature.-In 79 cases temperature charts 
were kept, and out of 37 cases of gastro-intestinal catarrh, the 
temperature remained normal in 14; in 4 the temperature 
rose once or twice to 100° F.; in 7 it ranged from 99° to 100° 
for several days; and in 6 it occasionally went as high as 103°, 
returning to 99° or 98°. 
Of 42 cases of intestinal-catarrh, the temperature remained 
normal in 28 cases; in 5 it occasionally rose to 100° ; in 7 it 
continued for two or three days between 99° and 100° ; and 
in 2 it rose once from normal to 103°. There was, in fact, 
no regularity in the temperature charts, as in cases of cholera 
infantum, and it was of but little value in prognosis. Al- 
though, as a rule, the sicker the case the more apt was the 
temperature to be occasionally elevated, still some of the 
sickest cases had normal temperature. It does not seem pos- 
sible, therefore, to distinguish a "simple diarrhoea" from intes- 
tinal catarrh by absence of an elevation of the temperature. 
With reference to the important subject of treatment, I have 
carefully analyzed the cases, taking into consideration the num- 
ber and character of the dejections and vomitings, and the 
daily weight of the patients. An analysis of this sort is very 
difficult, owing to the fact that the cases differ so, no two being 
exactly alike; there is also great danger of falling into the 
post hoc propter hoc fallacy. It would, for example, be useless 
to compare the results in those given drugs and in those with- 
out such treatment, for the latter were generally the mild cases. 
All the cases had the advantage of the change of air from 
the hot crowded city to the country ; and the good effects of this 
alone were in many cases very marked, resulting in a speedy 
recovery in some of the very mild cases,* and in a marked im- 
provement in many of the severe cases. But it is evident that 
* The Sea-Shore Home is situated in the middle of the peninsula of 
Winthrop, about a mile distant from the ocean on one side and Boston 
harbor on the other. Summer Diarrhoea in Infants. 
5 
a change in the air alone is not sufficient for the cure of any 
but the most transitory cases. 
A change of diet was found to be the most important of all 
considerations, for in all some defect in the quality or quantity 
of the food given previous to entrance was found, the most 
marked defect being that the food was generally far from fresh 
or sterile, as was easily discovered by an examination of the 
bottles brought with the patients. 
Diet.-During the second and third summers all the bottle- 
foods were systematically sterilized by steam, and the benefit 
obtained, as seen in the more favorable progress of the cases, 
was evident. 
Breast-milk.-In 35 cases the infants were partly or wholly 
breast-fed. In 6 cases the breast-milk did not agree, in 29 
cases it did agree, although in many of these the milk was 
evidently bad at first, as shown by the character of the stools 
and by the loss of weight in the infants; but later, as the 
mothers improved, with the change of air and diet and the 
freedom from household cares, the infants improved corre- 
spondingly. 
Milk and lime-water, in varying proportions, were used in 
39 cases. In 14 of these the mixture did not agree; in 25 
improvement occurred during its use. 
Milk and barley-water, in varying proportions, were used in 
66 cases. In 17 it did not agree; in 49 improvement occurred 
during its use. Many of these were mild cases, and it was 
generally given to infants over a year old, where it was evi- 
dent that the disease was of a transitory nature. Whether 
the same proportions of milk and plain water would not have 
done as well I do not know. 
Peptonized milk was given in 11 cases, all rather severe, in 6 
of which no improvement followed; in 5 there was improve- 
ment. 
Modified milk mixture.-This, during the first summer, was 
the mixture of Dr. A. V. Meigs, consisting of cream (fifteen 
per cent.), 2 parts; milk, 1 part; lime-water, 2 parts; sugar- 
water (seventeen and three-quarters drachms of milk-sugar to 
the pint), 3 parts. After this it was given in the form recom- 
mended by Dr. Rotch, in the proportion of cream (fifteen per 6 
Summer Diarrhoea in Infants. 
cent.), 4 parts; milk, 2 parts; water, 9 parts; lime-water, 1 
part; sugar of milk, 6^ drachms to the pint of mixture. 
This latter mixture was variously modified to suit individual 
cases, by the reduction of the fat or of both fat and albumi- 
noids. The mixture, in one form or other, was used in 75 
cases, and, as a rule, in more severe cases than those in which 
milk and barley-water were given; 50 of these did well; 25 
did not do well; but it was noticeable that the proportion of 
those with whom the mixture agreed increased in the last two 
years, owing partly to the fact that the food was sterilized and 
partly because the proportions of the food were differently ar- 
ranged. I am, therefore, more and more satisfied with the 
use of this mixture, and can add that my results in private 
practice have been even more satisfactory. This difference is 
largely owing to the fact that, among the poorer class of patients, 
such as are taken to the Sea-Shore Home, many are to be found 
whose constitutions are so feeble that even with the best treat- 
ment they succumb to disease. 
The only other forms of dietetic preparations used at the 
Home were beef-juice and white of egg in sterilized water. 
These were particularly useful in cases where vomiting was a 
prominent symptom ; of 36 cases in which beef-juice was used, 
in 27 it acted well, in 9 it did not. The white-of-egg mixture 
was used in 23 cases, with good results in 16; without them 
in 7. Infants with severe gastro-intestinal catarrh were, as a 
rule, given beef-juice or that alternate with white-of-egg and 
water for twenty-four or forty-eight hours. At the end of 
this time the modified milk mixture was cautiously given in 
place of a few feedings of the beef-juice, was gradually in- 
creased, and the beef-juice diminished, until the latter was 
entirely replaced by the milk mixture. In a few cases the 
complete starvation plan was tried, of giving the baby water 
only for the first twenty-four hours, but it was not as suc- 
cessful as the above method, besides causing considerable 
anxiety and complaint on the part of the mothers. 
Brandy was used in a large number of the cases, including 
all the severe ones. 
Drugs.-Eighty-seven cases were treated without drugs, 
reliance being placed on diet, the change of air, and good hy- Summer Diarrhoea in Infants. 
7 
gienic measures; 76 of these cases did well, 11 did not improve. 
The mild cases are, as a rule, included in this list, also some 
of the serious cases. Treatment by drugs was limited, with a 
few exceptions, to bismuth, salicylate of soda, and lactic acid, 
belonging to the class of antiseptics, and these were, I think, 
given a thorough trial. 
Bismuth was used in 42 cases. In 25 cases no improve- 
ment occurred during its use, as shown by the character of the 
stools or by the weight of the infant; in some of these its 
administration was objected to by the infant, with the result 
of causing vomiting. In 17 cases improvement occurred 
during its use. In either case, it is to be remembered that 
dietetic and hygienic measures were also employed. 
Salicylate of soda was used in 26 cases, being given in 
water in doses of two grains every two hours to an infant of a 
year. In 14 cases there was no improvement; in 12 cases 
improvement occurred during its use. 
Lactic acid was given in 12 cases, in doses of a drachm of 
the two-per-cent, solution, at intervals varying from a quarter- 
hour to two hours. No effect was noticed in 6 of these cases; 
in 5 improvement occurred under its use. 
Resorcin was given in 4 cases, in 3 without effect, in 1 im- 
provement occurred. 
As the cases differed so in degree of severity and in dura- 
tion before entrance, it is impossible to draw exact conclusions 
from these figures; but, taking into consideration the number 
of cases that did well without drugs, I am inclined to be 
rather sceptical as to the value of these antiseptics in the treat- 
ment of summer diarrhoea. Their use in my hands has cer- 
tainly not been followed by the brilliant results reported by 
some. This difference can perhaps be explained by the fact 
that my cases remained constantly under observation, and 
were not of the uncertain out-patient class where favorable 
results are too often wrongly inferred from the non-reappearance 
of the patient aijd partly from the fact that zeal for a theory 
of intestinal antisepsis may have warped these reported judg- 
ments in deciding on the benefit obtained. 
On theoretical grounds, if I am not mistaken, intestinal 
antisepsis by means of the drugs used at the present time is 8 
Summer Diarrhoea in Infants. 
impossible without danger to life, and with the late views on 
the function of certain intestinal bacteria it would, even if 
possible, be inadvisable. 
Lavage of the large intestine with tepid water was used in 
13 cases. In 10 of these, improvement was certainly marked, 
in 1 there was temporary improvement only, and in 2 no im- 
provement took place. The results in these few cases encour- 
age me to continue this treatment, although, as the small in- 
testine is not reached by the washing, it does not seem to me 
that we should expect too much from this treatment alone. 
Lavage of the stomach I have not employed. 
Relapses were not uncommon, and I have often wondered 
whether the patients might not be reinfected or their recovery 
delayed by the presence of so many others suffering from 
diarrhoeal diseases. Infection through the food was prevented 
by the process of sterilization. There has been a steady im- 
provement in the three years in the quarters given to the 
patients as regards space and ventilation, and with this an 
improvement in the progress of the cases. 
Observations on weight.-A daily gain in weight is of course 
a most favorable indication. Some of the infants were dis- 
charged well in the course of one or two weeks, gaining in 
weight daily, yet weighing less than on entrance owing to the 
large initial loss before the diarrhoea was cured. The subse- 
quent gain in weight was generally irregular, being often in- 
terrupted for a day or two. In a few cases there would be no 
gain in weight, notwithstanding the cure of the diarrhoea. Of 
1(10 cases, there occurred a gain in weight over the lowest point 
reached in 105 ; 55 lost weight, and did not regain any. The 
average daily gain among the former cases was 38.8 grammes; 
the largest average gain for any one patient being 134 grammes 
(four and a half ounces) daily for eight days. The average 
daily loss in these 105 cases, until the lowest point was reached, 
was 34.8 grammes; the largest for any one patient being 255 
grammes daily for two days. The average duration of the 
loss of weight was four and a half days. In other words, the 
average infant, after treatment was begun at the Home, lost 
weight at the rate of 35 grammes a day for four and a half 
days, and then began to gain at the rate of 39 grammes daily. Summer Diarrhoea in Infants. 
9 
Thirty-four, or one-third, of the cases did not lose weight, but 
began to gain at once. 
Of 49 cases that did not gain weight, the average daily loss 
was 40.6 grammes, the greatest being 130 grammes daily for 
four days. The average stay of these cases at the Home was 
ten days. It is probable that many of these would have soon 
begun to gain weight if they had stayed longer, as 18 were 
considered well, diarrhoea and vomiting having ceased, and the 
stools showed that the food was well digested. 
Of 6 fatal cases, the average daily loss was 29 grammes, the 
average stay in the hospital being 11 days. Volume begins with January Number. 
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