In the second class of cases this chronic form of diarrhoea establishes itself with out any preceding acute attack. Eustace Smith considers that in the majority of these cases the affection is due to re peated chillings of the surface of the body, producing a catarrhal condition of the gastrointestinal tract. Another im portant factor is undoubtedly a more or less faulty dietary, associated with the depressing influence of unhygienic sur roundings. It is a form of diarrhoea fre quently met with in young infants under four months reared in hospitals or found ling institutions.
The onset of the attack is gradual and insidious. A failure to gain in weight, or an actual loss, may be the first symptom demanding attention. On inquiry the infant will be found to pass several pale, pasty evacuations during the day, which on examination will be found to consist in great measure of undigested food. In spite of ordinary therapeutic measures this condition is apt to persist. Some weeks a slight improvement may be noted, but occasional exacerbations of the diarrhom with fever soon dissipate any gain that may have been made. As the disease progresses, the stools change in character and become more frequent; at times they may be frothy and sour-smell ing; at other times thin, dark-colored and offensive; their character is very variable. The abdomen is generally more or less distended. Cool perspira tions occur when the infant falls asleep. The urine becomes scanty and contains both indican and urobilin. Nutrition fails. The skin assumes an earthy hue, and the face acquires a curious look of old age. The infant lies in its cot 'in a helpless, apathetic state, and makes its wants known by a scarcely audible whine. Such infants readily succumb to some in tercurrent disease. Any of the complica tions which we have already referred to in connection with the preceding groups may be met with in this condition; the mortality is very great. Medicines ap pear of no avail. A complete change of air, to the sea-side or a bracing country or mountain- air, appears to be the only remedial measure to any extent effectual.
Diagnosis.—An exact diagnosis in these cases is often difficult. The ques tion arises as to whether the condition present in the intestine is a sufficient ex planation in itself of the serious failure in general nutrition, or whether we have in addition to deal with some underlying constitutional disease,—such as tuber culosis, a disease which not infrequently manifests itself as a sequel after severe or prolonged diarrhceal attacks. The question will always be a difficult one, but the physician will act wisely if he base his opinion rather upon the history of the case and the general condition of the patient than upon any one particu lar symptom or physical sign.
Prognosis.—The prognosis in cases of chronic diarrhoea must always be very guarded. To some extent it is dependent on the previous constitution of the in fant, on the hygienic conditions obtain able, and upon the zeal and regularity with which all instructions are carried out. To a great extent it is also depend ent upon the severity and extent of the intestinal lesions. When ulceration, either catarrhal or follicular, is present to any considerable degree, the prognosis is always bad, though perhaps, under favorable conditions, not hopeless. In those cases, on the other hand, where mere catarrhal or follicular inflammation without ulceration is present the prog nosis is distinctly better. With favoring circumstances we may hope that a large proportion of these will proceed to com plete recovery. To distinguish accurately between these two classes by the symp toms or physical signs existing at the time of examination is impossible. Our chief dependence must be placed on the previous history of the case. The longer the inflammation has lasted, and the higher has been the temperature, the greater the probability of ulcerative le sions. (Holt.) Treatment.—With the conditions pres ent in chronic diarrhoea no good, but often harm, may result from the employ ment of ordinary astringent, or even antiseptic, remedies administered by the mouth. If drugs are to be given, only those should be employed which will not disturb the stomach, and may to some extent improve general nutrition. Given with this object in view, some cases among older infants do undoubtedly de rive benefit from the prolonged adminis tration of iron. It may be given either in one of its acid preparations, or in a neutral and less irritating salt. Nutri tion may also in some instances be as sisted by the inunction over the abdomen or body generally, of codliver-oil, or cocoa-butter. The moderate employ ment of stimulants is called for in almost all cases. Great attention must be given to the dietary and to its proper regula tion; and to this end the stools should be frequently examined. Fats are only to be allowed with much caution. Starchy foods should be more or less predigested. Considerable benefit may be derived from the employment of scraped meat, meat-juice, broths, and peptonized foods. For younger infants milk-foods will require very careful preparation; and in some cases may have to be gether discontinued. In older children they may be cautiously employed, always watching the stools for signs of undi gested material. No absolute rules can be laid down suitable for all cases; each case must be studied by itself.