Second Period

The stools become more frequent and serous. They are almost continuous, and enormous quantities of fluid are rapidly drained from the system, in which whitish flakes of desquamated intestinal epithelium are suspended. Sometimes they contain blood. As much as two quarts of fluid may be discharged in a single evacuation. Nausea and epigastric distress occur with projectile vomiting of fluid, which exceeds in quantity that which is drunk. Intense abdominal cramps follow and extend down the legs. The patient rapidly emaciates, and the feebleness and prostration are extreme. There is a cold clammy perspiration, and in a few hours the victim passes into collapse. Active efforts must be made to stop the vomiting and diarrhoea. The abdomen must be incased in flannel, and turpentine stupes are of service if the cramps are severe. A mustard paste may be placed over the epigastrium, and a hypodermic injection of morphine is required. Cracked ice, cold lime water, iced champagne and carbonic-acid water, iced fresh lime juice in Vichy, weak cold brandy and Seltzer, or plain soda - are all good remedies which should be offered in very small doses every five or ten minutes. Strong black coffee may be tried. The thirst may be assuaged by dilute hydrochloric acid or lemon juice in water.

A little fluid held in the mouth for a few minutes sometimes affords more relief of this symptom than larger quantities swallowed. It is worse than useless to attempt to give even predigested milk while the vomiting and diarrhoea continue.

Third Period

In both the second stage and in the third stage of collapse the best results are obtained by the method of hypoder-moclysis - that is, of hypodermic injections into the thighs and sides of the abdominal wall of large quantities of normal salt solution made by dissolving 60 grains (a scant teaspoonful) of salt to the pint of boiled water. The injections are given at the temperature of the blood, and the entire quantity may be used in the course of half an hour. The salt solution replaces to some extent the fluid drained by the serous diarrhoea and emesis, restores the blood pressure and equilibrium of the circulation, and almost immediately relieves the thirst.

Fourth Period

If vomiting ceases and the symptoms of collapse abate, a little fluid nourishment must be very slowly and cautiously tried. A teaspoonful or two of pancreatinised milk, koumiss, Liebig's or Valentine's meat extract, or fresh beef juice is first given. If this is retained, the dose is to be repeated and continued by increasing the quantity and diminishing the frequency of administration as the patient improves. The stomach remains feeble and irritable for many days, and for a week or two it may be necessary to limit the diet to predigested milk, beef albumoses, nutritious broths, egg 31 albumen in diluted brandy, and champagne. The further dietetic treatment may be conducted in the manner of that of the convalescence of typhoid fever (p. 440).