Part 124

Although the summer complaint in its commencement may be promptly arrested by proper hygienic and medicinal treatment, if it continue a few weeks the anatomical changes which occur are such that recovery, if it take place, is necessarily slow and gradual. Improvement is shown by better digestion, fewer stools and of better appearance, less frequent vomiting, a more cheerful countenance, and the absence of symptoms which indicate a complication. Many recover after days of anxious watching and perhaps after many fluctuations.

Death may occur early from a sudden aggravation of symptoms and rapid sinking, or the attack may be so violent from the first that the infant quickly succumbs; but more frequently death takes place after a prolonged sickness. Little by little the patient loses flesh and strength, till a state of marked emaciation is reached. The eyes and cheeks are sunken, the bony projections of the face, trunk, and limbs become prominent, and the skin lies in wrinkles from the wasting. The altered expression of the face makes the patient look older than the actual age. The joints in contrast with the wasted extremities seem enlarged and the fingers and toes elongated. The stools diminish in frequency from diminished peristaltic and vermicular action, and vomiting, if previously present, now ceases. A feeble, quick, and scarcely appreciable pulse, slow respiration, and diminished inflation of the lungs, sightless and contracted pupils, over which the eyelids no longer close, announce the near approach of death. The drowsiness increases and the limbs become cool, while perhaps the head is hot. The infant no longer has the ability to nurse, or if bottle-fed the food placed in the mouth flows back or is swallowed with apparent indifference. So low is its vitality that it lies pallid and almost motionless for hours or even days before death, and death occurs so quietly that the moment of its occurrence is scarcely appreciable.

ANATOMICAL CHARACTERS.--Since the prominent and essential symptoms of the disease which we are considering pertain to the digestive apparatus, it is evident that the lesions which attend and characterize it are to be found in this part of the system. Lesions elsewhere, so far as they are appreciable to us, are secondary and not essential. I have witnessed a large number of autopsies of infants who have perished from the summer complaint, chiefly in institutions, and they have been sufficiently marked and uniform to enable us to designate it an entero-colitis. Several years since I preserved records of the autopsical appearances in the intestinal catarrh of infants, most of the cases being of summer diarrhoea. The number aggregated eighty-two. Since then I have each summer witnessed autopsies in the institutions in cases of this disease, and the lesions observed were the same as in the eighty-two cases.

The question may properly be asked: Can inflammatory hyperæmia of the intestinal mucous membrane be distinguished from simple congestion if there be no ulceration and no appreciable thickening of the intestine? It is possible that occasionally I have recorded as inflammatory what was simply a congestive lesion, but I do not think I have incorporated a {737} sufficient number of such cases to vitiate the statistics. In a large proportion of the cases there was evident thickening of the intestinal mucous membrane or other unequivocal evidence of inflammation. The following is an analysis of the eighty-two cases:

The duodenum and jejunum presented the appearance of inflammatory hyperæmia in 12 cases. The hyperæmia was usually in patches of variable extent or of that form described by the term arborescent. In 51 cases the duodenal and jejunal mucous membrane was pale and without any other appearance characteristic of catarrh or inflammation. In the remaining 19 cases the appearance of the duodenum and jejunum was not recorded, so that it was probably normal. On the other hand, in the ileum inflammatory lesions were present as a rule. In 49 cases I found the surface of the ileum distinctly hyperæmic, and in that portion of it nearest the ileo-cæcal valve, including the valve itself, the inflammation had evidently been the most intense, since in this portion the hyperæmia and thickening of the mucous membrane were most marked. In 16 cases the surface of the ileum appeared nearly or quite normal; in 14 hyperæmia in the small intestines in patches, streaks, or arborescence was recorded, but the records do not state in which division of the intestines they were observed.

Billard, with other observers, has noticed the frequency and intensity of the inflammatory lesions in entero-colitis in the terminal portion of the small intestines, and the thickening in many cases of the ileo-cæcal valve, and he asks whether the vomiting which is so common and often obstinate in this disease may not be sometimes due to obstruction to the passage of fecal matter at the valve in consequence of the hyperæmia and swelling, but has not observed any retained fecal matter above it, such as we find in any part of the colon, or any other appearance which indicated sufficient obstruction to cause symptoms. Still, it seems not improbable that the reason why the inflammatory lesions are more pronounced at and immediately above the valve than in other parts of the small intestine is that the fecal matter, so commonly acid and irritating in this disease, is somewhat delayed in its passage downward at this point.

Small superficial circular or oval ulcers were observed in the ileum in 4 cases, in 2 of which they were found also in the lower part of the jejunum. In 1 case the records state that ulcers were in the jejunum, but do not mention whether they were also in the ileum. In 1 case, in which there was much thickening of the ileum next to the ileo-cæcal valve, many small granulations had sprouted up from the submucous connective tissue, so that the mucous surface appeared as if studded with small warts.

Softening of the mucous membrane was also apparent in certain cases. The firmness of its attachment to the parts underneath varied considerably in different specimens. I was able in cases in which there was considerable softening to detach readily the mucous membrane with the nail or handle of the scalpel within so short a period after death that it was probable that the change of consistence was not cadaveric. In some cases the vessels of the submucous tissue were injected and this tissue infiltrated.

In all the cases except one lesions were present indicating inflammation {738} of the mucous membrane of the colon. In 39 hyperæmia, thickening, and other signs of inflammation extended over nearly or quite the entire colon; in 14 the colitis was confined to the descending portion entirely or almost entirely; in 28 cases the records state that inflammatory lesions were found in the colon, but their exact location is not mentioned. In 18 of the autopsies the mucous membrane of the colon was found ulcerated.

Therefore, according to these statistics--and autopsies which I have witnessed that are not embraced in them disclosed similar lesions--colitis is present, almost without exception, in cases of summer diarrhoea, associated with more or less ileitis. The portion of the colon which presents the most marked inflammatory lesions is that in and immediately above the sigmoid flexure--that portion, therefore, in which any fermenting fecal matter has reached its greatest degree of fermentation, and consequently contains the most irritating elements, and where, next to the caput coli, it is longest delayed in its passage downward.

The solitary glands of both the large and small intestines and Peyer's patches undergo hyperplasia. In cases of short duration, and in parts of the intestine where the inflammatory action has been mild, the solitary glands present a vascular appearance, like the surrounding membrane, and are slightly enlarged. The enlargement is most apparent if the intestine be viewed by transmitted light, when not only are the glands seen to be swollen, but their central dark points are distinct. If a higher grade of intestinal catarrh or a catarrh more protracted have occurred, the volume of these follicles is so increased that they rise above the common level and present a papillary appearance. Peyer's patches are also distinct and punctate. The enlargement of Peyer's patches, like that of the solitary glands, is due to hyperplasia, the elementary cells being largely increased in number.

The small ulcers which, as we have seen from the above statistics, are present in a certain proportion of cases in the mucous membrane of the colon, and more rarely in that of the small intestine when the inflammation has been protracted and of a severe type, appear to occur in the solitary glands and in the mucous membrane surrounding them. While some of these glands in a specimen are simply tumefied, others are slightly ulcerated, and others still nearly or quite destroyed. The ulcers are usually from one to three lines in diameter, circular or oval, with edges slightly raised from infiltration. Rarely, I have seen minute coagula of blood in one or more ulcers, and I have also observed ulcers which have evidently been larger and have partially healed. The ulcers are more frequently found in the descending colon than in other portions of the intestines. When ulcers are present they commonly occur in the descending colon, or if occurring elsewhere they are most abundant in this situation.

According to my observations, these ulcers are found chiefly in infants over the age of six months--during the time, therefore, when there is greatest functional activity and most rapid development of the solitary glands. Peyer's patches, though frequently prominent and distinct, have not been ulcerated in any of the cases observed by me.

The appendix vermiformis participates in the catarrh when it occurs in the caput coli, its mucous membrane being hyperæmic and thickened. In {739} certain rare cases the inflammation is so intense that a thin film of fibrin is exuded in places upon the surface of the colon. It is apt to be overlooked or to be washed away in the examination. The rectum usually presents no inflammatory lesions, or but slight lesions in comparison with those in the colon. It usually remains of the normal pale color, or but slightly vascular even when there is almost general colitis. Hence the infrequency of tenesmus.

As might be expected from the nature of the disease, the secretion of mucus from the intestinal surface is augmented. It is often seen forming a layer upon the intestinal surface, and it appears in the stools mixed with epithelial cells and sometimes with blood and pus.

The mesenteric glands in cases which have run the most protracted course and end fatally are found more or less enlarged from hyperplasia. They are frequently as large as a pea or larger, and of a light color, the color being due not only to the hyperplasia, but in part to the anæmia. Occasionally, when patients have been much reduced from the long continuance of the diarrhoea, and are in a state of marked cachexia at death, we find certain of these glands caseous.

The condition of the stomach is interesting, since indigestion and vomiting are so commonly present. I have records of its appearance in 59 cases, in 42 of which it seemed normal, having the usual pale color and exhibiting only such changes as occur in the cadaver. In the remaining 17 cases the stomach was more or less hyperæmic, and in 3 of them points of ulceration were observed in the mucous membrane.

All physicians familiar with this disease have remarked the frequency of stomatitis. In protracted and grave cases it is a common complication. The buccal surface in these cases is more vascular than natural, and if the vital powers are much reduced superficial ulcerations are not infrequent, oftener upon the gums than elsewhere. The gums are apt to be spongy, more or less swollen, bleeding readily when rubbed or pressed upon. Thrush is a common complication of the summer complaint in infants under the age of three or four months, but is infrequent in older infants. Occurring in those over the age of six or eight months, it has an unfavorable prognostic significance, indicating a form of summer diarrhoea which commonly eventuates in death.

The belief has long been prevalent in the past that the liver is also in fault. The green color of the stools was supposed to be due to vitiated bile. But usually in the post-mortem examinations which I have made I have found that the green coloration of the fecal matter did not appear at the point where the bile enters the intestines, but at some point below the ductus communis choledochus in the jejunum or ileum. The green tinge, at first slight, becomes more and more distinct on tracing it downward in the intestine. It appears to be due to admixture of the intestinal secretions with the fecal matter.

I have notes of the appearance and state of the liver in 32 fatal cases. Nothing could be seen in these examinations which indicated any anatomical change in this organ that could be attributed to the diarrhoeal malady. The size and weight of the liver varied considerably in infants of the same age, but probably there was no greater difference than usually obtains among glandular organs in a state of health. The following was the weight of this organ in 20 cases: {740}

Age. Weight. | Age. Weight. 4 weeks 5 ounces. | 10 months 6¾ ounces. 2 months 3½ " | 13 " 6 " 2 " 3½ " | 14 " 9 " 4 " 5 " | 15 " 6 " 5 " 6½ " | 15 " 7½ " 5 " 9 " | 15 " 9½ " 7 " 4½ " | 16 " 6 " 7 " 6 " | 19 " 4½ " 7 " 6¼ " | 20 " 9¼ " 9 " 8 " | 23 " 15 "

In none of these cases did the size, weight, or appearance of this organ seem to be different from that in health or in other diseases, except in one in which fatty degeneration had occurred, but this was probably due to tuberculosis, which was also present. In most of these cases the liver was examined microscopically, and the only noteworthy appearance observed was the variable amount of oil-globules in the hepatic cells. In some specimens the oil-globules were in excess, in others deficient, and in others still they were more abundant in one part of the organ than in another. Little importance was attached to these differences in the quantity of oily matter.

Hypostatic congestion of the posterior portions of the lungs, ending if it continue in a form of subacute catarrhal pneumonia and giving rise to an occasional painless cough, has been described in the preceding pages. The character of the cough in connection with the wasting might excite suspicions of the presence of tubercles in the lungs; but tubercles are rare in this disease, and when present I should suspect a strong hereditary predisposition. They occurred in only 1 of the 82 cases.

The state of the encephalon in those patients in whom spurious hydrocephalus occurs is interesting. In protracted cases of the diarrhoea the brain wastes like the body and limbs. In the young infant, in whom the cranial bones are still ununited, the occipital and sometimes the frontal bones become depressed and overlapped by the parietal, the depression being of course proportionate to the diminution in size of the encephalon. The cranium becomes quite uneven. In older children, with the cranial bones consolidated, serous effusion occurs according to the degree of waste, thus preserving the size of the encephalon. The effusion is chiefly external to the brain, lying over the convolutions from the base to the vertex. Its quantity varies from one or two drachms to an ounce or more. Along with this serous effusion, and antedating it, passive congestion of the cerebral veins and sinuses is also present. This congestion is the obvious and necessary result of the feebleness of the heart's action and the loss of brain substance.

DIAGNOSIS.--The occurrence and continuance of diarrhoea in the warm months, without any apparent cause except the agencies which hot weather produces, indicate this disease. The exciting cause of the attack may be the use of some indigestible and irritating substance, dietetic or medicinal, as fruits with their seeds or a purgative medicine; but if it continue after the immediate effects of the agent have passed off, it is proper to attribute the diarrhoea to the summer season.

In the adult abdominal tenderness is an important diagnostic symptom of intestinal catarrh, but in the infant this symptom is lacking or is not in general appreciable, so that it does not aid in diagnosis. When the {741} diagnosis of the disease is established, the symptoms do not usually indicate what part of the intestinal surface is chiefly involved, but it may be assumed that it is the lower part of the ileum and the colon. The presence of mucus or of mucus tinged with blood in the stools shows the predominance of colitis.

PROGNOSIS.--Although this disease every summer largely increases the death-rate of young children, most cases can be cured if the proper hygienic and medicinal measures be early applied. It is obvious, from what has been stated in the foregoing pages, that cholera infantum is the form of this malady which involves greatest danger. Except in such cases there is sufficient forewarning of a fatal result, for if death occur it is after a lingering sickness, with fluctuations and gradual loss of flesh and strength. Patients often recover from a state of great prostration and emaciation, provided that no fatal complications arise. The eyes may be sunken, the skin lie in folds from the wasting, the strength may be so exhausted that any other than the recumbent position is impossible, and yet the patient may recover by removal to the country, by change of weather, or by the use of better diet and remedies. Therefore an absolutely unfavorable prognosis should not be made except in cases that are complicated or that border on collapse. The most dangerous symptoms, except those which indicate commencing or actual collapse, arise from the state of the brain. Rolling the head, squinting, feeble action or permanent contraction of the pupils, spasmodic or irregular movements of the limbs, indicate the near approach of death, as do also coldness of face and extremities and inability to swallow. It is obvious also that in making the prognosis in ordinary cases we should consider the age of the patient, the state of the weather, the time in the summer, whether in the beginning or near its close, and the surroundings, especially in reference to the impurity of the air, as well as the patient's condition.

Cholera Infantum, or Choleriform Diarrhoea.