Part 125

This is the most severe form of the summer complaint. It receives the name which designates it from the violence of its symptoms, which closely resemble those of Asiatic cholera. It is, however, quite distinct from that disease. It is characterized by frequent stools, vomiting, great elevation of temperature, and rapid and great emaciation and loss of strength. It commonly occurs under the age of two years. It sometimes begins abruptly, the previous health having been good; in other cases it is preceded by the ordinary form of summer diarrhoea. The stools have been thinner than natural and somewhat more frequent, but not such as to excite alarm, when suddenly they become more frequent and watery, and the parents are surprised and frightened by the rapid sinking and real danger of the infant.

The first evacuations, unless there have been previous diarrhoea, may contain fecal matter, but subsequently they are so thin that they soak into the diaper like urine, and in some cases they scarcely produce more of a stain than does this secretion. Their odor is peculiar--not fecal, but musty and offensive, and occasionally almost odorless. Commencing simultaneously with the watery evacuations or soon after is another {742} symptom, irritability of the stomach, which increases greatly the prostration and danger. Whatever drinks are swallowed by the infant are rejected immediately or after a few moments, or retching may occur without vomiting. The appetite is lost and the thirst is intense. Cold water is taken with avidity, and if the infant nurse it eagerly seizes the breast in order to relieve the thirst. The tongue is moist at first, and clean or covered with a light fur, pulse accelerated, respiration either natural or somewhat increased in frequency, and the surface warm, but the temperature is speedily reduced in severe cases. The internal temperature or that of the blood is always very high. In ordinary cases of cholera infantum the thermometer introduced into the rectum rises to or above 105°, and I have seen it indicate 107°. Although the infant may be restless at first, it does not appear to have any abdominal pain or tenderness. The restlessness is apparently due to thirst or to that unpleasant sensation which the sick feel when the vital powers are rapidly reduced. The urine is scanty in proportion to the gravity of the attack, as it ordinarily is when the stools are frequent and watery.

The emaciation and loss of strength are more rapid than in any other disease which I can recall to mind, unless in Asiatic cholera. In a few hours the parents scarcely recognize in the changed and melancholy aspect of the infant any resemblance to the features which it exhibited a day or two before. The eyes are sunken, the eyelids and lips are permanently open from the feeble contractile power of the muscles which close them, while the loss of the fluids from the tissues and the emaciation are such that the bony angles become more prominent and the skin in places lies in folds.

As the disease approaches a fatal termination, which often occurs in two or three days, the infant remains quiet, not disturbed even by the flies which alight upon its face. The limbs and face become cool, the eyes bleared, pupils contracted, and the urine scanty or suppressed. In some instances, when the patient is near death, the respiration becomes accelerated, either from the effect of the disease upon the respiratory centres or from pulmonary congestion resulting from the feeble circulation. As the vital powers fail the pulse becomes progressively more feeble, the surface has a clammy coldness, the contracted pupils no longer respond to light, and the stupor deepens, from which it is impossible to arouse the infant.

In the most favorable cases cholera infantum is checked before the occurrence of these grave symptoms, and often in cases which are ultimately fatal there is not such a speedy termination of the malady as is indicated in the above description. The choleriform diarrhoea abates and the case becomes one of ordinary summer complaint.

ANATOMICAL CHARACTERS.--Rilliet and Barthez, who of foreign writers treat of cholera infantum at greatest length, describe it under the name of gastro-intestinal choleriform catarrh. "The perusal," they remark, "of anatomico-pathological descriptions, and especially the study of the facts, show that the gastro-intestinal tube in subjects who succumb to this disease may be in four different states: (a) either the stomach is softened without any lesion of the digestive tube; (b) or the stomach is softened at the same time that the mucous membrane of the intestine, and especially its follicular apparatus, is diseased; (c) or the stomach is healthy, {743} while the follicular apparatus or the mucous membrane is diseased; (d) or, finally, the gastro-intestinal tube is not the seat of any lesion appreciable to our senses in the present state of our knowledge, or it presents lesions so insignificant that they are not sufficient to explain the gravity of the symptoms.

"So far, the disease resembles all the catarrhs, but what is special is the abundance of serous secretion and the disturbance of the great sympathetic nerve.

"The serous secretion, which appears to be produced by a perspiration (analogous to that of the respiratory passages and of the skin) rather than by a follicular secretion, shows, perhaps, that the elimination of substances is effected by other organs than the follicles; perhaps, also, we ought to see a proof that the materials to eliminate are not the same as in simple catarrh. Upon all these points we are constrained to remain in doubt. We content ourselves with pointing out the fact."

On the 1st of August, 1861, I made the autopsy of an infant sixteen months old who died of cholera infantum with a sickness of less than one day. The examination was made thirty hours after death. Nothing unusual was observed in the brain, unless perhaps a little more than the ordinary injection of vessels at the vertex. No marked anatomical change was observed in the stomach and intestines, except enlargement of the patches of Peyer as well as of the solitary and mesenteric glands. Mucous membrane pale. In this and the following cases there was apparently slight softening of the intestinal mucous membrane, but whether it was pathological or cadaveric was uncertain, as the weather was very warm. The liver seemed healthy. Examined by the microscope, it was found to contain about the normal number of oil-globules.

The second case was that of an infant seven months old, wet-nursed, who died July 26, 1862, after a sickness also of about one day. He was previously emaciated, but without any marked ailment. The post-mortem examination was made on the 28th. The brain was somewhat softer than natural, but otherwise healthy. There was no abnormal vascularity of the membranes of the brain, and no serous effusion within the cranium. The mucous membrane of the intestines had nearly the normal color throughout, but it seemed somewhat thickened and softened; the solitary glands of the colon were prominent. The patches of Peyer were not distinct.

In the New York Protestant Episcopal Orphan Asylum an infant twenty months old, previously healthy, was seized with cholera infantum on the 25th of June, 1864. The alvine evacuations, as is usual with this disease, were frequent and watery, and attended by obstinate vomiting. Death occurred in slight spasms in thirty-six hours. The exciting cause was probably the use of a few currants which were eaten in a cake the day before, some of which fruit was contained in the first evacuations. The brain was not examined. The only pathological changes which were observed in the stomach and intestines were slightly vascular patches in the small intestines and an unusual prominence of the solitary glands in the colon. The glands resembled small beads imbedded in the mucous membrane. The lungs in the above cases were healthy, excepting hypostatic congestion.

{744} Since the date of these autopsies I have made others in cases which terminated fatally after a brief duration, and have uniformly found similar lesions--namely, the gastro-intestinal surface either without vascularity or scantily vascular in streaks or patches, sometimes presenting a whitish or soggy appearance and somewhat softened, while the solitary glands were enlarged so as to be prominent upon the surface. In cases which continue longer evident inflammatory lesions soon appear which are identical with those which have already been described in our remarks on the ordinary form of the summer diarrhoea.

During my term of service in the New York Foundling Asylum in the summer of 1884, an infant died after a brief illness with all the symptoms of cholera infantum, and the intestines were sent to William H. Welch, now of Johns Hopkins Hospital, for microscopic examination. His report was as follows: "I found undoubted evidence of acute inflammation. There was an increased number of small, round cells (leucocytes) in the mucous and submucous coats. This accumulation of new cells was most abundant in and around the solitary follicles, which were greatly swollen. Clumps of lymphoid cells were found extending even a little into the muscular coat. The epithelial lining of the intestine was not demonstrable, but this is usually the case with post-mortem specimens of human intestine, and justifies no inferences as to pathological changes. The glands of Lieberkühn were rich in the so-called goblet-cells, and some of the glands were distended with mucus and desquamated epithelium, so as to present sometimes the appearance of little cysts. This was observed especially in the neighborhood of the solitary follicles. The blood-vessels, especially the veins of the submucous coat, were abnormally distended with blood. I searched for micro-organisms, and found them in abundance upon the free surface of the intestine in the mucous accumulations there, and also in the mouths of the glands of Lieberkühn. Both rod-shaped and small round bacteria were found. I attach no especial importance to finding bacteria upon the surface of the intestine. The general result of the examination is to confirm the view that cholera infantum is characterized by an acute intestinal inflammation."

NATURE.--Cholera infantum appears from its symptoms and lesions to be the most severe form of intestinal catarrh to which infants are liable. The alvine discharges, to which the rapid prostration is largely due, probably consist in part of intestinal secretions and in part of serum which has transuded from the capillaries of the intestines. That the intestinal mucous membrane sometimes presents a pale appearance at the autopsy of an infant who, previously well, has died of cholera infantum after a sickness of twenty-four or forty-eight hours, is perhaps due to the great amount of liquid secretion and transudation in which the inflamed surface is bathed. Moreover, it is, I believe, a recognized fact that the hyperæmia of an acutely-inflamed surface when of short duration frequently disappears in the cadaver, as that of scarlet fever and erysipelas. The early hyperplasia of the solitary and mesenteric glands, and the hyperæmia and thickening of the surface of the ileum and colon in those who have survived a few days, indicate the inflammatory character of the malady.

The opinion has been expressed by certain observers that cholera {745} infantum is identical with thermic fever or sunstroke. There is indeed a resemblance to thermic fever as regards certain important symptoms. In cholera infantum the temperature is from 105° to 108°; in sunstroke it is also very high, often running above 108°. Great heat of head, contracted pupils, thin fecal evacuations, embarrassed respiration, scanty urine, and cerebral symptoms are common toward the close of cholera infantum, and they are the prominent symptoms in sunstroke. Nevertheless, I cannot accept the theory which regards these maladies as identical, and which removes cholera infantum from the list of intestinal diseases. In cholera infantum the gastro-intestinal symptoms always take the precedence, and are, except in advanced cases, always more prominent than other symptoms. It does not commence as by a stroke like coup de soleil, but it comes on more gradually, though rapidly, and it often supervenes upon a diarrhoea or some error of diet. In the commencement of cholera infantum the infant is not apt to be drowsy, and it is often wide awake and restless from the thirst. Contrast this with the alarming stupor of sunstroke. Sunstroke only occurs during the hours of excessive heat, but cholera infantum may occur at any hour or in any day during the hot weather, provided that there be sufficient dietetic cause. Again, intestinal inflammation is not common in sunstroke, while it is the common or, as I believe, the essential lesion of cholera infantum. These facts show, in my opinion, that the two maladies are essentially and entirely distinct. Nevertheless, cases of apparent sunstroke sometimes occur in the infant, and if the bowels are at the same time relaxed the disease is apt to be regarded as cholera infantum, and if fatal is usually reported as such to the health authorities. Cases of this kind I have occasionally observed or they have been reported to me, although they are not common.

With the exception of the organs of digestion no uniform lesions are observed in any of the viscera in cholera infantum, except such as are due to change in the quantity and fluidity of the blood and its circulation. Writers describe an anæmic appearance of the thoracic and abdominal viscera, and occasionally passive congestion of the cerebral vessels. The cerebral symptoms often present toward the close of life in unfavorable cases of cholera infantum are often due to spurious hydrocephalus, which we have described above; but as the urinary secretion is scanty or suppressed, cerebral symptoms may in certain cases be due to uræmia.

DIAGNOSIS.--This form of the summer diarrhoea is diagnosticated by the symptoms, and especially by the frequency and character of the stools. The stools have already been described as frequent, often passed with considerable force, deficient in fecal matter, and thin, so as to soak into the diaper almost like urine. The vomiting, thirst, rapid sinking, and emaciation serve to distinguish cholera infantum from other diarrhoeal maladies.

When Asiatic cholera is prevalent the differential diagnosis between the two is difficult if not impossible.

PROGNOSIS.--Cholera infantum is one of those diseases in regard to which physicians often injure their reputation by not giving sufficient notice of the danger, or even by expressing a favorable opinion when the case soon after ends fatally. A favorable prognosis should seldom be expressed without qualification. If the urgent symptoms be relieved, {746} still the disease may continue as an ordinary intestinal inflammation, which in hot weather is formidable and often fatal. If the stools become more consistent and less frequent without the occurrence of cerebral symptoms, while the limbs are warm and the pulse good, we may confidently express the opinion that there is no present danger.

The duration of true cholera infantum is short. It either ends fatally, or it begins soon to abate and ceases, or it continues, and is not to be distinguished in its subsequent course from an attack of summer diarrhoea beginning in the ordinary manner.

TREATMENT.--Preventive Measures.--Obviously, efficient preventive measures consist in the removal of infants so far as practicable from the operation of the causes which produce the disease. Weaning just before or in the hot weather should, if possible, be avoided, and removal to the country should be recommended, especially for those who are deprived of the breast-milk during the age when such nutriment is required. If for any reason it is necessary to employ artificial feeding for infants under the age of ten months, that food should obviously be used which most closely resembles human milk in digestibility and in nutritive properties. Care should be taken to prevent fermentation in the food before its use, since much harm is done by the employment of milk or other food in which fermentative changes have occurred and which occur quickly in dietetic mixtures in the hot months.

It is also very important that the infant receive its food in proper quantity and at proper intervals, for if the mother or nurse in her anxiety to have it thrive feed it too often or in too large quantity, the surplus food which it cannot digest if not vomited undergoes fermentation, and consequently becomes irritating to the gastro-intestinal surface. The physician should be able to give advice not only in reference to the frequency of feeding, but also in regard to the quantity of food which the infant requires at each feeding. Correct knowledge and advice in this matter aid in the prevention and cure of the dyspeptic and diarrhoeal maladies of infancy.

Chadbourne of this city and myself made some observations in order to ascertain how much food well-nourished infants receive daily. We selected infants that had an abundance of breast-milk, and weighed them before and after each nursing, so as to determine how much each infant took during twenty-four hours. The avoirdupois ounce contains 437.5 grains, and we ascertained by careful weight and measurement, employing the metric system for its greater accuracy, that one fluidounce of human milk, with a specific gravity of 1.031, weighed 451.9 grains. With these data it was easy to determine the quantity of milk in fluidounces from its weight. Our first observations related to 12 infants under the age of five weeks, 8 of which nursed twelve times, and the remaining 4 eight, nine, nine, and eleven times respectively, in the twenty-four hours. The quantity of milk received by them in twenty-four hours varied considerably in the different cases, but the average was 12.41 fluidounces. Therefore if a baby in the first five weeks nurse every two hours, it receives only a little more than one fluidounce at each nursing.

The next observations were made upon 15 infants between the ages of five weeks and ten months: 8 of the 15 were under the age of six {747} months, and the remaining 7 were between the ages of six months and ten months. The weighing showed that the younger took nearly the same quantity per day, on the average, as the older infants in this group. The average quantity received by each was twenty-four and six-tenths fluidounces. Hence if the nursings were eight in the twenty-four hours, three ounces were taken at each nursing; if the nursings were twelve, the quantity each time was two ounces.

Biedert of Germany has also made similar observations in order to determine the amount of nutriment required by infants. The results of his weight-studies, as he designates them, were published in the Jahrbuch für Kinderheilkunde, xix. B., 3 H. His weighing showed that infants during their first month, if fed on cow's milk, required from 160 to 200 grammes of milk daily, and in the third month 300 grammes. These quantities in fluid measure are 5.44 to 6.83 ounces, the quantity required each day in the first month, and 10.22 ounces, the quantity required daily the second month. Therefore, both my weights and Biedert's show that infants under the age of two months assimilate a smaller quantity of milk than is usually supposed. For infants older than two months he estimates the quantity of milk required by infants by their weight. He believes that the greater the weight the greater is the amount of food which the infant needs. The method pursued by Chadbourne and myself is more simple, and it seems to indicate with sufficient exactness the amount of food required.

Some infants, like adults, need more food than others, so that there can be no exact schedule of the quantity which they require at each feeding; but while in the first and second months they do not need more than from one to one and a half fluidounces at each feeding, whether of breast-milk, or of cow's milk prepared so as to resemble as closely as possible human milk, infants as they grow older and their stomachs enlarge can take food in larger quantity, and therefore require less frequent feeding. Under the age of two months the stomach is so small that it cannot receive much more than one or one and a half fluidounces without undue distension. At the age of six months it can probably receive and digest without discomfort three ounces, and in the last half of the first year even four ounces. Infants nourished at the breast should be allowed to nurse every two hours in the daytime, whatever the age, after the second month, but less frequently at night, for frequent nursing promotes the secretion of milk, and the milk is of better quality than when it is long retained in the breast. If by the fifth or sixth month mothers or wet-nurses find, as is frequently the case, that they do not have sufficient milk, other food should be given in addition, perhaps after each second nursing or every fourth hour. The kind of food which it is best to employ to supplement the nursing will be mentioned under the head of curative measures. By knowledge on the part of the mother and nurse of the dietetic needs of the infant, and by consequent judicious alimentation, and by measures also to procure the utmost purity of the air, there can be no doubt that the summer diarrhoea may to a great extent be prevented.

Curative Treatment.--The indications for treatment are--1st, to provide the best possible food; 2d, to procure pure air; 3d, to aid the digestive function of the infant; 4th, to employ such medicinal agents as can be safely given to check the diarrhoea and cure the intestinal catarrh.

{748} The infant with this disease is thirsty, and is therefore apt to take more nutriment in the liquid form than it requires for its sustenance. If nursing, it craves the breast, or if weaned, craves the bottle, at short intervals to relieve the thirst. No more nutriment should be allowed than is required for nutrition, for the reason stated above, and the thirst may best be relieved by a little cold water, gum-water, or barley-water, to which a few drops of brandy or whiskey are added.