malady causes even under the surveillance of an energetic health board;
and before this board was established it was much greater, as I had
abundant opportunities to observe. The last annual report of the New
York Board of Health was made in 1875, since which time weekly
bulletins have been {727} issued. The deaths from diarrhoea at all ages
in the three last years in which annual reports were issued were as
follows:
1873. 1874. 1875.
January 94 43 46
February 84 34 52
March 97 40 58
April 114 47 45
May 95 61 89
June 220 144 157
July 1514 1205 1387
August 967 1007 1012
September 424 587 608
October 213 255 185
November 87 105 57
December 53 56 50
Thus, in these three years the aggregate deaths from diarrhoea during
the months from June to October inclusive, in which months the summer
diarrhoea prevails, were 9885, while in the remaining seven months the
number was only 1407. How large a proportion of these deaths in the
warm season occurred in children we may infer from remarks made by the
Health Board in regard to another year. In their annual report for 1870
the board state: "The mortality from the diarrhoeal affections amounted
to 2789, or 33 per cent. of the total deaths; and of these deaths 95
per cent. occurred in children less than five years old, 92 per cent.
in children less than two years old, and 67 per cent. in those less
than a year old." Every year the reports of the Health Board furnish
similar statistics, but enough have been given to show how great a
sacrifice of life the summer complaint produces annually in this city.
What we observe in New York in reference to this disease is true also,
to a greater or less extent, in other cities of this country and
Europe, so far as we have reports. Not in every city is there the same
proportionate mortality from this cause as in New York, but the
frequency of the summer diarrhoea and the mortality which attends it
render it an important disease in, I believe, most cities of both
continents. In country towns, whether in villages or farm-houses, this
disease is comparatively unimportant, inasmuch as few cases occur in
them, and the few that do occur are of mild type, and consequently much
less fatal than in the cities.
The comparative immunity of the rural districts has an important
relation, as we will see, to the hygienic management of these cases.
ETIOLOGY.--In the causation of this disease two distinct factors are
recognized--the one atmospheric, the other dietetic.
The prevalence and severity of the summer diarrhoea correspond closely
with the degree of atmospheric heat, as may be inferred from the
foregoing statistics. In New York this disease begins in the month of
May--earlier in some years than in others--in a few scattered cases,
commonly of a mild type. Cases become more and more numerous and severe
as the weather grows warmer until July and August, when the diarrhoea
attains its maximum prevalence and severity. In these two months it is
by far the most frequent and fatal of all the diseases in cities. In
the middle of September new patients begin to be less common, and in
the latter part of this month and subsequently new cases do not occur,
unless under unusual circumstances which favor the development of this
malady. In New York a considerable number of deaths {728} of infants
occur from the diarrhoea in October. October is not a hot month in our
latitude--its average temperature is lower than that of May--and yet
the mortality from this disease is considerably larger in the former
than in the latter month. This fact, which seems to show that the
prevalence of the summer diarrhoea does not correspond with the degree
of atmospheric heat, is readily explained. The mortality in October,
and indeed in the latter part of September, is not that of new cases,
but is mainly of infants, as I have observed every year, who contract
the disease in July or August or earlier, and linger in a state of
emaciation and increasing weakness till they finally succumb, some even
in cool weather.
The fact is therefore undisputed, and is universally admitted, that the
summer season, stated in a general way, is the cause of this
annually-recurring diarrhoeal epidemic, but it is not so easy to
determine what are the exact causative conditions or agents which the
summer weather brings into activity. That atmospheric heat does not in
itself cause the diarrhoea is evident from the fact that in the rural
districts there is the same intensity of heat as in the cities, and yet
the summer complaint does not occur. The cause must be looked for in
that state of the atmosphere engendered by heat where unsanitary
conditions exist, as in large cities. Moreover, observations show that
the noxious effluvia with which the air becomes polluted under such
circumstances constitute or contain the morbific agent. Thus, in one of
the institutions of this city a few years since, on May 10, which
happened to be an unusually warm day for this month, an offensive odor
was noticed in the wards, which was traced to a large manure-heap that
was being upturned in an adjacent garden. On this day four young
children were severely attacked by diarrhoea, and one died. Many other
examples might be cited showing how the foul air of the city during the
hot months, when animal and vegetable decomposition is most active,
causes diarrhoea. Several years since, while serving as sanitary
inspector for the Citizens' Association in one of the city districts,
my attention was particularly called to one of the streets, in which a
house-to-house visitation disclosed the fact that nearly every infant
between two avenues had the diarrhoea, and usually in a severe form,
not a few dying. This street was compactly built with wooden
tenement-houses on each side, and contained a dense population, mainly
foreign, poor, ignorant, and filthy in their habits. It had no sewer,
and the refuse of the kitchens and bed-chambers was thrown into the
street, where it accumulated in heaps. Water trickled down over the
sidewalks from the houses into the gutters or was thrown out as slops,
so that it kept up a constant moisture of the refuse matter which
covered the street, and promoted the decay of the animal and vegetable
substances which it contained. The air in the domicils and street under
such conditions of impurity was necessarily foul in the extreme, and
stifling during the hot days and nights of July and August; and it was
evidently the important factor in producing the numerous and severe
diarrhoeal cases which were in these domicils.
In another locality, occupied by tripe-dealers and a low class of
butchers who carried on fat- and bone-boiling at night, the air was so
foul after dark that the peculiar impurity which tainted it could be
distinctly noticed in the mouth for a considerable time after a night
visit. In the street where {729} these nuisances existed and in
adjacent streets the summer diarrhoea was very prevalent and
destructive to human life. Murchison states that twenty out of
twenty-five boys were affected with purging and vomiting from inhaling
the effluvia from the contents of an old drain near their school-room.
Physicians are familiar with a similar fact showing this purgative
effect of impure air--that the atmosphere of a dissecting-room often
causes diarrhoea in those otherwise healthy.
The exact nature of the deleterious agent or agents in foul air which
cause the diarrhoea, whether they be gases or organisms, has not been
fully determined; but at a recent meeting of the Berliner Med.
Gesellschaft, A. Baginsky made a report on the bacilli of cholera
infantum, which he states he has found both in the dejections and in
the intestinal mucous membrane in the bodies of those who have perished
with this disease. In the stools, along with numerous other organisms,
Baginsky states that he found masses of zoögloea, and the same
organisms he detected on the surface of the small intestines, and could
trace their wanderings as far as the submucous tissue.[1] But it is
evidently very difficult to determine whether such organisms sustain a
causative relation to diarrhoea or spring into existence in consequence
of the foul secretions and decomposing fecal matters which are present.
[Footnote 1: _Allegem. Wien. Mediz. Zeitung_, Nov. 6, 1883.]
The impurities in the air of a large city are very numerous. Among
those of a gaseous nature are sulphurous acid, sulphuric acid,
sulphuretted hydrogen; various gases of the carbon group, as carbonic
acid, carburetted hydrogen, and carbonic oxide; gases of the nitrogen
group, as the acetate, sulphide, and carbonate of ammonium, nitrous and
nitric acids; and at times compounds of phosphorus and chlorine
(Parkes). A theory deserving consideration is that certain gaseous
impurities found in the air form purgative combinations. D. F. Lincoln,
in his interesting paper on the atmosphere in the _Cyclopædia of
Medicine_, writes in regard to sulphuretted hydrogen: "When in the air,
freely exposed to the contact of oxygen, it becomes sulphuric acid.
Sulphide of ammonium in the same circumstances becomes a sulphate,
which, encountering common salt (chloride of sodium), produces sulphate
of sodium and chloride of ammonium. The sulphates form a characteristic
ingredient of the air in manufacturing districts." The sulphates, we
know, are for the most part purgatives, but whether they or other
chemical agents exist in the respired air in sufficient quantity to
disturb the action of the intestines, even where atmospheric impurities
are most abundant, is problematical and uncertain.
Again, the solid impurities in the air of a large city are very
numerous, as any one may observe by viewing a sunbeam in a darkened
room, which is made visible by the numerous particles floating in it.
These particles consist largely of organic matter, which sometimes has
been carried a long distance by the wind. The remarkable statement has
been made that in the air of Berlin organic forms have been found of
African production. Ehrenberg discovered fragments of insects of
various kinds--rhizopods, tardigrades, polygastrica, etc.--which,
existing in considerable quantity and inhaled in hot weather, when
decomposition and fermentation are most active, may be deleterious to
the system. Monads, bacteria, vibriones, amorphous dust containing
spores which {730} retain their vitality for months, are among the
substances found in the air of cities. The well-known hazy appearance
of the atmosphere resting over a large city like New York when viewed
from a distance is due to the gaseous and solid impurities with which
the air is so abundantly supplied--impurities which assume importance
in pathological studies, since minute organisms are now believed to
cause so many diseases the etiology of which has heretofore been
obscure. With our present knowledge we must be content with the general
statement that impure air is one of the two important factors which
cause summer diarrhoea, without being able to state positively which of
the elements in the air are most instrumental in causing this result.
But the theory is plausible that minute organisms rather than chemical
products are the chief cause. Henoch of Berlin, writing upon this
subject, calls attention to the disease known as intestinal mycosis,
its prominent symptom being a severe diarrhoea produced by eating
diseased meat containing a fungus. He believes that "a portion of the
fungus not destroyed by the gastric juice settles upon different parts
of the intestine, and there produces its effects;" and he adds, "At
present, however, we can regard the mykotic theory of cholera infantum
only as a very probable hypothesis. There is no doubt that high
atmospheric temperature increases the tendency to fermentation
dyspepsias which is present in imperfectly-nourished children at all
seasons, and causes them to appear not only epidemically, but also in
an extremely acute form which is not frequent under ordinary
circumstances. This would lead to the conclusion that, in addition to
the heat, infectious germs are present, which, being developed in great
masses by the former, enter the stomach with the food." The fungus
theory of the causative relation of atmospheric heat to the diarrhoea
of the summer season as thus explained by Henoch commands the readier
assent since it comports with the well-known facts relating to the
etiology of the summer complaint. This disease, as we have seen, is
most prevalent and fatal under precisely those conditions of dense
population, filthy domicils and streets, and atmospheric heat which are
favorable for the development of low organisms.
In those portions of our cities which are occupied by the poor, more
than anywhere else, those conditions prevail which render the
atmosphere deleterious. One accustomed to the pure air of the country
would scarcely believe how stifling and poisonous the atmosphere
becomes during the hot summer days and close summer nights in and
around the domicils in the poor quarters of the city. Among the causes
of this foul air may be mentioned too dense a population, the occupancy
of small rooms by large families, rigid economy and ceaseless endeavor
to make ends meet, so that in the absorbing interest sanitary
requirements are sadly neglected. Adults of such families, and children
of both sexes as soon as they are old enough, engage in laborious and
often filthy occupations. Many of them seldom bathe, and they often
wear for days the same undergarments, foul with perspiration and dirt.
The intemperate, vicious, and indolent, who always abound in the
quarters of the city poor, are notoriously filthy in their habits and
add to the insalubrity by their presence. Children old enough to be in
the streets and adults away at their occupations escape to a great
extent the evil effects of impure air, but the infantile population
always suffer severely.
Every physician who has witnessed the summer diarrhoea of infants is
{731} aware of the fact that the mode of feeding has much to do with
its occurrence. A large proportion of those who each summer fall
victims to it would doubtless escape if the feeding were exactly
proper. In New York City facts like the following are of common
occurrence in the practice of all physicians: Infants under the age of
eight months, if bottle-fed, nearly always contract diarrhoea, and
usually of an obstinate character, during the summer months. The
younger the infant, the less able is it to digest any other food than
breast-milk, and the more liable is it therefore to suffer from
diarrhoea if bottle-fed. In the institutions nearly every bottle-fed
infant under the age of four or even six months dies in the hot months
with symptoms of indigestion and intestinal catarrh, while the
wet-nursed of the same ages remain well. Sudden weaning, the sudden
substitution of cow's milk or any artificially-prepared food in place
of breast-milk in hot weather, almost always produces diarrhoea, often
of a severe and fatal nature. Feeding an infant in the hot months with
indigestible and improper food, as fruits with seeds or the ordinary
table-food prepared in such a way that it overtaxes the digestive
function of the infant, causes diarrhoea, and not infrequently that
severe form of it which will be described under the term cholera
infantum. Many obstinate cases of the summer complaint begin to improve
under change of diet, as by the substitution of one kind of milk for
another or the return of the infant to the breast after it has been
temporarily withdrawn from it. It is a common remark in the families of
the city poor that the second summer is the period of greatest danger
to infants. This increased liability of infants to contract diarrhoea
in the second summer is due to the fact that most infants in their
second year are table-fed, while in the first year they are wet-nursed.
Such facts, with which all physicians are familiar, show how important
the diet is as a factor in causing the summer complaint.
Occasionally, from continued ill-health, the milk of the mother or
wet-nurse does not agree with the nursling. Examined with the
microscope, it is found to contain colostrum. Under such circumstances
if a healthy wet-nurse be employed the diarrhoea ceases. It is very
important that any woman furnishing breast-milk to an infant should
lead a quiet and regular life, with regular meals and sleep. In the
_Louisville Med. Journal_, Aug. 19, 1882, R. B. Gilbert relates
striking cases in which venereal excesses on the part of wet-nurses
were immediately followed by fatal diarrhoea in the infants which they
suckled.
One not a resident would scarcely be able to appreciate the difficulty
which is experienced in a large city in obtaining proper diet for young
children, especially those of such an age that they require milk as the
basis of their food. Milk from cows stabled in the city or having a
limited pasturage near the city, and fed upon a mixture of hay with
garden and distillery products, the latter often largely predominating,
is unsuitable. It is deficient in nutritive properties, prone to
fermentation, and from microscopical and chemical examinations which
have been made it appears that it often contains deleterious
ingredients. If milk be obtained from distant farms where pasturage is
fresh and abundant--and in New York City this is the usual source of
the supply--considerable time elapses before it is served to customers,
so that, particularly in the hot months of July and August, it
frequently has begun to undergo {732} lactic-acid fermentation when the
infants receive it. That dispensed to families in the morning is the
milking of the previous morning and evening. The common result of the
use of this milk in midsummer by infants under the age of ten months is
more or less diarrhoea.
The ill-success of feeding with cow's milk has led to the preparation
of various kinds of food which the shops contain, but no dietetic
preparation has yet appeared which agrees so well with the digestive
function of the infant as breast-milk, and is at the same time
sufficiently nutritive.
In New York City improper diet, unaided by the conditions which hot
weather produces, is a common cause of diarrhoea in young infants, for
we meet with this diarrhoea in infants who are bottle-fed at all
seasons; but when the atmospheric conditions of hot weather and the use
of food unsuitable for the age of the infant are both present and
operative, this diarrhoea so increases in frequency and severity that
it is proper to designate it the summer epidemic of the cities. Several
years since, before the New York Foundling Asylum was established, the
foundlings of New York, more than a thousand annually, were taken to
the almshouse on Blackwell's Island and consigned to the care of the
pauper-women, who were mostly old, infirm, and filthy in their habits
and apparel. Their beds, in which the foundlings were also placed
alongside of them, were seldom clean, not properly aired and washed,
and under the beds were various garments and utensils which these
pauper-women had brought with them as their sole property from their
miserable abodes in the city. With such surroundings, the air which
these infants breathed day and night manifestly contained poisonous
emanations; while their diet was equally improper, for it was prepared
by these women from such milk and farinaceous food as were furnished
the almshouse. When assigned to duty in the almshouse, this service
being at that time a branch of Charity Hospital, I was informed that
all the foundlings died before the age of two months; one only was
pointed out as a curiosity which had been an exception to the rule. The
disease of which they perished was diarrhoea, and this malady in the
summer months was especially severe and rapidly fatal. The unpleasant
experiences in this institution furnished additional evidence, were any
wanting, that foul air and improper diet are the two important factors
in causing the summer diarrhoea of infants. Since that beneficial
charity, the New York Foundling Asylum, in East Sixty-eighth street,
came into existence, providing pure air and, for a considerable
proportion of the foundlings, breast-milk, many of these waifs have
been rescued from death.
I have already stated that this disease occurs, with an occasional
exception, under the age of two and a half years. The following table
embraces all the cases that came to one of the city dispensaries during
my service between the months of May and October, inclusive:
Age. Cases.
5 months or under 58
5 months to 12 months 212
12 months to 18 months 174
18 months to 24 months 93
24 months to 36 months 36
---
Total 573
After the third year the liability to the summer complaint so rapidly
{733} diminishes that comparatively few are affected by it. It is seen
from the above statistics that by far the largest number of cases occur
during the period of first dentition; hence the prevalent opinion among
families that dentition causes the diarrhoea. It is the common belief
among the poor of New York that diarrhoea occurring during dentition is
conservative, and should not be checked. They believe that an infant
cutting its teeth suffers less, and may be saved from serious illness,
if it have frequent stools. Every summer I see infants reduced to a
state of imminent danger through the continuance of diarrhoea during
several weeks, nothing having been done to check it in consequence of
this absurd belief. The progressive loss of flesh and strength and
wasting of the features do not excite alarm, under the blinding
influence of this theory, till the diarrhoea has continued so long and
become so severe that it is with difficulty controlled, and the patient
is in a state of real danger when the physician is first summoned. The
following statistics, which comprise cases occurring during my service
in one of the city dispensaries, show the preponderance of cases during
the age when dental evolution is occurring:
Cases.
No teeth and no marked turgescence of gums 47
Cutting incisors 106
" anterior molars 41
" canines 40
" last molars 20
All the teeth cut 28
---
Total 282
It so happens that the period of dental evolution corresponds with that
of the most rapid development and the greatest functional activity of
the gastric and intestinal follicles, and the predisposition which
exists to diarrhoeal maladies at this age must be attributed to this
cause rather than to dentition.
SYMPTOMS.--The summer diarrhoea of infants commonly begins gradually
with languor, fretfulness, and slight febrile movement. The diarrhoea
at first usually attracts little attention from its mildness. The
stools, while they are thinner than natural, vary in appearance, being
yellow, brown, or green. Infants with milk diet are apt to pass green
and acid stools containing particles of undigested casein. The tongue
in the commencement of the attack is moist and covered with a slight
fur. At a more advanced stage it may be moist, but is often dry, and in
dangerous forms of the malady, accompanied by prostration, the buccal
surface is red and the gums more or less swollen and sometimes
ulcerated. Vomiting is common. It may commence simultaneously with the
diarrhoea, especially when food that is unusually indigestible and
irritating to the stomach has been given, but more frequently this
symptom does not appear until the diarrhoea has continued a few days. I
preserved memoranda of the date when vomiting began in the cases
treated in two consecutive summers, and found that ordinarily it was
toward the close of the first week. When it is an early and prominent
symptom it appears to be due to the presence in the stomach of
imperfectly digested or fermented and acid food, which, when ejected,
gives a decidedly acid reaction with appropriate tests. It contains
coagulated casein and undigested particles of whatever food has been
given. In many patients the progressive loss of flesh and {734}
strength is largely due to the indigestion and vomiting by which the
food, which is so much required for proper nourishment, is lost.