to commencing spurious hydrocephalus, which is not an infrequent
complication, as we will see, of protracted cases. Perhaps when a late
symptom it may sometimes have an uræmic origin, for the urine is
usually quite scanty in advanced cases. It seems probable, however,
that deleterious effects from non-elimination of urea are to a
considerable extent prevented by the diarrhoea.
The fecal evacuations may remain nearly uniform in appearance during
the disease, but in many patients they vary in color and consistence at
different periods. In the same case they may be brown and offensive at
one time, green at another, and again they may contain masses of a
putty-like appearance, the partly-digested casein or altered epithelial
cells. The stools sometimes consist largely of mucus, with or without
occasional streaks of blood, indicating the predominance of
inflammation in the colon. This is the mucous diarrhoea of Barrier. The
stools are sometimes yellow when passed, but become green on exposure
to the air from chemical reaction due to admixture with the urine.
The character of the alvine discharges is interesting. In addition to
undigested casein I have found epithelial cells, single or in clusters
(sometimes regularly arranged as if detached in mass from the villi),
fibres of meat, crystalline formations, mucus, and occasionally blood,
as stated above. In one instance I observed an appearance resembling
three or four crypts of Lieberkühn united, probably thrown off by
ulceration. If the stools are green, colored masses of various sizes,
but mostly small, are also seen under the microscope.
The pulse is accelerated according to the severity of the attack. The
heat of the surface is at first apt to be increased, though but
slightly in ordinary cases; but when the vital powers begin to fail
from the continuance of the diarrhoea the warmth of the surface
diminishes. In advanced cases approaching a fatal termination the face
and extremities are pallid and cool, and the pulse gradually becomes
more frequent and feeble. The skin is usually dry, and, as already
stated, the urinary secretion diminished. In severe cases attended by
frequent alvine discharges the infant does not pass urine oftener than
once or twice daily. The imperfect action of the skin and kidneys is
noteworthy.
Protracted cases of the summer complaint are apt to be complicated by
two cutaneous eruptions--erythema extending over the perineum and
frequently as far as the thighs and lower part of the abdomen, due to
the acid and irritating character of the stools; and boils upon the
forehead and scalp. The latter sometimes extend to the pericranium, and
in case of recovery leave permanent cicatrices. This furuncular
affection of the scalp has seemed to me useful in consequence of the
external irritation which it causes, since it occurs at a time when, on
account of the feeble heart's action and languid circulation, passive
congestion of the vessels of the brain and meninges is liable to be
present.
Patients who are weak and wasted in consequence of protracted
diarrhoea, remaining almost constantly in the recumbent position, often
have an occasional dry cough which continues till the close of life. It
is due to hypostatic congestion in the lungs, usually limited to the
posterior and {735} inferior portions of the lobes, extending but a
little way into the lungs. It is the result of prolonged recumbency
with feeble heart's action and feeble pulmonary circulation. Infants
reduced by chronic diseases, lying day after day in their cribs with
little movement of their bodies, are very liable to this passive
congestion of depending portions of their lungs, toward which the blood
gravitates, and into which but little air enters in consequence of
their distance and position and the feeble respirations. The hyperæmia
which results is of a passive character, a venous congestion, and the
affected lobules have a dusky-red color. This congestion, continuing,
soon results in pneumonitis of the catarrhal form, subacute and of a
low grade, for pulmonary lobules in which the blood remains stagnant
soon exhibit augmented cell-proliferation, perhaps from the irritating
effects of the elements of the blood now withdrawn from the
circulation.
I have made or procured a considerable number of microscopic
examinations in these cases of hypostatic pneumonia, and the
solidification of the pulmonary lobules has been found to be due to the
exaggerated development of the epithelial cells in the alveoli,
together with venous congestion. The affected lobules, whether in the
stage of hypostatic congestion or the more advanced stage of hypostatic
pneumonitis, when examined at the autopsy, were somewhat softer than in
health, of dark color, and many of the lobules could be inflated by
strong force of the breath; but in protracted cases the alveoli in
central parts of the inflamed area resisted insufflation. The lung in
hypostatic pneumonia, even when it is inflated, still feels firmer
between the fingers than normal lung.
Hypostatic pneumonia is so common in hospitals for infants that some
physicians whose observations have been chiefly in such institutions
have almost ignored other forms of pulmonary inflammation. Billard,
many years ago, wrote: "... The pneumonia of young children is
evidently the result of stagnation of blood in their lungs. Under these
circumstances the blood may be regarded as a kind of foreign body." Of
all the chronic and exhausting diseases of infancy, no one has,
according to my observations, been so frequently complicated by
hypostatic pneumonia as the disease which we are considering, although
it does not usually give rise to any more prominent symptom than an
occasional cough. Limited to a small and almost immovable part of the
lung, it does not ordinarily accelerate respiration or render it
painful, and the cough is also apparently painless.
When progressive loss of flesh and strength has continued several
weeks, and the patient is much exhausted, another complication is apt
to occur, known as spurious hydrocephalus or the hydrocephaloid
disease, the anatomical characters of which will be described in the
proper place. The commencement of spurious hydrocephalus is announced
by gradually increasing drowsiness, perhaps preceded by a period of
unusual fretfulness. Vomiting and rolling the head are occasional early
symptoms of this complication. As the drowsiness increases the pupils
become less sensitive to light than in their normal state, and are
usually contracted. When the drowsiness becomes profound and constant,
the pupils remain contracted as in sound sleep or in opium narcotism.
The functional activity of the organs is now also diminished, the
vomiting ceases, the stools become less frequent, the buccal surface
dry, and the urine more {736} scanty, while the pulse is more frequent
and feeble. Spurious hydrocephalus either continues till death, or by
stimulation the patient may emerge from it. When profound the usual
result is death.
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.