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.
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."[2]
[Footnote 2: _Maladies des Enfants_.]
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.