Infantile Interitis -Cholera Infantum-Summer Complaint of Children.

BY F. W. HUNT, M.D., NEW YORK.

The extensive prevalence at the present time of the disease usually known under some one of the above names, its great mortality, and annual recurrence in all the large cities of our country during the Summer months, will justify an effort to present a condensed eclectic review of our present knowledge of its pathology; with such suggestions in regard to its treatment as our space and personal observations may permit.

GENERAL REMARKS.-The seat of the disease is the Gastrointestinal Mucous membrane. The Epithelium which lines the whole alimentary canal with all its appendices, even to the minutest ramifications of their tubes, also covers the skin; forms the surface of all the serous and synovial cavities, and lines the heart, blood-vessels, lymphatic glands, and all other secreting surfaces. On the external surface of the body, it consists of numerous layers of minute scales or laminae, which are easily separated by rubbing the skin with a flesh brush. These scales are formed by the drying of the vesicles or cells of which the epidermis primarily consists. The structure of the epithelium which lines the mucous membrane of the Intestinal Canal is essentially the same. It consists of spheroid cells of very small size, each containing within it a roundish oval nucleus, which is a hollow sphere, and sometimes encloses a nucleolus more minute. They are situated on a primary membrane, from which they appear to grow; are bound together by a delicate tissue, and are believed to perform important services in the function of secretion. The epithelial cells are constantly undergoing the process of further development. Those composing the outer layer burst and discharge their contents, and the next layer of cells is pressed forward to supply the place of the former. “New cells,” says Sharpey, “are developed from germs contained in the ”basement membrane“ and formed and nourished from the blood which transudes from the blood-vessels beneath. No vessels enter the tissue of the epithelium, but the nutrient fluid penetrates a certain way into the growing mass, and the cells continue to assimilate this fluid, and pass through their changes at a distance from, and independently of the blood vessels.” Even in the finest vascular network of mucous membrane, as well as in the muscular structure, the nutrient fluid, on exuding from the vessels, has to penetrate the adjoining mass by transudation, in order to reach and yield new substance at every point where secretion or renovation is going on.

As the mucous membrane of the alimentary canal performs the important function of absorption, and its covering of epithelial cells are at the same time the agents by which the secretion of mucous is effected, its structure must be highly complicated. The extent of its surface is prodigiously increased by means of numerous folds and projections, as well as by the pits or follicular depressions dispersed along its whole extent. And it is believed that the function of absorption is performed by the epithelial cells of the villi which cover the folds and projections on this surface: while that of secretion is performed by those cells which line the follicular pits and depressions dispersed along its whole extent. The villi, like the spongioles of the roots of plants, are endowed with the peculiar property of selecting the nutritive fluid and conveying it to the lacteals. These absorbents do not reach into the extremity of the villi; and they do not open on the surface of the mucous membrane by any appreciable apertures; but the end of each villus is composed of a loose spongy tissue, in which a number of cells may be seen in various stages of development, during the process of absorbing the chyle.

In health this delicate surface of the mucous membrane is either of a grayish white or yellow color, from the coloring principle of the bile, or of a darkish livid hue, from the imbibition of blood. It adheres closely to the subjacent tissue, and can only be detached with difficulty. The solitary glands of the small intestines and colon, as well as the villous layer and the glands of Lieberkuhn, are invisible to the naked eye. The patches of Peyer's glands may be distinguished at the earliest period of life by their greater opacity when the membrane is held up to the light When distinctly seen they are always in some degree diseased. The largest patches are situated near the ilio-colic valve; the smallest are in the jejunum. They vary in number from 18 to 36 patches, and are referred by pathologists to atrophy of the mucous membrane.

DIAGNOSIS.-First stage. Diarrhea, succeeded about the second day, sometimes later, by vomiting and remittent fever, with evening exacerbations. Pulse varying with the fever, small and quick or full and tense; slight delirium, when the brain is sympathetically affected; there is then a fierce wild expression of the countenance which at other times is bright and animated; the stools are thin, watery, pasty, or mushy, and variable in color, sometimes resembling mucus in color, or like eggs chopped and scalded with water. The vomiting occurs three or four times a day, the matters thrown up consist of the food but little changed, or only mixed with mucus. The milk of the nurse is thrown up in an acid, coagulated state. The skin is generally dry, warmest on the head and abdomen, while the lower extremities are cooler: respiration little affected: tongue moist, red at the tip and edges, with a yellow or brownish coating toward its base; sleep generally quiet except when the fever is highest; the child is then irritable and restless. As the disease progresses the abdomen grows tense, tumid, painful on pressure; and the thirst becomes more intense.

In general, the true Follicular Gastro-Enteritis is characterized by frequent discharges from the bowels: the bowels are primarily affected. The cerebral symptoms occur only in the latter stages of the disease; there is then drowsiness or stupor. The rattling of wind in the stomach and the lenticular spots seen in Typhoid fever are absent, and there is agitation, and delirium at night.

Tubercular Meningitis is characterized by: bowels usually torpid; the brain is the primary seat of the disease, and it commonly occurs in delicate scrofulous children. The pain in the head is intermittent, and is manifested by a peculiar cry, disturbed sleep, tossing about of the hands, rolling of the head from side to side, moaning, grinding the teeth, delirium, and a peculiar expression of countenance; the drowsiness and stupor often accompanied by convulsions.

CAUSES.-The heated, confined, and impure air of the city in Summer acts directly on the skin, and indirectly on the mucous membrane. At the period of dentition several collateral influences operate to predispose to disease of the gastrointestinal mucous membrane. The irritation of the teeth during the process of dentition, produces inflammation and even ulceration m the lining membrane of the mouth; and, since the same membrane extends throughout the whole intestinal canal, the irritation is usually propogated along this delicate surface, producing indigestion, vomiting or diarrhea; and at the same time there is also increased development, and activity of the muciparous follicles. If this period of infantile life could be passed in a pure atmosphere of a moderate temperature, the disturbance of the health caused by dentition might not be very great; but it is always sufficiently so to strongly predispose to disease, and to aid other agencies in exciting or perpetuating diseases of the most serious character; and often such maladies are excited by dentition alone. The other causes which originate the fatal “Summer complaint” of cities and towns are: improper food, whether too stimulating or indigestible; irritating drugs; vicissitudes of temperature; insufficient clothing in the summer when hot days are succeeded by cool nights; intestinal worms, and all other irritating substances originating in, or received into, the digestive organs. But, in addition to all these causes which operate in the country as well as in the metropolis, there is certainly a zymotic or other poisonous miasm in the air of all large cities, which conspires with bad diet, bad clothing and inefficient medical treatment to originate this disease as well as render it more unmanageable when excited by other causes. A large proportion of the cases in large cities occur in ill ventilated houses, situated in courts and alleys in which bad air stagnates, and fifth accumulates, where light is deficient, and where heat during the Summer months is intense.

PATHOLOGY.-Effects of Congestion. 1. In the mucous membrane. The membrane presents a rose-red or cherry-red color, diffused in isolated patches, or in arborizing trunks. It is diminished in consistency but still adheres firmly.

2. The glands of Peyer, which occupy the free border of the intestine, are rendered more red and prominent. These glands are only mucous follicles which are not perceptible until about the fourth month, or about the time when nature by pushing forward the teeth is preparing the digestive organs to digest and assimilate a higher order of food, they are found distributed over every part of the intestinal surface, and each receives an artery, a vein and a nerve. These follicles perform an active part in the process of digestion by furnishing the surface of these organs with a fluid which assists in the elaboration of the food. In carnivorous animals, as dogs and lions, they are largely developed. From them is usually discharged the excess of mucous fluids thrown off by diarrhea at the time of teething. In severer cases of Cholera infantum and Follicular enteritis they are inflamed, and in protracted cases are destroyed by ulceration.

3. Inflammation of the Peyerian glands,-When this disease has contained in the chronic form the patches show a grey-blue or slate-grey color, contrasting with the mucous membrane which is quite pale. The tissue appears atrophied or elevated according to the stage at which death took place. As inflammation of the Peyerian glands constitutes the essential pathological basis of Follicular enteritis, or Summer complaint; so, a continuation of the same diseased action in the same glands becomes the anatomical base of Marasmus or Atrophy. These inflammatory affections are extremely common; whereas enlargement of the mesenteric glands, aphthous formations, gastromalacia, &c, are comparatively rare.

4. Softening of the Intestinal Mucous Membrane.-This pathological change of structure occurs more frequently in the small intestine than in the colon. The adhesion of the mucous membrane to the tissue below it is lessened; it becomes edematous, homogeneous, pulpy, and easily lacerated. When this state continues long, the red color it presents in earlier stages disappears, as the inflammation subsides. The softened membrane becomes white in the same manner as the softened brain does in ramolissement, and from the same cause.

It is thus seen that acute inflammation of the Peyerian glands is the most frequent and dangerous of the diseases of children during the first year of life. That it is a real inflammation is proved by the fact that tubercular disease is seldom complicated with it, though inflammatory affections of the lungs, and purulent effusion in the brain are quite common and frequently cause the fatal termination.

In children of a tubercular diathesis, secondary acute inflammation of Peyer's glands, as well as of the solitary glands, often occurs; but it is observed that abdominal tubercules and typhoid fever belong almost exclusively to the second and later years of life; whilst Follicular enteritis is peculiarly severe and fatal in the first year, which is to every child, particularly in the city, the most perilous of earthly existence.

PROGNOSIS.-Favorable: When the pulse becomes slower, the skin warmer; when the vomiting ceases, the alvine discharges become less frequent and more natural; a gentle perspiration appears over the whole surface.

Unfavorable: The pulse continues quick, feeble and more irregular; the skin is cold, the discharges continue, increasing in frequency, and resemble the washings of meat; the uneasiness and restlessness increase; the limbs are tossed about in restless agony or become rigid and partially paralyzed. Cerebral symptoms, stupor and delirium increasing.

TREATMENT.-Prophylactic. When the season in which the disease is expected arrives, examine the condition of every child which presents any marks of indisposition and let them be removed to the country, or at least to the most healthy location attainable. From the commencement to the termination of the process of Dentition, the teeth should receive special attention. The complicated apparatus by which the teeth are to be formed consists of a vascular and nervous pulp, covered by a very delicate membrane; and these again are invested by a fibrous membrane of very firm texture composed of two distinct layers. The body part of the tooth is secreted by the fine membrane of the pulp; and, as the ossification advances from within outwards, the cavity occupied by the pulp is contracted, until reduced to the dimensions of the hollow of the perfect tooth. As soon as the ossification is completed, the inner surface of the fibrous coat takes on the office of secretion and furnishes the tooth with its covering of enamel; and as soon as this is done the fibrous membrane is no longer of any use, and must be removed to make way for the tooth before it can advance above the gum. Its removal is effected by the action of the absorbent vessels; and the increased now of saliva, and the increased flow of mucus from the bowels carry off the effects of increased excitement Such is the process of dentition in a state of health. Growth and absorption are going on at the same time; and the absorption should progress just fast enough to remove the investing membrane out of the way of the advancing tooth. In a state of disease this dose not occur, and the growth of the tooth may be irregular or imperfect. Pressing against the investing membrane it excites irritation and then inflammation. The gums become red, tumid, painful, and even ulcerated. From this focus of irritation a similar state of excitement extends down the alimentary canal to the stomach and bowels, exciting obstinate vomiting or exhausting diarrhea. If this state of things is removed in any way, it is most likely to be effected by removing the chief source of irritation. If this be not done, it frequently progresses to either a fatal inflammation of the intestinal follicles, or to a more sudden termination in convulsions or inflammation of the brain.

In every case of disease of the stomach and bowels, of the brain, or general fever occurring between the beginning and termination of the period of dentition, the gums should be carefully examined; and in every case where the gum is inflamed it should be so lanced as to give little or no pain; but still take off the tension of the membrane and permit a drop of blood to flow from each tooth suspected of causing or keeping up excitement. The objections still made even by physicians, to this simple and important operation no longer deserve a serious answer.

In the first stage of Summer Follicular enteritis, when the disease consists chiefly of an abnormal development of the mucous follicles of the digestive organs, the fever and irritation can always be removed by change of air, proper temperature and clothing, restricted diet, and the mildest treatment. The child should occupy a large and well ventilated room; it should lie on a mattrass rather than on a feather bed; and cleanliness and comfort should be secured by proper washings, bathings, &c. When there is much fever and restlessness, a warm bath always procures better rest, and diminishes the internal local disease. It should be repeated at intervals regulated by the violence of the fever, and continued each time just long enough to show evident relaxation. If the external heat should be increased by the bath it will always be found to have reduced the local inflammation, and this is always a real gain, and advance towards recovery.

The diet should be regulated with great care. Nothing is so good as the mother's milk when it is perfect; and when her health is good it should be almost exclusively relied on, giving all reasonable care in her choice of food, and attention to health in all other respects. But there are cases in which the mother's milk acts as a poison, even when her health is considered good. In these cases it acts as a drastic purgative passing off speedily from the bowels in a curdled state, undigested, but giving severe griping pain. Upon making an entire change, for even one half day, and substituting other food, a sufficient respite is allowed to enable the child to bear the milk again. But in many cases other food must be substituted for that originally designed for children; and we seek for it among the purest, most nutritious and most easily digested articles. Of these, the best is the milk of the cow properly diluted, boiled, or at least slightly sweetened and reduced to the blood temperature. When cows are kept in stalls the milk is unfit for any use whatever; the cows themselves become tuberculous, the milk loses most of its sugar, and the butter and casein diminish. After the first teeth come through, the child may be allowed a greater variety of milk and nutritious substances. Whatever is used should be often made fresh, and never kept long enough to undergo any change. Mucilaginous drinks, rice, barley, farina, pure starch, toast water, sago, tapioca, and a great variety of articles well known to cooks and nurses, are in common use.

Medical treatment. -Follicular Enteritis is in its first stage an incipient inflammation. As soon as all exciting causes of irritation are removed, Aconite will be found a specific for the congestive stage of the irritation and fever. It is indispensable when there is great heat of the skin, thirst, sleeplessness, or agitated sleep; fretfulness, with inflammation of the intestinal follicles imperfectly established. Alternated with Belladonna when the head is the chief seat of suffering, or with Mercurius sol. when the dysenteric symptoms are serious. I have never failed in arresting this disease when it appeared in the form already described.

SECOND STAGE.-The disease when not successfully treated advances to its second stage, in which it still exhibits the same general features, though in an aggravated degree. The vomiting becomes less frequent but the alvine discharges are more painful, accompanied by nausea and great prostration; and the limbs are drawn up towards the abdomen. The matters evacuated become more watery, stained with blood, or more generally of a dark green color. The abdomen now becomes tumid or painful on pressure; its temperature increases while the extremities are cool. As the disease progresses the pulse increases in frequency from 130 to 150 per minute, and often intermittent, irregular or entirely imperceptible. Emaciation progresses till the skin hangs about the neck in folds; the eyes are sunken in the orbits, with a dark areola around each: the nose becomes sharp, the lips shrivelled; the feet edematous; the skin loses its sensibility; and the flies are permitted to collect on the face; petechiae come out on the skin; the tongue is dry, incrusted, and covered with aphthae; deglutions is painful; the mouth dry, and the child thrusts its fingers far back toward the throat. The appetite is capricious; thirst constant; an eruption of the minute vesicles often come out on the chest. As death approaches, the brain becomes more strongly engorged with blood; the eyes are suffused, the lids tumid, conjunctiva injected; the pupils are unequally dilated, though they contract on exposure to light; the hand is frequently raised to the head; twitchings of the muscles, and throwing back of the head, portend convulsions which often terminate in death.

The Pathology of this extreme form of the disease presents inflammation and softening of the mucous membrane; ulceration of the follicles, particularly of the large intestine; the inner surface of the stomach is less changed, though it is sometimes injected and softened; the change of structure extending to all the coats. More frequently there is found a layer of whitish opaque mucous covering the lining membrane of the stomach; the mucous follicles of the stomach and intestines are visible, the mucous membrane of the latter being softened and pale. The duodenum is often inflamed, presenting a shade of pink, with injection of the minute vessels. The large intestine is generally inflamed and softened, sometimes in bands extending longitudinally for several inches, injected with fine arteries, and of a deeper red than the surrounding membrane. In some cases the whole lining membrane of the colon is thickened and of a vivid red. The follicles of the colon, having been the points first inflamed, proceed to ulceration as the inflammation extends to the surface around them. The rectum presents the deepest ulcerations; its lining membrane being thickened, inflamed, or covered with a thick layer of mucous.

The brain or its membranes in all cases, attended by the above symptoms, presents after death marks of active disease. The Pia Matter is more or less distended or injected, the arachnoid is pale and moist, with effusion into the sub-arachnoid cellular tissue. When the brain itself has not been the seat of active inflammation it is usually injected, showing that congestion had existed at the time of death.

The treatment of Follicular Enteritis in its severest form and in its advanced stage demands the highest degree of professional skill. Our first object is to so read the external phenomena presented, as to detect the true source of the existing irritation, and, so far as is possible, remove it immediately. There is probably no disease that more severely tests the tact and discriminating powers of the physician than this: since it presents not a single symptom that might not have originated in any one of several causes. He will begin by reviewing the causes of disease that may be still in operation in the individual case before him and provide for their removal. The remedies capable of having caused the then existing pathological condition will then be carefully compared; and the remedies selected would perhaps always be successful if actual disorganization of vital organs had not already progressed too far.

The remedies that are generally successful in arresting this fatal form of “Summer Complaint” are:-

1. ACONITE-In all the earlier stages it is indispensable. It is specific for the hot and dry skin, flushed face, tormina and tenesmus; pain in the head and back, flushes of heat alternating with chills, burning pain in the abdomen; eyes, glistening and painful, suffused and red; urine high colored; alvine discharges watery, frequent, attended with nausea and exhaustion, manifested by paleness and perspiration followed by reaction and fever; mourning and weeping.

2. BELLADONNA in alternation with Aconite greatly increases its power in all febrile affections in which cerebral symptoms are prominent.

3. MERCURIUS SOLUBILIS. This, with other preparations of Mercury, is peculiarly applicable in cases in which the symptoms most resemble dysentery; in children that exhibit scrofulous tendencies; who are often affected with glandular swellings or cutaneous eruptions. They are pale, sickly, precocious in intellect, suffer much from slow and imperfect dentiton, during which the superficial glands about the neck are enlarged. When the intestines become slightly irritated, the restating inflammation assumes a dysenteric form. Constipation is complete; and, instead of solid or fluid feces, the evacuations consist of bloody mucous passed with pain, tenesmus and nausea. In other cases of Cholera Infantum in which the stools are watery and of a dark green color, frothy or composed of undigested chopped matter, mixed sometimes with dead lumbrici, Mercurius has given immediate relief. When the chronic stage, usually called Marasmus commences; when emaciation is progressing, and aphthous crusts begin to form on the lining membrane of the mouth, Mercurius sol. is generally effective in destroying the parasites of which the crusts consist.

4. IPECACUANHA.-Serous diarrhea, with vomiting of green or white mucus, with much griping pain; nausea, eructations, flatulent colic, faintness from excessive efforts to vomit; pain in the head relieved by vomiting.

5. BRYONIA-Diarrhea, thirst, and vomiting after eating, caused by cold, or by excessive hot weather. The heat is more internal than on the surface. Digestion is imperfect; all food disagrees, causing acidity, pain in the head, pleuritic pain in the sides of the chest, constipation, dry cough, with quick anxious breathing.

6. DULCAMARA.-The diarrhea excited by exposure to cold, damp air, and commencing with colic and aching in the epigastrium.

Veratrum album, Senna, Kreosotum, Tartar emetic, Arsenicum, Argentum nitricum, Rhus toxicodendron, and a long catalogue of remedial agents suggest themselves as appropriate in particular cases; but the subject has already taken up all the space that can be here given to it. In the chronic form of this disease called Atrophy or Marasmus, I have succeeded in the use of Arsenicum and Iodine.

Success will more frequently depend on the skilful application of a small number of remedies, after preliminary and adjuvant measures are disposed of, than on bringing forward a great many agents whose powers are imperfectly understood. When the purity of the air, the degree of light, the temperature of the room, the clothing, food, and drinks have been judiciously regulated; and when the condition of the teeth and gums has been duly attended to and its influence fairly estimated, some of the above remedies, properly selected and administered, will be generally successful; and if they fail, it will only be in cases which present some constitutional or psoric peculiarity which may still admit of removal by homoeopathic remedies properly directed.

In the treatment of this disease Allopathic experience is not entirely without value. And it may now be observed that the practitioners who have acquired the highest distinction in curing diseases of the alimentary canal in children, have always succeeded by measures, the action of which can only be explained on homoeopathic principles. Dr. Parrish employed small blisters behind the ears to produce counter irritation; and this practice was adopted by Professor Eberle, who says he was afterwards much more successful. Professor Mettauer advised the blister to be made by employing the strong acetous tincture of Cantharides, by wetting the skin with the “fly vinegar,” and covering the head with a leaf of oiled silk, a blister is formed in an hour or two which lessens the cerebral irritation. The vomiting has always been a perplexing symptom, and, when relieved at all, it has been effected on homoeopathic principles. Dr. Chapman allayed it by teaspoonful doses of lemonade, Dr. Parrish succeeded with half-ounce vials of soda water, kept ready and administered at intervals; Dr. Condie gave Saccharum Saturni with white sugar in solution, in minute doses every hour till the vomiting ceased. Mercury in minute doses has been generally successful. Dr. Hallowell used Blue Mass triturated with gum-arabic and white sugar, forming what we might call a “second trituration” of Mercurius viv., a teaspoonful of the syrup every three hours. Other Mercurials in minute doses have long been successfully used in this disease. The best were the Hydrargyrum cum creta, and a trituration of proto Iodide of Mercury with Magnesia, and containing but an infinitesimal proportion of the Mercury. All the external applications ever used advantageously act homoeopathically. The Cayenne poultice, in which the quantity of Cayenne is very small, applied over the epigastrium, lessens the local inflammation within, by acting homoeopathically on the intestinal inflammation through the sympathy existing between that surface and the skin. All the mild purgatives and the demulcent and mucelaginous drinks, remove irritation through that power which they all possess of causing it when given in larger quantities. The Rhubarb and Blackberry syrups arrest dysenteric purging because they are capable of producing it. Hence, in doses small enough, they are remedies in this disease.

Coffee, as an article of diet, as well as a medicine is highly useful in the summer complaint of children, I have often used it for the following symptoms: Extreme emaciation, distended abdomen; pulse small and frequent; great restlessness, imperfect sleep with the eyes half open, and convulsive motion of the eyes when awake. A teaspoonful every hour of an ordinary infusion of coffee has arrested the vomiting, caused tranquil sleep, changed the character of the evacuations from the bowels, and improved the digestion and general strength. It has been occasionally used for various medical purposes for more than half a century; but has seldom been directed according to any definite principle of science.

So long as the Weekly Report of Deaths in this city shall exhibit the large proportion of nearly one third of the whole number of deaths in the city as the result of “Cholera Infantum,” “Infantile Marasmus,” and “Infantile Convulsions,” the common treatment of the disease we have considered in this article can hardly be considered satisfactory. We hope by our present effort to draw forth from practitioners of larger experience the results of their practical observations.

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