With the advent of hot weather the pediatrist again faces the diagnostic and therapeutic problems of summer complaint. The normal process of dentition is usually blamed for the various gastrointestinal disturbances due directly to the action of micro-organisms and their toxins, or to the effect of improper or indigestible food and impure water upon the system of the infant or young child. Dentition as an etiological factor in the causation of summer complaint has been abandoned in the light of advanced scientific research, diagnosis and the results of selective therapy.

Each of the four conditions commonly classed by many practitioners and the laity under the general symposium of summer complaint, is, in itself, a separate entity, having a distinctive pathology and symptomatology, and requiring a specialized therapy for its proper treatment. These conditions are :

1. Acute catarrhal gastritis.
2. Cholera infantum.

3. Ileo-colitis.

4. Fermental diarrheas.

While the symptomatologies of these conditions have some phases in common, still an accurate differentiation between them is necessary in order to appreciate the value of selective therapeutic measures in the treatment of each.

ACUTE CATARRHAL GASTRITIS.

This condition is an exaggerated form of indigestion, due either to the ingestion of improper or indigestible food, or to a decrease in the secretion of the gastric fluids. Pathologically there is hyperemia of the mucous membrane, with occasional thickening, a hypersecretion of mucus and occasional punctate hemorrhages. Ingested

milk, instead of being digested in the usual time, remains in the stomach from four to five hours, acting as a decided irritant, while a microscopic examination of gastric contents exhibits in a coverglass preparation varied micro-organisms and pus cells.

The sub-acute form of gastric catarrh is the more common. Slight fever, nausea, vomiting of food mixed with mucus, tenderness in the epigastrium, loss of appetite, coated glossy tongue, eructations of gas, preliminary constipation followed in several days by diarrhea, encompass the symptomatology of the disease.

The onset in acute gastric catarrh is sudden. The vomiting immediately becomes active and severe, the temperature ranges from 103° to 105° F., with attendant delirium or stupor, making it difficult to differentiate the condition from incipient scarlet fever, cerebro-spinal meningitis and developing pneumonia. The vomiting, however, continues without the scarlet fever remission, and as it becomes less frequent the other symptoms point to the abdomen instead of to either the brain or lungs.

Except in debilitated children, the prognosis in both acute and subacute catarrhal gastritis is favorable.

In initiating the treatment of both forms of catarrhal gastritis it will be found advisable to withhold food for many hours, allaying extreme thirst by iced soda-water, given as seldom as possible. When the cases do not respond to feeding with modified alkaline milk, given at long intervals, lavage of the stomach proves valuable, and nourishment must be attempted by enemata of peptonized milk.

Before resorting to extreme expedients, however, brandy, barley or albumen water

should be tried. Albumen water is readily made by dissolving the white of an egg in eight ounces of water heated to 105° F., which process keeps the albumen in suspension, even when the preparation is afterwards kept on ice until required for use. Brandy or salt may be added to make the mixture more palatable. Modified feeding must be pursued for several days before a return to a milk diet is advisable. Meanwhile the child should be kept in a well-ventilated, darkened room, and the pulse watched for any irregularity, which will require the use of digitalin or strychnine as stimulants to sustain the patient. Nux vomica is of especial value as a reconstructive tonic during convalescence.

CHOLERA INFANTUM.

Cholera infantum is a rare disease, characterized by disturbance of the entire gastro intestinal tract, with intense choleriform symptoms. The etiological factors in its causation are a micro-organism of the proteus group, associated with the ingestion of non-sterile milk during hot weather. It most commonly occurs during the first two years of life.

Pathologically it is classed among the non-inflammatory disturbances, as its lesion is limited to a desquamative catarrh. The onset of this condition may be preceded by a short period of gastro-intestinal restlessness, but is usually ushered in by violent vomiting and profuse diarrhea. The vomit and stool are both odorless and serous, while epithelial cells and many bacteria are to be found in the dejecta.

The patient's skin becomes pallid or cyanotic; the face wears a pinched expres. sion; the extremities grow cold; the abdomen is somewhat distended, although remaining flaccid, and the fontanelles are depressed. There is rapid emaciation of the child, and the subjective symptom of extreme thirst. The pulse is usually too rapid to count, while the respirations are quick and decidedly shallow. The temperature is peculiar, the body surface temperature being low or normal, while the deep rectal temperature varies between 103° and 105° F. The urine is scanty or entirely suppressed; when voided is highly acid and albumin is present, associated with blood and casts.

Restlessness is at first pronounced. This period of excitement lapses into listlessness, followed either by stupor or convulsions.

The disease is self-limited. The temperature falls by crisis on the third or fourth day. Under treatment convalescence is established with a simple diarrhea and slight gastric irritability persisting. Without treatment the diarrheic condition becomes chronic, with the usual intestinal complications.

The prognosis is bad before the crisis, depending upon the violence of the attack, the heighth of the temperature, both rectal and atmospheric, and the vitality of the child. After the crisis the prognosis is more favorable.

The treatment of cholera infantum must be active and at the same time cautious. While during the initial stage of the disease peristalsis is increased, later on a vasomotor paralysis is superinduced, with the transudation of serum. In this condition the absorption of drugs is almost entirely decreased and the digestive functions fail to act. Later, when absorption is re-established, if medication has been excessive there is great danger from the accumulative action of the drugs prescribed.

Before prostration lavage of the stomach and irrigation of the bowel are indicated. A high rectal temperature allows the use of ice-water for irrigation purposes. Thirst is abated by permitting the child to suck sterile ice-water from the nippled bottle.

Cyanosis or coldness of the skin calls for a warm pack. The child is placed in sheets wrung out of water 100.4° F., and then wrapped in warm blankets. This procedure is to be repeated as often as the infant shows signs of collapse. Normal salt solution (one drachm to every pound of the child's weight, introduced during a period of fifteen minutes) may be tried subcutaneously, with the additional hypodermatic injection of digitalis if the heart does not respond to the other stimulation. Morphine, 1-100 gr., and atropine, 1-800 gr., may be tried hypodermatically in an infant one year old, when the vomiting and diarrhea continue uncontrollable. Repetitions of this dose must be given with caution.

A decidedly attenuated fresh sterile milk may be given as food after the acute symptoms have begun to lessen in severity, but stimulants and food (brandy water) must be given hypodermatically if they cause increased vomiting.

Fortunately, this disease is rare in our climate. The Asiatic form is invariably

fatal for infants, and is to be differentially diagnosticated by the presence of Koch's comma bacillus in the dejecta.

ILEO COLITIS.

Ileo-colitis, usually encompassed by the term dysentery, includes all severer and destructive lesions of the intestinal tract. Two forms of the disease are now etiologically established: (a) Ambebic, due to the activity of the ameba coli, an animal micro-parasite belonging to the group protozoa; and (b) bacillary, due to the infection of Shiga's bacillus.

Amebic Ileo Colitis.-This form of tropical or endemic dysentery, caused by the ameba coli, is infrequently seen in the temperate zone, being restricted to the tropics and occurring usually after the drinking of polluted water.

Pathologically, the disease is marked by undermining ulcers, with occasional connecting submucous sinuses. These ulcers are found in all portions of the large intestine, while the amebæ are found both in the lesion and the intestinal discharge. Sloughs of the intestinal mucosa occur, with frequent local necroses and abscess formations in the liver.

The course of this disease is marked by exacerbations and remissions. It is only when the stools are watery that the amebæ seem to be active, causing nausea, vomiting and adominal pain from the increased peristalsis. During the remissions the stools are fairly well formed. Acute in onset, the disease either takes a tedious course of two or three months' duration, or in its gangrenous form is rapidly fatal in its effect. Diagnostically, it is to be differentiated from the other forms of ileocolitis only by the presence of the ameba.

The prognosis is distinctly unfavorable. Relapses are the rule, and involvement of the liver usually ends in death.

The treatment limits itself to the irrigation of the bowel with sulphate of quinine solution, 1-5000, and a diet of milk, broths and egg albumen. While appendicostomy to facilitate the irrigation of the large intestine has been successfully utilized in the treatment of amebic dysentery in the adult, it is not as yet a surgical procedure of choice in ameliorating the condition in infants and small children.

Acute Ileo Colitis.-This, the bacillary form of dysentery, is due to the activity of the invading Shiga bacillus. Whether

this micro-organism is responsible for both the simple catarrhal and the follicular as well as the pseudo-membranous forms of the disease, has not yet been definitely determined. The sporadic pseudo-membranous form is generally primary, while as a complication it is noted as a sequela of the infectious diseases.

When associated with fermental diarrhea the symptomatology of ileo-colitis is confusing. As a primary disease the onset is abrupt, accompanied by accelerated pulse and moderate fever. Loss of weight is rapid, stools are small in amount and range between ten and twenty-five in number during twenty-four hours. Tenesmus is marked both before and after movements. The stool rapidly loses its fecal character and consists of mucus, pus, blood and shreds of membrane. Odor varies in offensiveness with the presence or absence of fecal matter. Consistency of the discharge is lessened and the color varies between mixtures of green, brown and yellow. When diarrhea continues frequent prolapse of the rectum occasionally occurs, while the discharge is extremely irritating to the skin of the anus and buttocks.

If the condition persists the temperature increases, restlessness becomes pronounced, and delirium or convulsions may be present. The abdomen becomes tympanitic and pain is greatest along the course of the colon. The urine is diminished in quantity, is highly colored and contains a trace of albumin, indicating a degenerative change in the kiney.

Catarrhal ileo-colitis is the mildest form. If ulceration is not present the child usually begins improving after several weeks, although convalescence may be protracted by relapses due to errors of diet.

In the follicular ulcerative form the stomach symptoms are least pronounced, the temperature is moderate, but the course is irregular, with a steady progressive failure of vitality in the child.

Pseudo-Membranous Ileo Colitis.-The epidemic or sporadic form of dysentery is rare among children. The temperature varies between 103° to 105° F. Blood and shreds of mucus predominate in the stools. The progress of the disease is marked by rapid decline without remissions, and death occurs in from seven to ten days. Delirium and convulsions are pronounced.

Without ulceration the prognosis of ileo-colitis is passably favorable. Intractable vomiting or diarrhea, with considerable flux of blood and discharge of membrane, unhygienic surroundings, hot weather, complications of tuberculosis or broncho-pneumonia make the result almost necessarily fatal.

When not preceded by fermental diarrhea, ileo-colitis is best treated by an initial mild laxative dose of castor oil. Irrigation of the colon is indispensable. Two or three quarts of sterile warm water (one drachm sodium borate to the pint) should be used twice in the twenty-four hours. Between irrigations enemata may be used:

M. Sig. Use as an enema every four hours.

Cocaine suppositories (togr.) will relieve excessive tenesmus and painful lesions in the rectum. Exhausting tenesmus associated with higher lesions may require 1-20 gr. morphia and 1-200 gr. atropia hypodermatically.

Sterilized brandy-water, with barleywater added as indications permit, is the best nourishment and stimulant for the early stages of the disease. Milk may be tried later, but it must be attenuated to a percentage of 2 and 5 respectively for the fat and sugar. Whey as a diluent should provide the proteid element, and this may be gradually increased. Cleanliness of the anus and buttocks is essential, while the use of soothing dusting powders will do much to relieve the irritation of the skin in these regions.

Chronic Ileo- Colitis.-Neglect in treating the acute attack of ileo-colitis, consequent hypertrophy of the mucosa and extensive ulceration may lead to the chronic form of dysentery. The stools become. less frequent, averaging from two to eight in twenty-four hours, pain and tenderness are scarcely noticeable, the temperature is low or may become normal. The dejecta are partially mucous in character and contain undigested food. Exacerbations are frequent during the many months during which the dysentery continues, and intercurrent diseases are usually responsible for the fatalities.

The treatment is limited to a dietetic care of the patient, with the possible. change of environment and air.

FERMENTAL DIARRHEA.

By fermental diarrhea is now understood the non-inflammatory disease of the intestine produced by acid fermentation and albuminous decomposition consequent upon the activity of micro organisms, and associated with the ingestion of impure or indigestible foods in unhygienic surroundings. The small intestine is the pathological seat of the disease, and a desquamative catarrh is usually the severest lesion.

Fermental diarrhea, in its most characteristic clinical aspect, is a toxemia. The temperature rises abruptly to 100° to 105° F., stools vary in number from nine to fifteen in the twenty-four hours; are large in quantity, accompanied by cons.derable pain and a great amount of gas. In acid fermentation the stool is sour; in albuminous decomposition the odor is decidedly offensive, while the color is almost always a green or greenish-yellow. some cases vomiting may be excessive and restlessness extreme. Emaciation is rapid and pronounced. A degenerative renal condition accompanied by albuminuria is present (Morse) in 15 per cent. of all

cases.

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In the subacute form the onset is slow; vomiting is infrequent, as are also the stools, while the nervous symptoms of restlessness and insomnia and gaseous distension of the bowel may be somewhat more pronounced. Fever is mild, and rapid recovery under treatment differentiates it from the more violent forms of intestinal derangement.

In the acute form the characteristic color and consistency of the stools differentiates fermental diarrhea from cholera infantum, while the nervous symptoms are never so decidedly choleriform. The amount of discharge, lesser frequency of vomit and stools, absence of blood and shreds of membrane and fall of temperature by crisis upon complete elimination of the toxic products in the intestine give a differential clinical picture from ileo-colitis.

Except in cases of infantile atrophy and debilitated children from previous illness or intestinal disturbances, the prognosis of fermental diarrhea is good. Neglected or improper treatment, however, may invite the invasion of specific bacteria, and cholera infantum or ileo-colitis in its amebic or bacillary form result. The prognosis then is graver.

Castor oil, one to two teaspoonfuls, or calomel, one to two grains in divided doses, is the initial step in the treatment. If neither remedy effectually controls the diarrhea, irrigation of the bowel is indicated, and in persistent vomiting lavage of the stomach should be used. Food must be positively withheld from six to eight hours, and stimulants used to counteract prostration. After the first twelve or twenty-four hours, milk containing 10 to 15 per cent. lime-water, and reduced in the percentage of its elements, may be tried.

In acid fermentation the percentage of sugar should be fractional, while in albuminous decomposition the proteids must be similarly reduced. The milk, however, must be absolutely fresh and free from the toxic products of bacteria. Chicken and beef broth may be used to advantage when the milk is not well tolerated.

Medication has little effect until after thorough elimination of the toxic products has been obtained. Then tinct. opii camphorat. to control excessive peristalsis and subnitrate of bismuth to act mechanically upon the mucous membrane of the bowel are indicated. High fever is readily controlled by cool baths. If the nervous symptoms are extreme soda bromide (two to ten grains) is indicated. It is only in the worst cases that morphia hypodermatically (1-100 gr.) may be tried.

One attack of fermental diarrhea predisposes to another, and the diet must be regulated for a long period during convalescence to insure permanent results. Cooler localities and country or sea-shore air assist materially in hastening convalescence.

Chronic Fermental Diarrhea.-Acute cases with continuous feeding of improper food, occurring in children afflicted with rhachitis, syphilis, tuberculosis or bronchopneumonia, give rise to the chronic form of fermental diarrhea. Treatment must be directed to the initial cause, the fermental diarrheic condition being best controlled by climatological and dietetic measures.

From the foregoing it is evident that if summer complaint is to be rationally treated it must be differentiated into its distinctive pathological and etiological forms, and when differentiated it must be treated energetically, according to the best methods of selective therapy, dietetics and climatology.

As in the amelioration of all medical

diseases, so with summer complaint, the present energies should be bent toward prophylaxis. A consideration of this phase of the question is too extensive for detailed discussion. Only its chief points need be touched upon.

Tenement life, polluted water and impure milk are to a greater extent responsible for the majority of summer complaint cases. Competent building inspection and health-board supervision of sanitation will go far toward bettering the conditions in congested districts. While the new waterworks filtration plant may improve the local water supply, still for infant feeding a thoroughly boiled, then aërated and cooled water is the only safe method of preventing infection from this source. By recent announcement in the local press the Board of Health promises to investigate Cincinnati's milk supply according to the bacteriological as well as the dilution and hygienic standards. This is a progressive step. Milk for infant feeding is absolutely bad if sterilized after hours of opportunity for the millions of bacteria present to produce toxins. Fresh milk is essential, and then sterilization becomes of value. cally, in order to meet a growing demand, one milk firm is making a specialty of certified milk for infants and invalids. Such a milk has a distinctive therapeutic as well as dietetic value in the treatment of summer complaint, reducing as it does the prospect of continued infection and toxic irritation to nil.

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This point must be impressed upon those having the care of babies and young children in their charge. If one feeding of a certain amount of milk disagrees with the child, the full amount of milk purchased at the time should be rejected as improper food. An absolutely fresh milk properly sterilized and modified according to requirements should be substituted. This is imperative. Little harm may result from one feeding of a contaminated or toxic milk, but when the same milk is given for four, five or six feedings the results cannot be other than disastrous.

Parents and nurses must also be taught that it is essential to follow the dietetic menu for the child to the very letter of the physician's prescription; and physicians themselves should be careful to give written directions for the modification of milk if they think their verbal advice has not been fully understood or appreciated.